18 Personality Disorders Disorders The diagnoses in this chapter had in the past been listed on Axis II, but as the DSM-5 shifts from a multiaxial system (as discussed in Chapter 1) all mental disorders will be assessed on a single axis. In addition, pilot research has been conducted on an alternate dimensional model for personality disorder diagnoses, and it is included for further study in Section III of The DSM-5 (APA, 2013).    The personality disorders refer to pervasive, persistent, and relatively inflexible personality traits that lead to functional impairment or subjective distress. In this sense, departures from expectations of the individual's culture may include the cognitive approaches to viewing the self or others, emotional range, intensity, stability and/or appropriateness, interpersonal functioning, and/or impulse control. The pattern in question should be stable across a broad range of situations, be established by early adulthood, and not be due to another mental disorder, a general medical condition, or substance usage (APA, 2013).    Although the criteria for the specific personality disorders do not preclude their use with children or adolescents (with the exception of antisocial personality disorder), clinicians are encouraged to be extremely circumspect in applying these labels with young people. Usually, problematic personality traits exhibited in early years will often not persist into adulthood. In any event, for these diagnoses to be applied to persons under the age of 18, the specified behavior needs to have been present for at least 1 year. Antisocial and Borderline types of personality disorders tend to lessen and abate with age, but this is not typical for the remaining personality types (APA, 2013).    The specific diagnoses in this section are divided into three “clusters” or subgroupings based on similarities in symptom presentation. Often, an individual warranting a diagnosis of a particular personality disorder will exhibit traits related to other diagnoses within the same cluster. Less frequently, an individual may exhibit a grouping of traits related to a particular cluster of personality disorders without fully meeting any specific diagnosis; this may be diagnosed as either “other specified personality disorder” and/or “unspecified personality disorder.” Additionally, clients can be diagnosed with a personality change due to another medical condition (e.g., temporal lobe epilepsy). For greater detail please see the DSM-5 (APA, 2013).    Cluster A personality disorders, refer to those with a pattern of behavior that is generally viewed as odd or eccentric. Commonly, clients with one of these disorders tend to isolate themselves and/or be suspicious. Frequently, a pattern of social isolation can be traced into childhood. People with cluster A personality disorders seldom seek treatment (APA, 2013).    The first cluster A diagnosis is Paranoid Personality Disorder. A pervasive distrust and/or suspiciousness ...

1. 18 Personality Disorders
Disorders
The diagnoses in this chapter had in the past been listed on Axis
II, but as the DSM-5 shifts from a multiaxial system (as
discussed in Chapter 1) all mental disorders will be assessed on
a single axis. In addition, pilot research has been conducted on
an alternate dimensional model for personality disorder
diagnoses, and it is included for further study in Section III of
The DSM-5 (APA, 2013).
The personality disorders refer to pervasive, persistent, and
relatively inflexible personality traits that lead to functional
impairment or subjective distress. In this sense, departures from
expectations of the individual's culture may include the
cognitive approaches to viewing the self or others, emotional
range, intensity, stability and/or appropriateness, interpersonal
functioning, and/or impulse control. The pattern in question
should be stable across a broad range of situations, be
established by early adulthood, and not be due to another mental
disorder, a general medical condition, or substance usage (APA,
2013).
Although the criteria for the specific personality disorders do
not preclude their use with children or adolescents (with the
exception of antisocial personality disorder), clinicians are
encouraged to be extremely circumspect in applying these labels
with young people. Usually, problematic personality traits
exhibited in early years will often not persist into adulthood. In
any event, for these diagnoses to be applied to persons under
the age of 18, the specified behavior needs to have been present
for at least 1 year. Antisocial and Borderline types of
personality disorders tend to lessen and abate with age, but this
is not typical for the remaining personality types (APA, 2013).
The specific diagnoses in this section are divided into three
“clusters” or subgroupings based on similarities in symptom
presentation. Often, an individual warranting a diagnosis of a

2. particular personality disorder will exhibit traits related to other
diagnoses within the same cluster. Less frequently, an
individual may exhibit a grouping of traits related to a
particular cluster of personality disorders without fully meeting
any specific diagnosis; this may be diagnosed as either “other
specified personality disorder” and/or “unspecified personality
disorder.” Additionally, clients can be diagnosed with a
personality change due to another medical condition (e.g.,
temporal lobe epilepsy). For greater detail please see the DSM-
5 (APA, 2013).
Cluster A personality disorders, refer to those with a pattern
of behavior that is generally viewed as odd or eccentric.
Commonly, clients with one of these disorders tend to isolate
themselves and/or be suspicious. Frequently, a pattern of social
isolation can be traced into childhood. People with cluster A
personality disorders seldom seek treatment (APA, 2013).
The first cluster A diagnosis is Paranoid Personality Disorder.
A pervasive distrust and/or suspiciousness of others
characterize clients with this diagnosis. More specifically, they
may suspect others of having malevolent motives, be
preoccupied with concerns about others, be reluctant to confide
in others, be extremely sensitive to perceived criticisms, and/or
bear grudges against others (APA, 2013).
The next cluster A diagnosis is Schizoid Personality Disorder.
Clients with this diagnosis are characterized by avoidance and
lack of desire for social relationships. In addition, clients with
Schizoid Personality Disorder show emotional coldness, lack of
empathy, and a narrow range of affect. More particularly, they
consistently prefer technical occupations and activities that
involve little social contact. They are often described as loners
who derive little pleasure in leisure time activities. The person
with schizoid personality disorder, however, does not have
distorted perceptions or cognitions. (APA, 2013).
The diagnosis of Schizotypal Personality Disorder completes
cluster A and is characterized by a general detachment from
social relationships and a restricted range of emotional

3. expression. Essential features include social and interpersonal
deficits that are expressed by clients who consistently prefer
isolation to social relations, generally have few interests or
hobbies, seldom engage in intimate relationships, seem
indifferent to others' opinions of them, and/or are described as
cold or emotionless (APA, 2013). Clients with this diagnosis
typically have restricted interpersonal relationships and
evidence marked peculiarities in thinking and perception. More
specifically, they show thinking and perceptual processes
similar to, but not as severe as, those in persons diagnosed with
schizophrenia or other psychotic disorders. In this matter,
symptoms mirror those seen in schizophrenia except individuals
can usually distinguish between their distorted ideas and reality.
For example, someone with this personality disorder may have
ideas of reference but not so pervasively as to be considered
delusions of reference (APA, 2013).
The cluster B personality disorders refer to a pattern of
behavior that is generally viewed as dramatic or emotional. In
particular, clients with one of these disorders often display
erratic or impulsive behaviors. Further, there is generally a
marked self-absorption that results in a diminished capacity for
empathy (APA, 2013).
The first cluster B personality diagnosis is Antisocial
Personality Disorder. It should be noted that for diagnosis,
clients must be aged 18 or older (who have shown symptoms of
conduct disorder with onset before the age of 15). Clients with
this diagnosis usually engage in illegal activities, routinely
practice deceit, are often aggressive or violent, are typically
irresponsible, and generally ignore the rights and feelings of
others. Further, these clients rarely show remorse for their
behavior. Typically, they do not seek treatment but may be
referred because of interactions with the legal system or in
conjunction with substance-abuse treatment (APA, 2013).
The next cluster B diagnosis is Borderline Personality
Disorder. Clients with this diagnosis typically evidence erratic
interpersonal relationships, fluctuating self-image and/or affect,

4. and marked impulsivity. They frequently engage in suicidal or
self-mutilating behaviors. They are noted for extremes in affect
and in judgment; people diagnosed with this disorder rarely see
themselves or others in a balanced way. These clients are the
most likely of people with personality disorders to seek
treatment (APA, 2013).
Another cluster B diagnosis is Histrionic Personality
Disorder. Clients with this diagnosis evidence emotionality and
attention seeking. They generally are only comfortable when
they are the “center of attention” and will use physical
appearance, speech, and emotions to command others' attention
(APA, 2013).
The final cluster B diagnosis is Narcissistic Personality
Disorder. A grandiose sense of self-importance, a need for
attention, and a reduced capacity for empathy characterize
clients with this diagnosis. They often seem to have an
exaggerated sense of entitlement and expect to be admired and
obeyed by others. With these last two personality disorders,
clients usually seek treatment to address their frustration with
other people (APA, 2013).
The cluster C personality disorders include patterns of
behavior that are essentially fearful and/or anxious. Clients with
these disorders tend toward being perfectionistic or rigid in
standards or expectations for themselves or others. Like people
with cluster A diagnoses, clients with cluster C disorders are
relatively unlikely to seek treatment (APA, 2013).
The first of the cluster C diagnoses is Avoidant Personality
Disorder. Clients with this diagnosis show marked feelings of
inadequacy that are associated with hypersensitivity to negative
feedback and/or social inhibition. More specifically, these
clients seldom put themselves in “risky” or even new situations
in which they may perform poorly. They seldom develop
intimate interpersonal relationships and may even constrain
occupational choices based on fear of negative judgments and/or
a demand for high levels of social interaction (APA, 2013).
The next diagnosis in cluster C is Dependent Personality

5. Disorder. Clients with this disorder seek someone to take care
of them, even to the extent of being submissive, clinging, and
fearful of separation. These clients avoid decisive action and
encourage others to make decisions for them. The characteristic
subservience makes it quite difficult to express disagreement,
even when asked to undertake unpleasant activities. These
clients fear being alone and quickly substitute a new
relationship if an old one is lost. They systematically
underestimate themselves and their ability to function
independently (APA, 2013).
The final cluster C diagnosis is Obsessive-Compulsive
Personality Disorder. Clients with this diagnosis have well -
controlled, perfectionistic patterns of behavior at the expense of
spontaneity, flexibility, and even efficiency. More particularly,
there is often such preoccupation with planning and details that
tasks are not completed. These clients have difficulty delegating
responsibilities and, in fact, tend to work long hours in order to
meet their own standards regarding productivity. Also, they
tend to collect and hoard things even when those things have
little value. Unlike persons with obsessive-compulsive disorder,
individuals with Obsessive-Compulsive Personality Disorder do
not necessarily have obsessions or compulsions. Rather, they
tend to be rigid in their actions and thinking, adhering to stri ct
and controlled patterns of thought and behaviors (APA, 2013).
Assessment
Detailed and thorough histories are necessary for the diagnosis
of a personality disorder. Assessment of the characteristics of a
personality disorder must be consistent over time and across
circumstances. Diagnosis is often complicated by the fact that
many individuals with personality disorders often do not seek
out treatment on their own, have overlapping symptoms as well
as coexisting disorders. It is worth mentioning, that caution
should be used when employing many self-report scales due to
the possibility of built-in gender and/or ethno-cultural bias.
The Structured Clinical Interview for DSM-IV Axis II
Personality Disorders (SCID-II; First, Gibbon, Spitzer,

6. Williams, & Benjamin, 1997) is the recognized benchmark for
the diagnosis of the 10 personality disorders currently in the
DSM-5 (APA, 2013). This semistructured instrument can make
a diagnosis by either the presence/absence of symptoms or by
counting (sum scores) the number of criteria needed to meet
diagnosis. Additionally, the personality questionnaire (SCID-II
PQ; First et al., 1997) consists of 119 items and can be used as
a self-report screening tool. Training on both the administration
and scoring of this instrument is recommended. The inter-rater
reliability for this instrument ranges from fair to excellent. For
a listing of the numerous reliability studies, see instrument
website (www.scid4.org) under psychometric reliability. Of
note, the more dimensionally the SCID-II pathology is indexed,
the higher inter-rater reliability (Lobbestael, Leurgans, & Arntz,
2011). As pointed out by Ryder, Costa, and Bagby (2007) as
well as others, the major concern with this instrument is
comorbidity across diagnoses due to overlap in symptoms
within the clusters.
Another comprehensive measure, the MMPI-2 (see Chapter
1 for details) can be useful in assessing the presence of the
various personality disorders, particularly as the clinical and
validity scales are included in its administration. Due to the
target age range of the MMPI-A, there is much less emphasis on
the possibility of personality disorders in its interpretation. The
MMPI-2 is a widely used instrument with years of supportive
research and requires training in the administration and scoring
of this instrument.
Two other broad-based assessment instruments have been
designed to address the presence of a personality disorder more
directly. The Millon Clinical Multiaxial Inventory (MCMI-
III; Millon & Davis, 1997) consists of 175 true-false items
designed primarily to detect a variety of personality disorders as
well as additional subscales for detecting some of the more
common co-occurring mental disorders. In its third edition, this
instrument reflects the diagnostic constructs for the 10
personality disorders currently found in the DSM-5 (APA,

7. 2013) as well as the addition of 42 Grossman Facet Scales.
Similar to other NCS Pearson products, the MCMI has been
well researched and validated in its various versions. Details
and psychometrics can be found in the author's test manual
(Millon, Millon, Davis, & Grossman, 2006).
Another set of instruments designed to detect personality
disorders has been developed by Coolidge and associates. The
Coolidge Axis II Inventory (CATI; Coolidge, 2005; Coolidge &
Merwin, 1992) consists of 250 questions self-rated on a 4-point
scale, ranging from “strongly false” to “strongly true” designed
to measure personality disorders based on current diagnostic
criteria. There are 14 personality disorder scales in the CATI,
including the 10 personality disorders included in this chapter
as well as 4 others (e.g., passive-aggressive, depressive,
sadistic, and self-defeating). Additionally, some scales may
help when determining the possible presence of a personality
change due to another medical condition (e.g., General Medical
Condition scale). Three other companion instruments are
available. The short-form of the Coolidge Axis II inventory
(SCATI; Coolidge, 2001); which is a shorter, 70-item version
with similar psychometrics (Coolidge, Segal, Cahill, &
Simenson, 2010); The CATI—Significant Other Form
(Coolidge, Burns, & Mooney, 1995), which is designed
for completion by a person familiar with the client; and, the
Kids' Coolidge Axis II Inventory (KCATI; Coolidge et al.,
1990), which is designed to assess personality disorders or their
precursors in children and adolescents (ages 5–17). All of these
instruments have demonstrated reasonable psychometric
properties. For further information on use and psychometrics
see author references.
For screening purposes, the self-report Standardized
Assessment of Personality Abbreviated Scale (SAPAS-
SR; Moran et al., 2003) is an 8-item, dichotomously rated
measure for personality disorders (further validated by Hesse &
Moran, 2010). When a response indicates pathology, the
interviewer must administer additional questions (up to 8 more).

8. This tool screens for the presence of a general personality
disorder versus diagnosing which disorder may be present.
Summing items produces a total score ranging from (0–8) with
higher scores indicating greater likelihood for the presence of a
personality disorder. During validation, a cutoff score of 3
correctly identified the presence of a DSM- IV personality
disorder in 90% of participants. The sensitivity (.94) and
specificity (.85) were reported in the original validation study
(Moran, et al., 2003). This brief instrument takes less than 5
minutes to complete. Limitations have been reported for some
personality disorders (e.g., antisocial, histrionic, and obsessive-
compulsive) and with the trait narcissism (Hesse & Moran,
2010).
Additionally, the DSM-5 (APA, 2013) contains new disorder
specific assessment measures (e.g., Personality Inventory for
DSM-5—Brief Form; PID-5-BF) for both adults and children,
which can be found under online assessment measures, for
examples please see www.psychiatry.org.
Cultural Considerations
Judgments about persistent and pervasive personality traits
cannot be made without consideration of a person's cultural
background. Caution should be exercised when evaluating
clients whose culture of origin is unfamiliar to the assessor.
Particular care should be exercised in diagnosing members of
minority groups with paranoid personality disorder. There is a
tendency to underestimate the existence of prejudice and
discrimination by people who are not members of the group in
question.
In a study of personality disorders and ethnicity, Chavira et
al., (2003) found that of four targeted personality disorder
categories (schizotypal, borderline, obsessive-compulsive, and
avoidant), Hispanic men and women (primarily Puerto Rican)
were more likely to be diagnosed with borderline personality
disorder than Caucasians or African Americans. The authors
clearly state that the explanations for such findings are
inconclusive. Hispanic men and women may display borderline

9. type symptoms due to the stress of acculturation to a majority
society. On the other hand, a diagnosis of borderline personality
disorder may be a misdiagnosis due to cultural bias by Western
clinicians. For example, in Puerto Rican culture, men are
expected to display emotions openly, to shout and cry during
crises, and have physical and verbal outbursts of aggression.
These symptoms would be considered an ataque de nervios in
Hispanic culture. The authors suggest that there are major
problems with the categorization of personality disorders among
diverse ethnic groups due to a lack of understanding on the part
of Western society regarding the cultural nuances and
upbringing of non-Western populations. Lin (1997) argues that
the diagnosis of “borderline” is extremely rare in some non-
Western societies calling the universality of the diagnosis into
question. He states that in China, for example, this diagnosis is
rarely utilized. Other personality disorder diagnoses may be
overused due to a lack of cultural competence on the part of
clinicians. Schizotypal personality disorder, for example, has
been overdiagnosed among African and African-American
groups.
The incidence of certain personality disorders seems sharply
divided along gender lines. For example, men are much more
likely to be diagnosed with antisocial personality disorder,
whereas women predominate in diagnoses of borderline,
histrionic, and dependent personality disorders. Even though
this may, in fact, reflect an actual difference in prevalence,
clinicians should be cautious about over- or underdiagnosing
these disorders based on gender role stereotypes.
Social Support Systems
The impact of personality disorders on both social relationships
and occupational functioning is both “constraining” and
“disrupting.” Because these are persistent patterns of behavior
established by early adulthood, the characteristics directly
influence both social and vocational choices. For example,
individuals with a diagnosis of dependent personality disorder
would not likely seek or be comfortable with an egalitarian

10. relationship. Similarly, people with a cluster A personality
disorder are not likely to become salespeople.
These constraints are also evidenced in patterns of seeking
treatment. As has been indicated, few people with personality
disorders actively seek treatment. Those who do are frequently
“motivated” by circumstances that prevent them from
comfortably continuing their pattern of behavior. For example,
someone with antisocial personality disorder may seek
intervention only to minimize the intrusion of the legal system
into his or her life. People with a cluster A personality disorder
may be “forced” into treatment when changing circumstances
force them to interact more broadly with the world (e.g., when
their parents die).
With these characteristics in mind, it is not surprising that
most community resources and Internet sites are devoted to
“explaining” personality disorders to those who may be
associated with the client. Some resources are as follows:
· www.nami.org: The National Alliance on Mental Illness is a
grassroots mental health organization dedicated to the advocacy
and support of people living with mental illness, including
personality disorders.
· www.nimh.nih.gov: The National Institute of Mental Health
seeks to transform the understanding and treatment of mental
illnesses through research and education. For information on
some personality disorders see the “Health & Education”
section of their website.
Case 18.1
Identifying Information
Client Name: Natalie Loftin
Age: 29 years old
Ethnicity: Caucasian
Educational Level: College graduate
Occupation: Administrative assistant
Intake Information
Natalie Loftin contacted the Marriage and Family Counseling
Center due to concerns about her relationship with her

11. boyfriend, Larry Watkins, over the past 6 months. She reported
that she has been so upset that she hasn't been able to function
at work, and her coworkers told her she needs to get some help.
When the intake worker asked her what she meant by “upset,”
Natalie stated that she felt so depressed and empty that she
didn't think she could stand it. A friend of hers gave her the
name of this agency since it has a sliding-scale fee structure.
Natalie said she also was having financial difficulties and hoped
her insurance would cover the cost of counseling. The intake
worker assured her that the cost of sessions was based on the
client's ability to pay and that if Natalie had insurance
coverage, the cost would be minimal. Natalie agreed to come in
for an initial interview the following week. Her case was
assigned to you.
Initial Interview
You find Natalie restlessly moving around in the waiting ar ea
chewing on her fingernail and flipping through a magazine
while she walks. She is a petite, well-groomed woman wearing a
dark blue suit, a yellow blouse, and small heels. Her long,
brown, curly hair is pulled back in a large clip, and she has
applied a considerable amount of makeup.
You introduce yourself as the counselor and ask her to come
with you to your office. Natalie readily agrees and begins
talking as you walk down the hall.
“My friend, Denise, told me that this was a good place to
come to talk to someone. Do you know Denise?” she asks.
“No, I'm afraid I don't, but even if I did, I couldn't tell you
because everything we discuss here is confidential. We don't
even tell anyone that someone is being seen by a counselor at
this agency,” you reply. “Won't you come in and have a seat?”
“Oh, I see. Well, I guess that's a good thing,” Natalie
responds. “What is your degree? I have a bachelor's degree in
math and computer science.”
“That's impressive,” you respond. “My degree is in mental
health counseling. All the counselors at this agency are master's
level counselors, and we work with people who are attempting

12. to cope with a variety of emotional issues. Everything we talk
about is confidential, but I must tell you that if you tell me that
you may harm yourself or someone else, I cannot keep that
confidential and I must report that information to either the
police or my supervisor. Do you understand that?” you ask.
Natalie thinks for a minute and then replies, “Yes, that makes
sense. I haven't really thought about suicide this week. That's
what you're talking about, isn't it?”
You decide to note that Natalie inferred that she has thought
about suicide in the past but to wait before delving into that
issue since it might be too much divulgence too fast for Natalie
to handle. “Yes, maybe we could begin by you telling me why
you decided to make an appointment.”
“Okay. Well, I've been dating this guy, Larry— Larry
Watkins—for about the last 6 months. He and I just seemed to
have a whole lot in common, and I really thought this was going
to turn into a permanent relationship. We just seemed to get
along so well and, you know, after seeing each other for about a
month, he moved in with me and it just seemed to be great. I
just don't know what happened.” Tears well up in Natalie's eyes,
and she looks as if she's about to burst into tears.
“I see. You were living together for the past 5 months and
everything seemed to be going well. Then what happened?” you
inquire.
“Well, we got into this big argument about my parents. I mean
it was a huge argument one night. We stayed up all night
arguing, and in the morning, he just said he couldn't take it
anymore and packed a bag and left.”
“Okay. Did you ever argue before this?” you ask.
“Well, sometimes, usually over little things. One time I
remember thinking I had some kind of love-hate relationship
with Larry, but then things got better, and I just felt like this
guy could really take care of me. But since the other night, I'm
wondering what's wrong with me. This has been the sixth time
I've been involved with someone and had the relationship just
blow up in my face. I hate it and I hate myself when this

13. happens.” Natalie slumps down in her chair, and tears well up in
her eyes again, but she doesn't actually cry.
“Okay, so you've had other relationships that have ended
abruptly,” you suggest.
“Yes, five other relationships that were serious. I guess I
dated other boys in high school, but those don't really count. I
just don't understand it.”
“Can you tell me what you and Larry were arguing about the
other night? You said it was about your parents,” you
acknowledge.
“Yes, you see, Larry doesn't like my parents or, at least, he
thinks I'm too involved with my family. He got mad because I
talked to my mother on the phone about the car accident I had a
few weeks ago, and she just infuriated me because she refused
to help me out. My car was totaled, and I really need to get
another car, but I don't have enough money to get the one I
want. My parents have plenty of money and could help me if
they wanted, but my mother can be a real ‘witch’ sometimes.
She said that they had already bought me two other cars, and
they weren't going to buy me another one. I couldn't believe
what a witch she was being. She can be crazy, I'm telling you.
She had the nerve to suggest I need to get a better job where I
could use my college education, but she doesn't realize how
hard it is to get a job in the computer industry, and besides, I
think she just hates me. Sometimes I think I hate her, too.”
She continues, “So, I'm just telling Larry about this
conversation, and he gets really angry and says I'm too
dependent on my parents and that I still act like I'm a teenager
and should let go of them since they always make me furious.
He knows that the whole subject of my parents is a ‘hot button’
for me. I think he said that just to make me mad and he did. He
knows what a temper I have! He made me so angry I thought I
was going to explode. Actually, I did explode. I told him what
an idiot I thought he was. Just because he doesn't have a
relationship with his parents doesn't mean I shouldn't have one
with my parents. It's weird—sometimes I am so in love with

14. Larry and other times I hate his guts. Is that the way it i s for
most people?” Natalie curiously inquires.
“I don't think it's unusual to have disagreements with people
you love,” you suggest. “How did the argument end?”
Natalie stares out the window for a moment and then says
matter-of-factly, “He just said he couldn't take it anymore and
went to the bedroom and packed a suitcase and left. I actually
thought he was joking. I told him if he walked out the door, he'd
be a stupid fool. And then when I realized he was serious, I
begged him not to leave me, and he just shrugged his shoulders
and said, ‘Life is too short, Natalie; you are always running hot
and cold. I just can't take it anymore.’”
“What do you think he meant by that statement?” you ask.
“Well, I think he's referring to the fact that I sometimes hate
him and then, other times, I love him. It just seems too empty
inside when he's not around. I wonder if it's all really worth it,”
Natalie responds.
“So, sometimes you feel really empty when you're not
involved in a relationship. Is that right?” you ask.
“Maybe that's why I've had so many,” Natalie ponders. “It
seems like the …
Chapter 20
Neurocognitive Disorders
Gerald Goldstein
Introduction and Recent Developments
Most neurological disorders are ancient diseases, and
developments in treatment and cure have been painfully slow.
However, we continue to learn more about these disorders, and
in previous versions of this chapter (Goldstein, 1997, 2007,
2014) we highlighted substantive developments. A new
disorder, acquired immunodeficiency syndrome (AIDS)
dementia, had appeared, and the marker for the Huntington's
disease gene had been discovered. At the time of the 1997
writing, it was mentioned that a still mysterious and
controversial disorder appeared, sustained by military personnel

15. during the war with Iraq in the Persian Gulf area, popularly
known as the Gulf War syndrome. An aspect of this syndrome
has been said to involve impaired brain function (Goldstein,
2011; Goldstein, Beers, Morrow, Shemansky, & Steinhauer,
1996). A more readily understood condition emerging from the
recent Iraq and Afghanistan wars involves the blast injuries
caused largely by roadside bombs. These injuries appeared to
have different characteristics from those associated with the
open or closed head injuries associated with previous wars and
accidents in civilian life (Belanger, Kretzmer, Vanderploeg, &
French, 2010).
Another consequence of the Iraq and Afghanistan wars has been
a reconsideration of the problem of mild traumatic brain injury
(TBI), often called concussion. Concussion is a common sports
injury, but it also appears to be a common consequence of
sustaining a blast injury. It is sometimes complicated by its
association with post-traumatic stress disorder (PTSD) acquired
in reaction to the injury, and diagnostic difficulties have been
created regarding whether the victim sustained brain injury,
developed PTSD, or both. It was commonly accepted that
concussion was a self-limiting disorder, and that essentially full
recovery could be expected within no more than 90 days.
Recently, however, it has been observed that some individuals
with histories of concussion do not fully recover and continue
to have complaints of cognitive problems, notably in attention,
memory, and organizational abilities. Individuals with multiple
concussions appear to experience a cumulative and long-lasting
effect.
Initially, these symptoms were attributed to stress, but
neuroimaging studies using advanced technologies have found
that identifiable brain damage may result from concussion,
involving the upper brain stem, base of the frontal lobe,
hypothalamic–pituitary axis, medial temporal lobe, fornix, and
corpus callosum. Bigler (2008) has written a review of this area,
using the phrase “persistent postconcussive syndrome” to
describe this condition. Substantial support for the neurological

16. basis for this disorder comes from use of a technology that was
just beginning its development and widespread use at the last
writing, called diffusion tensor imaging (DTI). DTI is an
magnetic resonance imaging (MRI)-related procedure that tracks
axonal white matter, identifying misalignments.
In the Gulf War, concussion and more serious trauma were
associated with blast injuries sustained mainly as a result of
roadside bombing. Blast injuries remain a controversial area,
with some authorities claiming they are no different from the
commonly accepted types of brain injury (Hoge et al., 2008;
Wilk et al., 2010), whereas others claim they are a unique form
of trauma not identified previously. The matter is further
complicated by the fact that the bombs used were sometimes
loaded with depleted uranium or possibly infectious agents.
Thus, the understanding of head injury has changed in recent
years, with the development of methods that can detect
persistent neurological consequences of concussion, producing a
new diagnosis called persistent postconcussive syndrome, and
the problem of blast injury among military personnel, which is
still under intensive investigation.
Diagnostic Considerations
With the publication of DSM-5, there are substantial changes
from DSM-IV in terminology and content. The name of the
category “Delirium, Dementia, Amnestic, and Other Cognitive
Disorders” has been replaced by the phrase “Neurocognitive
Disorders.” The term delirium remains as part of a set of three
major subcategories: major neurocognitive disorder, minor
neurocognitive disorder, and delirium. The term dementia has
been eliminated.
It may be useful to review the rationale for the changes made
in DSM-5. The DSM-5 Neurocognitive Disorders Work Group
prepared a document that contains their proposals for changes
and their rationales for proposing them (American Psychiatric
Association, 2010). We summarize some of their major points
here:
1. Efforts were made to eliminate demeaning or stigmatizing

17. terminology. Just as the term mental retardation has been
replaced by intellectual disability in the neurodevelopmental
disorders section, the term dementia has been replaced by major
and mild neurocognitive disorders. These new terms are felt to
reflect more accurately the nature of the disorder and a general
attempt made by the writers of DSM-5 to correct for the
demeaning, stigmatizing connotations of the names of some
psychiatric disorders. The change from mental
retardation to intellectual disability has already been widely
accepted.
2. Diagnostic criteria wording was changed to increase
precision. Thus, for example, the term consciousness has been
changed to level of awareness. The changes in cognition
specified in DSM-IV mention only memory, orientation, and
language. In DSM-5 the domains of executive ability and
visuospatial impairment are also specified.
3. Mention of severity is added to characterize development of a
disturbance.
4. Specific symptoms of delirium are provided, such as
hallucinations, delusions, and sleep–wake cycle disturbances.
5. Delirium is subcategorized into hyperactive, hypoactive, and
mixed groups, again providing greater specificity.
6. There is a major reconceptualization regarding
characterization of cognitive changes. The term cognitive
decline replaces cognitive deficits to emphasize that major
cognitive disorder is acquired and reflects a decline from
previous level of performance. The previous model, based on
Alzheimer's disease, requires that memory impairment must be
present. However, data now indicate that in other
neurocognitive disorders, other domains such as language or
executive functions may be impaired first, and most
prominently. The changed wording calls for decline from
previous performance in one or more specified domains
including memory, but also language (aphasia), disturbances of
skilled movement (apraxia) or of recognition (agnosia) and
executive function.

18. 7. Emphasis is placed on objective assessment of performance
that may include neuropsychological testing.
8. Emphasis is placed on independent performance of
instrumental activities of daily living.
There have been changes in the number and description of the
neurocognitive disorders. Dementia of the Alzheimer type has
been renamed major or mild neurocognitive disorder due to
Alzheimer's disease. The term vascular dementia has been
replaced with major or mild vascular neurocognitive disorder.
Other neurocognitive disorders/diagnoses now include
frontotemporal, Lewy bodies disease, Huntington's disease,
Parkinson's disease, TBI, substance/medication use, HIV
infection, and prion disease neurocognitive disorders, each of
which can be modified by a major or mild descriptor (see
clinical presentation section).
The diagnosis of mild neurocogni tive disorder is new to
the DSM system. The distinction is a matter of severity.
Cognitive decline is characterized as modest or mild, it should
not interfere with capacity for independence in everyday living,
and delirium or another mental disorder can make a better
explanation of the condition. This change allows for the
diagnosis of less disabling syndromes that may still benefit
from treatment.
In general, the changes in DSM-5 have gone in the direction of
increased specificity, including more detailed documentation of
symptoms, description of cognitive domains involved, providing
an etiological diagnosis, consideration of subtypes and use of
more precise terminology. The distinction between major and
mild disorders allows for diagnosis of individuals wi th mild
impairment who would not meet criteria for a diagnosable
neurological disorder, but who have experienced cognitive
decline associated with brain dysfunction that would benefit
from programs of treatment and management, such as cognitive
rehabilitation.
Clinical Presentation
The theoretical approach taken here will be neuropsychological

19. in orientation, and based on the assumption that clinical
problems associated with brain damage can be understood best
in the context of the relationship between brain function and
behavior. Thus, we expand our presentation beyond the
descriptive psychopathology of DSM-5 (APA, 2013) in order to
provide some material related to basic brain–behavior
mechanisms. There are many sources of brain dysfunction, and
the nature of the source has a great deal to do with determining
behavioral consequences: morbidity and mortality. Thus,
understanding key neuropathological processes is crucial to
understanding the differential consequences of brain damage,
and, in turn, that requires an understanding of how the brain
functions, and in some cases the genetics and neurochemistry of
how memories and other cognitive abilities are preserved in
brain tissue.
In recent years, knowledge of the neurological systems
important for such areas as memory and language has been
substantially expanded. It seems clear now that there are several
separate memory systems located in different areas of the brain,
notably the hippocampus, the amygdala, the neocortex, and the
cerebellum. Each system interacts with the others but supports a
different form of memory, such as immediate recall, remote
recall, and the brief storage of information during ongoing
cognitive activity known as working memory (Baddeley, 1986).
Initially, two major methodologies were used to assess brain
dysfunction: direct investigations of brain function through
lesion generation or brain stimulation in animal subjects; and
studies of patients who had sustained brain damage, particularly
localized brain damage. The latter method can be dated back to
1861 when Paul Broca produced his case report (Broca, 1861)
on a patient who had suddenly developed speech loss. An
autopsy revealed that he had sustained an extensive infarct in
the area of the third frontal convolution of the left cerebral
hemisphere. Thus, an important center in the brain for speech
had been discovered, but perhaps more significantly, this case
produced what many would view as the first reported example

20. of a neuropsychological or brain–behavior relationship in a
human. Indeed, to this day, the third frontal convolution of the
left hemisphere is known as Broca's area, and the type of speech
impairment demonstrated by the patient is known as Broca's
aphasia.
Following Broca's discovery, much effort was devoted to
relating specific behaviors to discrete areas of the brain. These
early neuropsychological investigations not only provided data
concerning specific brain–behavior relationships, but also
explicitly or implicitly evolved a theory of brain function, now
commonly known as classical localization theory. In essence,
the brain was viewed as consisting of centers for various
functions connected by neural pathways. In human subjects, the
presence of these centers and pathways was documented through
studies of individuals who had sustained damage to either a
center or the connecting links between one center and another
such that they became disconnected. To this day, the behavioral
consequences of this latter kind of tissue destruction are
referred to as a disconnection syndrome (Geschwind, 1965). For
example, there are patients who can speak and understand, but
who cannot repeat what was just said to them. In such cases, it
is postulated that there is a disconnection between the speech
and auditory comprehension centers.
Not all investigators advocated localization theory. The
alternative view is that the brain functions as a whole in an
integrated manner, currently known as mass action, holistic, or
organismic theories of brain function. In contemporary
neuropsychology the strongest advocates of holistic theory were
Kurt Goldstein, Martin Scheerer, and Heinz Werner. Goldstein
and Scheerer (1941) are best known for their distinction
between abstract and concrete behavior, their description of the
“abstract attitude,” and the tests they devised to study abstract
and concrete functioning in brain-damaged patients. Their major
proposition was that many of the symptoms of brain damage
could be viewed not as specific manifestations of damage to
centers or connecting pathways but as some form of impairment

21. of the abstract attitude. The abstract attitude is not localized in
any region of the brain but depends upon the functional
integrity of the brain as a whole. Goldstein (1959) describes the
abstract attitude as the capacity to transcend immediate sensory
impressions and consider situations from a conceptual
standpoint. Generally, it is viewed as underlying such functions
as planning, forming intentions, developing concepts, and
separating ourselves from immediate sensory experience.
The notion of a nonlocalized generalized deficit underlying
many of the specific behavioral phenomena associated with
brain damage has survived to some extent in contemporary
neuropsychology, but in a greatly modified form. Similarly,
some aspects of classical localization theory are still with us,
but also with major changes (Mesulam, 1985). None of the
current theories accepts the view that there is no localization of
function in the brain, and correspondingly, none of them would
deny that some behaviors cannot be localized to some structure
or group of structures. This synthesis is reflected in several
modern concepts of brain function, the most explicit of these
probably being that of Luria (1973). Luria has developed the
concept of functional systems as an alternative to both strict
localization and mass action theories. Basically, a functional
system consists of several elements involved in the mediation of
some complex behavior. For example, there may be a functional
system for auditory comprehension of language. Thus, no
structure in the brain is only involved in a single function.
Depending upon varying conditions, the same structure may
play a role in several functional systems. With regard to clinical
neuropsychology, the main point is that there are both specific
and nonspecific effects of brain damage. Evidence for this point
of view has been presented most clearly by Teuber and his
associates (Teuber, 1959) and by Satz (1966). The Teuber group
was able to show that patients with penetrating brain wounds
that produced very focal damage had symptoms that could be
directly attributed to the lesion site, but they also had other
symptoms that were shared by all patients studied, regardless of

22. their specific lesion sites.
An old principle of brain function in higher organisms that has
held up well and that is commonly employed in clinical
neuropsychology involves contralateral control: the right half of
the brain controls the left side of the body and vice versa. The
contralateral control principle is important for clinical
neuropsychology because it explains why patients with damage
to one side of the brain may become paralyzed only on the
opposite side of their body or may develop sensory disturbances
on that side. We see this condition most commonly in
individuals who have had strokes, but it is also seen in some
patients who have open head injuries or who have brain tumors.
Although aphasia, or impaired communicative abilities as a
result of brain damage, was recognized before Broca (Benton &
Joynt, 1960), it was not recognized that it was associated with
destruction of a particular area of one side of the brain. Thus,
the basic significance of Broca's discovery was the discovery
not of aphasia, but of cerebral dominance. Cerebral dominance
is the term that has been commonly employed to denote the fact
that the human brain has a hemisphere that is dominant for
language and a nondominant hemisphere. In most people, the
left hemisphere is dominant, and left hemisphere brain damage
may lead to aphasia. However, some individuals have dominant
right hemispheres, while others do not appear to have a
dominant hemisphere. Although it remains unknown why most
people are left-hemisphere dominant, what is clear is that for
individuals who sustain left hemisphere brain damage, aphasia
is a common symptom, while aphasia is a rare consequence of
damage to the right hemisphere.
Following Broca's discovery, other neuroscientists discovered
that just as the left hemisphere has specialized function in the
area of language, the right hemisphere also has its own
specialized functions. These functions seem to relate to
nonverbal abilities such as visual-spatial skills, perception of
complex visual configurations, and, to some extent,
appreciation of nonverbal auditory stimuli such as music. Some

23. investigators have conceptualized the problem in terms of
sequential as opposed to simultaneous abilities. The left
hemisphere is said to deal with material in a sequential, analytic
manner, while the right hemisphere functions more as a detector
of patterns or configurations (Dean, 1986). Thus, while patients
with left hemisphere brain damage tend to have difficulty with
language and other activities that involve sequencing, patients
with right hemisphere brain damage have difficulties with such
tasks as copying figures and producing constructions, because
such tasks involve either perception or synthesis of patterns. In
view of these findings regarding specialized functions of the
right hemisphere, many neuropsychologists now prefer to use
the expression functional asymmetries of the cerebral
hemispheres rather than cerebral dominance.
With this basic brain–behavior background in mind, we now
turn to a clinical description of the individual disorders that are
included in the broad diagnostic category of neurocognitive
disorders. This includes delirium and a number of individual
disorders included under the major categories of major or mild
neurocognitive disorders.
Delirium
The first disorder listed in the DSM-5 is delirium. This
temporary condition is basically a loss of capacity to maintain
attention with corresponding reduced awareness of the
environment. Tremors and lethargy may be accompanying
symptoms. Delirium is reversible in most cases but may evolve
into a permanent neurocognitive or other neurological
disorder. DSM-5 allows for the specification of the cause of
delirium, whether it is due to substance intoxication, substance
withdrawal, medication-induced delirium due to another
medical condition, or delirium due to multiple etiologies.
Typically, delirium is an acute phenomenon and does not persist
beyond a matter of days. However, delirium, notably when it is
associated with alcohol abuse, may eventually evolve into
permanent disorders in the form of a persistent neurocognitive
disorder (formerly dementia). The behavioral correlates of

24. delirium generally involve personality changes such as
euphoria, agitation, anxiety, hallucinations, and
depersonalization.
Major and Mild Neurocognitive Disorders
There are several types of neurocognitive disorders, but they all
involve the usually slowly progressive deterioration of
intellectual function. The deterioration is frequently patterned,
with loss of memory generally being the first function to
decline, and other abilities deteriorating at later stages of the
illness. As noted in DSM-5, the term major or mild
neurocognitive disorder replaces the term dementia in an effort
to eliminate stigmatization. The DSM-5 approach to the
diagnosis of the major and mild neurocognitive disorders is that
there is first a determination of whether the individual is
suffering from a major or mild type of cognitive impairment,
and then the reason for the impairment is added (e.g., due to
Alzheimer's disease) to indicate the distinct behavioral features
and likely etiology. Furthermore, for either the major or mild
types, there are “probable” or “possible” specifiers depending
upon the strength of the evidence for the etiological factor
(genetics, neuroimaging).
Major or Mild Neurocognitive Disorders of the Alzheimer's
Type
One class of neurocognitive disorders, major or mild
neurocognitive disorder of the Alzheimer's type, arises most
commonly in late life, either during late middle age or old age,
although it may occur at any age. In children it is differentiated
from intellectual disability on the basis of the presence of
deterioration from a formerly higher level. These disorders are
defined as those conditions in which, for no exogenous reason,
the brain begins to deteriorate and continues to do so until
death. As indicated in the psychological and biological
assessment section, a diagnostic method has recently become
available to specifically diagnose Alzheimer's disease in the
living patient. Its presence also becomes apparent on
examination of the brain at autopsy.

25. Clinically, the course of the Alzheimer's type generally begins
with signs of impairment of memory for recent events, followed
by deficits in judgment, visual-spatial skills, and language. The
language deficit has become a matter of particular interest,
perhaps because the communicative difficulties of patients with
major or mild neurocognitive disorders of the Alzheimer's type
are becoming increasingly recognized. Generally, the language
difficulty does not resemble aphasia, but can perhaps be best
characterized as an impoverishment of speech, with word-
finding difficulties and progressive inability to produce
extended and comprehensible narrative speech as illustrated in
the descriptive writing of Alzheimer's disease patients (Neils,
Boller, Gerdeman, & Cole, 1989). The patients wrote shorter
descriptive paragraphs than did age-matched controls, and they
also made more handwriting errors of various types. The end
state is generalized, severe intellectual impairment involving all
areas, with the patient sometimes surviving for various lengths
of time in a persistent vegetative state.
Criteria for the Alzheimer's disease subtype include meeting
criteria for major or minor neurocognitive disorder, early and
prominent impairment in memory, deficits in at least one other
domain in the case of the major form of the disorder, a course
of gradual onset and continuing cognitive decline, and a ruling
out of the condition being attributable to other disorders (APA,
2013). The diagnosis may indicate whether it occurs with or
without behavioral disturbance. Separate criteria for psychosis
and depression have been written.
Major or Mild Frontotemporal Neurocognitive Disorder
In this disorder, there is specific impairment of social judgment,
decision-making, and particular language and memory skills.
The decline in language can take the form of speech production,
word finding, object naming, grammar, or word comprehension
(APA, 2013). Frontotemporal neurocognitive disorder is only
diagnosed when Alzheimer's disease has been ruled out, and the
patient must have symptoms that can be characterized as
forming a “frontal lobe syndrome” (Rosenstein, 1998). The

26. generic term commonly used to characterize the behaviors
associated with this syndrome is executive dysfunction, a
concept originally introduced by Luria (1966). Executive
function is progressively impaired, and personality changes
involving either apathy and indifference or childishness and
euphoria occur. Compared with patients with Alzheimer's
disease, frontal dementia patients have greater impairment of
executive function but relatively better memory and
visuoconstructional abilities. The outstanding features may all
be viewed as relating to impaired ability to control, regulate,
and program behavior. This impairment is manifested in
numerous ways, including poor abstraction ability, impaired
judgment, apathy, and loss of impulse control. Language is
sometimes impaired, but in a rather unique way. Rather than
having a formal language disorder, the patient loses the abili ty
to control behavior through language. There is also often a
difficulty with narrative speech, which has been interpreted as a
problem in forming the intention to speak or in formulating a
plan for a narrative. Such terms as lack of insight or of the
ability to produce goal-oriented behavior are used to describe
the frontal lobe patient. In many cases, these activating,
regulatory, and programming functions are so impaired that the
outcome looks like a generalized dementia with implications for
many forms of cognitive, perceptual, and motor activities.
Frontal dementia may occur as a result of several processes,
such as head trauma, tumor, or stroke, but the syndrome
produced is more or less the same.
Major or Mild Neurocognitive Disorder With Lewy Bodies
This disorder has a different pathology from Alzheimer's
disease, being associated more with Parkinson's disease
(Becker, Farbman, Hamilton, & Lopez, 2011; McKeith et al.,
2004). The major symptoms are variations in alertness,
recurrent hallucinations, and Parkinsonian symptoms (e.g.,
tremor, rigidity). Lewy bodies are intraneuron inclusion bodies
first identified in the substantia nigra of patients with
Parkinson's disease.

27. Major or Mild Vascular Neurocognitive Disorder
This is a progressive condition based on a history of small
strokes associated with hypertension. Patients with vascular
neurocognitive disorder experience a stepwise deterioration of
function, with each small stroke making the dementia worse in
some way. There are parallels between this disorder and the
older concept of cerebral arteriosclerosis in that they both relate
to the role of generalized cerebral vascular disease in producing
progressive brain dysfunction. However, vascular
neurocognitive disorder is actually a much more precisely
defined syndrome that, although not rare, is not extremely
common either. Furthermore, although it continues to be a
separate diagnosis, there is substantial evidence that vascular
neurocognitive disorder overlaps a great deal with Alzheimer's
disease. Autopsy studies often show that there is evidence of
vascular pathology in individuals diagnosed with Alzheimer's
disease, and the reverse is also true. It has been suggested that
cardiovascular illness may be a risk factor for Alzheimer's
disease. Moreover, there appears to have been an increased
focus of interest in the specific vascular disorders, including
heart failure, stroke, and arteriovenous malformations, each of
which has different cognitive consequences (Festa, 2010; Lantz,
Lazar, Levine, & Levine, 2010; Pavol, 2010).
Because this disorder is known to be associated with
hypertension and a series of strokes, the end result is substantial
deterioration in cognitive functioning. However, the course of
the deterioration is not thought to be as uniform as is the case in
Alzheimer's disease, but rather is generally described as
stepwise and patchy. The patient may remain relatively stable
between strokes, and the symptomatology produced may be
associated with the site of the strokes. It should be noted that
whereas these distinctions between vascular and Alzheimer's
type dementia are clearly described, in individual patients it is
not always possible to make a definitive differential diagnosis.
Even such sophisticated radiological methods as the computed
tomography (CT) scan and MRI do not always contribute to the

28. diagnosis. DSM-5 recognizes the significance of comorbidity
with the statement “Most individuals with Alzheimer's disease
are elderly and have multiple medical conditions that can
complicate diagnosis and influence the clinical course. Major or
mild NCD [neurocognitive disorder] due to Alzheimer's disease
commonly co-occurs with cerebrovascular disease which
contributes to the clinical picture” (p. 614).
Major or Mild Neurocognitive Disorder due to Huntington's
Disease
The progressive cognitive deterioration seen in Huntington's
disease also involves significant impairment of memory, with
other abilities becoming gradually affected through the course
of the illness. However, it differs from Alzheimer's disease in
that it is accompanied by choreic movements and by the fact
that the age of onset is substantially earlier than is the case for
Alzheimer's disease. Because of the chorea, a difficulty in
speech articulation is also frequently seen, which is not the case
for Alzheimer's patients.
There are other major or minor neurocognitive disorders listed
in the DSM-5, including major or mild neurocognitive disorder
due to TBI, substance/medication-induced major or mild
neurocognitive disorder, major or mild neurocognitive disorder
due to HIV infection, major or mild neurocognitive disorder due
to prion disease, and major or mild neurocognitive disorder due
to Parkinson's disease. Patients diagnosed with these …
Clinical Case Studies
8(6) 417 –423
© The Author(s) 2009
Reprints and permission: http://www.
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1534650109351930

29. http://ccs.sagepub.com
Psychotherapy of
Schizophrenia: A Brief History
and the Potential to Promote
Recovery
Paul H. Lysaker1 and Steven M. Silverstein2
Abstract
With growing awareness of the likelihood of recovery from
schizophrenia, interest has
arisen about the potential role of psychotherapy within
emerging treatment regimens. Could
psychotherapy uniquely promote recovery by addressing
symptoms, the achievement of
psychosocial milestones, and/or helping to enhance the extent to
which persons diagnosed with
schizophrenia experience themselves as meaningful agents in
the world? As an introduction to
a set of case studies of how psychotherapy can promote
recovery this article briefly reviews
the history of the psychotherapy of schizophrenia. In particular
the appearance and course
of psychoanalytically oriented treatments, as well as cognitively
and interpersonally based
treatments are detailed. Evidence supporting these approaches
and remaining questions for
research are discussed.
Keywords
schizophrenia, recovery, psychotherapy, psychosis
Recent reviews have suggested that contrary to long-standing

30. pessimistic views, most people with
schizophrenia do not experience lifelong dysfunction. Instead,
most with this condition move
meaningfully toward or achieve recovery over the course of
their lives (Bellack, 2006; Lysaker &
Buck, 2008; Silverstein, Spaulding, & Menditto, 2006). They
may not only experience improve-
ments with regard to symptoms or function, but also positive
changes in how persons think about
and experience themselves as individual human beings in the
world (Resnick, Rosenheck, &
Lehman, 2004; Roe, 2001; Silverstein & Bellack, 2008). As a
result of growing awareness of this
possibility, interest has arisen in whether some forms of
psychotherapy could play an important
role in treatment. Given literature suggesting psychotherapy
may help a wide range of people
without psychosis to develop both a richer sense of self and a
more adaptive self-concept
(Hermans & Dimaggio, 2005), it is now asked whether it could
do the same for many with schizo-
phrenia and thereby uniquely promote recovery (Lysaker &
Lysaker, 2008).
To explore this question and a wide range of related concerns,
this issue of Clinical Case Stud-
ies is devoted to case studies of the processes by which
individual psychotherapy can promote
recovery. Therapies which range from office to community
based and from existential to
1Indiana University School of Medicine
2University of Medicine and Dentistry of New Jersey,
Piscataway
Corresponding Author:

31. Paul H. Lysaker, 1481 West 10 street, Indiana University
School of Medicine, Indianapolis, IN 46202
Email: [email protected]
418 Clinical Case Studies 8(6)
metacognitive to cognitive behavioral are presented with the
unifying question of how they are
able to promote wellness. Before beginning with the first,
however, it seems important to note
that any advancement in this area should be considered in the
context of the long and controver-
sial past of the psychotherapy of schizophrenia, a past which,
almost as much as any, contains a
range of of conflicting scientific claims and emotional ladden
debates. To provide a framework
for considering how to think about contemporary developments
in schizophrenia, the current
article first offers a brief overview of the history of the
psychotherapy of schizophrenia and then
highlights some of the continuing points of contention.
The History of the Psychotherapy of Schizophrenia
Often overlooked is that one of the first clinicians to seriously
advocate for individual psycho-
therapy for people with schizophrenia was Jung (1907/1960).
Jung (1907/1960, 1939/1960,
1958) treated many hospitalized and significantly ill patients in
the early part of the 20th century
and contrary to the zeitgeist, argued that persons with
schizophrenia could accept and benefit
from a psychotherapy with certain modifications . Jung
suggested that even the most profoundly
disturbed aspects of illness were connected in some meaningful

32. way to the life history and self-
concept of the patient. As such Jung asserted that much of the
work of therapy necessarily
involved increasing the patient’s understanding of his or her
self-concept.
Initially though, Jung was alone in this pursuit, as Freud (1957)
had firmly announced that
psychoanalysis with people with schizophrenia was impossible
given that persons with schizo-
phrenia could not form a proper attachment to a therapist. And
psychotherapy for schizophrenia
briefly then vanished more or less once Jung left the Burghölzli
and with a few notable excep-
tions (Fierz, 1991; Perry, 2005), abandoned his interest in
schizophrenia.
In the 1930s and 40s, however, interest in the psychotherapy of
schizophrenia suddenly
appeared in a range of different settings. Psychoanalysts such as
Fromm-Reichmann (1954),
Hill (1957), Searles (1965), and Sullivan (1962) all produced
reports which contended that
meaningful intimate bonds with persons with schizophrenia
could emerge in therapy. They
noted patients with this condition were often eager for treatment
and could utilize the bonds that
formed with therapists as the basis of a movement tow ard
health. These and other authors pro-
duced a wealth of compelling anecdotal reports suggesting that
persons with schizophrenia
could accept and embrace psychotherapy as a means to make
sense of their lives in a holistic
manner they otherwise could not. Psychotherapy thus emerged
as a treatment that might thereby
help them develop both a healthier sense of themselves as

33. beings in the world and richer experi-
ences of daily life. As an illustration here is a quote from a
person with schizophrenia about
their experience of psychotherapy offered by Hayward and
Taylor (1956):
Meeting you made me feel like a traveler who’s been lost in a
land where no speaks his
language. Worst of all, the traveler doesn’t even know where he
should be going. He feels
completely lost and helpless and alone. Then suddenly he meets
a stranger who can speak
English. . . it feels so much better to be able to share the
problem. . . If you are not alone
you don’t feel hopeless any more. Somehow it gives you life
and a willingness to fight
again. (p. 221)
While this literature produced a series of interesting though
sometimes fantastic theories of
the subjective experience of psychosis and its antecedents, there
was little scientific evidence
supporting its efficacy. As reviewed in a range of sources,
controlled trials failed to find
significant benefits for psychoanalytic psychotherapy (Drake &
Sederer, 1986). For instance, in
what was referred to as the Boston Psychotherapy Study, more
than 160 adults with schizophrenia
Lysaker and Silverstein 419
were randomly assigned to receive exploratory insight oriented
therapy or a reality based
supportive psychotherapy (Gunderson et al., 1984). Extensive

34. efforts were devoted to the
training of therapists, the selection of appropriate participants,
assessment procedures and
methods. Nevertheless, the most notable result was a drop rate
of just more than 40% six months
after assigned to treatment and a drop rate of nearly 70% two
years following that. More detailed
analyses of the results of those who remained in the study
revealed some improvements in
insight as well as improvements in negative symptoms among
participants assigned to the more
skilled therapists (Glass et al., 1989; Gunderson et al., 1984).
Beyond the findings of the Boston psychotherapy study, another
blow was simultaneously
dealt to the credibility of at least some psychoanalytic
treatments for schizophrenia. In particular,
a range of approaches to the psychotherapy were based on the
idea that schizophrenia is primar-
ily caused by pathological family dynamics (e.g., Karon 2003).
Psychotherapy, according to this
view was the treatment of choice as it alone could repair the
damage done by caretakers to their
children by too great, too little, or too confusing levels of
involvement. Research, however, indi-
cated that schizophrenia was instead a genetically influenced,
neurobiological brain disorder
involving distortion of basic human experience, one that could
well develop regardless of family
dynamics. Beyond pointing to the reality that families had been
generically blamed without any
basis, the issue here was raised of whether there was anything at
all psychotherapy could offer,
that is, beyond general human support. Drake and Sederer
(1986), for instance likened some
psychotherapies of schizophrenia to the pouring of burning oil

35. over wounds, a medical practice
that went for centuries without any medical basis. Nevertheless,
when surveyed, 60% of men-
tally ill persons and their families indicated that they were
interested in psychotherapy, a rate that
possibly echoes the finding that three in five participants
remained in the Boston study at 6
months (Coursey, Keller, & Farrell, 1995; Hatfield, Gearon, &
Coursey, 1996).
Following this, and concurrent with the recognition of recovery
as a likely outcome of schizo-
phrenia, a range of new possible rationales for psychotherapy
for schizophrenia have been raised
as well as empirical support for the efficacy of psychotherapy.
Perhaps most prominent among
these involve cognitive behavior therapy (CBT). Originally
created to address depression, the
use of CBT has steadily expanded to address schizophrenia and
other psychotic disorders (Rector
& Beck, 2002). Treatment from this perspective has stressed
that the neurobiological processes
of schizophrenia interact with social, developmental, and
psychological factors resulting in mal-
adaptive beliefs about the self, and tendencies to attribute
malicious intentions to others in an
overly rigid manner. CBT thus helps to correct those beliefs
through a systematic, collaborative
process of belief examination and prediction of the
consequences of behaviors and events. Evi-
dence supporting its efficacy includes controlled trials showing
that persons with schizophrenia
are willing to attend CBT and that CBT can reduce
dysfunctional cognitions, leading to reduc-
tions in positive and negative symptoms, and improvements in
psychosocial function (Drury,

36. Birchwood, Cochrane, & MacMillian, 1996; Gumley et al.,
2003; Lysaker, Davis, Bryson, &
Bell, 2009; Pilling et al., 2002; Sensky et al., 2000).
Diverging slightly from this line of thought, Chadwick (2006)
developed Person-Based
Cognitive Therapy for distressing psychosis, in an effort to
move from a symptom-focused to
a person-focused therapy. Person-Based Cognitive Therapy is an
integrative form of treatment
which draws on cognitive theory, mindfulness, client centered
principles, and a social–
developmental perspective which understands language as a
socially available tool which
persons use to make meaning of their daily activities. This
approach uses cognitive and expe-
riential techniques for working with pervasively negative self
schemata and promoting
self-acceptance and self-awareness. In parallel, case studies by
other authors, have also sug-
gested cognitive behavior therapy for psychosis can address the
personal meaning of symptoms
and psychosocial dilemmas (Davis & Lysaker, 2005;
Silverstein, 2007).
420 Clinical Case Studies 8(6)
Interest has also increased in using a modified form of
psychoanalytic therapy for people with
schizophrenia. Bachmann, Resch, and Mundt (2003), has
suggested that psychoanalytic psycho-
therapy for people with schizophrenia may beneficially foster
an experience of the self and the
therapist as two separate people that share a relationship,

37. leading to the stabilization of a sense
of personal identity, and the integration of the psychotic
experience. Some evidence suggests that
such an approach can be helpful, at least for people who are
more clinically stable at the outset
of treatment (Hauff et al., 2002). Rosenbaum et al. (2005) have
also indicated that among more
than 560 first episode patients, those who received supportive
individual psychodynamic psy-
chotherapy or an integrated treatment had better overall
functional outcomes after 1 year of
treatment than those who received treatment as usual.
At perhaps an even larger holistic level, attention has turned to
whether psychotherapy might
promote recovery by helping some with schizophrenia develop a
richer sense of personal identity
as embedded with that person’s unique personal history or
narrative (France & Uhlin, 2006;
Lysaker, Buck, & Roe 2007; Silverstein et al., 2006). Beyond
exploring the validity of a particu-
lar conclusion or response to a particular symptom,
psychotherapy has been suggested as
something that could, as it does for many others (Adler,
Skalina, & McAdams, 2008; Neimeyer
& Raskin, 2000), represent a place where persons develop richer
and more layered stories about
who they are in the present, the person they have been across
the course of their life and what is
possible in the future for them. A deepened personal narrative
might then naturally be an oppor-
tunity for experience of oneself as an active agent who prevails
in the face of adversity. Providing
some support for this possibility are case studies suggesting that
improvements in the richness of
personal narratives may result during the course of individual

38. psychotherapy of persons with
schizophrenia and may be linked with other indicators of
recovery (Lysaker, Davis, Jones,
Strasburger, & Hunter, 2007; Lysaker et al., 2005), that self
concept is a meaningful predictor of
outcome in both first episode (Harder, 2006) and more advanced
phases of illness (Lysaker,
Buck, Hammoud, Taylor, & Roe, 2006). Finally, in the face of
evidence that many with schizo-
phrenia experience difficulties with metacognition, or thinking
about thinking (Brune, 2005;
Lafargue & Frank, 2009; McGlade et al., 2008; Stratta et al.,
2007), others have suggested that
psychotherapy could promote recovery by helping persons to
develop metacognitive capacity
(Lysaker, Buck, & Ringer, 2007). Just as psychotherapy has
been found to promote metacogni-
tion in persons who do not suffer from psychosis (Bateman &
Fonegy, 2001; Choi-Kain &
Gunderson, 2008; Dimaggio, Semerari, Carcione, Nicolò, &
Procacci, 2007), could it be tailored
to help persons with schizophrenia make better sense of their
own mental states and the mental
states of others and thereby evolve a complex storied
understanding of one’s life? Evidence of
this possibility includes some case studies (Lysaker et al., 2007)
suggesting that psychotherapy
interventions can be used to target metacognitive capacity as
well as empirical studies suggesting
that metacognitive deficits indeed limit personal narrative
beyond the effects of other aspects of
psychopathology and social factors such as stigma (Corcoran &
Frith, 2003; Lysaker, Buck,
Taylor, & Roe, 2008).
Summary and Questions

39. In summary, the history of the psychotherapy of schizophrenia
contains a series of different
epochs. Most recently we have observed a rise in possible
rationales for how psychotherapy
could promote recovery. These include approaches which
address a wide array of phenomenon,
some at the level of symptoms and others at the level of
personal narrative and the quality of
self-experience. Many questions however, remain. Whereas the
efficacy of symptom-focused
approaches are supported in part by randomized trials, more
holistic approaches are still develop-
ing and awaiting more rigorous testing. Beyond that it remains
to be articulated to what extent
Lysaker and Silverstein 421
the emerging cognitive, dynamic, interpersonal, and
phenomenological approaches differ from
one another. Are there key principles which might unite these in
some ways? Do they approach
the issue of recovery in fundamentally different ways? Is it
possible that each may be appropriate
for some but not all with schizophrenia? We hope that in the
following set of case studies the
detailed descriptions of the psychotherapy processes may
provide some partial answers to these
questions and push further the development of interventions
which assist persons with schizo-
phrenia to achieve and sustain recovery.
Declaration of Conflicting Interests
The authors declared that they had no conflicts of interests with

40. respect to their authorship or the publica-
tion of this article.
Funding
The authors received no financial support for the research
and/or authorship of this article.
References
Adler, J. M., Skalina, L. M., & McAdams, D. P. (2008). The
narrative reconstruction of psychotherapy and
psychological health. Psychotherapy Research, 12, 1-16.
Bachmann, S., Resch, F., & Mundt, C. (2003). Psychological
treatment for psychosis: History and over-
view. Journal of the American Academy of Psychoanalysis and
Dynamic Psychiatry, 31, 155-176.
Bateman, A., & Fonegy, P. (2001). Treatment of borderline
personality disorder with psychoanalytically
oriented partial hospitalization: An 18 month follow up.
American Journal of Psychiatry, 158, 36-42.
Bellack, A. S. (2006). Scientific and consumer models of
recovery in schizophrenia: Concordance, con-
trasts and implications Schizophrenia Bulletin, 32, 432-442.
Brune, M. (2005). Theory of mind in schizophrenia: A review of
the literature. Schizophrenia Bulletin, 31,
21-42.
Chadwick, P. (2006). Person-based cognitive therapy for
distressing psychosis. New York: John Wiley.
Choi-Kain, L. W., & Gunderson J. G. (2008). Mentalization:
Ontogeny, assessment and application in the

41. treatment of borderline personality disorder. American Journal
of Psychiatry, 165, 1127-1135.
Corcoran, R., & Frith, C. D. (2003). Autobiographical memory
and theory of mind: Evidence of a relation-
ship in schizophrenia. Psychology Medicine, 33, 897-905.
Coursey, R. D., Keller, A. B., & Farrell, E. W. (1995).
Individual psychotherapy and persons with serious
mental illness: The clients perspective. Schizophrenia Bulletin,
21, 283-301.
Davis, L. W., & Lysaker, P. H. (2005). Cognitive behavioral
therapy and functional and metacognitive out-
comes in schizophrenia: A single case study. Cognitive and
Behavioral Practice, 12, 468-478.
Dimaggio, G., Semerari, A., Carcione, A., Nicolò, G., &
Procacci, M. (2007). Psychotherapy of personality
disorders. London: Bruner Routledge.
Drake, R. E., & Sederer, L. I. (1986). The adverse effects of
intensive treatment of schizophrenia. Compre-
hensive Psychiatry, 27, 313-326.
Drury, V., Birchwood, M., Cochrane, R., & MacMillian, F.
(1996). Cognitive therapy and recovery from
acute psychosis: A controlled trial. British Journal of
Psychiatry,169, 593-601.
Fierz, H. K. (1991). Jungian Psychiatry. Einsiedeln,
Switzerland: Daimon Verlag (original works published
1963 and 1982).
France, C. M., & Uhlin, B. D. (2006). Narrative as an outcome
domain in psychosis. Psychology and

42. Psychotherapy-Theory Research and Practice, 79, 53-67.
Freud, S. (1957). Neurosis and psychosis (A. Strachev & J.
Strachev, Trans.). Collected papers, Vol. II.
London: Hogarth Press.
Fromm-Reichmann, F. (1954). Psychotherapy of schizophrenia.
American Journal of Psychiatry, 111,
410-419.
422 Clinical Case Studies 8(6)
Glass, L. L., Katz, H. M., Schnitzer, R. D., Knapp, P. H., Frank,
A. F., & Gunderson, J. G. (1989). Psycho-
therapy of schizophrenia: An empirical investigation of the
relationship of process to outcome. American
Journal of Psychiatry, 146, 603-608.
Gumley, A., O’Grady, M., McNay, L., Reilly, J., Power, K., &
Norrie, J. (2003). Early intervention for
relapse in schizophrenia: Results of a 12-month randomized
controlled trial of cognitive behavioural
therapy. Psychological Medicine, 33, 419-431.
Gunderson, J. G., Frank A. F., Katz, H. M., Vannicelli, M. L.,
Frosch, J. P., & Knapp, P. H. (1984). Effects
of psychotherapy in schizophrenia: II. Comparative outcome of
two forms of treatment. Schizophrenia
Bulletin, 10, 564-598.
Harder, S. (2006). Self-image and outcome in first-episode
psychosis. Clinical Psychology and Psycho-
therapy, 13, 285-296.

43. Hatfield, A. B., Gearon, J. S., & Coursey, R. D. (1996). Family
member’s rating of the use and value of
mental health services: Results of a nation NAMI survey.
Psychiatric Services, 47, 825-831.
Hauff, E., Varvin, S., Laake, P., Melle, I., Vaglum, P., & Friis,
S. (2002). Inpatient psychotherapy compared
with usual care for patients who have schizophrenic psychoses.
Psychiatric Services, 53, 471-473.
Hayward, M. L., & Taylor, J. E. (1956). A schizophrenic patient
describes the action of intensive psycho-
therapy. Psychiatric Quarterly, 30, 211-248.
Hermans, H. J. M., & Dimaggio, G. (2005). The dialogical self
in psychotherapy. London: Brunner-
Routledge.
Hill, L. B. (1957). Psychotherapy of a schizophrenia. American
Journal of Psychoanalysis, 17, 99-109.
Jung, C. G. (1907/1960). The psychology of dementia
praecox:1-151. In C. G. Jung (Ed.), The psychology
of dementia praecox (Vol. 8, The Collected Works of C. G.
Jung). Princeton: Princeton University Press
(original work published in 1907).
Jung, C. G. (1939/1960). On the psychogenesis of
schizophrenia:155-171. In C. G. Jung (Ed.), The psychol-
ogy of dementia praecox (Vol. 8, The Collected Works of C. G.
Jung). Princeton: Princeton University
Press (original work published 1939).
Jung, C. G. (1958). Schizophrenia:178-193.. In C. G. Jung
(Ed.), The psychology of dementia praecox (Vol.

44. 8, The Collected Works of C. G. Jung). Princeton: Princeton
University Press (original work published
1958).
Karon, B. P. (2003). The tragedy of schizophrenia without
psychotherapy. Journal of the American Acad-
emy of Psychoanalysis and Dynamic Psychotherapy, 31, 89-118.
Lafargue, G., & Franck, N. (2009). Effort awareness and sense
of volition in schizophrenia. Consciousness
and Cognition, 18, 277-89.
Lysaker, P. H., & Buck, K. D. (2008). Is recovery from
schizophrenia possible? An overview of concepts,
evidence, and clinical implications. Primary Psychiatry, 15, 60-
65.
Lysaker, P. H., Buck, K. D., Hammoud, K., Taylor, A. C., &
Roe, D. (2006). Associations of symptom
remission, psychosocial function and hope with qualities of self
experience in schizophrenia: Compari-
sons of objective and subjective indicators of recovery.
Schizophrenia Research, 82, 241-249.
Lysaker, P. H., Buck, K. D., & Ringer, J. (2007). The recovery
of metacognitive capacity in schizophre-
nia across thirty two months of individual psychotherapy: A
case study. Psychotherapy Research, 17,
713-720.
Lysaker, P. H., Buck, K. D., & Roe, D. (2007). Psychotherapy
and recovery in schizophrenia: A proposal of
critical elements for an integrative psychotherapy attuned to
narrative in schizophrenia. Psychological
Services, 4, 28-37.

45. Lysaker, P. H., Buck, K. D., Taylor, A. C., & Roe, D. (2008).
Associations of metacognition, self stigma and
insight with qualities of self experience in schizophrenia.
Psychiatry Research, 157, 31-38.
Lysaker, P. H., Davis, L. D., Bryson, G. J., & Bell, M. D.
(2009). Effects of cognitive behavioral therapy
on work outcomes in vocational rehabilitation for participants
with schizophrenia spectrum disorders.
Schizophrenia Research, 107, 186-191.
Lysaker and Silverstein 423
Lysaker, P. H., Davis, L. D., Eckert, G. J., Strasburger, A.,
Hunter, N., & Buck., K. D. (2005). Changes in
narrative structure and content in schizophrenia in long term
individual psychotherapy: A single case
study. Clinical Psychology and Psychotherapy, 12, 406-416.
Lysaker, P. H., Davis, L. W., Jones, A. M., Strasburger, A. M.,
& Hunter, N. L. (2007). The interplay of
relationship and technique in the long-term psychotherapy of
schizophrenia: A single case study. Coun-
selling and Psychotherapy Research, 7, 79-85.
Lysaker, P. H., & Lysaker, J. T. (2008). Schizophrenia and the
fate of the self. Oxford, UK: Oxford Univer-
sity Press.
McGlade, N., Behan, C., Hayden, J., O’Donoghue, T., Peel, R.,
Haq, F., et al. (2008). Mental state decod-
ing v. mental state reasoning as a mediator between cognitive
and social function in psychosis. British
Journal of Psychiatry, 193, 77-78.

46. Neimeyer, R. A., & Raskin, J. D. (2000). Constructions of
disorder: Meaning-making frameworks for psy-
chotherapy. Washington, DC: APA.
Perry, J. W. (2005). The far side of madness (2nd ed.). Putnam,
CT: Spring (first edition published 1974).
Pilling, S., Bebbington, P., Kuipers, E., Garety, P., Geddes, J.,
Orbach, G., et al. (2002). Psychological
treatments in schizophrenia: I. Meta-analysis of family
intervention and cognitive behaviour therapy.
Psychological Medicine, 32, 763-782.
Rector, N. A., & Beck, A. T. (2002). Cognitive therapy for
schizophrenia: From conceptualization to inter-
vention. Canadian Journal of Psychiatry, 47, 39-48.
Resnick, S. G., Rosenheck, R. A., & Lehman, A. F. (2004). An
exploratory analysis of correlates of recov-
ery. Psychiatric Services, 55, 540-547.
Roe, D. (2001). Progressing from patienthood to personhood
across the multidimensional outcomes in
schizophrenia and related disorders. Journal of Nervous and
Mental Disease, 189, 691-699.
Rosenbaum, B., Valbak, K., Harder, S., Knudsen, P., Køster, A.,
Lajer, M., et al. (2005). The Danish National
schizophrenia project: Prospective, comparative longitudinal
treatment study of first-episode psychosis.
British Journal of Psychiatry, 186, 394-399.
Searles, H. (1965). Collected papers of schizophrenia and
related subjects. New York: International
Universities Press.

47. Sensky, T., Turkington, D., Kingdom, D., Scott, J. L., Scott, J.,
Siddle, R., et al. (2000). A randomized
controlled trial of cognitive behavioral therapy for persistent
symptoms in schizophrenia resistant to
medication. Archives of General Psychiatry, 57, 165-172.
Silverstein, S. M. (2007). Integrating Jungian and self-
psychological perspectives within cognitive-
behavior therapy for a young man with a fixed religious
delusion. Clinical Case Studies, 6, 263-276.
Silverstein, S. M., & Bellack, A. S. (2008). A scientific agenda
for the concept of recovery as it applies to
schizophrenia. Clinical Psychology Review, 28, 1108-1124.
Silverstein, S. M., Spaulding, W. D., & Menditto, A. A. (2006).
Schizophrenia: Advances in evidence-based
practice. Cambridge, MA: Hogrefe & Huber.
Stratta, P., Riccardi, I., Mirabilio, D., Di Tommaso, S.,
Tomassini, A., & Rossi, A. (2007). Exploration of
irony appreciation in schizophrenia: A replication study on an
Italian sample. European Archives of
Psychiatry and Clinical Neuroscience, 257, 337-339.
Sullivan, H. S. (1962). Schizophrenia as a human process. New
York: Norton.
Bio
Paul H. Lysaker is a clinical psychologist at the Roudebush VA
Medical Center and Associate Professor of
Clinical Psychology at the Indiana University School of
Medicine. His ongoing research concerns the role
of metacognitive deficits in schizophrenia and

48. psychotherapeutic interventions aimed at improving func-
tion among persons with severe mental illness.
Week 4
Respond to the following question in a minimum of 175 words
each question, post must be substantive responses:
Normal and commonly accepted behaviors and expression of
personality can vary widely from culture to culture. As such,
what are the risks of not taking cultural differences into
consideration during assessment? What differences are noted in
the presence or diagnosis of personality disorders across
cultures?
Respond to classmates in a minimum of 175 words each person,
post must be substantive responses:
N.S
Whenever I read prompts like this regarding cultural context , I
always cringe a little bit because I have had personal biases that
made me misunderstand what people in my past were attempting
to express about themselves.
What comes to mind first is a very sweet and lovely friend who
was soft spoken but fiercely loyal to her loved ones, including
me. She suffered for a number of years starting in junior year of
high school and it continued in to her early 20's which was
when she finally found resolve. She and her boyfriend knew
they wanted to get married but she suffered over the idea
because her boyfriend was wealthy and sophisticated and
wanted to show her the world, however she wanted to fulfill her
cultural obligations as a traditional Mexican woman. She would
confide that wanted this new life with the man of her dreams
but she could not accept it because it wasn't "right" for her and
her ultimate familial goals.
I thought it was utterly ridiculous. I understood her concern but
I also thought it was something she could just get over. Now I

49. know very different.
The risks of not taking cultural differences in to account is that
we might apply generalizations to what we think should be
happening or consider traits to be pathological as opposed to
culturally relevant. Chapter 18 states that personality disorders
are often inappropriately categorized "due to a lack of
understanding on the part of Western society regarding the
cultural nuances and upbringing of non-Western
populations."Pomeroy, E. (2015).
References
Pomeroy, E. (2015). The clinical assessment workbook :
balancing strengths and differential diagnosis (2nd ed.).
Boston,, MA: Cengage Learning.
T.W.
When I first read this the first thing that came to mind was the
Japanese culture of not looking someone in the eye, mainly
pertaining to children. When looking at the list of personality
disorder, the child could be diagnosed with a couple based on
their "intentional" lack of eye contact based on their cultural
norm. Those diagnoses may not be correct either if the criteria
is followed. The lack of eye contact could be perceived as low
self-esteem, as not wanting to communicate or build
relationships, defiance, disrespect, rude, or cognitive
dysfunction such as they do not understand or comprehend what
he/she is being told.
I found this interesting article when I was researching.
https://journals.plos.org/plosone/article?id=10.1371/journal.pon
e.0118094