7#$׸W (**xr *cC3. You turn the book to the first page and read... . .P S Y C H I A T R I C D I A G N O S I S & T R E A T M E N T . . . . BORDERLINE AND OTHER PERSONALITY DISORDERS . Eduardo Val, MD. & Radu Saveanu, MD . . . . TABLE 11 1. DSM III R CLASSIFICATION OF PERSONALITY DISORDERS . . Disorders manifested by odd or eccentric behavior . Paranoid personality disorder . Schizoid personality disorder . Schizotypal personality disorder . . Disorders manifested by dramatic, emotional, or erratic behavior . Histrionic personality disorder . Narcissistic personality disorder . Antisocial personality disorder . Borderline personality disorder . . Disorders manifested by anxiety or fear . Avoidant personality disorder . Dependent personality disorder . Obsessive compulsive personality disorder . Passive aggressive personality disorder . . Disorder not otherwise specified (NOS), e.g., impulsive, sadistic personality . . DSM III R describes 11 personality disorders and designates a twelfth category as `personality disorder not otherwise specified (NOS)' (Table 11 1). This last category may encompass disorders (e.g., impulsive . or sadistic personality) not normally included in the classification of personality disorder. This chapter focuses primarily on borderline personality disorder (BPD); although narcissistic, antisocial, paranoid, and schizotypal personality disorders are briefly discussed. . . I. Definitions. When making a personality diagnosis, one must distinguish between personality traits and personality disorders. The DSM III R defines these terms as follows: . A. Personality traits are `enduring patterns of perceiving, relating to, and thinking about the environment and oneself, and are exhibited in a wide range of important social and personal contexts.' . B. Personality disorders exist `only when personality traits are inflexible and maladaptive and cause either significant impairment [in social or occupational functioning] or subjective distress.' . The enduring pattern of maladaptive behavior is an important component of the definition; it is most likely recognizable by adolescence, or earlier, and tends to continue throughout adult life. . . II. Classification of personality disorders . A. In DSM III R, personality disorders are grouped in 4 clusters based on presenting or elicited symptoms (Table 11 1). The introduction of operationally defined criteria represents an advance over classification in previous diagnostic manuals, but drawbacks . remain. For example, overlapping criteria make it difficult to distinguish between specific disorders, so that 2 or 3 different diagnoses could be made simultaneously. The diagnoses themselves are not predictive of functioning, nor do they suggest particular treatments. . . B. Another approach to classification (and assessment) of personality disorders uses a hierarchy of levels of personality organization, ranging from more archaic or more disturbed organizations to better integrated or healthier ones. . 1. Kernberg (1967) proposed a classification of pathological character types based on different levels of ego organization: high (neurotic), middle (borderline), and low (psychotic). . 2. From a different conceptual perspective, Kohut and Wolf (1978) also offered a hierarchical approach to the assessment of personality based on the organization and integration of the self. . Such an approach allows for a hierarchical assessment of categories of personality disturbances based on personality traits and thus may be useful to the clinician in the diagnosis and therapy of personality disorders (Table 11 2). According to this model, the . pathogenesis and classification of personality disorders are based on the concept of the self. The self is conceived as a psychic structure with varying degrees of cohesiveness. One can assess the degree of cohesiveness by evaluating the person's capacity to achieve and sustain ambitions, . goals, and a sense of self, to regulate tension; and to form relationships. Higher capacity would be associated with greater cohesiveness. Kohut and Wolf view a person as normal or pathological according to where he or she falls along a developmental continuum ranging from a cohesive to a fragmented self organization. . a. Cohesive (firm) organization. A healthy individual with a firm and cohesive self has a sense of intact identity. The person depends on internal regulation, and thus the need for feedback from . others in order to maintain a sense of vigor, enthusiasm, continuity, and productivity is minimal. Such an individual has well . balanced self esteem, has the capacity to pursue goals over time, shows resilience to slights, and can accept criticism. . b. Narcissistic (fragile) organization. An individual with a fragile self is characterized by a precarious sense of . identity, a prominent lack of authenticity (i.e., a feeling that he or she is only role playing rather than genuinely experiencing events from . within), feelings of unworthiness, shifts toward grandiosity or ideas of reference, and hypersensitivity to being ignored. This type of . person also needs responsive and available self objects in order to gain and maintain integration and equilibrium of the self. For a person with . a fragile self organization, the concept of self depends heavily on feedback (e.g., validation, calmness) established through the bond . between self and self object. When that bond is broken, by rejection, . unavailability through separation, empathic disruption or disruption of the self object's empathy, etc., a faltering of the self . develops and disintegration (fragmentation) of the personality . ensues. This may be manifested in various ways, including acting out behavior . (perversion, promiscuity, substance abuse), hypochondriasis, . feelings of emptiness, depression, panic, and ideas of reference. Once a bond with a self object is regained, through reinstatement or . replacement, equilibrium of the self resumes. Narcissistic personality disturbances demonstrate this level of tenuous cohesion . and are associated with a tendency toward transient fragmentation. . c. Borderline (fragmented) organization. Borderline . personality disturbances, in contrast, constitute a lower level of self . organization, in which fragmentation is protracted rather than . transient. In a person with such disturbances, cohesion is only . temporarily attained when a self object is found. The capacity to maintain a relationship with a self object is limited by intense fears . provoked by the reliance and dependence on the self object for . psychic stability. It is this type of unique relationship to others, organized around the simultaneous need for and fear of the self . object, that accounts for the characteristic description of borderline personality disorder as `stable unstable.' . . BORDERLINE PERSONALITY DISORDER . . I. Clinical features. The clinical picture of BPD is frequently dramatic. Often the patient experiences suicidal ideation, self mutilating behavior, or psychosis and comes to the attention of the clinician by way of emergency services. At times, consultation is . requested because borderline personality behavior becomes evident during management attempts by medical or surgical personnel in other impatient clinical facilities. However, in outpatient psychiatric practice, symptoms of BPD may be well shielded and not immediately manifested, or they may have to be inferred or elicited by the . interviewer. Regardless of the character traits present, any disturbance or conflict in modulation of affect (particularly anger), difficulty in sustaining a stable identity, multiple drug abuse, and impulsive or action oriented behavior warrants a detailed and careful exploration for the presence of other BPD criteria. A manipulative . suicidal gesture or changes in the sense of reality (e.g., patient has transient visions, `hears' or `sees' an imagined person) with otherwise preserved reality testing should alert the clinician to seriously consider a diagnosis of BPD. . II. Epidemiology. The prevalence of BPD is not known. Some estimate that this severe disturbance is present in about 20% of the psychiatric population diagnosed with other psychiatric problems. BPD alone is believed to constitute about 10 to 20% of inpatient population admissions. This disorder is found 3 times more frequently in females than in males. . . III. Etiology and pathogenesis. Until recently, etiologic considerations in personality disorders focused on psycho dynamics, with little attention paid to the role of biological factors, although investigators acknowledged that constitutional components underlie character disorders. . A. Psycho dynamic factors. . It remains unclear what causes the arrest in a child's development that characterizes the pathogenesis of BPD. Developmental theories have at tempted to explain the disorder in terms of . vicissitudes in the mother/child dyad during early childhood. It is more likely, however, that the pathological features of BPD reflect a pervasive pattern of interpersonal malfunction in the family not just . during early childhood but throughout all phases of development. The full extent of the family as a causative factor is still unclear. . The current state of knowledge of the psycho pathological features . underlying BPD suggests that it is a fundamental disturbance in interpersonal relationships and the ability to tolerate aloneness. . Further research is necessary to evaluate its psychological components. . Other psycho dynamic approaches to understanding the pathological functioning of the person with BPD make use of several . different and complex theoretical models: separation/individuation . (Mahler, Masterson), ego and object relations (Kernberg), failure of object constancy, transitional object phenomena, and self . organization (Kohut). For the purpose of this chapter, we discuss Gunderson's concept of borderline personality, which we believe offers . a clear and pragmatic approach to the clinical understanding and arrangement of this disorder. . Gunderson (1984) postulated that the psycho pathological process under lying BPD can be best understood in terms of the . individual's relationship to a major or primary object. The major object is any person with whom the borderline personality has a significant . current relationship that is perceived of as necessary (the . concept is similar to Kohut's self object.) The major object is . believed to have the potential to maintain homeostasis and ensure a stable self . image in the borderline personality. According to Gunderson, the . borderline person functions best when the attachment to a major . or primary object is seen as supportive, thus the individual strives to gain or regain the support of a major object. Regressive behavior . results from the individual's concern about the primary object's . reliability and strength to sustain him or her, on the one hand, and, on the other, the fear of becoming vulnerable to control or . exploitation by the primary object. Regression is often an attempt to provoke reassurance that the major object will continue to be available (emotionally or physically). . a. When the major object is felt to be supportive, the struggles of the person with BPD are manifested clinically by dysphoria and depression. . b. When the major object is not experienced as supportive but as frustrating (whether because of a lack of empathic . understanding and response on the part of the major object, or because of his or her emotional unavailability, or because of . separation), lower levels of functioning and behavior ensue. Anger, manipulation, and . devaluation of the major object represent attempts to defend oneself against the loss of the major object and to downplay the . importance of the loss. Suicidal gestures and manipulations are expressions of the attempt to regain control over the object. . c. When the major object is perceived as absent, an even more severe deterioration in functioning occurs. Under these conditions, panic sets in as the person begins to feel alone or abandoned. . Depersonalization, devaluation, ideas of reference, or frank brief psychotic episodes may then occur. Impulsive, acting out . behavior (promiscuity, drug abuse, self mutilation) represents an effort to ward off and manage the fear of aloneness and subsequent disintegration and to restore self esteem. . It should be emphasized that when regression is expressed through aggressive behavior, such behavior should not be seen as a primary or inherited basic aggression; but rather as a secondary . phenomenon stemming from the experienced failure of the self object. This distinction is crucial in the approach used to manage the patient with BPD. . B. Biogenetic factors . 1. Data from several studies have suggested a genetic link between borderline personality and affective disorders . Borderline personality has been found to be more prevalent in relatives of patients with affective disorders than in relatives of either . patients with schizophrenia or patients with other psychiatric disorders. Several studies have demonstrated the presence of major . affective disorders in over 50% of patients who meet the diagnostic criteria for borderline personality. . Family studies indicate that relatives of borderline patients have a high prevalence of the disorder as well as other personality disorders. . Longitudinal follow up studies of borderline patients have found that they are at great risk for development of depressive . episodes. Electroencephalographic sleep studies of borderline patients have shown a shortened REM latency period similar to that of patients suffering from major depression. This finding has prompted some to . suggest that BPD is a subtype of affective disorder. It is also possible that BPD shares some biological features with the . schizoid/schizotypal/schizophrenia group of disorders, although the evidence for this is less conclusive. . 2. It has also been proposed that a subgroup of adult patients with BPD may have suffered minimal brain dysfunction in . childhood, suggesting that the pathological features of BPD may in some cases be the result of `organic' factors. Our own studies indicate that 60% of men with BPD and 30% of female patients with the disorder have . borderline or impaired ratings in the Luria Nebraska Neuropsychological Battery tests. The studies described in 1. and 2. . above suggest that BPD may be a heterogeneous group of disorders with different degrees of severity and with a diversity of biogenetic factors implicated in the pathogenesis. These diverse factors may . contribute to a basic vulnerability in the individual's ability to regulate and . sustain a stable sense of identity, the hallmark of the borderline personality. IV. Diagnostic criteria. The DSM III R criteria for borderline personality disorder are given in Table 11 3. . . V. Differential diagnosis. The differential diagnosis includes other personality disorders, listed in Table 11 1. . . TABLE 11 3. DSM III R DIAGNOSTIC CRITERIA FOR BORDERLINE PERSONALITY DISORDER . . A pervasive pattern of instability of mood, interpersonal relationships, and self image, beginning by early adulthood and present in a variety of contexts, as indicated by at least 5 of the following: . . (1) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of over idealization and devaluation . (2) impulsiveness in at least 2 areas that are potentially self damaging, e.g., spending, sex, substance use, shoplifting, reckless driving, binge eating (Do not include suicidal or self mutilating behavior covered in [5]). . (3) affective instability: marked shifts from baseline mood to depression; irritability, or anxiety, usually lasting a few hours and only rarely more than a few days . (4) inappropriate, intense anger or lack of control of anger, e.g., frequent displays of temper, constant anger, recurrent physical fights . (5) recurrent suicidal threats, gestures, or behavior, or self mutilating behavior . (6) marked and persistent identity disturbance manifested by uncertainty about at least 2 of the following: self image, sexual . orientation, long term goals or career choice, type of friends desired, preferred values . (7) chronic feelings of emptiness or boredom . (8) frantic efforts to avoid real or imagined abandonment (Do not include suicidal or self mutilating behavior covered in [5]). . . Vl. Treatment . A. Basic principles of treatment . 1. Individual psychotherapy is the primary mode of intervention, and the use of medication, whenever indicated, should . always be considered in the context of an established psychotherapeutic relationship. . 2. Even after a successful treatment, the individual with BPD almost never achieves a neurotic organization . (higher level of functioning, cohesive identity). Rather, a successful outcome is characterized by more stable relationships resulting from the awareness of the meaning of manipulative behavior and dependence, which are no longer used unconsciously. However, the . vulnerability to fragmentation persists, although disintegration occurs less frequently, mainly because of the patient's ability, gained through therapy, to use others as supportive objects in buttressing the sense of identity. . 3. Because of the dynamic conditions inherent in the disorder, patients with BPD drop out of treatment at a high rate. They also tend to consult many therapists before entering into a consistent . and durable treatment relationship. Clinicians should not, therefore, be too pessimistic and view a patient's abandoning treatment as a therapeutic failure; or, when initiating new treatment, clinicians . should not consider a patient's having undergone previous treatments as a negative factor. . Estimates from several studies indicate that 50% of patients with BPD who seek treatment drop out within 6 months, and 75% quit . within the first year; only one out of 10 patients completes a course of psychotherapy. Even when experienced therapists were surveyed, they reported that only 33% of their patients completed treatment, and . of this group only 10% were considered to have been successfully treated. . Thus, the long term psychotherapy of patients with BPD is difficult. Clinicians inevitably experience strong counter transference . feelings (e.g., helplessness, despair, rage, fear) that interfere with the treatment. . Frequently, consultation and supervision are necessary to overcome counter transference impasses. . B. Psychotherapy . 1. General approach. Long term individual psychotherapy centers on overcoming the patient's resistance to establishing a . relationship with a primary object (the therapist) and understanding and dealing with the fluctuations once an ongoing therapeutic relationship has been established. . 2. Management of psychiatric crises. Self destructive acts, aggressive behavior, and psychotic regression are commonly seen in treatment. Self destructive behavior most frequently involves wrist . slashing and drug overdose. These suicidal attempts have a manipulative component in that they are efforts to induce a `rescuing' response. The clinician should take them seriously and respond, since they represent the first line of defense in `crying out for help' before further regression occurs, which may involve more serious life . threatening attempts. The clinician should always keep in mind that what seems to be on the surface a manipulative gesture is actually a desperate survival maneuver for the patient with BPD. The patient inevitably interprets a lack of response on the part of the therapist as a lack of concern and availability which in turn will provoke and . escalate the manipulative behavior. Crises requiring acute intervention in the context of an ongoing therapeutic relationship are not only unavoidable, they are essential, providing the groundwork for . eventual change and growth in the patient's psychic organization. These crises result from the therapist's entering and assuming the role of an ongoing primary object for the patient with the unavoidable risks for the patient to experience frustrations and disappointments. . a. The appropriate therapeutic response to a crisis is predicated on an understanding of the dynamics within the treatment relationship. The clinician must determine whether the behavior is an . attempt to regain a sense of control over an already existing primary object, an attempt to enlist a new object, or a result of . experiencing the primary object as overwhelming or intrusive? (See Chapter 4 for a detailed discussion of the suicidal patient.) The clinician must be emotionally available and maintain active and open . communication while at the same time set limits in a firm, consistent manner tailored to the particular patient's needs. With some patients, the clinician must be tactfully confrontational to discover . underlying issues of abandonment and neglect; with other patients, the therapist should concentrate on creating a `safe space' . for the patient as a way of diminishing the perceived over intrusiveness and control by the primary object and allowing for the possibility of reestablishing a bond. . b. General guidelines for acute management are: . (1) Identify the nature and cause of the disruption. . (2) Intervene appropriately to restore calm and . integration. Be readily available for telephone consultation throughout the crisis, provide frequent psychotherapy sessions, mobilize" #56747 . significant others, and provide hospitalization (see F, below) if required. . C. Family therapy is particularly helpful for adolescents . or young adults with BPD when the patient and family are enmeshed in a . complicated system in which hostility and anxiety over separation . and individuation are prevalent. Parents are often either overprotective or neglectful. . D. Group therapy is indicated when dilution of intense and negative transference reactions is needed or when group pressure and . control are required to curtail acting out or impulsive behavior. . E. Residential and rehabilitation treatment are important components of long term treatment, since vocational and scholastic . difficulties and poor work performance are prevalent in this population. . F. Hospital treatment. A decision to hospitalize should be made with clear, short term objectives and should be explained to the . patient to minimize any misperceptions or unfulfillable promises. The . aim is to provide a supportive, structured. and problem oriented milieu to reinstate equilibrium and avoid further regression. Much of . the success of a brief admission depends on the therapist's ability to share with both the patient and the ward staff the reasons for and . expectations of hospitalization. One must anticipate and facilitate the management of splitting (a frequently used defense . mechanism) between therapist and staff that is almost always occasioned by the behavior of a patient with BPD. Open communication and dialogue . between therapist and staff about the rationale of the treatment . plan is essential; this is particularly important for the beginning therapist who feels vulnerable and whose sense of confidence may be . shaken by a lack of experience in managing patients with BPD. . Often, this vulnerability manifests itself as a retreat into isolation . in order to cover up perceived deficiencies, and this only creates ideal conditions for splitting to occur between members of the treatment team. . G. Pharmacotherapy. Few systematic, extensive, controlled studies of drug treatment of BPD have been conducted. Many . reports are clinical and anecdotal in nature. Drugs should be chosen to treat certain readily identifiable target symptoms. . 1. Symptoms of mood disturbance . a. Lithium carbonate. Patients with BPD who demonstrate mood swings and lability characterized by withdrawal, . irritability, and suicidal ideation or by hyperactivity, increased social activity, and gregariousness tend to respond to lithium . carbonate. In evaluating such patients, the diagnosis of borderline personality disorder should be entertained, since the . diagnosis of a bipolar or cyclothymic disorder might have been . overlooked. The same considerations regarding the use of lithium carbonate in bipolar disorder apply to its use in the treatment of patients with BPD (see p. 79,Vl.A. 2 8). . b. Carbamazepine. Consider using carbamazepine in patients unresponsive to lithium who have cyclothymic mood instability, particularly when rage and irritability are present (see p. 81, C.2). . c. Anti psychotic agents. Mood stabilization also occurs with the use of anti psychotic agents such as trifluoperazine or . haloperidol in low doses (e.g., 1 mg orally twice daily, not to exceed 5 mg daily, may sometimes suffice). . d. Lithium carbonate plus tricyclic antidepressants. Patients with persistent affective symptoms that are sometimes as severe as those of major depression are good candidates for . the use of lithium carbonate in combination with tricyclics. Remarkable improvement occasionally results in the patient manifesting overall . borderline behavior, in which case the original diagnosis should be reconsidered in favor of an affective disorder. Imipramine . occasionally produces negative side effects, particularly greater irritability. Tricyclics should be started slowly and increased . gradually. Relatively low doses are sufficient to bring about improvement in target symptoms. . e. Monoamine oxidase inhibitors (MAOls). A subgroup of borderline patients who meet the criteria for Klein's . hysteroid dysphoria, characterized by extreme dependence on other people for admiration and approval and by high sensitivity to rejection, . demonstrate a specific response to the use of MAOls, with improvement in stability of mood and interpersonal relationships. . Phenelzine is one of the MAOls of choice (15 mg orally 3 times daily; occasionally up to 90 mg/d). Dietary and drug restrictions should . be clearly spelled out (see Table 3 2, p. 77), and the clinician should be aware of the potential for acting out through dietary noncompliance. . When severe anxiety and psychotic symptoms are also present, the addition of an anti psychotic in low doses may be required. . 2. Symptoms of panic. The presence of panic symptoms is frequently overlooked (50% of patients with BPD have been found to have primary or secondary panic attacks). . a. Imipramine or an MAOI agent is helpful in blocking panic attacks and preventing anticipatory anxiety. . b. Alprazolam may be used with caution (alone or in combination with an MAOI) to treat both anticipatory anxiety and . panic attacks; however, anger and violent outbursts have been reported as complications when this drug is used in patients with BPD. The usual starting dose is 0.25 mg 2 or 3 times daily, titrated . eventually, if needed, to a maximum total daily dose of 4 to 8 mg in divided doses. . 3. Symptoms of cognitive disturbance. When signs of thought disturbance are accompanied by protracted eccentric and bizarre . behavior, low dose, non sedative neuroleptics may be indicated (e.g., . haloperidol, 1 mg 2 or 3 times daily). Patients with severe anxiety with persistent odd speech and thought appear to benefit from MAOls alone or in combination with a low dose neuroleptic. . 4. Anger and impulsive behavior. Angry outbursts, sometimes unprovoked, dominate the clinical picture of some patients with BPD. Some of these patients may meet the criteria for an . intermittent impulse control disorder and sometimes demonstrate electroencephalographic abnormalities. This episodic behavior may improve with the use of anticonvulsants (e.g., primidone). The possibility of temporal lobe epilepsy with interictal personality traits (e.g., mood shifts, anger, irritability, disturbances in self image) must be . considered. Carbamazepine may be the drug of choice in these patients (see C.2 p. 81). . . NARCISSISTIC PERSONALITY DISORDER TABLE 11 4. DSM III R DIAGNOSTIC CRITERIA FOR NARCISSISTIC PERSONALITY DISORDER . . A pervasive pattern of grandiosity (in fantasy or behavior), lack of empathy, and hypersensitivity to the evaluation of others, . beginning by early adulthood and present in a variety of contexts, as indicated by at least 5 of the following: . (1) reacts to criticism with feelings of rage, shame, or humiliation (even if not expressed) . (2) is interpersonally exploitative: takes advantage of others to achieve his or her own ends . (3) has a grandiose sense of self importance, e.g., exaggerates achievements and talents, expects to be noticed as `special' without appropriate achievement . (4) believes that his or her problems are unique and can be understood only by other special people . (6) is preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love . (6) has a sense of entitlement: unreasonable expectation of especially favorable treatment, e.g., assumes that he or she does not have to wait in line when others must do so . (7) requires constant attention and admiration, e.g., keeps fishing for compliments . (8) lack of empathy: inability to recognize and experience how others feel, e.g., annoyance and surprise when a friend who is seriously ill cancels a date . (9) is preoccupied with feelings of envy . . . I. Clinical features. Narcissistic personality disorder (NPD) is characterized by grandiosity, entitlement, arrogance, and a constant need for admiration. Narcissistic individuals are hypersensitive to criticism and usually react to it with rage and deep humiliation. . Relationships are, for the most part, shallow and are characterized by either envy and admiration or contempt and devaluation. . There is usually lack of empathy and little genuine warmth in interactions with others. . . II. Epidemiology. NPD has received a tremendous amount of attention in the last 20 years, especially in the psychoanalytic . literature. As a reflection of this growing interest, this diagnosis became a new . addition to DSM III in 1980. There is, however, very little epidemiologic data on the prevalence of this disorder or its risk factors. . Narcissistic individuals are seen fairly often in outpatient settings (clinics, offices). Some sociologists contend that under the influence of rapidly changing cultural values, the prevalence of NPD is rising in our society. . . III. Etiology and pathogenesis. Clinical understanding of NPD derives largely from the psychoanalytic treatment of patients with this disorder. The 2 major psychoanalytic theorists of narcissistic . character, Kohut and Kernberg, essentially agree that pathological development of self esteem is the major etiologic factor in NPD. We find Kohut's theory of narcissistic pathology particularly . appealing (see p. 172, B.2). Kohut views the pathogenic process leading to NPD as an early arrest in the developmental line leading to mature and healthy narcissism. . This arrest, at the stage of the archaic, grandiose self, is the result of repeated empathic failures on the part of the parents to understand, encourage, and realistically support their child's emerging . sense of self. This leads to a premature consolidation of a maladaptive and unstable self organization, leaving the individual vulnerable to regression and fragmentation. . . IV. Diagnostic criteria. . The DSM III R criteria for narcissistic personality disorder are given in Table 11 4. . . V. Differential diagnosis. The differential diagnosis includes other types of personality disorder listed in Table 11 1. . . Vl. Treatment . A. Psychotherapy. Individual psychotherapy is the treatment of choice for narcissistic patients. Most experts agree that insight . oriented psychotherapy or psychoanalysis is the treatment of choice for higher level narcissistic patients, whereas supportive psychotherapy is indicated for those with poor ego control and . integration and poor functioning. Hospitalization is not usually indicated except when severe depression or self fragmentation occurs. . 1. Kohut stresses the importance of clinicians' allowing and tolerating the gradual development of patients' transferences (mirroring and idealizing type). Therapists need to refrain from . premature interpretations and remain emphatically attuned to the patients' narcissistic needs. Whenever therapists fall short of the wished, for ideal of `perfect' attunement, patients feel injured and . respond with anger or detachment. This kind of disruption in treatment needs to be identified and seen through the subjective eyes of the patient and not treated as irrational or immature behavior. . Therapists can then help patients understand how current disappointments relate to failures of significant objects in their past. In Kohut's terms, it is the oscillation between perceived narcissistic injury and repair, of the injury leading to gradual reintegration of the self, that constitutes the therapeutic process. . 2. Treating narcissistic personalities can be very trying and painful. Especially in the early stages of treatment, patients may be detached, grandiose, and totally self absorbed, and may treat . therapists as objects serving specific needed functions rather than as whole, separate individuals. This can easily engender strong counter transference responses in clinicians, such as feelings of . boredom, anger, and worthlessness, and wishes to be rid of the patient. When these counter transference responses become intense (and they inevitably do at some point in the treatment), it is essential . that, in an effort to go beyond the temporary impasse and reestablish contact with patients' pain and suffering, therapists keep in mind what brought the patients to therapy. . 3. Treatment of the narcissistic personality is often punctuated by abrupt terminations. . B. Pharmacotherapy. There are no pharmacological interventions specific to this disorder. Medications are sometimes used to treat symptoms such as depression (antidepressants), affective . lability (lithium), and vulnerability to rejection (MAOls) (see Vl.G p. 178). . . . ANTISOCIAL PERSONALITY DISORDER . . I. Clinical features. The essential feature of antisocial personality disorder (APD) is a chronic lack of concern for, and violation of, the rights of others. The childhood and adolescence of . individuals with this disorder are characterized by cruelty to people or animals, lying, stealing, running away from home, and initiating fights. In adulthood, irresponsible, aggressive, impulsive, and often illegal activities are typically seen. Individuals may . superficially appear charming and carefree but, on closer examination, they are egocentric, manipulative, and dishonest. Their relationships are characterized by lack of intimacy, lack of loyalty, . and promiscuous behavior. Work performance is usually poor. Antisocial individuals frequently get in trouble with the law, although criminal behavior is not synonymous with APD. Many people who exhibit the disorder do not follow a criminal career. . . II. Epidemiology. APD has a lifetime prevalence of about 2 to 3% and is 4 to 7 times more frequent among males than among females (Gunderson, 1988). This disorder appears to be more prevalent in urban . areas and is especially high in prison populations, where the prevalence may be as high as 50 to 75%. APD typically begins in childhood or early adolescence. Boys often develop signs of the disorder earlier than girls (sometimes even before age 8). The peak prevalence . occurs in the 24 to 44 age group, followed by a sharp decrease, described by some as a `burnout' syndrome and by others as spontaneous improvement. . As antisocial behavior diminishes, however, there is an increase in substance abuse and psychiatric symptoms such as depression, anxiety, and somatization. . . III. Etiology and pathogenesis. Several recent studies suggest that both genetic and environmental factors are implicated in the causation of this disorder. . A. Genetic factors. The risk that the disorder will develop in first degree relatives of individuals with APD is 5 to 10 times . greater than the risk for the general population. Several studies have shown a familial association between APD, histrionic personality disorder, and somatization. . B. Cognitive factors. Currently, an ongoing debate exists over whether childhood attention deficit disorder is related to the later development of antisocial behavior in adult life. . C. Environmental factors. Environmental studies have shown that this disorder frequently develops in children who live in homes where emotional deprivation and inconsistent parenting are the norm. . These children grow up with unavailable, impulsive parents who are incapable of giving affection or of providing consistent adequate discipline. At an early age, they learn that the world is a dangerous . place and life is a constant struggle. It has been suggested that psychopaths use aggression and manipulation to defend themselves against anticipated (and largely imagined) attacks by others. Selfishness, . ruthlessness, and lack of concern are, in their eyes, maneuvers to ensure survival. . . IV. Diagnostic criteria. . . The DSM III R criteria for antisocial personality disorder are given in Table 11 5. . . V. Differential diagnosis. The differential diagnosis includes other personality disorders listed in Table 11 1. . . Vl. Treatment . A. Individual psychotherapy has not been successful in treating antisocial individuals. this may be a result of their lack of motivation to change and poor tolerance of relationships, both being major obstacles to the establishment of a therapeutic alliance. . Individuals tend to be more invested in outwitting their therapists and keeping them at a safe distance than in trying to develop an honest mutual connection. In treating antisocial patients, clinicians need to remember that they experience relationships as potentially . threatening and inconsistent. Any attempt on the part of therapists to get `closer' will, therefore, be viewed with suspicion and fear. Clinicians often experience counter transference reactions ranging . from fantasies of rescuing deeply hurt and consistently misunderstood individuals to feeling disappointed, manipulated, angry, morally outraged, and gradually hopeless about treatment. . B. Family therapy may be useful, but not so much to treat the individual's psycho pathology as to provide support and some understanding to beleaguered family members. . C. Therapeutic communities (closed, highly structured, residential treatment programs offered by a few specialized hospitals, halfway houses, and correctional institutions) have so far shown the . most promising results (Reid,1986). Patients are usually referred to such programs by judges; dropping out most often means having to go . (or return) to prison. These programs have very clear and narrow . expectations, which become the focus of treatment: taking responsibility for one's actions, being honest, and assuming . . PARANOID PERSONALITY DISORDER . . TABLE 11 6. DSM III R DIAGNOSTIC CRITERIA FOR PARANOID PERSONALITY DISORDER . . A pervasive and unwarranted tendency, beginning by early adulthood and present in a variety of contexts, to interpret the . actions of people as deliberately demeaning or threatening, as indicated by at least 4 of the following: . (l) expects, without sufficient basis, to be exploited or harmed by others . (2) questions, without justification, the loyalty or trustworthiness of friends or associates . (3) reads hidden demeaning or threatening meanings into benign remarks or events, e.g., suspects that a neighbor put out trash early to annoy him . (4) bears grudges or is unforgiving of insults or slights . (5) is reluctant to confide in others because of unwarranted fear that the information will be used against him or her . (6) is easily slighted and quick to react with anger or to counterattack . (7) questions, without justification, fidelity of spouse or sexual partner . . I. Clinical features. The essential feature of this disorder is a long standing suspiciousness and mistrust of people (Gunderson, 1988). . Individuals with paranoid personality disorder (PPD) constantly question the motives and loyalty of friends, associates, and even family. Their expectation is that they will be exploited, manipulated, or . cheated by others and, therefore, need constantly to be on the lookout. They search for evidence of deception in others and are likely to be litigious. They externalize and project their own emotions and conflicts as a way to avoid inner struggles and discomfort. They . frequently suffer from pathological jealousy that renders them socially isolated and lonely. The day to day functioning of paranoid . individuals is stable; their biggest problem is with relationships, especially with people in positions of authority. . . II. Epidemiology. The prevalence of PPD is unknown. Individuals with this disorder rarely seek treatment. PPD appears to be more common in men than in women and its features are usually seen by adolescence. Epidemiologic risk factors for this disorder have not yet been identified. . . III. Etiology and pathogenesis. Little systematic data exist on the etiology of this disorder. . A. Biogenetic factors. Several studies suggest that familial genetic factors play a role, linking PPD to the paranoid subtype of schizophrenia and to delusional (paranoid) disorder. . B. Psycho dynamic factors. Several psychological theories directed at the etiology of PPD have been postulated, but none so far . has been tested. One of the early psychoanalytic theories, stating that paranoid phenomena are caused by an underlying struggle against latent homosexuality, has been discredited (Vaillant and Perry, 1985). More recent theories have suggested that actual humiliating . experiences by members of the same sex may constitute the basis for the development of this personality structure. According to these theories, individuals who have suffered such trauma later become . crusaders whose mission it is to find the evildoers of this world as away to ensure that they will never again feel the helplessness, shame, and humiliation they once experienced. Their defensive use of projection, denial, and distortion protects them from experiencing these unacceptable affects. . . IV. Diagnostic criteria. The DSM III R criteria for paranoid personality disorder are given in Table 11 6. . . V. Differential diagnosis. The differential diagnosis includes other personality disorders listed in Table 11 1. . . Vl. Treatment . A. Psychotherapy. The optimal treatment of patients with PPD is long term, insight oriented psychotherapy. . 1. General principles. According to Meissner (1989), the following principles are important to keep in mind: . . B. Occurrence not exclusively during the course of schizophrenia or a delusional disorder . a. There is a need to establish and maintain a firm therapeutic alliance. This obviously requires patients to have a degree of trust in therapists, something particularly difficult for individuals who are inherently guarded and suspicious of relationships. . b. Therapists should always be aware of patients' need for some degree of autonomy and control in the treatment situation, and should not use confrontation or limit setting too prematurely. The goal of therapy is to help paranoid patients give up their rigid defenses . (such as projection, distortion, and denial) and identify as well as accept their vulnerabilities. The uncovering of vulnerabilities (feelings of worthlessness, inferiority, helplessness) leads to a sense of emptiness and depression, which then becomes the focus of treatment. . 2. Counter transference responses may sometimes be difficult to control by clinicians, especially with patients who are suspicious, overly critical, arrogant, and demeaning. Therapists may . begin to feel angry, self righteous, argumentative, or rejecting, or, on the contrary, helpless, discouraged, and powerless. These feelings should be carefully monitored and used in a way that will strengthen the therapeutic process. . B. Group and family therapy may be used in conjunction with, not instead of, individual psychotherapy (these treatment modalities are sometimes too threatening for paranoid individuals). . C. Pharmacotherapy is limited to treating target symptoms that appear in the course of treatment. . 1. Low dose neuroleptics have been used with moderate success (Prolixin, Haldol, Trilafon) (see Appendix A). . 2. Minor antidepressants (Desipramine) or tranquilizers (Lorazepam) may be beneficial if symptoms of anxiety or depression . develop (see Appendices B and C). Note: Often, paranoid patients are very reluctant to take any kind of medication, and this issue needs to become part of the therapeutic process so that it does not threaten the ever fragile alliance. . . SCHIZOTYPAL PERSONALITY DISORDER . TABLE 11 7. DSM III R DIAGNOSTIC CRITERIA FOR SCHIZOTYPAL PERSONALITY DISORDER . . A pervasive pattern of deficits in interpersonal relatedness and peculiarities of ideation, appearance, and behavior, beginning by early adulthood and present in a variety of contexts, as indicated by at least 5 of the following: . (1) ideas of reference (excluding delusions of reference) . (2) excessive social anxiety, e.g., extreme discomfort in social situations involving unfamiliar people . (3) odd beliefs or magical thinking influencing behavior and inconsistent with subcultural norms, e.g., superstitiousness, belief in clairvoyance, telepathy, or `sixth sense', `others can feel my feelings' (in children and adolescents, bizarre fantasies or preoccupations) . (4) unusual perceptual experiences, e.g., illusions, sensing the presence of a force or person not actually present (e.g., `I felt as if my dead mother were in the room with me') . (5) odd or eccentric behavior or appearance, e.g., unkempt, unusual mannerisms, talks to self . (6) no close friends or confidants (or only one) other than first degree relatives . (7) odd speech (without loosening of associations or incoherence), e.g., speech that is impoverished, digressive, vague, or inappropriately abstract . (8) inappropriate or constricted affect, e.g., silly, aloof, rarely reciprocates gestures or facial expressions, such as smiles or nods . (9) suspiciousness or paranoid ideation . . B. Occurrence not exclusively during the course of schizophrenia or a pervasive developmental disorder motivation. Many patients, lacking the motivation to change, drop out of therapy within the first few weeks. . . 3. For long stretches of time, very little change occurs in treatment. Psychotherapy is slow, usually requiring years of painstaking work before changes (often minimal) are observed. Therapists often experience a sense of boredom or gradual discouragement, . forgetting how utterly dependent on the therapeutic relationship these individuals are. . . I. Clinical features. Schizotypal personality disorder (SPD) became a new diagnostic category in the DSM III. The term schizotype was introduced by Rado almost 30 years ago to describe individuals who seem . to have a genetic predisposition for schizophrenia but never develop the full blown syndrome. Over the years, other names have been used to describe the condition of this group of individuals: latent . schizophrenia, ambulatory schizophrenia, borderline schizophrenia, and pseudo neurotic schizophrenia. There are several . problems with the classification SPD. Unlike other character disorder categories, this one was created as a result of research . findings on schizophrenia. Clinical usage and perceived clinical need, therefore, remain highly variable. A substantial amount of . epidemiological research data is needed to establish the validity and reliability of this disorder. . A. General features. In general, individuals with this disorder have difficulty correctly identifying and processing thoughts . and feelings, either their own or those of people around them. Thus, . their relationships are tenuous, unstable, and without clear boundaries. A 1986 study by McGlashan (McGlashan, 1985) indicates that . SPD is a stable disorder carrying considerable disability in areas such as employment and social functioning. . B. Other specific features. Individuals with SPD have specific clinical features that can be divided, for heuristic purposes, into 2 categories. . behavior features that resemble schizophrenic . symptoms. Further research is necessary to differentiate the diagnostic criteria of this disorder from those of paranoid, borderline, and schizoid personalities. . . II. Epidemiology. According to Gunderson (1988), the prevalence of SPD in the general population is 2 to 6%, a rate arrived at by inference from several familial research studies. . . III. Etiology . A. Biogenetic factors. A higher incidence of SPD exists among relatives of schizophrenics than in the general population, . indicating a familial genetic association between the 2 disorders. A study by Torgersen (in Gunderson,1988) indicated that among the monozygotic twins of individuals with SPD, 33% fulfill criteria for . SPD as well. A great deal of research attempting to identify biological markers of this disorder is currently underway. . B. Psychodynamic factors. Studies have shown that environmental factors are also implicated in the etiology and . development of SPD, although the exact role of the environment remains to be elucidated. . . IV. Diagnostic criteria. The DSM III R criteria for schizotypal personality disorder are given in Table 11 7. . . V. Differential diagnosis. The differential diagnosis includes other personality disorders listed in Table 11 1. . . Vl. Treatment . A. Psychotherapy. According to Stone (1989), longterm supportive psychotherapy is the treatment of choice for the majority of schizotypal patients. . 1. As a general rule, it is important for clinicians to be active, direct, and clear in their interventions. These general recommendations are particularly relevant to the treatment of . individuals who tend to have a fair amount of `cognitive slippage,' which leads them to easily misinterpret communications, get . frightened or suspicious, and withdraw. According to Stone, therapists should not shy away from educating, clarifying misperceptions, and . giving advice, thus serving as a `reality organ' for patients. Supportive interventions, more often than interpretations, provide the vehicle for therapeutic change. . 2. Schizotypal patients are frequently concrete and repetitious in their thinking and speech; many exhibit a pervasive lack of interest and . B. Group and family therapy may be useful in individual cases, but little data are available so far. . C. Residential treatment (day hospitals, halfway houses, . vocational rehabilitation) may benefit socially dysfunctional schizotypal patients. . D. Pharmacotherapy is sometimes needed for symptom control but is not an integral part of treatment for many patients. . 1. One study (by Goldberg et al [1986]) found that low dose . neuroleptics (eg, thiothixene) helped to diminish symptoms such . as ideas of reference, obsessive/compulsive preoccupations, anxiety, and somatization (see Appendix A). . 2. When anxiety is the main disabling symptom, low dose . anxiolytics (eg, lorazepam [Ativan]) have proved beneficial (see Appendix C). . u achieve and sustain ambitions, ׸׻׼׽׾ <=>?@ABCDb !"#$%&'()*34TUVWXYZ[\]^_ @  `79yz bk*32;o.7tJ   .$2  +P)I