definition of personality trait enduring patterns of perceiving, relating to, and thinking about the...
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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
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:
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)
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)
Three Clusters of Personality Disorders
• Cluster A (odd eccentric)– Paranoid– Schizoid– Schizotypal
Three Clusters of Personality Disorders
• Cluster B (dramatic-emotional)– Antisocial– Borderline– Histrionic– Narcissistic
Three Clusters of Personality Disorders
• Cluster C (anxious-fearful)– Avoidant– Dependent– Obsessive-compulsive
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
“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
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
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
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.
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
Characteristics of Schemas
• They vary according to their function
• When particular schemas are hypervalent, the threshold for activation of the constituent schemas is low
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
Beck’s Profile of Personality Disorders
Personality Disorder
View of Self View of Others
Main Belief Main Strategy
Avoidant Vulnerable to rejection,
Inept, Incompetent
Beck’s Profile of Personality Disorders
Personality Disorder
View of Self View of Others
Main Belief Main Strategy
Avoidant Vulnerable to rejection,
Inept, Incompetent
Critical
Superior
Demeaning
Beck’s Profile of Personality Disorders
Personality Disorder
View of Self View of Others
Main Belief Main Strategy
Avoidant Vulnerable to rejection,
Inept, Incompetent
Critical
Superior
Demeaning
It’s terrible to be rejected;
If people know the real me, they will reject me
Beck’s Profile of Personality Disorders
Personality Disorder
View of Self View of Others
Main Belief Main Strategy
Avoidant Vulnerable to rejection,
Inept, Incompetent
Critical
Superior
Demeaning
It’s terrible to be rejected; If people know the real me they will reject me
Avoids evaluative situations
Beck’s Profile of Personality Disorders
Personality Disorder
View of Self View of Others
Main Belief Main Strategy
Paranoid Righteous
Innocent
Noble
Vulnerable
Beck’s Profile of Personality Disorders
Personality Disorder
View of Self View of Others
Main Belief Main Strategy
Paranoid Righteous
Innocent
Noble
Vulnerable
Interfering
Malicious
Abusive motives
Beck’s Profile of Personality Disorders
Personality Disorder
View of Self View of Others
Main Belief Main Strategy
Paranoid Righteous
Innocent
Noble
Vulnerable
Interfering
Malicious
Abusive motives
Be on guard, Don’t trust, Motives are suspect
Accuse or
Counter-attack
Beck’s Profile of Personality Disorders
Personality Disorder
View of Self View of Others
Main Belief Main Strategy
Paranoid Righteous
Innocent
Noble
Vulnerable
Interfering
Malicious
Abusive motives
Be on guard, Don’t trust, Motives are suspect
Accuse or
Counter-attack
Beck’s Profile of Personality Disorders
Personality Disorder
View of Self
View of Others
Main Belief Main Strategy
Dependent Needy
Weak
Helpless
Incompetent
Beck’s Profile of Personality Disorders
Personality Disorder
View of Self
View of Others
Main Belief Main Strategy
Dependent Needy
Weak
Helpless
Incompetent
Nurturant
Supportive
Competent
Beck’s Profile of Personality Disorders
Personality Disorder
View of Self
View of Others
Main Belief Main Strategy
Dependent Needy
Weak
Helpless
Incompetent
Nurturant
Supportive
Competent
Need people to survive;
Need steady flow of support, encouragement
Beck’s Profile of Personality Disorders
Personality Disorder
View of Self
View of Others
Main Belief Main Strategy
Dependent Needy
Weak
Helpless
Incompetent
Nurturant
Supportive
Competent
Need people to survive;
Need steady flow of support, encouragement
Cultivate dependent relationships
Beck’s Profile of Personality Disorders
Personality Disorder
View of Self
View of Others
Main Belief Main Strategy
Obsessive-compulsive
Responsible
Accountable
Competent
Fastidious
Beck’s Profile of Personality Disorders
Personality Disorder
View of Self
View of Others
Main Belief Main Strategy
Obsessive-compulsive
Responsible
Accountable
Competent
Fastidious
Irresponsible
Casual
Incompetent
Self-indulgent
Beck’s Profile of Personality Disorders
Personality Disorder
View of Self
View of Others
Main Belief Main 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
Beck’s Profile of Personality Disorders
Personality Disorder
View of Self
View of Others
Main Belief Main 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
Beck’s Profile of Personality Disorders
Personality Disorder
View of Self
View of Others
Main Belief Main Strategy
Narcisstic Special, unique
Superior
Deserve special rules
Beck’s Profile of Personality Disorders
Personality Disorder
View of Self
View of Others
Main Belief Main Strategy
Narcisstic Special, unique
Superior
Deserve special rules
Inferior
Admirers of me
Beck’s Profile of Personality Disorders
Personality Disorder
View of Self
View of Others
Main Belief Main Strategy
Narcisstic Special, unique
Superior
Deserve special rules
Inferior
Admirers of me
Since I’m special I deserve special rules
I’m better than others
Beck’s Profile of Personality Disorders
Personality Disorder
View of Self
View of Others
Main Belief Main Strategy
Narcisstic Special, 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
Beck’s Profile of Personality Disorders
Personality Disorder
View of Self
View of Others
Main Belief Main Strategy
Schizoid Self-sufficient
Loner
Beck’s Profile of Personality Disorders
Personality Disorder
View of Self
View of Others
Main Belief Main Strategy
Schizoid Self-sufficient
Loner
Intrusive
Beck’s Profile of Personality Disorders
Personality Disorder
View of Self
View of Others
Main Belief Main Strategy
Schizoid Self-sufficient
Loner
Intrusive Others are unrewarding
Relationships are undesirable
Beck’s Profile of Personality Disorders
Personality Disorder
View of Self
View of Others
Main Belief Main Strategy
Schizoid Self-sufficient
Loner
Intrusive Others are unrewarding
Relationships are undesirable
Stay Away
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
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
Cognitive Techniques
• Guided discovery
• Labeling of inaccurate inferences
• Collaborative empiricism
• Examining explanations of others’ behavior
• Scaling
• Reattribution training
• Deliberate exaggeration
• Decatastrophizing
Goals of Behavioral Techniques
• Alter self-defeating compensatory behaviors
• Skill building (e.g., assertiveness)
• Behavioral experiments designed to weaken maladaptive beliefs
Specific Behavioral Techniques
• Role playing• Use of imagery• Reliving childhood experiences• Assisting in decision-making
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
Significance of BPD Cont.
• Estimates of suicide rates for BPD patients are approximately 10%
• 74% of BPD referred patients are women
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
Linehan Model
B e h av io rIn s ta b ility
In te rp e rso n a lIn s ta b ility
S e lfIn s ta b ility
C o gn it iveIn s ta b ility
E m o tio n a l V u ln era b ility(A ffe c tive In sta b ility)
E m otio n R e g u la tion D ys fu nc tionIn va lid a tin g E n v iro n m e nt
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
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
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
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
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
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
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
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
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
Characteristics of the DBT Treatment
• Applies many standard CBT principles and techniques
• Attempts to reframe suicidal and other dysfunctional behaviors
Characteristics of the DBT Treatment
• Adopts a problem-solving focus
• Encourages exposure to fear-eliciting stimuli
Characteristics of the DBT Treatment
• Emphasizes strategies for validating client's thoughts, feelings, and actions
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
Major Modes of Treatment in DBT
• Individual psychotherapy
• Group skills training
• Telephone consultation
• Case consultation for therapists
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
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
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
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
Major Findings
20
25
30
35
40
45
50
% of patients meeting Jacobsen Criteria
ImprovedRecovered
Data from Renneberg et al (1990). Behavior Therapy, 21, 363-367.
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
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
Treatments
• 10 weekly group sessions (2-2.5 hour duration)
• Each group had 6-7 participants
• 6 masters-level therapists (2 therapists per group)
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
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
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
Description of Included Studies Cont.
• Treatment Modalities– 7 studies – psychodynamic– 4 studies – CBT– 2 Interpersonal group psychotherapy– 1 Supportive psychotherapy
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 amd 1.29 for observer-rated measures
• These did not differ for the different types of treatment