Essentials of Personality Disord

Essentials of
Personality Disorders
This page intentionally left blank
Essentials of
Edited by
John M. Oldham, M.D., M.S.

Andrew E. Skodol, M.D.
Donna S. Bender, Ph.D.
Washington, DC
London, England
Note: The authors have worked to ensure that all information in this book is accurate at
the time of publication and consistent with general psychiatric and medical standards,
and that information concerning drug dosages, schedules, and routes of administration is
accurate at the time of publication and consistent with standards set by the U.S. Food and
Drug Administration and the general medical community. As medical research and prac-
tice continue to advance, however, therapeutic standards may change. Moreover, specific
situations may require a specific therapeutic response not included in this book. For these
reasons and because human and mechanical errors sometimes occur, we recommend that
readers follow the advice of physicians directly involved in their care or the care of a
member of their family.
Books published by American Psychiatric Publishing, Inc., represent the views and opin-
ions of the individual authors and do not necessarily represent the policies and opinions
of APPI or the American Psychiatric Association.
Copyright 2009 American Psychiatric Publishing, Inc.
ALL RIGHTS RESERVED
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Library of Congress Cataloging-in-Publication Data
Essentials of personality disorders / edited by John M. Oldham, Andrew E. Skodol,
Donna S. Bender ; associate editors, Glen O. Gabbard ... [et al.]. 1st ed.
p. ; cm.
Companion to: The American Psychiatric Publishing textbook of personality disorders /
edited by John M. Oldham, Andrew E. Skodol, Donna S. Bender ; associate editors, Glen
O. Gabbard ... [et al.]. 1st ed. c2005.
Includes bibliographical references and index.
ISBN 978-1-58562-358-7 (alk. paper)
1. Personality disorders. I. Oldham, John M. II. Skodol, Andrew E. III. Bender, Donna S.,
1960 IV. American Psychiatric Publishing textbook of personality disorders.
[DNLM: 1. Personality Disorders. WM 190 E784 2009]
RC554.E883 2009
616.8581dc22
2008044430
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
To our families, who have supported us:
Karen, Madeleine, and Michael Oldham;

Laura, Dan, and Ali Skodol; and
John and Joseph Rosegrant.
To our colleagues, who have helped us.
To our patients, who have taught us.
And to each other, for the friendship that has enriched our work together.
Contents
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
PART I
Basic Concepts
1 Personality Disorders: Recent History and

the DSM System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2 Theories of Personality and Personality Disorders . . . . . . . . . . 13

Amy Heim, Ph.D., and Drew Westen, Ph.D.
PART II
Clinical Evaluation
3 Manifestations, Clinical Diagnosis, and Comorbidity . . . . . . . . 37

4 Course and Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Carlos M. Grilo, Ph.D., and Thomas H. McGlashan, M.D.
PART III
Etiology
5 Prevalence, Sociodemographics, and

Functional Impairment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Svenn Torgersen, Ph.D.
6 Neurobiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Emil F. Coccaro, M.D., and Larry J. Siever, M.D.
7 Developmental Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123

Patricia Cohen, Ph.D., and Thomas Crawford, Ph.D.
8 Childhood Experiences and

Development of Maladaptive and
Adaptive Personality Traits . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Jeffrey G. Johnson, Ph.D., Elizabeth Bromley, M.D., and
Pamela G. McGeoch, M.A.
PART IV
Treatment
9 Levels of Care in Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . 161

John G. Gunderson, M.D., Kim L. Gratz, Ph.D.,
Edmund C. Neuhaus, Ph.D., and George W. Smith, M.S.W.
10 Psychoanalysis and Psychodynamic Psychotherapy . . . . . . . . 185

Glen O. Gabbard, M.D.
11 Mentalization-Based Treatment of Borderline

Personality Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Peter Fonagy, Ph.D., F.B.A., and
Anthony W. Bateman, M.A., F.R.C.Psych.
12 Dialectical Behavior Therapy . . . . . . . . . . . . . . . . . . . . . . . . . 235

Barbara Stanley, Ph.D., and Beth S. Brodsky, Ph.D.
13 Group Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
William E. Piper, Ph.D., and John S. Ogrodniczuk, Ph.D.
14 Somatic Treatments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267

Paul H. Soloff, M.D.
15 Therapeutic Alliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289

16 Boundary Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309

Thomas G. Gutheil, M.D.
17 Collaborative Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321

Abigail Schlesinger, M.D., and Kenneth R. Silk, M.D.
18 Assessing and Managing Suicide Risk . . . . . . . . . . . . . . . . . . . 343

Paul S. Links, M.D., F.R.C.P.C., and Nathan Kolla, M.D.
19 Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361

Roel Verheul, Ph.D., Louisa M.C. van den Bosch, Ph.D., and
Samuel A. Ball, Ph.D.
PART V
New Developments and
Future Directions
20 Future Directions: Toward DSM-V . . . . . . . . . . . . . . . . . . . . . 381

Andrew E. Skodol, M.D., Donna S. Bender, Ph.D., and
Appendix: DSM-IV-TR Diagnostic Criteria for

Personality Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403
Contributors
Samuel A. Ball, Ph.D. Thomas Crawford, Ph.D.

Professor of Psychiatry, Department of Psy- Assistant Clinical Professor of Medical Psy-
chiatry, Yale University School of Medicine; chology, Columbia University College of
Director of Research, the APT Foundation, Physicians and Surgeons, New York, New
Inc., New Haven, Connecticut York
Anthony W. Bateman, M.A., F.R.C.Psych. Peter Fonagy, Ph.D., F.B.A.
Visiting Professor, Sub-Department of Clini- Freud Memorial Professor of Psychoanalysis
cal Health Psychology, University College and Head of the Research Department of
London; Consultant Psychotherapist, Bar- Clinical, Educational, and Health Psycholo-
net, Enfield, and Haringey Mental Health gy, University College London; Chief Execu-
Trust, London, England tive of the Anna Freud Centre, London,
England; Consultant to the Child and Family
Program, Menninger Department of Psychi-
Research Associate Professor of Psychiatry,
atry, Baylor College of Medicine, Houston,
University of Arizona College of Medicine;
Texas
Chief Executive Officer and Director, Sun-
belt Collaborative, Tucson, Arizona Glen O. Gabbard, M.D.
Brown Foundation Chair of Psychoanalysis
Beth S. Brodsky, Ph.D.
and Professor, Department of Psychiatry,
Assistant Clinical Professor of Medical Psy-
Baylor College of Medicine; Training and Su-
chology, Department of Psychiatry, Colum-
pervising Analyst, Houston-Galveston Psy-
bia University College of Physicians and
choanalytic Institute, Houston, Texas
Surgeons; Research Scientist, Department of
Molecular Imaging and Neuropathology, New Kim L. Gratz, Ph.D.
York State Psychiatric Institute, New York, Assistant Professor and Director, Personality
New York Disorders Research, Department of Psychia-
try and Human Behavior, University of Mis-
Elizabeth Bromley, M.D.
sissippi Medical Center, Jackson, Mississippi
Assistant Professor in Residence, Depart-
ment of Psychiatry and Biobehavioral Scienc- Carlos M. Grilo, Ph.D.
es, Semel Institute Health Services Research Professor of Psychiatry, Department of Psy-
Center, University of California, Los Ange- chiatry, Yale University School of Medicine;
les, California Professor of Psychology, Yale University,
New Haven, Connecticut
Emil F. Coccaro, M.D.
Ellen C. Manning Professor and Chairman, John G. Gunderson, M.D.
Department of Psychiatry, University of Chi- Professor of Psychiatry, Harvard Medical
cago, Chicago, Illinois School, Boston, Massachusetts; Director,
Psychosocial and Personality Research, and
Patricia Cohen, Ph.D.
Director, Borderline Personality Disorder
Professor of Clinical Epidemiology in Psy-
Center, McLean Hospital, Belmont, Massa-
chiatry, Columbia University College of Phy-
chusetts
sicians and Surgeons, New York, New York
xi
xii E ss e n t i a l s o f P e r s o n a l i ty D i s o r d e r s
Thomas G. Gutheil, M.D. William E. Piper, Ph.D.

Professor of Psychiatry, Department of Psy- Professor and Head, Division of Behavioural
chiatry, Beth Israel Deaconess Medical Cen- Science; Director, Psychotherapy Program,
ter, Harvard Medical School, and Co- Department of Psychiatry, University of
Founder, Program in Psychiatry and the British Columbia, Vancouver, British Co-
Law, Massachusetts Mental Health Center, lumbia, Canada
Boston, Massachusetts
Abigail Schlesinger, M.D.
Amy Heim, Ph.D. Assistant Professor, Western Psychiatric In-
Private practice, Lexington, Massachusetts stitute and Clinic, University of Pittsburgh
School of Medicine, Pittsburgh, Pennsylva-
Jeffrey G. Johnson, Ph.D.
nia
Associate Professor of Clinical Psychology,
Department of Psychiatry, College of Physi- Larry J. Siever, M.D.
cians and Surgeons, Columbia University; Executive Director, Mental Illness Research,
Research Scientist IV, Epidemiology of Men- Education and Clinical Center, Bronx Veter-
tal Disorders Department, New York State ans Administration Medical Center, Bronx,
Psychiatric Institute, New York, New York New York; Professor of Psychiatry, Depart-
ment of Psychiatry, The Mount Sinai School
Nathan Kolla, M.D.
of Medicine, New York, New York
Psychiatry Resident, Department of Psychia-
try, University of Toronto, Toronto, Ontario, Kenneth R. Silk, M.D.
Canada Professor and Director, Personality Disor-
ders Program, Department of Psychiatry,
Paul S. Links, M.D., F.R.C.P.C.
University of Michigan Health System, Ann
Arthur Sommer Rotenberg Chair in Suicide
Arbor, Michigan
Studies, Professor of Psychiatry, Department
of Psychiatry, St. Michaels Hospital, Uni- Andrew E. Skodol, M.D.
versity of Toronto, Toronto, Ontario, Canada Research Professor of Psychiatry, University
of Arizona College of Medicine; President,
Sunbelt Collaborative, Tucson, Arizona
Graduate Faculty, Department of Psycholo-
gy, The New School University, New York, George W. Smith, M.S.W.
New York Director, Outpatient Personality Disorder
Services, McLean Hospital, Boston, Massa-
Thomas H. McGlashan, M.D.
chusetts
Professor of Psychiatry, Department of Psy-
chiatry, Yale University School of Medicine, Paul H. Soloff, M.D.
New Haven, Connecticut Professor of Psychiatry, Western Psychiatric
Institute and Clinic, University of Pitts-
Edmund C. Neuhaus, Ph.D.
burgh, Pittsburgh, Pennsylvania
Director, Behavioral Health Partial Hospital
Program, Co-Director of Psychology Train- Barbara Stanley, Ph.D.
ing, McLean Hospital, Belmont, Massachu- Professor of Clinical Psychiatry, Department
setts; Assistant Clinical Professor, Harvard of Psychiatry, Columbia University College
Medical School, Boston, Massachusetts of Physicians and Surgeons; Research Scien-
tist, Department of Molecular Imaging and
John S. Ogrodniczuk, Ph.D.
Neuropathology, New York State Psychiat-
Associate Professor, Department of Psychia-
ric Institute, New York, New York
try, University of British Columbia, Vancou-
ver, British Columbia, Canada Svenn Torgersen, Ph.D.
Professor, Department of Psychology, Uni-
versity of Oslo, Oslo, Norway
Senior Vice President and Chief of Staff, The
Menninger Clinic; Professor and Executive Louisa M.C. van den Bosch, Ph.D.
Vice Chairman, Menninger Department of Clinical Psychologist/Psychotherapist, CSP
Psychiatry and Behavioral Sciences, Baylor Leiden; Administrative Executive, Dialexis,
College of Medicine, Houston, Texas Noordwijkerhout, The Netherlands
xiii
Roel Verheul, Ph.D. The following contributors have no competing in-

Professor of Personality Disorders, Vier- terests to report:
sprong Institute for Studies on Personality
Disorders (VISPD); University of Amster- Samuel A. Ball, Ph.D.
dam, Department of Clinical Psychology; Anthony W. Bateman, M.A., F.R.C.Psych.
Amsterdam, Chief Executive Officer, Center Donna S. Bender, Ph.D.
for Psychotherapy De Viersprong, Halster- Beth S. Brodsky, Ph.D.
en, The Netherlands Elizabeth Bromley, M.D.
Drew Westen, Ph.D. Thomas Crawford, Ph.D.
Professor, Department of Psychiatry and Be- Glen O. Gabbard, M.D.
havioral Sciences and Department of Psy- Carlos M. Grilo, Ph.D.
chology, Emory University, Atlanta, Georgia John G. Gunderson, M.D.
Amy Heim, Ph.D.
DISCLOSURE OF INTERESTS Nathan Kolla, M.D.
The following contributor to this book has indi-
cated a financial interest in or other affiliation
with a commercial supporter, a manufacturer of a John S. Ogrodniczuk, Ph.D.
commercial product, a provider of a commercial William E. Piper, Ph.D.
service, a nongovernmental organization, and/or Larry J. Siever, M.D.
a government agency, as listed below. Kenneth R. Silk, M.D.
George W. Smith, M.S.W.
Paul S. Links, M.D., F.R.C.P.C.Educational Paul H. Soloff, M.D.
grant: Eli Lilly Barbara Stanley, Ph.D.
Roel Verheul, Ph.D.
Introduction
From as early as the fifth century B.C., it has true in some cases involving significant ge-
been recognized that every human being de- netic loading or risk. In the twentieth cen-
velops an individualized signature pattern tury, however, we became more interested in
of behavior that is reasonably persistent and the role of the environment during early de-
predictable throughout life. Hippocrates velopment in determining the shape of last-
proposed that the varieties of human behav-
ing adult behaviora view that for a while
ior could be organized into what we might
extended well beyond the realm of the per-
now call prototypesbroad descriptive pat-
terns of behavior characterized by typical, sonality disorders to include most major
predominant, easily recognizable features mental disorders. We know, of course, that
and that most individuals could be sorted the early life environment is indeed critically
into these broad categories. Sanguine, mel- importantfrom health-promoting, highly
ancholic, choleric, and phlegmatic types of nurturing environments to stressful and ne-
behavior were, in turn, thought to derive glectful environments from which only the
from body humors, such as blood, black most resilient emerge unscathed. But we also
bile, yellow bile, and phlegm, and the pre- know that variable degrees of genetic risk
dominance of a given body humor in an in- predispose many of us to become ill in very
dividual was thought to correlate with a par- specific ways, should we unluckily encoun-
ticular behavior pattern. Although we now
ter more stress than we can tolerate.
call body humors by different names (neu-
In recent years, we have begun to see an
rotransmitters, transcription factors, second
messengers), the ancient principle that fun- upsurge of empirical and clinical interest in
damental differences in biology correlate personality disorders. Improved standard-
with relatively predictable patterns of be- ized diagnostic systems have led to semi-
havior is strikingly familiar. structured research interviews that are being
In spite of long-standing worldwide in- used not only in studies of clinical popula-
terest in personality types, however, remark- tions but also in community-based studies,
ably little progress has been made, until re- to give us, for the first time, good data about
cently, in our understanding of those severe the epidemiology of these disorders. Person-
and persistent patterns of inner experience ality disorders occur in about 10% of the gen-
and behavior that result in enduring emo- eral population, and their public health sig-
tional distress and impairment in occupa- nificance has been documented by studies
tional functioning and interpersonal rela- showing their extreme social dysfunction
tionshipsthe conditions we now refer to as and high health care utilization. As clinical
personality disorders. For decades, it was populations are becoming better defined,
widely recognized that some severely dis- new and more rigorous treatment studies are
turbed individuals just seemed to have been being carried out, with increasingly promis-
born that way, a view we now know to be ing results. No longer are personality disor-
xv
xvi E ss e n t i a l s o f P e r s o n a l i ty D i s o r d e r s
ders swept into the hopeless cases bin. An ment, and 5) New Developments and Future
explosion of knowledge and technology in Directions.
the neurosciences has made the formerly
black box, the brain, more and more trans-
parent. Mapping the human genome paved PART I: BASIC CONCEPTS
the way for new gene-finding technologies
that are being put to work to tackle complex Basic Concepts, the first part of Essentials of
psychiatric disorders, including the person- Personality Disorders, might be thought of as
ality disorders. New transgenic animal setting the stage for the parts that follow. In
models are providing important hints about Chapter 1, Oldham presents a brief overview
the genetic loci driving certain behavior of the recent history of the personality disor-
types, such as attachment and bonding be- ders, along with a summary look at the evo-
havior. Brain imaging studies are allowing lution of the personality disorders compo-
researchers to zero in on malfunctioning ar- nent in successive editions of the American
eas of the brain in specific personality disor- Psychiatric Association Diagnostic and Statisti-
ders. cal Manual of Mental Disorders. Heim and
A great deal of work must still be done. Westen, in the next chapter, review the major
Fundamental questions remain, such as theories that have influenced our thinking
what is the relationship between traits of about the nature of personality and person-
general, or normal, personality functioning ality disorders.
and personality psychopathology. Directly
related to this issue is the ongoing debate
about whether dimensional or categorical
PART II: CLINICAL EVALUATION
systems best capture the full scope of person-
ality differences and personality pathology.
In the section on clinical evaluation begin-
Extensive impairment can be associated with
ning with Chapter 3, Skodol reviews the de-
personality disorders, but we are gaining
fining features of DSM-IV-TR personality
new knowledge regarding their longer-term
disorders, discusses complementary ap-
course and increased understanding of fac-
proaches to the clinical assessment of a pa-
tors contributing to variations in course.
tient with a possible personality disorder,
There is a strong momentum of interest inter-
provides guidance on general problems en-
nationally in these issues, as new research
countered in the routine clinical evaluation,
findings emerge daily to inform the process.
and describes patterns of Axis I and Axis II
In light of the continuing and increased
disorder comorbidity. In Chapter 4, Grilo
activity and progress in the field of personal-
and McGlashan provide an overview of the
ity studies and personality disorders, we
clinical course and outcome of personality
judged the time to be right to develop a com-
disorders, synthesizing the empirical litera-
panion volume to The American Psychiatric
ture on the stability of personality disorder
Publishing Textbook of Personality Disorders,
psychopathology.
published in 2005 to cover and update the es-
sentials of this topic. Because of space con-
straints, it was necessary to be selective re-
garding what material to include in the PART III: ETIOLOGY
Essentials volume, and we have tried to focus
on material that is up-to-date and useful to The section on etiology of the personality
practicing clinicians. This new volume is or- disorders begins with Chapter 5. Torgersen
ganized into several parts: 1) Basic Concepts, presents the best data we have to date on the
2) Clinical Evaluation, 3) Etiology, 4) Treat- population-based epidemiology of the per-
Introduction xvii
sonality disorders. Although there are rela- and maladaptive personality traits. They em-
tively few well-designed population-based phasize the importance of stress, but also of
studies, Torgersen reviews a number of stud- protective factors that can offset and even
ies, including his own Norwegian study, and prevent the development of maladaptive
tabulates prevalence ranges and averages for traits in vulnerable individuals.
individual DSM-defined personality disor-
ders as well as for all personality disorders
taken together (showing an overall average PART IV: TREATMENT
prevalence rate for the personality disorders
of over 12%). Of particular interest in these The treatment section begins with Chapter 9,
data are cross-cultural comparisons, sug- a discussion of the levels of care available for
gesting significant cultural differences in the patients with personality disorders. Gunder-
prevalence of selected personality disorders. son, Gratz, Neuhaus, and Smith offer guide-
Substantial progress has been made in our lines for determining the appropriate inten-
understanding of the neurobiology of the sity of treatment services for individual
personality disorders, as reviewed in Chap- patients. Four levels of care are addressed:
ter 6 by Coccaro and Siever. Although a great hospitalization, partial hospitalization/day
deal more is known about the neurobiology treatment, intensive outpatient, and outpa-
of some personality disorders (e.g., schizo- tient.
typal personality disorder and borderline Chapters 10 through 14 offer a range of
personality disorder) than others (e.g., treatment options. Gabbard (Chapter 10)
Cluster C personality disorders), the under- summarizes the salient features of psycho-
lying neurobiological dysfunction involved analysis and psychodynamic psychotherapy
in personality disorders characterized by as applied to patients with character pathol-
cognitive symptomatology, impulsivity, and ogy. One psychodynamic model, mentaliza-
mood dysregulation is becoming increas- tion-based therapy, is of special interest in
ingly clear. the treatment of patients with borderline per-
Understanding the etiology of the personality disorder, as described in Chapter 11
sonality disorders involves not just cross-sec- by Fonagy and Bateman. In this model, bor-
tional genetic and neurobiological analysis; derline personality disorder is seen as dys-
environmental influences shaping personal- function in self-regulation, critically related
ity must be understood as well. In Chapter 7, to interpersonal dynamics. In Chapter 12,
Cohen and Crawford provide a developmen- Stanley and Brodsky outline the core ele-
tal perspective. Although, by convention, ments of dialectical behavior therapy, which
DSM-IV-TR personality disorders are gener- includes individual and group interventions,
ally not diagnosed until late adolescence, and is chiefly used to treat parasuicidal be-
there is increasing recognition of early pat- haviors in patients with borderline personal-
terns of behavior that are thought to be pre- ity disorder.
cursors to certain personality disorders. The Apart from the realm of individual treat-
challenge to identify true early precursors of ments, there are other venues for therapeutic
personality disorders, versus the risk of inac- interventions. In Chapter 13, Piper and Og-
curate labeling of transient symptoms, is cen- rodniczuk demonstrate the application of
tral to the work ahead of us as we focus more group therapy to personality disorders. So-
and more on prevention strategies. Comple- loff (Chapter 14) takes up the issue of phar-
menting this developmental approach, the macotherapy and other somatic treatments,
authors of Chapter 8, Johnson, Bromley, and because many patients with personality dis-
McGeoch, review the relevance of childhood orders may benefit by complementing their
experiences to the development of adaptive psychosocial treatments with medication.
xviii E ss e n t i a l s o f P e r s o n a l i ty D i s o r d e r s
The final five chapters of this section ad-

dress issues of great importance pertaining to PART V: NEW DEVELOPMENTS AND
most, if not all, treatments. Bender (Chapter FUTURE DIRECTIONS
15) underscores the necessity of explicitly
considering alliance building across all treat- In the final section of Essentials of Personality
ment modalities, while Gutheil (Chapter 16) Disorders, Skodol, Bender, and Oldham sum-
cautions practitioners about dynamics that marize current controversies and speculate
can lead treaters to boundary violations about future directions, as the work gets un-
when working with certain patients with per- der way to consider the best strategies to clas-
sonality disorders. Schlesinger and Silk, in sify and understand the personality disor-
Chapter 17, provide recommendations about ders in DSM-V.
the best way of negotiating collaborative We are grateful to all of the authors of
treatments, since many patients with person- each chapter for their careful and thoughtful
ality disorders are engaged in several modal- contributions, and we hope that we have suc-
ities with several clinicians at the same time. ceeded in providing a current, definitive re-
In recognition of the fact that patients view of the field. We would particularly like
with personality disorders can be particu- to thank Liz Bednarowicz for her organized
larly challenging, we have included two and steadfast administrative support, with-
chapters devoted to the issues often faced out which this volume would not have been
when treating these individuals. Of prime possible.
importance is the risk for suicide. In Chapter
18, Links and Kolla provide evidence on the John M. Oldham, M.D., M.S.
association of suicidal behavior and person- Houston, Texas
ality disorders, examine modifiable risk fac-
tors, and discuss clinical approaches to the as- Andrew E. Skodol, M.D.
sessment and management of suicide risk. In Phoenix, Arizona
Chapter 19, Verheul, van den Bosch, and Ball Donna S. Bender, Ph.D.
focus on pathways to substance abuse in pa- Tucson, Arizona
tients with personality disorders, and discuss
issues of differential diagnosis and treatment.
Part I
Basic Concepts
1
Recent History and
the DSM System
As to why we behave the way we do, we

PERSONALITY TYPES know now that a fair amount of the reason re-
AND PERSONALITY DISORDERS lates to our hardwiring. To varying de-
grees, heritable temperaments that vary
Charting a historical review of efforts to un- widely from one individual to another deter-
derstand personality types and the differ- mine the amazing range of behavior in the
ences among them would involve exploring newborn nursery, from cranky to placid.
centuries of scholarly archives, worldwide, Each individuals temperament remains a
on the varieties of human behavior. For it is key component of that persons developing
human behavior, in the end, that serves as the personality, to which is added the shaping
most v alid measurable and observable and molding influences of family, caretakers,
benchmark of personality. In many impor- and environmental experiences. This process
tant ways, we are what we do. The what of is, we now know, bidirectional, so that the
personality is easier to come by than the inborn behavior of the infant can elicit be-
why, and each of us has a personality style havior in parents or caretakers that can, in
that is unique, almost like a fingerprint. At a turn, reinforce infant behavior: placid, happy
school reunion, recognition of classmates not babies may elicit warm and nurturing behav-
seen for decades derives as much from famil- iors; irritable babies may elicit impatient and
iar behavior as from physical appearance. neglectful behaviors.
Sections of this chapter have been modified from Oldham JM, Skodol AE: Charting the Future of Axis II.
Journal of Personality Disorders 14:1729, 2000. Reprinted with permission of Guilford Press.
3
4 E ss e n t i a l s o f P e r s o n a l i ty D i s o r d e r s
However, even-tempered, easy-to-care- cursors or less extreme forms of psychotic

for babies can have bad luck and land in a conditions, such as schizophrenia or manic-
nonsupportive or even abusive environment depressive illnesssystems that can clearly
that may set the stage for a personality disor- be seen as forerunners of current Axis I/Axis
der, and difficult-to-care-for babies can have II spectrum models. Schneider, on the other
good luck and be protected from future per- hand, described a set of psychopathic per-
sonality pathology by specially talented and sonalities that he viewed as separate disor-
attentive caretakers. Once these highly indi- ders co-occurring with other psychiatric dis-
vidualized dynamics have had their main ef- orders. Although these classical systems of
fects and an individual has reached late ado- descriptiv e psychopathology resonate
lescence or young adulthood, his or her strongly with the framework eventually
personality will usually have been pretty adopted by the American Psychiatric Associ-
well established. We know that this is not an ation (APA) and published in its Diagnostic
ironclad rule; there are late bloomers, and and Statistical Manual of Mental Disorders
high-impact life events can derail or reroute (DSM), they were widely overshadowed in
any of us. How much we can change if we American psychiatry during the mid-twenti-
need and want to is variable, but change is eth century by theory-based psychoanalytic
possible. How we define the differences be- concepts stimulated by the work of Sigmund
tween personality styles and personality dis- Freud and his followers.
orders, how the two relate to each other, what Freud emphasized the presence of a dy-
systems best capture the magnificent variety namic unconscious, a realm that, by defini-
of nonpathological human behavior, and tion, is mostly unavailable to conscious
how we think about and deal with extremes thought but is a powerful motivator of hu-
of behavior that we call personality disorders man behavior (key ingredients of his topo-
are all spelled out in great detail in the chap- graphical model). His emphasis on a dy-
ters of this textbook. In this first chapter, I namic unconscious was augmented by his
briefly describe how psychiatrists in the well-known tripartite structural theory, a
United States have approached the definition conflict model serving as the bedrock of his
and classification of the personality disor- psychosexual theory of pathology (Freud
ders, building on broader international con- 1926). Freud theorized that certain uncon-
cepts and theories of psychopathology. scious sexual wishes or impulses (id) could
threaten to emerge into consciousness (ego),
thus colliding with conscience-driven prohi-
bitions (superego) and producing signal
TWENTIETH-CENTURY CONCEPTS OF anxiety, precipitating unconscious defense
PERSONALITY PSYCHOPATHOLOGY mechanisms and, when these coping strate-
gies prove insufficient, leading to frank
Personality pathology has been recognized in symptom formation. For the most part, this
most influential systems of classifying psy- system was proposed as an explanation for
chopathology. The well-known contributions what were called at the time the symptom neu-
by European pioneers of descriptive psychia- roses, such as hysterical neurosis or obsessive-
try, such as Kraepelin (1904), Bleuler (1924), compulsive neurosis. During the 1940s,
Kretschmer (1926), and Schneider (1923/ 1950s, and 1960s, these ideas became domi-
1950) had an important impact on early twen- nant in American psychiatry, followed later
tieth-century American psychiatry. For the by interest in other psychoanalytic principles,
most part, Kraepelin, Bleuler, and Kretschmer such as object relations theory.
described personality types or temperaments, Freuds concentration on the symptom
such as aesthenic, autistic, schizoid, cyclothy- neuroses involved the central notion of anxi-
mic, or cycloid, that were thought to be pre- ety as the engine that led to defense mecha-
Personality Disorders: Recent History and the DSM System 5
nisms and to symptom formation, and as a other syndromes characterized by discrete,

critical factor in motivating patients to work persistent symptom patterns such as major
hard in psychoanalysis to face painful real- depressive episodes, persistent anxiety, or
izations and to tolerate stress within the dementia. General clinical experience and
treatment itself (such as that involved in the wisdom guided treatment recommendations
transference neurosis). Less prominently for these patients, at least for those who
articulated were Freuds notions of character sought treatment. Patients with paranoid,
pathology, but generally character disorders schizoid, or antisocial patterns of thinking
were seen to represent pre-oedipal pathol- and behaving often did not seek treatment.
ogy. As such, patients with these conditions Others, however, often resembled patients
were judged less likely to be motivated to with symptom neuroses and did seek help
change. Instead of experiencing anxiety re- for problems ranging from self-destructive
lated to the potential gratification of an un- behavior to chronic misery. The most se-
acceptable sexual impulse, patients with verely and persistently disabled of these pa-
fixations at the oral-dependent stage, for tients were often referred for intensive, psy-
example, experienced anxiety when not grat- choanalytically oriented long-term inpatient
ifying the impulsein this case, the need to treatment at treatment centers such as Aus-
be fed. Relief of anxiety thus could be accom- ten Riggs, Chestnut Lodge, Menninger
plished by some combination of real and Clinic, McLean Hospital, New York Hospital
symbolic feedingattention from a parent or Westchester Division, New York State Psy-
parent figure or consumption of alcohol or chiatric Institute, Sheppard Pratt, and other
drugs. Deprivations within the psychoana- long-term inpatient facilities available at the
lytic situation, theninevitable by its very time. Other patients, able to function outside
naturecould lead to patient flight and in- of a hospital setting and often hard to distin-
terrupted treatment. guish from patients with neuroses, were
In a way, social attitudes mirrored and referred for outpatient psychoanalysis or
extended these beliefs such that although intensive psychoanalytically oriented psy-
personality pathology was well known, it chotherapy. As Gunderson (2001) described,
was often thought to reflect weakness of the fact that many such patients in psycho-
character or willfully offensive or socially de- analysis regressed and seemed to get worse,
viant behavior produced by faulty upbring- rather than showing improvement in treat-
ing, rather than understood as legitimate ment, was one factor that contributed to the
psychopathology. A good example of this emerging concept of borderline personality
view could be seen in military psychiatry in disorder (BPD), thought initially to be in the
the mid-1900s, where those discharged from border zone between the psychoses and the
active duty for mental illness, with eligibility neuroses. Patients in this general category in-
for disability and medical benefits, did not cluded some who had previously been la-
include individuals with character disor- beled as having latent schizophrenia (Bleuler
ders (or alcoholism and substance abuse) 1924), ambulatory schizophrenia (Zillborg
because these conditions were seen as bad 1941), pseudoneurotic schizophrenia (Hoch
behavior and led to administrative, non- and Polatin 1949), psychotic character
medical separation from the military. (Frosch 1964), or as-if personality (Deutsch
In spite of these common attitudes, clini- 1942).
cians recognized that many patients with sig- These developments coincided with new
nificant impairment in social or occupational approaches based on alternative theoretical
functioning, or with significant emotional models that were emerging within the psy-
distress, needed treatment for psychopathol- choanalytic framework, such as the British
ogy that did not involve frank psychosis or object relations school. New conceptual
frameworks, such as Kernbergs (1975) which persist to the present. Generally, per-
model of borderline personality organization sonality disorders were viewed as more or
or Kohuts (1971) concept of the central im- less permanent patterns of behavior and hu-
portance of empathic failure in the histories man interaction that were established by
of narcissistic patients, served as the basis for early adulthood and were unlikely to change
an intensive psychodynamic treatment ap- throughout the life cycle. Thorny issues such
proach for selected patients with personality as how to differentiate personality disorders
disorders. These strategies and others are re- from personality styles or traits, which re-
viewed in detail in Chapter 10, Psychoanal- main actively debated today, were clearly
ysis and Psychodynamic Psychotherapy. identified at the time. Personality disorders
were contrasted with the symptom neuroses
in a number of ways, particularly that the
THE DSM SYSTEM neuroses were characterized by anxiety and
distress, whereas the personality disorders
Contrary to assumptions commonly encoun- were often ego-syntonic and thus not recog-
tered, personality disorders have been in- nized by those who had them. Some person-
cluded in every edition of DSM. Largely ality disorders are currently referred to as
driven by the need for standardized psychi- externalizing disordersthat is, disorders
atric diagnosis in the context of World War in which the patient disavows any problem
II, the U. S. War Department in 1943 devel- but blames all discomfort on the real or per-
oped a document labeled Technical Bulletin ceived unreasonableness of others.
203, representing a psychoanalytically ori- In DSM-I, personality disorders were
ented system of terminology for classifying generally viewed as deficit conditions reflect-
mental illness precipitated by stress (Barton ing partial developmental arrests or distor-
1987). The APA charged its Committee on tions in development secondary to inade-
Nomenclature and Statistics to solicit expert quate or pathological early caretaking. The
opinion and to develop a diagnostic manual personality disorders were grouped prima-
that would codify and standardize psychiat- rily into personality pattern disturbances,
ric diagnoses. This diagnostic system became personality trait disturbances, and socio-
the framework for the first edition of DSM pathic personality disturbances. Personality
(DSM-I; American Psychiatric Association pattern disturbances were viewed as the most
1952). This manual was widely utilized, and entrenched conditions and likely to be recal-
it was subsequently revised on several occa- citrant to change, even with treatment; these
sions, leading to DSM-II (American Psychiat- included inadequate personality, schizoid
ric Association 1968), DSM-III (American personality, cyclothymic personality, and
Psychiatric Association 1980), DSM-III-R paranoid personality. Personality trait distur-
(American Psychiatric Association 1987), bances were thought to be less pervasive and
DSM-IV (American Psychiatric Association disabling, so that in the absence of stress these
1994), and DSM-IV-TR (American Psychiat- patients could function relatively well. If un-
ric Association 2000). Figure 11 (Skodol der significant stress, however, patients with
1997) portrays the ontogeny of diagnostic emotionally unstable, passive-aggressive, or
terms relevant to the personality disorders compulsive personalities were thought to
from DSM-I through DSM-IV (DSM-IV-TR show emotional distress and deterioration in
involved only text revisions; it used the same functioning, and they were variably moti-
diagnostic terms as DSM-IV). vated for and amenable to treatment. The cat-
Although not explicit in the narrative egory of sociopathic personality disturbances re-
text, DSM-I reflected the general view of per- flected what were generally seen as types of
sonality disorders at the time, elements of social deviance at the time, including antiso-
DSM -I (1952) DSM -II (1968) DSM -III (1980) DSM-IV (1994)/
DSM-IV-TR (2000)
Personality pattern Axis I cyclothymic Axis I cyclothymic
disturbance disorder disorder
Inadequate Inadequate Cluster A Cluster A
Paranoid Paranoid Paranoid Paranoid
Cyclothymic Cyclothymic
Schizoid Schizoid Schizoid Schizoid
Schizotypal Schizotypal
Personality trait
disturbance Cluster B Cluster B
Emotionally unstable Hysterical Histrionic Histrionic
Passive- aggressive Antisocial Antisocial
dependent type Borderline Borderline
aggressive type Passive - aggressive Narcissistic Narcissistic
Cluster C Cluster C
Compulsive Obsessive - compulsive Compulsive Obsessive- compulsive
Avoidant Avoidant
Dependent Dependent
Passive - aggressive
Sociopathic personality
disturbance Asthenic
Antisocial Antisocial
Dyssocial Explosive Axis I intermittent Axis I intermittent
explosive disorder explosive disorder
DSM-IV Appendix
Passive -aggressive
Depressive
DSM - III - R Appendix*
Self- defeating
Sadistic
Indicates that category was discontinued.
Figure 11. Ontogeny of personality disorder classification.

*No changes were made to the personality disorder classification in DSM-III-R except for the inclusion of
self-defeating and sadistic personality disorders in Appendix A: Proposed Diagnostic Categories Need-
ing Further Study. These two categories were not included in DSM-IV or in DSM-IV-TR.
Source. Reprinted with permission from Skodol AE: Classification, Assessment, and Differential Diag-
nosis of Personality Disorders. Journal of Practical Psychiatry and Behavioral Health 3:261274, 1997.
cial reaction, dyssocial reaction, sexual devia- were observable, measurable, enduring, and
tion, and addiction (subcategorized into alco- consistent over time. The earlier view that
holism and drug addiction). patients with personality disorders did not
The primary stimulus leading to the de- experience emotional distress was dis-
velopment of a new, second edition of DSM carded, as were the DSM-I subcategories of
was the publication of the eighth edition of personality pattern, personality trait, and so-
the International Classification of Diseases ciopathic personality disturbances. One new
(World Health Organization 1967) and the personality disorder was added, called as-
wish of the APA to reconcile its diagnostic thenic personality disorder, only to be de-
terminology with this international system. leted in the next edition of the DSM.
In the DSM revision process, an effort was By the mid-1970s, greater emphasis was
made to move away from theory-derived di- placed on increasing the reliability of all di-
agnoses and to attempt to reach consensus agnoses; whenever possible, diagnostic crite-
on the main constellations of personality that ria that were observable and measurable
were developed to define each diagnosis. diagnoses were added in DSM-III: BPD and
DSM-III, the third edition of the diagnostic narcissistic personality disorder. In contrast
manual, introduced a multiaxial system. Dis- to initial notions that patients called border-
orders classified on Axis I included those line were on the border between the psy-
generally seen as episodic, characterized by choses and the neuroses, the criteria defining
exacerbations and remissions, such as psy- BPD in DSM-III emphasized emotional dys-
choses, mood disorders, and anxiety disor- regulation, unstable interpersonal relation-
ders. Axis II was established to include the ships, and loss of impulse control more than
personality disorders as well as mental retar- cognitive distortions and marginal reality
dation; both groups were seen as composed testing, which were more characteristic of
of early-onset, persistent conditions, but schizotypal personality disorder. Among
mental retardation was understood to be bi- many scholars whose work greatly influ-
ological in origin, in contrast to the person- enced and shaped our understanding of bor-
ality disorders, which were generally re- derline pathology were Kernberg (1975) and
garded as psychological in origin. The Gunderson (1984, 2001, 2008). Although con-
stated reason for placing the personality dis- cepts of narcissism had been described by
orders on Axis II was to ensure that consid- Freud, Reich, and others, the essence of the
eration is given to the possible presence of current views of narcissistic personality dis-
disorders that are frequently overlooked order emerged from the work of Millon
when attention is directed to the usually (1969), Kohut (1971), and Kernberg (1975).
more florid Axis I disorders (American Psy- DSM-III-R was published in 1987 after an
chiatric Association 1980, p. 23). It is gener- intensive process to revise DSM-III involving
ally agreed that the decision to place the per- widely solicited input from researchers and
sonality disorders on Axis II led to greater clinicians and following similar principles to
recognition of the personality disorders and those articulated in DSM-III, such as assuring
stimulated extensive research and progress reliable diagnostic categories that were clini-
in our understanding of these conditions. cally useful and consistent with research
As shown in Figure 11, the DSM-II diag- findings, thus minimizing reliance on theory.
noses of inadequate personality disorder and Efforts were made for diagnoses to be descrip-
asthenic personality disorder were discon- tive and to require a minimum of inference,
tinued in DSM-III. The diagnosis of explo- although the introductory text of DSM-III-R
sive personality disorder was changed to in- acknowledged that for some disorders, par-
termittent explosive disorder, cyclothymic ticularly the Personality Disorders, the cri-
personality disorder was renamed cyclothy- teria require much more inference on the part
mic disorder, and both of these diagnoses of the observer (American Psychiatric Asso-
were moved to Axis I. Schizoid personality ciation 1987, p. xxiii). No changes were made
disorder was felt to be too broad a category in in DSM-III-R diagnostic categories of person-
DSM-II, and it was recrafted into three per- ality disorders, although some adjustments
sonality disorders: schizoid personality disor- were made in certain criteria sets, for exam-
der, reflecting loners who are uninterested ple, making them uniformly polythetic in-
in close personal relationships; schizotypal stead of defining some personality disorders
personality disorder, understood to be on the with monothetic criteria sets (e.g., dependent
schizophrenia spectrum of disorders and personality disorder) and others with poly-
characterized by eccentric beliefs and non- thetic criteria sets (e.g., BPD). In addition, two
traditional behavior; and avoidant personality personality disorders were included in DSM-
disorder, typified by self-imposed interper- III-R in Appendix A (Proposed Diagnostic
sonal isolation driven by self-consciousness Categories Needing Further Study)self-
and anxiety. Two new personality disorder defeating personality disorder and sadistic
personality disorderbased on prior clinical DSM-IV. The intent of DSM-IV-TR was to re-
recommendations to the DSM-III-R personal- vise the descriptive, narrative text accom-
ity disorder subcommittee. These diagnoses panying each diagnosis where it seemed in-
were considered provisional, pending further dicated and to update the information
review and research. provided. Only minimal revisions were
DSM-IV was derived after an extensive made in the text material accompanying the
process of literature review, data analysis, personality disorders.
field trials, and feedback from the profession.
Because of the increase in research stimulated
by the criteria-based multiaxial system of CURRENT CONTROVERSIES AND
DSM-III, a substantial body of evidence ex-
isted to guide the DSM-IV process. As a re-
FUTURE DIRECTIONS
sult, the threshold for approval of revisions There is a general consensus, at least in the
for DSM-IV was higher than that used in United States, that the placement of the per-
DSM-III or DSM-III-R. DSM-IV introduced, sonality disorders on Axis II has stimulated
for the first time, a set of general diagnostic research and focused clinical and educa-
criteria for any personality disorder (Table 1 tional attention on these disabling condi-
1), underscoring qualities such as early onset, tions. However, there is growing debate
long duration, inflexibility, and pervasive- about the continued appropriateness of
ness. Diagnostic categories and dimensional maintaining the personality disorders on a
organization of the personality disorders into separate axis in future editions of the diag-
clusters remained the same in DSM-IV as in nostic manual and about whether a dimen-
DSM-III-R, with the exception of the reloca- sional or a categorical system of classification
tion of passive-aggressive personality disor- is preferable. As new knowledge has rapidly
der from the official diagnostic list to Ap- accumulated about the personality disor-
pendix B (Criteria Sets and Axes Provided ders, these controversies take their places
for Further Study). Passive-aggressive per- among many ongoing constructive dia-
sonality disorder, as defined by DSM-III and logues, such as the relationship of normal
DSM-III-R, was thought to be too unidimen- personality to personality disorder, the pros
sional and generic; it was tentatively retitled and cons of polythetic criteria sets, how to
negativistic personality disorder, and the determine the appropriate number of criteria
criteria were revised. In addition, the two (i.e., threshold) required for each diagnosis,
provisional Axis II diagnoses in DSM-III-R, which personality disorder categories have
self-defeating personality disorder and sadis- construct validity, which dimensions best
tic personality disorder, were dropped be- cover the scope of normal and abnormal per-
cause of insufficient research data and clini- sonality, and others. Many of these discus-
cal consensus to support their retention. One sions overlap with and inform each other,
other personality disorder was proposed and and these considerations for the future are
added to Appendix B: depressive personality discussed in detail in Chapter 20 of this vol-
disorder. Although substantially controver- ume, Future Directions: Toward DSM-V.
sial, this provisional diagnosis was proposed
as a pessimistic cognitive style; its validity
and its distinction from passive-aggressive
personality disorder on Axis II or dysthymic
CONCLUSION
disorder on Axis I, however, remain to be es- This brief review of recent notions of person-
tablished. ality pathology serves as a window on the
DSM-IV-TR, published in 2000, did not rapid progress in our field and in our under-
change the diagnostic terms or criteria of standing of psychiatric disorders. Increas-
Table 11. General diagnostic criteria for a personality disorder
A. An enduring pattern of inner experience and behavior that deviates markedly from the
expectations of the individual's culture. This pattern is manifested in two (or more) of the
following areas:
(1) cognition (i.e., ways of perceiving and interpreting self, other people, and events)
(2) affectivity (i.e., the range, intensity, lability, and appropriateness of emotional
response)
(3) interpersonal functioning
(4) impulse control
B. The enduring pattern is inflexible and pervasive across a broad range of personal and
social situations.
C. The enduring pattern leads to clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
D. The pattern is stable and of long duration, and its onset can be traced back at least to
adolescence or early adulthood.
E. The enduring pattern is not better accounted for as a manifestation or consequence of
another mental disorder.
F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a
drug of abuse, a medication) or a general medical condition (e.g., head trauma).
Source. Reprinted with permission from American Psychiatric Association: Diagnostic and Statistical
Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Associa-
tion, 2000.
ingly, a stress/diathesis framework seems somewhat unique to the personality disor-

applicable in medicine in general as a unify- ders is their correlation and continuity with
ing model of illnessa model that can easily normal functioning, which could be an im-
encompass the personality disorders (Paris portant consideration in future revisions of
1999). Variable genetic vulnerabilities pre- our diagnostic system. As we learn more
dispose us all to potential future illness that about the etiologies and pathology of the
may or may not develop depending on the personality disorders, it will no longer be
balance of specific stressors and protective necessary, or even desirable, to limit our di-
factors. agnostic schemes to atheoretical, descriptive
The personality disorders represent mal- phenomena, and we can look forward to an
adaptive exaggerations of nonpathological enriched understanding of these disorders.
personality styles resulting from predispos-
ing temperaments combined with stressful
circumstances. Neurobiology can be altered REFERENCES
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2
Theories of Personality and
Amy Heim, Ph.D.
Drew Westen, Ph.D.
P ersonality refers to enduring patterns of need not be broadly generalized to be con-

cognition, emotion, motivation, and be- sidered aspects of personality (or to lead to
havior that are activated in particular cir- dysfunction), because many aspects of
cumstances (see Mischel and Shoda 1995; personality are triggered by specific situa-
Westen 1995). This minimalist definition tions, thoughts, or feelings. For example, a
(i.e., one that most personality psycholo- tendency to bristle and respond with op-
gists would accept, despite widely differ- position, anger, or passive resistance to
ing theories) underscores two important perceived demands of male authority fig-
aspects of personality. First, personality is ures may or may not occur with female au-
dynamic, characterized by an ongoing in- thorities, peers, lovers, or subordinates.
teraction of mental, behavioral, and envi- Nevertheless, this response tendency rep-
ronmental events. Second, inherent in per- resents an enduring way of thinking, at-
sonality is the potential for variation and tending to information, feeling, and re-
flexibility of responding (activation of spe- sponding that is clearly an aspect of
cific processes under particular circum- personality (and one that can substantially
stances). Enduring ways of responding affect adaptation).
Preparation of this manuscript was supported in part by National Institute of Mental Health grants
MH62377 and MH62378 (Westen).
13
Among the dozens of approaches to per- had understood psychological problems in

sonality advanced over the past century, two terms of conflict and defense using Freuds
are of the most widespread use in clinical topographic model (conscious, precon-
practice: the psychodynamic and the cogni- scious, unconscious) or his structural model
tive-social or cognitive-behavioral. Two (id, ego, superego). In classical psychoana-
other approaches have gained increased in- lytic terms, most symptoms reflect maladap-
terest among personality disorder research- tive compromises, forged outside of aware-
ers: trait psychology, one of the oldest and ness, among conflicting wishes, fears, and
most enduring empirical approaches to the moral standards. For example, a patient with
study of normal personality; and biological anorexia nervosa who is uncomfortable with
approaches, which reflect a long-standing her impulses and who fears losing control
tradition in descriptive psychiatry as well as over them may begin to starve herself as a
more recent developments in behavioral ge- way of demonstrating that she can control
netics and neuroscience. Although most the- even the most persistent of desires, hunger.
ories have traditionally fallen into a single Some of the personality disorders currently
camp, several other approaches are best identified in DSM-IV (American Psychiatric
viewed as integrative. These include Ben- Association 1994) and its update, DSM-IV-
jamins (1996a, 1996b) interpersonal ap- TR (American Psychiatric Association 2000),
proach, which integrates interpersonal, psy- have their roots in early psychoanalytic the-
chodynamic, and social learning theories; orizing about conflictnotably dependent,
Millons (1990) evolutionarysocial learning obsessive-compulsive, and to some extent
approach, which has assimilated broadly histrionic personality disorders (presumed
from multiple traditions (e.g., psychoana- to reflect fixations at the oral, anal, and phal-
lytic object relations theory); and Westens lic stages, respectively).
(1995, 1998) functional-domains model, Although some psychoanalysts have ar-
which draws on psychodynamic, evolution- gued that a conflict model can account for se-
ary, behavioral, cognitive, and developmen- vere personality pathology (e.g., Abend et al.
tal research. In this chapter we briefly con- 1983), most analytic theorists have turned to
sider how each approach conceptualizes ego psychology, object relations theory, self
personality disorders. psychology, and relational theories to help
understand patients with personality disor-
ders. According to these approaches, the
PSYCHODYNAMIC THEORIES problems seen in patients with character dis-
orders run deeper than maladaptive compro-
Psychoanalytic theorists were the first to mises among conflicting motives, and reflect
generate a concept of personality disorder derailments in personality development re-
(also called character disorder, reflecting the garding temperament, early attachment ex-
idea that personality disorders involve char- periences, and their interaction (e.g., Balint
acter problems not isolated to a specific 1969; Kernberg 1975b). Many of the DSM-IV
symptom or set of independent symptoms). personality disorders have roots in these
Personality disorders began to draw consid- later approaches, notably schizoid, border-
erable theoretical attention in psychoanaly- line, and narcissistic personality disorders.
sis by the middle of the twentieth century Psychoanalytic ego psychology focuses
(e.g., Fairbairn 1952; Reich 1933/1978), in on the psychological functions (in contempo-
part because they were common and difficult rary cognitive terms, the skills, procedures,
to treat, and in part because they defied un- and processes involved in self-regulation)
derstanding using the psychoanalytic mod- that must be in place for people to behave
els prevalent at the time. For years, analysts adaptively, attain their goals, and meet exter-
Theories of Personality and Personality Disorders 15
nal demands (see Bellak et al. 1973; Blanck stantial body of research supports many of
and Blanck 1974; Redl and Wineman 1951). these propositions, particularly vis--vis bor-
From this perspective, patients with person- derline personality disorder (BPD), the most
ality disorders may have various deficits in extensively studied personality disorder
functioning, such as poor impulse control, (e.g., Baker et al. 1992; Gunderson 2001; Wes-
difficulty regulating affects, and deficits in ten 1990a, 1991a).
the capacity for self-reflection. These deficits From a psychodynamic point of view,
may render them incapable of behaving con- perhaps the most important features of per-
sistently in their own best interest or of tak- sonality disorders are the following: a) they
ing the interests of others appropriately into represent constellations of psychological
account (e.g., they lash out aggressively processes, not distinct symptoms that can be
without forethought or cut themselves when understood in isolation; b) they can be lo-
they become upset). cated on a continuum of personality pathol-
Object relations, relational, and self psy- ogy from relative health to relative sickness;
chological theories focus on the cognitive, af- c) they can be characterized in terms of char-
fective, and motivational processes pre- acter style, which is orthogonal to level of
sumed to underlie functioning in close disturbance (e.g., a patient can have an ob-
relationships (Aron 1996; Greenberg and sessional style but be relatively sick or rela-
Mitchell 1983; Mitchell 1988; Westen 1991b). tively healthy); d) they involve both implicit
From this point of view, personality disor- and explicit personality processes, only some
ders reflect a number of processes. Internal- of which are available to introspection (and
ization of attitudes of hostile, abusive, criti- thus amenable to self-report); and e) they re-
cal, inconsistent, or neglectful parents may flect processes that are deeply entrenched,
leave patients with personality disorder vul- often serve multiple functions, and/or have
nerable to fears of abandonment, self-hatred, become associated with regulation of affects
a tendency to treat themselves as their par- and are hence resistant to change.
ents treated them, and so forth (Benjamin The most comprehensive theory that em-
1996a, 1996b; Masterson 1976; McWilliams bodies these principles is the theory of per-
1998). Patients with personality disorder of- sonality structure or organization developed
ten fail to develop mature, constant, multi- by Otto Kernberg (1975a, 1984, 1996). In his
faceted representations of the self and others. theory, Kernberg proposed a continuum of
As a result, they may be vulnerable to emo- pathology, from chronically psychotic levels
tional swings when significant others are of functioning, through borderline function-
momentarily disappointing, and they may ing (severe personality disorders), through
have difficulty understanding or imagining neurotic to normal functioning. In Kern-
what might be in the minds of the people bergs view, people with severe personality
with whom they interact (Fonagy and Target pathology are distinguished from people
1997; Fonagy et al. 1991, 2003). Those with whose personality is organized at a psy-
personality disorder often appear to have chotic level by their relatively intact capacity
difficulty forming a realistic, balanced view for reality testing (the absence of hallucina-
of themselves that can weather momentary tions or psychotic delusions) and their rela-
failures or criticisms and may have a corre- tive ability to distinguish between their own
sponding inability to activate procedures thoughts and feelings and those of others
(hypothesized to be based on loving, sooth- (the absence of beliefs that their thoughts are
ing experiences with early caregivers) that being broadcast on the radio; their recogni-
would be useful for self-soothing in the face tion, although sometimes less than complete,
of loss, failure, or threats to safety or self- that the persecutory thoughts in their heads
esteem (e.g., Adler and Buie 1979). A sub- are voices from the past rather than true hal-
lucinations, etc.). What distinguishes indi- According to Kernberg, whereas borderline

viduals with severe personality pathology patients lack an integrated identity, narcissis-
from people with neurotic (that is, health- tic patients are typically developmentally
ier) character structures includes 1) their more advanced, in that they have been able
more maladaptive modes of regulating their to develop a coherent (if distorted) view of
emotions through immature, reality-distort- themselves. Narcissistic phenomena, in
ing defenses such as denial and projection Kernbergs view, lie on a continuum from
(e.g., refusing to recognize the part they play normal (characterized by adequate self-
in generating some of the hostility they en- esteem regulation) to pathological (narcissis-
gender from others); and 2) their difficulty in tic personality disorder) (Kernberg 1984,
forming mature, multifaceted representa- 1998). Individuals with narcissistic personal-
tions of themselves and significant others ity disorder need to construct a grossly in-
(e.g., believing that a person they once loved flated view of themselves to maintain self-
is really all bad, with no redeeming features, esteem and may appear grandiose, sensitive
and is motivated only by the desire to hurt to the slightest attacks on their self-esteem
them). Kernberg refers to these two aspects (and hence vulnerable to rage or depression),
of borderline personality organization as or both. Not only are the conscious self-rep-
primitive defenses and identity diffu- resentations of narcissistic patients inflated
sion. This level of severe personality distur- but so too are the representations that consti-
bance shares some features with the DSM- tute their ideal selves. Actual and ideal self-
IVs BPD diagnosis. However, borderline representations stand in dynamic relation to
personality organization is a broader con- one another. Thus, one reason narcissistic pa-
struct, encompassing patients with para- tients must maintain an idealized view of self
noid, schizoid, schizotypal, and antisocial is that they have a correspondingly grandi-
personality disorders as well as some pa- ose view of who they should be, a divergence
tients who would receive a DSM-IV diagno- that leads to tremendous feelings of shame,
sis of narcissistic, histrionic, or dependent failure, and humiliation.
personality disorder. (Some schizotypal and The concept of a grandiose self is central to
borderline patients may at times fall south the self psychology of Heinz Kohut, a major
of the border into the psychotic range.) theorist of narcissistic personality pathology
Some research supports the notion that pa- whose ideas, like those of Kernberg, contrib-
tients fall on a continuum of severity of per- uted to the DSM-III diagnosis of narcissistic
sonality pathology (see Millon and Davis personality disorder (Goldstein 1985). Ko-
1995; Tyrer and Johnson 1996), with disor- huts theory grew out of his own and others
ders such as paranoid and borderline per- clinical experiences with patients whose prob-
sonality disorder representing more severe lems (such as feelings of emptiness or unstable
forms, and disorders such as obsessive- self-esteem) did not respond well to existing
compulsive personality disorder less severe (psychoanalytic) models. Narcissistic pathol-
(Westen and Shedler 1999a). ogy, according to Kohut, results from faulty
Although many of Kernbergs major con- self-development. Kohuts concept of the self
tributions have been in the understanding of refers to the nucleus of a persons central am-
borderline phenomena, his theory of narcis- bitions and ideals and the talents and skills
sistic disturbance contributed substantially used to actualize them (Kohut 1971, 1977;
to the development of the diagnosis of nar- Wolf 1988). It develops through two pathways
cissistic personality disorder in DSM-III (poles) that provide the basis for self-es-
(American Psychiatric Association 1980), just teem. The first is the grandiose selfan ideal-
as his understanding of borderline phenom- ized representation of self that emerges in chil-
ena contributed to the borderline diagnosis. dren through empathic mirroring by their
parents (Mommy, watch!) and provides the stant interplay between environmental de-
nucleus for later ambitions and strivings. The mands and the way the individual processes
second is the idealized parent imagoan ideal- information about the self and the world
ized representation of the parents that pro- (Bandura 1986).
vides the foundation for ideals and standards Cognitive-social theorists have only re-
for the self. Parental mirroring allows the child cently begun to write about personality dis-
to see his or her reflection in the eyes of a lov- orders (e.g., Beck et al. 2003; Linehan 1993a;
ing and admiring parent; idealizing a parent Pretzer and Beck 1996; Young 1990). In large
or parents allows the child to identify with part this late entrance into the study of per-
and become like them. In the absence of ade- sonality disorders reflects the assumption,
quate experiences with parents who can mir- initially inherited from behaviorism, that
ror the child or serve as appropriate targets of personality is composed of relatively dis-
idealization (for example, when the parents crete, learned processes that are more mallea-
are self-involved or abusive), the childs self- ble and situation specific than implied by the
structure cannot develop, preventing the concept of personality disorder. Cognitive-
achievement of cohesion, vigor, and normal social theories focus on a number of variables
self-esteem (described by Kohut as healthy presumed to be most important in under-
narcissism). As a result, the child develops a standing personality disorders, including
disorder of the self, of which pathological nar- schemas, expectancies, goals, skills and com-
cissism is a prototypic example. petencies, and self-regulation (Bandura 1986,
1999; Cantor and Kihlstrom 1987; Mischel
1973, 1979; Mischel and Shoda 1995). Al-
COGNITIVE-SOCIAL THEORIES though particular theorists have tended to
emphasize one or two of these variables in
Cognitive-social theories (Bandura 1986; explaining personality disorders, such as the
Mischel 1973, 1979) offered the first compre- schemas involved in encoding and process-
hensive alternative to psychodynamic ap- ing information about the self and others
proaches to personality. First developed in (Beck et al. 2003) or the deficits in affect reg-
the 1960s, these approaches are sometimes ulation seen in borderline patients (Linehan
called social learning theories, cognitive- 1993a), a comprehensive cognitive-social ac-
social learning theory, social cognitive theo- count of personality disorders would likely
ries, and cognitive-behavioral theories. Cog- address all of them.
nitive-social theories developed from behav- For example, patients with personality
iorist and cognitive roots. From a behaviorist disorders have dysfunctional schemas that
perspective, personality consists of learned lead them to misinterpret information (as
behaviors and emotional reactions that tend when patients with BPD misread and misat-
to be relatively specific (rather than highly tribute peoples intentions); attend to and en-
generalized) and tied to particular environ- code information in biased ways (as when pa-
mental contingencies. Cognitive-social theo- tients with paranoid personality disorder
ries share the behaviorist belief that learning maintain vigilance for perceived slights or at-
is the basis of personality and that person- tacks); or view themselves as bad or incompe-
ality dispositions tend to be relatively spe- tent (pathological self-schemas). Related to
cific and shaped by their consequences. They these schemas are problematic expectancies,
share the cognitive view that the way people such as pessimistic expectations about the
encode, transform, and retrieve information, world, beliefs about the malevolence of oth-
particularly about themselves and others, is ers, and fears of being mocked. Patients with
central to personality. From a cognitive- personality disorders may have pathological
social perspective, personality reflects a con- self-efficacy expectancies, such as the depen-
dent patients belief that she or he cannot sur- p. 55). Becks theory highlights three aspects
vive on his or own, the avoidant patients of cognition: 1) automatic thoughts (beliefs
belief that he or she is likely to fail in social and assumptions about the world, the self,
circumstances, or the narcissistic patients and others); 2) interpersonal strategies; and
grandiose expectations about what she or he 3) cognitive distortions (systematic errors in
can accomplish. Equally important are com- rational thinking). Beck and colleagues have
petenciesthat is, skills and abilities used for described a unique cognitive profile charac-
solving problems. In social-cognitive terms, teristic of each of the DSM-IV personality
social intelligence includes a variety of com- disorders. For example, an individual diag-
petencies that help people navigate interper- nosed with schizoid personality disorder
sonal waters (Cantor and Harlow 1994; Can- would have a view of himself as a self-suffi-
tor and Kihlstrom 1987), and patients with cient loner, a view of others as unrewarding
personality disorders tend to be notoriously and intrusive, and a view of relationships as
poor interpersonal problem solvers. messy and undesirable, and his primary in-
Of particular relevance to severe person- terpersonal strategy would involve keeping
ality disorders is self-regulation, which refers his distance from other people (Pretzer and
to the process of setting goals and subgoals, Beck 1996). He would use cognitive distor-
evaluating ones performance in meeting tions that minimize his recognition of how
these goals, and adjusting ones behavior to relationships with others can be sources of
achieve these goals in the context of ongoing pleasure. A study of dysfunctional beliefs (as
feedback (Bandura 1986; Mischel 1990). assessed by the Personal Beliefs Question-
Problems in self-regulation, including a defi- naire [A.T. Beck, J.S. Beck, unpublished as-
cit in specific skills, form a central aspect of sessment instrument, The Beck Institute for
Linehans (1993a, 1993b) work on BPD. Line- Cognitive Therapy and Research, Bala Cyn-
han regards emotion dysregulation as the wyd, Pennsylvania, 1991]) provides some
essential feature of BPD. The key character- initial support for the link between particular
istics of emotion dysregulation include dif- beliefs and the DSM-IV personality disorders
ficulty 1) inhibiting inappropriate behavior (Beck et al. 2001).
related to intense affect, 2) organizing oneself Building on Becks cognitive theory,
to meet behavioral goals, 3) regulating phys- Young and colleagues (Young and Gluhoski
iological arousal associated with intense 1996; Young and Lindemann 2002; Young et
emotional arousal, and 4) refocusing atten- al. 2003) have added a fourth level of cog-
tion when emotionally stimulated (Linehan nition: early maladaptive schemas, which
1993b). Many of the behavioral manifesta- they have defined as broad and pervasive
tions of BPD (e.g., cutting) can be viewed as themes regarding oneself and ones relation-
consequences of emotional dysregulation. ships with others, developed during child-
Deficits in emotion regulation lead to other hood and elaborated throughout ones life
problems, such as difficulties with interper- (Young and Lindemann 2002, p. 95). The au-
sonal functioning and with the development thors distinguish these schemas from auto-
of a stable sense of self. matic thoughts and underlying assumptions,
According to another cognitive-behav- noting that the schemas are associated with
ioral approach, Becks cognitive theory (Beck greater levels of affect, are more pervasive,
1999; Beck et al. 2003; Pretzer and Beck 1996), and involve a strong interpersonal aspect.
dysfunctional beliefs constitute the primary Young and colleagues have identified 16
pathology involved in the personality disor- early maladaptive schemas, each of which
ders (Beck et al. 2001), which are viewed as comprises cognitive, affective, and behav-
pervasive, self-perpetuating cognitive- ioral components. They have also identified
interpersonal cycles (Pretzer and Beck 1996, three cognitive processes involving schemas
that define key features of personality disor- ductive empirical research programs. Traits
ders: schema maintenance, which refers to the are emotional, cognitive, and behavioral ten-
processes by which maladaptive schemas are dencies on which individuals vary (e.g., the
rigidly upheld (e.g., cognitive distortions, tendency to experience negative emotions).
self-defeating behaviors); schema avoidance, According to Gordon Allport (1937), who pi-
which refers to the cognitive, affective, and oneered the trait approach to personality, the
behavioral ways individuals avoid the nega- concept of trait has two separate but comple-
tive affect associated with the schema; and mentary meanings: it is both an observed ten-
schema compensation, which refers to ways of dency to behave in a particular way and an
overcompensating for the schema (e.g., be- inferred underlying personality disposition
coming a workaholic in response to a schema that generates this behavioral tendency. In
of self as failure). the empirical literature, traits have largely
Mischel and Shoda (1995) have offered a been defined operationally, as the average of
compelling social-cognitive account of per- a set of self-report items designed to assess a
sonality that focuses on ifthen contingen- given trait (e.g., items indicating a tendency
ciesthat is, conditions that activate parti- to feel anxious, sad, ashamed, guilty, self-
cular thoughts, feelings, and behaviors. doubting, and angry that all share a common
Although they have not linked this model to core of negative affectivity or neuroticism).
personality disorders, one could view per- Researchers have begun recasting person-
sonality disorders as involving a host of ality disorders in terms of the most promi-
rigid, maladaptive ifthen contingencies. For nent contemporary trait theory, the Five-
example, for some patients, the first hints of Factor Model (FFM) of personality (McCrae
trouble in a relationship may activate con- and Costa 1997; Widiger 2000; Widiger and
cerns about abandonment. These in turn may Costa 1994). (We address other trait models
elicit anxiety or rage, to which the patient re- that have been more closely associated with
sponds with desperate attempts to lure the biological theories later.) The FFM is a de-
person back that often backfire (such as ma- scription of the way personality descriptors
nipulative statements and suicidal gestures). tend to covary and hence can be understood
From an integrative psychodynamic-cogni- in terms of latent factors (traits) identified via
tive viewpoint, Horowitz (1988, 1998) of- factor analysis. Based on the lexical hypothe-
fered a model that similarly focused on the sis of personalitythat important personal-
conditions under which certain states of ity attributes will naturally find expression in
mind become active, which he has tied more words used in everyday languagethe FFM
directly to a model of personality disorders; emerged from factor analysis of adjectival de-
and Wachtel (1977, 1997) has similarly descriptions of personality originally selected
scribed cyclical psychodynamics, in which from Websters Unabridged Dictionary (Allport
people manage to elicit from others precisely and Odbert 1936). Numerous studies, includ-
the kind of reactions of which they are the ing cross-cultural investigations, have found
most vigilant and afraid. that when participants in nonclinical (nor-
mal) samples are asked to rate themselves on
dozens or hundreds of adjectives or brief sen-
TRAIT THEORIES tences, the pattern of self-descriptions can of-
ten be reduced to five overarching constructs
Trait psychology focuses less on personality (Costa and McCrae 1997; Goldberg 1993):
processes or functions than do psychody- 1) neuroticism or negative affect (how much
namic or cognitive-social approaches, and they tend to be distressed); 2) extraversion or
hence has not generated an approach to treat- positive affect (the extent to which they tend
ment, although it has generated highly pro- to be gregarious, high-energy, and happy);
3) conscientiousness; 4) agreeableness; and ever, are that it integrates the understanding

5) openness to experience (the extent to and assessment of normal and pathological
which they are open to emotional, aesthetic, personality and that it establishes dimen-
and intellectual experiences). sions of personality pathology using well-
McCrae and Costa (1990, 1997) proposed understood empirical procedures (factor
a set of lower-order traits, or facets, within analysis).
each of these broadband traits that can allow Another way to proceed using the FFM is
a more discriminating portrait of personality. to translate clinically derived categories into
Thus, an individuals personality profile is five-factor language (Coker et al. 2002;
represented by a score on each of the five fac- Lynam and Widiger 2001; Widiger and Costa
tors plus scores on six lower-order facets or 1994). For example, Widiger et al. (2002) de-
subfactors within each of these broader con- scribed antisocial personality disorder
structs (e.g., anxiety and depression as facets (ASPD) as combining low agreeableness
of neuroticism). Advocates of the FFM argue with low conscientiousness. Because analy-
that personality disorders reflect extreme sis at the level of five factors often lacks the
versions of normal personality traits, so that specificity to characterize complex disorders
the same system can be used for diagnosing such as BPD (high neuroticism plus high ex-
normal and pathological personality. From traversion), proponents of the FFM have of-
the perspective of the FFM, personality dis- ten moved to the facet level. Thus, whereas
orders are not discrete entities separate and all six neuroticism facets (anxiety, hostility,
distinct from normal personality. Rather, depression, self-consciousness, impulsivity,
they represent extreme variants of normal and vulnerability) are characteristic of pa-
personality traits or blends thereof. tients with BPD, patients with avoidant per-
In principle, one could classify personal- sonality disorder are characterized by only
ity disorders in one of two ways using the four of these facets (anxiety, depression, self-
FFM. The first, and that more consistent with consciousness, and vulnerability).
the theoretical and psychometric tradition Similarly, Widiger et al. (1994, 2002) de-
within which the FFM developed, is simply scribed obsessive-compulsive personality
to identify personality pathology by extreme disorder as primarily an extreme, maladap-
values on each of the five factors (and per- tive variant of conscientiousness. They add,
haps on their facets). For example, extremely however, that obsessive-compulsive patients
high scores on the neuroticism factor and its tend to be low on the compliance and altru-
facets (anxiety, hostility, depression, self- ism facets of agreeableness (i.e., they are op-
consciousness, impulsivity, and vulnerabil- positional and stingy) and low on some of
ity) all represent aspects of personality pa- the facets of openness to experience as re-
thology. Whether this strategy is appropriate flected in being closed to feelings and closed
for all factors and facets, and when to con- to values (i.e., morally inflexible). Numerous
sider extreme responses on one or both poles studies have shown predicted links between
of a dimension pathological, are matters of DSM-IV Axis II disorders and FFM factors
debate. Extreme extraversion, for example, and facets (Axelrod et al. 1997; Ross et al.
may or may not be pathological, depending 2002; Trull et al. 2001), although other studies
on the social milieu and the persons other have found substantial overlap among the
traits. Similarly, extreme openness to experi- FFM profiles of patients with very different
ence could imply a genuinely open attitude disorders (e.g., borderline and obsessive-
toward emotions, art, and so forth or an un- compulsive) using major FFM self-report in-
critical, flaky, or schizotypal cognitive ventories (Morey et al. 2002).
style. The advantages of this approach, how-
pulsivity/aggression (impulse control disor-

BIOLOGICAL PERSPECTIVES ders); affective instability (mood disorders);
and anxiety/inhibition (anxiety disorders).
The first biological perspectives on personal- Conceptualized in dimensional terms, Axis I
ity disorders, which influenced the current disorders such as schizophrenia represent
Axis II classification, stemmed from the ob- the extreme end of a continuum. Milder ab-
servations of the pioneering psychiatric tax- normalities can be seen in patients with per-
onomists in the early twentieth century, sonality disorder, either directly (as sub-
notably Bleuler (1911/1950) and Kraepelin threshold variants) or through their influence
(1896/1919). These authors and others on adaptive strategies (coping and defense).
noticed, for example, that the relatives of Siever and Davis linked each dimension
schizophrenic patients sometimes appeared to biological correlates and indicators, some
to have attenuated symptoms of the disorder presumed to be causal and others to provide
that endured as personality traits, such as in- markers of underlying biological dysfunction
terpersonal and cognitive peculiarity. More (e.g., eye movement dysfunction in schizo-
recently, researchers have used the methods phrenia, which is also seen in individuals
of trait psychology (particularly the reliance with schizotypal personality disorder and in
on self-report questionnaires and factor anal- nonpsychotic relatives of schizophrenic
ysis) to study personality disorders from a probands). They also pointed to suggestive
biological viewpoint. In some cases, they data on neurotransmitter functioning that
have developed item sets with biological might link Axis II disorders with Axis I syn-
variables in mind (e.g., neurotransmitters dromes such as depression. More recently,
and their functions) or have reconsidered Siever and colleagues (New and Siever 2002;
patterns of covariation among different traits Siever et al. 2002) proposed an approach to
in light of hypothesized neurobiological sys- BPD that tries to circumvent the problems
tems or circuits. In other cases, they have ap- created by the heterogeneity of the diagnosis
plied behavior-genetic approaches to study by examining the neurobiology of specific di-
personality traits (as well as DSM-IV disor- mensions thought to underlie the disorder
ders). We explore each of these approaches (endophenotypes), especially impulsive ag-
in turn. (Researchers are just beginning to gression and affective instability.
use neuroimaging to study personality dis- The major attempt thus far to develop a
orders, particularly BPD [e.g., Herpertz et al. trait model of personality disorders based on
2001], but the results at this point are prelim- a neurobiological model is Cloninger s
inary, and hence we do not address them fur- seven-factor model of personality (Cloninger
ther here.) 1998; Cloninger et al. 1993). In his model,
Cloninger divided personality structure into
Traits and Neural Systems two domains: temperament (automatic asso-
ciative responses to basic emotional stimuli
Siever and Davis (1991) provided one of the that determine habits and skills) and charac-
first attempts to reconsider the personality ter (self-aware concepts that influence vol-
disorders from a neurobiology perspective. untary intentions and attitudes) (Cloninger
They proposed a model based on core char- 1998, p. 64). According to Cloninger, each of
acteristics of Axis I disorders relevant to per- these domains is defined by a mode of learn-
sonality disorders and related these charac- ing and the underlying neural systems in-
teristics to emerging knowledge of their volved in that learning: temperament is asso-
underlying neurobiology. They focused on ciated with associative/procedural learning,
cognitive/perceptual organization (schizo- and character is associated with insight learn-
phrenia and other psychotic disorders); im- ing. The temperament domain includes four
dimensions, each theoretically linked to par- emergent phenotypes arising from the inter-
ticular neurotransmitter systems: 1) novelty action of basic neurobehavioral systems that
seeking (exploration, extravagance, impul- underlie major personality traits (Depue and
sivity), associated with dopamine; 2) harm Lenzenweger 2001, p. 165). Through an ex-
avoidance (characterized by pessimism, fear, tensive examination of the psychometric lit-
timidity), associated with serotonin and - erature on the structure of personality traits
aminobutyric acid (GABA); 3) reward depen- as well as a theoretical analysis of the neu-
dence (sentimentality, social attachment, robehavioral systems likely to be relevant to
openness), associated with norepinephrine personality and personality dysfunction,
and serotonin; and 4) persistence (industri- they identified five trait dimensions that may
ousness, determination, ambitiousness, per- account for the range of personality disorder
fectionism), associated with glutamate and phenotypes. They labeled these five traits
serotonin (Cloninger 1998, p. 70). The charac- 1) agentic extraversion (reflecting both the
ter domain includes three dimensions: 1) self- activity and gregariousness components of
directedness (responsibility, purposefulness, extraversion); 2) neuroticism; 3) affiliation;
self-acceptance), considered the major de- 4) nonaffective constraint (the opposite pole
terminant of the presence or absence of per- of which is impulsivity); and 5) fear. For ex-
sonality disorder (Cloninger et al. 1993, ample, the neurobehavioral system underly-
p. 979); 2) cooperativeness (empathy, coming the trait of agentic extraversion is posi-
passion, helpfulness); and 3) self-transcen- tive incentive motivation, which is common
dence (spirituality, idealism, enlightenment). to all mammalian species and involves posi-
Cloninger (1998) proposed that all per- tive affect and approach motivation. The
sonality disorders are low on the character dopaminergic system has been strongly im-
dimensions of self-directedness and cooper- plicated in incentive-motivated behavior,
ativeness. What distinguishes patients with such that individual differences in the former
different disorders are their more specific predict differences in the latter. Research on
profiles. In broad strokes, the Cluster A per- this model is just beginning, but the model is
sonality disorders (schizotypal, schizoid, promising in its integration of research on
paranoid) are associated with low reward neural systems involved in fundamental
dependence; the Cluster B personality disor- functions common to many animal species
ders (borderline, antisocial, narcissistic, his- (such as approach, avoidance, affiliation
trionic) are associated with high novelty with conspecifics, and inhibition of punished
seeking; and the Cluster C personality disor- behavior) with individual differences re-
ders (dependent, avoidant, obsessive-com- search in personality psychology.
pulsive) are associated with high harm
avoidance. Individual personality disorders Behavior-Genetic Approaches
may be described more fully by profiles ob-
tained from Cloningers self-report Temper- The vast majority of behavior-genetic studies
ament and Character Inventory (Cloninger of personality have focused on normal per-
and Svrakic 1994). For example, BPD would sonality traits, such as those that compose
consist of high harm avoidance, high novelty the FFM and Eysencks (1967, 1981) three-
seeking, and low reward dependence as well factor model (extraversion, neuroticism, and
as low scores on the character dimensions. psychoticism). These studies have generally
More recently, a dimensional neurobe- shown moderate to high heritability (30%
havioral model was offered by Depue, Len- 60%) for a range of personality traits (Lives-
zenweger, and colleagues (e.g., Depue and ley et al. 1993; Plomin and Caspi 1999) rele-
Collins 1999; Depue and Lenzenweger 2001). vant to personality disorders. The most fre-
Their model regards personality disorders as quently studied traits, extraversion and
neuroticism, have produced heritability esti- the higher- and lower-order factors they
mates of 54%74% and 42%64%, respec- identified.
tively (Eysenck 1990). Compared with research on normal per-
Behavior-genetic data are proving in- sonality traits (as well as many Axis I disor-
creasingly useful in both etiological and tax- ders), behavior-genetic studies of personality
onomic work (e.g., Krueger 1999; Livesley et disorders are relatively rare. The most com-
al. 1998). Livesley et al. (2003) noted that be- mon designs have been family studies in
havior-genetic data can help address the per- which researchers begin with the personality
sistent lack of consensus among trait psy- disorder proband and then assess other fam-
chologists regarding which traits to study by ily members. The major limitation of this
helping them study the causes of trait cova- method is that familial aggregation of disor-
riation (as opposed to simply describing it). ders can support either genetic or environ-
Establishing congruence between a pro- mental causes. As in all behavior-genetic re-
posed phenotypic model of personality traits search, twin and adoption studies provide
and the genetic structure underlying it more definitive data. Most of these studies
would support the validity of a proposed have examined only a subset of the DSM per-
factor model. The same holds true for models sonality disorders, particularly schizotypal,
of personality disorders. antisocial, and borderline personality disor-
To test this approach, Livesley et al. ders. These disorders appear to reflect a con-
(1998) administered the Dimensional Assess- tinuum of heritability, with schizotypal most
ment of Personality PathologyBasic Ques- strongly linked to genetic influences, antiso-
tionnaire to a large sample of individuals cial linked both to environmental and genetic
with and without personality disorders, in- variables, and borderline showing the small-
cluding twin pairs. This self-report measure est estimates of heritability in the majority of
consists of 18 traits considered to underlie studies (see Nigg and Goldsmith 1994).
personality disorder diagnoses (e.g., identity Research on the heritability of schizo-
problems, oppositionality, social avoidance). typal personality disorder provides the clear-
Factor analysis indicated a four-factor solu- est evidence of a genetic component to a per-
tion: emotional dysregulation, dissocial be- sonality disorder. (Schizotypal personality
havior, inhibition, and compulsivity. Results disorder is defined by criteria such as odd be-
also showed high congruence for all four fac- liefs or magical thinking, unusual perceptual
tors between the phenotypic and behavior- experiences, odd thinking and speech, suspi-
genetic analyses, indicating strong support ciousness, inappropriate or constricted af-
for the proposed factor solution. In addition, fect, and behavior or appearance that is odd
the data showed substantial residual herita- or eccentric.) As mentioned earlier, Bleuler
bility for many lower-order traits, suggesting and Kraepelin noted peculiarities in lan-
that these traits likely are not simply compo- guage and behavior among some relatives of
nents of the higher-order factors but include their schizophrenic patients. Bleuler called
unique components (specific factors) as well. this presentation latent schizophrenia and
Krueger and colleagues (e.g., Krueger 1999) considered it to be a less severe and more
have similarly found, using structural equa- widespread form of schizophrenia. Further
tion modeling with a large twin sample, that research into the constellation of symptoms
broadband internalizing and externalizing characteristic of relatives of schizophrenic
personality factors account for much of the patients ultimately resulted in the creation of
variance in many common Axis I disorders the DSM diagnosis of schizotypal personal-
(e.g., mood, anxiety, and substance use) and ity disorder (Spitzer et al. 1979). A genetic re-
that genetic and environmental sources of lationship between schizoph renia an d
variance are associated with many of both schizotypal personality disorder is now well
established (Kendler and Walsh 1995; Len- nent to several personality disorders, with
zenweger 1998). In one study, Torgersen most heritability estimates between 0.50 and
(1984) found that 33% (7 of 21) of identical co- 0.60, including BPD. Increasingly, research-
twins had schizotypal personality disorder, ers are suggesting that specific components
whereas only 4% (1 of 23) of fraternal co- of BPD may have higher heritability than the
twins shared the diagnosis. Data from a later BPD diagnosis taken as a whole. For exam-
twin study (Torgersen et al. 2000), which ple, several authors (Nigg and Goldsmith
used structural equation modeling, esti- 1994; Widiger and Frances 1994) suggest that
mated heritability at 0.61. neuroticism, which is highly heritable, is at
ASPD, in contrast, appears to have both the core of many borderline features (e.g.,
genetic and environmental roots, as docu- negative affect and stress sensitivity). Other
mented in adoption studies (Cadoret et al. components of BPD have shown substantial
1995). An adult adoptee whose biological heritability as well (e.g., problems with iden-
parent has an arrest record for antisocial be- tity, impulsivity, affective lability) (Livesley
havior is four times more likely to have prob- et al. 1993; Skodol et al. 2002).
lems with aggressive behavior than a person A caveat worth mentioning, however, is
without a biological vulnerability. At the that behavior-genetic studies that systemati-
same time, a person whose adoptive parent cally measure environmental influences di-
has ASPD is more than three times more rectly (e.g., measuring developmental toxins
likely to develop the disorder, regardless of such as sexual abuse), rather than deriving
biological history. As is the case with other estimates of shared and nonshared environ-
behavior-genetic findings, twin studies sug- ment statistically from residual terms, often
gest that environmental and genetic factors obtain very different estimates of environ-
grow more predictive as individuals get mental effects, and this may well be the case
older (Lyons et al. 1995). In considering the with many personality disorders. For exam-
data on ASPD and other personality disor- ple, if one child in a family responds to sex-
ders, however, it is important to remember ual abuse by becoming avoidant and con-
that all estimates of heritability are sample stricted and another responds to the same
dependent. Turkheimer et al. (2003) found, experience by becoming borderline and
for example, that genes account for most of impulsive, researchers will mistakenly con-
the variability in IQ among middle-class chil- cludeunless they actually measured de-
dren but that over 60% of the variance in IQ velopmental variablesthat shared envir-
in samples from low socioeconomic back- onment has no effect, because a shared
grounds reflects shared environment. Socio- environmental event led to nonshared re-
economic status may similarly moderate the sponses (see Turkheimer and Waldron 2000;
relation between genes and environment and Westen 1998). Recent work by Caspi et al.
antisocial behavior. (2002) showing genes and environmental
Data on the behavioral genetics of BPD events (e.g., sexual abuse) interacting in pre-
are mixed. Several studies have found only dicting subsequent personality and psycho-
modest evidence of heritability (e.g., Dahl pathology emphasize the same point.
1993; Nigg and Goldsmith 1994; Reich 1989).
A rare twin study conducted by Torgersen
(1984) failed to find evidence for the genetic INTEGRATIVE THEORIES
transmission of the disorder, although the
sample was relatively small. A more recent Of all the disorders identified in DSM-IV-TR,
twin study by Torgersen et al. (2000) focused the personality disorders are likely to be
on the heritability of several personality dis- among those that most require biopsychoso-
orders, finding a substantial genetic compo- cial perspectives. They are also disorders for
which we may gain substantially by integrat- which refer to the extent to which the person
ing data from both clinical observation and focuses on individuation or nurturance of
research, from classical theories of personal- others and which are reflected in the self/
ity that delineate personality functions, and other polarity; and 4) processes of abstrac-
from more contemporary research that em- tion, which refer to the ability for symbolic
phasizes traits. The emergence of several in- thought and which are represented by the
tegrative models is thus perhaps not surpris- thinking/feeling polarity.
ing. We briefly describe three such models in Millon identified 14 personality proto-
the following discussion: Millons evolution- types that can be understood in terms of the
arysocial learning model, Benjamins inter- basic polarities. For example, patients with
personal model, and Westens functional- schizoid personality disorder tend to have
domains model. little pleasure, to have little involvement
with others, to be relatively passive in their
Millons EvolutionarySocial stance to the world, and to rely on abstract
thinking over intuition. In contrast, patients
Learning Model
with histrionic personality disorder are plea-
Millon developed a comprehensive model of sure seeking, interpersonally focused (al-
personality and personality disorders that he though in a self-centered way), highly active,
initially framed in social learning terms (Mil- and short on abstract thinking. Millons the-
lon 1969), describing personality in terms of ory led to the distinction between avoidant
three polarities: pleasure/pain, self/other, and schizoid personality disorder in DSM-
and passive/active. These polarities reflect III. Whereas schizoid personality disorder
the nature of reinforcement that controls the represents a passive-detached personality
persons behavior (rewarding or aversive), style, avoidant personality disorder repre-
the source or sources that provide reinforce- sents an active-detached style characterized
ment (oneself or others), and the instrumen- by active avoidance motivated by avoidance
tal behaviors and coping strategies used to of anxiety. Millon also developed both a com-
pursue reinforcement (active or passive). prehensive measure to assess the DSM per-
Millon (Davis and Millon 1999; Millon 1990; sonality disorders and his own theory-
Millon and Davis 1996; Millon and Gross- driven personality disorder classification,
man 2005) eventually reconceptualized his the Millon Clinical Multiaxial Inventory
original theory in evolutionary terms. In do- (Millon and Davis 1997). The instrument,
ing so, he added a fourth polarity, thinking/ now in its third edition, has been used in
feeling, which reflects the extent to which hundreds of studies and is widely used as an
people rely on abstract thinking or intuition. assessment tool in clinical practice (e.g., Es-
Millons reconceptualized theory out- pelage et al. 2002; Kristensen and Torgersen
lined four basic evolutionary principles con- 2001).
sistent with the polarities described by his
earlier theory: 1) aims of existence, which re- Benjamins Interpersonal Model
fer to life enhancement and life preservation,
and which are reflected in the pleasure/pain Benjamins (1993, 1996a, 1996b) interpersonal
polarity; 2) modes of adaptation, which he theory, called Structural Analysis of Social
described in terms of accommodation to, ver- Behavior (SASB), focuses on interpersonal
su s m od if ica t ion o f , th e e n v iron me n t processes in personality and psychopathol-
(whether one adjusts or tries to adjust the ogy and their intrapsychic causes, correlates,
world, particularly other people) and which and sequelae. Influenced by Sullivans (1953)
are reflected in the passive/active polarity; interpersonal theory of psychiatry, by object
3) strategies of replication or reproduction, relations approaches, and by research using
the interpersonal circumplex (e.g., Kiesler neglect or abandonment. Anger in narcissis-

1983; Leary 1957; Schaefer 1965), the SASB is a tic personality disorder tends to follow from
three-dimensional circumplex model with perceived slights or failures of other people to
three surfaces, each of which represents a give the patient everything he or she wants
specific focus. The first surface focuses on ac- (entitlement). Anger in patients with ASPD is
tions directed at a person (e.g., abuse by a often cold, detached, and aimed at control-
parent toward the patient). The second sur- ling the other person. Second, the SASB
face focuses on the persons response to real model is able to represent multiple, often con-
or perceived actions by the other (e.g., recoil- flicting aspects of the way patients with a
ing from the abusive parent). The third sur- given disorder behave (or complex, multifac-
face focuses on the persons actions toward eted aspects of a single interpersonal interac-
him- or herself, or what Benjamin calls the tion) simultaneously. Thus, a single angry
introject (e.g., self-abuse). The notion be- outburst by a borderline patient could reflect
hind the surfaces is that the first two are inter- an effort to get distance from the other, to hurt
personal and describe the kinds of interaction the other, and to get the other to respond and
patterns (self with other) in which the patient hence be drawn back into the relationship.
engages with significant others (e.g., parents, Benjamin has devised several ways of opera-
attachment figures, therapists). The third sur- tionalizing a persons dynamics or an inter-
face represents internalized attitudes and ac- personal interaction (e.g., in a therapy hour),
tions toward the self (e.g., self-criticism that ranging from direct observation and coding
began as criticism from parents). According of behavior to self-report questionnaires, all
to Benjamin, children learn to respond to of which yield descriptions using the same
themselves and others by identifying with circumplex model.
significant others (acting like them), recapitu-
lating what they experienced with significant Westens Functional-Domains
others (e.g., eliciting from others what they
Model
experienced before), and introjecting others
(treating themselves as others have treated Westen (1995, 1996, 1998) described a model
them). of domains of personality functioning that
As with all circumplex models, each sur- draws substantially on psychoanalytic clini-
face has two axes that define its quadrants. In cal theory and observation as well as on em-
the SASB (as in other interpersonal circum- pirical research in personality, cognitive,
plex models), love and hate represent the two developmental, and clinical psychology. Al-
poles of the horizontal axis. Enmeshment and though some aspects of the model are linked
differentiation are the endpoints of the verti- to research on etiology, the model is less a
cal axis. The SASB offers a translation of each theory of personality disorders than an at-
of the DSM Axis II criteria (and disorders) tempt to delineate and systematize the major
into interpersonal terms (Benjamin 1993, elements of personality that define a patients
1996b). In this respect, it has two advantages. personality, whether or not the patient has a
First, it can reduce the number of co-occur- personality disorder. The model differs from
ring conditions that need to be identified in a trait approaches in its focus on personality
given patient by specifying the interpersonal processes and functions (e.g., the kinds of af-
antecedents that elicit the patients responses. fect regulation strategies the person uses, the
For example, maladaptive anger is character- ways she represents the self and others men-
istic of many of the DSM-IV personality dis- tally, as well as more behavioral dispositions,
orders but has different interpersonal triggers such as whether she engages in impulsive or
and meanings (Benjamin 1993). Anger in pa- self-destructive behavior). However, it shares
tients with BPD often reflects perceived with trait approaches the view that a single
model should be able to accommodate rela- dure Q-Sort, a personality pathology mea-
tively healthy as well as relatively disturbed sure for use by expert informants, although
personality styles and dynamics. the model and the measure are not closely
The model suggests that a systematic linked (i.e., one does not require the other).
personality case formulation must answer From this point of view, individuals with
three questions, each composed of a series of particular personality disorders are likely to
subquestions or variables that require assess- be characterized by 1) distinct constellations
ment: 1) What does the person wish for, fear, of motives and conflicts, such as chronic wor-
and value, and to what extent are these mo- ries about abandonment in BPD or a conflict
tives conscious or unconscious, collaborating between the wish for and fear of connected-
or conflicting? 2) What psychological re- ness to others in avoidant personality disor-
sourcesincluding cognitive processes (e.g., der; 2) deficits in adaptive functioning, such
intelligence, memory, intactness of thinking as poor impulse control, lack of self-reflective
processes), affects, affect regulation strate- capacities (see Fonagy and Target 1997), and
gies (conscious coping strategies and uncon- difficulty regulating affect (Linehan 1993a;
scious defenses), and behavioral skillsdoes Westen 1991a) in BPD or subclinical cogni-
the person have at his or her disposal to meet tive disturbances in schizotypal personality
internal and external demands? 3) What is disorder; and 3) problematic ways of think-
the persons experience of the self and others, ing, feeling, and behaving toward them-
and how able is the individualcognitively, selves and significant others, such as a ten-
emotionally, motivationally, and behavior- dency to form simplistic, one-dimensional
allyto sustain meaningful and pleasurable representations of the self and others, to mis-
relationships? understand why people (including the self)
From a psychodynamic perspective, behave as they do, and to expect malevo-
these questions correspond roughly to the is- lence from other people (characteristics seen
sues raised by classical psychoanalytic theo- in patients with many personality disorders,
ries of motivation and conflict (Brenner such as paranoid, schizoid, and borderline)
1982); ego-psychological approaches to (Kernberg 1975a, 1984; Westen 1991a). In this
adaptive functioning; and object-relational, model, a persons level of personality health
self-psychological, attachment, and contem- sickness (from severe personality disorder to
porary relational (Aron 1996; Mitchell 1988) relatively healthy functioning), which can be
approaches to understanding peoples expe- assessed reliably using a personality health
rience of self with others. Each of these ques- prototype or a simple rating of level of per-
tions and subdimensions, however, is also sonality organization derived from Kern-
associated with a number of research tradi- bergs work (Westen and Muderrisoglu 2003;
tions in personality, clinical, cognitive, and Westen and Shedler 1999b), reflects his or her
developmental psychology (e.g., on the de- functioning in each of these three domains.
velopment of childrens representations of People who do not have severe enough
self, representations of others, moral judg- pathology to receive a personality disorder
ment, attachment styles, ability to tell coher- diagnosis can similarly be described using
ent narratives) (see Damon and Hart 1988; this approach. For example, a successful
Fonagy et al. 2002; Harter 1999; Livesley and male executive presented for treatment with
Bromley 1973; Main 1995; Westen 1990a, troubles in his marriage and his relationships
1990b, 1991b, 1994). Westen and Shedler at work, as well as low-level feelings of anx-
(1999a) used this model as a rough theoreti- iety and depression. None of these character-
cal guide to ensure comprehensive coverage istics approached criteria for a personality
of personality domains in developing items disorder (or any Axis I disorders, except the
for the Shedler-Westen Assessment Proce- relatively nondescript diagnosis of adjust-
ment disorder with mixed anxious and de- very distant, whom he saw twice a
pressed mood). Using this model, one would month and with whom he rarely had
sex. Prior to her, his sexual experiences
note that he was competitive with other peo-
had all been anxiety provoking and
ple, a fact of which he was unaware (Ques- short lived, in every sense.
tion 1); had impressive capacities for self- Mr. A tended to be inhibited in
regulation but was intellectualized and many areas of his life. He was emotion-
afraid of feelings and often used his enjoy- ally constricted and seemed particularly
ment of his work as a way of retreating from uncomfortable with pleasurable feel-
his family (Question 2); and had surprisingly ings. He tended to speak in intellectual-
ized terms about his life and history and
noncomplex representations of others
seemed afraid of affect. He felt stifled in
minds (for a person who could solve nonin- his chosen profession, which did not al-
terpersonal problems in complex ways) and low him to express many of his intellec-
consequently would often became angry and tual abilities or creative impulses. He al-
attack at work without stopping to empa- ternated between overcontrol of his
thize with the other persons perspective impulses, which was his modal stance in
(Question 3). This description is, of course, life, and occasional breakthroughs of
poorly thought-out, impulsive actions
highly oversimplified, but it gives a sense of
(as when he bought an expensive piece
how the model can be used to describe per- of equipment with little forethought
sonality dynamics in patients without a diag- about how he would pay for it).
nosable personality disorder (Westen 1998; Mr. A came from a working-class
Westen and Shedler 1999b). family in Boston and had lost his father,
a policeman, as a young boy. He was
reared by his mother and later by a step-
father with whom he had a positive re-
CASE EXAMPLE lationship. He also described a good re-
lationship with his mother, although
To see how some of the models discussed she, like several members of her ex-
here operate in practice, consider the follow- tended family, struggled with depres-
ing brief case description: sion, and she apparently suffered a
lengthy major depressive episode after
her husbands death.
Mr. A was a man in his early 20s who
came to treatment for lifelong problems
with depression, anxiety, and feelings For purposes of brevity, we briefly expli-
of inadequacy. He was a kind, intro- cate this case from two theoretical stand-
spective, sensitive man who neverthe- points that provide very different approaches
less had tremendous difficulty making to case formulation: the FFM and the func-
friends and interacting comfortably
tional-domains viewpoint. (In clinical prac-
with people. He was constantly worried
that he would misspeak, he would ru- tice, a functional-domains account and a psy-
minate after conversations about what chodynamic account are similar, because the
he had said and the way he was per- former reflects an attempt to systematize and
ceived, and he had only one or two integrate with empirical research [and mini-
friends with whom he felt comfortable.
mal jargon] the major domains emphasized
He wanted to be closer to people, but he
was frightened that he would be re- by classical psychoanalytic, ego-psychologi-
jected and was afraid of his own anger cal, and object-relational/self-psychological/
in relationships. While interacting with relational approaches.)
people (including his therapist), he From a five-factor perspective, the most
would often have a running commen-
salient features of Mr. As personality profile
tary with them in his mind, typically
filled with aggressive content. He was were his strong elevations in neuroticism and
in a 2-year relationship with a woman introversion (low extraversion). He was high
who was emotionally and physically on most of the facets of neuroticism, notably
anxiety, depression, anger, self-conscious- pacity to lead a fulfilling life. He wanted to

ness, and vulnerability. He was low on most connect with people, but he was inhibited by
facets of extraversion as well, particularly social anxiety, feelings of inadequacy, and an
gregariousness, assertiveness, activity, and undercurrent of anger toward people that he
happiness. This combination of high negative could not directly express (which emerged in
affectivity and low positive affectivity, which his running commentaries in his mind).
left him vulnerable to feelings of depression, Although he worried that he would fail oth-
captures his anxious, self-conscious social ers, he always felt somehow unfulfilled in his
avoidance. relationships with them and could be subtly
No other broadband factors describe Mr. critical. He likely had high standards with
A adequately, although specific FFM facets which he compared himself and others and
provide insight into his personality. He was against which both frequently fell short. He
moderately high in agreeableness, being also had trouble handling his anger, aggres-
compliant, modest, and tender-minded; sive impulses, and desires for self-assertion.
however, he was not particularly high on He would frequently behave in passive or
trust, altruism, or straightforwardness (re- self-punitive ways rather than appropriately
flecting his tendency to behave passive- asserting his desires or expressing his anger.
aggressively). He was moderately conscien- This pattern contributed in turn to a linger-
tious, showing moderate scores on the facets ing hostile fantasy life and a tendency at
of orderliness and discipline. He similarly times to behave passive-aggressively.
showed moderate openness to experience, Sex was particularly conflictual for Mr. A,
being artistically oriented but low on com- not only because it forced him into an inti-
fort with feelings. His scores on facets such as mate relationship with another person but
intellectual curiosity would likely be moder- because of his feelings of inadequacy, his dis-
ate, reflecting both an interest and an inhibi- comfort in looking directly at a womans
tion. Indeed, a tendency to receive moderate body (because of his associations to sex and
scores because of opposing dynamics would womens bodies), and his worries that he
be true of his facet scores on several traits, was homosexual. When with a woman, he
such as achievement orientation. frequently worried that he would acciden-
A functional-domains perspective would tally touch her anus and be repulsed, al-
offer a similar summary diagnosis to that of a though interestingly, his sexual fantasies
psychodynamic approach, along with a de- (and humor) had a decidedly anal tone. Ho-
scription of his functioning on the three major mosexual images would also jump into his
domains outlined in the model. In broadest mind in the middle of sexual activity, which
outline, from this point of view Mr. A had a led to considerable anxiety.
depressive, avoidant, and obsessional per- With respect to adaptive resources, Mr. A
sonality style organized at a low-functioning had a number of strengths, notably his im-
neurotic level. In other words, he did not have pressive intellect, a dry sense of humor, a ca-
a personality disorder, as evidenced by his pacity to introspect, and an ability to perse-
ability to maintain friendships and stable em- vere. Nevertheless, his overregulation of his
ployment, but he had considerable psycho- feelings and impulses left him vulnerable to
logical impediments to love, work, and life breakthroughs of anger, anxiety, and impul-
satisfaction, with a predominance of depressive action. He distanced himself from emo-
sive, avoidant, and obsessional dynamics. tion, in an effort to regulate anxiety, depres-
With respect to motives and conflicts sion, excitement, and pleasure, which seemed
(and interpersonal issues, around which to him both undeserved and threatening.
many of his conflicts centered), Mr. A had a With respect to his experience of self and
number of conflicts that impinged on his ca- relationships, Mr. As dominant interpersonal
concerns centered around rejection, shame,

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Guilford, 2003
Part II
Clinical Evaluation
3
Manifestations, Clinical
Diagnosis, and Comorbidity
A personality disorder is defined in DSM-IV- and includes paranoid, schizoid, and schizo-
TR as an enduring pattern of inner experi- typal personality disorders. Cluster B, the
ence and behavior that deviates markedly dramatic, emotional, or erratic cluster, in-
from the expectations of the individuals cul- cludes antisocial, borderline, histrionic, and
ture, is pervasive and inflexible, has an onset narcissistic personality disorders. Cluster C,
in adolescence or early adulthood, is stable the anxious and fearful cluster, includes
over time, and leads to distress or impair- avoidant, dependent, and obsessive-compul-
ment (American Psychiatric Association sive personality disorders. DSM-IV-TR also
2000, p. 685). Personality disorders are re- provides for a residual category of personality
ported on Axis II of the DSM-IV-TR multiax- disorder not otherwise specified (PDNOS).
ial system to ensure that consideration is This category is to be used when a patient
given to their presence in all patient evalua- meets the general criteria for a personality dis-
tions, even when Axis I disorder psychopa- order and has features of several different
thology is present and prominent. types but does not meet criteria for any spe-
DSM-IV-TR includes criteria for the diag- cific personality disorder (i.e., mixed per-
nosis of 10 specific personality disorders, ar- sonality disorder) or is considered to have a
ranged into three clusters based on descrip- personality disorder not included in the offi-
tive similarities. Cluster A is commonly cial classification (e.g., self-defeating or de-
referred to as the odd or eccentric cluster pressive personality disorders).
Sections of this chapter have been modified with permission from Skodol AE: Problems in Differential Di-
agnosis: From DSM-III to DSM-III-R in Clinical Practice. Washington, DC, American Psychiatric Press, 1989
37
This chapter considers the manifesta- with other people and about themselves.
tions, problems in differential diagnosis, and Most of the DSM-IV-TR diagnostic criteria for
patterns of comorbidity of the DSM-IV-TR paranoid personality disorder reflect a distur-
personality disorders. Included in this chap- bance in cognition, characterized by perva-
ter are descriptions of the clinical characteris- sive distrust and suspiciousness of others. Pa-
tics of the 10 DSM-IV-TR personality disor- tients with paranoid personality disorder
ders; discussions of problems in interviewing suspect that others are exploiting, harming, or
the patient with a suspected personality dis- deceiving them; doubt the loyalty or trust-
order in state versus trait discrimination, trait worthiness of others; read hidden, demean-
versus disorder distinctions, categorical ver- ing, or threatening meanings into benign re-
sus alternative classificatory approaches to marks or events; and perceive attacks on their
personality disorder diagnosis, and diagno- character or reputation. Among the major
sis based on inferential judgments; and an symptoms of schizotypal personality disorder
overview of personality disorder comorbid- are characteristic cognitive and perceptual
ity. Despite limitations in the DSM approach, distortions, such as ideas of reference; odd be-
personality disorders diagnosed by this sys- liefs and magical thinking (e.g., superstitious-
tem have been shown since the 1980s to have ness, belief in clairvoyance or telepathy);
considerable clinical utility in predicting bodily illusions; and suspiciousness and para-
functional impairment over and above that noia similar to that observed in patients with
associated with comorbid Axis I disorders, paranoid personality disorder.
extensive and intensive utilization of treat- Patients with borderline personality dis-
ment resources, and in many cases, adverse order (BPD) may also experience transient
outcomes. paranoid ideation when under stress, but the
characteristic cognitive manifestations of
borderline patients are dramatic shifts in
DEFINING FEATURES OF their views toward people with whom they
are intensely emotionally involved. These
PERSONALITY DISORDERS shifts emanate from disturbances in mental
representations of self and others (Bender
Patterns of Inner
and Skodol 2007) and result in their overide-
Experience and Behavior alizing others at one point and then devalu-
ating them at another point, when they feel
The general diagnostic criteria for a person-
disappointed, neglected, or uncared for. This
ality disorder in DSM-IV-TR (see Table 11)
phenomenon is commonly referred to as
indicate that a pattern of inner experience
splitting. Patients with narcissistic person-
and behavior is manifest by characteristic
ality disorder exhibit a grandiose sense of
patterns of 1) cognition (i.e., ways of perceiv-
self; have fantasies of unlimited success,
ing and interpreting self, other people, and
power, brilliance, beauty, or ideal love; and
events); 2) affectivity (i.e., the range, inten-
sity, lability, and appropriateness of emo- believe that they are special or unique.
tional response); 3) interpersonal function- Patients with avoidant personality disor-
ing; and 4) impulse control. Patients with der have excessively negative opinions of
themselves, in contrast to patients with nar-
personality disorders are expected to have
cissistic personality disorder. They see them-
manifestations in at least two of these areas.
selves as inept, unappealing, and inferior,
and they constantly perceive that they are be-
Cognitive Features ing criticized or rejected. Patients with depen-
Personality disorders commonly affect the dent personality disorder also lack self-confi-
ways patients think about their relationships dence and believe that they are unable to
Manifestations, Clinical Diagnosis, and Comorbidity 39
make decisions or to take care of themselves. ety in social situations; those with dependent
Patients with obsessive-compulsive person- personality disorder are preoccupied by anx-
ality disorder (OCPD) are perfectionistic and iety over the prospects of separation from car-
rigid in their thinking and are often preoccu- egivers and the need to be independent.
pied with details, rules, lists, and order.
Interpersonal Features
Affective Features
Interpersonal problems are probably the
Some patients with personality disorders are most typical of personality disorders (Ben-
emotionally constricted, whereas others are jamin 1996; Gunderson 2007; Hill et al. 2008;
excessively emotional. Among the con- Kiesler 1996). Other mental disorders are
stricted types are patients with schizoid per- characterized by prominent cognitive or af-
sonality disorder, who experience little plea- fective features or by problems with impulse
sure in life, appear indifferent to praise or control. All personality disorders, however,
criticism, and are generally emotionally cold, also have interpersonal manifestations that
detached, and unexpressive. Patients with can be described along the two orthogonal
schizotypal personality disorder also often poles of the so-called interpersonal circum-
have constricted or inappropriate affect, al- plex: dominance versus submission and af-
though they can exhibit anxiety in relation to filiation versus detachment.
their paranoid fears. Patients with OCPD Personality disorders characterized by a
have considerable difficulty expressing lov- need for or a tendency toward dominance in
ing feelings toward others, and when they do interpersonal relationships include antisocial,
express affection, they do so in a highly con- histrionic, narcissistic, and obsessive-compul-
trolled or stilted manner. sive. ASPD patients deceive and intimidate
Among the most emotionally expressive others for personal gain. Patients with histri-
patients with personality disorders are those onic and narcissistic personality disorders
with borderline and histrionic personality need to be the center of attention and require
disorders. Patients with BPD are emotionally excessive admiration, respectively. OCPD pa-
labile and react very strongly, particularly in tients need to control others and have them
interpersonal contexts, with a variety of in- submit to their ways of doing things. On the
tensely dysphoric emotions, such as depres- submissive side are patients with avoidant
sion, anxiety, or irritability. They are also and dependent personality disorders. Patients
prone to inappropriate, intense outbursts of with avoidant personality disorder are inhib-
anger and are often preoccupied with fears of ited in interpersonal relationships because
being abandoned by those they are attached they are afraid of being shamed or ridiculed.
to and reliant upon. Patients with histrionic Patients with dependent personality disorder
personality disorder often display rapidly will not disagree with important others for
shifting emotions that seem to be dramatic fear of losing their support or approval and
and exaggerated but are shallow in compari- will actually do things that are unpleasant, de-
son to the intense emotional expression seen meaning, or self-defeating in order to receive
in BPD. Patients with antisocial personality nurturance from them. BPD patients may al-
disorder (ASPD) characteristically have prob- ternate between submissiveness and domi-
lems with irritability and aggressive feelings nance, seeming to become deeply involved
toward others, which are expressed in the and dependent only to turn manipulative and
context of threat or intimidation. Patients demanding when their needs are not met.
with narcissistic personality disorder display In the domain of affiliation versus detach-
arrogant, haughty attitudes and have no em- ment, patients with histrionic, narcissistic,
pathy for other people. Patients with avoidant and dependent personality disorders have
personality disorder are dominated by anxi- the greatest degrees of affiliative behavior,
whereas patients with paranoid, schizoid, addition, patients with BPD engage in recur-
schizotypal, avoidant, and obsessive-com- rent suicidal threats, gestures, or attempts
pulsive personality disorders are the most de- and in self-mutilating behavior such as cut-
tached. Patients with histrionic, narcissistic, ting or burning. Finally, patients with BPD
and dependent personality disorders are pro- have problems with anger management,
social because of their needs for attention, ad- have frequent temper outbursts, and at times
miration, and support, respectively. Patients may even engage in physical fights.
with paranoid personality disorder do not In contrast, patients with avoidant per-
trust others enough to become deeply in- sonality disorder are generally inhibited, es-
volved; patients with schizotypal personality pecially in relation to people, and are re-
disorder have few friends or confidants, in luctant to take risks or to undertake new
part from a lack of trust and in part as a result activities. Patients with dependent personal-
of poor communication and inadequate relat- ity disorder cannot even make decisions and
edness. Patients with avoidant personality do not take initiative to start things. Patients
disorder are socially isolated because of their with OCPD are overly conscientious and
feelings of inadequacy and their fears of rejec- scrupulous about morality, ethics, and val-
tion, whereas those with schizoid personality ues; they cannot bring themselves to throw
disorder neither desire nor enjoy relation- away even worthless objects and are miserly.
ships. Patients with OCPD opt for work and The DSM-IV-TR personality disorder
productivity over friendships and interper- clusters, specific personality disorder types,
sonal activity because they feel more in con- and their principal defining clinical features
trol in the former than the latter. Patients with are presented in Table 31.
BPD again can vacillate between being overly
attached and dependent on someone (often Pervasiveness and Inflexibility
one who is not the best match) and being iso-
lated, distant, and aloof. For a personality disorder to be present, the
disturbances reviewed earlier have to be
Problems With Impulse Control manifest frequently over a wide range of be-
haviors, feelings, and perceptions and in
Problems with impulse control can also be many different contexts. In DSM-IV-TR, at-
viewed as extremes on a continuum. Person- tempts are made to stress the pervasiveness
ality disorders characterized by a lack of im- of the behaviors caused by personality disor-
pulse control include ASPD and BPD. Disor- ders. Added to the basic definition of each
ders involving problems with overcontrol personality disorder, serving as the stem
include avoidant, dependent, and obsessive- to which individual features apply, is the
compulsive personality disorders. ASPD is a phrase present in a variety of contexts. For
prototype of a personality disorder charac- example, the essential features of paranoid
terized by impulsivity. Patients with ASPD personality disorder in DSM-IV-TR, preced-
break laws, exploit others, fail to plan ahead, ing the specific criteria, begin: A pervasive
get into fights, ignore commitments and ob- distrust and suspiciousness of others such
ligations, and exhibit generally reckless be- that their motives are interpreted as malevo-
haviors without regard to consequences, lent, beginning by early adulthood and
such as speeding, driving while intoxicated, present in a variety of contexts, as indicated
having impulsive sex, or abusing drugs. Pa- by four (or more) of the following (Ameri-
tients with BPD also show many problems can Psychiatric Association 2000, p. 694).
with impulse control, including impulsive Similarly, for dependent personality disor-
spending, indiscriminate sex, substance der, the criteria are preceded by the descrip-
abuse, reckless driving, and binge eating. In tion: A pervasive and excessive need to be
Table 31. DSM-IV-TR personality clusters, specific types, and their defining clinical features
Cluster Type Characteristic features
A Odd or eccentric
Paranoid Pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent
Manifestations, Clinical Diagnosis, and Comorbidity

Schizoid Pervasive pattern of detachment from social relationships and restricted range of expression of emotions
in interpersonal settings
Schizotypal Pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced
capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of
behavior
B Dramatic, emotional, or erratic
Antisocial History of conduct disorder before age 15; pervasive pattern of disregard for and violation of the rights
of others; current age at least 18
Borderline Pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked
impulsivity
Histrionic Pervasive pattern of excessive emotionality and attention seeking
Narcissistic Pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy
C Anxious or fearful
Avoidant Pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative
evaluation
Dependent Pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears
of separation
Obsessive- Pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal
compulsive control at the expense of flexibility, openness, and efficiency
Source. Adapted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC,
American Psychiatric Association, 2000, p. 685. Used with permission. Copyright 2000 American Psychiatric Association.
41
taken care of that leads to submissive and havior (BPD), may be evidenced much less
clinging behavior and fears of separation, be- frequently than traits such as views self as
ginning by early adulthood and present in a socially inept, personally unappealing or infe-
variety of contexts, as indicated by five (or rior to others (avoidant personality disor-
more) of the following (American Psychiat- der). How stable individual manifestations of
ric Association 2000, p. 725). personality disorders actually are and what
Inflexibility is a feature that helps to dis- the stable components of personality disor-
tinguish personality traits or styles and per- ders are have become areas of active empirical
sonality disorders. Inflexibility is indicated research. It may be that personality psychopa-
by a narrow repertoire of responses that are thology waxes and wanes depending on the
repeated even when the situation calls for an circumstances of a persons life (see Chapter 4,
alternative behavior or in the face of clear ev- Course and Outcome).
idence that a behavior is inappropriate or not
working. For example, an obsessive-compul- Distress or Impairment in
sive person rigidly adheres to rules and orga- Functioning
nization even in recreation and loses enjoy-
ment as a consequence. An avoidant person Another important aspect of personality dis-
is so fearful of being scrutinized or criticized, orders that distinguishes them from traits or
even in group situations in which he or she styles is that personality disorders lead to
could hardly be the focus of such attention, distress or impairment in functioning. By
that life becomes painfully lonely. their nature, some personality disorders may
not be accompanied by obvious subjective
distress on the part of the patient. Examples
Onset and Clinical Course would include schizoid personality disorder,
Personality and personality disorders have in which a patient is ostensibly satisfied with
traditionally been assumed to reflect stable his or her social isolation and does not seem
descriptions of a person, at least after a certain to need or desire the companionship of oth-
age. Thus, the patterns of inner experience ers, and ASPD, in which the patient has utter
and behaviors described earlier are called disdain and disregard for social norms and
enduring. Personality disorder is also de- will not experience distress unless his activi-
scribed as of long duration, with an onset ties are thwarted. On the other side of the
that can be traced back at least to adolescence coin are patients with BPD, who are likely to
or early adulthood (American Psychiatric experience and express considerable dis-
Association 2000, p. 686). These concepts per- tress, especially when disappointed in a sig-
sist as integral to the definition of personality nificant other, or patients with avoidant per-
disorder despite a large body of empirical ev- sonality disorder, who, in contrast with
idence that suggests that personality disorder schizoid patients, are usually very uncom-
psychopathology is not as stable as the DSM fortable and unhappy with their lack of close
definition would indicate. Longitudinal stud- friends and companions.
ies indicate that personality disorders tend to All personality disorders are maladap-
improve over time, at least from the point of tive, however, and are accompanied by func-
view of their overt clinical signs and symp- tional problems in school or at work, in social
toms (Grilo et al. 2004; Johnson et al. 2000; relationships, or at leisure. The requirement
Lenzenweger 1999; Zanarini et al. 2006). Fur- for impairment in psychosocial functioning is
thermore, personality disorder criteria sets codified in DSM-IV-TR in its criterion C of the
consist of combinations of pathological per- general diagnostic criteria for a personality
sonality traits and symptomatic behaviors disorder, which states that the enduring pat-
(McGlashan et al. 2005; Zanarini et al. 2007). tern [of inner experience and behavior, i.e.,
Some behaviors, such as self-mutilating be- personality] leads to clinically significant dis-
tress or impairment in social, occupational, or even beyond apparent improvement in per-

other important areas of functioning (Amer- sonality disorder psychopathology itself
ican Psychiatric Association 2000, p. 689). (Seivewright et al. 2004; Skodol et al. 2005).
A number of studies have compared pa- The persistence of impairment is under-
tients with personality disorders to patients standable if one considers that personality
with no personality disorder or with Axis I disorder psychopathology has usually been
disorders and have found that patients with long-standing and, therefore, has disrupted a
personality disorders were more likely to be persons work and social development over
functionally impaired (Skodol and Gunder- a period of time (Roberts et al. 2003). The
son 2008). Specifically, they are more likely to scars or residua of personality disorder pa-
be separated, divorced, or never married and thology take time to heal or be overcome.
to have had more unemployment, frequent With time (and treatment), however, im-
job changes, or periods of disability. It is inter- provements in functioning can occur.
esting that only rarely have patients with per-
sonality disorders been found to be less well
educated. Fewer studies have examined APPROACHES TO
quality of functioning, but in those that have,
CLINICAL INTERVIEWING
poorer social functioning or interpersonal re-
lationships and poorer work functioning or Interviewing a patient to assess for a possible
occupational achievement and satisfaction personality disorder presents certain chal-
have been found among patients with per- lenges that are somewhat unique. Thus, the
sonality disorders than with other disorders. interviewer is likely to need to rely on a vari-
When patients with different personality dis- ety of techniques for gathering information to
orders were compared with each other on arrive at a clinical diagnosis, including obser-
levels of functional impairment, those with vation and interaction with the patient, direct
severe personality disorders such as schizo- questioning, and interviewing informants.
typal and borderline were found to have sig-
nificantly more impairment at work, in social Observation and Interaction
relationships, and at leisure than patients
with less severe personality disorders, such One problem in evaluating a patient for a per-
as OCPD, or with an impairing Axis I disor- sonality disorder arises from the fact that
der, such as major depressiv e disorder most people are not able to view their own
(MDD) without personality disorder. Patients personality objectively (Zimmerman 1994).
with avoidant personality disorder had inter- Because personality is, by definition, the way
mediate levels of impairment. Even the less a person sees, relates to, and thinks about
impaired patients with personality disorders himself or herself and the environment, a per-
(e.g., OCPD), however, had moderate to se- sons assessment of his or her own personal-
vere impairment in at least one area of func- ity must be colored by it. The expression of
tioning (or a Global Assessment of Function- Axis I psychopathology may also be colored
ing rating of 60 or less) (Skodol et al. 2002). by Axis II personality stylefor example,
The finding that significant impairment may symptoms exaggerated by the histrionic or
be in only one area suggests that patients minimized by the compulsive personality
with personality disorders differ not only in but the symptoms of Axis I disorders are usu-
the degree of associated functional impair- ally more clearly alien to the patient and more
ment but also in the breadth of impairment easily identified as problematic. People usu-
across functional domains. ally learn about their own problem behavior
Another important aspect of the impair- and their patterns of interaction with others
ment in functioning in patients with person- through the reactions or observations of other
ality disorders is that it tends to be persistent people in their environments.
Traditionally, clinicians have not con- or contextthat is, the evaluation itself. Al-
ducted the same kind of interview in assess- though the interaction of patient and clini-
ing patients suspected of having a personal- cian can be a useful and objective observa-
ity disturbance as they do with persons tion, caution should be used in interpreting
suspected of having, for example, a mood or its significance, and attempts must be made
an anxiety disorder. Rather than directly to integrate this information into a broader
questioning the patient about characteristics overall picture of patient functioning.
of his or her personality, the clinician, assum-
ing that the patient cannot accurately de- Direct Questioning
scribe these traits, looks for patterns in the
way the patient describes social relations and In psychiatric research, a portion of the poor
work functioning. These two areas usually reliability of personality disorder diagnosis
give the clearest picture of personality style in has been assumed to be due to the variance in
general and personality problems specifi- information resulting from unsystematic as-
cally. Clinicians have also relied heavily on sessment of personality traits. Therefore, ef-
their observations of how patients interact forts have been made to develop various
with them during an evaluation interview or structured methods for assessing personality
in treatment as manifestations of their pa- disorders (McDermut and Zimmerman 2008)
tients personalities (Westen 1997). comparable with those that have been suc-
These approaches have the advantage of cessful in reducing information variance in
circumventing the lack of objectivity patients assessing Axis I disorders (Kobak et al. 2008).
might have about their personalities, but they These methods include both 1) self-report
also create problems. The clinician usually measures such as the Personality Diagnostic
comes away with a global impression of the Questionnaire4 (Hyler 1994), the Millon
patients personality but frequently is not Clinical Multiaxial InventoryIII (Millon et
aware of many of that patients specific per- al. 1997), and the Minnesota Multiphasic Per-
sonality characteristics because he or she has sonality Inventory2 (Somwaru and Ben-
not made a systematic assessment of the signs Porath 1995); and 2) clinical interviews such
and symptoms of the wide range of personal- as the Structured Interview for DSM-IV Per-
ity disorders (Blashfield and Herkov 1996; sonality (Pfohl et al. 1997), the International
Morey and Ochoa 1989; Zimmerman and Personality Disorder Examination (Loranger
Mattia 1999). In routine clinical practice, clini- 1999), the Structured Clinical Interview for
cians tend to use the nonspecific DSM-IV-TR DSM-IV Axis II Personality Disorders (First
diagnosis of PDNOS when they believe that a et al. 1997), the Diagnostic Interview for
patient meets the general criteria for a per- DSM-IV Personality Disorders (Zanarini et
sonality disorder, because they often do not al. 1996), and the Personality Disorder Inter-
have enough information to make a specific viewIV (Widiger et al. 1995).
diagnosis (Verheul and Widiger 2004). Alter- The interviews are based on the general
natively, clinicians will diagnose personality premise that the patient can be asked specific
disorders hierarchically: once a patient is seen questions that will indicate the presence or
as having one (usually severe) personality absence of each of the criteria of each of the
disorder, the clinician will not assess whether 10 DSM-IV-TR personality disorder types.
traits of other personality disorders are pres- The self-report instruments are generally
ent (Adler et al. 1990; Herkov and Blashfield considered to require a follow-up interview
1995). because of a very high rate of apparently
Reliance on interaction with the clinician false-positive responses, but data from stud-
for personality diagnosis runs the risk of gen- ies comparing self-report measures with clin-
eralizing a mode of interpersonal relating ical interviews suggest that the former aid in
that may be limited to a particular situation identification of personality disturbances
(Hyler et al. 1990, 1992). Thus, the clinician a report about the patient with his or her own
can keep in mind that patients do not neces- personality style. In fact, the correspondence
sarily deny negative personality attributes: in between patient self-assessments of person-
fact, the evidence suggests that they may ality disorder psychopathology and infor-
even overreport traits that clinicians might mant assessments has been generally found
not think are very important, and that pa- to be modest at best (Klonsky et al. 2002).
tients can, if asked, consistently describe a Agreement on pathological personality
wide range of personality traits to multiple traits, temperament, and interpersonal prob-
interviewers. A self-report inventory might lems appears to be somewhat better than on
be an efficient way to help focus a clinical in- DSM personality disorders. Informants usu-
terview on a narrower range of personality ally report more personality psychopathol-
disorder psychopathology. A semistructured ogy than patients. Self/informant agreement
interview is useful clinically when the results on personality disorders is highest for Clus-
of an assessment might be subject to close ter B disorders (excluding narcissistic per-
scrutiny, such as in child custody, disability, sonality disorder), lower for Clusters A and
or forensic evaluations (Widiger and Coker C, and lowest for traits related to narcissism
2002). and entitlement, as might be expected. So the
clinician must make a judgment about the
objectivity of the informant and use this as a
Interviewing Informants
part, but not a sufficient part, of the overall
data on which to base a personality disorder
Frequently, a patient with a personality dis-
diagnosis (Zimmerman et al. 1988). Which
order consults a mental health professional
source, the patient or the informant, provides
for evaluation or treatment because another
information that is more useful for clinical
person has found his or her behavior prob-
purposes, such as choosing a treatment or
lematic. This person may be a boss, spouse,
predicting outcome (e.g., Klein 2003), is yet
boyfriend or girlfriend, teacher, parent, or
representative of a social agency. Indeed, to be definitively determined.
some people with personality disorders do
not even recognize the problematic aspects
of their manner of relating or perceiving ex- PROBLEMS IN CLINICAL ASSESSMENT
cept as it has a negative effect on someone
with whom they interact. Assessing Pervasiveness
Because of these blind spots that peo-
ple with personality disorders may have, the The pervasiveness of personality distur-
use of a third-party informant in the evalua- bance can be difficult to determine. When a
tion can be useful (Zimmerman et al. 1986). clinician inquires if a person often has a
In some treatment settings, such as a private particular experience, a patient will fre-
individual psychotherapy practice, it may be quently reply sometimes, which then has
considered counterproductive or contraindi- to be judged for clinical significance. What
cated to include a third party, but in many in- constitutes a necessary frequency for a par-
patient and outpatient settings, certainly ticular trait or behavior (Widiger 2002) and
during the evaluation process, it may be ap- in how many different contexts or with how
propriate and desirable to see some person many different people the trait or behavior
close to the patient to corroborate both the needs to be expressed has not been well
patients report and ones own clinical im- worked out. Clinicians are forced to rely on
pressions. their own judgment, keeping in mind also
Of course, there is no reason to assume that maladaptivity and inflexibility are hall-
that the informant is bias-free or not coloring marks of pathological traits.
For the clinician interviewing a patient prompted the person to seek treatment, the
with a possible personality disorder, data consequences in terms of the decision to seek
about the many areas of functioning, the in- treatment, the current level of stress, and any
terpersonal relationships with people inter- actual Axis I psychopathology, if present.
acting in different social roles with the pa- The DSM-IV-TR multiaxial system is of
tient, and the nature of the patientclinician considerable aid in the assessment of these
relationship should be integrated into a com- problems because of its separation of Axis I
prehensive assessment of pervasiveness. Too disorders from Axis II disorders and its indi-
often, clinicians place disproportionate im- vidual axes for physical disorders and psy-
portance on a patients functioning at a par- chosocial stressors. A multiaxial system
ticular job or with a particular boss or signif- forces clinicians to think about the effects of
icant other person. aspects of patients current state on long-term
patterns of behavior, but it does not make the
State Versus Trait distinctions for them.
It is not clear from the diagnostic criteria
An issue that cuts across all personality disor- of DSM-IV-TR how long a pattern of person-
der diagnoses and presents practical prob- ality disturbance needs to be present, or
lems in differential diagnosis is the distinc- when it should become evident, for a person-
tion between clinical state and personality ality disorder to be diagnosed. Earlier itera-
trait. Personality is presumed to be an endur- tions of the DSM stated that patients were
ing aspect of a person, yet assessment of per- usually age 18 years or older when personal-
sonality ordinarily takes place cross-section- ity disorder was diagnosed because it can be
allythat is, over a brief interval in time. argued that, up to that age, a personality pat-
Thus, the clinician is challenged to separate tern could neither have been manifest long
out long-term dispositions of the patient from enough nor have become significantly en-
other more immediate or situationally deter- trenched to be considered a stable constella-
mined characteristics. This task is more com- tion of behavior. DSM-IV-TR states, however,
plicated by the fact that the patient often that some manifestations of personality dis-
comes for evaluation when there is some par- order are usually recognizable by adoles-
ticularly acute problem, which may be a so- cence or earlier and that personality dis-
cial or job-related crisis or the onset of an Axis orders can be diagnosed in persons younger
I disorder (Shea 1997). In either case, the situ- than age 18 years who have manifestated
ation in which the patient is being evaluated symptoms for at least 1 year. Longitudinal
is frequently a state that is not completely research has shown that personality disorder
characteristic of the patients life over the symptoms evident in childhood or early ad-
longer run. olescence may not persist into adult life
(Johnson et al. 2000). Longitudinal research
Assessing an Enduring Pattern has also shown that there is continuity be-
tween certain disorders of childhood and ad-
DSM-IV-TR indicates that personality disor- olescence and personality disorders in early
ders are of long duration and are not better adulthood (Kasen et al. 1999, 2001). Thus, a
accounted for as a manifestation or conse- young boy with oppositional defiant or at-
quence of another mental disorder (Ameri- tention-deficit/hyperactivity disorder in
can Psychiatric Association 2000, p. 689). childhood may go on to develop conduct dis-
Making these determinations in practice is order as an adolescent, which can progress to
not easy. First of all, an accurate assessment full-blown ASPD in adulthood (Bernstein et
requires recognition of current state. An as- al. 1996; Lewinsohn et al. 1997; Rey et al.
sessment of current state, in turn, includes 1995; Zoccolillo et al. 1992). ASPD is the only
knowledge of the circumstances that have diagnosis not given before age 18; an adoles-
cent exhibiting significant antisocial behav- pression, for example, may cause a person to
ior before age 18 years is diagnosed with con- seem excessively dependent, avoidant, or
duct disorder. self-defeating. Cyclothymia or bipolar disor-
Regarding the course of a personality dis- der (not otherwise specified; bipolar II) may
order, DSM-IV-TR states that personality dis- lead to periods of grandiosity, impulsivity,
orders are relatively stable over time, al- poor judgment, and depression that might be
though certain of them (e.g., ASPD and BPD) confused with manifestations of narcissistic
may become somewhat attenuated with age, or borderline personality disorders.
whereas others may not or may, in fact, be- The clinician must be aware of the Axis I
come more pronounced (e.g., obsessive-com- psychopathology and attempt to assess Axis
pulsive and schizotypal personality disor- II independently. This assessment can be at-
ders). As mentioned earlier and discussed in tempted in one of two ways. First, the clini-
greater detail in Chapter 4, Course and Out- cian can ask about aspects of personality func-
come, this degree of stability may not neces- tioning at times when the patient is not
sarily pertain to all of the features of all DSM- experiencing Axis I symptoms. This approach
IV-TR personality disorders equally. is feasible when the Axis I disorder is of recent
To assess stability retrospectively, the cli- onset and short duration or, if more chronic, if
nician must ask questions about periods of a the course of the disorder has been character-
persons life that are of various degrees of re- ized by relatively clear-cut episodes with
moteness from the current situation. Retro- complete remission and symptom-free peri-
spective reporting is subject to distortion, ods of long duration. When the Axis I disor-
however, and the only sure way of demon- der is chronic and unremitting, then the Axis I
strating stability over time is, therefore, to do psychopathology and personality function-
prospective follow-up evaluations. Thus ing blend together to an extent that makes dif-
from a practical, clinical point of view, per- ferentiating between them clearly artificial.
sonality disorder diagnoses made cross- A second approach to distinguishing
sectionally and on the basis of retrospectively signs of Axis I pathology from signs of Axis II
collected data would be tentative or provi- personality is longitudinal and would defer
sional pending confirmation by longitudinal an Axis II diagnosis pending the outcome of a
evaluation. On an inpatient service, a period trial of treatment for the Axis I disorder. This
of intense observation by many professionals strategy may be the preferred approach in the
from diverse perspectives may suffice to es- case of a long-standing and chronic Axis I dis-
tablish a pattern over time (Skodol et al. 1988, order, like cyclothymia, that has never been
1991). In a typical outpatient setting in which previously recognized or treated. Although
encounters with the patients are much less one always runs the risk of a partial response
frequent, more time may be required. Ideally, to treatment and some residual symptoms,
features of a personality disorder should be this tactic may bring the clinician as close,
evident over years, but it is not practical to practically speaking, as he or she will get to
wait inordinate amounts of time before observing the patients baseline functioning.
coming to a diagnostic conclusion. The following case is adapted from Skodol
(1989).
Assessing the Effect of an Axis I Disorder
Case Example
An Axis I disorder can complicate the diagno-
sis of a personality disorder in several ways
A 24-year-old unemployed man sought
(Widiger and Sanderson 1995; Zimmerman psychiatric hospitalization because of a
1994). An Axis I disorder may cause changes serious problem with depression. The
in a persons behavior or attitudes that can ap- man reported that he had felt mildly,
pear to be signs of a personality disorder. De- but continuously, depressed since the
age of 16. When he reached his twenties, him, and that he now carried a chip on
he had begun to have more severe bouts his sho ulder because he had been
that made him suicidal and unable to burned by others so often. He admit-
function. ted that he was not blame-free in rela-
During the most recent episode, be- tionships because he had also used peo-
ginning about 6 months previously, he ple, especially members of his family.
had quit his job as a taxi driver and iso- The patient felt that he was not im-
lated himself from his friends. He spent proving in his outpatient treatment of
his time lying around and eating a lot the last 3 years. His reason for seeking
and, in fact, had gained 60 pounds. He hospitalization, in addition to the fact
had difficulty falling asleep, felt fa- that he continually thought of suicide
tigued all day long, could not concen- and was frightened he might actually
trate, felt worthless (Theres no pur- succeed in killing himself, was that he
pose to my life) and guilty (I missed felt totally lost in his life, without di-
my chances; Ive put my family through rection, goals, or knowing what mat-
hell), and had taken an overdose of tered to him. He said he felt hollow.
sleeping pills. If they cut me open after I was dead,
The man received a semistructured he said, theyd probably find out I was
interview assessment of Axis II psycho- all shriveled up inside.
pathology. In describing his personality, This mans description of his per-
he said that he once thought of himself sonality, the ways in which he charac-
as lively and good-natured, but that teristically thought about himself, saw
over the past 4 or 5 years, he felt he had others and his relationships to them, and
changed. He said that he was very sen- behaved, actually met DSM-IV-TR crite-
sitive to criticism, afraid to get involved ria for avoidant, dependent, paranoid,
with people, fearful of new places and and borderline personality disorders. He
experiences, convinced he was making was hospitalized for long-term treat-
a fool of himself, and afraid of losing ment, which was available at the time. In
control. He felt very dependent on oth- addition to receiving individual, psy-
ers for decision making and for initia- choanalytically oriented psychotherapy
tive. He said that he was so needy of sessions and participating in a variety of
others that they could do anything to therapeutic groups, he was given fluox-
him and he would take it. He felt etine, up to 80 mg/day, for treatment of
helpless when alone, was sure he would Axis I MDD and dysthymia.
end up alone and in the streets, and Six months after admission, the pa-
was constantly looking to others, espe- tient reported that he felt significantly
cially family members, for comfort and less depressed. Measured in terms of the
reassurance. Hamilton Rating Scale for Depression,
The man also thought that people the initial severity of his depression was
took advantage of him now and that he 30, and his posttreatment score was 10.
let them because he never stood up for A repeat semistructured assessment of
his own self-interest. He felt like a total his personality functioning revealed
failure with no redeeming virtues. He that he no longer met DSM-IV-TR crite-
said he either deliberately passed up op- ria for any personality disorder, al-
portunities to improve his situation be- though he continued to exhibit some de-
cause he felt I dont deserve any better pendent traits.
or else undermined himself without
thinking by failing to follow through, Another example of the way in which
for example, on a job interview. He be- Axis I and II disorders interact to obscure dif-
lieved that no one could really be trus- ferential diagnosis is the case of apparent Axis
ted, that old friends probably talked
II psychopathology that, in fact, is the pro-
about him behind his back (They think
Im a slob), that he could not open up drome of an Axis I disorder. Distinguishing
with new people because they too Cluster A personality disorders, such as para-
would eventually turn on him and reject noid, schizoid, and schizotypal, from the
early signs of Axis I disorders in the schizo- For the patient with a diagnosis of schizo-
phrenia and other psychotic disorders class typal personality disorder, the occurrence of a
can be particularly difficult. If a clinician is 1-month-long psychotic episode almost cer-
evaluating a patient early in the course of the tainly means the disturbance will meet the
initial onset of a psychotic disorder, he or she criteria for schizophrenia, the symptoms of
may be confronted with changes in the person schizotypal personality disorder counting
toward increasing suspiciousness, social as prodromal symptoms toward the 6-month
withdrawal, eccentricity, or reduced function- duration requirement. Under these circum-
ing. Because the diagnosis of psychotic disor- stances, the diagnosis of schizophrenia, with
ders, including schizophrenia, requires that its pervasive effects on cognition, perception,
the patient have an episode of active psycho- functional ability, and so on, is sufficient, and
sis with delusions and hallucinations, it is not a diagnosis of schizotypal personality disor-
possible to diagnose this prodrome as a psy- der is redundant. When the patient becomes
chotic disorder. In fact, until the full-blown nonpsychotic again, he or she would be con-
disorder is present, the clinician cannot be cer- sidered to have residual schizophrenia in-
tain if it is, indeed, a prodrome. stead of schizotypal personality disorder.
If a change in behavior is of recent onset,
then it does not meet the stability criteria for Personality Traits Versus
a personality disorder. In such cases, the cli-
nician is forced to diagnose an unspecified
mental disorder (nonpsychotic; DSM-IV-TR Another difficult distinction is between per-
code 300.9). If, however, the pattern of suspi- sonality traits or styles and personality disor-
ciousness or social withdrawal with or with- ders. All patientsall people for that mat-
out eccentricities has been well established, it tercan be described in terms of distinctive
may legitimately be a personality disorder patterns of personality, but all do not neces-
and be diagnosed as such. sarily warrant a diagnosis of personality dis-
If the clinician follows such a patient over order. This error is particularly common
time and the patient develops a full-fledged among inexperienced evaluators. The im-
psychotic disorder, the personality distur- portant features that distinguish pathologi-
bance is no longer adequate for a complete di- cal personality traits from normal traits are
agnosis because none of the Axis II disorders their inflexibility and maladaptiveness, as
includes frankly psychotic symptoms. This discussed earlier.
fairly obvious point is frequently overlooked DSM-IV-TR recognizes that it is impor-
in practice. All of the personality disorders tant to describe personality style as well as to
that have counterpart psychotic disorders on diagnose personality disorder on Axis II.
Axis I have milder symptoms in which reality Therefore, instructions are included to list
testing is, at least in part, intact. For instance, personality features on Axis II even when a
a patient with paranoid personality disorder personality disorder is absent, or to include
may have referential ideas but not frank delu- them as modifiers of one or more diagnosed
sions of reference, and a patient with schizo- personality disorders (e.g., BPD with histri-
typal personality disorder may have illusions onic features). In practice, however, this op-
but not hallucinations. A possible exception tion has been seldom utilized (Skodol et al.
is BPD, in which brief psychotic experiences 1984), even though research has shown that,
(lasting minutes to an hour or two at most) in addition to the approximately 50% of
are included in the diagnostic criteria. In all clinic patients who meet criteria for a person-
cases, however, when the patient becomes ality disorder, another 35% warrant informa-
psychotic for even a day or two, an additional tion descriptive of their personality styles on
Axis I diagnosis is necessary. Axis II (Kass et al. 1985). The overlap among
the features of personality disorders also be- tially was agreeable to both parties. She
comes very evident when emphasis is placed craved affection and attention and fell
on the assessment of traits of all personality deeply in love with these men. How-
ever, she eventually became overtly
disorders, even when one is predominant.
self-centered, demanding, and manipu-
The following case example (adapted lative, and the man would break off the
from Skodol 1989) describes a patient with an relationship. After breaking up, she
Axis I disorder whose ongoing treatment would almost immediately start claim-
was very much affected by Axis II personal- ing that the particular man was going
ity traits, none of which met criteria for a per- nowhere, was not for her, and would
sonality disorder. not be missed. In between these rela-
tionships, she often had periods in
which she engaged in a succession of
Case Example
one-night stands, having sex with a
half-dozen partners in a month. Alter-
A 25-year-old, single female receptionist natively, she would frequent rock clubs
was referred for outpatient therapy fol- and bars, in-spots, as she called them,
lowing hospitalization for her first merely on the chance of meeting some-
manic episode. The patient had attended one who would introduce her to the
college for 1 year but dropped out in or- glamorous world she dreamed of.
der to go into advertising. Over the The patient had no female friends
next 5 years, she had held a series of re- other than her sister. She could see little
ceptionist, secretarial, and sales jobs, use for such friendships. She preferred
each of which she quit because she spending her time shopping for stylish
wasnt getting ahead in the world. She clothes or watching television alone at
lived in an apartment on the north side home. She liked to dress fashionably
of Chicago, by herself, that her parents and seductively but often felt that she
had furnished for her. She ate all of her was too fat or that her hair was the
meals, however, at her mothers house wrong color. She had trouble control-
and claimed not even to have a box of ling her weight and would periodically
crackers in her cupboard. Between her go on eating binges for a few days that
jobs, her parents paid her rent. might result in a 10-pound weight gain.
Her career problems stemmed She read popular novels but had very
from the fact that, although she felt few other interests. She admitted she
quite ordinary and without talent for was bored much of the time but would
the most part, she had fantasies of a ca- not admit that cultural or athletic pur-
reer as a movie star or high fashion suits were other than a waste of time.
model. She took acting classes and sing- This patient was referred for outpa-
ing lessons but had never had even a tient follow-up without an Axis II per-
small role in a play or show. What she sonality disorder diagnosis. In fact, her
desired was not so much the careers long-term functioning failed to meet
themselves but the glamour associated DSM-IV-TR criteria for any specific type
with them. Although she wanted to of personality disorder. On the other
move in the circles of the beautiful hand, she almost met the criteria for
people, she was certain that she had several, especially BPD: the patient
nothing to offer them. She sometimes showed signs of impulsivity (overeat-
referred to herself as nothing but a shell ing, sexual promiscuity), intense inter-
and scorned herself because of it. She personal relationships (manipulative,
was unable to picture herself working overidealization/devaluation), identity
her way up along any realistic career disturbance, and chronic feelings of
line, feeling both that it would take too emptiness. She did not, however, dis-
long and that she would probably fail. play intense anger, intolerance of being
She had had three close relation- alone, physically self-damaging behav-
ships with men that were characterized ior, stress-related paranoia or dissocia-
by an intense interdependency that inition, or affective instability indepen-
dent of her mood disorder. Similarly, passivity, emotionality, emphasis on work

she had symptoms of histrionic person- and productivity, and unusual beliefs and rit-
ality disorder: she was inappropriately uals are culturally sanctioned. Only when
sexually seductive and used her physi-
such behaviors are clearly in excess or discor-
cal appearance to draw attention to her-
self, but she was not emotionally over-
dant with the standards of a persons cultural
dramatic. She had shallow expression milieu would the diagnosis of a personality
of emotions and was uncomfortable disorder be considered. Certain sociocultural
when she was not the center of atten- contexts may lend themselves to eliciting and
tion, but was not overly suggestible. reinforcing behaviors that might be mistaken
She also had some features of narcissis- for personality disorder psychopathology.
tic, avoidant, and dependent personal- Members of minority groups, immigrants, or
ity disorders. The attention paid to per-
refugees, for example, might appear overly
sonality traits in her outpatient clinic
evaluation conveyed a vivid picture of guarded or mistrustful, avoidant, or hostile in
the patients complicated personality response to experiences of discrimination,
pathology, which became the focus of language barriers, or problems in accultura-
her subsequent therapy. tion (Alarcon 2005).
Age
Effects of Gender, Culture, and Age
Although personality disorders are usually
Gender not diagnosed prior to age 18 years, certain
thoughts, feelings, and behaviors suggestive
Although definitive estimates about the sex of personality psychopathology may be ap-
ratio of personality disorders cannot be made parent in childhood. For example, depen-
because ideal epidemiological studies do not dency, social anxiety and hypersensitivity,
exist, some personality disorders are believed disruptive behavior, or identity problems
to be more common in clinical settings among may be developmentally expected. Follow-
men and others among women. Personality up studies of children have shown decreases
disorders listed in DSM-IV-TR as occurring in such behaviors over time (Johnson et al.
more often among men are paranoid, schiz- 2000), although children with elevated rates
oid, schizotypal, antisocial, narcissistic, and of personality disordertype signs and symp-
obsessive-compulsive personality disorders. toms do appear to be at higher risk for both
Those occurring more often in women are Axis I and Axis II disorders in young adult-
borderline, histrionic, and dependent person- hood (Johnson et al. 1999; Kasen et al. 1999).
ality disorders. Avoidant is said to be equally Thus, some childhood problems may not
common in men and women. Apparently el- turn out to be transitory, and personality dis-
evated sex ratios that do not reflect true prev- order may be viewed developmentally as a
alence rates can be the result of sampling or failure to mature out of certain age-appropri-
diagnostic biases in clinical settings (Widiger ate or phase-specific feelings or behaviors. A
1998). True differences may be due to biolog- developmental perspective on personality
ical factors such as hormones, social factors disorders is presented more fully in Chapter
such as child-rearing practices, and their in- 7, Developmental Issues.
teractions (Morey et al. 2005).
Other Aspects of
Culture Personality Functioning
Apparent manifestations of personality dis- A problem with the DSM conceptualizations
orders must be considered in the context of a of personality disorders is that the individual
patients cultural reference group and the de- categories do not correspond well with exist-
gree to which behaviors such as diffidence, ing treatment approaches. Thus, whether a
clinician is a psychodynamically oriented includes a Defensive Functioning Scale and a

therapist, a cognitive-behavioral therapist, Glossary of Specific Defense Mechanisms
or a psychopharmacologist, information in and Coping Styles. The 27 defense mecha-
addition to that necessary for a DSM person- nisms defined in this glossary are acting-out,
ality disorder diagnosis is needed to formu- affiliation, altruism, anticipation, autistic
late a treatment plan. Usually, this additional fantasy, denial, devaluation, displacement,
information is based on the theory of why a dissociation, help-rejecting complaining, hu-
patient has a personality disorder and/or the mor, idealization, intellectualization, isola-
mechanisms responsible for perpetuating tion of affect, omnipotence, passive aggres-
the dysfunctional patterns. sion, projection, projective identification,
rationalization, reaction formation, repres-
Conflicts, Ego Functions, Object sion, self-assertion, self-observation, split-
Relations, and Defense Mechanisms ting, sublimation, suppression, and undoing.
Some defense mechanisms, such as projec-
Psychodynamically oriented clinicians have tion, splitting, or acting-out, are always mal-
expressed dissatisfaction with the DSM sys- adaptive, whereas others, such as sublima-
tem of axes, including Axis II, since its incep- tion or humor, are adaptive. Patients with
tion. The DSM multiaxial system fails, in personality disorders have characteristic
their opinion, to discriminate between pa- predominant defensive patterns. Thus pa-
tients according to clinical variables impor- tients with paranoid personality disorder use
tant for planning treatment with psychody- denial and projection, those with BPD typi-
namic psychotherapy (Karasu and Skodol cally rely on acting-out and splitting (among
1980). Thus, they may be more interested in others), and those with OCPD use isolation
exploring conflicts between wishes, fears, of affect and undoing (Perry and Bond 2005).
and moral standards; ego functions such as Clinicians may note current defenses or cop-
impulse control or affect regulation; or self ing styles as well as a patients predominant
and other (object) representations based on current defense level using the Defensive
early attachment experiences than on the Functioning Scale.
signs and symptoms of personality disor-
ders. Elaborations of psychodynamic theo- Coping Styles
ries of personality disorders can be found in
Chapter 2, Theories of Personality and Per- Although defense mechanisms in DSM-IV-
sonality Disorders, and Chapter 10, Psy- TR are said to include coping styles, the liter-
choanalysis and Psychodynamic Psycho- ature on coping discusses styles not included
therapy, along with discussions of relevant in the DSM list. Coping refers to specific
clinical variables. thoughts and behaviors that a person uses to
Several groups of researchers (Bond and manage the internal and external demands
Vaillant 1986; Perry and Cooper 1989; Vail- of situations appraised as stressful (Folkman
lant et al. 1986) have been able to document and Moskowitz 2004; Lazarus and Folkman
empirically the clinical utility of categorizing 1984; Pearlin and Schooler 1978). Coping in-
a patients defensive functioning. Defense volves cognitive, behavioral, and emotional
mechanisms are automatic psychological pro- responses and may or may not be consistent
cesses that protect people against anxiety across stressful situations or functional roles.
and against awareness of internal or external Two major broad styles of coping are prob-
stressors or dangers. Although this work was lem-focused coping and emotion-focused
considered too early in its development to coping. Problem-focused coping refers to ef-
justify including a separate official axis based forts to resolve a threatening problem or di-
on it, Appendix B in DSM-IV-TR (Criteria minish its impact by taking direct action.
Sets and Axes Provided for Further Study) Emotion-focused coping refers to efforts to re-
duce the negative emotions aroused in re- and judgment necessary to make many of the
sponse to a threat by changing the way the diagnoses. Numerous critics have noted that it
threat is attended to or interpreted. Meaning- is easy to disagree about symptoms such as af-
focused and social coping are other observed fective instability, self-dramatization, shallow
coping strategies. Coping has traditionally emotional expression, exaggerated fears, or
been assessed by retrospective self-report feelings of inadequacyall symptoms of
measures (e.g., the Coping Responses Inven- DSM-IV-TR personality disorders. Only the
tory [Moos 1993], the Ways of Coping Ques- antisocial criteria, among the personality dis-
tionnaire [Folkman and Lazarus 1988], and orders, have historically yielded acceptable
the COPE Inventory [Carver et al. 1989]) levels of reliability, and those criteria have em-
and more recently by ecological momentary phasized overtly criminal and delinquent acts.
assessment (real-time) techniques (Stone et These observations led several investiga-
al. 1998); but the major types of coping, such tors to attempt to determine sets of behaviors
as problem solving, seeking support, dis- that might serve to identify types of person-
tancing and distracting, accepting responsi- ality disorder. Although any one behavior
bility, positive reappraisal, or self-blame, can might not be sufficient to indicate a particu-
also be assessed by clinical interview. lar personality trait, multiple behavioral in-
dicators considered together would increase
Cognitive Schemas confidence in recognizing the trait.
Behaviors that typify a particular person-
Cognitive therapists want to characterize
ality style have been referred to as prototypi-
patients with personality disorders accord-
cal. Livesley (1986) developed a set of proto-
ing to patients dysfunctional cognitive sche-
typical behaviors for the DSM-III (American
mas (core beliefs by which they process
Psychiatric Association 1980) personality dis-
information) or their automatic thoughts,
orders and compared them with prototypical
interpersonal strategies, and cognitive dis-
traits. He found that highly prototypical be-
tortions. Again, particular personality disor-
haviors could be derived from corresponding
ders tend to have particular core beliefs. For
traits. For example, with regard to the con-
example, patients with BPD frequently have
cepts of social awkwardness and withdrawal
beliefs such as I am needy and weak or I
of the schizoid personality disorder, Livesley
am helpless if left on my own, whereas pa-
found that behaviors such as does not speak
tients with OCPD believe It is important to
unless spoken to, does not initiate social
do a perfect job on everything or People
contacts, and rarely reveals self to others
should do things my way (Beck et al. 2004).
were uniformly rated as highly prototypical.
In contrast to beliefs, which map onto per-
Corresponding to the overly dramatic and
sonality disorders specifically, schemas are
emotional traits of the histrionic personality
broader themes regarding the self and rela-
disorder were behaviors such as expressed
tionships with others and can cut across per-
feelings in an exaggerated way, considered
sonality disorder categories. For example, a
a minor problem catastrophic, and flirted
schema of impaired limits can encompass
with several members of the opposite sex.
the entitlement of narcissistic personality
Behaviors such as has routine schedules and
disorder as well as the lack of self-control of
is upset by deviations, overreacted to criti-
ASPD or BPD (Young and Klosko 2005).
cism, and spent considerable time on the
minutest details corresponded to the con-
Objective Behaviors trolled, perfectionist traits of OCPD.
Versus Inferential Traits DSM-IV-TR makes strides in translating
the characteristic traits of the personality dis-
Another difficulty in diagnosing personality orders into explicit behaviors. The criteria for
disorders stems from the degree of inference each personality disorder begin with the def-
inition of the overall style or set of traits, fol- describe a patients psychopathology and
lowed by a listing of ways this might be ex- virtually ensures that patients will receive
pressed. In some instances, for example, for more than one diagnosis. In addition to the
dependent personality disorder, the criteria co-occurrence of personality disorders with
are quite behavioral. For dependent person- Axis I disorders, it is also common for pa-
ality disorder, a pervasive and excessive tients to receive more than one personality
need to be taken care of that leads to submis- disorder diagnosis to fully describe their per-
sive and clinging behavior and fears of sepa- sonality problems (Lilienfeld et al. 1994; Old-
ration is indicated by such items as has dif- ham et al. 1992). In the sections that follow,
ficulty making everyday decisions without major patterns of personality disorder co-
an excessive amount of advice and reassur- morbidity will be described.
ance from others and needs others to as-
sume responsibility for most major areas of Co-Occurrence of Personality
his or her life (American Psychiatric Associ- Disorders and Axis I Disorders
ation 2000, p. 725). For other disorders, such
as OCPD, an example of the behavior is There are a number of explanations for the
given along with the trait. For OCPD, perfec- high rates of co-occurrence of personality dis-
tionism is indicated by the following crite- orders and Axis I disorders (Lyons et al.
rion: shows perfectionism that interferes 1997). Co-occurring disorders may share a
with task completion (e.g., is unable to com- common etiology and be different pheno-
plete a project because his or her own overly typic expressions of a common causal factor
strict standards are not met) (American Psy- or factors. They may also be linked by etiol-
chiatric Association 2000, p. 729). ogy or pathological mechanism, but one dis-
order may be a milder version of the other on
a spectrum of severity of pathology or im-
COMORBIDITY pairment. One disorder may precede and in-
crease the risk for the occurrence of another
Since the introduction of a multiaxial system disorder, making a person more vulnera-
for recording diagnoses in DSM-III, which ble to developing the second disorder. A
provided for the diagnosis of personality dis- second disorder may arise after a first as a
orders on an axis (II) separate from the ma- complication or residual phenomenon or
jority of other mental disorders, it has be- scar. People with certain personality disor-
come apparent that most patients with ders and related Axis I disorders may share
personality disorders also meet criteria for common psychobiological substrates that
other disorders. Rates have ranged from regulate cognitive or affective processes or
about two-thirds to almost 100% (Dolan- impulse control. The Axis I disorders may be
Sewell et al. 2001). The co-occurrence of Axis the direct symptomatic expression of dys-
I and Axis II disorders has often been re- functions in these systems, whereas personal-
ferred to as comorbidity, although our current ity disorders may reflect coping mechanisms
understanding of the fundamental nature of and more general personality predispositions
most mental disorders is insufficient to jus- arising from the same systems (Siever and
tify the use of the term according to its formal Davis 1991). This more comprehensive model
definition, which requires that a comorbid of disorder co-occurrence integrates aspects
disorder be distinct from the index disease of the common cause, spectrum, and vulner-
or condition (Feinstein 1970). The DSM sys- ability hypotheses.
tem, with its tendency to split as opposed Axis I/Axis II co-occurrence may be
to lump psychopathology via its many and viewed from the perspectives of the course of
expanding lists of disorders, encourages the a persons lifetime or the current presenting
diagnosis of multiple putative disorders to illness. Lifetime rates will obviously be
higher. Patients with personality disorders is most strongly associated with substance
who are seeking treatment also tend to have use disorders in clinical and general popula-
elevated rates of Axis I disorder co-occur- tion samples (Compton et al. 2007; Grant et
rence, because the development or exacerba- al. 2004; Hasin et al. 2007; Kessler et al. 1997;
tion of an Axis I disorder is often the reason a Morgenstern et al. 1997; see also Chapter 19,
personality disorder patient comes for clini- Substance Abuse). This association sup-
cal attention (Shea 1997). For disorder co- ports an underlying dimension of impulsiv-
occurrence to be significant from a scientific ity or externalization (acting-out and being at
perspective, rates must be elevated above odds with mainstream goals and values)
those expected by chance, based on the rates shared by these disorders (Krueger et al.
of occurrence of the individual disorders in a 1998, 2002, 2007).
given clinical setting or population. From a Cluster C personality disorders, espe-
treatment perspective, any co-occurrence cially avoidant and dependent personality
may be significant. disorders, are linked by theory and phenom-
The personality disorders of Cluster A enology to anxiety disorders (Tyrer et al.
paranoid, schizoid, and schizotypalare 1997). Several studies have demonstrated
linked by theory and phenomenology to Axis high rates of co-occurrence of avoidant per-
I psychotic disorders such as delusional dis- sonality disorder with MDD, agoraphobia,
order, schizophreniform disorder, or schizo- social phobia, and obsessive-compulsive dis-
phrenia. Few studies have actually docu- order (Herbert et al. 1992; Oldham et al. 1995;
mented these associations, however, possibly Skodol et al. 1995). The co-occurrence rates
because of problems in being able to differen- between avoidant personality disorder and
tiate between clinical presentations of attenu- social phobia (particularly the generalized
ated and full-blown psychotic symptoms that type) have been so high in some studies that
warrant two diagnoses instead of just one. investigators have argued that they are the
Oldham et al. (1995) found elevated odds of a same disorder. Several studies have indi-
current psychotic disorder in patients with cated that dependent personality disorder
Cluster A personality disorders but also co-occurs with a wide variety of Axis I disor-
found elevated odds for Clusters B and C per- ders, consistent with the notion of excessive
sonality disorders as well, suggesting less dependency as a nonspecific maladaptive
disorder specificity than might be expected. behavior pattern that may result from coping
In contrast, Cluster B personality disor- with other chronic mental disorders (Skodol
ders, especially BPD, which is linked by the- et al. 1996). OCPD may be specifically linked
ory and phenomenology to Axis I mood and to obsessive-compulsive disorder; however,
impulse control disorders, have repeatedly an association between them has only incon-
been shown to have high rates of co-occur- sistently been found.
ring MDD and other mood disorders, sub- Following the co-occurrence of Axis I and
stance use disorders, and bulimia nervosa Axis II disorders is more than an intellectual
(Oldham et al. 1995; Skodol et al. 1993, 1999; exercise. The presence of an Axis I disorder in
Zanarini et al. 1989, 1998). Taking into ac- a patient with a personality disorder may sug-
count co-occurrence expected by chance gest a more specific treatment approach, ei-
alone, however, neither Oldham et al. (1995) ther with pharmacological agents, psycho-
nor McGlashan et al. (2000) substantiated the therapy, or self-help groups (as in the case of
relationship between BPD and MDD. In ad- substance use disorders), that will favorably
dition, several studies have shown signifi- affect outcome in these patients. Conversely,
cantly elevated rates of anxiety disorders, in- the presence of personality disorder in a pa-
cluding panic disorder and posttraumatic tient with an Axis I disorder often indicates
stress disorder, in patients with BPD (Mc- greater and more widespread levels of impair-
Glashan et al. 2000; Skodol et al. 1995). ASPD ment (Jackson and Burgess 2002; Skodol et al.
2002), more chronicity (Grilo et al. 2005; Hart criteria for more than one disorder, clinicians
et al. 2001), and an overall poorer response to have found the practice of diagnosing multi-
treatment requiring more intensive and pro- ple disorders conceptually difficult and
longed care (Reich and Vasile 1993; Shea et al. therefore seldom attempt such diagnoses.
1992). Twenty years later, co-occurring Axis I Prior to DSM-III-R (American Psychiatric
and Axis II disorders present a higher risk for Association 1987), part of the problem had
negative prognoses than do disorders on ei- been that most of the personality disorders
ther axis alone (Crawford et al. 2008). were defined as classical categories (Cantor et
al. 1980)that is, ones in which all members
Co-Occurrence of Personality clearly share certain identifying features.
Disorders With Other Classical categories imply a clear demar-
cation between members and nonmembers,
but natural phenomena rarely fit neatly into
When thorough assessments of the full range such categories.
of Axis II disorders are conducted, as in re-
search studies employing semistructured in-
terviews, approximately half of patients re- CATEGORICAL VERSUS
ceive more than one personality disorder
diagnosis. Patterns of co-occurrence of per- DIMENSIONAL ASSESSMENTS
sonality disorders generally follow the DSM OF PERSONALITY
cluster structure (i.e, schizotypal personality
disorder occurs more frequently with para- Traditionally, in much of the psychological
noid and schizoid personality disorders than literature, personality has been described and
with personality disorders outside Cluster measured along certain dimensions (Frances
A). These patterns are consistent with factor- 1982). Dimensions of personality frequently
analytic studies that support the clustering of are continuous with opposite traits at either
personality disorders in DSM (Kass et al. end of a spectrum, such as dominant-sub-
1985; Sanislow et al. 2002). Some personality missive or hostile-friendly. People can then
disorders, however, particularly those in vary in the extent to which each of the traits
Cluster C, show associations with personal- describes them. Dimensional models of per-
ity disorders from other clusters. Dependent sonality diagnosis appear to be more flexible
personality disorder commonly occurs in pa- and specific than categorical models when
tients with BPD, which makes clinical sense the phenomenology lacks clear-cut bound-
because patients with BPD can display re- aries between normal and abnormal and be-
gressive, clinging, and dependent behavior tween different constellations of maladaptive
in interpersonal relationships. Some person- traits, as seems true of personality distur-
ality disorders rarely co-occur. OCPD and bance (Widiger et al. 1987). Scaled rating sys-
ASPD would be an exceedingly rare combi- tems have been devised to transform Axis II
nation, because the careful planning and disorders into dimensions (Kass et al. 1985;
work orientation of OCPD are the antithesis Oldham and Skodol 2000), but they are not
of the impulsivity and irresponsibility of representative of dimensional approaches
ASPD. currently in wide use. Dimensional models of
Elevated rates of personality disorder co- personality disorders are being seriously con-
occurrence raise questions about the appro- sidered for DSM-V (see Chapter 20, Future
priate application of DSM-IV-TR categories to Directions: Toward DSM-V.
phenomenology that rarely appears to have Some personality disorder researchers
discrete boundaries. Although DSM-IV-TR advocate a prototype matching approach to
clearly stipulates that for many patients, per- the diagnosis of personality disorders rather
sonality disturbance would frequently meet than the current DSM procedure, which con-
tinues to involve making present/absent American Psychiatric Association: Diagnostic and

judgments about individual criteria (Shedler Statistical Manual of Mental Disorders, 3rd
and Westen 2004; Westen et al. 2006). They
would replace the diagnostic criteria sets American Psychiatric Association: Diagnostic and
with descriptions of various personality dis- Statistical Manual of Mental Disorders, 3rd
order prototypes in paragraph form and ask Edition, Revised. Washington, DC, American
clinicians to rate the degree of similarity be- Psychiatric Association, 1987
tween the prototypes and the patient under- American Psychiatric Association: Diagnostic and
going evaluation. They argue that a proto- Edition, Text Revision. Washington, DC,
type matching approach allows the clinician American Psychiatric Association, 2000
to consider individual criteria in the context Andreoli A, Gressot G, Aapro N, et al: Personality
of the whole personality disorder descrip- disorders as a predictor of outcome. J Personal
tion, such that no single criterion can make Disord 3:307321, 1989
Beck AT, Freeman A, Davis DD, et al: Cognitive
or break the diagnosis. They also argue that
Therapy of Personality Disorders, 2nd Edi-
a prototype matching approach is closer to tion. New York, Guilford, 2003
the way clinicians make personality disorder Bender DS, Skodol AE: Borderline personality as a
diagnoses in actual practice. self-other representational disturbance. J Per-
sonal Disord 21:500517, 2007
Benjamin LS: Interpersonal Diagnosis and Treat-
ment of Personality Disorders, 2nd Edition.
CONCLUSION New York, Guilford, 1996
Bernstein DP, Cohen P, Skodol AE, et al: Child-
Although considerable dissatisfaction has hood antecedents of adolescent personality
disorders. Am J Psychiatry 153:907913, 1996
been expressed over the DSM approach to
Blashfield RK, Herkov MJ: Investigating clinician
these disorders and a major overhaul has adherence to diagnosis by criteria: a replica-
been recommended by many researchers tion of Morey and Ochoa (1989). J Personal
and clinicians in the field (Clark et al. 1997; Disord 10:219228, 1996
Shedler and Westen 2004; Widiger 1991, Bond MP, Vaillant JS: An empirical study of the re-
lationship between diagnosis and defense
1993), the DSM approach remains the official
style. Arch Gen Psychiatry 43:285288, 1986
standard for diagnosing personality disor- Cantor N, Smith EE, French RS, et al: Psychiatric
der psychopathology. Work on DSM-V has diagnosis as prototype categorization. J Ab-
recently begun, but its publication is not an- norm Psychol 89:181193, 1980
ticipated until at least 2012. Therefore, even if Carver CS, Scheier MF, Weintraub JK: Assessing
coping strategies: a theoretically based ap-
a dimensional approach to personality disor-
proach. J Pers Soc Psychol 56:267283, 1989
ders were to replace the categorical approach Casey PR, Tyrer P: Personality disorder and psy-
in DSM-V, these changes would not be im- chiatric illness in general practice. Br J Psychi-
plemented for several years. atry 156:261265, 1990
Clark LA, Livesley WJ, Morey L: Special feature:
personality disorder assessment: the chal-
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4
Course and Outcome
Carlos M. Grilo, Ph.D.
The diagnostic construct of personality dis- tion systems, DSM-IV-TR and ICD-10 (World
order has evolved considerably over the past Health Organization 1992), although the two
few decades (see Skodol 1997 for a detailed systems differ somewhat in their classification
ontogeny of the DSM system; and see Chapter and definitions for personality disorders and
1, Personality Disorders: Recent History and thus demonstrate only moderate convergence
the DSM System, for a historical overview). for some diagnoses (Ottosson et al. 2002). The
Substantial changes have occurred in both the extent of stability of personality disorders re-
number and types of specific personality dis- mains uncertain (Shea and Yen 2003; Tyrer
order diagnoses over time, as well as in the and Simonsen 2003). This chapter provides an
admixture of criteria (Sanislow and Mc- overview of the course and outcome of per-
Glashan 1998) representing possible manifes- sonality disorders and synthesizes the empiri-
tations of personality disorders (e.g., DSM-IV- cal literature on the stability of personality dis-
TR [American Psychiatric Association 2000] orders.
specifies that the enduring pattern can be
manifested by problems in at least two of the
following areas: cognition, affectivity, in- STABILITY AS THE CENTRAL TENET OF
terpersonal functioning, or impulse control).
PERSONALITY DISORDERS
One central tenetthat a personality disorder
reflects a persistent, pervasive, enduring, and The concept of stability has remained a cen-
stable patternhas not changed. The concept tral tenet of personality disorders throughout
of stability is salient in both major classifica- the various editions of DSM, dating back to
63
the first edition (American Psychiatric Asso- David and Pilkonis 1996; Perry 1993; Ruegg
ciation 1952). In what some experts have re- and Frances 1995; Stone 1993; Zimmerman
ferred to as a bold step (Tyrer and Simon- 1994). These reviews, although varied, have
sen 2003), personality disorders were placed agreed on the pervasiveness of methodolog-
on a separate axis (Axis II) of the multiaxial ical problems that characterize much of the
DSM-III (American Psychiatric Association literature and thereby preclude any firm con-
1980). DSM-III stated that the separation to clusions regarding the nature of the stability
Axis II was intended, in part, to encourage cli- of personality disorders. The reviews, how-
nicians to assess the possible presence of dis- ever, have also generally agreed that avail-
orders that are frequently overlooked when able research raises questions regarding
attention is directed to the usually more florid many aspects of the construct validity of per-
Axis I disorder. Conceptually, this separa- sonality disorders (Zimmerman 1994), in-
tion reflected the putative stability of person- cluding their hypothesized high degree of
ality disorders relative to the episodically un- stability (Grilo and McGlashan 1999).
stable course of Axis I psychiatric disorders The few early (pre-DSM-III era) studies
(Grilo et al. 1998; Skodol 1997). of the course of personality disorders re-
ported findings that borderline (Carpenter
and Gunderson 1977; Grinker et al. 1968) and
antisocial (Maddocks 1970; Robbins et al.
FIRST- AND SECOND-GENERATION
1977) personality disorders were highly sta-
RESEARCH STUDIES ON STABILITY ble. Carpenter and Gunderson (1977), for ex-
ample, reported that the impairment in func-
First, we provide a brief review of the empiri-
tioning observed for borderline personality
cal literature through the end of the twentieth
disorder (BPD) was comparable with that ob-
century. This period can be thought of as in-
served for patients with schizophrenia over a
cluding the first generation (mostly clinical-
5-year period. As previously noted (Grilo et
descriptive accounts) and the second genera-
al. 1998), the dominant clinical approach to
tion (the emerging findings based on attempts
assessing personality disorder diagnoses
at greater standardization of diagnoses and
based partly on treatment refractoriness nat-
assessment methods) of research efforts on
urally raises the question of whether these
personality disorders. Second, we provide a
findings simply reflect a tautology.
brief overview of methodological problems
The separation of personality disorders to
and conceptual gaps that characterize this lit-
Axis II in DSM-III contributed to increased re-
erature and that must be considered when in-
search attention to these clinical problems
terpreting ongoing research and designing fu-
(Blashfield and McElroy 1987). The develop-
ture studies. Third, we summarize emerging
ment and utilization of a number of struc-
findings from ongoing longitudinal studies
tured and standardized approaches to clini-
that have shed light on a number of key issues
cal interviewing and diagnosis during the
about the course of personality disorders.
1980s represented notable advances (Zim-
merman 1994). The greater attention paid to
defining the criteria required for diagnosis in
OVERVIEW OF THE LITERATURE the classification systems and by researchers
THROUGH 1999 during the development of standardized in-
terviews greatly facilitated research efforts in
A number of previous reviews have been this field.
published addressing aspects of the course In our previous reviews of the DSM-III
and outcome of personality disorders (Grilo and DSM-III-R (American Psychiatric Associ-
and McGlashan 1999; Grilo et al. 1998; Mc- ation 1987) studies, we concluded that the
Course and Outcome 65
available research suggested that personality

disorders demonstrate only moderate stabil- CONCEPTUAL AND
ity and that, although personality disorders METHODOLOGICAL QUESTIONS
are generally associated with negative out-
comes, they can improve over time and can
ABOUT COURSE
benefit from specific treatments (Grilo and
Previous reviews of personality disorders
McGlashan 1999, p. 157). In our 1998 review
have raised many methodological problems.
(Grilo et al. 1998), we noted that the 20 se-
Common limitations highlighted include
lected studies of DSM-III-R criteria generally
small sample sizes; concerns about nonstand-
found low to moderate stability of any per-
ardized assessments, interrater reliability,
sonality disorder over relatively short follow-
blindness to baseline characteristics, and nar-
up periods (6 to 24 months). For example, the
row assessments; failure to consider alterna-
major studies that employed diagnostic inter-
tive (e.g., dimensional) models of personality
views reported kappa coefficients for the pres-
disorder; reliance on only two assessments
ence of any personality disorder of 0.32
typically over short follow-up periods; insuf-
(Johnson et al. 1997), 0.40 (Ferro et al. 1998),
ficient attention to the nature and effects of
0.50 (Loranger et al. 1994), and 0.55 (Loranger
co-occurring Axis I and Axis II diagnoses;
et al. 1991). Especially noteworthy is that the
and inattention to treatment effects. Diag-
stability coefficients for specific personality
noses other than ASPD and BPD have re-
disorder diagnoses (in the few cases in which
ceived little attention. Particularly striking is
they could be calculated given the sample
the absence of relevant comparison or con-
sizes) were generally lower. In addition, fol-
trol groups in the longitudinal literature. We
low-up studies of adolescents diagnosed with
comment briefly on a few of these issues.
personality disorders also reported modest
stability; for example, Mattanah et al. (1995)
reported a 50% rate of stability for any person-
Reliability
ality disorder at 2-year follow-up. More re- Reliability of assessments represents a central
cently, Grilo et al. (2001) also found modest issue for any study of course and outcome.
stability in dimensional personality disorder The creation of standardized instruments for
scores in this adolescent follow-up study. collecting data was a major development of
Squires-Wheeler et al. (1992), as part of the the 1980s (Loranger et al. 1991; Zimmerman
New York State high-risk offspring study, re- 1994). Such instruments, however, were less-
ported low stability for schizotypal personal- than-perfect assessment methods and have
ity disorder and features, although the stabil- been criticized for a variety of reasons (Wes-
ity was higher for the offspring of patients ten 1997; Westen and Shedler 1999). It is crit-
with schizophrenia than for those with mood ical to keep in mind that interrater reliability
disorders or control subjects. and testretest reliability represent the limits
Subsequently, we (Grilo and McGlashan (or ceiling) for estimating the stability of a
1999) reviewed nine reports of longitudinal construct.
findings for personality disorder diagnoses Previous reviews (Grilo and McGlashan
published in 1997 and 1998. In terms of spe- 1999; Zanarini et al. 2000; Zimmerman 1994)
cific diagnoses, the studies generally reported of reliabilities for Axis II diagnostic inter-
moderate stability (kappa approximately 0.5) views have generally reported median inter-
for BPD and antisocial personality disorder rater reliabilities of roughly 0.70 and short-
(ASPD). These reports, like most of the previ- interval, testretest reliabilities of 0.50 for
ous literature, had small sample sizes and in- diagnoses. These reliabilities compare favor-
frequently followed more than one personal- ably with those generally reported for diag-
ity disorder. nostic instruments for Axis I psychiatric dis-
orders. Both int errat er and testre test unrelated to state-trait effects, reflects
reliability coefficients tend to be higher for some combination of the following: regres-
dimensional scores than for categorical diag- sion to the mean, error in either or both the
noses of personality disorders. Another find- baseline and repeated assessments, and
ing of note is that even when experts admin- overreporting by patients at hospital admis-
ister diagnostic interviews, the degree of sion and underreporting during retest at dis-
convergence or agreement produced by two charge (Loranger et al. 1991; Shea and Yen
different interviews administered only 2003). These phenomena were discussed fur-
1 week apart is limited (Oldham et al. 1992). ther by Gunderson et al. (2000).
Reliability and Change Categorical Versus

Dimensional Approaches
Testretest reliability is also relevant for ad-
dressing, in part, the well-known problem of Long-standing debate regarding the concep-
regression to the mean in repeated mea- tual and empirical advantages to dimen-
sures studies (Nesselroade et al. 1980). It has sional models of personality disorders
been argued that the multiwave or repeated (Frances 1982; Livesley et al. 1992; Loranger
measures approach lessens the effects of re- et al. 1994; Widiger 1992) has accompanied
gression to the mean (Lenzenweger 1999). the DSM categorical classification system.
This argument may be true in terms of the Overall, longitudinal studies of personality
obvious decreases in severity with time (i.e., disorder have reported moderate levels of
very symptomatic participants meeting eligi- stability for dimensional scores for most per-
bility at study entry are likely to show some sonality disorders, with the stability coeffi-
improvement because, by definition, they cients tending to be higher than for categori-
are already reporting high levels of symp- cal or diagnostic stability (Ferro et al. 1998;
toms). However, other effects need to be con- Johnson et al. 1997; Klein and Shih 1998; Lo-
sidered whenever assessments are repeated ranger et al. 1991, 1994).
within a study. As cogently noted by Shea
and Yen (2003), repeated measures studies of Comorbidity
both Axis II (Loranger et al. 1991) and Axis I
(Robins 1985) disorders have found hints Most studies have ascertained participants
that participants systematically report or en- who meet criteria for multiple Axis I and Axis
dorse fewer problems during repeated inter- II diagnoses. This problem of diagnostic over-
views to reduce interview time. For example, lap, or comorbidity, represents a well-known,
Loranger et al. (1991), in his testretest study long-standing major challenge (Berkson 1946)
of the Personality Disorder Examination in- in working with clinical samples. One expert
terview (Loranger 1988) conducted between and critic of DSM (Tyrer 2001), in speaking of
1 and 26 weeks after baseline, documented the spectre of comorbidity, noted that the
significant decreases in personality disorder main reason for abandoning the present clas-
criteria for all but two of the DSM-III-R diag- sification is summed up in one word, comor-
noses. Recall that the Personality Disorder bidity. Comorbidity is the nosologists night-
Examination, which requires skilled and mare; it shouts, you have failed (p. 82). We
trained research clinicians, has a required suggest, however, that such clinical realities
minimum duration stipulation of 5 years for (multiple presenting problems that are espe-
determining persistence and pervasiveness cially characteristic of treatment-seeking pa-
of the criteria being assessed. Thus, the mag- tients) represent not only potential confounds
nitude of changes observed during such a but also potential opportunities to under-
short period of time, which was shown to be stand personality and dysfunctions of person-
ality better. Comorbidity begs the question: during a 2-year follow-up, even after control-
what are the fundamental personality dimen- ling for previous psychiatric history (John-
sions and disorders of personality, and how son et al. 1997).
do their courses influence (and conversely,
how are their courses affected by) the pres-
Comorbidity and Continuity Models
ence and course of Axis I psychiatric disor-
ders? A variation of the comorbidity concept is that
certain disorders may be associated with one
Continuity another in a number of possible ways over
time. A variety of models have been pro-
A related issue pertaining to course concerns posed for the possible relationships between
longitudinal comorbidities (Kendell and Axis II and Axis I disorders (Dolan-Sewell et
Clarkin 1992) or continuities. An obvious al. 2001; Lyons et al. 1997; Tyrer et al. 1997).
example is that conduct disorder during ado- These include, for example, the predisposi-
lescence is required for the diagnosis of tion or vulnerability model, the complication
ASPD to be given to adults. This definitional or scar model, the pathoplasty or exacerba-
isomorphism is one likely reason for the con- tion model, and various spectrum models.
sistently strong associations between conduct We emphasize that these models do not nec-
disorder and later ASPD in the literature. essarily assume categorical entities. Indeed,
This association is, however, more than an ar- an especially influential spectrum model
tifactual relationship, because longitudinal proposed by Siever and Davis (1991) posits
research has clearly documented that chil- four psychobiological dimensions to account
dren and adolescents with behavior disor- for Axis II and Axis I psychopathology. The
ders have substantially elevated risk for anti- Cloninger et al. (1993) psychobiological
social behavior during adulthood (Robins model of temperament and character repre-
1966). More generally, studies with diverse sents another valuable approach that consid-
recruitment and ascertainment methods re- ers dimensions across personality and psy-
ported that disruptive behavior disorders chopathology. More broadly, Krueger noted
during the adolescent years prospectively that although most research has focused on
predicted personality disorders during pairs of constructs (i.e., Axis II and Axis I as-
young adulthood (Bernstein et al. 1996; sociations) (Krueger 1999; Krueger and Tack-
Lewinsohn et al. 1997; Myers et al. 1998; Rey ett 2003), it seems important to examine the
et al. 1995). The Yale Psychiatric Institute fol- multivariate structure of the personality-
low-up study found that personality disorder psychopathology domain (Krueger and
diagnoses in adolescent inpatients prospec- Tackett 2003, p. 109).
tively predicted greater drug use problems
but not global functioning (Levy et al. 1999). Age (Early Onset)
The importance of considering comor-
bidity is underscored in the findings of the A related point, stressed by Widiger (2003),
longitudinal study by Lewinsohn et al. is that personality disorders need to be more
(1997). They found that the apparent longitu- clearly conceptualized and carefully charac-
dinal continuity noted for disruptive behav- terized as having an early onset. However,
ioral disorders during adolescence and sub- the validity of personality disorders in ado-
sequent ASPD in adulthood was accounted lescents remains controversial (Krueger and
for, in part, by Axis I psychiatric comorbidity. Carlson 2001). It can be argued, for example,
A longitudinal study of young adult men that determining early onset of personality
found that personality disorders predicted disorders is impossible because adolescence
the subsequent onset of psychiatric disorders is a period of profound changes and flux in
personality and identity. A critical review of Age and the Aging Process
the longitudinal literature on personality
traits throughout the life span revealed that Another age issue concerns the aging process
personality traits are less stable during child- itself. Considerable research suggests that
hood and adolescence than they are through- personality remains relatively stable thor-
out adulthood (Roberts and DelVecchio ough adulthood (Heatherton and Wein-
2000). Roberts and DelVecchios (2000) meta- berger 1994; Roberts and DelVecchio 2000)
analysis of data from 152 longitudinal stud- and is highly stable after age 50 (Roberts and
ies of personality traits revealed that rank- DelVecchio 2000). Little is known, however,
order consistency for personality traits in- about personality disorders in older persons
creased steadily throughout the life span; (Abrams et al. 1998). The 12-year follow-up of
testretest correlations (over 6.7-year time in- personality disorders that was part of the
tervals) increased from 0.31 (during child- Nottingham Study of Neurotic Disorder
hood) to 0.54 (during college), to 0.64 (age 30 (Seivewright et al. 2002) documented sub-
years), to a high of 0.74 (ages 5070 years). stantial changes in personality disorder trait
Nonetheless, if childhood precursors of scores based on blind administration of a
personality disorders could be identified (as semistructured interview. Seivewright et al.
in the case of conduct disorder for ASPD), (2002) reported that Cluster B personality dis-
they could become part of the diagnostic cri- order diagnoses (ASPD, histrionic) showed
teria and thus create some degree of longitu- significant improvements, whereas Cluster A
dinal continuity in the diagnostic system. and Cluster C diagnoses appeared to worsen
Myers et al. (1998), for example, found that with age. Although the Seivewright et al.
early onset (before 10 years of age) of con- (2002) findings are limited somewhat by the
duct disorder problems predicted subse- two-point cross-sectional assessment (little is
quent ASPD. More generally, temperamental known about the intervening period), Tyrer
vulnerabilities or precursors to personality et al. (1983) previously reported good reliabil-
disorders have been posited as central in a ity (weighted kappa of 0.64) for this diagnos-
variety of models of personality disorders tic interview over a 3-year testretest period.
(Cloninger et al. 1993; Siever and Davis These findings echo somewhat the results of
1991). Specific temperamental features evi- the seminal Chestnut Lodge follow-up stud-
dent in childhood have been noted to be pre- ies (McGlashan 1986a, 1986b) that suggested
cursors for diverse personality disorders distinctions between BPD and schizotypal
(Paris 2003; Rettew et al. 2003; Wolff et al. personality disorders, decreases in impulsiv-
1991) as well as for differences in interper- ity and interpersonal instability with age, and
sonal functioning (Newman et al. 1997) in increased avoidance with age. There are
adulthood. For example, studies have noted other reports of diminished impulsivity with
early od d and w ithd raw n patterns for increasing age in BPD (Paris and Zweig-
schizotypal personality disorder in adults Frank 2001; Stevenson et al. 2003), although
(Wolff et al. 1991) and shyness for avoidant this type of reduction was not observed in a
personality disorder (Rettew et al. 2003). recent prospective analysis of individual BPD
Speaking more generally, although the criteria (McGlashan et al. 2005).
degree of stability for personality traits is The reader is referred to Judd and Mc-
higher throughout adulthood than through- Glashan (2003) for detailed accounts of four
out childhood and adolescence (Roberts and specific cases that elucidate the course and
DelVecchio 2000), longitudinal analyses of outcome of BPD. These detailed case studies,
personality data have revealed that the tran- based on rich clinical material available
sition from adolescence to adulthood is through the Chestnut Lodge study, demon-
characterized by greater personality conti- strate the considerable heterogeneity in the
nuity than change (Roberts et al. 2001). course of BPD.
Summary and Implications of the conceptual and methodological issues

noted earlier. These studies utilized multiple
To resolve these complex issues, comple- and standardized assessment methods, care-
mentary research efforts are required, with fully considered training and reliability,
large samples of both clinical and commu- andperhaps most notablymultiwave re-
nity populations. It is clear that prospective peated assessments that are essential for de-
longitudinal studies with repeated assess- termining longitudinal change. They have
ments over time are needed to understand employed, to varying degrees, multiple as-
the course of personality disorders. Such sessment methods and have considered per-
studies must consider (and cut across) differ- sonality and its disorders (personality disor-
ent developmental eras, broad domains of ders) as well as Axis I psychiatric disorders.
functioning, and multimodal approaches to Collectively, these studies have provided
personality and disorders of personality. valuable insights into the complexities of
These approaches have, in fact, been per- personality (traits and disorders) and its vi-
formed with personality traits (Roberts et al. cissitudes over time.
2001) and with other forms of psychiatric
problems and have yielded invaluable in-
sights. Notable are the contributions of the
Longitudinal Study of
National Institutes of Health (NIH)funded Personality Disorders
multisite efforts on depression (Collabora-
The Longitudinal Study of Personality Disor-
tive Depression Study; Katz et al. 1979) and
ders (Lenzenweger 1999; Lenzenweger et al.
anxiety (Harvard/Brown Anxiety Research
1997) assessed 250 participants drawn from
Project; Keller 1991).
Cornell University at three points over a 4-
year period. It utilized a semistructured di-
agnostic interview (International Personality
REVIEW OF RECENT EMPIRICAL Disorder Examination; Loranger et al. 1994)
ADVANCES AND UNDERSTANDING and a self-report measure (Millon Clinical
OF STABILITY Multiaxial InventoryII; Millon 1987) to ob-
tain complementary information on person-
Of particular relevance for this review are ality. Of the 250 participants, 129 met criteria
three prospective studies on the longitudinal for at least one personality disorder and 121
course of adult personality disorders funded did not meet any personality disorder diag-
by the NIH during the 1990s. These studies nosis. Dimensional scores for the personality
included the Longitudinal Study of Person- disorders were characterized by significant
ality Disorders (Lenzenweger 1999), the levels of stability on both the interview and
McLean Study of Adult Development (Za- self-report measures. Stability coefficients
narini et al. 2003), and the multisite Collabo- for the total number of personality disorder
rative Longitudinal Personality Disorders features ranged from 0.61 to 0.70. Cluster B
Study (CLPS; Gunderson et al. 2000). The personality disorders had the highest stabil-
NIH also funded a community-based pro- ity coefficients, and Cluster A personality
spective longitudinal study of personality, disorders had the lowest. Personality disor-
psychopathology, and functioning of chil- der dimensions showed significant declines
dren/adolescents and their mothers (Chil- over time, and the decline was more rapid
dren in the Community study; Brook et al. for the personality disorder group than for
2002) that began in 1975. These four studies the nonpersonality disorder group. Axis I
are especially noteworthy in that they, to psychiatric disorders (diagnosed in 63% of
varying degrees, partly correct for a number personality disorder subjects and 26% of
nonpersonality disorder subjects) did not by year 4, and 74% by year 6. Recurrences
significantly influence changes in personal- were rare and were reported for only 6% of
ity disorder dimensions over time. those patients who achieved a remission. The
The Longitudinal Study of Personality authors concluded that symptomatic im-
Disorders BPD findings are generally consis- provement is both common and stable, even
tent (although the three-point assessment is among the most disturbed borderline pa-
an important incremental contribution) with tients, and that the symptomatic prognosis
those previously reported by Trull et al. for most, but not all, severely ill borderline
(1997, 1998) in a prospective study of BPD patients is better than previously recog-
features using two different assessment in- nized (Zanarini et al. 2003; p. 274). Zanarini
struments administered to a college student et al. (2004) reported that Axis I psychiatric
sample assessed twice over a 2-year period. disorders are less common over time in pa-
The Longitudinal Study of Personality tients with BPD and particularly among
Disorders (Lenzenweger 1999), however, is those who remit from BPD.
limited by its relatively homogeneous study
group of college students, its narrow devel- Collaborative Longitudinal
opmental time frame, and most importantly Personality Disorders Study
the insufficient frequency of any personality
disorder diagnosis at a categorical (diagnos- The CLPS (Gunderson et al. 2000; McGlashan
tic) level to allow analysis of a clinical entity. et al. 2000; Skodol et al. 2005b) is an ongoing
Lenzenweger (1999) noted the need for re- prospective, longitudinal, repeated measures
peated measures longitudinal data from clin- study designed to examine the course and
ically based personality disorder samples to outcome of patients meeting DSM-IV (Amer-
address the question of the course and stabil- ican Psychiatric Association 1994) criteria for
ity of dysfunctions of personality. one of four personality disorders: schizo-
typal, borderline, avoidant, and obsessive-
McLean Study of compulsive. The CLPS includes a compari-
Adult Development son group of patients with major depressive
disorder (MDD) without any personality dis-
The McLean Study of Adult Development order. This comparison group was selected
(Zanarini et al. 2003, 2005) is an ongoing pro- because of its episodic and fluctuating course
spective, longitudinal study comparing the (thought to distinguish Axis I from Axis II)
course and outcome of hospitalized patients and because MDD has been carefully studied
with BPD with those of patients with other in similar longitudinal designs (e.g., Collabo-
personality disorders. It utilizes repeated as- rative Depression Study; [Katz et al. 1979; So-
sessments performed every 2 years (Zanarini lomon et al. 1997]). The CLPS has employed
et al. 2003) and has reported outcomes multimodal assessments (Gunderson et al.
through 6 years (Zanarini et al. 2003) and 10 2000; Zanarini et al. 2000) to prospectively
years (Zanarini et al. 2006) of follow-up. Za- follow and capture different aspects of the
narini et al. (2003) assessed personality disor- fluctuating nature of personality disorders
ders in 362 inpatients (290 with BPD and 72 and dimensions (both interviewer-based and
with other personality disorders) using two self-report representing different conceptual
semistructured diagnostic interviews and models) (Morey et al. 2007), Axis I psychiatric
administered assessments to characterize disorders and symptoms (Grilo et al. 2005,
Axis I psychiatric disorders, psychosocial 2007), various domains of psychosocial func-
functioning domains, and treatment utiliza- tioning (Markowitz et al. 2007; Skodol et al.
tion. Of the patients diagnosed with BPD, re- 2005a, 2005d), and treatment utilization
mission was observed for 35% by year 2, 49% (Bender et al. 2007).
To date, the CLPS has reported on differ- can be done given the parallel assessment
ent concepts of categorical and dimensional instrumentation) reveals that personality
stability of four personality disorders over 12 disorders demonstrate greater stability than
months (Shea et al. 2002) and 24 months Axis I mood and anxiety disorders (as hy-
(Grilo et al. 2004) using prospective data ob- pothesized) but show less diagnostic (cate-
tained for 668 patients recruited from diverse gorical) stability than conceptualized. Per-
settings at four universities. Based on the tra- haps noteworthy is that the longitudinal
ditional testretest approach, blind repeated studies for both mood and anxiety disorders
administration of a semistructured interview documented much greater chronicity (much
conducted 24 months after baseline revealed lower remission rates) than previously
remission rates (based solely on falling be- known.
low DSM-IV diagnostic thresholds) ranging Returning to the CLPS findings (Grilo et
from 50% (avoidant personality disorder) to al. 2004), Figure 41 reveals that although
61% (schizotypal personality disorder). Grilo personality disorders were more stable than
et al. (2004) applied lifetable survival analy- MDD, a substantial number of remissions
ses to prospective data obtained using an as- occurred during the 24 months of follow-up.
sessment methodology modeled after the Using the arbitrarily selected 2-month defini-
Collaborative Depression Study (Keller et al. tion (2 months with two or fewer criteria)
1982) and the Longitudinal Interval Follow- adopted from the MDD field (Keller et al.
Up Evaluation (Keller et al. 1987) methodol- 1982; Solomon et al. 1997), remission rates
ogy. These findings are summarized in Fig- range from 33% (schizotypal personality dis-
ures 41 and 42. order) to 55% (obsessive-compulsive per-
Figure 41 shows the times to remission sonality disorder). Figure 42 shows the
for the four personality disorder groups and comparable remission rates if a very strin-
for the MDD comparison group, which were gent definition of 12 consecutive months
calculated based on parallel definitions of with two or fewer criteria is adopted. As can
two con secutiv e months with minimal be seen, the remission rates using the 12-
symptoms (Grilo et al. 2004). As can be seen, month definition range from 23% (schizo-
the MDD group had a significantly higher re- typal personality disorder) to 38% (obses-
mission rate than the personality disorder sive-compulsive personality disorder). Grilo
groups. This study represents the first empir- et al. (2004) concluded that these four per-
ical demonstration of the central tenet that sonality disorders show substantial im-
personality disorders are characterized by provements in symptomatology over a 2-
greater degree of stability than the hypothe- year period even when a stringent definition
sized episodic course of Axis I psychiatric is used.
disorders (Grilo et al. 1998; Shea and Yen The CLPS also provided complementary
2003). analyses using dimensional approaches for
The reader is referred to Shea and Yen 12-month (Shea et al. 2002) and 24-month
(2003) for a broader discussion of this issue. (Grilo et al. 2004) follow-ups. Grilo et al.
These researchers, who have played roles in (2004) documented a significant decrease in
the CLPS as well as the longitudinal studies the mean proportion of criteria met in each of
of depression (Collaborative Depression the personality disorder groups over time,
Study) and anxiety (Harvard/Brown Anxi- which is suggestive of decreased severity.
ety Research Project), provide an overview of However, when the relative stability of indi-
the central findings that pertain to the issue vidual differences was examined across the
of stability as a distinction between Axis II multiwave assessments (baseline and 6-, 12-,
and Axis I diagnoses (Shea and Yen 2003). and 24-month time points), a high level of
Briefly, comparison across the studies (which consistency was observed as evidenced by
72
E s s e n t i a l s o f P e r so n a l i t y D i s o r d e r s
Proportion not remitted
Time from intake (months)
Figure 41. Time to remission for four personality disorder groups and major depressive disorder (MDD) comparison group using a 2-month
criterion in Collaborative Longitudinal Personality Study.
AVPD=avoidant personality disorder; BPD =borderline personality disorder; OCPD= obsessive-compulsive personality disorder; STPD= schizotypal personality
disorder.
Source. From Grilo CM, Shea MT, Sanislow CA, et al: Two-Year Stability and Change in Schizotypal, Borderline, Avoidant, and Obsessive-Compulsive Personality
Disorders. Journal of Consulting and Clinical Psychology 72:767775, 2004. Reprinted with permission.
correlation coefficients ranging from 0.53 to with certain psychiatric disorders (MDD and
0.67 for proportion of criteria met between posttraumatic stress disorder), whereas
baseline and 24 months. Grilo et al. (2004) avoidant personality disorder was signifi-
concluded that patients with personality dis- cantly associated with two anxiety disorders
order are consistent in terms of their rank or- (social phobia and obsessive-compulsive
der of personality disorder criteria (i.e., that disorder). While these findings were consis-
individual differences in personality disor- tent with predictions based on the Siever and
der features are stable), although they may Davis (1991) model, other personality disor-
fluctuate in the severity or number of person- ders (schizotypal and obsessive-compulsive)
ality disorder features over time. It is worth did not demonstrate significant longitudinal
noting that the range of the stability coeffi- associations. Gunderson et al. (2004) fol-
cients was quite similar to that documented lowed up on the Shea et al. (2004) findings re-
by the Longitudinal Study of Personality garding changes in BPD and MDD by per-
Disorders (Lenzenweger 1999) for a nonclin- forming a more fine-grained analysis of
ical sample. specific changes in the two disorders using
In contrast to their symptomatic im- 3 years of longitudinal data. Changes (im-
provement, however, patients with personal- provements) in BPD severity preceded im-
ity disorders show less significant and more provements in MDD but not vice versa (Gun-
gradual improvement in their functioning, derson et al. 2004).
particularly in social relationships (Skodol et Another report (Warner et al. 2004) exam-
al. 2005c). In addition, depressed patients ined whether personality traits are stable in
with personality disorders show longer time patients with personality disorders and
to remission from MDD (Grilo et al. 2005) tested the hypothesis that the stability of
and have greater risks for recurrences and for these personality disorders is due in part to
new onsets of MDD (Gunderson et al. 2008). the stability in these traits (Lynam and Widi-
Personality disorders, however, were unre- ger 2001). A series of latent longitudinal
lated to the course of some Axis I psychiatric models tests whether changes in specific
disorders, such as eating disorders (Grilo et traits prospectively predicted changes in rel-
al. 2007). Because personality psychopathol- evant personality disorders. Warner et al.
ogy usually begins in adolescence or early (2004) documented significant cross-lagged
adulthood, the potential for delays in occu- relationships between changes in specific
pational and interpersonal development is traits and subsequent (later) changes for
greatand even after symptomatic im- schizotypal, borderline, and avoidant per-
provement, it might take time to overcome sonality disorders but not for obsessive-
deficits and make up the necessary ground to compulsive personality disorder.
achieve normal functioning. Developmen- McGlashan et al. (2005) examined the in-
tal issues for patients with personality disor- dividual criteria for schizotypal, borderline,
ders are discussed in more detail in Chapter avoidant, and obsessive-compulsive person-
7, Developmental Issues. ality disorders and how they changed over a
Several reports from the CLPS are also 2-year period. The individual criteria for
relevant here given the issue of longitudinal these four personality disorders showed var-
comorbidities and continuities. Shea et al. ied patterns of stability and change over
(2004) examined the time-varying (longitu- time. Overall, within personality disorders,
dinal) associations between personality dis- the relatively fixed (least changeable) criteria
orders and psychiatric disorders, in part were generally more traitlike (and attitudi-
guided by the Siever and Davis (1991) cross- nal), whereas the more fluctuating criteria
cutting psychobiological dimension model. were generally behavioral (or reactive). Mc-
BPD demonstrated significant associations Glashan et al. (2005) posited that perhaps
74
Proportion not remitted
Time from intake (months)
Figure 42. Time to remission for four personality disorder groups using a 12-month criterion in Collaborative Longitudinal Personality Study.
AVPD=avoidant personality disorder; BPD =borderline personality disorder; OCPD= obsessive-compulsive personality disorder; STPD= schizotypal personality
disorder.
Source. From Grilo CM, Shea MT, Sanislow CA, et al: Two-Year Stability and Change in Schizotypal, Borderline, Avoidant, and Obsessive-Compulsive Personality
Disorders. Journal of Consulting and Clinical Psychology 72:767775, 2004. Reprinted with permission.
personality disorders are hybrids of traits bances predict personality disorders in ado-
and symptomatic behaviors and that it is the lescents and that personality disorders during
interaction of these over time that helps to adolescence, in addition to demonstrating sig-
define the observable diagnostic stability. nificant levels of continuity into adulthood,
Collectively, along with the recent CLPS ef- also predict psychiatric disorders, suicidality,
forts, these findings suggest that personality and violent and criminal behavior during
disorder traits are stable over time and across young adulthood (Crawford et al. 2008;
developmental eras and may generate intra- Johnson et al. 2000a, 2000b, 2005). Collec-
and interpersonal conflicts that result in be- tively, these findings support the continuity
haviors symptomatic of personality disor- and persistence of personality disturbances,
ders (which are less stable over time). although their developmental pathways are
not yet understood.
Children in the Community Study
The Children in the Community study (Brook CONCLUSION
et al. 1995, 2002; Cohen et al. 2005) is an espe-
cially impressive longitudinal effort that has We have reviewed the literature regarding
already provided a wealth of information the course and stability of personality disor-
about the course of personality and behav- ders. We once again conclude that personal-
ioral traits, psychiatric problems, substance ity disorders demonstrate only moderate sta-
abuse, and adversities. It is an ongoing pro- bility and that they can improve over time.
spective study of nearly 1,000 families with This conclusion is offered with less caution
children ages 110 years originally recruited than during our previous reviews (Grilo and
in 1975 in New York State using a random McGlashan 1999), given some notable ad-
sampling procedure. The study has em- vances in research. We also conclude that
ployed repeated multimodal assessments when personality disorders are considered
and has followed over 700 participants since dimensionally, the degree of stability is sub-
childhood and through the development eras stantial. Emerging work has suggested that
of childhood, adolescence, and early adult- personality disorder traits, although deviant,
hood. are stable over time and across developmen-
This landmark study, which has reported tal eras and may generate intra- and interper-
20-year outcomes (Crawford et al. 2008), has sonal conflicts that result in personality dis-
provided data that speak to the critical issues ordersymptomatic behaviors (which are
of longitudinal comorbidities and continu- less stable over time). Future research in per-
ities. In a series of papers, the collaborating sonality disorders is necessary to dissect and
researchers have documented important understand this trait-state interaction and
findings relevant to the issues raised in this track its vicissitudes across time and circum-
review but especially to the critical issues of stances.
continuity of risk and functioning across
developmental eras. These include docu-
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Part III
Etiology
5
Prevalence, Sociodemographics,
and Functional Impairment
F rom clinical work we get an impression of ciodemographic features may increase the
which personality disorders are more com- likelihood of a particular person to seek treat-
mon and which are rarer. However, people ment. These complexities mean that only
with some types of personality disorders population (epidemiological) studies can
may be more likely to seek treatment and ob- demonstrate the true relationship between
tain treatment compared with people with personality disorders and socioeconomic and
other types of personality disorders. Conse- sociodemographic variables, or any other
quently, if we are interested in how preva- variables such as traumas, disastrous events,
lent different personality disorders are in the upbringing, or partner relationships.
general population, we have to study repre-
sentative samples of the general population.
Epidemiological research does just that. PREVALENCE
Clinical work also gives us ideas about re-
lationships between socioeconomic and so- We know much about the prevalence of Axis
ciodemographic factors and personality dis- I disorders in the general population (Kring-
orders. However, in a clinical setting we only len et al. 2001). As to personality disorders,
meet those from an unfavorable environment however, less is known. Some studies have
who have developed a personality disorder. been performed, but few of them adequately
We do not meet those from an unfavorable represent the general population (Torgersen
environment who have not developed a dis- et al. 2001). In this chapter I review published
order. Furthermore, the combination of a studies that are closest to what one might call
specific personality disorder and specific so- an epidemiological population study. These
83
individual studies are discussed below (and medical or psychiatric history was per-
presented in Table 51) in view of different formed. The control probands, their spouses,
elements of epidemiology, beginning with a and first-degree relatives constituted the
discussion of sample selection for each study. sample.
The sample studied by Moldin et al.
Sample Selection (1994) consisted of parents and their off-
spring in two control groups used in the New
The sample studied by Zimmerman and York High Risk Project. One of the groups
Coryell (1989, 1990) included first-degree was recruited from two schools in the New
relatives of normal subjects (23%) and of psy- York metropolitan area. The other group
chiatric patients (mood disorders and schiz- came from the pool of a population sampling
ophrenia) as well as a smaller group of first- firm. The subjects were white, English-
degree relatives of nonpsychotic psychiatric speaking families screened for psychiatric
patients. Thus, even if this is a nonpatient disorder.
sample, it is not an average population sam- In the study by Klein et al. (1995), the sam-
ple. However, the prevalence of mania was ple comprised relatives of a control group
not higher than 2%, and the prevalence of screened for Axis I disorders in Stony Brook,
schizophrenia was not higher than 1%. Inter- New York. The interviews were partly con-
views were conducted in person (27%) and ducted in person and partly by telephone.
by telephone (73%). The Structured Inter- Lenzenweger et al. (1997) examined a
view for DSM-III Personality Disorders was sample consisting initially of 1,684 under-
applied (Stangl et al. 1985). The study took graduate students from Cornell University in
place in Iowa City. New York. They were screened by means of a
The sample reported on by Black et al. questionnaire; a sample of those expected
(1993) consisted of 120 relatives of 32 outpa- and those not expected to have a personality
tients with obsessive-compulsive disorder disorder was interviewed. The total number
and 127 relatives of a comparison group of subjects interviewed was 258. In this over-
screened for Axis I disorders. Strangely, no view (Table 51), I apply the actual numbers.
difference was found between the preva- The estimated prevalence for any personality
lence of personality disorders in the two rel- disorder is a little different.
ative groups. More than half of the sample The study by Torgersen et al. (2001) was
were siblings, a quarter were parents, and conducted in Oslo, the capital of Norway. A
the rest were children. A little more than half random sample of names of 3,590 citizens be-
were women. The mean age was 42 years. tween age 18 and 65 years was selected from
More than half were interviewed in person the National Register of Oslo. Some had
and the rest by telephone. moved out of town, some were impossible to
Maier et al. (1992) conducted one of the trace, and some were dead. Others refused to
few reported studies in which the sample is participate or postponed the interview be-
relatively representative of the general pop- yond the period of the study (18%). Of the
ulation. Control probands were selected by a original sample, 2,053 (57%) delivered inter-
marketing company to match patients older views of sufficient quality for the study. All
than age 20 on sex, age, residential area, and interviews were performed in person. The
educational level. The participants had to sampling procedure made it possible to iden-
have at least one living first-degree relative tify all causes of reduction in the sample from
who also had agreed to be interviewed. Oth- the initial to the final sample. There were al-
erwise, this sample represented the general most equal numbers of men and women.
population of a mixed urban/rural German The sampling procedure used by Sam-
residential area near Mainz. No screening for uels et al. (2002) was very complicated. Ini-
Prevalence, Sociodemographics, and Functional Impairment 85
tially, a sample of 3,481 adult household res- R (p. 554) was interviewed with the com-
idents in Baltimore was studied in the 1980s. plete IPDE.
About 10 years later, a subsample was se-
lected that included individuals previously Results
evaluated by psychiatrists or those who ap-
peared to have an Axis I diagnosis based on Table 51 presents the prevalences in the
the Diagnostic Interview Schedule. In addi- published studies discussed above, includ-
tion, a random sample was selected. A num- ing all personality disorders. So-called
ber of subjects could not be traced, refused, mixed personality disorders, defined by the
were too ill to participate, or were deceased. absence of one criterion for two or more per-
The remaining sample consisted of 742 indi- sonality disorders and not having the re-
viduals. Their ages varied between 34 and 94 quired number of criteria for any disorder,
years, and two-thirds were women. are excluded. The same is the case for per-
In the study by Grant et al. (2004), a very sonality disorders not otherwise specified
large sample (N=43,093; the so-called Na- (NOS), defined by having 10 or more criteria,
tional Epidemiologic Survey on Alcohol and but not a sufficient number of criteria ob-
Related Conditions [NESARC]), was inter- tained for any specific disorder. Unweighted
viewed. A measure named Alcohol Use Dis- prevalences (rather than weighted preva-
order and Associated Disabilities Interview lences based on questionable weighting pro-
SchedulIV (AUDADIS-IV) was applied. cedures) are presented, if possible, because
Borderline, schizotypal, and narcissistic per- the prevalences among those not reached
sonality disorders were not included. The re- cannot be known. The qualified, although
sults were weighted to represent the U. S. questionable, guesswork gives one an impres-
population age 18 years and older. sion of increased accuracy. A nonweighted
Crawford et al. (2005) studied prospec- rate is transparent and does not claim more
tively 597 community members from age 14 than it can stand for.
to 33 years. The reported percentages in Ta- In almost half of the studies, the preva-
ble 51 are based on the application of the lence of any disorder is between 7% and 13%.
Structured Clinical Interview for DSM-IV The median prevalence is above 10%. The
Axis II Personality Disorders (SCID-II) to re- median prevalence of specific personality
spondents at age 33 years. disorders is mostly between 1% and 2%.
Coid et al. (2006) interviewed 626 indi- Obsessive-compulsive personality disor-
viduals age 1674 years in the United King- der is the most frequently occurring personal-
dom. Table 51 reports the weighted preva- ity disorder (above 2%). Next come paranoid,
lences (unweighted prevalences for the avoidant, and passive-aggressive personality
specific disorders are not stated in the publi- disorder (1.7%); then borderline (1.6%), histri-
cation). The SCID-II screening questionnaire onic (1.5%), antisocial (1.1%), and schizoid
was applied. and schizotypal (0.9%); and finally narcissis-
Personality disorders were assessed in tic personality disorder (0.5%). The only two
the National Comorbidity Survey Repli- studies that included self-defeating and sa-
cation (NCS-R). A set of the International distic personality disorder reported an aver-
Personality Disorder Examination (IPDE) age of 0.4% and 0.1% respectively.
screening questions was applied to 5,692 in- The correlations between the different
dividuals age 18 years or older (Lenzen- studies are very low, around 0.17. The only
weger et al. 2007). A subsample of 214 indi- two studies that reflect the average preva-
viduals who screened positive for one or lences (calculated by intraclass correlation)
more of our outcome measures on the basis are those of Maier et al. (1992) and Torgersen
of the IPDE screening questions in the NCS- et al. (2001).
86
Table 51. Prevalences of personality disorders in twelve population studies
Zimmerman Black Maier Moldin Klein Lenzenweger Torgersen Samuels Grant Crawford Coid Lenzenweger
and Coryell et al. et al. et al. et al. et al. et al. et al. et al. et al. et al. et al.
1989 1993 1992 1994 1995 1997 2001 2002 2004 2005 2006 2007 Median
Place Iowa Iowa Mainz NYC New York New York Oslo Baltimore USA New York UK USA
Method SIDP SIDP SCID-II PDE PDE PDE SIDP-R IPDE AUDADIS SCID-II SCID-II IPDE
-IV screening
DSM system III III III-R III-R III-R III-R III-R IV IV IV IV IV
Personality
disorder
Paranoid 0.9 1.6 1.8 0.0 1.8 0.4 2.2 0.7 4.4 5.1 5.1 2.3 1.7
Schizoid 0.9 0.0 0.4 0.0 0.9 0.4 1.6 0.7 3.1 1.7 1.7 4.9 0.9
Schizotypal 2.9 3.2 0.7 0.7 0.0 0.0 0.6 1.8 1.1 1.1 3.3 0.9
Antisocial 3.3 0.8 0.2 2.6 2.6 0.8 0.6 4.5 3.6 1.2 1.2 1.0 1.1
Borderline 1.7 3.2 1.1 2.0 1.8 0.0 0.7 1.2 3.9 3.9 1.6 1.6
Histrionic 3.0 3.2 1.3 0.3 1.8 1.9 1.9 0.4 1.8 0.9 0.9 0.0 1.5
Narcissistic 0.0 0.0 0.0 0.0 4.4 1.2 0.8 0.1 2.2 2.2 0.0 0.5
Avoidant 1.3 2.0 1.1 0.7 5.7 0.4 5.0 1.4 2.4 6.4 6.4 5.2 1.7
Dependent 1.8 1.6 1.6 1.0 0.4 0.4 1.5 0.3 0.5 0.8 0.8 0.6 0.7
Obsessive- 2.0 9.3 2.2 0.7 2.6 0.0 1.9 1.2 7.9 4.7 4.7 2.4 2.1
compulsive
Passive- 3.3 10.5 1.8 1.7 1.8 0.0 1.6 1.7
aggressive
Self-defeating 0.0 0.8 0.4
Sadistic 0.0 0.2 0.1
Table 51. Prevalences of personality disorders in twelve population studies (continued)
Zimmerman Black Maier Moldin Klein Lenzenweger Torgersen Samuels Grant Crawford Coid Lenzenweger
and Coryell et al. et al. et al. et al. et al. et al. et al. et al. et al. et al. et al.
1989 1993 1992 1994 1995 1997 2001 2002 2004 2005 2006 2007 Median
Prevalence, Sociodemographics, and Functional Impairment

Any personality 14.3 22.7 10.0 7.3 14.8 3.9 13.1 10.0 15.7 4.4 10.3 10.3
disorder
Number 797 247 452 303 229 258 2,053 742 43,093 597 626 214
Note. IPDE=International Personality Disorders Examination; NYC=New York City; PDE=Personality Disorder Examination; SCID-II=Structured Clinical Interview for DSM-
IV Axis II Personality Disorders; SIDP=The Structured Interview for DSM-III Personality Disorders; SIDP-R=The Structured Interview for DSM-III-R Personality Disorders.
87
Dependent and borderline personality are between 1% and 2%. The validity of the
disorders display the most stable preva- prevalences of those personality disorders
lences from study to study, while narcissistic that are less frequently occurring is question-
and passive-aggressive personality disor- able. The prevalence of any personality dis-
ders vary most from study to study (based on order is around 10%. The sum of the per-
spreading/mean ratio or t test). It is notewor- centages for the specific disorders is higher,
thy that these two disorders are not included around 15%, pointing to the fact that around
among the ICD-10 (World Health Organiza- one-third of those with one disorder have
tion 1992) or DSM-IV (American Psychiatric one more. (The distribution is skewed with
Association 1994) personality disorders. most having only one, some having two, and
Table 52 shows a comparison between few having many personality disorders,
the prevalences in a large outpatient clinic in hence 50% of individuals will not have more
Oslo (Alns and Torgersen 1988) and in the than one disorder.) Studies of patients give
general population of that city (Torgersen et us a distorted impression of the absolute and
al. 2001). The ratio between the prevalence in relative prevalences of personality disorders,
the clinic and that in the population is calcu- because those with dependent and border-
lated separately for women and men and in line much more often seek treatment.
the total sample. There are relatively small
differences in the range of the ratios between
women and men, even if the ratios are a little SOCIODEMOGRAPHIC CORRELATES
larger for the specific personality disorder
among men (not for any personality disor- Gender
ders). Those with dependent, borderline,
avoidant, and obsessive-compulsive person- Gender differences are common among
ality disorder are strongly overrepresented mental disorders. Women more often have
among the patients based on prevalence mood and anxiety disorders, and men more
rates in the general population, whereas often have substance-related disorders
those with antisocial, schizoid, and paranoid (Kringlen et al. 2001). For personality disor-
personality disorder are less common in the ders, women and men also differ.
clinical compared with the general popula- With regard to personality disorders,
tion. To have a borderline, avoidant, or Zimmerman and Coryell (1989) observed a
schizotypal personality disorder implies higher prevalence of any personality disor-
pain and dysfunction, as I discuss later in the ders among males as did Jackson and Bur-
chapter. One may speculate that those who gess (2000) for ICD-10 screening when re-
are dependent seek help, whereas obsessive- gression analysis was applied. However,
compulsive patients want to do something differences between genders were very
with their problems, even if they do not suf- small, and Torgersen et al. (2001) did not ob-
fer as much. In the other direction, those who serve any differences.
are antisocial do not want psychological help As to the personality disorder clusters,
and are also refused help. Schizoid individu- Samuels et al. (2002) and Torgersen et al.
als keep their distance, whereas paranoid (2001) reported that Cluster A (odd/eccen-
subjects do not believe in any cure. tric) and Cluster B (dramatic/emotional) per-
In conclusion, while the prevalences of sonality disorders or traits were more com-
the specific personality disorders vary strongly mon among men. Coid et al. (2006) found the
from study to study, the number of pub- same for Cluster B only.
lished studies makes it possible to draw Among the specific Cluster A disorders,
some conclusions today. At least in the both Torgersen et al. (2001) and Zimmerman
United States and Europe, the prevalences and Coryell (1990) found that schizoid per-
Table 52. Prevalences of personality disorders in the common population and among outpatients in Oslo, Norway
Females Males Total

Personality Torgersen et Alns and Ratio Torgersen et Alns and Ratio Torgersen et Alns and Ratio
disorder al. 2001 Torgersen (range) al. 2001 Torgersen (range) al. 2001 Torgersen (range)

1988 1988 1988
Paranoid 2.2 3.9 1.8 (9) 2.3 7.6 3.3 (9) 2.2 5.0 2.3 (9)
Schizoid 1.1 0.0 0.0 (10) 2.2 5.4 2.5 (10) 1.6 1.7 1.1 (10)
Schizotypal 0.6 3.9 6.5 (6) 0.5 12.0 24.0 (3) 0.6 6.4 10.7 (4)
Antisocial 0.0 0.0 0.0 (10) 1.3 0.0 0.0 (11) 0.6 0.0 0.0 (11)
Borderline 0.9 17.0 18.9 (2) 0.4 9.8 24.5 (2) 0.7 14.8 21.1 (2)
Histrionic 2.5 15.0 6.0 (7) 1.2 10.9 9.1 (7) 1.9 13.8 7.3 (6)
Narcissistic 0.8 1.9 2.4 (8) 0.9 10.9 12.1 (6) 0.8 4.7 5.9 (8)
Avoidant 5.0 53.4 10.7 (3) 4.9 59.8 12.2 (5) 5.0 55.4 11.1 (3)
Dependent 2.0 47.6 23.8 (1) 0.9 45.7 50.8 (1) 1.5 47.0 31.3 (1)
Obsessive- 1.3 13.6 10.5 (4) 2.6 33.7 13.0 (4) 1.9 19.8 10.4 (5)
compulsive
Passive- 0.9 6.3 7.0 (5) 2.2 18.5 8.4 (8) 1.6 10.1 6.3 (7)
aggressive
Any 12.6 76.7 6.1 13.7 90.2 6.6 13.1 80.9 6.2
personality
disorder
Number 1,142 206 911 92 2,053 298
89
sonality disorder or traits were more com- borderline traits. In patient samples, border-
mon among men. Zimmerman and Coryell line personality disorder is not more preva-
(1990) found this also for paranoid traits. lent among women than among men (Alns
Grant et al. (2004), however, observed that and Torgersen 1988; Fossati et al. 2003;
women more often had a paranoid personal- Golomb et al. 1995). In one study of patients,
ity disorder. Neither Zimmerman and Cor- borderline personality disorder was, in fact,
yell (1989, 1990) nor Torgersen et al. (2001) more common among men than among
observed any gender difference for schizo- women (Carter et al. 1999). In our unsystem-
typal personality disorder. Among the Clus- atic impression of people, we are more likely
ter B personality disorders, antisocial disor- to see borderline features in women than
der is much more common among men in men. That schizotypal personality disor-
(Torgersen et al. 2001; Zimmerman and Cor- der does not show any gender bias will more
yell 1989, 1990). Those with histrionic per- easily be recognized. A trend in the direction
sonality disorder or traits appear more often of men being more often schizoid, narcissis-
to be women (Torgersen et al. 2001; Zimmer- tic, and obsessive-compulsive and women
man and Coryell 1990). Narcissistic traits are being more often histrionic and avoidant is
found more often among men, and there are in accordance with common opinion.
no statistically significant gender differences
for borderline personality disorder or traits Age
(Torgersen et al. 2001; Zimmerman and
Coryell 1990). To diagnose a personality disorder in an indi-
Among the Cluster C (anxious/fearful) vidual younger than age 18 years, the features
personality disorders, dependent personality must have been present at least 1 year (Amer-
disorder is much more common among ican Psychiatric Association 2000). At the
women (Grant et al. 2004; Torgersen et al. same time, it is assumed that personality dis-
2001; Zimmerman and Coryell 1989, 1990), orders start early in life and are relatively sta-
and obsessive-compulsive personality disor- ble. For some personality disorders, espe-
der or traits are found more often among men cially the dramatic types, it is also assumed
(Torgersen et al. 2001; Zimmerman and that they are typical for young people. On the
Coryell 1989, 1990). Zimmerman and Coryell other hand, the older people are, the longer
(1989, 1990) and Grant et al. (2004) reported they have had to develop personality disor-
more avoidant personality disorder and traits ders, even though personality disorders may
among women. also disappear. Suicide and fatal accidents
Regarding personality disorders pro- also may happen more often among those
vided for further study (American Psych- with personality disorders than among other
iatric Association 2000), Torgersen et al. individuals. These facts will influence the rate
(2001)but not Zimmerman and Coryell of specific personality disorders in older age.
(1989, 1990)found that men more often had What does empirical research show?
passive-aggressive personality disorder. Tor- Zimmerman and Coryell (1989) observed
gersen and colleagues also found that women that individuals with personality disorders
more often presented with self-defeating were younger than those without. Jackson
traits, and men more often presented with sa- and Burgess (2000) found the same using a
distic traits. short ICD-10 screening instrument (IPDE
The most clear-cut results from the stud- screener). Torgersen et al. (2001), however,
ies are that men tend to be antisocial and observed the opposite. This can be explained
women tend to be dependent. These results by the high prevalence of introverted and low
are perhaps not surprising. However, more prevalence of impulsive personality traits in
surprising is a lack of gender difference for Norway as compared with the United States.
As to the clusters of personality disor- and obsessive-compulsive personality disor-

ders, Torgersen et al. (2001) found that indi- ders are more common in younger age.
viduals with odd/eccentric personality dis- Zimmerman and Coryell (1989) found
orders were older, whereas Samuels et al. that individuals with passive-aggressive per-
(2002), Coid et al. (2006), and Lenzenweger et sonality disorder are typically of a younger
al. (2007) did not find any age variation. For age, and Torgersen et al. (2001) observed that
the dramatic/emotional cluster, Samuels et such traits were negatively correlated with
al. (2002), Coid et al. (2006), and Lenzen- age. The latter study also examined self-de-
weger et al. (2007) found a higher prevalence feating and sadistic traits and found that sa-
among the younger subjects, whereas Torg- distic traits were associated with younger age.
ersen et al. (2001) found that the dramatic/ To summarize, persons with antisocial,
emotional trait dimensions decreased with borderline, or histrionic personality disorder
age. As to the anxious/fearful cluster, neither seem to be younger. As for other disorders,
group observed any age trend. the studies are conflicting. The reason for the
Among the odd/eccentric personality age difference in disorders is that people be-
disorders, schizoid personality disorder or come less impulsive and overtly aggressive
traits seem to be associated with being older as they age. Agreeableness and conscien-
(Torgersen et al. 2001; Zimmerman and tiousness increase with age (Srivastava et al.
Coryell 1989, 1990). Several studies have 2003). Cluster B disorders are typically nega-
found that paranoid personality disorder is tively correlated with agreeableness and con-
unrelated to age (Torgersen et al. 2001; Zim- scientiousness (Saulsman and Page 2004).
merman and Coryell 1989, 1990). Zimmer-
man and Coryell (1989, 1990) observed that Marital Status
those with schizotypal personality disorder
were younger, and Torgersen et al. (2001) Most of the results concerning marital status
found that they were older. Grant et al. (2004) are from Zimmerman and Coryell (1989).
found that both schizoid and paranoid per- Some of the data from Torgersen et al. (2001)
sonality disorder decreased with age. have been calculated for this chapter to fit the
Among the dramatic/emotional person- tables in Zimmerman and Coryell (1989) (see
ality disorders, those with antisocial and bor- Table 53). Grant et al. (2004) also provide in-
derline personality disorder or traits are formation.
younger (Torgersen et al. 2001; Zimmerman As illustrated in Table 53, subjects with
and Coryell 1989, 1990), and Zimmerman personality disorder have more often been
and Coryell (1990) observed that those with separated or divorced compared with those
histrionic and narcissistic traits are younger without a personality disorder, and they are
as well. These results were not confirmed by more often divorced at the time of the inter-
Torgersen et al. (2001). Grant et al. (2004) ob- view (Zimmerman and Coryell 1989). They
served that histrionic and antisocial person- are less frequently married (Jackson and Bur-
ality disorders are more prevalent among gess 2000; Zimmerman and Coryell 1989),
younger respondents. and they are more often never married (Zim-
Zimmerman and Coryell (1989, 1990) did merman and Coryell 1989). If we include liv-
not find any age trend for any of the fearful ing nonmarried persons with a partner, sub-
disorders, whereas Torgersen et al. (2001) jects with personality disorder live more
observed that individuals with obsessive- often alone without a partner compared with
compulsive disorder and avoidant traits are those without a personality disorder in the
older. No difference was found for depen- general population (Torgersen et al. 2001).
dent personality disorders. Finally, Grant et However, as the risk of having a person-
al. (2004) reported that avoidant, dependent, ality disorder is related to gender and age,
92
Table 53. Marital status and personality disorders, calculated from Torgersen et al. (2001)
Single (never Ever Ever
Personality disorder Number married) (%) Married (%) Separateda (%) Divorceda (%) Widowed (%) separated b (%) divorcedc (%)
Paranoid 46 34.8 34.8 6.5 21.7c 2.2 15.8 36.7
Schizoid 32 56.3 31.3 0.0 6.3 6.3 20.0 28.6
Schizotypal 12 50.0 33.3 0.0 8.3 8.3 20.0 16.7
Antisocial 12 75.0d 8.3d 0.0 16.7 0.0 0.0 66.7
Borderline 14 57.1 35.7 7.1 0.0 0.0 20.0 16.7
Histrionic 39 46.2 35.9 0.0 17.9 0.0 0.0 47.6d
Narcissistic 17 35.6 52.9 0.0 5.9 5.9 10.0 9.1
Avoidant 102 45.1 36.3 1.0 14.7 2.9 7.5 28.6
Dependent 31 58.1d 25.8d 3.2 12.9 0.0 11.1 30.8
Obsessive-compulsive 39 41.6 43.6 0.0 10.3 5.1 5.6 21.7
Passive-aggressive 32 35.3 31.3 6.3 9.4 3.1 18.2 31.3
Self-defeating 17 35.3 17.6d 0.0 41.2e 5.9 25.0 63.6
Sadistic 4 50.0 56.0 0.0 0.0 0.0 0.0 0.0
Eccentric 80 45.6 33.8d 3.8 15.0 2.5 13.8 34.1
Dramatic 62 49.3 35.2 1.4 12.7 1.4 8.3 33.3
Fearful 189 45.5 36.5d 1.3 14.1 2.6 8.2 28.2
Any personality disorder 269 43.9 36.8f 2.2 15.6d 1.5 7.9 33.1f
No personality disorder 1,784 38.8 46.5 2.4 10.4 1.8 5.1 23.2
Number 2,053 693 830 43 185 33 43 253

a
At the time of interview.
bExcluding those
who are never married.
c
Excluding those who are never married and those who are divorced.
d X2 test, P<0.05
e 2
X test, P <0.001
fX2 test, P<0.01
the real effect of other sociodemographic al. 2001). Those with schizoid personality
variables such as marital status is difficult to disorder are more seldom separated (Zim-
determine. Younger people are less often merman and Coryell 1989), more often never
married, and education is related to gender married or separated/divorced/widowed
and age. The best way to determine the inde- (Grant et al. 2004), and more often living
pendent effect of other sociodemographic alone (Torgersen et al. 2001). Those with
variables is to apply multivariate methods. schizotypal personality disorder have more
However, to apply such methods one needs often been separated (Zimmerman and
large samples. Thus multivariate methods Coryell 1989) and live more often alone
have been used in very few studies. In the (Torgersen et al. 2001).
study of Torgersen et al. (2001), such multi- Among the Cluster B disorders, persons
variate analyses have been carried out for with histrionic personality disorder have
living alone versus living with a partner. more often been separated or divorced (Zim-
Those with eccentric personality disor- merman and Coryell 1989). They are also
ders have more often been divorced or sepa- more often not married when interviewed
rated (Coid et al. 2006; Samuels et al. 2002); (Zimmerman and Coryell 1989), more often
they are more often divorced when inter- never married or divorced/separated/wid-
viewed, and they have seldom been married owed (Grant et al. 2004), and live more often
(Samuels et al. 2002; Table 53). Those with alone (Torgersen et al. 2001). Those with an-
dramatic personality disorders are also often tisocial personality disorder also more often
unmarried and live more often alone (Torg- have been divorced, separated (Zimmerman
ersen et al. 2001), and they are more often sep- and Coryell 1989), or never married (Grant et
arated or divorced (Coid et al. 2006). Those al. 2004; Table 53); are less often married
with fearful personality disorders are also when interviewed; and live more often alone
less often married (Samuels et al. 2002) and (Torgersen et al. 2001). Persons with border-
live more often alone (Torgersen et al. 2001). line personality disorder also have more of-
When we examine the specific personal- ten been separated if married, are more often
ity disorders, we encounter problems in com- divorced, and are not married when inter-
paring the different studies. Marital status viewed (Zimmerman and Coryell 1989).
does not seem to be as important in the Nor- They are more often never married (Zimmer-
wegian study, perhaps because many Nor- man and Coryell 1989), and live more often
wegians live in stable relationships without alone (Torgersen et al. 2001). Finally, those
being married. When we include living to- with narcissistic personality disorder also
gether with a partner from the study of Torg- more often live alone (Torgersen et al. 2001).
ersen et al. (2001) and consider this life situa- Among persons with anxious/fearful
tion as analogous to marriage, we find more personality disorders, those with avoidant
similarity between this study and the study personality disorder have more often been
by Zimmerman and Coryell (1989). It is im- separated (Zimmerman and Coryell 1989).
portant to note that the relationships in the They are more often separated/divorced/
Torgersen et al. study are based on logistic widowed when interviewed, and more often
and linear regression analysis, taking into ac- never married (Grant et al. 2004). Those with
count a number of other sociodemographic dependent personality disorder more often
variables. have been separated when interviewed (Zim-
Among the odd/eccentric personality merman and Coryell 1989), never married
disorders, those with paranoid personality (Grant et al. 2004; Table 53), or separated/
disorder are more often nev er married divorced/widowed (Grant et al. 2004). Those
(Grant et al. 2004), divorced (Grant et al. with obsessive-compulsive traits are less of-
2004; Table 53), or living alone (Torgersen et ten married (Torgersen et al. 2001).
Among the proposed personality disor- In applying logistic regression analysis

ders, persons with passive-aggressive per- and taking into account a number of other
sonality disorder have more often been di- sociodemographic variables, Torgersen et al.
vorced and are less often married when (2001) observed that paranoid and avoidant
interviewed (Zimmerman and Coryell 1989) personality disorders and traits and schiz-
and live more often alone (Torgersen et al. oid, schizotypal, antisocial, borderline, de-
2001). Those with self-defeating personality pendent, and self-defeating personality traits
disorder have more often been divorced were related to lower education. Interest-
(Zimmerman and Coryell 1989), are more of- ingly, those with obsessive-compulsive dis-
ten divorced (Table 53) and not married order or traits in fact had higher education.
when interviewed (Zimmerman and Coryell Only histrionic, narcissistic, and passive-
1989), and more often live alone (Torgersen et aggressive personality disorders or traits
al. 2001). were unrelated to education. Grant et al.
In conclusion, those with personality dis- (2004) found that lower education was re-
orders typically live alone, which is most lated to all the studied personality disorders
likely specifically for those with self-defeat- (paranoid, schizoid, antisocial, histrionic,
ing, borderline, or schizotypal personality avoidant, and dependent), with the excep-
disorder. Those with obsessive-compulsive tion of obsessive-compulsive personality
personality disorder may be an exception. disorder, which was related to higher educa-
Never being married is often observed tion (as Torgersen et al. [2001]) found.
among those with antisocial and dependent Coid et al. (2006) found that Cluster A
personality disorder. The risk of divorce/ disorders were related to unemployment
separation is high among those with para- and lower social class, Cluster B disorders
noid personality disorder. In cultures where were related to lower social class, and Clus-
it is more common to live together unmar- ter C disorders were related to being eco-
ried, a breakup in the relationship is less easy nomically inactive but not unemployed.
to record. For whatever reason, living with- Grant et al. (2004) found that lower income
out a partner is very common among those was related to all the studied personality dis-
with personality disorders. orders, except obsessive-compulsive person-
ality disorder. Lenzenweger et al. (2007)
Education and Income found that only borderline personality disor-
der was related to unemployment.
Relatively few studies have investigated the Samuels et al. (2002) also investigated the
relationship between personality disorders relationship between income and personal-
and education and income. Torgersen et al. ity disorders but did not find any association.
(2001) observed that those with any person- Jackson and Burgess (2000) did not find any
ality disorder had less education. The same relationship to unemployment. It is impor-
was observed for those with odd/eccentric tant to note that these studies applied multi-
personality disorders, and those with dra- variate methods, taking into account other
matic/emotional as well as anxious/fearful sociodemographic variables.
personality disorder traits. Samuels et al. In conclusion, personality disorders,
(2002) and Lenzenweger et al. (2007) con- with a few exceptions, are related to lower
firmed that those with dramatic/emotional socioeconomic status and economic prob-
personality disorders had less education but lems. This holds true for all of the Cluster A
not those with odd/eccentric or anxious/ disorders (paranoid, schizoid, and schizo-
fearful personality disorders. Coid et al. typal) and for at least two Cluster B disorders
(2006), however, found lower education (antisocial and borderline). It is not true for
among those with Cluster A disorders. narcissistic personality disorder, and the so-
cioeconomic status of those with histrionic makes it easier to express the less socially ac-
personality disorder is equivocal. As to Clus- ceptable aspects of ones personality. We
ter C disorders, avoidant and dependent per- used to think that excessive social control
sonality disorders imply poorer socioeco- creates mental problems. Perhaps social con-
nomic status, whereas the opposite is true for trol hinders the development of accentuated
obsessive-compulsive personality disorder. eccentric, narcissistic, and impulsive person-
For the provisional disorders, there exists only ality styles.
one study (Torgersen et al. 2001) suggesting
lower education for those with self-defeating
and sadistic, but not passive-aggressive, per- QUALITY OF LIFE AND
sonality disorders.
DYSFUNCTION
Urban Location Central to the definition of personality disor-
der are the interpersonal problems, reduced
The study of Torgersen et al. (2001) showed well-being, and dysfunction that personality
that those living in the populated center of disorders imply. In the sample studied by
the city more often had a personality disor- Torgersen et al. (2001), quality of life was as-
der. The same was true for all clusters of per- sessed by interview and included the follow-
sonality disorders and all specific disorders ing aspects: subjective well-being, self-
except antisocial, sadistic, avoidant, and derealization, relation to friends, social support,
pendent personality. Grant et al. (2004) found negative life events, relation to family of ori-
this to be true only for paranoid and avoidant gin, and neighborhood quality (Cramer et al.
personality disorders, not antisocial, histri- 2003, 2006, 2007). All aspects were integrated
onic, schizoid, dependent, or obsessive-com- in a global quality-of-life index.
pulsive personality disorders. The two stud- Personality disorders turned out to be
ies agree that paranoid personality disorder, more strongly related to quality of life than
but not antisocial and dependent personality Axis I mental disorders, somatic health, and
disorders, are related to urbanicity. They dis- any other socioeconomic, demographic, or
agree about schizoid, histrionic, avoidant, life situation variable. Among the specific
and obsessive-compulsive personality disor- personality disorders, avoidant personality
ders, while the rest of the personality disor- disorder was most strongly related to quality
ders are not included in the study. of life, controlling for all the aforementioned
Given that more people with personality variables. Next came schizotypal, then para-
disorders are found in the center than in the noid, schizoid, borderline, dependent, anti-
outskirts of a city, one may speculate about social personality disorders, and narcissistic
the reason for this. Quality of life is generally and self-defeating personality disorders to a
lower in the center of the city (Cramer et al. lesser degree. Histrionic, obsessive-compul-
2004), and there is a higher rate of symptom sive, and passive-aggressive personality dis-
disorders in the city or in the center of the city orders were unrelated to quality of life. Some
(Kringlen et al. 2001; Lewis and Booth 1992, may be surprised that borderline personality
1994; Marcelis et al. 1998; Sundquist et al. disorder was not more strongly related to re-
2004; van Os et al. 2001). One reason may be duced quality of life. The reason for this is
that the concentrated urban life creates stress that the disorder is related to a number of
leading to personality disorders. Another other variables that are related to quality of
reason may be that individuals with person- life. Hence, the variables become weaker in a
ality problems drift to the center, where they multiple regression analysis.
can lead an anonymous life. A third explana- A dysfunction index was created by com-
tion may be that less social control simply bining quality of life (reversed); the answer
to the Structured Interview for DSM-III Per- ments for any specific number of criteria to
sonality DisordersRevised question do define a personality disorder if one uses
you feel that the way you usually deal with quality of life or dysfunction as validation
people and handle situations causes you variables. There is no natural cutoff point.
problems?; the number of lifetime Axis I di- A high level of dysfunction and disability
agnoses; and any incidence of seeking treat- was also observed among those with schizo-
ment with varying degrees of seriousness, typal personality disorder, followed by bor-
from private psychologist and psychiatrist derline and avoidant personality disorders,
via outpatient and inpatient clinicsto psy- in a large-scale multicenter study (Skodol et
chiatric hospitals. The dysfunction index was al. 2002). It was also observed that those with
related to personality disorder much as the obsessive-compulsive personality disorder
global quality-of-life index was. The only dif- showed much less disability.
ferences found in comparing results derived In another study, Ullrich et al. (2007),
from the dysfunction index with those from found that obsessive-compulsive personality
the global quality-of-life index were that disorder was not related to poor function-
those persons with borderline, dependent, or ingin fact, it was quite the opposite. Also
self-defeating personality disorder appeared histrionic personality disorder was positively
more dysfunctional, and those persons with related to status and wealth, while narcissis-
antisocial personality disorder appeared less tic and paranoid personality disorders were
dysfunctional. The reason for the differences unrelated to this index as well as to success-
is mainly that those with borderline, histri- ful intimate relationships. Taken together,
onic, dependent, and self-defeating person- those with schizoid personality disorder
ality disorders are more likely to seek treat- scored poorest on these two indexes, followed
ment and those with antisocial personality by antisocial, schizotypal, avoidant, border-
disorders are less likely to seek treatment. line, and dependent personality disorders.
However, the most important result in Zimmerman and Coryell (1989) also
this study was that for both quality of life and found a high frequency of psychosexual dys-
dysfunction, there was a perfect linear dose function among persons with avoidant per-
response relationship to numbers of criteria sonality disorder. Surprisingly, this dysfunc-
fulfilled for all personality disorders together tion was infrequent among persons with
and to the number of criteria fulfilled for any borderline personality disorder, and, not sur-
specific personality disorder. Thus, if a per- prisingly, it was also infrequent among those
son has one criterion fulfilled for one or an- with antisocial personality disorder.
other personality disorder, the quality of life Grant et al. (2004) applied a short form of
is lower and dysfunction is higher than quality of life assessment, the Short Form
among those with no criteria fulfilled. Those Health Survey, Version 2 (SF-12v2; Ware et al.
with two criteria fulfilled on one or more spe- 2002) and found that those with dependent
cific disorders have more problems than personality disorder had the poorest quality
those with one, those with three criteria have of life, followed by those with avoidant,
more problems than those with two, and so paranoid, schizoid, or antisocial personality
on. In other words, when those with zero disorders. There was no reduction in quality
criteria on all disorders were grouped to- of life for those with histrionic personality
getherthat is, those with a maximum of disorder, and a reduction on only one of three
one criterion on any disorder, those with a scores for those with obsessive-compulsive
maximum of two, and so onthe relation- personality disorder.
ship to global quality of life and dysfunction Crawford et al. (2005) studied impair-
was perfectly linear (Figures 51 and 52). ment using the Global Assessment of Func-
This result means that there are no argu- tioning (GAF) scale. Those with borderline
2.45 2.36
2.5
2.09

2 1.76
1.48
1.37
Quality of life
1.5
0.95
1
0.51
0.5
0
0 1 2 3 4 5 6 79
Number of criteria
Figure 51. The relationship between maximum number of criteria fulfilled on any personality disorder and quality of life.
As explained in text, the ordinate (quality of life) is a composite of subjective well-being, self-realization, social support, negative life events, and relation to family,
friends and neighbors. The mean is set to 2 and the standard deviation is 1.
97
98
3
2.69
2.5
2.05
Level of dysfunction
2 1.73
1.59
1.5 1.25
0.91
1
0.62
0.47
0.5
0
0 1 2 3 4 5 6 7 9
Number of criteria
Figure 52. The relationship between maximum number of criteria fulfilled on any personality disorder and dysfunction.
As explained in the text, the ordinate (dysfunction) is a composite of life quality (reversed), treatment seeking, the number of lifetime Axis I diagnoses, and the
notion that ones behavior causes problems. The mean and standard deviation are 1.
personality disorder had the poorest func- the percentage of the population with a disor-
tioning, followed by avoidant, schizotypal, der during the last 2 weeks, 1 month, 1 year,
narcissistic, antisocial, paranoid, histrionic, 2 years, or 5 years, the percentage will be lower
dependent, and schizoid personality disor- than if we follow a population throughout the
ders. Only obsessive-compulsive personality whole life span. This obvious fact has long
disorder had no indication of dysfunction. since been established for Axis I mental disor-
In conclusion, all studies taken together ders. The same will hold true for personality
show that reduced quality of life and dys- disorders, provided the disorders are not there
function are highest among those with already in early age and stay chronic through-
avoidant personality disorder, followed out life. While some theories may suggest this
closely by those with schizotypal or border- to be the case, empirical research shows that
line personality disorders. Those with para- many individuals are free of the personality
noid, schizoid, dependent, or antisocial per- disorder after a relatively short time (Grilo et
sonality disorder follow. There are few al. 2004; Zanarini et al. 2006). At the same time,
studies showing impaired quality of life for the 25 years point prevalence is much the
histrionic, narcissistic, or obsessive-compul- same over age, as we have seen. The implica-
sive personality disorder. The same is true tion is that new cases have to debut in the pop-
for the quality of provisional personality dis- ulation replacing those that disappear, even if
orders, passive-aggressive, self-defeating, some few reappear (Ferro et al. 1998; Durbin
and sadistic personality disorders. However, and Klein 2006). The consequence is that the
it should be noted that a problem with many percentage of the population that will fulfill
of these studies is a lack of control for other the criteria for a personality disorder in one or
variables correlating with specific personal- more periods of their life is much higher than
ity disorders and quality of life, dysfunction, 10%. This may be surprising for some, but it is
and impairment. an inevitable consequence of the continuous
There is reason to question whether his- nature of personality disorders and the appli-
trionic and obsessive-compulsive personal- cation of a threshold number of criteria to de-
ity disorders, in spite of their long histories, fine personality disorders. (Some with person-
deserve a status as personality disorder. Nar- ality disorders regress toward the population
cissistic personality disorder was not in- mean and do not any longer show the pre-
cluded in ICD-10, which some would view as scribed number of criteria. Other individuals
a wise decision. The provisional disorders with too few criteria display an increase and
provided for further study do not appear jump over and above the threshold.)
to deserve an inclusion in the nosology of In the future, longitudinal studies will
personality disorders. give us valuable insight into the epidemiol-
In the future, there is reason to believe ogy of personality disorders.
that we will see more studies of quality of
life, dysfunction, impairment, and disability
among subjects with personality disorders, CONCLUSION
either in the general population or in patient
samples. Personality disorders are prevalent: more
than 1 in 10 adult individuals has a personal-
ity disorder.
POINT PREVALENCE AND The average prevalence of the specific
LIFETIME PREVALENCE personality disorders is a little above 1%,
somewhat higher for obsessive-compulsive,
Lifetime prevalence for disorders is necessarily passive-aggressive, avoidant, histrionic, and
higher than point prevalence. If we measure antisocial personality disorders, and some-
what lower for sadistic, narcissistic, and self- tion, relational problems, lack of social sup-
defeating personality disorders. Two of these port, and frequent negative life events.
low-prevalence disorders, sadistic and self- Among the personality disorders, indi-
defeating, are only provided for further viduals with avoidant, schizotypal, and bor-
study in DSM-III-R (American Psychiatric derline personality disorders tend to have
Association 1987), and none of the three ex- the most reduced quality of life, dysfunction,
ists in ICD-10. and disability, followed by those with para-
Those with dependent, borderline, obses- noid, schizoid, dependent, and antisocial
sive-compulsive, avoidant, and schizotypal personality disorders. Individuals with ob-
personality disorders are overrepresented in sessive-compulsive, histrionic, narcissistic,
patient populations, both overall and when passive-aggressive, or sadistic personality
gender is controlled for, whereas those with disorders tend to have little or no reduction
antisocial, schizoid, and paranoid personal- in quality of life, dysfunction, and disability.
ity disorders are underrepresented. There is an even reduction in quality of
The highest prevalences of personality life and an even increase in dysfunction for
disorders in the general population are ob- each criterion manifested. Thus, there is a
served among subjects with lower education continuous relationship between those with
living in populated areas, for example in the no or small personality problems, those with
city center. They often have a history of di- moderate problems, and those with severe
vorce and separation and are more often liv- problems. No natural cutoff point exists. Any
ing without a partner. definition of how many criteria are required
Men have typically a schizoid, antisocial, for a personality disorder is arbitrary. Even
or obsessive-compulsive personality disor- so, to have a definition is important for com-
der, whereas women are more inclined to- munication. However, a change in criteria
ward a dependent or histrionic personality will immediately change the prevalence esti-
disorder. Antisocial, borderline, and passive- mates in the society. Consequently, correla-
aggressive personality disorders are more of- tions between personality disorders and
ten obse rv ed among younger persons, other variables are more important than
whereas older individuals more often have a prevalence rates. These correlations appear
schizoid personality disorder. It is typical for to be independent of how strictly personality
those with personality disorder (with an ex- disorders are defined.
ception for obsessive-compulsive personal- Because of the continuous nature of per-
ity disorder) to to live alone. In many cases, sonality disorders, their tendency to disap-
some are never married (antisocial, depen- pear, and the even distribution of point prev-
dent), have a history of frequent divorces alence over age, new personality disorders
(borderline), are divorced (paranoid), or not have to arise over the life span. Consequently,
married (histrionic) when interviewed. the likelihood of having a personality disor-
Lower education is most typical for those der once in the lifetime may be surprisingly
with paranoid and avoidant personality dis- high.
orders, whereas those with obsessive-com- Epidemiological research has perhaps
pulsive personality disorder in fact have changed some stereotypic notions about per-
higher education than those without the dis- sonality disorders. They are more frequent in
order. Those with paranoid, schizotypal, and the general population than we generally be-
passive-aggressive personality disorders are lieved, especially the introverted personality
most inclined to live in the city center. disorders. Borderline personality disorder is
Personality disorders imply dysfunction not a female disorder. Living without a
and reduction in quality of life, including re- partner is a risk factor for personality disor-
duced subjective well-being and self-realiza- ders, but being unmarried is less a risk factor
than many would have believed. Those liv- ders in depressed outpatients. J Personal Dis-
ing in a partnership without being married ord 13:6774, 1999
Coid J, Yang M, Tyrer P, et al: Prevalences and cor-
function well.
relates of personality disorder. Br J Psychiatry
Care must be taken to avoid believing 188:423431, 2006
that these correlations display one-direc- Cramer V, Torgersen S, Kringlen E: Personality
tional causal relationships. Personality disor- disorders, prevalence, sociodemographic cor-
ders may hinder obtaining higher levels of relations, quality of life, dysfunction, and the
education and may create socioeconomic dif- question of continuity. Persnlichkeitsstrun-
gen. Theorie und Therapie 7:189198, 2003
ficulties. Problematic personality traits may Cramer V, Torgersen S, Kringlen E: Quality of life
prevent a person from going into a relation- in a city: the effect of population density. Soc
ship or may lead to the breaking-up of rela- Indic Res 69:103116, 2004
tionships, rather than having relationship is- Cramer V, Torgersen S, Kringlen E: Personality
sues and problems causing problematic disorders and quality of life. A population
study. Compr Psychiatry 47:178184, 2006
personality traits.
Cramer V, Torgersen S, Kringlen E: Socio-demo-
Personality disorders are not something graphic conditions, subjective somatic health,
that a person necessarily has for life. Impul- Axis I disorders and personality disorders in the
sive and aggressive features may decrease common population: the relationship to quality
quickly with age, whereas introverted traits of life. J Personal Disord 21:552567, 2007
Crawford TN, Cohen P, JohnsonJG, et al: Self-re-
increase as people get older.
ported personality disorder in the children in
Perhaps one of the most important as- the community sample: convergent and pro-
pects of personality disorders is the reduc- spective validity in late adolescence and
tion of quality of life that is implied. How- adulthood. J Personal Disord 19:3052, 2005
ever, a low quality of life does not necessarily Durbin EC, Klein DN: Ten-year stability of person-
ality disorders among outpatients with mood
create a personality disorder; the opposite is
disorders. J Abnorm Psychol 115:7584, 2006
just as likely. Ferro T, Klein DN, Schwartz JE, et al: Thirty-
month stability of personality disorder diag-
noses in depressed outpatients. Am J Psychia-
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Function al impairment in patients with
6
Neurobiology
Emil F. Coccaro, M.D.
Larry J. Siever, M.D.
The study of personality disorders involves degree to which personality (or temperamen-
the study of both disordered character and tal) traits are under genetic influence. This
disordered temperament. Character relates to work largely involves studies of families and
how we see and operate in our world and is twins and is designed to document familial, if
based on how we develop and what we are not genetic, components to behavior. Previ-
taught about how to go through life. Temper- ous work defining the genetic underpinnings
ament, in contrast, relates to our innate ten- of temperament has been critical to our cur-
dency to behave and to react to any of a vari- rent understanding that temperament is in-
ety of challenges presented by other people herently biological in nature. Neuropsycho-
and our environment. Although both aspects pharmacological study informs us about the
of personality may be studied empirically, nature of brain chemistry and how the regula-
the study of temperament is uniquely suited tion of any of a variety of brain neurotrans-
to biological study because temperament has mitters influences temperament. Work in this
known genetic and neurobiological corre- area has led to the understanding that brain
lates, both of which are linked to critical pro- serotonin, for example, is critical in modulat-
cesses involving cognition, emotion, and being impulsive aggressive behavior in individ-
havior. uals with personality disorder. Consequently,
The neurobiology of temperament, as it work in neuropsychopharmacology leads to
appears in personality disorders, can be work in molecular genetics whereby the pres-
studied in a variety of ways, including those ence of a specific copy of a specific gene (e.g.,
that involve behavioral genetics, neuropsy- for a component of the brain serotonin sys-
chopharmacology, molecular genetics, psy- tem) influences a temperamental trait. For ex-
chophysiology, and neuroimaging. Behav- ample, individuals carrying a specific gene
ioral-genetic study informs us about the for the serotonin transporter may be more
103
anxious than other individuals who do not lustrating some of the points made about the
carry this gene. Finally, work in psychophys- psychobiology of prototypical patients with
iology and neuroimaging brings investiga- selected personality disorders.
tive work up to a level that integrates genes,
neuropsychopharmacology, and networks of
neural transmission. In this methodology,
both brain structure and brain function are
CLUSTER A PERSONALITY
examined regarding their contribution to the DISORDERS
expression of various temperamental traits.
In some groups of patients with personality The Cluster A personality disorders include
disorder, neuroimaging has revealed differ- schizotypal, paranoid, and schizoid person-
ences in the size and function of specific ality disorder. The criteria of these disorders
structures. capture shared characteristics of social isola-
Ultimately, the study of the neurobiology tion, detachment, suspiciousness, and in the
of personality disorders is conducted to lead case of schizotypal personality disorder, psy-
to a more comprehensive understanding of chotic-like cognitive/perceptional distortion.
the biological substrates of personality disor- Schizotypal personality was formulated in
der so that better treatments may be discov- part on the clinical profile observed in rela-
ered and existing treatments may be im- tives of schizophrenic probands, whereas the
proved. Uncovering the biological substrate other two were defined more in a clinical tra-
for a specific temperamental trait naturally dition. A high degree of overlap exists be-
leads to treatment strategies aimed at this spe- tween schizotypal and paranoid personality
cific substrate. The best example of this ap- disorder, whereas schizoid personality disor-
proach is the use of serotonin uptake inhibi- der is not frequently diagnosed in the clinical
tors in the treatment of impulsive aggression setting and may represent a milder version of
in individuals with personality disorders. Cu- the Cluster A personality disorders. These
riously, work in this area revealed the likely disorders can be perceived as consisting of a
presence of two treatment response groups: dimension of social deficits (no friends, de-
one responsive to serotonin uptake inhibitors, tached affect) and cognitive impairment, and
the other responsive to mood stabilizers. in the case of schizotypal personality disor-
In this chapter, we discuss the various as- der, a psychotic-like dimension. Because of
pects of the neurobiology of personality dis- its relationship to schizophrenia and its more
order on a cluster-by-cluster basis. We have common prevalence in clinical populations,
chosen this organization because the proto- most of the neurobiological research on this
typical personality disorders of interest tend cluster has focused on schizotypal personal-
to break out into one of the three personality ity disorder and is summarized here in rela-
disorder clusters. Despite this type of organi- tion to these dimensions.
zation, we should note that research has
clearly shown the relevance of a dimensional Behavioral Genetics
approach to the study of personality. Each
section begins with a brief summary of the Schizotypal personality disorder is found
phenomenology characteristic of each per- more frequently in the relatives of schizo-
sonality disorder cluster and follows with a phrenic probands than in the relatives of
summary of data relevant to behavioral ge- control subjects, and this association is
netics, neuropsychopharmacology (and mo- grounded in genetics rather than shared fa-
lecular genetics where relevant), and neu- milial environment as suggested by adoptive
ropsychology and neuroimaging. Each of the and twin studies (Siever 1991). The genetics
first two sections ends with a brief vignette il- of paranoid personality disorder are less well
Neurobiology 105
understood, but it has a high overlap with schizotypal personality disorder. Interest-
schizotypal personality disorder, and its ingly, however, when the negative symp-
presence may be greater in families of pa- toms were entered as a covariant, the positive
tients with schizophrenia or delusional disor- relationship with psychotic-like symptoms in
der (Webb and Levinson 1993). Schizoid per- plasma HVA emerged (Amin et al. 1997). Re-
sonality disorder has received little or no duced plasma HVA concentrations have
genetic study but is more common in the rel- been associated with impairment in tests of
atives of patients with schizophrenia (Kalus frontally mediated executive function such as
et al. 1993). the Wisconsin Card Sort Test (Siever et al.
1991). Thus, these results suggest that
Neuropsychopharmacology: dopaminergic activity may be relatively in-
Dopamine System creased or decreased depending on the pre-
dominance of psychotic-like versus deficit-
The dopamine system has been extensively like symptoms, respectively. This distinction
studied in patients with schizophrenia and is consistent with formulations that increased
particularly associated with the psychotic dopaminergic activity, particularly in stria-
symptoms of this disorder, consistent with tum, is associated with psychotic-like symp-
the antipsychotic effects of the neuroleptics, toms and that decreased dopaminergic ac-
which act as dopamine antagonists. Accord- tivity, particularly in prefrontal regions, is
ingly, given the phenomenological and ge- especially associated with deficit-like symp-
netic relationships between schizophrenia toms (Siever and Davis 2004).
and schizotypal personality disorder, the
dopaminergic system has been the primary Acute Pharmacological Interventions
neurotransmitter system studied in schizo-
typal personality disorder. Amphetamine, which stimulates the release
of the monoamines, particularly dopamine
Neurochemistry and norepinephrine, has been shown to im-
prove the cognitive performance of schizo-
Plasma homovanillic acid (HVA), a major typal personality disorder subjects on tests of
metabolite of dopamine, has been found to be executive function, working memory, and to
elevated in clinically selected patients with a lesser extent, sustained attention and ver-
schizotypal personality disorder, and this el- bal learning (Kirrane et al. 2000; Siegel et al.
evation is significantly correlated with psy- 1996). These improvements are more consis-
chotic-like criteria for this disorder, such that tent than those observed in schizophrenic
statistical correction for the presence of psy- subjects given amphetamine and are not ac-
chotic-like symptoms abolishes the differ- companied by the behavioral worsening
ence between groups (Siever et al. 1991). An that is, increased psychotic symptoms
identical configuration of results is found found after amphetamine administration in
with respect to cerebrospinal fluid (CSF) schizophrenic patients. Indeed, the deficit-
HVA (Siever et al. 1993). On the other hand, like symptoms of schizotypal personality
among relatives of patients with schizophre- disorder tend to improve following amphet-
nia, who are generally characterized more by amine administration (Laruelle et al. 2002;
the social and cognitive deficit-like symp- Siegel et al. 1996). These results suggest that
toms of schizotypal personality disorder, agents that enhance catecholamines, includ-
plasma HVA is lower in subjects with schizo- ing dopamine, may have beneficial effects on
typal personality disorder than control sub- cognition, presumably through stimulation
jects (Amin et al. 1999). In these studies, of D1 receptors in prefrontal cortex.
plasma HVA was negatively correlated with Similarly, the administration of a glu-
the negative or deficit-like symptoms of copyruvic stressor, 2-deoxyglucose, which
activates stress-sensitive subcortical systems phism, the allele for the COMT gene codes
such as the dopamine system and the hypo- for the amino acid valine (Val), as opposed to
thalamic-pituitary-adrenal (HPA) axis, re- methionine (Met), in the COMT enzyme. The
sults in greater stress-related (i.e., plasma substitution of Val for Met leads to a COMT
cortisol and HVA) responses in patients with enzyme that has far more activity than a
schizophrenia than in control subjects. In COMT enzyme coded by the MET allele.
contrast, patients with schizotypal personal- Thus, individuals with VAL alleles should
ity disorder show normal (plasma HVA) or have increased activity of COMT compared
even reduced (cortisol) activation compared with those with the MET allele. Because in-
with control subjects, suggesting that pa- creased COMT activity is associated with in-
tients with schizotypal personality disorder creased destruction of catecholamines, indi-
have better-buffered subcortical stress-re- viduals with VAL alleles should have less
sponsive systems than patients with schizo- central dopamine activity than those with
phrenia. Consequently, it is possible that this MET alleles. Consistent with this idea, cogni-
buffer provides a protective factor against tive impairment, particularly evident in
psychosis in patients with schizotypal per- dopamine-dependent working memory, has
sonality disorder (Siever and Davis 2004). been associated with the presence of the VAL
Longer-term pharmacological interven- allele in patients with schizophrenia (Wein-
tions have been evaluated in individuals berger et al. 2001) as well as their healthy sib-
with schizotypal personality disorder to de- lings and control subjects (Goldberg et al.
termine their effects on cognitive function. 2003). Studies in patients with schizotypal
Studies of guanfacine, an 2-adrenergic ago- personality disorder also suggest an associa-
nist, and pergolide, a D1/D2 agonist, suggest tion between cognitive impairment and the
improvement in cognitive function, particu- VAL allele, consistent with the role of re-
larly working memory, with these catechola- duced dopaminergic activity hypothesized
minergic interventions, consistent with the to contribute to the cognitive dysfunction in
facilitatory effects of the catecholamines on the schizophrenia spectrum disorders such
cognitive function and prefrontal cortex (Mc- as schizotypal personality disorder (Minzen-
Clure et al. 2007 ) . Cognitive function may berg et al. 2006).
also improve with risperidone (Koenigsberg
et al. 2003), possibly due to the effects that 5- Cognitive Function and
hydroxytriptamine (serotonin) type 2 recep- Psychophysiology
tor (5-HT 2 ) blockade has on facilitating
dopaminergic activity in frontal lobe. Anti- Although cognitive dysfunction may exist in
psychotic effects have been documented in a subtle forms in a variety of personality disor-
number of clinical trials of atypical and typi- ders, the most consistent and robust changes
cal neuroleptics in individuals with schizo- are found in people with Cluster A personal-
typal personality disorder (Hymowitz et al. ity disorders, more specifically schizotypal
1986; Schulz et al. 2003). personality disorder. Patients with schizo-
typal personality disorder show attenuated
DNA Polymorphisms patterns of cognitive impairment similar to
those of patients with schizophrenia but
Catechol-O-methyltransferase (COMT) somewhat more specific. For example, over-
plays a critical role in inactivation of dopa- all intelligence may not be impaired (Mitro-
mine in the frontal lobe, where the dopamine poulou et al. 2002; Trestman et al. 1995),
transporter is not the primary mode of inac- whereas specific disturbances in sustained
tivation of dopamine. Recently, a single nu- attention, in verbal learning, and particularly
cleotide polymorphism in the COMT gene in working memory have been reported in
has been discovered. With this polymor- patients with schizotypal personality disor-
Neurobiology 107
der compared with patients with other non- thermore, they show less capacity for inhibi-
schizophrenia-related personality disorders, tion on a prepulse inhibition paradigm and
the latter of whom are generally not im- P50-evoked potential paradigm (Cadenhead
paired in these indices, and with normal con- 2002). The latter finding is of particular inter-
trol subjects (Mitropoulou et al. 2002, 2005). est because it has been linked to a specific al-
Alth oug h patie nts with schizophrenia lele of the nicotinic receptor in families of
showed deviations from normal control sub- patients with schizophrenia. Backward mask-
jects on the order of two standard deviations, ing, reflecting early visual processing, has
patients with schizotypal personality disor- also been reported to be abnormal in patients
der have more on the order of one standard with schizotypal personality disorder and
deviation below the mean or less (Mitropou- schizophrenia (Siever and Davis 2004; see
lou et al. 2002, 2005). The deficits in working Braff and Freedman [2002] for an overview of
memory and attention may contribute to the these psychophysiological abnormalities).
impaired rapport and misreading of verbal
and facial cues in patients with schizotypal
Neuroimaging
personality disorder, who often clinically
complain that they have a hard time focusing Structural Imaging
on others, which detracts from their ability to
engage. Indeed, performances on working Patients with schizotypal personality disor-
memory tasks have been reported to be cor- ders show ventricular enlargement and re-
related with interpersonal impairment and duced volumes of several brain regions, as
account for the other cognitive impairments do patients with schizophrenia. In studies of
in schizotypal personality disorder (Mitro- patients with schizotypal personality disor-
poulou et al. 2005; Siever et al. 2002). der, ventricular volume is increased, al-
A variety of psychophysiological en- though studies of relatives of patients with
dophenotypes that may reflect genetic sub- schizotypal personality disorder are mixed
strates to the schizophrenia spectrum disor- (Shihabuddin et al. 1996; Siever 1995). Tem-
ders have been found to be abnormal in poral volume reductions in patients with
patients with schizotypal personality disor- schizotypal personality disorder appear to
der as well as in patients with chronic schizo- be comparable with th ose observ ed in
phrenia. Many of these psychophysiological schizophrenic patients and occur in both su-
abnormalities have also been found in rela- perior temporal gyrus and other temporal re-
tives of patients with schizophrenia, who gions. However, some data suggest that
may have mild schizophrenia-spectrum frontal volumes are relatively preserved, es-
symptoms or may even appear to be clini- pecially frontal pole (Brodmann area 10
cally healthy, raising the possibility that [BA10]), suggesting that greater frontal ca-
these abnormalities reflect an underlying ge- pacity may serve as a buffer against the se-
netic susceptibility to the schizophrenia vere cognitive and social deterioration we
spectrum that is variably expressed. Al- see in schizophrenia (Hazlett et al. 2008).
though a detailed review of psychophysio- Whereas striatal volumes of patients with
logical abnormalities is beyond the scope of schizophrenia are enlarged secondary (in
this chapter, abnormalities in eye movement, large part) to neuroleptic medications, the
visual processing, and inhibition of startle re- striatal volumes (including putamen [Shi-
sponse are among the most consistently rep- habuddin et al. 2001] and caudate [Levitt et
licated. Thus, individuals with schizotypal al. 2002]) of patients with schizotypal per-
personality d isorder showed impaired sonality disorder are reduced in comparison
smooth-pursuit eye movement, antisaccade with normal control subjects and unmedi-
generation, and velocity discrimination. Fur- cated patients with schizophrenia. Reduced
striatal volumes are consistent with the pos- striatum, which is normally inhibited by
sibility of reduced dopaminergic activity, dopamine, in unmedicated schizotypal pa-
which may be protective against the emer- tients compared with control subjects and
gence of psychosis. unmedicated schizophrenic patients as well
as the reduced plasma HVA responses to 2-
Functional Imaging deoxyglucose and striatal volumes noted
earlier in these studies, suggesting dopamin-
Both positron emission tomography (PET) ergic activity that is better buffered than that
and single photon emission computed to- of schizophrenic patients.
mography (SPECT) functional imaging stud-
ies suggest that patients with schizotypal per- Case Example
sonality disorder do not activate regions such
as dorsolateral prefrontal cortex in response Mr. B is a 56-year-old, common-law
to an executive function or learning task to the married male, emplo yed in his ex-
same degree as control subjects, but do so to a tended familys business, whose cur-
rent complaint is that people at work
greater degree than do patients with schizo-
are accusing me of saying things that I
phrenia. However, patients with schizotypal am not saying. Mr. B has been seen by
personality disorder are able to activate other the psychiatry service for more than 20
compensatory regions, including the anterior years, after he was admitted to medi-
pole of frontal cortex (BA 10), which is be- cine for complaints of back pain. He
lieved to be a high-level executive region was transferred to psychiatry because
(Buchsbaum et al. 2002). A recent functional he couldnt stand up. He was first
psychiatrically hospitalized when he
magnetic resonance imaging (fMRI) study
was in the Navy for an episode of go-
(Koenigsberg et al. 2005) using a visuospatial ing crazy after a dispute with his cap-
working-memory task also showed increased tain. He had symptoms of deperson-
activation in patients with schizotypal per- alization, irritability, and difficulty
sonality disorder in BA 10, but lesser activa- getting along with his peers. Six years
tion in dorsolateral prefrontal cortex than in after his tour in the Navy, he saw a ther-
normal control subjects. Thus, patients with apist but would have vivid dreams that
were disturbing to both the therapist
schizotypal personality disorder may have
and himself, at which point Mr. B states
compensatory mechanisms available to them
his therapy ended. He has had paranoid
that patients with schizophrenia do not have ideation, thinking that people at work
in the face of diminished capacity to use dor- are against him, although this suspi-
solateral prefrontal cortex. The compensatory ciousness and ideation are responsive
mechanisms may involve using higher execu- to reality testing, as are his ideas of ref-
tive regions than are required for normal in- erence. He has prolonged periods of an-
dividuals. hedonia and demoralization but, other
than insomnia at times, does not have
A n I B Z M SP E C T st u d y m e as ur in g
extensive vegetative symptoms of de-
dopamine released by displacement of [11C] pression. He has experienced episodes
iodine-methoxybenzamide (IBZM) demon- of depersonalization described as look-
strated that subjects with schizotypal per- ing down at himself. He complains of
sonality disorder released significantly more low self-esteem but denies worthless-
dopamine in response to amphetamine ad- ness, hopelessness, or helplessness. Mr.
ministration than did normal control sub- B notes that he was always a loner and
had no close friends since the fifth
jects but less than did acute schizophrenic
grade. He went to college just before he
patients (Siever et al. 2002). These results are went to Vietnam. He smokes one pack
consistent with functional imaging studies of cigarettes per day, does not use recre-
suggesting increased activation of ventral ational drugs, and drinks up to three
Neurobiology 109
drinks per night, although he goes for threshold of overt psychosis. For these rea-
periods without drinking significantly. sons, they present more in the context of their
Mr. B underwent a research evalua- disturbed interpersonal style and coping
tion in the Mood and Personality Dis-
mechanisms rather than in the context of
orders Program. Research diagnostic
evaluation revealed the presence of a overt psychosis as in schizophrenia. How-
schizotypal personality disorder with ever, this disorder provides an example of a
traits of paranoid and narcissistic per- spectrum that in its more extreme forms
sonality disorder; he was also found to manifests as an Axis I disorder (schizophre-
meet DSM-IV-TR (American Psychiatric
nia) but in milder forms as an Axis II disor-
Association 2000) criteria for alcohol
abuse (past). Neurobiological evalua- der. There are few biological data regarding
tion uncovered a number of abnormali- paranoid personality disorder when it is not
ties. First, he displayed modestly im- comorbid with schizotypal personality dis-
paired eye-movement accuracy (3.38 on order.
a 1=best to 5=worst scale) and mild cog-
nitive impairment. His dopaminergic in-
dices were high, with a plasma HVA
level of 14.5 ng/mL (mean for normal CLUSTER B PERSONALITY
subjects is 7.4 1.8 ng/mL) and a CSF
HVA level of 38.0 ng/mL (mean for nor- DISORDERS
mal control subjects = 24.1 6 ng/mL).
In addition, Mr. B showed hypofrontal- The Cluster B personality disorders include
ity on a PET scan during a verbal mem- antisocial, borderline, histrionic, and narcis-
ory task. Finally, he showed modest im- sistic personality disorders. Individuals with
provement following administration of
these disorders present with varied degrees
amphetamine. Since evaluation, Mr. B
has been treated with low-dose neuro- of impulsivity, aggression, and emotional
leptic medication that helps him control dysregulation. As in other clusters, there is a
multiple symptoms, including an olfac- high degree of overlap among the disorders
tory hallucination-like experience of the in Cluster B, particularly between antisocial
smell of cordite, a feeling that others personality disorder (ASPD) and borderline
are staring at him, a feeling of being de-
tached or separated by a bubble from personality disorder (BPD). ASPD and BPD
other people, a lack of any close friends are the best studied of the cluster, due to
other than a common-law wife, feelings clear and reliable criteria for the former and
in the past that his wife might be fol- the high prevalence of the latter in clinical
lowing around, and a feeling in the past populations.
that he has seen future events.
Behavioral Genetics
Summary
Twin studies suggest that the genetic influ-
These studies suggest that patients with ence underlying personality disorders is at
schizotypal personality disorder have at least as high as that of personality traits that
least a profile of cognitive impairment and underlie the various personality disorders.
structural brain abnormalities, particularly In a relatively small twin study (Torgersen et
in temporal cortex, similar to that found in al. 2000) that may tend to overestimate the
patients with schizophrenia, but a combina- underlying genetic influence of any of a vari-
tion of better prefrontal reserves and more ety of personality disorders, the heritability
subdued dopaminergic activity subcortically for Cluster B personality disorders was 0.60.
protects them from the emergence of psycho- The heritabilities of the specific Cluster B dis-
sis. Their more subtle cognitive impairments orders in this study were 0.79 for narcissistic
are reflected in their eccentricity and inter- personality disorder, 0.69 for BPD, and 0.67
personal disengagement but do not reach the for histrionic personality disorder. The best-
fitting models did not include shared famil- disorder diagnoses (Brown et al. 1979). This
ial environment effects, although such effects finding was extended (Brown et al. 1982) to
may influence the development of BPD. include a trivariate relationship between his-
Adoption studies of ASPD confirm a strong tory of aggression, suicide attempts, and
genetic, although a less strong environmen- reduced CSF 5-HIAA, whereby history of
tal, influence for this disorder (Cadoret et al. aggression and suicide attempts were corre-
1985). Although adoption studies of other lated directly with each other and inversely
Cluster B personality disorders have not with CSF 5-HIAA. Later work with violent
been conducted, the results of family history offenders (Linnoila et al. 1983) found re-
studies suggest a complex pattern of familial duced CSF 5-HIAA in impulsive, but not
aggregation in which traits related to impul- nonimpulsive, violent offenders with a vari-
sive aggressiveness and mood dysregulation, ety of DSM-II personality disorder diag-
rather than BPD itself, are transmitted in noses, suggesting that impulsive aggression
families (Silverman et al. 1991). was the form most associated with reduced
CSF 5-HIAA concentration. Although these
Neuropsychopharmacology findings have been replicated, an inverse re-
lationship between CSF 5-HIAA and aggres-
The 5-HT system has been extensively stud- sion has not been reported in samples of in-
ied in individuals with personality disorder dividuals with personality disorder without
in general and in particular as an inverse cor- a prominent history of criminal activity (Coc-
relate of impulsive aggressive behavior. caro et al. 1997a, 1997b; Gardner et al. 1990;
Other neurotransmitters and/or modulators Simeon et al. 1992). It is likely that CSF 5-
have also been studied in this regard, but to a HIAA, being a relatively insensitive index of
much lesser degree. 5-HT activity, is most reduced in the most se-
verely aggressive individuals and that it is
Serotonin difficult to detect this relationship in less se-
verely aggressive individuals.
There is a clear and consistent role for 5-HT
in the regulation of aggression and/or im- Acute pharmacological interventions. T h e r e
pulsivity, particularly in individuals with are a variety of 5-HT acute pharmacological
personality disorder. Most data suggest an challenge studies that have been performed
inverse relationship between any of a variety in individuals with personality disorder in
of measures of 5-HT levels and levels of ag- the context of the study of aggression. Typi-
gression or impulsivity. Although some cally, hormonal (e.g., prolactin) responses to
studies suggest a primary relationship with the 5-HT selective agents are reported to cor-
impulsivity, most studies report a 5-HT rela- relate inversely with various measures of ag-
tionship more consistent with the construct gression and impulsivity (Coccaro et al. 1989,
of impulsive aggression. 1997a, 1997b; Dolan et al. 2001; Moss et al.
1990; OKeane et al. 1992; Paris et al. 2004;
Neurochemical studies. Inverse relationships Siever and Trestman 1993). Pharmacological
between human aggression and measures of challenge studies using putatively receptor-
central 5-HT function have been reported selective 5-HT agents also seem to support
since 1979, when Brown and colleagues re- the hypothesis of an inverse relationship be-
ported an inverse relationship between CSF tween 5-HT and measures of aggression and
levels of the main central 5-HT metabolite, suggest a role for at least the 5-HT1A receptor
5-hydroxyindoleacetic acid (5-HIAA), and in particular (Cleare and Bond 2000; Coccaro
life history of actual aggressive behavior in et al. 1990, 1995; Hansenne et al. 2002). A
males with a variety of DSM-II (American more complex picture in regard to central 5-
Psychiatric Association 1968) personality HT1A receptors has been suggested by the
Neurobiology 111
observation of reduced 5-HT 1A receptor on the genotyping gel) was found to have
mediated responses in females with BPD some association with clinically relevant
with a history of sustained child abuse variables. For example, impulsive violent of-
(Rinne et al. 2000). Because childhood abuse fenders (nearly all with a personality disor-
has been linked to impulsive aggression in der) with at least one copy of the L TPH allele
later adolescence and adulthood (Crick and have been reported to have significantly
Dodge 1996), it remains to be determined lower CSF 5-HIAA compared with impul-
whether the relationships between 5-HT and sive violent offenders with the UU genotype
aggression are linked to this environmental/ (U referred to the upper band on the geno-
developmental variable. Although behav- typing gel) in at least one study (Nielson et
ioral responses to 5-HT stimulation in indi- al. 1994). This finding did not generalize to
viduals with personality disorder have not nonimpulsive violent offenders (many of
received much attention, at least one study whom also had a personality disorder) or to
reported a significant reduction in anger in normal control subjects and was not repli-
12 patients with BPD after administration of cated in a later study by the same authors
the mixed 5-HT agonist m-chlorophenylpip- (Nielson et al. 1998).
erazine (m-CPP) but not placebo (Hollander The presence of the L allele was associ-
et al. 1994); a reduction in fear was also ob- ated with an increased risk of suicidal behav-
served in the males with BPD. ior in all violent offenders in this and in a
later study by these authors (Nielson et al.
Platelet receptor markers. Despite consider-
1994, 1998). New et al. (1998) have also re-
able platelet receptor work in other psychiat-
ported that the self-reported tendency to-
ric populations, relatively little research in
ward aggression varies as a function of TPH
this area has been published on subjects with
genotype whereby subjects with the LL gen-
personality disorder. Inverse correlations be-
otype had higher aggression scores than
tween the number of platelet 3H-imipramine
those with the UU genotype. Curiously,
(5-HT transporter) binding sites and self-
however, the reverse finding was reported
mutilation and impulsivity have been re-
by Manuck et al. (1999) in a sample of healthy
ported in individuals with personality disor-
volunteers from the community: higher ag-
der but not in patients without a history of
gression scores were associated with the
self-mutilation (Simeon et al. 1992). Similarly,
presence of the U allele.
an inverse correlation between the number of
These disparate findings may be due to
platelet 3 H-paroxetine (5-HT transporter)
critical differences in the subject samples. As
binding sites (Coccaro et al. 1996), the quan-
such, the relationship between the TPH allele
tity of platelet serotonin (Goveas et al. 2004),
and 5-HT function may be dependent on the
and life history of aggression has been re-
TPH alleles relationship with some other
ported in persons with personality disorder.
gene depending on the subject sample. Lap-
DNA polymorphism studies. W o r k i n t h i s palainen et al. (1998) reported an association
area began with an examination of DNA between antisocial alcoholism (i.e., alco-
polymorphisms in the gene for tryptophan holism with ASPD or intermittent explosive
hydroxylase (TPH). TPH is the rate-limiting disorder) and the C allele for the 5-HT 1D
step for the synthesis of serotonin, and it was beta-receptor polymorphism. Because the
thought that polymorphisms in TPH would 5-HT1D beta receptor is a critical receptor in-
lead to TPH enzymes of different activities. volved in the regulation of 5-HT release on
Although this TPH polymorphism was not neuronal impulse, this finding could be
found to have a clear functional consequence highly relevant to the understanding of
regarding serotonin synthesis, the presence ASPD comorbid with alcoholism. Alleles of
of the L allele (L referred to the lower band the 5HTT transporter, 5HT 2A, and TPH2
have been found to be associated with BPD concentrations, it is possible that findings
or its traits (Ni et al. 2006a, 2006b, 2007; with CSF HVA may be related to similar find-
Siever et al. 2006). ings with CSF 5-HIAA concentration. If so, a
specific assessment of CSF HVA may not be
Catecholamines made unless the effect of CSF 5-HIAA con-
centration is accounted for, a statistical ad-
Compared with serotonin, far fewer data justment that has not been made in pub-
have been published regarding the role of lished studies to date.
other neurotransmitters and behavioral di-
Acute pharmacological interventions. E a r l y
mensions of relevance to the Cluster B per-
studies of the acute administration of am-
sonality disorders.
phetamine in patients with BPD demon-
Neurochemical studies. A positive correlation strated a greater behavioral sensitivity to am-
between CSF 3-methoxy-4-hydroxy-phenyl- phetamine challenge among the patients with
clycol (MHPG, the major metabolite of nore- personality disorder than among control sub-
pinephrine) concentrations and life history of jects (Schulz et al. 1985). Replication studies
aggression has been reported in males with found that global worsening in psychopathol-
personality disorder, although further analy- ogy after amphetamine was typical of pa-
sis revealed that CSF 5-HIAA concentration tients with both borderline and schizotypal
accounted for most (80%) of the variance in personality disorder, whereas global im-
aggression scores. Similarly, one study re- provement was typical of borderline subjects
ported a small positive correlation between without comorbid schizotypal personality
plasma norepinephrine and self-reported im- disorder (Schulz et al. 1988). This finding sug-
pulsivity in males with personality disorder gests important biological differences among
(Siever and Trestman 1993). In contrast, at patients with BPD as a function of comorbid
least one study (Virkkunen et al. 1987) re- schizotypy (perhaps because of preexisting
ported a significant reduction in CSF MHPG dopaminergic hyperactivity in mesolimbic
concentration in males who have committed dopamine circuits). In other studies of am-
violent offenses. Finally, Coccaro et al. (2003) phetamine challenge relevant to Cluster B
reported an inverse relationship between personality disorder, a direct relationship
plasma-free MHPG and life history of aggres- with affective lability has been noted in
sion in males with personality disorder. healthy volunteers, suggesting that increases
Compared with patients with nonborderline in norepinephrine and/or dopamine may
personality disorders, patients with BPD had play a role in the moment-to-moment dysreg-
lower plasma free MHPG compared with the ulation of affect seen in patients with BPD
nonborderline control subjects; a finding that (Kavoussi et al. 1993).
disappeared after differences in aggression Limited data are available regarding the
scores were accounted for. study of norepinephrine receptormediated
Evidence for the role of dopamine in ag- responses related to the features of Cluster B
gression in individuals with personality dis- personality disorder. One study reported a
order is limited and contradictory. Although positive correlation between the growth hor-
some studies demonstrate no relationship mone response to the 2 norepinephrine ago-
between CSF HVA concentration and aggres- nist clonidine and self-reported irritability
sion (Brown et al. 1979; Virkkunen et al. (a correlate of aggression) in a small sample of
1987), other studies demonstrate an inverse males with personality disorder and healthy
relationship between these variables (Lin- volunteers (Coccaro et al. 1991). A more re-
noila et al. 1983; Virkkunen et al. 1989). Given cent study of females with BPD, however, re-
the consistent observation of a strong corre- ported no difference in growth hormone re-
lation between CSF 5-HIAA and CSF HVA sponses to clonidine (Paris et al. 2004).
Neurobiology 113
DNA polymorphism studies. The presence of Other neurotransmitters or neuromodu-

the low-functioning monoamine oxidase A lators that may play a role in Cluster B
(MAO-A) allele in young men combined related features include vasopressin, which
with a history of childhood maltreatment has may have a direct relationship with aggres-
recently been shown to be associated with an sion (Coccaro et al. 1998); substances related
increased risk of aggressive and criminal of- to limbic HPA axis functioning (corticotropin
fending (e.g., antisocial) behavior (Caspi et releasing factor, adrenocorticotropic hor-
al. 2002). This specific MAO-A allele is asso- mone, cortisol), which may have varied rela-
ciated with reduced catabolism of catechola- tionships regarding aggressive behavior de-
mines (and serotonin) and accordingly with pendent on social context and stress (Rinne
higher levels of these neurotransmitters that et al. 2002); testosterone, which is variably
may be associated with aggressive behavior. correlated with aggression, particularly in vi-
These data suggest that although the pres- olent offenders with ASPD (Virkkunen et al.
ence of this allele may be important in in- 1994); and cholesterol and fatty acids, which
creasing the risk of antisocial behavior, the may play a role in both aggression (both: At-
co-occurrence of childhood maltreatment in maca et al. 2002; New et al. 1999) and mood
vulnerable individuals is also needed to regulation (fatty acids: Zanarini and Fran-
meaningfully increase the risk of antisocial kenburg 2003).
behavior.
Neuroimaging
Acetylcholine and Other
Neurotransmitters/Neuromodulators Structural Imaging
Reduced prefrontal gray matter (e.g., by 11%)
Studies of acetylcholine function in personal- has been associated with autonomic deficits
ity disorder have been limited to two studies. in individuals with ASPD characterized by
In the first (Steinberg et al. 1997), patients aggressive behaviors (Raine et al. 2000). Con-
with BPD reported greater self-rated depres- versely, increases in corpus callosum white
sion scores in response to the cholinomimetic matter volume and length have been de-
agent physostigmine than did patients with scribed in similar subjects (Raine et al. 2003),
nonborderline personality disorders or where larger callosal volumes were also asso-
healthy volunteer control subjects. Peak phy- ciated with affective/interpersonal deficit,
sostigmine-induced depression scores corre- low autonomic stress reactivity, and spatial
lated positively with the number of affective ability. Given the complex role these struc-
instability, but not with the number of im- tures play in mediating cognitive and affec-
pulsive aggression, borderline personality tive processes, these findings may represent
traits. This finding suggests that the trait of anatomical correlates of the complex behav-
affective lability in patients with BPD may be iors seen in ASPD. A confounding role for al-
mediated in part by a heightened sensitivity coholism in these matters must always be ad-
to acetylcholine. In the second study (Paris et dressed, however, because it also has been
al. 2004), however, no differences in hor- shown that volume changes may be corre-
monal responses to a different cholinomi- lated with duration of alcoholism (Laakso et
metic agent, pyridostigmine, were seen be- al. 2002).
tween females with BPD and control subjects. Similar structural imaging studies of fe-
These divergent findings suggest the possi- males with BPD report reductions in the vol-
bility that the cholinergic receptors mediating ume of subcortical structures such as the
behavioral and hormonal responses to cho- amygdala (Rusch et al. 2003; Schmahl et al.
linergic agents in these subjects may be very 2003; Tebartz van Elst et al. 2003; but see New
different by virtue of brain location. et al. 2007) and hippocampus (Schmahl et al.
2003; Tebartz van Elst et al. 2003). Studies tal and prefrontal regions as well as in the
also report reductions in the volumes of both hippocampus and cuneus (Juengling et al.
orbitofrontal and anterior cingulate (Hazlett 2003), supporting previous structural studies
et al. 2005; Tebartz van Elst et al. 2003). Given that demonstrated reductions in the volumes
the role these structures are thought to play of these brain areas. Although most of these
in emotional information processing, it is PET studies were performed in the resting
tempting to speculate that these structures condition, one PET study in females with
represent anatomical correlates of the emo- BPD showed that the replay of abandonment
tional dysregulation (including impulsive scripts prior to PET scan was associated with
aggression) seen in patients with BPD. greater increases in activity in dorsolateral
prefrontal cortex (bilaterally) and in cuneus,
Functional Imaging (PET and SPECT) but with reductions in activity in the right
anterior cingulate (Schmahl et al. 2003).
Whereas structural imaging yields only a Given that several of these structures have
static picture of the brain, SPECT or PET been shown to be smaller in these subjects
scanning can yield functional information re- compared with control subjects, the in-
lated to cerebral blood flow or cerebral glu- creased activity in these regions after the
cose metabolism, respectively. For example, abandonment task is quite notable.
SPECT studies have demonstrated reduced PET studies may also be performed after
perfusion in prefrontal cortex as well as focal the administration of neurotransmitter-
abnormalities in left temporal lobe and in- specific agents so that the activity of brain re-
creased activity in anteromedial frontal cor- gions in response to activation of specific re-
tex in limbic system in aggressive individu- ceptors by these agents can be assessed. To
als with ASPD and alcoholism (Amen et al. date, at least four studies of patients with per-
1996). A more recent study using SPECT re- sonality disorder have been performed in this
ported significant correlations between re- way. Two utilized the indirect 5-HT agonist
duced cerebral blood flow in frontal and fenfluramine, one utilized the more direct
temporal brain regions and the disturbed postsynaptic 5-HT agonist m-CPP, and one
interpersonal attitude factor from the Psy- examined the trapping of a 11 C analogue of
chopathy ChecklistRevised (Soderstrom et tryptophan. In the first fenfluramine study,
al. 2002). In homicide offenders (many of patients with prominent histories of impul-
whom presumably had ASPD), a bilateral sive aggression and BPD demonstrated
diminution of glucose metabolism has been blunted responses of glucose metabolism in
reported in both medial frontal cortex and at orbital frontal, ventral medial frontal, and
a trend level in orbital frontal cortex (Raine et cingulate cortex compared with normal sub-
al. 1994). In a study of patients with a variety jects (Siever et al. 1999). A similar result was
of personality disorders, an inverse relation- reported in the second fenfluramine study, in
ship was found between life history of ag- which patients with BPD displayed reduced
gressive impulsive behavior and regional glucose metabolism (relative to placebo)
glucose metabolism in orbital frontal cortex compared with control subjects in right me-
and right temporal lobe (Goyer et al. 1994). dial and orbital frontal cortex, left middle and
Patients meeting criteria for BPD had de- superior temporal gyri, left parietal lobe, and
creased metabolism in frontal regions corre- left caudate (Soloff et al. 2000). In the PET
sponding to BA 46 and BA 6 and increased study involving m-CPP, patients with promi-
metabolism in superior and inferior frontal nent histories of impulsive aggression and
gyrus (BA 9 and BA 45; Goyer et al. 1994). personality disorder were found to have re-
More-recent PET studies in females with duced activation of the anterior cingulate and
BPD reported hypometabolism in both fron- increased activation of the posterior cingulate
Neurobiology 115
compared with control subjects, as well as a ing emotionally aversive images (e.g., crying
relative amygdala-prefrontal disconnec- children) than did control subjects (Herpertz
tion (New et al. 2002, 2007). Given the role of et al. 2001). Another fMRI study in females
the anterior cingulate in emotional informa- with BPD reported a generally similar find-
tion processing, it is noteworthy that this area ing (left amygdala as opposed to bilateral ac-
is underactivated by 5-HT stimulation. In the tivation) using emotional faces (Donegan et
PET study examining the unilateral trapping al. 2003). Other recent studies from the two
of a 11C analogue of tryptophan, evidence for separate laboratories of the authors suggest
a reduction in 5-HT synthesis was present in a) increased activation in amygdala, and re-
the corticostriatal (e.g., medial frontal, ante- duced activation in orbitomedial prefrontal
rior cingulate, superior temporal gyri, and cortex, to anger faces in impulsively aggres-
corpus striatum) brain areas of subjects with sive subjects with personality disorders
BPD (Leyton et al. 2001). Reduction in 5-HT (none of whom was psychopathic; Coccaro et
synthesis in these regions was reported to al. 2007) and b) increased superior temporal
correlate with a laboratory measure of behav- cortex, rather than middle temporal cortex,
ioral disinhibition. Reduced transporter BOLD responses, suggesting increased re-
binding has also been reported in patients flexive processing and increased amygdala,
with impulsive aggressive personality disor- fusiform, and occipital visual area activation
der (Frankle et al. 2005), and increased 5 to emotional provocation (Koenigsberg et al.
HT2A receptor binding has been reported in 2007). Given the clear differences in known
currently aggressive subjects (Siever et al. emotional information processing between
2006). psychopathic antisocial subjects on the one
hand and borderline subjects on the other,
Functional Imaging (fMRI) these data suggest the brain sites of these dif-
Unlike PET or SPECT, fMRI does not require ferences.
the injection of a radiolabeled agent. Instead,
fMRI assesses changes in cerebral blood flow Case Example
using changes in the blood oxygenation
Mr. C is a 29-year-old, married male
leveldependent (BOLD) signal in the mag- computer technician referred for treat-
netic resonance imaging scanner. This offers ment of his impulsive aggressive out-
a much greater spatial and temporal resolu- bursts in the context of a threatened
tion compared with either PET or SPECT and separation from his wife of 4 years. Mr.
allows a finer assessment of the activation C reports impulsive aggressive out-
and deactivation of discrete regions of the bursts since his mid-teens. These out-
bursts typically involve screaming,
brain in response to specific stimuli. To date,
shouting, and throwing things around;
at least three studies using fMRI in patients he has only occasionally physically hit
with personality disorder have been pub- anyone. However, these aggressive out-
lished. In one study using fMRI, males with bursts occur several times a month and
(psychopathic) ASPD activated preselected usually several times a week, particu-
frontal and temporal regions of interest less larly when Mr. C is held up in traffic.
than did control subjects during trials of neg- Most recently, he has been having seri-
ous marital difficulty, and his wife is
atively charged emotional words (Kiehl et al.
now threatening to leave him if he does
2001), suggesting an important deficit in not get help for his anger problem. He
emotional information processing. In a simi- reports that his relationship with his
lar fMRI study in females with BPD, the wife is often stormy, with frequent
study group demonstrated greater activation fighting that sometimes goes on for
of the amygdala bilaterally (as well as activa- hours. Sometimes in the aftermath of
tion of selected frontal regions) while view- these fights Mr. C runs off and gets ex-
ceedingly drunk and drives recklessly norepinephrine, vasopressin for impulsivity

around to wn while high. At o ther and aggression, possibly acetylcholine for
times, he reports, he beats his head so mood reactivity) and in brain structures re-
hard against a wall that his forehead
lated to behavioral inhibition and emotional
bleeds (once he needed stitches). Still, at
other times he frantically pleads with
information processing (e.g., orbitofrontal
his wife not to leave him; once he took cortex, amygdala). Although patients with
an overdose of aspirin, in front of his BPD are often the most extreme in these fea-
wife, to get her to stay with him. Mr. C tures and in related biological dysfunction,
reports a history of alcohol abuse in his specific biological dysfunction related to spe-
late teens and early twenties and a his- cific traits (e.g., serotonin dysfunction with
tory of gambling to excess up until impulsive aggression) can be seen in patients
1 year prior to evaluation.
with other, nonborderline personality disor-
Mr. C underwent a research evalua-
tion in the Mood and Personality Disor- ders. As such, it is doubtful that any assess-
ders Program. Diagnostic evaluation re- ment of specific neurobiological function will
vealed the presence of BPD with traits of be specific to patients with BPD.
histrionic, narcissistic, and obsessive-
compulsive personality disorder. He
was also found to meet DSM-IV-TR cri-
teria for two episodes of major depres-
CLUSTER C
sion in the past and for alcohol abuse
The Cluster C personality disorders include
(past) and pathological gambling (past).
avoidant, dependent, and obsessive-compul-
He underwent a variety of research-
related studies including d-fenfluramine sive personality disorders. Individuals with
(d-FEN) challenge and was found to these disorders present with varied degrees
have a blunted, but not absent, prolactin of anxiety sometimes expressed as rigidity,
response to d-FEN (2.3 ng/mL com- particularly in the case of obsessive-compul-
pared with 6.3 3.4 ng/mL for healthy sive personality disorder. Of the three disor-
male control subjects); his CSF 5-HIAA ders, avoidant personality disorder is most
level was not abnormal (23.9 ng/mL
like generalized social phobia in Axis I, and a
compared with 20.0 4.9 ng/mL for
healthy male control subjects). The mod- great degree of comorbidity occurs between
est magnitude of his prolactin response the two diagnoses (Dahl 1996). As in other
to d-FEN suggests a limited degree of personality disorder clusters, there is overlap
central serotonin system dysfunction. among the disorders in this cluster and with
Mr. C entered a treatment trial of those in other personality disorder clusters,
fluoxetine and experienced a reduction
particularly Cluster B. To date, there has been
in overt aggressive behavior over a pe-
riod of several weeks. Over this time his much less empirical neurobiological research
relationship with his wife somewhat with patients in Cluster C.
improved, and he is now in dialectical
behavioral therapy to work on other as- Behavioral Genetics
pects of his interpersonal difficulties
with others in his life. As with the Cluster B personality disorders,
twin studies suggest substantial genetic in-
Summary fluence for each of the Cluster C personality
disorders (Torgersen et al. 2000). Heritability
The studies discussed in this section suggest for Cluster C personality disorders as a
that patients with Cluster B personality disor- group was estimated at 0.62; heritabilities for
der have dysfunction in a variety of neurobi- each disorder in the study were 0.78 for ob-
ological areas that may underlie their clinical sessive-compulsive, 0.57 for dependent, and
presentation. Dysfunction can occur in multi- 0.28 for avoidant personality disorder. The
ple monoaminergic systems (e.g., serotonin, best-fitting models did not include shared fa-
Neurobiology 117
milial environment effects, although a model creased cortisol responses to serotonergic

consisting only of shared familial and unique agents (Tancer et al. 1999), and social anxiety
environmental effects could not be defini- disorders respond to selective serotonin re-
tively ruled out for dependent personality uptake inhibitors that re-regulate serotoner-
disorders. Family studies suggest a familial gic activity (Schneier et al. 2003). Shyness (re-
association between social anxiety disorder lated to avoidant traits) has been associated
and avoidant personality disorder (Schneier with the serotonin transporter reporter re-
et al. 2002). Avoidant, dependent, and anx- gion L allele but not to COMT, MAO-A, or
ious cluster personality disorders show sig- DRD4 alleles. Growth hormone regulation
nificant familiarity (Reich 1989), and both has also been associated with social anxiety
avoidant and independent personality traits (Schneier et al. 2002).
are found in relatives of patients with panic
disorder (Reich 1991). Neuropsychological and
Psychophysiological Correlates
Neuropsychopharmacology
Increased amygdala activation in fMRI has
There has been little biological study of the been shown in social phobia in one study
Cluster C personality disorders. However, (Schneier et al. 1999) as well as in recognition
low dopamine metabolites in CSF have been bias for recall of disapproving faces in an-
identified in patients with social anxiety dis- other (Foa et al. 2000). However, skin con-
order (Johnson et al. 1994), which overlaps to ductance and heart rate change and startle
a great extent with avoidant personality dis- response during viewing of slides with emo-
order, whereas nonselective monoamine ox- tionally charged themes did not distinguish
idase inhibitors (which increase dopamine patients with avoidant personality disorder
transmission) or dopaminergic antidepres- from control subjects (Herpertz et al. 2000).
sants improve social anxiety (Schneier et al. Psychophysiological studies have not been
2002). Imaging studies are also consistent extensively undertaken in the other Cluster
with this finding, with low dopamine trans- C personality disorders.
porter binding demonstrated in generalized
social anxiety disorder (Tiihonen et al. 1997)
Summary
and lower D2 receptor binding in a SPECT
study of generalized social anxiety disorder Genetic and neurobiological research has
(Schneier et al. 2000). In addition, three PET been limited in patients with Cluster C per-
studies support a relationship of reduced D2 sonality disorders, but reductions in dopa-
binding associated with detachment, which minergic activity and increases in serotoner-
correlates with social avoidance consistent gic activity are hinted at in the data available.
with that observed both in patients with
Cluster C personality disorders and in pa-
tients with schizoid personality disorder
FUTURE DIRECTIONS
(Schneier et al. 2000). Genetic studies of these
types of behaviors have been found in asso- Research in the psychobiology of personality
ciation with the dopamine transporter gene disorder has advanced much since the 1980s.
DAT1 (Blum et al. 1997). These studies cumu- Although there is clear evidence of a number
latively suggest low dopaminergic activity in of biogenetic correlates of personality disor-
social anxiety disorder and likely in avoidant der traits, future efforts need to be directed
personality disorder as well. along a variety of lines to increase our under-
In the serotonergic system, on the other standing of how alterations in brain function
hand, patients with social anxiety have in- lead to the development and manifestation
of these traits. Such lines of investigation brospinal fluid amine metabolites. Psychiatry
may be aimed at 1) how genetic and environ- Res 1:131139, 1979
Brown GL, Ebert MH, Goyer PF, et al: Aggression,
mental influences interact with neurotrans-
suicide, and serotonin: relationships to CSF
mitter function to lead to specific traits; amine metabolites. Am J Psychiatry 139:741
2) how neurotransmitter function interacts 746, 1982
with the regulation of cognitive and emo- Buchsbaum MS, Nenadic I, Hazlett EA, et al: Dif-
tional function across distributed neural net- ferential metabolic rates in prefrontal and tem-
works to lead to specific traits; and 3) how poral Brodmann areas in schizophrenia and
schizotypal personality disorder. Schizophr
understanding brain function at these levels Res 54:141150, 2002
can enable us to devise more effective ways Cadenhead KS: Vulnerability markers in the
to treat personality disorder traits both phar- schizophrenia spectrum: implications for phe-
macologically and psychotherapeutically. nomenology, genetics, and the identification
of the schizophrenia prodrome. Psychiatr Clin
North Am 25:837853, 2002
Cadoret RJ, OGorman TW, Troughton E, et al: Al-
coholism and antisocial personality: interrela-
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7
Developmental Issues

Thomas Crawford, Ph.D.
A side from well-documented developmen- nally, we address problems in assessing

tal links between early conduct disorder and these disorders in young people based on the
antisocial personality disorder (ASPD), there limited number of measurement instru-
are large gaps in our knowledge about child- ments currently available.
hood antecedents of other DSM-IV-TR per-
sonality disorders (American Psychiatric As-
sociation 2000; Widiger and Sankis 2000). In ETIOLOGICAL AND
this chapter we discuss how developmental
DEVELOPMENTAL FACTORS
processes and selected risk factors lead to the
emergence and persistence of personality In an early paper on the borderline-child-to-
disorders in young people. We highlight be, Pine (1986) identified three key factors in
changes in how children and adolescents his developmental model of borderline per-
construct mental representations of them- sonality disorder (BPD) in young people.
selves and other people and then consider First, he hypothesized how early abuse or
how distortions in this developmental pro- trauma overwhelms the child, especially
cess manifest in personality disorder. We when the trauma is ongoing or experienced
outline what we have learned about early from a variety of sources. Second, childhood
trajectories of personality disorders and dis- trauma may interfere with the development
cuss how clinicians and researchers can eval- of how trust, personal attachments, anxiety,
uate the normative and clinical significance aggression, and self-esteem are experienced
of symptoms in children and adolescents. Fi- and expressed. Third, young people may fas-
123
ten onto immature defenses almost as though Early Working Models of

these defenses were survival techniques for Self and Other
desperate situations. More recent empirical
research points to other factors that contrib- Attachment theory (Bowlby 1969, 1973)
ute to the emergence and persistence of per- focuses on developmental experiences re-
sonality disorders over time, including ge- flecting secure and insecure relationships
netic effects (Coolidge et al. 2001; Jang 2005) between infants and caregivers and empha-
and co-occurring Axis I disorders (Crawford sizes how young people come to perceive
et al. 2001b, 2008; Kasen et al. 2007). themselves and others (Lyddon and Alford
When individual risk factors occur in iso- 2007). A secure attachment typically occurs
lation, they often may be offset by normative when the caregiver has been available and
maturational factors in social or cognitive sensitive to the needs of the infant or toddler,
domains. Conduct disorder in childhood, for especially in times of distress. Young chil-
instance, does not usually lead to ASPD in dren can better manage negative emotions,
adulthood. When risk factors occur in combi- such as anger or fear, within a secure rela-
nation, however, they may overwhelm the tionship because these feelings have been as-
young persons ability to cope, thus leading sociated with soothing and effective re-
immature defenses to become inflexible and sponses by the caregiver (Sroufe 1996). By
maladaptive over time. On the other hand, providing this external form of affect regula-
even a child who has experienced a signifi- tion, caregivers prevent infants from being
cant trauma may be protected from lasting overwhelmed and help them gradually de-
damage to personality functioning if he or velop the ability to regulate their own affect
she is securely attached to parents who can (Mikulincer et al. 2003). When caregivers are
buffer the impact of the trauma. If trauma- inconsistent or rejecting, infants and toddlers
tized children are anxiously attached to par- instead may underregulate their own affect
ents instead, thus reducing the protective ef- or restrict it excessively.
fects, they may be at greater risk for lasting As hypothesized in attachment theory,
personality dysfunction (Alexander 1992; very basic mental representations of self and
Bleiberg 2001; Levy 2005). Because genetic, others are thought to emerge during infancy
interpersonal, and early trauma risk factors through affective experiences that character-
are all addressed elsewhere (see Cloninger ize the childcaregiver relationship. These
2005 and Jang 2005; see in this volume Chap- preverbal experiences are labeled internal
ter 8, Childhood Experiences and the De- working models and broadly reflect whether
velopment of Maladaptive and Adaptive infants expect caregivers to be available or
Personality Traits, and Chapter 11, Mental- helpful when needed. Young children may
ization-Based Treatment of Borderline Per- also internalize a basic sense of whether they
sonality Disorder), we focus here on distur- are worthy of love and whether other people
bances in how children perceive themselves can be trusted to provide love and emotional
and the people around them and how devel- support. Individuals who have predomi-
opmental changes in cognitive ability may nantly negative self-representations usually
play a role in the formation of personality have anxious attachment styles, and those
disorders. In this context we draw on the the- who have predominantly negative represen-
oretical literature on attachment in infancy tations of others tend to have avoidant at-
and childhood (e.g., Cassidy and Shaver tachment styles. Avoidant attachment is
2008; Fonagy et al. 2003) and identity devel- thought to stem from cool, rejecting, and dis-
opment in adolescence (Erikson 1968) and tant treatment by attachment figures, and
seek to bridge the two using Harters (1998) anxious attachment is traced to inconsistent
work on development of self-representation. and unpredictable treatment by early attach-
Developmental Issues 125
ment figures (Ainsworth et al. 1978; Roth- trajectory leading toward paranoid or schizo-
bard and Shaver 1994). typal disturbances in adolescence and adult-
As a guide to behavior, internal working hood. In the absence of biological vulnerabil-
models influence whether young children ity, negative schemas regarding others and
seek to regulate affective distress by ap- corresponding behaviors may gradually be
proaching or by avoiding attachment figures, modified as young people learn that their
or even by alternating between these oppos- family is not typical of the broader social en-
ing strategies for managing negative emo- vironment. Normal maturation processes
tions. With growth in cognitive capacity, thus may reduce the likelihood that early
these basic mental representations of self and Cluster A disturbances persist over time.
other (schemas) are subject to elaboration, Early maltreatment by caregivers may
refinement, and increasing differentiation produce a serious disturbance called disorga-
from affective experiences that occur in close nized attachment (Solomon and George 1999;
relationships. Nevertheless, these schemas van Ijzendoorn and Bakermans-Kranenburg
appear to have a remarkably enduring im- 2003). Abused infants and children often ex-
pact on interpersonal strategies used to regu- perience sharp conflicts when approaching
late emotional distress (e.g., Waters et al. caregivers for comfort and support when
2000). Developmental changes often reflect they also expect maltreatment from them
heterotypic continuity in how attachment thus provoking unstable fluctuations be-
styles are expressed in different relationships tween conflicting attachment strategies and
across developmental stages. That is, a neg- behavior. Furthermore, children may fear the
ative self-schema may generate anxious loss of the caregivers they depend on, thus
preoccupation with changing attachment fig- limiting their ability to experience or express
uresa primary caregiver in early child- any age-appropriate anger or aggression to-
hood, a peer group in adolescence, a romantic ward that person. This phenomenon proba-
partner in adulthoodbut nevertheless re- bly pertains most to the development of the
flect the same basic difficulty regulating affect marked instability in interpersonal relation-
across the different kinds of relationships. ships associated with borderline psychopa-
Although distorted working models ac- thology (Fonagy et al. 2000; Levy 2005; Wes-
companying insecure attachment are not ten et al. 2006).
pathological by themselves, they may never-
theless contribute to the formation of Axis II Developmental Changes in How the
psychopathology, especially when combined Self and Others Are Perceived
with other risks or biological vulnerability.
Markedly negative representations of others, Harter (1998) described how cognitive devel-
for instance, may explain higher levels of dis- opment in infancy, childhood, and adoles-
trust and suspiciousness in avoidant preado- cence leads to changes in how young people
lescents when compared with more securely experience their sense of self. Harter charac-
attached age peers. From this developmental terized the self as a cognitive structure around
starting point, a variety of pathways leading which behavior is organized, thus anchoring
to pathological and nonpathological out- it squarely within the larger framework of
comes may depend on heritable and environ- personality. As a product of the interaction of
mental risk factors that also influence how biological and social forces, the self under-
personality unfolds. A negative working goes progressive change throughout devel-
model of others, reinforced by a hostile and opment. Despite these changes, the self pro-
secretive family environment and combined vides a sense of continuity and a source for
with a biological vulnerability to Cluster A scripts to organize behavior, thereby creating
disturbances, may foster a developmental a foundation for later identity.
Harter emphasized how self-representa- ble later symptoms of narcissistic personality

tion often reflects self-evaluation, a process of disorder. If unrealistically positive self-repre-
comparing oneself with other people or with sentations become inflexible and persist over
an ideal self, which evolves over time as new time, they may limit the young persons abil-
cognitive abilities emerge during develop- ity to abandon immature self-representa-
ment. Self-evaluation may be filled with in- tions as their cognitive resources and percep-
flated self-worth at one end of the spectrum or tual skills increase during the course of
laden with self-contempt at the other, and normal development. When serving defen-
both ends of the spectrum may play an early sive functions against childhood adversity,
role in the formation of personality disorders. early grandiosity may persist and harden
Even at these extremes, cognitive develop- into personality disorder symptoms. Fur-
ment may nevertheless allow gradual move- thermore, grandiosity may be pathological
ment toward a more accurate self-representa- when asserted aggressively as a way to pre-
tion with a balanced integration of positive vent all good self-representations from
and negative attributes. Although not ad- shifting and suddenly becoming all bad.
dressed in self-perception literature, per se, This defensive style may lead young people
changes in cognitive development probably with narcissistic disturbances to have dis-
influence how others are perceived in an anal- missing or derogatory perceptions of others.
ogous manner. In BPD, young people may lack sufficient in-
One aspect of the cognitive development ternal defenses to prevent self-representa-
of the self can be seen in how children de- tions from alternating frequently between
scribe themselves at different ages. At early the extremes of all good and all bad. Their
ages children usually describe themselves by perception of others similarly alternates be-
their physical characteristics, typical behav- tween extremes of idealization and devalua-
iors, or material possessions. Self-perception tion, thus constituting the clinical phenome-
thus lacks much coherence or integration and non called splitting. Although they remain
self-representation is organized instead unstable, these mental images of self and
around all-or-none thinking (all good or all others are frequently marked by self-con-
bad). Because negative and positive charac- tempt and attributions of malevolence in
teristics are polar opposites, the child cannot others (Bender and Skodol 2007)
recognize that a single person can have both. Among severely abused children, nega-
Given their inability to distinguish real and tive self-perceptions may predominate over
ideal selves, young children typically have positive self-images and lead those children
unrealistically positive self-perceptions that to feel profoundly unworthy and unlovable
often shade into childhood grandiosity. Older (Fischer and Ayoub 1994). In abusive family
children can admit to negative characteristics environments, caregivers typically reinforce
in one domain while retaining a positive self- negative evaluations of the child that are
representation in another. Vacillation between then incorporated into the childs self-repre-
positive and negative self-image in early ado- sentations. As a result, there may be little
lescence is gradually replaced by a more inte- foundation for any cognitive structure of self
grated sense of self and a greater awareness of that would allow the child to develop and in-
the importance of the context to behavior. tegrate both positive and negative self-eval-
Early grandiosity thus subsides as young peo- uations. Furthermore, negative self-evalua-
ple gain the ability to integrate conflicting self- tions may become automatic (Beck et al 2004;
perceptions into a coherent whole in adoles- Siegler 1991) in ways that make them even
cence and early adulthood. more resistant to change.
Inaccurate but age-appropriate self-per- Formal operational thinking, including
ceptions in young children thus may resem- logical and abstract reasoning abilities, nor-
mally emerges in adolescence (Keating 1990). cies past developmental stages when they
Dramatic increases in differentiation between normally decline. Linehan (1993) empha-
self and other also occur during adolescence sized how invalidating responses from par-
(Bowlby 1973) and thus increase young peo- ents can contribute substantially to the for-
ples ability to view themselves as distinct mation of BPD, and Bezirganian et al. (1993)
from caregivers. Because differentiation facil- have documented that kind of relationship
itates greater autonomy, dependence on pa- empirically.
rental attachment figures normally declines
during adolescence as young people identify Self-Understanding,
more with peer groups intead. At present we Self-Direction, and Identity
know little about how peer relationships in-
fluence personality maturation during ado- Erikson (1968) argued that once young peo-
lescence, but this important social factor may ple gain greater awareness of themselves
reinforce self-perceptions that are more inter- and more accurate perceptions of others,
nally based and less centered around the par- they often experience a normative crisis of
entchild relationship. Although elevated identity during adolescence and early adult-
dependency might not necessarily be patho- hood. This identity crisis is one of eight age-
logical in early adolescence, it may become a specific normative crises that occur in human
symptom of dependent personality disorder development from infancy through old age.
if it persists past late adolescence and into According to Erikson, a crisis is a turning
early adulthood. point when development must move in one
The advent of formal operational think- direction or another. In adolescence, young
ing provides adolescents with a greater ca- people either move toward consolidating a
pacity to evaluate and compare their relation- secure and stable sense of self or they experi-
ships with different attachment figures, not ence diffuse identities that provide limited
just with one another but also against hypo- direction or sense of continuity over time.
thetical ideals. The adolescents ability to con- When the developmental crisis of identity is
sider attachment relationships in the abstract successfully resolved, it normally leads to in-
may bring with it recognition that parents are creased integration of personality. When an
deficient in some ways (Kobak and Cole identity crisis goes unresolved, it may result
1994), perhaps provoking a dismissive rejec- in potentially pathological delays in matura-
tion of the parents or angry preoccupation tion instead.
with their shortcomings. Gains in adolescent Identity consolidation during adoles-
insight into parentchild relationships will cence primarily entails establishing a clear
ideally lead to greater openness, objectivity, sense of self and finding a place in the com-
and flexibility as young people reevaluate at- munity. Identity is broadly defined in Erik-
tachment relationships and attain a more re- sons theory to encompass self-esteem, satis-
alistic and integrated perception of parents. faction with personal and occupational goals,
This developmental process may reduce dis- and confidence in coping skills. Group mem-
missing behaviors or dramatic outbursts of bership and sexual identity represent other
anger that might appear earlier in adoles- important domains in a young persons iden-
cence to be symptoms of narcissism or histri- tity. Identity diffusion, on the other hand, is
onic personality disorder. If parents respond typically expressed in the inability to select
to these adolescent behaviors in maladaptive clear occupational goals or the adoption of
ways based on their own interpersonal dis- roles deviating from conventional social
turbances, they may not facilitate the resolu- norms. Erikson notes that identity diffusion
tion of parentchild conflicts and may instead may at times include delinquent behavior or
reinforce narcissistic and histrionic tenden- psychotic-like symptoms but cautions that
these disturbances are often transient during Despite the broad overlap between per-
adolescence. Any significant disturbances in sonality disorder symptoms and Eriksons
social and emotional development may act to construct of identity diffusion, relatively lit-
distort or interfere with normative identity tle research has investigated the association
consolidation, perhaps thereby contributing between the two. It thus remains unclear
to the persistence of early personality disor- whether identity disturbances contribute to
der symptoms that otherwise might resolve the emergence of personality disorders in ad-
through normal maturational processes. olescence and later persistence into adult-
As defined by Erikson, identity diffusion hood or if personality disorder symptoms
shares many characteristics with Axis II delay the consolidation of identity. Consis-
symptoms (Cloninger et al. 1993; Kernberg tent with Eriksons epigenetic theory of de-
1975; Taylor and Goritsas 1994). Indeed, velopment, Cluster B symptoms do appear
identity disturbances are explicitly included to interfere with the formation of lasting and
in diagnostic criteria for BPD. Identity dis- committed romantic relationships that repre-
turbances are strongly implied in the sug- sent the key developmental task of early
gestibility to other peoples influence in his- adulthood (Crawford et al. 2004). Identity
trionic personality disorder, idealized but consolidation may occur at a critical stage in
unrealistic self-perceptions in narcissistic the development of personality disorders be-
personality disorder, marked worry about cause it coincides with a period when paren-
other peoples criticism in avoidant person- tal influence declines and youths increas-
ality disorder, and difficulties in making ev- ingly assert their independence. As young
eryday decisions in dependent personality people gradually separate from the family,
disorder. Moreover, identity diffusion and the identity they choose plays that much
personality disorder symptoms share similar greater a role in defining their personality. If
developmental trajectories: both decline adolescents are unable to clearly differentiate
with age during adolescence and early adult- themselves from their parents or to resolve
hood (Johnson et al. 2000a; Meeus et al. 1999). any ongoing disturbances in their relation-
Distinctions between normal identity dif- ship, they are likely to carry internalized ver-
fusion and more enduring personality disor- sions of those difficulties with them in how
der symptoms in adolescence may be diffi- they perceive themselves and others, per-
cult to make in clinical evaluations. Erikson haps even recapitulating those disturbances
noted that it is normal for young people to in new relationships in adulthood. In other
try on different identities during adoles- words, if identity remains poorly differenti-
cence and later abandon them when they fail ated as young people separate from their
to fit comfortably with their sense of identity. family, any corresponding interpersonal dis-
For instance, early attempts to express sexu- turbances may become self-perpetuating
ality may manifest in provocative dress dur- during adulthood.
ing adolescence without necessarily being a
symptom of histrionic personality disorder
(Crawford and Cohen 2007). After trying out
that overt expression of sexuality, young PERSONALITY MATURATION AND
people may subsequently opt for less pro- AXIS II PSYCHOPATHOLOGY
vocative attire that corresponds more with
their internal sense of self. On the other hand, Personality traits reflect a complex adaptive
if provocative dressing co-occurs with poorly system to internal and environmental condi-
regulated affect and maladaptive preoccupations, including changes in affective and cog-
tion with interpersonal relationships, it may nitive structures during development (Caspi
signal a more lasting disturbance of person- 1998; Caspi et al. 2005). Specific affects, be-
ality. haviors, and cognitions that are age appro-
priate or normative at one stage of personalality disorders (paranoid, schizoid, and
ity development may reflect immaturity or schizotypal personality disorders) but also to
psychopathology at subsequent ages. As avoidant personality disorder. Parent re-
young people gain emotional and cognitive ports on individual CBCL items associated
skills, they usually abandon immature ways with Cluster B personality disorders (border-
of experiencing and interacting with the line, histrionic, and narcissistic personality
world around them. On the other hand, disorders and conduct disorder that pre-
when young people continue to experience cedes ASPD) similarly indicate declines in
affects, behaviors, or cognitions that their bragging, showing off, demanding attention,
peers have outgrown, they may encounter getting into fights, lying, cheating, having a
interpersonal difficulties that in some cases hot temper, crying a lot, feeling excessive de-
accumulate over time. Interpersonal difficul- pendence, having problems with peers, and
ties may be traced to various deficits in the experiencing jealousy (Achenbach 1991). De-
development of affect regulation during in- spite broad normative reductions in emo-
fancy, the formation of conscience during tional and behavioral problems, parents re-
early childhood, the establishment of age- port average increases in some childhood
appropriate impulse control in childhood and adolescent symptoms such as being sus-
and adolescence, or the consolidation of picious, secretive, and obsessively preoccu-
identity in late adolescence and early adult- pied with certain thoughts. Furthermore, age
hood. Although deficits or delays in emo- changes in symptoms in normative samples
tional development do not necessarily sig- do not necessarily follow the same trajecto-
nify Axis II pathology, they may indicate that ries as children and adolescents brought in
an individual is on a deviant pathway with for clinical evaluation or treatment (Achen-
increased risk for further maladaptive be- bach 1991). Parents may take normative age
havior. Persistence on a deviant pathway is changes into account when assessing the
related to increasing difficulty in returning to well-being of their children and thus become
a more normal developmental trajectory. concerned only when the expected norma-
Maturational change remains possible, but tive decline does not appear, at least for some
given the organizational function of person- problems.
ality, developmental change will be con- It may be useful to put these changes in
strained by the individuals previous history. symptom levels in the context of changes in
(For a further discussion of developmental the prevalence of Axis I symptoms and dis-
considerations, see Bleiberg 2001; Cohen orders over childhood and adolescence. Dis-
2008; De Clercq and De Fruyt 2007; Freeman ruptive behavior shows a standard inverted
and Reinecke 2007; Geiger and Crick 2001; U-shaped prevalence distribution in a wide
and Kernberg et al. 2000.) range of studies (see Moffitt 2007 for a re-
view), with large increases from childhood to
Emotional and Behavioral Problems adolescence and a sharp drop in young
and Personality Disorder Symptoms adulthood. Based on parent reports, there are
different curvilinear trajectories for mean
Children and adolescents appear to outgrow levels of anxious and depressive symptoms
many problem behaviors that are reflected in for boys and girls over the full age range
current symptom criteria for personality dis- from age 4 to 18 years, with higher rates of
order diagnoses. For instance, parent reports problems for boys in childhood followed by
on the Child Behavior Checklist (CBCL; an adolescent decline (Bongers et al. 2003).
Achenbach 1991) show a significant linear For girls these problems increase until the
decline in withdrawn behavior from age 4 to transitional stage of puberty and then level
age 18 (Bongers et al. 2003). Withdrawn be- off. Using teachers as informants in a large
havior pertains not just to Cluster A person- national epidemiological study, McDermott
(1996) found means on every symptom clus- age correlations were sometimes different in
ter changing with age between ages 5 and 17 direction in this study, with some neuroti-
years, often quite differently for males and cism facets increasing with age, some stable
females. over the age span, and some declining.
Although knowledge of normative age
Normal and Abnormal changes in personality disorder symptoms is
Personality Traits limited, the available data clearly show that
nearly every Axis II disorder has a gradual
Many researchers view personality disorder linear decrease in average symptom levels
symptoms as extreme variants of personality between ages 10 and 35. When tracked across
traits that are continuously distributed in the 20 years in approximately 800 youths in the
population (Costa and Widiger 2002; Livesley Children in the Community random sample
and Jang 2000). We currently have only par- (Cohen et al. 2005; Crawford et al. 2005),
tial information on developmental changes in mean personality disorder symptoms were
trait levels and no information in childhood highest in early adolescence (Johnson et al.
because of problems in conceptualizing and 2000a) and steadily declined with age well
measuring personality before adolescence into adulthood (Crawford et al. 2006). Since
(Shiner and Caspi 2003). mean levels are higher in early adolescence,
Perhaps the most complete information more youths are likely to meet fixed diagnos-
available on age changes is based on the five- tic criteria that do not take changing age
factor model (FFM) and its component facets norms into account, thereby possibly in-
that attempt to measure variation in the full creasing the rate of false-positive diagnoses
normative range of personality. These broad during adolescence. These data suggest that
dimensions and more narrowly defined fac- age-specific norms may be desirable for an
ets have also been proposed as a way of un- assessment instrument in this age range.
derstanding and potentially measuring per- However, they also make clear that the prob-
sonality disorder (Costa and Widiger 2002). lem of changing normative symptom levels
The dimension labeled neuroticism is espe- is not limited to childhood and adolescence.
cially pertinent because it is hypothesized to Despite changes in symptom level norms,
reflect many of the criteria for personality adolescent psychiatric disorders warrant
disorder. Age changes in self-reported scores clinical attention even in developmental pe-
on the NEO Personality InventoryRevised riods when they are most prevalent.
(NEO-PI-R; Costa and McCrae 1992) were On the whole, normative data do not
evaluated in a longitudinal sample of gifted show any clear congruence between average
children between age 12 and 16 years and in age changes in normal personality dimen-
a much larger cross-sectional sample of sions measured on the NEO-PI-R and nor-
Flemish adolescents between age 14 and 18 mative changes observed using personality
years (McCrae et al. 2002). Most age changes disorder measures based on combined youth
were very small and did not follow previ- and parent reports or parent-reported mea-
ously established adult trajectories that show sures of clinically relevant emotional and be-
a gradual decline in neuroticism from the havior symptoms. Some of the discrepancy
college years to age 30 years (e.g., McCrae et may reflect how the NEO-PI-R assesses per-
al. 1999). When evaluated in younger adoles- sonality traits in the normal range and may
cent samples, neuroticism showed an ele- be limited by ceiling effects at the extreme
vation in girls up to about age 14 years and range of functioning assessed by personality
stability thereafter, and there were no signif- disorder measures or the CBCL. Once again,
icant age changes in boys. Within each the direction of age-related changes in symp-
broader factor of the FFM, individual facet toms in normative community samples may
not always correspond to age-related change mental interactions also may be an important
in symptoms in children from clinical popu- source of variation in early childhood, when
lations. strong behavioral habits have not yet become
firmly established. There may be more error
in observation-based measures of tempera-
CHANGE AND STABILITY IN ment in infants and preschool children than
in older children due to their greater reactiv-
CHILDHOOD ity to fatigue, hunger, and other temporary
influences. Increased measurement error
Given our knowledge that the prevalence of
thus may contribute to lower stability esti-
particular behaviors changes with age, what
mates in younger children.
can be said about the correlational or rank-
An additional problem has been an ab-
order stability of personality or its tempera-
sence of consensus on how to define the ma-
mental precursors over childhood and ado-
jor temperament dimensions, an issue that
lescence? In particular, to what extent may
has only recently begun to be resolved. Some
we expect that the same individuals who
dimensions of temperament and the mea-
manifest the most extreme personality prob-
sures devised to assess them have been theo-
lems at one age will be among those who do
retically derived (Rothbart et al. 2001; Telle-
so at another age?
gen 1985), including predicted relationships
with specific personality disorders (Clonin-
Temperament ger 1987; Cloninger et al. 1993). However,
Temperament is often regarded as an early theoretically derived dimension names
precursor to personality (Shiner 2005) that sometimes do not clearly correspond to the
reflects basic biological differences in child- content of items. Despite an array of unique
hood characteristics such as activity level, construct-derived names, certain dimen-
fearful withdrawal, ability to be soothed, re- sions of temperament can be viewed in the
sponsiveness to stimuli, and affective inten- frame of the FFM (Shiner and Caspi 2003).
sity. Temperament is typically measured by This frame has the advantage of uniting the
observational ratings or maternal report. personality and temperament literatures but
Cloninger and his colleagues have devel- does only partial justice to the original con-
oped a measure assessing temperament di- ceptions of the important individual differ-
mensions in preschool children that are pos- ences in early childhood such as executive
ited to be related to later personality disorder control and emotional reactivity. Research
(Constantino et al. 2002). Mervielde et al. linking temperament measured in early
(2005) and De Clercq et al. (2006) have also childhood to later personality disorder is
conceptualized and developed measures to only beginning to appear (Constantino et al.
track continuities between childhood tem- 2002).
perament, personality, and personality pa-
thology. Personality Dimensions
In general, temperament shows signifi-
cant but low stability in early childhood There is clear evidence that, on average, a
(Rothbart and Bates 1998) for reasons that personality dimension assessed by a self-
may be intrinsic to the developmental pro- report instrument will show lower correla-
cess. For example, there may be effects spe- tion over equivalent time for younger per-
cific to maturational levels due to genetic or sons than for older persons (Roberts and
other constitutional influences. The impact DelVecchio 2000). Because instability in per-
of contextual factors may vary at different sonality dimensions continues throughout
maturational levels. Constitutionalenviron- life, correlations measuring stability reach a
maximum at about age 50 years. Stabilities 2005). Of adolescents diagnosed with Cluster
for symptom measures of personality disor- A disorders in a community sample, 35%
der are very likely to show a similar pattern. had disruptive disorders, 25% had anxiety
Although we have no preadolescent data, disorders, and 20% had depressive disorders
correlations measuring stability are moder- (Kasen et al. 1999). A full 47% of those with
ate in adolescence (Crawford et al. 2001a), Cluster B disorders had a comorbid disrup-
and it is not clear that they increase from ad- tive behavior disorder, 38% had an anxiety
olescence into young adulthood (Johnson et disorder, and 28% had a depressive disorder.
al. 2000a). General stability may not be the is- Over half (51%) of those with Cluster C diag-
sue if disorders are outcomes of geneenvi- noses had an anxiety disorder, 34% had a dis-
ronment interactions, so that it is expected ruptive behavior disorder, and 23% had a de-
that there may be lower stability on extreme pressive disorder.
scores than over the full range of relevant di- Co-occurrence of Axis I and Axis II disor-
mensions (DiLalla et al. 2000). ders is important because of its impact on
Axis II diagnoses, on the other hand, tend prognosis. When adolescent Cluster A disor-
to be much less stable in clinical and commu- ders co-occurred with disruptive behavior
nity samples of adolescents (Bernstein et al. disorders, the risk for a subsequent Cluster A
1993;Mattanah et al. 1995). Axis II diagnoses diagnosis in early adulthood was 24.6 times
in adults similarly tend to be unstable even in higher than the risk for adolescents with no
clinical samples (Shea et al. 2002; Zanarini et psychiatric disorder (Kasen et al. 1999). By
al. 2003). This instability is likely to be a con- comparison, the risk for Cluster A disorders
sequence not only of the generally poorer in early adulthood was only 2.76 times higher
measurement quality of dichotomized con- when Cluster A disorders in adolescence
tinuous measures (MacCallum et al. 2002) were diagnosed without any disruptive be-
but also of somewhat arbitrary decisions havior disorder. Similarly, the risk for Cluster
about diagnostic cut-points. Despite the rela- B diagnoses in early adulthood was 19 times
tive instability of categorically defined diag- higher when earlier Cluster B disorders co-
noses, there is increasing evidence of long- occurred with major depression, but only 3.83
term impairment and poor prognosis associ- times higher when these personality disor-
ated with adolescent personality disorder or ders occurred without major depression.
a high level of personality disorder symp- Recent research shows that the effects of
toms independent of Axis I disorders or comorbid Axis I and Axis II disorders con-
symptoms (Chen et al. 2006a, 2006b; Craw- tinue well beyond early adulthood. Com-
ford et al. 2008; Johnson et al. 1999, 2000b; pared with adolescents with no psychiatric
Kasen et al. 1999, 2007; Lofgren et al. 1991; disorder, adolescents with diagnoses on both
Rey et al. 1997; Skodol et al. 2007; Winograd axes had an almost nine-fold increase in risk
et al. 2008). We are thus accumulating evi- for psychiatric disorders 20 years later, when
dence that the criteria for adult disorders assessed at mean age 33 years (Crawford et
may be useful indicators of Axis II pathology al. 2008). Adolescents with co-occurring Axis
even in young samples and not necessarily I and II disorders also were more likely to
less predictive at times when they are more have been in treatment or take psychotropic
normative (also see Cohen et al. 2007; Ehren- drugs when subsequently assessed as adults
saft et al. 2006; Kasen et al. 2001). (Kasen et al. 2007). Impairment and lower
functioning were still evident 20 years later
Comorbidity With Axis I Disorders among adolescents with Axis II diagnoses
alone, but prognosis was consistently worse
Axis II disorders in adolescence frequently for academic, occupational, interpersonal,
co-occur with Axis I disorders (Cohen et al. and psychiatric functioning when Axis I and
Axis II disorders co-occurred in adolescence peared to be reinforced by defensive re-

(Crawford et al. 2008). Given effects that per- actions to one parents overinvolvement
sisted across two decades, it is important for and also by identification with the other
parents angry and dismissive interper-
clinicians to evaluate and treat adolescent
sonal style. Despite poor social adjust-
personality disorders, especially when they ment with peers, this youth nevertheless
co-occur with Axis I disorders. reported having a positive relationship
with his parents. Given this protective
Case Examples factor and an absence of key risk factors
such as childhood trauma, his personal-
Given what we know about developmental ity disorder symptoms may well sub-
side over time as he gains maturity.
trajectories of personality disorder symp-
Treatment in this case focused on assist-
toms in adolescents, it appears unwise to
ing the youth to regulate angry affect
make categorical diagnoses during initial more adaptively and to articulate how
clinical assessment except perhaps in ex- peers upset him so much. Treatment
treme cases. Nevertheless, it is meaningful to also helped the parents to become more
consider youths at risk for subsequent per- aware of how their own anxiety and
sonality disorder based on how they present mood disturbances contributed to mal-
for treatment and based on collateral risk fac- adaptive parentchild interactions in
ways that inhibited the youths gradual
tors in close family members, as illustrated
movement toward independent adult
by the following vignette. functioning.
A 15-year-old boy from an intact family Just as maturational factors appear to

was brought for individual psychother- confound the assessment of personality dis-
apy to address uncontrolled anger, a
orders in adolescents, they may also obscure
pervasive hatred toward age peers, and
oppositional and self-defeating behav- the presence of personality disorder in adults
ior (e.g., threatening to drop out of high who have outgrown some earlier manifesta-
school). His self-image reflected grandi- tions of the disorder. Knowledge of norma-
osity or self-contempt depending on tive trajectories of personality disorder thus
different social contexts, and he tended can inform the assessment and treatment of
to be avoidant and dismissive of others. personality disturbances in adult patients
During treatment it became evident
whose symptoms fall short of current diag-
that one parent tried to cope with exces-
sive anxiety by becoming overinvolved nostic criteria:
in the patients long-term plans in ways
that provoked stubborn and opposi- A 42-year-old woman presented for
tional behavior. The other parent had treatment with complaints of loneliness
recurrent depressive episodes, an ex- and an enduring inability to establish a
plosive and unpredictable temper, stable romantic relationship. She re-
identity diffusion, and a dismissive in- called adolescence and early adulthood
terpersonal style. as p erio ds characterized by labile
On initial evaluation, this 15-year- mood, frequent abandonment fears,
old youth appeared at increased risk for volatile and unpredictable romantic
lasting BPD based on persistent symp- relationships, reactive anger toward
toms of uncontrolled anger, marked an- parents and peers, and a series of sui-
tipathy for others, and poorly integrated cidal gestures. During childhood she
representations of self and others. The witnessed violent conflicts between
long-term risk may be compounded by mother and father before they divorced
the presence of parental anxiety and and experienced significant emotional
mood disturbances, especially as they neglect afterward. When presenting for
are woven into parentchild relation- treatment, this patient denied any
ships. Personality disturbances thus ap- mood lability or suicidal ideation and
functioned well at work. However, she diagnosis of personality disorders might lead
experienced abandonment fears, reac- to premature labeling.
tive anger, and mood lability whenever
she became involved in new romantic
relationships, thereby prompting a gen-
eral avoidance of close relationships CHOICE OF INFORMANT
and reinforcing unwanted feelings of
loneliness. In clinical assessment of adults the patient is
usually the primary informant, although the
Even allowing for inaccuracies that dis- corroboration and independent perspectives
tort retrospective clinical reports, this patient of knowledgeable sources such as family
undoubtedly met full criteria for BPD during members are welcome and often useful. Re-
adolescence and early adulthood. Although search measures designed for use with adults
her symptoms have since fallen below diag- in clinical or other samples generally are con-
nostic threshold, either due to maturational fined to self-report. In the child mental health
factors or the effects of prior individual psy- field, there is still little consensus about which
chotherapies, she nevertheless continues to informants should be considered primary
experience significant borderline psychopa- and which should be seen as auxiliary at dif-
thology in ways that become painfully ap- ferent points in childhood development. It is
parent whenever new romantic attachments often assumed that the primary caretaker
evoke long-standing abandonment fears she should be the principal informant for pre-
otherwise seeks to avoid. Treatment in this school children. As such, instruments mea-
case focused on clarifying and then reducing suring temperament, personality, and psy-
abandonment fears and addressing how her chopathology in children younger than age 9
reactive anger undermined the stability of or 10 years are most often based on informa-
her romantic relationships. Treatment also tion supplied by parentsfor example, the
addressed the disorganizing effects of child- Childrens Behavior Questionnaire (Rothbart
hood trauma and neglect. et al. 2001), the Personality Inventory for Chil-
dren (PIC-2; Lachar 1999a), and the CBCL. For
young children in preschool or day care,
WHAT IS THE BEST MEASUREMENT teachers or childcare leaders may provide the
best data based on greater familiarity with
STRATEGY FOR ASSESSING EARLY normative patterns of behavior for the age.
PERSONALITY DISORDERS? Similarly, parents and teachers are both
thought to provide relevant data for older
Three overall issues pose problems for the as- children in elementary school, although
sessment of personality disorders in children agreement on the childs problems is often
and adolescents. First, DSM-IV-TR does not poor across these informants (Achenbach et
take into account normative developmental al. 1987). Sometime in childhood, at least by
changes in the prevalence of certain problems age 9 or 10, most children are able to provide
and the consequent possibility that certain di- data on their own characteristics and prob-
agnostic criteria should not be seen as abnor- lems. For instance, the youth-reported ver-
mal behavior at some ages. Second, there is a sion of the Diagnostic Interview Schedule for
shortage of appropriate and validated diag- Children Version IV (Shaffer et al. 2000) as-
nostic instruments for children and adoles- sesses psychopathology in children as young
cents and unresolved questions about the as age 9 years. Similarly, the Personality In-
best measurement strategy. Third, aspects of ventory for Youth (PIY; Lachar and Gruber
personality are less stable in childhood and 1995) uses self-reports to assess personality
adolescence, thus raising concern that early in children starting at the same age. Most
self-report measures of normal personality, personality disorder instruments for adults

however, are used only with adolescents and have been specifically adapted to be age ap-
adults (Shiner and Caspi 2003). propriate for child or adolescent respon-
Agreement between parent and offspring dents. Among self- and parent-reported
on youth behaviors and problems is often instruments, Axis II scales are typically com-
poor (Achenbach et al. 1987). Age changes in bined with various measures of Axis I distur-
prevalence based on youth self-report look bances and thus facilitate the assessment of
different from those based on parent report or co-occurrence between these psychiatric con-
teacher report. Agreement between self and structs.
informant reports on personality disorder
measures for adults is similarly poor (Klon- Structured Clinical Interviews
sky et al. 2002). Despite these difficulties, the
research field generally agrees that all infor- Of the structured interviews designed to as-
mants add usefully to the assessment of Axis sess DSM-defined personality disorders in
I disorders in children and adolescents. As a adults, the Personality Disorder Examina-
consequence, the preferred strategy is to ob- tion (Loranger 1988) has been most thor-
tain data from at least two informants and oughly evaluated and appears to be a valid
consider any symptomatic report to be valid measure of Axis II disturbance in adoles-
providing there is evidence of associated im- cents. Nevertheless, more work is needed to
pairment. However, evidence indicates that identify age-related differences in adolescent
adolescents are better informants about emo- and adult manifestations of personality dis-
tions and often acknowledge disruptive or orders. In a longitudinal comparison of ado-
antisocial behaviors that may be unknown to lescent and adult inpatient samples, person-
the parent when only a single informant is ality disorders assessed with the Personality
used. Parents or teachers are thought to be Disorder Examination were less stable over a
better informants on issues where normative 2-year interval in adolescents than in adults
comparisons are relevant. (Mattanah et al. 1995). However, threshold
Where does this leave us when deciding effects often add unreliability to stability es-
which informants to assess for personality timates of categorically defined personality
disturbances in children and adolescents? At disorders, thus making comparisons across
present we do not know whether diagnostic age groups more difficult to interpret. When
criteria for Axis II are intrinsically more dif- assessed as dimensional constructs, stability
ficult to assess in youth than most criteria for estimates for personality disorders usually
Axis I. All things considered, it appears pru- appear higher than when assessed as cate-
dent to gather data from multiple sources gorical constructs.
whenever possible when assessing children
and adolescents. Self-Report Instruments
Although self-report instruments are easier
and more cost-efficient to administer than
CLINICAL MEASURES OF CHILD OR
structured interviews, questions are raised
ADOLESCENT PERSONALITY about whether respondents have sufficient
DISORDER self-awareness or willingness to acknowl-
edge Axis II symptoms that might stigmatize
As interest in early Axis II disturbances in them. Given problems in setting reliable
young people has grown, a variety of instru- thresholds, the available instruments for
ments designed to measure normal and ab- children and adolescents tend to assess Axis
normal personality in adults have been eval- II symptoms using continuous scales instead
uated for use in adolescent samples. Certain of making formal diagnoses.
The Millon Adolescent Clinical Inventory disturbances. Despite substantial similarity

(MACI) is a well-known instrument modeled on the PIY and PIC-2, youth and parent in-
on the Millon Clinical Multiaxial Inventory formants show moderate agreement (me-
designed for adults (see Davis et al. 1999). In- dian correlation= 0.43, range 0.280.53) (La-
tended for adolescents as young as age 13, the char 1999b). These concordance rates appear
MACI uses 160 self-report items to measure better than the 0.25 correlation between
personality disorder constructs congruent youth and parent reports for comparable age
with DSM-defined personality disorders but groups on the CBCL (Achenbach et al. 1987).
also reflecting Millons (1990) theory of per-
sonality. The MACI thus measures 12 person- Additional Instruments for
ality styles labeled Introversive, Inhibited,
DSM-IV/DSM-IV-TR
Doleful, Submissive, Dramatizing, Egotistic,
Unruly, Forceful, Conforming, Oppositional,
Self-Demeaning, and Borderline Tendency. The Adolescent Psychopathology Scale
Computer-generated scores on the MACI (Reynolds 1998) is a self-report measure de-
make adjustments for age and gender differ- signed for adolescents age 1219 years. It
ences in Axis II disturbances based on norms measures five of the 10 DSM-IV personality
from separate samples of normal and dis- disorders (borderline, avoidant, obsessive-
turbed adolescents. Standardized scores are compulsive, paranoid, and schizotypal per-
further adjusted to take estimated base rates sonality disorders) along with conduct disor-
of psych opathology into account ev en der as the childhood precursor of ASPD. The
though the prevalence of Axis II disturbances Coolidge Personality and Neuropsychologi-
in adolescents has yet to be established. These cal Inventory for Children (CPNI; Coolidge
built-in adjustments are not readily transpar- 1998) assesses DSM-IV Axis II disorders in
ent and effectively preclude their use for in- children and adolescents from age 517 years
vestigating the population prevalence of ado- by parent report. The CPNI assesses symp-
lescent Axis II disturbances or for assessing toms of all DSM-IV personality disorders as
developmental change. well as conduct disorder symptoms. The
Shedler-Westen Assessment Procedure200
Parallel Parent- and for Adolescents (SWAP-200-A; Westen et al.
Youth-Reported Instruments 2003, 2005) is a Q-sort instrument designed
for use by skilled clinical observers to assess
The PIC-2 and PIY were both originally mod- Axis II pathology in adolescent patients they
eled on the Minnesota Multiphasic Personal- see in treatment. Q-sort is a method by which
ity Inventory and thus do not correspond di- items are arrayed by the clinician from most
rectly to DSM-IV (American Psychiatric descriptive of the adolescent to least descrip-
Association 1994) Axis II disorders. The par- tive of the adolescent. This measure was
ent-reported PIC-2 uses 275 forced-choice adapted from the Shedler-Westen Assess-
items to measure constructs labeled Cogni- ment Procedure200, a Q-sort designed for
tive Impairment, Impulsivity and Distracti- adults that has shown evidence of validity,
bility, Delinquency, Family Dysfunction, reliability, and utility in taxonomic research
Reality Distortion, Somatic Concern, Psycho- with adult samples (e.g., Shedler and Westen
logical Discomfort, Social Withdrawal, and 1998). At present none of the available instru-
Social Skills Deficits. The youth-reported PIY ments has demonstrated clear superiority in
uses 270 forced-choice items to measure the clinical and research applications, and there
same constructs. As suggested by the labels, are limited validity data available for newly
the PIY and PIC-2 measure constructs that developed scales measuring DSM-IV and
probably tap a mixture of Axis I and Axis II DSM-IV-TR personality disorders.
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8
Childhood Experiences and
Development of Maladaptive
and Adaptive Personality Traits
Elizabeth Bromley, M.D.
During the past century, clinical experience warmth and support, may be likely to pro-
and research have provided considerable mote the development of adaptive traits
support for the hypothesis that interpersonal such as trust, altruism, and optimism, due to
experiences during childhood and adoles- social learning processes and development
cence play an important role in personality of a secure attachment style during child-
development (e.g., Erikson 1963). Childhood hood (e.g., Erikson 1963; Sroufe et al. 1999).
adversities such as maladaptive parenting This chapter presents a summary of research
and childhood abuse and neglect may be findings that are currently available regard-
likely to have an adverse impact on person- ing the role that childhood experiences may
ality development because they interfere play in the development of maladaptive and
with or alter the trajectory of normative so- adaptive personality traits. We begin by sum-
cialization processes during childhood and marizing the evidence that is currently avail-
adolescence (Cohen 1999; Johnson et al. able from retrospective and prospective stud-
2001a). Positive experiences during child- ies regarding the hypothesized association
hood and adolescence, such as parental between childhood adversities and personal-
143
ity disorders. The association of childhood findings supporting the validity of retrospec-
abuse and neglect with risk for the develop- tive reports of childhood adversities (e.g., Bi-
ment of personality disorders is examined in fulco et al. 1997; Robins et al. 1985), and al-
particular depth because this association is of though retrospective studies have promoted
considerable interest to clinicians and because the formulation of developmental hypothe-
comparatively little information is available ses, it is nevertheless problematic to make
regarding other adversities that may contrib- strong causal inferences based on retrospec-
ute to the development of maladaptive traits. tive data. In addition, a number of studies
The chapter concludes with an examination of have supported the hypothesis that genetic
and prenatal factors may play an important
the available evidence regarding the associa-
role in the development of behavioral and
tion of positive childhood experiences with the
emotional problems that may become evi-
development of adaptive traits.
dent during childhood (Livesley et al. 1993;
Neugebauer et al. 1999; Thomas and Chess
1984). Furthermore, research has indicated
CHILDHOOD ADVERSITIES that maladaptive childhood traits may have
ASSOCIATED WITH DEVELOPMENT an adverse influence on parenting behavior,
OF PERSONALITY DISORDERS potentially increasing risk for childhood
maltreatment (Kendler 1996). Such findings
A large body of research has provided find- have contributed to skepticism about the hy-
ings that are indirectly consistent with the pothesis that childhood adversities play an
hypothesis that some types of childhood ad- important role in the development of mal-
versities may contribute to the development adaptive personality traits and personality
of maladaptive personality traits and per- disorders.
sonality disorders. Retrospective studies, the However, in recent years, investigations
majority of which have been conducted with utilizing a number of different research para-
clinical samples, have demonstrated that in- digms have provided new and compelling
dividuals with personality disorders tend to evidence in support of the hypothesis that
be more likely than individuals without per- childhood experiences have an important in-
sonality disorders to report a history of child- fluence on personality development. Re-
hood maltreatment and other traumatic search has indicated that maladaptive per-
childhood experiences. These findings have sonality traits are likely to be caused by the
also been of interest because they have pro- interaction of genetic and environmental risk
vided evidence of specificity, indicating that factors (Caspi et al. 2002), including maternal
patients with personality disorders are par- behavior, health, and environmental charac-
ticularly likely to report having experienced teristics affecting prenatal development
specific types of childhood abuse or neglect. (Neugebauer et al. 1999). Epidemiological
However, retrospective studies cannot rule studies and co-twin analyses that have con-
out the alternative hypotheses that the asso- trolled for genetic factors have indicated that
ciation of childhood adversities with mal- childhood abuse is likely to be causally re-
adaptive personality traits is attributable to lated to an increased risk for a broad spec-
recall bias or to preexisting childhood traits trum of psychiatric symptoms (Kendler et al.
that may contribute to the onset of some 2000). Neurobiological studies have provided
types of childhood adversities (Maughan considerable evidence suggesting that child-
and Rutter 1997; Paris 1997). hood maltreatment may cause persistent def-
Both of these alternative hypotheses have icits in brain activity associated with a wide
presented significant challenges to research- range of psychiatric symptoms (Teicher et al.
ers in this field. Although there have been 2003). Prospective longitudinal studies and
Childhood Experiences and Development of Personality Traits 145
investigations that obtained evidence of depressive, passive-aggressive, and schizoid

childhood maltreatment from official records personality disorder traits after parental ed-
have supported the hypothesis that child- ucation and parental psychopathology were
hood abuse and neglect may contribute to in- controlled statistically (Johnson et al. 1999a).
creased risk for the development of personal- Antisocial and depressive personality disor-
ity disorders. (Drake et al. 1988; Guzder et al. der traits remained significantly associated
1996; Johnson et al. 1999a, 2000, 2001a, 2001b; with documented physical abuse after other
Luntz and Widom 1994). The findings of personality disorder traits were controlled
these studies and those that have provided statistically. Evidence of physical abuse,
relevant retrospective data are described in obtained from either official records or retro-
greater detail below. spective self-reports, was associated with
elevated antisocial, borderline, passive-ag-
Childhood Physical Abuse gressive, and schizotypal personality disor-
der traits after controlling for parental educa-
Research conducted with clinical, forensic, tion, parental psychopathology, sexual
and epidemiological samples has indicated abuse, and neglect (Johnson et al. 1999a).
that indices of childhood physical abuse may In summary, prospective epidemiologi-
be associated with antisocial, borderline, and cal studies and retrospective clinical studies
other personality disorder traits. Patients have provided considerable evidence in sup-
with antisocial personality disorder (ASPD) port of the hypothesis that childhood physi-
have been found to be more likely than pa- cal abuse may contribute to the onset of
tients with other psychiatric disorders to re- ASPD, independent of the effects of other
port a history of physical abuse during child- types of childhood maltreatment. Epidemio-
hood (e.g., Bierer et al. 2003; Bradley et al. logical studies that relied on prospective and
2005; Norden et al. 1995; see also Bernstein et retrospective data and retrospective clinical
al. 1998). Confirmatory findings have indi- findings have suggested that childhood phys-
cated that individuals identified as having ical abuse may be associated with elevated
experienced childhood physical abuse are risk for the development of borderline and
likely to have problems with aggressive, schizotypal personality disorders after other
criminal, or antisocial behavior (Pollock et. kinds of childhood maltreatment are ac-
al. 1990; Widom 1989). Patients with border- counted for. In addition, prospective or retro-
line personality disorder (BPD) have also spective studies have provided evidence
been found to be likely to report a history of suggesting that childhood physical abuse
physical abuse during childhood (e.g., may be associated with the development of
Brown and Anderson 1991; Goldman et al. depressive, paranoid, passive-aggressive,
1992). Other studies have yielded findings and schizoid personality disorder traits.
indicating that paranoid, schizoid, and
schizotypal traits were associated with re- Childhood Sexual Abuse
ports of childhood physical abuse in clinical
samples (Bernstein et al. 1998; Bierer et al. Many studies have provided evidence indi-
2003; Yen et al. 2002). cating that patients with personality disor-
Data from the Children in the Commu- ders are significantly more likely than pa-
nity study (CICS; for detailed information tients without personality disorders to report
about the study methodology, please see a history of sexual abuse. Patients with BPD
http://nyspi.org/childcom), a community- are more likely than other patients to report a
based longitudinal study, indicated that doc- history of childhood sexual abuse (Brown
umented physical abuse was associated with and Anderson 1991; Laporte and Guttman
elevated antisocial, borderline, dependent, 1996; Westen et al. 1990). Evidence also has
suggested that patients with BPD may tend of the effects of other types of childhood mal-
to have experienced chronic (as opposed to treatment. Epidemiological studies that re-
episodic) sexual abuse during childhood lied on prospective and retrospective data
(Weaver and Clum 1993). Systematic studies and retrospective clinical findings have sug-
have suggested that other personality disor- gested that childhood sexual abuse may be
ders may also be associated with a history of associated with elevated risk for the develop-
reported sexual abuse. Norden et al. (1995) ment of histrionic and depressive personal-
found that reports of childhood sexual abuse ity disorder traits after other kinds of child-
were associated with borderline, histrionic, hood maltreatment are accounted for. In
narcissistic, and schizotypal personality dis- addition, prospective or retrospective stud-
orders. Bierer et al. (2003) reported that ies have provided evidence suggesting that
childhood sexual abuse was associated with childhood sexual abuse may be associated
paranoid personality disorder in a sample of with the development of antisocial, avoidant,
psychiatric outpatients. Shea et al. (1999) ob- narcissistic, paranoid, passive-aggressive,
tained convergent findings from both inpa- schizoid, and schizotypal personality disor-
tient and outpatient samples indicating that der traits.
reported childhood sexual abuse in both
samples was associate d w it h elev ate d Childhood Emotional Abuse
avoidant, paranoid, and schizotypal person-
ality disorder symptom levels. Ruggiero et Research has suggested that emotional abuse
al. (1999) found that military veterans who (including verbal abuse, humiliation, and
reported severe childhood sexual abuse had other psychological maltreatment) may con-
higher antisocial, avoidant, passive-aggres- tribute, independently, to the development of
sive, schizoid, and schizotypal personality personality disorder traits during childhood
disorder symptom levels than did men who and adolescence. Childhood emotional abuse
reported minimal childhood maltreatment. may increase risk for the development of per-
Reports of childhood sexual abuse have also sonality disorders in part by increasing the
been found to be associated with depressive likelihood that youths will experience mal-
symptoms and interpersonal difficulties adaptive thoughts and feelings, such as ex-
(Browne and Finkelhor 1986). cessive guilt, resentment, social anxiety,
Community-based research findings shame, and mistrust of others during their
have indicated that documented sexual most critical years of psychosocial develop-
abuse was associated with elevated BPD ment. Severe childhood verbal abuse may
traits after parental education and parental leave deeper scars than other types of abuse,
psychopathology were controlled statisti- because children tend to internalize verbally
cally (Johnson et al. 1999a). Evidence of sex- abusive statements and to self-inflict these
ual abuse, obtained from either official abusive thoughts throughout their lives (Ney
records or retrospective self-reports, was as- 1987).
sociated with elevated borderline, depres- Clinical studies have indicated that many
sive, and histrionic personality disorder patients with BPD and other personality dis-
traits after controlling for parental education, orders report a history of childhood verbal
parental psychopathology, physical abuse, abuse (Laporte and Guttman 1996; Oldham
and neglect (Johnson et al. 1999a). et al. 1996; Zanarini et al. 1997). Childhood
In summary, prospective epidemiologi- emotional abuse and intolerant, shaming pa-
cal studies and retrospective clinical studies rental behavior have been found to be associ-
have provided considerable support for the ated with avoidant personality traits among
hypothesis that childhood sexual abuse may psychiatric patients (Grilo and Masheb 2002;
contribute to the onset of BPD, independent Stravynski et al. 1989). Bierer et al. (2003) re-
ported that childhood emotional abuse was Childhood Neglect

associated with paranoid personality disor-
der in a sample of psychiatric outpatients. The association of childhood neglect with the
Bernstein et al. (1998) reported that Cluster B development of personality disorders has
and C personality disorders were signifi- been investigated less extensively than the
cantly associated with retrospective reports corresponding associations regarding child-
of childhood emotional abuse. When sexual hood sexual and physical abuse. Neverthe-
and physical abuse have been statistically less, the available evidence suggests that
controlled, emotional abuse has also been childhood neglect may contribute as or more
found to be independently associated with strongly than physical and sexual abuse to
depressive personality traits, including poor the development of personality disorder
self-esteem and suicidality (Briere and Runtz symptoms and other maladaptive personal-
1990; Mullen et al. 1996). ity traits (Gauthier et al. 1996; Johnson et al.
Longitudinal research has indicated that 1999a). Many patients with personality disor-
verbal abuse during childhood, assessed in a ders report a history of childhood neglect
series of maternal interviews, was associated (Oldham et al. 1996), and reports of a lack of
with increased risk for borderline, narcissis- parental affection during childhood have
tic, obsessive-compulsive, and paranoid per- been found in clinical samples to be associ-
sonality disorders and with elevated border- ated with antisocial, avoidant, borderline, de-
line, narcissistic, paranoid, schizoid, and pendent, paranoid, and schizoid personality
schizotypal personality disorder symptom disorder symptoms (Arbel and Stravynski
levels during adolescence and early adult- 1991; Carter et al. 1999; Norden et al. 1995).
hood (Johnson et al. 2001b). These findings Reports of severe childhood neglect have
were obtained after behavioral and emo- been found to be associated with elevated
tional problems during childhood, physical avoidant, schizoid, and schizotypal personal-
abuse, sexual abuse, neglect, physical pun- ity disorder symptom levels among military
ishment, parental education, parental psy- veterans (Ruggiero et al. 1999). Childhood
chopathology, and co-occurring psychiatric neglect has also been found to be associated
disorders were controlled statistically. Such with a wide range of other maladaptive per-
findings have suggested that childhood ver- sonality traits, including antisocial or avoid-
bal abuse may contribute to the development ant behavior, attachment difficulties, hostil-
of some types of personality disorders, inde- ity, paranoia, and self-destructive behavior
pendent of the effects of other types of child- (Dubo et al. 1997; Gauthier et al. 1996; Robins
hood maltreatment. 1966; Sroufe et al. 1999).
When the available data from prospec- Longitudinal research has suggested that
tive epidemiological studies and retrospec- childhood neglect may increase risk for the
tive clinical studies are considered together, development of personality disorders. Evi-
considerable evidence supports the hypothe- dence of childhood neglect (i.e., lack of paren-
sis that childhood emotional abuse may con- tal affection and supervision during early ad-
tribute to the onset of BPD, independent of olescence) has been found to be associated
the effects of other types of childhood mal- with risk for dependent and passive-aggres-
treatment. In addition, prospective or retro- sive personality disorders during adulthood
spective studies have provided evidence (Drake et al. 1988). CICS findings indicated
suggesting that childhood emotional abuse that documented childhood neglect was as-
may be associated with the development of sociated with elevated antisocial, avoidant,
avoidant, depressive, narcissistic, obsessive- borderline, dependent, narcissistic, paranoid,
compulsive, paranoid, schizoid, and schizo- passive-aggressive, and schizotypal person-
typal personality disorder traits. ality disorder traits after parental education
and parental psychopathology were con- emotional, physical, and supervision neglect
trolled statistically (Johnson et al. 1999a). An- were independently associated with ele-
tisocial, avoidant, borderline, narcissistic, vated overall personality disorder symptom
and passive-aggressive personality disorder levels and overall risk for personality disor-
traits remained significantly associated with ders during adolescence or early adulthood
documented neglect after other personality after other types of childhood maltreatment
disorder traits were controlled statistically. were accounted for (Johnson et al. 2000).
Evidence of childhood neglect, obtained from These findings suggest that specific types of
either official records or retrospective self- childhood neglect may contribute in unique
reports, was associated with elevated antiso- ways, in combination with other childhood
cial, avoidant, borderline, dependent, narcis- adversities, to the development of different
sistic, passive-aggressive, and schizotypal types of personality disorder symptoms.
personality disorder traits after controlling In summary, prospective epidemiologi-
for parental education, parental psychopa- cal studies and retrospective clinical studies
thology, sexual abuse, and neglect (Johnson et have provided considerable evidence in sup-
al. 1999a). port of the hypothesis that childhood neglect
In recent years, research has suggested may contribute to the onset of avoidant, bor-
that specific types of childhood neglect may derline, passive-aggressive, and schizotypal
be differentially associated with specific personality disorders, independent of the ef-
types of personality disorder traits. Patients fects of other types of childhood maltreat-
with BPD have been found to be more likely ment. In addition, epidemiological studies
than patients with other personality disor- that relied on prospective and retrospective
ders to report a history of childhood emo- data and retrospective clinical findings have
tional, physical, and supervision neglect (Za- suggested that childhood neglect may be as-
narini et al. 1997). Patients with antisocial, sociated with risk for ASPD after other kinds
avoidant, dependent, and paranoid person- of childhood maltreatment are accounted for.
ality disorders have been found to be more Furthermore, prospective or retrospective
likely than other patients to report a history studies have provided evidence suggesting
of childhood emotional neglect (Carter et al. that childhood neglect may be associated
1999). Patients with elevated schizoid per- with the development of dependent, narcis-
sonality disorder symptom levels have been sistic, paranoid, and schizoid personality
found to be particularly likely to report a his- disorder traits.
tory of childhood emotional neglect (Bern- Prospective epidemiological studies
stein et al. 1998). Dubo et al. (1997) found that have suggested that specific types of child-
symptoms of self-mutilation and suicidality hood neglect may be differentially associated
were associated with retrospective reports of with elevated risk for specific types of per-
childhood emotional neglect among patients sonality disorder symptoms.
with BPD. Johnson et al. (2000) reported that
childhood emotional neglect was indepen- Case Example
dently associated with increased risk for Ms. D was a 19-year-old psychiatric out-
avoidant personality disorder and elevated patient diagnosed with depressive, ob-
paranoid personality disorder symptom lev- sessive-compulsive, and borderline per-
els, physical neglect was independently as- sonality disorder symptoms and severe
sociated with elevated schizotypal symptom narcissistic personality disorder symp-
levels, and supervision neglect was indepen- toms. During psychotherapy sessions,
she reported that she had been molested
dently associated with elevated borderline,
and sexually abused by an older half-
paranoid, and passive-aggressive personal- brother from age 4 years until early ad-
ity disorder symptom levels. In addition, olescence, when she became aware of
the meaning of sexual activity. The sex- ample, she reported that her mother fre-
ual abuse began with episodic molesta- quently forced her to wait until the other
tion but became more severe from age 7 family members had finished their meals
onward, occurring during lengthy peri- before allowing her to eat. She also re-
ods of time when she and her half- ported that her mother made her spend
brother were left alone and unsuper- substantially more of her time than her sib-
vised by her parents. Ms. D tried to tell lings doing housework and other chores.
her mother about the sexual abuseshe Ms. E reported that her mother often hu-
miliated her by doing things such as mak-
wrote a suicide note that her mother
ing her wear boys clothing to school, and
foundbut her mother did not put an
that her mother punished her severely for
end to her half-brothers behavior.
any appearance of sexual behavior. In ad-
Ms. D also reported that her father
dition, Ms. E reported that her mother ne-
frequently relied on harsh physical pun- glected her emotionally and that her
ishment to discipline her, for example, mother rarely, if ever, was affectionate,
using a belt to whip her when she re- nurturing, or supportive toward her.
ceived poor grades in school. At times, Ms. E reported that she was forced to
this punishment was so severe that it re- leave the family home at age 17 and soon
sulted in bruises or lacerations, includ- afterward became homeless. She became
ing an open gash in her leg, indicative of involved in an abusive relationship with a
physical abuse. Ms. D also reported that man who beat and raped her repeatedly.
her father abused her emotionally, call- She ran away from him and asked her
ing her names like stupid, lazy, and mother to take her in, but her mother told
a whore. In addition, she reported her, You chose your bed. Now you can lie
that her mother was emotionally and in it. Ms. E went to a homeless shelter,
physically abusive, although this abuse where she was beaten by some other
was not as severe as that perpetrated by young women on the day she arrived.
her father. During her stay at the shelter, Ms. E began
Ms. D frequently witnessed physi- receiving psychiatric treatment for the first
cal violence between her parents, who time. However, her sense of well-being
were often verbally or physically com- was frequently threatened while she lived
bative. Her father often drank heavily there, and she reported that she constantly
and had a number of extramarital af- felt endangered during that time. She re-
fairs. Ms. D informed her mother about ported that on one occasion she was raped
one of her father s indiscretions, and by a stranger while at the shelter. Prior to
her mother became so enraged that she her initial hospitalization, Ms. E reported
shot Ms. Ds father. There was abun- having cut her wrists on several occasions
dant evidence indicating that Ms. Ds when she found the adversities of life in
history of maltreatment and problem- the homeless shelter to be overwhelming.
atic parenting contributed to the devel- She received several years of treatment
opment and persistence of her depres- that enabled her to recover sufficiently to
sive, obsessive-compulsive, borderline, be able to live semi-independently. How-
and narcissistic personality disorder ever, many of her symptoms were so se-
traits, which were associated with con- vere and unremitting that she was eventu-
siderable impairment and distress. ally classified as chronically disabled.
Case Example
Ms. E was a 22-year-old psychiatric inpa- CLINICAL IMPLICATIONS OF
tient with severe BPD, dependent person- RESEARCH ON CHILDHOOD
ality disorder traits, and posttraumatic
stress disorder, with a history of dissocia- MALTREATMENT AND RISK FOR
tive symptoms, severe insomnia, de- PERSONALITY DISORDER
pressed mood, and psychotic episodes.
Ms. E reported that she had been emotion-
It may be possible to prevent the onset of
ally abused and scapegoated by her
mother throughout her childhood. For ex- chronic personality disorders among some
youths by providing high-risk parents with ality disorder symptoms, and paternal over-
services that assist them in developing more protection was associated with schizoid per-
adaptive parenting behaviors. Research has sonality disorder symptoms (Norden et al.
indicated that it is possible to reduce the like- 1995). Community-based longitudinal re-
lihood that children will develop psychiatric search has also indicated that a wide range of
disorders by helping parents to learn more problematic parenting behaviors may be as-
effective child-rearing techniques (Redmond sociated with risk for personality disorders
et al. 1999). In addition, because treatment of (Drake et al. 1988; Johnson et al. 2001a, 2006).
parental disorders may help to reduce the In addition, research has indicated that a
likelihood of childhood maltreatment and number of other childhood adversities in-
problematic parenting, it may be possible to cluding parental death, parental separation
decrease offspring risk for personality disor- or divorce, socioeconomic adversities, trau-
ders by improving the recognition and treat- matic life events, and victimization (e.g., as-
ment of psychiatric disorders among parents sault, bullying) may be associated with ele-
in the community (Chilcoat et al. 1996). vated risk for personality disorders (Coid
1999; Johnson et al. 1999b, 2006; Zanarini and
Frankenburg 1997).
OTHER CHILDHOOD ADVERSITIES

ASSOCIATED WITH THE PROTECTIVE FACTORS ASSOCIATED
DEVELOPMENT OF WITH THE DEVELOPMENT OF
PERSONALITY DISORDERS ADAPTIVE TRAITS
Although childhood abuse and neglect are Research has identified a wide variety of ex-
likely to play a particularly important role in periences, relationships, and community re-
the development of personality disorder sources that may promote the development
symptoms, a number of studies have in- of adaptive personality traits, such as hardi-
dicated that problematic parenting (e.g., ness or resiliency during childhood and ado-
parenting behavior that, although problem- lescence. Familial warmth, extrafamilial sup-
atic, is not sufficiently severe to be classified port, and other facilitative environmental
as abuse or neglect) is likely to be associ- characteristics have been found to be associ-
ated with the development of maladaptive ated with the development of adaptive traits.
personality traits and personality disorders These traits, in turn, are likely to play an im-
(see Chapter 7, Developmental Issues). Re- portant mediating role in determining
search has indicated that a lack of parental whether individuals are able to adapt effec-
affection during childhood, low family com- tively to adversities during adulthood (Gar-
munication and expressiveness, a lack of pa- mezy 1985; Shiner 2000; Werner and Smith
rental time with the child, and harsh, control- 1982).
ling parenting behavior are associated with
elevated personality disorder traits among
Familial Protective Factors
adolescent nonpatients and adult psychiatric
patients (Baker et al. 1996; Head et al. 1991; A wide range of parenting behaviors (e.g., af-
Johnson et al. 1997, 2006; Parker et al. 1999; fection, communication, time spent with
Stravynski et al. 1989). Retrospective reports children) and characteristics of the family
of a lack of parental affection during child- and home environment play an important
hood by patients with personality disorders role in healthy child development (Johnson
have been found, in a patient sample, to be et al. 2001a; see also Chapter 7, Develop-
associated with ASPD and schizoid person- mental Issues). Parental empathy, support,
and warmth have been found to help chil- community organizations that help young
dren and adolescents cope effectively with people to develop ethics and values; mentors
many types of adversities (Cowen et al. 1997; such as teachers, godparents, and adult role
Jaffee et al. 2007; Luthar and Zigler 1991; Wy- models; and confidants in the form of highly
man et al. 1991). Research has also indicated functioning and supportive peers may facili-
that children who develop a close, strong, tate the development of adaptive personality
and mutually respectful relationship with traits (Werner 1989). The presence of a men-
their parents tend to be particularly resilient tor during adolescence has been found to be
and to have adaptive coping skills (Kobak associated with improved academic achieve-
and Sceery 1988). Furthermore, strong and ment, attitudes about school, insight, rela-
supportive relationships with parents and tionships with parents and peers, and self-
family members tend to be associated with esteem, and with reductions in aggressive
healthy interpersonal functioning during behavior and psychoactive substance use
adulthood and successful adaptation to (Wolkow and Ferguson 2001; Zimmerman et
adult responsibilities (Werner and Smith al. 2002).
1982; see also Chapter 7, Developmental Is- Participation in community activities and
sues). Young adults who perceive their fam- organizations may also have a variety of ben-
ily as warm and supportive tend to be rela- eficial consequences. Community involve-
tively confident and adaptable and to have ment may help to provide a sense of purpose,
high self-esteem, whereas those who per- to increase the availability of social support,
ceive their parents as authoritarian tend to be and to foster resiliency (Vaillant 1977).
more uncertain about themselves and the fu- Youths who have a strong sense of member-
ture (Strage 1998). ship in and identification with the commu-
It is important to note that a variety of nity may adapt more effectively to stressful
parenting styles may lead to positive out- life events (Heath et al. 1999). Extracurricular
comes (Baldwin et al. 1990) and that the activities, such as participation in athletic ac-
child-rearing behavior of the parent is deter- tivities, arts and crafts, hobbies, musical en-
mined, in part, by the disposition or temper- sembles, and organized recreational activi-
ament of the child (Cohen 1999; Kendler ties may also promote healthy adaptation to
1996). For example, youths with externaliz- adversity (Bell and Suggs 1998). Thus, com-
ing behavior problems may need extra pa- munities and schools that provide young
rental supervision, and youths with internal- people with a wide range of opportunities to
izing problems may be in particular need of engage in such activities may help to pro-
parental warmth and support. However, remote healthy personality development dur-
search has indicated that most youths benefit ing childhood and adolescence.
from having responsible, nurturing, sup-
portive parents who gradually encourage
them to function in an increasingly autono- ADAPTIVE PERSONALITY TRAITS
mous manner as they mature (Cowen et al.
1997; Luthar and Zigler 1991; Rikhye et al. The research findings cited earlier are consis-
2008; Strage 1998; Wyman et al. 1991). tent with Erik Eriksons (1963) hypothesis
that personality development during child-
Extrafamilial Protective Factors hood and adolescence is determined, in large
measure, by the childs upbringing, chronic
Many different types of community and adversities, and other important interper-
neighborhood resources may help to pro- sonal experiences. Although each child be-
mote healthy personality development dur- gins life with behavioral tendencies that are
ing childhood and adolescence. Supportive influenced by genetic and prenatal factors
(Livesley et al. 1993; Neugebauer et al. 1999; view themselves as capable of changing the
Thomas and Chess 1984), life experiences ap- events and circumstances in their lives, and
pear to play a critical role in determining how to believe that planning and preparation can
these temperamental characteristics are ex- mitigate or prevent future problems (Kobasa
pressed (Caspi et al. 2002; Cohen 1999; Wil- 1979). In addition, hardy individuals have
son et al. 2006). Research has also supported been found to view changing circumstances
Eriksons hypothesis that children who grow as opportunities for growth (Pengilly and
up in a supportive environment are more Dowd 2000; Werner 1989, 1992).
likely to develop character strengths such as
trust in others, autonomy, industriousness, Self-Efficacy
and self-esteem (see Chapter 7, Develop-
mental Issues). These and other personality Children and adults who believe that they are
traits have been found to promote the devel- in control of their lives tend to remain well in
opment of strong, supportive relationships the face of adversity. Longitudinal research
with others to decrease risk for the develop- has indicated that children with high self-ef-
ment of psychiatric disorders (Bromley et al. ficacy scores who experienced a high level of
2006) and to facilitate adaptation to adversi- family stress were more likely than other chil-
ties later in life (Garmezy 1985; Rutter 1987; dren to have positive outcomes, such as being
Shiner 2000; Werner and Smith 1982). competent and caring (Werner 1989, 1992).
Similarly, self-mastery and an internal locus
Resiliency of control have also been found to be associ-
ated with positive outcomes (Wyman et al.
Research has identified personality traits, 1991). Longitudinal research has indicated
such as optimism and productivity, that tend that successful peer and school adaptation
to be associated with an adaptive, resilient re- are particularly evident among children who
sponse to stress (Pengilly and Dowd 2000; work enthusiastically, creatively, and persis-
Rutter 1987). The development of resiliency tently and who strive to achieve high stan-
may stem in part from experiences that teach dards (Shiner 2000).
individuals how to cope effectively with dif-
ficulties, thereby inoculating them so that Pro-Social Traits
they are able to deal with future adversities
more effectively (Rutter 1987). Adaptive Pro-social traits, including communication
traits referred to as ego resiliency (confi- skills, confidence, empathy, perceptiveness,
dent optimism, insight and warmth, produc- and warmth, appear to play an important
tive activity, and skilled expressiveness) have role in the development of adaptive func-
been found to be associated with positive out- tioning during childhood and adolescence
comes, such as the ability to arouse liking and (Shiner 2000). Resilient youths tend to inter-
acceptance by others (Block and Gjerde 1990; act with and reach out to others, rather than
Klohnen 1996; Klohnen et al. 1996). withdrawing, in both adverse and normal
circumstances. Longitudinal research has
Hardiness shown that adolescents with pro-social ten-
dencies tend to have better long-term psy-
Kobasa (1979) identified a similar set of chosocial outcomes (Shiner 2000). This may
adaptive traits as being indicative of hardi- be attributable in part to the familial and ex-
ness. Individuals with a high level of hardi- trafamilial support that may be made partic-
ness tend to view stressful events as being ularly abundant to individuals with pro-
potentially meaningful and interesting, to social personality traits (Garmezy 1985).
Other Adaptive Traits grew closer to her father and learned

more about his illness experience. She
Conscientiousness, impulse control, integ- took a long-wished-for trip to Italy to
rity, and persistence have been found to be visit her high school art teacher. She
committed herself to finishing her work
associated with the development of resil-
on a large painting exhibit with a friend,
iency during adolescence (Funder and Block saying I just knew my work and my
1989; Klohnen et al. 1996; Luthar and Zigler community would keep me upbeat and
1991; Rutter 1990; Shiner 2000). The ability to give my days hope. Referring to how
respond to humor and to share it with others she coped with a friends death as a
has been found to promote positive out- teen, she said she learned at the time
comes (Klohnen et al. 1996; Luthar and Zig- that I had the strength to find some
meaning in hardship. Ms. F was also
ler 1991; Vaillant 1977). Humor is viewed as
able to explore her anger, sense of loss,
an adaptive defense or coping style by psy-
and sorrow for those she would leave
choanalytic theorists, as are altruism, sup- behind.
pression (i.e., the conscious postponement of
attention to disturbing circumstances), antic- Ms. Fs story illustrates how community,
ipation (i.e., consciously planning how to activity, self-efficacy, parents, and loved ones
cope with stressful circumstances), self-regu- are called on in times of profound stress. She
lation (Gardner et al. 2008; Martel et al. 2007), not only coped with the difficulties of cancer
and sublimation (Vaillant 1977). treatment but also found generative ways to
help others. The love and encouragement
that she received from her parents and men-
Case Example
tors, her insight into her own feelings, her
Ms. F was a 31-year-old woman with perseverance, and her ability to rally others
metastatic adenocarcinoma. At the time around her were important aspects of her
of her diagnosis, she was living with her successful coping.
boyfriend and working as a painter
with some commercial success. She had
graduated from a prestigious univer-
sity and attended graduate art school. CLINICAL IMPLICATIONS OF
The oncologist described Ms. F as a
real fighter, all the way through the RESEARCH ON PROTECTIVE FACTORS
c hem o t he ra p y a nd s ur ge ry. She AND ADAPTIVE PERSONALITY TRAITS
learned what she could about the illness
and treatment. Ms. F brought small,
The present literature review supports the
bright paintings for the nurses and pa-
tients every week. She came to the hos- recommendation to assess protective factors
pital each week with a variety of close and personality strengths as well as symp-
friends and loved ones. Her parents toms and maladaptive traits. Assessing pro-
were helpful with the treatment ar- tective factors and adaptive personality traits
rangements. may increase the effectiveness of a clinical in-
When seen by the psychiatrist, Ms. tervention, in part, by making it clear to the
Fs boyfriend, mother, and father were
patient that the clinician is interested in de-
sitting around her bed. Flowers and
small paintings were on the bedside ta-
veloping a well-rounded understanding of
ble. Ms. F, bald and thin, smiled weakly. the patients strengths and weaknesses,
She said that at the time of her diagno- thereby fostering the development of a strong
sis, my career was really taking off, therapeutic alliance. Moreover, recent evi-
and my boyfriend and I were engaged. dence suggests that patients with some inter-
It was such a shock, but I had no choice personal problems who can cite positive de-
but to learn what I could from the hor-
velopmental experiences may have a better
ror. She described how she coped. She
prognosis than those patients who cannot
(Skodol et al. 2007). In addition, there are Bifulco A, Brown GW, Lillie A, et al: Memories of
many ways that clinicians and other profes- childhood neglect and abuse: corroboration in
a series of sisters. J Child Psychol Psychiatry
sionals who work with young people can
38:365374, 1997
help to promote the development of adaptive Block J, Gjerde PF: Depressive symptoms in late
personality traits during childhood and ado- adolescence: a longitudinal perspective on
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D, et al. Cambridge, England, Cambridge Uni-
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in taking advantage of community resources contributions of intercorrelated antecedents.
and in participating actively in the life of the J Nerv Ment Dis 193:2431, 2005
Briere J, Runtz M: Differential adult symptomatol-
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tant to assist parents in improving their child- histories. Child Abuse Neglect 14:357364, 1990
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supportive relationship with their children, strengths in adolescence and decreased risk of
and encouraging parents to minimize reli- developing mental health problems in early
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ance on disciplinary methods that have been
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Part IV
Treatment
9
Levels of Care in Treatment
John G. Gunderson, M.D.

Kim L. Gratz, Ph.D.
George W. Smith, M.S.W.
In this chapter, we describe the indications, The presence of a comorbid personality dis-
goals, structures, and empirical evidence re- order often complicates the treatment of an
lated to the use of four different and decreas- Axis I disorder (Tyrer et al. 1997); for exam-
ingly intensive levels of care: IVhospital; ple, the patient with avoidant personality
IIIpartial hospital/day treatment; IIin- disorder may not attend group sessions; the
tensive outpatient; and Ioutpatient. Al- patient with borderline personality disorder
though we are concerned primarily with the (BPD) may refuse family contacts; the pa-
roles these levels of care play in treating per- tient with histrionic personality disorder
sonality disorders, we recognize that pa- may express sensitivity to the side effects of
tients who have a personality disorder often medications, and so on. In such ways, per-
will be placed in levels of care due to a treat- sonality disorders may diminish the progno-
ment primarily directed at comorbid Axis I sis for the treatment of Axis I disorders.
conditions. For example, major depression
has a comorbidity of about 50% with Cluster
B and C disorders (Dolan-Sewell et al. 2001), DEFINITIONS
anxiety disorders have a comorbidity of
about 25% with Cluster C disorders (Dyck et Treatments can be organized according to the
al. 2001), and substance abuse is associated four different levels of care (see Table 91).
with a comorbid Cluster B disorder more Those personality disorders associated with
than 50% of the time (Oldham et al. 1995). the most severe crises and highest levels of
161
Table 91. Levels of care
IV Hospital; 24 hours/day with option of locked doors and seclusion

III Partial hospital/day treatment; 28 hours/day, 35 days/week, 630 hours/week;
usually heavily involving group therapies
II Intensive outpatient; 310 hours/week of specifically prescribed, scheduled, and
integrated therapies
I Outpatient; 13 hours/week of scheduled therapies
dysfunction are more apt to require higher search involving specified levels of care is
levels of care. The four levels of care are hier- shown in Table 92. Many of these studies
archical in terms of containment, intensity, have examined personality disorders in gen-
structure, and costs per day, and they are in- eral, and these studies vary in the extent to
versely related to usual length of stay. which they control for or examine the specific
impact of particular personality disorders or a
personality disorder cluster on treatment effi-
GENERAL PRINCIPLES cacy. Most research examining treatment for
GOVERNING LEVELS OF CARE specific personality disorders involves BPD
and antisocial personality disorder (ASPD),
The least restrictive level of care possible is with a growing number of studies examining
usually bestthis maximizes and requires the effectiveness of treatments at different
use of ones personal strengths, increases the levels of care on Cluster C disordersin par-
likelihood of being able to apply new capa- ticular, avoidant personality disorder. Cluster
bilities and skills to community settings (i.e., A disorders have received the least systematic
generalization), and decreases the likelihood attention from researchers. Furthermore, em-
of regressive aspects of treatment (e.g., rein- pirical support for the comparative efficacy of
forcement of dysfunctional behavior). different levels of care is rare.
Availability of all levels is clinically desir-
able (most treatment settings include only IV
and I) and possibly cost beneficial (Quayt-
OVERALL THEORY FOR
man and Scharfstein 1997). The availability
of levels II and III decreases use of hospital- USE OF DIFFERENT
izations, decreases dropouts, and increases LEVELS OF CARE
social rehabilitation interventions.
With each decrease in level of care, the The intended goals for therapeutic change are
treatments become more specific for differ- often classified within four domains: subjec-
ent types of personality disorders. tive distress, maladaptive behaviors, interper-
sonal, and intrapsychic (i.e., psychological).
These domains are identified in the sequence
in which change can be expected (Gabbard et
EVIDENTIARY BASE al. 2002; Gunderson and Gabbard 1999;
Several meta-analytic reports have affirmed Howard et al. 1986; Kopta et al. 1994; Lanktree
the value of psychotherapy, which really in- and Briere 1995) as well as a sequence that
cludes all psychosocial therapies, for person- generally should be prioritized in treatment
ality disorders (Leichsenring and Leibing planning. Table 93 indicates the relative ca-
2003; Perry and Bond 2000). The extant re- pacity for the different levels of care to effect
Table 92. Studies on level of care for personality disorders
Hospital Partial hospital Intensive outpatient Outpatient

All personality Dolan et al. 1992, 1997 Karterud et al. 1992, 2003 NA NA
disorders Mehlum et al. 1991
Vaglum et al. 1990
Wilberg et al. 1998b, 1999
Cluster A NA NA NA NA
Cluster B NA NA NA NA
BPD Barley et al. 1993 Bateman and Fonagy 1999, Linehan et al. 1991, 1993, 1994, Blum et al. 2002, 2008

Bohus et al. 2000, 2004 2001, 2008 2006 Brown et al. 2004
Silk et al. 1994 McQuillan et al. 2005 Davidson et al. 2006
Giesen-Bloo et al. 2006
Gratz and Gunderson 2006
Munroe-Blum and Marziali 1995
Stevenson and Meares 1992
Wilberg et al. 1998a
ASPD Cacciola et al. 1995 Cacciola et al. 1995 NA Brooner et al. 1998
Gabbard and Coyne 1987 Compton et al. 1998
Harris et al. 1994) Messina et al. 2003
Hildebrand et al. 2004
Messina et al. 1999, 2002
Ogloff et al. 1990
Reiss et al. 1999
Rice et al. 1992
Richards et al. 2003
Clusters B and C NA Krawitz 1997 NA Hoglend 1993
Winston et al. 1994
Cluster C Gude and Vaglum 2001 NA NA Hardy et al. 1995
AVPD NA NA NA Alden 1989
163
Note. ASPD= antisocial personality disorder; AVPD=avoidant personality disorder; BPD =borderline personality disorder; NA =not available.
Source. Search engine used: PsycINFO.
Table 93. Goals and their relationship to levels of care
Distress Behavioral Interpersonal Intrapsychic
Hospital ++ +
Partial hospital ++ ++ +
Intensive outpatient + ++ ++ +
Outpatient + + ++ ++
Note. Effectiveness: ++ =strong; += possible; =unlikely.
change in these four domains. Of course, this itive college. However, her completion of
profile is tied to the expected lengths of stay. college was repeatedly delayed due to an-
gry conflicts with peers and teachers usu-
Another way to classify goals is by the
ally followed by self-endangering behav-
priority they should be assigned in planning iors of variable seriousness. For the past
treatment interventions (Gunderson 2001). several years, she has been living at home
Here, for example, goals include crisis man- doing minimal work.
agement, behavioral stabilization, social re- On arrival, Ms. G was angry at her
habilitation, and psychological growth (Table parents for bringing her but desperate
about needing help. She refused to enter
94). These goals naturally map onto those in the residential program, insisting that she
Table 93 and vary in the extent to which they wasnt that sick. When advised it would
can and should be addressed within each provide a way to develop peer relation-
level of care. For example, crises are often ships, she angrily denied the need for that
managed by hospitalizations because of the and claimed sh e could mak e friends
whenever she wanted. Her parents effort
hospitals role in providing containment, asy-
to correct that claim only made her resis-
lum from stress, and the potential for rapid tance to entering the partial hospital more
medication changes that offer immediate resolute. She nonetheless reiterated that
symptom relief. Behavioral stabilization and she was desperate to receive an intensive
social rehabilitation are achieved through outpatient program (IOP, level II) that had
been unavailable at home.
corrective social learning experiences, as well
A clinical decision needed to be made:
as the continued opportunities for the acqui- either accept Ms. G in an IOP (level II) as
sition and generalization of coping skills that she insisted or not (under which circum-
are central to partial hospital (level III) and instances she claimed returning home was
tensive outpatient (level II) programs. Psy- not an option, and she would go to the
streets of Boston).
chological growth change requires longer-
At her parents urging, Ms. G was ac-
term and often repetitious learning experi- cepted into an IOP and quickly found res-
ences available only in stable longer-term set- idence with someone she met there. She
tingsthat is, in level I outpatient care. got attached to her individual therapist
but became preoccupied with her room-
mate, who had her own problems. After 6
Case Example months, the therapist and group therapy
leaders in the IOP concluded that Ms. G
Ms. G, a 26-year-old, single white woman, was making no progressthat she had in-
was referred from another state for treat- sufficient social supports or structure to
ment of personality disorder not other- use treatment for other than crisis man-
wise specified with borderline, schizo- agement. The therapist felt that to insist
typal, and avoidant features. With an on residential care would be experienced
excellent high school grade point average, as rejection and might precipitate suicidal
she had been accepted into a very compet- danger.
Levels of Care in Treatment 165
Ms. Gs case illustrates several common months) suggests that they can be useful in
and difficult problems involved in selecting ways that are not feasible in 214 days. That
or changing a level of care. One is making a research is described at the end of this section.
concession on level of care to accommodate a Potential risks associated with inpatient
patients insistence. Making a concession is hospitalization include reinforcement of
sometimes necessary but is best done with maladaptive behaviors (e.g., parasuicidal, at-
the proviso that the patient agrees to accept tention seeking, control struggles) and/or
your recommendations if he or she has not passive problem solving. Clinicians should
achieved some reasonable progress in some consider these issues for the particular pa-
agreed-upon time (e.g., has not achieved a tient. Nonetheless, the role of hospitalization
job, has not attended therapies regularly, has should be appreciated, because personality
not established a social support system, or disorder patients treated in community-ori-
has not diminished high-risk activities). A ented treatments (level I or II) with an ag-
second problem illustrated by this case is gressive emphasis on keeping patients out of
that once treatments are under way, it can be the hospital have worse outcomes than pa-
very difficult to change them without break- tients for whom hospitals were used as
ing the relational alliance with the patient needed (Tyrer and Simmonds 2003).
and/or precipitating a potentially dangerous
flight. In Ms. Gs case, the IOP team called for Indications
a consultation. Use of outside consultants to
oversee changes helps depersonalize what Hospitalization may be clinically indicated
often looms as a very difficult confrontation. during acute crises and in response to increas-
To do this required time-consuming commu- ingly severe behavioral dysfunction, espe-
nications by the treaters. It is more easily cially with regard to suicidal behaviors and
done within hospitals. How to make such violence toward others. Perhaps also worth
confrontations (advising patients of informa- noting is that hospitalization may be used as
tion that they do not want to hear) and how an asylum to permit patients with personality
to impose limits (prohibiting behavior[s] that disorders to leave abusive or otherwise harm-
a patient wishes to continue) without pa- ful situations or relationships. Hospitaliza-
tients becoming self-destructive or leaving tions can also enable patients to leave treat-
treatment is not easy (see Gunderson 2001 ments that were not helpful but that they
for discussion). would otherwise have had difficulty leaving.
Many people with personality disorders
enter hospitals because of comorbid psychiat-
LEVELS OF CARE ric disorders to which the personality disor-
der may predispose them. Indeed, more than
What follows is an elaboration of indications, half of psychiatrically hospitalized patients
goals, and structures for each of the four lev- have a personality disorder, with the most
els of care (see Table 94). Where available, common types being borderline, avoidant,
relevant empirical evidence is noted. and dependent personality disorders (Lor-
anger 1990). Attention to and consideration
Level IV: Hospital of the personality disorder may affect treat-
ment efficacy for the Axis I disorders and
Given that hospitalizations are almost always should influence treatment decisions.
214 days in duration in practice, the follow- Given that BPD is the predominant per-
ing discussion is geared to those lengths of sonality disorder found in inpatient hospital
stay. Still, research that has been done on hos- services (constituting about 15% of hospital-
pitalizations of longer durations (e.g., 23 izations; Koenigsberg et al. 1985; Loranger
166
Table 94. Levels of care: modalities, goals, duration, and therapeutic processes
Level Modalities Goals and procedures Duration Therapeutic processes
IV. Hospital Medication Crisis management 214 days Containment

Milieu Decrease distress 24 hours/day Support
Group Decrease suicide risk
Case management
Assessments
Neurological evaluations
Psychological evaluations
Plan/change treatment
Develop treatment plan
Identify primary therapist
Initiate medication changes
Expert consultation
III. Partial hospital Milieu Skills training 12 weeks Structure

Group Stabilize daily living skills 620 hours/week Support
Case management Structure daily activities Involvement
Family Identify maladaptive patterns
Individual
Behavioral stabilization
Decrease impulsive behavior 312 weeks
Increase coping skills 610 hours/week
Social rehabilitation 16+ weeks

Improve social functioning
Vocational rehabilitation
Community reentry
Table 94. Levels of care: modalities, goals, duration, and therapeutic processes
Level Modalities Goals and procedures Duration Therapeutic processes
II. Intensive outpatient Group Social (behavioral) adaptation 318 months Support
Family Vocational 310 hours/week Involvement
Individual Behavioral
Affective
Interpersonal
I. Outpatient Individual Psychological growth 1236 months Involvement

Group Interpersonal 13 hours/week Validation

Intrapsychic
167
1990; Widiger and Weissman 1991), it is worth Although level IV care is rarely indicated
noting a common clinical situation for which for Cluster C personality disorders, it is
hospitalizations should be used with caution. worth noting that hospitalization may offer
Hospitalization should rarely be used in re- useful exposures for patients with avoidant
sponse to self-injurious behavior without sui- personality disorder. For instance, hospital-
cidal intent. Furthermore, although inpatient ization may expose avoidant patients to typ-
stays may be warranted for BPD patients who ically avoided social situations (e.g., seeing
are acutely suicidal, such hospitalizations others in distress) or internal experiences
may not decrease the likelihood of future sui- (e.g., feeling helpless or anxious). Although
cide attempts (Van der Sande et al. 1997). hospitalization may result in initial improve-
Despite the widespread belief that hospi- ments in symptoms for these patients, how-
talization is generally contraindicated for pa- ever, research suggests that patients with
tients with ASPD, research on the effective- pure Cluster C personality disorders (espe-
ness of inpatient therapeutic community cially avoidant personality disorder) may be
drug treatment programs and inpatient sub- at greater risk for relapsing after discharge
stance abuse programs suggests that ASPD than patients with Cluster B personality dis-
patients may respond positively to certain orders (see Gude and Vaglum 2001).
types of inpatient programs (Cacciola et al.
1995; Messina et al. 1999, 2002). Of course, Goals: Crisis Management,
the generalizability of these results to other, Assessments, and Planning and
less specialized inpatient hospital programs
Implementing Treatment Changes
is indeterminable. With regard to contra-
indications to hospitalization, Gabbard and Following are the major goals of hospitaliza-
Coyne (1987) noted that negative responses tions and the usual time required for meeting
to hospitalization are likely for ASPD pa- them:
tients with a history of felony arrests or con-
victions; a history of repeated lying, aliases, Crisis management (26 days): Hospital-
and conning; an unresolved legal situation at ization can diminish acute suicidal or vio-
admission; forced hospitalization as an alter- lent dangers.
native to incarceration; and a history of vio- Extensive neurological or psychological
lence toward others. Moreover, research sug- evaluations (26 days): These evaluations
gests that psychiatric hospitalization is are more easily coordinated, and may
relatively contraindicated for those ASPD only be feasible, in hospital settings.
patients (approximately 25%65%; see Widi- Development of a treatment plan and per-
ger and Corbitt 1996) who are psychopathic sonnel (314 days): Such plans usually re-
(i.e., display a lack of remorse, lack of empa- quire arranging for continuity through
thy, and shallow affect; Harris et al. 1994; appropriate step-downs and assessing the
Hart and Hare 1997; Hildebrand et al. 2004; suitability of new therapy personnel. An
Reiss et al. 1999; Richards et al. 2003; see also essential part of these processes is to iden-
Salekin 2002). In contrast, there is evidence to tify the primary clinician who will be re-
suggest that ASPD patients without psych- sponsible for the patients treatment. For
opathy may respond positively to forensic primary clinicians, an essential first step is
hospitals with therapeutic community pro- to define roles and goalsthat is, estab-
grams (Rice et al. 1992) and that the presence lish a contractual allianceand to con-
of comorbid anxiety and/or depression may tract with the patient about participation
also be associated with a positive response to in aftercare services.
hospitalization among ASPD patients (see Changes in prior therapies (314 days):
Gabbard and Coyne 1987). These changes are often indicated, but
they may require expert consultation and The psychiatrist should oversee medica-
the introduction of new therapists. If the tions and involve the patient in any changes.
changes are considered undesirable by As important, the psychiatrist should caution
the patient, working through resistance patients about the relatively modest benefits
may be possible only in the hospital, they can expect. In addition, the psychiatrist
where the options for flight from the pro- should evaluate coexisting Axis I disorders
posed changes are reduced. and give them appropriate priority in after-
Hospitalizations may allow therapists to care planning. For example, comorbid sub-
review prior impasses or establish a stance or alcohol abuse almost always should
clearer framework for their ongoing work. be assigned high priority in aftercare, and co-
For many patients with personality disor- existing depression may not respond well to
der, hospitalization serves as an environ- medications (Gunderson et al. 2004; Koenigs-
ment to initiate medication changes and berg et al. 1999; Kool et al. 2003; Shea et al.
evaluate medication benefits. 1987; Soloff 1998) and may require further
monitoring at a less-restrictive level of care.
Structures
Longer-Term Hospitalizations:
A businesslike, practical, supportive, and task- Empirical Lessons
oriented atmosphere and orientation is useful.
Harmful is a milieu that encourages long one- Longer-term hospitalizations may address
to-one talks or the development of personal re- additional goals. Dolan et al. (1997) found
lationships with staff or other patients. Com- that long-term (i.e., average of 7 months)
munity meetings or group therapies that em- therapeutic community inpatient treatment
phasize cohesion or bonding among patients was associated with decreased borderline
are relatively contraindicated. Care should be psychopathology. Furthermore, hospitaliza-
taken not to reinforce maladaptive behaviors tions of 23 months may result in behavioral
or increasingly intense/severe expressions of stabilization (a goal usually reached in level
distress and suicidality. Furthermore, empha- III and generally not addressed in the 210
sizing the short-term nature of the treatment, day hospitalizations described above). Dia-
retaining a focus on impending discharge, and lectical behavior therapy (DBT)based inpa-
making aftercare plans for less-restrictive lev- tient programs in particular may be more ef-
els of care may be useful strategies for prevent- fective in fulfilling this goal than other
ing lengthy or contraindicated hospitaliza- inpatient programs with equally long stays
tions (see Bohus et al. 2000; Silk et al. 1994). (see Barley et al. 1993; Bohus et al. 2004). The
Given that it is easy for staff to feel trapped by advantages shown for such programs are
escalating suicidal ideation as patients ap- presumably due to the emphasis on skills
proach discharge, a consultant can help allevi- training (in particular, distress tolerance
ate unrealistic liability fears. skills), behavioral analyses of problem be-
In regard to staffing, a case manager haviors (with the goal of identifying precipi-
should be assigned and should keep the pa- tants and consequences of problem behaviors
tient oriented toward the problems preceding so as to determine appropriate interven-
the hospitalization that the patient will need tions), and the use of contingency strategies,
to cope with on discharge. A primary task of potentially minimizing unintended rein-
the case manager is to bring in relatives or forcement of maladaptive behaviors (Barley
other significant people to help understand et al. 1993; Bohus et al. 2000, 2004). Moreover,
precipitating events and diminish the likeli- the milieu can be used to practice, and begin
hood of their recurrence after discharge, to re- to generalize, the skills being learned.
ceive psychoeducation about the personality These studies of 2- to 3-month hospitaliza-
disorder, and to coordinate aftercare plans. tions can be used to inform the development
of hospital programs with shorter lengths of hospital programs may be indicated for pa-
stay. For instance, Silk et al. (1994) developed tients who lack either the social supports or
a DBT-based inpatient treatment for BPD vocational options to make community living
with an average length of stay of 1017 days. viable. Whether as an alternative to or step-
In assessing patients perceptions of improve- down from hospitalization, partial hospital
ment at the time of discharge, they found that programs are needed for personality disorder
patients in the DBT-based program (com- patients with marked social or behavioral im-
pared with patients assigned to a non-DBT pairment. Karterud et al. (2003) operational-
discussion group) felt that the lessons they ized the need for partial hospitalization by
learned would help them to better handle dif- suggesting that it was indicated for patients
ficult or painful situations. Although the with Global Assessment of Functioning
same level of change found with longer-term scores below 50. Partial hospital programs
hospital stays would not be expected with can assess the types of, and reasons for, social
short-term hospitalizations, a similar struc- disability and introduce rehabilitative efforts.
ture can be utilized with beneficial results. This level of care can also be used to intro-
duce or stabilize new treatments when close
Level III: Partial Hospital/Day supervision and evaluations are needed.
Treatment As with level IV, BPD is the personality
disorder most likely to use level III. Al-
The literature presents a diverse picture of though patients with ASPD are also socially
partial hospital treatments for personality impaired, there is some evidence to suggest
disorders, varying extensively with regard to that they may be likely to drop out of partial
treatment duration (i.e., length of stay) and hospital programs (Karterud et al. 2003; Wil-
treatment intensity (i.e., hours per week). berg et al. 1998b). However, given evidence
These programs offer more structure, con- of a positive response to level III therapeutic
tainment, and intensive treatment than out- com m un it y d ru g t re at m en t p rog ram s
patient care while providing the opportunity among ASPD patients (Cacciola et al. 1995),
for behavioral stabilizationand for skills it is possible that certain specialized pro-
building and generalizationthat are not grams may be effective in the treatment of
usually available in typical short-term inpa- ASPD patients. Patients with schizotypal
tient settings. Our discussion of partial hospi- personality disorder are unlikely to be
tal treatment is oriented toward the levels of helped by partial hospital programs (see
duration and intensitythat is, the shorter- Karterud et al. 1992; Vaglum et al. 1990). Sur-
term partial hospital programs (24 weeks in prisingly, however, patients with paranoid
duration) that are usually available in the cur- personality disorder treated in an 18-week
rent health care system. A discussion of the day treatment program evidenced signifi-
lessons that can be learned from the longer- cant improvements in global functioning,
term partial programs that have been the pri- symptom severity, and interpersonal func-
mary recipients of empirical attention can be tioningimprovements comparable with
found at the end of this section. those seen among patients with other per-
sonality disorders (Wilberg et al. 1998b).
Indications
For some patients with a personality disor- Goals: Skills Training, Stabilization, and
der, partial hospital programs offer an opti- Social Rehabilitation
mal level of care. They can diminish the like-
lihood of substance/alcohol abuse relapses A pragmatic and theoretically grounded ap-
or suicide attempts (although they do not proach conceptualizes treatment in stages,
have enough monitoring or containment to each of which has its own goals and interven-
prevent these behaviors). Moreover, partial tions. Stages are organized with respect to
their duration and intensity as well as to the Stage 2 (38 Weeks)

changes that can reasonably be expected to
occur within a given time frame. Based on Stabilize behavior: This goal involves at-
clinical experience, a high-intensity front- taining better impulse control, resulting in
loaded treatment is optimal initially, fol- a decrease in the frequency and severity of
lowed by treatment at a titrated intensity impulsive and self-destructive behaviors
over several months. Given that most pro- (e.g., self-harm, suicide attempts, sub-
grams can offer only short-term treatment stance use). This stabilization is often a
(what we refer to here as stage 1 of treat- nonspecific effect of asylum, structure,
ment), this titration is particularly relevant. and support.
One partial hospitalization program that em- Initiate vocational rehabilitation: This
phasizes stage 1 targets found that patients goal is not easily accomplished and typi-
can improve in the brief time frame of 12 cally gets overlooked due to the fact that
weeks (Neuhaus 2006; Neuhaus et al. 2007). patients with a personality disorder rarely
The following are goals for each stage: seek vocational rehabilitation. Young or
inexperienced staff are unlikely to give
Stage 1 (12 Weeks) this goal adequate value and importance.
Program administrators or staff involved
Develop a therapeutic alliance and the pa- with families are more apt to determine
tient attaches to treatment: This process is whether it is addressed.
assisted by defining goals and establish- Reevaluate the treatment contract on the
ing an initial treatment contract that gets basis of the extent to which patients are
reviewed and refined over time. working collaboratively and responsibly
Psychoeducation: This helps patients in treatment: In stage 2 treatment, after pa-
frame goals and understand treatment tients have achieved more competency
options, and enlists family support. with regard to coping skills (e.g., better
Stabilize or teach daily living skills (eat- impulse control, improved anxiety man-
ing, sleeping, hygiene): The need for this agement), a greater emphasis is placed on
goal varies, as does the optimal approach interpersonal relationships.
to achieving it. Most patients need consis-
tent monitoring and education about the
Structures
importance of eating and sleeping in reg-
ular patterns. Sleep medications may Partial hospital and day treatment programs
prove useful for patients who have trou- rely heavily on group therapy and the posi-
ble falling asleep because of fearfulness. tive effects of a therapeutic milieu. Such
Schedule and structure time and activi- structure must be actively constructed, pro-
ties: This assists with the management actively maintained, and updated as needed.
and planning of daily activities, promotes With a 1- or 2-week length of stay, patients
self-care routines (e.g., sleep, hygiene, do not have the luxury of time to settle in
good eating habits), and aids in overall to treatment. Clear and concise information
stress management. (e.g., description of the program and treat-
Begin to identify typical patterns (e.g., in- ment philosophy, expectations of patients,
terpersonal conflicts, loneliness) that lead roles of treatment team members) provided
to maladaptive behaviors: Although mal- upon entry can diminish a patients anxiety
adaptive patterns cannot be expected to and facilitate immediate involvement in
change in stage 1, it is often useful to in- treatment. Handouts with daily schedules
troduce basic behavioral strategies at this and brief descriptions of groups may further
point, including chain analyses and im- orient patients and promote memory of what
pulse control skills. to expect. The structure of the partial hospital
program may become a template for struc- havioral treatment, an intensive DBT ap-
turing their lives outside the program. proach has also been shown to be effective in
As with hospitals, a case manager respon- treating borderline patients in a 3- to 4-week
sible for implementing the treatment and time frame (McQuillan et al. 2005). Notably,
monitoring progress should be assigned. This even the psychoanalytic partial hospital pro-
person should work directly with the patient, gram developed by Bateman and Fonagy
treatment team members both within and (2004) is heavily cognitive-behavioral; espe-
outside of the program, and family members. cially in early phases. As such, a core constel-
To be an effective case manager with person- lation of groups within stage 1 treatment may
ality disorder patients requires clinical savvy include treatment contracting, community
to set limits, confront when necessary (e.g., meeting (for addressing therapy-interfering
when patients are missing groups), and stay behaviors), personality disorder psychoedu-
connected with a patient despite being vili- cation (with information about the influence
fied as not understanding or caring. An effec- of Axis I disorders), basic behavioral skills
tive case manager must also be willing and groups (including behavioral scheduling, im-
able to negotiate with treatment team mem- pulse control, distress tolerance, and anxiety
bers outside of the program (e.g., the patients management), self-assessment groups that
outpatient therapist). In short-term treatment teach patients how to identify maladaptive
the case manager may be invaluable to the behavioral patterns (including the emotional
family system in providing information, sup- and cognitive precipitants of maladaptive be-
port, and the framework of an overall treat- haviors), and rudimentary interpersonal
ment plan (e.g., anticipating the issues in- groups (e.g., assertiveness training, interper-
volved in less intensive levels of care). sonal effectiveness, and the impact of person-
Given the potential for treatment noncom- ality styles on relationships).
pliance at this level of care (patients may have Groups during stage 2 of treatment may
difficulty attending treatment when feeling follow the framework of stage 1, although
bad), the structure of the program should in- with greater depth and further opportunities
clude provisions for addressing noncompli- for patients to practice skills and achieve some
ance through program expectations, policies, competency in their use. At this stage of treat-
and an explicit emphasis on therapy-interfer- ment, as patients begin to feel like part of the
ing behaviors. Noncompliance is best ad- milieu, there is a natural progression to focus
dressed by the case manager and then fol- more explicitly on the patients interpersonal
lowed up in groups. It is useful to utilize a relationships. This stage may see an intensifi-
combination of validation, confronting, limit cation of treatment relationships and attach-
setting (e.g., patients cannot stay in the pro- ments, which offers challenges to patients and
gram unless attendance improves), and the treatment providers alike. Any honeymoon
teaching of coping skills to facilitate improved phase would likely be over by this stage of
attendance despite emotional distress. treatment, necessitating that the frustrations,
High-intensity, short-term treatment at disappointments, and realities of treatment be
this level of care should be front-loaded with addressed. For effective treatment to con-
skills training and psychoeducation to pro- tinue, the therapeutic alliance must be strong
mote stabilization and safety. It is essential to enough to endure these obstacles.
select and prioritize elemental skills that are
feasible for patients to learn quickly. This Longer-Term Partial Hospital/Day
bottom-up approach draws heavily from Treatment Programs: Empirical Lessons
cognitive-behavioral therapy (CBT) princi-
ples and simplifies the treatment program Research on longer-term partial hospital and
for patients (Levendusky et al. 1994; Neu- day treatment programs suggests that they
haus 2006). As an extension of cognitive-be- may provide the opportunity for behavioral
stabilization (including decreased parasui- from 816 hours/week) did not evidence any
cidal behavior) and symptom improvement improvements in work functioning at 1-year
and, unlike shorter-term programs, can also follow-up (Karterud et al. 2003).
positively affect social and interpersonal Finally, although it is often assumed that
functioning. Bateman and Fonagy (1999) more treatment (i.e., greater intensity) will re-
found that BPD patients treated in a partial sult in greater improvements, research sug-
hospital program organized around a men- gests that when it comes to the day treatment
talization-based model of treatment (Bate- of patients with BPD, less is more. Karterud
man and Fonagy 2004), compared with BPD et al. (2003) found that lower-intensity (i.e., 8
patients in standard outpatient care, evi- 10 hours per week) partial hospital treatment
denced significantly fewer suicide attempts was more effective (i.e., fewer dropouts and
after 6 months, significant reductions in de- greater improvements in global functioning
pression and anxiety after approximately and symptom severity) for patients with BPD
9 months, and significantly fewer acts of self- than high-intensity treatments (approxi-
harm after 12 months. Moreover, partial hos- mately 16 hours per week). This finding is
pital program patients not only maintained consistent with the level of intensity found to
their gains but reported further improve- be effective in Bateman and Fonagys (1999,
ments at follow-up (Bateman and Fonagy 2001, 2008) randomized controlled trial.
2001, 2008).
Global symptom severity of patients with Level II: Intensive
Cluster B and C disorders has been shown to Outpatient Program
decrease significantly after approximately
4 months of level III treatment (Karterud et When described as a level of care, an IOP dif-
al. 1992; Krawitz 1997; Vaglum et al. 1990; fers from an intensive schedule of individual
Wilberg et al. 1998b). These same improve- psychotherapy. For purposes of this review,
ments may also be found for patients with we define IOP as an integration of two or
paranoid personality disorder (Wilberg et al. more modalities in which efforts are coordi-
1998b). Research also suggests that patients nated and patients receive 310 hours of ser-
with Cluster C personality disorders may ex- vices per week. Thus, at its higher end, IOPs
perience improvements in social functioning overlap with low-intensity partial hospital
after 4 months (Karterud et al. 1992; Vaglum programs. When patients need fewer than 3
et al. 1990). For patients with BPD, on the hours of service per week and/or the ser-
other hand, significant improvements in so- vices do not need to regularly coordinate
cial adjustment and interpersonal function- their efforts, the treatment becomes level I.
ing may require up to 18 months of treatment IOP or level II care is of particular value for
(Bateman and Fonagy 1999). BPD patients (Gunderson 2001; Smith et al.
Moreover, even in these longer-term par- 2001). Although Linehans (1993) DBT treat-
tial hospital/day treatment programs, voca- ment has been identified as an outpatient
tional rehabilitation is difficult to achieve. Fol- service, it involves both individual and
lowing a 4-month day treatment program, group therapy provided by collaborating cli-
unemployment rates of patients with Cluster nicians at a level of 3.5 hours per week
B and C disorders did not change during the thus, it could be classified as an IOP.
2-year follow-up period despite other signifi-
cant improvements in global functioning and Indications
symptom severity (Krawitz 1997). Similarly,
in another study, patients with personality IOPs are indicated for personality disorder
disorder (primarily borderline, avoidant, and patients whose problems with living in the
paranoid) treated in a variety of day treatment community are not acutely self-endangering
programs (ranging from 1841 weeks and but are sufficiently severe that only daily, or
otherwise unusually intensive, care can Behavioral (412 months): Improve abili-
bring about changes. IOPs can provide a ties to control impulsive behaviors and
gradual transition from higher levels of care out-of-control (i.e., ineffective) expres-
(i.e., inpatient and partial hospital pro- sions of feelings. Improve ability to en-
grams). Because patients often experience gage in goal-directed, valued behaviors.
this transition as happening too quickly or Affective (652 weeks): Recognize feeling
before they are ready, treatment modalities states in self and others and learn to asso-
at this level of care should recognize and val- ciate them with behaviors (what Fonagy
idate patients subjective distress while si- [1991] has termed mentalization). This rec-
multaneously encouraging the use of their ognition is especially important for the
personal strengths and skills. feelings of fear and anger in avoidant per-
sonality disorder and BPD, respectively.
Case Example Increase emotional acceptance.
Interpersonal (6 months2 years): Recog-
Ms. H, a 38-year-old, single white
nize dependent needs as part of self and
woman with BPD and posttraumatic
stress disorder (PTSD), was hospital-
others. This goal initially involves recogni-
ized for increased PTSD symptoms and tion of such needs; becoming comfortable
reckless behavior following a serious with them follows (Gunderson et al. 1993).
accident in which her son was injured. Increase interpersonal effectiveness.
Previous hospitalizations had lasted
weeks longer than anticipated and were Structures
followed by 23 months in partial hos-
pital without obvious benefit. On the in- In addition to individual psychotherapy,
patient unit, the patient was disap- IOPs offer complementary groups that meet
pointed not to have the case manager three to five times per week and promote the
and psychiatrist she had worked with
resumption of functional capacities within
in the past and also was eager to go
home to spend Christmas with her son.
the community. Groups are best offered in
Her therapist was leaving for vacation the morning or late afternoon to allow time in
and seemed worried about the patient the patients schedules to pursue nonclinical
returning to outpatient care in her ab- activities such as work or volunteering. Of-
sence. The patient and therapist negoti- fering several different types of groups, each
ated with the leaders of the IOP groups with a different format and function, will
about how she could use the groups to help patients meet the various goals of this
manage emotional distress and to mon-
level of care.
itor any reckless behavior. The patient
was discharged to an IOP, resumed her For instance, daily self-assessment groups
functioning as a mother, and survived can provide a structured format for each pa-
her therapists absence. tient, in turn, to discuss the transition, identify
maladaptive behaviors and/or interpersonal
This vignette illustrates both the value of difficulties, and obtain support. Daily groups,
an IOP as a step-down from hospital (level by virtue of their frequency, enable patients to
IV) care and the ways it can assist during cri- become familiar with the details of each oth-
ses (in this case, the absence of a therapist) ers lives, contributing to their sense of being
while in outpatient (level I) care. heard and understood. The format of these
groups also enables group members to hold
Goals: Social (Behavioral) Adaptation each other accountable for managing mal-
adaptive behaviors and interpersonal prob-
Vocational (412 weeks): Enlist in needed lems. DBT or CBT skills groups in an IOP pro-
vocational training or develop skills and vide patients with the opportunity to further
initiative required to obtain work. develop and refine skills learned in more in-
tensive levels of care (e.g., skills to control im- Level I: Outpatient

pulses, regulate emotions, tolerate distress,
and improve their capacity to negotiate rela- Level I is the level of care in which most of
tionships). the treatment for personality disorders oc-
These groups are more rigorous than curs. In a previous generation, psychoana-
supportive groups (such as self-assessment lytic therapies were considered the treatment
ones) and require a serious commitment to of choice for all personality disorders, even
homework assignments and behavioral though the literature mainly consisted of
change. Interpersonal groups are process- negative accounts about the resistances en-
oriented psychotherapy groups that have a countered. Some of the problems tradition-
longer-term focus. These groups encourage ally encountered in outpatient care can be
patients to examine how they relate to others, addressed by utilizing higher levels of care
both within the group and in their lives. Con- especially IOPs. Other problems were due to
flicts between members are expected to be applying psychoanalysis to patients who
frequent and may reflect ambivalence about needed more structure, more of a here-and-
dependency needs and competitiveness for now focus, and more support. To some ex-
attention. Mentalization groupsderived tent, psychoanalytic theory has been modi-
from mentalization-based treatmentare fied to address these problems, acknowledg-
designed to help members develop more ing the importance of the real relationships
awareness of the mental states of other per- and putting insight into perspective. More-
sons and to consider how that awareness af- over, outpatient treatments for personality
fects their own mental state (Bateman and disorders have diversified to include a much
Fonagy 2006). stronger place for CBTs and medications.
The nature and function of these groups
provide useful information as to how best to Indications
incorporate them within the structure of the There are no specific indications or contrain-
IOP. Whereas self-assessment groups may be dications for outpatient care. There are ge-
invaluable during the initial period of transi- neric issues; because outpatient care requires
tion, lasting as little as a few weeks, interper- conscious willful effort, such care is limited
sonal and DBT/CBT skills groups have a de facto to those who seek it and who can be
longer-term focus and may be expected to sufficiently reliable to attend scheduled ses-
continue after the patient leaves the IOP for sions. Beyond these considerations, some pa-
outpatient care (level I), thereby assisting in tients primarily seek support or direction,
this new transition. and their motivation to work on changing
Finally, it is essential that the groups of their personality may not be present. The ab-
the IOP be coordinated and integrated with sence of this motivation may be a relative
the overall goals of the patients treatment. contraindication for outpatient treatment.
When a patients primary clinician works Research on the effectiveness of outpa-
outside the IOP setting, the responsibility for tient treatments for personality disorders has
coordination and implementation of the focused primarily on relatively high-func-
treatment plan can be handicapped. Regular tioning clients. For instance, Winston et al.
communication between the patients psy- (1994) required that clients with a personality
chotherapist and group leaders, as well as disorder have no suicidal behavior, no his-
among the group leaders themselves, is crit- tory of destructive impulse control prob-
ical. For instance, Linehans (1993) DBT in- lems, no use of psychotropic medications in
cludes a weekly 2-hour consultation team the past year, and the presence of one close
meeting, considered to be one of the neces- interpersonal relationship; Alden (1989) ex-
sary components of the treatment. cluded participants who had ever been hos-
pitalized for psychiatric difficulties, and the primary targets of psychodynamic

most of the participants were employed or in (and psychoanalytic) psychotherapies.
school; in Hoglends (1993) study, most par- Although the attention given to diagnoses
ticipants were employed and none had se- is often limited and idiosyncratic, there is
vere acting-out behaviors. Because we do not a body of evidence relevant to their effec-
know what fraction of the personality disor- tiveness with personality disorders (see
der patients in outpatient services meet these Gunderson and Gabbard 1999). The re-
requirements, the generalizability of this results published by Knight (1941) indi-
search is unclear. What may be concluded is cated that psychoanalytic psychothera-
that the results will not apply to patients with pies are more effective for neurosis
severe social dysfunction. (63%) and character disorders (57%) than
for psychosis (25%). A review of available
Goals: Interpersonal and literature suggests that such therapy is
Intrapsychic Growth particularly likely to help patients with
obsessive-compulsive, narcissistic, and
Goals for level I are often the same as those dependent personality disorders (Gun-
identified for an IOP. Indeed, because most derson 2003).
treatments for patients with a personality The effectiveness of psychodynamic
disorder are delivered in this nonintensive psychotherapy for BPD has received the
outpatient level of care, the goals identified most attention. Although a study con-
for an IOP are usually initiated in level I. ducted at McLean Hospital found that it
However, in outpatient care, achieving these was rare for a patient with BPD to remain
goals is more apt to involve active selection in long-term treatment and get dramati-
and motivation by the particular patient. cally better (Waldinger and Gunderson
An important discontinuity with the IOP 1989), such cases could be identified and
is that outpatient care is rarely directed at vo- the processes of change seemed to occur
cational rehabilitative needs; this may be es- in a predictable sequence (Gunderson et
pecially true for psychodynamic individual al. 1993). Moreover, three studies with
therapies. CBT- or DBT-based approaches larger samples of BPD patients have
may be more likely to accommodate this lack added credibility to the claim that long-
of vocational rehabilitation through role term psychodynamic psychotherapy can
playing and problem-solving issues related be effective for patients with BPD and
to applying for school or work. Still, because have significant cost offsets (Hoke LA:
outpatient therapies depend on what pa- Longitudinal Patterns of Behaviors in
tients identify as goals, and because voca- Borderline Personality Disorder, Doc-
tional rehabilitation is rarely a reason for toral dissertation, Boston University, 1989;
which patients with a personality disorder Howard et al. 1986; Stevenson and Meares
seek therapy, this arena is often neglected. 1992). Of particular note, the psychoana-
lytic psychotherapy offered in the Steven-
Enhance social involvement: Improve son and Meares (1992) study (a 1-year
level of, and satisfaction from, social and manualized treatment conducted by
recreational activities (as demonstrated trainees) was followed by continued im-
by Winston et al. 1994). provement. However, it is important to
Improve impulse control: Although often note that these studies do not show that
begun at higher levels of care, impulse the psychoanalytic components distin-
control can also occur in, or be strength- guish effective psychotherapy, nor do
ened by, outpatient care. they indicate to what extent the favorable
Work on changes in interpersonal related- outcomes can be generalized to the larger
ness and intrapsychic structure: These are universe of BPD patients.
Structures forts to interpret his calls or to set limits

on them, and she eventually sought con-
Individual psychotherapy assumes the cen- sultation. The consultant suggested an
tral role in most outpatient treatments for interpersonal group therapy be added.
personality disorders. Still, split treatments In the group, his anxieties about rejec-
(i.e., adding a suitable second modality to action were seen as unrealistic, and the
company the individual psychotherapy) maladaptive nature of his intrusive
wishes for reassurance were confronted.
have advantages (Gunderson 2001; see also
The patient resisted, but after starting
Chapter 17, Collaborative Treatment). At the group, his behavior in therapy
this level of care, the split treatment may in- changed dramatically. He was able to
volve medications (e.g., for schizotypal, bor- clearly see his reactions to his therapist
derline, or avoidant personality disorders; (and wife) as transference phenomena.
see Chapter 14, Somatic Treatments). The
second modality could also include a social Impasses in individual psychotherapy
rehabilitative component, including a CBT with patients with a personality disorder of-
group (Blum et al. 2002, 2008; Gratz and ten derive from the fact that such patients are
Gunderson 2006), an interpersonal therapy often unaware of how they create problems
group (Marziali and Munroe-Blum 1995; for others and then can feel unjustifiably crit-
Munroe-Blum and Marziali 1995), a self-help icized by therapists who point this out. In
group (e.g., Alcoholics Anonymous, Narcot- many cases, this obstacle can be overcome by
ics Anonymous; see Chapter 19, Substance the addition of a second modality. In this
Abuse), and/or some continuation of fam- case, the group therapy diminished the
ily involvement. These therapies are often in- transference and provided a source of feed-
dicated for dependent, borderline, histrionic, back to Mr. I that was less personalized.
avoidant, or schizoid personality disorders. Some evidence suggests that patients with
Moreover, a meta-analysis of treatment stud- a personality disorder may require longer-
ies on psychopathy suggests that the aug- term treatments to reach normative levels of
mentation of individual psychotherapy with functioning or to maintain treatment gains.
group or family therapy may enhance its ef- Alden (1989) found that although three differ-
fectiveness (see Salekin 2002). en t b eha viora lly b ased t rea tme nts fo r
avoidant personality disorder resulted in
Case Example greater improvements than a waiting list con-
trol group, the patients remained significantly
Mr. I was a 34-year-old man who sought more symptomatic than normative samples.
help because he wanted to reconcile Similarly, in a study of the long-term out-
with his wife, who had kicked him out. comes of patients with and without personal-
He was obsessed with his wife and
ity disorders treated with outpatient dynamic
claimed he did not understand why she
psychotherapy, Hoglend (1993) found that for
had rejected him. She had refused cou-
ples therapy, saying that Mr. I needed to the patients with personality disorders, the
change himself. Prior efforts to assuage number of sessions in treatment was signifi-
his agitation and insomnia with medica- cantly related to acquired insight (i.e., new
tions had proven helpfulbut he now emotional self-understanding) and to overall
needs to change himself, although he personality change at 2- and 4-year follow-up.
could offer no ideas about what he
wanted to change. In the ensuing ses-
sions, Mr. I described a very disturbed
childhood with a punitive mother. CONCLUSION
He became quite devoted to the ther-
apist, a woman, and began calling her Because personality disorders are defined by
frequently for what to her seemed trivial enduring social maladaptations, they are in-
reasons. He was deeply hurt by her ef- trinsically tied to social contingencies. To
bring about change, good treatments across chy of therapeutic processes (Gunderson
all levels of care must embody coherent and 1978, 2001). Viewed through this lens, the
repetitious interventions with a primary ini- levels of care move from most to least con-
tial focus on the here and now. tainment, with an attendant increase in reli-
The interventions offered by any level of ance on internal controls and self-agency.
care will only be effective if patients develop There is also a progressive decrease in the
an alliance with treaters. For patients with level of structure across the levels of care,
personality disorders, forming an alliance such that the organization of time and activ-
will be complicated by the obstacles created ities imposed by the treatment setting is re-
by their personalities, for example, avoid- duced at each step down. Even within the
ance, deceit, or attention seeking. This chap- least-structured treatment settingthat is,
ter emphasized that establishing an alliance outpatient psychotherapiesthere is a hier-
begins with establishing agreed-upon goals, archy in which more directive and active in-
selecting the level of care appropriate to (i.e., terventions give way to lesser ones as pa-
best able to fulfill) these goals, and clarifying tients progress. Support in the form of
what is expected of patients. These activities reassurance, advice, and expressions of con-
establish a contractual alliance. This form of cern are important elements of all levels of
alliance may be sufficient for hospitals but is care. Because support often bonds people, it
also a necessary prerequisite for all other lev- becomes an essential element for interper-
els of care. The relational alliance (i.e., an al- sonal attachments. Such attachments may be
liance based on liking or trusting the treaters) a negative factor in the highest levels of care
also is necessary. Such alliances usually de- because they can form a resistance to leaving,
velop from supportive attention, and in but they become more important, like the re-
some cases respectful listening may be all lational alliance noted earlier, as patients
that is required. When such an alliance is not move into longer-term settings.
formed with clinicians, progress is unlikely. Winnicott (1965) identified a holding en-
Beyond this relational alliance, the value of vironment as a social context that is a neces-
many specific forms of intervention depends sary prerequisite for the development of an
on what has been termed the working alli- internal sense of safety and security. Every-
ancethat is, an alliance that is needed for one requires a feeling of being securely con-
collaborative work toward the patients tained, but the degree to which this feeling
goals (e.g., acquiring new skills and capabil- depends on external factors varies. Although
ities). Although such a mutual task orienta- Winnicott originally conceptualized the hold-
tion is often assumed when contractual alli- ing environment as a function served by
ances are made, for patients with personality mothers early in development, it has been
disorders, a working alliance can be hard to transformed into a term that is used to de-
achieve. Clinicians working at all levels of scribe a function offered by therapies. As one
care need to be vigilant about whether per- moves through the levels of care, the hold-
sonality disorder patients are working with ing action depends progressively less on im-
the therapist for purposes of changing them- posed constraints and structures and more on
selves (i.e., their identity or self). internal resources. This shift has implications
Earlier in this review, we noted a relation- for the levels of care that may be most appro-
ship between the four levels of care and the priate for specific personality disorders.
domains of psychopathology that patients Although the role of hospitalization tends
are best able to change. Table 93 reflects this to be limited for the treatment of personality
progression as it relates to goals. Another disorders, many patients with personality
way to understand the distinctive effective- disorders use hospitalizations to treat comor-
ness of the four levels of care is via a hierar- bid conditions or crises. Hospitalizations may
be most useful for those patients whose sense This research has generally shown that BPD
of self is most disorganized or unstable (BPD) can be responsive to well-structured pro-
or whose unintegrated behaviors pose a dan- grams at all levels of institutional services.
ger to self or others (e.g., BPD and nonpsy- The results for ASPD are more complicated.
chopathic ASPD). Such patients may need Specialized programs at inpatient, partial
more containment and structure to feel hospital, and outpatient levels of care have
held. Partial hospital (day treatment) care been shown to be useful for nonpsycho-
(level III) is used primarily for stabilizing pathic ASPD patients. Although the higher
mental states and initiating longer-term ther- levels of care are generally contraindicated
apies within the 2 weeks usually allotted by for psychopathic ASPD patients, the afore-
the modern managed care environment. mentioned meta-analysis of treatments for
However, there is good evidence that longer- psychopathy suggests that long-term, inten-
term stays can add substantial benefits. The sive individual psychotherapy may have
limited durations of stay available in partial positive results for this population (see Sale-
hospitals have helped create the need for a kin 2002). However, the extent to which these
relatively new level of care, IOPs (level II). research findings generalize to standard
This level of care may be needed for at least practices in outpatient settings is unclear,
1 year and requires theoretically and structur- given the potential for problems related to
ally integrated individual and group compo- treatment retention and compliance at this
nents. These programs have been demon- level of care.
strated to be useful for BPD, but in principle Because research suggests that well-
they should be just as applicable to any per- structured and theoretically consistent pro-
sonality disorder with severe social func- grams are more useful for patients with a
tioning handicaps (e.g., schizoid, avoidant, personality disorder than programs that are
dependent, and antisocial personality disor- not, these qualities should become standards
ders). Ironically, this level of care, arguably for care. More attention should now be given
the most useful for dysfunctional personality to whether programs with different theoreti-
disorders, is the least available in the present cal models (e.g., dynamic vs. cognitive-be-
health care system. Outpatient care is the pri- havioral) have different effects. Research
mary setting for the treatment of most person- should also look at the relative cost-effective-
ality disorders. Here, long-term individual ness of different treatments using follow-up
psychotherapy by itself is thought to be the data, and to the extent indicated, reimburse-
treatment of choice for patients with narcissis- ment policies should be changed accord-
tic, histrionic, and obsessive-compulsive per- ingly. Another area that would benefit from
sonality disorders. Although it is thought that research attention is how well the therapeu-
significant personality change may be possi- tic alliance (and what type of alliance) pre-
ble in outpatient care, availability of this treat- dicts patients subsequent benefits from
ment is largely dependent on private pay and treatment. Furthermore, increased research
thus is frequently inaccessible. attention should focus on the intensive out-
There is very little research relevant to patient level of care (level II), a relatively new
systems of health care services for personal- level that seems particularly promising for
ity disorders. What little there is supports the BPD patients. Finally, given the apparent dif-
value of graduated step-down levels of care. ferences in effective treatments for psycho-
Not surprisingly, the two personality disor- pathic and nonpsychopathic ASPD, research
ders for which higher levels of care are most should continue to distinguish between
needed and that have the most public health these two groups when examining treat-
significance, BPD and ASPD, have generated ments for ASPD as well as begin to identify
the most research attention (see Table 92). the extent to which the positive results found
for specialized drug treatment programs (at Blum N, Pfohl B, St. John D, et al: STEPPS: a cog-
all levels of care) are generalizable to other nitive-behavioral systems-based group treat-
ment for outpatients with borderline person-
treatment programs for ASPD patients.
ality disorder. A preliminary report. Compr
This chapter provides an overview of the Psychiatry 43:301310, 2002
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as well as their relative appropriateness for ing for Emotional Predictability and Problem
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ders. Attention to and consideration of per- line personality disorder: a randomized con-
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10
Psychoanalysis and
Psychodynamic Psychotherapy
Glen O. Gabbard, M.D.
The field of psychoanalysis emerged in the up a lost object only by identifying with the
last decade of the nineteenth century as a lost person, suggesting that one seminal as-
means of treatment for hysterical symptoms. pect of the development of personality is
However, in a relatively short time the focus identification with parents and others in the
of psychoanalysis shifted toward long- course of development.
standing character pathology. As early as Freuds work was expanded by Karl Abra-
1908, Freud was inaugurating that shift ham (1923/1948) when he developed a sys-
when he wrote his classic paper Character tem of classifying character traits according
and Anal Eroticism (Freud 1908/1959). to their linkage with oral, anal, and genital
Freud linked specific character traits, such as eroticism. However, it was Wilhelm Reich
miserliness, obstinacy, and orderliness, with (1931) who was the true trailblazer in the psy-
the anal psychosexual stage of development. choanalytic understanding of character. He
Whereas he regarded neurotic symptoms as developed the term character armor to de-
reflecting the return of repressed uncon- scribe the unconscious and ego-syntonic de-
scious material, he viewed character traits as fensive style of patients who come to analytic
the end result of the successful use of repres- treatment. He postulated that childhood con-
sion as well as other defenses such as subli- flicts were mastered with specific defense
mation and reaction formation. As he moved mechanisms. These defenses subsequently
in the direction of the structural model, he emerged in the psychoanalytic setting in the
became aware that identification was of way patients entered the office, reclined on
great importance in the formation of charac- the couch, related to the analyst, and resisted
ter. He recognized that some people can give the psychoanalytic process. Although neu-
185
rotic symptoms were regarded as compro- agrees with this particular model, psychoan-
mise formations that produced distress, alysts and psychotherapists alike must accept
Reich stressed that character traits were the limitations of the treatment they under-
rarely sources of anxiety or emotional pain. take. Genetically based temperament is un-
This distinction continues into the present, likely to be altered by psychoanalysis or psy-
when clinicians often remark how the charac- chodynamic psychotherapy, but the areas of
ter traits in patients with personality disor- self-development, internal object relations,
ders often cause more distress in others than and the patients effectiveness in coping with
in the patient. However, this generalization the environment may be profoundly affected
understates the great extent to which many by psychoanalytically oriented treatments.
people with personality disorders suffer as a Temperament is highly stable over time,
result of their character pathology. whereas the character dimensions tend to be
malleable and undergo development through-
out life (Svrakic et al. 1993).
CONCEPTUAL MODEL From a psychoanalytic perspective, per-
sonality can be viewed as having five major
Contemporary psychoanalysis is primarily components: 1) a biologically based temper-
geared to address character. The symptom- ament, 2) a set of internalized object rela-
atic neuroses of Freuds day are rare in to- tions, 3) an enduring sense of self, 4) a spe-
days clinical setting. Analysts focus on how cific constellation of defense mechanisms,
distortions of self, compromises between and 5) a characteristic cognitive style. Ana-
wishes and defenses that oppose those lysts and analytically oriented therapists
wishes, and internal representations of self would regard the achievement of a stable
and others have forged the patients person- and positive sense of self and the establish-
ality (Gabbard 2000b). Psychodynamic psy- ment of mutually gratifying and enduring
chotherapy, which is derived from psycho- relationships as perhaps the two fundamen-
analysis, may be used for Axis I conditions, tal tasks of personality development (Blatt
such as panic disorder and major depression, and Ford 1994). These two fundamental fea-
but it is particularly useful to address the tures of character evolve in a synergistic and
problems associated with Axis II disorders. dialectical relationship throughout the life
Psychoanalysts and dynamic therapists cycle. Blatt (1992; Blatt and Ford 1994; Blatt et
who treat personality disorders today must al. 2007) has stressed that character pathol-
be biologically informed (Gabbard 2001). ogy often divides into two broad subgroups:
There is now abundant evidence that some anaclitic and introjective. The anaclitic type is
personality traits are heritable (Cloninger et mainly concerned with relationships with
al. 1993; Livesley et al. 1993; Svrakic et al. others, and these individuals have longings
199 3) . T h e p syc hob iologica l mo de l of to be nurtured, protected, and loved. The in-
Cloninger et al. (1993), for example, suggests trojective subtype, on the other hand, is pri-
that about 50% of personality is genetically marily focused on self-development, and
based temperament, whereas another 50% is these individuals struggle with feelings of
environmentally based character. These in- unworthiness, failure, and inferiority. They
vestigators stressed that the character vari- are highly self-critical, exceedingly perfec-
ables, based on interactions with family tionistic, and competitive.
members and peer groups, traumatic experi- Because the work of psychoanalysis is
ences, intrapsychic fantasy, and the cultural heavily influenced by transference and coun-
setting in which one develops, are highly in- tertransference developments in the treat-
fluential in determining the subtype of per- ment process, psychoanalytic clinicians tend
sonality disorder. Although not everyone to place a great deal of emphasis on how the
Psychoanalysis and Psychodynamic Psychotherapy 187
patients internal object relations are exter- choanalysts and psychodynamic therapists
nalized in interpersonal relationships with understand the clinical setting as one in
others. The psychoanalytic setting is seen as which patients attempt to re-create their in-
a laboratory in which analysts can directly ternal object relationships through the exter-
observe how their patients re-create their in- nalization of these relatedness patterns
ternal object world in the relationships they formed in childhood.
forge in the course of their daily lives. Hence, The wish-fulfilling nature of actualizing
psychoanalytically oriented therapists tend internal object relationships is clear in the ex-
to conceptualize the nature of the patients ample of an internal self wishing to be loved
psychopathology less in terms of DSM-IV-TR and admired by an internal object. The wish
(American Psychiatric Association 2000) cri- is less apparent in those patients who estab-
teria and more in terms of what unfolds in lish one conflictual and self-defeating rela-
the treatment relationship (Gabbard 1997a, tionship after another. However, even a
2001, 2007). bad or tormenting object may provide
The character dimension of personality is safety and affirmation to a patient for a vari-
usefully conceptualized as involving an on- ety of reasons (Gabbard 2001; Sandler 1981).
going attempt to actualize certain patterns of For abused children, for example, an abusive
relatedness that largely reflect unconscious relationship may be safe in the sense that it is
wishes. Through interpersonal behavior, pa- preferable to having no object at all or to be-
tients try to impose on the clinician a particu- ing abandoned. A basic paradoxical situation
lar way of responding and experiencing. arises in the lives of abused children, where
Character traits, therefore, must be viewed as the person to whom they look for safety and
playing a fundamental role in actualizing an protection is also the abuser. They may have
internal object relationship that is central to a no alternative, then, but to seek safety in the
wish-fulfilling fantasy in the patient (Sandler shadow of one who has abused them. They
1981). The key to understanding the patients may also assume that the only way of re-
relationships outside the treatment, then, maining connected to a significant figure of
may be the observation of what develops in safety is to maintain an abuservictim para-
the transference-countertransference dimen- digm in the relationship. These relationships
sions of the treatment process. may be sought out by patients who were
Developmental themes are at the heart of abused as children because they are reliable,
all psychoanalytic theories. Part of the predictable, and provide the patient with an
conceptual model of personality disorders ongoing sense of continuity and meaning.
assumes that a child internalizes a self-rep- The devil one knows is generally perceived
resentation in interaction with an object rep- as better than the devil one does not know.
resentation connected by an affect state. If, Some of the repetitive relationship pat-
for example, a father repeatedly yells at his terns seen in patients with personality disor-
son, the child internalizes an object relations der are approximations of actual relation-
unit involving a critical, angry object, an in- ships these individuals had with real figures
adequate and beleaguered self, and an affect in the past. However, in some cases they in-
of shame and smoldering resentment. At volve wished-for relationships that never ac-
other times, when the father praises his son, tually existed. Patients with severe child-
the little boy may internalize a loving and ad- hood trauma, for example, often develop
miring object, a good and praiseworthy self, elaborate fantasies about a rescuer who will
and an affect state of glowing self-regard. save them from abuse.
These interactions are etched in neural net- The mode of actualization within the
works and become repetitive patterns of re- clinical relationship is often referred to as
latedness (Westen and Gabbard 2002). Psy- projective identification (Gabbard 1995; Ogden
1979). Within this model, patients behave in a inations, he could have the fantasy of
characterologically driven way that exerts making his dad and his analyst suffer.
interpersonal pressure on the therapist to Eventually the analyst was also able to
point out to Mr. J that his graduate stu-
conform to what is being projected onto him
dent advisor, another male about the
or her. In other words, a patient may nudge age of his father, was also part of this
the analyst into assuming the role of an same pattern of relatedness. Through
abuser in response to the patients victim interpretation, the analyst made the pa-
role. A patient who treats the therapist with tient aware that he had placed this pa-
contempt, for example, may engender coun- ternal figure in the same role as his fa-
tertransference anger or hate and lead the ther and his analyst.
therapist to make sarcastic or devaluing
comments to the patient. In this model the patients self-represen-
tation can elicit a corresponding object repre-
sentation in the analyst. This model of charac-
Case Example
ter is closely related to the role relationship
Mr. J was a 24-year-old graduate stu-
model of Horowitz (1988, 1991, 1998). In his
dent who was struggling in his aca- theory, a persons schemas reflect uncon-
demic setting because he appeared to be scious selfother organizational units. These
threatened by success. He had all of the units are driven by powerful internal motives
primary symptoms of obsessive-com- that lead away from feared outcomes and to-
pulsive personality disorder (OCPD), ward desired ends. Another way to view these
and his highly perfectionistic expecta- schemas is as belief structures that have both
tions of himself led him to feel that he
form and content. They are often character-
was always failing. In the course of
analysis, he talked at great length about ized, however, by conflicting desires and be-
what a harsh taskmaster his father had liefs that become expressed in the transfer-
been and how he was never able to live ence relationship with the analyst.
up to what his father expected of him. In addition to the development of self in
Eventually this pattern emerged in the relation to objects in the formation of charac-
transference, when the patient revealed ter, psychoanalytically oriented therapists
that he feared that his analyst saw him
study the unique set of defense mechanisms
as a failure as well. He felt the analyst
was heavily invested in having him suc- found in each patient as a key to diagnostic
ceed in graduate school, and the patient understanding and treatment. Defenses ward
was feeling that he could not possibly off awareness of unpleasant affect states and
measure up to what his analyst ex- unacceptable aggressive or sexual wishes
pected. The analyst drew Mr. Js atten- and preserve a sense of self-esteem in the
tion to how he had re-created with the face of narcissistic vulnerability. They may
analyst the same relationship he had
also serve to ensure safety when one is feel-
w ith his father. The p atient co uld
readily see the co nnection, and he
ing threatened. A contemporary analytic
thanked the analyst for pointing it out. perspective, however, would recognize that
However, the analyst also recognized defense mechanisms do not merely change
that the patients deferential and ingra- the relationship between an emotional state
tiating quality was a reaction formation and an idea; they also influence the relation-
to a good deal of resentment about feel- ship between self and object (Vaillant and
ing driven by others to succeed. The an- Vaillant 1999). Patients may be able to man-
alyst thus interpreted that the patient
age unresolved conflicts with important fig-
had found a way to indirectly express
his resentment at both his analyst and ures in their lives or with old objects from the
his father by thwarting their perceived past that haunt them in the present through
ho p es fo r hi s s ucce ss in graduate the use of defenses. In patients with person-
school. By failing to pass his oral exam- ality disorder for whom relationship difficul-
ties are one of the major reasons for seeking patients recline on the analysts couch, al-
treatment, dynamic clinicians conceptualize though some prefer to sit for parts of the
defenses as embedded in relatedness. Vail- treatment when visual contact with the ana-
lant and Vaillant (1999) emphasized that the lyst is seen as necessary. The patient is asked
symptoms of patients with personality disor- to say whatever comes to mind in an effort to
der often are designed to cope with unbear- facilitate the process of free association. Pa-
able relationships or unbearable people, tients generally have difficulty saying what
whether in the present or in the past. comes to mind because of anxieties about
Psychoanalysts and psychodynamic what the analyst will think as well as shame
therapists view the specific constellation of about certain aspects of themselves that they
defenses that work in concert with character- find unacceptable.
istic patterns of object relations as having The difficulties encountered in lying on a
enormous importance for the diagnostic un- couch and saying whatever comes to mind
derstanding of the patient. For example, four or five times a week inevitably lead to
someone with OCPD would use defensive the development of transference and resis-
operations such as reaction formation, intel- tance, two of the major foci of psychoanalytic
lectualization, undoing, and isolation of af- treatment. Resistance is not simply the reluc-
fect (Gabbard 2000c). These defenses tone tance to say what comes to mind. It is also a
down powerful affect states so that the pa- manifestation of the patients unique defense
tient is not in danger of losing control. These mechanisms as they enter into the treatment
patients may be responsible, dutiful, and un- process. In other words, defenses are intra-
failingly courteous toward the analyst to be psychic mechanisms, but they become inter-
sure that no trace of aggression is revealed in personalized as resistances in the relationship
their clinical interactions. with the analyst (Gabbard 2000c). Resistance
The fifth component of charactercogni- also reveals significant internal object rela-
tive styleis intimately related to the pa- tionships. A contemporary view of resis-
tients characteristic defenses. Persons with tances would include the fact that they are
OCPD, for example, will come across as lack- forces that oppose the optimal state of con-
ing flexibility and spontaneity in their sciousness sought in analysis. In an ideal an-
thought processes because they are directed alytic process, patients develop a dual con-
toward the control of all affect states. They sciousness in which they relive certain
will also address every detail of a situation in experiences from their past in the transfer-
their pursuit of a perfect solution. Histrionic ence to the analyst while also reflecting on
personality disorder patients, on the other those experiences and being curious about
hand, have a cognitive style that is directly their meanings and origins (Friedman 1991).
linked to their excessive emotionality. Hence Psychoanalysts view resistances not sim-
they avoid detail and will give impressionis- ply as obstacles to be avoided but as a major
tic and global responses to questions that resource of significant information about pa-
flect the feel of a situation. These cognitive tients characteristic defensive operations
styles appear to be reasonably consistent and their deeply ingrained personality traits.
across personality types (Shapiro 1965). Analysts no longer spend most of their time
in an archeological search for buried relics
from the patients past. Contemporary ana-
MAJOR PRINCIPLES OF TECHNIQUE lysts focus more on the relationship between
analyst and patient as a privileged view of
Psychoanalysis is traditionally conducted in how the patients past has created certain
45- to 50-minute sessions four or five times a patterns of conflict and problematic object re-
week and may last for several years. Most lations in the present. In his 1914 paper, Re-
me mbe ring , Re pe atin g, an d Work ing - patients usual mode of object relatedness
Through, Freud (1914/1958) noted that outside the treatment situation. When the
what the patient cannot remember will be re- role being evoked by the patient is unfamil-
peated in action in the patients here-and- iar and distressing to the analyst, such as the
now behavior with the analyst, the original role of an abusive parent, some analysts may
meaning of the term acting-out. Hence the pa- feel that an alien force has taken them over,
tients characterological pattern of internal and their subjective experience may be some-
object relations and the conflicts about those thing along the lines of Im not behaving
relationships unfold in front of the analyst like myself (Gabbard 2001). If the wished-
without necessarily digging into childhood for interaction being actualized by the pa-
traumas to unlock hidden secrets. tient is that of an idealized parent who is nur-
While transference reflects the patients turing and understanding toward a needy
past experiences with similar figures, it also child, the analyst may feel quite comfortable
incorporates the real aspects of the analyst. in the role and be unaware of its counter-
Hence transference is now considered to be a transference origins. One of the key compo-
mixture of old relationships from the past nents of technique, then, is for the analyst to
and the new and real relationship with the clarify the nature of these unconscious rela-
analyst in the present. In other words, if an tional patterns, acknowledging that they are
analyst chooses to be aloof, silent, and emo- jointly created, and then make them under-
tionally remote, the patient may well de- standable to the patient. Transference-coun-
velop a transference to the analyst as a cold tertransference enactments may need to re-
and unfeeling figure. peat themselves a number of times before
As the patient repeats long-standing pat- they are apparent and can be interpreted to
terns of relatedness during the sessions, the the patient.
analyst is gradually drawn into a dance. Analysts listen to the development of
Through the process of projective identifica- themes in the associations of the patient. They
tion described earlier, the analyst is trans- carefully track patterns in the transference re-
formed into a transference object. Not all an- lationship that also emerge in narrative ac-
alysts will react in the same way, and the counts of the patients life in the present and
specific features of the analysts intrapsychic in the past. As recurrent themes emerge, they
world will work in concert with what is be- begin to make these unconscious patterns
ing projected by the patient to shape the more available to the patients conscious
unique form of the analysts countertransfer- awareness. A primary intervention is inter-
ence. Some analysts may ignore the role be- pretation, which seeks to make connections
ing thrust on them or reject it. Others may or linkages for the patient that are largely out-
defend against the role by assuming an op- side the patients awareness.
posite stance. Some analysts who are being Psychodynamic psychotherapy is based
pressured to take on the characteristics of a on the same principles of technique but is
projected abusive object, for example, may less focused on interpretation of transference
become overly kind and empathic as a reac- as the central intervention. Moreover, the fre-
tion formation to their growing feelings of quency of sessions (usually from one to three
sadism or anger. per week) is less intense and the patient sits
In any case, a key aspect of the psychoan- in a chair instead of reclining on a couch with
alytic treatment of patients with personality the analyst out of view. Depending on the na-
disorders is to maintain a free-floating re- ture of the psychopathology, some patients
sponsiveness (Sandler 1981) to what is being require more support, more visual contact
evoked by the patient and to use this re-cre- with the therapist, and less regression than
ated dance as a way of understanding the what occurs typically in analysis. Patients
with deficit-based pathology have often had patterns of relatedness in action and help the
extensive childhood deprivation or trauma. patient become aware of these patterns. A
They may hear interpretations as attacks and therapist may observe, for example, that the
feel shamed by them. In those situations, the patient looks ashamed whenever talking
therapist may need to use affirmative inter- about his mother and will thus point that out
ventions (Killingmo 1989) that confirm ex- to the patient. Fonagy (1999) stresses that a
actly the way the patient is feeling and em- crucial avenue for therapeutic change may
pathically validate the patients right to feel lie in a patients increasing capacity to find
that way. Many patients with this type of himself in the therapists mind. By consis-
background may ultimately be able to use in- tently observing and commenting on the pa-
terpretations if the way is paved for them by tients feeling states and nonverbal commu-
validating and affirming interventions (Gab- nications, the patient may begin to assemble
bard et al. 1994). a portrait of himself or herself based on the
The goals of the treatment vary according analysts observation and thereby develop
to the patients presenting complaints, the na- increased capacity for mentalization. Consis-
ture and severity of the psychopathology, and tent observations about the characterological
the clinician and analysts theoretical model. patterns of the patient also make ego-syn-
Among those goals that are commonly estab- tonic character traits more ego-dystonic as
lished are resolution of conflict (Brenner the patient recognizes the problematic as-
1976); a search for an authentic or true self, as pects of the traits as well as the interpersonal
Winnicott (1962) suggested; improved rela- impact that the traits have on others.
tionships as a result of a gain in understand- In all forms of psychoanalysis and psy-
ing about ones internal object relationships chodynamic psychotherapy, another source
(Gabbard 1996); an improved capacity to seek of therapeutic action is internalization of the
out appropriate selfobjects (Kohut 1984); the analyst or therapist and of the treatment re-
generation of new meanings within the ther- lationship. Internalizing does not necessarily
apeutic dialogue (Mitchell 1997); and an im- require the use of a conscious, declarative
proved capacity for mentalization (Fonagy representation. The clinical relationship itself
and Target 1996). (Selfobjects and mentalization is accompanied by unconscious affective
are defined and discussed later in the chap- connections that have been referred to by Ly-
ter.) Regardless of the diverse goals, all psy- ons-Ruth et al. (1998) as implicit relational
choanalytically oriented treatment probably knowing. This phenomenon refers to mo-
works through several modes of therapeutic ments of meeting between clinician and pa-
action, of which one is the provision of insight tient that are not symbolically represented or
through interpretation. dynamically unconscious in the ordinary
Another mode of therapeutic action is sense. Some change occurs in the realm of
simply making observations from an outside procedural knowledge involving how to act,
perspective on what one sees in the patient feel, and think in a particular relational con-
(Gabbard 1997b). Patients cannot know how text. As patients internalize the therapists
they come across to others because they are accepting and tolerant attitude, their super-
inside themselves. The therapist has the perego is also modified so they are less self-crit-
spective of an object and therefore can help ical and more accepting of their humanness.
them see things that they do not see. More- From a cognitive neuroscience perspec-
over, the how to of relatedness that is inter- tive, the internalization of the therapeutic
nalized in the earliest childhood relation- relationship gradually builds a new neural
ships is embedded in implicit procedural network with a different type of object repre-
memory (Gabbard and Westen 2003). Clini- sentation and a corresponding self-represen-
cians can see the automatic and unconscious tation. The old networks are not completely
obliterated by the treatment, but they are rel- Another feature that is necessary for
atively weakened or deactivated while the analysis or dynamic therapy is the capacity
new networks based on the treatment rela- to regress in the service of the ego. Patients
tionship are strengthened (Gabbard and must be able to let down their guard, relax
Westen 2003). their defenses, and get in touch with primi-
All of these techniques and modes of tive and unpleasant emotional states to learn
therapeutic action are adapted to the individ- about what drives them to behave or think in
ual patient and the type of personality disor- the way they do. They must also have high
der that most closely fits that patient. There is tolerance for frustration, intact reality test-
inevitably a trial-and-error component to ing, reasonably good impulse control, and
this approach as one finds out which types of enough suffering to motivate them for the
interventions are most suited to the patients treatment.
capacity to use psychoanalytically oriented Other signs of ego strength that make a
treatment. person a reasonable candidate for psycho-
analysis are the ability to sustain a job over a
long period of time despite encountering dif-
INDICATIONS AND ficulties and the capacity for enduring mean-
CONTRAINDICATIONS ingful relationships with others. Finally, the
presence of the capacity for mentalization
In determining for whom psychoanalysis based on secure attachment also is a positive
and/or psychodynamic psychotherapy is in- sign for analyzability. Mentalization refers to
dicated, two separate but related perspec- ones ability to differentiate inner from outer
tives are necessary: 1) suitability according states and to recognize that ones perceptions
to the psychological characteristics of the pa- are only representations rather than accurate
tient, and 2) suitability according to diag- replicas of external reality. In other words,
noses. Regardless of whether a patient meets the patient is aware that his or her own and
diagnostic criteria for a specific personality other peoples ways of viewing the world are
disorder, the patients psychological features influenced by inner beliefs, feelings, and past
may contraindicate the use of psychoanaly- experiences. This capacity may be present to
sis or dynamic therapy. a greater or lesser extent and exists on a con-
The indications and contraindications for tinuum that is influenced by the nature of the
psychoanalysis and psychodynamic psycho- relationship and the patients early experi-
therapy according to personality disorder ence. Some patients with impaired mental-
are summarized in Table 101. ization may nevertheless be amenable to
Foremost among the psychological char- psychoanalysis and psychodynamic psycho-
acteristics necessary to recommend psychotherapy (Fonagy 2001).
analytically oriented treatment is psycholog- Patients in a severe life crisis are rarely
ical mindedness. Although there are various suited for psychoanalytically oriented treat-
components to this construct, the key comment, although it may ultimately be appropri-
ponents are the capacity to see meaningful ate after the crisis is over. Other contraindica-
connections between ones difficulties and tions are poor reality testing, poor impulse
ones inner world. The capacity to think in control, lack of psychological mindedness, lit-
terms of analogy and metaphor is also crucial tle capacity for self-observation, cognitive im-
to psychological mindedness. In addition, pairment based on neurological dysfunction,
there must be a curiosity about the origins of extreme concreteness, and poor frustration
ones suffering and a strong motivation to tolerance (Gabbard 2004). These guidelines
endure anxiety and discomfort in the process are helpful in assessing analyzability, but ana-
of learning more about oneself. lysts recognize that they must retain a certain
Table 101. Indications and contraindications for psychoanalysis and psychodynamic

psychotherapy according to personality disorder diagnosis
Diagnosis Suitability for psychoanalytically oriented treatment
Paranoid personality disorder Rarely indicated

Schizoid personality disorder May be indicated in exceptional circumstances
Schizotypal personality Contraindicated
disorder
Borderline personality Psychodynamic psychotherapy, particularly transference-
disorder focused psychotherapy and mentalization-based therapy,
are efficacious
Narcissistic personality Strong indication for psychoanalysis or psychodynamic
disorder psychotherapy
Antisocial personality disorder Contraindicated
Histrionic/hysterical Strongly indicated for hysterical personality disorders and
personality disorders for most patients with histrionic personality disorder
Obsessive-compulsive Strong indication for psychoanalysis or psychodynamic
personality disorder psychotherapy
Avoidant personality disorder Indicated for cases that do not respond to brief cognitive-
behavioral or behavior therapy treatments
Dependent personality Likely to do well in psychoanalysis if motivation is sufficient
disorder and usually responds well to psychodynamic therapy
Masochistic or self-defeating Strong indication for psychoanalysis or dynamic therapy
personality disorder
degree of humility because prediction of how sonality disorders, clinicians must rely on
a particular patient will do in the psychoana- clinical wisdom and the psychological charac-
lytic process is less than perfect. Kantrowitz teristics favoring analyzability described
(1987), in a study of 22 patients in analysis, above. Moreover, the presence of various co-
concluded that even with highly sophisti- morbid conditions on Axis I, such as affective
cated psychological testing, clinicians cannot disorder, anxiety disorder, eating disorder, or
reliably predict who will do well in psycho- substance abuse, may complicate psychoana-
analysis. The following sections describe the lytic treatment even if the personality disor-
indications and contraindications for psycho- der itself is likely to be amenable to this ap-
analysis in patients with specific personality proach. As a general principle, the Cluster C
disorders. personality disorders appear to be amenable
Determining the appropriateness of psy- to dynamic therapy or psychoanalysis. Only a
choanalysis or psychodynamic therapy is also very small subgroup of patients with Cluster
influenced by ones diagnostic understanding A personality disorders are likely to respond
of the personality disorder, but this method, well to psychoanalytic efforts. Those patients
too, is imperfect in predicting outcomes. In with Cluster B personality disorders respond
the absence of randomized controlled trials of variably, depending on the diagnosis and the
psychoanalytic treatment for the various per- psychological characteristics.
Paranoid Personality Disorder borderline personality disorder. Problems of

impulsivity and difficulties in maintaining a
In a study of 100 patients who applied for therapeutic alliance make psychoanalytic
psychoanalysis at the Columbia Psychoana- treatment extremely challenging for patients
lytic Center, Oldham and Skodol (1994) in this category. There are reports in the liter-
noted that 12 met research criteria for the di- ature (Abend et al. 1983; Boyer 1977; Fonagy
agnosis of paranoid personality disorder. Of and Target 1996; Gabbard 1991) of patients
those, only four were selected for analysis, with borderline pathology who were ana-
and two of the four did not finish the analytic lyzed using the couch with somewhat modi-
treatment. Their data suggested that most fied forms of psychoanalytic technique. Bor-
patients with paranoid personality disorder derline patients who can use an analytic
are not suited, but for a very small number process represent a very small subgroup and
with exceptional characteristics analysis may are probably closer to the Kernberg construct
be worth a try. In general, paranoid patients of borderline personality organization
do not have sufficient trust to allow for the (Kernberg 1975) than a DSM-IV-TR border-
development of an analytic process. line personality disorder. These patients are
often conceptualized as part of the widen-
Schizoid and Schizotypal ing scope of psychoanalysis and generally
Personality Disorders require supportive interventions to make in-
terpretation acceptable to the patient (Hor-
Schizotypal personality disorder is thought
witz et al. 1996). Both mentalization-based
to be genetically linked with schizophrenia,
therapy (MBT) (Bateman and Fonagy 1999,
and patients with schizotypal personality
2001, 2008) and transference-focused psy-
disorder are rarely, if ever, suitable for psy-
chotherapy (TFP) (Clarkin et al. 2007) have
choanalysis or psychodynamic therapy. Pa-
been demonstrated efficacious in random-
tients with schizoid personality disorder, on
ized controlled trials.
the other hand, may in some cases be appro-
priate for analytically oriented treatment but
rarely seek it. In the study by Oldham and Narcissistic Personality Disorder
Skodol (1994), only one person applying for
Most experts in the treatment of narcissistic
psychoanalysis was diagnosed with schizoid
personality disorder agree that psychoanaly-
personality disorder. The British psychoana-
sis is the treatment of choice if the patient has
lytic literature suggests that there may be a
the psychological and financial resources to
small number of patients who can be reached
undertake a commitment to psychoanalysis.
by psychoanalytic approaches, and a num-
Although the treatments are long and ardu-
ber of British analysts have reported on work
ous, sometimes nothing short of this in-
with these patients (Balint 1979; Fairbairn
depth approach will touch a patient. In prac-
1954; Winnicott 1963/1965).
tice, many narcissistic patients are treated
with psychodynamic psychotherapy, and
Borderline Personality Disorder
clinical experience suggests that they may re-
After surveying the entire literature on the spond favorably if motivated. A frequent
treatment of borderline personality disorder, challenge in working with patients with nar-
the American Psychiatric Association prac- cissistic personality disorder is the common
tice guideline concluded that psychother- pattern of exaggerated self-importance, com-
apy, rather than psychoanalysis, in concert bined with devaluation of others, frequently
with medication, is probably the treatment of leading to counter-transference reactions in
choice for the great majority of patients with the therapist.
Case Example ject relations, and an intact superego. There-

fore, they are considered good candidates for
A patient with narcissistic personality dis- psychoanalysis or psychodynamic psycho-
order had been in psychodynamic psy- therapy. Those patients on the other end of
chotherapy for 5 weeks with a young ther-
the spectrum with histrionic personality dis-
apist in training. The patient began one
session by complaining about the thera- order may require modified versions of psy-
pists relative youth. He asserted that the choanalytic psychotherapy because they of-
therapist seemed to be a beginner who ten cannot tolerate the intense affective states
probably did not know what he was dothat are brought about in analytic treatment.
ing. Am I your first therapy case? he Some histrionic patients, however, appear to
taunted. The candidate replied, What
makes you ask that? The patient laughed
be able to make use of psychoanalysis and
and said, Ill bet your supervisor told you dynamic therapy.
not to answer my questions, right? The
candidate, feeling he was being treated
with contempt, became defensive and
Obsessive-Compulsive
said, No, Im able to think for myself. Personality Disorder
The patient responded with further con-
tempt, I dont see much evidence of Patients with OCPD, who must be differenti-
that. Without considering the potential ated from those with obsessive-compulsive
consequences of his comment, the thera- disorder, are generally good candidates for
pist blurted out, Maybe youre too busy
psychoanalytically oriented treatments.
insulting me to notice. As soon as the
words came out of his mouth, the thera- While there are no data from rigorously con-
pist felt a deep sense of shame. He had al- trolled trials on the efficacy of psychoanaly-
lowed himself to be nudged into sarcasm sis, psychodynamic therapy has been shown
by the patients contempt. to be useful in Cluster C personality disor-
ders, including OCPD (Svartberg et al. 2004).
Antisocial Personality Disorder
Because of lack of motivation, insufficient su- Avoidant and Dependent
perego development, general dishonesty, Personality Disorder
and impulsivity, patients with antisocial per-
sonality disorder represent a contraindica- Some patients with avoidant personality dis-
tion to psychoanalysis or psychodynamic order appear to respond well to behavioral
psychotherapy. or cognitive-behavioral techniques (Alden
1989; Brown et al. 1995; Stravynski et al.
Histrionic and Hysterical 1982). However, when patients do not re-
spond to brief behav ioral or cognitive-
behavioral treatments for avoidant personal-
The DSM-IV-TR construct of histrionic per- ity disorder, they may do well in analysis or
sonality disorder represents a particular type psychodynamic psychotherapy, particularly
of patient with personality disorder who is if they are motivated to understand the ori-
very close to the borderline diagnosis. In gins of their anxieties about intimate rela-
clinical practice, one frequently encounters a tionships with others.
higher level of histrionic personality disor- Patients with dependent personality dis-
der that has traditionally been referred to as order may do well in either psychoanalysis
hysterical personality disorder (Gabbard or psychodynamic psychotherapy depend-
2000c). These patients represent a neuroti- ing on their psychological mindedness, the
cally organized individual with reasonably extent of their suffering, and their motivation
good impulse control, mature triangular ob- to change and understand themselves.
Masochistic or Self-Defeating our understanding of patients with schizoid

Personality Disorder personality disorder, viewed the schizoid
retreat from object relations as a defense
Although not in the official DSM-IV-TR no- against a conflict between a wish to relate to
menclature, patients with predominantly others and a fear that ones neediness would
self-defeating or masochistic symptom pat- harm others. The child who initially per-
terns are widely seen in clinical practice. For ceives its mother as rejecting may withdraw
most of these patients, psychoanalysis or dy- from the world; however, the infants greed
namic therapy is the treatment of choice, pro- and neediness grow until they are experi-
vided they have the psychological character- enced as insatiable. The child then fears that
istics necessary for the treatment. its greed will devour the mother, resulting in
her disappearance. Relationships are experi-
enced as dangerous and to be avoided.
PSYCHOANALYTIC APPROACHES TO The clinician who endeavors to treat pa-
SPECIFIC PERSONALITY DISORDERS tients with schizoid personality disorder
must recognize that their fear of relation-
As noted above, the psychoanalytically ori- ships will manifest itself in the transference
ented therapists technique needs to be tai- and allow the patient the opportunity to re-
lored to the specific type of personality dis- treat without making demands for more ac-
order. Although most personality disorders tive participation. Winnicott (1963/1965) be-
are mixed, in that they have traits of several lieved that the isolation of the patients with
different personality disorders, here we con- schizoid personality disorder preserves an
sider each of the personality disorders ame- important authenticity that is absolutely sa-
nable to psychoanalysis and psychodynamic cred to the evolving self of the patient: There
psychotherapy in its pure form for the sake is an intermediate stage in healthy develop-
of clarity. In actual practice, several technical ment in which the patients most important
approaches may need to be combined for pa- experience in relation to the good or poten-
tients who have different personality fea- tially satisfying object is the refusal of it
tures in mixed personality disorder. The dis- (p. 182). Hence the therapist must recognize
cussion here is confined to those personality that the schizoid withdrawal is a way to com-
disorders that are likely to benefit from psy- municate with the true self within the pa-
choanalysis or psychodynamic psychother- tient instead of sacrificing that authenticity
apy approaches at least some of the time. to artificial interactions with others, includ-
ing the analyst, that would lead to a false
self adaptation.
Schizoid Personality Disorder
Although patients with schizoid person-
Much of our understanding of the inner ality disorder do not commonly seek help
world of a patient with schizoid personality from a psychoanalytically oriented therapist,
disorder derives from the work of the British when they do, the therapist must provide the
object relations theorists. Balint (1979) patient with a holding environment in which
viewed these patients as having a fundamen- their frozen internal object relations will
tal deficit in their ability to relatea basic eventually thaw through the provision of a
fault caused by significant inadequacies in new experience of relatedness. The goal of
the mothering they received as infants. He the psychoanalytic approach, then, is more to
believed that the patients difficulty in relat- provide a new relationship for internaliza-
ing to others stems from this basic incapacity tion than to interpret unconscious conflict.
rather than from neurotic conflict. Fairbairn Extraordinary patience is required for the
(1954), perhaps the foremost contributor to treatment to take effect, and the patient must
be allowed to go at his or her own pace. Ther- from being locked into the reality of one ex-
apists must recognize that their own agenda clusive view. In the MBT technique the focus
for change may get in the way of the patients is mainly on the patients current state of
timetable for venturing out into a world of mind. Transference interpretations that em-
potentially dangerous relationships. phasize genetic reconstructions are generally
not used. This approach stresses mentaliz-
Borderline Personality Disorder ing the transference. In other words, trans-
ference provides an opportunity to explore
Borderline personality disorder has a greater how the mind works with the therapists as-
research base than other personality disor- sistance. The therapist encourages the pa-
ders regarding the efficacy of psychodynamic tient to think about the present relationship
psychotherapy. As noted earlier, both MBT with the therapist in the same way that other
and TFP have demonstrated efficacy in ran- relationships are considered. Another mind
domized controlled trials. is in the room with the patient, so that the pa-
Mentalizing is defined as an understand- tients view can be contrasted with the ther-
ing that other peoples perceptions and be- apists view. The transference is used to dem-
havior are related to their thoughts, wishes, onstrate how the same behavior may be
feelings, and desires. In other words, they experienced differently and thought about
have a mind that interprets reality based on differently by two different minds.
who they areperceptions are not absolute Bateman and Fonagy (1999, 2001, 2008)
truths, but impressions. This capacity varies tested MBT in a randomized controlled trial
considerably from person to person. Bate- in which 38 patients with borderline person-
man and Fonagy (2004) base their MBT tech- ality disorder were randomly assigned to a
nique on the observation that patients with psychoanalytically oriented partial hospital
borderline personality disorder have a frag- program or to a control group. The partial
ile mentalizing capacity that is vulenerable to hospitalization condition (treatment group)
interpersonal and social interactions. This consisted of once-weekly individual psycho-
difficulty relates to the patients insecure ca- analytic psychotherapy, thrice-weekly group
pacity for attachment, which in turn can be psychotherapy, once-weekly expressive ther-
linked to the insecure attachment to the care- apy informed by psychodrama techniques, a
giver during childhood. As a result, the at- weekly community meeting, regular meet-
tachment context of psychotherapy is essen- ings with the case coordinator, and medica-
tial to improve ones capacity for mentalizing. tion review by a resident psychiatrist. The
As one builds a solid therapeutic alliance with control treatment consisted of regular psy-
the therapist, one is also building a secure at- chiatric review an average of two times per
tachment base. month with a senior psychiatrist, inpatient
The MBT therapist spends a good deal of admission as appropriate, outpatient and
time during psychotherapy sessions on community follow-up, no psychotherapy,
drawing the patients attention to the pa- and medication similar to that received by
tients mental states. By systematically ex- the treatment group.
ploring what it is the patient feels from mo- At 18-month follow-up, the investigators
ment to moment, the therapist helps build a found a clear reduction in the proportion of
sense of self in the patient. The dyadic nature the treatment groups patients who had at-
of psychotherapy provides the opportunity tempted suicide in the previous 6 months.
to generate multiple perspectives on situa- The average length of hospitalization in-
tions that may seem absolute. The therapist creased dramatically in the control group
repeatedly re-presents the patients subjec- durin g th e last 6 mont hs of th e stu dy,
tive experience in a way that frees the patient whereas it remained stable in the treatment
group at around 4 days per 6 months. Self- domains to an approximately equivalent ex-
reported state and trait anxiety both de- tent. In certain areas, though, TFP seemed to
creased substantially in the treatment group do better than the alternative treatments. It
but remained unchanged in the control was associated with significant improvement
group. Depression scores also decreased sig- in 10 of the 12 variables across the six symp-
nificantly in the treatment group. Five years tom domains, compared with improvement
after discharge from MBT, the treatment in six variables with SP and five with DBT.
group continued to show clinical and statis- Only TFP resulted in significant changes in
tical superiority to the control group. impulsivity, irritability, verbal assault, and di-
TFP was developed by Otto Kernberg, rect assault. Both TFP and DBT did better
John Clarkin, and their colleagues at New than SP in reducing suicidality. TFP also
York Presbyterian HospitalCornell Medi- brought about a move from an insecure at-
cal Center, Westchester Division (Clarkin et tachment classification to a secure one (Levy
al. 2007). It is based on an object relations et al. 2006), a change not seen with the other
model of borde rline psy chopathology. two treatments. In addition, the TFP patients
Hence TFP emphasizes representations of showed significantly greater changes in men-
self and others and how they are activated talizing capacity and in narrative coherence
with the therapist and with others in signifi- compared with those in other groups.
cant relationships outside the therapy. Affect The research on borderline personality
states connected with internal representa- disorder suggests that more than one ap-
tions of self and others are also a major focus proach may be effective. Hence the clinician
of the treatment. Controlling negative affect must tailor the therapeutic approach to the
states by understanding their origins is cen- particular patient (Gunderson 2001; Gunder-
tral to the treatment. In addition, the thera- son and Links 2008). Some patients, for exam-
pist hopes to awaken positive affect, particu- ple, may find transference work disturbing
larly through the protection of positive and will prefer a focus on outside relation-
attachments to others. TFP establishes a con- ships or the acquisition of coping skills.
tract regarding the expectations of the pa-
tient, the therapist, and the treatment. The Narcissistic Personality Disorder
therapist thus sets a frame designed to con-
trol destructive behavior and systematically The technical approaches to narcissistic per-
examines patterns of relationships to others sonality disorder tend to diverge along a di-
in the therapeutic relationship itself and in viding line marked by whether the clinician
outside relationships. In contrast to MBT, views the pathology as based on deficit, ac-
TFP therapists interpret aggression in the cording to the self psychology of Kohut
transference relationship and link it to its ge- (1971), or as related to conflict, as described
netic and intrapsychic origins. by Kernberg (1974a, 1974b, 1984). The differ-
TFP has been tested in a randomized con- ences between the two approaches are sum-
trolled trial involving 90 patients with bor- marized in Table 102.
derline personality disorder who were ran- Kohuts approach to the psychoanalysis
domly assigned to one of three treatment of narcissistic personality disorders used em-
groups: 1) TFP, 2) dialectical behavior therapy pathy as the cornerstone of the technique
(DBT), or 3) supportive psychotherapy (SP). (Ornstein 1974, 1998). Kohut stressed the
Six domains of outcome measures were as- need to empathize with the patients experi-
sessed at 4-month intervals over a 12-month ences of having numerous empathic failures
period by raters who were blind to treatment at the hands of parents. In this regard, he
group. All three treatments appeared to have advised analysts to accept the patients com-
brought about positive change in multiple ments in a straight manner, just as the pa-
Table 102. Techniques for treating narcissistic personality disorders: Kohut versus
Kernberg
Kohut Kernberg
Views mirror and idealizing transferences Views mirror and idealizing as aspects of
as two different poles of bipolar (Kohut transference related to projection and
1977) or tripolar (Kohut 1984) self reintrojection of patients grandiose self
Accepts idealization of patient as normal Interprets idealization as a defense
developmental need
Empathizes with patients feeling as an Helps patient see his or her own contribution
understandable reaction to failures of to problems in relationships
parents and others
Accepts patients comments at face value, Confronts and interprets resistances as
viewing resistances as healthy psychic defensive maneuvers
activities that safeguard the self
Looks at the positive side of patients Examines both positive and negative aspects
experience of patients experience (if only positive
experiences are emphasized, the patient
may develop an increased fear of internal
envy and rage)
Calls attention to patients progress Focuses on envy and how it prevents patient
from acknowledging and receiving help
Has treatment goal of helping patient Has treatment goal of helping patient to
acquire ability to identify and seek out develop guilt and concern and to integrate
appropriate selfobjects idealization and trust with rage and
contempt
Source. Based on Gabbard 2000c.
tient experiences them, rather than to inter- transferences typical of narcissistic personal-
pret hidden meanings (Miller 1985). Kohut ity disorders. The analysis of those transfer-
would accept this idealizing transference as a ences is the major part of the technical ap-
normal developmental need rather than in- proach. Kohut also strongly endorsed calling
terpreting what might lie beneath it. He attention to the positive aspects of the pa-
viewed the mirror and idealizing transfer- tients experience to avoid shaming or criti-
ences as the major developments in the anal- cizing the patient and repeating the traumas
ysis of narcissistic personality disorder. The of childhood. He would not hesitate to call
mirror transference is an effort on the patients attention to the patients progress. The goal
part to capture the gleam in mothers eye of the analysis was to help the patient acquire
by trying to impress the analyst. Sensitive to more appropriate and mature selfobjects
the patients potential for self-fragmentation, with the full recognition that the patient
Kohut would empathize with the patients could not possibly outgrow the need for self-
need to be affirmed and validated. object responses, such as idealization, affir-
Kohut (1984) later postulated a third mation, and validation.
transference, the twinship transference. All Kernbergs (1974a, 1974b) approach dif-
three of these were regarded as the selfobject fers in that he sees the patients grandiose
self as a highly pathological and conflict- riety of narcissistic personality disorder (Gab-
based solution that is not to be regarded as bard 2000c), they feel coerced into focusing
simply an arrested development of the nor- their attention completely on the patient dur-
mal self. He regards idealization as a defense ing every moment of the session, and they
against rage, contempt, and envy, and he ad- may feel controlled into meeting the patients
vocates active interpretation of idealization. unrealistic expectations of perfect attune-
In general, Kernbergs approach is more con- ment. If they fall short, they risk an explosion
frontational than Kohuts, and he stresses the of narcissistic rage by a patient who sees a
patients greed and demandingness rather slight around every corner. Narcissistic pa-
than his or her longings for affirmation. He tients may erupt with barrages of contempt
also focuses to a greater extent on envy and and hatred when they feel they have not been
how it prevents the patient from acknowl- given the attention they are due.
edging and receiving help. Whereas Kohut
views resistances as healthy psychic activi- Hysterical/Histrionic
ties designed to safeguard the self, Kernberg Personality Disorders
confronts and interprets resistances as defen-
sive maneuvers. He would see the goal of Patients with hysterical personality disorder
psychoanalysis as much broader than Ko- (i.e., the higher-functioning patients within
huts. He would hope that the patient would the histrionic personality disorder rubric)
develop a greater sense of guilt and concern generally are ideally suited for psychoanaly-
while integrating idealization and trust with sis and psychoanalytic therapy. They have
rage and contempt. internalized conflicts about relationships
In actual practice, many psychoanalysts that can be examined in a solid therapeutic
and dynamic therapists use elements of both alliance with the analyst. They are generally
Kernberg and Kohut in their approach to committed to change and to improving their
narcissistic patients. An empathic perspec- chronic difficulties in forming intimate rela-
tive, as described by Kohut, is often extremely tionships. The analyst may need to focus ini-
helpful early in the treatment to form a thera- tially on the global and impressionistic cog-
peutic alliance with the patient so that the pa- nitive style that prevents these patients from
tient is willing to explore his or her inner reflecting in detail on what is happening in-
world. Over time, patients often are more ca- side. Their displays of emotionality can be
pable of responding to interpretation and highly appealing and lead the analyst to feel
confrontation when they feel a stable rela- a sense of obligation to rescue the patient.
tionship has been established with the ana- Nevertheless, for the analyst to be useful, the
lyst. Both Kohut and Kernberg identify valid patient first needs to provide more details of
aspects of narcissistic pathology, but differ- the situations that create distress.
ent types of narcissistic patients require dif- Superficial and shallow feelings may de-
ferent emphases. fend against more disturbing and more
Regardless of which technical strategy is deeply experienced affects. Patients may need
chosen, clinicians treating narcissistic pa- assistance in identifying their true feelings
tients encounter formidable countertransfer- and the thoughts and events linked to them.
ence difficulties. They often have a sense that They often feel buffeted by powerful feeling
they are being used as a sounding board states and by external events. The analyst can
rather than a person with a separate internal help them to identify patterns in their lives
world. They may need to tolerate long peri- that lead to particular types of emotional re-
ods in which they feel they are peripheral to sponses. Horowitz (1977) pointed out that
the narcissistic patients associations. They these patients start to develop new patterns of
may also note that with the hypervigilant va- perceiving relationships when they attend in
more detail to themselves and others in their these patients tend to use primitive defenses;
personal context. The analyst helps them see in addition, they have overwhelming separa-
how they play an active role in perpetuating tion anxiety and a lax superego. Some may
certain patterns of relating to others. They de- be able to tolerate the frustration of the ana-
velop a capacity to compare the actual facts lytic setting if they have high intelligence,
in an interpersonal situation with the inter- some degree of impulse control, and an abil-
nal patterns they superimpose on external ity to mentalize. However, many of these pa-
situations. tients have much in common with patients
Hysterical patients generally work well who have borderline personality disorder
within the transference and use it as a primary and lack the requisite ego strengths to toler-
vehicle for change. They may see the solution ate the process. If they are motivated to per-
to their problem as simple identification with severe in psychodynamic psychotherapy,
the analyst, and the analyst needs to confront much of what applies to the technique re-
the wish to bypass painful self-examination in quired with hysterical patients also applies
the service of identification with the analyst. to histrionic patients. However, they will re-
They also may fall in love with the analyst and quire more ego support and greater post-
feel that a loving relationship is in itself cura- ponement of interpretation to be effectively
tive. However, the transference love needs to treated.
be carefully deconstructed in terms of its mul-
tiple meanings. It functions not only as a resis- Obsessive-Compulsive
tance to a deepening of the analytic process
Personality Disorder
but also as an indirect expression of aggres-
sion, because it may create a frustrating situa- Patients with OCPD are generally well
tion for both analyst and patient. Hysterical suited for psychoanalysis or psychodynamic
patients often find themselves in triangular psychotherapy, but they must first overcome
relationships in which they constantly repeat their anxieties about being out of control.
an oedipal romance that places them in the Spontaneity and free association present
role of the excluded party. This pattern of them with a situation in which they must be
longing for an unavailable romantic partner open and drop their guard. Most obsessive-
deserves a good deal of scrutiny in the course compulsive individuals have a host of rigid
of the analysis, as it often reveals conflicts defenses to avoid spontaneity so they can
about truly separating from parents and avoid loss of control. Hence they will use re-
establishing a life with a partner outside the sistances that reflect defensive operations
family unit. Women with hysterical person- such as isolation of affect, intellectualization,
ality disorder are often Daddys girls, and reaction formation. The clinician may
whereas men with the diagnosis are often need to confront the tendency to use factual
called Mamas boys. This attachment to the information as a way of avoiding emotional
opposite-sex parent may keep them in a state expression in the analysis.
of extended adolescence that prevents them OCPD patients may also attempt to be
from coming fully into their own. The analyst perfect, saying exactly the right thing and
must systemically analyze their loyalty con- thereby pleasing the analyst or therapist.
flicts of this nature. This wish to please may be a reaction forma-
Those patients with histrionic personal- tion against hostility about the power differ-
ity disorder proper (i.e., the more disturbed ential inherent in the analytic setting, the
variant within this category) may need a time constraints, and the fee. The analyst
form of dynamic therapy that includes con- carefully analyzes elements of hostility and
siderable support. Although many of the dy- resentment and tries to bring them into the
namics relate to the hysterical configuration, patients awareness when possible.
Moreover, patients with OCPD are driven tion is more accurate. Therapists need to be
by harsh superego pressures, and they fre- prepared to interpret this process (rather than
quently externalize that superego onto the enact it repeatedly) through the systematic in-
analyst. They assume the therapist will react terpretation of the rivalry. Obsessive-compul-
with disapproval and criticism to any expressive patients will then begin to recognize
sions of sexuality or aggression, and the ther- traces of sibling and oedipal rivalries of the
apist must interpret those fears as they past in contemporary relationships and will
emerge as resistances to being open with the gain understanding of how these rivalries in-
therapist about what is happening in their terfere with harmonious intimate relation-
lives and in their internal affective life. As the ships.
therapist conveys a sense of acceptance and
tolerance, the patient gradually enters into a Avoidant Personality Disorder
process of self-acceptance so that the super-
ego is modified in the course of the analytic Patients with avoidant personality disorder
treatment. may be reluctant to seek help because the
Another major thrust in the treatment of therapeutic relationship presents the same
these patients is helping them see that their threats as other intimate relationships. They
compromise formations against aggression are prone to feeling shame, embarrassment,
generally do not work. As they describe inter- and humiliation associated with exposure.
actions with coworkers or intimate family Shame is etymologically derived from the
members, the therapist needs to observe verb to hide (Nathanson 1987), and the
problematic patterns of relationships in avoidant patient often withdraws from inter-
which the patient tries to avoid any implica- personal relationships and situations of ex-
tions of anger. The analyst or therapist points posure out of a wish to hide out from the
out how their reaction formation against an- highly unpleasant affect of shame. Hence,
ger is imperfect, in that others sense the hos- when they come to treatment, avoidant pa-
tility and resentment below the surface, no tients may hide out from the treater and
matter how defended they are in their efforts try to avoid discussions of their fears.
to conceal anger. Part of the work also focuses This form of resistance, of course, is the
on helping the patient realize the futility of crux of the treatment. The therapist needs to
pursuing perfection. As self-acceptance in- patiently explore what it is that the patient
creases, expectations can be lowered and the fears from engaging the therapist in sharing
patient can understand that the perfectionis- his or her anxieties and fantasies. What does
tic ideals come from long-standing feelings of the patient imagine the therapist will think
being unloved as a child and no longer ad- about the patients fears? Initially, this explo-
dress the original situation that fostered ration may meet with clichs such as rejec-
them. Persons with OCPD are by nature com- tion. As the analyst encourages the patient
petitive. They want to be the best at whatever to elaborate more specific fantasies, core con-
they do, and they are constantly finding fault flicts in the patients internal object relation-
with the shortcomings of others. This pattern ships begin to emerge. One may learn of ex-
may well emerge in the transference, no mat- periences of humiliation from childhood that
ter how conscientiously the patient tries to the patient is convinced will be repeated
conceal it from the therapist. Clinicians treat- again and again. Another common theme in
ing such patients may f ind themselves avoidant patients is that they are secretly
evoked into competitive power struggles thrilled with the possibility of showing off,
with the patient about the amount of the bill, but they worry that their exhibitionistic dis-
who is correct about a literary reference, and play is self-centered and destructive to oth-
whose interpretation of a psychological situa- ers. They may fear that they will become in-
toxicated with themselves if they are center dent attachment rather than to analyze. Cli-
stage. They may also fear deep-seated re- nicians must systematically help them exam-
sentment and anger at parents who shamed ine the underlying anxieties associated with
them. The inhibition of anger is frequently becoming independent.
connected with the shame experience (Gab- These patients may also develop ideali-
bard 2000c). zation of the therapist (Perry 1995). The
When psychoanalysts or therapists treat transference serves as a resistance in this way
avoidant personality disorder, they may because the portrayal of the therapist as om-
need to combine other measures as adjuncts. niscient is a way of turning over all responsi-
For example, patients who are reluctant to bility for important decisions to the person
expose themselves to a feared situation may treating them. Dependency may also be a
need to be encouraged to do so (Gabbard and way of managing anger and aggressionthe
Bartlett 1998; Sutherland and Frances 1995). so-called hostile dependency. Dependent
In addition, a selective serotonin reuptake in- clinging often masks aggression and can be
hibitor may also help the patient overcome regarded as a compromise formation in the
anxieties by addressing the biological tem- sense that it defends against hostility while
perament known as harm avoidance. also expressing it. As many analysts know
from firsthand experience, the person who is
Dependent Personality Disorder the object of the dependent patients clinging
may experience the patients demands as
Insecure attachment is a hallmark of depen- hostile and tormenting (Gabbard 2000c).
dent personality disorder, and studies of The dependent patients dance may
these patients (West et al. 1994) have found a evoke a number of countertransference reac-
pattern of enmeshed attachment. Many of tions. Some clinicians may bask in the pa-
these patients grew up with parents who tients idealizing transference and fail to con-
communicated in one way or another that in- front the patients lack of real change (Perry
dependence was fraught with danger. They 1995). Others may try to take over for the pa-
may have been rewarded for maintaining tient and become authoritarian and directive
loyalty to their parents, who seemed to reject as a response to frustration with the patients
them in the face of any move toward inde- failure to become independent. Some thera-
pendence. The central motivation of such pa- pists may struggle with countertransference
tients is to obtain and maintain nurturing, contempt or disdain. Termination may be a
supportive relationships. particularly problematic time in which trans-
Patients with dependent personality dis- ference-countertransference impasses and
order who enter into psychoanalytically ori- enactments occur. Therapists must steer a
ented treatment may present a formidable re- course between coercing the patient to termi-
sistance that takes the form of transference nate and avoiding the topic for fear of upset-
longing. They may secretly or overtly hope ting the patient.
that they can attach themselves forever to the
therapist and solve their problem of having Masochistic or Self-Defeating
to face life as an independent individual.
Hence the treatment setting poses a paradox:
the patient must first develop dependency Even though masochistic or self-defeating
on the therapist to overcome problems with personality disorder is not one of the DSM-
dependency (Gabbard 2000c). IV-TR diagnostic entities on Axis II, it has a
Another variation on this dependence is time-honored tradition in psychoanalysis.
that some of these patients will do whatever Masochistic character features are found in
they can to get the therapist to tell them what patients of both genders with striking fre-
to do. Their goal is often to continue a depen- quency. Psychoanalytic practice is replete
with examples of individuals who engage in Analysts working with masochistic pa-
self-defeating relationships, undermine their tients must be attuned to this development
possibilities of vocational or financial success, and help the patient see the gratification he or
and repeatedly evoke negative responses she derives from thwarting the analysts ef-
from others. The origins of this self-defeating forts. This pleasure can often be traced back
pattern usually involve multiple determi- to a revenge fantasy in which the patient
nants. Some patients are defending against wishes to retaliate against parents who had
dangerous competitive impulses, whereas excessive expectations (Gabbard 2000a). In
others are presenting themselves as suffering some cases, patients may have felt that their
and helpless in order to ensure care from oth- parents wished to have them succeed so they
ers (Cooper 1993). Others may be actively would reflect well on the parents. Many mas-
mastering passively experienced childhood ochistic patients seek to deprive their parents
trauma by bringing on the adverse event of that pleasure by repeatedly failing. In this
through their own omnipotent control. They way these patients may sacrifice their own
also may be reestablishing traumatic relation- lives because of the pleasure they take in ven-
ships as a way of maintaining familiarity and geance against their parents. Analysts must
predictability instead of facing new anxieties. help them see that they have re-created that
Psychoanalytic work with masochistic situation in the analytic relationship and that
patients attempts to lay bare the underlying it is ultimately self-defeating rather than
psychodynamic themes and help patients see other-defeating.
how their role as victim is one they repeatedly Envy may also be a key component to the
set up in their interactions with others. Many impasses that masochistic patients produce.
masochistic individuals are grievance col- To acknowledge receiving help from the ana-
lectors who wallow in self-pity but ulti- lyst may make these patients riddled with
mately blame someone else for their predica- envy that is tormenting to them. If they can
ment. They also have a secret omnipotence simply collect one more grievance against the
that shares a lot in common with narcissistic analyst as someone who is failing them, they
personalitynamely, they feel that because can then avoid the envy of somebody who
they have suffered more extensively and has the capacity to give and to be positive
more severely than others, they are therefore about life. Some masochistic patients do not
deserving of special treatment. This sense of want to reveal how much they have changed
entitlement to special martyred status may be until after termination to ensure that the ana-
tenaciously held on to despite the analysts lyst derives no gratification from therapeutic
repeated interpretation of the wish. success (Gabbard 2000a). Hence analysts
A masochist requires a sadist to be com- must be wary of too much enthusiasm about
plete, and a frequent development in the changing the patient because that counter-
analysis of masochistic patients is that the transference wish for success will activate the
analyst begins to enact sadistic attacks on patients self-defeating spiral. Often the opti-
the patient. These may take the form of accu- mal analytic posture is to help the patient un-
rately worded but aggression-fueled inter- derstand what is happening while making it
pretations that make the patient worse, an clear that how the patient chooses to apply
example of negative therapeutic reaction the insight is ultimately up to the patient.
(Gabbard 2004). Because the patient is deteri-
orating, the analyst may escalate the inter-
pretive efforts, thus making the patient feel CONCLUSION
shamed and punished. The roles may be re-
versed as wellthe patient may identify Psychoanalysis is a long and expensive treat-
with the internal sadistic object and torment ment, but because of its intensity and dura-
the analyst. tion, it may be capable of far- reach ing
changes that briefer therapies cannot ap- trojective patients: the Menninger Psychother-
proach. Defense mechanisms and representa- apy Research Project revisited. J Am Psychoa-
nal Assoc 40:691724, 1992
tions of self and other may tenaciously resist
Blatt SJ, Ford TQ: Therapeutic Change: An Object
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atic working through of these resistances will 1994
allow for structural, long-lasting change. The Blatt SJ, Besser A, Ford TQ: Two primary configu-
field of psychoanalysis must develop a rations of psychopathology and change in
greater research base to gain full credibility thought disorder in long-term intensive inpa-
tient treatment of seriously disturbed young
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will yield significant results has been out- choanal Q 46:386424, 1977
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Brown EJ, Heimberg RG, Juster HR: Social pho-
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11
Mentalization-Based
Treatment of Borderline
Peter Fonagy, Ph.D., F.B.A.
Anthony W. Bateman, M.A., F.R.C.Psych.
B orderline personality disorder (BPD) is a troject was a consequence of early attach-

complex psychiatric problem characterized ment failures. He carefully described typical
by numerous deficits in cognitive, emotional, patterns of borderline dysfunction in terms of
and behavioral functioning. These difficulties exaggerated reactions of the insecurely at-
commonly include emotional instability, feel- tached infant; for example, clinging, fearful-
ings of emptiness, impulsivity, suicidal ide- ness about dependency needs, terror of aban-
ation and gestures, enmeshed dysfunctional donment, and constant monitoring of the
and volatile relationships, irrational anxieties proximity of the caregiver. Lyons-Ruth and
about being abandoned by those one cares Jacobovitz (1999) focused on the disorganiza-
about, and paranoid thoughts (Lieb et al. tion of the attachment system in infancy as
2004). These difficulties can be conceptual- predisposing to later borderline pathology.
ized as a dysfunction of self-regulation par- Notably, they identified an insecure, as op-
ticularly in the context of social relationships. posed to a secure, disorganized pattern as
Both the difficulty with affect regulation and predisposing to conduct problems. Crit-
the catastrophic reaction to the loss of in- tenden (1997) was particularly concerned
tensely emotionally invested social ties place with incorporating borderline individuals
BPD in the domain of attachment. A number deep ambivalence and fear of close relation-
of theorists have drawn on Bowlbys ideas in ships in her representation of adult attach-
explanation of borderline pathology. Most ment disorganization. Fonagy and colleagues
specifically, Gunderson (1996) suggested that (Fonagy and Bateman 2006a, 2006b; Fonagy
intolerance of aloneness was at the core of et al. 2003) also used the framework of attach-
borderline pathology, and the inability of ment theory but emphasized the crucial role
those with BPD to invoke a soothing in- played by attachment in the development of
209
the capacity for mentalization and the way in ment system. We consider BPD from an at-
which insecure disorganized attachment tachment theory perspective, and outline the
may generate vulnerability in the face of fur- modifications of classical attachment theory
ther turmoil and challenges. that have helped us to understand the disor-
We have discussed our developmental dered attachment of individuals with BPD.
model of BPD in detail elsewhere (Bateman In particular, we emphasize the link between
and Fonagy 2004; Fonagy et al. 2002, 2003). the development of the capacity of mental-
Essentially our account focuses around the ization and the quality of attachment rela-
development of the social affiliative system tionships, and link the failure of mentaliza-
that we consider to drive many higher-order tion with symptoms of BPD. Finally, the
social-cognitive functions that in turn under- treatment implications of our attachment
pin interpersonal interaction, specifically in theorybased model of BPD are discussed.
an attachment context. Four of these are of
primary importance in understanding BPD:
1) affect representation and, related to this, BRIEF OUTLINE OF
affect regulation; 2) attentional control, also ATTACHMENT THEORY
with strong links to the regulation of affect;
3) the dual arousal system involved in main- Bowlbys attachment theory has a biological
taining an appropriate balance between focus (Bowlby 1969). Attachment readily re-
mental functions undertaken by the anterior duces to a molecular level of infant behav-
and posterior portions of the brain; and iors, such as smiling and vocalizing, that
4) mentalization, a system for interpersonal alert the caregiver to the childs interest in so-
understanding within the attachment con- cializing and bring the caregiver close to the
text. Since these capacities evolve in the con- child. Smiling and vocalizing are attachment
text of the primary caregiving relationships behaviors, as is crying, which is experienced
experienced by the child, in addition to the by most caregivers as aversive, and they en-
childs constitutional vulnerabilities, they gage the caregiver in caretaking behaviors.
are vulnerable to extremes of environmental Bowlby emphasized the survival value of at-
deficiency as exemplified by severe neglect, tachment in enhancing safety through prox-
psychological or physical abuse, childhood imity to the caregiver in addition to feeding,
molestation, or other forms of maltreatment. learning about the environment, and social
If our understanding of others critically de- interaction, as well as protection from preda-
pends on whether as infants our own mental tors. Bowlby (1969) considered the latter to
states were adequately understood by atten- be the biological function of attachment be-
tive adults, then there is ample opportunity havior. Attachment behaviors were seen as
for this developmental process to be dis- part of a behavioral system (a term Bowlby
rupted. Our premise is that however this borrowed from ethology).
comes about, unstable or psychogenically/ In the second volume of his Attachment
defensively reduced mentalizing capacity is and Loss trilogy, Bowlby established the set
a core feature of BPD. Therefore, in order to goal of the attachment system as maintaining
be successful, any treatment must have men- the caregivers accessibility and responsive-
talization as one of its foci or, at the very least, ness, which he covered with a single term:
stimulate development of mentalizing as an availability (Bowlby 1973). Availability means
epiphenomenon arising from other thera- confident expectationgained from tolera-
peutic initiatives. bly accurately (p. 202) represented experi-
In this chapter we briefly outline the the- ence over a significant time periodthat the
ory of attachment and some empirical work attachment figure will be available. The at-
linking BPD with dysfunctions of the attach- tachment behavioral system thus came to be
Mentalization-Based Treatment of Borderline Personality Disorder 211
underpinned by a set of cognitive mecha- ued crying, or fuss in a passive way. The car-
nisms, discussed by Bowlby as representa- egivers presence or attempts at comforting
tional models or by Craik (1943) as internal fail to reassure, and the infants anxiety and
working models (Bretherton and Munhol- anger appear to prevent him or her from de-
land 1999; Crittenden 1994; Main 1991; riving comfort from proximity.
Sroufe 1996). Four representational systems A fourth group of infants who show
are implied by the internal working models: seemingly undirected behavior are referred
1) expectations of interactive attributes of to as disorganized/disoriented (Main and So-
early caregivers created in the first year of life lomon 1990). They show freezing, hand clap-
and subsequently elaborated; 2) event repre- ping, head banging, and a wish to escape the
sentations by which general and specific situation even in the presence of the caregiver
memories of attachment-related experiences (Lyons-Ruth and Jacobovitz 1999; van IJzen-
are encoded and retrieved; 3) autobiograph- doorn et al. 1999). It is generally held that for
ical memories by which specific events are such infants the caregiver has served as a
conceptually connected because of their rela- source of both fear and reassurance, and thus
tion to a continuing personal narrative and arousal of the attachment behavioral system
developing self-understanding; and 4) un- produces strong conflicting motivations.
derstanding of the psychological characteris- Prospective longitudinal research has
tics of other people and differentiating them demonstrated that children with a history of
from the characteristics of the self. It is in this secure attachment are independently rated
last layer of the internal working models that as more resilient, self-reliant, socially ori-
we consider the dysfunctions of individuals ented (Sroufe 1983; Waters et al. 1979), and
with BPD to be most profound. empathic to distress (Kestenbaum et al.
The second great pioneer of attachment 1989), with deeper relationships and higher
theory, Mary Ainsworth (1969, 1985; Ains- self-esteem (Sroufe 1983; Sroufe et al. 1990).
worth et al. 1978), developed the well-known Bowlby (1969) proposed that internal work-
laboratory-based procedure of the Strange ing models of the self and others provide
Situation for observing infants internal prototypes for all later relationships. Such
working models in action. When infants are models are relatively stable across the life
briefly separated from their caregivers in an span (Collins and Read 1994).
unfamiliar situation, they show one of four Because internal working models func-
patterns of behavior. Infants who display tion outside of awareness, they are change
secure attachment explore readily in the pres- resistant (Crittenden 1990). The stability of
ence of the caregiver, are anxious in the pres- attachment is demonstrated by longitudinal
ence of the stranger and avoid her, are dis- studies of infants assessed with the Strange
tressed by the caregiver s brief absence, Situation and followed up in adolescence or
rapidly seek contact with the caregiver after- young adulthood with the Adult Attachment
ward, and are reassured by this contact and Interview (AAI; C. George, N. Kaplan, M.
return to their exploration. Some infants, Main, The Adult Attachment Interview,
designated as anxious/avoidant, appear to be unpublished manuscript, Department of
made less anxious by separation, may not Psychology, University of California at
seek contact with the caregiver following Berkeley, 1985). This structured clinical in-
separation, and may not prefer her over the strument elicits narrative histories of child-
stranger. Anxious/resistant infants show lim- hood attachment relationshipsthe charac-
ited exploration and play, tend to be highly teristics of early relationships, experiences of
distressed by separation from the caregiver, separation, illness, punishment, loss, mal-
and have great difficulty in settling after- treatment, or abuse. The AAI scoring system
ward, showing struggling, stiffness, contin- (M. Main, R. Goldwyn, Adult Attachment
Rating and Classification System, Manual in Evidence by Slade et al. (1999) provided
Draft, Version 6.0, unpublished manuscript, an important clue about the puzzle of inter-
University of California at Berkeley, 1994) generational transmission of attachment se-
classifies individuals into secure/autono- curity. They demonstrated that autonomous
mous, insecure/dismissing, insecure/preoc- (secure) mothers on the AAI represented
cupied, or unresolved with respect to loss or their relationship with their toddlers in a
trauma, which are categories based on the more coherent way than dismissing and pre-
structural qualities of narratives of early ex- occupied mothers. Mothers interviewed
periences. Whereas autonomous individuals with the AAI who demonstrated a strong ca-
value attachment relationships, coherently pacity to reflect on their own and their own
integrate memories into a meaningful narra- caregiver s mental states in the context of
tive, and regard these as formative, insecure recollecting their own attachment experi-
individuals are poor at integrating memories ences were far more likely to have children
of experience with the meaning of that expe- securely attached to thema finding that we
rience. Those individuals who are dismissing have linked to the parents capacity to foster
of attachment show avoidance by denying the childs self-development (Fonagy et al.
memories and by idealizing or devaluing (or 1993). We have also found that mothers in a
both idealizing and devaluing) early rela- relatively high-stress (deprived) group char-
tionships. Preoccupied individuals tend to be acterized by single-parent families, parental
confused, angry, or passive in relation to at- criminality, unemployment, overcrowding,
tachment figures, often still complaining of and psychiatric illness would be far more
childhood slights, echoing the protests of the likely to have securely attached infants if
resistant infant. Unresolved individuals give their capacity to be reflective (psychologi-
indications of significant disorganization in cally minded) in relation to their attachment
their attachment relationship representation; histories was high (Fonagy et al. 1994).
this disorganization manifests in semantic or The disorganized/disoriented infant cat-
syntactic confusions in their narratives con- egory appears to have the strongest predic-
cerning childhood trauma or a recent loss. tive significance for later psychological dis-
Many studies have demonstrated that turbance (Carlson 1998; Lyons-Ruth 1996;
the AAI, administered to the mother or fa- Lyons-Ruth et al. 1993; Ogawa et al. 1997). A
ther, will predict not only the childs security number of studies (Lyons-Ruth 1995; Lyons-
of attachment to that parent but even more Ruth et al. 1989; Shaw and Vondra 1995; Shaw
remarkably the precise attachment category et al. 1997) have suggested that disorganized
that the child manifests in the Strange Situa- attachment is a vulnerability factor for later
tion (van IJzendoorn 1995). Thus, a dismiss- psychological disturbance in combination
ing AAI interview predicts avoidant Strange with other risk factors. A study with a large
Situation behavior, whereas a preoccupied sample (N=223) confirmed that those whose
interview predicts anxious/resistant infant attachment classification was disorganized in
attachment. Lack of resolution of mourning infancy or atypical at age 24 months were
(unresolved interviews) predicts disorgani- most likely to be rated high on externalizing
zation in infant attachment (discussed later). behavior at 3.5 years (Vondra et al. 2001). A
Temperament (child-to-parent effects) seems meta-analysis of studies of disorganized at-
an inadequate account of the phenomena, tachment based on 2,000 motherinfant pairs
because the AAI of each parent, collected and (van IJzendoorn et al. 1999) estimated its
coded before the birth of the child, predicts prevalence at 14% in middle-income samples
the attachment classification of the infant at and 24% in low-income groups. Similarly, ad-
12 and 18 months (Fonagy et al. 1991b; Steele olescent mothers tended to have an overrep-
et al. 1996). resentation of disorganized infants (23%) as
well as fewer secure infants (40% versus 62%) ment cues and when the mother gave con-
and more avoidant infants (33% versus 15%). flicting messages that both elicited and re-
The stability of the classification of disorga- jected attachment.
nized attachment is fair (r= 0.36) (van IJzen- Both cross-sectional and longitudinal in-
doorn et al. 1999), with some indication that vestigations indicate that disorganized in-
lack of stability may be accounted for by infant attachment shifts into controlling attach-
creases in the number of disorganized infants ment behavior in middle childhood (van
between 12 and 18 months (Barnett et al. IJzendoorn et al. 1999). Observational stud-
1999; Vondra et al. 1999). ies suggest that disorganized children are
Quite a lot is known about the causes of less competent in playing with other chil-
disorganized attachment. The prevalence of dren, in conflict resolution (Wartner et al.
attachment disorganization is strongly asso- 1994), and in consistency of interaction with
ciated with family risk factors such as mal- different peers (Jacobovitz and Hazen 1999).
treatment (Carlson et al. 1989) and major de- In terms of the long-term consequences
pressive disorder (Lyons-Ruth et al. 1990; of attachment classification from childhood,
Teti et al. 1995). In addition, there is an exten- studies only partially confirm initial hopes of
sively proven association between disorgani- theorists and researchers. There can be little
zation of attachment in the baby and unre- doubt that something is carried forward. Pre-
solved mourning or abuse in the mother s diction from insecure-disorganized attach-
own personal experience, revealed in the ment is particularly powerful for various
AAI (van IJzendoorn 1995). Three studies adverse outcomes, including psychiatric dis-
have helped to clarify this superficially mys- order. The pathways of association are by no
terious association between slips in the means straightforward (Sroufe et al. 1999).
mothers narrative about past trauma and bi- For individuals with extremely harsh or cha-
zarre behavior by the infant in the Strange otic early caregiving, the process of atten-
Situation with her. Jacobovitz et al. (1997) re- tional, emotional, and symbolic regulation
ported a strong association between such might be derailed, and the integration of self-
slips in the AAI before the child was born states across behavioral states may never be
and observations of frightened or frighten- fully achieved. Because early attachment dis-
ing behavior toward the baby at 8 months. turbance makes itself felt as a dysfunction of
These behaviors included extreme intrusive- self-organization (stress regulation, attention
ness, baring teeth, and entering apparently regulation, and mentalization)and be-
trancelike states. If the mothers unresolved cause these capacities are needed to deal
trauma happened before she was 17 years with social stress relationship disturbance
old, her frightened or frightening behavior in the early years, together with additional
was more evident. Interestingly, these unre- social pressures, does predict psychological
solved mothers did not differ from the rest of disturbance.
the sample in terms of other measures of
parenting such as sensitivity and warmth.
Maternal frightened or frightening behavior PROBLEMS WITH A SIMPLE
predicted infant attachment disorganization, ATTACHMENT MODEL
but the strongest predictor was maternal dis-
sociated behavior (Schuengel et al. 1999). In There is no doubt that borderline individuals
an independent investigation, Lyons-Ruth et are insecure in their attachment, but descrip-
al. (1999b) also found that frightened and tions of insecure attachment from infancy or
frightening behavior predicted infant disor- adulthood provide an inadequate clinical ac-
ganization, particularly when the mother count for several reasons: 1) Anxious attach-
strongly misinterpreted the babys attachment is very common; in working-class non-
clinical population samples, the majority of be distorted by later rather than earlier social
children are classified as anxiously attached, encounters. It is unclear in most theories pro-
with a high proportion classified as disorga- posing attachment as an explanatory vari-
nized (Broussard 1995). 2) Anxious patterns able how early attachment and later mal-
of attachment in infancy correspond to rela- treatment might interact. As we have seen,
tively stable adult strategies (Main et al. controlling for attachment styles does not ac-
1985), yet the hallmark of the disordered at- count for temperamental and characterolog-
tachments of borderline individuals is the ab- ical differences between BPD and non-BPD
sence of stability (Higgitt and Fonagy 1992). patients. Impulsivity and negative affectiv-
3) In both delinquent and borderline individ- ity/emotional dysregulation characterize
uals there are variations across situations or BPD best (Gurvits et al. 2000; Paris 2000; Silk
types of relationships; the delinquent adoles- 2000; Trull 2001a). Many attachment mea-
cent is, for example, aware of the mental sures such as the AAI rely on autobiograph-
states of others in his gang, and the border- ical memory. In fact, in the AAI specific
line individual is at times hypersensitive to memories are coded as indicators of insecu-
the emotional states of mental health pro- rity. Studies of autobiographical memory of
fessionals and family members. 4) The clini- borderline patients suggest that they have a
cal presentation of borderline patients fre- tendency to produce overly general memo-
quently includes a violent attack on the pa- ries (Startup et al. 2001), which again under-
tients own body or that of another human scores the difficulty of establishing indepen-
being. It is likely that the propensity for such dent measures of BPD status and attachment.
violence must include an additional compo-
nent that predisposes such individuals to act
upon bodies rather than upon minds. AN ATTACHMENT THEORY OF
To the extent that we assume that abnor- BORDERLINE PERSONALITY
mal patterns of attachment arise as a conse-
quence of abnormalities in child rearing, it is DISORDER
somewhat of an embarrassment that pro- Disorganization of Attachment
spective studies of maltreatment often fail to
yield powerful personality effects beyond The caregivers sensitivity to the childs men-
the contextual (e.g., life events; Widom 1999). tal state is strongly associated with secure at-
A more important problem is that all adult tachment and the development in the child
attachment measures are hopelessly con- of the capacity to mentalizethat is, to rep-
founded with symptoms and traits. Thus, for resent the behavior of self and others in
example, in Meyer et al.s (2001) study of terms of underlying mental states (Fonagy
Pilkoniss (1988) borderline attachment pro- and Target 1997; Fonagy et al. 1991a; Meins
totype, the correlation between the attach- and Fernyhough 1999; Meins and Russell
ment prototype and symptomatology was so 1997; Meins et al. 1998, 2001; Raikes and
high that only one of these variables could be Thompson 2006; Symons, 2004). Mentalizing
used in the regression because of colinearity is a relatively new term for a concept as an-
problems. Similarly, the AAI coding for fear- cient as philosophy of mind. Mentalizing is
ful preoccupied categories calls for state- akin to what Olson (1994) construes as sub-
ments about fear of loss that are also symp- jectivitythat is, the recognition that what is
tomatic of a diagnosis of BPD. in the mind is in the mind .. .the recognition
The model of attachment in use by at- of ones own and others mental states as
tachment theorists places greatest impor- mental states (p. 234). The term mentalizing
tance on early experience, yet the social expe- was introduced into the psychoanalytic liter-
riences of individuals with BPD are likely to ature some decades ago (Brown 1977; Comp-
ton 1983; De MUzan 1973; Lecours and Bou- behaviors that undermine the healthy devel-
chard 1997) and came to be applied to the opment of the infants representational ca-
understanding of autism as a neurobiologi- pacities (particularly the organization of af-
cally based failure of psychosocial develop- fect and the organization of focused attention
ment (Frith et al. 1991; Morton 1989). Fonagy or effortful control) (Fonagy and Target
and colleagues opened the door to wider 2002), which in turn can undermine attach-
clinical applications of this developmental ment processes, leading to the development
research in showing how mentalizing plays a of a disorganized self, parts of which are ex-
significant role in diverse forms of develop- perienced as alien or not really belonging
mental psychopathology (Fonagy 1991, 1995; to the self. In the absence of the capacity for
Fonagy and Target 1997; Fonagy et al. 2002; mentalization, the coherence of this self can
Target and Fonagy 1996), and we continue only be ensured by primitive psychological
expanding these clinical applications here. strategies such as projective identification. It
True to its origins in psychoanalysis, is the impact of attachment disorganization
mentalizing intertwines with the related con- on the self that might be most important for
cepts of psychological mindedness (Appel- us in understanding BPD.
baum 1973; Namnum 1968), observing ego,
and potential space (Bram and Gabbard Establishment of the Alien Self
2001; Ogden 1985; Winnicott 1971). Mentaliz-
ing also overlaps with the venerable con- An important complication arises if the pro-
cepts of empathy and insight. We do not processes that normally generate an agentive
pose replacing these traditional concepts self fail. In early childhood the failure to find
with mentalizing but rather argue that the- another being behaving contingently with
ory and research on mentalizing anchor this ones internal states can create a desperation
network of clinical concepts in evolutionary for meaning as the self seeks to find itself in
biology, neurobiology, contemporary devel- the other. This desperation leads the individ-
opmental research, and attachment theory. ual to take in noncontingent reflections from
High levels of parental reflective function the object. Unfortunately, as these reflections
(capacity for mentalization) are associated do not map onto anything within the childs
with good outcomes in terms of secure at- own experience, they cannot function as to-
tachment in the child. The converse, then, is tally effective experiences of the self. As Win-
that low levels of reflective function generate nicott (1967) noted, inaccurate mirroring
insecure and perhaps disorganized attach- leads the child to internalize representations
ment. The latter category of attachment in of the parents state rather than a usable ver-
infancy is most likely to be associated with sion of his or her own experience. This cre-
self-harming or aggressive and potentially ates what we have termed an alien experience
violent behavior later in development. A within the self: ideas or feelings are experi-
study by Grienenberger et al. (2001) showed enced as part of the self that do not seem to
that mothers with low levels of mentaliza- belong to the self (Fonagy et al. 1995, 2000).
tion (or reflective function) on the Parent De- These representations of the other internal-
velopment Interview (an interview assessing ized as part of the self probably originate in
the parents mental representation of the early infancy, when the mothers reflective
child) are more likely to show intrusiveness, function at least partially but regularly failed
fearfulness, withdrawing, and other behav- the infant.
iors shown to generate disorganized attach- This alien other, the residue of maternal
ment in the infant (Lyons-Ruth et al. 1999b). nonresponsiveness, probably exists in seed
The suggestion here is that poor mentali- form in all our self-representations, because
zation of the infant in the mother permits we have all experienced neglect to a greater
or lesser extent (Tronick and Gianino 1986). lative behavior reflects the individuals in-
Normally, however, parts of the self-repre- ability to contain the incoherence of his or
sentation that are not rooted in the internal- her self-structure. Unfortunately, in per-
ized mirroring of self-states are nevertheless forming this functionin becoming, for ex-
integrated into a singular, coherent self- ample, angry and punitive in response to un-
structure by the capacity for mentalization. conscious provocationthe attachment
The representational agentive self creates an figure is in the worst possible state to help re-
illusion of coherence within our representa- store the afflicted individuals mentalizing
tions of ourselves by attributing agency, function because he or she has lost touch
accurately or inaccurately assuming that with the individuals mental world. Thus the
mental states invariably exist to explain ex- controlling internal working model further
perience. Dramatic examples of this capacity undermines the childs capacity to establish
for mentalization were noted long ago in an agentive self-structure.
studies of individuals with neural lesions, To state it simply, disorganized attach-
such as individuals with surgical bisections ment is rooted in a disorganized self. Attach-
of the corpus callosum, so-called split-brain ment research has demonstrated the se-
patients (Gazzaniga 1985). When presented quelae of disorganized attachment in infancy
with emotionally arousing pictures in the to be extreme controlling and dominating be-
hemifield without access to language, they havior in middle childhood (see Solomon
would find improbable mentalized accounts and George 1999; Green and Goldwyn 2002).
for their heightened emotional state. The individual, when alone, feels unsafe and
vulnerable because of the proximity of a tor-
Controlling Internal turing and destructive representation from
which he or she cannot escape because it is
Working Model
experienced from within rather than from
The normal process of attributing agency without the self. Unless the individuals rela-
through putative mental states precon- tionship permits externalization, he or she
sciously works in the background of our feels almost literally at risk of disappearance,
minds to lend coherence and psychological psychological merging, and the dissolution
meaning to our lives, our actions, and our of all relationship boundaries. The need to
sense of self. Individuals whose capacity for externalize the alien part of the self may
mentalization is not well developed may serve inadvertently to re-create relationships
need to use controlling and manipulative in which the persecutor is generated out-
strategies to restore coherence to their sense side, in the shape of relationships of emo-
of self. The alien aspects of the self may be ex- tional turmoil and significant negativity.
ternalized into an attachment figure. Using
processes often described in the clinical liter- Failure of Mentalization
ature as projective identification, the at-
tachment figure is manipulated into feeling Disturbed interpersonal relatedness is a key
the internalized emotions as part of the self aspect of BPD related to temperamental at-
but not entirely of the self. These are not tributes of negative affectivity and impulsiv-
self-protective maneuvers in the sense of ity (Gurvits et al. 2000; Paris 2000; Silk 2000;
needing to shed feelings that the individual Trull et al. 2000; Domes et al. 2006) and psy-
cannot acknowledge; rather, they protect the chosocial experiences of maltreatment (e.g.,
self from the experience of incongruence or Trull 2001b; Zanarini et al. 1997; Zlotnick et
incoherence that has the potential to generate al. 2001). Studies that have attempted to find
far deeper anxieties (see Kernberg 1982, 1983; the underlying dimensions of borderline
Kohut 1977). Apparently coercive, manipu- phenomenology tended to identify either two
(Rosenberg and Miller 1989) or three factors states (Damasio 1999; Frith and Frith 1999;
(Clarkin et al. 1993; Sanislow et al. 2000). Lane et al. 1997, 1998). Lane (2000) proposed
These factors normally include a dimension more specifically that implicit self-represen-
of disturbed relatedness, emotional dysregu- tations (i.e., phenomenal self-awareness) can
lation and impulsivity, or behavioral dyscon- be localized to the dorsal anterior cingulate,
trol. At least the first of these may be related whereas explicit self-representations (i.e., re-
to a deficit in the capacity for accurate percep- flection) can be localized to the rostral ante-
tion of the respective mental states of self and rior cingulate. Moreover, intriguing findings
other and selfother differentiation (Fonagy regarding mirror neurons suggest that repre-
et al. 2000; Gunderson 2001). Deficits of this sentations of self and others bearing on inter-
aspect of interpersonal perception have been pretation of intentional action promote men-
demonstrated in analogue studies using film talization by virtue of shared anatomical
clips (e.g., Arntz and Veen 2001), affect recog- circuitry (Brothers 1997; Gallese 2000, 2001;
nition and alexithymic symptoms (e.g., Sayar Jeannerod 1997). Activation of the medial
et al. 2001), and narratives of childhood expe- prefrontal cortex (including the ventromedial
riences (Fonagy et al. 1996; Vermote et al. prefrontal cortex overlapping the orbitofron-
2004). Individuals with BPD exhibit emo- tal cortex) has been demonstrated in a series
tional hyperresponsiveness (see summary in of neuroimaging studies in conjunction with
Herpertz 2003; Leichsenring and Sachsse a wide range of theory of mind inferences in
2002) and deficits in emotion recognition and both visual and verbal domains (Fletcher et
the capacity for empathy (Bland et al. 2004; al. 1995; Gallagher et al. 2000; Goel et al. 1995;
Guttman and Laporte 2002; Soloff et al. 2003; Happe et al. 1996; Klin et al. 2000). It appears
Wagner and Ambrosini 2001). But the deficit likely that extensive prefrontal cortex (i.e., or-
in social cognition is evidently not straight- bitofrontal extending into more dorsal me-
forward; it is situation and context depen- dial cortex) is involved in mentalizing inter-
dent. For example, impaired recognition of actively in a way that requires implicitly
integrated emotional stimuli has been shown representing the mental states of others.
to be associated with interpersonal antago-
nism, particularly suspiciousness and as- Impact of Trauma
saultiveness (Minzenberg et al. 2006). It
seems that when an individual with BPD is Key to understanding severe personality dis-
emotionally aroused and as their relationship order is the inhibition of mentalization, per-
with another moves into the sphere of attach- haps prototypically in response to trauma.
ment, thereby intensifying the relationship, Patients with BPD defensively avoid think-
their ability to think about the mental state of ing about the mental states of self and others,
another can rapidly disappear (see Fonagy because these experiences have led them to
and Bateman 2006a, 2006b for further discus- experiences of unbearable pain in the course
sion of this point). of maltreatment (Fonagy 1991). Especially in
A deficit of interpersonal awareness im- individuals in whom the capacity for mental-
plies an underlying failure of effective and ization is already weak, trauma may bring
stable selfother differentiation at the level of about a complete collapse.
distinguishing respective mental states. Some Both clinical and experimental evidence
of the brain abnormalities identified in BPD supports the view that trauma commonly
patients correspond to a failure of representa- brings about a partial and temporary collapse
tion of self-states being a key dysfunction. of mentalization. The disorganizing effects of
Some evidence suggests that the anterior cin- trauma on attention and stress regulation are
gulate cortex plays a key role in mentalizing well known (Allen 2001). The capacity for
the self, at least in the domain of emotional mentalization is undermined in a significant
proportion of individuals who have experi- biological approaches underscore how

enced trauma. Maltreated toddlers have diffi- trauma may compromise the development
culty in learning to use internal state words of cerebral structures that support mentaliz-
(Beeghly and Cicchetti 1994; Cicchetti and ing. Schore (2001) reviewed extensive evi-
Beeghly 1987). Neglected children have dence that secure attachment relationships
greater difficulty in discriminating facial are essential to the normal development of
emotional expression, and physically abused the prefrontal cortex and thus to affect regu-
children show a response bias toward angry lation. Hence, early maltreatment, which is
expression and greater variance in their inter- associated with extremely compromised
pretation of facial affect (Pollak et al. 2000). A (disorganized) attachment (Barnett et al.
study of sexually abused Canadian girls dem- 1999; Lyons-Ruth and Jacobovitz 1999; Ly-
onstrated that children with sexual abuse his- ons-Ruth et al. 1999a, 1999b), is most likely to
tories had lower reflective functioning (RF) undermine the development of cortical
scores on the childhood attachment inter- structures key to mentalization.
views in relation to self than demographically Arnsten (1998; Arnsten et al. 1999) and
matched control subjects (Normandin et al. Mayes (2000, 2002) have linked extreme stress
2002). In the same study, dissociation was to altered dynamics in arousal regulation in a
shown to be closely related to the low RF of way that is highly pertinent to trauma. They
abused children. Whereas 75% of those with described how increasing levels of norepi-
low RF on the child attachment interview nephrine and dopamine interact with each
scored high in dissociation, only 20% of those other and differentially activate receptor
with high RF could be said to be dissociating. subtypes so as to shift the balance between
Young adults who have been maltreated ex- prefrontal executive control and posterior-
perience greater difficulty with the Reading subcortical automatic control over attention
the Mind in the Eyes Test (a relatively simple and behavior. Mild to moderate levels of
measure of implicit mentalization that in- arousal are associated with optimal prefron-
volves identifying photographs with one of tal functioning and thus with employment of
four mental states) (Fonagy et al. 2001). flexible mental representations and response
Considerable evidence supports the strategies conducive to complex problem
claim that individuals with a history of abuse solving. On the other hand, extreme levels of
who are also limited in their capacity to think arousal trigger a neurochemical switch that
about mental states in themselves and others shifts the individual into posterior cortical-
in the AAI are highly likely to have a diagno- subcortical dominance such that vigilance,
sis of BPD (Fonagy et al. 1996). Other re- the fight-or-flight response, and amygdala-
searchers have replicated this finding with mediated memory encoding predominate. In
other samples showing trauma. For example, effect, high levels of excitatory stimulation (at
in the Kortenberg-Leuven Process-Outcome 1 adrenergic and D1 dopaminergic recep-
Study of inpatient treatment of personality tors) take the prefrontal cortex offline. This
disorder (Vermote et al. 2004), a significant switch in attentional and behavioral control is
negative correlation was reported between adaptive in the context of danger that re-
RF measured on the Object Relations Inven- quires rapid automatic responding. Yet
tory (Blatt et al. 1996) and Structured Clinical Mayes (2000) pointed out that early stressful
Interview for DSM-IV Axis II Personality and traumatic experiences may permanently
Disorders diagnosis of BPD, and an even impair the dynamic balance of arousal regu-
stronger correlation was found with clinical lation, altering the threshold for this switch
observation of self-harm. process. Thus, sensitized individuals may be
Although psychological trauma is a func- prone to impaired prefrontal functioning in
tional route to impaired mentalizing, neuro- the face of stress, with automatic posterior-
subcortical responding taking control of at- side must by definition exist in his mind, be-
tention and behavior and undermining flexi- cause his mind is functionally equivalent to
ble mental representations and coping. In line the material world (Fonagy and Target 1996;
with this suggestion is the observation that Target and Fonagy 1996). The complement to
N-acetyl-aspartate, a marker of neural integ- this state is the pretend mode of experiencing
rity, is lowered in the anterior cingulate re- subjectivity, in which the child feels that noth-
gion of the medial prefrontal cortex of mal- ing that he experiences as subjective has any
treated children and adolescents (De Bellis et possible connection with reality.
al. 2000). We propose a synergy among psycholog-
These proposals regarding impaired ical defenses, neurobiological development,
arousal regulation and shifting the balance of and shifts in brain activity during posttrau-
prefrontal-posterior cortical functioning are matic states such that mentalizing activity is
consistent with neuroimaging studies em- compromised. The shift in the balance of cor-
ploying symptom provocation in persons tical control locks the traumatized person
with posttraumatic stress disorder (PTSD). into either 1) the psychic equivalence mode,
Such induced posttraumatic states are associ- associated with an inability to employ alter-
ated with diminished medial prefrontal and nate representations of the situation (i.e.,
anterior cingulate activity (Bremner et al. functioning at the level of primary rather
1999a, 1999b; Lanius et al. 2001; Rauch et al. than secondary representations), much less
1996; Shin et al. 2001). A similar observation the ability to explicate the state of mind
was reported in a positron emission tomo- (meta-representation); or 2) the pretend
graphy study comparing sexually abused mode, associated with states of dissociative
women who had PTSD with women with a detachment.
similar history who did not. The women with
PTSD were found to have lower levels of an- Exposure of the Alien Self
terior cingulate blood flow during traumatic
imagery (Shin et al. 1999). This finding sug- When mirroring fails in infancy, the child in-
gests that some BPD symptoms may be con- ternalizes a noncontingent mental state as
nected to an impairment of medial prefrontal part of a representation within the psycho-
cortical functioning (Zubieta et al. 1999). Van logical self. These internalizations sit within
der Kolk et al. (1996) viewed findings show- the self without being connected to it by a set
ing deactivation in Brocas area in posttrau- of meanings. It is this incoherence within the
matic states as indicative of speechless ter- self-structure that we referred to as an alien
ror and concluded that in such states, the self (Fonagy and Target 2000). As we have
brain is having its experience. The person said, such incoherencies in self-structure may
may feel, see, or hear the sensory elements of not only characterize profoundly neglected
the traumatic experience, but he or she may children. The coherence of self that we all ex-
be physiologically prevented from translat- perience is somewhat illusory. This illusion is
ing this experience into communicable lan- normally maintained by the continuous nar-
guage (p. 131). Thus, dysfunctional arousal rative commentary on behavior that mental-
may play a part in the reemergence of the ization provides, which fills in the gaps and
subjective state we have described as psychic makes us feel that our experiences are mean-
equivalence. Psychic equivalence is a develop- ingful. In the absence of a robust mentalizing
mentally primitive mode of experiencing the capacity, with disorganized patterns of at-
subjective world before mentalization has tachment, the disorganization of the self-
fully developed. The 2-year-old child is con- structure is clearly revealed.
vinced that all that is in his mind is equivalent When trauma inhibits mentalization, the
to that which exists outside and all that is out- self is suddenly experienced as incoherent.
Parts within the trauma survivor feel like the ables the individual to feel that they no
self yet also feel substantively different, longer own the persecutory alien part of the
sometimes even persecutory. The persecu- self. At the simplest level, the world then be-
tory nature of the alien part of the self arises comes terrifying because the persecutory
as a sequel to maltreatment in childhood, ad- parts are experienced as outside. At a more
olescence, or even adulthood. Anna Freud complex level, it is felt essential that the alien
(1936) described the process by which the experiences are owned by another mind, so
child aims to gain control over powerful, that another mind is in control of these parts
hostile external forces through identification of the self. This defensive externalization
with the aggressor. If the cohesion of the self- might help to explain why, strikingly, per-
structure has been weakened by limited in- sons with BPD frequently find themselves in
terpersonal interpretive function and the dis- interpersonal situations in which they are
continuity within the self represented by the maltreated or abused by their partners.
alien part of the self is well established, iden- Given that the relationship between
tification with the maltreater is most likely to childhood maltreatment and BPD is complex,
occur with the help of this alien part of the the statistics on the sequelae of childhood sex-
self-structure. In slight disagreement with ual abuse seem quite relevant to this point.
Anna Freud, we do not look at this process as Victims of childhood abuse who are revic-
an identification, because that would imply timized are most likely to have severe mental
(following Sandlers [1987] clarification of health problems, including (as we have seen
the concept) a change in the shape of the self frequently) BPD. According to one study, 49%
in the direction of achieving more significant of abused women compared with 18% of
similarities with the abusive figure. It is more women without the experience of sexual
like a kind of colonization of the alien part abuse had been battered by their partners
of the self by the childs or adolescents im- (Briere and Runtz 1987). In a large study with
age of the mental state of the abuser. a sample representative of San Francisco
The aim of the strategy is to gain a sense (Russell 1986), between 38% and 48% of
of control over the uncontrollable. This at- abused women (depending on the severity of
tempt at control is ultimately a highly mal- abuse) had physically abusive husbands com-
adaptive solution, because the persecution pared with 10%17% of nonabused women.
from the maltreating person is now experi- This finding should in no sense be taken to
enced from within. A part of the self-struc- mean that the men involved in the battering
ture is thought to wish to destroy the rest of are any less culpable. Individuals with expe-
the self. This experience of persecution from riences of maltreatment appear to be drawn to
within may be one aspect of the massive im- individuals who are likely to maltreat them,
pact that maltreatment can have on the self- we would argue, in order to increase the op-
esteem of those subject to abuse (e.g., Mullen portunity of externalizing intolerable mental
et al. 1996). They feel that they are evil be- states concerning themselves. As thus might
cause they have internalized evil into the be expected, many sexual assaults experi-
part of the self that is most readily decoupled enced by college-age survivors of sexual
from the self but nevertheless is felt as part of abuse occur at the hands of a known individ-
the self. A way of coping with the intolerable ual (Gidycz et al. 1995). Indeed, one survey
pain that this self-persecutory self within the demonstrated that 81% of the adult sexual as-
self represents is through externalization into saults experienced by revictimized women
the physically proximal other. The part of the were perpetrated by male acquaintances of
self that is so painful is forced outside and the survivors (Cloitre et al. 1997).
another physical being is manipulated and Another person is essential to create the
cajoled until they behave in a way that en- illusion of coherence. BPD patients require
rather than enjoy relationships. Relation- equivalence when a part of the body is con-
ships are necessary to stabilize the self-struc- sidered isomorphic with the alien part of the
ture but are also the source of greatest vul- self at the same time as creating a respite from
nerability because in the absence of the other, intolerable affects. Attempts at self-mutila-
when the relationships break down or if the tion are more common when the patient is in
other shows independence, the alien self re- isolation or after the loss of an other who, up
turns to wreak havoc (persecute from within) to that point, could fulfill the task of being a
and to destabilize the self-structure. Vulnera- vehicle for the persecuting alien part of the
bility is greatest in the context of attachment self.
relationships. Past trauma leaves an impov-
erished internal working model from the Suicide
point of view of clear and coherent represen-
tations of mental states in self and other. This Clinical and epidemiological studies have
representational system is activated by the demonstrated that between 55% and 85% of
attachment relationship with the conse- those who self-mutilate also attempt suicide
quence that the mental states of the other are (Dulit et al. 1994; Stanley et al. 1992), and BPD
no longer clearly seen. The physical other is carries a suicide risk of around 5%10% (Fyer
desperately needed to free the self from its et al. 1988; Stone et al. 1987). Most consider at-
inwardly directed violence, but only as long tempted suicide to be on a continuum of le-
as it acts as the vehicle for the patients self- thality with other types of deliberate self-
state. When this process occurs, dependence harm (e.g., Linehan 1986). We understand
on the other is total. Substitution is incon- suicide attempts as at the extreme of attempts
ceivable, no matter how destructive or hope- at self-mutilation often consequent on experi-
less the relationship might seem from the ence of loss of the other. In such states, feel-
outside. ings of despair, hopelessness, and depression
predominate. The loss of the other as a vehi-
Self-Harm cle for the alien parts of the selfthe disrup-
tion of the process of externalizationsignals
We can now begin to understand the violence the destruction of the constitutional, or real,
committed by certain individuals with BPD part of the self. Hence, the sense of despair is
against others or themselves. For such indi- not from the loss of the object who normally
viduals, self-harm may entail a fantasy of would not have been a genuine attachment
eradicating the alien part of the self uncon- figure in the first place but from the antici-
sciously imagined to be part of their body. pated loss of self-cohesion. The act of suicide
Self-mutilators report a range of conscious is at least in part an act in the psychic equiva-
motivations, including self-punishment, ten- lence mode aimed at destroying the alien part
sion reduction, improvement in mood, and of the self (hence the continuum with self-
distraction from intolerable affects (Favazza harm). When BPD patients attempt suicide,
1992; Herpertz 1995). Following the act of their subjective experience is decoupled from
self-harm, the individual mostly reports feel- reality (in the pretend mode of subjectivity),
ing better and relieved (Favazza 1992; Her- and in a sense they believe they (or their true
pertz 1995; Kemperman et al. 1997). We sug- selves) will survive the attempt but their alien
gest that in the absence of a person who may selves will be destroyed forever. Consistent
act as a vehicle for the alien part of the self, a with our view is evidence that suicide at-
person with BPD achieves self-coherence tempters with BPD features perceive their
through the externalization of this part of the suicidal attempts as less lethal, with a greater
self into a part of their body. Attempts at self- likelihood of rescue and with less certainty of
harm are acts carried out in a mode of psychic death (Stanley et al. 2001). In fact, in some pa-
tients suicide is felt as a secure base, a re-

union with a state that can reduce existential TREATMENT IMPLICATIONS OF THE
fear. ATTACHMENT MODEL
Impulsive Acts of Violence It should be apparent from this discussion

about attachment and BPD that the focus in
The same models of pathology that account treatment needs to be on stabilizing the sense
for self-harming behavior are generally held of self and helping the patient maintain an
to be applicable to certain categories of acts optimal level of arousal. To this end, we have
of interpersonal violence (Dutton 1995; Fon- defined some core underpinning techniques
agy 1999; Fonagy et al. 1997; Gilligan 1997; to be used in the context of group and indi-
Meloy 1992). In BPD we see interpersonal vi- vidual therapy and labeled them mentaliza-
olence of an explosive or affective type (Vi- tion-based treatment (MBT; Bateman and
tiello and Stoff 1997) that is often associated Fonagy 2004, 2006). The initial task in MBT is
with antisocial personality disorder. Iden- to stabilize emotional expression because
tification with the aggressor leads to the col- without improved control of affect there can
onization of the alien part of the self by the be no serious consideration of internal repre-
maltreating figure, and vulnerability to a sentations. Although the converse is true to
malevolent mind brings with it the defensive the extent that without stable internal repre-
inhibition of mentalizing capacity. Acts of sentations there can be no robust control of
violence themselves are usually the conse- affects, identification and expression of affect
quence of a failure of the externalization of are targeted first simply because they repre-
the alien self. When the other refuses to be a sent an immediate threat to continuity of
vehicle for intolerable self-stateshe or she therapy as well as potentially to the patients
refuses to be cowed or humiliatedthe vul- life. Uncontrolled affect leads to impulsivity,
nerable mind of such an individual turns to and only once this affect is under control is it
interpersonal destruction. An important trig- possible to focus on internal representations
ger for violence is the experience of ego- and to strengthen the patients sense of self.
destructive shame. The lack of a coherent To implement MBT effectively, greater ac-
sense of agentive self creates a massive vul- tivity on the part of the therapist is required,
nerability to humiliation in such individuals. with more collaboration and openness than
This humiliation is felt when the other re- is implied in the classical analytic stance. In
fuses to accept a role of complete passivity psychodynamic treatment of BPD patients,
and through manifesting agency presents the therapist has to become what the patient
unbearable humiliation to the violent mind. needs him or her to bethe vehicle for the
The challenge is unbearable in the mode of alien self, the carrier of alternative but not de-
psychic equivalence, in which shame is expe- stabilizing perspectives. Yet to become the
rienced not just as an idea or feeling but as alien self is to be lost to the patient as a pro-
having the actual power to destroy the self. vider of different perspectives and therefore
The destruction of the other through vio- to be of no help to the patient. The therapist
lence is an expression of the hoped-for de- must aim to achieve a state of equipoise be-
struction of the alien self; it is an act of hope tween the twoallowing him- or herself to
or liberation and is often associated with ela- do as required yet trying to retain as clearly
tion and only later with regret. The absence and coherently as possible an image of his or
of mentalization at these moments is of her own state of mind alongside that of the
course of further assistance. patient. This mental attitude is what we have
called the mentalizing stance of the therapist.
Enhancing Mentalization, Retaining no longer use the same circumspect subjec-

Mental Closeness, and Working tive criteria of historical accuracy that most
of us use but rather assume that because they
With Current Mental States
experience something in relation to a child-
A therapist needs to maintain a mentalizing hood (usually adult) figure, it is bound to be
stance in order to help a patient develop a ca- true. To avoid these risks, the focus of MBT
pacity to mentalize. Self-directed mentalistic needs to be on the present state and how it re-
questions are a useful way of ensuring that a mains influenced by events of the past rather
focus on mentalizing is maintained. Why is than on the past itself. If the patient persis-
the patient saying this now? Why is the pa- tently returns to the past, the therapist needs
tient behaving like this? What might I have to link back to the present, move the therapy
done that explains the patients state? Why into the here and now, and consider the
am I feeling as I do now? What has happened present experience.
recently in the therapy or in our relationship An important indicator of underlying
that may justify the current state? The thera- process and the here and now is the manifest
pist will be asking him- or herself these typi- affect that is specifically targeted, identified,
cal questions within the mentalizing thera- and explored within an interpersonal context
peutic stance and is perfectly at liberty to ask in MBT. The challenge for the professional
these out loud in a spirit of inquiry. This ap- working with the patient is to maintain a
proach pervades the entire treatment setting. mentalizing therapeutic stance in the context
Thus in group therapy, techniques focus on of countertransference responses that may
encouraging patients to consider the mental provoke the therapist to react rather than to
states and motives of other members as well think. Understanding within an interpersonal
as their own: Why do you think that she is context why the situation arose in the first
feeling as she does? The therapist is not place, why such an externalization became
looking for complex unconscious reasons necessary, is the likely immediate solution to
but rather the answers that common sense or this challenge. Retaining mental closeness is
folk psychology would suggest to most rea- done simply by representing accurately the
sonable people. current or immediately past feeling state of
Focusing the therapists understanding the patient and its accompanying internal
of his or her interactions with the patient on representations and by strictly and systemat-
the patients current mental state will allow ically avoiding the temptation to enter into
the therapist to link external events, however conversation about matters not directly
small, to powerful internal states that are linked to the patients beliefs, wishes, and
otherwise experienced by the patient as inex- feelings.
plicable, uncontrollable, and meaningless. A It could be argued that the focus on men-
focus on psychological process and the here talization in MBT is akin to the emphasis on
and now rather than on mental content in cognitions in cognitive-behavioral treat-
the present and past is implicit in this ap- ments and that the exploration of affects is
proach. Little therapeutic gain results from similar to the stress on affect control in dia-
continually focusing on the past. Recovering lectical behavior therapy (Linehan et al. 1991,
memories is now recognized as a somewhat 1999, 2002). There is some truth in this obser-
risky aim with BPD patients (Brenneis 1997; vation, but we would argue that the tech-
Sandler and Fonagy 1997). We would wish to niques used in those therapies are often effec-
add that another risk involves the possibility tive because they enhance mentalizing; the
of encouraging BPD patients to enter a pre- success that they have is through the stimu-
tend-psychic equivalent mode of relating, in lation of exploration of the mind and the joint
which they (unbeknownst to the therapist) attention given to mental processes. Our in-
terventions are more firmly rooted within mind that underpins our approach is the one
the interpersonal context and understood brilliantly advanced by Kernberg over the
within that framework, and they are perhaps past few decades (Kernberg 1975, 1976, 1980,
more inherently integrative in taking not 1984). However, there are also important dif-
only the specific mental processes and be- ferences, and nowhere are these differences
havior of the patient into account but also the more apparent than in our approach to the
relational context. Furthermore, we explic- transference. In the transference focused psy-
itly use transference to explore the meaning chotherapy (TFP) model, patients are seen as
of the patients experience, and we now turn reestablishing dyadic relations with their
to discuss this approach. therapists that reflect rudimentary represen-
tations of selfother relationships of the past
Transference, Interpretation, and (so-called partobject relationships). Thus,
Bearing in Mind the Deficits TFP considers the externalization of these
self-object-affect triads to be at the heart of
Bearing in mind the limited processing ca- therapeutic interventions. We do not differ
pacities of BPD patients in relation to attach- from the TFP therapist in emphasizing the ex-
ment issues, patients cannot be assumed to ternalization process, but we are far less con-
have a capacity to work with conflict, to ex- cerned with the apparent relationship that is
press feelings through verbalization, to use thus established between patient and thera-
metaphor, to resist actions, and to reflect on pist. In our model, the role relationships es-
content, all of which form part of standard tablished by the patient through the transfer-
psychoanalytic process. These attributes de- ence relationship are considered preliminary
pend on a stable self-structure and ability to to the externalization of the parts of the self
form secondary (symbolic) and perhaps ter- the patient wishes to disown. In order to
tiary representations (e.g., your feelings achieve a state of affairs where the alien part
about my thoughts about your wishes) that of the self is experienced as outside rather
buffer feelings, explain ideas, and give con- than within, the patient needs to create a re-
text and meaning to interpersonal and intra- lationship with the therapist through which
psychic processes. Borderline patients en- this externalization may be achieved. The pa-
feebled mentalizing capacity and emergence tient subtly and unconsciously manipulates
of psychic equivalence means that feelings, the therapist to experience particular intense
fantasies, thoughts, and desires are experi- feelings, sometimes quite specific thoughts.
enced with considerable force because they These originally belong to the patient, but af-
cannot be symbolized, held in a state of un- ter a period of coercive interactions they are
certainty, or given secondary representation reassuringly seen by him to be outside, in the
with meaning. Under these circumstances therapists mind. Once the externalization is
the use of metaphor and the interpretation of achieved, the patient has no interest in the re-
conflict are more likely to induce bewilder- lationship with the therapist and may in fact
ment and incomprehension than to heighten wish to repudiate it totally. At these moments
the underlying meaning of the discourse, so the therapist may feel abandoned. Some in-
the use of these techniques is minimized in stances of boundary violations may be re-
MBT. This technical stance has important im- lated to the therapists difficulty in coping
plications for the use of transference. with the implicit rejection entailed by the pa-
Our overall approach owes much to that tients wish to distance himself from the dis-
of Otto Kernberg, John Clarkin, Frank Yeo- owned part of his mind. Focusing the pa-
mans, and their groups (Clarkin et al. 1996, tients attention on the dyad that is established
1998, 1999; Kernberg 1992; Kernberg et al. through the externalization can be seen as
2002). In many respects, the model of the undermining their attempts to separate from
the disowned part of themselves. This focus and service providers. Costs were compared
can be counterproductive, leading the pa- 6 months prior to treatment, during 18 months
tient to prematurely terminate the treatment. of treatment, and at 18-month follow-up. No
cost differences were found between the
Effectiveness of Mentalization- groups during pretreatment or treatment.
Based Treatment During the treatment period, the costs of par-
tial hospital treatment were offset by less
Our initial study (Bateman and Fonagy 1999) psychiatric inpatient care and reduced emer-
of MBT compared its effectiveness in the con- gency department treatment. The trend for
text of a partial hospital program with rou- costs to decrease in the experimental group
tine general psychiatric care for patients with during follow-up was not duplicated in the
BPD. Treatment took place within a routine control group, suggesting that specialist par-
clinical service and was implemented by tial hospital treatment for BPD is no more ex-
mental health professionals without full psy- pensive than general psychiatric care and
chotherapy training who were offered expert leads to considerable cost savings after the
supervision. Results showed that patients in completion of 18 months treatment.
the partial hospital program showed a statis- All patients who participated in the par-
tically significant decrease on all measures in tial hospital treatment trial have now been
contrast with the control group, which followed up with 8 years after initial random-
showed limited change or deterioration over ization (Bateman and Fonagy 2008). The pri-
the same period. Improvement in depressive mary outcome for this long-term follow-up
symptoms, decrease in suicidal and self- study was in learning of the number of sui-
mutilatory acts, reduced inpatient days, and cide attempts. But in light of the limited im-
better social and interpersonal function be- provement related to social adjustment in fol-
gan after 6 months and continued to the end low-along studies, we were concerned with
of treatment at 18 months. establishing whether the social and interper-
The 44 patients who participated in the sonal improvements found at the end of 36
original study were assessed at 3-month in- months had been maintained and whether
tervals after completion of the trial using the additional gains in the area of vocational
same battery of outcome measures (Bateman achievement had been made in either group.
and Fonagy 2001). Results demonstrated that Patients treated in the MBT program re-
patients who had received partial hospital mained better than those receiving treatment
treatment not only maintained their substan- as usual (TAU). Although, while they main-
tial gains but also showed a statistically sig- tained their initial gains at the end of treat-
nificant continued improvement on most ment, their general social function remained
measures in contrast with the control group somewhat impaired. Nevertheless, many
of patients, who showed only limited change more were employed or in full-time educa-
during the same period. Because of contin- tion than the comparison group, and only
ued improvement in social and interpersonal 14% still met diagnostic criteria for BPD com-
function, these findings suggest that longer- pared with 87% of the patients in the compar-
term rehabilitative changes were stimulated. ison group who were available for interview.
Finally, an attempt was made to assess A number of important questions have
health care costs associated with partial hos- arisen from this research. First, although we
pital treatment compared with treatment operationalized treatment for research pur-
within general psychiatric services (Bateman poses, a more detailed manual was required
and Fonagy 2003). Health care utilization of if we were to demonstrate that treatment was
all patients who participated in the trial was generalizable across settings and practitio-
assessed using information from case notes ners and could be applied with fidelity by ge-
nerically trained mental health staff. Second, professionals in the various contexts in which
in common with other treatments of BPD, it individuals with BPD are being treated. We
remains unclear what exactly are the effective claim no originality for the intervention. How
ingredients of treatment. The partial hospital could we? MBT represents the relatively un-
program is a complex, multifaceted interven- adulterated implementation of a combination
tion including analytic and expressive thera- of developmental processes readily identi-
pies, and there is inevitably a milieu effect. fied in all our histories: a) the establishment
We were unable to show that the target of our of an intense (attachment) relationship based
interventions, mentalization, had been en- on contingent mirroring of the mental states
hanced in patients treated within the partial of patients, and b) the coherent re-presenta-
hospital program compared with control pa- tion of their feelings and thoughts so that pa-
tients because of the complexity of measuring tients are able to identify themselves as think-
reflective function. For research purposes ing and feeling in the context of powerful
Fonagy et al. (1998) have now operational- bonds and high levels of emotional arousal.
ized the ability to apply a mentalizing inter- In turn, the recovery of mentalization helps
pretational strategy as reflective function. In- patients regulate their thoughts and feelings,
dividuals are not expected to articulate this which then makes relationship and self-regu-
theoretically but to demonstrate it in the way lation a realistic possibility. Although we
they interpret events within attachment rela- would claim to have identified a particular
tionships. Individuals differ in the extent to method that makes the delivery of this thera-
which they are able to go beyond observable peutic process possible, we make no claims of
phenomena to give an account of their own or uniqueness. Many situations can likely bring
others actions in terms of beliefs, desires, about symptomatic and personality change
plans, and so on, and in BPD patients this ca- by this mechanism. The goal of further re-
pacity is reduced. search is to identify increasingly effective and
We have operationalized MBT as an out- cost-effective methods for generating change
patient adaptation to answer some of these in this excessively difficult group. In pursu-
questions. Outpatient treatment removes the ing this goal there may indeed be nothing
milieu aspect of therapy and focuses solely quite so practical as a good theory, such as the
on mentalization within individual and theory of human bonding.
group analytic therapy. Treatment consists of
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12
Dialectical Behavior Therapy
Barbara Stanley, Ph.D.
Beth S. Brodsky, Ph.D.
Dialectical behavior therapy (DBT) was de- special segments of the psychiatric popula-
veloped in the early 1990s by Marsha Line- tion, such as adolescents (Rathus and Miller
han as a treatment specifically for suicidal 2002) or geriatric patients (Lynch et al. 2003).
and self-injuring individuals with borderline DBT has been evaluated in several effi-
personality disorder (BPD) (Linehan 1993a), cacy studies, and it is currently undergoing a
a population with a broad range of serious large-scale evaluation under our direction,
problems in addition to suicidality (Kehrer funded by the National Institute of Mental
and Linehan 1996). A form of cognitive- Health (NIMH), at the New York State Psy-
behavioral psychotherapy, DBT can be chiatric Institute/Columbia University De-
adapted for use in other personality disor- partment of Psychiatry. In this chapter, we
ders, particularly those in which there is sig- summarize DBT as described in the two pub-
nificant behavioral and emotional dyscontrol lished treatment manuals (Linehan 1993a,
(Stanley et al. 2001). However, other than its 1993b) and as we apply it in our efficacy
use in BPD to date, most adaptations of DBT study (Stanley et al. 2007).
have been directed toward Axis I diagnoses, DBT was developed in response to the
such as eating disorders (Telch et al. 2001), or need for empirically supported psychothera-
This work was supported in part by National Institute of Mental Health grants R01 MH61079, MH062665,
and P20AA015630 to Dr. Stanley.
The authors would like to thank Alex Chapman, Ph.D., postdoctoral fellow in Behavior Research and
Therapy Clinics, under the direction of Marsha Linehan, Ph.D., of the University of Washington, for his
thoughtful comments on an earlier draft of this chapter.
235
pies for chronically suicidal individuals with the components of standard DBT treatment as
BPD. Although originally developed for the developed for individuals with BPD who ex-
self-injuring, it is also used in the segment of perience self-injurious and suicidal behavior,
the BPD population that does not exhibit discusses basic DBT techniques and strate-
self-harm behaviors (Robins et al. 2001). gies, reviews the empirical findings of its effi-
Treatment retention of individuals with BPD cacy, and provides case material demonstrat-
is a well-known and significant problem, as ing crucial aspects of the treatment. The intent
is their lack of progress and dissatisfaction of this chapter is to provide an overview of
with their therapies. At the time when DBT DBT and illustrate how it uniquely addresses
was developed, empirical support for exist- the difficulties specific to the treatment and
ing therapies, including supportive and psy- retention of individuals with BPD. For a com-
chodynamically oriented treatment, was prehensive description of DBT, the treatment
lacking. Cognitive-behavioral therapy (CBT) manuals (Linehan 1993a, 1993b) should be
showed efficacy in patients with depression consulted.
and anxiety disorders, but individuals with
BPD had trouble tolerating standard CBT
(Dimeff and Linehan 2001). CBT places a
THEORETICAL PERSPECTIVES
strong emphasis on change strategies that,
by themselves, are very difficult for individ- Biosocial Theory of Borderline
uals with BPD to accept and utilize. BPD pa- Personality Disorder
tients tend to experience an almost exclusive
focus on change as criticism and invalidation DBT was developed from a particular theo-
of their suffering rather than its intent as retical perspective on the nature of BPD
helpful. This approach, in turn, exacerbates (Linehan 1987, 1993a). BPD is viewed as a
their already harsh self-criticism and contrib- disorder of dysregulationdysregulation of
utes to their poor retention rate in therapy. behavior, affect, cognition, and interpersonal
In attempting to tackle this problem, DBT relationships. The chronic suicidal behavior
explicitly emphasizes the need to balance characteristic of many individuals with BPD
change strategies with acceptance and vali- is seen as a consequence of these dysregula-
dation techniques. This balance is important tions. The biosocial theory (Linehan 1993a)
for two primary reasons. First, acceptance on which DBT rests attributes the dysregula-
and change, in and of themselves, are impor- tion to a transaction between an inborn emo-
tant ingredients in any successful psycho- tional vulnerability and an emotionally in-
therapy. Many problems and issues con- validating childhood environment. The
fronted in psychotherapy cannot be changed. biologically based emotional vulnerability is
An obvious example is past history and characterized by an intense, quick reaction to
childhood experiences. Patients are some- emotionally evocative stimuli in the environ-
times entrenched in a place of nonacceptance ment, along with a slow return to baseline af-
about their past and consequently are unable ter emotional arousal. The invalidating envi-
to move beyond a stance that it should not ronment consists of caretakers who may
have happened. Second, acceptance and punish, ignore, reject, and/or disregard the
change have a dynamic interplay that creates childs emotional experience and therefore
a dialectic. Increased acceptance enables do not provide conditions in which the in-
greater change, and more change allows for dividual can learn to regulate emotional ex-
increased tolerance and acceptance of what periences. A transaction between these two
cannot be changed. elementsin which 1) the emotional sensi-
This chapter describes the theoretical un- tivity leads to increased perception of threat
derpinnings of DBT, provides an overview of in interpersonal situations and 2) the invali-
Dialectical Behavior Therapy 237
dating response from the environment exac- It is important to note that this theoretical
erbates the emotional vulnerabilityresults stance does not ascribe weights to how
in a propensity to dysregulation. Linehan much biological vulnerability and environ-
(1993a) also applies learning theory to ex- mental invalidation is necessary to yield
plain how the emotionally vulnerable indi- BPD. If an individual has a biological predis-
vidual develops self-destructive behaviors to position to emotional sensitivity, vulnerabil-
obtain a nurturing response from the invali- ity, and reactivity, he or she is likely to be
dating environment. As the behaviors esca- more easily hurt. Patients with preexisting
late, they are intermittently reinforced, mak- vulnerability experience hurt more deeply,
ing them very difficult to unlearn. react more strongly, and have a greater pro-
The most egregious example of an invali- pensity to feel invalidated. Thus, it can be
dating environment would be one involving challenging to provide a validating and sup-
sexual abuse, physical abuse, or neglect. Be- portive environment for the emotionally
sides being a clear example of invalidation of sensitive child. Finally, it is also important to
the childs needs, the experience of childhood underscore the fact that this theoretical per-
abuse and neglect is often characterized by spective awaits empirical validation. Al-
much inconsistency and conflict as the child though some research has begun to examine
experiences both nurturing and abuse/ne- this theory of BPD, at this point it remains a
glect from the same caretaker. Given the high theoretical perspective, and it may be shown
prevalence of reported childhood abuse ultimately that either biological predisposi-
among individuals with BPD (Brodsky et al. tions or environmental factors are the over-
1995; Herman et al. 1989; Ogata et al. 1990), riding determinants of BPD. Nevertheless,
the biosocial theory maintains that abuse can- like other forms of psychotherapy, DBT was
not be ignored as contributory to the etiology developed from a theoretical orientation, but
of BPD. Nor is abuse thought to have been its techniques and applicability are not de-
present in all individuals who develop BPD. pendent on it.
Less explicit forms of invalidation such as re-
peated dismissal or denial of a childs emo- Treatment Theoretical
tional experience and reinforcement of mal- Underpinnings
adaptive coping mechanisms can also lead to
severe impairment in self-regulation (Stanley DBT is a theoretically and philosophically
and Brodsky 2005). For example, if children coherent treatment, with dialectical philoso-
who cry in response to disappointments are phy at its core, embedded within which is be-
repeatedly told You have nothing to cry havioral science (learning principles) and
about, the result is often not what is in- Zen mindfulness practice (Linehan 1993a).
tendedthat is, to make them feel better. In- These perspectives have direct applicability
stead, if it is a frequent occurrence, children in the treatment techniques and the under-
begin to mistrust their inner states and be- standing of patients and their problems.
come unable to read their own emotional
cues. Children begin to question whether in
fact there is something to cry about and be- LEARNING PRINCIPLES
come confused about their internal sense of
upset and uncertain about what they are feel- The predominant theoretical approach of
ing. If carried forward into adulthood, their DBT is learning principles. An exhaustive re-
emotional experiences remain somewhat view of learning principles is beyond the
mysterious to them. Emotions are misper- scope of this review, but in brief, behaviors
ceived, misread, mistrusted, and experienced are understood as maintained through either
as an unidentifiable jumble of upset. operant or classical conditioning. This dis-
tinction serves to shape the way in which be- team is a source of support and guidance as
havior change should be approached. If a well as an aid to keep the therapist focused
maladaptive behavior is understood as main- on the treatment goals and format.
tained through operant conditioning, re-
moval of reinforcers is called for. Alterna-
tively, positive reinforcement of adaptive MINDFULNESS ORIENTATION
behaviors can be implemented. If a maladap-
tive behavior is maintained through respon- Certain aspects of Eastern philosophy are in-
dent (classical) conditioning, loosening the tegral to DBT (Robins 2002), particularly a fo-
connection between the conditioned and un- cus on acceptance and the importance of
conditioned stimuli is important. mindfulness practice. Linehan (1997) ob-
Although learning principles are promi- served that an exclusive focus on change in
nent in all forms of CBT, some forms of CBT behavior therapy is experienced as invalidat-
emphasize the importance of, and therefore ing by traumatized or rejection-sensitive in-
focus on, the role of cognitions. Other forms dividuals, and it can result in early dropout
of CBT place an emphasis on behavior. For or resistance to change within the treatment.
example, the CBT developed by Beck em- Therefore, the DBT strategy involves accep-
phasizes the importance of distorted cogni- tance of whatever is valid about the individ-
tions (Beck et al. 2003). Exposing and exam- uals current behaviors, viewing these be-
ining these faulty cognitions then becomes haviors as the patients best efforts to cope
an important focus of the treatment. Correct- with unbearable pain. However, Linehan
ing them is believed to be the pathway to (1997) also noted that ignoring the need for
change. Alternatively, DBT places a greater change is just as invalidating because it does
emphasis on emotion. Given the behavioral not take the problems and negative conse-
perspective, DBT defines cognition as behav- quences of the patients behavior seriously.
ior. DBT focuses on understanding that This can lead to hopelessness and suicidality.
reinforcers maintain a maladaptive behavior Thus, acceptance and validation are com-
and attempts to loosen the links that lead to bined with change strategies. The balance of
the behavior through a variety of means. change with acceptance is one of the most
This focus does not imply that DBT never ex- unique aspects of the dialectical approach
amines distorted cognitions or that Becks (described in the next section) and is solidly
CBT never examines behavioral reinforcers. based in the Zen mindfulness perspective.
Instead, CBT varies in its approach to prob- Change is achieved through the tension and
lems, as do the variety of psychodynamically resolution of this essential conflict between
oriented psychotherapies. acceptance of individuals as they are right
DBT aims to provide increased support now and the demand that they change. Thus,
for patients to remain safe on an outpatient the dialectical strategy encourages cognitive
basis as well as support for the therapist restructuring from an either/or to a yes/
working with the chronically suicidal outpa- and perspectivedirectly addressing the
tient. This goal is achieved through applying dichotomous thinking that is characteristic
learning principles toward capability and of individuals with BPD and that often leads
motivation enhancement of both patient and to maladaptive behaviors (Linehan 1997).
therapist. Patient capability is enhanced Mindfulness practice teaches controlling
through the teaching of adaptive skillful be- the mind to stay in the present moment with-
haviors, and motivation is enhanced through out judgment. This practice is extremely use-
the reinforcement of progress and nonrein- ful in helping patients remain in the present
forcement of maladaptive behaviors. For the rather than focusing on past worries or fu-
therapist, a DBT outpatient consultation ture fears. As patients fight urges to hurt
themselves, mindfulness practice is useful in enhancing motivation, and it removes blame

helping them distract themselves from from the patient regarding lack of moti-
urges, and it ultimately helps them to reduce vation. This approach is particularly helpful
the intensity of their urges. to patients who experience tremendous,
crippling self-blame that can inhibit taking
chances and extending themselves in both
DIALECTICAL APPROACH therapy and life generally.
DBT is based on a dialectical perspective rep-

resenting a reconciliation of opposites by TREATMENT COMPONENTS:
arriving at a synthesis of these opposites. A
dialectical worldview is the overarching per-
A TWO-PRONGED APPROACH
spective in DBT and is manifest in the strate- DBT consists of two components in which pa-
gies and assumptions of the treatment. Ther- tients participate: individual psychotherapy
apists create a balance between accepting the and group skills training. This approach de-
patients dysfunctions and helping patients rives from a point of view not only that indi-
modify their thinking and behavior. The dia- viduals need to understand their maladap-
lectical philosophy leads to the following as- tive patterns of behavior as they occur in
sumptions that underlie DBT. The first ex- individual psychotherapy but that they also
plicit assumption is that patients are doing have certain deficits that can best be over-
the best they can. At the same time, patients come by developing a means of compensa-
want to improve, but they need to do better, tion and skills. These patients often report
try harder, and be more motivated to change. that they know why they do what they do
A second assumption is that patients may not but they do not know what to do instead or
have caused all of their own problems, but how to get themselves to do what they know
they have to solve them anyway. An addi- they should do. Although the first half of this
tional assumption is that patients cannot fail statement may be only partially correct, the
in therapy; rather, if failure occurs, it is the second half is almost always true. A two-
treatment that fails (Linehan 1993a, 1997). pronged approach to treatment acknowl-
These philosophical assumptions serve edges this problem by adopting a stance that
to enhance motivation and inform the thera- patients may need to be taught coping strate-
peutic stance at all times (Cialdini et al. 1975; gies and skills in a more explicit manner than
Freedman and Fraser 1966). For example, the is typically done with patients who have per-
first assumption encourages a nonjudgmen- sonality disorders. Thus, this approach sug-
tal approach and discourages negative think- gests that both an understanding of maladap-
ing on the therapists part in the face of ongo- tive patterns of thinking and behavior and
ing difficult patient behavior. The second skill development are useful in treating pa-
assumption validates the need for change, tients with personality disorders. Personality
without blame or judgment, and promotes disorders are seen, in part, as deficits in cer-
effective problem solving. Furthermore, it tain skill areas that prevent the person from
also underscores the belief that the therapist behaving in an effective manner. In addition
cannot save the patientthe patient must do to these two forms of patient contact, a con-
most of the work with the help of the thera- sultation team for DBT therapists is consid-
pist. The therapists role is to encourage self- ered an integral aspect of the treatment.
care rather than to take care of the patient. If
the patient does not make progress, gets Individual Therapy
worse, or drops out of treatment, the burden
of the failure is assumed by the therapy Patients attend at least one, sometimes two,
that is, that the therapy was not successful in individual therapy sessions of 5060 minutes
each week. Double sessions of 90110 min- tice, behavior rehearsal, homework, and re-
utes can be utilized (Linehan 1993a). Al- inforcement of socially appropriate behav-
though not always possible, it is desirable to iors. Behavior change is facilitated by the
have the flexibility to alter session lengths de- combination of the direct instruction of infor-
pending on the patients needs and the task at mation, modeling of behaviors by role mod-
hand. For example, patients who have diffi- els, prompting of specific behaviors, and
culty opening up or who have trouble closing positive reinforcement of successive approx-
up at the end of sessions may benefit from imations toward the desired goal. The spe-
longer sessions for a period of time until they cific goal or behavior to be changed will dif-
develop the capacity to transition in and out fer depending on the patients presenting
of sessions. Also, there are times when the problem. The teaching of skillful behaviors
type of treatment work benefits from longer with which to replace the maladaptive ones
sessions. When conducting trauma exposure is a major component of capacity enhance-
sessions, longer session lengths are required. ment in DBT. Attending a weekly skills train-
Alternatively, some patients have difficulty ing group in which skills are taught within a
tolerating the intense closeness that can be ex- didactic framework, preferably by a thera-
perienced in individual treatment for more pist other than the individual therapist, is an
than brief periods of time. While this capacity essential component of the treatment. The
to tolerate closeness is being worked on with group serves to introduce and teach the con-
the patient, allowing briefer sessions avoids cepts of skills, and it provides an opportunity
premature termination. to interact with other patients who are also
The individual therapy session is struc- learning skills. A skills training manual
tured by the treatment hierarchy and a num- (Linehan 1993b) describes the skills and how
ber of behavioral techniques. Any life-threat- to teach them and contains worksheets and
ening behaviors (target 1) are the top priority homework assignments to facilitate learning.
and must be addressed within an individual In vivo skills coaching is conducted in such a
session if they have occurred. Therapy-inter- way as to enhance patient capability and mo-
fering behaviors (target 2) are the second in tivation.
priority and are the first priority in the ab- The first step in the process of skills train-
sence of life-threatening behaviors. As long ing is the assessment of the skill deficit,
as target 1 and 2 behaviors are either absent which in DBT takes place in the individual
or addressed within a session, quality-of-life therapy session. Once the specific deficit has
issues may also be targeted within any given been identified, skills training may be imple-
session. The patient is required to keep a mented. Direct instruction on the skill to be
daily record of behaviors, level of misery, learned begins the training. This instruction
and suicidal ideation on what is called a diary gives the patient the required knowledge to
card (Linehan 1993b) (described in more de- perform the skill. Next is modeling, by the
tail later). Therapist and patient review the therapist or skills trainer, of the skill behavior
diary card together and use it to create an to be learned. Modeling has many functions
agenda for the session. If the patient engaged for the patient (Spieglar and Guevremont
in self-injury, a behavioral analysis (de- 1998). First, it teaches the patient a new be-
scribed later) is required. havior through observation of a model. Sec-
ond, the patient is prompted to perform a be-
Skills Training havior after observing a model engage in the
behavior. Third, the patient is motivated to
Skills training is generally based on learning engage in similar behavior after observing
theory and utilizes behavioral principles the favorable consequences it receives,
such as shaping, modeling, repeated prac- which is the concept of vicarious reinforce-
areas of dysregulation of BPD: mindfulness

Table 121. Dialectical behavior therapy
skills address cognitive dysregulation, dis-
skills training modules
tress tolerance skills address behavioral dys-
I. Mindfulness regulation, emotion regulation skills address
A. Focus on the moment affect dysregulation, and interpersonal effec-
B. Awareness without judgment tiveness skills address dysregulation of inter-
II. Distress tolerance personal relationships (Table 121).
A. Crisis survival strategies Although the modules were developed
B. Radical acceptance of reality for BPD, they have broad applicability to
III. Emotion regulation other problems and disorders, such as avoid-
A. Observe and identify emotional ant, dependent, and paranoid personality
states disorders (Stanley et al. 2001). The individual
B. Validate and accept ones emotions modules have been designed to remedy a
C. Decrease vulnerability to negative specific dysfunction; however, they reinforce
emotions each other, thus creating a comprehensive
D. Increase experience of positive treatment of the whole patient.
emotions The first module is core mindfulness skills
IV. Interpersonal effectiveness training, which focuses on dysregulations of
A. Assertiveness training self and cognition. Mindfulness skills are
B. Cognitive restructuring based on Eastern Zen Buddhist principles.
C. Balance objectives with maintaining Patients are taught techniques for focusing
relationships and self-esteem their thoughts and attention on the present,
establishing attentional control, and cou-
ment. Lastly, after observing a person who is pling awareness with nonjudgmental think-
serving as a model safely engaging in the ing. The goal is to help the patient establish a
anxiety-provoking behavior, the patients lifestyle of mental awareness and inner con-
anxiety is decreased. nectivity.
After the skill has been modeled for the The second module is distress tolerance
patient, it is the patients turn to perform the skills training, which focuses on teaching
behavior, often referred to as behavior re- skills to help the patient tolerate and deal
hearsal. The first step is prompting or remind- with problems such as impulsivity and sui-
ing the patient to perform a behavior. Next is cidal ideation. The fundamental goal of this
the process of shaping, which is the reinforc- module is learning the skills of both distract-
ing of components of the target behavior that ing from a distressing situation and accept-
are successively closer approximations of the ing situations when they cannot be changed.
actual target behavior. Feedback is given to Distress tolerance skills focus on how to live
the patient regarding success, and there is re- through a crisis situation without engaging
inforcement of the behavior results. After the in destructive behaviors. Crisis survival
skill has been rehearsed or practiced, the pa- strategies include self-soothing and distract-
tient is then asked to participate in a role- ing techniques, pro-and-con analyses, and
play situation that requires use of the skill. strategies for accepting reality rather than
Outside of skills training sessions, patients fighting it.
may be asked to complete homework assign- The third skill module is emotion regula-
ments that will require more use of the skill. tion, which teaches the necessary skills to
Eventually, this repeated practice will lead to control dysregulated experiences and ex-
mastery of the targeted skill or behavior. pressions of anger, anxiety, fear, and depres-
Linehan (1993b) outlined four specific sion as well as dysregulated positive emo-
skills training modules that target the four tions such as love and joy. Emotion regulation
skills include observing and identifying stress. The individual therapist identi-
emotional states and validating and accept- fied the need for the patient to develop
ing ones emotional reactions. There are also more skillful coping mechanisms to re-
place the binge eating and impaired in-
techniques for decreasing vulnerability to
terpersonal functioning and referred
negative emotions and increasing the experi- her for adjunct DBT skills training. Al-
ence of positive emotions. though Ms. K was not initially inter-
Finally, the fourth module is interpersonal ested in changing her interpersonal
effectiveness training, which exposes border- behaviors, because she viewed her dif-
line patients to effective strategies for mend- ficulties with her supervisors as exter-
ing interpersonal conflict. Interpersonal ef- nal to herself, she was highly motivated
fectiveness skills incorporate assertiveness to gain control over her eating and
agreed to undergo skills training.
training techniques with cognitive restruc-
Ms. K immediately took to the skills
turing. Patients are encouraged and taught to training. She found the mindfulness
challenge distorted cognitions related to in- skills extremely helpful in allowing her
terpersonal interactions and to identify and to observe and describe urges to binge,
stay mindful of their goals within these inter- which gave her increasing control over
actions. They learn techniques for effectively her eating behaviors. She learned dis-
making requests or saying no to unwanted tress tolerance skills that helped her dis-
tract from and also tolerate the feelings
demands and balancing their objectives with
of anger and emptiness without resort-
maintaining relationships and self-esteem. ing to binge eating. She was able to use
the support of the other group members
Case Example to observe her interpersonal patterns,
and she became more willing to try new
Ms. K is a highly intelligent 28-year-old ways of interpreting the behaviors of
woman working as a secretary and others. She described it thus: Mindful-
studying for her bachelors degree. She ness skills helped me more clearly dis-
lives with her boyfriend of 6 years; the tinguish between my thoughts and be-
two were in couples therapy seeking haviors in an interpersonal interaction
help in deciding whether to get mar- and what the contribution of the other
ried. Ms. K was referred by the couples person was.
therapist to individual therapy for the
treatment of binge-eating disorder: the
patients obesity and out-of-control
binge eating were interfering with the STAGES OF TREATMENT AND
couples sex life. During the course of TREATMENT HIERARCHY
individual psychotherapy, it became
apparent that the patient was exhibiting DBT has four stages of treatment. Stage 1
symptoms of BPD that were contribut-
specifically targets the reduction of life-
ing to the primary difficulties in her re-
threatening behavior and is therefore the
lationship with her boyfriend. Her
binge eating was an impulsive behavior most researched and of particular interest to
that was often triggered by fears of clinicians who treat the chronic suicidality of
abandonment, feelings of emptiness, BPD patients on an outpatient basis. Within
and identity diffusion, and the binge the context of treating self-injury, other be-
eating was a self-soothing mechanism havioral, interpersonal, cognitive, and emo-
for feelings of uncontrollable rage. The tional difficulties are also addressed. These
patient was also having difficulties in
include behaviors that interfere with the
her relationships with supervisors at
work due to a tendency to idealize, and therapy and interpersonal difficulties. Once
then devalue, those in authority and to a patient has control over self-injurious be-
feel used and victimized and view the haviors, the patient enters into stage 2. Stage
supervisors with suspicion when under 2 in DBT helps patients increase emotional
experiencing. Because many individuals Case Example

with BPD have a history of childhood abuse
(Brodsky et al. 1995; Herman et al. 1989), ex- Ms. L is a 28-year-old, single white
posure-based procedures are used to treat woman living with two roommates in a
major metropolitan area. She was re-
the residue of childhood trauma (Foa 1997).
ferred to DBT from a day program she
Other quality-of-life issues, such as self-actu- had been attending for 3 months fol-
alization in social and vocational arenas, be- lowing hospitalization for a suicide at-
come the target of treatment during stage 3. tempt. The suicide attempt consisted of
Finally, stage 4 treatment focuses on increas- a serious overdose of her roommates
ing joy and a sense of completeness and con- benzodiazepines, which Ms. L took im-
nectedness. pulsively after an argument with her
boyfriend. She had lost consciousness,
was found by her roommate, and was
taken to the emergency department
HIERARCHY OF TREATMENT GOALS where she received gastric lavage. She
regained consciousness after a few
A standard hierarchy of goals is built into hours, and other vital signs were not af-
stage 1 DBT (Table 122). The primary goal is fected.
At the time of the attempt, Ms. L
the reduction of life-threatening behaviors.
was taking art courses and looking for a
The first task of the clinician is to establish a
position as an office worker. In the past,
commitment from the patient to accept this after graduating from college, she had
hierarchy of goals, particularly the primary worked as an administrative assistant
one of reducing self-injury. The sessions in at a bank for about 2 years until she be-
which this commitment is negotiated are came depressed, somewhat paranoid,
considered the pretreatment phase. and angry. She would miss work fre-
A second goal in stage 1 is the reduction quently and get into altercations with
coworkers when she was there. As she
of therapy-interfering behaviors. Such be-
described it, I stopped coming to work
haviors include lateness, missed sessions (of because I felt as if my boss was deliber-
individual and/or skills groups), failure to ately trying to give me a hard time. She
keep a diary card (described later), and any was referred to DBT because she had
other behavior on the part of the patient or been diagnosed with BPD and was in-
therapist that interferes with the therapy. The termittently suicidal. She experienced
third goal is the reduction of quality-of-life- suicidal ideation, she occasionally en-
gaged in self-injury consisting of cut-
interfering behaviors, such as interpersonal
ting her inner arm without intent to die,
difficulties and personal and vocational her mood fluctuated from depression to
functioning. anger to feelings of emptiness, and she
had interpersonal difficulties due to in-
creased guardedness and suspicious-
Table 122. Hierarchy of dialectical ness when she was under stress. She re-
behavior therapy goals in ported a severe history of repeated
stage 1 sexual abuse at the hands of her stepfa-
ther between the ages of 8 and 12. When
1. Reduction of life-threatening behaviors drunk he would enter her room at night
and would frighten her into having in-
2. Reduction of therapy-interfering
tercourse and remaining quiet about it.
behaviors
This abuse ended when her mother and
3. Reduction of quality-of-life-interfering stepfather divorced. Ms. L suspected
behaviors that her mother knew about the abuse
but was uncertain that this was the case.
She developed an inability to trust her
own perceptions and had a very con- hopelessness, and the horror of her
flicted relationship with her mother, childhood abuse.
whom she perceived as weak and in The use of validation strategies over
need of protection. Ms. L had a treat- a number of sessions allowed Ms. L to
ment history of not regularly attending feel that the therapist understood the
therapy and not remaining with one disruption that her trauma history
particular therapy treatment for more caused her in all areas of her life, despite
than a few months. She reported on in- the insistence on reducing her self-
take that she had never found therapy injury. The therapist explained that she
very helpful and never felt that she was very interested in working with
could allow herself to trust a therapist Ms. L on healing from the trauma.
to understand or help her. However, Ms. L needed first to be able
Following the DBT hierarchy, the to control the life-threatening behaviors
therapist identified treatment goals and increase her adaptive coping strat-
with Ms. L. Target 1 was the reduction egies for dealing with the painful feel-
of life-threatening behaviors. For Ms. L, ings surrounding the trauma. Ms. L and
these were suicide attempts in the form the therapist eventually made a com-
of overdoses, nonsuicidal self-cutting mitment to work together to reduce her
behaviors, and suicidal ideation. Target self-injury.
2 was the correction of treatment-inter- Consistent attendance to therapy
fering behavior; Ms. L needed to attend was identified as a second goal of treat-
therapy and skills training group ses- ment. Finding employment would be a
sions consistently and on time and with third, a quality-of-life goal that they
diary card and skills homework pre- would work toward in the absence of
pared. Target 3 would attend to quality- self-injury or therapy-interfering be-
of-life issuesin this case, finding and havior. Although Ms. L agreed to focus
maintaining employment. on reduction of self-injury as the pri-
The main challenge was to obtain mary goal, the therapist agreed to bal-
Ms. Ls commitment to the goal of re- ance this focus with understanding that
ducing self-injury. From the patients the suicidal feelings and self-injury
perspective, the self-injury was not were validations of Ms. Ls pain. Several
problematic. She would vacillate be- times during the course of Ms. Ls treat-
tween feeling that having to live with ment she would miss a session only to
the horrible feelings and memories is return and insist that she needed to fo-
just too much to bear and suicide feels cus on the trauma and not on the reduc-
like the only way out and feeling that tion of her self-injury. Later analysis re-
I dont think I will do something stu- vealed that she had felt invalidated by
pid like that [overdosing on pills] again; too strong an emphasis on change in the
Im not suicidal anymore. Her stated previous session. At these times, the
goal for treatment was to work through commitment needed to be revisited on
her childhood trauma, which was the both sides: Ms. Ls commitment to re-
main cause of her unhappiness and ducing her behaviors, and the thera-
hopelessness. pists commitment to balancing change
Every time the therapist asked Ms. with validation.
L to commit to the goal of reducing her
self-injury, she would respond, You This case demonstrates the DBT treatment
just dont get it, start crying, and with- hierarchy and how it is implemented when
draw from interaction. Ms. L was expe- working with patients. In Ms. Ls case, the pa-
riencing the focus on change of her be-
tient was experiencing an overwhelming
havior as invalidation of her trauma
history. Thus, the therapist imple- number of problems simultaneously. Having
mented the foot in the door rather a treatment hierarchy provided both the pa-
than the door in the face techniques. tient and the therapist with a road map for
This intervention required a major fo- the treatment and helped to prevent the con-
cus on validationof the pain, the tinual putting out of fires that can charac-
terize many treatments with BPD individu- Crisis Management, Coaching, and
als. This latter approach often comes at the Intersession Contact
expense of working on longer-term goals and
issues that will equip the individual for lead- Therapist availability between sessions is
ing a more functional and independent life. critical when treating suicidal patients. In
DBT, in vivo skills coaching is conducted by
the individual therapist to provide the neces-
MAJOR TREATMENT TECHNIQUES sary support for learning new behaviors in
the moment. Patients are encouraged to call
AND STRATEGIES
or page individual therapists between ses-
A broad range of techniques is employed in sions when they are fighting urges to self-
DBT. An exhaustive review is beyond the injure and require help in implementing a
scope of this chapter. Instead, in this section substitute skillful behavior. During these
we give some examples of the major tools phone contacts, the therapist and patient de-
and techniques to give the reader a sense of cide on a number of skillful ways of handling
how the treatment is conducted. the current stressful situation. Skills coach-
ing through phone consultation is also a
Behavioral Analysis strategy for encouraging the generalization
of skillful behavior to other life situations.
A major change technique used in the indi- Rather than resulting in constant calling
vidual session is the step-by-step behavioral by the patient, phone contacts are focused
analysis of self-injurious or therapy-interfer- and limited to skills coaching and relation-
ing behaviors. The dialectical approach to ship repair. If the patient calls but is not really
behavioral analysis is unique to DBT. This interested in problem solving, the therapist
approach involves identifying the vulnera- indicates availability when the patient is in-
bility the patient brings to the situation, the terested in skills coaching and quickly ends
precipitating event, and the reinforcing con- the contact. If skills coaching is agreed on,
sequences of the self-injurious behavior. The therapist and patient quickly review which
positive consequences for the patient, such skills the patient has already tried, and the
as immediate relief from unbearable emo- therapist cheerleads and helps the patient
tional pain, are highlighted and validated. generate a plan to try new skills. The thera-
The patient and therapist then collaborate in pist praises the patient for calling and vali-
reconstructing the series of events (thoughts, dates the difficulty of tolerating the pain and
feelings, actions, and environmental events) trying a new behavior. These contacts are
that led to the self-injury. The therapist asks generally brief and goal directed, often result
for as much detail as possible and weaves so- in the prevention of self-injury, and therefore
lutions or alternative skillful behaviors the are positively reinforcing for the therapist (if
patient might have used into the thread of not the patient).
the analysis. Behavioral analysis is a useful The 24-hour rule of DBT states that pa-
tool for gaining understanding into the emo- tients cannot call the therapist for 24 hours af-
tional and behavioral events that lead to an ter they have engaged in self-injury. This rule
unwanted behavior and for generating spe- does not apply to scheduled appointments. If
cific solutions. It is also built into DBT as an a patient calls the therapist after the fact, the
aversive consequence of the maladaptive be- therapist, once ascertaining that the patient is
havior. The expectation of spending a good safe from further self-harm, expresses regret
portion of the next therapy session involved that they cannot speak for the next 24 hours.
in a painstaking analysis of a self-injurious The therapist wishes out loud that the patient
act often serves as a deterrent. had called sooner so he or she could have re-
ceived skills coaching and support. The ther- contacts the therapist. Ms. Ms boy-
apist then expresses the desire to hear from friend had called her at the last minute
the patient as soon as the 24-hour period is the previous evening to cancel their
plans because he wanted to see a friend
past. Thus, patients are encouraged to call be-
first and then meet later. She became
fore they engage in self-injurious behavior, very angry with him and told him not to
giving the therapist a chance to intervene. bother coming at all. She then felt very
The rationale for this rule is to avoid rein- lonely and guilty that she had yelled at
forcement of life-threatening behavior and to him. She became agitated, lying awake
provide the opportunity for reinforcement of all night thinking that he would leave
appropriate help-seeking behavior. her. She then took the pills to help her
If a patient uses between-session contact get to sleep.
The therapist reminded the patient
inappropriately and begins to burn out the
that it might have been helpful to page
therapist, it is addressed as a therapy-inter- the therapist before taking the pills,
fering behavioraddressed by conducting evaluated the patients current safety,
behavioral analyses, generating solutions, and determined with the patient that
and applying skills to the reduction of the be- she should go to the emergency depart-
havior. ment to get a medical evaluation. Ms. M
expressed a desire to be admitted to the
hospital because she was tired and
Case Example needed a rest. She stated that she did
not really want to kill herself but was
Ms. M is a 24-year-old female with a his-
not sure she could prevent herself from
tory of more than 20 brief psychiatric
taking pills again and that she wanted
hospitalizations for suicidality. In re-
to go to the hospital to get away from
sponse to her distress, Ms. M often takes
things and have a rest. The therapist
overdoses of available medications and
validated her feelings of wanting a rest
then goes or is taken to the emergency
but also reminded her of all that they
department. These visits usually result
had been working on and expressed the
in hospitalization, which Ms. M finds
wish that Ms. M would stay out of the
both helpful (because it gives her a rest
hospital so that they could have their
from the troubles of her life) and dis-
outpatient appointment the next day.
ruptive (because of the negative reac-
The therapist offered to do whatever
tions of family and friends and because
she could to help the patient tolerate
she misses work and other responsibil-
staying out of the hospital and not re-
ities). Ms. M expressed a desire not to be
sort to taking another overdose. The
hospitalized anymore. The therapist
therapist reminded Ms. M that it was
suggested that developing a safety plan
her choice whether to present herself to
would help in the short term while
the emergency department as in need of
skills and strategies were being devel-
hospitalization. The therapist encour-
oped to handle distress.
aged Ms. M to call from the emergency
About 6 months into Ms. Ms treat-
department so that the therapist could
ment, she paged her therapist on a Sun-
either coach her to stay out of the hospi-
day morning because she had taken a
tal or engage the hospital staff to make
handful (1012) of pills to help her
them aware of the treatment goals.
calm down after being very upset by an
Ms. M called as requestedshe had
interaction with her boyfriend. The pa-
been medically cleared but still wanted
tient said she could not remember ex-
to be hospitalized for a rest. The thera-
actly which pills she took. It is impor-
pist spoke with emergency staff and
tant to note that although the 24-hour
asked them to evaluate her suicidality.
rule emphasizes the importance of
The therapist also encouraged them to
asking for help prior to engaging in a
make their decision to hospitalize based
self-injurious behavior, the safety of the
on the current level of suicidality rather
patient is evaluated and a safety plan is
than the patients desire to be hospital-
developed at any point that the patient
ized. The therapist indicated that she feel a great deal of shame about their behav-
would be willing to see Ms. M the next iors. If the shameful behaviors are not re-
day as an outpatient and work with her corded on the card, patients often feel too
to keep her safe outside the hospital.
embarrassed to bring them up. Surprisingly,
Ms. M called later that day, complaining
that the emergency staff had made her
although some patients do not record all rel-
wait 10 hours and she just wanted to go evant behaviors and urges on the cards, it
home. The therapist let Ms. M know seems easier for patients to be truthful and
that she was looking forward to seeing record these items on the cards than to take
her the next day for their appointment. the initiative of bringing up these behaviors
and urges in a session. Diary cards jog the
This case illustrates how a DBT approach memory of patients and often result in hav-
works both to ensure the safety of a poten- ing available information that would never
tially suicidal patient in crisis and to encour- have been brought up or recollected.
age the patient to stay out of the hospital and
continue building a life worth living. This vi-
gnette also describes the way in which DBT
encourages managing the contingencies in VALIDATION
the environment (working with the emer-
Validation is a strategy that is used in many
gency department staff) in order not to rein-
forms of psychotherapy including support-
force less skillful behavior and to promote
ive, psychodynamic, and client-centered
more skillful behavior (i.e., encouraging Ms.
therapies. Linehan (1993a) presented the es-
M to figure out a way to control her suicidal
sence of validation in the context of DBT psy-
urges and to stay out of the hospital and re-
chotherapy: The therapist communicates to
sume outpatient therapy).
the client that her responses make sense and
are understandable within her current life
Diary Cards context or situation. Validation strategies re-
Patients use diary cards to keep track of all quire the therapist to search for, recognize,
target 1 problems (life-threatening and self- and reflect to the client the validity inherent
injurious behaviors as well as behaviors that in her response to events (p. 223). Valida-
have an impact on target 1 problems) on a tion is at the core of the acceptance/change
daily basis. Some examples of these prob- dialectic and is a crucial aspect of the thera-
lems might be overall mood, use of nonpre- peutic approach in DBT. Linehan therefore
scribed substances, urges to self-injure, and delineated five levels of validation: 1) listen-
adherence to medication regimens. In addi- ing and observing; 2) accurate reflection;
tion, the therapist and patient decide to- 3) articulating the unverbalized; 4) validat-
gether about any other important behaviors, ing in terms of sufficient, but not necessarily
urges, and feelings to track. These may invalid, causes; 5) validating as reasonable in
clude eating disorders, urges to physically the moment.
hurt other people, and impulsive behaviors Validation is much less frequently uti-
such as shoplifting. lized in CBT. In DBT, discussions of the pa-
The diary card serves as the means for tients emotional experiences, suffering, and
setting the session agenda and is reviewed difficulty with changing are some of the
with the patient at the outset of each session. occasions for using validation. The basic
These cards are particularly useful for pa- function of validation is to communicate to
tients who experience frequent episodes of patients that their responses are understand-
dissociation or who tend to remember only able and make sense within their current life
what happened in their current mood states. situation or context (Linehan 1993a). Valida-
The cards are also helpful for patients who tion should never be patronizing, and it
should never validate that which is invalid. which can be experienced as overwhelming
Validation is composed of three steps: 1) ac- and intimidating to patients. Instead, each
tive observing of what the patient is report- staff members experience with the patient is
ing; 2) reflection of the patients feelings, treated as valid and a synthesis of their expe-
thoughts, and behaviors in a nonjudgmental riences is sought. Furthermore, staff mem-
and nonauthoritarian manner, whereby the bers are treated in the therapy as any other
therapist phrases the reflection not as a pro- person in the patients life. Therefore, instead
nouncement but more as a question; and of intervening and talking to the other staff
3) direct validation of the validity and un- member about a patients complaint or upset,
derstandability of the patients response. the therapist coaches a patient in how to
handle the complaint directly with the staff
member. For example, if a patient in DBT
BALANCING CHANGE AND complains bitterly to the therapist that the
psychiatrist is often late to appointments and
ACCEPTANCE the patient finds it enraging, the therapists
There is an ongoing focus on maintaining a first approach is to help the patient express
balance between change and acceptance the feelings about the lateness directly to the
strategies within each intervention and over psychiatrist rather than the therapist discuss-
the course of the treatment. Validation and ing it with the psychiatrist.
acceptance without a change focus can lead
to demoralization that things will never be
any different. An approach that focuses too EFFICACY DATA
intensely on change can make a patient feel
poorly understood and criticized. This effect, DBT was originally tested in a randomized,
in turn, can increase a patients self-blame controlled clinical trial (Linehan et al. 1991,
and lead to early treatment dropouts. 1993, 1994; Shearin and Linehan 1992). The 1-
year DBT treatment compared with treat-
ment as usual showed significant effects in
CONSULTATION TEAM three areas: 1) suicidal behavior and self-
mutilation, 2) maintenance in treatment, and
An assumption of DBT is that therapists treat- 3) amount of inpatient treatment. DBT sub-
ing suicidal individuals with BPD also need jects engaged in significantly fewer self-inju-
support. An integral aspect of DBT is the role rious acts than treatment-as-usual subjects.
of the consultation team to which therapists This effect was most marked in the first
can bring any problems they are experiencing 4 months of treatment. DBT patients also had
with their patients. The consultation team as- significantly fewer severe self-injurious acts,
sumes a dialectic stance and provides both in terms of medical consequences, than treat-
suggestions and support. In addition, the ment-as-usual patients. Also, DBT patients
team provides a valuable function of helping had greater retention in individual therapy
therapists stay on track and follow the treat- compared with treatment-as-usual patients
ment hierarchy as prescribed. It is important (84% remaining in DBT treatment) and had
to note that this consultation team is more significantly fewer days of hospitalization
similar to a supervision team than a patients per person. In addition, DBT showed greater
treatment team. In the DBT model, team reduction in anger and improved func-
members in a day hospital or an inpatient set- tioning (Linehan et al. 1994). There were no
ting tend not to have meetings jointly with group differences on measures of depres-
the patient in order to avoid splitting or to sion, hopelessness, suicidal ideation, or rea-
avoid presenting a unified front to patients sons for living. On 1-year follow-up, Linehan
et al. (1993) found that DBT subjects had sig- treating the more serious behavioral aspects
nificantly fewer suicidal and self-mutilating of BPD, namely suicidal behavior and self-
behaviors, less anger, fewer psychiatric inpa- mutilation. In addition, Bohus et al. (2000), in
tient days, and better social adjustment than an uncontrolled inpatient trial of DBT, found
treatment-as-usual subjects. that parasuicidal females with BPD showed
DBT has also been tested as a 6-month decreased self-injury, depression, dissocia-
treatment in two small sample studies (Koons tion, and anxiety postdischarge. Although
et al. 2001; Stanley et al. 1998). Stanley et al. there are no trials of patients with other per-
(1998), in a pilot study, found that individuals sonality disorders, efficacy data have been
in DBT demonstrated decreased rates of self- shown for DBT with domestic violence part-
injurious behavior and urges to self-injure ners (Fruzzetti and Levensky 2000) and in bu-
and decreased hopelessness and subjective limia (Safer et al. 2001), binge eating (Telch et
depression over the course of a 6-month treat- al. 2001), hyperactivity (Hesslinger et al.
ment. Treatment retention was very high, 2002), and substance use disorders (Linehan
with a 95% completion rate. Koons et al. et al. 1999, 2002; van den Bosch et al. 2002).
(2001), in an outpatient study of female veter- Also, adaptations and efficacy in special pop-
ans with BPD, found that those in DBT had ulations have been explored, including fo-
lower rates of self-injury, suicidal ideation, rensic patients (McCann et al. 2000; Trupin et
hopelessness, anger, and depression when al. 2002), the elderly depressed (Lynch et al.
compared with a treatment-as-usual group. 2003), and adolescents (Miller et al. 1997;
In addition, Verheul et al. (2003) conducted a Rathus and Miller 2002). Further treatment
12-month trial comparing DBT with treat- outcome studies comparing DBT with other
ment as usual in the Netherlands. This trial of forms of psychotherapy and/or psycho-
58 females with BPD found that DBT had a pharmacological treatment are currently un-
better retention rate and greater reductions in der way (Linehan et al. 2006). See Scheel
self-injury and other forms of self-damaging (2000) and Robins and Chapman (2004) for a
impulsive behavior. Suicide attempt rates comprehensive critical review of empirical
were low in both groups and approached but findings regarding DBT for all disorders.
did not reach significance, with 7% of the DBT
group making suicide attempts compared
with 26% of the treatment-as-usual group.
DBT has also been adapted for inpatient CONCLUSION
settings (Simpson et al. 1998; Swenson et al.
DBT is a cognitive-behavioral treatment that
2001; Turner 2000). Barley et al. (1993) con-
has demonstrated efficacy in BPD. It has also
ducted a partial replication of DBTs efficacy
been adapted to other disorders and special-
in a pre/post design by showing a reduction
ized populations. Although it has not yet
in rates of suicidal behavior and self-mutila-
been adapted to other personality disorders,
tion incidents with DBT. Monthly rates of
it is likely to be useful in those disorders in
self-destructive behavior on an inpatient unit
which impulsivity and behavioral dyscon-
were compared before and after the introduc-
trol are prominent.
tion of DBT with rates on a similar general
adult inpatient unit using a non-DBT treat-
ment. Mean monthly rates of self-injurious
behavior on the DBT unit were significantly REFERENCES
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13
Group Treatment
William E. Piper, Ph.D.
John S. Ogrodniczuk, Ph.D.
T his chapter focuses on group treatment tion 2000) personality disorders is reviewed,
for personality disorders. Group treatment is and two case examples of patients treated
a general type of therapy, similar to individ- with one of the most powerful forms of group
ual therapy or family therapy. Group thera- treatmentday treatmentare presented.
pies may take many different forms based on Finally, a number of conclusions are offered.
their theoretical and technical orientations.
Because of the presence of multiple patients,
group therapies have certain unique features
GROUP FEATURES THAT
that distinguish them from other general
types of therapy. These unique features may FACILITATE TREATMENT OF
facilitate or complicate the treatment of per- PERSONALITY DISORDERS
sonality disorders. Similarly, personality
disorders have certain features that may fa- Because personality disorders are serious
cilitate or complicate their treatment with long-term conditions that are resistant to
group therapies. change, powerful treatments are needed.
Initially, this chapter considers these fa- Group treatments are capable of mobilizing
cilitating and complicating features of group strong forces for change, such as peer pres-
therapies and personality disorders. Next, sure. The group, which is sometimes referred
forms of group treatment that differ in for- to as a cohesive social microcosm, can exert con-
mat, intensity, and objectives are considered, siderable pressure on patients to participate.
followed by a discussion of research support It is capable of eliciting the typical maladap-
for group treatments. The perceived useful- tive behaviors of each patient. The other pa-
ness of group treatment for each of the 10 tients can observe, provide feedback, and of-
DSM-IV-TR (American Psychiatric Associa- fer suggestions for change. The patient can
253
subsequently practice adaptive behavior. safety (Piper and Ogrodniczuk 2004). The
This process is commonly referred to as inter- therapist is subject to such concerns as well.
personal learning. Other patients may learn
through observation and imitation. Simply
recognizing that other patients share ones PERSONALITY DISORDER FEATURES
difficulties (universality) and helping other
patients with their problems (altruism) can be
THAT FACILITATE GROUP
therapeutic. These various processes (cohe- TREATMENT
sion, interpersonal learning, imitation, uni-
versality, and altruism) are regarded as pow- The predominant feature of patients with
erful unique therapeutic factors of group personality disorders that facilitates group
treatment (Yalom and Leszcz 2005). treatment is their strong tendency to openly
There are other facilitative features of demonstrate interpersonal psychopathology
group treatment as well. Paralyzing negative through behavior in the group. Compared
transference toward the therapist is less with patients with many Axis I disorders, pa-
likely to occur in group therapy compared tients with personality disorders are more
with individual therapy because the situa- likely to demonstrate rather than describe
tion is less intimate, and strong affects such their interpersonal problems. Although this
as rage are diluted and expressed toward also occurs in individual therapy, the stimuli
other patients. Similarly, feedback from the from multiple patients precipitate patholog-
therapist in the individual therapy situation ical interpersonal behavior more intensely
may be dismissed as biased, but this is much and quickly in group therapy. This behavior
less likely to occur in response to feedback can be clearly recognized and dealt with im-
from several peers in a therapy group. In ad- mediately in the group. A second facilitative
dition, because of the variety of affects ex- feature of patients with some personality dis-
pressed by different patients, integration of orders (e.g., dependent, histrionic, border-
positive and negative affects is facilitated. line) is that they are other seeking. They
tend to value the connections in the group.
GROUP FEATURES THAT

COMPLICATE TREATMENT OF PERSONALITY DISORDER FEATURES
PERSONALITY DISORDERS THAT COMPLICATE GROUP
TREATMENT
Group features may also produce complica-
tions. Some patients with personality disor- Many of the behaviors characteristic of those
ders resent sharing the therapist and feel ne- with personality disorders complicate group
glected and deprived. In the group situation, treatment. Because these behaviors are often
regressive behavior such as emotional out- offensive to members of the group, they tend
bursts, aggressive actions, or suicidal threats to weaken cohesion and distract members
are more difficult to manage and contain from working. Usually, such patients chal-
than in individual therapy. Groups are prone lenge the guidelines and norms that have
to scapegoating; patients with personality been established in the group. Examples of
disorders provide many provocations. There antitherapeutic behaviors include minimal
are a number of concerns in the group situa- disclosure, excessive disclosure, scapegoat-
tion, relative to individual therapy, that ing, extra-group socializing, absenteeism,
many patients with personality disorders lateness, and premature termination.
find troublesome, including loss of control, When a patients antitherapeutic behav-
individuality, understanding, privacy, and iors persist in the group over time, the behav-
Group Treatment 255
iors may be conceptualized as roles. The per- These groups are usually not intensive in na-
sons occupying the roles are commonly ture. They do not attempt to change the basic
labeled as difficult patients in the group personality traits or personality structure that
therapy literature (Bernard 1994; Rutan and characterize personality disorders. Many ex-
Stone 2001). These difficult patients are often amples are described in the literature, includ-
those with personality disorders. Examples of ing supportive groups for patients who expe-
difficult roles and the DSM-IV-TR personality rience complicated grief (Piper et al. 2001) or
disorders often associated with them are the for patients who are undergoing organ trans-
silent or withdrawn role (schizoid, schizo- plantation (Abbey and Farrow 1998).
typal, paranoid, avoidant); the monopolizing
role (histrionic, borderline, narcissistic); the
Long-Term Outpatient
boring role (narcissistic, obsessive-compul-
sive); the therapist helper role (histrionic,
Group Therapy
dependent); the challenger role (antisocial,
Long-term outpatient group therapy consists
borderline, obsessive-compulsive); and the
of one or two sessions per week for at least 1
help-rejecting complainer role (borderline,
2 years. It focuses on the interpersonal world
narcissistic, histrionic). Although these roles
of the patient. It is intensive in nature and
are occupied by individual persons, they fre-
over time involves confrontation and inter-
quently express something that other patients
pretation of the patients core conflicts, de-
wish to have expressed and therefore are sup-
fensive style, and long-term maladaptive be-
ported by others in the group. Among the per-
haviors. It attempts to change the basic
sonality disorders regularly seen in outpatient
personality traits and personality structure
groups, patients with borderline and nar-
that characterize personality disorders.
cissistic personality disorders are usually
Long-term outpatient group therapy is re-
viewed as the most difficult to treat and man-
garded as an appropriate and effective group
age (Leszcz 1989; Tuttman 1990). For that rea-
treatment for personality disorders, espe-
son, a combination of group therapy and indi-
cially when used in combination with long-
vidual therapy is often recommended.
term individual psychotherapy. The latter al-
lows stabilization of the patient and an op-
portunity to disclose private and sensitive in-
DIFFERENT FORMS OF formation that would be difficult to reveal in
GROUP TREATMENT the group setting initially, although over
time such revelation becomes possible. This
Forms of group treatment differ in structure group approach assumes that over time the
(format), intensity, and objectives. Four group comes to represent a social microcosm
forms can be distinguished: short-term out- in which the interpersonal difficulties of the
patient group therapy, long-term outpatient patients become vividly illustrated by the in-
group therapy, day treatment, and inpa- terpersonal behavior of the patients in the
tient/residential treatment. group. Two well-known texts that focus on
long-term group psychotherapy are those of
Short-Term Outpatient Rutan and Stone (2001) and Yalom (1995).
Group Therapy
Day Treatment
Short-term outpatient group therapy often
involves a single session per week for 20 or Day treatment is a form of partial hospitaliza-
fewer weeks. Certain focal symptoms (e.g., tion. It is designed for patients who do not re-
depression) or behaviors (e.g., affect expres- quire full-time hospitalization and who are
sion, social skills) are targeted for change. unlikely to benefit a great deal from outpa-
tient group therapy. Day treatment patients activities. Inpatient/residential treatments

have often had an unsuccessful course of out- include admission groups, community
patient group therapy. Patients typically par- groups, patient governance groups, insight
ticipate in a variety of therapy groups for sev- groups, occupational therapy groups, sup-
eral hours each day for 35 days per week. port groups, and discharge groups. Although
The therapy groups are often from different groups are a highly visible set of activities in
technical orientations. For example, be- acute treatment settings, they tend to be re-
havioral and cognitive interventions can be garded as a minor part of the treatment regi-
used in structured, skills-oriented groups; men. Instead, psychotropic medications that
whereas dynamic interventions are used in are used to calm the patient and facilitate
unstructured, insight-oriented groups. Fam- problem solving regarding the acute crisis are
ily and couples interventions may also be em- viewed as the dominant treatment. Two dif-
ployed. Day treatment is an intensive form of ferent approaches to inpatient treatment are
therapy. Its goals include relief of symptoms, described by Rosen et al. (2001).
reduction of problematic behaviors, modifi- In North America, the lengths of stay in
cation of maladaptive character traits, and fa- acute hospital settings have been decreasing
cilitation of psychological maturation. significantly in response to escalating costs.
Several other features contribute to mak- Today, length of stay in such settings has
ing day treatment a powerful treatment. First come to mean short-term crisis management
is the intensity of the group experience. Pa- often of a week or less. Similarly, the cost of
tients participate in a number of different long-term care, (e.g., several months to a
groups each day. Second, the groups vary in year) in retreat settings that in the past pro-
size, structure, objectives, and processes. This vided powerful milieu therapies has become
variety provides a comprehensive approach. prohibitive, with many centers having closed
Third, the different groups are integrated down or greatly scaled down in size. Others
and synergistic. Patients are encouraged to have accommodated to the changing health
think about the entire system. Fourth, pa- care environment but have preserved inten-
tients benefit from working with multiple sive hospital interdisciplinary treatment, car-
staff members and a large number of other ried out for an average length of stay of about
patients. Fifth, day treatment capitalizes on 6 weeks (e.g., The Menninger Clinic). An-
the traditional characteristics of a therapeutic other example of residential treatment is that
community (democratization, permissive- which occurs in some prisons. Some institu-
ness, communalism, reality confrontation). tions have treatment programs for inmates
These features strengthen cohesion, which with antisocial personality disorder (ASPD)
helps patients endure difficult periods of who have been convicted of crimes. Some ex-
treatment. The structure of day treatment perts have objected to residential care for per-
programs encourages patients to be respon- sonality disorders on the grounds that it pro-
sible, engenders mutual respect between pa- motes dependency. An approach to working
tients and staff, and facilitates patients par- with patients in residential treatment groups
ticipation in the treatment of their peers. is described by Kibel (2003).
Well-known approaches to day treatment
programs are described by Bateman and
Fonagy (1999) and Piper et al. (1996). RESEARCH SUPPORT FOR THE
GROUP TREATMENT OF
Inpatient/Residential Treatment
As in day treatment, hospital inpatient wards
and residential treatment centers commonly There is a striking absence of evaluative re-
provide a variety of group treatment patient search on treatments for personality disor-
Group Treatment 257
ders. In the case of group treatments, the Marziali and Munroe-Blum (1994) com-
number of studies are few indeed. There are pared time-limited interpersonal group ther-
very few randomized clinical trials of psy- apy, which consisted of weekly 90-minute
chosocial treatments. However, the trials sessions for 25 weeks and biweekly sessions
that have been published provide encourag- for the next 10 weeks (30 sessions in total),
ing findings. In this section, we summarize with open-ended, weekly individual therapy
findings from several of the recent clinical for a sample of 79 patients with borderline
trials. Outpatient group therapy studies are personality disorder. All patients demon-
followed by partial hospitalization studies. strated significant improvement on outcome
measures, with no difference between the
Randomized Clinical Trials two treatment conditions. However, both
conditions suffered high dropout rates.
Cappe and Alden (1986) compared brief Piper et al. (1993) compared time-limited
(8 weekly 2-hour sessions) behavioral group day treatment, which consisted of group
therapy with a waiting list control condition treatment in the form of a diverse set of daily
for a sample of 52 patients with avoidant per- group therapies for 7 hours per day, 5 days
sonality disorder. The patients who were per week, for 18 weeks, with a waiting list
treated with a combination of graduated ex- control condition for a sample of 120 patients
posure training and interpersonal process with affective and personality disorders. The
training improved significantly more than most prevalent personality disorders were
patients who received only graduated expo- dependent and borderline. Day treatment
sure and patients on the waiting list. In a sim- patients demonstrated greater improvement
ilar trial, Alden (1989) compared three varia- on a comprehensive set of seven outcome
tions of brief behavioral group therapy variables that included symptoms, interper-
(10 weekly 2.5-hour sessions) with a waiting sonal behavior, self-esteem, and life satis-
list control condition for a sample of 76 pa- faction. The control condition patients evi-
tients with avoidant personality disorder. All denced little improvementthat is, minimal
three treatment conditions demonstrated spontaneous remission. Improvements for
greater improvement than the waiting list the day treatment patients were maintained
control condition. However, the author noted at 8-month follow-up.
that despite significant improvements, the Bateman and Fonagy (1999) compared
patients did not achieve normal functioning. psychoanalytically oriented day treatment,
Linehan et al. (1991) compared dialectical which consisted of a combination of group
behavior therapy (DBT), which involved 2.5 and individual therapies for 5 days a week
hours of group skills training and 1 hour of for a maximum of 18 months, with a stan-
individual therapy per week for 1 year, with dard care control condition, which consisted
regular community treatment (usually indi- of infrequent meetings with a psychiatrist
vidual therapy) for a sample of 44 patients but no formal therapy, for a sample of 44 pa-
with borderline personality disorder. DBT tients with borderline personality disorder.
resulted in greater reductions in symptoms Day treatment patients showed significant
and parasuicidal and dysfunctional behav- improve men ts th at e xceed ed min imal
iors, decreased dropouts, fewer and shorter change for standard care on a variety of out-
inpatient admissions, and improved work come variables, including suicide attempts
status compared with regular treatment. and acts of self-mutilation and self-reports of
However, no differences were evident on depression, anxiety, general symptoms, in-
self-reported levels of depression, hopeless- terpersonal functioning, and social adjust-
ness, or suicidal ideation. Although useful, ment. Subsequent to discharge from day
the authors argued that treatment of 1 years treatment, patients were provided with
duration was not sufficient. 18 months of psychoanalytically oriented
outpatient group therapy. Following com- or studies with nonrandomly assigned con-
pletion of this treatment regimen, these pa- ditions. These studies involved outpatient
tients were compared to the treatment-as- group therapy (Budman et al. 1996), day
usual patients. Day treatment patients main- treatment (Hafner and Holme 1996; Tasca et
tained their earlier gains and in some cases al. 1999; Wilberg et al. 1998, 1999), and resi-
improved on them (Bateman and Fonagy dential treatment (Chiesa et al. 2003). In gen-
2001). Five years following the completion of eral, the findings from these naturalistic
the outpatient group therapy, the two patient studies were consistent with those of ran-
groups were compared again. The patients domized clinical trials in providing evidence
who received day treatment and outpatient of favorable outcomes for patients with per-
group therapy continued to have superior sonality disorders, in particular those with
performance on a number of outcome indica- borderline personality disorder. Most of the
tors, yet their general social performance re- randomized clinical trials and naturalistic
mained impaired (Bateman and Fonagy studies focused on group treatments from a
2008). psychodynamic or cognitive-behavioral ori-
Herbert et al. (2005) compared standard entation. A recent meta-analytic review that
cognitive-behavioral group therapy (CBGT) focused on both group and individual treat-
and CBGT with social skills training (SST) ments of personality disorders from psycho-
for patients with social anxiety disorder. dynamic and cognitive-behavioral orienta-
Although the study was focused on social tions concluded that both orientations were
anxiety disorder, 75% of the sample also met effective treatments (Leichsenring and Leib-
criteria for avoidant personality disorder. ing 2003).
Improvements on a variety of outcome in-
dexes occurred for both treatments; however, Clinical Reports
significantly greater gains were made with
the combination of CBGT and SST. Clinical reports of successful group treat-
Blum et al. (2008) compared Systems ments of patients with personality disorders
Training for Emotional Predictability and are the most prevalent type of evidence in the
Problem Solving (STEPPS), a 20-week CBGT literature. They provide the basis for most
for outpatients with borderline personality recommendations about the suitability of
disorder, with treatment as usual. STEPPS specific personality disorders for group
differs from typical CBGT in that it teaches treatment. The following section reflects con-
and trains key members of patients support clusions from a number of reviews that are
networks to use a consistent approach and based primarily on clinical reports (Azima
language with the patient. Patients treated 1993; Gunderson and Gabbard 2001; Robin-
with STEPPS made greater improvements in son 1999; Sperry 1999). There is considerable
impulsivity, affectivity, mood, and global consensus among these reviews.
functioning. However, there were no differ-
ences in suicide attempts, self-harm acts, or
hospitalization. FORMS OF GROUP TREATMENT FOR
SPECIFIC PERSONALITY DISORDERS
Naturalistic Studies
Cluster A
Findings from a number of carefully con-
Schizoid Personality Disorder
ducted naturalistic outcome studies that fo-
cused on the group treatment of personality There is agreement that some patients with
disorders also have been published. These schizoid personality disorder can definitely
tend to be pre/post, single-condition studies benefit from group treatment, which in-
Group Treatment 259
volves social learning stemming from consis- to rejection and scapegoating. Such patients
tent exposure to other patients. Difficulties are very challenging to treat.
can involve passivity and silence, which may
irritate other patients. Narcissistic Personality Disorder
Schizotypal Personality Disorder Group therapy for patients with narcissistic

personality disorder is usually regarded as
Group therapy may play an invaluable role problematic. Lack of empathy, a sense of enti-
in patients with schizotypal personality dis- tlement, and hunger for admiration are not en-
order, particularly in increasing socialization gaging characteristics of this disorder. Scape-
skills. Difficulties can arise if the patients pe- goating is common. Dropout rates are high. If
culiarities are bizarre and difficult for other the patient can be convinced to stay, much
patients to tolerate. Prolonged silence can useful learning can occur. Group therapy is of-
also be problematic. Preparation in individ- ten combined with individual therapy.
ual therapy can be very helpful.
Histrionic Personality Disorder
Paranoid Personality Disorder
For those with histrionic personality disor-
Patients with paranoid personality disorder der, group therapy can definitely be helpful.
usually do not do well in a group because of Such patients can help energize the group.
their hypersensitivity, suspiciousness, and However, there is a better prognosis for those
misinterpretation of others comments. with less dramatic behavior. Difficulties fol-
Feedback from other group members can be low if the patient slips into the role of monop-
very powerful if the patient remains in the olizer or help-rejecting complainer.
group and is receptive to feedback.
Cluster B
Outpatient group therapy is not suitable for
Borderline Personality Disorder patients with ASPD, although some inten-
Group therapy can be extremely effective for sive residential programs and therapeutic
borderline personality disorder patients and community programs in prisons have re-
is often combined with individual therapy. ported successes (Dolan 1998; Warren and
This appears to be the case for (DBT, which Dolan 1996).
includes a weekly group therapy session
(Linehan et al. 1991). The group treatment is Cluster C
psychoeducational with an emphasis on
Avoidant Personality Disorder
strengthening interpersonal skills, distress
tolerance/reality acceptance skills, and emo- Group therapy can be extremely useful for
tion regulation skills. (More detail about those with avoidant personality disorder be-
DBT can be found in Chapter 12 of this vol- cause such patients are usually well moti-
ume, Dialectical Behavior Therapy.) In vated. Often the therapy group follows a
group therapy, both transference and coun- course of individual therapy.
tertransference are diffused, and thus it is
more tolerable for both parties. As a result,
Dependent Personality Disorder
interpretations may be better tolerated in
group therapy. Nevertheless, the patients For patients with dependent personality dis-
tendency to express anger and other strong order, group therapy is regarded as an effec-
affects in an unpredictable manner can lead tive treatment, and some believe that it is the
treatment of choice because the patients Case Example

dependent cravings can be gratified and
their overclinging can be confronted (Azima Mr. N was a 50-year-old, unemployed
divorc who lived with his 75-year-old
1993). Group therapy provides many oppor-
widowed mother. His father had died
tunities for these patients to learn to be more 7 years previously. Mr. N presented
independent and expressive. with feelings of discontent about his life.
He had a pervasive feeling of having
Obsessive-Compulsive failed in his relationships and in the
Personality Disorder workplace. He was diagnosed as having
a dependent personality disorder with
Group therapy can be helpful for some ob- significant narcissistic traits. He was ex-
sessive-compulsive patients. Difficulties in- periencing a difficult phase of his life. At
volve the patients tendencies to act as an ad- Mr. Ns admission, the therapists etio-
logical formulation read as follows:
ditional therapist and to be stubborn and too
work oriented. This behavior usually results Patients hereditary factors may be indi-
in resentment from the other patients. cated by his fathers depression at age 50. In
terms of psychosocial factors, his current dis-
Summary tress seemed to have been triggered by recent
negative criticism at work and a growing per-
Thus, according to the clinical literature, ception of failure. His feelings likely intensified
schizoid, schizotypal, borderline, histrionic, through unsuccessful attempts at farming, en-
trepreneurship, and sales. He experienced both
avoidant, and dependent personality disor-
feelings of inadequacy and rage because others
ders are regarded as particularly suitable for
were unable to recognize his special and unique
group treatment. In contrast, paranoid, nar- qualities. The belief that he should be a strong
cissistic, and obsessive-compulsive person- role model seemed to start in his family of ori-
ality disorders are regarded as difficult to gin, where he was the eldest. His efforts to
treat. Most group treatments are contraindi- succeed were not acknowledged by either par-
cated for ASPD. Although single personality ent. There seemed to be a lack of support for
disorders, such as borderline, are often ad- expressing his opinions or making decisions.
He felt controlled by his mother. Neither parent
dressed in the clinical literature, it is quite
seemed receptive of his viewpoints. His uncon-
common for patients to meet criteria for sev- scious life seemed dominated by negative self-
eral personality disorders (Dolan et al. 1995), images and experiences of rejection, devalua-
and this comorbidity complicates treatment. tion, and control.
Research evidence from the individual ther- In relationships with women, Mr. N tried
apy literature has shown that the number of to see himself as the strongest and most deserv-
personality disorders a patient is diagnosed ing of attention. He perceived himself as giv-
ing to women and being there for them but
with is inversely related to favorable out-
avoided thinking about how much he needed
come (Ogrodniczuk et al. 2001). from them. He was drawn to women like his
The following illustration summarizes mother, whom he saw as emotional, control-
the treatment of a patient with dependent ling, and unable to meet his needs. He dealt
personality disorder and narcissistic traits in with these relationships in the same way his fa-
an intensive (7 hours per day, 5 days per ther had dealt with his motherby being sub-
week), time-limited (18 weeks), group-ori- missive and by walking away from conflicts.
In so doing, however, Mr. N became resentful
ented day treatment program with a daily
and fu rious toward w omen . He also ac-
census of approximately 35 patients. This
knowledged avoiding closeness with women.
powerful program is fully described in Piper In his last serious relationship, 10 years ear-
et al. (1996). lier, he had hoped that he had found his ideal-
ized mother-figure. The woman was seen as
Group Treatment 261
caring, easygoing, and submissive. Mr. N felt time, his difficulty identifying his own
deeply betrayed when she suddenly left after feelings and needs was evident. He fre-
2 years. Following this breakup, he may have quently treated the female members of
had a major depression. He avoided dealing the group with a mixture of devaluation
with his emotions by becoming preoccupied and condescension for their inability to
with pastimes such as woodwork and music. respond to his needs in the group. He
He eventually returned to another woman, his often sat next to the male psychiatrist in
mother, where he has continued to feel con- the large psychotherapy group but had
trolled and neglected but was unable to recog- difficulty elaborating on the possible
nize his conflicting needs for closeness and in- reasons for his need to be near the male
dependence. This conflict contributed to his leader of the program.
feelings of frustration and inadequacy. The staff members and fellow pa-
tients consistently co nfronted him
In summary, Mr. N was described as about his tendency to create distance by
a dependent man whose lack of self- giving advice and by not elaborating on
assertion in relation to women had con- personal issues. He gradually became
tributed to failure in intimate relation- able to talk about the failures in his life
ships. His craving for perfectly attuned and began to express feelings of hurt,
attention and responsiveness to his anger, shame, and guilt. During the
physical and emotional needs also in- middle phase of the 18-week program,
terfered with his relationships. The rein an interview with his mother, he ex-
sult was a growing sense of dissatisfac- pressed his feelings of anger toward her
tion with his life. for her controlling and neglectful ways.
On admission to the day treatment He explained his needs to separate
program, Mr. N received the following emotionally and physically from her
DSM-IV-TR diagnostic profile: and for her to recognize his needs. In
therapy groups, he was able to un-
Axis I: Phase-of-life problem derstand how his conflictual relation-
Axis II: Dependent personality disor- ship with his mother had resembled his
der with significant narcissis- relationships with other women in his
tic traits life. He began to see that his advice giv-
Axis III: None ing was part of a ploy to create depen-
Axis IV: Negative criticism at work dency on him so that his needs and de-
Axis V: Global assessment of func- mands could be catered to. He was
tioning deeply conflicted about dependency in
Current: 60 relation to women. Difficulty acknowl-
Highest during past year: 70 edging his own dependency drove him
to make women dependent on him
Mr. N formulated in his own words while at the same time he resented his
the following problem areas that he role in supporting them. His fear of in-
most wanted to work on in treatment: dependence interfered with his ability
1) Work problems: I have failed in the to assert himself with his mother and
past and am afraid to try again, to get with other significant women.
back into it; 2) Relationships: I am During the final phase of treatment,
afraid to get involved; I need a wife loss issues became predominant. His
and a family, but I have built up walls. youngest daughter confronted him
about his emotional distance as a father.
Summary of Mr. Ns Experience in This confrontation enabled Mr. N to be-
the Day Treatment Program gin exploration of unresolved grief in
relation to his own father. Not only was
Mr. Ns paternalism and grandiosity he faced with the loss of his father
emerged early in his treatment. He through death but also through emo-
quickly assumed the role of giving ad- tional distance during his early devel-
vice to fellow patients and lending an opmental years. In the therapy groups,
ear to those in distress. At the same Mr. N began to see that his giving ad-
vice to fellow patients had been done Case Example

partly in the hope that he would receive
similar support and caring from the Ms. O was a 26-year-old, single nursing
staff members and from the male psy- assistant who lived on her own. She
chiatrist in particular, who represented sought help because of repeated de-
his father. He also began to recognize structive relationships with men and an
that his escalating and sometimes fran- inability to tolerate male authority fig-
tic demands, enacted especially with ures, especially at work. A recent con-
the female group members, reflected frontation with a male supervisor, in
his needs for confirmation of his self- which she had become extremely an-
worth and the availability of someone gry, weepy, and confused, precipitated
to complete his fragmented self-image. the crisis that prompted her to seek
help. At admission, the therapists etio-
Outcome logical formulation read as follows:
At the time of his discharge, Mr. N still Ms. Os family of origin was divided as a
was living with his mother but had def- result of the emotional distance between her fa-
inite plans to move out. He did not elab- ther and mother. Mother was seen as overin-
orate on his intentions regarding his volved, dependent, and verbally abusive to-
current girlfriend. He found a tempo- ward Ms. O. Her father was seen as distant
rary job and intended to return to a ca- and emotionally unavailable to her. She tried
reer in sales. Mr. N showed consider- hard to win his approval and acceptance
able improvement on measures o f through the pursuit of academics and sports,
general symptomatic distress, mood but her efforts went unnoticed. Ms. Os father
level, self-esteem, and defensive func- abandoned the family for another woman
tioning. He demonstrated moderate im- when Ms. O was age 13 years. She felt deserted
provements in areas reflecting sexual, and responsible for his leaving. She developed
family, and social functioning as well as a persistent feeling of being a bad person. Un-
life satisfaction. He also made signifi- able to vent her anger and rage at her father for
cant improvements in the two problem leaving and at her mother for letting him go,
areas identified at the beginning of she instead became her mothers protector. At
treatment. school, she was a protector of the underdog.
This role continued into her adult life and into
We believe that the success of Mr. Ns her work environment. As a result, she fre-
treatment can, in part, be attributed to the ba- quently came into considerable conflict with
sic therapeutic features of day treatment, authority figures. There was evidence of trian-
which include exposure to multiple patients gulation in Ms. Os relationships in which she
symbolically ended up fighting for her mother
and multiple staff members in a variety of
against her father. There was also a strong pre-
therapy groups for several hours each day
oedipal pattern to her history. This pattern
over several months. The diversity of groups was manifested in the theme of destruction
allows patients to begin to participate in one throughout her adult life: the self-abuse
group in which they feel comfortable before through bulimic behavior, alcohol abuse, and
actively participating in others. It also pro- physical abuse by her boyfriends. Her desper-
vides a comprehensive approach to treat- ation for a relationship with her father may
ment. The experience provides many oppor- have hidden a deep sense of emotional neglect
at the hands of her inadequate mother.
tunities for the unique features of group
treatment (cohesion, interpersonal learning, In summary, Ms. O was described
imitation, universality, altruism) to have as an emotionally labile woman whose
their effects. The time-limited program in pervasive sense of inadequacy culmi-
which Mr. N participated created pressure to nated in frequent acts of self-destruc-
work hard in a relatively short period of time tion. Her oppositional disposition to-
in his life. ward authority figures and fear of
intimacy with men often interfered
Group Treatment 263
with her relationships. This disposition explore her mixed feelings toward her
resulted in a growing sense of instabil- father and brother. She also began to
ity in her mood and her relationships. consider how she had assumed the role
On admission to the day treatment of the bad child in her family and had
program, Ms. R received the following been scapegoated by her brother. How-
DSM-IV-TR diagnostic profile: ever, she showed considerable reluc-
tance to be open with her feelings to-
Axis I: Bulimia nervosa, cy- ward her mother.
clothymia, alcohol depen- Ms. O experienced considerable
dence (in remission) stress as she entered the termination
Axis II: Borderline personality disor- phase of treatment. Her symptoms re-
der with significant depen- turned with full force as she was con-
dent traits fronted with losing the group, a deep
Axis III: None reminder of the loss of her family when
Axis IV: Discord with boss, discord her father left. She once again began to
with parents and sibling test the limits of the therapists toler-
Axis V: Global assessment of func- ance through absenteeism and counsel-
tioning ing fellow patients outside designated
Current: 52 group hours. The other group members
Highest during past year: 65 confronted Ms. O about her defiant be-
havior and helped her recognize it as a
Ms. O formulated the following repetition of old maladaptive patterns:
problem areas in her own words that she loses important people in her life
she most wanted to work on in treat- because she is a bad person. Con-
ment: 1) to be able to deal with my de- tained by the group, she was able to talk
pression and mood swings; 2) to im- about her painful feelings in relation to
prove my relationships with others; losing the two male patients to whom
and 3) to understand and stop my eat- she had become attached. She was also
ing disorder. able to confront her father to let him
know for the first time of her feelings of
Summary of Ms. Os Experience in rejection. Ms. O also began to recognize
that her intolerance of authority and op-
the Day Treatment Program
positional behavior were manifesta-
Representative of Ms. Os functioning tions of the conflict between her wish to
outside of the treatment setting, her be accepted and cared for and her fear
passage through the day treatment pro- of being rejected.
gram was stormy. Early in treatment,
she demonstrated difficulty adhering to Outcome
the limits defined by the therapists. She
missed groups and spent considerable Upon her discharge from the day treat-
time counseling other patients during ment program, Ms. O returned to work
breaks. Within the groups, she would but continued to experience an uneasy
focus on other patients problems rather relationship with her supervisor. She
than her own. She was openly scathing showed moderate improvements on
of the therapists perceived failure to do measures of interpersonal functioning
the right thing for the patients. How- and general symptomatic distress. She
ever, she would move in quickly to de- also made modest improvements in
fend them when they were confronted two of the three problem areas that she
by other patients. identified at the beginning of treatment.
Through consistent confrontation Regarding her bulimia, there was little
and limit setting on the part of the ther- improvement. It was concluded that al-
apists, Ms. O began to explore her feel- though the groups were helpful for Ms.
ings of rejection and of being uncared O, the 18-week time limit was insuffi-
for by her family. Ms. O found herself cient to deal effectively with her multi-
becoming attached to two male pa- ple, long-standing problems. Long-
tients. This attachment enabled her to term group treatment was suggested.
The composition of the group (i.e.,

CONCLUSION: EVIDENCE OF whether it will be a group for patients
EFFICACY AND EFFECTIVENESS with mixed diagnoses or a homogeneous
group for those with a specific disorder)
The number of randomized clinical trials that The role of group therapy in the patients
have been conducted to evaluate the efficacy, treatment regimen (i.e., whether group
effectiveness, and utilization of group treat- therapy will be the only treatment the pa-
ments for those with personality disorders is tient receives or part of a more comprehen-
small, but growing and they have definitely sive regimen that includes other interven-
demonstrated the benefits of the various tions provided either concurrently or
forms of group therapy. It appears that many sequentially)
of the successful treatments are combina-
tions of interventions, some of which are There are a number of guiding principles
group treatments; for example DBT and the for the successful implementation of group
STEPPS treatment package. In a number of therapy services for patients with personality
ways, the components complement each disorder. We believe that clinicians should:
other.
It is likely that the successes that group Attend carefully to referral sources, be-
treatments have achieved are related to cause inappropriate referrals can be a sig-
unique features arising from the presence of nificant burden on resources.
peers in groups. Group influence is a power- Select patients with attention to optimal
ful agent. It becomes even more powerful in patienttreatment matching. The use of
programs such as day treatment in which pa- different groups will depend on the pa-
tients participate in a large number of groups tients degree of interpersonal deficit, mo-
that focus on different aspects of the patients tivations for treatment, ability to form re-
difficulties and capitalize on synergistic ef- lationships with the therapist and other
fects (Ogrodniczuk and Piper 2001). group members, and aptitude for particu-
The primary implication of the findings lar types of work (e.g., insight-oriented
from the studies reviewed in this chapter is work vs. SST).
that group therapy should be considered an Provide pre-therapy preparation. Group
effective treatment for patients with person- work can be difficult and is often foreign
ality disorders, including those that are typi- to many patients. Preparing patients for
cally regarded as difficult to treat (e.g., those the work of the group can contribute sig-
with borderline personality disorder). Selec- nificantly to the benefit that patients de-
tion of appropriate group therapy is not a rive from the group.
straightforward task, becasuse many clinical Encourage personal responsibility in the
research issues related to the group treat- patients, given that the group is only as
ment of personality disorders are still unan- good as the contributions from its mem-
swered. Important considerations include: bers.
Facilitate patient participation in the
group because passivity can lead to other
The locus of the group (i.e., inpatient or
problems within the group, such as scape-
outpatient; in a hospital, a residential set-
goating.
ting, or in private practice)
The time frame for the group (i.e., long-
Successful provision of group therapy
term or short-term)
services also involves avoiding certain pit-
The theoretical paradigm of the group,
falls that historically have plagued many
which will affect the goals of the group
programs. These include attempting to treat
Group Treatment 265
inappropriate patientsfor example, those

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14
Somatic Treatments
Paul H. Soloff, M.D.
example, schizotypal personality disorder is

BASIC ASSUMPTIONS UNDERLYING not the same as schizophrenia.
PHARMACOTHERAPY IN THE PATIENT Pharmacotherapy in personality disor-
ders is narrowly focused on those few di-
WITH PERSONALITY DISORDER mensions that command the most clinical at-
tention, such as affective dysregulation (e.g.,
A pharmacological approach to the treat- labile, depressed, angry, or anxious moods),
ment of personality disorders is based on the cognitive-perceptual symptoms (psychoti-
effects of medications on neurotransmitter cism), and impulsive aggression. These
functions that mediate expression of state symptoms prompt urgent care because they
symptoms and trait vulnerabilities related to mediate suicidal behavior, self-injury, or as-
basic personality dimensions. In terms of sault, and result in emergency department
neurotransmitter function, the distinction visits or hospitalization. As a result, most
between Axis I and Axis II disorders is arbi- drug trials have been conducted in patients
trary. Symptoms characteristic of patients with borderline, schizotypal, and antisocial
with personality disorder may be mediated, personality disorders.
in part, by the same neurotransmitter sys- Pharmacological interventions directed
tems as similar symptoms in Axis I disor- toward dimensions of personality disorders
ders. For example, ideas of reference, para- is a relatively new concept. The empirical lit-
noid ideation, and mild thought disorder in erature, although growing, is still woefully
patients with schizotypal personality disor- inadequate. The work group that developed
der may be mediated in part by the same the practice guideline for treating borderline
dopaminergic neurotransmitter systems as personality disorder (BPD) (American Psy-
more severe forms of thought disorder. Both chiatric Association 2001) identified approx-
respond to dopaminergic blockade with neu- imately 60 published reports on pharma-
roleptic agents. Symptom severity may be re- cotherapy of BPD; half were randomized
lated to other disease-specific genetic or bio- controlled trials (RCTs) and the rest were
logical differences in these disorders. For open-label or small sample studies. Since
267
then, additional RCTs have been published, personality disorder symptoms. For ex-
including new trials with second-generation ample, the Affective Lability Scale may be
antipsychotic drugs and anticonvulsants. In- more appropriate than the Hamilton Rat-
terpreting this literature requires an appreci- ing Scale for Depression (Ham-D) when
ation of the unique difficulties in conducting antidepressants are being used to stabilize
pharmacotherapy trials with personality dis- mood fluctuations rather than to treat a
order patients. Examples of these difficulties comorbid major depression.
include the following: 6. Symptoms in the patient with personality
disorder may be stress-related and tran-
1. Before the introduction of structured di- sient, resolving with time alone or with
agnostic interviews, clinician diagnoses crisis intervention therapy. A placebo
of personality disorders were notoriously condition is required to control for spon-
unreliable, raising questions about valid- taneous remission of symptoms in drug
ity of diagnoses and generalizability of trials. The need for placebo control raises
results. Some early reports used defini- additional problems, such as patient
tions of personality disorders no longer compliance and cooperation with an ex-
accepted in the modern nomenclature tended drug trial. Impulsive-aggressive
(e.g., emotionally unstable character dis- patients assigned to placebo, for example,
order [Rifkin et al. 1972]). Structured in- may not complete the study (Hollander et
terviews for personality disorder diag- al. 2001).
noses, corresponding to DSM definitions, 7. Measurement of efficacy against trait vul-
are now the accepted gold standard for nerabilities, such as impulsive aggression,
randomized controlled studies. must be done in appropriately long time
2. By definition, personality disorders are frames, because the base rates of targeted
Axis II diagnoses. Comorbidity with Axis behaviors (e.g., assaults, suicide gestures)
I disorders is common and must be con- may be low in a short time frame.
trolled in any research design. 8. Dropout rates are typically high and
3. Overlapping symptoms in definitions of must be carefully considered in evaluat-
Axis I and II disorders often make differing study results (Kelly et al. 1992). In-
ential diagnosis and determination of eti- ability to retain the patient in a thera-
ology of symptoms difficult (e.g., mood peutic trial may be attributable to the
instability in BPD and bipolar II disor- patients instability or the unacceptability
der). The relationship between depres- of the treatment.
sion and BPD has generated controversy,
because it is often unclear whether the A pharmacological approach to treatment
depressed patient with BPD has one dis- of personality disorders is symptom-specific
order or two (Gunderson and Philips and based on modifying neurotransmitter
1991; Koenigsberg et al. 1999; Soloff et al. function in cognitive, affective, and impul-
1991). sive-behavioral symptom domains. Both
4. Comorbidity with Axis II near neigh- acute state symptoms (such as anger and anx-
bors is often unavoidable. iety) and trait vulnerabilities (such as impul-
5. Because personality disorder diagnoses sivity and dysregulated affect) are targets for
are defined as syndromes, there is marked treatment. Pharmacotherapy is not a primary
heterogeneity in the symptom presenta- treatment for problems of character or mal-
tions within any given personality disor- adaptive interpersonal relationships, which
der. Target symptoms for pharmacother- are the focus of psychotherapy. Patients en-
apy must be quantified by standardized gaged in effective psychotherapy (e.g., dialec-
assessment measures tailored to specific tical behavior therapy [DBT]), may not re-
Somatic Treatments 269
quire adjunctive medication; however, for the et al. 1995). Dosages were typically in the
very unstable symptomatic patient, appro- lower range of clinical usage. While these
priate use of medication may facilitate adher- drugs appeared helpful in treating schizo-
ence to psychotherapy. To underscore the em- typal symptoms, such as ideas of reference,
pirical nature of this treatment, it is important paranoid ideation, and illusions, they also
to note that the U.S. Food and Drug Admin- demonstrated a much broader spectrum of
istration has not approved any medication efficacy against depression, anxiety and an-
for treatment of any personality disorder. All ger, impulsive-behavioral symptoms, and
recommendations made in this chapter are global symptom severity.
based on review of empirical studies and are, Random-assignment, parallel compari-
by definition, off-label uses. son studies comparing two neuroleptics
without placebo controls also demonstrated
a broad spectrum of efficacy in patients with
BPD. Leone (1982) found that loxapine succi-
PHARMACOTHERAPIES
nate (mean dosage, 14.5 mg/day) or chlor-
Neuroleptics promazine (mean dosage, 110 mg/day) pro-
duced improvement in depressed mood,
Neuroleptics have been studied more exten- anxiety, anger-hostility, and suspiciousness.
sively than any other medication class used Serban and Siegel (1984) reported that thio-
in the treatment of personality disorder. Ran- thixene (mean dose [ standard deviation
domized controlled studies have included (SD)], 9.4 mg [ 7.6 mg]) or haloperidol
inpatients, outpatients, and adult and ado- (mean dose [ SD], 3.0 mg [ 0.8 mg]) pro-
lescent patients treated with a wide variety duced improvements in anxiety, depression,
of first-generation and second-generation derealization, paranoia (ideas of reference),
(atypical) antipsychotic agents. Most of these and general symptoms in patients with BPD
studies have been conducted in patients with and schizotypal personality disorder. A glo-
BPD and/or schizotypal personality disor- bal measure of borderline psychopathology
der. Neuroleptic medications, used in low also improved with thiothixene.
dosages, are the treatment of first choice for Studies involving RCTs confirmed the
cognitive-perceptual symptoms, especially broad spectrum of efficacy for low-dose neu-
stress-related ideas of reference, transient roleptics, although efficacy against schizo-
paranoid ideas, and illusions. Neuroleptic typal symptoms and psychoticism, anger,
medications are also recommended for con- and hostility were most consistently noted.
trol of anger and hostility and have some ef- Goldberg et al. (1986) studied outpatients
ficacy in managing impulsive aggression. with either BPD or schizotypal personality
Neuroleptics have a broad spectrum of ef- disorder. They required each patient to have
fects and reduce symptom severity across all at least one mild psychotic symptom, intro-
symptom domains, including affective and ducing a bias toward cognitive-perceptual
impulsive-behavioral symptoms. symptoms. Patients received thiothixene
Cognitive disturbance was the rationale (mean dosage, 8.67 mg/day) for up to 12
for treatment in the earliest case reports and weeks and reported significant improve-
open-label trials. Patients often had both bor- ment over placebo in psychotic cluster symp-
derline and schizotypal symptom presenta- tomsspecifically, illusions and ideas of
tions. Many first-generation antipsychotic referencebut also in self-rated obsessive-
drugs were studied, including haloperidol, compulsive and phobic anxiety symptoms.
perphenazine, thiothixene (Brinkley et al. The more severely symptomatic the patient
1979, Hymowitz et al. 1986), thioridazine (Te- was at baseline, the better the patient re-
icher et al. 1989), and flupenthixol (Kutcher sponded to thiothixene.
Cowdry and Gardner (1988) conducted a with phenelzine and placebo, failed to repli-
complex, placebo-controlled, four-drug cate the broad spectrum efficacy of haloperi-
crossover study among outpatients with dol (mean dosage, 3.93 mg/day). BPD pa-
BPD using trifluoperazine (mean dosage, tients in the nonreplicating study spent less
7.8 mg/day) as the neuroleptic condition, time in the hospital and were significantly
with each trial lasting 6 weeks. Patients were less impaired (Soloff et al. 1993). At baseline,
also required to meet criteria for hysteroid they had less schizotypal symptoms, psy-
dysphoria, an affective syndrome defined by choticism, and impulsive ward behavior
histrionic traits, mood reactivity, rejection than did patients in the first study (Soloff et
sensitivity, and atypical depressive symp- al. 1989). By chance, patients randomized to
toms, and to have a history of extensive be- haloperidol in the nonreplicating study also
havioral dyscontrol, introducing a bias to- were more depressed than those assigned to
ward affective and impulsive-behavioral phenelzine and had more comorbid major
symptoms. Those patients who were able to depressive disorder (MDD) (Soloff et al.
stay on trifluoperazine for 3 weeks or longer 1993). Efficacy for haloperidol was limited to
(7 of 12 patients) were among the best mood hostile belligerence and impulsive-aggres-
responders in the study, with significant im- sive behaviors.
provement over placebo on physician ratings Cornelius et al. (1993) followed the sam-
of depression, anxiety, rejection sensitivity, ple used in the Soloff et al. (1989) study in a
and suicidality. continuation study of responders main-
Soloff et al. (1986, 1989) studied acutely ill tained on their original medication assign-
inpatients with BPD defined by the Diagnos- ments for 16 weeks following an initial
tic Interview for Borderline Patients and com- 5 weeks of acute treatment. Intolerance of
pared haloperidol with amitriptyline and medication over time resulted in significant
placebo in a 5-week trial. Symptom severity noncompliance and dropout. The 22-week
was an inclusion criterion, defined by a Glo- attrition rates were 87.5% for haloperidol,
bal Assessment Scale (GAS) score of less than 65.7% for phenelzine, and 58.1% for placebo.
50 and either a Ham-D score of 17 or greater Analysis of endpoint data (all subjects car-
(measuring depression) or a score of 66 or ried forward) revealed significant continu-
greater on the Inpatient Multidimensional ing improvement on haloperidol compared
Psychiatric Scale (assessing psychoticism). with placebo only in the treatment of irrita-
Patients receiving haloperidol (mean dosage, bility, with a trend in total hostility. Patients
4.8 mg/day) showed significantly more im- on haloperidol reported significant worsen-
proved symptom severity across all symp- ing in depressive symptoms over time,
tom domains than those receiving placebo. which was attributed in part to the side effect
Severity of schizotypal symptoms was a pre- of akinesia. Clinical improvement was mod-
dictor of favorable response. In the final anal- est and of limited clinical importance. This
ysis of this study (Soloff et al. 1989), haloperi- study illustrates the difficulties of continua-
dol was significantly superior to placebo on tion treatment with high-potency neurolep-
global measures, self- and observer-rated de- tics in the patient with personality disorder.
pression, anger and hostility, schizotypal In a 6-month study, Montgomery and
symptoms, psychoticism, and actual impul- Montgomery (1982) controlled for noncom-
sive behaviors on the wardin effect, a broad pliance by using depot flupenthixol de-
spectrum of symptom presentations. Halo- canoate 20-mg injections once a month in a
peridol was equal to amitriptyline against de- study of recurrently parasuicidal patients
pressive symptoms. with borderline and histrionic personality
A second study by the same group, using disorders. Patients receiving flupenthixol
the same design but comparing haloperidol demonstrated significant decreases in sui-
cidal behaviors by 4 months compared with weekly white blood cell counts must be ob-
the placebo group. tained for the first 6 months of treatment and
The introduction of second-generation biweekly thereafter for the duration of cloza-
neuroleptics greatly increases clinicians op- pine therapy. Fortunately, newer second-
tions for treating the patient with personality generation neuroleptics (e.g., olanzapine, ris-
disorder. In an open-label trial, Frankenburg peridone, quetiapine, aripiprazole) are less
and Zanarini (1993) reported that clozapine difficult to use than clozapine and are better
(mean dosage [ SD], 253.3 mg/day [ 163.7 tolerated than first-generation agents. Open-
mg/day]) improved positive and negative label and RCTs are now published describing
psychotic symptoms and global functioning the efficacy of each of these agents in BPD or
in 15 patients with BPD and comorbid Axis I schizotypal personality disorder.
psychotic disorder not otherwise specified Rocca et al. (2000) reported that risperi-
(NOS) who had been intolerant of, or whose done (mean dosage, 3.27 mg/day) produced
illness had been refractory to, other neuro- improvement in aggression, hostility and
leptic trials. Patients were recruited from a suspicion, depressive symptoms, and overall
larger study of patients with treatment-resis- global functioning in an open-label trial of
tant psychotic symptoms, raising the ques- 8 weeks duration in patients with BPD. In an
tion of whether their symptoms were truly RCT, Koenigsberg et al. (2003) found that low
part of the Axis II disorder. Improvement dosages of risperidone (to 2 mg/day), com-
was modest but statistically significant. pared with placebo, produced significant im-
These concerns were addressed by Benedetti provement by 3 weeks of treatment in nega-
et al. (1998), who excluded all Axis I psy- tive and positive symptoms of psychoticism
chotic disorders from a cohort of patients in patients with schizotypal personality dis-
with treatment-refractory BPD. Target symp- order, sustained through a 9-week trial.
toms included psychotic-like paranoid Open-label trials of olanzapine (mean
ideation and referential thinking (which dose, 9.32 mg) in patients with schizotypal
were transient and stress-related), visual illu- personality disorder have produced im-
sions, hypnagogic phenomena, and odd be- provement in measures of psychoticism
liefs (which never reached a clear-cut delu- (Brief Psychiatric Rating Scale [BPRS]); de-
sional or hallucinatory quality). Patients pressed mood (Beck Depression Inventory
symptoms had been refractory to 4 months [BDI], Ham-D); impulsive aggression (Overt
of prior treatment with medication and psy- Aggression Scale [OAS]); and overall global
chotherapy. In a 4-month trial of 12 patients functioning (GAS) in much longer trials of
treated with clozapine (mean dosage [ SD], 26 weeks duration (although only 8 of 11 pa-
43.8 mg/day [ 18.8 mg/day]) and concur- tients completed the full trial) (Keshavan et
rent psychotherapy, Benedetti et al. (1998) al. 2004). Schulz et al. (1999) conducted an 8-
reported that low-dose clozapine improved week open-label, dose-finding study of olan-
symptoms in all domainscognitive-per- zapine in patients with BPD and comorbid
ceptual, affective, and impulsive-behavioral. dysthymia. Patients received an average
Clozapine may also have utility in treatment dosage ( SD) of 7.5 mg/day ( 2.61 mg/
of self-mutilation and aggression in Axis I day), with a range of 2.510 mg. Significant
psychotic patients with comorbid Axis II improvement was reported in all global
BPD (Chengappa et al. 1995, 1999). scales including general symptom severity
Clozapine, arguably the most effective of (Hopkins Symptom Checklist90 [SCL-90]);
the atypical agents, is associated with low- hostility (Buss-Durkee Hostility Inventory);
ered white blood cell counts, jeopardizing impulsivity (Barratt Impulsiveness Scale);
the bodys immune responsea rare but depression (BPRS, the Depression Scale of
dangerous side effect. Because of this risk, the SCL-90 [ SCL-90-DEP]); and in interper-
sonal sensitivity, psychoticism, anxiety, and ceiving concurrent olanzapine (mean dosage
anger/hostility (SCL-90). Zanarini and Fran- [SD], 8.83 mg/day [3.8 mg/day]) did sig-
kenburg (2001) improved on this design in a nificantly better than patients receiving pla-
6-month placebo-controlled, RCT study of cebo on measures of depression (Ham-D),
olanzapine in patients with BPD (mean dos- anxiety (Hamilton Anxiety Rating Scale
age [ SD], 5.33 mg/day [ 3.43 mg/day]). [Ham-A]), and impulsivity/aggressive be-
They reported significant improvement over havior. This study allowed patients to con-
placebo in the areas of interpersonal sensitiv- tinue psychoactive medications established
ity, anxiety, anger and hostility, paranoia (all prior to the study. While preexisting medica-
SCL-90), dissociation, positive symptoms of tion use was similar in the two groups and
psychoticism (Positive and Negative Syn- held constant for the 12-week trial, the pres-
drome Scale [for schizophrenia] [PANSS]), ence of additional medications potentially
and global function (Global Assessment of confounds results.
Functioning [GAF] Scale). E ff ica cy and safety dat a hav e bee n
In a 12-week RCT, Bogenschutz and widely reported for the use of olanzapine in
Nurnberg (2004) found that olanzapine (2.5 routine treatment of BPD, using oral formu-
20 mg/day) was superior to placebo in im- lations. A recent prospective observational
proving global functioning on a Clinical study described the urgent use of intramus-
Global Impression (CGI) Scale modified for cular olanzapine (10 mg) for treatment of
patients with BPD. Zanarini et al. (2004) com- acute agitation in patients with BPD seen in
pared three medication treatments in patients an emergency room setting (Damsa et al.
with BPD: olanzapine (mean dosage [SD], 2007). All patients had refused oral medica-
3.3 mg/day [ 1.8 mg/day]), fluoxetine tions and 20 patients (80%) required physical
(mean dosage [SD], 15.0 mg/day [6.5 mg/ restraint. Diagnostic assessments were con-
day]) and olanzapine-fluoxetine combination ducted (by a separate research staff) after
(mean dosage [SD] fluoxetine, 12.7 mg/day treatment had resolved the agitation. Symp-
[ 5.9 mg/day] plus olanzapine 3.2 mg/day tomatic improvement, assessed on the
[1.5 mg/day]). They assessed symptomatic PANSSExcited Component (PANSS-EC) ,
changes in depressed mood (on the Mont- the Agitated Behavior Scale, and the Clinical
gomery-sberg Depression Rating Scale) and Global ImpressionSeverity of Illness (CGI-
impulsive aggression (on the Overt Agres- S) were assessed at baseline, 2 hours postin-
sion ScaleModified [OAS-M]) over an 8- jection and 1224 hours later. Although sev-
week trial. While all three interventions pro- eral patients required a second dose (5 mg),
duced some improvem ent, olan zapine and one patient required a third dose (5 mg),
monotherapy and the olanzapine-fluoxetine statistically significant improvement oc-
combination were superior to fluoxetine over curred after 2 hours in all three assessment
time on both measures. Treatment with a neu- measures (though no further significant
roleptic alone, olanzapine monotherapy, was change occurred 1224 hours later). Aside
superior to combined antidepressant and from asymptomatic decreases in blood pres-
neuroleptic medication (combination condi- sure, there were no significant medical com-
tion) in treating depressive symptoms. Fluox- plications.
etine monotherapy was associated with re- As newer atypical neuroleptics are intro-
ductions in both impulsive aggression and duced, offering more favorable side-effect
severity of depression. profiles (e.g., in terms of weight gain and
Soler et al. (2005) combined DBT with an metabolic syndrome), they have also been as-
RCT study of olanzapine and placebo in a 12- sessed for efficacy in BPD. In an RCT study of
week trial of BPD patients with moderate to aripiprazole (15 mg/day) in patients with
high degrees of clinical severity. Patients re- BPD, Nickel et al. (2006) found significant im-
provement for drug over placebo across all physical assaults, property destruction, or
scales of the SCL-90, most notably on obses- self-injury.) Rejection sensitivity and depres-
sive-compulsion, insecurity in social con- sive mood crashes result from a similar
tacts, depression, anxiety, aggressiveness/ disinhibition of mood. (Impulsive aggres-
hostility, phobic anxiety, paranoid thinking, sion is discussed later in greater detail.)
and psychoticism. Additionally, subjects on BPD has been studied most intensively
aripiprazole showed significantly greater im- with antidepressants because of the promi-
provement on the Ham-D and Ham-A scales nence of affective dysregulation as a major
and on four State-Trait Anger Expression In- component of temperament. Mood instabil-
ventory (STAXI) scales (i.e., the same broad ity, mood crashes, and rejection-sensitive
spectrum of effects described for earlier neu- dysphoria are familiar clinical terms de-
roleptic trials). Open-label trials also suggest scribing this trait vulnerability. Some investi-
that quetiapine may have broad spectrum ef- gators view the affective dysregulation of the
ficacy in treating patients with BPD. In dos- BPD patient as a subclinical manifestation of
ages ranging from 251 to 540 mg/day, and an affective disorder, evidence that some
durations of 12 weeks, three recent open-label variants of BPD may be part of the broader
studies demonstrated efficacy for quetiapine affective disorders spectrum (Akiskal et al.
on a broad spectrum of symptom measures 1985). Reviewing the antidepressant litera-
assessing affective, cognitive, and impulsive- ture, one should keep in mind that studies in
behavioral symptoms (Bellino et al. 2006, Per- which there is a lack of control for comorbid
rella et al. 2007, Villeneuve and Lemelin Axis I depression would be expected to dem-
2005). onstrate a favorable response for antidepres-
In these acute treatment studies, low- sant treatments but may not reflect the phar-
dose neuroleptics produced improvement in macological responsiveness of the Axis II
treatment trials extending from 5 weeks to syndrome.
6 months. A role for low-dose neuroleptics in Early case experience and small open-
continuation and maintenance therapies of label trials with fluoxetine, sertraline, and
the patient with personality disorder has yet venlafaxine (a mixed SSRI/norepinephrine
to be established through multiple con- uptake blocker) indicated efficacy against af-
trolled-treatment trials. fective, impulsive-behavioral, and even cog-
nitive-perceptual symptoms in patients with
BPD. Aggression and irritability, depressed
Antidepressants
mood, and self-mutilation responded to flu-
Selective Serotonin Reuptake Inhibitors oxetine (up to 80 mg), venlafaxine (up to
and Related Medications 400 mg), or sertraline (up to 200 mg) in treat-
ment trials of 812 weeks duration (Corne-
Selective serotonin reuptake inhibitor (SSRI) lius et al. 1990; Kavoussi et al. 1994; Marko-
antidepressants are the drugs of first choice vitz and Wagner 1995; Markovitz et al. 1991;
in the treatment of both affective dysregula- Norden 1989). An unexpected finding in
tion and impulsive-aggressive behavior in these early open-label reports was that im-
patients with personality disorder. Symp- provement in impulsive behavior appeared
toms of affective dysregulation include rapidly, often within the first week of treat-
marked lability of mood (intense, reactive, ment, and disappeared as quickly with dis-
angry, depressive, or anxious feelings). (An- continuation or noncompliance (Coccaro
ger may be a reflection of affective dysregu- and Kavoussi 1997). Improvement in impul-
lation or accompany impulsive aggression. sive aggression appeared to be independent
In extreme expression, anger can be ex- of effects on depression and anxiety and oc-
pressed behaviorally as temper tantrums, curred regardless of whether the patient had
comorbid MDD. Failure to respond to one given dosages ranging from 20 mg/day to
SSRI did not predict poor response to all SS- 80 mg/day. This sample was noteworthy for
RIs. For example, some patients with illness the high rate of comorbid Axis I affective dis-
that was refractory to fluoxetine (80 mg) orders (10 with MDD, 6 with bipolar disor-
have proved responsive to a subsequent trial der), anxiety disorders, and somatic com-
of sertraline. Similarly, some patients whose plaints (e.g ., headaches, premenstrual
illness failed to respond to sertraline, parox- syndrome, irritable bowel syndrome). Al-
etine, or fluoxetine in a first trial have proved though this sample is more typical of an im-
responsive to venlafaxine (Markovitz 1995). paired BPD patient population, comorbidity
In one study, higher doses (e.g., to the point with affective and anxiety disorders con-
of ind ucing t remor) and a lon ger t rial founds interpretation of results, because SS-
(24 weeks) of sertraline converted half of ser- RIs are effective for these disorders indepen-
traline nonresponders to responders (Mark- dent of BPD. Patients receiving fluoxetine
ovitz 1995). improved significantly more than those re-
Following these open-label reports, two ceiving placebo on measures of depression
placebo-controlled, randomized studies and anxiety and on global measures. Mea-
were reported in patients with BPD (Marko- sures of impulsive aggression were not in-
vitz 1995; Salzman et al. 1995). Neither study cluded in this study. Anecdotally, some pa-
is easily generalizable. Salzman et al. (1995) tients with premenstrual syndrome and
conducted a 12-week trial of fluoxetine (20 headaches noted improvement in these so-
60 mg/day) in 27 highly functional subjects matic presentations with fluoxetine, whereas
(not identified as patients) with BPD or bor- none improved with placebo.
derline-trait disturbances. The subjects had a A double-blind, placebo-controlled
mean baseline GAS score of 74. One advan- study by Coccaro and Kavoussi (1997) fo-
tage of this mildly symptomatic sample was cused attention on impulsive aggression as a
the absence of other Axis I or II comorbid di- dimensional construct (i.e., a symptom do-
agnoses. Exclusion criteria also included remain found across personality disorder cate-
cent suicidal behavior, self-mutilation, sub- gories but especially characteristic of BPD
stance abuse, or current severe aggressive and other Cluster B personality disorders).
behaviorthat is, behaviors typical of BPD They recruited 40 male subjects, not identi-
patients seeking treatment. This strategy lim- fied as patients, with prominent impulsive
its generalizability to more seriously ill pa- aggression as a behavioral disturbance in the
tients, but it allows for a test of efficacy context of a DSM-III-R (American Psychiat-
against symptoms unencumbered by comor- ric Association 1987) personality disorder.
bidity. For subjects who completed the study Personality disorder diagnoses included 11
(n = 22), significant improvements were re- (28%) eccentric cluster disorders, 19 (48%)
ported for subjects receiving fluoxetine com- dramatic cluster disorders, and 16 (40%) anx-
pared with those receiving placebo in self- ious cluster disorders. There was a high rate
and observer-rated anger, depression, and of comorbidity with dysthymic disorder or
global function. A large placebo response depression NOS, although MDD and bipolar
was noted. Improvement in anger was found disorder were excluded. Anxiety disorders
to be independent of changes in depressed and alcohol and drug abuse were also prom-
mood. Improvement in this highly func- inent. Following a 12-week double-blind,
tional sample was modest, with no subject placebo-controlled trial of fluoxetine (20
improving more than 20% on any measure. 60 mg), subjects receiving fluoxetine had sig-
Markovitz (1995) studied 17 patients (9 nificantly greater improvement than those
receiving fluoxetine, 8 receiving placebo) for receiving placebo on specific measures of
14 weeks; those receiving fluoxetine were verbal aggression and aggression against
property. Improvement was significant by standardized measures of depression, anxi-

week 10, with first trends (P=0.06) appearing ety, aggression, dissociation, anger, and glo-
by week 4. Improvement in irritability ap- bal functioning. Within the fluoxetine group,
peared by week 6, again with an early trend there were no significant pre-/posttreatment
apparent by week 4. Global improvement, fa- improvements (while the placebo group im-
voring fluoxetine, was significant by week 4. proved significantly in clinician-rated global
As in the open-label trials and the Salzman et functioning and depression, with meaning-
al. (1995) study, these investigators found ful reductions in anxiety and dissociation).
that the effects on aggression and irritability By chance, the fluoxetine group had signifi-
did not appear due to improvement in mood cantly higher pretreatment GAF scores com-
or anxiety symptoms. More recently intro- pared with placebo (mean dosage [ SD],
duced SSRIs appear to have similar proper- 49.39 mg/day [ 9.10 mg/day]) Admission
ties. An open-label, 8-week study using cit- to a 5-day partial program suggests acute-
alopram (mean dosage, 45.5 mg/day) in ness of symptomatic decompensation and
patients with Cluster B personality disorder moderate to severe functional impairment.
or intermittent explosive disorder (but no In the absence of a no treatment control
MDD) also demonstrated significant de- group, the effect of DBT cannot be distin-
creases in irritable (impulsive) aggression guished from the effects of time alone. None-
(Reist et al. 2003). theless, this study suggests that addition of
Rinne et al. (2002) reported a double- fluoxetine to an effective form of psychother-
blind, placebo-controlled trial of fluvoxamine apy was not helpful in this symptomatic BPD
in female patients with BPD treated for 6 sample.
weeks at 150 mg and then followed in a half- In summary, these studies show efficacy
crossover design (all patients on active for SSRI antidepressants against affective
drug) for 6 weeks with a 12-week open-label symptoms in the patient with personality dis-
continuation. Significant improvement with order, specifically depressed mood (Mar-
fluvoxamine was found only in a scale mea- kovitz 1995; Salzman et al. 1995; Zanarini et
suring rapid mood shifts, with the most imal. 2004), anger (Salzman et al. 1995), and anx-
provement in the first 6 weeks. There were no iety (Coccaro and Kavoussi 1997; Markovitz
significant changes in anger or impulsivity. 1995), and against impulsive-behavioral
The authors suggested that effects on anger symptoms, specifically, verbal and indirect
and impulsivity may be related to gender aggression (Coccaro and Kavoussi 1997). Glo-
that is, more easily demonstrated in male pa- bal symptom severity also improves (Coccaro
tients (as in the Coccaro and Kavoussi [1997] and Kavoussi 1997; Markovitz 1995; Salzman
study mentioned previously), who may re- et al. 1995). Effects on impulsive aggression
spond preferentially to an SSRI. However, in (Coccaro and Kavoussi 1997) and anger (Salz-
the Zanarini et al. (2004) study (in the earlier man et al. 1995) are independent of effects on
section Neuroleptics), fluoxetine mono- affective symptoms, including depressed
therapy was associated with reductions in mood (Coccaro and Kavoussi 1997; Salzman
both impulsive aggression and severity of de- et al. 1995) and anxiety (Coccaro and Ka-
pression among female subjects with BPD. voussi 1997). The study by Simpson et al.
An important negative study was re- (2004) cautions that pharmacotherapy may
ported by Simpson et al. (2004), who added a not improve outcomes in the context of an ef-
placebo-controlled RCT study of fluoxetine fective form of psychotherapy.
(to 40 mg/day) to a 12-week course of DBT in
women with BPD recruited from a 5-day Monoamine Oxidase Inhibitors
DBT-based partial hospital program. The ad-
dition of fluoxetine to DBT produced no sig- Monoamine oxidase inhibitor (MAOI) anti-
nificant advantage over DBT with placebo on depressants (phenelzine, tranylcypromine)
are second-line treatments for depressed Tricyclics or Heterocyclics

mood in the patient with personality disor-
der, especially atypical depression so com- The utility of tricyclic antidepressants (TCAs)
mon in the patient with BPD. They may also for the treatment of affective dysregulation or
be helpful in reducing social anxiety and hy- mood symptoms in BPD or other personality
persensitivity in patients with avoidant per- disorders is highly questionable. When a
sonality disorder in the context of social pho- clear diagnosis of major depression can be
bia (Liebowitz et al. 1986). made, therapy should be directed at the Axis
Although empirical support for MAOI I disorder. Where atypical depression is
antidepressants (phenelzine, tranylcypro- present, the MAOI antidepressants may be
mine) in the BPD patient is similar to that of preferred. At best, the response to TCA (e.g.,
the SSRI antidepressants, this class of medi- amitriptyline) appears modest in magnitude.
cations is considered a second choice because Paradoxical behavioral toxicity to amitrip-
of dietary restrictions, drug interactions, and tyline has been reported in some inpatients
safety concerns (e.g., risk of hypertensive cri- with BPD, consisting of increased suicide
ses). (We are not aware of any studies using threats, paranoid ideation, demanding and
the new transdermal formulation of the assaultive behaviors, and an apparent disin-
MAOI selegiline [Emsam] in patients with hibition of impulsive behavior (Soloff et al.
BPD.) Patients must be willing to comply 1986, 1987). A choice of antidepressant for
with the tyramine-free diet and abstain from Axis I major depression comorbid with BPD
certain classes of medication (e.g., many de- should take this literature into consideration.
congestants, meperidine, some older antihy- The possibility of behavioral toxicity, and the
pertensives) and drugs of abuse (especially known lethality of TCAs in overdose, sup-
cocaine and amphetamines) or risk acute hy- ports the preferential use of an SSRI or related
pertensive crisis. Only cooperative and com- antidepressant as treatment of first choice for
pliant patients should be considered for the affective dysregulation of the patient with
MAOI therapy. Many BPD patients do test personality disorder.
the dietary limits through minor indiscre-
tions as a manipulative gesture in the context Anxiolytics
of psychotherapy; however, few are willing
to risk a heart attack or stroke in order to test Anxiety is a common and chronic com-
the psychiatrist. (One sophisticated BPD pa- plaint among many patients with personal-
tient of mine intentionally ate a large portion ity disorders and is a defining characteristic
of quiche Lorraine, made with excellent aged of the anxious/fearful Cluster C disorders
cheeses, resulting in a hypertensive head- (avoidant, dependent, and obsessive-com-
ache, a visit to the emergency department, pulsive personality disorders). Although
and a late-night call to her psychiatrist say- anxiety is widely treated as a symptom inde-
ing, It looked like a piece of pie!) With pendent of any Axis I diagnosis, there is a
proper patient selection and instruction, hy- paucity of studies of anxiolytic use in pa-
pertensive crisis is rare, most frequently pre- tients ascertained specifically for personality
cipitated by the accidental use of over-the- disorder diagnoses. For example, studies of
counter decongestant medication (e.g., pseu- alprazolam efficacy for avoidant personality
doephedrine) or drugs of abuse (e.g., co- traits (mean dosage, 2.9 mg/day 8 weeks)
caine). Fear of MAOIs among inexperienced are reported in the context of treating social
clinicians, especially psychiatrists trained af- phobia (Reich et al. 1989).
ter the advent of SSRIs, has greatly reduced Cowdry and Gardner (1988) included al-
their use, even in disorders for which they prazolam, a short-acting, high-potency ben-
have clear advantages (e.g., atypical pattern zodiazepine, in their double-blind, placebo-
depression, refractory depression). controlled crossover study of female BPD
outpatients with comorbid hysteroid dys- BPD should be limited to patients who fail to
phoria and extensive histories of dyscontrol respond to other antianxiety treatments (e.g.,
(self-mutilation, overdoses, rage episodes). SSRI antidepressants) and who are at low
Patients received an dosage of 4.7 mg/day risk for abuse. Short-half-life benzodiazepine
on average of alprazolam for a 6-week trial. anxiolytics (e.g., alprazolam) should be used
Use of alprazolam was associated with seri- with great caution because of the risk of be-
ous episodes of behavioral dyscontrol in- havioral disinhibition or impulsive aggres-
volving drug overdoses, self-mutilation, and sion. Patients with histories of behavioral
throwing a chair at a child. Seven of 12 (58%) disinhibition who are in need of anxiolytic
patients receiving alprazolam had episodes treatment may be treated with clonazepam, a
of serious behavioral dyscontrol compared long-half-life benzodiazepine. There are no
with 1 of 13 patients receiving placebo (8%). currently available studies of nonbenzodiaz-
Four alprazolam trials were stopped by the epine anxiolytics in patients with personality
blind investigator, whereas none of the pla- disorder diagnoses in the absence of Axis I
cebo trials required early termination (Gard- anxiety disorders.
ner and Cowdry 1985). Alprazolam has been
associated with emergence of extreme anger Lithium Carbonate and
and hostile behavior, including physical as- Anticonvulsant Mood Stabilizers
saultiveness, in patients with panic disorder,
agoraphobia, obsessive-compulsive disor- Lithium carbonate and the anticonvulsant
der, and major depression. These patients mood stabilizers phenytoin, carbamazepine,
had histories of chronic anger and resent- divalproex sodium, and lamotrigine have all
ment whose overt expression was well sup- been studied in patients with personality dis-
pressed (Rosenbaum et al. 1984). However, orders for the treatment of impulse dyscon-
open-label case experience suggests that al- trol. These studies have been conducted in
prazolam may be helpful against anxiety in patients with borderline and antisocial per-
carefully selected patients with BPD (Faltus sonality disorders in whom behavioral im-
1984). pulsivity and impulsive aggression were
Open-label case experience has also been prominent characteristics. A separate litera-
reported in patients with BPD using clo- ture, although relevant, describes the suc-
nazepam, a long-half-life (1850 hours) ben- cessful use of anticonvulsants (e.g., carba-
zodiazepine with anticonvulsant properties mazepine) in the treatment of intermittent
similar to carbamazepine and serotonin- explosive disorder and rage outbursts in-
enhancing properties similar to lithium car- dependent of personality diagnosis (Mattes
bonate (Freinhar and Alvarez 1985). Clo- 1990). Efficacy of anticonvulsants against ag-
nazepam is helpful as an adjunctive agent in gression in patients with personality disor-
the treatment of impulsivity, violent out- der (e.g., borderline or antisocial) may be in-
bursts, and anxiety in a variety of disorders, dependent of electroencephalographical
including bipolar mania, schizoaffective dis- abnormalities (Reeves et al. 2003).
order, schizophrenia, and BPD. Its efficacy An early hypothesis concerning the origin
may be related to an increase in serotonin of impulse dyscontrol suggested that explo-
levels and increased serotonin synthesis and sive anger and impulsive aggression were
function (Chouinard 1987). mediated by the same neural mechanisms in-
Benzodiazepines in general warrant care- volved in seizure disorders (Barratt 1972).
ful supervision because of the potential for This hypothesis led to trials of the anticonvul-
abuse and the development of pharmacolog- sant phenytoin as a treatment for impulsive
ical tolerance with prolonged use. The use of aggression and nonepileptic rage in a variety
benzodiazepine anxiolytics in patients with of settings and populations. The results of
many early studies were inconclusive, due in significant differences between lithium and
part to methodological problems involving placebo treatment. The authors noted that
diagnosis and assessment of aggression. therapists were favorably impressed by de-
Nonetheless, in some studies phenytoin has creases in impulsivity during the lithium trial.
proved effective as an antiaggressive agent. There was a trend for patients receiving lith-
Barratt et al. (1997) conducted a double-blind, ium to report less anger and suicidal symp-
placebo-controlled crossover study in a cor- toms than patients receiving desipramine.
rectional facility using inmates with antisocial Carbamazepine has been studied in two
personality disorder but no Axis I comorbid- double-blind, placebo-controlled studies us-
ity. Using structured interviews for diagnoses ing very different patient samples and result-
and standardized measures for aggression, ing in inconsistent findings.
these investigators demonstrated that pheny- In the first study, Gardner and Cowdry
toin (in dosages up to 300 mg/day) signifi- (1986b; Cowdry and Gardner 1988) studied
cantly reduced impulsive-aggressive behav- female BPD outpatients who also had comor-
ior but not premeditated aggression. bid hysteroid dysphoria and extensive histo-
Lithium was also shown to have antiag- ries of behavioral dyscontrol. Patients re-
gressive efficacy in chronically assaultive ceived 6-week trials of medication, with
male prisoners in a placebo-controlled cross- 4 weeks at steady dosage (mean, 820 mg/
over study in which subjects received at least day). Among the 11 patients who completed
1 month of lithium therapy (Sheard et al. both a placebo and a carbamazepine trial,
1976) and in longer-term open-label trials patients showed less behavioral dyscontrol
with incarcerated aggressive prisoners (Tu- and less severe types of behavioral dyscon-
pin et al. 1973) and aggressive delinquents trol during the carbamazepine trials. Com-
followed both in institutional settings and as paring all patients, there were fewer suicide
outpatients (Sheard 1975). Decreases in ag- attempts or other major dyscontrol episodes
gressive behaviors were documented through during the carbamazepine trials (1 in 14 pa-
objective behavioral measures. Diagnoses of tients) compared with the placebo trials (7 of
patients in these studies were not controlled 11 patients, P =0.005). Patients receiving car-
and included patients with schizophrenia in bamazepine also showed improvement in
the Tupin et al. (1973) study and diverse per- anxiety, anger, and euphoria by physicians
sonality disorders among the adult and ado- assessments, although patients did not re-
lescent delinquent subjects in the Sheard port improved mood. There was a significant
study (Sheard 1971, 1975). Subsequently, case decrease in impulsivity and suicidality dur-
reports reported both mood-stabilizing and ing the carbamazepine trials compared with
antiaggressive effects of lithium in individual the placebo trials.
patients defined as having BPD (LaWall and In an earlier report from the same study,
Wesselius 1982; Shader et al. 1974). Gardner and Cowdry (1986a) reported de-
Links et al. (1990) compared lithium with velopment of melancholia during carba-
desipramine in 17 outpatients with BPD in a mazepine treatment as an untoward effect in
double-blind, placebo-controlled crossover 3 of 17 (18%) patients.
study. All patients received lithium for In the second study, de la Fuente and Lot-
6 weeks (with 4 weeks at constant dose) at an stra (1994) failed to replicate the findings of
average dosage of 985.7 mg/day and received efficacy for carbamazepine in BPD that were
concurrent psychotherapy. Among 10 pa- noted in the Cowdry and Gardner studies
tients completing both lithium and placebo (1988). De la Fuente and Lotstra (1994) con-
treatments, therapists blind ratings indicated ducted a double-blind, placebo-controlled
greater improvement during the lithium trial, trial of carbamazepine among inpatients in
although patients self-ratings did not reflect whom BPD was the main diagnosis. They
rigorously excluded patients with any co- dium, which was titrated to plasma levels of
morbid Axis I disorder, a history of epilepsy, 50100 g/mL. Among eight patients com-
or electroencephalographical abnormalities. pleting the study, half were responders on a
Unlike the studies of Cowdry and Gardner measure of global improvement. Improve-
(1988), patients were not selected for histo- ment was noted in physicians ratings of
ries of behavioral dyscontrol. In the study by mood, anxiety, anger, impulsivity, and rejec-
de la Fuente and Lotstra (1994), 20 patients tion sensitivity; in patients ratings of global
(10 receiving carbamazepine and 10 receiv- improvement (SCL-90); and in observed irri-
ing placebo) were studied in the hospital tability (OAS-M).
with medication trials of up to 32 days in du- Kavoussi and Coccaro (1998) also re-
ration. Carbamazepine dosages were ad- ported significant improvement in impulsive
justed to yield plasma levels in the low ther- aggression and irritability after 4 weeks of di-
apeutic range. There were no significant valproex sodium in 10 patients with impul-
differences between carbamazepine and pla- sive aggression in the context of a DSM-IV
cebo on measures of affective or cognitive- (American Psychiatric Association 1994) per-
perceptual symptoms, impulsive-behavioral sonality disorder. Eight patients completed
acting-out, or global assessments. The two the 8-week study; six had a 50% or greater re-
patients who failed to complete the study duction in aggression and irritability (OAS-
dropped out because of acting-out behav- M). All patients had previously failed a trial
iors. Both were receiving carbamazepine. of fluoxetine (up to 60 mg for 8 weeks) prior
Divalproex sodium has been used in to taking divalproex sodium.
open-label trials targeting the agitation and Frankenburg and Zanarini (2002) con-
aggression of BPD patients in a state hospital ducted a 6-month, double-blind, placebo-
setting (Wilcox 1995) and the mood instabil- controlled trial of divalproex sodium (aver-
ity and impulsivity of BPD patients in an out- age dose [ SD], 850 mg [249 mg]) in female
patient clinic (Stein et al. 1995). Wilcox (1995) patients meeting criteria for both BPD and
reported a 68% decrease in time in seclusion bipolar II disorder. Analyses at 8 weeks and
and improvement in anxiety, tension, and endpoint (using analysis of last observation
global symptom scores (BPRS) among 30 carried forward) demonstrated divalproex to
BPD patients receiving divalproex sodium be superior to placebo on measures of inter-
for 6 weeks in a state hospital setting. Patients personal sensitivity, anger/hostility (SCL-
did not have psychiatric comorbid condi- 90), and impulsive aggression (OAS-M). Co-
tions (by clinical assessment), although five morbidity with bipolar II disorder makes this
had abnormalities on the electroencephalo- study difficult to generalize to personality
gram (EEG) (with no seizure disorders). Pa- disorder patients without bipolar spectrum
tients received dosages titrated to plasma illness. However, the similarity in symptoms
levels of 100 g/mL. Concurrent psychotro- between bipolar II disorder and BPD sug-
pic medications were allowed. Both dival- gests clinical usefulness of divalproex so-
proex sodium and the abnormal EEG were dium trials with either disorder.
predictive of improvement, although only Using an RCT design, Hollander et al.
the medication effect was significant. The au- (2001) enrolled 16 outpatients with BPD (and
thor noted that anxiety played a role in the no Axis I depression or bipolar diagnoses)
agitation of these patients and that both the and compared divalproex sodium with pla-
antiaggressive and antianxiety effects of di- cebo in a 10-week randomized, controlled
valproex sodium were instrumental in de- study. Dropout rates were high, involving
creasing agitation and time in seclusion. 50% of those receiving divalproex sodium
Stein et al. (1995) treated 11 cooperative and 100% of those receiving placebo, due to
outpatients with BPD with divalproex so- lack of efficacy or impulsive decisions. No
placebo patient was a responder. Patients re- Oxcarbazepine, an anticonvulsant re-

ceiving divalproex sodium improved signifi- lated to carbamazepine, was studied in an
cantly on global functioning (GAS, Clinical open-label trial with patients with BPD (Bell-
Global ImpressionsImprovement of Ill- ino et al. 2005). Patients received 1,2001,500
ness), with nonsignificant trends for im- mg/day for 12 weeks. Significant improve-
provement in aggression and depressed ment was noted in global functioning (CGI-
mood. Hollander et al. (2003) followed this S) and BPRS mean scores, Ham-A, and four
study with an expanded RCT study that in- subscales of the Borderline Personality Dis-
cluded a broader spectrum of Cluster B pa- order Severity Index, including impulsivity,
tients. This expanded study also demon- affective instability, interpersonal relation-
strated significant treatment effects for ships, and outbursts of anger. As with previ-
divalproex sodium against irritability and ag- ous trials of mood stabilizers in BPD (e.g.,
gression compared with placebo in Cluster B lithium, carbamazepine, divalproex), oxcar-
patients in a multisite trial of 12 weeks dura- bazepine may be helpful in managing symp-
tion. (The study also included other compar- toms of affective instability and impulsivity.
ison groups with impulse-control disorders, Nickel and colleagues reported two RCTs
intermittent explosive disorder, and post- of topiramate, specifically targeting aggres-
traumatic stress disorder.) Differences be- sion in medication-free female subjects
tween Cluster B patients receiving divalproex (Nickel et al. 2004) and male subjects (Nickel
and those receiving placebo were significant et al. 2005) with BPD. After 8 weeks on topi-
in the last 4 weeks of the trial. Improvements ramate (up to 250 mg/day by week 6), pa-
in impulsive aggression were greater for the tients in both studies receiving active drug
Cluster B patients than for groups of patients had significantly greater improvement on
with other impulsive disorders. Treatment ef- state anger, trait anger, anger-out, and anger
fects were enhanced by excluding patients control subscales of the STAXI compared
with premeditated aggression rather than im- with patients receiving placebo. Weight loss
pulsive aggression. was a common side effect of topiramate.
In a follow-up analysis of this study, fo- Women receiving topiramate lost an average
cusing exclusively on patients with BPD, of 5.7 lb (vs. 0.7 lb, placebo), while men lost
Hollander et al. (2005) reported that dival- 11.4 lb (vs. 0.7 lb, placebo). A third study by
proex-treated patients responded signifi- the same group compared topiramate (up to
cantly better than placebo-treated patients 200 mg/day by week 6) to placebo in female
on measures of state aggression (OAS), trait BPD subjects assessed for general psychopa-
impulsiveness (Barratt Impulsiveness Scale), thology (on the SCL-90), for health-related
affective instability (depression and hypo- quality of life (Short-Form 36-Item Health
mania on the Young Mania Rating Scale and Survey [SF-36]), and on the Inventory of In-
on the Ham-D). Importantly, they noted that terpersonal Problems (IIP; Loew et al. 2006).
high pretreatment levels of trait impulsivity Compared with patients receiving placebo,
(Barratt Impulsiveness Scale) and state ag- patients taking topiramate showed signifi-
gression (OAS) were related to better respon- cant improvement after 10 weeks on SCL-90
siveness to divalproex. The effects of impul- subscales of Somatization, Interpersonal
sivity and aggression on treatment response Sensitivity, Anxiety, Hostility, Phobic Anxi-
appeared to be independent of each other. ety, and Global Symptom Severity. Addition-
As newer anticonvulsant medications ally, patients receiving topiramate had signif-
have been released, they have been tested icantly better outcomes on all eight quality-
against affective instability and impulsive of-life indicators on the SF-36, and four of the
aggression in patients with BPD; these symp- subscales of the IIP. Women receiving topira-
toms bear a close resemblance to symptoms mate lost an average of 12.5 lb in this study
in the bipolar spectrum. (vs. 3.1 lb, placebo.)
Working within the same group, Tritt et port to assess similar traits are often com-
al. (2005) studied the efficacy of lamotrigine pared. (Conversely, studies may be excluded
(200 mg/day by week 6) on aggression in from the analysis for not using comparable
women with BPD, applying the same meth- measures.) Pharmacotherapy literature in
ods as described by Nickel et al. (2004, 2005) BPD does not presently lend itself well to
for topiramate. At the end of the 8-week drug such an approach. Compared with literature
trial, subjects receiving lamotrigine had sig- in depression or schizophrenia, there are rel-
nificantly more improvement than subjects atively few RCT studies in BPD, meaning in-
receiving placebo on all five anger subscales sufficient power for analyses of critical core
of the STAXI. Weight loss did not differ sig- features (such as suicidality). Few studies of a
nificantly between groups, nor did any sub- given drug (or drug class) use comparable
jects develop a serious skin rash. methods in terms of dose, duration, and, most
importantly, outcome measures. Dropout
Meta-Analyses and rates tend to be high in studies of BPD, often
reflecting poor acceptability of treatment (an
Evidence-Based Practice
exclusion criterion for some meta-analyses).
Meta-analyses are rapidly becoming a major Despite these limitations, meta-analyses are
source for recommendations on evidence- becoming a more frequently cited tool for
based practice. Meta-analyses identify sig- making recommendations concerning evi-
nificant effects of a given treatment within dence-based practice and are appearing in the
multiple treatment trials and ask at what rate pharmacotherapy literature on treating BPD.
the treatment can be expected to produce the Nose et al. (2006) conducted a meta-anal-
effect. Typically, a large number of databases ysis of published RCT studies in patients
are first surveyed for studies meeting prede- with BPD. Among 84 potentially relevant
termined inclusion criteria (e.g., RCT studies RCT studies, only 22 placebo-controlled com-
with placebo controls, standardized assess- parisons met inclusion criteria for the meta-
ments, low attrition rates). Effect sizes for the analysis. Outcome categories included core
results of treatment on specific symptoms traits of BPD: affective instability and anger,
(e.g., depression, hostility) are calculated impulsivity and aggression, unstable inter-
from predetermined outcome measures and personal relationships, suicidality, and global
statistically compared between studies. In the function. Data extracted from four antide-
pooling of data, important clinical distinc- pressant studies and six mood stabilizer stud-
tions may be lost, including differing meth- ies found efficacy against affective instability
ods of diagnosis, different settings, confound- and anger. Antipsychotics (represented by
ing variables (such as concurrent treatments), three studies) had a positive effect on impul-
and assessment by multiple diverse outcome sivity and aggression. (In contrast, six antide-
measures. The results of the meta-analyses pressant trials and three mood stabilizer
are dependent on how one defines the treat- studies showed no significant effects.) Antip-
ment targets and selects the outcome mea- sychotics also had positive effects on unstable
sures. In symptom-specific analyses, the interpersonal relationships (three studies)
grouping of target symptoms for analysis is and global functioning (seven studies). The
critical (e.g., does anger belong with affective study did not target cognitive-perceptual
instability or impulsive aggression?). In an symptoms for analysis. Among specific
ideal model, all studies would use the same drugs, evidence was strong for the efficacy of
outcome measure for each target symptom, fluoxetine against affective instability and
allowing meaningful comparison of effect impulsivity, for topiramate and lamotrigine
sizes between studies. As this is not realistic against anger, and olanzapine for its effect on
practice, diverse outcome measures that pur- global functioning.
In marked contrast, the Cochrane Collab- forced by past success). Depressed patients
oration group, which conducts meta-analy- with prominent personality disorders are of-
ses across many medical treatments, sur- ten not referred for ECT because of a wide-
veyed 28 databases and identified only spread belief among practitioners that their
10 RCT studies in BPD meeting their rigor- illness is refractory to this somatic treatment.
ous inclusion criteria for meta-analysis The literature on the efficacy of ECT for the
(Binks et al. 2006). Though the review was depressed patient with personality disorder
also published in 2006 , no RCT study pub- is remarkably inconclusive. Methodological
lished after 1995 met their inclusion criteria. differences between studies make generaliza-
The Cochrane review was largely negative. tion difficult.
However, they found evidence that antide- The prejudice against the use of ECT
pressants may improve scores on anger and treatment for depressed personality disorder
perhaps depression (though not conclu- patients may be traced back to early case re-
sively) and that MAOIs may help those with ports and clinical series that described di-
hostility, but not reduce borderline symp- minished responsiveness to ECT in patients
toms or improve global functioning. They with neurotic depression, a broadly de-
found no advantages over placebo for anti- fined construct of low diagnostic reliability
psychotics (three studies), but some favor- incorporating many traits now attributed to
able change in global outcomes for one mood comorbid personality disorder. Patients with
stabilizer, divalproex. The Cochrane report hysterical personality features and BPD
concluded: If offered medication, people had poor outcomes with ECT (Kramer 1982;
with BPD should know that this is not based Lazare and Klerman 1968). Following the in-
on good evidence from trials. That does not troduction of structured interviews for Axis I
mean it may not do considerable good and and II disorders and standardized outcome
there is not indication of significant harm measures, empirical studies began to temper
(Binks et al. 2006, p. 19). It is important for cli- this view.
nicians to understand the methodology, Pfohl et al. (1984) studied 41 inpatients
strengths, and weaknesses of this kind of with DSM-III (American Psychiatric Associa-
analysis, which will certainly claim influence tion 1980) MDD and comorbid Axis II per-
in defining practice guidelines in the future. sonality disorder and compared them with
37 patients with MDD alone. Patients re-
ceived somatic treatment by antidepressant
ELECTROCONVULSIVE THERAPY medication or ECT, with all treatment deci-
sions made by their attending physicians.
Electroconvulsive therapy (ECT) is indicated Standard ratings of mood (Ham-D, BDI) and
for the treatment of Axis I psychiatric disor- global functioning (GAS) were done before
ders that have proved refractory to pharma- treatment and at discharge from the hospital.
cotherapy and are known to respond to ECT. Depressed patients with comorbid personal-
The vast majority of patients referred for ECT ity disorder receiving antidepressant medica-
have an affective spectrum disorder, al- tions were less improved at discharge than
though patients with schizoaffective disorder patients with MDD alone; however, there
and schizophrenia may also benefit. On rare was no difference between groups for pa-
occasions, ECT may be a treatment of first tients receiving ECT.
choice for responsive Axis I disorders when This result was extended in a naturalistic
clinical presentation requires urgency (e.g., study of outcomes in the treatment of 228 de-
catatonia), when pharmacotherapy poses un- pressed inpatients. Black et al. (1988) reported
acceptable risk (e.g., neuroleptic malignant that depressed patients with personality dis-
syndrome), or by patient preference (rein- order receiving adequate antidepressant
medication were less likely to recover than current antidepressant medication usage
patients with MDD alone. However, there were uncontrolled, although patients in both
were no differences between groups in recov- groups had similar numbers of treatments (5
ery after ECT. Depressed patients with per- with personality disorder and 5.2 with no
sonality disorder were less likely to be re- personality disorder) and days in the hospi-
ferred for ECT and generally received less tal. Depressed patients with personality dis-
aggressive treatment. In an expanded study order had acutely poorer outcomes on both
involving 1,471 depressed inpatients, Black et the depression and social functioning scale
al. (1991) found that the presence of a person- following ECT treatment compared with de-
ality disorder diagnosis was a significant sta- pressed patients with no personality disor-
tistical predictor of poor outcome for hospital der. The presence or absence of a personality
treatment in general (with antidepressant disorder was the strongest predictor of the
medication or ECT). Depressed patients with Social Functioning Schedule outcome, ex-
a personality disorder diagnosis were 50% plaining 31% of variance at discharge. Signif-
less likely to be recovered at hospital dis- icant differences between groups on Ham-D
charge than patients with MDD without a disappeared by the first 6-week follow-up
personality disorder. (There was no analysis and for the Social Functioning Schedule by
by separate treatment groups.) 12 weeks. There were no differences between
Zimmerman et al. (1986) found no signif- groups in reh ospitalizations af ter 6 or
icant differences in immediate response to 12 months. The authors concluded that the
ECT treatment (on Ham-D, BDI, or GAS) be- presence of a personality disorder adversely
tween DSM-III MDD patients with and with- affects early symptomatic recovery after ECT
out a comorbid personality disorder. Patients but not longer-term outcome.
had similar pretreatment symptom severity Blais et al. (1998) obtained personality
on Ham-D, BDI, and GAS and received sim- testing pre- and post-ECT in a small study
ilar (although uncontrolled) ECT treatments sample (N= 16) of depressed patients to de-
and pharmacotherapy. Follow-up (by phone) termine changes in significant personality
at 6 months indicated more episodes of re- traits with ECT. Using the self-rated Millon
hospitalization and higher symptom scores Clinical Multiaxial InventoryII, the inves-
in the personality disorder group. Although tigators found significant changes (improve-
starting with similar improvement at hospi- ment) in four personality scales with ECT
tal discharge, patients with personality dis- treatment: avoidant, histrionic, aggressive/
order were less likely to maintain recovery sadistic, and schizotypal. Changes in pas-
compared with the depressed patients with sive-aggressive and borderline personality
no personality disorder. scale scores tended toward improvement but
Casey and Butler (1995) and Casey et al. fell short of significance. Other personality
(1996) studied ECT treatment in 40 inpatients scales appeared stable and did not change
with DSM-III-R MDD who were examined with ECT. Controlling for pretreatment de-
for personality disorder using Tyrer s Per- pression scores, only a pretreatment diag-
sonality Assessment Schedule posttreat- nosis of BPD predicted posttreatment de-
ment. Patients were rated pretreatment, pression scores (on the BDI), with higher
pos tt re at me n t, a nd e v e ry 6 we e ks f or pretreatment BPD scores predicting poorer
6 months and at 1 year after discharge using outcome.
an outcome measure of mood (Ham-D-21) Feske et al. (2004) reported that outcome
and social functioning (Social Functioning differences following ECT for depressed pa-
Schedule). A 12-month follow-up rated patients with a comorbid personality disorder
tients globally according to medication us- depended on the type of personality disor-
age and patient status. ECT practice and con- der. They divided 139 patients with a pri-
mary diagn osis of u nipolar M DD into course of treatment. The greatest challenge
groups with comorbid BPD (n = 20), other for the clinician is not when to institute a
personality disorders (n = 42), or no comor- course of ECT in the depressed personality
bid personality disorder (n = 77). ECT meth- disorder patient but when to stop ECT. As
ods and concurrent medication were con- the neurovegetative symptoms of MDD re-
trolled by a standard protocol. Patients with solve, the patient may continue to report per-
comorbid BPD showed a poorer acute re- sonality characteristics that reflect the Axis II
sponse to ECT than the other two groups, pathology and are not responsive to ECT. For
who did not differ significantly. example, low self-esteem can be an acute
In a review of this literature, DeBattista symptom of MDD or a chronic personality
and Mueller (2001) concluded that 40%75% trait. Knowledge of the patients personality
of patients with MDD and comorbid person- functioning prior to the onset of MDD is crit-
ality disorder have a 50% decrease in depres- ical to knowing when the baseline has
sion scale scores with ECT, an efficacy equal been achieved. Many personality disorder
to response rates among other patients with patients with illness termed refractory to
treatment-resistant depression without per- ECT for persistence of depressive complaint
sonality disorder comorbidity. However, in- are, in fact, already in remission of their Axis
creased relapse rates, rehospitalization, and I disorder and exhibiting their chronic char-
psychosocial dysfunction (6 months to 1 year acterological complaints and behaviors.
posttreatment) suggest that underlying per-
sonality disorder affects long-term outcome.
A major confounding factor in these CONCLUSION
studies is difficulty separating affective
symptoms of the depressive disorder from Pharmacotherapy is an important adjunctive
those intrinsic to the personality disorder. treatment in the overall management of the
For example, the affective dysregulation patient with severe personality disorder.
(mood crashes), low self-esteem, pessi- Symptoms of cognitive-perceptual distur-
mism, chronic suicidality, and self-injurious bance, affective dysregulation, and impul-
behaviors of the patient with BPD are often sive-behavioral dyscontrol are appropriate
misconstrued as Axis I affective pathology targets for medication trials. Problems of
and assessed by outcome measures (e.g., character and of interpersonal dynamics are
BDI, Ham-D) that may correlate highly with the domain of the psychotherapies and will
diagnostic criteria. Not infrequently, a clini- not respond to medication. Because person-
cian will target these personality traits for ality disorders are dimensional syndromes, a
ECT treatment, resulting in a predictably symptom-specific approach is warranted,
poor outcome. A recommendation for ECT potentially involving multiple medications.
in the personality disorder patient with co- It is important to study the effects of each
morbid MDD, especially the BPD patient, medication before adding a second or third
must be guided by the presence and severity agent. Ineffective medications should be dis-
of verifiable neurovegetative symptoms continued. Expectations of efficacy should be
such as sleep disturbance, appetite distur- modest and residual symptoms are the rule.
bance, weight change, low energy, anhe- Pharmacotherapy of the personality
donia, and loss of libido. These symptoms disorders is still a relatively new and evolv-
should be confirmed by outside observers ing practice. Current recommendations are
because they provide an objective gauge of based on a woefully small database of drug
treatment response. Periodic use of an objec- trials. The patient with personality disorder
tive rating scale, such as the Ham-D, facili- is best served by a comprehensive treatment
tates documentation of change over the approach involving psychotherapy, symp-
tom-specific medication management, and Black DW, Goldstein RB, Nasrallah A, et al: The
psychoeducation for the patient and family. prediction of recovery using a multivariate
model in 1,471 depressed inpatients. Eur Arch
Psychiatry Clin Neurosci 241:4145, 1991
Blais MA, Matthews J, Schouten R, et al: Stability
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15
Therapeutic Alliance
Any patient beginning treatment enters a re- thology, Masterson (1988) has stated the fol-
lationship, whether it is for a short time dur- lowing:
ing a hospital stay or over many years in long-
term psychotherapy. This relationship with Each type of pathology produces its
own confusion and its own distorted
the clinician has the potential for improving
version of loving and giving. The bor-
the patients quality of life, perhaps through
derline patient defines love as a rela-
the alleviation of symptoms or more pro- tionship with a partner who will offer
foundly through shifts in character structure. approval and support for regressive
It is sometimes difficult to determine a priori behavior. .. . The narcissist defines love
who will benefit from what treatment with as the ability of someone else to admire
whom, but one factor has stood out in the re- and adore him, and to provide perfect
search lexicon as the most robust predictor of mirroring.. .. Psychopaths seek partners
who respond to their manipulations
outcome: therapeutic alliance (Horvath and
and provide them with gratification.
Greenberg 1994; Horvath and Symonds 1991; The schizoid.. .finds love in an internal,
Orlinsky et al. 1994). autistic fantasy. (pp. 110111)
Because establishing a productive alli-
ance arises within the matrix of a relation- In fact, several studies have shown that
ship between patient and therapist, when rather than categorical diagnosis, it is the
considering personality disorders one must preexisting quality of the patients relation-
note that most such disorders are associated ships that most significantly affects the qual-
in some way with significant impairment in ity of the therapeutic alliance (Gibbons et al.
interpersonal relations. Speaking about the 2003; Hersoug et al. 2002; Piper et al. 1991).
nature of relationships of individuals charac- Consequently, the clinician must consider an
terized by certain types of personality pa- individuals characteristic way of relating so
289
that appropriate interventions can be em- which allows the analyst to work with the
ployed to effectively retain and involve the healthier elements in the patient against re-
patient in the treatment, regardless of modal- sistance and pathology (p. 479). This defini-
ity. Forming an alliance is often difficult, tion is useful vis--vis personality disorders
however, particularly in work with patients in two regards: 1) the recognition that there
with severely narcissistic, borderline, or will be pathological parts of the patients per-
paranoid proclivities, because troubled inter- sonality functioning that may serve to thwart
personal attitudes and behaviors will also in- the attempted helpfulness of the clinician,
fuse the patients engagement with the ther- and 2) the need for the clinician to be creative
apist. For example, narcissistic patients may in enlisting whatever adaptive aspects of the
not be able to allow the therapist to act as a patients character may avail themselves for
separate, thinking person for quite a long the work of the treatment.
time, whereas someone with borderline is- Another definition that was developed in
sues may exhibit wildly fluctuating emo- an attempt to transcend theoretical traditions
tions, attitudes, and behaviors, thwarting the is Bordins (1979) identification of three inter-
potential helpfulness of the clinician. dependent components of the alliance: bond,
tasks, and goals. The bond is the quality of the
relationship formed in the treatment dyad
DEFINITION OF THERAPEUTIC that then mediates whether the patient will
take up the tasks inherent in working toward
ALLIANCE
the goals of a particular treatment approach.
At the same time, the clinicians ability to ne-
The concept of the therapeutic alliance is of- gotiate the tasks and goals with the patient
ten traced back to Freud, who observed very will also affect the nature of the therapeutic
early in his work the need to convey interest bond. This multifaceted view of the alliance
and sympathy to the patient to engage her or underscores the complexity of the factors in-
him in a collaborative treatment endeavor volved (Safran and Muran 2000).
(Meissner 1996; Safran and Muran 2000). Arguably, if the goal of treatment is funda-
Freud (1912/1946) also delineated an aspect mental character change, the Bordin defini-
of the transferencethe unobjectionable tion of alliance specifies necessary, but not
positive transferencewhich is an attach- sufficient, elements. Adler (1980) observed
ment that should not be analyzed because it that patients with borderline and narcissistic
serves as the motivation for the patient to col- difficulties may not be able to establish a
laborate: The conscious and unobjectionable mature working alliance until much later in a
component of [positive transference] re- successful treatment. Others who typically
mains, and brings about the successful result work with more disturbed patients have
in psychoanalysis as in all other remedial noted that establishing a therapeutic alliance
methods (p. 319). This statement is an early may be one of the primary goals of the treat-
precursor to the modern empirical evidence ment and that there may be different phases
showing that alliance is related to treatment in alliance development as treatment pro-
outcome across modalities. gresses. Gunderson (2000) observed the fol-
There are several contemporary defini- lowing alliance stages in the course of con-
tions of alliance that we might consider to ducting long-term psychotherapy with
further our discussion of treating patients patients with borderline personality disorder:
with personality disorders. One conceptual-
ization, using psychoanalytic language, was 1) Contractual (behavioral): initial agree-
posited by Gutheil and Havens (1979): The ment between the patient and therapist
patients ability to form a rational alliance on treatment goals and their roles in
arises from the therapeutic split in the ego achieving them (Phase I); 2) Relational
Therapeutic Alliance 291
(affective/empathic): emphasized by Ro- readily apparent to the clinician (Safran and

gerian client-centered relationships; pa- Muran 2000). One study (Hill et al. 1993)
tient experiences the therapist as caring, asked patients to report about thoughts and
understanding, genuine, and likable
feelings that they were not expressing to their
(Phase II); 3) Working (cognitive/moti-
vational): psychoanalytic prototype; pa-
therapists. Most things that were not dis-
tient joins the therapist as a reliable col- cussed were negative, and even the most ex-
laborator to help the patient understand perienced therapists were aware of uncom-
herself or himself; its development repre- municated negative material only 45% of the
sents a significant improvement for bor- time. It has also been suggested, however,
derline patients (Phases IIIIV). (p. 41) that therapist awareness of patients negative
feelings may actually create problems; thera-
Progression through these stages, if suc- pists, rather than being open and flexible in
cessful, typically takes a number of years. response, may at times become defensive and
The implication is that to reach a point at negative or may become more rigid in apply-
which work leading to substantive and ening treatment techniques (Safran et al. 2001).
during personality change can occur may re- Safran and Muran (2000) outlined a model
quire a lengthy initial alliance-building pe- specifying two subtypes of ruptures: with-
riod. As Bach (1998) noted, Perhaps the drawal and confrontation. Withdrawals are
primary problem in engaging the difficult sometimes fairly subtle. One example is a
patient is to build and retain what Ellman therapist who assumes the treatment is pro-
(1991) has called analytic trust. These diffi- gressing but may be unaware that a patient is
cult patients have generally lost their faith withholding important information because
not only in their caregivers, spouses, and of lack of trust or fear of feeling humiliated.
other objects but also in the world itself as a Other types of withdrawal behaviors include
place of expectable and manageable contin- such things as intellectualizing, talking exces-
gencies (p. 185). sively about other people, or changing the
subject. Withdrawal behaviors may be more
common in patients who are overly compliant
ALLIANCE STRAINS AND RUPTURES at times, such as those with dependent or ob-
sessive-compulsive personality disorder or
Although a strong positive alliance can pre- those who are uncomfortable about interper-
dict a successful treatment outcome, the con- sonal relations, such as patients with avoidant
verse is also true: problems in the treatment personality disorder.
alliance may lead to premature termination if Confrontations, on the other hand, are
not handled in a sensitive and timely manner. usually more overt, such as complaining
Evidence has shown that strains and ruptures about various aspects of therapy or criticizing
in the alliance are often related to unilateral the therapist. Some may be rather dramatic,
termination (Samstag et al. 1998). Thus, nego- such as a patient who storms out of session in
tiating ruptures in the alliance is another is- a rage or leaves an angry message on the ther-
sue that has garnered increasing attention in apists answering machine. Confrontation
the psychotherapy literature. For example, ruptures are likely to be more frequently expe-
Strauss et al. (2006) demonstrated that skill- rienced with more brittle patients such as
fully addressing ruptures strengthens the al- those with borderline, narcissistic, or para-
liance, leading to better treatment outcome noid personality disorder. In any event, clini-
for a group of patients with avoidant or ob- cians are best served by being alert to ruptures
sessive-compulsive personality disorder. and adopting the attitude that these are often
Disruptions in the alliance are inevitable excellent opportunities to engage the patient
and occur more frequently than may be in a collaborative effort to observe and learn
about that patients own style (Horvath and decreasing in size with each session (p. 3).
Greenberg 1994). Thus, Table 151 summarizes by personality
disorder the tendencies that may serve to
challenge early collaboration building as
ALLIANCE CONSIDERATIONS well as aspects that a clinician might use to
engage the patient.
BY DSM CLUSTER
For ease of discussion, this section is orga- Cluster A

nized by DSM-IV-TR (American Psychiatric
Cluster Athe so-called odd/eccentric clus-
Association 2000) personality disorder diag-
tercomprises schizotypal, schizoid, and
nostic clusters to address particular alliance-
paranoid personality disorders. What is most
relevant issues associated with each. How-
relevant for alliance building is the profound
ever, there is increasing evidence that the
impairment in interpersonal relationships as-
DSM categories and clusters do not ade-
sociated with these disorders. Because there
quately capture the complexity of character
are often pronounced paranoid or alienated
pathology traits and symptoms. For in- features, people with these characteristics of-
stance, patients often meet criteria for at least
ten do not seek treatment unless dealing with
two personality disorders, perhaps spanning
acute Axis I problems such as substance
different clusters, such as the co-occurrence
abuse. For those who are treatment seeking,
of schizotypal personality disorder with bor-
there is evidence that these patients have
derline personality disorder or borderline
great difficulty establishing a working alli-
personality disorder with avoidant personal-
ance (e. g., Lingiardi et al. 2005).
ity disorder (McGlashan et al. 2000). In other
cases, a patient may not meet full criteria for
Schizotypal
any one disorder but has prominent features
associated with one or several personality Schizotypal phenomena are thought by some
disorders. to exist on the schizophrenia spectrum, given
Thus, in practical terms, a clinician con- the associated disordered cognitions and bi-
sidering salient elements of the therapeutic zarre beliefs. Because it is almost always the
alliance should determine which aspects of a case that such individuals have one or no sig-
patients personality pathology are domi- nificant others outside family members, it is
nant or in ascendance at intake and at vari- often assumed that schizotypal individuals
ous points over the course of treatment. That have no desire to become involved in rela-
being said, it has been suggested that the na- tionships. However, in many cases, it is more
ture of the alliance established early in the a matter of being excruciatingly uncomfort-
treatment is more powerfully predictive of able around people rather than a lack of inter-
outcome (Horvath and Luborsky 1993). One est in connection. This discomfort may not be
example of the relationship of early alliance readily apparent, so establishing an alliance
and outcome regarding personality disor- with such patients may require being atten-
ders was demonstrated in a study of long- tive to clues about what is not being said. The
term psychotherapy with a group of patients therapist may be a player in some elaborated
with borderline personality disorder: thera- fantasy that is making it difficult for the pa-
pist ratings of the alliance at 6 weeks pre- tient to find some minimum level of comfort.
dicted subsequent dropouts (Gunderson et A study by Bender et al. (2003) assessed vari-
al. 1997). As Horvath and Greenberg (1994) ous attributes of how patients with personal-
noted: It seems reasonable to think of alli- ity disorder think about their therapists. In-
ance development in the first phase of ther- terestingly, results showed that patients with
apy as a series of windows of opportunity, schizotypal personality disorder had the
highest level of mental involvement with that is, they are vigilantly on the lookout for
therapy outside the session, missing their perceived slights, finding offense in even the
therapists and wishing for friendship while most benign of circumstances. Alliance-
also feeling aggressive or negative. One man building challenges are obvious. However, it
with schizotypal personality disorder (who has also been noted that paranoid individu-
had also become attached to the female re- als are often acting in defense of an extremely
search assistant) revealed the following view fragile self-concept and may possibly be
of his therapist: reached over time in treatment with an ap-
proach that includes unwavering affirmation
Very beautiful and attractive in a sense and careful handling of the many possible
that I yearn to have a sexual relationship ruptures (Benjamin 1993).
with her. Shes very smart and educated.
She knows what she wants out of life and
I wish I were working for I could take her Cluster B
out to the movies and dinner. She turns
me on and I desperately want to make The dramatic cluster includes borderline,
love to her eternally. Shes my life and narcissistic, histrionic, and antisocial person-
knowing she doesnt feel the same, I live
ality disorders. Each of these character styles
in dreams. (Bender et al. 2003, p. 231)
is associated in some way with pushing the
Schizoid limits, and great care is needed by clinicians to
avoid crossing inappropriate lines in a quest
Benjamin (1993) noted that schizoid person- to build an alliance. Thus, many Cluster B pa-
ality is more consistently associated with a tients present some of the most daunting
lack of desire for intimate human connection. treatment challenges.
She described that some people with schiz-
oid character can be found living very con- Borderline
ventional lives on the surface, having fami-
lies, jobs, and so on. However, usually things Kernberg (1967) described the borderline per-
are arranged such that people are kept at an sonality as being riddled with aggressive im-
emotional distance. There may also be a pro- pulses that constantly threaten to destroy pos-
nounced lack of conflict, with associated af- itive internal images of the self and others.
fective coldness or dullness such that a truly According to this model, the person with bor-
schizoid person is unlikely to become anx- derline personality disorder does not undergo
ious or depressed and thus is usually totally the normal developmental process of psy-
lacking any motivation to seek treatment. chological integration but rather, as a defen-
However, Akhtar (1992) suggested that un- sive attempt to deal with aggression, creates
derlying all of this apparent detachment is an splits in his or her mind to protect the good
intense neediness for others and the capabil- images from the bad. This splitting leads to a
ity of interpersonal responsiveness with a fractured self-concept and the identity prob-
few carefully selected people. Patients who lems associated with this disorder. Thus, one
may have more access to these latter at- can expect the alliance-building work to be
tributes have a greater likelihood of forming rather rocky because these patients frequently
an alliance in therapy if they choose to seek exhibit pronounced emotional upheaval, self-
treatment. destructive acting-out, and views of the ther-
apist that alternate between idealization and
Paranoid denigration. Within relationships, such indi-
viduals are very needy and demanding, often
The paranoid label largely speaks for itself. straining the boundaries of the treatment rela-
Paranoid individuals are incessantly loaded tionship and exerting pressure on clinicians to
for bear and see bears where others do not behave in ways they normally would not. Re-
294
Table 151. Alliance-relevant aspects of each personality disorder style
Personality disorder
trait cluster Alliance challenges Points of possible engagement in treatment
Schizotypal Suspiciousness/paranoia Possible motivation for human connection

Profound interpersonal discomfort
Bizarre thinking
Schizoid Social detachment Underlying neediness and sensitivity
Emotional aloofness
Paranoid Expectations of harm or exploitation Underlying need for affirmation
Hypersensitivity to perceived criticism
Inclination to withdraw or attack
Borderline Unstable emotional and cognitive states Relationship seeking
Extremely demanding Responds to warmth and support
Proneness to acting-out
Narcissistic Need for constant positive regard Responds over time to empathy and affirmation
Contempt for others
Grandiose sense of entitlement
Histrionic Attempts to charm and entertain Relationship seeking
Emotionally labile Responds to warmth and support
Unfocused cognitive style
Antisocial Controlling May engage in treatment if in self-interest or if Axis I symptoms
Tendency to lie and manipulate cause sufficient distress
No empathy or regard for others
Use of pseudoalliance to gain some advantage
Avoidant Expectations of criticism or rejection Responds to warmth/empathy
Proneness to shame and humiliation Desire for relationships in spite of vulnerabilities
Reluctance to disclose information
Table 151. Alliance-relevant aspects of each personality disorder style (continued)
Personality disorder
trait cluster Alliance challenges Points of possible engagement in treatment
Dependent No value placed on independence/taking initiative Friendly and compliant

Submission leading to pseudoalliance Likely to stay in treatment
Obsessive-compulsive Need for control Conscientious
Perfectionistic toward self and others Use of intellectualization may be helpful at times
Fear of criticism from therapist Will try to be a good patient
Restricted affect
Stubbornness
Therapeutic Alliance
295
search has demonstrated that such pressures sation or overreliance on admiration by oth-
can impair the clinicians ability to reflect on ers. Some people who are narcissistically
his or her mental states and those of the pa- vulnerable have difficulty maintaining a co-
tient (Diamond et al. 2003). Furthermore, cli- hesive sense of self because of ubiquitous
nicians who work with such patients must be shame, resulting from a sense that they fun-
able to tolerate and productively discuss an- damentally fall short of some internal ideal.
ger and aggression. However, because pa- They look for constant reinforcement from
tients with borderline personality disorder others to bolster their fragile self-images.
are, in most cases, relationship seeking, this is This combination of traits has been referred
a positive indicator for engagement in treat- to alternatively as vulnerable, deflated, or co-
ment. vert narcissism.
One treatment study of borderline pa- On the other side of the narcissistic
tients (Waldinger and Gunderson 1984) ex- coinwhat the DSM narcissistic personal-
amined alliance development over time. Psy- ity disorder diagnosis capturesare people
chodynamic psychotherapy was employed who are intensely grandiose, seeking to
using largely noninterpretive interventions maintain self-esteem through omnipotent
in the initial alliance-building period (the fantasies and defeating others. They defend
issue of intervention choice is discussed against needing others by maintaining fu-
further later in the chapter). The authors sions of ideal self, ideal other, and actual self-
observed that a strong alliance and good images. Thus, there is an illusion maintained
treatment outcome were linked to two fac- whereby this type of narcissistic person has a
tors: 1) a solid commitment by the participat- sense that because he or she is perfect, love
ing therapist to remain engaged in the treat- and admiration will be received from other
ment until significant gains had been made ideal people, and thus there is no need to
by the patients; and 2) special emphasis on associate with inferiors. In its most extreme
facilitating the patients expression of ag- form, this manifestation of character pathol-
gression and rage without fear of retaliation. ogy has been referred to as malignant narcis-
Other studies (e.g., Bennett et al. 2006; Hor- sism (Kernberg 1984).
witz et al. 1996) that have undertaken de- It is obvious that such personality traits
tailed analysis of alliance ruptures in the pose significant challenges in alliance build-
treatment of patients with borderline person- ing. It is often the case that the patient will
ality disorder have demonstrated the impor- need to keep the therapist out of the room, so
tance of the therapist vigilantly attending to to speak, for quite a long time by not allow-
the alliance. Horwitz et al. (1996) noted that ing him or her to voice anything that repre-
clinical observation of our cases revealed sents an alternative view to that of the pa-
that the repair of moment-to-moment dis- tients. For such patients, other people,
ruptions in the alliance often was the key fac- including the therapist, do not exist as sepa-
tor in maintaining the viability of the psycho- rate individuals but merely as objects for
therapy (p. 173). gratifying needs. The clinician must tolerate
this state of affairs, sometimes for a lengthy
Narcissistic period of time. Meissner (1996) observed,
Narcissistic character traits have received Establishing any degree of trust with such
considerable attention in the clinical litera- patients may be extremely difficult, but not
ture. Kohut (1977) described individuals in impossible, for a consistent respect for their
whom there is a fundamental deficit in the vulnerability and a recognition of their need
ability to regulate self-esteem without resort- not to trust may in time undercut their defen-
ing to omnipotent strategies of overcompen- sive need (p. 228).
Histrionic morse for hurting others; and take no re-

sponsibility for their actions. The most
A patient with histrionic personality needs to dramatic form is manifested by individuals
be the center of attention and may behave in who torture or murder their victims. Those
seductive ways in an attempt to keep the cli- who perpetrate such violence reside on the
nician entertained and engaged. At the same extreme end of the spectrum of antisocial be-
time, emotional expressions are often shal- havior and would be the most difficult to
low and greatly exaggerated, and the histri- treat.
onic patient assumes a deep connection and In keeping with the notion that there is a
dependence very quickly. Details are pre- spectrum of antisocial psychopathology, em-
sented in vague and overgeneralized ways. pirical evidence shows that some ASPD pa-
There is very little tolerance for frustration, tients are capable of forming a treatment alli-
resulting in demands for immediate gratifica- ance resulting in positive outcome (Gerstley
tion. As opposed to the more well-integrated, et al. 1989). Consequently, it has been recom-
higher-functioning, neurotic hysterical per- mended by some that a trial treatment of sev-
sonality often written about in the psycho- eral sessions be applied with ASPD patients
analytic literature, the histrionic personality who may typically be assumed to be untreat-
disorder organization more closely resembles able. However, there is always the risk that
the borderline personality disorder organiza- such patients, particularly within an institu-
tion. Particular borderline aspects include a tional context (e.g., a hospital or prison), may
tendency to utilize splitting defenses, rather exhibit a pseudoalliance to gain certain ad-
than repression, and a marked degree of vantages (Gabbard 2005). For example, there
identity diffusion (Akhtar 1992). The atten- could be a disingenuous profession of en-
tion-seeking attribute can be helpful in estab- hanced self-understanding and movement
lishing a preliminary alliance. However, as toward reform as an attempt to manipulate
with patients with borderline pathology, the the therapist into recommending inappropri-
clinician must be prepared to manage escalat- ate privileges.
ing demands and dramatic acting-out. There is some indication that depression
serves as a moderator in the treatment of
Antisocial ASPD patients. One study demonstrated
Antisocial personality is associated with on- that depressed ASPD patients are more likely
going violation of societys norms, mani- to benefit from treatment compared with
fested in such behaviors as theft, intimida- nondepressed ASPD patients (Shea et al.
tion, violence, or making a living in an illegal 1992). Thus, the presence of depression may
fashion such as by fraud or selling drugs. serve as motivation for these patients to seek
Also narcissistic by definition, people with and comply with treatment.
antisocial personality disorder (ASPD) have
little or no regard for the welfare of others. Sadomasochistic Character
Clearly, this personality disorder is found
extensively among inmates within the prison Cases in which difficult patients take a prom-
system. Stone (1993) suggested that there are inent role in orchestrating situations to sabo-
gradations of the antisocial style, with the tage a potentially helpful treatment are ubiq-
milder forms being more amenable to treat- uitous in the clinical literature. This type of
ment. However, within the broader label of dynamic points to an additional element
antisocial is a subset of individuals who are commonly overlooked in treatments in gen-
considered to be psychopathic. Psychopaths eral but of particular relevance when trying
are sadistic and manipulative pathological li- to establish and maintain an alliance with pa-
ars; show no empathy, compassion, or re- tients with character pathology: sadomas-
ochism. Most dramatically overt in patients ill treatmentthe only way of maintaining a
with borderline, narcissistic, and/or anti- connection is through suffering (Berliner
social issues, relational tendencies that are 1947). Early in development, this way of lov-
anywhere from tinged to saturated by sado- ing is self-preservativethe sadism of the
masochistic trends span the spectrum of per- love object is turned upon the self as a way of
sonality disorder pathology. The presence of maintaining a needed relationship (Menaker
sadomasochistic patterns does not mean that 1953). However, in an adult, this masochistic
overt sexual perversions will be present, al- solution, with its always-attendant aggres-
though they may be, but that the patient has sive-sadistic elements, serves to cause signifi-
characteristic ways of engaging others in a cant interpersonal dysfunction.
struggle in which one party is suffering at the
hands of the other. Patients with a sadomas- Case Example
ochistic approach to relationships make it A single woman in her forties, Ms. P,
very difficult for the clinician working in any was referred for psychotherapy after she
modality to be a helpful agent of change (see had gone to see four or five other thera-
Chapter 10 of this volume, Psychoanalysis pists, staying for only several sessions
and Psychodynamic Psychotherapy). Fur- maximum because she found them all to
thermore, it is sometimes the case with such be incompetent in some way. An avid
reader of self-help literature, she consid-
patients that at the foundation of the alliance
ered herself an expert on the helping
is a very subtle, or not so subtle, sadomas- professions. Highly intelligent and ex-
ochistic enactment. tremely articulate, Ms. P was aspiring to
For example, a patient may, on the surface, be a filmmaker. She had gone through a
be agreeing with the therapists observations series of day jobs with corporations,
but is actually experiencing them as verbal as- reporting that her women supervisors
saults while masochistically suffering in si- were always untalented, unreasonable,
and critical of her. Her interpersonal re-
lence and showing no improvement in treat-
lations were always tumultuous, her
ment. There is the patient who is highly moods very unstable, and it was appar-
provocative, attempting to bait the therapist ent that she had been grappling with
into saying and doing things that may prove narcissistic and borderline personality
to be counterattacks. There are also patients disorder issues for decades.
who act out in apparently punishing ways, Sadomasochistic trends became
such as attempting suicide using a newly pre- apparent very quickly. In the first meet-
scribed medication when it seemed as though ing, Ms. P launched the first of many
critiques, reporting that she had found
the treatment was progressing.
the therapists greeting to be too upbeat
Bach (1994) described a sadomasochistic but then also criticizing the therapist for
way of relating as arising as a defense against not reassuring her that she would have
and an attempt to repair some traumatic loss a successful treatment. She ultimately
that has not been adequately mourned (p. 4). anno unced that t he the rap ist w as
This trauma could have come in the form of gifted, so she would continue with
an actual loss of a parent, loss of love as a re- this treatment, but there were many ses-
sions in which she would find fault or
sult of abuse or neglect, or some experience of
deliver lectures on technique and the-
loss of the self due to such things as childhood o ry. At the same time, she was ex-
illness or circumstances leading to over- tremely brittle and incapable of reflect-
whelming anxiety. From this perspective, the ing on this type of behavior, feeling as a
cruel behavior of the sadist may, for instance, victim if there was any vague hint that
be an attempt to punish the object for threat- she might be doing something ques-
ened abandonment. The masochistic stance tionable. Thus, while attacking the ther-
apist, she was doing it in the service of
involves a way of loving someone who gives
collecting grievances and, as Berliner
(1947) observed about such patients, ance building, because the patient is willing to
she would rather be right than happy take some responsibility for his or her di-
(p. 46). Hence, both the sadistic and lemma and will somewhat more readily en-
masochistic sides of the same coin were
gage in a dialogue with the therapist to sort it
in evidence.
With patients such as this one, it is
all out, compared with patients with more se-
very important to be able to tolerate the vere Cluster A or B diagnoses (Stone 1993).
expression of aggression. Consequently,
to maintain an alliance with this very dif- Dependent
ficult woman, the therapist had to con-
stantly assess whether the attacks repre- Fearing abandonment, dependent patients
sented a rupture in the alliance that had to tend to be very passive, submissive, and
be addressed or whether Ms. P simply needy of constant reassurance. They go to
needed to give voice to some of her tre-
great lengths not to offend others, even at
mendous anger at the world. In the in-
stances it was judged that the alliance was great emotional expense, agreeing with oth-
in jeopardy, the therapist would discuss ers opinions when they really do not or vol-
Ms. Ps reaction to the therapists inter- unteering to do unsavory chores to stay in
ventions, acknowledging Ms. Ps distress someones good graces. In the context of treat-
and telling Ms. P that the therapist would ment, dependent patients are easily engaged,
reflect on what had led her to make such at least superficially, but often withhold a
comments. Ms. P usually found great re-
great deal of material for fear of alienating the
lief in this approach, appreciating the
therapists willingness to reflect on the sit- therapist in some way. The following is an ex-
uation. ample of how this might play out (Benjamin
What is central is that the therapist 1993).
withstood being portrayed as bad or in-
competent in the patients mind without A patient [with dependent personality
retaliating as though it were true. If the disorder] was chronically depressed,
therapist had had a different psychology, and the doctor tried her on a new anti-
it would have been rather easy to take up depressant. She did not improve and
the role of sadist in all of this, perhaps had a number of side effects, but did not
wrapped in the flag of interpreting her mention them to the doctor. Fortu-
aggression; however, Ms. P and this nately, the doctor remembered to ask
therapist were a good match, because for the specific side effects. The patient
such retributive behavior would have acknowledged the signs, and the doctor
been a sadomasochistic enactment and wrote a prescription for a different anti-
would have caused Ms. P to take a hasty depressant. The patient was willing to
departure. acknowledge the signs of problems,
but she did not offer the information
Cluster C spontaneously. The doctor asked her
why she did not say anything. She ex-
The anxious/fearful cluster comprises plained, I thought that maybe they
were just part of the way the drug
avoidant, dependent, and obsessive-compul-
worked. I figured you would know
sive personality disorders. Patients who are what was best. (p. 405)
most closely characterized by Cluster C disor-
ders are emotionally inhibited and averse to Benjamin also observed that one difficulty
interpersonal conflict and are often considered in working in psychotherapy with such pa-
to be the treatable neurotics on the spectrum tients is the reinforcement gained by the pa-
of personality disorders. These patients fre- tients behavior. That is, because the passivity
quently feel very guilty and internalize blame and submissiveness usually result in being
for situations even when it is clear there is taken care of, despite the associated cost, de-
none. This latter tendency often facilitates alli- pendent patients are loath to see the value in
asserting some independence. Furthermore, edness, and shame proneness aspects. An

there is a deeply ingrained assumption by underlying unrecognized narcissism in
these patients that they are actually incapable avoidant personality disorder has significant
of functioning more independently and that treatment implications, changing the nature
being more assertive will be experienced by of the forces affecting the alliance as well as
others as alienating aggressiveness. Thus, a shaping the types of treatment interventions
therapist must be very alert to the withdrawal that are indicated.
types of strains and ruptures, such as with-
holding information, as well as to the challenge
Obsessive-Compulsive
to the alliance that may occur when the thera-
pist attempts to encourage more indepen- The obsessive-compulsive character is asso-
dence. ciated with more stable interpersonal rela-
tionships than some other styles, but typical
Avoidant defenses are centered on repression, with pat-
The avoidant individual is extremely inter- terns of highly regulated gratification and on-
personally sensitive, afraid of being criticized, going denial of interpersonal and intrapsy-
and constantly concerned about saying or do- chic conflicts (Shapiro 1965). Self-willed and
ing something foolish or humiliating. In spite obstinate, with a constant eye toward rules
of an intense desire to connect with others, an and regulations, people with obsessive-com-
avoidant person does not let anyone get close pulsive attributes guard against any mean-
unless absolutely sure the person likes him or ingful consideration of their impulses toward
her. Because of this acute sensitivity, there is others. Maintaining control over internal ex-
some evidence that some avoidant patients perience and the external world is a top pri-
are somewhat difficult to retain in treatment. ority, so rigidity is often a hallmark of this
One study showed that a group of avoidant character type. Except in its most severe man-
patients was significantly more likely to drop ifestations, obsessive-compulsive character
out of a short-term supportive-expressive pathology is less impairing than some of the
treatment compared with obsessive-compul- others and more readily ameliorated by treat-
sive personality disorder patients (Barber et ment. Although stubborn and controlling
al. 1997). Clinicians who work with avoidant and averse to considering emotional content,
patients need to be constantly mindful of the obsessive-compulsive individuals also gen-
potentially shaming effects of certain com- erally try to be good patients and so can be
ments but can also work with the patients un- engaged in a constructive alliance that is less
derlying hunger for attachment to enlist them rocky compared with other types of person-
in building an alliance. ality disorder patients.
Furthermore, there is preliminary evi-
dence supporting the notion that at least Case Example
some patients diagnosed with avoidant per-
Mr. Q, a 25-year-old graduate student in
sonality disorder are actually better charac-
philosophy, began a twice-weekly psy-
terized as vulnerable narcissists. These pa- chotherapy. His presenting complaint
tients covertly crave admiration to bolster was difficulty with completing work ef-
their fragile self-esteem and secretly or un- fectively, particularly writing tasks, due
consciously feel entitled to it rather than sim- to excessive anxiety and obsessionality
ply being afraid of not being liked or ac- (he met criteria for obsessive-compulsive
ce pt e d ( D ick e ns on an d Pin c us 2 00 3 ) . personality disorder and generalized
anxiety disorder). When he came for
Gabbard (2005) also referred to this style as
treatment, he was struggling to make
hypervigilant narcissism, emphasizing ex-
progress on his masters thesis. Although
treme interpersonal sensitivity, other-direct- Mr. Q socialized quite a bit, he reported
that intimate relationships often felt these patients are likely to expect that the
wooden. He was usually overcommit- treatment holds no promise of helping, and
ted, with an endless list of shoulds that they behave in ways that contribute to that
he would constantly mentally review
outcome. The passive-aggressive (negativis-
and remind himself how much he was
failing to satisfy his obligations. A central
tic) personality disorder diagnosis was in-
theme throughout treatment was his ten- cluded in Cluster C in DSM-III-R (American
dency to be self-denigrating, loathing Psychiatric Association 1987) but was subse-
himself as a person deserving of punish- quently shifted to the appendix of disorders
ment in some way yet being extremely needing further study in DSM-IV (American
provocative (sadomasochistic trends). Psychiatric Association 1994). Some experts
He also held very strong political beliefs, on phenomenology argue that this diagnosis
sure that his way of viewing things was
is clinically very useful and should be re-
superior to others.
Establishing a productive alliance stored to the DSM list of personality disor-
with Mr. Q was not easily accomplished ders (e.g., Wetzler and Morey 1999).
at first. In the early phase of treatment, he
was extremely controlling and challeng-
ing in sessions, talking constantly and
tangentially, often losing the core point of
ALLIANCE CONSIDERATIONS
his statements because of a need to WITHIN DIFFERENT TREATMENT
present excessive details. Any statement
the therapist made was experienced as an
PARADIGMS
intrusion or interruption. For example, if
Clearly, no matter what treatment paradigm
the therapist attempted to be empathic
using a word Mr. Q had not used, such as
one adopts for working with personality dis-
saying, That sounds difficult, he would order patients, attention to the alliance is of
respond, Difficult? I dont know if Id utmost importance. Thoughts and feelings on
choose the word difficult. Challenging, the part of the therapist must be monitored
maybe, or daunting, but not difficult. closely, because interactions with difficult pa-
Thus, for a number of months in the ini- tients may often be provocative, inducing re-
tial phase of the treatment, the therapist
actions that must be carefully managed. (Re-
chose her words carefully, which eventu-
fer to Chapter 16, Boundary Issues, for a
ally paved the way for increased dia-
logue about his problems. Mr. Q also be- discussion of some of the most serious conse-
gan to tolerate a discussion o f his quences of treatments gone awry.) Although
emotional life, a topic that previously had this topic is usually discussed as counter-
been very threatening to him. transference in the psychoanalytic/psycho-
dynamic tradition, it is also quite applicable
Passive-Aggressive across all treatments (Gabbard 1999).
Treatment approach and technique must
Some of the aspects of this latter case example be flexible so that interventions can be made
may be described as passive-aggressive, par- appropriate to the individual patients style.
ticularly the patients tendency to excessively Otherwise, the alliance may be jeopardized
procrastinate in doing his work. Passive- and the patient will not benefit or may leave
aggressive traits include argumentativeness, treatment altogether. For example, Spin-
scorning authority, resistance to carrying out hoven et al. (2007) found an interaction be-
social and occupational responsibilities, an- tween alliance and therapeutic techniques,
gry pessimism, alternating between defiance influencing course and outcome of a group
and contrition, envy, and exaggerated com- of patients with borderline personality disor-
plaints about personal misfortune. These at- der. Furthermore, it is likely that noticeable
tributes pose challenges to the formation of improvements in symptoms and functioning
an effective therapeutic alliance because in patients with personality disorders will re-
quire a significantly longer period of treat- accept the analysts interpretations of his or
ment than is required for patients with no her unconscious motivations for quite a long
character pathology. Although the applica- time, so that supportive, empathic communi-
tion of specific treatment approaches is dis- cations may be more effective interventions in
cussed at length in other chapters of this building an alliance by helping the patient feel
book, it is worth mentioning here a few alli- heard and understood. Conversely, some ob-
ance-relevant considerations pertaining to sessional patients may benefit earlier in treat-
each broad treatment context. ment by interpretations of the repressed con-
flicts that may underlie the symptoms.
Psychodynamic Psychotherapy/ The results of the Psychotherapy Re-
Psychoanalysis search Project of The Menninger Foundation,
which included patients with personality
One long-standing issue within the psycho- disorders, led Wallerstein (1986) to conclude
dynamic psychotherapy tradition is the ap- that both expressive and supportive inter-
plication of particular techniques. Interpreta- ventions can lead to character change. At the
tion of the transference was long considered same time, there is empirical evidence sup-
the heart of the psychoanalytic approach. porting the notion that a fairly solid alliance
However, as the application of this treatment must be present to effectively utilize transfer-
evolved and clinicians gained more experience interpretations per se. Bond et al. (1998)
ence with more disturbed patientsmost demonstrated with a group of personality
notably those with borderline and narcissis- disorder patients in long-term treatment that
tic trendsit became apparent that, in many for those patients whose alliance was weak,
cases, transference interpretations with such transference interpretations caused further
patients were often counterproductive. Re- impairment to the alliance. Conversely, the
fraining from making deep, interpretive in- alliance was strengthened by transference in-
terventions early on is consistent with no- terpretations when already solidly estab-
tions of writers such as Winnicott (1965) and lished. At the same time, supportive inter-
Kohut (1984) who asserted that certain, more ve ntion s and d iscussions of d efen siv e
disturbed, patients cannot tolerate such in- operations resulted in moving the therapeu-
terpretations in the initial phase of treatment. tic work forward with both the weak and
Gabbard (2005) stressed the importance strong alliance groups of patients.
of understanding that there is usually a mix- These findings are consistent with a
ture of supportive and expressive (interpre- study conducted by Horwitz et al. (1996) ex-
tive) elements in every analysis or psychody- ploring the effect of supportive and interpre-
namic psychotherapy. That is, the expressive, tive interventions on the therapeutic alliance
insight-oriented mode of assisting patients in with a group of patients with borderline per-
uncovering unconscious conflicts, thoughts, sonality disorder. The authors concluded
or affects through interpretation or confron- that although many times therapists are ea-
tation may be appropriate at times, whereas ger to pursue transference interpretations,
a more supportive approach of bolstering the such interventions are high-risk, high-gain
patients defenses and coping abilities is and need to be employed carefully. They
preferable in other circumstances. may damage the alliance with patients who
For instance, it may be difficult to focus on are vulnerable and prone to feelings of
more insight-oriented interventions with a pa- shame and humiliation. Therefore, there
tient with borderline impairments until that must be flexibility in adjusting technique ac-
patient is assisted in achieving a safe, more cording to the dynamics of a particular pa-
stable alliance. Similarly, the severely narcis- tient at a particular time given the patients
sistically impaired patient may not be able to capacities and vulnerabilities, appropriately
balancing both supportive and expressive in- ending treatment, or becoming very
terventions. sleepy and shut down for several ses-
sions. On one occasion early on when an
attempt was made by the therapist to
Case Example address something in their relationship,
Ms. R became very angry and said,
Ms. R sought treatment when she was in Why is any of this about here? These
her early 30s. She was referred for psy- are my problems and I dont see what
chotherapy from her graduate schools any of this has to do with you! Clearly,
counseling center. Ms. R presented in a in the beginning phase of treatment
major depressive episode and met eight with some patients, one needs a differ-
out of a possible nine criteria for border- ent way of entering the patients psychic
line personality disorder. The initial world (Ellman 1998). On the other hand,
phase of the twice-weekly psychody- Ms. R was responsive to gentle interpre-
namic treatment focused on her depres- tations of her defenses, such as the ther-
sion and helping her to stabilize some- apist pointing out to her that her self-
times-devastating affective instability. harm behaviors were a way of being
She also reported intermittent, but not mean to herself instead of channeling
life-threatening, instances of cutting anger toward those who had upset her.
herself, particularly after some unsatis- Thus, for most of the first 34 years
factory encounter with a friend or col- of this treatment, the primary tasks were
league. to develop a working alliance and estab-
The patients lack of object con- lish a holding environment (Winni-
stancy, her affective instability, and a cott 1965) within which Ms. R could be-
fragmented sense of self contributed to gin to feel safe to explore her history, her
great variations in the nature of Ms. Rs feelings, and her own mind. This ap-
presence in sessions. At times she would proach paid off, because it eventually
be overwhelmed by fatigue, whereas became possible to uncover, in ways
other times she would be engaging, that were meaningful and transforma-
funny, and analytical. She would often tive to Ms. R, some of the split-off rage
defend against undesirable thoughts or and despair underlying the identity in-
emotions by spending the session re- stability and distorted cognitive func-
counting the details of her day-to-day tioning. Deeper experience and explora-
life in great detail. The disjunctions in tion of these feelings paved the way for
self-states made it difficult at times to further integration and less disjunctive
maintain continuity in the process, be- experiences in her life and from session
cause Ms. R did not remember what to session, and working with the trans-
happened from session to session. ference increasingly became both possi-
A Kernbergian formulation (Kern- ble and very productive. Ms. W has not
berg 1967) of this patient was theoreti- been depressed for years and no longer
cally informative in describing some of meets any borderline criteria.
her dynamics (defensive splitting had
been one prominent theme in the treat-
ment). However, the technical implica-
Cognitive-Behavioral Therapies
tions of this particular approach, with its
In recent years, work has been done to apply
direct confrontation of aggression in the
transference early in the treatment to personality disorders cognitive and cogni-
(Kernberg 1987) would have endan- tive-behavioral treatments that have typically
gered the sometimes fragile working al- been used to treat Axis I symptoms. How-
liance being forged. In fact, a few times ever, Tyrer and Davidson (2000) observed
when transference interpretations were that the approaches generally taken in these
attempted in the first phase of treat- therapies for Axis I mental state disorders
ment, Ms. R became confused and dis-
cannot be simply transferred to treating per-
tressed, quickly changing the subject
away from a discussion of her relation-
sonality disorders without certain adjust-
ship with the therapist, talking about ments. Most cognitive and cognitive-behav-
ioral therapies are based prominently on a she was resistant to beginning any of
therapistpatient collaboration that is as- the activities described. At the same
sumed to be present from very early in the time, while trying to pursue a classi-
cally behavioral approach, the therapist
treatment. Such a collaboration, which re-
realized that it was very important for
volves around the patient undertaking spe- Ms. S to spend some of the time talking
cific activities and assignments, depends on about her life and the impact the phobia
the establishment of a solid working alliance; symptoms had for her. This approach
however, it is sometimes very difficult to en- helped Ms. S to feel a connection to the
gage certain personality disorder patients in therapist. The therapist made this rela-
the therapeutic tasks. To facilitate this alliance tionship-building aspect explicit with
when working with personality disorder pa- Ms. S by agreeing to take a part of each
session to talk about her situation, but
tientsin addition to requiring lengthier pe-
the therapist also made it clear that it
riods to complete these treatmentswork was necessary to reserve enough time
needs to directly address patienttherapist for the exposure activities. This ap-
collaboration with clearly set boundaries and proach fostered an alliance sufficiently
to focus on the therapeutic relationship itself to begin the behavioral tasks. By being
when appropriate (Tyrer and Davidson 2000). flexible, while setting clear tasks and
For example, in using the initial sessions boundaries, the therapist was able to
engage Ms. S in the treatment, and she
of dialectical behavior therapy (DBT) (see
began taking short rides with the thera-
Chapter 12, Dialectical Behavior Therapy) pist on the bus, eventually overcoming
to begin establishing a working relationship, these fears completely.
Marsha Linehan (1993) observed: These ses-
sions offer an opportunity for both patient
and therapist to explore problems that may Psychopharmacology Sessions
arise in establishing and maintaining a ther-
apeutic alliance (p. 446). Even though DBT One large-scale depression study (Krupnick
is a manualized treatment with clearly elab- et al. 1996) comparing several different psy-
orated therapeutic tasks, it is quickly evi- chotherapies with medication and placebo
dent, particularly in working with patients showed that the quality of the alliance was
with borderline personality disorder, that a significantly related to outcome for all of the
great deal of flexibility must be maintained study groups. This finding demonstrates the
within this paradigm to achieve an alliance. importance of considering the alliance not
More specifically, there may be frequent oc- only in psychotherapies but in medication
currences of therapy-interfering behaviors sessions as well. Gutheil (1982) suggested
ranging from ambivalence causing missed that there is a particular aspect of the thera-
sessions to multiple suicide attempts that peutic alliancewhat he calls the pharmaco-
prevent the treatment from progressing as therapeutic alliancethat is relevant to the
the method outlines. prescription of medications. In this formula-
tion of the alliance, it is recommended that
the physician adopt the stance of participant
Case Example
prescribingthat is, rather than adopting an
Ms. S, a young woman with dependent authoritarian role, the clinician should make
personality disorder, was referred for every effort to involve the patient as a collab-
behavioral treatment of a phobia of all orator who engages actively in goal-setting
forms of transportation (her other is- and observing and evaluating the experience
sues were already being addressed in of using specific medications. Such collabo-
an ongoing psychotherapy). The thera-
ration, like other therapeutic processes, may
pist spent several sessions with Ms. S
outlining the exposure techniques rec- be affected by the patients transference dis-
ommended for treating her phobia, but tortions of the clinician.
This latter notion can be more broadly in this treatment context is that there is al-
applied in transtheoretical terms to personal- ways a team of individuals responsible for
ity disorders, where it is appropriate to con- the patient. With patients with borderline is-
sider how the patients characteristic style sues, splitting tendencies frequently are
may influence his or her attitudes and behav- quite pronounced. That is, as a way of trying
iors toward taking psychiatric medications. to cope with inner turmoil, the patients men-
Some patients may become upset if medica- tal world is often organized in black/white,
tion is not prescribed, feeling slighted be- good/bad polarities, and through compli-
cause they think their problems are not being cated (see explanation of projective identifi-
taken seriously. Others with paranoid ten- cation in Chapter 10, Psychoanalysis and
dencies may think the physician is trying to Psychodynamic Psychotherapy) interaction
put something over on them, or worse. Some patterns with various staff members, this in-
patients who are prone to somaticizing, such ternal world becomes replayed externally,
as those with borderline or histrionic tenden- dividing staff member against staff member.
cies, might be hypersensitive to any possible Gabbard (1989) observed that this dy-
side effects (real or imagined) and argue with namic is often set up because the patient will
the prescriber about his or her competence. present one self-representation to one or sev-
The following is another example (Benjamin eral team members and a very different rep-
1993) illustrating the importance of being resentation to another. One of these staff fac-
mindful of how personality disorder patients tions may be viewed as the good one by
might react around issues of medication: the patient and the other as the bad one
although these designations can flip precipi-
A patient [with avoidant personality dis- tously in the patients mindand this split
order] overdosed one evening on the becomes enacted among team members as
medicine her doctor had prescribed for they begin to work at cross-purposes. It can
her persistent depression. She liked and be seen rather readily that trying to develop a
respected him a lot. She was discovered
constructive alliance with such a patient can
comatose by a neighbor who wondered
why her cat would not stop meowing. be extremely precarious, particularly given
The neighbor was the patients only the ever-decreasing length of hospital stays
friend. It turned out that that morning under managed care. That means that com-
her doctor had wondered aloud whether munication and close collaboration among
she had a personality disorder. The pa- the members of the team are vital during ev-
tient was deeply humiliated by that idea ery phase of the hospital treatment.
but secretly agreed with it. She felt ex-
Matters are complicated further at times
tremely embarrassed and was con-
vinced that her doctor now knew she by the need to find a productive way for hos-
was a completely foolish person . pital staff to collaborate with clinicians pro-
Rather than endure the humiliation of viding ongoing outpatient psychotherapy
facing him again, she decided to end it and/or psychopharmacology treatments.
all. (p. 411) Although the hospitalization may represent
a significant rupture in the outpatient treat-
Psychiatric Hospital Settings ment alliance, this rupture does not necessar-
ily indicate that the outpatient treatment was
Across the spectrum of personality disor- ineffective and must be terminated but that
ders, psychiatric hospitalizationsboth in- work will be needed to reestablish the conti-
patient and day treatment programsare nuity of the treatment relationship. How-
most common for those with borderline per- ever, it is not uncommon for the hospital
sonality disorder (Bender et al. 2001). The staff, seeing the patients current condition,
central consideration regarding the alliance to conclude that the outpatient clinicians
were somehow not doing a competent job to confer with other team members on
(this conclusion may, of course, be fueled by the matter, the psychiatrist proceeded
further splitting on the part of the patient). to tell Ms. T that he was initiating legal
proceedings to keep her in the hospital.
Moreover, at times it may be obvious that the
Mindful of the splitting tendencies of
outpatient treatment was inadequate or in- such patients, the psychiatrist was care-
appropriate. In any event, it becomes rather ful to make it clear that he represented
dicey for all parties concerned to sort out the the viewpoint of the entire team, includ-
proper role of hospital staff versus outpatient ing the psychologist. However, he un-
staff over the course of the inpatient or day wittingly created another split. Ms. T,
treatment program. feeling betrayed, stared hatefully at the
psychologist, the fragile working alli-
ance was shattered, and she subse-
Case Example quently refused to participate in psy-
chotherapy or any other therapeutic
A young woman, Ms. T, with border- activities for the rest of the hospitaliza-
line personality disorder was admitted tion. It is possible this rupture could
to a psychiatric inpatient unit after com- have been ameliorated had there been
ing to the emergency department re- adequate consultation among treat-
porting acute suicidal ideation. This pa- ment team members so that a less alien-
tient had been hospitalized several ating approach could be formulated.
times previously, was in the mental
health field, and knew the ropes quite
well. She had been assigned a psychia-
trist who was responsible for overall CONCLUSION
case management and a psychologist
who was to provide short-term psycho- Establishing an alliance in any treatment par-
therapy on the unit. adigm requires a great deal of empathy and
The initial psychotherapy session attunement to a patients way of seeing the
was extremely difficult, with Ms. T re-
world. Attention to alliance building is even
fusing to speak very much and regard-
more important when working with patients
ing the therapist with rageful contempt.
However, after several more encoun- with personality disorders, because these in-
ters, there was some softening by Ms. T dividuals often present with disturbed pat-
and she began to discuss the upsetting terns of interpersonal relations. Research has
circumstances that led to her hospital- shown not only the importance of building an
ization. It appeared there might be the alliance but also that this alliance is vital in the
beginnings of a working alliance. In- earliest phase of treatment. One cannot rig-
deed, as she opened up more about her
idly pursue the dictates of ones treatment
life, she reported feeling slightly more
hopeful and less fragmented. paradigm without being prepared to make
However, at the same time, she had frequent adjustments to address the various
created quite a bit of trouble with the ruptures that may occur. Gleaning clues from
rest of the staff by being very demand- the patients accounts of his or her relation-
ing and uncooperative and attempting ships can serve to guide the clinicians general
to initiate discharge procedures even interpersonal stance. Furthermore, monitor-
while refusing to deny that she would
ing the therapeutic alliance in response to clin-
kill herself. Having reached a point of
needing to take some action in the ical interventions is a useful way to assess the
courts to keep Ms. T hospitalized, the effectiveness of ones approach and is infor-
psychiatrist hastily called a meeting in- mative in determining appropriate adjust-
cluding himself, the psychologist, and ments in the style and content of the thera-
the patient. Having had no opportunity pists interactions with the patient.
Diamond D, Stovall-McClough C, Clarkin JF, et al:

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16
Boundary Issues
E xperience teaches us that any discussion of cuss boundary issues in relation to patients
boundary issuesboundary crossings and with personality disorders is not to imply
violationsmust begin with certain caveats, that all or only personality-disordered pa-
best delivered in the form of axioms. First, tients experience or pose boundary prob-
only the professional member of the treat- lems. Instead, this chapter examines a subset
ment dyad has a professional code to honor of the wider universe of boundary-related
or violate; thus only the professional is re- potential problem areas.
sponsible for setting and maintaining profes- According to my own evidence, the above
sional boundaries. Second, patients, having caveats do not indicate obsessive caution. In
no professional code, may transgress or at- 1989, I pointed out that patients with border-
tempt to transgress professional boundaries; line personality disorder (BPD) presented
if they are competent adults, they are respon- particular challenges with regard to bound-
sible or accountable for their behavior. How- aries (Gutheil 1989). That article was based on
ever, the professional must hold the line. my forensic caseload and thus drawn from
Third, to explore the dynamics of interaction empirical reality. As discussed therein, the
between therapist and patient is neither to topic of boundaries for patients with BPD is
blame the victim (i.e., the patient) nor to ex- fraught with tension, confusion, and political
onerate the professional from responsibility incorrectness.
for the boundaries. The profession as a whole has had its con-
Boundary issues in the treatment of psy- sciousness raised by the careful study of
chiatric patients are universal, as are con- trauma victims, many of whom had become
cerns about these issues. Therefore, to dis- highly sensitive to boundary transgressions
309
in their treaters; indeed, boundary issues mon 1990; Gabbard 1999; Gabbard and Lester
within the nuclear families of these individ- 2002; Gutheil and Brodsky 2008; Gutheil and
uals may have constituted, or been a compo- Gabbard 1993, 1998; Gutheil and Simon 2002;
nent of, the trauma. The frequent association Ingram 1991; Langs 1976; Simon 1989, 1992;
of boundary problems as precursors to actual Smith 1977; Spruiell 1983; Stone 1976). In
sexual misconduct also focused attention on summary, boundary problems may emerge
the subject. from role issues, time, place and space,
It is critically important to retain non- money, gifts and services, clothing, language,
judgmental clarity in the important area of and physical or sexual contact as elsewhere
boundary issues, because the consequences addressed (Gutheil and Gabbard 1993).
of confusion about this topic may be serious.
This chapter aims to alleviate possible confu-
sion. Before turning our attention to person- BOUNDARY CROSSINGS AND
ality disorders and their implications for
boundary theory, the basic elements are sum-
BOUNDARY VIOLATIONS
marized. In an earlier publication, Gabbard and I pro-
posed a distinction that has proved important
both in theory and in litigation related to
BASIC ELEMENTS OF BOUNDARY boundaries: the difference between bound-
THEORY ary crossings and boundary violations (Guth-
eil and Gabbard 1993).
Just what is a boundary? A working defini- Boundary crossings are defined as tran-
tion might be that a boundary is the edge of ap- sient, nonexploitative deviations from classi-
propriate, professional conduct. The defini- cal therapeutic or general clinical practice in
tion is highly context dependent. The relevant which the treater steps out to a minor degree
contexts may be the treaters ideology, the from strict verbal psychotherapy. These cross-
stage of the therapy, the patients condition or ings do not hurt the therapy and may even
diagnosis, the geographical setting, or the promote or facilitate it. Examples might in-
cultural milieu, among others. Although at- clude offering a crying patient a tissue, help-
torneys, boards of licensure, and young clini- ing a fallen patient up from the floor, helping
cians may long for a checklist of approved an elderly patient on with a coat, giving a frag-
and disapproved behaviors, the matter is not ile patient a home telephone number for
that simple. Context is a critical and determi- emergencies, giving a patient traveling on
native factor. foot a lift in your car during a blizzard, writ-
Besides complaint procedures and their ing cards to a patient during a long absence,
aftermath, data about boundary issues come visiting a patient at home based on his or her
from consultations, supervision and training medical needs, answering selected personal
settings, the literature, professional meetings, questions, disclosing selected personal infor-
informal remarks by colleagues, and formal mation, and so on. None of these actions is
studies. These data permit empirical exami- psychotherapy in its pure talking form;
nation of the varieties of boundary phenom- they constitute instead a mixture of manners,
ena, the criteria for boundary assessment, helpfulness, support, or social amity. No one
and the clinical contexts in which problems could reasonably claim that these actions are
arise. An extensive literature has grown up exploitative of the patient or the patients
around this subject in recent decades, and the needs. Depending on the context, the appro-
reader is directed to this literature for addi- priate response to such actions is for the ther-
tional discussion beyond the narrower focus apist to explore their impact, maximize their
of this chapter (Celenza 2007; Epstein and Si- therapeutic utility, and detect and neutralize
Boundary Issues 311
any difficulties the patient may have as a re-

sult. Even the therapists well-mannered ges- CONTEXT DEPENDENCE
ture of putting out a hand for a handshake
may be experienced as an attack or threat by a In a conceptual vacuum, it may be impossi-
patient with a horrendous trauma history. An ble to distinguish clearly a boundary cross-
important point about boundary crossings is ing from a boundary violation. A therapist
that when they occur, the therapist should re- who sends a dependent patient a reassuring
view the matter with the patient on the next postcard from his vacation is merely crossing
available occasion and fully document the ra- the boundary; however, if the postcard is
tionale, the discussion with the patient, and highly eroticized, contains inappropriate
the description of the patients response. content, and is part of an extended sexual se-
Boundary violations, in contrast, constitute duction, the same gesture carries entirely dif-
essentially harmful deviations from the nor- ferent weight.
mal parameters of treatmentdeviations Another element of context is the type and
that do harm the patient, usually through goal of the therapy. A favorite example is an
some sort of exploitation that breaks the rule analyst doing classical psychoanalysis, for
of First, do no harm. Usually, the thera- whom no justification would exist for accom-
pists needs are gratified by taking advantage panying an adult patient into the bathroom;
of the patient in some manner. The therapy is however, in the behaviorist treatment of paru-
not advanced and may even be destroyed by resis (fear of urinating in public restrooms),
such violations. Examples might include tak- the last step in a behavioral paradigm of treat-
ing advantage of the patient financially, using ment might well be the therapist accompany-
the patient to gratify the therapists narcissis- ing the patient there. This example also im-
tic or dependency needs, using the patient for plies that the context may be affected by issues
menial services (cleaning the office, getting such as informed consent to the type of ther-
lunch, running errands for the therapist), or apy, the nature and content of the therapeutic
engaging in sexual or sexualized relations or contract, the patients expectations, and so on.
relationship with the patient. A useful test for
distinguishing a boundary crossing from a vi-
olation is whether the event can be discussed POWER ASYMMETRY AND
in the therapy (Gutheil and Gabbard 1993). FIDUCIARY DUTY
An even better test is whether the behavior in
question can be discussed openly (hence, is The concepts of power asymmetry and fidu-
admissible) with a colleague. Many violators ciary duty play an important theoretical role
have admitted that they did not seek consul- in analyzing boundary problems and are fre-
tations with a colleague because they knew quently used in discussing the consequences
the consultant would tell them to stop the be- of boundary breaches. Power asymmetry re-
havior. In any case, the only proper response fers to the unequal distribution of power be-
to boundary violations is not to do them in tween the two parties in the therapeutic
the first place. dyad: the therapist has greater social and le-
As the next section illustrates, the differ- gal power than the patient. With this power
ence between these two types of boundary comes the greater responsibility for directing
issues is highly context dependent. How- and containing the therapeutic envelope.
ever, forensic experience demonstrates that The occasional protest of its not my fault,
some agencies, such as the more punitive the patient seduced me carries little weight
state boards of registration, tend to view all under this formulation.
boundaries from a rigid checklist perspec- A fiduciary duty is a duty based on trust
tive that does violence to clinical flexibility and obligation. The doctor, as a fiduciary,
and the essential relevance of context. owes a duty to the patient to place the latters
interests first; primarily, the doctor does ation(s) from the appropriate standard of
what the patient needs, not what the doctor care were occasioned by negligence and that
wants to do. Exploitative boundary viola- the patient consequently sustained some
tions are thus viewed as breaches of the doc- form of damages (Gutheil and Appelbaum
tors fiduciary duty to the patient: the treater 2000; Gutheil and Brodsky 2008). This blunt
has placed his or her own gratification ahead legal analysis scants the commonly encoun-
of the patients needs. tered clinical complexity of these claims. Al-
though lawsuits for clinician sexual miscon-
duct were a serious problem in past decades,
CONSEQUENCES OF BOUNDARY observers have noted an increase in what
PROBLEMS might be termed pure boundary cases; that
is, cases in which actual sexual intercourse
The consequences of boundary problems has not occurred, but the patient is claiming
may be divided into those intrinsic to the harm from boundary violations short of that
therapy and those extrinsic to the therapy. As extreme.
indicated earlier, a serious and exploitative Other factors may come into play in the
boundary violation may doom the therapy litigation arena. The growing awareness of
and cause the patient accurately to feel be- both boundary issues and their common
trayed and used. The clinical consequences precursor role in actual sexual misconduct
of boundary violations, including sexual has led some disgruntled patients to use a
misconduct, may encompass the entire spec- boundary claim as a means of taking revenge
trum of emotional harms from mild and against a disliked clinician. A current joke
transient distress to suicide. holds that under the advent of managed care
The extrinsic harms fall into three major and the severe restrictions placed on length
categories: civil lawsuits (in some jurisdic- of treatment, no therapy will continue long
tions, criminal charges for overtly sexual enough for the patient to develop erotic
activity); complaints to the board of regis- transferences for the doctor.
tration, the licensing agency; and ethics com- On the one hand, a malpractice suit
plaints to the professional society (such as the against the clinician will generally be de-
district branch of the American Psychiatric fended andin case of a losspaid for by the
Association), usually directed to the ethics malpractice insurer; on the other hand, many
committee of the relevant organization. insurance policies contain exclusionary lan-
The above three types of complaints con- guage that avoids coverage for the more sex-
stitute the most common forms of negative ualized forms of boundary violation.
consequence from boundary problems; alas
for fairness, neither attorneys, boards, nor Board of Registration/Licensure
eth ics committ ees may be sufficien tly Complaint
sophisticated to distinguish between bound-
ary crossings and violations. Thus, any A complaint to the board of registration chal-
boundary issues should be clearly described lenges the physicians fitness to practice, as
in the records together with their rationales, supposedly rendered questionable by the
readily discussed, and explored within the boundary problem in question. There are
therapy itself. The major categories of extrin- three serious problems with this form of
sic harms are discussed below. complaint. First, boards in some areas are ex-
tremely punitive, seeking to meet quotas of
de-licensed practitioners and ignoring both
Civil Litigation
context and evidence. Second, unlike a mal-
A civil lawsuit for boundary problems is practice case, a loss in these cases may cost
based on the concepts that the treaters devi- the clinician his or her license and livelihood.
Boundary Issues 313
Finally, because a complaint to the board is discussion addresses the interactions be-
not a malpractice issue, insurers often will tween patients with personality disorders
not fund the defense, leaving the legal ex- and the clinicians attempting to treat them.
penses to be met out-of-pocket by the doctor. As might be inferred from the earlier dis-
One implication of this grim scenario is that cussion, no particular therapist, patient, or
board complaints should be taken very seri- personality disorder should be considered
ously and must include legal assistance, no immune from actual or potential boundary
matter how bizarre, overreactive, and trivial problems (Norris and Gutheil 2003). Indeed,
the complaint may seem. both members of the dyad may present risk
factors increasing the likelihood of boundary
Ethics Complaints problems. Therapist issues may include life
crises; transitions in a career; illness; loneli-
The field of ethics has produced a vast ness and the impulse to confide in someone;
wealth of philosophical opinion and litera- idealization of a special patient; pride,
ture as to what does and does not constitute shame, and envy; problems with limit set-
ethical conduct, but an ethics complaint to ting; denial; and issues peculiar to being in a
ones professional society has an extremely small-town environment wherein interac-
concrete denotation: it asserts that a specific tion with patients outside the office is un-
section of the American Psychiatric Associa- avoidable. Patient issues increasing vulnera-
tion Code of Ethics (American Psychiatric bility to boundary problems may include
Association 2001b) has been violated by the enmeshment with the therapist; retraumati-
boundary issue in question. What is ethical is zation from earlier childhood abuse and felt
what is in the book. The outcome of a for- helplessness from that earlier event; the rep-
mal ethics complaint (informal complaints etition compulsion; shame and self-blame;
are not accepted) ranges from censure and feelings that the transference is true love;
warning (not reportable to the National Prac- dependency; narcissism; and masochism
titioner Data Bank) to suspension or expul- (Norris and Gutheil 2003).
sion from the professional society (both of Empirically, the Cluster A group, marked
which are reportable). Such reportage may by a tendency toward detachment, is less
plague every subsequent job application and likely to be involved in a boundary issue
usually also reaches the relevant board of than the other two clusters; however, indi-
registration. viduals in the group with very poor social
skills and poor perspective-taking of others
may cross boundaries more out of social in-
eptness than other dynamics.
SOME PERSONALITY TYPES
ENCOUNTERED IN CLINICAL Histrionic and Dependent
PRACTICE Personality Disorders
We turn now to boundary issues that arise in Consultative experience demonstrates that
relation to various personality disorders. As a two symptoms manifested by patients with
reminder, the clinical correlation of boundary histrionic or dependent personality disor-
problems with patients with a personality derdrama and needinesstend to play
disorder neither blames the victim nor exon- roles in boundary excursions. A patients in-
erates the treater, nor does it remove from the tense need for contact, self-esteem, approval,
latter the burdens of setting and maintaining or relief from anxiety or tension may pres-
boundaries. Indeed, it takes two to generate a sure clinicians into hasty actions that cross
true boundary problem. Thus, the following boundaries.
A dependent patient who had been out being able to turn the patient away when the
drinking for an evening called her ther- latter was behaving inappropriately. Con-
apist in a panic and begged him to pick flicts about sadism are a common source of
her up at the bar and drive her home.
boundary difficulties, especially in younger
Feeling somewhat trapped and choice-
less, the therapist did so. The situation,
therapists; the issue of countertransference is
though presented by the patient as an further addressed later in the chapter.
emotional emergency, was clearly one One of the earliest and most famous ex-
merely of urgency. amples of histrionic (it would then have been
called hysterical) behavior was the hyster-
Although probably harmless, such an ical pregnancy and pseudochildbirth of
event may well be used by a board of regis- Anna O., who was in the throes of an erotic
tration as evidence of boundary problems in transference to Joseph Breuer, as described in
the treater. Appropriate responses may have the Studies in Hysteria (Breuer and Freud
included the therapists calling a cab, recom- 18931895/1955). Although Breuer is not re-
mending public transportation if available, corded as violating any boundaries, the point
or the therapists calling the patients family can be made that patient reactions in this dis-
or friends. order may operate independently of the cli-
Dramatic behav ior may trigger a nicians actual behavior, a fact leading to con-
boundary problem because of the clinicians fusion among decision-making bodies.
wish to turn down the volume:
A patient with histrionic personality
disorder, distraught after a session in Individuals with antisocial personality disor-
which the therapist announced vaca- der may strain the boundary envelope with
tion plans, seated herself on the floor the intent of furthering manipulation of the
just outside the therapists door and
therapist or, through the therapist, others in
moaned loudly for a prolonged inter-
val. The therapist, embarrassed by this the environment. Examples might include get-
scene taking place in full view of the ting the therapist to advocate for the patient at
clinic waiting room in front of other pa- work, at school, and in other areas in which the
tients and staff, brought the patient therapist is induced to step out of the limits of
back into the office and conducted an the clinical role to abet the patients purposes.
impulsive, prolonged session, intrud- Another boundary issue seen with pa-
ing into other patients appointments.
tients in this category is excessive familiarity
and pseudocloseness designed to get the
Patients are free to cross boundariesbut
therapist to perform uncharacteristic actions
the limits must be set by the clinician. The pa-
that transgress boundaries:
tient in this vignette might have been told
that the behavior was inappropriate and Doctor (on first meeting): How do you
should be discussed at the next appointment. do, I am Dr. Thomas Gutheil.
If the patient refused to leave, security might Patient (with warm handclasp): Very
have been called and the matter explored at glad to meet you, Thomas.
the next session. Doctor (slightly nonplussed): Um, well,
Thomas is my given name, but I go
Although supervisory data were lacking
by Doctor Gutheil.
in this vignette, it appears likely that the dy-
Patient (affably): Whatever you say,
namic operating therein was the therapists Tommy.
countertransference-based inability to deal
with his own sadistic feelings both about As illustrated, the patient may shift on first
planning a vacation (and thus causing aban- acquaintance to a first-name or nickname ba-
donment feelings in the patient) and about sis to establish an artificial rapport designed to
Boundary Issues 315
persuade the therapist to alter the rules of cialness can lead therapists to grant favors
proper conduct. The therapist may feel silly or that transgress boundaries with these pa-
stuffy correcting this undue familiarity or tients. (Because BPD empirically poses the
even bringing it up at all, but the effort should greatest boundary difficulties, the reader
probably be made in concert with attempts to may wish to review the axioms given at the
explore the meaning of the behavior. outset of this chapter in order to maintain a
Some common goals of this tendency to- properly nonjudgmental perspective.)
ward pseudocloseness are obtaining excus- The surprising power of the manipula-
ing or exculpatory letters sent to nonclinical tion to slip under the clinicians radar, as it
recipients; obtaining prescriptions of inap- were, is one of the more striking findings in
propriate, or inappropriately large amounts the boundary realm. I sensed that I was do-
of, controlled substances; and intervention in ing something that was outside my usual
the patients extratherapeutic reality (I need practice and, in fact, outside the pale, the
you to meet with my parole officer to go eas- therapist will lament to the consultant, but
ier on me; you know how ill I am). somehow I just found myself making excep-
From the patients viewpoint, the bound- tions for this patient and doing it anyway.
aries, if even recognized, may be ignored in a In an earlier paper (Gutheil 1989), I de-
goal-directed manner. From the clinicians scribed my experience with therapists seek-
viewpoint, the boundary transgressions may ing consultation who would begin their nar-
lead to trouble, especially if the patients ac- ratives with, I dont ordinarily do this with
tions encompass illegal behavior (e.g., selling my patients, but in this case I [insert a
prescriptions) into which the doctor is drawn broad spectrum of inappropriate behaviors
by association. here]. The patients sense of entitlement and
The following is an unfortunately com- of being special may infect the therapist
mon clinically observed constellation of with the same view of their specialness, such
boundary problems: a female psychothera- that even inappropriate exceptions are made.
pist is treating a male patient with antisocial The patients own boundary problems
personality disorder, but she misses the anti- both in the ego boundary sense (Gabbard
social elements in the patient, seeing him as a and Lester 2002) and in the interpersonal
needy infant who requires loving care to get spacemay evoke comparable boundary
better. In the course of this rescue operation, blindness in the therapist:
boundary incursions occur and increase
(Gabbard and Lester 2002). A therapist noted that a patient with very
primitive BPD would sidle out of the of-
fice along the wall in a puzzling manner
Borderline Personality Disorder that seemed to convey a fearful state. On
exploration the patient revealed that she
As in the previous diagnostic category, pa- was struggling with the fantasy that if
tients with BPD may manifest conscious or she passed too close to the therapist she
unconscious manipulative tendencies for a might accidentally fall forward and sink
number of reasons. Some scholars assert that into the therapists chest and be absorbed
as though into quicksand. (D. Buie, per-
these patients manipulate because their low
sonal communication, 1969)
self-esteem leaves them feeling unentitled to
ask directly to have their needs met. It is a We may be able to detect clinically the un-
clinical truism that a sense of being unenti- conscious wishes for fusion hidden under
tled may be masked by an overt attitude of this fear, but the point of the anecdote is that
entitlement; the patient operates from the for some patients, the boundary even of the
position that he or she is special and deserv- physical self may be extremely tenuous. In-
ing of extra attention. This demand for spe- deed, wishes for fusion in both patient and
therapist may provide the stimulus to bound- As noted elsewhere, borderline rage may
ary transgressions. leave therapists feeling pressured into inap-
The patient with BPD may manifest im- propriate self-disclosure, conceding to inap-
pulsivity that presses the therapist to act pre- propriate requests, and manifesting other
cipitously without forethought: I need you signs of being moved through fear (Guth-
to do this now, right now! The patient may eil 1989, p. 598).
demand an immediate appointment, an im- Disappointed in many past relationships,
mediate telephone contact, an immediate the patient with BPD may contrive to test
home visit, an immediate ride home, an ex- the therapists care or devotion in bound-
tended session, a medication refill, or a fee ary-transgressing ways that often represent
adjustment. Note, of course, that any or all of reenactments of earlier developmental
these may be clinically indicated but may also stages. One source of this view is the pa-
constitute or lead to boundary problems. tients perception that therapy offers some
form of promise, such as the inclusion in the
A patient with BPD in a subsequent therapists idealized family (Gutheil 1989;
psychotherapy commented out of the
Smith 1977). The patient may demand to sit
blue that she really felt her previous
therapist should not have charged her a on the therapists lap or to be held or hugged,
fee but should in fact have paid her, be- arguing that without this demonstration of
cause her case was so interesting. caring, there can be no trust in the therapy.
Herman (cited in Gutheil and Gabbard 1993)
Research data indicate that patients with pointed out that because so many patients
BPD often have a history of trauma; that is, with BPD have histories of sexual abuse, they
they were at one time victims (Herman, cited may have been conditioned to interact with
in Gutheil and Gabbard 1993). Some of these significant others on whom they depend in
patients adopt a posture of victimization (an eroticized or seductive ways.
element of entitlement distinguishable from Forensic experience reveals the sad truth
narcissistic entitlement). This posture may of how often these primitive maneuvers ac-
mobilize rescue feelings, fantasies, or at- tually succeed, to the detriment of the ther-
tempts in the therapist that lead the latter to apy and often to the censure of the therapist.
bend the rules to achieve the rescue and As might well be expected, the wellspring of
thus transgress boundaries. Indeed, consul- these deviations is commonly the counter-
tative experience leads to the conclusion that transference in the dyad, our next topic.
a number of cases of sexual misconduct
spring from claimed attempts to rescue the
patient, to prevent suicide, to elevate the pa-
tients self-esteem, or to provide a good re- COUNTERTRANSFERENCE ISSUES
lationship to counter a string of bad ones that
the patient has experienced. The patients need for help and the treaters
Borderline rage is also a factor in lead- membership in a helping profession ordi-
ing to boundary problems, often through its narily provide a salutary and symmetrical
power to intimidate: reciprocity, but it is not immune to distortion
or miscarriage. The basic wish to help and
A 6-foot, 7-inch tall former college line- heal, unfortunately, may inspire efforts
backer, now a therapist, was asked in thatno matter how well-intendedtrans-
consultation why he went along with a gress professional boundaries in problematic
boundary violation that he knew was
ways. The patients transferential neediness
inappropriate but was demanded by
the patient: why did he not simply
and dependency may evoke a countertrans-
refuse? Looking down from his height ferential need in the therapist to rescue, save,
he stated, I just didnt dare. or heal the patient at any cost. Wishes to save
Boundary Issues 317
the patient from anxiety, depression, or sui- ways avoid boundary violations; and fourth,
cide are common stimuli to boundary viola- obtain consultation for striking deviations
tions in the name of rescue. from the usual manner of practice. These
An example of this problem is what I call points are fully congruent with the material
the brute force attempt at cure. Frustrated by in this chapter.
the difficulty of working with the patient and In summarybecause of borderline pa-
disappointed at the latters lack of progress, tients own difficulties with boundaries, their
the therapist sees the patient more and more capacity to evoke powerful countertransfer-
often each week, for longer and longer session ence reactions, and the particular elements of
times; weekends, holidays, even vacations are their interpersonal stylepatients with BPD
no exception to this relentless crescendo. Ther- pose some of the most noteworthy examples
apists in this situation are being held hostage of boundary problems and challenges to cli-
by the patients insatiable need and are setting nicians to maintain proper limits.
themselves the wholly unrealistic goal of
meeting that need by giving more.
Related to this, such patients suicidal risk SOME CROSS-CULTURAL
may lead the therapist to try desperate mea- OBSERVATIONS
sures to prevent this outcome at all costs, in-
cluding violating boundaries to achieve this One might expect that boundary issues are a
rescue. Gabbard (2003) described this phe- uniquely American problem, what with our
nomenon in detail under the heading of the litigious and entitled population and our ac-
therapists masochistic surrender, a dynamic tive attention in the professional literature to
issue closely linked to boundary problems. boundary issues. However, a recent cross-
This frustration may rise to the level of cultural study (Commons et al. 2006) com-
overt anger, in which the therapist acts out paring boundary matters in the United States
countertransference hostility by violating and Rio de Janeiro, Brazil, turned up some
boundaries such as confidentiality. The ther- interesting findings.
apist who angrily and inappropriately calls The U.S. sample and the Brazilian sample
the patients partner at home and rails at him agreed at the extremesthat is, in both coun-
or her to protest some action involving the tries overt sexual misconduct at one end of
patient has lost the compass that would keep the spectrum was seen as proscribed, and
one in bounds. trivial deviations at the other end were seen
In a useful discussion Smith (1977) de- as harmless. In the middle ranges, however,
fined the golden fantasy entertained by divergence was revealed. For example, sub-
some patients with BPD and others, the be- jects in the U.S. sample believed hugging a
lief that all needsrelational, supportive, patient was suspect and kissing was surely
nurturing, dependent, and therapeuticwill wrong, but it was fully acceptable to display
be met by the treater. As the patient loses licenses, certificates, and some honors on the
track of what constitutes the therapeutic as- walls of the office. The Brazilian cohort found
pect of the work, the therapist may begin to kissing the cheek in greeting to be universally
lose track of the actual parameters within acceptable and an accepted manner of greet-
which the treatment should take place. ing patients, whereas display of certificates
The American Psychiatric Association was considered a deviation.
(2001a) practice guideline stresses four basic It is likely that both cultural differences
points relating to patients with BPD and and personal data, such as trauma history,
boundaries. First, monitor countertransfer- shape a patients perception of boundary
ence carefully; second, be alert to deviations problems and the degree of their harmful ef-
from usual practice (red flags); third, al- fect, if any.
been hurt by some action of the doctor.

RISK MANAGEMENT PRINCIPLES Instead of writing I am sorry you feel
AND RECOMMENDATIONS hurt, the doctor wrote, I am sorry I hurt
you. This ill-chosen expression of inap-
Clearly, a rigid formalism and an icy de- propriate self-blame made it almost im-
meanor are not the solution to boundary possible to convince the board that the
problems when dealing with patients with doctor had remained within proper
personality disorders; patients so treated boundaries.
will simply leave treatment. Rather, some ba- The learning point here: When in
sic guidelines may prove helpful to the clini- doubt, obtain forensic or legal consulta-
cian who desires to stay out of trouble while tion.
preserving the therapeutic effect of the work. 3. The therapist should develop a red flag
warning response when finding him- or
1. First, clinicians of any ideological stripe herself doing what I do not usually
must obtain some basic understanding of dothat is, making an exception to cus-
the dynamic issues relating to transfer- tomary practice. The exception in ques-
ence and countertransference. Training tion may be an act of laudatory creativity
programs that foolishly boast of having in treatment, but it may also be a bound-
transcended that Freudian stuff do a ary problem. Self-scrutiny and consulta-
serious disservice to their graduates. A tion may be most useful at such times.
patient with BPD in the idealizing phase 4. Gutheil and Simon (1995) observed that
of treatment may worship the therapist, the neutral space and timewhen both
but if the latter is untrained in the vagar- parties rise from their chairs and move to-
ies of transference, he or she is left to as- ward the door at the end of a session
sume that his/her own natural gifts of represents an occasion when both parties
person have evoked this reactiona dan- may feel that the rules do not really apply
gerous view, indeed. anymore because the session is theoreti-
2. Treaters of these patients must keep in cally over. We recommended that thera-
mind the latter s capacity to distort or pists pay attention to their experiences
overreact. If you write to such a patient and to the events and communications
and sign the letter, Love, Dr. Smith, you that occur during this windowbe-
may intend agape (nonerotic love), but cause a tendency toward crossing or even
the patient may interpret eros and expect violating boundaries may emerge in em-
treatment consistent with that emotion. bryonic form during this period, allow-
Even if the patient initially understands ing the therapist to open the subject for
the meaning, the regulatory agencies exploration in the following session and,
may interpret that salutation as a sign one hopes, to deflate its problematic na-
that the clinician has lost objectivity and ture.
may assume that boundaries have been 5. When in doubt, get consultation; doing
violated (note that this sequence of events so honors my favorite maxim: Never
is not speculative but empirical). Thera- worry alone. Although getting consulta-
pists should of course take responsibility tion before taking a step that might
for their actions, but these patients can present boundary ambiguities is an excel-
evoke strong feelings of guilt that distort lent idea, the therapist should also begin
the clinicians perception of what hap- presenting the case to a colleague or su-
pened and who is responsible. pervisor when boundary problems begin
For example, in a board of registration to appear on the horizon or when the
complaint, the patient claimed to have transference becomes eroticized. Such
Boundary Issues 319
consultation will aid in keeping perspec- Breuer J, Freud S: Studies on hysteria (18931895),
tive and in ensuring that the standard of in Standard Edition of the Complete Psycho-
logical Works of Sigmund Freud, Vol 2. Trans-
care is being met.
lated and edited by Strachey J. London, Hog-
6. Any potential boundary excursion of un- arth Press, 1955, pp 1319
certain meaning should be marked by Celenza A: Sexual Boundary Violations: Thera-
three critical steps: professional behavior; peutic, Supervisory, and Academic Contexts.
discussion with the patient; and docu- New York, Jason Aronson, 2007
mentation. Under some circumstances, a Commons ML, Miller PM, Gutheil TG: Cross-cul-
tural aspects of boundaries: Brazil and the
tactful apology to the patient for misread- United States. J Am Acad Psychiatry Law
ing a situation may be in order. Failure to 33:3342, 2006
perform these steps casts the therapist in Epstein RS, Simon RI: The exploitation index: an
the light of one who wants to conceal early warning indicator of boundary viola-
wrongdoing. tions in psychotherapy. Bull Menninger Clin
54:450465, 1990
For example, driving home from a late
Gabbard GO: Boundary violations, in Psychiatric
last appointment, a therapist sees his pa- Ethics, 3rd Edition. Edited by Bloch S, Chodoff
tient slogging wearily homeward on foot P, Green SA. Oxford, England, Oxford Univer-
through the 2-foot high drifts that a recent sity Press, 1999, pp 141160
blizzard had deposited on the area. To Gabbard GO: Miscarriages of psychoanalytic
treatment with suicidal patients. Int J Psycho-
prevent the patient from dying of expo-
anal 84:249261, 2003
sure in the subfreezing weather, he offers Gabbard GO, Lester EP: Boundaries and Bound-
her a ride home in his Jeep. In the car he ary Violations in Psychoanalysis, 2nd Edition.
continues to behave in a formal, profes- Washington, DC, American Psychiatric Pub-
sional manner, despite the odd circum- lishing, 2002
Gutheil TG: Borderline personality disorder,
stances. At the office the next day, he
boundary violations and patient-therapist sex:
records a careful note outlining his rea- medicolegal pitfalls. Am J Psychiatry 146:597
soning and the risk-benefit analysis of the 602, 1989
incident. At the patients next appoint- Gutheil TG, Appelbaum PS: Clinical Handbook of
ment, he inquires how the patient felt Psychiatry and the Law, 3rd Edition. Balti-
more, MD, Lippincott, Williams & Wilkins,
about the incident, and its therapeutic
2000
significance is explored. Gutheil TG, Brodsky A: Preventing Boundary Vi-
7. Finally, the majority of boundary difficul- olations in Clinical Practice. New York, Guil-
ties may be averted by the following ap- ford, 2008
proach: Explore before acting. Impul- Gutheil TG, Gabbard GO: The concept of bound-
sive responses to patient demands are aries in clinical practice: theoretical and risk
management dimensions. Am J Psychiatry
likely to go astray, and such responses
150:188196, 1993
may inappropriately model impulsivity. Gutheil, TG, Gabbard GO: Misuses and misunder-
standings of boundary theory in clinical and
regulatory settings. Am J Psychiatry 155:409
414, 1998
REFERENCES Gutheil TG, Simon RI: Between the chair and the
door: boundary issues in the therapeutic
American Psychiatric Association: Practice transition zone. Harv Rev Psychiatry 2:336
Guideline for the Treatment of Patients with 340, 1995
Borderline Personality Disorder. Washington, Gutheil TG, Simon RI: Non-sexual boundary
DC, American Psychiatric Association, 2001a crossings and boundary violations: the ethical
American Psychiatric Association: The Principles dimension. Psychiatr Clin North Am 25:585
of Medical Ethics With Annotations Especially 592, 2002
Applicable to Psychiatry, 2001 Edition. Wash- Ingram DH: Intimacy in the psychoanalytic rela-
ington, DC, American Psychiatric Association, tionship: a preliminary sketch. Am J Psychoa-
2001b nal 51:403411, 1991
Langs R: The Bipersonal Field. New York, Jason Simon RI: Treatment boundary violations: clinical,
Aronson, 1976 legal and ethical considerations. J Am Acad
Norris DM, Gutheil TG, Strasburger LH: This Psychiatry Law 20:269288, 1992
couldnt happen to me: boundary problems Smith S: The golden fantasy: a regressive reaction
and sexual misconduct in the psychothera- to separation anxiety. Int J Psychoanal 58:311
peutic relationship. Psychiatr Serv 54:517522, 324, 1977
2003 Spruiell V: The rules and frames of the psychoan-
Simon RI: Sexual exploitation of patients: how it be- alytic situation. Psychoanal Q 52:133, 1983
gins before it happens. Psychiatr Ann 19:104 Stone MH: Boundary violations between therapist
122, 1989 and patient. Psychiatr Ann 6:670677, 1976
17
Collaborative Treatment
Abigail Schlesinger, M.D.
Kenneth R. Silk, M.D.
volves a psychiatrist prescribing psychiatric

WHAT IS SPLIT OR medication and another clinician (e.g., psy-
COLLABORATIVE TREATMENT? chiatrist, psychologist, social worker, thera-
pist, case manager) performing the therapy.
Collaborative treatment can mean different Increasingly, collaborative treatment has
things in different clinical practice settings. come to represent a situation in which a pri-
In this chapter, collaborative treatment refers to mary care physician (PCP) prescribes psy-
the treatment relationship that occurs when chotropic medication while a nonpsychia-
two (or more) treatment modalities are pro- trist clinician conducts psychotherapy. In
vided by more than one mental health or addition, treatment can be divided up in
medical professional. This type of treatment many ways among PCPs, psychoanalysts,
arrangement has had many names, such as specialty medical doctors, psychiatrists, spe-
split treatment, joint (or conjoint) treatment, or cialty psychiatrists, therapists, clinical nurse
in certain specific circumstances, medication therapists, visiting nurses, physician assis-
backup (Riba and Balon 1999). We reserve use tants, case managers, different people and
of the term split treatment to circumstances in disciplines on an inpatient unit or in a partial
which there is disagreement among or be- hospital program, and many others.
tween the collaborators. Collaborative treat- The term collaborative highlights the need
ment can be contrasted with integrative for treating clinicians to communicate and
treatment, in which one mental health care work together, because there are many legal,
providermost frequently a psychiatrist ethical, and treatment issues and pitfalls that
performs all mental health modalities for a can arise when more than one provider is in-
patient. volved in a persons treatment. Patients with
In the most common form of collabora- personality disorders, especially those with
tive treatment, one clinician prescribes psy- Cluster B traits, tend to split even without
chotropic medication (or somatic treatments) a split treatment relationship, and this pro-
and another performs psychotherapy. In pensity must be kept in mind when entering
psychiatry, collaborative treatment often in- into a collaborative care model with another
321
clinician for a patient with a personality dis- over all of the treatment. The psychia-
order. Splitting, in its most formal psychoan- trist always sent Ms. U back to discuss
alytic sense, is a defensive process wherein a these issues with her psychologist, even
though the psychiatrist was aware that
patient appears to attribute good characteris-
many of the accusations made about the
tics almost exclusively to one person (or one therapist were, in some ways, not un-
provider of treatment) while attributing the true.1
other treater with all bad or negative feel- As the therapy progressed, Ms. Us
ings. The patient appears to take the natural self-destructive behavior diminished
ambivalence one feels about almost all peo- and then eventually ceased as her inter-
personal relationships grew more sta-
ple and divide it into two packagesa posi-
ble. Longer periods elapsed between
tive package bestowed upon one person and her complaints about her therapist, and
a negative package bestowed upon another. eventually the complaints stopped. The
Each package almost exclusively contains ei- treatment terminated successfully.
ther good or bad attributes, rarely contami-
nated by the opposite attribute. Defensive This chapter discusses collaborative
splitting can be accompanied by projective treatment in general and then collaborative
identification, in which the patient projects treatment of patients with personality disor-
different aspects of himself onto different ders. Much of what is discussed applies to
treaters. The different treaters, in turn, un- any collaborative treatment, regardless of the
consciously identify with those projected patients diagnosis, but the issues of col-
characteristics and may experience pressure laboration are heightened when the patient
to respond accordingly (Gabbard 1989; Gab- has a diagnosis of a personality disorder. Al-
bard and Wilkinson 1994; Ogden 1982). though the techniques, strategies, or issues
presented are pertinent to many patients
Case Example with personality disorders, they cannot be
applied to all such patients because we often
Ms. U, a young woman diagnosed with discuss treatments in which psychotherapy
borderline personality disorder (BPD), is conducted by one person and psychophar-
was in psychotherapy with a psycholo- macology is managed by another, and there
gist and receiving medication from a
are few data to support prescribing medica-
psychiatrist. Ms. U had an extensive
history of self-mutilating behavior. The tions to patients with schizoid, antisocial,
psychologist was, even in his everyday histrionic, narcissistic, and dependent per-
interactions, quite restrained. sonality disorders.
Ms. U was acutely aware of rejec-
tion, and she would call the psychiatrist
to complain vociferously about her psy-
chotherapists lack of feeling or empa-
EVIDENCE FOR EFFECTIVENESS OF
thy. Every 6 or 9 months of this 5-year COLLABORATIVE CARE
treatment, she would try to convince
the psychiatrist, who she knew did psy- Although collaborative treatment is increas-
chodynamic psychotherapy, to take ingly common in mental health care, the ef-
1 This
situation may occur frequently in collaborative treatment. The patient presents an observa-
tion about the collaborating psychotherapist that may be an astute and accurate perception of
the psychotherapist. Despite the face validity of the observation, the psychiatrist must refrain
from agreeing or disagreeing with the patient. Each patient brings his or her unique history and
transference into play when making such observations, and a comment at this point might
undermine that particular transferential process occurring in the psychotherapy.
Collaborative Treatment 323
fectiveness of collaborative versus integra- these studies, or personality disorders are

tive treatment has not been well studied. not assessed. Thus, for patients with person-
There are no head-to-head efficacy studies ality disorders, no clear conclusions can be
comparing collaborative with integrative made concerning the effectiveness of a med-
treatment, although there are studies that ex- ication versus psychotherapy; furthermore,
amine one treatment modality versus anno conclusions about effectiveness or effi-
other modality versus both modalities to- cacy can be made if these treatments are com-
gether (Greenblatt et al. 1965; Klerman 1990). bined and performed by one provider versus
Many patients with personality disorders being divided between two (or more) pro-
have complex biological and psychosocial is- viders with one providing psychotherapy
sues and do not respond as well to medica- and the other prescribing medications. The
tions as would patients whose primary diag- exceptions are the study by Kool et al. (2003),
nosis is from Axis I (except perhaps those which found that patients with personality
with schizotypal personality disorder [Dug- pathology and depression responded best to
gan et al. 2008; Binks et al. 2006; Koenigsberg a combined approach of both psychophar-
et al. 2003; Nose et al. 2006; Paris 2003; Soloff macology and psychotherapy, although per-
1990, 1998]). Treatment modalities beyond sonality pathology of patients with Cluster C
psychopharmacological treatment are neces- diagnoses responded better than that of pa-
sary, and often each modality is provided by tients with Cluster B diagnoses; the 12-week
a different mental health professional. Thus study by Soler et al. (2005) that found greater
there are many clinical situations in which improvement in depression, anxiety, and im-
multimodal treatment implies and warrants pulsivity/aggression in patients assigned to
collaboration between at least two mental dialectical behavior therapy plus olanzapine
health professionals. than in those assigned to dialectical behavior
Most current outcome studies in psychotherapy alone; and the small study by Simp-
therapy and psychopharmacology do not son et al. (2004) that randomly assigned pa-
measure the effects of any treatment other tients to placebo or fluoxetine after com-
than the one being studied. There are sur- pletion of a course of dialectical behavior
prisingly few studiesand even fewer ran- therapy and found that those assigned to pla-
domized controlled trialscomparing psy- cebo had more positive pre-/posttreatment
chotherapy alone, medication alone, and differences than those assigned to fluoxetine.
psychotherapy and medicine in combination
to determine the differential efficacy or effec-
tiveness (Browne et al. 2002). Studies of cog- IMPORTANCE OF COLLABORATIVE
nitive-behavioral therapy and nefazodone
for depression (Keller et al. 2000) and cogni-
TREATMENT IN CURRENT
tive-behavioral therapy and tricyclic antide- PERSONALITY DISORDERS CARE
pressants for panic disorder (Barlow et al.
General Issues
2000) have interesting findings about the
course and continuation of response to spe- A large proportion of antidepressants being
cific interventions (Manber et al. 2003). De prescribed in the United States is prescribed
Jonghe et al. (2004) found equivalent results by PCPs (Lecrubier 2001). Serotonin re-
between groups of mild to moderately de- uptake inhibitors are less complicated to pre-
pressed patients treated with psychotherapy scribe, with fewer general side effects and
(short-term psychodynamic) or a combina- less lethality, than tricyclic antidepressants
tion of psychotherapy and psychopharma- (Healy 1997). PCPs appear ready to provide
cology with antidepressants. Often patients the ongoing management of psychopharma-
with personality disorders are excluded from cological medication in consultation with a
psychiatrist. Although they do not always in patients with personality disorders. The
prescribe concurrent psychotherapy, a num- effectiveness of antidepressants in treating
ber of PCPs are collaborating with therapists depression in such patients is moderate at
of varying levels of training. An interesting best, even as their prescriptions are increas-
triangular relationship can develop: a thera- ing (Duggan et al. 2008; Binks et al. 2006;
pist, a PCP writing the prescriptions for psy- Nose et al. 2006; Paris 2003). Many patients
chotropic medication, and a psychiatrist for who may have been treated by psychother-
referral or collaboration. Smith (1989) wrote, apy alone in the past are now receiving psy-
In contemporary treatment situations that chopharmacological treatment as well. An
include a patient, a therapist, a pharmaco- emerging literature suggests that antidepres-
therapist, and a pill, the transference issues sants can be helpful in the treatment of spe-
can become more complex than the landing cific symptom complexes such as employing
patterns of airplanes at an overcrowded air- selective serotonin reuptake inhibitors or
port (p. 80). Add a managed care utilization mood stabilizers for impulsivity, affect labil-
reviewer to the picture, and things really get ity, and aggression in patients with BPD
complicated. (Coccaro and Kavoussi 1997; Coccaro et al.
Managed care companies often believe 1989; Cowdry and Gardner 1988; Hollander
that patients with personality disorders use et al. 2001, 2005; Loew et al. 2006; Markowitz
too much or at least more than their share of 2001, 2004; Nickel et al. 2005; Rinne et al.
treatment. One of the challenges associated 2002; Salzman et al. 1995; Sheard et al. 1976;
with providing collaborative care for these Soloff 1998; Soloff et al. 1993; Tritt et al. 2005).
patients is convincing utilization reviewers The American Psychiatric Association prac-
that more than one modality of care is tice guideline recommends treatment with
needed. To avoid divergent reports that neg- selective serotonin reuptake inhibitors in a
atively affect the reimbursed care for the pa- symptom-specific manner for patients with
tient, it is best to designate one member of BPD; this recommendation is based on evi-
the team to report the progress of treatment dence from several double-blind, placebo-
and the treatment plan to the reviewer. In controlled studies; a number of open studies;
general, this designated reporter should be and clinical experience in conjunction with a
the psychiatrist. relatively benign side-effect profile and risk
of overdose (American Psychiatric Associa-
Increasing Prescription of tion 2001). Also, some strong evidence sug-
gests that neuroleptics and atypical antipsy-
Antidepressants
chotics can be effective for patients with
Despite the lack of hard evidence for the ben- schizotypal personality disorder and BPD
efits of psychopharmacology in personality (Bogenschutz and Nurnberg 2004; Goldberg
disorders, the practice of prescribing antide- et al. 1986; Koenigsberg et al. 2003; Markow-
pressants for a wide array of symptom com- itz 2001, 2004; Nickel et al. 2006; Schulz and
plexes suggestive of depression continues to Camlin 1999 ; Soloff et al. 1986b, 1993; Za-
increase (Healy 1997). Although depression narini and Frankenburg 2001).
is prevalent among patients with personality Patients with personality disorders
disorders (Skodol et al. 1999), quite often the present with a complex admixture of symp-
nature of the depression, especially among toms and problems, some of which appear to
patients with Cluster B disorders, is not the arise from psychosocial issues and interper-
classic psychophysiological presentation fre- sonal events, whereas others appear more
quently seen in a major depressive episode related to expressions of underlying traits
(Westen et al. 1992). There has been much de- such as baseline anxiety, emotional lability,
bate about the type and nature of depression and impulsivity (Livesley 2000; Livesley et
al. 1998; Putnam and Silk 2005). When treat- personality disorder. In all these in-
ment is divided among two providers, the stances, the good therapist may be able
psychotherapist may believe that all prob- to provide support to the criticized, or
lems arise from psychosocial issues and sub- bad, therapist. One way this support
tly demean, undermine, or dismiss the psy- may occur is by the good therapist pro-
chopharmacological treatment. Conversely, viding examples of other situations in
the psychopharmacologist may think that which he or she had the misfortune of
difficulties are primarily due to trait expres- owning and bearing the bad therapist
sion and that once the right combination of label and how difficult it was to bear at
medications is discovered, all symptoms will the time but how useful it was to the
be alleviated. eventual outcome of the treatment. The
good therapist may also try to mini-
mize the negative countertransferential
feelings the bad therapist is experienc-
STRENGTHS AND WEAKNESSES OF ing and may be able to ward off the bad
COLLABORATIVE TREATMENT therapists wish to end treatment with the
patient.
There are many positives to a collaborative 2. Collaborative treatment provides a basis
treatment. Some of these positives have di- for ongoing consultation between pro-
rect reference to patients with personality viders. It also provides the potential for
disorders. multiple perspectives on complicated
clinical and diagnostic situations. Such
1. Collaborative treatment can provide the complex situations are not uncommon in
patient with both a clinician to idealize patients with personality disorders,
and a clinician to denigrate within one whose symptoms, behaviors, and inter-
treatment relationship. Although this sit- personal interactions can be so entwined
uation might at first appear to be prob- that it is difficult to unravel the trait bio-
lematic, it can be useful if both providers logical functioning from the interperson-
confer with each other and work to have ally and experientially learned behaviors
the patient develop a more balanced view and maneuvers (Cloninger et al. 1993;
of each of them. For example, both treat- Livesley et al. 1998).
ers may have an opportunity to model 3. When collaboration is with a PCP, the
more appropriate coping mechanisms for mental health professional can confer
the patient, or the idealized therapist with someone who may have a longitudi-
might be able to work with the patient to nal relationship with and understanding
modify or mollify the patients denigra- of the patient. The PCP often is viewed as
tion of the other treater and thus help fairly neutral by the patient and may be
keep the patient in treatment with the more impervious to the distortions of
therapist being denigrated. The classic transference that appear frequently
example is the patient with BPD, but pa- among patients with personality disor-
tients with narcissistic personality disorders. The PCP may be able to assist the pa-
der also contemptuously devalue and tient in remaining medication compliant.
criticize treaters who do not treat them in 4. Patients with personality disorders can be
the way in which they believe they are en- very draining to treat. Patients with BPD
titled. Feeling devalued can occur when can be demanding and threatening. Con-
faced with the moralistic, judgmental, stant demands for attention from the pa-
and somewhat contemptuous attitude of tient with histrionic or narcissistic person-
the patient with obsessive-compulsive ality disorder can become exhausting. The
complaints of histrionic patients can be specific patient, while each staff mem-
very difficult to listen to and to take seri- ber believes that she or he alone really
ously. Patients with dependent personal- knows best. The director of the ward,
who has frequently encountered such
ity disorder can be draining and pulling,
sudden disagreements, decides to deal
whereas the chronic anger and distrust- with these types of difficulties by bring-
fulness of patients with paranoid person- ing together the warring parties and
ality disorder can be quite difficult to tol- wondering out loud with them why
erate. Therefore, a group of therapists and each has suddenly begun to despise his
psychiatrists working as a team to pro- or her other colleague on the unit. The
vide overall patient management can sup- director emphasizes that prior to the
port and confer with one another to re- disagreement, each person appeared to
have great respect for and to enjoy
duce burnout.
working with the other person. The di-
rector moves to a discussion of the pa-
Collaborative treatment can readily turn tient and tries to show the parties how
into a split treatment when the collaborators each is really only seeing a part of the
fail to collaborate. There can be many causes patient, upon which they have each
for this failure. Some patients with personal- constructed the idea that they alone
ity disorders have a tendency, as explained know how best to treat the patient.
earlier, to split by attributing all good to one
Collaboration in divided treatment is es-
person and all bad to another. Although this
sential but does not always occur easily or
splitting is most blatant among patients with
frequently; a concerted effort must be made.
BPD, it occurs in more subtle forms among
Regularly scheduled phone calls or e-mail
patients with schizotypal, narcissistic, anti-
exchanges may be the best way to sustain the
social, and obsessive-compulsive personal-
collaboration even when there is skepticism
ity disorders. Failure to collaborate in the
as to its value or a belief that another pro-
treatment of these patients can lead to seri-
vider is causing difficulty.
ous problems in the treatment. Table 171
presents specific issues that need to be con-
sidered in a collaborative treatment for each
of the personality disorders. COLLABORATIVE TREATMENT AND
Failure to collaborate or the end of collab- PERSONALITY DISORDERS
oration can develop when the treaters iden-
tify with the projections of the patient. In this Treatment with psychopharmacology and
situation, each of the treaters begins to lose psychotherapy is more common now in the
respect for the other treater as each begins to treatment of all personality disorders than it
identify and psychologically own some of has ever been. This probably is due to a num-
the negative projections of the patient (Gab- ber of factors:
bard 1989; Ogden 1982). Such events or situ-
ations are not uncommon on inpatient units 1. Use of psychopharmacological agents
where the split is often between the attend- among all psychiatric patients has in-
ing or resident psychiatrist and a member or creased, reflecting the general ascen-
members of the nursing staff, although they dancy of biological psychiatry (Siever
can occur between nurses as well (see Gab- and Davis 1991; Siever et al. 2002; Silk
bard 1989; Gunderson 1984; Main 1957; Stan- 1998; Skodol et al. 2002).
ton and Schwartz 1954). 2. Since the early 1990s, there has been an ex-
pansion in specific types of psychother-
A ward staff member suddenly accuses apy for patients with personality disor-
another staff member of deliberately ders, such as dialectical behavior therapy
trying to jeopardize the treatment of a (Linehan et al. 1993), transference-focused
psychotherapy (Clarkin et al. 1999; Kern- pharmacological agents, and even in the
berg et al. 2000), dynamic therapy (Bate- absence of a clear Axis I comorbid diag-
man and Fonagy 1999, 2001), cognitive- noses, the patient may have pharmaco-
behavioral therapy (Beck and Freeman logically responsive symptom clusters
1990; Davidson et al. 2006), interpersonal that are reminiscent of Axis I and should
reconstructive psychotherapy (Benjamin be treated as such.
2003), aand schema-focused cognitive-be-
havioral therapy (Young et al. 2003). None
of these therapies opposes the concurrent SITUATIONS OF COLLABORATIVE
use of psychopharmacological agents. TREATMENT
3. Psychopharmacological agents are in
more common use in psychiatric treat- Although collaborative treatment usually re-
ment today, and the medications used are fers to the arrangement in which a nonmedi-
generally safer and have more tolerable cal psychotherapist performs the psycho-
side-effect profiles (Healy 2002). Safety is therapy and a psychiatrist or other medical
important among a group of patients, doctor prescribes medication, variations on
particularly patients with BPD, who have that arrangement still qualify as collabora-
very high suicide rates (Paris 2002; Stone tive treatment. Some such variations occur
1990). regardless of the diagnosis, but others are
4. Managed care companies play a signifi- more prone to occur in the treatment of pa-
cant role. They are reluctant to approve tients with personality disorders.
treatment sessions with seriously ill pa-
tients (including a significant number of Comorbid Substance Abuse
patients with personality disorders) who
Treatment
are not receiving medication.
5. There is a growing appreciation of the Collaboration should occur when the patient
role of biological and constitutional fac- is in both substance abuse treatment and
tors in the etiology of personality dis- treatment with a psychiatrist for personality
order symptoms. The nature-nurture disorder issues. Continuous use of sub-
dichotomy has been replaced by consider- stances can exacerbate personality disorder
ation of the subtle interplay of biological psychopathology, and in these instances it is
predisposition, resulting in traits that are very important that the substance abuse
expressed through behavior that is af- counselor and/or psychotherapist and the
fected by experiential and environmental treating psychiatrist immediately confer
factors (both shared and nonshared) (Rut- (Casillas and Clark 2002; de Groot et al.
ter 2002). Such a theory of interaction be- 2003). If an increase in or a resumption of
tween biological predispositions and life substance use after a period of abstinence
experience supports a multimodal treat- should occur, the counselor/psychothera-
ment approach (Paris 1994). pist needs to initiate contact with the psychi-
6. The comorbidity of both Axis I and Axis atrist. Sometimes a patient will feel embar-
II disorders has received increased con- rassed about resuming use of substances
sideration. If one prefers to treat Axis II after a period of sobriety and may ask the
problems with psychotherapy, Axis I co- counselor/psychotherapist not to inform the
morbidity still must be considered and psychiatrist. Obviously this wish cannot be
treated, or it will likely worsen the clini- granted, because there would be 1) collusion
cal manifestation of the Axis II disorder between the counselor/psychotherapist and
(Yen at al. 2003; Zanarini et al. 1998). Axis the patient to keep the psychiatrist in the
I comorbid diagnoses may respond to
328
Table 171. Specific issues to address in collaborative treatment with specific personality disorders
Personality disorder Classic features Tips for providers of collaborative treatment
Paranoid Distrust, suspiciousness Be clear about frequency of contact among providers and be sure to inform
patient whenever a contact between any of the providers has occurred.
Regularly remind patient about sources of specific information and be sure that
each treater knows whether the information he or she has about the patient
comes from the patient or other sources (providers).
Schizoid Detachment from emotional relationships Work among providers to minimize redundancy of visits so that patient can
come as infrequently as possible.
Coordinate treatment visits so patient can visit all providers on the same day.
Schizotypal Discomfort with close relationships, Be prepared to contact other providers when increased distortions arise in
cognitive or perceptual distortions, sessions.
eccentricities of behavior Work together to minimize redundancy of visits (see schizoid above).
Antisocial Disregard for rights of others Convey clearly that all members of the treatment team will communicate
regularly.
Be prepared for misrepresentations of facts.
Be prepared to verify information with providers. If different providers are
getting very different facts from the patient, a designated provider needs to
discuss the discrepancies with the patient.
Borderline Instability in mood and interpersonal Provide support for the patient without becoming caught up in splitting among
relationships, impulsivity providers.
Discuss strong countertransference feelings with other providers.
Have a clear plan about roles and responses of all providers to emotional
outbursts, threats, increased suicidality, other crises, and medication changes.
Be careful that repeated crises or turmoil are not reinforced by increased
attention from providers.
Histrionic Excessive emotionality, attention seeking Have a clear plan among providers as to how to handle emotional outbursts.
Be prepared to contact other providers at periods of increasing physical
symptoms and/or increasing attention-seeking behavior.
Table 171. Specific issues to address in collaborative treatment with specific personality disorders (continued)
Personality disorder Classic features Tips for providers of collaborative treatment
Narcissistic Grandiosity, lack of empathy Be prepared to contact other providers when overt or covert signs of increasing
contempt toward one of the treaters occurs.
Have a clear plan among providers regarding how to handle contemptuous
behavior so that one of the providers addresses the issue even if the patient is
expressing contempt toward only one of them.
Avoidant Social inhibition, feelings of inadequacy, Work among each other to encourage consistent treatment relationships and
hypersensitivity to negative evaluation attitudes in all treatments involved in the collaboration.
Be prepared to communicate with other providers whenever missed
Collaborative Treatment
appointments with any provider occur.
Coordinate treatment visits so patient can visit all providers on the same day.
Dependent Submissive behavior, a need to be taken Work with patient to minimize appointments and avoid overutilization of
care of services.
Work together to anticipate how to handle patient needs during vacations.
Plan to ensure that increasing distress does not lead to increasing number of
appointments.
Obsessive- Preoccupation with order, cleanliness, Ensure that consistent recommendations are made by each provider.
compulsive control Be prepared to communicate with other providers when patient is having
difficulty adhering to recommendations.
Have a clear plan regarding how to confront a patient who constantly obsesses
and complains about the lack of consistency or thoroughness of the treatment
when the particular obsessing is a sign of disdain toward other people.
Note. In many personality disorders in which there is no clear indication or no data to support the use of medications, collaborative treatment might arise because
there is psychopharmacological treatment of a comorbid Axis I disorder. This table provides tips with respect to how the patients personality disorder might be
dealt with in a collaborative treatment even if the medication is being administered for reasons other than the patients personality disorder diagnosis.
329
dark and 2) a splitting between the counse-

lor/psychotherapist and the psychiatrist. SEVEN PRINCIPLES TO FOLLOW IN
COLLABORATIVE TREATMENT
Case Example
An engineer in his mid-50s, Mr. V was A number of principles can apply to any col-
referred for substance abuse treatment laborative treatment, but they have special
after his second citation for driving application in personality disorders. Adher-
while intoxicated. The substance abuse
ence to these principles can lead to a smoother
counselor referred Mr. V to a psychia-
trist for treatment of narcissistic person- and more synergistic approach to collabora-
ality disorder. Whenever Mr. V in- tive treatment (Silk 1995).
creased his alcohol use, he would miss
his appointments with the psychiatrist
because he was embarrassed, although Understanding and Clarifying the
he would attend his substance abuse ses- Relationship Between the Therapist
sions. The psychiatrist called the sub- and the Prescriber
stance abuse counselor whenever Mr. V
missed an appointment, and the coun-
selor always convinced Mr. V to return
The relationship between a psychotherapist
to and continue with the psychiatrist. and a pharmacotherapist, or prescriber,
The psychiatrist eventually concluded has been described as the pharmacother-
that Mr. Vs shame about his substance apy-psychotherapy triangle (Beitman et al.
abuse behavior related more to avoid- 1984). In managed care, psychiatrists may be
ance than narcissism in interpersonal
expected to provide medical backup for ther-
functioning, and this information al-
lowed the substance abuse counselor to apists whose work they do not know, whose
modify his approach to Mr. V. approach they may not agree with, or whom
they do not respect (Goldberg et al. 1991).
Somatic Complaints, the Primary Conversely, the psychotherapist may have to
Care Physician, and the Psychiatrist deal with a psychiatrist whom he or she does
not know or agree with. In the best of worlds,
Patients with personality disorders, particu- neither the psychiatrist nor the psychothera-
larly those with Cluster B and Cluster C per- pist would feel obligated to collaborate with
sonality disorders, have a tendency to be so- a treater whom he or she does not respect.
matically preoccupied (Benjamin et al. 1989; Patients with personality disorders are
Frankenburg and Zanarini 2006). Although quite sensitive to disagreements among
the treating psychiatrist may suspect mere members of the treatment team (Main 1957;
somatic preoccupation, one cannot make the Stanton and Schwartz 1954). Without com-
mistake of not taking the complaint seri- munication and knowledge about what
ously. If complaints persist or if different so- other professionals involved in the case are
matic concerns frequently appear, it is im- doing, the patient can become caught in the
portant for the psychiatrist to share his mid d le of d isa gree me nt ( St an ton a nd
concern with the physician working up the Schwartz 1954). Each treater should respect
somatic issues. Together, the two physicians what the other is trying to accomplish. This
can decide how much physical exploration respect for treatment modality should be
of somatic concerns should occur and coordi- separated from personal feelings (although it
nate a consistent therapeutic response to per- is always easier if there is mutual liking).
sisting somatic issues (Williams and Silk Each provider should be free to conduct an
1997). open communication with the other so that
treatment collaboration and coordination
can occur (Koenigsberg 1993).
Ideally, the prescriber and the therapist stand the general indications for pharmaco-
will know each other or at least know some- therapy and be aware of the specificity as
thing about each others practice and prac- well as the limitations of the psychopharma-
tice reputation. The prescriber should have cological treatment. The therapist should
an appreciation for the basic psychological have some rudimentary knowledge of both
issues involved in treatment and a general the expected therapeutic effects as well as the
understanding of how they may manifest in possible side effects of at least the broader
psychopharmacological treatment. The pre- classes of psychotropic medications. In the
scribing psychiatrist needs to be clear with course of the psychotherapy, the therapist
the therapist as to his or her beliefs in the pu- should be willing to discuss, albeit on a lim-
tative efficacy of psychotherapy in the per- ited basis, the patients experience (both pos-
sonality disorder in general as well as for itive and negative) of taking the medication.
each patient specifically. Psychotherapy will Additionally, the therapist needs to have
not proceed constructively if the prescriber some knowledge of medications so that he or
does not believe in the usefulness of psycho- she can have some appreciation of what
therapy, particularly with patients with per- might be subjective versus objective reac-
sonality disorders (especially those belong- tions of the patient to taking the medication.
ing to Cluster B). Maintenance of therapeutic As stated earlier, no psychotherapist or
boundaries between treaters is crucial in pa- psychopharmacologist should feel obligated
tients with personality disorders and must to work with a collaborative partner with
be clarified (Woodward et al. 1993). Some whom they do not agree or respect. They
questions to ask are: Should between-session each must respect the roles and competence
phone calls be permitted in the pharmaco- of their co-treater. In this atmosphere of mu-
logical treatment if they are not permitted or tual respect, both the prescriber and the ther-
are frowned upon in the psychotherapy? In apist need to appreciate the perceived effi-
what quantities will pills be prescribed, and cacy as well as limitations of each of the
what course should the therapist take if there interventions. Both need to be able to tolerate
is a sudden increase in the suicidality of the treatment situations where progress is often
patient? When the patient requests a change slow, punctuated by periods of improvement
or an increase in dosage, will the prescriber and regression, and where the long-range
contact the therapist beforehand to under- prognosis is often guarded but not necessar-
stand better what issues might be coming up ily negative. Appreciating each others diffi-
in the psychotherapy? How frequently will culties and those of the patient in the treat-
discussions between the prescriber and the ment may help each treater avoid blaming
therapist take place? How will issues that be- the other (or the patient) during difficult pe-
long primarily in the psychotherapy be dealt riods.
with if they are brought up in the psycho- Appelbaum suggested that, to address
pharmacological treatment? Will the psy- both clarity of treatment and treatment ex-
chopharmacologist notify the psychothera- pectations, as well as medicolegal issues, the
pist that he or she has directed some issue therapist and prescriber draw up a formal
back to the psychotherapist? contract that delineates their respective roles
The psychotherapist, in a similar manner, as well as the expected frequency and range
needs to have respect for the prescriber and of, or limitations on, their communication
for the intervention of psychopharmacology (Appelbaum 1991; Chiles et al. 1991). Such a
(Koenigsberg 1993). Although there is prob- contract works well when the two people
ably little need for nonmedical therapists to share responsibility for a number of patients
be experts in psychotropic drug usage, non- (Smith 1989). These ideas about contracts are
medical psychotherapists should under- merely suggestions and certainly may not be
necessary or useful when the two collabora- prescriber in an attempt to assure that the
tors work in the same clinic or the same pharmacological decision was correct. The
health system. prescriber and/or the therapist may deny
Much of what we diagnose as personality ambivalence about the medication, become
disorder reflects a group of patients who intolerant of the patients (or the other pro-
have chronic maladaptive interpersonal viders) questions and concerns, and present
functioning across a wide range of settings. the possible therapeutic effects of the medi-
Interpersonal dysfunction cannot and should cations in a more positive light than the evi-
not be ignored, dismissed, or denied, and dence would imply. This idealization of the
whenever and wherever it occurs in the ther- medication, similar to the patients periodic
apeutic endeavor, it should be discussed not idealization of the treatment, will usually be
only between the two therapists but among short-lived.
the treaters and the patient. Transference is Pessimism about progress in the therapy
not solely reserved for transference-oriented was given as a reason to consider prescribing
psychotherapy (Beck and Freeman 1990; medications by 65% of the respondent psy-
Goldhamer 1984), and pharmacotherapy is chotherapists in a study by Waldinger and
[also] an interpersonal transaction (Beitman Frank (1989). Given that some patients with
1993, p. 538). personality disorders, particularly BPD, seem
especially attuned to feelings, a treaters pes-
Understanding What the simism or frustration with the course of ther-
Medication Means to Both apy may be inadvertently and unconsciously
Therapist and Prescriber conveyed to the patient. Conversely, a refer-
ral to a psychopharmacologist could be
Medications may play both a positive and a viewed as an opportunity for consultation
negative role in treatment. The therapist and and second opinion (Chiles et al. 1991).
the prescriber need to be attuned to what the It is easy for treaters to develop anger and
initiation of medication means to each of rage at patients with personality disorders,
them. particularly with patients with substantial
Although DSM-IV-TR (American Psychi- borderline, narcissistic, and paranoid per-
atric Association 2000) lists 10 personality sonality disorder characteristics, when there
disorders, in clinical practice patients with is little apparent therapeutic progress (Gab-
personality disorders defy easy classification bard and Wilkinson 1994). At these times,
and do not always fit neatly into any of these one treater may try to pull back from the
DSM categories (Westen and Arkowitz- treatment or, conversely, try to take over con-
Westen 1998). In addition, no medications trol of the entire treatment. The best way to
have yet been indicated for any specific per- handle these feelings is not to isolate oneself
sonality disorder. Although there are algo- but to approach the other provider and be
rithms with respect to the pharmacological willing to share ones frustrations. More of-
treatment of personality disorders (particu- ten than not, the first provider will discover
larly BPD [American Psychiatric Association that the other provider shares similar frustra-
2001; Soloff 1998]), there are no clear-cut tions. This shared frustration not only will
rules as to when or what medication should lead to less tension in each provider and in
be used in any given Axis II diagnosis. In cir- the therapy but also, at times, to a discussion
cumstances with prescriber self-doubt, am- and a review of the treatment.
bivalence, and uncertainty about either the When medication is being considered in
diagnosis or, more probably, the chosen a collaborative treatment, the following ques-
pharmacological agent, a defensive and au- tions may be asked: Where is the impetus for
thoritarian posture might be assumed by the the medication coming from? Does the ther-
apist think the medication will affect or troduced early in the treatment process, the
change the therapeutic relationship? In turn, potential negative transferential reaction to
the prescriber should be able to let the thera- the introduction of medications later may be
pist know if he or she feels that the thera- minimized. It is important that the therapist
pists expectations for the medication are un- and the prescriber be on the same page as to
realistic and what might be a reasonable how medication will be chosen, intro-
expected response. duced, continued, discontinued, and so on.
Discussions at the beginning of treatment
Understanding What the can model the ethos of an open forum for ex-
change of information about medications
Medication Means to the Patient
and other feelings.
Beginning pharmacotherapy or changing
medication may not always be seen as favor- Case Example
able by patients, and a negative reaction to
Mr. W, a 50-year-old man with histri-
the idea of medication needs to be antici- onic personality disorder and panic dis-
pated. A propensity to put the most negative order, was referred to an anxiety disor-
spin on interpersonal encounters or per- der clinic after several emergency
ceived intentions may cause patients with department visits because of uncom-
fortable arousal symptoms precipitated
personality disorders to experience the intro-
by an antidep ressant (Soloff et al.
duction of medication as a failure of their 1986a). He received cognitive-behav-
role in treatment or as the psychotherapist ioral therapy and responded well, al-
giving up on them. Patients might also, albeit though he had trouble starting an anti-
rarely, experience the introduction of medi- depressant without having his panic
cation as a hopeful sign, as an additional mo- symptoms increase. He did tolerate a
low-dose benzodiazepine but was fear-
dality that might help speed the progress of ful of becoming addicted to the ben-
the treatment (Gunderson 1984, 2001; Wal- zodiazepine and would intermittently
dinger and Frank 1989). Whatever the pa- reduce his dosage despite his thera-
tients reaction, understanding what the pists attempts to discourage it. When
medication means to the patient and how the Mr. Ws insurance ran out, he stopped
seeing his therapist because he was
patient understands the use of medication
doing so well, and he also stopped his
within the context of the therapy as well as in medication. He began to have emo-
the context of his or her own life experience is tional outbursts and increased panic at-
crucial (Metzl and Riba 2003). tacks and called the psychiatric emer-
Understanding the patients reaction to gency department inquiring about
rehabilitation for drug abuse. Therapy
the introduction of medication can be impor-
was reinitiated after both the therapist
tant not only for the patients cooperation and psychiatrist discussed Mr. Ws con-
and compliance but also for transferential is- cerns about medication and how these
sues. The patient may take medication in a concerns were affecting his life. The
spirit of collaboration with the therapist and providers developed clear plans as to
whom Mr. W would call for medica-
the prescriber. The patient may disagree with
tion questions, whom for exposure
the decision, but cooperate out of a strong questions, and how they would re-
need to please. A patients reactions will de- spond to emotional upheavals.
pend on whether the therapist and prescriber
are truly collaborating or at odds. Both therapist and prescriber should be
The introduction of medication into any aware that patients may use medications as
therapy, even if by a conferring psychiatrist, transitional objects (particularly patients
has repercussions on the transference (Gold- with borderline, histrionic, and perhaps se-
hamer 1984). If the idea of medication is in- verely dependent personality disorders
[Cardasis et al. 1997; Gunderson et al. 1985; ing five medications: two mood stabiliz-
Winnicott 1953]). In this context, the patients ers, a low-dose atypical antipsychotic,
attachment and/or resistance to changing or an antidepressant, and a benzodiaz-
epine. She insisted that this combination
altering medications may seem out of pro-
was the correct regimen for her and that
portion to the actual therapeutic benefit de- the new psychiatrist not tamper with
rived from the medication (Adelman 1985). It her medications. She said it took many
may also explain why the patient who has re- months and finally a referral to the most
peatedly complained about the medications prominent psychopharmacologist in
is unwilling to change them even when there her region before the right combination
has been little clear evidence that the medica- was found. She also stated that she was
tions have been effective. going to remain in psychotherapy with
her old therapist through weekly long-
distance phone contacts.
Understanding That the Medication The new psychiatrist, after seeing
Will Probably Have Limited Ms. X five or six times, began to feel that
Effectiveness Ms. X primarily had a narcissistic per-
sonality disorder and that her depres-
Therapists and prescribers need to appreciate sions were brought about by her ex-
the therapeutic benefits and limitations of treme sensitivity to anything that could
medication. Therapists should inquire about remotely represent a narcissistic injury.
The psychiatrist called Ms. Xs thera-
their patients medications at moments of
pist, who acknowledged that although
calm, not during periods of crisis. Perhaps the
Ms. X did have some narcissistic issues,
most instructive and useful time for (ex)change she really had experienced a number of
is when things are actually going well and major depressive episodes during their
treatment does not seem bleak or hopeless. treatment together.
The prescriber should describe what fea- After a few months, Ms. X grew
tures of a specific medication may or may not more depressed, but her depression
was marked primarily by lethargy, ab-
be useful in this particular patient at this par-
senteeism from work, and an inability
ticular time. The prescriber should tell the to concentrate. She was, however, able
therapist what unusual idiosyncratic reac- to date and had no loss of libido or ap-
tions to the medication might occur (Gardner petite. Instead of feelings of guilt or
and Cowdry 1985; Soloff et al. 1986a), espe- worthlessness, she had feelings of gran-
dio sity and entitlement. M s. X re-
cially because these paradoxical reactions or
quested a psychostimulant to help with
tendencies toward dependency may not al- her concentration and lethargy. The
ways be listed in the package insert or in the psychiatrist balked and tried to address
Physicians Desk Reference. some of the ways in which he felt her
With effective collaboration, medication depression was atypical. He pointed
decisions will not be solely in the hands of out that she seemed more invested in
wanting the psychiatrist to figure out
the prescriber. A dialogue between therapist what pills would make her better rather
and prescriber should take place as to how than in exploring events in her life that
each particular type or category of medica- might be leading to what she thought
tion with the particular patient might work. was depression. She stormed out of the
office. Later that week, Ms. X called the
psychiatrist to say that her therapist
Case Example also believed that she could benefit
from a psychostimulant, and she was
Ms. X was referred by a psychiatrist going to find a psychiatrist who was an
from out of town for treatment of anxi- expert in depression and more up-to-
ety and depression. Ms. X had a long date about treatment. Calls the psychia-
history of major depressive episodes. At trist made to Ms. Xs long-distance ther-
the time of the evaluation, she was tak- apist went unanswered.
Understanding How the Medication and the benzodiazepines also have a signifi-
Fits Into the Overall Treatment and cant morbidity and mortality associated with
Treatment Plan for the Patient overdose, especially when combined with
other agents. Suicide potential needs to be
continually assessed, and when it increases, a
If a psychotherapist considers using medica-
plan should be enacted that takes into ac-
tions at some time during the course of treat-
count when the therapist will contact the pre-
ment, it is hoped that he or she will have an
scriber, whether the prescriber is going to
ongoing arrangement with a prescriber or
limit the size of the prescription, which of the
know ahead of time who the prescriber
treating professionals might hold onto the
might be. It is never wise to begin searching
medications if a decision is made to limit their
for a prescriber during a time of pressing
administration, and so on. At a minimum, if
need for medications.
the therapist believes there is an increase in
The goal of treatment for a patient with
suicide potential, then the prescriber should
personality disorder cannot be cure. Decid-
be notified. If the therapist is fearful that the
ing to use medications or changing medica-
patient may overdose, this issue should be
tions should not imply that one is going for
discussed openly with the prescriber.
the cure. The goal of treatment should be to
Patients with personality disorders, par-
try to improve the ways in which our pa-
ticularly BPD, are potentially volatile and
tients cope, to help them develop increased
can act out when they feel that relationships
awareness of their cognitive rigidity and dis-
are threatened (Gunderson 1984). The thera-
tortions, to assist them in becoming some-
pistpatient relationship is one that, when
what less impulsive and less affectively la-
complicated by transference, can increase the
bile, and to try to increase the distance
possibility of acting-out in ways that include
between, while reducing the amplitude of,
suicidal and other self-destructive behaviors;
their interpersonal crises (Koenigsberg
the prescriberpatient relationship is another
1993). These goals are attributable to both the
that also holds the potential for these types of
psychotherapy and psychopharmacology
dangers. Mutual respect and communication
and need to be appreciated by both the ther-
between the therapist and the prescriber are
apist and the prescriber. A prescriber who
indispensable to ensuring that a crisis is de-
conveys a powerful belief in finding the
fused.
right medication will promote an unrealis-
tic and difficult situation.
Any therapy for patients with character Understanding That Interpersonal
disorders must have realistic and limited Crises and Affective Storms Cannot
goals set early in the therapy, lest any of the Be Relieved Simply Through
players begin to idealize another player or Initiation or Modification of the
another modality. Such idealization can only Medication
lead to disappointment and the multiple re-
percussions that occur in the treatment as a Introducing medication into the treatment of
result. a patient with personality disorder should
not be a spur-of-the-moment decision. It
Understanding the Potential and should be done in a controlled manner with
Actual Lethality of the Medication forethought and not in the midst of an in-
terpersonal or transferential crisis. Our
Many psychotropic medications can be le- patients lives and affects do not follow well-
thal, particularly tricyclic antidepressants, designed courses or even respond to well-
lithium, and the mood stabilizers/anticon- designed plans. Even if careful plans are
vulsants. The monoamine oxidase inhibitors made, the interpersonal crises and affective
storms that occur in treatment, combined the psychiatrist feels capable of and compe-
with the interpersonal demandingness and/ tent in providing both the medication and
or helplessness and passivity of the patient, the specific form of psychotherapy most use-
put enormous pressure on the therapist to do ful to the patient.
something, to change something, to make the There may be situations in which collab-
pain go away. There is a tendency to promise orative treatment is contraindicated. The first
much more than can be accomplished, ulti- situation would be when the patient is ex-
mately leading to idealization, disappoint- tremely paranoid or psychotic. These types
ment, and subsequent devaluation. If there is of patients may not agree to having people
a collaborative relationship, and it is very talk about them and thus would not sign a
good and mutually supportive, then neither release of information for such exchanges to
treater should deal with the patients attacks occur. Also, paranoid people often think that
and demands alone. Each can use the oppor- all or most other people are talking about
tunity to think through and resolve the crisis. them, and the therapist may not wish to rein-
In a crisis, all of the six points just de- force this idea by means of an arrangement
scribed come into play. How well has there wherein people are talking about the patient.
been open collaboration between the psycho- There may also be instances in which pa-
therapist and the prescriber? How well do tients have an admixture of serious medical
they work together, and can they trust each and psychiatric problems. The medical prob-
other and each others judgment? How do lems may directly affect the patients psycho-
they each, as well as the patient, understand logical problems and presentation as well as
the role of medication in the treatment and the patients cognitive processes and ability
the medications benefits and symbolic to comprehend. A physician who under-
meaning? How well does each person understands the impact of medical conditions on
stand the limits of the medication, and is one psychological presentation and functioning
of the treaters overreacting, merely prescrib- and who can conduct the psychotherapy as
ing or wanting a prescription written for well as manage the medications would be
medication in order to feel that a crisis is be- most helpful in these cases, especially if the
ing defused? What has been said about med- medical condition or related psychological
ications in the treatment in the past, and how problems wax and wane. In this instance,
and when have medications been used in the drugdrug interactions may have a direct
treatment? Have medications been em- impact on psychological and medical well-
ployed successfully, and have they been used being, and changes in medical condition may
safely by the patient? warrant repeated reevaluation of psychotro-
pic drug regimens.
In other instances, practical reality issues
CONTRAINDICATIONS TO may lead to treatment by a single provider
rather than collaborative treatment. If a pa-
COLLABORATIVE TREATMENT
tient has a severe limit on the number of ses-
Before concluding, we need to make mention sions of psychological or psychiatric treat-
of situations in which collaborative treatment because of third-party payer restrictions,
ment may be contraindicated. First, how- then the psychiatrist must consider how to
ever, we must point out that when a patient use those sessions most efficiently and cost-
needs both medication and psychotherapeu- effectively for the patient. In this instance, be-
tic treatment, it is very common that both ing able to manage medications and conduct
treatments are provided by a single psychia- psychotherapy in a single session may be im-
trist. We continue to urge treatment by one portant. A similar situation can occur when
individual psychiatrist whenever possible if the patient has severely restricted financial
resources or lives so far away that a trip to the treatment, the providers must communicate
psychotherapist and/or psychiatrist in- with each other on a regular basis. This com-
volves a significant expenditure of time or munication is not only a hallmark of good
money. In this case, if both psychotherapy psychiatric care but is also a method whereby
and psychopharmacology can be accom- two or more providers can coordinate their
plished in a single trip or visit, then this ap- treatment approach and collaborate on deci-
proach should be seriously considered. sion making so that the experience can be a
synergistic rather than a divisive one.
Collaborative treatment at its best occurs
in an atmosphere of respect and results in
CONCLUSION open and free communication with fellow
Collaborative treatment is increasing because providers. An opportunity for collaborators
of a number of factors, some economic, some to consult and learn from one another exists,
because of advances in neuroscience and and this collaboration has the potential to re-
pharmacology, and some because of man- sult in more comprehensive and thoughtful
aged care and the way health care in the care for difficult-to-treat groups of patients.
United States is delivered. The various com-
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18
Assessing and Managing
Suicide Risk
Paul S. Links, M.D., F.R.C.P.C.
Nathan Kolla, M.D.
R obins and colleagues in 1959 demon- uncommunicative patient and patients with
strated the strong association between men- antisocial, borderline, and narcissistic per-
tal disorders and suicide, but the relationship sonality disorders presenting at risk for sui-
between suicidal behavior and personality cide are discussed.
disorders (Axis II disorders) has only been
systematically studied since the mid-1980s.
The purpose of this chapter is threefold. First, DEFINITION OF TERMS AND
the epidemiological evidence for the associa-
METHODOLOGY
tion between suicidal behavior and suicide in
individuals diagnosed with personality dis- For purposes of this review, suicidal behavior is
orders is reviewed. Second, we examine defined through three components: suicide,
whether any potentially modifiable risk fac- suicide attempts, and self-injurious behav-
tors are associated with these diagnoses, iors. The definitions of OCarroll et al. (1996)
based on existing empirical evidence. Last, have been adopted. They defined suicide as
clinical approaches to the assessment of the self-injurious behavior with a fatal outcome
This chapter is adapted with permission from Links PS, Gould G, Ratnayake R: Assessing Suicidal
Youth With Antisocial, Borderline, or Narcissistic Personality Disorder. Canadian Journal of Psychiatry
48:301310, 2003.
343
for which there is evidence (either explicit or nicative and patients with antisocial, border-
implicit) that the individual intended at some line, and/or narcissistic personality disorder.
(nonzero) level to kill him- or herself. A suicide These observations are based on clinical ex-
attempt is defined as self-injurious behavior perience and not on empirical evidence. The
with a nonfatal outcome for which there is ev- observations would not replace the need for
idence (either explicit or implicit) that the in- doing a comprehensive suicide risk assess-
dividual intended at some (nonzero) level to ment based on formats such as those de-
kill him- or herself. A definition of self-injuri- scribed by Jacobs et al. (1999), Rudd and
ous behavior not intended to be fatal has also Joiner (1998), and the American Psychiatric
been utilized. Simeon and Favazza (2001) de- Associations (2003) practice guideline for as-
fined self-injurious behavior as all behaviors sessing and treating patients with suicidal
that involve deliberate infliction of direct behavior. The difficult decisions that arise
physical harm to ones body with zero intent during a suicide risk assessmentsuch as
to die as a consequence of this behavior. whether the patient should be admitted to
Our discussion of suicide risk focuses on hospital, whether such admission should be
the clinical entities known as personality dis- involuntary, or whether the persons risk of
orders. Primarily, the diagnoses from DSM- suicide should be communicated to the fam-
III, DSM-III-R, DSM-IV, and DSM-IV-TR ilyare most soundly based on careful clini-
(American Psychiatric Association 1980, cal assessment, because there is no measure-
1987, 1994, 2000) are discussed; however, we ment scale that can replace clinical expertise.
also include studies employing ICD-9 and
ICD-10 diagnoses (World Health Organiza-
tion 1977, 1992) for completeness. Personal-
ity or personality traits are often discussed
PERSONALITY, PERSONALITY
from a dimensional approach. These dimen- DISORDERS, AND SUICIDE RISK
sions have inherent advantages for measure- ASSESSMENT
ment and statistical purposes, describing
cases at categorical borders and connecting Goldsmith et al. (1990) articulated modern
with the large body of normal personality re- conceptualizations of the causal relationship
search. A diagnostic or categorical approach between personality and/or personality dis-
has certain advantages for the practicing cli- order and suicidal behavior, but most impor-
nician, because a considerable body of re- tantly, they asked whether personality disor-
search related to risk assessment exists based ders directly predispose to suicidal behavior
on psychiatric and personality disorder diag- independent of other risk factors. Although
noses. As discussed later, there is a lesser the causal relationship between personality
body of clinical research and little consensus and/or personality disorders and suicidal
related to personality dimensions and sui- behavior is likely complex, research since
cide risk assessment. 1990 has suggested that certain personality
This review is based on the English-lan- features and/or disorders are related to sui-
guage literature from 1991 to 2003 using the cidal behavior and are independent of other
search terms of all personality disorders and known risk factors.
suicide and suicidal behavior. In particular, Conner et al. (2001) thoroughly reviewed
this chapter focuses on research that exam- the empirical literature to determine whether
ined potential risk factors for these diagnoses psychological vulnerability was a risk factor
compared with those for other psychiatric for completed suicide. The authors argued
disorders. The final section of this chapter that personality traits was too narrow a con-
describes clinical approaches to patients at cept and that psychological vulnerabilities
risk for suicidal behavior who are uncommu- encompassed dysfunctional cognitions, be-
Assessing and Managing Suicide Risk 345
havior, and emotions. For example, hope- jective personality measure; however, the au-
lessness was examined as a form of psycho- thors found no support of the notion that
logical vulnerability, although it remains any MMPI item(s), scale or configural profile
unclear whether hopelessness is best consid- consistently differentiates suicidal from non-
ered a personality trait, an affect, or a part of suicidal patients (p. 178). Overall, Johnson
a psychiatric illness. et al. (1999) concluded there was little indica-
Reviewing databases from January 1966 tion of the utility for any single inventory,
to February 2000 and including only con- scale, or item in the prediction of long-term
structs found to be associated with suicide by suicide risk.
at least two independent teams, Conner et al. These two authoritative reviews expose
(2001) identified five dimensions: impulsiv- the limits of our current understanding of the
ity/aggression, depression, hopelessness, relationship between personality and sui-
anxiety, and self-consciousness/social disen- cide. However, research continues, and three
gagement. The proportion of significant find- personality characteristics are highlighted as
ings out of the studies testing the constructs uniquely related to suicidal behavior and as
did not differ significantly across the five di- principal areas for further study. Impulsive
mensions: impulsivity/aggression (14/20, aggressiveness has been shown to have a
70%); hopelessness (11/16, 69%); depression unique relationship to a history of suicidal
(13/22, 59%); anxiety (13/22, 59%); and self- behavior, and Mann et al. (1999) demon-
consciousness/social disengagement (18/24, strated that impulsive aggressiveness was
75%). Given the breadth of concepts identified more strongly associated with a history of
by their review, the authors concluded that suicide attempts than was the strength of
no single conceptual or empirically derived psychiatric symptomatology. In addition,
model of personality constructs (p. 371) was various biological research strategies have
sufficient to explain the relationship of psy- demonstrated that low serotonergic function
chological vulnerabilities to suicide. No such was specifically related to impulsive aggres-
comprehensive review was found relating siveness, providing evidence for the biologi-
personality traits and suicide attempts. cal bridge between suicide and personality
Johnson et al. (1999) reviewed the empir- traits (Mann et al. 1999).
ical literature to determine the value of objec- At the other extreme, the individual who
tive personality inventories for predicting as- appears perfectionistic and vulnerable to nar-
sessment of long-term suicide risk. The cissistic injury might be at risk for suicidal be-
authors searched PsychLit journal databases havior. Hewitt et al. (1998) demonstrated that
from January 1974 to March 1996 and re- perfectionism was significantly related to sui-
stricted their inquiry to self-reported inven- cide risk even after controlling for the level of
tories and reports on entire measures rather hopelessness and depression. In particular,
than focusing on subscales. The measures re- perceiving oneself as not meeting others ex-
viewed included the California Personality pectations was significantly related to in-
Inventory; Edwards Personal Preference creased suicide risk. Finally, emotional dys-
Schedule; Eysenck Personality Tests; Millon regulation, characterized as rapidly shifting
Clinical Multiaxial Inventory, versions IIII; mood states, has been theoretically and em-
Minnesota Multiphasic Personality Inven- pirically linked to suicidal behavior. Linehan
tory (MMPI), versions 1 and 2; Myers-Briggs (1993) hypothesized that emotional dysregu-
Type Indicator; 16 Personality Factors Test; lation in conjunction with an invalidating en-
Neuroticism, Extroversion, Openness Per- vironment explained the suicidal behavior
sonality Inventory; and the Personality Diag- characteristic of individuals with borderline
nostic Questionnaire. personality disorder (BPD). Fawcett et al.
Based on the review, the MMPI was con- (1990) found that depressive turmoil, defined
sidered the most empirically investigated ob- as rapid shifts from one dysphoric state to an-
other without persistence of one affect, was personality disorder (ASPD). When Mart-
significantly predictive of suicide in their co- tunen et al. (1994) examined adolescents
hort of individuals with major affective disor- with nonfatal suicidal behavior, approxi-
ders. Although emotional dysregulation mately 45% of males and one-third of fe-
should be a primary focus of research, the males were characterized by antisocial be-
precise definition of this characteristic re- havior. In other research, suicidal behavior
quires further refinement. Emotional dysreg- was found to be higher among adolescents
ulation is often subsumed within the concept with conduct disorders than in the compari-
of neuroticism; however, we have suggested son groups even after controlling for major
that emotional dysregulation or affective la- depression (Brent et al. 1993b). Beautrais et
bility might encompass four elements: cyclical. (1996) studied individuals who had made
ity, intensity, variability, or hyperreactivity of medically serious suicide attempts and com-
mood to external stimuli. Because suicidal be- pared them with community comparison
havior is undoubtedly multidetermined, subjects. After controlling for the intercorre-
complex modeling of various personality lations between mental disorders, these re-
characteristics with other distal and proximal searchers found the risk of a serious suicide
risk factors and utilizing multilevel analyses attempt was 3.7 times higher for individuals
will be required to explain suicide or suicidal with ASPD than for those without. When
behavior as the outcome. they examined men under age 30, the risk of
a serious suicide attempt was almost nine
times more likely among individuals with
EPIDEMIOLOGICAL EVIDENCE ASPD than among those without the disor-
der; for women, the risk of a serious suicide
Most of the evidence points to the relation- attempt was 2.3 times higher.
ship between antisocial and borderline per- A few studies have documented the life-
sonality disorders and suicidal behavior. time risk of suicide in samples of individuals
Therefore, we begin by reviewing the epide- with ASPD. Maddocks (1970), in a 5-year fol-
miological evidence for each of the Cluster B low-up of a small sample of 59 persons with
personality disorders. The more limited liter- the disorder, estimated a 5% lifetime risk of
ature related to Clusters A and C and sui- suicide. Laub and Vaillant (2000) examined
cidal behavior is reviewed according to the causes of death of 1,000 delinquent and non-
respective clusters rather than the individual delinquent boys followed up from ages 14 to
personality disorders. To organize the litera- 65 years. Deaths due to violent causes (acci-
ture, we discuss the rates of the various per- dent, suicide, or homicide) were significantly
sonality disorders in individuals who com- more common in delinquent compared with
pleted suicide or made suicide attempts. nondelinquent boys; however, equal propor-
Then we present the rates of suicide and sui- tions of both groups died by suicide.
cide attempts in samples of individuals with Patients with BPD represent 9%33% of
the various personality disorders. all suicides (Kullgren et al. 1986; Runeson and
Beskow 1991). Bongar et al. (1990) studied
Cluster B chronically suicidal patients with four or
more visits in a year to a psychiatric emer-
Studies have been done of the rates of per- gency department, and most often these pa-
sonality disorders in adolescents who died tients met criteria for BPD. These patients ac-
by suicide. Marttunen et al. (1991), from the counted for over 12% of all psychiatric
Comprehensive Psychological Autopsy emergency department visits during the year
Study in Finland, estimated that 17% of ado- studied. Crumley (1979) showed a high inci-
lescents ages 1319 who died by suicide met dence of BPD in adolescents and young
criteria for conduct disorder or antisocial adults age 1524 years who engaged in sui-
cidal behavior. Paris and Zweig-Frank (2001) traits were significantly more likely to have
indicated that this diagnosis significantly in- died by suicide compared with patients
creases the risk of eventual suicide. Depend- without the disorder or traits (14% versus
ing on the study, the lifetime risk of suicide 5%; P<0.02).
among patients with BPD patients is between Few studies have reported on the risk of
3% and 10% (Paris and Zweig-Frank 2001). suicide or suicide attempts in individuals
Those at highest risk appeared to be young, with histrionic personality disorder, and
ranging from adolescence into the third de- studies that do comment on the relationship
cade (Berman 1985; Friedman and Corn 1987; between this diagnosis and suicidal behavior
Stone 1990), which likely reflects a decrease in have rarely controlled for the presence of
severity of symptoms later in adulthood in BPD. Although histrionic personality disor-
the majority of patients (Crumley 1979; Stone der has been diagnosed in 1%17% of all
1990). The high rates of suicidal behavior in adult suicide attempters being assessed at
patients with BPD are reflected by, or some hospital emergency departments (Braun-
would say result from, the inclusion of recur- Scharm 1996; Dirks 1998; Ferreira de Castro
rent suicidal behavior, gestures, threats, or et al. 1998; Gupta and Trzepacz 1997; Markar
self-mutilating behavior as a diagnostic crite- et al. 1991; Soderberg 2001) as well as in 16%
rion in DSM-IV-TR. A history of suicidal be- of individuals forming a sample of adoles-
havior is found in 55%70% of individuals cent inpatient suicide attempters (Brent et al.
with a personality disorder (Casey 1989; Clar- 1993a), Ferreira de Castro et al. (1998) noted
kin et al. 1984; Gomez et al. 1992) and in 60% that histrionic personality disorder was the
78% of individuals with BPD (Gunderson most common personality disorder diagno-
1984; Kjellander et al. 1998). sis (22% of all subjects) in their sample, com-
Narcissistic personality disorder is an un- prising individuals who engaged in self-inju-
common diagnosis in community samples rious behavior but whose intention was not
compared with ASPD and BPD, and few data death. Other studies examining the connec-
exist regarding the risk of suicide in individ- tion between histrionic personality disorder
uals with this disorder. In samples of suicide and completed suicide include one by Har-
victims studied with the psychological au- wood et al. (2001), who observed that 4% of
topsy method, narcissistic personality is in- their sample of individuals over age 60 years
frequently identified. However, Apter et al. had the disorder. The prevalence of suicidal
(1993) studied 43 consecutive suicides by Is- tendencies in a sample of patients diagnosed
raeli males ages 1821 that occurred during with hysterical personality disorder, the
their compulsory military service. Psycho- ICD-9 equivalent of histrionic personality
logical autopsies were carried out using pre- disorder, has been found to be approxi-
induction assessment information, service mately 39% (Ahrens and Haug 1996).
records, and extensive postmortem inter-
views. Based on this methodology, the most Clusters A and C
common Axis II personality disorders were
schizoid personality in 16 of 43 (37.2%) and Epidemiological evidence for the risk of sui-
narcissistic personality in 10 of 43 (23.3%). cide or suicide attempts among individuals
Stones (1990) extensive follow-up study of with either Cluster A or Cluster C personality
550 patients admitted to the general clinical disorders is relatively scarce. Again, most
service of the New York State Psychiatric In- studies do not control for the possibility of co-
stitute provided some information on this existing BPD mediating the observed suicidal
outcome for individuals hospitalized with behavior in the subjects examined. Depend-
the diagnosis of narcissistic personality dis- ing on the study, the prevalence of Cluster A
order. According to the 15-year follow-up, or C personality disorders in adults present-
patients with the disorder or narcissistic ing to an emergency department following a
suicide attempt or self-injury ranges from 3% anxious, and anankastic personality disor-
to 5% for schizoid personality disorder ders. Analyzing data from the National Sui-
(Braun-Scharm 1996; Dirks 1998; Ferreira de cide Prevention Project in Finland, Isomets
Castro et al. 1998), 9% for schizotypal person- et al. (1996) determined that 1% of their sam-
ality disorder (Markar et al. 1991), 8%10% ple fulfilled criteria for paranoid personality
for paranoid personality disorder (Persson et disorder, 6% for avoidant personality disor-
al. 1999; Soderberg 2001) , 6%20% for der, 7% for dependent personality disorder,
avoidant personality disorder (Persson et al. 3% for obsessive-compulsive personality
1999; Soderberg 2001), 30% for anxious per- disorder, and 18% for Cluster C personality
sonality disorder (Dirks 1998), 1%9% for de- disorders not otherwise specified. Harwood
pendent personality disorder (Braun-Scharm et al. (2001) examined individuals over the
1996; Dirks 1998; Gupta and Trzepacz 1997), age of 60 whose deaths received a verdict of
6% for obsessive-compulsive personality dis- suicide and found that 4% of their sample
order (Soderberg 2001), and 13% for anankas- had had anankastic personality disorder
tic personality disorder (Dirks 1998). In their during their lifetimes. Finally, data from a
study of inpatient suicide attempters be- psychological autopsy study comprising 163
tween ages of 13 and 19 years, Brent et al. subjects revealed that Cluster A and Cluster
(1993a) reported that 27% fulfilled criteria for C personality disorders were associated with
any Cluster A personality disorder and 70% completed suicide (Schneider et al. 2006).
for any Cluster C personality disorder. How- Significantly higher frequencies of isolated
ever, only a diagnosis of BPD or any person- Cluster C personality disorders were also ob-
ality disorder was significant in this sample served among male but not female suicide
of adolescent suicide attempters when com- victims.
pared with a group of psychiatric nonsuicidal Studies have also reported on rates of at-
control subjects. tempted and completed suicides among in-
Similar to the studies just cited, Haw et al. dividuals diagnosed with personality disor-
(2001) reported on the prevalence of ICD-10 ders. Fenton et al. (1997) located patients
personality disorders among individuals ad- from the Chestnut Lodge Follow-Up Study
mitted to a British hospital following an epi- who were originally diagnosed with schizo-
sode of deliberate self-harm and diagnosed typal personality disorder and found that 3%
on follow-up approximately 1216 months had committed suicide, 24% had attempted
later. These researchers found that 5% of suicide, and 45% had expressed suicidal ide-
their sample fulfilled criteria for schizoid ation at some point during the previous
personality disorder, 15% for paranoid per- 19 years. Among patients admitted to the
sonality disorder, 21% for anxious personal- psychiatric department of a German hospital
ity disorder, 13% for dependent personality between 1981 and 1994 who were assigned a
disorder, and 20% for anankastic personality primary diagnosis of personality disorder
disorder. upon admission, Ahrens and Haug (1996)
Several studies have employed the psy- found that 44% of individuals diagnosed
chological autopsy method of retrospec- with schizoid personality disorder displayed
tively diagnosing personality disorders in suicidal tendencies, as did 47% of the pa-
completed suicides. Among individuals tients with paranoid personality disorder or
older than 23 whose deaths received a ver- anankastic personality disorder.
dict of suicide or unknown cause, Houston et
al. (2001) reported that 4% of the victims had Summary
a primary paranoid personality disorder, 4%
a primary anxious personality disorder, and Modestin et al. (1997) noted that suicidal be-
7% a primary anankastic personality disor- havior in women is independently corre-
der, whereas 4% had secondary paranoid, lated with each of the three personality dis-
order clusters, whereas suicidal behavior in key studiesthose employing carefully

men only correlates with the clusters as a characterized comparison groups and con-
group. Thus, although evidence suggests trolling for potential confounding factors.
that Cluster A and C personality disorders
are associated with the risk of suicide or sui- Comorbid Disorders
cide attempts, the relationship between
Cluster B personality disorders and suicidal The presence of two or more psychiatric dis-
behavior has been well documented and ap- orders appears to substantially increase the
pears to be more robust. suicide attempt rate compared with the pres-
ence of a single disorder, and comorbidity is
found to be higher in adolescents than in
RISK FACTORS FOR SUICIDE AND adults (Lewinsohn et al. 1995). Most of the re-
SUICIDAL BEHAVIOR search has been done with regard to BPD, and
the following studies indicate that certain
Many studies have identified factors at a specific comorbidities may increase the risk
population level that alone or in combination for suicidal behavior in patients with BPD.
increase the risk of suicide. Although extrap-
olating these risk factors to an individual al- Major Depressive Episode
lows for categorization of risk, it does little to
predict which individual will commit sui- Several studies have documented that the ex-
cide and when. The goal of a suicide assess- istence of depression plus BPD may confer an
ment is not to predict suicide, but rather to increased risk for suicidal behavior. In ado-
place a person along a putative risk contin- lescents, coexistence of disruptive behavior
uum, to appreciate the bases of suicidality, plus depression is felt to be a particularly
and to allow for a more informed interven- dangerous combination (McCracken et al.
tion (Jacobs et al. 1999; p. 4). Many risk fac- 1993). The most careful study of this combi-
tors are fixed (age, race, gender), providing nation was completed by Soloff et al. (2000).
little opportunity to intervene. However, They examined a well-characterized group of
several of the most significant risk factors are patients with BPD comorbid with major de-
modifiable. Forster and Wu (2002) captured pressive episodes and compared them with
the concept eloquently in the following state- subjects with BPD without a major depres-
ment, Suicide is almost always the cata- sive episode and with subjects with current
strophic result of inadequately treated psy- major depressive episode only. The number
chiatric illness (p. 105). Forster and Wu of lifetime suicide attempts significantly dif-
suggested concentrating on modifiable risk ferentiated the comorbid patients from the
factors. Therefore, the purpose of this review other two comparison groups, with a mean of
is to discuss risk factors that place patients 3.0 lifetime attempts among the comorbid
with personality disorders at a higher risk group versus 1.9 lifetime attempts for sub-
relative to other individuals with like disor- jects with pure BPD and 0.8 lifetime attempts
ders or place them at higher risk relative to for subjects with major depressive episodes
other times in the course of their illness. In only. Comorbid patients reported signifi-
addition, purportedly modifiable risk factors cantly higher levels of objective planning
are discussed because they might present op- based on the most serious lifetime attempt
portunities for interventions. By far, the ma- than the other comparison groups. Using re-
jority of the studies have focused on subjects gression analysis, the researchers demon-
with BPD, with little or no research on pa- strated that the number of lifetime attempts
tients with other personality disorders. This was predicted by BPD diagnosis and comor-
chapter reviews each of the major risk factors bidity, history of aggression, and the level of
and discusses, in some detail, findings from hopelessness. Overall, the patients with co-
morbidity demonstrated an increased risk for The baseline diagnosis of a drug use disorder
suicidal behavior, particularly with a higher and BPD was predictive of suicide attempts
number of lifetime attempts and evidence for during the follow-up interval; however, al-
more objective planning. The authors con- cohol use disorder did not significantly add
cluded that suicidal behavior in inpatients to the model once the BPD diagnosis was
with BPD should not be considered less se- entered. McGirr et al. (2007) demonstrated that
rious than the suicidal behavior of inpa- individuals with BPD who died by suicide
tients with a major depressive episode. In a were significantly more likely to have had al-
five-year prospective follow-up study, Soloff cohol dependence and Cluster B comorbidity
and Fabio (2008) found that comorbid major than living individuals with BPD. Evidence
depressive disorder increased the risk of sui- also indicates that comorbidity between
cide attempts in the first year of follow-up substance abuse disorder and conduct dis-
while poor social adjustment predicted in- order increases the risk for suicidal behav-
creased risk across the whole follow-up pe- ior in youth (Kelly et al. 2002 ; Marttunen et
riod. There is also some evidence to suggest al. 1991).
that major depressive disorder increases risk
of suicidal behavior among individuals with Recent Life Events
pure Cluster C personality disorders (Dervic
et al. 2007). Adverse life events may push high-risk pa-
tients into actual suicidal crises. Kelly et al.
Substance Abuse Disorder (2000) studied the impact of recent life events
and the level of social adjustment in patients
Comorbidity of substance abuse disorder with major depression, patients with BPD,
with BPD has also been found to be related to and patients comorbid for major depression
increased suicidal behavior (Runeson and Be- and BPD. Kelly et al. (2000) found that the sui-
skow 1991; Soloff et al. 1994). Links et al. cide attempters within this sample had expe-
(1995) examined the prognostic significance rienced more adverse life events recently,
of comorbid substance abuse in BPD patients. particularly in the area of stressful events at
These patients were followed prospectively home, either family or financially related. In
over a 7-year period. The researchers found addition, the total number of life events was
that patients comorbid for substance abuse related to increased risk of suicidal behavior.
and BPD perceived themselves at signifi- When the authors did a regression analysis to
cantly more risk for the likelihood of killing predict suicide attempter status, the diagno-
themselves than the comparison groups of sis of BPD was predictive, as was the level of
BPD patients without comorbidity, patients social adjustment in the family unit. How-
with substance abuse without BPD, and pa- ever, once these variables were accounted for
tients with borderline traits only. The comor- in the model, the level of recent life events
bid patients also demonstrated a more fre- was not predictive. Patients characterized by
quent pattern of self-mutilative behavior and the presence of low social adjustment and the
reported a more frequent pattern of suicide BPD diagnosis were found to be 16 times
threats and attempts than the noncomorbid more likely to be classified as suicide attempt-
patients. Yen et al. (2003) prospectively stud- ers than the patients with major depressive
ied the diagnostic predictors of suicide at- episodes. Heikkinen et al. (1997) similarly re-
tempts using the Collaborative Longitudinal ported that life events such as job problems,
Personality Disorders sample made up of family discord, financial trouble, unemploy-
four personality-disordered groupsschizo- ment, and interpersonal loss were more com-
typal, borderline, avoidant, and obsessive- mon among suicide victims with personality
compulsiveand a group with major depres- disorders than among suicide victims with-
sive disorder without personality disorder. out personality disorders. Interestingly, these
researchers also concluded that interpersonal a number of other selected risk factors into
and job-related or financial problems most the analysis. The severity of childhood sex-
closely preceded suicide among individuals ual abuse was associated with the severity of
with personality disorders. On the other comorbid depression in these patients, the
hand, rates of financial trouble and unem- presence of antisocial traits, and a trend to-
ployment among individuals with Cluster C ward greater hopelessness. Childhood sex-
personality disorders were found to be no ual abuse as a risk factor for suicidal behav-
different from rates for suicide victims with- ior may be mediated by these factors. Soloff
out a diagnosis of personality disorder. Rune- et al. (2002) indicated that patients with a his-
son and Beskow (1991) also found the num- tory of childhood sexual abuse had a 10-fold
ber of stressful life situations was related to greater risk of suicidal behavior versus those
death by suicide for adolescents with BPD patients without such a history.
versus others without BPD. These situations
included such things as unstable employ- Case Example
ment, financial problems, lack of a permanent
Ms. Y, a 28-year-old single female, pre-
residence, and a sentence by a court of law.
sented herself to the emergency depart-
Discharge from hospital should be con- ment complaining that she felt terrible.
sidered a stressful event. Kullgren (1988) I am close to overdosing, she ex-
found that patients with BPD were at some- plained. For the last 2 days, she had
what increased risk for suicide around the medicated herself by binging on co-
time of imminent discharge from hospital caine and alcohol. The patient was clear
and that suicides of such patients occurred about her distress. Two days prior to
presentation, her gynecologist had in-
during the period of inpatient care and in the
formed Ms. Y that she needed a hyster-
weeks following discharge. Kjelsberg et al. ectomy and that the surgery could not
(1991) noted that patients with BPD who be put off any longer. Although the pre-
died by suicide during or following hospital- cipitating events were plain, a more
ization were more frequently discharged af- complete picture emerged after the pa-
ter violating an in-hospital contract than tient was hospitalized. She and her col-
were the surviving borderline patients. leagues at work reported a 2-month his-
tory of declining work performance,
increasing depression with suicidal ide-
History of Childhood Abuse ation, and heightened irritability. Ms. Y
had not been under psychiatric care for
A history of childhood abuse needs to be
several years; however, she had a his-
mentioned because its association with sui- tory of three previous suicide attempts,
cidal behavior has been documented by sev- very stormy relationships, impulsivity
eral investigators (Dubo et al. 1997; Runeson including periodic binging on alcohol
and Beskow 1991; Stone 1990); however, it is and cocaine, and chronic feelings of
debatable whether childhood abuse is a dysphoria. Her previous therapist had
modifiable risk factor. Soloff et al. (2002) given her a diagnosis of BPD. During
her worst bout of depression, Ms. Y
completed a key study examining the rela-
carefully planned her first suicide at-
tionship between childhood abuse and sui- tempt. She acquired several months
cidal behavior in a sample of patients with worth of prescription tricyclic antide-
BPD. They found that suicidal behavior, in pressants and made arrangements to be
terms of the number of attempts, was pre- unavailable to her family for the week-
dicted by a history of childhood sexual end. While taking a hot bath, she in-
abuse, by the severity of BPD, and by the gested all of the pills and waited for her
outcome. Fortunately, her stomach was
level of hopelessness. In fact, childhood sex-
the first organ affected, and she became
ual abuse continued to predict the number of violently ill and unable to keep her
attempts independently, even after entering death potion down.
This case demonstrates the association be- denial of suicidal ideation does not negate the
tween major depression and BPD and how it risk of suicide. Duberstein and colleagues
can lead to heightened risk for suicide. The un- (Conner et al. 2001) found that individuals
derlying depression could have been missed if who committed suicide lacked an openness
the time had not been taken to elicit a careful to experience, and the authors connected this
history of the last few weeks and months lead- personality feature to the interpersonal pro-
ing to Ms. Ys presentation. Collateral sources cess of individuals who, when assessed, are
of information were extremely beneficial in less likely to feel and report feeling suicidal.
confirming the patients deteriorating mood. Fawcett et al. (1990) found that suicidal ide-
One should always look for the effects on func- ation was not predictive of suicide in the short
tioning that comorbid depression most often term, within 1 year of the assessment, but was
has on BPD patients. Although anger is part of related to suicide in the longer term. When
the BPD diagnosis, for this woman anger was questions related to suicidal ideation are de-
an indication of her comorbid depression. nied or not responded to, the clinician must
In summary, patients with ASPD or BPD judge the level of risk based on the inference
are likely to be at increased risk when they of all available risk and protective factors.
demonstrate the risk factors described. In In assessing the uncommunicative pa-
particular, patients with these disorders are tient, the clinician has to pay particular atten-
likely to be at increased risk when they dem- tion to the interview process. What is the pa-
onstrate a confluence of risk factors. The pres- tient communicating through his or her lack
ence of comorbidity, particularly when it is of verbal communication? For many uncom-
acutely evident, may lead high-risk patients municative patients, their failure to respond
into episodes of acute suicidal behavior. The expresses the lack of personal safety they feel
accumulation of recent life events and/or the during the assessment encounter. Creating
lack of intimate or family support also indi- some sense of safety may facilitate more ver-
cates times of high risk for these patients. If bal communication. For suicidal men, in par-
factors such as a history of childhood sexual ticular, the clinician must attend to the pro-
abuse and the associated psychopathological cess of the assessment interview. Suicidal
deficits, the level of hopelessness, or a history men may enter a clinical encounter with the
of impulsivity are modifiable based on clini- expectation that no help is available. There-
cal interventions, then potentially these inter- fore, from a single question or comment the
ventions could reduce the ongoing risk in patient may interpret the clinician as being
these patients. uninterested or dismissive, and the patient
will terminate his willingness to be frank and
truthful. The clinician must carefully attend
to such lapses in cooperation. Finally, the cli-
CLINICAL APPROACH TO THE nician should remember that uncooperative-
UNCOMMUNICATIVE PATIENT AND ness is a patient characteristic that is predic-
PATIENTS WITH ANTISOCIAL, tive of the need for hospitalization, and
sometimes this is the necessary outcome for
BORDERLINE, AND NARCISSISTIC
such patients.
Uncommunicative Patients Case Example
Mr. Z, an 18-year-old man called the
Uncommunicative patients are among the
Street Kid by the emergency staff, pre-
most difficult to assess for the risk of suicide. sented himself to hospital stating Im
The presence or absence of suicidal ideation suicidal. I dont feel safe. After utter-
should be elicited if possible. However, the ing those few words, the patient re-
mained mute and huddled in the corner tively. They need to be involved in encourag-
of the examination room. When I ening the patient to attend follow-up appoint-
tered the room, the patient was sitting ments. Family members or significant others
cross-legged on the stretcher with his
need to be educated to take action and re-
jacket hood covering almost all of his
face. In spite of the winter jacket, scars
move the patients access to means of sui-
from previous self-attacks were appar- cide; for example, disposing of firearms or
ent on his wrists, hands, and neck. large quantities of pills. Evidence has estab-
Im the docto r with the Crisis lished that simple educational interventions
Team. They asked me to speak with significantly increase the chances that fami-
you. You are feeling suicidal? No re- lies will remove access to means (Brent et al.
sponse. No acknowledgment at all. 2000; Kruesi et al. 1999).
Can you tell me your name and
In most cases when the patient is deemed
where youre living? No response.
Have you ever been to this hospi- a risk to him- or herself and will not provide
tal before? No response. Several ques- consent to speak to family or significant oth-
tions later, I stated the following: ers, the psychiatrist is well advised to atten-
Youre obviously not feeling safe uate confidentiality to the extent needed to
and not safe enough to speak with address the safety of the patient (see Ameri-
someone that you have never met be- can Psychiatric Association 2003). In the case
fore. Is there something I could do to
of Mr. Z, we were able to resolve some of the
make you feel safer while youre here in
the hospital? He made no response, al- miscommunication between himself and
though he moved his hooded head up Angela, which helped lessen his risk of
as if to catch a glance of my face. suicide. He became more cooperative and
Is there someone I could talk with agreed to a referral to a safe house. The safe
who knows about your problems and house was able to offer Mr. Z a nonmedical
can help me understand why youve community crisis bed for a few days to help
come to the hospital today?
resolve the situation.
Angela, at Streetview, knows why
Im here, the patient abrup tly re-
sponded. Patients With Antisocial
Is Angela a counselor at Street-
view?
Yea. She told me to get lost . . . so I
came here. Patients with ASPD or conduct disorder
That sounds pretty hurtful. Can present a unique challenge to the clinician.
you tell me more abou t what hap - When these patients present in crisis, the cli-
pened? nician is faced with the risk of assessing the
For Mr. Z, identifying his hurt feel- potential for violence in addition to the risk
ings allowed the interview to progress.
of suicide or suicidal behavior. For example,
The patient gave permission for the
psychiatrist to speak with his counse-
Marttunen et al. (1994) reported that 10 of
lors and the staff at Streetview. 23 patients with antisocial behavior had a
history of violence against others. In fact, all
For the immediate management of indi- of the patients that met criteria for conduct
viduals at risk for suicide, involvement of disorder or ASPD had had a history of vio-
significant others including family members lence. Clinicians need to carefully consider
is crucial. The patients primary care physi- interventions, such as hospitalization, based
cian or family doctor should be another re- on the potential risk to the patient versus the
source included in the aftercare plan. The risk this individual might represent to other
family members or significant others need to patients.
understand the likelihood of future suicidal Besides the usual factors involved in a
behavior to be able to monitor the risk effec- risk assessment, when the clinician is trying
to balance the risks to the patient versus oth- psychopaths. Physiological studies have
ers, the psychopathy concept can be clini- demonstrated that psychopathic individuals
cally of value. Cleckleys (1976) classic de- have reduced startle response when process-
scription of psychopathic personality disorder ing adverse stimuli (Herpertz et al. 2001;
described that these patients had a disincli- Patrick 1994). This deficit may indicate a tem-
nation toward suicide. Clinically, he ob- peramental difficulty in their capacity to re-
served that among ward patients, suicidal flect negative affect or to experience depres-
behavior was much rarer among psycho- sion or dysphoric states (Lovelace and
pathic patients than other patients. Cleckley Gannon 1999). Therefore, the psychopathic
wrote instead of a predilection for ending Factor 1 might assist the clinician deciding
their own lives, psychopaths, on the con- on the relative risk a patient presents for him-
trary, show much more evidence of a specific self or herself versus others. It appears that
and characteristic immunity for such an act patients demonstrating elements of the Fac-
(p. 359). tor 1 emotional detachment are more likely
Cleckleys clinical observation has had to be a risk to others than to themselves. In
some support from empirical research. Hare making particular decisions to admit such
(1991) developed the Psychopathy Check- patients to an inpatient psychiatric environ-
listRevised to capture the aspects of Cleck- ment, one must be careful to weigh the risks
leys psychopathic concept. Research has to vulnerable others versus the risk to the pa-
shown that the concept is composed of two tient him- or herself.
underlying dimensions. The first dimension,
called Factor 1 or emotional detachment, Patients With Borderline
includes the affective component of psych- Personality Disorder
opathy: the glibness, superficial charm, gran-
diose sense of self-worth, pathological lying, The clinical assessment of the BPD patient in
cunning and manipulativeness, lack of re- crisis is complicated. Often these patients
morse or guilt, shallow affect, callousness, have made multiple suicide attempts, and it
lack of empathy, and failure to accept respon- is unclear whether a short-term admission
sibility. Factor 2 relates to antisocial behavior; will have any impact on the ongoing risk of
in this factor, items such as a proneness to suicidal behavior. These patients typically
boredom, poor behavioral controls, early are at a chronically elevated risk of suicide
problematic behavior, lack of realistic long- much above that of the general population.
term goals, impulsivity, irresponsibility, ju- This risk exists because of a history of multi-
venile delinquency, and revocation of condi- ple attempts; in addition, these patients his-
tional release were found (Hare 1991). In a di- tory of self-injurious behavior also increases
rect examination of the relationship between the risk for suicide (Linehan 1993; Stanley et
the factors of psychopathy, ASPD, and sui- al. 2001). Stanley et al. (2001) found that pa-
cide risk, Verona et al. (2001) attempted to tients with self-injurious behavior were at
determine whether a suicidal history was risk for suicide attempts because of their
differently related to Factors 1 and 2. The au- high level of depression, hopelessness, and
thors found that suicidal history was signifi- impulsivity and also because they misper-
cantly related to Factor 2. However, Factor 1 ceive and underestimate the lethality of their
was negatively related to a history of suicidal suicidal behaviors. The patients level of
behavior, although this relationship was not chronic risk can be estimated by taking a
statistically significant. careful history of the previous suicidal be-
The mechanism by which Factor 1 might havior and focusing on the times when the
work to lessen the risk of suicide seems re- patient may have demonstrated attempts
lated to the emotional deficit found in some with the greatest intent and medical lethal-
ity. By documenting the patients most seri- cisions regarding interventions. For exam-
ous suicide attempt, one can estimate the se- ple, if a patient is felt to be at a chronic but not
verity of the patients ongoing chronic risk acute-on-chronic risk for suicide, one can
for suicide. document and communicate that a short-
In patients with BPD, the acute-on- term hospital admission will have little or no
chronic level of risk (i.e., the acute risk that impact on a chronic risk that has been present
occurs over and above the ongoing chronic for months and years. However, an inpatient
risk) is related to several factors. An acute- admission of a patient demonstrating an
on-chronic risk will be present if the patient acute-on-chronic risk might well be indi-
has comorbid major depression or if the pa- cated. In this circumstance, a short-term ad-
tient is demonstrating high levels of hope- mission may allow the level of risk to return
lessness or depressive symptoms, as re- to chronic preadmission levels. Managing
viewed earlier. The study by Yen et al. (2003) the chronic level of suicide risk in patients
supported the need to look for an acute-on- with BPD often involves strategic outpatient
chronic change in status; the authors demon- management such as dialectical behavior
strated that a worsening of depression or therapy, which has been shown to be effec-
substance use occurred in the month preced- tive in reducing suicidal behavior (Koerner
ing a suicide attempt relative to the general and Linehan 2000; Linehan 1993).
levels of change in all other months. In addi-
tion, patients with BPD are known to be at Patients With Narcissistic
risk for suicide around times of hospitaliza- Personality Disorder
tion and discharge. The clinical scenario of a
patient presenting in crisis shortly after dis- Assessing patients with narcissistic person-
charge from an inpatient setting illustrates a ality disorder for suicidal risk presents a
time when the risk assessment must be very unique clinical challenge. Ronningstam and
carefully completed to ensure that a proper Maltsberger (1998) thought-provokingly de-
disposition is made. This patient is poten- scribed how narcissistic patients can be at
tially at an acute-on-chronic risk and the as- risk for suicide at times when they are not de-
sessment cannot be truncated because of the pressed. Certainly, narcissistic patients will
recent discharge from hospital. Proximal be at increased risk during episodes of co-
substance abuse can increase the suicide risk morbid depression (Perry 1990). However,
in a patient with BPD. Of course, the exist- these patients present a unique clinical chal-
ence of a diagnosis of substance abuse in- lenge because they can become acutely sui-
creases the chronic risk for suicidal behavior. cidal outside of episodes of clinical depres-
The risk is acutely elevated in patients who sion. Suicide attempts in narcissistic patients
have less immediate family support or who can arise because of their very fragile self-
have lost or perceive the loss of an important esteem and in response to perceived narcis-
relationship. sistic injury. Ronningstam and Maltsberger
Gunderson (1984) made the distinction (1998) described that suicidal behavior can
that the BPD patient who is attempting to have several meanings in these patients, in-
manipulate the environment is at less risk cluding an attempt to raise self-esteem
than the BPD patient who presents in a through a sense of mastery; as a way to pro-
highly regressed dissociative state. At these tect themselves against anticipated narcissis-
times, interventions frequently have to be tic threatsdeath before dishonor; as a re-
put in place acutely to reduce the risk of sui- vengeful act against a narcissistic trauma; the
cide attempts or self-harm. Using the acute- false belief of indestructibility; and the ex-
on-chronic model can be very effective for pression of a wish to destroy or attack an im-
communicating in the medical record the de- perfect self. Narcissistic individuals, there-
fore, can demonstrate a Richard Corey refuse to respond to questions regarding sui-
suicidethat is, like the title character in cidal ideation or intent, the assessment needs
the poem by Edwin Arlington Robinson, to be carefully based on the balance of other
they are individuals who take their lives in risk and protective factors. For the ASPD pa-
spite of seeming to have every happiness and tient, the risk of violence has to be judged in
good fortune. addition to the risk of suicide or self-harm.
The clinician can take four steps to mon- For BPD patients, one has to differentiate an
itor the risk of suicide and suicidal behavior acute from chronic risk and determine inter-
in patients with narcissistic personality dis- ventions based on this approach. Finally, pa-
order. First, the patient should be routinely tients with narcissistic personality disorder
monitored for evidence of coexisting major can be at high risk of suicide outside of times
depression or for an acute episode of low- of clinical depression. These episodes can
ered self-esteem resulting from a felt narcis- seem to arise in an unpredictable fashion.
sistic injury. Because suicide attempts in nar- This chapter provides some clinical ap-
cissistic individuals tend to arise abruptly, proaches to the assessment of these patients.
the risk can be lessened by preventing the pa- However, in the future we hope that empiri-
tient from having access to a means of sui- cal evidence will provide a more sound foot-
cide. Therefore, attention should be paid to ing for assessing and managing suicide risk
ensure the patient has no access to highly le- in patients with antisocial, borderline, narcis-
thal means of suicide such as guns or large sistic, and other personality disorders.
quantities of pills. The patients family and
other significant supports should be aware of
the potential for an acute onset of suicidal
feelings and the need to avoid access to lethal
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19
Substance Abuse
Roel Verheul, Ph.D.
Louisa M.C. van den Bosch, Ph.D.
Samuel A. Ball, Ph.D.
S ince the introduction of DSM-III in 1980, stance abuse is rarely given any coverage.
there has been a growing interest in the study Several reasons might account for this. First,
of personality disorder comorbidity among the field of personality disorder research
patients with substance use disorders (Amer- started relatively recently in the 1980s,
ican Psychiatric Association 1980). The driv- whereas the field of addiction has long recog-
ing force behind this interest has been and nized the interconnection with personality
still is the difficult clinical management of dysfunctionif for no other reason than be-
these dual-diagnosis patients as well as their cause the first two editions of DSM embed-
high comorbidity. Although the evaluation ded alcohol and drug addiction under soci-
of co-occurring personality disorders has opathy. Second, institutes and therapists
been the subject of countless studies by ad- specializing in the treatment of personality
diction researchers, very little attention is disorder, particularly out of a psychodynamic
paid by personality disorder researchers to tradition, traditionally excluded patients
the co-occurrence of substance abuse. This with comorbid substance abuse from pro-
state of affairs is difficult to understand when grams because they were considered to have
one considers that substance abuse and per- little potential for change, could not be ana-
sonality disorders are far and away the most lyzed, and were at high risk for dropout. Fi-
common form of dual diagnosis. In most per- nally, funding possibilities for personality
sonality disorder books, the topic of sub- disorder research has been limited, at least
361
when compared with funding for research on joint comorbidity is evident for ASPD and
Axis I. Thus, the major part of personality BPD and perhaps paranoid and avoidant
disorder studies has actually been conducted personality disorders.
in samples of patients referred for treatment Reported prevalence rates of personality
of Axis I disorders such as substance abuse. disorders in nonpatient samples of individu-
An inevitable consequence of this situa- als with substance use disorder are at least
tion is that this chapter is mostly based on three times higher than in normal individu-
studies focusing on the occurrence and im- als (i.e., those without mental disorders in-
plications of personality disorder in patients cluding substance use disorder) (Verheul et
with substance use disorder. In addition, eval. 1998a). The interpretation of these comor-
idence from the literature on (normal) per- bidity figures is hampered because little
sonality traits will be borrowed whenever knowledge is available about the extent to
informative. The primary focus in this chap- which a high personality disorder preva-
ter is on causal pathways and treatment is- lence among individuals with substance use
sues, supplemented by some attention to ep- disorder is attributable to conceptually over-
idemiology and diagnostic issues. lapping diagnostic criteria and measurement
issues such as trait-state artifacts. Clearly
overlapping criteria seem to be restricted to
EPIDEMIOLOGY only a few of the criteria for ASPD and BPD.
The possibility of trait-state artifacts in pa-
Substance abuse is highly prevalent among tients with substance use disorder is dis-
individuals with personality disorders. For cussed later.
example, in a nonpatient sample, the lifetime
prevalence of alcohol use disorders was
found to range from 43% to 77% among pa- ASSESSMENT AND DIAGNOSIS
tients with various personality disorders
(Zimmerman and Coryell 1989). In a sample Semistructured interviews and self-report
of more than 500 patients, Zanarini et al. questionnaires for the assessment of DSM-IV
(1998) reported substance use disorder to be (American Psychiatric Association 1994) per-
prevalent in 64% of patients with borderline sonality disorders provide diagnoses with
personality disorder (BPD) and in 54% of pa- reliability that is comparable with diagnoses
tients with other personality disorders. of Axis I disorders obtained using standard-
A much larger number of studies has ized procedures (Ball et al. 2001). There is
investigated prevalence of personality dis- some consensus that self-reports overdiag-
orders among patients with substance use nose personality disorders. This tendency
disorder. Verheul et al. (1995, 1998a) have might be especially relevant in patients with
provided the most comprehensive overview substance use disorder, because these instru-
to date. The best estimate of personality dis- ments do not ask respondents to differentiate
order prevalence ranged from 44% among al- personality traits from the effects of sub-
coholic patients to 79% among opiate abus- stance abuse or other prolonged changes in
ers. The two most prevalent personality mental status. Thus, diagnostic interviews
disorders among patients with substance use may have greater specificity because ques-
disorder are antisocial personality disorder tions and answers can be clarified to tease
(ASPD) and BPD, with reported best esti- out whether a symptom is chronic and per-
mates of 22% for ASPD and 18% for BPD. vasive, more situation-specific, or related to
Other personality disorders are usually prev- substance abuse. Further clinical inquiry can
alent among patients with substance use dis- also determine whether other behavioral ex-
order in the range of 1%10%. Thus high amples of the trait exist that are not specifi-
Substance Abuse 363
cally related to substance abuse. An inter- only a limited impact on the diagnosis of sec-
view also provides important behavioral ondary personality disorder.
observations of the patients interpersonal Intuitively, one might suggest that ex-
style that may inform clinical judgment cluding substance-related symptoms (at
(Zimmerman 1994). Some studies have least following the less stringent strategy)
shown promising findings in favor of the va- would result in more valid diagnoses. Diag-
lidity of personality disorder diagnoses in nosing personality disorders independent of
substance abusers obtained using a semi- substance use disorder is consistent with
structured interview schedule. First, Skodol guidelines suggested by DSM-IV-TR (Amer-
et al. (1999) reported similar prevalence rates ican Psychiatric Association 2000). However,
of personality disorders among patients with the task of differentiating substance-related
a current substance use disorder and patients symptoms from personality traits is not easy
with a lifetime substance use disorder. Sec- for patients or clinical interviewers and thus
ond, in a sample of 273 patients with sub- may not be reliable. This task becomes al-
stance use disorder, remission of the disor- most impossible when the patients entire
der was not significantly associated with adolescent and adult life is characterized by
remission of personality pathology, suggest- chronic abuse of substances. Furthermore, al-
ing that the two conditions follow an inde- though most patients with substance use dis-
pendent course (Verheul et al. 2000). order can distinguish behaviors that are only
Part of the reliability and validity issue related to substance intoxication or with-
for personality disorder diagnosis in patients drawal, they have greater difficulty making
with substance use disorder centers on the same distinction for other activities, such
whether to include or exclude personality as lying or breaking the law, that may be re-
disorder symptoms that seem to be sub- lated to obtaining substances. Such a distinc-
stance related (i.e., behaviors directly related tion requires a high level of introspection and
to intoxication and/or withdrawal or other cognitive competence in making the judg-
behaviors required to maintain an addic- ment necessary to differentiate a trait from a
tion). The magnitude of the effect of exclu- situation or state. It also requires an empathic
sion on the prevalence estimate seems partly awareness of the impact of ones behavior on
attributable to the strategy used for exclu- self and others and a willingness to accept re-
sion. Measures with more stringent criteria sponsibility for ones actions (Zimmerman
exclude any symptom that has ever been 1994).
linked to substance abuse and yield signifi- Patients with substance use disorder may
cantly reduced rates. Measures that exclude be particularly impaired in the skills neces-
symptoms only if they were completely ab- sary to make these distinctions. Consistent
sent before substance abuse or during peri- with this view, Rounsaville et al. (1998)
ods of extended abstinence show minimal ef- found that excluding substance-related
fects on rates. It is important to realize that symptoms reduced the reliability of ASPD
the more stringent strategy will probably ex- diagnoses (but not of BPD diagnoses). Fur-
clude all secondary personality pathology thermore, they found that patients with inde-
and may even exclude primary personality pendent diagnoses had a rather similar clin-
pathology. The less stringent strategy is ical profile compared with patients with
meant to exclude behaviors and/or symp- substance-related diagnoses, thereby ques-
toms that do not persist beyond periods of tioning the feasibility and clinical utility of
abuse and do not qualify for a personality exclusion. If one chooses to exclude sub-
disorder diagnosis. Consequently, the less stance-related symptoms from the measure-
stringent approach will probably not exclude ment of any personality disorder, several
primary personality pathology and will have considerations are in order:
It is probably more reliable to determine empirical attention. Bernstein and Handels-

whether a symptom should be eliminated man (1995) tentatively proposed three mech-
as substance related on an item-by-item anisms: 1) substance abuse often occurs
basis and not wait until the end of the in- within the context of a deviant peer group,
terview or until all items relating to a spe- and antisocial behaviors might be shaped
cific disorder are administered. and reinforced by social group norms (social
Criteria in which substance dependence is learning hypothesis); 2) some Cluster A traits
an inherent part should be scored as due (e.g., suspiciousness, eccentric behaviors,
to substance abuse unless non-substance- ideas of reference, magical thinking), Cluster
related behavioral indicators of the trait B traits (e.g., exploitativeness, egocentrism,
(e.g., impulsivity, unlawful behaviors) are manipulativeness), and Cluster C traits (e.g.,
also present. passivity, social avoidance) may be shaped
The interviewer should periodically re- and maintained by the reinforcing and condi-
mind patients that questions refer to the tioning properties of psychoactive substances
way the patients usually arethat is, when (behavioristic learning hypothesis); and
they are not symptomatic with either sub- 3) chronic substance abuse or withdrawal
stance abuse or another Axis I disorder. may alter personality through neuroadaptive
changes or a direct effect on brain chemistry
(neuropharmacological hypothesis).
CAUSAL PATHWAYS As Bernstein and Handelsman (1995)
pointed out, it is unclear to what extent these
High (joint) comorbidity that cannot be ex- effects can overwrite or interact with pre-
plained by conceptual or measurement arti- existing personality patterns to form new
facts strongly suggests that the co-occurrence personality configurations. Considering the
of substance use disorder and personality dis- primary substance use disorder model, it is
orders is not due solely to random or coinci- important to distinguish new enduring per-
dental factors. It seems reasonable to explore sonality patterns from temporary behavior
the assertion that substance use and personal- patterns that disappear with reductions of
ity disorders are in some way causally linked. substance use. The latter should not be taken
Evidence for causal relationships between into account for a diagnosis of personality
substance use and personality disorders can disorder. According to DSM-IV-TR, it is only
be derived from long-term longitudinal stud- when the consequences of substance abuse
ies, epidemiological findings, genetic epide- persist beyond the period of alcohol and/or
miology, and retrospective studies that ac- drug consumption that these features consti-
count for the order of onset of each disorder. tute personality pathology. To the best of our
Three superordinate meta-models of comor- knowledge, there are currently no studies
bidity can be distinguished: the primary sub- yielding substantive evidence in favor of the
stance use disorder model, the primary per- primary substance use disorder model; on
sonality disorder model, and the common the contrary, some indirect evidence refutes
factor model. the model. For example, personality disorder
diagnoses in adults with alcoholism have
been found to be associated with maladjust-
Primary Substance Use
ment in childhood, even after partialling out
Disorder Model the current and cumulative effects of sub-
The primary substance use disorder model stance use (Bernstein et al. 1998; Morgen-
postulates that substance abuse contributes stern et al. 1997).
to the development of personality pathology. In summary, there is currently no direct
This pathway has received relatively little evidence supporting the primary substance
Substance Abuse 365
use disorder model, and there is some indi- that teachers ratings of low constraint, low
rect evidence against the model. However, it harm avoidance, lack of social conformity,
would be premature to fully preclude the unconventionality, antisociality, and aggres-
possibility that some symptoms in some indi- sion in children, particularly boys, predicted
vidual patients with substance use disorder alcohol and drug abuse in adolescence and
are shaped and maintained by the reinforcing young adulthood (Caspi et al. 1997; Cloninger
and conditioning properties of psychoactive et al. 1988; Krueger et al. 1996; Masse and
substances. Tremblay 1997). The same pattern was ob-
served in university students (Sher et al.
Primary Personality 2000). More direct evidence can be derived
from a study by Cohen et al. (2007), which
Disorder Model
found that personality disorders, especially
The primary personality disorder model de- those from Cluster B, were diagnosed on av-
scribes comorbid relationships in which erage for patients age 13 years to be highly
(pathological) personality traits contribute to predictive of diagnoses and symptoms of
the development of substance use disorder. substance use disorders and their effects were
Since the 1990s, many studies have yielded independent of correlated family risks, partic-
empirical support for this model. It has been ipant sex, and other Axis I disorders. Third,
proposed that the available evidence sug- Bahlman et al. (2002) found that the onset of
gests at least two or three different develop- ASPD characteristics preceded that of alcohol
mental pathways from personality to addic- dependence by approximately 4 years. The
tion (Finn et al. 2000; Verheul and van den relationship between behavioral disinhibition
Brink 2000). These pathways have been de- and early-onset addictive behaviors is proba-
fined as the behavioral disinhibition path- bly mediated through deficient socialization,
way, the stress reduction pathway, and the school failure, and affiliation with deviant
reward sensitivity pathway. peers (Sher and Trull 1994; Tarter and Van-
yukov 1994; Wills et al. 1998). The behavioral
Behavioral Disinhibition Pathway disinhibition pathway is associated with an
early onset of drinking, a more rapid develop-
The behavioral disinhibition pathway to sub- ment of alcohol dependence once drinking
stance abuse predicts that individuals scoring begins, and more severe symptoms than
high on traits such as antisociality and impul- nonantisocial subjects (Verheul et al. 1998a).
sivity and low on constraint or conscientious-
ness have lower thresholds for deviant behav- Stress Reduction Pathway
iors such as alcohol and drug abuse. This
pathway might account for the association of The stress reduction pathway to substance
ASPD and, to some extent, BPD with sub- abuse predicts that individuals scoring high
stance abuse. Of the three proposed path- on traits such as stress reactivity, anxiety sen-
ways, this one is the best documented. First, sitivity, and neuroticism are vulnerable to
high relative comorbidity is observed be- stressful life events. This pathway might ac-
tween substance use disorder and Axis I and count for the comorbidity of borderline,
Axis II disorders from the impulse control avoidant, dependent, and schizotypal per-
spectrum. For example, in a large sample re- sonality disorders. These individuals typi-
cruited from the general population, individ- cally respond to stress with anxiety and
uals with substance use disorder were 17.2 mood instability, which in turn can become a
times more likely to have ASPD than those motive for substance use as self-medication.
without (Zimmerman and Coryell 1989). Sec- Longitudinal studies have shown that teach-
ond, several longitudinal studies have shown ers ratings of negative emotionality, stress
reactivity, and low harm avoidance in chil- family histories of alcoholism demonstrated
dren predicted substance abuse in adoles- elevated resting heart rates (index of psycho-
cence and young adulthood (Caspi et al. 1997; stimulation) in response to alcohol intake,
Cloninger et al. 1988; Wills et al. 1998). Fur- suggesting that this pathway partly mediates
thermore, Conrod et al. (1998) showed that the role of genetic vulnerability in the etiol-
coping motives for drinking as well as the ogy of alcoholism.
fear-dampening properties of alcohol were
far more pronounced among men scoring Common Factor Model
high on anxiety sensitivity than among their
The common factor model assumes that both
low-scoring counterparts. The self-medica-
personality pathology and substance abuse
tion pathway, which has most frequently
are linked to an independent third factor that
been investigated for alcoholism, typically
contributes to the development of both dis-
accounts for late-onset alcohol use disorders
orders. This model is more likely for person-
and is more prevalent among women than
ality disorders that show relatively high joint
among men.
comorbidity, such as ASPD and BPD. This
hypothesis is consistent with a psychobio-
Reward Sensitivity Pathway logical perspective on personality disorders
The reward sensitivity pathway predicts that suggesting that BPD and ASPD are phenom-
individuals scoring high on traits such as enologically, genetically, and/or biologically
novelty seeking, reward seeking, extraver- related to Axis I impulse disorders such as
sion, and gregariousness will be motivated to substance abuse (Siever and Davis 1991; Za-
substance use for its positive reinforcing narini 1993).
properties. This pathway might account for Family, twin, and adoption studies are
the comorbidity of antisocial, histrionic, and generally considered most appropriate to
narcissistic personality disorder. Consistent evaluate whether a common risk factor is
with this hypothesis, some longitudinal stud- transmitted genetically or otherwise. Evi-
ies (Cloninger et al. 1988; Masse and Trem- dence from several adoption studies suggests
blay 1997; Wills et al. 1998) have shown that that alcoholism and ASPD are genetically
novelty seeking as a temperamental trait in separate disorders (Cadoret et al. 1985). Fur-
childhood predicts later substance use prob- thermore, Loranger and Tulis (1985) reported
lems. Furthermore, some evidence suggests that family members of patients with BPD
that students scores of extraversion, at least were at greater risk for alcoholism than those
among those without a family history of alco- of schizophrenic or bipolar-affective patients,
holism, predict alcohol dependence at age but when patients were further subdivided
30 years (Schuckit et al. 1994). As observed in based on their own level of alcohol consump-
animal studies, hyperresponsiveness to the tion, family risk differences for alcoholism al-
positive reinforcing or rewarding effects of most disappeared. A study by Fu et al. (2002)
substances is partly accounted for by the sen- reported that the shared genetic risk between
sitization processes initiated by the repetitive major depression and alcohol and marijuana
use of the substances themselves (Robinson dependence was largely explained by genetic
and Berridge 1993) and to that extent is not effects on ASPD, which in turn was associ-
precipitated by premorbid personality fac- ated with increased risk of each of the other
tors. However, this hyperresponsiveness or disorders. These data presented no evidence
hypersensitivity might develop most strongly for cross-transmission of pure forms and no
among individuals characterized by a more support for the shared-etiology model. How-
general sensitivity to positive reinforcements ever, the available studies do not preclude the
(Zuckerman 1999). Conrod et al. (1998) dem- possibility of common factors that, for exam-
onstrated that men with multigenerational ple, are less specific to ASPD. For example,
Substance Abuse 367
Slutske et al. (2002) reported that genetic in- ditions for aggressive suicide attempts. Si-
fluences contributing to variation in behav- multaneously, the patient may get entangled
ioral undercontrol accounted for about 40% with a deviant peer group, leading to both in-
of the genetic variation in alcohol depen- creased antisocial behavior and additional
dence and conduct disorder risk and about substance abuse.
90% of the common genetic risk for alcohol
dependence and conduct disorder. This and
other studies (e.g., Krueger et al. 2002) sug- TREATMENT OUTCOME
gest that genetic factors contributing to vari-
ation in dimensions of personality, particu- Outcomes of Treatments
larly behavioral undercontrol or impulsivity, Focusing on Substance Abuse
account for a substantial proportion of the ge-
netic diathesis for alcohol dependence and Personality pathology has been found to be
most of the common genetic diathesis for al- significantly related to poor treatment re-
cohol dependence and conduct disorder sponse and outcome in patients with affec-
among men and women. tive and anxiety disorders (Reich and Vasile
Another approach in the search for com- 1993). In the early 1990s it was generally be-
mon factors has relied on high-risk strategies, lieved that the same applied to patients with
with the aim of identifying markers of bio- substance abuse. However, the available
logical vulnerability for both conditions. Jus- studies at the time had many methodological
tus et al. (2001) found that a reduced ampli- and interpretative problems, making it diffi-
tude of the P300 component of the scalp- cult to draw conclusions. Consequently, it
recorded event-related brain potential in men was often unclear whether the reported ef-
is strongly associated with a general ten- fects on outcome were attributable to a poor
dency toward antisocial, defiant, and impul- treatment response of comorbid patients or
sive traits, which in turn increase the risk for to differences in pretreatment characteristics.
alcohol abuse. Furthermore, some reviewers Several studies published later on showed
(Bernstein and Handelsman 1995; Siever and convincingly that personality pathology is
Davis 1991) have concluded that abnormali- associated with pre- and posttreatment prob-
ties in serotonergic function may form a bio- lem severity but is not a robust predictor of
logical substrate underlying both substance the amount of improvement (e.g., Cacciola et
abuse and impulsive/aggressive behavior. al. 1995, 1996; Verheul et al. 1999). Further-
more, some studies showed that Axis II co-
morbidity is not associated with premature
Comment drop-out or a shorter time-in-program
It is important to note that the different meta- (Kokkevi et al. 1998; Marlowe et al. 1997; Ver-
models are not necessarily mutually exclu- heul et al. 1998b), nor with less motivation to
sive. In any individual case, more than one change (Verheul et al. 1998b) or outcomes in
model may have explanatory value. Further- pharmacotherapy (Ralevski et al. 2007). In
more, it is possible that one model best de- the late 1990s, some authors concluded that
scribes the initiation of a comorbid disorder, the available studies did not allow any firm
whereas another describes long-term main- conclusions about the prognosis of patients
tenance of the same comorbid association. with both substance use disorder and per-
For example, a borderline patient may use sonality disorders. This conclusion from em-
stimulants to reduce feelings of boredom pirical studies was in sharp contrast to clini-
and use alcohol to regulate affective insta- cal experiences and knowledge.
bility. After a while, the patient becomes A number of other studies have yielded
addicted to both substances, which in turn results that provide somewhat more clarity.
aggravates the impulsivity and sets the con- For example, two studies showed that per-
sonality disorders predict a shorter time to and Axis II psychopathology was the best
relapse after discharge (Thomas et al. 1999), predictor of a return to substance use at
even when controlling for the baseline sever- 1 year posttreatment compared with those
ity of alcohol problems (Verheul et al. 1998b). factors alone.
Thus it seems that an equal amount of im- An alternative explanation of the avail-
provement does not resemble a similar risk able data that seems to refute common clini-
of relapse. A possible explanation for this ap- cal knowledge with respect to the prognosis
parent discrepancy is that patients without of ASPD is that the disorder s criteria set
personality pathology improve to a level of identifies a heterogeneous group of patients
problem severity that no longer leaves them that includes both individuals with only an-
at risk for relapse, whereas patients with per- tisocial behaviors and individuals with both
sonality pathology are at risk for relapse de- antisocial and psychopathic personality
spite their improvement. Other studies fo- traits, such as shallow affect, grandiosity, and
cused on normal personality traits and lack of empathy and remorse. The latter
reported that low persistence (Cannon et al. group might be particularly at risk of poor
1997; Janowsky et al. 1999; Sellman et al. treatment response and outcome. Consistent
1997) and high novelty seeking (Meszaros et with this view, Woody et al. (1985) have
al. 1999) are strong predictors of time to re- shown that opiate addicts with ASPD and a
lapse. Finally, it was found that high neurot- lifetime diagnosis of major depression were
icism and low conscientiousness predicted able to benefit about as much from individ-
the time to relapse after discharge and that ual psychotherapy as patients without
the combination of these two features was as- ASPD. This finding is in comparison with
sociated with the highest odds of relapse pure ASPD subjects, who experienced
(Fischer et al. 1998). very little benefit from psychotherapy. An-
Early studies typically examined the im- other interesting study found that antisocial
pact of personality pathology separately patients who were able to form a working al-
from other patient characteristics, although liance with their therapists had better treat-
this approach might have failed to identify ment response and outcome at follow-up
possible interactions with other important than did antisocial patients who lacked this
characteristics. For example, one study ex- ability (Gerstley et al. 1989).
amined motivation for change and time in
program as potential moderators and medi- Outcomes of Treatments
ators of the relationship between personality
Focusing on Personality Disorder
disorders and relapse (Verheul et al. 1998b).
It appeared that although motivation for Little is known about the impact of substance
change was unrelated to personality pathol- abuse on outcome for patients in treatment
ogy, it moderated the relationship between for personality problems; as noted earlier,
personality disorders and relapse so that per- this neglect in literature might be accounted
sonality pathology was a strong predictor of for by the exclusion of dual-diagnosis pa-
relapse among less motivated individuals tients from the treatment system. A similar
but not among their more motivated coun- phenomenon can also be observed in re-
terparts. In addition, two studies suggest search. For example, patients with substance
that personality pathology interferes with use disorder are often excluded from studies
the patienttherapist working alliance, examining the efficacy of treatments de-
thereby resulting in poorer outcomes or a signed to target borderline symptoms. The
higher risk for relapse (Gerstley et al. 1989; exclusion from research is often justified as a
Verheul et al. 1998b). Finally, Pettinati et al. strategy to preserve the homogeneity in co-
(1999) found that the combination of Axis I horts. This differential approach illustrates
Substance Abuse 369
the limitations specific to a mental health done maintenance patients comparing DFST
system and a research policy oriented to- with 12-step facilitation therapy (Ball 2007).
ward the treatment of single rather than mul- Patients met criteria for an average of 3.3 per-
tiple disorders (Ridgely et al. 1990). sonality disorders, with ASPD present in
To the best of our knowledge, only one over 70% and BPD and avoidant personality
study has investigated the impact of sub- disorder present in over 50% of the cases. Pa-
stance abuse on the outcome of a treatment tients assigned to DFST reduced substance
focusing on personality disorders. In their use frequency more rapidly over the 24-week
randomized trial of dialectical behavior ther- treatment than did patients assigned to 12-
apy (DBT) among Dutch women with BPD, step facilitation therapy. Further inspection
Verheul et al. (2003) found no differences in of the data suggested that a difference began
effectiveness for patients with versus those to emerge at month 3, which corresponds to a
without substance use problems. This finding point in the manual at which the treatment
is in obvious contrast with the tradition de- shifts from an assessment and education fo-
scribed earlier. Furthermore, studies of the ef- cus to an active change focus. Furthermore,
ficacy of mentalization-based treatment DFST patients reported an increase from a
(MBT) for severe BPD have typically in- good early therapeutic alliance to a very
cluded a large number of comorbid substance strong alliance over the subsequent months
use disorders and have shown extremely fa- of treatment, whereas the 12-step facilitation
vorable outcomes (Bateman and Fonagy patients demonstrated no such increase.
2001), including in the long run (Bateman and Consistent with this finding, DFST therapists
Fonagy 2008). MBT seems to be among the reported feeling as though they had a stron-
few promising programs for the treatment of ger working alliance with patients than did
comorbidity between severe BPD and sub- 12-step facilitation therapists.
stance use disorder. In a second randomized clinical trial, Ball
et al. (2005) evaluated the treatment retention
Outcomes of Dual-Focus and utilization of 52 individuals with per-
Treatments sonality disorders who abused substances
receiving services within a drop-in center for
Two psychotherapies developed for the
the homeless. Participants were randomly
treatment of personality disordersschema-
assigned either to receive DFST or a standard
focused therapy and DBThave been modi-
drug counseling group sessions for 24 weeks,
fied to meet the specific needs of dual-diag-
both delivered on-site as enhancements to
nosis patients.
case management services. Results indicated
superior utilization of DFST over drug coun-
Dual-Focus Schema Therapy
seling for participants overall. However, fur-
The only documented integrated dual-focus ther analyses of separate Cluster A, Cluster
treatment for the broad range of personality B, and Cluster C symptoms scores favored
disorders is dual-focus schema therapy drug counseling over DFST for therapy utili-
(DFST), developed by Ball and Young (Ball zation by more severe Cluster A and C cli-
1998; Ball and Young 2000). DFST is a 24- ents. Thus, the two published randomized
week, manual-guided individual therapy in- trials of DFST suggest this is a promising ap-
cluding both symptom-focused relapse pre- proach, but one that needs further research
vention and coping skills techniques and with larger samples to determine what types
schema-focused techniques for maladaptive of patients with personality disorder do well
schemas and coping styles. Some prelimi- with this integrative model and what types
nary empirical support can be derived from a do well (or better) with a single-focus addic-
randomized pilot study among 30 metha- tion treatment.
Case Example coping behaviors that perpetuated this

schema, including expecting too much
Mr. AA was a 36-year-old divorced of himself and others and being a per-
male whose primary personality disor- fectionistic workaholic. At other times,
der diagnosis was obsessive-compul- he sought relief from the pressures of
sive personality disorder. In addition to these standards and would avoid occu-
symptoms of depression, obsessive pational or social commitments, de-
thoughts, compulsive behavior, and velop somatic symptoms, procrastinate,
paranoid ideation, he had interpersonal or give up on himself and use drugs
problems related to being both exploit- when he could not get things to be per-
able and domineering as well as vindic- fect. These avoidance strategies actually
tive. He began using substances at the reinforced his high standards even
age of 14, had several prior substance more because he would subsequently
abuse treatments, and had been on have to redouble his efforts to get de-
methadone for 1 year before starting in- sired outcomes.
dividual therapy. His heroin depen- Mr. AA began therapy in a loud,
dence was in remission (on agonist challenging manner, wanting to know
medication), and his primary drug for sure that therapy was going to help
abuse problem was cocaine, with more him and that he was going to get as
sporadic use of a high-potency solvent much out of it as we got out of him as a
to which his part-time job gave him research participant. Because he contin-
ready accessibility. Mr. AA also met cri- ued to abuse cocaine and inhalants for
teria for ASPD. This diagnosis does not the first 3 months, therapy necessarily
frequently co-occur with obsessive- remained more relapse-prevention fo-
compulsive personality disorder; how- cused while he struggled to grasp cog-
ever, it w as difficult to determine nitively any of the schema-focused psy-
whether the ASPD diagnosis was inde- choeducational material. By month 4,
pendent of substance abuse given the he had achieved complete abstinence
very early age at onset and persistent from solvents and was using cocaine
use of multiple substances during ado- much less frequently. This had a signif-
lescence and adulthood. In addition, icant positive effect on his personality
Mr. AA met diagnostic criteria for de- (more agreeable and sociable, less de-
pressive personality disorder, a cate- pressed and agitated); however, his
gory mentioned in the appendix of unrelenting standards/hypercritical-
DSM-IV as needing further study. ness schema was expressed even more
Mr. AA was treated for 6 months as strongly. Cognitively oriented interven-
part of a research protocol evaluating tions included cost-benefit analyses of
DFST. His co re early maladap tive his unrelenting standards and reducing
schema was unrelenting standards/ the perceived risks of imperfection in
hypercriticalness (i.e., perfectionism, his relationships. A core cognitive dis-
rigid rules, and preoccupation with tortion targeted for dispute was When
time and efficiency), which appeared to I dont accomplish or get what I want, I
originate from the seemingly contradic- should get enraged, give up, use drugs,
tory combination of parental perfec- and be dejected. Experiential tech-
tionism (with physical or emotional niques involved imagery dialogues
abuse for Mr. AAs failures as child) with his parents about how they always
and defeat secondary to both parents made mistakes seem like catastrophes.
being torture survivors who escaped to Behavioral techniques included learn-
the United States from another country. ing to accept good enough work from
Mr. AA put a great deal of pressure on himself and others, accepting directions
himself, and any minor deviation in his from people he did not respect, and re-
striving for perfection triggered a mas- developing old leisure interests. Ther-
sive substance relapse, irresponsible apeutic relationship interventions
giving up, and antisocial acting-out. He included the therapist modeling accep-
engaged in a number of maladaptive tance of his own mistakes, processing
Substance Abuse 371
homework noncompliance due to self- between DBT-S and a comprehensive vali-

imposed rigid standards, and confront- dation therapy incorporating 12-step facil-
ing his dichotomous views of the thera- itation in that both effectively promoted
pist. Much of the work in Mr. AAs out-
retention and reduced opiate use and psy-
si de rel atio ns hip s and in ther apy
involved helping him change his di-
chopathology relative to standard L - -
chotomous view of other people as well acetyl-methadone treatment (although the
as his own recovery (i.e., all good/sober lower follow-up in DBT-S complicated the
vs. all bad/relapsed). Despite a rather findings). Likewise, van den Bosch et al.
turbulent course of treatment, Mr. AA (2002) found that DBT was no more effective
appeared genuinely interested in im- for reducing parasuicide or improving reten-
proving himself and made some sig- tion than an addiction-focused comparison
nificant changes. In addition to his
intervention. The efficacy of DBT has been
reduced substance abuse, he also expe-
rienced significant reductions in psy- clearly established in a subgroup of patients
chiatric symptoms and negative affect. with BPD and not with the wide range of per-
sonality disorders found in individuals who
Dialectical Behavior Therapy abuse substances, especially ASPD which
has been described as a possible contraindi-
The second dual-focus treatment involves a cation for DBT (Linehan and Korslund 2006).
modified version of DBT known as DBT-S.
This program includes all of the components Case Example
of standard DBT (i.e., weekly individual cog-
nitive-behavioral psychotherapy sessions Ms. BB was a 27-year-old patient with
BPD. Her first suicide attempt was at
with the primary therapist, weekly skills
the age of 12; alcohol abuse began at 16,
training groups lasting 22.5 hours per ses-
followed by cocaine and heroin. Her
sion, weekly supervision and consultation first admission into a psychiatric hospi-
meetings for the therapists, and phone con- tal was at age 12, and she had had a
sultation) plus application of dialectics to ab- criminal record since age 16. In addition
stinence issues, application of a specific to interpersonal problems, anger out-
pharmacotherapy module, a treatment tar- bursts, parasuicidal behaviors, and ag-
get hierarchy relevant to substance abuse, gressive impulsiveness, she abused her-
oin, cocaine, cannabis, and alcohol.
new strategies to keep difficult-to-engage
Previously, she had been in psychiatric
and easily lost patients, the addition of six and addiction treatments on both an
new and modified skills, an individual skills o utp at ient and an inp atient basis.
consultation mode, and increased emphasis Among her typical therapy-interfering
on using natural and arbitrary reinforcers for behaviors was attempting to invite the
maintenance of abstinence. There is some therapist into a very special and some-
evidence from a randomized controlled trial times intimate relationship. She usually
dropped out each time she failed to se-
that DBT-S is effective in reducing substance
duce a therapist. At the time of admis-
abuse in BPD patients with substance use sion to the DBT program, she was in an
disorder: Linehan et al. (1999) found that addiction-oriented day hospital pro-
DBT-S yielded greater reductions in sub- gram.
stance-related outcomes and psychiatric Soon after the start of therapy, a ba-
functioning (although not parasuicidality) sic behavior pattern became clear: after
when compared with referral for psycho- work on Friday evening, she would
start to feel lonely. The thought I need
therapy in the community for which poor re-
to comfort myself would pop up. She
tention and utilization provided potent ex-
would close the curtains, drink a glass
planations for differences in outcomes. of wine, and smoke cannabis while
Linehan et al. (2002) found few differences listening to good old days music.
Around 10 P.M. she would become rest- with the words this relationship is the
less, followed by feeling angry because most horrible thing that has ever hap-
she also deserved some company. p ened to me in my life. Thanks so
Then she would dress up in sexy clothes much.
and go out for a drink. In the pub, she
would often meet familiar drug dealers. Comment on Treatment Outcome
After having had a few drinks together,
the drug dealers would offer her co- In summary, we have seen that 1) personal-
caine. Because she could not afford to ity pathology has a strong impact on the
buy it, she would agree to have sex with course of addictive problems after discharge
them. Feelings of guilt would lead to from addiction treatment, 2) individuals
more substance abuse, and finally she
with substance use disorder are usually
would lose contact with reality. The
next morning, she would awake next to without a proper theoretical or empirical ba-
a stranger and would become self- sisexcluded from personality disorder
destructive. treatments, and 3) some preliminary data are
The behavior pattern described was supportive of treatments with a dual focus.
targeted for treatment. Because of its Together, these data provide strong support
threshold-lowering capacities for im- for the current movement toward treatment
pulsive and self-destructive behavior,
approaches that pay simultaneous attention
the alcohol abuse was given high prior-
ity early in treatment. Telephone con-
to both addictive and personality problems,
sultation was of utmost importance in such as DFST and DBT-S. However, we need
this stage. After 3 months, Ms. BB suc- more empirical evidence that these treat-
ceeded for the first time in not acting on ments really have improved effectiveness
the impulse to go to the bars late at over existing approaches. Attention to the
night. Her contact with her father, feasibility of these treatments is also re-
mother, and sisters was restored. Be-
quired. As currently developed, DFST and
cause communication improved, rein-
DBT-S require additional or separate clinical
forcement contingencies were changed.
She resumed contact with a network of training beyond the standard programs from
old friends who were not involved in which they are derived. The focus on one tar-
drug abuse, and she accepted a new, get behavior seems to be a common charac-
more challenging job. teristic of the different DBT programs. The
The cannabis use appeared to be the question is to what extent this approach is
most change-resistant behavior. Re- useful for common clinical practice, which
minding her of her own commitment
includes patients who have multiple symp-
(no hard or soft drugs), the therapist in-
sisted that she practice her mindfulness toms. It would therefore be worthwhile to
skills every time she was tempted to use examine the possibility of integrated, multi-
again. After 8 months she was clean and targeted treatment programs, rather than
was able to surf the craving. Then, fi- separate symptom-specific programs. This
nally, her attachment problems were might imply that therapists are trained to ad-
targeted in treatment. Efforts to become dress a range of symptomatic manifestations
more intimate with the therapist failed,
of personality pathology in the impulse con-
as well as all efforts to make the thera-
pist reject her (e.g., stalking by tele-
trol spectrum, including suicidal and self-
phone, anger outbursts). The therapist damaging behavior, binge eating, and sub-
was able to validate her behavior as fear stance abuse.
of abandonment, and she finally recog-
nized that she was more afraid of say-
ing goodbye than of being rejected. Af- TREATMENT GUIDELINES
ter 54 sessions she left the program and
the therapist by mutual agreement; she In general, clinical guidelines for the treat-
left a bouquet of flowers, combined ment of personality disorders recommend
Substance Abuse 373
psychotherapy whenever possible, completion and compliance associated with sub-
mented by symptom-targeted pharmacother- stance abuse raise questions of what the ap-
apy whenever necessary or useful. We see no propriate treatment goals are for this group.
reason to substantially deviate from this rec- In most cases, the goal will not be to accom-
ommendation in dual-diagnosis patients, al- plish deep and permanent change in person-
though effective treatment of these patients ality structure within a relatively short term.
often requires modifications to traditional If facilities or resources are limited, a more
programs and methods. In the remainder of practical aim may be to improve substance
this chapter, some clinical recommendations abuse treatment outcome by teaching pa-
for psychotherapy and pharmacotherapy, re- tients how to cope with or modulate mal-
spectively, are formulated. adaptive personality processes.
Psychotherapy Required Therapist Training
Dual Focus Patients with substance use disorder and se-

vere personality disorders are commonly
Dual focus does not necessarily mean that at- seen in treatment programs and consume a
tention to both foci should always take place disproportionate amount of staff time. They
simultaneously but rather that the program tend to be admitted into treatment repeat-
should consist of an integrated package of edly and exhaust the resources of one coun-
these elements. During the earlier sessions, it selor after another. Therapists treating these
is often best to place the greatest emphasis on dual-disorder patients probably should be
the establishment and maintenance of absti- professional or highly skilled therapists with
nence but with a secondary focus on identifi- extensive education and training in psycho-
cation of and psychoeducation about mal- therapy, psychopathology, personality dis-
adaptive personality traits. During later orders, and addiction. Drug counselors with
sessions, a greater emphasis can be placed on limited training and supervision may not be
confronting and changing maladaptive as effective treating the complex psychopa-
traits, cognitive-affective processes, or inter- thology of these patients, although this has
personal relationships. not been studied to date. Given the chal-
lenges of treating this population, all thera-
Clinical Setting pists should have some forum for supervi-
sion.
Psychotherapy with patients with both sub-
stance use disorder and personality disorder Essential Ingredients
probably should not be provided as a stand-
alone treatment. Psychotherapy is likely to Effective treatment of patients with both sub-
have greater success if it is provided in the stance use disorder and personality disor-
context of a relatively long-term treatment ders requires special and professional atten-
program that provides sufficient structure tion from the very beginning. Particular
and safety (e.g., day hospital, residential emphasis on motivational interviewing
treatment, or methadone maintenance pro- (Martino et al. 2002) during the admission
gram). phase and throughout the entire treatment
process may be necessary with these dual-di-
Duration and Treatment Goals agnosis patients. In addition to the regular
program modules, intensive individual
The treatment of individuals with personal- counseling is recommended to establish a
ity disorders can be a long-term process. The working alliance and to prevent these pa-
added problems of limited treatment reten- tients from leaving treatment early. Direct
therapeutic attention to maladaptive person- in female borderline patients but had no ef-
ality traits may increase cognitive and cop- fect on impulsivity or aggression (Rinne et al.
ing skills, which in turn may improve symp- 2002).
tomatology and reduce the risk for relapse.
Finally, participation in an appropriate after- Mood Stabilizers
care program is highly recommended.
Lithium and other mood stabilizers (e.g.,
carbamazepine, divalproex sodium) have
Pharmacotherapy been reported to reduce aggressive and vio-
lent behaviors in prison inmates with ASPD
Pharmacotherapy may have an important and to decrease within-day mood fluctua-
role in the treatment of dual-diagnosis pa- tions in BPD patients (Cowdry and Gardner
tients. Medications may ameliorate some per- 1988; Stein 1992). Early anecdotal reports and
sonality disorder symptoms while simulta- a small double-blind, placebo-controlled
neously improving the outcome of substance study also suggested that lithium may be ef-
use disorder. It should be noted, however, ficacious in the treatment of alcohol depen-
that the co-occurrence of these disorders is dence. However, a large Veterans Adminis-
also associated with high rates of noncompli- tration study showed no benefits of lithium
ance and an increased risk of lethal overdose over placebo for alcohol-dependent patients
as well as the potential for dependence on the with or with out depressiv e symptoms
medication. The pharmacotherapy of person- (Dorus et al. 1989). Similar negative findings
ality disorders is discussed in detail in Chap- are now available for the treatment of co-
ter 14 of this volume, Somatic Treatments. caine dependence with mood stabilizers
(Silva de Lima et al. 2002).
Neuroleptics
Benzodiazepines
Low doses of neuroleptics have been re-
ported to be associated with a range of bene- Benzodiazepines are generally contraindi-
ficial effects in patients with borderline, cated for this group because of the risk of ad-
schizotypal, or paranoid personality disor- diction and of paradoxical reactions involv-
ders (Rocca et al. 2002; Soloff 1998) as well as ing behavioral disinhibition (Cowdry and
with a decrease in craving in cocaine abusers Gardner 1988).
(Gawin et al. 1989). However, recent studies
do not support the anticraving or abstinence-
Buspirone
promoting effect of neuroleptics (e.g., Dackis
and OBrien 2002). The partial serotonin agonist buspirone
seems to combine a lack of abuse potential
Selective Serotonin Reuptake Inhibitors with a positive effect on social phobia and
avoidant personality disorder (Zwier and
Selective serotonin reuptake inhibitors have Rao 1994) and a delay in the return to heavy
been shown to reduce aggression/impulsiv- alcohol consumption in anxious alcohol-
ity in patients with BPD and ASPD (Coccaro dependent patients (Kranzler et al. 1994).
and Kavoussi 1997; Soloff 1998) and may
have some positive effect on substance abuse Stimulants
in alcohol- and cocaine-dependent patients
(Cornelius et al. 1997). However, a more re- Various stimulants, including methylphen-
cent study showed that fluvoxamine, as com- idate, pemoline, dexamphetamine, and
pared with placebo, produced a robust and levodopa, have been reported to reduce im-
long-lasting reduction in rapid mood shifts pulsivity in BPD and ASPD patients with a
Substance Abuse 375
history of attention-deficit/hyperactivity substance use disorderthat is, the behav-

disorder. It has been claimed that childhood ioral disinhibition, stress reduction, and re-
hyperactivity and a history of drug abuse are ward sensitivity pathways. With respect to
predictors of a favorable response to both the common factor model, evidence suggests
psychostimulants and monoamine oxidase that genetic factors contributing to variation
inhibitors among patients with personality in personality dimensions, particularly be-
disorders (Stein 1992). However, stimulants havioral undercontrol, might account for a
are known for their addictive and abuse po- substantial proportion of the comorbidity of
tential, and restraint should be used in pre- ASPD and substance use disorder.
scribing these drugs. Contrary to expectations, evidence has
convincingly shown that comorbid patients
Naltrexone usually benefit from addiction treatments.
However, they often only improve to a level
It has been reported that the opioid antago- of problem severity that leaves them at con-
nist naltrexone is effective in the treatment of siderable risk for relapse. In addition, the
alcohol and opiate dependence as well as in maladaptive personality traits remain un-
the prevention of self-mutilation in a BPD treated and also contribute to higher odds of
patient (Griengl et al. 2001; Soloff 1993). relapse. Also contrary to expectations, some
evidence suggests that comorbid patients
benefit from treatments focusing on the per-
CONCLUSION sonality disorder as much as do those with-
out substance use disorder. Yet the current
Substance abuse is highly prevalent among clinical consensus is that, if possible, so-
patients with personality disorder, irrespec- called dual-focus treatments consisting of an
tive of type, with prevalences of 50% and be- integrated package of elements targeting
yond. Among patients with substance use both the substance use disorder and the mal-
disorder, ASPD and BPD are the predomi- adaptive traits are preferable over strategies
nant Axis II diagnoses, with prevalences of with a single focus. Some preliminary data
approximately 20%. Thus, high joint comor- are supportive of dual-focus treatments.
bidity is evident for ASPD/BPD and sub- Clinical guidelines for the treatment of
stance use disorder. personality disorder recommend psycho-
Personality disorders can be reliably and therapy whenever possible, complemented
validly measured in patients with substance by symptom-targeted pharmacotherapy
use disorder, but assessment and diagnosis whenever necessary or useful. We see no rea-
require careful attention to disentangling son to substantially deviate from this recom-
substance-related and independent person- mendation in dual-diagnosis patients, al-
ality pathology. though effective treatment of these patients
With respect to causal pathways, the pri- often requires modifications to traditional
mary personality disorder model and com- programs and methods.
mon factor model have received the stron-
ge st emp irical s upp ort. T hes e m od els
describe comorbid relationships in which
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Part V
New Developments and
Future Directions
20
Future Directions
Toward DSM-V
P reparations for DSM-V began in 1999, cifically, needed reexamination. No labora-

when a DSM-V Research Planning Confer- tory marker had been found to be specific for
ence was held. As a result of that conference, any DSM-defined Axis I or Axis II syn-
12 DSM-V Research Planning Work Groups drome. Epidemiological and clinical studies
were constituted, most of which met and showed high rates of comorbidity within
produced white papers on the research and across axes, as well as short-term diag-
needed to inform the revision process. In nostic instability. A lack of treatment speci-
2002, A Research Agenda for DSM-V was pub- ficity for individual disorders has been
lished (Kupfer et al. 2002), which contained found to be the rule rather than the excep-
the first series of these papers. In that book, tion. Thus, the question of whether mental
the authors argued that the categorical ap- disorders, including personality disorders,
proach to the diagnosis of mental disorders should be represented by sets of dimensions
in general, and of personality disorders spe- of psychopathology and other features,
Sections of this chapter have been modified with permission from Oldham JM, Skodol AE: Charting the
Future of Axis II. Journal of Personality Disorders 14:1729 2000.
381
rather than by multiple categories, was iden- tional members in consultation with the
tified as one of seven basic nomenclature is- DSM-V Task Force leadership. Individuals
sues needing clarification for DSM-V. were chosen to represent the disciplines of
In A Research Agenda for DSM-V, Roun- both psychology and psychiatry, to have di-
saville et al. (2002) elaborated: There is a verse theoretical perspectives, and to have
clear need for dimensional models to be de- specific research and clinical expertise. The
veloped and their utility compared with that Work Group members and their primary ac-
of existing typologies in one or more limited ademic affiliations are listed in Table 201.
fields, such as personality. If a dimensional The initial task of the Work Group was to
system performs well and is acceptable to cli- consider key questions to be addressed in or-
nicians, it might be appropriate to explore di- der to inform potential revisions in DSM-V.
mensional approaches in other domains (e.g., Some of these questions are specific to the
psychotic or mood disorders) (p. 13). Thus, Personality and Personality Disorders Work
personality disorders became a test case for Group itself, such as what is the core defini-
the return to a dimensional approach to the tion of a personality disorder that distin-
diagnosis of mental disorders in DSM-V. guishes it from other types of psychopathol-
A DSM-V Research Planning Conference ogy? Is personality psychopathology better
was held in 2004 on Dimensional Models of represented by diagnostic categories or by
Personality Disorder: Etiology, Pathology, extremes on dimensions of general personal-
Phenomenology, and Treatment. Two spe- ity functioning? If dimensions are better,
cial issues of the Journal of Personality Disor- which dimensional system is preferable and
ders were published in 2005, containing the why? Is there a value in retaining a separate
review papers prepared for this conference. Axis II for the assessment of personality dis-
Topics reviewed included alternative dimen- orders and traits? Other questions were ad-
sional models of personality disorders, be- dressed to the other DSM-V Work Groups.
havioral and molecular genetic contributions For example, can fundamental tempera-
to a dimensional classification, neurobiolog- ments or personality traits be the basis for re-
ical dimensional models of personality, de- organizing disorders in DSM-V in a more
velopmental perspectives and childhood clinically or empirically meaningful way?
antecedents, cultural perspectives, the conti- What is the clinical importance (e.g., risk or
nuity of Axes I and II, coverage and cutoffs prognostic factor) of assessing personality or
for dimensional models, clinical utility, and personality disorders in other diagnostic do-
the problem of severity in personality disor- mains, such as mood, anxiety, substance use,
der classification (Widiger and Simonsen or eating disorders? Of the Task Force, we
2005b, 2005c). These issues guided early de- asked what the criteria for making changes
liberations of the DSM-V Personality and in DSM-V should be and under what circum-
Personality Disorders Work Group. stances would field trials of proposed revi-
sions be indicated?
These questions then served as the focus
PERSONALITY AND PERSONALITY for the formation of four working subgroups
DISORDERS WORK GROUP led by different Work Group members: 1) the
core definition of personality disorder and
In 2007, the Work Group was appointed to evidence of its significance as a mental disor-
officially consider the future of personality der that might justify inclusion of personality
and personality disorder assessment and disorders on the same axis as other mental
classification for DSM-V. The Chair of the disorders (Donna S. Bender, Ph.D.); 2) the rel-
Work Group and first author of this chapter, ative validity and clinical usefulness of alter-
Andrew E. Skodol, M.D., appointed 10 addi- native models of personality psychopathol-
Future Directions: Toward DSM-V 383
Table 201. Personality and Personality Disorders Work Group membership
Renato A. Alarcon, M.D., M.P.H. Mayo Clinic College of Medicine

Carl C. Bell, M.D. University of Illinois at Chicago
Donna S. Bender, Ph.D. University of Arizona College of Medicine
Lee Anna Clark, Ph.D. University of Iowa
Robert Krueger, Ph.D. Washington University St. Louis
W. John Livesley, M.D., Ph.D. University of British Columbia
Leslie C. Morey, Ph.D. Texas A&M University
John M. Oldham, M.D. Baylor University College of Medicine
Larry J. Siever, M.D. Mt. Sinai School of Medicine
Andrew E. Skodol, M.D. (Chair) University of Arizona College of Medicine
Roel Verheul, Ph.D. Viersprong Institute (The Netherlands)
ogy (Robert Krueger, Ph.D.); 3) personality as dict stability and change in personality disor-
an organizing principle for the classification ders, and are associated with outcomes over
of psychopathology, integration of personal- time. Personality disorders, therefore, may
ity disorders and Axis I disorders, tempera- be best conceptualized as hybrids of more
ment and personality development over the stable personality traits and less stable symp-
life span, and personality as a risk or protec- tomatic behaviors.
tive factor (Lee Anna Clark, Ph.D.); and 4) the The implications of hybrid models are
validity of existing personality disorder cate- several. First, defining the core features of
gories (Larry J. Siever, M.D.). personality disorders, as distinct from per-
sonality traits or styles, is a high priority. One
potential hybrid model would have a generic
personality disorder diagnosis on Axis I with
A NEW MODEL OF the types represented by dimensional trait
PERSONALITY DISORDERS structures or prototypes on Axis II. Other
types of psychopathology, such as depres-
Recent longitudinal research in patient (Sko- sion, anxiety, substance abuse, or suicidality
dol et al. 2005a; Zanarini et al. 2005), nonpa- that might become manifest secondary to
tient (Lenzenweger 2006), and general popu- stress or other life circumstances, would be
lation samples (Cohen et al. 2005) indicates noted separately. Functional impairment
that personality disorders show consistency could continue to be rated on a separate axis,
as syndromes over time but show rates of im- if a multiaxial system persisted in DSM-V, or
provement that are inconsistent with their by independent notations similar to those for
DSM-IV definitions (American Psychiatric psychopathology (see later section in this
Association 1994). Functional impairment in chapter, Tripartite Model of Mental Disor-
personality disorders is more stable than der).
personality psychopathology itself (Skodol One initial attempt at redefining the core
et al. 2005c). Some personality disorder crite- features of personality disorder was made by
ria are more stable than others (McGlashan et Krueger et al. (2007). According to this con-
al. 2005) and, in fact, personality traits are ceptualization, personality disorder is char-
more stable than personality disorders, pre- acterized by a persistent inability to accom-
plish one or more of the basic tasks of adult Borderline psychopathology emanates from
life: 1) the establishment of coherent and impairment in the ability to maintain and use
adaptive working models of self and others benign and integrated internal images of self
(e.g., is capable of formulating a clear and and others, which leads to associated unsta-
consistent sense of his or her goal in life and ble interpersonal relationships, affective in-
perceives other people as coherent entities); stability, and impulsivity. The centrality of
2) establishment of intimate relationships and selfother representational disturbance to
activities (e.g., is able to form long-term rela- borderline personality disorder is recog-
tionships that involve mutual emotional sup- nized across a wide theoretical spectrum
port); and 3) establishment of occupational spanning psychodynamic, interpersonal,
relationships and activities (e.g., is able to cognitive-behavioral, and trait models.
maintain employment that provides a stable, An example of a trait-based description
independent source of income). This concept of borderline personality disorder features
has been elaborated by Livesley and Jang was also proposed by Krueger et al. (2007).
(2005) in their proposed revised diagnostic Based on the traits derived by Livesley at al.
criteria for personality disorder. According to (1998) from twin studies using the Dimen-
these criteria, personality disorder is present sional Assessment of Personality Pathology
when a person exhibits a persistent failure to (DAPP), the prototypical descriptive features
develop adaptive solutions to life tasks as a of borderline personality disorder are the fol-
result of impaired functioning in self and in- lowing: anxiousness, emotional reactivity,
terpersonal domains, as a result of 1) a poorly emotional intensity, attachment need, cog-
differentiated self-structure (e.g., an impover- nitive dysregulation, impulsivity, insecure
ished self-concept manifested by difficulty in attachment, pessimistic anhedonia, self-
identifying or describing self attributes, or a harming acts, and self-harming ideas. In or-
confused self-concept manifested by poorly der to meet the criteria for borderline person-
delineated interpersonal boundaries); 2) a ality disorder according to this type of hy-
poorly integrated self-structure (e.g., the lack brid model, a patient would need to meet the
of a sense of personal unity and continuity generic criteria for a personality disorder and
leading to the experience of being fragmen- to have extreme levels on a number of proto-
ted or experiences of marked different self- typical traits. The minimum number of ex-
states and feeling like a different person on treme traits would need to be determined
different occasions); 3) low self-directedness empirically. Extreme might be defined on a
(e.g., difficulty with setting and attaining re- dimensional scale for traits characteristic of
warding personal goals, or a lack of direction, the patient ranging from highly characteris-
meaning, and purpose to life); or 4) chronic tic (needed) to highly uncharacteristic.
interpersonal dysfunction (e.g., impaired ca- Other trait-based models of personality
pacity for close, intimate, attachment rela- (e.g., the five-factor model [FFM] or a three-
tionships, or impaired societal functioning factor model) with empirical support and
due to the failure to develop the capacity for clinical utility might substitute for the DAPP
prosocial behavior). It is anticipated that a ge- model in describing personality. Ratings of
neric, unitary personality disorder diagnosis descriptive prototypes of personality styles
could be listed at the same level as other men- and disorders are alternatives to trait-based
tal disorders in DSM-V and be diagnosed ei- descriptions (Westen et al. 2006a). Prototypes
ther alone or in combination with other psy- have been found to be user friendly and to re-
chopathology. ceive high approval ratings from clinicians
Borderline personality disorder is a clas- (Spitzer et al. 2008).
sic example of a disturbance of selfother Combining a categorical with a dimen-
representations (Bender and Skodol 2007). sional approach, the Psychodynamic Diagnos-
tic Manual (PDM; Psychodynamic Diagnos- despite having criteria for 10 different per-
tic Manual Task Force 2006) offers a method sonality disorder types, the DSM system still
for personality assessment that addresses the may not cover the domain of personality
importance of both identifying personality psychopathology adequately. This has been
disorder types and designating the level of suggested by the observation that the most
severity of personality impairment. The frequently used personality disorder diagno-
PDM Personality Axis (P-Axis) allows clini- sis is personality disorder not otherwise
cians to characterize a patient by choosing specified (PDNOS) (Verheul and Widiger
from among 14 personality types, some 2004), a residual category for evaluations in-
which include subtypes. In addition, severity dicating that a patient is considered to have a
is addressed dimensionally by indicating personality disorder but does not meet full
where a patient falls on a spectrum ranging criteria for any one of the DSM-IV-TR types,
from healthy personality to neurotic level to or is judged to have a personality disorder
borderline level. The PDM Mental Function- not included in the classification (e.g., de-
ing Axis (M-Axis) includes nine dimensions pressive, passive-aggressive, or self-defeat-
used to rate a patients level of functioning ing personality disorders).
for specific psychological capacities such as Dimensional models of personality psy-
defensive patterns, affective experience, and chopathology make the co-occurrence of so-
psychological mindedness. called personality disorders and their heter-
ogeneity more rational, because they include
multiple dimensions that are continua on all
of which people can vary. The configurations
CATEGORICAL VERSUS of dimensional ratings describe each per-
DIMENSIONAL MODELS: sons profile of personality functioning, so
ADVANTAGES AND DISADVANTAGES many different multidimensional configura-
tions are possible. Trait dimensional models
Considerable research has shown excessive were developed to describe the full range of
co-occurrence among personality disorders personality functioning, so it should be pos-
diagnosed using the categorical system of sible to describe anyone.
DSM (Oldham et al. 1992; Zimmerman et al. Dimensional models, however, are unfa-
2005). In fact, most patients diagnosed with miliar to clinicians trained in the medical
personality disorders meet criteria for more model of diagnosis, in which a single diag-
than one. In addition, use of the polythetic nostic concept is used to communicate a
criteria of DSM, in which a minimum num- large amount of important clinical informa-
ber (e.g., five) from a list of criteria (e.g., nine) tion about a patients problems, the treat-
are required, but no single one is necessary, ment needed, and the likely prognosis. Di-
results in extreme heterogeneity among pa- mensional models are also more difficult to
tients receiving the same diagnosis. For ex- use; up to 30 dimensions (see the next sec-
ample, there are 256 possible ways to meet tion, Alternative Proposals for a Dimen-
criteria for borderline personality disorder in sional Model of Personality Disorders) may
DSM-IV-TR (American Psychiatric Associa- be necessary to fully describe a persons per-
tion 2000; Johansen et al. 2004). Furthermore, sonality. Finally, there is little empirical infor-
all of the personality disorder categories mation on the treatment or other clinical im-
have arbitrary diagnostic thresholds (i.e., the plications of dimensional scale elevations
number of criteria necessary for a diagnosis). and, in particular, where to set cut-points on
There are no empirical rationales for setting dimensional scales to maximize their clinical
the boundaries between pathological and utility. Thus, the advantages of both categor-
normal personality functioning. Finally, ical and dimensional approaches are recipro-
cals of the other models disadvantages. Pro- and Westen (Shedler and Westen 2004; Wes-
ponents of dimensional models point out ten et al. 2006b). In this system, a patient is
how extremes of some clinical phenomena in compared to a description of a prototypical
medicine that have continuous distributions, patient with each disorder and the match
such as blood pressure, lead to meaningful is rated on a 5-point scale from very good
categorical diagnoses (i.e., hypertension), match to little or no match.
once cut-points with significance for morbid- An example of a dimensional system in
ity and a need for treatment are established. which criteria for personality disorders are
And, as an example from the realm of psychi- arranged by trait dimensions instead of by
atry, meaningful cut-points based on pro- categories is the assessment model of the
gressive degrees of functional impairment Schedule for Nonadaptive and Adaptive
have been established for extreme (low) val- Personality (SNAP) (Clark 1993). This model
ues of intelligence. has three higher-order factors similar to Tel-
legen and Wallers (1987) model: negative
temperament (or affectivity), positive tem-
perament (or affectivity), and disinhibition
ALTERNATIVE PROPOSALS FOR A (or constraint) (A. Tellegen, N. G. Waller:
DIMENSIONAL MODEL OF Exploring Personality Through Test Con-
PERSONALITY DISORDERS struction: Development of the Multidimen-
sional Personality Questionnaire, Minneap-
Widiger and Simonsen (2005a) reviewed 18 olis, MN, unpublished manuscript, 1987). In
alternative proposals for dimensional mod- addition, there are 12 lower-order trait scales
els of personality disorders. The proposals that measure traits such as dependency, ag-
included 1) dimensional representations of gression, and impulsivity. Another example
existing personality disorder constructs; of this approach is Livesleys DAPP (Lives-
2) dimensional reorganizations of diagnostic ley and Jackson 2000), with broad domains of
criteria; 3) integration of Axes II and I via emotional dysregulation, dissocial behavior,
common psychopathological spectra; and inhibition, and compulsivity, as well as 28
4) integration of Axis II with dimensional lower-order, primary traits.
models of general personality structure. Models designed to integrate Axis II and
An example of dimensional representa- Axis I disorders based on shared spectra of
tions of existing constructs was proposed by psychopathology have been developed;
Oldham and Skodol (2000). This proposal Siever and Daviss (1991) model, for exam-
converted each DSM-IV personality disorder ple, hypothesizes fundamental dimensions
into a six-point scale ranging from absent of cognitive/perceptual disturbance, affec-
traits to prototypical disorder. Significant tive instability, impulsivity, and anxiety that
personality traits and subthreshold disor- link related disorders across the DSM axes.
ders could be noted, in addition to full di- Thus, schizophrenia and related psychotic
agnoses. This schema has been shown to be disorders and schizotypal personality disor-
significantly associated with functional im- der (STPD) are on a spectrum of cognitive/
pairment of patients with personality disor- perceptual disturbance, sharing some funda-
ders when seeking treatment, outperforming mental genetic and neurobiological pro-
DSM categories and other dimensional sys- cesses, but also having differences that ac-
tems based on diagnostic criteria or on gen- count for flagrant psychotic episodes in
eral personality traits (Skodol et al. 2005a). schizophrenic disorders and only psychotic-
Another example of this type of person-cen- like symptoms in STPD (Siever and Davis
tered dimensional system is the prototype 2004). Another integrative model has been
matching approach described by Shedler proposed that hypothesizes only two funda-
mental dimensions: internalization and ex- order, would also be characterized by low
ternalization (Krueger 2005; Krueger et al. agreeableness and low cooperativeness. Ac-
2001). Internalizing disorders include mood cording to the Temperament and Character
and anxiety disorders on Axis I and avoidant Model, personality disorders would be char-
and dependent personality disorders on acterized by low self-directedness and low
Axis II. Externalizing disorders include sub- cooperativeness. Personality disorders in
stance use disorders, for example, on Axis I Cluster B would also show high novelty seek-
and antisocial personality disorder (ASPD) ing; those in Cluster C, high harm avoidance;
on Axis II. Differences between Axis I and II and those in Cluster A, low reward depen-
disorders are a function of the extensiveness dence. Some research has suggested that it is
of the psychopathology, with personality easier to distinguish personality disorders
disorders being more extensive and Axis I from normality using these models than to
disorders more circumscribed. distinguish specific personality disorders
Finally, the fourth group of alternatives from each other (Morey et al. 2002).
hypothesizes that personality disorders are With so many models from which to
on a continuum of general personality func- choose, attempts have been made to synthe-
tioningextremes of normal personality size them into an overarching dimensional
traits. Three- and five-factor models have a model. One such synthesis proposed that the
long history. Three-factor models (Eysenck alternative models could be integrated over
1987; A. Tellegen, N. G. Waller: Exploring four levels of specificity (Widiger and Simon-
Personality Through Test Construction: De- sen 2005a). In this scheme, at the highest
velopment of the Multidimensional Person- level, personality psychopathology is di-
ality Questionnaire, Minneapolis, MN, un- vided by the dimensions of internalization
published manuscript, 1987) usually include and externalization. Below these are three to
neuroticism, extroversion, and psychoticism five broad domains of personality function-
(or disinhibition vs. constraint) as higher- ing: extroversion versus introversion, antag-
order factors, and the FFM includes neuroti- onism versus compliance, impulsivity ver-
cism, extroversion, agreeableness, openness, sus constraint, emotional dysregulation
and conscientiousness (Costa and McCrae versus emotional stability, and unconven-
1992). Each of the FFM factors is composed of tionality versus closed to experience. Below
six trait dimensions or facets. Another these are a number (2530) of lower-order
model is the Temperament and Character traits, each with behaviorally specific diag-
Model (Cloninger 2000); this model consists nostic criteria.
of four dimensions of temperament (novelty Despite this integration, questions re-
seeking, harm avoidance, reward depen- main. What is the evidence that personality
dence, and persistence), originally hypothe- psychopathology is best represented by cate-
sized as genetic, and three dimensions of gorical entities or by dimensions (Widiger
character (self-directedness, cooperation, and Samuel 2005)? If by dimensions, should
and self-transcendence) that were believed these be abnormal constructs or are extremes
to result from the environment, learning, or of normal variation sufficient? Should per-
life experience. sonality psychopathology be described by
Theoretical and empirical work has been the few (three to five) higher-order broad fac-
done to describe personality disorders in tors, or does the specificity of lower-order,
terms of dimensional models (Trull 2005). For more narrowly defined traits add to clinical
example, according to the FFM, personality utility? Finally, should personality psycho-
disorders, in general, would be characterized pathology be conceptualized as static pheno-
by high neuroticism. A specific personality types or as dynamic processes?
disorder, such as borderline personality dis-
and medication use over 2 years and 4 years

COMPARISONS OF of follow-up were the predicted outcome
ALTERNATIVE MODELS variables. All models showed substantial va-
lidity across marker variables over time. Di-
It remains to be seen how alternative models mensional models, especially the dimension-
of personality psychopathology compare on alized DSM personality disorders and the
important aspects of clinical utility to per- SNAP model, consistently outperformed
sonality disorders and their dimensional DSM personality disorder categories and the
representations. Testing the association of al- FFM in predicting external validators. The
ternative models to a variety of antecedent SNAP model, which incorporates both nor-
(e.g., abuse, positive child experiences), con- mal and abnormal personality dimensions,
current (e.g., functioning, treatment utiliza- seemed best, because it not only captured
tion), and predictive (e.g., future function- variables of clinical significance at baseline
ing, course of Axis I disorders) validators has when most subjects were seeking treatment
been the subject of ongoing studies in the but also maintained its predictive power
Collaborative Longitudinal Personality Dis- over time better than the DSM dimensions.
orders Study (CLPS) (Skodol et al. 2005a). The data demonstrated the importance of
In an initial study, Skodol et al. (2005b) both stable trait and dynamic psychopatho-
compared DSM-IV personality disorder cat- logical influences in predicting external crite-
egories, dimensional representations (six- ria over time.
point continuous scales based on number of
criteria met) of personality disorders, the
FFM, and a three-factor model (positive af- TRIPARTITE MODEL OF
fectivity, negative affectivity, disinhibition) MENTAL DISORDERS
derived from the SNAP on their associations
to both interviewer-rated and self-reported Integrating work on the core features of per-
domains of functional impairment. The sonality disorder and on organizing psycho-
DSM-IV dimensional representations had pathology according to personality dimen-
the strongest associations to employment, sions, Donna Bender, Ph.D. (2008, personal
social, leisure, and global functioning. communication), proposed for the Work
A more elaborate study was undertaken Group a tripartite model of mental disor-
by Morey et al. (2007). In this study, multiple ders, based on a model of patient assess-
antecedent, concurrent, and predictive mar- ment commonly used in clinical practice
kers of construct validity were examined for (Skodol and Bender 2008; Westen et al.
three major models of personality disorder: 2006a) (Figure 201). The tripartite model
the FFM (five factors and 30 facets), the 15- consists of three fundamental assessment
trait SNAP model, and the DSM-IV person- domains: functioning, personality, and psy-
ality disorders (both as categories and as cri- chopathology. Within the functional do-
teria counts). Antecedent validity markers main, strengths and challenges are assessed
included various types of childhood abuse on cognitive, self, emotional, behavioral,
and neglect, positive childhood experiences physical, interpersonal, occupational, and
reflecting resiliency, past history of medica- recreational dimensions. These adaptive ca-
tion use, and past history of psychiatric hos- pacities encompass processes by which hu-
pitalization. Concurrent markers included mans know about themselves and the world
psychosocial functioning in multiple do- around them; how they think, learn, reason,
mains, co-occurring Axis I disorders, and and express themselves; how they feel and
current medications. Functioning, Axis I dis- express these feelings; how they perceive
orders, suicide attempts, hospitalizations, their bodies, experience their sensations, and
Functional domain
Adaptive capacities
Cognitive
Self
Emotional
Behavioral
Personality domain
Traits, e.g.,
Physical
Negative emotionality
Interpersonal
Positive emotionality
Work/School
Agreeableness/Antagonism
Recreational
Conscientiousness
Prototypes, e.g.,
Idiosyncratic/Schizotypal
Mercurial/Borderline
Sensitive/Avoidant
Conscientious/Compulsive
Psychopathological domain
Symptoms, e.g., suicidal behavior
Syndromes, e.g., depressive episode
Disorders, e.g., personality disorder
Figure 201. Tripartite model of mental disorder.
perform essential functions; and how they cur? Approaches such as these are appeal-
act and react to both internal and external ing because they represent a return to the
stimuli. Functioning constructs span adap- time-honored tradition of careful clinical as-
tive to maladaptive functioning, integrating sessment and formulation.
the assessment of dysfunctions with the as- Once a functional assessment according
sessment of functional strengths associated to the tripartite model has been made, dsy-
with mental health and the resilient person- functions can be traced to personality prob-
ality (Vaillant 2003). lems, to psychopathology, or to both. The as-
In support of a tripartite model, Westen sessment of the personality domain may
and Arkowitz-Westen (1998) argued in favor include personality traits, prototypes, or
of a functional assessment of personality, styles. Dimensional traits may range from
resembling a case-formulation approach. normal to abnormal, and normal personality
They argued that instead of asking diagnos- types that correspond to extreme forms (i.e.,
tic questions such as Does the patient cross the DSM disorders) may be included (Old-
the threshold for a personality disorder? or ham and Morris 1995). So, for example, an id-
How low is the patient on the trait of agree- iosyncratic type would be a normal variant
ableness? a functional assessment would of STPD, mercurial would correspond to bor-
ask, Under what circumstances are which derline, sensitive to avoidant, and consci-
dysfunctional cognitive, affective, motiva- entious to compulsive. Of course, normal
tional, and behavioral patterns likely to oc- personality types would need to have dem-
Table 202. Examples of associations of functional domains and psychopathology

Cognitive Emotional
Psychotic spectrum Affective disorders
Mental retardation Anxiety disorders
Delirium Behavioral
Dementia Substance abuse
Self Suicide/self-harm
Dissociative spectrum Impulse control spectrum
Eating disorders Physical
Personality disorders Somatic concern disorders
Interpersonal Sexual dysfunction
Pervasive developmental disorders Sleep disorders
Personality disorders
onstrated clinical utility. An empirically data on the classification of mental disorders

based set of prototypes, as described by Wes- according to developmental, latent trait, or
ten and Shedler (1999a, 1999b), could be spectrum criteria. It promotes a whole per-
adopted. These prototypes are derived from son approach to assessment that the five-
clinical constructs closely related to DSM-IV, axis DSM system often failed to do.
based on clinician consensus.
Finally, the psychopathology domain
would require assessment of any relevant FUTURE DIRECTIONS
symptoms, syndromes, or disorders. Thus,
suicidality, major depressive episode, or per- The implications of this growing body of evi-
sonality disorder could be diagnosed in this dence are several. In the future, personality
domain. It is expected that the impairments in disorders may need to be redefined in terms
the specific adaptive capacities in the func- of their trait, symptom, and functional com-
tional domain would map onto specific symp- ponents. The course of personality disorders
tom disorders (see Table 202). For example, may need to be reconceptualized as waxing
impairments in cognitive functioning would and waning, depending on life circumstances.
suggest mental retardation, delirium, demen- Since personality disorders can improve, it
tia, or psychotic disorders. Impairment in may be possible to convey a more optimistic
emotional functions would suggest mood or prognosis to patients and their families. Fi-
anxiety disorders. Although most mental dis- nally, it will be important to focus treatments
orders have impairments in multiple do- on attaining adequate psychosocial function-
mains, identification of the primary (and sec- ing, in addition to symptom relief.
ondary) impairments is usually very helpful The simplest change in approach to Axis
in the process of differential diagnosis. II in the future that would likely increase va-
Thus the tripartite model of mental disor- lidity would be to rate (revised) personality
ders 1) provides a clinically useful assess- disorder categories as dimensions, as pro-
ment, grounded in the mental status exami- posed by Oldham and Skodol (2000) and oth-
nation; 2) eliminates the need for a multiaxial ers. Another possibility would be to move
system of assessment; 3) provides a template personality disorders as a class of disorders to
for dimensional ratings of functioning, per- Axis I, but to supplement their categorical di-
sonality, and psychopathology for all pa- agnosis by rating personality traits on Axis II
tients; and 4) is consistent with empirical (Widiger et al. 2002). More dramatic revisions
that include the reorganization of both Axis I Krueger RF, McGue M, Iocono WG: The higher-
and Axis II disorders according to tempera- order structure of common DSM mental disor-
ders: internalization, externalization, and
mental dimensions (Clark 2005; Krueger
their connections to personality. Pers Individ
2005) and/or developmental stages (Kupfer Dif 30:12451259, 2001
2005) are also possible. Any decisions to re- Krueger RF, Skodol AE, Livesley WJ, et al: Synthe-
vise Axis II should be considered carefully, siz in g dim ensio na l a nd ca t eg ori ca l a p-
backed by empirical data, and tested for clin- proaches to personality disorders: refining the
ical utility (First 2005). research agenda for DSM-V Axis II. Int J Meth-
ods Psychiatr Res 16(S1):S65S73, 2007
Kupfer DJ: Dimensional models for research and
diagnosis: a current dilemma. J Abnorm Psy-
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21Appendix
Appendix
DSM-IV-TR Diagnostic Criteria for
Diagnostic criteria in this Appendix are reprinted, with permission, from American Psychiatric Associa-
tion: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC,
American Psychiatric Association. Copyright 2000 American Psychiatric Association.
393
DSM-IV-TR Diagnostic Criteria for Personality Disorders 395
General diagnostic criteria for a personality disorder
A. An enduring pattern of inner experience and behavior that deviates markedly from the
expectations of the individual's culture. This pattern is manifested in two (or more) of the
following areas:
(1) cognition (i.e., ways of perceiving and interpreting self, other people, and events)
(2) affectivity (i.e., the range, intensity, lability, and appropriateness of emotional
response)
(3) interpersonal functioning
(4) impulse control
B. The enduring pattern is inflexible and pervasive across a broad range of personal and
social situations.
C. The enduring pattern leads to clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
D. The pattern is stable and of long duration, and its onset can be traced back at least to
adolescence or early adulthood.
E. The enduring pattern is not better accounted for as a manifestation or consequence of
another mental disorder.
F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a
drug of abuse, a medication) or a general medical condition (e.g., head trauma).
Personality disorder not otherwise specified
This category is for disorders of personality functioning (refer to the general diagnostic
criteria for a personality disorder) that do not meet criteria for any specific personality
disorder. An example is the presence of features of more than one specific personality
disorder that do not meet the full criteria for any one personality disorder (mixed
personality), but that together cause clinically significant distress or impairment in one
or more important areas of functioning (e.g., social or occupational). This category can
also be used when the clinician judges that a specific personality disorder that is not
included in the classification is appropriate. Examples include depressive personality
disorder and passive-aggressive personality disorder.
CLUSTER A
Diagnostic criteria for paranoid personality disorder
A. A pervasive distrust and suspiciousness of others such that their motives are interpreted
as malevolent, beginning by early adulthood and present in a variety of contexts, as
indicated by four (or more) of the following:
(1) suspects, without sufficient basis, that others are exploiting, harming, or deceiving
him or her
(2) is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends
or associates
(3) is reluctant to confide in others because of unwarranted fear that the information will
be used maliciously against him or her
(4) reads hidden demeaning or threatening meanings into benign remarks or events
(5) persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights
(6) perceives attacks on his or her character or reputation that are not apparent to others
and is quick to react angrily or to counterattack
(7) has recurrent suspicions, without justification, regarding fidelity of spouse or sexual
partner
B. Does not occur exclusively during the course of schizophrenia, a mood disorder with
psychotic features, or another psychotic disorder and is not due to the direct
physiological effects of a general medical condition.
Diagnostic criteria for schizoid personality disorder
A. A pervasive pattern of detachment from social relationships and a restricted range of

expression of emotions in interpersonal settings, beginning by early adulthood and
present in a variety of contexts, as indicated by four (or more) of the following:
(1) neither desires nor enjoys close relationships, including being part of a family
(2) almost always chooses solitary activities
(3) has little, if any, interest in having sexual experiences with another person
(4) takes pleasure in few, if any, activities
(5) lacks close friends or confidants other than first-degree relatives
(6) appears indifferent to the praise or criticism of others
(7) shows emotional coldness, detachment, or flattened affectivity
psychotic features, another psychotic disorder, or a pervasive developmental disorder
and is not due to the direct physiological effects of a general medical condition.
CLUSTER A (CONTINUED)
Diagnostic criteria for schizotypal personality disorder
A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with,
and reduced capacity for, close relationships as well as by cognitive or perceptual
distortions and eccentricities of behavior, beginning by early adulthood and present in a
variety of contexts, as indicated by five (or more) of the following:
(1) ideas of reference (excluding delusions of reference)
(2) odd beliefs or magical thinking that influences behavior and is inconsistent with
subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or sixth
sense; in children and adolescents, bizarre fantasies or preoccupations)
(3) unusual perceptual experiences, including bodily illusions
(4) odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or
stereotyped)
(5) suspiciousness or paranoid ideation
(6) inappropriate or constricted affect
(7) behavior or appearance that is odd, eccentric, or peculiar
(8) lack of close friends or confidants other than first-degree relatives
(9) excessive social anxiety that does not diminish with familiarity and tends to be
associated with paranoid fears rather than negative judgments about self
psychotic features, another psychotic disorder, or a pervasive developmental disorder.
CLUSTER B
Diagnostic criteria for antisocial personality disorder
A. There is a pervasive pattern of disregard for and violation of the rights of others occurring
since age 15 years, as indicated by three (or more) of the following:
(1) failure to conform to social norms with respect to lawful behaviors as indicated by
repeatedly performing acts that are grounds for arrest
(2) deceitfulness, as indicated by repeated lying, use of aliases, or conning others for
personal profit or pleasure
(3) impulsivity or failure to plan ahead
(4) irritability and aggressiveness, as indicated by repeated physical fights or assaults
(5) reckless disregard for safety of self or others
(6) consistent irresponsibility, as indicated by repeated failure to sustain consistent work
behavior or honor financial obligations
(7) lack of remorse, as indicated by being indifferent to or rationalizing having hurt,
mistreated, or stolen from another
B. The individual is at least age 18 years.
C. There is evidence of conduct disorder with onset before age 15 years.
D. The occurrence of antisocial behavior is not exclusively during the course of
schizophrenia or a manic episode.
CLUSTER B (CONTINUED)
Diagnostic criteria for borderline personality disorder
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
Diagnostic criteria for histrionic personality disorder
A pervasive pattern of excessive emotionality and attention seeking, beginning by early

adulthood and present in a variety of contexts, as indicated by five (or more) of the
following:
(1) is uncomfortable in situations in which he or she is not the center of attention
(2) interaction with others is often characterized by inappropriate sexually seductive or
provocative behavior
(3) displays rapidly shifting and shallow expression of emotions
(4) consistently uses physical appearance to draw attention to self
(5) has a style of speech that is excessively impressionistic and lacking in detail
(6) shows self-dramatization, theatricality, and exaggerated expression of emotion
(7) is suggestible, i.e., easily influenced by others or circumstances
(8) considers relationships to be more intimate than they actually are
CLUSTER B (CONTINUED)
Diagnostic criteria for narcissistic personality disorder
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 that others are envious of him or her
(9) shows arrogant, haughty behaviors or attitudes
CLUSTER C
Diagnostic criteria for avoidant personality disorder
A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to

negative evaluation, beginning by early adulthood and present in a variety of contexts,
as indicated by four (or more) of the following:
(1) avoids occupational activities that involve significant interpersonal contact, because
of fears of criticism, disapproval, or rejection
(2) is unwilling to get involved with people unless certain of being liked
(3) shows restraint within intimate relationships because of the fear of being shamed or
ridiculed
(4) is preoccupied with being criticized or rejected in social situations
(5) is inhibited in new interpersonal situations because of feelings of inadequacy
(6) views self as socially inept, personally unappealing, or inferior to others
(7) is unusually reluctant to take personal risks or to engage in any new activities because
they may prove embarrassing
Diagnostic criteria for dependent personality disorder
A pervasive and excessive need to be taken care of that leads to submissive and clinging
behavior and fears of separation, beginning by early adulthood and present in a variety
of contexts, as indicated by five (or more) of the following:
(1) has difficulty making everyday decisions without an excessive amount of advice and
reassurance from others
(2) needs others to assume responsibility for most major areas of his or her life
(3) has difficulty expressing disagreement with others because of fear of loss of support
or approval
Note: Do not include realistic fears of retribution.
(4) has difficulty initiating projects or doing things on his or her own (because of a lack
of self-confidence in judgment or abilities rather than a lack of motivation or energy)
(5) goes to excessive lengths to obtain nurturance and support from others, to the point
of volunteering to do things that are unpleasant
(6) feels uncomfortable or helpless when alone because of exaggerated fears of being
unable to care for himself or herself
(7) urgently seeks another relationship as a source of care and support when a close
relationship ends
(8) is unrealistically preoccupied with fears of being left to take care of himself or herself
CLUSTER C (CONTINUED)
Diagnostic criteria for obsessive-compulsive personality disorder
A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and

interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by
early adulthood and present in a variety of contexts, as indicated by four (or more) of the
following:
(1) is preoccupied with details, rules, lists, order, organization, or schedules to the extent
that the major point of the activity is lost
(2) shows perfectionism that interferes with task completion (e.g., is unable to complete
a project because his or her own overly strict standards are not met)
(3) is excessively devoted to work and productivity to the exclusion of leisure activities
and friendships (not accounted for by obvious economic necessity)
(4) is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or
values (not accounted for by cultural or religious identification)
(5) is unable to discard worn-out or worthless objects even when they have no
sentimental value
(6) is reluctant to delegate tasks or to work with others unless they submit to exactly his
or her way of doing things
(7) adopts a miserly spending style toward both self and others; money is viewed as
something to be hoarded for future catastrophes
(8) shows rigidity and stubbornness
Index
Page numbers printed in boldface type refer to tables or figures.
Abuser-victim paradigm, 187 Amphetamine challenge

Acceptance and change dialectic, 236, 238239, borderline personality disorder, 112
247248 schizotypal personality disorder, 105, 108
Acetylcholine, 113 Amygdala, borderline personality disorder,
Acting-out, 190 113, 115
Acute-on-chronic suicide risk, 355 Anaclitic character, definition, 186
Adaptive personality traits, 151154 Anankastic personality disorder, suicidality,
Adolescent Psychopathology Scale, 136 348
Adolescents Anger
assessment, 134136 antidepressants in, 273275
Axis I comorbidity, prognosis, 132133 neuroleptics, 272273
cognitive developmental changes, 127 Anna O, 314
identity crisis, 127128 Anterior cingulate cortex
maturational changes, 128130 and mentalization, 217
personality traits stability, 4647, 6768, 132 posttraumatic stress effect on, 219
suicide epidemiology, 346347 Anticonvulsants, 277282
Adult Attachment Interview (AAI), 211213 meta-analysis, 281282
Affective dyscontrol, antidepressant treatment, in personality disorders, 277282
273276 Antidepressants, 273276
Affective features, personality disorders, 39 in collaborative treatment, 323325
Affiliation need, personality disorders, 3940 in personality disorders, 273276
Age factors. See also Developmental factors meta-analysis, 281282
epidemiology, 4647, 51 Antipsychotic drugs. See Neuroleptics
personality disorders course/endurance, Antisocial personality disorder
6768 Axis I comorbidity, 55
symptom change and stability, 130132 behavior genetics, 24
Aggression. See also Impulsivity/impulsive boundary issues, 314315
aggression; Violence brain imaging, 113114
neurobiology, 109115 characteristic features, 41
serotonin system, 110112, 114115 childhood maltreatment association, 145
Aging process, 68 collaborative treatment issues, 328
Ainsworth, Mary, attachment theory, 211 continuity, 67
Albany-Saratoga study. See Children in the DSM ontogeny, 7
Community Study DSM-IV-TR diagnostic criteria, 398
Alcohol abuse. See Substance abuse early onset, 68
Alien self Five-Factor Model, 20
in abuse victims, 219221 gender differences, 60
establishment of, 215216 group treatment, 259
and violent acts, 222 heritability, 24
Alliance. See Therapeutic alliance hospitalization, 168
Alprazolam, 276277 level of care, 162, 163, 179
Amitriptyline, 276 marital status, 92, 93
403
Antisocial personality disorder (continued) comorbidity, 5456, 67

neurobiology, 109115 differential diagnosis, 4849
prevalence, 85, 86, 88, 89 Axis II disorders
psychoanalytic therapy contraindication, Axis I disorders effect on, 4749
193, 195 versus Axis I disorders, stability, 71
substance abuse, 362, 365366 Axis I integration, fundamental
suicidality, 346, 353354 dimensions, 386387
therapeutic alliance, 294, 297 comorbidity, 5456
Anxiety disorders, stability, 71 current controversies, 9
Anxiolytic drugs, 276277 differential diagnosis, 4849
Anxious attachment, 211, 213214 in DSM ontogeny, 7
Anxious or fearful cluster. See Cluster C
Aripiprazole, 272273
Arousal, trauma effect on, 218219 Backward masking, 107
Attachment Beck, Aaron, cognitive theory, 18
borderline personality disorder, 214226 Behavior genetics, 2224, 104105, 109110,
empirical studies, 197198 116117
mentalization-based treatment, 222226 Behavior rehearsal, in skills training, 241
intergenerational transmission, 212 Behavioral analysis, dialectical approach, 245
internal working models formation, Behavioral disinhibition, and substance abuse,
124125 365
stability, 214 Behavioral dyscontrol, benzodiazepines, 277
theoretical outline, 210213 Behavioral indictors
Attention disturbances, schizotypal in DSM-IV-TR, 5354
personality disorder, 106107 versus inferential traits approach, 5354
Atypical antipsychotic drugs, 271273 Behavioral problems, maturational changes,
Atypical depression, 276 129130
Avoidance behavior, and aging, 68 Behavioral techniques, in dialectical behavior
Avoidant personality disorder therapy, 237238
Axis I comorbidity, 55 Benjamins interpersonal theory, 2526
benzodiazepines, 276 Benzodiazepines
characteristic features, 41 dual-diagnosis patients, 374
childhood maltreatment association, in personality disorders, 276277
146147 Biological perspectives, 2124. See also specific
cognitive features, 3839 aspects
collaborative treatment issues, 329 Biosocial theory, 236237
course and outcome, 7074 Board of registration complaints, 312313
DSM ontogeny, 7 Borderline personality disorder
DSM-IV-TR diagnostic criteria, 401 affective features, 39
group treatment, 259 antidepressant treatment, 273276, 281282
hospitalization, 168 attachment theory, 214222
level-of-care research, 162, 163 Axis I comorbidity, 55
marital status, 92, 93 behavior genetics, 24
monoamine oxidase inhibitors, 276 boundary issues, 315316
neurobiology, 116117 childhood maltreatment association,
prevalence, 85, 86, 88, 89 145148
psychoanalytic therapy, 193, 195 cognitive features, 38
remission rates, 71, 72, 73, 74 collaborative treatment, 328
suicidality, 348 comorbidity, longitudinal study, 73
therapeutic alliance, 294, 300 conceptual history, 56
Axis I disorders course and outcome, 6875
assessment of effect of, 4749 longitudinal studies, 6975
versus Axis II disorders, stability, 71 developmental model, 123124
Axis II integration, fundamental dialectical behavior therapy, 235251
dimensions, 386387 disorganized attachment link, 214215
Index 405
DSM ontogeny, 7, 8 Categorical models

DSM-IV-TR diagnostic criteria, 399 advantages and disadvantages, 385386
emotional dysregulation, 18 comparative studies, 388
gender differences, 90 versus dimensional systems, 89, 5657, 66,
group treatment, 257, 259 385386
hospitalization, 165, 166, 168170 future directions, 9, 385386
level of care, 162, 163, 165, 168170, 173, 179 and personality disorders stability, 71,
marital status, 92, 93 385386
mentalization-based treatment, 197198, stability coefficients, 66
209, 222226 Change and acceptance dialectic, 238, 247248
mindfulness-based therapy, 238239 Character
mood stabilizers/lithium treatment, in personality structural model, 2122
278281 in psychoanalytic theory, 56, 18, 185188
neurobiology, 109116 Character armor, 185
neuroleptics in, 269273 Child adversity/trauma, 143151
prevalence, 85, 86, 88, 89 borderline personality disorder, 237
psychoanalytic therapy, 193, 194, 197198 developmental model, 123124
psychodynamic therapy, 176 internal working models link, 187188
remission rates, 7174, 72, 74 and maladaptive personality traits, 144151
self-presentations, 126 mentalization inhibition effect, 218219
substance abuse, 362, 365367 and self-representations, 126
suicidality, 346, 349352, 354355 Childhood emotional abuse, 146147
therapeutic alliance, 293, 294, 296 Childhood neglect, 147148
trait-based description, 384 Childhood physical abuse, 145
violence, 222 Childhood sexual abuse
Borderline rage, 316 mentalization inhibition effect, 218
Boundary issues, 309320 personality disorders link, 145146
antisocial personality disorder, 314315 suicide risk factor, 351
basic elements, 310 Children. See also Child adversity/trauma
borderline personality disorder, 315317 assessment, 134136
practice guidelines, 317 developmental issues, 123136
boundary crossings versus boundary maturational changes, 128131
violations, 310311 personality disorders course, 68
civil litigation, 312 personality traits change and stability,
context factors, 311 4647, 6768, 131133
and countertransference, 316317 Children in the Community Study, 75, 130, 145,
cross-cultural observations, 317 147
dependent personality disorder, 313314 Chlorpromazine, 268
fiduciary duty considerations, 311312 Citalopram, 275
histrionic personality disorder, 313314 Civil litigation, boundary violations, 312
licensure complaints, 312313 Clinical course, 6379
power asymmetry considerations, 311312 age and aging process effect, 68
risk management principles/ assessment methodology questions, 6569
recommendations, 318319 and Axis I comorbidity, adolescents, 132
Brain imaging. See also specific modalities longitudinal studies, 6775
Cluster A personality disorders, 107108 overview, 42
Cluster B personality disorders, 113115 and stability, 47, 6375
Buspirone, in alcohol abuse, 374 Clinical interviewing. See also Semistructured
interviews
approaches to, 4345
Carbamazepine, 278279 children and adolescents, 135
Case manager versus questionnaires, 4445
hospitalized patients, 169 standardized instruments, 6566
and partial hospitalization, 172 substance abuse assessment, 362364
Catechol-O-methyltransferase, 106 Clonazepam, 277
Cloningers model, 2122, 186, 387 Coaching, in dialectical behavior therapy,

Clozapine, 271 245247
CLPS (Collaborative Longitudinal Personality Cocaine. See Substance abuse
Disorders Study), 7075, 72, 74, 388 Cognitive development
Cluster A personality disorders attachment representations role in, 124125
age differences, 91 and self-representations, 125127
aging process effect, 68, 91 Cognitive schemas. See Schemas
Axis I comorbidity, 55 Cognitive-behavioral therapy. See also
Axis I differential diagnosis, 4849 Dialectical behavior therapy
behavior genetics, 104105 group format, 258
clinical features, 41 mentalization link, 223224
DSM-IV-TR diagnostic criteria, 396397 therapeutic alliance, 303304
functional imaging, 108109 Cognitive-social theories, 1719
gender differences, 88, 90 Cognitive style, and defense mechanisms, 189
group treatment, 258259 Cognitive theory, personality disorders, 18
levels of care research, 162, 163 Collaborative Longitudinal Personality
marital status, 92, 93 Disorders Study (CLPS), 7075, 72, 74, 388
maturational decline, 129 Collaborative treatment, 321341
neurobiology, 104109 contraindications, 336337
profile, 22, 41 definition, 321322
structural imaging, 107108 effectiveness, 322323
suicidality, 347349 and personality disorders, 326327,
therapeutic alliance, 292293, 294 328329
Cluster B personality disorders principles, 330336
aging process effect, 68, 91 psychotherapy and medication, 323327,
Axis I comorbidity, 55 330336
behavior genetics, 109110 strengths and weaknesses, 325326
brain imaging, 113115 Comorbidity, 5456
clinical features, 41 Axis I and Axis II, 5456
DSM-IV-TR diagnostic criteria, 398400 prognosis, adolescents, 132133
functional imaging, 114115 and categorical diagnosis, 385
gender differences, 88, 90 and clinical course, 6667
group treatment, 259 longitudinal study, 73
level of care research, 162, 163 continuity models, 67
marital status, 92, 93 definition, 54
maturational decline of, 129130 substance abuse, 361
neurobiology, 109116 suicide risk factor, 349350
profile, 22, 41 COMT polymorphisms, schizotypal
suicidality, 346347 personality disorder, 106
therapeutic alliance, 293, 294, 296297 Confrontational psychotherapeutic approach,
Cluster C personality disorders 199, 200
aging process effect on, 68, 91 Conjoint therapy. See Collaborative treatment
Axis I comorbidity, 55 Consultation team, dialectical behavior
brain imaging, 117 therapy, 248
clinical features, 41 Continuity
DSM-IV-TR diagnostic criteria, 401402 longitudinal study, 73, 75
gender differences, 90 personality disorders course, 67, 73, 75
group treatment, 259260 Contractual alliance, 178
levels of care research, 162, 163 Controlling/manipulative behavior, 216
marital status, 92, 93 Coolidge Personality and Neuropsychological
maturational decline of, 129130 Inventory for Children (CPNI), 136
neurobiology, 116117 Coping styles, diagnostic approach, 5253
profile, 22, 41 Countertransference
suicidality, 347349 and boundary violations, 316317
therapeutic alliance, 294295, 299301 dependent personality disorder, 203
Index 407
narcissistic personality disorder, 200 and identity diffusion, 127128

in psychoanalytic therapy, 190 and internal working models, 124125
Course. See Clinical course maturational effects, 128131
CPNI (Coolidge Personality and psychoanalytic theory, 187
Neuropsychological Inventory for symptom change and stability, 131134
Children), 136 Diagnostic criteria, 395402
Crisis management DSM-IV-TR, 395402
in dialectical behavior therapy, 241, 241, personality disorders, 10, 395402
245246 proposed revision, 384
and hospitalization, 163, 166, 168169 in prototype model, 5657
Cultural factors Diagnostic Interview for DSM-IV Personality
and boundary issues, 317 Disorders (DIPD-IV), 44
personality disorders, 51 Diagnostic and Statistical Manual of Mental
Cut-points, diagnostic decision utility, 386 Disorders (DSM). See DSM entries
Dialectical behavior therapy, 235251
acceptance and change, dialectic, 236,
DAPP-BQ. See Dimensional Assessment of 238239, 247248
Personality PathologyBasic antidepressant addition, 275
Questionnaire borderline personality disorder, 235251
Day treatment. See Partial hospital/day consultation team, 248
treatment diary cards, 240
Defensive functioning efficacy data, 248249
diagnostic approach, 52 group skills training, 240242, 241
psychoanalytic theory, 188189 individual therapy component, 239240
2-Deoxyglucose challenge, schizotypal inpatient programs, 169170
personality disorder, 105106 learning principle, 237238
Dependent personality disorder stages of treatment, 242245
Axis I comorbidity, 55 and substance abuse comorbidity, 371
boundary issues, 313314 techniques and strategies, 245247
characteristic features, 41 theoretical perspective, 236237
childhood maltreatment link, 147148 therapeutic alliance, 304
cognitive features, 3839 Dialectical philosophy, 239
collaborative treatment issues, 329 Diary cards, in dialectical behavior therapy,
DSM ontogeny, 7 240
DSM-IV-TR diagnostic criteria, 401 Differential diagnosis, Axis I and Axis II, 4749
gender correlates, 91 Difficult patients, in group treatment, 255
group treatment, 259260 Dimensional Assessment of Personality
marital status, 92, 93 PathologyBasic Questionnaire (DAPP-
prevalence, 86, 88, 89 BQ)
psychoanalytic therapy, 193, 195, 203 borderline personality basic features, 384
suicidality, 348 characteristics, 23, 386
therapeutic alliance, 295, 299300 higher-order dimensions, 386
Depression Dimensional models
assessment of effect of, 47 and adolescent symptom stability, 131132
borderline personality disorder advantages and disadvantages, 385386
comorbidity, 73 alternative proposals, 386387
differential diagnosis, 55 versus categorical systems, 8, 5657, 66,
Cluster B comorbidity, 55 385386
remission rates, 71, 72, 73 comparative studies, 388
stability of, versus Axis II disorders, 7071 future directions, 9, 390392
suicide risk factor, 345, 349350 neurobehavioral approach, 22
Depressive personality disorder, 145146 and personality disorders stability, 71
Detachment need, 3940 stability coefficients, 66
Developmental issues, 123141 DIPD-IV (Diagnostic Interview for DSM-IV
case examples, 133134 Personality Disorders), 44
Direct questioning, assessment method, 4445 Educational level

Discharge from hospital, suicide risk, 351 epidemiology, 9495
Disinhibited behavior, substance abuse and impairment studies, 4243
pathway, 365 Ego functions, diagnostic approach, 52
Disorganized attachment Ego psychology, conceptualization, 1415
and borderline psychopathology, 214222 Electroconvulsive therapy (ECT), 282284
causes, 213 Emotion-focused coping, 5253
controlling/dominant behavior sequelae, Emotion regulation, dialectical behavior
216 therapy, 241242, 241
development of, 124125 Emotional dysregulation
mentalization-based treatment, 216217 borderline personality disorder, 18
predictive significance, 212214 suicide risk factor, 345
theoretical outline, 211212 Emotionally abused children, 146147
Distress tolerance skills training, 241, 241 Empathy, narcissistic personality disorder,
Divalproex sodium, 279280 198199
Divorce, epidemiological studies, 91, 92, 9394 Entitlement beliefs, and boundary issues, 316
DNA polymorphisms. See specific Environmental factors
polymorphisms behavior genetics research, 2224
Dominance need, personality disorders, 39 gene interactions, 24
Dopamine system, schizotypal personality Epidemiology. See also Prevalence
disorder, 105106 age factors, 9091
Dopamine transporter, social anxiety disorder, gender differences, 88, 90
117 marital status, 91, 92, 9394
Dramatic, Emotional, or Erratic Cluster. prevalence studies, 8389, 99
See Cluster B quality of life, 9599
Drug abuse. See Substance abuse substance abuse, 362
Drug treatment. See Pharmacotherapy suicidality, 346349
DSM (Diagnostic and Statistical Manual of Eriksons identity development theory,
Mental Disorders) 127128
future directions, 381392 Ethics complaints, boundary violations, 313
history, 69, 7, 10 Evolutionary model, personality disorders, 25
DSM-I (1952), 6, 7 Externalizing symptoms, personality trait
DSM-II (1968), 6 7 superfactor, 387
DSM-III (1980), 6, 7 Extraversion
DSM-III-R (1987), 6, 7, 8 in Five-Factor Model, 1920, 387
DSM-IV (1994)/DSM-IV-TR (2000) heritability, 2223
diagnostic criteria, 393402 Extreme traits, 384
ontogeny, 6, 7, 9, 10 Eye movement abnormalities, schizophrenia
DSM-V, future directions, 381392 spectrum, 107
DSM-V Personality and Personality Disorders
Work Group, 382383, 383
DSM-V Research Planning Conference, 382 Family factors, protective aspects, 150151
Dual diagnosis. See Substance abuse Fearful disorders. See Cluster C
Dual-focused treatments, outcome, 369372 Fenfluramine studies, impulsive aggression,
Dysfunction index, 9596 114115
Dysregulation theory, 236237 FFM. See Five-Factor Model
Fiduciary duty, boundary issues, 311312
Five-Factor Model (FFM)
Early onset case example, 2829
developmental issues, 123134 comparative studies, 388
overview, 6768 concept, 1920
temperament, 131 dimensional model link, 387
Eccentric disorders. See Cluster A personality and normal developmental changes, 130
disorders as personality disorder model, 388
ECT (electroconvulsive therapy), 282284 and temperament, 131
Index 409
Fluoxetine, 273275, 281 Heterocyclic antidepressants, 276

Flupenthixol, 270271 5-HIAA (5-hydroxyindoleacetic acid), 110112
Fluvoxamine, 275, 374 Hierarchical decision rules, in diagnosis, 44
Formal operational thinking, 126127 Histrionic personality disorder
Freud, Sigmund affective features, 39
personality disorders conceptualization, 14 boundary issues, 313314
positive transference delineation, 290 childhood maltreatment association, 146
psychodynamic theory, 45, 185 collaborative treatment, 328
structural model, 185 DSM-IV-TR diagnostic criteria, 399
Functional imaging DSM ontogeny, 7
Cluster B personality disorders, 114115 group treatment, 259
schizotypal personality disorder, 108 marital status, 92, 93
Functional impairment prevalence, 8586, 88, 89
diagnostic requirement, 4243 psychoanalytic therapy, 194, 195, 200201
epidemiology, 9599, 9798 suicidality, 347
in personality disorder models, 2630, 383, therapeutic alliance, 294, 297
388390 Holding environment, 178
in tripartite model, 388390, 389390 Homovanillic acid, schizotypal personality
Functional-domains model, 2630 disorder, 105
Fusion, and boundary transgressions, 315316 Hospital care
Future directions, 9, 381391 definition, 162
evidentiary basis, 162, 163
indications, 165, 168, 178179
GAF (Global Assessment of Functioning) scale, length of stay, inpatients, 66, 168170
96 structures, 169
Gender factors therapeutic goals, 165, 166, 168169
epidemiology, 88, 90 5-HT1A receptor, 110111
personality disorders, 51, 88, 90 5-HT2A receptor, 111112
Generic personality disorder diagnosis, 384 5-HT1D receptor C allele, 111
Genetics. See Heritability
5-HTT transporter alleles, 111112
Global Assessment of Functioning (GAF) scale,
Hybrid models, personality disorders, 383
96
5-Hydroxyindoleacetic acid (5-HIAA), 110, 112
Grandiose self, 16
Hypervigilant narcissism, therapeutic alliance,
Grandiosity, developmental aspects, 126
300
Group skills training, 240241, 241
Hysterical personality disorder,
Group treatment, 253266
psychoanalytic therapy, 194, 195, 200201
advantages and disadvantages, 253255
Hysteroid dysphoria, 278
case examples, 260263
efficacy and effectiveness, 264265
forms of, 255256
Idealized parent image, 17
and intensive outpatient care, 174175
Idealizing transference, 199
naturalistic studies, 258
Identity diffusion, adolescent development,
randomized clinical trials, 257258
127128
research support, 256258
Identity formation
specific personality disorder indications,
adolescents, 127128
258260
projective identification role in, 187188
Guanfacine, 106
If-then contingencies, 19
Imaging studies. See Brain imaging
Impairment. See Functional impairment
Haloperidol, 269270
Implicit relational knowing, 191
Hardiness, 152
Impulsivity/impulsive aggression
Heritability
aging process effect on, 68
Cluster B personality disorders, 109
antidepressants in, 273275
Cluster C personality disorders, 116
lithium and mood stabilizers, 277280
personality disorders/traits, 2224
mentalization-based treatment, 222
Impulsivity/impulsive aggression (continued) Kernberg, Otto

neurobiology, 109115 narcissism therapeutic technique, 198200,
neuroleptic treatment, 269, 271272 199
serotonin system, 110112, 114115 object relations theory, 198
substance abuse pathway, 365 personality disorders conceptualization,
as a suicide risk factor, 345 1516
Income, epidemiology, 9495 Kohut, Heinz
Inferential traits, 5354 narcissism therapeutic technique, 1617,
Inflexibility feature, 40, 42 198200, 199
Informant interviews self-psychology theory, 1617
children and adolescents, 134135
in clinical diagnosis, 45
self/informant agreement, 45 L TPH allele, 111
Inpatient care, group therapy, 256. Lamotrigine, 281
See also Hospital care Learning principle, dialectical behavior
Insecure attachment. See Disorganized therapy, 237238
attachment Length of stay, inpatients, 166, 168170
Insight-oriented interventions, and therapeutic Levels of care, 161183
alliance, 302 case example, 164165
Intensive outpatient care definitions, 161162, 162
definition, 162 evidentiary basis, 162, 163
evidentiary basis, 62, 163 therapeutic goals, 162, 164, 164
indications, 173174 Life event stress, suicide risk factor, 350351
therapeutic goals, 164, 164, 167, 174 Lifetime prevalence, personality disorders, 99
structures, 174 Limit setting, and boundary issues, 314
Intergenerational transmission, attachment Lithium carbonate, 277278
security, 212 dual-diagnosis patients, 374
Intermittent explosive disorder, 7, 111, 277, 280 in personality disorders, 277278
Internal working models Longitudinal studies, personality disorders
attachment relationship link, 124125 course, 6775
disorganized attachment effect on, 216 Longitudinal Study of Personality Disorders,
representational systems in, 211 6970, 73
Internalization of the analyst, 191 Long-term hospitalization, 169170, 172173
Internalization, personality trait superfactor, Long-term outpatient group therapy, 255
386387 Loxapine, 269
Internalized object relations. See Object
relations
International Personality Disorders MACI (Millon Adolescent Clinical Inventory),
Examination (IPDE), 44 136
Interpersonal circumplex, theory, 2526 Magnetic resonance imaging (MRI). See also
Interpersonal effectiveness training, 241, 242 Functional imaging
Interpersonal relationships, 3940, 4243 Cluster B personality disorders, 115
Interpretation (psychotherapy) schizotypal personality disorder, 108
in mentalization-based treatment, 224225 Maladaptive schemas, 18
in psychoanalytic therapy, 190191 Malignant narcissism, and therapeutic
therapeutic alliance link, 302 alliance, 296
Interrater reliability, 6566 Malpractice suits, boundary violations,
Interviews, 4345. See also Clinical 312313
interviewing Managed care, and collaborative treatment,
Introjective character, 186 327, 330
MAO-A allele, 113
MAOIs (monoamine oxidase inhibitors),
Joint treatment. See Collaborative treatment 275276
Index 411
Marital status, epidemiology, 91, 92, 9394 Motivation, and relapse, substance abuse, 368
Masochistic personality disorder, Motivational interviewing, and dual
psychoanalytic therapy, 193, 196, 203204 diagnosis, 373
Maternal behavior, and attachment security, MRI. See Magnetic resonance imaging
212213
Maturation, and personality development,
128131 Naltrexone, 375
McLean Study of Adult Development, 70 Narcissistic pathology, 198200
MCMI-III (Millon Clinical Multiaxial Narcissistic personality disorder
Inventory-III), 44 affective features, 39
Medical model, and dimensional diagnosis, characteristic features, 41
385 childhood maltreatment association,
Medication. See Pharmacotherapy 146148
Mentalization cognitive developmental factors, 126
anatomy, 217 collaborative treatment issues, 329
attachment theory link, 214215 DSM ontogeny, 7, 8
borderline personality disorder, 209226 DSM-IV-TR diagnostic criteria, 400
definition, 192, 197 group treatment, 259
and disorganized attachment, 214216 Kernbergs contribution, 16
enhancement of, 223224 Kohuts contribution, 16
failure of, 216217 marital status, 92, 93
intensive outpatient group, 175 prevalence, 85, 86, 88, 89
partial hospitalization program, 173 psychoanalytic therapy, 194, 194
psychoanalytic therapy indication, 192 self-representation development, 126
theory of, 214215 suicidality, 347, 355356
trauma effect on, 217219 therapeutic alliance, 294, 296
Mentalization-based treatment Neglected children, 147148
borderline personality disorder, 197198, NEO Personality InventoryRevised
222226, 369 (NEO-PI-R), 130
cognitive-behavioral therapy difference, Neuroimaging. See Brain imaging
223224 Neuroleptics, 269273
effectiveness, 225226 dual-diagnosis patients, 374
substance abuse comorbidity, 369 in personality disorders, 269273
Meta-analysis, pharmacotherapy, 281282 dual-diagnosis patients, 374
3-Methoxy-4-hydroxy-phenylglycol (MHPG), schizotypal personality disorder, 106
112 Neuroticism
Military psychiatry, and character disorders, in Five-Factor Model, 1920, 387
45 heritability, 2223
Millon Adolescent Clinical Inventory (MACI), normative developmental changes, 130
136 Normal personality, maturational changes,
Millon Clinical Multiaxial InventoryIII 130131
(MCMI-III), 44 Novelty seeking, substance abuse pathway,
Millons evolutionarysocial learning model, 366
25
Mindfulness practice, 238239, 241, 241
Minnesota Multiphasic Personality Object relations
Inventory2, 44 diagnostic approach, 52
Mirror transference, 199 personality disorders conceptualization,
Mirroring, 1617, 215216 1415
Monoamine oxidase inhibitors (MAOIs), psychoanalytic theory, 187189
275276 psychoanalytic therapy, 189191, 198
Mood stabilizers Observational assessment, 4344
in dual-diagnosis patients, 374 Obsessive-compulsive personality disorder
in personality disorders, 277281 affective features, 39
meta-analysis, 281282 childhood maltreatment association, 147
Obsessive-compulsive personality disorder Passive-aggressive personality disorder

(continued) childhood maltreatment association,
cognitive features, 39 145148
collaborative treatment issues, 329 DSM ontogeny, 7, 9
course and outcome, longitudinal study, marital status, 92, 94
7074 prevalence, 85, 87, 88, 89
DSM ontogeny, 7 therapeutic relationship, 301
DSM-IV-TR diagnostic criteria, 402
Five-Factor Model, 20 PDI-IV (Personality Disorder InterviewIV),
group treatment, 260 44
marital status, 92, 93 PDNOS. See Personality disorders not
prevalence, 85, 8687, 89 otherwise specified
psychoanalytic therapy, 193, 195, 201202 Personality Diagnostic Questionnaire4, 44
remission rates, 7174, 72, 74 Personality Disorder InterviewIV (PDI-IV),
suicidality, 348 44
therapeutic alliance, 295, 300301 Personality disorders not otherwise specified
case example, 300301 (PDNOS)
Odd or Eccentric Cluster. See Cluster A DSM-IV-TR diagnostic criteria, 395
Olanzapine, 271272, 281 frequency of use, 385
Onset, 42. See also Early onset Personality Inventory for Children (PIC-2),
Outcome, 6379. See also Clinical course 134, 136
Outpatient care Personality Inventory for Youth (PIY), 134, 136
case example, 164 Personality traits
definition, 162 behavior genetics, 2224
evidentiary basis, 162, 163 biological perspective, 2122
goals, 164, 167, 176 childhood experiences link, 144154
indications, 175176, 179 Five-Factor Model, 19
structures, 177 heritability, 2223
Oxcarbazepine, 280 longitudinal study, 73, 75
normative developmental stages, 130131
in personality disorder models, 383385
Paranoid personality disorder personality disorders distinction, 4950
Axis I comorbidity, 55 versus states, assessment problems, 4647
characteristic features, 41 in tripartite model, 389, 389
childhood maltreatment association, Personality and Personality Disorders Work
145148 Group, 382383, 383
cognitive features, 38 Pervasiveness feature, 40, 42, 4546
collaborative treatment issues, 328 PET. See Positron emission tomography
DSM-IV-TR diagnostic criteria, 396 Pharmacotherapy, 267282
DSM ontogeny, 7 antidepressants, 273276
marital status, 92, 93 anxiolytics, 276277
prevalence, 85, 86, 88, 89 basic assumptions, 267269
psychoanalytic therapy, 193, 194 in collaborative treatment, 323325, 330336
suicidality, 348 controlled trial difficulties, 268
therapeutic alliance, 293, 294 dual-diagnosis patients, 374375
Parent informants, 134135 lethality potential, 335
Parenting, protective aspects, 150151 lithium and mood stabilizers, 277281
Paroxetine, 274 meaning to patient, 333
Partial hospital/day treatment meta-analysis, 281282
definition, 162 neuroleptics, 269273
evidentiary basis, 162, 163 patients understanding of, 333335
group experience in, 255256 and psychotherapy, 323325, 330336
indications, 170, 179 therapeutic alliance in, 304305
structure, 171172 Phenelzine, 275276
therapeutic goals, 164, 166, 170171 Phenytoin, 277278
Index 413
Phone consultation, dialectical behavior Psychodynamic Diagnostic Manual (PDM),

therapy, 245246 384385
Physically abused children, 145 Psychodynamic Diagnostic Manual Mental
PIC-2 (Personality Inventory for Children), Functioning Axis (M-Axis), 385
134, 136 Psychodynamic Diagnostic Manual
PIY (Personality Inventory for Youth), 134, 136 Personality Axis (P-Axis), 385
Point prevalence, 99 Psychodynamic psychotherapies, 185207
Polythetic criteria, 8 indications and contraindications, 192196,
Positron emission tomography (PET) 193
borderline personality disorder, 114115 outpatients, 176
Cluster B personality disorders, 114115 personality disorders psychopathology,
schizotypal personality disorder, 108 196204
Posttraumatic stress disorder, 219 theoretical basis, 186189
Power discrepancies therapeutic alliance, 302303
obsessive-compulsive personality disorder, Psychodynamic theory, 1417
201202 diagnostic approach, 52
therapist and patient, 311 functional domain model, 2628
Preoccupied attachment, 212 personality disorders conceptualization,
Prevalence, 8388, 86, 89, 99 1417
research review, 8388 Psychological mindedness, 215
substance abuse, 362363 Psychopathology domain, in tripartite model,
Primary care, collaborative treatment, 323325, 388390, 389390
330 Psychopathy
Problem-focused coping, 52 suicide immunity in, 353354
Prognosis. See Clinical course therapeutic alliance, 297
Projective identification Psychopathy ChecklistRevised, 354
in attachment relationship, 216 Psychopharmacology. See Pharmacotherapy
in collaborative treatment, 322 Psychophysiology, schizophrenia spectrum,
psychoanalytic theory, 187189, 190 106107
Pro-social traits, development, 152 Psychostimulant medication, dual-diagnosis
Protective factors, 150154 patients, 374375
Prototypes Psychotic symptoms, in differential diagnosis,
behavioral measures, 53 49
versus classical categories, 5657 Psychoticism, in three-factor model, 387
in diagnostic models, 5657, 384, 386
matching approach, 5657, 386
in tripartite model, 389390, 389 Quality of life, epidemiology, 9599, 9798
Psychiatric hospital settings Questionnaires, 4445
splitting effects, 305 Quetiapine, 273
therapeutic alliance, 305306
Psychic equivalence, 219, 221
Psychoanalytic theory, 186189, 196205 Rage outbursts, 277
diagnostic approach, 52 Reflective function. See Mentalization
Eriksons contribution, 127128 Regression to the mean problem, 66
personality psychopathology, 186189, Rejection sensitivity, with pharmacotherapy,
196205 273
Psychoanalytic therapy Relapse factors, in substance abuse, 368
group treatment, 257258 Relational alliance, 178
indications and contraindications, 192196, Relational theory, 1415
193 Reliability (psychometrics)
versus psychodynamic therapy, 190191 in clinical course assessments, 65
major principles, 189192 in diagnostic assessments, 78
in partial hospitalization program, 172 Remission rates, longitudinal study, 7174, 72,
theoretical basis, 186189 74
therapeutic alliance, 302303 Repeated measures studies, and reliability, 66
Residential treatment, group therapy, 256 Axis I comorbidity, 55

Resiliency, development of, 152153 behavior genetics, 104105
Resistance, in psychoanalytic therapy, 189 childhood maltreatment association,
Revictimized women, 220 146148
Reward sensitivity, and substance abuse, 366 cognitive features, 38, 106107
Richard Corey suicide, 356 collaborative treatment, 328
Risk factors course and outcome, longitudinal study,
childhood adversities as, 123124 7074
suicide, 349352 differential diagnosis, 4849
Risperidone, 271 dopamine system, 105106
Role relationship model, 188 DSM ontogeny, 7, 8
DSM-IV-TR diagnostic criteria, 397
functional imaging, 108
Sadistic personality disorder group treatment, 259
DSM ontogeny, 7, 89 heritability, 2324
marital status, 92 neurobiology, 104109
prevalence, 85, 87 neuroleptic treatment, 269271
Sadomasochistic character prevalence, 85, 86, 88, 89
case example, 298 psychoanalytic therapy, 193, 194
therapeutic alliance, 297298 remission rates, 109111, 110111
SASB (Structural Analysis of Social Behavior), schizophrenia differential diagnosis, 49
theory, 2526 structural imaging, 107108
Schedule for Nonadaptive and Adaptive suicidality, 348
Personality (SNAP), 386, 388 therapeutic alliance, 292293, 294
Schema therapy, substance abuse comorbidity, SCID-II (Structured Clinical Interview for
469471 DSM-IV Axis II Personality Disorders), 44
Schemas Secure attachment, 124, 211
diagnostic approach, 53 infant behavior, 211
internal working models link, 124125 intergenerational transmission, 212
personality disorders conceptualization, internal working models, 211
1819 Selective serotonin reuptake inhibitors,
in role relationship model, 188 273275
Schizoid personality disorder collaborative treatment, 323327
affective features, 39 dual-diagnosis patients, 374
Axis I comorbidity, 55 in personality disorders, 273275
characteristic features, 41 Selegiline, 276
childhood maltreatment association, Self psychology
145147 theory, 1415,
collaborative treatment, 328 therapeutic application, 191
DSM ontogeny, 7, 8 Self-assessment groups, 174175
DSM-IV-TR diagnostic criteria, 396 Self-defeating personality disorder
group treatment, 258259 DSM ontogeny, 7, 89
marital status, 92, 93 marital status, 92, 94
Millons theory, 25 prevalence, 85, 87
prevalence, 85, 86, 8889 psychoanalytic therapy, 193, 196, 203204
psychoanalytic therapy, 193, 194, 196197 Self-efficacy, 152
suicidality, 348 Self-harm, 221. See also Self-injurious behavior
therapeutic alliance, 293, 294 Self-injurious behaviors
Schizophrenia behavioral analysis, 245
Cluster A comorbidity, 4849 definition, 344
schizotypal personality disorder link, dialectical behavior therapy, 242246
2324 efficacy data, 248249
Schizotypal personality disorder and suicide risk, 354
affective features, 39 Self-medication pathway, alcoholism,
and aging process, 68 365366
Index 415
Selfobject transferences Social anxiety disorder, neurobiology, 117

Kohuts theory, 199 Social-cognitive theory, 1719
therapeutic effect, 191 Social functioning, longitudinal study, 73
Self-regulation, conceptualization, 18 Socioeconomic status, epidemiology, 9495
Self-report measures Sociopathic personality disturbances, 67, 7
children and adolescents, 134136 Somatic treatments, 267288. See also
in clinical assessment, 4445 Pharmacotherapy
versus interviews, 4445 SPECT. See Single photon emission computed
Self-representations tomography
in abuse victims, 219221 Split treatment, 321. See also Collaborative
attachment disorganization effect on, treatment
215217 Splitting
attachment relationship link, 124125 borderline personality disorder, 38
developmental changes, 125127 developmental aspects, 126
and mentalization failure, 216 psychiatric hospital settings, 305
object relations theory, 189191 in split treatment, 322, 325326
psychoanalytic perspective, 188189 and therapeutic alliance, 293, 297
psychoanalytic therapy, 192193 SSRIs. See Selective serotonin reuptake
Semistructured interviews inhibitors
in clinical assessment, 45 Stability tenet
substance abuse assessment, 362363 Axis I versus Axis II disorder, 71
Sense of self, attachment relationship effect, in children and adolescents, 131132
124125 longitudinal studies, 6975
Serotonergic system personality disorders course, 6364
borderline personality disorder, 110112 research review, 6475
Cluster B personality disorders, 110112 Standardized assessment, 6566
Cluster C personality disorders, 117 State versus trait, and assessment, 4647
impulsive aggression, 110112, 114115, 345 Step-down levels of care, 179
Serotonin receptors, Cluster B personality STEPPS (Systems Training for Emotional
disorders, 110111 Predictability and Problem Solving), 258
Serotonin transporter alleles Stimulant medications, dual-diagnosis
borderline personality disorder, 111112 patients, 374375
shyness association, 117 Strange Situation procedure, 211212
Sertraline, 273274 Stress reduction, substance abuse motivation,
Seven-factor model, 2122 365366
Sex ratio. See Gender factors Stressful life events, and suicidality, 350351
Sexual boundaries. See Boundary issues Striatal volumes, schizotypal personality
Sexually abused women, revictimization, 220 disorder, 107108
Shame, and avoidant personality disorder, 202 Structural Analysis of Social Behavior (SASB),
Shedler-Westen Assessment Procedure-200 for theory, 2526
Adolescents (SWAP-200-A), 136 Structural imaging
Short-term outpatient group therapy, 255 Cluster B personality disorder, 113114
SIDP-IV (Structured Interview for DSM-IV schizotypal personality, 107108
Personality Disorders), 44 Structured Clinical Interview for DSM-IV Axis
Siever/Davis model, 21 II Personality Disorders (SCID-II), 44
Single photon emission computed Structured Interview for DSM-IV Personality
tomography (SPECT) Disorders (SIDP-IV), 44
Cluster B personality disorders, 114115 Structured interviews, children and
schizotypal personality disorder, 108 adolescents, 135
Skills training Submissiveness, personality disorder, 39
in dialectical behavior therapy, 240242, Substance abuse, 361378
241, 245247 assessment and diagnosis, 362364
partial hospitalization programs, 170172 causal pathways, 364367
SNAP (Schedule for Nonadaptive and Cluster B comorbidity, 5556
Adaptive Personality), 386, 388 and collaborative treatment, 327, 330
Substance abuse (continued) Cluster B personality disorders, 293, 294,

common factor model, 366367 296297
dialectical behavior therapy, 371372 Cluster C personality disorders, 294295,
epidemiology, 362 299301
pharmacotherapy, 374375 cognitive-behavioral therapy, 303304
primary personality disorder model, definition, 290291
365366 in levels of care, 178
primary substance abuse model, 364365 in psychiatric hospital settings, 305306
psychotherapy guidelines, 373374 in psychodynamic therapy, 302303
relapse factors, 367368 in psychopharmacology, 304305
schema therapy, 369374 stages in, 290291
suicide risk factor, 350 strains and ruptures, 291292
treatment outcome, 367372 and substance abuse outcome, 368
Suicidality, 343359 in transference-focused psychotherapy,
and alien self-eradication fantasy, 221222 189191
anankastic personality disorder, 348 Therapeutic community, 169
antisocial personality disorder, 346, 353354 Therapist-patient relationship. See Therapeutic
borderline personality disorder, 346, alliance
349352, 354355 Thiothixene, 269
boundary violations, 315317 Three-factor model, 387388
in Clusters A and C, 347349 Time to remission, longitudinal study, 73, 74
comorbidity role, 349352 Topiramate, 280281
definitions, 343344 TPH (tryptophan hydroxylase), 111
dialectical behavior therapy, 245247 Trait theory. See Personality traits
efficacy data, 248249 Transference
epidemiological evidence, 346249 dependent personality disorder, 203
histrionic personality disorder, 347 hysterical/histrionic personality disorder,
hospitalization, 168 201
narcissistic personality disorder, 347, interpretations, and therapeutic alliance,
355356 302
risk assessment, 344346 in mentalization-based treatment, 224225
risk factors, 349352 and narcissistic personality disorder,
in uncommunicative patients, 352353 199200, 199
SWAP-200-A (Shedler-Westen Assessment in pharmacotherapy, 332333
Procedure-200 for Adolescents), 136 psychoanalytic theory, 186188
Symptom levels therapeutic principles, 189191
developmental stability and change, 128132 and transference-focused psychotherapy,
longitudinal study, 7075, 131133 198, 224
Symptom neuroses, Freudian theory, 4 Transference-focused psychotherapy
Systems Training for Emotional Predictability borderline personality disorder, 198
and Problem Solving (STEPPS), 258 effectiveness, 198
versus mentalization-based treatment,
224
Teachers, as informants, 134 Transgenerational factors, and attachment,
Temperament 212
change and stability, 131 Tranylcypromine, 275276
and personality structure model, 2122 Trauma. See also Child adversity/trauma
psychoanalytic perspective, 186 and alien self development, 219221
Temperament and Character Model, 387 mentalization inhibition, effect of, 217219
Test-retest reliability, 6566 Tricyclic antidepressants, 276
Therapeutic alliance, 289308 Trifluoperazine, 270
and borderline personality disorder, 293, Tripartite model, 388390, 389390
294, 296 Tryptophan hydroxylase (TRH)
Cluster A personality disorders, 292293, polymorphism, 111
294 Twin studies, 24
Index 417
Uncommunicative patients, and suicidality, Vicarious reinforcement, 240241

352353 Violence, borderline personality disorder, 222
Unconscious, psychodynamic model, 4, 191
Urban location, personality disorders
prevalence, 95 Westens functional domains model, 2628
Women. See Gender factors
Working alliance, in levels of care, 178
VAL alleles. See COMT polymorphism Working memory, schizotypal personality
Validation strategy, in dialectical behavior disorder, 107
therapy, 247248
Venlafaxine, 273274
Ventricular volume, schizotypal personality Zen mindfulness orientation, 238239
disorder, 107

Essentials of Personality Disord

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Essentials of Personality Disord

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Essentials of

John M. Oldham, M.D., M.S.

Karen, Madeleine, and Michael Oldham;

To our colleagues, who have helped us.

To our patients, who have taught us.

1 Personality Disorders: Recent History and

2 Theories of Personality and Personality Disorders . . . . . . . . . . 13

3 Manifestations, Clinical Diagnosis, and Comorbidity . . . . . . . . 37

4 Course and Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

5 Prevalence, Sociodemographics, and

7 Developmental Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123

8 Childhood Experiences and

9 Levels of Care in Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . 161

10 Psychoanalysis and Psychodynamic Psychotherapy . . . . . . . . 185

11 Mentalization-Based Treatment of Borderline

12 Dialectical Behavior Therapy . . . . . . . . . . . . . . . . . . . . . . . . . 235

14 Somatic Treatments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267

15 Therapeutic Alliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289

16 Boundary Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309

17 Collaborative Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321

18 Assessing and Managing Suicide Risk . . . . . . . . . . . . . . . . . . . 343

19 Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361

20 Future Directions: Toward DSM-V . . . . . . . . . . . . . . . . . . . . . 381

Appendix: DSM-IV-TR Diagnostic Criteria for

Samuel A. Ball, Ph.D. Thomas Crawford, Ph.D.

Thomas G. Gutheil, M.D. William E. Piper, Ph.D.

Roel Verheul, Ph.D. The following contributors have no competing in-

The final five chapters of this section ad-

As to why we behave the way we do, we

However, even-tempered, easy-to-care- cursors or less extreme forms of psychotic

nisms and to symptom formation, and as a other syndromes characterized by discrete,

Figure 11. Ontogeny of personality disorder classification.

Table 11. General diagnostic criteria for a personality disorder

ingly, a stress/diathesis framework seems somewhat unique to the personality disor-

P ersonality refers to enduring patterns of need not be broadly generalized to be con-

Among the dozens of approaches to per- had understood psychological problems in

lucinations, etc.). What distinguishes indi- According to Kernberg, whereas borderline

3) conscientiousness; 4) agreeableness; and ever, are that it integrates the understanding

pulsivity/aggression (impulse control disor-

the interpersonal circumplex (e.g., Kiesler neglect or abandonment. Anger in narcissis-

anxiety, depression, anger, self-conscious- pacity to lead a fulfilling life. He wanted to

concerns centered around rejection, shame,

Harter S: The Construction of the Self: A Develop- Psychopathology. Edited by Lenzenweger M,

Cluster Type Characteristic features

Manifestations, Clinical Diagnosis, and Comorbidity

tress or impairment in social, occupational, or even beyond apparent improvement in per-

dent of her mood disorder. Similarly, passivity, emotionality, emphasis on work

clinician is a psychodynamically oriented includes a Defensive Functioning Scale and a

tinues to involve making present/absent American Psychiatric Association: Diagnostic and

available research suggested that personality

Reliability and Change Categorical Versus

Summary and Implications of the conceptual and methodological issues

Time from intake (months)

Time from intake (months)

Prevalence, Sociodemographics, and Functional Impairment

Females Males Total

Prevalence, Sociodemographics, and Functional Impairment

Number 1,142 206 911 92 2,053 298

As to the clusters of personality disor- and obsessive-compulsive personality disor-

Number 2,053 693 830 43 185 33 43 253

Among the proposed personality disor- In applying logistic regression analysis

Prevalence, Sociodemographics, and Functional Impairment

DNA polymorphism studies. The presence of Other neurotransmitters or neuromodu-

ceedingly drunk and drives recklessly norepinephrine, vasopressin for impulsivity