Textbook of Personality Disorders

THE AMERICAN PSYCHIATRIC PUBLISHING
TEXTBOOK OF
PERSONALITY
DISORDERS
S E C O N D E D I T I O N
This page intentionally left blank
THE AMERICAN PSYCHIATRIC PUBLISHING
TEXTBOOK OF
PERSONALITY
DISORDERS
S E C O N D E D I T I O N
EDITED BY
John M. Oldham, M.D., M.S.

Andrew E. Skodol, M.D.
Donna S. Bender, Ph.D., FIPA
Washington, DC
London, England
Note. The authors have worked to ensure that all information in this book is accu-
rate 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 practice continue to advance, however, therapeutic standards
may change. Moreover, specific situations may require a specific therapeutic response
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rors sometimes occur, we recommend that readers follow the advice of physicians di-
rectly involved in their care or the care of a member of their family.
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Library of Congress Cataloging-in-Publication Data
The American Psychiatric Publishing textbook of personality disorders / edited by
John M. Oldham, Andrew E. Skodol, Donna S. Bender. — Second edition.
p. ; cm.
Textbook of personality disorders
Includes bibliographical references and index.
ISBN 978-1-58562-456-0 (hardcover : alk. paper)
I. Oldham, John M., editor. II. Skodol, Andrew E., editor. III. Bender, Donna S.,
editor. IV. American Psychiatric Publishing, issuing body. V. Title: Textbook of person-
ality disorders.
[DNLM: 1. Personality Disorders—therapy. 2. Personality Disorders—diagnosis.
3. Personality Disorders—etiology. WM 190]
RC554
616.85c81—dc23
2014008220
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
Foreword. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xv
Steven E. Hyman, M.D.
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix
John M. Oldham, M.D., M.S., Andrew E. Skodol, M.D., and
1 Personality Disorders: Recent History

and New Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Part I
Clinical Concepts and Etiology
2 Theories of Personality and Personality Disorders. . . . . 13
Amy K. Heim, Ph.D., and Drew Westen, Ph.D.
3 Articulating a Core Dimension of

Personality Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Leslie C. Morey, Ph.D., and Donna S. Bender, Ph.D., FIPA
4 Development, Attachment, and Childhood

Experiences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Peter Fonagy, Ph.D., Anthony W. Bateman, M.A., FRCPsych,
Nicolas Lorenzini, M.Sc., M.Phil., and Chloe Campbell, Ph.D.
5 Genetics and Neurobiology . . . . . . . . . . . . . . . . . . . . . . . 79

Harold W. Koenigsberg, M.D., Antonia S. New, M.D.,
Larry J. Siever, M.D., and Daniel R. Rosell, M.D., Ph.D.
6 Prevalence, Sociodemographics, and

Functional Impairment . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Svenn Torgersen, Ph.D.
7 Manifestations, Assessment, and

Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
8 Course and Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . 165

Carlos M. Grilo, Ph.D., Thomas H. McGlashan, M.D.,
and Andrew E. Skodol, M.D.
Part II
Treatment
9 Therapeutic Alliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
10 Psychodynamic Psychotherapies and

Psychoanalysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Frank E. Yeomans, M.D., John F. Clarkin, Ph.D.,
and Kenneth N. Levy, Ph.D.
11 Cognitive-Behavioral Therapy I:
Basics and Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
Martin Bohus, M.D.
12 Cognitive-Behavioral Therapy II:

Specific Strategies for Personality Disorders. . . . . . . . . 261
J. Christopher Fowler, Ph.D., and John M. Hart, Ph.D.
13 Group, Family, and Couples Therapies . . . . . . . . . . . . . 281

John S. Ogrodniczuk, Ph.D., Amanda A. Uliaszek, Ph.D.,
Jay L. Lebow, Ph.D., and William E. Piper, Ph.D.
14 Psychoeducation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
Alan E. Fruzzetti, Ph.D., John G. Gunderson, M.D.,
and Perry D. Hoffman, Ph.D.
15 Somatic Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321

S. Charles Schulz, M.D., and Katharine J. Nelson, M.D.
16 Collaborative Treatment . . . . . . . . . . . . . . . . . . . . . . . . . 345

Abigail B. Schlesinger, M.D., and Kenneth R. Silk, M.D.
17 Boundary Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369

Thomas G. Gutheil, M.D.
Part III
Special Problems,
Populations, and Settings
18 Assessing and Managing Suicide Risk. . . . . . . . . . . . . . 385
Paul S. Links, M.Sc., M.D., FRCPC, Paul H. Soloff, M.D., and
Francesca L. Schiavone, B.Sc.
19 Substance Use Disorders . . . . . . . . . . . . . . . . . . . . . . . 407
Seth J. Prins, M.P.H., Jennifer C. Elliott, Ph.D.,
Jacquelyn L. Meyers, Ph.D., Roel Verheul, Ph.D.,
and Deborah S. Hasin, Ph.D.
20 Antisocial Personality Disorder and Other

Antisocial Behavior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
Donald W. Black, M.D., and Nancee S. Blum, M.S.W.
21 Personality Disorders in the Medical Setting . . . . . . . . 455

Randy A. Sansone, M.D., and Lori A. Sansone, M.D.
22 Personality Disorders in the Military

Operational Environment . . . . . . . . . . . . . . . . . . . . . . . . 475
Ricky D. Malone, M.D., Col., M.C., U.S.A., and
David M. Benedek, M.D., Col., M.C., U.S.A.
Part IV
Future Directions
23 Translational Research in Borderline
Personality Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489
Christian Schmahl, M.D., and Sabine Herpertz, M.D.
24 An Alternative Model for Personality Disorders:

DSM-5 Section III and Beyond. . . . . . . . . . . . . . . . . . . . 511
Andrew E. Skodol, M.D., Donna S. Bender, Ph.D., FIPA
and John M. Oldham, M.D., M.S.
Appendix: Alternative DSM-5 Model for

Personality Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . 545
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 569
Contributors
Anthony W. Bateman, M.A., FRCPsych Medical College of Cornell University,
Professor, Halliwick Unit, St Ann’s Hos- New York, New York
pital; Research Department of Clinical,
Jennifer C. Elliott, Ph.D.
Educational, and Health Psychology, Uni-
versity College London, London, United Postdoctoral Fellow, Substance Use Dis-
Kingdom orders Training Program, Department of
Epidemiology, Columbia University, New
Donna S. Bender, Ph.D., FIPA York, New York
Director, Counseling and Psychological
Services, Tulane University, New Orleans, Peter Fonagy, Ph.D.
Louisiana Professor and Head, Research Department
of Clinical, Educational, and Health Psy-
David M. Benedek, M.D., Col., M.C., chology, University College London; Anna
U.S.A. Freud Centre, London, United Kingdom
Department of Psychiatry, Uniformed Ser-
vices University of the Health Sciences, J. Christopher Fowler, Ph.D.
Bethesda, Maryland Associate Professor, Menninger Depart-
ment of Psychiatry and Behavioral Sci-
Donald W. Black, M.D.
ences, Baylor College of Medicine,
Professor and Vice-Chair for Education, Houston, Texas
Department of Psychiatry, University of
Iowa Roy J. and Lucille A. Carver Col- Alan E. Fruzzetti, Ph.D.
lege of Medicine, Iowa City, Iowa Professor of Psychology and Director,
Dialectical Behavior Therapy and Re-
Nancee S. Blum, M.S.W.
search Program, University of Nevada,
Adjunct Instructor, Department of Psy-
Reno, Nevada
chiatry, University of Iowa Roy J. and
Lucille A. Carver College of Medicine, Carlos M. Grilo, Ph.D.
Iowa City, Iowa Professor of Psychiatry, Department of
Martin Bohus, M.D. Psychiatry, Yale University School of
Chair in Psychosomatic Medicine and Medicine, New Haven, Connecticut
Psychotherapy, Heidelberg University, John G. Gunderson, M.D.
Germany; Director, Department of Psy-
Professor of Psychiatry, Harvard Medi-
chosomatic Medicine and Psychothera-
cal School; Director, Psychosocial and
py, Central Institute of Mental Health,
Personality Research, McLean Hospital,
Mannheim, Germany
Boston, Massachusetts
Chloe Campbell, Ph.D.
Research Department of Clinical, Educa-
Professor of Psychiatry, Harvard Medi-
tional, and Health Psychology, University
cal School, and Co-Founder, Program in
College London, London, United Kingdom
Psychiatry and the Law, Beth Israel-
John F. Clarkin, Ph.D. Deaconess Medical Center and the Mas-
Professor of Clinical Psychology in Psy- sachusetts Mental Health Center, Boston,
chiatry, Department of Psychiatry, Weill Massachusetts
xi
xii The American Psychiatric Publishing Textbook of Personality Disorders
John M. Hart, Ph.D. Paul S. Links, M.Sc., M.D., FRCPC

Cognitive and Behavioral Therapy Spe- Professor and Chair, Department of Psy-
cialist, Menninger Department of Psy- chiatry, Schulich School of Medicine and
chiatry and Behavioral Sciences, Baylor Dentistry, The University of Western
College of Medicine, Houston, Texas Ontario; Chief of Psychiatry, London
Health Sciences Centre and St. Joseph’s
Deborah S. Hasin, Ph.D. Health Care, London, Ontario, Canada
Professor of Clinical Epidemiology (in
Psychiatry), Columbia University, New Nicolas Lorenzini, M.Sc., M.Phil.
York, New York Research Department of Clinical, Educa-
tional, and Health Psychology, Universi-
Amy K. Heim, Ph.D. ty College London; Anna Freud Centre,
Private Practice, Lexington, Massachusetts London, United Kingdom
Sabine Herpertz, M.D. Ricky D. Malone, M.D., Col., M.C., U.S.A.
Medical Director, Department of Gener- Center for Forensic Behavioral Sciences,
al Psychiatry, Centre of Psychosocial Walter Reed National Military Medical
Medicine, Heidelberg, Germany Center, Bethesda, Maryland
Perry D. Hoffman, Ph.D. Thomas H. McGlashan, M.D.
President and Co-Founder, National Ed- Professor of Psychiatry, Department of
ucation Alliance for Borderline Person- Psychiatry, Yale University School of
ality Disorder, Rye, New York Medicine, New Haven, Connecticut
Steven E. Hyman, M.D. Jacquelyn L. Meyers, Ph.D.
Director, Stanley Center for Psychiatric Postdoctoral Fellow, Psychiatric Epidemi-
Research at the Broad Institute of MIT ology, Department of Epidemiology, Co-
and Harvard; Harvard University Dis- lumbia University, New York, New York
tinguished Service Professor of Stem
Cell and Regenerative Biology, Harvard Leslie C. Morey. Ph.D.
University, Cambridge, Massachusetts George T. and Gladys H. Abell Profes-
sor, Department of Psychology, Texas
Harold W. Koenigsberg, M.D. A&M University, College Station, Texas
Professor of Psychiatry and Co-Director,
Mood and Personality Disorders Pro- Katharine J. Nelson, M.D.
gram, Icahn School of Medicine at Assistant Professor of Psychiatry and
Mount Sinai, New York, New York; Staff Medical Director of the Borderline Per-
Psychiatrist, James J. Peters VA Medical sonality Disorder Program, Department
Center, Bronx, New York of Psychiatry, University of Minnesota
Medical School, Minneapolis, Minnesota
Jay L. Lebow, Ph.D.
Clinical Professor of Psychology, Family In- Antonia S. New, M.D.
stitute at Northwestern, Evanston, Illinois Professor of Psychiatry, Icahn School of
Medicine at Mount Sinai, New York,
Kenneth N. Levy, Ph.D. New York
Assistant Professor, Department of Psy-
chology, Pennsylvania State University, John S. Ogrodniczuk, Ph.D.
University Park, Pennsylvania; Adjunct Professor, Department of Psychiatry,
Assistant Professor of Psychology, De- University of British Columbia, Vancou-
partment of Psychiatry, Joan and San- ver, British Columbia, Canada
ford I. Weill Medical College of Cornell
University, New York, New York John M. Oldham, M.D., M.S.
Senior Vice President and Chief of Staff,
The Menninger Clinic; Barbara and Cor-
Contributors xiii
bin Robertson Jr. Endowed Chair for Endowed Chair, Department of Psychia-
Personality Disorders, and Professor try, University of Minnesota Medical
and Executive Vice Chair, Menninger School, Minneapolis, Minnesota
Department of Psychiatry and Behavior-
al Sciences, Baylor College of Medicine, Larry J. Siever, M.D.
Houston, Texas; Past President, Ameri- Professor of Psychiatry, Icahn School of
can Psychiatric Association Medicine at Mount Sinai, New York,
New York; Director Mental Illness Re-
William E. Piper, Ph.D. search, Education and Clinical Centers,
Professor Emeritus, Department of Psy- James J. Peters VA Medical Center,
chiatry, University of British Columbia, Bronx, New York
Vancouver, British Columbia, Canada
Kenneth R. Silk, M.D.
Seth J. Prins, M.P.H. Professor, University of Michigan School
Predoctoral Fellow, Psychiatric Epide- of Medicine, Ann Arbor, Michigan
miology Training Program, Department Andrew E. Skodol, M.D.
of Epidemiology, Columbia University, Research Professor of Psychiatry, Depart-
Mailman School of Public Health, New ment of Psychiatry, University of Arizona
York, New York College of Medicine, Tucson, Arizona
Daniel R. Rosell, M.D., Ph.D. Paul H. Soloff, M.D.
Fellow, James J. Peters VA Medical Cen- Professor of Psychiatry, Department of
ter, Bronx, New York Psychiatry, School of Medicine, Universi-
ty of Pittsburgh, Pittsburgh, Pennsylvania
Lori A. Sansone, M.D.
Civilian Family Medicine Physician and Svenn Torgersen, Ph.D.
Medical Director, Family Health Clinic, Professor, Department of Psychology,
Wright-Patterson Air Force Base, Day- University of Oslo, Blindern, Norway
ton, Ohio
Amanda A. Uliaszek, Ph.D.
Randy A. Sansone, M.D. Assistant Professor, Department of Psy-
Professor, Departments of Psychiatry and chology, University of Toronto Scarbor-
Internal Medicine, Wright State Universi- ough, Toronto, Ontario, Canada
ty School of Medicine, Dayton, Ohio; Di-
Roel Verheul, Ph.D.
rector of Psychiatry Education, Kettering
Medical Center, Kettering, Ohio Professor of Personality Disorders, Uni-
versity of Amsterdam; Chief Executive
Francesca L. Schiavone, B.Sc. Officer/President of de Viersprong, Neth-
Medical Student, Schulich School of Medi- erlands Center for Personality Disorders,
cine and Dentistry, The University of West- Halsteren, The Netherlands
ern Ontario, London, Ontario, Canada
Drew Westen, Ph.D.
Abigail B. Schlesinger, M.D. Professor, Department of Psychology and
Assistant Professor, University of Pitts- Department of Psychiatry and Behav-
burgh School of Medicine, Pittsburgh, ioral Sciences, Emory University, Atlan-
Pennsylvania ta, Georgia
Christian Schmahl, M.D. Frank E. Yeomans, M.D.

Department of Psychosomatic Medicine Clinical Associate Professor of Psychiatry,
and Psychotherapy, Central Institute of Department of Psychiatry, Weill Medical
Mental Health, Mannheim, Germany College of Cornell University; Adjunct
Associate Professor, Columbia University
S. Charles Schulz, M.D. Center for Psychoanalytic Training and
Professor and Head, Donald W. Hastings Research, New York, New York
xiv The American Psychiatric Publishing Textbook of Personality Disorders
Disclosures of Competing Interests

The following contributors to this book have The following contributors to this book have
indicated a financial interest in or other affili- indicated no competing interests to disclose
ation with a commercial supporter, a manu- during the year preceding manuscript sub-
facturer of a commercial product, a provider of mission:
a commercial service, a nongovernmental or-
Anthony W. Bateman, M.A., FRCPsych
ganization, and /or a government agency, as
Donna S. Bender, Ph.D.
listed below:
David M. Benedek, M.D., Col., M.C.,
Donald W. Black, M.D.—Research grant: U.S.A.
AstraZeneca. Royalties: American Psychi- Martin Bohus, M.D.
atric Publishing; Oxford University Press Chloe Campbell, Ph.D.
Nancee S. Blum, M.S.W.—Royalties: Level John F. Clarkin, Ph.D.
One Publishing (publisher of STEPPS, Jennifer C. Elliott, Ph.D.
STEPPS UK, and STAIRWAYS treatment Peter Fonagy, Ph.D.
manuals, as first author). Consultant: Iowa J. Christopher Fowler, Ph.D.
Department of Corrections Carlos M. Grilo, Ph.D.
John G. Gunderson, M.D.
Thomas G. Gutheil, M.D.—More than
John M. Hart, Ph.D.
300 publications in national and interna-
Deborah S. Hasin, Ph.D.
tional professional literature, some of
Amy K. Heim, Ph.D.
which generate income
Sabine Herpertz, M.D.
Paul S. Links, M.Sc., M.D., FRCPC— Harold W. Koenigsberg, M.D.
Honorarium: Lundbeck Canada 2012 Jay L. Lebow, Ph.D.
Antonia S. New, M.D.—The author has Nicolas Lorenzini, M.Sc., M.Phil.
been a consultant for Alkermes. Other- Ricky D. Malone, M.D., Col., M.C.,
wise, no conflicts of interest to report. U.S.A.
The author believes consultation with Thomas H. McGlashan, M.D.
Alkermes is not a conflict of interest. She Jacquelyn L. Meyers, Ph.D.
has consulted on pharmacology in per- Leslie C. Morey
sonality disorders with Alkermes. She John S. Ogrodniczuk, Ph.D.
did not include any Alkermes product in John M. Oldham, M.D.
authoring of her chapter. William E. Piper, Ph.D.
S. Charles Schulz, M.D.—Consultant: Eli Seth J. Prins, M.P.H.
Lilly, Genentech; Grant/research support: Daniel R. Rosell, M.D., Ph.D.
AstraZeneca, Otsuka, Myriad/RBM, Na- Lori A. Sansone, M.D.
tional Institute of Mental Health Randy A. Sansone, M.D.
Kenneth R. Silk, M.D.—Consultant:
Abigail B. Schlesinger, M.D.
One time consultancy on potential drug
Christian Schmahl, M.D.
development; Royalties: American Psy-
Larry J. Siever, M.D.
chiatric Press, Cambridge University
Press, Up-to-Date, Wiley Blackwell
Paul H. Soloff, M.D.
Roel Verheul, Ph.D.
Frank E. Yeomans, M.D.
Foreword
Personality disorders occupy polygenic risk with diverse developmen-

an important and particularly challeng- tal and environmental factors; as a result
ing place in psychiatry. There is broad these disorders would be better concep-
recognition that for affected individuals, tualized in dimensional terms that are
personality disorders cause significant continuous with health and that recog-
distress, impairment, and disproportion- nize shared features within and across
ate health care utilization. In addition, families of disorders (Sullivan et al. 2012).
several personality disorders, most no- The clinical and scientific problems cre-
tably borderline, narcissistic, and anti- ated by the imposition of a nosology based
social, often produce significant adverse on discontinuous categories are perhaps
effects on families, in workplaces, and, greater for the study and treatment of
more broadly, for society. The clinical and personality disorders than for any other
societal significance of these disorders area of psychiatry. Personality represents
notwithstanding, there remains consid- a complex set of attributes that mediate
erable disagreement on how best to de- how each human being experiences his
fine them and how to make reliable, clin- or her self and understands and interacts
ically useful, and ultimately scientifically with the external world, especially the so-
valid diagnoses. cial but also the nonsocial world. As de-
The challenges facing the field of per- scribed in several chapters of this textbook,
sonality disorders, as well documented it is an intensely active area of investiga-
in this textbook, arise partly from difficul- tion to find the scientifically strongest—
ties that are common to the study of all and at the same time clinically useful—
psychiatric disorders: a lack of objective approaches to capturing and enumerat-
medical or neuropsychological diagnosing personality traits. In the study of per-
tic tests or of biomarkers that track sever- sonality disorders, however, this task is
ity or reflect improvement with treatment. further complicated by the need to iden-
As for essentially all psychiatric disor- tify boundaries among personality traits
ders, the personality disorders are poorly (and trait clusters) that are adaptive, mal-
captured by the categorical diagnostic adaptive, or disordered, a scientific task
approach that has been the hallmark of complicated by the need to account for the
DSM since its third edition (American context dependence of what can be judged
Psychiatric Association 1980). Personal- adaptive versus pathological.
ity disorders, like almost all psychiatric As is documented within this textbook,
disorders, are heterogeneous syndromes serious attempts were made in the pro-
that result from the interaction of highly cess of developing DSM-5 (American
xv
xvi The American Psychiatric Publishing Textbook of Personality Disorders
Psychiatric Association 2013) to create di- the science by facilitating better cluster-
mensional alternatives to the problematic ing of patients for study.
contemporary categorical treatment of The challenges taken on by the authors
the personality disorders. The end result of this textbook might frighten all but the
of this process is represented by an alter- most stalwart clinicians and investiga-
native diagnostic model contained within tors, especially when combined with the
DSM-5, but not within the main section of task of treating such a demanding popu-
the manual. This alternative model, de- lation. In a field that finds itself in a
tailed by the editors of this textbook in period of serious, but hopefully construc-
Chapter 24, “An Alternative Model for tive disagreement, it is particularly im-
Personality Disorders: DSM-5 Section III portant to have a textbook such as this
and Beyond,” was rightly or wrongly one. It presents the clinical wisdom and
judged too complex for the clinical com- scientific data that should be expected of
munity and too radical a departure from a comprehensive volume. More impor-
the status quo. Unfortunately, the prob- tantly, it does not push the current con-
lems with the status quo remain quite se- troversies into the background, but ad-
vere: these are described throughout the dresses them head-on with many very
textbook, but perhaps most saliently in interesting chapters written by protago-
Chapter 3, “Articulating a Core Dimen- nists in the attempts to advance better sci-
sion of Personality Pathology.” Thus, for entific understandings. Despite the un-
example, the current DSM-5 personality settled nature of the classification, many
disorder categories discussed in the main chapters contained within this textbook
text of the manual have the peculiar prop- bear powerful witness to advances in the
erties of being too broad and too narrow understanding of personality disorders
at the same time. In short, each personal- and to a very solid body of treatment re-
ity disorder category is too broad in that search. Over the last decade it has been
it selects a highly heterogeneous group of recognized that the course of many per-
individuals but also too narrow as evi- sonality disorders, including the most
denced by the remarkably high fre- researched disorder, borderline personal-
quency of co-occurrence with other per- ity disorder, is not as fixed and mono-
sonality disorders and other DSM-5 tonic as had previously been believed.
disorders. As a result of the arbitrary and Especially when treated with evidence-
narrow diagnostic silos, the majority of based psychosocial interventions and ju-
patients with any personality disorder di- dicious use of medications, many patients
agnosis receive more than one diagnosis, can achieve reasonably good outcomes.
and often many. Despite the challenges that remain, there
Of course, it is far easier to identify has been significant and meaningful prog-
problems than to propose solutions that ress. Overall, I commend this textbook to
will aid the clinicians who treat this chal- mental health professionals as extremely
lenging population or facilitate scientific useful and as capturing the excitement of
advances aimed at better understandings this field.
and treatments. Perhaps the disagree-
ments that surfaced in the development Steven E. Hyman, M.D.
of DSM-5 can be taken as a starting point Director, Stanley Center for Psychiatric
for progress in classification, which would Research Broad Institute of MIT and
represent a step toward strengthening Harvard, Cambridge, Massachusetts
Foreword xvii
American Psychiatric Association: Diag-

References nostic and Statistical Manual of Mental
Disorders, 5th Edition. Arlington, VA,
American Psychiatric Association, 2013
Sullivan PF, Daly MJ, O’Donovan M: Genetic
nostic and Statistical Manual of Mental
architecture of psychiatric disorders: the
Disorders, 3rd edition. Washington, DC,
emerging picture and its implications.
Nat Rev Genet 13:537-551, 2012
Introduction
There is a vast and rich literature in also critically important—these range

science, medicine, philosophy, and the from health-promoting, highly nurturing
arts reflecting worldwide fascination environments to stressful and neglectful
with the subject of personality—what environments from which only the most
makes each of us unique and different resilient emerge unscathed. We are
from each other, and what determines the steadily learning more about complex
ways in which we are alike. The tradi- polygenic risk factors that confer vul-
tional mandate of medicine, however, is nerability to the development of most
to understand illness—how to identify it, psychiatric disorders. The importance of
how to treat it, and how to prevent it. This epigenetics is increasingly recognized,
new edition of the Textbook of Personality clarifying the capacity of stressful en-
Disorders brings to its pages the wisdom vironmental experience to activate risk
and guidance of some of the world’s ex- genes and launch a cascade of events re-
perts to teach us about the illnesses we sulting in the emergence of psychopathol-
call personality disorders. Particularly in ogy, including the personality disorders.
the realm of personality, there are not clear With the advent of standardized di-
categorical distinctions differentiating in- agnostic systems, empirical and clinical
dividuals with “normal” personalities research on the personality disorders
from those who suffer from impairments has expanded. Semistructured research
in personality functioning. Personality interviews are being used to study clinical
functioning and personality traits exist and community-based populations to
along continuous spectra, from healthy to provide better data about the epidem-
unhealthy and from adaptive to maladap- iology of these disorders. Overall, per-
tive. There are variations in the degree of sonality disorders occur in over 10% of
disturbance in a person’s sense of self and the general population, and their public
in interpersonal relationships (central de- health significance has been well docu-
fining aspects of personality disorders), mented, reflecting sometimes extreme
but significant impairment in these areas impairment in functioning and high
of functioning plus the prevalence of health care utilization. As clinical popu-
pathological traits can impede a person’s lations are becoming better defined, new
effective navigation in the world. and more rigorous treatment studies are
For decades, it was widely thought that being carried out, with increasingly prom-
some severely disturbed individuals just ising results. In addition, longitudinal
seemed to have been “born that way,” a naturalistic studies have shown surpris-
view resulting from cases with signifi- ing patterns of improvement in patients
cant genetic loading or risk. We know, of with selected personality disorders, chal-
course, that environments in early life are lenging the assumption that these dis-
xix
xx The American Psychiatric Publishing Textbook of Personality Disorders
orders are almost always “stable and en-

during” over time. Genetic and neurobi- Part I: Clinical Concepts
ological studies have clarified that the
personality disorders, like other psychi-
and Etiology
atric disorders, emerge developmentally
The first section of this textbook might
based on the combination of heritable
be thought of as the foundation for the
risk factors and environmental stress.
parts that follow. In Chapter 2, Heim and
Fundamental challenges remain, such
Westen review the major theories that
as clarifying the relationship between nor-
have influenced thinking about the na-
mal personality and personality disor-
ture of personality and personality disor-
ders themselves. A strong consensus has
ders. The next chapter, by Morey and
developed among personality experts
Bender, follows naturally from the previ-
that the personality disorders are best
ous one, emphasizing the fundamental
conceptualized dimensionally, and Sec-
roles of self and interpersonal function-
tion III, “Emerging Measures and Mod-
ing as core components of personality
els,” of the recently published DSM-5
and as defining features of impairment in
contains an alternative model for the per-
personality disorders. These concepts are
sonality disorders, a hybrid dimensional
central components of the alternative
and categorical model that is extensively
model for personality disorders in DSM-5,
referenced and discussed in this volume
described in more detail in Chapters 7 and
(see particularly Chapter 7, “Manifesta-
24. Fonagy and colleagues, in Chapter 4,
tions, Assessment, and Differential Diag-
then present a developmental perspec-
nosis,” and Chapter 24, “An Alternative
tive, stressing the importance of healthy
Model for Personality Disorders: DSM-5
attachment experiences as building blocks
Section III and Beyond”).
for effective adult personality functioning.
In light of the continuing and increased
Disruptions in attachment, conversely, set
activity and progress in the field of per-
the stage for future impairment, and they
sonality studies and personality disor-
correlate strongly with the development
ders, we judged the time to be right to de-
of the neurobiological dysregulation that
velop this new edition of the Textbook of
is present in many patients with personal-
Personality Disorders, with an emphasis on
ity disorders, described in Chapter 5 by
updating information we believe to be es-
Koenigsberg and colleagues. New data on
sential to clinicians. First, in Chapter 1,
prevalence, sociodemographics, and lev-
Oldham presents a brief overview of the
els of functional impairment are described
recent history of the personality disor-
by Torgersen in Chapter 6. Although
ders, along with a summary look at the
there are relatively few well-designed
evolution of the personality disorders
population-based studies, Torgersen re-
component in successive editions of DSM.
views important contributions, including
Then, this new volume is organized into
his own Norwegian study, and he tabu-
four parts: 1) Clinical Concepts and Etiol-
lates prevalence ranges and averages for
ogy; 2) Treatment; 3) Special Problems,
individual DSM-defined personality dis-
Populations, and Settings; and 4) Future
orders as well as for all personality disor-
Directions.
ders taken together.
Introduction xxi
In Chapter 7, Skodol reviews the de- ing this conceptual overview by Bohus,
fining features of DSM-5 Section II and Fowler and Hart summarize several spe-
Section III personality disorder assess- cific cognitive-behavioral therapy strate-
ment models, discusses complementary gies, including traditional cognitive-
approaches to the clinical assessment of a behavioral therapy itself, schema-focused
patient with possible personality psychotherapy, and dialectical behavior therapy,
pathology, provides guidance on general as applied in working with patients with
problems encountered in the routine clin- personality disorders.
ical evaluation, and outlines differential Apart from the realm of individual
diagnosis according to the alternative treatments, there are other venues for
DSM-5 model for personality disorders. therapeutic interventions. In Chapter 13,
Throughout, Skodol provides expert guid- Ogrodniczuk and colleagues demonstrate
ance to introduce readers to the new the application of group, family, and cou-
model, clarifying the differences in the ples therapies to personality disorders.
application of this new dimensional Fruzzetti and colleagues, in Chapter 14,
hybrid system compared with the tradi- review the important role of psychoedu-
tional DSM-IV categorical approach. In cation in the treatment of personality
Chapter 8, Grilo and colleagues provide disorders, as well as the growing impor-
an overview of the clinical course and tance of family involvement in treatment
outcome of personality disorders, syn- and of peer support programs. Schulz and
thesizing the empirical literature on the Nelson then take up the issue, in Chap-
long-term course of personality disorder ter 15, of pharmacotherapy and other so-
psychopathology, including the impor- matic treatments, because many patients
tance of comorbidity and continuity of with personality disorders may benefit
psychopathology over time. from complementing their psychosocial
treatments with evidence-based, symp-
tom-targeted, adjunctive medications.
Part II: Treatment Schlesinger and Silk, in Chapter 16, pro-
vide recommendations about the best way
Chapters 9–17 offer a range of treatment of negotiating collaborative treatments,
options and considerations. The treatment because many patients with personality
section begins with Chapter 9, in which disorders are engaged in several treatment
Bender underscores the necessity of ex- modalities with several clinicians at the
plicitly considering aspects of alliance same time. In the final chapter in this sec-
building with various styles of personal- tion, Gutheil cautions practitioners about
ity psychopathology across all treatment dynamics that can lead to boundary viola-
modalities. Yeomans and colleagues, in tions when working with certain patients
Chapter 10, summarize the salient fea- with personality disorders.
tures of psychodynamic psychotherapies
and psychoanalysis, including mecha-
nisms of change and empirical validation, Part III: Special
as applied to patients with personality pa-
thology. In Chapter 11, Bohus outlines the
Problems, Populations,
core elements of cognitive-behavioral and Settings
therapies, approaches that have increas-
ingly been shown to be effective in the In recognition of the fact that patients
treatment of a number of different per- with personality disorders can be partic-
sonality disorders. In Chapter 12, follow- ularly challenging, we have included
xxii The American Psychiatric Publishing Textbook of Personality Disorders
five chapters devoted to special issues ognized but can eventually lead to sig-
and populations. Of prime importance is nificant impairment in functioning. The
the risk for suicide. In Chapter 18, Links armed services are increasingly alert to
and colleagues provide evidence on the the accurate recognition of personality
association of suicidal behavior and per- disorders within their ranks, and to the
sonality disorders, examine modifiable not uncommon co-occurrence of post-
risk factors, and discuss clinical ap- traumatic stress disorder, traumatic brain
proaches to the assessment and manage- injury, major depression, and suicide
ment of suicide risk. In Chapter 19, Prins risk.
and colleagues focus on pathways to
substance abuse in patients with person-
ality disorders, and they discuss issues Part IV: Future
of differential diagnosis and treatment.
Substance use and abuse is common in
Directions
many patients with personality dis- In the first of two chapters in the final
orders, perhaps particularly in patients section of this textbook, Schmahl and
with antisocial personality disorder. Black Herpertz focus on the increasing useful-
and Blum, in Chapter 20, present the lat- ness of translational research to deepen
est findings regarding antisocial behav- understanding of the biopsychosocial
ior. Of the personality disorders, antiso- nature of the personality disorders. To
cial personality disorder is one of the most close, the book’s editors Skodol, Bender,
costly to society, and it can be associated and Oldham summarize current contro-
with serious personal consequences. Un- versies about and present a detailed
fortunately, far too little is available to of- chronicle of the evidence supporting the
fer at this point in terms of effective treat- alternative DSM-5 model for personality
ment, and many of these individuals end disorders, and the complex process of its
up in correctional and forensic settings. development.
In Chapter 21, Sansone and Sansone
discuss the substantial prevalence of per- We are grateful to all of the chapter
sonality disorders within general medi- authors for their careful and thoughtful
cal settings, demonstrating that physical contributions, and we hope that we have
conditions frequently coexist with and succeeded in providing a current, defin-
are complicated by personality pathol- itive review of the field. We would par-
ogy and that patients with personality ticularly like to thank Liz Golmon for
disorders often seek treatment from pri- her organized and steadfast administra-
mary care or family medicine physicians. tive support, without which this volume
In the final chapter in this section, Chap- would not have been possible.
ter 22, Malone and Benedek focus on an
important population that often gets
overlooked: soldiers on active duty in the
U.S. military. In military settings, person- Andrew E. Skodol, M.D.
ality disorders can be masked or unrec- Donna S. Bender, Ph.D., FIPA
CHAPTER 1
Personality Disorders
Recent History and New Directions
cess is also bidirectional, so that the “in-

Personality Types and born” behavior of the infant can elicit be-
havior in parents or caretakers that can, in
Personality Disorders turn, reinforce infant behavior: placid,
happy babies may elicit warm and nur-
People are different, and what makes us turing behaviors; irritable babies may
different from each other has a lot to do elicit impatient and neglectful behaviors.
with something called personality, the But even-tempered, easy-to-care-for
phenotypic patterns of thoughts, feelings, babies can have bad luck and land in a
and behaviors that uniquely define each nonsupportive or even abusive environ-
of us. In many important ways, we are ment, which may set the stage for a per-
what we do. At a school reunion, for ex- sonality disorder, and difficult-to-care-
ample, recognition of classmates not seen for babies can have good luck, protected
for decades derives as much from famil- from future personality pathology by spe-
iar behavior as from physical appearance. cially talented and attentive caretakers.
To varying degrees, heritable tempera- Once these highly individualized dynam-
ments that differ widely from one indi- ics have had their main effects and an indi-
vidual to another determine an amazing vidual has reached late adolescence or
range of human behavior. Even in the young adulthood, his or her personality
newborn nursery, one can see strikingly will often have been pretty well estab-
different infants, ranging from cranky ba- lished. This is not an ironclad rule, how-
bies to placid ones. Throughout life, each ever; there are “late bloomers,” and high-
individual’s temperament remains a key impact life events can derail or reroute any
component of that person’s developing of us. How much we can change if we
personality, added to by the shaping and need to and want to is variable, but change
molding influences of family, caretakers, is possible. How we define the differences
and environmental experiences. This pro- between personality styles and personal-
1
2 The American Psychiatric Publishing Textbook of Personality Disorders
ity disorders (PDs), how the two relate to ery edition of the APA’s Diagnostic and
each other, what systems best capture the Statistical Manual of Mental Disorders
magnificent variety of nonpathological (DSM). Largely driven by the need for
human behavior, and how we think about standardized psychiatric diagnoses in the
and deal with extremes of thoughts, feel- context of World War II, the U.S. War De-
ings, and behaviors that we call PDs are partment, in 1943, developed a document
spelled out in great detail in the chapters labeled Technical Bulletin 203, represent-
that follow in this textbook. In this first ing a psychoanalytically oriented system
chapter, I briefly describe how the Ameri- of terminology for classifying mental ill-
can Psychiatric Association (APA) has ap- ness precipitated by stress (Barton 1987).
proached the definition and classification The APA charged its Committee on No-
of the PDs, building on broader interna- menclature and Statistics to solicit expert
tional concepts and theories of psychopa- opinion and to develop a diagnostic man-
thology. ual that would codify and standardize
Although personality pathology has psychiatric diagnoses. This diagnostic
been well known for centuries, it is often system became the framework for the
thought to reflect weakness of character first edition of DSM (American Psychiat-
or willfully offensive behavior, produced ric Association 1952). This manual has
by faulty upbringing, rather than to be a subsequently been revised on several oc-
type of “legitimate” psychopathology. In casions, leading to new editions: DSM-II
spite of these common attitudes, clini- (American Psychiatric Association 1968),
cians have long recognized that patients DSM-III (American Psychiatric Associa-
with personality problems experience sig- tion 1980), DSM-III-R (American Psychi-
nificant emotional distress, often accom- atric Association 1987), DSM-IV (Ameri-
panied by disabling levels of impairment can Psychiatric Association 1994), DSM-
in social or occupational functioning. IV-TR (American Psychiatric Association
General clinical wisdom has guided treat- 2000), and DSM-5 (American Psychiatric
ment recommendations for these patients, Association 2013).
at least for those who seek treatment, plus Figure 1–1 (Skodol 1997) portrays the
evidence-based treatment guidelines ontogeny of diagnostic terms relevant to
have been developed for patients with the PDs, from the first edition of DSM
borderline PD. Patients with paranoid, through DSM-5. DSM-IV-TR involved
schizoid, or antisocial patterns of think- only text revisions but retained the same
ing and behaving often do not seek treat- diagnostic terms as DSM-IV, and DSM-5
ment. Others, however, seek help for (in its main diagnostic component, Sec-
problems ranging from self-destructive tion II, “Diagnostic Criteria and Codes”)
behavior to anxious social isolation to just includes the same PD diagnoses as DSM-
plain chronic misery, and many of these IV except that the two provisional diag-
patients have specific or mixed PDs, often noses, passive-aggressive and depres-
coexisting with other conditions such as sive, listed in DSM-IV Appendix B, “Cri-
mood or anxiety disorders. teria Sets and Axes Provided for Further
Study,” have been deleted. Additionally,
Section III, “Emerging Measures and Mod-
The DSM System els,” of DSM-5 includes an alternative
model for personality disorders, which
Contrary to assumptions commonly en- is reviewed extensively throughout this
countered, PDs have been included in ev- book.
Personality Disorders 3
DSM-I (1952) DSM-II (1968) DSM-III (1980) DSM-IV (1994)/

DSM-5 (2013)
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- Narcissistic Narcissistic
aggressive
Cluster C Cluster C
Compulsive Obsessive- Compulsive Obsessive-compulsive
compulsive Avoidant Avoidant
Dependent Dependent
Passive-aggressive
Sociopathic personality
disturbance Asthenic
Antisocial Antisocial
Dyssocial Explosive Axis I intermittent
explosive disorder
Indicates that category was discontinued.
FIGURE 1–1. Ontogeny of personality disorder classification.

Note. 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. These two cate-
gories were not included in DSM-IV, DSM-IV-TR, or DSM-5. Passive-aggressive and depressive
personality disorders were present in Appendix B of DSM-IV and DSM-IV-TR but have been
removed for DSM-5. An alternative model for the personality disorders (not shown in Figure 1–1)
is included in Section III, “Emerging Measures and Models,” of DSM-5.
Source. Modified from Skodol AE: “Classification, Assessment, and Differential Diagnosis of Person-
ality Disorders.” Journal of Practical Psychiatry and Behavioral Health 3:261–274, 1997.
Although not explicit in the narrative issues such as how to differentiate PDs
text, the first edition of DSM reflected from personality styles or traits, which re-
the general view of PDs at the time, ele- main actively debated today, were clearly
ments of which persist to the present. identified.
Generally, PDs were viewed as more or In the first edition of DSM, PDs were
less permanent patterns of behavior and generally viewed as deficit conditions,
human interaction that were established reflecting partial developmental arrests,
by early adulthood and were unlikely to or distortions in development secondary
change throughout the life cycle. Thorny to inadequate or pathological early care-
taking. The PDs were grouped primarily By the mid 1970s, greater emphasis
into personality pattern, personality trait, was placed on increasing the reliability of
and sociopathic personality. Personality all diagnoses. DSM-III defined PDs (and
pattern disturbances were viewed as the all other disorders) by explicit diagnostic
most entrenched conditions, likely to be criteria and introduced a multiaxial eval-
recalcitrant to change, even with treat- uation system. Disorders classified on
ment; these conditions included inade- Axis I included those generally seen as
quate personality, schizoid personality, episodic “symptom disorders” charac-
cyclothymic personality, and paranoid terized by exacerbations and remissions,
personality. Personality trait disturbances such as psychoses, mood disorders, and
were thought to be less pervasive and dis- anxiety disorders. Axis II was established
abling, so in the absence of stress these to include the PDs as well as specific de-
patients could function relatively well. If velopmental disorders; both groups were
under significant stress, however, pa- seen as composed of early-onset, persis-
tients with emotionally unstable, pas- tent conditions, but the specific develop-
sive-aggressive, or compulsive person- mental disorders were understood to be
alities were thought to show emotional “biological” in origin, in contrast to the
distress and deterioration in functioning, PDs, which were generally regarded as
and they were variably motivated for and “psychological” in origin. The decision to
amenable to treatment. The category of place the PDs on Axis II led to greater rec-
sociopathic personality reflected what ognition of the PDs and stimulated ex-
were generally seen as types of social de- tensive research and progress in our un-
viance; it included antisocial reaction, derstanding of these conditions. (New
dyssocial reaction, sexual deviation, and data, however, have called into question
addiction (subcategorized into alcohol- the rationale to conceptualize the PDs as
ism and drug addiction). fundamentally different from other types
The primary stimulus leading to the of psychopathology, such as mood or
development of a new, second edition of anxiety disorders, and in any event the
DSM was the publication of the eighth multiaxial system of DSM-III and IV has
revision of the International Classifica- been removed in DSM-5.)
tion of Diseases (World Health Organi- As shown in Figure 1–1, the DSM-II
zation 1967) and the wish of the APA to diagnoses of inadequate PD and asthenic
reconcile its diagnostic terminology with PD were discontinued in DSM-III. Also
this international system. In the DSM rein DSM-III, the DSM-II diagnosis of ex-
vision process, an effort was made to plosive PD was changed to intermittent
move away from theory-derived diag- explosive disorder, cyclothymic PD was
noses and to attempt to reach consensus renamed cyclothymic disorder, and both
on the main constellations of personality of these diagnoses were moved to Axis I.
that were observable, measurable, endur- Schizoid PD was felt to be too broad a
ing, and consistent over time. The earlier category in DSM-II and therefore was re-
view that patients with PDs did not expe- crafted into three PDs: schizoid PD, re-
rience emotional distress was discarded, flecting “loners” who are uninterested in
as were the subcategories described close personal relationships; schizotypal
above. One new PD was added, called as- PD, understood to be on the schizophre-
thenic PD, only to be deleted in the next nia spectrum of disorders and character-
edition of DSM. ized by eccentric beliefs and nontradi-
tional behavior; and avoidant PD, typified In addition, on the basis of prior clinical
by self-imposed interpersonal isolation recommendations to the DSM-III-R PD
driven by self-consciousness and anxi- subcommittee, two PDs were included
ety. Two new PD diagnoses were added in DSM-III-R in Appendix A, “Proposed
in DSM-III: borderline PD and narcissis- Diagnostic Categories Needing Further
tic PD. In contrast to initial notions that Study”: self-defeating PD and sadistic
patients called “borderline” were on the PD. These diagnoses were considered
border between the psychoses and the provisional.
neuroses, the criteria defining borderline DSM-IV was developed after an exten-
PD in DSM-III emphasized emotion dys- sive process of literature review, data anal-
regulation, unstable interpersonal rela- ysis, field trials, and feedback from the
tionships, and loss of impulse control profession. Because of the increase in re-
more than persistent cognitive distor- search stimulated by the criteria-based
tions and marginal reality testing, which multiaxial system of DSM-III, more evi-
were more characteristic of schizotypal dence existed to guide the DSM-IV pro-
PD. Among many scholars whose work cess. As a result, the threshold for ap-
greatly influenced and shaped the con- proval of revisions for DSM-IV was a
ceptualization of borderline pathology higher one than that used in DSM-III or
introduced in DSM-III were Kernberg DSM-III-R. DSM-IV introduced, for the
(1975) and Gunderson (1984). Although first time, a set of general diagnostic crite-
concepts of narcissism had been described ria for any PD, underscoring qualities
by Sigmund Freud, Wilhelm Reich, and such as early onset, long duration, inflex-
others, the essence of the current views ibility, and pervasiveness. These general
of narcissistic PD emerged from the work criteria, however, were developed by ex-
of Millon (1969), Kohut (1971), and Kern- pert consensus and were not derived em-
berg (1975). pirically. Diagnostic categories and di-
DSM-III-R was published in 1987 after mensional organization of the PDs into
an intensive process to revise DSM-III, in- clusters remained the same in DSM-IV as
volving widely solicited input from rein DSM-III-R, with the exception of the
searchers and clinicians and following relocation of passive-aggressive PD from
similar principles to those articulated in the “official” diagnostic list to Appendix
DSM-III, such as assuring reliable diag- B, “Criteria Sets and Axes Provided for
nostic categories that were clinically Further Study.” Passive-aggressive PD,
useful and consistent with research find- as defined by DSM-III and DSM-III-R,
ings, thus minimizing reliance on theory. was thought to be too unidimensional and
In DSM-III-R, no changes were made in generic; it was tentatively retitled “nega-
diagnostic categories of PDs, although tivistic PD” and the criteria were revised.
some adjustments were made in certain In addition, the two provisional Axis II
criteria sets—for example, they were diagnoses in DSM-III-R, self-defeating
made uniformly polythetic instead of PD and sadistic PD, were dropped, be-
defining some PDs with monothetic cri- cause of insufficient research data and
teria sets (i.e., with all criteria required), clinical consensus to support their reten-
such as for dependent PD, and others tion. One other PD, depressive PD, was
with polythetic criteria sets (i.e., with proposed and added to Appendix B. Al-
some minimum number, but not all cri- though substantially controversial, this
teria required), such as for borderline PD. provisional diagnosis was proposed as a
pessimistic cognitive style, presumably height might be better conceptualized di-

distinct from passive-aggressive PD or mensionally because there is no exact
dysthymic disorder. definition of “tall” or “short,” notions of
The diagnostic terms and criteria of tallness or shortness may vary among
DSM-IV were not changed in DSM-IV-TR, different cultures, and all gradations of
published in 2000. The intent of DSM- height exist along a continuum.
IV-TR was to revise the descriptive, nar- We know, of course, that the DSM sys-
rative text accompanying each diagnosis tem is referred to as categorical and is
where it seemed indicated and to update contrasted with any number of systems
the information provided. Only minimal referred to as dimensional, such as the in-
revisions were made in the text material terpersonal circumplex (Benjamin 1993;
accompanying the PDs. Kiesler 1983; Wiggins 1982), the three-fac-
Since the publication of DSM-IV, new tor model (Eysenck and Eysenck 1975),
knowledge has rapidly accumulated several four-factor models (Clark et al.
about the PDs, and discussions about 1996; Livesley et al. 1993, 1998; Watson et
controversial areas have intensified. Al- al. 1994; Widiger 1998), the “Big Five”
though DSM-IV had an increased empir- model (Costa and McCrae 1992), and the
ical basis compared with previous ver- seven-factor model (Cloninger et al.
sions of DSM, a number of limitations of 1993). How fundamental is the difference
the categorical approach were apparent, between the two types of systems? Ele-
and many unanswered questions re- ments of dimensionality already exist in
mained. Are the PDs fundamentally dif- the traditional DSM categorical system,
ferent from other categories of major represented by the organization of the
mental illness such as mood disorders or PDs into Cluster A (odd or eccentric),
anxiety disorders? What is the relation- Cluster B (dramatic, emotional, or er-
ship of normal personality to PD? Are the ratic), and Cluster C (anxious or fearful).
PDs best conceptualized dimensionally In addition, a patient can just meet the
or categorically? What are the pros and threshold for a PD or can have all of the
cons of polythetic criteria sets, and what criteria, presumably a more extreme ver-
should determine the appropriate num- sion of the disorder. Certainly, if a patient
ber of criteria (i.e., threshold) required for is one criterion short of being diagnosed
each diagnosis? Which PD categories with a PD, clinicians do not necessarily
have construct validity? Which dimen- assume that there is no element of the dis-
sions best cover the full scope of normal order present; instead, prudent clinicians
and abnormal personality? Many of these would understand that features of the
discussions overlap with and inform disorder need to be recognized if present
each other. and may need attention. Busy clinicians,
Among these controversies, one stands however, often think categorically, decid-
out with particular prominence: whether ing what disorder or disorders a patient
a dimensional approach or a categorical “officially” has. In practice, when a pa-
one is preferred to classify the PDs. Much tient is thought to have a PD, clinicians
of the literature poses this topic as a de- generally assign only one PD diagnosis,
bate or competition, as if one must choose whereas systematic studies of clinical
sides. Dimensional structure implies con- populations utilizing semistructured in-
tinuity, whereas categorical structure im- terviews show that patients with person-
plies discontinuity. For example, being ality psychopathology generally have
pregnant is a categorical concept, whereas multiple PD diagnoses (Oldham et al.
1992; Shedler and Westen 2004; Skodol et by the APA as an alternative model and
al. 1988; Widiger et al. 1991). placed in Section III of DSM-5, whereas
In the early 2000s, the APA convened, the DSM-IV criteria-defined categorical
in collaboration with the National In- system was retained in Section II of the
stitute of Mental Health (NIMH), a series manual, for continued use. The alterna-
of research conferences to develop an tive model includes six specific PDs, plus
agenda for DSM-5, the proceedings of a seventh diagnosis of personality disor-
which were subsequently published. In der—trait specified that allows description
an introductory monograph (Kupfer et al. of individual trait profiles of patients with
2002), a chapter was devoted to personal- PDs who do not have any of the six speci-
ity and relational disorders, in which First fied disorders. In addition, the alternative
et al. (2002) stated that “the classification model involves assignment of level of im-
scheme offered by the DSM-IV for both of pairment in functioning, an important ad-
these domains is woefully inadequate in ditional element of dimensionality when
meeting the goals of facilitating commu- making PD diagnoses. As described in
nication among clinicians and researchers Chapter 7, “Manifestations, Assessment,
or in enhancing the clinical management and Differential Diagnosis,” the alterna-
of those conditions” (p. 179). In that same tive model also presents a coherent core
volume, in a chapter on basic nomencla- definition of all PDs, as moderate or
ture issues, Rounsaville et al. (2002) ar- greater impairment in self and interper-
gued that “well-informed clinicians and sonal functioning.
researchers have suggested that variation Questions have been raised about the
in psychiatric symptomatology may be stability of the PDs over time, even though
better represented by dimensions than by their enduring nature is one of the generic
a set of categories, especially in the area of defining features of the PDs in DSM-5
personality traits” (p. 12). Subsequently, Section II. Personality pathology is often
an entire monograph, “Dimensional Mod- activated or intensified by circumstance,
els of Personality Disorders: Refining the such as loss of a job or the end of a mean-
Research Agenda for DSM-V” (Widiger et ingful relationship. In the ongoing find-
al. 2006), was published, with in-depth ings of the Collaborative Longitudinal
analyses of dimensional approaches for Personality Disorders Study (CLPS), for
the PDs. Shortly thereafter, a Work Group example, stability of DSM-IV–defined PD
on Personality and Personality Disorders diagnoses reflected sustained pathol-
was established by the APA, and efforts ogy at or above the diagnostic threshold,
were launched to develop a dimensional but substantial percentages of patients
proposal for the PDs for DSM-5. This pro- showed fluctuation over time, sometimes
cess is described in detail in the final chap- being above and sometimes below the di-
ter of this volume (Chapter 24, “An Alter- agnostic threshold. In the CLPS, which
native Model for Personality Disorders: used a stringent definition of remission
DSM-5 Section III and Beyond”). It was (the presence of no more than two criteria
challenging for the work group to reach a for at least 1 year), 85% of patients with
consensus in support of a single dimen- DSM-IV–defined borderline personality
sional model for the PDs to be used in disorder at intake showed remission at
clinical practice, just as it had been diffi- the 10-year follow-up point. However,
cult for the field. In the end, a hybrid di- impairment in functioning was much
mensional and categorical model was slower to remit, perhaps consistent with
proposed, and this model was approved more recent evidence demonstrating that
trait-defined PDs are more persistent over Disorders. Washington, DC, American
time than DSM-IV–defined PDs (Hop- Psychiatric Association, 1952
wood et al. 2013).
Disorders, 2nd Edition. Washington, DC,
Conclusion American Psychiatric Association: Diag-
This brief review of the history of the clas- Disorders, 3rd Edition. Washington, DC,
sification of personality pathology serves American Psychiatric Association, 1980
as a window on the progress in our field nostic and Statistical Manual of Mental
and in our understanding of the PDs. In- Disorders, 3rd Edition, Revised. Wash-
creasingly, a stress/diathesis framework ington, DC, American Psychiatric Asso-
seems applicable in medicine in general, ciation, 1987
as a unifying model of illness—a model American Psychiatric Association: Diag-
that can easily apply to the PDs. Variable
Disorders, 4th Edition. Washington, DC,
genetic vulnerabilities predispose us all American Psychiatric Association, 1994
to potential future illness, which may or American Psychiatric Association: Diag-
may not develop depending on the bal- nostic and Statistical Manual of Mental
ance of specific stressors and protective Disorders, 4th Edition, Text Revision.
factors. Washington, DC, American Psychiatric
Association, 2000
The PDs can be thought of as maladap- American Psychiatric Association: Diag-
tive exaggerations of nonpathological nostic and Statistical Manual of Mental
personality styles, resulting from predis- Disorders, 5th Edition. Arlington, VA,
posing temperaments combined with American Psychiatric Association, 2013
stressful circumstances. Neurobiological Barton WE: The History and Influence of the
American Psychiatric Association. Wash-
abnormalities have been demonstrated in
ington, DC, American Psychiatric Press,
at least some PDs, as is the case in many 1987
other psychiatric disorders. Our chal- Benjamin LS: Interpersonal Diagnosis and
lenge for the future is to better character- Treatment of Personality Disorders. New
ize variations in personality psycho- York, Guilford, 1993
pathology and determine whether and Clark LA, Livesley WJ, Schroeder ML, et al:
Convergence of two systems for assess-
how PDs are different from other classes ing specific traits of personality disor-
of psychiatric disorders. As we learn der. Psychol Assess 8:294–303, 1996
more about the etiologies and pathology Cloninger CR, Svrakic DM, Przybeck TR: A
of the PDs, it will no longer be necessary, psychobiological model of tempera-
or even desirable, to limit our diagnostic ment and character. Arch Gen Psychia-
try 50:975–990, 1993
schemes to atheoretical, descriptive phe-
Costa PT, McCrae RR: The five-factor model
nomena, and we can look forward to an of personality and its relevance to per-
enriched understanding of personality sonality disorders. J Pers Disord 6:343–
pathology, better treatments, and guid- 359, 1992
ance for prevention. Eysenck HJ, Eysenck SBG: Manual of the
Eysenck Personality Questionnaire. San
Diego, CA, Educational and Industrial
Testing Service, 1975
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PART I
Clinical Concepts and Etiology
CHAPTER 2
Theories of Personality
and Personality Disorders
Amy K. Heim, Ph.D.
Drew Westen, Ph.D.
Personality refers to enduring pat- resistance to perceived demands of male

terns of cognition, emotion, motivation, authority figures may or may not co-oc-
and behavior that are activated in par- cur with a similar response tendency to-
ticular circumstances (see Mischel and ward female authorities, peers, lovers,
Shoda 1995; Westen 1995). This is a min- or subordinates. Nevertheless, this ten-
imalist definition—that is, one that most dency represents an enduring way of
personality psychologists would accept, thinking, attending to information, feel-
despite widely differing theories—but it ing, and responding that is clearly an as-
underscores two important aspects of pect of personality (and one that can
personality: its dynamic nature (that per- substantially affect adaptation).
sonality reflects an ongoing interaction Among the dozens of approaches to
of mental, behavioral, and environmen- personality advanced over the past cen-
tal events) and the potential for variation tury, two are most widely used in clini-
and flexibility of responding (activation cal practice: psychodynamic and cogni-
of specific processes under particular cir- tive-social or cognitive-behavioral. Two
cumstances). Enduring ways of respond- other approaches have gained increased
ing need not be broadly generalized to interest among personality disorder (PD)
be considered aspects of personality (or researchers: trait psychology, one of the
to lead to dysfunction) because many as- oldest and most enduring empirical ap-
pects of personality are triggered by spe- proaches to the study of normal person-
cific situations, thoughts, or feelings. For ality, and biological approaches, which
example, a tendency to bristle and re- reflect a long-standing tradition in de-
spond with opposition, anger, or passive scriptive psychiatry as well as more re-
Preparation of this manuscript was supported in part by National Institute of Mental Health
grants MH59685 and MH60892.
13
cent developments in behavioral genet- awareness among conflicting wishes,

ics and neuroscience. Although most fears, and moral standards. For exam-
theories have traditionally fallen into a ple, a patient with anorexia nervosa who
single “camp,” several other approaches is uncomfortable with her impulses and
are best viewed as integrative. These who fears losing control over them may
include Millon’s (1990) evolutionary- begin to starve herself as a way of dem-
social learning approach, which has as- onstrating that she can control even the
similated broadly from multiple tradi- most persistent of desires, hunger. Some
tions (e.g., psychoanalytic object rela- of the PDs identified in DSM-IV (Amer-
tions theory); Benjamin’s (1996a, 1996b) ican Psychiatric Association 1994) have
interpersonal approach, which integrates their roots in early psychoanalytic theo-
interpersonal, psychodynamic, and so- rizing about conflict—notably dependent,
cial learning theories; and Westen’s obsessive-compulsive, and to some ex-
(1995, 1998) functional domains model, tent histrionic PD (presumed to reflect
which draws on psychodynamic, evolu- fixations at the oral, anal, and phallic
tionary, behavioral, cognitive, and devel- stages, respectively).
opmental research. In this chapter we Although some psychoanalysts have
briefly consider how each approach con- argued that a conflict model can account
ceptualizes PDs. for severe personality pathology (e.g.,
Abend et al. 1983), most analytic theorists
have turned to ego psychology, object
Psychodynamic relations theory, self psychology, and
relational theories to help understand pa-
Theories tients with PDs. According to these
approaches, the problems seen in patients
Psychoanalytic theorists were the first to with character disorders run deeper than
generate a concept of personality disor- maladaptive compromises among con-
der (also called character disorder, reflect- flicting motives and indicate derailments
ing the idea that PDs involve character in personality development reflecting
problems not isolated to a specific symp- temperament, early attachment experi-
tom or set of independent symptoms). ences, and their interaction (e.g., Balint
PDs began to draw considerable theoret- 1969; Kernberg 1975b). Many of the DSM-
ical attention in psychoanalysis by the IV PDs, notably schizoid, borderline, and
middle of the twentieth century (e.g., narcissistic PDs, have roots in these later
Fairbairn 1952; Reich 1933/1978), in part approaches.
because they were common and difficult Psychoanalytic ego psychology focuses
to treat and in part because they defied on the psychological functions (or, in con-
understanding using the psychoanalytic temporary cognitive terms, skills, proce-
models prevalent at the time. For years, dures, and processes involved in self-reg-
analysts had understood psychological ulation) that must be in place for people
problems in terms of conflict and defense to function adaptively, attain their goals,
using Sigmund Freud’s topographic and meet external demands (see Bellak et
model (conscious, preconscious, un- al. 1973; Blanck and Blanck 1974; Redl
conscious) or his structural model (id, and Wineman 1951). From this perspec-
ego, superego). In classical psychoana- tive, patients with PDs have various def-
lytic terms, most symptoms reflect mal- icits in functioning, such as poor impulse
adaptive compromises forged outside of control, difficulty regulating their affects,
Theories of Personality and Personality Disorders 15
and deficits in the capacity for self-reflec- derline PD (BPD), the most extensively
tion. These deficits may render them in- studied PD (e.g., Baker et al. 1992; Gun-
capable of behaving consistently in their derson 2001; Westen 1990a, 1991a).
own best interest or of taking the interests From a psychodynamic point of view,
of others appropriately into account (e.g., perhaps the most important features of
lashing out aggressively without fore- PDs are the following: 1) they represent
thought, cutting themselves when they constellations of psychological processes,
become upset). not distinct symptoms that can be un-
Object relations and relational and self derstood in isolation; 2) they can be lo-
psychological theories focus on the cog- cated on a continuum of personality pa-
nitive, affective, and motivational pro- thology from relative health to relative
cesses presumed to underlie functioning sickness; 3) they can be characterized in
in close relationships (Aron 1996; Green- terms of character style, which is orthog-
berg and Mitchell 1983; Mitchell 1988; onal to level of disturbance (e.g., a pa-
Westen 1991b). From this point of view, tient can have an obsessional style but
PDs reflect a number of processes, in- be relatively sick or relatively healthy);
cluding the following: First, internaliza- 4) they involve both implicit and explicit
tion of attitudes of hostile, abusive, criti- personality processes, only some of which
cal, inconsistent, or neglectful parents are available to introspection (and thus
may leave patients with PDs vulnerable amenable to self-report); and 5) they re-
to fears of abandonment, self-hatred, a flect processes that are deeply entrenched,
tendency to treat themselves as their par- which often serve multiple functions and/
ents treated them, and so forth (Benjamin or have become associated with regula-
1996a, 1996b; Masterson 1976; McWil- tion of affects and are hence resistant to
liams 1998). Second, patients with PDs change.
often fail to develop mature, constant, The most comprehensive theory that
multifaceted representations of the self embodies these principles is the theory of
and others. As a result, they may be vul- personality structure or organization de-
nerable to emotional swings when sig- veloped by Otto Kernberg (1975a, 1984,
nificant others are momentarily disap- 1996). Kernberg proposed a continuum
pointing, and they may have difficulty of pathology, from chronically psychotic
understanding or imagining what might levels of functioning, through borderline
be in the minds of the people with whom functioning (severe PDs), through neu-
they interact (Fonagy and Target 1997; rotic to normal functioning. In Kernberg’s
Fonagy et al. 1991, 2003). Third, patients view, people with severe personality pa-
with PDs often appear to have difficulty thology are distinguished from people
forming a realistic, balanced view of the whose personality is organized at a psy-
self that can weather momentary failures chotic level by their relatively intact capac-
or criticisms and a corresponding inability for reality testing (the absence of hal-
ity to activate procedures (hypothesized lucinations, psychotic delusions, etc.) and
to be based on loving, soothing experi- their relative ability to distinguish be-
ences with early caregivers) that would be tween their own thoughts and feelings
useful for self-soothing in the face of loss, and those of others (the absence of beliefs
failure, or threats to safety or self-esteem that their thoughts are being broadcast on
(e.g., Adler and Buie 1979). A substantial the radio; their recognition, though some-
body of research supports many of these times less than complete, that the perse-
propositions, particularly vis-à-vis bor- cutory thoughts they may hear inside
their heads are voices from the past rather used to assess degree of impairment in
than true hallucinations; etc.). Individu- areas of identity, self-direction, intimacy,
als with severe personality pathology are and empathy. (Additional information on
distinguished from people with “neurotic” this model is available in Chapter 7, “Man-
(i.e., healthier) character structures by the ifestations, Assessment, and Differential
former’s 1) more maladaptive modes of Diagnosis,” and Chapter 24, “An Alter-
regulating their emotions, through im- native Model for Personality Disorders:
mature, reality-distorting defenses such DSM-5 Section III and Beyond.”)
as denial and projection (e.g., refusing to Although many of Kernberg’s major
recognize the part they play in generating contributions have been in the under-
some of the hostility they engender from standing of borderline phenomena, his
others), and 2) difficulty forming mature, theory of narcissistic disturbance contrib-
multifaceted representations of them- uted substantially to the development of
selves and significant others (e.g., believ- the diagnosis of narcissistic PD in DSM-
ing that a person they once loved is really III (American Psychiatric Association
all bad, with no redeeming features, and 1980), just as it did to the BPD diagnosis.
is motivated only by the desire to hurt According to Kernberg, whereas patients
them). This level of severe personality with BPD lack an integrated identity, pa-
disturbance, which Kernberg calls “bor- tients with narcissistic PD are typically
derline personality organization” (Kern- developmentally more advanced, in that
berg 1996), shares some features with the they have been able to develop a coher-
DSM-IV BPD diagnosis. However, bor- ent (if distorted) view of themselves.
derline personality organization is a Narcissistic phenomena, in Kernberg’s
broader construct, used to describe pa- view, lie on a continuum from normal
tients with paranoid, schizoid, schizo- (characterized by adequate self-esteem
typal, and antisocial PDs, as well as some regulation) to pathological (narcissistic
who would receive a DSM-IV diagnosis PD) (Kernberg 1984, 1998). Individuals
of narcissistic, histrionic, or dependent with narcissistic PD need to construct a
PD. (Some schizotypal and borderline grossly inflated view of themselves to
patients may at times fall in the psychotic maintain self-esteem, and they may ap-
range.) More recent research supports the pear grandiose, sensitive to the slightest
notion that patients fall on a continuum attacks on their self-esteem (and hence
of severity of personality pathology (see vulnerable to rage or depression), or
Millon and Davis 1995; Tyrer and John- both. Not only are the conscious self rep-
son 1996), with disorders such as para- resentations of patients with narcissistic
noid and BPDs representing more severe PD inflated but so, too, are the represen-
forms, and disorders such as obsessive- tations that constitute their ideal self. Ac-
compulsive PD representing less severe tual and ideal self representations stand
forms (Westen and Shedler 1999a). This in dynamic relation to one another. Thus,
perspective is also represented in the one reason that patients with narcissistic
Level of Personality Functioning Scale, PD must maintain an idealized view of
which is part of the alternative DSM-5 self is that they have a correspondingly
model for personality disorders (see DSM- grandiose view of whom they should be,
5 Section III, “Emerging Measures and divergence from which leads to tremen-
Models”; American Psychiatric Associa- dous feelings of shame, failure, and hu-
tion 2013). This dimensional measure is miliation.
The concept of a grandiose self is cen- which pathological narcissism is a pro-

tral to the self psychology of Heinz totypical example.
Kohut, a major theorist of narcissistic
personality pathology, whose ideas, like
those of Kernberg, contributed to the de- Cognitive-Social
velopment of the diagnosis of narcis-
sistic PD in DSM-III (Goldstein 1985). Theories
Kohut’s theory grew out of his own and
others’ clinical experiences with patients Cognitive-social theories (Bandura 1986;
whose problems (e.g., feelings of empti- Mischel 1973, 1979) offered the first com-
ness or unstable self-esteem) did not re- prehensive alternative to psychodynamic
spond well to existing (psychoanalytic) approaches to personality. First devel-
models. Pathology, according to Kohut, oped in the 1960s, these approaches are
results from faulty self development. The sometimes called social learning theory,
“self,” in its particular Kohutian mean- cognitive-social learning theory, social
ing, refers to the nucleus of a person’s cognitive theory, and cognitive-behav-
central ambitions and ideals and the tal- ioral theory. Cognitive-social theories de-
ents and skills used to actualize them veloped from behaviorist and cognitive
(Kohut 1971, 1977; Wolf 1988). It devel- roots. From a behaviorist perspective,
ops through two pathways (in Kohut’s personality consists of learned behaviors
language, “poles”), which provide the and emotional reactions that tend to be
basis for self-esteem. The first is what relatively specific (rather than highly
Kohut calls the grandiose self—an ideal- generalized) and tied to particular envi-
ized representation of self that emerges ronmental contingencies. Cognitive-so-
in children through empathic mirroring cial theories share the behaviorist beliefs
by their parents (“Mommy, watch!”) and that learning is the basis of personality
provides the nucleus for later ambitions and that personality dispositions tend to
and strivings. The second he calls the be relatively specific and shaped by their
idealized parent imago—an idealized rep- consequences. These theories share the
resentation of the parents, which pro- cognitive view that the way people en-
vides the foundation for ideals and stan- code, transform, and retrieve informa-
dards for the self. Parental mirroring tion, particularly about themselves and
allows the child to see his or her reflec- others, is central to personality. From a
tion in the eyes of a loving and admiring cognitive-social perspective, personality
parent; idealizing a parent or parents al- reflects a constant interplay between en-
lows the child to identify with and be- vironmental demands and the way the
come like them. In the absence of ade- individual processes information about
quate experiences with parents who can the self and the world (Bandura 1986).
mirror the child or serve as appropriate Cognitive-social theorists have only
targets of the child’s idealization (e.g., relatively recently begun to write about
when the parents are self-involved or PDs (e.g., Beck et al. 2004; Linehan 1993b;
abusive), the child’s self structure can- Pretzer and Beck 1996; Young 1990). In
not develop, preventing the achieve- large part this relatively late arrival to
ment of cohesion, vigor, and normal the PD discourse reflected the assump-
self-esteem (which Kohut describes as tion, initially inherited from behavior-
“healthy narcissism”). As a result, the ism, that personality comprises relatively
child develops a disorder of the self, of discrete, learned processes that are more
malleable and situation specific than im- navigate interpersonal waters (Cantor
plied by the concept of PD. Cognitive- and Harlow 1994; Cantor and Kihlstrom
social theories focus on a number of vari- 1987), and patients with PDs tend to be
ables presumed to be most important in notoriously poor interpersonal problem
understanding PDs, including schemas, solvers.
expectancies, goals, skills and compe- Of particular relevance to severe PDs
tencies, and self-regulation (Bandura is self-regulation, which refers to the pro-
1986, 1999; Cantor and Kihlstrom 1987; cess of setting goals and subgoals, evalu-
Mischel 1973, 1979; Mischel and Shoda ating one’s performance in meeting these
1995). Although particular theorists goals, and adjusting one’s behavior to
have tended to emphasize one or two of achieve these goals in the context of on-
these variables in explaining PDs, such going feedback (Bandura 1986; Mischel
as the schemas involved in encoding 1990). Problems in self-regulation, in-
and processing information about the cluding a deficit in specific skills, form a
self and others (Beck et al. 2004) or the central aspect of Linehan’s (1993a, 1993b)
deficits in affect regulation seen in pa- work on BPD. Linehan regards emotion
tients with BPD (Linehan 1993b), a com- dysregulation as the essential feature of
prehensive cognitive-social account of BPD. The key characteristics of emotion
PDs would likely address all of them. dysregulation include difficulty 1) inhib-
For example, patients with PDs have iting inappropriate behavior related to
dysfunctional schemas that lead them to intense affect, 2) organizing oneself to
misinterpret information (as when pa- meet behavioral goals, 3) regulating phys-
tients with BPD misread and misattrib- iological arousal associated with intense
ute people’s intentions), attend to and emotional arousal, and 4) refocusing at-
encode information in biased ways (as tention when emotionally stimulated
when patients with paranoid PD main- (Linehan 1993a). Many of the behavioral
tain vigilance for perceived slights or at- manifestations of BPD (e.g., impulsivity)
tacks), or view themselves as bad or in- can be viewed as consequences of emo-
competent (pathological self-schemas). tional dysregulation. Deficits in emotion
Related to these schemas are problem- regulation lead to other problems, such
atic expectancies, such as pessimistic ex- as difficulties with interpersonal func-
pectations about the world, beliefs about tioning and the development of a stable
the malevolence of others, fears of being sense of self.
mocked, and so forth. Patients with PDs According to another cognitive-
may have pathological self-efficacy ex- behavioral approach, Beck’s cognitive
pectancies, such as the dependent pa- theory (Beck 1999; Beck et al. 2004;
tient’s belief that he cannot survive on Pretzer and Beck 1996), dysfunctional
his own, the avoidant patient’s belief that beliefs constitute the primary pathology
she is likely to fail in social circumstances, involved in the PDs (Beck et al. 2001),
or the narcissistic patient’s grandiose ex- which are viewed as “pervasive, self-
pectations about what he can accom- perpetuating cognitive-interpersonal cy-
plish. Equally important are competen- cles” (Pretzer and Beck 1996, p. 55). Beck’s
cies—that is, skills and abilities used for theory highlights three aspects of cogni-
solving problems. In social-cognitive tion: automatic thoughts (beliefs and as-
terms, social intelligence includes a vari- sumptions about the world, the self, and
ety of competencies that help people others), interpersonal strategies, and cog-
nitive distortions (systematic errors in propose three cognitive processes involv-

rational thinking). Beck and colleagues ing schemas that define key features of
have described a unique cognitive pro- PDs: schema maintenance, which refers
file characteristic of each of the DSM-IV to the processes by which maladaptive
PDs. For example, an individual diag- schemas are rigidly upheld (e.g., cogni-
nosed with schizoid PD would have a tive distortions, self-defeating behav-
view of himself as a self-sufficient loner, iors); schema avoidance, which refers to
a view of others as unrewarding and in- the cognitive, affective, and behavioral
trusive, and a view of relationships as ways individuals avoid the negative af-
messy and undesirable, and his primary fect associated with the schema; and
interpersonal strategy would involve schema compensation, which refers to
keeping his distance from other people ways of overcompensating for the EMS
(Pretzer and Beck 1996). He would use (e.g., workaholism in response to an EMS
cognitive distortions that minimize his of self as failure).
recognition of ways relationships with More recently, Young and colleagues
others can be sources of pleasure. Stud- (Young and Kellogg 2006; Young et al.
ies of dysfunctional beliefs (as assessed 2003) have incorporated psychody-
by the Personality Beliefs Questionnaire namic and attachment theories, as well
[A. T. Beck, J. S. Beck, unpublished reas some strategies from emotion-focused
search instrument, The Beck Institute for approaches, resulting in a more integra-
Cognitive Therapy and Research, Bala tive conceptualization and treatment of
Cynwyd, Pennsylvania, 1991]) have PDs. One feature of this revised approach
shown some support for the link between has been the development of the concept
particular beliefs and the DSM-IV PDs of “modes” as central to PDs, especially
(Beck et al. 2001; Bhar et al. 2012). to what Young and colleagues refer to as
Building on Beck’s cognitive theory, the more severe PDs (borderline, narcis-
Young and colleagues (see Young and sistic, and antisocial). For example, five
Gluhoski 1996; Young and Kellogg 2006; modes, or “aspects of self,” are regarded
Young and Lindemann 2002; Young et as central to BPD: the abandoned and
al. 2003) have added a fourth level of abused child, the angry and impulsive
cognition, early maladaptive schemas child, the detached protector, the puni-
(EMSs), defined as “broad and pervasive tive parent, and the healthy adult. Treat-
themes regarding oneself and one’s rela- ment strategies were designed to target
tionships with others, developed during each mode via four “mechanisms of
childhood and elaborated throughout healing and change”: limited reparent-
one’s life” (Young and Lindemann 2002, ing, emotion-focused work, cognitive
p. 95). Young and colleagues distinguish restructuring and education, and behav-
these from automatic thoughts and un- ioral pattern breaking. Research examin-
derlying assumptions, noting that EMSs ing the effectiveness of schema therapy
are associated with greater levels of af- has largely focused on BPD and pro-
fect, are more pervasive, and involve a vides some support for the model (e.g.,
strong interpersonal aspect. Young and Lobbestael et al. 2005; Nadort et al. 2009).
colleagues have identified 18 EMSs, each Mischel and Shoda (1995) have of-
comprising cognitive, affective, and be- fered a compelling social-cognitive ac-
havioral components (Young and Kel- count of personality that focuses on if-
logg 2006; Young et al. 2003). They also then contingencies—that is, conditions
that activate particular thoughts, feel- empirical literature, traits have largely
ings, and behaviors. Although Mischel been defined operationally, as the aver-
and Shoda have not linked this model to age of a set of self-report items designed
PDs, one could view PDs as involving a to assess them (e.g., items indicating a
host of rigid, maladaptive if-then contin- tendency to feel anxious, sad, ashamed,
gencies. For example, for some patients, guilty, self-doubting, and angry, which
the first hints of trouble in a relationship all share a common core of negative af-
may activate concerns about abandon- fectivity or neuroticism).
ment. These in turn may elicit anxiety or Researchers have begun recasting PDs
rage, to which the person with a PD rein terms of the most prominent contem-
sponds with desperate attempts to lure porary trait theory, the five-factor model
the other person back (e.g., through of personality (FFM; McCrae and Costa
manipulative statements and suicidal 1997; Widiger 2000; Widiger and Costa
gestures) that often backfire. From an in- 1994). (We address other trait models that
tegrative psychodynamic-cognitive view- have been more closely associated with
point, Horowitz (1988, 1998) has offered biological theories in the section “Biolog-
a model that focuses on the conditions un- ical Perspectives” below.) The FFM is a
der which certain states of mind become description of the way personality de-
active, which he has tied more directly to scriptors tend to covary and hence can be
a model of PDs. Similarly, Wachtel (1977, understood in terms of latent factors
1997) has described cyclical psychody- (traits) identified via factor analysis. On
namics, in which people manage to elicit the basis of the lexical hypothesis of per-
from others precisely the kinds of reac- sonality—that important personality at-
tions of which they are the most vigilant tributes will naturally find expression in
and afraid. words used in everyday language—the
FFM emerged from factor analysis of ad-
jectival descriptions of personality origi-
Trait Theories nally selected from Webster’s Unabridged
Dictionary (Allport and Odbert 1936). Nu-
Trait psychology focuses less than psy- merous studies, including cross-cultural
chodynamic or cognitive-social ap- investigations, have found that when
proaches on personality processes or participants in nonclinical (so-called nor-
functions and hence has not generated an mal) samples are asked to rate themselves
approach to treatment, although it has on dozens or hundreds of adjectives or
generated highly productive empirical brief sentences, the pattern of self-descrip-
research programs. Traits are emotional, tions can often be reduced to five over-
cognitive, and behavioral tendencies on arching constructs: neuroticism or nega-
which individuals vary (e.g., the tentive affect (how much the individuals
dency to experience negative emotions). tend to be distressed), extraversion or
According to Gordon Allport (1937), who positive affect (the extent to which they
pioneered the trait approach to person- tend to be gregarious, high energy, and
ality, the concept of trait has two sepa- happy), conscientiousness, agreeable-
rate but complementary meanings: a ness, and openness to experience (the ex-
trait is both an observed tendency to be- tent to which they tend to be open to
have in a particular way and an inferred, emotional, aesthetic, and intellectual ex-
underlying personality disposition that periences) (Costa and McCrae 1997; Gold-
generates this behavioral tendency. In the berg 1993).
McCrae and Costa (1990, 1997) have assessment of normal and pathological
proposed a set of lower-order traits, or personality and establishes dimensions
facets, within each of these broadband of personality pathology using well-
traits, which can allow a more discrimi- understood empirical procedures (factor
nating portrait of personality. Thus, an analysis).
individual’s personality profile is repre- Another way to proceed using the FFM
sented by a score on each of the five fac- is to translate clinically derived catego-
tors plus scores on six lower-order facets ries into five-factor language (Coker et
or subfactors within each of these broader al. 2002; Lynam and Widiger 2001; Widi-
constructs (e.g., anxiety and depression ger and Costa 1994; Widiger et al. 2002).
as facets of neuroticism). Advocates of For example, Widiger and colleagues
the FFM argue that PDs reflect extreme (2002) describe antisocial PD as combin-
versions of normal personality traits, so ing low agreeableness with low consci-
the same system can be used for diag- entiousness. Because analysis at the level
nosing normal and pathological person- of five factors often lacks the specificity
ality. From the perspective of the FFM, to characterize complex disorders such
PDs are not discrete entities separate and as BPD (high neuroticism plus high ex-
distinct from normal personality. Rather, traversion), proponents of the FFM have
they represent extreme variants of nor- often moved to the facet level. Thus,
mal personality traits or blends thereof. whereas all six neuroticism facets (anxi-
In principle, one could classify PDs in ety, hostility, depression, self-conscious-
one of two ways using the FFM. The first, ness, impulsivity, and vulnerability) are
and most consistent with the theoretical characteristic of patients with BPD, pa-
and psychometric tradition within which tients with avoidant PD are characterized
the FFM developed, is simply to identify by only four of these facets (anxiety, de-
personality pathology by extreme values pression, self-consciousness, and vulnera-
on each of the five factors (and perhaps bility). Similarly, Widiger and colleagues
on their facets). For example, extremely (2002) describe obsessive-compulsive
high scores on the neuroticism factor and PD as primarily an extreme, maladap-
its facets (anxiety, hostility, depression, tive variant of conscientiousness. They
self-consciousness, impulsiveness, and add, however, that patients with obses-
vulnerability) all represent aspects of per- sive-compulsive PD tend to be low on
sonality pathology. Matters of debate, the compliance and altruism facets of
however, are whether this strategy is ap- agreeableness (i.e., they are oppositional
propriate for all factors and facets and and stingy) and low on some of the fac-
when to consider extreme responses on ets of openness to experience, as re-
one or both poles of a dimension to be flected in being closed to feelings and
pathological. Extreme extraversion, for closed to values (i.e., morally inflexible).
example, may or may not be pathologi- Numerous studies have shown predicted
cal, depending on the social milieu and links between DSM-IV Axis II disorders
the person’s other traits. Similarly, ex- and FFM factors and facets (Axelrod et
treme openness to experience could im- al. 1997; Ross et al. 2002; Trull et al. 2001),
ply a genuinely open attitude toward although other studies have found sub-
emotions, art, and so forth, or an uncriti- stantial overlap among the FFM profiles
cal, “flaky,” or schizotypal cognitive style. of patients with very different PDs (e.g.,
The advantage of this approach, however, borderline and obsessive-compulsive)
is that it integrates the understanding and using major FFM self-report inventories
(Morey et al. 2002). The alternative DSM-5 proposed a model based on core charac-
model for personality disorders includes teristics of symptom disorders relevant
a set of 25 maladaptive trait facets in five to PDs and related these characteristics
trait domains (see DSM-5, Table 3, pp. to emerging knowledge of their un-
779–781) reflecting, to a significant ex- derlying neurobiology. They focused on
tent, the structure of the FFM. cognitive-perceptual organization (schizo-
phrenic and other psychotic disorders),
impulsivity/aggression (impulse con-
Biological Perspectives trol disorders), affective instability (mood
disorders), and anxiety/inhibition (anx-
The first biological perspectives on PDs, iety disorders). Conceptualized in di-
which influenced the earlier DSM Axis II mensional terms, symptom disorders
classification, stemmed from the obser- such as schizophrenia represent the ex-
vations of the pioneering psychiatric treme end of a continuum. Milder ab-
taxonomists in the early twentieth cen- normalities can be seen in patients with
tury, notably Bleuler (1911/1950) and PDs, either directly (as subthreshold vari-
Kraepelin (1896/1919). Bleuler, Kraepe- ants) or through their influence on adap-
lin, and others noticed, for example, that tive strategies (coping and defense).
the relatives of patients with schizophre- Siever and Davis (1991) linked each di-
nia sometimes appeared to have attenu- mension to biological correlates and indi-
ated symptoms of the disorder that cators, some presumed to be causal and
endured as personality traits, such as in- others to provide markers of underlying
terpersonal and cognitive peculiarity. biological dysfunction (e.g., eye move-
More recently, researchers have used the ment dysfunction in schizophrenia, which
methods of trait psychology (particu- is also seen in individuals with schizo-
larly the reliance on self-report question- typal PD and in nonpsychotic relatives
naires and factor analysis) to study PDs of schizophrenic probands). They also
from a biological viewpoint. In some pointed to suggestive data on neurotrans-
cases, they have developed item sets with mitter functioning that might link per-
biological variables (e.g., neurotransmit- sonality disorders with syndromes such
ters and their functions) in mind, or have as depression. More recently, Siever and
reconsidered patterns of covariation colleagues (New and Siever 2002; Siever
among different traits in light of hypoth- et al. 2003) proposed an approach to BPD
esized neurobiological systems or cir- that tries to circumvent the problems
cuits. In other cases, they have applied created by the heterogeneity of the diag-
behavioral genetic approaches, and more nosis by examining the neurobiology of
recently neuroimaging techniques, to specific dimensions thought to underlie
study personality traits as well as DSM-IV the disorder (endophenotypes), espe-
PDs. We explore each of these approaches cially impulsive aggression and affective
in turn. instability.
The major attempt thus far to develop
a trait model of PDs based on a neurobio-
Traits and Neural Systems logical model is Cloninger’s seven-factor
Siever and Davis (1991) provided one of model of personality (Cloninger 1998;
the first attempts to reconsider the PDs Cloninger et al. 1993). Cloninger divided
from a neurobiology perspective. They personality structure into two domains,
which he called temperament (“auto- dent, avoidant, obsessive-compulsive),

matic associative responses to basic emo- with high harm avoidance. Individual
tional stimuli that determine habits and PDs may be described more fully by pro-
skills”) and character (“self-aware con- files obtained from Cloninger et al.’s self-
cepts that influence voluntary intentions report Temperament and Character In-
and attitudes”) (Cloninger 1998, p. 64). ventory (TCI; Cloninger and Svrakic
According to Cloninger, these domains 1994; Cloninger et al. 1993). For example,
are defined by a mode of learning and the BPD would consist of high harm avoid-
underlying neural systems involved in ance, high novelty seeking, and low re-
each form of learning: temperament is ward dependence, as well as low scores
associated with associative/procedural on the character dimensions.
learning, and character is associated with More recently, Cloninger (2004, 2008)
insight learning. The temperament do- revised his psychobiological theory and
main includes four dimensions, each related measurement instrument, now
theoretically linked to particular neu- called the TCI-R (Cloninger 2004), result-
rotransmitter systems: novelty seeking (ex- ing in a more precise and complex as-
ploration, extravagance, impulsivity), assessment of the subscales of tempera-
sociated with dopamine; harm avoidance ment and character. In the revised model
(characterized by pessimism, fear, timid- Cloninger proposes five layers of per-
ity), associated with serotonin and J-ami- sonality (“planes of being”): sexual, ma-
nobutyric acid; reward dependence (senti- terial, emotional, intellectual, and spiri-
mentality, social attachment, openness), tual. Each plane includes five subplanes
associated with norepinephrine and sero- (sexual, material, emotional, intellectual,
tonin; and persistence (industriousness, and spiritual), resulting in a 5u5 matrix
determination, ambitiousness, perfec- that provides data on the basis of specific
tionism), associated with glutamate and modules of temperament and character.
serotonin (Cloninger 1998, p. 70). The The 25 modules of the matrix are re-
character domain includes three dimen- garded as sufficient descriptors of the
sions: self-directedness (responsibility, pur- key aspects of personality. (For a thor-
posefulness, self-acceptance), considered ough description of this complex model,
the “major determinant of the presence or see Cloninger 2004.)
absence of personality disorder” (Clon- Depue, Lenzenweger, and colleagues
inger et al. 1993, p. 979); cooperativeness (e.g., Depue and Collins 1999; Depue and
(empathy, compassion, helpfulness); and Fu 2011; Depue and Lenzenweger 2001)
self-transcendence (spirituality, idealism, have offered a dimensional neurobehav-
enlightenment). ioral model that regards PDs as emer-
Cloninger (1998) proposed that all PDs gent phenotypes that arise from the inter-
are low on the character dimensions of action of basic neurobehavioral systems
self-directedness and cooperativeness. that underlie major personality traits
What distinguishes patients with differ- (Depue and Lenzenweger 2001, p. 165).
ent disorders are their more specific pro- Through an extensive examination of
files. In broad strokes, the Cluster A PDs the psychometric literature on the struc-
(schizotypal, schizoid, paranoid) are as- ture of personality traits, as well as a the-
sociated with low reward dependence; oretical analysis of the neurobehavioral
the Cluster B PDs (borderline, antisocial, systems likely to be relevant to person-
narcissistic, histrionic), with high novelty ality and personality dysfunction, they
seeking; and the Cluster C PDs (depen- identified five trait dimensions (extra-
version, neuroticism, social closeness/ evance to PDs. The most frequently stud-
agreeableness, constraint/conscientious- ied traits, extraversion and neuroticism,
ness, and social rejection sensitivity) and have produced heritability estimates of
six neurobehavioral systems underlying 54%–74% and 42%–64%, respectively
these traits that they argue can account (Eysenck 1990).
for the range of PD phenotypes (see Behavioral genetic data are proving
Depue and Fu 2011). For example, the increasingly useful in both etiological
neurobehavioral system underlying the and taxonomic work (e.g., Krueger 1999;
trait of extraversion is positive incentive Livesley et al. 1998). Livesley et al. (2003)
motivation, which is common to all noted that behavioral genetic data can
mammalian species and involves posi- help address the persistent lack of con-
tive affect and approach motivation. The sensus among trait psychologists regard-
dopaminergic system has been strongly ing which traits to study by examining
implicated in incentive-motivated be- the causes of trait covariation (as opposed
havior, such that individual differences to simply describing it). Establishing con-
in the former predict differences in the gruence between a proposed phenotypic
latter. In addition, Depue and colleagues model of personality traits and the ge-
emphasize the role of “epigenetics” in netic structure underlying it would sup-
PDs, whereby environmental factors port the validity of a proposed factor
influence genes and neurobehavioral model. The same holds true for models
systems, thus having the potential, es- of PDs. To test this approach, Livesley et
pecially at critical developmental junc- al. (1998) administered the Dimensional
tures, of mitigating or exacerbating PD Assessment of Personality Pathology—
phenotypes. Research on this model is Basic Questionnaire (DAPP-BQ) to a large
promising in its integration of research sample of individuals with and without
on neural systems involved in funda- PDs, including twin pairs. The self-re-
mental functions common to many ani- port DAPP-BQ consists of 18 traits con-
mal species (e.g., approach, avoidance, sidered to underlie PD diagnoses (e.g.,
affiliation with conspecifics, inhibition identity problems, oppositionality, social
of punished behavior) and individual avoidance). Factor analysis indicated a
differences research in personality psy- four-factor solution: emotional dysregu-
chology. lation, dissocial behavior, inhibition, and
compulsivity. Results showed high con-
Behavioral Genetic gruence for all four factors between the
phenotypic and behavioral genetic anal-
Approaches yses, indicating strong support for the
The vast majority of behavioral genetic proposed factor solution. In addition, the
studies of personality have focused on data showed substantial residual herita-
normal personality traits, such as those bility for many lower-order traits, sug-
that comprise the FFM and Eysenck’s gesting that these traits likely are not
(1967, 1981) three-factor model (extra- simply components of the higher-order
version, neuroticism, and psychoticism). factors but include unique components
These studies have generally shown (specific factors) as well. Similarly, Krue-
moderate to large heritability (30%–60%) ger and colleagues (e.g., Krueger 1999)
for a range of personality traits (Livesley found, using structural equation model-
et al. 1993; Plomin and Caspi 1999) of rel- ing with a large twin sample, that broad-
band internalizing and externalizing per- onstrated significant variability, most

sonality factors account for much of the likely due to the range of samples and
variance in many common symptom dis- methods used. Although the precise her-
orders (e.g., mood, anxiety, substance itability estimate may vary, several PDs
use) and that genetic and environmental have consistently shown heritability fig-
sources of variance are associated with ures in the 0.40–0.60 range or above (see
many of both the higher- and lower-order Torgersen 2009). The majority of studies
factors they identified. have examined only a subset of the DSM
More recently, Livesley (2011) pro- PDs, particularly schizotypal, antisocial,
posed a dimensional model of PDs based and borderline PDs. These disorders ap-
on the four factors mentioned above— pear to reflect a continuum of heritabil-
slightly modified as emotional dysregu- ity (see Nigg and Goldsmith 1994), with
lation, dissocial behavior, social avoid- schizotypal most strongly linked to
ance, and compulsivity— which have genetic influences; antisocial linked both
emerged consistently across a number of to environmental and genetic variables;
studies, including behavioral genetic and borderline showing the smallest
studies (e.g., Livesley et al. 1998). Within estimates of heritability in the majority
this model, individual differences in PD of studies, with some exceptions (e.g.,
are described using 30 primary person- Coolidge et al. 2001; Torgersen et al.
ality traits thought to underlie the four 2000).
dimensions. For example, the primary Research on the heritability of schizo-
traits attributed to the social avoidance typal PD provides the clearest evidence
domain include low affiliation, avoidant of a genetic component to a PD. (Schizo-
attachment, restricted emotional expres- typal PD is defined by criteria such as
sion, self-constraint, inhibited sexuality, odd beliefs or magical thinking, unusual
and attachment need (Livesley 2011). The perceptual experiences, odd thinking and
structure of four higher-order dimen- speech, suspiciousness, inappropriate or
sions and 30 primary traits is proposed constricted affect, and behavior or ap-
to represent the genetic “architecture” of pearance that is odd or eccentric.) As
personality. noted above in “Biological Perspectives,”
Compared with research on normal Bleuler (1911/1950) and Kraepelin (1896/
personality traits (as well as many symp- 1919) identified peculiarities in language
tom disorders), behavioral genetic stud- and behavior among some relatives of
ies of PDs are less common. The most their schizophrenic patients. Bleuler
typical designs have been family stud- called this presentation “latent schizo-
ies, in which researchers begin with the phrenia” and considered it to be a less
PD proband and then assess other fam- severe and more widespread form of
ily members. The major limitation of this schizophrenia. Further research into the
method is that familial aggregation of constellation of symptoms characteristic
disorders can support either genetic or of relatives of schizophrenic patients ul-
environmental causes. As in all behav- timately resulted in the creation of the
ioral genetic research, twin and adoption DSM-III diagnosis of schizotypal PD
studies provide more definitive data. A (Spitzer et al. 1979). A genetic relation-
number of these studies have assessed ship between schizophrenia and schizo-
heritability for a subset of DSM-IV PDs, typal PD is now well established (Kend-
and a few have examined all 10 of the ler and Walsh 1995; Lenzenweger 1998).
DSM-IV PDs. The results have often dem- In one study, Torgersen (1984) found that
33% (7 of 21) of identical co-twins had including BPD, with many heritability
schizotypal PD, whereas only 4% (1 of 23) estimates between 0.50 and 0.60. Increas-
of fraternal co-twins shared the diagno- ingly, researchers are suggesting that
sis. Data from a later twin study (Torg- specific components of BPD may have
ersen et al. 2000) using structural equa- higher heritability than the BPD diagno-
tion modeling estimated heritability at sis taken as a whole. For example, Nigg
0.61, whereas Kendler et al. (2007) found and Goldsmith (1994) and Widiger and
a heritability estimate of 0.72. Frances (1994) suggested that the person-
Antisocial PD, in contrast, appears to ality trait neuroticism, which is highly
have both genetic and environmental heritable, is at the core of many border-
roots, as documented in both adoption line features (e.g., negative affect and
and twin studies (Cadoret et al. 1995; stress sensitivity). Other components of
Torgersen et al. 2008). An adult adoptee BPD have shown substantial heritability
whose biological parent has an arrest reas well (e.g., problems with identity, im-
cord for antisocial behavior is four times pulsivity, affective lability) (Distel et al.
more likely to have problems with ag- 2010; Livesley et al. 1993; Skodol et al.
gressive behavior than a person without a 2002). A caveat worth mentioning, how-
biological vulnerability. At the same time, ever, is that behavioral genetic studies
a person whose adoptive parent has anti- that systematically measure environmen-
social PD is more than three times more tal influences directly (e.g., developmen-
likely to develop the disorder, regardless tal toxins such as sexual abuse), rather
of biological history. As is the case with than deriving estimates of shared and
other behavioral genetic findings, twin nonshared environment statistically
studies suggest that environmental ge- from residual terms, often obtain very
netic factors grow more predictive as indifferent estimates of environmental ef-
dividuals get older (Lyons et al. 1995). In fects, and this may well be the case with
considering the data on antisocial and many PDs. For example, if one child in a
other PDs, however, it is important to re- family responds to sexual abuse by be-
member that all estimates of heritability coming avoidant and constricted and an-
are sample dependent. Turkheimer et al. other responds to the same experience by
(2003) found, for example, that genes ac- becoming borderline and impulsive, re-
count for most of the variability in IQ searchers will mistakenly conclude, un-
among middle-class children but that less they actually measured developmen-
more than 60% of the variance in IQ in tal variables, that shared environment
samples with low socioeconomic status has no effect because a shared environ-
reflects shared environment. Socioeco- mental event led to nonshared responses
nomic status may similarly moderate the to it (see Turkheimer and Waldron 2000;
relation between genes and environment Westen 1998).
and antisocial behavior.
Data on the behavioral genetics of BPD
are mixed. Several studies have found Integrative Theories
only modest evidence of heritability (e.g.,
Dahl 1993; Nigg and Goldsmith 1994; Of all the disorders identified in DSM-5,
Reich 1989). Twin studies focusing on the the PDs are likely to be among those that
heritability of several PDs (Coolidge et al. most require biopsychosocial perspec-
2001; Torgersen et al. 2000) found a sub- tives. Our understanding of PDs may im-
stantial genetic component to several PDs, prove substantially by integrating data
from both clinical observation and re- world, particularly other people) and are
search and from classical theories of reflected in the passive/active polarity; 3)
personality that delineate personality strategies of replication or reproduction,
functions and more contemporary re- which refer to the extent to which the per-
search that emphasizes traits. The emer- son focuses on individuation or nurtur-
gence of several integrative models is ance of others and are reflected in the
thus perhaps not surprising. We briefly self/other polarity; and 4) processes of ab-
describe three such models here: Millon’s straction, which refer to the ability for
evolutionary-social learning model, symbolic thought, and are represented by
Benjamin’s interpersonal model, and the thinking/feeling polarity.
Westen’s functional domain model. Millon and colleagues (Millon 1977,
1987; Millon et al. 1994) identified 14 per-
Millon’s Evolutionary– sonality prototypes that can be under-
stood in terms of the basic polarities noted
Social Learning Model above. For example, patients with schiz-
Millon developed a comprehensive model oid PD tend to have little pleasure, to
of personality and PDs that he initially have little involvement with others, to be
framed in social learning terms (Millon relatively passive in their stance to the
1969) and eventually reframed in evolu- world, and to rely on abstract thinking
tionary terms (Millon 1990; Millon and over intuition. In contrast, patients with
Davis 1996). Millon initially described histrionic PD are pleasure seeking, inter-
personality in terms of three polarities: personally focused (although in a self-
pleasure/pain, self/other, and passive/ centered way), highly active, and short
active. These polarities reflect the nature on abstract thinking. Millon’s theory led
of reinforcement that controls the per- to the distinction between avoidant and
son’s behavior (rewarding or aversive), schizoid PD in DSM-III. Whereas schizoid
the source or sources that provide rein- PD represents a passive-detached per-
forcement (oneself or others), and the in- sonality style, avoidant PD represents an
strumental behaviors and coping strate- active-detached style, characterized by
gies used to pursue it (active or passive). active avoidance motivated by avoidance
Millon later added a fourth polarity, of anxiety. Millon also developed a com-
thinking/feeling, which reflects the ex- prehensive measure to assess the DSM
tent to which people rely on abstract PDs and his own theory-driven PD clas-
thinking or intuition. sification, the Millon Clinical Multiaxial
Millon (Davis 1999; Millon 1990; Mil- Inventory (MCMI; Millon 1977). The in-
lon and Davis 1996) eventually recon- strument, now in its third edition (MCMI-
ceptualized his original theory in evo- III; Millon and Davis 1997), has been used
lutionary terms. He outlined four basic in hundreds of studies and is widely used
evolutionary principles consistent with as an assessment tool in clinical practice
the polarities described by his earlier the- (e.g., Espelage et al. 2002; Kristensen and
ory: 1) aims of existence, which refer to Torgersen 2001).
life enhancement and life preservation
and are reflected in the pleasure/pain po- Benjamin’s
larity; 2) modes of adaptation, which Mil-
lon describes in terms of accommodation Interpersonal Model
to versus modification of the environment Benjamin’s interpersonal theory, called
(whether one adjusts or tries to adjust the Structural Analysis of Social Behavior
(SASB; Benjamin 1993, 1996a, 1996b), fo- DSM-IV PD criteria (and disorders) into
cuses on interpersonal processes in per- interpersonal terms (Benjamin 1993,
sonality and psychopathology and their 1996b). In this respect, it has two advan-
intrapsychic causes, correlates, and se- tages. The first is that it reduces comor-
quelae. Influenced by Sullivan’s (1953) bidity among disorders by specifying
interpersonal theory of psychiatry, ob- the interpersonal antecedents that elicit
ject relations approaches, and research the patient’s responses. For example, mal-
using the interpersonal circumplex (e.g., adaptive anger is characteristic of many
Kiesler 1983; Leary 1957; Schaefer 1965), of the DSM-IV PDs but has different in-
the SASB is a three-dimensional circum- terpersonal triggers and meanings (Ben-
plex model with three “surfaces,” each jamin 1993). Anger in patients with BPD
of which represents a specific focus. The often reflects perceived neglect or aban-
first surface focuses on actions directed donment. Anger in patients with narcis-
at another person (e.g., abuse by a parent sistic PD tends to follow from perceived
toward the patient). A second surface fo- slights or failures of other people to give
cuses on the person’s response to real or the patient everything he or she wants
perceived actions by the other (e.g., re- (entitlement). Anger in antisocial patients
coiling from the abusive parent). The is often cold, detached, and aimed at con-
third focus is on the person’s actions to- trolling the other person. The second ad-
ward himself or herself, or what Benja- vantage is that the SASB model is able to
min calls the “introject” (e.g., self-abuse). represent multiple, often conflicting as-
The notion behind the surfaces is that the pects of the way patients with a given
first two are interpersonal and describe disorder behave (or complex, multifac-
the kinds of interaction patterns (self eted aspects of a single interpersonal in-
with other) in which the patient engages teraction) simultaneously. Thus, a single
with significant others (parents, attach- angry outburst by a patient with BPD
ment figures, therapists, etc.). The third could reflect an effort to get distance
surface represents internalized attitudes from the other, to hurt the other, and to
and actions toward the self (e.g., self- get the other to respond and hence be
criticism that began as criticism from par- drawn back into the relationship. Benja-
ents). According to Benjamin, children min has devised several ways of opera-
learn to respond to themselves and oth- tionalizing a person’s dynamics or an in-
ers by identifying with significant others terpersonal interaction (e.g., in a therapy
(acting like them), recapitulating what hour), ranging from direct observation
they experienced with significant others and coding of behavior to self-report
(e.g., eliciting from others what they ex- questionnaires, all of which yield de-
perienced before), and introjecting oth- scriptions using the same circumplex
ers (treating themselves as others have model.
treated them).
As with all circumplex models, each Westen’s Functional
surface has two axes that define its quad-
rants. In the SASB (as in other interper- Domain Model
sonal circumplex models), love and hate Westen (1995, 1996, 1998) has described a
represent the two poles of the horizontal model of domains of personality func-
axis. Enmeshment and differentiation tioning that draws substantially on psy-
are the endpoints of the vertical axis. The choanalytic clinical theory and observa-
SASB offers a translation of each of the tion as well as on empirical research in
personality, cognitive, developmental, lytic theories of motivation and conflict

and clinical psychology. Although some (Brenner 1982); ego-psychological ap-
aspects of the model are linked to re- proaches to adaptive functioning; and
search on etiology, the model is less a the- object-relational, self psychological, at-
ory of PDs than an attempt to delineate tachment, and contemporary relational
and systematize the major elements of (Aron 1996; Mitchell 1988) approaches
personality that define a patient’s person- to understanding people’s experience of
ality, whether or not the patient has a PD. self with others. Each of these questions
The model differs from trait approaches and subdimensions, however, is also as-
in its focus on personality processes and sociated with a number of research tra-
functions (e.g., the kinds of affect regula- ditions in personality, clinical, cognitive,
tion strategies the person uses, the ways and developmental psychology (e.g., on
she represents the self and others men- the development of children’s represen-
tally, as well as more behavioral disposi- tations of self, representations of others,
tions, such as whether she engages in im- moral judgment, attachment styles, abil-
pulsive or self-destructive behavior). ity to tell coherent narratives, etc.) (see
However, it shares with trait approaches Damon and Hart 1988; Fonagy et al. 2002;
the view that a single model should be Harter 1999; Livesley and Bromley 1973;
able to accommodate relatively healthy as Main 1995; Westen 1990a, 1990b, 1991b,
well as relatively disturbed personality 1994). Westen and Shedler (1999a) used
styles and dynamics. this model as a rough theoretical guide
The model suggests that a systematic to ensure comprehensive coverage of
personality case formulation must an- personality domains in developing items
swer three questions, each composed of for the Shedler-Westen Assessment Pro-
a series of subquestions or variables that cedure (SWAP-200) Q-sort, a personality
require assessment: 1) What does the pathology measure for use by expert in-
person wish for, fear, and value, and to formants, although the model and the
what extent are these motives conscious measure are not closely linked (i.e., one
or unconscious, collaborating or conflict- does not require the other).
ing? 2) What psychological resources— From this point of view, individuals
including cognitive processes (e.g., intel- with particular PDs are likely to be char-
ligence, memory, intactness of thinking acterized by 1) distinct constellations of
processes), affects, affect regulation motives and conflicts, such as chronic
strategies (conscious coping strategies worries about abandonment in BPD or a
and unconscious defenses), and behav- conflict between the wish for and fear of
ioral skills—does the person have at his connectedness to others in avoidant PD;
or her disposal to meet internal and ex- 2) deficits in adaptive functioning, such
ternal demands? 3) What is the person’s as poor impulse control, lack of self-
experience of the self and others, and reflective capacities (see Fonagy and Tar-
how able is the individual—cognitively, get 1997), and difficulty regulating affect
emotionally, motivationally, and behav- (Linehan 1993b; Westen 1991a) in BPD or
iorally—to sustain meaningful and plea- subclinical cognitive disturbances in
surable relationships? schizotypal PD; and 3) problematic ways
From a psychodynamic perspective, of thinking, feeling, and behaving toward
these questions correspond roughly to themselves and significant others, such
the issues raised by classical psychoana- as a tendency to form simplistic, one-
dimensional representations of the self how the model can be used to describe
and others, to misunderstand why peo- personality dynamics in patients without
ple (including the self) behave as they do, a diagnosable PD (Westen 1998; Westen
and to expect malevolence from other and Shedler 1999b).
people (characteristics seen in many pa-
tients with PDs, such as paranoid, schiz-
oid, and borderline) (Kernberg 1975a, Use of Theory in
1984; Westen 1991a). In this model, a per-
son’s level of personality health-sickness
Case Formulation
(on a range from severe PD to relatively To see how two models operate in prac-
healthy functioning), which can be as- tice, consider the following brief case de-
sessed reliably using a personality health scription:
prototype or a simple rating of level of
personality organization derived from
Kernberg’s work (Westen and Muderri-
Case Example
soglu 2003; Westen and Shedler 1999b), Sean was a man in his early 20s who
reflects his or her functioning in each of came to treatment for lifelong prob-
lems with depression, anxiety, and
these three domains. feelings of inadequacy. He was a
People who do not have severe enough kind, introspective, sensitive man who
pathology to receive a PD diagnosis can nevertheless had tremendous diffi-
similarly be described using Westen’s culty making friends and interacting
approach. For example, a successful male comfortably with people. He was con-
stantly worried that he would mis-
executive presented for treatment with
speak, would ruminate after conver-
troubles in his marriage and his relation- sations about what he had said and
ships at work, as well as low-level feel- the way he was perceived, and had
ings of anxiety and depression. None of only one or two friends with whom he
these characteristics approached criteria felt comfortable. He wanted to be
for a PD (or any symptom disorders, ex- closer to people, but he was fright-
ened that he would be rejected and
cept the relatively nondescript diagnosis
was afraid of his own anger in rela-
of adjustment disorder with anxiety and tionships. While interacting with peo-
depressed mood). Using this model, one ple (including his therapist), he would
would note that he was competitive with often have a running commentary
other people, of which he was unaware with them in his mind, typically filled
with aggressive content. He was in a
(Question 1); had impressive capacities
2-year relationship with a woman who
for self-regulation but was intellectual- was emotionally and physically very
ized, afraid of feelings, and often used distant, whom he saw twice a month
his enjoyment of his work as a way of re- and with whom he rarely had sex.
treating from his family (Question 2); Prior to her, his sexual experiences
and had surprisingly noncomplex repre- had all been anxiety provoking and
short lived.
sentations of others’ minds for a person
Sean tended to be inhibited in many
who could solve noninterpersonal prob- areas of his life. He was emotionally
lems in complex ways and consequently constricted and seemed particularly
would often became angry and attack at uncomfortable with pleasurable feel-
work without stopping to empathize with ings. He tended to speak in intellectu-
alized terms about his life and history
the other person’s perspective (Ques-
and seemed afraid of affect. He felt sti-
tion 3). This is, of course, a highly oversim- fled in his chosen profession, which
plified description, but it gives a sense of did not allow him to express many of
his intellectual abilities or creative im- tivity and low positive affectivity left
pulses. He alternated between over- him vulnerable to feelings of depression
control of his impulses, which was his
and captures his anxious, self-conscious
modal stance in life, and occasional
breakthroughs of poorly thought out, social avoidance.
impulsive actions (such as when he No other broadband factors describe
bought an expensive piece of equip- Sean adequately, although specific factors
ment with little forethought about how provide insight into his personality. He
he would pay for it). was moderately high in agreeableness,
Sean came from a working class
being compliant, modest, and tender
family in Boston and had lost his fa-
ther, a policeman, as a young boy. He minded; however, he was not particu-
was reared by his mother and later a larly high on trust, altruism, or straight-
stepfather, with whom he had a posi- forwardness (reflecting his tendency to
tive relationship. He also described a behave passive-aggressively). He was
good relationship with his mother, al-
moderately conscientious, showing mod-
though she, like several members of
her extended family, struggled with erate scores on the facets of orderliness
depression, and she apparently had a and discipline. He similarly showed mod-
lengthy major depressive episode af- erate openness to experience, being artis-
ter her husband’s death. tically oriented but low on comfort with
feelings. His scores on facets such as intel-
For purposes of brevity, we briefly ex- lectual curiosity would likely be moder-
plicate this case from two theoretical ate, reflecting both an interest and an in-
standpoints that provide very different hibition. Indeed, this would be true of
approaches to case formulation: the five- his facet scores on several traits, such as
factor model and a functional domains achievement orientation.
viewpoint. (In clinical practice, a func-
tional domains account and a psychody- A Functional Domains View
namic account are similar because the for-
A functional domains perspective would
mer reflects an attempt to systematize and
offer a similar summary diagnosis as a
integrate with empirical research [and
psychodynamic approach, along with a
minimal jargon] the major domains em-
description of Sean’s functioning on the
phasized by classical psychoanalytic, ego-
three major domains outlined in the
psychological, and object-relational/self-
model. In broadest outline, from this point
psychological/relational approaches.)
of view, Sean had a depressive, avoidant,
and obsessional personality style orga-
A Five-Factor View nized at a low-functioning neurotic level.
From a five-factor perspective (e.g., In other words, he did not have a PD, as
Widiger et al. 2002), the most salient fea- evidenced by his ability to maintain
tures of Sean’s personality profile were friendships and stable employment, but
his strong elevations in neuroticism and he had considerable psychological im-
introversion (low extraversion). He was pediments to love, work, and life satisfac-
high on most of the facets of neuroti- tion, with a predominance of depressive,
cism, notably, anxiety, depression, anger, avoidant, and obsessional dynamics.
self-consciousness, and vulnerability. With respect to motives and conflicts
He was low on most facets of extraver- (and interpersonal issues, around which
sion as well, particularly gregariousness, many of his conflicts centered), Sean had
assertiveness, activity, and happiness. a number of conflicts that impinged on
This combination of high negative affec- his capacity to lead a fulfilling life. He
wanted to connect with people, but he throughs of anger, anxiety, and impul-
was inhibited by social anxiety, feelings sive action. He distanced himself from
of inadequacy, and an undercurrent of emotion in an effort both to regulate anxi-
anger toward people that he could not ety and depression and to regulate ex-
directly express (and that emerged in his citement and pleasure, which seemed to
“running commentaries” in his mind). him both undeserved and threatening.
Although he worried that he would fail With respect to his experience of self
others, he always felt somehow unful- and relationships, Sean’s dominant in-
filled in his relationships with them and terpersonal concerns centered around
could be subtly critical. He likely had rejection, shame, and aloneness. He was
high standards with which he compared able to think about himself and others in
himself and others and against which complex ways and to show genuine care
both frequently fell short. He also had and concern toward other people, al-
trouble handling his anger, aggressive though these strengths were often not
impulses, and desires for self-assertion. manifest because of his interpersonal
He would frequently behave in passive avoidance. He had low self-esteem, al-
or self-punitive ways rather than appro- though he had some intellectual aware-
priately asserting his desires or express- ness that his feelings toward himself were
ing his anger. This contributed in turn unrealistically negative. He often voiced
to a lingering hostile fantasy life and a identity concerns, wondering what he
tendency at times to behave passive- was going to do with his life and where
aggressively. he would fit in, and feeling adrift with-
Sex was particularly conflictual for out either meaningful work or love rela-
Sean, not only because it forced him into tionships that were sustaining. (This is,
an intimate relationship with another of course, a very skeletal description of
person but because of his feelings of in- functional domains for Sean; for a more
adequacy, discomfort looking directly at thorough description and an empirical
a woman’s body (because of his associa- description using the SWAP-200 Q-sort,
tions with sex and women’s bodies), and see Westen 1998.)
worries that he was homosexual. When
with a woman, he frequently worried
that he would “accidentally” touch her Conclusion
anus and be repulsed, although, interest-
ingly, his sexual fantasies (and humor) These highly schematic versions of what
had a decidedly anal tone. Homosexual an FFM or a functional domains (or
images would also jump into his mind in psychodynamic) account might have to
the middle of sexual activity, which led offer in describing Sean’s case provide
to considerable anxiety. some sense of how a therapist might
With respect to adaptive resources, conceptualize a case from two very dif-
Sean had a number of strengths, notably, ferent theoretical perspectives. Theory,
his impressive intellect, a dry sense of research, and this brief case example all
humor, a capacity for introspection, and suggest the importance of indexing a
an ability to persevere. Nevertheless, broader range of personality pathology
his overregulation of his feelings and in any comprehensive personality classi-
impulses left him vulnerable to break- fication system.
Beck A: Cognitive aspects of personality disor-

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CHAPTER 3
Articulating a Core
Dimension of Personality
Pathology
Leslie C. Morey, Ph.D.
Problems with the categorical nate situation results in manifestations

approach to personality disorders pre- of putatively different “personality
sented in DSM-III (American Psychiatric diagnoses” that are more highly associ-
Association 1980), DSM-IV (American ated than different phenotypic variations
Psychiatric Association 1994), and the within the same “personality diagnosis”
DSM-5 (American Psychiatric Associa- (e.g., Morey and Levine 1988).
tion 2013) Section II personality disorder Although extensive co-occurrence is
(PD) classification (which is virtually iden- perhaps the most consistently replicated
tical to DSM-IV) have been well docu- result in the field of PDs, the various edi-
mented. Among the issues of greatest tions of DSM, including PDs in DSM-5
concern is the extensive co-occurrence of Section II (“Diagnostic Criteria and
PDs, such that most patients who receive Codes”), have yet to offer any represen-
a PD diagnosis meet criteria for more tation of PD that accounts for this phe-
than one (e.g., Grant et al. 2005; Morey nomenon or provide a compelling expla-
1988; Oldham et al. 1992; Zimmerman et nation as to why it is so reliably found. At
al. 2005). Another concern is the rela- the outset of work on DSM-5, the Person-
tively poor convergent validity of PD ality and Personality Disorders (P&PD)
criteria sets, apparent when considering Work Group was charged with develop-
that patient groups diagnosed by differing a new approach to the Personality
ent methods may be only weakly related Disorders section of DSM-5 that would
to one another (Clark 2007; Hyler et al. begin to rectify the comorbidity problem
1989; Pilkonis et al. 1995). This unfortu- (Kupfer et al. 2002; Rounsaville et al.
39
2002). As part of these deliberations, the IV-like inclusion and exclusion criteria,
work group sought to provide some this combination of core impairments
representation of PD that would delin- and pathological traits yields diagnoses
eate the essential similarities, apparently that bear substantial empirical similarity
shared by most, if not all, DSM PD cate- to DSM-IV PDs (Morey and Skodol 2013)
gories, that were driving the remarkable but have a clear conceptual structure that
comorbidity among these disorders. The maps out the elemental “traits” that are
DSM-IV general criteria for a PD indi- present to an unusual degree, and also
cate that an enduring pattern of inner provides an essential assessment struc-
experience and behavior is manifest by ture of the core features of personality
two or more of the following areas: cog- dysfunction.
nition, affectivity, interpersonal func- In this chapter we provide an over-
tioning, and impulse control. These very view of the notion of “core dysfunction”
broad criteria do not appear to be very in PD, describing the history of such a
specific for PDs, nor are they always con- concept and the instantiation of the con-
sistent with the specific criteria for indi- cept in the DSM-5 Section III model. Re-
vidual PDs in DSM, creating possible search that helps articulate the concept
confusion about whether individual and demonstrates its potential validity
PDs always meet the general criteria. Fi- and utility is also reviewed, along with
nally, it is important to understand that clinical illustrations of its utility.
these general PD criteria were introduced
in DSM-IV without justification or any
empirical basis—there is no mention of Historical Background
them in the PD chapters of the DSM-IV
Sourcebook (Gunderson 1996; Widiger et It is somewhat ironic that there was a
al. 1996) or in papers that described the significant subgroup of PD experts op-
development of the revised classification posing the DSM-5 Section III model on
(Frances et al. 1990, 1991; Pincus et al. the grounds that it is a substantial depar-
1992; Widiger et al. 1991). Consequently, ture from precedent, given that the no-
the general criteria for PD in DSM have tion of a unitary construct of personality
commonly been ignored in clinical prac- disturbance greatly predates the DSM-
tice and research, and they fail to pro- III/DSM-IV representation of discrete
vide any insight into the shared elements personality disorder categories. In fact,
that are common to PDs and that differ- in 1963, Menninger surveyed 2,000 years
entiate them from other forms of mental of the history of classification in psychia-
disorder. try and identified “a steady trend toward
The proposal from the P&PD Work simplification and reduction of the catego-
Group, found in DSM-5 Section III, ries from thousands to hundreds to doz-
“Emerging Measures and Models,” con- ens to a mere four or five” (p. 9). Men-
sists of dimensional assessments of shared ninger thus proposed a revolutionary
core impairments in personality func- psychiatric classification that comprised
tioning common to all PDs, as well as di- a single class—a unitary conception of
mensional assessments of pathological what he called “personality dysorgani-
personality traits that may be found to zation,” in contrast with “disorganiza-
varying degrees across different pation” in that personality organization has
tients. When combined with other DSM- not been lost but only impaired to various
Articulating a Core Dimension of Personality Pathology 41
degrees. This “dysorganization” was but Rushton and Irwing (2011) noted that
manifest at five different levels of sever- the common denominator to moral in-
ity of impairment in adaptive control, sanity was self-control (“will-power”), a
impulse management, and ego failures. lack of which could cause harm to oneself
Menninger and others (e.g., Rushton or to others.
and Irwing 2011) have pointed out that In contrast to the taxonomic work of
the history of the study of personality is psychiatric writers such as Emil Kraepe-
replete with such unitary, dimensional lin (1902), who delineated classes of dis-
severity models. Sir Francis Galton (1887) order such as manic-depression and de-
described a general factor of personality mentia praecox that were presented as
in his paper “Good and Bad Temper in qualitatively different phenomena, many
English Families,” using ratings from fam- personality-oriented writers continued to
ily members across generations to group emphasize a more unitary approach that
15 adjectives indicative of “good temper” identified critical differences as existing
(e.g., self-controlled) and 46 markers of between points along a single continuum.
“bad temper” (e.g., proud, uncertain, vin- In many accounts, this continuum was
dictive) that could be arrayed along a sin- thought to reflect a developmental pro-
gle dimension. Although there were cess, and individuals could be grouped
roughly three times as many markers of according to various “stages” in this pro-
“bad” personality as “good,” he felt that cess. Whereas Freud’s models of devel-
the ratio of the number of these markers opment, including psychosexual stages
present was distributed in a bell-shaped (Freud 1905/1953) and the evolution of
fashion with comparable numbers of in- narcissism to object-love (Freud 1914/
dividuals at each extreme (identified by 1957), were of considerable heuristic in-
Galton as those manifesting a 2:1 ratio of fluence, many other theorists described
these adjectives, in either direction). In this stage models with considerable over-
description, Galton was echoing in many lap in the indicators of placement along
ways James Cowles Prichard’s (1835) con- this continuum. Theorists such as Piaget
cept of moral insanity, which Prichard de- (1932), Kohlberg (1963), Erikson (1950),
scribed as “a morbid perversion of the and Loevinger (1976) all denoted devel-
natural feelings, affections, inclinations, opmental sequences that with matura-
temper, habits, moral dispositions, and tion resulted in greater self-control and
natural impulses, without any remarkable increased prosocial behavior.
disorder or defect of the intellect or know- Although Menninger (1963) obviously
ing and reasoning faculties, and particu- misread the trend that produced the ex-
larly without any insane illusion or hallu- plosion of diagnostic entities in DSM-III
cination” (p. 24). Prichard acknowledged that descended from a Kraepelinian rather
that this single class of mental disorder than a unitary tradition (Blashfield
could take many forms, stating that “the 1984), Menninger’s overview of the his-
varieties of moral insanity are perhaps as torical evolution of this model provides
numerous as the modifications of feeling a compelling reminder that the signifi-
or passion in the human mind” (Prichard cance of a severity gradient in evaluat-
1835, p. 24). These different forms could ing personality problems has been de-
involve extremes in emotion (despon- scribed for far longer than the specific
dency or excitement), impulses, hostility, personality entities introduced in DSM-
eccentricity, or “decay of social affection,” III. For example, in the long history of
personality assessment research, the spec- two super factors are themselves sub-
ter of a single, overarching dimension of sumed by a higher-order dimension. In
personality dysfunction has repeatedly two meta-analyses of Big-Five interscale
emerged in various empirical approaches correlations, Rushton and Irwing (2008)
to the study of personality. Early per- and Van der Linden et al. (2010) con-
sonality inventories such as the Minne- cluded that there was strong evidence of
sota Multiphasic Personality Inventory what Rushton and Irwing described as a
(Hathaway and McKinley 1943) were single “general factor of personality”;
seemingly saturated with a large single these meta-analyses included the data sets
source of variability, with repeated ef- that Digman (1997) had used to establish
forts to “eliminate” the contributions of the “alpha” and “beta” factors. Additional
this large component as an undesirable analyses found very poor fit of a model
artifact (e.g., Meehl 1945; Tellegen et al. specifying that the Big Two were uncor-
2003) rather than as a personality char- related.
acteristic of substantive significance. In addition to results from factor anal-
The “lexical” tradition of factor analysis ysis studies, there are also theoretical ac-
of personality adjectives, pioneered by counts that support the contention of a
Norman (1963) and Digman (1990) and “superfactor” of personality functioning.
culminating in the five-factor model Block (2010) provided the interesting ob-
(FFM), began with a set of personality servation that the Big Two components
descriptors that purposefully sought to of stability and plasticity, as two presum-
remove “evaluative” (i.e., good vs. bad) ably desirable elements of personality,
descriptors of personality as a basis for have important theoretical parallels to
the resulting dimensional structure, pre- Piaget’s (1932) notions of assimilation
sumably because of the compelling in- and accommodation, fundamental pro-
fluence such a dimension had on sub- cesses in the development of the child.
sequent factor analyses (Block 1995). Piaget identified these as the core princi-
Despite those efforts, it appears that a ples by which the child constructs and
unitary dimension of dysfunction may modifies internal representations of ob-
underlie even putatively orthogonal fac- jects and actions, allowing him or her to
tor structures such as the FFM. For ex- achieve equilibrium as well as adapt to
ample, research studying the different the world. As Block (2010) noted, assim-
DSM PDs consistently finds that the var- ilation and accommodation represent
ious disorders display quite similar con- manifestations of a single, central devel-
figurations on the FFM (Morey et al. 2000, opmental process that continues to influ-
2002; Saulsman and Page 2004; Zweig- ence behavior throughout the life span,
Frank and Paris 1995), a configuration and research on social cognition sup-
particularly characterized by high neu- ports the conclusion that these processes
roticism and low conscientiousness and play a foundational role in shaping inter-
agreeableness. A number of studies have actions with others. For example, Ander-
concluded that the five factors them- son and Cole (1990) demonstrated that
selves are subsumed under higher-order when a new acquaintance is assimilated
factors, such as the “Big Two” factors, la- into a category of “significant-other rep-
beled alpha and beta by Digman (1997) or resentations,” perceivers are quick to in-
stability and plasticity by DeYoung et al. appropriately apply preconceived no-
(2002). However, there is evidence sup- tions that were, in some instances, quite
porting the contention that even these inaccurate. Thus, maturation (or the fail-
ure thereof) of these representational pro- For example, numerous studies using
cesses has a powerful influence on one’s measures of self and interpersonal func-
view of self and of others. tioning have demonstrated their utility
Kernberg (1967) was one of the first for determining the existence, type, and
contemporary writers to formulate a clas- severity of personality pathology. These
sification of character pathology that en- measures include clinician-completed
compasses different forms of personal- rating scales or interviews, as well as pa-
ity problems as being arrayed along a tient self-report measures.
severity continuum reflecting what he Representative clinician instruments
terms different levels of “personality or- are measures such as the Social Cogni-
ganization.” Central to this concept was tion and Object Relations Scale (SCORS;
the notion of identity, comprising the M. Hilsenroth, M. Stein, J. Pinsker, “So-
various ways in which individuals expe- cial Cognition and Object Relations Scale:
rience themselves in relation to others Global Method [SCORS-G],” unpub-
(Kernberg 1984). Normal identity in- lished manuscript, The Derner Institute
volves a self-view that is realistic and in- of Advanced Psychological Studies, Adel-
tegrated, with a correspondingly realis- phi University, Garden City, NY, 2004;
tic and stable experience of others. With Westen et al. 1990) and the Structured
increasingly problematic personality or- Interview of Personality Organization
ganization, identity becomes more dif- (STIPO; Stern et al. 2010). The SCORS
fuse, inflexible, unstable, and poorly in- has different adaptations suitable for use
tegrated. Kernberg and Caligor (2005) with information from clinical inter-
offered an ordering of the different DSM views, Thematic Apperception Test
categories of PD, as they could be arrayed (TAT) stories, and psychotherapy tran-
along this continuum of personality or- scripts (Westen et al. 1990). The develop-
ganization severity. ers of the SCORS sought to integrate so-
cial cognition with object relations
theory in providing assessments of four
Contemporary Status of dimensions: 1) complexity of represen-
tations of people, 2) affect-tone of rela-
Global Concept of tionship paradigms, 3) capacity for emo-
Personality Impairment tional investment in relationships and
moral standards, and 4) understanding
Efforts to identify core elements of PD are of social causality. The underlying sever-
found in numerous measures and scales ity dimension ratings range from devel-
designed to identify personality prob- opmentally immature representations
lems. In the process of attempting to that are poorly differentiated, malevo-
identify these core impairments in per- lent, and illogical to more mature per-
sonality functioning, Bender et al. (2011) sonality functioning, in which represen-
reviewed a number of reliable and valid tations are complex and predominantly
clinician-administered measures for as- positive, with autonomy in and appreci-
sessing personality functioning and psy- ation for committed relationships with
chopathology and demonstrated that others. The STIPO is a semistructured
content relevant to representations of self interview based on the model of person-
and other permeate such instruments ality health and disorder advanced by
and that these instruments have solid em- Kernberg (Kernberg 1984; Kernberg and
pirical bases and significant clinical utility. Caligor 2005). Questions were designed
to provide a dimensional assessment of thesis of these common elements sug-

identity, primitive defenses, and reality gested that the components most central
testing, and STIPO assessment of one’s to effective personality functioning fall
sense of self and significant others has under the rubrics of identity, self-direction,
been shown to be predictive of various empathy, and intimacy, with reliability es-
measures of positive and negative affect. timates for measures of these constructs
Self-report measures of global per- typically exceeding 0.75.
sonality functioning include instruments
such as the Severity Indices of Personal-
ity Problems (SIPP; Verheul et al. 2008) Empirically Articulating
and the General Assessment of Person-
ality Disorder (GAPD; Hentschel and the Core Impairments
Livesley 2013). The SIPP is a dimen-
sional self-report questionnaire designed One of the central efforts of our research
to measure the severity and core compo- program has been to attempt to isolate
nents of personality pathology. The items, common mechanisms that may underlie
which the patient completes taking into all PDs. In many respects, this pursuit
consideration the previous 3 months, was precipitated as a result of analyses
can be arranged into five broad domains: conducted for a rather obscure 1989 con-
identity integration, self-control, rela- ference presentation (Widiger et al. 1989).
tional functioning, social concordance, Those analyses involved a search for
and responsibility. The GAPD is also a strategies to address the increasingly ap-
self-report questionnaire, designed to parent high rates of co-occurring PD di-
assess dimensions of self and interper- agnoses in DSM-III (e.g., Morey 1988) and
sonal pathology central to the adaptive DSM-III-R (American Psychiatric Associ-
impairment model of personality pathol- ation 1987) that could be adopted by the
ogy as suggested by Livesley and col- in-development DSM-IV. Thus, we exam-
leagues (Livesley 2003; Livesley and Jang ined various diagnostic rules in a number
2000). The GAPD scales were developed of DSM-III/III-R PD data sets to deter-
by defining components of self pathol- mine whether alterations to the diagnos-
ogy linked to failures in development of tic criteria could lead to lower co-occur-
an integrated self-system or structure, as rence. At the time, we were surprised by
well as interpersonal pathology linked the results of our analyses: efforts to make
to failures in the capacity for intimacy, the DSM diagnostic rules more restric-
attachment, and cooperative behavior. Al- tive, thus narrowing the diagnostic rules
though there are multiple scales on the to include only the most “prototypical”
GAPD, Hentschel and Livesley (2013) cases, had the seemingly paradoxical ef-
found that a single-factor solution fit their fect of increasing rather than decreasing
clinical data better than multidimen- PD comorbidity. In other words, the most
sional alternatives. “prototypical” patients with, say, avoid-
The literature review of these various ant PD—one who had all seven of the
measures by Bender et al. (2011) revealed DSM-III-R criteria for that disorder—also
that all such measures sampled content tend to have more additional PD diagno-
pertaining to distorted and maladaptive ses than the “average” avoidant patient.
thinking about oneself and others. A syn- Thus, narrowing the diagnostic rules by
implementing higher thresholds (e.g., re- values indicated that this was not sim-
quiring 5 of 7 rather than 4 of 7 features) ply a computational artifact but rather
or mandating the presence of one “patho- the operation of a substantive construct.
gnomonic” feature of a PD (such as, say, To elaborate the nature of this dimen-
self-injury for borderline PD) ended up sion, Morey (2005) reported the results of
increasing comorbidity rates among those a Rasch scaling of criteria most reflective
patients receiving a specific diagnosis. It of this dimension in order to determine
also created an ever-expanding pool of features that provide information at high
patients diagnosed with personality dis- and low ends of this continuum. The
order not otherwise specified, a designa- characteristic features represented the
tion that was largely uninformative be- full spectrum of the DSM PDs, with the
cause of the lack of clear definition of “anchor point” for the extreme high end
what the core features of PD actually were. of this global continuum involving the
As a result, PD diagnostic algorithms for feature of lack of empathy. The conclusion
DSM-IV were little changed from those in from this paper was that failures in em-
DSM-III-R, but for the most part the field pathic relatedness, including the ability
paid little attention to this interesting to accurately understand the perspective
phenomenon in which increased “proto- of others in shaping the self-concept, were
typicality” equaled increased “comorbid- present in varying degrees in all PDs.
ity.” However, given the consistency of Furthermore, more severe and pervasive
the phenomenon across multiple data empathy problems are linked to the pres-
sets, we were intrigued by the phenome- ence of more and diverse PD features and
non and determined to attempt to further hence to assignment of multiple PD diag-
describe the mechanisms underlying this noses to such patients.
finding. Our work with the Collaborative Lon-
Hence, a follow-up study (Morey 2005) gitudinal Personality Disorders Study
examined three different data sets that (CLPS; Gunderson et al. 2000; Skodol et
each included information about every al. 2005) provided an important opportu-
DSM-defined PD criterion. In these data nity to better understand the correlates
sets, a score was calculated for each cli- and implications of this putative global
ent that reflected the summed count of personality pathology dimension. The
all PD criteria present in that client. In CLPS study was a 10-year prospective, re-
these three data sets, the coefficient al- peated-measures study that included pa-
pha values were 0.81, 0.96, and 0.94, sug- tients with one of four specific DSM-IV-
gesting that the problematic behaviors TR PDs (schizotypal, borderline, avoid-
and characteristics listed in the criteria ant, or obsessive-compulsive) or patients
for the various DSM PDs formed an in- with major depressive disorder in the ab-
ternally consistent dimension that cuts sence of PD as a comparison group. Par-
across virtually all of the disorders. Given ticipants in the CLPS study were assessed
the nature of the DSM decision rules, it with interview and questionnaire mea-
was apparent that higher “scores” on this sures of PD symptoms, traits, and func-
single dimension would account for the tioning regularly throughout the course
widely observed comorbidity because of the study. In a set of CLPS analyses
the presence of additional symptom fea- reported by Hopwood et al. (2011), we
tures would by definition increase the sought to disentangle elements of global
likelihood of any particular disorder. personality severity from the stylistic
However, the high internal consistency expression of these problems because
these were confounded in the DSM-III that accommodates a diverse array of ele-
and DSM-IV conceptualization of PD. ments, including dysfunction in social, emo-
tional, and identity-related functioning, anal-
Thus, that study had four aims: 1) to iden-
ogous to the GAF [Global Assessment of
tify which DSM PD features comprise the Functioning] score for general functioning
best markers of “severity,” 2) to isolate el- but specifically linked to personality systems.
ements of personality style that are inde- (Hopwood et al. 2011, p. 317)
pendent of general severity, 3) to examine
whether the severity and stylistic ele- The DSM-5 P&PD Work Group explic-
ments of PD should be assessed in paral- itly attempted to follow through on these
lel, and 4) to determine whether each ele- recommendations by reviewing relevant
ment provides incremental information literature (Bender et al. 2011) and by an-
about course and outcome of patients. alyzing additional existing data sets to
As in the various data sets described further elaborate this dimension (Morey
by Morey (2005), the severity composite et al. 2011). Specifically, Morey et al.
representing the sum of all DSM-IV PD (2011) sought to identify items reflective
criteria was highly internally consistent of the core impairments in self and other
(coefficient D=0.90). The PD criteria that representation described by the DSM-5
demonstrated the largest item-total cor- P&PD Work Group (Bender et al. 2011),
relations with this severity composite con- with the aim of characterizing the mani-
sistently demonstrated problems in self festations of this impairment continuum
(e.g., avoidant: “feelings of inadequacy”; at different levels of severity using item
borderline: “identity disturbance”) or response theory (Lord 1980). The study
interpersonal (e.g., avoidant: “social in- derived a composite dimension of sever-
eptness” or “preoccupation with being ity that was significantly associated with
rejected”; schizotypal: “paranoid ide- 1) the probability of being assigned any
ation”) domains. The analyses of predic- DSM-IV PD diagnosis, 2) the total num-
tive validity of this composite suggested ber of DSM-IV PD features manifested,
that generalized personality pathology and 3) the probability of being assigned
severity was the strongest predictor of multiple DSM-IV PD diagnoses. The key
concurrent and prospective dysfunc- markers of this dimension involved im-
tion, although stylistic elements of per- portant functions related to self (e.g.,
sonality pathology symptom expression identity integration, integrity of self-
proved incrementally useful for predict- concept) and interpersonal (e.g., capacity
ing specific kinds of dysfunction. Inter- for empathy and intimacy) relatedness—
estingly, most pathological personality features that, as reviewed by Bender et
traits and even those normative (i.e., al. (2011), play a prominent role in influ-
FFM) traits thought to be most related to ential theoretical conceptualizations of
PD tended to be strongly related to global core personality pathology (Kernberg
severity rather than to specific styles of and Caligor 2005; Kohut 1971; Livesley
dysfunction. Given that the global sever- 2003). The patterning of markers along
ity score accounted for most of the valid the putative severity continuum demon-
variance provided by PD concepts in strated a number of interesting features.
predicting patient outcome, the authors Self-related features such as identity is-
offered the following recommendation sues, low self-worth, and impaired self-
for DSM-5: direction appear to be central character-
istics of milder levels of personality pa-
PD severity should be represented in the
thology, whereas interpersonal issues (in
DSM-5 by a single quantitative dimension
addition to self pathology) become dis- that this rating would differentiate those
criminating at the more severe levels of receiving such diagnoses from those not
personality pathology. Such a finding is diagnosed with PD. Second, the study
consistent with the view of Kernberg explored whether LPFS ratings were sig-
(e.g., Kernberg 1984) and others that nificantly related to critical clinical judg-
identity issues play a foundational role ments, such as estimates of broad adap-
in driving the characteristic interper- tive functioning, risk for harm to self or
sonal dysfunction noted in PDs. other, long-term prognosis, and clinical
Taking findings from these and other appraisals of needed treatment intensity.
studies into account, the DSM-5 P&PD Finally, the study sought to determine
Work Group sought to synthesize vari- whether mental health professionals
ous concepts across self-other models to would view the LPFS ratings as clinically
form a foundation for rating personality useful—that conceptualizing their patient
functioning on a continuum, with the goal in this way would be seen as relevant for
of creating a severity scale that could be patient description and treatment de-
easily applied by clinicians. This rating cision making. These questions were
scale was refined through a focus on ele- addressed using a national sample of 337
ments that could be assessed reliably in clinicians providing complete PD diag-
prior research (Bender et al. 2011) and that nostic information about a patient with
also emerged in various studies as dis- whom they were familiar, which in-
criminating markers of this dimension. volved a full formulation of both DSM-
The resulting scale, titled the Level of Per- IV and DSM-5 diagnostic judgments.
sonality Functioning Scale (LPFS; Ameri- The results of the Morey et al. (2013)
can Psychiatric Association 2013), was study demonstrated that, consistent with
thus designed to serve as a basis for de- the assumption that these personality
termining global level of impairment in functioning deficits underlie all PDs, the
personality functioning in DSM-5. This single-item LPFS demonstrated solid
rating represents a single-item composite sensitivity (0.846) and specificity (0.727)
evaluation of impairment in the four self- for identifying the presence or absence of
other areas described in Table 3–1. The DSM-IV PDs. Furthermore, the scale was
LPFS rating scale provides anchor points also related to DSM-IV PD comorbidity,
describing characteristics of five impair- with those individuals receiving multiple
ment levels (little or none, some, moder- DSM-IV diagnoses obtaining more se-
ate, severe, and extreme). (The LPFS is vere ratings on the LPFS. Furthermore,
provided in its entirety in the Appendix analyses were conducted to compare the
to this volume.) incremental validity of the DSM-5 LPFS
To ascertain the utility and validity of rating with DSM-IV PD diagnoses with
clinician judgments using this scale, Mo- respect to their ability to predict clinical
rey et al. (2013) examined clinician-rated judgments of psychosocial functioning,
LPFS scores as applied to a broad sample short-term risk, estimated prognosis, and
of patients with and without prominent optimal level of treatment intensity. All
PD features. There were three important predictive validity correlations for both
aspects to this study. First, it was assumed LPFS ratings and DSM-IV diagnoses were
that LPFS ratings should be related to statistically significant. However, results
DSM-IV PD diagnoses, given the as- indicated that for three of the four valid-
sumption that all PDs reflect impairment ity variables, the single-item DSM-5 LPFS
in this core self-other dimension, and rating yielded adjusted multiple correla-
TABLE 3–1. Four self-other areas of personality functioning typically impaired in

personality disorder
Self
Identity: Experience of oneself as unique, with clear boundaries between self and others; sta-
bility of self-esteem and accuracy of self-appraisal; capacity for, and ability to regulate, a
range of emotional experience
Self-direction: Pursuit of coherent and meaningful short-term and life goals; utilization of con-
structive and prosocial internal standards of behavior; ability to self-reflect productively
Interpersonal
Empathy: Comprehension and appreciation of others’ experiences and motivations; tolerance
of differing perspectives; understanding of the effects of own behavior on others
Intimacy: Depth and duration of positive connection with others; desire and capacity for close-
ness; mutuality of regard reflected in interpersonal behavior
tions that were larger than those pro- greater presumed familiarity with DSM-
vided when considering all 10 DSM-IV IV over the past 18 years and their hav-
PD diagnoses. In the areas of functioning, ing no experience with the DSM-5 Sec-
prognosis, and treatment intensity needs, tion III proposal at the time of the study.
the DSM-5 LPFS successfully captured an
appreciable part of the valid variance
contributed by DSM-IV PD diagnoses and Level of Personality
significantly incremented that infor- Functioning Case
mation as well. Only in the area of risk
assessment did information about the Illustrations
specific PD diagnoses prove useful as a
supplement to the LPFS rating of impair- To demonstrate the enhanced utility of the
ment in personality functioning. DSM-5 Section III LPFS over the DSM-IV/
Finally, immediately following com- DSM-5 Section II categorical approach to
pletion of ratings for DSM-IV criteria and PDs, we offer a case comparison. As men-
the LPFS rating, clinicians were asked tioned above, one of the problems with
six questions about perceived clinical the categorical polythetic criteria ap-
utility of each set of information pro- proach to PDs is that there can be signifi-
vided. Compared with the DSM-5 LPFS cant variations within the same diagnosis,
rating, DSM-IV was seen as easier to use causing important clinical information
and more useful for communication with to be lost if one does not look beyond the
other professionals. However, in every limited information conveyed by a cate-
other respect—for treatment planning, pa- gorical diagnostic label. The following
tient description, and communicating to two clinical case examples show the im-
the patient—the DSM-5 LPFS had higher portance of assessing the core LPFS ele-
mean usefulness ratings than DSM-IV. ments of personality functioning.
Thus, clinicians perceive the single-item
DSM-5 LPFS rating as being generally Case Example 1
more useful in several important ways Madison is an intelligent, funny, talk-
than the entire set of 79 DSM-IV PD cri- ative, attractive, age 20-something
teria. This is in spite of these clinicians’ woman who sought psychotherapy
because she was determined to build loaded schedule. She also has a boy-
a better life for herself than her fam- friend but is having some difficulty
ily, particularly her emotionally vola- getting close to him and is inhibited in
tile mother and sister, had managed. expressing her affection. She is jealous
She also has been “too stressed out” at of other women as well, with likely
her job. Madison had done very well unwarranted worries that her boy-
academically in college and succeeded friend will be unfaithful, but she does
in obtaining a good position with a not understand why he finds it trou-
large consulting firm. She works long blesome to be distrusted in that way.
hours but is often concerned that she Given her excessive devotion to
is not doing her projects “perfectly,” work, perfectionism, overconscien-
which makes her very anxious at tious approach to tasks, and refusal
times. Her perfectionism causes her to delegate tasks to others, Madison
to spend excessive effort trying to be meets criteria for DSM-IV/DSM-5
completely thorough, adding unnec- Section II obsessive-compulsive PD.
essary additional time at the office. Looking more closely at her inner life
She also refuses to take help from and personality functioning using the
colleagues because she is sure they LPFS, Madison’s profile fits with level
will make mistakes or not have high 1—some impairment. She has a rela-
enough standards. In spite of her tively intact sense of self but has some
worries, she has gotten very positive difficulty handling strong emotions
reviews from her supervisors, but she (identity); she is overly intellectualiz-
does not derive much reassurance ing, is excessively goal-directed, and
from that. She also attends a demand- has unrealistically high standards
ing master’s program during the eve- (self-direction); she is resistant to ap-
nings and weekends, so most of her preciating others’ perspectives, al-
time is devoted to work, with little left though she can, and does not quite
for socializing. understand why her jealousy bothers
Madison also impresses one as de- her boyfriend (empathy); and she has
termined to be an engaged and pro- solid and enduring relationships, but
ductive “good patient.” She talks in they are somewhat compromised by
excessive detail and in a highly in- her inhibitions in emotional expres-
tellectualized manner, but strong sion and excessively high standards
emotions are very difficult for her to for others (intimacy).
tolerate and talk about. She can ex-
plain very well how she thinks about
things but has trouble considering how
Case Example 2
she feels. She described one occasion Ryan presented with a similar style to
when it was apparent she had a panic Madison’s. He is a married, well-ed-
attack rather than let herself know ucated, highly intelligent and verbal
how angry she was at her colleagues. 28-year-old engineer. Ryan greatly
Although she is able to consider oth- values his career and is proud of work-
ers’ perspectives, she has little toler- ing for a prestigious firm. His present-
ance for those who do not agree with ing complaint was difficulty with
her or live up to her standards. These completing work effectively, due to
attitudes lead to additional stress and perfectionism that generates exces-
frustration for Madison in the work- sive anxiety. Ryan puts in long hours
place. at his job attempting to make prog-
Madison has a close group of ress on his projects but often dwells
women friends she has known since on fairly insignificant points for days
the beginning of college, but she is on end. He also experiences some
sometimes critical of some of their life friction at times with his coworkers
choices. She obviously values these because of his insistence that his opin-
friends and does what she can to so- ions and approach to tasks are most
cialize with them, given her over- correct. Ryan also reported that he is
very active in his church, at least on In the area of empathy, Ryan does
Sundays, the only day he does not not have a very good sense of how
work. He seemingly derives satisfac- his stubborn, opinionated behavior
tion from that community, with his might affect others, nor does he seem
and his wife’s social life centering to care very much. He longs for praise
on their relationships there. How- and acceptance at work and at church,
ever, Ryan has been very upset that but he seems to lack the ability to
his suggestions to the church leader- consider why others might have a
ship for changing procedures have different opinion, and he has trouble
not been accepted unconditionally. having dialogues. When asked about
He is considering leaving the congre- his marriage and friendships, Ryan
gation because of this, but his wife says his relationships often disappoint
has managed to convince him to stay him because people do not appreci-
thus far. ate him enough (intimacy). Not sur-
Like Madison, Ryan’s perfection- prisingly, he was having some mari-
ism interferes with task completion tal problems.
and he is excessively devoted to work.
He is stubborn and rigid in his collab- As can be seen in the comparison of
orations with others and becomes too these two cases, it is important to clini-
preoccupied with the small details of
cally explore the core components of per-
his projects. Given these characteris-
tics, Ryan also meets criteria for obses- sonality functioning to get beyond sur-
sive-compulsive PD. face behaviors and attitudes. Both of these
However, if one stopped the clini- patients meet criteria for obsessive-com-
cal interview of Ryan at this point, a pulsive PD under the DSM-5 Section II
great deal of very important informa-
criteria, but the significant differences in
tion would be lost, and an inadequate
treatment plan may be formulated. their character structures are identified
By probing about the LPFS areas of by the LPFS assessment. Whereas Madi-
identity, self-direction, empathy, and son showed personality difficulties rated
intimacy, one discovers important dif- at level 1, indicating some impairment,
ferences between Madison and Ryan. Ryan had more marked problems, which
Ryan reported that he often feels terri-
would be scored 2, for moderate impair-
ble about himself and has an ongoing
terror of being criticized. He constantly ment. In addition, as assessed with the
seeks approval from his boss and feels new Section III model, Madison would
miserable if he is not praised for his not meet full criteria for a PD because an
work. He sees himself as particularly LPFS level of 2 or greater is required for
gifted and entitled to special recogni-
disorder status to be assigned. As a clini-
tion and as much smarter than his col-
leagues. Similarly, his anger at his cian, one would likely take a different ap-
church for not taking his suggestions proach with Madison, because her self-
makes him feel “invisible” and indig- structure is more intact, than with Ryan,
nant. “I have an Ivy League degree, who has more vulnerable self-esteem. Fur-
and those dullards can’t seem to ap- thermore, with the greater severity of
preciate what I have to offer.” Clearly,
Ryan’s central personality issues, we be-
he has some issues with regulating
self-esteem and looks to others for on- gin to see indications of other PD diag-
going approval (identity). It is also noses (such as attributes of narcissistic
apparent that Ryan’s slavish devotion PD), which in DSM-IV/DSM-5 Section II
to work is not motivated only by an would be portrayed as “comorbidity.”
internal set of high standards but is
However, rather than resulting in the
primarily a means to try to gain exter-
nal approval (self-direction). confusing diagnosis of several disorders,
the LPFS more effectively represents
these phenomena simply as increased American Psychiatric Association: Diag-

impairment in the core components. nostic and Statistical Manual of Mental
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CHAPTER 4
Development,
Attachment, and
Childhood Experiences
Peter Fonagy, Ph.D.
Anthony W. Bateman, M.A., FRCPsych
Nicolas Lorenzini, M.Sc., M.Phil.
Chloe Campbell, Ph.D.
Attachment theory (Bowlby affect close relationships in later life, as

1969) describes how individuals manage well as expectations of social acceptance
their most intimate relationships with and attitudes toward rejection. When
their “attachment figures”: their parents, the attachment figure responds appro-
children, and romantic partners. Attach- priately to an infant who is undergoing
ment, at an evolutionary level, is an adap- a stressful experience by providing sta-
tation for survival—it is the mechanism bility and safety, the infant is reassured,
by which babies elicit essential care. As confident, and able to explore the sur-
more is understood about the interface of roundings. Through the consistent expe-
brain development and early psychoso- rience of this reassuring interaction, the
cial experience, however, it becomes child is able to build mental models of
clear that the evolutionary role of the self and of others (internal working mod-
attachment relationship goes far beyond els), which often endure across life. These
giving physical protection to the human early attachment interactions are central
infant. to the development of the child’s ability
Beginning at birth, the infant’s inter- to regulate affect and stress, to mental-
actions with his or her primary caregiv- ize, and to acquire attentional control
ers will form a characteristic pattern that and a sense of self-agency (Fonagy et al.
will shape personality development and 2010).
55
Attachment has traditionally been An avoidant infant appears less anx-

measured through assessments of char- ious at separation, may not seek contact
acteristic patterns of relating. The most with the caregiver on his or her return,
influential protocol for observing indi- and may not seem to prefer the caregiver
vidual differences in infants’ attachment over the stranger. In adults, avoidant/
security has been the Strange Situation dismissing AAI narratives will seem in-
(Ainsworth et al. 1978), during which an coherent; these adults will struggle to
infant is briefly separated from the care- recall specific memories in support of
giver and left with a stranger in an unfa- general arguments and will idealize or
miliar setting. Three distinct attachment devalue their early relationships (Fon-
patterns have been identified in infants’ agy et al. 2010). These behaviors are the
behavior: secure (63% of children tested), result of a hyperdeactivation of the at-
anxious/resistant or ambivalent (16%), tachment system. The individual will
and avoidant (21%). The attachment characteristically appear inhibited when
styles in adults are secure/autonomous it comes to seeking proximity, seem de-
(58% of the nonclinical population), termined to manage stress alone, and tend
avoidant/dismissing (23%), and anx- to adopt noninterpersonal strategies for
ious/preoccupied (19%) (Bakermans- regulating negative emotions and han-
Kranenburg and van IJzendoorn 2009). dling moments of vulnerability.
The Adult Attachment Interview (AAI; An anxious/resistant infant shows
George et al. 1994; Hesse 2008), which is less interest in exploration and play in
based on reported attachment narratives the new environment, becomes highly
of the subject’s childhood, is the mea- distressed by the separation, and strug-
sure used to classify adults. A fourth gles to settle after being reunited with
pattern has now been identified, labeled the caregiver. Correspondingly, an anx-
as unresolved/disorganized for adults ious/preoccupied adult’s AAI narratives
and disoriented/disorganized for infants will also lack coherence and will express
(Levy et al. 2011); unresolved/disorga- confusion, anger, or fear in relation to
nized adults are additionally classified early attachment figures. This strategy,
within one of the three primary categories entailing the hyperactivation of proxim-
(Fonagy et al. 2010). ity-seeking and protection-seeking be-
During the Strange Situation proce- haviors, is an adaptation to hypersensi-
dure, a securely attached infant curiously tivity toward signs of possible rejection
investigates his or her new surround- or abandonment and to an intensifica-
ings in the primary caregiver’s presence, tion of undesirable emotions during
appears anxious in the stranger’s pres- these moments.
ence, is distressed by the caregiver ’s A disoriented/disorganized infant will
brief absence, rapidly seeks contact with show undirected or bizarre behavior,
the caregiver when the caregiver re- such as freezing, hand clapping, or head
turns, and is easily reassured enough to banging, or may try to escape the situa-
resume exploration and investigation. tion. An unresolved/disorganized adult’s
Analogously, an adult categorized as se- AAI narratives about bereavements or
cure/autonomous during the AAI co- childhood traumas will contain seman-
herently integrates attachment mem- tic and/or syntactic confusions. This
ories into a meaningful narrative and corresponds to the breakdown of strate-
shows an appreciation for attachment gies to cope with stress, which leads to
relationships. emotion dysregulation.
Development, Attachment, and Childhood Experiences 57
These styles generally persist into (Sroufe et al. 1990). Securely attached in-
adulthood: the correlation in attachment dividuals trust their attachment figures
classification between infancy and adult- and do not exaggerate environmental
hood is 68%–75% (Fonagy et al. 2010). threat; as a result, they can respond pro-
The factors most likely to disrupt or mod- portionately to challenges (Nolte et al.
ify attachment style are negative early life 2011).
events: loss of a parent, parental divorce, Avoidant/dismissing individuals may
life-threatening illness of parent or child, have a higher tolerance for experiencing
parental psychiatric disorder, physical negative emotions, whereas anxious/pre-
maltreatment, or sexual abuse. occupied individuals, who tend to be
The influence of genetic factors in at- wary following a history of inconsistent
tachment security has been estimated at support from caregivers, are likely to have
between 23% and 45% (Brussoni et al. a lower threshold for perceiving environ-
2000; Torgersen et al. 2007) and under- mental threat and, therefore, stress. This is
scores the bidirectional nature of the de- likely to contribute to frequent activation
velopment of attachment relationships: of the attachment system, with the con-
infants and children co-create patterns of comitant distress and anger such activa-
relating with their caregivers. Neverthe- tion can cause being likely to manifest as
less, to the extent that these are separable, compulsive care-seeking and overdepen-
environmental factors ubiquitously ap- dency. Unresolved/disorganized indi-
pear to be the most important influence viduals—the adult analog of disoriented/
in the development of attachment. Among disorganized infants—frequently have
these external factors, the most important parents who are themselves abusive or
is the secure presence of an effective pri- unresolved regarding their own losses or
mary caretaker who is sensitive to the in- abuse experiences.
fant’s verbal and nonverbal cues and is Evidence linking attachment in infancy
able to respond to them without being with more general personality charac-
overwhelmed by anxiety. teristics is stronger in some studies than
The persistent quality of attachment in others. Findings from the Minnesota
styles produces similarly enduring strat- Longitudinal Study of Parents and Chil-
egies for dealing with emotions and so- dren cohort show a prediction from in-
cial contact. For example, the increased fantile attachment insecurity to perfor-
sense of agency in the secure child al- mance on adult measures of psychiatric
lows him or her to move toward the morbidity, with many potential con-
ownership of inner experience and to- founding factors controlled for, linking
ward an understanding of self and oth- insecurity and adversity to indications
ers as intentional beings whose behavior of personality disorder (Carlson et al.
is organized by mental states, thoughts, 2009). A “dose-response” relationship
feelings, beliefs, and desires. Consistent between psychological disturbance and
with this, longitudinal research has dem- insecurity is suggested by the observa-
onstrated that children with a history of tion of Kochanska and Kim (2013), who
secure attachment are independently found that children who are insecure
rated as more resilient, self-reliant, so- with both parents tend to report more
cially oriented (Sroufe 1983; Waters et al. overall problems and to be rated by
1979), and empathic to distress (Kesten- teachers as having more externalizing
baum et al. 1989) and as having deeper problems than those who are secure
relationships and higher self-esteem with at least one parent. However, in
contrast to Bowlby’s (1980) prediction, egory (Westen et al. 2006). Adults pre-
the avoidant and resistant classifications senting a preoccupied style are more sen-
tend not to be strongly related to later sitive to rejection and anxiety and are
measures of maladaptation. It is the dis- prone to histrionic, avoidant, borderline,
oriented/disorganized infant category and dependent PDs. The hypoactivation
that appears to have the strongest pre- of attachment shown by individuals with
dictive significance for later psychologi- a dismissing style explains the associa-
cal disturbance (Fearon et al. 2010), al- tion with schizoid, narcissistic, antisocial,
though there is also some evidence to and paranoid PDs.
suggest a connection between avoidance A high prevalence of childhood trauma
and internalizing conditions (depres- occurs in both insecurely attached indi-
sion and anxiety) (Groh et al. 2012). viduals and patients with PD. Childhood
Attachment processes are, then, a nec- trauma is strongly correlated with an in-
essary and universal mechanism for coherent/disorganized adult attachment
survival and development; they do not, style more than just with the general cat-
for example, show gender differences or egory of attachment insecurity (Barone
variations with language or culture. At- 2003; Westen et al. 2006). Rates of child-
tachment theory is also, however, in- hood trauma among individuals with PDs
creasingly thought to have a bearing on are high (73% report abuse, of which 34%
the understanding and treatment of per- is sexual abuse, and 82% report neglect).
sonality disorders (PDs). With its inte- Compared with healthy adults, patients
gration of psychological, psychiatric, ge- with PD are four times as likely to have
netic, developmental, neuroscientific, suffered early trauma (Johnson et al. 1999).
and clinical perspectives, the theory is Childhood physical abuse increases the
uniquely well placed to inform and de- risk for adult antisocial, borderline, de-
velop our thinking about PDs, in all their pendent, depressive, passive-aggressive,
enduring and pervasive complexity. and schizoid PDs (McGauley et al. 2011).
Infantile neglect is associated with risks
for antisocial, avoidant, borderline, nar-
Attachment History cissistic, and passive-aggressive PDs
(Battle et al. 2004; Johnson et al. 1999).
and the Development BPD is more consistently associated with
of Personality Disorder childhood abuse and neglect than are
other PD diagnoses. Obsessive-compul-
The characteristics, behaviors, and symp- sive PD has been associated with sexual
toms associated with insecurely attached abuse by noncaretakers (Battle et al.
adults are often also manifested by indi- 2004).
viduals with a PD (Adshead and Sarkar However, not all people who have suf-
2012). Studies of attachment patterns in fered childhood trauma develop adult
people with PDs, particularly those in psychopathology. The effects of trauma
DSM-IV Cluster B (Bender et al. 2001), in- are influenced by attachment and by bio-
dicate that such individuals show higher logical dispositions. For example, female
rates of insecure attachment than the victims of maltreatment and sexual abuse
general population (Cassidy and Shaver in adolescence or adulthood are at greater
2008). Conversely, those diagnosed with risk of developing posttraumatic symp-
borderline PD (BPD) and avoidant PD toms if they have an anxious attachment
rarely fall into the secure attachment cat- style (Sandberg et al. 2010), and female
victims of childhood trauma are more associated with different attachment

likely to develop somatization symptoms styles: BPD with comorbid anxiety or
if they are fearfully attached (Waldinger mood disorders tends to be associated
et al. 2006). If traumatic events provoke with preoccupied attachment, whereas
activation of the attachment system, then BPD with comorbid substance or alcohol
individuals who tend to respond to these abuse tends toward a dismissing style.
experiences by the inhibition of mentaliz- In spite of these differences, the unre-
ing function and emotional regulation solved/disorganized attachment style
are less likely to resolve these events and seems to be common in patients with
more likely to manifest personality pa- BPD overall, which explains the patho-
thology later in life (Bateman and Fonagy gnomonic emotional dysregulation of
2012). these patients (Barone et al. 2011). These
BPD is strongly associated with pre- research limitations accentuate the value
occupied attachment in the presence of of the new efforts toward dimensional
unresolved trauma and with unresolved rather than categorical diagnostic systems
attachment patterns. Studies have found (Cartwright-Hatton et al. 2011; Widiger
that 50%–80% of patients with BPD fit ei- et al. 2011) and toward person-centered
ther or both of those two attachment rather than symptom-centered ways of
styles (Agrawal et al. 2004; Barone et al. addressing mental disorders. Such ways
2011); this makes sense in light of both of understanding and conceptualizing
the approach-avoidance social dynamics psychopathology (and particularly PDs)
and sensitivity to rejection (preoccupied are necessarily longitudinal because
dimension) and the cognitive-linguistic only a developmental perspective can
slippage (incoherent/disorganized di- offer an insight into the processes under-
mension) that are evident in patients with lying symptomatic manifestations and
BPD. Misunderstanding of social causal- allow clinicians to assess a particular pa-
ity and thought disturbances are distinc- tient’s risks and strengths, account for
tive features of BPD. In behavioral terms, high rates of comorbidity, tailor inter-
patients with BPD exhibit angry with- ventions, and maintain a fruitful thera-
drawal and compulsive care seeking. This peutic relationship. We review the alter-
implies their lack of capacity to use and native model for the classification of PDs
obtain relief from new attachment fig- that appears in DSM-5 Section III, “Emerg-
ures, which has important implications ing Measures and Models,” later in this
within a close helping relationship like chapter (see section “An Attachment The-
the therapeutic exchange: patients with ory of Borderline Personality Disorder
BPD will be more attentive to the fail- Based on Mentalization”).
ures or perceived failures of the thera-
pist than to the therapist’s efforts to help
(Aaronson et al. 2006). Neuroscience
Most research assessing the relation-
ship between attachment and PDs does of Attachment
not control for comorbidity on either
Axis I or Axis II of DSM-IV, which could The neurobiological processes at work in
result in diffuse patterns of association attachment are now fairly well under-
(Barone et al. 2011; Westen et al. 2006). stood. Two major neural systems have
For example, in the case of BPD, differ- been shown to play a critical role in attach-
ent symptom disorder comorbidities are ment behaviors: the dopaminergic re-
ward-processing system and the oxyto- male offspring, which themselves grow
cinergic system (Fonagy et al. 2011). The to have limited competence in maternal
role of the dopaminergic reward system behavior. Oxytocin is a facilitator of at-
in attachment behavior is understood as tachment: it enhances sensitivity to social
an evolutionary mechanism to motivate cues, accelerates social connectedness
reproductive mating, maternal care, and (Bartz and Hollander 2006), improves so-
ultimately, offspring survival. This re- cial memory, and facilitates the encoding
ward system leads individuals to seek and retrieval of happy social memories.
close relations with other humans and By attenuating activity in the extended
produces satisfaction when they are at- amygdala, oxytocin also acts to neutral-
tained. Oxytocin is a neuroactive hor- ize negative feelings toward others and
mone produced in the hypothalamus and enhance trust. Oxytocin can inhibit hypo-
projected to brain areas that are associ- thalamic-pituitary-adrenal (HPA) axis
ated with emotions and social behaviors. activity when the attachment system is
It plays an important role in the activa- activated (Fonagy et al. 2011): secure at-
tion of the dopaminergic reward system tachment leads to “adaptive hypoactiv-
(oxytocin receptors are located in the ven- ity” of the HPA axis, which, in turn, re-
tral striatum, a key dopaminergic area) duces social anxiety (Nolte et al. 2011).
and in the deactivation of neurobehav- It must be noted that these positive ef-
ioral systems related to social avoidance fects of oxytocin are not universal. The
(Fonagy et al. 2011; see also Chapter 23, administration of oxytocin to adults has
“Translational Research in Borderline been shown to facilitate prosocial behav-
Personality Disorder,” in this volume). ior toward members of their in-group
Oxytocin receptors are found in areas only and to enhance trust toward reli-
known to be recruited in attachment and able and neutral peers but not peers who
other social behaviors, such as the bed have proven to be unreliable (De Dreu et
nucleus of the stria terminalis, the hypo- al. 2010; Mikolajczak et al. 2010). Corre-
thalamic paraventricular nucleus, the spondingly, insecure attachment is closely
central nucleus of the amygdala, the ven- bound to the divergent effects of oxyto-
tral tegmental area, and the lateral sep- cin. The neuropeptide is found in lower
tum. Oxytocin promotes dopamine path- concentrations among maltreated chil-
ways to and from the emotional brain dren and adults with a history of early
(amygdala/thalamus), memory brain separation and in insecurely attached
(hippocampus), and executive brain (fron- mothers during the puerperal period,
tal lobes). which further hampers the establish-
“Knockout” laboratory animals with a ment of secure attachment in their chil-
genetic mutation rendering them devoid dren (Fonagy et al. 2011). In the case of
of oxytocin do not develop normally in insecurely attached patients with BPD,
terms of sociability and caregiving. Oxy- oxytocin decreases trust and the likeli-
tocin helps promote social behavior; for hood of cooperative responses, but it
example, monkeys without oxytocin do reduces dysphoric responses to social
not read social cues as well as those with stress (Simeon et al. 2011).
oxytocin, and they fall to the bottom of Oxytocin, therefore, does not uni-
the troop status hierarchy. Oxytocin also formly facilitate trust and prosocial be-
promotes the “caregiver’s bond.” Female havior; its behavioral effects are medi-
rats without oxytocin mother poorly, and ated by the social context, personality
this has downstream effects on their fe- traits, and the quality of early attachment
(Simeon et al. 2011). These interactions the attachment system (e.g., triggered
highlight the need to address mental by perceived threat, loss, or harm) may
health in general as an indivisible com- evoke intense arousal and overwhelming
bination of environmental, psychologi- negative affect, bringing about an activa-
cal, and physical factors. For example, tion of posterior cortical and subcortical
early maltreatment is more likely to pro- areas and switching off of frontal cortical
duce adult antisocial behavior only in activity, including mentalization. 3) Mean-
males with a polymorphism in the gene while, a secure and predictable attach-
involved in the production of the neuro- ment relationship may be most effective
transmitter-metabolizing enzyme mono- in preempting threat, which possibly re-
amine oxidase A (MAO A). Males with duces the need for frequent activation of
high MAO A activity show less antiso- the attachment system.
cial behavior even if they have experi- It is perhaps worth noting that Bowlby
enced early maltreatment, indicating that (1969) considered fear, in particular, fear
certain genotypes can moderate sensi- of the loss of the attachment figure, to be
tivity to stressors. In monkeys, impul- the primary reason for activation of the
sive aggression is correlated with low attachment system. An unpredictable,
cerebrospinal fluid concentrations of insecure caregiver-infant relationship is
5-hydroxyindoleacetic acid (5-HIAA), likely to result in frequent activation of
which is involved in serotonergic metab- the attachment system accompanied by
olism. However, this inherited charac- the deactivation of neural structures un-
teristic is modulated by attachment ex- derpinning aspects of social cognition.
periences: monkeys reared by their own Evidence also suggests that the level of
mothers show higher concentrations of attachment anxiety is positively corre-
5-HIAA than those reared by peers (Barr lated with activation in emotion-related
et al. 2004). People with an avoidant at- areas of the brain (e.g., the anterior tem-
tachment style show decreased activity poral pole, which is activated when a per-
of the striatum and the ventral tegmen- son is sad) and inversely correlated with
tal area, suggesting lack of response to activation in a region associated with
social rewards. Conversely, people with emotion regulation (the orbitofrontal
a preoccupied attachment style show in- cortex) (Gillath et al. 2005). These find-
creased activity in the left amygdala, sug- ings suggest that anxiously attached peo-
gesting increased sensitivity to social ple might under-recruit brain regions
punishment (Vrticka et al. 2008). normally used to downregulate negative
Broadly speaking, we may envision emotions.
three types of association between as-
pects of social cognition and attachment,
created by attachment relationships based Attachment Experience
on intense romantic and maternal love or
by attachment relationships based on and Mentalization
threat or fear: 1) Love-related activation
of the attachment system, mediated by Mentalization, the impulse and ability to
dopaminergic structures of the reward understand and imagine other people’s
system in the presence of oxytocin and thoughts, is one of humanity’s most dis-
vasopressin, can inhibit the neural sys- tinguishing and powerful characteristics.
tems that underpin the generation of neg- The first minds that are offered to infants
ative affect. 2) Threat-related activation of to ponder on and attempt to decipher are,
of course, those of their closest family— agy 2010). Mental disorders in general
primarily the major attachment figures. can be seen as the mind misinterpreting
These individuals provide the earliest its own experience of itself and therefore
lessons in how other people think and of others (Bateman and Fonagy 2010).
also, through their reactions to the infant, Mentalization involves both a self-
formative lessons in how their thoughts reflective component and an interper-
are interpreted by others. The mentaliza- sonal component, is both implicit and
tion model concerns itself with the par- explicit, and concerns both feelings and
ent’s understanding and reflection on the cognitions. In combination, mentaliza-
infant’s internal world, and it claims a tion skills enable a child to distinguish
central relationship between attachment inner from outer reality, construct repre-
processes and the growth of the child’s sentations of his or her own mental states
capacity to understand interpersonal be- from perceptible cues (arousal, behavior,
havior in terms of mental states (Fonagy context), and infer and attribute others’
et al. 2002). mental states from subtle behavioral and
Mentalization-based treatment has its contextual cues. The full development of
roots in attachment theory. The focus of mentalization depends on interaction
the approach is provided by attachment with more mature and sensitive minds;
theory–inspired developmental research there is growing evidence that links men-
into the growth of understanding of mentalization to the quality of attachment re-
tal states in self and other. The mentaliza- lationships.
tion model was first outlined in the con- Many studies support the suggestion
text of a large empirical study in which that secure children are better than inse-
security of infant attachment with par- cure children at mentalization (measured
ents proved to be strongly predicted not by Theory of Mind tasks) (see, e.g., de
only by the parents’ security of attach- Rosnay and Harris 2002). Children with
ment during the pregnancy (Fonagy et al. secure attachment relationships assessed
1991) but even more by the parents’ ca- by the Separation Anxiety Test do better
pacity to understand their own child- than children with disorganized attach-
hood relationships with their own par- ment on a test of emotion understand-
ents in terms of states of mind (Fonagy et ing. The first of these findings, reported
al. 1991). The capacity to mentalize is a from the London Parent-Child Project
key determinant of self-organization and (Fonagy et al. 1997), found that 82% of
affect regulation, and it emerges in the children who were secure with the mother
context of early attachment relationships. in the Strange Situation passed Harris’s
The concept of mentalization postulates Belief-Desire Reasoning Task at 5.5 years,
that one’s understanding of others de- compared with 50% of those who were
pends on whether one’s own mental states avoidant and 33% of the small number
were adequately understood by caring, who were preoccupied. Findings along
attentive, nonthreatening adults. Prob- these lines are not always consistent (see,
lems in affect regulation, attentional con- e.g., Meins et al. 2002), but it generally
trol, and self-control stemming from seems that secure attachment and men-
dysfunctional attachment relationships talization are subject to similar social in-
(Agrawal et al. 2004; Lyons-Ruth et al. fluences.
2005; Sroufe et al. 2005) are mediated Two decades of research have con-
through a failure to develop a robust firmed parenting as the key determinant
mentalizing capacity (Bateman and Fon- of attachment security; more recent work
additionally suggests that parenting can scorers on the PDI’s mentalizing (Reflec-
account for the overlap between mental- tive Functioning) scale are aware of the
ization and attachment security. Re- characteristics of their infant’s mental
searchers describe the mother’s capacity functioning, and they grasp the complex
to take a psychological perspective on her interplay between their own mental states
child using different terms, including ma- and their child’s putative inner experi-
ternal mind-mindedness, insightfulness, and ence. They are likely to have secure rela-
reflective function. These overlapping at- tionships with infants whom they describe
tributes appear to be associated with both in a mentalizing way. Low-mentalizing
secure attachment and mentalization mothers were more likely to show atypi-
(Sharp et al. 2006). Meins et al. (2001), Op- cal maternal behavior on the Atypical
penheim and Koren-Karie (2002), and Maternal Behavior Instrument for Assess-
Slade et al. (2005) have sought to link pa- ment and Classification (AMBIANCE)
rental mentalization with the develop- system, which relates not only to infant
ment of affect regulation and secure at- attachment disorganization but also to
tachment by analyzing interactional unresolved (disorganized) attachment
narratives between parents and children. status in the mother’s AAI (Grienenberger
Although Meins and colleagues assessed et al. 2005).
parents’ quality of narrative about their Taken together, these results suggest
children in real time (while the parents that a mentalizing style of parenting facil-
were playing with their children) and itates the development of mentalization.
Oppenheim and Koren-Karie did this in a Mindful parenting probably enhances
more “offline” manner (with parents nar- both attachment security and mentaliza-
rating a videotaped interaction), both tion in a child. Consistent with this is a
concluded that maternal mentalizing range of findings covering aspects of par-
was a more powerful predictor of attach- enting that have been shown to predict
ment security than, say, global sensitivity. performance on Theory of Mind tasks.
Meins and colleagues found that mind- Precocious understanding of false beliefs
related comments by mothers when a is predicted by more reflective parenting
child was age 6 months predicted attach- practices, including the quality of paren-
ment security at 12 months (Meins et al. tal control, parental discourse about emo-
2001), mentalizing capacity at 45 and 48 tions, the depth of parental discussion in-
months (Meins et al. 2002), and perfor- volving affect, parents’ beliefs about
mance in a stream-of-consciousness task parenting, and non-power-assertive dis-
at 55 months (Meins et al. 2003). Oppen- ciplinary strategies that focus on mental
heim and Koren-Karie (2002) found that a states (e.g., a victim’s feelings or the non-
secure mother-child relationship was intentional nature of transgressions). All
predicted by high levels of mentalization of these measures reflect concern with the
about the child’s behavior. child’s subjective state.
Slade et al. (2005) observed a strong cor- One should, however, be cautious
relation between infant attachment and about these correlations. They are as
the quality of the parent’s mentalizing readily explained by child-to-parent ef-
about the child. Rather than using an ep- fects as by parent-to-child effects. For in-
isode of observed interaction, these au- stance, less power-assertive parenting
thors used an autobiographical memory– may be associated with mentalization not
based interview about the child, the Par- because it facilitates it but because less
ent Development Interview (PDI). High mentalizing children are more likely to
elicit controlling parenting behavior. faces. Understanding sad and angry emo-
Moreover, the same aspects of family tions at age 6 years predicts social com-
functioning that facilitate secure attach- petence and ability to avoid or cope with
ment may also facilitate the emergence of social isolation at age 8 (Rogosch et al.
mentalizing. For example, tolerance for 1995).
negative emotions is a marker of secure In addition to reports of problems of
attachment and precocious mentalizing. emotional understanding, there have also
The process of acquiring mentalization is been reports of delayed Theory of Mind
so ordinary and normal that it may be understanding in maltreated children
more correct to consider secure attach- (Pears and Fisher 2005). The capacity to
ment as removing obstacles to it rather parse complex and emotionally charged
than actively and directly facilitating its representations of the parent and of the
development. Coherent family discourse self might even deteriorate with devel-
characteristic of secure attachment helps opment (Cicchetti et al. 2000).
to generate explanatory schemas with Considered in relation to attachment,
which the behavior of others can be un- mentalization deficits associated with
derstood and predicted. It is fair to say childhood maltreatment may be a form
that in normal circumstances, conversa- of decoupling, inhibition, or even a pho-
tions with frequent accurate elaboration bic reaction to mentalizing. The processes
of psychological themes may be the at work here are multiple: 1) adversity
“royal road” to understanding minds may undermine cognitive development
(Harris 2005). Main’s (2000) groundbreak- in general; 2) mentalization problems may
ing work has linked attachment to this reflect arousal problems associated with
kind of communication with words. The exposure to chronic stress; and 3) the
key to understanding the interaction of child may avoid mentalization to avoid
attachment with the development of men- perceiving the abuser’s frankly hostile
talization may be to look at instances in and malevolent thoughts and feelings
which normally available catalysts for about him or her.
mentalization are absent. Maltreatment can contribute to an
Maltreatment disorganizes the attach- acquired partial “mind blindness” by
ment system. There is also evidence to compromising open reflective communi-
suggest that it may disrupt mentaliza- cation between parent and child. Mal-
tion. Young maltreated children mani- treatment may undermine the benefit
fest certain characteristics that could sug- derived from learning about the links be-
gest problems with mentalization: 1) they tween internal states and actions in at-
engage in less symbolic and dyadic play; tachment relationships (e.g., the child
2) they sometimes fail to show empathy may be told that he or she “deserves,”
when witnessing distress in other chil- “wants,” or even “enjoys” the abuse). This
dren; 3) they have poor affect regulation; will more likely be destructive if the mal-
4) they make fewer references to their in- treatment is perpetrated by a family mem-
ternal states; and 5) they struggle to un- ber. Even when this is not the case, par-
derstand emotional expressions, partic- ents’ ignorance of maltreatment taking
ularly facial ones, even when verbal IQ place outside the home may serve to in-
is controlled for. Maltreated children tend validate the child’s communications with
to misattribute anger and to show ele- the parents about his or her feelings. The
vated event-related potentials to angry child finds that reflective discourse does
not correspond to these feelings—a con- talization appears to be the developmen-

sistent misunderstanding that could re- tal mechanism for the connection between
duce the child’s ability to understand/ attachment problems and the difficulties
mentalize verbal explanations of other often experienced in PD.
people’s actions. In such circumstances,
the child is likely to struggle to detect
mental states behind actions and will tend Natural Pedagogy
to see these actions as inevitable rather
than intended. This formulation implies
and a Theory of the
that treatments should aim to engage Differentiation of the Self
maltreated children in causally coherent
psychological discourse. In the previous section, “Attachment
These speculations clearly imply that Experience and Mentalization,” we dis-
the foundations of subjective selfhood cussed how insecure and unpredictable
will be less robustly established in indi- attachment relationships may create an
viduals who have experienced early adverse social environment for the acqui-
neglect. Such individuals will find it sition of mentalization. The theory of ped-
harder to learn about how subjective ex- agogy explains how this acquisition or
periences inevitably vary between peo- learning process is smoother for secure
ple. In some longitudinal investigations, infants: it gives a theoretical and analyti-
low parental affection or nurturing in cal underpinning to an understanding of
early childhood appears more strongly the development of mentalizing and the
associated with elevated risk for border- growth of an agentive sense of self; con-
line, antisocial, paranoid, and schizo- versely, it provides a powerful develop-
typal PDs diagnosed in early adulthood mental explanation for how the social
than even physical or sexual abuse in ad- and interpersonal difficulties of PD might
olescence (Johnson et al. 2006). A number emerge.
of studies have pointed to the importance Pedagogy theory predicts that young
of neglect, low parental involvement, children will initially view everything
and emotional maltreatment rather than they are taught as generally available cul-
the presence of abuse as the critical pre- tural knowledge, shared by everyone
dictor of severe PD (e.g., Johnson et al. (Csibra and Gergely 2006). Thus, when
2001). Studies of family context of child- they are taught a word for a new referent,
hood trauma in BPD tend to see the un- they do not need to check who else knows
stable, non-nurturing family environ- it. Young children assume that knowl-
ment as the key social mediator of abuse edge of subjective states is also common
(Bradley et al. 2005) and underinvolve- and that there is nothing unique about
ment as the best predictor of suicide their own thoughts or feelings. A sense of
(Johnson et al. 2002) and personality the uniqueness of their own perspective
dysfunction. Disturbance of attachment develops only gradually.
relationships, by inhibiting the capacity The gradual nature of this develop-
for mentalization, disrupts key social- ment was underscored by developmen-
cognitive capacities (the ability to con- tal discussion of the phenomenon that
ceive mental states as explanations for has been termed the “curse-of-knowl-
behavior in oneself and in others) and edge bias”; this refers to the common
thus creates profound vulnerabilities in enough observation that if one knows
the context of social relationships. Men- something about the world, one expects
that everyone else should know it too The acquisition of a sense of the pretend
(e.g., Birch and Bloom 2003). Young chil- in relation to mental states is therefore es-
dren commonly report that other chil- sential. Repeated experience of affect-
dren will know facts that they themselves regulative mirroring helps the child to
have just learned. The curse-of-knowl- learn that feelings do not inevitably spill
edge bias explains the apparent egocen- out into the world: they are decoupled
trism of young children, who cannot ap- from physical reality. At first this decou-
preciate another person’s perspective: it pling is complete (what we have called the
is not the overvaluing of private knowl- pretend mode [Fonagy and Target 2007]).
edge, as Piaget’s (1951) concept of ego- While a child is focused on the internal,
centrism implies, but rather the undiffer- no connection with physical reality is
entiated experience of shared knowledge possible. Only gradually, by engaging in
that hinders children from taking the playful interaction with a concerned
perspective of the other. Children are adult who seriously entertains the child’s
correct to assume universal knowledge pretend world, will the pretend and psy-
during development because their repre- chically equivalent modes integrate to
sentations of their own subjectivity were form genuine subjectivity.
indeed someone else’s beliefs about the In understanding the emergence of
children before social mirroring enabled mentalization, it is not necessary to ac-
the children to make these representa- count for how children come to under-
tions their own. This phenomenon will stand that other people have minds.
gradually be less and less true as children Children assume, once they acquire in-
mature, yet even as adults, individuals trospectively accessible representations,
may occasionally catch themselves as- that this is always the case. Recent re-
suming that others think the same way search on Theory of Mind using an
they do. adapted version of the displacement
Young children do not yet know that task suggests that awareness of other
they can choose whether or not to share minds is present from as early as age 15
their thoughts and feelings with adults. months (Kovacs et al. 2010). The new
Toddlers may be prone to tantrums be- theoretical perspective of pedagogy the-
cause they fully expect other people to ory focuses developmental attention on
know what they are thinking and feeling children’s understanding that others
and to see situations in the same way have separate minds with different con-
they do. Disagreement cannot yet be un- tents. The question is: What social condi-
derstood as the result of different points tions might help infants to learn when to
of view, so if adults thwart them, the suspend their default assumption of
adults must be either malign or willfully universal knowledge?
obtuse. Thus, conflict is not just hurtful Pedagogy theory clarifies the role of
but also intolerable and maddening be- early attachment relationships in the
cause it denies this probably highly val- emergence of individual subjectivity and
ued shared reality. What exists in the perspective taking. The establishment of
mind must exist “out there” and what subjectivity is linked to attachment via
exists out there must also exist in the the overlap between consistent ostensive
mind. This “psychic equivalence,” as a and accurate referential cueing and what
mode of experiencing the internal world, attachment theorists have designated
can cause intense distress because the “sensitive parenting” (Fearon et al. 2006).
projection of fantasy can be terrifying. By building second-order representations
on the one hand and providing mental ing the false belief test—that is, “having a
reasoning schemes to make sense of ac- Theory of Mind”—was associated with
tion on the other, the relationship with sensitivity to information coming from
the mind-minded reflective caregiver positively versus negatively connoted
transforms the child’s implicit and auto- sources.
matic mentalizing competence into an ex- A person monitors the mental states
plicit, potentially verbally expressible, of others in part to establish the possible
and systematized “theory of mind.” As- motivations behind any giving of infor-
pects of secure attachment (e.g., attun- mation. The quality of the relationship
ement sensitivity) appear to have a peda- between parent and child plays an im-
gogical function, teaching us what we portant role in establishing one’s capac-
cannot learn about the world through ity to do this. Children who have experi-
simple observation. Subjectivity, of course, enced disorganized attachment will be
belongs to this class of phenomena. Se- disadvantaged because of confusion about
cure attachment and the mind-minded the possibility of trust. The secure child,
reflective mirroring environment extend by contrast, has already developed a ro-
awareness to include internal states, bust sense of shared subjectivity and
thereby making self-prediction and emo- may also be most open to learn about the
tional self-control possible. Pedagogical uniqueness and separateness of his or
referential communication applied to the her self-experience. Attachment may well
domain of the emotional and disposi- be a helpful behavioral marker of shared
tional/intentional states of the self cre- genetic makeup (Belsky and Jaffee 2006)
ates the context wherein the caregiver can and consequently a kind of “hallmark of
teach the child about the subjective self. authenticity of knowledge.” The indica-
The benign effects of secure attachment tions of generic cognitive benefits associ-
arise at least in part out of superior com- ated with secure attachment are in line
petence at ostensive cueing. with the assumption of more reliable
There is a second aspect of this pro- processing of pedagogical information
cess, however, in which the attachment in caregiving environments that engen-
relationship may play a crucial part: com- der attachment security (Cicchetti et al.
petition with other people, which is po- 2000).
tentially a primary driver of the evolution In summary, we suggest that the ad-
of mentalization. The pedagogical func- vantage of secure attachment for the pre-
tion needs to be protected from deliberate cocious development of mentalization
misinformation by competitors who do and for the stronger establishment of an
not have genetic material in common agentive sense of self is the conse-
with the infant and are therefore not in- quence of the infant’s general predispo-
vested in his or her survival. The 3- to 4- sition to learn from adults. As learning is
year-old child’s sensitivity to false beliefs triggered by ostensive cues that share
suggests that he or she has become aware characteristics with secure parenting,
not only that knowledge is not invariably the teaching of secure infants may be
shared but also that it is not necessarily smoother than that of insecure ones. By
communicated with benign intent. In contrast, disorganized attachment inter-
Mascaro and Sperber’s (2009) study, pre- feres with ostensive cues and would be
school children responded differentially expected to disrupt learning. It is ex-
to information supplied by a benevolent pected that the influence of secure at-
versus a malevolent communicator. Pass- tachment will be particularly crucial in
teaching the infant about his or her own vided in Section III of DSM-5 (American
subjectivity. Finally, the characteristics Psychiatric Association 2013), differs
of communication associated with sensi- from the categorical approach expressed
tive caregiving also reassure the infant in DSM-IV and in DSM-5 Section II, “Di-
about the trustworthiness of the infor- agnostic Criteria and Codes.” This sig-
mation to be communicated. From an nificant new model is pertinent here be-
evolutionary standpoint, one may con- cause it is conceptually quite congruent
sider such ostensive cues (at least in in- with key findings of attachment theory–
fancy) to trigger a “basic epistemic trust” based research on PDs. The alternative
in the caregiver as a benevolent, cooper- DSM-5 model describes PDs according to
ative, and reliable source of cultural in- two primary criteria. Criterion A consti-
formation (Gergely 2007). This basic tutes impairments in personality func-
trust enables the infant to rapidly learn tioning, both personal self-functioning
what is communicated without the need and interpersonal functioning. Function-
to test for social trustworthiness (Slade ing can be evaluated on a continuum
et al. 2005). Adults mainly teach infants that determines levels of impairment.
they look after, whom they have genetic Criterion B constitutes pathological per-
reasons to care for. Infants are also selec- sonality traits—that is, tendencies to be-
tive, identifying attachment figures to have or think in certain ways, which may
teach them what in the world is safe and rise and fall across life according to cir-
trustworthy, and, furthermore, how they cumstances and experience. Disturbances
can think about their thoughts and feel- in self and interpersonal functioning (Cri-
ings and how knowledge of such inter- terion A) are thus central components in
nal states can eventually make a bridge the conceptualization and diagnosis of
to understanding and prediction in the PD. Self-functioning encompasses an
wider social world. individual’s identity and sense of self-
direction; interpersonal functioning en-
compasses empathy and the capacity for
An Attachment Theory of intimacy. Both of these fundamental ele-
ments of personality function are gener-
Borderline Personality ated by attachment relations: secure at-
Disorder Based on tachment develops the clarity of identity
and a distinct set of boundaries between
Mentalization self and other that are necessary for this
aspect of healthy self-functioning. Simi-
To show that attachment theory can use- larly, the sense of agency in the secure
fully be integrated to address clinical child enables him or her to set and aspire
problems, we briefly review the mental- to reasonable goals using appropriate be-
ization-based theory and treatment of haviors and to reflect constructively on
BPD (Bateman and Fonagy 2006; Fonagy his or her own experience. In the arena of
and Bateman 2006). We consider the fail- interpersonal functioning, secure attach-
ure of mentalization within the attachment drives the development of mental-
ment context to be the core pathology of ization—the ability to understand other
BPD (Bateman and Fonagy 2004), and people’s emotions and motivations accu-
our treatment package aims to assist in its rately—and provides a working model
recovery (Bateman and Fonagy 2006). for forming intimate and enduring rela-
The alternative model for PDs, pro- tionships. Conversely, impairments in
both self-functioning and interpersonal we list two examples here. First, the reluc-
functioning are adaptations to insecure tance to conceive of mental states on the
attachment experiences. Many of the fea- part of maltreated individuals might be
tures of insecure attachment in adult- understandable given the hostile and ma-
hood correlate with the impairments in levolent thoughts and feelings that the
functioning described in Section III of abuser must realistically hold to explain
DSM-5: a weak or distorted self-image, a his or her actions against a vulnerable
limited capacity to regulate affect, inco- young person. Consistent with this as-
herent or unrealistic goal setting, the in- sumption, forms of maltreatment that are
ability to consider and comprehend oth- most clearly malevolent and clearly target
ers’ feelings or motivations (the inability the child (i.e., physical, sexual, and psy-
to mentalize), and a diminished capacity chological abuse) have the greatest im-
for enduring and reciprocal intimacy in pact on mentalization. Second, it could be
interpersonal relationships. argued that adversity undermines cogni-
In cases of BPD, individuals have sche- tive development in general. Certainly,
matic, rigid, and sometimes extreme there is strong evidence to suggest that
views, which make them vulnerable to addressing issues of maltreatment in par-
powerful emotional storms and apparent-child relationships can facilitate the
ently impulsive actions and which can child’s cognitive development (Cicchetti
create profound problems of behavioral et al. 2000). Our current model stresses
regulation, including affect regulation. In that minor experiences of loss or rela-
our model of the failure of mentalization tively small emotional upsets without ex-
in BPD, the role of the attachment envi- pectation of being comforted may be
ronment is considered alongside consti- enough to cause intense activation of the
tutional vulnerabilities. The vulnerability attachment system in these individuals.
reflected in the heritability of BPD may be Their attachment system is hyperacti-
directly linked to the capacity for mental- vated, probably because of interpersonal
ization or may represent the fragility of experiences associated with childhood
this capacity in situations of environmen- trauma. This state of arousal inhibits
tal deficiency, as exemplified by severe mentalization and, combined with an un-
neglect, psychological or physical abuse, stable capacity for affect regulation, trig-
childhood molestation, or other forms of gers the typical symptoms of the disorder.
maltreatment. There is ample evidence that maltreat-
As we considered earlier in the section ment puts children at risk of profound
“Attachment Experience and Mentaliza- deficits in the skills required to negotiate
tion,” mentalization may be temporarily social interactions with peers and friends.
inhibited by strong emotional arousal, by These deficits are broad ranging and may
the intensification of attachment needs, or affect verbal ability, the comprehension
by a defensive turning away from the of emotional stimuli and situations, and
world of hostile and malevolent minds in possibly also Theory of Mind. We have
the context of severe maltreatment. Men- seen that the level of mental state under-
talization deficit associated with mal- standing (particularly emotion under-
treatment may not necessarily reflect in- standing) is closely linked to the extent to
capacity but rather a form of decoupling, which emotions are openly discussed in
inhibition, or even a phobic reaction to the mother-child dyad or can be dis-
mentalizing in maltreated individuals. cussed given the child’s deficits and the
There are multiple possibilities, of which parents’ ability to overcome them. We
may then argue that maltreatment acts on ent-child interaction is in crucial respects
mentalization in many ways; it compro- not genuine, the child might well be de-
mises the unconstrained, open reflective conditioned from using mentalization as
communication between parent and his or her predictive strategy. Severely in-
child or indeed between child and child. secure, abusive, inconsistent, and disor-
Maltreatment undermines the parent’s ganized attachment relations may well be
credibility in linking internal states and detrimental for mentalization to survive
actions. This limitation in communica- as a dominant, predictive interpersonal
tion is not hard to comprehend and could strategy. However, within the same con-
hardly be otherwise if the maltreatment is texts of deprivation and risk, mentaliza-
perpetrated by a family member. How- tion could hold the key to breaking the
ever, even in cases where maltreatment is cycle of abuse and deprivation for that
not perpetrated by a family member, the child growing up and for the children he
centrality of the maltreatment experience or she may go on to produce.
for the child, coupled with the oversight We see the capacity to mentalize as
on the part of the parent of the maltreat- particularly helpful when people have
ment that the child encounters outside been traumatized. Mentalization of expe-
the home, could serve to invalidate the riences of adversity can moderate their
child’s communications with the parent negative sequelae (Fonagy et al. 1996).
concerning the child’s subjective state. The capacity to mentalize enables those
Thus, apparently reflective discourse will who are subjected to traumatic experi-
not correspond to the core of the child’s ences to hold back modes of primitive
subjective experiences, and this discrep- mental functioning. It makes conceptual
ancy moderates or reduces the facilitative sense, therefore, for mentalizing to be a
effect of mentalizing verbal rationaliza- focus for therapeutic intervention if ther-
tions of actions in generating an inten- apists are to help patients with BPD bring
tional as opposed to a teleological orien- primitive modes of mental functioning
tation. The formulations advanced here under better regulation and control.
imply that therapeutic interventions
should aim to engage maltreated chil-
dren in causally coherent psychological Attachment and
discourse within appropriate contexts.
The more reliable processing of pedagog-
Treatment Outcome for
ical information in the context of secure Personality Disorders
attachment would account for the broad
and generic intellectual benefits that ap- A child who is securely attached has had
pear to accrue from secure attachment in his or her acute affective states consis-
infancy. tently reflected back to him or her in an
Insecure and unpredictable attach- accurate, but not overwhelming, manner.
ment relationships between parent and This repeated mirroring enables the in-
infant may create an adverse social envi- fant to develop an increasing capacity for
ronment for the acquisition of mentaliza- mental processing, particularly mental-
tion or “mind reading” in the child. This ization. In other words, it allows the indi-
may to a limited extent be adaptive, in vidual to imagine that others have a
that within extreme social contexts men- mind that is essentially like his or her
talization is a less useful strategy. If par- own and to interpret and respond to oth-
ers’ feelings. The emergence of spoken or the treatment. Psychotherapy can be

language about feelings seems to be re- seen as a threat to these patients’ defen-
lated to the attachment figure’s ability to sive apathy, and a negative transference
put the child’s mental experience into pattern may emerge. Contrastingly, pre-
words. Securely attached children seem occupied patients are at risk of dropout
to acquire speech more rapidly and re- after perceived abandonments such as
main more verbally competent than in- emergency cancellations or scheduled
secure children. Conversely, insecure vacations. Fearfully preoccupied individ-
attachment leads to developmental im- uals are prone to dropout in response to
pairment of the internal state lexicon and feeling attached to or dependent on the
to subsequent alexithymia in adulthood. therapist and treatment (Levy et al. 2011).
Effective therapies must therefore in- Attachment also influences the thera-
clude a component that allows patients to peutic alliance, which in turn has impor-
recognize, label, and verbally communi- tant effects on outcome. Whereas secure
cate their feelings. patients perceive their therapists as re-
On the basis of empirical evidence sponsive and emotionally available,
demonstrating that insecure attachments avoidant/fearful patients are reluctant to
are risk factors for PDs and other mental make personal disclosures, feel threat-
illnesses, researchers have taken an in- ened, and suspect that the therapist is dis-
terest in the relationship between attach- approving. Preoccupied patients wish for
ment and psychotherapeutic success. It more contact with the therapist and may
is widely accepted that attachment char- seek to expand the relationship beyond
acteristics influence psychotherapeutic the bounds of therapy (Levy et al. 2011).
outcomes, but results are inconsistent. Following Bowlby’s attachment the-
Most studies show that securely attached ory, both protection-seeking and care-
patients obtain better results (Cartwright- giving behavior are influenced by at-
Hatton et al. 2011), but others indicate tachment (Bowlby 1988). Therefore, the
better outcomes for avoidant and disor- therapist’s attachment style also influ-
ganized patients (Fonagy et al. 1996). ences the process and outcome of treat-
The largest meta-analysis on the influ- ment. Therapists with anxious attach-
ence of attachment on psychotherapeutic ment styles create strong therapeutic
outcome in various diagnoses (including alliances, but the quality of the alliance
PDs) and heterogeneous psychothera- decreases with time when patients show
peutic orientations consistently found interpersonal distress. Sessions between
that although attachment anxiety nega- an avoidant therapist and an anxious
tively affects outcome, attachment avoid- patient attain less depth.
ance has no effect. This meta-analysis Some studies have shown changes in
confirmed that higher attachment secu- patients’ attachment resulting from treat-
rity predicts better therapeutic outcomes ment. Fonagy et al. (1995) reported on a
(Levy et al. 2011). sample of patients with BPD under psy-
In addition to affecting symptomatic chodynamic treatment. After treatment,
outcomes, attachment is associated with 40% of the patients were classified as se-
treatment dropout. Adult avoidant at- cure; none of the patients had this classi-
tachment constitutes a risk for dropout fication before treatment. A multisite
because patients are not fully committed, study of several inpatient group psycho-
attached, or engaged with the therapist therapies found consistent improvement
of attachment security after 9 weeks of dent expectation that distress will be met
treatment, compared with nonclinical with comfort and reassurance. But beyond
controls, that was maintained at 1-year this, because secure attachment facilitates
follow-up (Kirchmann et al. 2012). In a the emergence of psychic structures linked
randomized controlled trial of transfer- to emotion, the entire representational
ence-focused psychotherapy, dialectical system is likely to be more stable and co-
behavior therapy, and supportive ther- herent with a history of generally secure
apy, only transference-focused psycho- attachment experiences. The way people
therapy achieved an increased number of experience thoughts, including attach-
patients classified as secure after treatment-related thoughts and the cognitive
ment (Levy et al. 2006). A successful treat- structures that underpin them, may be
ment does not necessarily imply attain- seen as linked to physical aspects of early
ing a secure attachment style, however: infantile experience. Attachment imme-
female patients with BPD whose attach- diately takes center stage once research
ment style changed from ambivalent to recognizes the physical origins of thought.
avoidant have shown improved symp- It is possible now to see insecure patterns
tomatic results at the end of short-term of attachment as adaptations that maxi-
therapy (Strauss et al. 2011). mize the chances of survival of the infant
to reproductive maturity despite adverse
conditions for child rearing: continuing
Conclusion to cry when comforted may bring vital re-
sources when individual attention is a
Building on the scientific cogency and rare commodity.
fruitfulness of attachment research, at- Missing out on early attachment ex-
tachment theory is now being increas- perience creates a long-term vulnerabil-
ingly translated into clinical settings. ity from which the child may never re-
Recent work has demonstrated how prac- cover; the capacity for mentalization is
titioners can profit from the use of simple never fully established, leaving the child
measures of attachment in order to tailor vulnerable to later trauma and unable to
their interventions to maximize gains cope fully with attachment relationships.
and minimize iatrogenic effects, a com- More importantly, by activating attach-
mon difficulty in the treatment of PDs ment, trauma will often disrupt mental-
(Adshead 2010; Adshead et al. 2012; Con- ization. This, of course, is further exacer-
radi et al. 2011; Davila and Levy 2006; bated when the trauma is attachment
Levy et al. 2011; Westen et al. 2006). Men- trauma. Attachment is the evolutionary
tal health interventions can often stimu- instrument for humanity’s most defin-
late the attachment needs of patients but ing feature: the capacity for a complex
may not provide the necessary protection social understanding both of oneself and
and structure required to deal with the of others.
consequences of activating attachment The resistant pattern of attachment,
systems, ranging from dropout to suicide characterized by an exaggeration of dis-
(Levy et al. 2012; Spinhoven et al. 2007). tress to ensure care, is linked to preoc-
The concept of a “secure base”—from cupied states of mind in relation to at-
which to start a curative change in rela- tachment, usually involving anger or
tionship representations—needs to be in- passivity. The common markers in the
tegrated into approaches to treatment. AAI include unfinished, run-on, or en-
Secure attachment is built on the confi- tangled sentences. The gesture that is ex-
pressed is one of needing to hold on yet

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CHAPTER 5
Genetics and
Neurobiology
Harold W. Koenigsberg, M.D.
Antonia S. New, M.D.
Larry J. Siever, M.D.
Daniel R. Rosell, M.D., Ph.D.
In the last 30 years, there has stem from a long-standing clinical tradi-
been a rapid explosion in knowledge re- tion. Of the multiple PD categories in-
garding the neurobiology of brain sub- cluded in versions of DSM from DSM-III
strates of the severe personality disor- (American Psychiatric Association 1980)
ders (PDs). Once conceived solely in through DSM-5 (American Psychiatric
traditional psychodynamic or behav- Association 2013), the categories of bor-
ioral terms, these disorders are increas- derline, schizotypal, antisocial, and avoid-
ingly understood as emerging from bio- ant PDs emerge as having the greatest
logical susceptibilities shaped by genetic number of studies of external validators.
dispositions in concert with environ- Complementary to this categorical ap-
mental insults or constraints. These ad- proach is a dimensional approach to PDs
vancements have stimulated the devel- consonant with a long tradition in aca-
opment of interactional models of the demic psychology of defining PDs as con-
PDs, ultimately leading to new forms of tinuous dimensions of pathology or, at a
treatment in both the pharmacotherapy more refined level, of multiple interactive
and the psychosocial treatment arenas. traits. Both of these systems are acknowl-
They also have opened the door to pos- edged in “Alternative DSM-5 Model for
sible neurobiological as well as clinical Personality Disorders” in Section III,
predictors of responses to these treat- “Emerging Measures and Models,” of the
ments. DSM-5 diagnostic manual.
The PDs have traditionally been con- In this chapter, we discuss the genetics
ceptualized in terms of categories that and neurobiology underlying the catego-
79
ries of borderline, schizotypal, antisocial, first introduced into the official nosology
and avoidant PDs. Major domains or di- in DSM-III. Affective instability in BPD is
mensions of psychopathology that we ac- marked by vulnerability to rapid and in-
knowledge in this chapter include affect tense shifts in affect. Changes in affective
or emotion regulation, impulse/action state occur over intervals of hours to a few
modulation, interpersonal/social cog- days at a time. These changes are often,
nition, and anxiety related to defenses but not always, triggered by identifiable
against its emergence. psychosocial stressors. In BPD the insta-
bility is associated primarily with the af-
fects of anger, anxiety, and depression
Borderline Personality (Koenigsberg et al. 2002).
Linehan (1993) has suggested that af-
Disorder fective instability in BPD is a result of the
The neurobiology of borderline PD (BPD) combination of a high sensitivity to emo-
has been more extensively studied than tional stimuli coupled with a deficient
that of any other PD. BPD is defined in ability to regulate emotions. Consistent
DSM-5 by the presence of five of nine cri- with the notion of heightened sensitivity
teria, encompassing pervasive patterns to emotion cues are reports that patients
of emotion dysregulation, impulsive ag- with BPD require less visual information
gression, unstable interpersonal relation- than do healthy control (HC) subjects to
ships, and self-inflicted injury. An alter- correctly identify facial emotion. Others
native conceptualization of BPD, focusing have suggested that patients with BPD
on pathological expressions of several are less accurate in identifying emotion
personality traits and impairments in in- because they have a bias to preferentially
terpersonal and self-functioning, is intro- identify negative or hostile emotions
duced in DSM-5 Section III, “Emerging (Domes et al. 2009). However, both ob-
Measures and Models.” The DSM-5 traits servations are consistent with the over-
relevant to BPD include negative affectiv- sensitivity of patients with BPD to facial
ity, disinhibition, and antagonism. Com- cues of hostile or negative emotion.
mon to both diagnostic conceptualizations Healthy individuals draw on a num-
are the important borderline phenotypes ber of emotion regulatory mechanisms to
of emotion dysregulation, impulsive ag- maintain or restore emotional responses
gression, and disturbed interpersonal to tolerable levels. These include explicit
functioning. The high incidence of self- regulation strategies such as cognitive re-
injurious behavior, including nonsuicidal appraisal, in which a narrative is created
self-injury, in patients with BPD high- to reframe an emotional situation in a less
lights the need to study pain-processing disturbing or more exciting fashion, and
mechanisms in BPD. For each of these implicit regulation mechanisms such as
phenotypes, we review recent neuroim- habituation, in which the emotional in-
aging and genetic findings. tensity of a stimulus is reduced with re-
peated exposure to the stimulus. Top-
down neural control processes facilitate
Emotion Dysregulation the former, whereas bottom-up processes
enable the latter. The reallocation of at-
Affective instability has been a defining tention may play a role in both types of
criterion for BPD since the disorder was regulatory process.
Genetics and Neurobiology 81
Neuroimaging Findings umes in patients with BPD, compared

with those of HC subjects, have been re-
Structural and functional neuroimaging ported as increased (Minzenberg et al.
methods, such as magnetic resonance im- 2008), the same (New et al. 2007), and
aging (MRI), positron emission tomogra- decreased (Brambilla et al. 2004; Dries-
phy (PET), functional MRI (fMRI), and sen et al. 2000; Nunes et al. 2009; Schmahl
diffusion tensor imaging (DTI), provide a et al. 2003; Tebartz van Elst et al. 2003).
window into the neurobiology underly- These discrepancies in amygdala vol-
ing emotion regulation in BPD. To un- ume may be due to the confounding ef-
derstand differences in the underlying fect of comorbid depression in some
neural substrates for emotion processing subjects. However, a recent meta-analy-
between patients with BPD and HC sub- sis of amygdala and hippocampal vol-
jects, investigators have examined brain umes in BPD concluded that the vol-
regions of interest that are known to play umes of these structures in patients with
a role in emotion processing and also have BPD are reduced compared with those
examined whole-brain neural activity of HC subjects (Nunes et al. 2009). Exam-
patterns and network connectivity dur- ining gender differences and correlates
ing emotional tasks. of the structural anomalies in BPD, Sol-
The amygdala is a structure particu- off et al. (2008) found decreased gray
larly relevant to emotion processing. It is matter density in patients with BPD com-
engaged during fear processing as well pared with HC subjects in the ventral cin-
as during the assessment of emotional gulate and in a number of temporal lobe
salience and in processing facial expres- regions, including the amygdala, hippo-
sions. The fusiform gyrus is a structure campus, parahippocampal gyrus, and
specialized for face processing. The in- uncus in both genders. Controlling for
sula plays an important role in the inte- the current level of depression, all of
gration of affective, cognitive, and in- these differences remained except in the
teroceptive aspects of emotion, as well ventral cingulate. Only male patients
as a role in emotional appraisal and social with BPD showed decreased gray mat-
emotion. Another region relevant for ter concentrations in the ACC (Soloff et
emotion processing is the anterior cingu- al. 2008).
late cortex (ACC). The rostral ACC has Studies that examined neural activity
been implicated in emotion processing as patients with BPD and HC subjects
and the dorsal ACC in cognitive process- viewed emotional faces or emotional
ing, cognitive modulation of emotion, scenes have identified functional ana-
and integration of emotional informa- tomical features differentiating the sub-
tion for adaptively planning behavioral ject groups. Patients with BPD show
responses. increased amygdala activation during
A series of studies comparing the vol- passive viewing of fearful, sad, happy,
umes of brain structures involved in and neutral faces. Increased amygdala
emotion processing have reported dif- and fusiform face region activity has
ferences between patients with BPD and also been identified in subjects with BPD
HC subjects. Patients with BPD have de- viewing photographs depicting emo-
creased cingulate gray matter (Hazlett et tion-inducing scenes (Herpertz et al.
al. 2005; Minzenberg et al. 2008) and hip- 2001; Koenigsberg et al. 2009b). When
pocampal volumes (Nunes et al. 2009) viewing negative pictures compared
relative to HC subjects. Amygdala vol- with neutral pictures, patients with BPD
showed greater activation of the primary tancing, the patients with BPD were not
visual areas and the superior temporal able to activate the dorsal ACC or intra-
gyrus (Koenigsberg et al. 2009b). In- parietal sulcus, regions implicated in
creased activation in the visual areas emotion regulation and attentional allo-
could contribute to the heightened sen- cation, to the extent that HC subjects did
sitivity of patients with BPD to negative (Koenigsberg et al. 2009a). In addition,
facial expressions. The superior tempo- the patients were not able to downregu-
ral gyrus is thought to play a role in the late amygdala activity as HC subjects
assessment of another’s intentions based could. A subsequent study (Schulze et
on gaze, posture, and movement and is al. 2011) found that during distancing,
part of the fast-operating, nonreflective patients with BPD did not decrease in-
reflexive system posited by Satpute and sula activity and did not increase orbito-
Lieberman (2006). Increased activation frontal activity as HC subjects did. Thus,
of this region could then be a neural cor- patients with BPD do not engage the
relate of a tendency to reflexively judge same brain regions as HC subjects do
the intentions of others. when attempting to downregulate nega-
One possible contributor to affective tive affect using cognitive reappraisal,
instability in patients with BPD could be and they do not downregulate amyg-
impairment in processes used by healthy dala and insula activity as HC subjects
individuals to regulate emotion. One do.
such process is cognitive reappraisal, In addition to explicit voluntary emo-
one form of which is creating a narrative tion regulatory processes such as cogni-
frame of reference that modifies the emo- tive reappraisal, implicit processes such
tional valence of a given situation. For as emotional habituation may engage
example, a healthy person who encoun- spontaneously to downregulate negative
ters someone looking ill in a hospital bed affect. Such processes are highly adap-
might think about the excellent medical tive and form the basis for desensitiza-
resources available and focus on the like- tion-based psychotherapies. Patients with
lihood of the patient’s recovery. A sec- BPD do not behaviorally habituate to
ond form of cognitive reappraisal is dis- negative pictures. Imaging studies have
tancing, a process in which one focuses shown that when repeatedly exposed to
on one’s own separateness from a dis- negative pictures, patients with BPD do
tressing situation. Thus, the emergency not activate the dorsal ACC as strongly
room physician maintains a “clinical dis- as HC subjects do and that the less they
tance” from a seriously injured and suf- activate this region, the greater the level
fering patient in order to be able to effec- of affective instability that they display
tively help the patient. Such processes (Koenigsberg et al. 2013). Hazlett et al.
are ubiquitous and highly adaptive. The (2012b) reported an increase in amyg-
clinical observation that patients with dala activation (i.e., a sensitization) in
BPD readily become emotionally over- patients with BPD to repeated exposure
involved with others raises the possibil- to negative pictures. These findings sug-
ity that they cannot engage the distancing gest that patients with BPD do not habit-
process as effectively as healthy individ- uate to negative stimuli as HC subjects
uals can. In an fMRI study in which pa- do. Such a dysfunction of this implicit
tients with BPD and HC subjects were emotion regulatory mechanism could
asked to downregulate their emotional contribute to borderline affective insta-
reactions to disturbing pictures by dis- bility.
Genetics across diagnostic categories and is pres-

ent across the PD spectrum as well as in
Although studies exist that implicate
mood disorders, posttraumatic stress
specific candidate genes in BPD, none
disorders, and other disorders. What is
has shown a relationship specifically with
less clear is whether impulsive aggres-
affective instability in BPD. Indeed, the
sion is present in most individuals with
one large twin study that specifically ex-
BPD or whether there is an “impulsive
amined heritability of BPD and four main
aggressive” subset of patients with BPD.
symptom domains associated with BPD
This empirical question has not been
(affective instability, identity problems,
completely answered and speaks to the
relationship disturbances, and self-
need for research into the possibility of
harm) showed that heritability was best
heterogeneity within the group of indi-
explained by a genetic common path-
viduals with BPD. Early factor analyses
way model. This unitary latent heritabil-
of DSM-III-R criteria showed three pre-
ity factor accounted for 51% of the vari-
dominant factors—disturbed related-
ance, and the remainder was explained
ness, behavioral dysregulation, and af-
by unique environmental influences. For
fective dysregulation—in BPD; however,
each BPD scale except self-harm, around
subsequent analyses showed that these
50% of its variance was explained by the
factors were highly correlated with one
latent unitary BPD factor. The remaining
another (r=0.90, 0.94, and 0.99) (Clifton
variance for each of the four scales was
and Pilkonis 2007). Further support for a
explained by genetic (4% for affective in-
unitary construct underlying BPD came
stability to 20% for self-harm) and envi-
from a study in a mixed clinical and non-
ronmental (38% for negative relation-
clinical sample (N = 362); this study re-
ships to 67% for self-harm) factors (Distel
vealed two latent classes (symptomatic
et al. 2010).
and asymptomatic) and a single severity
dimension that fit the BPD criteria (Clif-
Impulsive Aggression ton and Pilkonis 2007). However, a fol-
Although some violence is the result of low-up analysis, including not only DSM-
premeditated aggression, most acts of IV criteria but also other symptom do-
domestic violence and many acts of ag- mains in 100 symptomatic subjects, sug-
gression in the workplace are impulsive gested that there might be heterogeneity
responses to interpersonal interactions. within BPD along the angry/aggressive,
Individuals who engage in impulsive angry/mistrustful subtypes. Interestingly,
aggression are typically remorseful about this subclass did not differ in sex ratio
their acts and perceive the adverse con- from other patients with BPD. In gen-
sequences of these acts. Nevertheless, eral, this study provides some support
these individuals often have difficulty for the idea that a subset of patients with
exerting control over their aggression. BPD may be particularly at risk for im-
Impulsive aggression is a common fea- pulsive aggression (Hallquist and Pilko-
ture of BPD, as identified in one of its nis 2012).
DSM-5 criteria: “Inappropriate, intense
anger or difficulty controlling anger (e.g., Behavioral Data
frequent displays of temper, constant Self-report data have consistently shown
anger, recurrent physical fights).” that patients with BPD score higher than
Although common in BPD, impulsive healthy individuals in impulsive aggres-
aggression is clearly a symptom that cuts sion and anger. However, these self-re-
port measures do not distinguish well be- Although the behavioral tasks did
tween patients with BPD and patients show elevated impulsive aggression in
with other PDs. The most studied labora- patients with BPD, the PSAP was no bet-
tory provocation of aggression in PDs is ter than self-report in distinguishing pa-
the Point Subtraction Aggression Para- tients with BPD from patients with other
digm (PSAP). The aim of behavioral PDs and did an equally good job in dis-
provocation studies is to overcome the tinguishing patients with BPD and other
difficulty of studying a behavior that is PDs from controls. Thus, neither self-
intermittent in nature. A patient suffering report data nor aggression provocation
from poor impulse control can appear elicited BPD-specific responses. This
normal until provoked, often by an inter- finding may reflect that the symptom
personal conflict, which then elicits a se- domain of impulsive aggression cuts
vere reaction with marked consequences across diagnostic categories and is not
both to the patient and to those around specific to BPD.
him or her. Individuals at risk for reactive
aggression tend to respond aggressively Neuroimaging Findings
to minor interpersonal provocation or Preclinical and human studies involving
stressful situations. The PSAP is a well- brain lesions suggest that the prefrontal
validated laboratory provocation of ag- cortex, particularly the prefrontal OFC
gression that involves an experimental and adjacent anterior cingulate gyrus
subject and a “confederate” (a computer) (ACG), plays a central role in the regula-
(Cherek et al. 1997). The experimental tion of aggressive behavior. Irritability
subject accumulates “points” that can be and angry outbursts are associated with
exchanged for money, and provocation damaged OFC in neurological patients.
occurs when the “confederate” removes Lesions of the OFC early in childhood
points from the experimental subject. This can result in antisocial, disinhibited, and
has been shown to be a safe and effective aggressive behavior later in life, and re-
way to measure the tendency to become duced prefrontal gray matter has been
aggressive in a laboratory setting, and it associated with autonomic deficits in ag-
permits the assessment of a wide range of gressive individuals with antisocial PD
levels of aggression. (Raine and Lencz 2000). Decreased ACG
Studies in patients with BPD have volume as measured by structural MRI
shown that hospitalized female subjects is associated with aggression in adults
with BPD were more aggressive on the without psychiatric illness and in chil-
PSAP than HC subjects. In a study of dren. These studies suggest that the OFC
outpatients with PDs, both subjects with and ACG are critical in modulating the
BPD and patients with other PDs made emergence of aggression, especially in
a higher proportion of aggressive button emotionally complex social situations
selections and a lower proportion of mon- (reviewed by Coccaro et al. 2011).
etary button selections than did HC sub- The concept that the prefrontal cortex
jects. Aggressive responding on the PSAP controls and inhibits the amygdala and
correlated with symptoms of reactive other limbic structures was proposed de-
aggression, and individuals with a high cades ago and is supported by abundant
degree of aggression showed impaired preclinical and clinical evidence (Roxo et
recruitment of orbitofrontal cortex (OFC) al. 2011). Evidence for the involvement
during aggression provocation (New et of the prefrontal cortex in modulating an
al. 2009). aggressive response includes structural
imaging data. Volume reduction in OFC have demonstrated decreased metabolic

and ACG has been shown in individuals activity in OFC and ACG in response to
with impulsive aggression; interestingly, serotonergic challenge in impulsive ag-
structural abnormalities in OFC and gressive patients with BPD compared
ACG have been reported in patients with with HC subjects. One such study, using
BPD, but the relationship of those struc- PET, found that whereas normal subjects
tural abnormalities to aggressive symp- showed increased metabolism in OFC
toms in BPD has not been clearly dem- and ACG following administration of
onstrated. One study showed diminished D,L-fenfluramine, a serotonin-releasing
regulatory input from medial OFC in agent, impulsive aggressive patients with
healthy individuals during anger provo- PDs showed significant increases only in
cation (Pietrini et al. 2000). Functional the inferior parietal lobe (Siever et al.
amygdala-OFC connectivity has been 1999). A larger study confirming pre-
shown in healthy individuals responding frontal hypometabolism in response to
to aggressive faces. Disruption of amyg- D,L-fenfluramine demonstrated that HC
dala-OFC coupling has been shown in subjects showed increased metabolism
BPD patients with impulsive aggression in ACG and OFC following serotonergic
(New et al. 2007) and in PD patients with stimulation, whereas patients with BPD
intermittent explosive disorder in re- showed decreased metabolism in these
sponse to angry faces (Coccaro et al. 2007). areas (Soloff et al. 2000). Our work em-
Few studies have used DTI to study the ploying 18-fluorodeoxyglucose PET to
white matter tracts in patients with ag- assess relative metabolic activity after
gression. One DTI study showed de- administration of meta-chlorophenylpi-
creased fractional anisotropy, an indica- perazine, a serotonin agonist, reuptake
tion of decreased directional coherence inhibitor, and releasing agent, showed
in white matter tracts, in women with reduced metabolic responses in medial
BPD and self-injury (Grant et al. 2007); OFC and ACG in impulsive aggressive
another showed that increased mean patients, all but one of whom met crite-
diffusivity (another measure of white ria for BPD, compared with control sub-
matter tract integrity) in inferior frontal jects (New and Hazlett 2002). In addition,
white matter was associated with higher in patients with BPD, we found increased
levels of anger and hostility (Rüsch et al. activity in the posterior cingulate both at
2007). Recently, decreased fractional an- rest and in response to a serotonergic
isotropy has been shown in the white challenge; posterior cingulate is a brain
matter tracts in the temporal lobes of ad- area that has been specifically implicated
olescents with BPD, but an adult sample in the recognition of facial emotion and
studied in a similar manner did not show therefore is particularly interesting in
this anomaly (New et al. 2013). This find- BPD. Further support for serotonergi-
ing raises the possibility of a develop- cally mediated hypometabolism in OFC
mental difference in white matter tract in- in BPD comes from evidence of a nor-
tegrity in patients with BPD. malization of OFC function with fluox-
Peripheral evidence for decreased etine treatment in impulsive aggressive
serotonergic responsiveness in patients patients with BPD (New et al. 2004).
with BPD led to brain imaging studies to The mechanism of the serotonergic
explore central serotonergic responsive- abnormality in BPD has been examined
ness more directly. A number of studies more closely with molecular neuroimag-
ing studies. A PET study of serotonin syn- tryptophan-containing genotypes of

thesis showed lower synthesis in men TPH-2 have been associated with BPD.
with BPD compared with control sub- A study of a well-characterized clinical
jects in medial frontal gyrus, ACG, supe- sample of 103 HC subjects and 251 pa-
rior temporal gyrus, and corpus striatum; tients with PDs (109 with BPD) replicated
women with BPD had lower serotonin the finding that the “risk” haplotype of
synthesis compared with controls in TPH-2 was significantly higher in patients
right ACG and superior temporal gyrus with BPD than in HC subjects. Those with
(Leyton et al. 2001). More recently, the the “risk” haplotype had higher aggres-
serotonin transporter PET radiotracer sion and affect lability scores and more
[ 11 C]McN5652 was used to show re- suicidal/parasuicidal behaviors than
duced availability of serotonin transporter those without it (Perez-Rodriguez et al.
(5-HTT) in ACG of individuals with PD 2010).
and impulsive aggression compared with Single-gene study findings note an as-
HC subjects, suggesting reduced seroto- sociation with BPD diagnosis and genes
nergic innervation in this brain region for MAOA, a key regulator of serotonin
(Frankle et al. 2005). These findings lend metabolism and 5-HT2C . However, 5-
further support to serotonergic dysfunc- HT2A variants are associated with per-
tion in patients with BPD. sonality traits such as relational aggres-
sion but not with BPD diagnosis. Thus,
Genetics genes associated with impulsive aggres-
Twin and family studies suggest that ag- sion, including SLC6A4, TPH-2, MAOA,
gression, particularly impulsive aggres- COMT, and 5-HT receptor genes, are also
sion, has substantial heritability (44%– implicated in BPD. However, these asso-
72%), consistent with a meta-analysis of ciations are not consistently replicated,
more than 20 twin studies (Miles and and authors have suggested that gene
Carey 1997), although gene-environment variants may be associated with person-
interactions also play an important role ality traits such as relational aggression
in aggression. Which specific genes are rather than diagnosis.
involved is less clear. Evidence for an as-
sociation between genes and aggression,
per se, is strongest for monoamine oxi-
Relationship Disturbances
dase A (MAOA), serotonin transporter An impaired capacity to engage in stable
(SLC6A4), tryptophan hydroxylase 2 interpersonal relationships is a central
(TPH2), dopamine beta-hydroxylase and highly maladaptive feature of BPD.
(DBH), and catechol O-methyltransfer- This impairment manifests as a pervasive
ase (COMT). inability to sustain rewarding relation-
Studies of impulsive aggression in ships and recurring lapses into tumultu-
patients with BPD have also been prom- ous interpersonal crises. Persons with
ising. Tryptophan hydroxylase (TPH), whom the patient with BPD is engaged
the rate-limiting enzyme in serotonin are often perceived in extremes of ideal-
5-HT biosynthesis, has two isoforms, ization or devaluation, often with rapid
TPH-1 and TPH-2. Studies associating shifts from one perception to the other.
aggression in BPD with TPH-1 were in- Intimate relationships are troubled, and
consistent, and it was determined that patients with BPD are often preoccupied
the isoform of TPH present in brain is ac- with fears of abandonment. The relation-
tually TPH-2. The allele rs2171363T and ship instability of patients with BPD could
be the result of disturbances in one or ing emotions when facial expression must
more of the sensory, cognitive, emotional, be integrated with prosodic emotional
and behavioral systems that play a role in information. Taken together, these find-
social processing. These include systems ings support the notion that patients
that read the emotional cues displayed by with BPD are more sensitive than healthy
others (e.g., in facial expression or tone of volunteers regarding detecting emotion
voice), infer the intentions of others on the in faces, tend to show a bias toward an-
basis of their postures and movements, gry and fearful facial emotion, and have
understand the mental states (wishes or difficulty in accurately labeling the facial
desires) of others (often referred to as the- emotions they detect. Increased sensitiv-
ory of mind), and communicatively sig- ity in reading facial emotion is consistent
nal to others one’s own emotional state with imaging studies that show increased
(e.g., by facial expression or tone of voice). blood oxygen level–dependent activity
Overlying these processes, social interac- in the primary visual area and fusiform
tion is shaped by the attachment system, gyrus in patients with BPD compared
which shapes affiliative behavior, bond- with HC subjects when processing emo-
ing, and the adaptation to separation (see tional social scenes (Herpertz et al. 2001;
Chapter 4, “Development, Attachment, Koenigsberg et al. 2009b). Hypersensitiv-
and Childhood Experiences”). ity to detecting emotions could lead pa-
Behaviorally, patients with BPD de- tients with BPD to overreact to low-in-
scribe their daily relationships as more tensity emotional states in others (i.e.,
disagreeable, angry, sad, ambivalent, and facial microexpressions that pass below
empty than do patients with other PDs or the radar of healthy individuals). This
no PD. One characteristic feature of the pattern, combined with a tendency to
interpersonal pattern of patients with overread anger and fear, could contrib-
BPD is a great emotional reactivity to in- ute to the interpersonal hyperreactivity
terpersonal events and a hypersensitivity of patients with BPD.
to interpersonal stressors (Gunderson A second factor that could seriously
and Lyons-Ruth 2008). This interpersonal disrupt the interpersonal interactions of
hypersensitivity could result in part from patients with BPD is their defective abil-
a tendency to read emotional expressions ity to accurately infer the intentions and
in other persons’ faces that are so subtle mental states of others. Patients with BPD
that they would go unnoticed by most in- often fail to appreciate the goals, subjec-
dividuals. The literature on reading facial tive experience, or perspective of another
emotion in BPD is mixed (Domes et al. person, or they emotionally over- or un-
2009), with some studies suggesting that derresonate with the experience of others.
patients with BPD have an increased sen- Such disturbances have been described as
sitivity to detecting emotions in faces, deficits in mentalizing, theory of mind,
and other studies suggesting that pa- or empathy—three somewhat overlap-
tients with BPD do not read facial emo- ping constructs, each incorporating sepa-
tion as accurately as HC subjects. Patients rable cognitive and affective components.
with BPD also have a greater sensitivity One approach to quantifying cognitive
to perceiving negative emotions and a and emotional empathy has relied on the
bias toward interpreting neutral faces as Interpersonal Reactivity Index (IRI; Da-
negative. There is also evidence that pa- vis 1980), a 28-item self-report instrument
tients with BPD are impaired in recogniz- with two cognitive empathy subscales
(Perspective Taking and Fantasy) and two ships, leading to alternations among
emotional empathy subscales (Empathic clinginess, aloofness, dependence, or
Concern and Personal Distress). Patients controllingness. Rejection sensitivity can
with BPD show deficits in cognitive em- be studied in the laboratory by means of
pathy, but the findings are mixed in terms a computerized task, Cyberball, a com-
of affective empathy. The discrepant puter game in which avatars represent-
findings among studies may be explained ing the subject and two other players
by the effect of the patient’s current emo- toss a ball back and forth. The actions of
tional state on his or her capacity for cog- the other “players” are actually controlled
nitive or affective empathy. In addition, by the experimenter. After three-way ball
patients with BPD have been shown to be tossing is enacted for a time, the other
alexithymic, and alexithymia could affect “players” abruptly stop tossing the ball
self-reports of emotional reactions to in- to the subject but continue tossing it back
terpersonal situations (New et al. 2012). and forth between themselves. This
One approach to bypassing the limita- change has been shown to consistently
tions of relying on retrospective self-re- create a feeling of rejection in healthy in-
port is to engage subjects in a laboratory dividuals. When engaged in Cyberball,
task in which they infer the feelings of in- in comparison with HC subjects, players
dividuals depicted in social photographs. with BPD more readily reported feeling
One study employing this methodology excluded, even when included. In addi-
found that patients with BPD were im- tion, following this social rejection expe-
paired in both cognitive and affective rience, subjects with BPD were more likely
empathy compared with HC subjects than healthy volunteers to display multi-
(Dziobek et al. 2011), whereas another ple emotional expressions simultaneously
study did not distinguish patients with on the face (Staebler et al. 2011). This sug-
BPD from HC subjects (New et al. 2012). gests that when under particular emo-
Imaging data in the study by Dziobek et tional stresses, patients with BPD may
al. (2011) revealed increased neural activ- send confusing or ambiguous facial emo-
ity in the right superior temporal sulcus tional signals to others (see Chapter 23,
and right insula in patients with BPD “Translational Research in Borderline
compared with healthy volunteers dur- Personality Disorder”).
ing the emotional empathy subtask and Impairments in the ability to main-
decreased activity in the left superior tain trust could also rapidly lead to a
temporal sulcus and superior temporal breakdown in interpersonal relation-
gyrus region in the patients with BPD ships. Trust may be studied in the labo-
during the cognitive empathy subtask. ratory by means of a multiround eco-
One criterion for BPD in DSM-IV nomic exchange game, the trust game,
(American Psychiatric Association 1994) in which one participant (the investor)
and DSM-5 is a pattern of desperate at- chooses how much money to invest with
tempts to avoid real or imagined aban- a trustee. The money is tripled, and the
donment. Ecological momentary assess- trustee then chooses how much of the
ment has demonstrated that states of current amount to return to the investor.
aversive tension in patients with BPD are The cycle repeats over multiple rounds.
likely to be preceded by feelings of being When patients with BPD played this game
rejected or being alone. A desperate pre- in the role of trustee interacting with
occupation with fear of rejection could healthy volunteer investors, trust rapidly
seriously distort interpersonal relation- broke down, as demonstrated by a re-
duction in the amount invested with a ing, social norm violation awareness
trustee with BPD versus a healthy vol- training, or desensitization to perceived
unteer trustee from early to late rounds rejection.
in the game (King-Casas et al. 2008). De-
tailed examination of the investment/
repayment behavior revealed that healthy
Pain Processing
trustees tended to “coax” the investor to Self-injurious behavior, including non-
invest following rounds of low invest- suicidal self-injury, is reported to occur in
ment by giving greater returns at those 70%–90% of patients with BPD (Reitz et
times, but trustees with BPD did not do al. 2012). Such behavior most often takes
this. Trustees with BPD also self-reported the form of skin cutting, but it can also in-
lower levels of trust in the investor than clude severe scratching, burning, punch-
did healthy trustees. fMRI data reveal ing, and head banging. Self-injurious be-
that during the time period in each round havior is often followed by a decrease in
when healthy trustees learned how much states of aversive tension in patients with
was invested with them, the anterior BPD and may represent an emotion regu-
insula activated in inverse proportion to latory strategy. Moreover, compared with
the amount invested, signaling a per- HC subjects, patients with BPD show de-
ceived feeling of unfairness or violation creased pain sensitivity, and this de-
of social norm. In contrast, trustees with creased sensitivity diminishes further un-
BPD showed a flat insula response, sug- der conditions of high stress.
gesting an anomalous neural response Several neuroimaging studies have
to interpersonal norm violation. Lacking examined the neural response to painful
such a natural neural mechanism to mon- stimuli in patients with BPD (see Chap-
itor interpersonal unfairness, the patient ter 23). When exposed to comparable
with BPD may resort to a defensive stance, subjective levels of thermal pain, pa-
becoming hypervigilant to being taken tients with BPD, relative to HC subjects,
advantage of, or even transiently para- showed increased activation of the dor-
noid. Disturbances in attachment/sepa- solateral prefrontal cortex and deactiva-
ration systems could also impair the qual- tion of the perigenual ACC and the right
ity of social interactions for the patient amygdala (Schmahl et al. 2006). The ACC
with BPD. is a component of the affective-motiva-
Because of the evidence of a multifac- tional pain pathway, and the dorsolateral
eted breakdown in social processes in prefrontal cortex has been implicated in
patients with BPD that could contribute pain control. During pain processing,
to interpersonal hypersensitivity, fur- differences between patients with BPD
ther work is needed to better delineate and HC subjects have been observed in
these disturbances and their neural cor- functional connectivity to nodes in the
relates. A better understanding of the so- default mode network, a network impli-
cial processing disturbances could help cated in internally preoccupied non-
shape treatment strategies to improve task-related processing and in self-refer-
the quality of relationships in the lives of ential thinking. Patients with BPD showed
patients with BPD. Understanding the less connectivity between the retrosple-
specific social process impairments could nial cortex and the posterior cingulate
enhance the development of such treat- cortex (PCC) and between the PCC and
ment approaches as mentalization-based the dorsolateral prefrontal cortex. In ad-
therapy, facial emotion–recognition train- dition, patients with BPD showed less of
a signal decrease compared with HC subsumed by an earlier, broader iteration of

jects in the posterior default mode net- the borderline personality syndrome—
work during pain processing (Kluetsch were reapportioned to establish a sepa-
et al. 2012). Moreover, this decreased at- rate STPD. Numerous studies have sub-
tenuation of default mode network sig- sequently validated the STPD construct
nal in response to pain was correlated as well as its relation to the schizophre-
with BPD symptom severity and disso- nia spectrum.
ciation. Taken together, these connectiv- Similar to other PDs, STPD has been
ity findings are consistent with a model demonstrated to be multifactorial, con-
in which patients with BPD are more sisting of three or four symptom do-
self-preoccupied during the experience mains with varying degrees of colinear-
of pain, experience pain as less aversive ity. Three-factor models of schizotypy
than HC subjects do, and do not engage consist of cognitive-perceptual, interper-
emotion regulatory systems to address sonal, and oddness (or disorganization) do-
the pain to the extent that HC subjects mains (Hummelen et al. 2012). Four-fac-
do. Finally, to determine whether a neu- tor models have also been described that
ral mechanism was activated in patients are similar to the three-factor models but
with BPD to permit painful stimuli to re- differ primarily on 1) whether paranoia/
duce negative emotional states, fMRI suspiciousness represents a separate do-
images were obtained as subjects were main or is a subfactor of cognitive-per-
shown emotionally negative pictures in ceptual disturbances and 2) whether so-
the context of painful or control thermal cial anxiety and social anhedonia are
stimuli. Thermal stimuli, both painful separate factors or belong to a single in-
and control, reduced amygdala and interpersonal domain. In a recent report,
sula activity in patients with BPD as well Hummelen et al. (2012) confirmed a three-
as HC subjects, suggesting that a nonspe- factor model but argued that two fac-
cific attentional mechanism decreases tors—cognitive-perceptual (referential
limbic activity in response to thermal thinking, magical thinking, and unusual
sensory stimuli (Niedtfeld et al. 2010). perceptual disturbances) and oddness
(odd thinking and speech, odd appear-
ance or behavior, and constricted af-
Schizotypal Personality fect)—are specific for STPD relative to
Disorder other PDs; the interpersonal phenomena
(social anhedonia, social anxiety, and
Schizotypal PD (STPD) is characterized certain manifestations of suspiciousness)
by disturbances in the realms of cogni- are considered secondary elements be-
tion and reality testing, affect regulation, cause they are significantly present in
and interpersonal function. other PDs. A question for further inves-
tigation is whether interpersonal symp-
Background toms are truly nonspecific or are in fact
qualitatively distinct STPD spectrum
and Factor Structure difficulties of social anhedonia, social
Characterization of the neurobiology of anxiety, and suspiciousness/paranoia
any psychiatric condition is dependent that are difficult to distinguish phenom-
on its taxometric validity. In DSM-III, enologically from similar symptoms of
schizotypal symptoms—originally sub- asociality associated with avoidant, nar-
cissistic, or antisocial PDs or high-func- relationship between childhood trauma

tioning autism spectrum conditions. and schizotypal personality traits. In a
study of participants with a family his-
tory of bipolar disorder, greater schizo-
Genetics
typal personality traits were associated
A number of genes associated with STPD, with the Val allele, specifically in those
schizotypy, and related schizophrenia with higher levels of self-reported child-
spectrum endophenotypes have been hood trauma (Roussos and Siever 2012).
identified (Roussos and Siever 2012). A Consistent with the importance of
number of studies indicate a role for the genes involved in the dopaminergic sys-
catechol O-methyltransferase gene, tem, a dopamine D3 receptor (D3R) poly-
COMT. The COMT enzyme plays an im- morphism has been implicated in STPD.
portant role in the catabolism of dopa- The Ser9Gly polymorphism is a common
mine and other catechols. A common al- variant of the D3R, which leads to signif-
lele of COMT is a valine substitution for icant functional differences of this recep-
methionine at position 158 (Val158Met). tor. Specifically, the Gly allele is associ-
Through at least two mechanisms, the ated with a more than fourfold increase
Val allele leads to lower synaptic dopa- in affinity for dopamine, along with an
mine levels, owing to its relatively greater increase in second messenger signaling.
enzymatic activity and higher levels of Psychophysiological tests of sensorimo-
expression compared with the Met al- tor gating have been used as quantitative
lele. Greater levels of schizotypy have endophenotypes of schizotypy and the
been observed in healthy young males schizophrenia spectrum and to identify
with the COMT Val allele. Interestingly, in gene-behavior relationships with greater
one study, there was no difference in the resolution. Examining the prepulse inhi-
frequency of the Val or Met COMT alleles bition (PPI) of the acoustic startle reflex
among STPD patients, PD patients with- (i.e., reduction of the reflexive motor re-
out STPD, and healthy controls, but there sponse to a loud noise due to a preceding
was a significant association between allow-intensity auditory stimulus), it was
lele status and tests of executive function determined that the Gly allele was asso-
and working memory—two neuropsy- ciated with poorer prepulse processing
chologically based endophenotypes of (Roussos and Siever 2012).
STPD/schizotypy (Minzenberg et al. A number of genes originally identi-
2006). As expected, being homozygous fied owing to a relationship with schizo-
for the Val allele was related to worse phrenia have, not surprisingly, been found
cognitive function. In relatives of patients to be related to schizotypal personality
with schizophrenia, the Val allele was traits and symptom dimensions, as well
associated with greater levels of self-reas associated endophenotypes. Neuregu-
ported social and physical anhedonia, lin 1 (NRG1), a member of the epidermal
which are two important symptom di- growth factor family involved in nervous
mensions of STPD; this association was system development, is a schizophrenia-
not observed in HC participants or in associated gene. A functional polymor-
relatives of patients with bipolar disorder. phism of NRG1 was shown to be associ-
The COMT Val158Met polymorphism ated with results on the Perceptual Aber-
was also shown to possibly moderate the ration Scale (PAS), a self-report measure
of a schizotypy symptom domain related evaluate cognitive or information pro-

to psychotic-like perceptual disturbances, cessing deficits. PPI of a startle response
in a large sample of adolescents (Lin et al. is found not only in patients with schizo-
2005). In a related manner, single-nucleo- phrenia but also in their first-degree rela-
tide polymorphisms of NRG1, in a popu- tives and, in some studies, in patients
lation of young healthy men, were shown with schizophrenia spectrum PDs. More-
to be associated with smooth eye pursuit over, anomalies in P50 auditory-evoked
movements, another STPD-related endo- potentials have been observed in patients
phenotype (Smyrnis et al. 2011). The dis- with schizophrenia and STPD (Siever
rupted in schizophrenia 1 gene, DISC1, and Davis 2004).
which is involved in neuronal develop- Disordered eye movements have been
ment and migration, has been shown to used to assess frontal cortical sensorim-
be related to the specific dimension of so- otor processes. A large body of evidence
cial anhedonia in a large human popula- suggests that smooth pursuit eye move-
tion. High-risk polymorphisms of proline ments, in particular, are impaired in pa-
dehydrogenase (PRODH), which have tients with STPD and in relatives of pa-
been implicated in schizophrenia, were tients with schizophrenia. Additionally,
shown to be related to a self-report mea- antisaccades—the voluntary movements
sure of schizotypy, as well as the STPD- of eyes in the opposite direction of a
salient indices PPI, working memory, and target stimulus—which involve frontal
trait-anxiety (Roussos and Siever 2012). mechanisms that inhibit prepotent re-
sponses, have also been described in pa-
tients with STPD, in high-schizotypy
Cognition healthy subjects, and in unaffected first-
Cognitive Impairment: degree relatives of patients with schizo-
phrenia (Siever and Davis 2004).
Memory/Processing The neural correlates of these cogni-
Deficits tive, psychophysiological, and sensorim-
Cognitive impairment, often associated otor abnormalities have been the focus of
with deficit symptoms, is characteristic of a number of studies. Tests of executive
patients with STPD. The cognitive do- function, smooth pursuit eye movements,
mains that have been reported to be im- and working memory are more corre-
paired in patients with STPD, but not lated with volume reductions in the fron-
in comparable comparison groups with tal lobe, whereas verbal learning may be
other PDs, include auditory and visual more related to temporal lobe abnormali-
working memory, attention, verbal learn- ties (Hazlett et al. 2012a). These structural
ing, and executive function (Mitropoulou findings are also accompanied by altera-
et al. 2002). These deficits are less severe tions in brain function during cognitive
and more circumscribed and selective in tasks as well as under “baseline” steady-
patients with STPD (approximately 1 stan- state conditions. A particular finding of
dard deviation below the mean of HC interest in STPD is that frontal lobe–based
subjects) than in patients with schizo- deficits, specifically those of the dorsolat-
phrenia (2 standard deviations below the eral prefrontal cortex, may lead to com-
mean of HC subjects). In addition to for- pensatory activity in other frontal regions,
mal neuropsychological testing, psycho- such as the medial frontal and anterior
physiological paradigms can be used to frontal pole (Hazlett et al. 2012a).
Structural connectivity between brain measures of dopamine metabolism, in-

regions may also be compromised. Ab- cluding plasma and cerebrospinal fluid
normalities in white matter tracts de- homovanillic acid, suggest increases in
tected by DTI have been found, particu- patients with STPD that are accounted
larly in regions connecting the temporal for by the psychotic-like symptoms rather
and frontal lobes, such as the superior lon- than the other symptoms of this disor-
gitudinal fasciculus (Hazlett et al. 2012a). der, as shown in covariant analyses. In-
Preliminary, unpublished findings from deed, for both of these measures, there
our group, using resting-state functional are significant correlations of psychotic-
connectivity MRI, indicate that differenti- like symptoms with these metabolite
ation between cognitive control networks measures (Siever and Davis 2004).
and social-emotional networks (i.e., the Patients with STPD also show in-
default mode network) is attenuated in creased release of dopamine in striatal
patients with STPD compared with HC structures, as indexed by amphetamine-
subjects and psychiatric controls. We hy- induced displacement of [123I]iodobenza-
pothesize that impaired differentiation of mide (IZBM) binding (Abi-Dargham et
cognitive control networks from the deal. 2004) as well as in raclopride displace-
fault mode network may limit the ability ment studies (Siever et al., unpublished
of the cognitive control networks to opti- data). Interestingly, although reductions
mally couple with other attentional net- in dopaminergic metabolites have been
works (e.g., dorsal attention network), associated with negative or deficit-like
possibly contributing to cognitive deficits symptoms, particularly in the relatives of
in patients with STPD (Rosell et al. 2013). patients with schizophrenia, evidence
suggests that there is a bivariate relation-
Cognitive-Perceptual ship of dopamine with psychotic-like
and deficit-like symptoms, such that in-
Disturbances
creased activity is related to greater psy-
In addition to having deficits in cogni- chotic-like activity, whereas decreased
tion, patients with STPD also have com- dopaminergic activity is associated with
promised reality testing, although not to increased deficit-like symptoms (Roussos
the point of overt psychosis. Thus, peo- and Siever 2012).
ple with STPD may exhibit signs of para- In studies of dopamine release using
noia, sometimes to the point of referen- IBZM, however, people with STPD do
tial ideas, such as believing people are not show the increased release associated
staring at them or have a malevolent in- with actively psychotic schizophrenia pa-
tent toward them. They often experience tients and are more similar to HC subjects
cognitive-perceptual distortions, such as and schizophrenia patients in remission
hearing their mother’s voice whispering (Abi-Dargham et al. 2004). Thus, to the
their name, but they do not experience extent that patients with STPD are better
command or elaborate auditory halluci- buffered with respect to subcortical do-
nations. Just as in patients with chronic paminergic activity, they may be pro-
schizophrenia, patients with STPD may tected against the severe psychosis of
respond to the neuroleptics (dopamine schizophrenia. The possibility that certain
antagonists) with reductions in psychotic- differences between STPD and schizo-
like symptoms, suggesting that dopa- phrenia reflect factors that limit the
mine plays a role in the formation of these transition to overt psychosis is further
symptoms (Ripoll et al. 2011). Indeed, supported by studies that have shown
metabolic activity in the striatum (namely, performance was associated with greater
ventral putamen) is greater in STPD pa- frontal cortical D1 receptor availability,
tients relative to control subjects, whereas specifically in patients with STPD but
in schizophrenia, striatal metabolic ac- not in controls (Abi-Dargham et al. 2002).
tivity is lower compared with controls This finding may reflect a compensatory,
(Shihabuddin et al. 2001). Newer studies albeit insufficient, upregulation of the
suggest that larger ventral striatal vol- D1 receptor in response to putative low
umes in patients with STPD are associ- frontocortical dopamine. Preliminary
ated with less severe symptoms of paranoia data obtained by our group from a pilot
(Chemerinski et al. 2013). trial of dihydrexidine, a more specific D1
agonist, showed promising improve-
Treatments in the ments in working memory performance
in individuals with STPD (Rosell et al.
Cognitive Domain 2013).
The cognitive deficits of the schizophre- Other agents demonstrated to improve
nia spectrum have been studied in rela- cognitive performance are D2-adrenergic
tion to dopaminergic agents, D2-adren- agonists, such as guanfacine and cloni-
ergic agonists, and cholinergic agents. dine. The D 2 -adrenergic receptor has
Observations that stimulants such as been shown to modulate working mem-
amphetamine can cause improvement ory, and D2-adrenergic agonists improve
in some individuals with schizophrenia working memory in aging primates. The
(Barch and Carter 2005) or with STPD D 2 -adrenergic agonist guanfacine im-
(Siegel et al. 1996) have led to the inves- proves cognitive function in attention-
tigation of more selective dopaminergic deficit/hyperactivity disorder and is
agents. The mixed dopamine D1/D2 ago- now an approved medication for that in-
nist pergolide, administered over 6 weeks dication. In our laboratory we have shown
to subjects with STPD, resulted in im- that guanfacine improved working mem-
provements in working memory, verbal ory in auditory as well as visual domains
learning, and executive function (McClure in persons with STPD (McClure et al.
et al. 2010). These findings are consistent 2007).
with several decades of preclinical inves- The psychotic-like symptoms in STPD
tigations suggesting that D1 receptors are hypothesized to be related to dopa-
play a critical role in modulation of work- mine hyperfunction in the subcortex, al-
ing memory and that optimal concentra- though such activities are considerably
tions of dopamine at D1 receptors can lower than those observed in chronic
improve working memory performance schizophrenia. Several studies have dem-
in animals with deficits (Williams and onstrated that the symptoms of STPD re-
Castner 2006). According to this hypoth- spond to neuroleptic medication (Ripoll
esis, people with STPD might respond to et al. 2011). In a randomized controlled
D1 agonists with improvement in working study from our laboratory, patients with
memory owing to putative low dopami- STPD were shown to have improvement
nergic activity in the prefrontal cortex of in the psychotic-like symptoms, particu-
people with this disorder. Consistent larly with risperidone (Koenigsberg et al.
with this hypothesis, a PET study with the 2003). However, in the same study in an
D1 receptor radioligand [11C]NNC 112 extended sample, there was no evidence
suggested that poorer working memory of cognitive improvement with risperi-
done (McClure et al. 2009), although it been no clear differences in the underly-
might be hypothesized that 5-HT2A an- ing pathophysiology of the comorbid
tagonism may make more dopamine and noncomorbid conditions.
available in the prefrontal cortex (Ichi-
kawa et al. 2001). Anxiety
Anxiety, particularly social anxiety, is a
Affect Regulation common concomitant of STPD. Although
People with STPD are characterized by anxiety occurring in social contexts is
their bland, constricted affect with mini- common in other PDs, such as avoidant
mal reactivity to the environment, in PD, there are important qualitative dis-
contrast to people with many of the tinctions from the anxiety that occurs in
other PDs that are characterized by ex- patients with STPD. For example, social
cessive reactivity to the environment. anxiety in STPD tends not to attenuate
There may be a continuum along this with familiarity with other persons or
variable in which individuals with greater with greater experience within a partic-
psychotic-like symptoms have more re- ular social context. Moreover, social anx-
activity to the environment and those with iety in STPD tends to be more global and
profound deficits and negative symp- concrete and is described by patients in
toms may be less affectively reactive, terms such as “a negative energy in the
possibly on the basis of hypofunction of room” or “feeling watched by every-
the dopamine system and related subcor- one.” In other PDs with social anxiety,
tical systems. There is a trend in imaging there are more specific and characteristic
studies for alterations in dopamine re- feared interpersonal situations or associ-
ceptors to be associated with anhedonia, ated maladaptive beliefs (e.g., “If I don’t
but this could not be confirmed after say something intelligent, everyone will
tests for multiple comparisons. Presum- think I’m dumb”).
ably, the diminished affectivity in STPD Little has been described in terms of
is part of the constellation of social and the neural underpinnings of social anxi-
cognitive deficits attributable to faulty ety in STPD and how it may differ from
structure and function of the cortex and those of social phobia and avoidant PDs.
reduced dopaminergic tone. A recent study, however, demonstrated
a correlation between impaired facial
affect recognition and schizotypal spec-
Impulse/Action Patterns trum social anxiety in healthy individu-
Individuals with STPD tend not to be als assessed with the Schizotypal Person-
particularly impulsive unless driven by ality Questionnaire (Abbott and Green
a fixed psychotic-like belief. However, 2013). Since the dopaminergic system
individuals with this disorder may also (Delaveau et al. 2005) and the COMT
have comorbid borderline or antisocial Val158Met allele (Soeiro-de-Souza et al.
PD, in which case the neurobiology of 2012) have more recently been impli-
their impulsive aggression would be cor- cated in facial affect recognition, an im-
respondent to that of the impulsive ag- portant area of focus for future studies
gressive PDs. To the extent that the ag- would be determining their role in the
gression in STPD with comorbid impul- social anxiety and other interpersonal
sive PDs has been studied, there have deficits of STPD.
Interpersonal Function eral population survey (Grant et al. 2004).

ASPD is more common in men, and men
People with STPD are marked by detach- are more likely than women to have a
ment, aloofness, and social discomfort. persistent course of antisocial behavior.
These traits are believed to be related to DSM-5 also includes a trait-specific
the underlying cognitive vulnerabilities classification system in Section III. In
associated with the disorder. For exam- this section, the diagnosis of ASPD is
ple, in a study of volunteers selected on characterized by impairments in person-
the basis of smooth pursuit eye move- ality (self and interpersonal) functioning
ment, an established biomarker for schizo- and the presence of pathological per-
phrenia that presumably reflects cortical sonality traits, including disinhibition
processing and efficiency, those selected (characterized by risk taking, impulsiv-
by virtue of their impaired smooth pur- ity, and irresponsibility) and antagonism
suit eye movements tended to have (characterized by manipulativeness, cal-
fewer friends, had more trouble or dis- lousness, deceitfulness, and hostility).
comfort in dating, and were uncomfort- The trait focus will permit attention to
able socially. These characteristics were the heterogeneity within the diagnosis
more clearly associated with inaccuracy of ASPD. One particularly notable area
of the smooth pursuit system than the of heterogeneity within the ASPD diag-
psychotic-like symptoms of STPD (Siever nosis is that some individuals show pre-
and Davis 2004). These data raise the dominantly impulsive aggression and
possibility that impaired cortical infor- emotional reactivity, whereas others ap-
mation processing can impede the de- pear to represent a distinct cohort in which
velopment of accurate, empathic repre- comorbid psychopathy is more promi-
sentations of others and can interfere nent. Psychopathy is a construct charac-
with the interpretation of interpersonal terized by pronounced problems in emo-
cues, so that interpersonal interactions tional processing (reduced guilt, empathy,
become problematic. Although there and attachment to significant others; cal-
have been few studies explicitly evaluat- lous and unemotional traits). Although
ing these types of mechanisms in pa- individuals with psychopathy are at in-
tients with STPD, one study showed that creased risk for displaying antisocial be-
patients with STPD were impaired on a havior, psychopathy is a distinct concept.
theory of mind task (Ripoll et al. 2013). Whereas most of those who are charac-
terized as psychopathic will also meet
criteria for ASPD, only about 10% of
Antisocial Personality those with ASPD meet criteria for psy-
Disorder chopathy (Hare et al. 2000).
Another essential difference between
In DSM-5 Section II, “Diagnostic Criteria ASPD and psychopathy is the type of ag-
and Codes,” antisocial personality disor- gression characteristic of each condition.
der (ASPD) is characterized as a perva- Individuals with psychopathy engage in
sive pattern of disregard for and viola- aggressive behavior that is controlled/
tion of the rights of others that has been planned and that serves an instrumen-
occurring since age 15 years. The preva- tal, goal-directed end (e.g., a planned
lence of ASPD has been estimated to be robbery to obtain the victim’s money);
3.6% in a nationally representative gen- this behavior is often called instrumental
aggression. Individuals with ASPD with In a study of inhibitory control during

predominantly emotional and behav- an emotional-linguistic go/no-go task,
ioral disinhibition engage in aggressive alterations were found that were spe-
behavior that is more retaliatory/impul- cific to psychopathy (Verona et al. 2012).
sive (e.g., road rage) and is associated Event-related brain potentials were stud-
with negative affect (i.e., hostility or an- ied during this emotional go/no-go task
ger); this behavior is often called impul- in offenders with psychopathy, offenders
sive or reactive aggression. Impulsive with ASPD, and control offenders. In the
aggression reflects a lack of impulse con- control group, inhibitory control de-
trol (Dolan and Park 2002). mands modulated frontal P3 amplitude
to negative emotional words, indicating
Cognitive-Behavioral in response to appropriate prioritization
of inhibition over emotional process-
Processing ing. In contrast, the psychopathic group
Previous research investigating whether showed blunted processing of negative
subjects with ASPD have impaired cogni- emotional words regardless of inhibitory
tive functioning has yielded inconsistent control demands. The ASPD group dem-
findings (Crowell et al. 2003; Morgan and onstrated enhanced processing of nega-
Lilienfeld 2000). Although some authors tive emotion words in both go and no-go
have found a broad range of deficits in trials, suggesting a failure to modulate
patients with ASPD with respect to their negative emotional processing when in-
planning ability, mental flexibility, re- hibitory control is required. This group
sponse inhibition, and visual memory, difference in inhibitory control during an
others have found only circumscribed emotion provocation task suggests an op-
deficits in processing speed or response posite effect of negative emotional stimuli
inhibition. A large meta-analysis of 39 in ASPD without psychopathy (enhanced
studies found that although antisocial be- response interfering with inhibitory con-
haviors and psychopathic features were as- trol) than is observed with psychopathy
sociated with executive dysfunction, ex- (decreased response to negative emo-
ecutive function deficits among subjects tional stimuli regardless of the demand
with ASPD were statistically significant for inhibitory control).
but of such a minor degree as to be clini- Social information processing was ex-
cally imperceptible, and others could amined through a facial affect recogni-
find no differences in executive function tion task in criminals without psychopa-
between ASPD and healthy or psychiat- thy, criminals with psychopathy, and HC
ric control subjects (Morgan and Lilien- subjects (Pham and Philippot 2010). Both
feld 2000). It should be noted that most criminal groups were less accurate than
authors did not define the rates of psy- controls in decoding facial expression of
chopathy among the ASPD subjects stud- emotion, although this effect was ac-
ied. Therefore, it is impossible to tease counted for by differences in participants’
apart the respective contributions of psy- level of education. Criminals with and
chopathy and ASPD to the deficits re- without psychopathy did not differ in fa-
ported. One additional study found that cial affect recognition accuracy. Similarly,
among offenders with ASPD, there was a meta-analysis showed substantial defi-
no significant association between execu- cits in fear recognition in individuals
tive function impairment and scores on a with ASPD, and this was consistent re-
measure of psychopathy (Dolan 2012). gardless of the absence or presence of psy-
chopathy (Marsh and Blair 2008). Taken related to amygdala and OFC dysfunc-
together, these data suggest that a deficit tion (Blair 2010).
in facial affect recognition is broadly pres- Because of the hypothesized dysfunc-
ent across individuals with ASPD, and tion in the amygdala and OFC, individ-
not only in those with comorbid psy- uals with psychopathic traits have diffi-
chopathy. culty socializing (related to dysfunction
in stimulus reinforcement learning) and
make poor decisions (because of the OFC
Neuroimaging dysfunction). According to this model,
Impulsive or reactive aggression is com- individuals with psychopathic traits
mon in ASPD, whereas instrumental ag- should show reduced amygdala and
gression is characteristic of psychopathy OFC responses to emotional provoca-
(Blair 2007; Dolan 2010; Ostrov and tion and during emotion-based deci-
Houston 2008). Preclinical studies point sion-making tasks (Blair 2007, 2010).
to a neural circuitry underlying these Although the data strongly support a
forms of aggression. Reactive aggres- disruption of amygdala and prefrontal
sion is part of a gradated response to cortex functioning—specifically, in the
threat: distant threats induce freezing, OFC, ACG, and dorsolateral prefrontal
closer threats induce flight, and very cortex—in individuals with psychopathic
close threats in which escape is impossi- traits and/or antisocial behavior, the data
ble induce impulsive aggression. This for ASPD itself are less conclusive (Nor-
progressive response to threat is medi- dstrom et al. 2011; Yang et al. 2009). This
ated by a neural system that involves the uncertainty may reflect the heterogene-
amygdala, the hypothalamus, and the ity of the ASPD diagnosis itself and of
periaqueductal gray. It is believed that the samples and control groups analyzed
this system is regulated by medial, or- (e.g., different demographic groups, var-
bital, and inferior frontal cortices (Blair ied psychiatric comorbidities). The ma-
2007, 2010). According to this threat sys- jority of studies and meta-analyses focus
tem, those individuals at increased risk of on broadly defined antisocial constructs,
showing impulsive aggression should which includes some individuals with
show heightened amygdala responses to comorbid psychopathy and others with-
emotionally provocative stimuli and re- out. We have shown that psychopathy
duced frontal emotion regulatory activity and ASPD differ markedly in behavioral
(Blair 2010). Instrumental aggression, like and neurobiological measures; the inclu-
any other form of motor response, is hy- sion of a heterogeneous group of indi-
pothesized to be mediated by the motor viduals with ASPD makes these studies
cortex and the caudate. For most individ- hard to interpret. There is a paucity of
uals, the costs of instrumental aggression data about ASPD specifically, and even
(e.g., harm to the victim or oneself, risk of fewer studies have assessed the effect of
punishment) outweigh the benefits, and comorbid psychopathy on neuroimag-
prosocial behaviors are chosen instead of ing findings in ASPD subjects (Boccardi
instrumental aggression. However, it is et al. 2010; Gregory et al. 2012; Tiihonen
believed that individuals with psychopa- et al. 2008).
thy engage in instrumental aggression Structural imaging data show reduc-
because of an impaired representation of tions in volume of the dorsolateral, me-
the costs of the behavior, which may be dial frontal, and orbitofrontal cortices in
subjects with ASPD. The reduced pre- and learning. The first functional neuro-
frontal volumes in patients with ASPD imaging study involving ASPD showed
are present even after controlling for the that compared with HC subjects, subjects
effects of substance use (Dolan 2010; with BPD or ASPD activated different
Raine and Lencz 2000; Tiihonen et al. neural networks during response inhibi-
2008). Raine et al. (2010) observed that in- tion in a go/no-go task (Völlm et al. 2004).
dividuals with cavum septum pellu- Although HC subjects mainly activated
cidum, a marker of limbic neural malde- right dorsolateral and left orbitofrontal
velopment, had significantly higher cortex during response inhibition, pa-
levels of antisocial personality, psychop- tients with BPD and ASPD showed a more
athy, arrests, and convictions compared bilateral and extended pattern of activa-
with controls, even after controlling for tion across the medial, superior, and infe-
the effects of potential confounders, in- rior frontal gyri extending to the ACG
cluding prior trauma exposure, head in- (Völlm et al. 2004). At least some of the
jury, demographic factors, or comorbid neural abnormalities found in ASPD sub-
psychiatric conditions. Most studies have jects may not be specific to this disorder
examined ASPD without controlling for but rather may be associated with aggres-
the presence of psychopathy. One study sive traits that correlate with a tendency
did examine psychopathy separately to violent behavior.
from ASPD, showing smaller gray matter
volume in the anterior frontal pole (BA
10) in patients with ASPD with psychop-
Genetic Vulnerability
athy than in patients with ASPD without Family, twin, and adoption studies sug-
psychopathy or in HC subjects (Gregory gest that antisocial spectrum disorders
et al. 2012). This is particularly interest- and psychopathy are heritable, account-
ing because BA 10 has been implicated in ing for about half of the variance in anti-
the cognitive processes underlying eval- social behavior and even a greater per-
uation of risk taking. centage in individuals with callous/
Studies have shown that in addition unemotional traits. A twin study of the
to having frontal lobe volume reduction, DSM-IV criteria for ASPD provided fur-
ASPD subjects have smaller temporal ther support that the phenotypic struc-
lobes, smaller whole brain volumes, larger ture of ASPD results largely from ge-
putamen volumes, larger occipital and netic and not from environmental
parietal lobes, larger cerebellum vol- influences. However, it did not reflect a
umes, and decreased volumes in specific single dimension of liability but rather
areas of the cingulate cortex, insula, and showed two dimensions of genetic risk
postcentral gyri (Tiihonen et al. 2008). reflecting aggressive-disregard and dis-
Using DTI to examine white matter tracts, inhibition (Kendler et al. 2012).
Raine and Lencz (2003) found that com- In the last decade, considerable efforts
pared with HC subjects, psychopathic have focused on identifying specific ge-
antisocial subjects had a longer, thinner netic factors involved in the development
corpus callosum with overall increased of aggressive behavior. However, despite
volume. great advances, the field of behavioral ge-
Most of the few functional neuroimag- netics has yet to elucidate specific genetic
ing studies with subjects diagnosed with pathways that lead to ASPD and psy-
ASPD suggest a dysfunction in brain re- chopathy, a situation similar to that seen
gions involved in emotional processing in other psychiatric disorders (Gunter et
al. 2010). Association studies on single D2 and D4 (DRD2 and DRD4), serotonin
candidate genes have not yielded any loci receptors 5-HT1B and 5-HT2A (5HTR1B
with a major effect size, although some and 5HTR2A), the serotonin transporter
candidate gene association studies have (SLC6A4), and dopamine transporter
been replicated and are noted in the fol- gene (SLC6A3). Other targets include
lowing paragraphs. Future directions in androgen receptors, based on the gender
the study of the genetics of ASPD and differences in frequencies of antisocial
psychopathy will need to take into ac- spectrum disorders, and novel sites such
count gene-environment interactions, ex- as SNAP25, which was identified as a re-
amine the genome more broadly, and ex- gion of interest in genome-wide studies
amine the role of epigenetics. One of the (Gunter et al. 2010). Currently, the stron-
challenges presented by the existing re- gest evidence available points to MAOA,
search is the heterogeneity of the phe- TPH2, and the serotonin transporter gene,
notypes analyzed in different studies, SLC6A4, in antisocial spectrum disorders
which include individuals with ASPD (Gunter et al. 2010).
with or without psychopathy; individu- Other interesting avenues of research
als with psychopathy with or without include analysis of gene expression and
ASPD; individuals with antisocial behav- epigenetic modification of gene expres-
ior, conduct disorder, oppositional defi- sion via methylation and histone modi-
ant disorder, or disruptive behavior dis- fication, but data on the antisocial spec-
order; criminals; violent offenders; or trum are still very scarce (Gunter et al.
aggressive individuals. Only a handful of 2010). In summary, there is compelling
studies have focused on ASPD specifi- evidence that genes involved in the sero-
cally (Gunter et al. 2010). tonergic system are implicated in impul-
Several genome-wide linkage and as- sive aggression.
sociation studies have suggested possible
genomic locations in a number of chro-
mosomes for antisocial spectrum disor-
Future Directions
ders, but the results must be interpreted The population diagnosed with ASPD is
with caution because very few findings heterogeneous, limiting neurobiological
reach genome-wide significance, and even research efforts. However, considerable
fewer have been replicated (Gunter et al. progress has been made in the under-
2010). These studies have also focused standing of impulsive aggression, a core
on diverse phenotypes for aggression dimension of antisocial spectrum disor-
(Gunter et al. 2010). However, a large ge- ders and psychopathy, including the roles
nome-wide association study examining of the prefrontal cortex, the amygdala, and
ASPD specifically found no single hit im- neurocognitive deficits. Neural circuitry
plicating a gene or a chromosome region underlying ASPD suggests both smaller
(Tielbeek et al. 2012). gray matter volume in areas of the pre-
The most widely studied candidate frontal cortex and disruption of the circuit
genes in ASPD have been those related including the prefrontal cortex and amyg-
to serotonergic and dopaminergic sys- dala. This finding is not specific to ASPD
tems, including catechol O-methyltrans- and in fact is quite similar to that found in
ferase (COMT), monoamine oxidase A BPD. However, one rather specific find-
(MAOA), dopamine E-hydroxylase ing in psychopathy per se is the smaller
(DBH), tryptophan hydroxylase 1 and 2 volume in the anterior frontal pole, a brain
(TPH1 and TPH2), dopamine receptors region specifically implicated in the cog-
nitive processes underlying evaluation of order (social phobia), and there is high
risk taking. The strongest genetic evi- comorbidity for the two disorders. The
dence points to the MAO A, TH-2, and primary distinction in defining criteria
5-HTT genes, and promising new ap- for the two disorders is the centrality of
proaches include genome-wide analyses, anxiety. Fear of social situations and the
epigenetics, gene expression, and neuro- occurrence of anxiety in such settings is a
imaging genetics. sine qua non for social anxiety disorder,
Using an interdisciplinary research whereas it is possible to meet criteria for
team and a systems approach to the biol- AVPD by avoiding occupational and in-
ogy of complex illnesses such as antiso- terpersonal situations, being interperson-
cial spectrum disorders and psychopathy ally restrained, and feeling inadequate
may help to shed light on the interplay without necessarily experiencing anxiety.
among genetic factors, neural networks, Nevertheless, it is unclear whether a sub-
and behavior (Gunter et al. 2010). stantial portion of patients with AVPD do
or do not experience anxiety in social set-
tings. At present, there is controversy
Avoidant Personality about whether AVPD and social anxiety
disorder are distinct disorders or fall on a
Disorder continuum. Both disorders respond to
similar psychotherapeutic and pharma-
Avoidant PD (AVPD) is a prevalent dis- cotherapeutic interventions. Further
order, occurring in 1%–2% of the popu- study of their neurobiological features
lation. The defining features of AVPD may help to clarify the relationship be-
are social inhibition, feelings of inade- tween these disorders. Several studies of
quacy, and hypersensitivity to negative social anxiety disorder have been pub-
evaluation, which are associated with lished, but far less research has been con-
avoiding occupational and interpersonal ducted on the neurobiological correlates
situations because of fears of being criti- of AVPD. We review this limited litera-
cized, shamed, or disapproved of and ture here.
feeling socially inept and undesirable. One factor that could contribute to
AVPD can have serious functional con- hypersensitivity to negative evaluation
sequences, with limitations in occupa- in AVPD would be a heightened sensi-
tional success because of a need to choose tivity to detecting negative facial expres-
highly circumscribed interpersonal set- sions in others. In one study, patients
tings and an inhibition in expressing with AVPD and HC subjects were shown
ideas, opinions, and suggestions second- a series of emotional faces morphed by
ary to fears of being criticized. Similarly, computer to generate 39 steps of grada-
the individual with AVPD has great dif- tion from neutral to full emotional ex-
ficulties engaging in intimate interper- pression (Rosenthal et al. 2011). Subjects
sonal relationships. The functional im- were shown the graduated facial expres-
pairment of individuals with AVPD can sions in sequence, beginning with the
be substantial and is greater than that of neutral expression and leading up to the
obsessive-compulsive PD, but impair- full emotional face. Trials were pre-
ment is more severe in BPD and STPD sented for six emotions: anger, fear, sad-
(Skodol et al. 2002). ness, surprise, happiness, and disgust.
The criteria for AVPD overlap consid- Subjects were asked to specify the facial
erably with those for social anxiety dis- emotion at the earliest point when they
could identify it. Subjects with AVPD impaired ability to behaviorally habitu-
were more likely than controls to make ate to aversive social scenes. Patients
errors in identifying fearful faces but with AVPD and HC subjects were pre-
were equally accurate at identifying the sented with novel and repeat viewings
other emotions. They did not differ from of negative and neutral social pictures as
controls in speed with which emotions fMRI images were obtained, and sub-
were correctly identified. Interestingly, jects were asked to rate their emotional
subjects with AVPD were not more sen- reactions to the pictures. Preliminary
sitive to identifying anger or disgust, fa- analysis showed that the patients with
cial expressions that could signal social AVPD did not demonstrate behavioral
disapproval. habituation to the negative pictures as
Psychophysiological measures pro- the HC subjects did. In addition, the pa-
vide a means of assessing emotional re- tients did not increase insula-amygdala
activity to stimuli, independent of self- connectivity as the HC subjects did when
report. The magnitude of the eye blink viewing pictures for the second time
response to a white noise burst corre- (Koenigsberg et al. 2013). These findings
lates with perceived valence (positive suggest that an inability to adequately
vs. negative) of the stimulus, whereas engage behavioral habituation processes
skin conductance response and heart rate associated with altered neural network
correlate with arousal. These parameters function may contribute to the difficulty
were measured in a sample of female pa- that patients with AVPD have in adapt-
tients with AVPD and BPD and in HC ing to social contexts.
subjects while they viewed negative,
neutral, and positive emotional pictures
(Herpertz et al. 2000). Subjects with Conclusion
AVPD showed higher baseline startle re-
sponse magnitude relative to the other The development of new technologies in
groups; however, they did not differ neuroimaging and molecular genetics
from the other groups in any of the phys- and of specific pharmacodynamic probes
iological responses to viewing emotional has led to exponential growth in re-
pictures. This finding suggests that pa- search in the neurobiology of the PDs
tients with AVPD have an increased con- over the last three decades. Borderline,
textual fear level and wariness, but it schizotypal, and antisocial PDs have
does not support that they have in- been the most extensively studied. Much
creased reactivity to specific emotional work remains to be done to examine the
stimuli. neurobiological correlates of the other
Habituation to aversive emotional PDs. In addition, few studies have ap-
stimuli (the decrease in negative replied the same research paradigms to
sponse upon exposure to a repetition of several PDs within the same study, which
the stimulus) is a highly adaptive mech- would permit distinguishing between
anism in healthy individuals, which features shared among several PDs and
moderates the negative reaction to dis- those unique to a specific disorder. Some
turbing stimuli. Because patients with neurobiological features cut across sev-
AVPD have difficulty accommodating to eral PD diagnoses and may be better un-
interpersonal situations, even over time derstood as correlates of personality trait
or with repeated exposure, it could be disturbances, such as those proposed in
hypothesized that they would have an Section III of DSM-5. Much remains to
be learned about the relationship be- Brambilla P, Soloff PH, Sala M, et al: Anatom-
tween the neurobiological features of the ical MRI study of borderline personality
disorder patients. Psychiatry Res 131:125–
PDs and their relationship to gene-envi-
133, 2004
ronment interaction. Finally, another im- Chemerinski E, Byne W, Kolaitis JC, et al:
portant area for further research is the Larger putamen size in antipsychotic-
developmental trajectory of the biologi- naïve individuals with schizotypal per-
cal features of PDs. sonality disorder. Schizophr Res 143:158–
164, 2013
Cherek DR, Moeller FG, Dougherty DM, et
al: Studies of violent and nonviolent male
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CHAPTER 6
Prevalence,
Sociodemographics,
and Functional Impairment
From clinical work therapists and specific sociodemographic features

get an impression of which personality may increase the likelihood that a partic-
disorders (PDs) are more common and ular person will seek treatment. These
which are rarer. However, people with complexities mean that only population
some types of PDs may be more likely to (epidemiological) studies can demon-
seek treatment and obtain treatment com- strate the “true” relationship between
pared with people with other types of PDs and socioeconomic and sociodemo-
PDs. Consequently, to find out how prev- graphic variables, or any other variables
alent different PDs are in the general pop- such as traumas, disastrous events, up-
ulation, one needs data about representa- bringing, or partner relationships.
tive samples of the general population.
Epidemiological research provides ex-
actly that type of information. Prevalence
Clinical work also gives therapists
ideas about relationships between socio- A number of studies have been per-
economic and sociodemographic factors formed to estimate the prevalence of PDs
and PDs. However, in clinical settings, in samples more or less representative of
therapists meet only those from an unfa- the general population. Table 6–1 pres-
vorable environment who have devel- ents the results of these studies. Many
oped a PD. Clinicians do not meet those samples were relatively small. One study
from an unfavorable environment who consisted of control groups in family stud-
have not developed a disorder. Further- ies (Maier et al. 1992), one was a study of
more, the combination of a specific PD relatives of patients with mood disorders
109
TABLE 6–1. Prevalence of personality disorders in different epidemiological

studies
Zimmerman
and Coryell Maier et al. Moldin et Klein et Lenzenweger Torgersen Samuels
PD 1989 1992 al. 1994 al. 1995 et al. 1997 et al. 2001 et al. 2002
Number 797 452 303 229 258 2000 742

System DSM-III DSM-III-R DSM-III-R DSM-III-R DSM-III-R DSM-III-R DSM-IV
Method SIDP SCID-II PDE PDE PDE SIDP-R IPDE
Place Iowa Mainz, New York New York New York Oslo, Baltimore,
Germany Norway Maryland
PPD 0.9 1.8 0.0 1.8 0.4 2.2 0.7
SPD 0.9 0.4 0.0 0.9 0.4 1.6 0.7
STPD 2.9 0.4 0.7 0.0 0.9 0.6 1.8
ASPD 3.3 0.2 2.6 2.6 0.8 0.6 4.5
BPD 1.7 1.1 2.0 1.8 0.0 0.7 1.2
HPD 3.0 1.3 0.3 1.8 1.9 1.9 0.4
NPD 0.0 0.0 0.0 4.4 1.2 0.8 0.1
AvPD 1.3 1.1 0.7 5.7 0.4 5.0 1.4
DPD 1.8 1.6 1.0 0.4 0.4 1.5 0.3
OCPD 2.0 2.2 0.7 2.6 0.0 1.9 1.2
PAPD 3.3 1.8 1.7 1.8 0.0 1.6
SDPD 0.0 0.8
SAPD 0.0 0.2
DEPD
Cl A 3.9 3.0
Cl B 3.0 5.8
Cl C 9.2 2.7
Total PD 14.3 10.0 7.3 14.8 3.9 13.1 10.0
and schizophrenia (Zimmerman and Co- 1992; Moldin et al. 1994; Samuels et al.
ryell 1989), and another was a study of 2002; Torgersen et al. 2001). Semistruc-
subjects with nonspecific chronic back tured or structured interviews were used
pain (Gerhardt et al. 2011). One con- in most studies, except that of Lindal and
sisted of young participants (Johnson et Stefansson (2009), who used a question-
al. 2008), and another focused on a sam- naire, the DSM-IV and ICD-10 Personal-
ple in which half the subjects were ity Questionnaire (DIP-Q). One study
young children of the other half (Barnow (Zimmerman and Coryell 1989) was
et al. 2010). Many studies are from nearly based on DSM-III (American Psychiatric
the same place: New York City or upstate Association 1980), others (Klein et al.
New York (Johnson et al. 2008; Klein et 1995; Lenzenweger et al. 1997; Maier et
al. 1995; Lenzenweger et al. 1997; Moldin al. 1992; Moldin et al. 1994; Torgersen et
et al. 1994). Most are from urban areas al. 2001) were based on DSM-III-R (Amer-
(Gerhardt et al. 2011; Johnson et al. 2008; ican Psychiatric Association 1987), and
Klein et al. 1995; Lenzenweger et al. 1997; some (Barnow et al. 2010; Coid et al.
Lindal and Stefansson 2009; Maier et al. 2006; Gerhardt et al. 2011; Johnson et al.
Prevalence, Sociodemographics, and Functional Impairment 111
TABLE 6–1. Prevalence of personality disorders in different epidemiological

studies (continued)
Johnson Lindal and Barnow Medi-
Coid et Lenzenweger et al. Stefansson et al. Gerhardt an;
al. 2006 et al. 2007 2008 2009 2010 et al. 2011 Range mean
Number 656 214 568 420 745 110

System DSM-IV DSM-IV DSM-IV DSM-IV DSM-IV DSM-IV
Method SCID-II IPDE SCID-II DIP-Q SCID-II SCID-II
Place United United States New York Reykjavik, Me.-Vor. Heidelberg,
Kingdom Iceland Germany
PPD 0.7 2.3 2.4 4.8 3.2 2.7 0.0–4.8 1.8; 1.7
SPD 0.8 4.9 1.3 3.1 0.8 0.0 0.0–4.9 0.8; 1.3
STPD 0.1 3.3 0.9 4.5 0.1 0.0 0.0–4.5 0.7; 1.3
ASPD 0.6 1.0 2.2 1.4 0.8 0.0 0.0–4.5 1.0; 1.8
BPD 0.7 1.6 2.2 4.5 2.3 3.6 0.0–4.5 1.7; 1.6
HPD 0.0 0.0 1.5 0.7 0.7 0.0 0.0–3.0 0.7; 1.2
NPD 0.0 0.0 1.1 1.2 0.7 0.9 0.0–4.4 0.7; 0.8
AvPD 0.8 5.2 3.7 5.2 2.3 4.5 0.0–5.2 2.3; 2.7
DPD 0.1 0.6 1.4 1.7 1.3 0.0 0.1–1.8 1.0; 1.0
OCPD 1.9 2.4 1.5 7.1 6.3 4.5 0.0–7.1 2.0; 2.5
PAPD 1.7 0.9 0.0–3.3 2.1; 1.7
SDPD 0.0–0.8 0.4
SAPD 0.0–0.2 0.1
DEPD 1.5 1.5 1.5
Cl A 1.6 6.2 3.8 2.7 1.6–6.2 3.4; 3.5
Cl B 0.5 2.3 3.9 4.5 0.5–5.8 3.5; 3.3
Cl C 2.6 6.8 8.6 9.1 2.6–9.2 7.7; 6.5
Total PD 4.4 11.9 13.3 11.1 12.8 15.5 3.9–15.5 11.9;
11.0
Note. ASPD=antisocial personality disorder; AvPD=avoidant personality disorder; BPD= borderline
personality disorder; Cl A=Cluster A; Cl B=Cluster B; Cl C=Cluster C; DEPD=depressive personality dis-
order; DPD=dependent personality disorder; HPD=histrionic personality disorder; NPD=narcissistic
personality disorder; OCPD=obsessive-compulsive personality disorder; PAPD=passive-aggressive per-
sonality disorder; PD=personality disorder; PPD=paranoid personality disorder; SAPD=sadistic person-
ality disorder; SDPD=self-defeating personality disorder; SPD=schizoid personality disorder; STPD=
schizotypal personality disorder.
DIP-Q=DSM-IV and ICD-10 Personality Questionnaire; IPDE=International Personality Disorder Exam-

ination; PDE=Personality Disorder Examination; SCID-II=Structured Clinical Interview for DSM-IV Axis
II Personality Disorders; SIDP=Structured Interview for DSM-III-R Personality; SIDP-R=Structured Inter-
view for DSM-III-R Personality—Revised.
2008; Lenzenweger et al. 2007; Lindal (SIDP) (Torgersen et al. 2001; Zimmer-
and Stefansson 2009; Samuels et al. 2002) man and Coryell 1989), some used the
were based on DSM-IV (American Structured Clinical Interview for DSM-
Psychiatric Association 1994). Some re- IV Axis II Personality Disorders (SCID-
searchers used the Structured Interview II) (Barnow et al. 2010; Coid et al. 2006;
for DSM-III-R Personality Disorders Gerhardt et al. 2011; Johnson et al. 2008;
Maier et al. 1992), and others used ver- the ranks of schizotypal, antisocial, and
sions of the Personality Disorder Ex- histrionic PDs are spread over the whole
amination (PDE) (Klein et al. 1995; Len- range.
zenweger et al. 1997, 2007; Moldin et al. Avoidant and obsessive-compulsive
1994; Samuels et al. 2002). Most studies PDs are the most frequent PDs, each af-
are from the United States (Klein et al. fecting around 2.5% of the population.
1995; Lenzenweger et al. 1997, 2007; Next come paranoid, borderline, anti-
Moldin et al. 1994; Samuels et al. 2002; social, and passive-aggressive PDs (if
Zimmerman and Coryell 1989), although the latter from the DSM-IV appendix is
some are from northwestern Europe included), affecting around 1.5% each.
(Barnow et al. 2010; Coid et al. 2006; Ger- Schizoid, dependent, schizotypal, and
hardt et al. 2011; Lindal and Stefansson histrionic PDs affect about 1.0% of pop-
2009; Maier et al. 1992; Torgersen et al. ulations. The prevalence of narcissistic
2001). Surprisingly, the prevalence for PD is often below 1%. The few studies of
any PD is very similar in these different the other PDs from either the DSM-III-R
studies: 10 of 13 studies reported the or DSM-IV appendixes showed very
prevalence for any PD between 10% and low prevalence rates for self-defeating
15%. On average, the prevalence was and sadistic PDs and a high frequency
11% or 12%, depending on whether the for depressive PD. On average, the prev-
means or the medians were used in the alence of specific PDs is around 1%–
calculations. 1.5%. Although there has not been defin-
The table also shows prevalence infor- itive empirical work justifying retaining
mation about the PD clusters. In five of these “provisional” PDs in DSM-5 (Amer-
the six studies that reported such data, ican Psychiatric Association 2013), indi-
Cluster C (anxious/fearful) disorders are viduals who exhibit tendencies such as
reported to be the most frequent. The these can now be characterized with re-
prevalence rates of Cluster A (odd/ec- spect to personality functioning and path-
centric) and Cluster B (dramatic/emo- ological traits in the alternative DSM-5 PD
tional) disorders average around 3.5% model in Section III, “Emerging Measures
each, and the prevalence of Cluster C dis- and Models.” I include data on the prev-
orders averages around 7.0%. alence of these PDs for those clinicians
As to the specific PDs, the variation in and researchers who retain an interest in
prevalence across studies is relatively them.
higher, not surprisingly, because the per- There are no obvious differences de-
centages are lower, and hence the rela- pending on whether DSM-III, DSM-III-
tive standard errors are larger. However, R, or DSM-IV is the basis for the preva-
the rank orders of the specific PDs are lence or what kind of instrument is ap-
not so different from study to study. For plied. However, the number of studies
obsessive-compulsive and avoidant PDs, in each category is too low to draw any
the rank is between one and three for the conclusions. In a comparison of studies
majority of the studies. Borderline PD is from the United States and from north-
between three and five, dependent PD west Europe, one finds that obsessive-
between five and seven, schizoid PD be- compulsive and paranoid PDs, and pos-
tween six and eight, and narcissistic PD sibly avoidant, schizoid, and dependent
consistently least or next to least fre- PDs, are more common in Europe, whereas
quent. Paranoid PD is also relatively sta- antisocial and schizotypal PDs, and pos-
ble between ranks two and five, whereas sibly histrionic and narcissistic PDs, are
more common in the United States. It 22, and 33 years—was 13.4%, the cumu-
may be the case, therefore, that an affec- lative prevalence over the four time points
tively inhibited, skeptical, and with- was 28.2%. The same relationship was
drawn personality style is more common observed for the specific PDs. The ratio
in northwest Europe, whereas an affec- between the cumulative prevalence and
tively expressive, impulsive, flamboy- the average prevalence at a specific time
ant, and possibly eccentric style is more was around 3.
likely in America. In the National Epidemiological Sur-
vey on Alcohol and Related Conditions
(NESARC), interviewers tried to obtain a
Lifetime Prevalence lifetime assessment instead of a 2- to 5-
Lifetime prevalence for disorders is nec- year assessment of PD prevalence (Grant
essarily higher than point prevalence. If et al. 2004, 2008, 2012; Pulay et al. 2009;
the percentage of a population with a Stinson et al. 2008) (Table 6–2). When the
given disorder is measured during the prevalence of individual PDs is compared
past 2 weeks, 1 month, 1 year, 2 years, or with the average for PDs in all published
5 years, the percentage will be lower than epidemiological studies, the lifetime
if the population is followed throughout prevalence (as far as the respondents can
the whole lifespan. This obvious fact has remember) is around three times as high.
long been established for many mental The implications are that the average life-
disorders, and the same will hold true for time prevalence of a specific PD will be at
PDs, provided that the disorders are not least 3%–4%, and the lifetime prevalence
present at an early age and do not remain of any PD will be at least around 30% but
chronic throughout life. Indeed, empiri- probably much higher. Thus, according
cal research shows that many treated to the present criteria for PDs as defined
individuals are free of their PDs after a in DSM-5 Section II, “Diagnostic Criteria
relatively short time (Grilo et al. 2004; and Codes,” a large percentage of people
Shea et al. 2002; Skodol et al. 2005; Zana- at some point in their lives will qualify for
rini et al. 2006). The same is true in the having a PD. The rest of the time they
general population (Johnson et al. 2008; may be only slightly below the level of a
Lenzenweger 1999). At the same time, clinical disorder or perhaps far below the
the 2- to 5-year point prevalence rates do level for a shorter or longer time of their
not diminish much over age, as I discuss lifespan. The reason for this clinical course
in the following paragraphs. The impli- is the semicontinuous nature of PDs. An
cation is that new cases have to debut in individual’s personality dysfunction is
the population to replace those that dis- not stable. Events and life situations bring
appear, even if some few reappear (Dur- the dysfunction up to the threshold for a
bin and Klein 2006; Ferro et al. 1998; PD usually during one period in life. The
Zanarini et al. 2006). dysfunction often decreases back toward
A direct indication of the difference the mean in the population, although it
between the point prevalence of PDs does not necessarily reach the mean level
and the lifetime prevalence is found in a in the population. However, it is below
study from New York of adolescents the level for a PD. Other individuals who
followed from age 14 to age 32 years previously met too few criteria for a diag-
(Johnson et al. 2008) (Table 6–2). Although nosis will display an increase and rise
the mean point prevalence of PDs over over the threshold. Many individuals will
the four observation points—ages 14, 16, reach the above-threshold level at least
114
TABLE 6–2. Difference between point prevalence and lifetime prevalence for personality disorders
Grant et al. 2004, 2008, 2012; Pulay

et al. 2009; Stinson et al. 2008 Johnson et al. 2008
The American Psychiatric Publishing Textbook of Personality Disorders

Mean, Cumulative over Ratio: point
all studies, Ratio: lifetime/ Mean over 4 waves, 4 waves, prevalence/ Average
Disorder point prevalence Lifetime point prevalence ages 14–32 years ages 14–32 years cumulative ratio
PPD 1.7 4.4 2.6 2.1 7.0 3.3 3.1

SPD 1.3 3.1 2.4 1.1 3.9 3.6 3.1
STPD 1.3 3.9 3.0 1.2 4.0 3.3 3.5
ASPD 1.8 3.6 2.0 2.2 (3.2)a (1.6)a (1.8)a
BPD 1.6 5.9 3.7 1.5 5.5 3.7 4.0
HPD 1.2 1.8 1.5 1.5 4.6 3.1 2.3
NPD 0.8 6.2 7.8 2.2 6.3 2.9 5.4
AvPD 2.7 2.4 0.9 2.4 8.1 3.4 2.2
DPD 1.0 0.5 0.5 0.8 3.2 4.0 2.3
OCPD 2.5 7.8 3.1 0.7 3.0 4.3 4.1
PAPD 1.9 5.6 2.9
DEPD 0.8 3.0 3.8
Average 1.6 4.0 2.8 1.5 4.8 3.2 3.1
Any PD 13.4 28.2 2.1
Note. ASPD=antisocial personality disorder; AvPD=avoidant personality disorder; BPD=borderline personality disorder; DEPD=depressive personality disorder;
DPD=dependent personality disorder; HPD=histrionic personality disorder; NPD=narcissistic personality disorder; OCPD=obsessive-compulsive personality disorder;
PAPD=passive-aggressive personality disorder; PD=personality disorder; PPD=paranoid personality disorder; SPD=schizoid personality disorder; STPD=schizotypal
personality disorder.
a
Waves at ages 14 and 16 years do not include ASPD.
once in a lifetime. The waxing and wan- although the quality of life is not so low
ing of personality pathology argues for for these individuals (Cramer et al. 2006,
movement away from traditional cate- 2007), whereas schizoid and paranoid
gorical approaches to classification and PDs are uncommon in clinical popula-
diagnosis and toward more dimensional tions, although these individuals suffer a
representations. lot; obviously, strongly dependent and
extroverted individuals seek help and
Prevalence in support, whereas skeptical, introverted
individuals prefer to be more self-reliant,
Clinical Populations try to solve problems themselves, and
Knowledge about the prevalence of PDs keep away from treatment. Thus, person-
in clinical populations is very important ality, more than psychological suffering,
for clinicians and health administrators. is a strong factor in illness behavior.
Previously, most information available In summary, although the prevalence
about the prevalence of PDs stemmed rates of PDs vary strongly from study to
from such clinical populations. Today, study, the number of published studies
much more is known about prevalence in makes it possible to draw some conclu-
the general population. A comparison be- sions. At least in the United States and Eu-
tween clinical and community prevalence rope, the prevalence rates of specific PDs
rates provides meaningful information are around 1.5% (Table 6–1). The preva-
about the different tendencies to be treated lence of “any PD” is 11%–12%. The sum of
among individuals with various PDs. the percentages for the specific disorders
Table 6–3 presents a comparison be- is higher, close to 20%, pointing to the fact
tween the prevalence in the general pop- that a large number of individuals with
ulation and in nine clinical populations one disorder also have one, two, three, or
adapted from the Oxford Handbook of even more additional disorders.
Personality Disorders (Torgersen 2012). Studies only of patients provide a dis-
Epidemiological studies of the general torted impression of the absolute and
population make it possible to have a di- relative prevalence of PDs, because those
rect comparison of individuals who have with dependent and extroverted traits
been treated for psychological problems much more often seek treatment, whereas
and those who have not been treated. As the opposite is the case for skeptical, in-
shown in the table, borderline and de- troverted persons.
pendent PDs are much more prevalent in
the clinical population than in the general
population. Other PDs relatively highly Sociodemographic
more common in clinical populations
are narcissistic, histrionic, avoidant, and Correlates
schizotypal PDs. Passive-aggressive, para-
noid, antisocial, and obsessive-compul-
sive PDs are relatively weakly more com-
Gender
mon in the clinical population, while Gender differences are common among
schizoid PD does not seem to be more mental disorders. Women more often
common in clinical populations than in have mood and anxiety disorders, and
the general population. Notably, narcis- men more often have substance-related
sistic, dependent, and histrionic PDs are disorders (Kringlen et al. 2001). For PDs,
quite prevalent in clinical populations, women and men also differ. Zimmerman
116
TABLE 6–3. Relative risk of attending or having attended psychiatric care for different personality disorders
Common population, Oslo, Norway

Common Clinical
population, population, Relative
international international Relative risk rank of
(median; (median; (median; Relative Relative relative risk,
Disorder mean) mean) mean) rank of risk Nontreated Treated Relative risk rank of risk combined
PPD 1.8; 1.7 6.3; 9.6 3.5; 5.6 8 2.1 5.8 2.8 6 6
SPD 0.8; 1.3 1.4; 1.9 1.8; 1.5 11 1.4 7.2 5.1 4 8
STPD 0.7; 1.3 6.4; 5.7 9.1; 4.4 6 0.6 1.4 2.3 8 6
ASPD 1.0; 1.8 3.9; 5.9 3.9; 3.3 9 0.6 0.0 0.2 11 11
BPD 1.7; 1.6 28.5; 28.5 17.8; 17.8 1 0.5 7.2 14.4 1 1
HPD 0.7; 1.2 8.0; 9.7 11.4; 8.1 4 1.8 4.3 2.4 7 5
NPD 0.7; 0.8 5.1; 10.1 7.3; 12.6 3 0.8 2.9 3.6 5 3
AvPD 2.3; 2.7 21.5; 24.6 9.3; 9.1 5 4.3 23.2 5.4 3 3
DPD 1.0; 1.0 13.0; 15.0 13.0; 15.0 2 1.3 8.7 6.7 2 2
OCPD 2.0; 2.5 6.1; 10.5 3.1; 4.2 10 1.9 2.9 1.5 9 10
PAPD 2.1; 1.7 10.1; 9.5 4.8; 5.6 7 1.6 1.4 0.9 10 9
Cl A 3.4; 3.5 11.2; 10.2 3.3; 2.9 3 3.6 13.0 3.6 2 3
Cl B 3.5; 3.3 32.1; 31.7 9.2; 9.6 1 3.3 8.7 2.6 3 2
Cl C 7.5; 6.5 27.6; 26.9 3.6; 4.1 2 7.0 26.1 3.7 1 1
Any PD 11.9; 11.0 65.6; 64.4 5.5; 5.9 12.5 31.9 2.6
Note. ASPD=antisocial personality disorder; AvPD=avoidant personality disorder; BPD=borderline personality disorder; Cl A=Cluster A; Cl B=Cluster B; Cl C = Clus-
ter C; DPD=dependent personality disorder; HPD=histrionic personality disorder; NPD=narcissistic personality disorder; OCPD=obsessive-compulsive personality
disorder; PAPD = passive-aggressive personality disorder; PD = personality disorder; PPD = paranoid personality disorder; SPD = schizoid personality disorder;
STPD=schizotypal personality disorder.
Source. Adapted from Torgersen 2012, p. 193, and Torgersen et al. 2001.
and Coryell (1989) observed a higher Among the Cluster C disorders, de-
prevalence of any PD among males, as pendent PD was much more common
did Jackson and Burgess (2000) for ICD- among women (Grant et al. 2004; Torg-
10 screening when regression analysis ersen et al. 2001; Ullrich and Coid 2009;
was applied. However, differences be- Zimmerman and Coryell 1989, 1990),
tween genders were very small, and and obsessive-compulsive PD or traits
Torgersen et al. (2001) did not observe were found more often among men
any differences. (Torgersen et al. 2001; Ullrich and Coid
As to the PD clusters, Samuels et al. 2009; Zimmerman and Coryell 1989,
(2002) and Torgersen et al. (2001) re- 1990). Zimmerman and Coryell (1989,
ported that Cluster A and Cluster B 1990), Grant et al. (2004), and Ullrich and
disorders or traits were more common Coid (2009) reported more avoidant PD
among men. Coid et al. (2006) found the and traits among women.
same for Cluster B only. Regarding PDs “provided for further
Among the specific Cluster A disor- study” in DSM-III-R or DSM-IV, Torg-
ders, Torgersen et al. (2001), Ullrich and ersen et al. (2001), but not Zimmerman
Coid (2009), and Zimmerman and Cory- and Coryell (1989, 1990), found that men
ell (1990) found that schizoid PD or traits more often had passive-aggressive PD.
were more common among men. Zim- Torgersen and colleagues also found that
merman and Coryell (1990) found this women more often presented with self-
also for paranoid traits. Grant et al. (2004), defeating traits, and men more often pre-
however, observed that women more of- sented with sadistic traits.
ten had a paranoid PD. Neither Zimmer- The most clear-cut results from the
man and Coryell (1989, 1990) nor Torg- studies are that men with PDs tend to be
ersen et al. (2001) observed any gender antisocial and narcissistic, and women
difference for schizotypal PD, Pulay et al. with PDs tend to be histrionic and depen-
(2009) found that schizotypal PD was dent. These results are perhaps not sur-
more common among men, and Ullrich prising. More surprising, however, are
and Coid (2009) found it was more com- the few indications of gender differences
mon among women. Among the Cluster for borderline traits even though border-
B disorders, antisocial PD was much line features are often considered to be
more common among men (Grant et al. more common in women than in men. In
2004; Torgersen et al. 2001; Ullrich and patient samples, borderline PD was not
Coid 2009; Zimmerman and Coryell more prevalent among women than
1989, 1990). Individuals with histrionic among men (Alnæs and Torgersen 1988;
PD or traits were, it appears, more often Fossati et al. 2003; Golomb et al. 1995). In
women (Torgersen et al. 2001; Zimmer- one study of patients, borderline PD was,
man and Coryell 1990). Narcissistic PD in fact, more common among men than
and traits were found more often among among women (Carter et al. 1999). Re-
men (Stinson et al. 2008; Torgersen et al. ports that paranoid and schizotypal PDs
2001; Ullrich and Coid 2009; Zimmerman do not show any gender bias, that men
and Coryell 1989, 1990). Although there more often have schizoid and obsessive-
were few statistically significant gender compulsive PDs or traits, and that women
differences for borderline PD or traits, more often have avoidant and histrionic
Ullrich and Coid (2009) reported more PDs or traits are more in accord with com-
among women. mon opinion.
Age orders, no age trend was reported in any

of the studies.
For an individual younger than age 18 Among the Cluster A disorders, schiz-
years to be diagnosed with a PD, the fea- oid PD or traits were generally found to
tures must have been present at least 1 be associated with older people (Engels
year (American Psychiatric Association et al. 2003; Torgersen et al. 2001; Ullrich
2013). At the same time, it is assumed and Coid 2009; Zimmerman and Coryell
that PDs start early in life and are rela- 1989, 1990), although Grant et al. (2004)
tively stable. For some PDs, especially found them to be more common in
the dramatic types (Cluster B), it is also younger people. In contrast, most re-
assumed that they are typical for young searchers found schizotypal PD to be
people. On the other hand, the older peo- more common in younger individuals
ple are, the longer they have had to de- (Engels et al. 2003; Pulay et al. 2009; Ull-
velop PDs, even though PDs may also rich and Coid 2009; Zimmerman and
disappear. Suicide and fatal accidents Coryell 1989, 1990), but Torgersen et al.
also may happen more often among those (2001) found it to be more common in
with PDs than among other individuals. older individuals. Paranoid PD was ob-
These facts will influence the rate of spe- served more among younger people in
cific PDs in older age. two studies (Grant et al. 2004; Ullrich and
Zimmerman and Coryell (1989) ob- Coid 2009).
served that individuals with PDs were Many study authors reported that
younger than those without. Jackson and younger people more frequently had
Burgess (2000) found the same age distri- Cluster B disorders or traits: borderline
bution using a short ICD-10 screening (Engels et al. 2003; Grant et al. 2004, 2008;
instrument, the International Personal- Torgersen et al. 2001; Ullrich and Coid
ity Disorder Screener. Torgersen et al. 2009; Zimmerman and Coryell 1989,
(2001), however, observed the opposite. 1990), antisocial (Grant et al. 2004, 2008;
This difference can be explained by the Torgersen et al. 2001; Ullrich and Coid
high prevalence of introverted and the 2009; Zimmerman and Coryell 1989,
low prevalence of impulsive personal- 1990), histrionic (Grant et al. 2004; Ull-
ity traits in Norway compared with the rich and Coid 2009; Zimmerman and
United States. Introverted PDs are more Coryell 1990), and narcissistic (Stinson
prevalent among older people, and im- et al. 2008; Ullrich and Coid 2009; Zim-
pulsive PDs are less prevalent. merman and Coryell 1990).
As to the clusters of PDs, Torgersen et Individuals with obsessive-compulsive
al. (2001) found that individuals with PD and traits appear to be older (Engels
Cluster A disorders were older, whereas et al. 2003; Grant et al. 2012; Torgersen et
Samuels et al. (2002), Coid et al. (2006), al. 2001; Ullrich and Coid 2009). One
and Lenzenweger et al. (2007) did not study has found that individuals with
find any age variations for these disor- avoidant PD are older (Torgersen et al.
ders. For the Cluster B disorders, Samu- 2001), and another reported that they are
els et al. (2002), Coid et al. (2006), and younger (Ullrich and Coid 2009). One
Lenzenweger et al. (2007) found a higher study has observed that those with de-
prevalence among the younger subjects, pendent PD are younger (Grant et al.
whereas Torgersen et al. (2001) found 2004).
that the Cluster B trait dimensions de- Zimmerman and Coryell (1989) found
creased with age. For the Cluster C dis- that individuals with passive-aggressive
PD are typically of a younger age, and without a PD in the general population

Torgersen et al. (2001) observed that (Torgersen et al. 2001).
such traits were negatively correlated However, because the risk of having a
with age. The latter study also examined PD is related to gender and age, the real
self-defeating and sadistic traits and effect of other sociodemographic vari-
found that sadistic traits were associated ables such as marital status is difficult to
with younger age. determine. Younger people are less often
To summarize, persons with border- married, and education is also related to
line, antisocial, and possibly schizotypal, gender and age. The best way to deter-
histrionic, and narcissistic PDs seem to mine the independent effect of individ-
be younger, whereas those with schizoid ual sociodemographic variables is to ap-
and obsessive-compulsive PDs are older. ply multivariate methods; however, these
These findings are in accordance with methods have been used in very few
those from a follow-up study by Seive- studies because they need large samples.
wright et al. (2002) showing a strong de- In the study by Torgersen et al. (2001),
velopmental trend from Cluster B to such multivariate analyses have been
Cluster A disorders and a somewhat carried out for living alone versus living
weaker change to Cluster C disorders. with a partner.
The reason for the age difference may be Those with Cluster A disorders have
that people become less impulsive and more often been divorced or separated
overtly aggressive as they age. Agree- (Coid et al. 2006; Samuels et al. 2002);
ableness and conscientiousness increase they are more often divorced when inter-
with age (Srivastava et al. 2003). Cluster viewed, and they have seldom been mar-
B disorders are typically negatively cor- ried (Samuels et al. 2002 and Table 6–4).
related with agreeableness and consci- Those with Cluster B disorders are also
entiousness (Saulsman and Page 2004). often unmarried and more often live
alone (Torgersen et al. 2001), and they
are more often separated or divorced
Marital Status
(Coid et al. 2006). Those with Cluster C
Most of the results concerning marital disorders are also less often married
status are from Zimmerman and Coryell (Samuels et al. 2002) and more often live
(1989). Some of the data from Torgersen alone (Torgersen et al. 2001).
et al. (2001) have been calculated for this When examining the specific PDs, one
chapter to be comparable in format to the encounters problems in comparing the
tables in Zimmerman and Coryell (1989) different studies. Marital status does not
(Table 6–4). seem to be as important in the Norwe-
As illustrated in Table 6–4, subjects gian study (Torgersen et al. 2001), per-
with PDs have more often been sepa- haps because many Norwegians live in
rated or divorced compared with those stable relationships without being mar-
without a PD. They are less frequently ried. When one includes “living together
married (Jackson and Burgess 2000; Zim- with a partner” from the study of Torg-
merman and Coryell 1989), and they are ersen et al. (2001) and considers this life
more often never married (Zimmerman situation as analogous to marriage, the
and Coryell 1989). If nonmarried per- findings of this study and the study by
sons living with a partner are consid- Zimmerman and Coryell (1989) are more
ered, subjects with PD more often live similar. It is important to note that the
alone without a partner than do subjects observations in the study by Torgersen
120
TABLE 6–4. Marital status and personality disorders, calculated from Torgersen et al. 2001
Single (never Married Separateda Divorceda Widowed Ever separatedb Ever divorcedc
Personality disorder N married) (%) (%) (%) (%) (%) (%) (%)

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
Cluster A: eccentric 80 45.6 33.8d 3.8 15.0 2.5 13.8 34.1
Cluster B: dramatic 62 49.3 35.2 1.4 12.7 1.4 8.3 33.3
Cluster C: fearful 189 45.5 36.5d 1.3 14.1 2.6 8.2 28.2
f d
Any personality disorder 269 43.9 36.8 2.2 15.6 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
Total 2,053 693.0 830.0 43.0 185.0 33.0 43.0 253.0
a
At the time of interview.
b
Excluding those who were never married.
c
Excluding those who were never married and those who are divorced.
d 2
F test, P0.05.
e 2
F test, P0.001.
f 2
F test, P0.01.
and colleagues were based on logistic (Grant et al. 2008). Finally, those with
and linear regression analysis, taking narcissistic PD also more often live alone
into account a number of other sociode- (Torgersen et al. 2001), and they are
mographic variables. more often separated/divorced/wid-
Among individuals with Cluster A owed or never married (Stinson et al.
disorders, those with paranoid PD are 2008).
more often single (never married) (Grant Among persons with Cluster C disor-
et al. 2004), divorced (Grant et al. 2004 ders, those with avoidant PD have more
and Table 6–4), or living alone (Torgersen often been separated (Zimmerman and
et al. 2001). Those with schizoid PD are Coryell 1989). They are more often sepa-
less often separated at time of interview rated/divorced/widowed when inter-
(Zimmerman and Coryell 1989), more viewed and more often never married
often ever separated/divorced/widowed (Grant et al. 2004). Those with depen-
or never married (Grant et al. 2004), and dent PD more often have been separated
more often living alone (Torgersen et al. when interviewed (Zimmerman and Co-
2001). Those with schizotypal PD have ryell 1989), have never married (Grant et
more often been separated (Zimmerman al. 2004 and Table 6–4), or are separated/
and Coryell 1989) and more often living divorced/widowed (Grant et al. 2004).
alone (Torgersen et al. 2001). They are Those with obsessive-compulsive traits
more often separated/divorced/wid- are less often married (Torgersen et al.
owed or never married (Pulay et al. 2009), 2001), and females with obsessive-
all compared with those without the spe- compulsive PD are less often separated/
cific PDs. divorced/widowed when interviewed.
Among the Cluster B disorders, per- Among the proposed PDs, persons
sons with histrionic PD have more often with passive-aggressive PD have more
been separated or divorced (Zimmerman often been divorced and are less often
and Coryell 1989). They are also more of- married when interviewed (Zimmerman
ten not married when interviewed (Zim- and Coryell 1989) and more often live
merman and Coryell 1989), more often alone (Torgersen et al. 2001). Those with
divorced/separated/widowed or never self-defeating PD have more often been
married (Grant et al. 2004), and more of- divorced (Zimmerman and Coryell 1989),
ten living alone (Torgersen et al. 2001). are more often divorced (see Table 6–4) or
Those with antisocial PD also more often not married when interviewed (Zimmer-
have been divorced, separated (Zimmer- man and Coryell 1989), and more often
man and Coryell 1989), or never married live alone (Torgersen et al. 2001).
(Grant et al. 2004 and Table 6–4); are less In conclusion, persons with PDs, and
often married when interviewed; and particularly those with self-defeating,
are more often living alone (Torgersen et borderline, or schizotypal PD, typically
al. 2001). Persons with borderline PD live alone. Those with obsessive-compul-
also have more often been separated if sive PD may be an exception. Never be-
married, are more often divorced, and ing married is often observed among
are not married when interviewed (Zim- those with antisocial and dependent PDs.
merman and Coryell 1989). They are The risk of divorce/separation is high
more often never married (Zimmerman among those with paranoid PD. In cul-
and Coryell 1989), are more often living tures where it is more common to live
alone (Torgersen et al. 2001), and are together unmarried, a breakup in the re-
more often separated/divorced/widowed lationship is less easy to record. For what-
ever reason, living without a partner is Coid et al. (2006) found that Cluster A
very common among people with PDs. disorders were related to unemployment
and lower social class, Cluster B disor-
Education and Income ders were related to lower social class,
and Cluster C disorders were related to
Relatively few studies have investigated being “economically inactive” but not
the relationship between PDs and educa- unemployed. Grant et al. (2004) found
tion and income. Torgersen et al. (2001)
that lower income was related to all of the
observed that people with any PD had studied (NESARC Wave 1) PDs except
less education than those without a PD. obsessive-compulsive PD. Lenzenweger
The same was observed for those with dis-
et al. (2007) found that only borderline
orders or traits in Clusters A, B, and C. PD was related to unemployment.
Samuels et al. (2002) and Lenzenweger et Samuels et al. (2002) also investigated
al. (2007) confirmed that those with Clus-
the relationship between income and
ter B disorders, but not those with Clus- PDs but did not find any association.
ter A or Cluster C disorders, had less ed- Jackson and Burgess (2000) did not find
ucation. Coid et al. (2006), however,
any relationship between PDs and un-
found lower education among those with employment. It is important to note that
Cluster A disorders. these studies applied multivariate meth-
In applying logistic regression analy-
ods, taking into account other sociode-
sis and taking into account a number of mographic variables.
other sociodemographic variables, Torg- In summary, with a few exceptions,
ersen et al. (2001) observed that paranoid
PDs are related to lower socioeconomic
and avoidant PDs and traits and schiz- status and economic problems. This
oid, schizotypal, antisocial, borderline, holds true for all of the Cluster A disor-
dependent, and self-defeating personal-
ders (paranoid, schizoid, and schizotypal)
ity traits were related to lower education. and for at least two Cluster B disorders
Interestingly, individuals with obses- (antisocial and borderline). It is not true
sive-compulsive PD or traits had higher
for narcissistic PD, and the socioeco-
education. Only histrionic, narcissistic,
nomic status of those with histrionic PD
and passive-aggressive PDs or traits is equivocal. As for Cluster C disorders,
were unrelated to education. In Wave 1 avoidant and dependent PDs imply
of the NESARC, Grant et al. (2004) found
poorer socioeconomic status, whereas the
that lower education was related to all opposite is true for obsessive-compulsive
the studied PDs (paranoid, schizoid, an- PD. For the provisional disorders, there
tisocial, histrionic, avoidant, and depen-
exists only one study (Torgersen et al.
dent), with the exception of obsessive- 2001), which suggests lower education
compulsive PD, which was related to for those with self-defeating and sadistic,
higher education (as Torgersen et al.
but not passive-aggressive, PDs.
[2001] found). Also, in NESARC Wave 2,
Grant et al. (2008) found that borderline
PD was more common among those with Urban Location
lower education and income. The same The study of Torgersen et al. (2001)
was true for low income and schizotypal showed that persons living in the popu-
PD (Pulay et al. 2009) but not narcissistic lated center of the city more often had
PD (Stinson et al. 2008). PDs. The same was true for all clusters of
PDs and all specific disorders except an- with PDs experience. In the sample stud-
tisocial, sadistic, avoidant, and depen- ied by Torgersen et al. (2001), quality of
dent PDs. In Wave 1 of the NESARC, life was assessed by interview and in-
Grant et al. (2004) found this to be true cluded the following aspects: subjective
for paranoid and avoidant PDs but not well-being, self-realization, relation to
for antisocial, histrionic, schizoid, depen- friends, social support, negative life
dent, or obsessive-compulsive PDs. The events, relation to family of origin, and
two studies agree that paranoid PD, but neighborhood quality (Cramer et al.
not antisocial and dependent PDs, is re- 2003, 2006, 2007). All aspects were inte-
lated to urbanicity. They disagree about grated in a global quality-of-life index.
schizoid, histrionic, avoidant, and obses- In the Torgersen et al. (2001) study, PDs
sive-compulsive PDs, and the rest of the turned out to be more strongly related to
PDs were not included in the NESARC quality of life than Axis I mental dis-
study at Wave 1. orders, somatic health, and any other
Given that more people with PDs are socioeconomic, demographic, or life sit-
found in the center than in the outskirts uation variable. Among the specific PDs,
of a city, one may speculate about the rea- avoidant PD was most strongly related
son for this. Quality of life is generally to poor quality of life, after the research-
lower in the center of the city (Cramer et ers controlled for all the aforementioned
al. 2004), and there is a higher rate of variables. Next came schizotypal, then
symptom disorders in the city or in the paranoid, schizoid, borderline, depen-
center of the city (Kringlen et al. 2001; dent, and antisocial PDs, followed by nar-
Lewis and Booth 1992, 1994; Marcelis et cissistic and self-defeating PDs to a lesser
al. 1998; Sundquist et al. 2004; van Os et degree. Histrionic, obsessive-compul-
al. 2001). One reason may be that the con- sive, and passive-aggressive PDs were
centrated urban life creates stress leading unrelated to quality of life. Some may be
to PDs. Another reason may be that indi- surprised that borderline PD was not
viduals with personality problems drift more strongly related to reduced quality
to the center, where they can lead an of life. The reason for this is that the dis-
anonymous life. A third explanation may order is related to a number of other vari-
be that less social control in cities simply ables that are related to quality of life.
makes it easier to express the less socially Hence, the variables become weaker in a
acceptable aspects of one’s personality. multiple regression analysis.
Previous belief held that excessive social A dysfunction index was created by
control creates mental problems. Perhaps combining quality of life (reversed); the
social control hinders the development answer to the Structured Interview for
of accentuated eccentric, narcissistic, and DSM-III Personality Disorders—Revised
impulsive personality styles. question “Do you feel that the way you
usually deal with people and handle situ-
ations causes you problems?”; the num-
Quality of Life ber of lifetime Axis I diagnoses; and any
incidence of seeking treatment with vary-
and Dysfunction ing degrees of seriousness, from private
psychologists and psychiatrists—via out-
Central to the definition of PDs are the patient and inpatient clinics—to psychi-
interpersonal problems, reduced well- atric hospitals. The dysfunction index
being, and dysfunction that individuals was related to PD, much as the global
quality-of-life index was. The only differ- gest determinant of current and prospec-
ences found in comparing results derived tive (3-year) psychosocial dysfunction.
from the dysfunction index with those In DSM-5 Section III, the Level of Per-
from the global quality-of-life index were sonality Functioning Scale (LPFS) mea-
that those persons with borderline, histri- sures the overall severity of impairment
onic, dependent, or self-defeating PD ap- in personality functioning on a contin-
peared more dysfunctional, and those uum and is predictive of the presence of
persons with antisocial PD appeared less a PD, PD comorbidity, and the presence
dysfunctional. The reason for the differ- of a severe PD.
ences is mainly that those with borderline, A high level of dysfunction and dis-
histrionic, dependent, and self-defeating ability was also observed among those
PDs are more likely to seek treatment, and with schizotypal PD, followed by bor-
those with antisocial PD are less likely to derline and avoidant PDs, in a large-scale
seek treatment. multicenter study (Skodol et al. 2002). It
However, the most important result was also observed in this study that those
in this study was that for both quality of with obsessive-compulsive PD showed
life and dysfunction, there was a perfect much less disability, even though they
linear dose-response relationship to had severe impairment in at least one
numbers of criteria fulfilled for all PDs area of functioning.
together and to the number of criteria In another study, Ullrich et al. (2007)
fulfilled for any specific PD (Torgersen found that obsessive-compulsive PD
et al. 2001). Thus, if a person has one cri- was not related to poor functioning—in
terion fulfilled for one or another PD, his fact, it was quite the opposite. Also, his-
or her quality of life is lower and dys- trionic PD was positively related to “sta-
function is higher than among those with tus and wealth,” whereas narcissistic
no criteria fulfilled. Those with two cri- and paranoid PDs were unrelated to this
teria fulfilled for one or more specific index as well as to “successful intimate
disorders have more problems than those relationships.” Taken together, those
with one, those with three criteria have with schizoid PD scored poorest on these
more problems than those with two, and two indexes, followed by those with anti-
so on. In other words, when those with social, schizotypal, avoidant, borderline,
zero criteria on all disorders were grouped and dependent PDs.
together—that is, those with a maximum Zimmerman and Coryell (1989) also
of one criterion on any disorder, those found a high frequency of psychosexual
with a maximum of two, and so on—the dysfunction among persons with avoid-
relationship to global quality of life and ant PD. Surprisingly, this dysfunction was
dysfunction was perfectly linear (Fig- infrequent among persons with border-
ures 6–1 and 6–2). This result means that line PD; not surprisingly, it was also infre-
there are no arguments for any specific quent among those with antisocial PD.
number of criteria to define a PD if one Grant et al. (2004) applied a short form
uses quality of life or dysfunction as val- of a quality-of-life assessment, the 12-item
idation variables. There is no natural Short Form Health Survey, Version 2 (SF-
cutoff point. These results are consistent 12v2; Ware et al. 2002), and found that
with those of Hopwood et al. (2011), who those with dependent PD had the poorest
found that a general dimension of sever- quality of life, followed by those with
ity of personality pathology based on avoidant, paranoid, schizoid, or antisocial
counts of criteria met was the single stron- PD. There was no reduction in quality of
3.0
2.69
2.5
2.05
Level of dysfunction
2.0 1.73
1.59
1.5 1.25
0.91
1.0
0.62
0.47
0.5
0.0
0 1 2 3 4 5 6 7–9
Number of criteria
FIGURE 6–1. Relationship between maximum number of criteria fulfilled on any personality
disorder and dysfunction.
Note. As explained in the text, the ordinate (dysfunction) is a composite of life quality (reversed), treat-
ment seeking, the number of lifetime Axis I diagnoses, and the notion that one’s behavior causes problems.
The mean and standard deviation are 1.
life for those with histrionic PD and a re- life of persons with the provisional pas-
duction on only one of three scores for sive-aggressive, self-defeating, and sa-
those with obsessive-compulsive PD. distic PDs.
Crawford et al. (2005) studied impair- There is reason to question, on the ba-
ment using the Global Assessment of sis of quality-of-life and dysfunction
Functioning (GAF) scale. Subjects with studies, whether histrionic and obses-
borderline PD had the poorest function- sive-compulsive PDs, in spite of their
ing, followed by those with avoidant, long histories, deserve their status as
schizotypal, narcissistic, antisocial, para- PDs. Narcissistic PD was not included in
noid, histrionic, dependent, and schizoid ICD-10 (World Health Organization
PDs. Only those with obsessive-compul- 1992), which some would view as a wise
sive PD had no indication of dysfunction. decision. All 10 of the DSM-IV PDs have
In conclusion, all studies taken together been retained as specific disorders in
show that reduced quality of life and DSM-5 Section II, although in Section III
dysfunction are highest among persons histrionic PD is diagnosed as personality
with avoidant PD, followed closely by disorder—trait specified. As mentioned pre-
those with schizotypal and borderline viously in the section “Sociodemographic
PDs. Those with paranoid, schizoid, de- Correlates,” there has been insufficient
pendent, and antisocial PDs follow. There evidence established for retaining as
are few studies showing impaired qual- full-fledged disorders the DSM-III-R
ity of life for persons with histrionic, and DSM-IV provisional disorders “pro-
narcissistic, or obsessive-compulsive vided for further study,” but personality
PD. The same is true for the quality of characteristics consistent with those de-
2.45 2.36
2.5
2.09
2.0 1.76
1.48 1.37
Qualit y of life
1.5
0.95
1.0
0.51
0.5
0.0
0 1 2 3 4 5 6 7–9
Number of criteria
FIGURE 6–2. Relationship between maximum number of criteria fulfilled on any personality
disorder and quality of life.
Note. As explained in text, the ordinate (quality of life) is a composite of subjective well-being, self-real-
ization, social support, negative life events, and relation to family, friends, and neighbors. The mean is set
to 2, and the standard deviation is 1.
scriptions may be specified by the new between personality disorders and other
DSM-5 Section III model. variables are more important than preva-
lence rates. These correlations appear to
be independent of how strictly personal-
Conclusion ity disorders are defined.
Because of the continuous nature of
There is an even reduction in quality of personality disorders, their tendency to
life and an even increase in dysfunction disappear, and the even distribution of
for each PD criterion manifested. Thus, point prevalence over age, new person-
there is a continuous relationship be- ality disorders have to arise over the life
tween those with no or small personality span. Consequently, the likelihood of
problems, those with moderate prob- having a personality disorder once in
lems, and those with severe problems. the lifetime may be surprisingly high.
No natural cutoff point exists. Any defi- Epidemiological research has perhaps
nition of how many criteria are required changed some stereotypical notions about
for a personality disorder to be diag- personality disorders. These disorders
nosed is arbitrary. Even so, to have a def- are more frequent in the general popula-
inition is important for communication. tion than we generally believed, espe-
However, a change in criteria will imme- cially the introverted personality disor-
diately change the prevalence estimates ders. Borderline personality disorder is
in the society. Consequently, correlations not a “female disorder.” Living without a
partner is a risk factor for personality disorders in Deutschland: results of the
orders, but being unmarried is less a risk Greifswald family study. Pschotherapie,
Psychosomatik, Medizinische Psycholo-
factor than many would have believed.
gie 60:334–341, 2010
Those living in a partnership without be- Carter JD, Joyce PR, Mulder RT, et al: Gender
ing married function well. differences in the frequency of person-
Care must be taken to avoid believing ality disorders in depressed outpatients.
that correlations display one-directional J Pers Disord 13:67–74, 1999
causal relationships. Personality disor- Coid J, Yang M, Tyrer P, et al: Prevalences and
correlates of personality disorder. Br J Psy-
ders may hinder obtaining higher levels
chiatry 188:423–431, 2006
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nomic difficulties. Problematic personality disorders, prevalence, sociodemo-
ity traits may prevent a person from going graphic correlations, quality of life, dys-
into a relationship or may lead to the function, and the question of continuity.
Persønlichkeitsstørungen Theorie und
breaking up of relationships, rather than
Therapie 7:189–198, 2003
having relationship issues and problems Cramer V, Torgersen S, Kringlen E: Quality of
causing problematic personality traits. life in a city: the effect of population den-
Poor quality of life may be a consequence sity. Soc Indic Res 69:103–116, 2004
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netically informative, longitudinal epi- ity disorders and quality of life. A popu-
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demiological studies may disclose the
184, 2006
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understanding of this important group mographic conditions, subjective somatic
of mental disorders. health, Axis I disorders and personality
disorders in the common population:
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CHAPTER 7
Manifestations,
Assessment, and
Differential Diagnosis
In DSM-5 Section II, “Diagnostic uting to problems in differential diagno-

Criteria and Codes” (American Psychi- sis. An alternative set of general criteria
atric Association 2013), personality dis- was proposed for DSM-5 (see Chapter
orders (PDs) are defined by general cri- 24, “An Alternative Model for Personal-
teria identical to those in DSM-IV ity Disorders: DSM-5 Section III and Be-
(American Psychiatric Association 1994), yond” in this volume) and can be found
despite the virtual absence of theoretical in Section III, “Emerging Measures and
or empirical justifications for key as- Models,” of the manual.
pects of these criteria. According to PDs are associated with significant dif-
DSM-5 Section II, PDs are enduring pat- ficulties in self-appraisal and self-regula-
terns of inner experience and behavior tion, as well as with impaired interper-
that are inflexible and pervasive and cause sonal relationships. Thus, the alternative
clinically significant distress or impair- criteria focus on impairments in aspects of
ment in social, occupational, or other ar- what is called personality functioning,
eas of functioning. The patterns deviate which has been shown to be at the core of
markedly from the expectations of an in- personality psychopathology according
dividual’s culture and are said to be to multiple personality theories and
manifested in two or more of the follow- research traditions (Bender et al. 2011;
ing areas: cognition, affectivity, interper- Livesley and Jang 2000; Luyten and Blatt
sonal functioning, and impulse control. 2013). Impairments in personality func-
These features are not specific to PDs, tioning have been empirically demon-
however, and may characterize other strated to discriminate PDs from other
chronic mental disorders, thereby contrib- types of psychopathology (Morey et al.
131
2011), thereby facilitating differential di- classification (e.g., self-defeating or de-

agnosis. In addition, for a PD diagnosis, pressive PD). The latter category is used
the Section III general criteria require the when the general criteria for a PD are
presence of pathological personality traits, met but there is no further specification
which describe the myriad variations in of the PD’s characteristics (e.g., when
personality features that characterize PDs. insufficient information is available to
Because the Section II classification of make a more specific diagnosis).
PDs remains the official classification for DSM-5 Section III provides diagnostic
clinical use, I provide guidance in this criteria for those 6 of the 10 Section II cat-
chapter on assessing personality psycho- egories—antisocial, avoidant, borderline,
pathology and diagnosing PDs using narcissistic, obsessive-compulsive, and
Section II concepts. The process of diag- schizotypal—that are judged to have the
nosing PDs and distinguishing them most empirical evidence of validity and/
from other mental disorders may be more or clinical utility. The other four Section II
difficult with DSM-5, which has discon- PDs and all other presentations that meet
tinued the multiaxial recording system the Section III general criteria for a PD are
of DSM-IV (American Psychiatric Asso- diagnosed in the alternative model as
ciation 1994). Because of the many docu- personality disorder—trait specified (PD-
mented problems with the DSM-IV, and TS) (Table 7–1). The clinician notes the
now DSM-5 Section II, categorical ap- specific level of impairment in personal-
proach to personality pathology (see ity functioning and the specific patholog-
Chapter 24 in this volume), I also outline ical personality traits that describe the
in this chapter the diagnostic process patient (see section “Defining Features
embodied by the Section III alternative of Personality Disorders” below). Thus, in
hybrid dimensional-categorical PD all cases for which a PD is diagnosed us-
model. ing the Section III model, important de-
DSM-5 Section II includes criteria for scriptive information about personality
the diagnosis of 10 specific PDs, arranged functioning and pathological personality
into three clusters based on descriptive traits is recorded for treatment planning
similarities. Cluster A is commonly re- and prognosis.
ferred to as the “odd or eccentric” clus- This chapter considers the manifesta-
ter and includes paranoid, schizoid, and tions, assessment, diagnosis, and differ-
schizotypal PDs. Cluster B, the “dra- ential diagnosis of PDs. Included are de-
matic, emotional, or erratic” cluster, in- scriptions of the clinical characteristics
cludes antisocial, borderline, histrionic, of the 10 DSM-5 PDs according to both
and narcissistic PDs. Cluster C, the “anx- Section II and Section III criteria. (In the
ious and fearful” cluster, includes avoid- case of the four Section II PDs repre-
ant, dependent, and obsessive-compul- sented by PD-TS in Section III, the de-
sive PDs. DSM-5 Section II also provides scriptions are based on typical impair-
the residual categories of other specified ments in personality functioning and
PD and unspecified PD. The former cat- characteristic pathological personality
egory is to be used when the general cri- traits—see Table 7–1.) Also included are
teria for a PD are met and features of approaches to clinical interviewing,
several different types of PD are present, along with discussions of problems in
but the criteria for a specific PD are not assessing a patient with a suspected PD,
met (i.e., “mixed” PD features) or the pa- such as state versus trait discrimination,
tient has a PD not included in the official trait versus disorder distinctions, and
Manifestations, Assessment, and Differential Diagnosis 133
TABLE 7–1. Crosswalk of DSM-5 Section II personality disorders to Section III

personality disorders and Criterion B pathological personality traits
DSM-5 Section II DSM-5 Section III personality disorder Pathological personality
personality disorder (Criterion B decision rules) traits (domains)
Paranoid PD-TSa Suspiciousness (DET)
Hostility (ANT)
Schizoid PD-TS Withdrawal (DET)
Intimacy avoidance (DET)
Anhedonia (DET)
Restricted affectivity (DET)
Schizotypal Schizotypal Cognitive and perceptual dys-
(4 or more) regulation (PSY)
Unusual beliefs and experi-
ences (PSY)
Eccentricity (PSY)
Withdrawal (DET)
Suspiciousness (DET)
Antisocial Antisocial Manipulativeness (ANT)
(6 or more) Callousness (ANT)
Deceitfulness (ANT)
Hostility (ANT)
Risk taking (DIS)
Impulsivity (DIS)
Irresponsibility (DIS)
Borderline Borderline Emotional lability (NA)
(4 or more; at least one of following traits Anxiousness (NA)
is required: impulsivity, risk taking, Separation insecurity (NA)
hostility) Depressivity (NA)
Impulsivity (DIS)
Risk taking (DIS)
Hostility (ANT)
Histrionic PD-TS Emotional lability (NA)
Attention seeking (ANT)
Manipulativeness (ANT)
Narcissistic Narcissistic Grandiosity (ANT)
(both) Attention seeking (ANT)
Avoidant Avoidant Anxiousness (NA)
(3 or more; anxiousness trait is required) Withdrawal (DET)
Anhedonia (DET)
Intimacy avoidance (DET)
Dependent PD-TS Submissiveness (NA)
Anxiousness (NA)
Separation insecurity (NA)
Obsessive-compulsive Obsessive-compulsive Rigid perfectionism (C)
(3 or more; rigid perfectionism trait is Perseveration (NA)
required) Intimacy avoidance (DET)
Note. ANT=Antagonism; C=Conscientiousness (opposite pole of DIS); DET=Detachment; DIS= Disinhibition;
NA=Negative Affectivity; PD-TS=personality disorder—trait specified; PSY=Psychoticism.
a
When a patient’s level of impairment in personality functioning is moderate or greater, but the pattern of im-
pairments or pathological personality traits do not correspond to one of the specific Section III personality dis-
orders, a diagnosis of PD-TS is made.
the effects of gender, culture, and age. least two of these areas. In contrast, Sec-
Despite limitations in the traditional cat- tion III general criteria focus on impair-
egorical DSM approach to personality ment in personality functioning and the
psychopathology, PDs diagnosed by this presence of pathological personality traits.
system have been shown since the 1980s Personality functioning consists of sense
to have considerable clinical utility in of self (identity and self-direction) and
predicting functional impairment over interpersonal relatedness (empathy and
and above that associated with other co- intimacy), capturing aspects of all four
morbid mental disorders, chronicity of Section II areas. The Section III patholog-
other co-occurring mental disorders, ex- ical trait domains of Negative Affectivity
tensive and intensive utilization of treat- and Disinhibition (see subsection “Crite-
ment resources, and, in many cases, ad- rion B: Pathological Personality Traits”
verse psychosocial outcomes. Thus, the below) elaborate on two of the Section II
recognition and accurate diagnosis of areas. Although the general criteria of the
personality psychopathology should be two models overlap, the Section III gen-
an important clinical priority. eral criteria have been shown empiri-
cally to be associated specifically with
PDs (Morey et al. 2011, 2013a), whereas
Defining Features of the Section II general criteria have not.
DSM-5 Section III
DSM-5 PDs are defined differently in
Section II and Section III. Each section has
Alternative Model for
a set of general criteria defining what is Personality Disorders
meant by a PD and individual criteria
The general criteria for a PD according to
sets for each specific diagnosis. When a
DSM-5 Section III require two initial de-
diagnosis is being made, it is useful to
terminations: 1) an assessment of the
consider how the specific manifestations
level of impairment in personality func-
of each PD align with the general defini-
tioning, which is needed for Criterion A,
tions according to each model.
and 2) an evaluation of pathological per-
sonality traits, which is required for Cri-
DSM-5 Section II Patterns terion B. The impairments in personality
of Inner Experience and functioning and personality trait expres-
sion are relatively inflexible and perva-
Behavior sive across a broad range of personal and
The general diagnostic criteria for a PD in social situations (Criterion C); relatively
DSM-5 Section II indicate that a pattern stable across time, with onsets that can be
of inner experience and behavior is man- traced back to at least adolescence or early
ifested by characteristic patterns of 1) cog- adulthood (Criterion D); not better ex-
nition (i.e., ways of perceiving and inter- plained by another mental disorder (Cri-
preting self, other people, and events); terion E); not attributable to a substance
2) affectivity (i.e., the range, intensity, la- or another medical condition (Criterion
bility, and appropriateness of emotional F); and not better understood as normal
response); 3) interpersonal functioning; for an individual’s developmental stage
and 4) impulse control. Persons with PDs or sociocultural environment (Criterion
are expected to have manifestations in at G). All Section III PDs described by crite-
rion sets and PD-TS meet these general ments to differentiate five levels of im-
criteria, by definition. (The appendix to pairment, ranging from little or no impair-
this textbook includes the complete ment (i.e., healthy, adaptive functioning;
wording of these general criteria.) Level 0), to some (Level 1), moderate
(Level 2), severe (Level 3), and extreme
Criterion A: Level of (Level 4) impairment.
Personality Functioning Impairment in personality function-
Disturbances in self and interpersonal ing predicts the presence of a PD, and
functioning constitute the core of per- the severity of impairment predicts
sonality psychopathology (Bender et al. whether an individual has more than one
2011). In the alternative Section III diag- PD or one of the more typically severe
nostic model, they are evaluated on a PDs (Morey et al. 2011). A moderate level
continuum, using the Level of Personal- of impairment in personality function-
ity Functioning Scale (LPFS). The LPFS ing is required for the diagnosis of a PD
assesses capacities that lie at the heart of based on empirical evidence that a mod-
personality and adaptive functioning. erate level of impairment maximizes the
Self functioning involves identity and ability of clinicians to accurately and ef-
self-direction; interpersonal functioning ficiently identify PD pathology (Morey
involves empathy and intimacy. et al. 2013a).
To use the LPFS, the clinician selects
• Identity is defined as the experience of the level that most closely captures the
oneself as unique, with clear boundar- individual’s current overall level of im-
ies between self and others; stability pairment in personality functioning. The
of self-esteem and accuracy of self- rating not only is necessary for the diag-
appraisal; and the capacity for, and the nosis of a PD (moderate impairment or
ability to regulate, a range of emo- greater) but also can be used to specify
tional experience. the severity of impairment present for an
• Self-direction is the pursuit of coher- individual with any PD at a given point
ent and meaningful short-term and in time. The LPFS may also be used as a
life goals; the utilization of construc- global indicator of personality function-
tive and prosocial internal standards ing without specification of a PD diag-
of behavior; and the ability to self- nosis, in the event that personality im-
reflect productively. pairment is subthreshold for a disorder
• Empathy is the comprehension and diagnosis, or as a severity change mea-
appreciation of others’ experiences sure during or following treatment. The
and motivations; tolerance of differ- full LPFS can be found in the appendix
ing perspectives; and an understand- to this textbook.
ing of the effects of one’s own behav-
ior on others.
Criterion B: Pathological
• Intimacy reflects the depth and dura- Personality Traits
tion of connection with others; a de- Pathological personality traits in DSM-5
sire and capacity for closeness; and a Section III are organized into five broad
mutuality of regard reflected in inter- trait domains: Negative Affectivity, De-
personal behavior. tachment, Antagonism, Disinhibition,
and Psychoticism. Within these five broad
The LPFS utilizes each of these ele- domains are 25 specific trait facets that
have been developed initially from a re- sonality trait model involves reviewing
view of existing trait models and then all five broad personality domains. This
through iterative research on samples of approach to personality assessment is
persons who sought mental health ser- similar to the well-known review of sys-
vices (Krueger et al. 2011a, 2011b, 2012). tems in clinical medicine.
The full trait taxonomy can be found in Clinical use of the Section III person-
the appendix to this textbook. Definitions ality trait model begins with an initial re-
of all personality domains and facets are view of all five broad domains of per-
provided in DSM-5 (American Psychiat- sonality. This systematic review may be
ric Association 2013, pp. 779–781). For facilitated by the use of formal psycho-
example, the domain of Negative Affec- metric instruments designed to measure
tivity is defined as “frequent and intense specific domains and facets of personal-
experiences of high levels of a wide range ity. For example, the personality trait
of negative emotions (e.g., anxiety, de- model is operationalized in the Personal-
pression, guilt/shame, worry, anger), and ity Inventory for DSM-5 (PID-5; Krueger
their behavioral (e.g., self-harm) and in- et al. 2012). The PID-5 can be completed
terpersonal (e.g., dependency) manifes- in its self-report form by patients and in
tations” (p. 779). The trait facet of emo- its informant-report form (Markon et al.
tional lability, a component of Negative 2013) by those who know the patient
Affectivity, is defined as “instability of well (e.g., a spouse). A detailed clinical
emotional experiences and mood; emo- assessment might involve collection of
tions that are easily aroused, intense, data from both patients and informants
and/or out of proportion to events and on all 25 facets of the personality trait
circumstances” (p. 779). The B criteria for model. However, if this is not possible,
the specific PDs comprise subsets of the because of time or other constraints, as-
25 trait facets, based on meta-analytic re- sessment focused at the five-domain level
views (Samuel and Widiger 2008; Sauls- is an acceptable clinical option when
man and Page 2004) and empirical data only a general portrait of a patient’s per-
on the relationships of the traits to DSM- sonality is needed. However, the more
IV PD diagnoses (Hopwood et al. 2012; that personality-based problems are the
L.C. Morey: “Developing and Evaluat- primary focus of treatment, the more im-
ing a DSM-5 Model for Personality Dis- portant it will be to assess individuals’
order Diagnosis: Data From a National trait facets as well as domains (Skodol et
Clinical Sample,” unpublished manual. 2013).
script, August 2012).
A personality trait is a tendency to feel,
perceive, behave, and think in relatively
Manifestations of Personality
consistent ways across time and across Psychopathology
situations in which the trait may be man-
ifested. The clinical utility of the Section Cognitive Features
III multidimensional personality trait PDs affect the ways persons think about
model lies in its ability to focus attention themselves and about their relationships
on multiple areas of personality varia- with other people. Most of the DSM-5 di-
tion in each individual patient. Rather agnostic criteria for paranoid PD (PPD)
than attention being focused on the iden- reflect a disturbance in cognition charac-
tification of one optimal diagnostic label, terized by pervasive distrust and suspi-
clinical application of the Section III per- ciousness of others. Persons with PPD
suspect that others are exploiting, harm- feels disappointed, neglected, or uncared
ing, or deceiving them; doubt the loyalty for. This phenomenon is commonly re-
or trustworthiness of others; read hid- ferred to as “splitting.” BPD is also a
den, demeaning, or threatening mean- specific PD in Section III, with severe im-
ings into benign remarks or events; and pairments in personality functioning,
perceive attacks on their character or rep- including a markedly impoverished,
utation. PPD would be diagnosed as PD- poorly developed, or unstable self-image.
TS in the alternative DSM-5 model for Persons with DSM-5 Section II narcis-
PDs (see Table 7–1). The level of impair- sistic PD (NPD) exhibit a grandiose sense
ment in personality functioning typically of self; have fantasies of unlimited suc-
would be severe or extreme, in part be- cess, power, brilliance, beauty, or ideal
cause of serious distortions in sense of love; and believe themselves to be spe-
self, and relevant pathological personal- cial or unique. DSM-5 Section III criteria
ity traits would include suspiciousness for NPD reflect evolved conceptualiza-
and possibly hostility. tions of pathological narcissism in which
Among the major symptoms of schizo- exaggerated self-appraisal may be either
typal PD (STPD) are characteristic cogni- inflated or deflated or vacillating between
tive and perceptual distortions, such as extremes, and grandiosity may be either
ideas of reference; odd beliefs and magi- overt or covert.
cal thinking (e.g., superstitiousness, be- In the area of personal identity, per-
lief in clairvoyance or telepathy); bodily sons with antisocial PD (ASPD), also a
illusions; and suspiciousness and para- specific PD in Section III, exhibit notable
noia similar to those observed in persons egocentrism bordering on grandiosity (al-
with PPD. STPD is a specific PD in the although the egocentrism may be masked
ternative DSM-5 model. It is characterized by relative immunity to stress) and a con-
by extreme impairments in personality comitant sense of entitlement and invul-
functioning, such as confused boundar- nerability. Self-esteem is disproportion-
ies between self and others, and by four ately high, leading to selfishness and
or more of six pathological personality overt or covert disregard for legal, moral,
traits, which include cognitive and per- or cultural restrictions, because goals are
ceptual dysregulation, unusual beliefs based on “instant gratification.”
and experiences, and suspiciousness— Persons with avoidant PD (AVPD) have
all cognitive manifestations. excessively negative opinions of them-
Persons with borderline PD (BPD) may selves. They see themselves as inept, un-
also experience transient paranoid ide- appealing, and inferior, and they con-
ation when under stress, but the charac- stantly perceive that they are being criti-
teristic cognitive manifestations of indi- cized or rejected. AVPD is a specific PD in
viduals with BPD are dramatic shifts in the alternative DSM-5 model. Specific im-
their views toward people with whom pairments in personality functioning are
they are intensely emotionally involved. generally at a moderate level, character-
These shifts emanate from disturbances ized in part by low self-esteem associated
in mental representations of self and oth- with self-appraisal as socially inept, per-
ers (Bender and Skodol 2007) and result sonally unappealing, or inferior.
in the individual’s overidealizing others Persons with dependent PD (DPD)
at one point and then devaluating them also lack self-confidence and believe that
at another point, when the individual they are unable to make decisions or to
take care of themselves. These individu- anxiety, or irritability. They are also prone
als are characterized by moderate im- to inappropriate, intense outbursts of an-
pairment in personality functioning ac- ger and are often preoccupied with fears
cording to the Section III model because of being abandoned by those they are at-
of identities that are dependent on the tached to and reliant upon. Emotional la-
presence of reassuring others. bility, depressivity, and hostility are three
Persons with obsessive-compulsive Criterion B personality traits in the alter-
PD (OCPD) are perfectionistic and rigid native model rendition of BPD. Persons
in their thinking and are often preoccu- with histrionic PD often display rapidly
pied with details, rules, lists, and order. shifting emotions that seem to be dra-
Their personality functioning is also at a matic and exaggerated but are shallow in
moderate level of impairment, in part be- comparison to the intense emotional ex-
cause of a sense of self that is derived pre- pression seen in BPD. Emotional lability
dominantly from work or productivity. would be a relevant trait for such patients
diagnosed according to Section III. Per-
Affective Features sons with ASPD characteristically have
Some persons with PDs are emotionally problems with irritability and aggressive
constricted, whereas others are exces- feelings toward others, as expressed in the
sively emotional. Among the constricted context of threat or intimidation. Hostility
types are individuals with schizoid PD, is one of the trait criteria for ASPD in Sec-
who experience little pleasure in life, ap- tion III. Persons with AVPD are domi-
pear indifferent to praise or criticism, and nated by anxiety in social situations; those
are generally emotionally cold, detached, with DPD are preoccupied by anxiety
and unexpressive. Persons with STPD over the prospects of separation from
also often have constricted or inappro- caregivers and the need to be indepen-
priate affect, although they can exhibit dent. Anxiousness also characterizes
anxiety in relation to their paranoid fears. AVPD in the Section III criteria and would
Persons with OCPD have considerable be a relevant trait for the PD-TS represen-
difficulty expressing loving feelings to- tation of DPD.
ward others, and when they do express
affection, they do so in a highly con- Interpersonal Features
trolled or stilted manner. Restricted af- Interpersonal problems are probably
fectivity is a trait in the Section III B cri- most obviously identifiable in PDs (Benja-
teria for both STPD and OCPD. Schizoid min 1996; Gunderson 2007; Hill et al. 2008;
PD is diagnosed as PD-TS in the alterna- Kiesler 1996). Other mental disorders are
tive model. The relevant pathological per- characterized by prominent cognitive or
sonality traits would include anhedonia affective features or by problems with im-
and restricted affectivity, from the De- pulse control. All PDs, however, have in-
tachment trait domain. terpersonal manifestations coupled with
Among the most emotionally expres- problems in sense of self, as captured by
sive persons with PDs are those with bor- the Section III LPFS and the A criteria for
derline and histrionic PDs. Persons with the six specific PDs and PD-TS. Each of
BPD are emotionally labile and react very the six disorders has characteristic prob-
strongly, particularly in interpersonal lems with empathy and intimacy.
contexts, with a variety of intensely dys- Persons with ASPD deceive and in-
phoric emotions, such as depression, timidate others for personal gain. Sub-
stantially lacking in empathy, they have of losing their support or approval and
no concern for the feelings of others and will actually do things that are unpleas-
lack remorse if they hurt someone. In the ant, demeaning, or self-defeating to re-
area of intimacy, they are incapable of ceive nurturance from others. Because of
having mutually intimate relationships, the self-sacrificing approach to relation-
because they are exploitative or control- ships, real intimacy and empathy are elu-
ling of others. Pathological personality sive. Submissiveness and separation in-
traits include manipulativeness, callous- security would be relevant Section III
ness, deceitfulness, and irresponsibility. personality traits.
Persons with histrionic and narcissistic The empathy of persons with BPD is
PDs need to be the center of attention biased toward the negative tendencies
and require excessive admiration. Inti- and vulnerabilities of others. Intimate re-
mate relationships are generally shal- lationships are extremely challenging,
low, and people are sought out predom- with a pattern of becoming “deeply” in-
inantly in the service of bolstering self- volved and dependent only to turn ma-
esteem. Empathic concerns center on is- nipulative and demanding when their
sues that have direct implications for the needs are not met. They have interper-
person with the PD. Both disorders would sonal relationships that are unstable and
be characterized by the trait of attention conflicted, and these individuals alternate
seeking according to the Section III between overinvolvement with others
model. In addition, histrionic PD might and withdrawal. Separation insecurity is
also be characterized by the trait of ma- a relevant Section III Criterion B trait.
nipulativeness. The degree of detachment associated
Persons with OCPD have difficulties with persons with paranoid, schizoid, and
appreciating others’ perspectives, and schizotypal PDs serves as a pronounced
instead need to control them and have impediment to empathy and intimacy in
them submit to their ways of doing things. interpersonal relations. Individuals with
Intimacy is circumscribed by stubborn- schizoid PD manifest an apparent lack
ness and rigidity, and a preference for of need for closeness with others; those
engaging in tasks rather than pursuing with PPD do not trust others enough to
close relationships. Traits of rigid per- become deeply involved; and those with
fectionism and intimacy avoidance ad- STPD have few friends or confidants, in
versely affect the interpersonal relation- part from a lack of trust and in part as a
ships of individuals with OCPD. result of poor communication and inad-
The interpersonal relationships of equate relatedness. Section III traits of
persons with AVPD and DPD are im- suspiciousness, withdrawal, and inti-
poverished as a result of fear and sub- macy avoidance lead to social isolation.
missiveness. Individuals with AVPD are
inhibited in interpersonal relationships
Problems With Impulse
because they are afraid of being shamed Control
or ridiculed. Empathy is impaired be- Problems with impulse control can also
cause of a distorted sense of others’ ap- be viewed as extremes on a continuum.
praisal and acute rejection sensitivity. In- PDs characterized by a lack of impulse
timacy avoidance and withdrawal are control include ASPD and BPD. Disor-
Criterion B personality traits for Section ders involving problems with overcon-
III AVPD. Individuals with DPD will not trol include AVPD, DPD, and OCPD.
disagree with important others for fear ASPD is a prototype of a PD character-
ized by impulsivity. Persons with ASPD in Table 7–2 and contrasted to DSM-5
break laws, exploit others, fail to plan Section III central features.
ahead, get into fights, ignore commit-
ments and obligations, and exhibit gener- Pervasiveness and
ally reckless behaviors without regard for
consequences, such as speeding, driving Inflexibility
while intoxicated, having impulsive sex, For a PD to be present, the disturbances
or abusing drugs. Persons with BPD also have to be manifested frequently through
show many problems with impulse con- a wide range of behaviors, feelings, and
trol, including impulsive spending, in- perceptions and in many different con-
discriminate sex, substance abuse, reck- texts. In DSM-5 Section II, attempts are
less driving, and binge eating. In made to stress the pervasiveness of the
addition, individuals with BPD experi- behaviors caused by PDs. Added to the
ence recurrent suicidal thoughts and im- basic definition of each PD and serving as
pulses. Suicide attempts and self-injuri- the “stem” to which individual features
ous behavior, such as cutting or burning, apply is the phrase “present in a variety
are common. Section III personality traits of contexts.” For example, the diagnostic
that predispose to these behaviors in- features of PPD in DSM-5 Section II, pre-
clude impulsivity and risk taking from ceding the specific criteria, begin as fol-
the Disinhibition trait domain and are lows: “A pervasive distrust and suspi-
among the B criteria for both ASPD and ciousness of others such that their
BPD. Finally, persons with BPD have motives are interpreted as malevolent,
problems with anger management, have beginning by early adulthood and pres-
frequent temper outbursts, and at times ent in a variety of contexts, as indicated
may even engage in physical fights. Hos- by four (or more) of the following”
tility is a trait in the criteria for both (American Psychiatric Association 2013,
ASPD and BPD. p. 649). Similarly, for DPD, the criteria are
In contrast to individuals with disin- preceded by this description: “A perva-
hibited behavior, persons with AVPD are sive and excessive need to be taken care
excessively inhibited, especially in rela- of that leads to submissive and clinging
tion to people, and are reluctant to take behavior and fears of separation, begin-
risks or to undertake new activities. Per- ning by early adulthood and present in a
sons with DPD cannot even make basic variety of contexts, as indicated by five
decisions and do not take initiative to start (or more) of the following” (American
things. Persons with OCPD are overly Psychiatric Association 2013, p. 675). The
conscientious and scrupulous about mo- manifestations of Section III personality
rality, ethics, and values; they cannot traits are pervasive by definition, in that
bring themselves to throw away even they are tendencies or predispositions to
worthless objects and can be miserly. think, feel, and behave in particular pat-
They are characterized by rigid per- terned ways.
fectionism, which is the opposite of the Inflexibility is a feature that helps to
traits characterizing the domain of Disin- distinguish personality traits or styles
hibition. and PDs. Inflexibility is indicated by a
The DSM-5 Section II PD clusters, narrow repertoire of responses that are
specific PD types, and their principal de- repeated even when the situation calls for
fining clinical features are summarized an alternative behavior or in the face of
Manifestations, Assessment, and Differential Diagnosis
TABLE 7–2. Defining features of DSM-5 Section II and Section III personality disorders
Personality disorder Section II features Section III features
Section II Cluster A Odd or eccentric

Paranoid Pervasive distrust and suspiciousness of others such that See Table 7–1.
their motives are interpreted as malevolent
Schizoid Pervasive pattern of detachment from social relationships See Table 7–1.
and a restricted range of expression of emotions in inter-
personal settings
Schizotypal Pervasive pattern of social and interpersonal deficits Typical features are impairments in the capacity for social and close
marked by acute discomfort with, and reduced capacity relationships, and eccentricities in cognition, perception, and be-
for, close relationships as well as by cognitive or percep- havior that are associated with distorted self-image and incoherent
tual distortions and eccentricities of behavior personal goals and accompanied by suspiciousness and restricted
emotional expression.
Section II Cluster B Dramatic, emotional, or erratic
Antisocial Pervasive pattern of disregard for and violation of the Typical features are a failure to conform to lawful and ethical behav-
rights of others, occurring since age 15 years; current age ior, and an egocentric, callous lack of concern for others, accompa-
at least 18 years nied by deceitfulness, irresponsibility, manipulativeness, and/or
risk taking.
Borderline Pervasive pattern of instability of interpersonal relation- Typical features are instability of self-image, personal goals, inter-
ships, self-image, and affects, and marked impulsivity personal relationships, and affects, accompanied by impulsivity,
risk taking, and/or hostility.
Histrionic Pervasive pattern of excessive emotionality and attention See Table 7–1.
seeking
Narcissistic Pervasive pattern of grandiosity (in fantasy or behavior), Typical features are variable and vulnerable self-esteem, with at-
need for admiration, and lack of empathy tempts at regulation through attention and approval seeking, and
either overt or covert grandiosity.
141
142
TABLE 7–2. Defining features of DSM-5 Section II and Section III personality disorders (continued)
Personality disorder Section II features Section III features

Section II Cluster C Anxious or fearful
Avoidant Pervasive pattern of social inhibition, feelings of inade- Typical features are avoidance of social situations and inhibition in
quacy, and hypersensitivity to negative evaluation interpersonal relationships related to feelings of ineptitude and in-
adequacy, anxious preoccupation with negative evaluation and re-
jection, and fears of ridicule or embarrassment.
Dependent Pervasive and excessive need to be taken care of that See Table 7–1.
leads to submissive and clinging behavior and fears
of separation
Obsessive-compulsive Pervasive pattern of preoccupation with orderliness, Typical features are difficulties in establishing and sustaining close
perfectionism, and mental and interpersonal control, relationships, associated with rigid perfectionism, inflexibility, and
at the expense of flexibility, openness, and efficiency restricted emotional expression.
Source. Adapted from the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Arlington, VA, American Psychiatric Association, 2013. Used with permission.
Copyright © 2013 American Psychiatric Association.
clear evidence that a behavior is inappro- tations of PDs actually are and what the
priate or not working. For example, a stable components of PDs are have be-
person with OCPD rigidly adheres to come areas of active empirical research.
rules and organization even in recreation It may be that personality psychopathol-
and loses enjoyment as a consequence. A ogy waxes and wanes depending on the
person with AVPD is so fearful of being circumstances of a person’s life (see Chap-
scrutinized or criticized, even in group ter 8, “Course and Outcome,” in this vol-
situations in which he or she could hardly ume). Personality traits (Hopwood et al.
be the focus of such attention, that life be- 2013) and impairments in personality
comes painfully lonely. functioning may be more stable than
PDs themselves. In DSM-5 Section III,
Onset and Clinical Course the course of PDs is described, in the cri-
teria, as “relatively” stable to allow for
Personality and PDs have traditionally
some fluctuation in their manifestations.
been assumed to reflect stable descrip- Although the age at onset of PDs has
tions of a person, at least after a certain traditionally been considered to be in
age. Thus, the patterns of inner experi-
childhood or adolescence, later onsets
ence and behaviors described earlier are can be observed (e.g., Skodol et al. 2007),
called “enduring.” PD is also described including onsets in late life (Oltmanns
as “of long duration,” with an onset that
and Balsis 2011).
“can be traced back at least to adolescence
or early adulthood” (American Psychi-
atric Association 2013, pp. 646–647). Impairment in Functioning
These concepts persist as integral to the All PDs are maladaptive and are accom-
definition of PD despite a large body of panied by functional problems in school
empirical evidence that suggests that PD or at work, in social relationships, or at
psychopathology is not as stable as the leisure. The requirement for impairment
DSM definition would indicate. Longi- in psychosocial functioning is codified in
tudinal studies indicate that PDs, as de- DSM-5 Section II in its Criterion C of the
fined by DSM-IV (and DSM-5 Section II) general diagnostic criteria for a PD: “the
criteria, tend to improve over time, at enduring pattern [of ‘inner experience
least from the point of view of their overt and behavior’—i.e., personality] leads to
clinical signs and symptoms (Gunder- clinically significant distress or impair-
son et al. 2011; Johnson et al. 2000; Len- ment in social, occupational, or other im-
zenweger et al. 2004; Zanarini et al. portant areas of functioning” (American
2012). These traditional PD criteria sets, Psychiatric Association 2013, p. 646).
however, consist of combinations of path- A number of studies have compared
ological personality traits and symptom- patients with PDs with patients with no
atic behaviors (McGlashan et al. 2005; PD or with DSM-IV Axis I disorders and
Zanarini et al. 2007). Some behaviors, have found that patients with PDs were
such as self-mutilating behavior (a man- more likely to be functionally impaired
ifestation of one of the criteria for BPD), (Skodol and Gunderson 2008). Specifi-
may be evidenced much less frequently cally, they are more likely to be separated,
than traits such as “views self as socially divorced, or never married and to have
inept, personally unappealing, or infe- had more unemployment, frequent job
rior to others” (one of the criteria for changes, or periods of disability. Fewer
AVPD). How stable individual manifes- studies have examined quality of func-
tioning, but in those that have, poorer so- DSM-5 Section III criteria for PDs do
cial functioning or interpersonal relation- not include a requirement for impair-
ships and poorer work functioning or ment in psychosocial functioning. This
occupational achievement and satis- change is in keeping with some other
faction have been found among patients disorders in DSM-5, for which attempts
with PDs than among patients with other have been made to separate the mani-
disorders. When patients with different festations of a disorder (i.e., signs, symp-
PDs were compared with each other on toms, traits) from their consequences (i.e.,
levels of functional impairment, those impact on occupational, social, and lei-
with severe PDs, such as STPD and BPD, sure functioning). Furthermore, Section
were found to have significantly more III PDs all include specific impairments
impairment at work, in social relation- in personality functioning at a moderate
ships, and at leisure than patients with level or greater. This change is consistent
less severe PDs, such as OCPD, or with with the distinction between mental func-
an impairing other mental disorder, such tions that lead to symptoms (e.g., emo-
as major depressive disorder without PD. tional regulation, reward dependence,
Patients with AVPD had intermediate reality testing) and the disabilities that ac-
levels of impairment. Even the less im- company disturbances in these func-
paired patients with PDs (e.g., those with tions (Sartorius 2009).
OCPD), however, had moderate to severe
impairment in at least one area of func-
tioning (or a Global Assessment of Func- Approaches to
tioning rating of 60 or less) (Skodol et al. Clinical Interviewing
2002). The finding that significant impair-
ment may be in only one area suggests Interviewing a patient to assess for a pos-
that persons with PDs differ not only in sible PD presents certain challenges that
the degree of associated functional im- are somewhat unique. Thus, the inter-
pairment but also in the breadth of im- viewer is likely to need to rely on a variety
pairment across functional domains. of techniques for gathering information
Another important aspect of the im- to arrive at a clinical diagnosis, including
pairment in functioning in persons with observation and interaction with the pa-
PDs is that it tends to be persistent even tient, direct questioning of the patient,
beyond apparent improvement in the PD and interviewing of informants.
psychopathology itself (Gunderson et al.
2011; Seivewright et al. 2004; Skodol et al. Observation and
2005). The persistence of impairment is
understandable if one considers that PD Interaction
psychopathology has usually been long- One problem in evaluating a patient for
standing and, therefore, has disrupted a a PD arises from the fact that many peo-
person’s work and social development ple are not able to view their own per-
over a period of time (Roberts et al. sonality objectively (Zimmerman 1994).
2003). The residua, or “scars,” of PD pa- Because personality is, by definition, the
thology take time to heal or be over- way a person sees, relates to, and thinks
come. With time (and treatment), how- about himself or herself and the environ-
ever, improvements in functioning can ment, a person’s assessment of his or her
occur (Zanarini et al. 2010). own personality must be colored by it.
The expression of other psychopathology range of PDs (Blashfield and Herkov

may also be colored by personality style— 1996; Morey and Ochoa 1989; Zimmer-
for example, symptoms of depression are man and Mattia 1999). In routine clinical
exaggerated by the histrionic personal- practice, clinicians have tended to use
ity or minimized by the compulsive per- the nonspecific diagnosis of PD not oth-
sonality—but the symptoms of most erwise specified when they believed that
mental disorders are usually more clearly a patient’s presentation met the general
alien to the patient and more easily iden- criteria for a PD, because they often did
tified as problematic. People often learn not have enough information to make a
about their own problem behaviors and specific diagnosis (Verheul and Widiger
their maladaptive patterns of interaction 2004). Alternatively, clinicians will diag-
with others through the reactions or ob- nose PDs hierarchically: once a patient is
servations of other people in their envi- seen as having one (usually severe) PD,
ronments. such as BPD, the clinician will not assess
Traditionally, clinicians have not con- whether traits of other PDs are also pres-
ducted the same kind of interview in as- ent (Herkov and Blashfield 1995).
sessing patients suspected of having a Reliance on the clinician-patient in-
personality disturbance as they do with teraction for personality diagnosis runs
persons suspected of having, for exam- the risk of generalizing a mode of inter-
ple, a mood or an anxiety disorder. personal relating that may be limited to
Rather than directly questioning the pa- a particular situation or context—that is,
tient about characteristics of his or her to the evaluation itself. Although the cli-
personality, the clinician, assuming that nician-patient interaction can be a use-
the patient cannot accurately describe ful and objective observation, caution
these traits, looks for patterns in the way should be used in interpreting its signif-
patients describe themselves, their social icance, and the clinician must attempt to
relations, and their work functioning. integrate this information into a broader
These three areas usually give the clear- overall picture of a patient’s personality
est picture of personality traits or style in functioning.
general and of problems in personality
functioning specifically. Clinicians have
also relied heavily on their observations
Direct Questioning
of how patients interact with them dur- In psychiatric research, a portion of the
ing an evaluation interview or in treat- poor reliability of PD diagnosis has been
ment as manifestations of their patients’ assumed to be due to the variance in in-
personalities (Westen 1997). formation resulting from unsystematic
These approaches have the advantage assessment of personality traits. There-
of circumventing the potential lack of fore, efforts have been made to develop
objectivity patients might have about various structured methods for assess-
their personalities, but they also create ing PDs (McDermut and Zimmerman
problems. The clinician usually comes 2008) comparable with those that have
away with a global impression of the pa- been successful in reducing information
tient’s personality but frequently is not variance in assessing other mental disor-
aware of many of that patient’s specific ders (Kobak et al. 2008). These methods
personality characteristics because the include 1) self-report measures such as the
clinician has not made a systematic as- Personality Diagnostic Questionnaire–4
sessment of the manifestations of the wide (Hyler 1994), the Millon Clinical Multiax-
ial Inventory–III (Millon et al. 2009), the diagnoses have been shown to have in-
Minnesota Multiphasic Personality In- cremental validity in predicting psycho-
ventory–2 (Butcher et al. 2001), and the social functioning prospectively after 5
aforementioned Personality Inventory for years over diagnoses assigned by a treat-
DSM-5 (Krueger et al. 2012), and 2) clin- ing clinician (Samuel et al. 2013). A sem-
ical interviews such as the Structured In- istructured interview for the DSM-5
terview for DSM-IV Personality (Pfohl et Section III alternative model for PDs is
al. 1997), the International Personality under development.
Disorder Examination (Loranger 1999),
the Structured Clinical Interview for
DSM-IV Axis II Personality Disorders
Interviewing Informants
(First et al. 1997), the Diagnostic Inter- Frequently, an individual with a PD con-
view for DSM-IV Personality Disorders sults a mental health professional for
(Zanarini et al. 1996), and the Personal- evaluation or treatment because another
ity Disorder Interview–IV (Widiger et al. person has found his or her behavior
1995). problematic. This person may be a boss,
The interviews have been based on spouse, boyfriend or girlfriend, teacher,
the general premise that the patient can parent, or representative of a social agency.
be asked specific questions that will in- Indeed, some people with PDs do not
dicate the presence or absence of each of even recognize the problematic aspects of
the criteria of each of the 10 DSM-IV PD their manner of relating or perceiving ex-
types. The self-report instruments are cept as it has a negative effect on someone
generally considered to require a follow- with whom they interact.
up interview because of a very high rate Because of these “blind spots” that peo-
of apparently false-positive responses, ple with PDs may have, the use of a third-
but data from studies comparing self-re- party informant in the evaluation can be
port measures with clinical interviews useful. In some treatment settings, such
suggest that the former aid in identifica- as a private individual psychotherapy
tion of personality disturbances (Hyler practice, it may be considered counter-
et al. 1990). Thus, the clinician can keep productive or contraindicated to include
in mind that patients do not necessarily a third party, but in many inpatient and
deny negative personality attributes. In outpatient settings, at least during the
fact, the evidence suggests that patients evaluation process, it may be appropriate
may even overreport traits that clini- and desirable to see some person close to
cians might not think are very important the patient to corroborate both the pa-
and that patients can, if asked, consis- tient’s report and one’s own clinical im-
tently describe a wide range of personal- pressions.
ity traits to multiple interviewers. A self- Of course, there is no reason to as-
report inventory might be an efficient sume that the informant is free of bias or
way to help focus a clinical interview on not coloring a report about the patient
a narrower range of PD psychopathology. with his or her own personality style. In
A semistructured interview is useful clini- fact, the correspondence between pa-
cally when the results of an assessment tient self-assessments of PD psychopa-
might be subject to close scrutiny, such thology and informant assessments has
as in child custody, disability, or forensic generally been found to be modest at
evaluations. Both self-report question- best (Klonsky et al. 2002). Agreement on
naires and semistructured interview PD pathological personality traits, tempera-
ment, and interpersonal problems ap- sonal relationships with people inter-
pears to be somewhat better than on acting in different social roles with the
DSM PDs. Informants usually report patient, and the nature of the patient-
more personality psychopathology than clinician relationship should be inte-
patients. Agreement on PDs between grated into a comprehensive assessment
patient self-assessments and informant of pervasiveness. Too often, clinicians
assessments is highest for Cluster B displace disproportionate importance on a
orders (excluding NPD), lower for Clus- patient’s functioning at a particular job
ters A and C, and lowest for traits re- or with a particular boss or significant
lated to narcissism and entitlement, as other person. Therefore, it is very impor-
might be expected. Therefore, the clini- tant to ask patients to describe their rela-
cian must make a judgment about the tionships and functioning across several
objectivity of the informant and use this different areas of life.
as a part, but not a sufficient part, of the
overall data on which to base a PD diag- State Versus Trait
nosis. Which source—the patient or the
informant—provides information that is An issue that cuts across all PD diagno-
more useful for clinical purposes, such ses and presents practical problems in
as choosing a treatment or predicting differential diagnosis is the distinction
outcome (e.g., Klein 2003), has yet to be between clinical state and personality
determined definitively. trait. Personality is presumed to be a rel-
atively enduring aspect of a person, yet
assessment of personality ordinarily
Problems in takes place cross-sectionally—that is, over
a brief interval in time. Thus, the clini-
Clinical Interviewing cian is challenged to separate out long-
term dispositions of the patient from
Pervasiveness other more immediate or situationally
The pervasiveness of personality distur- determined characteristics. This task is
bance can be difficult to determine. When made more complicated by the fact that
a clinician inquires whether a person the patient often comes for evaluation
“often” has a particular experience, a pa- when there is some particularly acute
tient will frequently reply “sometimes,” problem, which may be a social or job-
which then has to be judged for clinical related crisis or the onset of an another
significance. What constitutes a neces- mental disorder. In either case, the situa-
sary frequency for a particular trait or tion in which the patient is being evalu-
behavior and in how many different ated is frequently a state that is not com-
contexts or with how many different pletely characteristic of the patient’s life
people the trait or behavior needs to be over the longer run.
expressed have not been well worked
out. Clinicians are forced to rely on their Assessing an
own judgment, keeping in mind also Enduring Pattern
that maladaptivity and inflexibility are
hallmarks of pathological traits. DSM-5 Section II indicates that PDs are
For the clinician interviewing a pa- of long duration and are not “better
tient with a possible PD, data about the explained as a manifestation or con-
many areas of functioning, the interper- sequence of another mental disorder”
(American Psychiatric Association 2013, years; an adolescent exhibiting signifi-

p. 647). Making these determinations in cant antisocial behavior before age 18 is
practice is not easy. First of all, an accu- diagnosed with conduct disorder.
rate assessment requires recognition of Regarding the course of a PD, DSM-5
current state. An assessment of current states that PDs are relatively stable over
state, in turn, includes knowledge of the time, although certain of them (e.g., ASPD
circumstances that have prompted the and BPD) may become somewhat atten-
person to seek treatment, the conse- uated with age, whereas others (e.g.,
quences in terms of the decision to seek OCPD and STPD) may not or may, in
treatment, the current level of stress, and fact, become more pronounced. As men-
any other psychopathology, if present. tioned earlier (see the subsection “Onset
It is not clear from the diagnostic cri- and Clinical Course”) and discussed in
teria of DSM-5 how long a pattern of greater detail in Chapter 8 of this vol-
personality disturbance needs to be pres- ume, this degree of stability may not
ent, or when it should become evident, necessarily pertain to all of the features
for a PD to be diagnosed. Earlier itera- of all DSM-5 PDs equally.
tions of DSM stated that patients were To assess stability retrospectively, the
usually 18 years or older when a PD was clinician must ask questions about peri-
diagnosed because it can be argued that, ods of a person’s life that are of various
up to that age, a personality pattern degrees of remoteness from the current
could neither have been manifest long situation. Retrospective reporting is sub-
enough nor have become significantly ject to distortion, however, and the only
entrenched to be considered a stable sure way of demonstrating stability over
constellation of behavior. DSM-5 states, time, therefore, may be to do prospective
however, that some manifestations of follow-up evaluations. Thus, from a prac-
PD are usually recognizable by adoles- tical, clinical point of view, PD diagnoses
cence or earlier and that PDs can be di- made cross-sectionally and on the basis
agnosed in persons younger than age 18 of retrospectively collected data might be
years who have manifested symptoms considered tentative or provisional pend-
for at least 1 year. Longitudinal research ing confirmation by longitudinal evalua-
has shown that PD symptoms evident in tion. On an inpatient service, a period of
childhood or early adolescence may not intense observation by many profession-
persist into adult life (Johnson et al. 2000). als from diverse perspectives may suffice
Longitudinal research has also shown to establish a pattern over time (Skodol et
that there is continuity between certain al. 1991). In a typical outpatient setting in
disorders of childhood and adolescence which encounters with the patients are
and PDs in early adulthood (Kasen et al. much less frequent, more time may be re-
1999, 2001). Thus, a young boy with op- quired. Ideally, features of a PD should be
positional defiant or attention-deficit/ evident over several years, but it is not
hyperactivity disorder in childhood may practical to wait inordinate amounts of
go on to develop conduct disorder as an time before coming to a diagnostic con-
adolescent, which can progress to full- clusion. Interestingly, even PDs that im-
blown ASPD in adulthood (Bernstein et prove with time are associated with ad-
al. 1996; Lewinsohn et al. 1997; Rey et al. verse outcomes of a variety of other
1995; Zoccolillo et al. 1992). ASPD is the comorbid mental disorders (Ansell et al.
only diagnosis not given before age 18 2011; Grilo et al. 2005).
Assessing the Effect of a thology that in fact is the prodrome of an-

other mental disorder. Distinguishing
Comorbid Disorder
Cluster A PDs, such as paranoid, schiz-
The presence of another comorbid men- oid, and schizotypal, from the early signs
tal disorder can complicate the diagnosis of disorders in the schizophrenia spec-
of a PD in several ways (Zimmerman trum and other psychotic disorders class
1994). Another mental disorder may cause can be particularly difficult. When evalu-
changes in a person’s behavior or atti- ating a patient early in the course of the
tudes that can appear to be signs of a PD. initial onset of a psychotic disorder, a cli-
Depression, for example, may cause a per- nician may be confronted with changes in
son to seem excessively dependent, avoid- the person toward increasing suspicious-
ant, or self-defeating. Cyclothymic or bi- ness, social withdrawal, eccentricity, or
polar II disorder may lead to periods of reduced functioning. Because the diag-
grandiosity, impulsivity, poor judgment, nosis of psychotic disorders, including
and depression that might be confused schizophrenia, requires that the patient
with manifestations of NPD or BPD. have an episode of active psychosis with
The clinician must be aware of the delusions, hallucinations, or disorga-
other psychopathology and assess it nized speech, it is not possible to diag-
within the context of an individual’s per- nose this prodrome as a psychotic disor-
sonality. The clinician can attempt this der. In fact, until the full-blown disorder
by asking about aspects of personality is present, the clinician cannot be certain
functioning at times when the patient is if it is, indeed, a prodrome.
not experiencing other mental disorder If a change in behavior is of recent on-
symptoms. This approach is particularly set, then it may not meet the stability cri-
feasible when the other disorder is of re- teria for a PD. In such cases, the clinician
cent onset and short duration or, if more is forced to diagnose an other specified or
chronic, if the course of the disorder has unspecified mental disorder. If, however,
been characterized by relatively clear- the pattern of suspiciousness or social
cut episodes with complete remission withdrawal with or without eccentricities
and symptom-free periods of long dura- has been well established, it may legiti-
tion. When the other disorder is chronic mately be a PD and be diagnosed as such.
and unremitting, that psychopathology If the clinician follows such a patient
and personality functioning blend to- over time and the patient develops a full-
gether to an extent that can make differ- fledged psychotic disorder, the personal-
entiating between them seem artificial. ity disturbance is no longer adequate for
Nonetheless, research has shown that a complete diagnosis because no PD in-
PDs diagnosed in the presence of an- cludes frankly psychotic symptoms. This
other mental disorder, specifically major fairly obvious point is frequently over-
depressive disorder, have a clinical course looked in practice. All of the PDs that have
and outcomes very similar those of PDs counterpart psychotic disorders have
diagnosed in the absence of major de- milder or “attenuated” symptoms in
pressive disorder (Morey et al. 2010). which reality testing is, at least in part, in-
Another example of the way in which tact. For instance, a patient with PPD may
other mental disorders and PDs interact have referential ideas but not frank delu-
to obscure differential diagnosis is the sions of reference, and a patient with
case of apparent personality psychopa- STPD may have illusions but not halluci-
nations. A possible exception is BPD, in nosed PDs (e.g., BPD with histrionic fea-
which brief psychotic experiences (last- tures). In practice, however, this option
ing minutes to an hour or two at most) has been seldom used, even though re-
are included in the Section II diagnostic search has shown that in addition to the
criteria. In all cases, however, when the approximately 50% of clinic patients
patient becomes psychotic for even a day whose presentation meets criteria for a
or two, an additional psychotic disorder PD, another 35% warrant information de-
diagnosis is necessary. scriptive of their personality styles (Kass
For the patient with a diagnosis of et al. 1985). This issue is likely to become
STPD, the occurrence of a 1-month-long exacerbated by the elimination of Axis II
psychotic episode (active-phase symp- in DSM-5, although the comprehensive
toms) almost certainly means the distur- pathological trait model in Section III
bance will meet the criteria for schizo- gives the clinician more guidance about
phrenia, with the symptoms of STPD potentially relevant traits and explicitly
“counting” as prodromal symptoms to- states that they are intended to be used
ward the 6-month continuous duration whether a person has a PD or not.
requirement. Under these circumstances, The following case example describes
the diagnosis of schizophrenia, with its a patient with a mental disorder whose
pervasive effects on cognition, perception, ongoing treatment was very much af-
functional ability, and so on, is sufficient, fected by personality traits, none of which
and a diagnosis of STPD is redundant. met the criteria for a specific PD.
When the patient becomes nonpsychotic
again, he or she would be considered to Case Example
have “residual schizophrenia” instead
Sara, a 25-year-old single female re-
of STPD. ceptionist, was referred for outpatient
therapy following hospitalization for
Personality Traits Versus her first manic episode. The patient
had attended college for 1 year but
Personality Disorders dropped out in order to “go into ad-
vertising.” Over the next 5 years, she
Another difficult distinction is between had held a series of receptionist, sec-
personality traits or styles and PDs. All retarial, and sales jobs, each of which
patients—all people for that matter— she quit because she wasn’t “getting
ahead in the world.” Sara lived alone
can be described in terms of distinctive
on the north side of Chicago in an
patterns of personality, but all do not apartment that her parents had fur-
necessarily warrant a diagnosis of PD. nished for her. She ate all of her meals,
Overdiagnosing is particularly common however, at her mother’s house and
among inexperienced evaluators. The claimed not even to have a box of
important features that distinguish path- crackers in her cupboard. Between
her jobs, her parents paid her rent.
ological personality traits from normal
Sara’s “career” problems stemmed
traits are their inflexibility and maladap- from the fact that although she felt
tiveness. quite ordinary and without talent for
DSM-5 acknowledges that it is impor- the most part, she had fantasies of a
tant to describe personality style as well career as a movie star or high fashion
model. She took acting classes and
as to diagnose PDs. Therefore, instruc-
singing lessons, but she had never
tions are included to list personality traits had even a small role in a play or
even when a PD is absent, or to include show. What she desired was not so
them as modifiers of one or more diag- much the careers themselves as the
glamour associated with them. Al- to meet DSM-5 criteria for any specific
though she wanted to move in the cir- type of PD. On the other hand, her
cles of the “beautiful people,” she was presentation almost met the criteria
certain that she had nothing to offer for several PDs, especially BPD: the
them. Sara sometimes referred to her- patient showed signs of impulsivity
self as nothing but a shell and scorned (overeating, sexual promiscuity), in-
herself because of it. She was unable tense interpersonal relationships
to picture herself working her way up (manipulativeness, overidealization/
along any realistic career line, feeling devaluation), identity disturbance,
both that it would take too long and and chronic feelings of emptiness.
that she would probably fail. She did not, however, display intense
Sara had had three close relation- anger, intolerance of being alone,
ships with men that were character- physically self-damaging behavior,
ized by an intense interdependency stress-related paranoia or dissocia-
that initially was agreeable to both tion, or affective instability indepen-
parties. She craved affection and atten- dent of her mood disorder. Similarly,
tion and fell deeply in love with these Sara had symptoms of histrionic PD:
men. However, she eventually became she was inappropriately sexually se-
overtly self-centered, demanding, and ductive and used her physical appear-
manipulative, and the man would ance to draw attention to herself, but
break off the relationship. After break- she was not emotionally overdramatic.
ing up, she would almost immediately She had shallow expression of emo-
start claiming that the particular man tions and was uncomfortable when
was “going nowhere,” was not for her, she was not the center of attention, but
and would not be missed. Between was not overly suggestible. Sara also
these relationships, Sara often had pe- had some features of narcissistic,
riods in which she engaged in a suc- avoidant, and dependent PDs. A
cession of one-night stands, having DSM-5 Section II diagnosis of other
sex with half a dozen partners in a specified PD (mixed features) could
month. Alternatively, she would fre- be made.
quent rock clubs and bars—“in-spots,”
as she called them—merely on the In terms of the DSM-5 alternative
chance of meeting someone who
model of PDs, Sara might be best de-
would introduce her to the glamorous
world she dreamed of. scribed as having PD-TS. Her level of
Sara had no female friends other impairment in personality functioning
than her sister. She could see little use would be “severe,” with impairment in
for such friendships. She preferred identity, self-direction, empathy, and in-
spending her time shopping for styl-
timacy. She has a poor sense of auton-
ish clothes or watching television
alone at home. She liked to dress fash- omy and agency and experiences the lack
ionably and seductively, but often felt of a true identity and emptiness. She
that she was too fat or that her hair vacillates between overidentification with
was the wrong color. She had trouble and dependence on others and overem-
controlling her weight and would pe- phasis on independence. She has fragile,
riodically go on eating binges for a
incoherent self-esteem that includes
few days that might result in a 10-
pound weight gain. She read popular both self-denigration and self-aggran-
novels but had very few other inter- dizement. She has difficulty establishing
ests. She admitted she was bored much and achieving her goals in life. She is un-
of the time but also asserted that cul- aware of the effects of her own actions on
tural or athletic pursuits were a waste
others. Her relationships with others are
of time.
Sara was referred for outpatient based on her needs, with little mutuality,
follow-up without a PD diagnosis. In as others are in her life primarily to sat-
fact, her long-term functioning failed isfy her fantasies and desires. Pathological
personality traits that describe her in- and rituals are culturally sanctioned. Only
clude attention seeking, manipulative- when such behaviors are clearly in excess
ness, and grandiosity from the Antago- or discordant with the standards of a per-
nism domain, impulsivity and risk-taking son’s cultural milieu would the diagnosis
from the Disinhibition domain, and sub- of a PD be considered. Certain sociocul-
missiveness from the Negative Affectiv- tural contexts may lend themselves to
ity domain. The attention paid to per- eliciting and reinforcing behaviors that
sonality functioning and traits in her might be mistaken for PD psychopathol-
evaluation can convey a vivid picture of ogy. Members of minority groups, immi-
Sara’s complicated personality pathol- grants, or refugees, for example, might
ogy, which would be the focus of her appear overly guarded or mistrustful,
subsequent therapy. avoidant, or hostile in response to experi-
ences of discrimination, language barriers,
Effects of Gender, or problems in acculturation (Alarcon
2005).
Culture, and Age
Age
Gender Although PDs usually are not diagnosed
Although definitive estimates about the prior to age 18 years, certain thoughts,
sex ratio of PDs cannot be made because feelings, and behaviors suggestive of
ideal epidemiological studies do not ex- personality psychopathology may be
ist, some PDs are believed to be more apparent in childhood. For example, de-
common in clinical settings among men pendency, social anxiety and hypersen-
and others among women. PDs listed in sitivity, disruptive behavior, or identity
DSM-5 as occurring more often among problems may be developmentally ex-
men are paranoid, schizoid, schizotypal, pected. Follow-up studies of children
antisocial, narcissistic, and obsessive- have shown decreases in such behaviors
compulsive PDs. Those occurring more over time (Johnson et al. 2000), although
often in women are borderline, histri- children with elevated rates of PD-type
onic, and dependent PDs. Avoidant PD signs and symptoms do appear to be at
is said to be equally common in men and higher risk for personality and other men-
women. Apparently elevated sex ratios tal disorders in young adulthood (Johnson
that do not reflect true prevalence rates et al. 1999; Kasen et al. 1999). Thus, some
can be the result of sampling or diagnos- childhood problems may not turn out to
tic biases in clinical settings (Widiger be transitory, and PD may be viewed de-
1998). True differences may be due to bi- velopmentally as a failure to mature out
ological factors such as hormones, social of certain age-appropriate or phase-spe-
factors such as child-rearing practices, cific feelings or behaviors. A developmen-
and their interactions (Morey et al. 2005). tal perspective on PDs is presented more
fully in Chapter 4, “Development, At-
Culture tachment, and Childhood Experiences,”
Apparent manifestations of PDs must be in this volume.
considered in the context of a patient’s Until recently, little was known about
cultural reference group and the degree the nature and importance of personality
to which behaviors such as diffidence, and PDs in later life. Anecdotal clinical
passivity, emotionality, emphasis on work information was abundant, but system-
and productivity, and unusual beliefs atic data were sparse. Many important
issues persist concerning the prevalence sideration of pathological trait domains,

of PDs in later life and their manifesta- because these broad propensities toward
tions, development and course, and im- particular ways of thinking, feeling, and
pact on aspects of living (Oltmanns and behaving underlie certain PDs and other
Balsis 2011). Personality pathology may mental disorders (Krueger and Eaton
not be accurately diagnosed in older 2010; Krueger et al. 2007) with which they
populations if the clinician employs the are commonly comorbid.
same criteria that are used in younger At the broadest level, PDs and other
ones. Modifications have to be made to mental disorders can be divided into ex-
account for changes in life circumstances, ternalizing and internalizing disorders
such as the loss of a spouse or friends, re- (Krueger et al. 2011b). Externalizing disor-
tirement from work, or physical infir- ders are characterized primarily by Dis-
mity, that make some criteria not applica- inhibition, that is, an “orientation to-
ble. Some early-onset PDs (e.g., BPD and ward immediate gratification, leading to
ASPD) may improve with advancing age, impulsive behavior driven by current
whereas others (e.g., NPD and OCPD) thoughts, feelings, and external stim-
may get worse. PDs may actually have uli, without regard for past learning or
an onset in later life. The long-term con- consideration of future consequences”
sequences of pathological versus adap- (American Psychiatric Association 2013,
tive personalities for health, longevity, p. 780). Externalizing disorders are also
marital and other social relationships, characterized by Antagonism, that is,
and the experience of important late-life “behaviors that put the individual at
events are currently under study (see, odds with other people, including an ex-
e.g., Oldham and Skodol 2013). Specific aggerated sense of self-importance and a
personality traits or types may represent concomitant expectation of special treat-
risk factors for the development of de- ment, as well as a callous antipathy to-
pression, dementia, or other psychiatric ward others, encompassing both an un-
syndromes in later life. In contrast, other awareness of others’ needs and feelings
traits or types serve as protective factors and a readiness to use others in the ser-
against the development of these condi- vice of self-enhancement” (American Psy-
tions, or could even enhance healthy chiatric Association 2013, p. 780). Disrup-
aging. The Section III personality func- tive behavior disorders (e.g., conduct
tioning and personality trait model en- disorder), substance-related and addic-
hances the clinician’s ability to assess tive disorders, and ASPD are representa-
and track important personality charac- tive of the externalizing “meta-cluster”
teristics throughout the lifespan. of disorders.
Internalizing disorders are characterized
by Negative Affectivity, that is, “frequent
Differential Diagnosis and intense experiences of high levels of
a wide range of negative emotions (e.g.,
In this section, the focus is on differential anxiety, depression, guilt/shame, worry,
diagnosis of PDs as defined by the DSM-5 anger) and their behavioral (e.g., self-
Section III alternative model. The guide- harm) and interpersonal (e.g., depen-
lines for the differential diagnosis of Sec- dency) manifestations” (American Psy-
tion II PDs remain unchanged from DSM- chiatric Association 2013, p. 779). An in-
IV and can be found in DSM-5. Differen- ternalizing meta-cluster of disorders
tial diagnosis of PDs is facilitated by con- would include depressive disorders, anxi-
ety disorders characterized by distress be under consideration and also to dis-

(e.g., generalized anxiety disorder) or cern the critical differences between
fear (e.g., phobic disorders), and PDs them, in order to arrive at the most accu-
such as AVPD. At least one PD—that is, rate and appropriate diagnosis.
BPD—appears to straddle both external- In general, the major issues for differ-
izing and internalizing spectra (Eaton et ential diagnosis of PDs are 1) distin-
al. 2011). A third meta-cluster of disor- guishing PDs from other PDs with simi-
ders is characterized by Psychoticism; lar features, 2) distinguishing personality
that is, they include “a wide range of pathology from the psychopathology of
culturally incongruent odd, eccentric, or other mental disorders, and 3) distin-
unusual behaviors and cognitions, in- guishing personality pathology warrant-
cluding both process (e.g., perception, ing a PD diagnosis from personality pa-
dissociation) and content (e.g., beliefs)” thology that arises from the use of a
(American Psychiatric Association 2013, substance of abuse or from a co-occurring
p. 781). In this cluster would be found other medical condition. PDs can be dis-
schizophrenia spectrum and other psy- tinguished from one another on the basis
chotic disorders, bipolar disorder, and of their characteristic impairments in per-
STPD (Keyes et al. 2013). sonality functioning, described by Crite-
Other DSM-5 trait domains are related rion A for each specific disorder, or on the
more strongly to the principal domains basis of their characteristic patterns of
within these large spectra. Detachment pathological personality traits, described
is correlated more strongly with Nega- by Criterion B. PDs can be distinguished
tive Affectivity than with Disinhibition from other mental disorders based on the
(Morey et al. 2013b). Detachment has presence of impairments in personality
also been shown to correlate with Psy- functioning at the moderate level or
choticism. Individual PDs in Section III greater for the diagnosis of a PD. Apply-
are characterized by different combina- ing the single-item LPFS as a first step in
tions of underlying trait domains: ASPD differential diagnosis can discriminate
is a combination of Antagonism and the presence of a PD with very good ac-
Disinhibition; BPD is a combination of curacy (i.e., sensitivity and specificity)
Negative Affectivity, Antagonism, and (Morey et al. 2013a). In many cases, PDs
Disinhibition; AVPD is a combination of and other mental disorders co-occur,
Negative Affectivity and Detachment; based on shared trait vulnerabilities or
STPD is a combination of Psychoticism predispositions, and in such cases both
and Detachment; and OCPD is a combi- types of disorders should be diagnosed,
nation of Conscientiousness (the oppo- because it has been shown that PDs
site of Disinhibition), Negative Affectiv- worsen the course (i.e., longer time to re-
ity, and Detachment. Of the specific PDs mission, shorter time to relapse, more
in Section III, only NPD is characterized time in episodes) of disorders such as ma-
by a single trait domain (Antagonism). jor depressive disorder, anxiety disor-
Thus, thinking about differential diagno- ders, and substance use disorders (Ansell
sis in terms of underlying dispositions— et al. 2011; Fenton et al. 2012; Grilo et al.
with shared pathophysiologies (e.g., 2005; Hasin et al. 2011; Skodol et al. 2011)
Iacono et al. 2002) and etiologies (e.g., and require special treatment. Comorbid-
Kendler et al. 2011)—helps the clinician ity among other mental disorders and
to include all the disorders that should PDs has been shown to increase the risk
for negative prognoses with respect to nism [hostility trait] and Disinhibition
adult attainments and functioning that [impulsivity and risk-taking traits]), but
can last 20 years (Crawford et al. 2008). individuals with BPD show more Nega-
Substance- or medication-induced tive Affectivity (e.g., emotional lability,
personality change is distinguished from separation insecurity), whereas individ-
PD primarily on the basis of the relation- uals with ASPD show a broader range of
ships in time of the personality distur- traits of Antagonism (e.g., callousness,
bance to the exposure to the substance or manipulativeness) associated with im-
medication. If there is a close historical posing on and/or controlling others. Im-
association between the onset of the per- pulsivity in BPD is more often oriented
sonality change and the exposure to sub- toward self than toward others (i.e., self-
stances (also corroborated when possible harmful or suicidal behaviors). Suicide
by physical examination or laboratory attempts and overall psychological dis-
tests), then the personality pathology is tress are also higher in BPD.
probably due to the substance or medi- Individuals with NPD and those with
cation. There is no diagnosis for sub- ASPD are both self-centered and lacking
stance/medication-induced PD in DSM-5, in empathy. Individuals with ASPD, how-
however, so a clinician would use the di- ever, are more manipulative, deceitful,
agnosis of an “other substance-induced callous, hostile, irresponsible, and impul-
disorder” (specifying the substance, if sive than individuals with NPD. Those
possible). If the PD preceded involvement with NPD do use others to enhance self-
with substances or persists for a consid- esteem needs and for personal gain, but
erable time after the cessation of sub- they are not as openly exploitative of
stance use, it most likely represents an in- others as are individuals with ASPD, and
dependent disorder. Again, a substance they are more likely to use charm or se-
use disorder can co-occur with a PD be- duction than coercion or intimidation to
cause of underlying traits of impulsivity get what they want from others.
or risk taking. In that case, both disorders NPD is characterized by self-appraisal
should be diagnosed. Similarly, evidence that may be inflated or deflated, or that
from history, physical examination, and may vacillate between extremes. Individ-
laboratory tests, coupled with a tempo- uals with BPD also have unstable self-
ral sequence suggesting the primacy of images. Both disorders are characterized
another medical condition, distinguishes by problems with empathy. The absence
personality change due to another medi- of impulsivity, risk taking, separation in-
cal condition (Section II) from a PD. security, and fears of abandonment in
NPD help to distinguish between the dis-
orders. In addition, individuals with
Externalizing NPD tend to be disdainful and dismis-
Personality Pathology sive of others, especially when the others
are not meeting the needs of the individ-
Antagonism and uals with NPD, whereas individuals with
Disinhibition BPD can be both disdainful and very in-
terpersonally needy.
Personality disorders. BPD has some The entitlement and superiority seen
trait features in common with ASPD (e.g., in individuals with NPD may be con-
similarities in the domains of Antago- fused with the rigid perfectionism (at the
opposite pole of the Disinhibition do- destructive tendencies of mood distur-

main) of OCPD, which leads the individ- bances.
ual to believe that there is only one right Posttraumatic stress disorder may be
way to do things. Both disorders are also manifested by impulsive behaviors, an-
characterized by personal standards that tagonism/hostility, incapacity for inti-
may be unreasonably high. Individuals macy, or unreliability, and a history of
with either PD also have problems with early traumatic experiences also seen in
empathy: their ability to recognize, un- externalizing PDs. However, posttrau-
derstand, or identify with the feelings matic stress disorder has other well-de-
and needs of others is impaired, and refined clinical features (e.g., reexperienc-
lationships can be largely superficial. In- ing and intrusion symptoms; specific
dividuals with NPD, however, rely on avoidance behaviors) that are not diag-
positive reactions from others for self- nostic of PDs.
definition and self-esteem regulation Attention-deficit/hyperactivity dis-
and seek the attention of others, in con- order (ADHD), typically first detected in
trast to individuals with OCPD, whose childhood or early adolescence, has also
sense of self is derived predominantly been described in adulthood. Character-
from work or productivity, often at the ized mostly by distractibility, motor rest-
expense of interpersonal relationships. lessness, and cognitive performance def-
Individuals with NPD may also pro- icits, ADHD does not include prominent
fess a commitment to perfection and be- antagonistic features such as callous-
lieve that others cannot do things as well, ness, deceitfulness, manipulativeness,
but these individuals are preoccupied or hostility. Conduct disorder, particu-
with striving for perfection as a means of larly in its adult version, must be distin-
shoring up a fragile self-image, whereas guished from ASPD on the basis of an
those with OCPD are concerned about absence in the former of the severe
receiving punishment or criticism for in- manifestations (secondary to impulsiv-
adequate achievement. Individuals with ity, violence proneness, etc.) and serious
AVPD are usually self-critical but lack the consequences (e.g., behavioral, legal, eth-
behavioral and cognitive rigidity that ical) seen in the latter.
characterizes those with OCPD. The grandiosity that is frequently man-
ifested in individuals with NPD may
Other mental disorders. Impulsivity, suggest a manic or hypomanic episode.
irresponsibility, risk-taking behaviors The absence of other manic or hypomanic
(including law breaking), hostility, and symptoms, such as decreased need for
self-centeredness can be seen in manic or sleep, pressured speech, flight of ideas,
hypomanic episodes of bipolar I or II and psychomotor agitation, helps to dis-
disorders, but, compared with individu- tinguish NPD from bipolar I or bipolar II
als with externalizing PDs, individuals disorder.
with bipolar disorders frequently do not Despite the similarity in names, ob-
demonstrate callousness or manipula- sessive-compulsive disorder is usually
tiveness and are more likely to exhibit easily distinguished from OCPD by the
behavioral disorganization of psychotic presence of true obsessions and compul-
proportions. Agitated or anxious patients sions in the former. When criteria for
with major depressive disorder may both personality and obsessive-compul-
present with an impulsive act (e.g., a sui- sive spectrum disorders are met, both
cide attempt) but also have morbid self- diagnoses should be recorded.
Substance use and other medical ets are required for diagnosis. In OCPD
conditions. When externalizing be- the core Negative Affectivity feature is
havior in an adult is associated with a perseveration—persistence at tasks long
substance use disorder, the diagnosis of after the behavior has ceased to be func-
ASPD is not made unless signs of the tional or effective—whereas in AVPD
former were also present in childhood the core Negative Affectivity feature is
(i.e., conduct disorder) and have contin- anxiousness, with particular apprehen-
ued into adulthood. The onset of ASPD sion in social situations and fears of em-
typically precedes, for example, that of barrassment.
alcohol dependence by several years.
When substance use and antisocial be- Other mental disorders. BPD often co-
havior both began in childhood and con- occurs with major depressive disorder or
tinued into adulthood, both disorders other disorders of anxiety or mood, and
should be diagnosed if the criteria for multiple disorders should be diagnosed
both are met, even though some antiso- when present. However, because the
cial behaviors may be a consequence of cross-sectional presentation of BPD can
the substance use disorder (e.g., illegal resemble an episode of a depressive, bi-
drug selling, theft to obtain money for polar, or anxiety disorder, the clinician
drugs). In adults, particularly older adults, should use caution in giving multiple di-
the appearance or significant, unexpected agnoses based only on cross-sectional
worsening of antisocial behaviors (or iso- presentation.
lated traits of them) should be the subject The most important differential diag-
of a careful diagnostic assessment to rule nosis for AVPD is social anxiety disorder
out other medical conditions as triggering (social phobia), and the two disorders are
factors. Common conditions include highly comorbid. There are no discern-
brain tumors or other occult malignan- ible qualitative differences between the
cies, sequelae of head injuries, degener- two disorders with regard to demo-
ative neurological diseases, or late-life graphic features (including age at onset),
metabolic disturbances (e.g., affecting social skills deficits, cognitive features,
the liver, thyroid, parathyroid, pancreas, physiological reactions, and comorbid
or hypothalamic-pituitary-adrenal axis). depression, although the clinical picture
of individuals with AVPD typically is
Internalizing more severe and is associated with a
broader pattern of avoidance, including
Personality Pathology of positive emotions and novel situations.
Importantly, in AVPD, the anxiousness
Negative Affectivity
from hypersensitivity to social evaluation
Personality disorders. NPD and BPD is associated with core impairment in
may both be characterized by angry re- identity, specifically the belief that the self
actions to minor stimuli and fluctuations is inferior. Thus, an important distinction
in self-image, but the lack of self-de- between the disorders is how social anxi-
structiveness, impulsivity, and separa- ety, which they have in common, relates
tion insecurity in NPD distinguishes this to the self-concept. Although avoidant
disorder from BPD. AVPD and OCPD behavior also characterizes agoraphobia,
both are characterized by high Negative in AVPD the focus is on social evaluation,
Affectivity, although different trait fac- whereas in agoraphobia it is on the diffi-
culty of escape or the lack of help in the of NPD. However, whereas individuals
event of incapacitation. with AVPD are afraid of not being liked
or accepted, those with covert narcissis-
Detachment and tic tendencies crave admiration to bol-
Psychoticism ster their fragile self-esteem and secretly
or unconsciously feel entitled to it.
Personality disorders. Regarding De-
tachment traits, AVPD and STPD share Other mental disorders. STPD is dis-
(social) withdrawal, but STPD is further tinct from psychotic schizophrenia spec-
characterized by restricted affectivity trum disorders, including schizophrenia
(constricted emotional experience and itself, as well as other psychotic disor-
expression), whereas AVPD is further ders such as delusional disorder or mood
characterized by anhedonia (deficits in disorder with psychotic features, be-
the capacity to feel pleasure or take in- cause individuals with STPD do not have
terest in things) and intimacy avoidance overt persistent psychotic symptoms
(avoidance of interpersonal attachments, (i.e., delusions and hallucinations). Al-
especially romantic relationships). Also, though psychotic symptoms may occur
in AVPD, withdrawal is driven by a fear in the context of a discrete psychotic
of rejection and reluctance to enter into disorder in the course of STPD, this is un-
situations or relationships that may ulti- usual because STPD must have been
mately lead to rejection, whereas in STPD, present before the onset of the psychotic
Detachment is more pervasive, not easily symptoms and persist even when the
reversed even when there are guarantees psychotic symptoms are in remission. If
of acceptance, and characterized by ex- STPD features are observed for more
treme difficulty in negotiating the affec- than 6 months in an individual who later
tive/cognitive complexities of interper- develops overt psychosis (i.e., delusions,
sonal relationships. Finally, individuals hallucinations, or disorganized speech)
with AVPD lack the traits of Psychoticism of 1 month or longer and severe functional
(e.g., cognitive and perceptual dysregu- impairments required for a schizophre-
lation, eccentricity, unusual beliefs and nia diagnosis, the schizotypal features
experiences) that characterize individu- would be considered a “premorbid” or
als with STPD. prodromal state of schizophrenia rather
Individuals with BPD may display than STPD. Individuals with STPD may
psychotic-like symptoms, but such symp- exhibit restricted affect and have associ-
toms are more intense and transient, and ated depression or dysphoria of mood
more related to affective shifts, than the disorders, but may not complain of any
chronic, pervasive suspiciousness or psychotic-like symptoms. In such indi-
typically less dramatic cognitive distor- viduals, STPD may be present but over-
tions in individuals with STPD. BPD, looked.
however, may be comorbid with STPD. In children or adolescents, features of
Some individuals traditionally diag- STPD may be difficult to discriminate
nosed with AVPD may actually be better from those of developmental disorders
characterized as having covert/vulnera- in the autism spectrum because both may
ble narcissistic personality characteris- be characterized by social isolation, ec-
tics. Social withdrawal is a common fac- centricity, and peculiarities of language
tor among both individuals with AVPD and behavior. Individuals with autism
and those with the covert presentation spectrum disorder, however, often ex-
hibit stereotyped behaviors and inter- including the presence of additional

ests that are not typical for STPD and prominent personality traits, then a PD-
social and nonverbal communication TS diagnosis should be made. For exam-
deficits and lack of emotional reciprocity ple, if an individual’s personality func-
that may be more prominent than in tioning disturbance matches that of the
STPD. AVPD well and the individual’s trait
profile is characterized by the traits com-
Personality Disorder— prising AVPD Criterion B (i.e., anxious-
Trait Specified ness, withdrawal, anhedonia, and inti-
macy avoidance), but the individual’s
Personality disorder—trait specified personality also is characterized by other
vs. pathological personality traits. traits, it must be determined whether
One major differential diagnostic issue the most prominent features of the indi-
with PD-TS is the determination of vidual’s personality are those of the
whether a diagnosis of PD is warranted, AVPD or whether the additional person-
or whether one simply should note the ality features are also clinically relevant.
individual’s relevant pathological per- In the former case, the diagnosis would
sonality features. The DSM-5 personality be AVPD with additional features speci-
trait model can be used to record person- fied (e.g., with depressivity), whereas in
ality features regardless of whether they the latter case, the more appropriate di-
are manifestations of a PD diagnosis. agnosis would be PD-TS, with specifica-
Therefore, the evidence for Criterion A tion of all prominent traits (e.g., with
(disturbances in self and interpersonal depressivity, submissiveness, anxious-
functioning) should be carefully assessed ness, withdrawal, intimacy avoidance).
to determine whether a diagnosis of PD is PD-TS should be diagnosed if an indi-
warranted; the LPFS is provided to assist vidual meets the general criteria for PD
in this determination. but lacks one or more of the personality
trait facets required for a diagnosis of a
Personality disorder—trait specified
vs. a specific personality disorder. specific PD (e.g., subthreshold or other
A second important differential diag- specified PD).
nostic issue with PD-TS is the determi- Comorbid specific personality disor-
nation of whether a diagnosis of one of ders vs. personality disorder—trait
the six specific PD types or of PD-TS specified. A third important differen-
should be made. This determination is tial diagnostic issue with PD-TS is the
based on the clinician’s judgment of the determination of whether a diagnosis of
degree to which the patient’s 1) self and two or more of the six specific PDs or of
interpersonal disturbance (Criterion A) PD-TS should be made. This determina-
and 2) personality trait configuration tion also is based on clinician judgment
(Criterion B) match the characterization of the degree to which the individual’s
of a specific PD. If an individual’s spe- self and interpersonal disturbance (Cri-
cific personality disturbance and trait terion A) and personality trait configu-
configuration match those of a specific ration (Criterion B) match the character-
PD well, that PD diagnosis should be ization of multiple specific PDs. If an
made. If, however, there are notable dis- individual’s specific personality distur-
crepancies between the individual’s spe- bance and trait configuration match
cific personality disturbance and trait those of multiple specific PDs, the spe-
configuration and those of a specific PD, cific PD diagnoses should be made. If,
however, there are notable discrepancies festations, assessment, diagnosis, and

between the individual’s specific per- differential diagnosis. Although clini-
sonality disturbance and trait configura- cians will continue to use the criteria of
tion and those of the multiple specific Section II for official purposes, they are
PDs being considered, then a PD-TS di- encouraged to study and use the Section
agnosis should be made. III model, which presents a coherent
conceptual basis for all personality psy-
Other mental disorders. With regard
chopathology, an efficient and effective
to differential diagnosis of other condi-
approach to assessment, and a more em-
tions that may resemble PD-TS (e.g., ma-
pirically based formulation of PD crite-
jor depressive disorder vs. PD-TS with
ria than Section II.
Criterion B characterized by prominent
depressivity and anhedonia), the major
consideration is whether Criterion A
features (disturbances in self and inter-
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CHAPTER 8
Course and Outcome

Carlos M. Grilo, Ph.D.
Thomas H. McGlashan, M.D.
In DSM-5 Section II, “Diagnostic tion III, “Emerging Measures and Mod-
Criteria and Codes,” a personality disor- els,” one central tenet—that a PD reflects
der (PD) is defined as “an enduring pat- a persistent, pervasive, enduring, and
tern of inner experience and behavior stable pattern—has not changed. Al-
that deviates markedly from the expecta- though the concept of stability is salient
tions of the individual’s culture, is perva- in the two major classification systems,
sive and inflexible, has an onset in ado- DSM-5 and ICD-10 (World Health Orga-
lescence or early adulthood, is stable nization 1992), the two systems differ
over time, and leads to distress or im- somewhat in their classifications and
pairment” (American Psychiatric Asso- definitions of PDs and thus demonstrate
ciation 2013, p. 645). DSM-5 Section II only moderate convergence for some di-
specifies that the “enduring pattern” is agnoses (Ottosson et al. 2002). Empirical
manifested by problems in at least two of evidence regarding the extent of stability
the following areas: cognition, affectivity, of PDs, however, has historically been
interpersonal functioning, and impulse mixed and the subject of debate (Grilo
control. The diagnostic construct of PD and McGlashan 1999; Grilo et al. 1998;
has evolved considerably over the past Shea and Yen 2003).
few decades, and substantial changes The concept of stability has remained
have occurred over time in the number a central tenet of PDs through the vari-
and types of specific PD diagnoses and ous editions of DSM dating back to the
their criteria (see Skodol 1997 and Skodol first edition published in 1952 (American
2012 for a detailed ontogeny of the DSM Psychiatric Association 1952). In DSM-III
system). Until the introduction of the al- (American Psychiatric Association 1980),
ternative model for PDs in DSM-5 Sec- PDs were placed on a separate axis (Axis
165
II) of the multiaxial system. DSM-III in-

dicates that the assignment to Axis II was Overview of
intended, in part, to encourage clinicians
to assess for additional disorders that
Early Literature
might be overlooked when focusing on
Axis I psychiatric disorders. Conceptu- Previous reviews addressing aspects of
ally, this reflected, in part, the putative the course and outcome of PDs (e.g., Grilo
stability of PDs relative to the episodi- and McGlashan 1999; Grilo et al. 1998;
cally unstable course of so-called Axis I McDavid and Pilkonis 1996; Perry 1993;
psychiatric disorders (Grilo et al. 1998; Ruegg and Frances 1995; Stone 1993;
Shea and Yen 2003; Skodol 1997; Skodol Zimmerman 1994), although varied, have
et al. 2002). The multiaxial system of re- agreed on the pervasiveness of method-
cording diagnoses has been discontin- ological problems characterizing much
ued in DSM-5, and all mental disorders of the early literature, which precluded
are now categorized in the same section any firm conclusions about the nature of
(Section II). Although the concept of di- the stability of PDs. The reviews, how-
agnostic stability of PD persists unmodi- ever, have also generally agreed that the
fied in DSM-5 Section II, the stability of emerging research was raising questions
trait pathology and impairment in func- regarding many aspects of the construct
tioning is emphasized in the Section III validity of PDs (Zimmerman 1994), in-
alternative model (see also Chapter 7, cluding their hypothesized high degree
“Manifestations, Assessment, and Differ- of stability (Grilo and McGlashan 1999).
ential Diagnosis,” and Chapter 24, “An The few early (pre-DSM-III era) stud-
Alternative Model for Personality Disor- ies of the course of PDs reported find-
ders: DSM-5 Section III and Beyond”). ings that borderline PD (BPD) (e.g., Car-
In this chapter, we first provide a brief penter and Gunderson 1977; Grinker
review of the twentieth-century empiri- et al. 1968) and antisocial PD (ASPD)
cal literature on the stability of PDs. This (Maddocks 1970; Robbins et al. 1977)
period can be thought of as including the PDs were highly stable. Carpenter and
first generation (mostly clinical descrip- Gunderson (1977), for example, reported
tive accounts) and the second generation that the impairment in functioning ob-
(emerging findings based on attempts at served for BPD was comparable to that
greater standardization of diagnoses and observed for patients with schizophre-
assessment methods) of empirical re- nia over a 5-year period. Grilo et al. (1998)
search efforts on PDs. Second, we provide noted that the dominant clinical ap-
a brief overview of methodological prob- proach to assessing PD diagnoses based
lems and conceptual gaps that charac- partly on treatment refractoriness natu-
terize this literature and that must be rally raises the question of whether
considered when interpreting ongoing these findings simply reflect a tautology.
research and designing future studies. The separation of PDs to Axis II in
Third, we summarize new findings from DSM-III (American Psychiatric Associa-
several major long-term longitudinal tion 1980) contributed to increased re-
studies that have contributed much- search attention to these clinical prob-
needed information regarding the course lems (Blashfield and McElroy 1987). The
of PDs and that call into question their development and utilization of a num-
inherent stability. ber of structured and standardized ap-
Course and Outcome 167
proaches to clinical interviewing and di- offspring of patients with schizophrenia

agnosis during the 1980s represented no- than of those with mood disorders or
table advances (Zimmerman 1994). The controls. Subsequently, we (Grilo and
greater attention paid to defining the cri- McGlashan 1999) reviewed nine reports
teria required for diagnosis in the classifi- of longitudinal findings for PD diag-
cation systems and to developing stan- noses published from 1997 to 1998. In
dardized interviews greatly facilitated terms of specific diagnoses, the studies
research efforts in this field. generally reported moderate stability
In our previous reviews of DSM-III and (kappa coefficients of approximately 0.50)
DSM-III-R (American Psychiatric Asso- for BPD and ASPD. The studies in these
ciation 1987) studies, we concluded that reports, like those in most of the previ-
the available research suggested that ous literature, had small sample sizes and
“personality disorders demonstrate only infrequently followed more than one
moderate stability and that, although PD.
personality disorders are generally as- Two longitudinal studies assessed PD
sociated with negative outcomes, they features using standardized interview
can improve over time and can benefit and self-report methods to obtain com-
from specific treatments” (Grilo and plementary information on personality
McGlashan 1999, p. 157). In our 1998 re- changes over time in nonclinical sam-
view (Grilo et al. 1998), we noted that the ples. In the first study, Trull et al. (1997,
20 selected studies of DSM-III-R criteria 1998) reported modest stability coeffi-
generally found low to moderate stabil- cients, ranging from 0.28 to 0.62, for both
ity of any PD over relatively short follow- self-report and interview measures of
up periods (6–24 months). For example, borderline PD features using two differ-
studies that employed diagnostic inter- ent assessment instruments adminis-
views reported kappa coefficients be- tered to a college student sample assessed
tween assessments for the presence of twice over a 2-year period. Two-year sta-
any PD of 0.32 (Johnson et al. 1997), 0.40 bility coefficients for the self-report mea-
(Ferro et al. 1998), 0.50 (Loranger et al. sures tended to be higher than those for
1994), and 0.55 (Loranger et al. 1991). Es- interview-based measures of features.
pecially noteworthy is that the stability There was some heterogeneity in the
coefficients for specific PD diagnoses (in borderline feature changes and reduc-
the few cases they could be calculated tions over time; negative affectivity, but
given the sample sizes) were generally not personal distress levels, moderated
lower. Follow-up studies of adolescents the stability of scores (Trull et al. 1998).
diagnosed with PDs also reported mod- Borderline PD features were associated
est stability; for example, Mattanah et al. with greater academic and interpersonal
(1995) reported a 50% rate of stability for difficulties at 2-year follow-up. The Lon-
any PD at 2-year follow-up, and Grilo et gitudinal Study of Personality Disorders
al. (2001) reported modest stability for (LSPD; Lenzenweger 1999) assessed 250
dimensional PD scores in a follow-up participants drawn from Cornell Uni-
study of psychiatrically hospitalized adversity at three points over a 4-year pe-
olescents. Squires-Wheeler et al. (1992), riod. Of the 250 participants, 129 had
as part of the New York State high-risk presentations that met the criteria for at
offspring study, reported low stability least one PD; 121 had presentations that
for schizotypal PD (STPD) and features, did not meet the full criteria for any PD.
although the stability was higher for the Lenzenweger found that dimensional
scores for the PDs were characterized by ple sizes; concerns about unstandardized
significant levels of stability on both the assessments, interrater reliability, blind-
interview and self-report measures of ness to baseline characteristics, and nar-
PD. Stability coefficients for total num- row assessments; failure to consider al-
ber of PD features ranged from 0.61 to ternative (e.g., dimensional) models of
0.70, and PD dimensions showed signif- PDs; reliance on only two assessments
icant declines over time, with the PD typically over short follow-up periods;
group showing more rapid declines than insufficient attention to the nature and ef-
the group without PDs. Cluster B had the fects of other co-occurring disorders; and
highest stability coefficients, and Cluster inattention to treatment effects. Particu-
A had the lowest. Subsequent reanalyses larly striking is the absence of “relevant”
of the LSPD data using individual growth comparison or control groups in the lon-
curve methods revealed considerable gitudinal literature. We comment briefly
variability in PD features across individ- on a few of these issues.
uals over the 4-year period (Lenzen-
weger et al. 2004). The reanalyses also
indicated that the course of PD features
Reliability
is heterogeneous, with different trajecto- Reliability of assessments represents a
ries characterizing individuals consid- central issue for any study of course and
ered symptomatic or meeting criteria for outcome. The emergence of standardized
a diagnosis versus those not meeting cri- instruments for collecting diagnostic data
teria (Hallquist and Lenzenweger 2013). on PDs was a major development of the
The two nonclinical longitudinal stud- 1980s (Zimmerman 1994). Such instru-
ies (Lenzenweger 1999; Trull et al. 1997, ments, however, were less than perfect
1998) demonstrated the value of using assessment methods and have been criti-
multiple assessment methods in re- cized for a variety of reasons (e.g., Westen
peated-measures longitudinal designs 1997; Westen and Shedler 1999). It is crit-
and highlighted that borderline features ical, however, to recognize that interrater
may be associated with poorer out- reliability and test-retest reliability repre-
comes, even in nonclinical populations sent the upper limits (or ceiling) for esti-
(Trull et al. 1997). These studies, how- mating the stability of a construct.
ever, were limited by their relatively ho- Previous reviews of diagnostic in-
mogeneous study groups of college stu- terviews for PDs (Grilo and McGlashan
dents, narrow development time frames, 1999; Zanarini et al. 2000; Zimmerman
and insufficient frequency of any specific 1994) have generally reported median
PD diagnosis (i.e., at diagnostic caseness interrater reliability coefficients of roughly
level), so meaningful analyses of clinical 0.70 and short-interval test-retest reli-
entities were not possible. ability coefficients of 0.50 for diagnoses.
These reliability coefficients compare fa-
vorably with those generally reported
Conceptual and for diagnostic instruments for other psy-
Methodological Issues chiatric disorders. Similar interrater and
short-term test-retest findings have con-
Previous reviews of PDs have raised var- tinued to characterize the reliability lit-
ious methodological concerns. Common erature through DSM-IV (American Psy-
limitations highlighted include small sam- chiatric Association 1994) and initially for
DSM-5 for mental disorder diagnoses between 1 and 26 weeks after baseline,
determined using various assessment observed significant decreases in PD cri-
methods (Regier et al. 2013). Both inter- teria for all but two of the DSM-III-R di-
rater and test-retest reliability coeffi- agnoses. The PDE, which requires skilled
cients tend to be higher for dimensional and trained research clinicians, has a re-
scores than for categorical diagnoses of quired minimum duration stipulation of
PDs. Although technically not a “reli- 5 years for determining persistence and
ability issue,” a related point is that even pervasiveness of the criteria being as-
when experts administer diagnostic in- sessed. Thus, the magnitude of changes
terviews, the degree of convergence or observed during such a short period of
agreement produced by two different in- time, which was shown to be unrelated
terviews administered only a week apart to “state-trait effects,” reflects some com-
is limited (Oldham et al. 1992). Also, the bination of the following: regression to
degree of concordance between different the mean, error in either or both the base-
diagnostic interviews, clinical interviews, line and repeated assessments, overre-
and self-report methods is limited (Sam- porting by patients at intake assessment,
uel et al. 2013). and underreporting during retest at fol-
low-up (Gunderson et al. 2004; Loranger
et al. 1991; Shea and Yen 2003). There-
Reliability and “Change” fore, in assessing patients for personality
Test-retest reliability is also relevant for psychopathology, clinicians should be
addressing, in part, the well-known prob- wary of incentives for overreporting (e.g.,
lem of “regression to the mean” in re- admission to a desirable treatment facil-
peated-measures studies (Nesselroade et ity) and underreporting (e.g., discharge
al. 1980). It has been argued that the mul- from a hospital).
tiwave or repeated-measures approach
lessens the effects of regression to the Categorical Versus
mean (Lenzenweger 1999). This might be
the case in terms of the obvious decreases Dimensional Approaches
in severity with time (i.e., very symp- Long-standing debate regarding the con-
tomatic participants meeting eligibility ceptual and empirical advantages of di-
at study entry are likely to show some mensional models of PDs (Frances 1982;
improvement since by definition they are Livesley et al. 1992; Loranger et al. 1994;
already reporting high levels of symp- Skodol 2012; Widiger 1992) has accom-
toms). However, other effects need to be panied the DSM categorical classifica-
considered whenever assessments are tion system. Overall, longitudinal stud-
repeated within a study. For example, ies of PDs have reported moderate levels
Shea and Yen (2003) noted that repeated- of stability for dimensional scores for
measures studies of both PD (Loranger most disorders, and stability coefficients
et al. 1991) and other mental disorder tend to be higher than for categorical or
(Robins 1985) diagnoses have found diagnostic stability (Ferro et al. 1998;
hints that participants systematically re- Hopwood et al. 2013; Johnson et al. 1997;
port or endorse fewer problems during Klein and Shih 1998; Loranger et al.
repeated interviews to reduce interview 1991, 1994; Morey et al. 2007). Dimen-
time. Loranger et al. (1991), in their test- sional assessments of personality psy-
retest study of the Personality Diagnostic chopathology (functioning and traits)
Examination (PDE) interview conducted are highlighted in the hybrid dimen-
sional-categorical model of PDs in DSM- adults. This definitional isomorphism is

5 Section III. Recognizing that diagnostic one likely reason for the consistently
thresholds for most PDs in Section II of strong associations between conduct dis-
DSM-5 are set without strong empirical order and later ASPD in the literature.
bases, clinicians should regard “sub- This is, however, more than an artifac-
threshold” cases as possibly milder ver- tual relationship, because longitudinal
sions of full-blown disorders and treat research has documented that children
these patients as such. and adolescents with early-onset behav-
ior disorders have substantially elevated
Comorbidity risk for antisocial behavior during adult-
hood (Moffitt 1993; Robins 1966). More
Most studies have had some partici-
generally, studies with diverse recruit-
pants whose presentations met the crite-
ment and ascertainment methods found
ria for multiple mental disorder diagno-
that disruptive behavior disorders dur-
ses. This problem of diagnostic overlap
ing the adolescent years prospectively
or comorbidity represents a well-known,
predicted PDs of various types during
long-standing major challenge in work-
young adulthood (Bernstein et al. 1996;
ing with clinical samples (Berkson 1946).
Lewinsohn et al. 1997; Myers et al. 1998;
One expert and critic of DSM (Tyrer 2001),
Rey et al. 1995). In addition, children with
in speaking of the “spectre of comorbid-
conduct disorder are at risk for other
ity,” noted “the main reason for abandon-
externalizing and internalizing mental
ing the present classification is summed
disorders, not only for ASPD (e.g., Kim-
up in one word, comorbidity. Comorbid-
Cohen et al. 2003). Moreover, other
ity is the nosologist’s nightmare; it shouts,
childhood disorders, in addition to con-
‘You have failed’” (p. 82). We suggest,
duct disorder, increase the risk of ASPD
however, that such clinical realities (mul-
(e.g., Kasen et al. 2001). Thus, the rela-
tiple presenting problems that are espe-
tionship between conduct disorder and
cially characteristic of treatment-seeking
ASPD is not specific. The Yale Psychiatric
patients) represent both potential con-
Institute follow-up study found that PD
founds and potential opportunities to
diagnoses in adolescent inpatients pro-
understand personality and dysfunc-
spectively predicted greater drug use
tions of personality better. Comorbidity
problems but not global functioning
begs the question: What are the funda-
(Levy et al. 1999).
mental personality dimensions and dis-
The importance of considering comor-
orders of personality, and how do their
bidity is underscored in the findings of
courses influence (and conversely, how
the longitudinal study by Lewinsohn et
are their courses affected by) the pres-
al. (1997). These authors found that the
ence and course of other psychiatric dis-
apparent longitudinal continuity for
orders?
disruptive behavioral disorders during
adolescence and subsequent ASPD in
Continuity adulthood was predicted, in part, by the
A related issue pertaining to course con- presence of other mental disorder co-
cerns longitudinal comorbidities (Ken- morbidity. More recently, analyses from
dell and Clarkin 1992) or continuities. the National Epidemiologic Survey on
An obvious example is that conduct dis- Alcohol and Related Conditions com-
order during adolescence is required for paring adults with ASPD with adults
the diagnosis of ASPD to be given to whose presentation met all the criteria for
ASPD except the requirement that con- Age (Early Onset)

duct disorder be present before age 15
differed little in 3-year course of antiso- As stressed by Widiger (2003), PDs need
cial behaviors after adjusting for differ- to be more clearly conceptualized and
ences in psychiatric comorbidity (Gold- carefully characterized as having an early
stein and Grant 2009). A longitudinal onset. However, the validity of PDs in ad-
study of young adult men found that olescents remains controversial (Krueger
PDs predicted the subsequent onset of and Carlson 2001). It can be argued, for
psychiatric disorders during a 2-year fol- example, that determining early onset of
low-up, even after the researchers con- PDs is impossible because adolescence is
trolled for previous psychiatric history a period of profound changes and flux in
(Johnson et al. 1997). personality and identity. A critical review
of the longitudinal literature on personal-
ity traits throughout the life span re-
Comorbidity and vealed that personality traits are less sta-
Continuity Models ble during childhood and adolescence
than they are later in life (Roberts and
Certain disorders may be associated with
DelVecchio 2000). Roberts and DelVec-
one another in a number of possible ways
chio’s (2000) meta-analysis of data from
over time. A variety of models have been
152 longitudinal studies of personality
proposed for the possible relationships
traits revealed that rank-order consistency
between personality and other mental
for personality traits increased steadily
disorders (e.g., Dolan-Sewell et al. 2001;
throughout the life span; test-retest corre-
Lyons et al. 1997; Shea et al. 2004; Tyrer
lations (over 6.7-year time intervals) in-
et al. 1997). These include, for example,
creased from 0.31 during childhood to
the predisposition or vulnerability model,
0.54 during college, to 0.64 at age 30, to a
the complication or scar model, the
high of 0.74 at ages 50–70.
pathoplasty or exacerbation model, and
Nonetheless, if childhood precursors
various spectrum models. We empha-
of PDs could be identified (as in the
size that these models do not necessarily
case of early-onset conduct disorder for
assume categorical entities. Indeed, an
ASPD), they could become part of the di-
especially influential spectrum model
agnostic criteria, creating some degree of
proposed by Siever and Davis (1991)
longitudinal continuity in the diagnostic
posits four psychobiological dimensions
system. More generally, temperamen-
to account for all types of psychopathol-
tal vulnerabilities or precursors to PDs
ogy. The Cloninger et al. (1993) psycho-
have been posited as central in a variety
biological model of temperament and
of models (e.g., Cloninger et al. 1993;
character represents another valuable
Siever and Davis 1991). Specific tempera-
approach that considers dimensions
mental features evident in childhood
across personality and other psychopa-
have been noted to be precursors for di-
thology. More broadly, Krueger (1999;
verse PDs (Paris 2003; Rettew et al. 2003;
Krueger and Tackett 2003) noted that al-
Wolff et al. 1991), as well as for differ-
though most research has focused on
ences in interpersonal functioning (New-
pairs of constructs (i.e., personality and
man et al. 1997) in adulthood. For exam-
other disorder associations), it seems im-
ple, studies have noted early odd and
portant to examine the “multivariate
withdrawn patterns preceding STPD in
structure of the personality-psychopa-
adults (Wolff et al. 1991) and shyness pre-
thology domain” (p. 109).
ceding avoidant PD (AVPD) (Rettew et interpersonal instability but increases in

al. 2003). Speaking more generally, al- avoidance occur with age. There exist
though the degree of stability for person- other reports of diminished impulsivity
ality traits is higher throughout adult- with increasing age in patients with BPD
hood than throughout childhood and (Paris and Zweig-Frank 2001; Stevenson
adolescence (Roberts and DelVecchio et al. 2003), although this was not ob-
2000), longitudinal analyses of personal- served in a prospective analysis of indi-
ity data have revealed that the transition vidual borderline criteria (McGlashan et
from adolescence to adulthood is charac- al. 2005). Galione and Oltmanns (2013),
terized by greater personality continuity using data from a large-scale epidemio-
than change (Roberts et al. 2001). logical study, reported significant asso-
ciations between BPD and major de-
Age and the Aging Process pression in older adults and found that a
history of major depression is particu-
Another age issue concerns the aging larly associated with stable BPD features
process. Considerable research suggests related to distress, which are more com-
that personality remains relatively sta-
mon than acute features among older
ble through adulthood (Heatherton and adults. Schuster et al. (2013), in another
Weinberger 1994; Roberts and DelVec- large epidemiological study, found that
chio 2000) and is highly stable after age
PDs are both common and strongly as-
50 (Roberts and DelVecchio 2000). Little sociated with various forms of disability
is known, however, about PDs in older and medical/psychiatric comorbidities
persons (Abrams et al. 1998), although
among older adults.
this topic has recently become the focus Clinicians may have to adjust their
of increasing research attention (Old- thresholds for diagnosis of PDs in el-
ham and Skodol 2013).
ders, because some of the standard crite-
A 12-year follow-up of PDs as part of ria may not be applicable because of life
the Nottingham Study of Neurotic Dis- events (e.g., death of a spouse) or cir-
orders (Seivewright et al. 2002) docu-
cumstances (e.g., retirement). The DSM-
mented substantial changes in trait scores
5 Section III personality functioning and
based on blind administration of a sem- trait-based criteria may be easier to use
istructured interview. Seivewright et al. in assessing the elderly, because these
(2002) reported that two Cluster B PD di-
criteria do not depend as heavily on spe-
agnoses (antisocial, histrionic) showed cific exemplars, which are often age de-
significant improvements, whereas di- pendent, as do the Section II criteria.
agnoses in Cluster A (schizoid, schizo-
typal, paranoid) and Cluster C (obses-
sional, avoidant) appeared to worsen
Summary and Implications
with age. The Seivewright et al. (2002) To resolve the various complex issues
findings, however, are limited by the discussed in this section, complemen-
two-point cross-sectional assessment, tary research efforts are required with
which could not address the nature of large samples of both clinical and com-
changes during the intervening period. munity samples. Prospective longitudi-
These findings echo somewhat the re- nal studies with repeated assessments
sults of the seminal Chestnut Lodge fol- over time are needed to understand the
low-up studies (McGlashan 1986a, 1986b), course of PDs. Such studies must con-
which found decreases in impulsivity and sider (and cut across) different devel-
opmental eras, broad domains of func- fully considered training and reliability,
tioning, and multimodal approaches to and—perhaps most notably—employed
personality and PDs. These approaches multiwave repeated assessments that
have, in fact, been performed with per- are essential for determining longitudi-
sonality traits (Roberts et al. 2001) and nal change. They have employed, to
with other forms of psychiatric prob- varying degrees, multiple assessment
lems, such as the National Institute of methods and have considered personal-
Mental Health (NIMH)–funded multi- ity and PDs, as well as other mental dis-
site effort on depression, the Collabora- orders and psychosocial functioning.
tive Depression Study (NIMH-CDS; Katz Collectively, these studies have pro-
et al. 1979), and have yielded invaluable vided valuable insights into the com-
insights. Over the past two decades, such plexities of personality (features, traits,
advances have come to characterize the and disorders) and its vicissitudes over
PD longitudinal literature, to which we time.
turn next.
Collaborative Longitudinal
Review of Major Personality Disorders Study
Empirical Advances The CLPS (Gunderson et al. 2000; Mc-
Glashan et al. 2000; Skodol et al. 2005b)
and Understanding is a prospective, longitudinal, repeated-
of Stability measures study designed to examine the
natural course and outcome of PDs, with
Of particular relevance for our literature a primary focus on patients whose pre-
review are three large-scale long-term sentation met DSM-IV criteria for one of
prospective studies on the longitudinal four specific PDs: STPD, BPD, AVPD, or
course of PDs funded by NIH through- obsessive-compulsive PD (OCPD). The
out the 1990s and continuing into the CLPS includes a comparison group of
twenty-first century. The three studies patients with major depressive disorder
are the multi-site Collaborative Longitu- (MDD) without any PD. This compari-
dinal Personality Disorders Study (CLPS; son group was selected because of the
Gunderson et al. 2000); the McLean purported episodic and fluctuating course
Study of Adult Development (MSAD; of MDD (thought to distinguish what
Zanarini et al. 2003); and the Children in were called Axis I from Axis II disorders
the Community Study (CICS; D.W. Brook in DSM-III through DSM-IV) and be-
et al. 2002; Cohen et al. 2000), a commu- cause MDD has been carefully studied
nity-based prospective longitudinal in similar longitudinal designs (e.g., the
study of personality, psychopathology, NIMH-CDS; Katz et al. 1979; Solomon et
and functioning of children/adolescents al. 1997). The CLPS employed multimodal
and their mothers that began in 1983. assessments (Gunderson et al. 2000;
These studies, which corrected for many Zanarini et al. 2000) to prospectively fol-
of the limitations that characterized the low and capture various aspects of the
previous literature, have provided valu- fluctuating nature of PDs and dimen-
able data for understanding the natural sions (both interviewer based and self-
life course of persons with PDs. These report representing different conceptual
long-term studies utilized multiple and models) (Morey et al. 2007, 2012; Samuel
standardized assessment methods, care- et al. 2011), other psychiatric disorders
and symptoms (Cain et al. 2012; Grilo et et al. 1987) methodology used in the
al. 2005, 2007), psychosocial functioning NIMH-CDS (Solomon et al. 1997), which
(Markowitz et al. 2007; Skodol et al. was also used by the CLPS to prospec-
2005a, 2005c), and treatment utilization tively evaluate MDD and other mental
(Bender et al. 2007). disorders.
Studies of course and outcome of many The CLPS has reported on different
disorders have generally employed con- concepts of categorical and dimensional
cepts of remission or recovery (Frank et al. stability of the four PDs over 12 months
1991), although these concepts have not, (Shea et al. 2003), 24 months (Grilo et al.
until recently, been applied much in PD 2004), and 10 years (Gunderson et al.
research, likely because of the “presump- 2011), using prospective data obtained
tion of stability” (Skodol 2012). Frank et for 668 patients recruited from diverse
al. (1991) defined remission as a brief settings at four universities. Shea et al.
period of improvement with no more (2002) reported that a significantly greater
than minimal symptoms and recovery as proportion of patients in each of the four
improvement lasting for an indefinite PD groups (BPD, STPD, AVPD, and
amount of time, implying recovery from OCPD) remained at diagnostic threshold
the disorder. The CLPS (e.g., Grilo et al. throughout the first 12 months of follow-
2004) employed the concept of remission up than did those in the MDD group; the
using two definitions in order to allow di- majority of patients with PDs, however,
rect comparison of the PD groups to the did not consistently remain above diag-
group of patients with MDD without PD, nostic threshold. Grilo et al. (2004) re-
given the established methodology in ported that on the basis of the traditional
the depression literature used by the Na- test-retest approach, blinded repeated
tional Institute of Mental Health (NIMH)– administration of a semistructured inter-
CDS (Solomon et al. 1997). To parallel the view conducted 24 months after baseline
NIMH-CDS conventions, one definition revealed remission rates (based solely on
of remission required at least 8 consecu- falling below DSM-IV diagnostic thresh-
tive weeks (2 months) with two or fewer olds) ranging from 50% (AVPD) to 61%
criteria of the diagnosis being present, (STPD). Grilo et al. (2004), using life table
and one definition required a longer time survival analyses of prospective data re-
requirement of 12 consecutive months garding time to remission for the PD and
with no more than two criteria of the di- MDD groups (based on parallel defini-
agnosis being present. The latter 12- tions of 2 consecutive months with mini-
month definition was adopted to provide mal symptoms), found that compared
a much more stringent definition of re- with the four PD groups, the MDD group
mission to reflect a more clinically signifi- had significantly shorter time to—and
cant change in PD psychopathology. The higher rates of—remission. These find-
CLPS adopted a parallel definition of re- ings represent the first definitive empiri-
lapse, defined as the return to diagnostic cal demonstration of the central tenet that
threshold for at least 2 consecutive months PDs are characterized by greater degree
for PDs and all other disorders, again to of stability than the hypothesized epi-
parallel the NIMH-CDS conventions. The sodic course of other mental disorders
CLPS prospectively evaluated time to re- (see Shea and Yen 2003). Surprisingly,
mission and relapse using a PD interview however, although PDs were more “sta-
assessment modeled after the Longitudi- ble” than MDD, a substantial number of
nal Interval Follow-Up Evaluation (Keller remissions occurred during the 24 months
of follow-up. When the 2-month defini- groups. Collectively, these findings—

tion of remission was used, rates ranged based on 10 years of prospective yearly
from 33% (STPD) to 55% (OCPD). Impor- multimethod follow-up—indicate that
tantly, even when the stringent definition the course of BPD is characterized by
of 12 consecutive months with two or high rates of diagnostic remission and
fewer criteria was used, remission rates low rates of relapse (return to diagnostic
ranged from 23% (STPD) to 38% (OCPD). threshold), but severe and enduring so-
These early CLPS findings highlighted cial functioning impairment (Gunderson
that substantial improvements in PD psy- et al. 2011).
chopathology are not uncommon, even The CLPS also provided complemen-
when stringent criteria for improvement tary analyses using various dimensional
are applied. approaches and alternative models for
Gunderson et al. (2011) reported the PD psychopathology for 12-month (Shea
primary CLPS 10-year outcome findings et al. 2003), 24-month (Grilo et al. 2004;
regarding both diagnostic stability and Samuel et al. 2011), 5-year (Morey et al.
psychosocial functioning. In this report, 2007), and 10-year (Hopwood et al. 2013;
two definitions of remission were consid- Morey et al. 2012) follow-ups. Grilo et al.
ered: 1) 12-month duration at two or fewer (2004) documented a significant decrease
criteria for comparing BPD with other in the mean proportion of criteria met in
PDs (OPD, comprising AVPD and OCPD) each of the PD groups over 2 years, later
and 2) 2-month duration for comparing confirmed and extended through 10 years
BPD with MDD. By 10 years, 85% of pa- (Gunderson et al. 2011), which is sugges-
tients with BPD attained a remission tive of sustained decreased severity.
using the 12-month duration definition However, when the relative stability of in-
and 91% attained a remission using the dividual differences was examined across
2-month definition; most changes oc- the multiwave assessments (at baseline
curred during the first 2 years (Grilo et al. and at 6-, 12-, and 24-month time points),
2004). Remission of BPD was signifi- a high level of consistency was observed,
cantly slower than remission of MDD as evidenced by correlation coefficients
and significantly, albeit less markedly, ranging from 0.53 to 0.67 for proportion
slower than remission of OPD. Only 12% of criteria met between baseline and 24
of patients with BPD experienced a re- months. Grilo et al. (2004) concluded that
lapse, and this rate was lower, and the it appears that patients with PDs are con-
time to relapse slower, than that observed sistent in terms of their rank order of PD
for MDD and for OPD. Gunderson et al. criteria (i.e., that individual differences in
(2011) also reported that all BPD criteria PD features are stable), although there
declined at similar rates over time. Im- may be fluctuation in the severity or num-
portantly, and in sharp contrast to the ber of features over time. McGlashan et al.
substantial and durable reductions in (2005) found that individual criteria across
BPD-specific psychopathology over time, the four PDs studied in the CLPS had var-
social functioning measures continued to ied patterns of stability and change over
evidence severe impairment with only time. Overall, within PDs, the relatively
modest clinical, albeit statistically signifi- fixed (least changeable) criteria were
cant, improvements over time. Social generally more traitlike (and attitudinal)
functioning in patients with BPD re- whereas the more fluctuating criteria
mained persistently more impaired than were generally behavioral (or reactive).
observed in both the MDD and OPD McGlashan et al. (2005) posited that per-
haps PDs are hybrids of traits and symp- time as their mean levels decreased and
tomatic behaviors, and that it is the inter- stability increased. Sanislow and col-
action of these over time that help to leagues suggested that the higher corre-
define the observable diagnostic stability lations among the constructs over time
versus instability. might reflect a greater shared base of pa-
Hopwood et al. (2013) extended these thology for PDs.
findings in several notable ways through In contrast to their symptomatic im-
10 years of follow-up by testing rank- provement, however, patients with PDs
order stability of normal traits, patho- showed less significant and more grad-
logical traits, and PD dimensions, while ual improvement in their functioning
correcting for both test-retest depend- (Gunderson et al. 2011), and this seemed
ability and internal consistency. De- particularly so for social relationships
pendability-corrected stability estimates (Markowitz et al. 2007; Skodol et al.
ranged from 0.60 to 0.90 for normal/ 2005d). Because personality psychopa-
abnormal traits but only 0.25 to 0.65 for thology usually begins in adolescence or
PDs. Hopwood and colleagues suggested early adulthood, the potential for delays
that the relatively lower stability ob- in occupational and interpersonal devel-
served for PD symptoms could reflect opment is great, and even after symptom-
differences between unstable/episodic atic improvement, it might take time to
PD pathology and more stable normal overcome deficits and make up the neces-
traits. Such findings highlight the need sary ground to achieve “normal” func-
to consider both personality traits and tioning. However, Shea et al. (2009) found
symptoms for a fuller understanding of that although age was not associated with
the longitudinal course of personality differential improvement in BPD criteria
and personality disturbances (Hopwood over 6 years of prospective follow-up, age
et al. 2013). Warner et al. (2004) used a se- was significantly associated with differ-
ries of latent longitudinal models to test ential course in functioning, with older
whether changes in specific traits pro- patients with BPD showing some de-
spectively predicted changes in relevant clines in functioning over time.
PDs and reported significant cross- Several reports from the CLPS are also
lagged relationships between changes in relevant here in regard to the issue of lon-
specific traits and subsequent (later) gitudinal comorbidities and continuities.
changes for STPD, BPD, and AVPD, but Shea et al. (2004) examined the time-vary-
not for OCPD. Morey et al. (2007, 2012) ing (longitudinal) associations between
compared alternative models for PDs PDs and psychiatric disorders, in part
(Five Factor Model, Schedule for Non- guided by the Siever and Davis (1991)
adaptive and Adaptive Personality, and model of cross-cutting psychobiological
DSM-IV PDs) for predicting important dimensions. The course of BPD demon-
clinical outcomes (functioning, Axis I strated significant associations with the
psychopathology, medication use) over course of certain other mental disorders
time. Morey et al. (2012) reported that (MDD and posttraumatic stress disor-
approaches that integrate both normative der), whereas the course of AVPD was
traits and PD pathology show the great- significantly associated with the course
est predictive utility. Sanislow et al. (2009) of two anxiety disorders (social phobia
examined the latent structure and stabil- and obsessive-compulsive disorder). Al-
ity of the four CLPS PDs and reported though these findings were consistent
that they became less differentiated over with predictions based on the Siever and
Davis (1991) model, other PDs did not from her friends. She had had a few
demonstrate significant longitudinal as- “counseling” sessions on a number of
occasions while in high school, at the
sociations. Gunderson et al. (2004) fol-
instigation of her parents, but would
lowed up on the Shea et al. (2004) find- stop therapy after a few weeks be-
ings regarding changes in BPD and MDD cause she felt misunderstood by the
by performing a more fine-grained anal- therapists, who did not “get” her, and
ysis of specific changes in the two disor- she believed that the therapy was
ders using 3 years of longitudinal data. “not helping.”
Within the first months of college,
Changes (reductions) in BPD severity pre-
Roberta became significantly de-
ceded improvements in MDD, but not pressed. She felt that she did not fit in
vice versa (Gunderson et al. 2004). Stud- with her average fellow student. She
ies of the predictive significance of PDs became increasingly isolated, attended
on other mental disorder psychopathol- classes only sporadically, and, after a
rebuff from the only boy with whom
ogy over time revealed complex and
she had become friends and to whom
mixed findings. PDs predicted signifi- she had proposed “hooking-up,” be-
cantly worse course for MDD (Grilo et al. gan to abuse substances more fre-
2005, 2010) and for some but not other quently, and ended up taking an over-
anxiety disorders (Ansell et al. 2011), but dose of over-the-counter sleeping
not for eating disorders (Grilo et al. 2007). pills. Following a brief 3-day hospital-
ization, she took a leave of absence
Collectively, comorbid PDs appear to be
from college and returned home to
negative prognostic indicators of many live with her parents. She entered a
important psychiatric disorders (Grilo self-help treatment program for sub-
et al. 2010). This finding has since been stance abuse and outpatient treatment
extended to an epidemiological sample with a psychiatrist, who prescribed
antidepressant medications. For the
and confirmed particularly for the nega-
ensuing 4 years, she lived at home and
tive impact of BPD on MDD persistence tried to work at various retail sales po-
(Skodol et al. 2011). sitions, which she would continue for
several months at a time before quit-
Case Example ting out of anger at an “asshole” cus-
tomer or from “boredom.” Initially,
Roberta is a 23-year-old, single, white she had little sense of herself beyond
female whose first psychiatric hospi- her identification with a couple of for-
talization occurred during her fresh- mer high school friends she clung to,
man year in college at a large state who had never left town; she had no
university. She had been an average long-term plans or goals of her own,
student in a medium-sized high school, she remained very sensitive to per-
somewhat isolated from most of her ceived slights by her friends or at her
peers except for a small group of friends jobs, and she became temporarily “ob-
who shared similar interests in goth sessed” with a couple of men she met
clothing, music, and books. Her only at bars, only to feel rejected and aban-
ostensible problems in high school re- doned by them after sleeping with
sulted from alcohol and marijuana them, when they did not call her im-
use, which caused her to be truant mediately on the next day. She fre-
frequently, leading to angry rows quently thought about suicide but did
with her parents and to her being not make another suicide attempt.
“grounded” for periods of time. Ro- Roberta remained in therapy, how-
berta attributed her use of substances, ever, because she believed that her
however, to seeking relief from un- psychiatrist at least “tried to under-
predictable “bad moods” and her ten- stand” her. Although initially diag-
dency to “blow up” in the face of dis- nosed as having BPD, she went long
appointments or perceived slights
stretches of time not meeting full 74% by years 2, 4, and 6, respectively. Re-
criteria, because she curtailed her porting on findings consistent with those
substance use and did not attempt
in the early CLPS reports, Zanarini et al.
suicide. Her depression gradually
improved and her moodiness stabi- (2003) concluded that “symptomatic im-
lized over the initial years of treat- provement is both common and stable,
ment. Her tendencies to be insecurely even among the most disturbed border-
attached to others and to fear aban- line patients, and that the symptomatic
donment were more persistent, how- prognosis for most, but not all, severely
ever. In addition, she became more
ill borderline patients is better than pre-
socially isolated, not wanting to risk
rejection, and less inclined to try to viously recognized” (p. 274). Zanarini
find work. After 4 years of therapy, and colleagues also reported, on the ba-
she was “in remission” from her persis of findings that were generally con-
sonality disorder but was completely sistent with findings from the NIMH-
dependent financially on her parents
CDS, that personality traits and BPD psy-
and continued to live at home.
chopathology had predictive prospective
This case illustrates improvement in utility (Hopwood and Zanarini 2010),
BPD psychopathology (and depression), and that BPD had negative prognostic
persistence of problematic borderline significance for some other mental dis-
“traits,” and a disconnection between orders, although they later reported that
the remission of personality psychopa- other mental disorders are less common
thology and the persistence of poor psy- over time in patients with BPD, particu-
chosocial functioning. larly among those whose BPD remits
(Zanarini et al. 2004). The MSAD also
McLean Study of found BPD to be associated with signifi-
cant psychosocial impairment (Zanarini
Adult Development et al. 2009); however, in contrast to find-
The MSAD (Zanarini et al. 2003, 2005a) ings from the CLPS, much of the impair-
is an ongoing prospective longitudinal ment was associated with vocational
study comparing the course and out- rather than social impairment (Zanarini
come of hospitalized patients with BPD et al. 2009, 2010a).
to those with “other” PDs utilizing re- In their report of 16 years of prospective
peated assessments performed every follow-up, Zanarini et al. (2012) showed
2 years (Zanarini et al. 2003) and has re- that patients with BPD were significantly
ported outcomes through 6 (Zanarini et slower to achieve remission (defined in
al. 2003, 2005a, 2005b), 10 (Zanarini et al. the MSAD as good social and vocational
2010b), and 16 years (Zanarini et al. functioning, in addition to minimal PD
2012) of follow-up. Zanarini et al. (2003) symptoms) than the comparison group
assessed PDs in 362 inpatients (290 with with other PDs. After 16 years, however,
BPD and 72 with other PDs) with two remission rates ranged from 78% to 99%
complementary semistructured diag- for patients with BPD and from 97% to
nostic interviews administered reliably, 99% for patients with other PDs, but those
and administered assessments to char- with BPD had lower recovery rates (40%–
acterize other psychiatric disorders, psy- 60%) than those with other PDs (75%–
chosocial functioning domains, and treat- 85%). Relapses occurred significantly
ment utilization. The authors reported faster and at a higher rate among patients
remission rates for BPD of 35%, 49%, and with BPD than among those with other
PDs. Zanarini et al. (2012) concluded that cluding their moderate levels of stability
remission is more common than recovery throughout adolescence and early adult-
from BPD and that recovery is more diffi- hood (Crawford et al. 2008; Johnson et
cult to sustain for patients with BPD than al. 2000a, 2000b, 2005); 3) the association
for those with other PDs. Patients with between PD psychopathology in adoles-
BPD should continue with psychother- cents and impairments in educational
apy after symptomatic remission to guard achievement (Cohen et al. 2005a; John-
against relapse and to help promote im- son et al. 2005) and greater interpersonal
provement in psychosocial functioning. and partner conflicts (Chen et al. 2004);
and 4) indications that early forms of be-
Children in the havioral disturbances predict PD in ado-
lescents and that PDs during adolescence,
Community Study in addition to demonstrating significant
The CICS (D.W. Brook et al. 2002; J.S. levels of continuity into adulthood, also
Brook et al. 1995; Cohen et al. 2000; Co- predict other mental disorders and sui-
hen et al. 2005a, 2005b) is an especially cidality (Johnson et al. 1996), as well as
impressive ongoing longitudinal effort violent and criminal behavior (Johnson
that has already provided a wealth of et al. 2000b) during young adulthood.
information about the course of person- The continuity of these persistent forms
ality and behavioral traits, psychiatric of impairment associated with PD pa-
problems, substance abuse, and adversi- thology into young and middle adult-
ties. The CICS is a prospective study of hood has also been reported by the CICS.
nearly 1,000 families with children ages Skodol et al. (2007) reported that young
1–10 years when originally recruited in adults (mean age 33 years) with persis-
1975 in New York State using a random tent forms of PD had significantly poorer
sampling procedure. The CICS research- functioning and greater impairment
ers have performed repeated multi- than those whose PD had gone into re-
modal assessments and followed over mission. Collectively, these findings
700 participants through the developmen- support the continuity and persistence
tal eras of childhood, adolescence, and of personality disturbances, although
early adulthood. This landmark study— their mutual developmental pathways
which has reported 20-year outcomes are not yet understood (Cohen et al.
(Crawford et al. 2008)—has provided 2005b; Crawford et al. 2001a, 2001b; John-
data that speak to the critical issues of son et al. 2000a, 2000b; Skodol et al. 2007).
longitudinal comorbidities and continu- Although many children and adoles-
ities. In a series of papers, the collaborat- cents with personality psychopathology
ing researchers have documented im- may be expected to improve, the most
portant findings that speak to many severely affected are likely to have prob-
issues raised in this review, but especially lems in later life and should be followed
to the critical issues of continuity of risk closely. They may require ongoing treat-
and functioning across developmental ment to prevent the development of
eras. Important findings include 1) doc- later impairments in functioning. All
umentation of the validity of certain forms PDs in DSM-5 Section II and Section III
of dramatic-erratic PDs in adolescents can be diagnosed in children or adoles-
(Crawford et al. 2001a, 2001b); 2) age- cents except ASPD, which requires a min-
related changes in PD symptoms, in- imum age of 18.
toms, traits, and consequences. Third, el-

Conclusion ements of personality functioning and
personality traits are expected to incre-
We have reviewed the literature regard- ment each other in predicting important
ing the stability, course, and outcome of clinical outcomes over time. Fourth, by
PDs, focusing particular attention on re- representing PDs in terms of a broad hier-
cent findings from three methodologi- archical trait structure known to underlie
cally rigorous, prospective, longitudinal most of psychopathology (i.e., internal-
studies with periods of follow-up rang- ization, externalization, and their lower-
ing from 10 to 20 years. We conclude that order factors), the ubiquitous comorbid-
PDs as defined in Section II of DSM-5 ity and homotypic continuity between
demonstrate only moderate stability PDs and other psychiatric disorders be-
and that they can improve over time, come understandable on the basis of
with the reductions in pathology persist- shared liabilities (for more details of the
ing in many cases. We also conclude that alternative model and its derivation, see
PDs represent negative prognostic fac- Chapter 7 and Chapter 24 in this volume).
tors for many types of other psychiatric Future longitudinal studies should com-
disorders and are associated with persis- pare the stability of Section III PD concep-
tent impairments in social functioning. tualizations both with traditional cate-
These conclusions are offered with more gorical definitions and with other types
confidence than in our previous re- of dimensional or hybrid representations
views, given the notable methodological of personality psychopathology.
advances in the empirical literature on
the clinical course and outcome of PDs.
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PART II
Treatment
CHAPTER 9
Therapeutic Alliance
Any patient beginning treatment Each type of pathology produces its

enters a relationship, whether it is for a own confusion and its own distorted
version of loving and giving. The
short time during a hospital stay or over
borderline patient defines love as a
many years in long-term psychotherapy. relationship with a partner who will
This relationship with the clinician has offer approval and support for re-
the potential for improving the patient’s gressive behavior. . . . The narcissist
quality of life, perhaps through the alle- defines love as the ability of someone
viation of symptoms or more profoundly else to admire and adore him, and to
provide perfect mirroring.... Psycho-
through shifts in character structure. It is
paths seek partners who respond to
sometimes difficult to determine a priori their manipulations and provide them
who will benefit from what treatment with gratification. The schizoid . . .
with whom, but one factor—therapeutic finds love in an internal, autistic fan-
alliance—has stood out in the research lit- tasy. (pp. 110–111)
erature as the most robust predictor of
outcome (Horvath et al. 2011; Safran et al. In fact, several studies have shown that
rather than categorical diagnosis, the
2011).
Because establishing a productive al- preexisting quality of the patient’s rela-
liance arises within the matrix of a relationships is what most significantly af-
fects the quality of the therapeutic alli-
tionship between patient and therapist,
when considering personality disorders ance (Cookson et al. 2012; Gibbons et al.
(PDs) one must note that all such disor- 2003; Hersoug et al. 2002; Piper et al. 1991).
For example, it has been suggested that
ders are associated in some way with
significant impairment in interpersonal patients’ attachment styles and internal
relations. Speaking about the nature of working models of therapy expectations
significantly influence the process of alli-
relationships of individuals character-
ized by certain types of personality pa- ance development (Diener and Monroe
thology, Masterson (1988) noted the fol- 2011; Hatcher 2010). Consequently, the
clinician must consider an individual’s
lowing:
189
characteristic way of relating so that ap- discussion of treating patients with PDs.
propriate interventions can be employed One conceptualization, using psychoan-
to effectively retain and involve the pa- alytic language, was posited by Gutheil
tient in the treatment, regardless of mo- and Havens (1979): The patient’s ability
dality. Forming an alliance is often diffi- to form a rational alliance arises from “the
cult, however, particularly in work with therapeutic split in the ego which allows
patients with severely narcissistic, bor- the analyst to work with the healthier el-
derline, or paranoid proclivities, because ements in the patient against resistance
troubled interpersonal attitudes and be- and pathology” (p. 479). This definition is
haviors will also infuse the patient’s en- useful vis-à-vis PDs in two regards: 1) the
gagement with the therapist. For exam- recognition that there will be pathologi-
ple, narcissistic patients may not be able cal parts of the patient’s personality func-
to allow the therapist to act as a separate, tioning that may serve to thwart the at-
thinking person for quite a long time, tempted helpfulness of the clinician, and
whereas someone with borderline issues 2) the need for the clinician to be creative
may exhibit wildly fluctuating emotions, in enlisting whatever adaptive aspects of
attitudes, and behaviors, thwarting the the patient’s character may avail them-
potential helpfulness of the clinician. selves for the work of the treatment.
Another definition that was developed
in an attempt to transcend theoretical
Definition of traditions is Bordin’s (1979) identifica-
Therapeutic Alliance tion of three interdependent compo-
nents of the alliance: bond, tasks, and
The concept of the therapeutic alliance is goals. The bond is the quality of the rela-
often traced back to Freud, who ob- tionship formed in the treatment dyad
served very early in his work the need to that then mediates whether the patient
convey interest in and sympathy to the will take up the tasks inherent in work-
patient to engage him or her in a collab- ing toward the goals of a particular treat-
orative treatment endeavor (Meissner ment approach. At the same time, the
1996; Safran and Muran 2000). Freud clinician’s ability to negotiate the tasks
(1912/1958) also delineated an aspect of and goals with the patient will also af-
the transference—the unobjectionable fect the nature of the therapeutic bond.
positive transference—which is an at- This multifaceted view of the alliance un-
tachment that should not be analyzed derscores the complexity of the factors
because it serves as the motivation for involved (Safran and Muran 2000).
the patient to collaborate: “The conscious Arguably, if the goal of treatment is
and unobjectionable component of [pos- fundamental character change, the Bor-
itive transference] remains, and brings din (1979) definition specifies necessary,
about the successful result in psycho- but not sufficient, elements of alliance.
analysis as in all other remedial methods” Adler (1980) observed that patients with
(p. 319). This statement is an early pre- borderline and narcissistic difficulties
cursor to the modern empirical evidence may not be able to establish a mature
showing that alliance is related to treat- working alliance until much later in a
ment outcome across modalities. successful treatment. Others who typi-
Several contemporary definitions of cally work with more disturbed patients
alliance might be useful to further this have noted that establishing a therapeu-
Therapeutic Alliance 191
tic alliance may be one of the primary the converse is also true: problems in the
goals of the treatment and that there may treatment alliance may lead to prema-
be different phases in alliance develop- ture termination if not handled in a sen-
ment as treatment progresses. Gunder- sitive and timely manner. Evidence has
son (2000) observed the following alli- shown that strains and ruptures in the al-
ance stages in the course of conducting liance are often related to unilateral ter-
long-term psychotherapy with patients mination (Safran et al. 2011). Thus, nego-
with borderline PD: tiating ruptures in the alliance is another
issue that has garnered increasing at-
1) Contractual (behavioral): initial tention in the psychotherapy literature.
agreement between the patient and
For example, Strauss et al. (2006) dem-
therapist on treatment goals and their
roles in achieving them (Phase I); 2) onstrated that skillfully addressing rup-
Relational (affective/empathic): em- tures strengthens the alliance, leading
phasized by Rogerian client-centered to better treatment outcome for a group
relationships; patient experiences of patients with avoidant or obsessive-
the therapist as caring, understand- compulsive PD.
ing, genuine, and likable (Phase II);
Disruptions in the alliance are inevi-
3) Working (cognitive/motivational):
psychoanalytic prototype; patient table and occur more frequently than
joins the therapist as a reliable collab- may be readily apparent to the clinician
orator to help the patient understand (Hill 2010; Safran et al. 2011). In one study
herself or himself; its development (Hill et al. 1993), patients were asked to
represents a significant improvement
report about thoughts and feelings that
for borderline patients (Phases III–IV).
(p. 41) they were not expressing to their thera-
pists. Most things that were not discussed
Progression through these stages, if were negative, and even the most expe-
successful, typically takes a number of rienced therapists were aware of uncom-
years. The implication is that to reach a municated negative material only 45%
point at which work leading to substan- of the time. It has also been suggested,
tive and enduring personality change however, that therapist awareness of pa-
can occur may require a lengthy initial tients’ negative feelings may actually
alliance-building period. As Bach (2006) create problems; therapists, rather than
noted, “Perhaps the primary problem being open and flexible in response, may
when engaging the challenging patient at times become defensive and negative
is to build and retain what Ellman (1998a) or may become more rigid in applying
has called analytic trust. These challeng- treatment techniques (Hill 2010).
ing patients have generally lost their Safran and Muran (2000) outlined a
faith not only in their caregivers, spouses, model specifying two subtypes of rup-
and other objects but also in the world it- tures: withdrawal and confrontation.
self as a place of expectable and manage- Withdrawals are sometimes fairly subtle.
able contingencies” (p. 35). One example is a therapist who assumes
that treatment is progressing but may be
unaware that a patient is withholding im-
Alliance Strains portant information because of lack of
and Ruptures trust or fear of feeling humiliated. Other
types of withdrawal behaviors include
Although a strong positive alliance can such things as intellectualizing, talking
predict a successful treatment outcome, excessively about other people, or chang-
ing the subject. Withdrawal behaviors different clusters, such as the co-occur-
may be more common in patients who rence of schizotypal PD with borderline
are overly compliant at times, such as PD or borderline PD with avoidant PD
those with dependent or obsessive-com- (McGlashan et al. 2000). In other cases, a
pulsive PD or those who are uncomfort- patient’s presentation may not meet full
able about interpersonal relations, such criteria for any one disorder but includes
as patients with avoidant PD. prominent features associated with one
Confrontations, on the other hand, are or several PDs.
usually more overt, such as complaining The second, alternative DSM-5 model,
about various aspects of therapy or criti- presented in Section III (“Emerging
cizing the therapist. Some may be rather Measures and Models”), is organized
dramatic, as with a patient who storms around the conceptual framework that
out of session in a rage or leaves an angry personality dysfunction emanates from
message on the therapist’s answering disturbances in self and interpersonal
machine. Confrontation ruptures are capacities. This approach for assessing
likely to be more frequently experienced PD adds a functioning/severity of im-
with more brittle patients, such as those pairment scale (Level of Personality
with borderline, narcissistic, or paranoid Functioning Scale) and a set of 25 trait
PD. In any event, clinicians are best served dimensions to more broadly and flexibly
by being alert to ruptures and adopting represent the range of psychopathology
the attitude that these are often excellent that might occur in the personality realm.
opportunities to engage the patient in a Six specific PDs are also featured, com-
collaborative effort to observe and learn prising relevant aspects of functioning
about that patient’s own style (Eubanks- and constituent traits. Personality di-
Carter et al. 2010). agnosis can be specified by designating
1) the level of personality functioning
impairment and 2) the presence of one
Personality Functioning, or more pathological traits or a specific
PD that best characterizes the individ-
Traits, Diagnoses, and ual’s presentation. (For more detailed
Alliance Considerations consideration of this model, please re-
fer to Chapter 3, “Articulating a Core
There are two models of conceptualizing Dimension of Personality Pathology,”
personality psychopathology in DSM-5 and Chapter 7, “Manifestations, Assess-
(American Psychiatric Association 2013). ment, and Differential Diagnosis,” in this
The first approach, in Section II (“Diag- volume.)
nostic Criteria and Codes”), retains the In practical terms, it must be under-
DSM-IV PD diagnostic clusters and cat- stood that personality is a complex amal-
egories (American Psychiatric Associa- gam of characteristic ways of thinking
tion 1994). However, there is consider- about oneself and others, and that how
able evidence demonstrating that this one conceptualizes the interpersonal
approach is limited in its capacity to ad- world influences behavior. Whether us-
equately capture the complexity of char- ing PD diagnostic categories, or consider-
acter pathology traits and symptoms. ing aspects of personality functioning
For instance, patients often meet criteria and dominant traits, a clinician consider-
for at least two PDs, perhaps spanning ing salient elements of the therapeutic al-
liance should determine which aspects of ered in determining salient aspects of

a patient’s personality pathology are patients’ personality profiles. Table 9–1
dominant or in ascendance at intake and presents DSM categorical personality di-
at various points over the course of treat- agnoses with corresponding self and in-
ment. It has been suggested that the na- terpersonal functioning elements and
ture of the alliance established early in traits from the new model. For each di-
the treatment is an especially powerful agnosis, tendencies that may serve to
predictor of outcome (Horvath and Lu- challenge early collaboration building
borsky 1993). One example of the rela- are presented, as well as points of possi-
tionship of early alliance and outcome re- ble engagement.
garding PDs was demonstrated in a study
of long-term psychotherapy with a group Cluster A
of patients with borderline PD: therapist
ratings of the alliance at 6 weeks pre- Cluster A—the so-called odd or eccentric
dicted subsequent dropouts (Gunderson cluster—comprises paranoid, schizoid,
et al. 1997). As Horvath and Greenberg and schizotypal PDs. What is most rele-
(1994) noted, “It seems reasonable to vant for alliance building is the profound
think of alliance development in the first impairment in interpersonal relationships
phase of therapy as a series of windows associated with these disorders. Because
of opportunity, decreasing in size with there are often pronounced paranoid or
each session” (p. 3). alienated features, people with these
The following discussion is arranged characteristics often do not seek treatment
according to the DSM-5 Section II cluster unless dealing with acute symptom disor-
and category system. However, this ap- ders such as substance abuse. There is ev-
proach should be considered in the con- idence that patients with these disorders
text of the limitations discussed in the who do seek treatment have great diffi-
previous paragraphs. The most impor- culty establishing a working alliance (e.g.,
tant data for understanding one’s pa- Lingiardi et al. 2005).
tients in forging an alliance is how an in-
dividual typically thinks about himself
Paranoid
or herself and other people. In the Sec- The “paranoid” label speaks largely for
tion III alternative DSM-5 PD model, per- itself. Paranoid individuals are inces-
sonality functioning—based on charac- santly loaded for bear and see bears where
teristic mental representations of self others do not—that is, they are vigilantly
and others—comprises aspects of iden- on the lookout for perceived slights,
tity, self-direction, empathy, and inti- finding offense in even the most be-
macy. Personality functioning, assessed nign of circumstances. Alliance-building
using the Level of Personality Function- challenges are obvious. However, it has
ing Scale, can be determined indepen- also been noted that paranoid individuals
dent of PD diagnosis and used to inform are often acting in defense of an ex-
thinking about the therapeutic alliance. tremely fragile self concept and may pos-
Nevertheless, to bridge DSM-5 Section II sibly be reached over time in treatment
categories and the new model, the author with an approach that includes unwav-
has suggested typical functioning patterns ering affirmation and careful handling
for each diagnosis. In addition, promi- of the many possible ruptures (Benjamin
nent problematic traits can be consid- 1993).
194
TABLE 9–1. Alliance-relevant aspects of each personality disorder style
Personality DSM-5
disorder DSM-5 alternative model: self and interpersonal alternative Alliance Points of possible engagement

category functioning model: traits challenges in treatment
Paranoid Identity: Serious distortions in sense of self, which is organized • Suspiciousness Expectations of harm Underlying need for affirmation:
around defending against perceived mistreatment (e.g., attacks • Hostility or exploitation Paranoia arises from patient’s dis-
on his or her character or reputation that are not apparent to Hypersensitivity to owned aggression; ideas about
others); dominant affect is reactive anger, which may be accom- perceived criticism harm and persecution are projected.
panied by aggression. Inclination to with- Appreciating the patient’s funda-
Self-direction: Goals are reactive rather than proactive, oriented draw or attack mental wish for safety and respect
toward self-protection rather than productivity, and thus lack may help the therapist empathically
coherence and/or stability. Thoughts and actions may be con- find ways of connecting. Tolerance
fused, and capacity to reflect on internal experience is com- and nonretaliation of hostility are
promised by firmly held view that life is dangerous. essential.
Empathy: A self-focused perspective in the service of harm avoid-
ance significantly compromises ability to appreciate and under-
stand others’ motivations and perceptions (e.g., frequently
believes, without sufficient basis, that others are exploiting or
deceiving him or her).
Intimacy: Significantly limited by reluctance to confide in others
because of unwarranted fear that the information will be used
maliciously against him or her; relationships and even coop-
erative efforts are disrupted due to persistent, unjustified
doubts about the loyalty or trustworthiness of friends or
associates, including suspicions regarding fidelity of spouse
or partner.
TABLE 9–1. Alliance-relevant aspects of each personality disorder style (continued)
Personality DSM-5
Schizoid Identity: Rigid, idiosyncratic self-definition with overemphasis • Withdrawal Social detachment Hidden neediness and sensitivity:
on independence from others; emotional expression is highly • Intimacy Emotional aloofness Therapist’s tacit recognition of pa-
restricted. avoidance tient’s deep-seated vulnerabilities,
Self-direction: Personal goals are highly constrained and fo- • Restricted along with sensitive interventions,
cused on pursuing solitary activities; little insight into own affectivity may create opportunity for build-
mental processes; greatly impaired prosocial motivation. • Anhedonia ing some trust. Therapist must tol-
Empathy: Significant deficits and disinterest in understanding erate patient’s defensive distance.
others’ experiences and perspectives, as well as effect of own
behavior on others, associated with apparent indifference to
mutual relationships.
Intimacy: Does not manifest desire for close relations, including
being part of a family; cooperative efforts may be minimal,
based only on necessity to meet basic needs.
Schizotypal Identity: Confused boundaries between self and others; dis- • Cognitive and Suspiciousness/ Possible motivation for human con-
torted self-concept; emotional expression often not congru- perceptual paranoia nection:
ent with context or internal experience. dysregulation Profound interper- Therapist may become a key support
Self-direction: Unrealistic or incoherent goals; no clear set of • Unusual beliefs sonal discomfort for a person who lacks a social net-
internal standards. and experiences Bizarre thinking work. Helping the patient feel
Empathy: Pronounced difficulty understanding impact of own • Eccentricity heard, appreciated, and under-
behaviors on others; frequent misinterpretations of others’ • Restricted stood in spite of off-putting presen-
motivations and behaviors. affectivity tation offers an experience different
Intimacy: Marked impairments in developing close relation- • Withdrawal from daily encounters.
ships, associated with mistrust and anxiety. • Suspiciousness
195
196
Personality DSM-5

Antisocial Identity: Egocentrism; self-esteem derived from personal gain, • Manipulativeness Controlling Possible attendance at treatment
power, or pleasure. • Callousness Tendency to lie and if in self-interest or if symptoms
Self-direction: Goal setting based on personal gratification; ab- • Deceitfulness manipulate such as depression cause
sence of prosocial internal standards associated with failure • Hostility No empathy or regard sufficient distress:
to conform to lawful or culturally normative ethical behavior. • Risk taking for others Points of engagement may at first be
Empathy: Lack of concern for feelings, needs, or suffering of • Impulsivity Use of pseudo- found in speaking to the patient’s
others; lack of remorse after hurting or mistreating another. • Irresponsibility alliance to gain some immediate personal benefit. It is im-
Intimacy: Incapacity for mutually intimate relationships, as ex- advantage portant to communicate in a
ploitation is a primary means of relating to others, including straightforward and honest man-
by deceit and coercion; use of dominance or intimidation to ner, addressing reality, keeping a
control others. firm handle on frame issues such as
session time and fee, and being con-
sistent and nonpunitive.
Borderline Identity: Markedly impoverished, poorly developed, or unsta- • Emotional lability Unstable emotional Relationship seeking, responding
ble self-image, often associated with excessive self-criticism; • Anxiousness and cognitive states to warmth and support:
chronic feelings of emptiness; dissociative states under stress. • Separation inse- Extremely demanding Understanding the suffering, vulner-
Self-direction: Instability in goals, aspirations, values, or career curity Proneness to acting ability, and inherent loneliness of
plans. • Depressivity out patient with borderline problems
Empathy: Compromised ability to recognize the feelings and • Impulsivity can help therapist tolerate emo-
needs of others associated with interpersonal hypersensi- • Risk taking tional storms and alliance ruptures.
tivity (i.e., prone to feel slighted or insulted); perceptions of • Hostility It is important to express ongoing
others selectively biased toward negative attributes or vul- appreciation of the patient’s experi-
nerabilities. ence through communicating em-
Intimacy: Intense, unstable, and conflicted close relationships, pathically and maintaining a
marked by mistrust, neediness, and anxious preoccupation supportive stance, and to assist the
with real or imagined abandonment; close relationships often patient in reflecting on his or her
viewed in extremes of idealization and devaluation and al- thoughts, emotions, and needs.
ternating between overinvolvement and withdrawal.
Personality DSM-5
Histrionic Identity: Excessive dependence on physical appearance for • Attention seeking Attempts to charm Relationship seeking, responding
identity definition; sense of self is lacking in detail and easily • Emotional lability and entertain to warmth and support:
influenced by others or circumstances. • Manipulativeness Emotionally labile Therapist needs to appreciate the pa-
Self-direction: Suggestibility leads to difficulty establishing Unfocused cognitive tient’s fragile sense of self that leads
and/or achieving enduring personal goals; impaired capac- style to sometimes dramatic attempts to
ity to reflect on internal experience, as cognitions tend to be bolster self-esteem, along with a
impressionistic and lacking in detail. sense of obligation to charm and en-
Empathy: Excessive self-focus with limited ability to or interest tertain. Therapist should adopt an
in trying to appreciate or understand others’ experiences, or empathic and supportive stance
to consider alternative perspectives. and gently assist the patient in
Intimacy: Personal relationships may be numerous but are learning to reflect on his or her
largely superficial, and often are considered to be more inti- thoughts, emotions, and needs.
mate than they actually are.
Narcissistic Identity: Excessive reference to others for self-definition and • Grandiosity Need for constant Response over time to empathy and
self-esteem regulation; exaggerated self-appraisal may be in- • Attention seeking positive regard affirmation:
flated or deflated, or may vacillate between extremes; emo- Contempt for others Narcissistic problems stem from a
tional regulation mirrors fluctuations in self-esteem. Grandiose sense of significant impoverishment of the
Self-direction: Goal setting is based on gaining approval from entitlement self that is coped with by looking to
others; personal standards are unreasonably high in order to others for approval. Patience, affir-
see oneself as exceptional, or too low based on a sense of mation, and empathic mirroring of
entitlement; often unaware of own motivations. the patient’s experience are impor-
Empathy: Impaired ability to recognize or identify with the feel- tant components of the treatment.
ings and needs of others; excessively attuned to reactions of
others, but only if perceived as relevant to self; over- or un-
derestimation of own effect on others.
Intimacy: Relationships largely superficial and exist to serve
self-esteem regulation; mutuality constrained by little genu-
ine interest in others’ experiences and predominance of a
197
need for personal gain.
198
Personality DSM-5

Avoidant Identity: Low self-esteem associated with self-appraisal as so- • Anxiousness Expectations of criti- Response to warmth/empathy, de-
cially inept, personally unappealing, or inferior; excessive • Withdrawal cism or rejection siring relationships in spite of vul-
feelings of shame. • Anhedonia Proneness to shame nerabilities:
Self-direction: Unrealistic standards for behavior associated • Intimacy and humiliation If the therapist is very cognizant of the
with reluctance to pursue goals, take personal risks, or en- avoidance Reluctance to disclose patient’s vulnerability to shame, a
gage in new activities involving interpersonal contact. information sensitive approach to discussing the
Empathy: Preoccupation with, and sensitivity to, criticism or patient’s longing for connection may
rejection, associated with distorted inference of others’ per- be effectively pursued. Patience must
spectives as negative. be employed toward the patient’s re-
Intimacy: Reluctance to get involved with people unless being luctance to open up. Expressed ap-
certain of being liked; diminished mutuality within intimate preciation of the patient’s difficulties
relationships because of fear of being shamed or ridiculed. is important, and attunement to pos-
sible perceived slights is essential.
Dependent Identity: Identity definition and emotion regulation are exces- • Submissiveness No value placed on in- Friendly and compliant, and likely
sively dependent on the presence of reassuring others, fre- • Separation dependence/taking to stay in treatment:
quently with compromised boundary delineation. insecurity initiative The clinician should be aware that
Self-direction: Difficulty establishing, pursuing, or achieving • Anxiousness Submission leading to abandonment is feared above all
personal goals without significant support from others; un- pseudo-alliance else, and the patient is terrified of
able to make everyday decisions or to initiate or sustain proj- negative consequences of self-
ects without an excessive amount of advice or reassurance; assertion. Careful encouragement
need for others to assume responsibility for most major areas of the patient in learning about his
of his or her life. or her own thoughts and feelings is
Empathy: Hyperattuned to the experience of others, but only very important. Pushing the patient
with respect to perceived relevance to self; attention to others’ prematurely toward independence
perspectives is associated with excessive emphasis on fulfill- should be avoided, and it is crucial
ing own needs; constantly monitors effect of own behavior to monitor the patient’s “going
on others for fear of loss of care, attention, or approval. through the motions” of therapy
Intimacy: Intimate relationships largely based on unrealistic ex- merely to please.
pectations of being completely cared for by others; feelings
about intimate involvement with others are centered around
extreme fear of rejection and desperate desire for connection.
Personality DSM-5
Obsessive- Identity: Sense of self derived predominantly from work or pro- • Rigid perfection- Need for control Conscientious and will try to be a
compulsive ductivity; constricted experience and expression of strong ism Perfectionistic toward “good patient”:
emotions. • Perseveration self and others Clinicians should be tolerant of the
Self-direction: Difficulty completing tasks and realizing goals • Intimacy Fear of criticism from patient’s need for control and
associated with rigid and unreasonably high and inflexible avoidance therapist should resist becoming embroiled
internal standards of behavior; overly conscientious and • Restricted Restricted affect in power struggles or becoming a
moralistic attitudes. affectivity Stubbornness critical authority figure. A kind
Empathy: Difficulty understanding and appreciating the ideas, and playful acceptance of nonper-
feelings, or behaviors of others. fection may help the patient de-
Intimacy: Relationships seen as secondary to work and produc- velop greater trust.
tivity; rigidity and stubbornness negatively affect relation- Appreciate the patient’s intellectual-
ships with others. izing stance, while eventually
gently encouraging consideration
of emotions.
199
Schizoid cult for the patient to find some mini-

mum level of comfort. Bender et al. (2003)
Benjamin (1993) noted that schizoid per-
assessed various attributes of how pa-
sonality is consistently associated with a
tients with PD think about their therapists.
lack of desire for intimate human con-
Interestingly, results showed that pa-
nection. She described that some people
tients with schizotypal PD had the highest
with schizoid character can be found liv-
level of mental involvement with ther-
ing very conventional lives on the sur-
apy outside the session, missing their
face, having families, jobs, and so on.
therapists and wishing for friendship
However, usually things are arranged
while also feeling aggressive or negative.
such that people are kept at an emo-
One man with schizotypal PD (who had
tional distance. There may also be a pro-
also become attached to the female re-
nounced lack of conflict, with associated
search assistant) revealed the following
affective coldness or dullness, such that
view of his therapist:
a truly schizoid person is unlikely to be-
come anxious or depressed and thus is
Very beautiful and attractive in a sense
usually totally lacking any motivation
that I yearn to have a sexual relation-
to seek treatment. Nonetheless, Akhtar ship with her. She’s very smart and
(1992) suggested that underlying all of educated. She knows what she wants
this apparent detachment is an intense out of life and I wish I were working
neediness for others and the capability for I could take her out to the movies
and dinner. She turns me on and I
of interpersonal responsiveness with a
desperately want to make love to her
few carefully selected people. Patients eternally. She’s my life and knowing
who may have more access to these lat- she doesn’t feel the same, I live in
ter attributes have a greater likelihood of dreams. (Bender et al. 2003, p. 231)
forming an alliance in therapy if they
choose to seek treatment.
Cluster B
Schizotypal Cluster B, the “dramatic” cluster, includes
Schizotypal phenomena are thought by antisocial, borderline, histrionic, and
some to lie on the schizophrenia spec- narcissistic PDs. Each of these character
trum, given the associated disordered styles is associated in some way with
cognitions and bizarre beliefs. Because it pushing the limits, and great care is
is almost always the case that individu- needed by clinicians to avoid crossing
als with such cognitions have one or no inappropriate lines in a quest to build an
significant others outside family mem- alliance. Thus, many patients with Clus-
bers, it is often assumed that schizotypal ter B PDs present some of the most
individuals have no desire to become daunting treatment challenges.
involved in relationships. However, in
many cases, it is more a matter of being Antisocial
excruciatingly uncomfortable around Antisocial personality is associated with
people than a lack of interest in connec- ongoing violation of society’s norms,
tion. This discomfort may not be readily manifested in such behaviors as theft, in-
apparent, so establishing an alliance with timidation, violence, or making a living
such patients may require being atten- in an illegal fashion such as by fraud or
tive to clues about what is not being said. selling drugs. Also narcissistic by defini-
The therapist may be a player in some tion, people with antisocial PD have little
elaborated fantasy that is making it diffi- or no regard for the welfare of others.
Clearly, this PD is found extensively tients with antisocial PD are more likely
among inmates within the prison system. to benefit from treatment compared with
Stone (1993) suggested that there are gra- nondepressed patients with antisocial
dations of the antisocial style, with the PD (Shea et al. 1992). Thus, the presence
milder forms being more amenable to of depression may serve as motivation
treatment. However, within the broader for these patients to seek and comply
label of antisocial is a subset of individuals with treatment.
who are considered to be psychopathic.
Those who are psychopathic are sadistic Borderline
and manipulative pathological liars; show Kernberg (1967) described the borderline
no empathy, compassion, or remorse for personality as being riddled with aggres-
hurting others; and take no responsibil- sive impulses that constantly threaten to
ity for their actions. The most dramatic destroy positive internal images of the
form is manifested by individuals who self and others. According to this model,
torture or murder their victims. Those the person with borderline PD does not
who perpetrate such violence reside on undergo the normal developmental pro-
the extreme end of the spectrum of anti- cess of psychological integration. Rather,
social behavior and would be the most as a defensive attempt to deal with ag-
difficult to treat (see Chapter 20, “Antiso- gression resulting from caregiver misat-
cial Personality Disorder and Other Anti- tunements or failures, this person creates
social Behavior,” in this volume for more “splits” in the mind to protect the good
detail). images from the bad. This splitting leads
In keeping with the notion that there is to a fractured self concept and the iden-
a spectrum of antisocial psychopathology, tity problems associated with this disor-
empirical evidence shows that some pa- der. Thus, a therapist can expect the alli-
tients with antisocial PD are capable of ance-building work to be rather rocky
forming a treatment alliance resulting in because these patients frequently exhibit
positive outcome (Gerstley et al. 1989). pronounced emotional upheaval, self-
Consequently, it has been recommended destructive acting-out, and views of the
by some that a trial treatment of several therapist that alternate between ideal-
sessions be applied with these patients ization and denigration. Within relation-
who may typically be assumed to be un- ships, such individuals are very needy
treatable. However, there is always the and demanding, often straining the
risk that such patients, particularly within boundaries of the treatment relationship
an institutional context (e.g., a hospital or and exerting pressure on clinicians to be-
prison), may exhibit a pseudo-alliance to have in ways they normally would not.
gain certain advantages (Gabbard 2005). Research has demonstrated that such
For example, there could be a disingenu- pressures can impair the clinician’s abil-
ous profession of enhanced self-under- ity to reflect on his or her mental states
standing and movement toward reform and those of the patient (Diamond et al.
as an attempt to manipulate the therapist 2003). Furthermore, clinicians who work
into recommending inappropriate privi- with such patients must be able to toler-
leges. ate and productively discuss anger and
There is some indication that depres- aggression. However, because patients
sion serves as a moderator in the treat- with borderline PD are, in most cases, re-
ment of patients with antisocial PD. One lationship seeking, this is a positive indi-
study demonstrated that depressed pa- cator for engagement in treatment.
One treatment study of patients with tempt to keep the clinician entertained
borderline personality examined alliance and engaged. At the same time, emotional
development over time (Waldinger and expressions are often shallow and greatly
Gunderson 1984). Psychodynamic psy- exaggerated, and the histrionic patient
chotherapy was employed using largely assumes a deep connection and depen-
noninterpretive interventions in the ini- dence very quickly. Details are presented
tial alliance-building period (the issue in vague and overgeneralized ways. There
of intervention choice is discussed later is very little tolerance for frustration,
in the section “Alliance Considerations resulting in demands for immediate grat-
Within Different Treatment Paradigms”). ification. As opposed to the better in-
The authors observed that a strong alli- tegrated, higher-functioning, neurotic
ance and good treatment outcome were “hysterical personality” often written
linked to two factors: 1) a solid commit- about in the psychoanalytic literature, the
ment by the participating therapist to re- DSM histrionic PD organization more
main engaged in the treatment until sig- closely resembles the borderline personal-
nificant gains had been made by the ity organization. Particular borderline
patients and 2) special emphasis on facil- aspects include a tendency to use split-
itating the patients’ expression of aggres- ting defenses, rather than repression, and
sion and rage without fear of retaliation. a marked degree of identity diffusion
Other studies that have undertaken de- (Akhtar 1992). The attention-seeking attri-
tailed analysis of alliance ruptures in the bute can be helpful in establishing a pre-
treatment of patients with borderline PD liminary alliance. However, with patients
have demonstrated the importance of the with histrionic pathology, as with patients
therapist vigilantly attending to the alli- with borderline pathology, the clinician
ance (e.g., Bennett et al. 2006; Horwitz et must be prepared to manage escalating
al. 1996). As Horwitz et al. (1996) noted, demands and dramatic acting-out.
“Clinical observation of our cases revealed
that the repair of moment-to-moment Narcissistic
disruptions in the alliance often was the Narcissistic character traits have received
key factor in maintaining the viability of considerable attention in the clinical lit-
the psychotherapy” (p. 173). Bateman and erature. Kohut (1977) described individ-
Fonagy (2012) have outlined specific tech- uals in whom there is a fundamental def-
niques for maintaining the integrity of icit in the ability to regulate self-esteem
the alliance through tracking and re- without resorting to omnipotent strate-
sponding to fluctuations in patients’ men- gies of overcompensation or overreli-
talizing status—the ability to reflect on ance on admiration by others. People
the mental and emotional states of self and who are narcissistically vulnerable have
others (see Chapter 10, “Psychodynamic difficulty maintaining a cohesive sense
Psychotherapies and Psychoanalysis,” in of self because of ubiquitous shame, re-
this volume for more information on this sulting from a sense that they fundamen-
approach to treatment). tally fall short of some internal ideal.
They look for constant reinforcement
Histrionic from others to bolster their fragile self-
An individual with histrionic personality images. This combination of traits has
needs to be the center of attention and been referred to alternatively as vulnera-
may behave in seductive ways in an at- ble, deflated, or covert narcissism.
On the other side of the narcissistic served, “Establishing any degree of trust
“coin”—what the DSM-5 Section II nar- with such patients may be extremely dif-
cissistic PD diagnosis captures—are ten- ficult, but not impossible, for a consis-
dencies toward intense grandiosity, and tent respect for their vulnerability and a
attempts to maintain self-esteem through recognition of their need not to trust
omnipotent fantasies and defeating oth- may in time undercut their defensive
ers. Needing others is defended against need” (p. 228).
by maintaining fusions of ideal self,
ideal other, and actual self-images. Thus,
there is an illusion maintained whereby
Cluster C
this manifestation of narcissism is asso- Cluster C, the “anxious or fearful” clus-
ciated with a sense that because he or ter, comprises avoidant, dependent, and
she is perfect, love and admiration will obsessive-compulsive PDs. Individuals
be received from other “ideal people,” whose personality functioning is most
and thus there is no need to associate closely characterized by Cluster C disor-
with inferiors. In its most extreme form, ders are emotionally inhibited and averse
this manifestation of character pathology to interpersonal conflict and are often
has been referred to as malignant narcis- considered to be the treatable “neurot-
sism (Kernberg 1984). ics” on the spectrum of PDs. These pa-
It is important to note that narcissism tients frequently feel very guilty and in-
is not necessarily exhibited in distinctive ternalize blame for situations even when
or rigid inflated or deflated types (Bender it is clear there is none. This latter ten-
2012; Levy 2012). Self-esteem oscillation dency often facilitates therapeutic alli-
is associated with pathological narcis- ance building, because the patient is will-
sism more generally, and both grandiose ing to take some responsibility for his or
and vulnerable styles can be observed her dilemma and will somewhat more
within the same individual. Moreover, readily engage in a dialogue with the
there is evidence that narcissistic diffi- therapist to sort it all out, compared with
culties are dimensional—that is, they patients with more severe Cluster A or B
vary in severity or degree—and are pres- diagnoses (Stone 1993).
ent across all PDs (Morey and Stagner
2012). Avoidant
In any event, it is obvious that narcis- The individual with avoidant personal-
sistic personality traits pose significant ity is extremely interpersonally sensi-
challenges in alliance building (Ron- tive, afraid of being criticized, and con-
ningstam 2012). It is often the case that stantly concerned about saying or doing
the patient will need to keep the thera- something foolish or humiliating. In spite
pist out of the room, so to speak, for quite of an intense desire to connect with oth-
a long time by not allowing the therapist ers, an avoidant person does not let any-
to voice anything that represents an alone get close unless absolutely sure the
ternative view to that of the patient’s. For person likes him or her. Because of this
such patients, other people, including acute sensitivity, there is some evidence
the therapist, do not exist as separate in- that some patients with avoidant per-
dividuals but merely as objects for grati- sonality are somewhat difficult to retain
fying needs. The clinician must tolerate in treatment. One study showed that pa-
this state of affairs, at times for a lengthy tients with avoidant PD were signifi-
period of time. As Meissner (1996) ob- cantly more likely than patients with ob-
sessive-compulsive PD to drop out of a A patient [with dependent PD] was

short-term supportive-expressive treat- chronically depressed, and the doctor
tried her on a new antidepressant. She
ment (Barber et al. 1997). Clinicians who
did not improve and had a number of
work with patients with avoidant per- side effects, but did not mention them
sonality need to be constantly mindful to the doctor. Fortunately, the doctor
of the potentially shaming effects of cer- remembered to ask for the specific
tain comments but can also work with side effects. The patient acknowl-
the patients’ underlying hunger for at- edged the signs, and the doctor wrote
a prescription for a different antide-
tachment to enlist them in building an
pressant. The patient was willing to
alliance. acknowledge the signs of problems...,
Furthermore, preliminary evidence but she did not offer the information
supports the notion that at least some pa- spontaneously. The doctor asked her
tients diagnosed with avoidant PD are ac- why she did not say anything. She
explained, “I thought that maybe
tually better characterized as demonstrat-
they were just part of the way the
ing vulnerable narcissist tendencies. These drug worked.... I figured you would
patients covertly crave admiration to bol- know what was best.” (Benjamin 1993,
ster their fragile self-esteem and secretly p. 405)
or unconsciously feel entitled to it rather
than simply being afraid of not being liked Benjamin (1993) also observed that one
or accepted (Dickenson and Pincus 2003). difficulty in working in psychotherapy
Gabbard (2005) referred to this style as with such patients is the reinforcement
hypervigilant narcissism, emphasizing ex- gained by the patient’s behavior. That is,
treme interpersonal sensitivity, other- because the passivity and submissive-
directedness, and shame proneness as- ness usually result in being taken care of,
pects. An underlying unrecognized nar- despite the associated cost, patients with
cissism in avoidant PD has significant dependent personality are loath to see the
treatment implications, changing the na- value in asserting some independence.
ture of the forces affecting the alliance as Furthermore, there is a deeply ingrained
well as shaping the types of treatment in- assumption by these patients that they
terventions that are indicated. are actually incapable of functioning
more independently and that being more
Dependent assertive will be experienced by others as
Fearing abandonment, individuals with alienating aggressiveness. Thus, a thera-
dependent personality tend to be very pist must be very alert to the withdrawal
passive, submissive, and needy of con- types of strains and ruptures, such as
stant reassurance. They go to great lengths withholding information, and to the chal-
not to offend others, even at great emo- lenge to the alliance that may occur when
tional expense, agreeing with others’ the therapist attempts to encourage more
opinions when they really do not or vol- independence.
unteering to do unsavory chores to stay
in someone’s good graces. In the context Obsessive-Compulsive
of treatment, patients with dependent The obsessive-compulsive character is
PD are easily engaged, at least superfi- associated with more stable interpersonal
cially, but often withhold a great deal of relationships than some other styles, but
material for fear of alienating the thera- typical defenses are centered on repres-
pist in some way. The following is an ex- sion, with patterns of highly regulated
ample of how this might play out: gratification and ongoing denial of in-
terpersonal and intrapsychic conflicts sure that his way of viewing things
(Shapiro 1965). Self-willed and obstinate, was superior to that of others.
Establishing a productive alliance
with a constant eye toward rules and reg-
with Quentin was not easily accom-
ulations, individuals with obsessive - plished at first. In the early phase of
compulsive attributes guard against any treatment, he was extremely control-
meaningful consideration of their im- ling and challenging in sessions, talk-
pulses toward others. Maintaining con- ing constantly and tangentially, often
trol over internal experience and the ex- losing the core point of his statements
because of a need to present exces-
ternal world is a top priority, so rigidity is
sive details. Any statement the thera-
often a hallmark of this character type. pist made was experienced as an in-
Except in its most severe manifestations, trusion or interruption. For example,
obsessive-compulsive character pathol- if the therapist attempted to be em-
ogy is less impairing than some of the pathic using a word Quentin had not
used, such as saying, “That sounds
others and more readily ameliorated by
difficult,” he would respond, “Diffi-
treatment. Although stubborn and con- cult? I don’t know if I’d choose the
trolling and averse to considering emo- word difficult. Challenging, maybe,
tional content, individuals with obses- or daunting, but not difficult.” Thus,
sive-compulsive PD also generally try to for a number of months in the initial
be “good patients” and therefore can be phase of the treatment, the therapist
chose her words carefully, which even-
engaged in a constructive alliance that is
tually paved the way for increased di-
less rocky than that with patients who alogue about his problems. Quentin
have other types of PD. also began to tolerate a discussion of
his emotional life, a topic that previ-
ously had been very threatening to
Case Example 1 him.
Quentin, a 25-year-old graduate stu-
dent in philosophy, began twice- Quentin’s case is also an example of
weekly psychotherapy. His present-
the limitations of categorical diagnosis.
ing complaint was difficulty with
completing work effectively, particu- Although Quentin’s personality function-
larly writing tasks, due to excessive ing ostensibly meets the diagnostic crite-
anxiety and obsessionality (he met ria for obsessive-compulsive PD, there
criteria for obsessive-compulsive PD are also clear indications of narcissistic
and generalized anxiety disorder). disturbance. His problems tolerating his
When he came for treatment, he was
therapist’s presence and interventions
struggling to make progress on his mas-
ter’s thesis. Although Quentin social- and his unreasonably high personal stan-
ized quite a bit, he reported that inti- dards are consonant with a narcissistic
mate relationships often felt “wooden.” level of personality functioning.
He was usually overcommitted, with
an endless list of “shoulds” that he
would constantly mentally review and Sadomasochistic
that triggered thoughts of how much
he was failing to satisfy his obliga-
Character
tions. A central theme throughout Cases in which difficult patients take a
treatment was his tendency to be self- prominent role in orchestrating situations
denigrating, loathing himself as a
to sabotage a potentially helpful treat-
person deserving of punishment in
some way yet being extremely pro- ment are ubiquitous in the clinical litera-
vocative (sadomasochistic trends). He ture. This type of dynamic points to an
also held very strong political beliefs, additional element commonly overlooked
in treatments in general but of particular abuse or neglect, or some experience of

relevance when trying to establish and loss of the self due to such things as child-
maintain an alliance with patients with hood illness or circumstances leading to
character pathology: sadomasochism overwhelming anxiety. From this per-
(Drapeau et al. 2012; Rosegrant 2012). spective, the cruel behavior of the sadist
Most dramatically overt in patients with may, for instance, be an attempt to punish
borderline, narcissistic, and/or antisocial the object for threatened abandonment.
issues, relational tendencies that range The masochistic stance involves a way of
from tinged to saturated by sadomasoch- loving someone who gives ill treatment—
istic trends span the spectrum of PD pa- the only way of maintaining a connec-
thology. The presence of sadomasochistic tion is through suffering. Early in devel-
patterns means not that overt sexual per- opment, this way of loving is self-preser-
versions will be present, although they vative—the sadism of the love object is
may be, but rather that the patient has turned upon the self as a way of main-
characteristic ways of engaging others in taining a needed relationship. However,
a struggle in which one party is suffering in an adult, this masochistic solution,
at the hands of the other. Patients with a with its always-attendant aggressive-sa-
sadomasochistic approach to relation- distic elements, serves to cause signifi-
ships make it very difficult for the clini- cant interpersonal dysfunction.
cian working in any modality to be a
helpful agent of change. Furthermore, it Case Example 2
is sometimes the case with such patients Elena, a single woman in her 40s, was
that at the foundation of the alliance is a referred for psychotherapy after she
very subtle, or not so subtle, sadomas- had gone to see four or five other ther-
ochistic enactment. apists, staying with each for no more
than several sessions because she
For example, a patient may, on the sur-
found them all to be incompetent in
face, be agreeing with the therapist’s ob- some way. An avid reader of self-help
servations but is actually experiencing literature, she considered herself an
them as verbal assaults while masochis- expert on the helping professions.
tically suffering in silence and showing Highly intelligent and extremely artic-
no improvement in treatment. Another ulate, Elena was aspiring to be a film-
maker. She had gone through a series
patient may be highly provocative, at-
of “day jobs” with corporations, re-
tempting to bait the therapist into saying porting that her women supervisors
and doing things that may prove to be were predictively untalented, unrea-
counterattacks. There are also patients sonable, and critical of her. Her inter-
who act out in apparently punishing personal relations were always tumul-
tuous, her moods were very unstable,
ways, such as by attempting suicide, us-
and it was apparent that she had been
ing a newly prescribed medication, grappling with narcissistic and bor-
when it seemed as though the treatment derline PD issues for decades.
had been progressing. Sadomasochistic trends became
Bach (1994) described a sadomasoch- apparent very quickly. In the first meet-
istic way of relating as arising as “a de- ing, Elena launched the first of many
critiques, reporting that she had found
fense against and an attempt to repair
the therapist’s greeting to be too up-
some traumatic loss that has not been beat but then also criticizing the ther-
adequately mourned” (p. 4). This trauma apist for not reassuring her that she
could have come in the form of an actual would have a successful treatment.
loss of a parent, loss of love as a result of She ultimately announced that the
therapist was “gifted,” so she would because such retributive behavior would
continue with this treatment, but have been a sadomasochistic enactment
there were many sessions in which
and would have caused Elena to take a
she would find fault or deliver lec-
tures on technique and theory. At the hasty departure.
same time, she was extremely brittle
and incapable of reflecting on this
type of behavior, feeling as a victim if
there was any vague hint that she
Alliance Considerations
might be doing something question- Within Different
able. Thus, while attacking the thera-
pist, she was doing it in the service of Treatment Paradigms
collecting grievances. (As Berliner
[1947] observed about such patients, Clearly, no matter what treatment para-
she “would rather be right than digm one adopts for working with pa-
happy” [p. 46].) Hence, both the sa-
distic and masochistic sides of the
tients who have PD, attention to the alli-
same coin were in evidence. ance is of utmost importance. Thoughts
and feelings on the part of the therapist
With patients such as Elena, it is very must be monitored closely, because in-
important to be able to tolerate the ex- teractions with many patients may often
pression of aggression. Consequently, to be provocative, inducing reactions that
maintain an alliance with this very diffi- must be carefully managed. (See Chap-
cult woman, the therapist had to con- ter 17, “Boundary Issues,” in this volume
stantly assess whether the attacks repre- for a discussion of some of the most seri-
sented a rupture in the alliance that had ous consequences of treatments gone
to be addressed or whether Elena simply awry.) Although this topic is usually dis-
needed to give voice to some of her tre- cussed as countertransference in the psy-
mendous anger at the world. When judg- choanalytic/psychodynamic tradition, it
ing that the alliance was in jeopardy, the is also quite applicable across all treat-
therapist would discuss Elena’s reaction ments (Gabbard 1999).
to the therapist’s interventions, acknowl- Treatment approach and technique
edging Elena’s distress and telling Elena must be flexible so that interventions can
that the therapist would reflect on what be made appropriate to each individual
had led the therapist to make the com- patient’s style. Otherwise, the alliance
ments that had upset Elena. Elena usually may be jeopardized and the patient will
found great relief in this approach, appre- not benefit or may leave treatment alto-
ciating the therapist’s willingness to re- gether. For example, Spinhoven et al.
flect on the situation. (2007) found an interaction between alli-
What is central is that the therapist ance and therapeutic techniques that in-
withstood being portrayed as bad or influence course and outcome in a group
competent in the patient’s mind without of patients with borderline PD. Further-
retaliating as though it were true. If the more, it is likely that noticeable improve-
therapist had had a different psychol- ments in symptoms and functioning in
ogy, it would have been rather easy patients with PDs will require a signifi-
to take up the role of sadist, perhaps cantly longer period of treatment than is
wrapped in the flag of “interpreting the required for patients with no character
patient’s aggression”; however, Elena pathology. Although the application of
and this therapist were a good match, specific treatment approaches is dis-
cussed at length in other chapters of this pairments until that patient is assisted in
book, it is worth mentioning here a few achieving a safe, more stable alliance.
alliance-relevant considerations pertain- Similarly, the patient with severe narcis-
ing to each broad treatment context. sistic impairment may not be able to ac-
cept the analyst’s interpretations of his
or her unconscious motivations for quite
Psychodynamic a long time, so that supportive, empathic
Psychotherapies communications may be more effective
interventions in building an alliance by
and Psychoanalysis helping the patient feel heard and un-
One long-standing issue within the psy- derstood. Conversely, some obsessional
chodynamic psychotherapy tradition inpatients may benefit earlier in treatment
volves the application of particular tech- by interpretations of the repressed con-
niques. Interpretation of the transference flicts that may underlie the symptoms.
was long considered the heart of the psy- The results of the Psychotherapy Re-
choanalytic approach. However, as the search Project of The Menninger Founda-
application of this treatment evolved and tion, which included patients with PDs,
clinicians gained more experience with led Wallerstein (1986) to conclude that
more disturbed patients—most notably both expressive and supportive interven-
those with borderline and narcissistic tions can lead to character change. At the
trends—it became apparent that in many same time, there is empirical evidence
cases, transference interpretations with supporting the notion that a fairly solid
such patients were often counterproduc- alliance must be present to effectively uti-
tive. Refraining from making deep, in- lize transference interpretations per se.
terpretive interventions early on is con- Bond et al. (1998) demonstrated with a
sistent with notions of writers such as group of patients with PDs in long-term
Winnicott (1965) and Kohut (1984), who treatment that for those patients whose
asserted that certain patients cannot tol- alliance was weak, transference interpre-
erate such interpretations in the initial tations caused further impairment to the
phase of treatment. alliance. Conversely, when already solidly
Gabbard (2005) stressed the impor- established, the alliance was strengthened
tance of understanding that there is usu- by transference interpretations. At the
ally a mixture of supportive and expres- same time, supportive interventions and
sive (interpretive) elements in every discussions of defensive operations re-
analysis or psychodynamic psychother- sulted in moving the therapeutic work
apy. That is, the expressive, insight- forward with both the weak- and strong-
oriented mode of assisting patients in un- alliance patient groups.
covering unconscious conflicts, thoughts, These findings are consistent with a
or affects through interpretation or con- study conducted by Horwitz et al. (1996)
frontation may be appropriate at times, exploring the effect of supportive and in-
whereas a more supportive approach of terpretive interventions on the therapeu-
bolstering the patient’s defenses and tic alliance with a group of patients with
coping abilities is preferable in other cir- borderline PD. The authors concluded
cumstances. that although therapists are often eager to
For instance, it may be difficult to fo- pursue transference interpretations, such
cus on more insight-oriented interven- interventions are “high-risk, high-gain”
tions with a patient with borderline im- and need to be employed carefully. These
interventions may damage the alliance its direct confrontation of aggression in

with patients who are vulnerable and the transference early in the treatment
(Kernberg 1987), would have endan-
prone to feelings of shame and humilia-
gered the sometimes fragile working
tion. Therefore, the therapist must be flex- alliance being forged. In fact, a few
ible in adjusting technique according to times when transference interpreta-
the dynamics of a particular patient at a tions were attempted in the first phase
particular time, taking into account the of treatment, Rebecca became con-
patient’s capacities and vulnerabilities, fused and distressed, quickly changing
the subject away from a discussion of
and appropriately balance both support-
her relationship with the therapist,
ive and expressive interventions. talking about ending treatment, or be-
coming very sleepy and shut down for
several sessions. On one occasion early
Case Example 3 on, when the therapist attempted to
Rebecca sought treatment when she address something in their relation-
was in her early 30s. She was referred ship, Rebecca became very angry and
for psychotherapy from her graduate said, “Why is any of this about here?
school’s counseling center. Rebecca These are my problems and I don’t see
presented in a major depressive epi- what any of this has to do with you!”
sode and met eight out of nine criteria (Clearly, in the beginning phase of
for borderline PD. The initial phase treatment with some patients, one
of the twice-weekly psychodynamic needs a different way of entering
treatment focused on her depression the patient’s psychic world [Ellman
and on helping her to stabilize her 1998b].) However, Rebecca was re-
sometimes devastating affective insta- sponsive to gentle interpretations of
bility. She also reported intermittent, her defenses, such as the therapist’s
but not life-threatening, instances of pointing out to her that her self-harm
cutting herself, particularly after some behaviors were a way of “being mean”
unsatisfactory encounter with a friend to herself instead of channeling anger
or colleague. toward those who had upset her.
Rebecca’s lack of object constancy, Thus, for most of the first 3–4 years
her affective instability, and a frag- of this treatment, the therapist’s pri-
mented sense of self contributed to mary tasks were to develop a work-
great variations in the nature of her ing alliance and establish a “holding
presence in sessions. At times she environment” (Winnicott 1965) within
would be overwhelmed by fatigue, which Rebecca could begin to feel
whereas at other times she would be safe to explore her history, her feel-
engaging, funny, and analytical. She ings, and her own mind. This approach
would often defend against undesir- paid off, because it eventually be-
able thoughts or emotions by spend- came possible to uncover, in ways
ing the session recounting the details that were meaningful and transfor-
of her day-to-day life in great detail. mative to Rebecca, some of the split-
The disjunctions in self-states made it off rage and despair underlying the
difficult at times to maintain continu- identity instability and distorted cog-
ity in the process, because Rebecca nitive functioning. Deeper experience
did not remember what happened and exploration of these feelings paved
from session to session. the way for further integration and
A Kernbergian formulation (Kern- less disjunctive experiences in her life
berg 1967) of this patient was theoreti- and from session to session, and work-
cally informative in describing some of ing with the transference increasingly
her dynamics (defensive splitting had became both possible and very pro-
been one prominent theme in the treat- ductive. Rebecca has not been de-
ment). However, the technical implica- pressed for years and no longer meets
tions of this particular approach, with any borderline criteria.
Cognitive-Behavioral a great deal of flexibility must be main-

tained within this paradigm to achieve
Therapies an alliance (see Chapter 12, “Cognitive-
In recent years, work has been done to ap- Behavioral Therapy II: Specific Strate-
ply to PDs the cognitive and cognitive- gies for Personality Disorders,” in this
behavioral treatments that have typically volume). More specifically, there may be
been used to treat symptoms such as de- frequent occurrences of therapy-inter-
pression and anxiety. However, Tyrer and fering behaviors ranging from ambiva-
Davidson (2000) observed that the ap- lence causing missed sessions to multi-
proaches generally taken in these thera- ple suicide attempts that prevent the
pies for “mental state disorders” cannot treatment from progressing as the method
be simply transferred to treating PDs outlines.
without certain adjustments. Most cogni-
tive and cognitive-behavioral therapies Case Example 4
are based prominently on a therapist- Lourdes, a young woman with depen-
patient collaboration that is assumed to dent PD, was referred for behavioral
be present from very early in the treat- treatment of a phobia of all forms of
transportation (her other issues were
ment. Such a collaboration, which re-
already being addressed in an ongo-
volves around the patient undertaking ing psychotherapy). The behavioral
specific activities and assignments, de- therapist spent several sessions with
pends on the establishment of a solid Lourdes outlining the exposure tech-
working alliance; however, it is sometimes niques recommended for treating her
very difficult to engage certain patients phobia, but the patient was resistant
to beginning any of the activities de-
with PDs in the therapeutic tasks. Facili-
scribed. At the same time, while try-
tating this alliance with patients with PDs ing to pursue a classically behavioral
requires work that directly addresses pa- approach, the therapist realized that
tient-therapist collaboration with clearly it was very important for Lourdes to
set boundaries and that focuses on the spend some of the time talking about
her life and the impact the phobia
therapeutic relationship itself when ap-
symptoms had for her. This approach
propriate, as well as lengthier periods to helped Lourdes to feel a connection
complete these treatments (Tyrer and to the therapist. The therapist made
Davidson 2000). this relationship-building aspect ex-
For example, regarding the use of the plicit with Lourdes by agreeing to
initial sessions of dialectical behavior take a part of each session to talk about
her situation, but the therapist also
therapy to begin establishing a working
made it clear that it was necessary to
relationship, Linehan (1993) observed, reserve enough time for the exposure
“These sessions offer an opportunity for activities. This approach fostered an
both patient and therapist to explore alliance sufficiently to begin the be-
problems that may arise in establishing havioral tasks. By being flexible, while
setting clear tasks and boundaries, the
and maintaining a therapeutic alliance”
therapist was able to engage Lourdes
(p. 446). Even though dialectical behav- in the treatment, and she began tak-
ior therapy is a manualized treatment ing short rides with the therapist on
with clearly elaborated therapeutic tasks, the bus, eventually overcoming these
it is quickly evident, particularly in work- fears completely.
ing with patients with borderline PD, that
Psychopharmacology (real or imagined) and argue with the pre-

scriber about his or her competence. The
Sessions following is another example illustrating
One large-scale depression study (Krup- the importance of being mindful of how
nick et al. 1996) comparing several dif- patients with PD might react around is-
ferent psychotherapies with medication sues of medication.
and placebo showed that the quality of
the alliance was significantly related to A patient [with avoidant PD] over-
dosed one evening on the medicine
outcome for all of the study groups. This
her doctor had prescribed for her per-
finding demonstrates the importance of sistent depression. She liked and re-
considering the alliance not only in psy- spected him a lot. She was discovered
chotherapies but also in medication ses- comatose by a neighbor who won-
sions. Gutheil (1982) suggested that dered why her cat would not stop
there is a particular aspect of the thera- meowing. The neighbor was the pa-
tient’s only friend. It turned out that
peutic alliance—what he calls the phar-
that morning her doctor had won-
macotherapeutic alliance—that is relevant dered aloud whether she had a per-
to the prescription of medications. In sonality disorder. The patient was
this formulation of the alliance, it is rec- deeply humiliated by that idea but
ommended that the physician adopt the secretly agreed with it. She felt ex-
tremely embarrassed and was con-
stance of participant prescribing—that is,
vinced that her doctor now knew she
rather than adopting an authoritarian was a completely foolish person. . . .
role, the clinician should make every ef- Rather than endure the humiliation
fort to involve the patient as a collabora- of facing him again, she decided to
tor who engages actively in goal setting end it all. (Benjamin 1993, p. 411)
and in observing and evaluating the ex-
perience of using specific medications. Psychiatric Hospital
Such collaboration, like other therapeu-
tic processes, may be affected by the Settings
patient’s transference distortions of the Across the spectrum of PDs, psychiatric
clinician. hospitalizations—both inpatient and
This notion of collaborative prescrib- day treatment programs—are most com-
ing can be more broadly applied in trans- mon for those patients with borderline
theoretical terms to PDs, because it is ap- PD (Bender et al. 2001). The central con-
propriate to consider how the patient’s sideration regarding the alliance in this
characteristic style may influence his or treatment context is that there is always
her attitudes and behaviors toward tak- a team of individuals responsible for the
ing psychiatric medications. Some pa- patient. With patients who have border-
tients may become upset if medication is line issues, splitting tendencies frequently
not prescribed, feeling slighted because are quite pronounced. That is, as a way
they think their problems are not being of trying to cope with inner turmoil, the
taken seriously. Others with paranoid patient’s mental world is often organized
tendencies may think the physician is try- in black-and-white, good-and-bad po-
ing to put something over on them, or larities, and through complicated inter-
worse. Some patients who are prone to action patterns with various staff mem-
somaticizing, such as those with border- bers, this internal world is over time
line or histrionic tendencies, might be hy- replayed externally, dividing staff mem-
persensitive to any possible side effects ber against staff member.
Gabbard (1989) observed that this dy- the course of the inpatient or day treat-
namic is often set up because the patient ment program.
will present one self-representation to
one or several team members and a very Case Example 5
different representation to another. One
Meghan, a young woman with bor-
of these staff factions may be viewed as derline PD, was admitted to a psychi-
the “good” one by the patient and the atric inpatient unit after coming to
other as the “bad” one—although these the emergency department report-
designations can flip precipitously in the ing acute suicidal ideation. This pa-
patient’s mind—and this split becomes tient had been hospitalized several
times previously, worked in the men-
enacted among team members as they
tal health field, and “knew the ropes”
begin to work at cross-purposes. It can be quite well. She had been assigned a
seen rather readily that trying to develop psychiatrist who was responsible for
a constructive alliance with such a patient overall case management and a psy-
can be extremely precarious, particularly chologist who was to provide short-
term psychotherapy on the unit.
given the ever-decreasing length of
The initial psychotherapy session
hospital stays under managed care. That was extremely difficult, with Meghan
means that communication and close col- refusing to speak very much and re-
laboration among the members of the garding the therapist with rageful con-
team are vital during every phase of the tempt. However, after several more
hospital treatment. encounters, there was some soften-
ing by Meghan and she began to dis-
Matters are complicated further at
cuss the upsetting circumstances
times by the need to find a productive that led to her hospitalization. It ap-
way for hospital staff to collaborate with peared there might be the beginnings
clinicians providing ongoing outpatient of a working alliance. Indeed, as she
psychotherapy and/or psychopharma- opened up more about her life, she
reported feeling slightly more hope-
cology treatments. Although the hospi-
ful and less fragmented.
talization may represent a significant However, at the same time, she
rupture in the outpatient treatment alli- had created quite a bit of trouble with
ance, this rupture does not necessarily the rest of the staff by being very de-
indicate that the outpatient treatment manding and uncooperative and at-
was ineffective and must be terminated tempting to initiate discharge proce-
dures even while refusing to deny
but rather demonstrates that work will
that she would kill herself. Having
be needed to reestablish the continuity reached a point of needing to take
of the treatment relationship. However, some action in the courts to keep
it is not uncommon for the hospital staff, Meghan hospitalized, the psychia-
seeing the patient’s current condition, to trist hastily called a meeting that in-
cluded himself, the psychologist, and
conclude that the outpatient clinicians
the patient. Having had no opportu-
were somehow not doing a competent nity to confer with other team mem-
job (this conclusion may, of course, be fu- bers on the matter, the psychiatrist
eled by further splitting on the part of the proceeded to tell Meghan that he was
patient). Moreover, at times it may be ob- initiating legal proceedings to keep
vious that the outpatient treatment was her in the hospital. Mindful of the
splitting tendencies of such patients,
inadequate or inappropriate. In any event,
the psychiatrist was careful to make
it becomes rather dicey for all parties it clear that he represented the view-
concerned to sort out the proper role of point of the entire team, including the
hospital staff versus outpatient staff over psychologist. However, he unwittingly
created another split. Meghan, feel-

ing betrayed, stared hatefully at the References
psychologist, the fragile working alli-
ance was shattered, and she subse-
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C H A P T E R 10
Psychodynamic
Psychotherapies and
Psychoanalysis
Frank E. Yeomans, M.D.
John F. Clarkin, Ph.D.
Kenneth N. Levy, Ph.D.
Psychodynamic means “the mind emphasis on evidence-based treatments,

in motion.” Psychodynamic psychotherapy models of psychodynamic therapy to
refers to psychotherapies that stem from treat specific types of personality disor-
the psychoanalytic tradition and focus der (PD) have been developed and re-
on the role of conflicting forces within searched (Bateman and Fonagy 2012;
the mind—competing desires, impulses, Clarkin et al. 2006). As the field contin-
emotions, fears, and prohibitions—and ues to evolve, the dialogue between evi-
their interface with external reality as dence-based models and clinical ana-
sources of suffering and symptoms. The lytic practice is enriching both.
psychoanalytic tradition centers on the In this chapter, we summarize psy-
understanding of the mind elaborated choanalytic and psychodynamic con-
initially by Freud (1923/1961) that em- cepts and describe psychoanalysis and
phasizes the role of unconscious aspects different models of psychodynamic psy-
of mental functioning and the interac- chotherapy for PDs. Although psycho-
tion of constitutional biological predis- analysis historically preceded the psy-
positions and environmental influences chodynamic therapies, we begin with
in the course of psychological develop- discussion of the latter because some have
ment. As psychoanalysis evolved, its been developed specifically to address
focus shifted to character pathology the challenges of working with patients
(Gabbard 2005a). More recently, with the with PDs. As the field evolves, the bound-
217
ary between psychoanalysis and psy- ing, are more structured in a way that
chodynamic therapies is becoming less might seem to include elements of CBT.
precise. Across these variations, the principles of
Shedler (2010) listed how psychody- technical intervention within a psycho-
namic therapy differs from other thera- analytic framework are 1) interpretation,
pies. In the following description, we 2) transference analysis, 3) a technically
borrow from and add to his list: psycho- neutral stance, and 4) use of counter-
analysis and the psychodynamic thera- transference awareness. Psychoanalysis
pies are characterized by 1) an emphasis and the different forms of psychodynamic
on the role of unconscious mental forces therapy can be categorized according to
(e.g., urges, fantasies, prohibitions) and the degree to which they employ each of
the notion that an individual’s conscious these four technical principles (O. F.
mind is only a slice of his or her mental Kernberg, personal communication, No-
activity and that unconscious forces influ- vember 2012). One can also consider a
ence the individual’s feelings, thoughts, spectrum across psychodynamic thera-
and actions in ways beyond his or her pies from those that stress the impor-
awareness; 2) an emphasis, to varying de- tance of verbal communication and in-
grees, on the past and development—as terpretation as the motor of change to
filtered through and registered in the those that emphasize the experience of a
mind—as determining the individual’s containing and reflective relationship as
experience of the present; 3) a focus on af- the main element in change (Gabbard
fect and expression of emotion; 4) explo- and Westen 2003; Winnicott 1965).
ration of attempts to avoid distressing The development of a model of therapy
feelings and thoughts; 5) identification of is closely linked to the conceptualization
recurring themes and patterns; 6) a focus of the disorder to be treated, yet the con-
on interpersonal relations; 7) a focus on cept of PD is complex and controversial.
the therapy relationship; 8) exploration of Personality can be thought of in terms
fantasy life; and 9) the goal of deep change of a set of personality traits (McCrae and
in the personality to improve the overall Costa 1997) or in terms of a style of pro-
quality of the patient’s life experience be- cessing information (Mischel and Shoda
yond symptom change. 1995). PDs can be conceptualized cate-
Psychodynamic therapies vary along gorically or dimensionally. The categori-
a number of dimensions. First, these cal approach to classification, which has
variations reflect the fact that the catego- continued from DSM-IV (American Psy-
rization of therapies into distinct models, chiatric Association 1994) to DSM-5 Sec-
such as psychodynamic and cognitive- tion II, “Diagnostic Criteria and Codes”
behavioral, is somewhat artificial be- (American Psychiatric Association 2013),
cause most therapists practicing dy- has led to considerable overlapping of
namic therapy include some elements of diagnostic categories, comorbidity, and
cognitive-behavioral therapy (CBT), and use of the personality disorder not oth-
vice versa (Ablon and Jones 2002). Sec- erwise specified diagnosis. An alterna-
ond, some psychodynamic therapies, tive approach is found in the Psychody-
such as self psychology and the inter- namic Diagnostic Manual (PDM Task
subjective-interpersonal approaches, are Force 2006). The DSM-5 Work Group on
more open-ended and unstructured and Personality and Personality Disorders
thus seem closer to psychoanalysis per developed broad-ranging changes that are
se. Others, such as contingency contract- included in DSM-5 Section III, “Emerging
Psychodynamic Psychotherapies and Psychoanalysis 219
Measures and Models,” as an alternative relevant research. Among psychother-

model for additional study. In this model, apy researchers, there are divisions be-
impairments in self and interpersonal tween those who narrowly construe evi-
functioning constitute the core of per- dence as consisting of findings exclusive
sonality psychopathology (American to randomized controlled trials (Chamb-
Psychiatric Association 2013). The model less and Ollendick 2001) and those who
emphasizes consideration of the level of seek to broaden what is considered
personality functioning as essential to evidence to a range of findings from di-
the understanding of an individual’s verse data (see Norcross 2011). These
PD, using the Level of Personality Func- researchers point out that narrow con-
tioning Scale as its measure for assessing ceptions of evidence usually include
severity of impairment. This under- nongeneralizable samples in which pa-
standing is compatible with Kernberg’s tients lack the complexity usually experi-
(1984) long-standing structural model of enced in psychotherapy practice (Westen
PDs, a model that is based on psychoan- and Morrison 2001). Another area of ten-
alytic concepts and guides treatment sion within psychotherapy research is
techniques according to the level of the the use of treatment manuals. Some re-
pathology (Bender et al. 2011). The model searchers criticize manuals for promot-
will be discussed below in the subsection ing rigid therapies that do not respect ei-
“Object Relations Theory.” Of course, ther the complexity of the patient as an
the conceptualization of the disorder has individual or therapy as a process unique
an impact on treatment approach, such to each patient-therapist dyad. These
as whether one addresses symptoms authors tend to espouse clinically based
more directly or focuses on underlying models of treatment that are difficult to
processes. study empirically because they are not
In the overall field of psychotherapy, manualized. Arguments for manualiz-
since the 1990s there has been an increasing a treatment, in addition to its provid-
ing emphasis on evidence-based treating systematic guidelines for therapists,
ments. There exists a misunderstanding include that it makes it possible to dem-
that the body of evidence for CBT treat- onstrate adherence to the model across
ments far outweighs that for psychody- therapists. Some applaud this, saying it
namic treatments. A series of meta-anal- leads to clearer and more effective deliv-
yses (see Shedler 2010 for a review) has ery of services, whereas others criticize
corrected that misunderstanding. The it, saying that it ties the hands of the
current emphasis on evidence-based therapist. A moderate position sees evi-
treatments has important implications dence-based psychodynamic therapies
for students of therapy. This emphasis as principle driven so that the therapist
has intensified divisions in the field of can use his or her best clinical judgment
psychotherapy between researchers and within the structure and principles of
clinicians. Some researchers have raised the therapy.
questions about the neglect of science by Psychotherapy research is a broad field.
practitioners (Baker et al. 2008). Some The most publicized studies to date in-
clinicians have experienced researchers volve randomized controlled trials de-
as imposing findings from studies that signed to compare a model of treatment
do not represent real-world clinical set- with a control to establish the efficacy of
tings and have called for more clinically treatment. However, an emerging area of
research investigates the impact of spe- tendency has begun to change with the
cific elements within a therapy. An ex- introduction of manualized treatments.
ample of this is Høglend et al.’s (2008) Traditionally, as in classical psychoanaly-
work that studied transference interpre- sis, therapists tended to avoid setting a
tations in contrast to interpretations that specific agenda, to follow the patient’s as-
did not address the transference. His sociations, and to keep the treatment
findings turned traditional clinical open-ended with little attention to spe-
thinking on its head: transference inter- cific treatment goals. Early psychody-
pretations were found to have the great- namic literature often assumed that an
est impact on patients who were at a understanding of the characteristic un-
lower level of self-other relatedness. conscious conflicts in a patient with a
This research supports the utility of given PD allowed the therapist to use the
thinking in terms of level of pathology psychoanalytic method of free associa-
and the implications for clinical practice. tion and interpretation to treat the pa-
The work of Høglend and colleagues tient. However, psychodynamic thera-
also challenges the conventional wis- pists and analysts who treat patients with
dom that psychodynamic therapies are severe character pathology have increas-
only helpful to those who are psycholog- ingly realized that effective treatment of
ically minded. It seems that in working PDs requires specific treatment modifica-
with lower-level patients, basing inter- tions of general analytic technique. The
pretations on the experience shared by trend of a more specific focus on tech-
the patient and therapist can make tan- nique and the development of treatment
gible those aspects of the patient’s psy- manuals began with the detailed descrip-
chological functioning that had previ- tion of psychodynamic treatments for
ously been beyond their grasp. Further patients with interpersonal difficulties
research is consistent with Høglend’s (Luborsky 1984; Strupp and Binder 1984)
findings in that transference-focused psy- and recently has been expanded with de-
chotherapy (TFP), a transference-based scriptions of psychodynamic treatments
psychotherapy described below (see for those with severe PDs (Bateman and
subsection “Object Relations Theory”), Fonagy 2012; Clarkin et al. 2006).
was found to be particularly good for Psychoanalytic explorations of charac-
patients with low mentalizing capacities ter pathology not only predate but also
as compared with dialectical behavior attempt to go beyond the descriptive fo-
therapy or supportive psychotherapy cus on signs and symptoms of DSM-III
(Levy et al. 2012). (American Psychiatric Association 1980)
In this chapter, as we explore different and its successors. The alternative model
psychodynamic models in terms of their in DSM-5 connects with some of this
understanding of PDs and then describe thinking. DSM-III started the trend of
the application of these models in treat- taking the American Psychiatric Associ-
ment, we first address those therapies that ation’s diagnostic system away from a
have an evidence base and then discuss conceptual understanding of psychiatric
those based more on clinical experience illnesses to one based on signs and
and theory. The psychodynamic litera- symptoms, with the goal of increasing
ture has historically focused more on de- the reliability of diagnosis. However, a
scribing the underlying dynamics of PDs side effect of this approach has been to
than on describing treatment techniques increase the number of personality dis-
in a detailed and methodical way. This order diagnoses per patient. From the
phenomenological vantage point of tinguishes a psychodynamic approach is

DSM-IV, there are 10 different and sup- the further elaboration of mental func-
posedly distinct PDs. We do not think it tioning that focuses on both the con-
is conceptually valid, however, to de- scious and unconscious meanings of ex-
scribe psychodynamic treatments for perience as biological forces interact
each of the 10 PDs as if they are separate with interpersonal (social, cultural, and
and distinct. Many patients who appear linguistic) influences. Beyond these com-
for evaluation with PD have multiple PD monalities, the various schools of psy-
diagnoses according to DSM-IV and chodynamic thinking lend different em-
might be better conceptualized by con- phases to libidinal/affiliative drives or
sidering the overall severity of their per- to aggressive drives, to drives as a whole
sonality dysfunction as laid out in the al- or to defenses, and to the role of conflict
ternative model. In most cases, it is not among intrapsychic forces or to deficits
clinically relevant to think of assessment in the development of psychic structures
and treatment for one of the 10 PDs as and psychological capacities. Most of
separate from the others. We will there- these differences are not either/or de-
fore consider how a psychodynamic bates but rather “degree of emphasis”
therapy addresses the underlying psy- debates.
chological structures that subtend many
of the PDs and their specific symptoms.
Ego Psychology
Ego psychology stems directly from the
Psychodynamic Freudian “structural model” (Freud 1923/
Perspectives on 1961). This model provides many funda-
mental concepts incorporated into other
the Nature of psychoanalytically based therapies but
Personality Pathology provides the least specific formulation
of PDs. In this model the id, ego, and su-
Psychoanalysis has spawned many perego are the key psychic structures
branches. The psychodynamic models that interact in ways that lead either to
of psychological developments most rel- successful or unsuccessful resolution of
evant to the treatment of character pa- competing pressures. Unsuccessful reso-
thology are 1) ego psychology, 2) object lution results in psychopathology such
relations theory, 3) self psychology, and as anxiety, depressive affect, obsessive
4) attachment theory. These psychody- symptoms, or sexual inhibition. The id is
namic models can be contrasted with the seat of pleasure seeking and aggres-
and complemented by other models of sive drives and strives for their immedi-
pathology, such as the cognitive, inter- ate satisfaction. The ego is the more
personal, evolutionary, and neurocogni- largely conscious system that mediates
tive models (Lenzenweger and Clarkin contact with the constraints of reality, in-
2005). Psychodynamic approaches do volving perception and the use of rea-
not espouse a purely “psychological” un- son, judgment, and other “ego functions.”
derstanding of psychopathology and do The ego also includes defense mecha-
incorporate brain findings as research nisms, which are unconscious ways of
advances. Psychodynamic concepts such attempting to resolve or deal with the
as affects and drives have a clear ground- anxiety stemming from the conflicts be-
ing in biology (Valzelli 1981). What dis- tween the competing psychic agencies.
Certain defense mechanisms are more ma- fect related to the drive (Fairbairn 1952;
ture and successful, whereas others are Jacobson 1964; Kernberg 1980, 1995;
more primitive and provide a subopti- Klein 1946/1975). Within this model, in-
mal decrease in anxiety and/or a reduc- ternalized representations of relation-
tion in anxiety that is at the expense of ships are referred to as “object relation
successful adaptation to life. If the de- dyads.” Each dyad comprises a particu-
fense mechanism is “mature”—such as lar image of the self as it experiences an
humor or sublimation—the conflict may affect connected to a libidinal or aggres-
be dealt with in a way that does not in- sive drive in relation to a particular image
terfere with the individual’s functioning of the other who is the object of that af-
or feeling state. However, less mature, or fect. An example is the contented, satis-
neurotic, defense mechanisms—such as fied self in relation to a nurturing other
repression or reaction formation—tend linked by an affect of warmth and love.
to result in psychological symptoms, An opposite example is the abandoned
such as anxiety or impaired functioning, self in relation to the neglectful other
and related behaviors, such as compul- linked by an affect of fear and anger. In
sive behaviors. The most primitive de- the course of development, opposing ex-
fenses—such as splitting or projective periences of gratification or frustration
identification—characterize the rigid and with others are internalized, and these
distortion-prone psychological struc- dyads, laid down as memory traces, be-
tures found in severe PDs. The superego come the building blocks of psychic
is the largely unconscious set of rules (a structure which then influence the indi-
combination of prohibitions and ideals) vidual’s perceptions of the world and, in
that often oppose the strivings of the id particular, of relationships.
for unbridled drive satisfaction. Broadly In normal psychological development,
speaking, ego psychology addresses the representations of self and others be-
question of what are the individual’s psy- come increasingly differentiated to bet-
chological resources—ego functions and ter correspond to the individuality of
defenses—for adapting to internal and real external objects and become inte-
external demands. It views character pa- grated so that they better match the com-
thology as the result of the habitual use plexity of real beings. These mature, in-
of maladaptive defense mechanisms, with tegrated representations allow for the
corresponding problems in functioning realistic blending of good and bad, posi-
such as impulsive behavior, poor affect tive and negative, and the tolerance of
control, and an impaired capacity for ac- ambivalence, difference, and contradic-
curate self-reflection. tion in oneself and others. For Kernberg
(1984), the degree of differentiation and
integration of these representations of
Object Relations Theory self and other determines the level of
With object relations theory, psycho- personality organization. He describes a
analysis transitioned from a one-person range of PDs from neurotic to high-level
system concerned primarily with drive borderline to low-level borderline. Bor-
forces and prohibitions against them to a derline organization—which is a broader
more complex system considering the concept than the DSM-5 borderline PD
drives in relation to their objects—that is, but fits with the alternative model of lev-
the object of the positive or negative af- els of severity—is a psychological struc-
ture based on simplistic representations splitting, idealization-devaluation, prim-

of self and other divided into purely good itive denial, projective identification, and
and purely negative segments, in contrast omnipotent control. These defense mecha-
to more integrated and complex repre- nisms are attempts to wall off intense
sentations of self and other that charac- feelings, affects, and impulses that the in-
terize healthier personality organization dividual has difficulty accepting in him-
and better functioning in the world. self of herself. This walling off does not
Given the fragmented nature of this eliminate these feelings, but instead leads
psychological makeup, borderline orga- to dealing with them in ways that inter-
nization is characterized by three features: fere with functioning. For instance, be-
1) the use of primitive defense mecha- cause the split prevents the integration of
nisms (e.g., splitting, projective identifi- aggressive feelings and libidinal/affec-
cation, dissociation), 2) identity diffusion tionate feelings into a more complex whole,
(an inconsistent view of self and others in the individual may alternate abruptly
contrast to a coherent one), and 3) gener- between extremely positive and ex-
ally intact but unstable reality testing. The tremely negative feelings toward other
borderline level of organization includes people in his or her life. This underlies
the paranoid, schizoid, schizotypal, bor- the instability in interpersonal relations
derline, narcissistic, antisocial, histrionic, seen in many patients with PDs. An indi-
and dependent PDs of DSM-5, as well as vidual may also deal with split-off feel-
other patterns of personality pathology ings by subtly inducing them in another
referred to as sadomasochistic, hypo- person and then experiencing an aware-
chondriachal, cyclothymic, and hypo- ness of them as though they originated in
manic (Kernberg 1996). In this system of the other person (projective identifica-
classification, the obsessive-compulsive, tion). This leads to chaos and confusion
hysterical, and depressive-masochistic in relationships as well as in the ability to
PDs are at the more highly organized deal with one’s own feelings. We return
neurotic level; they are characterized by a to concepts of object relations in discuss-
more integrated sense of self and others, ing the specific therapies below.
defense mechanisms based on repression
rather than splitting, and accurate reality
testing. This classification system has
Self Psychology,
treatment implications: those PDs orga- Relational, and
nized at the neurotic level may be treated
by psychoanalysis or a modified psycho-
Interpersonal Schools
analytic psychotherapy (Caligor et al. The self psychology model, developed by
2007), whereas those organized at a bor- Kohut (1971, 1977), is distinguished by an
derline level need a more structured emphasis on the centrality of the self as
form of psychodynamic therapy such as the fundamental psychic structure and
TFP (Clarkin et al. 2006) or mentaliza- by the view of narcissistic and most other
tion-based therapy (MBT; Bateman and character pathologies as resulting from a
Fonagy 2012). deficit in the structure of the self without
To understand how psychic structure giving a role to conflict among structures
leads to symptoms, one can consider the within the psyche (Ornstein 1998). Adler
primitive defense mechanisms that de- and Buie (Adler 1985; Buie and Adler
volve from the split psychic structure: 1982) applied this model specifically to
patients with borderline PD. Self psychol- The anger and rage that often accom-
ogy focuses on the cohesiveness and vi- pany narcissistic pathology are seen as
tality versus weakness and fragmenta- reactions either to attacks on the grandi-
tion of the self and on the role that ose self or to disillusionment in the ide-
external relationships play in helping alized imago. Because the rage is not
maintain the cohesion of the self. It posits considered related to an innate constitu-
that primary infantile narcissism, or love tional psychological aggression, the
of self, is disturbed in the course of devel- therapeutic focus is not on the rage itself
opment by inadequacies in caretaking. In but on the external circumstances that
the course of development, in an effort to occasioned it. Self psychology stresses
safeguard a primitive experience of per- the importance of early deficits in con-
fection, the infant places the sense of per- trast to unconscious conflicts and disre-
fection both in an image of a grandiose self gards the existence of aggressively in-
and in an idealized parent imago, which are vested internalized object relations, seeing
considered the archaic but healthy nuclei the negative transference as reflecting the
of the bipolar self. In the subsequent nor- traumatic disruption of a “self-selfobject
mal development of the bipolar self, the relationship” rather than an activation
grandiose self evolves into self-assertive of negative introjects. The therapist’s
ambitions and involves self-esteem regu- task is to facilitate the consolidation of
lation, goal-directedness, and the capac- the grandiose self with later elaboration
ity to enjoy physical and mental activities. of more mature forms of the self upon
The idealized parental imago becomes that foundation.
the individual’s internalized values and The relational and interpersonal
ideals that function as self-soothing, self- schools also focus on the importance of
calming, affect-containing structures that the relationship and consider that the
maintain internal psychological balance. personality of both patient and therapist
Problems in either of these evolutions lead contribute to the experience that needs to
to psychopathology. Although self psy- be analyzed in the therapy (Gill 1982;
chology does not emphasize diagnostic Greenberg 1991; Mitchell 1988). This is in
distinctions, it targets primarily narcissis- contrast to the view that the therapist’s
tic pathology and some types of border- establishing a neutral frame for the ther-
line pathology. Inadequate development apy and maintaining a position of neu-
of the grandiose self results in low self- trality (i.e., not taking sides with any of
esteem, lack of motivation, anhedonia, the forces or pressures involved in the pa-
and malaise. Inadequate development of tient’s conflicts) create a field in which the
the idealized parental imago results in “map” of the patient’s internal world is
difficulty regulating tension and in the reproduced in the experience with or of
many behaviors that can attempt to the therapist (the transference), in which
achieve this function (e.g., addictions, case the material to be analyzed is more
promiscuity), as well as a sense of empti- purely the patient’s. There is an emphasis
ness, depression, and chronic despair. on emotional attunement as a basic atti-
Pathology stems from deficits in the tude to help the patient’s own subjectivity
development of the bipolar self. The in- develop as a means of change. Whereas
dividual responds to these deficits in self psychology was developed to help
psychic structure by developing defen- patients with a type of narcissistic per-
sive structures that attempt to fill that sonality, the relational and interpersonal
gap and lead to the manifest pathology. approaches do not focus on diagnosis;
therefore, although it is relevant to men- term effects of early attachment experi-

tion these two models in a review of ma- ences on personality development and
jor psychodynamic models, it is less im- psychopathology.
portant to flesh them out in terms of clear Central to attachment theory is the con-
models for PDs. Like self psychology, cept of internal working models or
these approaches tend to see negative mental representations that are formed
transference not as the manifestation of through repeated transactions with at-
constitutional aggressive affects within tachment figures (Bretherton 1987; Shaver
the patient but as a response to the em- et al. 1996). These working models subse-
pathic failures, or a breakdown of the quently act as heuristic guides in relation-
positive relation in the patient-therapist ships, organizing personality develop-
interaction. This brings us to the last dif- ment and the regulation of affect. They
ference we will mention between these include expectations, beliefs, emotional
approaches and an object relations ap- appraisals, and rules for processing or ex-
proach: the understanding of empathy. cluding information. These working mod-
These approaches describe empathy with els are partly conscious and partly uncon-
the patient’s conscious experience in conscious and need not be completely
trast to a deeper empathy with both the consistent or coherent. The reader may be
conscious experience and the elements of reminded of the concept of the object re-
the patient’s mind that the patient is not lations dyad discussed above; indeed, the
aware of because of defenses such as pro- similarities speak to underlying concep-
jection and dissociation. tual similarities between object relations
theory and attachment theory. For in-
stance, although Bowlby (1973) stressed
Attachment Theory that internal working models “are tolera-
Attachment theory, first formulated by bly accurate reflections of the experiences
Bowlby (1969, 1973, 1980), emerged from those individuals actually had” (p. 20), he
the object relations tradition. However, in also realized that internal working mod-
contrast to object relations theorists who els could be distorted as Kernberg em-
retained much of Freud’s emphasis on phasized in arguing for the centrality of
sexual and aggressive drives and fanta- transference interpretation. Moreover,
sies, Bowlby stressed the centrality of the both object relations dyads and internal
affective bond developed in close inter- working models include representations
personal relationships. Although this of self and others that are complementary
perspective has led to much interesting and mutually confirming and include
developmental and clinical work, it has unconscious and emotional aspects of
emphasized the importance of the attach- representation. Both theories note that
ment system with little attention to the these representations need not be consis-
other main motivational systems, such as tent or coherent and that, to the degree
the sexual and assertive/aggressive sys- that multiple inconsistent representa-
tems. Although Bowlby’s work fell within tions exist, the individual will have diffi-
the framework of psychoanalysis, he also culty behaving consistently. Both Kern-
turned to other scientific disciplines, in- berg and Bowlby note that these multiple
cluding ethology, cognitive psychology, and inconsistent representations could
and developmental psychology, to ex- oscillate in the individual’s conscious-
plain affectional bonding between in- ness. Finally, both authors discuss de-
fants and their caregivers and the long- fensive processes for excluding repre-
sentational information that is difficult to ment, which in turn facilitates the devel-
integrate with conscious representations opment of mentalization in the child. The
of self and others; Kernberg (1984) called authors proposed that a secure attach-
this splitting, whereas Bowlby referred to ment relationship with the caregiver
this process as defensive exclusion.” gives the child a chance to explore his or
Bowlby (1973) postulated that inse- her own mind and the mind of the care-
cure attachment lies at the center of dis- giver. The caregiver’s having the child’s
ordered personality traits, and he tied the mind in mind contributes to the child’s
overt expression of felt insecurity to spe- understanding of himself or herself as a
cific characterological disorders. For in- thinker. This model includes an under-
stance, he connected anxious ambiva- standing of the relationship between PDs
lent attachment to “a tendency to make and childhood abuse. Individuals who
excessive demands on others and to be experience early trauma may defensively
anxious and clingy when they are not inhibit their capacity to mentalize to avoid
met, such as is present in dependent and having to think about their caregiver’s
hysterical personalities,” and avoidant wish to harm them. This inhibition of
attachment to “a blockage in the capac- mentalizing is associated with an absence
ity to make deep relationships, such as is of adequate symbolic representations of
present in affectionless and psychopathic affects and self-states and creates a sub-
personalities” (Bowlby 1973, p. 14). Many jective experience of internal chaos typi-
of the symptoms of borderline PD, such cal of severe PDs.
as the unstable, intense interpersonal re- Failures to mentalize are seen as un-
lationships, feelings of emptiness, chronic derlying the characteristics of borderline
fears of abandonment, and intolerance PD and also as central to other PDs and
of aloneness, have been reinterpreted as other types of psychopathology. In cases
sequelae of insecure internal working of maltreatment, the child internalizes
models of attachment (Blatt and Levy the self-directed attitudes of the abusive
2003; Diamond et al. 1999; Fonagy et al. attachment figure into the child’s own
1995; Gunderson 1996; Levy and Blatt self-structure. In such a case, however,
1999). the internalized other and its aggressive
The work of Fonagy and colleagues characteristics remain alien and uncon-
(Fonagy et al. 1995, 2003) has elaborated nected to the rest of the self; the self is
on attachment theory and led to the de- “colonized” by an aggressive element that
velopment of MBT for borderline PD. is not actually a part of the self. Although
Mentalization, defined as the capacity to lodged within the self, this alien self is
think about mental states in oneself and projected outside—both because it does
in others, is seen as a form of social cogni- not match the rest of the self and because
tion—that is, an imaginative mental ac- of its persecutory nature. This projection
tivity that enables one to perceive and and the attempt to control the object of
interpret human behavior in terms of in- the projection are seen as the basis for
tentional mental states, such as needs, many symptoms of borderline PD.
desires, feelings, goals, and so forth (Bate- Fonagy and colleagues (2012) have
man and Fonagy 2012). Fonagy and expanded their concept of mentalization
colleagues’ developmental research sug- along four functional spectra that can be
gests that the capacity for reflective considered in evaluating and treating
awareness in a child’s caregiver increases patients: 1) automatic (reflexive and im-
the likelihood of the child’s secure attach- plicit) to controlled (explicit, reflective)
mentalizing, 2) internally focused to ex- Patients with the more severe PDs are
ternally focused, 3) self-oriented to other seen by some researchers (Bateman and
oriented, and 4) cognitive processing to Fonagy 2012; Clarkin et al. 2006; Kern-
affective processing. berg 1984) as potentially responsive to
modified, more highly structured, empir-
ically based psychodynamic treatments
Indications for (Bateman and Fonagy 1999, 2001; Clarkin
Psychodynamic et al. 2007; Levy et al. 2006). In parallel to
the development of these manualized
Treatment treatments, psychoanalytic practice in
general is broadening to incorporate
In general, patients with the less severe
modifications in technique to work more
PDs such as obsessive-compulsive, hys-
effectively with this patient population.
terical, avoidant, and dependent, are
Kernberg (1984) cautioned, however, that
suited for psychoanalytic or general
borderline patients with a high level of
psychodynamic treatment (Caligor et al.
narcissistic, paranoid, and antisocial traits,
2009; Gabbard 2005a, 2005b). These pa-
a syndrome termed malignant narcissism,
tients would be seen as neurotically or-
are the most challenging to treat and that
ganized, as compared with patients who
even with a highly structured treatment
have the more severe PDs with border-
have a poorer prognosis than other pa-
line organization (Kernberg 1984). Neu-
tients organized at the borderline level.
rotic psychological organization in-
Patients with antisocial PD (those with
volves a generally integrated sense of
no capacity for remorse or for nonex-
self but with a consistently rigid repres-
ploitative relationships) may be beyond
sive defensive system that does not al-
the reach of psychodynamic, or any, psy-
low for adequate integration of an element
chotherapy.
of psychological life, such as aggressive
Across the spectrum of the PDs, psy-
affects in the case of obsessive-compul-
chodynamic clinicians utilize nondiag-
sive PD or sexual affects in the case of
nostic patient variables as indicators of
hysterical PD. The decision whether to
psychodynamic treatment. In general,
recommend psychoanalysis or psycho-
the presence and capacity for meaning-
dynamic therapy for these disorders de-
ful relationships and attachments to oth-
pends on a number of factors. One con-
ers, investment in work at the level of
sideration is the patient’s motivation for
one’s capacities and training, normal in-
deep change influencing all areas of his
telligence or higher, the capacity to re-
or her life versus seeking more specific
flect on one’s experience, relatively good
relief from anxiety or resolution of prob-
impulse control, absence of secondary
lems in specific areas. Other consider-
gain of illness (i.e., lack of practical ill-
ations include psychological minded-
ness-related benefits such as disability
ness, 1 propensity to regress without
payments or extra attention), and intact
becoming disorganized, impulse con-
reality testing would be good prognostic
trol, frustration tolerance, and financial
signs for psychodynamic psychotherapy
resources.
1
Assessing patients for psychological mindedness may require a period of working with the
patient, because apparent lack of these capacities may serve as an initial defense against insight
and may change with interpretation.
(Gabbard 2005b). Lack of meaningful rement techniques to the Cluster A, B, and
lations or investment in work, presence C groupings of the disorders. At present
of secondary gain, and impaired im- there are an increasing number of stud-
pulse control or reality testing are not ies of psychotherapy for PDs, along with
contraindications to psychodynamic ther- a long-standing history of case reports
apy but rather present challenges in the and a number of uncontrolled trials, all
framing and execution of the therapy. contributing to the evidence for the ef-
Nonetheless, patients with low intelli- fectiveness of psychodynamic therapy
gence, those who lack psychological (Abbass et al. 2006; American Psychiatric
mindedness (in contrast to defensive Association 2001; Leichsenring and Leib-
nonreflectiveness), and those who will ling 2003; Leichsenring and Rabung 2008;
not give up secondary gain of illness Levy et al. 2012; Shedler 2010).
may be referred to psychodynamically It is difficult to address treatment of all
informed supportive treatment (Rock- the specific DSM-5 PD diagnoses sepa-
land 1992) in contrast to a more explor- rately, because most research to date has
atory one. focused on a mix of PDs, avoidant PD, or
borderline BD, and because, as men-
tioned in the introduction to this chapter,
Descriptions of there is extensive co-occurrence among
Psychodynamic DSM personality categories. Therefore,
the therapist should have an understand-
Treatments of ing both of the basic psychological struc-
Personality Disorders ture that underlies severe PDs as reflected
in the DSM-5 discussion of sense of self
We described the principal psychody- and quality of relations with others as core
namic models of personality pathology axes underlying the PDs and of the par-
earlier in this chapter in the order of their ticular dynamic issues that distinguish
historical development. In this section, the different disorders.
we describe both some specific treat- Waldinger (1987) described a set of
ments that have derived from these common characteristics of dynamic thera-
models and the more eclectic expressive- pies for patients with borderline PD, be-
supportive model of therapy. The most yond the fundamental characteristics of
fully articulated treatments include a clin- dynamic therapies in general that were
ical description of the pathology, a treat- listed in the introduction to this chapter.
ment manual, and empirical research. Waldinger’s list, which generalizes to
Psychodynamic thinking about treating those PDs with borderline organization
character pathology has historically cen- or Cluster B disorders other than antiso-
tered on narcissistic (Kernberg 1984; cial PD, includes the following charac-
Kohut 1971), borderline (Fonagy et al. teristics: 1) emphasis on the stability of
1995, 2003; Gunderson 1984; Kernberg the frame of the treatment; 2) increase in
1980, 1984), hysterical (Kernberg 1980; the therapist’s participation during ses-
Zetzel 1968), obsessive-compulsive sions as compared with therapy with
(Reich 1972), and schizoid (Fairbairn neurotic patients; 3) tolerance of the pa-
1952) character pathology. Others (e.g., tient’s hostility as manifested in the neg-
Gabbard 2005b) have more specifically ative transference; 4) use of clarification
addressed the individual PDs as defined and confrontation to discourage self-
by DSM-IV, sometimes gearing treat- destructive behaviors and render them
ego-dystonic and ungratifying; 5) use of erating their emotions in the context of

interpretation to help the patient estab- relationships with others, including with
lish bridges between actions and feel- the therapist, this model emphasizes the
ings; 6) blocking acting-out behaviors need for a clear understanding of the
by setting limits on actions that endan- conditions of treatment to be established
ger the patient, others, or the treatment; between therapist and patient before be-
7) focusing early therapeutic work and ginning the actual therapy. The verbal
interpretations on the here and now contract is the foundation for containing
rather than on material from the past; acting out, for communicating that feel-
and 8) careful monitoring of countertrans- ings can be contained and experienced
ference feelings. in contrast to being acted out, and for
Taking into account these common observing and interpreting the patient’s
modifications to general psychodynamic interactions within a clear frame.
technique, we review below how differ- This twice-weekly individual therapy
ent specific models address the treat- emphasizes the therapist’s empathy with
ment of PDs. While we discuss these the entire range of the patient’s affective
models separately, in practice many responses, including negative affects as
therapists use their clinical judgment they inevitably arise in the transference,
to combine elements of the different with the implicit message that even the
models. most intense and disturbing affects can
be contained and reflected on. Address-
ing the negative transference early on is
Object Relations Theory
felt to create a fuller alliance with the pa-
Among object relations models of ther- tient by indicating that the therapist can
apy (Gabbard 2005b; Strupp 1984), TFP tolerate, and help the patient tolerate,
is the most fully elaborated (Clarkin et the expression of the patient’s most dif-
al. 2006; Yeomans et al. 2002) and evi- ficult internal states in order to move on
dence based (Clarkin et al. 2007; Doering to helping integrate them with the aid of
et al. 2010; Levy et al. 2006). TFP com- the interpretive process.
bines an emphasis on the structure of the
treatment, established through the con- Mutative Techniques
tracting process, with the exploration of TFP advocates early interpretation of
the patient’s internal world of represen- transference as the patient stabilizes in
tations of self and others. the treatment frame. This involves elab-
The goal of TFP is to help patients orating the patient’s experience of the
with severe PDs change from a state of therapist at different moments as it is
identity diffusion to a coherent identity, distorted by the patient’s internal repre-
a process that involves increased reflec- sentations, encouraging reflection on
tive functioning and is accompanied by those representations, and helping the
improved modulation of affects. The ther- patient develop internal representations
apist focuses on the patient’s principal that are richer, more nuanced, and more
representations of self and of others as flexible in their ability to adapt to shift-
they unfold in the transference and helps ing external realities (Caligor et al. 2009).
the patient become more consciously This strategy focuses on the affect experi-
aware of them in order to then integrate enced in the here and now with the thera-
them. Because patients with character pist in contrast to early interpretation of
pathology have chronic difficulties in tol- the patient’s past.
Transference interpretation is a pro- see this aspect of herself and to see such
cess. The ground for it is set by clarifica- things as coming only from others. He
tion of the patient’s feeling states—that added that two things might happen if
is, by helping the patient symbolically the patient were aware of these feelings
and cognitively represent or describe his in herself: first, she might find ways to
experience of self in relation to the ther- express them in a healthier way, and sec-
apist. The work then helps the patient ond, she might be in a better position to
observe that forms of acting out repre- see her contribution to difficult relations
sent identifications with parts of him- that she tended to experience as always
self—usually of an aggressive nature, but originating in the other party. However,
sometimes of a loving nature—that the the therapist also expressed empathy with
patient sees in others but typically does the fact that gaining this awareness would
not accept in himself. The therapy moves be a painful step. The working through
on to explore contradictions in the pa- of a theme such as this consists of repeat-
tient’s presentation over time. These edly analyzing the dyads that appear first
contradictions are considered reflections in the transference and then analyzing
of the split, unintegrated internal world them as they appear in the patient’s life
underlying borderline pathology that outside the therapy and in the patient’s
keeps positive and negative representa- past.
tions of self, and of others, separate. The
therapist brings these dyads more fully Mechanisms of Change
into the patient’s awareness and explores Change comes both from interpretations
the unconscious motivations for keep- that increase the patient’s awareness of
ing distinctly different, often opposite, aspects of himself or herself that are split
dyads separated. Key moments in ther- off and projected onto others and from
apy occur when the patient becomes the patient’s eventual ability to experi-
aware of an aspect of himself that, up to ence the relationship with the therapist
now, he had only expressed in behavior, as different from his or her prior “reper-
with no awareness, and/or has projected toire” of relations and to generalize this
and seen in others. more full-bodied experience of self and
For example, when a patient was vig- other to relationships outside the thera-
orously accusing, even verbally attack- peutic setting.
ing, her therapist for being both ne-
glectful and useless because she still Mentalization-Based
experienced unfair rejection and criti-
cism from her classmates, the therapist
Therapy
said, “I understand the conviction in MBT, rooted in attachment theory, has
what you’re saying, but I wonder if you been developed for Cluster B PDs; it was
could take a step back and reflect on initially practiced as a day hospital treat-
what is going on here right now.” The pa- ment and generally combines individual
tient paused and acknowledged that she sessions with group sessions. MBT was
might seem as if she were being “mean developed as a basic model of therapy to
and critical” to the therapist. The thera- be delivered largely by nurse therapists
pist pointed out that the patient had ev- in the British National Health Service and
ery right to be critical, and even mean, if does not aim to achieve structural per-
she chose to, but that she appeared to not sonality change or to alter cognitions and
schemas. Rather, its goal is to enhance Central to the MBT process, especially
mentalization so that the individual is with borderline patients who are seen as
more equipped to solve problems and readily destabilized in their attachment
manage emotional states, especially men- relationships, is the ability of the thera-
tal states stimulated in interpersonal situ- pist to titrate the shifting attachment
ations (Bateman and Fonagy 2012). process between therapist and patient so
The emotional instability of Cluster B that the level of emotional arousal in the
disorders is seen as secondary to failures patient is modulated without destabiliz-
in an individual’s capacity to mentalize— ing intensity. Contrary moves are used
or to reflect on and appreciate intentions, by the therapist so that, for example, if
feelings, and motivations in self and oth- the patient is internallyfocused and self-
ers. It is the role of psychotherapy to focused, the therapist inquires about
challenge automatic, distorted, and sim- how such mentation or action would af-
plistic assumptions about self and others fect others. A sequence of intervention is
and to reflect and reevaluate the as- suggested, progressing from supportive
sumptions in the context of the relation- and empathic clarification (i.e., clarify-
ship between therapist and patient. In ing the patient’s perception of self in
this sense, MBT shares TFP’s focus on relation to others), to challenge (i.e., not
helping the patient achieve accurate, in to confront but to question the patient’s
contrast to inaccurate distorted, percep- perception), to affect focus (i.e., focus on
tions of self and others. However, MBT the current affect shared by patient and
restricts its emphasis to helping the pa- therapist), to mentalizing the transfer-
tient repair failures in mentalizing with- ence (Bateman and Fonagy 2012). Mental-
out addressing the resolution of intra- izing the transference refers to a collab-
psychic conflicts and therefore can be orative process of exploring alternative
situated toward the cognitive end of the perspectives on the current patient-ther-
spectrum on psychodynamic therapies. apist relationship, seeing this as a re-
Failures in mentalization are believed hearsal of mentalizing ability in other in-
to be related to attunement difficulties be- timate relationships in the patient’s life.
tween infant and caretaker that impede
the development of a secure sense of at- Mutative Techniques
tachment. The therapist’s efforts to in- The MBT technique centers on identify-
crease the patient’s capacity to mentalize ing moments when mentalization is lost
help the patient move from a disorga- and the patient reverts to thinking in
nized attachment, in which affects are vol- terms of psychic equivalency, pretend
atile and unpredictable and the patient’s mode, or teleological mode. The therapist
subjectivity is vulnerable to collapse, to- rewinds to the moment before the break,
ward a more secure attachment in which focusing on the momentary affects be-
they are less capricious and more stable. tween patient and therapist (e.g., love,
Identifying and fostering appropriate ex- desire, hurt, catastrophe, excitement),
pression of affect is integral to this pro- slowly clarifying and naming the affects,
cess. Within the range of affects, anger and including identification of the thera-
and aggression are seen as responses to pist’s contribution to the break. The focus
neglect and abuse rather than primary af- remains on the mind rather than behav-
fects that eventually need to be integrated ior, relating affects to the current event or
into the self as part of treatment. activity and the “mental reality,” using
the therapist’s mind as a model with the The core of the work is helping pa-
option of disclosure. The work may in- tients understand their intense emotional
clude the therapist’s accepting, through reactions in the context of the treatment
projection and countertransference, as- relationship. The patient is urged to “re-
pects of the alien self (described earlier in wind” and consider who engendered the
this chapter in the attachment theory sub- feeling that is being experienced and how
section of “Psychodynamic Perspectives and to ask, “What feeling may I have en-
on the Nature of Personality Pathology”) gendered in someone else even if I am not
so that elements of the patient’s mind can conscious of it that may have made him
be better reflected on. Throughout the pro- behave that way toward me?” An impor-
cess, the therapist uses concise “sound tant part of this is focusing the patient’s
bite” interventions because of the patient’s attention on the therapist’s experience,
current absence of symbolic representa- with the goal of the exploration of a mind
tion (and consequent difficulty taking in by a mind within an interpersonal con-
interpretations) and to avoid intellectual- text. This involves “mental closeness” in
ization. the sense of representing accurately the
feeling state of the patient and its accom-
Mechanisms of Change panying internal representations, distin-
The mechanism of therapeutic action in guishing the state of mind of self and
MBT is based on developing the patient’s other, and helping the patient appreciate
ability to have an awareness of mental this distinction.
states and thus find meaning in his or her A clinical example of MBT involves a
own and other people’s behavior. Trans- patient who came into a session looking
ference interpretations are avoided be- agitated and frightened and remained
cause of concern that 1) they excessively silent. The therapist proposed, “You ap-
activate the attachment system (arouse af- pear to see me as frightening today.” The
fect to levels that interfere with cognition) patient replied, in a challenging way,
and 2) direct transference interpretation is “What makes you say that?” The thera-
at too high a level of abstraction for pa- pist provided the immediate evidence:
tients with BPD to understand. Bateman “You had your head down and avoided
and Fonagy therefore recommend using looking at me.” The patient responded,
“transference tracers”—that is, comments “Well, I thought that you were cross with
that predict likely future action on the ba- me.” The therapist then proposed to ex-
sis of the patient’s previous experience in plore a bit more deeply within the pa-
a way that heightens the patient’s abil- tient: “I am not aware of being cross with
ity to begin to see transference patterns. In you, so it may help if we think about why
this sense, one difference between this ap- you were concerned that I was” (Bateman
proach and the TFP approach described and Fonagy 2003, pp. 198–199).
in the previous subsection on object rela- The strength of the MBT approach is
tions theory is that the MBT therapist implied by impressive outcome data, both
would tend to “hold the projection” of at the end of treatment and on long-term
certain elements of the patient’s internal follow-up. The ability of MBT to reduce
world within himself of herself longer be- symptoms, and the maintenance of that
fore interpreting the projection or would symptom reduction, would be better un-
even complete the therapy without bring- derstood with research data showing
ing these elements back to the patient. patient increase in aspects of mentaliza-
tion as related to symptom change in patient’s reactions to inevitable empathic

treatment. failures on the therapist’s part. These
failures can lead to disruptions in this
transference that result in the fragment-
Self Psychology ing of the self and the return of symp-
Self psychology is described (Kohut 1971; tomatology, often in the form of rage. In
Ornstein 1998) as a form of psychoanaly- the idealizing transference, the therapist
sis whose principles can be applied to is put on a pedestal so that the patient
therapy as well. The therapist’s task is to may borrow some of the therapist’s “per-
help the patient resume an arrested de- fectness” to achieve the grandiose self
velopmental path by facilitating the con- that is necessary for further psychologi-
solidation of the grandiose self with later cal development. This transference also
elaboration of more mature forms of the provides some cohesiveness to the pa-
self on that foundation. To this end, the tient’s experience of self. Again, thera-
main emphasis at the beginning of ther- peutic attention is focused on inevitable
apy is facilitating the development of sel- disappointments occasioned by em-
fobject transferences in which the thera- pathic failures on the part of the therapist
pist accepts being an object that the patient and the rage and symptomatology that
can utilize to complete the arrested de- may follow.
velopment of his or her self. This process
creates the precursors of a therapeutic al- Mechanisms of Change
liance. This model sees the patient’s even- The selfobject’s responsiveness (in the
tual capacity for a true therapeutic alliance case of treatment, the therapist’s) cata-
as evidence that he or she has resolved lyzes this transformation by activating
his or her borderline or narcissistic PD the individual’s innate potential. Empa-
and has advanced to a neurotic level of thy is at the center of the therapeutic pro-
difficulty (Adler 1985). The model does cess. The patient’s transference is seen as
not emphasize establishing the treatment including a positive striving for a new be-
frame through contracting as a separate ginning (Ornstein 1998) in addition to the
process, but in the case of acting-out bor- repetition and distortion based on past
derline patients, it describes the therapist’s experiences. Therapy proceeds not by
need to set limits and participate in pro- challenging or focusing on the specific
tecting the patient. features of the patient’s psychopathology
but by focusing on the matrix, the vulner-
Mutative Techniques able self, from which it emerged, with
The self psychology model emphasizes more of a focus on past history than in
the role of therapist empathy in facilitat- TFP or MBT. The therapist’s role is seen
ing the selfobject transferences that can as that of facilitating the therapeutic reac-
lead to developing a more adequate sense tivation of the patient’s original need for
of self. These transferences are the mirror appropriate selfobject responses. The ther-
transference and the idealizing transfer- apist generally empathizes with the pa-
ence. The former involves experiencing tient’s need for resistances rather than in-
the therapist as an affirming, approving, terpreting them. The therapist addresses
validating, and admiring presence and is defenses by helping to see what function
believed to provide a “psychic glue” that the defense/defensive behavior serves in
holds the patient’s fragile self together. maintaining some degree of cohesiveness
The therapist helps the patient analyze the in the fragile, fragmentation-prone self.
Once the patient experiences appropriate trality of the importance of sense of self
selfobject responses, he or she will be able and other within the PDs.
to end therapy and establish appropriate
selfobjects in life outside therapy. Supportive-Expressive
An example emphasizes the need for
the therapist to provide a perfect mirror- Therapy
ing attunement in order for a patient to The most widely practiced version of
delve behind his or her defensive wall psychodynamic psychotherapy of PDs is
and experience and reveal the affects at probably expressive-supportive therapy
the core of his or her dysfunction. In dis- (Gabbard 2005b; Gunderson 2001; Lubor-
cussing a case, Ornstein (2009) describes sky 1984). Wallerstein (1986), in analyz-
that the patient’s experiencing full emo- ing the Menninger Foundation Psy-
tional receptivity from the therapist—in chotherapy Research Project, concluded
the therapist’s tone as well as his words— that most therapy included a mix of the
allowed the patient to accept the analyst more formal elements of psychoanalysis,
as a “validating witness” and to connect termed expressive (e.g., the therapist’s
to his inner feelings in a milieu of safety. neutrality and use of interpretation, with
This sense of acceptance, in contrast to the goal of helping the patient become
an experience of rejection, was required more aware of internal conflicts and re-
in addition to an emphasis on insight for solving them to become more integrated,
a process of change to occur. The thera- harmonious, and effective), and of ele-
pist helped the patient see what—in the ments described as supportive (e.g., the
therapist’s attitude, tone of voice, or be- therapist at times supporting rather than
havior—the patient had experienced as interpreting the patient’s current de-
hurtful. The patient could then under- fenses so that the patient makes more ef-
stand that his behavioral response to the fective use of coping skills and relies on
therapist had included a feeling of being the healthier in contrast to the more prim-
assaulted. The patient went on to elabo- itive of the defenses within his or her rep-
rate on the poisonous family atmosphere ertoire). Supportive-expressive therapy
in which he grew up. This exploration refers to an eclectic therapeutic stance of
helped clarify how the situation in anal- selecting interventions from any of the
ysis could inadvertently replicate this more specific theoretical models accord-
early environment. From the beginning ing to what seems to be the best fit with a
of the treatment, the analyst viewed the given patient at a given moment in the
patient’s dysfunctions in life as behav- treatment. Therapeutic goals can vary
ioral expression of rage and revengeful- from more analytic (e.g., gaining insight
ness at his parents. In the course of the and achieving resolution of internal psy-
work together, the analyst’s task was to chological conflict, increasing the cohe-
perfectly reflect the patient’s inner expe- siveness of the self, improving the quality
riences with the goal of “making them to interpersonal relationships) to more
real” and thereby giving the patient a supportive (e.g., helping the patient to
chance to “let go of them.” adapt to stresses while not directly ad-
Although this example has clear dif- dressing the split psychological struc-
ferences from the illustrations provided ture that underlies severe PDs). This
in the earlier sections on TFP and MBT, form of therapy proposes the “expres-
it is another demonstration of the cen- sive-supportive continuum of interven-
tions” (Gabbard 2005b). Moving from the ing interpretation. Similarly, the therapist
supportive to the expressive end, this can choose between a more expressive
continuum includes affirmation, giving approach to resistance—exploring un-
advice and praise, empathic validation, conscious material by interpreting and
encouragement to elaborate, clarification, helping the patient understand the func-
confrontation, and interpretation. tion of the resistance—and a supportive
The expressive-supportive approach approach—bolstering resistances to dis-
allows the therapist to modulate between turbing material in the service of rein-
more analytic exploration and more sup- forcing weak defensive structures in the
portive involvement according to what he patient.
or she feels will be tolerated by and help- The supportive-expressive therapist
ful for the patient in the moment. A risk, gears interventions to the particular de-
however, is that the therapist may uncon- fensive structure of the patient. For in-
sciously collude with the patient in avoid- stance, in treating a patient with para-
ing certain “hot” areas by shifting from an noid PD (Gabbard 2005b), the therapist
analytic focus to a supportive one when would be informed by an awareness of
that area comes up. Awareness of this risk, the patient’s tendency to perceive attack
and appropriate supervision, are the best from the therapist and thus to evoke the
guarantees against this collusion. Sup- therapist’s defensive responses. Resist-
portive-expressive therapy emphasizes ing these responses, the expressive psy-
establishing the alliance as the sine qua chodynamic therapist would leave the
non of the therapeutic process, a view patient’s suspicious accusations and pro-
that is supported by research (Luborsky jections “hanging,” neither denying nor
et al. 1980). Therefore, the central task, es- interpreting them. In this way, the pro-
pecially early in therapy, is primarily sup- jections of hatred and badness are con-
portive and relationship building, with tained by the therapist. The hope is that
the fostering of positive or even idealiz- as this lack of defensiveness, combined
ing aspects of the transference (Buie and with empathy for the patient’s subjec-
Adler 1982). Alliance building takes pre- tive state, creates a sense of alliance, the
cedence over focusing on the contract and patient will become more open and re-
conditions of treatment out of concern vealing. In this process, the therapist
that emphasis on these latter might elicit helps the patient label feelings and dis-
negative transference or too quickly chal- tinguish better between internal emo-
lenge the patient’s defenses. Luborsky’s tions and reality (Meissner 1976). A more
(1984) manual for expressive-supportive supportive intervention would involve
therapy summarizes many aspects of the guiding the patient’s perceptions of real-
treatment. ity by questioning his or her assump-
tions. (“You assumed that when your
Mutative Techniques friend didn’t wave back from the other
Depending on the relative expressiveness side of the theater that he was trying to
versus supportiveness of the therapy, the avoid you. But are you sure that he saw
therapist would either directly offer in- you in that crowd?”)
terpretations to the patient (these could The fact that the therapist does not re-
address the transference, defenses, im- spond in the way anticipated, and pro-
pulses, and/or the patient’s past) or use voked, by the patient is meant to lead
the therapist’s own awareness to guide an the patient to a “creative doubt” (Meiss-
understanding of the patient while avoid- ner 1986) about the way the patient per-
ceives the world. This questioning of his less, psychoanalytic training is increas-
or her own way of thinking will help the ingly including technical modifications
patient develop a better capacity to ac- for working with lower-level PDs as
curately reflect on and perceive himself well, and it is important to refer more
or herself in relation to others. disturbed patients to clinicians who have
this training.
Mechanisms of Change The higher-level PDs that might be
The traditional psychoanalytic principle optimally helped by psychoanalysis dif-
of bringing subconscious aspects of the fer from more severe PDs in that the in-
patient’s mind into consciousness still dividual has a generally integrated—in
holds. However, the expressive-support- contrast to fragmented—sense of self but
ive model emphasizes both the role of with one element of his or her internal
increasing the patient’s understanding experience that is not integrated into the
through interpretation and the role of rest. In addition, the individual uses re-
the experience of a new type of relation- pression-based defenses that tend to keep
ship with the therapist as mechanisms of the unintegrated element of the mind
change. Another way to consider sup- successfully at bay at the price of con-
portive-expressive therapy is that it pro- stricting his or her fullness of experience
motes the therapist’s independence to of life. This is in contrast to the splitting-
delve into the toolbox of the common fac- based defense mechanisms of the more
tors of therapy elements and techniques. severe PDs that allow quicker access to
Judging what is the best combination for the defended-against psychological ele-
a given patient requires great skill at as- ments as they emerge in a discontinuous
sessing the person’s level of personality sequential disarray. An example of a pa-
pathology in order to determine what tient with a higher-level PD would be the
degree of deep change and improve- office worker, husband, and father whose
ment versus stabilization at the current life appears stable but who experiences
level of psychological structure can be bouts of depression and anxiety, along
expected. with a constricted engagement in life.
Analytic treatment would focus on mo-
ments when dreams, jokes, fantasies, or
Psychoanalysis slips of the tongue might reveal aggres-
sive strivings that are walled off from the
The proposal to conceptualize the sever- rest of the patient’s identity and whose
ity of PDs along the lines of sense of self, integration will leave him with more
relations with others, and characteristic comfort in asserting himself and in com-
defense mechanisms informs thinking petitive strivings, and with greater en-
about referral to psychoanalysis. Psycho- gagement in love and work.
analysis developed around the treat-
ment of “neurotic” disorders, a term no
longer included in official psychiatric Conclusion
nomenclature, but evolved to focus on
character pathology. Currently, patients Psychoanalysis and psychodynamic ther-
with higher-level PDs may be referred apy have long traditions of addressing
for psychoanalysis or forms of psycho- understanding and treatment of PDs.
dynamic psychotherapy (Caligor et al. Psychodynamic models may differ in
2007; Gabbard 2005a, 2005b). Nonethe- certain areas, such as the degree to which
PDs are considered the result of intra- American Psychiatric Association: Diag-
psychic conflict or of a deficit in psychic nostic and Statistical Manual of Mental
structure or self-structure. According to
a model’s position on this issue, the tech- American Psychiatric Association: Practice
nical approach may put more emphasis guideline for the treatment of patients
on interpretation versus empathy. Nev- with borderline personality disorder.
ertheless, it is important to keep in mind Am J Psychiatry 158 (10 suppl):1–52,
a common theme: the individual’s bio- 2001
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cipled approach to mental and behav-
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C H A P T E R 11
Cognitive-Behavioral
Therapy I:
Basics and Principles
Martin Bohus, M.D.
In general, cognitive, cognitive- in the so-called third wave of CBT (e.g.,

behavioral, and metacognitive interven- acceptance and commitment therapy
tions are some of the most empirically [ACT; Hayes and Smith 2005]) (Wells
supported and widely practiced types of 2003). Thus, modern CBT no longer pri-
psychosocial interventions (Hollon and marily aims to change basic assumptions
Beck 2013). Traditional cognitive-behav- and cognitions but rather encourages pa-
ioral approaches are based on the as- tients to learn how to observe their emo-
sumption that dysfunctional and mal- tions and cognitions from a metacogni-
adaptive thinking play a major role in the tive perspective, accept them as they are,
etiology and persistence of personality anticipate the impact of action tendencies
disorders (PDs), and these approaches on short- and long-term goals, and learn
aim to change maladaptive beliefs, auto- how to practice goal-oriented behavior in
matic thoughts, and related behavior. the face of dysfunctional cognitions.
Two major dimensions have extended From a scientific perspective, empiri-
the traditional field of cognitive-behav- cally validated treatment recommen-
ioral therapy (CBT) in recent years and dations currently exist only for three
have influenced the conceptualization of specific PDs: borderline, antisocial, and
psychosocial treatments focusing on PDs: avoidant (American Psychiatric Associ-
1) the increasing importance of emotions ation 2001; Andrews and Dowden 2006;
and emotion regulation as outlined in di- Emmelkamp et al. 2006; Herpertz et al.
alectical behavior therapy (DBT) (Line- 2008; Stoffers et al. 2012). On the basis
han et al. 2007) and 2) the importance of of the empirical data, it surely makes
metacognitive processing as manifested sense to apply disorder-specific treatment
241
strategies for these patient groups. How- and unpredictable sequelae can happen
ever, in clinical practice, therapists trained in any psychotherapy. The question, then,
in CBT usually treat far more than these is whether it is really possible to develop
three groups of specific PDs. Thus, the general treatment algorithms for such
focus of this chapter is mainly on gen- complex problems as PDs.
eral principles, strategies, and methods To address this question I will start
of modern CBT as applicable for patients with general considerations regarding
with PDs or pathological personality controllability and the handling of com-
traits. plex dynamic systems and then provide
an overview of the general structures
and principles of cognitive-behavioral
Case Example psychotherapy with patients meeting
Consider a psychotherapist who ap- criteria for the PDs.
plies a cognitive-behavioral standard
intervention: He motivates his pa-
tient, Jim, to check the validity of his Handling Dynaxity
dysfunctional assumptions regarding
explicitly assumed hostility of his col-
leagues. It has taken a long time for Principles
the therapist to develop a good thera-
peutic relationship and to help Jim Dynaxity is a cybernetic neologism de-
recognize his paranoid assumption scribing the close interaction of dynamics
that the world is uncontrollable and and complexity in modern management
hostile. Jim was even able to identify theory; from a cybernetic perspective,
his automatized major coping strate- psychotherapy of PDs can be considered
gies: suspiciousness and attack, espe-
cially against apparently friendly
as a professional attempt to solve prob-
neighbors and colleagues. After a long lems within a complex network governed
debate with this gifted therapist, Jim by semitransparent dynamics (Gonzalez
dares to try a new behavioral strategy: et al. 2005). Psychotherapists work with
He invites two colleagues for an after- problems that are generally controlled
work drink. Unfortunately, both of the
by multiple variables, which are mostly
colleagues turn him down, rejecting
his invitations and making him look unknown and which are interacting
rather silly in front of others. Jim im- with each other at the same time. As in
mediately leaves the office, heading Jim’s case, mentioned above, mechanisms
for the next bar, where he drinks and vectors of controlling variables are
heavily, becomes highly aggressive, mostly unknown, making it impossible
and picks a fight with other custom-
ers. As a result, his face is decked out
to predict the precise impact of a psycho-
with a shiner when he comes to the therapeutic intervention on the com-
next therapy session: “How was it?” plexity of the system. Unfortunately,
the therapist asks. “Everything as ex- psychotherapists and their patients have
pected,” the patient replies. to handle real-time problems driven by
complex dynamics. Crises can occur,
Did the therapist make a mistake? Not sometimes requiring immediate inter-
necessarily. He might have done a better ventions by the therapist, often based
job anticipating potentially negative reac- only on some intuitive assumptions.
tions of the colleagues, but the variability Fortunately, most psychotherapists han-
of human behavior in the social environ- dle these critical situations intuitively
ment is broad and rather unpredictable, without major discomfort, and they can
Cognitive-Behavioral Therapy I: Basics and Principles 243
consult with numerous experts who have Rules

experience treating PDs.
Elucidation of the principles and rules Helping the patient to conceptualize
of how to control complex dynamic sys- and to realize clear goals, related to in-
tems is a major issue in international ternal values, shifts the therapeutic fo-
research (e.g., Tiltmann et al. 2006). It cus from dysfunctional components to
might be useful to consider some basic a more resource-oriented perspective.
principles and rules of this research as Processing of goals in complex dynamic
they apply to psychotherapy of complex systems can be portrayed by an algo-
problems such as PDs: rithm such as that shown in Figure 11–1.
1. Therapists should be aware that they

Elucidating Individual
are handling a dynamic and highly Values
complex system, so any intervention In social sciences, values can be defined
impacts an unknown number of vari- as relatively stable conceptions that in-
ables with unknown impact on each fluence the way people select action, eval-
other. uate events, activate motivation, and con-
2. Therapists should be aware that any struct meaning (e.g., Schwartz and Bilsky
of their assumptions about a patient 1987). Examples for individual values
and the patient’s cognitive, emotional, include benevolence, security, stimu-
motivational, biographical, and social lation, hedonism, achievement, power,
aspects represent nothing more than and conformity, among others. Because
a model of reality. Mostly, these mod- values are relatively stable over time, the
els comprise more implicit than ex- uppermost priority of psychotherapy is
plicit components. Usually, these helping the patient process values rather
models are incomplete and represent than change them. It has been shown
only small aspects of the patient’s that life satisfaction is strongly correlated
reality. to the process of value driven (self-con-
3. The best way to operate a complex cordant) goals (Judge et al. 2005). Values
dynamic system is not to change this have strong motivational power. Thus,
system but to define clear goals within behavior change, which can be aversive
this system. and sometimes exhausting, should be
4. Translating this axiom to cognitive- closely linked to the individual values of
behavioral psychotherapy has far- the patient so as to benefit from the
reaching consequences: the idea of strong motivational forces of values.
changing the basic assumptions of
patients might be idealistic but not Defining an
very realistic. Habits, by definition, are Overarching Aim
strongly self-perpetuating and not In general, overarching aims describe
necessarily linked to specific cues; something like “missions” or “motives,”
they can persist even in the face of transposing individual values into the so-
negative consequences. Thus, tradi- cial environment. For instance, the value
tional behavioral treatment tools, benevolence can be transposed to an over-
such as behavior analyses or contin- arching aim such as “I want to be a good
gency management, can often fail father” or the value achievement to “I want
(e.g., Dahlstrand and Biel 1997). to be successful in my job.” As outlined
Individual values Overarching aim
Evaluation and SMART Goals

revision of strategies
Modelling (including
functional and dysfunctional
Change determining variables)
management
Prognosis and
extrapolation
FIGURE 11–1. The process of “dynaxity” in psychotherapy: a general algorithm.
below (see “Individual Expectations, Val- giving them a target date.

ues, and Aims of the Patient”), in psycho-
therapy these aims should be based on Establishing a Model of the
situational analyses and follow some Determining Variables
clearly defined principles. Once a goal is defined, the current deter-
mining variables, both functional and
Defining SMART Goals dysfunctional—the threats, barriers, and
Aims are good for talking but mostly in- challenges to achieving the end state—
sufficient for accomplishment. Thus, should be analyzed. Not all determining
aims have to be broken into small pieces variables identified are within the direct
that can be called SMART goals. SMART and immediate control of the patient to
stands for Significant, Measurable, At- change. Therefore, a review of the pa-
tainable, Relevant, and Time-bound tient’s resources and the required sup-
(e.g., Siegert and Taylor 2004). Signifi- port is used to prioritize which anteced-
cance stresses the need for a specific goal ent conditions will be targeted first.
rather than a general one; measurability
involves establishing concrete criteria Prognosis and Extrapolation
for assessing progress toward the attain- Once a sufficient model of the relevant
ment of the goal; attainability stresses the determining variables has been estab-
importance of setting realistic goals that lished, the therapist should be able to
are neither out of reach nor below stan- answer the following questions: If a pa-
dard performance; relevance highlights tient indeed accomplishes a goal within
the importance of choosing goals that are the defined time frame, what will be dif-
linked to overarching goals; and time- ferent in the patient’s life? Will accom-
bound stresses the importance of ground- plishing this specific goal actually help
ing SMART goals within a time frame, the patient to reach the overarching aims
and indeed improve the patient’s quality Dynamics of the Loops

of life? Considering questions like these
It is a characteristic of dynamic complex
helps to ensure that the therapist does
systems that it is simply impossible to
not engage in “activity traps” (“feel-
analyze in depth all antecedent and de-
good” activities that will not lead to de-
termining components that would help
sired changes) and does not overlook
or hinder a patient in reaching a goal. To
goals with higher priorities.
be clear, most therapists have only a
Change Management slight idea of these components at the
beginning of the treatment, but they
Strategies are then developed to target
learn from the trial-and-error experiences
the prioritized determining variables and
of their patients. However, determining
to cope with the reasonably foreseeable
why a plan did not work and what has
obstacles. In psychotherapy the main fo-
been learned requires 1) a plan, 2) an as-
cus is on 1) intrapsychic variables, such as
sessment, 3) skills of failure analysis,
dysfunctional expectations, automatic
and 4) motivational skills to encourage
thoughts, or problems in behavior plan-
the patient and the therapist to continue
ning, and 2) external variables, such as
trying. The dynamic of these loops (ogoal
partnerships, occupational conditions,
definition o analysis of determining
and other socioeconomic parameters.
components ochange management o
Psychotherapists can have a strong ten-
evaluationofailure analysisostrategy
dency to underestimate the importance
adaptationo change management) is of
and pertinence of social environments and
critical importance. There are two sorts
their inherent influence against change
of failures: 1) goals and strategies can be
for individual patients. Even patients with
expected to change too quickly, or 2) they
the most eccentric behavior usually are
can be placed on a timetable that is too
embedded in social environments to
long. The first kind of mistake may re-
which they are accustomed. Thus, the
sult in instability or chaos, whereas the
social environments 1) reinforce habits
second kind of mistake may result in
and behaviors of the patient and 2) de-
rigid perseveration.
mand this behavior, if the patient dares
The art of therapy involves the need
to change. Thus, change management
to define clear goals, models, and strate-
should consider that changing habits and
gies; to rely on them a certain amount of
behavioral strategies not only challenges
the time; and to revise them if they do
the patient’s intrapsychic system but also
not work. From a cybernetic perspective,
threatens the social environment.
this process can be described as a spiral
more than a linear process. In addition,
Evaluating and
the diameter of this spiral (i.e., how of-
Revising Strategies ten one has to revise or adapt strategies)
Once the strategies are defined, per- is determined by the urgent needs of the
formance measures and indicators are patient: suicidal patients need clear goals,
sought to track progress toward and im- highly frequent assessments, and imme-
pact on the desired end state. Tracking diate revisions (i.e., spirals with small di-
and assessing progress is essential in or- ameters), whereas highly functioning
der to consecutively adapt and improve patients can be tracked with much more
the strategies. equanimity.
family issues; vocational training and

General Principles of current occupation; financial issues, in-
cluding potential obligations; housing
Psychotherapy for situation; and so forth.
Treatment History
As mentioned in the introduction, em- For several reasons, psychotherapists
pirically validated therapy recommen- tend to avoid talking about former ther-
dations exist only for three specific PDs: apeutic experiences of their patients. But
borderline, antisocial, and avoidant. The would you consider a heart surgeon as
following general recommendations are responsible who does not carefully re-
based on clinical experience and on the flect the results and complications of
German treatment guidelines for PDs as former surgeries in his or her planning?
developed by an expert commission The same standards should be applied
during the years 2004–2007 (Bohus et al. in psychotherapy. Therapy dropout or
2009; Herpertz et al. 2008). For the devel- prolonged ineffective treatments are in
opment of these guidelines, a panel of the nature of PDs. Thus, therapists and
German experts aimed to define princi- their patients should seriously consider
ples and rules for psychosocial treat- these former experiences in order to
ments of PDs, based on the description learn from them instead of falling in the
of psychotherapeutic interventions that same traps repetitively.
are empirically founded or—if miss-
ing—are developed consensually. The Individual Expectations,
guidelines were developed objectively, Values, and Aims
independent of cognitive-behavioral or
In most cases, patients with PDs consult a
psychodynamic preferences and inde-
psychotherapist because they have psy-
pendent of the specific semantic conno-
chiatric disorders such as depression,
tations of the psychotherapeutic schools.
anxiety disorders, somatoform disorders,
To discover similarities and differences,
or substance abuse. Others report ongo-
the panel compared therapy manuals re-
ing troubles with their partners or relate
garding therapy planning, the nature of
experiences of being bullied by their col-
the therapeutic relationship, the treat-
leagues. In most cases patients do not ar-
ment setting, treatment goals, and spe-
rive with clear aims or goals for treatment.
cific treatment foci.
Experienced therapists carefully help
their patients formulate treatment aims
Treatment Planning more precisely, but this process may take
Treatment planning for patients with time. The therapist must balance between
personality disorders requires numer- two extremes: 1) allowing the patient to
ous considerations. Table 11–1 lists the extensively describe vague problems and
key elements, some of which are elabo- general concerns in an unfocused way,
rated on in the following text. and 2) potentially jeopardizing the thera-
peutic relationship by pushing the pa-
Socioeconomic Status tient too strongly.
As in any other psychotherapy, the first It might be helpful to begin therapy by
step is to get a general picture about the exploring the patient’s individual values.
basic socioeconomic variables of the One could ask simple questions such as,
patient. This includes partnership and “What do you think is really important
TABLE 11–1. Key elements of treatment planning for patients with personality
disorders
• Socioeconomic status
• Treatment history
• Individual expectations, values, and aims of the patient
• Potential treatment confounders
• Suicidality
• Behavior control
• Co-occurring psychiatric disorders
• Co-occurring somatic disorders
• External social problems
• Problem analysis
for you—I mean, how would you live if values to help patients cope with craving
you could choose freely?” Alternatively, for drugs or alcohol (e.g., Miller 1983).
one could use tools such as those de- These tools can also be powerful when it
scribed by Hayes and Smith (2005) (e.g., comes to behavior change in PDs.
the tombstone exercise, in which clients Once the individual values are clear,
are encouraged to design their own epi- the second step is to define individual
taphs). Another useful tool is Schwartz’s missions that transfer values to the cur-
Value Survey, a well-established short rent social environment. As a third step,
questionnaire with excellent psychomet- aims should be defined as SMART goals
ric properties (Lindeman and Verkasalo (see earlier subsection “Defining SMART
2005). This survey presents the patient Goals”). “Time-bound,” the fifth compo-
with an overview about general human nent of a SMART goal, reminds the ther-
values and encourages the patient to se- apist to set a target date. As shown in
lect those that are of intrinsic importance. Figure 11–1, SMART aims are iterative:
Clarification of the patient’s personal val- they should be reconsidered and even-
ues not only helps to define treatment tually revised from time to time. How-
aims (“We should definitely work to im- ever, they also should be tracked long
prove the purposes of your life”) but also enough to function as a clear orientation
enhances motivation for change. Behav- for treatment planning.
ior change per se mostly is aversive: one
has to overcome obstacles such as nega- Potential Treatment
tive feelings, dysfunctional cognitions, or Confounders
automatized rules and habits. Thus, moti- If a patient is currently suicidal or in an
vational aspects are of uppermost impor- acute crisis situation, these urgent con-
tance, especially in psychotherapy of PDs, cerns must be dealt with, whether or not
where the psychopathology is not as clear a sustainable therapeutic relationship
and intuitively convincing as it is, for ex- has been developed. It is important to
ample, in anxiety disorders. In addition, determine whether or not patients are
values are strong motivators when it able to control their behavior and emo-
comes to long-term goals; values can even tion regulation sufficiently. Sometimes,
help patients overcome strong emotion- the patient’s emotional learning capa-
driven impulses and actions. Experienced bility is affected by neurobiological fac-
therapists, for example, use this power of tors (e.g., severe comorbid anorexia, co-
morbid substance use disorder requiring 11–4) includes severe comorbid disor-
detoxification). As a rule of thumb, co- ders such as major depression, severe
occurring psychiatric disorders should anxiety disorders, substance use disor-
always be treated with first priority, if ders, eating disorders, and so on. Some-
these disorders are pervasive and inhibit times, severe behavioral dyscontrol can
emotional learning or behavioral change. be attenuated by treating the relevant
It goes without saying, that acute or comorbid psychiatric disorders. Other
chronic somatic disorders that influence forms of severe behavioral dyscontrol
the daily life habits of the patient should may not be life threatening but may in-
also be recorded. In addition, social vari- terfere with adequate problem solving or
ables (e.g., malignant partnership, un- goal attainment (e.g., repetitive nonsui-
employment) may have significant influ- cidal self-harm in patients with border-
ence on the success of the therapy. line PD, aggressive outbursts, intoxica-
According to Linehan (1993), the pri- tion, criminal behavior). The third aspect
orities of treatment targets should follow of this domain is the major target of treat-
a dynamic hierarchy (Figure 11–2). At the ment: goal-impeding behavior, which re-
top, always to be treated as a primary fo- quires a thoroughly elaborated and de-
cus if present, is severe crisis-generating tailed problem analysis.
behavior (acute suicidality, severe ag-
gressive outbursts, life-threatening para- Problem Analysis
suicidal behavior, etc.). The second target
Even if different therapeutic schools rec-
concerns patterns or variables that en-
ommend different methodologies, gen-
danger the maintenance of the therapy or
erally a problem analysis should con-
the therapeutic relationship. A patient’s
sider the key aspects shown in Table 11–2,
behavior, neurocognitive problems, or
which are discussed below.
problems related to the therapeutic set-
ting have to be considered. In addition, External conditions. People with PDs
problematic behavior patterns can de- often are characterized by a restricted
velop in the therapist. When these two repertoire of possible ways to flexibly re-
higher-ranked targets are absent, the ther- act to changing social conditions (Millon
apist should focus on attainment of the et al. 2001). Therefore, they strongly de-
defined treatment goals and work on goal- pend on “suitable” external conditions.
related behavior. Under specific favorable constant envi-
Defining the relevant treatment tar- ronmental conditions, people with PDs
gets requires a sufficient functional anal- can live without apparent pathology or
ysis of those parameters that are currently interference with quality of life. How-
impeding attainment of goals by the pa- ever, changes in the environment often
tient. Usually, there are three domains to demand adaptations that overtax their
be considered (Figure 11–3): 1) external capacity. Thus, psychic crises are based
social variables, which usually require mostly on changes in environmental cir-
problem solving; 2) skills deficits, which cumstances.
require skills teaching and training; and Thorough problem analysis in gen-
3) dysfunctional cognitions, emotions, eral requires the assessment of the pres-
and behavior, which require more so- ent social conditions of the patient, with
phisticated interventions. a special focus on current or most recent
The domain of dysfunctional cogni- changes (e.g., problems or even changes
tions, emotions, and behavior (see Figure at the workplace, changes in occupa-
Crisis-generating
behavior
Treatment-interfering
behavior
Goal-related
behavior
FIGURE 11–2. Dynamic treatment hierarchy.
External variables
Goal-impeding Skills deficits

variables
Dysfunctional cognitions,
emotions, and behavior
FIGURE 11–3. Hierarchy of goal-impeding variables.
tional demands, financial problems, re- tives or close friends at a comparatively

lationship problems, illnesses of close early stage.
relatives, political pressure).
Cognitive-behavioral therapists ei- Exaggerated perceptions and interpre-
ther use detailed situation analysis to get tations. Patients with PDs tend to pro-
a picture of the external conditions of the cess information according to their spe-
patient or gather collateral information cial filters, and sometimes their percep-
(at least in inpatient settings) from relations are highly selective or biased. They
Severe comorbidity
Dysfunctional cognitions, Severe behavioral

emotions, and behavior dyscontrol
Specific goal-impeding
behavior
FIGURE 11–4. Hierarchy of treatment targets in the domain of dysfunctional cognitions,

emotions, and behavior.
TABLE 11–2. Key components of a problem analysis
• External conditions
• Exaggerated perceptions and interpretations
• Distorted patterns of cognitive and experiential processing
• Accentuated action tendencies and behavioral repertoire
• Manifest behavior and interaction patterns
• Specific reactions of the social environment
can have exaggerated or dysfunctional Cognitive-behavioral therapists often

assessments and appraisals of informa- use questionnaires, which can detect pro-
tion. Most PDs are characterized by prototypical interpretation patterns of their
totypical misinterpretations. The envi- patients, with the help of case vignettes
ronment, for instance, can be perceived (Beck et al. 2003). Behavior and situation
as too threatening, too sexualized, or too analyses are used to reflect peculiarities
embarrassing, leading to specific experi- that are reproduced in the therapeutic
ences and behaviors. It is important to relationship or in other therapeutic set-
stress that patients with PDs mostly per- tings. Generally, however, cognitive-
ceive these interpretations not as dys- behavioral schools point out that these
functional but rather as evident, valid, disturbed interpretation patterns may
and realistic. Therefore, they do not ex- be specific to distinct social domains,
perience these problems as originating roles, or situations and therefore may
within themselves. Rather, the problems not necessarily be reflected in the thera-
have to be deduced indirectly via obser- peutic relationship. The residential set-
vations of the therapist, reflection on the ting allows the use of more complex
therapeutic relationship, or observations sources of information (dealing with other
in residential settings or in groups. patients, handling of restrictions and
rules, dealing with hierarchically higher solve a problematic situation adequately.

or lower persons). The patient’s difficulties in anticipating
potential social consequences of a partic-
Distorted patterns of cognitive and
ular behavior, along with deficient im-
experiential processing. The analy-
pulse control, additionally impair the
sis of peculiarities in cognitive process-
ability to act or react appropriately. This
ing and emotional experiencing of pa-
restricted behavioral repertoire can be
tients with PDs is one of the core features
based on negative experience and dys-
of the problem analysis. This analysis
functional cognition. For example, se-
can be seen as a multilevel process. Hy-
vere embarrassment combined with the
potheses, which are formulated at the
cognition “It is written all over my face
beginning of the therapy, should contin-
that I am a loser” can activate thoughts
ually be adjusted because the degree of
of escape during a public speech. Many
information correlates positively with
behavior tendencies are based on the at-
treatment progress as the individual char-
tempt to avoid anticipated unpleasant
acteristics of the patient become more and
emotions. For example, a patient with
more obvious. At the beginning of the
avoidant PD will try very hard to avoid
therapy, it is certainly helpful to rely on
getting into a potentially shame-induc-
prototypical categorical knowledge. For
ing situation. Finally, the restricted ac-
example, it is very likely that patients
tion possibilities could simply be based
meeting criteria for obsessive-compul-
on deficient social learning processes.
sive PD will experience severe distress if
they have to decide between two equally Manifest behavior and interaction pat-
ranked alternatives, and they likely feel terns. Visible behavior is embedded in
better if the decision is externally deter- a social context and is determined by
mined. Histrionic patients may react aver- multiple variables. In addition to predis-
sively to continuity and routine because posing biological factors, the ability to
they tend to switch between different ex- control one’s actions and to anticipate
ternal stimuli. It is also characteristic their consequences strongly interacts
that patients with paranoid personality with earlier learning and relationship
patterns may threaten or file a lawsuit experiences. Limited impulse control,
for perceived infringement on their rights. conditioned reaction patterns, socially
Nevertheless, therapists should be aware reinforced behavior patterns, and dys-
of the danger of generalizing too much functional relationships are only par-
and should be open to the individual tially under the control of the patient.
characteristics and peculiarities of each On the other hand, these dysfunctional
patient. behavior patterns do have effects in the
social context and thus may be rein-
Accentuated action tendencies and be- forced in vicious cycles. This can be il-
havioral repertoire. People with PDs lustrated using borderline PD as an ex-
often show restricted flexibility in their ample: self-harming behavior is mostly
ability to react to external and internal
used to attenuate intensive negative
cues. This is true not only for cognitive emotions or states of aversive tension
or emotional processes but also for be- (Kleindienst et al. 2008). If superficial
havior and action. Very often, problems
cuts are followed by intense emotional
are based on the fact that the spectrum of attention from partners or therapists,
possible actions is too narrow—that is, the these reactions will influence future be-
patient simply does not “know” how to
havior, even if this was not intended by
the patient. A hasty reaction by the ther- many years. Arguments against openly
apist (e.g., “Could it be that you try to at- communicating the PD diagnosis refer to
tract attention by injuring yourself?”), the stigmatizing language and deficit
however, could be interpreted by the pa- orientation of categorical diagnoses of
tient as an invalidating and harshly crit- PDs. They also refer to the potentially
ical statement. negative effect that communicating the
diagnosis might have on transference
Specific reactions of the social envi-
ronment. The most prototypical be- and countertransference reactions or to
the ego-syntonic nature of the PDs. Those
havior patterns develop during adoles-
cence and stay rather stable during the who favor open communication argue
further course of life. Therefore, it is not that because of this ego-syntonic pattern,
there is a greater need for information by
surprising that persons with limited be-
havioral flexibility seek social environ- patients and relatives and that they have
ments that meet their expectations. If a right to be told this information. Propo-
nents also point out the clarifying, emo-
they succeed in doing so, their degree of
suffering is low and treatment may not be tionally relieving, and hope-building as-
necessary. (This phenomenon may at pects of such open communication that
result from a clear definition of a mental
least partially explain some discrepancies
between the prevalence rates of PDs in disorder and evidence that there is effec-
the general public and those in clinical tive treatment. In practice, psychoeduca-
tion that includes information about the
treatment populations.) Conversely, one
can assume that the social environment diagnosis prevails as an essential compo-
may “become accustomed” to the behav- nent of manualized, disorder-specific
therapy programs (e.g., Hoffman and
ior patterns of the individual concerned,
stabilizing and reinforcing those behav- Fruzzetti 2005). The positive results of
iors from the perspective of learning the- specific psychoeducational programs for
patients with PDs and/or for their rela-
ory. Therefore, although changes in the
social environment can often precipitate tives suggest that, at least for selected
crises, as described earlier (see “Change PDs, the benefits of openly communicat-
Management”), continuity in the social ing the diagnosis mostly outweigh the
disadvantages. Most patients report be-
environment can impede learning pro-
cesses and the likelihood of the patient’s ing relieved after a diagnosis is profes-
changing. As a result, the therapist should sionally communicated to them. The in-
formation about the diagnosis should be
integrate specific reaction patterns of the
environment into the treatment. This ap- not an isolated intervention but a flexibly
plies not only to partners and peers but scheduled part of a psychoeducational
approach. Such an approach, using in-
also to friends, colleagues, and superiors.
formed and clear language about the PD
and the treatment model, can help con-
Communicating the siderably to destigmatize and demystify
Diagnosis and the diagnosis and to enhance treatment
motivation. Helpful suggestions are con-
Psychoeducation tained, for example, in the psychoeduca-
Whether a patient with a PD should be tional program of Oldham and Morris
informed about his or her diagnosis has (1995), which anticipates the dimen-
been the subject of controversial debate for sional perspective (see Chapter 24, “An
Alternative Model for Personality Disor- special features should be taken into con-
ders: DSM-V Section III and Beyond,” in sideration, such as financial arrange-
this volume). ments and the duration and frequency of
According to a resource- and problem- treatment. Especially for patients with se-
oriented view of the personality, addi- vere PDs, suicidal crises can be expected,
tional information about diagnosis and and the therapist should clarify in ad-
explanatory models should be guided vance under which conditions inpatient
not solely by DSM-5 criteria (American care makes sense. Inpatient admission
Psychiatric Association 2013) but also by without consultation with the therapist
the patient’s individual thinking and should take place only in emergency situ-
unique and specific experiences and be- ations. Particularly for chronically sui-
havior patterns. Following the overarch- cidal patients, a “crisis management
ing treatment algorithm presented in this schedule,” in terms of an escalation plan,
chapter, which prioritizes clarification of should be developed. This plan lists ap-
individual values and SMART treatment propriate interventions (including tele-
aims, therapists can link these specific phone numbers of emergency facilities)
patterns to goal attainment and can ana- correlated with the patient’s ability to
lyze which conditions might interfere maintain control and stay safe. It may be
with achieving those goals and how they useful to tell the patient where and under
could be changed. Most patients are not which conditions the therapist can be
aware of the correlations between current reached by the patient in case of an emer-
interpersonal needs, attitudes, emotions, gency, depending on the severity of the
and behaviors and their own history of crisis. Finally, the therapy contract should
learning and development. It is an impor- include arrangements concerning the use
tant task to enable the patient to under- of electronic media (audio and video
stand these correlations and to offer a communication and records, as well as e-
plausible explanatory model for the pa- mail) both for self-management and for
tient’s problems. Although such an ap- supervision. The patient also has a right
proach mostly does not solve the patient’s to know how and from whom the thera-
problems, it provides relief by making pist receives supervision, if applicable,
them understandable and comprehensi- and which materials are used in that pro-
ble. It helps establish purpose and mean- cess. In practice, so-called therapy con-
ing to the behavior and builds a bridge tracts, which contain the contents of the
between the subjective experience and agreements in written form and which
motives for behavior. A subsequent goal are signed by both parties, can be quite
involves helping the patient accept re- useful.
sponsibility for current problems and rec-
ognize that they can be reduced only by Therapeutic Relationship
the patient’s own efforts to change.
Dysfunctional cognitions, emotions, and
behavior patterns of patients meeting
Therapy Contracts criteria for PDs become especially mani-
Use of a therapy contract to clarify the fest in interpersonal domains. Accord-
general conditions of treatment is basic ingly, the therapeutic relationship is of
and a prerequisite for all psychothera- critical importance. Three issues are par-
peutic interventions. For the treatment of ticularly important to consider: First, the
patients with PDs, however, a number of establishment of the therapeutic rela-
tionship will be mostly influenced by realize that a dependent patient expects

the patient’s previous interpersonal rela- that the therapist will take over all re-
tionships and by expectations based on sponsibility in the treatment, even if the
those experiences. These implicit expec- patient does not verbalize this. Accord-
tations will be transferred to the interac- ingly, by this model, the therapist should
tion with the therapist. Therefore, in es- meet these expectations during the initia-
tablishing the relationship, the therapist tion of the treatment and demonstrate
needs to modify his or her own behavior strength and leadership qualities, giving
to a degree that includes but goes far practical everyday advice to handle prob-
beyond “empathy.” Second, deviations lems. Such a strategy might not be help-
from these usual expectations can and ful for all patients, however. With a para-
should be detected and used to reevalu- noid patient, for example, experienced
ate diagnostic and interpersonal pat- therapists might “intervene” in the orga-
terns. Third, the therapeutic relation- nization of the patient’s everyday life as
ship—after a solid establishment phase— little as possible but rather try to gain the
can be used as a field for learning and confidence of the patient first. The thera-
experimentation in order to extend the pist needs to be rather flexible in an at-
patient’s experience and behavioral rep- tempt to comply with the expectations of
ertoire. the respective patients, especially in the
beginning of the therapeutic relation-
Establishment ship. However, it is important that the
of the Relationship therapist does not “play act” but is au-
All therapeutic schools emphasize how thentic in the relationship.
important it is that the therapist has a ba-
sic attitude that reflects confidence and
Relationship as a
expertise and inspires trust (e.g., Del Re Diagnostic Source
et al. 2012). In the treatment of patients As mentioned in the previous subsec-
with PDs, however, the therapeutic relation, at the beginning of the therapy, the
tionship has a special function. A patient therapist will try to meet the explicit and
with a PD often has expectations or fears implicit expectations of the patient to a
regarding interactions with a partner that certain degree in order to gain the confi-
are strongly shaped by earlier negative dence of the patient and create a solid
relationship experiences; however, the base for necessary change processes. At
experience and behavior patterns of pa- the same time, the therapist will notice
tients with PDs, in contrast to those of pa- and reflect on the patient’s demands or
tients with many other mental disorders, interactional patterns and observe the
are characteristically ego-syntonic and therapist’s own cognitive and emotional
perceived as consistent and logical, not a responses as well as actions and urges (a
reason to need treatment. As a result, pa- process that psychodynamic therapists
tients with PDs may expect that the ther- might refer to as countertransference). The
apist will confirm their perceptions. In therapist now has a dual function: 1) to
psychotherapy research the term comple- become an authentic partner in a relation-
mentary relationship has been proposed ship and 2) to observe, on a metacogni-
(e.g., Kramer et al. 2009) to characterize tive-emotional level, potential peculiari-
therapeutic behavior that adapts deliber- ties in the relationship structure. These
ately to the expectations of the patient. “deviations from the norm” in the thera-
For instance, experienced therapists will peutic relationship are valuable diagnostic
clues. Psychodynamic schools often view evidence” of the assumptions of the pa-
this process of transference and counter- tient—possibly in relation to the patient’s
transference as the primary source of own biographical experience—while at
diagnostic information. Cognitive- the same time critically reflecting the so-
behavioral therapists additionally use cial reality. Table 11–3 outlines how to use
questionnaires and information derived the emotional awareness of the therapist
from third parties. for behavior change. This dialectical dy-
namic of establishing the relationship via
Relationship as a Source acceptance and endangering the relation-
for Change ship through challenge is often the key to
Patients’ interpersonal expectations and successful therapeutic work. Cognitive-
reaction patterns are usually transferred behavioral therapists mostly act like
to their interactions with the therapist. “coaches,” reviewing “the disorder” to-
Thus, the therapeutic relationship offers gether with the patient and helping the
the possibility of first-hand experience patient to risk new experiences, especially
and learning in the interpersonal area— outside of the therapeutic relationship.
and under quasi-controlled conditions. However, as happens in psychodynamic
After a phase during which the relation- therapies, they also observe which of the
ship is established, the therapist can care- relevant social interaction patterns evolve
fully begin to question dysfunctional ex- in the “therapeutic dyad.” The therapist
pectations or interactive patterns and intervenes via clarifications, confronta-
motivate the patient to start behavioral tions, and interpretations by helping the
experiments to gain new experiences. patient to reflect on the evolving pro-
This process requires exceptional thera- cesses on a metacognitive level, experi-
peutic skill, because any challenge to the ence them emotionally, and link them to
patient’s expectations may activate aver- biographically relevant reference points.
sive emotions toward the therapist. Thus, The therapist should be flexible enough
these change-oriented interventions to adjust the intensity of these processes
have to be counterbalanced by active to the ability of the patient and to poten-
strengthening of the relationship by the tially change social conditions. For exam-
therapist. ple, if a dependent patient loses a job
Linehan coined the phrase “balance during the therapy, even in an advanced
between acceptance and change” and stage, the therapist initially will give the
called it a “dialectical” relational strategy patient the desired support once again
(Linehan 1993, p. 98). This approach has before activating new resources already
been of great help in establishing thera- learned.
peutic relationships with patients with
borderline PD, and it can be easily ex-
panded to a general principle in the treat- Core Change Strategies
ment of PDs: whenever the therapist is
challenging dysfunctional expectations
or interpersonal behavior, it must be External Conditions
done in the context of strengthening the Factors that trigger psychological de-
therapeutic alliance. A helpful strategy is compensation in people with PDs are
to always describe the behavior, never often external stresses, including social
the person. Another important therapeu- variables (divorce, changes in work life,
tic strategy is to validate the “subjective etc.). Analysis and objectification of these
TABLE 11–3. A clinical algorithm to use for in-session observations for behavioral
change
1. Observe dysfunctional verbal or behavioral in-session patterns and observe your emo-
tional reactions (e.g., patient looks hostile and falls into silence after reporting suicidal
thoughts).
2. Ask the patient whether feedback is desired: “May I give you some short feedback?”
3. Describe the behavior observed and validate:
“It seems to me that you have become silent and look quite angry after telling me your
suicidal thoughts. If I am right, I am sure that you have good reasons for how you’re
feeling. Is that right?”
4. Describe your own cognitive or emotional reaction:
“Nevertheless, your behavior makes me feel quite helpless and anxious.”
5. Ask whether your reaction is intended by the patient:
“Is this your intention?”
6. If the patient denies it (as is typical), then ask for the “real” intention:
“Fine, so what is your intention?”
7. Whatever the patient answers, help the patient process intentions adequately:
“Oh, you feel helpless by yourself and you expect clear advice from me, such as how to
cope with suicidal thoughts? That makes sense to me—so please try to think about and
tell me what your expectations are, because otherwise we might run into trouble.”
8. Link functional behavior to the individual goals of the patient:
“...and by the way...it might be not entirely useless to learn how to ask for concrete help
and advice—perhaps regarding your wish to continue your fellowship program in May.”
9. Do not forget to shape functional behavior:
“This time it seems to me that you directly ask for advice about the skills needed to take
that step, and it looks like an effort to change your communication style—which is one
of the goals we’ve been working on. Is that correct?”
external stresses should have a high pri- 2) applying either cognitive reappraisal
ority in therapy. On the basis of the prob- techniques or metacognitive interven-
lem analyses, therapeutic strategies such tions (e.g., Cristea et al. 2013). As out-
as problem solving, competence build- lined earlier (see subsection “Problem
ing, or acceptance-based methods are Analysis”), identification of dysfunc-
recommended as interventions. The use tional information processing by the pa-
of structured problem-solving manuals tient requires the help of the therapist.
has become firmly established as an im- Maladaptive cognitive responses can be
portant option in numerous multimodal considered via retrospectively applied
treatment procedures (e.g., Black et al. behavioral or chain analyses (e.g., Kohlen-
2013). berg et al. 1993) or, even better, under
real-time conditions by counting mal-
Maladaptive Perceptions adaptive thoughts. Counting thoughts
requires observation and can be an en-
and Beliefs of the Patient gaging exercise, and patients become
Changing maladaptive perceptions and aware of how often they automatically
dysfunctional appraisals of the patient process these thoughts. The next step
in general requires two sorts of interven- is to clarify the consequences of these
tions: 1) identifying, observing, describ- thoughts on an emotional or behavioral
ing, and labeling these automatisms and level. The therapist could encourage the
patient to take short notes regarding the finable trigger variables, whether they
prompting events or cues, the related are activated internally or externally,
thoughts, and the consequences. A third and whether they are stabilized by reac-
step would be to evaluate the conse- tions of the environment. Depending on
quences and reconsider how strongly the results of the analysis, the therapist
these automatic thoughts and assump- will choose exposure-based change tech-
tions impair the realization of personal niques or methods of cognitive restruc-
values and goals. After this step, the turing or will try to partner with the pa-
therapist should be able to help the patient to reorganize the reinforcement
tient to critically discriminate between systems. In general, most cognitive-be-
the origins and former relevance of these havioral therapists teach their patients
assumptions and their lack of validity basic knowledge about relevant emo-
under current social conditions. This tions, their evolutionary background, the
methodological approach shifts the work prompting cognitions, and the related
toward cognitive restructuring, which action tendencies. They teach patients
emphasizes the problems of automated how to discriminate between justified and
thoughts (“What benefit do you gain from nonjustified emotions and how to atten-
this perspective?”) and carefully carves uate these emotions if the emotions are
out alternative perspectives (“Could there too strong or inadequate under current
be another possible explanation?” or “Un- social conditions.
der which conditions would this differ-
ent perspective be more effective?”). Maladaptive Action
More recently, metacognitive approaches
have been shown to be effective alterna- Tendencies and
tives to cognitive restructuring: instead Behavioral Repertoires
of attempting to change dysfunctional
Dependent on their individual histories,
cognitions or emotions, the patient is en-
patients possess specific repertoires of
couraged to accept these thoughts and
possible ways to react to certain demands
emotions as inadequate but existing and
or situations. Behavior patterns and hab-
to learn to tolerate them without fol-
its that are often used or that have
lowing them (learn to react without re-
proven effective in the short term will be
action).
self-reinforcing and will be activated au-
tomatically. To gain a higher degree of
Distorted Emotional flexibility, the patients should learn to
Experience Patterns identify these automated concepts and
to work toward developing a “menu” of
of the Patient first responses. Methodologically, the
Processing a patient’s dysfunctional emo- therapist will begin by offering model-
tional experience patterns initially re- based learning and by encouraging be-
quires a detailed analysis of the individ- havioral experiments in situ.
ual’s specific reactions. The therapist can
use behavior analyses, schema analyses, Manifest Behavior and
planning analyses, and formal therapeu-
tic induction techniques (e.g., Dobson
Interaction Patterns
2010). Attempts should be made to clar- After becoming aware of their maladap-
ify whether the patterns are linked to de- tive behavioral repertoires and learning
some replacement behaviors, the patient (“Whenever your behavior feels a bit
should be able to use the newly conceptu- unfamiliar or whenever you tend to fall
alized behavioral possibilities under real- back, that is a strong hint that you are on
life conditions. Therapeutic role-plays the right path”). In some cases it can
prepare the patient for this experimental make sense to involve selected individu-
phase. The in vivo behavioral experi- als in the patient’s immediate social en-
ments should not be left to chance but in- vironment to help identify and change
stead planned and recorded. The emo- undesired reinforcement systems.
tional reactions of the patient as well as
the (unfamiliar) reactions that could be ex- Supervision
pected from the environment are dis-
cussed in terms of anticipated behavior Considering the particularity and the
analyses and role-plays. This stage is often importance of the therapeutic relation-
ship in work with patients with PDs, it is
very stressful for patients because they
need to get past strong emotional barriers obvious that supervision should be an
(anxiety, embarrassment, etc.) in order to integral part of the therapy. As described
above (see “Therapeutic Relationship”),
learn new habits. Therefore, this phase of
treatment needs to be strongly and sensi- the therapist needs to find a good bal-
tively supported by the therapist. ance between fulfilling and frustrating
the interactional expectations of the pa-
tient toward the therapist. Depending
Implementation of on the level of stress influencing the pa-
Changes Under tient, the therapist should react flexibly
in the relationship and in providing emo-
Everyday Conditions tional support. Experienced cognitive
Once the patient is successful at imple- therapists, however, carefully try to
menting changes through extended role- avoid reinforcing patients’ ongoing dys-
play in the treatment setting, the patient functional behavior. In contrast to psy-
should be encouraged to implement chodynamic therapists, cognitive thera-
newly acquired behavior patterns in the pists do not try to maintain a technically
real environment (e.g., at the workplace, neutral relationship but instead aim to
in relationships, during family or leisure be flexible, linking therapeutic attention
activities). Recording behavioral change and care to behavior change. Maintain-
with individualized protocols is helpful. ing this strategy is not easy, however, be-
cause patients with PDs tend to “punish”
Specific Reactions of the their therapists for effective therapy.
Also, therapists often prefer a smooth
Social Environment and pleasant relationship with their pa-
It is to be expected that friends and ac- tients and tend to adapt to a patient’s
quaintances in the patient’s social envi- maladaptive behavior. In other words,
ronment will initially react with confu- even very well-trained therapists may
sion or surprise to the changes in the comply with the wishes of the patient
patient’s behavior. The therapist should and may not be able to completely recog-
prepare the patient that this could hap- nize their countertransference, thereby
pen and encourage the patient to with- risking a delay in the change process.
stand the urge to fall back on old behav- Here, the collegial supervision serves as
ior. Sometimes “reframing” is helpful a corrective mechanism.
Supervisors of all therapeutic schools

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C H A P T E R 12
Cognitive-Behavioral
Therapy II:
Specific Strategies for
J. Christopher Fowler, Ph.D.
John M. Hart, Ph.D.
ing individuals with PDs (Beck et al. 2004)

Theory, Definition, and and to view the products of these core
problems as available for conscious-
Interventions level psychological work (Ingram and
Cognitive-behavioral therapy (CBT) for Hollon 1986). A tripartite intervention
individuals with personality disorders strategy, targeting schemas about the
(PDs) is an ongoing, fluid process in self and others, self-destructive and de-
which collaboratively planned interven- feating behaviors, and affect dysregula-
tions are intended to become part of the tion, is assumed to be necessary to work
patient’s way of experiencing the world effectively with patients with PDs. As dis-
and himself or herself. Challenging the cussed in Chapter 11, “Cognitive-Behav-
maladaptive negative thoughts extends ioral Therapy I: Basics and Principles,”
beyond examining the content of a belief in this volume, CBT is an evolving theo-
or the truth and falsity of any particular retical and treatment structure with the
thought to considering how the process capacity to integrate interventions and
of thinking functions within a person’s concepts from a broad base of scientific
life and the world in which he or she disciplines.
lives (Björgvinsson and Hart 2006). Cog- Cognitive-behavioral therapies incor-
nitive therapy theorists generally agree porate a wide range of techniques, in-
that it is necessary to identify and mod- cluding cognitive restructuring, behavior
ify core problems in interpersonal, emo- modification, exposure, psychoeduca-
tional, and cognitive domains when treat- tion, and skills training (Matusiewicz et
261
al. 2010). Effective CBT for the PDs in- alization of the alternative model for
cludes a careful negotiation of a therapeu- PDs appearing in DSM-5 Section III,
tic alliance with specific attention to de- “Emerging Measures and Models”
veloping an agreement on the goals of the (American Psychiatric Association 2013).
treatment. The collaborative nature of According to this alternative model, the
goal setting is one of the most important central, defining features of PDs are 1) an
features of cognitive therapy in general, overarching pattern of distorted and
although achieving an effective collabora- maladaptive thinking about oneself and
tion can be particularly challenging be- 2) impaired interpersonal relationships
cause patients struggling with PDs are be- (Bender et al. 2011; Morey et al. 2011).
ing asked to modify their primary modes Numerous studies indicate that mal-
of operating and to alter their schemas adaptive patterns of mental representa-
about the self and others (Beck et al. 2004). tions form a common substrate of core
Not surprisingly, CBT for PDs requires impairments across PDs (Bender and
modification of brief treatment models to Skodol 2007). Thus, internal working
bring about lasting improvement in un- models or schemas constitute an over-
derlying schemas, affect regulation, and arching domain of personality function
behavioral patterns that frequently pro- that impacts the quality of relationships.
duce negative reinforcement such as non- The focus on a dimensional conceptual-
suicidal self-injury (NSSI) to decrease ization of personality traits as an orga-
emotional distress and produce analgesic nizing approach to the identification of
effects (Nock and Prinstein 2005). problematic areas of functioning also fits
Broadly speaking, the problematic well with the philosophy of cognitive-
personality traits and disturbance in behavioral therapies that attend to dys-
schemas about self and other are main- function in behavioral and interpersonal
tained by a combination of maladaptive domains but do not necessarily sub-
beliefs about self and others, and contex- scribe to a view of categorical PDs.
tual factors that reinforce problematic be-
havior and undermine effective behavior
(Beck et al. 2004; Linehan 1993). Sperry Meta-Analyses and
(2006) construed PDs as a disharmony in Reviews
the interaction of character and tempera-
ment. Character refers to developmen- Randomized controlled trials (RCTs) and
tally learned psychosocial influences on high-quality effectiveness studies of CBT
the individual and is commonly associ- for PDs reveal generally positive out-
ated with the term schema. Schemas are comes (for a review of the CBT outcome
cognitive structures consisting of basic literature for PDs, see Matusiewicz et al.
beliefs that individuals use to organize 2010). A series of meta-analyses on the
the view of the world, the self, and the fu- effectiveness of psychotherapy for treat-
ture; these implicit and explicit schemas ment of PDs demonstrated that cogni-
interact with genetic factors that influ- tive-behavioral and psychodynamic
ence expression of personality. psychotherapies of middle to long dura-
Cognitive-behavioral treatments that tion are effective in reducing depression
emphasize the role of distorted schemas and the burden of global psychiatric
about self and other, along with distur- symptoms, even when co-occurring dis-
bance in affect regulation and behavior, orders are present (Leichsenring and
are readily integrated into the conceptu- Leibing 2003; Leichsenring and Rabung
Cognitive-Behavioral Therapy II: Specific Strategies for Personality Disorders 263
2008). Far less evidence exists on the ef- age of 16 sessions. The active ingredients
fectiveness of psychotherapies in the of the CBT arm included cognitive re-
treatment of specific PDs other than bor- structuring, modifying dysfunctional
derline PD (BPD); nonetheless, evidence schemas and core beliefs, implementing
has emerged in the past decade to sug- behavioral change (decreasing self-
gest that CBT is effective in treating other defeating and self-destructive behaviors),
PDs (Matusiewicz et al. 2010; McMain and increasing adaptive responses to
and Pos 2007). problems. Although patients in both
Because the vast majority of effective- treatment groups demonstrated im-
ness and efficacy studies target BPD provement, those in the TAU+CBT group
symptomatology, more is known about reported fewer suicide attempts. At treat-
effective treatment for this particular dis- ment termination TAU+CBT subjects re-
order. The American Psychiatric Associa- ported lower symptom distress, reduced
tion’s (2001) guideline for the treatment anxiety, and fewer dysfunctional cogni-
of patients with BPD and the subsequent tions; however, the active treatment arm
guideline watch (Oldham 2005) confirm did not demonstrate superiority over
that psychotherapy represents the pri- TAU in number of hospitalizations, num-
mary treatment for BPD, with adjunctive, ber of emergency department admissions,
symptom-targeted pharmacotherapy frequency of NSSI or psychiatric symp-
used to mitigate severity of core symptoms, level of interpersonal functioning,
toms. A persuasive review of data from and level of global functioning at follow-
approximately 24 RCTs of BPD (Leich- up. A 6-year follow-up demonstrated
senring et al. 2011) demonstrated clear durable gains for the TAU+CBT subjects
and compelling evidence that several (Davidson et al. 2010). A reexamination
forms of psychotherapy, including CBT of therapist effects in the BOSCOT trial
and dialectical behavior therapy (DBT), indicated that patients receiving higher
help patients with BPD decrease the fre- quantity and more competent delivery
quency of self-destructive behaviors such of CBT had two to three times greater
as NSSI, as well as common secondary improvement in suicide-related out-
symptoms of depression, anxiety, and comes (Norrie et al. 2013).
substance abuse. An RCT of treatment of patients with
BPD demonstrated equivalent outcomes
between CBT and Rogerian supportive
Traditional Cognitive- counseling on measures of anxiety, de-
Behavioral Therapy pression, dysfunctional cognitions, and
suicide-related behaviors; however, pa-
Efficacy trials of traditional CBT demon- tients in the CBT condition demon-
strate generally positive results for the strated superior outcomes at 24-month
treatment of PDs. In the Borderline Per- follow-up of patient- and clinician-rated
sonality Disorder Study of Cognitive global symptom severity (Cottraux et al.
Therapy (BOSCOT), individuals were 2009). The latter finding must be inter-
randomly assigned to a treatment as preted with caution, however, because
usual (TAU) arm consisting of commu- intent-to-treat analyses were not per-
nity-based medication management and formed and dropout/loss-to-follow-up
emergency services (n=52) or to TAU + rates were high.
CBT (n=54) (Davidson et al. 2006). Treat- Another CBT designed to augment
ment duration was 1 year, with an aver- individual psychotherapy is Manual As-
sisted Cognitive Treatment (MACT). This follow-up. STEPPS does not, however,
six-session treatment combines compo- appear to reduce the targeted suicide-re-
nents of CBT with elements of DBT, lated behaviors, NSSI, or corresponding
including distress tolerance and func- rates of inpatient hospitalizations or
tional analysis of NSSI. In the most re- emergency department visits.
cent RCT for MACT (Weinberg et al. A second group treatment, Emotion
2006), MACT+TAU demonstrated supe- Regulation Group Therapy (ERGT; Gratz
riority to TAU in decreasing frequency and Gunderson 2006), is an acceptance-
and severity of NSSI, but did not differ based model that aims to increase the ca-
from TAU in time to the first suicidal pacity of patients to control behavior
ideation or repeat suicide attempt. while in states of distress, rather than at-
Group-based cognitive-behavioral in- tempting to control the experiences of
terventions specifically developed for emotions. The model and treatment high-
reducing the self-defeating and self- light the functional aspects of emotion
destructive behaviors associated with problem solving and the difficulties as-
BPD have demonstrated considerable sociated with attempts to control and
promise. Systems Training for Emotional suppress emotional experiences. A pre-
Predictability and Problem Solving liminary RCT of women diagnosed with
(STEPPS; Blum et al. 2002) is based on BPD randomly assigned to TAU (n=10)
the premise that individuals with BPD or weekly group sessions of ERGT +TAU
have limited access to specific emotion (n=14) demonstrated significant reduc-
regulation and behavior management tion in frequency of NSSI as well as clini-
strategies. Such deficits negatively im- cally significant reductions in symptoms
pact the emotional and interpersonal of depression, anxiety, stress, emotional
stability of relationships, thereby im- dysregulation, experiential avoidance,
pairing an individual’s capacity to uti- and BPD criteria. The TAU group failed
lize support systems (Blum at al. 2002, to demonstrate improvements in any
2008). The active treatment consists of 20 outcomes of interest. This small RCT was
weekly group sessions divided into four followed by an open trial of ERGT treating
modules: 1) assembling a support system, a wider array of individuals with NSSI
2) psychoeducation about BPD for the (Gratz and Trull 2011). Results indicate
members of the support system, 3) psy- significant changes from pretreatment to
choeducation for patients to identify posttreatment, with large effect sizes on
thoughts and emotions that contribute all measures except quality of life and
to problematic behavior, and 4) emotion blatantly self-destructive behaviors (the
management skills training for patients. latter demonstrated a medium-large ef-
STEPPS has been evaluated in three fect size). Importantly, 55% of the ERGT
RCTs involving outpatients diagnosed group reported abstinence from NSSI
with BPD who were randomly assigned during the last 2 months of the group
to receive either TAU or TAU+STEPPS treatment.
(Blum et al. 2008; Freije et al. 2002; Van Effectiveness of cognitive psychother-
Wel et al. 2006). Results from all three apy for avoidant PD has been demon-
trials indicate superiority of STEPPS to strated in an RCT in which CBT proved
TAU in decreasing BPD symptom sever- superior to brief dynamic therapy in im-
ity, negative affectivity, impulsivity, and proving social phobia, avoidance, and
global impairment in functioning, with obsessive symptoms (Emmelkamp et al.
gains generally maintained over 1-year 2006). A 52-week open trial of CBT showed
reductions in depression and personal- receive either CBT or TAU. In both treat-
ity symptoms at the end of treatment of ment conditions, patients demonstrated
patients with avoidant PD and patients lower frequency of verbal and physical
with obsessive-compulsive PD (Strauss aggression at follow-up; however, there
et al. 2006). were no improvements observed in sec-
Group CBT for patients with avoid- ondary symptoms such as anger, nega-
ant PD utilizes cognitive restructuring, tive beliefs about others, depression, or
exposure, skills training, and intimacy anxiety. At the present time, there are no
skills training to decrease social avoid- known open trials or RCTs assessing CBT
ance and anxiety. A well-designed for schizoid, schizotypal, paranoid, de-
multi-arm RCT (Alden et al. 1989) com- pendent, narcissistic, or histrionic PDs.
pared three active group CBT treatments
with a wait-list control group. The stan-
dard group CBT arm included exposure Schema-Focused
with limited cognitive components, the Therapy
second arm consisted of standard group
CBT plus general skills training, and the Schema-focused therapy (SFT) integrates
third consisted of the group CBT plus in- techniques from behavioral, psychody-
timacy-focused skills training. All active namic, experiential, interpersonal, and
treatment conditions produced reduc- cognitive-behavioral techniques (Young
tions in depression, anxiety, and avoid- 1999; Young and Lindemann 2002). Its
ant behavior, as well as improvements in primary cognitive theoretical framework
social functioning, with gains main- incorporates the construct of psycholog-
tained at 3 months posttreatment. Ren- ical schemas about the self and others
neburg et al. (1990) found modest and assumes that rigid patterns of avoid-
recovery rates following brief, intensive ant and compensatory behaviors de-
group CBT, which consisted of exposure velop to avoid the triggering of underly-
and skills training across 4 full-day group ing painful schemas. Modifying early
sessions. At treatment completion, 40% maladaptive schemas is a primary focus
of patients receiving group CBT were of the treatment and requires individual
considered recovered on the basis of psychotherapy treatment durations rang-
their fear of negative evaluation; how- ing from 1 to 4 years.
ever, much lower rates of recovery were In a large-scale RCT, patients with BPD
demonstrated for depression, anxiety, were randomly assigned to receive either
social avoidance, distress, and overall SFT or transference-focused psycho-
social functioning. A series of studies therapy (TFP) (Giesen-Bloo et al. 2006).
demonstrated that exposure and skills Patients in the SFT arm demonstrated
training were sufficient to bring about greater improvement across BPD dimen-
significant improvement and target symp- sions, including relationship impairment,
toms, whereas cognitive restructuring identity disturbance, abandonment fears,
had minimal effect (Stravynski et al. 1982, dissociation, impulsivity, and NSSI. SFT
1994). also proved efficacious in decreasing
Thus far, CBT has demonstrated mod- symptomatic behaviors consisting of gen-
est efficacy in the treatment of antisocial eral symptoms, defense mechanisms, and
PD but has not demonstrated superiority paranoia. These latter symptoms imply
over TAU. Davidson et al. (2009) ran- change in underlying schemas. Although
domly assigned men with antisocial PD to both treatment arms demonstrated sig-
nificant improvement in targeted symp- 1993; Lynch et al. 2007). DBT differs
toms and behaviors, SFT demonstrated a from traditional CBT in that it focuses on
66% overall gain in clinically significant acceptance and validation of behavior as
change compared with 43% for TFP. it is in the present moment, on reducing
SFT has been adapted for a 30-session therapy-interfering behaviors, on the
group format as an augmentation to indi- therapeutic alliance, and on the dialecti-
vidual psychotherapy. Farrell et al. (2009) cal processes (Linehan 1993). The over-
randomly assigned patients with BPD to arching emphasis on dialectics helps pa-
receive TAU+SFT or TAU (TAU consisted tients’ reconciliation of opposites in an
of high-quality psychodynamic psycho- ongoing process of synthesis. Linehan
therapy delivered by well-trained and ex- delineated three basic dialectics: 1) com-
perienced clinicians). Compared with petence versus active passivity, 2) unre-
patients receiving TAU alone, patients lenting crisis versus inhibiting experi-
receiving TAU+SFT evidenced signifi- encing, and 3) emotional vulnerability
cantly greater decrease in BPD symptoms versus self-invalidation. A major treat-
and in general level of psychiatric impairment dialectic concerns problem solving
ment, and showed greater improvement versus acceptance.
in overall functioning. Technical interventions focus on de-
veloping skills in core mindfulness,
emotion regulation, interpersonal effec-
Dialectical Behavior tiveness, and self-management. Linehan
Therapy full-package DBT includes individual
sessions with support from weekly skill-
DBT was developed to treat patients with building groups, ideally led by some-
BPD, with a specific focus on suicide- one other than the individual therapist.
related behaviors and NSSI (Linehan Therapy occurs in four stages: 1) focus-
1993). DBT is the most investigated treating on reducing suicidal behaviors, ther-
ment for BPD (Kliem et al. 2010) and is apy-interfering behaviors, and behav-
currently used in the treatment of multi- iors that negatively impact patients’
ple psychiatric conditions. Drawing from quality of life; 2) aiding patients in mov-
behavioral science, dialectic philosophy, ing from desperation to emotional expe-
and Zen practice, DBT balances accep- riencing through supportively reducing
tance and change in the pursuit of not the patient’s learned avoidance of aver-
only surviving but constructing a life sive emotions; 3) targeting problems of
worth living (Lynch et al. 2007). living including trauma-related issues,
Linehan (1993), in her biosocial the- family, academic, and career problems,
ory of BPD, contends that the patient’s and other disorders; and 4) increasing
emotional and behavioral dysregulation the capacity for freedom and joy (Lynch
are elicited and then reinforced by the et al. 2007).
interplay between an invalidating de- The full package generally requires a
velopmental environment and a bio- 1-year treatment duration and has dem-
logical tendency toward emotional vul- onstrated significant improvement in
nerability and reactivity. Moreover, DBT BPD symptoms and self-destructive be-
characterizes maladaptive behaviors as haviors. Early RCTs varied in the quality
natural and understandable reactions to of the TAU condition (Linehan et al. 1991;
environmental reinforcements (Linehan Verheul et al. 2003). Nonetheless, out-
comes were quite favorable, with the functioning; however, psychodynamic

DBT arm demonstrating substantial re- supportive therapy did not impact rates
duction and frequency of NSSI and an- of suicide-related behavior. Consistent
ger, as well as high rates of treatment with previous findings, DBT produced a
retention, with durable gains maintained decrease in suicide-related behaviors;
at 6- and 12-month follow-up (Linehan however, patients in the TFP arm had
et al. 1993). In a more recent RCT (Line- fewer suicide attempts than did those in
han et al. 2006), outpatients with BPD DBT. Reductions in physical assault, ver-
were randomly assigned to receive either bal aggression, and irritability were also
1 year of community treatment by BPD demonstrated in the TFP condition.
experts (n=51) or the full-package DBT DBT has been adapted to inpatient
(n=52). Groups were matched for clini- treatments with significant success. Bar-
cian characteristics including gender, ley et al. (1993) found that patients in a
level of training, supervision, and treat- long-term inpatient ward who were tran-
ment allegiance. At 1-year outcome, the sitioned to a DBT treatment model evi-
patients in the DBT condition evidenced denced a decrease in NSSI and overdose
fewer suicide attempts, emergency de- attempts after the ward transitioned to
partment contacts, and inpatient psy- DBT. The authors compared the DBT
chiatric days, and they had superior phase of treatment with TAU on another
retention rates compared to those re- long-term general psychotherapy ward,
ceiving treatment from community BPD demonstrating that NSSI decreased
experts. significantly on the DBT unit, whereas
Two RCTs that included a DBT arm no decrease was observed on the TAU
demonstrated equivalence in outcomes unit. An open pilot trial of inpatient DBT
between DBT and the comparator treat- (Bohus et al. 2000) found similar out-
ment. McMain et al. (2009) compared a comes for a 3-month inpatient DBT-based
large sample of patients randomly as- treatment, with significant decrease in
signed to receive DBT (n=90) and general the frequency of NSSI, depression,
psychiatric management (n=90); the lat- stress, anxiety, and overall psychiatric
ter consisted of psychodynamic treatment symptoms. A subsequent trial (Bohus et
and targeted medication management. al. 2004) randomly assigned women with
Both treatment arms demonstrated a sig- BPD to a wait-list TAU condition (n=31)
nificant decrease in frequency of suicide or inpatient DBT (n=19). The inpatient
attempts and NSSI, medical severity of DBT group demonstrated decrease in
suicide-related behaviors, number and NSSI, depression, anxiety, and social
frequency of emergency department vis- and global function with gains at out-
its, and inpatient psychiatric days; how- comes maintained at 1 month postdis-
ever, DBT did not prove superior—a find- charge. The TAU condition demonstrated
ing counter to the study hypothesis. no discernible improvement in any out-
Clarkin et al. (2007) randomly assigned comes.
outpatients with BPD to receive 1 year of
twice-weekly TFP (n=23), full-package
DBT (n=17), or weekly psychodynamic New Directions
supportive therapy (n = 21). All three
treatment arms demonstrated significant A number of developments in the treat-
improvement in symptoms of depression ment of PDs have emerged in recent
and anxiety, social adjustment, and global years. Cognitive Analytic Therapy is an
integrative combination of cognitive ther- Falling short of these unrelenting stan-

apy and psychodynamic object relations dards generated so much anxiety and
(Ryle and Kerr 2002) and as such cannot shame that she failed to maintain any
be viewed as a pure brand of CBT. Rather, adaptive life path.
the treatment model and evidence base Ana developed an eating disorder
supporting its efficacy in decreasing the and polysubstance abuse, both of which
symptom burden for individuals with functioned to reduce stress and anxiety.
BPD (Chanen et al. 2008; Clarke et al. Ana also experienced frequent panic at-
2013) point to a shift to integrated treat- tacks that were associated with feeling
ments with structured, well-defined in- rejected by peers. Her rejection sensitiv-
terventions targeting specific personality led to frequent ruptures in relation-
ity trait pathology. Similarly, Acceptance ships and abrupt endings. Eventually,
and Commitment Therapy (Hayes et al. Ana’s unrelenting standards and her ex-
2013) and mindfulness-based treatments cessive need for autonomy and approval
(Kabat‐Zinn 2003) integrate interven- seeking failed, and Ana began to avoid
tions from a broader philosophical and things that mattered to her. She gave up
treatment tradition that includes but is on athletics, had many failed attempts at
not exclusively focused on modifying college, and increased her drug abuse.
distorted cognitions. These treatments She avoided social and public events
are being modified and applied with due to self-consciousness and excessive
some success to the treatment of indi- fears of negative evaluation. Attempts at
viduals with multiple co-occurring dis- work and college were met with a simi-
orders. The case example that follows lar inability to sustain functioning due to
highlights this integrative approach in unremitting anxiety. As she became more
the treatment of a young woman with dysfunctional, Ana was admitted to a
avoidant PD. residential treatment center for her eat-
ing disorder and substance abuse. These
earlier treatments proved moderately
Empirical Case Study
beneficial; however, Ana’s pattern of in-
Ana is a young woman of Hispanic heri- terpersonal avoidance and social anxi-
tage who was admitted to the Menninger ety interfered with outpatient treatment.
Clinic due to severe depression, anxiety, After nearly 2 years of failed school at-
and the inability to benefit from outpa- tempts, short-term jobs, and intermit-
tient therapy. She received twice-weekly tent drug use, she sought voluntary ad-
CBT (as part of an integrated multimodal mission at the Menninger Clinic.
treatment package) at the clinic to ad- An integral part of the Menninger
dress severe social anxiety and fear of be- Clinic treatment program includes stan-
ing imperfect. In the years prior to this dardized research-based diagnostic as-
admission, Ana was a competitive athlete sessment and routine assessment of
and excelled in academics through high symptomatic functioning at 2-week in-
school. She placed unrelenting pressure tervals throughout the course of treat-
on herself to excel and constantly felt that ment, with feedback provided to the
she failed to live up to her internal stan- patient and treatment team to aid treat-
dards. Ana developed a highly perfec- ment planning and monitoring of prog-
tionistic style of organizing her interests, ress (Allen et al. 2009). Ana’s research
daily tasks, and relationships to the point diagnoses at admission included dys-
of being unable to complete basic tasks. thymic disorder, major depressive disor-
der (recurrent and severe), substance tions of the principles of CBT helped to re-
abuse, eating disorder not otherwise duce her fears of failure and rejection and
specified, and avoidant PD (AVPD) with to begin to foster a therapeutic alliance.
significant borderline and obsessive- Ana self-rated her therapeutic alliance
compulsive traits. Her responses to the with the treatment team (Working Alli-
battery of psychological measures con- ance Inventory; Horvath and Greenberg
ducted at admission indicated that Ana 1989) as average to high from the outset
had a broad array of severe psychiatric of treatment (Figure 12–5), which was a
symptoms and significant impairments good predictor of a positive outcome.
in daily functioning and emotion regu- Upon further assessment, Ana’s psy-
lation. Ana’s responses to the Patient chiatric disturbance was confirmed to be
Health Questionnaire (PHQ; Spitzer et much broader than her presenting com-
al. 1999) indicated that she experienced plaint and was more consistent with
severe anxiety and depressive symptoms AVPD. There was some debate among
(Figure 12–1). Results from the World her treating clinicians about whether so-
Health Organization Disability Assess- cial anxiety disorder (SAD) was more
ment Schedule 2.0 (WHODAS 2.0; applicable than AVPD. There is a signif-
World Health Organization 2013) and icant overlap between SAD and AVPD,
the five-item World Health Organiza- and some researchers conclude that AVPD
tion Well-Being Index (WHO-5; Bech is a more severe variant of SAD (Chamb-
1997) showed that Ana had severe dis- less et al. 2008; Cox et al. 2009). Others,
ability and a poor sense of well-being, however, argue for a distinction between
respectively (Figure 12–2). According to the two disorders, characterizing AVPD
her scores on the Difficulties in Emotion as encompassing more severe depres-
Regulation Scale (DERS; Gratz and Roe- sion, introversion, and social and occu-
mer 2004), Ana had trouble accepting pational impairment (Sanislow et al.
her emotional responses, experienced 2012). Individuals with SAD alone tend
deficits in strategies for regulating her to avoid anxiety-provoking situations
emotions, and had problems sustaining for fear of doing something embarrass-
goal-directed activity because of emo- ing or of being negatively evaluated in
tional interference (Figure 12–3). Her the moment. In contrast, individuals such
performance on the Acceptance and Ac- as Ana have a broader pattern of avoid-
tion Questionnaire—II (AAQ-II; Bond et ance that is driven by pervasive emo-
al. 2011) indicated that Ana struggled tional avoidance, fears of rejection, and
with experiential avoidance and lack of severe feelings of inadequacy. Patients
psychological flexibility (Figure 12–4). with AVPD—whether it is a discrete en-
During the first session of individual tity or a severe variant of SAD—have
CBT, Ana described intense distaste for more interpersonal fears (Perugi et al.
the interpersonal intensity of the social 2001) and are more emotionally guarded
milieu on the hospital unit. She was de- than those with SAD (Marques et al.
fensive, emotionally guarded, and iso- 2012). Clinically, patients with AVPD are
lated from peers and staff. Education less likely to accept exposure-based in-
on the cognitive-behavioral model was terventions than are those with SAD
introduced, with special emphasis on de- alone (Taylor et al. 2004); patients with
veloping a collaborative treatment frame. AVPD tend to be less willing to tolerate
Liberal use of explanations and illustra- the anxiety of repeated exposure be-
15–30 = Severe
PHQ Anxiety Severity
30 10–14 = Moderate
25
5–9 = Mild
0–4 = Normal
20
17 Severe
15
Moderate
10 7 7
5 Mild
5 2
0
Admission 2 weeks 4 weeks 6 weeks Discharge
15–27 = Severe
PHQ Depression Severity
30 10–14 = Moderate
25 5–9 = Mild
0–4 = Normal
20 19
14 Severe
15
Moderate
10 7
5 4 Mild
5
0
FIGURE 12–1. Patient Health Questionnaire (PHQ).
cause it triggers a more pervasive emo- needed to be addressed in order to help

tional response (Huppert et al. 2008). her reach her treatment goals: 1) effort-
In early individual therapy sessions ful suppression and hiding of her anxi-
Ana described her childhood as difficult ety, 2) self-criticism and ruminations,
but not overtly abusive. She felt she could 3) intense rejection sensitivity, and 4) lim-
never live up to her parents’ expecta- ited strategies for contending with strong
tions and felt constant disapproval from emotions.
her family. The fear of disapproval was During the first 2 weeks of treatment,
internalized and became a salient schema Ana hid her anxiety from peers and staff,
in her processing of information and believing that being anxious was a sign of
emotional responding. To fend off self- weakness that would evoke disapproval
criticism, she frequently became argu- from others. Like other patients with vul-
mentative and would often “melt down” nerability to shame (Hejdenberg and An-
when corrected or challenged. She de- drews 2011), she showed flashes of anger
scribed herself as a hard worker and whenever she felt criticized. She rumi-
viewed success in sports and school as nated over past events and used these to
buffers against disapproval, rejection, and anticipate future criticism. Rumination as
shame. Ana’s stated goals for treatment an emotion regulation strategy has been
were to “be able to go to school, be more shown to have a strong link across sev-
independent, and not be so afraid of peo- eral forms of psychopathology (Aldao et
ple.” Several patterns were identified that al. 2010), as well as a strong association
World Health Organization Disability Assessment

Schedule 2.0 (WHODAS 2.0)
100
95 Extremely severe
90 Severe
90
Moderate
Percentage
80 75 Mild
70
60
50
50
50
World Health Organization Well-Being Index (WHO-5)

100
90
80
70
Percentage
56 60 56
60
50
40 32
30 Poor quality of life
20 and well-being (52%)
10
0
8
FIGURE 12–2. World Health Organization Disability Assessment Schedule 2.0 (WHODAS
2.0) and five-item World Health Organization Well-Being Index (WHO-5).
Note. A change of 10% indicates a significant alteration in sense of well-being.
with shame proneness and self-criticism individual therapy sessions she learned
(Gilbert and Proctor 2006; Rector et al. that worry was an insulator against over-
2008). Additionally, Ana frequently en- whelming emotions—worrying about
gaged in post-event processing. Repeti- negative outcomes at every turn protected
tive thinking about perceived inade- her from being hopeful and then disap-
quacy in social interactions is related to pointed. Due to the rigid and overgeneral-
depression and anxiety (McEvoy et al. ized nature of Ana’s worry, she missed
2010). At times Ana would externalize opportunities for self-soothing and for de-
these feelings, but typically she would in- veloping capacities for processing under-
ternalize anger and retreat into rumina- lying emotions of sadness, shame, and
tive self-criticism and harsh self-judg- guilt (Newman and Llera 2011).
ment. Ana’s self-criticism was intense During early sessions the therapist
and a potential treatment barrier. Self- shared these observations and formula-
criticism has been identified, for exam- tions as an integral part of CBT. After
ple, as an impediment to treatment with feedback and education about the con-
CBT for depression (Rector et al. 2000). ceptualization of her condition, Ana re-
Ana worried excessively about a vari- formulated her treatment goals to include
ety of themes but primarily about becom- work on rumination/worry, shame, anxi-
ing overwhelmed by her emotions. In ety in social situations, and anger. She rec-
DERS–Acceptance, Impulse, and Clarity

30
25 24 24
22
20
20 18 Severe
15 13 Moderate
12 12 12
10 Mild
10 Normal
11 10 9
6
5 7
A1 F1 F2 F3 F4
Acceptance 24 24 20 22 9 Acceptance
Impulse 12 18 13 10 7 Impulse
Clarity 6 10 11 12 12 Clarity
DERS–Awareness, Goals, and Strategies

40
35 36
33
27 Severe
26 23 24
22
19 24 Moderate
19 17 16
13 Mild
13 11 Normal
12 15
7
5
A1 F1 F2 F3 F4
Awareness 13 19 13 11 7 Awareness
Goals 22 23 17 24 15 Goals
Strategies 35 36 24 27 16 Strategies
FIGURE 12–3. Difficulties in Emotion Regulation Scale (DERS).
ognized that she was plagued with dysfunctional thought records, pro-and-
rumination and saw this as a major im- con analysis, and downward arrow exer-
pediment to progress in life. A functional cises (Beck 2011). Many patients like Ana,
assessment was initiated that emphasized however, have ongoing internal dia-
the consequences of rumination, while logues about the accuracy of their
analysis at the content level was neces- thoughts, which can be aimed at avoiding
sary to help Ana modify distorted beliefs, a painful emotional experience. Although
challenge maladaptive thoughts, and cor- useful, analysis at the content level can run
rect faulty assumptions. These goals were the risk of providing fodder for the rumi-
worked on using a variety of traditional native process. Ana said that throughout
cognitive therapy interventions, such as her life, family and others close to her al-
AAQ-II
60
50
40
30
30 26 26
20 25
19
10
0
FIGURE 12–4. Acceptance and Action Questionnaire–II (AAQ-II).

Scores below 28 indicate increased psychological flexibility.
Working Alliance Inventory–Treatment Team 61–84 = High alliance

90 37–60 = Average alliance
80 12–36 = Low alliance
70 72
70
68
High alliance
60
58
50 Average alliance
40
30
Low alliance
20
10
Admission 2 Weeks 4 Weeks Discharge
FIGURE 12–5. Working Alliance Inventory—Treatment Team.
ways tried to offer solutions and to talk them. Being able to identify emotions
her out of her negative feelings. Breaking when she had them gave her greater ac-
this cycle of being broken and needing re- cess to a range of emotions and helped
pair required empathic understanding by her process them more fully. Another part
the therapist of her underlying emotions. of the functional analysis looked at how
In direct response to Ana’s ruminations, these patterns of avoidance developed
the therapist asked her to reflect on how throughout her life. Ana maintained that
her current rumination helped her im- emotions such as sadness, fear, and
prove her life or sense of longer-term well- shame were met by her parents with at-
being. Another part of the functional anal- tempts to solve her problems and quickly
ysis was to help Ana identify her underly- alleviate her emotions. These attempts by
ing emotional states. others to alleviate her distress led Ana to
Identifying emotions was difficult for conclude that emotions were “wrong.”
Ana. A good deal of time was spent help- Interventions aimed at increasing self-
ing her identify and define her emotions, compassion were engaged to address her
including her response tendencies for self-critical rumination and shame prone-
ness. Increasing self-compassion has been various situations.

shown to effectively address self-criti- Ana’s anticipatory anxiety prior to at-
cism and maladaptive levels of shame, as tending a group on the unit was so in-
well as to increase a sense of well-being tense that she often decided not to go.
(Germer and Neff 2013). Particularly This emotionally driven avoidance was
helpful for Ana was writing a letter of negatively reinforced by a reduction in
self-compassion from an “imaginary com- her anxiety; however, this short-lived re-
passionate friend” in which the friend ex- duction would be followed by guilt and
presses compassion that is balanced and shame in which a chain reaction of avoid-
realistic but not indulgent or placating ances occurred, such as avoiding staff,
(Neff and Lamb 2009). Many self-critical missing subsequent groups and activities,
patients believe that without their own and so on. Cognitive reappraisal helped
criticism, they will lapse into a complete Ana gain a more realistic assessment of
state of inadequacy. Although initially re- the actual threat. Cognitive reappraisal
sistant to self-compassion, Ana eventu- also included skill-building interventions
ally caught on to the balanced and to help her cope with the “worst that
realistic self-compassionate approach could happen” scenario. Ana developed
that helped her think about her deficits the capacity to reappraise and rehearse
and flaws in a more open and accepting coping strategies in the event that her
way so that she could change what was fears would come to fruition. Other
possible to change. chances for skill building occurred in
One technique that helped Ana learn vivo, such as when she found herself in
to identify and process unwanted emo- conflict with her roommate and was able
tions was to determine the nature of a to use a “Dear Man” skill from DBT (Line-
threat in situations in which she felt ei- han 1993). To prepare for implementing
ther overwhelmed with anger and/or such an interpersonally challenging tech-
anxiety. Mindfulness exercises helped nique, Ana realistically appraised the po-
her develop an observer mode that miti- tential problems and was able to realize
gated against overidentification with her that she could not be effective unless she
thoughts and feelings. Ana often found was willing to feel anxious.
herself responding to troubling situations It was also emphasized with Ana that
with emotion-driven behaviors that were behavioral avoidance was a type of emo-
characterized by avoidance and with- tional suppression that was ineffective
drawal or externalizing defensive aggres- for adaptively regulating emotional re-
sion. Threats typically involved making sponses and that interrupted effective
mistakes, feeling embarrassed or exposed emotion processing. Breaking the pattern
to perceived weaknesses, and being eval- of behavioral avoidance was essential for
uated or judged negatively. Because of Ana’s recovery. For most patients with
her history of emotion-regulation prob- AVPD, exposures typically need to be
lems, Ana had strong emotional re- carried out with a clear rationale as to
sponses to even neutral social events. In how these experiences fit with the rest of
other situations her automatic emotional their treatment. Skill building and cogni-
response was frequently out of propor- tive reappraisal are important, but an ex-
tion to the event. Cognitive reappraisal periential component is also needed. In-
helped her identify and modify maladap- session experiential components in-
tive thinking patterns with the aim of involved directly addressing past hurts and
creasing her flexibility in appraising traumas, with full allowance for her to
experience her emotions fully. Ana re- healthy. Similarly, she became more in
sponded to a mindfulness exercise that touch with “lost” values, such as feel-
consisted of just listening to her critical ings of gratitude and forgiveness. She
voice, and she eventually constructed re- began to make a shift from fixed, specific
alistic responses to this inner voice. This superlative goals to more flexible, rea-
exercise was in the service of helping Ana sonable goals guided by her identified
experience her distressing emotions in a values. In a more self-compassionate
safe and empathic environment. way, Ana developed a greater balanced
These strategies provided a stage for and realistic view of her strengths and
increasing Ana’s willingness to experi- flaws. Interpersonally, she began taking
ence aversive emotions in more public more risks by interacting with others
settings. She reframed her participation without heavy reliance on externalizing
in groups from a performance to an expe- or internalizing defenses.
rience. This was an important factor for Ana made clinically significant im-
Ana—as she viewed it, her entire life had provement through her treatment. At
been a performance that she could never admission she had a broad range of psy-
get right. The concept of willingness to chiatric disturbances that required a va-
experience was vital to her recovery as riety of interventions but with a focused
she began to realize that pursuing valued set of therapeutic targets. CBT for her so-
life experiences could not be done if she cial anxiety alone was unlikely to suc-
insisted on controlling unwanted emo- ceed, but it was an essential component
tions. Ana was able to set valued life ex- of therapy throughout the treatment.
periences as goals rather than “emotional Targets for treatment were her basic core
goals,” which were typically managed beliefs in her basic inadequacy, her ex-
with avoidance, rumination/worry, and pectation that others would ultimately re-
suppression of thoughts and feelings. To ject and hurt her, and her pervasive fear
increase her willingness to experience of her own emotions.
unwanted thoughts and feelings, Ana As can be seen from Ana’s outcome
constructed a “what for” list, consisting measures, her anxiety and depression
of values and experiences she wanted to levels decreased significantly (see Figure
pursue. Constructing a list of experiences 12–1). Her overall sense of well-being in-
to increase motivation for change was es- creased, and her perceived severity of dis-
sential for breaking maladaptive pat- ability dramatically decreased (see Figure
terns, because valued patterns are in- 12–2). Her ability to accept aversive inter-
dividualized and are intrinsically self- nal experiences and gain psychological
reinforcing (Wilson and Dufrene 2008). flexibility increased moderately (see Fig-
Once Ana’s values were established ure 12–4). Lastly, as shown in Figure 12–3,
through a structured exercise, she became her ability to accept her emotional experi-
more cognizant of the costs of controlling ences (Acceptance), take a more workable
and avoiding painful thoughts and feel- look at her feeling about herself and her
ings in contrast to pursuing more effec- relationships (Awareness), set goals and
tive and satisfying experiences. commit to effective behaviors without
Ana listed the following among her emotionally driven interference (Goals),
most important values: having relation- and construct strategies to help her effec-
ships with family and friends, learning, tively regulate her emotions (Strategies)
helping and caring for others, and being all improved in meaningful ways.
In examining Ana’s outcome mea- psychopathology: a meta-analytic re-

sures, it is noteworthy that during week 6 view. Clin Psychol Rev 30:217–237, 2010
Alden L: Short-term structured treatment for
she had a spike in her self-reported de-
avoidant personality disorder. J Consult
pression severity (see Figure 12–1) and Clin Psychol 57:756–764, 1989
functional disability (see Figure 12–2), as Allen JG, Frueh BC, Ellis TE, et al: Integrating
well as a decrease in her sense of well-be- outcomes assessment and research into
ing (see Figure 12–2). At this juncture she clinical care in inpatient adult psychi-
admitted to secretively engaging in her atric treatment. Bull Menninger Clin
73:259–295, 2009
eating disorder symptoms after many
American Psychiatric Association: Practice
months of control. She felt ashamed, em- guideline for the treatment of patients
barrassed, and humiliated and believed with borderline personality disorder.
that she would be asked to leave treat- Am J Psychiatry 158 (10 suppl):1–52,
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tinued to believe that she had lost the Barley WD, Buie SE, Peterson EW, et al: De-
confidence of those trying to help her and velopment of an inpatient cognitive-be-
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7:232–40, 1993
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Manualized cognitive-behavioral thera- Bender DS, Morey LC, Skodol AE: Toward a
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Blum N, Pfohl B, St. John DS, et al: STEPPS:
PDs, especially those PDs with relatively a cognitive-behavioral systems-based
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(Fowler and Oldham 2013). borderline personality disorder—a pre-
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C H A P T E R 13
Group, Family, and

Couples Therapies
John S. Ogrodniczuk, Ph.D.
Jay L. Lebow, Ph.D.
William E. Piper, Ph.D.
Although individual therapy are formed by early attachments, shaped

has long been the mainstay of treatment by family dynamics, and consolidated
for personality disorders (PDs), there is by repetitive interactions and habitual
a growing appreciation for the place of patterns of communication and interac-
multi-person therapies (group, family, tion (Magnavita 2000). As such, PDs are
couples) and the need for a multimodal expressed relationally in various inter-
approach when treating patients with personal configurations, evident in mar-
PD. As Magnavita (1998) noted, “The dy- riages and romantic partnerships, fami-
namic interplay between our biological lies, and other groups that are part of an
and intrapersonal organization interacts individual’s social system (Magnavita
with the social systems and not only 2000). Treating PD as if it exists only in
adds to the shaping of our personality, the individual’s thoughts, actions, or
but also is crucial in the pathogenesis or brain chemicals ignores important as-
maintenance of self-defeating patterns pects of human functioning. The inter-
of behavior” (p. 8). Interpersonal dynam- personal context of PD deserves careful
ics help organize, shape, and consolidate attention.
individuals’ self-perceptions and self- This chapter focuses on multi-person
concepts, and can be observed in the dy- therapies (group, family, couples) for PDs.
namics within family systems and other These therapies may take many different
social groups. PDs and the clinical syn- forms based on their theoretical and
dromes that they engender are not con- technical orientations. Because of the
tained solely within the individual but presence of multiple patients, multi-per-
281
son therapies have certain unique fea- as interpersonal learning. Other patients
tures that distinguish them from other may learn through observation and imi-
types of therapy. These unique features tation. Simply recognizing that other pa-
may facilitate or complicate the treat- tients share one’s difficulties (universal-
ment of PDs. Similarly, PDs have certain ity) and helping other patients with their
features that may facilitate or complicate problems (altruism) can be therapeutic.
their treatment with different types of A sense of “we-ness” or togetherness de-
multi-person therapies. velops, providing patients with a feeling
Considering each of these multi-person of belonging and cohesion with a caring
therapies (group, family, couples) sepa- group of others. These various processes
rately, we discuss the facilitating and (cohesion, interpersonal learning, imita-
complicating features of these therapies tion, universality, and altruism) are re-
and PDs. For each of the three categories garded as powerful unique therapeutic
of multi-person therapies, we also review factors of group treatment (Yalom and
various forms, which differ in format, in- Leszcz 2005).
tensity, and objectives; discuss research Group treatments have other facilita-
support; and present case examples. tive features as well. Paralyzing nega-
Given its brevity, this chapter should be tive transference toward the therapist is
considered only as an abridged intro- less likely to occur in group therapy than
duction to the use of group, family, and in individual therapy because the situa-
couples therapies for PD. tion is less intimate and because strong
affects such as rage are diluted and ex-
pressed toward multiple targets. Simi-
Group Therapy larly, feedback from the therapist in the
individual therapy situation may be dis-
Features of Group Therapy missed by the patient as biased, but this
reaction is much less likely to occur in
That Facilitate Treatment response to feedback from several peers
of PDs in a therapy group. In addition, because
of the variety of affects expressed by dif-
Group therapy can be used effectively ferent patients, integration of positive
for treating most PDs, especially when and negative affects is facilitated.
the patient is unaware of his or her mal-
adaptive behavior and the presenting
problems have a clearly interpersonal Features of Group Therapy
context. In group therapy, character pat- That Complicate Treatment
terns unfold in the myriad interactions
with other group members. The inten-
of PDs
sive verbal and nonverbal interchanges Group features may also produce compli-
within the group quickly unmask a pa- cations in treatment of PDs. Some patients
tient’s repetitive maladaptive personal- with PD resent sharing the therapist and
ity traits. The other patients may recog- feel neglected and deprived. In the group
nize and identify with similar behavior situation, regressive behaviors, such as
patterns, provide feedback, and offer emotional outbursts, aggressive actions,
suggestions for change. The patient can or suicidal threats, are more difficult to
subsequently practice adaptive behav- manage and contain than in individual
ior. This process is commonly referred to therapy. Groups are prone to scapegoat-
Group, Family, and Couples Therapies 283
ing; patients with PD provide many prov- the group. Examples of anti-therapeutic
ocations. There are a number of concerns behaviors include stoic silence or, con-
in the group situation, relative to individ- versely, excessive disclosure; scapegoat-
ual therapy, that many patients with PD ing; extragroup socializing; disregard for
find troublesome, including loss of con- boundaries; and absenteeism.
trol, individuality, understanding, pri- When a patient’s anti-therapeutic be-
vacy, and safety. The therapist is subject to haviors persist in the group, the behav-
such concerns as well. iors may be conceptualized as roles. The
persons occupying the roles are com-
Features of PDs That monly labeled as “difficult” patients in
the group therapy literature (Bernard
Facilitate Group Therapy 1994). These difficult patients are often
The predominant feature of patients those with PD. Examples of difficult
with PD that facilitates group treatment roles and the DSM-5 PDs (American
is their strong tendency to openly dem- Psychiatric Association 2013) often asso-
onstrate interpersonal psychopathology ciated with them are the silent or with-
through behavior in the group. Com- drawn role (schizoid, schizotypal, para-
pared with patients without personality noid, avoidant); the monopolizing role
disorders, patients with PDs are more (histrionic, borderline, narcissistic); the
likely to demonstrate rather than de- boring role (narcissistic, obsessive-com-
scribe their interpersonal problems. Al- pulsive); the therapist’s helper role (his-
though these problems are also demon- trionic, dependent); the challenger role
strated in individual therapy, the stimuli (antisocial, borderline, obsessive-com-
from multiple patients precipitate path- pulsive); and the help-rejecting com-
ological interpersonal behavior more in- plainer role (borderline, narcissistic,
tensely and quickly in group therapy. histrionic). Although these roles are oc-
This behavior can be clearly recognized cupied by individual persons, they often
and dealt with immediately in the group. represent something shared by others in
A second facilitative feature of patients the group. The person occupying the
with some PDs (e.g., dependent, histri- role unwittingly serves a defensive func-
onic, borderline) is that they are “other tion for the entire group, with the other
seeking.” They tend to value the connec- members disavowing ownership of un-
tions in the group. comfortable thoughts and feelings and
projecting them onto particular mem-
bers. In this way, the behavior of those
Features of PDs That fulfilling certain roles represents a wish
Complicate Group or conflict that is shared by all members
of the group. These roles can interfere
Therapy with the work of the group by prevent-
Many of the behaviors that are character- ing the occupier of the role and the other
istic of patients with PD can complicate group members who project onto that
group treatment. These behaviors can be role from experiencing certain aspects of
offensive to other members of the group, themselves. Therefore, when addressing
thereby weakening cohesion and dis- “difficult” behavior represented by a par-
tracting members from working. Usually, ticular patient role, the therapist must
such patients challenge the guidelines discern what aspect of the behavior is
and norms that have been established in serving a defensive function for the group
and what is an authentic reflection of the patient’s core conflicts, defensive style,
person’s particular personality pathol- and long-term maladaptive behaviors. It
ogy. This task can be very difficult con- attempts to modify the core traits and
sidering the complex and volatile na- personality structure that characterize
ture of some PDs, such as borderline PD PDs. Long-term outpatient group ther-
(Tuttman 1990). For that reason, a com- apy is regarded as an appropriate and ef-
bination of group therapy and individ- fective group treatment for PDs, espe-
ual therapy is often recommended. cially when used in combination with
long-term individual psychotherapy. The
Different Forms of latter allows stabilization of the patient
and an opportunity to disclose private
Group Therapy and sensitive information that would be
Group therapies differ in structure (for- difficult to reveal in the group setting
mat), intensity, and objectives. Four initially, although over time such revela-
forms can be distinguished: short-term tion in the group becomes possible. This
outpatient group therapy, long-term out- group approach assumes that over time
patient group therapy, day treatment, the group comes to represent a social mi-
and inpatient or residential treatment. crocosm in which the interpersonal diffi-
Short-term outpatient group therapy of- culties of the patients become vividly il-
ten involves a single session per week lustrated by the interpersonal behavior of
for 20 or fewer weeks. Certain focal symp- the patients in the group. Examples of
toms (e.g., depression) or behaviors (e.g., long-term group psychotherapy used
affect expression, social skills) are tar- with patients who have PDs are those of
geted for change. These groups usually Rutan and Stone (2001) and Lorentzen et
are not intensive in nature; they do not al. (2002).
attempt to change the basic personality Day treatment is a form of partial hospi-
traits and personality structure that char- talization. It is designed for patients who
acterize PDs. An example of this type of do not require full-time hospitalization
group therapy is Systems Training for and who are unlikely to benefit a great
Emotional Predictability and Problem deal from outpatient group therapy. Day
Solving (STEPPS), which was designed treatment patients have often had an un-
as an adjunctive treatment program for successful course of outpatient group
patients with borderline PD (Blum et al. therapy. Patients typically participate
2008). Participants attend 2-hour weekly in a variety of therapy groups for several
group seminars organized around learn- hours each day for 3–5 days per week. The
ing specific emotional, cognitive, and be- therapy groups are often approached
havioral self-management skills. STEPPS from different technical orientations. For
also involves a psychoeducation group example, behavioral and cognitive inter-
for key members of the patients’ support ventions can be used in structured, skills-
networks. oriented groups, whereas dynamic inter-
Long-term outpatient group therapy conventions can be used in unstructured, in-
sists of one or two sessions per week for sight-oriented groups. Family and cou-
at least 1–2 years. It focuses on the inter- ples interventions may also be employed.
personal world of the patient. It is in- Day treatment is an intensive form of
tensive in nature and, over time, involves therapy. Its goals include relief of symp-
confrontation and interpretation of the toms, reduction of problematic behav-
iors, modification of maladaptive charac- ing the acute crisis are viewed as the
ter traits, and facilitation of psychological dominant interventions. An example of
maturation. group-based inpatient treatment is de-
Several other features contribute to scribed by Chiesa et al. (2003).
making day treatment a powerful inter- In North America, the lengths of stay
vention. The first is the intensity of the in acute hospital settings have been de-
group experience: patients participate in a creasing significantly in response to esca-
number of different groups each day. Sec- lating costs. Today, length of stay in such
ond, the groups vary in size, structure, ob- settings has come to mean short-term cri-
jectives, and processes. This variety pro- sis management. Similarly, the cost of
vides a comprehensive approach. Third, long-term care (i.e., lasting from several
the different groups are integrated and months to a year) in retreat settings that
synergistic. Patients are encouraged to in the past provided powerful milieu
think about the entire system. Fourth, pa- therapies has become prohibitive, with
tients benefit from working with multiple many centers having closed down or
staff members and a large number of other greatly scaled back in size. Other centers
patients. Fifth, day treatment capitalizes have made accommodations to the chang-
on the traditional characteristics of a ther- ing health care environment but have
apeutic community (democratization, preserved intensive hospital interdisci-
permissiveness, communalism, reality plinary treatment, carried out for an av-
confrontation). These features strengthen erage length of stay of about 6 weeks
cohesion, which helps patients endure (e.g., the Menninger Clinic). Conversely,
difficult periods of treatment. The struc- in many European countries, most nota-
ture of day treatment programs encour- bly Germany, group-based, psychothera-
ages patients to be responsible, engenders peutically oriented, long-term inpatient
mutual respect between patients and staff, treatment is common and supported by
and facilitates patients’ participation in the national health care system.
the treatment of their peers. Well-known
approaches to day treatment programs Research Support for
are mentalization-based therapy, de-
scribed by Bateman and Fonagy (1999), Group Therapy for PDs
and time-limited day treatment, described Group therapy is usually regarded as an
by Piper et al. (1996). adjunct to individual therapy for patients
As in day treatment, hospital inpatient with PDs or as a component to a compre-
wards and residential treatment centers com- hensive, multimodal treatment program.
monly provide a variety of group treat- Therefore, few studies have examined
ment activities. Inpatient or residential the effectiveness of group therapy as a
treatment groups include admission stand-alone intervention for PDs. One ex-
groups, community groups, patient gov- ample of such a study is that of Cappe
ernance groups, insight groups, occupa- and Alden (1986), who compared brief
tional therapy groups, support groups, behavioral group therapy (eight weekly
and discharge groups. Although group 2-hour sessions) with a wait-list control
sessions are a highly visible set of activi- condition for 52 patients with avoidant
ties in acute treatment settings, they tend PD. The patients who were treated with a
to be regarded as a minor part of the treat- combination of graduated exposure train-
ment regimen. Instead, psychotropic ing and interpersonal process training
medications and problem solving regard- showed significantly more improvement
than patients who received only gradu- of DBT; the effectiveness of any one sin-
ated exposure and patients on the wait gular component of DBT is unclear. Fur-
list. In a similar trial, Alden (1989) com- thermore, DBT has not been established
pared three variations of brief behavioral as superior to other structured treat-
group therapy (10 weekly 2.5-hour ses- ments for borderline PD.
sions) with a wait-list control condition STEPPS was developed to supplement
for a sample of 76 patients with avoidant ongoing care for borderline PD with a 20-
PD. All three treatment conditions dem- week course of cognitive-behavioral ther-
onstrated greater improvement than the apy and psychoeducation (Blum et al.
wait-list control condition. However, the 2008). STEPPS involves psychoeducation
author noted that despite significant im- for the patient’s family members and
provements, the patients did not achieve other health care providers, so that the
normal functioning. Similarly, Marziali patient’s support network can remain
and Munroe-Blum (1994) compared time- appropriately engaged and responsive.
limited interpersonal group therapy, Patients also attend 2-hour seminars each
which consisted of weekly 90-minute ses- week regarding cognitive-behavioral
sions for 25 weeks and sessions every therapy and self-management skills.
other week for the next 10 weeks (30 ses- STEPPS is intended as an adjunct to the
sions in total), with open-ended weekly patient’s regular treatment. Patients with
individual therapy in a sample of 79 pa- borderline PD (N=124) were randomly
tients with borderline PD. All patients assigned to receive STEPPS+TAU or sim-
demonstrated significant improvement ply TAU alone. The treatment groups
on outcome measures, with no differ- demonstrated no significant differences
ence between the two treatment condi- in overall crisis-service utilization, sui-
tions. However, both conditions had high cide attempts, and self-harm; however,
dropout rates. patients who received STEPPS + TAU
More common are studies of treat- showed greater improvement in depres-
ment packages that include group ther- sion, negative affects and disturbed cog-
apy as one component. The most notable nitions, impulsivity, and global and in-
of such treatments is dialectical behavior terpersonal functioning (Blum et al.
therapy (DBT; Linehan 1993), which is a 2008). The benefit of adding STEPPS to
multimodal cognitive-behavioral treat- standard care is thus encouraging, given
ment for borderline PD. DBT uses a its relatively brief duration and its effect
skills-training group (2.5 hours per week on affective symptoms, an area in which
for the usual 1 year of treatment) that DBT has been less successful.
complements twice-weekly individual Bateman and Fonagy (1999) developed
therapy and telephone coaching to ad- mentalization-based therapy as a psycho-
dress emotion regulation, distress toler- analytically oriented day treatment pro-
ance, and interpersonal behavior. DBT gram that consists of a combination of
remains the most researched structured group and individual therapies for 5 days
treatment for borderline PD. Several reper week for a maximum of 18 months. In
search studies support DBT as being su- a randomized controlled trial, they com-
perior to treatment as usual (TAU) in the pared this program with a standard-care
reduction of suicidal and self-injurious control condition, which consisted of in-
behaviors (Chapman 2006). It is impor- frequent meetings with a psychiatrist but
tant to note that these studies have ex- no formal therapy, for a sample of 44 pa-
amined a complete multimodal delivery tients with borderline PD. Day treatment
patients showed significant improve- uralistic studies focused on group treat-

ments that exceeded minimal change for ments from a psychodynamic or cogni-
standard care on a variety of outcome tive-behavioral orientation. A meta-
variables, including suicide attempts and analytic review that focused on both
acts of self-mutilation and self-reports of group and individual treatments of PDs
depression, anxiety, general symptoms, from psychodynamic and cognitive-be-
interpersonal functioning, and social ad- havioral orientations concluded that both
justment. Subsequent to discharge from orientations were effective treatments
day treatment, patients were provided (Leichsenring and Leibing 2003).
with 18 months of psychoanalytically ori-
ented outpatient group therapy. Five
Case Example 1
years following the completion of the out-
patient group therapy, patients who re- Debra, a 40-year-old associate profes-
ceived day treatment and outpatient sor at a prominent university, was di-
agnosed with narcissistic PD. While
group therapy continued to have supe-
Debra was receiving long-term indi-
rior performance on a number of outcome vidual psychodynamic therapy, her
indicators, including suicidality, diagnos- therapist referred her to a long-term
tic status, service use, use of medication, psychodynamic group, because her
Global Assessment of Functioning scores therapist felt that a group experience
above 60, and vocational status. The long could help with her entrenched inter-
personal problems. Debra had sought
time frame for the follow-up period in this
psychological help for feelings of ex-
study is unparalleled in contemporary treme loneliness, something she has
psychotherapy research, and the impres- felt for as long as she can remember,
sive findings regarding the maintenance and for multiple physical complaints.
of gains (and continued improvement, in Debra seemed unable or unwilling to
recognize or accept her own contribu-
many ways) demonstrated by treated pa-
tions to her problems, and instead
tients provide compelling evidence for would blame others and show con-
the lasting effects of mentalization-based tempt and envy toward them. She re-
therapy for borderline PD (Bateman and garded her peers to be immature and
Fonagy 2008). inferior to her, but deep down inside,
Findings from a number of carefully she felt the opposite.
Even though the group therapist
conducted naturalistic outcome studies
managed to facilitate affective in-
that focused on the group treatment of volvement of the group members and
PDs also have been published. These in- a strong sense of cohesion within the
vestigations, which tend to be pre-post, group, Debra remained aloof for a
single-condition studies or studies with long time and missed a lot of sessions.
She developed an erotic transference
nonrandom assignment to conditions, in-
toward the group therapist—an older
volved outpatient group therapy (Bud- man who was a well-known figure in
man et al. 1996), day treatment (Wilberg the medical community—but felt de-
et al. 1998), and residential treatment spised by him, as well as by the other
(Chiesa et al. 2003). In general, the find- group members. She was not ready to
ings from these naturalistic studies were participate in the group work, which
would mean disclosing emotionally
consistent with those of randomized clin-
charged experiences and exposing her
ical trials in providing evidence of favor- vulnerability. To her, revealing inti-
able outcomes for patients with PDs, in mate details about herself to others
particular those with borderline PD. Most was too threatening and would lead
of the randomized clinical trials and nat- to being humiliated and hurt. This
was interpreted many times by the shared genetic, personality, environmen-

group therapist, but to no avail. tal, and biological vulnerabilities with
During one session, Debra care-
the client; their actions have the ability
lessly made a condescending remark
about the other group members. In to intensify the symptomatology of the
line with the work ethic of the group patient; and they are at risk of develop-
to be relational and respectful, one ing their own symptoms (e.g., White et
member asked Debra if she realized al. 2003). Family therapy can help family
the meaning and impact of what she members cope and manage in the face of
had just said. Debra was taken off
PD symptoms and promote relationship
guard at being confronted with her
contempt for others. She apologized stability that is likely to be helpful for all
and admitted tearfully how hard it members of the system. Other forms of
was for her to deal with feeling mis- therapy do not provide such direct help
erable and inferior to others. The to family members.
group’s empathic response to her dis-
An important component of family
play of vulnerability shocked her,
and this intense emotional experience therapy is the assumption that families
seemed influential in shaping her sub- are systems in which individuals recip-
sequent attitudes toward the group rocally influence one another (Lebow
and its members. Debra began to re- 2005). Recent advances in theory and re-
spond more respectfully to the other search stress that the arcs of causal influ-
group members’ emotional experi-
ence are not entirely equal in the circular
ences. She started to attend the group
regularly and slowly ventured into ex- pathways they follow, and this leads to
pressing and sharing her problems. and maintains ongoing difficulties. In
modern systems theory, there is a place
for acknowledging the power of indi-
Family Therapy vidual behavior and individual psycho-
pathology. From this viewpoint, family
systems that include an individual with
Features of Family Therapy a PD tend to be dominated by that indi-
That Facilitate Treatment vidual’s problematic behavior in the fam-
ily context; yet reciprocal patterns read-
of PDs ily become established. For example,
The unique features of family therapy frequent rage episodes by someone with
make it especially suited for the treat- borderline PD might cause family mem-
ment of patients with PDs. According to bers to walk on eggshells and give in to
DSM-5, a primary criterion for the diag- demands, thus reinforcing the displays
nosis of a PD is the existence of consider- of emotion dysregulation. Family ther-
able interpersonal dysfunction. Because apy is uniquely able to target this pat-
significant interpersonal problems are tern by focusing not only on emotion
found across PDs, treatments that target regulation strategies for the person with
the entire family system may be neces- the PD but also on behavioral reinforce-
sary to achieve a full amelioration of PD ment and punishment strategies for the
symptoms. First, research shows that in- family members.
dividual treatment rarely has a positive Finally, the stable holding environment
impact on unsatisfying family relation- provided by family members can miti-
ships (Gurman and Fraenkel 2002). Sec- gate some PD symptoms. Certain PDs
ond, first-degree relatives of individuals are associated with high interpersonal
with a PD are a high-risk group: they have sensitivity (e.g., borderline PD, avoidant
PD). The family system can be a validat- Second, families often seek treatment
ing environment that reduces pain and when the person with a PD does not want
distress. Family therapy can instruct treatment (Friedlander et al. 2006). In this
family members in optimal ways of sup- situation, family therapy may be over-
port and validation. The success of the whelmed by the person’s resistance and
family unit as a place of safety and sup- uncontrolled emotionality. When this is
port often ameliorates the impact of PDs, the case, considerable work must be done
whereas difficulty in relational systems with the person with the PD to enlist his
promotes greater symptoms and prob- or her cooperation and involvement. If
lems. A mindful, supportive holding en- the person refuses to participate or if
vironment may be an essential ingredi- meetings in the context of family become
ent to treatment success (Critchfield and the source of frequent dysregulation, a
Benjamin 2006). therapist might recommend individual
therapy for the patient and a psychoedu-
cation group for the family.
Features of Family Therapy Third, alliances in family therapy in-
That Complicate Treatment volving someone with a PD are likely to
of PDs be complex; that is, different family mem-
bers are likely to have different degrees
Although family therapy may be an ap- of alliance with the therapist. This may
propriate setting to target the interper- cause split alliances whereby some fam-
sonal dysfunction found in individuals ily members have a strong alliance and
with PDs, there are features of family some have a poor one. A split alliance has
therapy that may introduce problems been related to poor outcome (Friedlander
when treating someone with a PD. First, et al. 2006); therefore, the therapist
family therapy may be contraindicated should target the strength of the alliance
for certain patients. Such patients might early in treatment, with an eye toward
include individuals who are unable to maintaining a positive alliance with all
speak in the presence of family members family members.
because of fear or anxiety. For example, Fourth, the nature of PDs makes them
a person with avoidant PD may feel over- too pervasive a problem to be treated with
whelming embarrassment and have fears a single treatment modality. Although
of criticism when discussing personal is- this chapter highlights the importance of
sues in front of family members, as de- interventions outside of individual psy-
scribed in the diagnostic criteria for the chotherapy, we consider a successful treat-
disorder. In other cases, family members ment plan to be one that combines family
may be too afraid to participate in family therapy with individual treatment. Re-
therapy. Family members of someone search has shown that for people with
with antisocial PD may fear retribution complex PD problems, treatments com-
if they are open about feelings and be- bining such diverse modalities as individ-
haviors in the home. Some people with a ual, family, couples, and group therapy
PD cannot manage the complex feelings are the most efficacious (e.g., Fruzzetti
that evolve in family settings, especially et al. 2007; Miller et al. 2007). Individual
early in treatment. Therapists must al- work promotes change in behavior, cog-
ways formulate and have at ready an ac- nitions, and affect that may be largely in-
tion plan for when sessions lose any con- accessible in family therapy. Without see-
structive value. ing immediate positive changes, families
may lose their motivation to provide the tion within the family system and actu-
support and nurturance that are essential ally interpret it as a sign of care and nur-
to family therapy. turance. This hypothesis is based on data
that show that persons with borderline
Features of PDs That PD, when compared with control partic-
ipants, exhibit less physiological arousal
Facilitate Family Therapy in response to emotional stimuli (e.g.,
The primary feature of PDs that is con- Herpertz et al. 1999). Thus, those with
ducive to family therapy is the fact that borderline PD may be able to tolerate the
individuals with PDs have significant stress of family therapy because it in-
interpersonal problems within the fam- volves emotional expression by loved
ily and need help rectifying these issues. ones.
Furthermore, frequently both the indi-
vidual and his or her family are desper- Features of PDs That
ate for better family connection. Thus, it
is often the case that those with PDs and
Complicate Family Therapy
their families arrive in treatment highly Although the interpersonal problems
motivated to work on familial issues. evident in most people with PDs serve
They may be distressed because they de- as prime treatment targets in family ther-
sire closer and more stable relationships, apy, some features of PDs may compli-
or they may be motivated by necessity cate the delicate structure found in family
because of cohabitation or financial sup- therapies. First, engagement is typically
port provided by family members. difficult with patients with PDs, and this
Certain family patterns that are par- may be part of the reason that empiri-
ticularly well treated by family therapy cally supported treatments for depres-
may be evident in PDs. One example of sion and anxiety tend to be less effica-
such a pattern involves expressed emo- cious with individuals with comorbid
tion—that is, the extent to which a fam- PDs (Shea and Elkin 1996). Because fam-
ily member expresses critical, hostile, or ily therapy may be complex—coordinat-
emotionally overinvolved attitudes and ing schedules, turn-taking, and compro-
behavior toward the family member mising on agenda items—it may be
with the disorder (Vaughn and Leff 1976). difficult to engage those with PDs in treat-
Expressed emotion is a strong predictor ment. In addition, it may be that other
of poor outcome in a range of disorders. family members display symptoms of
However, expressed emotion displays a PDs, thus compounding the difficulty in
unique pattern in borderline PD. Emo- organizing and engaging a family ther-
tional overinvolvement actually predicts apy session.
positive outcomes, whereas the other Second, patients with PD and their
aspects of expressed emotion (i.e., criti- families tend to have a high rate of ther-
cism, hostility) are unrelated to outcome apy dropout (Strauss et al. 2006). Studies
(Hooley and Hoffman 1999). Hooley and have found that early treatment dropout
Gotlib (2000) hypothesize that persons rates for individual treatment of PDs are
with borderline PD are seemingly un- as high as 38%–57%, with the average
affected by high levels of hostility and rate estimated to be between 15% and
criticism and respond well to emotional 22% (Leichsenring and Leibing 2003).
overinvolvement because they have a Research has found similar rates of drop-
higher tolerance for affective stimula- out for family therapy, with rates be-
tween 15% and 55% (Boddington 1995). ous strategies must be planned carefully
The combination of the presence of a PD by the therapist, who must anticipate
and the complexities of family therapy strong reactions and retain the patient’s
make it likely that a family therapy inter- experience in special focus.
vention for PDs would result in a large
loss of patients early in treatment.
Third, when working with patients
Forms of Family Therapy
who can be frustrating or challenging, a In this subsection, we review three pri-
therapist can easily fall into the trap of mary types of family therapy: psychoed-
blaming the patient or of assuming that ucation, cognitive-behavioral therapy,
the intended effect of the patient’s behav- and systemic therapy. Our descriptions
ior is to aggravate the therapist (e.g., San- illustrate common ways that families are
tisteban et al. 2003). In these cases, a ther- integrated and treated in a psychother-
apist may become hopeless, disengaged, apy setting; however, other therapeutic
or hostile. These thoughts and emotions orientations, including psychodynamic
may have a negative direct effect on the and experiential, often integrate the fam-
therapy in terms of the therapist’s siding ily into current practice.
with other family members or avoiding Psychoeducational approaches to family
serious topics. Although these issues therapy involve educating the family on
have been discussed almost exclusively the etiology, course, presentation, and
in terms of borderline PD, they likely ex- prognosis of the disorder of focus. This
tend to all or most of the other PDs. Just education may include common behav-
as a patient with borderline PD might tax ioral patterns within the family, as well as
the therapist with demands of immediate information about medication and treat-
relief and late-night phone calls, a patient ment, ways for the family to cope with
with avoidant PD might refuse to speak stress, and ways to interact with the pa-
honestly because of fears of being judged. tient to best alleviate symptoms. These
A therapist must be aware of the urge to approaches are based on the assumption
identify the person with a PD as the sole that certain mental disorders seriously
source of the problems within the family impair day-to-day living and education
or to always believe the interpretation of of the family can reduce bias, stigma, and
the family members. It is important for the family-induced exacerbation of symp-
therapist to be open and compassionate toms. Psychoeducation is most commonly
to all participating members. delivered in a group format without in-
Finally, there is some evidence that including the person with the mental dis-
dividuals with certain PDs, particularly order. This format allows family members
borderline PD, have experienced neglect to gain support from others in similar
and/or abuse within the family context situations. Treatments that include psy-
(e.g., Bornovalova et al. 2013). They may choeducation of the family have been
have experienced childhood neglect or highly effective for individuals with se-
physical and sexual abuse. In these cases, vere mental illnesses, such as bipolar dis-
it may be inappropriate to include abu- order and schizophrenia.
sive family members in treatment. Cognitive-behavioral approaches to fam-
For all these reasons, family therapy ily therapy begin with the assumption
(and couples therapy) necessarily pro- that the most efficacious pathways to
ceeds more slowly and carefully in the change involve targeting dysfunctional
presence of PD. When to introduce vari- thoughts and maladaptive behavioral
patterns. One essential building block of PD (Fruzetti et al. 2007; Santisteban et al.
cognitive-behavioral family therapy is 2003) but little research regarding other
the introduction of skills training. Tech- PDs. Therefore, we focus on the research
niques such as communication training relevant to borderline PD.
and negotiating strategies are explained Psychoeducational approaches to the
and practiced during therapy sessions treatment of borderline PD have received
through role-play and practiced at home some research support. One study found
through the implementation of home- that family members of individuals with
work. Social learning theory is a second borderline PD knew very little about the
essential building block for this approach, disorder; however, those who reported
with social reinforcers assuming the great- having more information demonstrated
est importance within the family. In this heightened levels of criticism, hostility,
context, modeling becomes an important and depression, as well as less warmth
source of change. The family learns inter- (Hoffman et al. 2003). In contrast, numer-
personal skills by observing the therapist ous studies have demonstrated the pos-
enact them within the familial context. itive use of psychoeducation in other
For example, a patient might learn how disorders, ranging from depression to
to be assertive with his mother by observ- schizophrenia. These results point to the
ing the therapist being assertive with the care needed in determining the content of
mother and then observing her positive the psychoeducation and the process for
reaction. In addition, parents learn the providing it. Hoffman and colleagues
importance of modeling adaptive behav- (2003) concluded that much of the family
iors for their children. members’ information was likely inaccu-
Although all family therapies include rate and had been presented in a pessimis-
attention to recursive patterns in families, tic style (possibly on the Internet). A small
systemic therapies maintain as their central amount of unedited knowledge can lead
focus attention to altering such patterns to pejorative use of labels and a profound
(Lebow 2005). The emphasis is on finding sense of pessimism and hopelessness.
a place to interrupt dysfunctional se- To respond to this perceived need for
quences. Closely related, systemic thera- formalized psychoeducation for families
pies look to change dysfunctional aspects of individuals with borderline PD, Hoff-
of family structure, such as disengage- man et al. (2005) developed Family Con-
ment or enmeshment. Efforts are also nections, a 12-week, multifamily, manu-
made to understand what function the alized psychoeducation program. This
dysfunctional behavior may serve for the program covers current information and
system and to find a more helpful way of research on borderline PD, its develop-
accomplishing this function. mental course, available treatments, co-
morbidity, individual skills to promote
Research Support for patient well-being, family skills to im-
prove familial interactions, instruction
Family Therapy for PDs in validation, and problem-solving tech-
A sizable empirical literature exists on in- niques. Families participating in the
terpersonal difficulties and PDs, yet few Family Connections program decreased
studies have targeted these difficulties by their level of burden and grief while in-
examining family therapy interventions. creasing their level of mastery through-
There is a small literature on family inter- out the program and at 3-month follow-
ventions for individuals with borderline up (Hoffman et al. 2005).
DBT is an efficacious treatment of bor- more primary emotions and practice

derline PD (Linehan 1993). Although DBT bringing attention to everyday interac-
is traditionally delivered in an individual tions. These so-called relationship mind-
plus skills group format, an adaptation of fulness skills have the potential to re-
this therapy for suicidal adolescents induce the negative reactivity of a person
cludes a family therapy component (Miller with borderline PD to other members of
et al. 2007). Both the adolescents and their the family system, thereby reducing con-
parents attend a weekly 2-hour multifam- flicts between family members. Mindful-
ily skills group. This group is modeled on ness exercises have the added value of
traditional DBT skills training (e.g., mind- an established track record of impact on
fulness, interpersonal effectiveness, emo- different types of PDs and could be im-
tion regulation, distress tolerance) but has plemented in family therapy with other
an added component involving behavior- PDs (Robins et al. 2004).
ism, validation, and dialectics. This group
approach has been shown to be an effec- Case Example 2
tive addition to individual family therapy.
Mary, age 28 years and living with
Other researchers have explored an adher parents, had problems in person-
aptation of DBT focused on the family ality functioning that fully met the
(Fruzzetti and Iverson 2004; Fruzzetti et criteria for borderline PD. In conjunc-
al. 2007; Santisteban et al. 2003). In this tion with individual and group DBT,
Mary and her family participated in 6
adaptation, the family members learn
months of weekly family therapy.
how to understand the other person, The first set of sessions focused on
communicate that understanding genu- helping the family understand bor-
inely, and reinforce the accurate expres- derline PD, which fit well with Mary’s
sion of emotions. The emphasis on creat- growing understanding in her indi-
ing a validating environment for a person vidual therapy. Her family learned
how to take a nonjudgmental stance
with borderline PD stems from a basic te-
in approaching Mary’s symptoms and
net of the biosocial model (Linehan 1993): reduce using labels such as “manipu-
that an important cause of borderline PD lative” and “crazy.” These modifica-
is an inherent difficulty with emotion reg- tions helped Mary feel more sup-
ulation, interacting with an invalidating ported and better able to ask for help
instead of using extreme displays of
childhood environment. In an invalidat-
aggression or despair. Early in ther-
ing environment, a person learns that apy the family and Mary also formed
only extreme emotional displays (often in agreements for how crises and mo-
the form of self-harm) succeed in garner- ments of dysregulation would be
ing help (Linehan 1993). Emotion dysreg- handled. These included Mary’s use
ulation is reinforced, and adaptive cop- of distress tolerance skills. When Mary
needed to take a break, complete a
ing mechanisms are not formed. The
self-soothing task, or engage in a dis-
process of validation within the family traction activity, her family gave her
therapy context allows the person with space and did not accuse her of being
borderline PD to trust his or her emotions dramatic or high maintenance. In
and use more adaptive coping skills when addition, family members were able
to use mindfulness to notice times
feeling dysregulated.
when they were beginning to feel
Mindfulness also is emphasized in dysregulated and use some of the
family DBT (Fruzzetti et al. 2007). A per- same skills that Mary was practicing.
son is encouraged to transfer anger into These changes fostered a mutually
supportive environment and a reduc- with PDs have considerable interper-

tion in Mary’s sick role within the fam- sonal dysfunction. Individual therapy
ily. Building on this success, the fam-
alone may not always have a positive ef-
ily sessions then moved to examining
the family experience more broadly, fect on relationship satisfaction, even
including both how the family could though relationship satisfaction has a di-
be helpful in relation to Mary’s treat- rect relationship with overall functioning
ment plan and how experiences in the and symptom severity. Couples therapy
family related to Mary’s dysregulation. is uniquely able to target problematic
Specifically, Mary and her mother
systemic patterns within a romantic rela-
spent considerable time processing
their difficult relationship during tionship and aid both parties in making
Mary’s childhood. The combined ther- changes that affect PD symptoms. The
apy ultimately helped Mary to be- success of the couple unit as a place of
come better regulated and Mary and safety and support often ameliorates the
her family to be better able to relate
impact of PD, whereas difficulty in rela-
with one another without the bidirec-
tional conflicts that typified earlier tional systems promotes greater symp-
times. toms and problems.
Moreover, research demonstrates the
beneficial effect of positive romantic rela-
Couples Therapy tionships for PD clients. Lewis (1998) re-
viewed a series of studies that examined
In this section, we outline the intersec- the role of marriage in the adult conse-
tion of couples therapy and the treat- quences of childhood trauma. He found
ment of PDs. Many of the guiding prin- that a good marriage can have a healing
ciples, theories, and techniques used in effect on borderline PD characteristics in
couples therapy are identical to those adulthood. In a longitudinal follow-up
used in family therapy; this is because study of inpatients with borderline PD,
couples therapy, particularly in the con- marriage predicted better clinical out-
text of disorder-related treatments, is a come and improved functional status; be-
subset of family therapy, drawing from ing in a stable marital relationship ap-
the same pool of interventions. In seek- peared to dampen levels of impulsivity
ing a reduction of redundancy between (Links and Heslegrave 2000).
this section and the previous section on An additional benefit of couples ther-
family therapy, we highlight only the apy is that many topics related to indi-
unique aspects that make couples ther- vidual functioning may come into focus
apy relevant to the treatment of PDs. only when raised by the partner. These
topics may include certain ego-syntonic
behaviors whose maladaptiveness the
Features of Couples individual, lacking insight, does not re-
Therapy That Facilitate alize. Examples may include medication
compliance, frequent paranoid cogni-
Treatment of PDs tions, or an increase in parasuicidal be-
The format of couples therapy uniquely havior. Furthermore, because living with
deals with the creation of an environ- an individual with a PD can be just as
ment that is conducive to improving cou- difficult as having a PD oneself, the part-
ple functioning and maintaining a sooth- ner is often further along in the stages of
ing home environment. As outlined in change than is the person with PD. A
the family therapy section, individuals feeling of safety in being with one’s part-
ner can spur the exploration of these is- vere PDs, the presence of a partner in
sues in patients who have great difficulty therapy sessions may at times be dysreg-
with such exploration in individual ulating and intolerable. Special plans for
therapy. handling such circumstances are always
indicated.
Features of Couples
Features of PDs That
Therapy That Complicate
Facilitate Couples Therapy
Treatment of PDs
The vast interpersonal problems evident
In the earlier section on family therapy, in individuals with PDs make these dis-
we outlined four primary features of orders particularly appropriate for a
family therapy that could complicate couples therapy intervention. For exam-
treatment of PDs: contraindication for ple, there is an increasing amount of re-
certain patients, resistance, complex alli- search demonstrating the relationship
ances, and the necessity of individual between borderline PD and insecure at-
work in addition to family work. All tachment styles in adulthood (Agrawal
four reasons apply equally in couples et al. 2004). In a meta-analysis of 13 stud-
therapy. A person with PD may be expe- ies, borderline PD demonstrated a con-
riencing serious issues regarding a part- sistent inverse relationship with secure
ner—urge to cheat, thoughts of divorce, attachment styles; this was best charac-
or the presence of domestic violence. In terized as fearfulness in romantic rela-
these cases, individual therapy to work tionships. A second study examined the
through some of these issues may need relationship between 10 PDs and attach-
to be done before couples therapy can ment styles (Brennan and Shaver 1998).
commence. Again, complex alliances re- This study found that most PD symp-
sulting in jealousy or resentment on the toms corresponded to insecure and de-
part of one member of the couple could fensive attachment styles. Because of
compromise both the therapeutic and these difficulties, persons with PDs may
partners’ relationships. be specifically motivated to engage in
A special factor to consider in couples couples therapy.
therapy is that persons with mental dis- In addition to problematic attach-
orders often marry other individuals ment styles, individuals with PDs have
with mental disorders. In such instances, problematic couple relationships. One
the expectation that the partner can as- study found that avoidant PD was asso-
sume more of a “helper” position to- ciated with a lower likelihood of mar-
ward the individual with PD is unjusti- riage. Avoidant, antisocial, and obsessive-
fied, and the cycle of difficult behavior compulsive PDs were also associated
often escalates. In this case, it may be with marital disruption, which included
most helpful for each partner to engage divorce and separation (Whisman et al.
in individual therapy to stabilize symp- 2007). Another study found that among
toms and then to reconnect at a later point individuals with borderline PD, 29% of
in time for couples therapy. Further- men and 52% of women were married at
more, there is something about couple follow-up, compared with 80%–90% of
relationships that can make for the most adults (Stone 1990). These obvious prob-
dysregulating feelings in partners, even lems obtaining and maintaining long-
in those without PDs. For those with se- term successful relationships make an
appropriate treatment target for couples and integrative therapy. Some methods
therapy. used for couples therapy are like those de-
scribed above in the family therapy sec-
Features of PDs That tion, so in this section we elaborate only
on therapies that are specific to couples.
Complicate Couples Psychoeducational approaches to couples
Therapy therapy are nearly identical to what we
described in the family therapy section.
In the family therapy section, we re- The main goals of these interventions are
viewed aspects of PDs that may compli- to educate the partner on facts about the
cate treatment; these include difficult en- targeted mental disorder and to include
gagement of individuals with PDs, high helpful treatment and couple interaction
dropout rates, and difficulties from in- information. Psychoeducation therapy
teracting with potentially frustrating pa- that specifically targets romantic part-
tients. These features also would apply ners may include information on inti-
to couples therapy. Therapists should be macy, planning for the future, and the
aware of the importance of building a sharing of household responsibilities.
strong alliance with PD patients within Many aspects of cognitive-behavioral ap-
couples therapy in order to assure treat- proaches to couples therapy, including so-
ment compliance and reduced hostility cial learning theory, skills training, and
within sessions. homework implementation, are identical
In addition, not only do persons with to those of family therapy. However,
PDs have objectively more problems in there are additional theoretical and tech-
relationships than persons without PDs, nical aspects to cognitive-behavioral cou-
but they also perceive their relationships ples therapy. One is the importance of so-
to be more difficult. For example, one cial exchange theory, which posits that
study found that patients with border- individuals strive to increase their re-
line PD perceived their relationships wards and decrease their costs in social
with families, partners, and children to relationships. In other words, behavior
be much more difficult than did a com- from the partner is reciprocated to main-
parison group of depressed individuals tain a balance between partners: negative
(Gerull et al. 2008). This enhanced per- behavior is responded to with negative
ception of relational difficulties may cause behavior, and positive with positive. Of-
progress to seem slow or even intracta- ten couples can be caught in mutually co-
ble. The presence of easily hurt feelings ercive behavioral patterns. In cognitive-
followed by angry outbursts or with- behavioral couples therapy, there also is a
drawal in patients with borderline PD, focus on how to deescalate arguments
or of total avoidance of feelings in some when one or both partners are emotion-
other PDs, can further complicate cou- ally dysregulated. Techniques include
ples therapy. engaging in calming behaviors, slowing
down the process, suggesting that affects
Different Forms of have become too heated, and using dees-
calation techniques (breathing, taking a
Couples Therapy walk, etc.) until the conversation can be
In this subsection, we review three pri- resumed.
mary types of couples therapy: psycho- Integrative treatments that blend ac-
education, cognitive-behavioral therapy, ceptance and cognitive-behavioral strat-
egies have proven highly effective in the han (1993) to better fit a couples therapy
treatment of couples (Jacobson and dynamic. The new dialectics for couples
Christensen 1996). Integrative behavioral therapy include 1) closeness versus con-
couples therapy focuses on changing what flict, 2) partner acceptance versus change,
can be changed, building skills, chang- 3) one partner’s needs and desires ver-
ing cognitions, working with affects, and sus the other’s, 4) individual versus rela-
working with internal dynamics and ob- tionship satisfaction, and 5) intimacy
ject relations. This therapy retains a focus versus autonomy. From these central di-
on acceptance by both the person with the alectics, Fruzzetti and Fruzzetti identify
PD and his or her partner; therapist and five functions that must be included in
clients examine what cannot be changed DBT for couples. The first of these func-
and find ways to work within these con- tions, skill acquisition or enhancement, in-
strictions. cludes development of individual and
One popular integrative empirically relational skills that are taught and prac-
supported couples therapy, Gottman’s ticed in sessions. The second, skill general-
Sound Marital House Treatment (Gott- ization, refers to the transfer of skills from
man and Gottman 2008), emphasizes the the therapeutic situation to life outside
positive effects of having a strong mar- of therapy, and may combine outside
ital foundation made of friendship, planning and telephone coaching. The
fondness, admiration, and positive sen- third function, motivation/behavior change,
timent. According to this approach, re- involves collaboration between the ther-
sistance is common in therapy because apist and clients to identify and change
people have a distorted working model dysfunctional patterns. Fourth, therapist
of how relationships are supposed to capability enhancement and motivation re-
function. This therapy works on increas- fers to the requirement that counselors
ing positive interactions between cou- who work from a DBT model acquire the
ples, deescalating conflict, and develop- necessary skills and maintain high levels
ing a “love map” of shared future goals, of motivation. The final function is the
memories, and hopes. structuring of the environment. These mod-
ifications of DBT for couples in which one
Research Support for person has borderline PD can be adapted
to fit couples in which one of the couple
Couples Therapy for PDs has a different PD.
As was true for family therapies, dis- Oliver et al. (2008) present a case study
cussed earlier in this chapter, there are in which they demonstrated the positive
few empirically based couples therapies effects of combining Linehan’s (1993)
for PDs. We focus in this section on treat- DBT with the couples therapy of Gott-
ments for borderline PD that have the man (Gottman and Gottman 2008). Again,
potential for dissemination to other this research focused on borderline PD
types of PDs. We discuss one adaptation but has the potential to be expanded to
of DBT and one case study that com- other PDs. DBT focuses on radical be-
bines theories from DBT and Gottman’s haviorism, the balance between accep-
couples therapy. tance and change, and skills building, all
DBT has been expanded for specific with a foundation in mindfulness (Line-
work with couples. Fruzzetti and Fruz- han 1993). Gottman’s therapy focuses on
zetti (2003) have adapted the dialectical the building of mutual appreciation and
dilemmas originally put forth by Line- positive sentiment override through
exercises and attention to positive ex- therapist role-played adaptive com-

changes. Gottman also targets what he munication patterns, and the thera-
pist modeled validation techniques.
calls the “four horsemen” of negative be-
The combination of acceptance (in-
haviors during conflict—criticism, concluding deescalation and self-sooth-
tempt, defensiveness, and stonewalling. ing) and change (improvement of
All four of these behaviors are likely to skills) gave balance to the treatment
be manifested by individuals with PDs. for such a high-conflict couple.
In about the eleventh session of
couples therapy, the therapist began
Case Example 3 with an assessment of a recent event.
An extremely volatile fight had re-
Jose and Susan presented for treat- sulted in the police being called. Susan
ment after frequent fighting, with had smashed Jose’s hand with a ham-
complaints about difficulties morph- mer, and she was arrested for domes-
ing into violence. Susan demonstrated tic battery. Susan almost immediately
signs of borderline PD, including emo- became flooded with affect. She raised
tional sensitivity within the relation- her voice and began to cry uncontrol-
ship; these signs included extreme re- lably. Jose angrily voiced his frustra-
activity to ambiguous responses from tion, calling Susan “crazy” and saying
Jose and difficulty calming herself that he should get a divorce. The ther-
down after becoming upset. She had apist first paused the session so that
difficulties in interpersonal interac- each could tell his or her story sepa-
tions that resulted in alternating be- rately, without using judgmental or
tween passivity and aggressiveness. blaming language (deescalation of ar-
Susan would easily become inconsol- gument). During that time, Susan was
able and cope with the extreme affect helped to engage in some self-sooth-
by taking substances or becoming vio- ing skills. The therapist focused on ab-
lently aggressive. Jose presented as dominal breathing and mindfulness
withdrawn and indifferent. He spent practice so that Susan could calm her-
the majority of the day alone in his self and carry on the conversation
home office, avoiding interactions further, and therapy continued, with
with Susan and their children. He also the rule that it would pause again if
showed signs of depression, includ- the fight escalated. The therapist re-
ing anhedonia and reduced motiva- framed the issue behind the fight (Su-
tion and concentration. When con- san wanted to go on a bike ride to-
fronted with Susan’s extreme affect, gether, but Jose wanted to be left alone
Jose would withdraw further. Even- to do his work) as their struggling with
tually, he would try to remove himself how to be close with one another. This
from these conflicts, only to be met notion further calmed the fight and
by physical confrontation from Susan. fostered empathy between the couple.
At this point, he would often lose con- The therapist then moved to contract-
trol and respond with physical aging with Susan and Jose about how the
gression. couple could meet each of their needs
The treatment plan put a primary when they wanted to do different
focus on deescalating the emotion things. This included assertiveness
dysregulation and violence that sur- training for both, with Susan learning
rounded many of the couple’s argu- how to avoid insisting on time together
ments. This included practice in in an aggressive way and Jose learning
mindfulness, which emphasizes ef- how to avoid being passive-aggres-
fective, nonjudgmental behavior, and sive when uninterested in spending
self-soothing exercises, such as deep time with Susan at that moment. As
breathing and muscle relaxation. The both Susan and Jose became more
treatment plan also focused on skill emotionally regulated, the therapist
building. Jose and Susan and the asked them to look more directly at
one another and see whether they ferently in different contexts, and indi-
could begin to find their better feel- vidual therapy may not allow the thera-
ings for one another (promoting en-
pist to observe the patient interacting
gagement and communication). The
therapist also referred back to their dis- with anyone other than the therapist.
cussions about what could be changed Some traits may not become readily ap-
in their communication and engage- parent in individual treatment, whereas
ment with one another and what recapitulative interpersonal patterns are
could not, thus promoting a balance evoked automatically in group, family,
between acceptance and change.
or couples therapy.
A multi-person approach to treatment
does not mean that the approach is sim-
Conclusion ply interactional and ahistorical, based
on overt behavior and not on content. In-
It could be argued that cultural bias to- stead, a multi-person approach allows
ward individualism has led people to the clinician to take other levels of human
neglect the power of collectivity as a functioning into consideration, because
helping resource. The emphasis on indi- interactions and processes also instill
vidual psychotherapy puts out of reach content and affects, particularly the inter-
the range of helping behaviors that are subjectivity that is present in any human
potentially available from parents, fami- interaction. Multi-person therapy often
lies, and other human groupings. Yet, moves back and forth between process
the scarcity of professional resources and content. How the content is dis-
may force a return to more traditional cussed and how the members behave
(from a sociological sense) helping pat- and react are observed in order to help
terns and to the use of resources that ex- them see how they may be ineffective in
ist within natural groups, such as the dealing with particular issues.
family and the community, or within Clinicians who work with people
groups developed by, or for, people with who have PDs should be familiar with
similar interests or problems. various treatment modalities, including
The presence of many individuals in individual, group, family, and couples
therapeutic settings, such as family, cou- therapies. Therapeutic flexibility is im-
ples, or group therapy, also brings a portant, and the ability to shift or inte-
greater variety of ways of intervening grate modalities is likely crucial to a suc-
compared to individual psychotherapy. cessful outcome. For example, when
In individual therapy, a therapist does individual therapy seems stalled, cou-
not usually directly observe the patient’s ples therapy sessions may help address
interpersonal environment and may mis- marital dynamics that may be perpetu-
interpret the patient’s experience, which ating the patient’s difficulties. That be-
is subjective and easily distorted by both ing said, a mix-and-match approach to
parties, compared with the more objec- treatment that utilizes techniques as and
tive interpersonal reality. Not observing when the clinician deems appropriate is
the patient in an interpersonal setting not ideal. Treatment decisions should be
limits the information gathered about based on a coherent theory of the disor-
the relational context in which the prob- der, supported by an understanding of
lem is embedded, even though this in- the mechanisms of change, which can be
formation is part of the patient’s cognitive used to carefully craft a logically inte-
world. The patient may behave quite dif- grated therapeutic package. A team ap-
proach is likely necessary. In general, the twin design. J Abnorm Psychol 122:180–
more severe a person’s problems are, the 194, 2013
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greater the need to include multiple com-
and personality disorders: their connec-
ponents in the treatment. Using a diver- tions to each other and to parental divorce,
sity of approaches in a carefully con- parental death, and perceptions of paren-
sidered, coherent, and well-structured tal caregiving. J Pers 66:835–878, 1998
manner helps keep clinicians from adopt- Budman SH, Demby A, Soldz S: Time-lim-
ing the adage “If all you have is a ham- ited group psychotherapy for patients
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mer, everything looks like a nail.”
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C H A P T E R 14
Psychoeducation
Alan E. Fruzzetti, Ph.D.
John G. Gunderson, M.D.
Perry D. Hoffman, Ph.D.
Psychoeducation is a well- of programs have been developed and

established, evidence-based practice for evaluated.
many psychiatric disorders. Numerous
randomized clinical trials have demon-
strated that psychoeducation programs, Overview
although varied in form, are very cost
effective and help significantly to reduce Psychoeducation programs are based on
relapse, improve individual outcomes the assumption that an educational ap-
and course of illness, and enhance fam- proach can benefit individuals in their
ily functioning and other social rela- efforts to manage a particular disorder
tionships. Psychoeducation has been and may also be of benefit to their family
employed successfully with patients with members or others in their social net-
schizophrenia, bipolar disorder, major work. Psychoeducation is quite distinct
depression, and obsessive-compulsive from psychotherapy because the meth-
disorder. Despite the established efficacy ods and procedures are entirely educa-
of psychoeducation in the treatment of tional and frequently are delivered by
these other psychiatric disorders, few professionals without psychotherapy
psychoeducation programs for person- training, by individuals in recovery, or
ality disorders (PDs) have been devel- by family members. It also differs from
oped. In this chapter, we highlight the family therapy because there is little fo-
development and success of psychoedu- cus on changing family dynamics per se
cation in general and then describe the and because training in family therapy is
components and evidence for psychoed- not necessary.
ucation for PDs, with an emphasis on Early psychoeducation interventions
borderline PD (BPD), for which the bulk focused primarily on education about a
303
particular disorder. Over time, psycho- burden of care of those with severe and
education has expanded its scope to in- chronic disorders from institutions to
clude education about the role of family family settings. Unfortunately, when the
members and other caregivers or loved mandate to reduce the number of pa-
ones vis-à-vis the maintenance, relapse, tients in institutions was implemented,
or recovery from a particular disorder, the promise to offer comprehensive out-
as well as individual, social, and family patient services did not sufficiently mate-
skills that are believed to be instrumen- rialize. Consequently, most individuals
tal in minimizing distress due to a disor- with psychiatric illnesses returned to
der or in facilitating recovery. Thus, psy- live in the community with their family
choeducation is quite varied and may members with minimal outpatient ancil-
include 1) providing patient and/or fam- lary psychiatric services available. Recent
ily education, 2) teaching individual cop- years have demonstrated even further
ing skills, 3) teaching family skills, and deterioration of outpatient resources, so
even 4) providing training in problem- burdens on patients and families have
solving techniques. A set of guidelines not decreased.
for recovery and maintenance is some- Research on expressed emotion showed
times offered as well. Although psycho- that specific characteristics of the family
education groups are generally led by environment often predicted the course
mental health professionals from a vari- of the patient’s illness in schizophrenia
ety of backgrounds, sometimes patients (Anderson et al. 1980). Expressed emo-
or family members are trained to lead tion includes the number of critical com-
these groups. The goal is to help individ- ments, levels of expressed hostility, and
uals and/or family members engage in emotional overinvolvement that family
and increase knowledge about skillful members express about their diagnosed
behaviors that have been shown either relatives. Research on schizophrenia and
to augment other treatment components other severe problems has demonstrated
to improve patient outcomes or to more reduced relapse rates following modifi-
generally facilitate patient and family cation of family members’ attitudes and
well-being. other behaviors associated with beliefs
expressed about the patient (Anderson
et al. 1980).
Background, Theory, Research on schizophrenia helped to
move thinking about etiology from sub-
and Rationale jective and empirically unsupported ob-
servations (e.g., the “schizophrenogenic
Since the 1970s there has been a major ef- mother”) to more evidence-based factors
fort to develop and implement compre- based on medical/biological and social/
hensive, multi-component treatment family science. This critical change in the
programs for those affected by mental understanding of the etiology of schizo-
illness either directly or indirectly. A ma- phrenia helped reduce blame on fami-
jor focus has been on programs for pa- lies and led instead to greater apprecia-
tients and their families. Several factors tion of the needs and experiences of family
provided the impetus for the develop- members of people with schizophrenia.
ment of psychoeducation, not the least Constructs such as family member bur-
of which was the deinstitutionalization den, grief, and depression were recog-
movement in the 1960s, which shifted the nized (Greenberg 1993; Maurin and Boyd
Psychoeducation 305
1990), with a consequent change in the 3) ongoing social support to the patient
perception of relatives from the strictly and/or family members; and 4) a prob-
pathological model of family members lem-solving forum in which participants
as “patients” to family members as rele- learn to translate the knowledge and
vant to good outcomes as potential “pro- skills (learned through education) into
viders” (Marsh 1992). more effective attitudes, emotional reac-
In the 1970s psychoeducation pro- tions, and interpersonal behaviors toward
grams for family members with a relative the patients or other family members.
with schizophrenia were implemented, Not all programs that are designated
and the family treatment modality called “psychoeducation” or “family psycho-
family psychoeducation—a term appar- education” include all four of the com-
ently first used in print by Anderson et al. ponents listed above. Some programs
(1980)—began to be established. A sub- have been developed only for patients,
stantial (and increasing) body of empiri- others only for family members, and some
cal research supports this treatment mo- for both patients and family members.
dality as perhaps the most successful Thus, the terms are used rather broadly,
family treatment component for patients which can be confusing. To further com-
with schizophrenia (see McFarlane et al. plicate the picture, skills-training pro-
2003). This family psychoeducation model grams in treatment settings, primarily
subsequently was adapted for other diag- for patients but sometimes for families,
noses, such as bipolar disorder and major sometimes include different combina-
depression. Family psychoeducation has tions of the four psychoeducation com-
been shown consistently to reduce in- ponents. Such skills-training programs,
dividual relapse rates as well as family however, are typically not designated as
members’ levels of stress and burden psychoeducation per se, although there
(Cuijpers 1999). may be considerable overlap. Thus, the
inconsistency of terms employed in la-
beling programs makes it difficult to eval-
Patient uate psychoeducation objectively and
comprehensively.
Psychoeducation and These four components of psychoed-
Family Psychoeducation ucation models are described below in
more detail to establish the “core” tar-
Comprehensive patient psychoeduca- gets and approaches and to help provide
tion and family psychoeducation models a less amorphous definition of psycho-
today may include several key compo- education.
nents: 1) education of patients and fam-
ily members about a particular disorder
and its etiological factors, research find-
Education
ings, factors that ameliorate or exacer- The educational component of psycho-
bate symptoms or severity, treatment education models is predicated on the
options and expected outcomes, and com- assumption that offering information to
munity resources; 2) teaching of coping patients and families about the particu-
skills and individual and family skills lar disorder is helpful. Participants are
to manage the disorder and its effects, given the most current information on
minimize disability and maximize func- etiology, treatment options, medications
tioning, and improve family functioning; and pharmacological issues, and re-
search findings. Issues regarding devel- may not become defensive at all. Rather,
opmental and environmental influences, they may identify factors in their own
medications, psychotherapy, and the im- development that help them understand
plications of research findings are usu- their own struggles, which in turn may
ally of particular interest to participants. help them blame the patient less. Thus, it
However, knowledge alone does not is imperative that whoever leads the
seem to suffice to improve outcomes psychoeducation interventions has and
(Hoffman et al. 2003); the educational promotes a well-grounded nonjudg-
facet of the program may require the ad- mental perspective.
ditional and complementary component Also, it is important in psychoeduca-
of skill acquisition to have a significant tion for professionals to stress that de-
impact. spite wide acceptance of various theo-
Providing education to patients and ries, not much is known about specific
family members presents many chal- etiological pathways for any PD. Thought-
lenges clinically. For example, it is not ful professionals may reasonably inter-
uncommon for parents, partners, or chil- pret myriad studies in a variety of ways.
dren of patients with serious disorders What is clear is the heterogeneity of fac-
to suffer from these or other disorders tors, including family interaction and
themselves. Consequently, although one family functioning, that may be found in
member of the family may be desig- the developmental histories of patients.
nated as the patient, others in the family For instance, being physically or sexu-
can often benefit from knowledge and ally abused may be a risk factor for sev-
skill building as well. Thus, psychoedu- eral PDs, yet the vast majority of survi-
cation can afford professionals an op- vors of physical and sexual abuse do not
portunity to help additional individuals develop PDs. Similarly, having loving
consider behavioral change and even and attentive parents who do not have
engage in their own treatment, and to in- substance abuse or other mental health
tervene directly in the family system (or problems is a protective factor for most
provide referral to family therapy) to people; however, some people with severe
help the entire family. On occasion, fam- PDs have parents who fit this descrip-
ily members may be so impaired them- tion. The current focus in the child devel-
selves that participating in a psychoedu- opment literature on transactional models
cation program primarily designed to (ongoing, reciprocal influence between
help family members may be unproduc- individual psychological and biological
tive. However, most family members can factors and responses from parents and
benefit from psychoeducation, even when other caregivers) promises improved
they have significant distress of their clarity about etiology in the future (Cum-
own (Hoffman et al. 2007). mings et al. 2000; Eisenberg et al. 2003;
In educating the family on the etiol- Fruzzetti et al. 2005). Currently, however,
ogy of PDs, professionals might at first therapists can only speculate on the
be reluctant to include a description of causes in any given case and must con-
the putative role of family interactions sider the impact of the hypotheses on
and might worry about defensive reac- patients and family members and their
tions from family members. However, if ability to reduce destructive patterns
the content is understood and presented and love and support each other without
in a nonblaming way, family members blame in the future. The best available
Psychoeducation 307
data suggest that current family func- whelmed and frustrated, even resentful,
tioning factors are very relevant to both that I do almost all the chores around the
short- and long-term patient outcomes house”).
and thus should be a focus of psychoed-
ucation. Social Support
In addition to providing education and
Skills Training skill acquisition, family psychoeduca-
Skills training has substantial empirical tion, depending on setting, also can pro-
support as a way to help patients and vide an opportunity for the development
family members. Patient skills training of an alliance and partnership among
may include social skills, problem solv- professional and family care providers
ing, assertion training, stress manage- and collaboration with the patient him-
ment, anger management, and relaxation self or herself. Such alliances and part-
techniques (O’Donohue and Krasner nerships allow the possibility of greater
1995). Family skills include awareness of continuity and consistency of care. Joint
others (relationship mindfulness), com- participation promotes support because
munication (accurate expression, valida- group members share similar struggles
tion, and support), parenting, collab- and experiences. Having often been iso-
orative problem solving, and other lated from friends and other family mem-
relationship and interpersonal skills. bers, participants report that this sup-
However, skill acquisition is only one port system that often develops is very
piece of effective skills training: skill important to them (Hoffman et al. 2005,
strengthening and skill generalization 2007). In addition, family members and
are also necessary components to help patients bring a lot of practical expertise
ensure successful skill transfer into daily to group psychoeducation because they
life. To be most effective, psychoeduca- often have learned how to cope with or
tion should include in-session or at-home how to solve certain problems with which
exercises, as well as skill orientation, ra- others may be struggling. Consequently,
tionale, and instruction. family members and patients can often
For example, just about every adult provide not only specific suggestions for
“knows” that good communication in- handling a situation but also the social
volves accurate expression and accurate, and emotional support needed to imple-
active listening. However, most par- ment a solution.
ticipants in psychoeducation do not dis-
tinguish between “description” and Problem Solving/
“blaming” (or being judgmental) when
thinking about “accurate” expression. Integrating Knowledge
Family members often say things such and Skills to Change
as, “Well, it is accurate to say he’s lazy.”
Thus, it may take a lot of practice to trans-
Key Behaviors
form “knowledge” into effective practice The problem-solving component may be
(e.g., being able to say, “I see him sit- the one least consistently found in psy-
ting around all day, and I know he’s de- choeducation programs. It is also the
pressed; it makes me unhappy to see closest to cognitive-behavioral family or
him this way, and sometimes I feel over- group therapy. Specific problems as ex-
perienced by participants are brought to paranoid, schizoid, schizotypal) or their

the group with the explicit purpose of families, but there are many successful
having the group collectively work to ap- programs for related disorders. Although
ply their newly acquired skills and with the potential utility is obvious, and there
the goal of effectively resolving or man- are no data to contraindicate psycho-
aging the given situation. A structured education programs for any PD, it is sur-
protocol is typically available to keep the prising that researchers have not adapted
discussion focused and constructive. those programs for use with Cluster A
Toward the end of a psychoeducation problems.
program on problem solving, patients
and families are provided opportunities Avoidant Personality
to put whole skill sets together to ame-
liorate current problems that could Disorder
easily become crises, and to practice Avoidant PD has several behavioral and
problem solving as a skill they may use theoretical connections to other severe
into the future. The opportunity to have disorders. Although some evidence sug-
seen good skills modeled by other mem- gests that it can be reliably discriminated
bers of the group (or group leaders) can from social phobias and schizoid PD
be very helpful. Together with other (Trull et al. 1987; Turner et al. 1986), the
skills and social support, participants distinction between these disorders is of-
may then be able to succeed when try- ten blurred. For example, several studies
ing new approaches in previously diffi- of avoidant PD have shown positive out-
cult situations. comes using psychoeducation and grad-
uated exposure techniques, which are
the standard psychological interventions
Psychoeducation for used in treating related disorders. In one
Personality Disorders study of avoidant PD employing social
skills training and patient psychoeduca-
Other Than Borderline tion, Alden (1989) found significant im-
provement in most domains, and those
Despite the strong rationale for the four
treatment gains were maintained at fol-
intervention components discussed in
low-up 3 months later. Because these
the previous section and the consider-
studies aggregate various interventions
able positive data supporting their use
(psychoeducation plus other interven-
with some major psychiatric disorders,
tions), it is difficult to isolate the effect of
psychoeducation programs have not been
psychoeducation per se.
developed widely for most PDs, with
the exception of BPD, which is reviewed
separately in the next section. The use or Antisocial Personality
potential use of psychoeducation pro- Disorder
grams for PDs other than BPD is reviewed
No studies have specifically evaluated
in this section.
psychoeducation for antisocial PD
(ASPD), although many studies have
Cluster A Disorders evaluated various psychoeducation and
No patient or family psychoeducation skills-training programs for anger, ag-
programs have been established for pa- gression, or violent behaviors—prob-
tients with Cluster A PD diagnoses (i.e., lems that overlap to some extent with
Psychoeducation 309
ASPD. The extent of this overlap is not for Borderline Personality Disorder
clear, however, and the effectiveness of (www.borderlinepersonalitysdisor-
these treatments in reducing violence re- der.com)—the Internet also includes
cidivism is controversial (Babcock et al. much that is contradictory and even dis-
2004). credited or incorrect “information.” For
Although only a minority of men who example, some apparent psychoeduca-
batter their partners have problems in tion patient sites focus a lot of vitriolic
personality functioning that meet criteria accusations toward parents, and on some
for ASPD or other PDs, and only a minor- other sites, “caregivers” complain bit-
ity of men with ASPD batter (Dutton terly and judgmentally about individu-
1998), there has been a lot of research on als with BPD. Consequently, many family
treating male batterers. Thus, although members alternate between anger/de-
the extent to which these data are gener- fensiveness (being told that parents of
alizable to ASPD in general is not clear, patients with BPD are always “abusers”)
these treatments may be instructive in and fear/guilt.
developing psychoeducation for this It is important for clinicians to point
population. out to patients and families the variety
Most batterer treatment programs use of outcomes and causes associated with
a combination of psychoeducation and PDs. In this section, we begin with some
cognitive-behavioral interventions. A recommendations about the elements
typical curriculum includes instruction that are essential to include in psychoed-
in anger management and violence in- ucation about BPD, and then describe
terruption skills (e.g., anger recognition, several specific patient and family psy-
time-out, self-talk, relaxation), sex-role choeducation programs.
education, sex-role resocialization, and
discussions of patriarchal and male power
issues. Programs often include training
Recommended
in skills to improve relationship func- Psychoeducation
tioning, such as communication and Content for BPD
conflict resolution skills, social skills,
and assertion skills (Holtzworth-Mun- All modalities of treatment should be in-
roe et al. 1995). troduced by educating consumers (in-
cluding both patients and their families)
about the nature of BPD (the diagnosis)
Psychoeducation for and the treatments for it. Similarly, when
a patient’s treatment plan has been es-
Borderline Personality tablished, consumers should be edu-
Disorder cated about the plan, including informa-
tion about what can be expected from
Unfortunately, accurate general knowl- their treatment provider(s) and what
edge about BPD is quite poor (Hoffman et will be expected from the consumers. If
al. 2003). The Internet is a frequent the person identifying the diagnosis will
source of information. Although it can also be offering the treatment, that per-
be a rich resource for useful and accu- son needs to take special care to describe
rate psychoeducation—one excellent treatment alternatives fairly to help con-
Web site for BPD psychoeducation is sumers make good treatment decisions.
that of the National Education Alliance It is also useful to encourage consumers
to enrich their education by consulting mistreated and angry and devaluing oth-
reading materials, relevant organiza- ers and at other times feeling inherently
tions, or other professionals; this conveys bad, painfully dysphoric, and unable to
the message that the consumers should attain what they feel they need. Self-
be active participants in selecting and destructive behaviors (e.g., self-harm) oc-
evaluating treatment. Patients and their cur that can be self-punitive and most
families should know basic information often relieve intense negative emotion,
about the diagnoses, course, etiology, and including dysphoria, shame, and anger.
treatment of BPD. Dysphoric states and/or self-harming
acts can evoke sympathetic attention,
Diagnosis although for some individuals self-harm
BPD includes problems with 1) intense is entirely private. Because of develop-
negative affect and affect regulation; mental difficulties and consequent emo-
2) relationships, including chaos in relation and “self” deficits (such as not know-
tionships and fears of relationship loss ing what one wants or feels), fears of being
and abandonment; 3) impulsivity and alone and of abandonment are common.
self-control; 4) identity and a sense of When individuals with BPD feel alone
emptiness; and 5) transient cognitive and/or abandoned, they can become des-
deficits and distortion. BPD is heteroge- perately impulsive, which is exacerbated
neous, however, with different clusters under the disinhibiting influence of alco-
of problems more prominent in different hol or other drugs. In these situations they
people. It is very common that people also can experience cognitive-perceptual
with BPD have grown up feeling their distortions, including dissociation and
needs were not fulfilled, sometimes in brief paranoid perceptions.
problematic (neglecting or abusive) and
quite often in “mismatched” family en- Course
vironments. In a psychodynamic view, A great deal has been learned about the
many of these individuals hope when course of PDs in general and of BPD in
they get into adolescence that they can particular from prospective longitudinal
find a partner who will be able to fill research. Whereas stability across time
those needs and believe that such a part- has been used to distinguish PDs from
ner needs to be exclusively and consis- other psychiatric disorders, longitudinal
tently attendant to them. Fulfilling such studies have shown PDs to be only rela-
a role is rewarded by idealization and can tively stable; that is, they are more stable
be very appealing to others, but invari- than most other disorders, but they do
ably those relationships lead to real or nonetheless change, often improving,
just perceived failures with feelings of over time.
anger and betrayal. From a behavioral or With respect to BPD, about 20% of cases
social-learning perspective, a mismatched remit by 1 year, 40% by 2 years, and 85%
family environment results in pervasive by 10 years. Over the course of 10 years,
invalidation of the child’s experiences use of expensive treatments such as those
and can lead to significant deficits in administered in emergency rooms and
awareness of self and others, in emotion hospitals gradually diminished (Gunder-
identification and management, and in son et al. 2011). In the longest follow-up
interpersonal skills. to date, at 16 years, about 65% of patients
Regardless of theory, persons with BPD were said to have “recovered,” meaning
can vacillate between at times feeling they had both sustained and satisfying
Psychoeducation 311
partnerships and vocations (Zanarini et volves consideration of the home

al. 2012). Thus, in general, the course of environment (loss of relationships due to
BPD looks much like that of ASPD, with death or divorce, hostility, illness, sibling
an early onset and a gradual course of im- rivalry, etc.) and of trauma. Researchers
provement over time such that with age do not yet know what is inherited, what
the prevalence greatly diminishes. More- is learned, or how these factors interact.
over, the course of improvement reported In particular, substrates of BPD such as
in the study by Zanarini et al. (2012) oc- emotional dysregulation, interpersonal
curred in the absence of sustained disor- hypersensitivity, and impulsivity may be
der-specific treatments, suggesting that key components that lead to vulnerability
life offers corrective experiences. to developing BPD. However, researchers
However, this portrait of the course do not know what genes or what family
runs the risk of being unduly optimistic. environments transmit these vulnerabili-
It overlooks the more sobering reports ties. Almost certainly, however, multiple
from 10-year follow-up data indicating genes will play a role, interacting with
that less than one-third of the patients many kinds of family environments.
with BPD had achieved either a stable The presence of trauma in the history
partnership or full-time employment of people who develop BPD is not un-
(Gunderson et al. 2011). Many of those common (up to 75% of inpatient and out-
whose BPD was in remission had as- patient samples have retrospectively re-
sumed a more avoidant posture in their ported trauma; Battle et al. 2004). Trauma
lives, in that they had ceased utilizing has sometimes been hypothesized to be a
treatment and ceased searching for cor- major cause of BPD, despite data that
rective and exclusive relationships, and clearly suggest otherwise. Patients and
continued to report significant distress. families should be educated about the
Ten years is a long period to have sus- fact that trauma is neither necessary nor
tained social disability and represents a sufficient to cause BPD. A meta-analysis
very severe public health burden. of its role found that only 15% of the vari-
ance in BPD’s etiology is due to trauma
Etiology (Fossatti et al. 1999). Of course, whether
BPD has a significant level of heritability, a severely adverse childhood event (e.g.,
with estimates ranging from a low of sexual abuse) is traumatic depends in
15%–20% to a high of 55% (White et al. part on the vulnerability and disposition
2003). It is important to understand that of the child and on whether the event
the estimates represent average levels gets communicated to a supportive and
and that for any individual patient the receptive family.
level of heritability could vary consider- A predictable consequence of having
ably. Some people develop the disorder a child with a psychiatric disorder is that
with heavy genetic loading on BPD parents wonder what they did wrong
traits such as affectivity and impulsivity, (or defensively protest that they did
whereas others may develop it with low nothing wrong). Clinicians should antic-
genetic loading. The level of genetic load- ipate this concern and educate parents
ing can be estimated by asking whether about their role. Most parents get reas-
other family members have had similar surance from learning about the role of
symptoms, such as anger, suicidality, and genes, but this should not be considered
generally unstable relationships. Estimat- an adequate explanation (i.e., an expla-
ing the level of environmental loading in- nation of BPD as solely a “brain disease”
is inaccurate). Rather, parents should be and Fonagy 2004) has more recently be-
seen as having played an essential, albeit gun to accumulate substantial support
unwilling and unintended, role. A par- as well. However, even though an in-
ent (or any primary caretaker) should be creasing variety of treatments with at
supported by being told that, for ex- least some evidence to support them
ample, a luckily well-matched caregiver have been developed for BPD, most of
(consistent, calm, nonreactive, or per- these continue to remain inaccessible to
haps matched in a different way) might the vast majority of patients with BPD.
have had a deterring effect on the child’s Therefore, patients and families should
development of BPD or that the parent’s be advised that although making prog-
particular style of parenting might have ress does not necessarily depend on
been better suited for a less disposed child, finding experts in PD, almost all studies
and so on. Similarly, a clinician should suggest that a thoughtful treatment spe-
support parents by openly stating that cifically developed for patients with
he or she knows that they love their BPD will produce better outcomes than
child and understands that any actions generic treatment. When patients and
that later were considered mistakes were, families cannot access providers with
in retrospect, never intended to harm experience in evidence-based treatment,
and were always thought to be helpful or even BPD-specific treatments for
based on what they had learned from which evidence is not yet available, they
their own personal experiences. may need to be referred to providers
As important as these messages are, it who at least have had experience with
is equally important and usually neces- treating patients with BPD and who feel
sary to tell parents that they have an es- comfortable or even enjoy doing so. Pa-
sential role in their child’s recovery. They tients (and families) should actively
should educate themselves about BPD, avoid clinicians who are uncomfortable
get support for their ongoing difficulties with making PD diagnoses, express
through talking with friends or joining stigma about BPD, reveal they lack ei-
family psychoeducation programs (if ther experience or satisfaction with such
available) and support groups, and be- treatments, or do not like working with
come supportive collaborators with their people with BPD. Unfortunately, such
loved one’s treatment team. providers are not uncommon.
Patients and families should have in
Treatment mind a reasonable timetable for change
It is essential that patients and families and become active monitors of whether
be informed that the success of their expectable progress is happening. Suc-
treatment will depend on an active in- cessful outcomes are associated with
vestment of time and energy. This pro- significant reductions in self-injury and
cess starts with their being active and angry verbal outbursts within about
invested in selecting treatment pro- 6 months, and resumption of school, do-
viders. They should be advised to seek mestic, or vocational functions should be
providers of evidence-based treatments under way within 6–12 months from the
whenever possible. Dialectical behavior start of treatment. These are general
therapy (DBT; Linehan 1993a, 1993b) has guidelines, however, and patients vary
the most supporting studies, with doz- considerably in achieving these changes,
ens of controlled and uncontrolled trials. but consumers should be encouraged to
Mentalization-based therapy (Bateman expect change and to examine why prog-
Psychoeducation 313
ress is impeded when these changes do been shown in dozens of studies to be an

not occur in a timely fashion. effective treatment for BPD and its asso-
ciated problems (e.g., self-harm, substance
Medications abuse, eating disorders, depression, an-
Clinicians need to establish realistic, ger, social adjustment, hospitalization).
modest expectations about the benefits Although it is difficult to parse the con-
from taking medications. This first mes- tribution of skills training per se to DBT
sage is important because expectations outcomes, psychoeducation about BPD,
of benefit are often excessive. Patients emotion dysregulation, and a variety of
with BPD should be told directly that no BPD-relevant topics, as well as emo-
medications are consistently or dramati- tional, attention, distress tolerance, and
cally helpful. This is a particularly im- interpersonal skills, is a central feature
portant message when, as is typical, the of DBT.
patient with BPD has previously received DBT patient psychoeducation and
a mood disorder diagnosis for which skills training include four separate mod-
medications were prescribed. Such a his- ules that have specific targets: 1) mind-
tory does more than raise unrealistic fulness, to increase attention control and
hopes and subsequent despair; it con- awareness of self and others, decrease a
veys an appealing, albeit counterpro- sense of emptiness and increase identity
ductive, model of treatment in which the and an integrated sense of self, and re-
patient is not an active and responsible duce cognitive dysregulation; 2) emo-
agent. The second message for patients tion regulation, to understand the role of
is that evaluating medication effects, for emotions in life, identify and label emo-
better and for worse, will require their tions accurately, reduce vulnerability
collaboration. It may even be worthwhile and suffering associated with negative
to educate them about the research indi- emotion, and tolerate and/or change
cating that their assessments of benefit negative emotions; 3) distress tolerance,
might contradict those of their providers to interrupt crises, reduce destructive
(Cowdry and Gardner 1988). Patients impulsivity, and facilitate tolerating emo-
should also be warned about the danger tions and situations without engaging in
of polypharmacy, for which there is no dysfunctional behaviors that exacerbate
evidence of value, and advised that it is the situation or negative emotion; and
generally important to discontinue an 4) interpersonal effectiveness, to achieve
ineffective medication before initiating a interpersonal objectives without damag-
new one. ing the relationship or the person’s self-
respect, and to build relationships. In
Specific Psychoeducation DBT these skills are typically taught in a
group format, and patients also receive
for Patients With BPD individual therapy and out-of-session
Dialectical Behavior Therapy skill coaching in which the skills are em-
ployed as solutions to current treatment
Skills targets.
Although no isolated psychoeducation
program for patients with BPD has been Peer Support
shown to be effective by itself, DBT has a People intuitively seek the informal sup-
substantial patient psychoeducation com- port and wisdom of others who are ex-
ponent (Linehan 1993a, 1993b) that has periencing situations similar to their
own as they deal with everyday prob- a variety of needs, NAMI chapters host
lems or unique life events. Seeking and several programs such as NAMI Connec-
giving such support is a fundamental tions Recovery Support Group and NAMI
human behavior. Typically, such sup- Peer-to-Peer. The groups offer relapse-
port involves the sharing of knowledge prevention planning and other directives
and experiences and the offering of emo- that assist with recovery in the context of
tional and tangible support in conjunc- support and education.
tion with advice, coaching, or other Although the NAMI groups are open
guidance. Since the first Alcoholics Anon- to persons with BPD, the focus of the
ymous meeting in 1935, the provision of content and areas of discussion gener-
support around a specific mental health ally do not address the unique issues
issue has evolved to include more formal specific to BPD. Efforts to organize and
structures. Several types or categories of sustain in-person peer support groups
peer support are relevant to BPD: 1) in- expressly for those who have a diagnosis
person peer-led support groups; 2) online of BPD have met with minimal success.
self-help groups; and 3) peer support One issue creating crucial roadblocks is
specialists. the stigma of the disorder, which can in-
The organizing function of peer sup- terfere with obtaining help for people
port is that members of the group come with BPD. Fears of liability have led to
together as equals to deal with shared is- difficulties in obtaining meeting space,
sues or problems. No one person adopts and the presence of interpersonal con-
the role of expert per se, and although flict is noted as another impediment.
the leader may be more advanced in re- A model of success for a peer-led group
covery or knowledge, there is either an developed specifically for BPD can be
implicit or explicit understanding of equal seen in a group that has been in exis-
status within the group. This agreement tence in the greater New York area since
allows a forum for open interactions and 2007 through the national organization
serves as a catalyst for the acquisition of Meetup.com. The group was organized
knowledge and skills, a sense of em- by a person in recovery and was started
powerment, and new perspectives that as a way to bridge the gap the founder
can lead to positive connections and out- felt after completion of BPD treatment.
comes. More than 500 people are registered as
In mental health, peer support pro- members; however, only about 3–15 peo-
grams are now frequently available and ple attend the meetings once every other
have become an integral part of the recov- week. The group ran for over 5 years un-
ery process for many people. The most der the founder’s tutelage but struggled
common format of peer support programs to continue after the founder stepped
is the peer-led group. Some groups, such down, until a family member assumed
as the Depression and Bipolar Support leadership to support the continued ac-
Alliance, are disorder specific, targeting tivities of the group program.
one psychiatric diagnosis. In contrast, The second modality of peer support
nonspecific-illness peer-led groups are is online support groups. For persons with
offered by the National Alliance on Men- BPD, however, these often appear to be
tal Illness (NAMI), whose groups are de- short-lived, appearing and disappearing
signed for the psychiatric population re- with little stability. One group that has
gardless of psychiatric diagnoses. To meet retained a consistent presence and
Psychoeducation 315
serves as a good template for others is lies’ emotional involvement is typically

DBTselfhelp.com, which began in 2001 considered to be overinvolvement and is
and is maintained by a person in recov- perceived as a negative characteristic
ery. It focuses on reinforcing past skill and one targeted for change. With BPD
learning and promoting further skill use patients, families’ emotional involve-
and learning. ment is a positive attribute and a buffer
The third type of support offered by against short-term problems. Each of the
peers with mental illness is provided interventions outlined in the following
through the Certified Peer Specialist Pro- subsections promotes family involve-
gram. Peer specialists are individuals ment and has as a central goal to educate
who, through personal experiences, offer family members on effective ways of be-
themselves as mentors and advocates to ing emotionally involved.
others who are further behind in their re-
covery. Formal training is required, and
Gunderson’s Multifamily
the number of peer specialists is growing Therapy Groups
substantially. It is now a service covered Gunderson and his colleagues at McLean
by Medicaid in more than 50% of states, Hospital in Belmont, Massachusetts,
with peer experts nationally recognized have been conducting family groups
as an increasingly important component since the mid-1990s (Gunderson 2001).
of recovery, but these resources have The format and structure, with addi-
very limited availability. The promise of tions and modifications specifically
peer specialists so far suggests applica- adapted to the needs of the BPD popula-
tions for BPD are likely to follow. tion, are based on the programs for
schizophrenia pioneered and evaluated
Family Psychoeducation by William McFarlane (see McFarlane et
al. 2003). Gunderson’s treatment follows
for BPD McFarlane’s three-phase format, which
Family psychoeducation programs for includes 1) joining, 2) a half-day psycho-
BPD include 1) psychoeducational multi- education workshop, and 3) multifamily
family therapy groups; 2) DBT-oriented group meetings every other week.
family skills-training groups; 3) the Sys- In the joining phase, the relatives from
tems Training for Emotional Predictabil- one family meet alone with the leaders,
ity and Problem Solving (STEPPS) pro- whose primary goal is to create an alli-
gram; and 4) a family education program ance and connection with the relatives.
for parents, partners, and others who Information on the diagnosis of BPD is
have a loved one with BPD. Each of these provided, and information on and his-
programs is discussed further below. tory of the family members’ experiences
The research on BPD and expressed and perspectives on their relative’s diffi-
emotion informs family psychoeduca- culties are shared. Acknowledgment of
tion for BPD. In one study of patients the family members’ anger and angst is
with BPD and their families, the higher crucial, allowing for the open expression
the family members’ level of emotional of feelings, both positive and negative,
involvement, the better the patients did and concerns. Although there is no time
at 1-year follow-up (Hooley and Hoff- limit on this phase of the treatment, par-
man 1999). With other diagnostic groups ticipants nearing completion of this
(e.g., patients with schizophrenia), fami- joining phase are asked to commit, in gen-
eral, to a 4-month period for the remain- als to families (Hoffman et al. 1999). All
der of this phase. of these interventions with families are
The second phase is the half-day psy- based on Linehan’s (1993a) conceptual-
choeducation workshop, in which par- ization of BPD and include a simultane-
ticipants are taught about BPD and of- ous (dialectical) emphasis on both accep-
fered an annotated list of guidelines tance and change strategies. In addition to
with coping strategies. This component having a psychoeducation component,
of the program is conducted with sev- all of these interventions include skills
eral families at one time and offers par- training. Because of their differing em-
ticipants the experience of hearing from phases, we describe each approach sep-
and sharing with others in similar situa- arately.
tions. Families are given the opportunity
DBT–family skills training. DBT–fam-
to discuss Family Guidelines (Gunderson ily skills training (DBT-FST) includes
and Berkowitz 2002), a booklet that in- both the DBT client and his or her family
cludes recommendations on a variety of
members. DBT-FST was intentionally
important issues such as the “tempera- created to offer participants an opportu-
ture” of the family environment, manag- nity to learn about BPD and to develop
ing crises, addressing problems, and set-
self and relationship skills, with the ulti-
ting limits. mate goal of enhancing both individual
The final and lengthiest phase of this and relationship needs. This treatment
modality is the multifamily group, in
incorporates the basic structures of stan-
which families meet every other week dard DBT, such as skill acquisition and
for 90 minutes. This phase, which runs skill generalization, directly into the fam-
for approximately 1 year, includes an av-
ily program. Groups include skill lectures
erage of six families and focuses primar- and skill rehearsal, and skill generaliza-
ily on problem solving. Although the in- tion is promoted through problem-solv-
dividual diagnosed with BPD is invited
ing discussion and practice among family
to participate, it is reported that typically and group members. DBT-FST also in-
few choose to do so, and patient atten- cludes a component called “structuring
dance is reported to be poor (Gunderson the environment,” which offers a forum
2001).
to put skill acquisition and skill general-
Data available on this intervention ization practice directly into the family
show that 66.7% of family members re- environment. The family forum provides
ported decreased burden as well as an
everyone the chance for self and rela-
increased ability to modulate angry feel- tionship change, both emotional and be-
ings. One hundred percent of partici- havioral, by coaching all members of the
pants felt supported by the group and
family simultaneously. All of this occurs
indicated an improvement in communi- in the context of a no-blame and non-
cation with their family member. Sev- judgmental setting. Because DBT-FST is
enty-five percent reported that the com-
intended for the mutual benefit of both
munication improvement was “great” client and relatives, the dialectical target
(Gunderson 2001). is a synthesis that balances the needs of
both.
DBT for Family-Oriented
There are four primary goals of DBT-
Skills-Training Groups FST. The first goal is to educate family
There have been several adaptations and participants on two central aspects of
extensions of DBT skills from individu- BPD: 1) its definitions and presenting
Psychoeducation 317
problems and 2) the etiological theory of colleagues (Fruzzetti 2006, in press), in-
BPD on which DBT is based—that is, the clude education materials and skill mod-
transactional model (Fruzzetti et al. 2005). ules for families with a member with
The second goal is to teach a new lan- BPD. There are specific psychoeduca-
guage of communication based on DBT tion/skills programs for parents of ado-
skills. Relatives and clients readily ac- lescents and young adults and separate
knowledge a lack of commonality in psychoeducation/skills programs for
words and terminology in their commu- couples.
nications, so providing a common set of In a couples psychoeducation/skills
structures and labels is very useful. The program, the patient and his or her
third goal is to promote an attitude that partner (Fruzzetti 2006) participate in a
is nonjudgmental. Frequently, there are one-couple or couple group format. This
family patterns of accusation and finger program focuses on increasing skills to
pointing. High-stress families such as reduce dysfunctional interactions (espe-
those that attend DBT-FST are typically cially those related in any way to indi-
quicker to assess fault and blame toward vidual target behaviors, such as self-harm,
each other than in other relationships in aggression, or substance abuse); enhanc-
their lives. The fourth goal is to provide ing partner awareness; understanding
a safe forum in which discussions and and improving couple communication
problem solving on family issues may (accurate expression and validation); and
occur so that new communication pat- improving couple interaction patterns,
terns are established and a new reper- problem management, and closeness
toire for problem solving is developed. and intimacy.
Groups for parents whose adolescent
DBT with adolescents. A n a d a p t a -
(or young adult) children have BPD (or
tion of DBT by Miller et al. (2006) includes
significant BPD features) have also been
a multifamily group skills program for
developed. Sometimes, of course, these
suicidal adolescent patients with BPD fea-
groups include parents who are them-
tures and their families. This 16-week pro-
selves BPD patients. The goals of these
gram includes both patients and family
groups include education about parent
members. Parents (or another adult in a
and adolescent roles, effective self-man-
patient’s life) are given the role of “skills
agement practices, and effective parent-
coach” to facilitate the patient’s mastering
ing practices (Fruzzetti, in press). This
of DBT skills (Linehan 1993b). This treat-
particular group is challenging both be-
ment program, consisting of the multi-
cause of the inherent fear that parents of
family skills group plus individual DBT
suicidal adolescents have and because
therapy for the adolescent patient, has
many of these parents are themselves
been shown to be successful in reducing
very distressed and lacking in skills.
suicidality, hospitalizations, and depres-
Thus, the following dialectic is embraced
sion while increasing treatment retention
wholeheartedly: “Taking care of your-
and global adjustment (Rathus and Miller
self is taking care of your children; and
2002). However, no component analysis
taking care of your children is taking
studies have attempted to determine the
care of yourself.” The basic idea under-
impact of the family psychoeducation
lying these groups is for parents to learn
component per se.
many of the same skills that their chil-
DBT family skills groups. DBT family dren need—to manage their emotions
skills groups, developed by Fruzzetti and and themselves—in addition to learning
good parenting skills (e.g., limit setting, tion program developed specifically for
positive attention, listening and valida- family members, so patients do not at-
tion, fostering independence). tend. FC was developed to provide all
four functions of psychoeducation: edu-
Systems Training for cation/knowledge, coping and family
Emotional Predictability skills, social support, and problem solv-
and Problem Solving ing. The groups are co-led by trained
Blum and colleagues (2002, 2008) devel- family members who volunteer their
oped STEPPS, a program for patients and time in a mentoring capacity or by mental
families that focuses on psychoeduca- health professionals (or mixed co-lead-
tion. STEPPS, which is added to ordi- ers). FC is a 12-week multifamily group
nary treatment, includes two phases: a program that follows a standardized man-
20-week basic skills group and a 1-year ual (Fruzzetti and Hoffman 2002). The
advanced program that meets once ev- course content was adapted in consulta-
ery other week. It utilizes two modali- tion with family members and consumers.
ties: 1) cognitive-behavioral training FC provides participants with informa-
and skills training and 2) a systems com- tion and research, teaches skills to im-
ponent that encompasses the patient’s prove well-being, and offers an opportu-
environment and the individuals who nity for attendees to acquire tools to help
compose that environment. The patient manage their own emotional states more
system includes anyone with whom the effectively. Using information and educa-
patient has regular contact and who is tion modules as building blocks, the
deemed important to educate about the course focuses on education, skill acqui-
disorder. Family and significant others sition, and skill application. Additionally,
become an integral part of the treatment because family members of persons with
and are encouraged to attend education BPD typically express feelings of isola-
and skill sessions to learn ways to sup- tion and aloneness, FC provides the op-
port the patient’s treatment and to rein- portunity for them to work together as
force his or her newly acquired skills. a group on skill building, to share ex-
The patient assumes the role of co- periences and hear that others are going
teacher to inform people important to through similar situations, and to de-
him or her about the disorder and also to velop a support network. Several pub-
educate them on skills that are helpful lished studies of FC (Hoffman et al. 2005,
for managing one’s emotions more ef- 2007; Rajalin et al. 2009) demonstrate that
fectively. Studies show that participa- this program is effective in 1) reducing
tion in STEPPS contributed to reduced family member grief, 2) lessening bur-
BPD severity, negative affectivity, and den, 3) reducing depression, and 4) in-
impulsivity and to improved general creasing mastery and empowerment.
functioning (Blum et al. 2008).
Family Connections Conclusion

Family Connections (FC) is administered
by the National Education Alliance for There are several well-established and
Borderline Personality Disorder, a nonempirically supported applications of
profit organization dedicated to improv- psychoeducation for PDs in general and
ing the lives of people with BPD and their for BPD in particular. These include
loved ones. FC is a no-cost family educa- Gunderson’s multifamily groups, applica-
Psychoeducation 319
tions of DBT, STEPPS, and Family Con- patients with borderline personality
nections. Good effects have been shown disorder: a randomized controlled trial
and 1-year follow-up. Am J Psychiatry
in programs using psychoeducation as
165:468–478, 2008
part of a treatment package for BPD, and Cowdry RW, Gardner DL: Pharmacotherapy
good outcomes have been shown for us- of borderline personality disorder: al-
ing family psychoeducation to improve prazolam, carbamazepine, trifluopera-
family functioning and/or the well-being zine, and tranylcypromine. Arch Gen
of non-patient family members. Clearly, Psychiatry 45:111–119, 1988
Cuijpers P: The effects of family interven-
more research is needed to develop and
tions on relatives’ burden: a meta-analy-
apply psychoeducation to the variety of sis. J Ment Health8:275–285, 1999
PDs currently under study and to under- Cummings EM, Davies PT, Campbell SB:
stand the relative importance of the var- Developmental Psychopathology and
ious components of psychoeducation Family Process: Theory, Research, and
Clinical Implications. New York, Guil-
(education, social support, individual
ford, 2000
and family skills, supported problem Dutton DG: The Abusive Personality: Vio-
solving) to improve patient outcomes lence and Control in Intimate Relation-
across all PDs. ships. New York, Guilford, 1998
Eisenberg N, Valiente C, Morris AS, et al:
Longitudinal relations among parental
emotional expressivity, children’s regu-
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C H A P T E R 15
Somatic Treatments
S. Charles Schulz, M.D.
Katharine J. Nelson, M.D.
The emergence of the diagnos- with the goal of improving the outcomes
tic category of personality disorders of patients who had been known to have
(PDs) derived primarily from the psy- substantial difficulty in improvement,
choanalytic field, in which the concept including patients with disorders rang-
of PDs and specific symptoms were de- ing from schizophrenia and bipolar
scribed. Therefore, the early treatment disorder to borderline PD (BPD), schizo-
approaches tended to focus on psycho- typal PD (STPD), and other symptoms
dynamic treatment techniques. As DSM- classified in the realm of personality
III became established in 1980 as the dysfunction.
manual for the categorization of objec- The vast majority of the literature on
tive diagnostic criteria for PDs (Ameri- PDs is centered on the pathophysiology
can Psychiatric Association 1980), the and treatment of BPD. BPD significantly
methodology and rate of completion of impacts the lives of individuals with the
clinical trials improved. These efforts disorder, as well as their family, medical
were aided by structured diagnostic in- providers, and society, particularly be-
terviews, such as the Diagnostic Inter- cause of the high rates of morbidity and
view for Borderlines (Kolb and Gunder- mortality due to the presence of nonsui-
son 1980). At the same time, the field of cidal self-injury and suicidal behaviors.
psychiatry was exploring neuroscience Patients with BPD suffer enormously with
aspects of psychiatric illness, such as the difficulties in emotion regulation and in-
theoretical role of neurotransmitters in terpersonal functioning, resulting in dis-
specific symptoms, and biological mark- ability and functional problems in multi-
ers of illness, such as variations in levels ple domains of living. BPD tends to by
of cortisol associated with depression ego-dystonic, which prompts patients to
(Carroll 1986). This neuroscientific- seek care from mental health profession-
biological approach to psychiatry led to als. The other PDs tend to be ego-syntonic
an increase in clinical medication trials and thus offer fewer opportunities for di-
321
rect treatment and certainly fewer oppor- havior therapy (DBT; Linehan et al. 1991)
tunities for patient participation in clini- and mentalization-based therapy (Bate-
cal treatment trials. Early descriptions of man and Fonagy 2008).
BPD conceptualized this disorder as un- The introduction of a number of sec-
treatable because it tended to be associ- ond-generation medications—beginning
ated with worsening of symptoms in the with fluoxetine and followed by other
psychoanalytic treatment setting, includ- selective serotonin reuptake inhibitors
ing the observation of the emergence of (SSRIs), and then second-generation/
psychotic-like symptoms during periods atypical antipsychotic medications and
of stress. This observation resulted in mood-stabilizing anticonvulsant medica-
the use of the term pseudoneurotic schizo- tions such as divalproex—led to increased
phrenia, a precursor to the diagnostic label momentum and attention to medication
of borderline personality disorder (Hoch and treatment over the past two decades. Dur-
Polatin 1949). ing this time, the field has produced a
The second most studied PD is STPD, number of positive studies of classes of
which is now described as being part of medications for the treatment of PDs,
the continuum of psychotic spectrum without the intolerable side effects ob-
disorders in DSM-5 (American Psychi- served with the first-generation medica-
atric Association 2013). This disorder is tions. However, emerging controversy
notable for the presence of ideas of refer- and diverging international opinion ex-
ence, magical thinking, oddness, and ec- ists regarding the effect size of and the
centricity that significantly interfere with generalizability of treatments with these
an individual’s functioning but do not medications. Furthermore, because of the
meet full criteria for a psychotic disor- positive outcomes of structured therapies
der, such as schizophrenia. such as DBT, there has been considerable
With the increase in classical clinical controversy and debate over the role of
trial studies in the 1980s came the assess- medications versus psychosocial treat-
ment of a number of first-generation an- ments for the treatment of PDs. A chal-
tipsychotic and antidepressant medi- lenge for the somatic approach to the
cations for PDs. Mood-stabilizing agents treatment of PDs is rooted in compari-
such as lithium were also tested based sons of effect sizes when matched against
on the observation of rapidly undulating psychotherapies, concerns about meta-
mood in patients with PDs. However, bolic side effects, and other issues.
during the first decade of these medi- Clinical research for somatic treatment
cines being tested, the positive results of of PDs is now at a point where there
studies were often outweighed by the have been a number of emerging studies
side effects of the medications, such as in recent years as well as very interesting
movement disorders. These concerns meta-analyses. In this chapter, we dis-
led to a pause in the series of trials in the cuss the pharmacotherapies for PDs, as
PD medication treatment arena. Inter- well as electroconvulsive therapy (ECT).
estingly, at this same time there was in- We also review meta-analytic studies,
creasing interest in the development and explore future directions for additional
empirical substantiation of psychothera- study, and discuss suggestions for best
peutic approaches such as dialectical be- clinical management practices.
Somatic Treatments 323
University of Pittsburgh and therefore

Pharmacotherapies were clearly persons seeking help for se-
vere symptoms rather than symptomatic
volunteers. In this study, haloperidol at
Antipsychotic Medications low dosages was significantly superior to
placebo, and, compared with Goldberg et
First-Generation al.’s study, even better than placebo on
Antipsychotics essentially all of the ratings. Haloperidol
Historically, antipsychotic medications was superior to amitriptyline in this pa-
were tried for disorders that would now tient group. In subsequent reports, Soloff
be considered BPD and/or STPD. Inter- et al. (1986) described a number of patients
estingly, the early results indicated that a with BPD who actually had worsening
number of psychotropic agents were ben- symptoms when taking amitriptyline.
eficial for the patients. In reflecting on Findings from these two blinded and pla-
these early trials, however, one wonders cebo-controlled trials were consistent with
whether these patients were very signifi- those of other studies in which two anti-
cantly ill and may not have had the same psychotic medications were compared
characteristics as the patients with BPD with each other (Serban and Siegel 1984),
currently being seen in clinics. An initial resulting in a significant interest in the
description of patients receiving what use of antipsychotic medications for
was termed “low-dose neuroleptic treat- treating patients with BPD, mainly those
ment” (Brinkley et al. 1979) led to a series with comorbid STPD.
of medication trials that were structured Subsequent to these studies, Soloff et
in a way similar to studies of psychotic al. (1993) continued work examining halo-
illnesses, such as schizophrenia. peridol as a treatment for BPD and noted
The report by Brinkley et al. on a group that, in their second trial, haloperidol
of antipsychotic medications was fol- did not separate from placebo. As in the
lowed by the first placebo-controlled tri- earlier trial, in which the design focused
als of low doses of first-generation anti- on the ability to compare the effects of an
psychotic medications for patients with antipsychotic with an antidepressant,
BPD or STPD. Goldberg et al. (1986) de- the monoamine oxidase inhibitor (MAOI)
signed a double-blind, placebo-controlled phenelzine was included and was more
trial of thiothixene given at a low dosage effective than placebo. Other reports ex-
(8.7 mg/day) in patients recruited from amined antipsychotic medications for
the community. The research team noted patients with STPD (Hymowitz et al. 1986)
statistically significant changes while ex- and reported some benefit but also noted
amining a number of schizotypal symp- some difficulties with patients’ manage-
toms. Of interest, however, was that the ment of side effects. Investigators noted
group of patients receiving placebo had that even if patients may not have had
the same amount of global improvement major movement disorders with the
as the group taking thiothixene. Soloff et first-generation antipsychotic medica-
al. (1989) designed a trial for patients with tions, they felt somewhat stultified or
BPD to compare haloperidol at low dos- slowed and chose not to continue taking
ages (4–16 mg/day) with amitriptyline at the medication.
regular depression treatment dosages In this same era, Cowdry and Gardner
(100–175 mg/day) and placebo. In this (1988) examined outpatients referred to
trial, the subjects were inpatients at the their National Institute of Mental Health
program in which they examined four noses. In one trial, 12 inpatients with BPD
classes of compounds in order to deter- and severe psychotic-like symptoms were
mine whether there was specificity for treated with clozapine at dosages rang-
the complex illness of BPD. They studied ing from 25 to 100 mg/day. Participants
the antipsychotic trifluoperazine, the ben- in this small sample experienced overall
zodiazepine alprazolam, the anticonvul- improvement, specifically in impulsivity
sive carbamazepine, and the antidepres- and affective instability (Benedetti et al.
sant tranylcypromine. Many participants 1998). The use of clozapine has been lim-
did not continue use of trifluoperazine ited clinically by the need for initial as-
beyond the first phase of the trial be- sessment and monitoring of blood counts
cause of limited tolerability. There was (specifically neutrophils) to assess for
no statistical difference in patient or and minimize the risk of developing se-
staff rating scale scores between the an- vere neutropenia, a life-threatening con-
tipsychotic and placebo for the patients dition associated with use of this medica-
who did continue taking this medication. Clozapine and all other second-
tion. The authors noted that there may generation antipsychotics are associated
have been issues with the generalizabil- with metabolic risks, such as weight gain,
ity of this finding because the partici- diabetes, and elevated blood lipids, that
pants in this study tended to demonstrate increase the risk of cardiovascular risks,
symptoms that emphasized difficulties such as coronary artery disease, myocar-
with affective and behavioral problems dial infarction, and stroke. Movement
rather than transient psychotic states or side effects have also been observed, such
schizotypy. as dystonic reactions, tardive dyskinesia,
and neuroleptic malignant syndrome, a
Second-Generation rare but serious condition that could be
Antipsychotics life threatening.
Clozapine was the first second-genera- Following the introduction of cloza-
tion antipsychotic demonstrated to be pine, other second-generation antipsy-
effective for treatment-refractory schizo- chotics emerged. These medications are
phrenia in a large, multi-center trial in the also referred to as atypical antipsychotics
1980s (Kane et al. 1988). Positive reports because they result in substantially de-
of efficacy and relative lack of movement creased movement disorders compared
disorder side effects led to substantial in- with first-generation antipsychotics.
terest in its use for schizophrenia. Inter- Risperidone, the first second-generation
estingly, clozapine was the first atypical antipsychotic approved for the treatment
antipsychotic medication to be studied for of schizophrenia, was tested in BPD in an
BPD. Frankenburg and Zanarini (1993) 8-week trial by Rocca et al. (2002). In this
assessed the use of clozapine in signifi- case series, there was a significant reduc-
cantly ill hospitalized patients with BPD tion in symptoms. Koenigsberg et al.
and comorbid major psychiatric illness. (2003) examined the effect of risperidone
The authors noted a significant decrease on patients with STPD and found a sta-
in the PD symptoms. This remains an ex- tistically significant reduction in the
cellent clinical contribution to the field, symptoms of psychoticism in these pa-
because most studies have examined out- tients with a low dosage of risperidone
patients. In further work using clozapine, (starting dose of 0.25 mg, titrated up-
researchers examined patients who had ward to a dosage of 2 mg/day). The au-
only a PD and no other psychiatric diag- thors noted that two of the patients were
comorbid for both STPD and BPD, and Impulsiveness Scale. The authors noted
those two also showed improvement. that 9 of the 11 subjects who completed
Schulz (1998) compared low doses of ris- the 8-week study found the medication
peridone with placebo in symptomatic to be tolerable. In an open-label trial fo-
participants who qualified for the BPD cusing on STPD, Keshavan et al. (2004)
diagnosis and were recruited through noticed improvement both in measures
advertising media. This double-blind, of psychoticism and in mood. This
placebo-controlled trial was conducted study, which took place over nearly 6
in an outpatient program in which the months, observed improvement in 8 of
staff members were trained in DBT tech- 11 subjects and represented an impor-
niques, the patients were given education tant contribution to the field.
handouts and books, and the patients Following the initial open-label trials,
were told that they had 24-hour staff avail- other investigators designed placebo-
ability. In this report, the subjects as- controlled studies of olanzapine in pa-
signed to receive risperidone did have a tients with BPD. Zanarini and Franken-
significant reduction on a number of rat- burg (2001) tested olanzapine in women
ing scales; however, they did not sepa- and noted a positive improvement com-
rate from the placebo group. The inves- pared with placebo. Of interest, the dos-
tigators speculated that the substantial age of olanzapine in this study was low
psychosocial support was of significance (average of 5.3 mg/day) compared with
for the subjects with BPD in both the pla- that used in the treatment of schizophre-
cebo and active medication groups. nia. A larger study compared olanza-
The second atypical antipsychotic pine with placebo in 40 patients with
medication to be released in the United BPD (Bogenschutz and George Nurnberg
States was olanzapine. The compound 2004). This study was the first to use
was found, in comparisons with pla- DSM-based criteria as an outcome mea-
cebo, to reduce symptoms of schizo- sure. Of note, the severity of seven of the
phrenia and was not observed to have nine DSM-specified criteria for BPD was
the same degree of movement disorder reduced in patients taking olanzapine
side effects as do first-generation anti- compared with those receiving placebo.
psychotic medications such as haloperi- Zanarini et al. (2004) compared olan-
dol (Tollefson et al. 1997). Initial assess- zapine with fluoxetine and an olanza-
ments of olanzapine for BPD were open- pine/fluoxetine compound. In this trial,
label studies aimed at assessing the ef- the olanzapine/fluoxetine compound
fect of the medication on standard rating was most effective, but the gains were not
scale symptoms (e.g., Symptom Check- statistically greater than those for olan-
list–90 [SCL-90]; Derogatis et al. 1973) zapine. Both the olanzapine/fluoxetine
and examining potential side effects. compound and olanzapine were supe-
The first trial by Schulz (1998) assessed rior to fluoxetine. This was of interest to
11 patients at a total daily dose of 7.5 mg, the field because at the time there had
approximately half the dose used in pa- been a number of successful fluoxetine
tients with schizophrenia. The results case series.
demonstrated a significant change in An issue facing the field of treatment
symptoms as assessed by the Hopkins for BPD has been the lack of information
Symptom Checklist–90, the Buss-Dur- regarding medication treatment and
kee Hostility Inventory, and the Barratt structured psychosocial treatments. To
address this issue, Soler et al. (2005) 10 mg of olanzapine, or placebo. There

tested olanzapine by giving either the was a statistical reduction of ZAN-BPD
active medication or placebo to patients symptoms in the 5- to 10-mg group, but
enrolled in DBT. The authors entered 60 the 2.5-mg group did not separate from
subjects in the study and found an ad- placebo. As in the previous trial, the olan-
vantage for olanzapine over placebo on zapine groups showed statistically sig-
depression and impulsivity rating scales. nificant increased metabolic side effects.
Linehan et al. (2008) similarly reported After the completion of the two studies,
an advantage of olanzapine added to the open-label continuation trial (Zanarini
DBT compared to placebo added to DBT. et al. 2012) showed that the patients who
Their results showed a reduction in an- had been assigned to receive placebo in
ger during the study—an area of potential either of the two double-blind studies
usefulness in engaging the patients in had a reduction in symptoms with open-
treatment. label use of olanzapine. Also, the patients
To further address olanzapine’s poten- who continued in the study after having
tial in the treatment of BPD, two large taken olanzapine in an earlier study con-
registration trials were designed to test tinued their improvement.
the medication versus placebo (Schulz et The third second-generation antipsy-
al. 2008; Zanarini et al. 2011). The design chotic medication to be released in the
included patients with BPD, but to assess United States for the treatment of schizo-
the specificity of the treatment, no sub- phrenia was quetiapine. This antipsy-
jects with a comorbid PD were studied. chotic medication was shown to reduce
Also, comorbidities of other major psy- symptoms of schizophrenia relative to
chiatric disorders were substantially lim- placebo (Small et al. 1997). The medi-
ited. This design differs substantially cation has since been assessed using an
from the design of a number of the earlier open trial methodology for both inpa-
studies of antipsychotic medications in tients and outpatients with a BPD diag-
patients with comorbid BPD and STPD. nosis (Adityanjee et al. 2008). Of interest
In the first published of these two large is the wide range in dosing of quetia-
trials, Schulz et al. (2008) reported that pine, with relatively high doses being
olanzapine was not statistically signifi- assessed in the inpatient setting for pa-
cantly superior to placebo by the end of tients with BPD. These open-label studies
the 12-week study, and both the placebo and case series frequently cite sedation as
and medication groups showed a reduc- a side effect, as well as increased appetite,
tion of symptoms over the course of the dry mouth, and weight gain (Adityanjee
trial, as assessed by the Zanarini Rating et al. 2008).
Scale for Borderline Personality Disorder Aripiprazole is an antipsychotic med-
(ZAN-BPD). The authors also reported ication with a unique activity in the brain;
on the metabolic side effects in the two it is a partial agonist of dopamine recep-
groups; the olanzapine group had signif- tors, in addition to having the usual do-
icantly greater weight gain and a higher paminergic antagonism effects of other
incidence of treatment-emergent abnor- antipsychotics. This medication was
mally high levels of prolactin. Later, in judged to have significant effectiveness
the largest BPD study performed to date, in schizophrenia (Kane et al. 2002) and
Zanarini et al. (2011) randomly assigned has now been tested by M.K. Nickel et al.
451 outpatients, ages 18–65, to receive a (2006) for BPD. In this trial, 43 women
fixed low dose of olanzapine (2.5 mg), 5– and 9 men with DSM-III-defined BPD
were randomly assigned to receive ei- trial, phenelzine was superior to pla-
ther 15 mg/day of aripiprazole (n=26) cebo. Despite the positive results of the
or placebo (n=26) for 8 weeks. The au- study, issues related to side effects (in-
thors noted that symptoms of anxiety cluding diet management issues) did
and depression, as well as anger, were not lead to significant use or further tri-
broadly reduced. This study was ex- als of MAOIs.
tended to an 18-month follow-up to as- The MAOI tranylcypromine (40 mg/
sess long-term use of the medication. The day) was tested by Cowdry and Gardner
authors noted significant improvement (1988) in a multiple medication study of
on all outcome measures over this pe- 16 female outpatients. The authors noted
riod of time (M.K. Nickel et al. 2007). that this MAOI was rated better than pla-
In summary, antipsychotic medications cebo by the patients and the physicians.
have been tested for BPD, BPD and STPD They also commented on its potential
together, and STPD alone. Some, but not usefulness in combination with the psy-
all, of the studies have shown symptom chotherapy the subjects were receiving.
reductions in open-label trials, and anti- This report, perhaps combined with some
psychotic medications have been supe- of the safety issues related to TCAs, such
rior to placebo in some, but not all, stud- as the significant toxicity in the case of
ies. Also of note are the two studies in overdose, diminished the interest in TCAs
which an antipsychotic medication was for BPD. Examination of MAOI studies
added to a structured psychosocial treat- has shown dosing ranges similar to doses
ment (i.e., DBT), and the combination used in depression treatment. In this cat-
demonstrated a statistical advantage. Of egory of medication, the selegiline patch
concern to the field is the issue of side ef- is a newer compound with less significant
fects of the medications, and clinicians dietary side effects, but there are as yet no
must carefully weigh the advantages of studies of this compound in the treat-
the medicine versus the side effects. ment of BPD.
With the introduction of fluoxetine,
the first SSRI, investigators interested in
Antidepressants
BPD felt that fluoxetine might be useful
In the early stages of testing antidepres- in reducing symptoms of depression
sant medications in BPD, Soloff et al. and anxiety. The first trials were open
(1986) aimed to assess the potential of label, and results on rating scales such as
specificity of medications and found the SCL-90 indicated that the subjects
that the tricyclic antidepressant (TCA) had a statistically significant reduction
amitriptyline was no better than pla- of symptoms. The first report, by Corne-
cebo. In a subsequent report, Soloff et al. lius et al. (1990), noted improvements,
(1989) noted that approximately a quar- mostly in depressive and impulsive symp-
ter of the subjects experienced deteriora- toms, in five subjects with BPD. In another
tion in their behavior. The group’s next early open-label trial, this time with 22
assessment of antidepressant medica- subjects with BPD, Markovitz et al.
tions examined the MAOI phenelzine at (1991) noted decreased self-injury and
60 mg/day (Soloff et al. 1993). This med- SCL-90 scores. Additionally, Salzmann
ication was selected on the basis of pre- et al. (1995) reported, in a 13-week dou-
vious work demonstrating efficacy in pa- ble-blind, placebo-controlled study, the
tients with anxiety disorders (Ravaris et reduction of anger and commented that
al. 1976). In the Soloff et al. (1993) BPD this is a substantial issue for patients with
BPD. In examining these latter two stud- toms of impulsivity and aggression.
ies, it is interesting to note that the doses Whereas the previously reviewed stud-
of fluoxetine appeared higher than those ies assessed use of antidepressants alone
used in major depression. Dosages ranged in clinical trial format, Simpson et al.
from 20 to 80 mg/day in the study by (2004), in contrast, examined the addi-
Markovitz et al. (1991) and 20 to 60 mg/ tion of fluoxetine to DBT. In this study, in
day in the study by Salzmann et al. (1995). which all subjects received DBT in com-
At the time, the treatment of BPD symp- bination with either fluoxetine or pla-
toms with antidepressant medication cebo, fluoxetine did not emerge as pro-
was a significantly controversial topic in viding an advantage over placebo.
the clinical management field. In summary, early studies of TCAs
Markovitz and Wagner (1995) addi- showed that this class of compounds did
tionally examined venlafaxine, a sero- not lead to an improvement for an entire
tonin-norepinephrine reuptake inhibi- group, and may have led to worsening
tor (SNRI) in an open-label trial. In this of symptoms for the inpatients with
study, patients who had not responded BPD (Soloff et al. 1986). The initial re-
to SSRIs did show improvement with ports on SSRIs, based on open-label stud-
venlafaxine. ies of fluoxetine, showed improvement
The early investigations of medica- in depressive and impulsive symptoms,
tions for BPD focused on those subjects and these open-label findings were con-
whose personality functioning met the firmed in some, but not all, subsequent,
criteria for BPD on the basis of DSM-III controlled studies. It is noteworthy that
criteria (American Psychiatric Associa- Markovitz and Wagner (1995) found that
tion 1980) or the Diagnostic Interview the SNRI venlafaxine may be useful in
for Borderline Patients (Gunderson et al. patients who had had a failed trial with
1981). Of interest in the pharmacothera- an SSRI. With the emergence of PD studies
peutic approach to BPD is examination examining trait domains rather than only
of trait domains in the PDs rather than DSM criteria, Coccaro and Kavoussi
only the global DSM-based criteria. Coc- (1997) demonstrated the potential use-
caro and Kavoussi (1997) investigated fulness of fluoxetine in impulsive/ag-
impulsive/aggressive symptoms in pa- gressive patients. Also of note is the ob-
tients who initially had PD characteris- servation of the higher than usual dosage
tics. Coccaro and colleagues (Coccaro range of fluoxetine in the clinical treat-
and Kavoussi 1991; Coccaro et al. 1997) ment of BPD and the observed safety and
examined the serotonergic underpin- tolerability.
ning of impulsive and aggressive dis-
orders, using both behavioral and neu-
roscientific measures over the years
Anxiolytics
preceding these studies. In a double- Anxiety is a prominent symptom in pa-
blind, placebo-controlled trial (Coccaro tients with BPD. Clinicians have noted
et al. 1997), fluoxetine, given at dosages that difficulties in interpersonal rela-
of up to 60 mg/day, led to improvement tionships, sensitivity to rejection, and
in the early phase of the study, which ex- misperception of the intent of others can
tended to the end of the trial. Thus, a lead to significant distress, and at times
combination of neuroscience and clini- this may lead to dangerous behaviors in
cal trial studies indicated that fluoxetine these patients. Therefore, examination of
could be useful in the domain of symp- anxiolytic medications, such as benzodi-
azepines, seemed reasonable. The highly countries to be very effective in reducing

creative study by Cowdry and Gardner mood swings in patients with BPD. Fur-
(1988) examined four medications from thermore, it did not have the side effects,
different classes, including the benzodi- such as sedation, movement disorders, or
azepine alprazolam (4.7 mg/day), to emotional flattening, that were associ-
learn about the specificity of medication ated with neuroleptic medication. In their
treatment. The results of other parts of pre-DSM-III study, Rifkin et al. (1972) de-
this study are presented elsewhere in the scribed patients who would now be diag-
chapter (see “Antipsychotic Medications” nosed with BPD as having “emotionally
above and “Anticonvulsants” below). No- unstable character disorder.” In this
tably, in the study of alprazolam, which study of inpatients, lithium was substan-
had just been released at the time of the tially superior to placebo in the manage-
study, participants experienced no im- ment of rapid mood swings. Doses simi-
provement in symptoms, and their im- lar to those used for the treatment of
pulsivity and dyscontrol actually wors- bipolar disorder were used in this study.
ened (Gardner and Cowdry 1985). This These results led to a continued interest
carefully controlled study led to concern in this compound, which was considered
about using disinhibiting medication for nonsedating and safe.
such patients, and further trials have not In another study examining lithium
been pursued. Therefore, even though it carbonate in BPD, Links et al. (1990) noted
might occur to a clinician to use benzo- some reduction in symptoms based on the
diazepines in treating symptoms of anx- therapists’ rating scales, but participants’
iety in patients with BPD, there is no em- reports indicated no significant reduction
pirical evidence that the medications are in symptoms for lithium versus placebo.
useful. Of note are the emerging find- The authors noted that lithium reduced
ings of functional imaging in patients impulsive symptoms. Despite these re-
with BPD that are revealing a pattern of ports on lithium carbonate and the obser-
hypofrontal metabolism or blood flow vations of mood changes in patients with
that is related to impulsive/aggressive BPD, the lack of further evidence is diffi-
behavior; in other words, the higher the cult to explain.
rating of impulsive and aggressive be- When lithium carbonate is used in pa-
havior, the lower the frontal lobe activ- tients with BPD, as when it is used to treat
ity (Goyer et al. 1996). Decreasing the patients with mood disorder, assessment
mechanism of self-control may be an un- and monitoring of thyroid and kidney
derpinning of these observations of ben- function is necessary. Patients and fami-
zodiazepine-induced disinhibition in lies need to know about side effects, such
patients with BPD. as tremor, thirst, and increased urination,
as well as the potential for neurological
complications in the setting of lithium
Lithium Carbonate toxicity. Lithium blood levels must be
Lithium carbonate was approved by the monitored. This medication may pose sig-
U.S. Food and Drug Administration nificant morbidity or mortality if taken in
(FDA) for use in bipolar disorder in the an overdose, which is a particular risk
early 1970s. This medication had been factor for patients with BPD and suicidal
found over the previous 20 years in other behavior.
Anticonvulsants bipolar II disorder who also qualified for

the diagnosis of BPD. This was a very
During the 1970s, there was emerging useful study in light of the frequent co-
research examining the impact of anti- morbidity of these disorders. Interest-
convulsant medications on bipolar dis- ingly, Frankenburg and Zanarini exam-
order. An early report from Japan noted ined symptoms of impulsive aggression
a reduction in bipolar symptoms in sub- using a standardized rating scale and
jects treated with carbamazepine (Okuma found a statistically significant reduction
1983). This work was followed closely by of symptoms with divalproex in this co-
reports examining the potential brain morbid group. In a related trial of dival-
physiology underpinning temporal lobe proex sodium in outpatients with BPD,
stimulation leading to an increased fre- Hollander et al. (2001) found a reduction
quency of mood symptoms (Ballenger of symptoms in the patients receiving di-
and Post 1978; Post et al. 1986). The first valproex sodium. However, there was a
group to examine use of an anticonvulsant very significant dropout rate in the pla-
medication in BPD was Cowdry and cebo group, which made interpretation of
Gardner (1988), drawing on their earlier the results somewhat difficult. Hollander
work in bipolar disorder, in which car- et al. (2005) later examined subjects with
bamazepine was used in one of the arms impulsive and aggressive symptoms to
of their four-medication treatment trial. look further into the borderline, narcissis-
The significantly useful outcome mea- tic, antisocial, and histrionic PD groups.
sure was a decrease in suicide attempts There was a reduction in symptoms in
by this impulsive group. Interestingly, these diagnostic groups overall. However,
although there was no overall change in when Hollander and colleagues then fo-
the participants’ assessment of improve- cused only on the patients with BPD, they
ment in their own symptoms, an objec- noted a significant decrease in aggression
tive decrease in measured impulsivity and trait impulsiveness when divalproex
and suicidality was considered mean- was used. In these studies, the mean dos-
ingful. Unfortunately, there was also an age was approximately 1,250 mg/day,
increase in depressive symptoms in these similar to the dosages used for epilepsy
patients during the anticonvulsant pe- and bipolar disorder. Because blood lev-
riod of the trial. In a subsequent double- els of divalproex can vary widely at a
blind, placebo-controlled study, de la given dosage, assessment of blood levels
Fuente and Lotstra (1994) examined the is important. The monitoring of side ef-
use of carbamazepine in hospitalized in- fects, which include weight gain and se-
patients with BPD. In this trial, there were dation, is also important. Women with
no differences in symptomatic outcomes the potential to bear children should be
between patients given carbamazepine counseled about the risk of birth defects,
and those given placebo. including neural tube abnormalities, es-
During the 1980s, there was a greater pecially following exposure to valproic
interest in assessing the utility of dival- acid in the first trimester.
proex sodium for the treatment of bipolar Other anticonvulsant medications
disorder. This led to examination of the have been released since these early trials
medication for PDs. Frankenburg and were begun, and medications such as ox-
Zanarini (2002), in one of their studies of carbazepine and topiramate have been
patients with BPD, also examined dival- examined for patients with PDs. Of note
proex sodium in a group of patients with are studies by M.K. Nickel et al. (2004,
2005) and C. Nickel et al. (2005) examin- this work was spawned from early stud-
ing topiramate. In this series of studies, ies of lamotrigine in bipolar disorder by
topiramate was assessed in double-blind, Calabrese et al. (1999), who reported
placebo-controlled trials, first in women that lamotrigine had positive impact on
(M.K. Nickel et al. 2004) and then in men the depressive phase of the illness. These
(M.K. Nickel et al. 2005). In both studies, findings led to speculation about the po-
the investigators used the State-Trait An- tential usefulness of lamotrigine for de-
ger Expression Inventory (STAXI; Spiel- pressive symptoms in patients with
berger et al. 1999) as an outcome measure BPD. Pinto and Akiskal (1998) reported
and noted significant reductions in anger on an eight-subject case series in which
in both groups. The group given topira- three patients with BPD showed im-
mate (up to 250 mg/day) interestingly provement in global functioning. Tritt et
lost more weight than the placebo group. al. (2005) completed the first placebo-
This research group then used SCL-90 controlled study of lamotrigine in the
measures to assess the effects of topira- treatment of patients with BPD, using
mate and noted a significant decrease the STAXI as the outcome tool, and they
in scores on some of the scales, such as noted significant improvement and safety.
Somatization, Interpersonal Sensitivity, More recently, Reich et al. (2009) as-
Anxiety, Hostility, and Phobic Anxiety sessed lamotrigine in patients with BPD
(Loew et al. 2006). In this study, the high- in a double-blind trial using the ZAN-BPD
est dosage was 200 mg/day. Of clinical and noted reductions in Affective Labil-
note was the reduction in weight for pa- ity Scale scores and in the affective insta-
tients taking topiramate, because weight bility item. They also noted a reduction
gain has been a substantial clinical issue in impulsivity. Of special note in clinical
for second-generation antipsychotic management is the importance of using
medications and, to a lesser degree, other a slow titration of the medication and
psychiatric medications, such as anticon- monitoring for possible skin rash or le-
vulsants and some antidepressants. sion, to minimize the risk of potentially
Topiramate has been studied in many life-threatening development of Ste-
areas of neurology and psychiatry, and vens-Johnson syndrome.
observations have emerged indicating
that it may have a negative impact on cog-
nition. Loring et al. (2011) assessed this is-
Omega-3 Fatty Acids
sue in a study of both epilepsy patients Although much of the discussion of so-
and healthy volunteers. The authors matic treatments for PDs may focus on
noted a negative impact of topiramate on pharmaceuticals, omega-3 fatty acids have
neuropsychological assessment and noted been the object of a double-blind, placebo-
that it was dose related, with the greatest controlled trial for BPD. This study, in
impact for those given topiramate at the which subjects were assigned to receive
highest dosage (384 mg/day). The cogni- either omega-3 fatty acid (1 g/day) (n=20)
tive impact of topiramate related to its or placebo (n=10), found a statistical ad-
dose is important if the medication is used vantage of the compound compared with
in patients with PDs. placebo. The study’s focus was on aggres-
Lamotrigine is another medication that sion and depressive symptoms (Zanarini
has been explored for use in BPD. Some of and Frankenburg 2003).
vidual studies is somewhat limited. The

Electroconvulsive Cochrane Collaboration conducted a
meta-analytic study of randomized con-
Therapy trolled medication trials of patients with
Numerous patients with PDs who have antisocial PD (Khalifa et al. 2010). The
comorbid depression and are not re- existing evidence is sparse. Eight trials
sponsive to first-line treatments may be examining eight medications were iden-
considered for ECT. The studies in the lit- tified, but data could be reviewed for
erature do not appear to have tested ECT only four of the trials. The quality of the
utilizing clinical trial methodology for studies was considered insufficient, and
BPD, but have examined ECT outcomes thus no conclusions could be drawn.
for patients with comorbid depression The Cochrane Collaboration is in the
and BPD compared with depressed pa- midst of preparing reviews for the phar-
tients. Zimmerman et al. (1986) examined macological treatment of paranoid,
depressed patients with and without BPD schizoid, schizotypal, histrionic, narcis-
and noted equivalent short-term out- sistic, avoidant, and obsessive-compul-
comes but greater symptomatology at 6- sive PDs, each of which unfortunately
month follow-up. In another evaluation has limited literature on which to base
of personality traits and major depres- clinical decisions.
sion, Blais et al. (1998) reported no signifi-
cant change in personality traits after ECT BPD and International
treatment. Feske et al. (2004) noted that
patients with BPD and depression had
Practice Guidelines
poorer outcomes at an 8-day follow-up To address the significant need for evi-
than did those with major depression dence-based guidance on clinical man-
and another group with major depression agement of BPD, researchers in several
and other personality symptoms. These countries have developed practice guide-
findings do not address using ECT for lines based on meta-analytic reviews. A
patients with BPD alone, but the lack of consistent theme among such efforts is
improvement of BPD symptoms in de- the acknowledgment of methodological
pressed patients leads to some caution in limitations due to the relatively limited
the application of ECT for this disorder. number of clinical trials in the area of
BPD treatment and differences in study
design, which challenge pooling of the
Meta-Analytic Studies data.
The first practice guideline for the
of Somatic Treatments treatment of patients with BPD was de-
veloped in the United States by the
Personality Disorders American Psychiatric Association (APA)
in 2001, and it included a set of clinical al-
Other Than BPD gorithms for the adjunctive use of medi-
Significant effort has been invested in re- cations for BPD, based on the limited
viewing the available literature to best research available at the time. This guide-
advise practicing clinicians in the care of line was developed prior to the majority
patients with PDs. As described in this of research described earlier in this chap-
chapter, many clinical trials have been ter and included only seven placebo-con-
small, and the generalizability of indi- trolled clinical trials. The APA guideline
suggested that clinicians consider symp- treatment, the authors recommended

tom domains of BPD and pointed to anti- identification of clear treatment targets
depressant medications as a first-line and discontinuation of treatment if im-
treatment for affective symptoms. The provement in these targets is not ob-
guideline noted that the combination of served. The data suggested that SSRIs
psychotherapy and psychopharmacol- are possibly effective for the treatment of
ogy is probably the most useful strategy anxiety, depression, and affective insta-
in the overall management of BPD. The bility symptoms. Evidence also suggested
APA guideline is currently considered that atypical neuroleptics and mood sta-
outdated because of the significant num- bilizers may possibly be effective for
ber of clinical medication and combined hostility, anger, impulsivity, aggression,
medication-psychotherapy trials that and depression.
have been conducted since its develop- After examination of the individual
ment. Furthermore, the FDA has not ap- medications, Stoffers et al. (2010) noted
proved any medication for use in the an important clinical point related to
treatment of PDs. selection of treatment by clinicians—
A Cochrane Collaboration review was namely, that there were very few com-
conducted by German researchers and parisons of medications (which are very
serves to identify high-quality evidence useful in determining a treatment). The
that clinicians may use in making indi- authors also noted that among the ther-
vidualized practice decisions (Stoffers apeutic effects of medications, changes
et al. 2010). The reviewers identified 28 in feelings of emptiness or abandonment
qualifying studies for analysis of first- were not reported. These symptoms are
and second-generation antipsychotics, an important target of treatment and
mood stabilizers, and antidepressants. would be important to note in managing
Omega-3 fatty acid was also included. the expectations of clinicians and pa-
Outcome measures included treatment tients. This clinical pattern is very simi-
impact on BPD severity, amelioration of lar to that of antipsychotic medications
BPD core pathology, changes in associ- on schizophrenia, in that the medica-
ated psychopathology, and participant tions reduce hallucinations and delu-
attrition. In this comprehensive assess- sions but have little effect on negative
ment, the reviewers noted some sup- symptoms or cognition.
porting evidence for medication therapy In a similar Cochrane Collaboration
in the treatment of BPD—mostly for the review, Stoffers et al. (2012) carefully as-
second-generation antipsychotic medi- sessed psychological therapies for BPD,
cations, mood stabilizers, and omega-3 describing 28 studies that included psy-
fatty acid. In the area of safety, the most chological treatment modalities such as
prominent side effects were related to DBT, schema-focused therapy, mentaliza-
weight gain and metabolic abnormali- tion-based therapy, group therapy, and
ties observed with olanzapine. Similar to Systems Training for Emotional Predict-
the recommendations of the APA Practice ability and Problem Solving. Examina-
Guideline, the reviewers in the Coch- tion of the articles shows that in some
rane meta-analysis noted that medica- studies, many of the subjects were receiv-
tion treatment should be combined with ing medications on entry and throughout
psychotherapy with close attention to the studies. This observation highlights
the therapeutic relationship. Based on the fact that because many patients with
the limited long-term data of medication BPD are being treated with medications
even if they are being referred to psycho- care system. The guidelines describe strat-
therapy treatment, the evidence for the egies for improved access to care, the im-
efficacy of psychotherapy is not necessar- portance of therapeutic relationships,
ily derived in isolation from pharmaco- patient autonomy and choice, and ser-
logical treatment and effects. vice planning in the community. The
In the Netherlands, Ingenhoven et al. guidelines also clearly state, however,
(2010) conducted a meta-analysis of 21 that the existing level of evidence for the
BPD medication treatment studies, with use of medication in the treatment of
the intent of identifying high-quality clin- BPD does not yet meet the standard
ical evidence. This analysis focused spe- needed in order to recommend use. The
cifically on the BPD domains, which in- guidelines also nonempirically describe
cluded cognitive-perceptual symptoms, using sedating antihistamines, such as
impulsive-behavioral dyscontrol, affec- hydroxyzine, to assist in immediate cri-
tive regulation, and global functioning. sis or insomnia.
The studies under consideration in the The most recent clinical guideline,
analysis used placebo-controlled trials from the Australian National Health and
that included participants with BPD and/ Medical Research Council (2012), con-
or STPD. The authors reported a moder- tains 63 recommendations for compre-
ate to very large effect of mood stabilizers hensive patient care, including, diag-
on impulsive-behavioral dyscontrol, an- nosis, treatment, management, and
ger, and anxiety, and a moderate effect on information for caregivers. The guide-
depression (Table 15–1). For antipsy- line states that persons with BPD should
chotic medications, a moderate effect was be referred to structured psychothera-
seen on cognitive-perceptual disturbances pies designed for BPD and should be of-
and a moderate to large effect was seen fered choices. Regarding medication
on anger. For the antidepressants, there treatment, the guideline notes that med-
were small effects on anxiety and anger. ication should not be used as a primary
The authors concluded that this analysis therapy for BPD because of effects that
supports the use of medications to target are modest, inconsistent, and not helpful
specific symptom domains, a finding that for modifying the course of the disorder,
is consistent with the American Psychiat- although short-term use of medication
ric Association (2001) guideline, discussed as an adjunct to psychological therapy to
at the beginning of this subsection. The manage specific symptoms may be con-
Dutch have developed a clinical guide- sidered. Similar to the NICE guidelines
line that approaches BPD management (National Collaborating Centre for Men-
through the use of hierarchical symptom- tal Health 2009), this guideline recom-
targeted treatment algorithms (Practice mends that medications be used in acute
Guideline on Diagnosis and Treatment of crisis situations and discontinued after
Adult Patients With a Personality Disor- the crisis is resolved.
der 2008).
In the United Kingdom, the National
Collaborating Centre for Mental Health Future Directions
(2009) issued its National Institute for
Health and Clinical Excellence (NICE) Even though the field of somatic treat-
guidelines for the treatment and man- ments of PDs has advanced in many ways
agement of BPD to equip clinicians prac- with a significant number of clinical tri-
ticing through the governmental health als, specific and objective rating scales,
Somatic Treatments
TABLE 15–1. Results of a meta-analysis of controlled trials
Dosage range
Medication class Target domains (effect size) Major trials (mg/day) Major side effects
Antipsychotics Anger (moderate/large) Haloperidol 4–16 Weight gain, hyperlipidemia, diabetes mellitus, dys-
Cognitive-perceptual (moderate) Olanzapine 2.5–20 tonia, tardive dyskinesia, neuroleptic malignant
syndrome
Aripiprazole 15
Risperidone 0.25–2
Anticonvulsant Impulsive-behavioral dyscontrol Valproate 500 (or plasma Dizziness, drowsiness, fatigue, tremor, weight gain,
mood stabilizers (very large) level) Stevens-Johnson Syndrome, cognitive problems
Anger (very large) Lamotrigine 50–200
Anxiety (large)
Carbamazepine 820 (or plasma level)
Depressed mood (moderate)
Topiramate 25–250
Antidepressants Anxiety (small) Phenelzine 60–90 Nausea, constipation, dry mouth, agitation, irritabil-
Depressed mood (small) Fluoxetine 20–80 ity, loss of sexual desire and impairment in sexual
functioning
Fluvoxamine 150
Desipramine 163
Tranylcypromine 40
Amitriptyline 100–175
Source. Adapted in part from Ingenhoven et al. 2010.
335
and meta-analytic comparisons, a signif- per advertisements or recruited from

icant number of issues remain to be ad- clinics or inpatient units.
dressed. These include the following • An emerging area of interest in so-
points: matic treatments for PDs that builds
on the meta-analytic assessments of
• In early clinical medication trials of domains of treatment involves “per-
PDs, multiple types of PDs (e.g., BPD sonalized” treatment predictors uti-
and comorbid STPD) were frequently lizing methodologies such as brain im-
included in trials. Thus, trying to de- aging (New et al. 2004).
termine the specificity of medication • Existing clinical trial methodology
to an isolated PD is quite challenging. utilizes a variety of instruments to
• In the study of PDs, there has been an measure specific traits associated with
emergence of the concept of trait do- PDs, and the field would benefit from
mains within the PDs, perhaps most agreed-on assessments to better com-
frequently in BPD, and new analyses pare trial data (Zanarini et al. 2010).
of clinical trials point to efficacy in • The role of noninvasive neuromodu-
specific symptom domains of PDs lation, such as transcranial magnetic
(e.g., affective instability) rather than stimulation or transcranial direct cur-
for the treatment of the overall PD. rent stimulation, has yet to be ap-
• For major psychiatric disorders, elab- proached in a clinical trial format.
orate trials have been performed to • DSM-5 has retained the diagnostic cri-
examine the effects of medication teria for PDs that appeared in DSM-IV
alone versus medication plus specific (American Psychiatric Association
therapies. Hogarty et al. (1986) showed 1994); however, DSM-5 Section III,
that combined medication and ther- “Emerging Measures and Models,”
apy was better than medicine alone in contains proposed major changes to
the treatment of schizophrenia. How- the criteria and categorization of PDs.
ever, at this point there is very little The impact and application of exist-
similar research for PDs. ing research on this new model re-
• For major psychiatric disorders, there mains to be determined.
has been continued exploration of the
length of time to use medication treat-
ment, yet in PDs there has been no Clinical Approaches
similar empirical assessment.
• Although men and women are both Although the various clinical practice
affected by BPD, evidence suggests guidelines may diverge in the case of med-
that the level of disability and psy- ication therapy indications and practices,
chopathology may be somewhat dif- all agree on the importance of skillful and
ferent. These differences have yet to effective treatment of patients with PDs.
be fully explored in the medication A careful psychiatric evaluation, which
treatment literature. includes assessment of the presence of
• Clinical trials in BPD have tended to all psychiatric disorders, including co-
recruit symptomatic volunteers. There morbid PDs, will serve to inform man-
has been considerable controversy re- agement decisions and expectations. PDs
garding potential differences in study are often comorbid with other psychiat-
outcome based on whether the partic- ric disorders, including major depres-
ipant was obtained through newspa- sion, bipolar disorder, attention-deficit/
hyperactivity disorder, and posttraumatic a pattern of adding or increasing medi-

stress disorder. These comorbid disor- cations, which may result in long medi-
ders require identification and treatment; cation lists that increase the risk of side
however, the presence of a PD has been effects, medication interactions, and ex-
noted to confer aspects of treatment resis- pense, and that may negatively impact
tance (Feske et al. 2004). This finding quality of life. Approaching patients in a
highlights the importance of identifying manner that is responsive and validates
and treating comorbid personality and their distress but without reactively
other disorders concurrently. Of critical adding or increasing a medication in the
importance is correctly discriminating midst of crisis has been noted clinically
BPD from other types of mood disorders, to stabilize the treatment course (Nelson
such as major depression or bipolar and Schulz 2011). Iatrogenic harm has un-
disorder, or identifying the comorbid fortunately played a role historically in
presence of both due to the significant well-meaning attempts to provide care
differences in treatment approaches and for these patients. Many clinicians have
divergence in the weight placed on the noted that patients with BPD in particu-
role of pharmacotherapy. lar tend to be sensitive to side effects,
Cultivation of healthy therapeutic re- and the general wisdom is to start at a
lationships in which patients are edu- low dose and titrate over time based on
cated about their diagnoses and provided tolerability of the medications. Even with
with autonomy and shared decision the low doses of antipsychotic medica-
making will improve chances of recov- tion used for BPD, it is recommended to
ery, based on clinical experience. Patients monitor movement disorder side effects
with BPD benefit from diagnosis dis- and to assess and follow metabolic is-
closure, which can often be facilitated sues such as weight gain, diabetes melli-
through use of a symptom screening tus, and other cardiovascular metabolic
tool, such as the McLean Screening In- side effects. Compliance and suicidal ide-
strument for Borderline Personality Dis- ation are also necessary elements of care
order (Zanarini et al. 2003a). Symptoms that require close monitoring and regu-
can be followed over time with use of a lar follow-up, ideally in a multidisci-
continuous rating scale, such as the plinary manner through coordination
Zanarini Rating Scale for Borderline Per- with the primary care provider. Helping
sonality Disorder (Zanarini et al. 2003b). patients to understand that medication
Zanarini and Frankenburg (2008) dem- will be used to target a problematic
onstrated significant reduction in core symptom domain, with the goal of facil-
BPD symptoms of impulsivity and rela- itating recovery and emotional develop-
tionship conflict in patients provided with ment, will help to set the stage that fu-
psychoeducation shortly after disclo- ture crises are to be expected and not
sure of the diagnosis compared with necessarily representative of medication
those on a waitlist, highlighting the critical or psychotherapeutic treatment failure.
role of informing and teaching patients Identifying the symptom domain that
about their diagnosis. poses the most difficulty for a patient
Patients with PDs have been known can facilitate a discussion in which an
to present in acute distress or crisis. The evidence-based medication may be se-
level of affective intensity tends to prompt lected and titrated over time.
Case Example three times daily as needed to offer

additional treatment of anxiety symp-
Yvette is a 25-year-old college student toms, which had not improved after
referred to the psychiatry clinic by her 6 weeks of treatment with citalopram.
primary care provider. She had been Yvette states that the citalopram causes
treated by her primary care provider nausea, has reduced her sex drive,
for anxiety but wonders if she “might and has not helped with her symp-
actually have bipolar disorder” and is toms. She notes that the lorazepam is
seeking the opinion of a psychiatrist. very helpful for 2–3 hours after taking
She describes a long history of intense the medication, but that she has had
anxiety; she says, “I’ve always been more angry outbursts and recently ex-
this way.” Her anxiety prompts mood perienced increased urges of self-
swings, especially when she is talking injury. On the basis of these worsening
with others on the phone or in person. symptoms, she observes that the lo-
She is frequently irritable and angry, razepam may need to be increased to
and has not been able to work at the better manage her anxiety.
same setting for more than 1 year. She As part of the diagnostic discus-
has had frequent relationships with sion, the psychiatrist offers Yvette a
men that rarely last beyond 6 weeks. symptom screen for BPD. Yvette reads
Yvette describes these relationships as over the symptoms, looks up from the
becoming serious quickly and then page, and states, “These symptoms
ending suddenly without reason. She perfectly describe me. What is this?”
worries that her mental health and She is provided with education about
anxiety play a role in this pattern. She the symptoms and hopeful prognosis
frequently stays up late wondering if of BPD. The psychiatrist has prepared
people are angry with her and won- a handout of reputable resources and
dering what she has done wrong to Web sites for patients to learn more
lead to her multiple perceived fail- about this disorder. Yvette is referred
ures. She has considered suicide, usu- to psychotherapy and considers this
ally in the period following a breakup, option, but she is highly interested in
and she has scars on her wrists and pursuing medication treatment for
thighs from self-injury from early in her symptoms. The psychiatrist vali-
college but none from the past year. dates Yvette’s response to lorazepam,
She avoids alcohol because her mother acknowledging that this medication is
“was an alcoholic.” She denies grandi- helpful in temporarily relieving anxi-
osity or ever having a decreased need ety symptoms, but problems with
for sleep. When asked about elevated its long-term use, such as tolerance,
mood, she described a period of ela- physiological dependency, disinhibi-
tion, lasting 3–4 hours, following re- tory effects, and impact on learning,
ceiving a compliment. She has never indicate that it would seem reasonable
experienced delusions, but she does to begin a slow taper of this medica-
describe frequent mistrust of others’ tion. Yvette is initially reluctant but
intentions and worries that people trusts this recommendation based on
will leave her based on her prior expe- her strong agreement with the diagno-
riences. She also describes frequent sis. The psychiatrist provides coaching
periods of intense sadness, prompted on breathing retraining to assist in the
by interpersonal circumstances, which management of acute anxiety symp-
improve if others work to help her feel toms. Yvette identifies her primary
better. She states, “My moods are all problematic symptom as being affec-
over the place, and I can’t live this tive instability. The risks and benefits
way.” of anticonvulsant mood-stabilizing
Her primary care provider initi- medication are discussed, and Yvette
ated citalopram 20 mg/day to help opts to begin treatment with lamotri-
with anxiety and depression and gine. The clinician gives Yvette the
recently prescribed lorazepam 1 mg option of either continuing or discon-
tinuing the citalopram, and Yvette de- Disorders, 3rd Edition. Washington, DC,
cides to discontinue this medication. American Psychiatric Publishing, 1980
A follow-up session is scheduled for American Psychiatric Association: Diagnostic
2 weeks later. Yvette agrees to com- and Statistical Manual of Mental Disor-
plete a symptom tracking card to mon- ders, 4th Edition. Washington, DC,
itor her symptoms and agrees to look American Psychiatric Association, 1994
into the feasibility of initiating a struc- American Psychiatric Association: Practice
tured, evidence-based psychotherapy guideline for the treatment of patients
for the treatment of BPD. with borderline personality disorder. Am
J Psychiatry 158 (10 suppl):1–52, 2001
Conclusion nostic and Statistical Manual of Mental
American Psychiatric Publishing, 2013
Somatic treatments for PDs appear to Ballenger JC, Post RM: Therapeutic effects of
have been assessed for over 50 years in carbamazepine in affective illness: a pre-
psychiatry. With the emergence of the liminary report. Commun Psychophar-
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major groups of medications have been Psychiatry 165:631–638, 2008
described and comments about the prac- Benedetti F, Sforzini L, Colombo C, et al: Low-
dose clozapine in acute and contin-
tical use of these medications are noted.
uation treatment of severe borderline
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etine in the treatment of borderline per- gine treatment of aggression in female
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2010
C H A P T E R 16
Collaborative Treatment
Abigail B. Schlesinger, M.D.
Kenneth R. Silk, M.D.
Increasing interest in collabo- In the most common form of collabor-

ration across providers, provider types, ative treatment, one clinician prescribes
disciplines, and specialties has resulted psychotropic medication (or somatic
in many definitions of collaborative treatments) and another performs psy-
treatment. In this chapter, collaborative chotherapy. In psychiatry, collaborative
treatment refers to the treatment relation- treatment often involves a psychiatrist
ship that occurs when two or more treat- prescribing psychiatric medication and
ment modalities are provided by more another clinician (e.g., psychiatrist, psy-
than one mental health or medical pro- chologist, social worker, therapist, case
fessional. The tenets presented in this manager) performing the therapy. In-
chapter also apply to integrated models of creasingly, collaborative treatment has
care, when care is provided under one come to represent a situation in which a
clinical organization or umbrella, and primary care physician prescribes psy-
when integration ranges from complete chotropic medication and a nonpsychi-
integration, including discussion and atric clinician conducts psychotherapy.
collaboration, to minimal integration, Collaborative care models in which a
including only shared billing systems, psychiatrist provides consultation to a
records, or administrative support. When care manager, who along with the pri-
two providers are working with a patient mary care physician is systematically
with no collaboration or integration, measuring the response of a patient to
which could be viewed as the most trou- medication treatment, have gained in-
blesome of shared care situations, so- creasing popularity in recent years due to
called split treatment can occur. We re- evidence of their effectiveness (Gilbody
serve the term split treatment for situa- et al. 2006) as well as the increasing need
tions in which lack of communication or to meet the needs of more patients due to
agreement between providers causes a the Patient Protection and Affordable Care
potential impasse in treatment. Act of 2010 (Donohue et al. 2010). Treat-
345
ment can also be divided in many ways age almost exclusively contains either
among primary care physician, psycho- good or bad attributes, rarely contami-
analysts, specialty medical doctors, psy- nated by the opposite attribute. In addi-
chiatrists, specialty psychiatrists, thera- tion, the roles of “good” and “bad” treater
pists, clinical nurse therapists, visiting can shift back and forth over time, with
nurses, physician assistants, case manag- the previously favored professional sud-
ers, different people and disciplines on an denly viewed negatively, and vice versa.
inpatient unit or in a partial hospital pro- Defensive splitting can be accompanied
gram, and many others. by projective identification, in which the pa-
Use of the term collaborative highlights tient projects disavowed aspects of him-
the need for treating clinicians to commu- self or herself onto different treaters. The
nicate and work together because there treaters, in turn, unconsciously identify
are many legal, ethical, and treatment is- with those projected characteristics and
sues and pitfalls that can arise when more may experience pressure to respond ac-
than one provider is involved in a person’s cordingly (Gabbard 1989; Gabbard and
treatment. Patients with personality disor- Wilkinson 1994; Ogden 1982).
ders (PDs), especially those who have
traits that are common to Cluster B disor-
ders, such as emotional lability (Negative Case Example 1
Affectivity), depressivity (Negative Af- Zia, a young woman diagnosed with
fectivity), separation insecurity (Negative borderline PD, was in psychotherapy
Affectivity), and hostility (Antagonism), with a psychologist and receiving
tend to “split” even without a “split” medication from a psychiatrist. Zia
had an extensive history of self-muti-
treatment relationship, and treaters must
lating behavior. The psychologist was,
keep this propensity in mind when enter- even in his everyday interactions,
ing into a collaborative care model with quite restrained.
another clinician for a patient with a PD. Zia was acutely aware of rejection,
Splitting, in its most formal psychoana- and she would call the psychiatrist to
lytic sense, is a defensive process wherein complain vociferously about her psy-
chotherapist’s lack of feeling or em-
a patient appears to attribute good char-
pathy. Every 6 or 9 months of this, she
acteristics almost exclusively to one per- would try to convince the psychia-
son (or one provider of treatment) while trist, whom she knew did psychody-
attributing to the other treater all bad or namic psychotherapy, to take over all
negative feelings. The patient appears to of her treatment. The psychiatrist
always sent Zia back to discuss these
take the natural ambivalence one feels
issues with her psychologist, even
about almost all people and divide it though the psychiatrist was aware
into two packages—a positive package that many of the accusations made
bestowed on one person and a negative about the therapist were, in some
package bestowed on another. Each pack- ways, not untrue.1
1
This situation may occur frequently in collaborative treatment. The patient presents an obser-
vation 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 re-
frain from agreeing or disagreeing with the patient. Each patient brings his or her unique his-
tory 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 347
As the therapy progressed, Zia’s macological strategies (Greenblatt et al.

self-destructive behavior diminished 1965; Klerman 1990) either alone or in
and then eventually ceased as her in-
combination, none of them address the
terpersonal relationships grew more
stable. Longer periods elapsed be- use of single versus multiple providers.
tween her complaints about her ther- In models in which a psychiatrist pro-
apist, and eventually the complaints vides oversight of a care manager who is
stopped. The treatment terminated monitoring the response to a primarily
successfully. pharmacological treatment, the “collabo-
ration” is actually a typical consultative
In this chapter, we discuss collabora- relationship. Patients who do not respond
tive treatment in general and then collab- to the care manager intervention within a
orative treatment of patients with PDs. specified time often will be referred to a
Much of what we address applies to any behavioral health provider, but the treat-
collaborative treatment, regardless of ment results for these patients have not
the patient’s diagnosis, but the issues of been well studied.
collaboration are heightened when the Many patients with PDs have complex
patient has a diagnosis of a PD. Although biological and psychosocial issues and do
the techniques, strategies, or issues pre- not respond as well to medications as
sented are pertinent to many patients with would patients with other primary diag-
PDs, they cannot be applied to all such noses (except perhaps those with schizo-
patients because we often discuss treat- typal PD [Duggan et al. 2008; Herpertz et
ments in which psychotherapy is con- al. 2007; Koenigsberg et al. 2003; Paris
ducted by one person and psychophar- 2003; Soloff 1990, 1998]). Treatment mo-
macology is managed by another, and dalities beyond psychopharmacological
few data are available to support pretreatment are necessary, and often each
scribing medications to patients with modality is provided by a different men-
schizoid, antisocial, histrionic, narcissis- tal health professional. Thus, there are
tic, and dependent PDs. many clinical situations in which multi-
modal treatment implies and warrants
collaboration between at least two mental
health professionals.
Evidence for Most current outcome studies in psy-
Effectiveness of chotherapy and psychopharmacology do
not measure the effects of any treatment
Collaborative Care other than the one being studied. Surpris-
ingly few studies—and even fewer ran-
Despite a lack of efficacy studies compar- domized, controlled trials—have com-
ing behavioral health treatment pro- pared psychotherapy alone, medication
vided by more than one provider to that alone, and psychotherapy and medicine
provided by one provider (i.e., when a in combination to determine the differen-
psychiatrist performs both therapy and tial efficacy or effectiveness (Browne et al.
medication management), the use of 2002). Studies of cognitive-behavioral
multiple providers in behavioral health therapy and nefazodone for depression
treatment continues to increase. Although (Keller et al. 2000) and cognitive-behav-
there are studies that compare the use of ioral therapy and tricyclic antidepressants
different pharmacological and nonphar- for panic disorder (Barlow et al. 2000)
have interesting findings about the

course and continuation of response to Importance of
specific interventions (Manber et al. 2003).
De Jonghe et al. (2004) found equivalent
results for groups of mildly to moder- in Current Personality
ately depressed patients treated with Disorders Care
psychotherapy (short-term psychody-
namic supportive psychotherapy) or a
combination of psychotherapy and General Issues
psychopharmacology with antidepres- A 1997 survey revealed that 38% of pa-
sants. Often patients with PDs are ex- tients seen by a psychiatrist had been
cluded from these studies, or PDs are not seen by another mental health profes-
assessed. Thus, for patients with PDs, no sional in the prior 30 days (Pincus et al.
clear conclusions can be made concern- 1999). Almost half of those patients seen
ing the effectiveness of medication versus by another mental health provider had
psychotherapy. Furthermore, no conclu- received psychotherapy from that other
sions about effectiveness or efficacy can provider. In more than two-thirds of the
be made if these treatments are combined. instances in which an additional mental
The exceptions are 1) the study by Kool et health provider was caring for the pa-
al. (2003), who found that patients with tient, the psychiatrist indicated that he
personality pathology and depression re- or she had discussed the diagnosis and/
sponded best to a combined approach of or treatment of the patient with this
both psychopharmacology and psycho- other provider. In an unpublished elec-
therapy, although personality pathology tronic survey conducted in 2010 by the
of patients with Cluster C diagnoses re- American Psychiatric Association (in-
sponded better than that of patients with volving 394 psychiatrists, representing a
Cluster B diagnoses; 2) the 12-week study 14% response rate), 67% of the respond-
by Soler et al. (2005), who found greater ing psychiatrists’ patients received both
improvement in depression, anxiety, and psychotherapeutic and psychopharma-
impulsivity/aggression in patients as- cological treatment (West et al. 2012). Half
signed to dialectical behavior therapy of those patients received both modali-
(DBT) plus olanzapine than those assigned ties from the same psychiatrist. For al-
to DBT alone; and 3) the small study by most half of the cases, the psychiatrist pro-
Simpson et al. (2004), who randomly as- vided the pharmacological treatment
signed patients to receive fluoxetine or while another clinician performed the
placebo after completion of a course of therapy. In 2% of the cases, the psychia-
DBT and found that those assigned to pla- trist was the therapist and another phy-
cebo had more positive pre/post treat- sician or psychiatrist managed the phar-
ment differences than those assigned to macotherapy. Research suggests that
fluoxetine. None of these studies ad- about three-fourths of patients receive
dressed the differential effectiveness of their antidepressants from their primary
therapy and medication management care physician (up from 37.3% in 1987)
performed by one provider versus two (Mojtabal and Olfson et al. 2011).
(or more) providers. Serotonin reuptake inhibitors are less
complicated to prescribe, with fewer gen-
eral side effects and less lethality, than tri-
cyclic antidepressants (Healy 1997). Par- depression is prevalent among patients

ticularly with this class of medications, with PDs (Skodol et al. 1999), quite often
primary care physicians appear ready to the nature of the depression, especially
provide the ongoing management of psy- among patients with Cluster B disor-
chopharmacological medication in con- ders, is not the classic psychophysiologi-
sultation with a psychiatrist. Although cal presentation frequently seen in a major
they do not always prescribe concurrent depressive episode (Silk 2010; Westen et
psychotherapy, a number of primary care al. 1992). There has been much debate
physicians are collaborating with thera- about the type and nature of depression
pists of varying levels of training. An in- in patients with PDs. The effectiveness
teresting triangular relationship can de- of antidepressants in treating depression
velop among a therapist, a primary care in such patients is moderate at best, even
physician writing the prescriptions for as the number of patients given these
psychotropic medication, and a psychia- medications is increasing (Paris 2003; Silk
trist for referral or collaboration. Smith and Fuerino 2012). Many patients who
(1989) noted, “In contemporary treatment may have been treated by psychother-
situations that include a patient, a thera- apy alone in the past are now receiving
pist, a pharmacotherapist, and a pill, the psychopharmacological treatment as well.
transference issues can become more com- An emerging literature suggests that the
plex than the landing patterns of airplanes use of antidepressants can be helpful in
at an overcrowded airport” (p. 80). Add a the treatment of specific symptom com-
managed care utilization reviewer to the plexes, such as the use of selective sero-
picture, and things really get complicated. tonin reuptake inhibitors or mood stabi-
Managed care companies often believe lizers for impulsivity, affect lability, and
that patients with PDs use too much or at aggression in patients with borderline
least more than their share of treatment. PD (Coccaro and Kavoussi 1997; Coccaro
One of the challenges associated with et al. 1989; Cowdry and Gardner 1988;
providing collaborative care for these pa- Fuerino and Silk 2011; Hollander et al.
tients is convincing utilization reviewers 2001, 2005; Loew et al. 2006; Markowitz
that more than one modality of care is 2001, 2004; Nickel et al. 2005; Rinne et al.
needed. To avoid divergent reports that 2002; Ripoll 2012; Salzman et al. 1995;
negatively affect the reimbursed care for Sheard et al. 1976; Silk and Fuerino 2012;
the patient, it is best to designate one Soloff 1998; Soloff et al. 1993; Tritt et al.
member of the team to report the progress 2005). The American Psychiatric Associ-
of treatment and the treatment plan to the ation’s (2001) practice guideline recom-
reviewer. In general, this designated “re- mends treatment with selective sero-
porter” should be the psychiatrist. tonin reuptake inhibitors in a symptom-
specific manner for patients with border-
Increasing Prescription line PD. This recommendation is based on
evidence from several double-blind, pla-
of Antidepressants cebo-controlled studies; a number of
Despite the lack of hard evidence for the open studies; and clinical experience in
benefits of psychopharmacology in PDs, conjunction with a relatively benign
the practice of prescribing antidepres- side-effect profile and risk of overdose
sants for a wide array of symptom com- (American Psychiatric Association 2001).
plexes suggestive of depression contin- Also, some strong evidence suggests
ues to increase (Healy 1997). Although that neuroleptics and atypical antipsy-
chotics can be effective for patients with idealize and a clinician to denigrate
schizotypal and borderline PDs (Bogen- within one treatment relationship. Al-
schulz and George Nurnberg 2004; Gold- though this situation might at first ap-
berg et al. 1986; Koenigsberg et al. 2003; pear to be problematic, it can be useful
Markowitz 2001, 2004; Nickel et al. 2006; if both providers confer with each
Schulz and Camlin 1999; Soloff et al. other and work to have the patient de-
1986b, 1993; Zanarini and Frankenburg velop a more balanced view of each of
2001). them. For example, both treaters may
Patients with PDs present with a com- have an opportunity to model more
plex admixture of symptoms and prob- appropriate coping mechanisms for
lems, some of which appear to arise from the patient, or the idealized therapist
psychosocial issues and interpersonal might be able to work with the patient
events, whereas others appear more re- to modify or mollify the patient’s den-
lated to expressions of underlying traits igration of the other treater and thus
such as baseline anxiety, emotional labil- help keep the patient in treatment with
ity, and impulsivity (Livesley 2000; Lives- the therapist being denigrated. The
ley et al. 1998; Putnam and Silk 2005). classic example is the patient with bor-
When treatment is divided among two derline PD, but patients with narcis-
providers, the psychotherapist may believe sistic PD also contemptuously de-
that all problems arise from psychosocial value and criticize treaters who do not
issues and subtly demean, undermine, or treat them in the way in which they
dismiss the psychopharmacological treat- believe they are entitled. Feeling de-
ment. Conversely, the psychopharmacol- valued can occur when faced with the
ogist may think that difficulties are due moralistic, judgmental, and somewhat
primarily to “trait expression” and that contemptuous attitude of the patient
once the right combination of medications with obsessive-compulsive PD. In all
is discovered, all symptoms will be allevi- these instances, the “good” therapist
ated. The increasing use of polypharmacy may be able to provide support to the
in patients with PDs, despite limited to no criticized, or “bad,” therapist. One way
evidence of effectiveness (Zanarini et al. this support may occur is by the “good”
2003), can hopefully be abated with col- therapist providing examples of other
laboration and communication among situations in which he or she had the
multiple providers (Silk 2011). misfortune of owning and bearing the
“bad” therapist label and how diffi-
cult it was to bear at the time but how
Strengths and useful it was to the eventual outcome
of the treatment. The “good” therapist
Weaknesses of may also try to minimize the negative
Collaborative Treatment countertransferential feelings the
“bad” therapist is experiencing and
Collaborative treatment has many posi- may be able to ward off the “bad”
tive attributes, some of which have direct therapist’s wish to end treatment with
applicability to patients with PDs: the patient.
2. Collaborative treatment provides a
1. Collaborative treatment can provide basis for ongoing consultation be-
the patient with both a clinician to tween providers. It also provides the
potential for multiple perspectives on tients with PDs have a tendency, as ex-
complicated clinical and diagnostic plained earlier, to split by attributing all
situations. Such complex situations good to one person and all bad to an-
are not uncommon in patients with other. Although this splitting is most
PDs, whose symptoms, behaviors, and blatant among patients with borderline
interpersonal interactions can be so PD, it occurs in more subtle forms among
entwined that it is difficult to unravel patients with schizotypal, narcissistic,
the trait biological functioning from antisocial, and obsessive-compulsive
the interpersonally and experientially PDs. Failure to collaborate in the treat-
learned behaviors and maneuvers ment of these patients can lead to serious
(Cloninger et al. 1993; Livesley et al. problems in the treatment. Table 16–1
1998). presents specific issues that need to be
3. When collaboration is with a primary considered in a collaborative treatment
care physician, the mental health pro- for each of the PDs.
fessional can confer with someone Failure to collaborate or the end of col-
who may have a longitudinal relation- laboration can develop when the treaters
ship with and understanding of the identify with the projections of the pa-
patient. The primary care physician tient. In this situation, each of the treaters
often is viewed as fairly neutral by the begins to lose respect for the other treater
patient and may be more impervious as each begins to identify and psycholog-
to the distortions of transference that ically own some of the patient’s negative
appear frequently among patients projections (Gabbard 1989; Ogden 1982).
with PDs. The primary care physician Such events or situations are not uncom-
may be able to assist the patient in re- mon on inpatient units where the split is
maining medication compliant. often between the attending or resident
4. Patients with PDs can be very draining psychiatrist and a member or members
to treat. Patients with borderline PD of the nursing staff, although they can
can be demanding and threatening. occur between nurses as well (see Gab-
Constant demands for attention from bard 1989; Gunderson 1984; Main 1957;
histrionic or narcissistic patients can Stanton and Schwartz 1954).
become exhausting. The complaints
of histrionic patients can be very diffi- Case Example 2
cult to listen to and to take seriously.
A ward staff member suddenly ac-
Patients with dependent PD can be cuses another staff member of delib-
draining and pulling, whereas the erately trying to jeopardize the treat-
chronic anger and distrustfulness of ment of a specific patient, while each
patients with paranoid PD can be quite staff member believes that he or she
difficult to tolerate. Therefore, thera- alone really knows best. The director
of the ward, who has frequently en-
pists and psychiatrists working as a
countered such sudden disagreements,
team to provide overall patient man- decides to deal with these types of
agement can support and confer with difficulties by bringing together the
one another to reduce burnout. “warring parties” and wondering out
loud with them why each has sud-
denly begun to despise his or her other
Collaborative treatment can readily
colleague on the unit. The director
turn into a split treatment when the col- emphasizes that prior to the dis-
laborators fail to collaborate. There can agreement, each person appeared to
be many causes for this failure. Some pa- have great respect for and to enjoy
352
TABLE 16–1. Specific issues to address in collaborative treatment with classic personality disorders features
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 when-
ever a contact between any providers has occurred.
Regularly remind patient about sources of specific information and be sure that each treater
knows whether information he or she has about patient comes from patient or other
sources (providers).
Schizoid Detachment from emotional Work among providers to minimize redundancy of visits so that patient can visit providers
relationships as infrequently as possible.
Coordinate treatment visits so patient can visit all providers on same day.
Schizotypal Discomfort with close relationships, Be prepared to contact other providers when increased distortions arise in sessions.
cognitive or perceptual distor- Work together to minimize redundancy of visits (see Schizoid above).
tions, eccentricities of behavior
Antisocial Disregard for rights of others Convey clearly that all members of 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 patient, a designated provider needs to discuss discrepancies with
patient.
Borderline Instability in mood and interper- Provide support for patient without becoming caught up in splitting among providers.
sonal relationships, impulsivity Discuss strong countertransference feelings with other providers.
Have 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 Have clear plan among providers as to how to handle emotional outbursts.
seeking Be prepared to contact other providers at periods of increasing physical symptoms
and/or increasing attention-seeking behavior.
TABLE 16–1. Specific issues to address in collaborative treatment with classic personality disorders features (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 a treater occurs.
Have a clear plan among providers regarding how to handle contemptuous behavior so
that one provider addresses the issue even if patient is expressing contempt toward only
one treater.
Avoidant Social inhibition, feelings of Work among providers to encourage consistent treatment relationships and attitudes in
inadequacy, hypersensitivity all treatments involved in the collaboration.
to negative evaluation Be prepared to communicate with other providers whenever patient misses appointments
with any provider.
Coordinate treatment visits so patient can visit all providers on same day.
Dependent Submissive behavior, a need Work with patient to minimize appointments and avoid overutilization of services.
to be taken care of 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-compulsive Preoccupation with order, Ensure that consistent recommendations are made by each provider.
cleanliness, control Be prepared to communicate with other providers when patient is having difficulty ad-
hering to recommendations.
Have a clear plan regarding how to confront a patient who constantly obsesses and com-
plains about lack of consistency or thoroughness of treatment when particular obsessing
is a sign of disdain toward other people.
Note. Because many patients’ presentations meet criteria for more than one personality disorder, features of multiple disorders may need to be considered in treatment.
In addition, when personality disorders have no clear indication or no data to support the use of medications, collaborative treatment might arise because there is psycho-
pharmacological treatment of a comorbid symptom disorder. This table provides tips with respect to how the patient might be dealt with in a collaborative treatment even
if the medication is being administered for reasons other than the patient’s personality disorder diagnosis.
353
working with the other person. The sonal reconstructive psychotherapy

director moves to a discussion of the (Benjamin 2003), cognitive-behavior
patient and tries to show the parties
therapy (Beck and Freeman 1990;
how each is really only seeing a part
of the patient, upon which they have Davidson et al. 2006), and schema-
each constructed the idea that they focused cognitive-behavioral therapy
alone know how best to treat the pa- (Young et al. 2003). None of these ther-
tient. apies opposes the concurrent use of
psychopharmacological agents.
Collaboration in divided treatment is 3. Psychopharmacological agents are
essential but does not always occur eas- more commonly used in psychiatric
ily or frequently; a concerted effort must treatment today, and the medications
be made. Regularly scheduled phone calls used are generally safer and have more
or e-mail exchanges may be the best way tolerable side-effect profiles than in
to sustain the collaboration even when the past (Healy 2002). Safety is impor-
there is skepticism as to its value or a tant among a subgroup of PD pa-
belief that another provider is causing tients, particularly patients with bor-
difficulty. derline PD, who have very high
suicide rates (Paris 2002; Stone 1990).
4. Managed care companies play a sig-
Collaborative Treatment nificant role in types of treatment.
and Personality They are reluctant to approve treat-
ment sessions with seriously ill pa-
Disorders tients (including a significant num-
ber of patients with PDs) who are not
Treatment with combined psychophar- receiving medication.
macology and psychotherapy is more 5. There is a growing appreciation of the
common now in the treatment of all PDs role of biological and constitutional
than it has ever been. A number of factors factors in the etiology of PD symp-
are probably involved, including the fol- toms. The nature-nurture dichotomy
lowing: has been replaced by consideration
of the subtle interplay of biological
1. Use of psychopharmacological agents predisposition, resulting in traits that
among all psychiatric patients has are expressed through behavior that
increased, reflecting the general ascen- is affected by experiential and envi-
dancy of biological psychiatry (Siever ronmental factors (both shared and
and Davis 1991; Siever et al. 2002; Silk nonshared) (Rutter 2002). Such a the-
1998; Skodol et al. 2002). ory of interaction between biological
2. Since the early 1990s, there has been an predispositions and life experience
expansion in specific types of psycho- supports a multimodal treatment ap-
therapy for patients with PDs; these proach (Paris 1994).
therapies include DBT (Linehan et al. 6. The comorbidity of PDs and other
1993), transference-focused psycho- disorders more amenable to psycho-
therapy (Clarkin et al. 1999; Kernberg pharmacological intervention has re-
et al. 2000), mentalization-based ther- ceived increased consideration. If one
apy based on dynamic therapy (Bate- prefers to treat personality problems
man and Fonagy 1999, 2001), interper- with psychotherapy, one must still
consider and treat comorbid condi- riod of abstinence should occur, the coun-
tions so as not to worsen the clinical selor or psychotherapist needs to initiate
manifestation of the PD (Yen et al. contact with the psychiatrist. Sometimes,
2003; Zanarini et al. 1998). Comorbid a patient will feel embarrassed about re-
mental health diagnoses may respond suming use of substances after a period
to pharmacological agents, and even of sobriety and may ask the counselor or
in the absence of a clear comorbid di- psychotherapist not to inform the psychi-
agnosis, the patient with PD may have atrist. Obviously, this wish cannot be
pharmacologically responsive symp- granted, because there would be 1) collu-
tom clusters that are reminiscent of sion between the counselor or psycho-
other comorbidities (such as mood therapist and the patient to keep the psy-
and anxiety disorders) and should be chiatrist in the dark and 2) a splitting
treated as such. between the counselor or psychothera-
pist and the psychiatrist.
Specific Situations in Case Example 3

Which Collaborative An engineer in his mid-50s, Sam was
Treatment Might Occur referred for substance abuse treatment
after his second citation for driving
while intoxicated. The substance abuse
Although collaborative treatment usually counselor referred Sam to a psychia-
refers to the arrangement in which a non- trist for treatment of narcissistic PD.
medical psychotherapist performs the Whenever Sam increased his alcohol
psychotherapy and a psychiatrist or other use, he would miss his appointments
medical doctor prescribes medication, with the psychiatrist because he was
embarrassed, although he would at-
variations on that arrangement still qual- tend his substance abuse sessions.
ify as collaborative treatment. Some such The psychiatrist called the substance
variations occur regardless of the diagno- abuse counselor whenever Sam missed
sis, but others are more prone to occur in an appointment, and the counselor
the treatment of patients with PDs. always convinced Sam to return to
and continue with the psychiatrist.
The psychiatrist eventually concluded
Comorbid Substance that Sam’s shame about his substance
abuse behavior related more to avoid-
Abuse Treatment ance than narcissism in interpersonal
functioning, and this information al-
Collaboration should occur when the pa-
lowed the substance abuse counselor
tient is undergoing both substance abuse to modify his approach to Sam.
treatment and treatment with a psychia-
trist for PD issues. Continuous use of
substances can exacerbate PD psychopa-
Somatic Complaints, the
thology, and in these instances it is very Primary Care Physician,
important that the substance abuse coun-
selor and/or psychotherapist and the
and the Psychiatrist
treating psychiatrist immediately confer Patients with PDs, particularly those with
(Casillas and Clark 2002; de Groot et al. Cluster B and Cluster C PDs, have a ten-
2003). If an increase in substance use or a dency to be somatically preoccupied
resumption of substance use after a pe- (Benjamin et al. 1989; Frankenburg and
Zanarini 2006). Although the treating psy- pist may have to deal with a psychiatrist
chiatrist may suspect mere somatic pre- whom he or she does not know or agree
occupation, he or she cannot make the with. In the best of worlds, neither the psy-
mistake of not taking the complaint seri- chiatrist nor the psychotherapist would
ously. If complaints persist or if different feel obligated to collaborate with a pro-
somatic concerns frequently appear, it is vider whom he or she does not respect.
important for the psychiatrist to share Patients with PDs are quite sensitive to
his or her concern with the physician who disagreements among members of the
is working up the somatic issues. To- treatment team (Main 1957; Stanton and
gether, the two physicians can decide Schwartz 1954). Without communication
how much physical exploration of so- and knowledge about what other profes-
matic concerns should occur and coordi- sionals involved in the case are doing, the
nate a consistent therapeutic response to patient can become caught in the middle
persisting somatic issues (Williams and of disagreement (Stanton and Schwartz
Silk 1997). 1954). Each treater should respect what
the other is trying to accomplish. This re-
spect for treatment modality should be
Seven Principles to separated from personal feelings (al-
though it is always easier if there is mu-
Follow in Collaborative tual liking). Each provider should be free
Treatment to conduct an open communication with
the other so that treatment collaboration
A number of principles can apply to any and coordination can occur (Koenigsberg
collaborative treatment, but they have 1993).
special application in the treatment of Ideally, the prescriber and the thera-
patients with PDs. Adherence to these pist will know each other or at least know
principles can lead to a smoother and something about each other’s practice
more synergistic approach to collabora- and practice reputation. The prescriber
tive treatment (Silk 1995). should have an appreciation for the basic
psychological issues involved in treat-
Understanding and ment and a general understanding of
how they may manifest in psychophar-
Clarifying the Relationship macological treatment. The prescribing
Between Therapist and psychiatrist needs to be clear with the
therapist as to his or her beliefs in the pu-
Prescriber tative efficacy of psychotherapy for the
The relationship among the patient, the PD in general as well as for each patient
psychotherapist, and the pharmacothera- specifically. Psychotherapy will not pro-
pist (or “prescriber”) has been described ceed constructively if the prescriber does
as the “pharmacotherapy-psychotherapy not believe in the usefulness of psycho-
triangle” (Beitman et al. 1984). In man- therapy, particularly with patients with
aged care, psychiatrists may be expected PD (especially those with Cluster B PDs).
to provide medical backup for therapists Maintenance of therapeutic boundaries
whose work they do not know, whose between treaters is crucial in working
approach they may not agree with, or with patients with PDs and must be clar-
whom they do not respect (Goldberg et ified (Woodward et al. 1993). Some ques-
al. 1991). Conversely, the psychothera- tions to consider follow:
• Should between-session phone calls taking the medication. Additionally, the

be permitted in the pharmacological therapist needs to have some knowledge
treatment if they are not permitted of medications so that he or she can have
or are frowned upon in the psycho- some appreciation of what might be sub-
therapy? jective versus objective reactions of the
• In what quantities will pills be pre- patient to taking the medication.
scribed, and what course should the As stated earlier, no psychotherapist
therapist take if there is a sudden in- or psychopharmacologist should feel ob-
crease in the suicidality of the patient? ligated to work with a collaborative part-
• When the patient requests a change or ner whom he or she does not agree with
an increase in dosage, will the pre- or respect. Each treater must respect the
scriber contact the therapist before- roles and competence of the other. In this
hand to understand better what issues atmosphere of mutual respect, both the
might be coming up in the psycho- prescriber and the therapist need to ap-
therapy? preciate the perceived efficacy as well as
• How frequently will discussions be- limitations of each of the interventions.
tween the prescriber and the thera- Both need to be able to tolerate treatment
pist take place? situations in which progress is often slow,
• How will issues that belong primarily punctuated by periods of improvement
in the psychotherapy be dealt with if and regression, and in which the long-
they are brought up with the pre- range prognosis is often guarded but not
scriber? necessarily negative. Appreciating the
• Will the psychopharmacologist no- other’s difficulties and those of the pa-
tify the psychotherapist that he or she tient in the treatment may help each
has directed some issue back to the treater avoid blaming the other (or the
psychotherapist? patient) during difficult periods.
Appelbaum suggested that, to ad-
The psychotherapist also needs to have dress clarity of treatment and treatment
respect for the prescriber and for the expectations, as well as medicolegal is-
intervention of psychopharmacology sues, the therapist and prescriber should
(Koenigsberg 1993). Although there is draw up a formal contract that delineates
probably little need for nonmedical ther- their respective roles as well as the ex-
apists to be experts in psychotropic drug pected frequency and range of, or limita-
usage, nonmedical psychotherapists tions on, their communication (Appel-
should understand the general indica- baum 1991). Such a contract works well
tions for pharmacotherapy and be aware when the two people share responsibil-
of the specificity as well as the limita- ity for a number of patients (Smith 1989).
tions of the psychopharmacological These ideas about contracts are merely
treatment. The therapist should have suggestions, and contracts certainly may
some rudimentary knowledge of both not be necessary or useful when the two
the expected therapeutic effects and the collaborators work in the same clinic or
possible side effects of at least the broader the same health system.
classes of psychotropic medications. In Much of what is diagnosed as PD re-
the course of the psychotherapy, the flects a group of patients with chronic
therapist should be willing to discuss, maladaptive interpersonal functioning
albeit on a limited basis, the patient’s ex- across a wide range of settings. Interper-
perience (both positive and negative) of sonal dysfunction cannot and should not
be ignored, dismissed, or denied, and pharmacological decision was correct.

whenever and wherever it occurs in the The prescriber and/or the therapist may
therapeutic endeavor, it should be dis- deny ambivalence about the medication,
cussed not only between the two thera- become intolerant of the patient’s (or the
pists but among the treaters and the pa- other provider’s) questions and concerns,
tient. Transference is not solely reserved and present the possible therapeutic ef-
for transference-oriented psychotherapy fects of the medications in a more posi-
(Beck and Freeman 1990; Goldhamer tive light than the evidence would imply.
1984), and “pharmacotherapy is [also] an This idealization of the medication, simi-
interpersonal transaction” (Beitman 1993, lar to the patient’s periodic idealization of
p. 538). the treatment, will usually be short-lived,
however.
Pessimism about progress in the ther-
Understanding What the apy was given as a reason to consider
Medication Means to Both prescribing medications by 65% of the re-
spondent psychotherapists in a study by
Therapist and Prescriber
Waldinger and Frank (1989). Given that
Medications may play both positive and some patients with PDs, particularly bor-
negative roles in treatment. The thera- derline PD, seem especially attuned to
pist and the prescriber need to be at- feelings, a treater’s pessimism or frustra-
tuned to what the initiation of medication with the course of therapy may be in-
tion means to each of them. advertently and unconsciously conveyed
In Section III, “Emerging Measures to the patient. Conversely, a referral to a
and Models,” of DSM-5 (American Psy- psychopharmacologist could be viewed
chiatric Association 2013), an alternative as an opportunity for consultation and a
model to the categorical approach to PD second opinion (Chiles et al. 1991).
diagnosis has been proposed. In clinical When there is little apparent therapeu-
practice, patients with PDs defy easy tic progress, treaters can easily develop
classification and do not always fit neatly anger and rage at patients with PDs,
into any DSM categories (Westen and Ar- particularly patients with substantial
kowitz-Westen 1998). In addition, no borderline, narcissistic, and paranoid
medications have yet been indicated for PD characteristics (Gabbard and Wilkin-
any specific PD. Although there are algo- son 1994). At these times, one treater may
rithms with respect to the pharmaco- try to pull back from the treatment or,
logical treatment of PDs (particularly conversely, try to take over control of the
borderline PD [American Psychiatric As- entire treatment. The best way to handle
sociation 2001; Soloff 1998]), there are no these feelings is not to isolate oneself but
clear-cut rules as to when or what medi- to approach the other provider and be
cation should be used in any given per- willing to share one’s frustrations. More
sonality disorder. In circumstances of often than not, the first provider will dis-
prescriber self-doubt, ambivalence, and cover that the other provider shares sim-
uncertainty about either the diagnosis or, ilar frustrations. This shared frustration
more probably, the chosen pharmacolog- will lead not only to less tension in each
ical agent, a defensive and authoritarian provider and in the therapy but also, at
posture might be assumed by the pre- times, to a discussion and a review of the
scriber in an attempt to assure that the treatment.
When medication is being considered eration and compliance but also for trans-
in a collaborative treatment, the follow- ferential issues. The patient may take
ing questions may be asked: medication in a spirit of collaboration
with the therapist and the prescriber. The
• Where is the impetus for the medica- patient may disagree with the decision
tion coming from? but cooperate out of a strong need to
• Does the therapist think the medica- please. A patient’s reactions will depend
tion will affect or change the thera- on whether the therapist and prescriber
peutic relationship? are truly collaborating or at odds.
The introduction of medication into
In turn, the prescriber should be able any therapy, even if by a conferring psy-
to let the therapist know if he or she feels chiatrist, has repercussions on the trans-
that the therapist’s expectations for the ference (Goldhamer 1984). If the idea of
medication are unrealistic and what might medication is introduced early in the
be a reasonable expected response. treatment process, the potential negative
transferential reaction to the introduc-
Understanding What the tion of medications later may be mini-
mized. It is important that the therapist
Medication Means to and the prescriber be on the same page
the Patient as to “how” medication will be chosen, in-
Beginning pharmacotherapy or changing troduced, continued, discontinued, and so
medication may not always be seen as fa- on. Discussions at the beginning of treat-
vorable by patients, and a negative reac- ment can model the ethos of an open fo-
tion to the idea of medication needs to be rum for exchange of information about
anticipated. A propensity to put the most medications and other feelings.
negative spin on interpersonal encoun-
ters or perceived intentions may cause Case Example 4
patients with PDs to experience the intro- Charles, a 50-year-old man with histri-
duction of medication as a failure of their onic PD and panic disorder, was re-
role in treatment or as the psychothera- ferred to an anxiety disorder clinic af-
pist giving up on them. Patients might ter several emergency department
also, albeit rarely, experience the intro- visits because of uncomfortable arousal
symptoms precipitated by an anti-
duction of medication as a hopeful sign,
depressant (Soloff et al. 1986a). He re-
as an additional modality that might help ceived cognitive-behavioral therapy
speed the progress of the treatment and responded well, although he had
(Gunderson 1984, 2001; Waldinger and trouble starting an antidepressant
Frank 1989). Whatever the patient’s reac- without having his panic symptom in-
crease. He did tolerate a low-dose
tion, both therapist and prescriber need
benzodiazepine but was fearful of be-
to understand what the medication means coming “addicted” to the medication
to the patient and how the patient under- and would intermittently reduce his
stands the use of medication within the dosage despite his therapist’s at-
context of the therapy as well as in the tempts to discourage his doing so.
context of his or her own life experience When Charles’s insurance ran out, he
stopped seeing his therapist because
(Metzl and Riba 2003).
he was “doing so well,” and he also
Understanding the patient’s reaction stopped his medication. He began to
to the introduction of medication can be have emotional outbursts and in-
important not only for the patient’s coop- creased panic attacks and called the
psychiatric emergency room inquir- tient at this particular time. The pre-
ing about rehabilitation for drug scriber should tell the therapist what
abuse. Therapy was reinitiated after
unusual idiosyncratic reactions to the
both the therapist and the psychiatrist
discussed Charles’s concerns about medication might occur (Gardner and
medication and considered how these Cowdry 1985; Soloff et al. 1986a), espe-
concerns were affecting his life. The cially because these paradoxical reac-
providers developed clear plans as to tions or tendencies toward dependency
whom Charles would call for “medi- may not always be listed in the package
cation questions,” whom for “expo-
insert or in the Physician’s Desk Reference.
sure questions,” and how they would
respond to emotional upheavals. With effective therapist-prescriber col-
laboration, medication decisions will not
Both therapist and prescriber should be solely in the hands of the prescriber.
be aware that patients may use medica- A dialogue between therapist and pre-
tions as transitional objects (particularly scriber should take place as to how each
patients with borderline, histrionic, and particular type or category of medication
perhaps severely dependent PDs [Car- might work for the particular patient.
dasis et al. 1997; Gunderson et al. 1985;
Winnicott 1953]). In this context, the pa- Case Example 5
tient’s attachment and/or resistance to
After moving to a new city, Diane was
changing or altering medications may referred by a psychiatrist from out of
seem out of proportion to the actual ther- town for treatment of anxiety and de-
apeutic benefit derived from the medica- pression. Diane had a long history of
tion (Adelman 1985). It may also explain major depressive episodes. At the time
of the evaluation, she was taking five
why the patient who has repeatedly com-
medications: two mood stabilizers, a
plained about the medications is unwill- low-dose atypical antipsychotic, an an-
ing to change them even when there has tidepressant, and a benzodiazepine.
been little clear evidence that the medi- She insisted that this combination was
cations have been effective. the correct regimen for her and that
the new psychiatrist not tamper with
her medications. She said it took many
Understanding That the months and finally a referral to the
Medication Will Probably most prominent psychopharmacolo-
gist in her region before the right com-
Have Limited Effectiveness bination was found. She also stated
that she was going to remain in psy-
Therapists and prescribers need to appre- chotherapy with her old therapist
ciate the therapeutic benefits and limita- through weekly long-distance phone
tions of medication. Therapists should in- contacts.
quire about a patient’s medications at The new psychiatrist, after seeing
Diane five or six times, began to feel
moments of calm, not during periods of
that Diane primarily had a narcissis-
crisis. Perhaps the most instructive and tic PD and that her depressions were
useful time for discussion about or change brought about by her extreme sensi-
of medication is when things are actually tivity to anything that could remotely
going well and treatment does not seem represent a narcissistic injury. The
psychiatrist called Diane’s therapist,
bleak or hopeless.
who acknowledged that although Di-
The prescriber should describe what ane did have some narcissistic issues,
features of a specific medication may or she really had experienced a number
may not be useful for this particular pa- of major depressive episodes during
their treatment together.
After a few months, Diane grew to try to both increase the distance be-
more depressed, but her depression tween and reduce the amplitude of their
was marked primarily by lethargy, ab-
interpersonal crises (Koenigsberg 1993).
senteeism from work, and an inability
to concentrate. She was, however, able These goals are attributable to both the
to date and had no loss of libido or ap- psychotherapy and psychopharmacol-
petite. Instead of feelings of guilt or ogy and need to be appreciated by both
worthlessness, she had feelings of the therapist and the prescriber. A pre-
grandiosity and entitlement. Diane re- scriber who conveys a powerful belief in
quested a psychostimulant to help
finding the “right” medication will pro-
with her concentration and lethargy.
The psychiatrist balked and tried to mote an unrealistic and difficult situation.
address some of the ways in which he Any therapy for patients with charac-
felt her depression was atypical. He ter disorders must have realistic and lim-
pointed out that she seemed more in- ited goals set early in the therapy, lest
vested in wanting the psychiatrist to
any of the players begin to idealize an-
figure out what pills would make her
better than in exploring events in her other player or another modality. Such
life that might be leading to what she idealization can only lead to disappoint-
thought was depression. She stormed ment and the multiple repercussions
out of the office. Later that week, Diane that occur in the treatment as a result.
called the psychiatrist to say that her
therapist also believed that she could
benefit from a psychostimulant, and Understanding the
she was going to find a psychiatrist
who was an expert in depression and Potential and Actual
more up-to-date about treatment. Calls
the psychiatrist made to Diane’s long-
Lethality of the Medication
distance therapist went unanswered. Many psychotropic medications can be
lethal, particularly tricyclic antidepres-
Understanding How the sants, lithium, and mood stabilizers/an-
Medication Fits Into the ticonvulsants. Monoamine oxidase in-
hibitors and benzodiazepines also have
Patient’s Overall Treatment significant morbidity and mortality as-
If a psychotherapist considers using med- sociated with overdose, especially when
ications at some time during the course of combined with other agents. Suicide po-
treatment, ideally he or she already has an tential needs to be continually assessed,
ongoing arrangement or relationship and when it increases, a plan should be
with a prescriber. It is never wise to begin enacted that takes into account when
searching for a prescriber during a time of the therapist will contact the prescriber,
pressing need for medications. whether the prescriber is going to limit
The goal of treatment for a patient with the size of the prescription, which of the
PD cannot be cure. A decision to use or treating professionals might hold onto
change medications should not imply the medications if a decision is made to
that one is “going for the cure.” The goal limit their administration, and so on. At
of treatment should be to try to improve a minimum, if the therapist believes there
the ways in which patients cope, to help is an increase in suicide potential, then
them develop increased awareness of the prescriber should be notified. If the
their cognitive rigidity and distortions, to therapist is fearful that the patient may
assist them in becoming somewhat less overdose, this issue should be discussed
impulsive and less affectively labile, and openly with the prescriber.
Patients with PDs, particularly bor- ther treater should deal with the patient’s
derline PD, are potentially volatile and attacks and demands alone. The two can
can act out when they feel that relation- collaborate to think through and resolve
ships are threatened (Gunderson 1984). the crisis.
The therapist-patient relationship is one
that, when complicated by transference,
can increase the possibility of a patient’s
Collaboration During
acting out in ways that include suicidal a Crisis
and other self-destructive behaviors; the
In a crisis, all seven points just described
prescriber-patient relationship is an-
come into play. The therapist and pre-
other that holds the potential for these
scriber need to consider various questions:
types of dangers. Mutual respect and com-
munication between therapist and pre-
• How well has there been open collab-
scriber are indispensable to ensuring
oration between the psychotherapist
that a crisis is defused.
and the prescriber?
• How well do they work together, and
Understanding That can they trust each other and each
Interpersonal Crises and other’s judgment?
• How does each of them, as well as
Affective Storms Cannot the patient, understand the role of
Be Relieved Simply medication in the treatment and the
medication’s benefits and symbolic
Through Initiation or meaning?
Modification of Medication • How well does each person under-
stand the limits of the medication, and
Introducing medication into the treat-
is one of the treaters overreacting,
ment of a patient with PD should not be a
merely prescribing or wanting a pre-
spur-of-the-moment decision. It should
scription written for medication to
be done in a controlled manner with fore-
feel that a crisis is being defused?
thought and not in the midst of an inter-
• What has been said about medica-
personal or transferential crisis. Patients’
tions in the treatment in the past, and
lives and affects do not follow well-de-
how and when have medications
signed courses or even respond to well-
been used in the treatment?
designed plans. Even if careful plans are
• Have medications been employed
made, the interpersonal crises and affec-
successfully, and have they been used
tive storms that occur in treatment, com-
safely by the patient?
bined with the interpersonal demanding-
ness and/or helplessness and passivity
of the patient, put enormous pressure on
the therapist to do something, to change
Contraindications to
something, to make the pain go away. Collaborative Treatment
There is a tendency to promise much more
than can be accomplished, ultimately Before concluding, we need to make
leading to idealization, disappointment, mention of situations in which collabor-
and subsequent devaluation. If a collab- ative treatment may be contraindicated.
orative relationship exists, and it is very First, however, we must point out that
good and mutually supportive, then nei- when a patient needs both medication
and psychotherapeutic treatment, it is the number of sessions of psychological

very common that both treatments are or psychiatric treatment because of third-
provided by a single psychiatrist. We party payer restrictions, then the psychi-
continue to urge treatment by one indi- atrist must consider how to use those
vidual psychiatrist whenever possible if sessions most efficiently and cost-effec-
the psychiatrist feels capable of and com- tively for the patient. In this instance, be-
petent in providing both the medication ing able to manage medications and
and the specific form of psychotherapy conduct psychotherapy in a single ses-
most useful to the patient. sion may be important. A similar situa-
In some situations, collaborative treat- tion can occur when the patient has se-
ment is contraindicated. The first situa- verely restricted financial resources or
tion would be when the patient is ex- lives so far away that a trip to the psy-
tremely paranoid or psychotic. These chotherapist and/or psychiatrist in-
types of patients may not agree to having volves a significant expenditure of time
people “talk about them” and thus would or money. In this case, if both psycho-
not sign a release of information for such therapy and psychopharmacology can
exchanges to occur. Also, paranoid per- be accomplished in a single trip or visit,
sons often think that all or most other peo- then this approach should be seriously
ple are talking about them, and the thera- considered.
pist may not wish to reinforce this idea by
means of an arrangement wherein people
are talking about the patient. Conclusion
There may also be instances in which
patients have an admixture of serious Collaborative treatment is increasing be-
medical and psychiatric problems. The cause of a number of factors, some due
medical problems may directly affect the to economic reasons, some because of
patient’s psychological problems and advances in neuroscience and pharma-
presentation, as well as the patient’s cog- cology, and some because of managed
nitive processes and ability to compre- care and the way health care in the United
hend. A physician who understands the States is delivered. The various combi-
impact of medical conditions on psycho- nations and permutations of collabora-
logical presentation and functioning and tive treatment are growing beyond the
who can conduct the psychotherapy as standard combination of one person writ-
well as manage the medications would ing prescriptions for psychiatric medica-
be most helpful in these cases, especially tions while another person provides the
if the medical condition or related psy- psychotherapy. Psychiatrists, psycholo-
chological problems wax and wane. In gists, primary care physicians, social
this instance, drug-drug interactions may workers, case managers, physician assis-
have a direct impact on psychological tants, and visiting nurses are just some
and medical well-being, and changes in of the players involved in a collaborative
medical condition may warrant repeated treatment.
reevaluation of psychotropic drug regi- Advances in neuroscience and trends
mens. toward using psychotropic medications
In other instances, practical reality is- more regularly for patients with PDs
sues may lead to treatment by a single have led to more such patients receiv-
provider rather than collaborative treating collaborative treatment. Managed
ment. If a patient has a severe limit on care puts pressure on psychiatrists to use
medications for a “quicker” response, and American Psychiatric Association: Diagnos-

patients, bolstered by direct-to-consumer tic and Statistical Manual of Mental Dis-
orders, 5th Edition. Arlington, VA,
advertising, assume that a medication is
available for every ailment. Given the co- Appelbaum PS: General guidelines for psy-
occurrence of many disorders with PDs, it chiatrists who prescribe medications for
is not uncommon to find one provider patients treated by nonmedical psycho-
managing medications while another di- therapists. Hosp Community Psychiatry
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C H A P T E R 17
Boundary Issues
Experience teaches that any or that only patients with PDs experience
discussion of boundary issues—bound- or pose boundary problems. Instead, the
ary crossings and violations—must begin purpose of this chapter is to examine a
with certain caveats, best delivered in the subset of the wider universe of bound-
form of three axioms. First, only the pro- ary-related potential problem areas.
fessional member of the treatment dyad The profession as a whole has had its
has a professional code to honor or to vi- consciousness raised by the emergence
olate; thus, only the professional is of careful study of trauma victims, many
responsible for setting and maintaining of whom had become highly sensitive to
professional boundaries. Second, pa- boundary transgressions by their treat-
tients, having no professional code, may ers; indeed, boundary issues within the
transgress or attempt to transgress pro- nuclear families of these individuals may
fessional boundaries; if they are compe- have constituted, or been a component
tent adults, they are responsible or ac- of, the trauma. The frequent association
countable for their behavior. However, per of boundary problems as precursors to
axiom 1 above, it is the professional who actual sexual misconduct also focused
must hold the line. Third, exploring the attention on the subject. Nevertheless, the
dynamics of interaction between thera- cases continue to appear (Brooks et al.
pist and patient is not intended to “blame 2012).
the victim” (i.e., the patient) or to exoner- It is critically important to retain non-
ate the professional from responsibility judgmental clarity in this important area,
for the boundaries. especially because the consequences of
Boundary issues in the treatment of confusion about this topic may be seri-
psychiatric patients are universal, as are ous. This chapter aims at alleviating some
concerns about these issues. Therefore, by of this confusion. Before turning atten-
discussing boundary issues in relation to tion to PDs and their implications for
patients with personality disorders (PDs), boundary theory, I review the basic ele-
I do not imply that all patients with PDs ments of this theory.
369
ary problems may emerge from role is-

Basic Elements of sues, time, place and space, money, gifts
and services, clothing, language, and
Boundary Theory physical or sexual contact (Gutheil and
What exactly is a boundary? The follow- Gabbard 1993).
ing serves as a working definition: a
boundary is the edge of appropriate, pro- Boundary Crossings and
fessional conduct. It is highly context de-
pendent. The relevant contexts might be
Boundary Violations
the treater’s ideology, the stage of the In an earlier publication Gabbard and I
therapy, the patient’s condition or diag- (Gutheil and Gabbard 1993) proposed a
nosis, the geographical setting, the cul- distinction that has proven important
tural milieu, and others. Another dimen- in both theory and litigation related to
sion of context, quite relevant for PDs, is boundaries: the difference between bound-
the clinical versus the forensic setting ary crossings and boundary violations.
(Faulkner and Regehr 2011; Zwirn and Boundary crossings are defined as tran-
Owens 2011). Context is a critical and de- sient, nonexploitative deviations from
terminative factor. classical therapeutic or general clinical
Unfortunately, a number of boards of practice in which the treater steps out to
registration and some attorneys ignore a minor degree from strict verbal psy-
the matter of context, to the detriment of chotherapy. These crossings do not hurt
fair decision making. Boards may draw the therapy and may even promote or
from case law and complaints and resort facilitate it. Examples might include of-
to a “list of forbidden acts,” ignoring con- fering a crying patient a tissue, helping a
text entirely (Gutheil and Brodsky 2008), fallen patient up from the floor, helping
as discussed in the following section. an elderly patient to put on a coat, giv-
Besides the data derived from coming a fragile patient a home telephone
plaint procedures and their aftermath, number for emergencies, giving a pa-
data about boundary issues come from tient on foot a lift in a car during a bliz-
consultations, supervision and training zard, writing a patient cards during a long
settings, the literature, professional meet- absence, making home visits based on
ings, informal remarks by colleagues, the patient’s medical needs, answering
and formal studies. These data permit selected personal questions, disclosing
empirical examination of the varieties of selected personal information, and the
boundary phenomena, the criteria for like. None of these actions is psychother-
boundary assessment, and the clinical or apy in its pure “talking” form—they
forensic contexts in which problems arise. constitute instead a mixture of manners,
An extensive literature has grown up helpfulness, support, or social amity—
around this subject in recent decades, and yet no one could reasonably claim they
the reader is directed to it for additional are exploitative of the patient or the pa-
discussion beyond the narrower focus of tient’s needs. Depending on the context,
this chapter (Epstein and Simon 1990; the appropriate response to such actions
Gabbard 1999; Gabbard and Lester 2003; is for the therapist to explore their
Gutheil and Gabbard 1993, 1998; Gutheil impact to maximize their therapeutic
and Simon 2000, 2002; Ingram 1991; Langs utility and to detect and neutralize any
1976; Simon 1989, 1992; Smith 1977; difficulties the patient may have as a re-
Spruiell 1983; Stone 1976). In sum, bound- sult; even the therapist’s well-mannered
Boundary Issues 371
gesture of putting out a hand for a hand- ary violations is not to do them in the
shake may be experienced by a patient first place.
with a horrendous trauma history as an As discussed in the next subsection,
attack or threat. the difference between these two types
An important point about boundary of boundary issues is highly context de-
crossings is that when they occur, the pendent. However, forensic experience
therapist should review the matter with demonstrates that some agencies, such
the patient on the next available occasion, as the more punitive state boards of
and fully document the rationale, the dis- registration, tend to view all boundaries
cussion with the patient, and the descrip- from a rigid “checklist” perspective that
tion of the patient’s response. This advice does violence to clinical flexibility and
may be summarized as the “3 Ds”: de- the essential relevance of context, as in
meanor (remaining professional at all this real-life example.
times), debriefing (with the patient at the
next session), and documentation (of In a hearing before the board of regis-
both the crossing event and its rationale). tration, one complaint was that the
therapist, who was treating the wife
Boundary violations, in contrast, consti-
in a couple, had been given a book by
tute essentially harmful deviations from the husband in appreciation for the
the normal parameters of treatment— therapist’s work. In some contexts, gift
deviations that do harm the patient, usu- giving to therapists may be a bound-
ally by some sort of exploitation that ary problem. The therapist’s expert
was on the stand.
breaks the rule “first, do no harm”; usu-
ally, it is the therapist’s needs that are BOARD’S PROSECUTING ATTOR-
gratified by taking advantage of the pa- NEY (forcefully and accusingly):
tient in some manner. In the case of vio- Now, Dr. Expert, are you
lations, the therapy is not advanced and aware that the husband gave
may even be destroyed. Examples might the therapist a book?
include taking advantage of the patient EXPERT: Yes, and I cannot wait
to hear how you believe that
financially; using the patient to gratify
that exploited the wife.
the therapist’s narcissistic or dependency
needs; using the patient for menial ser- The attorney moved directly to the
vices (cleaning the office, getting lunch, next topic.
running errands); or engaging in sexual
or sexualized relations or relationship
with the patient. A useful test that may Context Dependence
distinguish a boundary crossing from a In a conceptual and contextual vacuum,
violation is whether the event is discuss- it may be impossible to make a clear dis-
able in the therapy (Gutheil and Gab- tinction between a boundary crossing
bard 1993); an even better test might be and a boundary violation. A therapist,
whether the behavior in question would say, who sends a dependent patient a re-
be discussable (hence, admissible) with assuring postcard from his vacation is
a colleague, because many violators ad- merely crossing the boundary; however,
mit that they did not seek consults be- if the postcard is highly erotized, contains
cause they knew the consultant would inappropriate content, and is part of an
tell them to stop the behavior. In any extended sexual seduction, the same ges-
case, the only proper response to bound- ture carries an entirely different weight.
Another element of context is the type not what the doctor wants to do. Ex-
and goal of the therapy. A favorite exam- ploitative boundary violations, there-
ple is this: for an analyst doing classical fore, are viewed as breaches of the doc-
psychoanalysis, no justification would tor’s fiduciary duty to the patient: the
exist for accompanying an adult patient treater has placed his or her own gratifi-
into the bathroom; however, in the be- cation ahead of the patient’s needs.
haviorist treatment of paruresis (fear of
urinating in public rest rooms), the last
step in a behavioral paradigm of treat- Consequences of
ment might well be the therapist accom-
panying the patient there (Goisman and
Boundary Problems
Gutheil 1992). This example also implies
The consequences of boundary problems
that the context may be affected by is-
may be divided into those intrinsic to the
sues such as informed consent to the
therapy and those extrinsic to the ther-
type of therapy, the nature and content
apy. As discussed in the previous section,
of the therapeutic contract, the patient’s
“Basic Elements of Boundary Theory,” a
expectations and so on.
serious and exploitative boundary viola-
tion may doom the therapy and cause the
Power Asymmetry and patient to feel (accurately) betrayed and
Fiduciary Duty used. The clinical consequences of bound-
ary violations, including sexual miscon-
The concepts of power asymmetry and duct, may encompass the entire spectrum
fiduciary duty play an important theo- of emotional harms from mild and tran-
retical role in analyzing boundary prob- sient distress to suicide.
lems and are frequently used in discuss- The extrinsic harms fall into three ma-
ing the consequences of boundary jor categories: civil lawsuits (in some ju-
breaches. Power asymmetry refers to the risdictions, criminal charges for overtly
unequal distribution of power between sexual activity); complaints to the state’s
the two parties in the therapeutic dyad: board of registration, the licensing agency;
the therapist has greater social and legal and ethics complaints to the professional
power than the patient. Part of this power society (e.g., the district branch of the
derives from the fact that the therapist American Psychiatric Association), usu-
often has detailed knowledge of the pa- ally directed to the ethics committee of
tient, including, theoretically, the pa- the relevant organization.
tient’s weaknesses and vulnerabilities—
knowledge that may be used for good or
ill. With this power comes the greater re- Civil Litigation
sponsibility for directing and containing A civil lawsuit for boundary problems is
the therapeutic envelope. The occasional based on the concept that the treater’s
plaint, “It’s not my fault—the patient se- deviation(s) from the appropriate stan-
duced me,” carries little weight under this dard of care constitute professional neg-
formulation. ligence and the patient consequently
A fiduciary duty is a duty that is based sustained some form of damages (Appel-
on trust and obligation. The doctor, as a baum and Gutheil 2008). This blunt legal
fiduciary, owes a duty to the patient to analysis scants the commonly encoun-
place the latter’s interests first; primarily, tered clinical complexity of these claims.
the doctor does what the patient needs, Although lawsuits for clinician sexual
Boundary Issues 373
misconduct were a serious problem in issue, one’s insurance policy will often
past decades, observers have noted an not fund the defense, leaving the doctor
increase in what might be termed “pure” with out-of-pocket legal expenses. One
boundary cases—that is, cases in which implication of this grim scenario is that
actual sexual intercourse has not oc- board complaints should be taken very
curred, but the patient is claiming harm seriously and must include legal assis-
from boundary violations short of that tance, no matter how bizarre, overreac-
extreme. tive, and trivial the complaint may seem.
Other factors may come into play in
the litigation arena. The growing aware- Ethics Complaints
ness of both boundary issues and their
The field of ethics has produced a vast
common precursor role in actual sexual
wealth of philosophical opinion and lit-
misconduct has led some disgruntled pa-
erature as to what does and does not
tients to use a boundary claim as a means
constitute ethical conduct, but an ethics
of taking revenge against a disliked cli-
complaint to one’s professional society
nician. A current joke holds that under
has an extremely concrete denotation: it
the advent of managed care and the severe
asserts that a specific section of the Amer-
restrictions placed on length of treat-
ican Psychiatric Association’s (2009) code
ment, no therapy will continue long
of ethics has been violated by the bound-
enough for the patient to develop erotic
ary issue in question. What is ethical is
transferences for the doctor.
what is in the “book.” The outcome of a
Although most malpractice suits
formal ethics complaint (informal ones
against the clinician will be defended
are not accepted) ranges from censure
and—in case of a loss—paid for by the
and warning (not reportable to the Na-
malpractice insurer, many insurance pol-
tional Practitioner Data Bank) to suspen-
icies contain exclusionary language that
sion or expulsion from the professional
avoids coverage for the more sexualized
society (both of which are reportable).
forms of boundary violation.
Such reportage may plague every subse-
quent job application and will usually
Board of Registration also reach the relevant board.
Complaints
A board of registration complaint chal- Summary
lenges the physician’s fitness to practice, The three types of complaints discussed
as supposedly rendered questionable by in this section constitute the most com-
the boundary problem in question. There mon forms of negative consequence from
are three serious problems with this form boundary problems. Alas for fairness, at-
of complaint. First, registration boards in torneys, boards, and ethics committees
some areas are extremely punitive, seek- may not be sufficiently sophisticated to
ing to meet quotas of delicensed practi- distinguish between boundary crossings
tioners and ignoring both context and and violations. Thus, any boundary is-
evidence. Second, unlike in a malprac- sues should be clearly described in the re-
tice case, a loss in a board of registration cords, together with their rationales, as
case may cost the clinician his or her li- well as readily discussed and explored in
cense and, hence, livelihood. Finally, be- the therapy itself.
cause this complaint is not a malpractice
PDs, which are marked by a tendency

Some Personality Types toward detachment, than in the other
two clusters; however, individuals in the
Encountered in Clinical group with very poor social skills and
Practice poor perspective-taking of others may
cross boundaries more out of social in-
I turn now to boundary issues that come eptness than other dynamics.
up in relation to various PDs. As discussed
in the introduction to this chapter, our
study of the clinical correlation of bound-
Histrionic and Dependent
ary problems with a patient with a PD Personality Disorder
neither blames the victim nor exonerates Consultative experience demonstrates
the treater, nor does it remove from the that two symptoms manifested by pa-
treater the burdens of setting and main- tients with either histrionic or depen-
taining boundaries. Indeed, it takes two dent PD tend to play roles in boundary
to generate a true boundary problem. excursions: neediness and drama. A
Thus, the following discussion addresses patient’s intense need for contact, self-
the interactions between patients with esteem or approval, or relief from any
PDs and the clinicians attempting to anxiety or tension may pressure clini-
treat them. cians into hasty actions that cross bound-
As might be inferred from earlier sec- aries.
tions of this chapter, no particular thera-
pist, patient, or PD should be considered A dependent patient who had been
immune from actual or potential bound- out drinking for an evening called
ary problems (Norris et al. 2003). In- her therapist in a panic and begged
deed, both members of the dyad may him to pick her up at the bar and drive
her home. Feeling somewhat trapped
present risk factors that increase the like-
and choiceless, the therapist did so.
lihood of boundary problems. Therapist The situation, though presented by
issues may include life crises; transitions the patient as an emotional emer-
in a career; illness; loneliness, and the gency, was clearly one merely of “ur-
impulse to confide in someone; idealiza- gency.”
tion of a “special patient”; pride, shame,
and envy; problems with limit setting; Although probably harmless, such an
denial; and issues peculiar to being in a event may well be used by a board of
small-town environment where interac- registration as evidence of boundary
tion with patients outside the office is problems in the treater. Appropriate re-
unavoidable. Patient issues that increase sponses may have included calling a cab,
vulnerability may include enmeshment recommending public transportation if
with the therapist; retraumatization from available, or making a call to family or
earlier childhood abuse and felt help- friends.
lessness from that earlier event; the rep- Dramatic behavior may “trigger” a
etition compulsion; shame and self- boundary problem because of the clini-
blame; feelings that the transference is cian’s wish to “turn down the volume.”
“true love”; dependency; narcissism; and
A patient with histrionic PD, who was
masochism (Norris et al. 2003). distraught after a session over a thera-
Empirically, boundary issues are less pist’s just-announced vacation plan,
likely to occur in the Cluster A group of seated herself on the floor just outside
Boundary Issues 375
the therapist’s door and moaned loudly

for a prolonged interval. The thera-
Antisocial Personality
pist, embarrassed by this scene taking Disorder
place in full view of the clinic waiting
room in front of other patients and Individuals with antisocial personality
staff, brought the patient back into the disorder may strain the boundary enve-
office and conducted an impulsive, lope with the intent of furthering manip-
prolonged session, intruding into other ulation of either the therapist or, through
patients’ appointments.
the therapist, others in the environment.
That environment may be clinical or fo-
Although patients are free to cross bound-
rensic (Faulker and Regehr 2011; Zwirn
aries, the limits must be set by the clini-
and Owens 2011). Examples might in-
cian. The therapist in this example might
clude getting the therapist to advocate
have told the patient that the behavior
for the patient at work, at school, and in
was inappropriate and should be dis-
other areas where the therapist is in-
cussed at the next appointment; should
duced to step out of the limits of the clin-
the patient refuse to leave, security might
ical role to abet the patient’s purposes.
be called, and the matter explored at the
Another boundary issue seen with pa-
next session. It appears likely that the dy-
tients in this category is excessive famil-
namic operating in the vignette was the
iarity and pseudo-closeness designed to
therapist’s countertransference-based
get the therapist to perform uncharacter-
inability to deal with his own sadistic
istic actions that transgress boundaries.
feelings about both planning a vacation
(and thus causing abandonment feelings DOCTOR (on first meeting): How do
in the patient) and being able to turn the you do, I am Dr. Thomas Gutheil.
patient away when the latter was behav- PATIENT: (with warm handclasp): Very
ing inappropriately. Conflicts about sa- glad to meet you, Thomas.
dism are a common source of boundary D OCTOR (slightly nonplused): Um,
difficulties, especially in younger thera- well, Thomas is my given name,
but I go by “Doctor Gutheil.”
pists; the issue of countertransference is
PATIENT (affably): Whatever you say,
further addressed in the section “Coun- Tommy.
tertransference Issues” below.
One of the earliest and most famous As illustrated, the patient may shift on first
examples of histrionic (it would then acquaintance to a first-name or nickname
have been called “hysterical”) behavior basis to establish an artificial rapport de-
was the hysterical pregnancy and pseudo- signed to persuade the therapist to alter
childbirth of Anna O., who was in the the rules of proper conduct. The therapist
throes of an erotic transference to Joseph may feel silly or stuffy about correcting
Breuer, as described in the “Studies on this undue familiarity or even bringing it
Hysteria” (Breuer and Freud 1893–1895/ up at all, but the effort should probably be
1955). Although Breuer is not recorded made, in concert with attempts to explore
as violating any boundaries, the point the meaning of the behavior.
can be made that patient reactions in this Some common goals of this tendency
disorder may operate independently of toward pseudo-closeness are obtaining
the clinician’s actual behavior, a fact lead- excusing or exculpatory letters sent to
ing to confusion among decision-mak- nonclinical recipients; obtaining pre-
ing bodies. scription of inappropriate or inappropri-
ately large amounts of controlled sub-
stances; and intervention in the patient’s special and deserving of extra attention.
extratherapeutic reality (“I need you to This demand for specialness can lead
meet with my parole officer to go easier therapists to grant favors that transgress
on me; you know how ill I am”). boundaries with these patients.1
From the patient’s viewpoint, the
boundaries, even if recognized, may be A patient with BPD in a subsequent
ignored in a goal-directed manner. From psychotherapy commented out of the
blue that she really felt her previous
the clinician’s viewpoint, the boundary
therapist should not have charged her
transgressions may lead to trouble, espe- a fee but should in fact have paid her,
cially if the patient’s actions encompass because her case was so interesting.
illegal behavior (e.g., selling of prescrip-
tions) into which the doctor is drawn by The surprising power of the manipu-
association. lation to slip under the clinician’s radar,
An unfortunately common clinically as it were, is one of the more striking find-
observed constellation of boundary prob- ings in the boundary realm. “I sensed
lems is the following: a female psycho- that I was doing something that was out-
therapist is treating a male patient with side my usual practice and, in fact, out-
antisocial PD but misses the antisocial el- side the pale,” the therapist will lament to
ements in the patient, seeing the latter as the consultant, “but somehow I just found
a needy infant who requires loving care myself making an exception with this pa-
to “get better.” In the course of this rescue tient and doing it anyway.”
operation, boundary incursions occur In an earlier article (Gutheil 1989), I de-
and increase (Gabbard and Lester 2003). scribed my experience with therapists
In a “ladies love outlaws” paradigm, a fe- seeking consultation, who would begin
male therapist may occasionally interpret their narratives saying, “I don’t ordinar-
her role as “taming a wild psychopath.” ily do this with my patients, but in this
case I...[insert a broad spectrum of inap-
Borderline Personality propriate behaviors here].” The patients’
sense of entitlement and of being “spe-
Disorder cial” may infect the therapist with the
Like patients with antisocial PD, patients same view of their specialness, such that
with borderline personality disorder even inappropriate exceptions are made.
(BPD) may manifest conscious or uncon- Clearly, a therapist who realizes that an
scious manipulative tendencies for a exception to usual practice is about to be
number of reasons. Some scholars assert made should view this impulse as a “red
that these patients manipulate because flag” signaling the need for reflection
their low self-esteem leaves them feeling and consultation.
unentitled to ask directly to have their The patient’s own boundary prob-
needs met. It is a clinical truism that un- lems—both in the ego boundary sense
entitlement may be masked by an overt (Gabbard and Lester 2003) and in the in-
attitude of entitlement; the patient oper- terpersonal space—may evoke compara-
ates from the position that he or she is ble boundary blindness in the therapist:
1
Because borderline PD (BPD) empirically poses the greatest boundary difficulties, the reader
may wish to review the axioms given at the outset of this chapter in order to maintain a prop-
erly nonjudgmental perspective.
Boundary Issues 377
A therapist noted that a patient with sexual misconduct spring ultimately from
very primitive BPD would sidle out claimed attempts to rescue the patient,
of the office along the wall in a puz-
to prevent suicide, to elevate the pa-
zling manner that seemed to convey
a fearful state. On exploration the patient’s self-esteem, or to provide a “good”
tient revealed that she was struggling relationship in an effort to counter a
with the fantasy that—if she passed string of bad ones that the patient has ex-
too close to the therapist—she might perienced.
accidentally fall forward and sink into Borderline rage is also a factor leading
the therapist’s chest and be absorbed
to boundary problems, often through its
as though into quicksand. (D. Buie,
personal communication, 1969) power to intimidate.
A 6-foot 7-inch former college line-

Although the reader may detect the un- backer, now a therapist, was asked in
conscious wishes for fusion hidden under consultation why he went along with
this fear, the point of the anecdote is that, a boundary violation that he knew
for some patients, the boundary even of was inappropriate but was demanded
by the patient. When asked why he
the physical self may be extremely tenu-
did not simply refuse, he looked
ous. Indeed, wishes for fusion in both pa- down from his height and stated, “I
tient and therapist may provide the stim- just didn’t dare.”
ulus to boundary transgressions.
The patient with BPD may manifest im- As I have noted elsewhere, this rage may
pulsivity—“I need you to do this now, leave therapists feeling pressured into
right now!”—that presses the therapist inappropriate self-disclosure, conceding
to act precipitously without forethought. to inappropriate requests and manifest-
The patient may demand an immediate ing other signs of being “moved through
appointment, an immediate telephone fear” (Gutheil 1989, p. 598).
contact, an immediate home visit, an im- Disappointed in many past relation-
mediate ride home, an extended session, ships, the patient with BPD may contrive
a medication refill, or a fee adjustment. to “test the therapist’s care or devotion”
Note, of course, that any or all of these in boundary-transgressing ways that of-
may be clinically indicated but may also ten represent reenactments of earlier de-
constitute or lead to boundary problems. velopmental stages. For example, a pa-
Research data indicate that patients tient may perceive that therapy offers
with BPD often have a trauma history; some form of promise—such as inclusion
that is, they were at one time victims in the therapist’s idealized family (Gutheil
(Herman, personal communication, 1980, 1989; Smith 1977). The patient may de-
cited in Gutheil and Gabbard 1993). Some mand to sit on the therapist’s lap or to be
of these patients adopt a posture of vic- held or hugged, arguing that without
timization (an element of entitlement this demonstration of caring, there can
distinguishable from narcissistic entitle- be no trust in the therapy. Herman (per-
ment). This posture may mobilize rescue sonal communication, 1980, cited in
feelings, fantasies, or attempts in the ther- Gutheil and Gabbard 1993) pointed out
apist that lead him or her to “bend the that because so many patients with BPD
rules” to achieve the rescue and thus to have histories of sexual abuse, they may
transgress boundaries (Gabbard 2003). have been conditioned to interact with
Indeed, consultative experience leads to significant others on whom they depend
the conclusion that a number of cases of in eroticized or seductive ways (p. 598).
Forensic experience reveals the sad desperate measures to prevent this out-
truth of how often these primitive ma- come at all costs, including the cost of
neuvers to obtain inappropriate close- violating boundaries to achieve this
ness or contact actually succeed, to the rescue. Gabbard (1999) described this
detriment of the therapy and often to the phenomenon in detail as the therapist’s
censure of the therapist. As might well masochistic surrender, a dynamic issue
be expected, the wellspring of these de- closely linked to boundary problems.
viations is commonly the countertrans- The therapist’s frustration may rise to
ference in the dyad, my next topic. the level of overt anger, in which the ther-
apist acts out countertransference hostil-
ity by violating boundaries such as con-
Countertransference fidentiality; the therapist who angrily
Issues and inappropriately calls the patient’s
partner at home and rails at him or her
The patient’s need for help and the to protest some action involving the pa-
treater’s membership in a helping pro- tient has lost the compass that would keep
fession ordinarily provide a salutary one in bounds.
and symmetrical reciprocity, but one In a useful discussion, Smith (1977) de-
that is not immune to distortion or mis- fined the “golden fantasy” entertained
carriage. The basic wish to help and heal, by some patients with BPD and others;
unfortunately, may inspire efforts that— the golden fantasy is the belief that all
no matter how well intended—trans- needs—relational, supportive, nurturant,
gress professional boundaries in prob- dependent, and therapeutic—will be met
lematic ways. The patient’s transferential by the treater. As the patient loses track
neediness and dependency may evoke a of what constitutes the therapeutic as-
countertransferential need in the thera- pect of the work, the therapist, too, may
pist to rescue, save, or heal the patient at begin to lose track of the actual parame-
any cost. Wishes to save the patient from ters within which the treatment should
anxiety, depression, or suicide are com- take place.
mon stimuli to boundary violations in The “Practice Guideline for the Treat-
the name of rescue. ment of Patients With Borderline Per-
An example of this problem is what I sonality Disorder” (American Psychiat-
call the “brute force” attempt at cure. Frus- ric Association 2001) stresses four basic
trated by the difficulty of working with points relating to patients with BPD
the patient and disappointed at the lat- and boundaries. The therapist should
ter’s lack of progress, the therapist sees 1) monitor countertransference care-
the patient more and more often each fully, 2) be alert to deviations from usual
week, for longer and longer session times; practice (“red flags”), 3) always avoid
weekends, holidays, even vacations are boundary violations, and 4) obtain con-
no exception to this relentless crescendo. sultation for “striking deviations from
Therapists in this situation are being the usual manner of practice” (Ameri-
held hostage by the patient’s insatiable can Psychiatric Association 2001, p. 24).
need and are setting themselves the These points are fully congruent with
wholly unrealistic goal of meeting that the material in this chapter.
need by “giving more.” In sum, because of their own difficul-
In a related manner, such patients’ sui- ties with boundaries, their capacity to
cide risk may lead the therapist to try evoke powerful countertransference reac-
Boundary Issues 379
tions, and the particular elements of their leave treatment. Rather, some basic guide-
interpersonal style, patients with BPD lines may prove helpful to the clinician
pose some of the most noteworthy exam- desirous of staying out of trouble while
ples of boundary problems and challenges preserving the therapeutic effect of the
to clinicians to maintain proper limits. work.
1. Clinicians of any ideological stripe

Some Cross-Cultural must obtain some basic understand-
ing of the dynamic issues relating to
Observations transference and countertransference.
Culture, of course, is itself a context; al- Training programs that foolishly boast
though some forms of boundary issues of having transcended “that Freudian
might be expected in all cultures, the ma- stuff” do a serious disservice to their
jority of litigation and theoretical discus- graduates. A patient with BPD in the
sion seems to occur in the United States. idealizing phase of treatment may
A cross-cultural study (Commons et al. worship the therapist, but a therapist
2006), however, comparing boundary who is untrained in the vagaries of
matters in the United States and in Rio de transference may be left to assume
Janeiro, Brazil, turned up some interest- that his or her own natural gifts of
ing findings. The U.S. sample and the person have evoked this reaction—a
Brazilian sample agreed at the extremes; dangerous view, indeed.
that is, in both countries overt sexual mis- 2. Treaters of patients with PDs must
conduct at one end of the spectrum was keep in mind the latter’s capacity to
seen as proscribed, and trivial deviations distort or overreact. A therapist who
at the other end were seen as harmless. In writes to such a patient and signs the
the middle ranges, divergence was re- letter, “Love, Dr. Smith,” may intend
vealed. For example, subjects in the U.S. agape (nonerotic love), but the patient
sample believed hugging a patient was may interpret eros and expect treat-
suspect and kissing was surely wrong, but ment consistent with that emotion.
it was fully acceptable to display licenses, Even if the patient initially under-
certificates, and some honors on the wall. stands the meaning, the regulatory
In contrast, the Brazilian cohort found agencies may interpret that salutation
kissing the cheek in greeting to be univer- as a sign that the clinician has lost ob-
sally acceptable and an accepted manner jectivity and may assume boundaries
of greeting patients, but display of certif- have been violated (note that this se-
icates was considered a deviation. quence of events is not speculative
but empirical). Therapists should, of
course, take responsibility for their
Risk Management actions, but these patients can evoke
strong feelings of guilt that distort
Principles and the clinician’s perception of what
Recommendations happened and who is responsible.
In a board of registration complaint,
Clearly, a rigid formalism and an icy de- a patient claimed to have been hurt by
meanor are not the solution to boundary some action of a doctor. Instead of
problems when dealing with patients writing, “I am sorry you feel hurt,” the
with PDs; patients so treated will simply doctor wrote, “I am sorry I hurt you.”
This ill-chosen expression of inap- begin to appear on the horizon or

propriate self-blame made it almost when the transference becomes ero-
impossible to convince the board tized. Such consultation will aid in
that the doctor had remained within keeping perspective and in ensuring
proper boundaries. that the standard of care is being met.
The learning point here: When in 6. Any potential boundary excursion of
doubt, obtain forensic or legal con- uncertain meaning should be marked
sultation. by three critical steps: maintenance of
3. The therapist should develop a “red professional behavior, discussion with
flag” warning response when find- the patient, and documentation. Un-
ing himself or herself doing what he der some circumstances a tactful apol-
or she would not usually do—that is, ogy to the patient for misreading a sit-
making an exception to customary uation may also be in order. Failure to
practice. The exception in question perform these steps casts the therapist
may be an act of laudable creativity in the light of one who wants to con-
in treatment, but it may also be a ceal wrongdoing. The “3 Ds” noted
boundary problem. Self-scrutiny and earlier (see subsection “Boundary
consultation may be most useful un- Crossings and Boundary Violations”)
der the circumstances. should be invoked, as in this example:
4. Simon and I (Gutheil and Simon 1995)
observed that the neutral space and Driving home from a late last appoint-
ment, a therapist sees his patient
time when both parties rise from their
slogging wearily homeward on foot
chairs and move toward the door at through the 2-foot-high drifts that a
the end of a session represents an oc- recent blizzard has deposited on the
casion when both parties may feel that area. To prevent the patient from dy-
the rules do not really apply, because ing of exposure in the subfreezing
the session is theoretically over. We weather, he offers her a ride home in
his Jeep. In the car he continues to be-
recommended that therapists pay at-
have in a formal, professional manner,
tention to their experiences and the despite the odd circumstances. Next
events and communications occur- day at the office he records a careful
ring during this “window”; a tendency note outlining his reasoning and the
toward crossing or even violating risk-benefit analysis of the incident.
At the patient’s next appointment, the
boundaries may emerge in embryonic
therapist inquires how the incident
form during this period, allowing the felt to the patient, and its therapeutic
therapist to open the subject for explo- significance is explored.
ration in the following session and,
one hopes, to deflate its problematic 7. Therapists can avert the majority of
nature. boundary difficulties by taking this
5. When in doubt, a therapist should approach: “Explore before acting.”
seek consultation; this honors my fa- Impulsive responses to patient de-
vorite maxim, “Never worry alone.” mands are likely to go astray, as well
Although getting consultation be- as inappropriately to model impul-
fore taking a step that might present sivity. Boundary issues pose special
boundary ambiguities is an excellent challenges for therapists; adherence
idea, the therapist should also begin to the basic principles described in this
presenting the case to a colleague or chapter may aid in protecting both
supervisor when boundary problems therapists and patients.
Boundary Issues 381
Gutheil TG: Borderline personality disorder,

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165, 2011
PART III
Special Problems,
Populations, and Settings
C H A P T E R 18
Assessing and Managing

Suicide Risk
Paul S. Links, M.Sc., M.D., FRCPC
Paul H. Soloff, M.D.
Personality disorders (PDs) psychiatric care and management can re-

are highly prevalent disorders that im- duce the risk of future suicidal behavior
part significant morbidity and mortality. in patients with PDs and therefore is
In the National Comorbidity Survey highly indicated. In this chapter, we dis-
Replication, the prevalence of PDs was cuss the association between PDs and
found to be approximately 9% in the gen- suicide and describe the nonmodifiable
eral population (Lenzenweger et al. and potentially modifiable risk factors
2007). Borderline PD (BPD), in particular, for suicide and suicidal behavior; review
is a disabling condition affecting approx- research that contributes to the under-
imately 2% of the general population, standing of the possible neurobiological
10% of psychiatric outpatients, and 20% mechanisms leading to suicide and sui-
of psychiatric inpatients (Lieb et al. 2004). cidal behavior in individuals with PDs;
Individuals with BPD are significant us- and discuss the assessment of suicide
ers of health services (Zanarini et al. risk and approaches to crisis manage-
2004), and their lifetime risk of suicide ment in patients with PDs.
ranges between 3% and 10% (Paris and Much of this chapter focuses on pa-
Zweig-Frank 2001). As a result of the risk tients with BPD, which is the only PD in
of suicide and repeated suicidal behav- DSM-IV (American Psychiatric Associa-
ior (referring to behaviors with some tion 1994) and DSM-5 (American Psychi-
level of intent to die), these patients are atric Association 2013) to have recurrent
often considered difficult to treat and are suicidal or self-injurious behavior as one
often actively avoided by clinicians. How- of the diagnostic criteria. In the alterna-
ever, research indicates that appropriate tive model for personality disorders in
385
DSM-5 Section III, “Emerging Measures onstrated attempts with the greatest sub-
and Models,” the proposed revision to jective intent, objective planning, and
BPD still includes “self-harming behav- medical lethality. By studying the patient’s
ior under emotional distress” as a defin- most serious suicide attempts, one can
ing feature of the disorder (p. 767). We em- estimate the severity of the patient’s on-
phasize BPD in this review because much going chronic risk for suicide, particu-
of the research done on PDs over the last larly because the method of previous at-
two decades has been focused on BPD, tempts tends to predict the seriousness
with relatively little attention paid to the of suicide vulnerability (Modai et al. 2004).
other PDs. Some of the important factors that contrib-
We have organized our discussion of ute to an acute risk of suicide in patients
the assessment of suicide risk in patients with PDs are discussed in this chapter;
with PDs based on the model of an “acute- however, a more complete discussion of
on-chronic” risk (Figure 18–1). Chronic suicide risk factors and suicide risk as-
risk for suicide relates to factors that have sessment in psychiatric patients is avail-
existed for many months or years and able in other resources, such as the “Prac-
generally are not modifiable. In contrast, tice Guideline for the Assessment and
acute risk for suicide relates to factors that Treatment of Patients with Suicidal Be-
have existed for days, weeks, or months haviors” (American Psychiatric Associa-
and are often modified by clinical inter- tion 2003).
ventions. The acute-on-chronic risk model
is presented as a way of assessing and
communicating the suicidal risk of pa-
tients with PDs and, in particular, those
Epidemiology
patients with histories of repeated sui-
cidal behaviors. This model should be PDs are associated with a significant bur-
differentiated from other models of sui- den of illness and a relatively high prev-
cide and suicidal behavior, such as the alence of suicidal behavior and death by
stress-diathesis model (discussed later in suicide. In one psychological autopsy
the section “Neurobiological Diathesis to study of 163 suicide completers diagnosed
Suicidal Behavior in Personality Disor- using semistructured diagnostic inter-
ders”), which is a proposed causal model views with informants, 72.3% of men
of suicidal behavior. With regard to the and 66.7% of women had features that met
acute-on-chronic risk model, PD patients the criteria for at least one PD, and 42.6%
typically are at a chronically elevated risk of men and 30.8% of women had fea-
of suicide much above the risk in the gen- tures that met the criteria in multiple PD
eral population. This risk exists primar- clusters (Schneider et al. 2006). Another
ily because of a history of multiple previ- autopsy study of 229 suicide victims di-
ous attempts, although in some studies agnosed by two pairs of psychiatrists
the patients’ history of (nonsuicidal) self- found that 29.3% of their sample had fea-
injurious behavior has been shown to tures that met the criteria for at least one
also increase the risk for suicide (Line- PD (Isometsa et al. 1996).
han 1993; Stanley et al. 2001). A patient’s
level of chronic risk can be estimated by Cluster A
taking a careful history of the previous
suicidal behavior and focusing on the In Schneider et al.’s (2006) psychological
times when the patient may have dem- autopsy study of suicide completers, 20%
Assessing and Managing Suicide Risk 387
Acute exacerbation of risk

Major
depression
Self-soothing
Substance skills
abuse
Distraction
Hospital discharge approaches
(or other loss
of support)
Risk level
Chronic level in BPD patients
General population
Time course
FIGURE 18–1. Acute-on-chronic suicide risk in borderline personality disorder (BPD).

Source. Adapted from Gunderson JG, Links P: Borderline Personality Disorder: A Clinical Guide, 2nd Edition.
Washington, DC, American Psychiatric Publishing, 2008, p. 97. Copyright 2008, American Psychiatric Pub-
lishing, Inc. Used with permission.
of men and 17.9% of women had features Cluster B

that met the criteria for paranoid PD,
10.8% of men and 12.8% of women for Isometsa et al.’s (1996) psychological au-
schizoid PD, and 6.5% of men and 5.1% of topsy study of suicide victims found a
women for schizotypal PD. Isometsa et prevalence of Cluster B PDs of 18.8%. Of
al. (1996) found a much lower rate, with those with PDs, 25% had BPD, 6% had
0.4% of suicide victims (N=1) having fea- narcissistic PD, and 4% had antisocial
tures that met the criteria for paranoid PD. In the Schneider et al. (2006) study,
PD; in no cases were the criteria for other 10.8% of men and 17.9% of women had
Cluster A disorders met. features that met the criteria for histrionic
In the Chestnut Lodge follow-up study PD, 27.7% of men and 20.5% of women
of patients with schizotypal PD over age for narcissistic PD, 7.9% of men and 2.6%
19 years, 3% died by suicide, 24% at- of women for antisocial PD, and 28.1% of
tempted suicide, and 45% expressed men and 25.6% of women for BPD.
suicidal ideation (Fenton et al. 1997). In The rate of suicide in individuals with
Lentz et al.’s (2010) sample of 307 living BPD has been estimated to range as high
individuals with schizotypal PD, cases as 10% to as low as 0%, depending on set-
were 1.51 times more likely to have at- ting, patient characteristics, and method
tempted suicide than controls. In a study of study. Paris and Zweig-Frank, in a 27-
of inpatients with a primary diagnosis of year follow-up study of patients hospital-
PD, Ahrens and Haug (1996) found that ized with a diagnosis of BPD, reported a
44% of individuals with schizoid PD and suicide rate of 10% (Paris 2004; Paris and
47% of individuals with paranoid PD dis- Zweig-Frank 2001), and one Japanese
played “suicidal tendencies.” study reported an incidence of 6.9%
(Yoshida et al. 2006). Several prospective
studies, however, have found a lower rate A Finnish psychological autopsy study of
of suicide. In a 10-year prospective study adolescents ages 13–19 years found that
by Zanarini et al. (2006), the rate of death 17% had features that met the criteria for
by suicide was only 4%. Among patients conduct disorder or antisocial PD (Mart-
with BPD recruited at the Austin Riggs tunen et al. 1991).
Center, a voluntary residential treatment Data on histrionic and narcissistic PDs
center, and followed in treatment for 7 are limited. There are no prospective
years, Perry et al. (2009) found no deaths studies on suicide in histrionic PD. One
by suicides. In a prospective follow-up psychological autopsy study of suicides
study of BPD patients who received 1 year in individuals over age 60 found that 5.2%
of BPD-indicated treatment, Links et al. of the individuals had histrionic PD ac-
(2013) found that none died by suicide cording to ICD-10 criteria (Harwood et
over 1 year of treatment and 2 years of al. 2001). In the case of narcissistic PD, a
follow-up. These results suggest that pa- 15-year follow-up study found that pa-
tients receiving regular outpatient treat- tients with narcissistic traits or disorder
ment may be at significantly lower risk had an increased likelihood of death by
compared to an untreated population of suicide (Stone 1989). One report sug-
patients with BPD. gested that narcissistic personality was a
The rate of attempted suicide among risk factor for suicide ideation in elderly
individuals with BPD is much higher depressed patients (Heisel et al. 2007).
than the rate of suicide, and an estimated
85% of these patients have a history of
Cluster C
such behavior (Paris 2004). In one cohort
of previous suicide attempters, the rate of In the Isometsa et al. (1996) study of sui-
medically significant suicide attempts cides, the prevalence of Cluster C PDs in
was 27.8% by the sixth year of follow-up the total sample was 10%. Of the suicide
(Soloff and Chiappetta 2012). In another victims who met criteria for PDs, 7% had
cohort recruited from an inpatient set- features that met the criteria for depen-
ting, 79.3% had made an attempt at base- dent PD, 6% for avoidant PD, and 3% for
line and 32% made an attempt within the obsessive-compulsive PD (Isometsa et
first 2 years of follow-up (Wedig et al. al. 1996). In the Schneider et al. study,
2012). Neither of these studies controlled 21.3% of men and 15.4% of women had
for the amount or type of treatment re- features that met the criteria for avoid-
ceived. In the prospective study by Links ant PD, 6.2% of men and 5.1% of women
et al. (2013) of treated patients with BPD, for dependent PD, and 23.1% of men and
81.1% of patients had made a suicide at- 17.9% of women for obsessive-compulsive
tempt in the past, 26% of participants PD (Schneider et al. 2006).
made a suicide attempt during the 1-year A cross-sectional study of psychiatric
treatment phase, and 16.7% made an at- inpatients examined for Cluster C PDs
tempt during the 2-year follow-up period found that 35% of patients with depen-
(Links et al. 2013). dent PD, 18% of patients with avoidant
Patients with antisocial PD are also PD, and 14% of patients with obsessive-
considered to be at elevated risk for sui- compulsive PD had made a suicide at-
cide. One 5-year follow-up study found tempt in the past (Chioqueta and Stiles
that 5.7% of subjects died of suicide within 2004). In a study of 31 patients with de-
the follow-up period (Maddocks 1970). pression and comorbid obsessive-com-
pulsive PD, 52% had made a suicide at- older patients with BPD with a chronic
tempt and 37.5% had made multiple course of illness may be at increased risk
attempts (Diaconu and Tureki 2009). for suicide as discussed below (see sub-
section “Course of Suicide Behavior” later
Summary in this chapter).
Research evidence supports an associa- Personality disorder features. Three
tion between PD diagnoses and death by subcategories of BPD symptoms have
suicide. Although some evidence indi- been investigated with respect to suicide
cates that Clusters A and C disorders are risk: impulsivity, affective instability, and
associated with suicide and suicidal dissociation. Impulsivity has previously
behavior, the strongest association has been considered a risk factor for suicide
been found for Cluster B PDs and BPD (Wedig et al. 2012). Some research, how-
in particular. ever, has called this finding into question.
McGirr et al. (2007) compared individu-
als with BPD, either with or without
Risk Factors Cluster B comorbidity, who had com-
pleted suicide with individuals living
According to the acute-on-chronic risk with BPD. The authors found a gradient of
model, the ongoing risk of suicide is de- psychopathology across the groups, par-
termined by chronic risk factors, which ticularly for substance-dependent disor-
are typically nonmodifiable factors, while ders and impulsive aggressiveness, with
discrete periods of increased risk arise the highest levels of psychopathology be-
from acute risk factors (Zaheer et al. ing found in those individuals with BPD
2008). Assessment of risk at both levels and Cluster B comorbidity. With respect
allows the clinician to place the patient to attempter status, Wedig et al. (2012)
along a suicide risk continuum and to similarly found that impulsivity did not
decide when an increased level of care is predict attempter status when self-harm
temporarily required to prevent immi- and substance use disorder were not in-
nent suicide because of an acute-on- corporated into the measurement. These
chronic exacerbation. findings suggest that these specific com-
ponents of impulsivity may be the true
Chronic or predictors of risk (Wedig et al. 2012) and
Nonmodifiable Risk that more precise clinical definitions of
impulsivity as it relates to suicide risk are
Most empirical work on chronic risk fac- needed. The characterization of impul-
tors in PDs has been done in BPD. The sivity using neurobiological methods is
limited data related to the other PDs will discussed later in this chapter (see “Neu-
be presented separately in the last sub- robiological Diathesis to Suicidal Behav-
section of this section. ior in Personality Disorders”).
Borderline Personality Affective instability and dissociation
were associated with attempter status in
Disorder Wedig et al.’s (2012) longitudinal follow-
Demographics. The literature on BPD up study, and Yen et al. (2004), in their 2-
reports little association between age, year follow-up, also identified affective
race, or sex and suicide attempter or high- instability as a predictor of suicide at-
lethality status (Links et al. 2013; Soloff tempts. In an experience sampling study,
et al. 2005; Wedig et al. 2012). However, Links et al. (2008) found that negative
mood intensity and mood amplitude were other than BPD. The Collaborative Lon-
the facets of affective instability most as- gitudinal Personality Disorders Study
sociated with history of suicidal behav- (CLPS), in which the sample included pa-
ior. On the other hand, both affective in- tients with schizotypal, avoidant, and ob-
stability and dissociative symptoms were sessive-compulsive PDs as well as BPD,
protective against death by suicide in found no association between attempter
the study by McGirr et al. (2009). These status and age, gender, race, occupation,
findings may support the concept of or education level (Yen et al. 2005).
two distinct trajectories of suicidal be- Some evidence indicates an associa-
havior in BPD, one involving multiple tion between suicide risk and treatment
low-lethality behaviors and another in- history, burden of illness, and PD fea-
volving high-lethality and potentially tures. In Ahrens and Haug’s (1996) sam-
fatal behaviors. ple of inpatients with any PD, the number
of previous attempts was associated with
Psychosocial functioning and treat-
ment history. Markers of impaired func- “suicidal tendencies”; hospitalizations
tion, such as low socioeconomic status, and other exposures to psychiatric treat-
poor global functioning, and preexisting ment were not investigated. In a study by
treatment history, represent significant Blasco-Fontecilla et al. (2009a), “diffuse”
risk factors for suicidal behavior in pa- PD (PD comorbidity across multiple PD
tients with BPD. clusters) was associated with number of
suicide attempts but not lethality. Simi-
Childhood abuse. Childhood abuse is larly, in a psychological autopsy, multi-
a nonmodifiable risk factor in BPD pa- ple-cluster pathology was associated with
tients that may persist in spite of treat- an increased odds ratio of 16.13 in men
ment (Links et al. 2013). Most research and 20.43 in women for death by suicide
has focused on sexual abuse, but child- (Schneider et al. 2006). Lastly, in a sample
hood abuse of any type can be a risk fac- of patients with Cluster B PDs, all suicide
tor (Zaheer et al. 2008). attempters except those with narcissistic
In Wedig et al.’s (2012) naturalistic fol- PD had significantly higher impulsivity
low-up study of BPD patients, posttrau- than nonattempters, suggesting that im-
matic stress disorder (PTSD) was an inde- pulsivity may be important in histrionic
pendent predictor of attempter status, PD and antisocial PD (Blasco-Fontecilla et
whereas childhood abuse was not. Con- al. 2009b).
versely, in a treated sample, severity of Collectively, these data suggest that
childhood sexual abuse emerged as a con- some of the chronic risk factors that apply
tinuing risk factor, whereas PTSD did not to BPD, including burden of illness and
(Links et al. 2013). These findings suggest extensive treatment history, may also ap-
that certain shared factors may explain ply to the other PDs. More research is
the association between trauma and the necessary to fully explore this area.
risk for suicide. Potential mediators of
this risk include Cluster A traits and poor
social adjustment, as well as neurobiolog-
Acute or Modifiable
ical changes (Soloff et al. 2008a). Risk Factors
Other Personality Disorders Comorbidities
Limited information is available about The role of psychiatric comorbidity in
chronic risk factors for suicide in PDs suicide attempter status and in lethality
of attempts has been investigated exten- Stressful Life Events

sively, particularly with respect to PTSD,
Stressful life events present significant ob-
major depressive disorder (MDD), sub-
stacles to patients with PDs, because the
stance use disorder, and antisocial PD;
pathology related to BPD often renders
however, the results have been inconsis-
these individuals unable to cope effec-
tent (McGirr et al. 2007; Soloff et al. 2005;
tively. In addition, their PD features may
Zaheer et al. 2008).
be responsible for causing stressful life
Wedig et al. (2012) found that MDD,
events to occur. Although various stress-
substance use disorder, and PTSD were
ful life events are risk factors, clinicians
all significantly associated with attempter
should be aware that patients with cer-
status during 16 years of naturalistic fol-
tain personality pathologies might be
low-up. Conversely, in the prospective
uniquely vulnerable to specific life events;
follow-up of a treated sample, Links et al.
for example, patients with BPD are partic-
(2013) found that none of these diagnoses
ularly reactive to interpersonal stressors
predicted attempter status. One way to
(Blasco-Fontecilla et al. 2010; Horesh et al.
interpret this discrepancy is to view co-
2009; Kelly et al. 2000; Kolla et al. 2008).
morbid conditions as modifiable risk fac-
tors, and treatment status as an important Borderline Personality
consideration in evaluating the evidence
(Links et al. 2013).
Disorder
Predictors of high lethality status have Acute interpersonal stress is especially
been similarly inconsistent. Zaheer et al. pertinent to evaluation of patients with
(2008) identified the presence of specific BPD. In a study by Brodsky et al. (2006),
phobias, lifetime PTSD, and schizotypal depressed patients with BPD were more
traits as risk factors for increased lethal- likely than those without BPD to report
ity, whereas Soloff et al. (2005) found an interpersonal triggers for both initial
association only with antisocial PD. and subsequent suicide attempts. Inter-
According to Zaheer et al. (2008), the personal triggers may be characteristic
heterogeneity of studied populations, of stressors for patients with BPD, but other
measurement tools used, and of defini- kinds of loss and transitions may also be
tions of high lethality employed across relevant. For example, recent discharge
studies may explain the variable find- from hospital and the associated loss of
ings. Another explanation is that comor- supportive structures can be a risk factor
bid conditions may act nonspecifically for patients with BPD (Kolla et al. 2008).
by increasing the burden of illness expe- Shame surrounding an interpersonal
rienced by an individual, which in turn stressor has been suggested as an inter-
may lead to an increased risk of suicide. mediate risk factor between interper-
Finally, it is possible that comorbid con- sonal events and suicidal behavior (Brown
ditions are surrogates for more specific et al. 2009).
risk factors included among their symp-
toms. For example, a subgroup of patients Other Personality Disorders
with PTSD could experience perceptual Yen et al. (2005) assessed the relationship
or dissociative symptoms that put them between stressful life events and suicide
at higher risk independent of the overall attempts in the CLPS sample and found
diagnosis (Zaheer et al. 2008). that negative life events were associated
with suicide attempts in that mixed sam-
ple. Specifically, events categorized as 2009). Similarly, the MSAD found pro-
love-marriage and crime-legal (for vic- gressive remission of diagnostic criteria
tim and for perpetrator) were significant for BPD patients through 16 years of fol-
predictors of suicide attempts in the next low-up (Zanarini et al. 2010, 2012). Acute
month after their occurrence. symptoms, including suicide attempts,
It remains to be determined whether remitted most rapidly. “Manipulative
some life events are as pertinent to other suicide attempts,” which were found in
PDs as interpersonal events are to BPD. 56.4% of subjects at 2-year follow-up, were
Blasco-Fontecilla et al. (2010) explored this only reported in 4.3% by year 10. These
question in a mixed sample of patients favorable longitudinal outcomes beg the
from all three clusters of PDs. Only in question, Who dies by suicide? Are there
Cluster B disorders were suicide attempts clinical characteristics that predict at-
found to be associated with specific tempts of higher lethality over time? In a
stressors independent of Axis I diagnosis. prospective longitudinal study of attempt-
Attempts by individuals with antisocial ers with BPD, Soloff and Chiappetta
PD were associated with jail terms, minor (2012) defined clinical characteristics of
violations of the law, and spousal death, 91 repeat attempters who had increasingly
whereas attempts by individuals with lethal attempts over time. The time from
narcissistic PD were associated with mar- the first attempt to the attempt of maxi-
ital arguments, personal injury/illness, mum lethality was long and extremely
and mortgage foreclosure. Although con- variable. Among attempters with up to
founded by the presence of Axis I pathol- five lifetime attempts, the time to maxi-
ogy, some relationships were also identi- mum medical lethality was 8.94 years,
fied between specific event categories with a median of 6.81 years, and a range
and Cluster A and Cluster C disorders. of 8 weeks to 37.1 years. High-lethality at-
tempts (defined operationally by a Medi-
Course of Suicide cal Lethality Scale score t4) were best
predicted by older age and a history of
Behavior prior hospitalizations, suggesting that
Despite a fatal outcome in a minority of chronicity and illness severity play criti-
patients with PDs (e.g., 3%–10% for those cal roles in the vulnerability to high-lethal-
with BPD [Paris and Zweig-Frank 2001]), ity behavior over time. A trajectory anal-
the vast majority can expect significant ysis separated two groups of attempters,
symptom relief over time. In the McLean one with increasingly greater Medical
Study of Adult Development (MSAD), a Lethality Scale scores over time (the high-
prospective longitudinal study of patients lethality group), and another with recur-
with PDs, Zanarini et al. (2012) reported rent attempts of low lethality. High-le-
remission in both symptoms and diagno- thality subjects were predominately re-
sis over the course of 10- to 16-year fol- cruited from inpatient units and had
low-ups among patients with BPD. CLPS poorer psychosocial functioning at base-
researchers found that diagnostic criteria line compared to the low-lethality group.
among their BPD patients decreased sig- High-lethality subjects were character-
nificantly in the first 6–12 months follow- ized by poor relationships in the immedi-
ing assessment, with improvement con- ate family and a poor work history. The
tinuing through the following 10 years low-lethality group endorsed more nega-
(Gunderson et al. 2011; Shea et al. 2002, tivism (on the Buss-Durkee Hostility In-
ventory), lifetime substance use disorder, decreased rapidly with time. Prospective
and comorbidity with Cluster B histri- predictors of suicide attempts changed
onic and/or narcissistic PDs. This group dramatically over time. In the shortest
is more likely to include patients whose follow-up interval (12 months), attempts
suicidal acts are “communicative ges- were predicted by comorbidity wit h
tures,” intended to demonstrate distress MDD, an acute stressor. Thereafter, no
and coerce a caring response from others. acute clinical stressors predicted interval
Studies of suicide in patients with BPD attempts. These results were attributed
report that the duration of the “suicidal to illness severity and inpatient recruit-
process,” from first unequivocal suicidal ment for nearly half of the sample. Suicide
communication (by verbal threat and at- attempts following hospital treatment
tempt) to death, may be as brief as 30 (and predicted by MDD) strongly sug-
months (Runeson et al. 1996) or as long as gest persisting depression. Similarly, ill-
10 years (Paris and Zweig-Frank 2001). ness severity, marked by psychiatri c
Death by suicide in BPD tends to occur hospitalizations in the follow-up interval
relatively late in the course of the illness. (but preceding any attempt), was predic-
In their 27-year follow-up study, Paris tive of subsequent attempts through year
and Zweig-Frank (2001) reported that 4 of follow-up. It is noteworthy that any
suicide occurred at an average age of 37 outpatient department treatment in the
years. Younger patients with BPD tended 12-month interval diminished the sui-
to make frequent low-lethality attempts cide risk. Importantly, absence of outpa-
as communicative gestures, whereas older tient department treatment remained a
patients committed suicide after years of predictor of suicide risk to the 6-year fol-
illness. low-up.
There are few prospective longitudi- Acute symptoms are unlikely to have
nal studies of suicidal behavior in sub- predictive value for suicidal behavior in
jects with PDs. Prospective studies are the long-term course. The MSAD showed
limited when assessing predictors of at- that acute symptoms remitted early in
tempt behavior by the rarity of suicide the course of BPD (i.e., the remission rate
and to some extent attempts. In a 6-year exceeded 60% by 6 years) (Zanarini et al.
prospective longitudinal study of sui- 2006). In the CLPS, suicide attempt s
cidal behavior in subjects with BPD, Sol- were predicted by a history of childhood
off and Chiappetta (2012) found that sui- sexual abuse (Yen et al. 2004), a known
cide attempts over a 6-year interval were risk factor in BPD (Soloff et al. 2002) and
best predicted by poor psychosocial across diagnoses, but not a proxima l
functioning at baseline, a family history cause. However, a history of childhood
of suicide, and the absence of any outpa- sexual abuse is associated with neurobi-
tient treatment (prior to any attempt). ological changes—including dysregu-
Good psychosocial functioning at base- lation of the hypothalamic-pituitary -
line was a protective variable that de- adrenal axis; volume loss in areas o f
creased risk. In this prospective study, sui- prefrontal cortex, hippocampus, an d
cide attempts occurred most frequently amygdala; and diminished central sero-
in the first 2 years of follow-up (e.g., 19% tonergic function—any of which may
of 137 subjects in the first 12 months, contribute to the diathesis to suicidal be-
24.8% of 133 subjects by the second year). havior in these subjects at the time of
Thereafter, the number of new attempts acute stress.
The frequency of repeated suicide at- (Zanarini et al. 2010). Vocational failure
tempts in the year following hospitaliza- contributed most to poor psychosocial
tion for an index attempt has been re- functioning in this study. Although sui-
ported at 17%, independent of diagnosis cidal and self-injurious behaviors remit-
(Cedereke and Ojehagen 2005). The CLPS ted early, symptomatic improvement
found that 20.5% of treatment-seeking did not prevent poor psychosocial out-
patients with BPD attempted suicide come in the long term.
during the first 2 years of study (Yen et Across many studies, poor psychoso-
al. 2003). Worsening of MDD predicted cial function (defined by socioeconomic
suicide attempts in the following month status, social relationships, and educa-
in the CLPS sample of four PDs. In Soloff tional and vocational achievement) is a
and Chiappetta’s (2012) prospective lon- predictor of attempt behavior indepen-
gitudinal study, the most consistent pre- dent of diagnoses. Poor psychosocial
dictors of suicide attempts across all time function is associated with high-lethality
intervals to 6 years were measures of psy- attempts and suicide in some but not all
chosocial and global function. Poor psy- studies of BPD (Soloff 2005) and in non-
chosocial function predicted increased clinical populations. Community sub-
risk of suicidal behavior at 12 months, jects with PDs who commit suicide have
2 years, and 6 years, whereas good base- more problems with loss of relationships,
line functioning (high baseline Global jobs, unemployment, and family com-
Assessment Scale [GAS] score) was pro- pared with subjects with no PD diagno-
tective at 4- and 6-year intervals. By year ses who commit suicide (Heikkinen et al.
6, low socioeconomic status was also a 1997). Community subjects with BPD
predictor of high risk. Good social sup- have lower educational and vocational
port is a known protective factor against achievement than subjects with other
suicide, buffering the adverse effects of PDs, and are more likely than other pa-
negative life events, which are promi- tients with PDs to be receiving disability
nent in the lives of patients with BPD payments (Zanarini et al. 2005).
and predict suicide attempts (Yen et al. A subgroup of patients with BPD may
2005). experience increasing psychosocial im-
Poor baseline Global Assessment of pairment as they age, increasing vulner-
Functioning (GAF) scores and poor fam- ability to suicidal behavior (McGlashan
ily relationships were among the signifi- 1986). Older patients in the CLPS sample
cant predictors of poor psychosocial out- (e.g., those recruited at ages 35–45 years)
comes (low GAF scores) in patients with began to lose previously achieved psy-
BPD followed for 2 years in the CLPS chosocial improvement by year 3 of fol-
study (Gunderson et al. 2006). Func- low-up, reversing the direction of change.
tional impairment in social relationships From years 3–6 of follow-up, the older
changed little in patients with BPD in cohort showed a progressive decline in
this time frame despite improvement in function and an increase in psychopa-
diagnostic criteria (Skodol et al. 2005). thology, significantly different from two
The MSAD found that half of subjects younger, more stable cohorts (Shea et al.
with BPD had failed to achieve social and 2009).
vocational recovery at 10-year follow-up Poor psychosocial function remains a
despite symptomatic remission of BPD risk factor for suicidal behavior in indi-
diagnostic criteria in 93% of subjects viduals with BPD long after acute and
temperamental symptoms of the disor-

der have remitted. Among patients in Neurobiological
the MSAD study who failed to obtain
good psychosocial functioning, 93.9%
Diathesis to Suicidal
failed because of impaired vocational Behavior in Personality
achievement, not poor social function- Disorders
ing (Zanarini et al. 2010). The CLPS anal-
ysis found that unstable interpersonal
relationships were a significant predic- Stress-Diathesis Model
tor of poor outcome at 2-year follow-up, A stress-diathesis causal model of sui-
but the study did not assess vocational cidal behavior suggests that specific per-
achievement (Gunderson et al. 2006). sonality traits may constitute a vulnera-
Soloff and Chiappetta (2012) found that bility to suicidal behavior at times of
a high-lethality BPD attempter group stress. The likelihood of suicidal behav-
was characterized by impairment in both ior increases when acute stressors are ex-
family relationships and work achieve- perienced by patients with personality
ment. This finding is consistent with traits such as emotion dysregulation or
those from studies in PD patients that impulsive aggression, as in patients with
report death by suicide to be associated BPD, or a chronic tendency toward pes-
with job problems, unemployment, and simism, as in depressed patients (Mann
financial difficulties, but also with prob- et al. 1999; Oquendo et al. 2004). In BPD,
lems with family relationships, interper- acute stressors such as MDD or negative
sonal loss, separations, and loneliness life events prospectively predict suicidal
(Heikkinen et al. 1997). behavior at 1-year (Soloff and Chiap-
petta 2012) and 3-year follow-ups (Yen
Summary et al. 2005), respectively. The stress-
diathesis model postulates an interac-
Findings from studies of risk factors sug-
tion between 1) these acute stressors and
gest that stressful life events and some co-
the patient’s core personality traits re-
morbid psychiatric disorders might be
sulting in failure of adaptive coping and
modifiable risk factors for reducing an
2) increased likelihood of disinhibited
acute-on-chronic exacerbation of suicide
suicidal behavior.
risk in patients with PDs. Early and sus-
In some cases, personality traits such
tained outpatient department treatment
as impulsivity and impulsive aggression
directed at enhancing family, social, and
may be heritable endophenotypes re-
vocational functioning might decrease
flecting genetic variations in the func-
long-term suicide risk for patients with
tioning of neurotransmitter systems reg-
BPD. Current treatment modalities for
ulating mood, impulse, and behavior in
BPD (e.g., dialectical behavioral therapy,
the brain. In other cases, the vulnerable
pharmacotherapy) are focused on symp-
temperament may be acquired (e.g., from
tomatic relief. Efforts to increase overall
head injury or early childhood abuse).
psychosocial function may be more rele-
Within a stress-diathesis model, the vul-
vant to long-term prognosis. A rehabilita-
nerability to suicidal behavior in the pa-
tion model of treatment (as in the treat-
tient with PD may be mediated by the
ment of schizophrenia) may be required to
effects of negative emotion on neural
optimize outcome in patients with BPD
circuits that regulate cognitive control
(Links 1993).
of mood, impulse, and behavior. Among
participants with PD in the CLPS, fol- cluding the hippocampus, parahippo-

lowed to 7 years, the personality trait of campal gyrus, uncus, and amygdala
negative affectivity was the most robust (Soloff et al. 2008b). Hippocampal volume
predictor of interval suicide attempts in loss (with and without diminished vol-
multivariate analyses (more so than dis- ume in the amygdala) is the most widely
inhibition or impulsivity, which were replicated finding in morphometric stud-
also significant predictors in univariate ies of BPD and has been related to child-
analyses) (Yen et al. 2009). hood histories of trauma or abuse in some
Neuroimaging studies have begun to studies (Brambilla et al. 2004; Driessen et
define the structural, metabolic, and func- al. 2000; Irle et al. 2005; Schmahl et al.
tional biology of brain circuits that medi- 2003), though not all (Zetzsche et al.
ate personality traits such as impulsive 2007). In patients with BPD, Zetzsche et
aggression and emotion dysregulation in al. (2007) found decreased hippocampal
subjects at high risk for suicidal behav- volume to be more pronounced among
ior. Specifically, magnetic resonance im- patients with histories of multiple hospi-
aging (MRI), positron emission tomogra- talizations but not childhood abuse. An
phy (PET), and functional MRI (fMRI) inverse relationship was found between
studies have demonstrated significant hippocampal volumes and measures of
differences in structural morphometry, aggression and hostility (Zetzsche et al.
metabolism, and functional activation 2007). Childhood sexual abuse is a risk
patterns in patients with BPD and other factor for suicidal behavior, increasing
impulsive PDs compared with healthy 10-fold the risk of suicide attempts in
control subjects, and, in some instances, subjects with BPD (Soloff et al. 2002). An
related these differences to the vulnerabil- inverse relationship has been reported
ity traits of impulsive aggression and emo- between hippocampal and amygdala
tion dysregulation. volumes and measures of aggression and
hostility. Taken together, findings from
Structural MRI Studies these MRI studies of subjects with BPD
MRI studies using hand-drawn regions- suggest multiple areas of structural ab-
of-interest morphometry demonstrate normality in prefrontal and frontolimbic
volume loss in subjects with BPD com- networks involved in emotion regulation,
pared with healthy controls in areas of executive cognitive function, and epi-
the frontal lobes, including the orbitofron- sodic memory.
tal cortex, anterior and ventral cingulate Few imaging studies of subjects with
cortex, and areas of the medial temporal PDs have been done specifically to as-
lobe, including the hippocampus and certain potential causes of suicidal be-
amygdala (see Schmahl and Bremner havior. A voxel-based morphometry
2006 for review; see also Hazlett et al. study of suicidal behavior in BPD found
2005; Lyoo et al. 1998; Tebartz van Elst et that specific structural abnormalities
al. 2003; Zetzsche et al. 2007). Studies us- discriminated attempters from nonat-
ing computer-driven voxel-based mor- tempters and high- from low-lethality
phometry for whole brain analysis also attempters (Soloff et al. 2012). Attempt-
demonstrate significant bilateral reduc- ers had diminished gray matter concen-
tions in gray matter concentrations in sub- trations compared with nonattempters
jects with BPD compared with healthy in the insular cortex, a limbic integration
controls in ventral cingulate gyrus and area that is activated in tasks involving
regions of the medial temporal lobe, in- social interaction, trust, and cooperation,
but also social exclusion (rejection). The comorbid intermittent explosive disor-
insular cortex processes internal signals der, New et al. (2007) found a disconnec-
concerning subjective awareness of one’s tion in the normally tight coupling of
own emotional state and perceived emo- metabolic activity between the right or-
tion in others (as in empathy) (New et al. bitofrontal cortex and ventral amygdala
2008). High-lethality attempters differed seen in control subjects. The orbitofron-
from low-lethality attempters in having tal cortex exerts inhibitory control over
significant decreases in gray matter con- the amygdala, moderating the effects of
centrations in areas of orbitofrontal, tem- affective arousal. Uncoupling frontal in-
poral, insular, and paralimbic cortex— hibition during affective arousal in the
areas broadly involved in emotion regu- BPD sample would increase the likeli-
lation, behavioral control, executive cog- hood of behavioral dyscontrol.
nitive function, and adaptive respond- PET studies have also demonstrated
ing to social situations. diminished metabolic responses to sero-
tonergic challenge with D,L- (or D-) fen-
PET Studies fluramine (FEN) or meta-chlorophenyl-
PET studies in subjects with BPD have piperazine (mCPP) in patients with BPD
found decreased glucose utilization in (and other impulsive PDs) in orbitofron-
areas of prefrontal cortex, including or- tal, adjacent ventromedial, and cingu-
bitofrontal and ventromedial cortex, cin- late cortex. These areas overlap those
gulate gyrus, and temporal cortex (see with structural abnormalities in BPD
Schmahl and Bremner 2006 for review). (New et al. 2002; Siever et al. 1999; Soloff
These areas overlap regions with known et al. 2000, 2003). A blunted central sero-
structural abnormality in BPD. The orbi- tonergic response to FEN or mCPP is as-
tofrontal and ventromedial prefrontal sociated with impulsive aggression and
cortex areas are involved in response in- suicidal behavior in patients with BPD
hibition, regulation of impulsivity, and and other diagnoses (Oquendo and Mann
reactive aggression. A PET study of im- 2000). Impulsivity and impulsive aggres-
pulsive female subjects with BPD com- sion may be mediated, in part, by dimin-
pared with healthy control subjects found ished serotonergic function in prefrontal
prefrontal hypometabolism, centered in cortex and a resulting loss of connectiv-
medial orbital cortex bilaterally (Brod- ity in frontolimbic circuits.
mann’s areas 9, 10, and 11) (Soloff et al.
2003). Covarying for impulsivity or ag- Functional MRI Studies
gression rendered insignificant the dif- In experimental studies, subjects with
ferences in prefrontal metabolism be- BPD experience emotions more strongly
tween subjects with BPD and control than healthy control subjects, especially
subjects. in response to negative affect (Levine et
PET studies in subjects with BPD (and al. 1997), and are slower to return to base-
other impulsive PDs) have described an line once aroused (Jacob et al. 2008). The
inverse relationship between measures dysregulation of emotion and behavior
of impulsive aggression and relative glu- that is characteristic of patients with BPD
cose utilization in areas of prefrontal cor- at times of stress reflects both the in-
tex (e.g., orbitofrontal, anterior medial tensity of affective arousal and a failure
frontal cortex) and right temporal cortex of cognitive inhibition. Strong affective
(Goyer et al. 1994). In a sample of impul- arousal and dysregulated inhibition re-
sive-aggressive subjects with BPD and sult in marked impairment of executive
cognitive functions such as response in- in the face of negative emotion increases
hibition, conflict resolution, and future a patient’s vulnerability to impulsive
planning, which are critical for adaptive suicidal behavior.
coping. Among clinical patients with
BPD, executive cognitive function is sig-
nificantly impaired at times of emotional Assessing Suicide Risk
stress, contributing to episodes of affec-
tive instability, impulsive aggression,
in Patients With
and suicidal behavior (see Fertuck et al. Personality Disorders
2006, for review.)
In fMRI paradigms testing affective The treatment of patients with PDs can
interference with cognitive task perfor- be challenging because of the potential
mance, subjects with BPD demonstrate for these patients to present in suicidal
decreased activity in inhibitory brain crises. Frequently, these patients have a
structures (e.g., medial orbitofrontal cor- history of previous suicidal behavior.
tex, anterior cingulate cortex [ACC]) and Clinicians may avoid accepting such pa-
increased activity in the amygdala com- tients in their practice because they feel
pared with control subjects (Koenigs- unskilled to manage these crises; how-
berg et al. 2009; Minzenburg et al. 2007; ever, evidence-based therapies have
Silbersweig et al. 2007). These fMRI demonstrated that individual psycho-
studies suggest that diminished cogni- therapy can be effective in preventing
tive function during affective arousal future suicidal behavior and in reducing
may result from the relative failure of the medical risk of future suicide attempts
“top-down” inhibition (e.g., medial orbi- (McMain et al. 2009).
tofrontal cortex, ACC functions) as well The clinical assessment of patients with
as excessive “bottom-up” activation (e.g., BPD in crisis is complicated. Often, these
amygdala), especially in response to neg- patients have made multiple suicide at-
ative emotion (Silbersweig et al. 2007). tempts, and it is unclear whether a short-
Similar results are reported in fMRI term admission will have any impact on
studies when subjects with BPD view the ongoing risk of suicidal behavior. In
negative social-emotional pictures. patients with BPD, the acute-on-chronic
Greater activity is noted in the amyg- level of risk (i.e., the acute risk that occurs
dala, fusiform, precuneus, and parahip- over and above the ongoing chronic risk;
pocampal regions (a rapid “reflexive see Figure 18–1) is related to several fac-
network”) in subjects with BPD compared tors. An acute-on-chronic risk will be
with healthy control subjects. Healthy present if a patient has comorbid major
controls activate dorsolateral and insu- depression or if a patient is demonstrat-
lar regions that constitute a slower “re- ing high levels of hopelessness or depres-
flective” network (Koenigsberg et al. sive symptoms. In addition, patients with
2009). Emotion dysregulation in BPD BPD are known to be at risk for suicide
may result from hyperarousal of amyg- around times of hospitalization and dis-
dala and other limbic structures in re- charge. These patients are potentially at
sponse to negative affective stimuli, cou- acute-on-chronic risk, and their assess-
pled with the relative failure of cortical ment cannot be truncated even following
inhibition from prefrontal and anterior a recent discharge from hospital. Proxi-
cingulate functions (Silbersweig et al. mal substance abuse can increase the sui-
2007). Diminished cognitive inhibition cide risk in a patient with BPD. The risk is
acutely elevated in patients who have less with respect, dignity, and empathy. When
immediate family support, including the patient has de-escalated, the clinician
those who have lost or who perceive the and the patient can begin the process of
loss of an important relationship, or those problem solving and establishing a safety
who have suffered recent stressful events, plan.
including legal contacts (Yen et al. 2005). Patients with BPD who present in cri-
Using the acute-on-chronic model sis with significant emotional dysregula-
can be very effective for communicating tion or extreme agitation can be difficult
in the health record the decisions regard- to assess and de-escalate. For the emer-
ing interventions. For example, if a pa- gency department staff, these patients
tient is felt to be at a chronic but not an can be likened to a patient who presents
acute-on-chronic risk for suicide, one with a bleeding wound; the first task with
can document and communicate that a patients in a suicidal crisis is to stop the
short-term hospital admission will have “emotional bleeding.” The emergency
little or no impact on a chronic risk that staff need to recognize that these patients
has been present for months or years. cannot participate in constructive prob-
However, an inpatient admission of a pa- lem solving until their emotional inten-
tient demonstrating an acute-on-chronic sity has been de-escalated. The staff can
risk might well be indicated. In this cir- use simple strategies such as monitoring
cumstance, a short-term admission may the patient’s breathing, distraction tech-
allow the level of risk to return to chronic niques such as having the patient name
preadmission levels. items in the room, or soothing strategies
such as recommending that the patient
listen to an MP3 player or iPod. The staff
Crisis Management and can point out examples of how the patient
Safety Planning has made positive choices to be safer,
such as choosing to come to the emer-
When patients with BPD present in a sui- gency department before making a sui-
cidal crisis, they can pose a challenge even cide attempt.
to experienced clinicians. Bergmans et al. Despite some inconsistent findings
(2007) discussed that health care provid- regarding the effectiveness of low-dose
ers responsible for treating patients with antipsychotics for affective dysregula-
BPD in the emergency department faced tion, depression, anger, and impulsivity
emotions including anxiety, anger, a lack in patients with BPD, Vita et al. (2011)
of empathy, and frustration over repeti- concluded in their meta-analytic review
tive behavior, as well as a perception that that antipsychotics were effective for the
patients are not appropriately using the treatment of the core symptoms of BPD.
emergency department. Patients with For example, in one randomized con-
BPD who present in crisis are often expe- trolled trial, aripiprazole (15 mg/day)
riencing intense and dysregulated emo- was found after 8 weeks to be more ef-
tions, and as a result, they have difficulty fective than placebo for symptoms of de-
articulating how they are feeling and pression, anxiety, and aggressiveness/
their problem-solving abilities are com- hostility in patients with BPD; however,
promised. Clinicians can help de-escalate no significant reductions in self-injuri-
patients by validating their emotional ous behavior were observed (Nickel et
distress, reinforcing that seeking help was al. 2006). Antipsychotic medications can
a good decision, and treating the patient be helpful in reducing a patient’s anxi-
ety, anger, hostility, and agitation in the of suicidal behavior when the risk moves
emergency department, facilitating as- toward true suicidal intention yet must
sessment, deescalation of the patient, avoid being therapeutically constrained
and development of a treatment plan. by concerns about the patient’s chronic
Patients with a known diagnosis of suicidality. An important strategy is for
BPD often have access to clinicians and the patient to develop a method of scal-
support in the community. A patient fre- ing his or her severity of suicidal thinking.
quently has a treatment plan with his or For example, the patient can be asked to
her primary caregiver that recommends consider the following question: “How
going to the emergency department if intense are your suicidal thoughts today?”
the patient feels unsafe or is in crisis. In (rating the intensity from 1, very low in-
the emergency department, it is impor- tensity, to 10, extreme intensity). In addi-
tant for staff to connect with a patient’s tion, the patient can be asked to rate his
health care team to inform them of the or her intent to act on these thoughts: “In
situation, arrange appropriate follow-up the next 24 hours, how likely do you
for the patient if admission is not indi- think it is that you will act on your sui-
cated, and coordinate ongoing care with cidal thoughts?” (rating the likelihood
other professionals on the team. Patients from 1, very unlikely, to 10, almost certain).
may benefit from family involvement in These methods of scaling should be un-
a crisis situation. A clinician can ask the dertaken in a collaborative manner, with
patient which family members are help- the patient joining the clinician in the re-
ful in times of crisis or can develop specific sponsibility of monitoring the level of
crisis interventions to avoid the inter- risk over time (Craven et al. 2011).
personal conflicts that may have precip- In the crisis situation, the clinician can
itated the original suicidal crisis. Links work with the patient to develop a safety
and Hoffman (2005) recommend that ed- plan. Stanley and Brown (2012) have de-
ucating family members about restrict- veloped a very useful tool for such a
ing access to means should be incorpo- purpose. The following vignette is an ex-
rated into the care of all mental health ample of a safety plan that was devel-
patients. oped with a patient with BPD who pre-
One of the most critical issues is dif- sented to an emergency department.
ferentiating suicidal from nonsuicidal
intentions. Too often, cutting oneself or Case Example
other self-harm behaviors are assumed
to be suicidal, although these behaviors Paula was a 53-year-old single female
with a diagnosis of BPD as well as a
can be deliberate acts by the patient
history of previous major depressions
intended for self-soothing and dealing and current social phobia. She came to
with overwhelming emotional distress. the attention of psychiatry at a some-
To avoid misinterpretation, the clinician what older age, having relatively mi-
and patient should develop a method to nor self-harm behaviors and, in more
differentiate nonlethal self-harm behav- recent years, some low-lethality over-
dose attempts. The clinician had seen
ior, in which the patient’s intent is to
Paula several times for her presenta-
seek a reduction in emotional distress, tions to the emergency department af-
from “true” suicidal intention, in which ter overdosing on small amounts of
the patient’s intent is to end his or her medication. The self-harm behaviors
life. The clinician must attend to the risk were often precipitated by arguments
with her adult daughter. After com- tion, and important personal supports.
pleting an assessment of the patient’s The kit should include recommended dis-
risk for suicide following her current
traction and soothing strategies that could
overdose attempt, the clinician dis-
cussed creating a safety plan with the be used in the emergency department.
patient. Working through the six steps The clinician should also rehearse with
listed below, Paula came up with the the patients how the emergency depart-
following safety plan for herself: ment staff experiences their presentations
to the emergency department. This prepa-
Step 1: What are your warning signs
ration helps patients understand the mul-
that you are going into a crisis?
Feeling panicky; can’t breathe; want- tiple demands faced by the emergency de-
ing to get out; wanting to take pills or partment staff and recognize that clear
drink repeated attempts at communication are
Step 2: What coping strategies such likely the best way to have patients’ needs
as distraction or soothing techniques heard in such a chaotic setting.
have you used successfully in the
past?
Petting my dog
Step 3: What social situations and/or Conclusion
people can help distract you when
you are in crisis? Clinicians need to assess patients with
Two girlfriends can be helpful to dis- PDs for evidence of both nonmodifiable
tract me (chronic) and modifiable (acute) risk fac-
Step 4: Who can you ask for help
tors for suicide. Although PD diagnoses
when you are in crisis (or who is un-
helpful when you are in crisis)? are associated with the risk for suicide
Do not ask my mother for help during and suicidal behavior, psychotherapeu-
a crisis tic interventions and outpatient psychi-
Step 5: What professionals or agen- atric care appear to be very effective in
cies can you contact during a crisis? reducing the short- and long-term risk of
Crisis phone line; therapist; family
doctor
recurrent suicidal behavior in patients
Step 6: What can you do to make with PDs. When clinicians have the ap-
your home environment safer? propriate knowledge and skills, and pa-
Lock up my medications so they are tients collaborate with treatment, the
not readily available1 work with these patients can be effective
and rewarding.
In addition, patients should be edu-
cated to be better consumers of the emer-
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C H A P T E R 19
Substance Use Disorders

Seth J. Prins, M.P.H.
Jennifer C. Elliott, Ph.D.
Jacquelyn L. Meyers, Ph.D.
Roel Verheul, Ph.D.
Deborah S. Hasin, Ph.D.
Since the introduction of DSM-III in (American Psychiatric Association 1952,

1980 (American Psychiatric Association 1968). Historically, the major part of PD
1980), there has been a growing interest research has actually been conducted in
in the study of personality disorder (PD) samples of patients referred for treatment
comorbidity among patients with sub- of other mental disorders such as sub-
stance use disorders (SUDs). The driving stance abuse. That said, researchers with a
force behind this interest is the high co- forensic or criminological focus also study
morbidity of these disorders and the PDs and tend to have a keen awareness of
more complex clinical management of substance use issues (e.g., Skeem and
dual-diagnosis patients. Although the Cooke 2010; Skeem et al. 2011).
evaluation of co-occurring PDs has been An inevitable consequence of this re-
the subject of many studies by addiction search history is that much of this chap-
researchers, PD researchers have histori- ter is based on studies focusing on the
cally paid less attention to the co-occur- occurrence and implications of PD in pa-
rence of SUDs. This lack of attention may tients with SUD. In addition, evidence
be because the field of PD research started from the literature on (normative) per-
relatively recently, in the 1980s, whereas sonality traits will be included whenever
the field of addiction has long recognized informative. We focus in this chapter on
the interconnection with personality dys- the epidemiology of co-occurring PD
function—if for no other reason than the and SUD, diagnostic issues, causal path-
first two editions of DSM embedded alco- ways and treatment, and the latest ge-
hol and drug addiction under sociopathy netic research on these disorders.
407
The prevalence of PDs is also high

Epidemiology among individuals with SUDs. Again,
numerous findings are available from
SUDs are highly prevalent among indi- studies based on the NESARC. After con-
viduals with PDs. For example, in a clini- trolling for sociodemographic character-
cal sample of nearly 700 individuals with istics, Hasin et al. (2007) found that indi-
DSM-IV PDs, the prevalence of alcohol viduals with 12-month alcohol use
use disorder was 40.9% and the preva- disorder had 2.1 times the odds of having
lence of drug use disorders was 37.3% any DSM-IV personality disorder. Among
(McGlashan et al. 2000). The National Ep- individuals with 12-month SUDs, 8.2%
idemiologic Survey on Alcohol and Re- had lifetime schizotypal PD (Pulay et al.
lated Conditions (NESARC; Grant et al. 2009), 14.1% had lifetime BPD (Grant et
2004), a nationally representative commu- al. 2008), and 11.8% had narcisistic PD
nity sample of approximately 43,000 peo- (Stinson et al. 2008). The prevalence of an-
ple, has generated numerous findings. For tisocial PD among respondents with life-
example, Pulay et al. (2008) used a dimen- time drug use disorders was 18.3% (Gold-
sional categorization of PDs and found stein et al. 2007). The lifetime prevalence
that the 12-month prevalence of alcohol of Cluster A, B, and C PDs among indi-
dependence was 4.48% for individuals viduals with 12-month nicotine depen-
with subthreshold PD, 8.28% for those dence was 19.04%, 28.59%, and 14.84%,
with simple PD, and 14.27% for those respectively (Pulay et al. 2010). Finally,
with complex PD (i.e., at least two PDs) in after sociodemographic characteristics
Wave 1 of the NESARC. For 12-month were controlled for, individuals with
drug dependence, prevalence was 0.54%, PDs had significantly higher odds of nic-
1.98%, and 5.03% across those three PD otine dependence than those without
categories, respectively (Pulay et al. 2008). (Pulay et al. 2010). Table 19–1 summarizes
The prevalence of 12-month SUDs was prevalence estimates and odds ratios for
44.1% among individuals with lifetime co-occurring PDs and SUDs.
schizotypal PD (Pulay et al. 2009), 50.7% The most common PDs in the general
among those with lifetime borderline PD population (among individuals without
(BPD) (Grant et al. 2008), and 40.6% co-occurring SUDs) are obsessive-com-
among those with lifetime narcissistic PD pulsive PD (7.9%), paranoid PD (4.4%),
(Stinson et al. 2008). These findings from antisocial PD (3.6%), schizoid PD (3.1%),
NESARC are consistent with those from avoidant PD (2.4%), histrionic PD (1.8%),
older studies. A much earlier community and dependent PD (0.5%) (Grant et al.
survey found lifetime prevalence of alco- 2005).1 It is thus clear that the prevalence
hol use disorders ranging from 43% to of PDs among individuals with co-occur-
77% among patients with various PDs ring SUDs is much higher than among the
(Zimmerman and Coryell 1989). general population. Interpretation of this
1
These estimates come from the NESARC, referring to the data in Wave 1 of the project, cover-
ing only seven of the 10 DSM-IV PDs (i.e., avoidant, dependent, obsessive-compulsive, para-
noid, schizoid, histrionic, and antisocial disorders). For a more detailed discussion of
prevalence, demographics, and impairment, see Chapter 6, “Prevalence, Sociodemographics,
and Functional Impairment.”
Substance Use Disorders 409
TABLE 19–1. Summary of NESARC findings on the prevalence and odds ratios of
substance use disorders and personality disorders
Prevalence (%) OR of lifetime PD and:
PD among SUD among 12-month 12-month 12-month

SUD PD SUD AUD DUD
Antisociala 18.3 (DUD) — — 8.0 11.3

Borderlineb 14.1 50.7 3.4 2.7 5.6
Narcissisticb 11.8 40.6 2.4 2.2 3.7
Schizotypalb 5.9 44.1 2.5 2.0 4.7
Note. AUD=alcohol use disorder; DUD=drug use disorder; NESARC=National Epidemiologic Survey
on Alcohol and Related Conditions; OR=odds ratio; PD=personality disorder; SUD=substance use dis-
order.
a
ORs significant at D=0.05.
b
ORs significant at D=0.01, and adjustment made for sociodemographic characteristics.
Source. Data from NESARC studies as described in text.
high comorbidity remains unclear, be-

cause little is known about the extent to Assessment and
which it is attributable to conceptually
overlapping diagnostic criteria and mea-
Diagnosis
surement issues such as state-trait arti-
facts. Semistructured interviews and self-report
Also of note, the epidemiology of PDs questionnaires for the assessment of
is being explored within the context of DSM-IV (American Psychiatric Associa-
substantial evidence for a “metastructure” tion 1994) PDs provide diagnoses with
of psychopathology (e.g., see Krueger reliability that is comparable to that of di-
1999). This metastructure, represented by agnoses of other disorders obtained us-
two latent dimensions—“internalizing” ing standardized procedures (Ball et al.
(e.g., unipolar mood and anxiety disor- 2001). A diagnostic interview designed
ders) and “externalizing” (e.g., disinhib- for use by lay interviewers was used in
itory disorders)—may help explain pat- the NESARC described in the previous
terns of psychiatric comorbidity (Keyes et section, “Epidemiology.” The instrument
al. 2013). For instance, the externalizing had fair to excellent reliability for specific
dimension comprises antisocial PD and PDs, consistent with or better than reli-
SUDs, whereas avoidant, schizoid, schizo- abilities found in clinical samples (Grant
typal, and paranoid PDs may be compo- et al. 2003; Ruan et al. 2008). Furthermore,
nents of a “thought disorder” subdi- dimensional symptom scales for PDs had
mension of the internalizing dimension greater reliability than diagnostic catego-
(Keyes et al. 2013). Borderline PD, in ries, which is consistent with prior re-
contrast, may straddle the internalizing search (Grant et al. 2003; Ruan et al. 2008).
and externalizing dimensions (Eaton et Instruments based on self-report may
al. 2011). This ongoing line of research result in overdiagnosis of PDs; this may be
has significant implications for optimiz- even more of a concern with patients who
ing the treatment of individuals with co- have SUDs, because these instruments do
occurring psychiatric disorders (Keyes not ask respondents to differentiate per-
et al. 2013). sonality traits from the effects of substance
use or other prolonged changes in mental thology. The less stringent strategy is
status (van den Bosch and Verheul 2012). meant to exclude behaviors and/or
Diagnostic interviews may have greater symptoms that do not persist beyond pe-
specificity because clarifications can be riods of substance use and do not qualify
made about whether a symptom is chronic for a PD diagnosis. Consequently, the less
and pervasive, more situation specific, or stringent approach will probably not ex-
related to substance use (van den Bosch clude primary personality pathology and
and Verheul 2012). An interview also al- will have only a limited impact on the di-
lows for behavioral observations of the agnosis of secondary PD.
patient’s interpersonal style, which may Intuitively, one might suggest that ex-
inform clinical judgment (Zimmerman cluding substance-related symptoms (at
1994). Some studies have shown promis- least following the less stringent strat-
ing findings in favor of the validity of PD egy) would result in more valid diagno-
diagnoses in individuals with SUDs obses. Diagnosing PDs independent of SUD
tained using a semistructured interview is consistent with guidelines suggested
schedule. For example, Skodol et al. (1999) in DSM-IV (American Psychiatric Associ-
reported similar prevalence rates of PDs ation 1994) and carried over to DSM-5 Sec-
among patients with a current SUD and tion II, “Diagnostic Criteria and Codes.”
patients with a lifetime SUD. Also, in a However, the task of differentiating sub-
sample of 273 patients with SUDs, remis- stance-related symptoms from personal-
sion of the disorder was not significantly ity traits is not easy for patients or clini-
associated with remission of personality cal interviewers and therefore may not be
pathology, suggesting that the two condi- reliable. This task becomes almost impos-
tions follow an independent course (Ver- sible when substance use is chronic. Fur-
heul et al. 2000). thermore, although most patients with
Part of the issue regarding reliability SUDs can distinguish behaviors that are
and validity of PD diagnosis in patients only related to substance intoxication or
with SUDs centers on whether to include withdrawal, they have greater difficulty
or exclude PD symptoms that seem to be making the same distinction for other
substance related (i.e., behaviors directly activities, such as lying or breaking the
related to intoxication and/or withdrawal law, which may be related to obtaining
or other behaviors required to maintain substances. In other words, there is a dif-
an addiction). The magnitude of the ef- ference between symptoms of intoxica-
fect of exclusion on the prevalence esti- tion or withdrawal and symptoms that
mate seems partly attributable to the strat- may be viewed as drug-seeking behav-
egy used for exclusion. Measures with iors. Such a distinction requires a high
more stringent criteria exclude any symp- level of introspection and cognitive
tom that has ever been linked to substance competence in making the judgment
use and yield significantly reduced rates. necessary to differentiate a trait from a
Measures that exclude symptoms only if situation or state. It also requires self-
they were completely absent before sub- awareness and accountability (Zimmer-
stance use or during periods of extended man 1994). Furthermore, PD criteria in
abstinence show minimal effects on rates. DSM-IV and in DSM-5 Section II are a
The more stringent strategy will likely ex- mix of symptoms, traits, behaviors, and
clude all secondary personality pathol- consequences, making such distinctions
ogy and possibly primary personality pa- even more difficult in practice.
Patients with SUDs may be particularly organized under “primary SUD,” “pri-
impaired in the skills necessary to make mary PD,” and “common factor” catego-
these distinctions. Rounsaville et al. (1998) ries, although it is unclear whether these
found that excluding substance-related distinctions remain relevant, for reasons
symptoms reduced the reliability of anti- discussed in the following subsection.
social PD diagnoses but not of BPD diag- The behavioral disinhibition pathway,
noses. Furthermore, the authors found stress reduction pathway, reward sensi-
that patients with independent PD diag- tivity pathway, and common factor model
noses had a rather similar clinical profile (with an emphasis on genetics) are also
compared with patients with substance- summarized below.
related diagnoses, thereby calling into
question the feasibility and clinical utility “Primary” Disorder Models
of exclusion.
If one chooses to exclude substance- The primary SUD model postulates that
related symptoms from the measurement SUDs contribute to the development of
of any PD, several considerations are in personality pathology. Currently, no di-
order: rect evidence supports this model, and
there is some indirect evidence against it.
• Symptoms should be eliminated as One study did find that drug use pre-
being substance related on an item- dicted the progression of conduct disor-
by-item basis. der to antisocial PD (Myers et al. 1998).
• Unless there are behavioral indicators Bernstein and Handelsman (1995) pointed
of a trait present that are not substance out that it is unclear to what extent the ef-
related, criteria in which substance fects of substance use can “overwrite” or
use is an inherent component should interact with preexisting personality pat-
be scored as due to substance use. terns to form new personality configura-
• The interviewer should remind pa- tions. It is important to distinguish new
tients that questions refer to the way enduring personality patterns from tem-
the patients usually are—that is, when porary behavior patterns that disappear
they are not symptomatic with either with reductions of substance use. The
substance abuse or other disorders latter should not be taken into account
(e.g., when sober at work, with friends for a diagnosis of PD. According to DSM-
who do not use substances). IV, only when the consequences of sub-
stance use persist beyond the period of
alcohol and/or drug consumption (or
Causal Pathways withdrawal) do these features constitute
personality pathology. The primary PD
High comorbidity that cannot be ex- model, which has some empirical sup-
plained by conceptual or measurement port, holds that pathological personality
artifacts strongly suggests that the co- traits contribute to the development of
occurrence of SUDs and PDs is not due SUD. However, the primary versus sec-
solely to random or coincidental factors. ondary distinction may not be an accu-
It seems reasonable to explore the asser- rate one, given that both types of disor-
tion that substance use and PDs are in ders may be equally severe, have shared
some way causally linked. Causal mod- genetic origin, and be of indeterminate
els of comorbidity have historically been temporality.
Behavioral Disinhibition Stress Reduction Pathway

Pathway The stress reduction pathway regards
substance use as self-medication for the
The behavioral disinhibition pathway to
anxiety and mood instability that indi-
SUDs predicts that individuals with
viduals with PDs may exhibit in response
antisocial and impulsive traits and low
to stressful life events. In longitudinal
constraint or conscientiousness have
studies, teachers’ ratings of negative emo-
lower thresholds for behaviors such as
tionality, stress reactivity, and low harm
alcohol and drug abuse. Several longitu-
avoidance in children predicted sub-
dinal studies have shown that teachers’
stance abuse in adolescence and young
ratings of low constraint, low harm avoid-
adulthood (Caspi et al. 1997; Cloninger
ance, lack of social conformity, uncon-
et al. 1988; Wills et al. 1998). Coping and
ventionality, antisociality, and aggression
fear dampening as motives for drinking
in children, particularly boys, predicted
alcohol are also more pronounced among
alcohol and drug abuse in adolescence
men scoring high on anxiety sensitivity
and young adulthood (Caspi et al. 1997;
(Conrod et al. 1998).
Cloninger et al. 1988; Krueger et al. 1996;
Masse and Tremblay 1997). The same pat-
tern was observed in university students Reward Sensitivity
(Sher et al. 2000). More direct evidence Pathway
can be derived from a study by Cohen et
The reward sensitivity pathway regards
al. (2007), who found that individuals
the positive, reinforcing properties of
diagnosed with schizotypal, borderline,
substance use as the motivating factor
narcissistic, passive-aggressive, or con-
among individuals scoring high on traits
duct disorder by age 13 years had signif-
such as novelty seeking, reward seeking,
icantly elevated rates of SUD between
extraversion, and gregariousness. Longi-
early adolescence and young adulthood,
tudinal studies (Cloninger et al. 1988;
independent of correlated family risks,
Masse and Tremblay 1997; Wills et al.
participant sex, and other disorders. Bahl-
1998) have shown that novelty seeking in
mann et al. (2002) found that the onset of
childhood predicts later substance use
antisocial PD characteristics preceded
problems. Some evidence suggests that
that of alcohol dependence by approxi-
students’ extraversion predicts alcohol
mately 4 years. The relationship between
dependence at age 30 among students
behavioral disinhibition and early-onset
without a family history of alcoholism
addictive behaviors is probably mediated
(Schuckit et al. 1994). Hyperresponsive-
through deficient socialization, school
ness or hypersensitivity to the positive re-
failure, and affiliation with deviant peers
inforcing effects of substances might de-
(Sher and Trull 1994; Tarter and Vanyu-
velop most strongly among individuals
kov 1994; Wills et al. 1998). The behav-
with a more general sensitivity to posi-
ioral disinhibition pathway is associated
tive reinforcements (Zuckerman 1999).
with earlier onset of drinking, more rapid
development of alcohol dependence
once drinking begins, and more severe Common Factor Model
symptoms among individuals with ASPD The common factor model holds that PDs
than among those without (Verheul et and SUDs share a common cause. This
al. 1998). model is consistent with a psychobiolog-
ical perspective of some PDs that suggests Molecular Genetic Studies

they are phenomenologically, geneti-
Since the completion of the Human Ge-
cally, and/or biologically related to im-
nome Project, technological advances
pulse disorders such as substance abuse
have enabled researchers to identify spe-
(Siever and Davis 1991; Zanarini 1993).
cific genetic variants influencing human
This model is also consistent with find-
behavior and disorder. Psychiatric disor-
ings from psychiatric epidemiology (see
ders are complex behavioral traits, influ-
section “Epidemiology” above) that ex-
enced by a multitude of genetic variants
plore the metastructure of psychopa-
of subtle effect, which act in conjunction
thology, and is reflected in the structure
with each other (gene-gene interaction)
of DSM-5, wherein at least some “exter-
and the individual’s social context (gene-
nalizing” disorders are grouped together.
environment interaction). Because of the
In this section, we explore the common
complex genetic architecture, researchers
factor model from the perspective of ge-
have only begun to identify specific ge-
netic epidemiology, molecular genetics,
netic risk factors for psychiatric disorders,
and biological markers, but this focus is
including SUDs and PDs. However, pre-
not intended to downplay or depriori-
liminary molecular genetic studies lend
tize common factors originating in de-
further support to the premise that shared
velopmental, environmental, and social
genetic factors influence both SUDs and
experiences and exposures.
PDs. For example, data on Han Chinese
Genetic Epidemiological males demonstrate that individuals with
genetic risk factors previously associated
Studies with alcohol dependence—that is, dopa-
Epidemiological studies find that indi- mine receptor 2 (DRD2) and aldehyde de-
viduals rarely abuse a single substance hydrogenase 2 (ALDH2)—were at a 5.39
(Swendsen et al. 2012). Instead, polysub- times greater risk for antisocial PD than
stance abuse and dependence are norma- were those without the genetic risk (Lu et
tive, with high rates of comorbidity al. 2012). Furthermore, data from the Col-
across various drug classes (Swendsen et laborative Study on the Genetics of Alco-
al. 2012). Twin studies, in which the rela- holism suggest that chromosome 2p14–
tionships between monozygotic (identi- 2q14.3 may contain a gene (or genes) with
cal) and dizygotic (fraternal) twins are effects on alcohol dependence and co-
used to differentiate genetic and nonge- morbid psychiatric conditions, including
netic (environmental) sources of variance conduct disorder, a prerequisite for anti-
in a given trait, suggest that this comor- social PD (Dick et al. 2010).
bidity is due at least in part to a shared
genetic etiology. Several twin and family Biological Markers
studies have found evidence of a shared A final piece of evidence suggesting a
underlying genetic susceptibility to sub- shared genetic liability across externaliz-
stance use and other psychopathologies, ing psychopathology comes from the
specifically antisocial PD and BPD (Clon- electrophysiological literature. Electro-
inger et al. 1988; Goldman et al. 2005; physiological endophenotypes, which
Kendler et al. 2011; Roysamb et al. 2011). are thought to index genetic vulnerabil-
Furthermore, this shared genetic factor ity to psychiatric phenotypes, are also
appears to be more heritable (influenced shared across SUDs and comorbid psy-
by genetics) than the individual disor- chiatric disorders (Iacono et al. 1999;
ders themselves (Goldman et al. 2005). Porjesz et al. 2005). For example, a reduced
P3 event–related potential amplitude has sults do not allow for firm conclusions
been found among adolescents with both about the prognosis of patients with both
SUDs and antisocial PD (Gilmore et al. SUDs and PDs.
2010; Iacono et al. 2002). However, there is reason to believe that
recovery among individuals with SUDs
who also have PDs may not be as long
Treatment Outcome lasting as among those without PDs. For
example, some studies showed that PDs
Personality pathology has been found to predict a shorter time to relapse after dis-
be significantly related to poor treatment charge (Mather 1987; Thomas et al. 1999),
response and outcome in patients with even when the study design controls for
affective and anxiety disorders (Reich the baseline severity of substance use
and Vasile 1993). Many clinicians believe problems (Verheul et al. 1998). Thus, it
that the same applies to patients with seems that although individuals with
SUDs, a belief that is consistent with find- PDs can improve with treatment, their
ings from some studies showing worse posttreatment state may be more suscepti-
treatment outcome (Galen et al. 2000; ble to relapse.
Grella et al. 2003; Haro et al. 2004; King et Moderator and mediator studies have
al. 2001; Krampe et al. 2006) and lower explored who is most at risk and how
levels of retention (Daughters et al. 2008; PDs interfere with treatment. A study by
Fernandez-Montalvo and Lopez-Goni Verheul et al. (1998) suggested that moti-
2010; Samuel et al. 2011; Tull and Gratz vation for change moderated the relation-
2012) in patients who have both SUDs ship between PDs and relapse; personal-
and PDs. As in treatment-seeking sam- ity pathology was a strong predictor of
ples, large nationally representative sam- relapse among less motivated individu-
ples also indicate more chronic SUDs in als but not among their more motivated
individuals with PDs (Fenton et al. 2012; counterparts. In another study, Pettinati
Hasin et al. 2011). However, these find- et al. (1999) found that PD psychopathol-
ings contrast with those of other studies ogy combined with other types of psy-
that are more optimistic about the out- chopathology was the best predictor of a
come for these individuals. Several stud- return to substance use at 1 year post-
ies suggest that although personality treatment compared with either factor
pathology may be associated with indi- alone. However, this finding conflicts with
viduals’ problem severity, it may not pre- other studies that have found that indi-
dict how much they improve in response viduals with opiate addiction and antiso-
to treatment (e.g., Cacciola et al. 1995, cial PD who also have a lifetime diagno-
1996; Verheul et al. 1999). Other studies sis of major depression may benefit more
show that PD comorbidity does not pre- from treatment than those without de-
dict treatment outcomes (Easton et al. pression (Alterman et al. 1996; Woody et
2012; Gill et al. 1992; Longabaugh et al. al. 1985). Studies of mediators have sug-
1994; Messina et al. 2002; Nace et al. 1986; gested that personality pathology inter-
Ouimette et al. 1999; Ralevski et al. 2007), feres with the patient-therapist working
premature dropout (Easton et al. 2012; alliance and that this results in poorer
Gill et al. 1992; King et al. 2001; Kokkevi outcomes or a higher risk for relapse
et al. 1998; Marlowe et al. 1997; Verheul (Gerstley et al. 1989; Verheul et al. 1998).
et al. 1998), or less motivation to change In contrast with the extensive litera-
(Verheul et al. 1998). These conflicting re- ture on the effect of PDs on substance use
treatment outcomes, less research has designed to address both substance use
been done on the impact of SUDs on PD problems and PD symptomology. DFST
outcomes. This lack is likely related to is a manual-guided program that incor-
the exclusion of dual-diagnosis patients porates relapse prevention, coping skills,
from treatment systems and research and discussion of maladaptive schemas.
studies, and illustrates the limitations In 2005, Ball et al. evaluated DFST among
of mental health systems and research 52 individuals with PDs who abused
policies oriented toward the treatment of substances and were receiving services
single rather than multiple disorders at a drop-in center for the homeless. Par-
(Ridgely et al. 1990). Studies addressing ticipants were randomly assigned to re-
whether treatment of SUD affects PD sta- ceive either DFST or standard drug coun-
tus have had conflicting results. Whereas seling group sessions for 24 weeks, both
one study showed that recovery from delivered on-site as enhancements to
PDs is not seen more among those recov- case management services. Results indi-
ered from SUDs (Verheul et al. 2000), an- cated more overall utilization of DFST,
other study did find improvement in but patients with more severe Cluster A
pathological personality traits following and C symptomatology preferred drug
treatment for SUDs (Borman et al. 2006). counseling. In 2007, Ball tested DFST
Additionally, although some research against 12-Step Facilitation Therapy (TSFT)
has suggested similar levels of pathol- with 30 methadone maintenance pa-
ogy in individuals with PDs who did or tients. Treatment retention and utiliza-
did not have comorbid SUDs (Verheul et tion were similar for the two treatments.
al. 2003), research is needed that specifi- However, DFST patients evidenced a
cally addresses whether SUD status af- quicker decrease in substance use and
fects outcome of PD treatment. strong therapeutic alliance, whereas
TSFT patients reported more improve-
Outcomes of ment in dysphoric symptoms. In a third
study, Ball et al. (2011) compared DFST
Dual-Focus Treatments with individual drug counseling in pa-
Types of therapy that have been devel- tients receiving residential treatment.
oped for or applied to individuals with Their results suggested similar retention
comorbid PDs and SUDs include Dy- and initial response to treatment for the
namic Deconstructive Psychotherapy two groups, with more sustained changes
(Goldman and Gregory 2010; Gregory et among the individual drug counseling
al. 2009), Personality-Guided Treatment group. Results are mixed but seem to in-
for Alcohol Dependence (Nielsen et al. dicate that DFST is generally comparable
2007), and Integrated Dual Disorder to other types of therapy and may even of-
Treatment (van Wamel et al. 2010). How- fer certain advantages (better utilization,
ever, two forms of therapy have been better therapeutic alliance).
studied more extensively and are dis-
cussed in more detail below: Dual Focus Case Example 1
Schema Therapy (DFST) and dialectical
Andrew was a 36-year-old divorced
behavior therapy (DBT). male whose primary PD diagnosis
was obsessive-compulsive PD. In ad-
Dual Focus Schema Therapy dition to having symptoms of depres-
DFST, developed by Ball and Young (Ball sion, obsessive thoughts, compulsive
1998; Ball and Young 2000), is a treatment behavior, and paranoid ideation, he
had interpersonal problems related to and use drugs when he could not get
being exploitative and aggressive in things to be perfect. These avoidance
response to even minor irritation. He strategies actually reinforced his high
began using substances at age 14 and standards even more because he
had occasionally sold drugs or stolen would subsequently have to redouble
property to fund his use. Andrew had his efforts to get desired outcomes.
several prior substance abuse treat- Andrew began therapy in a loud,
ments and had been taking methadone challenging manner, wanting to know
for 1 year before starting individual for sure that therapy was going to
therapy. His heroin dependence was help him and that he was going to get
in remission (he was taking agonist as much out of it as the researchers
medication), and his primary drug would get out of him as a research
abuse problem was cocaine, with more participant. Because he continued to
sporadic use of a high-potency sol- abuse cocaine and inhalants for the
vent to which his job gave him ready first 3 months, therapy necessarily re-
accessibility. Andrew also met criteria mained more focused on relapse pre-
for antisocial PD. This diagnosis does vention while he struggled to grasp
not frequently co-occur with obses- cognitively any of the schema-focused
sive-compulsive PD; however, it was psychoeducational material. By month
difficult to determine whether the an- 4, he had achieved complete absti-
tisocial PD diagnosis was indepen- nence from solvents and was using
dent of substance abuse given the cocaine much less frequently. This
very early age at onset and his persis- change had a significant positive ef-
tent use of multiple substances during fect on his personality (more agree-
adolescence and adulthood. able and sociable, less depressed and
Andrew was treated for 6 months agitated); however, his unrelenting
as part of a research protocol evaluat- standards/hypercriticalness schema
ing DFST. His core early maladaptive was expressed even more strongly.
schema was unrelenting standards/ Cognitively oriented interventions
hypercriticalness (i.e., perfectionism, included cost-benefit analyses of his
rigid rules, and preoccupation with unrelenting standards and reducing
time and efficiency), which appeared the perceived risks of imperfection. A
to originate from the seemingly con- core cognitive distortion targeted for
tradictory combination of parental dispute was “When I don’t accom-
perfectionism (with physical or emo- plish or get what I want, I should get
tional abuse for Andrew’s “failures” enraged, give up, use drugs, and be
as a child) and defeat secondary to dejected.” Experiential techniques in-
both parents being torture survivors volved imagery dialogues with his
who escaped to the United States parents about how they always made
from another country. Andrew put a mistakes seem like catastrophes. Be-
great deal of pressure on himself, and havioral techniques included learning
any minor deviation in his striving to accept “good enough” work from
for perfection triggered an impulsive himself and others, accepting direc-
return to substance use, missing work tions from people he did not respect,
or appointments, and antisocial act- and redeveloping old leisure interests.
ing-out. He engaged in maladaptive Therapeutic relationship interven-
coping behaviors that perpetuated tions included the therapist modeling
this schema, including expecting too acceptance of his own mistakes, pro-
much of himself and others. At other cessing homework noncompliance
times, he sought relief from the pres- due to self-imposed rigid standards,
sures of these standards and would and confronting Andrew’s dichoto-
avoid occupational or social commit- mous views of the therapist. Much of
ments, develop somatic symptoms, the work in Andrew’s outside relation-
procrastinate, or give up on himself ships and in therapy involved helping
him change his dichotomous view of comprehensive validation therapy group

other people as well as his own recov- showed better retention, it also demon-
ery (i.e., all good/sober vs. all bad/
strated slightly increased opiate use at
relapsed).
Despite a rather turbulent course of the end of treatment that was not seen in
treatment, Andrew appeared genu- patients receiving DBT-S. In 2011, Rizvi
inely interested in improving himself et al. found that even a smartphone ad-
and made some significant changes. aptation of DBT-S skills may be useful in
In addition to his reduced substance decreasing distress and substance crav-
abuse, he also experienced signifi-
ing among individuals with co-occurring
cant reductions in psychiatric symp-
toms and negative affect. BPD and SUD. Overall, studies indicate
support for DBT-S among patients with
Dialectical Behavior Therapy BPD and comorbid SUD. However,
DBT-S has not been studied for other PDs.
Standard DBT has been shown to be as-
Encouraging results from patients with
sociated with more reduction of sub-
BPD should not be extrapolated to other
stance use than treatment as usual in
PDs, especially because antisocial PD
some studies of patients with PDs
has been described as a possible contra-
(Harned et al. 2008) but not others (van
indication for DBT (Linehan and Kors-
den Bosch et al. 2002). However, a mod-
lund 2006).
ified version of DBT, known as DBT-S,
has been developed specifically for indi-
viduals with comorbid SUDs. DBT-S in- Case Example 2
cludes individual and group treatment Belinda was a 27-year-old patient with
components, similar to standard DBT, BPD. Her first suicide attempt was at
but also tailors DBT skills to substance use age 12; alcohol abuse began at age 16,
issues. Several studies have assessed the followed by abuse of cannabis, co-
caine, and heroin. Her first admission
efficacy of DBT-S in individuals with co-
into a psychiatric hospital was at age
occurring SUDs and PDs. In 1999, Line- 12, and she had had a criminal record
han et al. tested DBT-S in patients with since age 16. In addition to her abuse
BPD and various SUDs. They found that of heroin, cocaine, cannabis, and alco-
patients treated with DBT-S had better hol, she had interpersonal problems,
substance use and psychiatric outcomes anger outbursts, parasuicidal behav-
iors, and aggressive impulsiveness.
than did individuals referred for psy-
Previously, she had been in psychiat-
chotherapy in the community; retention ric and addiction treatments as both
and utilization provided possible expla- an outpatient and an inpatient. Among
nations for differences in outcomes. A her typical therapy-interfering behav-
very small uncontrolled pilot study con- iors was attempting to invite the ther-
apist into a very close and sometimes
ducted in 2000 suggested that DBT-S
intimate relationship. She usually
may be beneficial in increasing drug ab- dropped out each time she failed to se-
stinence in borderline methamphetamine- duce a therapist. At the time of admis-
dependent patients (Dimeff et al. 2000). sion to the DBT program, she was in
In 2002, Linehan et al. compared DBT-S an addiction-oriented day hospital
and a comprehensive validation therapy program.
Soon after Belinda started therapy,
(including 12-step facilitation) in BPD
a basic behavior pattern became clear
patients with opiate dependence. Both to the therapist: After work on Friday
groups showed improvements in opiate evening, Belinda would start to feel
use and psychopathology. Although the lonely. The thought “I need to com-
fort myself” would pop up. She would
close the curtains, drink a glass of with the therapist failed, as did all her
wine, and smoke cannabis while lis- efforts to make the therapist reject her
tening to music. Around 10 P.M. she (e.g., stalking by telephone, anger out-
would become restless, followed by bursts). The therapist was able to vali-
feeling angry because she also de- date Belinda’s behavior as fear of aban-
served “some company.” Then she donment, and she finally recognized
would dress up in sexy clothes and that she was more afraid of saying
go out for a drink. In the pub, she good-bye than of being rejected. After
would often meet familiar drug deal- 54 sessions Belinda left the program
ers. After a few drinks together, the and the therapist by mutual agree-
drug dealers would offer her cocaine. ment; she left a bouquet of flowers,
Because Belinda could not afford to along with the words, “This relation-
buy it, she would agree to have sex ship is the most horrible thing that has
with them. Feelings of guilt would ever happened to me in my life.
lead to more substance abuse, and fi- Thanks so much.”
nally she would lose contact with re-
ality. The next morning, she would
awake next to a stranger and would Comment on
become self-destructive, usually mak-
ing a series of cuts on her arm. Treatment Outcome
The behavior pattern described was
targeted for treatment. Because of its In summary, we have discussed that
threshold-lowering capacities for im- 1) personality pathology may affect re-
pulsive and self-destructive behavior, sponse to treatment of SUDs, although
the alcohol abuse was given high pri- the effect is not found as consistently as
ority early in treatment. Telephone
might have been anticipated; 2) more re-
consultation was of utmost impor-
tance in this stage. After 3 months, Be- search is needed on the effect of SUD
linda succeeded for the first time in status on response to PD treatment; and
not acting on the impulse to go to the 3) some preliminary data are supportive
bars late at night. Her contact with her of treatments with a dual focus (includ-
father, mother, and sisters was gradu-
ing DFST and DBT-S). Together, these
ally restored, and she resumed contact
with a network of old friends who data emphasize the importance of effec-
were not involved in substance abuse. tive treatment approaches that pay si-
Reinforcement contingencies were multaneous attention to addictive and
thus introduced such that she would personality problems. However, there is
have enjoyable interactions with her a need for more empirical evidence that
friends and family when she chose to
these treatments really have improved
contact them instead of going to the
bar by herself. effectiveness over existing approaches.
Despite Belinda’s verbalized com- Attention to the feasibility of these treat-
mitment to stop using all drugs, canna- ments is also required; as currently devel-
bis use was the most change-resistant oped, DFST and DBT-S require addi-
behavior. The therapist introduced the
tional clinical training and supervision.
concept of mindfulness, which al-
lowed Belinda to practice being more The development of integrated, multitar-
aware of her cravings and more inten- geted treatment programs, rather than
tional in her response to them. After 8 separate symptom-specific programs,
months she was clean and was able to could offer great benefit to patients with
“surf the craving” (i.e., be fully aware comorbid conditions. On a related note,
of—but resist—the urge to use canna-
therapist training should incorporate
bis). Then, finally, her attachment prob-
lems were targeted in treatment. Be- training on working with individuals with
linda’s efforts to become more intimate comorbid disorders.
treatment, detoxification, methadone

Treatment Guidelines maintenance program).
Patients with PDs are often treated with Duration and

psychotherapy, and pharmacotherapy is Treatment Goals
used to address specific symptoms as The treatment of individuals with PDs can
needed. We see no reason to deviate sub- be a long-term process. The added prob-
stantially from this general protocol in lems of reduced treatment retention and
dual-diagnosis patients, although effec- compliance associated with substance
tive treatment of these patients often re- abuse raise questions of what the appro-
quires modifications to traditional propriate treatment goals are for this group.
grams and methods. In the remainder of The goal should not be to accomplish deep
this chapter, we provide some clinical rec- and permanent change in personality
ommendations for psychotherapy and structure within a relatively short term. If
pharmacotherapy, respectively. facilities or resources are limited, a more
practical aim may be to improve sub-
Psychotherapy stance abuse treatment outcome by teach-
ing patients how to cope with or modu-
Dual Focus late maladaptive personality processes.
Dual focus does not necessarily mean
that attention to both foci should always Required Therapist Training
take place simultaneously. During the ear- Patients with comorbid SUD and PD can
lier sessions, it is often best to place the put a strain on the resources of many
greatest emphasis on the establishment treatment programs. Therapists treating
and maintenance of abstinence but with a these patients should have thorough ed-
secondary focus on identification of and ucation and training in PDs, addiction,
psychoeducation about maladaptive per- and therapy in general. More experienced
sonality traits. During later sessions, once therapists may be more appropriate given
a strong therapeutic relationship is estab- the complex array of presenting prob-
lished and substance-related concerns lems, although even seasoned therapists
have become less pressing, a greater em- would likely benefit from consultation
phasis can be placed on confronting and on difficult cases.
changing maladaptive traits, cognitive-
affective processes, or interpersonal rela-
Essential Ingredients
tionships. The dual focus of treatment should be
clear from the beginning of treatment,
Clinical Setting even if different problems are targeted at
Psychotherapy with patients with both different points in treatment. The trait-
SUD and PD is often insufficient as a based approach to personality pathology
stand-alone treatment. Psychotherapy is introduced in DSM-5 Section III, “Emerg-
likely to be most useful if it is offered as ing Measures and Models,” may aid the
part of a comprehensive program incor- therapist in treatment planning. Use of
porating varied treatment modalities (in- motivational interviewing (Martino et
dividual and group therapy, pharmaco- al. 2002) during the admission phase and
therapy if needed) and external resources throughout the treatment process may be
(e.g., Alcoholics Anonymous or Narcot- beneficial with dual-diagnosis patients.
ics Anonymous meetings, residential Regular individual therapy is helpful in
establishing a therapeutic alliance and amine, as compared with placebo, pro-

fostering commitment to treatment. Di- duced a robust and long-lasting reduction
rect therapeutic attention to maladap- in rapid mood shifts in female patients
tive personality traits may increase cog- with BPD but had no effect on impulsiv-
nitive and coping skills, which in turn ity or aggression.
may improve symptomatology and re-
duce the risk for relapse. Participation in Mood Stabilizers
some modality of aftercare (ongoing out- Lithium and other mood stabilizers (e.g.,
patient therapy, Alcoholics Anonymous carbamazepine, divalproex sodium) have
or Narcotics Anonymous meetings) could been reported to reduce aggressive and
be beneficial to patients who have com- violent behaviors in prison inmates with
pleted more intensive treatment. antisocial PD and to decrease “within-
day mood fluctuations” in patients with
Pharmacotherapy BPD (Cowdry and Gardner 1988; Stein
1992). Early anecdotal reports and a
Medications may alleviate symptoms of
small double-blind, placebo-controlled
PDs and improve substance use out-
study also suggested that lithium may be
comes, but noncompliance, substance de-
efficacious in the treatment of alcohol
pendence, and lethal overdose are all
dependence. However, a large Veterans
risks. The pharmacotherapy of PDs is dis-
Administration study showed no bene-
cussed in detail elsewhere in this volume
fits of lithium over placebo for patients
(see Chapter 15, “Somatic Treatments”).
with alcohol dependence with or with-
Neuroleptics out depressive symptoms (Dorus et al.
1989). Similar negative findings are avail-
Low doses of neuroleptics have been re-
able for the treatment of cocaine depen-
ported to be associated with a range of
dence with mood stabilizers (de Lima et
beneficial effects in patients with bor-
al. 2002).
derline, schizotypal, or paranoid PDs
(Rocca et al. 2002; Soloff 1998). Although Benzodiazepines
Gawin et al. (1989) reported that neuro-
Benzodiazepines are generally contrain-
leptics helped decrease craving in cocaine
dicated for individuals with BPD because
abusers, a study by Dackis and O’Brien
of the risk of addiction and of paradoxical
(2002) did not support the anticraving or
reactions involving behavioral disinhibi-
abstinence-promoting effect of neuro-
tion (Cowdry and Gardner 1988).
leptics.
Buspirone
Selective Serotonin
The partial serotonin agonist buspirone
Reuptake Inhibitors seems to combine a lack of abuse poten-
Selective serotonin reuptake inhibitors tial with a positive effect on social phobia
have been shown to reduce aggression and avoidant PD (Zwier and Rao 1994)
and impulsivity in patients with border- and a delay in the return to heavy alco-
line and antisocial PDs (Coccaro and Ka- hol consumption in anxious alcohol-
voussi 1997; Soloff 1998) and may have dependent patients (Kranzler et al. 1994).
some positive effect on substance abuse
in alcohol- and cocaine-dependent pa- Stimulants
tients (Cornelius et al. 1997). Rinne et al. Various stimulants, including methylphe-
(2002), however, showed that fluvox- nidate, pemoline, dexamphetamine, and
levodopa, have been reported to reduce two or more criteria for the diagnosis of
impulsivity in patients with borderline or SUD was selected, with mild, moderate,
antisocial PD with a history of attention- and severe SUD indicated by 2–3, 4–5,
deficit/hyperactivity disorder (Stein and t6 criteria, respectively. The newly
1992). It has been claimed that childhood defined SUD was based on extensive re-
hyperactivity and a history of drug abuse search showing that each of the set of 11
are predictors of a favorable response to criteria was an indicator of the same un-
both psychostimulants and monoamine derlying latent trait (Hasin et al. 2013).
oxidase inhibitors among patients with Evidence remains to be presented on
PDs (Stein 1992). However, stimulants whether the high reliability and validity
are known for their addictive and abuse of DSM-IV dependence is maintained or
potential, and restraint should be used in improved upon by the new category of
prescribing these drugs. DSM-5 SUD. Although the definitions of
PDs have remained the same in DSM-5
Naltrexone Section II as they were in DSM-IV, an al-
ternative model for conceptualizing and
The opioid antagonist naltrexone has
diagnosing PDs based on impairments in
been reported to be effective in the treat-
personality functioning and pathological
ment of alcohol and opiate dependence
personality traits was developed for Sec-
(Soloff 1993) as well as in the prevention
tion III of DSM-5 (See Chapter 7, “Mani-
of self-mutilation in a patient with BPD
festations, Assessment, and Differential
(Griengl et al. 2001). However, the latter
Diagnosis,” and Chapter 24, “An Alter-
finding is based on a single case, and more
native Model for Personality Disorders:
research is needed.
DSM-5 Section III and Beyond,” in this
volume). With the DSM-5 changes re-
garding SUDs, and an inevitable change
Using DSM-5 in the nomenclature at some future point
for PDs, the relationships reviewed in
The DSM-IV system of two SUD types, this chapter will need to be reexamined.
abuse and dependence, was problematic
because abuse had inconsistent reliability
and validity, although dependence was Conclusion
consistently shown to be reliable and
valid (Hasin et al. 2006). In DSM-5, abuse Substance use disorders are highly prev-
and dependence have been replaced by a alent among patients with PDs. Although
single substance use disorder (Hasin et PDs can be measured reliably and val-
al. 2013). This use disorder is generally idly in patients with SUDs, it can be dif-
defined by 11 criteria: all seven of the ficult to distinguish the symptoms and
DSM-IV dependence criteria, three of the pathologies of each.
four DSM-IV abuse criteria (legal prob- With respect to causal pathways, evi-
lems as a criterion was dropped), and dence supports multiple pathways from
craving.(Several substances, such as phen- personality (and PDs) to SUD (behav-
cyclidine, other hallucinogens, and inhal- ioral disinhibition, stress reduction, re-
ants, do not have established withdrawal ward sensitivity) and a common factor
signs and symptoms, so the 11th criterion model. The latest evidence from genetic
for withdrawal does not apply to these epidemiology and molecular genetics
substance use disorders.) A threshold of supports a common factor model.
Although evidence is somewhat equiv- American Psychiatric Association: Diagnos-

ocal, several studies suggest that individ- tic and Statistical Manual of Mental Dis-
orders, 2nd Edition. Washington, DC,
uals with comorbid SUDs and PDs bene-
fit from SUD treatment as much as do American Psychiatric Association: Diagnos-
those with only SUDs, which empha- tic and Statistical Manual of Mental Dis-
sizes the importance of providing treat- orders, 3rd Edition. Washington, DC,
ment to individuals with comorbidities. American Psychiatric Association, 1980
However, these individuals may im- American Psychiatric Association: Diagnos-
tic and Statistical Manual of Mental Dis-
prove only to a level of problem severity
orders, 4th Edition. Washington, DC,
that still leaves them at considerable risk American Psychiatric Association, 1994
for relapse. In addition, maladaptive per- American Psychiatric Association: Diag-
sonality traits, such as impulsivity, nov- nostic and Statistical Manual of Mental
elty seeking, and affective instability, Disorders, 4th Edition, Text Revision.
may also contribute to higher odds of re-
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morbid SUD benefit from treatments personality disorder and alcohol depen-
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Psychotherapy, with pharmacotherapy stance dependence: case study results.
targeted to specific symptoms, is recom- Cogn Behav Pract 7:270–281, 2000
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C H A P T E R 20
Antisocial Personality
Disorder and Other
Antisocial Behavior
Donald W. Black, M.D.
Nancee S. Blum, M.S.W.
In this chapter, we summarize ASPD is largely ignored or misunder-

much of what has been learned about an- stood by many clinicians and researchers.
tisocial personality disorder (ASPD) and ASPD is associated with a pattern of
other forms of antisocial behavior, includ- socially irresponsible, exploitative, and
ing childhood conduct disorder, adult an- guiltless behavior manifested by distur-
tisocial behavior, and psychopathy. ASPD bances in many areas of life, including
is perhaps the most troublesome form of family relations, schooling, work, mili-
antisocial behavior and wreaks more tary service, and marriage (North and
havoc on society than most other mental Yutzy 2010). Behaviors include criminal
disorders because it primarily involves acts and failure to conform to the law,
actions directed against the social envi- failure to sustain consistent employment,
ronment. Antisocial criminals are respon- manipulation and deception of others
sible for untold financial losses and refor personal gain, and failure to develop
quire additional billions to police and or sustain stable interpersonal relation-
punish them. The despair and anxiety ships. Other attributes of ASPD include a
wrought by antisocial persons tragically lack of empathy for others, rare experi-
affect families and communities. Many ences of remorse, and failure to learn from
people with ASPD live in poverty or draw the negative results of one’s behavior.
on the social welfare system, hampered The spectrum of behaviors seen in people
by poor school and work performance with ASPD ranges from relatively minor
and an inability to establish a life plan. acts at one end (e.g., lying, cheating) to
Despite high public health significance, heinous acts at the other (e.g., rape, mur-
429
der). Common and widespread, the pres- ered psychopathy a true illness, and our
ence of ASPD is rarely acknowledged, present understanding reflects much of
and determining its causes is as elusive their early work.
as understanding its treatment.
DSM
Diagnostic Issues Cleckley inspired the creation of a new
diagnostic category, sociopathic personality
disturbance, in DSM-I (American Psychi-
Historical Overview atric Association 1952). Generally abbre-
Clinical descriptions of antisocial behav- viated as sociopathy, the term was used to
ior date to the early nineteenth century describe persons whose abnormal behav-
when Philippe Pinel, a leader in the ior was directed toward the social envi-
French Revolution and founding father ronment: “Individuals to be placed in this
of modern psychiatry, used the term category are ill primarily in terms of soci-
manie sans délire to describe people with ety and of conformity with the prevailing
irrational outbursts of rage and violence cultural milieu, and not only in terms of
(North and Yutzy 2010). English physi- personal discomfort and relations with
cian James Pritchard wrote about moral other individuals” (American Psychiatric
insanity, a condition in which a person’s Association 1952, p. 38). Subtypes in-
intellectual faculties were unimpaired cluded antisocial reaction, dyssocial reac-
but moral principles were “depraved or tion, sexual deviation, and addiction which
perverted.” His term foreshadowed the included alcoholism and drug addiction.
later focus on the moral dimensions of Antisocial reaction referred to the behavior
ASPD. German psychiatrist Julius Koch of chronically antisocial individuals who
introduced the term psychopathic inferior- were always in trouble and without loy-
ity in the late nineteenth century to re- alties to other persons, groups, or codes.
place moral insanity as a diagnosis. The Dyssocial reaction referred to those with
term described a broad range of deviant disregard for the usual social codes, hav-
behaviors and eccentricities and implied ing lived in an “abnormal moral environ-
that the disorder resulted from constitu- ment, but who [were] capable of strong
tional factors (Black 2013). loyalties” (American Psychiatric Associa-
Scottish psychiatrist David Henderson tion 1952, p. 38). The term antisocial per-
(1939) and American psychiatrist Hervey sonality disorder was introduced in DSM-II
Cleckley (1941/1976), working indepen- (American Psychiatric Association 1968),
dently at about the same time, each used and the new definition combined ele-
the term psychopathy. In Mask of Sanity: An ments of the antisocial and dyssocial re-
Attempt to Clarify Some Issues About the So- actions of DSM-I. Listed among other
Called Psychopathic Personality, Cleckley personality disturbances, the disorder
(1941/1976) provided a detailed descrip- was no longer linked with addictions or
tion of psychopathic behavior, which he deviant sexuality. As defined in DSM-II,
set apart from other psychiatric conditions the term was “reserved for individuals
and behavioral abnormalities. Through a who are basically unsocialized and whose
series of case vignettes, Cleckley showed behavior pattern brings them repeatedly
how the disorder transcends social class. into conflict with society” (American
Both Cleckley and Henderson consid- Psychiatric Association 1968, p. 43).
Antisocial Personality Disorder and Other Antisocial Behavior 431
Diagnostic criteria introduced in lousness, deceitfulness, hostility, risk tak-

DSM-III (American Psychiatric Associa- ing, impulsivity, and irresponsibility.
tion 1980) were inspired by the work of Table 20–1 presents a comparison of
Robins (1966), as well as both the Wash- the DSM-5 Section II (“Diagnostic Crite-
ington University (“Feighner”) criteria ria and Codes”) criteria (left column)
(Feighner et al. 1972) and the Research with the alternative model (right column).
Diagnostic Criteria (Spitzer et al. 1978), (For additional details on the alternative
and emphasized the continuity between model, see Chapter 3, “Articulating a Core
adult and childhood behavioral prob- Dimension of Personality Pathology”;
lems. The criteria were simplified in sub- Chapter 7, “Manifestations, Assessment,
sequent editions, including DSM-III-R and Differential Diagnosis”; and Chap-
(American Psychiatric Association 1987) ter 24, “An Alternative Model for Per-
and DSM-IV (American Psychiatric As- sonality Disorders: DSM-5 Section III
sociation 1994), and no changes were and Beyond,” in this volume.)
made in DSM-5 Section II criteria (Amer-
ican Psychiatric Association 2013). Relation of ASPD to
The DSM-5 Section II criteria require
that a person have at least three of seven Psychopathy
pathological personality traits (e.g., de- Although the word psychopathy predates
ceitfulness, impulsivity, irritability or ag- the word antisocial, the terms initially were
gressiveness, irresponsibility, lack of re- used interchangeably. The term psychop-
morse). The person must be age 18 years athy gradually came to be used in a re-
or older, and the criteria for conduct dis- stricted fashion defined by a constella-
order must have been met prior to age 15. tion of psychological manifestations and
Schizophrenia and bipolar disorder must traits to describe a clinical entity distinct
be ruled out as a cause of the disturbance. from ASPD. Many clinicians and re-
An alternative model for personality searchers were dissatisfied with DSM-
disorders, created during the develop- III’s criteria for ASPD and its focus on
ment of DSM-5, appears in Section III, behaviors (e.g., criminality, aggression)
“Emerging Measures and Models,” of the rather than underlying psychological
manual. All the personality disorders— traits. Although DSM-III proved to be
including ASPD—are defined in terms of reliable, critics felt that validity had been
impairments in self functioning (iden- sacrificed in favor of reliability because
tity and self-direction) and interpersonal of the failure to include all the traits of psy-
functioning (empathy and intimacy), as chopathy identified by Cleckley (Widi-
well as pathological personality traits ger 2006). In response, the authors of
shown to be empirically related to the dis- DSM-III-R (American Psychiatric Asso-
order. The personality functioning crite- ciation 1987) added lack of remorse as a
rion (Criterion A) focuses on the ego- criterion for ASPD, and for DSM-IV the
centrism, absence of prosocial internal criteria were simplified and became more
standards, lack of empathy, and exploit- trait-based. Of note, in the alternative
ative interpersonal relationships charac- personality disorder model presented in
teristic of ASPD, and the personality DSM-5, all of the “B criteria” for ASPD
traits criterion (Criterion B) requires six (and other personality disorders) are de-
or more of the following pathological scribed in trait terms.
traits from the domains of Antagonism Motivated by concerns that the DSM
and Disinhibition: manipulativeness, cal- approach emphasized delinquent and
432
TABLE 20–1. Comparison of DSM-5 Section II and Section III criteria for antisocial personality disorder (ASPD)
DSM-5 Section II ASPD DSM-5 Section III ASPD

A. There is a pervasive pattern of disregard Typical features of antisocial personality disorder are a failure to conform to lawful and ethical behavior,
for and violation of the rights of others and an egocentric, callous lack of concern for others, accompanied by deceitfulness, irresponsibility,
occurring since age 15 years, as indicated manipulativeness, and/or risk taking. Characteristic difficulties are apparent in identity, self-direction,
by three (or more) of the following: empathy, and/or intimacy, as described below, along with specific maladaptive traits in the domains of
1. Failure to conform to social norms Antagonism and Disinhibition.
with respect to lawful behaviors as A. Moderate or greater impairment in personality functioning, manifest by difficulties in two or more of
indicated by repeatedly performing the following four areas:
acts that are grounds for arrest 1. Identity: Ego-centrism; self-esteem derived from personal gain, power, or pleasure.
2. Deceitfulness, as indicated by re- 2. Self-direction: Goal setting based on personal gratification; absence of prosocial internal standards
peated lying, use of aliases, or con- associated with failure to conform to lawful or culturally normative ethical behavior.
ning others for personal profit or
3. Empathy: Lack of concern for feelings, needs, or suffering of others; lack of remorse after hurting or
pleasure
mistreating another.
3. Impulsivity or failure to plan ahead
4. Intimacy: Incapacity for mutually intimate relationships, as exploitation is a primary means of re-
4. Irritability and aggressiveness, as in- lating to others, including by deceit and coercion; use of dominance or intimidation to control others.
dicated by repeated physical fights
B. Six or more of the following seven pathological personality traits:
or assaults
1. Manipulativeness (an aspect of Antagonism): Frequent use of subterfuge to influence or control others;
5. Reckless disregard for safety of self
use of seduction, charm, glibness, or ingratiation to achieve one’s ends.
or others
2. Callousness (an aspect of Antagonism): Lack of concern for feelings or problems of others; lack of
6. Consistent irresponsibility, as indi-
guilt or remorse about the negative or harmful effects of one’s actions on others; aggression; sadism.
cated by repeated failure to sustain
consistent work behavior or honor fi- 3. Deceitfulness (an aspect of Antagonism): Dishonesty and fraudulence; misrepresentation of self;
nancial obligations embellishment or fabrication when relating events.
7. Lack of remorse, as indicated by be- 4. Hostility (an aspect of Antagonism): Persistent or frequent angry feelings; anger or irritability in
ing indifferent to or rationalizing response to minor slights and insults; mean, nasty, or vengeful behavior.
having hurt, mistreated, or stolen 5. Risk taking (an aspect of Disinhibition): Engagement in dangerous, risky, and potentially self-
from another damaging activities, unnecessarily and without regard for consequences; boredom proneness and
B. The individual is at least age 18 years. thoughtless initiation of activities to counter boredom; lack of concern for one’s limitations and
denial of the reality of personal danger.
Antisocial Personality Disorder and Other Antisocial Behavior
TABLE 20–1. Comparison of DSM-5 Section II and Section III criteria for antisocial personality disorder (ASPD) (continued)
DSM-5 Section II ASPD DSM-5 Section III ASPD
C. There is evidence of Conduct Disorder 6. Impulsivity (an aspect of Disinhibition): Acting on the spur of the moment in response to immediate
(see Diagnostic criteria for Conduct Dis- stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty estab-
order) with onset before age 15 years. lishing and following plans.
D. The occurrence of antisocial behavior is 7. Irresponsibility (an aspect of Disinhibition): Disregard for—and failure to honor—financial and other
not exclusively during the course of obligations or commitments; lack of respect for—and lack of follow through on—agreements and
Schizophrenia or a Manic Episode. promises.
C. The impairments in personality functioning and the individual’s personality trait expression are rela-
tively inflexible and pervasive across a broad range of personal and social situations.
D. The impairments in personality functioning and the individual’s personality trait expression are rela-
tively stable across time, with onsets that can be traced back at least to adolescence or early adulthood.
E. The impairments in personality functioning and the individual’s personality trait expression are not
better explained by another mental disorder.
F. The impairments in personality functioning and the individual’s personality trait expression are not
attributable to a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe
head trauma).
G. The impairments in personality functioning and the individual’s personality trait expression are not
better understood as normal for the individual’s developmental stage or sociocultural environment.
Note. The individual is at least 18 years of age.
Source. Reprinted from American Psychiatric Association 1994, 2013. Copyright 1994, 2013, American Psychiatric Association. Used with permission.
433
antisocial symptoms to the exclusion of Conduct Disorder

psychological traits, Hare created the
Psychopathy Checklist (PCL) to assess Conduct disorder was introduced in
traits he and others have associated with DSM-III and included four subtypes
psychopathy as a distinct clinical syn- based on a 2u2 matrix on the axes of so-
drome (e.g., glibness, callousness, lack cialization and aggressivity (American
of emotional connection to others, inca- Psychiatric Association 1980). This
pacity for guilt or remorse) (Hare and scheme was dropped from DSM-III-R
Neumann 2006). Much of his work in val- and subsequent editions because the sub-
idating the questionnaire, or its revision typing was judged to lack clinical utility
(the PCL-R), has taken place in correc- and to be at variance with research find-
tional settings, where the instrument has ings (American Psychiatric Association
proven reliable in identifying people with 1987). Conduct disorder is defined as “a
these traits, as well as predicting recidi- repetitive and persistent pattern of be-
vism, parole violations, and violence in havior in which the basic rights of others
offenders and psychiatric patients (Hare or major age-appropriate societal norms
and Neumann 2006). Several of these or rules are violated” (American Psychi-
traits (e.g., manipulativeness, callous- atric Association 2013, p. 469). In DSM-5,
ness) are included in the alternative conduct disorder has been moved from
model for ASPD in DSM-5. the DSM-IV chapter “Disorders Usually
Psychopathy has gained support as a First Diagnosed in Infancy, Childhood, or
topic of investigation, perhaps because it Adolescence” to “Disruptive, Impulse-
is measurable and identifies a homoge- Control, and Conduct Disorders.”
neous group of people. However, it also Conduct disorder is a predominantly
has contributed to confusion among cli- male disorder and affects approximately
nicians and researchers who have diffi- 5%–15% of children (Black 2013). The
culty distinguishing the two syndromes. disorder has an early onset and is gen-
ASPD and psychopathy overlap and, al- erally present by the preschool years,
though Hare (1983) notes that most anti- usually by age 8. By age 11 years, 80% of
social persons are not psychopaths as future cases have had a first symptom
defined by his checklist, nearly all psy- (Robins and Price 1991). Most children
chopaths exhibit antisocial traits and be- with conduct disorder do not develop
havior that meet the criteria for ASPD. adult ASPD, although they remain at
This overlap has been looked at in pris- high risk, with an estimated 25% of girls
oners, in whom the prevalence of both and 40% of boys with conduct disorder
conditions is high. Nearly one-third of eventually developing ASPD (Robins
incarcerated men with ASPD are psycho- 1987). Rates for the progression from con-
paths. Psychopathy appears to lie along a duct disorder to ASPD are much higher
continuum of severity with ASPD and in adolescent substance abusers (Myers
likely constitutes its most severe variant et al. 1998). The likelihood of a child’s
(Coid and Ullrich 2010). developing ASPD is associated with the
The alternative model for ASPD in variety and severity of childhood misbe-
DSM-5 includes the specifier “with psy- haviors and early onset.
chopathic features” to denote individu- The diagnosis of conduct disorder re-
als who are also characterized by low quires that at least three of 15 problematic
anxiety and a particularly dominant in- behaviors be present in the previous 12
terpersonal style. months, with at least one criterion pres-
ent in the past 6 months. Although the di- problems, and have a greater variety of
agnosis may be made in adults, the problems. In contrast, most antisocial
symptoms usually emerge in childhood youths develop adolescence-limited an-
or adolescence, and onset is rare after tisocial behavior, which is less severe
age 16 years. The criteria specify a child- and typically arises in the context of teen-
hood-onset type (prior to age 10 years) age peer group pressure.
and an adolescence-onset type (after age
10 years), in recognition of the fact that
early onset is one of the strongest predic-
Adult Antisocial Behavior
tors of poor outcome. DSM-5 includes adult antisocial behavior
When considering the diagnosis, cli- in the section “Other Conditions That May
nicians should note misbehaviors in four Be a Focus of Clinical Attention.” This
main areas: aggression toward people or designation is used when adult antisocial
animals, destruction of property, deceit- behavior is the focus of clinical attention
fulness or theft, and serious violations of and is not considered due to a mental dis-
rules. Childhood symptoms include fights order even though the condition may be
with peers, conflicts with parents and troublesome to the individual and com-
other authority figures, stealing, vandal- munity (American Psychiatric Associa-
ism, fire setting, and cruelty to animals tion 2013). The category is used to de-
or other children. School-related behav- scribe persons who manifest antisocial
ior problems are common, as is poor ac- behavior but do not otherwise meet crite-
ademic performance. In addition, many ria for ASPD or other disorders that could
of these children have a history of run- explain the behavior (e.g., professional
ning away from home. These behavior thieves, racketeers, or dealers of illegal
problems must significantly impair the substances). Typically, these individuals
child’s social, academic, or occupational have no history of conduct disorder.
functioning. Boys with conduct disorder In the absence of long-standing be-
are more likely to exhibit physical aggres- havioral problems dating to childhood
sion, whereas girls are more likely to show or early adolescence, individuals with
relational aggression—that is, behavior adult antisocial behavior are presumed
that harms social relationships (American to be fundamentally normal people whose
Psychiatric Association 2013). choices and decisions have led them
Moffitt (1993a) differentiated adoles- astray. Research shows there is a full spec-
cence-limited and life-course-persistent trum of antisocial behavior in the gen-
antisocial behaviors. Youths with ado- eral population, with adult antisocial be-
lescence-limited antisocial behaviors havior at the less severe end (Goldstein
have little or no history of earlier anti- et al. 2007).
social behavior, and they tend to sponta-
neously improve, explaining why most
children and adolescents with conduct Epidemiology
disorder never develop adult ASPD. A
small proportion of men with extreme Surveys in the United States and United
behavioral problems have life-course- Kingdom indicate that between 2% and
persistent antisocial behaviors; these men 5% of the general adult population have
have an early onset of antisocial behav- antisocial features that meet the criteria
ior, develop more severe behavioral for lifetime ASPD. The National Institute
of Mental Health’s Epidemiologic Catch- based study that used a structured inter-
ment Area (ECA) survey was the first view to identify ASPD found that 35% of
large study conducted in the United States offenders had antisocial features that met
(Robins et al. 1984). Data from nearly the criteria for ASPD (Black et al. 2010).
15,000 subjects at five sites showed that The rate is also high in particular patient
2%–4% of men and 0.5%–1% women groups. For example, the prevalence of
have antisocial features that meet the cri- ASPD in persons undergoing residential
teria for ASPD. The National Comorbid- drug treatment may reach 55% (Goldstein
ity Survey, a probability survey of more et al. 1996). The rate among homeless per-
than 8,000 adult Americans, found an sons is also high (North et al. 1993).
overall rate of 3.5% (Kessler et al. 1994). ASPD is associated with low socioeco-
More recently, the National Epidemiologic nomic status, which can be attributed in
Survey on Alcohol and Related Condi- part to poor educational achievement,
tions (NESARC), involving over 43,000 poor job performance, and frequent un-
Americans, reported an overall rate of employment. In the NESARC, respon-
3.6% (5.5% for men, 1.9% for women) dents with lower educational levels and
(Compton et al. 2005). The British Na- lower income levels were more likely to
tional Survey of Psychiatric Morbidity re- have ASPD (Compton et al. 2005). Accord-
ported a prevalence rate of 2.9% for ASPD ing to Robins (1987), persons with ASPD
in the United Kingdom (Ullrich and Coid begin life at a disadvantaged level and
2009). These surveys may underestimate their adult social class continues to de-
the prevalence of ASPD, however, be- cline, even falling below that of their par-
cause they do not include data on institu- ents. However, low social class itself is not
tionalized and incarcerated persons who responsible for ASPD, as demonstrated in
are likely to have higher rates of ASPD. a study of African American youths by
The NESARC study also reported rates Robins et al. (1971). The authors showed
for other antisocial syndromes. The prev- that children without conduct disorder
alence in adults for lifetime conduct dis- symptoms were not at risk for ASPD when
order (in the absence of adult antisocial raised in impoverished families, but that
behavior) was 1.1% (1.5% for men, 0.7% children with high rates of conduct symp-
for women). Lifetime adult antisocial be- toms were at risk for ASPD even when
havior without a history of conduct dis- reared in “white-collar” families.
order was found in 12.3% (16.5% for men, The question of whether ASPD is more
8.5% for women). These data suggest that common in certain racial or ethnic groups
antisocial behavioral syndromes occur is unsettled. The ECA showed that Afri-
along a continuum of severity (Compton can American respondents were more
et al. 2005; Goldstein et al. 2007). likely than Caucasians to exhibit antiso-
ASPD is overrepresented among men cial symptoms that could lead to arrest
and women in jails and prisons (Black et and incarceration, although there were
al. 2010). An early study showed that up no racial differences in ASPD preva-
to 80% of incarcerated men and 65% of in- lence (Robins 1987). In the NESARC,
carcerated women were judged to have Native Americans were at increased risk
ASPD based on the Feighner criteria for ASPD, whereas Asian American and
(Guze 1976). Recent work suggests that Hispanic/Latino respondents were at
prevalence may have declined as the lower risk for ASPD than Caucasians
prison population has grown. A prison- (Compton et al. 2005).
ASPD is primarily a disorder of younger toms of ASPD, as found in the NESARC

persons. According to the ECA survey, (Goldstein et al. 2007), are shown in Ta-
rates of ASPD diminish with advancing ble 20–2.
age (Robins et al. 1984). This finding is
counterintuitive, because one might ex-
pect that rates of this lifelong diagnosis Gender Differences
would be higher in older persons. The
lower prevalence rates in older adults There are differences between men and
may be attributable in part to forgetful- women in ASPD onset and symptoms.
ness (i.e., not recalling past behaviors) or Robins (1966) observed that troubled
denial. Another possibility is that be- girls later diagnosed antisocial were more
cause many antisocial persons die pre- likely than boys to have engaged in sex-
maturely, they are not available for late- ual misbehavior and had a later onset of
life surveys. behavioral problems. As women, they
married at a younger age than their non-
antisocial peers and chose husbands
Clinical Manifestations “who drank, were arrested, were unfaith-
ful, deserted, or failed to support them”
The clinical manifestations of ASPD be- (p. 49). Those with children had more of
gin early, often leading to the diagnosis them than non-antisocial women, and
of conduct disorder (Black 2013; North their children tended to be difficult,
and Yutzy 2010). As antisocial youth at- perhaps sadly destined to follow their
tain adult status, problems develop in parents’ path in life. Like her male coun-
other areas of life reflecting age-appro- terpart, a woman with ASPD has low
priate responsibilities. These problems earning potential, is often financially de-
include uneven job performance, unreli- pendent on others (or the government),
ability, frequent job changes, and losing and exhibits aggressive behavior. Women
jobs through quitting or being fired. Path- with ASPD are disconnected from the
ological lying and the use of aliases are community and have high rates of de-
common. Many antisocial persons are pression, anxiety disorders, and sub-
sexually promiscuous and become sexu- stance use disorders.
ally active at a younger age than their Other data on gender differences sug-
peers. Marriages are often unstable, lead- gest that antisocial boys are more likely
ing to high rates of divorce, and may be than antisocial girls to engage in fight-
accompanied by domestic violence. ing, use weapons, engage in cruelty to
Antisocial persons who join the armed animals, or set fires. Girls are more often
forces often have unsatisfactory experi- involved in “victimless” antisocial be-
ences because of their inability to accept haviors such as running away. As adults,
military discipline (Black et al. 1995a; women with ASPD are more likely to
Robins 1966). They are more likely than have problems that center on the home
others to be absent without leave, court- and family, such as irresponsibility as a
martialed, or dishonorably discharged. parent, neglectful or abusive treatment
Criminality is common among antisocial of their children, and physical violence to-
persons. Offenses vary but range from ward husbands and partners (Goldstein
nonviolent property offenses to acts of et al. 1996).
extreme violence, which may include Some have suggested that this higher
sodomy, rape, or murder. Clinical symp- prevalence of ASPD in men than in
TABLE 20–2. Antisocial personality disorder (ASPD) symptoms in 305 women and
750 men in the NESARC study
Symptoms Women Men Total
Repeated unlawful behaviors, % 81 85 84

Deceitfulness, % 56 46 49
Impulsivity/failure to plan ahead, % 62 54 56
Irritability/aggressiveness, % 74 75 75
Recklessness, % 62 85 79
Consistent irresponsibility, % 89 86 87
Lack of remorse, % 53 52 52
Total ASPD criteria since age 15, mean 4.8 4.8 4.8
Lifetime violent symptoms, mean 3.0 3.3 3.2
Note. NESARC=National Epidemiologic Survey on Alcohol and Related Conditions.
Source. Adapted from Goldstein et al. 2007.
women is due to genetic influence, but while adoption studies have shown that
this does not appear to be the case (Slutske ASPD is more frequent in adoptees with
2001). Others attribute gender differ- antisocial biological relatives (Cadoret et
ences to cultural norms, and point out al. 1985).
that because overt aggression is less com- These same studies also suggest that
mon in women, they may act out in less much of the risk for becoming antisocial
obvious ways (e.g., promiscuous sex, is due to shared family experiences or
emotionally manipulative relationships), to experiences specific to an individual
leading to a diagnosis of borderline per- (Slutske 2001). An important study in the
sonality disorder instead of ASPD (Black new era of molecular genetics points to
2013). the influence of the monoamine oxidase A
gene, MAOA. (Monoamine oxidase is an
enzyme that breaks down the neurotrans-
Etiology mitter serotonin.) The low-activity vari-
ant of the gene has been found in anti-
Genetics of Antisocial social persons who had been severely
abused as children (Caspi et al. 2002). In
Behavior contrast, children who had a high-activ-
Research supports a genetic diathesis for ity variant of the gene rarely became anti-
antisocial behavior. Results from more social, despite the presence of abuse. Re-
than 100 family, twin, and adoption stud- cently, Tielbeek et al. (2012) conducted a
ies indicate that antisocial behavior runs genome-wide association study of adult
in families in part due to the transmission antisocial behavior in nearly 5,000 per-
of genes (Slutske 2001). In fact, nearly sons but were unable to link any genes
20% of first-degree relatives of persons with antisocial behavior.
with ASPD will have the disorder them-
selves (Guze et al. 1967). A review of twin Psychophysiology and
study data reported monozygotic con-
cordance for ASPD of nearly 67% com- Neurodevelopment
pared with 31% concordance for dizy- Autonomic underarousal has been pos-
gotic twins (Brennan and Mednick 1993), ited as underlying psychopathy, a con-
dition that likely constitutes a poor- in particular has been linked with im-
prognosis subset of individuals with pulsive and aggressive behavior. Low
ASPD (Hare 1986). Briefly, psychopathic levels of its metabolite 5-hydroxyindole-
persons require greater sensory input to acetic acid (5-HIAA) have repeatedly
produce normal brain functioning than been found in cerebrospinal fluid of per-
normal subjects, possibly leading these sons with violent or impulsive behavior
individuals to seek potentially danger- (Åsberg et al. 1976; Virkkunen et al. 1987).
ous or risky situations to raise their level It is thought that the presence of sero-
of arousal to desired levels. Evidence tonin may curb impulsive and aggressive
supporting this theory includes the find- behaviors. Genetic disturbances in sero-
ing that antisocial adults (and youth with tonin function may predispose to impul-
conduct disorder) have low resting pulse sive and aggressive behavior (Nielsen et
rates, low skin conductance, and in- al. 1994).
creased amplitude on event-related po-
tentials (Scarpa and Raine 1997). One Neuroimaging
study of 15-year-old English schoolchil-
Abnormal CNS functioning in antisocial
dren found that those who committed
crimes during the subsequent 9 years individuals has been suggested from
were more likely to have low resting pulse brain imaging studies (Dolan 2010; Yang
et al. 2008). Several crucial brain regions
at baseline, reduced skin conductance,
and more slow-wave electroencephalo- have been implicated, including the pre-
graphic (EEG) activity than the others frontal cortex, the superior temporal cor-
tex, the amygdala-hippocampal com-
(Raine et al. 1990).
The presence of EEG abnormalities in plex, and the anterior cingulate cortex.
nearly half of antisocial persons, along Raine and coworkers have conducted
a series of relevant imaging studies. Using
with high rates of minor facial anomalies,
learning disorders, enuresis, and be- positron emission tomography to mea-
havioral hyperactivity, further suggests sure glucose uptake in murderers, Raine
et al. (1997) found impairments in the
that ASPD is a neurodevelopmental syn-
prefrontal cortex and other underlying
drome (Moffitt 1993b). Maternal smoking
and starvation have also been linked with structures. Based on results from magnetic
antisocial behavior (Neugebauer et al. resonance imaging, Raine et al. (2000) re-
ported that antisocial men had reduced
1999; Wakschlag et al. 1997). The mecha-
nism behind these relationships is un- gray matter volume in the prefrontal
clear, but it could be that subtle brain in- lobes; this was the first indication that
anomalies in these structures may un-
jury contributing to antisocial behavior
results from lower levels of oxygen avail- derlie some antisocial behavior. In an at-
able to the fetus, from fetal exposure to tempt to localize symptoms, they looked
at a group of pathological liars—a com-
chemicals generated from tobacco smoke,
or from the deleterious effect of malnutri- mon characteristic of individuals with
tion on the developing brain. ASPD (Yang et al. 2007). The liars had an
increase in prefrontal white matter vol-
ume, prompting the authors to compare
Neurotransmission this finding with “Pinocchio’s nose” (i.e.,
Central nervous system (CNS) neuro- repeated lying activates the prefrontal
transmitters are thought to have a role in circuitry, leading to permanent changes
mediating antisocial behavior. Serotonin in brain structure). More recently, they
found smaller amygdalae in psychopathic Family and Social Factors

individuals compared with controls, pos-
sibly explaining the shallow emotions Child abuse is reported to contribute to
observed in psychopathic persons (Yang the development of ASPD. Parents of
et al. 2009). persons who develop ASPD are often in-
Kiehl and colleagues used functional competent, absent, or abusive (Robins
magnetic resonance imaging to investi- 1966, 1987). They are often significantly
gate brain activity in psychopathic indi- troubled themselves, showing high lev-
viduals during various emotional and els of antisocial behavior; furthermore,
cognitive experiments. Kiehl et al. (2001) some have an alcohol use disorder, are
reported reduced activity in the amyg- divorced or separated, or exhibit anti-
dala in psychopathic individuals in re- social behavior. Erratic or inappropriate
sponse to hearing emotionally charged parental discipline and inadequate su-
words, a finding that might help explain pervision have been linked with antiso-
why these individuals have difficulty cial behavior (Reti et al. 2002). Antisocial
learning to avoid behaviors with un- parents are unlikely to effectively moni-
wanted or negative outcomes. A later tor their child’s behavior, set rules and
study, conducted under similar condi- ensure that they are obeyed, check on
tions but using a different experimental the child’s whereabouts, or steer them
task, showed that psychopaths had in- away from troubled playmates. How-
creased activation in the right temporal ever, having an antisocial child also may
lobe, suggesting that a malfunction in induce negative, neglectful responses in
this brain region could contribute to the parents (Bell and Chapman 1986).
fearlessness that characterizes psychopa- Individuals with ASPD are more likely
thy (Kiehl et al. 2004). than others to report histories of child-
Although research points to evidence hood abuse (Luntz and Widom 1994). In
of subtle structural and functional defi- some instances, abuse may become a
cits in the neural circuits that may help learned behavior that formerly abused
mediate antisocial behavior, their clinical adults perpetuate with their own chil-
significance remains unclear, and data dren, leading to an intergenerational cy-
interpretation is hampered by variation cle of abuse.
among the studies in terms of imaging
method and study population. None- Peer Relationships
theless, it is possible that frontal deficits Disturbed peer relationships are often
(prefrontal cortex and anterior cingulate overlooked as contributing to the de-
cortex) contribute to impulsivity, poor velopment of antisocial behavior (Black
judgment, and irresponsible behavior, 2013). Glueck and Glueck (1950) reported
whereas dysfunction in temporal re- that 98% of 500 delinquent boys had de-
gions (amygdala-hippocampal and su- linquent friends, compared with 7% of
perior temporal cortex) predisposes to 500 nondelinquent peers. The delin-
antisocial features such as inability to fol- quent boys were also more likely than
low rules and deficient moral judgment nondelinquent peers to report that they
(Yang et al. 2009). Taken together, these had been gang members (56% vs. 1%).
findings are suggestive of a link between This pattern of association (i.e., the “birds
cortical dysfunction and antisocial be- of a feather” phenomenon) usually be-
havior. gins during the elementary school years.
More recently, Juvonen and Ho (2008) Robins pointed out that improvement
found that youths who are attracted to can occur at any age.
antisocial peers often engage in antiso- Black et al. (1995a) followed 71 antiso-
cial behavior themselves to gain accep- cial men (mean age 54 years), who had
tance. These relationships can reward ag- been admitted to an academic hospital,
gressive behavior and encourage gang for a mean of 29 years after discharge. Of
membership. Gangs may be attractive to these individuals, 27% were rated as hav-
those who feel rejected by their families ing had remission of their antisocial be-
and peer group. havior, 31% as improved, and 42% as un-
improved. The men most likely to have
improved were the least deviant at base-
Media Influence line and were older at follow-up. The
Since the advent of television, media course for the men was compared with
depictions of violence have long been previously published data from the “Iowa
thought to foster the development of an- 500” study of individuals with schizo-
tisocial behavior. Huesmann and Taylor phrenia and depression, as well as nor-
(2006) concluded that exposure to media mal control subjects, all hospitalized at
violence is related to the development of the same facility (Black et al. 1995b). Anti-
violent behavior. It is thought that chil- social men fared less well than depressed
dren become desensitized to violence and subjects and control subjects in their mar-
learn to accept a more hostile view of the ital, occupational, and psychiatric adjust-
world. Those most vulnerable to the me- ment. They also functioned better than
dia onslaught appear to be those who al- people with schizophrenia in their mari-
ready live in a “culture of violence” where tal status and housing, but not in their oc-
there are few curbs against aggressive cupational status or aggregate psychiat-
behavior. It is not known whether vio- ric symptoms. In other words, they were
lent media depictions are a risk factor for more likely than persons with schizo-
ASPD or other antisocial syndromes. phrenia to be married and to have their
own housing, but they were just as likely
to perform poorly in the workplace and
Course and Outcome to have disabling psychiatric symptoms
(but not psychotic symptoms).
ASPD is a lifelong disorder with an onset The studies of Robins (1966) and Black
in childhood that is fully expressed by the et al. (1995a, 1995b) show that most dan-
late teens or early 20s. In a 30-year follow- gerous and destructive behaviors associ-
up of 82 antisocial persons originally seen ated with ASPD may improve or remit,
in a child guidance clinic, Robins (1966) yet other troublesome problems remain.
found that the disorder was worse early Older people with ASPD are less likely
in its course and that antisocial persons to commit crimes or become violent, al-
tended to improve with advancing age. though many remain troublesome to
She observed that at a mean age of 45 their families and the community. Some
years at follow-up, 12% of the subjects fail to improve at all. When improvement
had remitted (defined as no symptoms of occurs, it typically follows many years
ASPD) and another 20% had improved; of antisocial behavior that has stunted
the rest were as disturbed as (or more so the individuals’ educational and work
than) at study intake. The median age achievement, thus limiting their poten-
for improvement was 35 years, although tial achievement.
Marriage is another moderating vari- age 16 for 2 years. While in the refor-
able. In Robins’s (1966) study, more than matory, he slashed another boy with a
razor blade in a fight. Russell had his
half of married antisocial persons im-
first sexual experience before his
proved, but few unmarried persons did peers, and after leaving the reforma-
so. More recently, Burt et al. (2010) used tory, he had several different sexual
twin data to show that men with lower partners. He chain-smoked and ad-
levels of antisocial behavior were more mitted to abusing alcohol. An electro-
likely to marry and that those who mar- encephalogram was normal, and his
IQ was measured at 112. He was dis-
ried engaged in less antisocial behavior
charged from the hospital after a 16-
than their unmarried co-twin. These data day stay and was considered unim-
appear to confirm Robins’s (1966) obser- proved. He had been poorly coopera-
vation that marriage has a buffering ef- tive with attempts at both individual
fect on antisocial behavior and are largely and group therapy.
Russell was interviewed 30 years
consistent with those of the Gluecks
later. He used an alias and lived in an
(Sampson and Laub 1993), whose work impoverished community. Now age
linked job stability and marital attach- 48, Russell appeared ill and haggard.
ment with improvement. He admitted to more than 20 arrests
The following vignette demonstrates and more than five felony convic-
the continuity of antisocial behavior over tions on charges ranging from at-
tempted murder and armed robbery
time, the high frequency of co-occurring
to driving while intoxicated. He had
substance use disorders, and the toll spent more than 17 years in prison.
ASPD takes on individuals, society, and While in prison, Russell had escaped
family members (Black and Andreasen with the help of his biological mother,
2014, pp. 475–476). with whom he then had a sexual rela-
tionship. He was returned to prison 2
months later. His most recent arrest
Case Example occurred within the past year and was
Russell, age 18, was admitted for for public intoxication and simple
evaluation of antisocial behavior. His assault.
early childhood was chaotic and abu- Russell reported over nine hospi-
sive. His alcoholic father had married talizations for alcohol detoxification,
five times and abandoned his family the latest occurring earlier that year.
when Russell was age 6. Because his He admitted to past use of marijuana,
mother had a history of incarceration amphetamines, tranquilizers, cocaine,
and was unable to care for him, Rus- and heroin.
sell was placed in foster care until he Russell had never held a full-time
was adopted at age 8. His adoptive job in his life. The longest job he had
father was a university professor; his held lasted only 60 days. He was cur-
adoptive mother was described as rently doing bodywork on cars in his
compulsive and strict. own garage to earn a living but had not
Russell had a criminal streak from done any work for several months. He
early childhood. He lied, cheated at had lived in six different states and had
games, shoplifted, and stole money moved more than 20 times in 10 years.
from his mother’s purse. He once bur- Russell reported that nine persons
glarized a church and, when older, lived in his home, including his four
stole an automobile. Despite an above- children. He had met his common-
average IQ, Russell’s school per- law wife in a psychiatric hospital. She
formance was poor, and he was fre- used tranquilizers for emotional prob-
quently in detention for breaking rules. lems, and the marriage was unsatis-
Because of continued law breaking, he factory. He reported occasionally at-
was sent to a juvenile reformatory at tending Alcoholics Anonymous at a
local church but otherwise did not so- attention may help to pinpoint specific
cialize outside his family. learning or other cognitive deficits. Anti-
Russell admitted that he had not
social persons generally score about 10
yet settled down and told us that he
still spent money foolishly, was fre- points lower than people without ASPD
quently reckless, and got into frequent on traditional IQ tests and are also more
fights and arguments. He said that he likely to show evidence of learning dis-
got a “charge out of doing dangerous abilities (Moffitt 1993b). Understanding a
things.” patient’s specific learning disabilities
may help identify goals for therapy or re-
habilitation.
Assessment A medical history is helpful because
The patient’s history is key to diagnosing of the antisocial person’s tendency to en-
ASPD (Black 2013). The diagnosis is made gage in impulsive or risky behavior, which
on the basis of a history of chronic and re- places him or her at risk for accidental
petitive behavioral problems beginning in injuries, closed head injuries, and sexu-
childhood or early adolescence. Because ally transmitted diseases including the
antisocial individuals may not be forth- human immunodeficiency virus and
coming regarding their past symptoms, hepatitis C (Brooner et al. 1993). The pres-
family members and friends may be help- ence of tattoos has traditionally been as-
ful informants when available (and the sociated with ASPD. Even as their fre-
patient has consented to their participa- quency in the general population has
tion). Family members may be more accu- increased for men (26%) and women
rate in describing their relatives’ antisocial (22%), tattoos continue to be associated
behavior than the patients themselves with risk-taking behaviors, such as greater
(Andreasen et al. 1986). Records of previ- use of alcohol or other drugs and crimi-
ous clinic or hospital visits can provide nality (Laumann and Derick 2006). Tat-
important diagnostic clues. toos are especially prevalent in prison
Psychological tests can be helpful, par- populations, where they may have spe-
ticularly when a patient refuses to allow cial significance by indicating indi-
interviews with relatives or when infor- vidual or group identity (Cardasis et al.
mants are unavailable. The Minnesota 2008).
Multiphasic Personality Inventory Antisocial persons often die prema-
(MMPI), and subsequent revisions, yields turely from accidental deaths, suicides,
a broad profile of personality function- or homicides (Black et al. 1996; Robins
ing, and a certain pattern of results is typ- 1966). For that reason they should rou-
ical of ASPD (Butcher et al. 1989; Dahl- tinely be asked about suicidal ideations
strom et al. 1972; Tellegen et al. 2003). The and past suicide attempts.
PCL-R can be used to measure the pres-
ence and severity of psychopathic traits
and may be useful if the antisocial person Differential Diagnosis
is being assessed in a forensic setting
(Hare 1991). There are many structured The differential diagnosis of ASPD in-
interviews and paper-and-pencil ques- cludes other personality disorders (e.g.,
tionnaires that assess personality disor- borderline personality disorder, narcis-
ders in general, but they are mainly used sistic personality disorder), substance use
by researchers. Formal neuropsychologi- disorders, psychotic and mood disorders,
cal assessment of cognition, memory, and intermittent explosive disorder, and medi-
cal conditions such as temporal lobe epi- Most children experience episodes of ram-
lepsy (Black 2013). Chronic or intermit- bunctious behavior that can be accompa-
tent alcohol or drug use can contribute to nied by inappropriate language or de-
the development of antisocial behavior, structive acts. Similarly, many children
either as a by-product of the intoxication or adolescents engage in reckless behav-
itself or from the result of a drug habit ior, vandalism, or even minor criminal
that needs financial support. Psychoses activity such as shoplifting, often involv-
or bipolar disorder can also lead to vio- ing peers. Isolated acts of misbehavior are
lent or assaultive behavior and should be inconsistent with the diagnosis of either
considered as a cause of antisocial behav- conduct disorder or ASPD, which in-
ior. Psychotic patients occasionally com- volve repetitive misbehavior over time.
mit criminal offenses, but such behavior Adults with criminal or antisocial behav-
typically results from psychotic thought ior but no evidence of childhood conduct
processes. Intermittent explosive disor- disorder (e.g., a man who is involved in
der involves isolated episodes of assaul- organized crime following a conven-
tive or destructive behavior, but there is tional upbringing) have adult antisocial
usually no history of childhood conduct behavior (see “Other Conditions That
disorder or other features of ASPD, such May Be a Focus of Clinical Attention” in
as a pattern of chronic irresponsibility or DSM-5).
failure to honor obligations. Medical ex-
planations for antisocial behavior that
need to be ruled out include temporal Clinical Management
lobe epilepsy, which can cause random
outbursts of violence, and tumors or Few persons seek psychiatric care specif-
strokes, which could lead to personality ically for ASPD, yet in the ECA study al-
changes. most 20% of those with ASPD had sought
The differential diagnosis in children mental health care in the past year (Shap-
with conduct disorder includes opposi- iro et al. 1984). A more recent study from
tional defiant disorder, ADHD, autistic the United Kingdom showed that nearly
spectrum disorder, and psychotic and 25% of persons with ASPD had sought
mood disorders, all of which can be as- care (Ullrich and Coid 2009). Antisocial
sociated with sporadic verbal outbursts persons are prompted to seek care for co-
or physical assaults. Arguably the most occurring depression, substance misuse,
difficult aspect of diagnosis involves dis- or problems relating to marital malad-
tinguishing between conduct disorder justment, anger dyscontrol, or suicidal
and oppositional defiant disorder. The behavior (Black and Braun 1998), or they
child with oppositional defiant disorder are taken for evaluation by family mem-
is difficult and uncooperative, but his or bers or the legal system (e.g., forensic
her behavior generally does not involve evaluation).
outright aggression, destruction of prop- The mental health care needs of a per-
erty, theft, or deceit, as with conduct dis- son with ASPD can generally be ad-
order. A child with ADHD may be inat- dressed in outpatient settings via an array
tentive, hyperactive, or disruptive but of services (e.g., medication management,
usually does not violate the rights of oth- individual and family therapy). There is
ers or societal norms. generally little reason to psychiatrically
Both ASPD and conduct disorder are hospitalize antisocial persons, who can be
distinguishable from normal behavior. disruptive to the ward milieu (Black 2013).
The exception is when a person needs su- 1976), as well as bullying, fighting, and
pervision to provide a safe environment temper outbursts in aggressive children
because of recent (or imminent) suicidal (Campbell et al. 1995). The anticonvul-
behavior, recent violent or assaultive acts, sant phenytoin has been shown to reduce
or monitoring of alcohol or drug with- impulsive aggression in prison settings
drawal. (Barratt et al. 1991), whereas divalproex
has been found to reduce temper out-
bursts and mood lability in disruptive
Psychopharmacology youths (Donovan et al. 2000). Antipsy-
No drugs are routinely used for the treat- chotic medications have also been shown
ment of ASPD, and none have been ap- to deter aggression in adults as well as
proved by the U.S. Food and Drug Ad- youth with conduct disorder (Reyes et al.
ministration. Medications are sometimes 2006; Walker et al. 2003).
used “off-label” to treat antisocial persons, Other drugs, including carbamazepine,
generally for their aggressive behaviors valproate, propranolol, buspirone, and
and irritability, or co-occurring disorders. trazodone, have been used to treat ag-
The use of psychotropic medications gression primarily in brain-injured or in-
to treat ASPD was reviewed by the Na- tellectually disabled patients (Black 2013).
tional Collaborating Centre for Mental Response to medication is variable, and
Health (2009), commissioned by the Na- although some patients improve, others
tional Institute for Health and Clinical fail to improve at all. When improvement
Excellence (NICE) in the United King- occurs, it tends to be partial; improve-
dom. The review was unable to identify ment may only mean that the individual
any randomized controlled trials con- has fewer outbursts than before, or has a
ducted in persons with ASPD. The re- “longer fuse” giving him or her more
port concluded that the sparse evidence time to reflect before lashing out. Because
did not support the routine use of medi- these drugs target symptoms found in
cation for antisocial persons, but that ASPD, it is possible that they may be ef-
medication for co-occurring disorders fective in antisocial persons.
should be used according to guidelines As recommended by NICE (National
for the disorder in question (e.g., major Collaborating Centre for Mental Health
depression). NICE cautioned clinicians 2009), psychotropic medication can be
to be aware of the poor adherence, high targeted to treat co-occurring disorders.
attrition, and potential for misuse of pre- Mood and anxiety disorders are among
scription medication common to these the most common conditions accompa-
patients. Similarly, a Cochrane Database nying ASPD. These disorders may re-
review found that the body of evidence spond to treatment with antidepressant
was insufficient to allow conclusions or tranquilizing medications. Similarly,
about the use of drug treatments for bipolar patients with antisocial behavior
ASPD (Khalifa et al. 2010). can be treated with mood stabilizers, such
Nonetheless, several drugs have been as lithium carbonate, carbamazepine, or
shown to reduce aggression, a target valproate. Benzodiazepines should be
symptom of many antisocial persons, and avoided. They have the potential to in-
these may be helpful in select patients. crease “acting out” behaviors (e.g., ag-
Lithium carbonate has been reported to gressive outbursts), as has been shown
reduce anger, threatening behavior, and in patients with borderline personality
assaults in prison inmates (Sheard et al. disorder (Cowdry and Gardner 1988).
Furthermore, the drugs can be habit sonality disorders, patterned after those
forming and should be avoided in pa- created for the treatment of depression
tients prone to addiction, such as people or anxiety disorders. According to Beck
with ASPD. Stimulant medications can be et al. (2004), the goal of CBT is to “im-
used to reduce symptoms of co-occur- prove moral and social behavior through
ring ADHD. Caution should be used be- enhancement of cognitive functioning”
fore prescribing potentially addictive (p. 152). To achieve these aims, the ther-
stimulants such as methylphenidate or apist focuses on evaluating situations in
dextroamphetamine. Use of these agents which a patient’s distorted beliefs and
should be preceded by trials with non- attitudes may have interfered with in-
addicting alternatives such as bupropion, terpersonal functioning or in achieving
clonidine, or atomoxetine. goals. Once the patient has gained an
understanding of how he or she has con-
tributed to his or her own problems, the
Psychological Treatments therapist can help the patient to gradu-
According to NICE (National Collaborat- ally make sensible changes in his or her
ing Centre for Mental Health 2009) and thinking and behavior. Guidelines are
the Cochrane Database reviews, insuffi- set for the patient’s involvement, includ-
cient data are available to assess the value ing regular attendance, active participa-
of psychotherapy in persons with ASPD tion, and completion of homework out-
(Gibbon et al. 2010). Complicating these side of office visits. CBT may be helpful to
reviews is the fact that most studies re- persons with mild antisocial disorders
viewed involved participants other than who possess some insight and have rea-
those with ASPD. NICE identified one son to improve—for example, those who
randomized controlled trial involving risk losing a spouse or job if their behav-
subjects with ASPD: Davidson et al. (2009) ior is not controlled.
compared cognitive-behavioral therapy The CBT model described by Beck et
(CBT) with “usual care” in 52 antisocial al. (2004) for antisocial persons focuses
men but found no effect of CBT on anger on evaluating situations in which a pa-
or verbal aggression. Nonetheless, David- tient’s distorted beliefs and attitudes in-
son et al. (2010) reported, “The view from terfere with functioning or achieving
the ground...was that doing [CBT] was success. For example, unable to assess
helpful in reducing antisocial behaviours his actions critically, an antisocial man
and changing thinking” (p. 94). They rec- may attribute a history of work conflicts
ommended that therapists be aware of to unjust persecution or other factors be-
personal risks while carrying out therapy yond his control, never pausing to ex-
and be skilled at modifying session con- amine the consequences of his actions.
tent and their behavior to control levels of Working together, patient and therapist
“high affect.” Although this research and develop a problem list to help clarify prob-
other early data suggest that CBT can be lems and expose tensions, and to show
helpful, only larger and longer-term stud- how—and when—they interfere with
ies will reveal its true effectiveness. daily life. Once identified, cognitive dis-
Individual psychotherapy has long tortions that underlie each problem are
been used with antisocial patients, and systematically exposed and challenged.
CBT models, such as that employed by Some of the distortions most common to
Davidson et al. (2009), have been devel- ASPD, as outlined by Beck et al. (2004),
oped specifically for persons with per- include the following:
• Justification—the patient’s belief that aware of their own feelings and remain
his desires are adequate grounds for vigilant to prevent countertransference
his actions from disrupting therapy. No matter how
• Thinking is believing—a tendency to determined the therapist may be to help
assume that his thoughts and feel- an antisocial patient, it is possible that
ings are correct simply because they the patient’s criminal past, irresponsibil-
occur to him ity, and unpredictable tendency toward
• Personal infallibility—the idea that he violence may render him or her thor-
can do no wrong oughly unlikable. Mental health profes-
• Feelings make facts—the conviction that sionals should anticipate their emotions
his decisions are always right when and display an attitude of acceptance
they feel good without moralizing.
• The impotence of others—a belief that Those persons at the extreme end of
everyone else’s views are irrelevant the antisocial spectrum may be more dif-
unless they directly affect the patient’s ficult to engage in therapy. According to
immediate circumstances Hare (1993), the rigid personality struc-
• Low-impact consequences—the notion ture of psychopathic persons generally
that the results of his behaviors will resists outside influence. He has observed
not affect him that in therapy, many such persons sim-
ply go through the motions and may
Another therapy model for antisocial even learn skills that help them better
persons that has shown promise is men- manipulate others. Hare is particularly
talization-based therapy (MBT; Bateman skeptical of group therapy for these indi-
2013), which has a theoretical basis in at- viduals. There is no evidence, however,
tachment theory. Mentalizing is consid- that therapy makes psychopaths worse
ered a key component of self-identity and (D’Silva et al. 2004).
a central aspect of interpersonal relation- Although therapy may not help those
ships and social function. Developed for at the extreme end of the antisocial spec-
people with borderline personality disor- trum, Beck et al. (2004) point out that an-
der, the model has been adapted to focus tisocial people are unfairly labeled as
on the unique mentalizing problems of unable to profit from therapy, which they
ASPD, such as showing overcontrol of call the “untreatability myth.” Treatment
their “emotional states within well struc- may be challenging, but CBT is one ap-
tured, schematic attachment relation- proach that may help some antisocial
ships” (pp. 182–183). A subanalysis of persons develop the capacity to make
data from a trial of MBT in persons with appropriate decisions and get their lives
borderline personality disorder, some of on track.
whom had comorbid ASPD, showed that Alcohol and drug abuse are common
MBT was more effective than a control among antisocial persons and may aggra-
condition (Bateman 2013). vate antisocial symptoms. Once with-
Antisocial persons often possess traits drawal has been medically managed, the
that interfere with the process of psycho- patient can be referred to specialized treat-
therapy and make working with them ment program, the goal of which should
difficult; these traits include their ten- be abstinence. Antisocial individuals who
dency to be impulsive, blame others, abuse substances and who achieve absti-
and have difficulty in trusting others nence are less likely to engage in antisocial
(Strasburger 1986). Therapists must be or criminal behaviors, and also have fewer
family conflicts and emotional problems been demonstrated.

(Cacciola et al. 1996). Patients should be Family therapy may offer the best help
encouraged to attend meetings of Alco- for dealing with children with a conduct
holics Anonymous or similar organiza- disorder (Sholevar 2001). Treatment
tions (e.g., Narcotics Anonymous). Gam- should focus on enhancing parental man-
bling disorders also are common in those agement skills to improve communica-
with ASPD, and although few formal tion and to provide more effective and
treatment programs are available, antiso- consistent discipline. Parents can learn to
cial persons with these disorders should supervise the child more effectively, and
be encouraged to attend Gamblers Anon- to steer impressionable children away
ymous (Black 2013). from troubled peers. In these programs,
Antisocial people with spouses and parents also learn skills to help stop mis-
families may benefit from marriage and behavior before it escalates into violence,
family counseling. Allowing family mem- which may eventually help reduce their
bers into the process may help antisocial child’s risk for ASPD.
persons realize the impact of their disor-
der on others. Therapists who specialize
in family counseling may address the Conclusion
antisocial person’s difficulties in main-
taining enduring attachments, inability Antisocial behavior has been clinically
to be an effective parent, problems with recognized for over two centuries, is
dishonesty and irresponsibility, and an- common, and is disruptive to individu-
ger and hostility that can contribute to als, families, and society. There is a full
domestic violence (Dutton and Golant spectrum of severity ranging from psy-
1995). chopathic behavior at the severe end to
With juvenile offenders, treatment pro- milder adult antisocial behavior at the
grams that emphasize behavior modifica- other. Although antisocial behaviors im-
tion or skills training may produce mod- prove or even remit in some persons, the
est benefits and reduce recidivism (Lipsey majority of individuals with these be-
1992). Traditional counseling and deter- haviors have lifelong, recurrent behav-
rent strategies such as “shock” incarcera- ioral problems, including criminality.
tion have generally been unhelpful. With The cause of antisocial behavior is un-
shock incarceration, offenders receive stiff known, but it is likely that both genetic
sentences to “shock” them into improv- and nongenetic factors are involved in its
ing; once incarcerated, the sentence is re- development. There are no standard or
duced. “Scared straight” type programs, proven treatments. Several psychotropic
in which troubled youth visit prisons to medications, including anticonvulsants,
frighten them out of crime, are also un- lithium, and antipsychotics, have been
successful (Gibbons 1981). More recently, shown to reduce aggression and may
“boot camps” or “wilderness” programs benefit some antisocial persons. Phar-
have garnered attention; in an attempt to macological treatment should target co-
foster prosocial behavior, troubled youth occurring disorders such as major de-
are placed in isolated “camps” away from pression or bipolar disorder. Substance
negative influences for experiences that use disorders should be treated with the
foster bonding and trust with similarly aim of achieving abstinence; this may re-
disturbed kids. Whether these programs duce antisocial symptoms. CBT models
offer more than transitory benefit has not have been developed for antisocial per-
sons and may help those with milder Bell RQ, Chapman M: Child effect in studies
syndromes. Prevention strategies target- using experimental or brief longitudinal
approaches to socialization. Dev Psy-
ing troubled children may offer hope to
chol 22:595–603, 1986
parents and their troubled offspring. Black DW: Bad Boys, Bad Men: Confronting
Antisocial Personality Disorder (Sociop-
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C H A P T E R 21
Personality Disorders in
the Medical Setting
Randy A. Sansone, M.D.
Lori A. Sansone, M.D.
Patients with personality disor- recognition and use of the proposed

ders (PDs) are by nature inherently chal- techniques.
lenging. Perhaps they are even more so
in medical settings because of the murky
interface between psychiatric and medi- Prevalence Rates of
cal symptoms. In this chapter, we exam- Personality Disorders
ine these intriguing patients in the
context of the medical setting. We ini-
tially review the prevalence of PDs in General Population
the U.S. general population and in med- PDs are surprisingly commonplace in the
ical settings. We then discuss patient U.S. general population (see also Chapter
behavioral patterns in medical settings 6, “Prevalence, Sociodemographics, and
that are suggestive of personality dys- Functional Impairment,” this volume).
function as well as syndromes and diag- At present, the empirically determined
noses that may be encumbered with prevalence rate for any type of PD is at
higher than expected rates of personal- least 10% (Sansone and Sansone 2011a).
ity pathology. Finally, we propose man- As for the prevalence of specific PDs, the
agement techniques for these patients in National Epidemiologic Survey on Al-
both acute and longitudinal patient care cohol and Related Conditions, a robust
contexts. Although patients with PDs are study that was sponsored by the U.S. De-
undoubtedly challenging, we believe partment of Health and Human Services,
that most of these individuals can be the National Institutes of Health, and the
reasonably managed through effective National Institute on Alcohol Abuse and
The views and opinions expressed in this chapter are those of the authors and do not reflect the
official policy or position of the U.S. Air Force, Department of Defense, or U.S. government.
455
Alcoholism, examined rates of each per- et al. 2000). As for patients seen in a spe-
sonality dysfunction in the U.S. general cialized medical setting, using two mea-
population. Findings indicated that ob- sures for BPD among patients undergo-
sessive-compulsive PD was most coming evaluation for cardiac stress testing,
mon (7.8%; Grant et al. 2012), followed by we encountered a rate of 8.8% (i.e., con-
narcissistic PD (6.2%; Stinson et al. 2008) firmed as being positive on either mea-
and borderline PD (BPD) (5.9%; Grant et sure) (Sansone et al. 2011a).
al. 2008). Importantly, the sum of the in-
dividual rates for these three PDs alone
exceeds the estimated overall rate in the Personality Disorders
general population, indicating that a and Comorbidity
number of individuals harbor more than
one PD. Of the PDs recognized in DSM-5 Loadings in Medical
(American Psychiatric Association 2013), Settings
BPD has undergone the most empirical
research—in the general population, in Personality dysfunction in the medical
mental health settings, and in medical setting is frequently accompanied by
settings. some type of comorbidity, either psychi-
atric or somatic. As for comorbid major
Medical Settings psychiatric disorders, mood and/or anx-
iety syndromes are fairly common. As for
The prevalence of PDs in various types of somatic comorbidity, indistinct or ambig-
medical settings is underresearched, but uous medical symptoms (e.g., medically
individuals with personality dysfunc- unexplained symptoms) are frequently
tion are not uncommon and are frequently encountered. Therefore, multiple clinical
identified by clinicians as “difficult pa- phenomena, psychiatric and/or medical,
tients.” To our knowledge, no extensive are likely to be reported by individuals
large-scale study has simultaneously ex- with personality dysfunction.
amined rates of several PDs within a sin- In individuals with personality dys-
gle or combined group of primary care function and comorbid symptoms, it ap-
patients. pears that each symptom complex rein-
With regard to the examination of a forces the intensity of the other symptom
single PD in a medical setting, Gross et complex(es) (i.e., a bidirectional phenom-
al. (2002) explored the prevalence of BPD enon). Specifically, personality pathology
among internal medicine outpatients in appears to intensify comorbid major psy-
a private-practice setting and determined chiatric disorders and medical symptoms
a rate of 6.4%. We have previously exam- (medically explainable or not), and vice
ined rates of borderline personality symp- versa. Given this impression of bidirec-
tomatology among internal medicine tionality or the mutual exacerbation of
outpatients seen predominantly by resi- symptoms, it is also reasonable to assume
dent physicians; in this particular clinic, that treating one disorder will alleviate, at
there is a large proportion of indigent in- least to some degree, the symptom inten-
dividuals as well as high rates of govern- sity of the other disorder(s). Likewise,
ment-sponsored insurance. Using self- responses to treatment may be robust if
report measures, we have encountered the medical condition itself (e.g., endo-
rates for borderline personality symptom- crinopathy) or administered drugs ac-
atology between 18% and 25% (Sansone count for a significant portion of the pa-
Personality Disorders in the Medical Setting 457
tient’s personality changes (Dhossche

and Shevitz 1999). Patient Behavioral
Patterns Associated
Possible Models for the With Personality
Relationship Between Pathology
Personality Dysfunction Patients in medical settings may display
and Medical Symptoms a number of behaviors, discussed in the
following subsections, that are suggestive
Given that a substantial proportion of in- of personality pathology. When these be-
dividuals with PDs in medical settings haviors are clinically present, the clini-
evidence some type of somatic symp- cian should consider an assessment for
tom, what might be the functional rela- personality pathology. The longitudinal
tionship between personality dysfunc- nature or pervasiveness of these behav-
tion and somatic symptoms? From our iors is particularly indicative of the pres-
experience, two associations appear pre- ence of personality dysfunction. In other
dominant. First, PD symptoms may sim- words, the presence of repetitive or long-
ply function as the interpersonal me- standing patterns with regard to any of
dium through which bona fide medical these behaviors supports the diagnosis
symptoms are expressed (e.g., a diabetic of personality pathology, whereas novel
patient who exhibits noncompliance be- fleeting behaviors are more likely due to
cause of antisocial PD). In other words, contemporary psychosocial stressors,
the two entities coexist and interface but medications, and/or the illness itself.
somewhat separately. Alternatively, PD Importantly, the most problematic PDs
symptoms may complexly meld with in the medical setting appear to be those
medical symptoms in such a way that the characterized by disinhibition in general
PD symptoms appear to express them- and impulsivity in particular (designated
selves directly through the medical symp- as the Cluster B PDs). In contrast, some
toms (e.g., an obese individual with types of personality pathology may ac-
BPD, who experiences the fundamental tually be advantageous with regard to
self-regulatory disturbances encountered medical management, such as obsessive-
in this type of personality dysfunction compulsive PD. Other PDs may be en-
and whose excessive calorie ingestion countered very infrequently by medical
manifests as new-onset diabetes). These personnel (e.g., schizotypal or avoidant
proposed relational models do not ex- PDs). Therefore, much of the following
clude other possible models. In terms of material focuses on those PDs that are
treatment approach and outcome, the most challenging in the medical set-
implications of these two proposed ting—namely antisocial, narcissistic,
models are presently unknown. and borderline PDs.
Noncompliance With tion medication misuse and personality

dysfunction has been infrequently un-
Medications and/or dertaken.
Treatment In two studies, one a compilation of
multiple databases and the other a con-
Given that a number of PDs are charac- secutive sample of 419 internal medicine
terized by the temperamental features of patients, we confirmed relationships be-
disinhibition and impulsivity (e.g., bor-
tween the self-reported misuse of pre-
derline and antisocial PDs), it is not sur- scription medications and borderline
prising that patient noncompliance with personality symptomatology (Sansone
medications and/or other treatment is
and Wiederman 2009a; Sansone et al.
associated in the empirical literature with 2010a). Although the reasons for patient
personality dysfunction (Dhossche and misuse of prescription medications in
Shevitz 1999; Meyer and Block 2011).
these two studies remain unclear, expla-
From a psychodynamic perspective, non- nations may include sensation seeking,
compliance with medications and/or blocking traumatic memories, and/or
other treatment may function as a means
experimenting with self-harm behavior.
to create medical instability, and thereby
justify repetitive and ongoing contact with
the health care provider and/or treatment Aggressive and/or
team. This is a particularly salient psy- Disruptive Behaviors
chodynamic among individuals with
BPD. Noncompliance may also be a mani- in the Medical Setting
festation of underlying self-regulation A number of authors have indicated that
difficulties (e.g., BPD) and/or rebellion aggressive and/or disruptive behav-
against authority (e.g., antisocial PD). iors by patients are a potential behav-
Overall, when noncompliance is not re- ioral marker of personality dysfunction
lated to forgetfulness, cognitive changes, (Dhossche and Shevitz 1999; Meyer and
or finances, the consideration of person- Block 2011; Sansone et al. 2011b), particu-
ality dysfunction is warranted. larly in patients with borderline, narcis-
sistic, and/or antisocial PDs. Although
Abuse of Prescription various aggressive and/or disruptive be-
haviors have been noted in the clinical lit-
Medications erature, such as refusing treatment, angry
According to findings of the National Sur- outbursts that are grossly out of propor-
vey on Drug Use and Health, 7% of com- tion to the situation, and/or pressuring
munity participants reported the misuse demands or intimidation, little empirical
of prescription medications during the research has been undertaken to examine
month preceding the survey (Substance the range of these behaviors.
Abuse and Mental Health Services Ad- In an effort to clarify the range of poor
ministration 2008). Clearly, misuse of pre- patient conduct in medical settings, we
scription medication is a common and explored in a survey of internal medicine
disturbing problem in the United States. outpatients the prevalence of 17 disrup-
This particular behavior is often clinically tive behaviors as well as their relation-
associated with borderline and/or anti- ship to borderline personality symptom-
social PDs. However, empirical examina- atology (Sansone et al. 2011b). We found
tion of the relationships between prescrip- that the number of different types of dis-
ruptive office behaviors reported by par- amined a compiled sample of databases

ticipants was statistically significantly and scrutinized the subsample that con-
correlated with both self-report measures sisted of internal medicine outpatients
for BPD used in this study. Compared only (n=332) (Sansone and Wiederman
with participants without borderline per- 2009c). In this subsample, 16.7% of partic-
sonality symptomatology, patients with ipants acknowledged intentionally mak-
such symptoms were significantly more ing medical situations worse, and this
likely to report yelling, screaming, verbal phenomenon demonstrated a statistically
threats, and/or refusing to talk to medical significant relationship with the measure
personnel, as well as talking disrespect- for borderline personality symptomatol-
fully about medical personnel to both ogy that was used in this study.
family and friends (Sansone et al. 2011b). In addition, we recently examined a
Although these behaviors are clearly in- peculiar variation of making medical situ-
timidating and demoralizing for treat- ations worse—the intriguing behavior of
ment-providers as well as disruptive to exercising an injury on purpose (San-
the patient-clinician environment, they sone and Wiederman, in press). To do so,
are not necessarily life-threatening to the we compiled four databases to enhance
clinician. the overall sample size (the resulting
sample comprised 1,511 internal medi-
Intentional Sabotage cine outpatients). We found that 2.9% of
participants reported having intention-
of Medical Care ally exercised an injury “on purpose.” As
Intentionally sabotaging one’s own medi- expected, there were significant statisti-
cal care is a phenomenon that has been cal correlations between the endorsement
recognized for some time, through clini- of this behavior and scores on two self-re-
cal experience as well as occasional case port measures for BPD, suggesting that
reports and small empirical studies of fac- exercising an injury on purpose may be
titious disorder. However, links between an unusual and covert variant of self-harm
medical sabotage and specific types of behavior.
personality pathology have only recently Preventing wounds from healing—
been clarified. A prime PD contender for another form of medical self-sabotage—
the intentional sabotage of one’s own has been empirically investigated in re-
medical care is BPD, because this type of lation to personality dysfunction. At the
behavior may function as a self-injury outset, the idea of preventing wounds
equivalent (Sansone and Sansone 2012b). from healing is somewhat disconcerting,
However, antisocial PD cannot be ex- but the phenomenon is not particularly
cluded, particularly if the intent of medi- rare in clinical populations. For exam-
cal sabotage serves some illicit purpose ple, we have found modest prevalence
such as the procurement of narcotic anal- rates in various types of clinical sam-
gesics with an intent to sell them. ples (i.e., between 0.8% in cardiac-stress-
In addition to factitious disorder, an- test patients and 4.2% in internal medi-
other form of medical self-sabotage is in- cine outpatients) (Sansone and Sansone
tentionally making medical situations 2012b). With regard to links to personal-
worse. We have confirmed relationships ity pathology, in a consecutive sample of
between intentionally making medical internal medicine outpatients, an obstet-
situations worse and borderline person- rics-gynecology sample, and a sample of
ality symptomatology. Explicitly, we ex- four compiled databases, we consistently
found statistically significant relation- sider the “Headlines Test”—that is, how
ships between intentionally preventing the clinician’s behavior would appear to
wounds from healing and borderline the public if it were publicized in the head-
personality symptomatology (Sansone lines of the local newspaper (see also
and Wiederman 2009b; Sansone et al. Chapter 17, “Boundary Issues,” in this
2010a, 2012c). This association may be volume).
the manifestation of the borderline pa-
tient’s intense needs to be taken care of.
Excessive Health Care
Boundary Issues Utilization Patterns
With time and experience in the clinical Health care utilization and high health
setting, clinicians gradually discern the care costs are contentious issues in to-
range of appropriate behaviors that are day’s fiscal climate. Not surprisingly, per-
acceptable in the clinician-patient rela- sonality pathology is one of the various
tionship. As expected, this range of sanc- contributory variables to high health care
tioned behaviors corresponds to an as- costs. In support of this contention,
sociated set of interpersonal boundaries available empirical data indicate that
as well. Unfortunately, individuals with patients with PDs tend to be high utiliz-
PDs (e.g., narcissistic and/or borderline ers of health care services. For example,
PDs) often have intense needs to disrupt in a study by Hueston et al. (1999), pa-
these professional boundaries—perhaps tients in a designated high-risk category
to be uniquely “known” by the clinician, (i.e., individuals suffering from one or
to be perceived as “the special patient” in more of four specific PDs: borderline, de-
the medical setting, and/or to be “loved.” pendent, schizotypal, and schizoid PDs)
These intense needs by the patient can, were compared to patients without PDs.
at times, manifest as overtly inappropri- The former cohort was found to have
ate behaviors and may include sexual significantly higher rates of outpatient,
innuendos, provocative clothing and/or emergency room, and inpatient visits for
body displays, awkward solicitations somatic concerns during the preceding
for social outings, inappropriate or pre- 6 months.
mature addressing of the clinician by In a study of 389 internal medicine
first name, excessive or expensive gift outpatients, we examined relationships
giving, and/or requests for special ser- between physician utilization patterns
vices or “favors.” Clinicians need to be and borderline personality symptom-
extremely wary of inappropriately reso- atology (Sansone et al. 2011c). Accord-
nating with these types of boundary vi- ing to our findings, over the preceding
olations, because to do so may lead to 5 years, participants with borderline
further deterioration in the boundaries personality symptomatology were sig-
of the professional relationship (i.e., an nificantly more likely to see a greater
escalating need by the patient for repeated number of primary care physicians and
affirmations). These boundary distur- specialists compared with participants
bances may ultimately culminate in cli- without this personality dysfunction. In-
nician entrapment and/or legal conse- deed, we have consistently found that
quences. When the clinician is unsure compared to patients without borderline
about how to respond to a patient’s pro- personality symptomatology, those with
vocative behavior, he or she should con- such personality pathology consistently
evidence higher rates of health care uti- do not exclude other contenders, such as
lization in the primary care setting, in- narcissistic PD.
cluding a greater number of office visits In empirical support of the relation-
and documented prescriptions (Sansone ship between substance use disorders
et al. 1996a, 1998a), more contacts with and BPD, we found in a review of the ex-
the treatment facility (e.g., telephone calls) tant data that there were four studies de-
(Sansone et al. 1996a), and more frequent noting lifetime prevalence rates of sub-
referrals to specialists (Sansone et al. stance misuse in patients with BPD; the
1996a). Clearly, personality pathology is averaged prevalence rate was 64% (San-
a significant contributory factor to the sone and Sansone 2011c). This averaged
high cost of health care. percentage indicates that approximately
two-thirds of patients with BPD have
experienced substantial substance use
Possible Diagnostic problems at some point during their life-
times—this is an astounding rate. Pre-
Patterns Associated ferred substances in the medical setting
With Personality commonly include benzodiazepines,
opiates, and stimulants (Dhossche and
Pathology Shevitz 1999).
Prescription substance misuse is a pe-
Given the preceding sampling of patient
culiar variant of substance use disorder.
behaviors that suggest underlying per-
We previously presented in this chapter
sonality pathology, we next discuss syn-
the relationship between the abuse of
dromes and diagnoses that may be ei-
prescription medications and BPD (see
ther suggestive of or highly associated
“Patient Behavioral Patterns Associated
with personality dysfunction. As a ca-
With Personality Pathology”). In this sec-
veat, these syndromes and diagnoses are
tion, we underscore prevalence rates and
only suggestive and not confirmatory of
gender patterns. In a study of 419 internal
personality dysfunction. Specifically, not
medicine outpatients, we found that 9.2%
every patient who harbors these types of
of participants reported the past abuse of
symptoms suffers from personality dys-
prescription medications (Sansone et al.
function. Likewise, not every individual
2010a). Surprisingly, we found no differ-
with a PD displays these types of symp-
ences in prescription medication misuse
toms. However, these diagnostic patterns
when comparing men and women (i.e.,
may be the impetus for evaluating the pa-
this finding is notable in that men are tra-
tient’s personality functioning in a more
ditionally more likely than women to
formal manner.
abuse alcohol and illicit substances) (San-
sone et al. 2010b). Therefore, either sex is
Alcohol and Substance likely to engage in the misuse of prescrip-
tion medications.
Use Disorders
Substance use disorders are rampant in Multiple Somatic
the United States. In terms of the associ-
ated personality pathology, the abuse of Complaints
substances by individuals with border- A number of investigators have noted
line and/or antisocial PD is clinically well associations between multiple somatic
known. However, these identified PDs complaints and antisocial and/or border-
line PDs. Interestingly, much of the ear- in which patients presented with somatic
lier empirical work on the intersection symptoms.
between somatic complaints and person- In addition to the clinical observations,
ality dysfunction focused on somatiza- empirical research has confirmed rela-
tion disorder, a very narrowly defined tionships between somatic preoccupation
subset of multiple somatic complaints and personality pathology, specifically
(e.g., diagnosis according to DSM-IV BPD. Lloyd et al. (1983) examined the psy-
[American Psychiatric Association 1994] chological test responses of patients with
required eight somatic symptoms in four BPD and confirmed a proneness to re-
distinct categories). However, more reporting somatic complaints. We exam-
cent empirical work has focused on so- ined 120 internal medicine outpatients
matic preoccupation (i.e., the presence of with regard to somatic preoccupation and
multiple somatic symptoms, without borderline personality symptomatology,
category specificity), which, when ac- and found a moderate statistical correla-
companied by maladaptive thoughts, tion (Sansone et al. 2000). We repeated this
feelings, and behaviors, is called somatic study in a sample of 116 internal medicine
symptom disorder in DSM-5. outpatients and found statistically signif-
Several researchers have found rela- icant correlations between these variables
tionships between formal somatization in the moderate to high range (Sansone et
disorder and PDs. Smith et al. (1991) pro- al. 2008). Finally, in a study using path
vide a persuasive summary on the rela- analysis among family medicine outpa-
tionship between somatization disorder tients, we again found evidence for a rela-
and antisocial PD. Using a diagnostic in- tionship between somatic preoccupation
terview, Prasad et al. (1990) identified a and borderline personality symptomatol-
subset of patients with BPD and comor- ogy (Sansone et al. 2001). In these three
bid somatization disorder. Likewise, Hud- previous studies, we used the Bradford
ziak et al. (1996) examined the prevalence Somatic Inventory (Mumford et al. 1991)
of somatization disorder among a sample for the assessment of somatization.
of patients with BPD and confirmed a To further confirm a relationship be-
rate of 36%. Finally, Spitzer and Barnow tween somatic preoccupation and bor-
(2005) described a distinct relationship derline personality symptomatology, we
between somatoform disorders and BPD. undertook a final project using a 35-item
In contrast to somatization disorder, medical review of systems for the assess-
somatic preoccupation (i.e., excessive so- ment of somatic preoccupation in a sam-
matic complaints) is a broader and more ple of 381 internal medicine outpatients
clinically widespread phenomenon, par- (Sansone et al. 2011d). In keeping with
ticularly in primary care settings. Since our previous findings, the total number
the 1980s, a number of authors have de- of symptoms endorsed on the medical
scribed clinical relationships between review of systems was positively corre-
somatic preoccupation and BPD. For ex- lated with scores on both measures of
ample, Schreter (1980–1981) reported a borderline personality symptomatology
relationship between chronic somatic (Personality Diagnostic Questionnaire–4
symptoms and BPD; Giovacchini (1993) [Hyler 1994]; Self-Harm Inventory [San-
described a subset of borderline pa- sone et al. 1998b]). In addition, the per-
tients with a psychosomatic focus; and centages of participants with borderline
Janssen (1990) reported two cases of BPD personality features increased as the num-
ber of endorsed symptoms increased. In samples of individuals with various types

this study, no individual symptom or of chronic pain syndromes (Sansone and
symptom pattern was particularly evi- Sansone 2012a). We encountered eight
dent among participants with BPD fea- studies since 1994 and found that the av-
tures. In other words, there was no explicit erage prevalence rate for BPD among
symptom profile suggestive of BPD— these samples was 30%. We also discov-
somatic symptoms were panoramic and ered in this review that individuals with
diverse. BPD reported higher levels of pain than
What might be the psychodynamic participants without BPD; older individ-
function of multiple somatic complaints uals with BPD, rather than younger indi-
in patients with PDs? A likely explana- viduals, were more likely to report higher
tion is the elicitation of caring responses pain levels; and the first-degree relatives
from others, without the fear of rejection of participants with BPD demonstrated
or interpersonal vulnerability entailed statistical coaggregation with somatoform
in negotiating a relationship in a more pain disorder. Unexpectedly, we also
naturalistic manner. Somatic symptoms found that the prevalence of medical dis-
may also function to maintain and sustain ability did not substantially differ among
an interpersonal connection with the chronic-pain participants with versus
health care provider, as in patients with without BPD.
borderline personality symptoms, as well Chronic pain and the use of narcotic
as to reinforce a dysfunctional and self- analgesic prescriptions represent a unique
defeating lifestyle (e.g., the “victim” role clinical dilemma, particularly in the pri-
in BPD). mary care setting. In the current practice
climate, clinicians are compelled to screen
patients about current pain levels. How-
Chronic Pain Syndromes ever, contemporary pain assessments
Chronic pain is a globally complex issue, are limited to the use of subjective tools,
including its relationship with personal- such as visual analog scales (e.g., a row
ity dysfunction. In the context of PDs, of 10 faces, transitioning from a smiling
chronic pain may be the psychodynamic face representing no pain to a frowning
outgrowth of magnification, helpless- face representing the highest level of
ness, and/or rumination (i.e., alterations pain). These imprecise approaches to
in the actual perception and/or experi- pain assessment may unintentionally in-
ence of pain); the inability to effectively vite the overendorsement of pain com-
self-regulate pain; a covert attempt to elicit plaints by patients with characterological
caring responses from health care profes- problems. Recognizing that patients are
sionals; a means of maintaining a disabled not to suffer in pain, clinicians may pre-
status (i.e., a self-defeating lifestyle); scribe unwarranted analgesics and/or
and/or a means of procuring prescrip- overtreat pain in patients with personal-
tion medications for illicit purposes. Be- ity pathology. This clinical response may
cause of these varying factors, chronic lead to the patient’s subsequent addiction
pain syndromes may encompass a num- or demise through intentional or unin-
ber of different types of individuals with tentional overdose. In these cases, screen-
personality dysfunction, especially boring for and confirming character pathol-
derline and antisocial PDs. ogy may indicate the need for careful
Through a review of the literature, we patient follow-up, contracts with the pa-
examined the prevalence of BPD among tient, small prescriptions, low to moder-
ate doses rather than high doses of anal- Hair Pulling

gesics, and frequent reevaluation.
Hair pulling, or trichotillomania, may be
clinically conceptualized as a disorder re-
Case Example lated to either compulsive behavior (i.e.,
Janet, a 54-year-old white female who an obsessive-compulsive spectrum dis-
was diagnosed with chronic low back
order) or impulsive behavior. Individu-
pain and fibromyalgia, was seen by
her primary care physician for unre- als in the impulsive category may suffer
lenting back pain. Because of Janet’s from a disinhibited temperament in the
poor response to treatment, the pri- impulsive spectrum, such as BPD. In the
mary care physician referred the pa- specific context of BPD, hair pulling may
tient to a pain management special- be viewed as a self-injury equivalent.
ist, who evaluated the patient.
To explore the relationship between
The pain management specialist
initiated with the patient a conserva- hair pulling and borderline personality
tive pain treatment regimen in con- symptomatology, we undertook two sep-
junction with a strict pain management arate studies. In the first study, we exam-
contract that included the proviso ined 379 internal medicine outpatients
that all pain medications be prescribed
and found a prevalence rate for self-re-
only through the pain management
specialist. However, the treatment reported hair pulling of 2.9% (Sansone et
sponse by the patient remained only al. 2012c). Statistical analyses indicated
moderate, and the pain management significant associations between hair
specialist recommended a referral to pulling and two self-report measures for
an anesthesiologist/pain specialist for borderline personality pathology. In a
injection therapy. Janet agreed to the
second study, we examined women in an
referral and underwent the recom-
mended injections. However, imme- obstetrics-gynecology clinic, using the
diately following the injections, the same query for hair pulling and the same
patient reported excessive pain at the two self-report measures for BPD (San-
injection site, and the anesthesiolo- sone et al. 2012a). In this study, 7.2% of
gist/pain specialist prescribed 160 tab-
participants reported hair pulling, and,
lets of hydrocodone after each injec-
tion. When this additional prescribed as in our previous study, this behavior
medication was discovered by the pain was statistically significantly associated
management specialist, he promptly with both self-report measures for BPD.
terminated his professional relation-
ship with the patient.
This action resulted in a fracas be-
Obesity
tween the two pain specialists and the Although obesity is clearly a multideter-
primary care physician, until a psy- mined condition, one relevant contribu-
chiatrist was consulted, evaluated the
tory variable may be personality pathol-
patient, and informed the other phy-
sicians that the patient suffered from ogy—particularly personality pathology
BPD and was highly prone to split- of an impulsive nature, such as BPD and
ting and medication misuse. With this associated overeating behavior. Through
clinical information, the two pain spe- a review of the literature, we encountered
cialists tightened and coordinated
nine studies on the prevalence of BPD
their management styles, particularly
with regard to medications, and the among individuals with obesity (Sansone
patient clinically improved. and Sansone 2013). The earliest was pub-
lished in 1989, sample sizes varied from
17 to 150 individuals, and five of the nine
studies were from bariatric surgery sites.
Participants were mostly women, and so- sexual behaviors in BPD, we found that
cioeconomic status was highly varied. various authors have reported among
The averaged prevalence rate of all mea- such patients 1) greater sexual preoccu-
sures for BPD in these various samples, pation as well as sexual dissatisfaction;
some of which included multiple mea- 2) greater promiscuity in the presence of
sures of BPD, was 27%. Note that this substance abuse; 3) a higher number of
percentage is 4.5 times the rate of BPD en- casual sexual relationships; 4) more fre-
countered in the general population. Be- quent high-risk sexual behaviors; 5) a
cause more than half of these samples higher prevalence of sexually transmit-
were from bariatric surgery sites, where ted diseases; 6) a higher number of homo-
assessments were undertaken prior to the sexual experiences; 7) earlier sexual ex-
surgery, it is likely that a meaningful pro- periences; 8) a greater likelihood of date
portion of participants underreported rape; 9) an overall greater number of sex-
symptoms (e.g., self-mutilation, suicide ual partners; and 10) a greater likelihood
attempts, alcohol/substance abuse) in or- of experiences with sexual coercion (San-
der to secure the surgery, regardless of sone and Sansone 2011b).
whether such disclosure would have pre- In our review (Sansone and Sansone
cluded the surgery. Although the nature of 2011b), we included our three studies in
the association between obesity and BPD the area of sexual behavior and BPD. In
is speculative (e.g., assuming that they the first study, we examined 76 women in
share mutual self-regulation difficulties), an internal medicine outpatient setting
there is clearly an association. and found that those with borderline per-
From a developmental perspective, it sonality symptomatology reported ear-
is highly likely that the presence of in- lier sexual experiences as well as higher
herent self-regulation difficulties as en- rates of date rape. In the second study,
countered in BPD may be a contributory which consisted of a compiled database,
factor to the development of obesity. It is we found that participants with border-
also likely that the treatment of mental line personality symptomatology from
health problems with weight-inducing nonpsychiatric settings were twice as
psychotropic medications contributes to likely to endorse casual sexual relation-
weight gain in individuals with BPD. In- ships (a lack of familiarity with partners)
deed, in partial support of this latter im- as well as promiscuity (multiple sexual
pression, it is evident that the rate of BPD partners) than participants without these
among obese individuals in mental health symptoms. In a third study of 354 internal
settings is higher than among those in medicine outpatients, we found that par-
primary care settings. ticipants with borderline personality fea-
tures reported twice the number of differ-
Promiscuity and Sexually ent sexual partners than participants
without this personality dysfunction.
Transmitted Diseases Findings generally indicate that individ-
Impulsive sexual behavior, which may uals with BPD appear to have more sex-
lead to sexually transmitted diseases as ual experiences, a greater number of sex-
well as unplanned pregnancies, may also ual partners, and a broader range of
be associated with personality dysfunc- sexual experiences. This conclusion may
tion, particularly borderline and antiso- clinically manifest in higher rates of sexu-
cial PDs. In a review of the literature on ally transmitted diseases.
Multiple Allergies interpersonal and intrapsychic purposes

as well as foster a self-defeating life-
to Medications style—without the threat of diagnostic
Patients with personality pathology ap- exposure.
pear to have a greater number of self-
reported allergies than patients without
personality dysfunction. These reactions Psychiatric
tend to fall into three broad categories: Consultation
1) genuine allergic reactions, 2) exagger-
ated adverse reactions to medication, and Given the preceding preamble regarding
3) unusual idiosyncratic reactions that are patient behaviors and syndromes/diag-
novel and at times bizarre (e.g., numbness noses that may be associated with per-
over the dorsal aspect of the left foot). sonality dysfunction, we now discuss
Therefore, reported allergies may be gen- psychiatric assessment and management
uine, or partially or fully influenced by from the perspective of psychiatric con-
personality dysfunction. Contributory sultation. We divide the consultation ap-
factors to the high numbers of reported al- proach into acute and longitudinal pa-
lergies among individuals with PDs may tient-care situations.
include excessive exposure to medica-
tions due to multiple somatic complaints; Acute Patient-Care
hypervigilance to the side effects of medi-
cation due to trauma dynamics, as in BPD; Situation
attention-seeking behavior as in narcissis- Clinicians will at times be asked to con-
tic PD; and/or underlying needs by the sult on patients with PDs who are being
patient to be unique and exotic. acutely treated in the hospital or emer-
gency room. In these pressing circum-
Medically Unexplained stances, the consultant’s emphasis is on
the acute and immediate management
Symptoms of the patient in order to accomplish the
Medically unexplained symptoms and medical task rather than an ongoing psy-
their association with personality pathol- chotherapeutic approach to the patient’s
ogy are well known to primary care phy- personality dysfunction.
sicians. However, the extant empirical
literature on this association is minimal, Assessment
and we were not able to locate any stud- At the outset of the assessment, the clini-
ies on the relationship between medi- cian should identify and document the
cally unexplained symptoms and bona patient’s explicit problem behaviors by
fide PDs. On a speculative note, it may providing graphic examples in the medi-
be that syndromes with indistinctly de- cal record (i.e., rather than using general
fined diagnostic criteria (e.g., chronic fa- descriptions such as “aggressive and dis-
tigue syndrome), easily replicable crite- ruptive,” the clinician should vividly de-
ria (e.g., attention-deficit/hyperactivity scribe patient behaviors, such as “the pa-
disorder), and no confirmatory diagnos- tient threw a chair against the wall while
tic tests (e.g., fibromyalgia) attract indi- screaming obscenities such as...”). The
viduals with personality pathology. In clinician should then determine whether
this way, affected individuals can read- acute nonpsychological factors might
ily assimilate somatic pathology for both be contributing to the patient’s unaccept-
able behavior, such as acutely adminis- avoiding the use of benzodiazepines, be-
tered medications, exposure to illicit cause these medications can result in dis-
drugs, or uncontrolled medical condi- inhibition in some patients, particularly
tions (Dhossche and Shevitz 1999). The those with character pathology.) It may
assessment should next entail a clinical also be crucial to clear up any distortions
screen of the patient for any contributory in communication between patient and
major psychiatric disorders (e.g., a psy- staff (Norton 2000). In addition, if the pa-
chotic or bipolar disorder). Following tient is directing detrimental commen-
this, the consultant should consider the tary to specific staff members, these indi-
assessment of personality pathology. viduals need to be informed to deflect the
During this portion of the assessment, negative content on a personal level, de-
symptom duration may help clarify the spite the very personal intent by the pa-
role of PD. To substantiate duration, a tient (Pare and Rosenbluth 1999). Finally,
history from the family may be necessary. the consulting clinician may need to rein-
Long-standing patterns of problematic force boundaries between the patient and
behavior suggest personality pathology, staff (Devens 2007), which may entail the
whereas acute behavioral changes sug- reassignment of the patient to another
gest contemporary influences. In certain provider or nursing staff member, or
circumstances, examination of the effects even transferring the patient to another
of the patient’s behavior on the clinician medical service or to a mental health fa-
and staff may be indicated, particularly if cility. The key strategy during the acute
there appears to be evidence of severe consultation is to quickly assess the situa-
manipulation, intimidation, or splitting. tion, and review and suggest available
Throughout the assessment, the consult- options for intervention. (On a side note,
ing clinician should at all times take rea- if any adjunctive major psychiatric disor-
sonable precautions with patients who are ders are present, these may be addressed
emotionally escalating toward a “melt- through recommendations for psychotro-
down” with either self-injurious behav- pic medications and/or psychotherapy,
ior or violence (e.g., the clinician should although results may not be apparent for
use a verbal approach that is calming, weeks or longer and may not benefit the
maintain an appropriate distance from acute situation.)
the patient, leave an open door at all By focusing in acute patient-care situ-
times, place the security team on alert). ations on the immediate and reasonable
stabilization of the patient instead of on
Management the treatment of the patient’s personality
The clinical situation may at times be pathology, the clinician is aiming to pac-
promptly resolved by clarifying limits ify the patient so that the clinical situa-
(i.e., “We need to complete this test by tion will conclude successfully. The goal
the end of the day”), particularly if fam- is to enable the physician and treatment
ily support is available (Dhossche and team to provide the appropriate and in-
Shevitz 1999). Brief negotiation and/or dicated medical assessment and care.
verbal contracting with the patient may
be helpful (Pare and Rosenbluth 1999). Longitudinal Patient-Care
The acute use of psychotropic medica-
tions (e.g., antipsychotics) with rapid-on- Situation
set effects may be indicated to calm or re- In contrast to being asked to consult on the
organize the patient. (We recommend acute needs of an inpatient or a patient in
the emergency room, the consultant may cially minded clinicians are more prone
be contacted by a clinician about manag- to reporting difficult encounters with
ing a patient with personality pathology patients. In addition, patients with more
in a longitudinal context, commonly in the severe PDs tend to evoke stronger emo-
primary care setting. Although many of tions in clinicians, and these emotions
the assessment and management tasks are may be expressed by the clinician in
similar to those of the acute situation, problematic ways toward the patient. For
there are additional considerations in the example, clinicians who underrespond
longitudinal situation. to the intense emotions of patients by
passively withdrawing may cause un-
Assessment due patient distress related to feelings of
During the assessment for longitudinal abandonment. Alternatively, clinicians
management, as in the assessment of the who actively respond to the strong emo-
acute situation, the clinician should ini- tions of patients with brusqueness or con-
tially and explicitly define the patient’s frontation may unintentionally distance
problem behaviors and/or patient-clini- the patient. In addition, Meyer and Block
cian/staff impasses in the medical re- (2011) emphasize that some clinicians
cord. The clinician should next determine may struggle with their own personal
whether any administered medications, concepts of appropriate and inappropri-
illicit drugs, or uncontrolled medical ate behaviors during patient encounters,
conditions might be contributing to the be vexed by their sense of personal re-
patient’s behavior (Dhossche and Shevitz sponsibility for a positive outcome in a
1999). Likewise, the clinician should con- seemingly uncooperative patient, and/
sider whether there are any comorbid or be overly attached to the concept of
major psychiatric disorders (e.g., de- “tireless caregiver” and wind up feeling
pression, anxiety, posttraumatic stress emotionally exhausted by a demanding
disorder) that might be aggravating the patient. The key consideration for the
interpersonal situation between the pa- consultant is to entertain the clinician’s
tient and clinician or staff. Finally, the possible role in a patient-management
clinician should determine the patient’s issue, which may not only acutely allevi-
explicit personality pathology to enable ate the current situation but also prevent
more precise management planning future crises.
(e.g., note that at the outset, effective and On a related note, Pare and Rosenbluth
cooperative liaisons are difficult to estab- (1999) discuss the role of the clinician’s
lish with patients who suffer from anti- experience in medicine and the resulting
social PD). impact on his or her expectations of
On a side note, on occasion, a clini- medical practice in relationships with
cian’s personal qualities and attitudes patients. At the outset, newly trained cli-
may be unintentionally contributing to nicians tend to initially idealize the prac-
the difficulties in his or her relationship tice of medicine. Many are initially at-
with the patient. Although less relevant tracted to the field of medicine because
in the acute patient-care situation, the they are driven by their own deep needs
clinician-patient relationship is para- to help others, and to feel effective and
mount in the longitudinal patient-care potent while doing so. Unfortunately,
situation. In this regard, Meyer and Block patients with dramatic personality dys-
(2011) broach a number of important function tend to leave clinicians feeling
points. They indicate that less psychoso- ineffective and impotent, particularly
when derailing the treatment course of options. Suggested options for the cli-
with noncompliance, eruptions of dis- nician include 1) maintaining an emo-
ruptive behavior, and demands for un- tionally neutral treatment environment
necessary and potentially harmful med- (e.g., self-monitoring one’s responses to
ications. These types of clinical impasses the patient, avoiding the direct expres-
with patients tend to compromise the sion of anger, not making personal nega-
obsessive-compulsive mindset of many tive comments); 2) being supportive to
young clinicians by thwarting their ef- the patient; 3) limiting in-office attempts
forts to “do the right thing” for the patient. at psychotherapy; 4) scheduling multiple
With time in the field, a more realistic brief appointments to address the needs
perspective begins to gradually evolve. of those individuals who struggle with
Indeed, Pare and Rosenbluth (1999) strong attachment dynamics; and 5) pre-
stress that “all” clinicians eventually venting the patient from getting into
learn that “medicine is not as powerful high-risk medical situations (i.e., main-
and effective as they had hoped it would taining conservative medical manage-
be” (p. 262), suggesting that with sea- ment). High-risk medical situations may
soning, clinicians will be less susceptible include the unnecessary prescription of
to these kinds of initial unrealistic expec- scheduled and potentially harmful medi-
tations of the practice of medicine. cations (e.g., narcotic analgesics, con-
trolled weight-loss medications, stimu-
Management lants for attention-deficit/hyperactivity
Scant empirical research exists on the ef- disorder, controlled anxiolytic medica-
fectiveness of longitudinal management tions), unnecessary laboratory studies
techniques for patients with PDs in the (i.e., given a sufficient number of labora-
medical setting. Therefore, the majority tory studies, occasional spurious results
of the material in this section is based on are bound to occur, creating more chal-
clinical experience and tradition. lenges in the treatment), and unnecessary
When consulting in longitudinal pa- referrals to specialists for invasive diag-
tient-care situations, we initially stress to nostic procedures or treatments (i.e.,
the physician that he or she cannot hope some specialists may not be aware of the
to “fix” or “rescue” the patient who suf- nature of personality pathology and may
fers from personality pathology (i.e., to unintentionally overtreat patients with
effectively treat and resolve the patient’s PDs). In addition, the centering of care in
PD). We stress that in most cases, the only the medical office enables the streamlin-
legitimate resolution of the patient’s per- ing of patient management by main-
sonality pathology is through longitudi- taining clearly defined treatment goals,
nal psychotherapy and/or the aging pro- including a clear explanation of the treat-
cess. Even then, some individuals with ment plan to the patient, and a consistent
PDs (e.g., antisocial PD) may be less ame- treatment provider (“one cook in the
nable to either psychotherapy treatment kitchen”). Because of this, patient visits to
or the mellowing effects of time. There- the emergency room are to be discour-
fore, we emphasize in the nonpsychiatric aged except in a genuine emergency. We
setting the importance of managing rather also encourage establishing a treatment
than treating the patient with PD. milieu in which symptom resolution is
The recommended overall manage- deemed unlikely, but symptom manage-
ment approach to patients with PDs in ment is the more realistic treatment goal
the medical setting entails a broad menu (e.g., by warning patients “We are never
going to rid you of your pain, but we can

reduce the amount of pain”) (Dhossche Conclusion
and Shevitz 1999).
As in the acute patient-care situation, Without doubt, personality pathology in
limits are frequently necessary to main- the medical setting is a genuine challenge
tain stability in long-term patient-care for clinicians. In the past, these patients
situations (Dhossche and Shevitz 1999). have been labeled as “difficult patients.”
Intermittent brief negotiation and/or Through ongoing research efforts, a more
verbal contracting with the patient may precise diagnostic picture is beginning to
be useful, particularly around medica- emerge—that the majority of these pa-
tions and/or procedures (e.g., by stating tients appear to suffer from personality
“We will attempt to complete the testing dysfunction. Personality dysfunction in
as soon as possible if you can cooperate the medical setting may be heralded by
and allow us to”) (Pare and Rosenbluth the clinician reacting more strongly to the
1999). It may also be necessary to resolve patient than is seemingly warranted as
communication distortions (Norton 2000); well as the presence of suggestive pa-
encourage staff not to personalize the tient behaviors and syndromes/diagno-
patient’s derogatory comments (Pare and ses. Patient management is typically indi-
Rosenbluth 1999); and reinforce bound- vidualized and consists of a menu of
aries between the patient and staff therapeutic options. Not surprisingly, few
(Devens 2007). Finally, because of the co- intervention techniques have been sys-
morbid nature of symptoms, it is always tematically studied to determine their ef-
essential to address any co-occurring ficacy among character-disordered pa-
major psychiatric disorders by incorpo- tients in the medical setting.
rating the traditional and recommended The intersection of personality pathol-
treatments. In Table 21–1, we provide ogy and the medical setting is prime for
some additional clinical mantras for con- various types of research endeavors, in-
sultants to consider when directing clini- cluding further studies on the preva-
cians who are struggling with patients lence of PDs in various medical settings,
with PDs in a longitudinal context (San- simultaneous examination of multiple
sone and Sansone 2007). PDs with regard to a specific syndrome/
On a cautionary note, although it may diagnosis (e.g., fibromyalgia), and as-
seem appealing to discharge difficult pa- sessment of intervention techniques in
tients from one’s medical practice, it may this under-researched subset of patients.
actually be in the patient’s best interest Only future research will clarify these
to remain in the practice, particularly if and other intriguing issues, and poten-
the interpersonal situation between the tially improve the management of these
clinician and patient can be stabilized. chronically chaotic individuals.
On occasion, patients with PDs may seek
atypical treatments from unprofessional
treatment resources—a situation that
should be avoided at the outset to pro-
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TABLE 21–1. Mantras to consider when consulting on patients with personality

disorders
• Patients with personality pathology cannot psychologically heal in medical settings.

• Among clinicians in the medical setting, there are vastly different knowledge bases with
regard to personality pathology and specific personality disorders.
• Even though the clinician who is seeking consultation in the medical setting may be knowl-
edgeable about a given personality pathology, this does not mean that he or she can effec-
tively manage all patients with this disorder.
• The clinician who is operating from a defensive position with the patient cannot be objective
with the patient’s care.
• Emotionally neutral limit setting is typically required in the management of patients with
personality disorders; however, this will likely affect clinicians’ patient-satisfaction scores.
• Regardless of limited options and escalating patient dissatisfaction, “do no harm.”
• Patients with personality pathology seen in the medical setting may improve with crisis
intervention and management.
• Sustained remissions can be attained by patients with personality disorders who are willing
to undergo psychotherapy treatment; one goal of primary care clinicians and consultants
is to identify and refer potentially amenable patients.
Source. Adapted from Sansone and Sansone 2007.
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C H A P T E R 22
Personality Disorders in
the Military Operational
Environment
Ricky D. Malone, M.D., Col., M.C., U.S.A.
David M. Benedek, M.D., Col., M.C., U.S.A.
The unique aspects of military uations, and the potential witnessing of

life—particularly in times of prolonged sudden and severe injury or death. Im-
involvement in international conflict— pulsivity, disregard for safety of self or
may prove particularly challenging for others, and lack of empathy or concern
persons with personality disorders (PDs). for the needs of others, all of which char-
To the extent that PDs may be defined as acterize Cluster B pathology, may com-
pervasive, stable, and inflexible patterns promise mission capability. The inability
of inner experience and behavior that de- to take initiative or reluctance to engage
viate markedly from the expectations of in new activities and the lack of decisive-
an individual’s culture (American Psychi- ness observed in avoidant and depen-
atric Association 2013), it is evident that dent PDs also interfere with military oc-
the patterns of behavior characterizing cupational tasks. Finally, the emotional
the various PDs would prove particu- and behavioral consequences of diffi-
larly maladaptive in a military opera- culty developing and maintaining sup-
tional environment requiring strict adher- portive social relationships experienced
ence to regulations, limits on personal by those with Cluster A pathology often
freedoms, life in a harsh and austere envi- declare themselves in deployed environ-
ronment, frequent and lengthy separa- ments where service members must live
tions from usual sources of social support, and work in close quarters with little pri-
repeated exposure to life-threatening sit- vacy or personal space.
The views expressed in this chapter are those of the authors and do not reflect the official policy
or position of the Department of Defense or the U.S. government.
475
Perhaps less obvious is the notion that centrating, stating that she had failed
behaviors composing various PDs also all of her tests on the first try but passed
on the second. She reported that she
deviate markedly from the expectations
had difficulty sleeping at night and
of a service member’s organizational cul- subsequently suffered daytime som-
ture. Although there are certainly cul- nolence that impaired her academic
tural differences between members of the performance. Further history revealed
U.S. Army, Navy, Air Force, and Coast that Private Jenkins had experienced a
Guard, all branches of the uniformed ser- chaotic childhood, having been raised
by her father since age 2 after he di-
vices espouse values of honor and integ-
vorced her drug-abusing mother. She
rity, trust for—and dedication to—fellow admitted to physical abuse during her
service members, personal sacrifice, cour- elementary school years, sexual abuse
age, and devotion to duty (Halvorson at age 13, and emotional abuse for
and Substance Abuse and Mental Health most of her life, but was reluctant to
provide details. She had a history of
Services Administration 2010). Thus, pat-
self-mutilation but none recently. Ms.
terns of inner experience and behavior, Jenkins had enlisted in the National
including disregard for regulations or so- Guard “pretty much on a whim” after
cial norms, mistrust of others, discomfort an argument with her father about her
in the presence of others, intense feelings lack of employment. She said she was
of abandonment, exploitation of others, following in her father’s footsteps in
an attempt to garner his approval and
impulsiveness, or inability to maintain
sought training as a medic in order to
interpersonal or occupational commit- be in his unit when she returned to her
ments, would most certainly deviate from home state after active duty training.
the expectations of persons steeped in Private Jenkins agreed with the psychi-
military culture. The vignettes through- atrist that her personality was a “poor
fit with the military” and that she
out this chapter illustrate the idea that
joined mainly to please her father. She
behaviors and affective states observed expressed that she would feel a sense
in persons with PDs may become even of relief if the decision to leave the mil-
more apparent to fellow service mem- itary was made for her rather than a
bers during times of occupational stress result of her quitting or failing.
and may come to the attention of clini-
cians in a variety of ways, including self- The U.S. military has long recognized
referral, referral from other (i.e., non– that persons with behavioral or interper-
mental health) care providers, or by re- sonal impairments that are commonly
ferral from military command. The fol- manifested in PDs may be poorly suited
lowing vignette illustrates how some of for military duty. Both military culture
these personality traits may manifest in and military regulations require that lead-
the military environment. ers must strive to correct the deficiencies
in their service members and to rehabil-
Case Example 1 itate behavior that is detrimental to oc-
cupational or social functioning within
Vanessa Jenkins, an 18-year-old Na-
tional Guard private, completed basic the military (e.g., through mentoring, cor-
training and began military occupa- rective training, or even nonjudicial pun-
tional skill training as a medic. Shortly ishment). Behavioral health care, rang-
afterward, Private Jenkins presented to ing from medication management to
the mental health clinic with com- individual and group supportive, psy-
plaints of mood lability with frequent
choeducational, cognitive-behavioral,
tearfulness and marked difficulty con-
and in some cases intensive psychody-
Personality Disorders in the Military Operational Environment 477
namic psychotherapy, is available to ser-

vice members who seek treatment for Epidemiology of
mental disorders within a wide variety
of treatment facilities on military bases
and during deployment. However, in in the U.S. Military
recognition of the traditional view of the
ingrained and enduring nature of PD- The U.S. military does not conduct com-
related behaviors and the barriers to prehensive psychiatric or psychological
effective treatment of PDs imposed by screening on all persons entering active
occupational requirements of military duty or such surveillance on any peri-
service (e.g., ready access to weapons, odic basis after entry into active duty.
frequent moves, short-notice deploy- Some specialized military occupations
ment to locations without the full pano- (e.g., Special Forces or recruiting duties)
ply of psychiatric resources), all branches may use psychological screening for as-
of the military also promulgate regula- sessment and selection purposes, but
tions that allow for relatively expedi- these represent exceptions rather than
tious administrative separation (without the norm for military duty. Military ac-
disability compensation) of service mem- cession standards preclude persons with
bers with PDs. The diagnosis of PD serves a variety of medical illnesses, including
as a bar to enlistment, and the emergence chronic psychotic disorders, substance
of a PD diagnosis after enlistment is abuse disorders, and PDs, from enlist-
viewed, from a disability compensation ment, and documented histories of these
standpoint, as the recognition of a con- illnesses serve as bars to initial enlistment.
dition that existed prior to enlistment. However, if such histories are not re-
More recent studies suggest that person- ported on enlistment applications or in
ality disordered behavior is more wax- medical records reviewed prior to enlist-
ing and waning than it is enduring; the ment, they may be missed. Therefore,
recurrent nature of the stressors inherent prevalence rates for psychiatric diagno-
to military life may precipitate episodes ses that do not necessarily come to clini-
of decompensation rather than protect cal attention (including PDs) have not
against them. been clearly established.
In this chapter we outline the limited As the military leadership has be-
data available on the prevalence of PDs come increasingly concerned with the
in the U.S. military and discuss the limi- psychological burden associated with
tations of these data. We then describe prolonged combat operations in Iraq
the manner in which individuals with and Afghanistan, systematic health sur-
PDs may come to the attention of military veillance efforts such as those conducted
leaders and clinicians. After a descrip- by the Mental Health Advisory Team
tion of the evolving regulations and pro- have led to considerable data on the
cesses for administrative disposition of prevalence of psychiatric disorders in
service members with PD and the cir- combat personnel. These studies have
cumstances prompting recent changes, demonstrated significant increases in
we conclude the chapter with a discus- rates of diagnoses including major de-
sion of areas for further study pertaining pression, posttraumatic stress disorder
to the treatment and management of ser- (PTSD), and substance use disorders at
vice members with PDs. 3 months, 6 months, and 1 year follow-
ing deployment, as well as increased iety disorders, depressive disorders, ad-

prevalence of these disorders during de- justment disorders, and other mental dis-
ployment when compared with garrison orders generally increased during this
or predeployment rates (Hoge et al. time period (with adjustment disorders
2004). The Mental Health Advisory Team accounting for 85% of all incident diag-
studies rely heavily on anonymous self- noses, and incidence rates of PTSD in-
report questionnaires through which creasing approximately sixfold). How-
service members report symptoms expe- ever, over the entire period, relatively
rienced at the time of survey administra- few incident diagnoses were attribut-
tion. Hence, they are not well suited for able to PDs (n=81,223 or 4.5%). The inci-
measuring prevalence of diagnoses best dence rate for the diagnostic category
established by a longitudinally based PD—which comprised all subtypes, in-
clinical assessment, as may be desirable cluding mixed—was generally stable at
for PD diagnosis or diagnoses character- approximately 500 cases/100,000 per-
ized by symptoms for which patients son-years, and actually declined slightly
may lack insight and therefore lack ca- over the period of study (n=8,281 in 2001;
pacity to self-report. n=4,110 in 2011). Similarly stable patterns
The military’s increasing use of elec- were observed for psychotic disorders
tronic data systems since the turn of the and substance abuse and dependence
century, however, has provided unprec- disorders (Figure 22–1).
edented opportunity to conduct epide- These data are consistent with the no-
miological research on health care utili- tion that disorders whose diagnosis ei-
zation (Hoge et al. 2003). One recently ther requires temporal linkage to precip-
published systematic examination of mili- itating events (e.g., PTSD, adjustment
tary health utilization databases showed disorders) or has been associated with
that from 2000 to 2011, a total of 936,283 exposure to stressful events (e.g., anxiety
service members received at least one disorders, depressive disorders) would
mental disorder diagnosis at a military be expected to increase during times of
treatment facility, and nearly half of these heightened military operational tempo,
individuals had more than one (Armed increased deployment, and combat ex-
Forces Health Surveillance Center 2012). posure. Although one might anticipate
Categories of mental diagnosis for this that substance use disorders would in-
analysis were ICD-9 (World Health Or- crease during such a period, it should be
ganization 1977) codes for adjustment noted that general military orders im-
disorders, alcohol abuse and depen- posed on all troops in the combat theater
dence disorders, substance abuse and specifically precluded the use of alcohol.
dependence disorders, anxiety disor- Because epidemiological studies demon-
ders, PTSD, depressive disorders, PDs, strate stable rates of PD in the general
schizophrenia, other psychoses, and U.S. population, the slight decrease in
other mental health disorders. Over this incidence rates of PD may also seem
time period, rates of incident diagnosis counterintuitive. However, the idea that a
of at least one mental disorder increased pattern of behavior and symptoms attrib-
by approximately 65% (from 75,353 utable to PD in times of peace and stabil-
cases or 5,387.1 cases/100,000 person- ity might be otherwise diagnostically ac-
years in 2000 to 129,678 cases or 8,900.5 counted for in patients with significant
cases/100,000 person-years in 2011). Not histories of traumatic combat exposure
surprisingly, incidence rates of PTSD, anx- seems plausible—particularly given the
2500
Incident diagnoses per 100,000
2000
PTSD
patient-years
1500
Substance abuse/
dependence
Depression
1000
Schizophrenia
Personality disorders
500
0
2001 2003 2005 2007 2009 2011
Year
FIGURE 22–1. Incidence rates of mental disorder diagnoses, by category, active compo-
nent, U.S. Armed Forces, 2001–2011.
Source. Adapted from “Mental Disorders and Mental Health Problems, Active Component, U.S. Armed
Forces, 2000–2011.” Medical Surveillance Monthly Report 19(6):13, 2012.
well-documented overlap of symptoms cal facilities. In addition to issues of ac-

of PTSD and, in particular, Cluster B PDs cess to care created by increased demand,
(Bollinger et al. 2000). Other contributing well-described barriers to psychiatric
factors might include an evolving and care in military settings include stigma,
heightened degree of caution in render- concerns about impact of receiving care
ing a diagnosis of PD, as reflected in re- on one’s career, concerns about the im-
cent changes to military policy regarding pact of the use of psychotropic medica-
such diagnoses in conjunction with po- tions on specific career assignments or
tential combat exposure in the preceding deployment capability, and the chal-
2 years (U.S. Department of Defense In- lenges associated with finding the time to
struction 2011). receive care (to attend appointments) in
the context of a demanding workload
(Hoge et al. 2004).
Clinical Presentation of Although service members with PDs
may not necessarily seek treatment, in
Personality Disorders in part because of lack of insight into the no-
the Military tion that their inner experience or behav-
ior deviates from cultural norms, they
Behavioral health care is available to may present to either primary care physi-
members of the active duty and their de- cians or mental health specialists for as-
pendents as well as retirees through a sistance in times of emotional crisis (e.g.,
worldwide network of tertiary medical suicidal ideation when a deployment
centers, community hospitals, and ambu- threatens the security of a romantic rela-
latory care facilities. In many instances, to tionship, excessive anger or depressed
facilitate access to care, military installa- mood after failing to receive a promo-
tions have established additional mental tion). In other circumstances, maladap-
health–specific ambulatory care centers tive behaviors (e.g., impulsive aggres-
on bases that already housed behavioral sion, substance misuse, disregard for
health clinics within their general medi- direct orders, self-injurious acts) may be
directly observed by or reported to com- politely declines all invitations to play

manders by subordinates concerned for cards, dominoes, or video games with
others in the tent. Moreover, he
the safety of the service member. Others
chooses not to join the others for meals
in the command may become concerned or to watch movies, and shies away
that a mental disorder may be jeopardiz- from all efforts to engage in spontane-
ing a service member’s ability to carry ously organized athletic or training
out his or her mission. Commanders, su- activities, or even to engage in small
pervisors, or peers may certainly en- talk. Finally, one member of the unit
tells his senior enlisted supervisor,
courage fellow service members to seek
“We’re all worried about Smith. We
mental health treatment in these circum- don’t think we can go into battle with
stances. Considerable effort has been in- this guy. He won’t talk to us—how do
vested by the services in promoting the we know he’s got our back? The com-
concept that service members should ac- mander should have this guy checked
out.” The supervisor approaches PFC
tively encourage their colleagues to vol-
Smith, reminds him of the importance
untarily seek treatment or counseling of teamwork and team spirit to mis-
when such concerns arise. sion success, and tells him that others
are worried about him. Smith replies,
“I’m fine. I don’t see what the big deal
Case Example 2 is. I’m just kind of a loner. I don’t need
A 22-year-old female soldier fails to them, and they don’t need me. We just
present for afternoon formation. Her need to do our jobs and get home.” The
barracks roommate reports having supervisor encourages PFC Smith to
heard Katie arguing with her boy- “do me a favor, and check in with the
friend on the phone just before for- doctors in the combat stress center. I
mation, goes back to the barracks to can’t make you go, but if you do and
search for her roommate, and discov- nothing comes of it, I can tell the
ers she has impulsively lacerated her commander the docs think you are
wrists. The service member is brought good to go.”
to the emergency room, where she
tells the emergency room physician
that her boyfriend broke up with her Military Administrative
over the phone because “he knew I
was going overseas for 6 months and Policies Regarding
didn’t want to be tied down to me if
I wasn’t going to be close by,” and Personality Disorders
notes, “break-ups are always hard for
me; I get like this every time I think I Each branch of the service has developed
am going to be alone again.” The ser- regulations and instructions allowing for
vice member’s commander refers the command-directed involuntary referral
soldier for psychiatric evaluation.
of service members for behavioral health
evaluation on an emergent basis if, upon
Case Example 3 consultation with a mental health profes-
While in Kuwait awaiting movement sional, there is reason to believe that a
orders to assume a security mission in mental disorder has rendered a service
Iraq, a platoon of 25 soldiers is housed
member at imminent risk of self-harm or
in a medium-sized tent, on cots ap-
proximately 18 inches apart. Members harm to others. These same regulations
of the unit become particularly con- outline procedures for nonemergent com-
cerned about a new member of the mand-directed involuntary referrals in
unit, 20-year-old PFC Smith. PFC Smith situations where the commander believes
mental disorder may be the cause of dec- dures for disability processing, only after
rement in job performance to the point of a member has received maximum degree
compromising a service member’s fitness of medical benefit from acute treatment,
for duty or ability to carry out the mis- are enumerated in “Physical Disability
sions unique to his or her military assign- Evaluation” (U.S. Department of Defense
ment and training. These regulations also Instruction 2006).
outline various protections afforded to Military policy and regulations have
the service member under such circum- been devised to take into account the de-
stances, including the required credentials mands of ongoing military service. His-
of the person conducting the evaluation, torically, service regulations have ad-
the right to be advised in advance and in dressed conditions that are considered
writing of the reason for the referral, the unsuitable for military service but that do
right to counsel, and the avenue for ap- not necessarily render the service mem-
peal of any recommendations made as a ber unfit for military service (i.e., not
result of such a referral (U.S. Department amounting to disability). These include
of Defense Directive 2003a, 2003b). Such such conditions as enuresis and motion
referrals may result in recommendations sickness, as well as behavioral condi-
for allowing time for ongoing treatment tions that would limit the person’s abil-
or other accommodations to be made by ity to adapt to the demands of military
the command, and may lead to the estab- service but not otherwise interfere with
lishment of a diagnosis which, if treat- routine civilian life activities. This regu-
ment is unsuccessful, may result in the lation allowed for the administrative
initiation of procedures for medical or separation of soldiers demonstrating “a
administrative discharge of the service deeply ingrained maladaptive pattern of
member. behavior of long duration that interferes
Regardless of whether service mem- with the Soldier’s ability to perform duty”
bers present of their own accord, present (U.S. Department of the Army 2011a, p.
at the encouragement of peers, or come to 58). The diagnosis of a PD for the pur-
clinical attention by virtue of command- pose of separation under these regula-
directed evaluation, appropriate treat- tions may be made only by a psychiatrist
ment is initiated. In the case of physical or a licensed clinical psychologist. The
illness, injury, or major mental disorders clinician is advised that a recommenda-
incurred or exacerbated while on active tion for this course of action should follow
duty or service, the conditions leading to only from a detailed history to support
medical retirement (to include disability the presence of long-standing maladap-
compensation) are articulated in Army tive behavior and difficulties function-
Regulation 40-501, “Standards of Medical ing in interpersonal relationships, rather
Fitness” (U.S. Department of the Army than simply an adjustment reaction to
2011b); Air Force Instruction 148-123, current stressors (Diebold 1997). The in-
“Medical Examination and Standards” dividual must meet the diagnostic crite-
(U.S. Department of the Air Force 2012); ria for the specific PD or the relevant
and the U.S. Navy Manual of the Medical personality traits for a diagnosis of other
Department, Chapter 15, “Physical Exam- specified or unspecified PD.
inations and Standards for Enlistment, Many of the larger military medical
Commission, and Special Duty” (U.S. De- centers are able to offer treatments such
partment of the Navy 2008). The proce- as dialectical behavior therapy or other
cognitive-behavioral therapies, both in exacerbated under stress and may have

groups and individually, to address mal- low potential for significant change over
adaptive symptoms of PDs. Most treat- time (Diebold 1997). Recent develop-
ment facilities are able to offer support- ments regarding the effectiveness of
ive counseling and psychodynamically treatments targeting particularly mal-
based therapies. Medication manage- adaptive behaviors in PDs may render
ment for associated symptoms of affec- this guidance more salient in the future,
tive dysregulation is also increasingly providing the potential for increased suc-
employed, even though such treatments cessful rehabilitation.
represent off-label use and have only lim- Service regulations that address con-
ited support in the literature. Nonethe- ditions considered unsuitable for mili-
less, the clinical utility of these treat- tary service (U.S. Department of the Army
ments continues to be limited by their 2011a; U.S. Department of the Air Force
relatively long-term nature in many cases 2011; U.S. Department of the Navy 2009)
and the lack of availability in the deployed are derived from Department of Defense
environment, where they are more likely (2011) policy. As previously noted, these
to be needed because maladaptive be- include conditions such as motion sick-
haviors increase in response to the addi- ness, enuresis, and sleepwalking, which
tional stressors. The commanders’ need would not generally be considered dis-
to address problematic behaviors ad- abling but which could obviously be in-
ministratively and/or through disciplin- compatible with military service. This
ary action will often result in separation category also includes adjustment disor-
before significant therapeutic improve- ders, which predictably are frequently
ment is possible. comorbid with PDs in the military envi-
The regulations further provide that ronment and also constitute a likely rea-
even when a service member is diagnosed son for presentation to clinical attention.
with a PD, a recommendation for admin- Adjustment disorders are viewed as the
istrative separation remains only a rec- manifestation of an inability to adapt to
ommendation, with final disposition de- the stressors of military life, which may
termined by the commander only after be situationally driven but also repre-
“the Soldier has been counseled formally sent some degree of underlying predis-
concerning deficiencies and has been af- position, whether or not it rises to the
forded ample opportunity to overcome level of a PD. If the clinician believes the
those deficiencies as reflected in appro- predisposition is significant enough to
priate counseling or personnel records” make chronic or recurrent adjustment
(p. 56). This guidance is in keeping with difficulties likely, this establishes the po-
the special emphasis the military places tential for administrative separation of
on mentorship and leadership, and is service members for the adjustment dis-
consistent with military values exhorting order without (or before) a diagnosis of
leaders to exhaust efforts to rehabilitate PD, even when underlying character-
deficiencies in their subordinates before ological issues predominate. This option
giving up on them. It may be in contra- serves to decrease the impetus to prema-
diction, however, to traditional theories turely diagnose a PD as a means of offer-
which conceptualize PD as being a deeply ing the individual administrative sepa-
ingrained and inflexible pattern of re- ration and to avoid the often pejorative
sponse, symptoms of which may become label that a PD diagnosis constitutes, when
in reality military enlistment simply rep- view, assess and, where needed, improve
resented a poor match for the individ- behavioral health evaluations and diag-
ual’s psychological makeup. noses in the context of Disability Evalua-
tion System” (Army Task Force on Be-
havioral Health 2013, p. 7). The task force
Recent Policy Changes made a number of recommendations re-
garding processes to improve the effi-
In 2009, public concern arose about sol- ciency of the disability evaluation sys-
diers who had been administratively septem, as well as the need to educate service
arated from the army for PD after combat members and clinicians regarding the di-
tours in Iraq and Afghanistan. The poten- agnostic assessment process. The goals of
tial injustice of soldiers being separated the recommended changes are to en-
without medical or other benefits when hance the comprehensiveness of the as-
symptoms of posttraumatic stress may sessment process and to ensure careful
have contributed to behavior problems evaluation of all symptoms, including be-
led the U.S. Army Medical Command to havioral changes that might stem from
develop policies assuring that those who PD or adjustment disorder. Although spe-
had served combat tours undergo screen- cific guidelines about the conducting of
ing for PTSD and traumatic brain injury. evaluations were not made, the process
If subsequent clinical evaluation confirms allows these behavioral changes to be
clinically significant symptoms, such in- considered in a light that would be most
dividuals are medically separated instead beneficial to the service member in terms
and thus retain benefits, even if comorbid of potential disability compensation ver-
PD complicates the clinical picture. In sus administrative separation.
2011, the Department of Defense revised
the instruction (U.S. Department of De- Case Example 4
fense Instruction 2011) to extend these A 24-year-old specialist returned from
safeguards to all of the military services. a combat tour in Afghanistan, where
Recognizing the potential for other diag- his unit had been under attack several
noses, including those considered un- times. In one mission, the convoy he
suitable but not disabling, this instruction was traveling in struck a roadside im-
provised explosive device, destroying
extended these safeguards to adminis- the vehicle in front of his and killing
trative separations for adjustment dis- one of his friends. In the weeks follow-
orders as well and requires comprehen- ing his redeployment, his wife noted
sive screening for mental health issues that his previous jealous tendencies
in addition to PTSD and traumatic brain were now expressed in angry verbal
outbursts whenever she returned
injury.
from errands. She also noted that he
In late 2011, concerns were raised was increasingly irritable and slept
about Medical Evaluation Boards for psy- poorly, awakening in the night thrash-
chiatric conditions conducted at Madi- ing about. When frustrated, he would
gan Army Medical Center at Joint Base strike her pet poodle and would fre-
Lewis-McChord in Washington State. quently sit alone in their suburban
backyard drinking beer and watching
These concerns eventually resulted in the a campfire, in violation of a city ordi-
establishment of the Army Task Force on nance against building fires in the
Behavioral Health, chartered to conduct a neighborhood. She convinced him to
comprehensive evaluation of the Disabil- go to the mental health clinic, where
ity Evaluation System in an effort to “re- an evaluation additionally revealed a
childhood history of conduct disorder, itative efforts in the context of the chal-
several legal detentions before age 18 lenges inherent to military life and
that were expunged from his record,
therefore as grounds for administrative
and an increase in speeding and reck-
less driving since his return. Because separation in accordance with military
these behaviors had markedly in- regulations. These same regulations
creased since his deployment, he was have always left room for commanders
offered treatment for posttraumatic to retain service members with PDs and
stress and referred for a disability presumably allow or encourage these
evaluation.
service members to avail themselves of
treatment opportunities in the military.
However, recent policy developments
Conclusion seem to suggest recognition that symp-
toms emerging in the aftermath of com-
Involvement in long-term combat opera-
bat—which may have in the past been
tions necessitating frequent and pro-
attributed to PD—should be considered
longed deployment, disruption of fami-
in a diagnostic light that best promotes
lies and other sources of social support,
ongoing treatment either within the mil-
repeated exposures to harsh and inter-
itary system or through the disability
mittently life-threatening environments,
system to provide the opportunity for
and higher workloads for service mem-
continued treatment in the Veterans Af-
bers (even while in garrison) have resulted
fairs setting after medical rather than ad-
in a heightened awareness of the emo-
ministrative discharge.
tional and behavioral challenges con-
Further research is needed not only to
fronting combat veterans. The military
focus diagnostic efforts but also to de-
has invested considerable efforts in the
velop treatment approaches to behav-
development of better approaches to the
iors that result in loss of fitness for fur-
assessment and management of PTSD,
ther military duty. Treatments are needed
traumatic brain injury, and the interper-
that target impulsive behavior (includ-
sonal and occupational impairments that
ing aggression), high-risk behaviors (in-
may result from these disorders. These
cluding substance abuse), and affective
efforts have also resulted in an increased
instability, whether these behaviors re-
awareness of the diagnostic overlap not
sult from PD, PTSD, or comorbid condi-
only between these entities, but also with
tions. The extent to which recent ad-
adjustment disorders and PDs, as each of
vances in the treatment of PDs (e.g.,
these may manifest in patterns of mal-
dialectical behavior therapy for border-
adaptive behavior that may only come to
line PD) may allow for effective treatment
clinical attention with the added stressors
in military operational environments
of deployment and redeployment.
must also be explored.
All branches of the military have his-
torically recognized PDs as ingrained
patterns of behavior developing in child-
hood or adolescence and blossoming in
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PART IV
Future Directions
C H A P T E R 23
Translational Research in
Borderline Personality
Disorder
Christian Schmahl, M.D.
Sabine Herpertz, M.D.
In this chapter, we focus on two do- ality disorder (ASPD). We then discuss
mains of borderline personality disorder disturbed pain processing and the role
(BPD) psychopathology—dysfunctions of pain in the context of emotion regula-
of social interaction and perceptual tion in BPD. Closely related to this as-
alterations (pain and dissociation)—to pect of BPD, dissociation as a distinct
demonstrate that modern behavioral feature of BPD has interesting parallels
neuroscience methodology and transla- in animal research, as we outline at the
tional approaches can be useful for un- end of this chapter.
derstanding mechanisms underlying
this psychopathology and ultimately
help to improve therapy for patients with Dysfunctions of
BPD. In these two domains, animal mod-
els are of particular value and can be
Social Interaction
used to better understand underlying
disease constructs as well as for testing Impaired Interpersonal
behavioral and pharmacological inter-
ventions. Animal models of research,
Functioning in BPD
however, are still in their infancy. Interpersonal dysfunction is the most
In this chapter, we provide an over- prominent characteristic of personality
view of dysfunctional social interaction disorders (PDs) in general, although its
in BPD, with a special focus on empathy nature varies among the different types.
and the role of oxytocin, with a short From the view of translational research,
side trip to the field of antisocial person- interpersonal dysfunction has been best
489
studied in BPD, although there has been design, the Cyberball (a ball-tossing com-
additional research in the antisocial realm. puter game paradigm), which reliably
Impairments in interpersonal func- provokes feelings of social exclusion
tioning have been discussed as being the (Staebler et al. 2011). In this study, pa-
best discriminator for diagnosis of BPD tients with BPD exhibited a biased per-
(Gunderson et al. 2007; Modestin 1987; ception of exclusion; they felt excluded
Zanarini et al. 1990), and longitudinal even when they were objectively in-
studies have shown the impact of inter- cluded. They had more negative self-ref-
personal problems on BPD functioning erential feelings and more negative feel-
in the long run (Gunderson et al. 2011; ings against others before the game
Zanarini et al. 2010). Intolerance of alone- started, and they reported resentments
ness, long regarded as one of the central against others during the ball-tossing
features of BPD resulting in dysfunc- game, which increased when being ex-
tional attachment behaviors, typically is cluded. In a recently developed animal
demonstrated as an oscillation between model for social rejection, rejected ani-
attention seeking and detached avoid- mals displayed higher emotional reactiv-
ance (Gunderson et al. 1996). ity as well as decreased pain sensitivity,
Gunderson et al. (2008) emphasized thus mirroring features of BPD (Schneider
“the fearful or highly reactive component et al. 2013).
of this interpersonal style that is probably Unresolved attachment might lie at the
the more distinctive and pathogenic com- core of BPD (Fonagy and Luyten 2009; see
ponent” (p. 2) and referred to this inter- also Chapter 4, “Development, Attach-
personal style as the interpersonal hyper- ment, and Childhood Experiences,” in
sensitivity phenotype. Experimental this volume), so that patients with BPD
studies point in particular to interper- show no coherent attachment style but in-
sonal threat hypersensitivity. Individuals stead demonstrate rapid shifts between
with BPD tend to frequently experience avoidant and anxious attachment. Re-
interpersonal threat, making them as- flecting avoidant attachment, they pay lit-
cribe resentment to others (Domes et al. tle attention to or have low memory for
2008). In one study, adolescents with BPD positive social information (Domes et al.
exhibited difficulties in disengaging at- 2006a), and in response to their attach-
tention from threatening facial informa- ment needs, they show hyperreactivity to
tion during early stages of attention socially negative, potentially threatening,
(Jovev et al. 2012). High rejection sensitiv- and even neutral stimuli in a neural net-
ity, defined as the disposition to anx- work of the brain that has been impli-
iously expect, readily perceive, and inten- cated in aversion, withdrawal, or even de-
sively react to rejection (Berenson et al. fense responses (Vrticka and Vuilleumier
2009), appears to be another facet of 2012). Buchheim et al. (2006) reported a
threat hypersensitivity, with individu- positive relationship between unresolved
als with BPD scoring highest on related attachment and activation in both the
measurements (the Rejection Sensitivity amygdala and the hippocampus, in re-
Questionnaire and the Questionnaire of sponse to traumatic adult attachment
Thoughts and Feelings) compared with projective images. In a later study, they
several other clinical samples or healthy showed an increased activation of the an-
control subjects (Staebler et al. 2011). Re- terior cingulate cortex in patients with
jection hypersensitivity has also been BPD, as well as increased activity in the
targeted by using an experimental study superior temporal sulcus when exposed
Translational Research in Borderline Personality Disorder 491
to adult attachment projective images by Meyer et al. (2004), the anxious attach-
(Buchheim et al. 2008). They speculated ment style of patients with BPD was re-
that these cortical sites may be key struc- lated to negative face appraisals and par-
tures of the theory of mind (ToM) net- ticularly a tendency to rate faces as less
work, probably reflecting high but not en- friendly and more rejecting. Consider-
tirely successful efforts of mentalization ing differences in the presentation times
linked to attachment anxiety. of facial stimuli across recent studies, Da-
Although individuals with BPD dem- ros et al. (2012) claim that the increased
onstrated no deficits in facial emotion arousal of patients with BPD may either
recognition for simple tasks (Domes et lead to enhanced detection of subtle fa-
al. 2009), they did demonstrate impair- cial threat or hinder classification of fully
ment in complex tasks for assessing emo- displayed facial emotions in binding at-
tion recognition. For example, patients tentional resources by salient social
with BPD showed lower performance cues. Studies in BPD that have applied
when integrated facial and prosodic physiological measurements of responses
stimuli were applied, but they showed to negative facial emotions consistently
normal ability to recognize isolated fa- indicate a bias toward emotionally nega-
cial or prosodic emotions (Minzenberg et tive or threatening social information,
al. 2006). Contradicting the previous as- such as increased and prolonged amyg-
sumption of general hypersensitivity to dala responses (Donegan et al. 2003;
facial emotions in patients with BPD, ex- Minzenberg et al. 2007), and thus sup-
perimental data suggest subtle impair- port behavioral findings. Interestingly,
ments in labeling accuracy accompanied Vrticka et al. (2008) showed that anxiously
by a bias toward negative emotions—that attached individuals—analogous to those
is, a tendency to interpret ambiguous with BPD—show amygdala hyperactiva-
faces in a more negative way (Arntz and tion in response to angry faces, which
Veen 2001; Wagner and Linehan 1999). may reflect a tendency to experience en-
Interestingly, when modifying presenta- hanced distress in aversive, nonvalidat-
tion times of facial cues, von Ceumern- ing interpersonal situations.
Lindenstjerna et al. (2010b) showed that Adaptive interaction requires unbi-
adolescent patients with BPD demon- ased perception of social signals as well
strated stronger initial attention to brief as the capability to take the perspective of
visualization of negative facial expres- others and exhibit empathy. Empathy sub-
sions than did healthy adolescent com- sumes three facets (Decety and Morigu-
parison subjects, and that, when in a chi 2007): 1) a cognitive capacity to take
negative mood, the adolescents with BPD the perspective of another person (i.e.,
also showed difficulties in disengaging at- cognitive empathy), 2) an affective re-
tention from negative facial expressions sponse to another individual (i.e., affec-
that were presented to them (von tive empathy), and 3) a self-regulatory ca-
Ceumern-Lindenstjerna et al. 2010a). pacity that modulates a person’s inner
Consistent with the expectation that pa- state. Thus, empathy is not sufficiently
tients with BPD are prone to anger, par- understood as an affective experience of
ticipants rather specifically showed a another person’s emotional state but also
bias toward the perception of anger in a requires attribution of emotions to others
study using ambiguous facial stimuli in independent of one’s own mental state.
the form of blends of basic emotions The latter requires self-awareness, no
(Domes et al. 2008). In a study performed confusion between self and other, and a
capacity to modulate one’s own emo- subjects scoring high on borderline traits
tional states. Impaired recognition of in- compared with those scoring low. Inter-
tentions and deficient mental state rea- estingly, cognitive empathy was shown
soning capacities have been found to be to correlate with self-report measures of
compromised in patients with BPD (Fon- emotion regulation, suggesting that high-
agy and Bateman 2006), suggesting im- arousal emotional states might interfere
paired cognitive empathy. Using self- with cognitive empathy ability, as exem-
report measures of cognitive empathy, plified by the model of empathy pro-
such as the Interpersonal Reactivity In- posed by Decety and Moriguchi (2007).
dex (IRI; Davis 1983), several authors Interestingly, in contrast with results as-
found a diminished capacity for appro- sessed by the MASC, two studies pro-
priate perspective taking in patients with vided evidence of a better and more rapid
BPD (Guttman and Laporte 2000; Harari performance by patients with BPD in the
et al. 2010; New et al. 2012). Other studies Reading the Mind in the Eyes Test (RMET;
testing for the capacity of patients with Barnow et al. 2012; Fertuck et al. 2009),
BPD to infer the mental states of others which is reported to relate to mentalizing
also suggest impairments of cognitive processes (but may relate to other psy-
empathy using the faux pas task that chological mechanisms, as discussed later
challenges participants’ capability to ac- in this section).
curately infer thoughts and intentions of Empathy measurements that facilitate
others (Harari et al. 2010). However, other differentiation between cognitive and af-
authors did not find abnormal cognitive fective empathy suggest that a dissocia-
empathy using other ToM tasks (Arntz et tion between these two facets is typical
al. 2009; Ghiassi et al. 2010). Therefore, of individuals with BPD. Harari et al.
studies on accuracy in cognitive empathy (2010), using the IRI as a self-report ques-
have not produced consistent results in tionnaire, as well as faux pas tasks, found
BPD. that patients with BPD showed impaired
In response to the critique that previ- performance in cognitive empathy and
ous research studies have made use of cognitive ToM measures but not impair-
stimulus material with low ecological va- ment in affective aspects of empathy. In
lidity, Dziobek et al. (2006) developed the a study by New et al. (2012), “personal
Movie for the Assessment of Social Cogni- distress” as one aspect of affective empa-
tion (MASC). The MASC is a highly eco- thy turned out to be even higher among
logically valid video-based test that pres- patients with BPD than among healthy
ents social interactions among multiple control subjects. However, when look-
characters and thereby assesses the ing at the Empathic Concern subscale, a
viewer’s capacity to identify social sig- measurement of compassion for others,
nals such as language, gestures, and fa- New et al. (2012) found that patients with
cial expressions. PreiEler et al. (2010) were BPD did not differ from nonclinical con-
the first to use this task in patients with trols. Dziobek et al. (2011) found that pa-
BPD and found them to have impaired tients with BPD reported slightly lower
recognition of the feelings, thoughts, and values on the IRI, and they reported
intentions of others. Sharp et al. (2011) lower performance on both affective and
applied the MASC in work with a group cognitive empathy, when compared to
of adolescents with BPD and reported nonclinical controls, on the Multifaceted
impaired cognitive empathy in young Empathy Task (MET), reflecting the re-
sults of a more objective and ecologically thors recommended that future research
valid instrument. The MET consists of designs use social cognition and em-
photographs depicting people in emo- pathy tasks under varying conditions of
tionally charged situations. In the condi- emotional arousal as well as in different
tion of affective empathy, subjects are in- social contexts.
structed to label their own emotion in Mier et al. (2013), applying an emo-
the context of another individual experi- tional ToM task, found lower neuronal
encing, for example, distress, whereas in activity in the superior temporal sulcus
the case of cognitive empathy, partici- and superior temporal gyrus together
pants had to label the emotional state of with lower activity in the inferior frontal
others in a particular context. gyrus in patients with BPD compared to
Neurobiological data support the nonclinical controls. In this study, sub-
model that cognitive and affective empa- jects viewed facial stimuli with neutral,
thy are distinct phenomena that rely on joyful, angry, and fearful expressions.
different neurocognitive circuits (Singer Each facial expression was introduced
2006). In a functional magnetic resonance by a different statement. In the emotional
imaging (fMRI) study using the MET, intention task (affective ToM), the partic-
Dziobek et al. (2011) found that indi- ipants had to indicate by button press
viduals with BPD exhibited worse perfor- whether or not the statement matched
mance than healthy control subjects on the picture of the person. This task, in
both cognitive and affective empathy. which participants are instructed to iden-
Neuronal activities were reduced in the tify the intentions of the presented per-
left superior temporal sulcus during the sons, challenges ToM or mentalizing
cognitive empathy condition, whereas in- processes, mediated in the inferior pre-
sular activity was enhanced in the emo- frontal cortex as a premotor area and part
tional empathy condition in the patients of the “mirror” neuron system with its
with BPD compared with the healthy activity being associated with the con-
controls. Interestingly, activation in the scious representation and mirroring of
right middle insula was positively corre- actions and intentions (Coricelli 2005; Ia-
lated with skin conductance responses, coboni et al. 2005). Using the RMET, Bar-
indicating increased arousal in the pa- now et al. (2012) also found lower activi-
tients with BPD. Given that the tendency ties in mentalizing areas such as the right
to experience personal distress in re- superior temporal gyrus and the right
sponse to the suffering of others has been precuneus, as well as higher activity in
associated with middle insular activation the amygdala and the left inferior frontal
in healthy subjects (Decety and Moriguchi gyrus (Brodmann area 45), in patients
2007), this fMRI study was interpreted to with BPD compared to controls. Differ-
reflect increased arousal and personal ent results, however, were obtained by
distress in patients with BPD due to defi- Mier et al. (2013). This inconsistency in
cient emotion regulatory processes in the findings may result from differences in
interpersonal realm, hampering empa- the tasks presented: the task used by Mier
thy processes. Roepke and colleagues et al. explicitly challenged conscious pro-
(2012) claimed that empathy may nega- cessing of the other’s intentions, whereas
tively interact with emotion dysregula- the RMET asks the subject to identify the
tion—that is, that high emotional arousal other’s emotional state and may be re-
decreases cognitive as well as emotional solved by automatic simulation (i.e., by
empathy in patients with BPD. These au- resonating with the other person’s mental
state in concert with one’s own emotional motor, somatosensory, and nociceptive
response). representations while perceiving the ac-
In correspondence with the assumptions of others, and they activate repre-
tion of high automatic simulation (but sentations of their own emotional states
low conscious mentalizing of the other’s while observing others’ emotions. Inter-
emotional states and intentions), pa- estingly, the somatosensory response in
tients with BPD exhibited higher activity the primary somatosensory cortex was
of the musculus corrugator supercilii dur- found to be associated with the empathy
ing viewing of negative facial stimuli such subscale “perspective taking” not only in
as anger, sadness, and disgust (Matzke tasks observing painful stimulation in an-
et al. 2013) but lower electromyographic other person (Chen et al. 2008) but also in
activity in the musculus levator labii in tasks that require vicarious somatosen-
response to happy and surprised faces sory responses for simple touch (e.g.,
(i.e., faces that reflect emotional states Schaefer et al. 2012). The somatosensory
rather distinct from the subjects’ own). cortex is part of the mirror neuron system,
Consistent with these behavioral data, the further consisting of the ventral premotor
hyperactivation in the somatosensory area of the left inferior frontal cortex (area
cortex as well as in the amygdala in per- F5 in monkeys) and the rostral cortical
sons with BPD found by Mier et al. (2013) convexity of inferior parietal lobule.
is likely to reflect emotional simulation Sharing emotions of others without
processes of which the person is unaware self-awareness corresponds to the phe-
(Adolphs and Spezio 2006; Decety and nomenon of emotional contagion, which is
Meyer 2008). These processes, in addi- not based on the proper discrimination
tion to conscious ToM capabilities, are between one’s feelings and those of oth-
involved during performance of social ers. High affective empathy as found in
tasks containing facial cues. some but not all behavioral studies in
Emotional simulation theory proposes BPD, and which is sometimes called the
that in social primates the mental states of phenomenon of hypermentalizing (e.g.,
others can be understood on the basis of Sharp et al. 2011), may be designated as
one’s own mental state (Gallese and Gold- emotional contagion due to exaggerated
man 1998), encompassing an understand- resonance with others’ mental states trac-
ing of social situations that is immediate, ing back to identity diffusion in BPD. This
automatic, and almost reflex-like. “This phenomenon may hinder the ability of in-
particular dimension of social cognition is dividuals with BPD to experience sympa-
embodied, in that it mediates between the thy with others (i.e., to put themselves in
multimodal experiential knowledge of others’ shoes) and cause them, instead, to
our own lived body and the way we ex- be affected by their own emotions trig-
perience others” (Gallese 2007, p. 659). gered through the emotions of others. In
This basal mechanism is not related to any case, higher-order metacognitive pro-
higher cognitive functions, and it is less cesses may fail to modulate the lower-
prone to learned knowledge about social level automatic emotional contagion.
interactions (Frith and Frith 2006). The In the future, researchers should com-
understanding of others’ sensory experi- pare responses to tasks that use either
ences, rather, seems to rely on vicarious borderline-specific or non-borderline-
activation of somatosensory cortices in specific themes to test whether patients
the observer. Humans activate their own with BPD are able to feel sympathy by
“putting themselves in others’ shoes,” or expresser’s emotional state (Goldman and

whether they transfer their own feelings Sripada 2005; Lawrence and Calder 2004).
onto others, a mechanism similar to pro- More specifically, significantly reduced
jective identification, a common theoret- fractional anisotropy as an indirect mea-
ical notion in psychoanalysis. sure of microstructural integrity reported
from diffusion tensor imaging suggests
Social Cognition and that abnormal connectivity in the amyg-
dala-orbitofrontal network may contrib-
Empathy in Psychopathy ute to the neurobiological mechanisms
In a meta-analysis of 20 studies on find- underlying emotional detachment and
ings from antisocial subjects regarding impulsive antisocial behavior in psy-
the processing of human faces, Marsh chopathy (Craig et al. 2009).
and Blair (2008) reported a robust link be- Regarding capabilities in ToM func-
tween antisocial behavior and deficits in tions, psychopathic subjects have been
recognizing fearful expressions. Antiso- shown to have unimpaired cognitive em-
cial subjects also showed some deficits pathy. Psychopathic patients do well on
when processing sad faces; however, the Reading the Mind in the Eyes task,
these responses were less prominent than but they may perform this task by means
responses to fearful faces, so that a spe- of other mechanisms than those used by
cific rather than a global deficit in expres- patients with BPD—namely, by cogni-
sion processing may be characteristic of tively adopting the perspective of oth-
individuals with ASPD. In functional neu- ers. In fact, subjects with ASPD or psy-
roimaging studies, adolescents with early- chopathy, in particular, are probably good
onset, but not those with late-onset, con- at perceiving others’ intentions; how-
duct disorder exhibited reduced amyg- ever, they disregard the emotions of oth-
dala activation in response to sad faces ers. “The psychopath cannot simulate
when compared to neutral faces. How- emotions he cannot experience, and
ever, adolescents with conduct disorder, must rely exclusively on cognitive in-
independent of age at onset, showed di- puts to his theory of mind mechanism”
minished amygdala response to angry (Decety and Moriguchi 2007, p. 14). Emo-
faces when compared to neutral faces tional incapacity has been intensively in-
(Fairchild et al. 2009; Passamonti et al. vestigated in males with psychopathic
2010), and this deficit has been associated traits, but future research is needed to
with amygdala dysfunction of develop- investigate whether a reliable emotional
mental origin. Additionally, the process- deficit is also true for psychopathic fe-
ing of fearful facial expressions has been male offenders.
studied in individuals with psychopathy Studies in psychopathic offenders
who showed poor fearful expression rec- found reduced gray matter volumes in
ognition as well as poor startle response, cortical areas related to empathic pro-
and thus a failure of aversive cues to cessing and moral judgment (i.e., in an-
prime normal defensive action (Blair et terior rostral prefrontal cortex and tem-
al. 2004; Patrick 1994). The co-occurrence poral poles) (Gregory et al. 2012). Volume
of both deficiencies has been interpreted reductions were also found in midline
to reflect an amygdala-based fear simu- cortical areas (Bertsch et al. 2013a) in-
lation deficit that explains reduced fear volved in the processing of self-referen-
response and is associated with an im- tial information and self-reflection (i.e.,
pairment in the capacity to identify the the dorsomedial prefrontal cortex and
posterior cingulate/precuneus) and in to a wide range of oxytocin receptors

recognizing emotions of others (i.e., the throughout forebrain structures, includ-
postcentral gyrus). Consistent with these ing amygdala (Knobloch et al. 2012).
findings, the psychopathy scores of indi- Oxytocin modulates the formation of
viduals who were instructed to perform social memories as well as the processing
moral compared with nonmoral decision- of social cues, such as facial expressions.
making processes were found to corre- A number of studies now shed light on the
late with decreased activation in an area specific facial processes in which oxytocin
extending from dorsolateral prefrontal is involved: oxytocin improves the recog-
cortex to medial prefrontal cortex (Reniers nition of emotions (Lischke et al. 2012)
et al. 2012). The authors suggested that and enhances early attentional processes
moral decision making entails intact selectively of happy faces (Domes et al.
self-referential and mentalizing process- 2013); it appears to enhance the recogni-
ing, which appears to be disrupted in tion of emotional expressions in static (Di
psychopathic individuals. However, in Simplicio et al. 2009; Guastella et al. 2010;
the study by Bertsch et al. (2013a), reduced Marsh et al. 2010) and dynamic (Fischer-
gray matter volumes in temporal poles, Shofty et al. 2010) images of faces; and it
compared with those in healthy control improves emotion recognition by direct-
subjects, were found not in those with ing attention to salient facial features,
ASPD and psychopathic traits, but rather such as the eyes (Gamer et al. 2010; Guas-
in criminal offenders with comorbid tella et al. 2008), with a higher perfor-
conditions of ASPD and BPD. mance when instructed to “read” the emo-
tional state of another from the eye region
Social Dysfunction and (Domes et al. 2006b). Interestingly, oxyto-
cin application was associated with
the Role of Oxytocin greater task-related pupil dilation, a find-
Oxytocin, the so-called prosocial hor- ing that also suggests increased recruit-
mone, plays a critical role in intimate rement of attentional resources (Prehn et al.
lationships such as parenting and roman- 2013). Furthermore, the latter study pro-
tic relationships; oxytocin may also, to vides the first evidence that oxytocin pro-
some degree, play a role in most mean- motes an attentional bias to positive so-
ingful interpersonal relationships. Oxy- cial cues; in correspondence with these
tocin is synthesized in magnocellular data, the intranasal administration of
neurons of the paraventricular and su- oxytocin was followed by increased rat-
praoptic nuclei of the hypothalamus, from ings of trustworthiness and attractiveness
which it is transported to the posterior pi- of unfamiliar faces in a study of healthy
tuitary, where it is released. Oxytocin re- volunteers by Theodoridou et al. (2009).
ceptors are especially prevalent in brain Oxytocin is thought not only to be in-
areas involved in social behaviors, involved in the attentional processing of sa-
cluding the bed nucleus of the stria termi- lient social cues, such as faces, but also to
nalis, the hypothalamic paraventricular interact with rewards associated with so-
nucleus, the amygdala, the ventral teg- cial interactions. Dopaminergic neurons
mental area, and the nucleus accumbens. running from the ventral tegmental area
Interestingly, in the animal model, oxyto- to the nucleus accumbens are responsible
cin neurons from the hypothalamic, para- for the active pathways facilitating the af-
ventricular, and supraoptic nuclei project filiation process. Interestingly, both areas
are known to show high density of oxyto- ward value of maternal attachment cues
cin receptors and to interact with the do- may be enhanced so that the quality of pa-
pamine system. One theory is that oxyto- rental cues may have greater implications
cin enhances the hedonic value of social for the child’s development (Gervai et
interactions by activating these areas that al. 2007).
are rich in dopamine receptors. Anatomi- Regarding BPD, Stanley and Siever
cal and immunocytochemical studies (2010) explored the hypothesis that the
have revealed that the receptor binding neurobiological underpinnings of mal-
sites and neuronal fibers of oxytocin and adaptive interpersonal functioning may
dopamine exist in the same central ner- be related to systems mediating affilia-
vous system regions, often in close appo- tion and affect regulation, which “shape
sition to each other (for a review, see the trajectory of interpersonal develop-
Baskerville and Douglas 2010), with oxy- ment in the context of the specific inter-
tocin-dopamine interactions within the personal environment” (p. 26). Recent
nucleus accumbens and the ventral teg- oxytocin studies in individuals with BPD
mental area probably being bidirectional. suggest reduced oxytocin concentrations
In addition, oxytocin may exert effects on in blood samples, even after controlling
dopamine release that mediate its effects for estrogen, progesterone, and contra-
on affiliation, social memory, and so on. ceptive intake (Bertsch et al. 2013b). Al-
In rodent mothers, suckling and ma- though plasma oxytocin correlated neg-
ternal cues (e.g., smell) related to their atively with experiences of childhood
infants enhance maternal care at least in trauma, in particular with emotional ne-
part by enhancing expression of oxyto- glect and abuse, the results of mediation
cin receptors in the nucleus accumbens analyses did not support a simple model
and the ventral tegmental area. Interest- of oxytocin being a prominent mediator
ingly, oxytocin has been shown to en- in the link between childhood trauma
hance the experience of attachment se- and BPD. Future studies are needed to
curity in humans (Buchheim et al. 2009). further elucidate the relationships among
Therefore, this effect may have early oxytocin in plasma and cerebrospinal
evolutionary primed roots: during early fluid, early adversity, attachment style,
development, interpersonal eye contact and adult interpersonal functioning. Re-
plays a particular role in facilitating the cently published oxytocin challenge stud-
development of dopaminergic-neuro- ies indicate that oxytocin decreases stress
peptidergic reward circuits that are later response not only in healthy individuals
responsive to social cues (Skuse and Galla- (Heinrichs et al. 2001, 2003, 2009) but
gher 2009). Therefore, oxytocin may pro- also in patients with BPD (Simeon et al.
mote interpersonal trust by inhibiting, 2011). Using the Trier Social Stress Test,
on the one hand, the hypothalamic-pitu- Simeon et al. (2011) found that intrana-
itary-adrenal (HPA) axis and defensive sal oxytocin application was followed by
behaviors and, on the other, activating a decrease of poststress dysphoria as well
dopaminergic reward circuits, enhancing as of cortisol response in patients with
the rewarding value of social encoun- BPD. In a study that applied a trust game
ters. Additionally, genetic studies sug- in which the payoff is highest for both
gest that in infants who carry the 4-repeat players in case of successful cooperation,
variant of the dopamine receptor D4 al- oxytocin was not found to uniformly fa-
lele (DRD4) (which is associated with cilitate trust and prosocial behavior in a
more efficient dopamine function), the re- gender-mixed sample of BPD individu-
als; rather, behavior depended on attach- sion by NSSI can be understood as a dys-
ment style (Bartz et al. 2010). Although functional coping mechanism of patients
analyses did not find more trusting be- with BPD when they try to regulate emo-
havior in patients with BPD following tions (Favazza 1989; Paris 1995) and as a
oxytocin challenge, data revealed that negative reinforcer for repetitive dys-
this neuropeptide promoted actual coop- functional behavior.
erative behavior for anxiously attached “Tension release” (Herpertz 1995) and
but low avoidant individuals but im- relief or escape from emotions (Brown et
peded cooperative behavior for anxiously al. 2002; Chapman et al. 2006; Kleindienst
attached, intimacy-avoidant individu- et al. 2008) are thought to be the predom-
als. Future studies should systematically inant motives for NSSI, although several
investigate the association between cen- studies revealed that motives of NSSI in
tral oxytocin function and attachment patients with BPD are complex and can-
style. not be easily reduced to a single reason.
Research on the role of oxytocin in the NSSI is also used to terminate symptoms
etiology and neurobiology of BPD is still of dissociation such as derealization and
in its infancy. Future studies on the mod- depersonalization. Further motives com-
ulating effects of oxytocin administration prise self-punishment, feeling physical
on face processing and more complex so- pain, reducing anxiety and despair, emo-
cial cognition functions are needed. tion generation, controlling others, dis-
traction, and preventing oneself from act-
ing on suicidal feelings (Brown et al. 2002;
Perceptual Alterations Favazza 1989; Shearer 1994; Osuch et al.
1999).
Pain and Nonsuicidal Some limited understanding of the
neurobiological underpinnings of NSSI
Self-Injury is emerging. Self-injury in patients with
Nonsuicidal self-injury (NSSI) is frequent BPD is clearly related to emotion dysreg-
in patients with BPD and involves phe- ulation as well as disturbed pain pro-
nomena such as cutting, burning, and cessing. Several studies have demon-
head banging; these behaviors can usu- strated that self-injurious patients with
ally be relatively clearly distinguished BPD show reduced pain sensitivity in re-
from suicidal behavior (Nock 2009). In lation to emotional stress (Bohus et al.
patients with BPD, auto-aggression with- 2000; Ludascher et al. 2007; Schmahl et
out suicidal intent is usually repetitive, al. 2004). In the first study (Bohus et al.
has limited potential for serious or fatal 2000), patients were investigated twice,
physical harm, and involves a different under baseline conditions and during
spectrum of motives than suicidal or am- high levels of stress. Even under base-
bivalent auto-aggression (Brown et al. line conditions, pain sensitivity in the
2002; Favazza 1989; Herpertz 1995). There Cold Pressor Test was significantly lower
is robust evidence that patients with BPD in patients with BPD than in members of
use NSSI to achieve quick release from a healthy control group. During high lev-
strong aversive inner tension (Brown et els of stress, the same patients revealed a
al. 2002; Favazza 1989; Herpertz 1995; further decrease of pain sensitivity in
Kleindienst et al. 2008; Leibenluft et al. comparison to the baseline condition.
1987). Release from aversive inner ten- The close correlation between aversive
tension and pain sensitivity was also least 6 months with patients who showed
replicated on an interindividual level ongoing NSSI. Sensitivity to pain, includ-
(Ludascher et al. 2007). Reduced pain sen- ing laser and heat pain sensitivity, was
sitivity was confirmed using different measured in these two groups as well as in
methods of pain stimulation such as la- a healthy comparison group. Overall, a
ser (Schmahl et al. 2004) or heat (Schmahl linear trend was found, with the BPD
et al. 2006). group that had terminated NSSI ranging
It was also demonstrated that reduc- halfway between the BPD group with on-
tion of pain sensitivity is not related to a going NSSI and the healthy comparison
disturbance of the sensory-discrimina- group. These findings suggest that cessa-
tive component of pain processing but tion of self-injurious behavior leads to a
rather to an alteration of affective pain normalization of pain sensitivity in pa-
processing (Cardenas-Morales et al. 2011; tients with BPD. Further longitudinal
Schmahl et al. 2004). Spatial discrimina- studies, including those measuring pain
tion of laser pain stimuli was not dis- sensitivity before and after treatment, are
turbed in spite of reduced subjective pain necessary to further elucidate the interac-
perception (Schmahl et al. 2004). Also, lation between BPD symptom severity and
ser-evoked potentials including the P300 pain.
component as a measure of attentional On a neural level, reduced pain sensi-
processes were not reduced. This finding tivity is related to the activation of an an-
speaks for normal processing of pain tinociceptive network of brain regions in
from the periphery through the lateral patients with BPD. More specifically,
pain pathway to the somatosensory cor- tonic heat pain stimuli, which were ad-
tex. Cardenas-Morales et al. (2011) used justed for individual pain sensitivity
repetitive peripheral magnetic stimula- during an fMRI study, elicited higher ac-
tion to evoke pain in patients with BPD as tivity in dorsolateral prefrontal cortex
well as in healthy control participants. In together with reduced activity in amyg-
both groups, stimulus intensity was dala, perigenual anterior cingulate cor-
closely correlated with subjective pain tex, and posterior parietal cortex in pa-
perception. However, the correlation be- tients with BPD compared with healthy
tween stimulus intensity and affective age-matched control subjects (Schmahl
markers of pain was lost in patients with et al. 2006). In a follow-up study, this an-
BPD. These findings again speak for a tinociceptive pattern was more pro-
disturbance of the affective processing of nounced in patients with BPD and co-
pain in BPD while sensory processing occurring PTSD than in those with only
appears to be intact. In addition, a func- BPD (Kraus et al. 2009).
tional polymorphism (Val158Met) of the As mentioned in the first paragraph
gene coding for catechol-O-methyltrans- of this section, painful stimuli—for ex-
ferase distribution was found to be asso- ample, in the context of NSSI—appear to
ciated with cognitive neural pain process- play a decisive role in the dysfunctional
ing in healthy persons but with affective attempts of patients with BPD to regu-
neural pain processing in patients with late emotions. As cognitive methods of
BPD (Schmahl et al. 2012b). emotion regulation such as reappraisal
In an attempt to test the influence of appear not to be successful to restore
psychopathological states on pain sensi- prefrontal-limbic dysbalance in pa-
tivity, Ludascher et al. (2009) compared tients with BPD (Koenigsberg et al. 2009;
patients who had not inflicted NSSI for at Schulze et al. 2011), one can speculate
that painful stimulation may have an ef- challenging task. In a first attempt to in-
fect on brain activation in regions related vestigate the role of tissue damage in the
to emotion regulation. Indeed, thermal context of NSSI, Reitz et al. (2012) studied
stimuli—independent of painfulness— incision-induced pain in patients with
led to a reduction of stress-induced amyg- BPD. In a pilot study, stress was first in-
dala hyperactivity (Niedtfeld et al. 2010). duced by mental arithmetic under time
In this study, viewing of pictures to in- pressure and negative social feedback.
duce negative versus neutral affect was Directly after this stress induction, the in-
combined with thermal (painful and vestigator made a small incision with a
nonpainful) stimulation. Picture view- scalpel on the subject’s forearm and then
ing led to increased activity in the amyg- recorded subjective as well as objective
dala and insula in patients with BPD (heart rate) measures of stress. The inci-
compared with healthy control subjects; sion led to a decrease of aversive tension
then, both nonpainful warm and painful in patients with BPD but to a further in-
hot stimuli were related to a reduction of crease of aversive tension in healthy con-
these increased signals. In a later func- trols. Heart rate in patients with BPD de-
tional connectivity analysis, Niedtfeld et creased after the incision but not after a
al. (2012) found that only painful heat sham condition, in which the skin was
stimulation, but not nonpainful warm touched with the blunt end of the scalpel.
stimulation, following negative emo- Findings from a recent fMRI study sug-
tional pictures led to more negative cou- gest that the incision, but not the sham
pling of amygdala with medial prefron- treatment, leads to a restoration of the
tal cortex. This negative coupling, which typical poststress connectivity pattern be-
can be associated with a normal inhibi- tween amygdala and medial prefrontal
tory connection, was found to be present cortex (S. Reitz, R. Kluetsch, I. Niedtfeld,
in healthy control participants during et al., manuscript under review).
nonpainful warm stimulation. Taken to- From a neurochemical point of view,
gether, findings from this study suggest the endogenous opioid system appears
that in patients with BPD, painful stimuli to play an important role in the context
are necessary to restore inhibitory pre- of disturbed pain processing and NSSI
frontal-limbic connection. This may ex- (Bandelow et al. 2010; Stanley and Siever
plain why patients need strong painful 2010). The endogenous opioid system is
stimuli, as in the context of NSSI, to reg- related to stress-induced analgesia, a
ulate their emotional arousal. mechanism related to NSSI as discussed
From a perspective of experimental earlier in this section, as well as to disso-
psychopathology (i.e., modeling of patho- ciation in patients with BPD. NSSI and
logical behavior under laboratory condi- dissociation can be reduced by treat-
tions), several aspects of NSSI should be ment with the opioid antagonist naltrex-
considered when studies on its neurobio- one (Bohus et al. 1999; Schmahl et al.
logical background are being designed. 2012b; Sonne et al. 1996). One potential
NSSI is a complex behavioral pattern, mechanism, besides blocking opioid-
which comprises—besides painful expe- mediated positive reinforcement pro-
rience—other aspects such as tissue dam- cesses, is the reduction of stress-related
age or seeing one’s own blood flow. To dissociative symptoms by naltrexone,
model such a complex behavior under which reduces the need to terminate dis-
laboratory conditions is a difficult and sociative states by using NSSI.
Dissociation dissociation (Ebner-Priemer et al. 2005).

This finding may also be interpreted in
Dissociation is composed of varying de- the light of reduced amygdala activity
grees of depersonalization, derealiza- during dissociative states as suggested
tion, and reduced sensory perception, by Sierra and Berrios (1998). Results from
including reduced pain sensitivity. In a study investigating the influence of dis-
patients with BPD, dissociation is state sociation on emotional-cognitive pro-
dependent and closely related to stress cessing lends further evidence for the
levels (Ludascher et al. 2007; Stiglmayr model of emotional overmodulation; dis-
et al. 2008). Although dissociative states sociation scores were negatively corre-
can be reliably assessed, the investigation lated with activity in amygdala, insula,
of neurobiological processes underlying and anterior cingulate cortex during
dissociative states is relatively new. Pa- emotional distraction while BPD subjects
tients with dissociative identity disorder were performing a working memory task
revealed markedly reduced volumes of (Krause-Utz et al. 2012).
hippocampus and, particularly, amygdala The results of a classical conditioning
(Vermetten et al. 2006). On a neurophys- study highlight a potential negative side
iological level, reduced P300 amplitudes effect of dampened limbic, particularly
(Kirino 2006), altered magnetoencepha- amygdala, activity: a significant reduc-
lography-measured brain waves (Ray et tion of fear conditioning and emotional
al. 2006), and altered cortical excitability learning processes during dissociative
(Spitzer et al. 2004) have been associated states (Ebner-Priemer et al. 2009). When
with dissociative experience in patients patients with BPD were retrospectively
and healthy control subjects. A close cor- separated into two groups (those with
relation between pain sensitivity and dis- dissociation during fear conditioning
sociation levels has also been demon- and those without), only those without
strated experimentally (Ludascher et al. dissociation revealed normal fear condi-
2007, 2010). In these studies, dissociation tioning processes, whereas patients with
was related to reduced pain sensitivity. dissociation did not show differential
It has been suggested that dissociation conditioning in terms of skin conduc-
constitutes an emotional overmodulation tance responses or emotional valence
mode in response to experience of (trau- coding. This experiment was repeated
matic) stress as opposed to an emotional using experimentally induced (script-
undermodulation mode with predomi- driven imagery) dissociative states. Script-
nant intrusive symptoms, and that these driven imagery is well suited to specifi-
two modes can also be segregated on a cally inducing dissociation in patients
neurofunctional level (Sierra and Berrios with BPD (Ludascher et al. 2010). Indi-
1998; Lanius et al. 2010; Ludascher et al. vidual situations eliciting dissociation
2010). Particularly, overactivity of medial are depicted for each patient. During the
prefrontal brain regions with concomi- presentation of the script, higher values
tant limbic down-regulation is thought to for dissociation as well as reduced pain
underlie dissociative psychopathology. sensitivity during induced dissociation
Corroboration of these assumptions were found (Ludascher et al. 2010). After
comes from several sources. Patients with script-induced dissociation, classical con-
BPD and high levels of dissociation had ditioning was again demonstrated to be
significantly lower startle responses com- disturbed in patients with BPD, and this
pared with patients with low levels of disturbance appeared to be based on al-
terations in amygdalar and hippocam- species-specific defense reaction (SSDR) the-

pal processing (Friederike Schriner, per- ory. When an animal is confronted by a
sonal communication, August 15, 2013). natural environmental threat (e.g., a pred-
Given the disturbance of emotional ator) or an artificial one (e.g., an electri-
learning processes in relation to changes cal shock), its behavioral repertoire be-
in limbic brain activity, it is not surpris- comes restricted to its SSDRs. Freeze,
ing to find a profound negative impact fight, and flight are examples of SSDRs.
of dissociation on psychotherapy out- The so-called defensive behavior system
come, because most psychological treat- (Fanselow 1994) is organized by the im-
ments rely on basic learning processes to minence of a predator and can be divided
reach changes in psychopathology. In into three stages: preencounter, posten-
several psychiatric disorders, dissocia- counter, and circa-strike. Preencounter de-
tion could be demonstrated to be a neg- fensive behaviors comprise reorganiza-
ative predictor of psychotherapy out- tion of meal patterns and protective nest
come (Rufer et al. 2006; Spitzer et al. maintenance, if an animal has to leave a
2007). In a study in patients with BPD, safe nesting area. When the level of fear
high baseline scores on the Dissociative increases (e.g., because of actual detection
Experience Scale predicted poor improve- of a predator), the postencounter defensive
ment after a 3-month course of dialecti- behavior mode becomes active. This mode
cal behavior therapy, even after control- includes multiple dimensions (Bohus et al.
ling for overall baseline symptom severity 1996; Fanselow 1994; Mayer and Fan-
(Kleindienst et al. 2011). selow 2003): 1) a motor component (freez-
The construct of dissociation has been ing), 2) a sensory component (opiate anal-
derived from clinical experience as well gesia), 3) an autonomic component
as research in humans. There is to date (activity of the sympathetic and para-
no animal model for dissociation. Hence, sympathetic nervous systems), 4) an en-
animal research must rely on human an- docrinological component (HPA axis),
alogues of this phenomenon. Transla- and 5) an emotional component (anxi-
tional research has to develop research ety). In the case of physical contact (e.g.,
designs to study these components in by the experience of pain), the animal en-
parallel in animals and humans. gages in more active defenses, such as
Dissociation is a phylogenetically biting and jumping. This is an example of
evolved, complex behavioral pattern circa-strike behavior. Analogies between
with species-specific modifications. One these types of animal behavior and disso-
possible analogue of dissociation in ciation in humans have been discussed
animals can be derived from behavioral (Nijenhuis and den Boer 2007).
research using fear-conditioning para- In animals, critical anatomical struc-
digms. The behavior systems approach tures for postencounter defensive behav-
views an animal as having a set of several ior are the amygdala, the ventral periaq-
genetically determined, prepackaged be- ueductal gray, and the hypothalamus (for
haviors that it uses to solve particular an overview, see Brandao et al. 2008). The
functional problems. If the problem has amygdala has a central relay function or
to be solved immediately, the animal’s mediation of postencounter defensive be-
behavioral repertoire becomes restricted havior with important glutamatergic in-
to those genetically hardwired behaviors. put from the thalamus to the lateral amyg-
This was outlined by Bolles (1970) in his dala (Fanselow 1994). Furthermore, the
central amygdala mediates transfer of in-

formation about the threat level to the Conclusion
ventral periaqueductal gray (PAG), which
in turn appears to mediate analgesia and Research in the field of specific types of
freezing by opioidergic neurotransmis- PDs, particularly BPD and ASPD, has
sion (Fanselow and Gale 2003; LeDoux significantly deepened the understand-
1992). The switch between freezing and ing of the nature of these disorders by
more active behavioral patterns (fight, applying methods of experimental psy-
flight) appears to involve two parts of the chopathology and neuroscience. Al-
PAG: whereas freezing is mediated by the though affect regulation—the pathologi-
ventral PAG, fight and flight responses cal trait of emotional lability, according to
involve the dorsal PAG (Brandao et al. DSM-5 Section III, “Emerging Measures
2008). Autonomic and endocrinological and Models”—is the functional domain
responses are mediated by connections of that has been most intensively studied in
the amygdala with the hypothalamus PDs, recent research has focused on the
(LeDoux et al. 1988). The exact localiza- interpersonal domain and on perception
tion of the emotional component is un- issues. Future studies should conflate
clear but can be assumed to rely on amyg- these approaches by giving priority to
dala-prefrontal cortex pathways (LeDoux detecting the unfavorable interaction be-
2002). Circa-strike behavior is mediated tween these domains. The alternative
by the superior colliculus and the dorso- model for PDs in Section III of DSM-5
lateral PAG, which receive nociceptive provides an elaborate classificatory ap-
input from the spinal cord and the tri- proach to future studies in this field,
geminal nucleus (Blomqvist and Craig making possible more homogeneous
1991). In phylogenetically more recent samples of patients to include in research
species, such as humans, these systems studies. The evaluation of the degree and
can be assumed to be usually controlled quality of impairment of interpersonal
by higher cortical regions and to be acti- functioning (empathy and intimacy) will
vated under high levels of stress. enable clinicians and researchers to pro-
It can be hypothesized that dissocia- foundly describe interpersonal dysfunc-
tion is the representation of the post- tioning in patients beyond nosological
encounter defense mode in humans, com- categorization and to identify its relation
prising the same dimensions as described to brain dysfunctions and facilitate trans-
in animals but extended by an emotional- lational research.
psychological component (depersonali- Although animal models related to
zation, derealization, and emotional the complex psychopathology of PDs are
numbness). In this model, self-destruc- still at the very beginning, they promise
tive behavior, which can be observed fre- further advance in understanding gene
quently during dissociative states, such u environment interactions and their
as in patients with BPD, may represent an epigenetic modulations in individuals
analogue of the pain-induced switch of prone to be highly vulnerable to adversity
behavioral modes from postencounter to throughout their lives. Finally, transla-
the circa-strike behavioral mode in a hu- tional research not only can contribute to
man being faced with high levels of aver- clarifying the pathophysiology of PDs
sive stress. but, based on a deepened understanding
of treatment mechanisms, also contribute
to developing innovative treatment op- Blair RJR, Mitchell DG, Peschardt KS, et al:
tions, whether it is psychotherapy or Reduced sensitivity to others’ fearful ex-
pressions in psychopathic individuals.
pharmacological add-on treatments with
Pers Indiv Dif 37:1111–1122, 2004
substances that may enhance psycho- Blomqvist A, Craig AD: Organization of spi-
therapeutic effects, such as oxytocin in nal and trigeminal input to the PAG, in
the interpersonal realm. The Midbrain Periaqueductal Grey Mat-
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C H A P T E R 24
An Alternative Model for

DSM-5 Section III and Beyond
The diagnosis of personality dis- that PDs are prevalent in both clinical
orders (PDs) according to explicit crite- and community settings. They are asso-
ria, and their placement on Axis II of the ciated with high rates of social and occu-
multiaxial diagnostic system of DSM-III pational impairment and predict slower
(American Psychiatric Association 1980), recovery, more likely relapse, and a
have had beneficial effects on this often more chronic course for a host of other
confusing and poorly understood area mental disorders. These broad effects of
of psychopathology. Since the innova- personality psychopathology have costly
tions of DSM-III, assessment methods implications for both individual well-
have been developed and refined, and being and society.
sound research on PDs has increased dra- Critiques of DSM’s approach to the di-
matically. Axis II provided a framework agnosis of PD, however, appeared al-
with which to determine the independent most immediately after the publication of
consequences of personality psychopa- DSM-III (Frances 1980, 1982). DSM’s ex-
thology for the individual and for soci- clusively categorical approach has re-
ety and the impact of PDs on the course sulted in well-documented problems:
and outcomes of other forms of psycho- extensive co-occurrence of PDs such that
pathology. It is now generally understood most patients receiving a PD diagnosis
The authors would like to thank the members of the DSM-5 Personality and Personality Disor-
ders Work Group, and especially Robert F. Krueger, Ph.D., Lee Anna Clark, Ph.D., and Leslie
C. Morey, Ph.D., for their contributions to this chapter.
511
have personality features that meet cri- to the PD section that would begin to rec-
teria for more than one (e.g., Grant et al. tify some of these problems (Kupfer et
2005; Oldham et al. 1992; Zimmerman et al. 2002; Rounsaville et al. 2002). When
al. 2005); extreme heterogeneity among the work group began its deliberations,
patients with the same PD diagnosis, a study endorsed by influential North
meaning that two patients with a partic- American (Association for Research on
ular disorder may share very few features Personality Disorders) and international
(Johansen et al. 2004); temporal instabil- (International Society for the Study of
ity of PD diagnoses occurring at rates in- Personality Disorders) PD research orga-
compatible with the basic definition of a nizations surveyed PD experts and found
PD (Gunderson et al. 2011; Zanarini et that 74% thought that the DSM-IV cate-
al. 2012); arbitrary diagnostic thresholds gorical approach to PDs should be re-
in polythetic criteria sets with little or no placed, 87% stated that personality
empirical basis, resulting in the reifica- pathology was dimensional in nature,
tion of disorders as present or absent and 70% supported a mixed categorical-
with variable levels of underlying pa- dimensional approach to PD diagnosis as
thology (Balsis et al. 2011) and limited the most desirable alternative to DSM-IV
validity and clinical utility (Hyman 2010; (Bernstein et al. 2007). Hybrid models
Morey et al. 2007, 2012); poor coverage combining elements of dimensions and
of personality pathology such that the categories have been suggested by PD ex-
diagnosis of PD not otherwise specified perts since before the publication of DSM-
(PDNOS) has been the most commonly IV (Benjamin 1993; Blashfield 1993).
diagnosed (Verheul and Widiger 2004); Such a categorical-dimensional hybrid
and poor convergent validity of PD cri- had been developed in a DSM-5 plan-
teria sets such that patient groups diag- ning meeting (Krueger et al. 2007), which
nosed by different methods may be only preceded the formation of the P&PD
weakly related to one another (Clark et Work Group and the start of work group
al. 1997). None of these problems was suc- discussions. A mixed approach improves
cessfully addressed in the ensuing itera- on the DSM-IV system by striking a bal-
tions of DSM, including DSM-IV (Ameri- ance between introducing new elements
can Psychiatric Association 1994). called for by the field (e.g., dimensional
As a consequence of these myriad elements) and maintaining continuity
problems, DSM-IV PD diagnoses have (e.g., preservation of PD categories)—an
often not been used (e.g., “Diagnosis De- approach that takes into account re-
ferred on Axis II”), have been underused search developments since the time of
(e.g., PDNOS), or have been erroneously DSM-III, while still aiming to be mini-
used (e.g., diagnoses made on the basis mally disruptive to clinical practice and
of too few of the required criteria). De- research.
spite these long-recognized and signifi- The alternative model for PDs in
cant shortcomings, however, the criteria DSM-5 Section III, “Emerging Measures
for PDs in DSM-5 Section II, “Diagnostic and Models” (American Psychiatric As-
Criteria and Codes,” have not changed sociation 2013), consists of assessments
from those in DSM-IV. of the following: 1) new general criteria
The Personality and Personality Disor- for PDs, 2) impairment in personality
ders (P&PD) Work Group for DSM-5 was functioning, 3) pathological personality
charged with developing a new approach traits, and 4) criteria for six specific PDs.
An Alternative Model for Personality Disorders 513
Impairments in personality functioning In the DSM-5 Section III GCPD (see

and pathological personality traits are the appendix to this textbook), the DSM-
fundamentally dimensional in nature IV A criterion is divided into two crite-
and, when combined with other DSM- ria: the new Criterion A requires moder-
IV-like inclusion and exclusion criteria, ate or greater impairment in personality
yield categorical diagnoses of the six PDs functioning, and the new Criterion B re-
and a category called personality disor- quires the presence of pathological per-
der–trait specified (PD-TS) for all other sonality traits. All PDs in Section III in-
PD presentations. All six of these PDs clude specific, typical expressions of these
were included in DSM-IV, but in the new A and B criteria, and PD-TS includes the
model they are more consistently and co- GCPD A and B criteria themselves, mak-
herently represented by impairment and ing all PD diagnoses in DSM-5 Section III
trait manifestations. In this chapter, we consistent with the GCPD.
review the rationale behind the alterna-
tive, hybrid model and discuss future Impairment in Personality
research needs relevant to the possible
inclusion of the model in the main sec- (Self and Interpersonal)
tion of the next revision of DSM. Functioning
Self and interpersonal impairments are
at the core of personality psychopathol-
General Criteria for ogy. Hopwood et al. (2011) demonstrated
Personality Disorder empirically that the DSM-IV PD criteria
most strongly related to a PD severity
The DSM-IV general criteria for a PD dimension (based on a count of all crite-
(GCPD) describe an enduring pattern of ria) were preoccupation with social re-
inner experience and behavior that is jection, fear of social ineptness, feelings
manifest in two or more of the following of inadequacy, anger, identity disturbance,
areas: cognition, affectivity, interper- and paranoid ideation. The nature and
sonal functioning, and impulse control. importance of these criteria are consis-
These general criteria were introduced tent with the proposition that at the core
without justification or indication of an of PDs of all types is disturbance in how
empirical basis. There is no mention of one views one’s self and other people. Pre-
the GCPD in the PD chapters of the DSM- viously, Morey (2005) demonstrated that
IV Sourcebook (Gunderson 1996; Widiger difficulties in empathic capacity, at vary-
et al. 1996) or in papers that described ing levels, can be found at the core of all
the development of the revised classifi- types of personality psychopathology
cation (Frances et al. 1990, 1991; Pincus (for a detailed discussion of this self-
et al. 1992; Widiger et al. 1991). The other core of personality psychopathol-
DSM-IV GCPD do not appear to be spe- ogy, see Chapter 3, “Articulating a Core
cific for PDs; other chronic mental disor- Dimension of Personality Pathology,” in
ders seem likely to also meet the GCPD, this volume).
leading to problems in differential diag- DSM-IV PD criteria are heavily ori-
nosis. Furthermore, the specific criteria ented toward self and interpersonal dif-
for individual PDs in DSM-IV are often ficulties. In the DSM-IV GCPD, the “cog-
inconsistent with the GCPD, creating nition” area under Criterion A gives
additional possible confusion. “ways of perceiving and interpreting self,
other people, and events” as a definition. schemas centering on a self that is defec-
The “interpersonal” criterion refers to tive and shame-ridden, expecting to be
“interpersonal functioning” (American abandoned because of their shortcom-
Psychiatric Association 1994). Thus, the ings, and that persons with obsessive-
centrality of self and interpersonal is- compulsive PD (OCPD) are burdened
sues in PDs was recognized in DSM-IV by a schema of self-imposed, unrelenting
but was not represented systematically standards. Eikenaes et al. (2013) found
or consistently. Hundreds of studies have that patients with AVPD could be distin-
been conducted on the relations between guished from patients with social pho-
self and interpersonal constructs and per- bia on the basis of having more problems
sonality psychopathology. The inclusion with self-esteem, identity, and relation-
of impairment in self and interpersonal ships. Several studies have found the rep-
functioning in the GCPD of the DSM-5 resentations of self and others of patients
Section III model, and as core elements of with borderline PD (BPD) to be more elab-
the Level of Personality Functioning Scale orated and complex than those of other
(LPFS, see the following subsection) and types of patients, but also more distorted
the Section III PDs, is an explicit exten- and biased toward hostile attributions
sion of what was implicit in DSM-IV and (e.g., Blatt and Lerner 1983; Lerner and
has been well supported empirically. St. Peter 1984; Stuart et al. 1990; Westen
The process of formulating the core et al. 1990). For example, patients with
impairments in personality functioning BPD are significantly more likely to as-
that are central to PDs began with a liter- sign negative attributes and emotions to
ature review (Bender et al. 2011) that con- the picture of a face with a neutral expres-
sidered a number of reliable and valid sion (Donegan et al. 2003; Wagner and
clinician-administered measures for as- Linehan 1999).
sessing personality functioning and psy- Reliable ratings can be made on a broad
chopathology. The review demonstrated range of self-other constructs, such as
that a self-other dimensional perspective identity and identity integration, agency,
has an empirical basis and significant self-control, sense of relatedness, ca-
clinical utility. Numerous studies using pacity for emotional investment in and
measures of self and interpersonal func- maturity of relationships with others, re-
tioning have shown that a self-other ap- sponsibility, and social concordance. The
proach is informative in determining the most reliable (ICC t 0.75) dimensions
existence, type, and severity of personal- found in the measures considered in the
ity pathology. For example, Salvatore et review by Bender et al. (2011) were iden-
al. (2005) illustrated that patients with par- tity, self-direction, empathy, and intimacy.
anoid PD (PPD) typically see themselves These were retained for the definition of
as weak and inadequate, and view oth- personality functioning in the DSM-5 al-
ers as hostile and deceitful. Patients with ternative model. Definitions of these four
narcissistic PD (NPD) have been found elements are presented in Table 24–1.
to have dominant states of mind pervaded Self-other constructs have shown ro-
by distrust toward others and feelings of bust reliability and validity in charac-
either being excluded or being harmed terizing PDs. Criterion-level reliability
(Dimaggio et al. 2008). Jovev and Jackson studies have found that criteria related to
(2004) demonstrated that individuals with self (e.g., chronic emptiness, identity dis-
avoidant PD (AVPD) utilize maladaptive turbance) and interpersonal (e.g., unsta-
TABLE 24–1. Elements of personality functioning

Self:
1. Identity: Experience of oneself as unique, with clear boundaries between self and others;
stability of self-esteem and accuracy of self-appraisal; capacity for, and ability to regulate,
a range of emotional experience.
2. Self-direction: Pursuit of coherent and meaningful short-term and life goals; utilization of
constructive and prosocial internal standards of behavior; ability to self-reflect productively.
Interpersonal:
1. Empathy: Comprehension and appreciation of others’ experiences and motivations; tol-
erance of differing perspectives; understanding the effects of one’s own behavior on others.
2. Intimacy: Depth and duration of connection with others; desire and capacity for closeness;
mutuality of regard reflected in interpersonal behavior.
ble or stormy relationships) functioning mains distinguished patients with no PDs

are rated as having reliability equal to or from those with one PD and those with
greater than other BPD criteria (e.g., af- one PD from those with two or more PDs.
fective instability, physically self-damag- These results were replicated in a sam-
ing acts), with no significant differences ple of 767 adolescent patients and com-
between self and interpersonal criteria parison subjects by Feenstra et al. (2011),
(Frances et al. 1984; Gamache et al. 2009; who found that all 16 SIPP-118 personal-
Grilo et al. 2004, 2007; Gunderson et al. ity functioning facets reflected greater
1981; Pfohl et al. 1986; Zanarini et al. impairments in patients with PDs. Pa-
2002a, 2003). A two-item self-report mea- tients with the most PD traits (criteria)
sure of personality functioning (one self had the most impairment in the five do-
item, one interpersonal item) had good mains of the SIPP-118, with self-control
test-retest reliability across four DSM-5 and identity integration showing the larg-
Academic Centers Field Trial sites (pooled est differences. Berghuis et al. (2012) as-
ICC=0.686) (Narrow et al. 2013). sessed personality functioning with the
Verheul et al. (2008) assessed core com- General Assessment of Personality Dis-
ponents of personality functioning in order and the SIPP-118, PDs with the
2,730 patients and community members Structured Clinical Interview for DSM-
in the Netherlands using the Severity In- IV Axis II Personality Disorders (SCID-II),
dices of Personality Problems (SIPP- and personality traits with the NEO Per-
118), a self-report questionnaire. Twelve sonality Inventory—Revised (NEO-PI-
of 16 facets of personality functioning R) in 424 patients. Principal component
distinguished patients with PDs from both analysis clearly distinguished general
psychiatrically healthy comparison sub- personality dysfunction from personal-
jects and patients with other mental dis- ity traits. The general personality dysfunc-
orders, with a median effect size of 0.92 tion model consisted of three factors:
(moderate to large) for the differences self-identity dysfunction, relational dys-
between PD and normal samples. The 16 function, and prosocial functioning.
facets factored into five higher-order do- These three studies, involving almost
mains: self-control, identity integration, 4,000 patients and control subjects, lend
relational capacities, social concordance, strong support for the inclusion of im-
and responsibility. Each of the five do- pairment in personality functioning (both
self and interpersonal) in Criterion A of tute of Mental Health Research Domain

the GCPD. Criterion of “social processes” (Sanislow
Morey et al. (2011) conducted second- et al. 2010), in which “perception and un-
ary analyses of data from two of the pre- derstanding of self” and “perception and
viously mentioned studies in the Neth- understanding of others” are core con-
erlands (Berghuis et al. 2012; Verheul et structs. The interpersonal dimension of
al. 2008) with more than 2,000 patient personality pathology has been related to
and community subjects who had com- attachment and affiliative systems regu-
pleted the self-report measures of per- lated by neuropeptides (Stanley and
sonality functioning and had received Siever 2010), and variation in the encod-
semi-structured interview assessments ing of receptors for these neuropeptides
of DSM-IV PDs. Approximately 44% of may contribute to variation in complex
patients in the Berghuis sample and 52% human social behavior and social cogni-
in the Verheul sample met criteria for a tion, such as trust, altruism, social bond-
DSM-IV PD. Item Response Theory anal- ing, and the ability to infer the emotional
yses characterized the types of self and state of others (Donaldson and Young
interpersonal problems associated with 2008). Neural instantiations of the “self”
different levels of impairment as repre- and of empathy for others also have been
sented by the LPFS in DSM-5 Section III linked to the medial prefrontal cortex
(see the following subsection). The re- and other cortical midline structures—
sults delineated a coherent global dimen- the sites of the brain’s so-called “default
sion of impairment in personality func- network” (Fair et al. 2008; Northoff et al.
tioning that was related to the likelihood 2006; Preston et al. 2007; Qin and Northoff
of receiving any PD diagnosis, two or 2011).
more PD diagnoses, and one of the more Impairment in personality function-
severe PDs (e.g., BPD, STPD, ASPD) ing exists on a continuum, and empirical
(Morey et al. 2011). analyses determined the level at which a
Impairment in self and interpersonal “disorder” is diagnosed. Moderate im-
functioning is consistent with multiple pairment in personality functioning is
theories of PD and their research bases, required by the revised Criterion A. Mod-
including cognitive-behavioral, inter- erate impairment is indicated by a rating
personal, psychodynamic, attachment, of 2 or greater on the LPFS. Moderate im-
developmental, social-cognitive, and evo- pairment in personality functioning had
lutionary theories, and has been viewed as a sensitivity of 0.85, a specificity of 0.73,
a key aspect of personality pathology in and an area under the ROC (receiver op-
need of clinical attention (e.g., Clarkin erating characteristic) curve of 0.83 for a
and Huprich 2011; Hopwood et al. 2013b; DSM-IV PD in a study of 337 clinician-
Luyten and Blatt 2011, 2013; Pincus rated patients conducted by Morey et al.
2011). A factor-analytic study of existing (2013a). Requiring only mild impairment
measures of psychosocial functioning increased sensitivity (99%) but decreased
found “self-mastery” and “interpersonal specificity dramatically (15%). From the
and social relationships” to be two of four clinician’s point of view, therefore, a sin-
major factors (Ro and Clark 2009). Fur- gle-item rating on the LPFS constitutes a
thermore, personality functioning con- highly efficient and effective screen for
structs align well with the National Insti- the possible presence of a PD.
Level of Personality ment and maladaptive schemas have been

shown to be associated significantly with
Functioning Scale PD psychopathology and impairments
Research indicates that generalized se- in psychosocial functioning, as well as to
verity is the most important single pre- affect clinical outcome (e.g., Bender et al.
dictor of concurrent and prospective dys- 1997; Fonagy et al. 1996; Jovev and Jack-
function in assessing personality son 2004; Levy et al. 2006). Self-other di-
psychopathology (Hopwood et al. 2011). mensions have discriminated different
Furthermore, PDs are optimally charac- types of PD pathology, predicted various
terized by a generalized personality se- areas of psychosocial functioning, and
verity continuum with additional stylis- been shown to be moderators of treat-
tic elements, derived from both PD ment alliance and outcome (e.g., DeFife
symptom constellations (e.g., peculiarity) et al. 2013; Diguer et al. 2004; Feenstra et
and personality traits. There is wide con- al. 2011; Peters et al. 2006; Piper et al.
sensus (e.g., Crawford et al. 2011; Parker 2004; Verheul et al. 2008).
et al. 2002; Pulay et al. 2008; Tyrer 2005; For example, in a sample of 90 patients
Wakefield 1992, 2008) that severity as- in outpatient treatment, a Social Cogni-
sessment is essential to any dimensional tions and Object Relations Scale (SCORS)
system for personality psychopathology. composite was significantly correlated
Moreover, the ICD-11 PD Work Group has with psychosocial functioning measured
proposed severity as the central element by the Global Assessment of Functioning
of PD (Tyrer et al. 2011). Thus, the DSM-5 (GAF), the Global Assessment of Rela-
P&PD Work Group determined that a tional Functioning (GARF), and the So-
personality dysfunction severity scale cial and Occupational Functioning As-
would be a necessary improvement to sessment Scale (SOFAS) (Peters et al.
PD assessment for DSM-5, and included 2006). The correlation was strongest (0.53,
the LPFS in the Section III model (see the large effect) for relational functioning. In
appendix to this textbook). a sample of 294 adolescent patients, the
The LPFS uses each of the elements of composite self-other variables from the
personality functioning that are incorpo- SCORS predicted global functioning,
rated into Criterion A of the alternative school functioning, externalizing behav-
model—identity, self-direction, empathy, ior, and past hospitalization (DeFife et al.
and intimacy—to differentiate five levels 2013). In this study, the SCORS compos-
of impairment on a continuum of sever- ite significantly predicted variance in the
ity ranging from little or no impairment domains of adaptive functioning above
(Level 0) to extreme impairment (Level 4). and beyond age and DSM-IV PD diagno-
The appendix to this textbook provides sis. In another sample of 378 adolescent
the full LPFS with definitions for every patients and 389 community adolescents
level of functioning. In the DSM-5 Aca- (Feenstra et al. 2011), the total amount of
demic Center Field Trials, the LPFS was PD pathology, as represented by the num-
rated with adequate test-retest reliabil- ber of diagnostic criteria met, was signif-
ity overall (ICC=0.416) by untrained but icantly related to the amount of impair-
experienced clinicians, and rated with ment in the domains of self-control,
higher reliability than a number of other identity integration, relational capacities,
DSM-5 dimensional measures. social concordance, and responsibility, as
With respect to utility, self-interper- measured by the SIPP-118. These studies
sonal problems such as insecure attach- support the clinical significance of mea-
suring severity of impairment in person- change, for example as a result of treat-

ality functioning on a continuum. ment. Thus, the LPFS provides a useful
The severity of impairment in self dimensional severity assessment capa-
and interpersonal functioning also has bility to the realm of DSM PDs.
predicted empirically important factors
such as treatment utilization and treat- Pathological Personality
ment course and outcome (e.g., Acker-
man et al. 2000; Bateman and Fonagy
Traits
2008; Feenstra et al. 2011; Harpaz-Rotem DSM-IV (and DSM-5 Section II) defines
and Blatt 2009; Piper et al. 2004; Verheul personality traits as “enduring patterns
et al. 2008; Vermote et al. 2010). The de- of perceiving, relating to, and thinking
gree of impairment in personality func- about the environment and oneself that
tioning shows short-term stability but is are exhibited in a wide range of social
sensitive to change. For example, in a and personal contexts” (American Psychi-
sample of university students, 14- to 21- atric Association 1994, p. 630) and states
day test-retest reliabilities of SIPP-118 that it is “only when personality traits
domains were very good to excellent, are inflexible and maladaptive and cause
with correlations ranging from 0.87 for significant functional impairment or sub-
social concordance to 0.95 for self-con- jective distress [that] they constitute Per-
trol (median =0.93) (Verheul et al. 2008). sonality Disorders” (p. 630). For each spe-
In 60 patients in that study who were cific DSM-IV PD, a brief summary of its
treated for an average of 11+ months as particular “pattern” (i.e., defining traits)
outpatients or in a day hospital and fol- is provided in the criteria “stem,” which
lowed-up after 2 years, SIPP-118 do- is followed by seven to nine specific cri-
mains of self-control, identity integra- teria designed to indicate the pattern.
tion, and responsibility gradually For example, diagnosis of BPD indicates
improved over time, relational capaci- a pattern of “instability of interpersonal
ties improved over the first year, and so- relationships, self-image, and affects,
cial concordance improved during the and marked impulsivity,” with five or
second year. In a subsample of 53 ado- more of nine specific criteria that rep-
lescents in the Feenstra et al. (2011) resent manifestations of this pattern re-
study who were treated as inpatients, 14 quired.
of 16 facets of the SIPP-118 showed sig- Thus, DSM-IV defines PDs in terms of
nificant improvement after 1 year, with personality traits. However, there are a
effect sizes ranging from 0.37 to 1.24, in- number of shortcomings of the DSM-IV
dicating small to very large effects. In a implementation of maladaptive person-
study of interpretative treatment in 72 ality traits for describing PDs that the
outpatients, level of the quality of object DSM-5 Section III model sought to rec-
relations predicted outcome measured tify. First, DSM-IV does not provide a
by general symptomatology and dys- comprehensive set of maladaptive per-
function (including self-esteem and in- sonality traits for the criteria of PDs. In-
terpersonal distress) and by social and stead, 79 specific (adult) PD criteria are
sexual maladjustment (Piper et al. 2004). provided, which together are an amal-
These studies illustrate that the self-other gam of traits, behaviors, symptoms, and
dimension is not subject to brief changes consequences. Second, for some DSM-IV
in clinical state but can reflect adaptive PDs, there are inconsistencies between
the defining trait(s) (i.e., those in the or sexual partner,” would not apply to a
“stem”) and the specific criteria by which person who has no partner, effectively
the trait(s) is to be indicated. For exam- limiting the number of criteria available
ple, STPD is defined by two basic traits: for the diagnosis. Criterion 1 of AVPD,
1) discomfort with, and reduced capacity “avoids occupational activities that in-
for, close relationships and 2) cognitive volve significant interpersonal contact,”
or perceptual distortions and eccentrici- could not apply to one of the spouses in
ties of behavior. However, because STPD a single-earner, two-person household,
is then indicated by nine criteria—four of or to a retired person.
which relate to interpersonal discomfort To address these shortcomings, the
and five of which relate to cognitive dis- DSM-5 P&PD Work Group recommended
tortions and eccentricity—and any five a number of changes. First, the DSM-5
of these nine criteria are sufficient for a Section III model provides a set of 25 mal-
diagnosis, it is possible to meet criteria adaptive personality trait facets whose
for STPD with no indicators of one of the empirically based structure reflects that
two presumed principal traits. For some of the well-established five-factor model
DSM-IV PDs, criteria indicators do not (FFM) of personality traits. The model is
appear to reflect the disorder’s defining an extension of the FFM of personality
trait(s). For example, ASPD is defined in that specifically delineates and encom-
DSM-IV as “disregard for and violation passes the more extreme and maladaptive
of the rights of others,” but Criterion 3, personality variants necessary to capture
“impulsivity or failure to plan ahead,” the maladaptive personality dispositions
does not necessarily reflect this trait, be- of individuals with PDs (Costa and Widi-
cause impulsivity need not result in the ger 2002). The model includes five broad,
violation of others’ rights. higher-order personality trait domains—
Furthermore, the DSM-IV PD diagnos- Negative Affectivity, Detachment, An-
tic criteria provide a very limited set of tagonism, Disinhibition, and Psychoti-
indicators for each defining trait. In most cism—each comprised of three to nine
cases, there are four or five indicators for lower-order, more specific trait facets that
a defining trait, which are too few for an are representative of the domains (e.g.,
internally consistent (reliable) assess- manipulativeness and callousness are
ment (Clark and Watson 1995). The results two of the seven specific facets in the An-
of four studies of the internal consistency tagonism domain) (Krueger and Eaton
of DSM criteria sets with a combined sam- 2010; Krueger et al. 2011a, 2011b, 2012;
ple size of 980 show that no PD had an Wright et al. 2012b). Trait domains and
average alpha coefficient of 0.80; only facets can be rated by clinicians on 4-
avoidant and dependent PDs had aver- point dimensional scales of descriptive-
age alphast0.70, indicating less than op- ness, and patient-report and lay infor-
timal reliability (Blais et al. 1998; Clark et mant-report forms have also been devel-
al. 2009; Morey1988; Warren and South oped. The structural validity of an original
2009). Finally, the specific trait indicators 37-trait model was tested in a three-wave
of the DSM-IV PDs have limited applica- community survey (Krueger et al. 2011b,
bility across gender, age, culture, or life 2012), and the model was subsequently
circumstances. For example, Criterion 7 revised to yield the five-domain, 25-trait
of PPD, “recurrent suspicions, without model on which the DSM-5 Section III di-
justification, regarding fidelity of spouse agnostic criteria for PDs are based.
There is extensive evidence that the From a psychometric perspective, per-

FFM represents a universal structure of sonality traits can be assessed reliably.
personality traits that encompasses both For example, the personality trait do-
the normal and abnormal range of traits mains all had very good test-retest reli-
in both self and observer ratings, as well ability in the DSM-5 Academic Centers
as across age groups and diverse cul- Field Trials, as measured by a 36-item self-
tures (McCrae and Costa 1997). For ex- report Patient Rated Personality Scale
ample, Yamagata et al. (2006) found high (ICCs ranged from 0.84 for Negative Af-
congruence for the FFM across descrip- fectivity to 0.77 for Antagonism and av-
tive, genetic, and environmental factors eraged 0.81). Structured interviews for
in three countries (Canada, Germany, personality traits also show strong psy-
and Japan) in a sample of 1,209 monozy- chometric properties: Stepp et al. (2005)
gotic and 701 dizygotic twin pairs, and reported ICCs!0.90 for all domains and
De Fruyt et al. (2009) found a universal facets of the Structured Interview for the
structure in observer ratings of over 5,000 Five-Factor Model (SIFFM) in clinical
adolescents in 24 countries. The initial and nonclinical samples.
set of 37 recommended traits was refined The DSM-5 Section III model lists the
empirically using representative popu- component traits for six specific PDs (see
lation samples (including treatment- section “Translation of Six DSM-IV Per-
seeking samples), as described by Krueger sonality Disorders” later in this chapter).
et al. (2012). The appendix to this text- For PD-TS, the clinician is directed sim-
book lists the definitions of the five PD ply to note the patient’s prominent mal-
trait domains and 25 facets of DSM-5. adaptive personality traits, whichever
(Further explanation on how to evaluate they may be. To maximize continuity
and rate traits can be found in Chapter 7, with the DSM-IV PDs and also to create
“Manifestations, Assessment, and Dif- a tighter connection between the hall-
ferential Diagnosis,” in this volume.) mark features of PDs and the criteria re-
Next, the DSM-5 Section III GCPD required to make a diagnosis, threshold al-
quires that there be one or more patho- gorithms for diagnoses are provided for
logical traits to diagnose PD. This re- the specific DSM-5 Section III PDs. For
quirement provides continuity with the example, ASPD is defined by four spe-
DSM-IV definition of PD (as maladap- cific trait facets of the higher-order trait
tive personality traits) and with DSM-IV domain of Antagonism and three spe-
PD diagnoses. Then, rather than provid- cific trait facets of the higher-order trait
ing a limited set of indicators for the domain of Disinhibition. As determined
traits of each PD, the DSM-5 Section III by empirical methods (Morey and Skodol
model includes the traits themselves to 2013), a total of six of these seven trait fac-
comprise the B criteria. Using traits as in- ets are required for diagnosis, thus ensur-
dicators solves the current problems of ing that there are at least two trait facets
the lack of correspondence between the from each of the broad domains that com-
defining traits of the PDs and the specific prise the trait set of ASPD (see also later
indicators and allows for variation in the subsection “Diagnostic Thresholds”).
expression of traits, depending on an in- The 25 facet-level Personality In-
dividual’s circumstances and personal ventory for DSM-5 (PID-5) scales have
characteristics (e.g., age). been shown to be reliable (alphas re-
ported by Krueger et al. [2012] ranged pirically structured set of trait facets also
from 0.72 to 0.96 in the normative U.S. explains overlap between some disor-
population sample, with a median of ders that do not have any facets in com-
0.86). Domain-level scales of the PID-5 mon because of the hierarchical structure
are also highly reliable because they con- of personality traits. Specifically, PDs
sist of empirically based combinations that are characterized by facets from the
of facet-level scales (range=0.84–0.96). same domain can be expected to overlap
(The PID-5, available in several ver- more than those whose facets are from
sions, can be accessed online at http:// different domains, because trait facets
www.psychiatry.org/practice/dsm/ within a domain are more strongly inter-
dsm5/online-assessment-measures.) correlated than trait facets across distinct
domains. Thus, even though ASPD and
Comprehensive Coverage of NPD share no specific trait facets, they
DSM-IV Personality Disorders may be expected to co-occur with some
An initial investigation of the link be- frequency because traits in the Antago-
tween the DSM-5 facets and DSM-IV PDs nism domain characterize both types.
was provided by Hopwood et al. (2012). Thus, although the DSM-5 formulation
DSM-IV PDs were assessed with the Per- does not eliminate the comorbidity built
sonality Diagnostic Questionnaire–4 into the DSM-IV system, the observed
(PDQ-4; Hyler 1994), a 99-item self-re- empirical overlap is now well explained
port instrument that assesses each of the via shared traits within the hierarchical
diagnostic criteria for the 10 DSM-IV PDs. empirical structure of personality trait
Traits proposed for DSM-5 PD types (see variation, and by the core components of
Table 24–2), as assessed by the PID-5, ex- the LPFS (see also Chapter 3, “Articulating
plained substantial variance in DSM-IV a Core Dimension of Personality Pathol-
PDs as assessed by the PDQ-4, and trait ogy,” in this volume).
indicators for the six PDs were mostly Convergence With the
specific for those disorders. Traits and an
indicator of general personality pathol-
Empirical Structure of
ogy severity also provided incremental Personality
information about PDs in this study, In addition to providing reproductions
further supporting the validity of the of DSM-IV PDs, the DSM-5 trait set pro-
hybrid personality functioning–trait vides a synthetic bridge between DSM-IV
model. PDs and the empirical structure of hu-
An empirically structured set of traits man personality, thus creating a pathway
helps make the observed comorbidity for moving systematically not only from
between PDs comprehensible. Some PDs DSM-IV to DSM-5, but also from DSM-5
share traits in common. For example, BPD to an even better system grounded in
and AVPD are both characterized by the data that will be collected using the pro-
trait facet anxiousness, which “builds in” posed structured set of trait facets. This
a certain degree of overlap or comorbid- synthetic bridge can be seen by examin-
ity. Similarly, BPD and ASPD may be ex- ing the joint structure of the DSM-5 facets
pected to overlap even more frequently and established markers of the five major
because they have three facets in com- domains of personality variation. That is,
mon: hostility, impulsivity, and risk tak- an extensive literature shows that person-
ing. Importantly, defining PDs by an em- ality constructs are organized empirically
TABLE 24–2. Assignment of 25 trait facets to DSM-5 personality disorders
Personality disorders
Trait domains/facets ASPD AVPD BPD NPD OCPD STPD
Negative Affectivity
(vs. Emotional Stability)
Emotional lability X
Anxiousness X X
Separation insecurity X
Perseveration X
Depressivity X
Detachment (vs. Extraversion)
Withdrawal X X
Intimacy avoidance X X
Anhedonia X
Restricted affectivity X X
Suspiciousness X
Antagonism (vs. Agreeableness)
Manipulativeness X
Deceitfulness X
Grandiosity X
Attention seeking X
Callousness X
Hostility X X
Disinhibition (vs. Conscientiousness)
Irresponsibility X
Impulsivity X X
Risk taking X X
Rigid perfectionism (lack of) X
Psychoticism (vs. Lucidity)
Unusual beliefs and experiences X
Eccentricity X
Cognitive and perceptual dysregulation X
Note. Underlining indicates common facets.
ASPD=antisocial personality disorder; AVPD=avoidant personality disorder; BPD=borderline person-
ality disorder; NPD=narcissistic personality disorder; OCPD=obsessive-compulsive personality disor-
der; STPD=schizotypal personality disorder.
into five broad domains (Costa and Widi- Openness (to unusual and novel experi-
ger 2002; Widiger and Simonsen 2005). ences), and Conscientiousness (orderly,
These domains often are labeled Neu- planful). These domains have been shown
roticism (tense, anxious), Agreeableness to organize both normal- and abnormal-
(oriented toward getting along with other range personality constructs (Markon et
people), Extraversion (outgoing, friendly), al. 2005). This organizational continuity
emerges because abnormal- and nor- proaches. Finally, in the only sample of
mal-range variation are continuous with clinician ratings of patients on the DSM-
each other, a fact for which there is con- 5 pathological personality trait system,
siderable and compelling evidence and, Morey et al. (2013b) found the same five-
contrariwise, no compelling evidence factor structure as proposed and repli-
that abnormal personality is different in cated in the above-mentioned studies
kind, as opposed to being different in which used self-report measures and
degree, from normal-range personality nonpatient samples.
(Eaton et al. 2011; Haslam et al. 2012).
Recent studies have validated the re-
lationship of the DSM-5 trait model to
Revision of DSM-IV
existing measures of the FFM and its General Criteria for PD
variants. Thomas et al. (2013) conjointly
for DSM-5 Section III
factor analyzed data on 808 participants
from a nonpatient sample collected us- Relatively minor changes have been made
ing the PID-5 and the Five Factor Model to DSM-IV GCPD Criteria B through F
Rating Form (FFMRF) and found a fac- for the DSM-5 Section III alternative
tor structure that reflected the domains model. A brief discussion of each of these
of the FFM. Wright et al. (2012b) examined criteria follows. (Some criteria letters
the hierarchical structure of DSM-5 traits differ in the two DSM editions, as clari-
measured by the PID-5 in 2,461 students. fied in the following text.)
Exploratory factor analysis replicated
the five-factor structure initially reported GCPD Criterion B
by the work group (Krueger et al. 2011a). DSM-IV Criterion B stated, “The endur-
The two-, three-, and four-factor solu- ing pattern is inflexible and pervasive
tions bore a close resemblance to exist- across a broad range of personal and so-
ing models of common mental disor- cial situations” (American Psychiatric
ders, temperament, and personality Association 1994, p. 633). The DSM-5
pathology. In another student sample in Section III model includes a revised GCPD
Belgium, the five-factor structure from Criterion C: “The impairments in per-
the U.S. derivation sample was also con- sonality functioning and the individual’s
firmed, and the joint structure of the DSM- personality trait expression are relatively
5 pathological traits and general person- [italics added] inflexible and pervasive
ality traits as measured by the NEO Per- across a broad range of personal and social
sonality Inventory–3 (NEO-PI-3) resem- situations” (American Psychiatric Asso-
bled the major dimensions of FFM and the ciation 2013, p. 761). The key elements of
Personality Psychopathology Five (PSY-5) Criteria A and B (i.e., impairments in
(De Fruyt et al. 2013). Anderson et al. personality functioning and the individ-
(2013) examined the convergence of PID-5 ual’s personality trait expression) are re-
domains and facets and the PSY-5 do- peated in this criterion, as well as all sub-
mains as measured by the Minnesota sequent GCPD, to keep the focus on these
Multiphasic Personality Inventory–2 Re- key elements, which the other GCPD
structured Form (MMPI-2-RF). Corre- modify or elaborate. The insertion of
spondence between PSY-5 scales and their “relatively” before “inflexible and perva-
PID-5 counterpart domains was high, and sive” is intended to dispel the mistaken
a joint factor analysis indicated the five- belief that personality characteristics are
factor structure shared by the two ap- cast in stone, and to convey that PD fea-
tures are not absolutely and completely showed that less than 50% of patients di-
unresponsive to any and all environ- agnosed with PDs retained these diag-
mental circumstances. noses over time (Skodol 2008, 2013). The
results of three methodologically rigor-
GCPD Criterion C ous, large-scale studies of the naturalis-
Criterion C of DSM-IV stated, “The en- tic course of PDs—The Collaborative
during pattern leads to clinically signifi- Longitudinal Personality Disorders Study
cant distress or impairment in social, oc- (CLPS) (Gunderson et al. 2000; Skodol et
cupational, or other important areas of al. 2005c), The McLean Study of Adult
functioning” (American Psychiatric As- Development (MSAD) (Zanarini et al.
sociation 1994, p. 633). This criterion has 2005), and The Children in the Commu-
been deleted from the DSM-5 Section III nity Study (CICS) (Cohen et al. 2005),
model because it is redundant with the conducted on patient (CLPS and MSAD)
proposed Criterion A for impairment in and community (CICS) populations—
personality functioning, which includes confirm that the longitudinal course of
social functioning. Furthermore, the PD psychopathology is much more wax-
DSM-5 Impairment and Disability As- ing and waning than stable. In addition,
sessment Study Group recommended personality traits show clear tempera-
that DSM-5 criteria should describe signs, mental antecedents (Shiner 2005) such
symptoms, and manifestations of disor- that by school age, children’s personal-
ders, and not their consequences, nei- ity structure is similar to adults’ struc-
ther internal (i.e., distress) nor external ture (Shiner 2009; Tackett et al. 2009). As
(e.g., occupational). early as age 3 years, personality traits are
moderately stable, but their stability in-
GCPD Criterion D creases across the lifespan until at least
DSM-IV Criterion D referred to the lon- age 50 (Roberts and DelVecchio 2000). The
gitudinal course of PDs as follows: “The insertion of “relatively” to modify “sta-
pattern is stable and of long duration, ble” in the revised Criterion D reflects
and its onset can be traced back at least to this large body of empirical evidence. The
adolescence or early adulthood” (Ameri- redefinition of PDs in terms of personal-
can Psychiatric Association 1994, p. 633). ity functioning and pathological traits is
Criterion D in DSM-5 Section III describes expected to increase the stability of PD
this pattern similarly: “The impairments diagnoses, because both the functional
in personality functioning and the indi- impairments (Skodol et al. 2005b) and
vidual’s personality trait expression are the trait manifestations (Hopwood et al.
relatively [italics added] stable across time, 2013a) of PDs have been found to be
with onsets that can be traced back to at more stable than the symptomatic mani-
least adolescence or early adulthood” festations (McGlashan et al. 2005). A
(American Psychiatric Association 2013, more detailed discussion of the longitu-
p. 761). dinal course of PDs can be found in Chap-
The notion of PDs as stable disorders ter 8, “Course and Outcome,” in this
to be distinguished from the more epi- volume.
sodic mental disorders, such as mood
disorders, has persisted despite a large GCPD Criterion E
number of one-time follow-up studies in DSM-IV Criterion E stated, “The endur-
the DSM-III and DSM-III-R (American ing pattern is not better accounted for as
Psychiatric Association 1987) eras that a manifestation or consequence of an-
other mental disorder” (American Psy- rion, and developmental considerations

chiatric Association 1994, p. 633). The re- are added. This change is consistent with
vised criteria adopt the “standard” DSM-5 the intention of DSM-5 to be widely ap-
language for Criterion E: “The impair- plicable in different cultures and devel-
ments in personality functioning and the opmental age groups.
individual’s personality trait expression
are not better explained by another men-
tal disorder” (American Psychiatric As- Translation of
sociation 2013, p. 761). Six DSM-IV
GCPD Criterion F Personality Disorders
Criterion F was meant to rule out sub-
stances and other medical conditions as a Criteria for individual PDs in DSM-IV
cause of personality psychopathology: were amalgams of traits, cognitions about
“The enduring pattern is not due to the di- self and others, behaviors, emotions,
rect physiological effects of a substance signs, symptoms, and interpersonal con-
(e.g., a drug of abuse, a medication) or a sequences of maladaptive personality
general medical condition (e.g., head functioning. Many of the individual cri-
trauma)” American Psychiatric Associa- teria for the DSM-IV PDs reflect distur-
tion 1994, p. 633). The revised criteria bances in sense of self and interpersonal
again reflect the “standard” DSM-5 lan- functioning. Also, DSM-IV acknowledges
guage for this criterion: “The impairments the importance of personality traits in its
in personality functioning and the indi- description of a PD when it says, “Only
vidual’s personality trait expression are when personality traits are inflexible and
not solely attributable to the physiological maladaptive and cause significant func-
effects of a substance or another medical tional impairment or subjective distress
condition (e.g., severe head trauma)” do they constitute Personality Disorders”
(American Psychiatric Association 2013, (American Psychiatric Association 1994,
p. 761). Mental disorders in DSM-5 are p. 630). Most of the criterion “stems” or
considered medical conditions. lead-ins to the specific PD manifestations
in DSM-IV rely heavily on self-interper-
GCPD Criterion G sonal or trait language. For example, the
Criterion G has been added to the DSM- criteria for NPD begin with “A perva-
5 Section III model for the GCPD and the sive pattern of grandiosity (in fantasy or
individual PDs. It states, “The impair- behavior), need for admiration, and lack
ments in personality functioning and of empathy. . .” (American Psychiatric
the individual’s personality trait expres- Association 1994, p. 661), and the criteria
sion are not better understood as normal for AVPD begin with “A pervasive pat-
for an individual’s developmental stage tern of social inhibition, feelings of inad-
or sociocultural environment” (Ameri- equacy, and hypersensitivity to negative
can Psychiatric Association 2013, p. 761). evaluation . . .” (American Psychiatric
In DSM-IV, GCPD Criterion A includes Association 1994, p. 664). Many criteria
the stipulation that the “enduring pat- for individual disorders vary from those
tern” must deviate “markedly from the that are directly trait-based (e.g., ASPD’s
expectations of the individual’s culture.” “deceitfulness,” “impulsivity,” “irritabil-
In the DSM-5 alternative model, this con- ity and aggressiveness,” “reckless disre-
cept is incorporated into a separate crite- gard for safety,” and “irresponsibility”;
American Psychiatric Association 1994, The other DSM-IV PDs (paranoid, schiz-
p. 650) to those that are more specific oid, histrionic, and dependent), DSM-IV
manifestations of traits (e.g., STPD’s Appendix B PDs (depressive, passive-
“ideas of reference,” “odd beliefs or magi- aggressive), and the residual category of
cal thinking,” “unusual perceptual expe- PDNOS are diagnosed by the DSM-5 Sec-
riences,” and “odd thinking and speech” tion III model with PD-TS (Skodol 2012),
[American Psychiatric Association 1994, which is represented by moderate or
p. 645], which are all manifestations of greater impairment in personality func-
various facets of the broad trait domain tioning, combined with specification by
of Psychoticism). pathological personality traits based on
One result of the extreme variation in individuals’ most prominent descriptive
the ways PDs are characterized is their trait features.
low convergent validity when opera-
tionalized in different measures. In an Specific Personality
early study, the average kappa across
specific PDs between an unstructured Disorders
clinical interview and the Personality The PDs with the most extensive empiri-
Disorder Questionnaire—Revised (Hyler cal evidence of validity and clinical util-
and Rieder 1987) was an abysmal 0.08 ity are BPD, ASPD, and STPD (Blashfield
(Hyler et al. 1989). A study comparing and Intoccia 2000; Morey and Stagner
the LEAD (Longitudinal Evaluation us- 2012). In contrast, there are very few em-
ing All Data; Spitzer 1983) standard to pirical studies focused explicitly on par-
two different structured assessments anoid, schizoid, or histrionic PDs. The ra-
yielded an average kappa of 0.25 for any tionales for retaining six of the 10 DSM-
PD—that is, simply whether individuals IV PDs (Skodol et al. 2011a) in DSM-5
did or did not have a PD (Pilkonis et al. Section III were based on their preva-
1991). Importantly, these are not isolated lence (and its consistency) in community
examples. Meta-analytic convergence and clinical populations, associated func-
between structured interviews and be- tional impairment, treatment and prog-
tween structured interviews and per- nostic significance, and (where informa-
sonality questionnaires, respectively, tion was available) neurobiological and
yielded kappas of 0.27 for specific PDs genetic studies. Moreover, the DSM-IV
and 0.29 for any PD (Clark et al. 1997). PDs for which the P&PD Work Group
The P&PD Work Group was charged elected not to provide full descriptions in
by the DSM-5 Task Force with develop- DSM-5 were characterized by the rela-
ing a standard approach to diagnostic tive simplicity of their trait composition,
criterion sets that would be consistent such that they are easily represented. A
with core personality functioning and recent study in a very large outpatient
trait dimensional constructs. Therefore, population revealed that 84% of PD di-
revised diagnostic criteria are included agnoses fell into one of the six specific
in DSM-5 Section III for six specific PDs: PDs included in DSM-5 Section III (Zim-
ASPD, AVPD, BPD, NPD, OCPD, and merman et al. 2012).
STPD. Each PD is translated into typical In both epidemiological (Torgersen
impairments in personality functioning 2009) and clinical (Stuart et al. 1998; Zim-
(Criterion A) and particular sets of path- merman et al. 2005) samples, AVPD and
ological personality traits (Criterion B). OCPD are consistently among the most
common PDs. BPD has a moderate prev- Grilo et al. 2005, 2010; Hasin et al. 2011;
alence in community studies but is one of Skodol et al. 2011b).
the most common in clinical settings.
STPD has relatively low prevalence in
Criteria Assignment
both populations but is highly impairing.
ASPD is less common but has consider- Initially, assignment of the specific A cri-
able individual and collective impact on teria to the six individual PD types was
society and related relevance in forensic made by inspection of the related DSM-
settings. NPD is among the less common IV criteria involving self and interper-
PDs, but constructs of narcissism have sonal functioning, by consideration of the
utility in treatment planning. definitions of the proposed core compo-
All DSM-IV PDs have moderate heri- nents of personality functioning, and by
tability (Coolidge et al. 2001; Kendler et clinical judgment; the proposed criteria
al. 2006; Reichborn-Kjennerud et al. 2007; were then examined in a survey of 337
Torgersen et al. 2000, 2008); however, es- clinician ratings of patients, hereafter re-
timates are inconsistent across samples. ferred to as “the Morey survey.” Item-to-
Behavioral genetics evidence supports at tal correlations for the 24 A criteria (four
least five of the six PD types retained for for each of the six PDs) with the entire
DSM-5 (the exception being NPD). STPD DSM-5 PD criterion set ranged from 0.70
has been found to have the strongest (ASPD empathy) to 0.25 (OCPD empa-
loadings on genetic and environmental thy), with an overall mean of 0.48. The
risk factors among DSM-IV Cluster A item-total correlation range was from 0.64
PDs (Kendler et al. 2006); ASPD and BPD (ASPD) to 0.38 (OCPD). Self functioning
have a second genetic and non-shared (identity, self-direction) criteria had a
environmental factor over and above the mean item-total correlation across the
genetic factor influencing all Cluster B dis- six PDs of 0.45, and interpersonal func-
orders (Torgersen et al. 2008); and of the tioning (empathy, intimacy) criteria had
Cluster C PDs, AVPD has been found to a mean of 0.51 (L.C. Morey, “Developing
be more heritable than dependent PD, and Evaluating a DSM-5 Model for Per-
and OCPD has disorder-specific genetic sonality Disorder Diagnosis: Data From a
influence not found for the other two PDs National Clinician Sample,” unpublished
(Reichborn-Kjennerud et al. 2007). The manuscript, August 2012).
retained PD types also have been associ- Saulsman and Page (2004) conducted a
ated with increased rate of various types meta-analysis of 15 independent sam-
of abuse and neglect in both prospective ples on relationships between the DSM-IV
(e.g., Johnson et al. 1999; Widom 1989) PDs and the broad, higher-order trait
and retrospective (e.g., Battle et al. 2004; domains of the FFM as measured by the
Zanarini et al. 2002b) studies. The re- self-report NEO-PI-R (Costa and McCrae
tained PDs are associated with high and 1992). Samuel and Widiger (2008) con-
persistent degrees of functional impair- ducted a non-overlapping meta-analysis
ment (Skodol et al. 2002, 2005a, 2005b), of 18 independent samples, first replicat-
and BPD is associated with an increased ing Saulsman and Page’s (2004) domain-
risk for suicidal behavior (Oldham 2006). level findings and then further examining
The retained specific PDs also are associ- relationships between the DSM-IV PDs
ated with poorer outcomes of a range of and the more specific, lower-order trait
mood, anxiety, and substance use disor- facets of the FFM. In addition to the NEO-
ders (Ansell et al. 2011; Fenton et al. 2012; PI-R, Samuel and Widiger also examined
studies that used either the SIFFM (Trull correlations than attention seeking (0.54).
et al. 1998) or the FFM Rating Form (Mull- These results paralleled the findings for
ins-Sweatt et al. 2006). The results of the NPD in the Hopwood et al. (2012) study.
two domain-level meta-analyses showed However, adding these traits to NPD in-
a high degree of similarity, indicating the creased overlap with ASPD consider-
robustness of the relations. The results of ably, so rather than being added to the
the FFM facet-level meta-analysis were NPD criterion set, they are mentioned as
used for the preliminary assignment of common “trait specifiers” for NPD, to
pathological personality traits to the B modify the diagnosis and capture the
criteria for PDs, as represented in DSM-5 concept of “malignant narcissism.” After
Section III. comparing the results from the Morey
These assignments then were exam- survey and the Hopwood et al. study, a
ined by Hopwood et al. (2012) and by change was made to the assigned traits of
Morey et al. (L.C. Morey, “Developing only one PD: intimacy avoidance and re-
and Evaluating a DSM-5 Model for Per- stricted affectivity were added to OCPD.
sonality Disorder Diagnosis: Data From The new criteria for BPD were rated
a National Clinician Sample,” unpub- with moderately good reliability in the
lished manuscript, August 2012). In the DSM-5 field trials (pooled interclass
Morey survey, each of the 25 traits from kappa=0.54), despite a monothetic B cri-
the pathological trait model proposed terion set used at the time requiring seven
for DSM-5 was correlated to the criterion of seven traits for a diagnosis (Regier et al.
count for DSM-IV PDs to examine the fi- 2013). Subsequent analyses of the field
delity of the rendering of DSM-IV crite- trial data suggested that a polythetic rule
ria by trait terms. For ASPD, each of the for the B criterion set requiring four or five
seven assigned traits had higher correla- or greater of the trait facets would im-
tions with a DSM-IV diagnosis of ASPD prove reliability and increase correspon-
than any of the other 18 traits (range 0.49 dence with the DSM-IV diagnosis. It is
for hostility to 0.73 for irresponsibility; important to recognize that the DSM-5
mean=0.65). The same was true for the Section III model provides a scientifi-
six criteria for STPD. For OCPD, both of cally based framework (of impairment
the assigned traits had the highest corre- in personality functioning and maladap-
lations, and two additional traits with tive personality traits) in which DSM-IV
significant correlations consistent with PD concepts can be faithfully represented,
rationale-theoretical considerations were meaning that validated aspects of these
added; for AVPD, three of the four as- concepts will have continuity under the
signed traits had the highest correlations; new system. As a demonstration, in the
and for BPD, five of seven had the high- Morey survey comparing patients on all
est correlations. Using Cohen’s metric, DSM-IV and DSM-5 specific PD criteria
half the correlations indicated a large ef- and dimensions, the correlations between
fect size, 47% a medium effect size, and rated criterion counts of DSM-IV and
only one a small effect size; in all cases, DSM-5 diagnostic concepts from the 337
the correlations were statistically signifi- patients are as follows: BPD, 0.80; ASPD,
cant (P0.01). For NPD, grandiosity had 0.80; AVPD, 0.77; NPD, 0.74; STPD, 0.63;
the highest correlation (0.77), but several and OCPD, 0.57 (Morey and Skodol
other traits including callousness, deceit- 2013). In most instances, these values are
fulness, and manipulativeness had higher comparable to the established joint in-
terview reliabilities of these diagnoses test-retest reliability of the diagnosis, a

under DSM-IV, suggesting that the agree- threshold of any four B criteria was com-
ment between DSM-IV and DSM-5 Section pared to any five using the Morey survey
III PD diagnoses is likely to be as high as the data. A threshold of any four criteria,
agreement between two diagnosticians on compared to any five criteria, was associ-
DSM-IV (and now DSM-5 Section II) diag- ated with a higher kappa of agreement
noses. However, an important difference with a DSM-IV diagnosis (0.64 vs. 0.57), a
is that in DSM-5, a coherent framework prevalence more closely approximating
for representing the potential underlying the DSM-IV prevalence of 40.2% (40.1%
endophenotypic structure of the PDs is vs. 28.7%), better discrimination from four
provided, in contrast to the mixed collec- of the five other DSM-5 PDs, and a stron-
tion of signs, symptoms, traits, and be- ger correlation to functioning (–0.30 vs. –
haviors that make up the DSM-5 Section 0.25). Requiring only four criteria, how-
II diagnostic criteria. ever, means that a patient could be diag-
nosed with BPD with only the four
criteria listed under the Negative Affec-
Diagnostic Thresholds tivity domain and, therefore, without any
Three scoring rules were compared for the evidence of Disinhibition or Antagonism.
A criteria for each PD using the data from Therefore, “any four criteria” was com-
the Morey survey: one or more each from pared to an algorithm requiring four cri-
self and from interpersonal functioning, teria and also requiring that one criterion
any single A criterion, and any two A cribe from either the Disinhibition domain
teria. Maximizing sensitivity and speci- (i.e., impulsivity or risk taking) or the An-
ficity for the corresponding DSM-IV PDs tagonism domain (hostility). This algo-
were used as the outcomes. Sensitivity rithm produced an equivalent kappa to
values are of particular importance rela- the any four rule with DSM-IV BPD of
tive to specificity for the A criteria, be- 0.64, little change in prevalence (38.9%),
cause all DSM-5 PDs are presumed to have and slightly more overlap with other PDs,
core impairments in personality func- but a slightly stronger relationship to
tioning and specificity will likely further functioning (–0.32). Thus, the final algo-
result from pathological traits (B criteria). rithm requires four or more Criterion B
Over all six PDs, any two A criteria re- traits, one of which must be a trait from
sulted in the best combination of strong either the Disinhibition or the Antago-
sensitivities and adequate specificities nism domains (Morey and Skodol 2013).
(Morey et al. 2013a). A similar iterative process was fol-
Originally, all specified PD traits were lowed for selecting the diagnostic thresh-
required for the diagnosis of a given PD. olds for the B criteria for the other five
As mentioned in the previous subsection, specified PDs proposed for DSM-5. Bal-
these monothetic scoring rules were ancing consideration of agreement with
tested in the DSM-5 field trials. Although DSM-IV diagnosis (kappa) and preva-
monothetic scoring reduces heterogene- lence, minimizing overlap with other
ity, it also reduces prevalence and reliabil- PDs (i.e., discriminant validity), and max-
ity, so polythetic decision rules were imizing the correlation to the composite
investigated in the Morey survey. As an of psychosocial functioning (social, occu-
example, based on the DSM-5 field trial pational, leisure) in the Morey survey,
result that requiring either four or five of the decision rules for the B criteria have
seven traits for BPD equally increased the been set as listed in Table 24–3.
TABLE 24–3. B criteria (trait domains/facets) diagnostic threshold algorithms for

six DSM-5 personality disorder types
Personality disorder Trait domains (facet Ns) Proposed algorithm
Antisocial Antagonism (4) 6 or more of 7

Disinhibition (3)
Avoidant Detachment (3) 3 or more of 4, and 1 must be
Negative Affectivity (1) anxiousness
Borderline Negative Affectivity (4) 4 or more of 7, and 1 must be
Disinhibition (2) impulsivity, risk taking, or
Antagonism (1) hostility
Narcissistic Antagonism (2) Both
Obsessive- Conscientiousness (1) 3 or more of 4, and 1 must be rigid
compulsive Negative Affectivity (1) perfectionism
Detachment (2)
Schizotypal Psychoticism (3) 4 or more of 6
Detachment (3)
Elimination of Childhood sible). Thus, the ASPD diagnosis in Sec-

tion III is based solely on contemporary
Conduct Disorder as assessment data, pertaining to a person’s
a Requirement for personality, and consistent with all other
PDs.
Antisocial PD Second, the requirement of CCD for
In previous DSM editions, ASPD could the diagnosis of ASPD implies that adult
be diagnosed only if childhood conduct antisocial behavior (AAB) can only pres-
disorder (CCD), with onset before age 15 ent in persons who met criteria for CCD.
years, was also present in the develop- This is not empirically accurate. AAB can
mental history of the patient. In DSM-5 also present in the absence of CCD. Also,
Section III, ASPD can be diagnosed in the the majority (more than 50%) of children
absence of CCD. This significant change with conduct disorder do not go on to
was made for several reasons. develop ASPD (Zoccoillo et al. 1992). For
First, the ASPD diagnosis in previous example, Silberg et al. (2007) studied
editions of DSM involved retrospective CCD and AAB in a sample of male twins
recall and/or review of records to estab- and reported a correlation of 0.46 be-
lish that the CCD requirement was met. tween CCD and AAB, indicating both
Retrospective recall has well-known continuity and discontinuity in the de-
shortcomings: not all patients are ac- velopment of antisocial behavior that is
curate reporters of their own history not recognized by the CCD requirement
(Moffitt et al. 2010); in addition, historical for ASPD. Moreover, AAB was associated
records with sufficient information con- with novel genetic effects that were not
tent and detail to establish or rule out a overlapping with genetic effects on CCD,
CCD diagnosis are not always available indicating etiological distinctiveness be-
for adult patients or may be inaccessible tween antisocial behavior syndromes
to the clinician for legal reasons (e.g., ju- occurring in different developmental
venile criminal records are often inacces- periods. By removing the CCD require-
ment from ASPD, both conduct disorder eral criteria for a Personality Disorder
and ASPD can be diagnosed as appro- and traits of several different Personality
priate, recognizing the fact that people Disorders are present, but the criteria for
can and do change in their antisocial any specific Personality Disorder are not
propensities over the life course. Chil- met; or 2) the individual’s personality
dren with conduct disorder are also at pattern meets the general criteria for a
risk for developing other externalizing Personality Disorder, but the individual
and internalizing mental disorders, not is considered to have a Personality Disor-
only for ASPD (e.g., Kim-Cohen et al. der that is not included in the Classifica-
2003). Moreover, other childhood disor- tion (e.g., passive-aggressive personality
ders, in addition to conduct disorder, in- disorder)” (American Psychiatric Associ-
crease the risk of ASPD (e.g., Kasen et al. ation 1994, p. 629). DSM-5 Section III in-
2001). cludes the more useful category person-
Third, AAB (ASPD in the DSM-5 Sec- ality disorder–trait specified (PD-TS) to
tion III) has been studied in both clinical replace PDNOS.
and epidemiological samples and has This new diagnosis in DSM-5 Section
been found to be both prevalent and con- III allows clinicians to turn the residual
sequential. Goldstein and Grant (2011) PDNOS category into a clinically more
provided an extensive review of litera- useful one by selecting from the set of
ture on the validity of AAB versus ASPD, maladaptive traits those that are most
focusing on both psychiatric and medical characteristic of an individual and assign-
correlates of these syndromes, and con- ing an appropriate specific level of im-
cluded as follows: “Findings concerning pairment in personality functioning. This
the similarities between AAB and ASPD can be done in both the instances de-
indicate the clinical and public health scribed in DSM-IV—that is, 1) when an
importance of AAB, calling into question individual meets the GCPD but not the
the requirement under DSM criteria of specific criteria for one of the specifically
CCD for the diagnosis of clinically seri- named disorders and 2) when an individ-
ous antisociality in adults” (p. 52). They ual has a PD not included in DSM-5,
noted also that the prevalence of AAB is whether it is a disorder from the DSM-IV
greater than the prevalence of ASPD, in appendix (i.e., depressive, passive-aggres-
spite of both syndromes having similar sive) or one that was rendered as a specific
validity evidence. By removing the CCD disorder in DSM-IV but is not specifically
requirement from ASPD, the proposed included in DSM-5 Section III (i.e., para-
DSM-5 ASPD recognizes the substantial noid, schizoid, histrionic, dependent). For
social costs of antisocial behavior in adult- example, an individual meeting all the cri-
hood that is not necessarily accompanied teria for DSMIV-TR depressive PD might
by antisocial behavior in a developmen- be characterized by depressivity (e.g., “is
tally earlier period. pessimistic”), anxiousness (e.g., “is brood-
ing and given to worry”), anhedonia (e.g.,
Redefinition of PDNOS “usual mood is dominated by dejection,
gloominess, cheerlessness, joylessness,
as PD-TS unhappiness”), and hostility (e.g., “is neg-
DSM-IV states that PDNOS “is a category ativistic, critical, and judgmental toward
provided for two situations: 1) the individ- others”) (American Psychiatric Associa-
ual’s personality pattern meets the gen- tion 1994, p. 733).
PD-TS also can be used as the diagno- BPD but can be specified if present. The
sis when patients have such extensive per- provision of 25 pathological personality
sonality pathology that they meet criteria traits permits more systematic use of
for several of the specific PD, with or with- personality information to inform clini-
out additional traits. In such a case, it may cal case formulation and treatment plan-
be clinically more useful to state, for ex- ning than was possible in DSM-IV.
ample, that the individual has extreme
and extensive Negative Affectivity, De- Traits to Augment the
tachment, and Disinhibition, with ma- Description of Personality
nipulativeness and eccentricity, than to
list the several diagnoses met (e.g., STPD,
Disorders
BPD, and AVPD plus manipulativeness), DSM-IV states that when an individual
because it provides a more precise picture meets criteria for more than one PD,
of the individual’s specific pattern of trait both should be diagnosed. This is true in
psychopathology. DSM-5 Section III PDs as well; however,
in addition, if an individual meets crite-
Use of Level of Personality ria for a specific PD and has several prom-
inent personality traits besides those
Functioning and needed to diagnose a specific PD, the ad-
Pathological Traits as ditional traits may be listed to provide
valuable personality information for use
Specifiers in treatment planning.
DSM-IV lacked a PD-specific severity
specifier. In DSM-IV, neither the general Traits of Clinical Significance
severity specifiers nor the Axis V GAF in Patients Who Do Not Have
Scale had sufficient specificity for person-
ality psychopathology to be useful in
a Personality Disorder
measuring its severity. The LPFS, there- DSM-IV also states that specific mal-
fore, functions as a PD-specific severity adaptive personality traits that do not
measure in the alternative DSM-5 Section meet the threshold for a PD may be listed.
III model. This is unchanged in DSM-5 Section III,
Both the severity level of personality except for the important difference that
functioning and the trait specifiers may DSM-5 Section III provides a set of 25 spe-
be used to record additional personality cific trait facets for clinicians to use in de-
features that may be present in a PD but scribing the personality difficulties of
are not required for the diagnosis. For their clients and in treatment planning.
example, although moderate or greater Given that personality has been shown to
impairment in personality functioning is be an important modifier of a wide range
required for the diagnosis of BPD (Crite- of clinical phenomena and a source of
rion A), the severity of impairment in per- dysfunction (e.g., Lahey 2009; Rapee 2002;
sonality functioning can vary between Roberts et al. 2007), and is associated with
patients and thus can also be specified, if economic costs exceeding those of many
it is more severe and/or if it improves mental disorders themselves (Cuijpers et
over time. In addition, traits of Psychoti- al. 2010), a dimensional trait model will
cism (e.g., cognitive and perceptual dys- strengthen DSM-5 Section III–based as-
regulation) are not diagnostic criteria for sessments, in general.
Schedule for Nonadaptive and Adaptive

Clinical Utility of a Personality (SNAP; Clark 1993) and its
second edition (SNAP-2; Clark et al.
Hybrid Model of 2009) performed the best, both at baseline
Personality Disorder and prospectively, because it combines
the strengths of a pathological disorder
In addition to the independent utility of diagnosis and more normal-range per-
measures of personality functioning and sonality traits by assessing personality
of pathological personality traits in identi- traits across the normal-to-abnormal spec-
fying and describing personality pathol- trum and by including clinically impor-
ogy and in planning and predicting the tant trait dimensions (e.g., self-harm, de-
outcome of treatment, a number of re- pendency) that are not included in
cent studies support a model of person- measures of normal-range personality. In
ality psychopathology that specifically fact, a model combining FFM and DSM-
combines ratings of disorder and trait IV PD constructs performed much like
constructs. Each has been shown to add the SNAP model. The results indicated
incremental value to the other in predict- that models of personality pathology that
ing important antecedent (e.g., family incorporate stable trait dispositions and
history, history of child abuse), concur- dynamic, maladaptive manifestations are
rent (e.g., functional impairment, medica- most clinically informative.
tion use), and predictive (e.g., function- Hopwood and Zanarini (2010) found
ing, hospitalization, suicide attempts) that FFM extraversion and agreeableness
variables (Hopwood and Zanarini 2010; were incrementally predictive (over a
Morey and Zanarini 2000; Morey et al. BPD diagnosis) of psychosocial func-
2007, 2012). tioning over a 10-year period and that
Morey and Zanarini (2000) found that borderline cognitive and impulse action
FFM personality domains captured sub- features had incremental effects over FFM
stantial variance in the diagnosis of BPD traits. They concluded that both BPD
with respect to its differentiation from symptoms and personality traits are im-
non-borderline PDs, but also that resid- portant long-term predictors of clinical
ual variance not explained by the FFM functioning and supported the inte-
was related significantly to important gration of traits and disorder in DSM-5.
clinical correlates of BPD, such as child- Morey et al. (2012) extended their earlier
hood abuse history, family history of findings comparing the FFM, SNAP, and
mood and substance use disorders, con- DSM-IV PDs in a 10-year follow-up of
current (especially impulsive) symptoms, CLPS patients. Baseline data were used to
and 2- and 4-year outcomes. In the CLPS, predict long-term outcomes, including
dimensional representations of DSM-IV functioning, Axis I psychopathology, and
PD diagnoses (i.e., criterion counts) pre- medication use. Each model was sig-
dicted concurrent functional impairment, nificantly valid, predicting a host of im-
but their predictive power diminished portant clinical outcomes. Overall, ap-
over time (Morey et al. 2007). In contrast, proaches that integrate normative traits
the FFM (assessed with the NEO-PI-R) and personality pathology proved to be
provided less information about current most predictive: the SNAP generally
behavior and functioning, but was more showed the largest validity coefficients
stable over time and more predictive of overall, and the DSM-IV PD syndromes
future outcomes. The model used in the and FFM traits tended to provide substan-
tial incremental information relative to Relationships to

one another (Morey et al. 2012).The re-
sults again indicated that DSM-5 PD as- Clinical Judgments
sessment ideally would involve an inte- The Morey survey investigated the rela-
gration of characteristic PD features and tionships of DSM-IV PDs and DSM-5
personality traits, to maximize clinical PDs and their components to important
utility. Such a hybrid model is presented clinical validators including psychoso-
in DSM-5 Section III. cial functioning; risk for self-harm, vio-
lence, and criminality; optimal level of
treatment intensity; and prognosis (Morey
Perceived Clinical Utility et al., unpublished data). DSM-5 compo-
In the DSM-5 field trials, clinicians were nents together and individually (person-
asked to rate the usefulness of tested di- ality functioning level and traits) had
agnostic criteria for all disorders. In both appreciably stronger unadjusted and
the academic centers and the routine clin- corrected correlations with these concur-
ical practice field trials (Kraemer et al. rent validators than DSM-IV disorders in
2010), the Section III PD model was rated 11 of 12 comparisons. The only exception
as “moderately,” “very,” or “extremely” was for level of personality functioning
useful by over 80% of clinicians. In the ac- and the composite risk prediction, which
ademic centers trial, the Section III model was more associated with DSM-IV PDs
was rated as “very” or “extremely” use- (L.C. Morey, “Developing and Evaluat-
ful compared to DSM-IV by more clini- ing a DSM-5 Model for Personality Dis-
cians than all disorders except somatic order Diagnosis: Data From a National
symptom disorders and feeding and eat- Clinician Sample,” unpublished manu-
ing disorders. In the routine clinical prac- script, August 2012).
tice trial, the Section III model was rated The incremental validity of the DSM-IV
as “very” or “extremely” useful compared and DSM-5 PD systems—that is, the as-
with DSM-IV by more clinicians than all sociations between each of the two PD
disorders except neurocognitive disor- systems and the four validators while
ders and substance use and addictive controlling for the effects of the other—
disorders. The Morey survey asked clini- was also examined. The partial multiple
cians to rate the perceived utility of the correlations (and corresponding PRESS
proposed DSM-5 rendering of personal- (Predicted Residual Sums of Squares)–
ity pathology compared with DSM-IV. corrected—for different numbers of vari-
Questions addressed ease of use and use- ables—correlations) show that DSM-5
fulness for communication, description, PD renderings significantly added to
and treatment planning. Although the DSM-IV in predicting all four clinical
clinicians were much more familiar with judgments, while DSM-IV did not provide
DSM-IV PDs, they rated all DSM-5 com- any validity information above and be-
ponents to be generally “as useful” or yond that provided by DSM-5. Thus, vir-
“more useful” than DSM-IV for clinical tually all valid variance in DSM-IV PD
description and treatment planning (L.C. diagnoses was captured by DSM-5, but the
Morey, “Developing and Evaluating a converse was not true. The DSM-5 formu-
DSM-5 Model for Personality Disorder lation accounted for significant elements
Diagnosis: Data From a National Clini- of functioning, risk, treatment needs,
cian Sample,” unpublished manuscript, and prognosis that were not captured by
August 2012). DSM-IV.
Agenda for DSM-V. Specifically, they sug-

Conclusion and gested that alternatives should 1) better
account for existing behavioral, neurobi-
Future Directions ological, genetic, and epidemiological
A new alternative model of PD psycho- data and adequately represent all clini-
pathology is included in DSM-5 Section cally important aspects of a PD; 2) be more
III, based on dimensional assessments of reliable, specific, and clinically informa-
impairment in personality (self/interper- tive; 3) be more effectively guide treat-
sonal) functioning and of pathological ment decisions; 4) have adequate levels
personality traits. Each of these aspects of of temporal stability in clinical settings;
personality pathology has an extensive 5) relate to motivational and cognitive sys-
empirical basis. Six DSM-IV PDs were tems of the brain; 6) provide a better un-
translated into consistent criteria sets de- derstanding of the interaction between
fined by typical impairments in personal- temperaments and environment that re-
ity functioning and specific pathological sult in PD; and 7) explicate the mecha-
personality traits for DSM-5 Section III. nisms by which maladaptive and adap-
The PDs selected to be represented as tive personality traits impact physical
specific PDs are those with the greatest disease and health. Although prior re-
research bases and clinical utility. Assign- search on which the Section III alterna-
ments of revised criteria were based on tive model is based suggests affirmative
careful consideration of continuity with answers to many of these questions, only
DSM-IV, literature reviews, and empiri- extensive research could address them
cal data. Diagnostic thresholds were set with certainty.
for the first time for all of the PD diagnoses At the beginning of the deliberations
using rational, empirical methods. The of the DSM-5 work groups, a “paradigm
alternative model represents DSM-IV shift” was deemed necessary for DSM-5
(and DSM-5 Section II) PDs with high because of the shortcomings of the “neo-
fidelity, thereby reducing concerns about Kraepelinian model” of mental disor-
potentially disruptive effects of the ders. The P&PD Work Group persisted in
changes on clinical practice or research. the pursuit of a hybrid dimensional-cate-
The new hybrid model is expected to in- gorical model for PDs for which the PD
crease the clinical utility of personality field was eager (Bernstein et al. 2007;
assessment over the 10-category DSM-IV Clark 2007; Widiger and Trull 2007) and
PD classification, based on prior research. which the DSM-5 research agenda em-
Data comparing the DSM-IV classifica- braced. A set of criteria for change were
tion and the proposed DSM-5 PD model proposed for DSM-5 to be applied across
reveals that the revised formulations are all categories, which focused on tradi-
viewed by clinicians as equally or more tional measures of validity (antecedent,
useful than DSM-IV and have consider- concurrent, and predictive) for making
ably greater ability to predict important changes. It is ironic that the motivation for
clinical correlates, including functioning, DSM-5 was that existing categories of
risks, treatment needs, and prognosis. mental disorders could not be validated
More research in diverse settings and using traditional (e.g., Robins and Guze
populations is obviously desired. First et 1970) criteria, but new options for these
al. (2002) outlined ideal steps for validat- disorders seem intended to meet these
ing a new model for the PDs in A Research standards. Furthermore, different valida-
tors (e.g., familiality vs. consistent longi- testable propositions about biological
tudinal course) are known to support dif- and social correlates....Diagnostic cate-
ferent definitions of disorder, and which gories provide invaluable information
is prioritized depends on the specific about the likelihood of future recovery,
purpose of the diagnosis (e.g., to study relapse, deterioration, and social handi-
heritability vs. to predict prognosis). cap; they guide decisions about treatment;
The guidelines for change in DSM-5 and they provide a wealth of informa-
stated that the magnitude of a suggested tion about similar patients encountered
change should be supported by a pro- in clinical populations or community
portional amount and quality of evidence surveys throughout the world...” (p. 9).
in support of the change. In the PD field, Therefore, in addition to the structural,
the problems with the existing 10-cate- genetic, and neurobiological validity of
gory system for diagnosing PDs were personality pathology, it is the belief of
deemed so severe that a reduced thresh- many of the clinicians and researchers
old for change seemed warranted. Fur- on the P&PD Work Group that attention
thermore, the relationship of empirical should be paid to the clinical utilities for
literature and clinical utility is not en- which diagnostic assessments are used.
tirely clear. Should the recommended DSM-5, as a whole, is intended to be a
changes in the classification reflect and “living document,” with the potential
promote progress on understanding for partial revision in an ongoing pro-
pathophysiology and etiology, or should cess, as research advances in a particular
they assist clinicians in doing their es- area warrant (Regier et al. 2009). Thus,
sential tasks? When these goals are in the edition published in 2013 technically
conflict, on what basis, by what process, should have been called DSM-5.0, with
and by whom should decisions be made future revisions called 5.1, 5.2, and so on.
(Skodol 2011)? Whether the notion of a continuing pro-
In addition, clinical utility should not cess of revision will be acceptable and can
be limited to user friendliness, feasibil- be implemented by the American Psy-
ity, and clinician acceptability of diag- chiatric Association, or will be too dis-
nostic approaches; rather, their usefulness ruptive to practice and research, is also a
in communication between clinicians or matter for the future.
between clinicians and patients, or their
ability to guide treatment decisions or
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APPENDIX
Alternative DSM-5 Model

for Personality Disorders
The current approach to personality disorders appears in Section II of DSM-5,

and an alternative model developed for DSM-5 is presented here in Section III. The inclu-
sion of both models in DSM-5 reflects the decision of the APA Board of Trustees to pre-
serve continuity with current clinical practice, while also introducing a new approach
that aims to address numerous shortcomings of the current approach to personality dis-
orders. For example, the typical patient meeting criteria for a specific personality disor-
der frequently also meets criteria for other personality disorders. Similarly, other
specified or unspecified personality disorder is often the correct (but mostly uninforma-
tive) diagnosis, in the sense that patients do not tend to present with patterns of symp-
toms that correspond with one and only one personality disorder.
In the following alternative DSM-5 model, personality disorders are characterized
by impairments in personality functioning and pathological personality traits. The
specific personality disorder diagnoses that may be derived from this model include
antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal
personality disorders. This approach also includes a diagnosis of personality disor-
der—trait specified (PD-TS) that can be made when a personality disorder is consid-
ered present but the criteria for a specific disorder are not met.
Reprinted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. Copyright
2013, American Psychiatric Association. Used with permission.
545
General Criteria for Personality Disorder
General Criteria for Personality Disorder

The essential features of a personality disorder are
A. Moderate or greater impairment in personality (self/interpersonal) functioning.
B. One or more pathological personality traits.
C. The impairments in personality functioning and the individual’s personality trait expres-
sion are relatively inflexible and pervasive across a broad range of personal and social
situations.
D. The impairments in personality functioning and the individual’s personality trait expres-
sion are relatively stable across time, with onsets that can be traced back to at least
adolescence or early adulthood.
E. The impairments in personality functioning and the individual’s personality trait expres-
sion are not better explained by another mental disorder.
F. The impairments in personality functioning and the individual’s personality trait expres-
sion are not solely attributable to the physiological effects of a substance or another
medical condition (e.g., severe head trauma).
G. The impairments in personality functioning and the individual’s personality trait expres-
sion are not better understood as normal for an individual’s developmental stage or so-
ciocultural environment.
A diagnosis of a personality disorder requires two determinations: 1) an assess-

ment of the level of impairment in personality functioning, which is needed for Cri-
terion A, and 2) an evaluation of pathological personality traits, which is required for
Criterion B. The impairments in personality functioning and personality trait expres-
sion are relatively inflexible and pervasive across a broad range of personal and social
situations (Criterion C); relatively stable across time, with onsets that can be traced
back to at least adolescence or early adulthood (Criterion D); not better explained by
another mental disorder (Criterion E); not attributable to the effects of a substance or
another medical condition (Criterion F); and not better understood as normal for an
individual’s developmental stage or sociocultural environment (Criterion G). All Sec-
tion III personality disorders described by criteria sets, as well as PD-TS, meet these
general criteria, by definition.
Criterion A: Level of Personality Functioning

Disturbances in self and interpersonal functioning constitute the core of personality
psychopathology and in this alternative diagnostic model they are evaluated on a con-
tinuum. Self functioning involves identity and self-direction; interpersonal functioning
involves empathy and intimacy (see Table 1). The Level of Personality Functioning
Scale (LPFS; see Table 2) uses each of these elements to differentiate five levels of im-
pairment, ranging from little or no impairment (i.e., healthy, adaptive functioning;
Level 0) to some (Level 1), moderate (Level 2), severe (Level 3), and extreme (Level 4)
impairment.
Appendix: Alternative DSM-5 Model for Personality Disorders 547
TABLE 1. Elements of personality functioning
Self:
1. Identity: Experience of oneself as unique, with clear boundaries between self and others;
stability of self-esteem and accuracy of self-appraisal; capacity for, and ability to regulate,
a range of emotional experience.
2. Self-direction: Pursuit of coherent and meaningful short-term and life goals; utilization of
constructive and prosocial internal standards of behavior; ability to self-reflect productively.
Interpersonal:
1. Empathy: Comprehension and appreciation of others’ experiences and motivations; toler-
ance of differing perspectives; understanding the effects of one’s own behavior on others.
2. Intimacy: Depth and duration of connection with others; desire and capacity for closeness;
mutuality of regard reflected in interpersonal behavior.
Impairment in personality functioning predicts the presence of a personality dis-

order, and the severity of impairment predicts whether an individual has more than
one personality disorder or one of the more typically severe personality disorders. A
moderate level of impairment in personality functioning is required for the diagnosis
of a personality disorder; this threshold is based on empirical evidence that the mod-
erate level of impairment maximizes the ability of clinicians to accurately and effi-
ciently identify personality disorder pathology.
Criterion B: Pathological Personality Traits

Pathological personality traits are organized into five broad domains: Negative Affec-
tivity, Detachment, Antagonism, Disinhibition, and Psychoticism. Within the five broad
trait domains are 25 specific trait facets that were developed initially from a review of
existing trait models and subsequently through iterative research with samples of per-
sons who sought mental health services. The full trait taxonomy is presented in Table 3.
The B criteria for the specific personality disorders comprise subsets of the 25 trait fac-
ets, based on meta-analytic reviews and empirical data on the relationships of the traits
to DSM-IV personality disorder diagnoses.
Criteria C and D: Pervasiveness and Stability

Impairments in personality functioning and pathological personality traits are relatively
pervasive across a range of personal and social contexts, as personality is defined as a
pattern of perceiving, relating to, and thinking about the environment and oneself. The
term relatively reflects the fact that all except the most extremely pathological personal-
ities show some degree of adaptability. The pattern in personality disorders is maladap-
tive and relatively inflexible, which leads to disabilities in social, occupational, or other
important pursuits, as individuals are unable to modify their thinking or behavior, even
in the face of evidence that their approach is not working. The impairments in function-
ing and personality traits are also relatively stable. Personality traits—the dispositions
to behave or feel in certain ways—are more stable than the symptomatic expressions of
these dispositions, but personality traits can also change. Impairments in personality
functioning are more stable than symptoms.
Criteria E, F, and G: Alternative Explanations for

Personality Pathology (Differential Diagnosis)
On some occasions, what appears to be a personality disorder may be better explained
by another mental disorder, the effects of a substance or another medical condition, or
a normal developmental stage (e.g., adolescence, late life) or the individual’s sociocul-
tural environment. When another mental disorder is present, the diagnosis of a person-
ality disorder is not made, if the manifestations of the personality disorder clearly are
an expression of the other mental disorder (e.g., if features of schizotypal personality
disorder are present only in the context of schizophrenia). On the other hand, personal-
ity disorders can be accurately diagnosed in the presence of another mental disorder,
such as major depressive disorder, and patients with other mental disorders should be
assessed for comorbid personality disorders because personality disorders often im-
pact the course of other mental disorders. Therefore, it is always appropriate to assess
personality functioning and pathological personality traits to provide a context for
other psychopathology.
Specific Personality Disorders

Section III includes diagnostic criteria for antisocial, avoidant, borderline, narcissistic,
obsessive-compulsive, and schizotypal personality disorders. Each personality disor-
der is defined by typical impairments in personality functioning (Criterion A) and char-
acteristic pathological personality traits (Criterion B):
• Typical features of antisocial personality disorder are a failure to conform to lawful
and ethical behavior, and an egocentric, callous lack of concern for others, accompa-
nied by deceitfulness, irresponsibility, manipulativeness, and/or risk taking.
• Typical features of avoidant personality disorder are avoidance of social situa-
tions and inhibition in interpersonal relationships related to feelings of ineptitude
and inadequacy, anxious preoccupation with negative evaluation and rejection, and
fears of ridicule or embarrassment.
• Typical features of borderline personality disorder are instability of self-image,
personal goals, interpersonal relationships, and affects, accompanied by impulsiv-
ity, risk taking, and/or hostility.
• Typical features of narcissistic personality disorder are variable and vulnerable
self-esteem, with attempts at regulation through attention and approval seeking, and
either overt or covert grandiosity.
• Typical features of obsessive-compulsive personality disorder are difficulties in
establishing and sustaining close relationships, associated with rigid perfection-
ism, inflexibility, and restricted emotional expression.
• Typical features of schizotypal personality disorder are impairments in the capac-
ity for social and close relationships, and eccentricities in cognition, perception, and
behavior that are associated with distorted self-image and incoherent personal goals
and accompanied by suspiciousness and restricted emotional expression.
The A and B criteria for the six specific personality disorders and for PD-TS follow.
All personality disorders also meet criteria C through G of the General Criteria for
Personality Disorder.
Antisocial Personality Disorder

Typical features of antisocial personality disorder are a failure to conform to lawful and
ethical behavior, and an egocentric, callous lack of concern for others, accompanied by
deceitfulness, irresponsibility, manipulativeness, and/or risk taking. Characteristic dif-
ficulties are apparent in identity, self-direction, empathy, and/or intimacy, as described
below, along with specific maladaptive traits in the domains of Antagonism and Disin-
hibition.
Proposed Diagnostic Criteria

A. Moderate or greater impairment in personality functioning, manifested by characteristic
difficulties in two or more of the following four areas:
1. Identity: Egocentrism; self-esteem derived from personal gain, power, or pleasure.
2. Self-direction: Goal setting based on personal gratification; absence of prosocial
internal standards, associated with failure to conform to lawful or culturally norma-
tive ethical behavior.
3. Empathy: Lack of concern for feelings, needs, or suffering of others; lack of re-
morse after hurting or mistreating another.
4. Intimacy: Incapacity for mutually intimate relationships, as exploitation is a primary
means of relating to others, including by deceit and coercion; use of dominance or
intimidation to control others.
B. Six or more of the following seven pathological personality traits:
1. Manipulativeness (an aspect of Antagonism): Frequent use of subterfuge to in-
fluence or control others; use of seduction, charm, glibness, or ingratiation to
achieve one’s ends.
2. Callousness (an aspect of Antagonism): Lack of concern for feelings or problems
of others; lack of guilt or remorse about the negative or harmful effects of one’s ac-
tions on others; aggression; sadism.
3. Deceitfulness (an aspect of Antagonism): Dishonesty and fraudulence; misrepre-
sentation of self; embellishment or fabrication when relating events.
4. Hostility (an aspect of Antagonism): Persistent or frequent angry feelings; anger
or irritability in response to minor slights and insults; mean, nasty, or vengeful be-
havior.
5. Risk taking (an aspect of Disinhibition): Engagement in dangerous, risky, and po-
tentially self-damaging activities, unnecessarily and without regard for conse-
quences; boredom proneness and thoughtless initiation of activities to counter
boredom; lack of concern for one’s limitations and denial of the reality of personal
danger.
6. Impulsivity (an aspect of Disinhibition): Acting on the spur of the moment in re-
sponse to immediate stimuli; acting on a momentary basis without a plan or consid-
eration of outcomes; difficulty establishing and following plans.
7. Irresponsibility (an aspect of Disinhibition): Disregard for—and failure to honor—
financial and other obligations or commitments; lack of respect for—and lack of fol-
low-through on—agreements and promises.
Note. The individual is at least 18 years of age.
Specify if:
With psychopathic features.
Specifiers
A distinct variant often termed psychopathy (or “primary” psychopathy) is marked by a
lack of anxiety or fear and by a bold interpersonal style that may mask maladaptive be-
haviors (e.g., fraudulence). This psychopathic variant is characterized by low levels of
anxiousness (Negative Affectivity domain) and withdrawal (Detachment domain) and
high levels of attention seeking (Antagonism domain). High attention seeking and low
withdrawal capture the social potency (assertive/dominant) component of psychopa-
thy, whereas low anxiousness captures the stress immunity (emotional stability/resil-
ience) component.
In addition to psychopathic features, trait and personality functioning specifiers
may be used to record other personality features that may be present in antisocial per-
sonality disorder but are not required for the diagnosis. For example, traits of Negative
Affectivity (e.g., anxiousness), are not diagnostic criteria for antisocial personality dis-
order (see Criterion B) but can be specified when appropriate. Furthermore, although
moderate or greater impairment in personality functioning is required for the diagno-
sis of antisocial personality disorder (Criterion A), the level of personality functioning
can also be specified.
Avoidant Personality Disorder

Typical features of avoidant personality disorder are avoidance of social situations and
inhibition in interpersonal relationships related to feelings of ineptitude and inade-
quacy, anxious preoccupation with negative evaluation and rejection, and fears of ridi-
cule or embarrassment. Characteristic difficulties are apparent in identity, self-
direction, empathy, and/or intimacy, as described below, along with specific maladap-
tive traits in the domains of Negative Affectivity and Detachment.

A. Moderate or greater impairment in personality functioning, manifest by characteristic
1. Identity: Low self-esteem associated with self-appraisal as socially inept, person-
ally unappealing, or inferior; excessive feelings of shame.
2. Self-direction: Unrealistic standards for behavior associated with reluctance to
pursue goals, take personal risks, or engage in new activities involving interper-
sonal contact.
3. Empathy: Preoccupation with, and sensitivity to, criticism or rejection, associated
with distorted inference of others’ perspectives as negative.
4. Intimacy: Reluctance to get involved with people unless being certain of being
liked; diminished mutuality within intimate relationships because of fear of being
shamed or ridiculed.
B. Three or more of the following four pathological personality traits, one of which must
be (1) Anxiousness:
1. Anxiousness (an aspect of Negative Affectivity): Intense feelings of nervous-
ness, tenseness, or panic, often in reaction to social situations; worry about the
negative effects of past unpleasant experiences and future negative possibilities;
feeling fearful, apprehensive, or threatened by uncertainty; fears of embarrass-
ment.
2. Withdrawal (an aspect of Detachment): Reticence in social situations; avoidance

of social contacts and activity; lack of initiation of social contact.
3. Anhedonia (an aspect of Detachment): Lack of enjoyment from, engagement in,
or energy for life’s experiences; deficits in the capacity to feel pleasure or take in-
terest in things.
4. Intimacy avoidance (an aspect of Detachment): Avoidance of close or romantic
relationships, interpersonal attachments, and intimate sexual relationships.
Specifiers
Considerable heterogeneity in the form of additional personality traits is found among
individuals diagnosed with avoidant personality disorder. Trait and level of personal-
ity functioning specifiers can be used to record additional personality features that may
be present in avoidant personality disorder. For example, other Negative Affectivity
traits (e.g., depressivity, separation insecurity, submissiveness, suspiciousness, hostil-
ity) are not diagnostic criteria for avoidant personality disorder (see Criterion B) but can
be specified when appropriate. Furthermore, although moderate or greater impairment
in personality functioning is required for the diagnosis of avoidant personality disorder
(Criterion A), the level of personality functioning also can be specified.
Borderline Personality Disorder

Typical features of borderline personality disorder are instability of self-image, per-
sonal goals, interpersonal relationships, and affects, accompanied by impulsivity, risk
taking, and/or hostility. Characteristic difficulties are apparent in identity, self-direc-
tion, empathy, and/or intimacy, as described below, along with specific maladaptive
traits in the domain of Negative Affectivity, and also Antagonism and/or Disinhibition.

1. Identity: Markedly impoverished, poorly developed, or unstable self-image, often
associated with excessive self-criticism; chronic feelings of emptiness; dissociative
states under stress.
2. Self-direction: Instability in goals, aspirations, values, or career plans.
3. Empathy: Compromised ability to recognize the feelings and needs of others asso-
ciated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); per-
ceptions of others selectively biased toward negative attributes or vulnerabilities.
4. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust,
neediness, and anxious preoccupation with real or imagined abandonment; close
relationships often viewed in extremes of idealization and devaluation and alternat-
ing between overinvolvement and withdrawal.
B. Four or more of the following seven pathological personality traits, at least one of which
must be (5) Impulsivity, (6) Risk taking, or (7) Hostility:
1. Emotional lability (an aspect of Negative Affectivity): Unstable emotional expe-
riences and frequent mood changes; emotions that are easily aroused, intense,
and/or out of proportion to events and circumstances.
2. Anxiousness (an aspect of Negative Affectivity): Intense feelings of nervous-
ness, tenseness, or panic, often in reaction to interpersonal stresses; worry about
the negative effects of past unpleasant experiences and future negative possibili-
ties; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling
apart or losing control.
3. Separation insecurity (an aspect of Negative Affectivity): Fears of rejection by—
and/or separation from—significant others, associated with fears of excessive de-
pendency and complete loss of autonomy.
4. Depressivity (an aspect of Negative Affectivity): Frequent feelings of being down,
miserable, and/or hopeless; difficulty recovering from such moods; pessimism
about the future; pervasive shame; feelings of inferior self-worth; thoughts of sui-
cide and suicidal behavior.
5. Impulsivity (an aspect of Disinhibition): Acting on the spur of the moment in re-
sponse to immediate stimuli; acting on a momentary basis without a plan or consid-
eration of outcomes; difficulty establishing or following plans; a sense of urgency
and self-harming behavior under emotional distress.
6. Risk taking (an aspect of Disinhibition): Engagement in dangerous, risky, and po-
tentially self-damaging activities, unnecessarily and without regard to conse-
quences; lack of concern for one’s limitations and denial of the reality of personal
danger.
7. Hostility (an aspect of Antagonism): Persistent or frequent angry feelings; anger
or irritability in response to minor slights and insults.
Specifiers
Trait and level of personality functioning specifiers may be used to record additional
personality features that may be present in borderline personality disorder but are not
required for the diagnosis. For example, traits of Psychoticism (e.g., cognitive and per-
ceptual dysregulation) are not diagnostic criteria for borderline personality disorder
(see Criterion B) but can be specified when appropriate. Furthermore, although moder-
ate or greater impairment in personality functioning is required for the diagnosis of
borderline personality disorder (Criterion A), the level of personality functioning can
also be specified.
Narcissistic Personality Disorder

Typical features of narcissistic personality disorder are variable and vulnerable self-
esteem, with attempts at regulation through attention and approval seeking, and either
overt or covert grandiosity. Characteristic difficulties are apparent in identity, self-direc-
tion, empathy, and/or intimacy, as described below, along with specific maladaptive
traits in the domain of Antagonism.

1. Identity: Excessive reference to others for self-definition and self-esteem regula-
tion; exaggerated self-appraisal inflated or deflated, or vacillating between extremes;
emotional regulation mirrors fluctuations in self-esteem.
2. Self-direction: Goal setting based on gaining approval from others; personal stan-
dards unreasonably high in order to see oneself as exceptional, or too low based
on a sense of entitlement; often unaware of own motivations.
3. Empathy: Impaired ability to recognize or identify with the feelings and needs of
others; excessively attuned to reactions of others, but only if perceived as relevant
to self; over- or underestimate of own effect on others.
4. Intimacy: Relationships largely superficial and exist to serve self-esteem regula-
tion; mutuality constrained by little genuine interest in others’ experiences and pre-
dominance of a need for personal gain.
B. Both of the following pathological personality traits:
1. Grandiosity (an aspect of Antagonism): Feelings of entitlement, either overt or co-
vert; self-centeredness; firmly holding to the belief that one is better than others;
condescension toward others.
2. Attention seeking (an aspect of Antagonism): Excessive attempts to attract and
be the focus of the attention of others; admiration seeking.
Specifiers
Trait and personality functioning specifiers may be used to record additional personal-
ity features that may be present in narcissistic personality disorder but are not required
for the diagnosis. For example, other traits of Antagonism (e.g., manipulativeness, de-
ceitfulness, callousness) are not diagnostic criteria for narcissistic personality disorder
(see Criterion B) but can be specified when more pervasive antagonistic features (e.g.,
“malignant narcissism”) are present. Other traits of Negative Affectivity (e.g., depres-
sivity, anxiousness) can be specified to record more “vulnerable” presentations. Fur-
thermore, although moderate or greater impairment in personality functioning is
required for the diagnosis of narcissistic personality disorder (Criterion A), the level of
personality functioning can also be specified.
Obsessive-Compulsive Personality Disorder

Typical features of obsessive-compulsive personality disorder are difficulties in estab-
lishing and sustaining close relationships, associated with rigid perfectionism, inflexi-
bility, and restricted emotional expression. Characteristic difficulties are apparent in
identity, self-direction, empathy, and/or intimacy, as described below, along with spe-
cific maladaptive traits in the domains of Negative Affectivity and/or Detachment.

1. Identity: Sense of self derived predominantly from work or productivity; constricted
experience and expression of strong emotions.
2. Self-direction: Difficulty completing tasks and realizing goals, associated with rigid
and unreasonably high and inflexible internal standards of behavior; overly consci-
entious and moralistic attitudes.
3. Empathy: Difficulty understanding and appreciating the ideas, feelings, or behav-
iors of others.
4. Intimacy: Relationships seen as secondary to work and productivity; rigidity and
stubbornness negatively affect relationships with others.
B. Three or more of the following four pathological personality traits, one of which must
be (1) Rigid perfectionism:
1. Rigid perfectionism (an aspect of extreme Conscientiousness [the opposite pole

of Disinhibition]): Rigid insistence on everything being flawless, perfect, and without
errors or faults, including one’s own and others’ performance; sacrificing of timeli-
ness to ensure correctness in every detail; believing that there is only one right way
to do things; difficulty changing ideas and/or viewpoint; preoccupation with details,
organization, and order.
2. Perseveration (an aspect of Negative Affectivity): Persistence at tasks long after
the behavior has ceased to be functional or effective; continuance of the same be-
havior despite repeated failures.
3. Intimacy avoidance (an aspect of Detachment): Avoidance of close or romantic
relationships, interpersonal attachments, and intimate sexual relationships.
4. Restricted affectivity (an aspect of Detachment): Little reaction to emotionally
arousing situations; constricted emotional experience and expression; indifference
or coldness.
Specifiers
ity features that may be present in obsessive-compulsive personality disorder but are
not required for the diagnosis. For example, other traits of Negative Affectivity (e.g.,
anxiousness) are not diagnostic criteria for obsessive-compulsive personality disorder
(see Criterion B) but can be specified when appropriate. Furthermore, although moder-
ate or greater impairment in personality functioning is required for the diagnosis of
obsessive-compulsive personality disorder (Criterion A), the level of personality func-
tioning can also be specified.
Schizotypal Personality Disorder

Typical features of schizotypal personality disorder are impairments in the capacity for
social and close relationships and eccentricities in cognition, perception, and behavior
that are associated with distorted self-image and incoherent personal goals and accom-
panied by suspiciousness and restricted emotional expression. Characteristic diffi-
culties are apparent in identity, self-direction, empathy, and/or intimacy, along with
specific maladaptive traits in the domains of Psychoticism and Detachment.

1. Identity: Confused boundaries between self and others; distorted self-concept;
emotional expression often not congruent with context or internal experience.
2. Self-direction: Unrealistic or incoherent goals; no clear set of internal standards.
3. Empathy: Pronounced difficulty understanding impact of own behaviors on others;
frequent misinterpretations of others’ motivations and behaviors.
4. Intimacy: Marked impairments in developing close relationships, associated with
mistrust and anxiety.
B. Four or more of the following six pathological personality traits:
1. Cognitive and perceptual dysregulation (an aspect of Psychoticism): Odd or
unusual thought processes; vague, circumstantial, metaphorical, overelaborate, or
stereotyped thought or speech; odd sensations in various sensory modalities.
2. Unusual beliefs and experiences (an aspect of Psychoticism): Thought content

and views of reality that are viewed by others as bizarre or idiosyncratic; unusual
experiences of reality.
3. Eccentricity (an aspect of Psychoticism): Odd, unusual, or bizarre behavior or
appearance; saying unusual or inappropriate things.
4. Restricted affectivity (an aspect of Detachment): Little reaction to emotionally
arousing situations; constricted emotional experience and expression; indifference
or coldness.
5. Withdrawal (an aspect of Detachment): Preference for being alone to being with
others; reticence in social situations; avoidance of social contacts and activity; lack
of initiation of social contact.
6. Suspiciousness (an aspect of Detachment): Expectations of—and heightened
sensitivity to—signs of interpersonal ill-intent or harm; doubts about loyalty and fi-
delity of others; feelings of persecution.
Specifiers
ity features that may be present in schizotypal personality disorder but are not required
for the diagnosis. For example, traits of Negative Affectivity (e.g., depressivity, anxious-
ness) are not diagnostic criteria for schizotypal personality disorder (see Criterion B)
but can be specified when appropriate. Furthermore, although moderate or greater im-
pairment in personality functioning is required for the diagnosis of schizotypal person-
ality disorder (Criterion A), the level of personality functioning can also be specified.
Personality Disorder—Trait Specified

A. Moderate or greater impairment in personality functioning, manifested by difficulties in
two or more of the following four areas:
1. Identity
2. Self-direction
3. Empathy
4. Intimacy
B. One or more pathological personality trait domains OR specific trait facets within do-
mains, considering ALL of the following domains:
1. Negative Affectivity (vs. Emotional Stability): Frequent and intense experiences
of high levels of a wide range of negative emotions (e.g., anxiety, depression, guilt/
shame, worry, anger), and their behavioral (e.g., self-harm) and interpersonal (e.g.,
dependency) manifestations.
2. Detachment (vs. Extraversion): Avoidance of socioemotional experience, includ-
ing both withdrawal from interpersonal interactions, ranging from casual, daily in-
teractions to friendships to intimate relationships, as well as restricted affective
experience and expression, particularly limited hedonic capacity.
3. Antagonism (vs. Agreeableness): Behaviors that put the individual at odds with
other people, including an exaggerated sense of self-importance and a concomi-
tant expectation of special treatment, as well as a callous antipathy toward others,
encompassing both unawareness of others’ needs and feelings, and a readiness
to use others in the service of self-enhancement.
4. Disinhibition (vs. Conscientiousness): Orientation toward immediate gratification,

leading to impulsive behavior driven by current thoughts, feelings, and external
stimuli, without regard for past learning or consideration of future consequences.
5. Psychoticism (vs. Lucidity): Exhibiting a wide range of culturally incongruent odd,
eccentric, or unusual behaviors and cognitions, including both process (e.g., per-
ception, dissociation) and content (e.g., beliefs).
Subtypes
Because personality features vary continuously along multiple trait dimensions, a com-
prehensive set of potential expressions of PD-TS can be represented by DSM-5’s dimen-
sional model of maladaptive personality trait variants (see Table 3). Thus, subtypes are
unnecessary for PD-TS, and instead, the descriptive elements that constitute personal-
ity are provided, arranged in an empirically based model. This arrangement allows
clinicians to tailor the description of each individual’s personality disorder profile, con-
sidering all five broad domains of personality trait variation and drawing on the de-
scriptive features of these domains as needed to characterize the individual.
Specifiers
The specific personality features of individuals are always recorded in evaluating Cri-
terion B, so the combination of personality features characterizing an individual di-
rectly constitutes the specifiers in each case. For example, two individuals who are both
characterized by emotional lability, hostility, and depressivity may differ such that the
first individual is characterized additionally by callousness, whereas the second is not.
Personality Disorder Scoring Algorithms

The requirement for any two of the four A criteria for each of the six personality disor-
ders was based on maximizing the relationship of these criteria to their corresponding
personality disorder. Diagnostic thresholds for the B criteria were also set empirically
to minimize change in prevalence of the disorders from DSM-IV and overlap with other
personality disorders, and to maximize relationships with functional impairment. The
resulting diagnostic criteria sets represent clinically useful personality disorders with
high fidelity, in terms of core impairments in personality functioning of varying degrees
of severity and constellations of pathological personality traits.
Personality Disorder Diagnosis

Individuals who have a pattern of impairment in personality functioning and maladap-
tive traits that matches one of the six defined personality disorders should be diagnosed
with that personality disorder. If an individual also has one or even several prominent
traits that may have clinical relevance in addition to those required for the diagnosis
(e.g., see narcissistic personality disorder), the option exists for these to be noted as
specifiers. Individuals whose personality functioning or trait pattern is substantially
different from that of any of the six specific personality disorders should be diagnosed
with PD-TS. The individual may not meet the required number of A or B criteria and,
thus, have a subthreshold presentation of a personality disorder. The individual may
have a mix of features of personality disorder types or some features that are less char-
acteristic of a type and more accurately considered a mixed or atypical presentation.
The specific level of impairment in personality functioning and the pathological per-
sonality traits that characterize the individual’s personality can be specified for PD-TS,
using the Level of Personality Functioning Scale (Table 2) and the pathological trait tax-
onomy (Table 3). The current diagnoses of paranoid, schizoid, histrionic, and dependent
personality disorders are represented also by the diagnosis of PD-TS; these are defined
by moderate or greater impairment in personality functioning and can be specified by
the relevant pathological personality trait combinations.
Level of Personality Functioning Scale

Like most human tendencies, personality functioning is distributed on a continuum.
Central to functioning and adaptation are individuals’ characteristic ways of thinking
about and understanding themselves and their interactions with others. An optimally
functioning individual has a complex, fully elaborated, and well-integrated psycholog-
ical world that includes a mostly positive, volitional, and adaptive self-concept; a rich,
broad, and appropriately regulated emotional life; and the capacity to behave as a pro-
ductive member of society with reciprocal and fulfilling interpersonal relationships. At
the opposite end of the continuum, an individual with severe personality pathology
has an impoverished, disorganized, and/or conflicted psychological world that in-
cludes a weak, unclear, and maladaptive self-concept; a propensity to negative, dysreg-
ulated emotions; and a deficient capacity for adaptive interpersonal functioning and
social behavior.
Self- and Interpersonal Functioning

Dimensional Definition
Generalized severity may be the most important single predictor of concurrent and pro-
spective dysfunction in assessing personality psychopathology. Personality disorders
are optimally characterized by a generalized personality severity continuum with ad-
ditional specification of stylistic elements, derived from personality disorder symptom
constellations and personality traits. At the same time, the core of personality psycho-
pathology is impairment in ideas and feelings regarding self and interpersonal relation-
ships; this notion is consistent with multiple theories of personality disorder and their
research bases. The components of the Level of Personality Functioning Scale—identity,
self-direction, empathy, and intimacy—are particularly central in describing a person-
ality functioning continuum.
Mental representations of the self and interpersonal relationships are reciprocally
influential and inextricably tied, affect the nature of interaction with mental health
professionals, and can have a significant impact on both treatment efficacy and out-
come, underscoring the importance of assessing an individual’s characteristic self-
concept as well as views of other people and relationships. Although the degree of
disturbance in the self and interpersonal functioning is continuously distributed, it is
useful to consider the level of impairment in functioning for clinical characterization
and for treatment planning and prognosis.
Rating Level of Personality Functioning

To use the Level of Personality Functioning Scale (LPFS) (Table 2), the clinician selects
the level that most closely captures the individual’s current overall level of impairment
in personality functioning. The rating is necessary for the diagnosis of a personality dis-
order (moderate or greater impairment) and can be used to specify the severity of im-
pairment present for an individual with any personality disorder at a given point in
time. The LPFS may also be used as a global indicator of personality functioning with-
out specification of a personality disorder diagnosis, or in the event that personality im-
pairment is subthreshold for a disorder diagnosis.
Personality Traits
Definition and Description

Criterion B in the alternative model involves assessments of personality traits that are
grouped into five domains. A personality trait is a tendency to feel, perceive, behave, and
think in relatively consistent ways across time and across situations in which the trait
may manifest. For example, individuals with a high level of the personality trait of anx-
iousness would tend to feel anxious readily, including in circumstances in which most
people would be calm and relaxed. Individuals high in trait anxiousness also would
perceive situations to be anxiety-provoking more frequently than would individuals
with lower levels of this trait, and those high in the trait would tend to behave so as to
avoid situations that they think would make them anxious. They would thereby tend to
think about the world as more anxiety provoking than other people.
Importantly, individuals high in trait anxiousness would not necessarily be anx-
ious at all times and in all situations. Individuals’ trait levels also can and do change
throughout life. Some changes are very general and reflect maturation (e.g., teenagers
generally are higher on trait impulsivity than are older adults), whereas other
changes reflect individuals’ life experiences.
Dimensionality of Personality Traits

All individuals can be located on the spectrum of trait dimensions; that is, personality
traits apply to everyone in different degrees rather than being present versus absent.
Moreover, personality traits, including those identified specifically in the Section III
model, exist on a spectrum with two opposing poles. For example, the opposite of the
trait of callousness is the tendency to be empathic and kind-hearted, even in circum-
stances in which most persons would not feel that way. Hence, although in Section III
this trait is labeled callousness, because that pole of the dimension is the primary focus,
it could be described in full as callousness versus kind-heartedness. Moreover, its opposite
pole can be recognized and may not be adaptive in all circumstances (e.g., individuals
who, due to extreme kind-heartedness, repeatedly allow themselves to be taken advan-
tage of by unscrupulous others).
Hierarchical Structure of Personality

Some trait terms are quite specific (e.g., “talkative”) and describe a narrow range of be-
haviors, whereas others are quite broad (e.g., Detachment) and characterize a wide
Appendix: Alternative DSM-5 Model for Personality Disorders
TABLE 2. Level of Personality Functioning Scale
SELF INTERPERSONAL
Level of
impairment Identity Self-direction Empathy Intimacy
0—Little or no Has ongoing awareness of a Sets and aspires to reasonable Is capable of accurately under- Maintains multiple satisfying and
impairment unique self; maintains role- goals based on a realistic standing others’ experiences enduring relationships in personal
appropriate boundaries. assessment of personal and motivations in most situ- and community life.
Has consistent and self-regulated capacities. ations. Desires and engages in a number of
positive self-esteem, with Utilizes appropriate stan- Comprehends and appreciates caring, close, and reciprocal rela-
accurate self-appraisal. dards of behavior, attaining others’ perspectives, even if tionships.
Is capable of experiencing, fulfillment in multiple disagreeing. Strives for cooperation and mutual
tolerating, and regulating realms. Is aware of the effect of own ac- benefit and flexibly responds to a
a full range of emotions. Can reflect on, and make con- tions on others. range of others’ ideas, emotions,
structive meaning of, inter- and behaviors.
nal experience.
1—Some Has relatively intact sense of self, Is excessively goal-directed, Is somewhat compromised in Is able to establish enduring rela-
impairment with some decrease in clarity somewhat goal-inhibited, ability to appreciate and un- tionships in personal and commu-
of boundaries when strong or conflicted about goals. derstand others’ experiences; nity life, with some limitations on
emotions and mental distress May have an unrealistic or may tend to see others as hav- degree of depth and satisfaction.
are experienced. socially inappropriate set of ing unreasonable expecta- Is capable of forming and desires to
Self-esteem diminished at times, personal standards, limiting tions or a wish for control. form intimate and reciprocal rela-
with overly critical or some- some aspects of fulfillment. Although capable of consider- tionships, but may be inhibited in
what distorted self-appraisal. Is able to reflect on internal ing and understanding differ- meaningful expression and some-
Strong emotions may be distress- experiences, but may ent perspectives, resists doing times constrained if intense emo-
ing, associated with a restriction overemphasize a single so. tions or conflicts arise.
in range of emotional experi- (e.g., intellectual, emotional) Has inconsistent awareness of Cooperation may be inhibited by
ence. type of self-knowledge. effect of own behavior on unrealistic standards; somewhat
others. limited in ability to respect or re-
spond to others’ ideas, emotions,
and behaviors.
559
560
TABLE 2. Level of Personality Functioning Scale (continued)
SELF INTERPERSONAL
Level of

2—Moderate Depends excessively on others Goals are more often a means Is hyperattuned to the experi- Is capable of forming and desires to
impairment for identity definition, with of gaining external approval ence of others, but only with form relationships in personal and
compromised boundary delin- than self-generated, and thus respect to perceived relevance community life, but connections
eation. may lack coherence and/or to self. may be largely superficial.
Has vulnerable self-esteem con- stability. Is excessively self-referential; Intimate relationships are predomi-
trolled by exaggerated concern Personal standards may be un- significantly compromised nantly based on meeting self-
about external evaluation, with reasonably high (e.g., a need ability to appreciate and un- regulatory and self-esteem needs,
a wish for approval. Has sense to be special or please others) derstand others’ experiences with an unrealistic expectation of
of incompleteness or inferiority, or low (e.g., not consonant and to consider alternative being perfectly understood by
with compensatory inflated, or with prevailing social val- perspectives. others.
deflated, ues). Fulfillment is compro- Is generally unaware of or un- Tends not to view relationships in re-
self-appraisal. mised by a sense of lack of concerned about effect of own ciprocal terms, and cooperates pre-
Emotional regulation depends authenticity. behavior on others, or unreal- dominantly for personal gain.
on positive external appraisal. Has impaired capacity to re- istic appraisal of own effect.
Threats to self-esteem may en- flect on internal experience.
gender strong emotions such as
rage or shame.
Appendix: Alternative DSM-5 Model for Personality Disorders
SELF INTERPERSONAL
Level of
3—Severe Has a weak sense of autonomy/ Has difficulty establishing Ability to consider and under- Has some desire to form relation-
impairment agency; experience of a lack of and/or achieving personal stand the thoughts, feelings, ships in community and personal
identity, or emptiness. Bound- goals. and behavior of other people life is present, but capacity for pos-
ary definition is poor or rigid: Internal standards for behavior is significantly limited; may itive and enduring connections is
may show overidentification are unclear or contradictory. discern very specific aspects significantly impaired.
with others, overemphasis on Life is experienced as mean- of others’ experience, particu- Relationships are based on a strong
independence from others, or ingless or dangerous. larly vulnerabilities and suf- belief in the absolute need for the
vacillation between these. Has significantly compro- fering. intimate other(s), and/or expecta-
Fragile self-esteem is easily influ- mised ability to reflect on Is generally unable to consider tions of abandonment or abuse.
enced by events, and self-image and understand own mental alternative perspectives; Feelings about intimate involve-
lacks coherence. Self-appraisal processes. highly threatened by differ- ment with others alternate be-
is un-nuanced: self-loathing, ences of opinion or alternative tween fear/rejection and
self-aggrandizing, or an illogi- viewpoints. desperate desire for connection.
cal, unrealistic combination. Is confused about or unaware Little mutuality: others are concep-
Emotions may be rapidly shifting of impact of own actions on tualized primarily in terms of how
or a chronic, unwavering feel- others; often bewildered they affect the self (negatively or
ing of despair. about peoples’ thoughts and positively); cooperative efforts are
actions, with destructive mo- often disrupted due to the percep-
tivations frequently misat- tion of slights from others.
tributed to others.
561
562
SELF INTERPERSONAL
Level of

4—Extreme Experience of a unique self and Has poor differentiation of Has pronounced inability to Desire for affiliation is limited be-
impairment sense of agency/autonomy are thoughts from actions, so consider and understand cause of profound disinterest or
virtually absent, or are orga- goal-setting ability is se- others’ experience and expectation of harm. Engagement
nized around perceived exter- verely compromised, with motivation. with others is detached, disorga-
nal persecution. Boundaries unrealistic or incoherent Attention to others’ perspec- nized, or consistently negative.
with others are confused or goals. tives is virtually absent Relationships are conceptualized al-
lacking. Internal standards for behav- (attention is hypervigilant, most exclusively in terms of their
Has weak or distorted self-image ior are virtually lacking. focused on need fulfillment ability to provide comfort or inflict
easily threatened by interac- Genuine fulfillment is and harm avoidance). pain and suffering.
tions with others; significant virtually inconceivable. Social interactions can be Social/interpersonal behavior is not
distortions and confusion Is profoundly unable to con- confusing and disorienting. reciprocal; rather, it seeks fulfill-
around self-appraisal. structively reflect on own ment of basic needs or escape from
Emotions not congruent with experience. Personal motiva- pain.
context or internal experience. tions may be unrecognized
Hatred and aggression may be and/or experienced as exter-
dominant affects, although they nal to self.
may be disavowed and attrib-
uted to others.
range of behavioral propensities. Broad trait dimensions are called domains, and specific
trait dimensions are called facets. Personality trait domains comprise a spectrum of more
specific personality facets that tend to occur together. For example, withdrawal and an-
hedonia are specific trait facets in the trait domain of Detachment. Despite some cross-
cultural variation in personality trait facets, the broad domains they collectively com-
prise are relatively consistent across cultures.
The Personality Trait Model

The Section III personality trait system includes five broad domains of personality trait
variation—Negative Affectivity (vs. Emotional Stability), Detachment (vs. Extraver-
sion), Antagonism (vs. Agreeableness), Disinhibition (vs. Conscientiousness), and Psy-
choticism (vs. Lucidity)—comprising 25 specific personality trait facets. Table 3 provides
definitions of all personality domains and facets. These five broad domains are mal-
adaptive variants of the five domains of the extensively validated and replicated
personality model known as the “Big Five”, or Five Factor Model of personality (FFM),
and are also similar to the domains of the Personality Psychopathology Five (PSY-5).
The specific 25 facets represent a list of personality facets chosen for their clinical rele-
vance.
Although the Trait Model focuses on personality traits associated with psychopathol-
ogy, there are healthy, adaptive, and resilient personality traits identified as the polar
opposites of these traits, as noted in the parentheses above (i.e., Emotional Stability,
Extraversion, Agreeableness, Conscientiousness, and Lucidity). Their presence can
greatly mitigate the effects of mental disorders and facilitate coping and recovery
from traumatic injuries and other medical illness.
Distinguishing Traits, Symptoms, and Specific Behaviors

Although traits are by no means immutable and do change throughout the life span,
they show relative consistency compared with symptoms and specific behaviors. For
example, a person may behave impulsively at a specific time for a specific reason (e.g.,
a person who is rarely impulsive suddenly decides to spend a great deal of money on
a particular item because of an unusual opportunity to purchase something of unique
value), but it is only when behaviors aggregate across time and circumstance, such that
a pattern of behavior distinguishes between individuals, that they reflect traits. Never-
theless, it is important to recognize, for example, that even people who are impulsive
are not acting impulsively all of the time. A trait is a tendency or disposition toward
specific behaviors; a specific behavior is an instance or manifestation of a trait.
Similarly, traits are distinguished from most symptoms because symptoms tend to
wax and wane, whereas traits are relatively more stable. For example, individuals with
higher levels of depressivity have a greater likelihood of experiencing discrete episodes
of a depressive disorder and of showing the symptoms of these disorders, such diffi-
culty concentrating. However, even patients who have a trait propensity to depressiv-
ity typically cycle through distinguishable episodes of mood disturbance, and specific
symptoms such as difficulty concentrating tend to wax and wane in concert with spe-
cific episodes, so they do not form part of the trait definition. Importantly, however,
symptoms and traits are both amenable to intervention, and many interventions tar-
geted at symptoms can affect the longer term patterns of personality functioning that
are captured by personality traits.
Assessment of the DSM-5 Section III Personality

Trait Model
The clinical utility of the Section III multidimensional personality trait model lies in its
ability to focus attention on multiple relevant areas of personality variation in each in-
dividual patient. Rather than focusing attention on the identification of one and only
one optimal diagnostic label, clinical application of the Section III personality trait
model involves reviewing all five broad personality domains portrayed in Table 3. The
clinical approach to personality is similar to the well-known review of systems in clin-
ical medicine. For example, an individual’s presenting complaint may focus on a spe-
cific neurological symptom, yet during an initial evaluation clinicians still systemati-
cally review functioning in all relevant systems (e.g., cardiovascular, respiratory,
gastrointestinal), lest an important area of diminished functioning and corresponding
opportunity for effective intervention be missed.
Clinical use of the Section III personality trait model proceeds similarly. An initial
inquiry reviews all five broad domains of personality. This systematic review is facil-
itated by the use of formal psychometric instruments designed to measure specific
facets and domains of personality. For example, the personality trait model is opera-
tionalized in the Personality Inventory for DSM-5 (PID-5), which can be completed in
its self-report form by patients and in its informant-report form by those who know
the patient well (e.g., a spouse). A detailed clinical assessment would involve collec-
tion of both patient- and informant-report data on all 25 facets of the personality trait
model. However, if this is not possible, due to time or other constraints, assessment
focused at the five-domain level is an acceptable clinical option when only a general
(vs. detailed) portrait of a patient’s personality is needed (see Criterion B of PD-TS).
However, if personality-based problems are the focus of treatment, then it will be impor-
tant to assess individuals’ trait facets as well as domains.
Because personality traits are continuously distributed in the population, an ap-
proach to making the judgment that a specific trait is elevated (and therefore is pres-
ent for diagnostic purposes) could involve comparing individuals’ personality trait
levels with population norms and/or clinical judgment. If a trait is elevated—that is,
formal psychometric testing and/or interview data support the clinical judgment of
elevation—then it is considered as contributing to meeting Criterion B of Section III
personality disorders.
Clinical Utility of the Multidimensional Personality

Functioning and Trait Model
Disorder and trait constructs each add value to the other in predicting important ante-
cedent (e.g., family history, history of child abuse), concurrent (e.g., functional impair-
ment, medication use), and predictive (e.g., hospitalization, suicide attempts) variables.
DSM-5 impairments in personality functioning and pathological personality traits each
contribute independently to clinical decisions about degree of disability; risks for self-
harm, violence, and criminality; recommended treatment type and intensity; and prog-
TABLE 3. Definitions of DSM-5 personality disorder trait domains and facets
DOMAINS (Polar
Opposites) and Facets Definitions
NEGATIVE AFFECTIVITY Frequent and intense experiences of high levels of a wide range of
(vs. Emotional Stability) negative emotions (e.g., anxiety, depression, guilt/ shame, worry,
anger) and their behavioral (e.g., self-harm) and interpersonal
(e.g., dependency) manifestations.
Emotional lability Instability of emotional experiences and mood; emotions that are
easily aroused, intense, and/or out of proportion to events and
circumstances.
Anxiousness Feelings of nervousness, tenseness, or panic in reaction to diverse
situations; frequent worry about the negative effects of past un-
pleasant experiences and future negative possibilities; feeling
fearful and apprehensive about uncertainty; expecting the worst
to happen.
Separation insecurity Fears of being alone due to rejection by—and/or separation from—
significant others, based in a lack of confidence in one’s ability to
care for oneself, both physically and emotionally.
Submissiveness Adaptation of one’s behavior to the actual or perceived interests
and desires of others even when doing so is antithetical to one’s
own interests, needs, or desires.
Hostility Persistent or frequent angry feelings; anger or irritability in re-
sponse to minor slights and insults; mean, nasty, or vengeful be-
havior. See also Antagonism.
Perseveration Persistence at tasks or in a particular way of doing things long after
the behavior has ceased to be functional or effective; continuance
of the same behavior despite repeated failures or clear reasons
for stopping.
Depressivity See Detachment.
Suspiciousness See Detachment.
Restricted affectivity The lack of this facet characterizes low levels of Negative Affec-
(lack of) tivity. See Detachment for definition of this facet.
DETACHMENT Avoidance of socioemotional experience, including both with-
(vs. Extraversion) drawal from interpersonal interactions (ranging from casual,
daily interactions to friendships to intimate relationships) and
restricted affective experience and expression, particularly lim-
ited hedonic capacity.
Withdrawal Preference for being alone to being with others; reticence in social
situations; avoidance of social contacts and activity; lack of initi-
ation of social contact.
Intimacy avoidance Avoidance of close or romantic relationships, interpersonal attach-
ments, and intimate sexual relationships.
Anhedonia Lack of enjoyment from, engagement in, or energy for life’s expe-
riences; deficits in the capacity to feel pleasure and take interest
in things.
Depressivity Feelings of being down, miserable, and/or hopeless; difficulty re-
covering from such moods; pessimism about the future; pervasive
shame and/or guilt; feelings of inferior self-worth; thoughts of
suicide and suicidal behavior.
Restricted affectivity Little reaction to emotionally arousing situations; constricted emo-
tional experience and expression; indifference and aloofness in
normatively engaging situations.
Suspiciousness Expectations of—and sensitivity to—signs of interpersonal ill-
intent or harm; doubts about loyalty and fidelity of others; feel-
ings of being mistreated, used, and/or persecuted by others.
TABLE 3. Definitions of DSM-5 personality disorder trait domains and facets (continued)
DOMAINS (Polar
ANTAGONISM Behaviors that put the individual at odds with other people,
(vs. Agreeableness) including an exaggerated sense of self-importance and a concom-
itant expectation of special treatment, as well as a callous antip-
athy toward others, encompassing both an unawareness of
others’ needs and feelings and a readiness to use others in the
service of self-enhancement.
Manipulativeness Use of subterfuge to influence or control others; use of seduction,
charm, glibness, or ingratiation to achieve one’s ends.
Deceitfulness Dishonesty and fraudulence; misrepresentation of self; embellish-
ment or fabrication when relating events.
Grandiosity Believing that one is superior to others and deserves special treat-
ment; self-centeredness; feelings of entitlement; condescension
toward others.
Attention seeking Engaging in behavior designed to attract notice and to make oneself
the focus of others’ attention and admiration.
Callousness Lack of concern for the feelings or problems of others; lack of guilt
or remorse about the negative or harmful effects of one’s actions
on others.
Hostility See Negative Affectivity.
DISINHIBITION Orientation toward immediate gratification, leading to impulsive
(vs. Conscientiousness) behavior driven by current thoughts, feelings, and external stim-
uli, without regard for past learning or consideration of future
consequences.
Irresponsibility Disregard for—and failure to honor—financial and other obliga-
tions or commitments; lack of respect for—and lack of follow-
through on—agreements and promises; carelessness with others’
property.
Impulsivity Acting on the spur of the moment in response to immediate stimuli;
acting on a momentary basis without a plan or consideration of
outcomes; difficulty establishing and following plans; a sense of
urgency and self-harming behavior under emotional distress.
Distractibility Difficulty concentrating and focusing on tasks; attention is easily
diverted by extraneous stimuli; difficulty maintaining goal-fo-
cused behavior, including both planning and completing tasks.
Risk taking Engagement in dangerous, risky, and potentially self-damaging ac-
tivities, unnecessarily and without regard to consequences; lack
of concern for one’s limitations and denial of the reality of per-
sonal danger; reckless pursuit of goals regardless of the level of
risk involved.
Rigid perfectionism Rigid insistence on everything being flawless, perfect, and without
(lack of) errors or faults, including one’s own and others’ performance;
sacrificing of timeliness to ensure correctness in every detail; be-
lieving that there is only one right way to do things; difficulty
changing ideas and/or viewpoint; preoccupation with details, or-
ganization, and order. The lack of this facet characterizes low
levels of Disinhibition.
TABLE 3. Definitions of DSM-5 personality disorder trait domains and facets (continued)
DOMAINS (Polar
PSYCHOTICISM Exhibiting a wide range of culturally incongruent odd, eccentric,
(vs. Lucidity) or unusual behaviors and cognitions, including both process (e.g.,
perception, dissociation) and content (e.g., beliefs).
Unusual beliefs and Belief that one has unusual abilities, such as mind reading, tele-
experiences kinesis, thought-action fusion, unusual experiences of reality,
including hallucination-like experiences.
Eccentricity Odd, unusual, or bizarre behavior, appearance, and/or speech;
having strange and unpredictable thoughts; saying unusual or
inappropriate things.
Cognitive and perceptual Odd or unusual thought processes and experiences, including
dysregulation depersonalization, derealization, and dissociative experiences;
mixed sleep-wake state experiences; thought-control experi-
ences.
nosis—all important aspects of the utility of psychiatric diagnoses. Notably, knowing

the level of an individual’s personality functioning and his or her pathological trait pro-
file also provides the clinician with a rich base of information and is valuable in treat-
ment planning and in predicting the course and outcome of many mental disorders in
addition to personality disorders. Therefore, assessment of personality functioning and
pathological personality traits may be relevant whether an individual has a personality
disorder or not.
Index
Page numbers printed in boldface type refer to tables or figures.
AAB. See Antisocial behavior Age and aging. See also Adolescents; Age at
AAI. See Adult Attachment Interview onset; Children
ACC. See Anterior cingulate cortex antisocial personality disorder and,
Acceptance and Action Questionnaire–II 437
(AAQ-II), 269, 273 assessment and, 152–153
Acceptance and Commitment Therapy, 268 as sociodemographic factor in prevalence
Accommodation, and core dysfunctions, of personality disorders, 118–119
42–43 stability of personality disorders and
Acute-on-chronic risk model, of suicide, 386, process of, 172
387, 389, 398–399 Age at onset
Adjustment disorders, 482, 484 of conduct disorder, 148, 434–435
Adolescents. See also Age and aging concept of stability and, 171–172
assessment of personality disorders in, Aggression. See also Auto-aggression;
148 Impulsive aggression; Instrumental
dialectical behavior therapy for border- aggression
line personality disorder and, 317 difference between antisocial personality
stability of personality disorders in, 171 disorder and psychopathy, 96–97
substance use disorders and, 412 gender differences in conduct disorder
Adolescence-limited antisocial behaviors, and, 435
435 in medical settings, 458–459
Adult Attachment Interview (AAI), 56 psychopharmacotherapy for antisocial
Adults. See also Age and aging personality disorder and, 445
antisocial behavior and, 435 Alcoholics Anonymous, 314, 448
attachment styles in, 56–57 Alexithymia, 71, 88
children’s personality structure and, 524 Allergies, to medications, 466
continuity of personality disorders from Alpha-adrenergic agonists, 94
adolescence and childhood into, 148 Alpha factor, and core dysfunctions, 42
Affective empathy, 492–493 Alprazolam, 329
Affective instability. See also Negative American Psychiatric Association (APA), 2,
affectivity; Restricted affectivity 7, 263, 332–333, 334, 348, 349, 373, 378
borderline personality disorder and, 80, Amitriptyline, 323, 335
138, 389–390 Amphetamine, 94
diagnostic criteria for personality Amygdala. See also Brain
disorders in DSM-5 and, 138 antisocial personality disorder and, 98
schizotypal personality disorder and, 95, borderline personality disorder and, 81,
138 82, 85, 501
Affective storms, and collaborative Analgesics, and chronic pain syndromes,
treatment, 362 463–464
569
Anger, and countertransference in treatment differential diagnosis of, 443–444

of borderline personality disorder, 378 educational level and, 122
Anhedonia efficacy of cognitive-behavioral therapy
antisocial personality disorder and, 550 for, 265
avoidant personality disorder and, 551 epidemiology of, 435–437
definition of in DSM-5, 565 etiology of, 438–441
Antagonism gender and, 117, 437–438
definition of in DSM-5, 566 General criteria for personality disorders
externalizing disorders and, 153, 155–157 and, 548, 549–550
personality disorder–trait specified and, genetic and environmental factors in, 26,
555 99–100, 527
personality traits in DSM-5 and, 522 impulsivity and, 140, 465
Anterior cingulate cortex (ACC), and interpersonal relationships and, 138–139
borderline personality disorder, 81, 82, marital status and, 120, 121
89 medical care and, 459
Anterior cingulate gyrus (ACG), and neurobiology of, 96–101, 495–496
borderline personality disorder, 84–85, prevalence of, 110–111, 112, 113, 114, 115,
86 116, 435–437
Anticonvulsants, 330–331, 335 psychoeducation and, 308–309
Antidepressants sexual behavior and, 465
borderline personality disorder and, social cognition and empathy in, 495–496
327–328, 335 substance use disorders and, 412, 417, 461
collaborative treatment and, 349–350 suicide and suicidal behavior in, 388
Antihistamines, 334 therapeutic alliance and, 196, 200–201
Antipsychotics. See also Atypical Antisocial reaction, 430. See also Antisocial
antipsychotics behavior
antisocial personality disorder and, 445 Anxiety
borderline personality disorder and, avoidant personality disorder and, 101
323–327, 333, 334, 335, 399–400 schizotypal personality disorder and, 95
suicidal behavior and, 399–400 Anxiolytics, 328–329
Antisaccades, and schizotypal personality Anxiousness. See also Anxiety
disorder, 92 avoidant personality disorder and, 550
Antisocial behavior, 435, 445, 530. borderline personality disorder and,
See also Antisocial reaction 551–552
Antisocial personality disorder (ASPD) definition of in DSM-5, 565
affective features of, 138 Anxious/preoccupied attachment, 56, 57,
age of patients with, 118, 119, 148 490, 491
assessment of, 443 Aripiprazole, 326–327, 335, 399
boundary issues and, 375–376 Army Task Force on Behavioral Health, 483
case example of, 442–443 ASPD. See Antisocial personality disorder
clinical management of, 444–448 Assessment. See also Diagnosis
cognitive manifestations of, 137 of antisocial personality disorder, 443
collaborative treatment and, 352 approaches to clinical interviewing and,
conduct disorder and, 530–531 144–147
as contraindication for dialectical General criteria for personality disorders
behavior therapy, 417 and, 546
course and outcome of, 441–443 of personality traits, 564
defining features of in DSM-IV and DSM- of problem behaviors in medical settings,
5, 141, 429–430, 432–433, 519, 520, 522 466–467, 468–469
diagnostic issues in, 430–435 problems in clinical interviewing and,
diagnostic threshold for in DSM-5, 530 147–153
Index 571
of substance use disorders in personality Avoidant personality disorder (AVPD)

disorder patients, 409–411 affective features of, 138
of suicide risk in patients with personality age of patients with, 118
disorders, 398–399 case examples of, 211, 268–276
Assimilation, and core dysfunctions, 42–43 cognitive-behavioral therapy for, 268–276
Association for Research on Personality cognitive manifestations of, 137
Disorders, 512 Collaborative Longitudinal Personality
Asthenic personality disorder, 4 Disorders Study and, 173–178
Attachment collaborative treatment of, 353
borderline personality disorder and, core impairments in personality
68–70, 490–491, 498 functioning and, 514
centrality of to development, 55 defining features of in DSM-IV and DSM-
clinical settings and, 72–73 5, 142, 519, 522, 525
couples therapy and, 295 diagnostic threshold for in DSM-5, 530
definition and styles of, 55, 56–57 educational level and, 122
development of personality disorders effectiveness of cognitive-behavioral
and, 58–59 therapy for, 264–265
differentiation of self and, 65–68 gender and, 117
environmental factors in, 57 General criteria for personality disorders
genetics of, 57 and, 548, 550–551
mentalization and, 61–65 genetics and, 527
neurobiology and, 59–61, 497 group therapy for, 286
personality characteristics and, 57–58 impulsivity and, 140
psychodynamic psychotherapy and interpersonal relationships and, 139
theory of, 225–227 marital status and, 120, 121
treatment outcome for personality neurobiology of, 101–102
disorders and, 70–72 prevalence of, 110–111, 112, 114, 115, 116
Attainability, and SMART goals, 244 psychoeducation and, 308
Attention-deficit/hyperactivity disorder quality of life and, 123, 124, 125
(ADHD) social anxiety disorder and, 101, 157–158, 269
antisocial personality disorder and, 444, suicide and suicidal behavior in, 388
446 therapeutic alliance and, 198, 203–204, 211
differential diagnosis of, 156, 444 AVPD. See Avoidant personality disorder
Attention seeking
definition of in DSM-5, 566 Barratt Impulsiveness Scale, 325
narcissistic personality disorder and, Beck, A., 18–19
553 Behavior. See also Aggression; Antisocial
Atypical antipsychotics, and borderline behavior; Attention seeking;
personality disorder, 324–327. See also Disinhibition; Eccentricity; Impulsivity;
Antipsychotics Intimacy; Irresponsibility;
Atypical Maternal Behavior Instrument for Manipulativeness; Self-injurious
Assessment and Classification behavior; Sexual behavior
(AMBIANCE), 63 cognitive-behavioral therapy and
Australian National Health and Medical maladaptive, 257–258
Research Council, 334 oxytocin and social, 60
Autism spectrum disorder, 158–159 personality pathology in medical settings
Auto-aggression, and borderline personality and, 457–461
disorder, 498 personality traits and specific forms of,
Automatic thoughts, and cognitive- 563–564
behavioral therapy, 256–257 treatment planning for psychotherapy
Avoidant/dismissing attachment, 56, 57, 490 and dyscontrol of, 248, 250, 251
Behavioral provocation studies, and compliance with medication and, 458

borderline personality disorder, 84 concept of borderline personality
Behavior disinhibition pathway, to organization and, 16
substance use disorders, 412 core impairments in personality
Behaviorism, and perspective on functioning and, 514
personality, 17–18 couples therapy and, 298–299
Belief(s) defining features of in DSM-5, 141, 522
cognitive-behavioral therapy and diagnostic threshold for in DSM-5, 530
maladaptive perceptions, 256–257 dialectical behavior therapy and, 266–267,
cognitive-social theories and 286, 293, 312, 313, 417
dysfunctional, 18–19 educational level and, 122
definition of unusual in DSM-5, 567 efficacy of cognitive-behavioral therapy
schizotypal personality disorder and, 555 for, 263–264
Belief-Desire Reasoning Task, 62 electroconvulsive therapy for, 332
Benjamin, L., 27–28 expressed emotion and, 290
Benzodiazepines, 329, 420, 445–446, 467 family therapy and, 293–294
Beta factor, and core dysfunctions, 42 gender and, 117
Biological markers, and comorbidity of General criteria for personality disorders
substance use disorders with and, 548, 551–552
personality disorders, 413–414 genetics of, 26, 83, 86, 311, 527
Biosocial theory, of borderline personality group therapy for, 286
disorder, 266 hospital settings and, 211–212
Bipolar disorders impulsivity and, 140, 465
comorbidity of with personality disorders interpersonal relationships and, 139,
and problems with clinical 489–495
interviewing, 149 marital status and, 120, 121
differential diagnosis of antisocial McLean Study of Adult Development
personality disorder and, 444 and, 178–179
differential diagnosis of externalizing medical care and, 459–460
disorders and, 156 mentalization and, 226
pharmacotherapy for antisocial behavior modes and, 19
in, 445 neurobiology of, 22, 80–90, 99, 396–398
Bipolar self, 224 as new diagnosis in DSM-III, 5
Bleuler, E., 22, 25 perceptual alterations in, 498–503
Board of registration, boundary problems peer support and, 313–315
and complaints to, 373, 379–380 pharmacotherapy for, 323–339
“Boot camps,” and antisocial personality prevalence of, 110–111, 112, 114, 115, 116,
disorder, 448 122, 456, 463
Borderline personality disorder (BPD) psychoeducation and, 292, 309–318
affective features of, 80, 138 quality of life and, 123
age of patients with, 118, 119 schema-focused therapy and, 265–266
attachment theory and, 59, 68–70 self-injurious behavior and, 89, 140, 464,
boundary issues and, 376–379 498–501
case examples of, 177–178, 209–210, sexual behavior and, 465
212–213, 293–294, 298–299, 338–339, stability of over time, 7, 177–178
346–347, 400–401, 417–418 substance use disorders and, 408,
chronic pain syndromes and, 463–464 417–418, 461
cognitive manifestations of, 137 suicide and suicidal behavior in, 140, 330,
Collaborative Longitudinal Personality 378, 385, 387–388, 389–395, 398–401, 498
Disorders Study and, 173–178 therapeutic alliance and, 196, 201–202,
collaborative treatment of, 352 209–210, 211–213
Index 573
Borderline Personality Disorder Study of of boundary issues, 371, 380

Cognitive Therapy (BOSCOT), 263–265 of cognitive-behavioral therapy, 242,
Borderline personality organization, 16, 268–276
222–223 of collaborative treatment, 346–347, 351,
Borderline rage, 377 354, 355, 359–361
Boundary issues of conduct disorder, 483–484
antisocial personality disorder and, of couples therapy, 298–299
375–376 of dependent personality disorder, 204,
board of registration complaints and, 373, 210
379–380 of family therapy, 293–294
borderline personality disorder and, of group therapy, 287–288
376–379 of Level of Personality Functioning Scale,
caveats in discussion of, 369 48–51
civil litigation and, 372–373 of medical settings and personality
context of, 371–372 pathology, 464
countertransference and, 378–379 of military and personality disorders, 476,
crossings versus violations of, 370–371 480, 483–484
cultural issues in, 379 of narcissistic personality disorder,
definition of, 370 287–288
dependent personality disorder and, of obsessive-compulsive personality
374–375 disorder, 48–51, 205, 415–417
ethics complaints and, 373 of personality traits versus personality
histrionic personality disorder and, disorders, 150–152
374–375 of pharmacotherapy, 338–339
in medical settings, 460 of sadomasochistic character, 206–207
power, asymmetry, and fiduciary duty, 372 of stability of borderline personality
risk management and, 379–381 disorder, 177–178
Bowlby, J., 58, 61, 71, 225–226 of substance use disorder, 355, 415–418
BPD. See Borderline personality disorder of therapeutic alliance, 204, 205, 206–207,
Brain, and attachment relationships, 73. 209–210, 211, 212–213
See also Amygdala; Neurobiology; of use of theory in case formulation, 30–31
Prefrontal cortex; Traumatic brain injury Case formulation, use of theory in, 30–32
Brazil, and cross-cultural study of boundary Catechol O-methyltransferase (COMT)
issues, 379 borderline personality disorder and, 86
Breuer, Joseph, 375 schizotypal personality disorder and,
British National Survey of Psychiatric 91
Morbidity, 436 Categorical approach, of DSM system
Buspirone, 420 concept of stability and, 169–170
Buss-Durkee Hostility Inventory, 325 critiques of, 511–512
dimensional approach and, 79
Callousness limitations of DSM system and, 6
antisocial personality disorder and, 549 problems with DSM personality disorder
definition of in DSM-5, 566 categories and, 39–40, 69
Carbamazepine, 324, 330, 335 Causal models, of comorbidity of substance
Case examples use disorders and personality disorders,
of antisocial personality disorder, 442–443 411–414
of avoidant personality disorder, 211, Cavum septum pellucidum, and antisocial
268–276 personality disorder, 99
of borderline personality disorder, CCD. See Conduct disorder
209–210, 212–213, 293–294, 298–299, CDS. See Collaborative Depression Study
338–339, 346–347, 400–401, 417–418 Certified Peer Specialist Program, 315
Change Coaches, cognitive-behavioral therapists as,

cognitive-behavioral therapy and 255
management of, 245, 255–259, 258 Cochrane Database review, 332, 333, 445, 446
psychodynamic psychotherapy and Cognition. See also Cognitive empathy;
mechanisms of, 230, 232–233, Cognitive-behavioral processing; Social
233–234, 236 cognition
Character, and personality structure, 23 cognitive-behavioral therapy and
Character disorder, 14 maladaptive, 256–257
Chestnut Lodge follow-up studies, 172, 387 cognitive reappraisal in borderline
Children. See Adolescents; Age and aging; personality disorder, 80, 82
Attachment; Development; Neglect; definition of dysregulation in DSM-5,
Physical abuse; Sexual abuse 567
assessment and, 152 DSM-IV general criteria for personality
attachment and development of speech disorders and, 513–514
in, 71 manifestations of personality
continuity of personality disorders into psychopathology and, 136–138
adolescence and adulthood, 148, 171 schizotypal personality disorder and
mentalization deficits and maltreatment impairment of, 92–95, 554
of, 64–65 treatment planning for psychotherapy
similarity of personality structure to and, 248, 250, 251
adult, 524 Cognitive Analytic Therapy, 267–268
Children in the Community Study (CICS), Cognitive-behavioral processing, and
173, 179–180, 524 antisocial personality disorder, 97–98
Chronic pain syndromes, 463–464 Cognitive-behavioral therapy (CBT). See also
Chronic risk, for suicide, 386 Dialectical behavior therapy
CICS. See Children in the Community Study for antisocial personality disorder,
Cigarettes. See Smoking 446–447
Circa-strike behavior, 503 case example of, 242, 268–276
Citalopram, 338, 339 clinical algorithm for in-session
Cleckley, Hervey, 430, 431 observations, 256
Clinical settings. See also Hospitals and core change strategies in, 255–259
hospitalization couples therapy and, 296–297
approaches to interviewing in, 144–147 definition and theory of, 261
attachment theory and, 72–73 dynaxity and, 242–245, 249
management of antisocial personality efficacy of for personality disorders,
disorder in, 444–448 241–242
multidimensional personality functioning family therapy and, 291–292
and trait model, 564, 567 general principles of psychotherapy and,
prevalence of personality disorders in, 246–255
115, 116 inclusion of in psychodynamic therapies,
problems in clinical interviewing and, 218
147–153 meta-analyses and reviews of, 262–263
psychotherapy for comorbid substance new directions in, 267–268
use and personality disorders in, 419 range of techniques in, 261–262
utility of hybrid model of personality schema-focused therapy and, 265–266
disorders in DSM-5 and, 533–535 therapeutic alliance and, 210
Clonidine, 94 Cognitive empathy, 492–493
Cloninger, C. R., 22–23 Cognitive-social theories, 17–20
Clozapine, 324 Cold Pressor Test, 498
CLPS. See Collaborative Longitudinal Collaborative Depression Study (CDS), 173,
Personality Disorders Study 174
Index 575
Collaborative Longitudinal Personality Competencies, in cognitive-social theories, 18

Disorders Study (CLPS), 45–46, 173–178, Complementary relationship, and cognitive-
390, 392, 393, 394, 395, 396, 524 behavioral therapy, 254
Collaborative prescribing, and Compliance, with medications, 458
psychopharmacology, 211 Conduct disorder
Collaborative Study on the Genetics of case example of in military, 484
Alcoholism, 413 differential diagnosis of antisocial
Collaborative treatment. See also personality disorder and, 444
Pharmacotherapy relationship of to antisocial personality
case examples of, 346–347, 351, 354, 355, disorder, 148, 434–435, 530–531
359–361 response to facial expressions and, 495
comorbid substance abuse treatment and, Confrontation, and ruptures in therapeutic
355 alliance, 191, 192
contraindications to, 362–363 Consultation. See also Referrals
definition of, 345 boundary issues and, 380
evidence for effectiveness of, 347–348 collaborative treatment and, 350–351
factors in increased use of for personality personality pathology in medical settings
disorders, 354–355 and, 466–470, 471
importance of in cases of personality Continuity, and concept of stability in course
disorders, 348–350 and outcome, 170–171
principles to follow in, 356–362 Contracts. See Therapy contracts
somatic complaints and, 355–356 Convergent validity, in characterization of
specific disorders and, 352–353 personality disorders, 526
strengths and weaknesses of, 350–354 Cooperativeness, and temperament, 23
Committee on Nomenclature and Statistics Core dysfunctions, in personality disorders
(APA), 2 case examples of, 48–51
Common factor model, and comorbidity of empirical articulation of, 44–48
substance use disorders with global concept of personality impairment
personality disorders, 412–413 and, 43–44
Communication, and psychoeducation, 307 historical background of concept, 40–43
Comorbidity Countertransference. See also Transference
avoidant personality disorder and, 101 boundary issues and, 378–379
borderline personality disorder and, 59, cognitive-behavioral therapy and, 254–255
157 Couples therapy. See also Marriage
collaborative treatment and, 354–355 antisocial personality disorder and, 448
concept of stability and, 170, 171 case example of, 298–299
core dysfunctions and, 44–48 features complicating treatment of
differential diagnosis and, 154–155, 157, personality disorders, 295, 296
159–160 features facilitating treatment of
of personality disorders in medical personality disorders, 294–296
settings, 456–457 forms of, 296–297
personality traits shared in different psychoeducation and, 317
personality disorders and, 521 research support for, 297–298
pharmacotherapy for antisocial Covert narcissism, 202
personality disorder and, 445–446 Criminality, and antisocial personality
problems in clinical interviewing and, disorder, 437
149–150 Crisis. See also Emergencies
as risk factor for suicide, 390–391 assessment of suicide risk and, 398
substance use disorders and, 407 collaborative treatment and, 362
treatment planning for psychotherapy management of and safety planning in
and, 247, 248, 250 suicidal, 399–401
“Crisis management schedule,” and therapy prevalence of, 110–111, 112, 114, 115, 116
contracts, 253 suicide and suicidal behavior in, 388
Culture. See also Race; Values therapeutic alliance and, 198, 204, 210
antisocial personality disorder and, 438, Depression. See also Depressivity; Major
441 depressive disorder
assessment and, 152 antidepressants and type or nature of in
boundary issues and, 379 patients with personality disorders,
General criteria for personality disorders 349
and, 525 comorbidity with personality disorders,
personality style and, 113 149
psychotherapy and bias toward electroconvulsive therapy for patients
individualism in, 299 with borderline personality disorder
“Curse-of-knowledge bias,” and and, 332
differentiation of self, 65–66 Depression and Bipolar Support Alliance,
Cyberball (computer game), 88, 490 314
Cyclical psychodynamics, 20 Depressive personality disorder (DEPD)
Cyclothymic disorder, 4, 149 addition of to appendix of DSM-IV, 5–6
prevalence of, 110–111, 112, 114
Day treatment, and group therapy, 284–285, Depressivity. See also Depression
286–287 borderline personality disorder and, 552
DBT. See Dialectical behavior therapy definition of in DSM-5, 565
DBT-family skills training (DBT-FST), Desipramine, 335
316–318 Detachment
DBTselfhelp.com, 315 definition of in DSM-5, 565
Debriefing, and boundary issues, 371 internalizing disorders and, 158–159
Deceitfulness personality disorder–trait specified and,
antisocial personality disorder and, 549 555
definition of in DSM-5, 566 personality traits in DSM-5 and, 522
Defense mechanisms. See also Projective Development. See also Children;
identification; Splitting Developmental disorders
ego psychology and, 222 centrality of attachment to, 55
object relations theory and, 223 of speech, 71
psychoanalysis and, 236 Developmental disorders, view of as
Defensive exclusion, 226 biological in origin in DSM-III, 4
Deficit condition, and view of personality DFST. See Dual focus schema therapy
disorders in DSM-I, 3–4 Diagnosis. See also Assessment; Differential
Demeanor, and boundary issues, 371 diagnosis; Overdiagnosis
DEPD. See Depressive personality disorder of antisocial personality disorder, 430–435
Dependent personality disorder (DPD) of borderline personality disorder, 310
age of patients with, 118 diagnostic thresholds for individual
boundary issues and, 374–375 personality disorders in DSM-5,
case example of, 204, 210 529–530
cognitive manifestations of, 137–138 psychotherapy and communication of to
collaborative treatment of, 353 patient, 252–253
defining features of in DSM-5, 142 Diagnostic Interview for Borderline Patients,
educational level and, 122 328
gender and, 117 Diagnostic Interview for DSM-IV Personality
impulsivity and, 140 Disorders, 146
interpersonal relationships and, 139 Dialectical behavior therapy (DBT)
marital status and, 120, 121 borderline personality disorder and,
pervasiveness of, 140 266–267, 286, 293, 312, 313
Index 577
collaborative treatment and, 348 Domestic violence, and psychoeducation for

couples therapy and, 297–298 antisocial personality disorder, 309
family-oriented skills-training groups Dopaminergic system
and, 316–318 attachment behavior and, 60
group therapy and, 286 borderline personality disorder and, 86
substance use disorders and, 417–418 incentive-motivated behavior and, 24
therapeutic alliance and, 210 schizotypal personality disorder and, 91,
Dialectical relational strategy, and cognitive- 93, 94
behavioral therapy, 256 Dose-response relationship
Differential diagnosis of psychological disturbance and insecure
alternative explanations for personality attachment, 57
pathology and, 548 of quality of life and dysfunction, 124
antisocial personality disorder and, DPD. See Dependent personality disorder
443–444 Drop-outs, from treatment
assessment and, 150, 153–160 attachment and, 71
Difficulties in Emotion Regulation Scale family therapy and, 290–291
(DERS), 269, 272 Drug counseling, 415
Dihydrexidine, 94 DSM system. See also Categorical approach;
Dimensional approach, of DSM system Dimensional approach
as complementary to categorical history of classification of antisocial
approach, 79 personality disorder and, 430–431
concept of stability and, 169–170 history of classification of personality
controversy on adoption of in DSM pathology and, 2–8
system, 6 DSM-I
development of DSM-5 and, 7, 40, 512 classification of personality disorders in, 3
personality traits and, 558 sociopathic personality disturbance in, 430
Dimensional Assessment of Personality DSM-II
Pathology—Basic Questionnaire antisocial personality disorder in, 430
(DAPP-BQ), 24 classification of personality disorders in,
Direct questioning, in clinical interviewing, 3, 4
145–146 DSM-III
Disability Evaluation Systems (military), 483 antisocial personality disorder in, 431
Disinhibition categorical approach in, 39, 511–512
definition of in DSM-5, 566 classification of personality disorders in,
externalizing disorders and, 153, 155–157 3, 4–5
personality disorder–trait specified and, concept of stability in, 165–166, 167
556 core dysfunctions and, 44–48
personality traits in DSM-5 and, 522 narcissistic personality disorder in, 5, 16, 17
Disoriented/disorganized attachment, 56, prevalence studies of personality
57, 58 disorders and, 112
Disruptive behaviors, in medical setting, schizotypal personal disorder in, 25
458–459 DSM-III Personality Disorders—Revised,
Dissociation, and borderline personality 123
disorder, 389–390, 501–503 DSM-III-R
Dissociative Experience Scale, 502 antisocial personality disorder in, 431
Distancing, and cognitive reappraisal, 82 classification of personality disorders in, 5
Distractibility, definition of in DSM-5, 566 concept of stability in, 167
Distress tolerance, and borderline core dysfunctions and, 44–48
personality disorder, 313 prevalence studies of personality
Divalproex sodium, 330, 445 disorders and, 112
Documentation, and boundary issues, 371, 380 provisional disorders in, 126
DSM-IV “provisional” personality disorder

antisocial personality disorder in, 431 diagnoses in, 112
borderline personality disorder in, 88 psychodynamic psychotherapy and,
categorical approach in, 39, 40, 512 218–219
classification of personality disorders in, revision of general criteria for personality
3, 5–6 disorders, 523–525
core dysfunctions and, 44–48 substance use disorders in, 421
criteria for individual personality trait theories and, 22
disorders in, 525–532 Dual focus schema therapy (DFST), 415–417,
five-factor model and, 21 418
General criteria for personality disorders Dual-focus treatments, for comorbid
and, 513–525 substance use and personality disorders,
prevalence studies of personality 415–418, 419
disorders and, 112 Dynamic Deconstructive Psychotherapy, 415
provisional disorders in, 126 Dynaxity, and cognitive-behavioral therapy,
psychoanalytic theory about conflict and 242–245
personality disorders in, 14 Dysfunction index, and quality of life, 123–124
DSM-IV Sourcebook (Gunderson 1996; Dyssocial reaction, 430
Widiger et al. 1996), 513
DSM-IV-TR, differences between DSM-IV Early maladaptive schemas (EMSs), 19
and, 2, 3, 6 Eating disorders, 268, 276
DSM-5. See also Level of Personality Eccentricity
Functioning Scale definition of in DSM-5, 567
antisocial personality disorder in, 96, 431, schizotypal personality disorder and, 554
432–433 Education. See also Psychoeducation
assignment of personality traits to specific as component of psychoeducation
disorders in, 522 process, 305–307
borderline personality disorder in, 80, 88 prevalence of personality disorders and
changes in criteria for individual levels of, 122
personality disorders in, 525–532 of therapists for treatment of comorbid
changes in personality trait facets in, substance use and personality
519–520 disorders, 419
classification of personality disorders in, Egocentrism, Piaget’s concept of, 66
3 Ego psychology, 14–15, 221–222
clinical utility of hybrid model of Electroconvulsive therapy, for borderline
personality disorders in, 533–535 personality disorder, 332
concept of diagnostic stability in, 166 Emergencies, and therapy contracts, 253. See
conduct disorder in, 434 also Crisis
defining features of personality disorders Emergency department, and suicide
in, 132, 133, 134–144 attempts, 399
definition of personality traits in, 565–567 Emotion(s). See Affective instability; Anger;
development of agenda for, 7 Antagonism; Emotional dysregulation;
development of alternative model for Emotional lability; Empathy; Expressed
personality disorders in, 512–513 emotion; Hostility
diagnostic thresholds for individual Emotional contagion, and borderline
personality disorders in, 530 personality disorder, 494
five-factor model of personality traits Emotional dysregulation. See also Emotional
and, 523 lability
future directions in research and, 535–536 borderline personality disorder and,
personality disorder–trait specified in, 80–83, 313
125 cognitive-social theories and, 18
Index 579
Emotional experience, cognitive-behavioral Expressive-supportive approach, in

therapy and distorted patterns of, 257, psychodynamic psychotherapy, 234–235
275 Externalizing disorders
Emotional lability. See also Emotional differential diagnosis and, 153, 155–157
dysregulation genetic studies of, 24–25
borderline personality disorder and, 551 metastructure of psychopathology and,
definition of in DSM-5, 565 409
Emotional Regulation Group Therapy Extraversion, heritability estimates for, 24
(ERGT), 264 Eye movements, and schizotypal personality
Emotional simulation theory, and borderline disorder, 92, 96
personality disorder, 494
Empathy Facets, of personality, 21, 519–520. See also
antisocial personality disorder and, 549 Personality traits
avoidant personality disorder and, 550 Facial expressions, interpretation of
borderline personality disorder and, 88, antisocial personality disorder and, 495
491–493, 551 avoidant personality disorder and,
core dysfunctions and, 45, 48 101–102
elements of personality functioning and, borderline personality disorder and, 87,
515, 547 490, 493, 494
Level of Personality Functioning Scale Factitious disorder, 459
and, 135, 559–562 Family. See also Family therapy; Marriage
narcissistic personality disorder and, 553 antisocial personality disorder and, 440, 443
obsessive-compulsive personality attachment security and mentalization, 64
disorder and, 553 expressed emotion and, 290, 304
schizotypal personality disorder and, 554 psychoeducation and, 305–308, 315–318
social cognition in psychopathy and, Family Connections (psychoeducation
495–496 program), 292, 318
Endogenous opioid system, and self- Family Guidelines (Gunderson and Berkowitz
injurious behavior, 500–501 2002), 316
Enduring patterns, assessment of, 147–148. Family therapy
See also Pervasiveness; Stability case example of, 293–294
Entitlement, and borderline personality dialectical behavior therapy and, 293
disorder, 376 features complicating treatment of
Environmental factors personality disorders, 289–291
attachment and, 57 features facilitating treatment of
etiology of antisocial personality disorder personality disorders, 288–289, 290
and, 26 forms of, 291–292
Epidemiologic Catchment Area (ECA) research support for, 292–293
survey, 435–436 Fear, and activation of attachment system, 61
Epidemiology. See Prevalence FFM. See Five-factor model
Epigenetics, 24 Fibromyalgia, 464
Ethics, and boundary issues, 373 Fiduciary duty, and boundary issues, 372
Etiology. See also Environmental factors; Fight and flight responses, 502, 503
Genetics; Risk factors Five-factor model (FFM)
of antisocial personality disorder, 438–441 case example and, 31, 32
psychoeducation for borderline changes in DSM-5 and, 519–520, 523, 533
personality disorder and, 311–312 core dysfunctions and, 42
Expectancies, schemas and problematic, 18 theories of personality traits and, 20–22,
Expectations, and treatment planning for 563
psychotherapy, 246–247 Five Factor Model Rating Form (FFMRF),
Expressed emotion, and family, 290, 304 523, 528
5-HIAA. See 5-Hydroxyindoleacetic acid of treatment for comorbid substance use

(5-HIAA) and personality disorders, 419
Fluoxetine, 85, 325, 327–328, 335, 348 treatment planning for psychotherapy
Fluvoxamine, 335, 420 and, 246–247, 250
Fonagy, P., 226 “Golden fantasy,” and boundary issues, 378
Freezing, and defensive behavior, 503 Grandiose self, 17, 224
Freud, Sigmund, 5, 14, 41, 190, 217, 221, Grandiosity
225 definition of in DSM-5, 566
Functional domain model, 28–30, 31–32 narcissistic personality disorder and, 553
Fusiform gyrus, 81 Group therapy
benefits of for personality disorders, 281,
Galton, Sir Francis, 41 299
Gamblers Anonymous, 448 case example of, 287–288
GAPD. See General Assessment of cognitive-behavioral interventions and,
Personality Disorder 264
GCPD. See General criteria for personality complications in treatment of personality
disorders disorders, 282–284
Gender different forms of, 284–285
antisocial personality disorder and, 117, multifamily therapy groups and, 315–316
437–438 narcissistic personality disorder and,
assessment and, 152 287–288
conduct disorder and, 435 research support for, 285–287
differences in personality disorders and, Guanfacine, 94
115, 117 Guidelines
General Assessment of Personality Disorder boundary issues and, 379–381
(GAPD), 44 pharmacotherapy for borderline
General criteria for personality disorders personality disorder and, 332–334
(GCPD), 513–525, 546 for treatment of comorbid substance use
Genetics and personality disorders, 419–421
antisocial personality disorder and, 26,
99–100, 438, 527 Habituation
attachment and, 57 avoidant personality disorder and
avoidant personality disorder and, 527 aversive emotional stimuli, 102
borderline personality disorder and, 26, emotion dysregulation in borderline
83, 86, 311, 527 personality disorder and, 80, 82
comorbidity of substance use disorders Hair pulling, 464
and personality disorders, 413 Haloperidol, 323, 335
obsessive-compulsive personality Harm avoidance, and temperament, 23
disorder and, 527 “Headlines Test,” and boundary issues, 460
personality disorder types in DSM-5 and, Health care. See Managed care; Medical
527 conditions; Medical settings; Primary
schizotypal personality disorder and, care physicians
25–26, 91–92, 527 Heart rate, and avoidant personality
studies of personality traits and, 24–26 disorder, 102
Global Assessment of Functioning (GAF), Henderson, David, 430
125, 287, 394, 517 Heterogeneity, in diagnosis of antisocial
Gly allele, and schizotypal personality personality disorder, 96, 100
disorder, 91 High lethality, of suicide attempts, 391,
Goals 392–393
of cognitive-behavioral therapy, 243–244, Histrionic personality disorder (HPD)
249 affective features of, 138
Index 581
age of patients with, 118, 119 Identity

boundary issues and, 374–375 antisocial personality disorder and, 549
case example of, 359–360 avoidant personality disorder and, 550
collaborative treatment of, 352, 359–360 borderline personality disorder and, 551
defining features of in DSM-5, 141 concept of core dysfunctions and, 43, 48
gender and, 117 elements of personality functioning and,
interpersonal relationships and, 139 515, 547
marital status and, 120, 121 Level of Personality Functioning Scale
prevalence of, 110–111, 112, 113, 114, 115, and, 135, 559–562
116 narcissistic personality disorder and, 552
quality of life and, 124, 125 obsessive-compulsive personality
suicide and suicidal behavior in, 388 disorder and, 553
therapeutic alliance and, 197, 202 schizotypal personality disorder and, 554
Hopkins Symptom Checklist–90, 325 If-then contingencies, 19–20
Hospitals and hospitalization. See also Impairment, and personality functioning,
Emergency department; Medical 135, 143–144, 513–516, 546. See also
settings Interpersonal relationships
antisocial personality disorder and, Impulse control, and diagnostic criteria in
444–445 DSM-5, 139–140. See also Impulsivity
group therapy in, 285 Impulsive aggression. See also Impulsivity
therapeutic alliance and, 211–213 antisocial personality disorder and, 98
Hostility borderline personality disorder and,
antisocial personality disorder and, 549 83–86
borderline personality disorder and, genetics of, 395
552 neurobiology of, 397
definition of in DSM-5, 565, 566 schizotypal personality disorder and, 95
HPD. See Histrionic personality disorder Impulsivity. See also Impulse control;
Hydrocodone, 464 Impulsive aggression
5-Hydroxyindoleacetic acid (5-HIAA) antisocial personality disorder and, 549
antisocial personality disorder and, 439 borderline personality disorder, 377, 389,
attachment and, 61 552
Hydroxyzine, 334 definition of in DSM-5, 566
Hypermentalizing, and borderline genetics of, 395
personality disorder, 494 neurobiology of, 397
Hypersensitivity. See also Rejection Inadequate personality disorder, 4
sensitivity; Separation insecurity Incentive-motivated behavior, and
avoidant personality disorder and dopaminergic system, 24
interpersonal, 101 Inflexibility, and diagnostic criteria in
borderline personality disorder patients DSM-5, 140, 143
and interpersonal, 87, 89, 490 Inhibitory control, and antisocial personality
Hypervigilant narcissism, 204 disorder, 97
Hypomania, and differential diagnosis of Insight-oriented interventions, and
personality disorders, 156 therapeutic alliance, 208
Instrumental aggression, 96, 98
ICD-9 (World Health Organization), 478 Insula, and emotion processing, 81, 82
ICD-10 Personality Questionnaire (DIP-Q), Integrated Dual Disorder Treatment, 415
110 Integrative theories, 26–30
ICD-11 (World Health Organization), 517 Integrative treatments, and couples therapy,
Id, and ego psychology, 221, 222 296–297
Idealized parent imago, 17, 224 Interactional models, of personality
Idealizing transference, 233 disorders, 79
Intermittent explosive disorder, 4, 444 Level of Personality Functioning Scale

Internalizing disorders and, 135, 559–562
differential diagnosis of, 153–154, 157–160 narcissistic personality disorder and, 553
genetics studies of, 24–25 obsessive-compulsive personality
metastructure of psychopathology and, disorder and, 553, 554
409 schizotypal personality disorder and, 554
Internal working models, and attachment Introject, and interpersonal model, 28
theory, 225 Irresponsibility
International Classification of Diseases antisocial personality disorder and, 549
(World Health Organization 1967), 4. definition of in DSM-5, 566
See also ICD-9; ICD-10 Item Response Theory analyses, 516
International Personality Disorder
Examination, 146 Kernberg, Otto, 5, 15–16, 43, 47, 201, 219, 222,
International Personality Disorder Screener, 225–226, 227
118 Koch, Julius, 430
International Society for the Study of Kohut, Heinz, 5, 17, 202, 208, 223
Personality Disorders, 512 Kraepelin, Emil, 22, 25, 41
Internet, and psychoeducation, 309, 314–315
Interpersonal crises, and collaborative Lamotrigine, 331, 335, 338
treatment, 362 Legal issues, and boundary issues, 372–373
Interpersonal learning, and group therapy, Level of Personality Functioning Scale
282 (LPFS), 16
Interpersonal model, of personality continuum of severity and, 16
disorders, 27–28 core dysfunctions and, 47–51
Interpersonal Reactivity Index (IRI), 87–88, differential diagnosis and, 154
492 dimensional approach in DSM-5 and, 135,
Interpersonal relationships. See also 557–558
Impairment; Intimacy; Marriage; Peer impairments of personality functioning
relationships; Social support in, 516, 517–518, 559–562
avoidant personality disorder and, 101 psychodynamic psychotherapy and,
borderline personality disorder and, 219
86–89, 313, 489–495 quality of life and, 124
core dysfunctions and, 48 specifiers in DSM-5 and, 532
couples therapy and, 295–296 therapeutic alliance and, 193
diagnostic criteria in DSM-5 and, 138–139, Life-course-persistent antisocial behavior,
557 435
role of oxytocin in social dysfunction and, Life satisfaction, and values, 243
496–498 Lifetime prevalence, of personality
schizotypal personality disorder and, 96 disorders, 113–115
therapeutic alliance and quality of Lithium carbonate, 329, 445
preexisting, 189–190 London Parent-Child Project, 62
Interpersonal school, of self psychology, Longitudinal Evaluation using All Data
224–225 (LEAD), 526
Intimacy. See also Interpersonal relationships Longitudinal Interval Follow-Up Evaluation,
antisocial personality disorder and, 549 174
avoidant personality disorder and, 550, Long-term outpatient group therapy, 284
551 Lorazepam, 338
borderline personality disorder and, 551 Love-related activation, of attachment
definition of avoidance in DSM-5, 565 system, 61
elements of personality functioning and, LPFS. See Level of Personality Functioning
515, 547 Scale
Index 583
Major depressive disorder (MDD). See also models for relationship between
Depression personality dysfunction and
Collaborative Longitudinal Personality symptoms of, 457
Disorders Study and, 173–178 Medical Evaluation Boards (military), 483
comorbidity of with borderline Medical settings. See also Hospitals and
personality disorder, 157 hospitalization; Medical conditions;
as risk factor for suicide, 391, 394 Primary care physicians
Malignant narcissism, 203, 227 case example of, 464
Malnutrition, antisocial personality disorder comorbidity of personality disorders in,
and maternal, 439 456–457
Maltreatment, and attachment system, diagnostic patterns associated with
64–65, 69–70. See also Neglect; Physical personality pathology in, 461–466
abuse patient behavior associated with
Managed care, and collaborative treatment, personality pathology in, 457–461
349, 354, 356, 363–364 prevalence of personality disorders in,
Mania, and differential diagnosis, 156 456
Manipulativeness psychiatric consultation in, 466–470, 471
antisocial personality disorder and, Medical Lethality Scale, 392
549 Medications. See also Pharmacotherapy
definition of in DSM-5, 566 allergies to, 466
Manual Assisted Cognitive Treatment differential diagnosis and personality
(MACT), 263–264. See also Treatment changes induced by, 155
manuals personality pathology in medical settings
Marriage. See also Couples therapy and compliance with, 458
antisocial personality disorder and, 442 potential and actual lethality of, 361–362
prevalence of personality disorders and, substance abuse and prescription, 458,
119–122 461
MASC. See Movie for the Assessment of substance use as self-medication and,
Social Cognition 412
Mask of Sanity: An Attempt to Clarify Some Meetup.com, 314
Issues About the So-Called Psychopathic Memory, and schizotypal personality
Personality (Cleckley 1941/1976), 430 disorder, 92, 94. See also Cognition
McLean Hospital (Belmont, Massachusetts), Menninger, K., 40–41
315 Mental Health Advisory Team (military),
McLean Screening Instrument for Borderline 477, 478
Personality Disorder, 337 Mentalization
McLean Study of Adult Development attachment and, 61–65, 226
(MSAD), 173, 178–179, 392, 393, 394, 395, failures in, 231
524 borderline personality disorder and,
MDD. See Major depressive disorder 68–70
Measurability, and SMART goals, 244 Mentalization-based therapy (MBT),
Media, influence of on antisocial personality 230–233, 286, 447
disorder, 441 MET. See Multifaceted Empathy Task
Medicaid, 315 Metastructure, of psychopathology, 409
Medical conditions. See also Medical settings Military
antisocial personality disorder and, 443, administrative policies on personality
444 disorders in, 480–484
differential diagnosis of personality barriers to treatment of personality
disorders and, 157 disorders in, 477, 479
General criteria for personality disorders behaviors of personality disorders and
and, 525, 548 organizational culture of, 476–477
Military (continued) Narcissistic personality disorder (NPD)

case examples of personality disorders in, age of patients with, 118, 119
476, 479, 483–484 case examples of, 287–288, 360–361
clinical presentation of personality cognitive manifestations of, 137
disorders in, 479–480 collaborative treatment of, 353
prevalence of personality disorders in, core impairments in personality
437, 477–479 functioning, 514
unique aspects of life in, 475 defining features of in DSM-IV and DSM-
Millon, T., 5, 14 5, 141, 522, 525
Millon Clinical Multiaxial Inventory–III, 146 diagnostic threshold for in DSM-5, 530
Mindfulness. See also Psychological gender and, 117
mindedness General criteria for personality disorders
cognitive-behavioral therapy and and, 548, 552–553
exercises in, 274, 275 group therapy for, 287–288
family dialectical behavior therapy and, 293 interpersonal relationships and, 139
psychoeducation for borderline marital status and, 120, 121
personality disorder and, 313 as new diagnosis in DSM-III, 5, 16, 17
Minnesota Longitudinal Study of Parents prevalence of, 110–111, 112, 113, 114, 115,
and Children, 57 116, 456
Minnesota Multiphasic Personality quality of life and, 125
Inventory (MMPI), 42, 146, 443 substance use disorders and, 408
Minnesota Multiphasic Personality Inventory– therapeutic alliance and, 197, 202
2 Restructured Form (MMPI-2-RF), 523 National Alliance on Mental Illness (NAMI),
Mirror transference, 233 314
Modes, concept of in cognitive-social theory, National Collaborating Centre for Mental
19 Health, 334, 445, 446
Monoamine oxidase A (MAOA) National Comorbidity Survey, 385, 436
antisocial personality disorder and, 100, National Education Alliance for Borderline
438 Personality Disorder, 309, 318
attachment and, 61 National Epidemiologic Survey on Alcohol
borderline personality disorder and, 86 and Related Conditions (NESARC), 113,
Mood stabilizers, 333, 334, 335, 420. See also 170–171, 408, 436, 438, 455–456
Lithium carbonate National Institute for Health and Clinical
Moral insanity, 41, 430 Excellence (NICE), 334, 445
Morey survey, 527–529, 534 National Institute of Mental Health (NIMH),
Mortality, and lethality of psychotropic 7, 173, 174, 323–324, 515
medications, 361–362 National Survey on Drug Use and Health,
Movie for the Assessment of Social 458
Cognition (MASC), 492 Negative affectivity. See also Anxiousness;
MSAD. See McLean Study of Adult Emotional lability; Restricted affectivity
Development definition of in DSM-5, 565
Multifaceted Empathy Task (MET), 492–493 internalizing disorders and, 153–154,
Mutative techniques, and psychodynamic 157–158
psychotherapy, 229–230, 231–232, 233, personality disorder–trait specified and,
235–236 555
personality traits in DSM-5 and, 136, 522
Naltrexone, 421, 500 suicidal behavior and, 396
Narcissism, and self psychology, 223–224. Negativistic personality disorder, 5
See also Covert narcissism; Neglect. See also Physical abuse
Hypervigilant narcissism; Malignant mentalization deficits and, 65
narcissism oxytocin and, 497
Index 585
risk of personality disorders and Nottingham Study of Neurotic Disorders,

childhood, 58 172
NEO Personality Inventory—Revised Novelty seeking, and temperament, 23
(NEO-PI-R), 515, 527 NPD. See Narcissistic personality disorder
NEO Personality Inventory–3 (NEO-PI-3), NSSI. See Nonsuicidal self-injury
523
Neuregulin 1 (NRG1), 91–92 Obesity, in medical settings, 464–465
Neurobiology. See also Brain; Object relations theory, 14, 15–16, 222–223,
Neurotransmitters 229–230
advances in research on, 79, 102 Observation
of antisocial personality disorder, 96–101, clinical interviewing and, 144–145
438–440, 495–496 cognitive-behavioral therapy and, 256
of attachment, 59–61 Obsessive-compulsive disorder, and
of avoidant personality disorder, 101–102 differential diagnosis of personality
of borderline personality disorder, 22, disorders, 156
80–90, 99 Obsessive-compulsive personality disorder
of personality traits, 22–24 (OCPD)
of schizotypal personality disorder, 90–96 affective features of, 138
of self-injurious behavior in borderline age of patients with, 118, 119
personality disorder, 498–499, 500 case examples of, 48–51, 205, 415–417
suicidal beahvior in personality disorders cognitive manifestations of, 138
and, 395–398 Collaborative Longitudinal Personality
treatment planning for psychotherapy Disorders Study and, 173–178
and, 247–248 collaborative treatment of, 353
Neuroimaging core impairments in personality
antisocial personality disorder and, functioning, 514
98–99, 439–440 defining features of in DSM-5, 142,
borderline personality disorder and, 522
81–82, 84–86 diagnostic threshold for in DSM-5, 530
suicidal behavior and, 396–398 differential diagnosis of, 156
Neuroleptics. See also Antipsychotics educational level and, 122
comorbid substance use and personality gender and, 117
disorders, 420 General criteria for personality disorders
schizotypal personality disorder and, 93, and, 548, 553–554
94–95 genetics and, 527
Neuroticism impulsivity and, 140
facets of personality and, 21 interpersonal relationships and, 139
heritability studies for, 24 marital status and, 120, 121
Neurotransmitters, and antisocial prevalence of, 110–111, 112, 114, 115, 116,
personality disorder, 439. See also 456
Dopaminergic system; Serotonergic quality of life and, 124, 125
system suicide and suicidal behavior in,
Neutrality, of therapists in self psychology, 388–389
224 therapeutic alliance and, 199, 204–205
NICE. See National Collaborating Centre for OCPD. See Obsessive-compulsive
Mental Health personality disorder
Nonsuicidal self-injury (NSSI). See also Off-label uses, of medications, 445
Self-injurious behavior Olanzapine, 325, 333, 335, 348
borderline personality disorder and, Omega-3 fatty acids, and borderline
498–501 personality disorder, 331, 333
cognitive-behavioral therapy and, 263, 264 Oppositional defiant disorder, 444
Orbitofrontal cortex (OFC). See also Patient(s). See also Therapeutic alliance;
Prefrontal cortex Therapeutic relationships; Transference
antisocial personality disorder and, 98 psychoeducation and, 305–308
borderline personality disorder and, 84 psychotherapy and communication of
Outcome. See Stability; Treatment diagnosis to, 252–253
Overdiagnosis, of personality disorders, 150 Patient Health Questionnaire (PHQ), 269,
Oxford Handbook of Personality Disorders 270
(Torgersen 2012), 115 Patient Protection and Affordable Care Act
Oxytocin of 2010, 345
attachment and, 60–61, 497 Patient Rated Personality Scale, 520
social dysfunction and, 496–498 PCL. See Psychopathy Checklist
PDE. See Personality Diagnostic Examination
Pain PDs. See Personality disorders
borderline personality disorder and PDQ-4. See Personality Diagnostic
processing of, 89–90 Questionnaire–4
chronic syndromes of in medical settings, PD-TS. See Personality disorder–trait
463–464 specified
self-injurious behavior and sensitivity to, Pedagogy theory, and differentiation of self,
498–500 65–68
PAPD. See Passive-aggressive personality Peer relationships, and antisocial personality
disorder disorder, 440–441. See also Interpersonal
Paranoia relationships
case example of cognitive-behavioral Peer support, and psychoeducation for
therapy for, 242 borderline personality disorder, 313–315
schizotypal personality disorder and, 93 Perceptual Aberration Scale (PAS), 91–92
Paranoid personality disorder (PPD) Perceptual alterations, in borderline
age of patients with, 118 personality disorder, 498–501. See also
cognitive features of, 136–137 Cognition
collaborative treatment and, 352 Pergolide, 94
core impairments in personality Periaqueductal gray (PAG), and defensive
functioning, 514 behavior, 503
defining features of in DSM-IV and DSM- Perseveration
5, 141, 519 definition of in DSM-5, 565
educational level and, 122 obsessive-compulsive personality
gender and, 117 disorder and, 554
interpersonal relationships and, 139 Persistence, and temperament, 23
marital status and, 120, 121 Personality. See also Personality functioning;
pervasiveness of, 140 Personality traits
prevalence of, 110–111, 112, 114, 115, 116 attachment and characteristics of,
therapeutic alliance and, 193, 194 57–58
urban locations and, 123 behaviorism and perspective on, 17–18
Parent Development Interview (PDI), 63 concept of “personality disorganization”
Parenting, and attachment security, 62–64, 70 and, 40–41
Participant prescribing, and core dysfunctions and global concept of
psychopharmacology, 211 impairment, 43–44
Passive-aggressive personality disorder (PAPD) culture and, 113
age of patients with, 118–119 definition of, 1, 13
gender and, 117 hierarchical structure of, 558, 563
marital status and, 120, 121 Personality Beliefs Questionnaire, 19
prevalence of, 110–111, 112, 114, 115, 116 Personality Diagnostic Questionnaire–4
relocation of in DSM-IV, 5 (PDQ-4), 145, 521
Index 587
Personality Disorder Examination (PDE), Personality traits. See also Personality;

112, 169 Personality functioning
Personality Disorder Interview-IV, 146 assessment of, 564
Personality disorder not otherwise specified behavioral genetic studies of, 24–26
(PDNOS), 512, 531–532 clinical significance of in patients without
Personality Disorder Questionnaire— personality disorders, 532
Revised, 526 clinical utility of Multidimensional
Personality disorders (PDs). See also Personality Functioning and Trait
Assessment; Boundary issues; Model, 564, 567
Comorbidity; Core dysfunctions; DSM definitions of in DSM-5, 565–567
system; Neurobiology; Prevalence; dimensionality of, 558
Severity; Stability; Suicide and suicidal hierarchical structure of personality and,
behavior; Theory; Therapeutic alliance; 558, 563
Treatment; specific disorders neurobiology of, 22–24
attachment history and development of, pathological in DSM-IV and DSM-5,
58–59 135–136, 518–523, 547
defining features and diagnosis of, 131, personality style and personality
134–144 disorders versus, 150–152
definition of, 131, 165 substance-related symptoms as distinct
differential diagnosis of, 153–160 from, 410
DSM system and history of classification symptoms and specific behaviors of,
of, 2–8 563–564
interactional models of, 79 therapeutic alliance and, 192–193, 200–207
in military environment, 475–484 Trait Model in DSM-5 and, 563
personality style and overdiagnosis of, trait theories and, 20–22
150–152 view of in DSM-I, 4
quality of life and, 123–126 Pervasiveness
scoring algorithms for, 556 diagnostic criteria in DSM-5 and, 140, 547
sociodemographic correlates of, 115, problems in clinical interviewing and, 147
117–123 Pharmacotherapy. See also Antidepressants;
stability of over time, 7–8 Anxiolytics; Antipsychotics;
Personality disorder–trait specified (PD-TS) Collaborative treatment; Medications;
alternative model for personality Mood stabilizers; Polypharmacy; Side
disorders in DSM-5 and, 7, 125, effects; Stimulants
531–532, 545 antisocial personality disorder and,
case example of, 151 445–446
differential diagnosis of, 159–160 borderline personality disorder and,
General criteria for personality disorders 323–339
and, 555–556 comorbid substance use and personality
Personality functioning. See also Personality; disorders, 420–421
Personality traits future directions in research on, 334, 336
impairment in, 131, 135, 143–144, 513–516, psychoeducation and, 313
546–547 therapeutic alliance and, 211
therapeutic alliance and, 192–193, Phenelzine, 323, 335
200–207 Phenytoin, 445
Personality-Guided Treatment for Alcohol Physician’s Desk Reference, 360
Dependence, 415 Physical abuse. See also Neglect; Sexual
Personality Inventory for DSM-5 (PID-5), abuse
136, 146, 520–521, 564 oxytocin and, 497
Personality Psychopathology Five (PSY-5), as risk factor for personality disorders, 58,
523, 563 390, 440
Piaget, J., 42, 66 Proline dehydrogenase (PRODH), and

PID-5. See Personality Inventory for DSM-5 schizotypal personality disorder, 92
Pinel, Philippe, 430 Prototypical cases, and core dysfunctions,
Point Subtraction Aggression Paradigm 44–45
(PSAP), 84 Provisional disorders, in DSM-III-R and
Polypharmacy, 313, 350 DSM-IV, 126
Postencounter defensive behavior, 502–503 PSAP. See Point Subtraction Aggression
Posterior cingulate cortex (PCC), and Paradigm
borderline personality disorder, 89–90 Pseudo-closeness, and antisocial personality
Posttraumatic stress disorder (PTSD) disorder, 375–376
comorbidity of with borderline “Psychic equivalence,” 66
personality disorder, 390, 391, 499 Psychoanalysis. See also Psychoanalytic
differential diagnosis of, 156 theory
military and treatment of, 483, 484 definition of, 217
prevalence of in military, 478 description of methods, 236
Power, and boundary issues, 372 framework of, 218
Preencounter defensive behaviors, 502 indications for, 227
Prefrontal cortex. See also Brain; therapeutic alliance and, 208–209
Orbitofrontal cortex Psychoanalytic theory, 14–17
antisocial personality disorder and, 98, Psychodynamic Diagnostic Manual (PDM Task
439–440, 495–496 Force 2006), 218
borderline personality disorder and, Psychodynamic psychotherapy. See also
84–85, 89 Psychodynamic theories
Prepulse inhibition (PPI), of acoustic startle definition of, 217
reflex, 91, 92 descriptions of treatments, 228–236
Pretend mode, and differentiation of self, 66 development of model of therapy,
Prevalence, of personality disorders 218–219
of antisocial personality disorder, indications for, 227–228
435–437 perspectives on nature of personality
in clinical populations, 115, 116 pathology in, 221–227
of comorbidity with substance use therapeutic alliance and, 202, 208–209
disorders, 408–409, 461 Psychodynamic theories, of personality
of conduct disorder, 434, 435 disorders, 14–17
gender and, 117 Psychoeducation
in general population, 109–115, 455–456 antisocial personality disorder and,
in medical settings, 456, 463 308–309
Pritchard, James Cowles, 41, 430 avoidant personality disorder and,
Primary care physicians, and collaborative 308
treatment, 348–349, 351, 355–356. borderline personality disorder and, 292,
See also Medical settings 309–318
Primary disorder models, of comorbidity of Cluster A disorders and, 308
substance use with personality couples therapy and, 296
disorders, 411 description and scope of, 303–304
Prisons, and antisocial personality disorder, education component of, 305–307
436, 448 family therapy and, 291, 292
Problem analysis, and treatment planning problem solving and, 307–308
for psychotherapy, 247, 248–252 psychotherapy and communication of
Problem solving, and psychoeducation, diagnosis to patient, 252–253
307–308 skills training and, 307
Projective identification, 346. See also Defense social support and, 307
mechanisms theory of and rationale for, 304–305
Index 589
Psychological mindedness, and Randomized controlled trials (RCTs), of

psychodynamic psychotherapy, 227, cognitive-behavioral therapy, 262–263
228. See also Mindfulness Reading the Mind in the Eyes Test (RMET),
Psychological tests, and assessment of 492, 493, 495
antisocial personality disorder, 443. See Reality
also Self-report instruments cognitive-behavioral therapy and model
Psychopathic inferiority, 430 of, 243
Psychopathy schizotypal personality disorder and
antisocial personality disorder and testing of, 93
construct of, 96, 430, 431, 434, 550 Receiver operating characteristic (ROC), 516
forms of aggression and, 98 Recovery, in studies of course and outcome,
neurobiology of antisocial personality 174. See also Remission
disorder and, 99 “Red flag” warning response, and boundary
social cognition and empathy in, 495–496 issues, 380
therapeutic alliance and, 201 Referrals, for behavioral health evaluation in
Psychopathy Checklist (PCL), 434, 443 military, 480–481
Psychosexual dysfunction, and quality of Reframing, of social environment, 258
life, 124. See also Sexual behavior Reich, Wilhelm, 5
Psychosocial function, and risk factors for Rejection sensitivity, and borderline
suicide, 394 personality disorder, 88, 490. See also
Psychotherapy. See also Cognitive-behavioral Hypersensitivity
therapy; Collaborative treatment; Relapse, and studies of course and outcome,
Couples therapy; Family therapy; 174, 175
Group therapy; Psychodynamic Relational school, of self psychology, 224–225
psychotherapy Relevance, and SMART goals, 244
for antisocial personality disorder, 446–448 Reliability, and concept of stability, 168–169
for comorbid substance use and Remission. See also Recovery
personality disorders, 419–420 antisocial personality disorder and, 441
for dissociation in borderline personality in studies of course and outcome, 174, 175
disorder, 502 Research Agenda for DSM-V, A (First et al.
general principles of for personality 2002), 535
disorders, 246–255 “Residual schizophrenia,” 150
influence of attachment on outcome of Restricted affectivity. See also Negative
treatment, 71–72 affectivity
Psychotherapy Research Project (Menninger definition of in DSM-5, 565
Foundation), 208, 234 obsessive-compulsive personality
Psychotic disorders, differential diagnosis of, disorder and, 554
149–150, 158, 444. See also Schizophrenia schizotypal personality disorder and, 555
Psychoticism Retrospective reporting, and assessment, 148
definition of in DSM-5, 567 Reward dependence, and temperament, 23
internalizing disorders and, 154, 158–159 Reward sensitivity pathway, and substance
personality disorder–trait specified and, use disorders, 412
556 Rigid perfectionism
personality traits in DSM-5 and, 522 definition of in DSM-5, 566
obsessive-compulsive personality
Quality of life, and definition of personality disorder and, 554
disorders, 123–126 Risk factors. See also Physical abuse; Sexual
Quetiapine, 326 abuse
insecure attachment and personality
Race, and prevalence of antisocial personal- disorders, 71
ity disorder, 436. See also Culture for suicide and suicidal behavior, 389–395
Risk management, and boundary issues, age and, 119

379–381 antipsychotics and, 323
Risk taking classification of in DSM-III, 4–5
antisocial personality disorder and, 549 clinical interviewing and differential
borderline personality disorder and, 552 diagnosis of, 150, 158–159
definition of in DSM-5, 566 cognitive and perceptual distortions in,
Risperidone, 94–95, 324–325, 335 137
Roles, of personality disorders in group Collaborative Longitudinal Personality
therapy, 283–284 Disorders Study and, 173–178
collaborative treatment and, 352
Sabotage, of medical care, 459–460 defining features of in DSM-IV and DSM-
Sadistic personality disorder (SAPD) 5, 141, 519, 522
age and, 119 diagnostic threshold for in DSM-5, 530
marital status and, 120 educational level and, 122
prevalence of, 110–111, 112 gender and, 117
as provisional diagnosis in DSM-III-R, 5 General criteria for personality disorders
Sadomasochistic character, and therapeutic and, 548, 554–555
alliance, 205–207 genetics of, 91–92, 527
Safety planning, and suicidal behavior, interpersonal relationships and, 139
399–401 marital status and, 120, 121
SAPD. See Sadistic personality disorder neurobiology of, 90–96
“Scared straight” type programs, and prevalence of, 110–111, 112, 113, 114, 115,
antisocial personality disorder, 448 116
Schedule for Nonadaptive and Adaptive quality of life and, 124
Personality (SNAP), 533 substance use disorders and, 408
Schema(s), and cognitive-social theories, 18, suicide and suicidal behavior, 387
19, 262 therapeutic alliance and, 195, 200
Schema-focused therapy (SFT), 265–266 Schizotypal Personality Questionnaire, 95
Schizoid personality disorder (SPD) SCL-90, 331
affective features of, 138 SCORS. See Social Cognition and Object
age of patients with, 118, 119 Relations Scale
classification of in DSM-III, 4–5 Script-driven imagery, 501–502
cognitive distortions in, 19 SDPD. See Self-defeating personality
collaborative treatment and, 352 disorder
defining features of in DSM-5, 141 “Secure base,” treatment and concept of, 72
educational level and, 122 Selective serotonin reuptake inhibitors
gender and, 117 (SSRIs)
interpersonal relationships and, 139 borderline personality disorder and, 333
marital status and, 120, 121 collaborative treatment and, 349
prevalence of, 110–111, 112, 114, 115, 116 comorbid substance use and personality
quality of life and, 124 disorders, 420
suicide and suicidal behavior, 387 Self. See also Grandiose self; Identity; Level of
therapeutic alliance and, 195, 200 Personality Functioning Scale;
Schizophrenia. See also Psychotic disorders Self-direction
differential diagnosis of, 149, 158 attachment and differentiation of,
genetic relationship between schizotypal 65–68
personality disorder and, 25–26, core dysfunctions and, 48
91–92 impairment in personality functioning
psychoeducation and, 304–305 and, 513–516, 546–547
Schizotypal personality disorder (STPD) Kohut’s concept of, 17
affective features of, 95, 138 object relations theory and, 222–223
Index 591
Self-defeating personality disorder (SDPD) Seven-factor model of personality, 22

age and, 119 Severity, of personality disorders. See also
educational level and, 122 Level of Personality Functioning Scale
marital status and, 120, 121 continuum of, 16
prevalence of, 110–111, 112 core dysfunctions and, 46
as provisional diagnosis in DSM-III-R, 5 impairment of personality functioning
Self-descriptions, and trait theories, 20 and, 135, 517
Self-direction. See also Self quality of life and, 124
antisocial personality disorder and, 549 specifiers in DSM-5 and, 532
avoidant personality disorder and, 550 Severity Indices of Personality Problems
borderline personality disorder and, 551 (SIPP), 44, 515, 518
elements of personality functioning and, Sexual abuse
515, 547 history of as risk factor for suicide,
Level of Personality Functioning Scale 393–394, 396
and, 135, 559–562 as risk factor for personality disorders, 58,
narcissistic personality disorder and, 552 306, 377, 390
obsessive-compulsive personality Sexual behavior, personality dysfunction
disorder and, 553 and impulsive, 465. See also
schizotypal personality disorder and, 554 Psychosexual dysfunction
temperament and, 23 Shedler-Westen Assessment Procedure
Self-help groups, and borderline personality (SWAP-200), 29
disorder, 314 Shock incarceration, and antisocial
Self-injurious behavior. See also Nonsuicidal personality disorder, 448
self injury Short Form Health Survey, Version 2
borderline personality disorder and, 89, (SF-12v2), 124–125
140, 464, 498–501 Short-term outpatient group therapy, 284
suicidal behavior distinguished from, 400 Side effects, of antipsychotics, 326–327
Self psychology Significance, and SMART goals, 244
psychodynamic psychotherapy and, SIPP. See Severity Indices of Personality
223–224, 225, 233–234 Problems
as theoretical framework, 14, 15–16, 17 Skills training. See also Systems Training for
Self-regulation, and cognitive-social theories, Emotional Predictability and Problem
18 Solving (STEPPS)
Self-report instruments. See also dialectical behavior therapy for families
Psychological tests of BPD patients and, 316–318
overdiagnosis of substance use disorders family therapy and, 292
and, 409 psychoeducation and, 307, 313
value of for assessment, 146 treatment planning and, 248
Self-transcendence, and temperament, 23 Skin conductance response, and avoidant
Semi-structured interviews, and assessment, personality disorder, 102
146 SMART goals, 244, 247
Separation Anxiety Test, 62 Smartphone adaptation, of dialectical
Separation insecurity. See also behavior therapy for substance use,
Hypersensitivity; Rejection sensitivity 417
borderline personality disorder and, 552 Smoking, antisocial personality disorder and
definition of in DSM-5, 565 maternal, 439
Serotonergic system SNAP. See Schedule for Nonadaptive and
antisocial personality disorder and, 100, Adaptive Personality
439 Social anxiety disorder, overlap of with
borderline personality disorder and, avoidant personality disorder, 101,
85–86 157–158, 269
Social cognition, and empathy in for obsessive-compulsive personality

psychopathy, 495–496 disorder, 554
Social Cognitions and Object Relations Scale for personality disorder–trait specified, 556
(SCORS), 43, 517 for schizotypal personality disorder, 555
Social control, in urban locations, 123 Species-specific defense reaction (SSDR), 502
Social environment, cognitive-behavioral Speech, attachment and development of, 71
therapy and specific reactions to, 258 Splitting. See also Defense mechanisms
Social exchange theory, and couples therapy, attachment theory and, 226
296 borderline personality disorder and, 201,
Social interaction. See Interpersonal 211–212
relationships collaborative treatment and, 346, 350, 351
Social learning theory, and family therapy, Split treatment, 345
292 Stability, of personality disorders
Social and Occupational Functioning conceptual and methodological issues in,
Assessment Scale (SOFAS), 517 168–173
Social processing impairments DSM system and concept of, 7–8, 165
antisocial personality disorder and, General criteria for personality disorders
97–98 and, 547
borderline personality disorder and, 89 overview of early literature on, 166–168
Social skills. See Interpersonal relationships; review of empirical advances and
Skills training understanding of, 173–180
Social support. See also Interpersonal Startle response, and avoidant personality
relationships disorder, 102
psychoeducation and, 307 State-Trait Anger Expression Inventory
risk factors for suicide and, 394 (STAXI), 331
Social variables, and treatment planning for STEPPS. See Systems Training for Emotional
cognitive-behavioral therapy, 247, 248, Predictability and Problem Solving
250, 252 Stimulants
Socioeconomic status antisocial personality disorder and, 446
antisocial personality disorder and, 436 for comorbid substance use and
prevalence of personality disorders and, personality disorders, 420–421
122 STIPO. See Structured Interview of
treatment planning and, 246 Personality Organization
Sociopathic personality disturbance, 430 STPD. See Schizotypal personality disorder
Somatic disorders. See also Somatic symptom Strange Situation, 56, 62
disorder; Somatization disorder Stress. See also Stress reduction pathway
borderline personality disorder and, risk of suicide and, 391–392
461–463 urban life and, 123
collaborative treatment and, 355–356 Stress-diathesis model, of suicidal behavior,
treatment planning and, 247, 248 395–398
Somatic preoccupation, 462–463 Stress reduction pathway, for substance use,
Somatic symptom disorder, 462 412
Somatization disorder, 462 Structural Analysis of Social Behavior
Sound Marital House Treatment, 297 (SASB), 27–28
SPD. See Schizoid personality disorder Structured Clinical Interview for DSM-IV
Specifiers. See also Personality disorder–trait Axis II Personality Disorders (SCID-II),
specified 111–112, 146, 515
for antisocial personality disorder, 550 Structured Interview for DSM-III-R
for avoidant personality disorder, 551 Personality Disorders (SIDP), 111
for borderline personality disorder, 552 Structured Interview for DSM-IV
for narcissistic personality disorder, 553 Personality, 146
Index 593
Structured Interview for the Five-Factor Support groups, and borderline personality
Model (SIFFM), 520, 528 disorder, 314–315. See also Social
Structured Interview of Personality support
Organization (STIPO), 43–44 Supportive-expressive therapy, 234–236
Submissiveness, definition of in DSM-5, 565 Surfaces, and interpersonal model, 28
Substance use disorders Suspiciousness
antisocial personality disorder and, 444, definition of in DSM-5, 565
447–448 schizotypal personality disorder and, 555
assessment and diagnosis of, 409–411 Symptomatic volunteers, and clinical trials
avoidant personality disorder and, 268 in borderline personality disorder, 336
case example of, 355, 415–417, 417–418 Systemic therapies, for families, 292
causal pathways of, 411–414 Systems Training for Emotional
collaborative treatment for comorbid, Predictability and Problem Solving
355 (STEPPS), 264, 284, 286, 318
comorbidity of with personality disorders
and risk of suicide, 391 Tattoos, and antisocial personality disorder,
differential diagnosis of personality 443
disorders and, 155, 157 Technical Bulletin 203 (U.S. War
DSM-5 system for, 421 Department), 2
General criteria for personality disorders Temperament, and personality structure, 23
and, 525, 548 Temperament and Character Inventory
in medical settings, 461 (TCI), 23
prescription medications and, 458 “Tension release,” and self-injurious
prevalence of comorbidity with behavior in borderline personality
personality disorders, 408–409 disorder, 498
treatment guidelines for, 419–421 Termination, and therapeutic alliance, 191
treatment outcome of personality TFP. See Transference-focused
disorders and, 414–418 psychotherapy
Subtypes, of personality disorder–trait Thematic Apperception Test (TAT), 43
specified, 556 Theories, of personality disorders. See also
Suicide and suicidal behavior Theory of Mind
acute-on-chronic risk model of, 386, 387, attachment theory, 58, 65–68
389, 398–399 biological perspectives on, 22–26
antisocial personality disorder and, case formulation and, 30–32
443 cognitive-social theories, 17–20
assessment of risk for, 398–399 integrative theories, 26–30
borderline personality disorder and, 140, psychodynamic theories, 14–17
330, 378, 385, 387–388, 389–401, 498 trait theories, 20–22
crisis management and safety planning, Theory of Mind
399–401 attachment and differentiation of self, 66,
epidemiology of, 386–389 67
general principles of psychotherapy and, mentalization deficits and, 63, 64
247 Therapeutic alliance. See also Therapeutic
neurobiology and, 395–398 relationships
psychotropic medications and, 361 aspects of each personality disorder style
risk factors for, 389–395 relevant to, 194–199
therapy contracts and, 253 attachment and, 71
Superego, and ego psychology, 221, 222 case examples of, 204, 205, 206–207,
Superior temporal gyrus, 82 209–210, 211, 212–213
Supervision, of cognitive-behavioral couples therapy and, 296
therapy, 258–259 definition of, 190–191
Therapeutic alliance (continued) collaborative treatment and, 358

family therapy and, 289 group therapy and, 282
personality functioning and traits, idealization and, 233
192–193, 200–207 mentalization-based therapy and, 232
quality of preexisting interpersonal psychodynamic psychotherapy and, 208,
relationships and, 189–190 218
strains and ruptures in, 191–192 self psychology model and, 233
treatment paradigms and, 207–213 Transference-focused psychotherapy (TFP),
Therapeutic community, and day treatment 220, 229, 265–266
programs, 285 “Transference tracers,” 232
Therapeutic relationships. See also Tranylcypromine, 324, 327, 335
Therapeutic alliance Trauma
cognitive-behavioral therapy and, attachment history and, 58–59, 72
253–255 borderline personality disorder and, 311,
pharmacotherapy and, 337 377, 497
Therapists. See also Boundary issues; Traumatic brain injury, 484
Therapeutic alliance; Transference Treatment. See also Clinical settings;
anger and countertransference in Cognitive-behavioral therapy;
treatment of borderline personality Collaborative treatment; Couples
disorder, 378 Pharmacotherapy; Psychoeducation;
attachment style of, 71 Psychotherapy; Split treatment;
as “coaches” in cognitive-behavioral Therapeutic alliance; Therapists;
therapy, 255 Transference; Treatment manuals;
neutrality of, 224 Treatment plans
training of for treatment of comorbid attachment and, 70–72
substance use and personality barriers to in military, 477, 479
disorders, 419 of comorbid substance use and
Therapy contracts, 253, 357 personality disorders, 447–448
Thinking and thoughts. See Automatic guidelines for substance use disorders
thoughts and, 419–421
Thiothixene, 323 outcome of for substance use disorders,
Third-party informants, and assessment, 414–418
146–147 planning of, 246–252
Threat-related activation, of attachment “untreatability myth” about antisocial
system, 61 personality disorder and, 447
Threat system, and antisocial personality Treatment manuals, for psychodynamic
disorder, 98 psychotherapy, 219. See also Manual
attachment and differentiation of self, 67, Assisted Cognitive Treatment
68 Treatment plans, and suicidal behavior, 400
borderline personality disorder and Trichotillomania, 464
interpersonal relationships, 88–89 Tricylic antidepressants (TCAs), 328
Topiramate, 331, 335 Trifluoperazine, 324
Topographic model, 14 Trust
Training, of therapists for treatment of attachment and differentiation of self, 67,
comorbid substance use and personality 68
disorders, 419. See also Education borderline personality disorder and
Traits. See Personality traits interpersonal relationships, 88–89
Trait theories, 20–22 Tryptophan hydroxylase (TPH)
Transference. See also Countertransference antisocial personality disorder and, 100
boundary issues and, 379 borderline personality disorder and, 86
cognitive-behavioral therapy and, 255 12-Step Facilitation Therapy (TSFT), 415
Index 595
U.S. War Department, 2 Westen, D., 28–30

Unresolved/disorganized attachment, 56, “Wilderness” programs, and antisocial
57, 59 personality disorder, 448
“Untreatability myth,” about antisocial Winnicott, D.W., 208
personality disorder, 447 Withdrawal
Urban locations, and frequency of antisocial personality disorder and, 550
personality disorders, 122–123 avoidant personality disorder and, 551
definition of in DSM-5, 565
Val allele, and schizotypal personality ruptures in therapeutic alliance and,
disorder, 91 191–192
Valproate, 335 schizotypal personality disorder and, 555
Values World Health Organization. See
cognitive-behavioral therapy and, 243, 275 International Classification of Diseases
organizational culture of military and, World Health Organization Disability
476 Assessment Schedule 2.0 (WHODAS
treatment planning and, 246–247 2.0), 269, 271
Venlafaxine, 328 World Health Organization Well-Being
Victimization, and borderline personality Index (WHO-5), 269, 271
disorder, 377
Violence, and media influence on antisocial Yale Psychiatric Institute, 170
personality disorder, 441. See also
Aggression; Criminality; Domestic Zanarini Rating Scale for Borderline Person-
violence ality Disorder (ZAN-BPD), 326, 331, 337

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THE AMERICAN PSYCHIATRIC PUBLISHING

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

To our colleagues, who have helped us.

To our patients, who have taught us.

And to each other, for the friendship that has

1 Personality Disorders: Recent History

3 Articulating a Core Dimension of

4 Development, Attachment, and Childhood

5 Genetics and Neurobiology . . . . . . . . . . . . . . . . . . . . . . . 79

6 Prevalence, Sociodemographics, and

7 Manifestations, Assessment, and

8 Course and Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . 165

10 Psychodynamic Psychotherapies and

12 Cognitive-Behavioral Therapy II:

13 Group, Family, and Couples Therapies . . . . . . . . . . . . . 281

15 Somatic Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321

16 Collaborative Treatment . . . . . . . . . . . . . . . . . . . . . . . . . 345

17 Boundary Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369

20 Antisocial Personality Disorder and Other

21 Personality Disorders in the Medical Setting . . . . . . . . 455

22 Personality Disorders in the Military

24 An Alternative Model for Personality Disorders:

Appendix: Alternative DSM-5 Model for

John M. Hart, Ph.D. Paul S. Links, M.Sc., M.D., FRCPC

Christian Schmahl, M.D. Frank E. Yeomans, M.D.

Disclosures of Competing Interests

Personality disorders occupy polygenic risk with diverse developmen-

American Psychiatric Association: Diag-

There is a vast and rich literature in also critically important—these range

orders are almost always “stable and en-

cess is also bidirectional, so that the “in-

DSM-I (1952) DSM-II (1968) DSM-III (1980) DSM-IV (1994)/

Indicates that category was discontinued.

FIGURE 1–1. Ontogeny of personality disorder classification.

pessimistic cognitive style, presumably height might be better conceptualized di-

Personality refers to enduring pat- resistance to perceived demands of male

cent developments in behavioral genet- awareness among conflicting wishes,

The concept of a grandiose self is cen- which pathological narcissism is a pro-

nitive distortions (systematic errors in propose three cognitive processes involv-

which he called temperament (“auto- dent, avoidant, obsessive-compulsive),

band internalizing and externalizing per- onstrated significant variability, most

personality, cognitive, developmental, lytic theories of motivation and conflict

Beck A: Cognitive aspects of personality disor-

Problems with the categorical nate situation results in manifestations

to provide a dimensional assessment of thesis of these common elements sug-

TABLE 3–1. Four self-other areas of personality functioning typically impaired in

these phenomena simply as increased American Psychiatric Association: Diag-

Widiger TA, Frances AJ, Pincus HA, et al disorders in psychiatric outpatients. Am

Attachment theory (Bowlby affect close relationships in later life, as

Attachment has traditionally been An avoidant infant appears less anx-

victims of childhood trauma are more associated with different attachment

not correspond to these feelings—a con- talization appears to be the developmen-

ers’ feelings. The emergence of spoken or the treatment. Psychotherapy can be

pressed is one of needing to hold on yet

the association between sensitivity and the neurobiology of attachment. Infant

Neuroimaging Findings umes in patients with BPD, compared

Genetics across diagnostic categories and is pres-

imaging data. Volume reduction in OFC have demonstrated decreased metabolic

ing studies. A PET study of serotonin syn- tryptophan-containing genotypes of

a signal decrease compared with HC sub- sumed by an earlier, broader iteration of

cissistic, or antisocial PDs or high-func- relationship between childhood trauma

of a schizotypy symptom domain related evaluate cognitive or information pro-

Structural connectivity between brain measures of dopamine metabolism, in-

Interpersonal Function eral population survey (Grant et al. 2004).