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PERSONALITY DISORDERS • TOTALITY OF EMOTIONAL AND BEHAVIORAL MANAGING NARCISSISTIC, TRAITS BORDERLINE AND ANTISOCIAL • ONSET TEENS PERSONALITY DISORDERS • ENDURING, INFLEXIBLE, CONSISTENT, AND MALADAPTIVE • CAUSES SIGNIFICANT IMPAIRMENT AND/OR DISTRESS CARDWELL C. NUCKOLS, PHD • SOME SEEM TO GET BETTER IN THE 30 AND 40 YEAR [email protected] OLD RANGE • TRAITS VS. DISORDER

PSYCHOBIOLOGICAL MODEL OF PSYCHOBIOLOGICAL MODEL OF PERSONALITY PERSONALITY • PERSONALITY (CLONINGER, 1993) • TEMPERAMENT –TEMPERAMENT -50% HEAVILY –NOVELTY-SEEKING –HARM-AVOIDANCE INFLUENCED BY GENETICS –REWARD-DEPENDENCE • AFFECTIVE TONE –PERSISTENCE • INTENSITY AND REACTIVITY • CHARACTER –CHARACTER -50% HEAVILY –SELF-DIRECTEDNESS (RESPONSIBLE, PURPOSEFUL & RESOURCEFUL) INFLUENCED BY ENVIRONMENT –COOPERATIVENESS • MORAL AND VALUE SYSTEM –SELF-TRANSCENDENCE –ALTRUISM

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PSYCHOBIOLOGICAL MODEL OF PERSONALITY TREATMENT CONSIDERATIONS • GENETICS • EGOSYNTONIC AND CHARACTEROLOGICAL • EXAMPLE-ANTISOCIAL PERSONALITY • CHARACTER TRAITS MORE AMENABLE TO DISORDER TREATMENT • INCREASED IMPULSIVITY • DECREASED EMPATHY • TRANSFERENCE/COUNTERTRANSFERENCE • LOW FRUSTRATION TOLERANCE • STRESS A VARIABLE IN INTENSITY • HIGH DRIVE • HIGH SENSATION SEEKING

TREATMENT CONSIDERATIONS PSYCHOTHERAPEUTIC TREATMENT STRATEGIES • PSYCHOTHERAPEUTIC TREATMENT STRATEGIES • INCREASE ACCEPTANCE AND –INCREASE ACCEPTANCE AND TOLERANCE TOLERANCE – PSYCHO-EDUCATION –REDUCE INTENSITY OF TRAIT – IDENTIFY ADAPTIVE FEATURES EXPRESSION • REDUCE INTENSITY OF TRAIT –PROMOTE ADAPTIVE TRAIT-BASED EXPRESSION BEHAVIOR – RESTRUCTURE TRIGGERING SITUATIONS –REDUCE STRESS (REAL AND PERCEIVED) – MODIFY AMPLIFYING COGNITIONS – ENHANCE INCOMPATIBLE BEHAVIORS – CREATE CONDUCIVE ENVIRONMENTS – MEDICATION

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CREATE CONDUCIVE PSYCHOTHERAPEUTIC ENVIRONMENT TREATMENT STRATEGIES • HELP THEM FIND AN ENVIRONMENT • PROMOTE ADAPTIVE TRAIT-BASED THEY CAN FLOURISH IN BEHAVIOR • ESPECIALLY TRUE WITH – HOW AND WHEN TO ASK FOR HELP BORDERLINE PD • CREATE CONDUCIVE ENVIRONMENTS • SET APPROPRIATE LIMITS – MODIFY ENVIRONMENT TO MATCH CLIENT INSTEAD OF ASKING THE CLIENT TO ADAPT TO • ENVIRONMENTAL ENRICHMENT THE ENVIRONMENT THAT HAS BEEN PROBLEMATIC

A “GOOD PARENT” SETS SETTING LIMITS “GOOD LIMITS”

TOO STRICT FAIR CONSISTENT TOO LOOSE AVAILABLE

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EMPATHY PERSONALITY DISORDERS • THREE TYPES OF EMPATHY • EMOTIONAL EMPATHY • LACK OF EMPATHY DISORDERS • SHARING ANOTHER'S FEELINGS • COGNITIVE EMPATHY –NARCISSISTIC PERSONALITY DISORDER • PERSPECTIVE TAKING OR THEORY OF MIND –ANTISOCIAL PERSONALITY DISORDER • THINK ABOUT AND UNDERSTAND ANOTHER’S FEELINGS • IMPULSIVE DISORDERS • EMPATHIC CONCERN OR • MOTIVATION TO DO SOMETHING ABOUT –ANTISOCIAL PERSONALITY DISORDER ANOTHER'S SUFFERING –BORDERLINE PERSONALITY DISORDER

EMPATHY EMPATHY • WHEN ONE MEMBER OF A HUSBAND/WIFE • PSYCHOPATHS UNDERSTAND WHAT OTHERS ARE TEAM EXPERIENCES … FEELING BUT HAVE A PROFOUND LACK OF • EMPATHY ACTIVATES THE EMOTIONAL OR EMPATHIC CONCERN AFFECTIVE PARTS OF THE PAIN NETWORK BUT • IMAGING REVEALS ABNORMAL CONNECTIONS AND NOT THE PHYSICAL SENSATION OF PAIN NEURAL ACTIVITY IN AREAS ASSOCIATED WITH • COGNITIVE EMPATHY IS AN ATTEMPT TO EMPATHY UNDERSTAND AND REASON ABOUT THE STATE • COGNITIVE EMPATHY BUT NOT EMOTIONAL OF ANOTHER. IT IS A CAPACITY CALLED EMPATHY PREDICTS A SENSE OF JUSTICE FOR MENTALIZING OR THEORY OF MIND OTHERS • INVOLVES THE SUPERIOR TEMPORAL SULCUS, • THOSE HIGH IN “COLDHEARTEDNESS” WERE LEAST TEMPORAL POLES AND TEMPOROPARIETAL MOTIVATED BY A SENSE OF JUSTICE JUNCTION. ALSO THE MEDIAL PREFRONTAL CORTEX DENWORTH, LYDIA. “I FEEL YOUR PAIN”. SCIENTIFIC AMERICAN. DECEMBER WHICH IS ASSOCIATED WITH THINKING ABOUT 2017, PGS. 58-63 ONESELF

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IMPULSIVITY IMPULSIVITY • IMPULSIVITY HAS BEEN VARIOUSLY DEFINED AS • SSRIS ARE SOME OF THE MOST FREQUENTLY PRESCRIBED PSYCHIATRIC MEDICATIONS. BASIC BEHAVIOR WITHOUT ADEQUATE THOUGHT, THE RESEARCH HAS LONG SHOWN THAT LOW LEVELS OF TENDENCY TO ACT WITH LESS FORETHOUGHT THAN THE SEROTONIN METABOLITE 5- DO MOST INDIVIDUALS OF EQUAL ABILITY AND HYDROXYINDOLEACETIC ACID AND BLUNTED KNOWLEDGE, OR A PREDISPOSITION TOWARD RAPID, SEROTONERGIC RESPONSE WITHIN THE UNPLANNED REACTIONS TO INTERNAL OR EXTERNAL VENTROMEDIAL PREFRONTAL CORTEX ARE STIMULI WITHOUT REGARD TO THE NEGATIVE ASSOCIATED WITH IMPULSIVE BEHAVIORS, ESPECIALLY CONSEQUENCES OF THESE REACTIONS. AGGRESSION. • IMPULSIVITY IS IMPLICATED IN A NUMBER OF • ANIMAL RESEARCH SUPPORTS AN EMERGING ROLE FOR PSYCHIATRIC DISORDERS INCLUDING MANIA, THE NORADRENALINE SYSTEM IN IMPULSE CONTROL. PERSONALITY DISORDERS, AND SUBSTANCE USE GIVEN THEIR POTENTIAL TO MODULATE PREFRONTAL DISORDERS INHIBITORY PROCESSES, SNRIS MAY HOLD PROMISE FOR THE TREATMENT OF SOME TYPES OF IMPULSIVITY

IMPULSIVITY IMPULSIVITY • SEVERAL CLINICAL CONCLUSIONS CAN BE DRAWN FROM THE DATA • LITHIUM HAS LONG BEEN CONSIDERED A REGARDING PHARMACOLOGICAL TREATMENT OF IMPULSIVE BEHAVIORS: POTENTIAL MEDICATION FOR REDUCING • • SSRIS APPEAR MOST HELPFUL FOR IMPULSIVE AGGRESSION IMPULSIVITY. ITS EFFECTIVENESS IN BIPOLAR • • STIMULANTS CAN WORSEN SOME TYPES OF IMPULSIVE BEHAVIOR EVEN MANIA IS DUE, IN PART, TO ITS ABILITY TO REDUCE THOUGH THEY ARE HELPFUL IN ADHD; IN SUCH CASES, OTHER TREATMENT OPTIONS, SUCH AS SNRIS, MERIT CONSIDERATION THE IMPULSIVITY ASSOCIATED WITH • • GLUTAMATERGIC AGENTS, N-ACETYLCYSTEINE AND MEMANTINE, HAVE GRANDIOSITY. SHOWN EARLY PROMISE FOR A RANGE OF IMPULSIVE BEHAVIORS AND PARTICULARLY MERIT FURTHER INVESTIGATION GIVEN THEIR HIGH • IN ADDITION, LITHIUM MAY BE EFFECTIVE IN TOLERABILITY AND MINIMAL ADVERSE-EVENT PROFILES REDUCING IMPULSIVE AGGRESSION. THE USE OF • • ATYPICAL ANTIPSYCHOTICS MAY ALSO BE PROMISING FOR A RANGE OF LITHIUM IS SOMEWHAT LIMITED BECAUSE OF IMPULSE BEHAVIORS, BUT THEIR ADVERSE-EFFECT PROFILE AND THE NEED FOR OCCASIONAL BLOOD MONITORING MUST BE SERIOUSLY TOLERABILITY PROBLEMS AND ITS ADVERSE CONSIDERED BEFORE USE; ARIPIPRAZOLE MAY WORSEN IMPULSIVITY IN EFFECTS (EG., TREMOR, NAUSEA, DIARRHEA, SOME INDIVIDUALS NEPHROTOXICITY). • • LITHIUM MAY BE MOST EFFECTIVE FOR THE IMPULSIVITY SEEN IN CONDUCT DISORDER, BUT ITS UTILITY IS HINDERED BY THE NEED FOR BLOOD MONITORING

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NARCISSISM-TRAITS NARCISSISM-TRAITS • INCREASING IN COLLEGE STUDENTS • WE LIVE IN A WORLD OF DUALITY BY FOR PAST FEW DECADES COMPARISON • BECOMING A MORE NARCISSISTIC • GRADES CULTURE • MONEY • • NARCISSISTS ARE OBSESSED WITH POSITION THEIR LOOKS • THAT PERPETUATES INFANTILE NARCISSISM (EGO) • THEY LIKE TO TALK ABOUT THEMSELVES • SECONDARY GAIN OF THE EGO • USE WORD “I” MUCH MORE THAN “WE”

NARCISSISM AND PRIDE NARCISSISM AND PRIDE • ENTITLEMENT COMES FROM UNRESOLVED INFANTILE NARCISSISTIC ENTITLEMENT EGOCENTRICITY (“BABY”) • TENACIOUS, RIGIDLY DEFENDED AND – PRODUCES LACK OF REMORSE SOMETIMES UNCORRECTABLE (ASPD). THE – JUSTIFIES RESENTMENTS MORE THE ENTITLEMENT THE LESS THE – REAL OR PERCEIVED SLIGHT CAN CAUSE LEVEL OF EMPATHY. INCREDIBLE RAGE • THIS ATTITUDE IS BASICALLY PSYCHOTIC AS – CREATES A “BETTER THAN” ATTITUDE SUCH THE INNER GRANDIOSITY IS DELUSIONAL. THAT IT IS NOW OK TO HOLD NEGATIVE JUDGMENT

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NARCISSISM AND PRIDE NARCISISM AND PRIDE • PSYCHOANALYTIC VIEW • PRIDE IS A PLEASURABLE SELF-CONSCIOUS EMOTION ARISING WHEN PEOPLE FEEL • GRANDIOSE VIEW BUFFERS A PERSON GOOD ABOUT THEMSELVES FROM UNCONSCIOUS INSECURITIES • THERE APPEARS TO BE TWO FACETS OF THE • HUBRISTIC PRIDE AND ITS ASSOCIATED SAME EMOTION AGGRESSIVENESS AND MANIPULATIVE • AUTHENTIC PRIDE TENDENCIES ALLOW NARCISSIST TO • HUBRISTIC PRIDE MAINTAIN AN ARTIFICIALLY POSITIVE • BOTH ARE ADAPTIVE-SECURE SOCIAL STATUS SENSE OF SELF (BULLY WHETHER ON TRACEY, JESSICA. “PRIDE AND POWER”. SCIENTIFIC AMERICAN MIND. NOV/DEC 2013, PGS. 64-68. PLAY GROUND OR CONFERENCE ROOM)

NARCISISM AND PRIDE NARCISISM AND PRIDE • AUTHENTIC PRIDE • HUBRISTIC PRIDE • MOTIVATES HARD WORK AND ACHIEVEMENT- • INVOKES ARROGANCE AND EGOTISM- EXAMPLE MIGHT BE BILL GATES EXAMPLE MIGHT BE KIM JONG UN • GENERALLY ASSOCIATED WITH HIGH SELF- ESTEEM • NARCISSISM AS A CLASSIC DEFENSE SYSTEM • TEND TO BE EXTROVERTED, AGREEABLE, TO WARD OFF UNCONSCIOUS INSECURITIES CREATIVE AND POPULAR AND SHAME • COMMUNALLY ORIENTED (VOLUNTEER • GENERALLY ASSOCIATED WITH LOW SELF- WORK) ESTEEM • ASSOCIATED WITH LONG-TERM SUCCESS • TEND TO BE DISAGREEABLE, AGGRESSIVE, • MOTIVATES ACHIEVEMENT AND CONCERN MANIPULATIVE, SOCIALLY ANXIOUS AND FOR OTHERS EVEN CLINICALLY DEPRESSED

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NARCISISM AND PRIDE NARCISSISTIC PERSONALITY • HUBRISTIC PRIDE (CONTINUED) DISORDER • MORE INTERESTED IN DEROGATING OTHERS • THREE LEVELS OF SEVERITY THAN HELPING THEM • MILD • SERVES AS A CRUTCH FOR OUR SENSE OF SELF • INTERPERSONAL PROBLEMS IN LONG-TERM • SHORT-TERM SUCCESS WITH LONGER-TERM INTERACTIONS NEGATIVE EFFECT ON RELATIONSHIPS AND • GENERALLY FUNCTIONAL WORK • MODERATE • FACILITATES ALL OF THE BEHAVIORS NEEDED • TYPICAL SYNDROME TO BE DOMINANT-ARROGANCE, SENSE OF • GRANDIOSITY SUPERIORITY AND WILLINGNESS TO • SENSITIVITY TO CRITICISM INTIMIDATE AND DEROGATE OTHERS • LACK EMPATHY

NARCISSISTIC PERSONALITY DISORDER NARCISSISTIC PERSONALITY DISORDER • THREE LEVELS OF SEVERITY (CONTINUED) • SUBTYPES • SEVERE OR MALIGNANT • GRANDIOSE, THICK-SKINNED AND OVERT • ANTISOCIAL BEHAVIOR WITH LACK OF IMPULSE • OVERT GRANDIOSITY CONTROL AND TOLERANCE • ATTENTION-SEEKING • SELF-DIRECTED OR OTHER-DIRECTED AGGRESSION • ENTITLEMENT • MAY HAVE SIGNIFICANT PARANOID IDEATION • ARROGANT

• LITTLE OBSERVABLE • SOCIALLY CHARMING BUT OBLIVIOUS TO THE NEEDS OF OTHERS • INTERPERSONALLY EXPLOITIVE • SELF-ABSORBED

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NARCISSISTIC PERSONALITY NARCISSISTIC PERSONALITY DISORDER DISORDER • FRAGILE, THIN-SKINNED AND COVERT • HIGH-FUNCTIONING, EXHIBITIONISTIC • INHIBITED OR AUTONOMOUS • MANIFESTLY DISTRESSED • GRANDIOSE • HYPERSENSITIVE TO CRITICISM • CHRONICALLY ENVIOUS • COMPETITIVE • CONSTANT EVALUATION OF SELF AND • ATTENTION SEEKING OTHERS • SEXUALLY PROVOCATIVE • INTERPERSONALLY SHY • DEMONSTRATE ADAPTIVE • OUTWARDLY SELF-EFFACING • HARBORS SECRET GRANDIOSITY FUNCTIONING USING TRAITS TO • SELF-ABSORBED SUCCEED

NARCISSISTIC PERSONALITY NARCISSISTIC PERSONALITY DISORDER DISORDER • DEPRESSION, ANXIETY, SELF-INJURIOUS • NO KNOWN CAUSE BEHAVIOR AND SUICIDE MORE COMMON • ONE THEORY HOLDS THEY ARE COMPENSATING FOR LOW SELF-ESTEEM BY BECOMING IN VULNERABLE SUBTYPE EGOTISTICAL (WEAK SCIENTIFIC SUPPORT) • GRANDIOSE TRAITS RELATED TO • ANOTHER THEORY SUGGESTS ONLY VULNERABLE NARCISSISTS LACK A SENSE OF SELF-WORTH SUBSTANCE ABUSE AND COMORBIDITY • SELF-DESTRUCTIVE BEHAVIOR MAY RESULT FROM WITH ASPD AND PARANOID PD DESPAIR. RESENT DATA SUGGESTS THE VULNERABLE BUT NOT THE GRANDIOSE NARCISSIST IS LINKED TO SUICIDAL THINKING AND SELF-HARM

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NARCISSISTIC PERSONALITY DISORDER NARCISSISTIC PERSONALITY • NOT A UNITARY CONSTRUCT DISORDER • COMBINATION OF AGENTIC AND • SELF-PROMOTION DRAWS PRAISE ANTAGONISTIC ASPECTS (TO BE ADMIRED) • AGENTIC-ASSERTIVENESS, DOMINANCE • SELF-DEFENSE DEMEANS OTHERS AND CHARM TO FEND OFF CRITICISM • ANTAGONISTIC-AGGRESSIVENESS AND DEVALUATION OF OTHERS • BOTH ASPECTS INVOLVED IN MAINTAINING POSITIVE SELF-ESTEEM

NARCISSISTIC PERSONALITY NARCISSISTIC PERSONALITY DISORDER DISORDER • READILY EMERGE AS LEADERS IN GROUP • ASSESSMENT DISCUSSIONS AND ARE MORE LIKELY TO • FOCUS ON MORAL FUNCTIONING (DISHONESTY RISE TO TOP POSITIONS IN BUSINESS AND EXPLOITATION) AMY BRUNELL, OHIO STATE UNIVERSITY AT NEWARK, 2009. • FOCUS ON DESCRIPTION OF SIGNIFICANT OTHERS • PERFORMED WELL IN JOB INTERVIEWS • DISMISSIVE OR DEROGATORY OR BECAUSE THEY ARE GOOD AT SELF- ALTERNATELY IDEALIZING PROMOTION • SUPERFICIAL AND VAGUE • TEND TO DESCRIBE OTHERS AS SIMILAR TO OR DIFFERENT FROM THEMSELVES

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NARCISSISTIC PERSONALITY NARCISSISTIC PERSONALITY DISORDER DISORDER • IN A SERIES OF 11 EXPERIMENTS INVOLVING MORE • PARTICIPANTS RATED THEMSELVES ON A SCALE OF THAN 2,200 PEOPLE OF ALL AGES, THE RESEARCHERS 1 (NOT VERY TRUE OF ME) TO 7 (VERY TRUE OF ME). FOUND THEY COULD RELIABLY IDENTIFY • RESULTS SHOWED THAT PEOPLE'S ANSWER TO THIS NARCISSISTIC PEOPLE BY ASKING THEM THIS EXACT QUESTION LINED UP VERY CLOSELY WITH SEVERAL QUESTION (INCLUDING THE NOTE): OTHER VALIDATED MEASURES OF NARCISSISM, • TO WHAT EXTENT DO YOU AGREE WITH THIS INCLUDING THE WIDELY USED NARCISSISTIC STATEMENT: "I AM A NARCISSIST." (NOTE: THE WORD PERSONALITY INVENTORY. "NARCISSIST" MEANS EGOTISTICAL, SELF-FOCUSED, AND VAIN.)

NARCISSISTIC PERSONALITY NARCISSISTIC PERSONALITY DISORDER DISORDER • THE DIFFERENCE IS THAT THIS NEW • THERAPIST’S REACTION SURVEY -- WHICH THE RESEARCHERS CALL • IDEALIZED THE SINGLE ITEM NARCISSISM SCALE (SINS) • PRESSURED TO PROVIDE CURE -- HAS ONE QUESTION, WHILE THE NPI HAS • BELITTLED AND DEVALUED 40 QUESTIONS TO ANSWER. • TREATED LIKE AN INCOMPETENT SARA KONRATH, BRIAN P. MEIER, BRAD J. • IGNORED BUSHMAN. DEVELOPMENT AND VALIDATION OF THE SINGLE ITEM NARCISSISM SCALE (SINS). PLOS ONE, 2014; 9 (8): E103469 DOI: 10.1371/JOURNAL.PONE.0103469

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NARCISSISTIC PERSONALITY NARCISSISTIC PERSONALITY DISORDER DISORDER • TREATMENT • TREATMENT (CONTINUED) • PHARMACOLOGICAL-SYMPTOM DRIVEN • USE PATIENTS OWN WORDS TO INCREASE ENGAGEMENT • TREAT CO-OCCURRING DISORDERS • DON’T CONFRONT GRANDIOSITY DIRECTLY • ENGAGEMENT IS DIFFICULT DUE TO • NON-JUDGMENTAL AND INQUISITIVE GRANDIOSITY AND DEFENSIVENESS • MONITOR COUNTERTRANSFERENCE • DBT (IF BORDERLINE TRAITS ARE PRESENT) • DON’T GET DEFENSIVE OR REACT AGGRESSIVELY • TRANSFERENCE FOCUSED • PAY ATTENTION TO NEGATIVE FEELINGS PATIENT HAS ABOUT TREATMENT AND CLINICIAN

NARCISSISTIC PERSONALITY NARCISSISTIC PERSONALITY DISORDER DISORDER • SYMPTOMS OF • OTHER SYMPTOMS NARCISSISTIC PERSONALITY DISORDER • EXPECTATION OF PREFERENTIAL – GRANDIOSITY TREATMENT – SENSITIVE TO • ENTITLEMENT CRITICISM • EXAGGERATED SELF-IMPORTANCE – LACK OF EMPATHY • GRANDIOSITY IS A WORLD • ARROGANCE VIEW THAT PROTECTS • EXPLOITATION OF OTHERS THE EGO FROM EXPERIENCING THE • CONTROLLING HURT, LONELINESS AND • LIKELY TO ENGAGE IN POWER STRUGGLES ISOLATION OF EXISTENCE. • COMPETITIVE

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NARCISSISTIC PERSONALITY NARCISSISTIC PERSONALITY DISORDER DISORDER • PATHOLOGY OF SELF • DIFFICULT TO TREAT • EXCESSIVE SELF-CENTEREDNESS • • OVERDEPENDENCE ON ADMIRATION FROM UNABLE TO ADMIT PERSONAL WEAKNESSES OTHERS • INABILITY TO APPRECIATE THE EFFECT • FANTASIES OF SUCCESS THEIR BEHAVIOR HAS ON OTHERS • GRANDIOSITY • LACK OF EMPATHY • BOUTS OF INSECURITY AND AVOIDANCE OF REALITY • FAILURE TO INCORPORATE FEEDBACK • PATHOLOGY OF THE RELATIONSHIP WITH • HIGH DROP OUT RATE OTHERS • INTOLERANCE OF CRITICISM • NARCISSISTIC RAGE

MANAGEMENT CONSIDERATIONS MANAGEMENT CONSIDERATIONS • COUNTERTRANSFERENCE • GOAL: TO REDUCE THE INTENSITY AND • CLINICIANS TEND TO FEEL BORED, HUE OF THE ACTING OUT DISTRACTED, AND ANNOYED IN SESSIONS • PREREQUISITES- “LEVEL PLAYING FIELD” WITH THESE PATIENTS. THEY DO NOT FEEL • BUSINESS LIKE. NON-CONFRONTATIONAL ENGAGED WHEN WORKING WITH THEM AND OFTEN FEEL FRUSTRATED. THERAPISTS ALSO YET ASSERTIVE WHILE ASSUAGING THE SOMETIMES FEEL INTERCHANGEABLE, AS IF SENSITIVE EGO THEY COULD BE ANYONE TO THE PATIENT. • BEHAVIORAL THEY CAN FEEL INEFFECTUAL, INVISIBLE, • “HOOK” THE GRANDIOSITY AND DESKILLED

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TACTICS NARCISSISTS USE TO TACTICS NARCISSISTS USE TO CONFUSE AND DOMINATE YOU CONFUSE AND DOMINATE YOU • BANDWAGON: AN ATTEMPT TO PRESSURE • EMOTIONAL APPEALS : ATTEMPTING TO PLAY ON EMOTIONS SUCH AS FEAR, GUILT AND ANOTHER TO GO ALONG BECAUSE “EVERYBODY IS LOYALTY RATHER THAN USING LOGIC AND DOING IT.” REASONING. • NARCISSISTS KNOW THE POWER OF NUMBERS. THEY • NARCISSISTS USE EMOTIONAL APPEALS TO SLAVISHLY FOLLOW THEIR “LIKES” ON SOCIAL DISGUISE FALSE OR OUTRAGEOUS CLAIMS. SINCE MEDIA AND OTHER MEASURES OF ATTENTION. MANY NARCISSISTS TEND TO BE DRAMA KINGS OR HAVING LOTS OF FOLLOWERS REASSURES THEM OF QUEENS, USING OVER-THE-TOP EMOTIONALITY TO THEIR WORTH. THEY USE THE POWER OF GROUP- CONTROL OTHERS COMES NATURALLY FOR THEM. THINK AND PEER PRESSURE TO PLAY ON OTHERS’ • EXAMPLE: “HOW DARE YOU QUESTION ME! AFTER FEARS OF MISSING OUT, BEING OSTRACIZED OR ALL I’VE DONE FOR YOU.” BEING IN THE WRONG. • EXAMPLE: “ALL YOUR FRIENDS AGREE WITH ME.”

TACTICS NARCISSISTS USE TO TACTICS NARCISSISTS USE TO CONFUSE AND DOMINATE YOU CONFUSE AND DOMINATE YOU • BURDEN OF PROOF: ASSERTING THAT THE • BLACK-AND-WHITE / EITHER-OR: PRETENDING SPEAKER DOES NOT NEED TO PROVE HIS POINTS THERE ARE ONLY TWO CHOICES WHEN THERE ARE BUT, RATHER, THAT THE BURDEN IS ON THE SEVERAL. LISTENER TO DISPROVE THEM. • NARCISSISTS VIEW THE WORLD IN EITHER-OR TERMS. • NARCISSISTS LOVE TO TAKE CREDIT BUT HAVE NUANCE IS LOST ON THEM. THEY DERIVE A FEELING LITTLE INTEREST IN TAKING RESPONSIBILITY. THEY HATE TO BE WRONG, SO PUTTING THE OF POWER FROM THIS DIVIDE-AND-CONQUER BURDEN ON OTHERS IS A STONEWALLING APPROACH. STRATEGY THAT MAKES IT ESPECIALLY DIFFICULT • EXAMPLE: “YOU’RE EITHER WITH ME OR AGAINST TO DISPROVE THEM. ME.” • EXAMPLE: “I KNOW I AM RIGHT. WHAT I SAY STANDS UNTIL YOU CAN PROVE OTHERWISE.”

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TACTICS NARCISSISTS USE TO TACTICS NARCISSISTS USE TO CONFUSE AND DOMINATE YOU CONFUSE AND DOMINATE YOU • FALSE FLATTERY: BUTTERING OTHERS UP TO • INCREDULITY: ACTING AS THOUGH WHAT MAKE THEM MORE RECEPTIVE. SOMEONE SAID IS UNBELIEVABLE. • NARCISSISTS RARELY MEET A COMPLIMENT THEY • RATHER THAN ADMIT THEY ARE CONFUSED, DON’T LIKE. THEY THINK OTHERS ARE AS THEY PRETEND THAT WHAT THE OTHER SUSCEPTIBLE TO FLATTERY AS THEY ARE. THEY PLY PERSON IS SAYING IS BEYOND BELIEF. THIS IS LISTENERS WITH PSEUDO-COMPLIMENTS, HOPING AN ATTEMPT TO DISMISS VALID CONCERNS. TO GET THINGS IN RETURN. • EXAMPLE: “YOU SERIOUSLY THINK THERE ARE • EXAMPLE: “I COULDN’T POSSIBLY BE MANIPULATING OTHER HUSBANDS WHO ARE BETTER THAN ME? YOU REALLY THINK OTHER WIVES GET YOU, YOU’RE WAY TOO SMART FOR THAT.” ANYWHERE NEAR WHAT I HAVE GIVEN YOU? YOU ARE NOT LIVING IN THE REAL WORLD.”

TACTICS NARCISSISTS USE TO TACTICS NARCISSISTS USE TO CONFUSE AND DOMINATE YOU CONFUSE AND DOMINATE YOU

• LABELING: APPLYING A NEGATIVE PHRASE • FALSE COMPROMISE: OFFERING TO MEET HALF OR ATTRIBUTING NEGATIVE WAY ON MATTERS IN WHICH THERE IS CLEARLY A FAIR AND UNFAIR CHOICE. CHARACTERISTICS TO A PERSON OR POSITION. • IF A NARCISSIST HAS A CHOICE TO TREAT ANOTHER • NARCISSISTS LOVE LABELS. HAVING A SINGLE PERSON FAIRLY OR UNFAIRLY, A “COMPROMISE” WORD TO INVALIDATE OR HUMILIATE THAT STILL TREATS THE OTHER UNFAIRLY IS NO ANOTHER FEELS LIKE AN ULTIMATE POWER COMPROMISE – IT’S STILL WRONG. FOR NARCISSISTS. • EXAMPLE: “OKAY, YOU WIN, I’LL PAY YOU BACK $50 OF • EXAMPLE: “YOU’RE TOO NEEDY. YOU’RE A THE $100 YOU GAVE ME AND WE’LL CALL IT EVEN. LOSER.” HEY, IT’S BETTER THAN NOTHING.”

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TACTICS NARCISSISTS USE TO TACTICS NARCISSISTS USE TO CONFUSE AND DOMINATE YOU CONFUSE AND DOMINATE YOU

• EMPTY PROMISES: PROMISING TO GIVE • QUOTING OUT OF CONTEXT: REPEATING ONLY OTHERS WHAT THEY WANT WITHOUT ANY PART OF WHAT ANOTHER PERSON SAID OR USING PLAN OR INTENTION OF FULFILLING THE ANOTHER’S WORDS COMPLETELY OUT OF CONTEXT. PROMISE. • NARCISSISTS DO THIS TO DISCREDIT OTHERS AND • EXAMPLE: “YOU’LL GET YOUR TURN. I PUT THEM ON THE DEFENSIVE. PROMISE.” • EXAMPLE: “YOU ALWAYS SAID PEOPLE HAVE TO TAKE RESPONSIBILITY FOR THEMSELVES SO I DIDN’T THINK YOU NEEDED MY HELP WHEN YOU HAD TO GO TO THE ER.”

TACTICS NARCISSISTS USE TO TACTICS NARCISSISTS USE TO CONFUSE AND DOMINATE YOU CONFUSE AND DOMINATE YOU

• RIDICULE: MOCKING OR HUMILIATING ANOTHER • SLIPPERY SLOPE: AN APPEAL TO FEAR WHICH PERSON OR THEIR REQUESTS OR FEELINGS. TAKES A SMALL PROBLEM AND PREDICTS THAT IT WILL LEAD TO AN ESCALATING SERIES OF WORST- • NARCISSISTS DEVALUE OTHERS THROUGH CASE SCENARIOS. DISMISSIVE REMARKS, SARCASM, OR HOSTILE HUMOR • THE GOAL IS TO USE AN EXTREME HYPOTHETICAL INSTEAD OF TAKING THE OTHER PERSON SERIOUSLY. TO DISTRACT FROM A REASONABLE COMPLAINT OR • EXAMPLE: “THAT’S THE DUMBEST THING I’VE EVER ARGUMENT. HEARD. YOU’RE JUST EMBARRASSING YOURSELF.” • EXAMPLE: “IF I DO THIS FOR YOU, YOU WILL THINK YOU CAN GET WHATEVER YOU WANT FROM ME. I’LL BECOME YOUR SLAVE AND HAVE NO LIFE.”

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TACTICS NARCISSISTS USE TO TACTICS NARCISSISTS USE TO CONFUSE AND DOMINATE YOU CONFUSE AND DOMINATE YOU

• SLOGANS: A SIMPLISTIC PHRASE THAT IS A • DEHUMANIZING: CLASSIFYING OTHERS AS CATCH-ALL DESIGNED TO SHUT DOWN INFERIOR, DANGEROUS OR EVIL TO JUSTIFY DISSENT. OPPRESSING OR ELIMINATING THEM. • NARCISSISTS OFTEN HAVE PAT PHRASES THEY • THIS ENDS-JUSTIFIES-THE-MEANS TACTIC IS EMPLOY WHEN THEY FEEL THREATENED. SECOND NATURE FOR NARCISSISTS, WHO SEE • EXAMPLE: “I’M YOUR LAST BEST HOPE. I’M ALL MOST OTHER PEOPLE AS INFERIOR. YOU’VE GOT.” • EXAMPLE: “THEY’RE BRINGING DRUGS. THEY’RE BRINGING CRIME. THEY’RE RAPISTS.”

BORDERLINE PERSONALITY BORDERLINE PERSONALITY DISORDER DISORDER • 2% OF GENERAL POPULATION • 10% IN AN OUTPATIENT SETTING • 20% OR HIGHER IN A PSYCHIATRIC INPATIENT SETTING FOUR PRESENTATIONS • 80% HAVE HISTORY OF TRAUMA (ESPECIALLY EARLY LIFE TRAUMA) • HYSTEROID DEPRESSIVE • SELF DESTRUCTIVE BEHAVIOR CAN PRECIPITATE DOPAMINE REWARD LIKE AN ADDICTIVE • OBSERVED DEPRESSED SUBSTANCE • CRISIS MAY PRECIPITATE ENDORPHIN RELEASE • SCHIZOTYPAL • HIGH INCIDENCE OF SUBSTANCE-USE DISORDER (OPIATES, COCAINE AND ALCOHOL), EATING • IMPULSIVE DISORDER, DISSOCIATIVE DISORDER, AND SEXUAL AND IDENTITY DISORDERS.

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BORDERLINE PERSONALITY BORDERLINE PERSONALITY DISORDER DISORDER • CLINICAL PRESENTATION OF 2 SYNDROMES • THESE FINDINGS ALIGN WITH PREVIOUS RESULTS (DEPRESSION AND MANIA) THAT CAN BE THAT INDICATE SHARED GENETIC VARIANCE CHARACTERIZED AS A UNITARY PSYCHIATRIC ENTITY BETWEEN BD AND BPD, AS WELL AS SHARED (BIPOLAR DISORDER) AND A THIRD SYNDROME ENVIRONMENTAL RISK FACTORS SUCH AS (BORDERLINE PERSONALITY DISORDER) THAT IS OFTEN CHILDHOOD PARENTAL LOSS, VARIOUS TYPES OF COMORBID WITH BIPOLAR DISORDER EARLY TRAUMA, AND A DYSFUNCTIONAL FAMILY • THE FINDINGS CONVERGE IN SUGGESTING THAT ENVIRONMENT BIPOLAR DISORDER AND BORDERLINE PERSONALITY WWW.NIMH.NIH.GOV/HEALTH/STATISTICS/PREVALENCE/BOR DISORDER ARE OVERLAPPING BUT DIFFERENT DERLINE-PERSONALITY-DISORDER.SHTML PATHOLOGIES,” WWW.NIMH.NIH.GOV/HEALTH/STATISTICS/PREVALENCE/BI POLAR-DISORDER-AMONG-.SHTML. .

BORDERLINE PERSONALITY BORDERLINE PERSONALITY DISORDER DISORDER • KIERA VAN GELDER IN HER MEMOIR, THE BUDDHA • THESE INDIVIDUALS SUFFER FROM PROFOUND AND THE BORDERLINE, OF HER OWN EVOLUTION, FEELINGS OF ALONENESS OR ANNIHILATORY “AM I RECOVERED? I NO LONGER STRUGGLE WITH PANIC AND WORTHLESSNESS, HAVING FAILED TO THE URGE TO HURT OR KILL MYSELF, BUT OTHER ACHIEVE A SOLID SENSE OF SELF. BECAUSE THEIR SYMPTOMS PERSIST: MY IMPULSIVITY, MY EMOTIONAL BOUNDARIES ARE FLUID, THE SENSITIVITY, MY SHIFTING MOODS, AND MY INEVITABLE UPS AND DOWNS OF EVERYDAY LIFE OFTEN CRUSH THEM. IN PRACTICE, IT IS RARE FOR INHERENT FRAGILITY WHEN I'M UNDER STRESS OR ONE CLINICIAN AND ONE INDIVIDUAL TO HAVE BEGIN TO FEEL CONNECTED TO SOMEONE. I STILL THE OPPORTUNITY TO WORK TOGETHER OVER HAVE DIFFICULTY BEING ALONE, A DEEP NEED FOR THE LONG HAUL. THEREFORE CLINICIANS’ SECURITY, AND A GNAWING DISSATISFACTION WITH UNDERSTANDING IS NECESSARILY INFLUENCED BY WHAT IS.” SHORTER-TERM PERSPECTIVES

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BORDERLINE PERSONALITY DISORDER BORDERLINE PERSONALITY DISORDER • WHY DO BPD CLIENTS HAVE MORE EMOTIONAL FLARE-UPS? • ONE POSSIBLE ANSWER IS HOW THEY READ FACIAL EXPRESSIONS (THOMAS LYNCH, DUKE, 2006) • ON AVERAGE PEOPLE WITH BPD RECOGNIZED BOTH PLEASANT AND UNPLEASANT FACIAL EXPRESSIONS AT A MUCH EARLY STAGE • THEY ARE HYPERAWARE OF EVEN SUBTLE EMOTIVE FACES WHICH IS PROBLEMATIC WHEN ONE IS INTENSELY REACTIVE TO OTHER PEOPLE’S MOOD STATES

BORDERLINE PERSONALITY BORDERLINE PERSONALITY DISORDER DISORDER • WHY ARE BPD CLIENTS SO SOCIALLY SENSITIVE • PEOPLE WITH BPD LACK THE BRAIN ACITIVTY AND MOODY? THAT INTERPRETS SOCIAL GESTURES SUCH AS • SUBJECTS STUDIED PHOTOS OF PEOPLE CRYING, ACTING THOSE SIGNALING TRUST (BROOKS KING-CASAS, VIOLENTLY AND MAKING SEXUAL GESTURES (HAROLD BAYLOR, 2008) KOENIGSBERG, MOUNT SINAI SCHOOL OF MEDICINE, 2009) • FOUND A PROBLEM WITH THE INSULA WHICH • USING FMRI FOUND THAT THE UNPLEASANT IMAGES ELICITED MORE ACTIVITY IN SEVERAL REGIONS OF THE BRAIN IN BPD ORDINARILY MONITORS UNCOMFORTABLE PATIENTS INCLUDING THE WHICH GOVERNS INTERACTIONS WITH OTHERS SUCH AS THOSE EMOTIONAL REACTIVITY AND MEMORY AND THE SUPERIOR STEMMING FROM THE VIOLATION OF TRUST AND TEMPORAL GYRUS WHICH IS INVOLVED IN “REFLEXIVE” OTHER SOCIAL NORMS. BPD PATIENTS TEND TO LACK PROCESSING THIS ABILITY TO GUAGE LEADING TO A DIFFICULTY IN • REACT MORE STRONGLY AND MORE RAPIDLY TO DISAGREEABLE IMAGES WITH LESS TIME TO REFLECT TRUSTING OTHERS

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BORDERLINE PERSONALITY BORDERLINE PERSONALITY DISORDER DISORDER • THE SAME REVIEW ALSO SUGGESTS PATIENTS MAY • NEUROIMAGING RESEARCH PUBLISHED SINCE 2010 HAVE “ALTERED FUNCTION IN NEUROTRANSMITTER FINDS “STRUCTURAL AND FUNCTIONAL SYSTEMS INCLUDING THE SEROTONIN, GLUTAMATE, ABNORMALITIES IN A FRONTO-LIMBIC NETWORK AND GABA SYSTEMS.” COMMONLY IT IS BELIEVED INCLUDING REGIONS INVOLVED IN EMOTION SEROTONIN CONTRIBUTES TO FEELINGS OF WELL- PROCESSING (E.G., AMYGDALA, INSULA) AND BEING, GLUTAMATE IS INVOLVED MORE GENERALLY FRONTAL BRAIN REGIONS IMPLICATED IN IN BRAIN FUNCTION AND COGNITION, WHILE GABA REGULATORY CONTROL PROCESSES (E.G., ANTERIOR IS A CHEMICAL MESSENGER THAT CALMS OVER- CINGULATE CORTEX, MEDIAL FRONTAL CORTEX, EXCITED NEURONS. ORBITOFRONTAL CORTEX, AND DORSOLATERAL PREFRONTAL CORTEX).”

BORDERLINE PERSONALITY BORDERLINE PERSONALITY DISORDER DISORDER • EMOTIONAL DYSREGULATION OF BPD APPEARS TO • DBT IS AN EMPIRICALLY VALIDATED BE A BIOLOGICAL VULNERABILITY THAT INCLUDES TREATMENT APPROACH EMPHASIZING THE BOTH INCREASED EMOTIONAL REACTIVITY ROLE OF EMOTION REGULATION IN THE (LIMBIC SYSTEM OVER ACTIVITY) , AS WELL AS, AN TREATMENT OF SUICIDAL AND SELF- IMPAIRED CAPACITY TO EMPLOY EFFORTFUL DESTRUCTIVE BEHAVIORS IN BPD. CONTROL (DEFICITS IN PREFRONTAL REGULATORY REGIONS). THE IMPAIRMENT IN EMOTIONAL • THIS APPROACH STRESSES SKILLS AND MODULATION RESULTS IN A SLOW RETURN TO THE TECHNIQUES FOR EMOTIONAL REGULATION, BASELINE EMOTIONAL STATE. AND ENCOURAGES COGNITIVE CONTROL OVER MALADAPTIVE BEHAVIORAL PATTERNS.

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BORDERLINE PERSONALITY MANAGEMENT DISORDER CONSIDERATIONS • DIALECTICAL BEHAVIOR THERAPY (MARSHA • TIME CONSUMING LINEHAN) – FEWER RESOURCES • AN INNOVATIVE FORM OF CBT – FEWER ALTERNATIVE • HELPS DETECT AND COMBAT DISTORTED THOUGHTS • POWERFUL WISHES TO CREATE CLINICIAN • COUNTERACT PROBLEMATIC BEHAVIORS AND INTO A FRIEND, LOVER, PARENT OR ENEMY ASSOCIATED EMOTIONS • “THERAPEUTIC RUPTURE” • INCORPORATES MEDITATIVE PRACTICES- • IMPULSIVITY-LIMIT SETTING MINDFULNESS • SELF-SOOTHING TECHNIQUES TO MANAGE MOOD • AFFECTIVE STORM-CALMNESS AND SWINGS (DEEP BREATHING, TAKING WALKS, LISTENING UNFLAPPABILITY TO MUSIC, ETC.) • POLARIZATION OF THOUGHT AND ATTITUDE- • BUILDING HEALTHY RELATIONSHIPS INTEGRATION AND FINDING MIDDLE GROUND

MANAGEMENT CONSIDERATIONS MANAGEMENT CONSIDERATIONS • IF A PATIENT HAS EXPERIENCED NEGLECT AND ABUSE • CLINICAL EXPERIENCE SUGGESTS THAT EFFECTIVE IN CHILDHOOD, HE OR SHE MAY WISH FOR THE THERAPY FOR PATIENTS WITH BORDERLINE THERAPIST TO PROVIDE THE LOVE THE PATIENT PERSONALITY DISORDER ALSO INVOLVES PROMOTING MISSED FROM PARENTS. THERAPISTS MAY HAVE RESCUE REFLECTION RATHER THAN IMPULSIVE ACTION. FANTASIES THAT LEAD THEM TO COLLUDE WITH THE THERAPISTS SHOULD ENCOURAGE THE PATIENT TO PATIENT’S WISH FOR THE THERAPIST TO OFFER THAT ENGAGE IN A PROCESS OF SELF-OBSERVATION TO LOVE. THIS COLLUSION IN SOME CASES LEADS TO GENERATE A GREATER UNDERSTANDING OF HOW PHYSICAL CONTACT AND EVEN INAPPROPRIATE BEHAVIORS ORIGINATE FROM INTERNAL MOTIVATIONS PHYSICAL CONTACT BETWEEN THERAPIST AND AND AFFECT STATES RATHER THAN COMING FROM PATIENT. CLINICIANS SHOULD BE ALERT TO THESE “OUT OF THE BLUE.” SIMILARLY, PSYCHOTHERAPY DYNAMICS AND SEEK CONSULTATION OR PERSONAL INVOLVES HELPING PATIENTS THINK THROUGH THE PSYCHOTHERAPY OR BOTH WHENEVER THERE IS A RISK CONSEQUENCES OF THEIR ACTIONS SO THAT THEIR OF A BOUNDARY JUDGMENT IMPROVES.

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MANAGEMENT CONSIDERATIONS MANAGEMENT CONSIDERATIONS • AS PREVIOUSLY NOTED, SPLITTING IS A MAJOR DEFENSE MECHANISM OF PATIENTS WITH BORDERLINE • NO PHARMACOLOGIC TREATMENT HAS RECEIVED PERSONALITY DISORDER. THE SELF AND OTHERS ARE OFTEN REGARDED AS “ALL GOOD” OR “ALL BAD.” THIS REGULATORY APPROVAL FOR BORDERLINE PHENOMENON IS CLOSELY RELATED TO WHAT BECK AND PERSONALITY DISORDER, IN THE UNITED STATES OR FREEMAN CALL “DICHOTOMOUS THINKING” AND WHAT LINEHAN (17) REFERS TO AS “ALL OR NONE THINKING.” ELSEWHERE. ACCORDING TO A 2010 COCHRANE PSYCHOTHERAPY MUST BE GEARED TO HELPING THE SYSTEMATIC REVIEW, 27 RANDOMIZED CLINICAL PATIENT BEGIN TO EXPERIENCE THE SHADES OF GRAY TRIALS OF PHARMACOLOGIC AGENTS HAD BEEN BETWEEN THE EXTREMES AND INTEGRATE THE POSITIVE AND NEGATIVE ASPECTS OF THE SELF AND OTHERS. A CONDUCTED IN BORDERLINE PERSONALITY MAJOR THRUST OF PSYCHOTHERAPY IS TO HELP PATIENTS DISORDER UP TO 2008. RECOGNIZE THAT THEIR PERCEPTION OF OTHERS, INCLUDING THE THERAPIST, IS A REPRESENTATION RATHER THAN HOW THEY REALLY ARE.

MANAGEMENT CONSIDERATIONS MANAGEMENT CONSIDERATIONS

• IN THE PAST 5 YEARS, MOST SUCH TRIALS HAVE • STUDIES HAVE SUGGESTED EFFICACY FOR FOCUSED ON MOOD STABILIZERS AND SECOND- SEVERAL ANTICONVULSANTS, INCLUDING GENERATION ANTIPSYCHOTICS. VALPROATE, LAMOTRIGINE, AND TOPIRAMATE . • AMONG THE SECOND-GENERATION THERE HAVE ALSO BEEN A NUMBER OF ANTIPSYCHOTICS, THERE HAS BEEN ONE STUDY NEGATIVE STUDIES FOR ANTIDEPRESSANTS, WITH POSITIVE FINDINGS FOR ARIPIPRAZOLE, ONE INCLUDING FLUOXETINE, FLUVOXAMINE AND STUDY WITH NEGATIVE FINDINGS FOR ZIPRASIDONE, PHENELZINE. AND THREE STUDIES WITH MIXED RESULTS FOR OLANZAPINE.

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MANAGEMENT CONSIDERATIONS MANAGEMENT CONSIDERATIONS • GOAL • A WELL-DESIGNED CLINICAL TRIAL THAT • PREREQUISITES PROVIDES EVIDENCE THAT LOW-DOSAGE – STRUCTURE QUETIAPINE (150 MG) IS EFFECTIVE IN THE – THERAPY SHORT-TERM TREATMENT OF SOME OF THE THREATENING CORE SYMPTOMS OF BORDERLINE – LIFE THREATENING PERSONALITY DISORDER. • MEDICATION IF NEEDED TOHEN, PHARMACOLOGIC TREATMENTS FOR BORDERLINE • PERSONALITY DISORDER." AMERICAN JOURNAL OF BEHAVIORAL PSYCHIATRY, 171(11), PP. 1139–1141. – LIMIT SETTING – TREATMENT PLAN

• CLOSURE

MANAGEMENT CONSIDERATIONS MANAGEMENT CONSIDERATIONS • COUNTERTRANSFERENCE • COUNTERTRANSFERENCE • CLINICIANS TEND TO FEEL OVERWHELMED BY • THERAPISTS CAN ALSO FEEL INCOMPETENT STRONG EMOTIONS AND INTENSE NEEDS. IN OR INADEQUATE AND OFTEN EXPERIENCE A PARTICULAR, MORE THAN WITH MOST SENSE OF CONFUSION AND FRUSTRATION IN PATIENTS, THERAPISTS FEEL LIKE THEY HAVE SESSIONS. THEY ARE AFRAID THEY ARE BEEN PULLED INTO THINGS BUT DO NOT FAILING TO HELP THESE PATIENTS AND CAN REALIZE IT UNTIL AFTER THE SESSION IS OVER. SOMETIMES FEEL GUILTY. THERAPISTS CAN BORDERLINE PATIENTS CAN “FRIGHTEN” DO THINGS FOR THEM, OR GO THE EXTRA CLINICIANS, WHO EXPERIENCE HIGH LEVELS MILE FOR THEM, IN WAYS THAT THEY DO NOT OF ANXIETY, TENSION, AND CONCERN DO FOR OTHER PATIENTS

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TREATMENT PLANNING BASED IDENTITY CLUSTER ON SYMPTOM CLUSTERS • IDENTITY CLUSTER • TREATMENT (PROJECTION) – ABANDONMENT FEARS – BEHAVIORAL – UNSTABLE SELF-IMAGE – RELATIONSHIP PROBLEMS • STRUCTURE • AFFECTIVE CLUSTER • IMMEDIATE REWARD (SPLITTING) – REACTIVITY OF MOOD – MEDICATION – INAPPROPRIATE, INTENSE • ANGER NEUROLEPTICS • IMPULSIVE CLUSTER (DENIAL, • SSRI’S DISTORTION) – SUICIDAL BEHAVIOR – POTENTIALLY SELF-HARMING BEHAVIOR (SUBSTANCE ABUSE, SEX, BINGE EATING, SPENDING)

SELF AND IDENTITY SELF AND IDENTITY

• INSECURE ATTACHMENT-LACK OF • HELPLESSNESS CONFIDENCE IN “OTHERS” AVAILABILITY • ABANDONMENT • DISORGANIZED TYPE • BETRAYAL • DISORGANIZED ATTACHMENT THEMES • FAILURE • COHERSIVE CONTROL • DEJECTION • BLAME • REJECTION • INTRUSION • HOSTILITY

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ABANDONMENT FEAR ABANDONMENT FEAR • MANY PEOPLE GROW UP WITH FEARS AROUND ABANDONMENT. SOME ARE PLAGUED BY THESE FEARS PRETTY CONSISTENTLY THROUGHOUT THEIR LIVES. TRAUMA ATTACHMENT THEY WORRY THEY’LL BE REJECTED BY PEERS, PARTNERS, SCHOOLS, COMPANIES, OR ENTIRE SOCIAL PROBLEMS CIRCLES. FOR MANY OTHERS, THESE FEARS AREN’T FULLY REALIZED UNTIL THEY ENTER INTO A ABANDONMENT INCREASED ROMANTIC RELATIONSHIP. THINGS WILL BE GOING ALONG SMOOTHLY, AND ALL OF A SUDDEN, THEY FEEL FEAR ANXIETY INUNDATED WITH INSECURITY AND DREAD THAT THEIR PARTNER WILL DISTANCE THEMSELVES, IGNORE, INCREASED IMPULSIVITY OR LEAVE THEM.

ABANDONMENT FEAR ABANDONMENT FEAR • IN EXTREME CASES, PEOPLE MAY STRUGGLE • IN ORDER TO FEEL SECURE, CHILDREN HAVE TO FEEL WITH “,” AN OVERWHELMING SAFE, SEEN, AND SOOTHED WHEN THEY’RE UPSET. HOWEVER, IT’S BEEN SAID THAT EVEN THE BEST OF FEAR OF BEING ALONE OR ISOLATED, IN PARENTS ARE ONLY FULLY ATTUNED TO THEIR WHICH THEY PERCEIVE THEMSELVES AS CHILDREN AROUND 30 PERCENT OF THE TIME. BEING IGNORED, OR UNCARED FOR EVEN EXPLORING THEIR EARLY ATTACHMENT PATTERNS CAN WHEN THEY’RE WITH ANOTHER PERSON. OFFER INDIVIDUALS’ INSIGHT INTO THEIR FEARS THEY MAY ALSO EXPERIENCE A FEAR OF AROUND ABANDONMENT AND REJECTION. UNDERSTANDING HOW THEIR PARENTS RELATED TO ABANDONMENT PHOBIA, WHICH IS THEM AND WHETHER THEY EXPERIENCED A SECURE CHARACTERIZED BY EXTREME DEPENDENCY ATTACHMENT VERSUS AN INSECURE ONE, CAN GIVE ON OTHERS PEOPLE CLUES INTO HOW THEY VIEW RELATIONSHIPS IN THE PRESENT.

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ABANDONMENT FEAR ABANDONMENT FEAR • A PARENT WHO MAY AT ONE MOMENT BE PRESENT • CHILDREN WHO EXPERIENCE AN AMBIVALENT ATTACHMENT AND MEETING THE CHILD’S NEEDS, THEN AT PATTERN MAY GROW TO HAVE A PREOCCUPIED ATTACHMENT ANOTHER MOMENT BE ENTIRELY UNAVAILABLE PATTERN AS ADULTS, IN WHICH THEY CONTINUE TO FEEL AND REJECTING OR, ON THE OPPOSITE END, INSECURE IN THEIR RELATIONSHIPS. THEY “OFTEN FEEL DESPERATE AND ASSUME THE ROLE OF THE “PURSUER” IN A INTRUSIVE AND “EMOTIONALLY HUNGRY” CAN RELATIONSHIP,” WROTE JOYCE CATLETT, CO-AUTHOR LEAD THE CHILD TO FORM AN AMBIVALENT/ OF COMPASSIONATE CHILD REARING. “THEY RELY HEAVILY ANXIOUS ATTACHMENT PATTERN. CHILDREN WHO ON THEIR PARTNER TO VALIDATE THEIR SELF-WORTH. EXPERIENCE THIS TYPE OF ATTACHMENT TEND BECAUSE THEY GREW UP INSECURE BASED ON THE TO FEEL INSECURE. THEY MAY CLING TO THE INCONSISTENT AVAILABILITY OF THEIR CAREGIVERS, THEY ARE “REJECTION-SENSITIVE.” THEY ANTICIPATE REJECTION PARENT IN AN EFFORT TO GET THEIR NEEDS MET. OR ABANDONMENT AND LOOK FOR SIGNS THAT THEIR HOWEVER, THEY MAY ALSO STRUGGLE TO FEEL PARTNER IS LOSING INTEREST.” SOOTHED BY THE PARENT.

ABANDONMENT FEAR ABANDONMENT FEAR • ADULTS WHO EXPERIENCE A FEAR OF ABANDONMENT MAY • ABANDONMENT BEHAVE IN WAYS THAT ARE PUNISHING, STRUGGLE WITH A PREOCCUPIED ATTACHMENT STYLE. THEY RESENTFUL, AND ANGRY WHEN THEIR PARTNER DOESN’T FREQUENTLY ANTICIPATE REJECTION AND SEARCH FOR GIVE THEM THE ATTENTION AND REASSURANCE THEY SIGNS OF DISINTEREST FROM THEIR PARTNER. THEY MAY BELIEVE THEY NEED TO FEEL SECURE. “THEY OFTEN FEEL TRIGGERED BY EVEN SUBTLE OR IMAGINED SIGNS OF BELIEVE THAT UNLESS THEY DRAMATICALLY EXPRESS REJECTION FROM THEIR PARTNER BASED ON THE REAL THEIR ANXIETY AND ANGER, IT IS UNLIKELY THAT THE REJECTIONS THEY EXPERIENCED IN THEIR CHILDHOOD. AS OTHER PERSON WILL RESPOND TO THEM,” WROTE CATLETT. HOWEVER, SOME PEOPLE WITH PREOCCUPIED A RESULT, THEY MAY ACT POSSESSIVE, CONTROLLING, ATTACHMENTS ARE MORE “RELUCTANT TO EXPRESS JEALOUS, OR CLINGY TOWARD THEIR PARTNER. THEY MAY THEIR ANGRY FEELINGS TOWARD A PARTNER FOR FEAR OF OFTEN SEEK REASSURANCE OR DISPLAY DISTRUST. POTENTIAL LOSS OR REJECTION.” THIS CAN LEAD THEM “HOWEVER, THEIR EXCESSIVE DEPENDENCY, DEMANDS AND TO SUPPRESS THEIR FEELINGS, WHICH CAN CAUSE THEM POSSESSIVENESS TEND TO BACKFIRE AND PRECIPITATE THE TO BUILD UP, AND, EVENTUALLY, SPILL OUT IN OUTBURSTS VERY ABANDONMENT THAT THEY FEAR, OF STRONG EMOTION

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ABANDONMENT FEAR ABANDONMENT FEAR • EXPERIENCING A SECURE ATTACHMENT CAN OFFER • ONE OF THE MOST EFFECTIVE WAYS FOR A PERSON TO DEVELOP SOMEONE A NEW MODEL FOR RELATIONSHIPS AND HOW SECURE ATTACHMENT IS BY MAKING SENSE OF HIS OR HER STORY. DR. DANIEL SIEGEL TALKS ABOUT THE IMPORTANCE PEOPLE BEHAVE IN THEM. IF A PERSON IS ABLE TO FORM A OF CREATING A COHERENT NARRATIVE IN HELPING INDIVIDUALS RELATIONSHIP WITH SOMEONE WHO HAS A LONG HISTORY FEEL MORE SECURE AND STRENGTHENED WITHIN THEMSELVES. OF BEING SECURELY ATTACHED, THAT PERSON CAN LEARN WHEN PEOPLE MAKE SENSE OF AND CONVEY THEIR STORY, THEY GET TO KNOW THEIR PATTERNS AND TRIGGERS, AND THEY THAT HE OR SHE DOESN’T HAVE TO DESPERATELY CLING AREN’T AS INSTINCTIVELY REACTIVE IN A RELATIONSHIP – BE IT TO A PERSON TO GET HIS OR HER NEEDS MET. ANOTHER WITH A ROMANTIC PARTNER OR WITH THEIR CHILDREN. WHEN WAY FOR INDIVIDUALS TO DEVELOP MORE SECURITY PEOPLE MAKE SENSE OF THEIR PAST, THEY MAY BE LESS LIKELY WITHIN THEMSELVES IS THROUGH THERAPY. TO FEEL SUCH INTENSE, KNEE-JERK FEAR OF ABANDONMENT. HOWEVER, EVEN WHEN THEY DO FEEL FEAR, THEY ARE FAR EXPERIENCING A SECURE RELATIONSHIP WITH A BETTER ABLE TO CALM THEMSELVES DOWN. THEY CAN IDENTIFY THERAPIST CAN HELP A PERSON FORM EARNED SECURE WHERE THEIR FEAR COMES FROM AND WHERE IT BELONGS, AND ATTACHMENT. THEY CAN TAKE ACTIONS THAT ARE MORE RATIONAL AND APPROPRIATE TO THE REALITY OF THEIR PRESENT LIVES.

ABANDONMENT FEAR ABANDONMENT FEAR • ENHANCING SELF-COMPASSION IS ACTUALLY FAVORABLE TO • 2. MINDFULNESS: BEING MINDFUL IS HELPFUL, BECAUSE IT BUILDING SELF-ESTEEM, BECAUSE SELF-COMPASSION HELPS PEOPLE NOT TO OVER-IDENTIFY WITH THEIR DOESN’T FOCUS AS MUCH ON JUDGMENT AND EVALUATION. THOUGHTS AND FEELINGS IN WAYS THAT ALLOW THEM TO RATHER, IT INVOLVES THREE MAIN ELEMENTS: GET CARRIED AWAY. WHEN PEOPLE FEEL AFRAID OF • 1.SELF-KINDNESS: THIS REFERS TO THE IDEA THAT PEOPLE SOMETHING LIKE BEING ABANDONED, THEY TEND TO HAVE SHOULD BE KIND, AS OPPOSED TO JUDGMENTAL, TOWARD A LOT OF MEAN THOUGHTS TOWARD THEMSELVES THEMSELVES. THIS SOUNDS SIMPLE IN THEORY BUT IS PERPETUATING THIS FEAR. IMAGINE IF YOU COULD MUCH MORE DIFFICULT IN PRACTICE. THE MORE PEOPLE ACKNOWLEDGE THESE THOUGHTS AND FEELINGS WITHOUT CAN HAVE A WARM, ACCEPTING ATTITUDE TOWARD LETTING THEM OVERTAKE YOU. COULD YOU TAKE A THEMSELVES AND THEIR STRUGGLES, THE STRONGER GENTLER ATTITUDE TOWARD YOURSELF AND LET THESE THEY’LL FEEL IN THE FACE OF DIFFICULT CIRCUMSTANCES. THOUGHTS PASS LIKE CLOUDS IN THE SKY INSTEAD OF WE CAN ALL BE A BETTER FRIEND TO OURSELVES, EVEN IF FLOATING OFF WITH THEM – WITHOUT LOSING YOUR SENSE WE FEEL HURT OR ABANDONED BY SOMEONE ELSE. OF YOURSELF AND, OFTEN, REALITY?

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ABANDONMENT FEAR ABANDONMENT FEAR • 3.COMMON HUMANITY: THE MORE EACH OF US • THERE ARE EFFECTIVE WAYS FOR PEOPLE TO CAN ACCEPT THAT WE ARE HUMAN AND, LIKE ALL DEVELOP MORE SECURITY WITHIN THEMSELVES HUMANS, WE WILL STRUGGLE IN OUR LIVES, THE AND OVERCOME THEIR FEAR OF ABANDONMENT. MORE SELF-COMPASSION AND STRENGTH WE CAN THEY CAN START BY UNDERSTANDING WHERE CULTIVATE. IF INDIVIDUALS CAN CONSISTENTLY THIS FEAR COMES FROM. HOW AND WHY DOES IT REMEMBER THAT THEY ARE NOT ALONE AND DEVELOP? HOW DOES IT AFFECT ME IN MY THAT THEY ARE WORTHY, THEY CAN HELP CURRENT LIFE? WHAT ARE STRATEGIES FOR THEMSELVES AVOID BELIEVING THOSE CRUEL DEALING WITH THE ANXIETY THAT ARISES? HOW AND INCORRECT MESSAGES, TELLING THEM THAT CAN I DEVELOP MORE RESILIENCE AND THEY WILL BE ABANDONED OR THAT THEY’RE EXPERIENCE LESS FEAR AROUND RELATIONSHIPS? UNWANTED.

BEHAVIORAL FOUNDATION IDENTITY CLUSTER PROGRAM • SECURE ATTACHMENT WITH THERAPIST TASK MON TU WED THU FRI SAT SUN – CAN BE ACCOMPLISHED VERBALLY SH – IN A SAFE ENVIRONMENT – LIBERATES CLIENT FROM PAST TX CONSTRAINTS OF RIGID PERSONALITY – FACILITATES SELF-OBSERVATION (ACTIVE FUN SCANNING OF INNER-WORLD) – OBSERVE WITHOUT CRITICISM OR NUT EVALUATION – ENHANCES CAPACITY FOR INTROSPECTION PEX – REDUCES PREDICTION ERROR

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AFFECTIVE CLUSTER LABELING OUR FEELINGS • TREATMENT • THE MORE MINDFUL YOU ARE, THE MORE – BEHAVIORAL ACTIVATION YOU HAVE IN THE RIGHT VENTROLATERAL PREFRONTAL CORTEX AND • STRUCTURE • SETTING LIMITS THE LESS ACTIVATION YOU HAVE IN THE • FAIR AMYGDALA. WE ALSO SAW ACTIVATION IN • CONSISTENT WIDESPREAD CENTERS OF THE PREFRONTAL • AVAILABLE CORTEX FOR PEOPLE WHO ARE HIGH IN – MEDICATIONS MINDFULNESS. THIS SUGGESTS PEOPLE WHO • MOOD STABILIZERS ARE MORE MINDFUL BRING ALL SORTS OF • ANTIDEPRESSANTS PREFRONTAL RESOURCES TO TURN DOWN THE AMYGDALA.

LABELING OUR FEELINGS LABELING OUR FEELINGS • VERBALIZING OUR FEELINGS AND LABELING • LABELING THE RESPONSE CAUSED THE EMOTIONS MAKES THEM LESS INTENSE. AMYGDALA TO BE LESS ACTIVE AND THE RIGHT VENTROLATERAL PREFRONTAL • PHOTOGRAPH OF AN ANGRY OR FEARFUL FACE CORTEX TO ACTIVATE. CAUSES INCREASED ACTIVITY IN THE • USING MINDFULNESS AND LABELING THE AMYGDALA FEELINGS ONE EXPERIENCES ALLOWS THE – CREATES A CASCADE OF EVENTS RESULTING IN PREFRONTAL CORTEX TO OVERRIDE THE “FIGHT OR FLIGHT” RESPONSE AMYGDALA. • LABELING THE ANGRY FACE CHANGES THE – MATTHEW LIEBERMAN, UCLA, PSYCHOLOGICAL SCIENCE, MAY BRAIN RESPONSE 2007

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IMPULSIVE CLUSTER IMPULSIVE CLUSTER

• SELF-DESTRUCTIVE BEHAVIOR • ASSESSMENT – A/D USE – ELABORATE – SUICIDAL AND PARASUICIDAL BEHAVIOR • TREATMENT • HURT SELF – CONTRACTS • DISSOCIATION • SETTING • REDUCE ANXIETY • PATIENT’S RESPONSIBILITY – EATING DISORDERS • ALTERNATIVES – MEDICATIONS

NON-SUICIDAL SELF INJURY NON-SUICIDAL SELF INJURY • WHAT IS THE FUNCTION OF SELF-INJURY? • BOTH POSITIVE AND NEGATIVE REINFORCEMENT • DID PATIENT WANT TO DIE? • NEGATIVE REINFORCEMENT IS REWARDING BY MAKING AND UNPLEASANT SITUATION STOP • USUALLY “NO” • POSITIVE REINFORCEMENT IS REWARDING BY GAINING • A WAY TO TOLERATE INESCAPABLE AND SOMETHING AFTER THE BEHAVIOR UNBEARABLE EMOTIONS, MOST OFTEN • WHEN NEGATIVE REINFORCEMENT GENERALLY INTENSE ANXIETY RELIEVES UNCOMFORTABLE EMOTIONS LIKE ANGER, • STUCK IN A BAD SITUATION AND CANNOT FIND ANXIETY, GUILT AND NUMBNESS ANOTHER WAY TO COPE • WHEN POSITIVE REINFORCEMENT INCLUDES “FEELING • SELF-INJURY IS REINFORCED TO THE EXTENT SOMETHING EVEN IF IT IS PAIN”, PUNISHING ONESELF THE BEHAVIOR IS EFFECTIVE AND FEELING RELAXED

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NON-SUICIDAL SELF INJURY NON-SUICIDAL SELF INJURY • MALES MORE LIKELY TO WANT TO “MAKE OTHERS • EARLY CHANGES THE ANGRY” DENSITY OF OPIATE RECEPTORS AND LEVEL OF B- ENDORPHIN BASELINE (CONTINUED) • FEMALES MORE LIKELY TO WANT TO “PUNISH MYSELF” • MAY FIND INJURING LESS PAINFUL AND SUBSEQUENT OPIOID RELEASE MORE PLEASURABLE • ENDOGENOUS OPIOIDS • PATIENTS WITH ONLY ONE EPISODE OF SELF- • HYPOTHESIZED THAT INJURY INDUCES THE RELEASE INJURIOUS BEHAVIOR SAY “IT HURT” AND DIDN’T OF ENDOGENOUS OPIOIDS WHICH CREATES REWARD REPEAT BEHAVIOR • B-ENDORPHINS COMFORT NEGATIVE EMOTIONS (STANLEY B ET AL, J • NON-SUICIDAL SELF INJURY (NSSI) MAY BE THE BEST AFFEC DISORD 2010:124 (1-20:134-140)) PREDICTOR OF SUICIDE ATTEMPT (WILKINSON P ET • EARLY CHILDHOOD TRAUMA CHANGES THE AL, AM J PSYCHIATRY 2011; FEBRUARY 1) DENSITY OF OPIATE RECEPTORS AND LEVEL OF • 70% OF PEOPLE WHO ENGAGE IN NSSI EVENTUALLY B-ENDORPHIN BASELINE ATTEMPT SUICIDE

RISK ASSESSMENT SAFETY PLANNING INTERVENTION • SAFETY PLAN 1. RECOGNIZING WARNING SIGNS. • CONTRACTING FOR SAFETY HAS NO EVIDENCE BASE AND ASKING THE PATIENT TO SIGN A DOCUMENT STATING THEY 2. EMPLOYING INTERNAL COPING STRATEGIES WITHOUT WILL NOT HARM THEMSELVES CAN BE PROBLEMATIC NEEDING TO CONTACT ANOTHER PERSON. • PROMISE WITHOUT “HOW TO NOT HARM SELF” 3. SOCIALIZING WITH FAMILY MEMBERS OR OTHERS WHO MAY • MAY FEEL THEY CANNOT TALK ABOUT BEING SUICIDAL OFFER SUPPORT AS WELL AS DISTRACTION FROM THE CRISIS • MAY GIVE CLINICAL TEAM A FALSE SENSE OF SECURITY (EXTERNAL STRATEGIES) • DEVELOP A PLAN FOR “WHAT TO DO” WHEN PATIENT 4. CONTACTING FAMILY MEMBERS OR FRIENDS WHO MAY HELP FEELS SUICIDAL TO RESOLVE A CRISIS (SEEKING SUPPORT). • SAFETY PLANNING INTERVENTION (SPI) IS A BRIEF INTERVENTION WITH ONGOING CLINICAL TRIAL BUT IS 5. CONTACTING MENTAL HEALTH PROFESSIONALS OR AGENCIES. A SUICIDE PREVENTION RESOURCE CENTER/AMERICAN 6. REDUCING THE POTENTIAL USE OF LETHAL MEANS FOUNDATION FOR SUICIDE PREVENTION BEST PRACTICE

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STEP ONE:RECOGNIZING WARNING SIGNS STEP ONE:RECOGNIZING WARNING SIGNS SAFETY PLAN IS ONLY USEFUL IF THE PATIENT CAN RECOGNIZE AUTOMATIC THOUGHTS THE WARNING SIGNS. “I AM A NOBODY” • THE CLINICIAN SHOULD OBTAIN AN ACCURATE ACCOUNT OF THE EVENTS THAT TRANSPIRED BEFORE, DURING, AND AFTER IMAGES THE MOST RECENT SUICIDAL CRISIS. FLASHBACKS ASK “HOW WILL YOU KNOW WHEN THE SAFETY PLAN SHOULD MOOD BE USED?” FEELING DEPRESSED ASK “WHAT DO YOU EXPERIENCE WHEN YOU START TO THINK BEHAVIOR ABOUT SUICIDE OR FEEL EXTREMELY DISTRESSED?” CRYING • WRITE DOWN THE WARNING SIGNS (THOUGHTS, IMAGES, ISOLATING MYSELF THINKING PROCESSES, MOOD, AND/OR BEHAVIORS) USING THE USING DRUGS PATIENTS’ OWN WORDS

STEP TWO:EMPLOYING INTERNAL TEP ONE:RECOGNIZING WARNING COPING STRATEGIES SIGNS • AUTOMATIC THOUGHTS LIST ACTIVITIES THAT PATIENTS CAN DO • THEY ARE SHORT, SNAPPY AND SPONTANEOUS WITHOUT CONTACTING ANOTHER PERSON. • “I AM GOING TO DIE” • ACTIVITIES FUNCTION AS A WAY TO HELP PATIENTS • “I LOOK LIKE AN IDIOT” TAKE THEIR MINDS OFF THEIR PROBLEMS AND PROMOTE MEANING IN THE PATIENT’S LIFE. • THEY ARE OVERGENERALIZATIONS MAKING THE STATEMENT FALSE • COPING STRATEGIES PREVENT SUICIDE IDEATION FROM ESCALATING • ALWAYS • NEVER EXAMPLES: GO FOR A WALK, LISTEN TO INSPIRATIONAL MUSIC, TAKE A HOT SHOWER, WALK • NOBODY THE DOG • EVERYBODY

• EVERYTHING

• NO ONE

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STEP TWO:EMPLOYING INTERNAL STEP THREE:EXTERNAL COPING STRATEGIES STRATEGIES ASK “HOW LIKELY DO YOU THINK YOU WOULD BE ABLE COACH PATIENTS TO USE STEP 3 IF STEP 2 DOES NOT TO DO THIS STEP DURING A TIME OF CRISIS?” RESOLVE THE CRISIS OR LOWER RISK. FAMILY, FRIENDS (BUDDY FROM THE SERVICE), OR ASK “WHAT MIGHT STAND IN THE WAY OF YOU ACQUAINTANCES WHO MAY OFFER SUPPORT AND DISTRACTION FROM THE CRISIS THINKING OF THESE ACTIVITIES OR DOING THEM IF YOU THINK OF THEM?” ASK “WHO HELPS YOU TAKE YOUR MIND OFF YOUR PROBLEMS AT LEAST FOR A LITTLE WHILE?” USE A COLLABORATIVE, PROBLEM SOLVING APPROACH ASK “WHO DO YOU ENJOY SOCIALIZING WITH?” TO ADDRESS POTENTIAL ROADBLOCKS ASK PATIENTS TO LIST SEVERAL PEOPLE, IN CASE THEY CANNOT REACH THE FIRST PERSON ON THE LIST

STEP FIVE:CONTACTING STEP FOUR:SEEKING SUPPORT PROFESSIONALS AND AGENCIES COACH PATIENTS TO USE STEP 4 IF STEP 3 DOES COACH PATIENTS TO USE STEP 5 IF STEP 4 DOES NOT RESOLVE NOT RESOLVE THE CRISIS OR LOWER RISK. THE CRISIS OR LOWER RISK. SEEKING SUPPORT FROM FRIENDS AND/OR ASK “WHICH CLINICIANS SHOULD BE ON YOUR SAFETY FAMILY PLAN?” IDENTIFY POTENTIAL OBSTACLES AND DEVELOP WAYS TO ASK “HOW LIKELY WOULD YOU BE OVERCOME THEM. WILLING TO CONTACT THESE INDIVIDUALS?” LIST NAMES, NUMBERS AND/OR LOCATIONS OF: CLINICIANS IDENTIFY POTENTIAL OBSTACLES AND LOCAL URGENT CARE SERVICES PROBLEM SOLVE WAYS TO OVERCOME THEM. SUICIDE PREVENTION HOTLINE

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BEHAVIORAL SAFETY PLAN ON ANTISOCIAL PERSONALITY DISORDER 3X5 INDEX CARD AND CONDUCT DISORDER • DIAGNOSTIC CRITERIA-CONDUCT MY PERSONAL SAFETY PLAN DISORDER – AGGRESSION TO PEOPLE OR ANIMALS • Remember that craving go away – DESTRUCTION OF PROPERTY • I can write in my journal – DECEITFULNESS OR THEFT – SERIOUS VIOLATIONS OF RULES • I can call my sponsor (299-289-5555) • SUBTYPES • I can call my lover (299-426-1776) – CHILDHOOD-ONSET • I can read from my favorite recovery book – ADOLESCENT-ONSET • I can read affirmations – UNSPECIFIED (UNABLE TO DETERMINE WHETHER ONSET WAS PRIOR TO AGE 10)

CONDUCT DISORDER CONDUCT DISORDER • CHILDHOOD-ONSET • ADOLESCENT-ONSET – NON-NORMATIVE PEER RELATIONS – NORMATIVE PEER RELATIONS – ONSET AFTER 10 YO – MOSTLY MALE – LESS LIKELY TO DISPLAY AGGRESSION – ONSET PRIOR TO 10 YO ALTHOUGH MAY DISPLAY CONDUCT PROBLEMS IN GROUPS – AGGRESSIVE STYLE MAY BE PREDATORY – EMOTIONAL OR PASSIVE-AGGRESSIVE – GENETICS INVOLVED ACTING-OUT – MAY ALSO HAVE OPPOSITIONAL DEFIANT – MALE/FEMALE RATIO MORE BALANCED – DISORDER OR ATTENTION-DEFICIT LESS LIKELY TO DEVELOP ANTISOCIAL PD DISORDER – MORE LIKELY TO PRECEDE ANTISOCIAL PD

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ANTISOCIAL PERSONALITY CONDUCT DISORDER DISORDER • SPECIFIERS • DSM-I CATEGORIZED ALCOHOLISM UNDER • WITH LIMITED PROSOCIAL EMOTION ANTISOCIALITY • LACK OF REMORSE OR GUILT • MAY HAVE ASSOCIATED IMPULSE • CALLOUS-LACK OF EMPATHY CONTROL PROBLEMS • UNCONCERNED ABOUT PERFORMANCE • HIGHER INCIDENCE (SCHOOL, WORK OR OTHER ACTIVITIES OF SUBSTANCE- RELATED DISORDERS • SHALLOW OR DEFICIENT AFFECT AND PATHOLOGICAL GAMBLING

ANTISOCIAL PERSONALITY ANTISOCIAL PERSONALITY DISORDER DISORDER • PSYCHOPATHIC INDIVIDUALS CAN FEEL • WHEN INDIVIDUALS WITH FEAR, BUT HAVE TROUBLE IN THE PSYCHOPATHY IMAGINE OTHERS IN AUTOMATIC DETECTION AND PAIN, BRAIN AREAS NECESSARY FOR RESPONSIVITY TO THREAT. FEELING EMPATHY AND CONCERN FOR SYLCO S. HOPPENBROUWERS, BEREND H. BULTEN, INTI A. OTHERS FAIL TO BECOME ACTIVE AND BRAZIL. PARSING FEAR: A REASSESSMENT OF THE EVIDENCE BE CONNECTED TO OTHER IMPORTANT FOR FEAR DEFICITS IN PSYCHOPATHY.. PSYCHOLOGICAL BULLETIN, 2016; 142 (6): 573 DOI: 10.1037/BUL0000040 REGIONS INVOLVED IN AFFECTIVE PROCESSING AND DECISION-MAKING

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ANTISOCIAL PERSONALITY ANTISOCIAL PERSONALITY DISORDER DISORDER • WHEN HIGHLY PSYCHOPATHIC PARTICIPANTS • BUT WHEN PARTICIPANTS IMAGINED IMAGINED PAIN TO THEMSELVES, THEY SHOWED A TYPICAL NEURAL RESPONSE WITHIN THE BRAIN PAIN TO OTHERS, THESE REGIONS REGIONS INVOLVED IN EMPATHY FOR PAIN, FAILED TO BECOME ACTIVE IN HIGH INCLUDING THE ANTERIOR INSULA, THE PSYCHOPATHS. MOREOVER, ANTERIOR MIDCINGULATE CORTEX, PSYCHOPATHS SHOWED AN INCREASED SOMATOSENSORY CORTEX, AND THE RIGHT RESPONSE IN THE VENTRAL STRIATUM, AMYGDALA. THE INCREASE IN BRAIN ACTIVITY IN AN AREA KNOWN TO BE INVOLVED IN THESE REGIONS WAS UNUSUALLY PRONOUNCED, SUGGESTING THAT PSYCHOPATHIC PEOPLE ARE PLEASURE, WHEN IMAGINING OTHERS SENSITIVE TO THE THOUGHT OF PAIN. IN PAIN.

ANTISOCIAL PERSONALITY ANTISOCIAL PERSONALITY DISORDER DISORDER • THIS ATYPICAL ACTIVATION COMBINED WITH A • ALTERED CONNECTIVITY MAY CONSTITUTE NEGATIVE FUNCTIONAL CONNECTIVITY NOVEL TARGETS FOR INTERVENTION. IMAGINING BETWEEN THE INSULA AND THE VENTROMEDIAL ONESELF IN PAIN OR IN DISTRESS MAY TRIGGER A PREFRONTAL CORTEX MAY SUGGEST THAT STRONGER AFFECTIVE REACTION THAN IMAGINING WHAT ANOTHER PERSON WOULD INDIVIDUALS WITH HIGH SCORES ON FEEL, AND THIS COULD BE USED WITH SOME PSYCHOPATHY ACTUALLY ENJOYED IMAGINING PSYCHOPATHS IN COGNITIVE-BEHAVIOR PAIN INFLICTED ON OTHERS AND DID NOT CARE THERAPIES AS A KICK-STARTING TECHNIQUE,. FOR THEM. THE VENTROMEDIAL PREFRONTAL JEAN DECETY, CHENYI CHEN, CARLA HARENSKI AND KENT A. CORTEX IS A REGION THAT PLAYS A CRITICAL KIEHL. AN FMRI STUDY OF AFFECTIVE PERSPECTIVE TAKING IN INDIVIDUALS WITH PSYCHOPATHY: IMAGINING ANOTHER IN ROLE IN EMPATHETIC DECISION-MAKING, SUCH AS PAIN DOES NOT EVOKE EMPATHY. FRONTIERS IN HUMAN CARING FOR THE WELLBEING OF OTHERS. NEUROSCIENCE, 2013 DOI: 10.3389/FNHUM.2013.00489

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ANTISOCIAL PERSONALITY DISORDER PARALIMBIC SYSTEM AND ASPD • NEVER DEVELOP A SENSE OF ATTACHMENT TO OTHERS AND THE WORLD • HAVE LOW ORBITOFRONTAL CORTEX ACTIVITY • INVOLVED IN ETHICAL BEHAVIOR • MORAL DECISION MAKING • IMPULSE CONTROL • COMBINATION OF GENETIC PATTERNS, BRAIN PATTERNS AND EARLY LIFE TRAUMA

PARALIMBIC SYSTEM AND ASPD PHINEAS GAGE • PARALIMBIC SYSTEM IS A CIRCUIT OF INTERCONNECTED BRAIN REGIONS THAT MAY WELL BE THE AREA OF MALFUNCTION IN ASPD • THESE INTERCONNECTED BRAIN REGIONS REGISTER FEELINGS AND OTHER SENSATIONS AND ASSIGN EMOTIONAL VALUE TO EXPERIENCES, AS WELL AS, BEING INVOLVED IN DECISION MAKING, HIGH LEVEL REASONING AND IMPULSE CONTROL • AREA IS UNDERDEVELOPED IN ASPD AND DAMAGE TO THESE AREAS CAN CREATE PSYCHOPATHIC TRAITS

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PHINEAS GAGE PHINEAS GAGE • 43 INCHES LONG, 1.25 INCHES IN DIAMETER AND WEIGHING 13.25 POUNDS THE TAMPING IRON PENETRATED THE LEFT CHEEK AND EXCITING THROUGHT THE SKULL • LOST A PART OF HIS BRAIN CALLED THE VENTROMEDIAL PREFRONTAL CORTEX (VMPFC) AN AREA STRUCTURALLY SIMILAR TO THE ORBITOFRONTAL CORTEX (OFC)

PHINEAS GAGE PARALIMBIC SYSTEM AND ASPD • OFC INVOLVED IN SOPHISTICATED DECISION- • EMPATHY INVOLVES MANY AREAS OF THE BRAIN BUT MAKING TASKS THAT INVOLVE SENSITIVITY TO THE AMYGDALA SEEMS TO BE A CENTRAL PLAYER AS IT GENERATES EMOTIONS SUCH AS FEAR-CREATES RISK, REWARD AND PUNISHENT FEARLESSNESS • LEADS TO PROBLEMS OF IMPULSIVITY AND • ASPD NOTED FOR FEARLESSNESS-WHEN CONFRONTED INSIGHT AND LASH OUT IN RESPONSE TO WITH AN ATTACKER THEY DO NOT BLINK PERCEIVED AFFRONTS • THEIR EEG READINGS ARE CONSISTENT WHEN SHOWN • THESE WERE GAGES’S PREDOMINANT WORDS LIKE “BLOOD” AND “HOUSE” ( A NEUTRAL WORD), THE PATTERNS ARE ALSO DIFFERENT THAN SYSMPTOMS ALTHOUGH HE STILL POSSESSED CONTROLS EMPATHY

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PARALIMBIC SYSTEM AND ASPD PARALIMBIC SYSTEM AND ASPD • EMPATHY INVOLVES OTHER AREAS OF • THE ANTERIOR CINGULATE REGULATES BRAIN SUCH AS EMOTIONAL STATES AND HELPS PEOPLE CONTROL THEIR IMPULSES AND MONITOR • ORBITOFRONTAL CORTEX THEIR BEHAVIOR FOR MISTAKES • EMOTIONAL AND SOCIAL DECISION MAKING • THE INSULA PLAYS A KEY ROLE IN THE • ANTERIOR CINGULATE RECOGNITON OF VIOLATION OF SOCIAL • AFFECT, DECISION MAKING AND COGNITIVE NORMS, AS WELL AS, THE EXPERIENCING OF CONTROL ANGER, FEAR, EMPATHY AND DISGUST • DORSOLATERAL PREFRONTAL CORTEX • INSULA ALSO INVOLVED IN PAIN PERCEPTION • COGNITIVE FLEXIBILITY AND PSYCHOPATHS ARE STRIKINGLY UNFAZED BY THREAT OF PAIN

ANTISOCIAL PERSONALITY PARALIMBIC SYSTEM AND ASPD DISORDER

• FMRI IMAGES OF BRAINS (KIEHL) SHOW • DELINQUENT ADOLESCENTS FROM THE PRONOUNCED THINNING OF NETHERLANDS AGED BETWEEN 15 AND 21 PARALIMBIC TISSUE INDICATING THE YEARS WHO HAD BEEN DIAGNOSED WITH AREA IS UNDERDEVELOPED AN ANTISOCIAL PERSONALITY DISORDER • THE DELINQUENT ADOLESCENTS SHOWED LESS ACTIVATION THAN THE CONTROL GROUP IN THE TEMPOROPARIETAL JUNCTION AND IN THE INFERIOR FRONTAL GYRUS (FMRI).

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ANTISOCIAL PERSONALITY ANTISOCIAL PERSONALITY DISORDER DISORDER • THE FINDINGS INDICATE THAT ALTHOUGH BOTH • THESE AREAS OF THE BRAIN ARE RESPONSIBLE FOR GROUPS SHOWED THE SAME LEVELS OF EMOTIONAL FUNCTIONS INCLUDING THE ABILITY TO PUT REACTIVITY TO UNFAIR OFFERS, THE DELINQUENT ONESELF IN ANOTHER PERSON'S POSITION AND ADOLESCENTS REJECTED THESE OFFERS MORE OFTEN. IMPULSE CONTROL. IN BOTH GROUPS, THE IN CONTRAST TO THE CONTROL GROUP, THEY DID NOT RESEARCHERS OBSERVED SIMILAR LEVELS OF TAKE ACCOUNT OF THEIR OPPONENT'S INTENTION -- OR OF WHETHER THEIR OPPONENT HAD NO ALTERNATIVE. ACTIVATION IN THE DORSAL ANTERIOR CINGULATE W. VAN DEN BOS, P. VAHL, B. GURO LU, F. VAN NUNSPEET, O. COLINS, M. MARKUS, S. A. R. B. CORTEX AND IN THE ANTERIOR INSULA -- AREAS OF ROMBOUTS, N. VAN DER WEE, R. VERMEIREN, E. A. CRONE. NEURAL CORRELATES OF SOCIAL DECISION-MAKING IN SEVERELY ANTISOCIAL ADOLESCENTS. SOCIAL COGNITIVE AND THE BRAIN ASSOCIATED WITH AFFECTIVE AFFECTIVE NEUROSCIENCE, 2014; DOI: 10.1093/SCAN/NSU003 PROCESSES •

ANTISOCIAL PERSONALITY ANTISOCIAL PERSONALITY DISORDER DISORDER • IS ASPD MADE OR BORN? • ONE WAY OF CONSIDERING TREATMENT IS TO • COMBINATION OF NATURE AND NURTURE- THINK OF DEVELOPMENT AS OCCURRING GENES AND ENVIRONMENT EASIEST DURING CERTAIN PERIODS OF LIFE • SOME ARE SCARED BY EARLY ENVIRONMENT OFTEN CALLED “CRITICAL PERIODS” OTHERS ARE “BLACK SHEEP” OF STABLE FAMILIES • CHILDHOOD AND EARLY ADOLESCENCE MAY BE A WINDOW FOR DEVELOPING • ARE THEY TREATABLE? SOCIAL AND COGNITIVE SKILLS WE CALL • ASPD IS A DISORDER OF RANGE, THE FAR END IS THE PSYCHOPATH WHO IS DIFFICULT, IF NOT “CONSCIENCE” IMPOSSIBLE, TO TREAT WITH TODAY’S TECHNOLOGY.

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ANTISOCIAL PERSONALITY ANTISOCIAL PERSONALITY DISORDER DISORDER • TREATMENT OF INTRACTABLE JUVENILE • HARE’S STUDIES SHOW THAT GROUP THERAPY OFFENDERS WITH PSYCHOPATHIC TENDENCIES FOR PSYCHOPATHS IN PRISON RESULTS IN MORE AT MENDOTA JUVENILE TREATMENT CENTER IN CRIMES THAN IF THEY HAD NO THERAPY. MADISON, WI. • NOTORIOUSLY GOOD AT LEARNING AND EXPLOITING (WWW.NREPP.SAMHSA.GOV/VIEWINTERVENTION.ASPX?ID=38 ) THE WEAKNESSES OF OTHERS • INTENSIVE ONE-ON-ONE THERAPY KNOWN AS • THEY HAVE TROUBLE ABSORBING ABSTRACT IDEAS SO DECOMPRESSION AIMED ENDING THE VICIOUS LECTURES ABOUT PERSONAL RESPONSIBILITY ARE CYCLE IN WHICH PUNISHMENT FOR BAD UNLIKELY TO BE HELPFUL BEHAVIOR INSPIRES MORE BAD BEHAVIOR • INSIGHT ORIENTED THERAPY ALSO • 150 YOUTHS WERE 50 % LESS LIKELY TO ENGAGE IN INEFFECTIVE VILENT CRIME THAN A COMPARABLE GROUP TREATED AT REGULAR JUVENILE CORRECTIONS FACILITIES

SIGNS YOU ARE DEALING WITH ASPD SIGNS YOU ARE DEALING WITH ASPD

• SHALLOW AFFECT AND • SUCH FINDINGS SUGGEST THAT LIMITED EMOTIONAL RESPONSIVENESS. PSYCHOPATHS HAVE A GREATER ABILITY • RESEARCH INDICATES THAT PSYCHOPATHS THAN OTHERS TO ENGAGE IN CRUEL AND HAVE REDUCED AFFECTIVE RESPONSES AND CALLOUS BEHAVIOR WITHOUT CONSIDERING AN ABSENCE OF A STARTLE RESPONSE THE EMOTIONAL CONSEQUENCES OR EVEN (PATRICK ET. AL, 1993). IN FACT, LAB PUNISHMENT FOR THEIR ACTIONS. EXPERIMENTS INDICATE THAT THEY LACK THE PHYSIOLOGICAL RESPONSES • WHEN PSYCHOPATHS ARE IN THEIR ASSOCIATED WITH FEAR NATURAL STATE, THERE IS AN EERIE SENSE (LYKKEN, 1995; OGLOFF & WONG, 1990). OF CALM, QUIET AND NONCHALANCE ABOUT THEM

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SIGNS YOU ARE DEALING WITH ASPD SIGNS YOU ARE DEALING WITH ASPD • THEIR PREDATORY GAZE ZOOMS IN ON • “MANY PEOPLE FIND IT DIFFICULT TO DEAL WITH POTENTIAL PREY. INTENSE, EMOTIONLESS, OR “PREDATORY” STARE OF THE PSYCHOPATH. NORMAL PEOPLE MAINTAIN • WHEN THEY ARE MANIPULATING SOMEONE, CLOSE EYE CONTACT WITH OTHERS FOR A VARIETY THOSE WITH ANTISOCIAL TRAITS ARE KNOWN FOR THEIR INTENSE “PREDATORY GAZE” WHEN OF REASONS, BUT THE FIXATED STARE OF THE THEY FIXATE ON A SPECIFIC VICTIM. THIS CAN BE PSYCHOPATH IS MORE OF A PRELUDE TO SELF- AN ALMOST REPTILIAN GAZE THAT IS DESCRIBED GRATIFICATION AND THE EXERCISE OF POWER AS “DEAD” AND “DARK” OR EVEN SEDUCTIVE IF THAN SIMPLE INTEREST OR EMPATHIC THE PSYCHOPATH IS ATTEMPTING TO LURE CARING…SOME PEOPLE RESPOND TO THE SOMEONE IN SEXUALLY. AS ROBERT HARE (1993) EMOTIONLESS STARE OF THE PSYCHOPATH, WITH WRITES IN WITHOUT CONSCIENCE: CONSIDERABLE DISCOMFORT, ALMOST AS IF THEY FEEL LIKE POTENTIAL PREY IN THE PRESENCE OF A PREDATOR.”

SIGNS YOU ARE DEALING WITH ASPD SIGNS YOU ARE DEALING WITH ASPD

• THEY REQUIRE HIGH LEVELS OF STIMULATION • THEIR EXCESSIVE NEED FOR STIMULATION BECAUSE OF PERPETUAL BOREDOM. AND ENTERTAINMENT, COMBINED WITH • THE PSYCHOPATHY CHECKLIST DEVELOPED BY ROBERT THEIR LACK OF REMORSE, IS ALSO WHAT HARE (2008) LISTS “PRONE TO BOREDOM” AS ONE OF THE ENABLES THEM TO ENGAGE IN MULTIPLE TRAITS OF BEING A PSYCHOPATH. SOMEONE WHO IS RELATIONSHIPS AND SEXUAL LIAISONS PERPETUALLY BORED IS UNBELIEVABLY RESTLESS AND CAN SIMULTANEOUSLY. BE IMPULSIVE WHEN IT COMES TO HIGH-RISK BEHAVIOR. IT IS UNSURPRISING THAT DUE TO THEIR CHRONIC BOREDOM, • FOR PSYCHOPATHS, THE NOVEL IS WHAT IS PSYCHOPATHS GAIN THE MOST EXCITEMENT FROM MOST EXCITING AND THEY QUICKLY GET CONNING OTHERS OR ENGAGING IN CRIMINAL ACTIVITIES BORED WITH THEIR CURRENT PURSUITS IN OF ALL KINDS. SEARCH OF SOMETHING “BETTER.”

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SIGNS YOU ARE DEALING WITH ASPD SIGNS YOU ARE DEALING WITH ASPD

• THEY DEMONSTRATE A HAUGHTY, • THIS FORM OF GRANDIOSITY ISN’T JUST YOUR SUPERIOR AND CONTEMPTUOUS ATTITUDE. GARDEN-VARIETY ARROGANCE, BUT RATHER, A CORE BELIEF THE PSYCHOPATH HOLDS ABOUT • AS NATURAL BRAGGARTS, PSYCHOPATHS TEND HIMSELF OR HERSELF THAT SHAPES TO OVERSELL THEMSELVES AND THEIR EVERYTHING THEY DO. NO AMOUNT OF THEFT, ABILITIES. THEY SELF-AGGRANDIZE CRIMINAL ACTIVITY, CON AND BELIEVE THE WORLD MUST CATER TO ARTISTRY, INFIDELITY, OR PATHOLOGICAL THEIR EGO. THEY TAKE PRIDE IN WHATEVER LYING MAY BE OUT OF BOUNDS FOR THEM; QUALITIES MAKE THEM SPECIAL AND THEY THEY ARE CONTEMPTUOUS OF THE “MERE BELIEVE THEMSELVES TO BE THE EXCEPTION MORTALS” WHO ALLOW THEIR VALUES OR TO EVERY RULE. MORALS TO INTERFERE WITH ACHIEVING THEIR GOALS.

SIGNS YOU ARE DEALING WITH ASPD SPECT STUDY-AMEN

• THEIR CURIOSITY IS LIMITED TO WHAT THEY THE STUDY FOUND THAT THE BLOOD FLOW AMONG CAN GAIN. MURDERERS IN THE PREFRONTAL CORTEX (PFC) OF THE BRAIN WAS SIGNIFICANTLY DECREASED. THIS AREA OF • PSYCHOPATHS AND OTHER SIMILARLY EMPATHY- THE BRAIN IS IMPLICATED IN ANGER MANAGEMENT AND CHALLENGED INDIVIDUALS DO NOT CARE ABOUT DEFICITS HERE INDICATE A RELATIVE INABILITY TO SOMEONE ELSE’S SUCCESSES, GOALS, INTERESTS, UTILIZE RESOURCES INVOLVED WITH INHIBITION, SELF- HOBBIES OR NEEDS UNLESS THOSE VERY THINGS CENSORSHIP, PLANNING, AND FUTURE CONSEQUENCES. CAN BE USED TO SERVE THEM. FOR EXAMPLE, A THE RESULTS SUGGEST THAT MURDERERS WHO COMMIT WEALTHIER PARTNER CAN BE “USEFUL” TO ACTS OF IMPULSIVE VIOLENCE SHOW A MARKED A PREDATOR SO LONG AS HE OR SHE CAN INABILITY TO UTILIZE IMPORTANT COGNITIVE FINANCIALLY DEPEND ON THEM FOR A PLACE TO RESOURCES WHEN CHALLENGED BY EMOTIONALLY STAY OR FUNDS. PSYCHOPATHS ARE KNOWN FOR NEUTRAL TASKS. LEADING PARASITIC LIFESTYLES.

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LOWER LEVELS OF PFC VOLUME ANTISOCIAL PERSONALITY AND ACTIVITY DISORDER • LOWER LEVELS OF PFC ACTIVITY AND VOLUME • HARE PSYCOPATHY CHECKLIST-REVISED FOUND IN IMPULSIVE MURDERERS BUT NOT • 20 CRITERIA EACH GRADED 0,1,OR 2 IN COLD, CALCULATING CRIMINALS • AVG. GENERAL POPULATION SCORE IS 4 • PFC VOLUME OF GRAY MATTER 22.3% • OVER 30 IS PSYCHOPATHIC RANGE DEFICIENT IN UNSUCCESSFUL OFFENDERS • MEASURES BUT PFC VOLUME IN NORMAL RANGE FOR • ANTISOCIAL BEHAVIOR • NEED FOR STIMULATION AND PRONENESS TO SUCCESSFUL OFFENDERS (AVOIDING CAPTURE BOREDOM AS CRITERIA FOR SUCCESS) • PARASITIC LIFESTYLE • STRUEBER ET AL. “THE VIOLENT BRAIN”. SCIENTIFIC POOR BEHAVIORAL CONTROL • AMERICAN MIND. DEC. 2006/JANUARY 2007. SEXUAL PROMISCUITY • LACK OF REALISTIC LONG-TERM GOALS

ANTISOCIAL PERSONALITY ANTISOCIAL PERSONALITY DISORDER DISORDER • HARE PSYCOPATHY CHECKLIST-REVISED • HARE PSYCOPATHY CHECKLIST-REVISED • MEASURES • MEASURES • ANTISOCIAL BEHAVIOR (CONTINUED) • EMOTIONAL/INTERPERSONAL TRAITS (CONTINUED) • IMPULSIVITY • CONNING AND MANIPULATIVENESS • IRRESPONSIBILITY • LACK OF REMORSE OR GUILT • EARLY BEHAVIOR PROBLEMS • SHALLOW AFFECT • JUVENILE DELINQUENCY • CALLOUSNESS AND LACK OF EMPATHY • PAROLE OR PROBATION VIOLATIONS • FAILURE TO ACCEPT RESPONSIBILITY FOR ACTIONS • EMOTIONAL/INTERPERSONAL TRAITS • OTHER FACTORS • GLIBNESS AND SUPERFICIAL CHARM • COMITTING A WIDE VARIETY OF CRIMES • GRANDIOSE SENSE OF SELF-WORTH • HAVING MANY SHORT-TERM MARITAL RELATIONSHIPS • PATHOLOGICAL LYING

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MANAGEMENT MANAGEMENT CONSIDERATIONS- ASPD CONSIDERATIONS- ASPD

• GOAL • COUNTERTRANSFERENCE • PREREQUISITES • CLINICIANS TEND TO FEEL MISTREATED, CRITICIZED, OR REPULSED AND CAN EXPERIENCE • BUSINESS-LIKE AN INTENSE ANGER AND IRRITATION WORKING • BEHAVIORAL WITH ANTISOCIAL PATIENTS. THEY OFTEN FEEL USED OR MANIPULATED BY THEM AND PUSHED – LIMIT SETTING TO SET FIRM LIMITS IN THE CLINICAL SETTING. – TREATMENT PLAN THEY CAN SOMETIMES FEEL THEY ARE BEING • INCORPORATE CRUEL, MEAN, OR AGGRESSIVE WHEN WORKING “OBSERVERS” WITH THESE PATIENTS AND WISH THEY HAD NEVER TAKEN THEM ON IN THERAPY.

REFERENCES REFERENCES

• PERRY, BRUCE. VIOLENCE AND TRAUMA: UNDERSTANDING • AGGRESSION. AND RESPONDING TO THE EFFECTS OF VIOLENCE ON HTTP://EMEDICINE.COM/MED/TOPIC3005.HTM YOUNG CHILDREN. GUND FOUNDATION PUBLISHERS, • PINCUS, J AND TUCKER, G. BEHAVIORAL CLEVELAND, PP 67-80, 1996. NEUROLOGY FOURTH EDITION.OXFORD • CLINICAL MANAGEMENT OF AGITATION. UNIVERSITY PRESS, NEW YORK,2003. HTTP://WWW.MEDSCAPE.COM/VIEWPROGRAM/2311_PNT. • GLOVER,JANIKOWSKI AND BENSHOFF.”THE INCIDENCE OF INCEST HISTORIES AMONG CLIENTS RECEIVING SUBSTANCE ABUSE TREATMENT”.JOURNAL OF COUNSELING AND DEVELOPMENT.MARCH/APRIL 1995.

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REFERENCES REFERENCES

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