1. Personality Disorders
 Personality is the totality of emotional and behavioral
traits apparent in a person’s
ordinary life that is usually stable and predictable.
Personality traits are enduring patterns of perceiving,
relating to, and thinking about the environment and
the self that are exhibited in a wide range of contexts.

2. A personality disorder
 deviant from cultural standards
 rigidly pervasive
 onset in adolescence or early adulthood
 stable over time,
 lead to unhappiness and impairment
 maladaptive behavior in at least two:
1.Affect 2. Cognition 3. Impulse control
4. Interpersonal functioning

3. Prevalence
 9% of US population

4. Cluster A:
 odd and eccentric
more common in biological relatives of client with
schizophrenia
 Types
 Paranoid - distrust and suspiciousness
 Schizoid - detachment from social relationships
 Schizotypal -acute discomfort in close relationships,
cognitive or perceptual distortions, and eccentric behavior

5. Cluster B:
 dramatic, emotional, erratic, defenses of dissociation,
acting out, denial, and splitting
 Types
 Antisocial - distrust of other and violations of their rights,
often co-morbid with substance use disorders
 Borderline - instability in interpersonal relationships, self-image,
affect, and impulse control, often co-morbid with mood
disorders
 Histrionic - excessive emotionality and attention-seeking, often
co-morbid with somatization
 Narcissistic - grandiosity, a need for admiration, and a lack of
empathy

6. Cluster C:
 These persons are anxious or fearful, and tend to
utilize the defenses of isolation,
passive aggression, and somatization
 Types
 Avoidant - social inhibition, feelings of inadequacy, and
hypersensitivity to negative evaluation
Dependent - submissive and clinging behavior related to
an excessive need to be taken care of
 Obsessive-compulsive - preoccupation with
orderliness, perfectionism, and control

7. Diagnostic Considerations
 low inter-rater reliability with personality disorders
 require a longitudinal versus a time-limited assessment approach
 Psychological testing can be helpful

8. + Coding
principal diagnosis if focus on PD
should rarely be applied to children and
adolescents because personality patterns are
evolving during and don’t reach a state of
constancy until late adolescence/young
adulthood.
- Symptoms should be present for a full yr in
adolescence in order to diagnose

9. + Borderline Personality Disorder
 a pattern of instability in interpersonal relationships, self-image,
and affect, featuring impulsive behavior
 Characterized by extremely unstable affect, mood, object
relations, and self-image
 frantic efforts to avoid abandonment
 failed to successfully negotiate task of separating from primary caregivers
while maintaining an internalized sense of being cared for
 often in crisis due to their intense feelings of anger, emptiness,
and hopelessness that occur when stressed
 Other features include anxiety, transient psychotic symptoms,
suicidal or self-mutilating behaviors, and substance abuse.
 Core features: highly variable mood and impulsive behavior

10. +
Prevalence of BPD
 5.9%
 most common personality disorder found in clinical settings
 In clinical samples, most frequent in females but in population, males
and females have equal rates

11. +
Assessment
 Determine through a social history whether the client’s presenting problems result from patterns of
interaction with others
 Assess for recent stressors; determine whether isolated situation or part of a general pattern
 Is the client’s presenting problem an outcome of conflicted interactions with significant
others? If so, is this an isolated situation, or part of a general pattern?
 Does the client maintain positive relationships with some significant others (such as
friends, family, and co-workers), or are most relationships conflicted?
 Influence of any substances that may account for the symptoms of anxiety and depression.
 Medical condition
 For older adolescents and young adults, determine whether relatively less severe identity concerns
are related to a developmental phase
 The client’s manipulative behavior must be related to a desire for nurturance rather than a desire for
power, profit, or personal gain

12. +
Assessment
 Is the client under the influence of any substances that might account for the symptoms of anxiety
and depression?
 Is there evidence of a history of hypomanic or manic episodes? Of depressive episodes?
 If the client is an older adolescent or young adult, are identity concerns related to a developmental
phase?
 If the client displays manipulative behaviors toward others, including the social worker, are they
related to a desire to elicit nurturance or for power or personal gain?
 What cultural conditions may be affecting the client’s relationship-seeking behavior?
 What environmental conditions may be affecting the client’s relationship-seeking behavior?

13. + Co-Morbidity
mood disorders, substance related disorders,
eating disorders (notably bulimia), PTSD and
other anxiety disorders, dissociative identity
disorder, and attention deficit hyperactivity
disorder
Symptoms of depression characteristic of BPD -
emptiness, self-condemnation, abandonment
fears, hopelessness, self-destructiveness, and
repeated suicidal gestures
mood swings that resemble bipolar disorder (the
interpersonal conflicts are a differentiating factor)

14. + Suicidality and Self-Mutilation
 55% of inpatients have histories of suicide
attempts, although suicide rate is 5-10%
Reasons for self-mutilation:
 express anger,
 punish oneself,
 generate normal feelings when experiencing depersonalization,
 or distract oneself from painful feelings

15. +
Risk and Protective Factors
37.1% genetic and 62.9% environmental influences
Psychodynamic formulation
Separation-individuation phase fixation – can’t distinguish between self and
others
have failed to successfully negotiate the delicate task of separating from
primary caregivers while maintaining an internalized sense of being cared
for.
Trauma in the social environment in childhood

16. +
Course
Variable
one-third recover ten years after initial diagnosis
Low SES do worse
a “natural course” recovery rate of 3.7% per year
clients receiving intervention recover at a rate seven
times that of persons who do not receive intervention
 25% recovery rate per year for clients receiving
intervention.
Substance use -risk

17. +
Intervention
40-60% drop out prematurely
Components:
 establishing and maintaining a therapeutic framework
and alliance
 responding to crises and monitoring the client’s safety
 providing education about the disorder
 consistent supportive or insight-oriented therapy
 coordinating intervention provided by other providers

18. +
Indications for partial or brief
inpatient hospitalization
 Dangerous, impulsive behavior that can’t be managed in an
outpatient setting
 Non-adherence with outpatient intervention and a deteriorating
clinical picture
 Complex comorbidity that requires intensive clinical
assessment of response to intervention
 Symptoms of sufficient severity to interfere with functioning,
work, or family life that are unresponsive to outpatient
intervention
 Transient psychotic episodes associated with loss of impulse
control or impaired judgment

19. +
Contract for services
 timing and frequency of sessions,
 plans for crises management,
 after-hours availability (if any)
 expectations about scheduling, attendance, and payment.

20. + Dialetical behavior therapy
 CBT and social learning, mindfulness
 assumes core difficulty of clients is affective instability
 "dialectical" intervention needs to address both biological and
environmental aspects of the disorder/self-acceptance and
change
 intensive, one-year outpatient intervention that combines
weekly individual sessions with weekly skills-training groups
 purpose of group– to teach adaptive coping skills in the areas
of emotional regulation, distress tolerance, interpersonal
effectiveness, and identity confusion, and to correct
maladaptive cognitions.

21. +
Modality of DBT
 individual therapy, a formal skills-training group, a therapist
consultation team, some form of coaching (usually by telephone), and
a treatment length of at least six months for outpatient clients and two
months for inpatient clients.

22. + Psychodynamic Intervention
 draws from three major theoretical perspectives:
 ego psychology
 object relations
 self-psychology

23. + Exploratory-supportive continuum of interventions
 Supportive
 strengthening of defenses,
 development of self-esteem,
 validation of feelings,
 internalization of the therapeutic relationship
 creation of a greater capacity to cope with disturbing feelings
 Exploratory
 make unconscious patterns more consciously available
 increase affect tolerance,
 build a capacity to delay impulsive action
 provide insight into relationship problems
 develop reflective functioning toward a greater appreciation of internal motivation in
the self and others

24. +
Difficulty Prescribing Medication
disorder’s symptom heterogeneity
diagnostic unreliability
presence of comorbid disorders, and the
potential for self-destructiveness.

25. +
Types of medication
 SSRI’s – mood and impulsive symptoms
 Small, positive effects
For symptoms in cognitive dimension
(suspiciousness, illusions, depersonalization, or
transient hallucinations), antipsychotics
Review of antidepressant, anti-anxiety,
antipsychotic, anticonvulsants, and lithium
medications, either modest or no symptom relief

26. +
Critique
 DSM doesn’t mention how long symptoms have to last
 May meet the criteria in 126 different ways
 Division between clinical disorders and personality disorders
questionable
 High co-morbidity
 Psychodynamic vs. atheoretical
 Recovery rates

27. +
Critique for personality disorders
Personality disorders appear to
describe the total person, rather than
a particular aspect of the person or
the result of person-in-environment
processes

28. +
Who in case studies might show Axis II