Treatment CH. 19

Beck's Dysfunctional Thought Record

can facilitate ID & mod of thoughts & fear. other inventories can help build a list of pleasurable activities so individuals can ^ involvement in activities they find interesting & rewarding schema therapy expands on cog therapy to address faulty assumptions that underlie cog. use of imagery, empathy, & lim reparenting - t works w/ c to mod maladaptive schemas which might include belief rel not worth trouble or life is boring no med indicated in treatment. symp of dep or pyschosis tho should be cause for referral schizoid pd no longer a named dis in alt model. would diagnosed as PD-TS, w/ level of impairment in personality func as extreme. relevant personality traits - anhedonia, flat affect, avoidance of intimacy, & withdrawal.

Other PDs

cat of other PDs applies to 1) personality change caused by another med condit 2) other specified PD 3) unspecified pd numb of personality changes can occur as result of cardiovascular disease, head trauma, epilepsy, HIV, & condit that have central nervous system involvement. to meet criteria for 1, change smust be persistent, rep change from usual patterns of behavior, & include med evidence. another med condit cannot be the cause of of personality change, & cannot be result of another PD.

Description of Paranoid PD

certain amt of paranoid thinking developmentally normal, & even necessary to determine how much interpersonal trust is approp in given sit but here rep extreme cases. thoughts, cogs, & behaviors charec by persistent suspiciousness & mistrust of behavior of others other's comments freq personalized & misinterpreted as being neg, malicious, or harmful. DSM-5 -> at least for our following behaviors necessary: pervasive mistrust of others from early age; constantly doubting loyalty of friends & fam ; holding grudges for past perceived misdeeds; believing others have malevolent intent & freq misconstruing other remarks or behaviors as harmful; withholding info out of fear that will be used against them; quick to anger if perceive charec or rep maligned being suspicious of partner faithfulness

Personality disorders are best understood in the context of lifetime development w/ traits beginning in

childhood or early teens & progressing in adulthood to full-blown dis many remit in late adulthood (ex borderline). others like schizotypal appear to become worse. diagnosis in person younger than 18 only made if symp present for at least 1 year. only exception is antisocial PD. cannot be diagnosed before 18. PD may worsen in mid to late adulthood following major life change but any major change in personality at this stage of life more likely result of undiagnosed sub use dis or other medical condit.

Unsupportive and defensive communication patterns are common in families & many people who are later diagnosed w/ APD have no

childhood role models of empathic tenderness. kids learned to look out for themselves, & often used violence or agg to intimidate ppl. many had behavior prob early on which were not deterred by punishment. more than any other PD, this pop is prone to sub-rltd dis. ppl w/ both dis have ^ scores on agg, impulsivity, & psychopathic traits. combined effect of affective instability & inhibitory dysfunc is magnified when both present -> greater risk for violence than any other single or dual psychiatric diagnosis.

PDs are grouped into the following three clusters, although the DSM-5 notes that limitations & overlap exist.

cluster system hasn't been consistently validated. as many as 15% of adult U.S. pop has at least one PD 1. cluster a (w/ guarded & eccentric ft): paranoid, schizoid, & schizotypal PD 2. Cluster B ( w/ dramatic, emo, & unpredictable traits): antisocial, borderline, histrionic, & narcissistic PD 3. Cluster C (anxious & fearful): avoidant, dependent, & OCPD

Behavior therapies that focus on relaxation techniques & stress inoculation training, social skills, training, & role playing can

contribute to improvement of OCPD symp encouraging involvement in leisure & social activities can ^ ability to plan & make decisions while ^ pos feelings. modeling humor & spont in controlled ways can offer cs new ways of reacting.

Synopsis of research on childhood factors leading to BPD include

1. freq of childhood sep from sig caregivers 2. on ass, persons w BPD report their rel w/ their mom either highly conflicted or overly protective 3. fathers in gen not present or uninvolved 4. disturbed rel w/ both parents are pathogenic to BPD earlier study found loss common ft in background. even more than kids who develop schizo or dep, more likely to come from divorced parents. 57 hist of parental loss. death or divorce; 50 hist of serious chronic illness and hosp ; 21 did not have the baove fam therapy often recc to improve parenting consistency.

HPD is one of the least common of the PD has a prevalence rate of less than

2% comorbid dis include somatic symptom, dep, dissociative, anxiety & sub use dis, & bipolar & cyclothymic dis. under condit of extreme stress ,are likely to develop traits of paranoid personality dis.

Description of Schizotypal

9 traits are charec. DSM req presence of five or more 1. ideas of reference or belief external events hold personal causality or delusions of reference 2. magical thinking & other cog that are in conflict w/ social norms 3. bodily illusions or bizarre perceptions 4. speech that is overly vague, or overly elab, metaphorical, or circumstantial 5. paranoia or suspiciousness. 6.flat or inapprop affect. 7. odd or peculiar appearance or behavior 8. solitary lifestyle lacking friends or close confidants 9. extreme social anxiety that is freq rltd ot paranoid fears.

Preferred typical characteristics (APD)

Adults most often enter treatment bc court ordered. may be condit of parole or probation or while in jail. bc most don't initiate or want treatment, motivation & reason must be addressed. t find more success in working w/ pop if initially empathize & join w/ c in hostility or ambivalence & proceed toward develop of collab rel. initially, may be charming or superficially compliant, affording initial honeymoon phase. once treatment progresses - likelihood that t seen as an authority figure to oppose ^. should be genuine, accepting, empathic & nonjudgemental & present themselves as specialists & collaborators.

For people with APD, time may be the greatest healer.

As people age they tend to become less impulsive & intensity of antisocial behavior dissipate. likelihood of successful treatment higher for ppl over 40 who express some remorse for actions, have some attachments, who not been sadistic or violent, & who do not create fear in the clinician

In a study of ~1k girls, the presence of ADHD and ODD at age 8 predicted _______ at age of 14

BPD. other markers for develop of BPD in childhood include agg, hostile, & distrustful views of world, & affective instability neither major dep dis nor conduct dis found predictive of develop of BPD.

Preferred Therapist Characteristics

Est trust is most imp goal of therapy for ppl w/ PPD, for it is only by trusting in rel w/ t that resistance can be overcome & c may decide to engage t should be prof & courteous, straightforward, & careful not to intrude on c's privacy & indep t who work w/ this pop should avoid behaviors that may evoke suspicion, like accepting phone calls from fam memb when c not preset neither should they excessively warn as this might trigger concerns abt t motivations. when ruptures in rel occur, should be responded to honestly, & in straight manner, w/o flourish or defensiveness

BPD Medication

FDA has not approved any single med for treatment of BPD. sometimes useful to reduce targeted symp. SSRIS used to treat symp of dep, mood swings, anxiety, or anger. low-dose antipsychotics like clozaril, zyprexa, seroquel, risperdal have been used to treat transient paranoia, depersonalization, hallucinations, or suspiciousness. meds along w/ mood stabilizers like lamictal & topamax sometime prescribed to help reduce impulsivity & self-harming behaviors benzos sometimes prescribed for panic, anxiety or sleeping aid, but bc of pot for addiction & freq of suicide attempts in this pop -> others meds should be considered.

APD adult treatment

Few RCTs exist on treatment of adult APD. even fewer in MH settings. CBT combined w/ social skills training & prov solving had most pos results w/ adults offenders & showed reduced recidivism. therapeutic communities had lowest success rate. altho research yet to ID any psychosocial treatment approach that has high degree of effectiveness, sometime types of behavioral & social skills training have resulted in at least some improvement in symptoms. bc comorbid dis magnifies antisocial straits, transdiagnostic treatment that addresses anger mgmt & sub use seems necessary.

Disruptions in attachment w/ primary caregiver seem common and frequent theme for more than ____ w/ BPD

HALF. early childhood trauma can derail ID growth & develop -> lifelong patterns of disordered or erratic attachment teens critical develop window where ID formation & develop paves way for future success in all aspects of life fam dysfunc is freq contributor to develop. mothers eps can be seen as overly harsh or overly permissive. may have sub use dis, mood dis, or BPD themselves that causes inconsistent parenting & presence if fathers present, often unavail or don't interfere w/ mom-c interactions.

Description of Schizoid PD

KEY ft is inability to relate to other ppl close interpersonal contact avoided & desire seems to be lacking, even fam rel. pattern noticeable by teens or early adulthood. social iso, & failure to comm w/ others has severe impact on ability to work, marry, or lead emo satisfying lives. four or more of following criteria needed: avoids close rel, & doesn't miss them prefers solitary activities; rarely dates or marries, & has minimal interest in romantic or sexual rel; anhedonic, expresses little, if any, pleasure; no close rels or friends (other than fam); unaffected by other's opinions whether good or bad; appears detached, flat affect, & lacks emo expression

Some studies have linked reduced serotonin w/ impulsivity and depressive symptoms, which are common in BPD

LINK also found btn brain chem & affective lability, dissociation, & comorbid mood dis research into neuro roots of emo reg found dysfunc in neutral circuitry of emo reg centers of brain that relate to impulsive agg research indicates pot neuro sim btn BPD & symp of ADHD. main symp overlap are in areas of impulsivity & emo dysreg both dis comorbid across lifetime. ppl w/ ADHD gen don't make intense efforts to avoid abandonment, or have extremes in thinking as in BPD. sim, inattention & hyperactivity, main symp of ADHD, not consistently seen in ppl w/ BPD. differences.

Mentalization-based therapy for ADP

MBT integrates cognitive and relational components of therapy w/ foundation based in attachment theory seeks to provide safe therapeutic environ in which the person can focus on anxiety-provoking internal states most feared internal states are threats to self-esteem likely to demand respect & create an atmosphere of fear to protect pride, prestige, & status loss of status viewed as shameful & threatens ability to regulate emo & impulses, losing all pov in effort to regain control even thru physical force. Do not have guilt or consciences, so empathy is lacking. so too is fear for self, danger & consequences of acting on violent impulses is secondary to need to regain respect & status.

Unlike OCD, people w/ OCPD do not often experience specific unwanted or intrusive thoughts or compulsions.

OCPD is freq ass/ anxiety & dep, esp if onset follows a failure that is partic meaningful or imp to the person. somatization often present, as it seems to be easier to discuss physical illness than it is to discuss emo, which are often equated to loss of control. emo rigidity, the result of always needed to be in control, can result in flattened affect. most tend to intellectualize & keep control of anxiety, but likely to respond in anger to any perceived challenges to need to be right.

Description of OCPD

OVERLY CONSCIENTIOUS. BC of need to be right, may have difficulty making decisions or bringing projects to closure. may appear neat, punctual, tidy, traits must consider virtues, & may be highly successful at work. imp to recog intense need for interpersonal control combined w/ fear of making mistakes, their need for absolute clarity, & other traits of the dis must cause sig distress & func prob at home, work, or in their rel w/ others.

Narc PD assessment

PD challenging to diagnose in gen, & NARC can be more challenging to discern, given prevalence of narc traits as symp of other dis. beck recc careful ass of this, given intense reacitons that may result when narc wound made. challenge to the self-img often results in crisis & dep can ensue. instruments: MMPI; MCMI; NPI; Personality belief questionnaire; diagnostic interview for narc; alt dsm-5 model for PD. thorough ass of any PD imp to determine if underlying dis present. alt model considers narc PD to be one of six distinct PD. traits of antagonism & neg affectivity can be added as specifiers but not req for diagnosis.

BPD Assessment

Structured interview for DSM-IV ; MMPI-2; MCMI; SCID-II; PDBQ; DIB-R; ZAN-BPD most t conduct own intake ass interviews & determine diagnosis based on person's hist following specific areas of behavior: impulsivity (agg toward self or others, ED, sub abuse), mood, & hist of disrupted rel & employment.

Research on paranoid thinking in general, has found relationships between personality traits and

^ risk of violence, antisocial or crim behavior, and stalking, threatening, or initiating partner violence. meta-analysis of non-clin pop -> when combined w/; high rumination, paranoid thinking ass/ agg behavior, but only when provoked.

Charec of HPD cont

aging may be esp challenging, esp to those overly flirtatious in youth & who may need to find another way to be center of attention as age. some cases, will link up w/ someone who is successful or famous to remain in limelight boredom can also lead to congoing prob in occup life & may have an unstable work hist. combo of temperament, illogical thinking & lack of interest in details make them poor candidates for many positions. if can find a career in which creativity, passion & energetic bursts valued, can be successful.

Symptoms of other disorders that co-occur with BPD must be considered.

alc & sub use dis, ADHD, anxiety & panic dis, dep, & PTSD ^ may req med mgmt for treatment for BPD to be effective. dep esp can become treatment resistant when comorbid w/ BPD.

People with PDs typically have sustained deficits in many areas of their lives.

along w/ presence of defense mechanisms, resistance, & freq presence of co-occur dis. greater improvements can be made after longer treatment duration psychotherapy considered first-line for most PDs. process of therapy entails develop collab working alliance & implementing treatment linked to c's stage of change, w/ goals ranging from reducing self-harming behaviors to improving maladaptive rel patterns. the better the alliance the more likely c will stay & work toward goals.

OCD is easily distinguished from OCPD by the former's presence of obsessive thoughts & compulsive behaviors.

also most people w/ OCD are very distressed abt amt of time spend performing compulsions, whereas ppl w/ OCPD don't gen believe they have a prob. in some cases both dis occur simul & both would be diagnosed if extreme hoarding occurs w/ OCPD, a sep diagnosis of HD would be approp other PDs can appear sim to OCPD . dis must be distinguished from sub use dis or personality changes due to another med condit.

BPD prognosis CONT.

altho the course of treatment for BPD can be slow w/ many setbacks along the way, ppl do experience success including reduction in suicidality ideation, improved rel, decreased anxiety & dep, & overall improvement in qual of life. altho remission is difficult to obtain, once it is achieved, the course seems to be stable for most ppl symptoms relapse after treatment reported to be rare, affecting only 6% who complete treatment. those who are treatment refractory or cannot control suicidal & self-harm have ^ risk od death from injury, accidents, or suicide in gen, treatment that address behavior, cog, emo reg, & comorbid dis more likely to be effective. many symp of BPD remit w/ age. alt model reframe PD as an impairment in personality func in which BPD has four of seven pathological traits.

PPD must be distinguished from others disorders in which

anger, persecutory thoughts & isolation are common. delusional dis, persecutory type; bipolar, or dep dis w/ psychotic ft; dis on schizo spectrum can all mimic PPD dis can be distinguished by presence of psychotic ft. ppl/ w PPD may be quick to anger & often distrustful, but tend to be grounded in reality & lacking delusions or hallucinations. symp should not be result of personality change due to another med condit; result of sub abuse, including alc use dis , which can mimic PDD; not ass/ physical handicaps.

Comorbid disorders with dependent PD

anxiety dis, somatoform, eating dis, sub use dis are also freq diagnosed along w/ it

Schizoid client charec cont.

as adults, few ppl experience internal wish to change. typically living rel stable lifestyle. others manage to find secure occup roles congruent w/ need for solitude. fam meb can be source of referral when hoping for change in fam memb ability to relate to others many can benefit from learning how to put themselves in another's shoes. schizoid may be more prevalent in the relatives of ppl w/ the dis, & some cult diff in immigrants may be perceived as being silent, solitary, & indiff to others.

Anxiety, hypersensitivity, & social isolation are common for people w/ Schizoid PD.

as are difficulties in school & personal interactions w/ peers. onset of ft in teens may be result of stress or intermittent emo prob & may resolve after crisis passed gen, PD maintains stable course & most will not go on to develop another psychotic ids. reduction in social & role func & any co-occur dis can -> poor long-term outcomes addit, teens who develop this pd at ^ risk for psychotic dis later in life. schizo pd (premorbid) neurodevelop dis, autism & other mental dis w/ psychotic symp should be ruled out. med causes & sub use.

PPD prognosis

as w/ all PDS, therapy long process during which motivaiton must be maintained & c must remain engaged in proess for treatment to be effective ppl w/ PPD, likely to give up & terminate prematurely. more pos the results, the more likely c is to cont, so goals should be short-term & small offer c the ability to feel good abt accomplishments even if treatment not complete. after initial goals met, further treatment can focus on more long-term goals.

DBT cont.

bc of reticence of ppl w/ BPD to commit to yr long therapy, first stage of treatment includes psychoeduc to est commitment. other specific skills training modules designed to reduce suicidal & self-harming behaviors, ^ emo & distress tolerance, teach present-moment awareness thru mindfulness, & reduce prob emo & behaviors. sensory awareness, emo labeling, fact checking, prob solving & crisis survival skills part of program. emo stability & connection imp goals of effective programs which includes DBT - Fam skills training to help fam understand BPD & provide adeq support, esp for teens & those who may be suicidal. DBT now has many adaptations.

Prognosis for DPD

bc ppl w/ DPD are capable of est & maintaining a rel , the prognosis for this dis is relatively good. ppl w/ DPD are trusting, & able to make commitments & keep them. want to please & ask for help. all of these attributes contribute to more pos treatment outcome than for most of PDS still, ct feelings must be recog & resolved by t if treatment is to be successful.

For some NARC clients, CBT or schema therapy may be more productive.

beginning w/ building collab thera rel & helping cs understand how t can beneficial to them after addressing any immediate crises & symptomatic dis, recc helping narc clients recog maladaptive coping styles, ^ frust tolerance, & learn to feel empathy for others focusing on sim w others than diff can -> improved attitudes & empathy by working collab, t provides praise & support, & helps c become more attuned to strengths. combo of psychoeduc, cog, experiential, & rel therapy -> noncondit self-worth

Other forms of therapy for NPD include

behavioral approaches, interpersonal psychotherapy, & imaginal exposure can also be integrated into treatment. behavioral approaches that incorporate contingency mgmt strat & behavioral response prevention can be used to reduce self-destructive habits (binge eating, buying, sex) interpersonal psychotherapy can help begin to examine own role in creation of prob by using focused challenges. t use caring confrontations that combine empathy w/ carefully worded confrontations to encourage self-explo. imaginal exposure -> desensitize to criticism. using fantasizing skills, can learn to sit w/ discomfort, how to ask for critical feedback, & react in nonconfrontational manner.

BPD- DBT

behavioral therapy w/ mindfulness component developed specifically for BPD considered best validated & easiest to learn of ebt for BPD yielded impressive empirical evidence of success in reducing suicidal & self-harm behaviors, reducing emotionality, & improving distress tolerance. improved occup & social func also been reported. treatment w/ DBT consists of 12 mo of weekly indiv & group therapy + psychoeduc, skills training, & adjunct fam therapy. t as a coach, accepting & empathizing w/ c's emo pain, taking dialectical stance, & challenging cs to develop better cog skills, reframe cog distortions, improve emo tolerance & reduce self-defeating behaviors.

NPD Prognosis

better outcomes likely to result in ppl who have less severe pathology & no comorbid traits of borderline or antisocial PDs prognosis better for those who attend higher func & those who attend group therapy or couples therapy. ts who able to create an empathic & supportive rel while providing direction & structure more likely to be helpful.

Narc PD intervention strategies cont.

both Kernberg & Kohut have developed psychoanalytic approaches that can help some make pos personality changes & develop more accurate sense of self. Kernberg - basic issues as anger, envy, self-sufficiency, & demands on self & other, both in reality & in transference. Kohut - transference rel to explore c's early develop as well as c's wish for perfect rel & ideal self. in empathic context, both have explored defenses & needs & frustrations. both types need yrs to complete, during which time any breaks in thera rel must be adressed. sig change will usually req long-term treatment, but bc of lack of insight & extensive rationalization, if difficult to engage them. some form of brief therapy on symp & sets goal specific to current crisis may be more approp.

Emotion-focused couples therapy can be helpful in situations in which person with NPD was forced into therapy.

by partner. helping c learn to empathize w/ spouse instead of being defensive or fighting back can promo change. once empathy has been instilled, motivation to change is usually not far behind

CONT.

c's likely to arrive on time, be coop if passive, & wait for t to ask q or provide direction within the session. often they view the t as a magical helper whom can rely on, & whom will work hard to please. ts must be aware pf dynamics involved & may use material from session to help build rapport & encourage ^ indep. ts should be aware that changes made solely to please the t unlikely to last. rarely will goal be to ^ assertiveness or indep, v overall goal to improve c's self-reliance & autonomy in safe context so newly found skills can be transferred into other settings outside of therapy. termination is likely to be difficult & should be tapered off so don't feel abandoned. offering cont booster sessions on monthly & later bimonthly basis can help to smooth the transition.

Overall, coping skills for persons w/ PPD tend to improve once the client becomes aware of, and learns to reduce,

defensiveness & hypervigilance. self-efficacy ^ too. gentle reality testing may become necessary, esp if person's behavior has decompensated to point that legal, prof, or rel consequences seem probable. t must help cs understand imp of mod behavior to prevent pos neg outcomes

Co-occurring disorders for schizoid PD

dep & anxiety dis. transient psychotic symp may also occur & usually precip by stress. early ass & treatment of psychotic symp imp to reduce long-term cog & neurobio effects on brain somatization is freq w/ ppl w/ this PD. may present w/ vague physical complaints than psych symp other pds esp paranoid, avoidant, OCPD, & borderline may be present.

Group therapy often recommended to help people with HPD see

themselves more clearly & be able to explore how behavior interfere w/ ability to develop & partake in meaningful rel some recc only for ppl who are high functioning, experience empathy, & can express concern for others no research avail to support effectiveness of group therapy.

Dependent personality disorder

dependent behaviors may be develop approp in children teens, in adults that need to be taken care of by others may be excessive & indicative of traits of a PD esp if desire to be taken care of is accompanied by five or more of following symp: difficulty making everyday decisions; avoids disagreement for fear of being rejected or losing support or approval difficulty doing things on own due to lack of self-confidence that can do it; excessive need for reassurance; needs others to be respon for certain areas of lives urgently seeks a replacement when rel ends & preoccupied w/ fears of being left to care for oneself.

After some degree of progress has been made, therapists may begin family or group counseling,

depending on needs of cs. couples or fam coun can provide the person w/ an opp to use newly acquired skills & to experiment w/ diff ways of expressing themselves & comm their needs. just as fam t can facilitate progress thru use of fam collab, group can provide extra support a c needs to try diff ways of comm. group therapy found to reduce of of meds for ppl w/ DPD. thera groups must be carefully selected to prevent cs from being overwhelmed or feeling threatened. cs who are ready will be less severely impaired & possess at least a modicum of prosocial skills. groups specific to DPD been shown to est group cohesion more quickly, offer interpersonal support, & result in faster symp relf. group can provide good transition from indiv therapy, can reduce transference & facilitate termination

DPD client characteristics cont.

develop pathways include temperament, parenting style, genetics, & cult high levels of parenting that make c feel week or powerless can cause ^ dependency & dep & anxiety. empirical research indicates that adults who score high on measures of secure attachment are likely to score low on measures of DPD insecure attachment place people at risk for developing DPD.

BPD mentalization based therapy

developed in U.K. by Bateman & Fonagy specifically to treat BPD rooted in attachment theory, psychodynamic approach that focuses on concept of mentalization holding mind in mind. thinking abt thinking. indiv learns to become aware of how interpret actions of others based on own mental states, process which develops childhood & may be maladaptive if learned within bounds of insecure attachment. RCTs - decreased symp of distress, ^ social & interpersonal func, & reduction in suicide attempts. includes options for in-pt hosp & day treatment.

Schizoid PD assessment

difficult bc of they shyness & discomfort being around ppl may present as aloof, detached, or even cold. inventories like the MMPI and MCMI can be helpful cs may be more forthcoming in writing than oral itnerviews deemed the PD w/o personality, ts may choose to mine c's fantasy life -> rich source of material abt private thoughts & feelings.

People w/ OCPD tend to have the following characteristics

difficulty delegating, overly involved in work to exclusion of vacation or social activities, rigidly held beliefs of a moral or ethical nature constricted emo affect, harshly self-critical, freq have difficulty discarding obj that no longer have value indecisive, miserly; reluctant to give w/o assurance will be reimbursed, preoccup w/ perfection, rules, details, & duties, to such an extreme that interferes w/ ability to get things done need to be in control

While many people w/ OCPD can be excessively orderly, neat, and punctual, many are not so, & in fact find great difficulty

discarding objects that might be needed in the ft. hoarding behavior is freq found in this dis as is procrastination. fear of making mistakes & being found imperfect -> indecisiveness that contributes to multiple prob. in mod, traits of OCPD can be highly adaptive & result in successful higher achievers. maintain high standards, tend to work late, & appear driven by devotion to work. BUT duties or rules used to govern own lives are not necessarily shared by colleagues & may -> prob at work.

Paranoid PD

distrust & suspicions abt motivations of others are main ft fear that others dislike them & will treat them badly to protect themselves from being exploited, criticized, or feeling weak, they may take defensive stance in rel & always feel on guard. prevents them from trusting others, or develop mutually satisfying rel.

histrionic personality disorder

dramatic, attention-seeking, & often seductive. exhibit pervasive pattern of excessive emotionality. freq like to be life of party & may be recog by provocative behavior imp for t to ID symp & aware of countertransferential feelings that may arise from idealization & seductiveness that c bring into treatment.

Avoidant PD prognosis

early ass & treatment can help children & teens w/ avoidant traits to est healthy rel, especially during imp transition from teens to adulthood adults in treatment for avoidant PD can have meaningful rel & find occup environ suited to particular needs even so, change slow & underlying self-doubts & behaviors that contribute to the develop of this dis will prob always be a part of personality.

With the revelation that BPD is caused by genetic predisposition in combo w/ environmental stressors, the gates have opened to

early diagnosis, intervention, & treatment toward prevention questionnaires admin to parents of daughters w/ BPD have found symptomatology since infancy. specifically affective symp, moodiness, & interpersonal difficulties noticed during toddler years & persisted into teens when added difficulties w/ agg, impulsivity, acting out, & self-destructive behaviors

ADP prognosis cont

early intervention & prevention programs ^ focus on kids at risk. improved screening can help ID ODD or CD w/ antisocial ft who are approp for services. new interventions should be designed to address parental expectations & reduce barriers to commitment once antisocial traits progressed to adulthood, prognosis not good. primarily bc lack of motivation to change. presence of dep or comorbid sub use, gambling, or hist of anger & violence make prognosis worse. many remain resistant to therapy, med mgmt, or particip in sub treatment program.

OCPD preferred therapist charec cont

est rapport & engaging in productive therapy can be a challenge. t must be bale to control the c's need to avoid feelings & intellectualize & always do the right thing. ts must be aware of own need for control to avoid ct issues & power struggles tend to come to therapy w/ prob that require a solution, & usually believe right & wrong solution to prob. few issues that have dogmatic solution, or few beliefs that are absolute. helping cs realize many solutions & many shades of gray may be most imp part of therapy.

PPD typical client charecteristics

est to affect btn 2.3 - 4.4 of pop. moe common among men some evidence points to genetic connection btn PPD, delusional dis of persecutory type, & schizo in relatives or fam memb. men w/ PPD have some of msot adverse outcomes & least likely to be employed. those employed most likely to report trouble w/ bosses or peers, & more likely to be fired or laid off study found ass/ complaining behaviors like litigation.

APD assessment

evidence exist that dis lies on a continuum beginning w/ early childhood behavior dis found in preschool to callous & unemo traits cs who score high on measures of callous & unemo traits also score lower on anxiety & may not care abt social rejection or disciplinary consequences that result from behavior -> don't learn from mistakes. careful ass for conduct or ODD, which can be diagnosed as young as age 5 ass must reply on descriptions of behavior from both teachers & parents since most behavior occurs away from home & outside parent awareness

A parallel process often develops in therapists who may report feeling overwhelmed, disorganized, and

experiencing strong negative feelings of resentment & wish to avoid cs w/ BPD need to also deal w/ own CT reactions to these complicated & sometimes frustrating cs. setting limits, seeking peer supervision, taking a team approach, or lim numb of cs w/ BPD in caseload are healthy ways to maintain equilibrium & energy.

The alternative DSM-5 model includes schizotypal PD as distinct disorder characterized by

extreme level of impairments in personality func w/ four or more of following personality traits; eccentricity, restricted affect, social withdrawal, suspiciousness, unusual beliefs & experiences, & disturbances in cogs & perceptions.

Group therapy is rarely tolerated by people w/ PPD because they are

extremely uncomfortable in intimate settings & may become agitated, anxious or confrontational to point leave the group neither is fam therapy recc, until person made substantial progress indiv, enough to understand own role & impact of behavior on creation of fam dynamic only then might be able to interact productively w/ fam med sometime useful to treat transient psychotic symp or extreme anxiety or paranoia. psychiatric referrals for med mgmt may be reserved for severe cases & should be made gently. can be taken wrong way -> feel manip, insulted, or controlled.

APD intervention (children & teens cont)

fam therapy can be useful to improve comm patterns & reverse familial pattern. parent management therapy can reduce reinforcement of neg behavior & replace w/ more desirable behavior. use of consistent & love, time-outs, behavior reinforcement, & expression of pos comm in 3 to 1 ratio to neg, parents can learn to set approp limits, be consistent, sep from c, & deal approp w/ own guilt, shame, or anger emotion recognition training that focuses on ^ understanding & internalization of specific emo may be helpful. sometimes environ intervention req thru in-home & comm based services by an integrated team. may include daily contact w fam. in severe cases, alt comm based strat in residential setting may be needed in detention or juvenile facility. here, CBT, RET, & prob-solving therapy used to help w/ anger & behavioral mgmt. for teens that don't respond well to PMT, residential treatment, group homes, or foster care placement often employed.

People w/ APD live lives that are constricted by:

fear of being embarrassed, publicly humiliated, or shamed tend to hyper focus on pot neg comments & exagg these comments to pt at which discussion of semantics may overshadow main pt of comment. bc of social anxiety, may refused to attend even most perfunctory of social func, preferring to stay home. some instances, ^ withdrawal, iso, self-absorbed behavior may -> fam dysfunc, anger, aroused states of agitation & delib self-harming behaviors.

BPD more often diagnosed in ________ at a ratio of 3 to 1.

females figure may be misleading bc men who exhibit same symp of BPD are more likely to be diagnosed w/ narc or antisocial PD fam risk of sub use dis, bipolar or dep dis, & antisocial PD also common.

DPD intervention strategies

few outcome studies been conducted on DP. sim to treatment for avoidant PD, the beginning of treatment will focus prim on providing support & develop a pos thera alliance. cbt for DPD will focus on improving indep & learning to develop social rel that are not based on dependency needs cog therapy that challenges maladaptive beliefs abt personal ineffectiveness & teaches them to reg affect w/o relying on others for supports can help ppl w/ DPD replace feelings of vulnb & experience self-efficacy. ult goal will be to focus on matters of self previously overlooked, including self interest, self-explo, & self-determination.

HPD intervention strategies

few studies of treatment been conducted. indiv psychodynamic therapy remains core treatment. most cs not likely to stay in therapy long term t that addresses the here and now of rel in session seems most likely to help c gain clearer understanding of how behavior affects others helping cs recog current behavior is preventing them from achieving long-term success in personal rel & helping them set realistic goals will help them est own sense of ID cbt can help reduce anger & agg found to be elevated in ppl w/ cluster b PD. assertiveness training & prob solving can help reduce impulsivity by ^ awareness of impact on others. behavior therapies that help cs ID & participate in new, healthier activities to meet needs for stim & novelty can help.

DPD typical client characteristics

fewer than 1% of gen pop meet criteria appears to be much more common among fem at rate of 2:1 fem to males. dsm-5 warns against diagnosis it in kids, as dependency needs may be develop approp for kids. not pathological. some cult value deference, passivity, & politeness. all of the criteria should be reviewing in light of cult dimensions, age factors, & gender. some cult may value or discourage dependent behavior in males & fem. ability to develop normal dependency & autonomy learned in childhood & those who fail to func indep of caregiver by time adults are pathologically dependent. ^ require vast amount of reassurance, unable to make even small decisions on own, & may seek support & guidance from others who may ult cause them harm.

HPD - therapist charec cont

focus on process, & on factors of person's hist, as way of setting limits and approp distance gentle challenges cna be sued to help them see often manip & self-destructive nature of behaviors limit setting & confrontation may be taken as rejection, so stage must be set in advance w/ series of clear short-term goals that are meaningful to c & provide foundation on which confrontations become interesting reminders of what c working on can provide opp to reinforce gains & reduce likelihood of cs turning to dramatization or premature termination bc needs not been met. even so, tend to be tangential so t need to keep them on task & specific.

Based on the DSM-5 criteria for BPD, at least five of the following symptoms must be present

frantic efforts to avoid real or imagined abandonment intense & fluctuating interpersonal rel lack of stable, internalized sense of self persistent sense of emptiness or boredom self-destructive & impulsive behavior erratic moods that fluctuate btn irritability, extreme dysphoria, & anxiety w/ episodes hrs- days intense anger or rage; difficulty controlling temper transient stres-rltd dissociation or paranoia self-harming behavior or ideation or actions

While avoidant PD clients may initially respond only to supportive therapy, later, after trusting relationship has been established, therapists may begin to

gently discuss c's defensive use of avoidance. subtle challenges to their auto thoughts & underlying core beliefs abt social ineptness & using thera rel as experimental rel in which c can role play or test beliefs can apply in real world little empirical research avail to guide treatment of this disorder

Preferred therapist charec cont

giving cs btn session tasks & scheduling sessions less freq, can give cs more control over nature of treatment t need to monitor own feelings abt these cs who can become hostile, abrasive, & sometimes angry or violent, & be careful not to respond in kind lest sit escalate. limits need to be set in prof manner if c reacts w/ agg or threatening behavior ending session or reducing session freq approp measures to give cs greater space

BPD tends to be particularly severe in late teens & YA when emotion dysregulation and self-identity are in

greatest flux. disprop numb of fem btn 11-21 meet criteria care must be taken to discrim btn normal teen emo lability & BPD symp grad improve w/ age as ppl attain greater stability in their rel & vocations tendency toward affective instability, strong emo, & intensity in rel may be lifelong.

Avoidant PD intervention strategies cont.

group therapy that provides an opp to learn & practice new social skills in a homogeneous & safe group contact can be added as improvement is made. use of systematic desensitization to reduce fear of neg eval appeared to be a cornerstone of the program. fam of ppl w/ avoidant PD tend to provide help for their fam memb by either offering protection to c who can foster dependency or insisting they ^ freq of socil interactions. little info avail on effectiveness of fam t. merging couples coun w/ social skills training helped to reduce social distance commonly found in such partner rel & can enhance rel for both addit benefits include reduction in social anxiety & encouragement for avoidant participants to take risks to improve other social interactions

BPD Systems training for emotional predictability and problem solving (STEPPS)

group treatment specific to BPD. demo clinical efficacy in RCTs. combines CBT w/ skills training & systems pov. after 20 wks of treatment, shown to reduce dep, impulsivity, & neg affect, & improve overall func.

HPD - prognosis

has fairly good prognosis, largely bc of ability to develop & maintain interpersonal rel tend to focus on others & may enter therapy at a lull in interpersonal activities, after having been ostracized from group, or at end of rel interventions targeted at resolving patterns of behavior that perpetuate interpersonal prob will help put them back on track. those who stay in therapy, develop self-awareness, & learn new patterns of behavior are likely to cont to learn & grow. terminate early or fail to develop inner resources -> remain caught in old patterns of childlike & teen behavior & cont look to others to fulfill needs

Young et al (2003) built on CBT w/ the development of detailed treatment model for NPD

help recog & understand early maladaptive schemas rltd to entitlement, emo deprivation, & defectiveness by reaching lonely child within, the t can help c learn to tolerate emo pain & iso than turning toward self-destructive, compulsive, or addictive forms. thera alliance can be a powerful tool in working w/ narc cs. experiential work, cog & educ strat, use of here and now, & mod of behavioral patterns, c can learn to change core schemas

Medication not usually prescribed for treatment of PD, although may people w/ DPD request medication to

help them relax & reduce anxiety. has only been documented that less progress is made in treatment when cs rely on meds. improvements that are made are lost when the meds is stopped. social skills training that focuses on cog, behaviors, emo reg, perceptions, & body work (relaxation) is msot likely to result in lasting change.

MBT cont

helps people develop awareness of their internal mental processes, recog when stop mentalizing & at risk of acting out, & begin to respond w/ alt behaviors that are consistent w/ self-determined goals actively explores violent behavior like DBT addresses suicide & self-harming behaviors in borderline c. found effective in RCTs in partial hosp for ppl w/ BPD, some who also had APD adaptation of MBT for ADP focuses on understanding emo cues, recog emo in others, exploring sensitivity to authority, & gen interpersonal processes to understand others pov group work essential when working w/ this pop

PPD Assessment

hist of childhood trauma may be present & should be ass along w/ careful chronology of paranoid thinking. all of this should be part of MSE. since PPD is one of least studied; specific ass instruments not avail. but several scales can be used. SCID-II is used to ass PDs in adults. can be used for teens, w/ stipulation that t verify diagnostic criteria over 5 yr period APS is a self-report measure, considered valid tech for acquiring info. should be aware that self-report measures & semistructured interviews tend to be less reliable the younger the child, & cuation when considering reliability of teens w/ PDs.

Prior to terminating therapy, clients w/ Avoidant PD should be encouraged to make a list of long-term goals that specify

how they will cont over coming months to implement the skills they have learned. cs should be told to pay particular attention to sit & behaviors find themselves avoiding & consider faulty cog that underlie behavior cs can cont to grow, or begin to recog when should re-enter therapy. ts may want to include on-going follow up sessions. meg mgmt not indicated for treatment, altho some prelim findings indicate monoamine oxidase inhibitors & some SSRIs may help benzos can help cs better manage anxiety caused by rejection sensitivity, fear of social sit, or trying new behaviors.

APD Description of the Disorder

hypersensitive to criticism & neg eval & tend to be on the lookout for statements that reinforce their neg bias, often exagg or ruminating. est of freq of ths dis vary from 1.7 to 10. occurs w/ equal freq in both men & women & is charec by presence of four or more of following symp: 1. excessive shyness in intimate rel bc of fear of being ridiculed. 2. preoccup w/ fear of being socially rejected or criticized 3. feelings of inferiority or social ineptness 4. fear of being embarrassed, to pt of refusing new opp 5. fear of new social sit bc of feeling of inadeq 6. participates in social sit w/ ppl who are guranteed to like them 7. fear of being neg eval, which is so strong that prevents acceptance of new job opp, promo or other areas of responsibility.

People with BPD are likely to engage in behaviors that are self-defeating

in an effort to overcome the neg feelings triggered by real or perceived attachment wounds severe cases, suicidal ideation & actions may result from frantic efforts to overcome neg affect

Avoidant PD assessment

initial age of onset appears to be late childhood or early teens w/ a chronic course if left untreated altho severe shyness & sensitivity may have been present since toddler or preschool yrs & seemed develop approp. no valid measures exist to ass Avoidant PD in childhood. mostly affects internal state so not readily observable nor child likely to share their concerns. even in adults, difficult to see full range of symp bc unlikely to self-disclose embarrassing info. anxiety & dep gen become focus of treatment & astute ts must conduct careful assessment to tease out variances btn a PD & other cormid dis. dissociative & schizo been reported in combo & in fam hist.

HPD - preferred therapist charec

initially charming, ingratiating, & expressive, cs seem eager to please as therapy progresses, cs exagg fear of rejection will become obvious seek constant emo reassurance that loved. not enough to be loved by fam & friends, need everyone's love. therapist no exception. fem w/ HPD likely to seek out male t. t should quickly set boundaries & maintain prof stance. ts who are warm, genuine, & consistent can build & maintain trust & reduce c neediness productive use of cs' transference reactions can help w c gain understanding of how relate to others & appreciate maladaptive use of attention-seeking behavior

Description of Narc PD cont

intense reactions may result when self-img is challenged. such an ID crisis results in dep & can be precipitating factor in seeking treatment. anger, criticism, or hurt feelings expressed at hint of any perceived criticism. may socially withdraw, become contentions & arrogant, & demand treatment believe they deserve. some may lash out after injury, seeking revenge. central them in mass murders & shootings. gen ppl w/ NARC PD have shallow capacity for intimacy, lack empathy, & seek to control & manipulate others. bc a dissatisfied partner is often motivation for seeking treatment, many appear in couples therapy. attempts to convince t of superiority & lack of any wrongdoing -> attempts to control therapy & manip t.

OCPD typical client characteristics

involves a life pil of perfectionist standards, which cause ppl to experience anxiety over not getting things perfectly. typically hard workers who successful in their occup endeavors, altho make poor supervisors & unable to delegate for fear that job will not be done correctly. dislike team projects or group dynamics, preferring to do everything alone. tend to be perfectionistic & have dichotomous thinking -> may look at things as right or wrong. gen believe themselves to be good ppl, & are harshly critical of themselves if feel made a mistake. can be judgmental, look for flaws in other's behavior, & end friendships or rel if other person violated one of their principles may have few friends, have marriages that end in divorce, & may become socially iso.

Description of APD cont

lead a parasitic life fail to abide by social or legal guidelines for behavior, often in financial difficulty, behave irrespon as parents & employees & likely to project blame onto others narcissism, entitlement, & self-centeredness freq present for adults have difficulty sustaining intimate rel & tend to change partners & jobs often 3 of men & less than 1 of women meet criteria. est that more than 70 in sub abuse clin or forensic settings meet criteria. not all adults engage in crim behavior. 5-6 of offenders commit more than 50% of crimes. persistent offenders have inherited or acquired neuropsych prob that combine w/ environ fact -> criminality. genetic & environ factors

BPD preferred therapist characteristics

leading cause of inpt & outpt treatment. bc of self-destructive & pot lethal behavior, ts must quickly est rapport while at same time ass pot risk for self-harm & suicide t should add topic head-on & develop safety plan for crises. even tho c may not need plan at moment, suicidal ideation & behavior can recur as a result of perceived abandonment, intense emo, or stressful/crisis time. remb more than 2/3 of BPD cs attempt, 10 die. cs must be helped to ID emo & link them w/ behaviors. main ego defense mechanisms - rationalization, projection, denial, & splitting. projecting is typical, more likely attribute own motivations to others than recog feelings in themselves. denial prevents them from looking at own behavior w/ critical eye.

BPD therapist charec cont

learning to self-sooth, finding pos ways to reduce disturbing neg affect will be focus. treatment resistance & inability of cs w/ BPD to coop often -> early term. nearly 100 have prior hist of treatment, & avg of 6.1 therapists. some of respon for treatment failure can be explained by two opp but = damaging mistakes being too avail (fostering dependence & unreasonable expectations) or not being avail enough (triggering concerns abt abandonment & escalating self-harm) do not abandon during crisis, but remain compassionate & nonjudgmental when emo volatile. provide stability, reassurance & hope until able to hold hope for self. set limits & est & maintain clear & consistent guidelines. extra sessions & phone calls can be done when advisable but shouldn't be treatment as usual. use EBP to provide structure & support.

Description of BPD

three core symp - erratic moods, intense anger, & impulsivity form pattern of pervasive instability that neg impacts rel, employment, & self img ^ risk of self-harming behaviors & even suicide, are common manifest in teens or YA & tends to remit w/ age.

Overview of Personality Disorders

lifelong disorders charec by maladaptive attitudes & behaviors that differ from the indiv's cultural expectations & manifest in at least two areas: perceptions & understanding of oneself & one's environment expression, nature, range, & approp of emotions interpersonal skills & rel impulse control ppl w/ PDs exhibit attitudes & behaviors that can be rigid & inflexible & cause distress and/or impairment across broad range of personal & social sit.

Schizoid Prognosis

likely to terminate prematurely. many lack motivation & instead referred by concerned employers, fam, & friends. if participate, likely to experience some ^ in social interactions but can be slow process. w/o cont treatment or follow-up sessions, ppl w/ this pd have ^ likelihood of reverting back to previous level of func

Intervention strategies (schizotypal)

lim research avail on treatment interventions. sim to those w/ pranoid PD, unlikely to seek treatment on own, but may be brought by fam or friend early diagnosis & intervention in teens can reduce symp severity & have pos effect on long-term prognosis. supportive indiv therapy that initially focuses on building an alliance seems most likely to help draw c in. allowing c to determine level of intimacy & pace of therapy can ^ sense of self-control & allow them to event be open to changing behaviors that tend to cause them prob in their rel w/ ppl treatment that focuses on building confidence & makes gentle use of cog & behavioral strat can help cs achieve some degree of self-awareness. therapy likely to focus on improving basic skills of daily living. self-care, indep. preventing iso, & finding pleasure.

Schizoid - intervention strategies

lim research avail on treatment modalities. some lim generalizations. cog behavior approaches found to reduce mood dis in kids & teens. may be good w/ this pop if persuasive, gentle approach used. as do kids on autism spectrums, kids w/ schizoid traits may need help w/ social skills, esp w/ pragmatic aspects of lang. cs & parents may benefit from clear structured approach w/ key points typed on hangout for reinforcement & review during week. behavioral tech cna help teens & adults improve social & comm skills. psychoeduc approach that ^ assertiveness, self-expression, & social skills more likely succeed than behavioral methods that rely on reinforcement.

PPD intervention strategies

little research avail on treatment, perhaps bc mistrust of interpersonal rel prevents many from seeking treatment. those who stay in treatment are most likely to benefit from supportive, indiv psychotherapy.. interpretations & reflection of feelings should not be emphasized bc likelihood of misin. behavioral therapy that is logical & org & that puts c in control may help allay concerns abt manipulation & keep c engaged long enough for thera rel to develop prob solving, stress mgmt, assertiveness, & other social skills training seem to work best in initial phase by presenting social skills as opp to experiment w/ diff types of behaviors or way for c to check out assumption abt others, t helps c develop more effective coping mechanisms & social skills.

Schizotypal PD

magical thinking & superstitious beliefs combined w/ odd or eccentric behaviors. rare. seen in less than 1% & occurs in = prop in both gender.s bc it is a mild schizo spectrum dis, present w many of schizo symp including severe cog deficits, social iso, downward drift, & in time of crisis severe psychotic symp most been symptomatic since childhood & become iso from society. in part due to reactions of others to idiosyncratic speech, mannerisms, & dress appear to be brunt of teasing, ridicule, & bullying behavior.

Schema therapy can help people to recognize core cognitions and help them to replace

maladaptive approval-seeing behavior w/ more autonomous behavior. sim to treatment of antisocial PD, ppl w/ DPD have an underlying fear that are defective & will be abandoned when other people discover their peccadilloes type of avoidant coping responses commonly ass/ DPD make it difficult for people to change.

Narcissistic PD

maladaptive pattern of behavior leads to develop of narc PD, but little sic evidence avail on exactly how it happens numb of diff pathways lead to develop of narc traits. est to affect 18 of males & 6 fem.

Schema therapy for ADP

maladaptive schemas typically found in ppl w/ APD include mistrust, sense of entitlement, lack of self-control, & belief that they are defective & will be abandoned by others. tend to make use of overcompensating schema modes that attempt to con & manip, devalue others, bully & intimidate, & are paranoid & seek to detect hidden threat or enemy focus is gen current behavior but gen less defensive when talking about the past, & may provide useful bridge to a discussion of current activities RCTs underway in netherlands. early findings show promise.

Avoidant PD

many of symp of APD, including excessive shyness & sensitivity, are present from childhood, altho certain level of shyness is to be expected & develop approp. in adulthood, PD manifests as severe anxiety in social sit, fear of being judged & found lacking, & feeling socially inept to pt that person becomes socially phobic or avoidant.

OCPD prognosis

many will not realize or accept that have a prob until force into treatment by fam or employers. since most people view their perfectionistic traits as right & unwilling to give up control or change behavior, prognosis prob only fair.

OCPD is more common in men.

many women w/ OCPD who ahre traits of control, perfectionism, & rigidly held beliefs, may have comorbid ED esp anorexia nervosa need for control may play out in details of own lives, including food choices, daily monitoring of weight & need to be thin three traits of OCPD - rigidly held beliefs, perfectionism & miserliness accounted for 65% of variance in binge ED

BPD Dynamic supportive therapy

may be helpful for ppl w/ BPD who need addit support. emphasis placed on imp of thera rel in bringing change. yrs of supportive treatment found to improve func for ppl w/ BPD high scores on callousness, lack of remorse, manip & other antisocial traits may be less likely to benefit. other factors that limit amt of progress that can be made in treatment - narcissistic traits, chaotic impulsivity, ego fragility, diminished capacity for reflection, & lack of empathy those w/ more stable obj relations & oral func, who have good reality testing & some insight, & use higher-level defenses are healthier w/ less pathology. lower func ppl have worse prognosis. those w/ secondary ft of histrionic or dep traits will have better prognosis w/ psychodynamic than those w/ antisocial or paranoid traits.

Schizoid PD

may be rarest of PDs. tend to avoid rel in gen, & rarely seek treatment. little research avail then & est vary from 1- 4.9

Narc PD - preferred therapist characteristics

may be resistant to treatment. it is difficult for them to acknowledge that have any prob, or believe that anyone else can understand unique nature of intuition. ts who comm warmth, acceptance, genuineness, & understanding are more likely to engage the c in treatment & altho t should not underest fragility of such ppl. may hide their vulb behind thin veil of self-confidence. even hint of criticism on t part may provoke hostile reaction -> premature termination

PPD - co-occurring disorders must also be assessed and treated.

may exacerbate the stymp of PPD combo of paranoid traits & other comorbid dis can be troublesome, as when presence of ADHD or sub use lowers impulse control, or in case of antisocial pd, anxiety, dep or psychotic ft

Therapists are likely to experience strong countertransference reactions to these clients.

may feel inclined to be overly protective to keep c out of harm's way, or may become annoyed or frustrated w/ slow progress of t & c's need for constant reassurance. t needs to manage these feelings so don't surface & damage the thera rel. any ruptures in thera rel must be attended to & repaired.

Avoidant PD therapist charec cont.

may leave therapy prematurely, sometimes in middle of a session, at slightest hint of criticism, disapproval, or feeling misunderstood. ~50% drop out. t must be gentle, nonthreatening, & willing to provide repeated reassurance. focusing on resilience & c's strengths can help build self-confidence for these ppl who are easily embarrassed & humiliated by perceived threats to self-esteem, bc of extreme fragility, ts must proceed at slow pace, comm warmth, concern, empathy support, avail & protection.

Combination treatment for ADP

med sometimes combined w/ therapy. lithium, prozac, zoloft, & beta-blockers all demo some effectiveness in helping control anger & impulsivity one review of RCTs found no convincing evidence for use of pharmacological interventions for ADP if med prescribed, should be done so carefully, bc pop tendency to misuse drugs & bc of reliance on external than internal sol to prob.

ADP environmental change

milieu & residential treatment programs & tera comm that use token econ, peer modeling, & clear consequences can sometimes succeed in effecting some change residential thera programs est specifically for ppl who have broken the law typically focus on ^ level of respon, trust in self & others, & sense of mastery, while ingraining understanding of consequences. imp benefit is remove ppl from former environ where behavior may have been reinforced by peers. for those who have been incarcerated, prelease or halfway programs can be helpful in facilitating transition to more socially acceptable way. developing new support systems & sense of belonging thru employment or self-help groups can help

Intervention strat cont.

modicum of success n this area will help c engage in more in-depth, cog therapy like beck's model for PPD - address core cog schema of inadeq that underlies PPD helping c develop sense of competency & self-esteem & looking at pt belief in light of reality may be useful, esp if suspicions first validated PPD - tend to overgen, magnify neg, & dichotomous thinking, cog therapy should focus on alt explanations. t can be rational, logical, & unthreatening as c begins t apply what learn to own metacognitions understanding cog distortions & errors & thinking, begin to see impact have had on others. taking on another's pov tends to reduce anger & hostility & at this stage paranoia can -> dep. astute t will work w/ c to process such concerns & provide acceptance, normalization, & warmth

BPD Transference--focused psychotherapy

modified psychodynamic therapy based on work of Kernberg. developed specifically for treatment of BPD. t uses the thera rel as vehicle to help ppl work thru & integrate internalized experiences of dysfunc from childhood thru reality testing, rage neutralization, & mgmt of transference rel, goal is help ppl integrate into whole object rel instead of splitting off into unrealistic pos or neg objects. both pos & neg transference interpretations are mod when working w/ cs. presented in manualized version in twice-weekly sessions over 1 yr. oral contract est prior to beginning. in RCT found to be effective as treatment as usual & reduce impulsivity & anger.

Ange is one of the most stable and persisting of BPD but borderline rage is not normal anger.

more like an emo storm that often preceded by perceived rejection. anger directed toward specific person when loved one appears to be rejecting, withholding or gives appearance of abandoning person rejection sens sets up cycle of behavior in which exhibit reactive agg to perceived slights -> solicits rejection from person must valued if anger internalized may -> self-harming behavior, or suicide. non-suicidal injury practices by many as 75 w/ BP as a way to relieve anxiety, dep, & other strong feelings that become unmanageable. if anger externalized can disrupt interpersonal & thera rel. when kids object of rage, frightening bc rep trusted adult out of control

Schizoid - typical client characteristics

more men than women. women w/ this more likely to have co-occurring alc or sub use dis. for most ppl w/ cluster A PDs, symp of schizoid traits gen present in childhood including being socially detached, cog & perceptual distortions, eccentricities, difficulty making friends, & easily preoccupied w/ an idea. being diff from other kids may -> poor peer rel, isolation, underachievement in school, & becoming brunt of teasing. kids & teens may also have tendency to develop dep dis.

DPD preferred therapist characteristics

more than any other diagnosis, those w/ DPD are most likely to develop romantic attachment to t. should set clear boundaries on the rel w/ c, avoid any physical contact & explain romantic feelings are not unusual in thera rel but will not be acted upon & rel will be prof. many seek treatment after loss of loved one due to bereavement or divorce. others seek treatment at suggestion of fam memb or employer. typically hesitant or anxious abt therapy but motivated to seek treatment to avoid loss of current rel or employment.

Prognosis of schizotypal

most do manage to live stable, if marginal, existence. suggested to be labeled schizo II, since it is midler schizo spectrum dis & most w/ PD don't devolve into more dysfunc schizo case mgmt & long-term oversight may be needed to help cs maintain indep living& find employment. crisis mgmt will be necessary during times when psychotic decompensation occurs.

Borderline Personality Disorder (BPD)

most freq diagnosed of any of the PDs & most commonly cited for treatment in outpatient settings, & for 72 of inpt mh hospitalizations multiple evidence-based treatment options exist that are effective in controlling intense emo, self-destructive behavior, & extreme impulsivity

OCPD preferred therapist characteristics

most ppl who seek treatment for OCPD do so at the urging of their spouse, employer, or for another reason altogether once in therapy, their need to intellectualize & tendency to live by rules of the way believe things should be may -> confrontations w/ t who expect will never make a mistake after est rapport, wise t will forewarn c of own humanity & that at some point will unintentionally say something that violates their standards. t can challenge c to bring incident up as an experiment of how to mng conflict. role-playing conflict can be effective thera tool. t must provide honest feedback & be real & avail to c.

Therapists must also address their own CT issues.

must learn ppl w/ BPD not respon for creating dis. genetics & life set them on develop pathways. ts who are flexible, take cs emo pain & anguish seriously, & able to set boundaries & limits in respectful manner, more likely to help c w/ BPD safely thru crisis while simul est secure thera rel -> pos change most t will recog common tendency toward splitting. idealizing t at beginning & then devaluing. healthy balance needed. t who recog & address underlying struggle & fear more likely help c recog benefits that treatment offers.

APD client charec cont

neuro vulnb in combo w/ environ prob, like oor or inconsistent parenting or presence of trauma, combine to create perfect storm kids who later develop APD ge grew up in fam in which first-degree relatives had APD, alc or sub abuse prob, or other dis. discipline may have been inconsistent, erratic or excessively punitive. interpersonal interactions are bidirectional & in some cases c's impulsive & difficult behavior may elicit excessive punishment. after a while may give up. reciprocal process -> parents responding to poor behavior & lack of self-reg by avoiding or ignoring behavior, through other ineffective methods than shaping c's behavior.

Etiology cont

neuroticism or neg affectivity is present to some degree in most personalities. low neuroticism may -> in PD that is unflappable, calm, & even-tempered, even in stressful times. high degree of neuroticism present in most PDs. normal as in stat normative, levels of neuroticism found in healthy ppl. most experience some level of maladaptive neuroticism.

Co-occurring disorders (APD)

notable narc, paranoid, & histrionic. if sadistic or neg personality pattern present, poorer outcome likely many have underling dep, which, in absence of treatment, ^ risk of suicide. est 11 w/ APD have attempted ^ 5 completed.

Description of HPD

often pepper their interactions w/ charm or unnecessarily provocative or sexualized behavior to draw attention to themselves often manipulative, may use style of speech, physical appearance, & exaggerated expressions of emo to influence others to do their bidding. early influenced by others & highly open to suggestion consider rel more intimate than are, can become uncomfortable or bored, not knowing how to be when focus of attention not on them sometimes considered to be shallow, or lacking depth of emo. style of speech often lacking in detail, & designed to leave impression than illuminate facts.

BPD developmental pathways

once thought that childhood abuse (both physical & sexual) responsible RCTs w/ kids who had been abused found most didn't develop BPD. kids who did found to have fam interactions that were invalidating, conflicted, neg, or critical -> biosocial stress model better accounted for by heritable vulnb to internalizing & externalizing dis when gen vulnb kids experience environ prob causes fissures in attachment rel. vicious cycle begins in which ft trauma, stress, or invalidation activates attachment system & c seeks proximity & protecting by caregiver to reduce anxiety & ^ attachment. ^ causes distress in child & caregiver which reactivates attachment cycle.

not all people w/ APD are criminals, & not all people who commit crimes have a PD.

only when the personality features are inflexible & maladaptive & persist in face of severe func impairment do they rise to level of APD many have antisocial traits & find themselves in business, politics, etc where charec charm, manip, & agg can propel them to higher positions. focus on self-interest & accumulation of material goods rewarded in such settings.

NARC PD therapist characteristics cont.

others may always appear calm & completely unflappable, & present w/ supercilious imperturbability. veneer of nonchalance, optimism, & being completely unimpressionable by what others say or do is hallmark of insouciant temperament. only severe narc wound that causes person to q own narc belief in themselves can shake confidence. loss of personal defenses can -> transient psychotic symp t should develop collab rel in whcih assert themselves as experts on psychotherapy, while accepting c as expert of their life. collab rel can facilitate acceptance of help & building of an alliance. any credit for pos changes would be given to c. thru extensive use of empathy & judicious self-disclosure in form of pos reactions to c, t can develop working alliance. transference reactions should be viewed as therapeutic material. true empathy & rapport may be elusive.

Millon (2001) notes that NPD is NOT commonly found in populationd

outside the U.S. & it seems to be more common in upper middle classes in this country. suggested that ^ in NPD in this country may -> from unique late 20th cent lifestyle. focus on indiv achievement, indep, & personal gratification are more commonly found in indiv societies v collectivism.

Some of the traits of Avoidant PD may arise as a result of the presence of other mental disorders

panic, agora, or dep or as result of med condit or substance use dis. sim, other PDs (histrionic, avoidant, borderline) may share comm traits. only when full criteria are met, & when traits are persistent & cause sig impairment or distress, would dependent PD be diagnosed. dependent traits must be so severe as to cause sig impairment in func, as when person chooses to stay in violent rel v risk living on own. ppl who have dep often have a hist of insecure attachment or chronic illness. dep which often manifests as result of loss or anticipated abandonment may co-occur two dis share many sim - neg thinking, catastrophizing, hopelessness, victimization, lack of initiative, poor self-esteem, & difficulty making decision

Description of NARC PD

parenting practices been proposed as main factor contributing to development of narc case studies point to hist of parental criticism or neglect in childhood -> feelings of vulnb & inability to trust or depend on others. to compensate for feelings, they develop mask of superiority & self-sufficiency that sep them from others & reduces ability to connect on intimate level lack of empathy & feelings of entitlement often result & fantasy freq serves as sub for reality. another develop pathway may result from parents who overvalue the child & instill inflated sense of self-worth. often occurs w/ only kids, favored kid, or in some cult groups. ^ kids internalize message special & deserve superior treatment. rarely learn respon, accountability, & concept of sharing. rarely does admiration & esteem extend beyond boundaries of home, & those who have had special esteem conferred on them know high regard is underserved or inflated & fear others find out not true & reject them. shame & humiliation often result when narc confronted w/ reality.

Women w/ APD tend to fit into stereotyped gender roles.

passive, insecure, & dep on others to make decisions for them. underlying anger may permeate their rel but are likely to be afraid to express it for fear of consequences. in gen, ppl w/ dis are unhappy & disappointed w/ their lives, their partners, & careers, if able to est & maintain such rel.. even then, keep others at a distance.

A modified version of cognitive therapy that proposes behavioral experiments rather than directly disputing cognitions can help

people to see the faulty logic in beliefs that can never make mistakes & must live in compliance w a perfection that can be achieved. inventories, worksheets, & between session experiments can appeal to these cs' perseverance & need for structure. other types of therapy likely to be received by ppl w/ OCPD will be structured, prob-centered, & present-focused. mindfulness-based cbt can be helpful. reduce anxiety & dep mood, & improving overall well being.

Schizoid - client characteristics

perceptual distortions, illusions, magical thinking, & paranoid ideation are rep by more than 78% odd attitudes & behaviors usually apparent & can contribute to creation of prob in employment & peer rel. social iso from others avoiding behavior can lead to cog slippage & downward drift which occurs more freq than expected in ppl w/ this dis considering gen above-avg level of intelligence. dis seem more freq in first-degree bio rel of ppl w/ schizo & both genetic & environ may be at play. neuro deficits in frontal lobe sim to what is found in schizo. some kids born w/ genetic predisp to schizotypy. abuse, bullying, rejection, & humiliation freq found in backgrounds of adults who seek treatment.

OCPD

perfectionist & inflexible behavior charec this PD. msot freq occurring, affecting abt 2% unlike OCD, OCPD is an ego syntonic dis in which a sense of right & wrong abt how life should be lived pervades every aspect of life. duties, rules & perfection surrounding a task often becomes more imp than actual completion of task itself.

antisocial personality disorder

pervasive pattern of irresponsible behavior that shows disregard for rights of others & violates social norms developed on a continuum thru life, from childhood behavior prob, to conduct dis, & on to develop of antisocial traits cannot be diagnosed prior to 19. presence of conduct dis prior to age of 15 must be documented.

Clients may be nudged forward, but encouraging confrontation too early in the treatment can result in

premature termination. contacting upfront for a specific numb of sessions may improve the person's commitment to stay in treatment. ts must be careful not to become too deferential or overly protective of ppl in treatment for avoidant PD. nor should they push them too quickly in treatment process.

APD intervention strategies

prevention seems most effective. early prevention in preschool & elem yrs when first diagnosed w/ ODD of CD can have profound pos effect on c's behavior. in early childhood, treatment should b based on behavioral principles & train cs in use of empathy. rude conversion rate of CD to adult APD by 40-70 + parent-focused & distinguish btn childhood onset and teen onset. improving parenting competencies is primary goal.

preferred therapist charec (APD) cont

psychoeduc & MI can elucidate options & focus on choice. helps cs recog in charge of goals & respon for behavior helping c to develop enlightened self-interest can be key to motivating ft behavior working w/ this pop can prove challenging, may develop countertransference to cs that could pot lead to boundary violations disbelief & collusion common as t prone to minimize illegal activities. clear guidelines can reduce power struggles. recc providing clear explanation of dis & setting explicit guidelines & limits. t can feel angered or threatened by histories, & frust or discouraged by lack of progress. reactions must be monitored & managed. therapy should be cont only if c exhibit clear evidence that benefitting.

Schizoid preferred therapist charecteristics

rarely seek treatment. when do, building trust becomes most crucial ingredient to develop of successful working rel. t must first help c see benefits of therapy, outlining pros & cons & working together to create hierarchy fo goals. est goals must be collab process, or may acquiesce to t's wishes. whether adult cs come to therapy bc of crisis or brought to treatment for dep or sub abuse prob, t will be wise to avoid interpretations or confrontations. gentle, consistent, accepting, optimistic, patient, & supportive stance. provide corrective emo experience may help c ^ optimism abt rel & stay in treatment to see value of rel.

Description of Schizoid cont.

reality testing usually intact, so psychotic dis can be ruled out due to presence of hallucinations & delusions. autism also share some of symp here but usually involves more social impairment persistent sub use, personality change due to med condit, & other PDs should be ruled out ppl w/ this dis often deny feelings, become tangential in thoughts & easily distracted some capable of living superficially w/ others, others prefer to engage in solitary activities. have rich fantasy that preoccupies time. rarely marry, likely to live alone or w/ parents, & work in jobs that req little personal interaction. some appear to maintain semblance of normal life, w/ superficial network of friends.

RCT of CBT for individuals at high risk for developing psychosis found that CBT was mor effective in

reducing conversion rates to psychosis than supportive therapy. improvement in symp also more rapid w/ CBT than supportive therapy. several studies suggest also combo treatment w/ med can help control paranoia & psychotic symp, esp acute symp ass/ psychotic decompensation. RCT - risperidone & olanzapine found to be effective in reducing anxiety & more severe cog disturbances ass/ shcizotypal PD. med can help reduce level of impairment, patterns of PD remain intact. several RCTs of polyunsaturated fatty acids for ppl transitioning to psychotic dis found them to sig reduce pos symp & reduce risk of progression to psychosis. omega-3 may provide safer alt for young ppl whose symp below threshold of full-blown psychoses

Research on resilience indicated that three major attributes in kids contribute protection from BPD

reflection - ability to think what has happened & consider other alt agency - knowing oneself & being able to persevere in face of frust relatedness - develop of at least one close rel that c can trust & feel comfortable comm w/

Unlike schizoid or other cluster A personality disorders in which people don't mind isolation, people w/ APD yearn for

relationships & are likely to fantasize abt their lives being diff fear of being maligned or embarrassed strongly outweighs need for companionship even in rel w/ fam memb or trusted friends, they are unlikely to reveal personal info bc of fear of being ridiculed or embarrassed

Because of the limited amount of empirical research about PDD, some have suggested its

removal altogether from DSM as sep dis. alt dsm-5 model would diagnose this disorder as personality disorder -TS (trait specified)

DSM-5 also includes an alternative dimensional model in Section III.

rep variety of traits & impairments in personality func & places greater emphasis on personality charec (e.g., empathy, narc, & self-direction) & psychopathy (e.g., callousness, impulsivity) reduces numb of PF to six: antisocial, avoidant, borderline, narc, obsessive-compulsive, & schizotypal. diagnosis of PD - trait specified can also be made when PD present but criteria for specific dis not been met. both systems may be used alone or in combo to provide cat & dimensional pov

Etiology of PDs

research into causes & risk factors for developing PDs seem to indicate triad of causation interaction btn genetic, environ, & psychosocial factors. genetic predisp to temperament including anxiety, neg affect, & neuroticism can lie dormant until ignited by environ events like neglect, trauma etc person's nature or temp -> reactions ranging from coping & calming to neg, destructive or psych vulnerable states early learning -> lifelong prob w/ emo expression, suppression, avoidance, & reg

ADP Prognosis

resistance to treatment common among kids & teens exhibiting antisocial traits & adults w ADP maybe low motivation to change from strong need for indep & resistance to authority figures (often viewed w/ contempt) others have allowed impulsive & violent actions to -> crim justice pathway than mh treatment approach when adults w/ ADP present for MH treatment, structured & active apporach that helps them learn how to reg behavior as part of enlightened self-interest seems provide min goal.

APD typical client characteristics

reuslt of interplay of genetic predisp, temperament, & environ factors. as muchas 50% of variance in APD can be attributed to genetics, with unique experiences respon for 31 & shared - 11. brains paralimbic system plays role. underdeveloped orbitofrontal cortex, the area that controls impulses & social & emo decision making contributes. kids tend to not recog social cues or emo underlying direction or verbal instructions from parents or other authority figures. in addit to impulsivity, this results in failure among kids to learn from their experiences.

Traits of schizotypal PD may first appear in childhood in the form of

rich & bizarre thoughts & strange lang or fantasies that cause these kids to be considered odd or eccentric by peers common cog & perceptual distortions that occur include psychic or paranormal experiences, ideas of reference, & bodily illusions. illusions or delusions occur freq & cause others to consider person as odd or eccentric. ex talk to themselves out loud, dress oddly. magical thinking & superstitious that are part of religious beliefs not SPD. all cs should be eval in context of religious & cult backgrounds.

Multiple research studies support the effectiveness of cognitive & behavioral interventions on PD

schema therapy can help develop new core cognitions & reduce the level of unrelenting standards sim to other cluster c PDs, avoidant coping responses common for those w/ OCPD avoidant coping responses temporarily defer neg feelings that arise when a schema response been triggered. avoidant responses can be both behavioral & cog

BPD Prognosis

seem to be able to achieve remission when have social support & low rates of interpersonal stressors. lower relapse than bipolar dis, panic dis, or MDD. improvement seen regardless of type of therapy. more research needed to determine why this is so. younger age & higher level of educ consistently predicted better func. those who didn't achieve remission likely to cont to remain chronically impaired.

Social skills training in a group format can teach ADP clients

self-control & delayed gratification & structured group therapy has achieved modicum of success in improving prosocial skills in ppl w/ APD Schema therapy, & MBT show promise.

Medication management is usually not indicated in treatment of OCPD unless

severe anxiety or dep co-occur SSRIs that work directly on brains 5-HT neurons may help reduce symp anxiolytics may be beneficial to treatments of anxiety.

Symptoms of APD likely to begin in childhood or teens and become more

severe in early adulthood, diminishing spont in midlife. kids who exhibit agg behaviors like hitting likely to cont & accelerate as grow older persistent physical fighting tends to predict promo from ODD to CD in kids. teens & adults w/ APD traits shown symp of conduct dis since childhood. persistent pattern of impulsive & agg behavior freq in reaction to social rules as opp to authority. impulsivity in kids doesn't seem play direct role but does interact w/ predisp toward APD. APD interacts w/ impulsivity to lessen internal controls that would prevent from acting on impulses. distinction should be made btn reactive agg (linked to internalized dis) & proactive agg linked to APD. criminality in teens predictive of APD in YA

HPD - comorbid disorders

should be addressed. until dep, anxiety, & somatic symp brought under control, cs may be unable or unwilling to mod behavior sim, if alc or sub use plays major role in ^ impulsive behavior, should be done. med sometimes helpful in reducing alc consumption. ReVia may be helpful for those who want to quit drinking, & those w/ self-harming behaviors antidep & antianxiety med can reduce symp of anxiety & dep, but if med recc, care taken bc some may be prone to suicidal threats & gestures.

Therapists should also conduct a risk assessment for adults diagnosed w/ APD.

should consider any history of violence, including nature & severity bc of high rate of comorbid dis, esp sub use, careful ass should include other diagnoses whenever possible, interviews should be conducted w/ fam to obtain hist of impulsivity, interpersonal difficulties, & current stress on rel. all efforts for an accurate diagnostic pic will help tailor treatment.

Avoidant PD intervention strat.

since six out of seven of DSM-5 criteria for APD relate to interpersonal rel, impt that social skills training necessary ft. relapse prevention will also be imp to help cs maintain gains after t ended. specific social skills most likely to make a diff in person's qual of life include interpersonal expression, assertiveness, & conflict negotiation. t can help promo interpersonal expression by setting up small experiential exercises. ex sending back a meal. assertiveness can be encouraged by eliciting feedback from c during the session.

Intervention strategies (schizoid) cont

small environ changes may afford opp to interact a bit more & provide natural lab where can experiment w/ newly found skills creating treatment plan that builds slowly on skills & abilities key. cs should not be pushed into fam or group sessions, nor overwhelmed by multimodal approaches teaching social cog skills of empathy & theory of mind found to improve comm & rel in teens & may be helpful for adults. cog & behavioral approaches that grad encourage social involvement & build on interest may be helpful. fantasies & fears provide other avenues.

Symptoms of PPD may first develop in childhood or teens & may appear as

social anxiety or sensitivity, withdrawal, or iso from others. kids may be bullied for being odd or having peculiar thoughts or fantasies, & may be underachievers in school. poor social rel may result. some cult factors or behavior might be misconstrued as paranoid traits. immigrants or memb of min groups may be guarded or distrustful of maj bc of abuse, indiff, lang barriers, or lack of knowledge abt each other's cult. might manifest in cycle of mutual mistrust -> guarded, defensive, or angry behavior. NOT PPD

In general, the assessment of APD symptoms in teens and adults should begin with

the use of a structured clinical rating scale like the PCL-R. t should look for external validators that support diagnostic symptoms. diagnosis of APD has greater temporal stability than any other PD, bc mostly based on antisocial & crim behavior t must keep in mind environ influences that impact childhood (SES, parent traits, high expressed emo). factors will affect ability to attend & participate in treatment. recog persons w/ APD will gen not be forthcoming abt prior hist of violent or other antisocial behavior. need collateral info, consultation w/ prof.

Description of antisocial

specific traits ass/ include failure to conform to societal norms & lawful behavior, deceitfulness or conning others for pleasure or personal gain. irritability & aggression, impulsivity & reckless disregard for safety of self or others, irrespon, indiff to other's pain, & lack of remorse neg correlation found btn APD & warmth, conscientiousness, & agreeableness in addit to need for indep, adults have tendency to trust only in themselves. often engage in preemptive aggression, attacking in anticipation of being attacked, defending behaviors. bc lack a conscience or empathy, rarely engage in introspection or feel bad. often shrewd judges of other ppl & can use verbal & interpersonal skills in manip & self-serving ways.

Over time, people w/ OCPD tend to develop interpersonal & social difficulties w/ those around them

spouse may complain that never stop working long enough to take a vacation, or that need for cleanliness turned into obsession. partner may insist on couples therapy to help address work/life imbalance that seems to plague ppl w/ OCPD demanding & controlling behavior combined w/ an inability to express emo put a trait on the relationship & soon their lives together lack joy or spontaneity & consist of only obligations & work. as partners, tend to be domineering, & can be critical of mistakes. home environ may emphasize order & control. parenting style often punitive & authoritarian, sim to way in which parents raised them. more freq found in first-degree relatives than it is in gen pop, & freq have n elevation in the unrelenting standards schema domain.

Intense fear of abandonment (perceived or real) sets up a pervasive pattern of behavior in BPD that

strikes at core of self-img -> frantic behavior intended to reduce anxiety & fear of being alone impulsive behavior usually self-defeating & often ends up causing abandonment feared can be high func or low func, depending on variables like level of insight into behavior, degree of occup & social impairment, comorbid dis. sub use, dep dis, anxiety dis, & other PDS commonly comorbid. dissociation common, esp in stressful sit. eating, sleeping, & self-care may be erratic, & almost always experience difficulties in rel & employment.

At work, poor, interpersonal skills, lack of tolerance for others, & failure to adhere to rules because they believe are somehow except can lead to

stunted careers. some have successful & impressive career hist. ability to be self-reliant & take control of own lives contributes to sense of direction. NARC PD should be distinguished from health narc. self-confidence & self-esteem valued traits in healthy ppl are also accompanied by empathy, social concerns, & ability to acknowledge role played in interpersonal misunderstandings.

Rarely does BPD occur w/o other accompanying disorders.

sub abuse, other PDS (esp antisocial), mood dis, & anxiety nearly 75% in one study had BPD w/ anxiety. 50% had panic attack most research before focused on adults. focus on early detection & prevention -> symps of dis lasting at least a yr can be diagnosed for those younger than 18. before hesitant bc of stigma, lack of support from insurance companies for axis II dis, & dearth of research on kids.

Early signs of avoidant traits in childhood include shyness, fear of rejection, interpersonal sensitivity, and avoidance of social situations.

teens may be less pop, be less involved in athletics, have few hobbies or interests, & have few, if any, friends. may begin to avoid social or other school func & may be at ^ risk of dropping out. by teens, many ppl w/ symp have already developed an inability to est healthy rel w/ others. social skills necessary for successful transition into adulthood are lacking including ability to develop rel, seek & maintain employment, or live on own. diminished interpersonal skills -> overall reduced qual of life. APD may remit w/ age, altho never completely goes away. more likely that a tendency to decompensate under stress.

HPD - typical client characteristics

tend to have exagg expressions of emotion. may cry hysterically or laugh too loud or for too long a time. freq sexually & socially active but may experience sexual difficulties at higher than avg rate. easily bored, may seek out new challenges & stim that can cause prob in current rel seem to be tweaking their rel in search for perfect partner. will often pair up w/ someone who is detached & unemo, who provides for dependency needs, but doesn't provide constant reassurance & strong feelings looking for. once found stability looking for, boredom may set in & change partners w/ alarming frequency.

OCPD treatment

tend to have limited patience for talking abt their feelings & more likely to respond to CBT after t est their credentials & developed rapport w/ indiv, ct can be introduced slowly to look at c's belief system of rules & reg for how life should be. lim research is avail specific to treatment of OCPD. one study found 83% reduction in severity level & 53% reduction in dep symp in ppl w/ OCPD who were treated w/ cbt.

Narcissistic personality disorder can be distinguished from BPD by

the narc's stronger sense of self & lack of deep feelings of abandonment that accompany BPD. common comorbid disorders include other PD, esp antisocial, histrionic, & paranoid dysthymia, anxiety dis, & develop of hypochondriacal concerns likely to occur following humiliating defeat, confrontation, or embarrassment, reverting back to being household tyrants. secondary gains, include having built-in excuse to rationalize failures & shortcomings.

Interpersonal relationships can present a minefield for person w/ OCPD and

their family being right often place of higher imp than rel itself. one might ask a c struggling w/ marital discord if would rather be right or happy.

BPD client characteristics

transient sense of ID prevents ppl w/ BPD from knowing who they are & ult accepting themselves lack of ID causes them to change jobs, religion, hair, & even names on reg basis take on falvor of those around them. const search for new group of friends, diff career, or changing major inability to reg emo appear to be caused by high emo sens + bias toward neg emo. this & low distress tolerance -> inability to reg neg affective states likely to do compensatory strat to try overcome neg affect. overeating, alc use, gambling, drugs, shopping etc end up having rebound effect. as crisis deepens, self-harming or suicidal behaviors can develop. impulsive agg & emo dysreg linked to suicidal & self-injurious behaviors.

BPD - Schema-focused CBT

type of cog behavioral therapy focuses on reframing schemas - the maladaptive core beliefs that ppl have abt themselves. helps cs recog how such core beliefs undermine their interactions w/ others & teaches them to challenge beliefs & develop a more pos self-image. several RCTs shown the effectiveness of schema-focused therapy in reducing suicidal actions, decreasing drop-out rates, & improving overall recovery.

Schizotypal intervention cont.

unusal experiences, magical thinking, & paranoid ideation are ego-syntonic & tend to be treatment resistant. cog therapy can help ppl consider types of thoughts & determine whether evidence avail to support them reality testing provided in environ of acceptance & support will be tolerated better than confrontation or interpretation. behavioral approach that fosters risk-taking & social skills training can help in reducing distorted emo reasoning & coping w/ perceived criticism, which common charec. even well-structured group approach can help, if participants carefully vetted & environ is structured as to not be threatening.

Avoidant PD preferred therapist characteristics

w/o treatment, may become more mistrustful, alienated, & avoidant of social sit, often becoming dependent on fam memb as only ppl are comfortable being around. low risk-taking behavior & limited social skills make them highly unlikely to seek treatment unless forced by fam memb or employer. may be enticed into treatment by partner to address a specific issue like dep or anger, or partake in couples therapy to improve rel. process may feel so threatening that t may need to devote lrg portion of each session to support c & providing reassurance that process can be trusted.

Narc PD intervention strategies

wealth of info abt develop & symp of narc but little empirical research avail on treatment. since controlled outcome studies are lacking, inferences from case studies must be drawn abt types of treatment likely to be successful. indiv psychotherapy is treatment of choice for dis, altho may will not enter on own, & some likely discredit t's knowledge or skills, & terminate therapy prematurely. psychodynamic, cog behavioral, & schema-focused therapies can be helpful if tailored to specific needs of cs. ppl w/ mild dysfunc who are motivated to engage in therapy might benefit from psychodynamic approach. cs w/ disturbances of affect & impulse control seems to respond better to expressive, cog, & supportive forms of therapy.

BPD client charec cont

when comorbid w/ MDD, bipolar, or sub abuse, the risk of suicide ^ psychotic symp not uncommon. nearly 3/4 experience paranoid ideation & dissociative symp. 24% report severe psychiatric symp. such usually transient & don't necessarily predict develop of psychotic dis overreactivity to stress & inability to reg emo are symp found in BPD, ADHD, & Bipolar -> wonder if neuro link? brain imaging studies indicate neuropathology in limbic system may explain behaviors like inability to self-calm rumination & lack of coping mechanisms can find ppl stuck & unable to move forward sense of urgency while in neg mood common. contributes to affect instability.

Gender distribution varies from one personality disorder to another.

women more likely -> borderline (75 fem) & 80% of ppl diagnosed w/ antisocial PD are male. gender diff may be actual variations in gender distributions, or may be caused, in part, by biases in making diagnoses. sim concerns for cult considerations. asians more likely to show signs of shyness & collectivism for ex. other factors (ex ses, status, race, age, marital status) have been linked to develop of PD.

BPD intervention strategies

worldview research confirms psychotherapy is primary treatment modality for BPD & that cs benefit from treatment. gone days where diagnosis is life sentence. most researched of any of the PDS. EBP are: DBT; Schema-focused CBT; systems training for emo predictability & prob solving; mentalization-based psychotherapy transference focused psychotherapy; dynamic supportive therapy