1. Definition of Personality Trait Enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts

2. Definitional Features of Personality Disorder Enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture and is manifested in at least two of the following areas:

3. Definitional Features of Personality Disorder The pattern is manifested in at least two of the following areas: cognition, affectivity, interpersonal functioning, or impulse control (Criterion A) The enduring pattern is inflexible and pervasive across a broad range of personal and social situations (Criterion B) Leads to significant distress or impairment in social, occupational, or other important areas of functioning (Criterion C)

4. Definitional Features of Personality Disorder The pattern is stable and of long duration, and its onset can be traced back to adolescence or early adulthood (Criterion D) The pattern is not better accounted for as a manifestation or consequence of another mental disorder (Criterion E) The pattern is not due to the direct physiologic effects of a substance or a general medical condition (Criterion F)

5. Three Clusters of Personality Disorders Cluster A (odd eccentric) –Paranoid –Schizoid –Schizotypal

6. Three Clusters of Personality Disorders Cluster B (dramatic-emotional) –Antisocial –Borderline –Histrionic –Narcissistic

7. Three Clusters of Personality Disorders Cluster C (anxious-fearful) –Avoidant –Dependent –Obsessive-compulsive

8. The Challenge of Working With Personality Disorders Patients typically come for therapy with presenting problems other than personality problems They require more work within the session Longer duration of treatment Greater strain on the therapist’s skills and patience Greater difficulty in treatment compliance

9. “Red Flags” for Identifying Personality Disorders A patient or significant other reports that the patient “has always done that” or has always been that way” The patient is not compliant with the therapeutic regimen Therapy progress seems to have come to a complete stop for no apparent reason Patients often will seem unaware of the effect their behavior has on others Patient’s problems appear to be acceptable and natural for them

10. Beck’s Theory of Personality Disorders Certain behavioral patterns or strategies that had adaptive value in evolutionary terms, become maladaptive in today’s society when these “strategies” become exaggerated

11. Beck’s Theory of Personality Disorders A strong relationship exists between the cognitive patterns on the one hand and the affective and behavioral patterns on the other

12. Definition of Schemas Schemas are relatively stable information processing structures that operate in a feed-forward system to guide the processing of information. They are not themselves conscious, although they can be recognized, evaluated, and their interpretations tested.

13. Characteristics of Schemas They integrate and attach meaning to events They can be described in terms of valence or level of activation They can be of a highly idiosyncratic content

14. Characteristics of Schemas They vary according to their function When particular schemas are hypervalent, the threshold for activation of the constituent schemas is low

15. Beck’s Theory of Personality Disorders Each personality disorder has its own profile that can be characterized by core beliefs about the self and others and compensatory strategies associated with those core beliefs

16. Beck’s Profile of Personality Disorders Personality Disorder View of SelfView of Others Main BeliefMain Strategy AvoidantVulnerable to rejection, Inept, Incompetent

17. Beck’s Profile of Personality Disorders Personality Disorder View of SelfView of Others Main BeliefMain Strategy AvoidantVulnerable to rejection, Inept, Incompetent Critical Superior Demeaning

18. Beck’s Profile of Personality Disorders Personality Disorder View of SelfView of Others Main BeliefMain Strategy AvoidantVulnerable to rejection, Inept, Incompetent Critical Superior Demeaning It’s terrible to be rejected; If people know the real me, they will reject me

19. Beck’s Profile of Personality Disorders Personality Disorder View of SelfView of Others Main BeliefMain Strategy AvoidantInept Incompetent Critical Superior Demeaning CORE: I am worthless CONDITIONAL If people know the real me they will reject me. It’s terrible to be rejected. Avoids evaluative situations

20. Beck’s Profile of Personality Disorders Personality Disorder View of SelfView of Others Main BeliefMain Strategy ParanoidRighteous Mistreated

21. Beck’s Profile of Personality Disorders Personality Disorder View of SelfView of Others Main BeliefMain Strategy ParanoidRighteous Mistreated Devious Treacherous Malicious Abusive motives

22. Beck’s Profile of Personality Disorders Personality Disorder View of SelfView of Others Main BeliefMain Strategy ParanoidRighteous Mistreated Devious Treacherous Malicious Abusive motives Be on guard, Don’t trust Accuse or Counter-attack

23. Beck’s Profile of Personality Disorders Personality Disorder View of SelfView of Others Main BeliefMain Strategy ParanoidRighteous Mistreated Devious Treacherous Malicious Abusive motives Be on guard, Don’t trust Accuse or Counter-attack

24. Beck’s Profile of Personality Disorders Personality Disorder View of Self View of Others Main BeliefMain Strategy DependentNeedy Weak Helpless Incompetent

25. Beck’s Profile of Personality Disorders Personalit y Disorder View of Self View of Others Main BeliefMain Strategy DependentNeedy Weak Helpless Incompetent Nurturant Supportive Competent

26. Beck’s Profile of Personality Disorders Personalit y Disorder View of Self View of Others Main BeliefMain Strategy DependentNeedy Weak Helpless Incompetent Nurturant Supportive Competent Need people to survive; Need steady flow of support and encouragement

27. Beck’s Profile of Personality Disorders Personalit y Disorder View of Self View of Others Main BeliefMain Strategy DependentNeedy Weak Helpless Incompetent Nurturant Supportive Competent Need people to survive; Need steady flow of support and encouragement Cultivate dependent relationships

28. Beck’s Profile of Personality Disorders Personality Disorder View of Self View of Others Main BeliefMain Strategy Obsessive- compulsive Responsible Accountable Competent Fastidious

29. Beck’s Profile of Personality Disorders Personality Disorder View of Self View of Others Main BeliefMain Strategy Obsessive- compulsive Responsible Accountable Competent Fastidious Irresponsible Casual Incompetent Self-indulgent

30. Beck’s Profile of Personality Disorders Personality Disorder View of Self View of Others Main BeliefMain Strategy Obsessive- compulsive Responsible Accountable Competent Fastidious Irresponsible Casual Incompetent Self-indulgent I know what’s best Details are crucial People should do better, try harder

31. Beck’s Profile of Personality Disorders Personality Disorder View of Self View of Others Main BeliefMain Strategy Obsessive- compulsive Responsible Accountable Competent Fastidious Irresponsible Casual Incompetent Self-indulgent I know what’s best Details are crucial People should do better, try harder Apply rules Perfectionism Evaluate Control Criticize

32. Beck’s Profile of Personality Disorders Personalit y Disorder View of Self View of Others Main BeliefMain Strategy NarcissticSpecial, unique Superior Deserve special rules

33. Beck’s Profile of Personality Disorders Personalit y Disorder View of Self View of Others Main BeliefMain Strategy NarcissticSpecial, unique Superior Deserve special rules Inferior Admirers of me

34. Beck’s Profile of Personality Disorders Personalit y Disorder View of Self View of Others Main BeliefMain Strategy NarcissticSpecial, unique Superior Deserve special rules Inferior Admirers of me Since I’m special I deserve special rules I’m better than others

35. Beck’s Profile of Personality Disorders Personality Disorder View of Self View of Others Main BeliefMain Strategy NarcissticSpecial, unique Superior Deserve special rules Inferior Admirers of me Since I’m special I deserve special rules I’m better than others Use others Transcend rules Manipulate

36. Beck’s Profile of Personality Disorders Personality Disorder View of Self View of Others Main BeliefMain Strategy SchizoidSelf- sufficient Loner

37. Beck’s Profile of Personality Disorders Personality Disorder View of Self View of Others Main BeliefMain Strategy SchizoidSelf- sufficient Loner Intrusive

38. Beck’s Profile of Personality Disorders Personality Disorder View of Self View of Others Main BeliefMain Strategy SchizoidSelf- sufficient Loner IntrusiveOthers are unrewarding Relationships are undesirable

39. Beck’s Profile of Personality Disorders Personality Disorder View of Self View of Others Main BeliefMain Strategy SchizoidSelf- sufficient Loner IntrusiveOthers are unrewarding Relationships are undesirable Stay Away

40. Cognitive Therapy for Personality Disorder Background

41. Therapeutic Assumptions Therapy will often evoke anxiety because the patient is being asked to change “who they are” Patients with personality disorders often come to therapy with presenting issues other than personality problems Patients with personality disorders are more difficult to treat Therapy must take a tripartite approach Schema work takes a much more central role in CT with personality disorders A much greater emphasis is placed on the client-therapist relationship

42. Problems in Collaboration Therapist or patient may lack the skill to be collaborative Patients’ beliefs regarding the potential failure in therapy Patients’ beliefs (fears) regarding the effects of changing on significant others or himself Poor socialization to the cognitive therapy model Frustration due to lack of progress

43. Cognitive Techniques Guided discovery Labeling of inaccurate inferences Collaborative empiricism Examining explanations of others’ behavior Scaling Reattribution training Deliberate exaggeration Decatastrophizing

44. Behavioral Techniques

45. Goals of Behavioral Techniques Alter self-defeating compensatory behaviors Skill building (e.g., assertiveness) Behavioral experiments designed to weaken maladaptive beliefs

46. Specific Behavioral Techniques Role playing Use of imagery Reliving childhood experiences Assisting in decision-making

47. Borderline Personality Disorder

48. Significance of BPD 2% of general population meet for BPD 11% of outpatients and 19% of inpatients meet criteria for BPD (Widiger & Francis, 1989) Of those meeting for some personality disorder, 33% of outpatients and 63% of inpatients meet for BPD 70-75% of BPD patients have a history of self- injurious acts

49. Significance of BPD Cont. Estimates of suicide rates for BPD patients are approximately 10% 74% of BPD referred patients are women

50. Diagnostic Features of BPD Hypersensitivity to abandonment Pattern of unstable and intense interpersonal relationships Unstable self-image or sense of self Marked impulsivity Recurrent suicidal behavior Affective instability Chronic feelings of emptiness Inappropriate or intense anger or difficulty controlling anger Transient stress-related paranoid ideation or dissociative symptoms

51. Risk Factors in BPD Family history of BPD, major depression, and SUDs (Widiger & Trull, 1993) Childhood physical/sexual abuse (Sabo, 1997) Personality traits of impulsivity and affective instability (Depue, 1996)

52. Treatment Perspectives in BPD Focus on identity disturbance (Millon, 1981) Focus on emotion dysregulation (Linehan, 1991) Early maladaptive schemas (Young, 1983)

53. CBT for Borderline Personality Disorder (Linehan)

54. Linehan Model

55. Components of Emotional Dysregulation Emotional vulnerability –High sensitivity to emotional stimuli –Intense response to emotional stimuli –Slow return to emotional baseline once emotional arousal has occurred

56. Components of Emotional Dysregulation Deficits in emotion modulation strategies –Ability to inhibit inappropriate behavior related to strong negative or positive emotions –Ability to act in a way that is not mood-dependent –Ability to self-soothe any physiological arousal that the strong emotion has induced –Ability to refocus attention in the presence of strong emotion

57. Features of the Invalidating Environment During development, people respond to the communication of the child's preferences, thoughts, and emotions with either nonresponsiveness or more extreme negative consequences An invalidating environment emphasizes the inhibition of emotional expressiveness

58. Role of the Invalidating Environment Persistent discrepancies between a child’s private experience and what others in the environment respond to as her experience provide the fundamental learning environment for many of the behavioral problems associated with BPD

59. Consequences of the Invalidating Environment Child fails to learn how to label emotion or modulate emotional arousal Child fails to learn to tolerate distress or form realistic goals and expectations Child learns that extreme emotional reactions will sometimes provoke a helpful environmental response Child fails to learn to trust her own internal experiences and hence looks for external cues about how to think, act, and feel

60. Linkage of Emotional Dysregulation and BPD Behavioral Characteristics The behavioral characteristics of borderline individuals (i.e., self-mutilation, suicide attempts) can be conceptualized as the effects of emotional dysregulation and maladaptive emotional regulation strategies

61. Linkage of Emotional Dysregulation and BPD Behavioral Characteristics Emotional lability leads to unpredictable behavior and cognitive inconsistency, thus interfering with identity development The chaotic relationships seen with BDPs is understandable given the person’s difficulties in controlling impulsive behaviors and negative emotions

62. Areas of Divergence From Standard CBT Emphasis on acceptance and validation of behavior as it is in the moment DBT emphasizes the importance of balancing the technology of change with the technology of acceptance

63. Areas of Divergence From Standard CBT Emphasis on treating therapy-interfering behaviors of both client and therapist Emphasis on the therapeutic relationship as essential to treatment Emphasis on dialectic processes

64. Characteristics of the DBT Treatment Applies many standard CBT principles and techniques Attempts to reframe suicidal and other dysfunctional behaviors

65. Characteristics of the DBT Treatment Adopts a problem-solving focus Encourages exposure to fear-eliciting stimuli

66. Characteristics of the DBT Treatment Gives some attention to cognitive change techniques

67. Characteristics of the DBT Treatment Emphasizes strategies for validating client's thoughts, feelings, and actions

68. Characteristics of the DBT Treatment Emphasis on modifying current maladaptive behaviors before ameliorating long-standing interpersonal conflicts or the effects of early trauma and abuse Combines therapy into two conceptual components – psychosocial skills training and motivational issues

69. Major Modes of Treatment in DBT Individual psychotherapy Group skills training Telephone consultation Case consultation for therapists

70. Specific Skill Training Modules in DBT Emotional regulation skills –Understanding emotions and their reactions –Observing emotions –Experiencing emotions –Reducing emotional vulnerability through exercise and reducing alcohol/drugs

71. Specific Skill Training Modules in DBT Interpersonal effectiveness skills

72. Specific Skill Training Modules in DBT Distress tolerance skills –Distraction techniques –Self-soothing procedures –Realistically evaluating the pros and cons of tolerating events –Acceptance strategies

73. Specific Skill Training Modules in DBT Mindfulness skills –Paying attention to the ebb and flow of emotional experience –Paying attention to thoughts in the moment –Paying attention to action urges –Practice labeling them correctly –Practice accepting them w/o trying to suppress them

74. Efficacy Data (Linehan, 1991;1993)

75. Major Findings Data from Linehan et al (1991). Archives of General Psychiatry, 48, 1060-1064.

76. CBT Treatment of Avoidant Personality Disorder Renneberg et al (1990)

77. Study Overview 17 patients were administered an intensive 4 day group treatment program consisting of (1) group systematic desensitization; (2) Behavioral rehearsal; (3) self-image enhancement

78. Major Findings Data from Renneberg et al (1990). Behavior Therapy, 21, 363-367.

79. CBT Treatment of Avoidant Personality Disorder Alden (1989)

80. Design 4-arm randomized clinical trial (constructive strategy design) –Graduated exposure –Graduated exposure + Interpersonal skill training –Graduated exposure + Interpersonal skill training + Intimacy Focus –Wait-list control

81. Subjects 76 subjects (42 men, 34 women) all unmarried Meeting DSM-III criteria based on clinical interview Must score above the 75% on Millon’s AVPD scale No current substance abuse or psychotropic medication

82. Treatments 10 weekly group sessions (2-2.5 hour duration) Each group had 6-7 participants 6 masters-level therapists (2 therapists per group)

83. Results Patients in all three active treatments improved significantly compared to the wait-list There were no significant differences between the three active treatments suggesting skill training did not add to the efficacy of graduated exposure

84. Results Cont. Significant others rated the patients’ improvement as noticeable; Clinical significance analyses revealed that while treated patients improved 1 SD during treatment, their scores did not move into the range of a normative sample

85. Effectiveness of Psychotherapy for Personality Disorders: A Quantitative Review Perry et al (1999)

86. Description of Included Studies 15 studies examining treatments for personality disorders that included pre-to posttreatment data Of these only 6 were randomized studies and 9 were uncontrolled treatment studies 5 focused on BPD, 1 schizotypal, 1 avoidant, and 8 mixed

87. Description of Included Studies Cont. Treatment Modalities –7 studies – psychodynamic –4 studies – CBT –2 Interpersonal group psychotherapy –1 Supportive psychotherapy

88. Major Findings Drop-out rates varied considerably and averaged 21.8% Drop-outs were positively associated with longer treatments Mean pre- to posttreatment effect sizes were 1.11 for self-report measures and 1.29 for observer-rated measures These did not differ for the different types of treatment