Professional Documents
Culture Documents
Textbook of Personality Disorders
Textbook of Personality Disorders
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
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
not included in this book. For these reasons and because human and mechanical er-
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.
Books published by American Psychiatric Publishing (APP) represent the findings,
conclusions, and views of the individual authors and do not necessarily represent the
policies and opinions of APP or the American Psychiatric Association.
If you would like to buy between 25 and 99 copies of this or any other American Psy-
chiatric Publishing title, you are eligible for a 20% discount; please contact Customer
Service at [email protected] or 800–368–5777. If you wish to buy 100 or more copies of
the same title, please e-mail us at [email protected] for a price quote.
Copyright © 2014 American Psychiatric Association
ALL RIGHTS RESERVED
Manufactured in the United States of America on acid-free paper
18 17 16 15 14 5 4 3 2 1
Second Edition
Typeset in Adobe’s Helvetica Std and Palatino Std.
American Psychiatric Publishing
A Division of American Psychiatric Association
1000 Wilson Boulevard
Arlington, VA 22209-3901
www.appi.org
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.
Part I
Clinical Concepts and Etiology
2 Theories of Personality and Personality Disorders. . . . . 13
Amy K. Heim, Ph.D., and Drew Westen, Ph.D.
11 Cognitive-Behavioral Therapy I:
Basics and Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
Martin Bohus, M.D.
14 Psychoeducation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
Alan E. Fruzzetti, Ph.D., John G. Gunderson, M.D.,
and Perry D. Hoffman, Ph.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.
Part IV
Future Directions
23 Translational Research in Borderline
Personality Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489
Christian Schmahl, M.D., and Sabine Herpertz, M.D.
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 569
This page intentionally left blank
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.
Thomas G. Gutheil, M.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
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
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
xix
xx The American Psychiatric Publishing Textbook of Personality Disorders
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 psycho- therapy, 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
John M. Oldham, M.D., M.S.
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
John M. Oldham, M.D., M.S.
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
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
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-
4 The American Psychiatric Publishing Textbook of Personality Disorders
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 re- in 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-
Personality Disorders 5
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 re- in 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
6 The American Psychiatric Publishing Textbook of Personality Disorders
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
8 The American Psychiatric Publishing Textbook of Personality Disorders
trait-defined PDs are more persistent over Disorders. Washington, DC, American
time than DSM-IV–defined PDs (Hop- Psychiatric Association, 1952
American Psychiatric Association: Diag-
wood et al. 2013).
nostic and Statistical Manual of Mental
Disorders, 2nd Edition. Washington, DC,
American Psychiatric Association, 1968
Conclusion American Psychiatric Association: Diag-
nostic and Statistical Manual of Mental
This brief review of the history of the clas- Disorders, 3rd Edition. Washington, DC,
sification of personality pathology serves American Psychiatric Association, 1980
American Psychiatric Association: Diag-
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-
nostic and Statistical Manual of Mental
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
References First MB, Bell CC, Cuthbert B, et al: Personal-
ity disorders and relational disorders: a
American Psychiatric Association: Diag- research agenda for addressing crucial
nostic and Statistical Manual: Mental gaps in DSM, in A Research Agenda for
Personality Disorders 9
DSM-V. Edited by Kupfer, DJ, First MB, Rounsaville BJ, Alarcón RD, Andrews G, et
Regier DA. Washington, DC, American al: Basic nomenclature issues for DSM-V,
Psychiatric Association, 2002, pp 123– in A Research Agenda for DSM-V. Ed-
199 ited by Kupfer DJ, First MB, Regier DA.
Gunderson JG: Borderline Personality Disor- Washington, DC, American Psychiatric
der. Washington, DC, American Psychi- Association, 2002, pp 1–30
atric Press, 1984 Shedler J, Westen D: Refining personality
Hopwood CJ, Morey LC, Donnellan MB, et disorder diagnosis: integrating science
al: Ten-year rank-order stability of per- and practice. Am J Psychiatry 161:1350–
sonality traits and disorders in a clinical 1365, 2004
sample. J Pers 81:335–344, 2013 Skodol AE: Classification, assessment, and
Kernberg O: Borderline Conditions and Path- differential diagnosis of personality dis-
ological Narcissism. New York, Jason orders. J Pract Psychiatry Behav Health
Aronson, 1975 3:261–274, 1997
Kiesler DJ: The 1982 interpersonal circle: a Skodol AE, Link BG, Shrout PE, et al: The re-
taxonomy for complementarity in hu- vision of axis V in DSM-III-R: should
man transactions. Psychol Review 90:185– symptoms have been included? Am J
214, 1983 Psychiatry 145:825–829, 1988
Kohut H: The Analysis of the Self: A System- Watson D, Clark LA, Harkness AR: Struc-
atic Approach to the Psychoanalytic tures of personality and their relevance
Treatment of Narcissistic Personality Dis- to psychopathology. J Abnorm Psychol
orders. New York, International Univer- 103:18–31, 1994
sities Press, 1971 Widiger TA: Four out of five ain’t bad (com-
Kupfer DJ, First MB, Regier DA (eds): A Re- mentary). Arch Gen Psychiatry 55:865–
search Agenda for DSM-V. Washington, 866, 1998
DC, American Psychiatric Association, Widiger TA, Frances AJ, Harris M, et al: Co-
2002 morbidity among Axis II disorders, in
Livesley WJ, Jang KL, Jackson DN, et al: Ge- Personality Disorders: New Perspectives
netic and environmental contributions on Diagnostic Validity. Edited by Old-
to dimensions of personality disorder. ham JM. Washington, DC, American
Am J Psychiatry 150:1826–1831, 1993 Psychiatric Press, 1991, pp 163–194
Livesley WJ, Jang KL, Vernon PA: Pheno- Widiger TA, Simonsen E, Sirovatka PJ, et al
typic and genetic structure of traits de- (eds): Dimensional Models of Person-
lineating personality disorder. Arch Gen ality Disorders: Refining the Research
Psychiatry 55:941–948, 1998 Agenda for DSM-V. Washington, DC,
Millon T: Modern Psychopathology: A Bioso- American Psychiatric Association, 2006
cial Approach to Maladaptive Learning Wiggins J: Circumplex models of interpersonal
and Functioning. Philadelphia, PA, WB behavior in clinical psychology, in Hand-
Saunders, 1969 book of Research Methods in Clinical Psy-
Oldham JM, Skodol AE, Kellman HD, et al: chology. Edited by Kendall P, Butcher J.
Diagnosis of DSM-III-R personality dis- New York, Wiley, 1982, pp 183–221
orders by two structured interviews: pat- World Health Organization: International
terns of comorbidity. Am J Psychiatry Classification of Diseases, 8th Revision.
149:213–220, 1992 Geneva, World Health Organization, 1967
This page intentionally left blank
PART I
Clinical Concepts and Etiology
This page intentionally left blank
CHAPTER 2
Theories of Personality
and Personality Disorders
Amy K. Heim, Ph.D.
Drew Westen, Ph.D.
Preparation of this manuscript was supported in part by National Institute of Mental Health
grants MH59685 and MH60892.
13
14 The American Psychiatric Publishing Textbook of Personality Disorders
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 inabil- ity 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
16 The American Psychiatric Publishing Textbook of Personality Disorders
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.
Theories of Personality and Personality Disorders 17
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-
Theories of Personality and Personality Disorders 19
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 re- in 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 ten- tive 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).
Theories of Personality and Personality Disorders 21
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
22 The American Psychiatric Publishing Textbook of Personality Disorders
(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,
Theories of Personality and Personality Disorders 23
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-
Theories of Personality and Personality Disorders 25
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 re- as 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 in- different 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
Theories of Personality and Personality Disorders 27
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
28 The American Psychiatric Publishing Textbook of Personality Disorders
(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
Theories of Personality and Personality Disorders 29
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
Theories of Personality and Personality Disorders 31
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
32 The American Psychiatric Publishing Textbook of Personality Disorders
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.
Theories of Personality and Personality Disorders 33
Cloninger CR: The genetics and psychobiol- ality traits: implications for modelling
ogy of the seven-factor model of person- personality disorders. Int Rev Psychia-
ality, in Biology of Personality Disorders. try 23:258–281, 2011
Edited by Silk KR (Review of Psychiatry Depue R, Lenzenweger M: A neurobehav-
Series, Vol 17; Oldham JM, Riba MB, ioral dimensional model, in Handbook
series eds). Washington, DC, American of Personality Disorders: Theory, Re-
Psychiatric Press, 1998, pp 63–92 search, and Treatment. Edited by Lives-
Cloninger CR: Feeling Good: The Science of ley WJ. New York, Guilford, 2001, pp
Well-Being. New York, Oxford Univer- 136–176
sity Press, 2004 Distel MA, Willemsen G, Lighthart L, et al:
Cloninger CR: The psychobiological theory Genetic covariance structure of the four
of temperament and character: comment main features of borderline personality
on Farmer and Goldberg (2008). Psychol disorder. J Pers Disord 24:427–444, 2010
Assess 20:292–299, 2008 Espelage DL, Mazzeo SE, Sherman R, et al:
Cloninger CR, Svrakic D: Differentiating nor- MCMI-II profiles of women with eating
mal and deviant personality by the seven- disorders: a cluster analytic investiga-
factor personality model, in Differentiat- tion. J Pers Disord 16:453–463, 2002
ing Normal and Abnormal Personality. Eysenck H: The Biological Basis of Personal-
Edited by Strack S, Lorr M. New York, ity. Springfield, IL, Charles C Thomas,
Springer, 1994, pp 40–64 1967
Cloninger CR, Svrakic DM, Przybeck TR: A Eysenck H: A Model for Personality. New
psychobiological model of tempera- York, Springer-Verlag, 1981
ment and character. Arch Gen Psychia- Eysenck HJ: Biological dimensions of person-
try 50:975–990, 1993 ality, in Handbook of Personality: The-
Coker L, Samuel D, Widiger T: Maladaptive ory and Research. Edited by Pervin LA.
personality functioning within the Big New York, Guilford, 1990, pp 244–276
Five and the five-factor model. J Pers Fairbairn WR: Psychoanalytic Studies of the
Disord 16:385–401, 2002 Personality. London, Tavistock, 1952
Coolidge FL, Thede LL, Jang KL: Heritability Fonagy P, Target M: Attachment and reflec-
of personality disorders in childhood: a tive function: their role in self-organiza-
population study. J Pers Disord 15:33– tion. Dev Psychopathol 9:679–700, 1997
40, 2001 Fonagy P, Steele H, Steele M: Maternal rep-
Costa P, McCrae R: Longitudinal stability of resentations of attachment during preg-
adult personality, in Handbook of Per- nancy predict the organization of infant-
sonality Psychology. Edited by Hogan R, mother attachment at one year of age.
Johnson J. San Diego, CA, Academic Child Dev 62:891–905, 1991
Press, 1997, pp 269–290 Fonagy P, Gergely G, Jurist EL, et al: Affect
Dahl A: The personality disorders: a critical Regulation, Mentalization, and the De-
review of family, twin, and adoption velopment of the Self. New York, Other
studies. J Pers Disord 7(suppl):86–99, Press, 2002
1993 Fonagy P, Target M, Gergely G, et al: The de-
Damon W, Hart D: Self-Understanding in velopmental roots of borderline person-
Childhood and Adolescence. New York, ality disorder in early attachment rela-
Cambridge University Press, 1988 tionships: a theory and some evidence.
Davis R: Millon: essentials of his science, the- Psychoanalytic Inquiry 23:412–459, 2003
ory, classification, assessment, and ther- Goldberg L: The structure of phenotypic per-
apy. J Pers Assess 72:330–352, 1999 sonality traits. Am Psychol 48:26–34,
Depue R, Collins P: Neurobiology of the 1993
structure of personality: dopamine, fa- Goldstein W: DSM-III and the narcissistic
cilitation of incentive motivation, and personality. Am J Psychother 39:4–16,
extraversion. Behav Brain Sci 22:491–569, 1985
1999 Greenberg JR, Mitchell S: Object Relations in
Depue RA, Fu Y: Neurogenetic and experien- Psychoanalytic Theory. Cambridge, MA,
tial processed underlying major person- Harvard University Press, 1983
Theories of Personality and Personality Disorders 35
Gunderson JG: Borderline Personality Disor- Kraepelin E: Dementia praecox and para-
der: A Clinical Guide. Washington, DC, phrenia (1896). Chicago, IL, Chicago
American Psychiatric Publishing, 2001 Medical Book Company, 1919
Harter S: The Construction of the Self: A Kristensen H, Torgersen S: MCMI-II person-
Developmental Perspective. New York, ality traits and symptom traits in parents
Guilford, 1999 of children with selective mutism: a case-
Horowitz M: Introduction to Psychodynam- control study. J Abnorm Psychol 110:648–
ics: A Synthesis. New York, Basic Books, 652, 2001
1988 Krueger RF: The structure of common mental
Horowitz M: Cognitive Psychodynamics: disorders. Arch Gen Psychiatry 56:921–
From Conflict to Character. New York, 926, 1999
Wiley, 1998 Leary T: Interpersonal Diagnosis of Personal-
Kendler KS, Walsh D: Schizotypal personality ity: A Functional Theory and Methodol-
disorder in parents and the risk for schizo- ogy for Personality Evaluation. Oxford,
phrenia in siblings. Schizophr Bull 21:47– UK, Ronald Press, 1957
52, 1995 Lenzenweger M: Schizotypy and schizotypic
Kendler KS, Meyers J, Torgersen S, et al: The psychopathology, in Origins and Devel-
heritability of cluster A personality dis- opment of Schizophrenia: Advances in
orders assessed both by personal in- Experimental Psychopathology. Edited
terview and questionnaire. Psychol Med by Lenzenweger M, Dworkin R. Wash-
37:655–665, 2007 ington, DC, American Psychological As-
Kernberg O: Borderline Conditions and Path- sociation, 1998, pp 93–122
ological Narcissism. Northvale, NJ, Jason Linehan M: Cognitive-Behavioral Treatment
Aronson, 1975a of Borderline Personality Disorder. New
Kernberg O: Transference and countertrans- York, Guilford, 1993a
ference in the treatment of borderline Linehan M: Skills-Training Manual for Treat-
patients. J Natl Assoc Priv Psychiatr Hosp ment of Borderline Personality Disorder.
7:14–24, 1975b New York, Guilford, 1993b
Kernberg O: Severe Personality Disorders. Livesley WJ: An empirically-based classifica-
New Haven, CT, Yale University Press, tion of personality disorders. J Pers Dis-
1984 ord 25:397–420, 2011
Kernberg O: A psychoanalytic theory of per- Livesley WJ, Bromley DB: Person Perception
sonality disorders, in Major Theories of in Childhood and Adolescence. London,
Personality Disorder. Edited by Clarkin Wiley, 1973
J, Lenzenweger M. New York, Guilford, Livesley WJ, Jang K, Jackson D, et al: Genetic
1996, pp 106–140 and environmental contributions to di-
Kernberg O: Pathological narcissism and mensions of personality disorder. Am J
narcissistic personality disorder: theo- Psychiatry 150:1826–1831, 1993
retical background and diagnostic clas- Livesley WJ, Jang KL, Vernon PA: Pheno-
sification, in Disorders of Narcissism: typic and genetic structure of traits de-
Diagnostic, Clinical, and Empirical Im- lineating personality disorder. Arch Gen
plications. Edited by Ronningstam E. Psychiatry 55:941–948, 1998
Washington, DC, American Psychiatric Livesley WJ, Jang K, Vernon P: Genetic basis
Association, 1998, pp 29–51 of personality structure, in Handbook of
Kiesler D: The 1982 interpersonal circle: a Psychology: Personality and Social Psy-
taxonomy for complementarity in hu- chology, Vol 5. Edited by Millon T, Le-
man transactions. Psychol Rev 90:185– rner M. New York, Wiley, 2003, pp 59–83
214, 1983 Lobbestael J, Arntz A, Sieswerda S: Schema
Kohut H: The Analysis of the Self: A System- modes and childhood abuse in border-
atic Approach to the Treatment of Narcis- line and antisocial personality disorders.
sistic Personality Disorders. New York, J Behav Ther Exp Psychiatry 36:240–253,
International Universities Press, 1971 2005
Kohut H: The Restoration of the Self. Madi- Lynam DR, Widiger TA: Using the five-factor
son, WI, International Universities Press, model to represent the DSM-IV person-
1977 ality disorders: an expert consensus ap-
36 The American Psychiatric Publishing Textbook of Personality Disorders
proach. J Abnorm Psychol 110:401–412, Millon T, Millon C, Davis R: The Millon Clini-
2001 cal Multiaxial Inventory–III. Minneapolis,
Lyons M, Toomey R, Faraone S, et al: Corre- MN, National Computer Systems, 1994
lates of psychosis proneness in relatives Mischel W: Toward a cognitive social learn-
of schizophrenic patients. J Abnorm Psy- ing reconceptualization of personality.
chol 104:390–394, 1995 Psychol Rev 39:351–364, 1973
Main M: Recent studies in attachment: over- Mischel W: On the interface of cognition and
view, with selected implications for clin- personality: beyond the person-situation
ical work, in Attachment Theory: Social, debate. Am Psychol 34:740–754, 1979
Developmental, and Clinical Perspec- Mischel W: Personality dispositions revisited
tives. Edited by Goldberg S, Muir R, Kerr and revised: a view after three decades,
J. Hillsdale, NJ, Analytic Press, 1995, pp in Handbook of Personality: Theory and
407–474 Research. Edited by Pervin L. New York,
Masterson J: Psychotherapy of the Borderline Guilford, 1990, pp 111–134
Adult: A Developmental Approach. Mischel W, Shoda Y: A cognitive-affective
New York, Brunner/Mazel, 1976 system theory of personality: reconcep-
McCrae R, Costa P: Personality in Adulthood. tualizing situations, dispositions, dy-
New York, Guilford, 1990 namics, and invariance in personality
McCrae RR, Costa PT Jr: Personality trait structure. Psychol Rev 102:246–268, 1995
structure as a human universal. Am Psy- Mitchell SA: Relational Concepts in Psycho-
chol 52:509–516, 1997 analysis: An Integration. Cambridge, MA,
McWilliams N: Relationship, subjectivity, Harvard University Press, 1988
and inference in diagnosis, in Making Morey L, Gunderson J, Quigley B, et al: The
Diagnosis Meaningful: Enhancing Eval- representation of borderline, avoidant,
uation and Treatment of Psychological obsessive-compulsive, and schizotypal
Disorders. Edited by Barron JW. Wash- personality disorders by the five-factor
ington, DC, American Psychological As- model. J Pers Disord 16:215–234, 2002
sociation, 1998, pp 197–226 Nadort M, Arntz A, Smit JH, et al: Implemen-
Millon T: Modern Psychopathology: A Bioso- tation of outpatient schema therapy for
cial Approach to Maladaptive Learning borderline personality disorder with ver-
and Functioning. Philadelphia, PA, WB sus without crisis support by the thera-
Saunders, 1969 pist outside office hours: a randomized
Millon T: Millon Clinical Multiaxial Inven- trial. Behav Res Ther 47:961–973, 2009
tory Manual. Minneapolis, MN, National New A, Siever L: Neurobiology and genetics
Computer Systems, 1977 of borderline personality disorder. Psy-
Millon T: Millon Clinical Multiaxial Inventory– chiatric Annals of Clinical Psychiatry
II. Minneapolis, MN, National Computer 32:329–336, 2002
Systems, 1987 Nigg JT, Goldsmith H: Genetics of personal-
Millon T: Toward a New Psychology. New ity disorders: perspectives from person-
York, Wiley, 1990 ality and psychopathology research. Psy-
Millon T, Davis R: Conceptions of personal- chol Bull 115:346–380, 1994
ity disorders: historical perspectives, the Plomin R, Caspi A: Behavioral Genetics and
DSMs, and future directions, in The Personality. New York, Guilford, 1999
DSM-IV Personality Disorders: Diagno- Pretzer JL, Beck AT: A cognitive theory of
sis and Treatment of Mental Disorders. personality disorders, in Major Theories
Edited by Livesley WJ. New York, Guil- of Personality Disorder. Edited by Clarkin
ford, 1995, pp 3–28 J, Lenzenweger M. New York, Guilford,
Millon T, Davis R: An evolutionary theory of 1996, pp 36–105
personality disorders, in Major Theories Redl F, Wineman D: Children Who Hate: The
of Personality Disorder. Edited by Clarkin Disorganization and Breakdown of Be-
J, Lenzenweger M. New York, Guilford, havior Controls. Glencoe, IL, Free Press,
1996, pp 221–346 1951
Millon T, Davis R: The MCMI-III: present and Reich J: Familiality of DSM-III dramatic and
future directions. J Pers Assess 68:69–85, anxious personality clusters. J Nerv Ment
1997 Dis 177:96–100, 1989
Theories of Personality and Personality Disorders 37
Reich W: Character Analysis, 3rd Edition Tyrer P, Johnson T: Establishing the severity
(1933). New York, Simon & Schuster, 1978 of personality disorder. Am J Psychiatry
Ross S, Lutz C, Bailley S: Positive and negative 153:1593–1597, 1996
symptoms of schizotypy and the five-fac- Wachtel P: Psychoanalysis and Behavior
tor model: a domain and facet level anal- Therapy. New York, Basic Books, 1977
ysis. J Pers Assess 79:53–72, 2002 Wachtel P: Psychoanalysis, Behavior Ther-
Schaefer E: Configurational analysis of chil- apy, and the Relational World. Washing-
dren’s reports of parent behavior. J Con- ton, DC, American Psychological Asso-
sult Psychol 29:552–557, 1965 ciation, 1997
Siever L, Davis K: A psychobiological per- Westen D: The relations among narcissism,
spective on the personality disorders. egocentrism, self-concept, and self-es-
Am J Psychiatry 148:1647–1658, 1991 teem: experimental, clinical and theoret-
Siever L, Torgersen S, Gunderson J, et al: The ical considerations. Psychoanalysis and
borderline diagnosis, III: identifying en- Contemporary Thought 13:183–239,
dophenotypes for genetic studies. Biol 1990a
Psychiatry 51:964–968, 2003 Westen D: Towards a revised theory of bor-
Skodol A, Siever L, Livesley W, et al: The bor- derline object relations: contributions of
derline diagnosis II: biology, genetics, empirical research. Int J Psychoanal
and clinical course. Biol Psychiatry 71:661–693, 1990b
51:951–963, 2002 Westen D: Cognitive-behavioral inter-
Spitzer RL, Endicott J, Gibbon M: Crossing ventions in the psychoanalytic psy-
the border into borderline personality chotherapy of borderline personality
and borderline schizophrenia. Arch Gen disorders. Clin Psychol Rev 11:211–230,
Psychiatry 36:17–24, 1979 1991a
Sullivan HS: The Interpersonal Theory of Psy- Westen D: Social cognition and object rela-
chiatry. New York, WW Norton, 1953 tions. Psychol Bull 109:429–455, 1991b
Torgersen S: Genetic and nosological aspects Westen D: Toward an integrative model of af-
of schizotypal and borderline personal- fect regulation: applications to social-
ity disorders. Arch Gen Psychiatry 41:546– psychological research. J Pers 62:641–
554, 1984 667, 1994
Torgersen S: The nature (and nurture) of Westen D: A clinical-empirical model of per-
personality disorders. Scand J Psychol sonality: life after the Mischelian ice age
50:624–632, 2009 and the NEO-lithic era. J Pers 63:495–
Torgersen S, Lygren S, Oien PA, et al: A twin 524, 1995
study of personality disorders. Compr Westen D: A model and a method for un-
Psychiatry 41:416–425, 2000 covering the nomothetic from the idio-
Torgersen S, Czajkowski N, Jacobson K, et al: graphic: an alternative to the five-factor
Dimensional representations of DSM-IV model? J Res Pers 30:400–413, 1996
cluster B personality disorders in a pop- Westen D: Case formulation and personality
ulation-based sample of Norwegian diagnosis: two processes or one? In
twins: a multivariate study. Psychol Med Making Diagnosis Meaningful: Enhanc-
38:1617–1625, 2008 ing Evaluation and Treatment of Psy-
Trull T, Widiger T, Burr R: A structured chological Disorders. Edited by Barron
interview for the assessment of the five- JW. Washington, DC, American Psycho-
factor model of personality: facet-level re- logical Association, 1998, pp 111–138
lations to the Axis II personality disorders. Westen D, Muderrisoglu S: Assessing per-
J Pers 69:175–198, 2001 sonality disorders using a systematic
Turkheimer E, Waldron M: Nonshared envi- clinical interview: evaluation of an al-
ronment: a theoretical, methodological, ternative to structured interviews. J Pers
and quantitative review. Psychol Bull Disord 17(4):351–369, 2003
126:78–108, 2000 Westen D, Shedler J: Revising and assess-
Turkheimer E, Haley A, Waldron M, et al: ing Axis II, part 1: developing a clini-
Socioeconomic status modifies heritabil- cally and empirically valid assessment
ity of IQ in young children. Psychol Sci method. Am J Psychiatry 156:258–272,
14:623–628, 2003 1999a
38 The American Psychiatric Publishing Textbook of Personality Disorders
Westen D, Shedler J: Revising and assessing Wolf E: Treating the Self: Elements of Clinical
Axis II, part 2: toward an empirically Self Psychology. New York, Guilford,
based and clinically useful classification 1988
of personality disorders. Am J Psychia- Young J: Cognitive Therapy for Personality
try 156:273–285, 1999b Disorders: A Schema-Focused Approach.
Widiger T: Personality disorders in the 21st Sarasota, FL, Professional Resource Ex-
century. J Pers Disord 14:3–16, 2000 change, 1990
Widiger T, Costa P: Personality and personal- Young J, Gluhoski V: Schema-focused diagno-
ity disorders. J Abnorm Psychol 103:78– sis for personality disorders, in Handbook
91, 1994 of Relational Diagnosis and Dysfunctional
Widiger T, Frances A: Towards a dimensional Family Patterns. Edited by Kaslow F. Ox-
model for the personality disorders, in ford, UK, Wiley, 1996, pp 300–321
Personality Disorders and the Five-Factor Young J, Kellogg S: Schema therapy for bor-
Model of Personality. Edited by Costa P, derline personality disorder. J Clin Psy-
Widiger T. Washington, DC, American chol 62:445–458, 2006
Psychological Association, 1994, pp 19–39 Young J, Lindemann M: An integrative
Widiger T, Trull T, Clarkin J, et al: A descrip- schema-focused model for personality
tion of the DSM-IV personality disor- disorders, in Clinical Advances in Cog-
ders with the five-factor model of per- nitive Psychotherapy: Theory and Ap-
sonality, in Personality Disorders and plication. Edited by Leahy R, Dowd T.
the Five-Factor Model of Personality, 2nd New York, Springer, 2002, pp 93–109
Edition. Edited by Costa P, Widiger T. Young J, Klosko J, Weishaar M: Schema ther-
Washington, DC, American Psychologi- apy for borderline personality disorder,
cal Association, 2002, pp 89–99 in Schema Therapy: A Practitioner ’s
Guide. New York, Guilford, 2003
CHAPTER 3
Articulating a Core
Dimension of Personality
Pathology
Leslie C. Morey, Ph.D.
Donna S. Bender, Ph.D., FIPA
39
40 The American Psychiatric Publishing Textbook of Personality Disorders
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 pa- tion” 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
42 The American Psychiatric Publishing Textbook of Personality Disorders
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-
Articulating a Core Dimension of Personality Pathology 43
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
44 The American Psychiatric Publishing Textbook of Personality Disorders
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
46 The American Psychiatric Publishing Textbook of Personality Disorders
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
Articulating a Core Dimension of Personality Pathology 47
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-
48 The American Psychiatric Publishing Textbook of Personality Disorders
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
Articulating a Core Dimension of Personality Pathology 49
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
50 The American Psychiatric Publishing Textbook of Personality Disorders
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
Articulating a Core Dimension of Personality Pathology 51
Strachey J. London, Hogarth Press, 1953, by Clarkin JF, Lenzenweger MF. New
pp 135–243 York, Guilford, 2005, pp 114–156
Freud S: On narcissism: an introduction (1914), Kohlberg L: The development of children’s
in The Standard Edition of the Complete orientations towards a moral order, I:
Psychological Works of Sigmund Freud, sequence in the development of moral
Vol 14. Translated by Strachey J. London, thought. Vita Hum Int Z Lebensalter-
Hogarth Press, 1957, pp 73–102 forsch 6:11–33, 1963
Galton F: Good and bad temper in English Kohut H: The Analysis of the Self: A System-
families. Fortnightly Review 42:21–30, atic Approach to the Psychoanalytic
1887 Treatment of Narcissistic Personality
Grant BF, Stinson FS, Dawson DA, et al: Co- Disorders. New York, International Uni-
occurrence of DSM-IV personality disor- versities Press, 1971
ders in the United States: results from Kraepelin E: Clinical Psychiatry: A Textbook
the National Epidemiologic Survey on for Students and Physicians, 6th Edition.
Alcohol and Related Conditions. Compr Translated by Diefendorf AR. London,
Psychiatry 46:1–5, 2005 Macmillan, 1902
Gunderson JG: Introduction to section IV: Kupfer DJ, First MB, Regier DA: A Research
personality disorders, in DSM-IV Source- Agenda for DSM-V. Washington, DC,
book, Vol 2. Edited by Widiger TA, Fran- American Psychiatric Association, 2002
ces AJ, Pincus HA, et al. Washington, Livesley WJ: Diagnostic dilemmas in classi-
DC, American Psychiatric Association, fying personality disorder, in Advanc-
1996, pp 647–664 ing DSM: Dilemmas in Psychiatric Diag-
Gunderson J, Shea T, Skodol A, et al: The Col- nosis. Edited by Phillips KA, First MB,
laborative Longitudinal Personality Dis- Pincus HA. Washington, DC, American
orders Study: development, aims, de- Psychiatric Publishing, 2003, pp 153–189
sign, and sample characteristics. J Pers Livesley WJ, Jang KJ: Toward an empirically
Disord 14:300–315, 2000 based classification of personality disor-
Hathaway SR, McKinley JC: Manual for the der. J Pers Disord 14:137–151, 2000
Minnesota Multiphasic Personality In- Loevinger J: Ego Development. San Fran-
ventory. New York, Psychological Cor- cisco, CA, Jossey-Bass, 1976
poration, 1943 Lord FM: Applications of Item Response
Hentschel AG, Livesley WJ: The General Theory to Practical Testing Problems.
Assessment of Personality Disorder Hillsdale, NJ, Erlbaum, 1980
(GAPD): factor structure, incremental Meehl PE: An investigation of a general nor-
validity of self-pathology, and relations mality or control factor in personality
to DSM-IV personality disorders. J Pers testing. Psychol Monogr 59:i–62, 1945
Assess 95:479–485, 2013 Menninger K: The Vital Balance. New York,
Hopwood CJ, Malone JC, Ansell EB, et al: Viking Press, 1963
Personality assessment in DSM-V: em- Morey LC: Personality disorders under
pirical support for rating severity, style, DSM-III and DSM-III-R: an examination
and traits. J Pers Disord 25:305–320, 2011 of convergence, coverage, and internal
Hyler SE, Rieder RO, Williams JB, et al: A consistency. Am J Psychiatry 145:573–
comparison of clinical and self-report di- 577, 1988
agnoses of DSM-III personality disor- Morey LC: Personality pathology as patho-
ders in 552 patients. Compr Psychiatry logical narcissism, in World Psychiatric
30:170–178, 1989 Association Series: Evidence and Expe-
Kernberg OF: Borderline personality organi- rience in Psychiatry. Edited by Maj M,
zation. J Am Psychoanal Assoc 15:641– Akiskal HS, Mezzich JE, et al. New York,
685, 1967 Wiley, 2005, pp 328–331
Kernberg OF: Severe Personality Disorders: Morey LC, Levine DJ: A multitrait multi-
Psychotherapeutic Strategies. New Ha- method examination of Minnesota Mul-
ven, CT, Yale University Press, 1984 tiphasic Personality Inventory (MMPI)
Kernberg OF, Caligor E: A psychoanalytic and Millon Clinical Multiaxial Inven-
theory of personality disorders, in Major tory (MCMI). J Psychopathol Behav As-
Theories of Personality Disorder. Edited sess 10:333–344, 1988
Articulating a Core Dimension of Personality Pathology 53
Morey LC, Skodol AE: Convergence between Rushton JP, Irwing P: A general factor of per-
DSM-IV-TR and DSM-5 diagnostic mod- sonality (GFP) from two meta-analyses
els for personality disorder: evaluation of the Big Five: Digman (1997) and Mount,
of strategies for establishing diagnostic Barrick, Scullen, and Rounds (2005).
thresholds. J Psychiatr Pract 19:179–193, Pers Individ Dif 45:679–683, 2008
2013 Rushton JP, Irwing P: The general factor of
Morey LC, Gunderson JG, Quigley BA, et al: personality, in The Wiley-Blackwell Hand-
Dimensions and categories: the “Big book of Individual Differences. Edited
Five” factors and the DSM personality by Chamorro-Premuzic T, von Stumm S,
disorders. Assessment 7:203–216, 2000 Furnham A. Oxford, UK, Wiley-Black-
Morey LC, Gunderson JG, Quigley BD, et al: well, 2011, pp 132–161
The representation of borderline, avoid- Saulsman LM, Page AC: The five-factor
ant, obsessive-compulsive and schizo- model and personality disorder empiri-
typal personality disorders by the five-fac- cal literature: a meta-analytic review.
tor model. J Pers Disord 16:215–234, 2002 Clin Psychol Rev 23:1055–1085, 2004
Morey LC, Berghuis H, Bender DS, et al: To- Skodol AE, Gunderson JG, Shea MT, et al:
ward a model for assessing level of per- The Collaborative Longitudinal Person-
sonality functioning in DSM-5, part II: ality Disorders Study (CLPS): overview
empirical articulation of a core dimen- and implications. J Pers Disord 19:487–
sion of personality pathology. J Pers As- 504, 2005
sess 93:347–353, 2011 Stern BL, Caligor E, Clarkin JF, et al: Struc-
Morey LC, Bender DS, Skodol AE: Validating tured Interview of Personality Organi-
the proposed DSM-5 severity indicator zation (STIPO): preliminary psychomet-
for personality disorder. J Nerv Ment rics in a clinical sample. J Pers Assess
Dis 201:729–735, 2013 92:35–44, 2010
Norman WT: Toward an adequate taxonomy Tellegen A, Ben-Porath YS, McNulty JL, et al:
of personality attributes: replicated MMPI-2 Restructured Clinical (RC)
factor structure in peer nomination per- Scales: Development, Validation, and In-
sonality ratings. J Abnorm Soc Psychol terpretation. Minneapolis, University of
66:574–583, 1963 Minnesota Press, 2003
Oldham JM, Skodol AE, Kellman HD, et al: Van der Linden D, te Nijenhuis J, Bakker AB:
Diagnosis of DSM-III-R personality dis- The general factor of personality: a meta-
orders by two structured interviews: analysis of Big Five intercorrelations and
patterns of comorbidity. Am J Psychia- a criterion-related validity study. J Res
try 149:213–220, 1992 Pers 44:315–327, 2010
Piaget J: The Moral Judgment of the Child. Verheul R, Andrea H, Berghout C, et al: Se-
New York, Free Press, 1932 verity Indices of Personality Problems
Pilkonis PA, Heape CL, Proietti JM, et al: The (SIPP–118): development, factor struc-
reliability and validity of two structured ture, reliability, and validity. Psychol As-
diagnostic interviews for personality sess 20:23–34, 2008
disorders. Arch Gen Psychiatry 52:1025– Westen D, Lohr N, Silk K, et al: Object rela-
1033, 1995 tions and social cognition in borderlines,
Pincus HA, Frances A, Davis WW, et al: DSM- major depressives, and normals: a the-
IV and new diagnostic categories: hold- matic apperception test analysis. Psy-
ing the line on proliferation. Am J Psy- chol Assess 2:355–364, 1990
chiatry 149:112–117, 1992 Widiger TA, Morey LC, Freiman KE: DSMIIIR
Prichard JC: A treatise on insanity and other and DSMIV decision rules for the person-
disorders affecting the mind. London, ality disorders. Paper presented at the
Sherwood, Gilbert, & Piper, 1835 meeting of the American Psychological
Rounsaville BJ, Alarcon RD, Andrews G, et Association, New Orleans, LA, August
al: Basic nomenclature issues for DSM-V, 1989
in A Research Agenda for DSM-V. Ed- Widiger TA, Frances AJ, Pincus HA, et al: To-
ited by Kupfer DJ, First MB, Regier DA. ward an empirical classification for the
Washington, DC, American Psychiatric DSM-IV. J Abnorm Psychol 100:280–288,
Association, 2002, pp 1–29 1991
54 The American Psychiatric Publishing Textbook of Personality Disorders
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.
55
56 The American Psychiatric Publishing Textbook of Personality Disorders
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
58 The American Psychiatric Publishing Textbook of Personality Disorders
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
Development, Attachment, and Childhood Experiences 59
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
Development, Attachment, and Childhood Experiences 61
(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,
62 The American Psychiatric Publishing Textbook of Personality Disorders
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 men- talization 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
Development, Attachment, and Childhood Experiences 63
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
64 The American Psychiatric Publishing Textbook of Personality Disorders
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
Development, Attachment, and Childhood Experiences 65
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
Development, Attachment, and Childhood Experiences 67
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
68 The American Psychiatric Publishing Textbook of Personality Disorders
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 attach- ment 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
Development, Attachment, and Childhood Experiences 69
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 appar- ent-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
70 The American Psychiatric Publishing Textbook of Personality Disorders
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-
Development, Attachment, and Childhood Experiences 71
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 treat- ment-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-
Development, Attachment, and Childhood Experiences 73
Bartz JA, Hollander E: The neuroscience of Brussoni MJ, Jang KL, Livesley WJ, Macbeth
affiliation: forging links between basic TM: Genetic and environmental influ-
and clinical research on neuropeptides ences on adult attachment styles. Pers
and social behavior. Horm Behav 50:518– Relatsh 7:283–289, 2000
528, 2006 Carlson EA, Egeland B, Sroufe LA: A pro-
Bateman A, Fonagy P: Psychotherapy for spective investigation of the develop-
Borderline Personality Disorder: Men- ment of borderline personality symp-
talization-Based Treatment. New York, toms. Dev Psychopathol 21:1311–1334,
Oxford University Press, 2004 2009
Bateman A, Fonagy P: Mentalization-Based Cartwright-Hatton S, McNally D, Field AP, et
Treatment for Borderline Personality al: A new parenting-based group inter-
Disorder: A Practical Guide. New York, vention for young anxious children:
Oxford University Press, 2006 results of a randomized controlled trial.
Bateman A, Fonagy P: Mentalization based J Am Acad Child Adolesc Psychiatry
treatment for borderline personality dis- 50:242–251, 2011
order. World Psychiatry 9:11–15, 2010 Cassidy J, Shaver PR (eds): Handbook of At-
Bateman A, Fonagy P (eds): Handbook of tachment: Theory, Research, and Clini-
Mentalizing in Mental Health Practice. cal Applications. New York, Guilford,
Washington, DC, American Psychiatric 2008
Publishing, 2012 Cicchetti D, Rogosch FA, Toth SL: The effi-
Battle CL, Shea MT, Johnson DM, et al: Child- cacy of toddler-parent psychotherapy
hood maltreatment associated with adult for fostering cognitive development in
personality disorders: findings from the offspring of depressed mothers. J Ab-
Collaborative Longitudinal Personality norm Child Psychol 28:135–148, 2000
Disorders Study. J Pers Disord 18:193– Conradi HJ, De Jonge P, Neeleman A, et al:
211, 2004 Partner attachment as a predictor of long-
Belsky J, Jaffee SR: The multiple determi- term response to treatment with couples
nants of parenting, in Developmental therapy. J Sex Marital Ther 37:286–297,
Psychopathology; Vol 3: Risk, Disorder, 2011
and Adaptation. Edited by Cicchetti D, Csibra G, Gergely G: Social learning and so-
Cohen DJ. New York, Wiley, 2006, pp 38– cial cognition: the case for pedagogy, in
85 Processes of Change in Brain and Cogni-
Bender DS, Dolan RT, Skodol AE, et al: Treat- tive Development. Attention and Per-
ment utilization by patients with person- formance XXI. Edited by Johnson MH,
ality disorders. Am J Psychiatry 158:295– Munakata Y. New York, Oxford Univer-
302, 2001 sity Press, 2006, pp 249–274
Birch SA, Bloom P: Children are cursed: an Davila J, Levy KN: Introduction to the spe-
asymmetric bias in mental state attribu- cial section on attachment theory and
tions. Psychol Sci 14:283–286, 2003 psychotherapy. J Consult Clin Psychol
Bowlby J: Attachment and Loss, Vol 1: At- 74:989–993, 2006
tachment. London, Hogarth Press and De Dreu CK, Greer LL, Handgraaf MJ, et al:
Institute of Psycho-Analysis, 1969 The neuropeptide oxytocin regulates pa-
Bowlby J. Attachment and Loss., Vol. 3: Loss, rochial altruism in intergroup conflict
Sadness and Depression. London, Hog- among humans. Science 328:1408–1411,
arth Press/Institute of Psychoanalysis, 2010
1980 de Rosnay M, Harris PL: Individual differ-
Bowlby J: A Secure Base: Clinical Applications ences in children’s understanding of
of Attachment Theory. London, Rout- emotion: the roles of attachment and
ledge, 1988 language. Attach Hum Dev 4:39–54,
Bradley R, Jenei J, Westen D: Etiology of bor- 2002
derline personality disorder: disentan- Fearon RM, Van Ijzendoorn MH, Fonagy P, et
gling the contributions of intercorrelated al: In search of shared and nonshared
antecedents. J Nerv Ment Dis 193:24–31, environmental factors in security of at-
2005 tachment: a behavior-genetic study of
Development, Attachment, and Childhood Experiences 75
ties, and risk for suicide attempts during Main M: The organized categories of infant,
late adolescence and early adulthood. child, and adult attachment: flexible vs
Arch Gen Psychiatry 59:741–749, 2002 inflexible attention under attachment-
Johnson JG, Cohen P, Kasen S, et al: Associa- related stress. J Am Psychoanal Assoc
tions of parental personality disorders 48:1055–1096, 2000
and Axis I disorders with childrearing Mascaro O, Sperber D: The moral, epistemic,
behavior. Psychiatry 69:336–350, 2006 and mindreading components of chil-
Kestenbaum R, Farber E, Sroufe LA: Individ- dren's vigilance towards deception. Cog-
ual differences in empathy among pre- nition 112:367–380, 2009
schoolers' concurrent and predictive va- McGauley G, Yakeley J, Williams A, et al: At-
lidity, in Empathy and Related Emotional tachment, mentalization and antisocial
Responses (New Directions for Child De- personality disorder: the possible contri-
velopment No 44). San Francisco, CA, bution of mentalization-based treatment.
Jossey-Bass, 1989, pp 51–56 European Journal of Psychotherapy and
Kirchmann H, Steyer R, Mayer A, et al: Ef- Counselling 13:371–393, 2011
fects of adult inpatient group psycho- Meins E, Fernyhough C, Fradley E, et al: Re-
therapy on attachment characteristics: thinking maternal sensitivity: mothers’
an observational study comparing rou- comments on infants’ mental processes
tine care to an untreated comparison predict security of attachment at 12
group. Psychother Res 22:95–114, 2012 months. J Child Psychol Psychiatry
Kochanska G, Kim S: Early attachment orga- 42:637–648, 2001
nization with both parents and future Meins E, Fernyhough C, Wainwright R, et al:
behavior problems: from infancy to mid- Maternal mind-mindedness and attach-
dle childhood. Child Dev 84:283–296, ment security as predictors of theory of
2013 mind understanding. Child Dev 73:1715–
Kovacs AM, Teglas E, Endress AD: The social 1726, 2002
sense: susceptibility to others' beliefs Meins E, Fernyhough C, Wainwright R, et al:
in human infants and adults. Science Pathways to understanding mind: con-
330:1830–1834, 2010 struct validity and predictive validity of
Levy KN, Meehan KB, Kelly KM, et al: Change maternal mind-mindedness. Child Dev
in attachment patterns and reflective 74:1194–1211, 2003
function in a randomized control trial of Mikolajczak M, Gross JJ, Lane A, et al: Oxyto-
transference-focused psychotherapy for cin makes people trusting, not gullible.
borderline personality disorder. J Consult Psychol Sci 21:1072–1074, 2010
Clin Psychol 74:1027–1040, 2006 Nolte T, Guiney J, Fonagy P, et al: Interper-
Levy KN, Ellison WD, Scott LN, et al: Attach- sonal stress regulation and the develop-
ment style. J Clin Psychol 67:193–203, ment of anxiety disorders: an attach-
2011 ment-based developmental framework.
Levy KN, Meehan KB, Yeomans FE: An up- Front Behav Neurosci 5:55, 2011
date and overview of the empirical evi- Oppenheim D, Koren-Karie N: Mothers’ in-
dence for transference-focused psycho- sightfulness regarding their children’s
therapy and other psychotherapies for internal worlds: the capacity underlying
borderline personality disorder, in Psy- secure child-mother relationships. In-
chodynamic Psychotherapy Research fant Ment Health J 23:593–605, 2002
(Current Clinical Psychiatry). Edited by Pears KC, Fisher PA: Emotion understanding
Levy RA, Ablon JS, Kachele H. New and theory of mind among maltreated
York, Springer, 2012, pp 139–167 children in foster care. Dev Psycho-
Lyons-Ruth K, Yellin C, Melnick S, et al: Ex- pathol 17:47–65, 2005
panding the concept of unresolved men- Piaget J: The Child’s Conception of the
tal states: hostile/helpless states of mind World. London, Routledge/Kegan Paul,
on the Adult Attachment Interview are 1951
associated with disrupted mother-infant Rogosch FA, Cicchetti D, Aber JL: The role of
communication and infant disorganiza- child maltreatment in early deviations in
tion. Dev Psychopathol 17:1–23, 2005 cognitive and affective processing abili-
Development, Attachment, and Childhood Experiences 77
ties and later peer relationship prob- Sroufe LA, Egeland B, Carlson EA, et al: The
lems. Dev Psychopathol 7:591–609, 1995 Development of the Person: The Minne-
Sandberg DA, Suess EA, Heaton JL: Attach- sota Study of Risk and Adaptation From
ment anxiety as a mediator of the rela- Birth to Adulthood. New York, Guilford,
tionship between interpersonal trauma 2005
and posttraumatic symptomatology Strauss BM, Mestel R, Kirchmann HA: Changes
among college women. J Interpers Vio- of attachment status among women
lence 25:33–49, 2010 with personality disorders undergoing
Sharp C, Fonagy P, Goodyer IM: Imagining inpatient treatment. Counselling and
your child’s mind: psychosocial adjust- Psychotherapy Research 11:275–283,
ment and mothers’ ability to predict 2011
their children’s attributional response Torgersen AM, Grova BK, Sommerstad R: A
styles. Br J Dev Psychol 24:197–214, 2006 pilot study of attachment patterns in
Simeon D, Bartz J, Hamilton H, et al: Oxytocin adult twins. Attach Hum Dev 9:127–138,
administration attenuates stress reactiv- 2007
ity in borderline personality disorder: a Vrticka P, Andersson F, Grandjean D, et al: In-
pilot study. Psychoneuroendocrinology dividual attachment style modulates
36:1418–1421, 2011 human amygdala and striatum activa-
Slade A, Grienenberger J, Bernbach E, et al: tion during social appraisal. PLoS One
Maternal reflective functioning, attach- 3:e2868, 2008
ment, and the transmission gap: a pre- Waldinger RJ, Schulz MS, Barsky AJ, et al:
liminary study. Attach Hum Dev 7:283– Mapping the road from childhood trauma
298, 2005 to adult somatization: the role of attach-
Spinhoven P, Giesen-Bloo J, van Dyck R, et al: ment. Psychosom Med 68:129–135, 2006
The therapeutic alliance in schema-focused Waters E, Wippman J, Sroufe LA: Attach-
therapy and transference-focused ment, positive affect, and competence in
psychotherapy for borderline personal- the peer group: two studies in construct
ity disorder. J Consult Clin Psychol validation. Child Dev 40:821–829, 1979
75:104–115, 2007 Westen D, Nakash O, Thomas C, et al: Clini-
Sroufe LA: Infant-caregiver attachment and cal assessment of attachment patterns
patterns of adaptation in preschool: the and personality disorder in adoles-
roots of maladaptation and competence, cents and adults. J Consult Clin Psychol
in Minnesota Symposium in Child Psy- 74:1065–1085, 2006
chology, Vol 16. Edited by Perlmutter M. Widiger TA, Huprich S, Clarkin J: Proposals
Hillsdale, NJ, Erlbaum, 1983, pp 41–83 for DSM-5: introduction to special sec-
Sroufe LA, Egeland B, Kreutzer T: The fate of tion of Journal of Personality Disorders.
early experience following developmen- J Pers Disord 25:135, 2011
tal change: longitudinal approaches to
individual adaptation in childhood.
Child Dev 61:1363–1373, 1990
This page intentionally left blank
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
80 The American Psychiatric Publishing Textbook of Personality Disorders
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
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 and Neurobiology 83
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
Genetics and Neurobiology 85
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
88 The American Psychiatric Publishing Textbook of Personality Disorders
(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-
Genetics and Neurobiology 89
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
90 The American Psychiatric Publishing Textbook of Personality Disorders
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-
Genetics and Neurobiology 95
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.
96 The American Psychiatric Publishing Textbook of Personality Disorders
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
Genetics and Neurobiology 99
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
100 The American Psychiatric Publishing Textbook of Personality Disorders
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-
Genetics and Neurobiology 101
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
102 The American Psychiatric Publishing Textbook of Personality Disorders
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 re- plied 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
Genetics and Neurobiology 103
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
References parolees, II: laboratory and psychomet-
ric measurements of impulsivity. Biol
Abbott GR, Green MJ: Facial affect recogni- Psychiatry 41:523–529, 1997
tion and schizotypal personality charac- Clifton A, Pilkonis PA: Evidence for a single
teristics. Early Interv Psychiatry 7:58–63, latent class of Diagnostic and Statistical
2013 Manual of Mental Disorders borderline
Abi-Dargham A, Mawlawi O, Lombardo I, et personality pathology. Compr Psychia-
al: Prefrontal dopamine D1 receptors try 48:70–78, 2007
and working memory in schizophrenia. Coccaro EF, McCloskey MS, Fitzgerald DA,
J Neurosci 22:3708–3719, 2002 et al: Amygdala and orbitofrontal reac-
Abi-Dargham A, Kegeles LS, Zea-Ponce Y, et tivity to social threat in individuals with
al: Striatal amphetamine-induced dopa- impulsive aggression. Biol Psychiatry
mine release in patients with schizotypal 62:168–178, 2007
personality disorder studied with single Coccaro EF, Sripada CS, Yanowitch RN, et al:
photon emission computed tomography Corticolimbic function in impulsive
and [123I]iodobenzamide. Biol Psychia- aggressive behavior. Biol Psychiatry
try 55:1001–1006, 2004 69:1153–1159, 2011
American Psychiatric Association: Diag- Crowell TA, Kieffer KM, Kugeares S, et al:
nostic and Statistical Manual of Mental Executive and nonexecutive neuropsy-
Disorders, 3rd Edition. Washington, DC, chological functioning in antisocial per-
American Psychiatric Association, 1980 sonality disorder. Cogn Behav Neurol
American Psychiatric Association: Diag- 16:100–109, 2003
nostic and Statistical Manual of Mental Davis MH: A multidimensional approach to
Disorders, 4th Edition. Washington, DC, individual differences in empathy. JSAS
American Psychiatric Association, 1994 Catalog of Selected Documents in Psy-
American Psychiatric Association: Diag- chology 10:85, 1980
nostic and Statistical Manual of Mental Delaveau P, Salgado-Pineda P, Wicker B, et al:
Disorders, 5th Edition. Arlington, VA, Effect of levodopa on healthy volunteers’
American Psychiatric Association, 2013 facial emotion perception: an FMRI
Barch DM, Carter CS: Amphetamine im- study. Clin Neuropharmacol 28:255–261,
proves cognitive function in medicated 2005
individuals with schizophrenia and in Distel MA, Willemsen G, Ligthart L, et al: Ge-
healthy volunteers. Schizophr Res 77:43– netic covariance structure of the four
58, 2005 main features of borderline personality
Blair RJ: Dysfunctions of medial and lateral disorder. J Pers Disord 24:427–444, 2010
orbitofrontal cortex in psychopathy. Dolan M: What imaging tells us about vio-
Ann N Y Acad Sci 1121:461–479, 2007 lence in anti-social men. Crim Behav
Blair RJ: Neuroimaging of psychopathy and Ment Health 20:199–214, 2010
antisocial behavior: a targeted review. Dolan M: The neuropsychology of prefrontal
Curr Psychiatry Rep 12:76–82, 2010 function in antisocial personality disor-
Boccardi M, Ganzola R, Rossi R, et al: Abnor- dered offenders with varying degrees of
mal hippocampal shape in offenders psychopathy. Psychol Med 42:1715–
with psychopathy. Hum Brain Mapp 1725, 2012
31:438–447, 2010
104 The American Psychiatric Publishing Textbook of Personality Disorders
Dolan M, Park I: The neuropsychology of Hazlett EA, New AS, Newmark R, et al: Re-
antisocial personality disorder. Psychol duced anterior and posterior cingulate
Med 32:417–427, 2002 gray matter in borderline personality dis-
Domes G, Schulze L, Herpertz S: Emotion order. Biol Psychiatry 58:614–623, 2005
recognition in borderline personality Hazlett EA, Goldstein KE, Kolaitis JC: A re-
disorder—a review of the literature. J Pers view of structural MRI and diffusion ten-
Disord 23:6–19, 2009 sor imaging in schizotypal personality
Driessen M, Herrmann J, Stahl K, et al: Mag- disorder. Curr Psychiatry Rep 14:70–78,
netic resonance imaging volumes of the 2012a
hippocampus and the amygdala in Hazlett EA, Zhang J, New AS, et al: Potenti-
women with borderline personality dis- ated amygdala response to repeated
order and early traumatization. Arch emotional pictures in borderline person-
Gen Psychiatry 57:1115–1122, 2000 ality disorder. Biol Psychiatry 72:448–
Dziobek I, Preissler S, Grozdanovic Z, et al: 456, 2012b
Neuronal correlates of altered empathy Herpertz SC, Schwenger UB, Kunert HJ, et al:
and social cognition in borderline per- Emotional responses in patients with
sonality disorder. Neuroimage 57:539– borderline as compared with avoidant
548, 2011 personality disorder. J Pers Disord
Frankle WG, Lombardo I, New AS, et al: 14(4):339–351, 2000
Brain serotonin transporter distribution Herpertz SC, Dietrich TM, Wenning B, et al:
in subjects with impulsive aggressivity: Evidence of abnormal amygdala func-
a positron emission study with [11C]McN tioning in borderline personality disor-
5652. Am J Psychiatry 162:915–923, 2005 der: a functional MRI study. Biol Psychi-
Grant BF, Hasin DS, Stinson FS, et al: Preva- atry 50:292–298, 2001
lence, correlates, and disability of per- Hummelen B, Pedersen G, Karterud S: Some
sonality disorders in the United States: suggestions for the DSM-5 schizotypal
results from the national epidemiologic personality disorder construct. Compr
survey on alcohol and related condi- Psychiatry 53:341–349, 2012
tions. J Clin Psychiatry 65:948–958, 2004 Ichikawa J, Ishii H, Bonaccorso S, et al: 5-
Grant JE, Correia S, Brennan-Krohn T, et al: HT(2A) and D(2) receptor blockade in-
Frontal white matter integrity in border- creases cortical DA release via 5-HT(1A)
line personality disorder with self-inju- receptor activation: a possible mecha-
rious behavior. J Neuropsychiatry Clin nism of atypical antipsychotic-induced
Neurosci 19:383–390, 2007 cortical dopamine release. J Neurochem
Gregory S, ffytche D, Simmons A, et al: The 76:1521–1531, 2001
antisocial brain: psychopathy matters. Kendler KS, Aggen SH, Patrick CJ: A multi-
Arch Gen Psychiatry 69:962–972, 2012 variate twin study of the DSM-IV crite-
Gunderson JG, Lyons-Ruth K: BPD’s inter- ria for antisocial personality disorder.
personal hypersensitivity phenotype: Biol Psychiatry 71:247–253, 2012
a gene-environment-developmental King-Casas B, Sharp C, Lomax-Bream L, et
model. J Pers Disord 22:22–41, 2008 al: The rupture and repair of cooperation
Gunter TD, Vaughn MG, Philibert RA: Be- in borderline personality disorder. Sci-
havioral genetics in antisocial spectrum ence 321:806–810, 2008
disorders and psychopathy: a review of Kluetsch RC, Schmahl C, Niedtfeld I, et al:
the recent literature. Behav Sci Law Alterations in default mode network
28:148–173, 2010 connectivity during pain processing in
Hallquist MN, Pilkonis PA: Refining the phe- borderline personality disorder. Arch
notype of borderline personality disor- Gen Psychiatry 69:993–1002, 2012
der: diagnostic criteria and beyond. Per- Koenigsberg HW, Harvey PD, Mitropoulou
sonal Disord 3:228–246, 2012 V, et al: Characterizing affective instabil-
Hare RD, Clark D, Grann M, et al: Psychopa- ity in borderline personality disorder.
thy and the predictive validity of the Am J Psychiatry 159:784–788, 2002
PCL-R: an international perspective. Be- Koenigsberg HW, Reynolds D, Goodman M,
hav Sci Law 18:623–645, 2000 et al: Risperidone in the treatment of
Genetics and Neurobiology 105
understanding of self-injury. Biol Psy- Ripoll LH, Snyder R, Steele H, et al: The neu-
chiatry 68:383–391, 2010 robiology of empathy in borderline per-
Nordstrom BR, Gao Y, Glenn AL, et al: Neu- sonality disorder. Curr Psychiatry Rep
rocriminology, in Advances in Genetics. 15:344, 2013
Edited by Huber R, Bannasch DL, Bren- Rosell DR, Mennes M, Chu KW, et al: Distinct
nan P. New York, Academic Press, 2011, patterns of altered functional connec-
pp 255–283 tivity in borderline and schizotypal
Nunes PM, Wenzel A, Borges KT, et al: Vol- personality disorders. December 2013
umes of the hippocampus and amyg- (manuscript in preparation)
dala in patients with borderline person- Rosell DR, Zaluda LC, McClure MM, et al:
ality disorder: a meta-analysis. J Pers Effects of the D1 dopamine receptor ag-
Disord 23:333–345, 2009 onist dihydrexidine (DAR-0100A) on
Ostrov JM, Houston RJ: The utility of forms working memory in schizotypal person-
and functions of aggression in emerging ality disorder. December 2013 (manu-
adulthood: association with personality script in preparation)
disorder symptomatology. J Youth Ado- Rosenthal MZ, Kim K, Herr NR, et al: Speed
lesc 37:1147–1158, 2008 and accuracy of facial expression classi-
Perez-Rodriguez MM, Weinstein S, New AS, fication in avoidant personality disor-
et al: Tryptophan-hydroxylase 2 haplo- der: a preliminary study. Personal Dis-
type association with borderline per- ord 2:327–334, 2011
sonality disorder and aggression in a Roussos P, Siever LJ: Neurobiological contri-
sample of patients with personality dis- butions, in Oxford Handbook of Person-
orders and healthy controls. J Psychiatr ality Disorders. Edited by Widiger T.
Res 44:1075–1081, 2010 New York, Oxford University Press, 2012,
Pham TH, Philippot P: Decoding of facial ex- pp 299–324
pression of emotion in criminal psycho- Roxo MR, Franceschini PR, Zubaran C, et al:
paths. J Pers Disord 24:445–459, 2010 The limbic system conception and its
Pietrini P, Guazzelli M, Basso G, et al: Neural historical evolution. Scientific World J
correlates of imaginal aggressive behav- 11:2428–2441, 2011
ior assessed by positron emission to- Rüsch N, Weber M, Il’yasov KA, et al: Infe-
mography in healthy subjects. Am J Psy- rior frontal white matter microstructure
chiatry 157:1772–1781, 2000 and patterns of psychopathology in
Raine A, Lencz T: Reduced prefrontal gray women with borderline personality
matter volume and reduced autonomic disorder and comorbid attention-deficit
activity in antisocial personality disorder. hyperactivity disorder. Neuroimage
Arch Gen Psychiatry 57:119–127, 2000 35:738–747, 2007
Raine A, Lencz T: Corpus callosum abnor- Satpute AB, Lieberman MD: Integrating au-
malities in psychopathic antisocial indi- tomatic and controlled processes into
viduals. Arch Gen Psychiatry 60:1134– neurocognitive models of social cogni-
1142, 2003 tion. Brain Res 1079:86–97, 2006
Raine A, Lee L, Yang Y, et al: Neurodevelop- Schmahl CG, Vermetten E, Elzinga BM, et al:
mental marker for limbic maldevelop- Magnetic resonance imaging of hippo-
ment in antisocial personality disorder campal and amygdala volume in women
and psychopathy. Br J Psychiatry 197:186– with childhood abuse and borderline
192, 2010 personality disorder. Psychiatry Res
Reitz S, Krause-Utz A, Pogatzki-Zahn EM, et 122:193–198, 2003
al: Stress regulation and incision in bor- Schmahl C, Bohus M, Esposito F, et al: Neural
derline personality disorder: a pilot correlates of antinociception in border-
study modeling cutting behavior. J Pers line personality disorder. Arch Gen Psy-
Disord 26:605–615, 2012 chiatry 63:659–667, 2006
Ripoll LH, Triebwasser J, Siever LJ: Evi- Schulze L, Domes G, Krüger A, et al: Neuro-
dence-based pharmacotherapy for per- nal correlates of cognitive reappraisal in
sonality disorders. Int J Neuropsycho- borderline patients with affective insta-
pharmacol 14:1257–1288, 2011 bility. Biol Psychiatry 69:564–573, 2011
Genetics and Neurobiology 107
Shihabuddin L, Buchsbaum MS, Hazlett EA, Soloff PH, Nutche J, Goradia D, et al: Struc-
et al: Striatal size and relative glucose tural brain abnormalities in borderline
metabolic rate in schizotypal personality personality disorder: a voxel-based mor-
disorder and schizophrenia. Arch Gen phometry study. Psychiatry Res 164:223–
Psychiatry 58:877–884, 2001 236, 2008
Siegel BV Jr, Trestman RL, O’Flaithbheartaigh Staebler K, Renneberg B, Stopsack M, et al:
S, et al: D-amphetamine challenge ef- Facial emotional expression in reaction
fects on Wisconsin Card Sort Test. Per- to social exclusion in borderline person-
formance in schizotypal personality dis- ality disorder. Psychol Med 41:1929–
order. Schizophr Res 20:29–32, 1996 1938, 2011
Siever LJ, Davis KL: The pathophysiology of Tebartz van Elst L, Hesslinger B, Thiel T, et al:
schizophrenia disorders: perspectives Frontolimbic brain abnormalities in pa-
from the spectrum. Am J Psychiatry tients with borderline personality disor-
161:398–413, 2004 der: a volumetric magnetic resonance
Siever LJ, Buchsbaum MS, New AS, et al: d,l- imaging study. Biol Psychiatry 54:163–
fenfluramine response in impulsive per- 171, 2003
sonality disorder assessed with [18F]flu- Tielbeek JJ, Medland SE, Benyamin B, et al:
orodeoxyglucose positron emission to- Unraveling the genetic etiology of adult
mography. Neuropsychopharmacology antisocial behavior: a genome-wide as-
20:413–423, 1999 sociation study. Plos One 7:e45086, 2012
Skodol AE, Gunderson JG, McGlashan TH, Tiihonen J, Rossi R, Laakso MP, et al: Brain
Dyck IR, et al: Functional impairment in anatomy of persistent violent offenders:
patients with schizotypal, borderline, more rather than less. Psychiatry Res
avoidant, or obsessive-compulsive 163:201–212, 2008
personality disorder. Am J Psychiatry Verona E, Sprague J, Sadeh N: Inhibitory con-
159(2):276–283, 2002 trol and negative emotional processing
Smyrnis N, Kattoulas E, Stefanis NC, et al: in psychopathy and antisocial personal-
Schizophrenia-related neuregulin-1 sin- ity disorder. J Abnorm Psychol 121:498–
gle-nucleotide polymorphisms lead to 510, 2012
deficient smooth eye pursuit in a large Völlm B, Richardson P, Stirling J, et al: Neuro-
sample of young men. Schizophr Bull biological substrates of antisocial and
37:822–831, 2011 borderline personality disorder: prelim-
Soeiro-de-Souza MG, Bio DS, David DP, et al: inary results of a functional fMRI study.
COMT Met (158) modulates facial emo- Crim Behav Ment Health 14:39–54, 2004
tion recognition in bipolar I disorder Williams GV, Castner SA: Under the curve:
mood episodes. J Affect Disord 136:370– critical issues for elucidating D1 recep-
376, 2012 tor function in working memory. Neuro-
Soloff PH, Meltzer CC, Greer PJ, et al: A fen- science 139:263–276, 2006
fluramine-activated FDG-PET study of Yang Y, Raine A, Narr KL, et al: Localization
borderline personality disorder. Biol Psy- of deformations within the amygdala in
chiatry 47:540–547, 2000 individuals with psychopathy. Arch
Gen Psychiatry 66:986–994, 2009
This page intentionally left blank
CHAPTER 6
Prevalence,
Sociodemographics,
and Functional Impairment
Svenn Torgersen, Ph.D.
109
110 The American Psychiatric Publishing Textbook of Personality Disorders
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
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;
112 The American Psychiatric Publishing Textbook of Personality Disorders
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
Prevalence, Sociodemographics, and Functional Impairment 113
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
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
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.
Prevalence, Sociodemographics, and Functional Impairment 117
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.
118 The American Psychiatric Publishing Textbook of Personality Disorders
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-
122 The American Psychiatric Publishing Textbook of Personality Disorders
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
Prevalence, Sociodemographics, and Functional Impairment 123
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
124 The American Psychiatric Publishing Textbook of Personality Disorders
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
Prevalence, Sociodemographics, and Functional Impairment 125
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-
126 The American Psychiatric Publishing Textbook of Personality Disorders
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
Prevalence, Sociodemographics, and Functional Impairment 127
partner is a risk factor for personality dis- orders 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
of education and may create socioeco- Cramer V, Torgersen S, Kringlen E: Personal-
nomic difficulties. Problematic personal- ity 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
just as well as a cause of PDs. Future ge- Cramer V, Torgersen S, Kringlen E: Personal-
netically informative, longitudinal epi- ity disorders and quality of life. A popu-
lation study. Compr Psychiatry 47:178–
demiological studies may disclose the
184, 2006
causal pathways and hence promote the Cramer V, Torgersen S, Kringlen E: Socio-de-
understanding of this important group mographic conditions, subjective somatic
of mental disorders. health, Axis I disorders and personality
disorders in the common population:
the relationship to quality of life. J Pers
References Disord 21:552–567, 2007
Crawford TN, Cohen P, Johnson JG, et al:
Self-reported personality disorder in the
Alnæs R, Torgersen S: DSM-III symptom dis-
children in the community sample: con-
orders (Axis I) and personality disorders
vergent and prospective validity in late
(Axis II) in an outpatient population.
adolescence and adulthood. J Pers Dis-
Acta Psychiatr Scand 78:348–355, 1988
ord 19:30–52, 2005
American Psychiatric Association: Diagnos-
Durbin EC, Klein DN: Ten-year stability of
tic and Statistical Manual of Mental Dis-
personality disorders among outpatients
orders, 3rd Edition. Washington, DC,
with mood disorders. J Abnorm Psychol
American Psychiatric Association, 1980
115:75–84, 2006
American Psychiatric Association: Diag-
Engels GI, Duijsens IJ, Harrigma R, et al: Per-
nostic and Statistical Manual of Mental
sonality disorders in the elderly com-
Disorders, 3rd Edition, Revised. Wash-
pared to four younger age groups: a
ington, DC, American Psychiatric Asso-
cross-sectional study of community res-
ciation, 1987
idents and mental health patients. J Pers
American Psychiatric Association: Diag-
Disord 17:447–459, 2003
nostic and Statistical Manual of Mental
Ferro T, Klein DN, Schwartz JE, et al: 30-
Disorders, 4th Edition. Washington, DC,
month stability of personality disorder
American Psychiatric Association, 1994
diagnoses in depressed outpatients. Am
American Psychiatric Association: Diag-
J Psychiatry 155:653–659, 1998
nostic and Statistical Manual of Mental
Fossati A, Feeney JA, Donati D, et al: Person-
Disorders, 5th Edition. Arlington, VA,
ality disorders and adult attachment di-
American Psychiatric Association, 2013
mensions in a mixed psychiatric sample:
Barnow S, Stopsack M, Ulrich I, et al: Preva-
a multivariate study. J Nerv Ment Dis
lence and familiarity of personality dis-
191:30–37, 2003
128 The American Psychiatric Publishing Textbook of Personality Disorders
Manifestations,
Assessment, and
Differential Diagnosis
Andrew E. Skodol, M.D.
131
132 The American Psychiatric Publishing Textbook of Personality Disorders
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.
Personality Disorders
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-
Manifestations, Assessment, and Differential Diagnosis 135
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
136 The American Psychiatric Publishing Textbook of Personality Disorders
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 manu- al. 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
Manifestations, Assessment, and Differential Diagnosis 137
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 al- though 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
138 The American Psychiatric Publishing Textbook of Personality Disorders
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-
Manifestations, Assessment, and Differential Diagnosis 139
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-
140 The American Psychiatric Publishing Textbook of Personality Disorders
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
141
142
TABLE 7–2. Defining features of DSM-5 Section II and Section III personality disorders (continued)
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-
144 The American Psychiatric Publishing Textbook of Personality Disorders
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.
Manifestations, Assessment, and Differential Diagnosis 145
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-
Manifestations, Assessment, and Differential Diagnosis 147
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 dis- place 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”
148 The American Psychiatric Publishing Textbook of Personality Disorders
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
Manifestations, Assessment, and Differential Diagnosis 151
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
152 The American Psychiatric Publishing Textbook of Personality Disorders
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
Manifestations, Assessment, and Differential Diagnosis 153
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
156 The American Psychiatric Publishing Textbook of Personality Disorders
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-
158 The American Psychiatric Publishing Textbook of Personality Disorders
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-
Manifestations, Assessment, and Differential Diagnosis 159
Butcher JN, Graham JR, Ben-Porath YS, et al: Hopwood CJ, Morey LC, Donnnellan MB, et
Minnesota Multiphasic Personality In- al: Ten year rank-order stability of per-
ventory—2: Manual for Administration sonality traits and disorders in a clinical
and Scoring, Revised Edition. Minneap- sample. J Pers 81:335–344, 2013
olis, University of Minnesota Press, 2001 Hyler SE, Skodol AE, Kellman D, et al: Validity
Crawford TN, Cohen P, First MB, et al: Comor- of the Personality Diagnostic Question-
bid Axis I and Axis II disorders in early naire: comparison with two structured in-
adolescence: outcomes 20 years later. terviews. Am J Psychiatry 147:1043–1048,
Arch Gen Psychiatry 65:641–648, 2008 1990
Eaton NR, Krueger RF, Keyes KM, et al: Bor- Hyler SE: Personality Diagnostic Question-
derline personality disorder comorbidity: naire—4. New York, New York State
relationship to the internalizing-external- Psychiatric Institute, 1994
izing structure of common mental disor- Iacono WG, Carlson SR, Malone SM, et al: P3
ders. Psychol Med 41:1041–1050, 2011 event-related potential amplitude and
Fenton MC, Keyes K, Geier T, et al: Psychiat- the risk for disinhibitory disorders in ad-
ric comorbidity and the persistence of olescent boys. Arch Gen Psychiatry
drug use disorders in the United States. 59:750–757, 2002
Addiction 107:599–609, 2012 Johnson JG, Cohen P, Skodol AE, et al: Per-
First M, Gibbon M, Spitzer RL, et al: User’s sonality disorders in adolescence and
Guide for the Structured Clinical Inter- risk of major mental disorders and sui-
view for DSM-IV Axis II Personality Dis- cidality during adulthood. Arch Gen
orders. Washington, DC, American Psy- Psychiatry 56:805–811, 1999
chiatric Press, 1997 Johnson JG, Cohen P, Kasen S, et al: Age-
Grilo CM, Sanislow CA, Shea MT, et al: Two- related change in personality disorder
year prospective naturalistic study of re- trait levels between early adolescence
mission from major depressive disorder and adulthood: a community-based lon-
as a function of personality disorder co- gitudinal investigation. Acta Psychiatr
morbidity. J Consult Clin Psychol 73:78– Scand 102:265–275, 2000
85, 2005 Kasen S, Cohen P, Skodol AE, et al: Influence
Gunderson JG: Disturbed relationships as phe- of child and adolescent psychiatric dis-
notype for borderline personality disor- orders on young adult personality disor-
der. Am J Psychiatry 164:1637–1640, 2007 der. Am J Psychiatry 156:1529–1535,
Gunderson JG, Stout RL, McGlashan TH, et 1999
al: Ten-year course of borderline person- Kasen S, Cohen P, Skodol AE, et al: Childhood
ality disorder: psychopathology and depression and adult personality disor-
function from the Collaborative Longi- der: alternative pathways of continuity.
tudinal Personality Disorders Study. Arch Arch Gen Psychiatry 58:231–236, 2001
Gen Psychiatry 68:827–837, 2011 Kass F, Skodol AE, Charles E, et al: Scaled rat-
Hasin D, Fenton MC, Skodol A, et al: Rela- ings of DSM-III personality disorders.
tionship of personality disorders to the Am J Psychiatry 142:627–630, 1985
three-year course of alcohol, cannabis, Kendler KS, Aggen SH, Knudsen GP, et al:
and nicotine disorders. Arch Gen Psy- The structure of genetic and environ-
chiatry 68:1158–1167, 2011 mental risk factors for syndromal and
Herkov MJ, Blashfield RK: Clinicians’ diag- subsyndromal common DSM-IV axis I
noses of personality disorder: evidence and all axis II disorders. Am J Psychiatry
of a hierarchical structure. J Pers Assess 168:29–39, 2011
65:313–321, 1995 Keyes KM, Eaton NR, Krueger RF, et al:
Hill J, Pilkonis P, Morse J, et al: Social domain Thought disorder in the meta-structure of
dysfunction and disorganization in bor- psychopathology. Psychol Med 43:1673–
derline personality disorder. Psychol 1683, 2013
Med 38:135–146, 2008 Kiesler DJ: Contemporary Interpersonal
Hopwood CJ, Thomas KM, Markon KE, et al: Theory and Research: Personality, Psy-
DSM-5 personality traits and DSM-IV chopathology, and Psychotherapy. New
personality disorders. J Abnorm Psychol York, Wiley, 1996
121:424–432, 2012
162 The American Psychiatric Publishing Textbook of Personality Disorders
Klein DN: Patients’ versus informants’ re- Loranger AW: International Personality Dis-
ports of personality disorders in predict- order Examination (IPDE): DSM-IV and
ing 7 1/2-year outcome in outpatients ICD-10 Modules. Odessa, FL, Psycho-
with depressive disorders. Psychol As- logical Assessment Resources, 1999
sess 15:216–222, 2003 Low L-F, Harrison F, Lackersteen SM: Does
Klonsky ED, Oltmanns TF, Turkheimer E: In- personality affect risk for dementia? A
formant-reports of personality disorder: systematic review and meta-analysis. Am
relation to self-reports and future direc- J Geriatr Psychiatry 21:713–728, 2013
tions. Clin Psychol Sci Pract 9:300–311, Luyten P, Blatt SJ: Interpersonal relatedness
2002 and self-definition in normal and dis-
Kobak KA, Skodol AE, Bender DS: Diagnos- rupted personality development: retro-
tic measures for adults, in Handbook of spect and prospect. Am Psychol 68:172–
Psychiatric Measures, 2nd Edition. Edited 183, 2013
by Rush AJ, First MB, Blacker D. Wash- Markon KE, Quilty LC, Bagby RM, et al: The
ington, DC, American Psychiatric Pub- development and psychometric proper-
lishing, 2008, pp 35–60 ties of an informant-report form of the
Krueger RF, Eaton NR: Personality traits and Personality Inventory for DSM-5 (PID-5).
the classification of mental disorders: to- Assessment 20:370–383, 2013
wards a more complete integration in McDermut W, Zimmerman M: Personality
DSM-5 and an empirical model of psycho- disorders, personality traits, and de-
pathology. Personal Disord 1:97–118, 2010 fense mechanisms, in Handbook of Psy-
Krueger RF, Markon KE, Patrick CJ, et al: chiatric Measures, 2nd Edition. Edited
Linking antisocial behavior, substance by Rush AJ, First MB, Blacker D. Wash-
use, and personality: an integrative ington, DC, American Psychiatric Pub-
quantitative model of the adult extern- lishing, 2008, pp 687–729
alizing spectrum. J Abnorm Psychol McGlashan TH, Grilo CM, Sanislow CA, et
116:645–666, 2007 al: Two-year prevalence and stability of
Krueger RF, Eaton NR, Clark LA, et al: Deriv- individual DSM-IV criteria for schizo-
ing an empirical structure for personal- typal, borderline, avoidant and obses-
ity pathology for DSM-5. J Pers Disord sive-compulsive personality disorders:
25:170–191, 2011a toward a hybrid model of Axis II disor-
Krueger RF, Eaton NR, Derringer J, et al: Per- ders. Am J Psychiatry 162:883–889, 2005
sonality in DSM-5: helping delineate Millon T, David R, Millon C, et al: Millon
personality disorder content and fram- Clinical Multiaxial Inventory, 3rd Edi-
ing the meta-structure. J Pers Assess tion. San Antonio, TX, Pearson, 2009
93:325–331, 2011b Morey LC, Ochoa ES: An investigation of ad-
Krueger RF, Derringer J, Markon KE, et al: herence to diagnostic criteria. J Pers Dis-
Initial construction of a maladaptive per- ord 3:180–192, 1989
sonality trait model and inventory for Morey LC, Alexander GM, Boggs C: Gender,
DSM-5. Psychol Med 42:1879–1890, 2012 in American Psychiatric Publishing
Lenzenweger MF, Johnson MD, Willett JB: Textbook of Personality Disorders. Ed-
Individual growth curve analysis illumi- ited by Oldham JM, Skodol AE, Bender
nates stability and change in personality DS. Washington, DC, American Psychi-
disorder features: the longitudinal study atric Publishing, 2005, pp 541–559
of personality disorders. Arch Gen Psy- Morey LC, Shea MT, Markowitz JC, et al: State
chiatry 61:1015–1024, 2004 effects of major depression on the assess-
Lewinsohn PM, Rohde P, Seeley JR, et al: ment of personality and personality disor-
Axis II psychopathology as a function of der. Am J Psychiatry 167:528–535, 2010
Axis I disorder in childhood and adoles- Morey LC, Berghuis H, Bender DS, et al: To-
cents. J Am Acad Child Adolesc Psychi- ward a model for assessing level of per-
atry 36:1752–1759, 1997 sonality functioning in DSM-5, part II:
Livesley WJ, Jang KL: Toward an empirically empirical articulation of a core dimen-
based classification of personality disor- sion of personality pathology. J Pers As-
der. J Pers Disord 14:137–151, 2000 sess 93:347–353, 2011
Manifestations, Assessment, and Differential Diagnosis 163
Morey LC, Bender DS, Skodol AE: Validating Skodol AE, Gunderson JG: Personality disor-
the proposed DSM-5 severity indicator ders, in The American Psychiatric Pub-
for personality disorder. J Nerv Ment lishing Textbook of Psychiatry, 5th Edi-
Dis 201:729–735, 2013a tion. Edited by Hales RE, Yudofsky SC,
Morey LC, Krueger RF, Skodol AE: The hier- Gabbard GO. Washington, DC, American
archical structure of clinician ratings of Psychiatric Publishing, 2008, pp 829–851
proposed DSM-5 pathological personal- Skodol AE, Oldham JM, Rosnick L, et al: Diag-
ity traits. J Abnorm Psychol 122:836–841, nosis of DSM-III-R personality disorders:
2013b a comparison of two structured inter-
Oldham JM, Skodol AE: Personality and per- views. Int J Methods Psychiatr Res 1:13–
sonality disorders, and the passage of 26, 1991
time. Am J Geriatr Psychiatry 21:709– Skodol AE, Gunderson JG, McGlashan TH,
712, 2013 et al: Functional impairment in patients
Oltmanns TF, Balsis S: Personality disorders with schizotypal, borderline, avoidant,
in later life: questions about the mea- or obsessive-compulsive personality
surement, course, and impact of disor- disorder. Am J Psychiatry 159:276–283,
ders. Annu Rev Clin Psychol 7:321–349, 2002
2011 Skodol AE, Pagano MP, Bender DS, et al: Sta-
Pfohl B, Blum N, Zimmerman M: Structured bility of functional impairment in pa-
Interview for DSM-IV Personality (SIDP- tients with schizotypal, borderline,
IV). Washington, DC, American Psychi- avoidant, or obsessive-compulsive per-
atric Press, 1997 sonality disorder over two years. Psy-
Rey JM, Morris-Yates A, Singh M, et al: Conti- chol Med 35:443–451, 2005
nuities between psychiatric disorders in Skodol AE, Johnson JG, Cohen P, et al: Per-
adolescents and personality disorders in sonality disorder and impaired func-
young adults. Am J Psychiatry 152:895– tioning from adolescence to adulthood.
900, 1995 Br J Psychiatry 190:415–420, 2007
Roberts BW, Caspi A, Moffitt TE: Work expe- Skodol AE, Grilo CM, Keyes K, et al: Rela-
riences and personality development tionship of personality disorders to the
in young adulthood. J Pers Soc Psychol course of major depressive disorder in a
84:582–593, 2003 nationally representative sample. Am J
Samuel DB, Widiger TA: A meta-analytic re- Psychiatry 168:257–264, 2011
view of the relationship between the Skodol AE, Krueger RK, Bender DS, et al:
five-factor model and DSM-IV-TR per- Personality disorders in DSM-5 Section
sonality disorders: a facet level analysis. III. Focus: The Journal of Lifelong Learn-
Clin Psychol Rev 28:1326–1342, 2008 ing in Psychiatry XI:187–203, 2013
Samuel DB, Sanislow CA, Hopwood CJ, et al: Verheul R, Widiger TA: A meta-analysis of
Convergent and incremental validity of the prevalence and usage of the person-
clinician, self-report, and diagnostic in- ality disorder not otherwise specified
terview assessment methods for person- (PDNOS) diagnosis. J Pers Disord 18:309–
ality disorders over 5 years. J Consult 319, 2004
Clin Psychol 81:650–659, 2013 Westen D: Divergences between clinical and
Sartorius N: Disability and mental illness are research methods for assessing person-
different entities and should be assessed ality disorders: implications for research
separately (abstract). World Psychiatry and the evolution of axis II. Am J Psychi-
8:86, 2009 atry 154:895–903, 1997
Saulsman LM, Page AC: The five-factor model Widiger TA: Sex biases in the diagnosis of
and personality disorder empirical litera- personality disorders. J Pers Disord 12:95–
ture: a meta-analytic review. Clin Psychol 118, 1998
Rev 23:1055–1085, 2004 Widiger TA, Mangine S, Corbitt EM, et al:
Seivewright H, Tyrer P, Johnson T: Persistent Personality Disorder Interview—IV: A
social dysfunction in anxious and de- Semistructured Interview for the Assess-
pressed patients with personality disor- ment of Personality Disorders. Odessa,
der. Acta Psychiatr Scand 109:104–109, FL, Psychological Assessment Resources,
2004 1995
164 The American Psychiatric Publishing Textbook of Personality Disorders
Zanarini MC, Frankenburg FR, Sickel AE, et Zanarini MC, Frankenburg FR, Reich DB, et
al: Diagnostic Interview for DSM-IV al: Attainment and stability of sustained
Personality Disorders (DIPD-IV). Bel- symptomatic remission and recovery
mont, MA, Laboratory for the Study of among patients with borderline person-
Adult Development, McLean Hospital, ality disorder and axis II comparison sub-
and Department of Psychiatry, Harvard jects: a 16-year prospective follow-up
Medical School, 1996 study. Am J Psychiatry 169:476–483, 2012
Zanarini MC, Frankenburg FR, Reich DB, et Zimmerman M: Diagnosing personality dis-
al: The subsyndromal phenomenology orders: a review of issues and research
of borderline personality disorder: a 10- methods. Arch Gen Psychiatry 51:225–
year follow-up study. Am J Psychiatry 245, 1994
164:929–935, 2007 Zimmerman M, Mattia JI: Differences be-
Zanarini MC, Frankenburg FR, Reich DB, et al: tween clinical and research practices in
Time to attainment of recovery from bor- diagnosing borderline personality disor-
derline personality disorder and stability der. Am J Psychiatry 156:1570–1574, 1999
of recovery: a 10-year prospective follow- Zoccolillo M, Pickles A, Quinton D, et al: The
up study. Am J Psychiatry 167:663–667, outcome of conduct disorder: impli-
2010 cations for defining adult personality
disorder and conduct disorder. Psychol
Med 22:971–986, 1992
CHAPTER 8
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
166 The American Psychiatric Publishing Textbook of Personality Disorders
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
Course and Outcome 169
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-
170 The American Psychiatric Publishing Textbook of Personality Disorders
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
174 The American Psychiatric Publishing Textbook of Personality 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
Course and Outcome 175
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
Course and Outcome 177
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
178 The American Psychiatric Publishing Textbook of Personality Disorders
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 per- sis 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
Course and Outcome 179
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.
180 The American Psychiatric Publishing Textbook of Personality Disorders
Ansell EB, Pinto A, Edelen MO, et al: The asso- Cohen P, Crawford TN, Johnson JG, et al: The
ciation of personality disorders with the children in the community study of de-
prospective 7-year course of anxiety dis- velopmental course of personality disor-
orders. Psychol Med 41:1019–1028, 2011 der. J Pers Disord 19:466–486, 2005b
Bender DS, Skodol AE, Dyck IR, et al: Ethnicity Crawford TN, Cohen P, Brook JS: Dramatic-
and mental health treatment utilization by erratic personality disorder symptoms,
patients with personality disorders. J Con- I: continuity from early adolescence into
sult Clin Psychol 75:992–999, 2007 adulthood. J Pers Disord 15:319–335,
Berkson J: Limitations of the application of 2001a
four fold table analysis to hospital data. Crawford TN, Cohen P, Brook JS: Dramatic-
Biometrics Bulletin 2:47–53, 1946 erratic personality disorder symptoms,
Bernstein DP, Cohen P, Skodol AE, et al: I: developmental pathways from early
Childhood antecedents of adolescent adolescence to adulthood. J Pers Disord
personality disorders. Am J Psychiatry 15:336–350, 2001b
153:907–913, 1996 Crawford TN, Cohen P, First MB, et al: Co-
Blashfield RK, McElroy RA: The 1985 journal morbid Axis I and Axis II disorders in
literature on the personality disorders. early adolescence: outcomes 20 years
Compr Psychiatry 28:536–546, 1987 later. Arch Gen Psychiatry 65:641–648,
Brook DW, Brook JS, Zhang C, et al: Drug use 2008
and the risk of major depressive dis- Dolan-Sewell RT, Krueger RF, Shea MT: Co-
order, alcohol dependence, and sub- occurrence with syndrome disorders, in
stance use disorders. Arch Gen Psychia- Handbook of Personality Disorders: The-
try 59:1039–1044, 2002 ory, Research, and Treatment. Edited by
Brook JS, Whiteman M, Cohen P, et al: Longi- Livesley WJ. New York, Guilford, 2001,
tudinally predicting late adolescent and pp 84–104
young adult drug use: childhood and Ferro T, Klein DN, Schwartz JE, et al: 30-
adolescent precursors. J Am Acad Child month stability of personality disorder
Adolesc Psychiatry 34:1230–1238, 1995 diagnoses in depressed outpatients. Am
Cain NM, Ansell EB, Wright AG, et al: Inter- J Psychiatry 155:653–659, 1998
personal pathoplasticity in the course of Frances A: Categorical and dimensional sys-
major depression. J Consult Clin Psychol tems of personality diagnosis: a compar-
80:78–86, 2012 ison. Compr Psychiatry 23:516–527, 1982
Carpenter WT, Gunderson JG: Five year fol- Frank E, Prien RF, Jarrett RB, et al: Conceptu-
low-up comparison of borderline and alization and rationale for consensus
schizophrenic patients. Compr Psychia- definitions of terms in major depressive
try 18:567–571, 1977 disorder. Arch Gen Psychiatry 48:851–
Chen H, Cohen P, Johnson JG, et al: Adoles- 855, 1991
cent personality disorder and conflict Galione JN, Oltmanns TF: The relationship
with romantic partners during the tran- between borderline personality disorder
sition to adulthood. J Pers Disord 18:507– and major depression in later life: acute
525, 2004 versus temperamental symptoms. Am J
Cloninger CR, Svrakic DM, Przybeck TR: A Geriatr Psychiatry 21:747–756, 2013
psychobiological model of tempera- Goldstein RB, Grant BF: Three-year follow-
ment and character. Arch Gen Psychia- up of syndromal antisocial behavior in
try 50:975–990, 1993 adults: results from the Wave 2 Na-
Cohen P, Crawford TN, Johnson JG, et al: The tional Epidemiologic Survey on Alcohol
children in the community study of de- and Related Conditions. J Clin Psychia-
velopmental course of personality disor- try 70:1237–1249, 2009
der. J Pers Disord 19:466–486, 2000 Grilo CM, McGlashan TH: Stability and course
Cohen P, Chen H, Kasen S, et al: Adolescent of personality disorders. Curr Opin Psy-
cluster A personality disorder symp- chiatry 12:157–162, 1999
toms, role assumptions in the transition Grilo CM, McGlashan TH, Oldham JM: Course
to adulthood, and resolution or per- and stability of personality disorders.
sistence of symptoms. Dev Psycho- J Pract Psychiatry Behav Health 4:61–75,
pathol 17:549–568, 2005a 1998
182 The American Psychiatric Publishing Textbook of Personality Disorders
Grilo CM, Becker DF, Edell WS, et al: Stabil- Heatherton TF, Weinberger JL (ed): Can
ity and change of personality disorder Personality Change? Washington, DC,
dimensions in adolescents followed up American Psychological Association,
two years after psychiatric hospitaliza- 1994
tion. Compr Psychiatry 42:364–368, 2001 Hopwood CJ, Zanarini MC: Borderline per-
Grilo CM, Shea MT, Sanislow CA, et al: Two- sonality traits and disorder: predicting
year stability and change in schizotypal, prospective patient functioning. J Con-
borderline, avoidant, and obsessive- sult Clin Psychol 78:58–66, 2010
compulsive personality disorders. J Con- Hopwood CJ, Morey LC, Donnellan MB, et
sult Clin Psychol 72:767–775, 2004 al: Ten-year rank-order stability of per-
Grilo CM, Sanislow CA, Shea MT, et al: Two- sonality traits and disorders in a clinical
year prospective naturalistic study of re- sample. J Pers 81:335–344, 2013
mission from major depressive disorder Johnson JG, Williams JB, Goetz RR, et al: Per-
as a function of personality disorder co- sonality disorders predict onset of Axis I
morbidity. J Consult Clin Psychol 73:78– disorders and impaired functioning
85, 2005 among homosexual men with and at
Grilo CM, Pagano ME, Skodol AE, et al: Nat- risk of HIV infection. Arch Gen Psychia-
ural course of bulimia nervosa and of try 53:350–357, 1996
eating disorder not otherwise specified: Johnson JG, Williams JBW, Goetz RR, et al:
5-year prospective study of remissions, Stability and change in personality dis-
relapses, and the effects of personality order symptomatology: findings from a
disorder psychopathology. J Clin Psy- longitudinal study of HIV+ and HIV–
chiatry 68:738–746, 2007 men. J Abnorm Psychol 106:154–158,
Grilo CM, Stout RL, Markowitz JC, et al: Per- 1997
sonality disorders predict relapse after Johnson JG, Cohen P, Kasen S, et al: Age-
remission from an episode of major de- related change in personality disorder
pressive disorder: a six-year prospective trait levels between early adolescence
study. J Clin Psychiatr 71:1629–1635, and adulthood: a community-based lon-
2010 gitudinal investigation. Acta Psychiatr
Grinker RR, Werble B, Drye RC: The Border- Scand 102:265–275, 2000a
line Syndrome. New York, Basic Books, Johnson JG, Cohen P, Smailes E, et al: Adoles-
1968 cent personality disorders associated
Gunderson JG, Shea MT, Skodol AE, et al: with violence and criminal behavior dur-
The Collaborative Longitudinal Person- ing adolescence and early adulthood.
ality Disorders Study, I: development, Am J Psychiatry 157:1406–1412, 2000b
aims, designs and sample characteris- Johnson JG, First MB, Cohen P, et al: Adverse
tics. J Pers Disord 14:300–315, 2000 outcomes associated with personality
Gunderson JG, Morey LC, Stout RL, et al: disorder not otherwise specified in a
Major depressive disorder and border- community sample. Am J Psychiatry
line personality disorder revisited: lon- 162:926–932, 2005
gitudinal associations. J Clin Psychiatry Kasen S, Cohen P, Skodol AE, et al: Child-
65:1049–1056, 2004 hood depression and adult personality
Gunderson JG, Stout RL, McGlashan TH, et disorder: alternative pathways of conti-
al: Ten year course of borderline person- nuity. Arch Gen Psychiatry 58:231–236,
ality disorder: psychopathology and 2001
function from the Collaborative Longitu- Katz MM, Secunda SK, Hirschfeld R, et al:
dinal Personality Disorders Study. Arch NIMH Clinical Research Branch Collab-
Gen Psychiatry 68:827–837, 2011 orative Program on Psychobiology of
Hallquist MN, Lenzenweger MF: Identifying Depression. Arch Gen Psychiatry 36:765–
latent trajectories of personality disor- 771, 1979
der symptom change: growth mixture Keller MB, Lavori PW, Friedman B, et al: The
modeling in the longitudinal study of Longitudinal Interval Follow-Up Evalu-
personality disorders. J Abnorm Psychol ation. Arch Gen Psychiatry 44:540–548,
122:138–155, 2013 1987
Course and Outcome 183
Kendell PC, Clarkin JF: Introduction to Loranger AW, Sartorius N, Andreoli A, et al:
special section: comorbidity and treat- The International Personality Disorder
ment implications. J Consult Clin Psy- Examination (IPDE). Arch Gen Psychia-
chol 60:833–834, 1992 try 51:215–224, 1994
Kim-Cohen J, Caspi A, Moffitt TE, et al: Prior Lyons MJ, Tyrer P, Gunderson J, et al: Special
juvenile diagnoses in adults with mental feature: heuristic models of comorbidity
disorder: developmental follow-back of of Axis I and Axis II disorders. J Pers
a prospective-longitudinal cohort. Arch Disord 11:260–269, 1997
Gen Psychiatry 60:709–717, 2003 Maddocks PD: A five year follow-up of
Klein DN, Shih JH: Depressive personality: untreated psychopaths. Br J Psychiatry
associations with DSM-III-R mood and 116:511–515, 1970
personality disorders and negative and Markowitz JC, Skodol AE, Petkova E, et al:
positive affectivity, 30-month stability, Longitudinal effects of personality dis-
and prediction of course of axis I depres- orders on psychosocial functioning of
sive disorders. J Abnorm Psychol patients with major depressive disorder.
107:319–327, 1998 J Clin Psychiatry 68:186–193, 2007
Krueger RF: The structure of common mental Mattanah JJ, Becker DF, Levy KN, et al: Diag-
disorders. Arch Gen Psychiatry 56:921– nostic stability in adolescents followed
926, 1999 up 2 years after hospitalization. Am J
Krueger RF, Carlson SR: Personality disor- Psychiatry 152:889–894, 1995
ders in children and adolescents. Curr McDavid JD, Pilkonis PA: The stability of
Psychiatry Rep 3:46–51, 2001 personality disorder diagnoses. J Pers
Krueger RF, Tackett JL: Personality and psy- Disord 10:1–15, 1996
chopathology: working toward the big- McGlashan TH: The Chestnut Lodge Follow-
ger picture. J Pers Disord 17:109–128, Up Study, part III: long-term outcome of
2003 borderline personalities. Arch Gen Psy-
Lenzenweger MF: Stability and change in chiatry 42:20–30, 1986a
personality disorder features: the longi- McGlashan TH: The Chesnut Lodge Follow-
tudinal study of personality disorders. Up Study, part VI: schizotypal personal-
Arch Gen Psychiatry 56:1009–1015, 1999 ity disorder. Arch Gen Psychiatry 43:329–
Lenzenweger MF, Johnson MD, Willet JB: In- 334, 1986b
dividual growth curve analysis illumi- McGlashan TH, Grilo CM, Skodol AE, et al:
nates stability and change in personality The Collaborative Longitudinal Person-
disorder features: the longitudinal study ality Disorders Study: baseline Axis I/II
of personality disorders. Arch Gen Psy- and II/II diagnostic co-occurrence. Acta
chiatry 61:1015–1024, 2004 Psychiatr Scand 102:256–264, 2000
Levy KN, Becker DF, Grilo CM et al: Concur- McGlashan TH, Grilo CM, Sanislow CA, et
rent and predictive validity of the per- al: Two-year prevalence and stability of
sonality disorder diagnosis in adolescent individual DSM-IV criteria for schizo-
inpatients. Am J Psychiatry 156:1522– typal, borderline, avoidant and obses-
1528, 1999 sive-compulsive personality disorders:
Lewinsohn PM, Rohde P, Seeley JR, et al: toward a hybrid model of Axis II disor-
Axis II psychopathology as a function of ders. Am J Psychiatry 162:883–889, 2005
Axis I disorder in childhood and adoles- Moffitt TE: Adolescence-limited and life-
cents. J Am Acad Child Adolesc Psychi- course-persistent antisocial behavior: a
atry 36:1752–1759, 1997 developmental taxonomy. Psychol Rev
Livesley WJ, Jackson DN, Schroeder ML: 100:674–701, 1993
Factorial structure of traits delineating Morey LC, Hopwood CJ, Gunderson JG, et
personality disorders in clinical and al: Comparison of alternative models for
general population samples. J Abnorm personality disorders. Psychol Med
Psychol 101:432–440, 1992 37:983–994, 2007
Loranger AW, Lenzenweger MF, Gartner AF, Morey LC, Hopwood CJ, Markowitz JC, et al:
et al: Trait-state artifacts and the diagno- Comparison of alternative models for per-
sis of personality disorders. Arch Gen sonality disorders, II: 6-, 8-, and 10-year fol-
Psychiatry 48:720–728, 1991 low-up. Psychol Med 42:1705–1713, 2012
184 The American Psychiatric Publishing Textbook of Personality Disorders
Myers MG, Stewart DG, Brown SA: Progres- nesses with the ten less common in a
sion from conduct disorder to antisocial study and 18-month follow-up of 314
personality disorder following treat- psychiatric emergency room patients,
ment for adolescent substance abuse. III: findings at follow-up. Arch Gen Psy-
Am J Psychiatry 155:479–485, 1998 chiatry 34:285–291, 1977
Nesselroade JR, Stigler SM, Baltes PB: Re- Roberts BW, DelVecchio WF: The rank-order
gression toward the mean and the study consistency of personality traits from
of change. Psychol Bull 88:622–637, 1980 childhood to old age: a quantitative re-
Newman DL, Caspi A, Moffitt TE, et al: An- view of longitudinal studies. Psychol
tecedents of adult interpersonal func- Bull 126:3–25, 2000
tioning: effects of individual differences Roberts BW, Caspi A, Moffitt TE: The kids are
in age 3 temperament. Devel Psychol alright: growth and stability in personal-
33:206–217, 1997 ity development from adolescence to
Oldham JM, Skodol AE: Personality and per- adulthood. J Pers Soc Psychol 81:670–
sonality disorders and the passage of 683, 2001
time. Am J Geriatr Psychiatry 21:709– Robins LN: Deviant Children Grown Up: A
712, 2013 Sociological and Psychiatric Study of
Oldham JM, Skodol AE, Kellman HD, et al: Sociopathic Personality. Baltimore, MD,
Diagnoses of DSM-III-R personality dis- Williams & Wilkins, 1966
orders by two structured interviews: Robins LN: Epidemiology: reflections on test-
patterns of comorbidity. Am J Psychia- ing the validity of psychiatric interviews.
try 149:213–230, 1992 Arch Gen Psychiatry 42:918–924, 1985
Ottosson H, Ekselius L, Grann M, et al: Ruegg R, Frances A: New research in person-
Cross-system concordance of personal- ality disorders. J Pers Disord 9:1–48, 1995
ity disorder diagnoses of DSM-IV and Samuel DB, Hopwood CJ, Ansell EB, et al:
diagnostic criteria for research of ICD- Comparing the temporal stability of
10. J Pers Disord 16:283–292, 2002 self-report and interview assessed per-
Paris J: Personality disorders over time: pre- sonality disorder. J Abnorm Psychol
cursors, course and outcome. J Pers Dis- 120:670–680, 2011
ord 17:479–488, 2003 Samuel DB, Sanislow CA, Hopwood C, et al:
Paris J, Zweig-Frank H: A twenty-seven year Convergent and incremental predictive
follow-up of borderline patients. Compr validity of clinician, self-report, and
Psychiatry 42:482–487, 2001 structured interview diagnoses for per-
Perry JC: Longitudinal studies of personality sonality disorders over 5 years. J Con-
disorders. J Pers Disord 7(suppl):63–85, sult Clin Psychol 81:650–659, 2013
1993 Sanislow CA, Little TD, Ansell EB, et al: Ten-
Regier DA, Narrow WE, Clarke DE, et al: year stability and latent structure of
DSM-5 field trials in the United States DSM-IV schizotypal, borderline, avoid-
and Canada, part II: test-retest reliability ant, and obsessive-compulsive personal-
of selected categorical diagnoses. Am J ity disorders. J Abnorm Psychol 118:507–
Psychiatry 170:59–70, 2013 519, 2009
Rettew DC, Zanarini MC, Yen S, et al: Child- Schuster JP, Hoertel N, Le Strat, Y, et al: Per-
hood antecedents of avoidant personal- sonality disorders in older adults: find-
ity disorder: a retrospective study. J Am ings from the national epidemiologic
Acad Child Adolesc Psychiatry 42:1122– survey on alcohol and related condi-
1130, 2003 tions. Am J Geriatr Psychiatry 21:757–
Rey JM, Morris-Yates A, Singh M, et al: Con- 768, 2013
tinuities between psychiatric disorders Seivewright H, Tyrer P, Johnson T: Change in
in adolescents and personality disorders personality status in neurotic disorders.
in young adults. Am J Psychiatry 152:895– Lancet 359:2253–2254, 2002
900, 1995 Shea MT, Yen S: Stability as a distinction be-
Robbins E, Gentry KA, Munoz RA, et al: A tween axis I and axis II disorders. J Pers
contrast of the three more common ill- Disord 17:373–386, 2003
Course and Outcome 185
Shea MT, Stout RL, Gunderson JG, et al: Solomon DA, Keller MB, Leon AC, et al: Re-
Short-term diagnostic stability of schizo- covery from major depression: a 10-year
typal, borderline, avoidant, and obses- prospective follow-up across multiple
sive-compulsive personality disorders. episodes. Arch Gen Psychiatry 54:1001–
Am J Psychiatry 159:2036–2041, 2002 1006, 1997
Shea MT, Stout RL, Yen S, et al: Associations Squires-Wheeler E, Skodol AE, Erlenmeyer-
in the course of personality disorders Kimling L: The assessment of schizo-
and Axis I disorders over time. J Ab- typal features over two points in time.
norm Psychol 113:499–508, 2004 Schizophr Res 6:75–85, 1992
Shea MT, Edelen MO, Pinto A, et al: Improve- Stevenson J, Meares R, Comerford A: Dimin-
ment in borderline personality disorder ished impulsivity in older patients with
in relation to age. Acta Psychiatr Scand borderline personality disorder. Am J
119:143–148, 2009 Psychiatry 160:165–166, 2003
Siever LJ, Davis KL: A psychobiological per- Stone MH: Long-term outcome in personal-
spective on the personality disorders. ity disorders. Br J Psychiatry 162:299–
Am J Psychiatry 148:1647–1658, 1991 313, 1993
Skodol AE: Classification, assessment, and Trull TJ, Useda D, Conforti K, et al. Borderline
differential diagnosis of personality dis- personality disorder features in nonclini-
orders. J Pract Psychiatry Behav Health cal young adults, 2: two-year outcome. J
3:261–274, 1997 Abnorm Psychol 106:307–314, 1997
Skodol AE: Personality disorders in DSM-5. Trull TJ, Useda JD, Doan B-T, et al. Two-year
Annu Rev Clin Psychol 8:317–344, 2012 stability of borderline personality mea-
Skodol AE, Siever LJ, Livesley WJ, et al: The sures. J Pers Disord 12:187–197, 1998
borderline diagnosis II: biology, genet- Tyrer P: Personality disorder. Br J Psychiatry
ics, and clinical course. Biol Psychiatry 179:81–84, 2001
15:951–963, 2002 Tyrer P, Gunderson J, Lyons M, et al: Special
Skodol AE, Grilo CM, Pagano ME, et al: Ef- feature: extent of comorbidity between
fects of personality disorders on func- mental state and personality disorders.
tioning and well-being in major depres- J Pers Disorders 11:242–259, 1997
sive disorder. J Psychiatr Pract 11:363– Warner MB, Morey LC, Finch JF, et al: The
368, 2005a longitudinal relationship of personality
Skodol AE, Gunderson JG, Shea MT, et al: The traits and disorders. J Abnorm Psychol
Collaborative Longitudinal Personality 113:217–227, 2004
Disorders Study (CLPS): overview and im- Westen D: Divergences between clinical and
plications. J Pers Disord 19:487–504, 2005b research methods for assessing person-
Skodol AE, Oldham JM, Bender DS, et al: Di- ality disorders: implications for research
mensional representations of DSM-IV and the evolution of axis II. Am J Psychi-
personality disorders: relationships to atry 154:895–903, 1997
functional impairment. Am J Psychiatry Westen D, Shedler J: Revising and assessing
162:1919–1925, 2005c axis II, part 2: toward an empirically
Skodol AE, Pagano ME, Bender DS, et al: Sta- based and clinically useful classification
bility of functional impairment in of personality disorders. Am J Psychia-
patients with schizotypal, borderline, try 156:273–285, 1999
avoidant, or obsessive-compulsive per- Widiger TA: Categorical versus dimensional
sonality disorder over two years. Psy- classification: implications from and for
chol Med 35:443–451, 2005d research. J Pers Disord 6:287–300, 1992
Skodol AE, Johnson JG, Cohen P, et al: Per- Widiger TA: Personality disorder and Axis I
sonality disorder and impaired func- psychopathology: the problematic bound-
tioning from adolescence to adulthood. ary of Axis I and Axis II. J Pers Disord
Br J Psychiatry 190:415–420, 2007 17:90–108, 2003
Skodol AE, Grilo CM, Keyes KM, et al: Rela- Wolff S, Townshend R, McGuire RJ, et al: Schiz-
tionship of personality disorder to the oid personality in childhood and adult
course of major depressive disorder in a life, II: adult adjustment and the continu-
nationally representative sample. Am J ity with schizotypal personality disorder.
Psychiatry 168:257–264, 2011 Br J Psychiatry 159:620–629, 1991
186 The American Psychiatric Publishing Textbook of Personality Disorders
World Health Organization: International Zanarini MC, Jacoby RJ, Frankenburg FR, et
Statistical Classification of Diseases and al: The 10-year course of social security
Related Health Problems, 10th Revision. disability income reported by patients
Geneva, World Health Organization, with borderline personality disorder and
1992 axis II comparison subjects. J Pers Dis-
Zanarini MC, Skodol AE, Bender D, et al: The ord 23:346–356, 2009
Collaborative Longitudinal Personality Zanarini MC, Frankenburg FR, Reich DB, et
Disorders Study: reliability of Axis I and al: The 10-year course of psychosocial
II diagnoses. J Pers Disord 14:291–299, functioning among patients with bor-
2000 derline personality disorder and axis II
Zanarini MC, Frankenburg FR, Hennen J, et comparison subjects. Acta Psychiatr
al: The longitudinal course of borderline Scand 122:103–109, 2010a
psychopathology: 6-year prospective Zanarini MC, Frankenburg FR, Reich DB, et
follow-up of the phenomenology of bor- al: Time to attainment of recovery from
derline personality disorder. Am J Psy- borderline personality disorder and sta-
chiatry 160:274–283, 2003 bility of recovery: a 10-year prospective
Zanarini MC, Frankenburg FR, Hennen J, et al: follow-up study. Am J Psychiatry 167:663–
Axis I comorbidity in patients with bor- 667, 2010b
derline personality disorder: 6-year fol- Zanarini MC, Frankenburg FR, Reich DB, et
low-up and prediction of time to remis- al: Attainment and stability of sustained
sion. Am J Psychiatry 161:2108–2114, 2004 symptomatic remission and recovery
Zanarini MC, Frankenburg FR, Hennen J, et among patients with borderline person-
al: The McLean Study of Adult attach- ality disorder and axis II comparison
ment (MSAD): overview and implica- subjects: a 16-year prospective follow-
tions of the first six years of prospective up study. Am J Psychiatry 169:476–483,
follow-up. J Pers Disord 19:505–523, 2012
2005a Zimmerman M: Diagnosing personality dis-
Zanarini MC, Frankenburg FR, Hennen J, et orders: a review of issues and research
al: Psychosocial functioning of border- methods. Arch Gen Psychiatry 51:225–
line patients and Axis II comparison 245, 1994
subjects followed prospectively for six
years. J Pers Disord 19:19–29, 2005b
PART II
Treatment
This page intentionally left blank
CHAPTER 9
Therapeutic Alliance
Donna S. Bender, Ph.D., FIPA
189
190 The American Psychiatric Publishing Textbook of Personality Disorders
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-
192 The American Psychiatric Publishing Textbook of Personality Disorders
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-
Therapeutic Alliance 193
Personality DSM-5
disorder DSM-5 alternative model: self and interpersonal alternative Alliance Points of possible engagement
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.
Therapeutic Alliance
TABLE 9–1. Alliance-relevant aspects of each personality disorder style (continued)
Personality DSM-5
disorder DSM-5 alternative model: self and interpersonal alternative Alliance Points of possible engagement
category functioning model: traits challenges in treatment
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
TABLE 9–1. Alliance-relevant aspects of each personality disorder style (continued)
Personality DSM-5
disorder DSM-5 alternative model: self and interpersonal alternative Alliance Points of possible engagement
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.
Therapeutic Alliance
TABLE 9–1. Alliance-relevant aspects of each personality disorder style (continued)
Personality DSM-5
disorder DSM-5 alternative model: self and interpersonal alternative Alliance Points of possible engagement
category functioning model: traits challenges in treatment
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
TABLE 9–1. Alliance-relevant aspects of each personality disorder style (continued)
Personality DSM-5
disorder DSM-5 alternative model: self and interpersonal alternative Alliance Points of possible engagement
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.
Therapeutic Alliance
TABLE 9–1. Alliance-relevant aspects of each personality disorder style (continued)
Personality DSM-5
disorder DSM-5 alternative model: self and interpersonal alternative Alliance Points of possible engagement
category functioning model: traits challenges in treatment
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
200 The American Psychiatric Publishing Textbook of Personality Disorders
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.
202 The American Psychiatric Publishing Textbook of Personality Disorders
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.
Therapeutic Alliance 203
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 al- one 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-
204 The American Psychiatric Publishing Textbook of Personality Disorders
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
206 The American Psychiatric Publishing Textbook of Personality Disorders
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 in- fluence 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-
208 The American Psychiatric Publishing Textbook of Personality Disorders
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 in- patients 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
Therapeutic Alliance 209
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
Therapeutic Alliance 213
Bond M, Banon E, Grenier M: Differential ef- Gabbard GO: Splitting in hospital treatment.
fects of interventions on the therapeutic Am J Psychiatry 146:444–451, 1989
alliance with patients with personality Gabbard GO: An overview of countertrans-
disorders. J Psychother Pract Res 7:301– ference: theory and technique, in Coun-
318, 1998 tertransference Issues in Psychiatric
Bordin ES: The generalizability of the psy- Treatment. Edited by Gabbard GO (Re-
choanalytic concept of the working alli- view of Psychiatry Series, Vol 18; Old-
ance. Psychotherapy: Theory, Research, ham JM, Riba MB, series eds). Washing-
and Practice 16:252–260, 1979 ton, DC, American Psychiatric Press,
Cookson A, Daffern M, Foley F: Relationship 1999, pp 1–25
between aggression, interpersonal style, Gabbard GO: Psychodynamic Psychiatry in
and therapeutic alliance during short- Clinical Practice, 4th Edition. Washing-
term psychiatric hospitalization. Int J ton, DC, American Psychiatric Press,
Ment Health Nurs 21:20–29, 2012 2005
Diamond D, Stovall-McClough C, Clarkin JF, Gerstley L, McLellan AT, Alterman AI, et al:
et al: Patient–therapist attachment in the Ability to form an alliance with the ther-
treatment of borderline personality dis- apist: a possible social marker of prog-
order. Bull Menninger Clin 67:227–259, nosis for patients with antisocial person-
2003 ality disorder. Am J Psychiatry 146:508–
Dickenson KA, Pincus AL: Interpersonal 512, 1989
analysis of grandiose and vulnerable Gibbons MB, Crits-Cristoph P, de la Cruz C,
narcissism. J Pers Disord 17:188–207, et al: Pretreatment expectations, inter-
2003 personal functioning, and symptoms in
Diener MJ, Monroe JM: The relationship the prediction of the therapeutic alliance
between adult attachment style and ther- across supportive-expressive psycho-
apeutic alliance in individual psycho- therapy and cognitive therapy. Psycho-
therapy: a meta-analytic review. Psycho- ther Res 13:59–76, 2003
therapy 48:237–248, 2011 Gunderson JG: Psychodynamic psychother-
Drapeau M, Perry JC, Korner A: Interper- apy for borderline personality disorder,
sonal patterns in borderline personality in Psychotherapy for Personality Disor-
disorder. J Pers Disord 26:583–592, 2012 ders. Edited by Gunderson JG, Gabbard
Ellman SJ: Enactment, transference, and ana- GO (Review of Psychiatry Series, Vol 19;
lytic trust, in Enactment: Toward a New Oldham JM, Riba MB, series eds). Wash-
Approach to the Therapeutic Relation- ington, DC, American Psychiatric Press,
ship. Edited by Ellman SJ, Moskowitz 2000, pp 33–64
M. Northvale, NJ, Jason Aronson, 1998a, Gunderson JG, Najavits LM, Leonhard C, et
pp 183–204 al: Ontogeny of the therapeutic alliance
Ellman SJ: The unique contribution of the in borderline patients. Psychother Res
contemporary Freudian position, in The 7:301–309, 1997
Modern Freudians. Edited by Ellman Gutheil TG: The psychology of psychophar-
CS, Grand S, Silvan M, et al. Northvale, macology. Bull Menninger Clin 46:321–
NJ, Jason Aronson, 1998b, pp 237–268 330, 1982
Eubanks-Carter C, Muran JC, Safran JD: Alli- Gutheil TG, Havens LL: The therapeutic alli-
ance ruptures and resolutions, in The ance: contemporary meanings and con-
Therapeutic Alliance: An Evidence-Based fusions. Int Rev Psychoanal 6:467–481,
Guide to Practice. Edited by Muran JC, 1979
Barber JP. New York, Guilford, 2010, pp Hatcher RL: Alliance theory and measure-
74–96 ment, in The Therapeutic Alliance: An
Freud S: The dynamics of transference (1912), Evidence-Based Guide to Practice. Ed-
in The Standard Edition of the Com- ited by Muran JC, Barber JP. New York,
plete Psychological Works of Sigmund Guilford, 2010, pp 7–28
Freud, Vol 12. Translated and edited by Hersoug AG, Monsen J, Havik OE, et al:
Strachey J. London, Hogarth Press, 1958, Quality of working alliance in psycho-
pp 99–108 therapy: diagnoses, relationship and in-
Therapeutic Alliance 215
Strauss JL, Hayes AM, Johnson SL, et al: American Psychiatric Press, 2000, pp
Early alliance, alliance ruptures, and 131–149
symptom change in a nonrandomized Waldinger RJ, Gunderson JG: Completed
trial of cognitive therapy for avoidant psychotherapies with borderline pa-
and obsessive-compulsive personality tients. Am J Psychother 38:190–202, 1984
disorders. J Consult Clin Psychol 74:337– Wallerstein RS: Forty-Two Lives in Treat-
345, 2006 ment: A Study of Psychoanalysis and
Tyrer P, Davidson K: Cognitive therapy for Psychotherapy. New York, Guilford,
personality disorders, in Psychother- 1986
apy for Personality Disorders. Edited by Winnicott DW: The Maturational Processes
Gunderson JG, Gabbard GO (Review of and the Facilitating Environment. Lon-
Psychiatry Series, Vol 19; Oldham JM, don, Hogarth Press, 1965
Riba MB, series eds). Washington, DC,
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.
217
218 The American Psychiatric Publishing Textbook of Personality Disorders
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
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
Psychodynamic Psychotherapies and Psychoanalysis 221
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-
Psychodynamic Psychotherapies and Psychoanalysis 223
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;
Psychodynamic Psychotherapies and Psychoanalysis 225
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)
Psychodynamic Psychotherapies and Psychoanalysis 227
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.
228 The American Psychiatric Publishing Textbook of Personality Disorders
(Gabbard 2005b). Lack of meaningful re- ment 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
Psychodynamic Psychotherapies and Psychoanalysis 229
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
Psychodynamic Psychotherapies and Psychoanalysis 231
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
232 The American Psychiatric Publishing Textbook of Personality Disorders
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-
Psychodynamic Psychotherapies and Psychoanalysis 233
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-
Psychodynamic Psychotherapies and Psychoanalysis 235
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-
236 The American Psychiatric Publishing Textbook of Personality Disorders
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
Psychodynamic Psychotherapies and Psychoanalysis 237
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
Disorders, 4th Edition. Washington, DC,
structure or self-structure. According to
American Psychiatric Association, 1994
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
American Psychiatric Association: Diag-
logical temperament, in combination
nostic and Statistical Manual of Mental
with aspects of development, can create Disorders, 5th Edition. Arlington, VA,
a psychic structure—especially in terms American Psychiatric Association, 2013
of experience of and reactions to self and Baker TB, McFall RM, Shoham V: Current
others—that does not adapt well to deal- status and future prospects of clinical
psychology: toward a scientifically prin-
ing with the complexities of the real
cipled approach to mental and behav-
world in ways that involve aspects of the ioral health care. Psychol Sci Public In-
person that are unconscious to him or terest 9:67–103, 2008
her. Psychoanalysis and psychodynamic Bateman A, Fonagy P: The effectiveness of
therapy can provide the tools to help the partial hospitalization in the treatment
individual integrate or complete that of borderline personality disorder: a ran-
domized controlled trial. Am J Psychiatry
psychic structure and thereby replace
156:1563–1569, 1999
failure and frustration in life with a real- Bateman A, Fonagy P: Treatment of border-
istic measure of satisfaction and achieve- line personality disorder with psychoan-
ment. Psychoanalysis and psychody- alytically oriented partial hospitalization:
namic therapy continue to evolve and an 18-month follow-up. Am J Psychiatry
158:36–42, 2001
enrich each other as more is learned
Bateman A, Fonagy P: The development of
about the mind and about the brain from an attachment-based treatment program
clinical experience and from research. for borderline personality disorder. Bull
Menninger Clinic 67:187–211, 2003
Bateman A, Fonagy P (eds): Handbook of
References Mentalizing in Mental Health Practice.
Washington, DC, American Psychiatric
Publishing, 2012
Abbass AA, Hancock JT, Henderson J, et al:
Bender DS, Morey LC, Skodol AE: Toward a
Short-term psychodynamic psychother-
model for assessing level of personality
apies for common mental disorders.
functioning in DSM-5, part I: a review of
Cochrane Database of Systematic Re-
theory and methods. J Pers Assess 93:332–
views 2006, Issue 4. Art. No.: CD004687.
346, 2011
DOI: 10.1002/14651858.CD004687.pub3.
Blatt SJ, Levy KN: Attachment theory, psy-
Ablon JS, Jones EE: Validity of controlled
choanalysis, personality development,
clinical trials of psychotherapy: findings
and psychopathology. Psychoanalytic
from the NIMH Treatment of Depres-
Inquiry 23:102–150, 2003
sion Collaborative Research Program.
Bowlby J: Attachment and Loss, Vol 1: At-
Am J Psychiatry 159:775–783, 2002
tachment. London, Hogarth Press and
Adler G: Borderline Psychopathology and Its
Institute of Psycho-Analysis, 1969
Treatment. New York, Jason Aronson,
Bowlby J: Attachment and Loss, Vol. 2: Sepa-
1985
ration, Anxiety, and Anger. London,
American Psychiatric Association: Diag-
Hogarth Press and Institute of Psycho-
nostic and Statistical Manual of Mental
Analysis, 1973
Disorders, 3rd Edition. Washington, DC,
American Psychiatric Association, 1980
238 The American Psychiatric Publishing Textbook of Personality Disorders
Bowlby J: Attachment and Loss, Vol. 3: Loss: self and other, in Emotion, Cognition,
Sadness and Depression. London, Hog- and Representation. Edited by Cicchetti
arth Press and Institute of Psycho-Anal- DT, Sheree L. Rochester, NY, University
ysis, 1980 of Rochester Press, 1995, pp 371–414
Bretherton I: New perspectives on attach- Fonagy P, Gergely G, Jurist E, et al: Affect
ment relations: security, communication, regulation, mentalization, and the de-
and internal working models, in Hand- velopment of the self. New York, Other
book of Infant Development, 2nd Edi- Books, 2003
tion. Edited by Osofsky JD. Oxford, UK, Fonagy P, Bateman, AW, Luyten P: Introduc-
Wiley, 1987, pp 1061–1100 tion and overview, in Handbook of
Buie DH, Adler G: Definitive treatment of the Mentalizing in Mental Health Practice.
borderline personality. Int J Psychoanal Edited by Bateman AW, Fonagy P. Wash-
Psychother 9:51–87, 1982 ington, DC, American Psychiatric Pub-
Caligor E, Kernberg OF, Clarkin JF: Hand- lishing, 2012, pp 3–42
book of Dynamic Psychotherapy for Freud S: The ego and the id (1923), in The
Higher Level Personality Pathology. Standard Edition of the Complete Psy-
Washington, DC, American Psychiatric chological Works of Sigmund Freud,
Publishing, 2007 Vol. 14. Translated and edited by
Caligor E, Diamond D, Yeomans FE, et al: Strachey J. London, Hogarth Press, 1961,
The interpretive process in the psycho- pp 1–66
analytic psychotherapy of borderline per- Gabbard GO: Psychoanalysis, in The Ameri-
sonality pathology. J Am Psychoanal As- can Psychiatric Publishing Textbook of
soc 57:271–301, 2009 Personality Disorders. Edited by Old-
Chambless DL, Ollendick TH: Empirically ham JM, Skokol AE, Bender DS. Wash-
supported psychological interventions: ington DC, American Psychiatric Pub-
controversies and evidence. Annu Rev lishing, 2005a, pp 257–274
Psychol 52:685–716, 2001 Gabbard GO: Psychodynamic Psychiatry in
Clarkin JF, Yeomans FE, Kernberg OF: Psy- Clinical Practice, 4th Edition. Washing-
chotherapy for borderline personality: ton, DC, American Psychiatric Publish-
focusing on object relations. Washing- ing, 2005b
ton, DC, American Psychiatric Publish- Gabbard GO, Westen D: Rethinking thera-
ing, 2006 peutic action. Int J Psychoanal 84:823–
Clarkin JF, Levy KN, Lenzenweger MF, et al: 841, 2003
Evaluating three treatments for border- Gill M: Analysis of Transference, Vol 1: The-
line personality disorder: a multiwave ory and Technique. New York, Interna-
study. Am J Psychiatry 164:922–928, tional Universities Press, 1982
2007 Greenberg S: Oedipus and Beyond. Cam-
Diamond D, Clarkin J, Levine H, et al: Bor- bridge, MA, Harvard University Press,
derline conditions and attachment: a 1991
preliminary report. Psychoanalytic In- Gunderson JG: Borderline Personality Disor-
quiry 19:831–884, 1999 der. Washington, DC, American Psychi-
Doering S, Hoerz S, Rentrop M, et al: Transfer- atric Press, 1984
ence-focused psychotherapy v. treatment Gunderson JG: Borderline patient’s intoler-
by community therapists for borderline ance of aloneness: insecure attachments
personality disorder: randomized con- and therapist availability. Am J Psychia-
trolled trial. Br J Psychiatry 196:389–395, try 153:752–758, 1996
2010 Gunderson JG: Borderline Personality Disor-
Fairbairn WRD: An object-relations theory of der: A Clinical Guide. Washington, DC,
the personality, in Psychoanalytic Stud- American Psychiatric Press, 2001
ies of the Personality. London, Rout- Høglend P, Bogwald KP, Amlo S, et al: Trans-
ledge and Kegan Paul, 1952, pp 3–179 ference interpretations in dynamic psy-
Fonagy P, Leigh T, Kennedy R, et al: Attach- chotherapy: do they really yield sustained
ment, borderline states and the repre- effects? Am J Psychiatry 165:763–771,
sentation of emotions and cognitions in 2008
Psychodynamic Psychotherapies and Psychoanalysis 239
Jacobson E: The Self and the Object World. disorder. J Consult Clin Psychol 74:1027–
New York, International Universities 1040, 2006
Press, 1964 Levy KN, Ellison WD, Temes CM, et al: The
Kernberg OF: Internal World and External outcome of psychotherapy for borderline
Reality: Object Relations Theory Ap- personality disorder: a meta-analysis, in
plied. New York, Jason Aronson, 1980 Specific and Common Factors of Psycho-
Kernberg OF: Severe Personality Disorders: therapy for Borderline Personality Disor-
Psychotherapeutic Strategies. New Ha- der. Livesley J (Chair). Paper presented at
ven, CT, Yale University Press, 1984 the 2nd International Congress on Bor-
Kernberg OF: Psychoanalytic object relations derline Personality Disorder and Allied
theories, in Psychoanalysis: The Major Disorders, Amsterdam, September 2012
Concepts. Edited by Moore B, Fine B. Luborsky L: Principles of Psychoanalytic
New Haven, CT, Yale University Press, Psychotherapy: A Manual for Support-
1995 ive-Expressive Treatment. New York,
Kernberg OF: A psychoanalytic theory of Basic Books, 1984
personality disorders, in Major Theories Luborsky L, Mintz J, Auerbach A, et al: Pre-
of Personality Disorder. Edited by Clar- dicting the outcome of psychotherapy:
kin JF, Lenzenweger MF. New York, findings of the Penn Psychotherapy
Guilford, 1996, pp 106–140 Project. Arch Gen Psychiatry 37:471–481,
Klein M: Notes on some schizoid mecha- 1980
nisms (1946), in Envy and Gratitude and McCrae RR, Costa PT Jr: Personality trait
Other Works, 1946–1963. New York, structure as a human universal. Am Psy-
Free Press, 1975, pp 1–24 chol 52:509–516, 1997
Kohut H: The Analysis of the Self: A System- Meissner WW: Psychotherapeutic schema
atic Approach to the Psychoanalytic based on the paranoid process. Int J Psy-
Treatment of Narcissistic Personality choanal Psychother 5:87–114, 1976
Disorders. New York, International Uni- Meissner WW: Psychotherapy and the Para-
versities Press, 1971 noid Process. Northvale, NJ, Jason Ar-
Kohut H: The Restoration of the Self. New onson, 1986
York, International Universities Press, Mischel W, Shoda Y: A cognitive-affective
1977 system theory of personality: reconcep-
Leichsenring F, Leibling E: The effectiveness tualizing situations, dispositions, dy-
of psychodynamic therapy and cogni- namics, and invariance in personality
tive behavior therapy in the treatment of structure. Psychol Rev 102:246–268, 1995
personality disorders: a meta-analysis. Mitchell SA: Relational Concepts in Psycho-
Am J Psychiatry 160:1223–1233, 2003 analysis: An Integration. Cambridge,
Leichsenring F, Rabung S: Effectiveness of MA, Harvard University Press, 1988
long-term psychodynamic psychother- Norcross JC: Psychotherapy Relationships
apy. JAMA 300:1551–1565, 2008 That Work, 2nd Edition. New York, Ox-
Lenzenweger MF, Clarkin JF: The personal- ford University Press, 2011
ity disorders: history, classification, and Ornstein PH: Psychoanalysis of patients with
research issues, in Major Theories of Per- primary self-disorder: a self psychologi-
sonality Disorder. Edited by Clarkin JF, cal perspective, in Disorders of Narcis-
Lenzenweger MF. New York, Guilford, sism: Diagnostic, Clinical, and Empirical
2005, pp 1–42 Implications. Edited by Ronningstam EF.
Levy KN, Blatt SJ: Attachment theory and Washington, DC, American Psychiatric
psychoanalysis: Further differentiation Press, 1998, pp 147–169
within insecure attachment patterns. Ornstein PH: “Chronic Rage from Under-
Psychoanalytic Inquiry 19:541–575, 1999 ground”: the treatment of a patient with
Levy KN, Meehan KB, Kelly KM, et al: a severe narcissistic disorder. Psychiatric
Change in attachment patterns and re- Annals 39:137–143, 2009
flective function in a randomized con- PDM Task Force: Psychodynamic Diagnostic
trol trial of transference focused psycho- Manual. Silver Spring, MD, Alliance of
therapy for borderline personality Psychoanalytic Organizations, 2006
240 The American Psychiatric Publishing Textbook of Personality Disorders
Reich W: Character Analysis. New York, Far- Waldinger RJ: Intensive psychodynamic ther-
rar, Straus & Giroux, 1972 apy with borderline patients: an overview.
Rockland LH: Supportive therapy for bor- Am J Psychiatry 144:267–274, 1987
derline patients: a psychodynamic ap- Wallerstein RS: Forty-Two Lives in Treatment:
proach. New York, Guilford, 1992 A Study of Psychoanalysis and Psycho-
Shaver PR, Collins N, Clark CL: Attachment therapy. New York, Guilford, 1986
styles and internal working models of Westen D, Morrison K: A multidimensional
self and relationship partners, in Knowl- meta-analysis of treatments for depres-
edge Structures in Close Relationships: sion, panic, and generalized anxiety disor-
A Social Psychological Approach. Ed- der: an empirical examination of the status
ited by Fletcher J. Hillsdale, UK, Law- of empirically supported therapies. J Con-
rence Erlbaum, 1996, pp 25–61 sult Clin Psychol 69:875–899, 2001
Shedler J: The efficacy of psychodynamic Winnicott DW: Maturational Processes and
psychotherapy. Am Psychol 65:98–109, the Facilitating Environment: Studies in
2010 the Theory of Emotional Development.
Strupp HH, Binder JL: Psychotherapy in a New York, International Universities
New Key: A Guide to Time-Limited Dy- Press, 1965
namic Psychotherapy. New York, Basic Yeomans FE, Clarkin JF, Kernberg OF: A
Books, 1984 Primer of Transference-Focused Psycho-
Valzelli L: Psychobiology of Aggression and therapy for the Borderline Patient.
Violence. New York, Raven Press, 1981, Northvale, NJ, Jason Aronson, 2002
pp 67–69 Zetzel ER: The so called good hysteric. Int J
Psychoanal 49:256–260, 1968
C H A P T E R 11
Cognitive-Behavioral
Therapy I:
Basics and Principles
Martin Bohus, M.D.
241
242 The American Psychiatric Publishing Textbook of Personality Disorders
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
Modelling (including
functional and dysfunctional
Change determining variables)
management
Prognosis and
extrapolation
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-
248 The American Psychiatric Publishing Textbook of Personality Disorders
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-
Cognitive-Behavioral Therapy I: Basics and Principles 249
Crisis-generating
behavior
Treatment-interfering
behavior
Goal-related
behavior
External variables
Dysfunctional cognitions,
emotions, and behavior
Severe comorbidity
Specific goal-impeding
behavior
• 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
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
Cognitive-Behavioral Therapy I: Basics and Principles 253
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-
254 The American Psychiatric Publishing Textbook of Personality Disorders
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
256 The American Psychiatric Publishing Textbook of Personality Disorders
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
Cognitive-Behavioral Therapy I: Basics and Principles 257
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 pa- tient 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
258 The American Psychiatric Publishing Textbook of Personality Disorders
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.
Cognitive-Behavioral Therapy I: Basics and Principles 259
Cognitive-Behavioral
Therapy II:
Specific Strategies for
Personality Disorders
J. Christopher Fowler, Ph.D.
John M. Hart, Ph.D.
261
262 The American Psychiatric Publishing Textbook of Personality Disorders
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 symp- toms, 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-
264 The American Psychiatric Publishing Textbook of Personality Disorders
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
Cognitive-Behavioral Therapy II: Specific Strategies for Personality Disorders 265
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-
266 The American Psychiatric Publishing Textbook of Personality Disorders
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 impair- ment 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 treat- ing 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-
Cognitive-Behavioral Therapy II: Specific Strategies for Personality Disorders 267
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-
270 The American Psychiatric Publishing Textbook of Personality Disorders
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
Admission 2 weeks 4 weeks 6 weeks Discharge
80 75 Mild
70
60
50
50
50
Admission 2 weeks 4 weeks 6 weeks Discharge
56 60 56
60
50
40 32
30 Poor quality of life
20 and well-being (52%)
10
0
8
Admission 2 weeks 4 weeks 6 weeks Discharge
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-
272 The American Psychiatric Publishing Textbook of Personality Disorders
25 24 24
22
20
20 18 Severe
15 13 Moderate
12 12 12
10 Mild
10 Normal
11 10 9
6
5 7
Admission 2 weeks 4 weeks 6 weeks Discharge
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
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
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-
Cognitive-Behavioral Therapy II: Specific Strategies for Personality Disorders 273
AAQ-II
60
50
40
30
30 26 26
20 25
19
10
0
Admission 2 weeks 4 weeks 6 weeks Discharge
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-
274 The American Psychiatric Publishing Textbook of Personality Disorders
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.
276 The American Psychiatric Publishing Textbook of Personality Disorders
order: a randomized controlled trial and (BOSCOT) trial. J Pers Disord 20:450–
1-year follow-up. Am J Psychiatry 465, 2006
165:468–478, 2008 Davidson KM, Tyrer P, Tata P, et al: Cognitive
Bohus M, Haaf B, Stiglmayr C, et al: Evalua- behaviour therapy for violent men with
tion of inpatient dialectical-behavioral antisocial personality disorder in the
therapy for borderline personality disor- community: an exploratory randomized
der—a prospective study. Behav Res controlled trial. Psychol Med 39:569–
Ther 38:875–887, 2000 577, 2009
Bohus M, Haaf B, Simms T, et al: Effective- Davidson KM, Tyrer P, Norrie J, et al: Cogni-
ness of inpatient dialectical behavioral tive therapy v. usual treatment for bor-
therapy for borderline personality disor- derline personality disorder: prospec-
der: a controlled trial. Behav Res Ther tive 6-year follow-up. Br J Psychiatry
42:487–499, 2004 197:456–462, 2010
Bond FW, Hayes SC, Baer RA, et al: Prelimi- Emmelkamp PM, Benner A, Kuipers A, et al:
nary psychometric properties of the Ac- Comparison of brief dynamic and cogni-
ceptance and Action Questionnaire–II: a tive-behavioural therapies in avoidant
revised measure of psychological inflex- personality disorder. Br J Psychiatry
ibility and experiential avoidance. Be- 189:60–64, 2006
hav Ther 42:676–688, 2011 Farrell JM, Shaw IA, Webber MA: A schema-
Chambless DL, Fydrich T, Rodebaugh TL: focused approach to group psychother-
Generalized social phobia and avoidant apy for outpatients with borderline per-
personality disorder: meaningful dis- sonality disorder: a randomized con-
tinction or useless duplication? Depress trolled trial. J Behav Ther Exp Psychiatry
Anxiety 25:8–19, 2008 40:317–328, 2009
Chanen AM, Jackson HJ, McCutcheon LK, et Fowler JC, Oldham JM: Co-occurring disor-
al: Early intervention for adolescents ders and treatment complexity. FOCUS
with borderline personality disorder us- 11:123–128, 2013
ing cognitive analytic therapy: ran- Freije H, Dietz B, Appelo M: Borderline per-
domised controlled trial. Br J Psychiatry soonlijkheidsstoornis met de VERS: de
193:477–484, 2008 vaardigheidstraining emotionele regu-
Clarke S, Thomas P, James K: Cognitive ana- latiestoornis. Directieve Therapie 4:367–
lytic therapy for personality disorder: 378, 2002
randomised controlled trial. Br J Psychi- Germer CK, Neff KD: Self‐compassion in
atry 202:129–134, 2013 clinical practice. J Clin Psychol 69:856–
Clarkin JF, Levy KN, Lenzenweger MF, et al: 867, 2013
Evaluating three treatments for border- Giesen-Bloo JH, van Dyck R, Spinhoven P, et
line personality disorder: a multiwave al: Outpatient psychotherapy for bor-
study. Am J Psychiatry 164:922–928, derline personality disorder: random-
2007 ized trial of schema-focused therapy vs
Cottraux J, Note ID, Boutitie F, et al: Cogni- transference-focused psychotherapy.
tive therapy versus Rogerian supportive Arch Gen Psychiatry 63:649–658, 2006
therapy in borderline personality disor- Gilbert P, Proctor S: Compassionate mind
der: two-year follow-up of a controlled pi- training for people with high shame and
lot study. Psychother Psychosom 78:307– self-criticism: overview and pilot study
316, 2009 of a group therapy approach. Clin Psy-
Cox BJ, Pagura J, Stein MB, et al: The relation- chol Psychother 13:353–379, 2006
ship between generalized social phobia Gratz K, Gunderson J: Preliminary data on
and avoidant personality disorder in a acceptance-based emotion regulation
national mental health survey. Depress group intervention for deliberate self-
Anxiety 26:354–362, 2009 harm among women with borderline
Davidson KM, Norrie J, Tyrer P, et al: The ef- personality disorder. Behav Ther 37:25–
fectiveness of cognitive behavior ther- 35, 2006
apy for borderline personality disorder: Gratz KL, Roemer L: Multidimensional
results from the borderline personality assessment of emotion regulation and
disorder study of cognitive therapy dysregulation: development, factor
278 The American Psychiatric Publishing Textbook of Personality Disorders
281
282 The American Psychiatric Publishing Textbook of Personality Disorders
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
284 The American Psychiatric Publishing Textbook of Personality Disorders
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 con- ventions 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-
Group, Family, and Couples Therapies 285
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
286 The American Psychiatric Publishing Textbook of Personality Disorders
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 re- per 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
Group, Family, and Couples Therapies 287
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
290 The American Psychiatric Publishing Textbook of Personality Disorders
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-
Group, Family, and Couples Therapies 291
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 in- cluding 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
292 The American Psychiatric Publishing Textbook of Personality Disorders
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).
Group, Family, and Couples Therapies 293
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
296 The American Psychiatric Publishing Textbook of Personality Disorders
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-
Group, Family, and Couples Therapies 297
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
298 The American Psychiatric Publishing Textbook of Personality Disorders
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-
300 The American Psychiatric Publishing Textbook of Personality Disorders
proach is likely necessary. In general, the twin design. J Abnorm Psychol 122:180–
more severe a person’s problems are, the 194, 2013
Brennan KA, Shaver PR: Attachment styles
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
with personality disorders. Int J Group
mer, everything looks like a nail.”
Psychother 46:357–377, 1996
Cappe RF, Alden LE: A comparison of treat-
ment strategies for clients functionally
References impaired by extreme shyness and social
avoidance. J Consult Clin Psychol 54:796–
Agrawal HR, Gunderson J, Holmes BM, et al: 801, 1986
Attachment studies with borderline Chapman AL: Dialectical behavior therapy:
patients: a review. Harv Rev Psychiatry current indications and unique elements.
12:94–104, 2004 Psychiatry 3:62–68, 2006
Alden L: Short-term structured treatment for Chiesa M, Fonagy P, Holmes J: When less is
avoidant personality disorder. J Consult more: an exploration of psychoanalyti-
Clin Psychol 57:756–764, 1989 cally oriented hospital-based treatment
American Psychiatric Association: Diag- for severe personality disorder. Int J Psy-
nostic and Statistical Manual of Mental choanal 84:637–650, 2003
Disorders, 5th Edition. Arlington, VA, Critchfield KL, Benjamin LS: Principles for
American Psychiatric Association, 2013 psychosocial treatment of personality
Bateman A, Fonagy P: Effectiveness of par- disorder: summary of the APA Division
tial hospitalization in the treatment of 12 Task Force/NASPR review. J Clin Psy-
borderline personality disorder: a ran- chol 62:661–674, 2006
domized controlled trial. Am J Psychia- Friedlander ML, Escudero V, Heatherington
try 156:1563–1569, 1999 L: Therapeutic Alliances in Couple and
Bateman A, Fonagy P: Eight-year follow-up Family Therapy: An Empirically In-
of patients treated for borderline person- formed Guide to Practice. Washington,
ality disorder: mentalization-based treat- DC, American Psychological Associa-
ment versus treatment as usual. Am J tion, 2006
Psychiatry 165:631–638, 2008 Fruzzetti AE, Fruzzetti AR: Borderline per-
Bernard HS: Difficult patients and challeng- sonality disorder, in Treating Difficult
ing situations, in Basics of Group Psycho- Couples: Helping Clients With Coexist-
therapy. Edited by Bernard HS, MacKen- ing Mental and Relationship Disorders.
zie KR. New York, Guilford, 1994, pp Edited by Snyder DK, Whisman MA.
123–156 New York, Guildford, 2003, pp 235–260
Blum N, St. John D, Pfohl B, et al: Systems Fruzzetti AE, Iverson KM: Mindfulness, ac-
Training for Emotional Predictability and ceptance, validation, and “individual”
Problem Solving (STEPPS) for outpatients psychopathology in couples, in Mind-
with borderline personality disorder: a fulness and Acceptance: Expanding the
randomized controlled trial and 1-year Cognitive-Behavioral Tradition. Edited
follow-up. Am J Psychiatry 165:468–478, by Hayes SC, Follette VM, Linehan MM.
2008 New York, Guilford, 2004, pp 168–191
Boddington SJA: Factors associated with drop- Fruzzetti AE, Stantisteban DA, Hoffman PD:
out from a couples therapy clinic. Sex Dialectical behavior therapy with fami-
Relation Therapy 10:321–327, 1995 lies, in Dialectical Behavior Therapy in
Bornovalova MA, Huibregtse BM, Hicks BM, Clinical Practice: Applications Across
et al: Tests of a direct effect of childhood Disorders and Settings. Edited by Dimeff
abuse on adult borderline personality LA, Koerner K. New York, Guilford, 2007,
disorder traits: a longitudinal discordant pp 222–244
Group, Family, and Couples Therapies 301
Gerull F, Meares R, Stevenson J, et al: Beneficial Lorentzen S, Bogwald KP, Hoglen P: Change
effect on family life in treating borderline during and after long-term analytic
personality. Psychiatry 71:59–70, 2008 group psychotherapy. Int J Group Psy-
Gottman JM, Gottman JS: Gottman method chother 52:419–429, 2002
couple therapy, in Clinical Handbook of Magnavita JJ: Challenges in the treatment of
Couple Therapy, 4th Edition. Edited by personality disorders: when the disor-
Gurman AS. New York, Guilford, 2008, der demands comprehensive integra-
pp 138–164 tion. In Session: Psychotherapy in Prac-
Gurman AS, Fraenkel P: The history of cou- tice 4:5–17, 1998
ple therapy: a millennial review. Fam Magnavita JJ: Integrative relational therapy
Process 41:199–260, 2002 of complex clinical syndromes: ending
Herpertz SC, Kunert HJ, Schwenger UB, et al: the multigenerational transmission
Affective responsiveness in borderline process. J Clin Psychol 56:1051–1064,
personality disorder: a psychophysio- 2000
logical approach. Am J Psychiatry Marziali E, Munroe-Blum H: Interpersonal
156:1550–1556, 1999 Group Psychotherapy for Borderline
Hoffman PD, Buteau E, Hooley JM, et al: Personality Disorder. New York, Basic
Family members’ knowledge about bor- Books, 1994
derline personality disorder: correspon- Miller AL, Rathus JH, Linehan MM: Dialecti-
dence with levels of depression, burden, cal Behavior Therapy With Suicidal Ad-
distress, and expressed emotion. Fam olescents. New York, Guilford, 2007
Process 42:469–478, 2003 Oliver M, Perry S, Cade R: Couples therapy
Hoffman PD, Fruzzetti AE, Buteau E, et al: with borderline personality disordered
Family connections: a program for rela- individuals. The Family Journal 16:67–
tives of persons with borderline personal- 72, 2008
ity disorder. Fam Process 44:217–225, 2005 Piper WE, Rosie JS, Joyce AS, et al: Time Lim-
Hooley JM, Gotlib IH: A diathesis-stress con- ited Day Treatment for Personality Dis-
ceptualization of expressed emotion and orders: Integration of Research and Prac-
clinical outcome. Applied and Preven- tice in a Group Program. Washington,
tive Psychology 9:135–151, 2000 DC, American Psychological Associa-
Hooley JM, Hoffman PD: Expressed emotion tion, 1996
and clinical outcome in borderline per- Robins CJ, Schmidt H, Linehan MM: Dialec-
sonality disorder. Am J Psychiatry tical behavior therapy: synthesizing rad-
156:1557–1562, 1999 ical acceptance with skillful means, in
Jacobson NS, Christensen A: Integrative Cou- Mindfulness and Acceptance: Expand-
ples Therapy: Promoting Acceptance and ing the Cognitive-Behavioral Tradition.
Change. New York, WW Norton, 1996 Edited by Hayes SC, Follette VM, Line-
Lebow JL: Handbook of Clinical Family han MM. New York, Guilford, 2004, pp
Therapy. Hoboken, NJ, Wiley, 2005 30–44
Leichsenring F, Leibing E: The effectiveness Rutan JS, Stone WN: Psychodynamic Group
of psychodynamic therapy and cogni- Psychotherapy, 3rd Edition. New York,
tive behavior therapy in the treatment of Guilford, 2001
personality disorders: a meta-analysis. Santisteban DA, Muir JA, Mena MP, et al: In-
Am J Psychiatry 160:1223–1232, 2003 tegrative borderline adolescent family
Lewis JM: For better or worse: interpersonal therapy: meeting the challenges of treat-
relationships and individual outcome. ing adolescents with borderline person-
Am J Psychiatry 155:582–589, 1998 ality disorder. Psychotherapy 40:251–
Linehan MM: Cognitive Behavioral Treat- 264, 2003
ment of Borderline Personality Disorder. Shea M, Elkin I: The NIMH Treatment of De-
New York, Guilford, 1993 pression Collaborative Research Pro-
Links PS, Heslegrave RJ: Prospective studies gram, in Interpersonal Factors in the Ori-
of outcome: understanding the mecha- gin and Course of Affective Disorders.
nisms of change in patients with border- Edited by Mundt C, Fiedler PL, Goldstein
line personality disorder. Psychiatr Clin ML, et al. London, Gaskell/Royal Col-
North Am 23:137–150, 2000 lege of Psychiatrists, 1996, pp 316–328
302 The American Psychiatric Publishing Textbook of Personality Disorders
Stone MH: The Fate of Borderline Patients: Vaughn CE, Leff JP: The influence of family
Successful Outcome and Psychiatric and social factors on the course of psy-
Practice. New York, Guilford, 1990 chiatric illness. Br J Psychiatry 129:125–
Strauss JL, Hayes AM, Johnson SL, et al: 137, 1976
Early alliance, alliance ruptures, and Whisman MA, Tolejko N, Chatav Y: Social
symptom change in a nonrandomized consequences of personality disorders:
trial of cognitive therapy for avoidant and probability and timing of marriage and
obsessive-compulsive disorders. J Con- probability of marital dysfunction. J Pers
sult Clin Psychol 74:337–345, 2006 Disord 21:690–695, 2007
Tuttman S: Principles of psychoanalytic White CN, Gunderson JG, Zanarini MC, et al:
group therapy applied to the treatment Family studies of borderline personality
of borderline and narcissistic disorders, disorder: a review. Harv Rev Psychiatry
in The Difficult Patient in Group: Group 11:8–19, 2003
Psychotherapy With Borderline and Wilberg T, Karterud S, Urnes O, et al: Out-
Narcissistic Disorders. Edited by Roth comes of poorly functioning patients
BE, Stone WN, Kibel HD. Madison, CT, with personality disorders in a day treat-
International Universities Press, 1990, ment program. Psychiatr Serv 49:1462–
pp 7–29 1467, 1998
Yalom ID, Leszcz M: The Theory and Practice
of Group Psychotherapy, 5th Edition.
New York, Basic Books, 2005
C H A P T E R 14
Psychoeducation
Alan E. Fruzzetti, Ph.D.
John G. Gunderson, M.D.
Perry D. Hoffman, Ph.D.
303
304 The American Psychiatric Publishing Textbook of Personality Disorders
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-
306 The American Psychiatric Publishing Textbook of Personality Disorders
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-
308 The American Psychiatric Publishing Textbook of Personality Disorders
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
310 The American Psychiatric Publishing Textbook of Personality Disorders
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 rela- tion 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
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
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
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
318 The American Psychiatric Publishing Textbook of Personality Disorders
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).
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-
References lation, and quality of socioemotional
functioning. Dev Psychol 39:3–19, 2003
Alden L: Short-term structured treatment for Fossati A, Madeddu F, Maffei C: Borderline
avoidant personality disorder. J Consult personality disorders and childhood sex-
Clin Psychol 57:756–764, 1989 ual abuse: a meta-analytic study. J Per-
Anderson CM, Hogarty GE, Reiss DJ: Family sonal Disord 13:268–280, 1999
treatment of adult schizophrenic pa- Fruzzetti AE: The High Conflict Couple: A DBT
tients: a psycho-educational approach. Guide to Finding Peace, Intimacy, and
Schizophr Bull 6:490–505, 1980 Validation. Oakland, CA, New Harbin-
Babcock JC, Green CE, Robie C: Does batter- ger Publications, 2006
ers’ treatment work? A meta-analytic re- Fruzzetti AE: Family Guide to Borderline
view of domestic violence treatment. Personality Disorder. Oakland, CA, New
Clin Psychology Rev 23:1023–1053, 2004 Harbinger Publications (in press)
Bateman A, Fonagy P: Psychotherapy for Fruzzetti AE, Hoffman PD: Family Connec-
Borderline Personality Disorder: Men- tions: Workbook and Training Manual.
talization-Based Treatment. New York, Rye, NY, National Education Alliance
Oxford University Press, 2004 for Borderline Personality Disorder,
Battle CL, Shea MT, Johnson DM, et al: Child- 2002
hood maltreatment associated with Fruzzetti AE, Shenk C, Hoffman PD: Family
adult personality disorders: findings interaction and the development of
from the Collaborative Longitudinal borderline personality disorder: a trans-
Personality Disorders Study. J Pers Dis- actional model. Dev Psychopathol
ord 18:193–211, 2004 17:1007–1030, 2005
Blum N, Pfohl B, John DS, et al: STEPPS: a Greenberg JS: Mothers caring for an adult
cognitive-behavioral systems-based child with schizophrenia: the effects of
group treatment for outpatients with subjective burden on maternal health.
borderline personality disorder—a pre- Family Relations: Interdisciplinary Jour-
liminary report. Compr Psychiatry nal of Applied Family Studies 42:205–
43:301–310, 2002 211, 1993
Blum N, St. John D, Pfohl B, et al: Systems Gunderson JG: Borderline Personality Disor-
Training for Emotional Predictability der: A Clinical Guide. Washington, DC,
and Problem Solving (STEPPS) for out- American Psychiatric Publishing, 2001
320 The American Psychiatric Publishing Textbook of Personality Disorders
Gunderson JG, Berkowitz C: Family Guide- Marsh DT: Families and Mental Illness: New
lines. Belmont, MA, New England Per- Directions in Professional Practice. New
sonality Disorder Association, 2002 York, Praeger, 1992
Gunderson JG, Stout RL, McGlashan TH, et Maurin JT, Boyd CB: Burden of mental illness
al: Ten year course of borderline person- on the family: a critical review. Arch Psy-
ality disorder: psychopathology and func- chiatr Nurs 4:99–107, 1990
tion from the Collaborative Longitudi- McFarlane WR, Dixon L, Lukens E, et al:
nal Personality Disorders study. Arch Family psychoeducation and schizo-
Gen Psychiatry 68:827–837, 2011 phrenia: a review of the literature. J Mar-
Hoffman PD, Fruzzetti AE, Swenson CR: Di- ital Fam Ther 29:223–245, 2003
alectical behavior therapy: family skills Miller AE, Rathus J, Linehan MM: Dialectical
training. Fam Process 38:399–414, 1999 Behavior Therapy Adapted for Suicidal
Hoffman PD, Buteau E, Hooley JM, et al: Adolescents. New York, Guildford, 2006
Family members’ knowledge about bor- O’Donohue WT, Krasner L (eds): Handbook
derline personality disorder: correspon- of Psychological Skills Training. Boston,
dence with their levels of depression, MA, Allyn & Bacon, 1995
burden, distress, and expressed emo- Rajalin M, Wickholm-Pethrus L, Hursti T, et
tion. Fam Process 42:469–478, 2003 al: Dialectical behavior therapy-based
Hoffman PD, Fruzzetti AE, Buteau E, et al: skills training for family members of
Family connections: a program for rela- suicide attempters. Arch Suicide Res
tives of persons with borderline personal- 13:257–263, 2009
ity disorder. Fam Process 44:217–225, 2005 Rathus JH, Miller AL: DBT adapted for sui-
Hoffman PD, Fruzzetti AE, Buteau E: Under- cidal adolescents. Suicide Life Threat Be-
standing and engaging families: an edu- hav 32:146–157, 2002
cation, skills, and support program for Trull TJ, Widiger TA, Frances A: Covariation
relatives impacted by borderline person- of criteria sets for avoidant, schizoid,
ality disorder. J Ment Health 16:69–82, and dependent personality disorders.
2007 Am J Psychiatry 144:767–771, 1987
Holtzworth-Munroe A, Markman H, O’Leary Turner SA, Beidel DC, Dancu DV, et al: Psy-
KD, et al: The need for marital violence chopathology of social phobia and com-
prevention efforts: a behavioral-cogni- parison to avoidant personality disor-
tive secondary prevention program for der. J Abnorm Psychol 95:389–394, 1986
engaged and newly married couples. White CN, Gunderson JG, Zanarini MC:
Applied and Preventive Psychology 4:77– Family studies of borderline personality
88, 1995 disorder: a review. Harv Rev Psychiatry
Hooley JM, Hoffman PD: Expressed emotion 11:8–19, 2003
and clinical outcome in borderline Zanarini MC, Frankenburg FR, Reich DB, et
personality disorder. Am J Psychiatry al: Attainment and stability of sustained
156:1557–1562, 1999 symptomatic remission and recovery
Linehan MM: Cognitive-Behavioral Treat- among patients with borderline person-
ment of Borderline Personality Disorder. ality disorder and Axis II comparison
New York, Guilford, 1993a subjects: a 16-year prospective follow-
Linehan MM: Skill Training Manual for up study. Am J Psychiatry 169:476–483,
Treating Borderline Personality Disor- 2012
der. New York, Guilford, 1993b
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
322 The American Psychiatric Publishing Textbook of Personality Disorders
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
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 medica- tion. 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
Somatic Treatments 325
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
326 The American Psychiatric Publishing Textbook of Personality Disorders
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
328 The American Psychiatric Publishing Textbook of Personality Disorders
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-
Somatic Treatments 329
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).
332 The American Psychiatric Publishing Textbook of Personality Disorders
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
336 The American Psychiatric Publishing Textbook of Personality Disorders
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
American Psychiatric Association: Diag-
Conclusion nostic and Statistical Manual of Mental
Disorders, 5th Edition. Arlington, VA,
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-
Diagnostic Interview for Borderlines and macol 2:159–175, 1978
Bateman A, Fonagy P: Eight-year follow-up
DSM-III, clinical trials in PDs—mostly of patients treated for borderline person-
BPD and STPD—increased in pace. In ality disorder: mentalization-based treat-
this chapter, the results of studies using ment versus treatment as usual. Am J
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
For those medications that have been personality disorder. J Clin Psychiatry
tested in conjunction with structured 59:103–107, 1998
psychosocial therapies, the results have Blais MA, Matthews J, Schouten R, et al: Sta-
been noted, as has the recommendation bility and predictive value of self-report
for further studies. Because the clinical personality traits pre- and post-electro-
convulsive therapy: a preliminary study.
trials mainly focused on diagnostic crite- Compr Psychiatry 39:231–235, 1998
ria with results not showing large effect Bogenschutz MP, George Nurnberg H: Olan-
sizes, meta-analytic studies of trait do- zapine versus placebo in the treatment
mains have been reviewed, with results of borderline personality disorder. J Clin
that may be very helpful in clinical deci- Psychiatry 65:104–109, 2004
Brinkley JR, Beitman BD, Friedel RO: Low-
sion making. Although more data and
dose neuroleptic regimens in the treat-
methods of analysis are available now ment of borderline patients. Arch Gen
than in the past, many issues remain that Psychiatry 36:319–326, 1979
need to be addressed to lead to best Calabrese JR, Bowden CL, Sachs GS, et al: A
treatments. double-blind placebo-controlled study
of lamotrigine monotherapy in outpa-
tients with bipolar I depression. Lamictal
602 Study Group. J Clin Psychiatry
References 60:79–88, 1999
Carroll BJ: Depression and urinary free corti-
Adityanjee, Romine A, Brown E, et al: Que- sol (abstract). Br J Psychiatry 148:218,
tiapine in patients with borderline per- 1986
sonality disorder: an open-label trial. Coccaro EF, Kavoussi RJ: Biological and
Ann Clin Psychiatry 20:219–226, 2008 pharmacological aspects of borderline
American Psychiatric Association: Diag- personality disorder. Hosp Community
nostic and Statistical Manual of Mental Psychiatry 42:1029–1033, 1991
340 The American Psychiatric Publishing Textbook of Personality Disorders
Coccaro EF, Kavoussi RJ: Fluoxetine and im- Hoch P, Polatin P: Pseudoneurotic forms of
pulsive aggressive behavior in personal- schizophrenia. Psychiatr Q 23:248–276,
ity-disordered subjects. Arch Gen Psy- 1949
chiatry 54:1081–1088, 1997 Hogarty GE, Anderson CM, Reiss DJ, et al:
Coccaro EF, Kavoussi RJ, Hauger RL: Sero- Family psychoeducation, social skills
tonin function and antiaggressive re- training, and maintenance chemother-
sponse to fluoxetine: a pilot study. Biol apy in the aftercare treatment of schizo-
Psychiatry 42:546–552, 1997 phrenia, I: one-year effects of a con-
Cornelius JR, Soloff PH, Perel JM, et al: trolled study on relapse and expressed
Fluoxetine trial in borderline personality emotion. Arch Gen Psychiatry 43:633–
disorder. Psychopharmacol Bull 26:151– 642, 1986
154, 1990 Hollander E, Allen A, Lopez RP, et al: A prelim-
Cowdry RW, Gardner DL: Pharmacotherapy inary double-blind, placebo-controlled
of borderline personality disorder: al- trial of divalproex sodium in borderline
prazolam, carbamazepine, trifluopera- personality disorder. J Clin Psychiatry
zine, and tranylcypromine. Arch Gen 62:199–203, 2001
Psychiatry 45:111–119, 1988 Hollander E, Swann AC, Coccaro EF, et al: Im-
de la Fuente JM, Lotstra F: A trial of carbam- pact of trait impulsivity and state aggres-
azepine in borderline personality disor- sion on divalproex versus placebo re-
der. Eur Neuropsychopharmacol 4:479– sponse in borderline personality disorder.
486, 1994 Am J Psychiatry 162:621–624, 2005
Derogatis LR, Lipman RS, Covi L: The SCL-90: Hymowitz P, Frances A, Jacobsberg LB, et al:
an outpatient psychiatric rating scale. Neuroleptic treatment of schizotypal per-
Psychopharmacol Bull 9:13–28, 1973 sonality disorders. Compr Psychiatry
Feske U, Mulsant BH, Pilkonis PA, et al: Clin- 27:267–271, 1986
ical outcome of ECT in patients with ma- Ingenhoven T, Lafay P, Rinne T, et al: Effec-
jor depression and comorbid borderline tiveness of pharmacotherapy for severe
personality disorder. Am J Psychiatry personality disorders: meta-analyses of
161:2073–2080, 2004 randomized controlled trials. J Clin Psy-
Frankenburg FR, Zanarini MC: Clozapine chiatry 71:14–25, 2010
treatment of borderline patients: a pre- Kane J, Honigfeld G, Singer J, et al: Clozapine
liminary study. Compr Psychiatry 34:402– for the treatment-resistant schizophrenic:
405, 1993 a double-blind comparison with chlor-
Frankenburg FR, Zanarini MC: Divalproex promazine. Arch Gen Psychiatry 45:789–
sodium treatment of women with bor- 796, 1988
derline personality disorder and bipolar Kane JM, Carson WH, Saha AR, et al: Effi-
II disorder: a double-blind placebo- cacy and safety of aripiprazole and hal-
controlled pilot study. J Clin Psychiatry operidol versus placebo in patients with
63:442–446, 2002 schizophrenia and schizoaffective disor-
Gardner DL, Cowdry RW: Alprazolam-induced der. J Clin Psychiatry 63:763–771, 2002
dyscontrol in borderline personality disor- Keshavan M, Shad M, Soloff P, et al: Efficacy
der. Am J Psychiatry 142:98–100, 1985 and tolerability of olanzapine in the
Goldberg SC, Schulz SC, Schulz PM, et al: treatment of schizotypal personality dis-
Borderline and schizotypal personality order. Schizophr Res 71:97–101, 2004
disorders treated with low-dose thio- Khalifa N, Duggan C, Stoffers J, et al: Phar-
thixene vs placebo. Arch Gen Psychiatry macological interventions for antisocial
43:680–686, 1986 personality disorder. Cochrane Data-
Goyer PF, Berridge MS, Morris ED, et al: PET base of Systematic Reviews 2010, Issue
measurement of neuroreceptor occu- 8. Art. No.: CD007667. DOI: 10.1002/
pancy by typical and atypical neurolep- 14651858.CD007667.pub2.
tics. J Nucl Med 37:1122–1127, 1996 Koenigsberg HW, Reynolds D, Goodman M,
Gunderson JG, Kolb JE, Austin V: The diag- et al: Risperidone in the treatment of
nostic interview for borderline patients. schizotypal personality disorder. J Clin
Am J Psychiatry 138:896–903, 1981 Psychiatry 64:628–634, 2003
Somatic Treatments 341
Kolb JE, Gunderson JG: Diagnosing border- Nickel C, Lahmann C, Tritt K, et al: Topira-
line patients with a semistructured inter- mate in treatment of depressive and
view. Arch Gen Psychiatry 37:37–41, 1980 anger symptoms in female depressive
Linehan MM, Armstrong HE, Suarez A, et al: patients: a randomized, double-blind,
Cognitive-behavioral treatment of chroni- placebo-controlled study. J Affect Disord
cally parasuicidal borderline patients. 87:243–252, 2005
Arch Gen Psychiatry 48:1060–1064, 1991 Nickel MK, Nickel C, Mitterlehner FO, et
Linehan MM, McDavid JD, Brown MZ, et al: al: Topiramate treatment of aggression
Olanzapine plus dialectical behavior in female borderline personality disor-
therapy for women with high irritability der patients: a double-blind, placebo-
who meet criteria for borderline person- controlled study. J Clin Psychiatry 65:1515–
ality disorder: a double-blind, placebo- 1519, 2004
controlled pilot study. J Clin Psychiatry Nickel MK, Nickel C, Kaplan P, et al: Treat-
69:999–1005, 2008 ment of aggression with topiramate in
Links PS, Mitton JE, Steiner M: Predicting out- male borderline patients: a double-blind,
come for borderline personality disorder. placebo-controlled study. Biol Psychia-
Compr Psychiatry 31:490–498, 1990 try 57:495–499, 2005
Loew TH, Nickel MK, Muehlbacher M, et al: Nickel MK, Muehlbacher M, Nickel C, et al:
Topiramate treatment for women with Aripiprazole in the treatment of pa-
borderline personality disorder: a double- tients with borderline personality dis-
blind, placebo-controlled study. J Clin order: a double-blind, placebo-con-
Psychopharmacol 26:61–66, 2006 trolled study. Am J Psychiatry 163:833–
Loring DW, Williamson DJ, Meador KJ, et al: 838, 2006
Topiramate dose effects on cognition: a Nickel MK, Loew TH, Pedrosa Gil F: Aripip-
randomized double-blind study. Neurol- razole in treatment of borderline pa-
ogy 76:131–137, 2011 tients, part II: an 18-month follow-up.
Markovitz PJ, Wagner SC: Venlafaxine in the Psychopharmacology (Berl) 191:1023–
treatment of borderline personality dis- 1026, 2007
order. Psychopharmacol Bull 31:773– Okuma T: Therapeutic and prophylactic ef-
777, 1995 fects of carbamazepine in bipolar disor-
Markovitz PJ, Calabrese JR, Schulz SC, et al: ders. Psychiatr Clin North Am 6:157–
Fluoxetine in the treatment of borderline 174, 1983
and schizotypal personality disorders. Pinto OC, Akiskal HS: Lamotrigine as a
Am J Psychiatry 148:1064–1067, 1991 promising approach to borderline per-
National Collaborating Centre for Mental sonality: an open case series without con-
Health: Borderline Personality Disorder: current DSM-IV major mood disorder. J
The National Institute for Health and Affect Disord 51:333–343, 1998
Clinical Excellence (NICE) Treatment Post RM, Rubinow DR, Ballenger JC: Condi-
and Management Guidelines. National tioning and sensitization in the longitu-
Clinical Practice Guideline No 78. Lon- dinal course of affective illness. Br J Psy-
don, RCPsych Publications, 2009 chiatry 149:191–201, 1986
National Health and Medical Research Council: Practice guideline on diagnosis and treat-
Clinical Practice Guideline for Manage- ment of adult patients with a personality
ment of Borderline Personality Disorder. disorder [in Dutch]. Utrecht, The Neth-
Melbourne, Australia, National Health erlands, Trimbos Instituut, 2008
and Medical Research Council, 2012 Ravaris CL, Nies A, Robinson DS, et al: A
Nelson KJ, Schulz SC: Pharmacotherapy for multiple-dose, controlled study of phen-
borderline personality disorder. Current elzine in depression-anxiety states. Arch
Psychiatry 10:30–40, 2011 Gen Psychiatry 33:347–350, 1976
New AS, Buchsbaum MS, Hazlett EA, et al: Reich DB, Zanarini MC, Bieri KA: A prelimi-
Fluoxetine increases relative metabolic nary study of lamotrigine in the treat-
rate in prefrontal cortex in impulsive ment of affective instability in border-
aggression. Psychopharmacology (Berl) line personality disorder. Int Clin
176:451–458, 2004 Psychopharmacol 24:270–275, 2009
342 The American Psychiatric Publishing Textbook of Personality Disorders
Rifkin A, Quitkin F, Carrillo C, et al: Lithium Soloff PH, Cornelius J, George A, et al: Effi-
carbonate in emotionally unstable char- cacy of phenelzine and haloperidol in
acter disorder. Arch Gen Psychiatry borderline personality disorder. Arch
27:519–523, 1972 Gen Psychiatry 50:377–385, 1993
Rocca P, Marchiaro L, Cocuzza E, et al: Treat- Spielberger CD, Sydeman SJ, Owen AE, et al
ment of borderline personality disorder (eds): Measuring anxiety and anger with
with risperidone. J Clin Psychiatry 63:241– the State-Trait Anxiety Inventory (STAI)
244, 2002 and the State-Trait Anger Expression In-
Salzman C, Wolfson AN, Schatzberg A, et al: ventory (STAXI), in The Use of Psycho-
Effect of fluoxetine on anger in symp- logical Testing for Treatment Planning
tomatic volunteers with borderline per- and Outcomes Assessment, 2nd Edition.
sonality disorder. J Clin Psychopharma- Mahwah, NJ, Erlbaum, 1999, pp 993–1021
col 15:23–29, 1995 Stoffers JM, Völlm B.A, Rücker G, et al: Phar-
Schulz SC, Camlin KL, Berry SA, et al: A dou- macological interventions for borderline
ble-blind study or risperidone for BPD personality disorder. Cochrane Data-
(NR270), in New Research Program and base of Systematic Reviews 2010, Issue
Abstracts, American Psychiatric Associ- 6. Art. No.: CD005653. DOI: 10.1002/
ation Annual Meeting, Toronto, Ontario, 14651858.CD005653.pub2.
Canada, May 30–June 4, 1998 Stoffers JM, Völlm BA, Rücker G, et al: Psy-
Schulz SC, Zanarini MC, Bateman A, et al: chological therapies for people with bor-
Olanzapine for the treatment of border- derline personality disorder. Cochrane
line personality disorder: variable dose Database of Systematic Reviews 2012,
12-week randomised double-blind pla- Issue 8. Art. No.: CD005652. DOI:
cebo-controlled study. Br J Psychiatry 10.1002/14651858.CD005652.pub2.
193:485–492, 2008 Tollefson GD, Beasley CM Jr, Tran PV, et al:
Serban G, Siegel S: Response of borderline Olanzapine versus haloperidol in the
and schizotypal patients to small doses treatment of schizophrenia and schizoaf-
of thiothixene and haloperidol. Am J fective and schizophreniform disorders:
Psychiatry 141:1455–1458, 1984 results of an international collaborative
Simpson EB, Yen S, Costello E, et al: Combined trial. Am J Psychiatry 154:457–465, 1997
dialectical behavior therapy and fluox- Tritt K, Nickel C, Lahmann C, et al: Lamotri-
etine in the treatment of borderline per- gine treatment of aggression in female
sonality disorder. J Clin Psychiatry 65:379– borderline-patients: a randomized, double-
385, 2004 blind, placebo-controlled study. J Psy-
Small JG, Hirsch SR, Arvanitis LA, et al: Que- chopharmacol 19:287–291, 2005
tiapine in patients with schizophrenia: a Zanarini MC, Frankenburg FR: Olanzapine
high- and low-dose double-blind com- treatment of female borderline personal-
parison with placebo. Seroquel Study ity disorder patients: a double-blind,
Group. Arch Gen Psychiatry 54:549–557, placebo-controlled pilot study. J Clin
1997 Psychiatry 62:849–854, 2001
Soler J, Pascual JC, Campins J, et al: Double- Zanarini MC, Frankenburg FR: Omega-3
blind, placebo-controlled study of dia- fatty acid treatment of women with bor-
lectical behavior therapy plus olanzapine derline personality disorder: a double-
for borderline personality disorder. Am blind, placebo-controlled pilot study.
J Psychiatry 162:1221–1224, 2005 Am J Psychiatry 160:167–169, 2003
Soloff PH, George A, Nathan RS, et al: Para- Zanarini MC, Frankenburg FR: A preliminary,
doxical effects of amitriptyline on border- randomized trial of psychoeducation for
line patients. Am J Psychiatry 143:1603– women with borderline personality dis-
1605, 1986 order. J Pers Disord 22:284–290, 2008
Soloff PH, George A, Nathan S, et al: Ami- Zanarini MC, Vujanovic AA, Parachini EA, et
triptyline versus haloperidol in border- al: A screening measure for BPD: the
lines: final outcomes and predictors of re- McLean Screening Instrument for Bor-
sponse. J Clin Psychopharmacol 9:238– derline Personality Disorder (MSI-BPD).
246, 1989 J Pers Disord 17:568–573, 2003a
Somatic Treatments 343
Zanarini MC, Vujanovic AA, Parachini EA, et Zanarini MC, Schulz SC, Detke HC, et al: A
al: Zanarini Rating Scale for Borderline dose comparison of olanzapine for the
Personality Disorder (ZAN-BPD): a con- treatment of borderline personality dis-
tinuous measure of DSM-IV borderline order: a 12-week randomized, double-
psychopathology. J Pers Disord 17:233– blind, placebo-controlled study. J Clin
242, 2003b Psychiatry 72:1353–1362, 2011
Zanarini MC, Frankenburg FR, Parachini EA: Zanarini MC, Schulz SC, Detke H, et al:
A preliminary, randomized trial of fluox- Open-label treatment with olanzapine
etine, olanzapine, and the olanzapine- for patients with borderline personality
fluoxetine combination in women with disorder. J Clin Psychopharmacol 32:398–
borderline personality disorder. J Clin 402, 2012
Psychiatry 65:903–907, 2004 Zimmerman M, Coryell W, Pfohl B, et al: ECT
Zanarini MC, Stanley B, Black DW, et al: response in depressed patients with and
Methodological considerations treat- without a DSM-III personality disorder.
ment trials for persons with personality Am J Psychiatry 143:1030–1032, 1986
disorder. Ann Clin Psychiatry 22:75–83,
2010
This page intentionally left blank
C H A P T E R 16
Collaborative Treatment
Abigail B. Schlesinger, M.D.
Kenneth R. Silk, M.D.
345
346 The American Psychiatric Publishing Textbook of Personality Disorders
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
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
Collaborative Treatment 351
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
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
354 The American Psychiatric Publishing Textbook of Personality Disorders
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.
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:
Collaborative Treatment 357
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
360 The American Psychiatric Publishing Textbook of Personality Disorders
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.
Collaborative Treatment 361
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.
362 The American Psychiatric Publishing Textbook of Personality Disorders
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
Collaborative Treatment 363
tiveness and costs. J Affect Disord 68:317– Donohue J, Garfield R, Lave J: The Impact of
330, 2002 Expanded Health Insurance Coverage
Cardasis W, Hochman JA, Silk KR: Transi- on Individuals With Mental Illnesses
tional objects and borderline personality and Substance Use Disorders. Washing-
disorder. Am J Psychiatry 154:250–255, ton, DC, U.S. Department of Health and
1997 Human Services, 2010
Casillas A, Clark LA: Dependency, impulsiv- Duggan C, Huband N, Smailagic N, et al: The
ity, and self-harm: traits hypothesized to use of pharmacological treatments for
underlie the association between cluster people with personality disorder: a sys-
B personality and substance use disor- tematic review of randomized controlled
ders. J Pers Disord 16:424–436, 2002 trials. Personality and Mental Health
Chiles JA, Carlin AS, Benjamin GAH, et al: A 2:119–170, 2008
physician, a nonmedical psychothera- Frankenburg FR, Zanarini MC: Personality
pist, and a patient: the pharmacotherapy- disorders and medical comorbidity. Cur
psychotherapy triangle, in Integrating Opin Psychiatry 19:428–431, 2006
Pharmacotherapy and Psychotherapy. Fuerino L 3rd, Silk KR: State of the art in the
Edited by Beitman BD, Klerman GL. pharmacologic treatment of borderline
Washington DC, American Psychiatric personality disorder. Curr Psychiatry
Press, 1991, pp 105–118 Rep 13:69–75, 2011
Clarkin JF, Yeomans FE, Kernberg OF: Psy- Gabbard GO: Splitting in hospital treatment.
chotherapy for Borderline Personality. Am J Psychiatry 146:444–451, 1989
New York, Wiley, 1999 Gabbard GO, Wilkinson SM: Management of
Cloninger CR, Svrakic DM, Przybeck TR: A Countertransference With Borderline
psychobiological model of temperament Patients. Washington, DC, American Psy-
and character. Arch Gen Psychiatry chiatric Press, 1994
50:975–990, 1993 Gardner DL, Cowdry RW: Alprazolam in-
Coccaro EF, Kavoussi RJ: Fluoxetine and duced dyscontrol in borderline person-
impulsive aggressive behavior in per- ality disorder. Am J Psychiatry 142:98–
sonality-disordered subjects. Arch Gen 100, 1985
Psychiatry 54:1081–1088, 1997 Gilbody S, Bower P, Fletcher J, et al: Collabor-
Coccaro EF, Siever L, Klar HM, et al: Seroto- ative care for depression: a cumulative
nergic studies in patients with affective meta-analysis and review of longer term
and personality disorders. Arch Gen outcomes. Arch Intern Med 166:2314–
Psychiatry 46:587–599, 1989 2321, 2006
Cowdry RW, Gardner DL: Pharmacotherapy Goldberg RS, Riba M, Tasman A: Psychia-
of borderline personality disorder: al- trists’ attitudes toward prescribing med-
prazolam, carbamazepine, trifluopera- ication for patients treated by nonmedi-
zine, and tranylcypromine. Arch Gen cal psychotherapists. Hosp Community
Psychiatry 45:111–119, 1988 Psychiatry 42:276–280, 1991
Davidson K, Norrie J, Tyrer P, et al: The effec- Goldberg SC, Schulz SC, Schulz PM, et al:
tiveness of cognitive behavior therapy for Borderline and schizotypal personality
borderline personality disorder: results disorders treated with low-dose thio-
from the borderline personality disorder thixene vs. placebo. Arch Gen Psychiatry
study of cognitive therapy (BOSCOT) 43:680–686, 1986
trial. J Pers Disord 20:450–465, 2006 Goldhamer PM: Psychotherapy and pharma-
de Groot MH, Franken IH, van der Meer CW, cotherapy: the challenge of integration.
et al: Stability and change in dimen- Can J Psychiatry 38:173–177, 1984
sional ratings of personality disorders Greenblatt M, Solomon MH, Evans A, et al
in drug abuse patients during treatment. (eds): Drug and Social Therapy in Chronic
J Subst Abuse Treat 24:115–120, 2003 Schizophrenia. Springfield, IL, Charles
de Jonghe F, Hendricksen M, van Aalst G, et al: C Thomas, 1965
Psychotherapy alone and combined with Gunderson JG: Borderline Personality Disor-
pharmacotherapy in the treatment of de- der. Washington, DC, American Psychi-
pression. Br J Psychiatry 185:37–45, 2004 atric Press, 1984
366 The American Psychiatric Publishing Textbook of Personality Disorders
Boundary Issues
Thomas G. Gutheil, M.D.
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
370 The American Psychiatric Publishing Textbook of Personality Disorders
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.
372 The American Psychiatric Publishing Textbook of Personality Disorders
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
374 The American Psychiatric Publishing Textbook of Personality Disorders
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 pa- tient’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.
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.
385
386 The American Psychiatric Publishing Textbook of Personality Disorders
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
General population
Time course
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-
Assessing and Managing Suicide Risk 389
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
390 The American Psychiatric Publishing Textbook of Personality Disorders
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
Assessing and Managing Suicide Risk 391
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-
Assessing and Managing Suicide Risk 393
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.
394 The American Psychiatric Publishing Textbook of Personality Disorders
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
Assessing and Managing Suicide Risk 395
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
398 The American Psychiatric Publishing Textbook of Personality Disorders
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
Assessing and Managing Suicide Risk 399
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-
400 The American Psychiatric Publishing Textbook of Personality Disorders
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
Assessing and Managing Suicide Risk 401
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-
gency department. They should prepare References
for the next crisis by developing a safety
plan, similar to Paula’s above. The clini- Ahrens B, Haug HJ: Suicidality in hospital-
cian should encourage patients to recog- ized patients with a primary diagnosis
nize their personal early warning signs of personality disorder. Crisis 17:59–63,
and to prepare a crisis kit to take with 1996
American Psychiatric Association: Diag-
them to the emergency department. This nostic and Statistical Manual of Mental
kit would include a card specifying their Disorders, 4th Edition. Washington, DC,
medications, physicians’ contact informa- American Psychiatric Association, 1994
1
Steps adapted from Stanley B, Brown GK: “Safety Planning Intervention: A Brief Intervention
to Mitigate Suicide risk.” Cognitive and Behavioral Practice 19:256–264, 2012.
402 The American Psychiatric Publishing Textbook of Personality Disorders
der: an event-related fMRI study. Psy- with childhood abuse and borderline per-
chiatry Res 155:231–243, 2007 sonality disorder. Psychiatry Res 122:193–
Modai I, Kuperman J, Goldberg I, et al: Sui- 198, 2003
cide risk factors and suicide vulnerabil- Schneider B, Wetterling T, Sargk D, et al: Axis
ity in various psychiatric disorders. Med I disorders and personality disorders as
Inform 29:65–74, 2004 risk factors for suicide. Eur Arch Psychi-
New AS, Hazlett EA, Buchsbaum MS, et al: atry Clin Neurosci 256:17–27, 2006
Blunted prefrontal cortical 18-fluorode- Shea MT, Stout R, Gunderson J, et al: Short-
oxyglucose positron emission tomogra- term diagnostic stability of schizotypal,
phy response to meta-chlorophenylpi- borderline, avoidant, and obsessive-
perazine in impulsive aggression. Arch compulsive personality disorders. Am J
Gen Psychiatry 59:621–629, 2002 Psychiatry 159:2036–2041, 2002
New AS, Hazlett EA, Buchsbaum MS, et al: Shea MT, Edelen MO, Pinto A, et al: Improve-
Amygdala-prefrontal disconnection in ment in borderline personality disorder in
borderline personality disorder. Neuro- relation to age. Acta Psychiatr Scand
psychopharmacology 32:1629–1640, 2007 119:143–148, 2009
New AS, Goodman M, Triebwasser J, et al: Siever LJ, Buchsbaum M, New AS, et al: d,l
Recent advances in the biological study fenfluramine response in impulsive per-
of personality disorders. Psychiatr Clin sonality disorder assessed with [18F]flu-
North Am 31:441–461, 2008 orodeoxyglucose positron emission to-
Nickel MK, Muehlbacher M, Nickel C, et al: mography. Neuropsychopharmacology
Aripiprazole in the treatment of patients 20:413–423, 1999
with borderline personality disorder: a Silbersweig D, Clarkin JF, Goldstein M, et al:
double-blind placebo-controlled study. Failure of fronto-limbic inhibitory func-
Am J Psychiatry 163:833–838, 2006 tion in the context of negative emotion
Oquendo MA, Mann JJ: The biology of im- in borderline personality disorder. Am J
pulsivity and suicidality. Psychiatr Clin Psychiatry 164:1832–1841, 2007
North Am 23:11–27, 2000 Skodol AE, Pagano ME, Bender DS, et al: Sta-
Oquendo MA, Galfalvy H, Russo S, et al: Pro- bility of functional impairment in patients
spective study of clinical predictors of with schizotypal, borderline, avoidant,
suicidal acts after a major depressive ep- or obsessive-compulsive personality
isode in patients with major depressive disorder over two years. Psychol Med
disorder or bipolar disorder. Am J Psy- 35:443–451, 2005
chiatry 161:1433–1441, 2004 Soloff PH: Risk factors for suicidal behavior
Paris J: Half in love with easeful death: the in borderline personality disorder: a re-
meaning of chronic suicidality in bor- view and update, in Borderline Person-
derline personality disorder. Harv Rev ality Disorder. Edited by Zanarini MC.
Psychiatry 12:42–48, 2004 Boca Raton, FL, Taylor & Francis, 2005,
Paris J, Zweig-Frank H: A 27-year follow-up of pp 333–365
patients with borderline personality dis- Soloff PH, Chiappetta L: Prospective predic-
order. Compr Psychiatry 42:482–487, 2001 tors of suicidal behavior in borderline
Perry JC, Fowler JC, Bailey A, et al: Improve- personality disorder at 6-year follow-
ment and recovery from suicidal and up. Am J Psychiatry 169:484–490, 2012
self-destructive phenomena in treat- Soloff PH, Meltzer CC, Greer PJ, et al: A fen-
ment-refractory disorders. J Nerv Ment fluramine-activated FDG-PET study of
Dis 197:28–34, 2009 borderline personality disorder. Biol
Runeson BS, Beskow J, Waern M: The suicidal Psychiatry 47:540–547, 2000
process in suicides among young people. Soloff PH, Lynch KG, Kelly TM: Childhood
Acta Psychiatr Scand 93:35–42, 1996 abuse as a risk factor for suicidal behav-
Schmahl C, Bremner JD: Neuroimaging in ior in borderline personality disorder.
borderline personality disorder. J Psy- J Pers Disord 16:201–214, 2002
chiatr Res 40:419–427, 2006 Soloff PH, Meltzer CC, Becker C, et al: Impul-
Schmahl CG, Vermetten E, Elzinga BM, et al: sivity and prefrontal hypometabolism in
Magnetic resonance imaging of hippo- borderline personality disorder. Psychi-
campal and amygdala volume in women atry Res 123:153–163, 2003
Assessing and Managing Suicide Risk 405
Soloff PH, Fabio A, Kelly TM, et al: High- havior. Am J Psychiatry 161:1296–1298,
lethality status in patients with border- 2004
line personality disorder. J Pers Disord Yen S, Pagano ME, Shea MT, et al: Recent life
19:386–399, 2005 events preceding suicide attempts in a
Soloff PH, Feske U, Fabio A: Mediators of the personality disorder sample: findings
relationship between childhood sexual from the Collaborative Longitudinal
abuse and suicidal behavior in border- Personality Disorders Study. J Consult
line personality disorder. J Pers Disord Clin Psychol 73:99–105, 2005
22:221–232, 2008a Yen S, Shea MT, Sanislow CA, et al: Personal-
Soloff PH, Nutche J, Goradia D, et al: Struc- ity traits as prospective predictors of
tural brain abnormalities in borderline suicide attempts. Acta Psychiatr Scand
personality disorder: a voxel-based mor- 120:222–229, 2009
phometry study. Psychiatry Res 164:223– Yoshida K, Tonai E, Nagai H, et al: Long-term
236, 2008b follow-up study of borderline patients in
Soloff PH, Pruitt P, Sharma M, et al: Struc- Japan: a preliminary study. Compr Psychi-
tural brain abnormalities and suicidal atry 47:426–432, 2006
behavior in borderline personality dis- Zaheer J, Links PS, Liu E: Assessment and
order. J Psychiatr Res 46:516–525, 2012 emergency management of suicidality
Stanley B, Brown GK: Safety planning inter- in personality disorders. Psychiatr Clin
vention: a brief intervention to mitigate North Am 31:527–543, 2008
suicide risk. Cogn Behav Pract 19:256– Zanarini MC, Frankenburg FR, Hennen J,
264, 2012 et al: Mental health utilization by bor-
Stanley B, Gameroff MJ, Michalsen V, et al: derline personality disorder patients
Are suicide attempters who self-muti- and axis II comparison subjects followed
late a unique population? Am J Psychia- prospectively for six years. J Clin Psychi-
try 158:427–432, 2001 atry 65:28–36, 2004
Stone MH: Long-term follow-up of narcissis- Zanarini MC, Frankenburg FR, Hennen J, et
tic/borderline patients. Psychiatr Clin al: Psychosocial functioning of border-
North Am 12:621–641, 1989 line patients and Axis II comparison
Tebartz van Elst L, Hesslinger B, Thiel T, et al: subjects followed prospectively for six
Frontolimbic brain abnormalities in pa- years. J Pers Disord 19:19–29, 2005
tients with borderline personality disor- Zanarini MC, Frankenburg FR, Hennen J, et
der: a volumetric magnetic resonance al: Prediction of the 10-year course of
imaging study. Biol Psychiatry 54:163– borderline personality disorder. Am J Psy-
171, 2003 chiatry 163:827–832, 2006
Vita A, De Peri L, Sacchetti E: Antipsychotics, Zanarini MC, Frankenburg FR, Reich DB, et
antidepressants, anticonvulsants, and al: Time to attainment of recovery from
placebo on the symptom dimensions of borderline personality disorder and sta-
borderline personality disorder. J Clin bility of recovery: a 10-year prospective
Psychopharmacol 31:613–624, 2011 follow-up study. Am J Psychiatry 167:663–
Wedig MM, Silverman MH, Frankenburg FR, 667, 2010
et al: Predictors of suicide attempts in Zanarini MC, Frankenburg FR, Reich DB, et
patients with borderline personality dis- al: Attainment and stability of sustained
order over 16 years of prospective fol- symptomatic remission and recovery
low-up. Psychol Med 22:1–10, 2012 among patients with borderline person-
Yen S, Shea MT, Pagano M, et al: Axis I and ality disorder and axis II comparison
Axis II disorders as predictors of pro- subjects: a 16-year prospective follow-up
spective suicide attempts: findings from study. Am J Psychiatry 169:476–483, 2012
the collaborative longitudinal personal- Zetzsche T, Preuss UW, Frodl T, et al: Hippo-
ity disorders study. J Abnorm Psychol campal volume reduction and history of
112:375–381, 2003 aggressive behavior in patients with
Yen S, Shea MT, Sanislow CA, et al: Borderline borderline personality disorder. Psychi-
personality disorder criteria associated atry Res 154:157–170, 2007
with prospectively observed suicidal be-
This page intentionally left blank
C H A P T E R 19
407
408 The American Psychiatric Publishing Textbook of Personality Disorders
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
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 ob- ses. 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.
Substance Use Disorders 411
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.
412 The American Psychiatric Publishing Textbook of Personality Disorders
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
Substance Use Disorders 415
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
416 The American Psychiatric Publishing Textbook of Personality Disorders
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
Substance Use Disorders 417
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.
Substance Use Disorders 419
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.
422 The American Psychiatric Publishing Textbook of Personality Disorders
Borman PD, Zilberman ML, Tavares H, et al: de Lima MS, de Oliveira Soares BG, Reisser
Personality changes in women recover- AA, et al: Pharmacological treatment of
ing from substance-related dependence. cocaine dependence: a systematic re-
J Addict Dis 25:59–66, 2006 view. Addiction 97:931–949, 2002
Cacciola JS, Alterman AI, Rutherford MJ, et Dick DM, Meyers J, Aliev F, et al: Evidence
al: Treatment response of antisocial sub- for genes on chromosome 2 contributing
stance abusers. J Nerv Ment Dis 183:166– to alcohol dependence with conduct
171, 1995 disorder and suicide attempts. Am J
Cacciola JS, Rutherford MJ, Alterman AI, et Med Genet B Neuropsychiatr Genet
al: Personality disorders and treatment 153B:1179–1188, 2010
outcome in methadone maintenance pa- Dimeff L, Rizvi SL, Brown M, et al: Dialectical
tients. J Nerv Ment Dis 184:234–239, 1996 behavior therapy for substance abuse: a
Caspi A, Begg D, Dickson N, et al: Personal- pilot application to methamphetamine-
ity differences predict health-risk behav- dependent women with borderline per-
iors in young adulthood: evidence from sonality disorder. Cogn Behav Pract
a longitudinal study. J Pers Soc Psychol 7:457–468, 2000
73:1052–1063, 1997 Dorus W, Ostrow DG, Anton R, et al: Lithium
Cloninger CR, Sigvardsson S, Bohman M: treatment of depressed and non-depressed
Childhood personality predicts alcohol alcoholics. JAMA 262:1646–1652, 1989
abuse in young adults. Alcohol Clin Exp Easton CJ, Oberleitner LM, Scott MC, et al:
Res 12:494–505, 1988 Differences in treatment outcome among
Coccaro EF, Kavoussi RJ: Fluoxetine and im- marijuana-dependent young adults with
pulsive aggressive behavior in personal- and without antisocial personality dis-
ity-disordered subjects. Arch Gen Psy- order. Am J Drug Alcohol Abuse 38:305–
chiatry 54:1081–1088, 1997 313, 2012
Cohen P, Chen H, Crawford TN, et al: Per- Eaton NR, Krueger RF, Keyes KM, et al: Bor-
sonality disorders in early adolescence derline personality disorder comorbid-
and the development of later substance ity: relationship to the internalizing-
use disorders in the general population. externalizing structure of common men-
Drug Alcohol Depend 88 (suppl 1):S71– tal disorders. Psychol Med 41:1041–
S84, 2007 1050, 2011
Conrod PJ, Pihl RO, Vassileva J: Differential Fenton MC, Keyes K, Geier T, et al: Psychiat-
sensitivity to alcohol reinforcement in ric comorbidity and the persistence of
groups of men at risk for distinct alco- drug use disorders in the United States.
holism subtypes. Alcohol Clin Exp Res Addiction 107:599–609, 2012
22:585–597, 1998 Fernandez-Montalvo J, Lopez-Goni JJ: Com-
Cornelius JR, Salloum IM, Ehler JG, et al: parison of completers and dropouts in
Fluoxetine in depressed alcoholics: a dou- psychological treatment for cocaine ad-
ble-blind, placebo-controlled trial. Arch diction. Addiction Research and Theory
Gen Psychiatry 54:700–705, 1997 18:433–441, 2010
Cowdry RW, Gardner DL: Pharmacotherapy Galen LW, Brower KJ, Gillespie BW, et al: So-
of borderline personality disorder: al- ciopathy, gender, and treatment out-
prazolam, carbamazepine, trifluopera- come among outpatient substance abus-
zine, and tranylcypromine. Arch Gen ers. Drug Alcohol Depend 61:23–33,
Psychiatry 45:111–119, 1988 2000
Dackis CA, O’Brien CP: Cocaine depen- Gawin FH, Allen D, Humblestone B: Outpa-
dence: the challenge for pharmacother- tient treatment of “crack” cocaine smok-
apy. Curr Opin Psychiatry 15:261–267, ing with flupenthixol decanoate: a pre-
2002 liminary report. Arch Gen Psychiatry
Daughters SB, Stipelman BA, Sargeant MN, 46:322–325, 1989
et al: The interactive effects of antisocial Gerstley L, McLellan AT, Alterman AI, et al:
personality disorder and court-man- Ability to form an alliance with the thera-
dated status on substance abuse treatment pist: a possible marker of prognosis for
dropout. J Subst Abuse Treat 34:157–164, patients with antisocial personality disor-
2008 der. Am J Psychiatry 146:508–512, 1989
424 The American Psychiatric Publishing Textbook of Personality Disorders
Gill K, Nolimal D, Crowley TJ: Antisocial Gregory RJ, Remen AL, Soderberg M, et al: A
personality disorder, HIV risk behavior controlled trial of psychodynamic psy-
and retention in methadone maintenance chotherapy for co-occurring borderline
therapy. Drug Alcohol Depend 30:247– personality disorder and alcohol use
252, 1992 disorder: six-month outcome. J Am Psy-
Gilmore CS, Malone SM, Iacono WG: Brain choanal Assoc 57:199–205, 2009
electrophysiological endophenotypes Grella CE, Joshi V, Hser YI: Followup of co-
for externalizing psychopathology: a caine-dependent men and women with
multivariate approach. Behav Genet antisocial personality disorder. J Subst
40:186–200, 2010 Abuse Treat 25:155–164, 2003
Goldman D, Oroszi G, Ducci F: The genetics Griengl H, Sendera A, Dantendorfer K: Nal-
of addictions: uncovering the genes. Nat trexone as a treatment of self-injurious
Rev Genet 6:521–532, 2005 behavior—a case report. Acta Psychiatr
Goldman GA, Gregory RJ: Relationships be- Scand 103:234–236, 2001
tween techniques and outcomes for bor- Harned MS, Chapman AL, Dexter-Mazza ET,
derline personality disorder. Am J Psy- et al: Treating co-occurring Axis I disor-
chother 64:359–371, 2010 ders in recurrently suicidal women with
Goldstein RB, Compton WM, Pulay AJ, et al: borderline personality disorder: a 2-year
Antisocial behavioral syndromes and randomized trial of dialectical behavior
DSM-IV drug use disorders in the United therapy versus community treatment by
States: results from the National Epi- experts. J Consult Clin Psychol 76:1068–
demiologic Survey on Alcohol and Re- 1075, 2008
lated Conditions. Drug Alcohol Depend Haro G, Mateu C, Martinez-Raga J, et al: The
90:145–158, 2007 role of personality disorders on drug de-
Grant BF, Dawson DA, Stinson FS, et al: The pendence treatment outcomes following
Alcohol Use Disorder and Associated Dis- inpatient detoxification. Eur Psychiatry
abilities Interview Schedule-IV (AUDA- 19:187–192, 2004
DIS-IV): reliability of alcohol consump- Hasin D, Hatzenbuehler ML, Keyes K, et al:
tion, tobacco use, family history of Substance use disorders: Diagnostic and
depression and psychiatric diagnostic Statistical Manual of Mental Disorders,
modules in a general population sample. fourth edition (DSM-IV) and Interna-
Drug Alcohol Depend 71:7–16, 2003 tional Classification of Diseases, tenth
Grant BF, Stinson FS, Dawson DA, et al: Co- edition (ICD-10). Addiction 101 (suppl
occurrence of 12-month alcohol and 1):59–75, 2006
drug use disorders and personality dis- Hasin DS, Stinson FS, Ogburn E, et al: Preva-
orders in the United States: results from lence, correlates, disability, and comor-
the National Epidemiologic Survey on bidity of DSM-IV alcohol abuse and de-
Alcohol and Related Conditions. Arch pendence in the United States: results
Gen Psychiatry 61:361–368, 2004 from the National Epidemiologic Sur-
Grant BF, Stinson FS, Dawson DA, et al: Co- vey on Alcohol and Related Conditions.
occurrence of DSM-IV personality disor- Arch Gen Psychiatry 64:830–842, 2007
ders in the United States: results from Hasin D, Fenton MC, Skodol A, et al: Person-
the National Epidemiologic Survey on ality disorders and the 3-year course of
Alcohol and Related Conditions. Compr alcohol, drug, and nicotine use disorders.
Psychiatry 46:1–5, 2005 Arch Gen Psychiatry 68:1158–1167, 2011
Grant BF, Chou SP, Goldstein RB, et al: Prev- Hasin D, O’Brien CP, Auriacombe M, et al:
alence, correlates, disability, and comor- DSM-5 criteria for substance use disor-
bidity of DSM-IV borderline personality ders: recommendations and rationale.
disorder: results from the wave 2 Na- Am J Psychiatry 170:834–851, 2013
tional Epidemiologic Survey on Alcohol Iacono WG, Carlson SR, Taylor J, et al: Behav-
and Related Conditions. J Clin Psychia- ioral disinhibition and the development
try 69:533–545, 2008 of substance-use disorders: findings from
the Minnesota Twin Family Study. Dev
Psychopathol 11:869–900, 1999
Substance Use Disorders 425
Iacono WG, Carlson SR, Malone SM, et al: P3 prehensive validation therapy plus 12-
event-related potential amplitude and step for the treatment of opioid depen-
the risk for disinhibitory disorders in dent women meeting criteria for border-
adolescent boys. Arch Gen Psychiatry line personality disorder. Drug Alcohol
59:750–757, 2002 Depend 67:13–26, 2002
Kendler KS, Aggen SH, Knudsen GP, et al: Longabaugh R, Rubin A, Malloy P, et al:
The structure of genetic and environ- Drinking outcomes of alcohol abusers
mental risk factors for syndromal and diagnosed as antisocial personality dis-
subsyndromal common DSM-IV axis I order. Alcohol Clin Exp Res 18:778–785,
and all axis II disorders. Am J Psychiatry 1994
168:29–39, 2011 Lu RB, Lee JF, Huang SY, et al: Interaction be-
Keyes KM, Eaton NR, Krueger RF, et al: tween ALDH2*1*1 and DRD2/ANKK1
Thought disorder in the meta-structure of TaqI A1A1 genes may be associated with
psychopathology. Psychol Med 43:1673– antisocial personality disorder not co-
1683, 2013 morbid with alcoholism. Addict Biol
King VL, Kidorf MS, Stoller KB, et al: Influ- 17:865–874, 2012
ence of antisocial personality subtypes Marlowe DB, Kirby KC, Festinger DS, et al:
on drug abuse treatment response. J Nerv Impact of comorbid personality disor-
Ment Dis 189:593–601, 2001 ders and personality disorder symp-
Kokkevi A, Stefanis N, Anastasopoulou E, et toms on outcomes of behavioral treat-
al: Personality disorders in drug abus- ment for cocaine dependence. J Nerv
ers: prevalence and their association Ment Dis 185:483–490, 1997
with AXIS I disorders as predictors of Martino S, Carroll K, Kostas D, et al: Dual di-
treatment retention. Addict Behav 23:841– agnosis motivational interviewing: a
853, 1998 modification of motivational interview-
Krampe H, Wagner T, Stawicki S, et al: Per- ing for substance-abusing patients with
sonality disorder and chronicity of ad- psychotic disorders. J Subst Abuse Treat
diction as independent outcome predic- 23:297–308, 2002
tors in alcoholism treatment. Psychiatr Masse LC, Tremblay RE: Behavior of boys in
Serv 57:708–712, 2006 kindergarten and the onset of substance
Kranzler HR, Burleson JA, Del Boca FK, et al: use during adolescence. Arch Gen Psy-
Buspirone treatment of anxious alcohol- chiatry 54:62–68, 1997
ics: a placebo-controlled trial. Arch Gen Mather DB: The role of antisocial personality
Psychiatry 51:720–731, 1994 in alcohol rehabilitation treatment effec-
Krueger RF: The structure of common mental tiveness. Mil Med 152:516–518, 1987
disorders. Arch Gen Psychiatry 56:921– McGlashan TH, Grilo CM, Skodol AE, et al:
926, 1999 The Collaborative Longitudinal Person-
Krueger RF, Caspi A, Moffitt TE, et al: Person- ality Disorders Study: baseline Axis I/II
ality traits are differentially linked to and II/II diagnostic co-occurrence. Acta
mental disorders: a multitrait-multidiag- Psychiatr Scand 102:256–264, 2000
nosis study of an adolescent birth cohort. Messina NP, Wish ED, Hoffman JA, et al: An-
J Abnorm Psychol 105:299–312, 1996 tisocial personality disorder and TC
Linehan MM, Korslund KE: Dialectical be- treatment outcomes. Am J Drug Alcohol
havior therapy: from soup to nuts. Work- Abuse 28:197–212, 2002
shop presentation at the annual meeting Myers MG, Stewart DG, Brown SA: Progres-
of the Association for Behavioral and sion from conduct disorder to antisocial
Cognitive Therapies. Chicago, IL, No- personality disorder following treat-
vember 15–16, 2006 ment for adolescent substance abuse.
Linehan MM, Schmidt H 3rd, Dimeff LA, et Am J Psychiatry 155:479–485, 1998
al: Dialectical behavior therapy for pa- Nace EP, Saxon JJ Jr, Shore N: Borderline per-
tients with borderline personality disor- sonality disorder and alcoholism treat-
der and drug-dependence. Am J Addict ment: a one-year follow-up study. J Stud
8:279–292, 1999 Alcohol 47:196–200, 1986
Linehan MM, Dimeff LA, Reynolds SK, et al: Nielsen P, Rojskjaer S, Hesse M: Personality-
Dialectical behavior therapy versus com- guided treatment for alcohol dependence:
426 The American Psychiatric Publishing Textbook of Personality Disorders
Skeem JL, Manchak S, Peterson JK: Correc- van den Bosch LM, Verheul R, Schippers GM,
tional policy for offenders with mental et al: Dialectical behavior therapy of bor-
illness: creating a new paradigm for re- derline patients with and without sub-
cidivism reduction. Law Hum Behav stance use problemsL implementation
35:110–126, 2011 and long-term effects. Addict Behav
Skodol AE, Oldham JM, Gallaher PE: Axis II 27:911–923, 2002
comorbidity of substance use disorders van Wamel A, Jansen H, Kuijpers E: Addic-
among patients referred for treatment of tion and personality disorders: towards
personality disorders. Am J Psychiatry integrated treatment. Implementation in
156:733–738, 1999 an Axis II treatment team. Mental
Soloff PH: Pharmacological therapies in bor- Health and Substance Use 3:219–226,
derline personality disorder, in Border- 2010
line Personality Disorder: Etiology and Verheul R, van den Brink W, Hartgers C: Per-
Treatment. Edited by Paris J. Washington, sonality disorders predict relapse in al-
DC, American Psychiatric Press, 1993, coholic patients. Addict Behav 23:869–
pp 319–348 882, 1998
Soloff PH: Algorithms for pharmacological Verheul R, van den Brink W, Koeter MW, et
treatment of personality dimensions: al: Antisocial alcoholic patients show as
symptom-specific treatments for cogni- much improvement at 14-month follow-
tive-perceptual, affective, and impulsive- up as non-antisocial alcoholic patients.
behavioral dysregulation. Bull Men- Am J Addict 8:24–33, 1999
ninger Clin 62:195–214, 1998 Verheul R, Kranzler HR, Poling J, et al: Axis I
Stein G: Drug treatment of the personality dis- and Axis II disorders in alcoholics and
orders. Br J Psychiatry 161:167–184, 1992 drug addicts: fact or artifact? J Stud Al-
Stinson FS, Dawson DA, Goldstein RB, et al: cohol 61:101–110, 2000
Prevalence, correlates, disability, and co- Verheul R, Van Den Bosch LM, Koeter MW, et
morbidity of DSM-IV narcissistic per- al: Dialectical behaviour therapy for
sonality disorder: results from the wave women with borderline personality dis-
2 national epidemiologic survey on alco- order: 12-month, randomised clinical
hol and related conditions. J Clin Psychi- trial in the Netherlands. Br J Psychiatry
atry 69:1033–1045, 2008 182:135–140, 2003
Swendsen J, Burstein M, Case B, et al: Use Wills TA, Windle M, Cleary SD: Tempera-
and abuse of alcohol and illicit drugs in ment and novelty seeking in adolescent
US adolescents: results of the National substance use: convergence of dimen-
Comorbidity Survey—Adolescent Sup- sions of temperament with constructs
plement. Arch Gen Psychiatry 69:390– from Cloninger’s theory. J Pers Soc Psy-
398, 2012 chol 74:387–406, 1998
Tarter RE, Vanyukov M: Alcoholism: a devel- Woody GE, McLellan AT, Luborsky L, et al:
opmental disorder. J Consult Clin Psy- Sociopathy and psychotherapy outcome.
chol 62:1096–1107, 1994 Arch Gen Psychiatry 42:1081–1086, 1985
Thomas VH, Melchert TP, Banken JA: Sub- Zanarini MC: Borderline personality disor-
stance dependence and personality der as an impulse spectrum disorder, in
disorders: comorbidity and treatment Borderline Personality Disorder: Etiol-
outcome in an inpatient treatment pop- ogy and Treatment. Edited by Paris J.
ulation. J Stud Alcohol 60:271–277, 1999 Washington, DC, American Psychiatric
Tull MT, Gratz KL: The impact of borderline Press, 1993, pp 67–86
personality disorder on residential sub- Zimmerman M: Diagnosing personality dis-
stance abuse treatment dropout among orders: a review of issues and research
men. Drug Alcohol Depend 121:97–102, methods. Arch Gen Psychiatry 51:225–
2012 245, 1994
van den Bosch LM, Verheul R: Personality Zimmerman M, Coryell W: DSM-III person-
disorders, in Drug Abuse and Addiction ality disorder diagnoses in a nonpatient
in Medical Illness: Causes, Consequences, sample: demographic correlates and co-
and Treatment. New York, Springer, 2012, morbidity. Arch Gen Psychiatry 46:682–
pp 311–321 689, 1989
428 The American Psychiatric Publishing Textbook of Personality Disorders
Antisocial Personality
Disorder and Other
Antisocial Behavior
Donald W. Black, M.D.
Nancee S. Blum, M.S.W.
429
430 The American Psychiatric Publishing Textbook of Personality Disorders
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
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
434 The American Psychiatric Publishing Textbook of Personality Disorders
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
436 The American Psychiatric Publishing Textbook of Personality Disorders
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).
Antisocial Personality Disorder and Other Antisocial Behavior 437
TABLE 20–2. Antisocial personality disorder (ASPD) symptoms in 305 women and
750 men in the NESARC study
Symptoms Women Men Total
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-
Antisocial Personality Disorder and Other Antisocial Behavior 439
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
440 The American Psychiatric Publishing Textbook of Personality Disorders
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.
442 The American Psychiatric Publishing Textbook of Personality Disorders
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
Antisocial Personality Disorder and Other Antisocial Behavior 443
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-
444 The American Psychiatric Publishing Textbook of Personality Disorders
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).
Antisocial Personality Disorder and Other Antisocial Behavior 445
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).
446 The American Psychiatric Publishing Textbook of Personality Disorders
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:
Antisocial Personality Disorder and Other Antisocial Behavior 447
• 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
448 The American Psychiatric Publishing Textbook of Personality Disorders
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-
athy), Revised and Updated. New York,
References Oxford University Press, 2013
Black DW, Andreasen NC: Introductory Text-
book of Psychiatry, 6th Edition. Washing-
American Psychiatric Association: Diagnos- ton, DC, American Psychiatric Publish-
tic and Statistical Manual: Mental Disor- ing, 2014
ders. Washington, DC, American Psy- Black DW, Braun D: Antisocial patients: a
chiatric Association, 1952 comparison of persons with and persons
American Psychiatric Association: Diagnos- without childhood conduct disorder. Ann
tic and Statistical Manual of Mental Dis- Clin Psychiatry 10:53–57, 1998
orders, 2nd Edition. Washington, DC, Black DW, Baumgard CH, Bell SE: A 16- to
American Psychiatric Association, 1968 45-year follow-up of 71 men with antiso-
American Psychiatric Association: Diag- cial personality disorder. Compr Psychi-
nostic and Statistical Manual of Mental atry 36:130–140, 1995a
Disorders, 3rd Edition. Washington, DC, Black DW, Baumgard CH, Bell SE: The long-
American Psychiatric Association, 1980 term outcome of antisocial personality
American Psychiatric Association: Diag- disorder compared with depression,
nostic and Statistical Manual of Mental schizophrenia, and surgical conditions.
Disorders, 3rd Edition, Revised. Wash- Bull Am Acad Psychiatry Law 23:43–52,
ington, DC, American Psychiatric Asso- 1995b
ciation, 1987 Black DW, Baumgard CH, Bell SE, et al:
American Psychiatric Association: Diag- Death rates in 71 men with antisocial
nostic and Statistical Manual of Mental personality disorder: a comparison with
Disorders, 4th Edition. Washington, DC, general population mortality. Psychoso-
American Psychiatric Association, 1994 matics 37:131–136, 1996
American Psychiatric Association: Diag- Black DW, Gunter T, Loveless P, et al: Antiso-
nostic and Statistical Manual of Mental cial personality disorder in incarcerated
Disorders, 5th Edition. Arlington, VA, offenders: clinical characteristics, co-
American Psychiatric Association, 2013 morbidity, and quality of life. Ann Clin
Andreasen NC, Rice J, Endicott J, et al: The Psychiatry 22:113–120, 2010
family history approach to diagnosis: Brennan PA, Mednick SA: Genetic perspec-
how useful is it? Arch Gen Psychiatry tives on crime. Acta Psychiatr Scand
43:421–429, 1986 Suppl 370:19–26, 1993
Åsberg M, Träskman L, Thoren P: 5-HIAA in Brooner RK, Greenfield L, Schmidt CW, et al:
the cerebrospinal fluid: a biochemical Antisocial personality disorder and HIV
suicide predictor? Arch Gen Psychiatry infection among intravenous drug abus-
33:1193–1197, 1976 ers. Am J Psychiatry 150:53–58, 1993
Barratt ES, Kent TA, Bryant SG, et al: A con- Butcher JN, Dahlstrom WG, Graham JR, et al:
trolled trial of phenytoin in impulsive The Minnesota Multiphasic Personality
aggression. J Clin Psychopharmacology Inventory–2 (MMPI-2): Manual for Ad-
11:388–389, 1991 ministration and Scoring. Minneapolis,
Bateman A: Antisocial personality disorder: University of Minnesota, 1989
a mentalizing framework. Focus 11:178– Burt SA, Donnellan MB, Humbad MN, et al:
186, 2013 Does marriage inhibit antisocial be-
Beck A, Freeman A, Davis D: Antisocial per- havior? An examination of selection vs
sonality disorder, in Cognitive Therapy causation via a longitudinal twin de-
of Personality Disorders, 2nd Edition. sign. Arch Gen Psychiatry 67:1309–1315,
New York, Guilford, 2004, pp 162–186 2010
450 The American Psychiatric Publishing Textbook of Personality Disorders
Cacciola JS, Alterman AI, Rutherford MJ, et COT, a pilot randomized controlled trial.
al: Treatment response of antisocial sub- Personal Ment Health 4:86–95, 2010
stance abusers. J Nerv Ment Dis 183:166– Dolan MC: What imaging tells us about vio-
171, 1996 lence in anti-social men. Crim Behav
Cadoret RJ, O’Gorman TW, Troughton E, et Ment Health 20:199–214, 2010
al: Alcoholism and antisocial personal- Donovan SJ, Stewart JW, Nunes EV, et al: Dival-
ity: interrelationships, genetic and envi- proex treatment for youth with explosive
ronmental factors. Arch Gen Psychiatry temper and mood lability: a double-blind,
42:161–167, 1985 placebo-controlled crossover design. Am J
Campbell M, Adams PB, Small AM, et al: Psychiatry 157:818–820, 2000
Lithium in hospitalized aggressive chil- D’Silva K, Duggan C, McCarthy L: Does treat-
dren with conduct disorder: a double- ment really make psychopaths worse? A
blind and placebo-controlled study. J Am review of the evidence. J Pers Disord
Acad Child Adolesc Psychiatry 34:445– 18:163–177, 2004
453, 1995 Dutton DG, Golant SK: The Batterer: A Psy-
Cardasis W, Huth-Bocks A, Silk KR: Tattoos chological Profile. New York, Basic Books,
and antisocial personality disorder. Per- 1995
sonal Ment Health 2:171–182, 2008 Feighner JP, Robins E, Guze SB, et al: Diag-
Caspi A, McClay J, Moffitt TE, et al: Role of nostic criteria for use in psychiatric re-
genotype in the cycle of violence in mal- search. Arch Gen Psychiatry 26:57–63,
treated children. Science 297:851–854, 1972
2002 Gibbon S, Duggan C, Stoffers J, et al: Psy-
Cleckley H: Mask of Sanity: An Attempt to chological interventions for antisocial
Clarify Some Issues About the So-Called personality disorder. Cochrane Data-
Psychopathic Personality, 5th Edition base of Systematic Reviews 2010, Issue
(1941). St. Louis, MO, Mosby, 1976 6. Art. No.: CD007668. DOI: 10.1002/
Coid J, Ullrich S: Antisocial personality dis- 14651858.CD007668.pub2.
order is on a continuum with psychopa- Gibbons DC: Delinquent Behavior, 3rd Edi-
thy. Compr Psychiatry 51:426–433, 2010 tion. Englewood Cliffs, NJ, Prentice Hall,
Compton WM, Conway KP, Stinson FS, et al: 1981
Prevalence, correlates, and comorbidity Gittleman R, Mannuzza S, Shanker R, et al:
of DSM-IV antisocial personality syn- Hyperactive boys almost grown up: I,
dromes and alcohol and specific drug use psychiatric status. Arch Gen Psychiatry
disorders in the United States: results 42:937–947, 1985
from the National Epidemiologic Sur- Glueck S, Glueck E: Unraveling Juvenile
vey on Alcohol and Related Conditions. Delinquency. Cambridge, MA, Harvard
J Clin Psychiatry 66:677–685, 2005 University Press, 1950
Cowdry RW, Gardner DL: Pharmacotherapy Goldstein RB, Powers SI, McCusker J, et al:
of borderline personality disorder: al- Gender differences in manifestations of
prazolam, carbamazepine, trifluopera- antisocial personality disorder among
zine, and tranylcypromine. Arch Gen residential drug abuse treatment clients.
Psychiatry 45:111–119, 1988 Drug Alcohol Depend 41:35–45, 1996
Dahlstrom WG, Welsh GS, Dahlstrom LE: An Goldstein RB, Dawson DA, Saha TD, et al:
MMPI Handbook. Minneapolis, Univer- Antisocial behavioral syndromes and
sity of Minnesota Press, 1972 DSM-IV alcohol use disorders: results
Davidson KM, Tyrer P, Tata P, et al: Cognitive from the National Epidemiologic Sur-
behaviour therapy for violent men with vey on Alcohol and Related Conditions.
antisocial personality disorder in the com- Alcohol Clin Exp Res 31:814–828, 2007
munity: an exploratory randomized con- Grant BF, Stinson FS, Dawson DA, et al: Co-
trolled trial. Psychol Med 39:569–577, occurrence of 12-month alcohol and
2009 drug use disorders and personality dis-
Davidson KM, Halford J, Kirkwood L, et al: orders in the United States—results
CBT for violent men with antisocial per- from the National Epidemiological Sur-
sonality disorder: reflections on the ex- vey on Alcohol and Related Conditions.
perience of carrying out therapy in MAS- Arch Gen Psychiatry 61:361–368, 2004
Antisocial Personality Disorder and Other Antisocial Behavior 451
Guze S: Criminality and Psychiatric Disor- Kiehl KA, Smith AM, Mendrek A, et al: Tem-
ders. New York, Oxford University Press, poral lobe abnormalities in semantic
1976 processing by criminal psychopaths as
Guze SB, Wolfgram ED, McKinney JK, et al: revealed by functional magnetic reso-
Psychiatric illness in the families of con- nance imaging. Psychiatry Res 130:27–
victed criminals: a study of 519 first de- 42, 2004
gree relatives. Dis Nerv Syst 28:651–659, Laumann AE, Derick AJ: Tattoos and body
1967 piercings in the United States: a national
Hare RD: Diagnosis of antisocial personality data set. J Am Acad Dermatol 55:413–
disorder in two prison populations. Am 421, 2006
J Psychiatry 140:887–890, 1983 Lipsey MW: The effect of treatment on juve-
Hare RD: Twenty years of experience with nile delinquents: results from meta-anal-
the Cleckley psychopath, in Unmasking ysis. Presented at a meeting sponsored
the Psychopath—Antisocial Personality by the National Institute of Mental
and Related Syndromes. Edited by Reid Health, Bethesda, MD, October 31–No-
WJ, Dorr D, Walker JI, et al. New York, vember 3, 1992
WW Norton, 1986, pp 3–27 Luntz BK, Widom CS: Antisocial personality
Hare RD: The Hare Psychopathy Checklist— disorder in abused and neglected chil-
Revised. North Tonawanda, NY, Multi- dren grown up. Am J Psychiatry 101:670–
Health Systems, 1991 674, 1994
Hare RD: Without Conscience: The Disturb- Moffitt T: Adolescence limited and life-
ing World of Psychopaths Among Us. course persistent antisocial behavior: a
New York, Pocket Books, 1993 developmental taxonomy. Psychol Rev
Hare RD, Neumann CS: The PCL-R assess- 100:674–701, 1993a
ment of psychopathy: development, Moffitt T: The neuropsychology of conduct
structural properties, and new develop- disorder. Development and Psychopa-
ments, in Handbook of Psychopathy. thology 5:135–151, 1993b
Edited by Patrick CJ. New York, Guil- Myers MG, Stewart DG, Brown SA: Pro-
ford, 2006, pp 58–90 gression from conduct disorder to anti-
Henderson D: Psychopathic States. New social personality disorder following
York, WW Norton, 1939 treatment for adolescent substance
Huesmann LR, Taylor LD: The role of media abuse. Am J Psychiatry 155:479–485,
violence in violent behavior. Annu Rev 1998
Public Health 27:393–415, 2006 National Collaborating Centre for Mental
Juvonen J, Ho AY: Social motives underlying Health: Antisocial Personality Disorder:
antisocial behavior across middle school Treatment, Management, and Preven-
grades. J Youth Adolesc 37:747–756, 2008 tion. The National Institute for Health
Kessler RC, McGonagle KA, Zhao S: Lifetime and Clinical Excellence (NICE) Guide-
and 12-month prevalence of DSM-III-R lines. National Clinical Practice Guide-
psychiatric disorders in the United line No 77. London, RCPsych Publica-
States: results from the National Comor- tions, 2009
bidity Survey. Arch Gen Psychiatry 51:8– Neugebauer R, Hoek HW, Susser E: Prenatal
19, 1994 exposure to wartime famine and devel-
Khalifa N, Duggan C, Stoffers J, et al: Phar- opment of antisocial personality disor-
macological interventions for antisocial der in early adulthood. JAMA 282:455–
personality disorder. Cochrane Data- 462, 1999
base of Systematic Reviews 2010, Issue Nielsen DA, Goldman D, Virkkunen M, et al:
8. Art. No.: CD007667. DOI: 10.1002/ Suicidality and 5-hydroxyindoleacetic
14651858.CD007667.pub2. acid concentration associated with tryp-
Kiehl KA, Smith AM, Hare RD, et al: Limbic tophan hydroxylase polymorphism.
abnormalities in affective processing Arch Gen Psychiatry 51:34–38, 1994
by criminal psychopaths as revealed by North C, Yutzy S: Goodwin and Guze’s Psy-
functional magnetic resonance imaging. chiatric Diagnosis, 6th Edition. New York,
Biol Psychiatry 50:677–684, 2001 Oxford University Press, 2010
452 The American Psychiatric Publishing Textbook of Personality Disorders
North C, Smith EM, Spitsnagel EL: Is antisocial Scarpa A, Raine A: Psychophysiology of an-
personality a valid diagnosis in the home- ger and violent behavior. Psychiatr Clin
less? Am J Psychiatry 150:578–583, 1993 North Am 20:375–403, 1997
Raine A, Venables PH, Williams M: Relation- Shapiro S, Skinner EA, Kesler LG, et al: Utili-
ship between central and autonomic zation of health and mental health ser-
measures of arousal at age 15 years and vices. Arch Gen Psychiatry 14:971–978,
criminality at age 24 years. Arch Gen 1984
Psychiatry 47:1003–1007, 1990 Sheard MH, Marini JL, Bridges CI, et al: The
Raine R, Buchsbaum MS, LaCasse L: Brain effect of lithium on impulsive aggres-
abnormalities in murderers indicated by sive behavior in man. Am J Psychiatry
positron emission tomography. Biol Psy- 133:1409–1413, 1976
chiatry 42:495–508, 1997 Sholevar GP: Family therapy for conduct dis-
Raine A, Lencz T, Bihrle S, et al: Reduced pre- orders. Child Adolesc Psychiatry Clin
frontal grey matter volume and reduced North Am 10:501–517, 2001
autonomic activity and antisocial per- Slutske WS: The genetics of antisocial behav-
sonality disorder. Arch Gen Psychiatry ior. Curr Psychiatry Rep 3:158–162, 2001
57:119–127, 2000 Spitzer RL, Endicott J, Robins E: Research di-
Reti IM, Samuels JF, Eaton WW, et al: Adult agnostic criteria: rationale and reliabil-
antisocial personality traits are associ- ity. Arch Gen Psychiatry 35:773–782,
ated with experiences of low paternal 1978
care and maternal over-protection. Acta Strasburger LH: The treatment of antisocial
Psychiatr Scand 106:126–133, 2002 syndromes: the therapists feelings, in
Reyes M, Buitelaar J, Toren P, et al: A random- Unmasking the Psychopath: Antisocial
ized, double-blind, placebo-controlled Personality and Related Syndromes. Ed-
study of risperidone maintenance treat- ited by Reid WH, Dorr D, Walker JI, et al.
ment in children and adolescents with New York, WW Norton, 1986, pp 191–
disruptive behavior disorders. Am J 207
Psychiatry 163:402–410, 2006 Tellegen A, Ben-Porath YS, McNulty JL, et al:
Robins LN: Deviant Children Grown Up: A The MMPI-2 Restructured Clinical Scales:
Sociological and Psychiatric Study of Development, Validation, and Interpre-
Sociopathic Personality. Baltimore, MD, tation. Minneapolis, University of Min-
Williams & Wilkins, 1966 nesota Press, 2003
Robins LN: The epidemiology of antisocial Tielbeek JJ, Medland SE, Benyamin B, et al:
personality disorder, in Psychiatry, Unraveling the genetic etiology of adult
Vol 3. Edited by Michels RO, Cavenar antisocial behavior: a genome-wide as-
JO. Philadelphia, PA, Lippincott, 1987, sociation study. PloS One 7:e45086, 2012
pp 1–14 Ullrich S, Coid J: Antisocial personality dis-
Robins LN, Price RK: Adult disorders pre- order: co-morbid Axis I mental disor-
dicted by childhood conduct problems: ders and health service use among a na-
results from the NIMH Epidemiologic tional household population. Personal
Catchment Area project. Psychiatry Ment Health 3:151–164, 2009
54:116–132, 1991 Virkkunen M, Nuutila A, Goodwin FK, et al:
Robins LN, Murphy GE, Woodruff RA, et al: Cerebrospinal fluid monoamine metab-
Adult psychiatric status of black school olite levels in male arsonists. Arch Gen
boys. Arch Gen Psychiatry 24:338–345, Psychiatry 44:241–247, 1987
1971 Wakschlag LS, Lahey BB, Loeber R, et al: Ma-
Robins L, Helzer JE, Weissman MM, et al: ternal smoking during pregnancy and
Lifetime prevalence of specific psychiat- risk of conduct disorder in boys. Arch
ric disorders in three sites. Arch Gen Gen Psychiatry 54:670–676, 1997
Psychiatry 41:949–958, 1984 Walker C, Thomas J, Allen TS: Treating im-
Sampson R, Laub J: Crime in the Making: pulsivity, irritability, and aggression of
Pathways and Turning Points Through antisocial personality disorder with que-
Life. Cambridge, MA, Harvard Univer- tiapine. Int J Offender Ther Comp Crim-
sity Press, 1993 inol 20:1–11, 2003
Antisocial Personality Disorder and Other Antisocial Behavior 453
Widiger TA: Psychopathy and DSM-IV psy- Yang Y, Glenn AL, Raine A: Brain abnormal-
chopathology, in Handbook of Psychop- ities in antisocial individuals: implica-
athy. Edited by Patrick CJ. New York, tions for the law. Behav Sci Law 26:65–
Guilford, 2006, pp 156–171 83, 2008
Yang Y, Raine A, Narr KL, et al: Localisation Yang Y, Raine A, Narr KL, et al: Localization
of prefrontal white matter in pathologi- of deformations within the amygdala of
cal liars. Br J Psychiatry 190:174–175, individuals with psychopathy. Arch Gen
2007 Psychiatry 66:986–994, 2009
This page intentionally left blank
C H A P T E R 21
Personality Disorders in
the Medical Setting
Randy A. Sansone, M.D.
Lori A. Sansone, M.D.
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
456 The American Psychiatric Publishing Textbook of Personality Disorders
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 com- ing 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
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
Personality Disorders in the Medical Setting 461
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-
462 The American Psychiatric Publishing Textbook of Personality Disorders
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 re- porting 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-
Personality Disorders in the Medical Setting 463
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.
466 The American Psychiatric Publishing Textbook of Personality Disorders
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
468 The American Psychiatric Publishing Textbook of Personality Disorders
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
Personality Disorders in the Medical Setting 469
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
470 The American Psychiatric Publishing Textbook of Personality Disorders
American Psychiatric Association: Diag- Hudziak JJ, Boffeli TJ, Kriesman JJ, et al: Clin-
nostic and Statistical Manual of Mental ical study of the relation of borderline
Disorders, 5th Edition. Arlington, VA, personality disorder to Briquet’s syn-
American Psychiatric Association, 2013 drome (hysteria), somatization disorder,
Devens M: Personality disorders. Prim Care antisocial personality disorder, and sub-
34:623–640, 2007 stance abuse disorders. Am J Psychiatry
Dhossche DM, Shevitz SA: Assessment and 153:1598–1606, 1996
importance of personality disorders in Hueston AJ, Werth J, Mainous AG: Personal-
medical patients: an update. South Med ity disorder traits: prevalence and effects
J 92:546–556, 1999 on health status in primary care patients.
Giovacchini PL: Treatment issues with bor- Int J Psychiatry Med 29:63–74, 1999
derline patients and the psychosomatic Hyler SE: Personality Diagnostic Question-
focus. Am J Psychother 47:228–244, 1993 naire–4. New York, Author, 1994
Grant BF, Chou SP, Goldstein RB, et al: Prev- Janssen PL: Scenarios of borderline distur-
alence, correlates, disability and comor- bances. Praxis der Psychotherapie und
bidity of DSM-IV borderline personality Psychosomatik 35:1–12, 1990
disorder: results from the wave 2 Na- Lloyd C, Overall JE, Kimsey LR, et al: A com-
tional Epidemiologic Survey on Alcohol parison of the MMPI-168 profiles of bor-
and Related Conditions. J Clin Psychia- derline and nonborderline outpatients. J
try 69:533–545, 2008 Nerv Ment Dis 171:207–215, 1983
Grant JE, Mooney ME, Kushner MG: Preva- Meyer F, Block S: Personality disorders in the
lence, correlates, and comorbidity of oncology setting. J Support Oncol 9:44–
DSM-IV obsessive-compulsive person- 51, 2011
ality disorder: results from the National Mumford DB, Bevington JT, Bhatnagar KS, et
Epidemiologic Survey on Alcohol and Re- al: The Bradford Somatic Inventory: a
lated Conditions. J Psychiatr Res 46:469– multi-ethnic inventory of somatic symp-
475, 2012 toms reported by anxious and depressed
Gross R, Olfson M, Gameroff M, et al: Bor- patients in Britain and the Indo-Pakistan
derline personality disorder in primary subcontinent. Br J Psychiatry 158:379–
care. Arch Int Med 162:53–60, 2002 385, 1991
472 The American Psychiatric Publishing Textbook of Personality Disorders
Norton JW: Personality disorders in the pri- care utilization in a primary care setting.
mary care setting. Nurse Pract 25:40–42, South Med J 89:1162–1165, 1996a
51, 55–58, 2000 Sansone RA, Wiederman MW, Sansone LA:
Pare MF, Rosenbluth M: Personality disor- The relationship between borderline
ders in primary care. Prim Care 26:243– personality symptomatology and health-
278, 1999 care utilization among women in an
Prasad RB, Val ER, Lahmeyer HW, et al: As- HMO setting. Am J Manag Care 2:515–
sociated diagnoses (comorbidity) in pa- 518, 1996b
tients with borderline personality disor- Sansone RA, Wiederman MW, Sansone LA:
der. Psychiatr J Univ Ott 15:22–27, 1990 Borderline personality symptomatol-
Sansone RA, Sansone LA: Borderline Person- ogy, experience of multiple types of
ality Disorder in the Medical Setting. trauma, and health care utilization among
Unmasking and Managing the Difficult women in a primary care setting. J Clin
Patient. New York, Nova Science Publi- Psychiatry 59:108–111, 1998a
cations, 2007 Sansone RA, Wiederman MW, Sansone LA:
Sansone RA, Sansone LA: Personality disor- The Self-Harm Inventory: development
ders: a nation-based perspective on prev- of a scale for identifying self-destructive
alence. Innov Clin Neurosci 8:13–18, behaviors and borderline personality
2011a disorder. J Clin Psychol 54:973–983, 1998
Sansone RA, Sansone LA: Sexual behavior in Sansone RA, Wiederman MW, Sansone LA:
borderline personality: a review. Innov Medically self-harming behavior and its
Clin Neurosci 8:14–18, 2011b relationship to borderline personality
Sansone RA, Sansone LA: Substance use dis- symptoms and somatic preoccupation
orders and borderline personality: com- among internal medicine patients. J Nerv
mon bedfellows. Innov Clin Neurosci Ment Dis 188:45–47, 2000
8:10–13, 2011c Sansone RA, Wiederman MW, Sansone LA:
Sansone RA, Sansone LA: Chronic pain syn- Adult somatic preoccupation and its re-
dromes and borderline personality. In- lationship to childhood trauma. Vio-
nov Clin Neurosci 9:10–14, 2012a lence Vict 16:39–47, 2001
Sansone RA, Sansone LA: Medically self-sabo- Sansone RA, Tahir NA, Buckner VR, et al: The
taging behavior and its relationship with relationship between borderline person-
borderline personality. Prim Care Rep ality symptomatology and somatic pre-
18:37–47, 2012b occupation among internal medicine
Sansone RA, Sansone LA: The relationship outpatients. Prim Care Companion J Clin
between borderline personality and obe- Psychiatry 10:286–290, 2008
sity. Innov Clin Neurosci 10:36–40, 2013 Sansone RA, Lam C, Wiederman MW: The
Sansone RA, Wiederman MW: The abuse of abuse of prescription medications: a re-
prescription medications: borderline per- lationship with borderline personality?
sonality patients in psychiatric versus J Opioid Manag 6:159–160, 2010a
non-psychiatric settings. Int J Psychiatry Sansone RA, Lam C, Wiederman MW: The
Med 39:147–154, 2009a abuse of prescription medications in
Sansone RA, Wiederman MW: Interference borderline personality disorder: a gen-
with wound healing: borderline patients der comparison. Prim Care Companion
in psychiatric versus medical settings. J Clin Psychiatry 12(6): PCC.10101001,
Prim Care Companion J Clin Psychiatry 2010b
11:271–272, 2009b Sansone RA, Lam C, Wiederman MW: Pre-
Sansone RA, Wiederman MW: Making med- venting wounds from healing: a relation-
ical situations worse: patient disclo- ship with borderline personality? Int J
sures in psychiatric versus medical set- Psychiatry Med 40:469–471, 2010c
tings. J Med 2:169–171, 2009c Sansone RA, Dittoe N, Hahn HS, et al: The
Sansone RA, Wiederman MW: Exercising an prevalence of borderline personality dis-
injury on purpose. Prim Care Compan- order in a consecutive sample of cardiac
ion J Clin Psychiatry (in press) stress test patients. Prim Care Compan-
Sansone RA, Sansone LA, Wiederman MW: ion CNS Disord 13(3): PCC.10101087,
Borderline personality disorder and health 2011a
Personality Disorders in the Medical Setting 473
Sansone RA, Farukhi S, Wiederman MW: cine outpatients. Intern Med J 42:345–
Disruptive behaviors in the medical set- 347, 2012c
ting and borderline personality. Int J Psy- Schreter RK: Treating the untreatables: a
chiatry Med 41:355–363, 2011b group experience with somaticizing
Sansone RA, Farukhi S, Wiederman MW: borderline patients. Int J Psychiatry Med
Utilization of primary care physicians in 10:205–215, 1980–1981
borderline personality. Gen Hosp Psy- Smith RG, Golding JM, Kashner TM, et al:
chiatry 33:343–346, 2011c Antisocial personality disorder in pri-
Sansone RA, Lam C, Wiederman MW: Re- mary care patients with somatization
sponses to the medical review of sys- disorder. Compr Psychiatry 32:367–372,
tems: borderline versus nonborderline 1991
patients in an internal medicine outpa- Spitzer C, Barnow S: Somatization as a
tient clinic. Prim Care Companion CNS unique dimension in personality disor-
Disord 13: pii: PCC.10m01120, 2011d ders. Personlichkeitsstorungen Theorie
Sansone RA, Chang J, Jewell B, et al: Hair und Therapie 9:106–115, 2005
pulling and borderline personality Stinson FS, Dawson DA, Goldstein RB, et al:
symptomatology among obstetrics/ Prevalence, correlates, disability, and co-
gynecology outpatients. Prim Care morbidity of DSM-IV narcissistic per-
Companion CNS Disord 14(1). pii: sonality disorder: results from the Wave
PCC.11?01211, 2012a 2 National Epidemiologic Survey on Al-
Sansone RA, Chang J, Jewell B: Preventing cohol and Related Conditions. J Clin
wounds from healing and borderline Psychiatry 69:1033–1045, 2008
personality symptomatology in an ob- Substance Abuse and Mental Health Services
stetrics/gynecology sample. Prim Care Administration: Results from the 2007
Companion CNS Disord 14(4). pii: National Survey on Drug Use and Health
PCC.11?01294, 2012b Care: national findings, 2008. Available
Sansone RA, Lam C, Wiederman MW: Hair- at: www.samhsa.gov/data/nsduh/
pulling and borderline personality 2k7nsduh/2k7results.pdf. Accessed Au-
symptomatology among internal medi- gust 26, 2013.
This page intentionally left blank
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 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
476 The American Psychiatric Publishing Textbook of Personality Disorders
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
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.
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
482 The American Psychiatric Publishing Textbook of Personality Disorders
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 sep- tem, 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
484 The American Psychiatric Publishing Textbook of Personality Disorders
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
References
early adulthood. As such, these disorders American Psychiatric Association: Diag-
have been viewed as having low proba- nostic and Statistical Manual of Mental
bility for significant response to rehabil- Disorders, 5th Edition. Arlington, VA,
American Psychiatric Association, 2013
Personality Disorders in the Military Operational Environment 485
Armed Forces Health Surveillance Center: U.S. Department of the Army: Active Duty
Mental disorders and mental health prob- Enlisted Administrative Separations
lems, active component, U.S. Armed (Army Regulation 635-200). Washing-
Forces, 2000–2011. Medical Surveillance ton, DC, Department of the Army, 2011a
Monthly Report 19(6):11–17, 2012. Avail- U.S. Department of the Army: Standards of
a b l e a t : h t t p : / / w w w. a f h s c . m i l / Medical Fitness (Army Regulation 40-
viewMSMR?file=2012/v19_n06.pdf. Ac- 501). Washington, DC, Department of
cessed August 27, 2013. the Army, 2011b
Army Task Force on Behavioral Health: Cor- U.S. Department of Defense Directive:
rective Action Plan, January 2013. Avail- Combat stress control (CSC) programs
able at: http://www.armyg1.army.mil/ (6490.5), 2003a. Available at: http://
documents/ATFBH%20Corrective www.calguard.ca.gov/csc/Documents/
%20Action%20Plan%205%20March%20 d64905p.pdf. Accessed August 27, 2013.
13.pdf. Accessed October 25, 2013. U.S. Department of Defense Directive: Men-
Bollinger AR, Riggs DS, Blake DD, et al: tal health evaluations of members of the
Prevalence of personality disorders armed forces (6490.1), 2003b. Available
among combat veterans with posttrau- at: http://biotech.law.lsu.edu/blaw/
matic stress disorder. J Trauma Stress dodd/corres/pdf2/D64901p.pdf. Ac-
13:255–270, 2000 cessed August 27, 2013.
Diebold CJ: Military administrative psychia- U.S. Department of Defense Instruction: En-
try, in Principles and Practice of Military listed administrative separations (1332.14),
Forensic Psychiatry. Edited by Lande 2011. Available at: http://www.dtic.mil/
RG, Armitage DT. Springfield, IL, whs/directives/corres/pdf/133214p.pdf.
Charles C Thomas, 1997 Accessed August 27, 2013.
Halvorson A, Substance Abuse and Mental U.S. Department of Defense Instruction: Physi-
Health Services Administration: Under- cal disability evaluation (1332.38), 2006.
standing the military: the institution, the Available at: http://www.dtic.mil/whs/
culture and the people, 2010. Available directives/corres/pdf/133238p.pdf.
at: http://partnersforrecovery.samhsa.gov/ Accessed August 27, 2013.
docs/military_white_paper_final.pdf. U.S. Department of the Navy: Manual of the
Accessed August 27, 2013. Medical Department. U.S. Department
Hoge CW, Messer SC, Engel CC, et al: Priori- of the Navy, 2008
ties for psychiatric research in the U.S. U.S. Department of the Navy: U.S. Navy
military: an epidemiological approach. MILPERSMAN: Separation by reason of
Mil Med 68:182–185, 2003 convenience of the government—per-
Hoge CW, Castro CA, Messer SC, et al: Com- sonality disorder(s) (1910-122), August
bat duty in Iraq and Afghanistan, men- 2009. Available at: http://www.pub-
tal health problems, and barriers to care. lic.navy.mil/bupers-npc/reference/
N Engl J Med 351:3–22, 2004 milpersman/1000/1900Separation/
U.S. Department of the Air Force: Adminis- Documents/1910-122.pdf. Accessed
trative Separation of Airmen (Air Force August 27, 2013.
Instruction [AFI] 36-3208). Washington, World Health Organization: International
DC, Department of the Air Force, 2011 Classification of Diseases, 9th Revision.
U.S. Department of the Air Force: Medical Geneva, World Health Organization,
Examination and Standards (Air Force 1977
Instruction [AFI] 148-123). Washington,
DC, Department of the Air Force, 2012
This page intentionally left blank
PART IV
Future Directions
This page intentionally left blank
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
490 The American Psychiatric Publishing Textbook of Personality Disorders
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
492 The American Psychiatric Publishing Textbook of Personality Disorders
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-
Translational Research in Borderline Personality Disorder 493
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
494 The American Psychiatric Publishing Textbook of Personality Disorders
state in concert with one’s own emotional motor, somatosensory, and nociceptive
response). representations while perceiving the ac-
In correspondence with the assump- tions 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
Translational Research in Borderline Personality Disorder 495
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-
498 The American Psychiatric Publishing Textbook of Personality Disorders
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
Translational Research in Borderline Personality Disorder 499
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, la- tion 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
500 The American Psychiatric Publishing Textbook of Personality Disorders
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.
Translational Research in Borderline Personality Disorder 501
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-
ter: Functional, Anatomical, and Immu-
nohistochemical Organization. Edited
References by Depaulis A, Bandler R. New York,
Plenum, 1991, pp 345–363
Bohus B, Koolhaas JM, Korte SM, et al: Fore-
Adolphs R, Spezio M: Role of the amygdala brain pathways and their behavioural
in processing visual social stimuli. Prog interactions with neuroendocrine and
Brain Res 156:363–378, 2006 cardiovascular function in the rat. Clin
Arntz A, Veen G: Evaluations of others by Exp Pharmacol Physiol 23:177–182, 1996
borderline patients. J Nerv Ment Dis Bohus MJ, Landwehrmeyer GB, Stiglmayr
189:513–521, 2001 CE, et al: Naltrexone in the treatment of
Arntz A, Bernstein D, Oorschot M, et al: The- dissociative symptoms in patients with
ory of mind in borderline and cluster-C borderline personality disorder: an open-
personality disorder. J Nerv Ment Dis label trial. J Clin Psychiatry 60:598–603,
197:801–807, 2009 1999
Bandelow B, Schmahl C, Falkai P, et al: Bor- Bohus M, Limberger M, Ebner U, et al: Pain
derline personality disorder: a dysregu- perception during self-reported distress
lation of the endogenous opioid system? and calmness in patients with border-
Psychol Rev 117:623–636, 2010 line personality disorder and self-muti-
Barnow S, Limberg A, Stopsack M, et al: lating behavior. Psychiatry Res 95:251–
Dissociation and emotion regulation in 260, 2000
borderline personality disorder. Psychol Bolles RC: Species-specific defense reactions
Med 42:783–794, 2012 and avoidance learning. Psychological
Bartz J, Simeon D, Hamilton H, et al: Oxyto- Review 77:32–48, 1970
cin can hinder trust and cooperation in Brandao ML, Zanoveli JM, Ruiz-Martinez
borderline personality disorder. Soc RC, et al: Different patterns of freezing
Cogn Affect Neurosci 6:556–563, 2010 behavior organized in the periaqueduc-
Baskerville TA, Douglas AJ: Dopamine and tal gray of rats: association with differ-
oxytocin interactions underlying behav- ent types of anxiety. Behav Brain Res
iors: potential contributions to behav- 188:1–13, 2008
ioral disorders. CNS Neurosci Ther Brown MZ, Comtois KA, Lineham MM: Rea-
16:92–123, 2010 sons for suicide attempts and nonsui-
Berenson KR, Gyurak A, Ayduk O, et al: Re- cidal self-injury in women with bor-
jection sensitivity and disruption of at- derline personality disorder. J Abnorm
tention by social threat cues. J Res Pers Psychol 111:198–202, 2002
43:1064–1072, 2009 Buchheim A, Erk S, George C, et al: Measur-
Bertsch K, Grothe M, Prehn K, et al: Volumet- ing attachment representation in an fMRI
ric differences between antisocial of- environment: a pilot study. Psychopa-
fenders with borderline personality dis- thology 39:144–152, 2006
order and antisocial offenders with Buchheim A, Erk S, George C, et al: Neural
psychopathic traits. Eur Arch Psychiatr correlates of attachment trauma in bor-
Clin Neurosci 38:129–137, 2013a derline personality disorder: a functional
Bertsch K, Schmidinger I, Neumann I, et al: magnetic resonance imaging study. Psy-
Reduced plasma oxytocin levels in fe- chiatr Res 163:223–235, 2008
male patients with borderline personal- Buchheim A, Heinrichs M, George C, et al:
ity disorder. Horm Behav 63:424–429, Oxytocin enhances the experience of at-
2013b tachment security. Neuroendocrinology
34:1417–1422, 2009
Translational Research in Borderline Personality Disorder 505
Fischer-Shofty M, Shamay-Tsoory SG, Harari Source Book, Section IV, Vol 2. Edited by
H, et al: The effect of intranasal adminis- Widiger TA, Frances AJ, Pincus HA, et
tration of oxytocin on fear recognition. al. Washington, DC, American Psychiat-
Neuropsychologia 48:179–184, 2010 ric Press, 1996, pp 717–733
Fonagy P, Bateman AW: Mechanisms of Gunderson JG, Bateman A, Kernberg O: Al-
change in mentalization-based treat- ternative perspectives on psychody-
ment of BPD. J Clin Psychol 62:411–430, namic psychotherapy of borderline per-
2006 sonality disorder: the case of “Ellen.”
Fonagy P, Luyten P: A developmental, men- Am J Psychiatry 164:1333–1339, 2007
talization-based approach to the under- Gunderson JG, Zanarini MC, Choi-Kain LW,
standing and treatment of borderline et al: Family study of borderline person-
personality disorder. Dev Psychopathol ality disorder and its sectors of psycho-
21:1355–1381, 2009 pathology. Arch Gen Psychiatry 68:753–
Frith CD, Frith U: The neural basis of mental- 762, 2011
izing. Neuron 50:531–534, 2006 Guttman HA, Laporte L: Empathy in families
Gallese V: Before and below “theory of of women with borderline personality
mind”: embodied simulation and the disorder, anorexia nervosa, and a control
neural correlates of social cognition. Phi- group. Fam Process 39:345–358, 2000
los Trans R Soc Lond B Biol Sci 362:659– Harari H, Shamay-Tsoory SG, Ravid M, et al:
669, 2007 Double dissociation between cognitive
Gallese V, Goldman AI: Mirror neurons and and affective empathy in borderline per-
the simulation theory of mind-reading. sonality disorder. Psychiatr Res 175:277–
Trends Cogn Sci 2:493–501, 1998 279, 2010
Gamer M, Zurowski B, Büchel C: Different Heinrichs M, Baumgartner T, Ehlert U, et al:
amygdala subregions mediate valence- Effects of oxytocin and social support on
related and attentional effects of oxyto- psychoendocrine stress responsiveness
cin in humans. Proc Natl Acad Sci USA in healthy men. Psychosomatic Medi-
107:9400–9405, 2010 cine 63:149–150, 2001
Gervai J, Novak A, Lakatos K, et al: Infant Heinrichs M, Baumgartner T, Kirschbaum C,
genotype may moderate sensitivity to et al: Social support and oxytocin inter-
maternal affective communications: at- act to suppress cortisol and subjective
tachment disorganization, quality of responses to psychosocial stress. Biol
care, and the DRD4 polymorphism. Soc Psychiatry 54:1389–1398, 2003
Neurosci 2:307–319, 2007 Heinrichs M, von Dawans B, Domes G: Oxy-
Ghiassi V, Dimaggio G, Brune M: Dysfunc- tocin, vasopressin, and human social be-
tions in understanding other minds in havior. Front Neuroendocrinol 30:548–
borderline personality disorder: a study 557, 2009
using cartoon picture stories. Psycho- Herpertz S: Self-injurious behaviour: psy-
ther Res 20:657–667, 2010 chopathological and nosological charac-
Goldman AI, Sripada CS: Simulationist mod- teristics in subtypes of self-injurers. Acta
els of face-based emotion recognition. Psychiatr Scand 91:57–68, 1995
Cognition 94:193–213, 2005 Iacoboni M, Molnar-Szakacs I, Gallese V, et
Gregory S, ffytche D, Simmons A, et al: The al: Grasping the intentions of others with
antisocial brain: psychopathy matters. one’s own mirror neuron system. PLoS
Arch Gen Psychiatry 69:962–972, 2012 Biol 3:e79, 2005
Guastella AJ, Mitchell PB, Dadds MR: Oxyto- Jovev M, Green M, Chanen A, et al: Attentional
cin increases gaze to the eye region of processes and responding to affective
human face. Biol Psychiatry 63:3–5, 2008 faces in youth with borderline personality
Guastella AJ, Kenyon AR, Alvares GA, et al: features. Psychiatry Res 199:44–50, 2012
Intranasal arginine vasopressin en- Kirino E: P300 is attenuated during dissocia-
hances the encoding of happy and angry tive episodes. J Nerv Ment Dis 194:83–
faces in humans. Biol Psychiatry 67:1220– 90, 2006
1222, 2010 Kleindienst N, Bohus M, Ludascher P, et al:
Gunderson JG, Zanarini MC, Kisiel C: Bor- Motives for nonsuicidal self-injury among
derline personality disorder, in DSM-IV
Translational Research in Borderline Personality Disorder 507
ality disorder. J Nerv Ment Dis 194:341– PreiEler S, Dziobek I, Ritter K, et al: Social
348, 2006 cognition in borderline personality dis-
Minzenberg MJ, Fan J, New AS, et al: Fronto- order: evidence for disturbed recogni-
limbic dysfunction in response to facial tion of the emotions, thoughts, and in-
emotion in borderline personality disor- tentions of others. Front Behav Neurosci
der: an event-related fMRI study. Psy- 2:182, 2010
chiatry Res 155:231–243, 2007 Ray WJ, Odenwald M, Neuner F, et al: De-
Modestin J: Counter-transference reactions coupling neural networks from reality:
contributing to completed suicide. Br J dissociative experiences in torture victims
Med Psychol 60:379–385, 1987 are reflected in abnormal brain waves in
New AS, Aan Het Rot M, Ripoll LH, et al: left frontal cortex. Psychol Science
Empathy and alexithymia in borderline 17:825–829, 2006
personality disorder: clinical and labora- Reitz S, Krause-Utz A, Pogatzki-Zahn EM, et
tory measures. J Pers Disord 26:660–675, al: Stress regulation and incision in bor-
2012 derline personality disorder—a pilot
Niedtfeld I, Schulze L, Kirsch P, et al: Affect study modeling cutting behavior. J Pers
regulation and pain in borderline per- Disord 26:605–615, 2012
sonality disorder: a possible link to the Reniers RL, Corcoran R, Völlm BA, et al:
understanding of self-injury. Biol Psy- Moral decision-making, ToM, empathy
chiatry 68:383–391, 2010 and the default mode network. Biol Psy-
Niedtfeld I, Kirsch P, Schulze L, et al: Func- chol 90:202–210, 2012
tional connectivity of pain-mediated af- Roepke S, Vater A, Preißler S, et al: Social
fect regulation in Borderline Personality cognition in borderline personality dis-
Disorder. PLoS One 7:e33293, 2012 order (abstract). Front Neurosci 6:195,
Nijenhuis ERS, den Boer JA: Psychobiology 2012
of traumatization and trauma-related Rufer M, Held D, Cremer J, et al: Dissociation
structural dissociation of the personality, as a predictor of cognitive behavior ther-
in Traumatic Dissociation: Neurobiol- apy outcome in patients with obsessive-
ogy and Treatment. Edited by Vermetten compulsive disorder. Psychother Psy-
E, Dorahy NJ, Spiegel D. Washington, chosom 75:40–46, 2006
DC, American Psychiatric Publishing, Schaefer M, Heinze HJ, Rotte M: Embodied
2007, pp 219–236 empathy for tactile events: interindivid-
Nock MK: Why do people hurt themselves? ual differences and vicarious somato-
New insights into the nature and func- sensory responses during touch obser-
tions of self-injury. Curr Dir Psychol Sci vation. Neuroimage 60:952–957, 2012
18:78–83, 2009 Schmahl C, Greffrath W, Baumgartner U, et
Osuch EA, Noll JG, Putnam FW: The motiva- al: Differential nociceptive deficits in pa-
tions for self-injury in psychiatric inpa- tients with borderline personality disor-
tients. Psychiatry 62:334–346, 1999 der and self-injurious behavior: laser-
Paris J: Understanding self-mutilation in bor- evoked potentials, spatial discrimination
derline personality disorder. Harv Rev of noxious stimuli, and pain ratings. Pain
Psychiatry 13:179–185, 1995 110:470–479, 2004
Passamonti L, Fairchild G, Goodyer IM, et al: Schmahl C, Bohus M, Esposito F, et al: Neural
Neural abnormalities in early onset and correlates of antinociception in border-
adolescence-onset conduct disorder. Arch line personality disorder. Arch Gen Psy-
Gen Psychiatry 67:729–738, 2010 chiatry 63:659–667, 2006
Patrick CJ: Emotion and psychopathy: star- Schmahl C, Kleindienst N, Limberger M, et
tling new insights. Psychophysiology al: Evaluation of naltrexone for dissocia-
31:319–330, 1994 tive symptoms in borderline personality
Prehn K, Schulze L, Rossmann S, et al: Effects disorder. Int Clin Psychopharmacol 27:61–
of emotional stimuli on working mem- 68, 2012a
ory processes in male criminal offenders Schmahl C, Ludascher P, Greffath W, et al:
with borderline and antisocial personal- COMT val158met polymorphism and
ity disorder. World J Biol Psychiatry neural pain processing. PLoS One
14:71–78, 2013 7:e23658, 2012b
Translational Research in Borderline Personality Disorder 509
Schneider P, Hannusch C, Schmahl C, et al: Stanley B, Siever LJ: The interpersonal di-
Adolecent peer-rejection persistently al- mension of borderline personality disor-
ters pain perception and CB1 receptor der: toward a neuropeptide model. Am J
expression in female rats. Eur Neuro- Psychiatry 167:24–39, 2010
psychopharmacol May 10, 2013 [Epub Stiglmayr CE, Ebner-Priemer UW, Bretz J, et
ahead of print] al: Dissociative symptoms are positively
Schulze L, Domes G, Kruger A, et al: Neuro- related to stress in borderline personality
nal correlates of cognitive reappraisal in disorder. Acta Psychiatr Scand 117:139–
borderline patients with affective insta- 147, 2008
bility. Biol Psychiatry 69:564–573, 2011 Theodoridou A, Rowe AC, Penton-Voak IS,
Sharp C, Pane H, Ha C, et al: Theory of mind et al: Oxytocin and social perception:
and emotion regulation difficulties in oxytocin increases perceived facial trust-
adolescents with borderline traits. J Am worthiness and attractiveness. Horm
Acad Child Adolesc Psychiatr 50:563– Behav 56:128–132, 2009
573, 2011 Vermetten E, Schmahl C, Lindner S, et al:
Shearer SL: Dissociative phenomena in women Hippocampal and amygdalar volumes
with borderline personality disorder. Am J in dissociative identity disorder. Am J
Psychiatry 151:1324–1328, 1994 Psychiatry 163:630–636, 2006
Sierra M, Berrios GE: Depersonalization: von Ceumern-Lindenstjerna IA, Brunner R,
neurobiological perspectives. Biol Psy- Parzer P, et al: Attentional bias in later
chiatry 44:898–908, 1998 stages of emotional information process-
Simeon D, Bartz J, Hamilton H, et al: Oxytocin ing in female adolescents with border-
administration attenuates stress reactiv- line personality disorder. Psychopathol-
ity in borderline personality disorder: a ogy 43:25–32, 2010a
pilot study. Psychoneuroendocrinology von Ceumern-Lindenstjerna I, Brunner R,
36:1418–1421, 2011 Parzer P, et al: Initial orienting to emo-
Singer T: The neuronal basis and ontogeny of tional faces in female adolescents with
empathy and mind reading: review of borderline personality disorder. Psycho-
literature and implications for future re- pathology 43:79–87, 2010b
search. Neurosci Biobehav Rev 30:855– Vrticka P, Vuilleumier P: Neuroscience of hu-
863, 2006 man social interactions and adult attach-
Skuse DH, Gallagher L: Dopaminergic-neuro- ment style. Front Hum Neurosci 6:212,
peptide interactions in the social brain. 2012
Trends Cogn Sci 13:27–35, 2009 Vrticka P, Andersson F, Grandjean D, et al: In-
Sonne S, Rubey R, Brady K, et al: Naltrexone dividual attachment style modulates
treatment of self-injurious thoughts and human amygdala and striatum activa-
behaviors. J Nerv Ment Dis 184:192–195, tion during social appraisal. PLoS One
1996 3:e2868, 2008
Spitzer C, Willert C, Grabe HJ, et al: Dissoci- Wagner AW, Linehan MM: Facial expression
ation, hemispheric asymmetry, and dys- recognition ability among women with
function of hemispheric interaction: a borderline personality disorder: implica-
transcranial magnetic stimulation ap- tions for emotion regulation? J Pers Disord
proach. J Neuropsychiatry Clin Neuro- 13:329–344, 1999
sci 16:163–169, 2004 Zanarini MC, Gunderson JG, Frankenburg
Spitzer C, Barnow S, Freyburger HJ, et al: FR: Cognitive features of borderline per-
Dissociation predicts symptom-related sonality disorder. Am J Psychiatry 147:57–
treatment outcome in short-term inpa- 63, 1990
tient psychotherapy. Aust N Z J Psychia- Zanarini MC, Frankenburg FR, Reich DB, et
try 41:682–687, 2007 al: The 10-year course of psychosocial
Staebler K, Renneberg B, Stopsack M, et al: functioning among patients with bor-
Facial emotional expression in reaction derline personality disorder and axis II
to social exclusion in borderline person- comparison subjects. Acta Psychiatr Scand
ality disorder. Psychol Med 41:1929– 122:103–109, 2010
1938, 2011
This page intentionally left blank
C H A P T E R 24
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
512 The American Psychiatric Publishing Textbook of Personality Disorders
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
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-
An Alternative Model for Personality Disorders 515
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.
520 The American Psychiatric Publishing Textbook of Personality Disorders
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
522 The American Psychiatric Publishing Textbook of Personality Disorders
Personality disorders
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
An Alternative Model for Personality Disorders 523
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-
524 The American Psychiatric Publishing Textbook of Personality Disorders
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-
An Alternative Model for Personality Disorders 525
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
An Alternative Model for Personality Disorders 527
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
528 The American Psychiatric Publishing Textbook of Personality Disorders
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-
An Alternative Model for Personality Disorders 529
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).
532 The American Psychiatric Publishing Textbook of Personality Disorders
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.
An Alternative Model for Personality Disorders 533
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
estimates of prognosis should be consid- References
ered (First et al. 2004). According to strict
definitions of validity (e.g., Kendell and Ackerman SJ, Hilsenroth MJ, Clemence AJ, et
Jablensky 2003), few psychiatric diagno- al: The effects of social cognition and ob-
ses can be said to be valid, because few ject representation on psychotherapy
continuation. Bull Menninger Clin 64:386–
“zones of rarity” (p. 4) in the manifesta-
408, 2000
tions of disorders have been found, and American Psychiatric Association: Diagnos-
few disorders have been identified to tic and Statistical Manual of Mental Dis-
have specific mechanisms of pathophys- orders, 3rd Edition. Washington, DC,
iology or etiology. According to Kendell American Psychiatric Association, 1980
and Jablensky (2003), however, a diag- American Psychiatric Association: Diag-
nostic and Statistical Manual of Mental
nosis possesses utility “if it provides
Disorders, 3rd Edition, Revised. Wash-
nontrivial information about prognosis ington, DC, American Psychiatric Asso-
and likely treatment outcomes, and/or ciation, 1987
An Alternative Model for Personality Disorders 537
American Psychiatric Association: Diag- Blais MA, Benedict KB, Norman DK: Estab-
nostic and Statistical Manual of Mental lishing the psychometric properties of
Disorders, 4th Edition. Washington, DC, the DSM-III-R personality disorders:
American Psychiatric Association, 1994 implications for DSM-V. J Clin Psychol
American Psychiatric Association: Diag- 54:795–802, 1998
nostic and Statistical Manual of Mental Blashfield RK: Variants of categorical and di-
Disorders, 5th Edition. Arlington, VA, mensional models. Psychol Inquiry
American Psychiatric Association, 2013 4:95–98, 1993
Anderson JL, Sellborn M, Bagby RM, et al: Blashfield RK, Intoccia V: Growth of the liter-
On the convergence between PSY-5 do- ature on the topic of personality disor-
mains and PID-5 domains and facets: ders. Am J Psychiatry 157:472–473, 2000
implications for assessment of DSM-5 Blatt SJ, Lerner H: The psychological assess-
personality traits. Assessment 20:286– ment of object representation. J Pers As-
294, 2013 sess 47:7–28, 1983
Ansell EB, Pinto A, Edelen MO, et al: The asso- Clark LA: Schedule for Nonadaptive and
ciation of personality disorders with the Adaptive Personality. Minneapolis, Uni-
prospective 7-year course of anxiety dis- versity of Minnesota Press, 1993
orders. Psychol Med 41:1019–1028, 2011 Clark LA: Assessment and diagnosis of per-
Balsis S, Lowmaster S, Cooper LD, et al: Per- sonality disorder: perennial issues and
sonality disorder diagnostic thresholds an emerging reconceptualization. Annu
correspond to different levels of latent pa- Rev Psychol 58:227–257, 2007
thology. J Pers Disord 25:115–127, 2011 Clark LA, Watson DB: Constructing validity:
Bateman A, Fonagy P: Eight-year follow-up basic issues in objective scale develop-
of patients treated for borderline person- ment. Psychological Assessment 7:309–
ality disorder: mentalization-based 319, 1995
treatment versus treatment as usual. Am Clark LA, Livesley WJ, Morey L: Personality
J Psychiatry 165:631–638, 2008 disorder assessment: the challenge of
Battle CL, Shea MT, Johnson DM, et al: Child- construct validity. J Pers Disord 11:205–
hood maltreatment associated with 231, 1997
adult personality disorders: findings Clark LA, Simms LJ, Wu KD, et al: Schedule
from the Collaborative Longitudinal for Nonadaptive and Adaptive Person-
Personality Disorders Study. J Pers Dis- ality, 2nd Edition (SNAP-2). Minneapo-
ord 18:193–211, 2004 lis, University of Minnesota Press, 2009
Bender DS, Farber BA, Geller JD: Cluster B Clarkin JF, Huprich SK: Do DSM-5 personal-
personality traits and attachment. J Am ity disorder proposals meet criteria for
Acad Psychoanal 29:551–563, 1997 clinical utility? J Pers Disord 25:192–205,
Bender DS, Morey LC, Skodol AE: Toward a 2011
model for assessing level of personality Cohen P, Crawford TN, Johnson JG, et al: The
functioning in DSM-5, part I: a review of children in the community study of de-
theory and methods. J Pers Assess 93:332– velopmental course of personality disor-
346, 2011 der. J Pers Disord 19:466–486, 2005
Benjamin LS: Dimensional, categorical, or Coolidge FL, Thede LL, Jang KL: Heritability
hybrid analyses of personality: a response of personality disorders in childhood: a
to Widiger’s proposal. Psychol Inquiry preliminary investigation. J Pers Disord
4:91–132, 1993 15:33–40, 2001
Berghuis H, Kamphuis JH, Verheul R: Core Costa PT Jr, McCrae RR: NEO PI-R Profes-
features of personality disorder: differ- sional Manual (Revised NEO Personality
entiating general personality dysfunc- Inventory and NEO Five-Factor Inven-
tion from personality traits. J Pers Dis- tory). Odessa, FL, Personality Assessment
ord 26:704–716, 2012 Resources, 1992
Bernstein DP, Iscan C, Maser J, et al: Opinions Costa PT Jr, Widiger TA (eds): Personality
of personality disorder experts regard- Disorders and the Five-Factor Model of
ing the DSM-IV personality disorders Personality, 2nd Edition. Washington,
classification system. J Pers Disord 21:536– DC, American Psychological Associa-
551, 2007 tion, 2002
538 The American Psychiatric Publishing Textbook of Personality Disorders
Crawford MJ, Koldobsky N, Mulder R, et al: Feenstra DJ, Hutsebaut J, Verheul R, et al: Se-
Classifying personality disorder accord- verity Indices of Personality Problems
ing to severity. J Pers Disord 25:321–330, (SIPP-118) in adolescents: reliability and
2011 validity. Psychol Assess 23:646–655, 2011
Cuijpers P, Smit F, Pennix BW, et al: Eco- Fenton MC, Keyes K, Geier T, et al: Psychiat-
nomic costs of neuroticism. Arch Gen ric comorbidity and the persistence of
Psychiatry 67:1086–1093, 2010 drug use disorders in the United States.
DeFife JA, Goldberg M, Westen D: Dimen- Addiction 107:599–609, 2012
sional assessment of self and interper- First MB, Bell CC, Cuthbert B, et al: Personal-
sonal functioning in adolescents: impli- ity disorders and relational disorders: a
cations for DSM-5’s general definition of research agenda for addressing crucial
personality disorder. J Pers Disord Feb- gaps in DSM, in A Research Agenda for
ruary 11, 2013 [Epub ahead of print] DSM-V. Edited by Kupfer, DJ, First MB,
De Fruyt F, De Bolle M, McCrae RR, et al: As- Regier DA. Washington, DC, American
sessing the universal structure of per- Psychiatric Association, 2002, pp 123–199
sonality in early adolescence: the NEO- First MB, Pincus H, Levine J, et al: Clinical
PI-R and NEO-PI-3 in 24 cultures. As- utility as a criterion for revising psychi-
sessment 16:301–311, 2009 atric diagnoses. Am J Psychiatry 161:946–
De Fruyt F, De Clercq B, De Bolle M, et al: 954, 2004
General and maladaptive traits in a five- Fonagy P, Leigh T, Steele M, et al: The relation
factor framework for DSM-5 in a univer- of attachment status, psychiatric classifica-
sity student sample. Assessment 20:295– tion, and response to psychotherapy. J
307, 2013 Consult Clin Psychol 64:22–31, 1996
Diguer L, Pelletier S, Hebert E, et al: Person- Frances A: The DSM-III personality disor-
ality organizations, psychiatric severity, ders section: a commentary. Am J Psy-
and self and object representations. Psy- chiatry 137:1050–1054, 1980
choanal Psychol 21:259–275, 2004 Frances A: Categorical and dimensional sys-
Dimaggio G, Nicolo A, Fiore D, et al: States of tems of personality diagnosis: a compar-
minds in narcissistic personality disor- ison. Compr Psychiatry 23:516–527, 1982
der: three psychotherapies analyzed us- Frances A, Clarkin JF, Gilmore M, et al: Reli-
ing the grid of problematic states. Psy- ability of criteria for borderline person-
chother Res 18:466–480, 2008 ality disorder: a comparison of DSM-III
Donaldson ZR, Young LJ: Oxytocin, vasopres- and the diagnostic interview for border-
sin, and the neurogenetics of sociality. line patients. Am J Psychiatry 141:1080–
Science 322:900–904, 2008 1084, 1984
Donegan NH, Sanislow CA, Blumberg HP, et Frances A, Pincus HA, Widiger TA, et al:
al: Amygdala hyperreactivity in border- DSM-IV: work in progress. Am J Psychi-
line personality disorder: implications for atry 147:1439–1448, 1990
emotional dysregulation. Biol Psychia- Frances A, First MB, Widiger TA, et al: An A to
try 54:1284–1293, 2003 Z guide to DSM-IV conundrums. J Ab-
Eaton NR, Krueger RF, South SC, et al: Con- norm Psychol 100:407–412, 1991
trasting prototypes and dimensions in Gamache D, Laverdière O, Diguer L, et al:
the classification of personality pathol- The personality organization diagnostic
ogy: evidence that dimensions, but not form: development of a revised version.
prototypes, are robust. Psychol Med J Nerv Ment Dis 197:368–377, 2009
41:1151–1163, 2011 Goldstein RB, Grant BF: Burden of syndro-
Eikenaes E, Hummelen B, Abrahamsen G, et mal antisocial behavior in adulthood, in
al: Personality functioning in patients with Antisocial Behavior: Causes, Correla-
avoidant personality disorder and social tions, and Treatments. Edited by Clarke
phobia. J Pers Disord June 20, 2013 [Epub RM. Hauppauge, NY, Nova Science
ahead of print] Publishers, 2011, pp 1–74
Fair DA, Cohen AL, Dosenbach NUF, et al: Grant BF, Stinson FS, Dawson DA, et al: Co-
The maturing architecture of the brain’s occurrence of DSM-IV personality disor-
default network. Proc Natl Acad Sci ders in the United States: results from
USA 105:4028–4032, 2008 the National Epidemiologic Survey on
An Alternative Model for Personality Disorders 539
Kendell R, Jablensky A: Distinguishing be- Levy KN, Meehan KB, Kelly KM, et al:
tween the validity and utility of psychi- Change in attachment patterns and re-
atric diagnoses. Am J Psychiatry 160:4– flective function in a randomized control
12, 2003 trial of transference-focused psychother-
Kendler KS, Czajkowski N, Tambs K, et al: apy for borderline personality disorder. J
Dimensional representation of DSM-IV Consult Clin Psychol 74:1027–1040, 2006
Cluster A personality disorders in a Luyten P, Blatt SJ: Integrating theory-driven
population-based sample of Norwegian and empirically derived models of per-
twins: a multivariate study. Psychol Med sonality development and psychopa-
36:1583–1591, 2006 thology: a proposal for DSM V. Clin Psy-
Kim-Cohen J, Caspi A, Moffitt TE, et al: Prior chol Rev 31:52–68, 2011
juvenile diagnoses in adults with mental Luyten P, Blatt SJ: Interpersonal relatedness
disorder: developmental follow-back of and self-definition in normal and dis-
a prospective-longitudinal cohort. Arch rupted personality development: retro-
Gen Psychiatry 60:709–717, 2003 spect and prospect. Am Psychol 68:172–
Kraemer HC, Kupfer DJ, Narrow WE, et al: 183, 2013
Moving toward DSM-5: the field trials. Markon K, Krueger RF, Watson D: Delineat-
Am J Psychiatry 167:1058–1060, 2010 ing the structure of normal and abnor-
Krueger RF, Eaton NR: Personality traits and mal personality: an integrative hierarchi-
the classification of mental disorders: to- cal approach. J Pers Soc Psychol 88:139–
wards a more complete integration in 157, 2005
DSM-5 and an empirical model of psy- McCrae RR, Costa PT Jr: Personality trait
chopathology. Personal Disord 1:97–118, structure as a human universal. Am Psy-
2010 chol 52:509–516, 1997
Krueger RF, Skodol AE, Livesley WJ, et al: McGlashan TH, Grilo CM, Sanislow CA, et
Synthesizing dimensional and categori- al: Two-year prevalence and stability of
cal approaches to personality disorders: individual DSM-IV criteria for schizo-
refining the research agenda for DSM-V typal, borderline, avoidant and obses-
Axis II. Int J Methods Psychiatr Res 16 sive-compulsive personality disorders:
(suppl 1):S65–S73, 2007 toward a hybrid model of Axis II disor-
Krueger RF, Eaton NR, Clark LA, et al: Deriv- ders. Am J Psychiatry 162:883–889, 2005
ing an empirical structure for personal- Moffitt TE, Caspi A, Taylor A, et al: How
ity pathology for DSM-5. J Pers Disord common are common mental disorders?
25:170–191, 2011a Evidence that lifetime prevalence rates
Krueger RF, Eaton NR, Derringer J, et al: Per- are doubled by prospective versus retro-
sonality in DSM-5: helping delineate spective assessment. Psychol Med 40:899–
personality disorder content and fram- 909, 2010
ing the meta-structure. J Pers Assess Morey LC: Personality disorders under
93:325–331, 2011b DSM-III and DSM-III-R: an examination
Krueger RF, Derringer J, Markon KE, et al: of convergence, coverage, and internal
Initial construction of a maladaptive consistency. Am J Psychiatry 145:573–
personality trait model and inventory 577, 1988
for DSM-5. Psychol Med 42:1879–1890, Morey LC: Personality pathology as patho-
2012 logical narcissism, in World Psychiatric
Kupfer DJ, First MB, Regier DA (eds): A Re- Association Series: Evidence and Expe-
search Agenda for DSM-V. Washington, rience in Psychiatry. Edited by Maj M,
DC, American Psychiatric Association, Akiskal HS, Mezzich JE, et al. New York,
2002 Wiley, 2005, pp 328–331
Lahey BB: Public health significance of neu- Morey LC, Skodol AE: Convergence between
roticism. Am Psychol 64:241–256, 2009 DSM-IV and DSM-5 diagnostic models
Lerner HD, St. Peter S: Patterns of object rela- for personality disorder: evaluation of
tions in neurotic, borderline, and schizo- strategies for establishing diagnostic
phrenic patients. Psychiatry 47:77–92, thresholds. J Psychiatr Pract 19:179–193,
1984 2013
An Alternative Model for Personality Disorders 541
Morey LC, Stagner BH: Narcissistic pathol- Parker G, Both L, Olley A, et al: Defining per-
ogy as core personality dysfunction: sonality disordered functioning. J Pers
comparing DSM-IV and the DSM-5 pro- Disord 16:503–522, 2002
posal for narcissistic personality disor- Peters EJ, Hilsenroth MJ, Eudell-Simmons
der. J Clin Psychol 68:908–921, 2012 EM, et al: Reliability and validity of the
Morey LC, Zanarini MC: Borderline person- Social Cognition and Object Relations
ality: traits and disorder. J Abnorm Psy- Scale in clinical use. Psychotherapy Res
chol 109:733–737, 2000 16:617–626, 2006
Morey LC, Hopwood CJ, Gunderson JG, et Pfohl B, Coryell W, Zimmerman M, et al:
al: Comparison of alternative models DSM-III personality disorders: diagnos-
for personality disorders. Psychol Med tic overlap and internal consistency of
37:983–994, 2007 individual DSM-III criteria. Compr Psy-
Morey LC, Berghuis H, Bender DS, et al: To- chiatry 27:21–34, 1986
ward a model for assessing level of per- Pilkonis PA, Heape CL, Ruddy J, et al: Valid-
sonality functioning in DSM-5, part II: ity in the diagnosis of personality disor-
empirical articulation of a core dimen- ders: the use of the LEAD standard. Psy-
sion of personality pathology. J Pers As- chol Assess 148:997–1008, 1991
sess 93:347–353, 2011 Pincus AL: Some comments on nomology,
Morey LC, Hopwood CJ, Markowitz JC, et al: diagnostic process, and narcissistic per-
Comparison of alternative models for sonality disorder in the DSM-5 proposal
personality disorders, II: 6-, 8- and 10- for personality and personality disor-
year follow-up. Psychol Med 42:1705– ders. Personal Disord 2:41–53, 2011
1713, 2012 Pincus HA, Frances A, Davis WW, et al:
Morey LC, Bender DS, Skodol AE: Validating DSM-IV and new diagnostic categories:
the proposed DSM-5 severity indicator holding the line on proliferation. Am J
for personality disorder. J Nerv Ment Psychiatry 149:112–117, 1992
Dis 201:729–735, 2013a Piper WE, Ogrodniczuk JS, Joyce AS: Quality
Morey LC, Krueger RF, Skodol AE: The hier- of object relations as a moderator of the
archical structure of clinician ratings of relationship between pattern of alliance
proposed DSM-5 pathological personal- and outcome in short-term individual
ity traits. J Abnorm Psychol 122:836–841, psychotherapy. J Pers Assess 83:345–356,
2013b 2004
Mullins-Sweatt SN, Jamerson JE, Samuel DB, Preston SD, Bechara A, Damascio H, et al:
et al: Psychometric properties of an ab- The neural substrates of cognitive empa-
breviated instrument of the Five-Factor thy. Soc Neurosci 2:254–275, 2007
Model. Assessment 13:119–137, 2006 Pulay AJ, Dawson DA, Ruan WJ, et al: The re-
Narrow WE, Clarke DE, Kuromoto SJ, et al: lationship of impairment to personality
DSM-5 field trials in the United States disorder severity among individuals
and Canada, part III: development and with specific axis I disorders: results from
reliability testing of a cross-cutting symp- the National Epidemiologic Survey on
tom assessment for DSM-5. Am J Psychi- Alcohol and Related Conditions. J Pers
atry 170:71–82, 2013 Disord 22:405–417, 2008
Northoff G, Heinzel A, de Greck M, et al: Qin P, Northoff G: How is our self related to
Self-referential processing in our brain— midline regions and the default-mode
a meta-analysis of imaging studies on the network? Neuroimage 57:1221–1233,
self. Neuroimage 31:440–457, 2006 2011
Oldham JM: Borderline personality disorder Rapee RM: The development and modifica-
and suicidality. Am J Psychiatry 163:20– tion of temperamental risk for anxiety
26, 2006 disorders: prevention of a lifetime of
Oldham JM, Skodol AE, Kellman HD, et al: anxiety? Biol Psychiatry 52:947–995,
Diagnosis of DSM-III-R personality dis- 2002
orders by two structured interviews: pat- Regier DA, Narrow WE, Kuhl EA, et al: The
terns of comorbidity. Am J Psychiatry conceptual development of DSM-V. Am
149:213–220, 1992 J Psychiatry 166:645–650, 2009
542 The American Psychiatric Publishing Textbook of Personality Disorders
Regier DA, Narrow WE, Clarke DE, et al: Shiner RL: A developmental perspective on
DSM-5 field trials in the United States personality disorders: lessons from re-
and Canada, part II: test-retest reliability search on normal personality develop-
of selected categorical diagnoses. Am J ment in childhood and adolescence. J Pers
Psychiatry 170:59–70, 2013 Disord 19:202–210, 2005
Reichborn-Kjennerud T, Czajkowki N, Shiner RL: The development of personality
Neale MC, et al: Genetic and environ- disorders: perspectives from normal per-
mental influences on dimensional rep- sonality development in childhood and
resentations of DSM-IV Cluster C per- adolescence. Dev Psychopathol 21:715–
sonality disorders: a population-based 734, 2009
multivariate twin study. Psychol Med Silberg JL, Rutter M, Tracy K, et al: Etiological
37:645–653, 2007 heterogeneity in the development of an-
Ro E, Clark LA: Psychosocial functioning in tisocial behavior. Psychol Med 37:1193–
the context of diagnosis: assessment and 1202, 2007
theoretical issues. Psychol Assess 21:313– Skodol AE: Longitudinal course and out-
324, 2009 come of personality disorders. Psychiatr
Roberts BW, DelVecchio WF: The rank-order Clin North Am 31:495–503, 2008
consistency of personality traits from Skodol AE: Scientific issues in the revision of
childhood to old age: a quantitative re- personality disorders for DSM-5. Person-
view of longitudinal studies. Psychol Bull ality and Mental Health 5:97–111, 2011
126:3–25, 2000 Skodol AE: Personality disorders in DSM-5.
Roberts BW, Kuncel NR, Shiner R, et al: The Annu Rev Clin Psychol 8:317–344, 2012
power of personality: the comparative Skodol AE: Borderline, schizotypal, avoidant,
validity of personality traits, socioeco- obsessive-compulsive, and other per-
nomic status, and cognitive ability for sonality disorders, in Life Course Epide-
predicting important life outcomes. Per- miology of Mental Disorders. Edited by
spectives on Psychological Science 2:313– Koenen K, Rudenstine S, Susser E, et al.
345, 2007 New York, Oxford University Press, 2013,
Robins E, Guze SB: Establishment of diag- pp 174–181
nostic validity in psychiatric illness: its Skodol AE, Gunderson JG, McGlashan TH, et
application to schizophrenia. Am J Psy- al: Functional impairment in patients
chiatry 126:983–987, 1970 with schizotypal, borderline, avoidant, or
Rounsaville BJ, Alarcon RD, Andrews G, et obsessive-compulsive personality disor-
al: Basic nomenclature issues for DSM-V, der. Am J Psychiatry 159:276–283, 2002
in A Research Agenda for DSM-V. Ed- Skodol AE, Oldham JM, Bender DS, et al: Di-
ited by Kupfer DJ, First MB, Regier DA. mensional representations of DSM-IV
Washington, DC, American Psychiatric personality disorders: relationships to
Association, 2002, pp 1–29 functional impairment. Am J Psychiatry
Salvatore G, Nicolo G, Dimaggio G: Impov- 162:1919–1925, 2005a
erished dialogical relationship patterns Skodol AE, Pagano ME, Bender DS, et al: Sta-
in paranoid personality disorder. Am J bility of functional impairment in
Psychother 59:247–265, 2005 patients with schizotypal, borderline,
Samuel DB, Widiger TA: A meta-analytic re- avoidant, or obsessive-compulsive per-
view of the relationship between the five- sonality disorder over two years. Psy-
factor model and DSM-IV-TR personal- chol Med 35:443–451, 2005b
ity disorders: a facet level analysis. Clin Skodol AE, Shea MT, McGlashan TH, et al:
Psychol Rev 28:1326–1342, 2008 The Collaborative Longitudinal Person-
Sanislow CA, Pine DS, Quinn KJ, et al: Devel- ality Disorders Study (CLPS): overview
oping constructs for psychopathology and implications. J Pers Disord 19:487–
research: research domain criteria. J Ab- 504, 2005c
norm Psychol 119:631–639, 2010 Skodol AE, Bender DS, Morey LC, et al: Per-
Saulsman LM, Page AC: The five-factor sonality disorder types proposed for
model and personality disorder empiri- DSM-5. J Pers Disord 25:136–169, 2011a
cal literature: a meta-analytic review. Skodol AE, Grilo CM, Keyes K, et al: Rela-
Clin Psychol Rev 23:1055–1085, 2004 tionship of personality disorders to the
An Alternative Model for Personality Disorders 543
course of major depressive disorder in a Tyrer P, Crawford M, Mulder R, et al: The ra-
nationally representative sample. Am J tionale for the reclassification of person-
Psychiatry 168:257–264, 2011b ality disorder in the 11th revision of the
Spitzer RL: Psychiatric diagnosis: are clini- international classification of diseases
cians still necessary? Compr Psychiatry (ICD-11). Personality and Mental Health
24:399–411, 1983 5:246–259, 2011
Stanley B, Siever LJ: The interpersonal di- Verheul R, Widiger TA: A meta-analysis of
mension of borderline personality disor- the prevalence and usage of the person-
der: toward a neuropeptide model. Am J ality disorder not otherwise specified
Psychiatry 167:24–39, 2010 (PDNOS) diagnosis. J Pers Disord 18:309–
Stepp SD, Trull TJ, Burr RM, et al: Incremen- 319, 2004
tal validity of the Structured Interview Verheul R, Andrea H, Berghout CC, et al: Se-
for the Five-Factor Model of Personality verity Indices of Personality Problems
(SIFFM). Eur J Pers 19:343–357, 2005 (SIPP-118): development, factor struc-
Stuart J, Westen D, Lohr N, et al: Object rela- ture, reliability and validity. Psychol As-
tions in borderlines, major depressives, sess 20:23–34, 2008
and normals: analysis of Rorschach Vermote R, Lowyck B, Luyten P, et al: Process
human figure responses. J Pers Assess and outcome in psychodynamic hospi-
55:296–318, 1990 talization-based treatment for patients
Stuart S, Pfohl B, Battaglia M, et al: The co- with a personality disorder. J Nerv Ment
occurrence of DSM-III-R personality dis- Dis 198:110–115, 2010
orders. J Pers Disord 12:302–315, 1998 Wagner AW, Linehan MM: Facial expression
Tackett JL, Balsis S, Oltmanns TF, et al: A uni- recognition ability among women with
fying perspective on personality pathol- borderline personality disorder: implica-
ogy across the life span: developmental tions for emotion regulation? J Pers Disord
considerations for the fifth edition of the 13:329–344, 1999
Diagnostic and Statistical Manual of Men- Wakefield JC: The concept of mental dis-
tal Disorders. Dev Psychopathol 21:687– order: on the boundary between biolog-
713, 2009 ical facts and social values. Am Psychol
Thomas KM, Yalch MM, Krueger RF, et al: The 47:373–388, 1992
convergent structure of DSM-5 personal- Wakefield JC: The perils of dimensionaliza-
ity trait facets and five-factor model trait tion: challenges in distinguishing nega-
domains. Assessment 20:308–311, 2013 tive traits from personality disorders. Psy-
Torgersen S: Prevalence, sociodemographics, chiatr Clin North Am 31:379–393, 2008
and functional impairment, in Essentials Warren JI, South SC: A symptom level exam-
of Personality Disorders. Edited by Old- ination of the relationship between Clus-
ham JM, Skodol AE, Bender DS. Arling- ter B personality disorders and patterns
ton, VA, American Psychiatric Publish- of criminality and violence in women.
ing, 2009, pp 83–102 Int J Law Psychiatry 32:10–17, 2009
Torgersen S, Lygren S, Oien PA, et al: A twin Westen D, Ludolph P, Lerner H, et al: Object
study of personality disorders. Compr relations in borderline adolescents. J Am
Psychiatry 41:416–425, 2000 Acad Child Adolesc Psychiatry 29:338–
Torgersen S, Czajkowski N, Jacobson K, et al: 348, 1990
Dimensional representations of DSM-IV Widiger A, Simonsen E: Alternative dimen-
cluster B personality disorders in a pop- sional models of personality disorder:
ulation-based sample of Norwegian finding a common ground. J Pers Disord
twins: a multivariate study. Psychol Med 19:110–130, 2005
38:1617–1625, 2008 Widiger TA, Trull TJ: Plate tectonics in the
Trull TJ, Widiger TA, Useda JD, et al: A struc- classification of personality disorder: shift-
tured interview for the assessment of the ing to a dimensional model. Am Psychol
five-factor model of personality. Psychol 62:71–83, 2007
Assess 10:229–240; 1998 Widiger TA, Frances AJ, Pincus HA, et al:
Tyrer P: The problem of severity in the classi- Toward an empirical classification for
fication of personality disorders. J Pers the DSM-IV. J Abnorm Psychol 100:280–
Disord 19:309–314, 2005 288, 1991
544 The American Psychiatric Publishing Textbook of Personality Disorders
Widiger TA, Frances AJ, Pincus HA, et al Zanarini MC, Vujanovic AA, Parachini EA, et
(eds): DSM-IV Sourcebook, Vol 2. Wash- al: Zanarini Rating Scale for Borderline
ington, DC, American Psychiatric Asso- Personality Disorder (ZAN-BPD): a con-
ciation, 1996 tinuous measure of DSM-IV borderline
Widom CS: The cycle of violence. Science psychopathology. J Pers Disord 17:233–
244:160–166, 1989 242, 2003
Wright AG, Pincus AL, Hopwood CJ, et al: Zanarini MC, Frankenburg FR, Hennen J, et
An interpersonal analysis of pathologi- al: The McLean Study of Adult Develop-
cal personality traits in DSM-5. Assess- ment (MSAD): overview and implications
ment 19:263–275, 2012a of the first six years of prospective follow-
Wright AG, Thomas KM, Hopwood CJ, et al: up. J Pers Disord 19:505–523, 2005
The hierarchical structure of DSM-5 path- Zanarini MC, Frankenburg FR, Reich DB, et
ological personality traits. J Abnorm al: Attainment and stability of sustained
Psychol 121:951–957, 2012b symptomatic remission and recovery
Yamagata S, Suzuki A, Ando J, et al: Is the ge- among patients with borderline person-
netic structure of human personality uni- ality disorder and axis II comparison
versal? A cross-cultural twin study from subjects: a 16-year prospective follow-
North America, Europe, and Asia. J Pers up study. Am J Psychiatry 169:476–483,
Soc Psychol 90:987–998, 2006 2012
Zanarini MC, Frankenburg FR, Vujanovic Zimmerman M, Rothchild L, Chelminski I:
AA: Inter-rater and test-retest reliability The prevalence of DSM-IV personality
of the Revised Diagnostic Interview for disorders in psychiatric outpatients. Am
Borderlines. J Pers Disord 16:270–276, J Psychiatry 162:1911–1918, 2005
2002a Zimmerman M, Chelminski I, Young D, et al:
Zanarini MC, Yong L, Frankenburg FR, et al: Which DSM-IV personality disorders
Severity of reported childhood sexual are most strongly associated with indices
abuse and its relationship to severity of of psychosocial morbidity in psychiatric
borderline personality psychopathology outpatients? Compr Psychiatry 53:940–
and psychosocial impairment among 945, 2012
borderline inpatients. J Nerv Ment Dis Zoccolillo M, Pickles A, Quinton D, et al: The
190:381–387, 2002b outcome of conduct disorder: implica-
tions for defining adult personality disor-
der and conduct disorder. Psychol Med
22:971–986, 1992
APPENDIX
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
546 The American Psychiatric Publishing Textbook of Personality Disorders
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.
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.
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.
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.
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.
Specifiers
Trait and personality functioning specifiers may be used to record additional personal-
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.
Specifiers
Trait and personality functioning specifiers may be used to record additional personal-
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.
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.
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.
Personality Traits
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
SELF INTERPERSONAL
Level of
impairment Identity Self-direction Empathy Intimacy
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
TABLE 2. Level of Personality Functioning Scale (continued)
SELF INTERPERSONAL
Level of
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.
geted at symptoms can affect the longer term patterns of personality functioning that
are captured by personality traits.
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.
566 The American Psychiatric Publishing Textbook of Personality Disorders
TABLE 3. Definitions of DSM-5 personality disorder trait domains and facets (continued)
DOMAINS (Polar
Opposites) and Facets Definitions
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.
Appendix: Alternative DSM-5 Model for Personality Disorders 567
TABLE 3. Definitions of DSM-5 personality disorder trait domains and facets (continued)
DOMAINS (Polar
Opposites) and Facets Definitions
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.
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
570 The American Psychiatric Publishing Textbook of Personality Disorders
“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
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
584 The American Psychiatric Publishing Textbook of Personality Disorders
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
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
594 The American Psychiatric Publishing Textbook of Personality Disorders