WPA/ISSPD Educational Program on Personality Disorders

Editors

Erik Simonsen, M.D., chair Elsa Ronningstam, Ph.D. Theodore Millon, Ph.D., D.Sc. December 2006 International Advisory panel

John Gunderson, USA Roger Montenegro, Argentina Charles Pull, Luxembourg Norman Sartorius, Switzerland Allan Tasman, USA Peter Tyrer, UK

2 Authors Module I Authors Module II

Renato D. Alarcon, USA Anthony W. Bateman, UK Judith Beck, USA Robert F. Bornstein, USA G.E. Berrios, UK Vicente Caballo, Spain Vicente Caballo, Spain David J. Cooke, UK Allen Frances, USA Peter Fonagy, UK Glen O. Gabbard, USA Stephen D. Hart, Canada Seth Grossmann, USA Elisabeth Iskander, USA W. John Livesley, Canada Yutaka Ono, Japan Juan J. Lopez-Ibor, Spain J. Christopher Perry, Canada Theodore Millon, USA Bruce Pfohl, USA Joel Paris, Canada Elsa Ronningstam, USA Robert Reugg, USA Henning Sass, Germany Michael Rutter, UK Reinhild Schwarte, Germany Erik Simonsen, Denmark Larry J. Siever, USA Peter Tyrer, UK Michael H. Stone, USA Irving Weiner, USA Svenn Torgersen, Norway Drew Westen, USA

Reviewer Module I Reviewers Module II

Melvin Sabshin, USA/UK David Bernstein, USA Sigmund Karterud, Norway Cesare Maffei, Italy John Oldham, USA James Reich, USA

3 Authors Module III Reviewers Module III

R.E. Abraham, The Netherlands Anthony Bateman, UK Claudia Astorga, Argentina Robert Bornstein, USA Marco Aurélio Baggio, Brazil Vicente Caballo, Spain Yvonne Bergmans, Canada Glen O. Gabbard, USA Mirrat Gul Butt, Pakistan Yutaka Ono, Japan H.R. Chaudhry, Pakistan Elsa Ronningstam, USA Dirk Corstens, The Netherlands Henning Sass, Germany Kate Davidson, UK Erik Simonsen, Denmark Mircea Dehelean, Romania Allan Tasman, USA Andrea Fossati, Italy E. Gómez Gazol, Spain Dishanter Goel, India H. Groen, The Netherlands Sabine C. Herpertz, Germany T.M.J. Huyen, The Netherlands Merete Johansen, Scandinavia Sigmund Karterud, Scandinavia Morten Kjølbye, Denmark Nestor Koldobsky, Argentina D. Lecic-Tosevski, Serbia and Montenegro Paul Links, Canada Cesare Maffei, Italy J.M. Mburu, Kenya Aurel Nirestean, Romania Joel Paris, Canada Gabriele Partscht, Germany A. Pérez Úrdaniz, Spain James Reich, USA Danilo Rolando, Uruguay Janine Stevenson, Australia M.M. Thunnissen, The Netherlands Jitindra Kumar Trivedi, India Øyvind Urnes, Scandinavia Sergio Valdivieso Fernández, Chile

4 Editorial introduction

In 2002 at the World Congress in Yokohama, the World Psychiatric Association, under the guidance of the International Society for the Study of Personality Disorders (ISSPD), established a new division on personality disorders as an official branch of the world organization. In accordance with this decision, the new division, entitled WPA Section on Personality Disorders, has been given the opportunity to develop a formal WPA educational program on personality disorders to be published on the website. An editorial steering committee (Erik Simonsen, Theodore Millon, and Elsa Ronningstam) was created to formulate, organize, and coordinate the development of the program. The program was designed to provide useful information about characteristics of personality disorders as conceived in the ICD and DSM. An outline of topics was developed and a set of authors was selected. The ISSPD Board and the Board of the WPA Section on Personality Disorders approved the proposal. Members of the ISSPD and WPA Section on Personality Disorders were then encouraged to take part in the development of the program. The project has been financially supported both by the ISSPD and WPA. The program represents the contributions and collaborations of researchers and clinicians from around the world. The response of our colleagues has been both generous and outstanding in quality. The target audience for the program is planned to be broad, ranging from medical and psychology students, psychiatric nurses and social workers, primary care clinicians, psychologists, psychiatrists, and the staff in academic institutions. The structure of the program is comparable to other WPA Educational programs. The first module provides information on history, concepts and methodological issues. The second module describes detailed diagnostic and clinical descriptions of each disorder, prevalence, age and gender issues, etiology and pathogenesis, course and prognosis, and comorbidity and treatment. The third module presents a series of clinical vignettes that illustrate their features in concrete and realistic forms. After each section you will find curriculum suggestions for classroom teaching and workshops. The program was written by several authors who are acknowledged at the following pages. The program has been approved by the WPA Educational Committee under the vigorous leadership of Allan Tasman, who has been very supportive throughout the process. On behalf of the editors, I would like to thank all the contributors for their steadfast efforts in making this possible. The material is easily accessible on the internet. Hopefully, the material will be used worldwide to advance the understanding of diagnosis and management of personality disorders. We would appreciate a feedback from those who used the program. Our plan is to make an update every 3 rd year.

Erik Simonsen M.D. Editor, Committee chair Chairman, WPA Section on Personality Disorders [email protected]

5 Foreword

Few problems in the field of psychiatry are more complex to address than personality disorders. The dilemma starts, in fact, with trying to decide what is the personality, and how we understand the influences that determine the mature personality? Contemporary views assume a complex interaction between genetic factors, with a present emphasis on temperament, and life experiences. While most believe that what will become the mature personality is, for most people, essentially determined by late adolescence, we know that a variety of adult life influences can exert modifying effects throughout the life cycle. Thus, the conceptualization that personality reflects a matrix of qualities of character and patterns of reactivity has become generally accepted, though still difficult to quantify. Moving from a general framework of understanding to a definition of specific aspects of personality has, therefore, been more difficult. This leads to the greater difficulty for our field, which is the differentiation of normal from abnormal personality. It is within this area of inquiry that the definition of personality disorders lies. Complicating this definition is the fact that not only genetic heritage and life experiences exert influences on personality development and structuralization, but also a wide range of cultural and ethnic variables also play a substantial, though thus far also not quantifiable, effect. If, given all of the dilemmas enumerated above, we can arrive at a consensus about what is a personality disorder, this leads to the next dilemma of how we can best assess personality disorders. There is little agreement in this area, best conceptualized through the ongoing debate about whether diagnosis of personality disorders should occur within a dimensional or categorical approach. A further complication arises due to the fact that advocates for either categorical or dimensional approaches have thus far not reached a consensus on the optimal approach even within their own domain of study. Finally, how to treat something defined as a disorder, but which is embedded in the person of the individual seeking treatment, and thus not easily amenable to modification, remains one of the most complex clinical problems in the field of psychiatry. The conceptual and diagnostic dilemmas have made research in the area of personality disorders’ treatment quite difficult, as comparisons across studies are difficult to make. An additional level of complexity occurs because we well know that personality disorders and other psychiatric disorders often co-exist, but unfortunately not in ways which lead us to easy construction of frameworks for treatment planning. Molecular genetics holds out the promise that if we identify genetic predispositions for a variety of psychiatric illnesses, that we can use this knowledge to develop more effective treatments for them. Few would suggest a similar likely outcome in the area of personality disorders. Our psychological task, then, is to provide state-of-the-art information which can be used by clinicians at any stage of training in understanding personality disorders and developing a treatment plan. This monumental task has been handled with aplomb by the workgroup responsible for the preparation of the work you are reading. Calling upon an outstanding group of experts in all aspects of personality studies around the globe, Eric Simonsen, M.D., and colleagues have produced a work that is comprehensive, yet organized in a way that makes access to the material easy for individuals at any stage of their professional career. Their work is an excellent illustration of ways in which the WPA can productively collaborate with other international organizations, in this case the International Society on the Study of Personality Disorders (ISSPD). The work is designed in three modules. Module 1, Conceptual and Methodological Foundations, reviews the scholarly contributions to our understanding of personality and how we might classify personality and personality disorders and reviews a variety of therapeutic management approaches. Module 2 addresses each personality disorder and reviews diagnostic criteria, etiology, epidemiology, comorbidity, and treatment. Module 3 presents a “casebook” to illustrate the range of personality

6 disorders. The vignettes are concise, yet illustrative, and accompanied by expert commentary. Recommended readings and curricular recommendations also are included for all three modules. While no one work can possibly encompass the entire field of personality disorders, and whether the reader is interested in a specific topic or an in-depth review, there is little question that time spent with this material will be universally felt to be very useful.

Allan Tasman, M.D. Secretary for Education World Psychiatric Association

7 8 Table of Contents

MODULE I: ...... 13 CONCEPTUAL AND METHODOLOGICAL FOUNDATIONS...... 13

I. INTRODUCTION...... 13 A. Scope of the Problem ...... 13 B. Social Costs...... 14

II. DEFINITIONS...... 14 A. Differentiating Normality and Abnormality...... 16

III. HISTORICAL REVIEW ...... 17

IV. CLASSIFICATION ALTERNATIVES...... 21 A. The Current Official Systems ...... 21 B. On the Reality of Personality “Syndromes” ...... 23 C. Structuring a taxonomy of personality disorders?...... 24

V. DEVELOPMENTAL PATHOGENESIS...... 27 A. The Role of Biogenic Influences...... 28 B. The Role of Psychogenic Influences...... 29 C. The Role of Sociogenic Influences ...... 31

VI. DIAGNOSTIC ASSESSMENT...... 36 B. Rating scales and Checklists...... 38 C. Self Report Inventories...... 39 D. Projective techniques...... 40

VII. THERAPEUTIC MANAGEMENT...... 40 A. Psychodynamic Therapies...... 41 B. Cognitive Therapies...... 43 C. Biological Treatments...... 44 D. Combining Pharmacology and Psychotherapy...... 46

References are listed in order of appearance in text ...... 48

Suggested Additional Reading List – Module I ...... 55

Curriculum Suggestions – Module I...... 56

9

MODULE II: THE PERSONALITY DISORDERS ...... 57

INTRODUCTION ...... 57 General Diagnostic Criteria...... 59 Antisocial Personality Disorder ...... 60 Avoidant Personality Disorder ...... 67 Borderline Personality Disorder...... 74 Dependent Personality Disorder...... 84 Histrionic Personality Disorder...... 90 Narcissistic Personality Disorder...... 95 Obsessive-Compulsive Disorder...... 104 Paranoid Personality Disorder...... 110 Passive-aggressive Personality Disorder...... 117 Sadistic Personality Disorder ...... 123 Schizoid Personality Disorder...... 129 Schizotypal Personality Disorder...... 135

Suggested Additional Reading List – Module II...... 142

Diagnostic Instruments ...... 143

Curriculum Suggestions – Module II ...... 144

10

MODULE III: CASE VIGNETTES ...... 145

INTRODUCTION ...... 145 CASE 1: Ronny: Paranoid personality disorder...... 147 CASE 2: Theo: Paranoid Personality Disorder...... 151 CASE 3: Sara: Borderline Personality Disorder...... 154 CASE 4: Jane: Borderline Personality Disorder...... 158 CASE 5: Ellen: Borderline Personality Disorder...... 163 CASE 6: Peter: Narcissistic Personality Disorder...... 166 CASE 7: Carmen: Histrionic Personality Disorder ...... 170 CASE 8: Patrick: Avoidant Personality...... 174 CASE 9: Saskia: Avoidant Personality Disorder...... 178 CASE 10: Sally: Dependent Personality Disorder...... 182 CASE 11: Brian: Obsessive-Compulsive Personality Disorder...... 185 CASE 12: Gregorio: Mixed Personality Disorder...... 189 CASE 13: John: Antisocial Personality Disorder...... 194 CASE 14: Sergio: Antisocial/Dissocial Personality Disorder...... 198 CASE 15: Marcel: Dissocial Personality Disorder...... 204 CASE 16: Mr. M: Antisocial Personality Disorder...... 209 CASE 17: Alejandro: Borderline Personality Disorder...... 213 CASE 18: Anna Z: Borderline Personality Disorder ...... 216 CASE 19: John: Schizoid Personality Disorder ...... 221 CASE 20: Jim: Narcissistic and Antisocial Personality Disorder ...... 224 CASE 21: Borderline Personality Disorder ...... 228 CASE 22 Marcello: Avoidant Personality Disorder...... 232 CASE 23: Erik: Narcissistic Personality Disorder...... 235 CASE 24: Mary: Borderline Personality Disorder...... 239 CASE 25: Francisc: Anxious/Avoidant Personality Disorder...... 244 CASE 26: Lola: Borderline Personality Disorder ...... 248 CASE 27: Paranoid Personality Disorder ...... 253 CASE 28 Jane: Obsessive-Compulsive Personality Disorder...... 258 CASE 29 AB: Borderline Personality Disorder ...... 262 CASE 30 Mr FA: Narcissistic Personality Disorder...... 265 CASE 31 Anja: Borderline Personality Disorder...... 270

Curriculum Suggestions – Module III...... 274

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11 12 MODULE I: CONCEPTUAL AND METHODOLOGICAL FOUNDATIONS

Editor: Theodore Millon, Ph.D., D.Sc. Reviewer: Melvin Sabshin, M.D.

I. INTRODUCTION

A. Scope of the Problem Treating psychopathology requires an understanding of personality. Research on the DSM and ICD disorders is making it increasingly clear that (a) anxiety, depression, eating disorders, substance abuse, sexual disorders, and other DSM Axis I Clinical Syndromes occur more often in the context of Personality Disorders (PDs) 1; (b) patients with multiple clinical syndrome diagnoses often have PDs 2; and (c) even those patients who lack personality disturbances severe enough to warrant a DSM or ICD personality diagnosis often have clinically significant pathology, such as difficulties with intimacy, management of aggression or self-assertion, rejection-sensitivity, etc 3. There is little question that inclusion of a PD axis in the DSM and ICD, and its refinement through two decades of research, has been a crucial step in the evolution of more clinically and empirically useful diagnostic manuals. Knowing that a patient has major depression is certainly important, but adding the "qualifier" that the patient also has borderline PD is equally important because it has significant implications for prognosis and treatment. PDs have historically been in a tangential position among diagnostic syndromes, never having achieved a significant measure of recognition in the literature of either clinical psychiatry or abnormal psychology. Prior to the DSM-III and ICD-8, they were categorized in the official nomenclature with a mélange of other miscellaneous and essentially secondary syndromes. Today, PDs occupy a place of diagnostic prominence, having been accorded a contextual role in the multiaxial schema of the DSM. Personality pathologies comprise one of two required “mental disorder” axes in the DSM. Henceforth, clinicians must not only assess the patient's current symptomatology, indicated on Axis I, but also evaluate those pervasive features which characterize the patient's enduring personality pattern, recorded on Axis II. In effect, the revised American multiaxial format requires that symptom states no longer be assessed as clinical entities isolated from the broader context of the patient's lifelong style of relating, coping, behaving, thinking, and feeling - that is, his or her personality. In fact, there are clinical theorists who assert that it is the patient’s personality that should be evaluated first; only secondarily should the patient’s clinical state be considered. There are substantive reasons for attending to the PDs first, beyond the pragmatics of adhering to official nosological requirements. Lifelong personality traits appear to serve as a substrate, as well as a context for understanding more florid and distinct forms of psychopathology. Since the early 1960s, most societies have been increasingly committed to the early identification and prevention of mental disorders. This emphasis has led clinicians to attend to both premorbid behavioural signs and the less severe variants of emotional disturbance. Ordinary anxieties, minor personal conflicts, and social inadequacies are now seen by many clinicians as the forerunners of more serious problems. A significant impetus to this movement is the emergence of community health centres whose attentions are directed to the needs of the less seriously disturbed. As a result of these developments, the scope of clinical psychopathology was broadened far beyond its historical province of “Hospital” psychiatry. As a field, it now encompasses the full spectrum of mild to severe mental disorders. With personality as a contextual foundation, diagnosticians have become more proficient in understanding personality dynamics and can more clearly trace the sequences through which both subtle and dramatic clinical symptoms unfold. Yet, it is necessary

13 that we recognize at the outset of this module how much more needs to be learned about the origins, development, structure and treatment of these disorders.

B. Social Costs PDs have been estimated to affect at least 10% of the population, and constitute a large percentage of the patients seen by psychiatrists. Yet unlike other diagnoses, PDs may or may not be associated with subjective symptoms. While some categories show high comorbidity with symptomatic diagnoses such as anxiety and depression, some PDs produce distress in other people rather than in the patient. But in either case, the overall functioning of patients with PDs is often marginally social, comparable in many cases to levels seen in patients with chronic conditions such as schizophrenia. Numerous studies suggest that PDs are underappreciated causes of social cost, morbidity, and mortality. PDs are associated with crime, substance abuse, disability, increased need for medical care, suicide attempts, self-injurious behaviour, assaults, delayed recovery from Axis I and medical illness, institutionalization, underachievement, underemployment, family disruption, child abuse and neglect, homelessness, illegitimacy, poverty, STDs, misdiagnosis and mistreatment of medical and psychiatric disorders, malpractice suits, medical and judicial recidivism, disruption of psychiatric treatment settings, and dependency on public support. The amount of social cost and disruption caused by the PDs is disproportionate to the amount of attention it gets in the public consciousness, in government research funding, in medical school education or even in psychiatric residency training 4 And no less important than dealing with the social costs of personality disorders is the potential value inherent in preventive programs designed to enhance personality resilience and adaptive capacities.

Contributors: Allen Frances, Joel Paris, and Robert Reugg

II. DEFINITIONS

Reification (Verdinglichung) is a process whereby cultural notions are converted into things. Thinghood, in general, is expressed along an ontological continuum which may range from objects with dense ontology, such as stones, orchids or dogs, to structures and cultural monuments exhibiting little or none. The objects of psychology are placed somewhere along such continuum. They are notions and ideas that can be measured, used as causes for behaviour and reasons for action, as explanatory accounts, and predictive devices, and which can be correlated with proxy variables representing the brain from which it could be said, they attempt to borrow ontology. The 19 th century impetus to naturalize the mind attempted to endow psychological notions with ontology. This entification was encouraged by evolutionary theory. Concepts such as character, self, constitution, identity, temperament, emotion, and personality felt the effects, in that the subtle differentiating features were disregarded and thrown into a semantic melting pot. By the end of the century, personality had taken morsels of meaning from other concepts: it was ‘singular’ such as the self, ‘enduring’ like character, and ‘somatic’ like temperament and constitution 5. This made personality appear as a candidate for ‘natural kind’ 6, which could then be measured, structured, related to the brain and most importantly affected by disease. With costly effects, the naturalization of the personality model required that it shed its semantics, such as its role for more than three millennia as the social representation of individuality (‘social representations’ is used here in the manner of Moscovici 7). This bowdlerization of meaning that allowed researchers to search for what Eysenck8 referred to as the “biological basis of personality” has been called by Graumann 9 the process of “desocialization of the individual”.

14 “Personality” is a member of a family of concepts constructed to talk about and shore up the view that society is a collection of singular individuals. Up to the 19 th century, these roles were exercised in the field of religion, morality, the law, and metaphysics. During the 19 th century the concept of personality and various of its companions were psychologized and naturalized.

What is the concept of personality today? The question is simple to pose, but difficult to answer, despite the fact that as an idea, personality is many thousands of years old. Historically, the word personality itself derives from the Greek term persona, originally representing the theatrical mask used by dramatic players. This meaning has changed through history. As a mask assumed by an actor it suggested a pretense of appearance, that is, the possession of traits other than those which actually characterized the individual behind the mask. In time, the term persona lost its connotation of pretense and illusion, and began to represent, not the mask, but the real person, his/her apparent, explicit, and manifest features. The third and most recent meaning that the term personality has acquired delves “beneath” surface impression and turns the spotlight on the inner, less revealed, and hidden psychological qualities of the individual. Thus, through history the meaning of the term has shifted from external illusion to surface reality, and finally to opaque or veiled inner traits. It is this third meaning that comes closest to contemporary use. Personality is seen today as a complex pattern of deeply embedded psychological characteristics that are largely nonconscious and not easily altered, expressing themselves automatically in almost every facet of functioning. Intrinsic and pervasive, these traits emerge from a complicated matrix of biological dispositions and experiential learnings, and ultimately comprise the individual's distinctive pattern of perceiving, feeling, thinking, coping, and behaving. Personality is the patterning of characteristics across the entire matrix of the person. Rather than being limited to a single trait, personality regards the total configuration of the person’s characteristics: interpersonal, cognitive, psychodynamic, and biological. Each trait reinforces the others in perpetuating the stability and behavioural consistency of the total personality structure. For the personality disorders, then, causality is literally everywhere. Each domain interacts to influence the others, and together, they maintain the integrity of the whole structure. In contrast, the causes of the Clinical Syndromes are assumed to be localizable. The cause of an adjustment disorder, for example, lies in a recent change in life circumstances. Here, causes and consequences are distinguishable, with discrete distinction between the underlying “cause” and its symptom expression. Difficulty making an adjustment might result in feelings of depression, for example. For the personality disorders, however, the distinction between cause and symptom is lost. Instead, causality issues from every domain of functioning. Each element in the whole structure sustains the others. This explains why personality disorders are often resistant to psychotherapy. Personality disorders are not diseases; thus, we must be very careful in our causal usage of the term “disease”. To imagine that a disorder, of any kind, could be anything other than a medical illness is very difficult. The idea that personality constitutes the immunological matrix that determines our overall psychological fitness is intended to break the long-entrenched habit of conceiving psychopathology as one or another variant of a disease, that is, some “foreign” entity or lesion that intrudes insidiously within the person to undermine his or her so-called normal functions. The archaic notion that these disorders represent external intrusions or internal disease processes is an offshoot of pre-scientific ideas such as demons or spirits that ostensibly “possess” or cast spells on the person. The role of infectious agents and anatomical lesions in physical medicine has reawakened this archaic view. While we no longer see demons, many still see PDs as involving some alien or malevolent force which invades and unsettles the patient's otherwise healthy status. This view is an appealing simplification to the layman, who can attribute his/her irrationalities to some intrusive or upsetting agent. It also has its appeal to the less sophisticated clinician, for it enables him or her to believe that the insidious intruder can be identified, hunted down, and destroyed. Such naive notions carry little weight among modern-day medical and behavioural scientists. Given our increasing awareness of the complex nature of both health and disease, we now

15 recognize, for example, that most physical disorders result from a dynamic and changing interplay between individuals' capacities to cope and the environment within which they live. It is the patients' overall constitutional makeup - their vitality, stamina, and immunological system - that serves as a substrate that inclines them to resist or to succumb to potentially troublesome environmental forces. To illustrate: infectious viruses and bacteria proliferate within the environment; it is the person’s defences that determine whether or not these microbes will take hold, spread, and, ultimately, be experienced as illness. Individuals with robust immune activity counteract the usual range of infectious microbes with ease, whereas those with weakened immunosuppressive capacities are vulnerable, fail to handle these “intrusions”, and quickly succumb. Similarly, structural disorders such as coronary artery disease are not merely a consequence of food consumed or life stress but reflect in large measure each individual’s metabolic capacity to break down lipoprotein intake; it is the body's ability to process nutritional excess that is a major determinant of whether arterial disease does or does not occur. Those with balanced enzymatic functions will readily transform and dispose of excess lipids, whereas those with less adequate equipment will cumulate arterial plaques that gradually develop into disease. PDs should be conceived as reflecting the same interactive pattern. Here, however, it is not the immunological defences or enzymatic capacities but the patient's coping skills and adaptive flexibilities that determine whether or not the person masters or succumbs to his/her psychosocial environment. Just as physical ill health is likely to be less a matter of some alien virus than it is a dysfunction in the body’s capacity to deal with infectious agents, so too is psychological ill health likely to be less a product of some intrusive psychic strain than it is a dysfunction in the personality’s capacity to cope with life’s difficulties. Viewed this way, the structure and characteristics of personality become the foundation for the individual’s capacity to function in a mentally healthy or ill way. To restate matters, PDs are not disorders in the usual medical disease sense. Rather, PDs are theoretical constructs employed to represent varied styles or patterns in which the personality system functions maladaptively in relation to its environment. When the alternative strategies employed to achieve goals, relate to others, and cope with stress are few in number and rigidly practiced ( adaptive inflexibility ), when habitual perceptions, needs, and behaviours perpetuate and intensify pre-existing difficulties ( vicious circles ), and when the person tends to lack resilience under conditions of stress ( tenuous stability ), we speak of a clinically maladaptive personality pattern, that is, a PD.

A. Differentiating Normality and Abnormality Numerous attempts have been made to develop definitive criteria for distinguishing psychological normality from abnormality. Some of these criteria focus on features that characterize the so-called normal, healthy, even ideal, state of mental health. Others have sought to specify criteria for concepts such as abnormality or psychopathology. Such distinctions between normality and pathology are largely social constructions or cultural artefacts. While persons may be segregated into groups according to overt and reproducible criteria, lending such classifications the respectability and occasionally even the substance of science, the desire to segregate and the act of segregating such persons is a uniquely social phenomenon. Hence, all definitions of pathology, ailment, malady, sickness, illness, disorder, or derangement are ultimately value-laden and circular. Disorders are what doctors treat, and what doctors treat is defined implicitly by social standards which for the most part are assumed and thus exist at a nonconscious level. Given its social heritage, positive aspects of normality are best exemplified by participation in those behaviours and customs that are prototypal for one's reference group. Conversely, pathology or disorder is exemplified by behaviours which are uncommon, irrelevant, or hostile to that reference group. However uncomfortable one may be with the knowledge that abnormality is largely a social construction, the origins of this construction may at least be acknowledged and dealt with

16 heuristically, without reification. Accordingly, normality and pathology must be viewed as relative concepts; they represent arbitrary points on a continuum or gradient - no sharp line divides normal from pathological behaviour. Among diverse and ostensibly content- and culture-free criteria used to signify normality are a capacity to function autonomously and competently, a tendency to adjust to one’s social milieu effectively and efficiently, a subjective sense of contentment and satisfaction, and the ability to self-actualize or to fulfil one’s potentials throughout the life span into one’s later years. PDs were noted either by deficits among the preceding or by the presence of characteristics that actively undermine these capacities. Perhaps these criteria are too Westernized or Eurocentric to be universal. While the unfolding and rich differentiation of some immanent plan of organismic potentials would seem to be generic to all development, its ultimate expression is specified by social and cultural forces. In some Asian cultures, for example, where the individual is expected to subordinate individual ambitions to group consensus, the capacity to function autonomously might be praiseworthy, but the desire to do so is not. Developmentally, personality pathology results from the same forces as involved in the development of normal functioning. Important differences in the character, timing, and intensity of these influences lead some individuals to acquire pathological constraints and others to develop more adaptive traits. When an individual displays an ability to cope with the environment in a flexible manner, and when his or her typical perceptions and behaviours foster increments in personal satisfaction, then the person is deemed by the larger reference group to possess a normal or healthy personality. Conversely, when average or everyday responsibilities are responded to inflexibly or defectively, or when the individual’s perceptions and behaviours result in increments in personal discomfort or curtail opportunities to learn and to grow, then we may speak as a linguistic contrivance of a pathological or maladaptive pattern. Despite the foregoing, it should be noted that the traits which compose a number of personality styles are likely in certain historical periods or cultures, such as contemporary Western societies, to promote healthy functioning (e.g., Histrionic, Compulsive, Narcissistic traits). Similarly, in this society, there are personality styles and traits that are highly conducive to pathological functioning (e.g., Avoidant, Dependent, Masochistic). There are other personality patterns (e.g., Schizotypal, Borderline, Paranoid) which have a very small probability of falling at the normal end of the continuum in almost all cultures.

Contributors: G. E. Berrios, Juan J. Lopez-Ibor

III. HISTORICAL REVIEW

The interest in the description of individual differences is very old. In Theophrastus’ 10 Characters, written in the 3 rd century BC, 32 different types of human beings are described, some of them familiar to clinicians nowadays. Among them there are some in which there is a poor control of their impulses (shamelessness, loutishness, coarseness) and in others obsessive traits (superstition). Since then universal literature is full of archetypal individuals, like the characters of Shakespeare, Molière, Cervantes or Dostoyevsky. Current conceptions of personality, therefore, are the result of a long and continuing history. Despite the desultory nature of our path to knowledge, there appear to be certain themes and concepts to which clinicians and theorists return time and again; these are noted as the discussion proceeds in this module. As noted, perhaps the first explanatory system to specify personality dimensions is likely to have been the doctrine of bodily humours posited by early Greeks some 25 centuries ago. Interestingly, history appears to have come full circle. The humoural doctrine sought to explain

17 personality with reference to alleged body fluids, whereas much of contemporary psychiatry seeks answers with biochemical and endocrinological hypotheses. In the fourth century B.C. Hippocrates concluded that all disease stemmed from an excess of or imbalance among four bodily humours: yellow bile, black bile, blood, and phlegm. Humours were the embodiment of earth, water, fire, and air - the declared basic components of the universe according to the philosopher Empedocles. Hippocrates identified four basic temperaments, the choleric, melancholic, sanguine, and phlegmatic; these corresponded, respectively, to excesses in yellow bile, black bile, blood, and phlegm. Modified by Galen centuries later, the choleric temperament was associated with a tendency toward irascibility, the sanguine temperament prompted the individual toward optimism, the melancholic temperament was characterized by an inclination toward sadness, and the phlegmatic temperament was conceived as an apathetic disposition. Although the doctrine of humours has been abandoned, giving way to scientific studies on topics such as neurohormone chemistry, its terminology and connotations still persist in such contemporary expressions as being sanguine or good humoured . The writer and physician Juan Huarte de San Juan, in his work Examination of wits for the sciences 11 introduced a clinical perspective in the description of individual differences. It was at the end of the 18 th century in France, coinciding with the birth of modern psychiatry, where the distinction between immoral behaviour and mental illness appeared. Up to then general hospitals, especially in France, were institutions for all those on the social margins of society, not just for the insane or the ill. Along the 19 th century the concept of pathological personality was forged. Pinel in 1809 described his manie sans délire , that is to say, mental illness without symptoms of illness, to which he later on also referred as folie raisonnante , that is to say, madness without insanity. The ancients speculated also that body structure was associated with the character of personality. Whereas the humoural doctrine may be seen as the forerunner of contemporary psychiatric neurobiology, phrenology and physiognomy may be conceived as forerunners of modern psychiatric morphology. Physiognomy, first recorded in the writings of Aristotle, sought to identify personality characteristics by outward appearances, particularly facial configurations and expressions. People sought to appraise others throughout history by observing their countenance, the play in their face, and the cast of their eyes, as well as their postural attitudes and the style of their movements. It was not until the late eighteenth century, however, that the first systematic effort was made to analyze external morphology and its relation to psychological functions. Despite its discredited side, phrenology, as practiced by Franz Josef Gall, was an honest and serious attempt to construct a science of personology. Although Gall referred to his studies of “brain physiology” as “organology” and “crainoscopy”, the term phrenology, coined by a younger associate, came to be its popular designation. The rationale that Gall presented for measuring contour variations of the skull was not at all illogical given the limited knowledge of eighteenth- century anatomy. In fact, his work signified an important advance over the naive and subjective studies of physiognomy of his time in that he sought to employ objective and quantitative methods to deduce the inner structure of the brain. That these assertions proved invalid should not be surprising when we recognize, as we do today, the exceedingly complex structure of neuroanatomy and its tangential status as a substrate for personality functions. Despite the now transparent weaknesses of Gall’s system, he was the first to attempt a reasoned thesis for the view that personality characteristics may correlate with body structure. A late nineteenth-century French psychologist, T. Ribot 12 attempted to formulate character types in a manner analogous to botanical classifications. By varying the intensity level of two traits, those of sensitivity and activity, Ribot sought to construct several major types. Among the personalities proposed were: (I) the “humble character”, noted by excess sensibility and limited energy; (2) the “contemplative character”, marked by keen sensibility and passive behaviour; and (3) the “emotional type”, combining extreme impressionability and an active disposition. Among other major categories were the “apathetic” and the “calculative” characters.

18 Attempts were made in the early twentieth century to identify the constituents of temperament and determine the ways in which they blend into distinctive patterns. The ideas proposed by several theorists illustrate this line of thinking. Among the first of these was the psychiatrist E. Hirt, director of a German asylum. Extrapolating from work with institutionalized cases, Hirt divided temperament in accord with the classical four humours, but, in addition, he attempted to find their parallels among psychiatric populations. To Hirt, those who possessed an accentuated phlegmatic temperament were inclined to exhibit a morbid apathy such as seen in cases of dementia praecox; these patients were not only inactive but lacked insight, seemed detached from the world, and were too indifferent to complain about their plight. Patients endowed with a sanguine temperament to an extreme degree were characterized by superficial excitability, enthusiasm, and unreliability, and were therefore typically diagnosed as hysterical types; to Hirt, vanity, a craving for attention, and the seeking of enjoyment served as their primary stimuli for action. The choleric temperament was found among several subcategories of patients, including suspicious characters who were forever anticipating treachery and ill-will, and grumbling types who were invariably critical of others, claiming their personal superiority to all “if only they were given a chance”. Those of a melancholic disposition were divided into two categories: Those of an active inclination were filled with an irritable pessimism and bitterness, and those more passively inclined were found among speculative and brooding types. Throughout the nineteenth century, German psychiatrists abandoned what they considered to be the value-laden theories of the French and English alienists of the time and moved toward what they judged to be empirical or observational research. Among this group was J.A. Koch who proposed replacing the label moral insanity with the term psychopathic inferiority , under which he included: “All mental irregularities whether congenital or acquired which influence a man in his personal life and cause him, even in the most favourable cases, to seem not fully in possession of normal mental capacity”. Koch used the term psychopathic , a generic label employed to characterize all personality diagnoses until recent decades, to signify his belief that a physical basis existed for these character impairments. Thus, he sated: “They always remain psychopathic in that they are caused by organic states and changes which are beyond the limits of physiological normality. They stem from a congenital or acquired inferiority of brain constitution”. The prime psychiatric nosologist at the turn of the century, Emil Kraepelin, did not systematize his thinking on PDs until the eighth edition of his major text, in 1913. Until then, Kraepelin paid but scant attention to personality disturbances, concentrating his organizing efforts on the two major syndromes of dementia praecox and maniacal depressive insanity. In his efforts to trace the early course of these syndromes, Kraepelin “uncovered” two premorbid types: the “cyclothymic disposition”, exhibited in four variants, each inclined to maniacal-depressive insanity; and the “autistic temperament”, notably disposed to dementia praecox. In addition, Kraepelin wrote on a number of so-called morbid personalities, those whom he judged as tending toward criminality and other dissolute activities. The four varieties of the cyclothymic disposition were labelled the “hypomanic”, the “depressive”, the “irascible”, and the ”emotionally unstable”. The best-known European classification of disordered personalities was proposed by Kurt Schneider. Schneider differed from many of his contemporaries, most notably Kretschmer, in that he did not view personality pathology to be a precursor to other mental disorders but conceived it as a separate group of entities that covaried with them. Ernst Kretschmer was the prime modern constitutionalist, suggesting a series of inventive propositions that he sought to support empirically. In his early research, Kretschmer categorized individuals in accord with their physical build and attempted to relate morphological differences to schizophrenia and manic-depressive psychosis. As his work progressed he extended the presumed relationship of physique, not only to severe pathology but also to premorbid personality and to “normal” temperament. The best-known and perhaps most fully conceptualized of PDs are those formulated by psychoanalytic theorists. Their work was crucial to the development of an understanding of the

19 causal agents and progressions that typify the background of these disorders. It was Sigmund Freud and his early associates who laid the foundation of the psychoanalytic character typology. These categories were conceived initially as a product of frustrations or indulgences of instinctual or libidinous drives, especially in conjunction with specific psychosexual stages of maturation. These notions, referred to as oral, anal and genital character types were fully formulated by his younger associates, Karl Abraham and Wilhelm Reich. Carl G. Jung, another young Freudian disciple and later dissident, was among the seminal thinkers in proposing his distinction between extraversion and introversion. Extraversion represented the flowing of energy toward the outer world, whereas introversion was a flow inward. Extraverts explain events from the viewpoint of the environment, seeing things as coming from without. The introvert's approach is essentially subjective, drawing from the environment whatever is perceived as necessary to satisfy inner inclinations. Faced with the insecurities and inevitable frustrations of life, the neo-Freudian analyst, Karen Horney, identified three broad modes of social relating: “moving toward” people, “moving against” people, or “moving away” from others. Horney formulated three character types to reflect each of these three social modes: Moving toward is found in a “compliant” type; moving against, in an “aggressive” type, and moving away, in a “detached” type. In 1950 Horney reconceptualized her typology in line with the manner in which individuals solve intrapsychic conflicts. Corresponding roughly to the prior trichotomy, they were termed the “self-effacement” solution, the “expansive” solution, and the solution of “neurotic resignation”. Although these sets of three do not match perfectly, they do correspond to the essential themes of Horney’s characterology. Although numerous analytic theorists have continued to contribute to the study of character, the contemporary work of Otto Kernberg deserves special note. Taking steps to develop a new psychoanalytic characterology, Kernberg constructed a framework for organizing personality types in terms of their level of severity. Breaking away from a rigid adherence to Freud’s psychosexual model, Kernberg proposed the dimension of structural organization. Coordinating character types in accord with severity and structural organization lead Kernberg to speak of “higher, intermediate and lower levels” of character pathology; both intermediate and lower levels are referred to as “borderline” personality organizations. Another contemporary theorist, Lorna Benjamin 13 , recognized the interplay of cognitive, affective, and interpersonal dimensions in her effort to articulate the qualities of each PD. Her model encompasses elements of the recent work of the cognivists and those of a psychodynamic orientation. Her venue is centred in the interpersonal sphere (although her schematic includes phenomenological and intrapsychic features as well). Note should be made of another productive personologist who utilized a mathematical/factorial approach to construct personality dimensions, namely Raymond Cattell 14 . His research has led him to identify 16 primary factors, or source traits, which he then arranged in sets of bipolar dimensions that would undergird personality types. Other contemporary quantitative contributors include Peter Tyrer 15 and W. John Livesley 16 . In a model which seeks to draw on genetic and neurobiologic substrates, Robert Cloninger 17 has proposed a complex theory based on the interrelationship of several trait dispositions. Central to his formula are a series of heritable characteristics or dimensions, notably: novelty seeking, harm avoidance, and reward dependence. Each of these is associated with different neurobiologic systems, respectively dopamaninergic, serotonergic, and noradrenergic. The interaction of these heritable traits shape the development of personality by influencing learning experiences, processing information, mood reactions, and general adaptation. Another biosocial model using three pairs of evolutionary polarities as a basis is one developed by Theodore Millon 18 . Here, he derived a PD taxonomy that subsumed the dependent, independent, ambivalent, and detached coping styles with an activity-passivity dimension. This produced eight theoretically-derived personality types of an innovative character, e.g., avoidant, narcissistic, borderline. Despite their correspondence to the official DSM PDs, these PDs were

20 considered to be conceptual and prototypal, seen essentially to represent styles of maladaptive functioning that stem from different deficiencies, imbalances, or conflicts in the human species’ capacity to relate to the environments it faces. Notably, in their recent work, numerous theorists have begun to turn their attention to positive mental health, speaking of personality resilience and adaptive capacities.

Contributors: Juan J. Lopez-Ibor and Erik Simonsen

IV. CLASSIFICATION ALTERNATIVES

Classification is “the act of distributing things into classes or groups of the same type”. It has been an important subject in psychiatry since modern ways of examining the subject started in 1900 with the first edition of the International Classification of Diseases (ICD). Interest has accelerated since the publication of the third edition of the DSM in the United States and the eight edition of the ICD. There have been many changes, not always based on good evidence, so now there are more than three times as many mental disorders than there were in 1979. When we focus our attention on the specific area of personality disorders, there has long been controversy. This is due to a combination of limited evidence, cultural variation, definitional uncertainty, variation in theoretical models, and the influence of pressure groups. Despite the many existing problems related to classifications in the general field of psychiatry, personality characteristics reflect the diversity of cultural influences. However, there is general agreement that personality disorders are conditions in which there is abnormal behaviour and attitudes, that these create distress and social dysfunction, and that they cannot be attributed to a temporary or longer term disruption created by the presence of a mental state disorder. There is also agreement it is only when a person’s behaviour pattern deviates markedly from the standards of the individual’s culture that the diagnosis of personality disorder should be entertained.

A. The Current Official Systems Two classificatory systems of mental disorders are recognized internationally today, namely, the Diagnostic and Statistical Manual of Mental Disorders - 4th Edition-Text Revised (DSM-IV-TR)19 and the International Classification of Mental and Behavioural Disorders (ICD-10) 20 . Personality disorders are given important weight in both classifications. The DSM-IV-TR places them in its separate Axis II (this classification comprises five such axes). The personality disorders in the DSM are grouped into three clusters, based essentially on empirical descriptive similarities; this cluster grouping has not (and maybe never will be) been satisfactorily validated but its widespread use indicates a frequent wish to reduce the number of categories. Cluster A includes paranoid, schizoid and schizotypal personality disorders (the so-called odd or eccentric individuals), Cluster B comprises antisocial, borderline, histrionic and narcissistic PDs (the ostensible dramatic, emotional or erratic individuals), and Cluster C includes avoidant, dependent and obsessive-compulsive PDs (anxious/fearful individuals). A last category, “PD not otherwise specified”, comprises disorders of personality that do not fulfil the specific criteria for any of the above individual PDs. An Appendix B includes two more PDs, those that need further study, the depressive and the passive-aggressive (negativistic) PDs. Also noteworthy are two other PDs included in Appendix A of the DSM-III-R21 ; these were dropped in the DSM-IV, the sadistic and the self-defeating personalities, this later type, known better as the masochistic personality, was said to be one of the most frequent PDs found in clinical studies. The ICD-10 Classification includes a single section covering all personality abnormalities and persistent behavioural disturbances. This is separated into specific named personality disorders, mixed and other personality disorders, and enduring personality changes. The individual personality

21 disorders are paranoid, schizoid, dissocial, emotionally unstable (impulsive and borderline types), histrionic, anxious (avoidant), anankastic and dependent ones. Two more categories are “other specific PDs” and “PD, unspecified”. The ICD classification is similar to that of DSM-IV, although differences are noteworthy. For example, the borderline PD of the DSM-IV is subsumed as one of the two emotionally unstable disorders in ICD-10, the obsessive-compulsive adjective in DSM-IV is retained as ‘anankastic’ in ICD-10, and avoidant personality disorder is only a partial equivalent of the ICD-10 anxious personality disorder. Two more disorders included in the official section of the DSM-IV are excluded from ICD-10; schizotypal disorder is a variant within the schizophrenia spectrum of conditions in ICD-10 and narcissistic personality disorder is only mentioned in the section on “other specific PDs” in ICD-10, without any specific criteria noted for this diagnosis. The ICD-10 contains other general categories that refer to PDs that have no counterpart in the DSM-IV, such as “mixed disorders” and “other disorders of adult personality and behaviour”. The official classification systems reflect a variety of personality related issues that are unlikely to be solved in the near future. First, there is the question of the retention of personality disorders on a different axis (Axis II) from that of clinical syndromes (Axis I) in the DSM-IV. The division between Axis I and Axis II seems to some to be arbitrary and not justified adequately. A second persistent problem is the classificatory status of the individual categories of personality disorder. There is great overlap between the criteria for diagnosing personality disorders in both DSM-IV and ICD-10 and this seriously compromises their validity as separate disorders. Clear differentiation between the disorders is often difficult and many individuals diagnosed with a personality disorder have several other personality disorders that do not always appear to be fundamentally different. A third issue is the overlap of some personality disorders with disorders in Axis I. An example is the relationship between avoidant PD and generalized social phobia, both of which address the same group of symptoms without a clear distinction between them. Although still included in the Appendix B of DSM-IV, there seems to be a similar problem between depressive personality disorder (Axis II) and dysthymia (Axis I). A fourth question is how many personality disorders deserve separate description in the two classification systems? It is also uncertain what type of criteria should constitute the building blocks of personality disorder and how many of them are needed for each diagnosis. Both classifications rest mainly on historical traditions and committee consensus rather than on empirical data or well-constructed theoretical grounds. Many of the assumptions of each classification are implicit or covert and need to be exposed so that diagnosis can be made consistently and subjected to systematic testing. There are also many questions about the division between “normal” personality and personality disorders that need answering and whether it is wise to have a division at all. Another major controversy in the field is the categorical/dimensional/prototypical controversy, to which we will turn shortly. A further issue is the polythetic criterion lists used in current classification systems; these produce considerable intragroup variability such that two people with the same diagnosed PD may display very different features because they score for different sections. Finally, as already mentioned, PDs are tied to cultural variables to a much greater extent than the clinical disorders in Axis I, creating difficulties when diagnosing this kind of disorders across different cultures, a topic we will also address in a later section. Given the need for a clear unambiguous official classificatory system for personality disorders and the dissatisfaction with the current two systems, there are likely to be important changes in the classification of personality disorders in DSM-V and ICD-11, both of which are planned to be published in 2011. Perhaps the most important question is “how to we improve the clinical utility of the classification of personality disorders so that it is recognised to be helpful in decision-making at all levels?” The following sections examine the areas in which such changes are likely to be made so as to achieve this goal.

22 B. On the Reality of Personality “Syndromes” Not only are personality data complex, they can also be approached from a variety of frames of reference. As previously noted, they can be conceived and grouped behaviourally as complex response patterns to environmental stimuli. Biophysically, then can be approached and analyzed as sequences of complex neural and chemical activity. Intrapsychically, they can be inferred and categorized as networks of entrenched unconscious processes that bind anxiety and conflict. Quite evidently, the complexity and intricacy of personological phenomena not only make it difficult both to establish clear-cut relationships among phenomena, but to find simple ways in which these phenomena can be classified or grouped. Should we artificially narrow our perspective to one data level to obtain at least a coherency of view? Or should we trudge ahead with formulations which bridge domains, but threaten to crumble by virtue of their complexity and potentially low internal consistency? There is a clear logic to classifying “syndromes” in medical disorders. Bodily changes wrought by infectious diseases and structural deteriorations repeatedly display themselves in a reasonably uniform pattern of signs and symptoms that “make sense” in terms of how anatomic structures and physiological processes are altered and dysfunction. Moreover, these biological changes provide a foundation not only for identifying the etiology and pathogenesis of these disorders, but also for anticipating their course and prognosis. Logic and fact together enable us to construct a rationale to explain why most medical syndromes express themselves in the signs and symptoms they do, as well as the sequences through which they unfold. Can the same be said for classifications of personality disorder? Is there a logic, or even evidence, for believing that certain forms of clinical expression (e.g. behaviours, cognitions, affects, defence mechanisms) cluster together as do medical syndromes - in other words, that they not only covary frequently, but “make sense” as a coherently organized and reasonably distinctive group of characteristics? Are there theoretical and empirical justifications for believing that the varied features of personality display a configurational unity and expressive consistency over time? Will the careful study of individuals reveal congruency among attributes such as overt behaviour, intrapsychic functioning, and biophysical disposition? Is this coherence and stability of psychological functioning a valid phenomenon - that is, not merely imposed upon observed data by virtue of clinical expectation or theoretical bias? There are reasons to believe that the answer to each of the preceding questions is yes. Stated briefly and simply, the observations of covariant patterns of signs and symptoms, and traits may be traced to the fact that people possess relatively enduring biophysical dispositions that give a consistent coloration to their experience, and that the range of experience to which people are exposed throughout their lives is both limited and repetitive 22 . Given the limiting and shaping character of these biogenic and psychogenic factors, it should not be surprising that individuals develop clusters of prepotent and deeply ingrained behaviours, cognitions, and affects that clearly distinguish them from others of dissimilar backgrounds. Moreover, once a number of the components of a particular clinical pattern are identified, knowledgeable observers are able to trace the presence of other, unobserved, but frequently correlated features comprising that pattern. If we accept the assumption that most people do display a pattern of internally consistent characteristics, we are led next to the question of whether groups of patients evidence commonality in the patterns they display. The notion of personality “syndromes” rests on the assumption that there exist a limited number of such shared covariances - for example, regular groups of diagnostic signs and symptoms that co-occur frequently and therefore can confidently be used to distinguish certain classes of patients. For example, why does the possession of characteristic A increase the probability, appreciably beyond chance, of also possessing characteristics B, C, and so on? Less abstractly, why do particular behaviours, attitudes, mechanisms, and so on covary in repetitive and recognizable ways, instead of exhibiting themselves in a more or less haphazard fashion? And even more concretely, why should, say, behavioural defensiveness, interpersonal provocativeness, cognitive suspicion, affective irascibility, and excessive use of the projection mechanism co-occur in

23 the same individual, instead of being uncorrelated and randomly distributed among different individuals? To answer these questions, we believe that temperament and early experience simultaneously affect the development and nature of several emerging psychological structures and functions; that is, a wide range of behaviours, attitudes, affects and mechanisms can be traced to the same origins, leading thereby to their frequently observed covariance. Second, once an individual possesses these initial characteristics, they set in motion a series of derivative life experiences that shape the acquisition of new psychological attributes causally related to the characteristics that preceded them in the sequential chain. Common origins and successive linkages increase the probability that certain psychological characteristics will frequently be found to pair with specific others, resulting thereby in repetitively observed symptom or trait clusters. Hence, the existence of legitimate and understandable “syndromes” of a personality nature. Whether these evolving patterns are lifelong, that is, extend into old age, remains unknown, a question that deserves active empirical study, particularly in light of humankind’s increasingly long lives this coming century.

C. Structuring a taxonomy of personality disorders? In addition to asking about the content of personality and how a taxonomy may be established and investigated, we need to know how personality data should be organized. What units of analysis are best for grouping and differentiating clinical personalities? Though a number of formulations are possible, including the radix and class-quantitative approaches, the answer to this question has traditionally turned on whether one believes that the person should be embedded in the diagnostic system, or whether the diagnostic system should be embedded in the person the perennial controversy between categories, dimensions and prototypes. Each has advantages and disadvantages 23,24 . Categorical Models: Among the advantages of categorical typologies is their ease of use by clinicians who must make relatively rapid diagnoses with large numbers of patients whom they see briefly. Although clinical attention in these cases is drawn to only the most salient features of the patient, a broad range of traits that have not been directly observed is often strongly suggested. In fact, the capacity to suggest characteristics beyond those immediately manifest adds special value to an established system of categories. For example, let us assume that an individual is suspected of being histrionic following the observation of behaviours which are seductive and dramatic in relating to the clinical staff. After observing behaviours associated with only these two traits, what clinician would not want to inquire whether the person is stimulus seeking, needful of attention, interpersonally capricious, emotionally labile, and so on? In effect, assignment to a particular type or category often proves useful by alerting the clinician to a range of unobserved but frequently correlated behaviours. The ability of categories to extend the scope of associated characteristics contrasts with the tendency of dimensional schemas to fractionate the intrinsic unity of personality into separate and uncoordinated traits. As such, typologies restore and recompose the unity of personality by integrating seemingly diverse elements into a single syndrome. Moreover, the availability of well-established syndromes provides a standard reference for clinicians who would otherwise be faced with repeated analyses and de novo personality constructions that could not be generalized from one patient to the next. Ardent proponents of dimensional classification note a number of disadvantages of the categorical model. Categories assume the existence of discrete boundaries both between separate personality styles and between normality and abnormality, a feature felicitous to the medical model, but not so for personality functioning, which exists on a continuum. Consequently, diagnostic thresholds, far from being coordinated with the definition of PD in a generic sense, are essentially arbitrary, with the result that small changes in diagnostic criteria may radically influence prevalence estimates. Moreover, by being oriented to the presence or absence of a disorder, even groups rigorously diagnosed by structured interviews may be biased by a substantial subsample that

24 possesses subclinical traits for another disorder. To state the problem more generally, assume a researcher is interested in an Axis I condition: If the Axis I disorder and an Axis II personality diagnosis are strongly comorbid, is it better for research purposes to include only those with the Axis I condition to obtain a pure representation of this disorder, or to let the group be biased together with the Axis II condition on the grounds that this sample is in fact more representative? Dimensional Models: Dimensional models possess a number of virtues. Most important is that they combine several clinical features or personality traits into a single profile, which can be grasped and interpreted by experienced clinicians almost in toto. Because of their comprehensiveness, little information of potential significance is lost; nor is any single trait given special attention, as when only one distinctive characteristic is brought to the foreground in a typology. Further, a trait profile permits the assessment of unusual or atypical cases; in typologies, odd, infrequent, or "mixed" conditions often excluded since they do not fit the prescribed categories. Given the diversity and idiosyncratic character of many clinical personalities, a dimensional system encourages the representation of individuality, rather than “forcing” patients into categories for which they are ill-suited. A final advantage of a dimensional format is that the strength of traits is gauged quantitatively - each characteristic extends into the normal range; as a consequence, normality and abnormality are merely arranged as points on a continuum rather than as distinct and separable phenomena. In contrast to categories, dimensional schemas recognize the tenuous nature of the normal-abnormal distinction. Indeed, continuity is the cardinal feature of dimensional systems as they are usually articulated. Unfortunately, while the arguments of those who favour the adoption of dimensional models centre mainly around one theme, that the categorical model, because it entails discrete boundaries between the various disorders and between normality and abnormality, is simply inappropriate for the PDs, the kind of discreteness that dimensional systems often bring to personality assessment, discreteness between dimensions, tends to be largely overshadowed by the continuity characteristic of each dimension itself. Many dimensional systems, for example, have been created methodologically through factor analytic techniques explicitly designed to extract independent or orthogonal factors (e.g. the five-factor model). In other words, an individual’s standing on any one dimension is in no way related to his or her standing on any other dimension. One can ask, however, as dimensional proponents have of the categorical model, does the world really work this way? The answer to this question is to be found in the systems conception of personality. The cardinal feature of systems is their functional-structural interdependence. What exists in one domain of the system constrains what can comfortably co-exist elsewhere. A child born with a reactive, choleric temperament, for example, might develop any number of future personality characteristics, but would probably not grow up to become a sanguine diplomat, delicately weighing this and that to the satisfaction of all sides with great premeditation. Thus, while a system is a system precisely because of interrelationship between essential variables, a taxonomy of orthogonal dimensions is orthogonal precisely because it presumes independence among essential variables, an absence of interrelationships. While the world does not exist in categories, neither can it be supposed to exist in “rows and columns” 25 . Other complications and limitations have been noted in the literature, and these should be recorded also. Some traits possess inherently positive connotations, and so are anchored in normality, while other traits possess inherently negative connotations, and so are anchored exclusively in the undesirable or clinical realm. An example here would be emotional stability versus emotional vulnerability. Other trait dimensions may be conceived that are psychologically curvilinear, such that both extremes have negative implications; an example of this would be found in an activity dimension such as listlessness versus restlessness. Additionally, while trait dimensions have a number of desirable properties, there is little agreement among their proponents concerning either the nature or number of traits necessary to represent personality adequately. For example, Menninger 26 contends that a single dimension will suffice; Eysenck 27 asserts that three are needed, whereas Cattell 28 claims to have identified as many as

25 33 and believes there to be many more. Theorists may, in fact, “invent” dimensions in accord with their expectations rather than "discovering" them as if they were intrinsic to nature, merely awaiting scientific detection. Apparently, the number of traits required to assess personality is not determined by the ability of our research to disclose some inherent truth but rather by our predilections for conceiving and organizing our observations. Describing personality with more than a few such trait dimensions produces schemas so complex and intricate that they require geometric or algebraic representation. Although there is nothing intrinsically wrong with such quantitative formats, they do pose considerable difficulty both in comprehension and in communication among professionals. Most mental health workers are hesitant about working with complex multivariate statistics, and the consequent feeling that one is lost in one's own professional discipline is not likely to make such schemas attractive, no less practical for everyday use. Apart from matters of convenience and comfort, dimensional profiles are often grouped into categories before the information they contain can be communicated. Indeed, it is not clear that dimensional models can free themselves from ultimately embracing the category-like entities their proponents so much eschew. Paradoxically, as more and more external variables are correlated with a particular profile, the profile itself begins to take on aspects of an integrative hypothesis, effectively acquiring a construct-like nature. Thus, clinicians and researchers begin to focus, for example, on 4-9 and 1-2 profiles, and these groups become an area of interest and investigation. The tendency to simplify dimensional profiles suggests that even if a dimensional format were universally adopted, researchers might well end up studying populations of profiles rather than persons. Prototypal Models: Prototypes are a relatively recent diagnostic innovation, one first implicitly adopted in the DSM. The prototype is neither category nor dimension, but a synthesis of both. For several reasons, prototypal models may become the preferred schema for representing PDs and clinical syndromes. First, most contemporary typologies neither imply, nor were constructed, as all- or-none categories. Most advocates of the dimensional approach to clinical practice choose to overlook the fact that the word “categories” has been used very loosely in the DSM. Second, the prototype construct recognizes the explicit heterogeneity of personality disordered patients. Pure prototypal cases are extremely rare; most patients meet criteria for multiple disorders and may have subclinical features of other personality styles as well. Indeed, the problems imputed to categorical models largely evaporate if categories are regarded as prototypes. Prototypal constructs do not assume discrete boundaries 29 and have the advantage that they are already implicit in the diagnostic system. A prototype consists of the most common features or properties of members of a category and thus describes a theoretical ideal or standard against which real people can be evaluated. All of the prototype's properties are assumed to characterize at least some members of the category, but no one property is necessary or sufficient for membership in the category. Therefore, it is possible that no actual person would match the theoretical prototype perfectly. Instead different people would approximate it to different degrees. The more closely a person approximates the ideal, the more closely the person typifies the concept. Explicit in this description is the use of diagnostic criteria as a heuristic method, not as a reified model. The surplus causal meaning associated with latent taxons need not be postulated. Such an approach would seem thoroughly consonant with the atheoretical orientation of the DSM, which, if taken to its logical conclusion, should be atheoretical not only with regard to the various schools of psychopathology but structurally as well. Because certain literatures, methodologies, and structural models appear to cohere tenaciously - for example, empiricism, the lexical approach, factor analysis, and dimensional models - this point cannot be underestimated. How might prototypes actually be used in clinical contexts? As Horowitz and associates 30 noted, the resemblance of an individual to the prototype is necessarily a qualitative as well as a quantitative affair. Although categories and dimensions inevitably sacrifice one or the other kind of information, the prototype conserves both. That is, by its heuristic nature, the prototype asks both how and how much the individual resembles the prototype. Thus, not all persons who have “coronary artery disease” (CAD) have the same blockages in their arteries; some have them in the

26 left descending main, some in the circumflex, and so on. However, all have CAD. Similarly, not all persons with metastatic carcinoma are identical in their pathology; the disease of some is relatively localized, others are widespread, some are slow growing, others faster, yet all importantly evidence the same basic disease process. Will the same variation be true for personality prototypes? There is a logic for asserting that certain behaviours, cognitions, and moods cluster together as do medical syndromes. As noted previously, these characteristics not only covary frequently, but they “make sense” as a distinctive group of clinical traits that evidence configurational unity and expressive consistency. The question remains, however, are there not variations in these “reasonably consistent” patterns of clinical characteristics? Each personality prototype will display a cluster of cohesive characteristics, but it is also clear that each PD will evidence variations in the manner in which its clinical features are manifested. It is these numerous variations that clinical theorists have termed personality subtypes or prototypal variants 31 . The fact that patients can profitably be classified into personality prototypes does not negate the fact that patients, so categorized, may display a measure of clinical difference as well, a fact observed quite routinely, as noted previously, with medical diseases. It is argued by prototypal researchers, such as Westen 31 , that the widely publicized categorical versus dimensional debate may, in part, be resolved by identifying the numerous prototypal variants that exist among PDs. According to this research, only a small subset of the basic trait characteristics that have been theoretically or empirically proposed in the literature are found to combine in clinically relevant ways. Every conceivable combination of traits does not emerge as personality variants; that is, only a few of the many combinations that are mathematically possible are in fact found to be theoretically coherent or clinically evident. Only those few prototypal variants which cohere “realistically” in actual clinical practices are worth including in a PD taxonomy.

Contributors: Vicente Caballo, Theodore Millon and Drew Westen

V. DEVELOPMENTAL PATHOGENESIS

PDs begin to be diagnosed in adolescence, but usually have precursors in childhood. For example, adults with antisocial disorder usually have a preceding history of conduct disorder, a childhood condition that closely resembles the adult diagnosis. In most cases, PDs continue over the course of adult life. However, certain groups of patients (notably those in the borderline category) have been shown to improve and a small proportion do attain normal levels of functioning. These observations underline the clinical challenge of understanding and treating these populations. The premise that early experience plays a central role in shaping personality attributes is one shared by numerous theorists. To say the preceding, however, is not to agree as to which specific factors during these developing years are critical in generating particular attributes, nor is it to agree that known formative influences are either necessary or sufficient. Psychoanalytic theorists almost invariably direct their etiologic attentions to the realm of early childhood experience. Unfortunately, they differ vigorously among themselves as to which aspects of nascent life are crucial to development. Of increasing importance to the study of developmental pathogenesis is the need to research the nature of personality disorders in the latter years of life. Before we proceed, there is reason to ask whether etiologic analysis is even possible in personality pathology in light of the complex and variable character of developmental influences. Can this most fundamental of scientific activities be achieved given that we are dealing with an interactive and sequential chain of “causes” composed of inherently inexact data of a highly probabilistic nature in which even the very slightest variation in context or antecedent condition often of a minor or random character produces highly divergent outcomes? Because this “looseness” in the causal network of variables is unavoidable, are there any grounds for believing

27 that such endeavours could prove more than illusory? Further, will the careful study of individuals reveal repetitive patterns of symptomatic congruence, no less consistency among the origins of such diverse clinical attributes as overt behaviour, intrapsychic functioning, and biophysical disposition? And will etiologic commonalities and syndromal coherence prove to be valid phenomena, that is, not merely imposed upon observed data by virtue of clinical expectation or theoretical bias? Among other concerns is that the “hard data”, the unequivocal evidence from well-designed and well-executed research, are sorely lacking. Consistent findings on causal factors for specific clinical entities would be extremely useful, were such knowledge only in hand. Unfortunately, our etiologic data base is both scanty and unreliable. As noted, it is likely to remain so owing to the obscure, complex, and interactive nature of influences that shapes psychopathologic phenomena. The yearning among theorists of all viewpoints for a neat package of etiologic attributes simply cannot be reconciled with the complex philosophical issues, methodological quandaries, and difficult-to-disentangle subtle and random influences that shape mental disorders. In the main, almost all etiologic theses today are, at best, perceptive conjectures that ultimately rest on tenuous empirical grounds, reflecting the views of divergent “schools of thought” positing their favourite hypotheses. These speculative notions should be conceived as questions that deserve empirical evaluation, rather than be promulgated as the gospel of confirmed fact. Arguments pointing to thematic or logical continuities between the character of early experience and later behaviours, no matter how intuitively rational or consonant with established principles they may be, do not provide unequivocal evidence for their causal connections; different, and equally convincing, developmental hypotheses can be and are posited. Each contemporary explication of the origins of most PDs is persuasive, yet remains but one among several plausible possibilities. Interaction and continuity should be major considerations in understanding personality pathogenesis. Interaction of influences persists over time. The course of later characteristics is related intrinsically to earlier events; an individual’s personal history is itself a constraint on future development. PD development must be viewed, therefore, as a process in which organismic and environmental forces display not only a mutuality and circularity of influence, but also an orderly and sequential continuity throughout the full life of the individual.

A. The Role of Biogenic Influences That characteristics of anatomic morphology, endocrine physiology, and brain chemistry would not be instrumental in shaping the development of personality is inconceivable. Biological scientists know that the central nervous system cannot be viewed as a simple and faithful follower of what is fed into it from the environment; not only does it maintain a rhythmic activity of its own, it also plays an active role in regulating sensitivity and controlling the amplitude of what is picked up by peripheral organs. Unlike a machine, which passively responds to external stimulation, the brain has a directing function that determines substantially what, when, and how events will be experienced. Each individual's nervous system selects, transforms, and registers objective events in accord with its distinctive biological characteristics. Unusual sensitivities in this delicate orienting system can lead to marked distortions in perception and behaviour. Any disturbance that produces a breakdown in the smooth integration of functions, or a failure to retrieve previously stored information, is likely to create chaos and pathology. Normal psychological functioning depends on the integrity of certain key areas of biological structure, and any impairment of this substrate will result in disturbed thought, emotion, and behaviour. It must be carefully noted, however, that although biogenic dysfunctions or defects may produce the basic break from normality, psychological and social determinants are likely to shape the form of its expression. Acceptance of the role of biogenic influences, therefore, does not negate the role of social experience and learning.

28 The clinical presentation and form of PDs is determined by underlying trait profiles. These traits are partly biological, and partly environmental, in origin. Behavioural genetic research demonstrates that about 40-50% of the variance between individuals in personality traits is attributable to genetic factors. PDs show similar levels of heritability. Genetic factors in personality can sometimes be apparent early in life. For example, longitudinal studies of children have established that antisocial personality can be predicted by observations of irritable and aggressive temperament as early as age three. Research has not yet identified gene linkages and associations that can identify these diatheses more precisely. The most consistent biological markers concern the relationship of reduced central serotonergic function to trait impulsivity. Other biological markers for impulsivity include defects in executive function on neuropsychological testing, as well as imaging findings pointing to dysfunction in prefrontal cortex. Other evidence links schizotypal PD with schizophrenia through shared biological markers. Similarly, avoidant PD is preceded by high levels of temperamental anxiety. Thus, PDs share biological factors with other mental disorders that are derived from the same traits. The role of heredity is usually inferred from evidence based on correlations among traits in members of the same family. Most psychopathologists understand that heredity must play a role in PD development, but they insist that genetic dispositions are modified substantially by the operation of environmental factors. This view states that heredity operates not as a fixed constant but as a disposition that takes different forms depending on the circumstances of an individual's upbringing. 33 A number of theorists have suggested that the milder pathologies, such as PDs, represent undeveloped or minimally expressed defective genes; for example, the schizoid personality may possess a schizophrenic genotype, but in this case the defective gene is weakened by the operation of beneficial modifying genes or favourable environmental experiences 34 . An alternate explanation might be formulated in terms of polygenic action; polygenes have minute, quantitatively similar, and cumulative effects. Thus, a continuum of increasing pathological severity can be accounted for by the cumulative effects of a large number of minor genes acting upon the same trait 35 . Psychological processes such as thought, behaviour, and emotion derive from complex and circular feedback properties of brain activity. Unless the awesomely intricate connections within the brain which subserve these psychological functions are recognized, the result will be simplistic propositions that clinical or personality traits can arise as a consequence of specific chemical imbalances or focal lesion. Psychological concepts such as emotion, behaviour, and thought represent diverse and complex processes that are grouped together by theorists and researchers as a means of simplifying their observations. These conceptual labels must not be confused with tangible events and properties within the brain. Certain regions are more involved in particular psychological functions than others, but it is clear that higher processes are a product of brain area interactions. Clinical signs and symptoms cannot be conceived as localized or fixed to one or another sphere of the brain. Rather, they arise from a network of complex interactions and feedbacks. We might say that all stimuli, whether generated externally or internally, follow long chains of reverberating circuits that modulate a wide range of activities. Psychological traits and processes must be conceived, therefore, as the product of a widespread and self-regulating pattern of interneuronal stimulation. If we keep in mind the intricate neural interdependencies underlying these functions, we should avoid falling prey to the error of interpretive simplification.

B. The Role of Psychogenic Influences Personality traits are also strongly shaped by psychological factors. Interactions between temperament and life experience lead to the formation of personality profiles. By age 18, traits tend to be stable and are likely to remain so throughout most of adult life, even into later years, Psychological factors, particularly adverse events, may also be crucial in influencing whether traits cross the so-called normal threshold into clinical disorders.

29 No single environmental adversity is sufficient to produce a PD. Rather, the cumulative effects of multiple psychological and social risk and protective factors determine the threshold for psychopathology. Thus, while traumatic childhood experiences and family pathology are common in antisocial and borderline disorders, they do not fully account for their pathogenesis. The reason is that it has been repeatedly shown that most children demonstrate a remarkable level of resilience to a wide range of adversities. For this reason, the impact of life events can only be understood through their interaction with temperamental vulnerability. Attitudes and behaviours may be learned as a consequence of instruction or indoctrination on the part of parents, but much of what is learned accrues from a haphazard series of casual and incidental events to which the child is exposed. Not only is the administration of rewards and punishments meted out most often in a spontaneous and erratic fashion, but the everyday and ordinary activities of parents provide the child with “unintended” models to imitate. Thus, the particulars and the coloration of many pathological patterns have their beginnings in the offhand behaviours and attitudes to which the child is incidentally exposed. It is important, therefore, that the reader keep in mind that children may acquire less from intentional parental training methods than from casual and adventitious experience. Children are exposed to and frequently learn different and contrasting sets of perceptions, feelings, attitudes, behaviours, and so on, as well as a mixed set of assumptions about themselves and others. In a manner similar to genetic recombination , where the child’s heredity-based dispositions reflect the contribution of both parents, so too do the child’s experiences and learnings reflect the input and interweaving of what he has been subjected to by both parents. To illustrate, one parent may have been cruel and rejecting, whereas the other may have been kindly and supportive. How this mix will ultimately take psychological form, and which set of these differential experiences will predominate, will be a function of numerous other factors. The point to note, however, is that we should expect that children will be differentially affected by each parent, and that pathogenesis will reflect a complex interaction of these combined experiences. The reader should be mindful that few experiences are singular in their impact, but are modulated by the interplay of multiple forces, but mostly the commingling and consolidation of two sets of parental influences. The belief that early interpersonal experiences within the family play a decisive role in the development of psychic resilience and adaptability, as well as personality pathology is well-accepted among professionals, but reliable and unequivocal data supporting these convictions are difficult to find. The deficits in these data are not due to a shortage of research efforts; rather, they reflect the operation of numerous methodological and theoretical difficulties which stymies progress. For example, most of these data depend on retrospective accounts of early experience; these data are notoriously unreliable. Thus, patients interviewed during their illness are prone to give a warped and selective accounting of their relationships with others; information obtained from relatives often is distorted by feelings of guilt or by a desire to uncover some simple event to which the disorder can be attributed. In general, then, attempts to reconstruct the complex sequence of events of yesteryear which may have contributed to pathological learning are fraught with almost insurmountable methodological difficulties. An atmosphere, a way of handling the daily and routine activities of life or a style and tone of interpersonal relatedness, all come to characterize the family setting within which the child develops. Events, feelings, and ways of communicating are repeated day in and day out. In contrast to the occasional and scattered events of the outside environment, the circumstances of daily family life have an enduring and cumulative effect upon the entire fabric of the child’s learning. Within this setting the child establishes a basic feeling of security, imitates the ways in which people relate interpersonally, acquires an impression of how others perceive and feel about him, develops a sense of self-worth and learns how to cope with feelings and the stresses of life. The influence of the family environment is pre-eminent during all of the crucial growth periods in that it alone among all sources exerts a persistent effect upon the child.

30 The lack of significant adult figures within the family may deprive children of the opportunity to acquire, through imitation many of the complex patterns of behaviour required in adult life. Parents who provide undesirable models for imitation, at the very least, are supplying some guidelines for the intricate give-and-take of human relationships. The most serious deficit usually is the unavailability of a parental model of the same sex. For example, the frequent absence of fathers in underprivileged homes, or the vocational preoccupations of fathers in well-to-do homes, often produce sons who lack a mature sense of masculine identity; they seem ill-equipped with goals and behaviours by which they can orient their adult lives. Children subject to persistent parental bickering and nagging not only are exposed to destructive models for imitative learning but are faced with upsetting influences that may eventuate in pathological behaviours. The stability of life, so necessary for the acquisition of a consistent pattern of behaving and thinking, is shattered when strife and marked controversy prevail. There is an ever present apprehension that one parent may be lost through divorce; dissension often leads to the undermining of one parent by the other; an air of mistrust frequently pervades the home, creating suspicions and anxieties: a nasty and cruel competition for the loyalty and affections of children may ensue. Children often become scapegoats in these settings, subject to displaced parental hostilities. Constantly dragged into the arena of parental strife, the child not only loses a sense of security and stability but may be subjected to capricious hostility and to a set of conflicting and destructive behaviour models. Despite the awful conditions to which some children have been subjected (e.g., Romanian infants in the 1970’s and 80’s), we must keep in mind the resilience and adaptive capacity of numerous such youngsters.

C. The Role of Sociogenic Influences Culture is defined as the set of norms and behavioural patterns, meanings, lifestyles, and values shared and utilized by members of a given human group. Cultural variables – considered as true referential points for the identity of the group – include language, religion, education, ethical principles, traditions, patterns of social or interpersonal relations, gender and sexual orientation, technology, legal norms, and even financial philosophies. In ancient times, the material elements (tools, housing, diet) predominated in the conceptualization of culture but, later on, the so-called “non-material culture”, conceived as the result of transgenerational legacies and the advent of social organizations of unique complexity, came to dominate the definition. Furthermore, culture can multiply its parameters as a result of social changes throughout history. Two other concepts are almost immediately associated with culture in academic textbooks and professional debates. The first one is race, which is based primarily on biological, physical, and genetic assumptions, and expressed or reflected in the physiognomic, external appearance of an individual. The social and political meaning of race has largely outweighed its scientific basis - in contemporary times, many human groups have chosen race as a way to congregate themselves and gain visibility and voice in the societal context. The other term, ethnicity, essentially refers to the notion of belonging to a group or a community whose members share a common historical and geographic origin. Ethnicity is a substantial component of what is known as personal or group identity, closely linked with the concept of personality. According to Devos and Romanucci-Ross 36 , ethnic identity is essentially subjective, based on a critical sense of loyalty, and on internally and externally conferred “role attributions.” It is, therefore, significantly integrated to the cultural inheritance of individuals and groups. Research concerning psychosocial adversities and the development of PDs has focused on the influence of the family. Patients with certain PDs frequently come from dysfunctional families, which are often marked by abuse and neglect. It has also been shown that the first degree relatives of these patients also have a high rate of psychopathology, including impulsive and mood disorders. Through genetic and environmental mechanisms, these families are transmitting psychopathology to

31 their children. Yet, not all patients with severe PDs come from severely dysfunctional families. About a third seems to come from reasonably normal backgrounds, and such cases may reflect the influence of stronger temperamental factors. Some of the factors shaping personality also come from outside the family, emerging out of experiences with peers and with the wider community. Unstable social structures and high rates of social change are probably factors in the development of PDs. For example, antisocial PD is very common in some countries, and relatively rare in others. Antisocial PD is increasingly frequent in Western societies. Some evidence suggests that a similar cohort effect has led to an increase in the prevalence of borderline PD. The pathways from personality traits to disorders depend on complex interactions between risk and protective factors. The causes can be biological, psychological, or social, and each can constitute risk or protective factors. Biological risk factors (e.g., abnormal temperament) can be balanced by protective factors (e.g., traits that promote resilience). Psychological risk factors (e.g., abuse and neglect) can be balanced by positive attachments. Social risk factors (e.g., difficulty in establishing social roles) can be balanced by increased economic opportunities. Cultural psychiatry occupies itself with the definition, description, evaluation, and management of all psychiatric conditions, inasmuch as they reflect the influence of cultural factors within a biopsychosocial context. Cultural psychiatry utilizes concepts and instruments of social and biological sciences, in an effort to advance the global understanding of psychopathological entities and their treatment. It promotes a culturally relevant clinical care for each and every patient, and the formulation of a universally valued management of emotional suffering. Numerous studies have documented the scope and limitations of conventional epidemiological research 37 . Modern concepts of mental illness address its multi-causality, the primary importance of culture in conforming the unity of experience and context, and the consideration of the individual’s surroundings as an object of epidemiological study. Epidemiologic personology introduces a developmental perspective on individual differences, paired with a population-based sampling frame to yield insights about the role of personality in consequential social outcomes 38 . Culture extends the conceptualization and conduction of epidemiological studies beyond a descriptive pattern, and towards areas such as quality of life, risk and protective factors, help-seeking patterns, and utilization of services. Cultural epidemiology incorporates important elements of the traditional descriptive approach (such as measurements of disease burden, risk factors, and outcome determinants), plus purely anthropological items (relationship between culture and disease burden, and the cultural context of suffering), in order to generate: a) descriptive reports or narratives of the experience of illness (ethnographies about patterns of discomfort) 39; b) reports on the meaning of symptoms (perceived causes of the clinical problem); and c) behaviours related to help-seeking patterns be that professional or lay 40. The informative and heuristic value of this approach is potentially extraordinary. Its application to the so-called “special populations” that include ethnic minorities, different age and gender groups, and socio-economically diverse communities, is critically important 41. Cultural epidemiology emphasizes individual and group evaluations based on cultural context, beliefs, and practices. The connection with illness prevention and health promotion is self- evident: Its data translates professional concepts of disease and disorder into local concepts of illness, and vice versa. From a developmental perspective, infants and young children lack in the cognitive sophistication that allows the individual to perceive and conceptualize the cultural atmosphere in which he/she is immersed. It is at the age of 3 or 4 years that the child starts to realize racial distinctions, and between 7 and 8 he/she is already capable of cataloguing what could be called ethnic differences 42. Research 43 postulates that ethnic identity develops itself only after an ethnic group recognizes the existence of those who do not belong to it. In turn, other research studies affirm that “nobody comes to this world as a black or a white person”. The so-called social identity is conferred upon us by a complex history, by patterns of social acculturation that are, surprisingly,

32 both labile and persistent; moreover, identity is never as rigid as some would like to pretend - it is involved, on the contrary, in a continuous process of questioning and negotiations between the individual and his/her surroundings. The complexities of PDs include some of the most difficult cases in cultural psychopathology. The current epidemiological and clinical literature is not yet sufficient in a field which, on the other hand, is ripe for deeper studies. Personality and PDs are particularly relevant to issues such as social context, social change, occupation, representation of mental illness, gender roles, social disparities, self-harm or self-threats, suicide, case identification, and treatment interventions 44 . The cultural implications of all these areas – and the need for well focused epidemiological studies – are undeniable and, hence, one should be cautious about the early results of international research findings. Different studies have found that maternal anxiety significantly correlates with “child difficultness” 45. It is well known that the entry of Western culture practices into the everyday life of Hutterite communities in the United States and Canada, or of Samoans in the South Pacific, generated social disruption, and subsequent increase of delinquent behaviours and PDs among these groups 46. The same may be happening currently in China, where a raising trend of PDs may result from the country’s increasing financial and political ties with the West 47. Similarly, in cultures where family life is revered and intrafamily hierarchies are well established, the risk for the passive-dependent, avoidant, and obsessive-compulsive PDs appears to be high 48. A ritualistic upbringing creates vulnerabilities that seem to predispose individuals towards obsessive-compulsive symptomatology, and highlights the influence of religion in the occurrence of PDs 49 . Religious beliefs and experiences have also a collective impact on fragile personalities as reflected in the Guyana mass suicide, or the alien-expecting members of religious cults. Authors 50 decry the lack of meaningful internalization of values in contemporary American society, that creates goods and resolves dependency strivings in subsequent individual psychopathology. Many others have studied the divisive and disruptive impact of rapid socio-cultural changes playing on developmental and intrafamily deficiencies, a key pathogenic mechanism identified in antisocial and borderline personalities 51 . The epidemiological studies of PDs across the world suffer by the constraints of conventional epidemiology. Sometimes the instruments used limit themselves to the broad category of “PDs” without specific diagnostic criteria or clinical parameters. The definition of PD, thus, reaches the lowest common denominator level and, therefore, may confuse it with other concepts (from adjustment disorders to incipient or residual, chronic or pervasive clinical pictures). As a result, the actual prevalence and incidence figures of PDs in major epidemiological surveys are difficult to evaluate. Sometimes, the prevalence is placed at 6-8 percent in “normal” community populations, a figure which is considered extremely high by other studies 52, focused on different types of settings, or conducted in different countries: those in the so-called Third World may have, interestingly enough, a lower prevalence of PDs 53 . Lyons 54 summarizes most epidemiological studies on PDs, and formulates a solid analysis of conceptual issues, models of PD (defining, descriptive, and predisposing), PD types, and methodological aspects. On the other hand, the whole category of “PDs” in such studies may include only those that have been more frequently studied, i.e., antisocial, borderline, or histrionic (to cite the DSM-IV TR nomenclature 55); this makes it difficult not only to ascertain the real prevalence levels, but also to determine what factors of a cultural nature may have an impact on these figures. Fortunately for the cultural perspective, however, those most studied PDs are the ones that may have more social and cultural roots: a) The antisocial personality, by definition, places the individual in an adversarial or antagonistic position vis-à-vis society and its different elements or components 56. b) Borderline PD has a lot to do with the dynamics of interpersonal relations, the nature of early communication patterns between the child (and future patient) with his/her immediate family, the management of reactivity and impulsiveness, the adoption and use of a permanent personal identity, and the inability to accomplish it past the life cycle or developmental

33 phase in which such event should have taken place 57. As pointed out before, the emotional instability of borderlines has also been identified with the instability of social times in the contemporary Western world 58. c) The histrionic, obsessive-compulsive, dependent, avoidant, and narcissistic personalities do have strong social and cultural components whose study has not yet been exhausted 59 . The pathogenic power of culture in the delineation of PDs is considerable in the occurrence of violent behaviours among children who, growing in an erratic, vulnerable environment, and carriers of vulnerabilities themselves, fall prey to, for instance, the temptations of media and technologically-based games and entertainment 60 . Similarly, the presence of gangs in “ghettoized” areas of metropolitan cities, responds also to social and cultural demands of everyday survival, or to the needs of individual and group assertiveness and self-affirmation 61. Finally, the different prevalence levels of types of PDs by gender, speaks to the high possibility of cultural implications: there are more borderline and passive personalities among women, possibly related to the conflict of social roles in contemporary society 62; there are more antisocial and narcissistic personalities among men, probably due to the perceived need for self-enhancement, subsequent competitiveness, and learning of social manoeuvring aimed at reaching control and exercising power 63. Coping mechanisms as critical elements of personality styles, can be decisive in the success or failure of the individual, and therefore affect his/her self-image, and his/her stands within the community or group of origin. The cultural manufacture of these coping mechanisms lies in the micro- environment of the family, and in the macro-environment of society at large throughout the different life cycles 64 . The study of cultural differences among PDs is related to basic individual-environmental interactions. It is as if society and social life shape up coping styles which, when confronted with everyday realities may succeed (normal personalities) or fail (PDs). This helps to understand why in the United States some epidemiological findings may emphasize the higher prevalence of dependency patterns among Asians, histrionic features among Latinos or Hispanic individuals, paranoid characteristics among African Americans, antisocial patterns among poor whites, and narcissistic personalities among wealthier whites 65. On the other hand, a Swiss study on diagnoses in a psychiatric emergency service showed less frequency of PDs among foreigners when compared with Swiss nationals 66 . The correlation between PDs and cultural variables such as socioeconomic status, educational level, and language proficiency is very evident. Factors such as immigration and the concomitant acculturation (with all of its different outcomes) complicate this picture and the interpretation of epidemiological findings 67. The differences between individualistic and socio-centric cultures, and their rates of narcissism, for instance, are striking 68. PDs are more frequent in urban than in rural settings 69, probably reflecting the effects of harsher stress in the everyday life of urban families. Life events of different nature affect behaviours such as incest, sexual assault, domestic violence, suicide attempts, and abuse of alcohol, tranquilizers, and other substances, all of them manifestations of different types of PDs 70 . Post-traumatic stress disorder, exemplified by victims of war, mass displacements, torture, exile, concentration camps, refugees, etc., and the pervasiveness of personality changes as a consequence, is another very relevant example 71 . Clinicians and care- providing agencies alike should be aware of the possibility that so-called “natural” responses to environmental adversities may cross the line into a truly pathological territory. This is evident in cases of antisocial behaviours, described as critical survival mechanisms among groups of young men and women in deprived areas of urban settings versus the actual diagnosis of antisocial personalities among those groups 72 . A word of caution about the interpretation of comparative data between international epidemiological surveys is important. International studies do not necessarily have the scope and depth to justify or sustain constructive cultural comparisons. A truly international psychiatric epidemiology can only be a reality through the integration of the universalist and cultural relativist approaches and their methods 73 . First of all, the findings in international surveys are based on broad

34 definitions, sometimes not even validated by socio-anthropological or clinical research. In other cases, the descriptive presentation of the rates of incidence and prevalence does not do justice to the number of cultural variables shaping up specific interpersonal behaviours. Thirdly, simplistic conclusions may not reflect or address the true purposes of the studies and, worst of all, the use of such figures for national, regional, or international mental health policy-making can be both misleading and damaging. An example of the misinterpretation of psychosocial stressors as pathogenic factors in PDs is the reality commonly faced by Latino immigrants 74. Their concern over loved ones left behind, the changes in social role or level of functioning, and in the resulting economic performance, the concomitant drop in socioeconomic status, loss of support systems, and alienation related to language difficulties may generate behaviours of resentfulness, anger, agitation, and anxious nostalgia that results in so-called “antisocial” behaviour. If we add to these, the culturally based tendency by Hispanic individuals to hide suffering due to personal pride, or in order to avoid shame or guilt, or to prevent the destruction of the family network, the implications for different types of interpersonal behaviours that may be interpreted as (or eventually lead to) pathological behaviours, is evident 75. Obviously, the chances that non-culturally structured epidemiological surveys will catch these web of circumstances and variables, are minimal at best. In sum, the influence of cultural factors in the production, diagnosis, prevalence, and impact of PDs is undeniable. It is important to keep in mind, however, that the interpretation of data responds only to the nature of the data obtained. In other terms, the current epidemiological information regarding PDs is a reflection of the limitations of the instruments utilized, and, on occasion, of the lack of cultural perceptiveness on the side of researchers, clinicians, and field workers. The cultural epidemiological approach to PDs is of critical importance. Well-conceived surveys should examine in detail child-rearing practices, family-based experiences, societal influences, life events, economic factors, acculturation events, and the value and strength of language, religion, and education in order to delineate accurate prevalence data, as well as comprehensive clinical descriptions useful for both therapeutic and preventive interventions. Cultural epidemiology addresses primarily context and meaning, concepts that have critical relevance in the study of PDs. The examination of cultural factors in personality types requires a good estimate of cultural distance at different levels,, cultural impact, and cultural and clinical characteristics of each patient 76 . This would allow more natural and conducive correlations between psychopathology and epidemiology. The field of PDs can be a serious challenge, as well as a true model for good epidemiological research. By the same token, it can generate new teaching and training approaches that will articulate epidemiological findings in a true social context, with resulting excellence in interpersonal functioning, public health enhancement, and clarity of mental health policies. Also noteworthy, we are now in a time in which few constants persevere, where values and customs are in conflict, and where the styles of human interaction today are likely to change tomorrow, we see the emergence of a new “unstructured” and “highly fluid” personality styles. In these adults we find a reflection of the contradictory and changing customs and beliefs of contemporary society. This newest pattern of childhood adaptation leaves the person unable to find the “centre” of him or herself. Such persons have learned not to demonstrate consistency and continuity in one’s behaviours, thoughts and feelings, no less in one’s way of relating to others.

Contributors: Renato D. Alarcon, Theodore Millon, Joel Paris, Michael Rutter

35 VI. DIAGNOSTIC ASSESSMENT

The clinical assessment of PD is generally considered to be one of the more difficult forms of assessment in psychiatry. For many years personality disorders were considered to be a pejorative label – best summarised as ‘the patients psychiatrists dislike’ - and this attitude still persists. However, the problems of assessing personality are really no different from assessing any condition that needs to be assessed in the round and over a long time scale. There are several questions that always need to be asked in such situations: Is the present state of the patient a representative one? What are the underlying features that are likely to persist? Is the condition part of the person’s habitual functioning or is it more likely to be part of a mental illness? The reason why a good clinical assessment is superior to other forms is that, in the right hands, it enables the patient’s premorbid personality, unaffected by any mental illness, to be assessed rather than a temporary distortion created by other illness or personality change. It also allows the key elements of the diagnosis of PD – the presence of traits that are deviant from normal in being ‘inflexible and maladaptive and cause either significant functional impairment or subjective distress’, to be analysed in a careful longitudinal way that is denied to almost all other forms of assessment. Thus the first part of assessment, deciding whether someone might or might not have a PD, is really much more satisfactorily assessed by someone who has taken the trouble to determine “enduring patterns of inner experience and behaviour that deviate markedly from the culturally expected and accepted range”, that any abnormal behaviour or attitudes is not just expressed at interview but “is inflexible, maladaptive or otherwise dysfunctional across a broad range of personal and social situations”, and has an “adverse effect on the social environment”. When choosing an instrument to assess PD it is useful to ask yourself several questions: Do I want to screen for personality disturbance or make a full assessment? Should I seek to identify only problematic personality disorders, or also identify adaptive personality traits that may be helpful in treatment? Is my reason for wanting to make an assessment a clinical or a research one? How long have I got to make the assessment? Am I interested in the type of PD, its severity, or both? There are several reasons why a quick screen for personality disturbance may be the most expedient option. First, it may be important in planning treatment for other mental disturbance. There is increasing evidence that PD has a negative influence on the outcome of other mental disorders, particularly in the longer term. It is not known whether this brake on treatment progress is a direct effect of the PD (i.e., the independent presence of a PD leads to a worse prognosis) or an indirect one in which PD interferes with the effects of treatment for a mental disorder (e.g., by reducing compliance or motivation, or impairing its application in some other way). In research studies it may be necessary to assess PD in a two-stage process; first to identify the group likely to have personality problems and then to focus on this group at a longer interview. Screening would be the first step in this process. The main advantage of research instruments is that they can be used to compare data from different investigators and settings. There is always something lost in even the best of research interviews and if an individual assessment only is needed it is preferable to combine sources of information (e.g., a screening instrument followed by a clinical interview in which the answers obtained in the screen can be explored further). An individual assessment is best shared with the subject and the personality status explored in relationship to mental symptoms. Time is one of the enemies of personality assessment. Although many would like to be able to make a quick assessment of personality status there are really no good shortcuts and an informed clinical interview, administration of a screening instrument or checklist are essential, with none of these giving the assessor confidence that an adequate assessment has been made. A good assessment takes at least an hour and can be accomplished either at one interview or, preferably if there is concurrent mental illness, several shorter ones.

36 Information is the basis of all measurement and, therefore, the basis of all clinical assessment. Four broad sources of information are available to help describe the clinical problem; each has its own advantages and limitations. The first comprise observations and clinical interviews ; the clinician observes and asks the questions and the subject responds verbally, often in a free-form style. The clinician is free to follow any particular line of questioning desired and usually mixes standard questions with those specific to the current problem. The second are formal rating scales and checklists ; a person familiar with the subject completes those forms in order to provide an objective perspective. The third source is the self-report inventory ; subjects literally report on themselves by completing a standard list of items. The fourth source of information is projective techniques , an attempt to access unconscious structures and processes that would not ordinarily be available to the subject at the level of verbal report. The use of intimates of the subject, perhaps a spouse, teacher, parent, or good friend, someone who can provide perspective on the problem, might also be considered another source of information. Physiological measurements, neurotransmitter or hormone levels, for example, provide a final source, though these are not available to most therapists. Nevertheless, where available, laboratory procedures may identify physical illnesses, e.g., AIDS, malaria, geriatric deterioration, that may induce or aggravate personality difficulties. Before we proceed to elaborate the preceding, a few words should be said about the use of the diagnostic criteria in the DSM or ICD. As matters new stand formal diagnostic criteria should not necessarily follow from any theoretical model of personality. Both the DSM and the ICD include a preamble to Axis II that defines PDs in terms of enduring, maladaptive, inflexible patterns of experience that can involve cognition, emotion, interpersonal functioning, and impulse control. Yet the actual criterion sets for almost all of the PDs do not encompass these domains of functioning and, with only eight or nine criteria per disorder, cannot do so in any but a perfunctory way. The criterion sets have evolved into multiple behavioural indicators of a single trait, not descriptions of multifaceted personality syndromes. For example, the criterion set for paranoid PD includes six criteria that are redundant measures of one trait, chronic mistrust. Establishing relative certainty that a patient is mistrustful, however, says little about the domains of functioning relevant to understanding the individual’s personality, such as how the patient thinks (e.g. how disordered can thought become?), the emotions the patient characteristically experiences (e.g., anger, sadness, anxiety), the ways the patient deals with those feelings (e.g., substance abuse? blaming others for misfortunes?), one's characteristic motives, etc. Clinically, the criteria set does not provide many essential elements of a case formulation and hence divorces case formulation from diagnosis. More systematic and comprehensive criteria than either the DSM or ICD may be found in several current texts, e.g., Millon 77.

A. Clinical Observation and Interview Methods Observation and the clinical interview are usually thought of as the standard in psychopathology, against which the validity of all other assessment instruments is judged. The development of a variety of formal, systematic observation procedures and clinical interviews, beginning around 1980, remains an important milestone in the history of PD assessment. Because interviews standardize the questions asked of patients, they greatly increase interdiagnostician reliability, defined as the extent to which different clinicians agree about the diagnosis of the same subject. This is especially true for the PDs, which are broad and overlapping constructs. Two kinds of observations and clinical interviews exist, structured and semistructured. Structured observation methods and interviews are intended to be administered by trained non- professionals and are usually used in large research projects, not in normal clinical work. A fixed series of questions is asked, and the interviewer is not allowed to deviate from these questions in any way. This standardizes the assessment process across interviewers, thus compensating somewhat for their lack of professional experience. Otherwise, the interviewer might get lost in some irrelevant tangent and waste time or record unnecessary information. Many structured interviews are

37 exclusively research instruments. Subjects are often paid to participate and may be asked to answer questions for several hours. In contrast, semistructured interviews draw on the experience and knowledge of the professional by allowing additional probes to be inserted as desired. Thus, if the subject makes a statement that might be relevant to any part of the assessment, the clinician is free to pursue the issue immediately, if desired. Some semistructured interviews are geared to a comprehensive assessment of the personality. These can take up to two hours to administer and score, even with training. Other semistructured interviews focus on a single construct and may take less than an hour. Given the necessary time commitment, semistructured interviews are not widely used in actual clinical practice. Nevertheless, they can be extraordinarily useful in clinical training. Because they already contain interview questions of demonstrated utility, they allow the student to quickly acquire a degree of knowledge in an unfamiliar diagnostic terrain. Especially useful may be the International Personality Disorders Evaluation (IPDE) interview that was developed by the World Health Organization78, 79 . At present it is the only structured interview that encompasses the diagnostic criteria for the PDs as formulated in both the ICD-10 and the DSM-IV. Studies employing this instrument in clinical facilities in 11 countries demonstrated interrater reliabilities and temporal stabilities roughly similar to instruments used to diagnose the less complicated clinical syndromes. The SCID-II 80 is a semistructured diagnostic interview assessing the 12 PDs included in DSM- IV ; the sadistic and masochistic personality constructs from the third revised edition of the DSM are not included. This interview method has often been used in research settings to describe personality profiles found in particular samples or to select patient groups for further study. In clinical settings, the SCID-II is occasionally used routinely as part of a standard intake procedure. Alternatively, a subset of the interview may be used to confirm the presence of a specific suspected PD. The SIDP-IV 81 is a semistructured clinical interview that assesses all the PDs of the DSM-IV , plus the self-defeating personality from the revised third edition of the DSM (the sadistic personality is not included). Whereas the questions of the SCID-II are grouped by disorder and closely rephrase the diagnostic criteria, those of the SIDP-IV are phrased more conversationally and grouped into 10 topic areas, such as interests and activities and emotions. Other well-designed interviews have been developed specifically to research particular PDs, notably Gunderson et al.’s DID, depressive personality 82 , the DIN, narcissistic personality 83 , and the DIB, borderline personality 84. Each includes questions geared to traits associated with its respective construct, as manifest in various domains of functioning. The Personality Assessment Schedule 85 is another assessment tool geared to identify 24 traits associated with several personality styles, notably passive-dependent, sociopathic, compulsive, schizoid and normal.

B. Rating scales and Checklists These can be completed by anyone who knows the subject well, perhaps a spouse, teacher, parent, coworker, priest, or even parole officer. Such persons are in a position to offer a unique perspective on the problem, its severity, and its causes. Rating scales and checklists may also be completed by the clinician, who makes a series of judgments on the basis of all available information, including the clinical interview. Here, rating scales and checklists often serve as a memory aid, ensuring that everything relevant to the disorder is included in developing a treatment plan. Rating scales usually have more items than the DSM-IV diagnostic criteria for the same syndrome and are usually held to a higher standard of scientific rigor. Because they have more items, they provide more fine-grained measurements, but they also take more time to complete. For example, the revised Psychopathy Checklist (PCL-R) 86 consists of 20 items, whereas the DSM-IV offers only seven criteria for the diagnosis of antisocial PD. Although the PCL-R is widely used in the study of psychopathy, few rating scales exist for use with other PDs.

38 Some situations offer a chance for flexibility, novelty, and the expression of individual differences in behaviour, and others do not. When situations are highly scripted, environmental constraints dominate and the behaviour of different individuals tends to converge, regardless of their personality traits. Almost everyone stops at a red light, and almost everyone cries at a funeral or at least tries to look sad. In contrast, when the social pull for any particular behaviour is weak, behaviour is no longer determined by the environment but by factors inside the person. An observer is, therefore, entitled to ask, “Of all the possible ways of behaving, why these particular responses, rather than others?”

C. Self Report Inventories Because self-reports represent the subject’s own responses, they can be especially valuable in quickly identifying clinical symptoms. Unless the individual is violent or psychotic, a self-report inventory can be given at any point during the clinical process, often with minimal supervision. A profile obtained at the beginning of therapy, for example, can be used as a baseline to evaluate future progress. Some questions, such as, “I am too outgoing for my own good,” assess personality traits. An item like this might be answered true by a histrionic personality, for example. Other questions, called critical items, are written to assess desperate situations that should receive immediate clinical attention, such as, “I intend to commit suicide”. In the era of managed care, where progress must be carefully documented, brief serial assessments with self-report measures chart the clinical course with speed and convenience. With more than 550 items, the MMPI-287 is not so much a standardized test as a standardized item pool that belongs to psychology itself. Literally hundreds of personality scales have been derived from the MMPI throughout its long career. In fact, there are now more auxiliary scales than there are items on the MMPI. Now in its third edition 88 , the MCMI is perhaps the most widely used PDs inventory currently. A principal goal in constructing the theoretically-based MCMI-III was to keep the total number of items constituting the inventory small enough to encourage use in all types of diagnostic and treatment settings, yet large enough to permit the assessment of a wide range of clinically relevant personality and clinical behaviours. At 175 items, the final form is shorter than are comparable comprehensive instruments. With terminology geared to an eighth-grade reading level, most subjects can complete the full-range MCMI-III in 20 to 30 minutes. A number of other self-report instruments are available. Notable are two variants of the MMPI and MCMI designed for use with troubled and troubling adolescents; the first, the MMPI-A89 is a bit briefer than the MMPI, as is the Millon Adolescent Clinical Inventory (MACI) 90 . Another recent child-oriented variant of the MCMI is the M-PACI, the Millon Preadolescent Inventory 91 for use with youngsters in the 9- to 12-year age range. Among adult-oriented inventories, there is the DSM-based Personality Diagnostic Questionnaire,92 now in its fourth revision. The Personality Assessment Inventory 93 consists of 344 items on 4 validity scales, 11 clinical scales, 5 treatment scales, and 2 interpersonal scales. Only three scales of this instrument however—Paranoia, Borderline Features, and Antisocial Features—directly assess personality pathology. The Dimensional Assessment of Personality Pathology-Basic Questionnaire 94 was based on an exhaustive literature review and a systematic scale development effort. The Schedule of Nonadaptive and Adaptive Personality 95 is a well-designed 375-item true-false instrument primarily oriented to trait dimensions derived from factor analytic research; diagnostic scales for the DSM PDs are also included. The Tridimensional Personality Questionnaire 96,97 attempts to tap Cloninger’s theoretically- derived temperament dispositions, notably novelty seeking, harm avoidance, and reward dependence. Finally, the Wisconsin PDs Inventory 98 is a 360-item inventory developed to operationalize Benjamin’s interpersonal theory 99 . Items were developed to represent the internal experience of each PD as conceived from the perspective of that theory. The NEO-PI-R100 , originally designed to assess normal personality factors, has also been employed recently to evaluate clinical personality traits.

39

D. Projective techniques These techniques seek to draw out internal, and frequently unconscious, influences on behaviour by presenting the subject with inherently unstructured, vague, or ambiguous situations. The Rorschach Inkblot Test is the classic example. The subject is presented with a series of 10 blots in turn and asked to report what he or she sees. Although the blots are not intended to look like anything in particular, subjects almost always report seeing something, ranging from the trivial to the obviously psychotic. In the Incomplete Sentence Blank, the subject writes in a response following an item stem, such as “My mother __”. The Thematic Apperception Test uses pictures of various interpersonal situations. The subject constructs a story to explain what is happening in the picture, what led up to these events, and how matters will end. Because projective instruments are time- consuming and not widely regarded as being as psychometrically sound as self-report inventories, their use has waned in recent years, especially with the economic constraints of managed care.

Contributors: Erik Simonsen, Peter Tyrer, Irving Weiner

VII. THERAPEUTIC MANAGEMENT

The history of psychotherapy in clinical psychiatry is fraught with dogmatism. Popular forms of therapy reflected various popular schools and inherited disciplinary rivalries. Their arguments were fuelled by different theoretical assumptions. The behavioural school, for example, denied the existence of mind and asserted that therapy should proceed through classical and operant principles of reinforcement. In contrast, the psychodynamic school held that behaviour reflects only the surface expression of deeply repressed or transformed motivations, percolating up from their origin in a deeper, biologically instinctive nature. A psychodynamically trained therapist would administer psychodynamic therapy. A behaviourally trained therapist would administer behavioural therapy. Rather than fit therapy to the patient, clinicians fit the patient to their own preconceived dogma. While such loyalties reigned, psychotherapists were condemned to treat only a part of the whole person. In the past few decades, however, dissatisfaction with school-oriented therapy, together with a new emphasis on efficacy motivated by managed care and governmental medicine, has led to the development of coordinated and more scientific approaches. Nevertheless, as in previous decades, the total number of therapies continues to increase. Today it is economic, social and political forces, not theoretical developments and empirical research that increasingly drive the direction of developments in psychotherapy. While modern times continue to see an explosion in the variety of therapies, it is brief therapies geared to quick and simple solutions that are in the ascendancy. These claim to accomplish in less time through patient selectivity and therapeutic specificity almost as much, if not more, than the longer term, more inclusive therapies of the past. The message to psychotherapists today is “do more, with less,” meaning, unfortunately, not only fewer sessions, but more patients, and therefore less time spent thinking about the dynamics of any one patient’s problems. For better or worse, the emphasis on efficiency has been and continues to be a primary impetus in the development of programmatic forms of therapy. Moreover, these forms have been adapted to variables at levels of analysis congruent with what is afforded by current political economic constraints. Operationalizing the content of therapy not only achieves experimental control, it diminishes the therapist’s need to “think,” at least at the “depth” levels characteristic of psychotherapy’s early origin, while presumably maintaining or even improving levels of efficacy. Interventions are linked more rigidly to diagnoses, and the need for case conceptualization is minimized.

40 Unfortunately, the PDs would seem to stand squarely and intrinsically in opposition to the current trend toward briefer and briefer therapies. The more focal Axis I clinical syndromes admit to more focal, and therefore, briefer, interventions, but the PDs, more longstanding and pervasive, stand like stone monoliths unmoved in the face of economic necessity. Is it reasonable to expect ten, or even fewer, hours with a therapist to “cure” a PD? Not only is personality not clay to be passively resculpted, the personality system, functioning as the immune system of the psyche, actively resists the influence of outside forces. To uproot a PD, one must wrangle with the ballast of a lifetime, a developmental disorder of the entire matrix of the person, produced and perpetuated across years. By any reasoning, the pervasiveness and entrenched tenacity of the pathology, soaks up therapeutic resources, leading inevitably to pessimism and disaffection for therapists. And yet, no clinician would deny the importance of personality to psychotherapy. In fact, “the characteristics that the patient brings to the treatment experience are the single most powerful sources of influence on the benefit to be achieved by treatment” 101 . Beyond the more obvious and widely discussed influences, such as transference and countertransference and the problems and opportunities these offer, the presence of a PD creates, by definition, a psychic vulnerability which not only disposes the individual to the development of an Axis I syndrome, but also complicates the course of that impairment once it in fact exists. These, in turn creates levels of stress and anxiety that keep the “psychic immune system” chronically weakened, extending the illness and making recovery even more problematic. Treating the Axis I syndrome without treating the PD is like neutralizing the symptoms without treating the disease. Whether it will prove cost-effective for mental health care concerns to follow such a course cannot be known with certainty in advance. Efforts to develop therapies which can be applied with automaticity do offer incremental gains over psychotherapy’s unstructured classical past. How long these gains will forestall the development of structured therapies specifically addressed to the PDs, to the source, in a society that seems bent on producing such pathology, is likewise an empirical question. Some disorders, after all, linger in the background and handicap the quality of life, but necessitate care only in times of acute crisis. Two major “psychological therapies” remain dominant approaches in practice worldwide. These will be presented briefly in the following paragraphs. Other schools of psychological thought and practice may be read in numerous books, e.g., 102 .

A. Psychodynamic Therapies The psychodynamic perspective on PDs derives from psychoanalytic theory. Both the diagnostic understanding and the treatment approach are based on a set of fundamental psychoanalytic principles: 1) adult personality is shaped by childhood experiences in conjunction with the genetically based temperament; 2) unconscious mental functioning is responsible for much of behaviour, emotional distress, and symptomatology; 3) transference, the displacement of past relationships onto present interactions with others, is a ubiquitous phenomenon that is of great importance to treatment; 4) countertransference, the therapist’s emotional response to the patient, is a significant source of information about the patient and the therapist in the treatment situation; 5) patients unconsciously resist efforts to help them; 6) the principle of psychic determinism, i.e., that multiple factors converge to produce symptoms and behaviour, must be taken into account in understanding causation and meaning; and 7) the unique nature of subjective experience is of equal importance to descriptive or phenomenonological factors in developing a diagnostic understanding. Psychoanalytic theory initially focused on symptomatic neuroses, such as hysterical paralysis, but rapidly evolved in the direction of studying character. One of the pioneers in this area, Wilhelm Reich 103, coined the term character armour to describe the unconscious and ego-syntonic defensive style of patients who came for analytic treatment. He postulated that childhood conflicts were mastered with specific defence mechanisms. This view has evolved over time so that a current psychodynamic perspective on personality could be viewed as having five major components: 1) a

41 biologically based temperament; 2) a set of internalized object relations; 3) an enduring sense of self; 4) specific constellation of defence mechanisms; 5) a characteristic cognitive style. The psychotherapeutic setting is seen as a laboratory in which clinicians can directly observe how their patients recreate their internal object world in the relationships they forge in the course of their daily lives. Hence the psychodynamic understanding of a patient is heavily influenced by transference and countertransference developments in the evaluation and treatment process. Personality is usefully conceptualized as involving an ongoing attempt to actualize certain patterns of relatedness that largely reflect unconscious wishes104. Through interpersonal behaviour patients try to impose a particular way of responding and experiencing on the therapist. The child internalizes a self in interaction with an “other” connected by an affect state. These interactions become etched in neural networks and become repetitive patterns of relatedness 105 . The psychodynamic therapist studies how these internal object relationships are recreated through the externalization of the self and “other” component in the transference - countertransference dimensions of the therapy. In addition to the development of the self in relation to object representations in the formation of personality, psychodynamic therapists also study the unique set of defence mechanisms found in each patient as a key to diagnostic understanding and treatment. Defences ward off awareness of unpleasant affect states, troubling sexual or aggressive wishes, and also attempt to stabilize a person’s self-esteem in the face of slights and attacks from others. In this way defences may ensure safety in response to threats. Psychodynamic therapists understand that a specific constellation of defences work in concert with the pattern of object relations to form the core of a person’s character. A person with obsessive-compulsive PD, for example, will use defences such as intellectualization, isolation of affect, and reaction formation. These defences will allow such an individual to master distressing affect states so that the patient would feel less worried about losing control. The nature of the internal object relations would be characterized by a dutiful, courteous, and responsible attitude towards those in authority. The specific defences would help to eliminate any trace of aggression or resentment toward authority figures that would allow the characteristic object relations banner to unfold. The fifth component of character, cognitive style, is closely linked to the person’s specific set of defence mechanisms. Someone with obsessive-compulsive PD, for example, lacks flexibility and spontaneity in thought processes so that the cognitive style is rigid and detail-focused. In this way it reflects a wish to control any disruptive affect states and focus on the task at hand in a way that is absorbed with detail but risks losing the broader meaning of the task. Cognitive styles appear to be reasonably consistent across personality types 106. Psychodynamic therapy has long been regarded as a highly effective treatment for PDs, and recent review articles of research in this area have confirmed this impression by citing a series of studies with impressive outcomes 107. Dynamic therapy approaches the patient as someone who will repeat in action, in the here-and-now behaviour with the therapist, unconscious aspects of the personality that cannot be remembered and verbalized. Hence the patient’s characterological pattern of internal object relations and conflicts about those relationships will unfold in front of the therapist without necessarily digging into childhood traumas to unlock hidden secrets. As a patient repeats the longstanding patterns of relatedness during the sessions, therapists will be drawn into a “dance.” As noted above, patients attempt to transform the therapist into someone from the patient’s past. The therapist maintains a free-floating responsiveness 108 to what is being evoked by the patient and uses this recreative “dance” as a way of understanding the patient’s way of relating to others outside the treatment situation. A key component of technique is for the therapist to clarify the nature of these unconscious relational patterns, acknowledging that countertransference enactments from the therapist may contribute to what is being observed. The therapist then relates these themes to narrative accounts of the patient’s life in the present and in the past. As recurrent themes emerge, they begin to make unconscious patterns more available to the patient’s conscious awareness. At the same time, the

42 therapist is observing characteristic defence mechanisms that try to ward off unpleasant feelings. When patterns of defences emerge with sufficient clarity and predictability but both patient and therapist have ample data in support of their existence, the therapist then tries to help the patient understand how the defences operate. The therapeutic action of dynamic psychotherapy involves a combination of a cognitive understanding of how the past is repeating itself in the present based on key components of one’s personality and internalization of a new object relationship with the psychotherapist. These two work in concert to modify longstanding neural networks and strengthen the development of new neural networks 109 . Psychodynamic therapy may be time-limited and be contracted to last from 20-52 sessions. Some patients with entrenched resistances, however, may be threatened by change and require a much longer period of time to accept the therapist’s observations and interpretations, as well as rethink the way they are living their lives. Some dynamic therapy is conducted at a frequency of once per week, while other dynamic therapists prefer two or three visits weekly. Psychoanalysis is on a continuum with dynamic therapy and is usually conducted at 3-4 times per week, using a couch format rather than the sitting up, vis-à-vis relationship of psychotherapy.

B. Cognitive Therapies Patients with PDs frequently pose a special challenge in cognitive therapeutic treatment 110 . The challenge is related, in part, to their deeply ingrained and overgeneralized beliefs about themselves, others, and their worlds and the compensatory strategies they have developed to cope with these painful beliefs. “Standard” cognitive therapy often must be modified to alleviate symptoms and help patients reach their goals by the coordinated use of behavioural treatment techniques that seek to implement cognitive changes in real world contexts. Therapy becomes especially difficult when patients’ Axis II related beliefs become activated during treatment itself, leading these patients to employ their characteristic, dysfunctional behavioural strategies in therapy sessions. Each PD is characterized by a specific set of dysfunctional beliefs and compensatory strategies. Dependent PD patients hold beliefs that they are incapable. They see others as strong and competent. They develop the belief, “If I try to manage on my own, I’ll fail but if I can rely on others, I’ll be okay”. Therefore, they maladaptively depend on others. Obsessive compulsive PD patients believe that they are vulnerable to having their worlds fall apart. They see others as irresponsible and negligent. Therefore they try to rigidly control themselves and others. Avoidant PD patients believe that they are defective and other people are critical and rejecting. They avoid intimacy because they are sure that they will be rejected if others see who they really are. Axis II patients bring these same kinds of beliefs and strategies to treatment. A patient with a narcissistic PD, although he acts as if he is superior, may really believe that he is inferior. He takes many opportunities to impress his therapist with his veneer of superiority, putting his therapist down and acting in entitled ways. A histrionic PD patient believes she is “nothing” if other people do not respond strongly to her so she spends the therapy session regaling her therapist with entertaining stories. Cognitive therapy for PDs has much in common with cognitive therapy for depression Both emphasize the development of a cognitive conceptualization, a strong therapeutic relationship, a relatively structured therapy session, an active problem-solving approach, evaluation of clients’ cognitions through collaborative empiricism, psychoeducation, and skill development. Treatment is based on a cognitive conceptualization. Through identifying their dysfunctional cognitions and behaviours, the therapist seeks to understand why patients show characteristic reactions to current situations. They also take a longitudinal view, examining how childhood experiences led to the development of extreme, negative core beliefs; how patients developed characteristic compensatory strategies to cope with these beliefs; and how these beliefs are operating in the here-and-now.

43 A strong therapeutic alliance is essential. PD patients often have negative reactions in treatment, as they perceive themselves and their therapist in an unfavourable light. Identification and testing of these beliefs within the therapeutic relationship presents an opportunity for important learning that can not only strengthen the therapeutic alliance but also be generalized and applied to other relationships important to the patient. Treatment is oriented to solving problems and achieving specific goals. Some PD patients have significant difficulty identifying goals or working toward solving problems, particularly those who believe that they are helpless or vulnerable - or that if they make progress in therapy, their lives will get worse. Modifying dysfunctional beliefs about change may be essential before some PD patients can progress. Sessions are structured and both therapist and patient actively collaborate. Some PD patients may feel uncomfortable with the standard structure. Negotiating the structure helps strengthen the therapeutic alliance and model good interpersonal problem solving. Beliefs about disadvantages of working actively and collaboratively with the therapist sometimes need to be identified and modified. Cognitive restructuring is emphasized. PD patients may have more difficulty identifying their automatic thoughts or evaluating them, or may find the process of doing so invalidating. Skilful Socratic questioning and a wider variety of techniques are often required. Patients are encouraged to record adaptive responses to their dysfunctional thinking and to read these therapy notes at home on a daily basis. Homework oriented to behavioural change is an essential part of treatment. Therapists usually need to motivate Axis II patients to respond to their distorted cognitions and practice new, more functional behaviours between sessions. They often must modify standard homework assignments and elicit and help patients respond to cognitions that interfere with completing behavioural homework assignments. A major part of cognitive therapy for PDs involves helping patients to evaluate and modify their global, rigid, negative beliefs about themselves, others, and their worlds, and to develop more realistic, adaptive ideas. Therapists often use an information processing model to help patients understand why their beliefs are so strong. Therapists hypothesize that patients have structures, or schemas, in their minds that contain their core beliefs. Whenever patients perceive a relevant negative event, they automatically process the event as supportive of their core belief. When they perceive potentially relevant positive events, however, they either discount the information or fail to register it at all. A borderline patient who believes she is bad might, for example, immediately understand that she is a terrible person for having forgotten a meeting. When she does nice things for others, she either discounts her efforts, blaming herself for not doing much more or she does not seem to register her positive behaviour at all. Having educated patients about their core beliefs, therapists use a variety of cognitive, behavioural, emotional, interpersonal, supportive, problem-solving, and environmental techniques to help them modify their rigid maladaptive ideas. Therapists aim to address belief change both at an intellectual and at an “emotional” level. Exploration and modification of the meaning of significant childhood experiences is often necessary. Experiential techniques are particularly valuable in helping patients understand emotionally what they may have already grasped intellectually. Finally, relapse prevention is important. Axis II patients in particular need to learn strategies to identify the re-activation of their core beliefs and dysfunctional behaviours and how to modify them.

C. Biological Treatments Medication is often an important part of PD treatment. Typically, medication is used in two ways. First, it is used to treat concurrent clinical syndromes. Most patients with PD have substantial symptoms of a clinical syndrome 111 and from 66% to 97% 112 have a diagnosable Axis I disorder. Second, medication is useful in managing specific features of PD. In both instances, medication induced change may facilitate the patient’s ability to use psychotherapeutic interventions.

44 The evidence suggests that medication is useful in treating individual difference variables such as: Perceptual-cognitive symptoms, namely confused and disorganized thinking, transient psychotic episodes, and quasi-psychotic features such as paranoid ideation and pseudo-hallucinations; impulsivity and aggression; and affective symptoms such as depressed, angry, anxious, and labile mood 113 . Algorithms for treating cognitive-perceptual, affective dysregulation, and impulsive- behavioural symptoms associated with borderline PD and strategies for dealing with non- responsiveness are suggested by Soloff 114. There is little evidence, however, that medication has a direct effect on core features although a reduction in symptomatic distress and modification of symptoms may lead to improved self and interpersonal functioning. This suggests a targeted approach in which medication is used to treat specific features and delivered in the context of interventions designed to manage and treat core pathology. Despite the lack of a comprehensive theoretical framework, empirical trials of pharmacotherapy have produced evidence of efficacy in PDs against specific symptom domains. In the cognitive-perceptual symptom domain, targets for pharmacotherapy include referential thinking, paranoid ideation, illusions, derealisation, and depersonalization. Pharmacotherapy trials have shown efficacy for neuroleptic drugs in low dose strategy against these symptoms in borderline and schizotypal patients. The symptom domain of affective dysregulation is manifested by lability of mood, rejection sensitivity, inappropriate intense anger, and temper outbursts. The angry and depressive components of these symptoms appear responsive to MAOI and SSRI antidepressants, while the instability itself may respond to anticonvulsants such as carbamazepine, or to lithium carbonate. Dysregulation of impulse is manifested in absence of reflective delay, sensation seeking, assaultiveness, binge behaviours (e.g., alcohol, drugs, food), and parasuicidal behaviours. Anti- impulse efficacy has been demonstrated for a variety of medications, but most specifically for the anticonvulsants, SSRIs, and lithium carbonate. The assessment process usually concludes with a collaborative discussion of the patient’s problems and with the clinician providing an initial formulation that forms the basis of a discussion of the treatment plan. This process should include a psychoeducational component that provides information about the nature of PD and treatment options. When medication is being considered, this is a good time to discuss how medication may fit into the treatment plan. Since medication is usually used to treat specific symptoms rather than PD per se , it is important that the clinician is explicit about the likely benefits. Patients and significant others need to understand what symptoms are being treated, what changes may be expected, and, equally importantly, what the medication is not likely to change. This information reduces unrealistic expectations about the likely benefits that may affect compliance. It also reduces pressure from patients and their families to change medication frequently in the quest a “cure” for all aspects of PD. A psychoeducational component also reduces the risk of unnecessary polypharmacy and acts as an important opportunity to remind patients of the importance of psychological work and motivate then to implement other interventions. Given the distinction between general and specific interventions, the next step once the decision has been reached that medication is indicated, is to build a collaborative relationship. This is essential to ensure compliance – a major problem in the treatment of PD – and to minimize any adverse effects that prescribing medication may have on other aspects of treatment. Collaborative discussion helps to avoid polarization of patient and clinician. The final decision should be made by the patient following a discussion of the likely benefits and possible side effects. Compliance is poor unless patients are motivated and committed to change. In emergencies and acute crisis states, this level of collaboration may not be achievable. Nevertheless, the patient should be involved as much as possible and the issue reviewed when the acute state begins to settle. Medication, like any specific intervention, has the potential to enhance or impair the treatment alliance. Given the central role of the alliance in managing core pathology and ensuring compliance with treatment, the impact of prescribing on the alliance should be carefully monitored and any adverse effects explored immediately before they have the chance to escalate. When monitoring the

45 alliance, it should be noted that it is the patient’s perception of the state of the alliance rather than the therapist’s that predicts outcome. Most forms of therapy for PD emphasize the importance of a consistent therapeutic process. Here consistency means that both patient and therapist are adhering to the treatment plan. When medication is part of the plan, the failure to take medication as prescribed should be addressed immediately. A therapeutic approach that may be described as supportive confrontation is probably most effective. The reasons for non-compliance need to be explored and its consequences discussed in a supportive way that avoids a split with the therapist asserting the benefits of medication and the patient rejecting the idea. Therapist effectiveness in handling non-compliance often depends on his or her ability to manage and control countertransference reactions. The process of prescribing often activates aspects of psychopathology that have widespread effects on the treatment process and the therapeutic relationship 115. The meaning that prescribing medication has for the patient needs to be considered and the clinician needs to be attuned to the way this meaning may change over time. Especially important are core schemata related to distrust, abandonment, control, and ambivalence and feelings of passivity and pessimism. These reactions may adversely affect the treatment relationship and influence both compliance with medication and the patient’ responsiveness. Although this may complicate treatment, the activation of these schemata in the context of the therapeutic relations also provides an important opportunity to explore and modify these beliefs.

D. Combining Pharmacology and Psychotherapy The evidence indicates that combining psychotherapy and medication 116 is effective in treating personality pathology. Although some features of the disorder respond to both treatments, psychotherapeutic interventions appear to have more pervasive effects. Although there are little empirical data evaluating the efficacy of combining psychotherapy and medication, the independent effects of both treatments, rational considerations, and expert opinion suggest that psychotherapy and medications should not be considered alternative treatment options but rather complementary interventions. The necessity of using psychotherapy and medication forces an examination of the principles and problems involved and the development of a cogent framework for combined treatment. The framework proposed is based on: 1)The nature of medication effects; and 2) An eclectic model for treating PD that uses a combination of interventions drawn from different therapeutic approaches that are delivered in an integrated way. A cogent strategy for combining psychotherapeutic and pharmacological interventions requires an understanding of the structure of PD. It may be useful to think of a PD as having two components: Core or defining features that characterize all patients with the disorder; and, destructive features such as particular diagnostic criteria that vary across individuals. Core features usually involve either chronic interpersonal dysfunction 117 or problems with self or identity that reduce the individual’s capacity for effective interpersonal and societal functioning. One of the main practical considerations when using combined treatment is whether the roles of psychotherapist and pharmacotherapist should be combined or separate. There are advantages and disadvantages of both arrangements. However, there is no empirical information to guide the decision. The advantage of the psychotherapist also prescribing is that it eliminates conflicts that occur due to the PD patient’s tendency to value one mode of treatment and hence to devalue one clinician over the over. It is also easier to ensure a more integrated, consistent, and cohesive approach. The disadvantage is that may lead to intense and volatile transference reactions although as noted earlier these may not necessarily be a hindrance if addressed effectively. Medication abuse does seem to be common when the psychotherapist also prescribes but there is no evidence that it is more frequent than with split care.

46 Split care is the norm in many settings 118. Although this may defuse some of the more intense aspects of the transference that occur when the therapist prescribes, it creates greater potential for “splitting” within the treatment team. This eventuality is avoided by developing an explicit understanding of the roles of the psychotherapist and pharmacotherapist that is shared with the patient and by regular communication between clinicians. Both parties need to take responsibility for ensuring that the other is aware of major events and any occurrence that has implications for the others modality. This is necessary to ensure that both clinicians do not inadvertently collude with the tendency of these patients to devalue important aspects of their treatment by implying that one form of treatment is more important than the other. In this context, it is important for the pharmacotherapist to support the psychotherapeutic endeavours actively, maintain a collaborative approach, and explain and discuss medication and its role in treatment. Given these problems the best arrangement is probably to use a single clinician when the therapist has prescribing powers. The neurobiology of personality dimensions provides a theoretical framework for the design of pharmacologic treatment and studies in the PD patient. Neurotransmitter mediation of specific dimensions, such as novelty seeking, impulsivity, or schizotypy, suggests the usefulness of highly selective medications as clinical treatments and, simultaneously, as confirmatory tests of hypotheses concerning the neurobiology of personality dimensions. For example, the efficacy of SSRI antidepressants against impulsivity suggests both a clinical treatment and confirmation of the role of diminished serotonergic function in impulse dysregulation. Similarly, the efficacy of neuroleptics against schizotypal symptoms supports the hypothesized role of dopamine in this dimension. The future of biologic research in the PDs lies in a better understanding of neurotransmitter and receptor function, using sophisticated PET neuroimaging techniques and receptor-specific radioligands to define the biologic basis of specific dimensions. As the focus of study gets smaller, we will no longer treat whole personalities, or even dimensions as we currently view them, but receptor-related functions. The challenge for the pharmacotherapist is to discriminate interpersonal from biologic pathologies, i.e., not to "biologize" all behaviour. In summary, we may best grasp the integrative process of PD therapy if we think of the major personality characteristics as analogous to the sections of an orchestra, and the pathological characteristics of a patient as a clustering of discordant instruments. To extend the analogy, therapists may be seen as conductors, whose task is to bring forth a harmonious balance among all the instruments, muting some here, accentuating others there, all to the end of fulfilling their knowledge of how "the composition" can best be made consonant. The task is not that of altering just one instrument, but of altering all, in concert. Just as music requires a balanced score, one composed of harmonic counterpoints, rhythmic patterns, and melodic combinations, what is needed in personality therapy is a likewise balanced and synergistic program, a coordinated strategy of counterpoised techniques designed to optimize treatment effects in an idiographically combinatorial and sequential manner. Obviously, a good amount of knowledge, both about the nature of the patient’s disorders and about diverse modes of intervention, is required to perform PD therapy. To maximize this synergism requires that the therapist be a little like a musical soloist. Not only should the professional be fully versed in the various musical keys, that is, in techniques of psychotherapy which span all personality domains, he or she should also prepare to respond to subtle fluctuations in the patient’s thoughts, actions, and emotions, any of which could take the individual in a wide variety of directions, and integrate these into the overall plan of therapy as it continues to evolve. After the therapeutic process is over, a retrospective account on the entire sequence should reveal a level of thematic continuity and treatment flexibility commensurate with that which would have existed had all relevant influences been known in advance. The fact that the societal environment of every culture throughout the world surrounds personality development and the individual’s PD, and is often powerful and systemic, argues for an important consideration in therapy: Pull as much of the surrounding interpersonal and cultural context into the therapeutic process as possible, or risk being defeated by it. Where sociocultural

47 factors are operative, therapeutic gains may be minimized and the risk of relapse increased. In the best case scenario, family members and social leaders might be brought into therapy as participants or as needed, to minimize the impact of subtle influences and to discuss characteristics of the status quo that perpetuate pathology and contingencies that might promote change.

Contributors: Judith Beck, Glen Gabbard, Seth Grossman, W. John Livesley

Editor’s Note : All contributors to this module submitted brief texts for their respective sections that were edited and synthesized so as to reduce overlap and to focus and abbreviate more discursive ideas.

References are listed in order of appearance in text

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49 32. Westen, D. (1998). Case formulation and personality diagnosis: Two processes or one? In James Barron (Ed.), Making diagnosis meaningful (pp. 111-138). Washington, DC: American Psychological Association Press. 33. Jang, K. L., & Vernon, P.A. (2001) Genetics. W. J. Livesley (ed) Handbook of personality disorders (177-195). New York: Guilford. 34. Meehl, P. E. (1990). Schizotaxia as an open concept. In A. I. Rabin, R. Zucker, R. Emmons, & S. Frank (Eds.), Studying persons and lives (248-303). New York: Springer. 35. Millon, T. (1969). Modern psychopathology: A biosocial approach to maladaptive learning and functioning . Philadelphia: Saunders. 36. DeVos, G. A., & Romanucci-Ross, L (Eds.) (1975). Cultural continuities and change . Palo Alto: Mayfield. 37. Pasick, R. J., Stewart, S. L., Bird, J. A., & D’Onofrio, C. N. (2001). Quality of data in multiethnic health surveys. Public Health Report, 116 , 1, 223-243. 38. Krueger, R. F., Caspi, A., & Moffitt, T. E. (2000). Epidemiological Personology: the unifying roles of personality in population-based research on problem behaviours. Journal of Personality, 68, 967-998. 39. Mattingly, C. (1998). In search of the good: narrative reasoning in clinical practice. Medical Anthropology Quarterly, 12 , 273-297. a) Yamamoto, J., Takeuchi, D. T., Sue, S., & Kurasaki, K. (1998). Cross-cultural epidemiology. Psychiatric Clinical Neurosciences , 52, S265-S267. 40. Rogler, L. H., & Cortes, D. E. (1993). Help-seeking pathways: a unifying concept in mental health care. American Journal of Psychiatry , 150 , 554-561. a) Weiss, M. G. (2001). Cultural Epidemiology: an introduction and overview. Anthropology & Medicine, 8 , 5-29. 41. U.S. Department of Health and Human Services. (2001). Mental Health: Culture, Race and Ethnicity –A Supplement to Mental Health : A Report of the Surgeon General . Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General. 42. Brofenbrenner, U. (1974). Ecology of childhood. Childhood Devevelopment , 45, 1-5. a) Cairns, R. B., Elder, G. H., & Costello, E. J. (1996). Developmental Science . New York: Cambridge University Press. b) Wadsworth, M. E., & Kuhn, D. J. (1997). Childhood influences on adult health: A review of recent work from the British 1946 National Birth Cohort Study, the NRC National Survey of Health and Development. Pediatric Perinatal Epidemiology, 11 , 2-20. 43. Devereaux, G. (1940). Primitive Psychiatry. Bulletin History of Medicine, 8 , 1194-1213. 44. Fombonne, E. (1993). Contribution of epidemiology to etiological research in psychiatry: from risk factors to risk mechanisms. Rev Epidemiiol Sante Publique, 41 , 263-276. a) Lenzenweger, M., Loranger, A. W., Korfine, L., & Neff, C. (1997). Detecting personality disorders in a nonclinical population. Aplication of a 2-stage procedure for case identification. Archives of General Psychiatry, 54 , 345-351. b) Gunderson, E. K., & Hourani, L. L. (2003). The epidemiology of personality disorders in the US Navy. Military Medicine, 168 , 575-582. 45. Mednick, B. R., Hocevar, D., & Baker, R. L. (1996). Personality and demographic characteristics of mothers and their ratings of child difficultness. International Journal of Behavioural Development, 19 , 121-140. 46. Leighton, D. C., Harding, J. S., Macklin, M. A., Hughes, C. C., & Leighton, A. H. (1963). Psychiatric findings of the Sterling County Study. American Journal of Psychiatry , 119, 1021-1026. a) Mead, M. (1928). Coming of age in Samoa . New York: Blue Ribbon Press. 47. Lee, S. (2001). From diversity to unity. The classification of mental disorders in 21 st -century China. Psychiatric Clinics of North America, 24 , 421-431.

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52 78. Loranger, A.W. (1999) International Personality Disorders Examination Manual: DSM-IV Module. Washington D.C.: American Psychiatric Press. 79. Loranger, A.W., Sartorius, N., Andreoli, A. et al. (1994). The IPDE. Archives of General Psychiatry , 51, 215-224. 80. First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. B., & Benjamin, L. S. (1997). User’s guide for the structured clinical interview for DSM-IV Axis II personality disorders . Washington, DC: American Psychiatric Association. 81. Pfohl, B., Blum, N., & Zimmerman, M. (1997). Structured interview for DSM-IV personality (SIDP-IV) . Washington, DC: American Psychiatric Press. 82. Gunderson, J.G., Phillips, K.A., Triebwasser, J., & Hirschfeld, R.M.A. (1994). The diagnostic interview for depressive personality. American Journal of Psychiatry, 151 (9), 1300–1304. 83. Gunderson, J.G., Ronningstam, E., & Bodkin, A. (1990). The diagnostic interview for narcissistic patients. Archives of General Psychiatry, 47 (7), 676–680. 84. Zanarini, M.C., Gunderson, J.G., Frankenburg, F.R., & Chauncey, D.L. (1989). The revised diagnostic interview for borderlines: Discriminating BPD from other Axis II disorders. Journal of Personality Disorders, 3 (1), 10–18. 85. Tyrer, P., & Alexandr, M.S. (1979). Reliability of a schedule for rating personality disorders. British Journal of Psychiatry, 135 , 168-174. 86. Hare, R.D. (1991). The Hare psychopathy checklist–revised manual . Toronto: Multi-Health Systems. 87. Butcher, J. N., Dahlstrom, W. G., Graham, J. R., Tellegen, A., & Kaemmer, B. (1989). MMPI-2: Manual for administration and scoring. Minneapolis: University of Minnesota Press. 88. Millon, T., Davis, R.D., & Millon, C. (1996). The Millon clinical multiaxial inventory–III manual. Minnetonka, MN: National Computer System. 89. Butcher, J. N., Williams, C. L., Graham, J. R., Archer, R. P., Tellegen, A., Ben-Porath, Y. S., et al. (1992). MMPI-A (Minnesota Multiphasic Personality Inventory-Adolescent): Manual for administration, scoring, and interpretation . Minneapolis: University of Minnesota Press. 90. Millon, T., Millon, C., & Davis, R. (1993). Millon adolescent clinical inventory (MACI) manual . Minneapolis, MN: NCS Assessments. 91. Millon, T., Tringone, R., Millon, C., & Grossman, S. (2005). Millon pre-adolescent clinical inventory (M-PACI). Minneapolis, MN: Pearson Assessments. 92. Hyler, S.E., & Rieder, R.O. (1987). PDQ-R: Personality diagnostic questionnaire-revised. New York: New York State Psychiatric Institute. 93. Morey, L. (1992). The personality assessment inventory . Odessa, FL: Psychological Assessment Resources. 94. Livesley, W.J., Jackson, D.N., & Schroeder, M.L. (1989). A study of the factorial structure of personality pathology. Journal of Personality Disorders, 3 , 292–306. 95. Clark, L.A., McEwen, J.L., Collard, L.M., & Hickok, L.G. (1993). Symptoms and traits of personality disorder: Two new methods for their assessment. Psychological Assessment, 5 (1), 81–91. 96. Cloninger, C.R., Przybeck, T.R., & Svrakic, D.M. (1991). The tridimensional personality questionnaire: U.S. normative data. Psychological Reports, 69 , 1047–1057. 97. Cloninger, C.R. (1987). A systematic method for clinical description and classification of personality variants. Archives of General Psychiatry, 44 , 573–588. 98. Klein, M.H., Benjamin, L.S., Rosenfeld, R., Treece, C., Husted, J., & Greist, J.H. (1993). The Wisconsin personality disorders inventory: Development, reliability, and validity. Journal of Personality Disorders, 7 , 285–303. 99. Benjamin, L.S. (1996). Interpersonal diagnosis and treatment of personality disorders . New York: Guilford Press. 100. Costa, Jr., P.T., & McCrae, R.R. (1992). The NEO-PI-R manual . Odessa, FL: Psychological Assessment Resources. 101. Beutler, L.E., & Clarkin, J.F. (1990). Systematic treatment selection . New York: Brunner/Mazel.

53 102. Millon, T. (1999) Personality-guided Psychotherapy. New York: Wiley. 103. Reich, W. (1945/1980). Character Analysis: Third, Enlarged Edition . New York: Noonday Press. 104. Sandler, J. (1981). Character traits and object relationships. Psychoanalytic Quarterly, 50 , 694- 708. Gabbard, G. O. (2001). Psychoanalysis and psychoanalytic psychotherapy. In Livesley J (Ed.) Handbook of Personality Disorders , 359-376. New York: Guilford Press. 105. Westen, D. & Gabbard, G. (2002). Developments in cognitive neuroscience: II. Implications for theories of transference. Journal of the American Psychoanalytic Association, 50 , 99- 134. 106. Shapiro, D. (1965). Neurotic Styles . New York: Basic Books. 107. Leichsenring & Leibing, E. (2003). The effectiveness of psychodynamic therapy and cognitive behaviour therapy in the treatment of personality disorders: A meta-analysis. American Journal of Psychiatry, 160 , 1223-1232. 108. Sandler, J. (1981). Character traits and object relationships. Psychoanalytic Quarterly, 50 , 694- 708. 109. Gabbard, G.O. & Westen, D. (2003). Rethinking therapeutic action. International Journal of Psychoanalysis, 84, 823-41. 110. Beck, A.T., Freeman, A.J. & Associates (2005) Cognitive therapy of personality disorders. New York: Guilford. 111. Dolan-Sewell, R.T., Krueger, R.F., & Shea, M.T. (2001). Co-occurrence with syndrome disorders. In W. J. Livesley (Ed.), Handbook of personality disorders (pp. 84-104). New York: Guilford Press. a) Oldham, J., Skodal, A.E., Kellman, H.D., Hyler, S.E., Doige, N., Rosnick, L., & Gallagher, P.E, (1995). Comorbidity of axis I and axis II disorders. American Journal of Psychiatry , 152, 571-578. 112. Dahl, A. A. (1986). Some aspects of the DSM-III personality disorders illustrated by a consecutive sample of hospitalized patients. Acta Psychiatrica Scandinavica Supplement , 328, 61-67. 113. Alnaes, R., & Torgersen, S. (1988). The relationship between DSM-III symptoms disorders (Axis I) and personality disorders (Axis II) in an outpatient population. Acta Psychiatrica Scandinavica , 78,485-492. 114. Soloff, P. H. (1998). Algorithms for pharmacological treatment of personality dimensions: Symptom specific treatments for cognitive-perceptual, affective, and impulsive-behavioural dysregulation. Bulletin of the Menninger Clinic, 62 , 195-214. a) Soloff, P. H. (2000). Psychopharmacology of borderline personality disorder. Psychiatric Clinics of North America , 23, 169-190. 115. Soloff, P. H. (2000). Psychopharmacology of borderline personality disorder. Psychiatric Clinics of North America , 23, 169-190. 116. Waldinger, R.J., & Frank, A.F. (1989). Transference and the vicissitudes of medication use by borderline patients. Psychiatry. 52(4):416-27. 117. Markovitz, P. (2001). Psychopharmacology. In W. J. Livesley (Ed.), Handbook of personality disorders (pp. 475-493). New York: Guilford Press. a) Markovitz, P. (2004). Recent trends in the pharmacotherapy in personality disorders. Journal of Personality Disorders, 18:1; 90-101. 118. Soloff, P. H. (1998). Algorithms for pharmacological treatment of personality dimensions: Symptom specific treatments for cognitive-perceptual, affective, and impulsive-behavioural dysregulation. Bulletin of the Menninger Clinic, 62 , 195-214. a) Soloff, P. H. (2000). Psychopharmacology of borderline personality disorder. Psychiatric Clinics of North America , 23, 169-190.

54 Suggested Additional Reading List – Module I

• Alarcon, R., Foulkes, E. & Vakkur, M. (1998). Personality disorders and culture. New York: Wiley. • Beck, A.T., & Freeman, A. (2003). Cognitive therapy of personality disorders. New York: Guilford. • Benjamin, L. S. (1996). Interpersonal treatment of personality disorders, 2nd ed. New York: Guilford. • Clarkin, J., & Lezenweger, M. (Eds.). (1999). Major theories of personality disorder. New York: Guilford. • Cloninger, C. (Ed). (1999). Personality and Psychopathology. Washington. American Psychiatric Press. • Groth-Marnat, G. (Ed.). (2003). Handbook of psychological assessment 4 th ed,. New York: Wiley. • Kahn, E. (1931). Psychopathic personalities. New Haven, CT: Yale University Press. • Kernberg, O. (1975). Borderline conditions and pathological narcissism. New York: Jason Aronson. • Kernberg, O. (1984). Severe personality disorders. New Haven, CT: Yale University Press. • Kraepelin, E. (1913). Psychiatrie: Ein Lehrbuch (8 th ed.). Leipzig: J.A. Barth Verlag. • Koldobsky, N.M.S. (2005) Trastorno borderline de la personalidad. Buenos Aires: Polemos. • Livesley, W. J., (Ed.). (2001). Handbook of personality disorders. New York: Guilford. • Maj, M., Akiskal, H., Mezzich, J., & Okasha, A. (Eds.). (2005). Personality disorders. Hoboken, NJ: John Wiley. • Menninger, K. (1930). The human mind. New York: Knopf. • Millon, T. (1969). Modern psychopathology. Philadelphia, PA: Saunders. • Millon, T. (1996). Disorders of personality: DSM-IV and beyond. New York: Wiley. • Millon, T. (2004). Masters of the mind: Exploring the stories of mental illness from ancient times to the new millennium. New York: Wiley. • Offer, D., & Sabshin, M. (1991). The diversity of normal behaviour. New York: Basic Books. • Oldham, J., Skodol, A., & Bender, D. (Eds.). (2005). Handbook of personality disorders. Washington, DC: American Psychiatric Association Press. • Schneider, K. (1950). Psychopathic personalities (9 th ed.). Cassell: London. • Shapiro, D. (1965). Neurotic styles. New York: Basic Books. • Stone, M. (1993). Abnormalities of personality: Within and beyond the realm of treatment. New York: Norton. • Stone, M. (1997). Healing the mind. New York: Norton. • Strack, S. (Ed.). (2005). Handbook of personology and psychopathology. New York: Wiley. • Strack, S. (Ed.). (2006). Differentiating normal and abnormal personality (2 nd ed.) . New York: Springer Publishing. • Tyrer, P. (2000). Personality Disorders – diagnosis, management and course. Oxford, Butterworth- Heineman • Widiger, T.A., Simonsen, E.,, Sirovatka, P. & Regier, D.A. (eds.) (2006 ). Dimensional models of Personality Disorders. Refining the Research Agenda for DSM-V. Washington: American Psychiatric Publishing, Inc.

55 Curriculum Suggestions – Module I

The following questions are best discussed among colleagues in classrooms or workshops.

1. Why are PDs useful for mental health workers (psychiatrists, psychologists, social workers) to understand as a key component of their clinical activities?

2. Discuss the social costs of the PDs, their widespread prevalence and their associated civic and public health consequences and disruptions.

3. Why is the traditional concept of “disease” not suitable when discussing the nature of the PDs? Why do some thinkers consider PDs to be best considered as similar to the biological immune system?

4. How can normality and abnormality best be differentiated? Is there a sharp line separating them or are they on a continuum?

5. The history of ideas about personality goes back to the early Greeks. Discuss some of these interesting ideas and major thinkers from the past to the present.

6. What are some of the issues, as well as the similarities and differences between the ICD-10 and DSM-IV in their formulation of the PDs.

7. Do personality disorders really exist or are they just convenient fictions of theory, clinical observation or research investigations?

8. What are the issues in the categorical vs. dimensional PD debate, and does the prototypical idea help solve them?

9. Discuss the role of biogenic, psychogenic and sociogenic influences in PD development pathogenesis? Describe some of the research evidence for their respective contributions.

10. Describe the several modes and specific tools of diagnosing the PDs, and discuss their respective strengths and weaknesses.

11. Go into considerable detail in specifying the strengths of either the cognitive or the psychodynamic approach to therapy for the PDs.

12. What are the comparative advantages and disadvantages of adhering to one specific school of therapy versus several combined schools, e.g., behavioural, pharmacologic in treating the PDs.

56 MODULE II: THE PERSONALITY DISORDERS

INTRODUCTION Elsa Ronningstam, Ph.D.

The studies of the DSM personality disorder have over recent years accumulated substantial evidence, especially on their epidemiology, etiology, course, and prognosis. In Module II, the descriptions of twelve personality disorders indicate ample clinical and empirical evidence supporting their prevalence, gender and age distribution, course, comorbidity, and changeability in course and treatment. The understanding of several of the disorders has been influenced by new theoretical approaches, such as metallization, attachment theory and intersubjectivity. Advances in identifying heritability and neurological functioning, as well as finding specific patterns in emotional and interpersonal dysregulation, have also added to our knowledge. New treatment modalities besides the psychodynamic have developed, such as the psychosocial, cognitive-behavioural and psychopharmacological, and by now there are evidenced based treatment recommendations and manuals for some of the personality disorders. More urgent interest and demands have spurred the development of treatment strategies for certain personality disorders, such as borderline personality disorder. Several significant longitudinal studies such as The Collaborative Longitudinal Study of Personality Disorders (CLIPS) and the McLean Study of Adult Development (MSAD), National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), and Torgersen’s epidemiological study in Norway have informed about prevalence, course and prognosis, and heritability of personality disorders. The changeability of personality disorders is a complex and controversial issue. Do personality disorders really remain stable, as indicated by their separate Axis in DSM, or do they actually change over time? What is the effect of life-events and environmental influence, maturity and aging, and co- occurrence of specific state disorders on the course and prognosis of pathological character functioning? While borderline personality disorder tends to remit, narcissistic, obsessive compulsive and paranoid personality disorder seem to remain stable, or even worsen with age. While life events can both improve and worsen narcissistic personality functioning, other personality disorders, such as the paranoid and schizoid, are less influenced by external matters. And while for some personality disorders there is ample evidence of their treatability, such as borderline and avoidant, for others, such as the obsessive compulsive, sadistic and paranoid personality disorders, changes through treatment are more rarely documented. For still others, such as antisocial and narcissistic personality disorders, despite plenty of empirical (ASPD) and psychoanalytic (NPD) studies, their changeability through treatment remains insufficiently explored. Another complex issue in the studies of personality disorder relates to their severity. The polythetic approach to personality disorders unfolds a vast heterogeneity within each prototypic disorder. For example, a borderline personality with impulsivity and parasuicidal behaviour and an antisocial with psychopathic malignant aggressive or sadistic behaviour are considered more severe compared to a borderline personality with identity diffusion and dependency, or a professional antisocial personality specialized on sophisticated financial crimes. While some traits or combination of traits and/or co-occurrence of certain Axis I states warrant serious pathological or even life threatening personality functioning, other combinations, even when meeting the threshold for personality disorder, may be more remittent and easily accessible to successful treatment. Some types of severe personality pathology remain concealed causing internal suffering not easily identified through overt traits and diagnostic interviews. Other severe personality traits are overtly expressed and enacted vis-à-vis other people and the environment, such as family, the workplace or the society. Evidence of prevalence and course, and possibilities to study prognosis and treatment

57 progress in personality disorders are also highly influenced by variations in help seeking behaviour. Some personalities, such as the narcissistic, schizoid and paranoid, are less inclined to seek treatment, unless they encounter environmental enforcement or severe symptoms. Others, such as borderline, are high consumers of treatment and frequently found in psychiatric settings. A third area open to debate concerns the separation and evaluation of functional or protective versus dysfunctional and maladaptive aspects of personality traits. For example, in some contexts, passive aggressive and obsessive-compulsive behaviour can be adaptive, narcissistic behaviour serve a protective or proactive function, and paranoid features reflect adequate responses to factual environmental circumstances. The question whether and when personality functioning change from healthy and adaptive to maladaptive and pathological, and vice versa, is still relatively unexplored. Similarly, cultural variations in personality functioning, and what is considered normal and accepted, and pathological or unaccepted do indeed vary between cultures all over the world. For example, avoidant personality disorder appears more common in cultures such as the Japanese and Norwegian, while the arrogant narcissistic and the obsessive-compulsive personality disorders have been considered products of the Western culture. Although our conceptualisation and understanding of personality functioning are evolving and will undergo major changes in the future, the introduction of Axis II personality disorders has helped determined the evolution of knowledge and research, and added a crucial dimension to the field of psychopathology.

Personality Disorder Author(s)

Antisocial Personality Disorder Stephen D. Hart and David J. Cooke Avoidant Personality Disorder Yutaka Ono Borderline Personality Disorder Anthony W. Bateman and Peter Fonagy Dependent Personality Disorder Robert F. Bornstein Histrionic Personality Disorder Bruce Pfohl Narcissistic Personality Disorder Elsa Ronningstam Obsessive-Compulsive Disorder Vicente E. Caballo Paranoid Personality Disorder Elisabeth Iskander and Larry J. Siever Passive-aggressive Personality Disorder J. Christopher Perry Sadistic Personality Disorder Michael H. Stone Schizoid Personality Disorder Henning Sass and Reinhild Schwarte Schizotypal personality disorder Svenn Torgersen

58

General Diagnostic Criteria

Diagnostic Criteria for a Personality Disorder (DSM-IV)

A. An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas: 1. Cognition (i.e., ways of perceiving and interpreting self, other people, and events) 2. Affectively (i.e., the range, intensity, lability, and appropriateness of emotional response) 3. Interpersonal functioning 4. Impulse control B. The enduring pattern in inflexible and pervasive across a broad range of personal and social situations. C. The enduring pattern leads to clinically significant distress or impairment in social, occupation, or other important areas of functioning. D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood. E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder. F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medial condition (e.g., head trauma).

Diagnostic criteria for a Personality Disorder (ICD-10)

General criteria A specific personality disorder is a severe disturbance in the characterological constitution and behavioural tendencies of the individual, usually involving several areas of the personality, and nearly always associated with considerable personal and social disruption. Personality disorder tends to appear in late childhood or adolescence and continues to be manifest into adulthood. It is therefore unlikely that the diagnosis of personality disorder will be appropriate before the age of 16 or 17 years. General diagnostic guidelines applying to all personality disorders are presented below; supplementary descriptions are provided with each of the subtypes.

Diagnostic guidelines Conditions not directly attributable to gross brain damage or disease, or to another psychiatric disorder, meeting the following criteria: (a) markedly dysharmonious attitudes and behaviour, involving usually several areas of functioning, e.g. affectivity, arousal, impulse control, ways of perceiving and thinking, and style of relating to others; (b) the abnormal behaviour pattern is enduring, of long standing and not limited to episodes of mental illness; (c) the abnormal behaviour pattern is pervasive and clearly maladaptive to a broad range of personal and social situations; (d) the above manifestations always appear during childhood or adolescence and continue into adulthood; (e) the disorder leads to considerable personal distress but this may only become apparent late in its course; (f) the disorder is usually, but not invariably, associated with significant problems in occupational and social performance. For different cultures it may be necessary to develop specific sets of criteria with regard to social norms, rules and obligations. For diagnosing most of the subtypes listed below, clear evidence is usually required of the presence of at least three of the traits or behaviours given in the clinical description.

59 Antisocial Personality Disorder Stephen D. Hart and David J. Cooke

Diagnostic Criteria DSM-IV 301.7 Antisocial Personality Disorder A. There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following: 1. Failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly performing acts that are grounds for arrest 2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure 3. Impulsivity or failure to plan ahead 4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults 5. Reckless disregard for safety of self or others 6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations 7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another B. The individual is at least age 18 years. C. The evidence of conduct Disorder with onset before age 15 years. D. The occurrence of antisocial behaviour is not exclusively during the course of Schizophrenia or a Manic Episode.

Diagnostic Criteria ICD-10 F60.2 Dissocial personality disorder Personality disorder, usually coming to attention because of a gross disparity between behaviour and the prevailing social norms, and characterized by: (a) callous unconcern for the feelings of others; (b) gross and persistent attitude of irresponsibility and disregard for social norms, rules and obligations; (c) incapacity to maintain enduring relationships, though having no difficulty in establishing them; (d) very low tolerance to frustration and a low threshold for discharge of aggression, including violence; (e) incapacity to experience guilt or to profit from experience, particularly punishment; (f) marked proneness to blame others, or to offer plausible rationalizations, for the behaviour that has brought the patient into conflict with society. There may also be persistent irritability as an associated feature. Conduct disorder during childhood and adolescence, though not invariably present, may further support the diagnosis. Includes: amoral, antisocial, asocial, psychopathic, and sociopathic personality (disorder) Excludes: conduct disorders (F91. - ) emotionally unstable personality disorder (F60.3)

Called antisocial personality disorder in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994), this disorder is known as dissocial personality disorder in the tenth edition of the International Classification of Diseases and Causes of Death (ICD-10; World Health Organization, 1992). It is also referred to by some as psychopathic personality disorder (psychopathy) or sociopathic personality disorder (sociopathy).

Clinical Description According to clinical descriptions made over the past 200 years (Arrigo & Shipley, 2001; Berrios, 1996), antisocial personality disorder is characterized by a broad range of symptoms evident in several major domains of personality functioning. In the domain of behavioural organization , symptoms include a lack of perseverance, unreliability, recklessness, restlessness, disruptiveness, and aggressiveness. The emotionality domain includes negative or deficit symptoms such as lack of anxiety,

60 lack of remorse, lack of emotional depth, and lack of emotional stability. In the domain of interpersonal attachment , the symptoms include detachment, lack of commitment, and lack of empathy or concern for others. In the domain of interpersonal dominance, the symptoms include antagonism, arrogance, deceitfulness, manipulativeness, insincerity, and glibness or garrulousness. The cognitive domain includes symptoms such as suspiciousness, inflexibility, intolerance, lack of planfulness, and lack of concentration. Finally, in the self-domain, the symptoms include self- centeredness, self-aggrandizement, self-justification, and a sense of entitlement, uniqueness, and invulnerability. Diagnostic criteria for antisocial personality disorder usually focus on a small subset of the symptoms described above. In the DSM-IV and ICD-10, the diagnostic criteria focus primarily on symptoms from the behavioural organization domain, especially those related to violation of explicit social norms. These symptoms are diagnostically useful in clinical settings, where they generally have adequate sensitivity (that is, are found to some degree in most people with the disorder) and specificity (that is, are not found frequently in people with other disorders). But heavy reliance on behavioural disorganization symptoms in diagnostic criteria for antisocial personality disorder leads to at least two potential problems (e.g., Widiger & Corbitt, 1995): First, behavioural disorganization symptoms have poor specificity in correctional or forensic psychiatric settings; and second, clinical formulations based solely or primarily on behavioural disorganization symptoms may have limited utility when making decisions about prognosis or intervention. Keeping these problems in mind may help evaluators to determine when it is necessary to go beyond the DSM-IV or ICD-10 criteria and base their diagnoses on a more broad and comprehensive conceptualization of antisocial personality disorder.

Course Although antisocial personality disorder is a form of adult psychopathology that should not be diagnosed prior to adulthood, early manifestations of the disorder often are first evident at a young age, typically between ages 6 and 10 (Robins, Tipp, & Przybeck, 1991). It is common for adults with antisocial personality disorder to have been diagnosed in childhood or adolescence as suffering from conduct disorder, oppositional defiant disorder, or attention deficit hyperactivity disorder. Indeed, the DSM-IV diagnostic criteria for antisocial personality disorder require that the person meet criteria for a conduct disorder before age 15 (American Psychiatric Association, 1994). Unfortunately, the prognostic significance of early onset conduct problems is limited by the fact that many – 50% -75% or even more – of children or adolescents diagnosed with conduct disorder spontaneously desist from this behaviour and do not go on to develop antisocial personality disorder as adults (Robins et al., 1991). Some research suggests that children or adolescents with comorbid conduct disorder and attention deficit hyperactivity disorder are most likely to develop adult antisocial personality disorder (McBurnett & Pfiffner, 1998). Although systematic research is lacking, there is indirect evidence that symptoms of antisocial personality disorder often persist into at least middle or late adulthood. For example, among correctional offenders diagnosed with the disorder, many are criminally active into their 50s and 60s (Hare, McPherson, & Forth, 1988). In addition, there is an increased rate of morbidity and mortality associated with the diagnosis of antisocial personality disorder (Repo-Tiihonen, Virkkunen & Tiihonen, 2001), which makes long-term follow-up studies difficult.

Prevalence Epidemiological research in the United States and Canada indicates that the lifetime prevalence of antisocial personality disorder in the general population is about 2-3% (Robins et al., 1991). Although the rate among community resident and psychiatric patients is relatively low, typically about 1-2%, the rate among correctional offenders, forensic psychiatric patients, and substance abusers is considerably higher, typically 50% or higher (Robins et al., 1991). Epidemiological research in other countries, such as Taiwan (e.g., Compton et al., 1991), has reported a lifetime

61 prevalence rate of antisocial personality disorder in the general population that is considerably lower, 1% or less; possible explanations for these cross-cultural differences are discussed below. The prevalence rates discussed above were obtained using diagnostic criteria from DSM-IV or its predecessors. When more comprehensive diagnostic criteria are used, which include symptoms in addition to those from the behavioural organization domain, the prevalence rate is considerably lower. For example, research using the Hare Psychopathy Checklist-Revised in correctional offenders and forensic psychiatric patients in Canada and the United States has reported lifetime prevalence rates of about 15% to 25% – about 1/3 the rate observed using the DSM criteria for antisocial personality disorder (Hare, 2003).

Gender, Age, and Sociocultural Factors Lifetime prevalence rates of antisocial personality disorder vary across three major group factors: gender, age, and culture. First, with respect to age, the male: female sex ratio in diagnosis typically is about 3:1 (Robins et al., 1991). This gender difference is not limited to a few clinical features, but is evident across the full range of symptomatology. Second, with respect to age, some epidemiological research in the United States using DSM-III and DSM-III-R criteria has reported a cohort effect, with higher lifetime prevalence rates in younger generations than in older generations (Robins et al., 1991). Third, with respect to culture, anthropological and epidemiological research indicates that antisocial personality disorder is found across cultures (Cooke, 1996). There is some cross-cultural difference in lifetime prevalence rate, however: The prevalence appears to be higher in individualistic cultures, which promote the development of self-identity that is independent of relationships with others, than in collectivistic cultures, which promote the development of an interdependent or highly relational self-identity (Paris, 1998). These group differences in lifetime prevalence rates may be the result of cultural facilitation (Cooke, Michie, Hart, & Clark, 2005). According to some theoretical views, important cultural norms and values encourage the expression of interpersonal behaviours consistent with those same norms and values. Concepts such as distinctiveness, status, self-confidence, honour, competition, and freedom from obligations to others, which are highly valued in individualistic cultures, may therefore foster the development of extreme manifestations of these characteristics such as conceit, manipulativeness, irresponsibility, pathological dominance, and aggressiveness. Similarly, within a dominant culture, the expression of antisocial personality disorder symptoms may be facilitated in certain subgroups – for example, males or younger generations – that subscribe to more individualistic norms and values. It is unclear to what extent these group differences in lifetime prevalence rates may be the result of inadequacies in diagnostic criteria. For example, it has been suggested that the current diagnostic criteria for antisocial personality disorder in the DSM-IV best reflect its prototypical manifestation in males and in industrialized countries (e.g., Cooke et al., 2005); if this is true, any differences due to gender, age, and culture may be smaller than suggested by research to date.

Comorbidity Antisocial personality disorder has a high rate of comorbidity with substance-use disorders (Hemphill, Hart, & Hare, 1990; Robins et al., 1991). In most cases, however, it is clear that symptoms of antisocial personality disorder were manifested either before or concurrently with symptoms of substance-use disorder, and the antisocial personality disorder has resulted in a great range and severity of disturbance in psychosocial functioning than has the substance-use disorder. For these reasons, antisocial personality disorder often is considered the primary diagnosis when it is comorbid with substance-use disorders. This comorbidity may reflect a common etiological mechanism, or it may be that in some cases substance-use disorders are a consequence or complication of antisocial personality disorder. Antisocial personality disorder also has a high rate of comorbidity with other personality disorders, specifically, borderline, the Cluster B narcissistic, and histrionic personality disorders in

62 DSM-IV or emotionally unstable and histrionic personality disorders in ICD-10 (Hart & Hare, 1989; Hildebrand & de Ruiter, 2004). As the symptoms of these various personality disorders substantially overlap, the high rate of comorbidity among them reflects to some extent inadequacies in their diagnostic criteria (i.e., a failure to “carve nature at its joints”), as well as common etiological factors. Low rates of comorbidity are observed between antisocial personality disorder and certain other personality disorders, specifically the Cluster C avoidant, dependent, and obsessive-compulsive personality disorders or anxious/avoidant, dependent, and anankastic personality disorder in ICD- 10 (Hart & Hare, 1989; Hildebrand & de Ruiter, 2004). The low rates of comorbidity among the disorders suggest they have independent or even competing etiologies. The rates of comorbidity between antisocial personality disorder and most other disorders are either inconsistent, unclear, or unremarkable (Hart & Hare, 1989; Hildebrand & de Ruiter, 2004; Robins et al., 1991).

Etiology The etiology of antisocial personality disorder is unknown. Theoretical models of etiology can be divided into two main categories based on whether they view antisocial personality disorder as a true disorder, that is, a bona fide form of mental abnormality. Theoretical models of antisocial personality disorder as mental abnormality have focused on the potential causal influence of social and biological factors. Overall, the research literature supports the relative importance of biological over social factors. With respect to social factors, there are no child rearing experiences, familial dysfunctions, or adverse life experiences that are found both frequently and specifically in people with antisocial personality disorder compared to people with other personality disorders. As noted previously, however, sociocultural factors certainly appear to play a role in the expression of the disorder (Cooke et al., 2005). With respect to biological factors, researchers have reported elevated rates of prenatal trauma, neurotransmitter abnormalities, and structural abnormalities of the brain associated with symptoms of antisocial personality disorder (e.g., Coccaro, 2001; Neugebauer, Hoek, & Susser, 1999; Raine, Lencz, Bihrle, LaCasse & Colletti, 2000), but none of these factors is clearly pathognomonic. Also, some adoption research has reported that the heritability of antisocial personality disorder is substantial (e.g., Cadoret, Troughton, Bagford, & Woodworth, 1990), but molecular genetic research has not identified genetic markers. A common theme underlying many etiological theories that focus on biological factors is that antisocial personality disorder is associated with impaired ability to experience emotions and integrate them in executive functions; this core emotional deficit results in a failure of attachment to others, inattention to cues of impending punishment, and insensitivity to reward or punishment. Other theoretical models reject the notion that antisocial personality disorder is a mental abnormality at all. First, some interpersonal and behavioural genetic theories view antisocial personality disorder as an extreme variant of the same personality traits found in all people (e.g., Livesley, 1998; Miller, Lynam, Widiger, & Leukefeld, 2001). According to these theories, antisocial personality disorder is not associated with any unique or specific causal influences and any differences between people with versus without the disorder are quantitative rather than qualitative in nature – that is, the differences are a matter of degree rather than of kind. Second, some sociobiological and evolutionary theories view antisocial personality disorder as an adaptation (e.g., Mealey, 1995). According to these theories, the human species has the genetic capacity to express traits associated with antisocial personality disorder. In sociobiological theories, the genetic capacity exists in only a minority of humans and its manifestation is only partially dependent on environmental circumstances; in evolutionary theories, the genetic capacity exists in all humans, but is manifested in only a minority of humans who are exposed to specific environmental circumstances. In both theories, people with antisocial personality disorder have an evolutionary advantage in terms of an increased likelihood of producing offspring.

Treatment

63 There is no good evidence that antisocial personality disorder can be successfully treated (Dolan & Coid, 1993). Indeed, there is no methodologically sound research on the treatment of antisocial personality disorder. Most treatment studies have simply attempted to reduce criminal behaviour in mixed groups of patients or offenders, including some with antisocial personality disorder, rather than on attempting specifically to alleviate symptoms of antisocial personality disorder. Keeping these methodological limitations in mind, the research literature suggests that people with antisocial personality disorder engage in more disruptive behaviour during treatment, are less likely to remain in treatment, and engage in more criminal behaviour after treatment than do controls (Hemphill & Hart, 2002).

With respect to modality of treatment, there is some evidence supporting the potential utility of structured psychosocial treatments that focus on the acquisition of important life skills, such as communication, assertiveness, and anger management skills (Hemphill & Hart, 2002). Pharmacological treatments that target treatment-interfering symptoms, such as extreme hostility or impulsivity, may play a useful adjunctive role in certain cases. There is little or no evidence supporting the utility of unstructured treatments that focus on interpersonal and emotional processes.

Major Contemporary Theoretical Perspectives and Controversies Since it was first described by clinical psychopathologists, there has been a major controversy concerning how central a role criminal behaviour should play in the assessment and diagnosis of antisocial personality disorder. Some view criminal conducts as a primary symptom of the disorder (e.g., American Psychiatric Association, 1994; Hare, 2003). Others view criminal conduct as a possible consequence or complication of antisocial personality disorder, emphasizing the fact that there is no specific association between the two and that criminal conduct has many possible motivations (e.g., Cleckley, 1948; Cooke, Michie, Hart, & Clark, 2004). Resolving this controversy may result in an improved set of diagnostic criteria that is particularly useful for research comparing lifetime prevalence rates of antisocial personality disorder across various groups, as well as for research on antisocial personality disorder as a risk factor for violent and criminal behaviour.

References • American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders , 4th edition. Washington, DC: Author. • Arrigo, B. A., & Shipley, S. (2001). The confusion over psychopathy (I): Historical considerations. International Journal of Offender Therapy and Comparative Criminology , 45 , 325-344. • Berrios, G. E. (1996). The history of mental symptoms: Descriptive psychopathology since the nineteenth century . Cambridge, UK: Cambridge University Press. • Cadoret, R., Troughton, E., Bagford, J., & Woodworth, G. (1990). Genetic and environmental factors in adoptee antisocial personality. European Archives of Psychiatry & Neurological Sciences , 239 , 231-240. • Cleckley, H. (1948). Antisocial personalities. In L. A. Pennington & I. A. Berg (Eds.), An introduction to clinical psychology (pp. 249-264). New York: Ronald Press. • Coccaro, E. F. (2001). Biological and treatment correlates. In W. J. Livesley (Ed.), Handbook of personality disorders: Theory, research and treatment (pp. 124-135). New York: Guilford. • Compton, W. M., Helzer, J. E., Hwu, H. G., Yeh, E. K., McEvoy, L., Tipp, J. E., et al.. (1991). New methods in cross-cultural psychiatry: Psychiatric illness in Taiwan and the United States. American Journal of Psychiatry , 148 , 1697–1704. • Cooke, D. J. (1996). Psychopathic personality in different cultures: What do we know? What do we need to find out? Journal of Personality Disorders , 10 , 23-40.

64 • Cooke, D. J., Michie, C., Hart, S. D., & Clark, D. A. (2004). Reconstructing psychopathy: Clarifying the significance of antisocial and socially deviant behaviour in the diagnosis of psychopathic personality disorder. Journal of Personality Disorders , 18 , 337-357. • Cooke, D. J., Michie, C., Hart, S. D., & Clark, D. A. (2005). Searching for the pan-cultural core of psychopathic personality disorder: Continental Europe and North America compared. Personality and Individual Differences , 39 , 283-295. • Dolan, B., & Coid, J. (1993). Psychopathic and antisocial personality disorders: Treatment and research issues . London, England: Gaskell. • Hare, R. D. (2003). Manual for the Hare Psychopathy Checklist – Revised, 2nd ed. Toronto, Canada: Multi Health Systems. • Hare, R. D., McPherson, L. E., & Forth, A. E. (1988). Male psychopaths and their criminal careers. Journal of Consulting and Clinical Psychology, 56 , 710-714. • Hart, S. D., & Hare, R. D. (1989). Discriminant validity of the Psychopathy Checklist in a forensic psychiatric population. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 1 , 211-218. • Hemphill, J. F., & Hart, S. D. (2002). Motivating the unmotivated: Psychopathy, treatment, and change. In M. McMurran (Ed.), Motivating offenders to change (pp. 193-219). Chichester, UK: Wiley. • Hemphill, J., Hart, S. D., & Hare, R. D. (1994). Psychopathy and substance use. Journal of Personality Disorders, 8, 32-40. • Hildebrand, M., & de Ruiter, C. (2004). PCL-R psychopathy and its relation to DSM-IV Axis I and II disorders in a sample of male forensic psychiatric patients in the Netherlands. International Journal of Law & Psychiatry , 27 , 233-248 • Livesley, W. J. (1998). The phenotypic and genotypic structure of psychopathic traits. In D. J. Cooke, A. E. Forth, & R. D. Hare (Eds.). Psychopathy: Theory, research, and implications for society (pp. 69-79). Dordrecht, The Netherlands: Kluwer. • McBurnett, K., & Pfiffner, L. (1998). Comorbidities and biological correlates of conduct disorder. In Cooke, D. J., Forth, A. E., & Hare, R. D. (Eds.). Psychopathy: Theory, research, and implications for society (pp. 189-203). Dordrecht, The Netherlands: Kluwer. • Mealey, L. (1995). The sociobiology of sociopathy: An integrated evolutionary model . Behavioural and Brain Sciences, 18 , 523-599. • Miller, J. D., Lynam, D. R., Widiger, T. A., & Leukefeld, C. (2001). Personality disorders as extreme variants of common personality dimensions: Can the Five-Factor Model adequately represent psychopathy? Journal of Personality , 69 , 253-276 • Neugebauer, R., Hoek, H. W., & Susser, E. (1999). Prenatal exposure to wartime famine and development of antisocial personality disorder in early adulthood. Journal of the American Medical Association , 282 , 455–462. • Paris, J. (1998). Personality disorders in sociocultural perspective. Journal of Personality Disorders , 12 , 289–301. • Repo-Tiihonen, E., Virkkunen, M., & Tiihonen J (2001). Mortality of antisocial male criminals Journal of Forensic Psychiatry , 12 , 677-683. • Raine, A., Lencz, T., Bihrle, S., LaCasse, L., & Colletti, P. (2000). Reduced prefrontal gray matter volume and reduced autonomic activity in antisocial personality disorder. Archives of General Psychiatry , 57 , 119-127 • Robins, L. N., Tipp, J., & Przybeck, T. (1991). Antisocial personality. In L. N. Robins & D. Regier (Eds.), Psychiatric disorders in America: The Epidemiologic Catchment Area study (pp. 258- 290). New York: Free Press. • Widiger, T. A., & Corbitt, E. M. (1995). Antisocial personality disorder in DSM-IV. In J. Livesley (Ed.), DSM-IV personality disorders (127-134). New York: Guilford.

65 • World Health Organization (1992). ICD-10: International statistical classification of diseases and related health problems (10th rev.). Geneva, Switzerland: Author.

66 Avoidant Personality Disorder Yutaka Ono

Diagnostic Criteria DSM-IV 301.82 Avoidant Personality Disorder A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 8. Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection 9. Is unwilling to get involved with people unless certain of being liked 10. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed 11. Is preoccupied with being criticized or rejected in social situations 12. Is inhibited in new interpersonal situations because of feelings of inadequacy 13. Views self as socially inept, personally unappealing, or inferior to others 14. Is unusually reluctant to tale personal risks or to engage in any new activities because they may prove embarrassing

Diagnostic Criteria ICD-10 F60.6 Anxious [avoidant] personality disorder Personality disorder characterized by: (a) persistent and pervasive feelings of tension and apprehension; (b) belief that one is socially inept, personally unappealing, or inferior to others; (c) excessive preoccupation with being criticized or rejected in social situations; (d) unwillingness to become involved with people unless certain of being liked; (e) restrictions in lifestyle because of need to have physical security; (f) avoidance of social or occupational activities that involve significant interpersonal contact because of fear of criticism, disapproval, or rejection Associated features may include hypersensitivity to rejection and criticism

Clinical description Avoidant personality disorder is a pervasive pattern of social inhibition, feelings of inadequacy or inferiority, and hypersensitivity to negative evaluation, according the definition of American Psychiatric Association DSM-IV-TR (American Psychiatric Association, 2000). The term of avoidant personality disorder has been used in DSM, while anxious personality disorder is used in ICD-10 (World Health Organization, 1993). Although the term avoidant personality disorder was first used by Millon, these patients have been described as sensitive character (Kretschmer, 1921), introvert (Jung, 1936), interpersonally avoidant (Horney, 1945)), insecure psychopath (Schneider, 1950), phobic personalities (Fenichel, 1945), or active-detached personalities (Millon, 1973). People with this disorder are timid, extremely self-conscious and fearful of criticism, humiliation, and rejection, which are thought to be an extreme variant of the fundamental personality traits of neuroticism. They usually feel inadequate and uncertain when meeting someone new or doing something that is unfamiliar. Despite their great desire for the warmth of companionship, they try to avoid social situations at any cost due to their alleged fear of rejection. Because of their extreme vigilance about rejection, they are afraid to speak up in public or make requests of others. The criteria of avoidant personality disorder of DSM-IV-TR consists of the following seven personality characteristics, and the presence of this disorder is indicated by four or more of them: 1) individuals with avoidant personality disorder avoid work or school activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection, 2) they will not become involved in new interpersonal relationships unless they are sure they will be accepted without criticism, 3) individuals tend to show restraint within intimate relationships, have difficulty talking

67 about themselves, and withhold intimacy for fear of being exposed or ridiculed despite their ability to establish such relationships, 4) they may be preoccupied with being criticized or rejected in social situations and easily notice subtle cues of criticism or rejection, 5) they tend to be shy, quiet, and inhibited in new interpersonal situations because of feelings of inadequacy and low self-esteem, 6) they view themselves as socially inept, personally unappealing, and these tendencies become manifest especially in situations involving interactions with strangers, 7) these individuals are unusually reluctant to take personal risks or to engage in any new activities. The main symptoms of anxious personality disorder, the counterpart of avoidant personality disorders in ICD-10, are the followings: 1) persistent, pervasive feelings of tension, 2) habitual self- consciousness and insecurity, 3) continuous yearning to be liked and accepted, 4) hypersensitivity to rejection and criticism, 5) needs uncritical acceptance in relationships, 6) exaggerates potential dangers or risks, 7) needs for security restrict lifestyles. In addition to the personality characteristics mentioned above, individuals with avoidant personality disorder may show excessive autonomic arousal, resulting from elevated peripheral sympathetic activity and adrenocortical responsiveness in social and occupational settings.

Prevalence Although there was concern that the prevalence of avoidant personality disorder might be low when it was first included in the DSMIII classification system, it became clear that this is one of most common personality disorders. The DSM-IV-TR (American Psychiatric Association, 2000) describes that the prevalence of the avoidant personality disorder is 0.5 to 1.0 of the general population. However, this disorder appears to be more prevalent according to the recent studies with a large sample size. In the study of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) (Grant, et al.., 2004), the prevalence of the disorder is 2.36%. The results of the Australian National Survey of Mental Health and Well-being indicate that the prevalence of ICD-10 anxious personality disorder, the concept equivalent to DSM-IV avoidant personality disorder is 2.25 % (Jackson, et al., 2004). It is more prevalent within clinical settings and reported to present 5% -35% in psychiatric populations (Mattia et al., 2001). The odds of avoidant personality disorder are greater for the lower income group, people with less than a high school education, the widowed/divorced /separated and never married, and residents in the most urbanized areas (Grant et al., 2004).

Gender and age DSM-IV-TR states that the avoidant personality disorder appears to be equally frequent in males and females; recent studies indicate that the risk of this disorder is greater among females than among males (Grant, et al.., 2004, Jackson & Burgess, 2004). In the Australian survey, results show that females are more likely to have just anxious personality disorder than anxious personality disorder and other comorbid personality disorders, which indicates that the comorbid personality disorders weaken the association with being female. The disorder tends to begin in infancy or in childhood with shyness, isolation, and anxiety (Bernstein & Travaglini L, 1999). These tendencies can also appear in adolescence and young adulthood. However, clinicians should be cautious about giving the diagnosis of this disorder to children and adolescents for whom these tendencies may be developmentally appropriate. The risk of the disorder appears to be higher among the 30-44-year-old age group (Grant et al., 2004).

Etiology Although the etiology of avoidant personality disorder is not known, a few models are proposed. The biological learning theory hypothesizes that the interaction of a biologically determined sensitivity to interpersonal relationships and social experiences affects the development of the disorder. It is also postulated to be an extreme variant of the personality traits of introversion and neuroticism which have heritability. According to the interpersonal etiology model, the disorder is

68 explained based on a conflict between seeking closeness and fearing it. Cognitive theory hypothesizes negative schema which originate in early childhood, and which lead to social avoidance behaviour. The individuals with this disorder tend to think “I should avoid situations where I call attention to myself and try to be inconspicuous”, and “I’d never live it down if people uncovered my insecurity”.

Course and prognosis When the disorder begins in childhood, the symptoms could worsen in adolescence due to the complex and demanding social relationships of this time. Furthermore, maladaptive strategies may decrease social effectiveness and worsen the person’s low self-confidence. Although data suggests that some improvement could be gained by various forms of treatment of individual, group, and family format, further research is needed to reach a conclusive statement regarding a definitive form of treatment. A study of non-clinical subjects revealed the relative stability of avoidant personality features (Lenzenweger, 1999), but a recent multi-centre study of treatment-seeking populations at clinical services shows that the symptomatic behavioural criteria remit more quickly and more frequently than trait criteria (McGlashan et al., 2005). A longitudinal study, the CLPS study (Skodol, Gunderson, Shea et al..), also suggested that exaggerated personality traits in avoidant personality disorder, such as feeling socially inept and feeling inadequate, may remain stable over time, while other dysfunctional behaviours that serve to adapt to defend against or compensate for a predominant trait, such as avoiding jobs with interpersonal contact, may change over time. The presence of avoidant personality disorder and borderline personality disorder is reported to predict the later development of new cases of major depression (Alnaes & Torgerson, 1997). Depressed individuals with both avoidant personality disorder and social phobia but not social phobia alone appear to have greater social dysfunction (Alpert et al., 1997). This disorder become less clear or diminishes as the person become older in some cases. Function at the work place may not be significantly impaired, as long as there is little demand for public performance.

Comorbidity Clinical literature has reported that Cluster C personality disorders including avoidant personality disorder often co-occur with mood and anxiety disorders (Alnaes & Torgersen, 1988, Johnson & Lydiad, 1995, Mauri et al., 1992, Oldham et al., 1995, Reich & Troughton E, 1988, Rossi et al., 2001, Schneier et al., 1991, Skodol et al., 1999, Stravynski et al., 1986). An epidemiological study of NESARC (Grant et al., 2005) also showed that avoidant and dependent personality disorders were strongly related to mood disorders, especially major depression, dysthymia, and mania. In the same study avoidant personality disorders were reported to be strongly related to anxiety disorders, especially panic disorder with agoraphobia and social phobia. In addition to mood and anxiety disorders, eating disorders tend to be comorbid with avoidant personality disorder (Oldham et al.., 1995). Avoidant personality disorder often co-occurs with other Cluster C personality disorders. This disorder is especially strongly correlated with dependent personality disorder (Alden et al., 2002; Kass et al., 1985, Oldham et al., 1992; Stuart et al., 1998, Trull et al., 1987). The same tendencies were also found among a nonclinical sample (Watson & Sinha, 1998). It also often co-occurs with Cluster A personality disorders such as paranoid and schizoid personality disorders (Grant et al., 2005). However, as many instruments fail to identify the underlying reason for lack of social interpersonal interactions, this relationship may be misleading. In addition, after years of failed relationships some avoidant personalities may “give up” and hence appear more like schizoid personality disorder. (Neenan, Felkner, Reich 1986). The Australian national survey reported that individuals with anxious personality disorder were more likely to have chronic physical conditions such as asthma, chronic bronchitis, anaemia, gastric ulcer,and so on (Jackson & Burgess, 2004).

69 Sociocultural factors There is variation in the appropriateness of avoidant behaviour and shyness between different cultures and ethnic groups. Some form of Taijin kyofusho proposed in Japan may correspond to avoidant personality disorder (Ono et al., 1996). The milder form of taijin kyofusho is characterized by strong tension in interpersonal situations and usually begins in adolescence and last for a long time, the clinical features of which mimic those of avoidant personality disorder.

Treatment It is essential to establish a good therapeutic relationship, which is however, very difficult because of the patients’ low self-esteem and hypersensitivity to rejection. Cognitive individual or group format is effective for these types of patients. Social skills training, systematic desensitization, and graded hierarchy of in vivo exposure to feared social situations could be useful (Beck &, Freeman, 1990). Both short-term dynamic psychotherapy and cognitive therapy have a place in the treatment of patients with cluster C personality disorders (Svartberg et al., 2004). At two-year follow-up, 42% – 54% of the patients showed symptomatic recovery, and about 40% recovered in their personality functioning and interpersonal relationships. While gains and changes noticed after short term treatment have been considered insufficient for determine long-term change (Alden 1989), Karterud (1992) confirmed that patients with Cluster C personality disorders improved more than those with borderline personality disorder in long-term dynamic psychotherapy. Exploratory and supportive group therapy may be helpful for these patients by providing a holding environment in which they can share their insecure feelings and practice more assertive behaviours. Pharmacotherapy can be useful for anxious patients (Widiger, 2001). Nevertheless, because of this type of patients’ fear of taking medicarion, the clinician should be cautious in prescribing. Antidepressants such as SSRI, SNRI, and monoamine oxydase inhibitors, anxiolytic medication, and B-blockers could be used to ease their symptoms. Although benzodiazepines are very popular, it is important to monitor them closely because of their risk of dependence.

Major contemporary theoretical perspectives and controversies Avoidant personality disorder is often comorbid with social anxiety disorder. It is still not clear if these two disorders are independent ones, if one is the extreme form of the other, or if one is the result of the other (Millon & Davis, 1996; Reich 2000). In addition, the controversial debate whether avoidant personality disorder and social anxiety disorder/generalized social phobia actually are the same disorder have even lead to the suggestion that avoidant personality disorder should be eliminated from the DSM. Others have identified central differential diagnostic features, e.g., that avoidant personalities have more pervasive non-social avoidance than people with generalized social phobia and may show marked preference for the familiar while avoiding situations involving novelty or excitement. (Taylor, Laposa, Alden, 2004). The other issue to be discussed is the relationship between avoidant personality disorder, which focuses more on phobic avoidant behaviours, and anxious personality disorder which focuses more on anxious feelings. People with these types of disorder are easily hurt by criticism and disapproval, afraid of being embarrassed in front of other people, and tend to keep their distance from other people. Avoidant personality disorder patients, however, are characterized by the hesitation about having close interpersonal relationships or trying new things, whereas anxious personality disorder patients show strong anxiety and tension. The relationship between avoidant personality disorder and other personality disorders such as dependent, schizoid, schizotypal, and paranoid personality disorders is also an issue to be discussed because they share common features. A dimensional approach, in addition to a categorical approach, might be considered to incorporate these common features.

References

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73 Borderline Personality Disorder Anthony W. Bateman and Peter Fonagy

Diagnostic Criteria DSM-IV 301.83 Borderline Personality Disorder A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Frantic efforts to avoid real or imagined abandonment. Note : Do not include suicidal or self-mutilating behaviour covered in Criterion 5. 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation 3. Identity disturbance: markedly and persistently unstable self-image or sense of self 4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note : Do not include suicidal or self-mutilating behaviour covered in Criterion 5. 5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour 6. Affective instability due to marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) 7. Chronic feelings of emptiness 8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger recurrent physical fights) 9. Transient, stress-related paranoid ideation or severe dissociative symptoms

Diagnostic Criteria ICD-10 F60.3 Emotionally unstable personality disorder A personality disorder in which there is a marked tendency to act impulsively without consideration of the consequences, together with affective instability. The ability to plan ahead may be minimal, and outbursts of intense anger may often lead to violence or "behavioural explosions"; these are easily precipitated when impulsive acts are criticized or thwarted by others. Two variants of this personality disorder are specified, and both share this general theme of impulsiveness and lack of self-control. F60.30 Impulsive type The predominant characteristics are emotional instability and lack of impulse control. Outbursts of violence or threatening behaviour are common, particularly in response to criticism by others. lncludes: explosive and aggressive personality (disorder) Excludes: dissocial personality disorder (F60.2) F60.31 Borderline type Several of the characteristics of emotional instability are present; in addition, the patient's own self- image, aims, and internal preferences (including sexual) are often unclear or disturbed. There are usually chronic feelings of emptiness. A liability to become involved in intense and unstable relations hip s may cause repeated emotional crises and may be associated with excessive efforts to avoid abandonment and a series of suicidal threats or acts of self-harm (although these may occur without obvious precipitants) lncludes: borderline personality (disorder)

Definition Borderline personality disorder (BPD) is a complex and serious mental disorder that is characterized by a pervasive pattern of difficulties with emotional regulation and impulse control, and instability both in relationships and in self-image (Skodol, Gunderson, Pfohl, et al., 2002). There are nine criteria for BPD in the DSM-IVR, of which only five need to be present to make the diagnosis giving 151 different combinations of criteria for a BPD diagnosis (Skodol, Gunderson, Pfohl, et al., 2002) The nine criteria describe frantic efforts to avoid real or imagined abandonment, a pattern of unstable and intense interpersonal relationships, identity disturbance, impulsivity, recurrent suicidal gestures, affective instability, chronic feelings of emptiness,

74 inappropriate intense anger, and transient stress-related paranoid ideation or severe dissociative symptoms. The ICD 10 (World, Health & Organization, 1992) uses the term “emotionally unstable personality disorder” and defines impulsive and borderline variants. The impulsive type is characterized by emotional instability and lack of impulse control with implicit paranoid sensitivity. The borderline type shows several of the characteristics of emotional instability but includes problems with self-image, lack of personal clarity about preferences (including sexual) and chronic feelings of emptiness. It is unclear whether these two variants are easily distinguished in clinical practice.

Epidemiology and sociocultural factors Borderline personality disorder is a common condition with a prevalence of between 0.2-1.8% of the general population (Swartz, Blazer, George, et al., 1990) . The most reliable study of the prevalence of the disorder in a community sample conducted in Oslo (Torgersen, Kringlen & Cramer, 2001) suggested that the prevalence of BPD was not as frequent as commonly assumed; only 0.7% of patients from a representative community sample were diagnosed as borderline. Prevalence rates increase if patients within the mental health system are sampled. 75% of patients diagnosed with BPD are female and are younger in age at diagnosis when compared with other personality disorders. Approximately 9% of patients eventually kill themselves (Frances, 1986). They tend to be single or divorced and in one study, all married patients with BPD had a lifetime history of being separated or divorced (Zimmerman & Coryell, 1989) . There is a high rate of reported abuse (Zanarini, Yong, Frankenburg, et al., 2002) and patients are high utilizers of mental health services (Zanarini, Frankenburg, Hennen, et al. , 2004) BPD is a socially sensitive disorder. Even taking into account diagnostic bias there has been a change in prevalence of the disorder. Epidemiological research has demonstrated an increase in impulsive personality disorders over recent decades especially in younger people. This cohort effect is highly likely to be due to social change and the problems people have in adapting to rapidly shifting social and peer group pressures since it has occurred over a relatively short period of time.

Etiology Most authors now propose a multifactorial model of etiology taking into account genetic and environmental factors. The major twin study of personality disorders so far is the Norwegian study by Torgersen and colleagues (Torgersen, Lygren, Oien, et al. , 2000) . Based on twin and patient registers heritability was 0.60 for Cluster B overall with borderline being 0.69, giving a clear indication that genetic factors are critical in the etiology of BPD. Genetic effects may be mediated, in part, through neurotransmitter systems. The overall findings suggest that the association between low serotonin and impulsive aggression, for example, may in part be genetic. However there is as yet no question that a genetic-molecular biological model of BPD can provide a comprehensive account of what is known about the disorder. A number of psychosocial factors supposed to be related to etiology of BPD have been investigated and Zanarini and Frankenburg have presented a comprehensive review of these (Zanarini & Frankenburg, 1997) . The factors listed by these authors included: 1) studies of prolonged early separations and losses confirming the high prevalence of these in the histories of individuals with BPD; 2) studies of disturbed parental involvement confirming the perception of individuals with BPD that their relationships with both their parents are highly conflictual; 3) childhood histories of physical or sexual abuse confirming the high prevalence particularly of sexual abuse and parent-child incest; 4) the high prevalence of affective disorder in first-degree relatives of borderline probands. Data in all these areas are fraught with methodological problems including bias from retrospective accounts. The effects of these environmental factors may be mediated through their influence on neurobiological development, particularly of the arousal system. Emotion regulation is regulated via

75 a complex circuit consisting of the orbital frontal cortex, which is itself an area high in serotonergic receptors, amygdala, and anterior cingulate cortex. In genetically predisposed individuals, developmental abnormalities in the frontal lobes may be stimulated by environmental insults, which lead to difficulty in inhibiting impulsive action. The borderline patient may also be more sensitive to stimuli and so quickly become over-aroused. Sustained sexual abuse is associated with permanently increased responsiveness of the hypothalamic pituitary axis (Rinne, de Kloet, Wouters, et al., 2002) . This finding coupled with subtle frontal lobe changes suggest that impulsive aggression found in BPD may result from a particular sensitivity to stress in the context of an impaired inhibitory mechanism.

Course and Prognosis Borderline patients improve symptomatically over time. One exceptionally long (27 year) follow-up (Paris & Zweig-Frank, 2001) showed that borderline patients continued to improve in late middle agewith only 8% of the BPD sample meriting diagnosis of BPD. Long-term outcome in this study was associated with severity of the disorder and the quality of adaptation (functioning) at the start of the study but not with parenting quality or child abuse or trauma (Zweig-Frank & Paris, 2002). A definitive study (Zanarini, Frankenburg, Hennen, et al., 2003) followed the syndromal and subsyndromal phenomenology of 362 inpatients with personality disorders over six years of prospective follow-up. When the entire follow-up period was considered almost three-quarters could be considered to have recovered at some stage and only 6% of those with remissions experienced recurrences. The overall evidence consistently suggests that even if the diagnosis of BPD ceases to be applicable, patients tend to remain functionally severely impaired (Skodol, Siever, Livesley, et al. , 2002). BPD patients who have been sexually abused in childhood (Paris, Zweig-Frank & Guzder, 1993) or have been victims of incest (Stone, 1990) have a poor prognosis. If the patient’s first psychiatric contact takes place at an early age (Links, Mitton & Steiner, 1993) and his/her symptoms are chronic, spontaneous recovery is less likely. Phenomenological factors that predict poor outcome include higher levels of affective instability, magical thinking and aggression in relationships (McGlashan, 1992), impulsivity and substance abuse and greater severity of disorder. Further, if the patients have co-morbid schizotypal, antisocial or paranoid features then the prognosis is likely to be poor (Links, 1998).

Comorbidity Comorbidity is common (Skodol, Gunderson, Pfohl, et al., 2002). Summarizing all the studies, around 60% of patients are diagnosed with major depressive disorder; 30% have panic disorder with agoraphobia; 12% substance misuse; 10% bipolar-I; and 4% bipolar-II disorder. A patient’s response to treatment of an Axis-I disorder is invariably worse if he or she also has BPD. Comorbidity may be an artifact of overlapping symptom sets used to define co-occurring disorders. An alternative hypothesis is that borderline and other Cluster B symptomatology are complications that arises from a primary affective disorder (Akiskal, Hirschfeld & Yerevanian, 1983). Thus, interpersonal maladjustment may be a residue of depressive illness and chronic personality disorder may result from recurrent depressive episodes. Currently the evidence is against this view.

Treatment All clinicians and researchers are agreed that there is no single effective treatment for BPD. Most argue that integration of psychotherapy and medication offers the best chance of a good outcome and this approach is encapsulated in the recommendations of the American Psychiatric Association (Oldham, Phillips, Gabbard, et al. , 2001).

Evidence base for psychotherapy

76 Dynamic psychotherapy. Overall specialist dynamic treatment is probably more effective than treatment as usual and this was first suggested in a non-controlled study of out-patient dynamic therapy (Stevenson & Meares, 1992). Prolonged in-patient treatment, formerly the mainstay of psychotherapeutic treatment has mostly been abandoned and shows little benefit over shorter stays. Comparison of in-patient treatment for one year versus a shorter in-patient stay of six months followed by community support, and treatment as usual confirmed that the brief in-patient stay was superior on most measures (Chiesa & Fonagy, 2003). Non-controlled studies indicate that day hospital stabilization followed by out-patient dynamic group therapy may be as useful as in-patient treatment of BPD (Wilberg, Friis, Karterud, et al. , 1998; Karterud, 2003; Chiesa, Bateman, Wilberg, et al., 2002). Robust support for a psychoanalytically based approach to treatment of BPD has come from a randomized study examining the effectiveness of a psychoanalytically oriented partial hospitalization program with standard psychiatric care (Bateman & Fonagy, 1999; Bateman & Fonagy, 2001). On all outcome measures there was significantly greater improvement in those allocated to psychotherapy. The treatment has now been fully manualized (Bateman & Fonagy, 2004) as mentalization-based treatment (MBT). Mentalization entails making sense of the actions of oneself and others on the basis of intentional mental states, such as desires, feelings, and beliefs. It involves the recognition that what is in the mind is in the mind and reflects knowledge of one’s own and others’ mental states as mental states. This capacity is enfeebled in borderline patients, possibly partly as a result of reduced psychological capacities related to frontal lobe abnormalities. The treatment has also been found to be cost-effective (Bateman & Fonagy, 2003). However, replication is required. Another manualized dynamic therapy known as Transference Focused Psychotherapy (TFP) is available and gives promising results (Clarkin, Foelsch, Levy, et al., 2001). A comparison study between patients treated with TFP and a matched untreated control group confirms the benefits of treatment (Clarkin, 2002). The outcome of a randomized controlled trial comparing TFP, Dialectical Behaviour Therapy, and supportive psychotherapy is not yet known although its rationale has been described (Clarkin, Levy, Lenzenweger, et al., 2004). Conference reports suggest that outcomes may be equivalent but there may be some treatment-specific effects.

Cognitive Analytical Therapy (CAT). CAT has been manualized for treatment of borderline personality (Ryle, 1997). There are some indications that the treatment method may be of help in some patients (Ryle & Golynkina, 2000). A formal randomised trial comparing CAT with “best available standard care’ is currently being carried out with adolescent patients with borderline personality disorder in Victoria, Australia.

Cognitive Therapy. Standard CBT has little evidence beyond case reports for effectiveness but there are tentative reports that schema-focused therapy and other modified CBT programs may be of use in BPD. In cognitive therapy for personality disorders much greater emphasis is placed on changing core beliefs than dysfunctional thoughts, with maintaining a collaborative therapeutic alliance and understanding interpersonal behaviour. Davidson and Tyrer (Davidson & Tyrer, 1996), in an open study, used modified cognitive therapy for the treatment of two cluster-B personality disorders. They evaluated a brief (10-session) cognitive therapy approach – Manual Assisted Cognitive Therapy (MACT) – using single-case methodology, which showed improvement in target problems. Results were mixed. In a larger study treating patients who self-harm, MACT was no better than treatment as usual in the primary outcome measure of self-harm. In BPD, MACT increased total costs in contrast to its effect in other personality disorders and had less satisfactory results in reducing self-harm (Tyrer, Tom, Byford, et al., 2004). The overall evidence in favor of cognitive-behaviour therapy in treatment of personality disorder is therefore relatively slim with much of it coming from one research group. Further research is required.

77 Dialectic Behaviour Therapy (DBT). This is a special adaptation of behaviour therapy, which was originally used for the treatment of a group of repeatedly parasuicidal female patients with borderline personality disorder and which led to a marked reduction in the frequency of self-harm episodes compared with treatment as usual (Linehan, Armstrong, Suarez, et al., 1991). Although DBT reduces episodes of self-harm initially, it is less effective in the longer term (Linehan, Heard & Armstrong, 1993). At six-month follow-up DBT patients continued to show less parasuicidal behaviour than controls, though at one year there were no between-group differences. DBT is a manualised therapy (Linehan, 1993) which includes techniques at the level of behaviour (functional analysis), cognitions (e.g. skills training), and support (empathy, teaching management of trauma). The aim of DBT is initially to control self-harm but its main aim is to promote change in the emotional dysregulation that is judged to be the core of the disorder (Robins, 2003), and this goes far beyond self-harm reduction. It has been suggested that the widespread adoption of DBT is not justified by the strength of the evidence (Tyrer, 2002) and conclusions about the effectiveness of DBT as a treatment for the personality itself are premature (Scheel, 2000; Turner, 2000; Levendusky, 2000). Since the original trial, handicapped by many methodological limitations, there has only been one randomized study that supports the findings unequivocally (Verheul, Van Den Bosch, Koeter, et al., 2003). In this study, 58 Dutch women who met DSM-IV criteria for BPD were randomly assigned to either one year of DBT or to treatment-as-usual (TAU), i.e., ongoing treatment in the community. Participants were clinical referrals both from addiction treatment and psychiatric services. Efficacy was measured in terms of treatment retention and course of high-risk suicidal, self-mutilating and otherwise self- damaging behaviours. DBT resulted in better retention rates (63% versus 23%) and significantly greater reductions of self-mutilating behaviours and self-damaging impulsive acts than TAU, especially among those with histories of frequent self-mutilating behaviours. The study suggests DBT is superior to TAU, in reducing self-mutilating and otherwise self-damaging impulsive behaviours in patients with BPD; post hoc analyses suggested that those with more severe self- harming behaviour were helped most. Other studies have either been uncontrolled, too small to add any useful data (Koons, Robins & Tweed, 2000) or have shown DBT to be no better than other active treatments such as the 12-step program for alcohol dependence (Linehan, Dimeff, Reynolds, et al., 2002).

Therapeutic Community Treatments . A therapeutic community (TC) may be defined as an intensive form of treatment in which the environmental setting becomes the core therapy in which behaviour can be challenged and modified, essentially through group interaction and interpersonal understanding. None has been specifically developed to treat BPD. However in one study of a mixed group of patients with PD comparing patients treated in a TC with patients not admitted, there was significantly greater reduction in core features of personality disorder on the Borderline Syndrome Index (Dolan, Warren & Norton, 1997) in the treated group than in the non-admitted group. In most countries the expense of in-patient TC treatment has led to widespread closure and this treatment model is rarely available in its in-patient form although some day facilities have adopted the model (Haigh, 2002).

Evidence-base for medication There is little to indicate that any form of psychotropic drug treatment has a specific effect on borderline personality disorder but some drugs may be useful in reducing disabling symptoms. Typical and atypical antipsychotic drugs . Low dosage antipsychotic drugs might be effective in the treatment of borderline personality disorder (Perinpanayagam & Haigh, 1977) (Brinkley, Beitman & Friedel, 1979). But the most impressive study (Soloff, George & Nathan, 1986), which showed superiority of haloperidol over placebo and amitriptyline, failed to be replicated in a continuation study for 16 weeks, in which haloperidol showed superiority over placebo only for the symptom of irritability, and was generally less effective than phenelzine

78 (Cornelius, Soloff & Perel, 1993). Two small trials with olanzapine and risperidone give some support for their efficacy (Zanarini & Frankenburg, 2001; Koenigsberg, Reynolds & Goodman, 2003). There have also been encouraging open studies with clozapine, olanzapine and quetiapine (Benedetti, Sforzini & Colombo, 1998; Zullino, Haefliger & Stigler, 2002; Walker, Thomas & Allen, 2003) that suggest better compliance.

Tricyclic antidepressants (TCA’s) and selective serotonin reuptake inhibitors (SSRI’s). There have been very few studies following that of Soloff (Soloff, George & Nathan, 1986) of tricyclic antidepressants in the treatment of personality disorder and none of the recent ones has included a tricyclic control. By contrast the SSRI’s have been widely assessed in formal trials against placebo control and found to be effective in reducing aggressive, impulsive and angry behaviour in those with borderline and aggressive personality disorders (Coccaro & Kavoussi, 1997).

Monoamine oxidase inhibitors (MAOI’s). Monoamine oxidase inhibitors, tranylcypromine and phenelzine, are now used relatively infrequently but have some evidence of effectiveness in the treatment of borderline personality disorder (Cowdry & Gardner, 1988) (Soloff, Cornelius & George, 1993). However, the high frequency of self-harm and the risks of overdose with these drugs are likely to inhibit prescription.

Mood stabilisers . All known mood stabilizers have been used in the treatment of personality disorder. Lithium may stabilize the serotonergic system and, as an effective mood stabilizer, is also an empirically sensible pharmacotherapy to investigate in personality disorders. The evidence for effectiveness of lithium is small, but relatively good. In an early study (Sheard, Martin & Bridges, 1976) showed that lithium reduced aggression markedly in those with personality disorder, and other studies (Links, Steiner & Boiago, 1990) support its anti-aggressive properties. Carbamazepine has also some presumptive evidence of efficacy but this is not well established (Gardner & Cowdrey, 1986) (De La Fuenta & Lostra, 1994). Sodium valproate in the form of divalproex sodium has been assessed in the treatment of borderline personality disorder and other disorders in the cluster B group and two small randomized trials support its efficacy compared with placebo (Frankenburg & Zanarini, 2002) (Hollander, Tracy & Swann, 2003).

Conclusions For the first time in the history of borderline personality disorder, people are regarding the condition as potentially treatable. Health departments are showing interest and mental health professionals have begun to develop services (DoH, 2003). It is likely that more effective treatments are going to be found in the course of the next two decades and, if this turns out to be true, it will help greatly in removing the pejorative label that currently is attached to the disorder as well as relieving the obvious suffering of patients and their families.

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83 Dependent Personality Disorder Robert F. Bornstein

Diagnostic Criteria DSM-IV 301.6 Dependent Personality Disorder A pervasive and excessive need to be taken care of that leads to submissive and clinging behaviour and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others 2. Needs others to assume responsibility for most major areas of his or her life 3. Has difficulty expressing disagreement with others because of fear of loss of support or approval. Note : Do not include realistic fears of retribution. 4. Has difficulty initiating projects or doing things on his or her own (because of a lack of self- confidence in judgment or abilities rather than a lack of motivation or energy) 5. Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant 6. Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself 7. Urgently seeks another relationship as a source of care and support when a close relationship ends 8. Is unrealistically preoccupied with fears of being left to take care of himself or herself

Diagnostic Criteria ICD-10 F60.7 Dependent personality disorder Personality disorder characterized by: (a) encouraging or allowing others to make most of one's important life decisions; (b) subordination of one's own needs to those of others on whom one is dependent, and undue compliance with their wishes; (c) unwillingness to make even reasonable demands on the people one depends on; (d) feeling uncomfortable or helpless when alone, because of exaggerated fears of inability to care for oneself; (e) preoccupation with fears of being abandoned by a person with whom one has a close relationship, and of being left to care for oneself; (f) limited capacity to make everyday decisions without an excessive amount of advice and reassurance from others. Associated features may include perceiving oneself as helpless, incompetent, and lacking stamina lncludes: asthenic, inadequate, passive, and self-defeating personality (disorder)

Although early diagnosticians discussed at length the clinical implications of exaggerated dependency needs, it was not until publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) that dependent personality disorder (DPD) became a full-fledged diagnostic category. DPD is defined as “a pervasive and excessive need to be taken care of that leads to submissive and clinging behaviour and fears of separation” (APA, 1994, p. 668). The person must show five of the following eight symptoms to receive a DPD diagnosis: (1) difficulty making everyday decisions without excessive advice and reassurance, (2) needing others to assume responsibility for most major areas of life, (3) difficulty expressing disagreement, (4) difficulty initiating projects or doing things on one’s own, (5) going to excessive lengths to obtain nurturance and support, (6) feeling uncomfortable and helpless when alone, (7) urgently seeking another source of support when an important relationship ends, (8) being unrealistically preoccupied with fears of being left to care for oneself.

Etiology

84 Evidence suggests that DPD is traceable in part to genetic factors: When Torgerson et al.. (2000) contrasted DPD prevalence rates in 92 monozygotic and 129 dizygotic twin pairs, they found substantially greater concordance in monozygotic twins, and concluded that approximately 30% of the variance in DPD symptoms was attributable to genetic influences. Although no studies have determined what inherited factors increase DPD risk, certain infantile temperament variables (e.g., withdrawal, soothability) warrant further investigation. Beyond genetics, two other processes have been implicated in the etiology of DPD.

Parenting : Overprotective and authoritarian parenting, alone or in combination, increase the likelihood that a child will show DPD later in life (Head, Baker & Williamson, 1991). Overprotective parenting teaches children that they cannot survive without the protection of powerful caregivers. Authoritarian parenting teaches children to look outward for guidance and direction, and accede to others’ demands. Both parenting styles contribute to the development of a representation of the self as weak and ineffectual, and increase dependent attitudes and behaviours (Bornstein, 1993).

Culture : Because sociocentric cultures (e.g., Japan, India) emphasize interpersonal ties more strongly than individual achievement, persons raised in these cultures show higher levels of dependency than those raised in individualistic cultures such as America or Great Britain (Cross, Bacon & Morris, 2000). Because dependent, other-centred behaviour is normative in many sociocentric cultures, DPD symptoms often go unnoticed by clinicians, who are more likely to label independent behaviour as dysfunctional. Studies only uncover increases in problematic dependency when DPD prevalence rates are assessed in matched samples of clinical or community populations that differ with respect to cultural background.

DPD Diagnosis In diagnosing DPD clinicians should be aware of two issues. First, because dependency is typically seen as a sign of weakness and immaturity, many adults - especially men -are reluctant to acknowledge dependent thoughts and feelings. Second, increases in depression are associated with increases in self-reported dependency, and even modest mood changes may have some impact on dependency levels (Bornstein, 1995). With these caveats in mind, two methods are used to diagnose DPD: interviews and questionnaires. In recent years three diagnostic interviews have been used most often: the Structured Clinical Interview for DSM Personality Disorders (SCID-II; Spitzer, Williams, Gibbon & First, 1990); the International Personality Disorder Examination (IPDE; Loranger, 1995); and the Structured Interview for Diagnosis of Personality-Revised (SIDP-R; Pfohl, Blum, Zimmerman & Stangl, 1989). Two self-report instruments have also been used quite frequently: the Millon Clinical Multiaxial Inventory-III (MCMI-III; Millon, Millon & Davis, 1994); and the Personality Diagnostic Questionnaire-IV (PDQ-IV; Davison, Morven & Taylor, 2001).

Epidemiology and Comorbidity Problematic dependency is widespread in the community as well as in clinical populations, and is associated with an array of psychological disorders. Studies typically report DPD prevalence rates of between 15 % and 25% in hospital and rehabilitation settings (Oldham et al.., 1995). The base rate of DPD in outpatients is not particularly high, however. In most studies it ranges from 0 % to 10% (Klein, 2003), considerably lower than the prevalence rates of several other personality disorders (e.g., borderline, histrionic, narcissistic). Bornstein’s (1993, 1997) meta-analyses of epidemiological findings indicated that gender moderates DPD prevalence rates. When data from extant studies were combined, the overall base rate of DPD was 11% in women and 8% in men. Although this difference seems modest, it is highly significant (X2 [1, N = 5,965] = 13.53 , p = .0005), and suggests that the base rate of DPD is 40% higher in women than men. The DSM-IV-TR indicates that three Axis I diagnoses - mood disorders, anxiety disorders, and adjustment disorder - show substantial comorbidity with DPD. Evidence supports continued

85 inclusion of these three categories in future versions of the DSM, but also suggests that eating disorders and somatisation disorder co-occur with DPD at higher-than-expected rates (Piper et al.., 2001). The DSM-IV-TR lists three Axis II PDs--borderline, histrionic, and avoidant--as comorbid with DPD. Studies indicate that DPD is actually comorbid with the majority of Axis II syndromes. Thus, Barber and Morse (1994) found that DPD showed significant comorbidity with paranoid, schizotypal, antisocial, borderline, histrionic, narcissistic, and obsessive-compulsive personality disorders in a mixed-sex sample of psychiatric outpatients. Wise (1996) obtained similar results in psychiatric inpatients.

Theoretical Conceptualizations Four theoretical frameworks have been particularly influential in conceptualizing and studying DPD.

Psychodynamic Models : Research does not support the hypothesis that variations in infantile feeding and weaning behaviours play a role in the development of dependent personality traits (Bornstein, 1996). Many psychodynamic researchers (e.g., Luborsky & Crits-Christoph, 1990) now conceptualize problematic dependency as resulting from unconscious conflicts , which take two forms: 1) conflicts between two competing urges (e.g., a wish to be cared for versus an urge to compete); and 2) impulse-defence conflicts (e.g., when an urge to be cared for conflicts with societal expectations regarding adult behaviour). Other psychodynamic researchers have developed models that are aligned closely with object relations theory, and trace the development of problematic dependency to a mental representation of the self as weak and ineffectual.

Cognitive Models : Cognitive models of DPD focus on the ways in which a person’s manner of thinking helps foster dependent behaviour. As Freeman and Leaf (1989) noted, dependency-related automatic thoughts (i.e., reflexive self-statements that reflect the person’s perceived lack of competence) are central in this process. Automatic thoughts are accompanied by negative self- statements, which combine to create a persistent attributional bias that reinforces the person’s view of himself as vulnerable and weak. A vicious cycle ensues wherein each new challenge triggers a set of cognitive responses that exacerbate the dependent person’s sense of helplessness; as the person’s sense of helplessness increases, each new challenge seems even more insurmountable (Young, 1994).

Behavioural and Social Learning Models : The basic premise of the behavioural perspective on DPD is that people exhibit dependent behaviours because those behaviours are rewarded, were rewarded, or are perceived by the individual as being likely to bring rewards. Studies confirm that intermittent reinforcement of dependent behaviour propagates problematic dependency in adults as well as children (Turkat, 1990). Some researchers further suggest that vicarious reinforcement (i.e., observation of dependency-derived rewards in others) and modelling may also play a role in the dynamics of dependency. Trait models: Trait models of DPD share a common goal of identifying the core traits that comprise a dependent personality orientation. Costa and McCrea’s (1992) five-factor model (FFM) has been the most influential trait model of dependency in recent years. The FFM classifies personality traits along five broad dimensions - neuroticism, extraversion, openness, agreeableness, and conscientiousness - and recent research confirms that high levels of trait dependency and DPD are associated with elevated levels of neuroticism, and low levels of openness (Costa & Widiger, 1994).

Treatment No studies have documented the long-term course of DPD in inpatients, outpatients, or community adults. In the short term, research confirms that dependent patients exhibit behaviours that both facilitate and undermine treatment. For example, dependent psychotherapy patients are cooperative and conscientious, but also make more requests for after-hours contact. Dependent patients delay

86 less long than nondependent patients when psychological symptoms appear, but they also have difficulty terminating treatment after symptoms remit (Bornstein, 1993). Over the years clinicians have provided recommendations for intervention strategies based on cognitive (Young, 1994), psychodynamic (Luborsky & Crits-Christoph, 1990), behavioural (Turkat, 1990), and experiential (Schneider & May, 1995) treatment models. However, only two studies assessed changes in DPD symptoms during the course of psychotherapy, and these investigations produced conflicting results. Rathus, Sanderson, Miller, and Wetzler (1995) found a significant decrease in MCMI-II dependency scores from pre- to post-treatment in a sample of 18 agoraphobic outpatients receiving 12 weeks of cognitive-behavioural therapy. In contrast, Black, Monahan, Wesner, Gabel, and Bowers (1996) reported no significant change in PDQ-derived dependency scores from pre- to post-treatment in 44 outpatients with panic disorder receiving 8 weeks of cognitive therapy. Several investigations assessed the impact of psychotropic medications on DPD symptoms, but these studies also produced inconclusive results. Some researchers reported significant decreases in DPD symptoms following antidepressant treatment (e.g., Zaretsky et al.., 1997); others found no change in DPD symptoms following antidepressant treatment (e.g., Rector, Bagby, Segal, Joffe & Levitt, 2000).

Major Contemporary Theoretical Perspectives and Controversies Continued investigation of the impact of various therapeutic interventions on DPD symptoms is clearly warranted. In addition, three areas require continued attention from clinicians and clinical researchers.

Assessing and revising DPD symptoms : When Bornstein (1997) evaluated empirical evidence bearing on the eight DSM-IV DPD symptoms, he found that four of these symptoms were supported by the results of laboratory and clinical data (Symptoms 1, 5, 6, and 8, listed earlier), while two (Symptoms 2 and 7) had never been tested empirically, and two (Symptoms 3 and 4) had been contradicted repeatedly. Without question, changes are needed in the DPD symptoms.

Alternative Conceptual Frameworks : Some clinicians have argued that a dimensional approach to PD diagnosis would be more useful than the current threshold model. In contrast to many Axis I syndromes, PD-related traits exist on a continuum, and it is difficult to specify a point at which these traits warrant diagnosis and treatment (Widiger & Clark, 2000). A dimensional approach is particularly applicable to DPD because dependent traits are common in clinical and community samples, and a DPD intensity rating would approximate the distribution of DPD in the general population more closely than the current dichotomous classification. Several frameworks have been described for conceptualizing DPD using a dimensional approach. Most prominent among these is the FFM, and evidence suggests that DPD is associated with predictable patterns of scores on the five FFM domains (Costa & Widiger, 1994). Other researchers (e.g., Bornstein & Languirand, 2003) have argued for a two-dimensional system, with dependent behaviours rated in terms of intensity and adaptiveness . Evidence confirms that certain persons express dependent strivings in a flexible, modulated manner which enables them to obtain needed help and support, whereas others express dependency in ways that undermine their help- and support-seeking efforts.

The temporal and situational stability of DPD : Studies suggest a population-wide increase in dependent behaviour through later adulthood, although this is primarily a consequence of the increase in functional dependency that occurs in old age (Baltes, 1996). Longitudinal research indicates considerable stability in dependency levels: Those individuals who show high rates of DPD symptoms relative to their peers during early adulthood continue to show comparatively high levels of DPD symptoms later in life (Abrams & Horowitz, 1996). Findings regarding situational variability contrast markedly with those documenting temporal stability. As Bornstein (1993) noted, even

87 though the dependent person’s core beliefs and motives remain stable over time and across situation, their behaviour changes dramatically in response to perceived opportunities and risks. When the dependent person believes that passive behaviour will strengthen ties to potential nurturers and caregivers, passivity ensues; when the dependent person believes that active behaviour is needed to strengthen these ties, assertive - even aggressive - behaviour is exhibited. Thus, clinicians must not only focus closely on behavioural manifestations of DPD symptoms, but should explore the situational contingencies that moderate dependent behaviour. Only when information regarding the interpersonal dynamics of dependency is combined with information regarding the contextual factors that influence the outward expression of dependent strivings can DPD be diagnosed accurately and treated effectively.

References • Abrams, R. C., & Horowitz, S. V. (1996). Personality disorders after age 50: A meta- analysis. Journal of Personality Disorders , 10 , 271-281. • American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th edition). Washington, DC: Author. • Baltes, M. M. (1996). The many faces of dependency in old age . Cambridge, UK: Cambridge University Press. • Barber, J. P., & Morse, J. Q. (1994). Validation of the Wisconsin Personality Disorders Inventory with the SCID-II and PDE. Journal of Personality Disorders , 8, 307-319. • Black, D. W., Monahan, P., Wesner, R., Gabel, J., & Bowers, W. (1996). The effect of fluvoxamine, cognitive therapy, and placebo on abnormal personality traits in 44 patients with panic disorder. Journal of Personality Disorders , 10 , 185-194. • Bornstein, R. F. (1993). The dependent personality . NY: Guilford Press. • Bornstein, R. F. (1995). Sex differences in objective and projective dependency tests: A meta-analytic review. Assessment , 2, 319-331. • Bornstein, R. F. (1996). Beyond orality: Toward an object relations/interactionist reconceptualization of the etiology and dynamics of dependency. Psychoanalytic Psychology , 13 , 177-203. • Bornstein, R. F. (1997). Dependent personality disorder in the DSM-IV and beyond. Clinical Psychology: Science and Practice , 4, 175-187. • Bornstein, R. F., & Languirand, M. A. (2003). Healthy dependency . NY: Newmarket Press. • Costa, P. T., & McCrea, R. R. (1992). Revised NEO Personality Inventory (NEO-PI-R) and NEO Five-Factor Inventory (NEO-FFI) professional manual . Odessa, FL: Psychological Assessment Resources. • Costa, P. T., & Widiger, T. A. (Eds.) (1994). Personality disorders and the five-factor model of personality . Washington, DC: American Psychological Association. • Cross, S. E., Bacon, P. L., & Morris, M. L. (2000). The relational-interdependent self- construal and relationships. Journal of Personality and Social Psychology , 78 , 791-808. • Davison, S., Morven, L., & Taylor, P. J. (2001). Examination of the screening properties of the Personality Diagnostic Questionnaire 4+ (PDQ-4+) in a prison population. Journal of Personality Disorders , 15 , 180-194. • Freeman, A., & Leaf, R. C. (1989). Cognitive therapy applied to personality disorders. In A. Freeman, K. M. Simon, L. E. Beutler, & H. Arkowitz (Eds.), Comprehensive handbook of cognitive therapy (pp. 403-434). NY: Plenum Press. • Head, S. B., Baker, J. D., & Williamson, D. A. (1991). Family environment characteristics and dependent personality disorder. Journal of Personality Disorders , 5, 256-263.

88 • Klein, D. N. (2003). Patients’ versus informants’ reports of personality disorders in predicting 7-year outcome in outpatients with depressive disorders. Psychological Assessment , 15 , 216-222. • Loranger, A. W. (1995). International Personality Disorder Examination (IPDE) manual . Unpublished manuscript, Cornell University Medical College. • Luborsky, L., & Crits-Christoph, P. (1990). Understanding transference: The Core Conflictual Relationship Theme method . NY: Basic Books. • Millon, T., Millon, C., & Davis, R. (1994). Millon Clinical Multiaxial Inventory-III . Minneapolis, MN: National Computer Systems. • Oldham, J. M., Skodol, A. E., Kellman, H. D., Hyler, S. E., Doidge, N., Rosnick, L., & Gallagher, P. E. (1995). Comorbidity of Axis I and Axis II disorders. American Journal of Psychiatry , 152 , 571-578. • Pfohl, B., Blum, N., Zimmerman, M., & Stangl, D. (1989). Structured Interview for DSM-III-R Personality (SIDP-R) . Iowa City, IA: Department of Psychiatry, University of Iowa. • Piper, W. E., Ogrodniczuk, J. S., Joyce, A. S., McCallum, M., Weideman, R., & Azim, H. F. (2001). Ambivalence and other relationship predictors of grief in psychiatric outpatients. Journal of Nervous and Mental Disease , 189 , 781-787. • Rector, N. A., Bagby, R. M., Segal, Z. V., Joffe, R. T., & Levitt, A. (2000). Self-criticism and dependency in depressed patients treated with cognitive therapy or pharmacotherapy. Cognitive Therapy and Research , 24 , 571-584. • Schneider, K. J., & May, R. (1995). The psychology of existence: An integrative, clinical perspective . NY: McGraw-Hill. • Spitzer, R. L., Williams, J. B. W., Gibbon, M., & First, M. B. (1990). Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) . Washington, DC: American Psychiatric Press. • Torgersen, S., Lygren, S., Oien, P. A., Skre, I., Onstad, S., Edvardsen, J., Tambs, K., & Kringlen, E. (2000). A twin study of personality disorders. Comprehensive Psychiatry , 41 , 416- 425. • Turkat, I. D. (1990). The personality disorders: A psychological approach to clinical management . NY: Pergamon Press. • Widiger, T. A., & Clark, L. A. (2000). Toward DSM-V and the classification of psychopathology. Psychological Bulletin , 126 , 946-963. • Wise, E. A. (1996). Comparative validity of MMPI-2 and MCMI-II personality disorder classifications. Journal of Personality Assessment , 66 , 569-582. • Young, J. E. (1994). Cognitive therapy for personality disorders: A schema-focused approach . Sarasota, FL: Professional Resources Press. • Zaretsky, A. E., Fava, M., Davidson, K. G., Pava, J. A., Matthews, J., & Rosenbaum, J. F. (1997). Are dependency and self-criticism risk factors for major depressive disorder? Canadian Journal of Psychiatry , 42 , 291-297.

89 Histrionic Personality Disorder Bruce Pfohl

Diagnostic Criteria DSM-IV 301.5 Histrionic Personality Disorder A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Is uncomfortable in situations in which he or she is not the centre of attention 2. Interaction with others is often characterized by inappropriate sexually seductive or provocative behaviour 3. Displays rapidly shifting and shallow expression of emotions 4. Consistently uses physical appearance to draw attention to self 5. Has a style of speck that is excessively impressionistic and lacking in detail 6. Shows self-dramatization, theatricality, and exaggerated expression of emotion 7. Is suggestible, i.e., easily influenced by others or circumstances 8. Considers relationships to be more intimate than they actually are

Diagnostic Criteria DSM-10 F60.4 Histrionic personality disorder Personality disorder characterized by: (a) self-dramatization, theatricality, exaggerated expression of emotions; (b) suggestibility, easily influenced by others or by circumstances; (c) shallow and labile affectivity; (d) continual seeking for excitement and activities in which the patient is the centre of attention; (e) inappropriate seductiveness in appearance or behaviour; (f) over-concern with physical attractiveness Associated features may include egocentricity, self-indulgence, continuous longing for appreciation, feelings that are easily hurt, and persistent manipulative behaviour to achieve own needs. lncludes: hysterical and psychoinfantile personality (disorder)

Clinical description Histrionic personality disorder (HPD) is described in DSM-IV as a pervasive pattern of excessive emotionality and attention-seeking, beginning by early adulthood and present in a variety of contexts. Individuals with HPD need attention from others to feel good about themselves and are especially uncomfortable in situations in which someone else is the centre of attention. They will use a variety of methods to steal the spotlight in social gatherings. This may include being sexually provocative or seductive in settings where this is inappropriate and when they have no particular sexual interest in the individuals whose attention they seek. They are often emotionally dramatic and expressive but the emotions have a shallow quality and shift rapidly depending on the response they get from others. These individuals often use physical appearance including choice of clothing, hair style, or makeup to draw attention. Their style of speaking is often dramatic or theatrical in a manner that commands attention. They are prone to express strong opinions but there is a lack of objective detail, suggesting that opinions have not been very carefully thought through. They are suggestible and quick to adopt ideas or opinions expressed by others so as to fit in with the group. They will identify other people whom they know only casually as very dear friends and greet them in a dramatic manner that may surprise or embarrass the recipient of their affection. Individuals with narcissistic personality disorder also like to be the centre of attention, but want the attention to be based on their perceived superiority over others, whereas individuals with HPD are willing to be perceived as impaired or fragile if this will get them attention. Individuals with borderline personality disorder can be emotionally dramatic but differ in that they are prone to alienate others by expressing hostility when they perceive someone is neglecting or abandoning them.

90 The origins of HPD can be traced to the psychoanalytic concept of hysterical neurosis which incorporated elements of both HPD and what we now refer to as the somatoform disorders. Easser and Lesser (1965) note that Freud postulated a relationship (though not a 1:1 correlation) between unusual and unexplained medical complaints and so-called “erotic personality, whose major goal in life is the desire to be in love or above all to be loved”. Many of the physical symptoms were conceptualized as being due to repressed emotions including unacknowledged sexual urges. Given the scope of clinical phenomena incorporated within these theories, it is not surprising that there were difficulties in applying the concept reliably. Easser and Lesser commented in 1965: “The terms, hysteria, hysterical character, etc., are so loosely defined and applied so promiscuously that their application to diagnostic categories has become meaningless (p. 392)”. In a similar vein, in 1971 Lazare wrote, "Hysterical is commonly used in a pejorative sense to describe a patient who is self-engrossed, incapable of loving deeply, lacking depth, emotionally shallow, fraudulent in affect, immature, emotionally incontinent, and a great liar... The presence, of just one of these traits together with a tired resident, may result in the diagnosis of 'just hysterical'" (p. 131). As this description suggests, the term hysterical was sometimes used in a loose, imprecise way to describe difficult patients in a manner similar to the way the terms “cluster B traits” or “borderline traits” may be used by more modern-day residents.

Etiology While it is difficult to empirically test the hypothesized link between repression of strong emotions and histrionic personality characteristics, there have been some interesting attempts. One study reported on a methodology in which anxiety-arousing visual stimuli were presented using a tachistoscope. Subject’s self-reports of what they perceived were then used to rate operationalized definitions of defence mechanisms. There was some support for the link between repression and HPD (Rubino & Pezzarossa, 1992). The association between HPD traits and somatisation disorders as noted by Freud is also supported by some modern-day studies (Garyfallos et al., 1999). Despite the central role of early childhood experiences in Freud’s formulations of psychopathology, he also acknowledged that biologic constitution played an important role in character and temperament. Torgersen and colleagues used a large twin registry to examine the hereditability of the criteria for various DSM-IV personality disorders. Unlike most other twin studies which use self-report scales to assess personality traits, the authors used a structured interview for DSM-IV personality disorder (the SCID-II) to make categorical diagnoses. High rates of heritability were found for all of the cluster B personality disorders and HPD was no exception with a heritability index of 0.67. With respect to environmental effects, shared environment explained little of the variance suggesting that either experience unique to the individual family member were operative or that the remaining variance is explained by imprecision in measurement tools (error variance). Another twin study using a rating scale filled out by parents of children 5 -17 years of age found significantly higher correlations of histrionic traits in monozygotic than dizygotic child twins.

Prevalence DSM-IV-TR suggests that about 2 - 3% of the general population meets criteria for HPD. More recently, data is available from a large probability sample of over 43,000 individuals aged 18 or older in the general community — the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) (Grant et al., 2004). The authors report a prevalence rate for HPD of 1.8 % which would suggest that 3.8 million individuals in the United States meet criteria for this Axis II disorder. Another community-based study of 742 individuals reported a lower prevalence rate — about 0.2% (Samuels et al., 2002). This study used a different diagnostic instrument and was limited to adults over the age of 34. Rates of HPD are much higher in most clinical samples. A multicentre study of 1116 psychiatric patients collected from a variety of inpatient and outpatient sources found that 9.1%

91 were diagnosed with HPD using a structured diagnostic interview for DSM-III-R (Stuart et al., 1998). Other studies have suggested rates in the 5 – 10 % range in clinical samples (Carter et al., 1999; Garyfallos et al. 1999)

Gender and age Historically, hysteria or HPD has been more frequently diagnosed in woman. The criteria themselves have been criticized for being gender- biased (Hartung and Widiger, 1998); however, studies using structured diagnostic interviews generally find equal rates among men and women. In the NESARC epidemiologic study described above, the rate of HPD was 1.9% among men and 1.8% among women (Grant et al., 2004). An Australian study of 225 depressed outpatients using the SCID-II interview found that 9.1% of men and 5.5% of woman met criteria for HPD (Carter et al., 1999). This difference was not significant. A similar study of depressed patients in this country using both the PDQ and the SCID-II found no significant differences in prevalence by gender for either instrument (Golomb et al., 1995). Some authors have hypothesized that HPD and antisocial personality disorder may be gender -influenced expression of the same underlying diathesis but support for this is limited (Cale and Lilienfeld, 2002, and may reflect problems with the categorical approach to describing personality differences. In the general population, the prevalence of HPD appears to go down with age. In the NESARC study, individuals aged 45 -64 were only a third as likely to meet criteria for this disorder compared to individuals aged 18 -29. However, the same may not necessarily apply to age cohorts in clinical populations, probably due to selection bias in clinical samples. In fact, HPD was slightly more common in older cohorts in a sample of 790 patients admitted to a psychiatric unit at a VA hospital.

Comorbidity As noted above, there does appear to be an association between somatoform disorders and HPD, at least in clinical populations. A large study of psychiatry outpatients in Greece found 24% of patients with somatoform disorders met criteria for HPD compared to 7% of psychiatric patients with non- somatoform diagnoses (Garyfallos et al., 1999). The study found that a comorbid personality disorder predicted worse functional impairment among patients with a somatoform disorder. Depression is probably the most common Axis I comorbid disorder with HPD. Rates of HPD in the range of 15 – 30% have been reported in inpatients with a current major depression as reported in a review of 11 different studies (Corruble et al., 1996). One study of nonpatient relatives of inpatients found that among relatives with HPD, 46% had a lifetime history of major depression (Zimmerman & Coryell, 1989). There are few studies that look at whether comorbid HPD independently portends a worse outcome among patients with depression but this does appear to be true of Cluster B personality disorders in aggregate (Mulder, 2002; Reich, 2003). One report that examined the effects of HPD independently found it did not predict a worse outcome for depression (Rothschild and Zimmerman, 2002).

Controversies and Questions Some authors have suggested that HPD and borderline personality disorder may exist on a continuum such that the latter is a more severe version of the former (Kernberg, 1988). Others have suggested a link between antisocial personality disorder and HPD (Cale and Lilienfeld, 2002), and there are clear overlaps with narcissistic and dependent personality disorders. In addition to questions that have been raised about whether there are gender differences (or gender bias) in how HPD is applied by clinicians, some authors have investigated whether rates of histrionic traits are more common in some cultural or ethnic groups or whether there is cultural bias in how this diagnosis is applied. There is a paucity of research on this question. One novel study of college students found that students associated the criteria for HPD with European Americans more

92 often than with African or Asian Americans suggesting there is some cultural stereotyping of this disorder (Iwamasa et al., 2000). An important issue is whether all of the DSM-IV categorical diagnoses might not be better conceptualized as a series of continuous personality traits (Widiger and Clark, 2000). If such an approach were adopted, it is unlikely there would be a single “histrionic” dimension since factor analytic studies suggest that the criteria for this disorder sort out on several different dimensions (Blashfield and Davis, 1993). This will doubtless be the subject of much research and debate in the next few years.

References • Blashfield RK, Davis RT. Dependent and histrionic personality disorders. In Sutker PB and Adams HE (eds.) Comprehensive Handbook of Psychopathology. Plenum Press, New York, 1993. • Cale EM, Lilienfeld SO. Histrionic personality disorder and antisocial personality disorder: sex-differentiated manifestations of psychopathy? J Personal Disord. 2002 Feb;16(1):52-72. • Carter JD, Joyce PR, Mulder RT, Sullivan PF, Luty SE. Gender differences in the frequency of personality disorders in depressed outpatients. J Personal Disord. 1999 Spring;13(1):67-74. • Corruble E, Ginestet D, Guelfi JD. Comorbidity of personality disorders and unipolar major depression: a review. J Affect Disord. 1996 Apr 12;37(2-3):157-70. Review • Easser, B., & Lesser, S. (1965). Hysterical character and psychoanalysis. Psychoanal Q, 1965; 34:390-405; • Funtowicz MN, Widiger TA. Sex bias in the diagnosis of personality disorders: an evaluation of the DSM-IV criteria. J Abnorm Psychol. 1999 May;108(2):195-201. • Garyfallos G, Adamopoulou A, Karastergiou A, Voikli M, Ikonomidis N, Donias S, Giouzepas J, Dimitriou E. Somatoform disorders: comorbidity with other DSM-III-R psychiatric diagnoses in Greece. Compr Psychiatry. 1999 Jul-Aug;40(4):299-307. • Golomb M, Fava M, Abraham M, Rosenbaum JF. Gender differences in personality disorders. Am J Psychiatry. 1995 Apr;152(4):579-82. • Grant BF, Hasin DS, Stinson FS, Dawson DA, Chou SP, Ruan WJ, Pickering RP. Prevalence, correlates, and disability of personality disorders in the United States: results from the national epidemiologic survey on alcohol and related conditions. J Clin Psychiatry. 2004 65:948-58. • Hartung CM, Widiger TA. Gender differences in the diagnosis of mental disorders: conclusions and controversies of the DSM-IV. Psychol Bull. 1998 May;123(3):260-78. • Iwamasa GY, Larrabee AL, Merritt RD. Are personality disorder criteria ethnically biased? a card-sort analysis. Cultural diversity and Ethnic Minority Psychology. 2000 6(3):284-296. • Kenan MM, Kendjelic EM, Molinari VA, Williams W, Norris M, Kunik ME. Age-related differences in the frequency of personality disorders among inpatient veterans.Int J Geriatr Psychiatry. 2000 Sep;15(9):831-7. • Kernberg OF. Severe Personality Disorder: Psychotherapeutic strategies. New Haven, CT: Yale University Press, 1988. • Lazare, A (1971). The hysterical character in psychoanalytic theory. Arch Gen Psychiatry, 25, 131-137. • Mulder RT. Personality pathology and treatment outcome in major depression: a review. Am J Psychiatry 2002; 159:359-371. • Reich J. The effect of Axis II disorders on the outcome of treatment of anxiety and unipolar depressive disorders: A review. J Personal Disord 2003; 17: 387-405.

93 • Rothschild L, Zimmerman M. Personality disorders and the duration of depressive episode: a retrospective study. J Personal Disord. 2002 16:293-303. • Samuels J, Eaton WW, Bienvenu OJ 3rd, Brown CH, Costa PT Jr, Nestadt G. Prevalence and correlates of personality disorders in a community sample. Br J Psychiatry. 2002 Jun;180:536-42. • Stuart S, Pfohl B, Battaglia M, Bellodi L, Grove W, Cadoret R The cooccurrence of DSM- III-R personality disorders. J Personal Disord 1998; 12:302-315. • The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (American Psychiatric Association, 1994. • Torgersen S, Lygren S, Oien PA, Skre I, Onstad S, Edvardsen J, Tambs K, Kringlen E A twin study of personality disorders. Compr Psychiatry. 2000; 41(6):416-25. • Widiger TA, Clark LA. Toward DSM-V and the classification of psychopathology. Psychol Bull. 2000; 126:946-63.

94 Narcissistic Personality Disorder Elsa Ronningstam

Diagnostic Criteria DSM-IV 301.81 Narcissistic Personality Disorder A pervasive pattern of grandiosity (in fantasy or behaviour), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements). 2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love 3. Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions) 4. Requires excessive admiration 5. Has a sense of entitlement, i.e., unreasonable expectations of especially favourable treatment or automatic compliance with his or her expectations 6. Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends 7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others 8. Is often envious of others or believes that others are envious of him or her 9. Shows arrogant, haughty behaviours or attitudes

Clinical Description Not yet accepted in the ICD system, narcissistic personality disorder, NPD, was included as an Axis II disorder in DSM-III in 1980. In the DSM-IV and DSM-IV-TR (APA, 1994, 2000), NPD is described as “a pervasive pattern of grandiosity, need for admiration, and lack of empathy”, and identified by nine criteria. People with NPD have a grandiose sense of self-importance and accompanying grandiose fantasies. They believe that they are special and unique and they have a strong need for admiring attention. Narcissistic people are considered unempatic, unwilling to recognize or identify with the feelings and needs of others, and they have both a sense of entitlement with expectations of special treatment and exceptions, and tendencies to be exploitive and take advantage of other people. They come across as arrogant and haughty, and they are often envious of others or they believe that others envy them because of their specialness or talents. Five of nine criteria need to be present to fulfil the diagnosis of NPD. In addition, the DSM acknowledges the associated features of vulnerable self-esteem, feelings of shame, sensitivity and intense reactions of humiliation, emptiness or disdain to criticism or defeat, and vocational irregularities due to difficulties tolerating criticism or competition. Patients presenting such secondary characteristics may on the surface appear quite different compared to those captured in the DSM criteria set, and a new diagnostic term, the covert or shy narcissistic personality disorder has been introduced (Akhtar, 1989, 2003; Gabbard, 1989; Cooper, Ronningstam, 1992). Although more sensitive, inhibited, vulnerable, shame-ridden and socially withdrawn, these individuals nevertheless possess the same pathological grandiose self-image and emotional dysregulation as their overt and more arrogant counterparts. Narcissistic patients can also present with psychopathic or antisocial characteristics (Gunderson, Ronningstam, 2001; Hart and Hare 1998) ranging from inconsistent and contradictory moral standards (moral perfectionism vs. moral compromises and dishonesty) to more specific criminal behaviour.

Prevalence The prevalence rate of NPD in the general population ranges from very low (0 – 0.4%), (Mattia, Zimmerman, 2001) to moderate, > 1% (Torgersen, et al. 2001; Reich, et al.. 1989) and 3.9 % - 5.3 % (Bodlund et al., 1993; Klein et al., 1995). Studies also indicate that NPD is more frequently found among people in higher education (Maffei, et al., 1995), or in special professional groups, such as the

95 military (Crosby, Hall 1992). In the adult clinical population, rates between 2% and 16% have been found (Gunderson, Ronningstam, Smith, 1991), and high rates of NPD were identified in the personality disorder population (22%, Morey 1988), as well as in specific clinical samples, i.e., 32% among cocaine abusers (Yates et al. 1989), 47% among bipolar patients (Turley et al., 1992), 21% among depressed patients (Sato, 1997). Clinicians use the NPD diagnosis more frequently, and the DSM criteria often fail to identify patients whom clinicians consider to have a NPD diagnosis (Gunderson, Ronningstam, Smith, 1991).

Gender and Age Differences Some research studies support the idea that NPD is more common in males than in females (Ronningstam & Gunderson, 1990; Millon, 1990), while others have found NPD to be equally prevalent in both sexes (Plakun, 1990). DSM-IV and DSM-IV-TR claim that 50% to 75% of those diagnosed with NPD are male. Narcissistic disturbances are frequent among people in their late teens and early twenties, due mainly to the specific developmental challenges in the transition from adolescence to adulthood. Such disturbances are usually corrected through developmental life experiences and normally do not develop into adult NPD (Ronningstam & Gunderson, 1995a). The presence of NPD in children has also been empirically verified (Abrams 1993; P. Kernberg, Hajal, Normandin 1998) and P. Kernberg (1989, 1998) noted that the narcissistic features found in adults also may be seen in children, i.e., excessive demandingness, omnipotent control, self-absorption, grandiose fantasies, possessiveness and lack of empathy. Profound narcissistic pathology can persist past middle age, and has even been reported in older geriatric subjects (Berezin, 1977; Kernberg, 1977).

Etiology Two studies have suggested a genetic influence on the development of personality disorders, including the narcissistic. In a study of 483 twin pairs, Jang and colleagues (1996) found an average of 45% heritability, and a more recent study of over 200 twins, Torgersen et al., (2000) indicated a genetic explanation for nearly 80 % of the variation in the trait of NPD. Of specific importance for the development of narcissistic personality disorder are inherited variations in hypersensitivity, strong aggressive drive, low anxiety or frustration tolerance, and defects in affect regulation (Schore, 1994). Early environmental influences including inconsistent attunement and insufficient attachment in the early parent-child interaction can lead to failure in the development of self-esteem and affect regulation. Fonagy et al. (2003) suggest that an incongruence between the child’s actual emotional state and the caregivers’ mirroring and misperception leads to the development of NPD. Both Schore’s and Fonagy’s et al. theoretical accounts further explain the internal developmental consequences of what has been described in the literature as the parents’ of the “narcissist-to- become” insensitivity to their child’s emotional experiences: their tendencies to assign roles and expectations to the child, to misread the child’s feelings and reactions and to ascribe their own feelings, intentions and ambitions onto their child. The child is intensively attended to, and specially valued as a regulator of the parent’s self-esteem, but the child is not valued and seen in his/her own right. In addition, certain types of family interaction create specific risks for development of NPD. Parents can give their children roles or functions beyond or inconsistent with the child’s normal developmental tasks (P. Kernberg, 1989), or be overly gratifying or indulging (Imbesi, 2000). A recently proposed diagnostic term, “trauma-associated narcissistic symptoms” or TANS (Simon, 2001), indicates that stress associated with an external traumatic experience in adults can overwhelm the self and trigger narcissistic symptoms such as shame, humiliation and rage. Although underlying vulnerability to such stress can stem from the presence of pathological narcissism or NPD, even people with relatively healthy self-esteem can develop narcissistic symptoms after experiencing a more-or-less severe narcissistic humiliation.

96 Course and prognosis NPD has been considered highly resistant to change. The perpetuation of narcissistic patterns especially in interpersonal relations leads to poor prognosis. Denial of problems and factors in the environment that interfere with grandiosity and narcissistic pursuits, combined with a compensatory fantasy life, and the opportunities for gratifying support of grandiose self-experience, are additional contributing factors. Narcissistic disorders may worsen over the years, with more severe envy, disillusionment and contempt (Millon, 1981; Kernberg, 1980). The presence of severe superego pathology, malignant narcissism, sexual deviations and overt borderline functioning worsens the prognoses for NPD patients, while tolerance for depression and mourning, and capacity for feeling and the ability to tolerate guilt improve prognoses (Kernberg, 1975). On the other hand, in some narcissistic individuals reaching middle age, an increased motivation for change has been found to make treatment efforts more favourable and improve prognosis (Kernberg, 1980). Empirical studies have provided moderate support for the poor prognosis of narcissistic patients. In a retrospective longitudinal study conducted over fourteen years, Plakun (1989) found that narcissistic patients have a lower level of social and global functioning with higher rates of rehospitalisation than the comparison group of borderlines. Contrasting empirical findings (Ronningstam, Gunderson, Lyons 1995) have shown that NPD patients with less severe narcissistically disturbed object relations may have a better prognosis and actually improve over time. Improvements were related to three types of corrective life events involving achievements, interpersonal relations, and disillusionments. Corrective achievements , i.e., graduations, promotions, recognitions, acceptance to schools, programs, or positions they applied for etc., often lead to a more realistic and accepted sense of self, with less need for unrealistic grandiose fantasies and exaggerations of talents and personal qualities. In corrective relationships, which typically were long- term, close and mutual, prior interpersonal characteristics such as devaluation, entitlement, exploitive behaviour and arrogance diminished. In corrective disillusionment, incompatible experiences challenge the previous grandiose self-experience, bringing the view of self into greater congruence with actual talents, abilities, and status. Such experiences may reflect the realization of personal, intellectual or vocational limitations, failure to achieve life goals or conform to narcissistically determined ideals and standards, or even reflect personal losses or lost opportunities in life. The impact of such experiences must not be too adverse, as narcissistic pathologies may actually worsen. Unlike other dramatic cluster disorders, narcissistic personality disorder does not necessarily remit with age. In fact, middle age is an especially critical period for the development or worsening of NPD. The challenge of facing personal and professional limitations, losses and other challenges to the self-esteem can reinforce specific pathological or defensive narcissistic traits, leading to chronic denial, emptiness, devaluation, guilt, and cynicism (Kernberg, 1980).

Comorbidity NPD is considered to have one of the highest rates of diagnostic overlap among the Axis II disorders, and especially with disorders in the dramatic cluster (Gunderson, Ronningstam & Smith, 1991; Morey & Jones 1998). Similarities between NPD and BPD include sensitivity to criticism, ragefulness and entitlement (Ronningstam, Gunderson 1991; Gunderson, 2001). Entitled rage can be found in both NPD and BPD, but while this rage in narcissistic people is triggered by threats to their superiority and to their sense of deserving special or inordinate rights, privileges, status and security, the entitled rage in borderlines is triggered by their needs not being met and feelings of entitlement because of their suffering or victimization. Holdwick et al. (1998) found that NPD shares with BPD affect dysregulation, impulsivity and unstable relationships. However, efforts to find a conceptual relativeness between NPD and BPD have actually resulted in both empirical and clinical evidence supporting their separateness. The most important discriminator is the inflated self- concept of NPD and its various manifestations of grandiosity, including exaggeration of talent, grandiose fantasies, sense of uniqueness (Plakun, 1987; Ronningstam, Gunderson, 1991; Holdwick, Hilsenroth 1998; Morey, Jones 1998).

97 The relatively high diagnostic overlap between ASPD and NPD (25%) (Gunderson, Ronningstam 2001) supports the view that ASPD may be conceptualized as lying along a continuum of narcissistic personality and pathological narcissism. Holdwick et al. (1998) found that NPD and ASPD share interpersonally exploitiveness, lack of empathy and envy, and Blais (1997) identified a sociopathic factor in NPD lack of empathy, exploitation, envy, and grandiose sense of self- importance. One study (Gunderson, Ronningstam 2001), confirms intrapsychic and interpersonal similarities between people with NPD and ASPD: both have grandiose fantasies and believe in their invulnerability; both are in need of admiring attention and are entitled, envious and have strong reactions to criticism. The major differences found in this study relate to narcissists being more grandiose – exaggerating their talents and feeling as being unique and superior – while people with ASPD are more actively exploitive and feel more empty. Major depression and dysthymia are the most common concomitant Axis I disorders in patients with NPD (42 - 50%). Previous studies of the opposite interrelation, i.e., the presence of NPD in major depression, have shown low prevalence rates, (0% to 5%) (Ronningstam, 1996). However, more recent empirical studies by Fava and colleagues reported higher prevalence rates for NPD (8.1%– 16.4%), especially in depression with anger attacks, (Fava, Rosenbaum, 1998, Tedlow et al., 1999). NPD was also significantly more common in early-onset major depression (Fava, et al.., 1996). Nevertheless, narcissistic patients may often show absence of overt depressive symptoms. Because of low affect tolerance, they make various efforts to escape intolerable feelings such as rage and shame, hopelessness and experiences of limitations. Suicidal ideations and behaviour in narcissistic patients may occur in the absence of depression (Kernberg, 1992; Maltsberger, 1998). NPD is one of the most commonly occurring personality disorder among bipolar patients (Brieger, Ehrt, Marneros, 2003), and bipolar disorder is the third most common Axis I disorder found in narcissistic patients (5 – 11%) (Ronningstam, 1996). Narcissistic vulnerability, impulse dysregulation and affect intolerance in the development of drug abuse and dependency have been considered important predisposing factors in substance abuse disorders (Vaillant, 1988; Richman et al. 1996), and the presence of NPD has actually been considered a risk factor for the development of cocaine abuse (Yates, Fulton et al., 1989). Co-occurring narcissistic features can have major implications for course and prognosis, as well as for the overall and in-depth understanding of the patient. Pathological narcissism can also have a major impact on the individual’s experiences of and attitudes towards treatment, and influence his/her motivation toward engaging in a treatment alliance and complying with treatment recommendations.

Treatment The often symptom-free narcissistic individual usually seeks treatment for three reasons: due to acute crises caused by vocational or personal failures or losses; in response to requests or ultimatums from family, employer, or court; or due to an increasing sense of dissatisfaction or meaninglessness in own life. The level of motivation varies greatly depending upon such factors as the patient’s experiences of urgency and ultimateness, capacity for affect tolerance and regulation, and the absence or availability of outside sources of narcissistic gratification that support a continuation of the patient’s narcissistic views and lifestyle. Psychoanalysis and psychoanalytically oriented psychotherapy have been considered the treatment of choice for patients with narcissistic personality disorder. However, recently new treatment strategies for narcissistic disorders outside the psychoanalytic realm have been developed, i.e., cognitive (Beck, Freeman, 1990; Young, Flanagan, 1998), short-term (Oldham, 1988), group (Roth, 1998), couples and family (Solomon, 1998; Kirshner, 2001; Lansky, 1985), and therapeutic milieu (Beaumont, 1998). In addition, treatment of narcissistic patients in programs and modalities focusing on other major symptoms, such as addiction or affective disorders, has also been reported on (Vaglum 1999). Psychopharmacological treatment is often challenging due to the narcissistic patients’ reluctance to subordinate themselves to ordinations, and their hypersensitivity to side

98 effects, especially those affecting sexual and intellectual functioning. While there are many accounts on psychodynamic and psychoanalytic treatment of people with NPD, there are presently no empirical studies on treatment course and efficacy for NPD. Comorbid narcissistic personality disorder can have serious implications in the treatment of patients with some Axis I disorders. Clinical observations suggest that the presence of pathological narcissism is associated with low treatment compliance of Axis I disorders (Smith, Deutsch et al., 1993; Gunderson, Ronningstam 2001; Jaminson, Akiskal 1983). Paradoxically, symptom reduction might not be of primary interest for the narcissistic patients if the symptomatology coincides with or accentuates grandiose self-experience, internal mastery or narcissistic pursuits. Axis I symptomatology such as substance abuse and hypomania or mania, can be specifically agreeable for the narcissistic patient, as they lead to an increase in the sense of grandiosity, mastery and control, self-sufficiency and limitlessness (Jaminson, Akiskal, 1983; Jaminson, Gerner, et al. 1980; Wurmser 1974).

Major Contemporary Theoretical Perspectives and Controversies Although there is by now general agreement about the dynamics and features of pathological narcissism and NPD, there are still contradictory opinions regarding conceptualization and clinical descriptions. The complex nature of pathological narcissism and the challenges involved in treating narcissistic patients have been major contributing factors. The predominant psychoanalytic influence on defining and treating NPD has by now been complemented by biosocial (Millon, 1998), social psychological (Morf, Rhodewalt 2001), and cognitive (Young 1998) studies, as well as by DSM- based psychiatric research. Two major areas of research have high priority: one is the interface between bipolar spectrum disorders and NPD, and specifically the differences between emotional dysregulation and mood shifts as reactions to self-esteem fluctuations versus bipolar mood variations, as well as their co-occurrence. Another involves studies identifying patients with shy NPD. The proposed criteria, such as predominance of shyness, shame, and inhibitions with hidden narcissistic self-esteem dysregulation, need further research on assessment and validation. The absence of a comprehensive clinical database that can guide the understanding of narcissistic patients is a significant obstacle for developing a clinically useful model and guidelines for treatment. Finding treatment modalities and approaches that effectively can motivate and help the suffering of the narcissistic patients and their families is of high priority.

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103 Obsessive-Compulsive Disorder Vicente E. Caballo

Diagnostic Criteria DSM-IV 301.4 Obsessive-Compulsive Personality Disorder A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost 2. Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met) 3. Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity). 4. Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification) 5. Is unable to discard worn-out or worthless objects even when they have no sentimental value 6. Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things. 7. Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes 8. Shows rigidity and stubbornness

Diagnostic Criteria ICD-10 F60.5 Anankastic personality disorder Personality disorder characterized by: (a) feelings of excessive doubt and caution; (b) preoccupation with details, rules, lists , order, organization or schedule; (c) perfectionism that interferes with task completion; (d) excessive conscientiousness, scrupulousness, and undue preoccupation with productivity to the exclusion of pleasure and interpersonal relationships; (e) excessive pedantry and adherence to social conventions; (f) rigidity and stubbornness; (g) unreasonable insistence by the patient that others submit to exactly his or her way of doing things, or unreas6nable reluctance to allow others to do things; (h) intrusion of insistent and unwelcome thoughts or impulses. lncludes: compulsive and obsessional personality (disorder) obsessive - compulsive personality disorder Excludes: obsessive - compulsive disorder (F42. - )

Nowadays behaviour styles promoting devotion to work and highly productive results are valued and reinforced in our society. Qualities such as being perfectionist, meticulous, organized and competent are highly regarded in the work environment, helping people to progress quickly in their enterprises. Individuals with an obsessive-compulsive personality style have those characteristics. They have a high ability to work during a long time; they like to do things well. They do not devote much time to leisure, which would mean loss of productive time. The obsessive-compulsive personalities have strong values guiding many of their actions and frequently believe they are making the right move. They defend moral, ethical, and community principles. They can be the anti- pollution environmentalist, the anti-noise neighbour, the driver who respects and makes others respect the traffic norms. However, when the characteristics of the obsessive-compulsive personality style are taken to the extreme, they will bring about maladaptive conduct making many of their behaviours become ineffective and inefficient, and significantly disturbing the individual's

104 functioning in daily life. In this last case we would be speaking of an obsessive-compulsive personality disorder (OCPD).

Clinical description Diagnostic criteria of ICD-10 (WHO, 1992) and DSM-IV-TR (APA, 2000) for the OCPD (or anankastic personality disorder, following the ICD10) are quite similar. Both nosological systems describe a syndrome characterized by symptoms such as excessive perfectionism, stubbornness, rigidity, and lack of decision. For the DSM-IV-TR, the OCPD is a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: (1) is preoccupied with details, roles, lists, order, organization, or schedules to the extent that the major point of the activity is lost; (2) shows perfectionism that interferes with task completion; (3) is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity); (4) is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification); (5) is unable to discard worn-out or worthless objects even when they have no sentimental value; (6) is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things; (7) adopts a miserly spending style toward both self and others; (8) shows rigidity and stubbornness. The ICD-10 calls the OCPD “anankastic personality disorder” and includes the following diagnostic criteria: The general criteria for personality disorder must be met and at least four of the following must be present: (1) preoccupation with details, rules, lists, order, organization, or schedule; (2) perfectionism that interferes with task completion; (3) excessive conscientiousness, scrupulousness, and undue preoccupation with productivity to the exclusion of pleasure and interpersonal relationships; (4) unreasonable insistence by the individual that others submit to exactly his or her way of doing things, or unreasonable reluctance to allow others to do things; (5) rigidity and stubbornness; (6) feelings of excessive doubt and caution; (7) excessive pedantry and adherence to social conventions; (8) intrusion of insistent and unwelcome thoughts or impulses. Five of the eight criteria are shared by both the ICD-10 and the DSM-IV-TR. Regarding the rest of the criteria, the field needs more research to determine the optimal set of symptoms. In the following pages we will systematize the behavioural, cognitive, emotional and physiological features characteristic of the OCPD (see Caballo, 2004 for a more extended description). Behavioural features of the OCPD are the following: a) structured and strictly organized behaviours; b) extreme scrupulosity and perfectionism that interfere with completion of tasks and decisions- making; c) continuous planning of activities and being good organizers; d) excessive devotion to work to the exclusion of leisure activities, e) excessive focus on details; f) tendency to procrastinate; g) loyal to the ideals they follow and organizations they belong to; h) unusually strict following of social norms and patterns; i) polite, formal, and distant social relationships; j) when talking to others, lack of warmth and involvement; k) highly respectful with authority; l) search for security and approval of his/her superiors; m) social interactions based on status; n) critical of others and seldom giving positive feedback; o) self-disciplined, obstinate, possessive; p) excessively punctual; q) clear and grammatically correct language; r) poorly expressive body language; s) personal appearance is serious, austere, formal, conservative; t) miserly spending style, may store money and goods; and u) inability to discard worn-out and worthless objects. The cognitive features characteristic of OCPD are the following: a) rigidity and stubbornness; b) limited and dogmatic thinking (dichotomous thinking); c) fear to be viewed as irresponsible by others; d) overly sensitive to criticism; e) doubts whether behaving in a submissive or assertive way; f) reluctant to delegate responsibilities to others; g) ambivalence and difficulty in decision-making; h) discomfort with uncertainty or ambiguity; i) vulnerable to unexpected changes; j) resistant to any new idea or different way of doing things; k) difficulties with establishing priorities and perspectives; l) focus too much on details, which can hinder the global view of tasks (trees do not let

105 him/her see the forest); m) lacks creativity, imagination and has few fantasies; n) scrupulous on topics of moral and ethics; o) difficulty in making them change their minds; p) lack empathy; q) construction of their world as a function of rules, norms and hierarchies; r) fear of failure and making mistakes; and s) frequently unsatisfied with their performance. Regarding the emotional features characteristic of OCPD, they could be summarized as: a) anxiety regarding novelty; b) over-control of emotions, whose expression is thought to be a sign of immaturity and irresponsibility, c) difficulty expressing affection, love and tenderness; d) disdain for frivolous and impulsive people; e) tension and stress; f) inability to relax; and g) emotions most easily expressed: anger or indignation. Tentative physiological and medical features characteristic of OCPD could be cardiovascular risks, arterial hypertension, headaches, ulcers and gastritis, and neuromuscular problems. Some of the typical consequences over the environment of this obsessive-compulsive personality disorder could be the following: a) easily promoted in their jobs because of their continuous effort and devotion; b) function well when working in detailed and methodical jobs; c) may organize campaigns against situations that challenge their ethical ideals, such as injustice, corruption, and so on; d) problems with spouse and children because of the little time devoted to them; and e) have few friends.

Prevalence Maier et al. (1992) found that the OCPD was the second most frequent personality disorder (among the 11 included in the DSM-III-R) in his study sample (individuals without psychiatric disorders), showing a range from 1.6% to 6.4%, while the prevalence found by Widiger & Sanderson (1997) ranged from 1% to 3%. Maier et al.. (1992) reported a rate of 2.2%, while the DSM-IV-TR (APA, 200) points to a prevalence of 1% in the general population and a range from 3% to 10% among people referred to mental health clinics, with a mean of 5%, following Widiger & Sanderson (1997).

Gender and age This personality disorder appears to be diagnosed about twice as often among males according to the DSM-IV-TR (APA, 2000) and is diagnosed most often in oldest children (generally, the oldest child in a family may have had more responsibility than the younger ones).

Etiology The etiology of OCPD is unknown. There are not data regarding the influence of biological factors in the onset and development of this disorder, but it is believed that environmental factors play an important role in the etiology of the OCPD. Millon (1996) and Millon & Everly (1985) propose some of these tentative variables: Parental over control : This is a method of restrictive child-rearing in which punitive processes are used to set distinct limits on children’s behaviour. As long as they operate within the parental approved boundaries, children are safe from parental punishment. Learned compulsive behaviour: The acquisition of behaviour patterns of OCPD are learned vicariously and by imitation. The child, fearing parental rejection and retaliation, follows adult demands, avoiding punishment and learning to be obedient through negative reinforcement. By vicarious learning, the child observes perfectionist, scrupulous, orderly, detailed parental behaviours, and eventually includes them in his/her behavioural repertoire. Learned responsibilities: Children are continuously taught that they have to comply strictly with their obligations, must be orderly, educated, organized, punctual, and scrupulous, and that it is irresponsible to behave by impulse or participate in frivolous games. They are continuously exposed to situations where they need to show their sense of responsibility and eventually behave this way to avoid feeling guilty.

Course and prognosis

106 The course of OCPD is relatively stable through time, although it is sometimes difficult to predict. It appears during adolescence or the beginning of adult life, tending to increase with age. It is more frequent to find this type of disorder among individuals with methodical and detailed jobs to which they hold a strict dedication (Robinson, 1999). Prognosis is poor.

Comorbidity The research on the comorbidity of OCPD with other disorders of Axis I has mainly focused on obsessive-compulsive disorder (OCD). However, the only overlapping diagnostic criterion of both disorders is the “inability to discard worn-out or worthless objects even when they have no sentimental value. Although some studies have found a certain association between these two types of disorders (e.g., Gruenberg, 1993; Skodol, 1993), most research shows that most individuals with OCD do not fulfil the criteria of OCPD. Furthermore, it has been found that patients with OCD and with a personality disorder show similar or more frequent relationships with the avoidant or dependent personality disorder than with OCPD. It has also been pointed that the OCD does not conform to a diathesis for OCPD (Black & Noyes, 1997). Some relationship between OCPD and some mood and anxiety disorders has been postulated (APA, 2000). Some individuals may present changes of personality due to the direct effects of a general medical condition on the central nervous system or to the chronic use of substances, but are distinguished from OCPD in that their onset is sudden because of those circumstances. Comorbidity with other personality disorders has varied markedly depending on the specific study. Pfohl & Blum (1991) reviewed several studies and pointed out that highest rates of comorbidity of OCPD took place with avoidant, borderline, narcissistic, paranoid and histrionic personality disorders. OCPD differs from narcissistic personality disorder in that individuals with this last disorder, although also perfectionists, lack the self-critical ability present in the OCPD. Neither individuals with OCPD nor antisocial and narcissistic personality disorders are generous with others, but while the two latter ones are generous with themselves, the OCPD subjects are not. Schizoid and OCPD are characterized by an apparent formality and social detachment, but in OCPD this stems from discomfort with emotions and with excessive devotion to work, whereas in schizoid personality disorder there is a lack of capacity for intimacy (APA, 2000).

Sociocultural factors Obsessive-compulsive personality features are quite frequent among people from Western cultures. Beck, Freeman and Davis (2004) point out that this is because of the high value that society puts on the moderate expression of some of the characteristics of this personality style, such as attention to detail, self-discipline, emotional control, perseverance, reliability, and politeness. So the DSM-IV-TR insists than when assessing an individual with OCPD, behaviours that reflect habits, customs, or interpersonal styles that are culturally sanctioned by the individual’s reference group should not be included. However, in some individuals these characteristics are expressed in such an extreme form that they lead either to significant functional impairment or subjective distress (Beck et al.., 2004), giving way to a diagnosable personality disorder.

Treatment Treatment of individuals with OCPD is difficult and prolonged. Even more, such people will rarely present themselves to a psychological or psychiatric clinic for treatment. Only in cases where the individuals become ineffective in their jobs, when their marriages are in danger or when health problems arise due to their behaviour patterns will they begin to consider that maybe something is wrong with them and a mental health professional could be of help.

Major contemporary theoretical perspectives and controversies Contemporary theoretical perspectives do not seem to show much evidence of the effectiveness of their treatment strategies for OCPD. Neither pharmacological, nor psychoanalytical, interpersonal,

107 or cognitive-behavioural perspectives have empirical proven techniques for the modification of OCPD. However, as many of the features of people with OCPD resemble those of the Type “A” behaviour pattern, and given that some cognitive-behavioural strategies have been successfully applied to this last type of behaviour, they could also be useful for the modification of obsessive- compulsive personality features. Following is a summary of the cognitive-behavioural procedures used in the treatment of OCPD (Caballo, 2001): a) increasing self-efficacy; b) time management and problem solving; c) modification of dichotomous thinking; d) training in relaxation; e) Thought- stopping for the management of obsessive thinking; f) activities programming; g) self-instructional training; h) modification of subjacent beliefs; and i) increasing empathy. One of the most frequent symptoms present in individuals with OCPD, causing ineffiency is their inability to give priority to important tasks instead of focusing on trivial or less important tasks, and also their inefficient distribution of time. A coping strategy would be good management of time strategies. Furthermore, these strategies would allow the individual to save time and devote it to other leisure and social activities. Rice (1992) present a program to save time, ordering through a list the activities from the most to the least important and devoting to the first items of the list most of the time and the remaining time to the rest of the items. Other elements of the program include: a) learning to delegate tasks to other people; b) avoid reviewing tasks continuously; c) devote time to leisure and rest, giving to them the same priority as work activities.

Conclusion Many of the characteristics of the obsessive-compulsive personality style are reinforced by our society. Only when these features are extreme, inflexible and cause suffering in the individual or in his/her environment can they be considered a personality disorder. Modification of this pattern of behaviour is difficult and currently there is no empirical evidence of efficient strategies of treatment for the modification of the OCPD. Much needs to be done in this regard the next few years.

References • American Psychiatric Association (APA) (2000). Diagnostic and statistical manual of mental disorders (4 0 ed.-Text revised) (DSM-IV-TR).Washington: • Beck, A. T., Freeman, A., & Davis, D. D. (2004). Cognitive therapy of personality disorders (2 nd edition). New York: Guilford. • Black, D. W. & Noyes, R. (1997). Obsessive-compulsive disorder and Axis II. International Review of Psychiatry, 9, 111-118. • Caballo, V. E. (2001). Cognitive-behavioural treatments for personality disorders [Spanish]. Psicologia Conductual, 9, 579-605. • Caballo, V. E., López-Gollonet, C., & Bautista, R. (2004). Obsessive-compulsive personality disorder. In V. E. Caballo (ed.), Handbook of personality disorders: description, assessment and treatment (pp. 231-247). Madrid: Síntesis [Spanish]. • Gruenberg, A. (1993, September). Co-ocurrence of mood and personality disorders. Paper presented at the Third International Conference of the International Society for the Study of the Personality Disorders, Cambridge, MA. • Maier, W., Lichtermann, D., Klingler, T., Heun, R., & Hallmayer, J. (1992). Prevalences of personality disorders (DSM-III-R) in the community. Journal of Personality Disorders, 6, 187-196. • Millon, T. (1996). Disorders of personality. DSM-IV and beyond. New York: Wiley. • Millon, T. & Everly, G. S. (1985). Personality and its disorders: A biosocial learning approach. New York: Wiley. • Pfohl, B. & Blum, N. (1991). Obsessive-compulsive personality disorders: A review of available data and recommendations for DSM-IV. Journal of Personality Disorders, 5, 363-375.

108 • Rice, P. L. (1992). Stress and health (2nd edition). Pacific Grove, CA: Brooks/Cole. • Robinson, D. J. (1999). Field guide to personality disorders. Port Huron, MI: Rapid Psychler Press. • Skodol, A. (1993, September). Fears and inhibitions: A study of anxiety and personality disorder comorbidity. Paper presented at the Third International Conference of the International Society for the Study of the Personality Disorders, Cambridge, MA. • WHO (1992). The ICD-10 Classification of Mental and Behavioural Disorders. Geneva: Author. • Widiger, T. A. & Sanderson, C. J. (1997). Personality disorders. . In A. Tasman, J. Kay & A. Lieberman (eds.), Psychiatry, vol. 2 (pp. 1291-1317). Philadelphia, PA: Saunders

109 Paranoid Personality Disorder Elisabeth Iskander and Larry J. Siever

Diagnostic Criteria DSM-IV 301.0 Paranoid Personality Disorder H. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her. 2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates 3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her 4. Reads hidden demeaning or threatening meanings into benign remarks or events 5. Persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights 6. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack 7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner I. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder With Psychotic Features, or another Psychotic Disorder and is not due to the direct physiological effects of a general medical condition.

Note : If criteria are met prior to the onset of Schizophrenia, add “Premorbid”, e.g., “Paranoid Personality Disorder (Premorbid)”.

Diagnostic Criteria ICD-10 F60.0 Paranoid personality disorder Personality disorder characterized by: (a) excessive sensitiveness to setbacks and rebuffs; (b) tendency to bear grudges persistently, i.e. refusal to forgive insults and injuries or slights; (c) suspiciousness and a pervasive tendency to distort experience by misconstruing the neutral or friendly actions of others as hostile or contemptuous; (d) a combative and tenacious sense of personal right s out of keeping with the actual situation; (e) recurrent suspicions, without justification, regarding sexual fidelity of spouse or sexual partner; (f) tendency to experience excessive self-importance, manifest in a persistent self-referential attitude; (g) preoccupation with unsubstantiated "conspiratorial" explanations of events both immediate to the patient and in the world at large. lncludes: expansive paranoid, fanatic, querulant and sensitive paranoid personality (disorder) Excludes: delusional disorder (F22. - ) schizophrenia (F20. - )

Paranoid personality disorder is a clinically well-recognized disorder that has not, however, been the object of a great deal of investigation. Although noted in the writings of psychiatrists since the late 1800's, the condition was first called “paranoid personality” by Kraepelin in 1921 (Akhtar, 1990). Some time passed before a standardized description and criteria were created. The Diagnostic and Statistical Manual of Mental Disorders (DSM) was first published in 1952, as a variant of the World Health Organization's ICD-6 ( International Classification of Diseases ), which included a section on mental disorders for the first time. This contained a broader scope of disorders than other manuals, and was influenced by the need to better classify and understand the disorders observed in World War II veterans. Paranoid personality disorder was included in the first DSM, and in all subsequent versions. The DSM I and II (published in 1968), though, did not contain explicit criteria. Overall, increased attention to diagnosis, classification and research into psychiatric disorders made necessary

110 the increasingly frequent updates and revisions to the DSM manuals. The same is reflected in the international diagnostic criteria set forth in the ICD, which is currently on version 10. In the interest of standardization, revisions to both American and international criteria were often coordinated to be published at the same time.

Clinical Description As per current opinion, the hallmark criteria regarding paranoid personality disorder are distrust and suspiciousness of others such that others are seen as purposefully attempting to harm one in some way without any evidence to suggest this is the case. Those with paranoid personality disorder also may be very critical of others, argumentative and rigid in beliefs, again stemming from harbouring unwarranted suspicions about people around them. This often leads to problems with relationships, both personal and in the work place. The current criteria for diagnosing paranoid personality disorder as per the DSM IV, published in 1994, includes seven symptoms of which at least four must be met. These include suspicion that others are harming or deceiving one in some way, preoccupation with doubts about the loyalty of friends, reluctance to confide in others out of fear that information may be used against them, reading threatening meaning into benign events, bearing grudges over insults or slights, hasty and angry reaction to perceived attacks on character, and unjustified suspicion regarding the fidelity of a spouse or partner. The ICD-10, created at virtually the same time, similarly lists seven criteria of which only three must be met. Most are essentially the same as the DSM IV criteria. There is one criterion that does not exist in the DSM IV and that is “tendency to experience excessive self-importance, manifest in a persistent self-referential attitude.” This item, basically implying a level of grandiosity, also did not exist in the DSM III or III-R versions.

Sociocultural Factors As with other disorders, cultural factors must be taken into account in diagnosing this disorder. There are some groups that might, for reasons of maltreatment, language barriers, and unfamiliarity to this society, display what could be labelled paranoid traits. Those groups include: minority groups, immigrants and refugees. In an epidemiologic study recently completed on personality disorders, minorities such as blacks, Hispanics and Native Americans were at greater risk for having paranoid personality disorder than whites (Grant et al., 2004). Also according to the same study, paranoid personality disorder was more common among younger people (18-29), those with lower incomes, and those who were divorced or never married. Some of these findings are not surprising, taking into account the nature of paranoid personality disorder. However, this does bring up the question of which came first: Are some paranoid traits the result of maltreatment by others due to socioeconomic status, race, etc., or does the disorder contribute to, for example, inability to succeed professionally or remain in a relationship? There appears to be a combination of both, which can contribute to complications in diagnosing the disorder.

Course and Prognosis Paranoid personality disorder can be noted first in childhood; symptoms observed include solitariness, social anxiety and odd thoughts and language. There is not a lot of data regarding the course and prognosis of the disorder. This is likely due to the fact that as it is a personality disorder, it tends to be stable over adult life and although it can cause interpersonal problems, does not often require treatment. It has been observed that the course of the disorder rarely worsens or goes into remission (Akhtar, 1990). In a comparison of paranoid and schizoid personality disorders, it was found that paranoid probands had less psychiatric intervention and were less likely to worsen on follow-up compared with schizoid subjects (Fulton et al., 1993).

Prevalence

111 According to the DSM-IV, the prevalence of paranoid personality disorder was 0.5 to 2.5% in the general public, and more common in males. More recently, though, an epidemiologic study was conducted on personality disorders in the general population (N=43,093) (Grant et al., 2004). Paranoid personality disorder was found to be the second most common after obsessive-compulsive personality disorder with a prevalence of 4.41%, somewhat higher than what the DSM IV concluded. It was also significantly more common among women. However, due to various constraints, borderline, schizotypal, and narcissistic personality disorders were not assessed. Interestingly, the 1997 National Survey of Mental Health and Wellbeing (conducted in Australia) using the ICD-10 to assess personality disorders found a 1.34 % prevalence of paranoid personality disorder and no sex difference, despite the similarities in criteria between the DSM and the ICD. Interestingly, an increase has been reported in the prevalence of paranoid personality disorder using DSM III-R – published in 1987, in comparison with DSM III – published in 1980 (Blashfield et al., 1992; Fulton et al., 1993). In eleven clinical samples, the prevalence of the disorder in the studies using DSM III-R was three times higher than in those using the DSM III (Bernstein et al., 1993). This may be due to the fact that since the previous criteria required symptoms to be met in the areas of paranoia, hypersensitivity and restricted affectivity, it was more difficult for individuals to fulfil all areas and therefore receive the diagnosis. Indeed, it turns out that upon analysis, when the criteria regarding restricted affectivity in the DSM III were removed, the number of subjects able to meet paranoid personality disorder increased dramatically (Blashfield et al., 1992). There is some current evidence that paranoid personality disorder may be more difficult to diagnose than other personality disorders. A study of interrater reliability using DSM IV achieved good agreement. However, in the same study, when analyzing test-retest reliability based on how consistent a patient’s report is from one clinician to another, and how information is interpreted and scored, paranoid personality disorder had the lowest reliability of all the personality disorders (Zanarini et al., 2000).

Comorbidity Paranoid personality disorder must be diagnosed to the exclusion of schizophrenia, or any other psychotic disorder including psychosis in the context of a mood disorder. Paranoid personality disorder is considered “premorbid” if it is present prior to an Axis I psychotic disorder. There is substantial comorbidity of Axis I disorders; individuals with paranoid personality disorder appear to have an increased likelihood of developing depression, agoraphobia, obsessive compulsive disorder and alcohol or substance abuse or dependence. It has also been found that the odds of developing paranoid personality disorder were increased between two and three times if one had a previous childhood substance-related disorder (Ramklint et al., 2003). With regard to comorbid personality disorders, there is some variation in the literature. Generally though, it has been suggested that in clinically based samples, over 75% of patients who met paranoid personality disorder criteria also met criteria for other personality disorders. In a number of studies from the late 1980’s, most likely employing the DSM III, the most common were found to be schizotypal, schizoid, narcissistic, avoidant, and borderline personality disorders (Bernstein et al., 1993). A recent study, using the DSM III-R, found that the most common comorbid personality disorders were, in decreasing order of prevalence, schizotypal, narcissistic, histrionic, and antisocial personality disorders (Golier et al., 2003). In addition subjects with paranoid personality disorder had a higher number of personality disorders in general than subjects without the disorder, with an average of 2.5 disorders. Although agreement exists on certain overlap, i.e., paranoid, schizotypal, and narcissistic personality disorders, high correlations were also found between paranoid, obsessive-compulsive and passive-aggressive personality disorders (Stuart et al., 1998). Interestingly, in the last study mentioned, two-thirds of subjects with schizotypal personality disorder also had paranoid personality disorder, but only about one-sixth of those with paranoid personality disorder had schizotypal personality disorder.

112 Etiology It has been suggested that paranoid personality disorder may be related to certain Axis I disorders, including schizophrenia and delusional disorder. There is some discussion in the literature over how closely paranoid personality disorder is linked to either disorder. Kendler concluded that schizophrenia spectrum disorders (defined as schizophrenia and schizotypal personality disorder) existed in much higher concentration in the biological relatives of those with schizophrenia, but not in relatives of those with delusional disorder, suggesting a separate genetic basis for schizophrenia and delusional disorder (Kendler et al., 1981). He went on to find a much higher risk of paranoid personality disorder in first degree relatives of those with delusional disorder as opposed to relatives of those with schizophrenia, 4.8% compared to 0.8% (Kendler et al., 1985). On the other hand, paranoid personality disorder was significantly more common in the biologic relatives of patients with schizophrenia when compared with relatives of controls (Kendler et al., 1982). In spite of this, a subsequent study analyzing relatives of patients admitted to the hospital with schizophrenia-like psychosis compared with relatives of controls with no reported history of psychosis in the immediate family, found no significant difference in frequency of paranoid personality disorder (Dorfman et al., 1993). This study, though, evaluated patients who were admitted for the first time with “schizophrenia-like” psychosis, which included schizophrenia, schizoaffective disorder, and schizophreniform disorder. This may have diluted the effects of only assessing schizophrenia. Using data from the Roscommon family study, an epidemiologic study conducted in Ireland, it was discovered that biological relatives of those with schizophrenia had a significantly higher amount of paranoid personality disorder compared with relatives of controls (Kendler et al., 1993). When analyzing two groups of adopted offspring from the Finnish adoptive family study of schizophrenia, those with biological mothers who had schizophrenia or schizophrenia spectrum disorders, and those whose mothers did not, there was no difference in prevalence of paranoid personality disorder (Tienari et al., 2003). However, the control group did include mothers who had other, non-schizophrenia spectrum psychiatric disorders. As discussed above, there have been changes in criteria for diagnosing paranoid personality disorder that could affect this data as it had been collected over the last few decades. In addition, a large percentage of studies involving schizophrenia spectrum disorders primarily focus on schizotypal personality disorder.

Treatment There is no specific treatment or medication for paranoid personality disorder. When existing in conjunction with other personality disorders, i.e., borderline personality disorder, treatment may be sought but that is primarily due to symptoms experienced in other personality disorders. There is some data on the effectiveness of day treatments for patients with personality disorders in general (Karterud et al., 2003). Treatment results, although effective for some personality disorders (i.e., borderline), were the poorest for those with paranoid, schizoid, and schizotypal personality disorders.

Major Contemporary Perspectives and Controversies As mentioned, there is not a lot of research on the topic of paranoid personality disorder. This disorder falls into a category of personality disorders that is less likely to be the cause of an individual seeking treatment. The very nature of mistrust and suspiciousness of others may prevent people from seeking clinical help. However, there are some recent studies that help to shed light on the nature of this disorder. One area of research is the possible relationship of PTSD with paranoid personality disorder. When 180 outpatients were analyzed using the DSM III-R, subjects with paranoid personality disorder had a higher rate of comorbid PTSD than subjects without the disorder (29% compared with 12%) (Golier et al., 2003). In addition, they had elevated rates of physical abuse and assault in childhood and adulthood (54% compared with 35%). This suggests a possible link between trauma

113 during early events in life and subsequent paranoid behaviour and mistrust. This was supported by another study that began with a group of drug-dependent women who had suffered physical, emotional or sexual abuse (Halles et al., 2004). The survivors of physical abuse in particular were more likely to be paranoid than the emotionally or sexually abused women. When one looks specifically at personality disorders in male combat veterans with PTSD, the most common one was paranoid personality disorder with 17.4% of the group (Dunn, et al. 2004). Related to this idea of a possible contribution of trauma in the role of personality disorders is a study concerning abuse in childhood looking specifically at the self-report the CTQ (Childhood Trauma Questionnaire) (Bierer et al., 2003). In a sample of 182 subjects, sexual and physical abuse in childhood appeared to be predictive of paranoid and antisocial personality disorders. Another area that has received some attention is the relationship of violence to paranoid personality disorder. Paranoid cognitive personality style was found to increase the risk of violence in subjects with personality disorders, particularly schizophrenia spectrum disorders (Nestor, 2002). A strong correlation was found between paranoid, narcissistic and passive-aggressive symptoms and violence. However, this study focused primarily on symptoms rather than whether or not a subject met the criteria for paranoid personality disorder, suggesting that paranoid traits can add to violence. Also with regard to paranoid traits and violent behaviour, clusters of personality disorders were evaluated in 164 violent male prisoners (Blackburn et al., 1999). Among six clusters identified, half of them, including those in the paranoid-antisocial group, had more extensive criminal backgrounds and a higher prevalence of substance -abuse history. However, it was also noted that more than half of the paranoid-antisocial group had a history of a psychotic disorder, and their crimes shared a “hostile-detached” style, including a high amount of fraudulent crime. These studies may be linked to findings of a relationship between violence and an excessive perception of threat in subjects with schizophrenia spectrum disorders (Arsenault et al., 2000). After studying a large group of young adults, Arsenault concluded that “distorted information processing may promote violence of a broader group of individuals in whom subclinical syndromes in the schizophrenia spectrum develop”. However, on a more general level, there has over the decades been mention of a connection between paranoid traits and poor information processing. This is evidenced in an increase in paranoid symptoms in elderly who had sensory deficits and cognitive impairment (Christenson et al., 1984). Recently, non-demented 85-year-olds with paranoid ideation were found to have worse cognitive test performance after adjustment for education, hearing and visual deficits, suggesting that the relationship may not simply a matter of sensory loss (Ostling et al., 2004).

Conclusion Personality disorders originate from a wide variety of factors including those with genetic and environmental components. Some are easier than others to diagnose as the criteria are more straightforward. Paranoid personality disorder, however, involves more judgment calls. Fortunately, the changes in the diagnostic criteria over the decades have aided in the diagnosis as they have become restrictive and less ambiguous, allowing for less subjectivity. It is also encouraging that the current DSM is in agreement with international criteria as this allows for uniformity of diagnosis, which aids in continued research. It has been shown that paranoid personality disorder is linked to other personality disorders, traumatic events in life, status within society and cognition. The question becomes how much these factors cause paranoid personality disorder to manifest itself later on, in other words: Do certain people have a propensity toward paranoid personality disorder that is exacerbated by trauma, interactions with society and cognitive deficits? On the other hand, without any outside factors to influence the disorder, is there a subset of paranoid personality disorder that is primarily genetic or linked to other, perhaps schizophrenia-elated disorders?

References

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115 • Kendler, K.S.; McGuire, M.; Gruenberg, A.M.; O’Hare, A.; Spellman, M.; Walsh, D., “The Roscommon Family Study. III. Schizophrenia-related personality disorders in relatives”, Arch Gen Psychiatry , 1993, 50(10): p. 781-8. • Nestor, PG., “Mental Disorder and Violence: Personality Dimensions and Clinical Features”, American Journal of Psychiatry , 159:12, December 2002. • Ostling, S; Johansson, B.; Skoog, I., “Cognitive test performance in relation to psychotic symptoms and paranoid ideation in non-demented 85-year-olds”, Psychol Med , 2004 Apr;34(3):443-450. • Ramklint, M; von Knorring, A.L.; von Knorring L.; Ekselius L., “Child and Adolescent Psychiatric Disorders Predicting Adult Personality Disorder: a Follow-up Study”, Nord J Psychiatry, 2003;57(1):23-8. • Stuart, S., Pfohl, B., Battaglia, M., Bellodi, L., Grove, W., Cadoret, R. “The Cooccurrence of DSM-III-R Personality Disorders”, Journal of Personality Disorders , 12(4), 302-315, 1998. Tienari P., Wynne, LC., Laksy, K., Moring, J., Nieminen, P., Sorri, A., Lahti, I., Wahlberg, KE. “Genetic Boundaries of the Schizophrenia Spectrum: Evidence From the Finnish Adoptive Family Study of Schizophrenia”, American Journal of Psychiatry , 160(9):1587-94, 2003. • Zanarini, MC., Skodol, AE., Bender, D., Dolan, R., Sanislow, C., ; Schaefer, E., Morey, Leslie C., Grilo, CM., Shea, MT., McGlashan, TH., Gunderson, JG. “The Collaborative Longitudinal Personality Disorders Study: Reliability of Axis I and II Diagnoses”, Journal of Personality Disorders , 14(4), 291-299, 2000.

116

Passive-aggressive Personality Disorder J. Christopher Perry

Clinical description Passive-aggressive personality disorder (PAPD) was first described as a diagnosis in World War II and has been featured in the American Psychiatric Association Diagnostic and Statistical Manuals as a personality disorder ever since. Most recently in DSM-IV it has been relegated to Appendix B for disorders requiring further research. This recent downgrade in status probably reflects the relative lack of growing research on PAPD compared to several other personality disorders, while grudgingly allowing that the problems of PAPD have not disappeared and may be worth understanding better. This is a disorder that, to paraphrase a comedic line, “gets no respect,” which, not surprisingly, mirrors the self-view of the person with PAPD. Despite this orphan status, the problems of those with PAPD can be quite serious and limiting. The ICD-10 (WHO, 1993) does not have a specific diagnosis of PAPD, but notes that such individuals may be coded in the Section of Adult Personality Disorders and Behaviour under the rubric, F60.8 Other specific personality disorders. When using this category, one should specify a name, description or vignette. The DSM-IV-TR lists research criteria for passive-aggressive (negativistic) personality disorder in the Appendix B, indicating that it requires further study. The major criteria (listed under heading A) reflect a pervasive pattern of negativistic attitudes and passive resistance to demands for adequate performance, beginning by early adulthood and present in a variety of contexts. To make the diagnosis, at least four criteria are required. They reflect the following seven features: showing passive resistance to fulfilling social and occupational tasks; complaining about being misunderstood and unappreciated; being sullen and argumentative; unreasonably criticizing or scorning authorities; expressing envy and resentment toward those viewed as more fortunate; persistently complaining about one’s personal misfortunes; and alternating between attitudes of defiance and contrition toward others. One exclusion criterion (heading B) requires that the traits not occur solely during Major Depression, nor is better accounted for by Dysthymia. The exclusion criteria are meant to ensure that individuals are not inappropriately diagnosed as PAPD because of state-dependent behaviour that is more attributable to depressive conditions. In history-taking it is important to discern whether the symptoms of PAPD have been manifested at times outside of when depressive disorder symptoms have predominated. When the patient has early onset dysthymia, one may need to rely on the more interpersonal criteria to determine whether PAPD is also present. The most salient features of PAPD are that they develop covertly hostile yet dependent relationships and lack more adaptive assertiveness skills. While most obvious in hierarchical relationships, they replicate this in personal and intimate relationships as well. Experiencing themselves as misunderstood, or victims of others’ neglect, grudging care or slights, they view themselves as disempowered. In fact, they may find themselves in punishing relationships, thus reinforcing these perceptions and beliefs. Taking initiative is expected to result in being criticized, so passivity and indecisiveness, letting or forcing others to make decisions, is safer. This results in a failure to get ahead in life, and may include prolonged periods of unemployment, public support, or even homelessness. Outbursts of anger and depressive affect may be common. Suicide attempts are less common than in borderline PD, but may have a higher degree of intent and lethality. Millon broadened the construct of PAPD to encompass a wide variety of negativistic phenomena beyond opposition to authority, and suggested the name Negativistic PD (Millon, 1996). The areas encompassed included irritable affectivity, cognitive ambivalence, discontented self-image, and interpersonal vacillation. While many of these aspects are also characteristic of borderline PD (BPD), they are more extreme and volatile in BPD, often accompanied by self-destructiveness.

117 Prevalence A review of 10 clinical and non-clinical studies, using DSM-III or DSM-III-R definitions, found a median prevalence of 1.7% or pooled mean prevalence of 2.6% for passive-aggressive PD (Torgersen et al.., 2001). A large systematic community interview survey found a point-prevalence of 1.7% for DSM-III-R PAPD (Torgersen, 2001).

Gender and age A large systematic community study found that the prevalence of PAPD was significantly more common in men (women 0.9%, men 2.2%) with a male: female ratio of 2.4 to 1 (Torgersen et al. 2001). PAPD is also more common in younger individuals, those living without a partner, and those living in urban centres as opposed to suburban areas.

Etiology While a number of theoretically based hypotheses have been offered about the etiology of PAPD, these are largely based on case reports, theoretical papers and cross-sectional studies, not more definitive studies. Millon took an early position that the disorder had bio-psycho-social roots.

Course and prognosis A follow-up of in-patients with PAPD found that after an average of 11 years 79% still had persistent difficulties, while 12% were symptom-free (Small et al.. 1970). Most seemed irritable, anxious and depressed, while somatic complaints were common. Only 44% were employed full-time in work or household duties, whereas neglect of responsibilities was more common. One patient died by suicide. Hospital readmission occurred in 28%. Those who received supportive psychotherapy over the follow-up were reported to have better outcomes. Anecdotally, some young adults with antisocial personality disorder and PAPD develop more prominent PAPD as they become less antisocial over ensuing years. PAPD is associated with occupational impairment. Many individuals with PAPD may go to school or work, but they fall short of expected performance or levels of success often by failure to complete work, fulfil obligations, or through acts of self-sabotage.

Comorbidity Perhaps because of the ego-syntonic quality of the personality disorder, individuals with PAPD usually seek help because of an intervening Axis I disorder, not because of personality problems per se. In clinical studies, individuals with PAPD often have accompanying major psychiatric syndromes including anxiety, mood, alcohol and substance use, and somatoform disorders. In a classic study (Whitman 1954) found the following comorbid disorder categories in patients with PAPD: anxiety (41%), depression (25%), or psychophysiological symptoms (11%). Another study (Small 1970) also found depressive episodes (30%) and alcoholism (18%). PAPD may also be found in association with other personality disorders, especially including antisocial, borderline, dependent, depressive and self-defeating types.

Sociocultural factors Socio-cultural factors are known to influence specific social role behaviours, which include the acceptability of the direct expression of requests, dependent behaviour, anger, competition and so forth. Many of these issues are relevant to PAPD. Socio-cultural settings which discourage direct expression, ignore individual wishes and needs, and demand compliance in social roles can be expected to increase the learning of passive-aggressive phenomena. This would be most evident in settings that are highly hierarchical, authoritarian, and somewhat unresponsive to the needs, requests, and expression of those lower in the hierarchy. This relationship is captured nicely in the old joke from the iron curtain era about the relationship between workers and central planners: “We pretend to work and they pretend to pay us.” What is yet to be clarified is whether such institutional

118 factors are actually sufficient to cause PAPD, whether individuals who already have PAPD seek or drift into such institutional settings, perhaps due to their familiar similarity to earlier formative settings, or whether both are true. These phenomena which shape or reinforce passive-aggression are not limited to society per se, but may be found in institutions within any society, for instance, schools, work settings, civil service, military or religious institutions or orders. The individual with PAPD is contained by the structure and rewards that the institution offers. These same factors may influence the prevalence of PAPD in a given society or institutional setting.

Treatment A small study by Klein (Klein et al., 1973) found that neither antidepressive, phenothiazines, nor placebo appeared to ameliorate the personality features of PAPD. Nonetheless, medications may be appropriate when there is a clearly defined Axis I syndrome that is the treatment target. However, treatment studies of major depression indicate that the additional presence of a personality disorder may be associated with higher symptom levels at the end of treatment. All authors agree that the treatment of PAPD is difficult and prone to ruptures and possibly early termination. The reasons relate to the conflict between dependency and control which the subject plays out in any help-giving relationship. The following list of problems arising in psychotherapy was offered to identify the signs of resistance to treatment characteristic of PAPD (updated from Perry, 1990): 1) Being tardy; 2) Missing appointments; 3) Not paying the bill, or cooperating with billing third parties; 4) Being silent for prolonged periods during sessions; 5) Failing to complete agreed-upon homework; 6) Rationalizing failures to comply with treatment requirements; 7) Responding to confrontation increasingly with feelings of shame, humiliation, resentment, and blame; 8) Increasing passive resistance to therapy and to change, including becoming oppositional and purposefully failing or becoming more symptomatic (negative therapeutic reaction); 9) Increasing the amount of help-rejecting complaining and anger over the therapist’s failure to help; 10) Talking about other types of treatments or scheduling consultations with other therapists without prior discussion. Recognition of the unique dynamics of PAPD was first identified by Wilhelm Reich (1929/1949) who described efforts to counter the patient’s passivity and complaining which served as a resistance to self-reflection in psychoanalysis. Reich hypothesized that the individual with PAPD (which he termed masochistic), experienced deep disappointment in parental care taking or love, resulting in an attitude of defiance. Subsequent provocativeness is intended to cause others to behave badly, thus putting them in the wrong. When this happens, the person experiences satisfaction that he or she has in fact been wronged. Whitman (1954) suggested that the direct expression of anger is inhibited by a fear of retaliation or neurotic guilt. Failure to act decisively follows, as the individual avoids taking decisions in ambiguous situations. Shame follows a sense of passivity and inadequacy to handle situations. Hostility further follows as a result of seeing others as demanding but unhelpful. Malinow (1981) suggested that by externalizing conflicts over dependency and hostility, the subject sees others as frustrating his or her needs to be taken care of. Superficial compliance is followed by covertly hostile behaviour. Anxiety and depression arise whenever the individual experiences his own role in bringing about frustrations and failures. Due to a low ability to modulate negative feelings, the individual prefers to keep them out of awareness. Malinow (1981) suggested setting up guidelines at the outset of treatment to mitigate such things as acting out and premature termination. He also recommended interpreting resistance and negative transference from the start “as angry acts directed at the therapist in order to provoke a punishing response and ultimately defeat the therapist and the therapy” (Malinow 1981, p129). The repetition of these dynamics in personal vignettes, and enactment of these patterns in the transference allows therapist in dynamic or psychoanalytic psychotherapy to interpret the dynamic and its function to the patient. Interpretation initially should generally focus on becoming aware of the disappointed wishes and negative affects, as well as the defences against them. PAPD is associated with action defences of passive-aggression; acting out and help-rejecting complaining;

119 disavowal defences, including denial, rationalization, and projection; minor image-distorting defences, such as devaluation of others’ images; and neurotic level defences, such as repression and reaction formation. As motives and affects enter awareness more, the therapy can focus on the positive feelings that attend putting others in the wrong. As the individual becomes aware of the sense of shame and guilt over this self-defeating pattern, the relationship with the therapist may be heavily tested. Avoiding comments or interpretations that heighten shame or a sense of guilt are important. Working through these patterns in therapy then allows the patient to experience the therapist and others in new, more adaptive ways. The goal is to heighten awareness of one’s own dynamics in order to handle important wishes and fears by high adaptive level defences, such as self- observation, self-assertion. Anger and resentment then diminish as more adaptive interactions bring more successful outcomes. Lending support to dynamic therapy, Ogrodniczuk et al. (2001) found that PAPD had less favourable outcome on self-reported depressive symptoms compared to other personality disorder patients in supportive therapy, but more favourable outcome in interpretive therapy. Early behavioural approaches emphasized the use of assertiveness training in PAPD (Burns and Epstein, 1983), emphasizing the necessity of modifications to avoid undue confrontation, and to avoid threatening the patient with change in personally important areas and relationships (Perry and Flannery, 1983). The patient’s ongoing relationships may in fact subvert positive changes, which require modifications in approach to self-assertion. Cognitive Behaviour therapy (CBT) has been applied to PAPD by Beck and colleagues (Beck et al., 2004). They posit that the cognitive basis for PAPD can be divided into deeply held core beliefs, conditional beliefs which influence actions in certain circumstances, and compensatory beliefs which help the patient rationalize his maladaptive beliefs and actions. Examples include the core beliefs such as: “No one should tell me what to do”; “Expressing anger may cause me difficulty”; or “People do not understand me.” These are reflected in conditional beliefs that occur in relevant situations, such as: “By resisting demands, I remain independent”; or “By not asserting myself directly, I stay in favour with others.” Finally they compensate for the anger and disappointment they experience by additional beliefs, such as: “I will superficially go along with others to avoid conflict”; or “I must assert myself indirectly so that I will not be rejected”; or “I do not receive the credit I’m due because others can’t appreciate me.” [All examples taken from Beck et al. 2004, Table 15.3, page 352]. CBT emphasizes developing a collaborative relationship in which the patient does not feel he or she has ceded control to the therapist. This involves frequently checking on the patient’s view and asking for feedback, while remaining consistent, objective and empathic. The therapist helps the patient identify shifts in affect in relationship to automatic thoughts, both in and between sessions. The therapist encourages the patient to choose what to work on and takes a Socratic approach to think through to the consequences of the patient’s views and explore new ways of perceiving and acting. The goal is to find a way of viewing and behaving that will lead to more beneficial outcomes from the patient’s point of view. The therapist must avoid challenging dysfunctional beliefs and actions too early or aggressively to avoid activating the patient’s automatic resistance to authority. Writing a contract early on may help forestall later power struggles over issues such as scheduling appointments, billing, and treatment limits. Both in the session and possibly with homework, the therapist emphasizes self-monitoring of affective shifts, particularly those involving anger, in response to others and how this relates to automatic thoughts and core beliefs. The therapist may help the patient learn to recognize interpersonal cues and appropriate communication skills, and also improve assertiveness in appropriate ways to counter old tendencies to remain passive and complaining. Anger management skills may help reduce wishes for “righteous revenge” and allow maladaptive thoughts and behaviours to be supplanted by more adaptive responses. Finally, as termination nears, the therapist and patient may construct a list of risks or situations that may activate older ways of thinking and behaving as a concrete reference for the patient. Follow-up visits

120 can then review problem areas and reinforce newer more adaptive patterns. While promising, there are no systematic studies yet of this approach. In group therapy, individuals with PAPD tend to allow themselves to be ignored by other group members, or elicit negative reactions from them. This requires active intervention by the therapist to avoid collusion by group members against the patient, which may otherwise result in early termination. The likelihood of positive outcome with group as the sole treatment is unknown.

Major contemporary theoretical perspectives and controversies Perhaps the major controversy is whether PAPD exists as a specific diagnosis or as simply a set of traits that may be found in any number of other personality disorders. This same critique was asserted at one point about borderline PD, but a plethora of research in the past 25 years has established that diagnosis firmly. Specifically, some have posited that it is a reaction to authority or control conflicts that cut across a variety of personality types. This controversy is best settled with more evidence about the etiology, mechanisms, stability, outcome and response to treatment of individuals with PAPD compared to other personality disorder types. However, the existing prevalence data, few systematic studies, and the clinical literature consistently support it. As such, the move of PAPD to the DSM-IV Appendix for Provisional Diagnoses needing further research is both true and false. The disorder has not been receiving much new research or interest – hence the move to the “dog house” of the diagnostic system – but existing data clearly support its existence. Most of the remaining controversies have to do with the underlying causes, whether based on biological, temperament, personality trait, psychological, familial, or socio-cultural factors. A number of methods of assessing psychological traits have been devised with the aim of studying the basic underlying traits of Axis II disorders. Each trait has a combination of heritable and learned components. Authors posit that correct identification of the etiological role of traits will allow future therapies to target these traits and help individuals adapt better. Benjamin has used the interpersonal circumplex model, Structural Analysis of Social Behaviour (SASB) to posit that PAPD is a consequence of learned social behaviours resulting from developmental events (Benjamin, 1996). Behaviours such as submitting, sulking, or recoiling are seen as complementary to controlling, blaming and attacking behaviours of caretakers. These lead to affective experiences of helplessness, humiliation and panic, and attitudes of being deferential, but constricted and closed. At present these are largely theoretical viewpoints.

References • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, D.C. American Psychiatric Association, 1994. • Beck AT, Freeman A, Davis DD and Associates. Cognitve Therapy of Personality Disorders, second ed. New York, Guilford Press, 2004, chapter 15, pp 341-361. • Benjamin LS. An interpersonal theory of personality disorders. Clarkin JF, Lenzenweger M, Eds. Major Theories of Personality Disorders. New York, Guilford, 1996. • Burns DD, Epstein N. Passive-aggressiveness: a cognitive-behavioural approach. Passive- aggressiveness Theory and Practice. New York, Brunner/Mazel, 1983. • Klein DF, Honigfeld G Feldman S. Prediction of drug effects in personality disorders. J Nerv Ment Dis 156:183-197, 1973. • Malinow KL. Passive-aggressive personality. Lion JR ed. Personality Disorders: diagnosis and Mangement, second ed. Baltimore, Williams and Wilkins, 1981. • Millon T. Disorders of Personality DSM-IV and Beyond. New York, Wiley, 1996. • Ogrodniczuk JS, Piper WE, Joyce AS, McCallum M. Using DSM Axis II information to predict outcome in short-term individual psychotherapy. J Pers Dis 15:110-122, 2001.

121 • Perry JC, Flannery R. Passive-aggressive personality disorder. Karasau TB, ed., Treatment of Psychiatric Disorders, vol III. American Psychiatric Press, Washington, D.C., 2762–2770, 1990. • Reich W. Character Analysis, third ed. New York, Farrar, Strauss, Giroux, 1949 [original publication in German, 1929]. • Small IF, Small JG, Alig VB. Passive-aggressive personality disorder: a search for a syndrome. Am J Psychiatry 126:973-983, 1970. • Whitman R, Trosman H, Koenig R. Clinical assessment of passive-aggressive personality disorder. Arch Neurol Psychiatry 72:540-549, 1954. • World Health Organization. Mental Disorders: Glossary and Guide to their Classification in Accordance with the Tenth Revision of the International Classification of Disease. Geneva, World Health Organization, 1993

122 Sadistic Personality Disorder Michael H. Stone

Problems of Definition Sadistic Personality Disorder [SdPD] appeared in the Appendix of DSM-III-R (1987) amidst controversy concerning the possible misuses of such a diagnosis. Many psychiatrists feared that inclusion of SdPD would conduce to inappropriate use in forensic settings, paving a path toward “medicalization of evil deeds” (Spitzer et al. 1991). Women feared that SdPD, if recognized in DSM, would be used in an exculpatory way by defence attorneys, arguing that their clients (rapists, for example) “suffered” from SdPD and should on that grounds be given a lighter sentence. The DSM- III-R definition emphasized in general a pervasive pattern of cruel, demeaning, and aggressive behaviour directed toward other people, beginning in early childhood.” Two additional problems that may have dissuaded the authors of subsequent editions of DSM against continued inclusion of SdPD (in the Appendix, let alone in Axis-II) were the degree of overlap between SdPD and Antisocial PD or Narcissistic PD (Spitzer et al. 1991-a), plus an insufficiency of hard evidence from field studies, studies of treatment, etc. (Hucker 1997). All definitions of SdPD, and of the related entity – sexual sadism – owe their origin to the writings and the behaviour of the infamous Donatien-Alphonse François, le Marquis de Sade [1740- 1814] (du Plessix-Gray 1999). It must not be thought that de Sade’s cruelty exceeded that of certain other French aristocrats of his day; he gives his name to the condition simply because he was, in addition, a gifted writer. In one of his works (“Justine”), for example, he describes a monk who achieves sexual arousal and gratification by means of inflicting humiliation and cruel physical suffering on his female victim (Baeza & Turvey 1999). The DSM-III-R definition of SdPD rested on eight descriptors: (a) the use of physical cruelty or violence to establish dominance, (b) humiliates or demeans in the presence of others, (c) harsh discipline of a child or spouse, (d) takes pleasure in the suffering of others, (e) lies – in order to inflict pain, (f) intimidates, (g) restricts others’ autonomy, and (h) is fascinated by violence, weapons, torture, injury, or martial arts. Any combination of four of these sufficed to establish the diagnosis. There are of course serious drawbacks to polythetic definitions of this sort: No effort is made to tease out what is the essential (or “prototypical”) feature of the disorder one is trying to define. Obviously, a person exemplifying items c-f-g-h of the list above is a very different person from one manifesting a-b-d-e. The former might be a verbally abusive, “macho” spouse – who has never laid a hand against a family member or anyone else. Such an SdPD pales in significance, compared with the latter person – who revels in the infliction of pain, and who deceives others in order to get them into helpless positions where he can carry out his cruelties with impunity. It is the person of this latter type that we have in mind when we think of what sadistic ought to signify – and what it does signify in everyday parlance. The specific characteristics of the Marquis, in other words, have over the years been broadened to include persons (the great majority of whom will be male) who take delight or at least a sense of power and reassurance – from subjecting others to cruelty, whether verbal, physical, or both. In contrast, Baeza and Turvey (1999), noting that the Marquis appeared to use cruelty to achieve sexual arousal and gratification, are unhappy with definitions that do not focus on this attribute. A murderer who commits necrophilia, but who killed his victim swiftly with a shot to the head first, is not being sadistic sensu strictu – because the dead cannot experience the pain or humiliation of the necrophile’s activities. Here the authors are quite correct. But in their preoccupation with the criminological aspects of the issue (Baeza is a sex-crimes detective with the New York City Police Department), they show a reluctance to acknowledge that “sadistic” – when referring to personality – has in the intervening two centuries come to mean a personality warp that is by no means so narrow as to include only those who need to inflict pain on a sexual partner (whether a willing or, as is more often the case, an unwilling partner) in order to achieve erection and orgasm. Their criticism warrants a brief discussion of differential diagnosis.

123

Differential Diagnosis Although SdPD, as mentioned above, is felt by some to overlap conceptually with antisocial or narcissistic PD’s – and by extension, with psychopathic personality as described by Hare and his colleagues (1990) – there is really no overlap at all, if one holds to the feature of deriving enjoyment or satisfaction from inflicting pain as central to the concept of SdPD. Some of the less important items, such as lying (though not necessarily to inflict pain) and lack of remorse are mentioned as items of both DSM’s antisocial and psychopathic personalities; lack of “empathy” (the word should be compassion here; empathy means only the ability to discern the feelings of others, and plenty of sadists and psychopaths excel at this) is mentioned as an item of narcissistic PD. The only descriptor that comes close to what is usually meant by sadistic is the callousness of the psychopath; Hare’s other 19 items, as it happens, do not overlap with SdPD. There is considerable justification, at all events, for retaining the concept of SdPD, by virtue of its importance in both conventional and forensic psychiatry, and its distinctness from other categories of personality disorder. The burning issue in differential diagnosis concerns the distinction between SdPD and sexual sadism. Baeza & Turvey (1999), who are purists on the subject of sexual sadism , would require the following elements for this diagnosis: (a) the intentional infliction of psychological or physical suffering on a conscious victim (who is therefore able to experience the suffering), (b) the infliction of such suffering over a period of time, and (c) the association of the intentional infliction of suffering with sexual arousal or gratification on the part of the offender (p 3). Curiously, the definition of sexual sadism in DSM-III [302.84] suggests criteria very close to those of Baeza and Turvey. Fourteen years later, we confront DSM-IV, in which the definition has gone, semantically speaking, from the frying pan into the fire. Now we are to believe that the definition rests on “at least 6 months of recurrent, intense sexually arousing fantasies, sexual urges or behaviours involving acts in which the…suffering of the victim is sexually exciting” and “the fantasies, sexual urges, or behaviours cause clinically significant distress….in important areas of functioning.” The key problem here is the word “or.” DSM is now willing to call a person who has experienced only fantasies of sexual arousal through infliction of pain as exhibiting sexual sadism, rather than to reserve this ominous diagnosis for persons who have built torture chambers for the prolonged and painful victimization of others in order to gain sexual excitement and gratification. The deficiencies of the DSM-IV definition and the tendency of those adhering to it – to tar with the brush of “sexual sadism” persons who have never inflicted harm on anyone have been pointed out elsewhere by Marshall (1997). À propos the distinctions between SdPD and Sexual Sadism, it should be noted that many rapists would meet DSM-III-R criteria for SdPD, but not necessarily for Sexual Sadism, since the main motive may be aggressive or retaliatory but not to achieve sexual arousal. Sexual sadism as it is meaningfully defined by Baeza and Turvey (1999) is more common within the ranks of serial killers (Stone 1998), but even in this group, where SdPD is almost universal, the paraphilia of sexual sadism, with its need for pain as a stimulus to arousal and the ability to perform sexually, is present only in a smaller proportion (35 out of 124 [28%] in my series). Besides instances of non-sexual sadistic behaviour, there are other varieties of cruelty that need to be distinguished from sexual sadism. Hazelwood and Michaud (2001) cite in this regard: cruelty committed during a crime, pathological group behaviour (as in mob-lynching), state- sanctioned cruelty, revenge-motivated cruelty, interrogative cruelty (often committed by persons who in everyday life do not behave sadistically), and, as mentioned also by Baeza and Turvey, post- mortem mutilation.

A Brief Historical Note Sadistic personality has always been with us, millennia before the Marquis gave it its name. There are examples of sexual sadism (by Baeza’s strict definition) from Roman times (the Emperor Caligula). There is at least one woman who qualifies as a sexual sadist: The Countess Erzsébet Báthory of 16 th

124 century Hungary (Penrose 1996): she would experience orgasm while pressing her body against the dying bodies of young girls hanging from ceiling hooks – whom the countess disemboweled with a knife. Many tyrannical leaders give ample evidence of sadistic personality. The biography of Saddam Hussein is replete with examples of his sadism: having the tongues ripped out of persons who spoke against the regime; causing the hands of those who wrote against his regime plunged into sulphuric acid – among a myriad of equally gruesome examples. The objections of Baeza and Turvey aside, I see no reason to quarrel with the definition of SdPD in DSM-III-R as making a good beginning to the description of the concept in question. I would want future editions that might re-include SdPD to give special emphasis to the notion of deriving pleasure from the infliction of pain on others. The concepts of SdPD and Sexual Sadism are distinct, so I see no need to scrap the adjective “sadistic” from the personality disorder. Granted the disorder existed long before de Sade, inventing new names would probably add rather than decrease confusion. A term like “Torturous” PD is too strong, because many persons with SdPD use primarily verbal means to create a hellish environment for their spouses or children, but stop short of physical torture. The Greek word basanistikos for torturous could give us Basanistic PD – but who would use it? As for the term “sadism” itself, it was coined by Krafft-Ebing (1886), in his treatise on sexual disorders.

The dynamics of Sadistic Personality Disorder In the early psychoanalytic literature there are references to “oral sadism” (viz., the presumed wish on the part of the infant to cannibalize the mother) and “anal sadism” (viz., excretory pleasure without consideration for the other person – as stressed by Karl Abraham 1927). Sadism as a sexual perversion, akin to the concept of Sexual Sadism, is described by Fenichel (1945), whose dynamics centre on the fear that what might happen passively to the subject is then done actively by him, in anticipation of attack, to others (p 354). Fenichel sees the sadists as fighting off not only unconscious anxiety over castration, but also fears concerning certain self-destructive tendencies within themselves (p 355). Psychoanalysts rarely work with truly sadistic patients, and almost never with sadistic offenders. The remarks of the psychoanalytic pioneers, in particular, based on small samples and on non-standardized definitions, have not been helpful in ascertaining the roots of sadistic behaviour. The need for gaining power over others, as an antidote to the feeling of powerlessness, is stressed by a number of authors writing on either SdPD or on Sexual Sadism. Wilson and Seaman (1992) coined the phrase “Roman Emperor Syndrome” in drawing attention to the need of serial killers to subjugate and to exert total dominion over their victims. Many sadistic persons (and here I include the subset of those manifesting sexual sadism as well) had been brutalized during their own childhood by their caretakers. This is arguably the most important factor predisposing to the eventual development of sadistic tendencies: Here we are speaking of the compulsion to repeat the early trauma, as emphasized in the work of Bessel van der Kolk (1996, p199). Constitutional predisposing factors may also play a role. In some sadistic persons, for example, there is no compelling evidence of early mistreatment, let alone torturous treatment by caretakers – nor even neglect. A small number of extraordinarily sadistic murderers (including serial killers) in my series of biographies of murderers came from non-abusive homes. Some were adoptee who may have had “risk genes” for low compassion or high impulsivity from their biological parents. Women who were abused in childhood tend to depression and to the development of borderline personality; men, because of their greater tendency to aggressivity, are more likely to develop SdPD. In my series of murder-biographees, which now numbers 466, there are 269 of 385 men who meet four or more of DSM-III-R criteria for SdPD, as opposed to 33 of 81 women (χ² = 24.9; P < .001).

Research on Sadistic Personality Disorder

125 SdPD covers a potentially wide range of personality aberrations, all the way from mean-spirited, over-controlling, and verbally humiliating persons who darken the environment for their spouses and children – to brutal, violent persons with a penchant for malicious behaviours that cause great suffering in others. Perhaps because of the impact that sexual sadists make on society, what little research there is in this area has been devoted to sexual sadism. The focus has been on accuracy of description, prediction of recidivism, and suggestions for intramural confinement and possible treatment. The same is true of rapists, many of whom show SdPD, but fewer of whom show sexual sadism per se . Cases have been described where head injury accompanied by unconsciousness have led to sadistic (even to sexually sadistic) behaviours. Damage to the temporal lobes is often a sequel of this damage (Graber et al. 1982; Gratzer & Bradford 1995). Among serial killers, the combination of schizoid personality and SdPD may confer added risk for violence, because of the heightened indifference to the feelings of others (i.e., diminished compassion) that may accompany schizoid PD. This seems to be the case among serial killers, a striking “excess” of whom (about 50 times the expected percentage from the general population) are comorbid for schizoid PD (Stone 1998-a). Among sex offenders who used violence, their scores on the Hare Psychopathy Checklist were higher on average than the scores of non-violent sex offenders (Miller 1994). The paucity of studies concerning SdPD, apart from the merely descriptive, has been remarked on by Meloy (2001). Meloy mentions the correlation between childhood cruelty to animals and later violent or sadistic behaviour, stemming from the work of Felthous and Kellert (1986). Millon (2004) has added to the conventional descriptions of sadistic personality – by enumerating the various domains of personality affected by this constellation. The sadistic person, for example, tends to be abrupt and abrasive (showing satisfaction in intimidating and humiliating others), dogmatic and combative, isolated (akin to being schizoid) and eruptive (that is: explosive, aggressive, and irritable), malicious, and hostile. There is a close correlation between persons who are habitually violent within family settings and sadistic personality, but the dimensions of this correlation are unknown, because in the larger, methodical studies of family violence, such as that of Straus & Gelles (1990), sadistic personality as a related entity was not addressed. Suffice it to say, that a formidable proportion of wife-beaters, caretakers who abuse their children repeatedly etc., would meet criteria for SdPD. Straus & Gelles drew attention to the greater frequency of intra-familial violence among the lower and lower-middle-class families, as opposed to the economically more advantaged. Paul Fink (2004) points out, however, that sexual and other forms of abuse occur aplenty in upper class families as well. Fink gives the example of a man who anally raped his young son for failing to clean his room, and then adding to this physical sadistic behaviour the verbal sadism of saying that “I wouldn’t have done that if you’d cleaned up your room.” Implication: it was the child’s “fault” that his father did this. But we don’t know if the father had been similarly victimized by his father, nor if the son, on becoming an adult, will visit such sadism on his children.

Treatment It is the hallmark of sadistic persons that they externalize their conflicts, blaming others – as in the example just cited of the father who raped his son. As amelioration of a personality disorder depends (among other factors) on the motivation to change – the absence of this critical element creates a bleak picture for our attempts to treat sadistic persons. Those who are capable of some remorse (men, for example, who beat their wives, but feel shabby about doing so) may benefit from psychotherapy – that may best be conducted along cognitive-behavioural lines, with the addition of group therapy. Wife-batterers in a group may be more ready to recognize the awfulness and the maladaptiveness of their behaviour when seated among half a dozen men with the same tendencies. The topic of treatment for sexual sadism is addressed by Hollin (1997), who mentions the use of libido-lowering pharmacological agents in chronic sex offenders. But rapists and the more clearly sadistic of sex offenders appear to respond less well to the interventions, be they pharmacological or psychotherapeutic, that are currently available.

126 As for persons with SdPD, it is my clinical impression that those manifesting only the less severe traits of DSM-III-R (harsh discipline of spouse or child, restriction of autonomy, etc.) can be more easily reached – and successfully treated – in psychotherapy, than those who show intense satisfaction in hurting others and who lie in order to corner their victims into positions of helplessness. The severely violent sadists one confronts in prisons or forensic hospitals seldom gain their freedom, such that we cannot easily evaluate the degree to which they would, or would not, reoffend. And in private practice, therapists see very few patients with SdPD (nor do they make long-term follow-ups of such patients). This is one of the main reasons we know little about either the best treatment for – or the fate of – SdPD, whose unwarranted exclusion from the current DSM is partly based upon this knowledge gap. But we do know that SdPD exists and that it differs significantly from other personality disorders. Including the disorder in future editions might at least have the salutary effect of inspiring further research into this important area.

References • Abraham K (1927). Selected Papers. London: Hogarth Press • Baeza JJ & Turvey BE. (May 1999) Sadistic behaviour: A Literature review. www.corpus- delicti.com/sadistic_behaviour.html • Diagnostic and Statistical Manual of Mental Disorders, 3 rd Edit., revised [DSM-III-R] (1987). Washington DC: Amer Psychiatric Press • Du Plessix-Gray F (1999). At Home with the Marquis de Sade: A Life. New York: Penguin Books • Felthous A & Kellert S (1986). Violence against animals and people: Is aggression against living creatures generalized? Bull Amer Acad Psychiatry & Law 14: 55-69 • Fenichel O (1945). The Psychoanalytic Theory of Neurosis. New York: W W Norton • Fink P (2004).Helping victims of sexual abuse. Clinical Psychiatry News. May, p 14 • Graber B, Hartmann K, Coffman J, Huey C & Golden C (1982). Brain damage among mentally disordered sex offenders. J Forensic Sci 27: 127-134 • Gratzer T & Bradfor J (1995). Offender and offense characteristics of sexual sadists: A comparative study. J Forensic Sci 40: 450-455 • Hare RD, Harpur TJ, Hakstian AR, Forth, AE, Hart SD & Newman JP (1990). The revised Psychopathy Checklist : Reliability and factor structure. Psychol Assessment 2: 338-341 • Hazelwood R & Michaud SG (2001). Sexual Violence, Homicide, and the Criminal Mind. New York: St Martin’s Press • Hollin CR (1997). Sexual sadism: Assessment and treatment. In DR Laws and W O’Donohue [Eds.], Sexual Deviance: Theory, Assessment and Treatment. New York: Guilford Press, pp 210-224 • Hucker SJ. (1997). Sexual sadism: Psychopathology and theory. In DR Laws and W O’Donohue [Eds.], Sexual Deviance: Theory, Assessment and Treatment. New York: Guilford Press, pp 194-209 • Krafft-Ebing R (1886). Psychopathia Sexualis: A Medico-Forensic Study. New York: Putnam, 1965 • Marshall WL. (1997). Pedophilia: Psychopathology and theory. In DR Laws and W O’Donohue [Eds.], Sexual Deviance: Theory, Assessment and Treatment. New York: Guilford Press, pp 152-174 • Meloy JR (2001). The psychology of wickedness. In JR Meloy [Ed.], The Mark of Cain: Psychoanalytic Insight into the Psychopath. HillsdaleNJ: Analytic Press, pp 171-179

127 • Miller MW, Geddings VJ, Levenston GK, & Patrick CJ (1994). The personality characteristics of psychopathic and nonpsychopathic sex offenders. Paper presented at the May meeting of the American Psychology & Law Society, Santa Fe. • Millon T (2004). Sadistic personality: Functional and Structural Domain Descriptions. www.millon.net/Taxonomy/SAD.htm • Penrose V (1996). The Bloody Countess: The Crimes of Erzsébet Báthory. London: Creation Books • Spitzer RL,Fiester SJ & Gay M (1991). Is sadistic personality disorder a valid diagnosis? Amer J Psychiatry 148: 875-879 • Spitzer RL,Fiester SJ, Gay M, & Pfohl B (1991). Is sadistic personality disorder a valid diagnosis? The results of a survey of forensic psychiatrists. Amer J Psychiatry 148: 586-590 • StoneMH (1998). The personalities of murderers: The importance of psychopathy and sadism. In AE Skodol [Ed.], Psychopathology and Violent Crime. Washington DC: Amer Psychiatric Press, pp 29-52 • Stone MH (1998-a). Sadistic personality in murderers. In T Millon, E Simonsen, M Birket- Smith & RD Davis [Eds.], Psychopathy: Antisocial, Criminal, and Violent Behaviour. New York: Guilford Press, pp 346-355 • Straus MA & Gelles RJ (1990). Physical Violence in American Families: Risk Factors and Adaptations to Violence in 8,145 Families. New Brunswick NJ: Transaction Publ • Van der Kolk BA (1996). The complexity of adaptation to trauma:Self-regulation, stimulus discrimination, and characterological development. In BA van der Kolk, AC McFarlane & L Weisaeth [Eds.], Traumatic Stress: The Overwhelming Experience on Mind, Body & Society. New York: Guilford Press, pp 182-213 • Wilson C & Seaman D (1992). The Serial Killers: A Study in the Psychology of Violence. New York: Carol Publishing Group

128 Schizoid Personality Disorder Henning Sass and Reinhild Schwarte

Diagnostic Criteria DSM-IV 301.20 Schizoid Personality Disorder J. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Neither desires nor enjoys close relationships, including being part of a family 2. Almost always chooses solitary activities 3. Has little, if any, interest in having sexual experiences with another person 4. Takes pleasure in few, if any, activities 5. Lacks close friends or confidants other than first-degree relatives 6. Appears indifferent to the praise or criticism of others 7. Shows emotional coldness, detachment, or flattened affectivity K. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder With Psychotic Features, another Psychotic Disorder or a Pervasive Developmental Disorder and is not due to the direct physiological effects of a general medical condition. Note : If criteria are met prior to the onset of Schizophrenia, add “Premorbid”, e.g., “Schizoid Personality Disorder (Premorbid)”.

Diagnostic Criteria ICD-10 F60.1 Schizoid personality disorder Personality disorder meeting the following description: (a) few, if any, activities, provide pleasure; (b) emotional coldness, detachment or flattened affectivity; (c) limited capacity to express either warm, tender feelings or anger towards others; (d) apparent indifference to either praise or criticism; (e) little interest in having sexual experiences with another person (taking into account age); (f) almost invariable preference for solitary activities; (g) excessive preoccupation with fantasy and introspection; (h) lack of dose friends or confiding relationships (or having only one) and of desire for such relationships; (i) marked insensitivity to prevailing social norms and conventions. Excludes: Asperger's syndrome (F84.5) delusional disorder (F22.0) schizoid disorder of childhood (F84.5) schizophrenia (F20. - ) schizotypal disorder (F21)

Clinical Description According to the DSM-IV the essential feature of the SPD “is a pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings”. The ICD-10 describes the SPD as “characterized by withdrawal from affectional, social and other contacts, with a preference for fantasy, solitary activities and introspection. There is a limited capacity to express feelings and to experience pleasures”. The DSM-IV diagnostic criteria for SPD state that there must be a pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, and this pattern of behaviour must have begun by early adulthood. The behaviour must be indicated by at least four of the following criteria: 1) The person neither desires nor enjoys close relationships, including being part of a family; 2) The person almost always chooses solitary activities; 3) The person has little interest, if any, in having sexual experiences with another person; 4) The person takes pleasure in few activities, if any; 5) The person lacks close friends or confidants other than first-degree relatives; 6) The person appears to be indifferent to the

129 praise or criticism of others; 7) The person shows emotional coldness, detachment or flattened affect. In addition, the disorder must not occur exclusively during the course of schizophrenia, a mood disorder with psychotic features, another psychotic disorder or a pervasive developmental disorder. It must not be due to the direct physiologic effects of a general medical condition. The ICD-10 diagnostic criteria for SPD differ in detail from the DSM-IV criteria but they define the same disorder. The ICD-10 also describes the SPD by seven criteria, of which at least three must be applicable. Criteria 1, 2, 4, 5, and 6 of the ICD-10 are identical to criteria 4, 7, 6, 3, and 2 of the DSM-IV. Further, the ICD indicates the following criteria: 3). The person has limited capacity to express warm, tender feelings for others as well as anger; 7) The person has an expressive preoccupation with fantasy and introspection. Beck (1990, pp. 51-52) suggests that individuals with SPD have a view of themselves as loners who prize independence, solitude, and mobility. Millon & Davis (1996, p. 232) believe that individuals with SPD are complacent, with little or no tendency to look into their personal feelings. The SPD is most clearly defined within relationships. Individuals with this disorder are characterized by a profound defect in their ability to form personal relationships or to respond to others in an emotionally meaningful way (Frances, 1995, p. 367) and appear to lack a desire for intimacy. They are aloof, introverted, and seclusive, and select activities that do not include interaction with others. This style of life easily results in social isolation. Individuals with SPD are going to be most comfortable with others who demand little intimacy and make few emotional demands. They may live or work in a group setting, which allow them to maintain superficial contact without intimacy. As individuals with SPD “feel lost” without people to whom they are attached, but when with them, feel swallowed, smothered, and absorbed, they may also seek relationships for security but break out again to gain freedom and independence. Individuals with SPD evidence little desire for sexual experiences. As sex can mean closeness and enmeshment, for these individuals personal space can become a greater need than maintaining relationships with the people they very much care about. The social communication of individuals with SPD is perfunctory and formal (Millon, 1996, pp. 217-231). They often react passively to adverse circumstances and may not respond appropriately to important life events. When social skills are required, they often have problems at work. They response passively to adverse difficulties, often have only poor social skills. Millon & Davis (1996, p. 217) describe the SPD as the "asocial" pattern characterized by a deficiency in the ability to experience pleasure.” While they are not intentionally unkind, they are preoccupied with tangential matters, and seem to have a fundamental incapacity to sense the needs of the people around them. They do not need to communicate and are generally underresponsive to most forms of stimulation or reinforcement. Beck (1990, p. 125) states that others view individuals with SPD as dull, uninteresting, and humourless; they are often ignored. They appear to be interpersonally indifferent, and unresponsive to praise, criticism, or feelings expressed by others (Frances, 1995, p. 367). People with relatively normal variants of the SPD appear untroubled and indifferent; they function adequately in their occupations but are rather colourless. Individuals with SPD have undifferentiated inner emotional experience. They are low in emotional arousal and reactivity; they are imperceptive and apathetic. Even their language shows a deficit in the range and subtlety of emotionally-related words (Millon, 1996, pp. 232-233). While these individuals do not particularly struggle with shame or guilt, they can be quite anxious about safety. Beck (1990, p.129) suggests that individuals with SPD experience a low level of sadness if separated from people and a low level anxiety if they are forced into interaction with others. Individuals with SPD have a lack of reactivity which results in little need for complex intrapsychic defences (Millon, 1996, p. 232). Millon noted that they often use intellectualization. He suggests that these individuals tend to be abstract and matter-of-fact about their emotional and social lives; they engage in few complicated unconscious processes. As the most adaptive capacity of individuals with SPD is creativity, another defence that defines SPD is withdrawal into fantasy.

130 Further they engage in rumination, rambling speech, cutting off affect, conflict avoidance, and withdrawal.

Differential Diagnosis The differential diagnosis of SPD includes: • a normal preference for solitary pursuits that does not meet the criteria for schizoid personality disorder; • schizophrenia (in which further characteristic negative or positive symptoms occur); • schizotypal personality disorder (in which there are cognitive and perceptual distortions); • paranoid personality disorder (in which the patient displays suspiciousness and paranoid ideations); • avoidant personality disorder (in which the patient has a fear of being embarrassed or inadequate, with excessive anticipation of rejection); • obsessive-compulsive personality disorder (in which there may be apparent social detachment that arises from devotion to work and discomfort with emotions; capacity for intimacy is usually preserved); • disorders of more severely impaired social interaction, stereotyped behaviours and limited interests (e.g. autistic disorder, Asperger’s disorder); • personality change caused by a general medical condition (e.g. temporal lobe epilepsy); • personality symptoms derived from chronic substance use.

Comorbidity The most frequent co-occurring personality disorders with SPD are schizotypal (2-80%) and avoidant (23-88%) personality disorders. Lesser degrees of comorbidity with SPD were demonstrated with paranoid (4-62%), antisocial (3-40%), borderline (19-60%) and passive-aggressive (4-50%) personality disorders (Kalus et al., in Livesley, 1995, p.65). The highest co-occurrences may perhaps be because of the high overlap between the two criteria sets. The SPD and the schizotypal personality disorder, for example, share the important criteria of social isolation and restricted affect. Also the avoidant personality disorder may seek isolation, but individuals with SPD will tolerate the separation with comfort, while individuals with avoidant personality disorder will be distressed and lonely. SPD can as well be, but is not necessarily, an antecedent disorder to schizophrenia, major depression, dysthymia or a delusional disorder. Further it shows high comorbidity with social phobia and agoraphobia. If people with SPD are detached from a supportive family they often become involved with drugs and alcohol.

Prevalence SPD is uncommon in clinical treatment settings. The prevalence of SPD is not known for certain, and there is a wide variation between studies – estimates of the prevalence in the general population based on community survey, non-psychiatric controls, and relatives of psychiatric patients have ranged from 0.5% to 7%. SPD is diagnosed more frequently in males who seem to be more impaired than females with SPD.

Etiology and Sociocultural Factors The etiology of SPD has not been established. A close genetic relationship to schizophrenia has been proposed but is doubtful. Conversely, introversion has been shown to be a highly heritable personality trait. From a neurobiological view dopaminergic abnormalities have been proposed as a possible etiological factor. Psychological theories suggest sociocultural factors in the genesis of the disorder: In the psychodynamic approach, the SPD emerges from inadequacies in earliest relationships with parental figures. The cognitive approach suggests that the most important source of dysfunctional behaviour

131 and affects lie in incorrect attributions that people make. Personality is considered as a relatively stable organization of so-called “schemas” and associated strategies. The strategy of the SPD is isolation and the cognitive style is “I need a great deal of room”. They see themselves as autonomous and as loners. They like to take decisions alone and do solitary activities. They see others as pushy and perceive the openness of other people as an attempt to hedge them in. Their essential conviction is “I am fundamentally alone”. Because of that, close relationships to other people are considered undesirable and limiting. Most modern etiological theories (Herpertz et al.., 2001) suggest an interaction of disposition (e.g. temperament) and environment.

Treatment As patients with SPD have few complaints and do not seek an interpersonal context for solving their problems, they rarely seek therapy. The disorder is most likely to come to medical attention in the course of intervention for another condition, in response to acute stressors or because of family influence. Others who come into treatment are forced to do so by family or even the legal system. Acutely stressful situations often require crisis intervention. Aims of long-term psychotherapeutic interventions are to maintain stability and support, to improve social skills and comfort, to help maximize quality of an isolated lifestyle. In treatment, clients with SPD challenge service providers with the absence of response. As they do not response to emotional leverage, therapists easily feel frustrated and ineffective. The contact between therapist and patient should be an important element of the therapy. An important step of the therapy should be to open possibilities to make new experiences and changes (Saß and Jünemann, 2001). The therapist should be aware that major changes and modifications of character structure are unlikely. The therapy should be aimed at achieving modest reductions in social isolation and in prompting more effective adjustment to new circumstances (Kalus et al., in Livesley, 1995). Especially pressure to focus on affective issues is potentially both aversive and confusing to clients with SPD. Behavioural psychotherapy can be helpful for some patients including, for example, methods such as problem solving, social skills training or role plays. Educational strategies may be effective in working with individuals with SPD to identify (1) their own emotions; (2) the emotions they elicit in others; and (3) possible feeling states of people with whom they relate. Intervention with individuals with SPD may include methods of cognitive therapy, e.g. exploring their self-concept and sense of where they belong in the world. Confrontation should clarify the relation of emotions to thinking and encourage these clients to be present with reality. Individual psychoanalytically oriented psychotherapies are less likely to succeed (Kalus et al.. in Livesley, 1995, p.66). If used they are most likely to be successful if they proceed slowly and with modest frequency, and if they respect the patient's discomfort with intimacy, disclosure and processes of interpersonal interactions. The task of the therapist would be to provide slowly a new experience of relatedness. Patients with SPD often live with their parents “at home” and often first-degree relatives are their sole social support. Family therapy, which can help family members to understand better, to accept the patient and to deal with their own emotional issues, can foster stronger stability and support for the patient. However, if individuals with SPD can engage in group therapy, which they usually find aversive, it can offer opportunities for development of social skills, insight into social conventions and possibly a means of strengthening the capacity for forming gratifying relationships. Controlled studies of pharmacological treatment are lacking. Most psychopharmacological interventions apply to comorbid disorders such as depression or anxiousness. Joseph (1997, pp. 46- 47), however, notes that there are several symptoms in SPD that are potentially responsive to medication. These include the symptoms that resemble the negative or deficit symptoms of schizophrenia: emotional apathy, social withdrawal, blunted or constricted affect, anhedonia, dysphoria, poverty of speech and thought, avolition, and slowed thinking. He suggests low doses of risperidone or olanzapine for the social deficits and blunted affect and Bupropion for anhedonia.

132 Major Contemporary Theoretical Perspectives and Controversies The description of the schizoid pattern goes back to Bleuler, who considered being schizoid a dimension of human personality: that indicated an inwardly directed tendency, away from the outside world, the absence of emotional expressivity, simultaneous contradictory dullness and sensitivity, and pursuit of vague interest. He differentiated between the common characteristic of being schizoid, schizoid psychopathy, latent schizophrenia and schizophrenian psychosis. Similarly to Bleuler, Kraepelin described a close relationship between schizoid characteristics and schizophrenia. Kretschmer, who described the schizoid typology in detail, posited in his so-called “continuity hypothesis” that there are fluent transitions between schizothymia, the schizoid temperament and schizophrenia. In contrast to these conceptualizations other researchers doubted the connection between schizophrenia and schizoid personality disorders. Bostroem and Kurt Schneider were two of the first who emphasized the differentiation between psychopathological personalities and schizophrenic processes. Today the similarities of the SPD to the residual and the prodromal phases of schizophrenia are still one key issue of discussion. Kalus et al. (in Livesley, 1995, p. 59), for example, suggest that there is a genetic link between schizophrenia and the schizoid personality disorder. The SPD appears to characterize the negative symptoms of schizophrenia, e.g. social, interpersonal, and affective deficits like little affect, low energy, anhedonia, diffidence about, shyness in, or detachment from relationships. Kalus et al. suggest that it is the schizotypal personality disorder, also seen as part of the schizophrenia spectrum disorders that exemplifies the positive symptoms at a non-psychotic level, e.g. non-delusional odd beliefs, eccentric behaviour, agitation, and paranoid thinking. From another point of view, Erkwoh et al. (2003) summarize that the hypothesis that the SPD is a part of the schizophrenia continuum should be maintained. In contrast to the schizotypal personality disorder the SPD does not include psychotic-like cognitive/perceptual distortions. In conformity with adoption studies Erkwoh et al. conclude that the schizotypal personality disorder seems to be part of the schizophrenic spectrum whereas the SPD does not. Also Saß and Jünemann (2001) state that: “till today there is no empirical evidence that can prove a connection to schizophrenia securely”. The second key issue concerning the SPD is the difficulty of separating it from other personality disorders, particularly the schizotypal and the avoidant personality disorders. Extensive comorbidity among these disorders raises questions of whether they represent distinct entities. Kretschmer differentiated between two types of schizoid characteristics: the “hyperathenic” (with overt insensitivity) and the “anaesthetic” (with inner sensitivity). The DSM-III separated these concepts into two distinct groups, the schizoid and the avoidant. Other researchers state that the DSM separated what the analysts understood as the schizoid personality into three separate personality disorders: the schizoid, avoidant, and the schizotypal. As the concepts of the three disorders are so close and the prevalence of the SPD is very low – although they tried to sharpen the criteria in the DSM-III-R to raise the prevalence – it is still an open question whether the SPD can be maintained as a distinct diagnosis.

References • Beck, Aaron T., M.D., Freeman, Arthur, Ed.D. (1990). Cognitive Therapy of Personality Disorders. New York: The Guilford Press. • Derksen, J. (1995). Personality disorders. Clinical and Social perspectives. New York: Wiley. • Erkwoh, R, Herpertz, S., Saß, H. (2003). Persönlichkeitsauffälligkeiten und schizophrene Psychose. Der Nervenarzt; 74 (9). • Frances, Allen, M.D., First, Michael B., M.D., & Pincus, Harold Alan, M.D. (1995). DSM- IV Guidebook. Washington, D.C.: American Psychiatric Press, Inc.

133 • Herpertz, S., Herpertz-Dahlmann, B., Jünemann, K., Saß, H. (2001): Prädiktoren von Persönlichkeitsstörungen – Temperament und Persönlichkeit als Anlagefaktor. Persönlichkeitsstörungen, Theorie und Therapie; 5: 205-15. • Joseph, S., M.D., Ph.D., MPH (1997) Personality Disorders: New Symptom-Focused Drug Therapy. New York: The Haworth Medical Press. • Kalus, Oren, Bernstein, David P., and Siever, Larry J. "Schizoid Personality Disorder," In Livesley, W. John, editor (1995). The DSM-IV Personality Disorders. New York: The Guilford Press. • Livesley, W. John, editor (1995). The DSM-IV Personality Disorders. New York: The Guilford Press. • Millon, Theodore (1996). Personality and Psychopathology: Building a Clinical Science. Selected Papers of Theodore Millon. New York: John Wiley & Sons, Inc. • Millon, Theodore & Davis, Rodger (1996). Disorders of Personality DSM-IV and Beyond. New York: John Wiley & Sons. • Saß, H. and Jünemann, K. (2001). Zur ätiologischen Stellung und Therapie der schizoiden und schizotypischen Persönlichkeitsstörung. Fortschritte in Neurologie und Psychiatrie; 69 Sonderheft 2: S. 120-126.

134 Schizotypal Personality Disorder Svenn Torgersen

Diagnostic Criteria DSM-IV 301.22 Schizotypal Personality Disorder L. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behaviour, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Ideas of reference (excluding delusions of reference) 2. Odd beliefs or magical thinking that influences behaviour and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents, bizarre fantasies or preoccupations) 3. Unusual perceptual experiences including bodily illusions 4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped) 5. Suspiciousness or paranoid ideation 6. Inappropriate or constricted affect 7. Behaviour or appearance that is odd, eccentric, or peculiar 8. Lack of close friends or confidants other than first-degree relatives 9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self M. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder With Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder.

Note : If criteria are met prior to the onset of Schizophrenia, add “Premorbid”, e.g., “Schizotypal Personality Disorder (Premorbid)”.

Historical background and clinical description The historical roots of schizotypal personality disorder (STPD) are the non-psychotic personality syndromes within the spectrum of schizophrenia. In part the conditions were observed in the beginning of the 20th century among the relatives of schizophrenic patients, usually not seeking treatment, in part among patients who were not psychotic, strictly speaking, had no mood disorder or any well-defined neurotic disorder, but even so were peculiar and eccentric and partly functioned marginally socially. The conditions were named variously: “ambulatory schizophrenia”, “latent schizophrenia”, “pseudoneurotic schizophrenia”, reflecting their familiar and phenomenological position between schizophrenia and the non-psychotic disorders, and at the same time definitely representing character disturbances. Patients with these conditions were characterized as being “irritable, obsessional, opinionated, suspicious, lonely, narrow in interests, having paranoid traits, eccentricities, lack of feelings, reserve” and so forth. After the Second World War, with the strong rise in psychoanalytic influence over the American psychiatry, a new source fro the description of these “borderline” cases emerged, namely patient who were difficult to analyze or patients who became transiently psychotic during analyses or as a reaction to different kinds of personal stressors. Patients who were “difficult” to handle in psychiatric wards, who behaved almost as if they were antisocial, but at the same time displayed a lot of overt anxiety and despair, were included in this category. Their dramatic, claiming and unstable behaviour represented a challenge to their surroundings. Some patients were as quiet as the so-called “as-if personalities”, but had definitely a defect in their identities. In 1968 Roy Grinker and his co-workers wrote a book defining the whole realm of borderline conditions. Some felt the concept was too broad, and when DSM-III was written, the chairman of the committee, Robert Spitzer, together with his co-workers (Spitzer et al., 1979) set out to regain the “true” nature of the schizophrenia-related personality syndrome, for the first time called “schizotypal” by Rado in 1953, a concept that was promoted by Mehl in 1962.

135 Spitzer and co-workers developed items partly from the interviews of relatives of schizophrenic and normal adoptee as well as non-psychotic adoptee in the famous Danish adoption study (Kety et al., 1992), partly from clinical descriptions of “borderlines,” and not least from the article by Gunderson et al. (1975). A validation study conducted among American clinicians resulted in two partially independent personality syndromes (Spitzer et al., 1979). One of them, the “unstable” pattern retained the designation “borderline personality disorder” in DSM-III, the other constituted the “schizotypal personality disorder”. The definition of schizotypal personality disorder has remained more or less the same during the revisions of DSM and consists in DSM-IV (APA, 1994) of the following criteria: (1) ideas of reference (excluding delusions of reference), (2) odd beliefs and magical thinking that influences behaviour and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents, bizarre fantasies or preoccupations), (3) unusual perceptual experience, including bodily illusions, (4) odd thinking and speech (e.g., vague, circumstantial, metaphorical, over elaborate, or stereotyped), (5) suspiciousness or paranoid ideation, (6) inappropriate or constricted affects, (7) behaviour or appearance that is odd, eccentric, or peculiar, (8) lack of close friends or confidants other than first-degree relatives, (9) excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgment about self. ICD-10 included schizotypal disorder among the psychoses and defined it partly similarly, partly differently from DSM (WHO, 1993). The only difference between DSM-IV and ICD-10 is that DSM-IV includes “ideas of reference” and “excessive social anxiety,” while ICD-10 includes obsessive rumination and micropsychoses. However, ideas of reference are close to suspiciousness, and micropsychoses are close to unusual perceptual experiences, so the only real difference is social anxiety and obsessive ruminations.

Boundaries with other disorders As evolving from the spectrum of schizophrenia, the boundaries between schizotypal personality disorder and schizophrenia are not easy to define. The prodromal symptoms of schizophrenia are similar to the schizotypal personality disorder. Thus, retrospectively, “premorbid” may be added to STPD, according to DSM-IV. When fully developed hallucinations and delusions are presented during a one -month period, the diagnosis is schizophrenia. However, a person with delusions or hallucinations plus negative symptoms may show a clinical picture similar to STPD; even so schizophrenia is the correct diagnosis, if the duration requirements are fulfilled. Even more difficult is the differentiation between simple schizophrenia and STPD in ICD-10. In practice, the differentiation is impossible, as the criteria for simple schizophrenia, personality changes, negative symptoms: and reduced social function is indistinguishable from the early developmental phase of STPD. However, simple schizophrenia requires change, while STPD implies no clear starting point. The possible early start of STPD, however, may make it difficult to distinguish STPD from milder forms of pervasive developmental disorders (autism). As to other psychotic disorders, the manifestation of full-blown delusions (not only ideas of reference and suspiciousness) and hallucinations (not only illusions) preclude any diagnosis of STPD. The boundaries between STPD and borderline personality disorder are of course difficult to draw, as both personality disorders emerged from the same borderline psychoses concept. They share the pseudo-psychotic and paranoid features, and quite a few people may live an unstable and turbulent life similar to those with borderline personality disorder. Even so, the impulsivity and affective intensity and variability in the borderline personality disorder are not part of the STPD criteria set. Furthermore, those with borderline personality disorder are not expected to display the socially inept and chronically withdrawn pattern of STPD. Instead, some people with borderline personality disorder may withdraw when they get older, as a consequence of using up the patience of

136 their acquaintances and having experienced a brimful of disappointments in their partnerships and relationships. STPD is close to schizoid personality disorders. The two disorders share the social isolation and the constricted affects. However, STPD has the oddness and the pseudo-psychotic features in addition. In the same vein, those with paranoid personality disorder share the paranoid features with STPD, but not the withdrawal, oddness and pseudo-psychotic features. STPD shares the social anxiety and the tendency to withdrawal with avoidant personality disorder, but not the eccentricity, paranoid features and illusions.

Prevalence and socio-demographic correlations Relatively few studies of the prevalence in the general population have been performed. The samples are seldom quite representative, and differently structured interviews are applied, based on different editions of DSM. The most representative studies show a prevalence of 0.7 (Maier et al., 1992) and 0.6 (Torgersen et al., 2001). Those with a higher number of schizotypal traits have less education and more often live alone in the city centre (Torgersen et al., 2001) compared with those with a lower number. They are also more often separated (Zimmerman & Coryell, 1989). In a Norwegian outpatient sample, Alnæs & Torgersen (1988) observed a prevalence of 3.9 among females and 12.0 among males. The prevalence was not much different in a mixed in- out-patient Italian sample, 3.3 and 6.8, respectively (Fossati et al., 2000). Schizophrenia was excluded from both samples: STPD seems thus more prevalent among men in clinical samples.

Comorbidity Axis II: Schizotypal personality disorder is part of the eccentric cluster (A) in DSM together with paranoid and schizoid personality disorders. A study of controls and relatives of patients and controls showed that paranoid PD was most highly correlated with STPD traits (Zimmerman & Coryell, 1989). However, schizoid personality disorder was only number seven. Avoidant and borderline personality disorders were especially highly correlated to STPD. In the study of Fossati et al. (2000) on the other hand, schizoid and paranoid personality disorders were those that were most strongly correlated with STPD. A large multi-centre Italian-American study once more showed that, in addition to schizoid and paranoid, borderline and avoidant personality disorders were related to STPD. The empirical studies thus confirm our observations about the defined closeness between STPD other personality disorders.

Axis I: STPD is of course associated with psychotic disorders including schizophrenia (Zimmerman & Coryell, 1989; Oldham et al., 1995). Furthermore, there seems to be an association with obsessive compulsive and phobic disorders (Alnæs & Torgersen, 1988; Zimmerman & Coryell, 1989). There may also be an association with dysthymic disorder (Alnæs & Torgersen, 1988), panic disorder (Zimmerman & Coryell, 1989), somatoform disorders (Noyes et al., 2001) and eating disorders (Oldham et al., 1995).

Relation to common personality dimensions A meta-analysis of the so-called “Big-Five” and personality disorders showed that what characterized those with STPD were first and foremost Neuroticism, second Introversion and third Non-Agreeableness. (Saulsman & Page, 2004).The pattern was similar to paranoid and borderline personality disorders in Neuroticism and Non-agreeableness, and similar to avoidant personality disorder in Neuroticism and Introversion. Furthermore, STPD was similar to schizoid personality disorder in Introversion, to antisocial and narcissistic personality disorders in Non-agreeableness, and to dependent personality disorder in Neuroticism. There were no similarities to histrionic and obsessive-compulsive personality disorders. Together with borderline personality disorder, those with STPD were extreme on most personality disorders, three out of five dimensions.

137 The results of the studies of the relationships between STPD and personality dimensions fit in with the large overlap between STPD and paranoid, avoidant and borderline personality disorders. A study of the relationships between personality disorders and Cloninger’s temperament and character scales suggests that STPD is negatively correlated to Self-directedness and Cooperation, and positively correlated to Self-transcendence (de la Rie et al., 1998). The results illustrate the vulnerable, withdrawn and psychotic-like aspects of STPD. Even if STPD is correlated to common personality dimensions one cannot jump to the conclusion that STPD is a construct based on these dimensions. It may be that those with schizotypal traits simply answer in an extreme way when these dimensions are measured by the questionnaires. Then we approach the question about the categorical or dimensional nature of schizotypal features. Some statistical analyses suggest that that a latent discontinuity underlies the variation in schizotypal traits (Lenzenweger & Korfine, 1995). Others believe more in a dimensional model of schizotypy, with poorly functional individuals at one end of the dimensions, and well-functioning individuals among those with somewhat lower scores on schizotypal inventories (Goulding, 2004). Those more poorly functioning are more anhedonic and with more cognitive disturbance, while those well-functioning are more characterized by unreal experiences.

Etiology STPD is genetically influenced as are other personality disorders (Torgersen 1986, Torgersen et al. 2000, Kendler & Hewitt, 1992). This is also the case for schizotypal traits in children (Coolidge et al., 2001). However, what is especially important is the genetic relationship to other mental disorders. Some studies suggest a familial relationship between STPD and the whole realm of psychoses (Squires-Wheeler et al., 1989; Kendler et al., 1995). As STPD evolved out of the familial schizophrenic spectrum, the genetic relationship to schizophrenia is of particular interest. Studies of co-twins of schizophrenic patients (Torgersen, 1992), and biological relatives of adopted-away schizophrenics (Kendler & Gruenberg, 1984) confirmed the specific familial and genetic relationship between STPD and schizophrenia. No other personality disorders seem to be consistently related to schizophrenia. However, STPD as defined by DSM does not seem to cover adequately the schizophrenia- related STPD. Those adopted -away offspring of schizophrenics who develop personality disorders seem to experience frequent somatoform complaints and poor social function in addition to withdrawal and emotional constriction (Gunderson et al., 1983). In fact, STPD consists of two syndromes that may be independently inherited (Siever, 1995; Kendler and Hewitt, 1992), a constricted/eccentric syndrome that is characterized by odd and eccentric appearance and behaviour, thoughts and communication, and a psychotic-like syndrome that is characterized by ideas of reference, magical thinking, illusions and depersonalization/derealization. While the former syndrome seems to be genetically related to schizophrenia (Torgersen, 1993), the latter is not. Even if there might exist a familial relationship between STPD and affective disorder, a genetic relationship to major depression is not confirmed (Torgersen, 1993). We do not know what environmental factors influence the development of STPD. A retrospective study showed that those with STPD more often reported neglectful parenting from both parents, which means little love and also little control (Torgersen & Alnæs, 1992). Those with borderline personality disorder more often reported affectionless control , meaning little love and much control. Those with other personality disorders more often experienced affectionate constraint ; much love and much control, while those without personality disorder reported optimal parenting ; much love and little control.

Dysfunction and quality of life A Norwegian twin study showed that those with STPD had poor social as well as occupational adjustment (Torgersen, 1986). Skodol et al.. (2002) found dysfunction in relation to parents, sibs, and friends, occupational dysfunction, and dysfunction in relation to more distant family members

138 among those with schizotypal personality disorder. Fossati et al. (2003) studied aspects of close relationships: confidence, discomfort with closeness, relationships as secondary, need for approval, and preoccupation with relationships, and found that those with STPD had a lot of problems. Quality of life is also reduced among those with STPD (Cramer et al., 2003). They have a poor subjective well-being, poor self-realization, less contact with friends and family, less social support, a lot of negative life events, poor neighbourhood quality, and generally a poorer global quality than those without STPD in the general population. Among the personality disorders, nobody displayed poorer quality of life than those with STPD.

Neuropsychology and biology The neuropsychological and biological fundamentals of STPD are far from settled. Even so, some results are forthcoming. There seems to be a difference between the constricted/ eccentric and the psychotic-like STPD syndromes. Neuro-psychological tests measuring attention and information processing observe impairment among those with constricted/eccentric traits (Siever, 1995). Indication of a low dopamine level are found among those with the constricted/eccentric syndrome, for instance by a low concentration of homovannilic acid (HVA). An adequate dopamine activity is necessary for maintenance of working memory, a function necessary for social engagement as well as other executive functions. The deficient information processing may contribute to the social withdrawal, emotional constriction and eccentricity among those with STPD. On the other hand, those with the psychotic- like syndrome seem to have an exceptionally high level of dopamine-activity, as also demonstrated in a high concentration of HVA. The increased dopaminergic activity may explain the psychotic-like traits such as illusions, paranoid ideations etc.

Treatment Usually psychotherapeutic approaches are applied for patients with STPD. No controlled results are published. However, from clinical experience there are some precautions that are important to take into account. Some less experienced clinicians may be fascinated with all the grotesque and symbol- rich material patients with STPD may produce. They show interest, ask for details and encourage the patient to tell more. This can be great for the clinician, but hardly helpful for the patient. The patient may slide even more into the disturbing inner fantasies. A better approach is to dedramatize the strange thoughts and pictures, not reject, if the patient is active in telling, not refrain from showing a strong interest in the material. Instead, it is important for the patient to learn social skills, to discuss what went wrong in interpersonal situations, what behaviour is common and appropriate. As to pharmacotherapy, the best approach is to treat the axis-I disorder in cases where those with STPD have it in addition. If the clinical picture is dominated by psychotic-like features, neuroleptic may be the treatment of choice. There are some indications that blocking of dopaminergic activation may help those with psychotic-like traits. On the other hand, those with constricted/eccentric features may be helped by drugs that functions like amphetamine - releasing dopamine and blocking its reuptake.

Conclusion STPD is a severe personality disorder with a questionable oncology on the border between the psychoses and the neuroses. In addition , its relationship to common personality dimensions and its categorical versus dimensional status is equivocal. It is rare, the prevalence probably being below one percent. As is probably true of all personality disorders, it is considerably influenced by genes. Its genetic relationship to schizophrenia is also complicated, maybe only the constricted, eccentric syndrome is within the schizophrenic spectrum. In the same way, the neuropsychological and biological aspects of STPD seem equally split between the eccentric/constricted and the psychotic- like syndromes. Most likely, these syndromes may be treated differently. An important aim may be to prevent a schizophrenic development or frequent psychotic outbursts. Learning social skills and

139 avoidance of situations patients cannot tackle would help. In contrast to individuals with schizoid and avoidant personality disorders, people with STPD do not keep away from difficult and dangerous situations. With optimal support and adequate education and occupational training, they should be able to live a good life in spite of their vulnerable outset.

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140 • Oldman JM, Skodol AE, Kellman HD et al.. Comorbidity of axis I and axis II disorders. Am J Psychiatry. 1995;152:571-578. • Rado S. Dynamics and classification of disordered behaviour. Am J Psychiatry. 1953;110:406-416. • Saulsman LM, Page AC. The five-factor model and personality disorder empirical literature: A meta-analytic review. Clin Psych Review. 2004;23:1055-1085. • Siever LJ, Brain structurte/function and the dopamine system in schizotypal personality disorders. In: Schizotypal personality (Eds.: A Raine, T Lencz, SA Mednick). Cambridge University Press, New York, 1995. • Skodol AE, Gunderson JC, McGlashan TH, Dyck IR et al.. Functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder. Am J Psychiatry. 2002;159:276-283. • Spitzer RL, Endicott J, Gibbon M. Crossing the border into borderline personality and borderline schizophrenia: the development of criteria. Arch Gen Psychiatry. 1979;36:17-24. • Squires-Wheeler E, Skodol AE, Bassett A et al.. DSM-III-R schizotypal personality traits in offspring of schizophrenic disorder, affective disorder , and normal control parents. J Psychiatr Res. 1989;23:229-239. • Torgersen S: Genetic and nosological aspects of schizotypal and borderline personality disorders: a twin study. Arch Gen Psychiatry. 1984; 41: 546-554. • Torgersen S, Alnæs R. Differential perception of parental bonding in schizotypal and borderline personality disorder patients. Compr Psychiatry. 1992;33:34-38. • Torgersen S, Kringlen E, Cramer V. The prevalence of personality disorders in a community sample. Arch Gen Psychiatry. 2001;58:590-596. • Torgersen S, Onstad S, Skre I et al.. "True" schizotypal personality disorder: A study of co- twins and relatives of schizophrenic probands. Am J Psychiatry. 1993;150:1661-1667. • Zimmerman M, Coryell W. DSM-III personality disorder diagnoses in a nonpatient sample. Demographic correlates and comorbidity. Arch Gen Psychiatry. 1989;46:682-689.

141 Suggested Additional Reading List – Module II

• Alarcon RD, Foulks, EF, Vakkur M. Personality Disorders and Culture: Clinical and Conceptual Interactions. New York, John Wiley & Sons, Ltd., 1998 • Beck A., Freeman A, Davis DD. Cognitive therapy for Personality Disorders. Second edition New York, The Guilford Press, 2004 • Benjamin L. Interpersonal Diagnosis and Treatment of Personality Disorders. Second Edition. New York, The Guilford Press, 2003. • Costa PT, Widiger TA. (Eds) Personality Disorsers and the Five Factor Model of Personality. Washington DC, American Psychological Association, 2002 • Derksen J. Personality Disorders: Clinical and Social Perspectives: Assessment and Treatment Based on DSM-IV and ICD 10. Chichester, UK John Wiley & Sons, Ltd., 1995 • Derksen JJL, Maffei C, Groen H. (Eds). Trearment of Personality Disorder. New York, Kluwer Academic/Plenum Publisher 1999 • Gabbard GO (Ed). Treatment of psychiatric Disorders. 2 Volume Set. Washington DC, American Psychiatric Press, Inc. 2001 • Gunderson JG, Gabbard G O (Eds). Psychotherapy for Personality Disorders. Washington DC, American Psychiatric Press, Inc. 2000 • Herpertz SC, Sass H, Persönlichkeitsstöerungen. Thieme-Verlag, Stuttgart, New York, 2002 • Kernberg PF, Weiner AS, Badenstein KK. Personality Disorders in Children and Adolescents. New York, Basic Books, 2000 • Lenzenweger MF, Clarkin J F. Major Theories of Personality Disorder. New York, Guilford Publications, 1996 • Livesley WJ. Handbook on Personality Disorders: Theory, Research and Treatment. New York, The Guilford Press, 2001 • Livesley, WJ. Practical Management of Personality Disorder. New York, The Guilford Press, 2003 • Magnavita JJ. Handbook of Personality disorders: Theory and Practice. New York, John Wiley & Sons, Ltd., 2003 • May M, Akiskal HS, Mezzich JE, Okasha A. (Eds) Personality Disorders. WPA Series : Evidence and Experience in Psychiatry. Chichester, UK John Wiley & Sons, Ltd., 2005 • Millon T, with Davis R. Disorders of Personality: DSM-IV and Beyond. New York, John Wiley & Sons, Ltd., 1996 • Millon T; Millon CM, Meagher C, Grossman S. Personality Disorders in Modern Life. Hoboken, New Jersey 2004 • Oldham, JM, Skodol AE, Bender DS (Eds). The American Psychiatric Publishing Textbook of Personality Disorders, Washington DC, American Psychiatric Press, Inc. 2005 • Paris J. Personality disorders over time: Precursors, Curse and Outcome. Washington DC, American Psychiatric Press, Inc. 2003 • Rubio Larrosa V, Perez Urdaniz A. Trastornos de la Personalidad. Madrid, Espania, Elsevier, 2003 • Sperry L. Handbook on Diagnosis and Treatment of DSM-IV Personality Disorders: Revised Edition.New York, Brunner –Routledge, 2003

142 Diagnostic Instruments

Clark LA. Schedule for Nonadaptive and Adaptive Personality , SNAP.

Cloninger CR, Przybeck, TR., Svarkic DM, Wetzel RD. The Temperament and Character Inventory TCI: A Guide to its development and use. St. Louis, MO: Washington University Center for Psychobiology and Personality 1994.

Costa P T, McCrae R R. The NEO Personality Inventory Revised (NEO-PI-R). Psychological Assessment Resource, Inc. 1995

First, M B, Gibbon, M, Spitzer RL, Williams J B W. Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID II) Washington DC, American Psychiatric Press, Inc. 2005 Hare RD. The Hare Psychopathy Checklist Revised (PCL-R). Toronto, OntarioMultihealth Systems 1991.

Hyler S. Personality Diagnostic Questionnaire- 4 th Edition (PDQ-4)

Loranger AW, Janca A, Sartorius N. Asessment and Diagnosis of Personality Disorders: The ICD 10 International Personality disorder Examination (IPDE). Cambridge UK, Cambridge University Press, 1997

Millon, M. Millon Clinical Multiaxial Inventory III (MCMI-III). Minneapolis, MN National Computer systems, Inc. 1994

Morey L. Personality Assessment Inventory (PAI). Psychological Assessment Recourses 1991

Pfohl B, Blum N, Zimmerman M. Structured Interview for DSM-IV Personality (SIDP-IV ). American Publishing Group, 1997.

Tyrer P. Personality Assessment Schedule, PAS (Original version), and PAS-I (ICD10). In P. Tyrer. Personality Disorders. Diagnosis, Management and Causes, London, Arnold 2000.

Zanarini M C, Frankenburg FR, Sickel AE, Yong L. The Diagnostic Interview for DSM IV Personality Disorders –IV (DIPD-IV ). Belmont, MA, McLean Hospital and Harvard Medical School 1996

143 Curriculum Suggestions – Module II

Curriculum Module II

The presentation of each personality disorder should be discussed among colleagues in classrooms or workshops. The following questions may be helpful:

1. What are the most outstanding and significant features for each personality disorder that best identifies and differentiates them from other personality disorders?

2. In what way does each personality disorder resemble or overlap with other disorders, including both Axis I and Axis II disorders?

3. What are the major commonalities in the etiology of the personality disorders? Which personality disorders have primarily developmental origin, and which have a strong potential genetic origin?

4. Identify specific cultural factors in your country/cultural environment that influence the understanding and treatment of certain personality disorder features.

5. What are the most striking gender differences among personality disorders – i.e., which disorders are, according to the text, most common among men, and among woman? How does that compare to your cultural experiences? Discuss reasons for observed differences

6. How does the prevalence of each personality disorder vary in your country/culture compare to those prevalence rates mentioned in the Module II text?

7. Discuss and compare the differences between treating personality disorders and Axis I disorders. How do co-occurring Axis I disorders influence treatment of a personality disorder, and vice versa, how can the presence of a personality disorder affect the course and treatment of an Axis I disorder such as Bipolar disorder or Major Depression or Eating Disorder. Give examples.

8. Compare the major contemporary controversies of each personality disorder and discuss future changes in diagnostic classifications and important areas for research.

144 MODULE III: CASE VIGNETTES

INTRODUCTION Erik Simonsen

The following case vignettes illustrate important psychopathological features and behavioural problems which distinguishes the personality disorders from normal behaviour. It is often difficult to draw an exact line between what is normal and what is dysfunctional. Also, sometimes it is difficult to separate the different personality disorders. Most often patients are mixtures of the prototypes as they are portrayed in the classification system. In Module II, each of the disorders is described in detail. In this module, authentic cases are described under the following subheadings: identifying data, presenting complaint, social and psychiatric history, medical history, mental status, differential diagnosis and treatment history. The authentic cases are written by clinicians from all over the world. At the end of each case, the author of the corresponding chapter in Module II or the editor of Module III have made some concluding comments regarding the case.

145 CASE 1: Ronny: Paranoid Personality Disorder, Scandinavia CASE 2: Theo: Paranoid Personality Disorder, The Netherlands CASE 3: Sara: Borderline Personality Disorder, Scandinavia CASE 4: Jane: Borderline Personality Disorder, UK CASE 5: Ellen: Borderline Personality Disorder, Canada CASE 6: Peter: Narcissistic Personality Disorder, The Netherlands CASE 7: Carmen: Histrionic Personality Disorder, Chile CASE 8: Patrick: Avoidant Personality Disorder, Scandinavia CASE 9: Saskia: Avoidant Personality Disorder, The Netherlands CASE 10: Sally: Dependent Personality Disorder, USA CASE 11: Brian: Obsessive-Compulsive Personality Disorder, Australia CASE 12: Gregorio: Mixed Personality Disorder, Italy CASE 13: John: Antisocial Personality Disorder, The Netherlands CASE 14: Sergio: Antisocial/Dissocial Personality Disorder, Uruguay CASE 15: Marcel: Dissocial Personality Disorder, Romania CASE 16: Mr. M.: Antisocial/Dissocial Personality Disorder, Canada CASE 17: Alejandro: Borderlind Disorder, Argentina CASE 18: Anna Z: Borderline Personality Disorder, Serbia and Montenegro CASE 19: John: Schizoid Personality Disorder, Scandinavia CASE 20: Jim: Narcissistic and Antisocial Personlity Disorder, The Netherlands CASE 21: Borderline Personality Disorder, Brazil CASE 22: Marcello: Avoidant Disorder, Italy CASE 23: Erik: Narcissistic Personality Disorder, Scandinavia CASE 24: Mary: Borderline Personality Disorder, Italy CASE 25: Francisc: Anxious/Avoidant Personality Disorder, Romania CASE 26: Lola: Borderline Personality Disorder, Spain

Additional cases: CASE 27: Paranoid Personality Disorder, Argentina CASE 28: Jane: Obsessive-compulsive Personality Disorder, Kenya CASE 29: AB: Borderline Personality Disorder, India CASE 30: Mr FA: Narcissistic Personality Disorder, Pakistan CASE 31: Anja: Borderline Personality Disorder, Germany

146 CASE 1: Ronny: Paranoid personality disorder Country of origin: Scandinavia Author: Øyvind Urnes

Identifying data A 40 year old divorced worker developed a severe depression after he was fired from his job. One year later he was referred from his medical doctor to a specialized treatment program for personality disorders. One year of SSRI medication had made him less depressed, but he was still socially isolated and unable to return to any kind of work.

Presenting complaint Considerable anxiety, fatigue, somatic complaints, sleeplessness, social isolation, disturbing inner feelings of hatred towards other people.

History of present illness His illness started in his childhood. He reported that he was very aggressive towards other children and involved in recurrent conflicts. Inside he felt lonely and anxious. At home he was constantly on guard, felt he had problems breathing and was very dissatisfied with his body. He felt fat and despised “his weak muscles”. His loneliness became more and more disturbing, and his self criticism got worse. In adolescence he fell in love with a woman from a distance, but when he was rejected by her after he had revealed his love for her, he made a serious suicidal attempt with an overdose of sleep tablets and alcohol. In the following years he spent a lot of time compulsively washing his hands and using checking rituals. After he was separated from his wife, he drank heavily for 4 years, but stopped by his own choice. His general nervousness continuously increased, and he suffered many hypochondriac symptoms. In spite of several consultations with his general practitioner for these symptoms, he was never referred to a psychiatrist or psychologist. In his work relations he was involved in severe interpersonal conflicts, reacting with aggressive attacks at the slightest offences. On one occasion he impulsively attacked one of his colleagues with a stranglehold after the colleague had taken his newspaper without asking. He was then dismissed from his job. This resulted in total social isolation, depression and suicidal ideation.

Family and social history Ronny’s father was a carpenter who suffered from stuttering and general nervousness. He started to drink heavily in early adulthood, but still managed to be a stable worker. Socially he was a loner, was very silent at home and violent with Ronny when he was drunk. He often hit Ronny in the face, and Ronny soon started to be on the alert for attacks. He could also call his son “a damned bastard, not my fucking son”. Ronny thought that his father had felt inferior to his own father who had had a more leading position at work. His father died when Ronny was 28 years old, but his death did not result in any worsening of his symptoms. Ronny’s mother was a nervous sales woman and was hospitalised for a major depression in a psychiatric ward for a few months when Ronny was 4 years old. During this time, he lived with his grandparents on his father’s side. The mother was occupied with the children’s clothes and other aspects of the family’s façade, did not show warm feelings for her children, and seemed unhappy most of the time. His mother used spanking when raising her son, who had to fetch the spanking rod himself when he had been impolite.

147 Ronny grew up with his parents and a two year older sister whom he felt made an alliance with his mother against him and his father. Most of the time he felt that all three were against him. The family atmosphere was very unsafe and hostile. They often quarrelled at the kitchen table. Ronny had stuttering problems like his father, and was sent to a special school. There he felt bullied by other children. He did not succeed at making friends, although he longed to. He also kept his sister at a distance. The inner feeling of aggression toward others continually increased, and he hated the teachers and later all people in authority. He was interested in sports as well as intellectual activities, and he deeply longed for a companion to discuss things with. He started a long and slow university education in literature, but did not manage to finish his courses due to the ever ongoing nervousness and tenseness. He got an ordinary job, not requiring any skills, as a worker in a chocolate factory and held this job until he was fired. During this time he had regularly attended some courses at the university, and he felt that this activity made his colleagues at work envious of him and excluded him from their social gatherings. He had some short term relationships with women during his years as a student, but married a woman from another country and had a daughter. He met this woman at the university. She had been in the country for only 3 months and didn’t know anyone beforehand. His wife left him after one year. She considered her husband to be too anxious and “peculiar”. After the divorce he had only one telephone conversation with his former wife and daughter. He had a strong inner sense of loss for both of them, but he didn’t stay in touch with them. He said it was impossible to travel to where they lived because of his fear of travelling by train. He had not been able to form new relationships with women since the break-up of his marriage ten years earlier. He developed a “hate/love relationship” to women and kept them at a distance. The last years he spent working, he was continuously involved in conflicts with his colleagues. After a short contact with a female colleague who terminated the relationship with him, he wrote her a letter where he expressed that he wished she would go and kill herself. The only person he stayed friends with was his brother-in-law who lived a hundred kilometres away.

Medical history As a child he was hospitalised for a liver disease. He was more or less isolated from his family for four months. In adulthood he had trouble with recurring tendonitis and a lot of symptoms in different organ systems, but without any medical findings.

Mental status Ronny presented himself with a courteous and friendly appearance. He soon became very talkative and attempts to get him into a dialogue did not seem to reach him. It was as though he overlooked signals from other people, and he insisted on talking from his own perspective. Not challenged as to this controlling behaviour, he talked at length of his subjective complaints and seemed eager to tell all the details about anxiety symptoms, compulsive symptoms, his feeling of loneliness and inner hatred of other people. He displayed from time to time some suspicious glances, and looked a bit angry when the interviewer tried to introduce gently challenging questions. He did not seem overtly depressed, and displayed very little emotion. Intellectually he showed good reasoning and no signs of delusional ideations.

Treatment history An evaluation with SCID-I at admission to the personality disorder unit revealed the following diagnoses on axis I, DSM-IV: Panic disorder with agoraphobia, obsessive compulsive disorder, somatoform pain disorder and major depression in remission. Evaluation of his dysfunctional personality traits with SCID-II concluded with paranoid (six criteria), obsessive compulsive (five criteria) and avoidant (four criteria) personality disorder and some criteria of schizotypal, narcissistic and borderline (impulsiveness, self destructiveness and inappropriate anger) personality disorder. Global symptom index (GSI) of Symptom Check List-90, SCL-90 was 2.4, indicating a considerable

148 level of subjective distress. He scored especially high on the subscales vulnerability, phobic anxiety and suspiciousness. Inventory of Interpersonal Problems Circumplex Version, IIP-C sum score was 1.9 with a heavy load on being too cold and socially insecure. Global Assessment of Functioning, GAF was 41, indicating not being able to work, being socially isolated, with serious symptoms. His own treatment goals at the start of the combined 18 week group program were to make friends, find a partner and to be more positive toward other people, more able to become trusting and to reduce the feelings of hatred. During the first weeks of the treatment program, he was very talkative and used a lot of intellectualisation in his impersonal comments, especially in the large group. In the small group he was avoidant of his own thoughts and feelings but expressed dislikes of his fellow patients. When confronted by this attitude by the other patients, became agitated, was difficult to calm down and tended to monopolize the session. His social anxiety got worse, and he felt that people standing in groups were talking about him behind his back. He behaved quite differently in the cognitive group for anxiety disorders. In this group he was goal-directed. He was very satisfied that he was able to go to a café and felt it was a big victory. In the middle of the treatment he was less afraid of the others in the groups. He shared more about his own feelings of being a looser, overly neurotic with a lot of details describing problems of breathing normally, sweating abnormally, having cold feet, dry mouth, being overly sensitive of low temperature, having lowered sexual lust, tiredness and so forth. When he felt that the others in the group got more attention from the therapists than he did, he got envious and jealous and reacted with aggressive verbal attacks and biting sarcasm. In the art therapy group the main themes in his pictures were the following: He drew pictures where his head exploded with rage, the feeling of a big eye above him that constantly held him under surveillance, the feeling of being squeezed in a large machine, the feeling of loneliness portrayed by a single chair standing in a large room without any other furniture, the therapists as robots talking bullshit and arrogantly talking in a derogatory way of him and the whole psychiatric ward as a killing machine of patients’ brains. In the small group he angrily attacked other patients’ weak and vulnerable sides that they had exposed in their art therapy group. When he was told how he was perceived, he accelerated his counterattacks. The therapist tried both to empathize with his sufferings and confront his interpersonal destructiveness. His reaction was increased withdrawal and resignation. This pattern repeated itself over and over again, and Ronny did not seem to change his behaviour in the direction he himself wanted and had stated in his treatment goals. This destructive pattern made a strong impact on the therapists who got tired of trying to help him out of this pattern, and they concluded that he had not achieved the necessary treatment alliance required to be offered follow-up treatment consisting of weekly out-patient group psychotherapy. His aggressiveness toward his fellow patients in the group made the group climate negative and probably contra-productive. The therapists were not able to turn his destructiveness into creative self assertiveness. He was given SSRI medication during the last three weeks, and this medication seemed to reduce his destructive impulsiveness, but not his suspiciousness and interpersonal aggressiveness. He was also recommended to apply for disability pension. His struggle to adapt to an ordinary working-role was considered to stand little chance of success. The therapists thought he would be better off if he were relieved of the pressure to perform. Perhaps more beneficial processes could show up in his brittle and defensive self if he did not have to constantly defend himself. The self report scores at the end of day treatment showed somewhat less subjective distress and interpersonal problems compared to the data upon admission, GSI was 1.7 and IIP-C 1.6, but his global function seemed to remain unchanged. The treatment had now come to an end and Ronny was referred back to his general practitioner. The specialized unit offered follow-up to all the patients after one year, but Ronny did not answer the letter.

149 There was also a five year follow-up and this time Ronny answered in a friendly manner and agreed to a supplementary telephone call. His self report test now revealed remarkable changes. GSI was now 0.12 and IIP-C 0.36! He was now without subjective distress and also reported no interpersonal problems. He scored his life quality as eight (Likert scale from 1-10). How come? In the telephone interview he answered in a friendly tone that he had been granted disability pension and had moved back to his family home after his mother had died. He now lived alone in a big house, had his own car and cottage. He missed work and more social contacts, especially contact with his daughter. His former wife did not want her daughter to have contact with her father. The only contact he had with her was by telephone or letter. The only people he managed to sustain a relationship with were his sister and brother-in-law, who lived nearby. He had had a short lived relationship to a psychotic woman half a year earlier. He complained about some back ache, but was in contact with the disability pension authorities in order to start up with some working activity, most probably as a postman. On the phone he spoke in a happy tone, said that he had learned a lot from therapy in the day treatment program, but that he was angry when denied follow-up treatment. This was the reason for not answering the one-year follow-up letter. He still had problems with making friends because of his mistrust toward other people. He terminated SSRI medication one year ago and did not notice any difference. In his daily life he read a lot of newspapers, went jogging in the forest nearby, was fond of gardening around his house and took care of necessary maintenance of his house himself. He followed a weekly seminar on literature in the nearest city but had not succeeded in making friends with any of the participants. GAF was now 63.

Editorial comment This vignette illustrates in a very elegant way several important issues and characteristic features of the paranoid personality. First, they do not seek treatment unless they are in a crisis (fired from job) or because of additional pathology (depression). Second, they often share pathology with the avoidant (their hypervigiliant, fearful attachment style, and their expectation that other people will reject and be untrustworthy) and the obsessive compulsive (rigidity and wish of controlling others). Third, when decompensated they most often get depression, panic attacks, OCD, somatoform disorder as in this case or in other cases an additional alcohol abuse. Fourth, the vignette may support a psychodynamic formulation of key elements in his personality functioning. His personality pathology is excessive aggression and mistrust. However, his projections toward other people seem to be inadequate for control of his feelings and they are then also directed towards his own body and through his rituals. Fifth, these patients would normally in a Scandinavian clinical setting be referred to individual psychotherapy. A mutual trustful working alliance is crucial before any other treatment goals can be achieved. His pathology was expelled in the small groups right away and he felt humiliated, which worsened his aggressive behaviour and social anxiety. However, he probably gained some insight by this confrontation, but only later when his life was without stress in his shut- off life. He may have felt some recognition from society by their acceptance of his working disability (due to back ache). It might then have been easier for him to accept parts of his own insecurity and its relation to his mistrust and social anxiety. Sixth, medication of overt aggressive behaviour and (concurrent) individual psychotherapy should be considered as an alternative before referring the paranoid personality to the specialized group treatment programmes.

150 CASE 2: Theo: Paranoid Personality Disorder Country of origin: The Netherlands Author: Dirk Corstens

Identifying data Theo was a 22 year old unemployed male, who was referred to the outpatient department of a psychiatric hospital by the social security service of a moderately sized town.

Presenting complaint Anger about not getting the payment he was entitled to.

Present History Weekly Theo had to fill in and deliver a form for the Social Security Service in order to get his money. He knew that when he delivered the form too late he would get less money. When he actually came a day too late to give his form to the social security officer, he verbally attacked the officer from the start. The officer simply closed the window between him and Theo and, because this wasn’t the first time Theo was that angry, said he should first go to the psychiatric hospital for treatment in order to get his money. Theo lived with his 16 year old girlfriend in an apartment building where, according to Theo, many drug-addicts lived. In the building came many dealers, there were regular fights between other inhabitants in the building. Theo had many locks on his door to prevent other people from breaking in. Burglars were all over the place. He had a dog to protect him and daily smoked about 5 grams cannabis, hashish, from his water pipe to diminish his anxiety. He was eager to move to a safer place. He had almost no friends apart from his girl friend. He knew many people, but he did not want to call them “friends”. He cooked for her and stimulated her to do her homework for school. He cared for her like a strict father. About her undisciplined behaviour they had many rows. Theo came to the department on his moped. He stated that he made a two hours long ride to prevent the police catching him. Normally he could reach the clinic in twenty minutes. The police wasn’t searching for him, but he was afraid of being caught because of his abnormal appearance.

Mental status Theo is a tall and solid young man with long blond hair and high boots with long pointed noses. He didn’t want to sit in a chair and walked agitatedly through the consulting room during the initial interview. He talked constantly, was angry and threatened everybody whom he was angry at. The questions the interviewer asked were often rejected as too offensive. In spite of this there was some establishment of contact with the interviewer. Although Theo’s thinking was suspicious and paranoid, there were no obvious systematic delusions. He denied having had hallucinations. His mood was not depressed, his prevailing affect was anger. Underneath this anger his anxiousness was clearly visible. He felt unsafe in his environment and was constantly on guard. He didn’t use other drugs or alcohol. He didn’t have a criminal record.

Family and social history Theo had a sister who was two years younger than him. His parents divorced when he was twelve years old. This was a significant event in his life. Before this he performed well at school. He recalled a happy childhood, playing with friends and he had an orderly life at home. His parents quarrelled sometimes, but in general the atmosphere was friendly. He couldn’t describe his parents’ characters and habits very well. The relationship with his sister was distant. Father worked as a plumber, mother did the house hold. After the divorce his life changed completely. He still was angry at his

151 parents for the divorce when he talked about it. He couldn’t explain why his parents separated. Initially he came to live with his mother, together with his sister. After a year or so he started to use amphetamines (speed) more and more. He became a member of what he called the “speed scene”, people who hated heroine or cocaine addicts. People, who listened to specific music, wore specific clothes, etcetera. People who had their own behaviour codes. Although he performed well at secondary school (MAVO), he spent nights with his friends and occasionally was involved in theft. The relationship with his mother became quarrelsome, at last he moved in with his father. Soon his father also got angry at him and he left home. Theo didn’t tell much about this period, at the time of the interview he showed much shame for it. At last he passed his school exams, when he was seventeen, while he was heavily addicted to speed. He did some cleaning jobs afterwards, stayed with friends and only occasionally met his parents. He had short intimate relationships. When he was nineteen he had to go into the military service. There he stopped using speed and became, after a short soldier training, an assistant to the dentist in the Military Hospital. Because of his anxious behaviour, he was sacked from the Service after one year, before he completed his term. He speaks of the Service as the best period in his life. It was a structured life and as a medic he was appreciated. Ever since then, he was unable to get a job and lived in his small apartment. He had met his girlfriend a year before the initial interview.

Medical history Theo suffered from nephrolithiasis. He had recurrent colic attacks. His dental status was bad due to a long history of neglect. He was extremely frightened of operations and the dentist, mainly because he was not in control then. He assumed that his demands, narcosis during dental examination and avoidance of surgery, wouldn’t be met.

Treatment history It cost the author about three interviews to understand what Theo needed and to establish some form of working alliance. Because of his angry presentation, his avoiding attitude regarding questions and the anxiety he provoked in the interviewer, we spent much time to become at ease with each other. Medication was not negotiable, neither benzodiazepines nor anti- psychotics. When the interviewer finally understood that he was out of money and that he was very afraid of having to live on the streets again, a phone call to the Social Services officer and an explanation of Theo’s behaviour, that was motivated by projective identification, was enough to re-establish the relationship with the Service. Theo was very grateful for that and became much more at ease with the author. Gradually he came to trust the author more. He even could tell his life history in an orderly manner. He asked the author to motivate his girlfriend to finish her school properly. He was worried that she wouldn’t pass her exams if she didn’t do her home work. His nice young girlfriend appeared to admire Theo and was really in love with him. She also had a history of parental divorce at a young age, she thought of Theo as her safe haven. Theo helped her with her homework and planned their life. Theo demanded that she should perform well at school. Their sexual relationship was good. He had no reason for jealousy. Both used cannabis, although Theo took care that she didn’t use as much as he did. The conversations between the author and them helped him to regain more trust in her. His entitlement diminished gradually. He said that he really was afraid in the apartment building he lived in. He asked if the author could help them find a safer living environment, preferably in a village where no drug addicts lived. Some phone calls to the administration made this possible in about a year. Again Theo was very grateful. Meanwhile Theo had some severe colic attacks. He refused going to the general practitioner. The author told him that nephrolitiasis could be treated without surgery, by ultra sonic crushing. He liked this idea and asked for an admission, although he insisted that he could not do without his water pipe. We asked and got an admission on the psychiatric ward, where he was permitted to regularly smoke his water pipe in order to diminish his anxiety for the medical treatment. The stay on the ward and the nephrological treatment went well. It took one week. In the same week his teeth were looked after

152 and treated under narcosis. After all this happened, and Theo and his girlfriend went to live in a small house in a village, he felt much more safe and was looking for a job as a mechanic, something he had always dreamed of. The author met Theo when he worked as a psychiatric intern in a psychiatric hospital. After half a year the author moved to another city, Theo didn’t want to go to someone else and visited the author regularly for three years total. He was never late for his appointments. After these three years it was possible to refer Theo to his general practitioner.

Editorial comment Sometimes it is difficult to differentiate between a paranoid psychosis and a paranoid personality. Patients with a paranoid personality disorder have no systematized delusions. They are suspicious and their prevailing emotion is anger. This case vignette illustrates the important issue of how anger affects the therapeutic alliance. It is often very difficult for the therapist to contain the patient’s anger. These patients provoke fear in their caretakers. However, it is important to realize that underneath they, themselves, are afraid. With this patient, it seemed helpful that the therapist explained that he provoked fear in him. Psychotherapy is often a difficult goal to achieve because of the general distrust of the paranoid personality. Creating a safe haven can stabilize the underlying anger and the anxiety.

153 CASE 3: Sara: Borderline Personality Disorder Country of Origin: Scandinavia Author: Morten Kjølbye

Identifying data Sara is a 26 year old female. She has not been able to complete any education and is unemployed. At the age of 23, she initially contacted the general practitioner after the death of her grandfather, to whom she was very much attached. She had initially been treated by a psychiatrist in private practise before being admitted to hospital and referred to a specialized outpatient unit for treatment of personality disorder.

Presenting complaint Sara’s presenting complaints were suicidal thoughts and self-destructive behaviour.

Family and social history Sara is an only child, but grew up with two maternal half brothers, who were 7 and 8 years older. She described her home as very poor because of both the parents’ alcohol abuse. The father was described as aggressive, often drunk, but at the same time quite helpful and caring towards Sara, when he was sober. When drunk, he was often violent, especially towards the two brothers but occasionally also towards the mother and Sara. Sara was the only one that could stop the father from hitting, and therefore, from the age of 5, she had the position of a “go between”. She often refused to leave home and often stayed away from school, because she was afraid that the father would kill the mother if she was not there to protect her. The mother is described as fragile and suffered for many years from fibromyalgia. Quite often she was heavily sedated, due to a combination of alcohol and pain-killing drugs. Sara describes her mother as loving and loveable, and she has a good relationship with her but not with her father. During her childhood she was frequently looked after by her grandparents, and stayed for long periods at their house. She thinks of them as her real parents. The grandfather is described as loving, caring and humorous, while the grandmother is described as loving and tender. Her first recollection is from the age of four. She could not find her small, red purse and the father consequently blamed the brothers for taking it. When they denied this, he was infuriated and beat them up. Some days later Sara found the purse among her toys but was too afraid and ashamed to tell her parents, so she threw away the purse. Sara went to various schools but was eventually thrown out of school because of too much absence and has not been able to succeed in any further education. Since the age of 11 Sara has had many boyfriends and has had sexual contact since the age of 14. Although she had one longer relationship for about 7 years, it was quite unstable, because she had several short termed sexual contacts during this relationship. Since the age of 16, when she left home, she has never slept a night alone. A typical pattern is her frantic effort to avoid being alone. She therefore has a list of potential boyfriends, who have been ready to come at her command. The relationships are often characterized by frequent conflicts and impulsivity. At one time she threw her boyfriend out of the apartment because of a small disagreement; then she got heavily drunk and had sexual intercourse with a stranger. The next day she was remorseful and in a flood of tears she was reconciliated with the boyfriend. At the moment she is living with a new boyfriend at about the same age. He is educated and has a steady job. He is described as quite tempered but loving. Sara is living on sickness benefits.

History of present illness

154 Since her childhood, Sara has complained of unstable mood, aggressive temperament and a tendency to be self-destructive, by banging her head against a door. At the age of 10 she was sexually abused by a 60 year old man, and since then she has had continuously suicidal thoughts. The mother was at that time working as a nurse visiting elderly and sick patients in their private homes. The mother took Sara along with her on these visits, and she was first lured to have sexual intercourse with this man and then threatened to continue the sexual relationship over the next year. However, the neighbours got suspicious and alarmed the police. The elderly man was convicted and transferred to a mental home. At the age of 11 Sara had her first boyfriend. She had suicidal thoughts and persuaded him to buy some medication for her, so that she could commit suicide. The boyfriend first agreed but then told the story to one of the teachers. He intervened and contacted the family, but after a single talk with the school nothing happened, and Sara felt abandoned. From the age of 13, Sara has had several sexual partners, who often were several years her senior. She dropped out of school because of too much absence, and has been living on sickness benefits, interrupted by short periods of unskilled employment. Three years ago her beloved grandfather died and she reacted with marked deterioration of her psychic condition, with vivid suicidal thoughts and devaluating herself. She developed the thought that she was fat and ugly, which is in sharp contrast with her actual good looks. She had also concentration problems and felt quite depressed. The general practitioner transferred Sara to a psychiatrist in private practise. For 3 years she was treated with excessive medication, SSRI’s, mood stabilizers, anxiolytics, and neuroleptics. After a suicidal attempt, Sara was admitted to hospital with suicidal thoughts and symptoms of depression. On the morning of the admittance she was sluggish, brief in her answers and with depressed mood and suicidal thoughts. However, the next day Sara had quickly got in contact with the others patients and was engaged in vivid conversations. During the second interview in the afternoon Sara was smiling and gave a good contact without delay in her response to questions. Sara was discharged with the diagnosis of personality disorder but was re-admitted a couple of day’s later because of suicidal thoughts. After a brief stay at the hospital she was transferred to a specialized outpatient unit for treatment of personality disorder.

Mental status Sara came to several assessment interviews in the outpatient clinic. She was a slim, good looking young female, but she walked without the normal swinging of the arms, and her appearance was a bit like a chronic schizophrenic patient. In the beginning of the first interview, Sara was quite nervous and felt insecure about what was going to happen. She had a fantasy that the interviewer would turn her insides out, and that she would not be able to defend herself. Sara told the interviewer, that just before her arrival she had a feeling of anxiety, which was relieved by suicidal thoughts. She admitted that suicidal thoughts generally made her feel more comfortable and secure. In the first interview, which was in the afternoon, the interviewer had the impression that Sara was sedated, which she totally denied, although she admitted that many of her friends and her boyfriend often had said so. In the following interview, which was in the morning, she was quite heavily sedated and now told the interviewer, that she normally slept additionally 3-4 hours during the morning because she felt tired after taking the medications. She was on SSRI’s, mood stabilizers, anxiolytics and neuroleptics. Her facial expression was stiff and her speech was a bit snuffling and throaty. She did not present any psychotic symptoms, nor any depressive hallucinations or ideations. During the interview she became more and more relaxed and was stunned by the fact that she never had the thought or was told that her suicidal intentions and the deterioration of her psychic condition had anything to do with the death of her grandfather three years ago. The SCID-II interview disclosed that Sara tried to avoid being alone and had very unstable relationships. She had difficulty describing herself and complained of having problems in holding

155 onto stable goals and thus demonstrated identity diffusion. She complained of impulsive behaviour with self-destructive tendencies. Her affect was instable; she had a craving feeling of emptiness and often reacted to stressful situations with paranoid ideations. She felt inferior and worthless, and had several sexual contacts. Also she tried to avoid contact with unknown people, because she was afraid of being rejected and was preoccupied by the thoughts of being criticized. But when she felt lonely she drank alcohol and plunged herself into relationships. She fulfils the criteria for borderline personality disorder and evasive personality disorder.

Medical history Sara never suffered from any serious illnesses.

Treatment history When she was 23, Sara’s grandfather died. She reacted with depressive symptoms and suicidal thoughts and was by her general practitioner transferred to a psychiatrist in private practise. He evaluated Sara as being depressive, but the above precipitating factor was never discussed. She was treated with an SSRI but without effect. Another SSRI was tried but also without any effect what so ever. Then a mood-stabilizer was added, also without effect. Sara became more and more anxious and was therefore prescribed additional anxiety reducing medication, but only with the effect that she became more tired and sedated. Sara had continuously suicidal thoughts and self-destructive behaviour. She threatened with suicide and cut herself badly with a razorblade several times. Then an antipsychotic drug was applied, also without convincing effect. Sara’s psychic conditions continued to deteriorate; she became more and more self-destructive and had suicidal thoughts. She wrote down in her diary a departing letter, conveyed that she saw no solutions to her problems, that she loved her family and her boyfriend dearly, and that she was very sorry that she had to commit suicide. She wrote that she wanted to die and that it was nobody’s fault. She expressed the wish that she would soon be sitting in heaven by her grandfather’s side. Although her boyfriend read her diary, he did not react on this. Neither did the psychiatrist in private practise react to a letter Sara sent to him, in which she informed him how she wanted to be buried after her death. At the assessment interview, in the outpatient unit, she came in touch with feelings of being let down by both her boyfriend and the psychiatrist. This resulted in a rage which left her in a paralysed state, followed by suicidal thoughts and an urge to leave the session and cut herself. However, she was able to endure her feelings and stay in the interview. Sara was offered a two year psychoanalytic treatment program containing one individual session and one group session a week. In addition, the program included psycho education, where she and other patients were taught the characteristic features of borderline personality disorder, the dynamics of borderline pathology with a special focus on self-destructive behaviour and correlated problems. The pharmacological treatment was slowly reduced and finally ceased after 6 months of treatment, with quite a striking effect. She quickly became less sedated and less anxious. In the beginning of the psychotherapeutic treatment she was quite self-destructive but after 3 month the self-destructive behaviour ceased and Sara became more in contact with her feelings of aggression and sadness. Towards the end of the first year of treatment Sara began going to school, with the intention of taking a degree, so that she could eventually become a teacher. The relationship with her boyfriend became more stable and satisfactory, and she began to have more stable contacts with school-comrades. She also stopped having conflicts with her teachers and her ability to begin to contain feelings increased dramatically.

Differential diagnosis

156 Sara was by the psychiatrist in private practise and the general practitioner seen as being depressed. However, the depressive symptoms were neither linked to Sara’s family situation nor the sexual abuse or the grandfather’s death. The depressive state continued despite medical treatment and her self-destructive behaviour became more apparent. These two circumstances should have alerted the psychiatrist in private practise to the possibility of a personality disorder in general and a borderline personality in particular.

Editorial comment The clarity of this case description is excellent. The vignette describes a characteristic developmental pathway leading to borderline personality disorder, along with a characteristic treatment trajectory of the borderline patient. Many patients with borderline disorder access a number of treatments before they are offered the most appropriate treatment. This patient experienced sexual abuse, and appears to have had a precocious sexual development having her first boyfriend at the age of 11 and having had several sexual partners from the age of 13. Interestingly, this patient had a key figure of a grandfather who may have acted as a stable attachment figure. On clinical rather than empirical grounds, we often find that the presence of a stable attachment figure within a family in chaos can represent a reasonable prognostic feature. The stable attachment figure is often a grandparent. The difficult treatment history shows how patients are commonly treated initially with antidepressants. Mood stabilisers are added and when those don’t work, anti-psychotic medication is added. Research shows that borderline patients tend to be taking a number of different classes of medication after a few years of treatment. This possibly represents much of the desperation experienced by practitioners who find themselves offering inadequate or inappropriate treatment. It is notable that at the beginning of structured psychotherapeutic treatment, the self- destructive acts of this patient decreased remarkably quickly. This is a common finding in research. As soon as a well-structured and coherent treatment programme is organised, self-destructive activity tends to decrease.

157 CASE 4: Jane: Borderline Personality Disorder Country of origin: UK Author: Kate Davidson

Identifying data The patient was a thirty three year old woman who trained as a nurse but at the time of referral, was unemployed. She was initially seen by the community mental health team because of depression and self-harm and was referred for cognitive therapy because of her persistent self harm and low mood, neither of which had responded well to antidepressant medication.

Presenting complaints Complaints: self-mutilation, low mood, hopelessness, difficulty with relationships. Had difficulties with staff of the community mental health team and had made an official compliant against a member of staff.

History of presenting complaints Jane initially took an overdose of her mother’s tablets at age fourteen when she felt unable to cope with social situations at school and her family situation. Following the overdose, she was referred to a child psychiatrist but her parents decided that she should not attend the appointment. Jane thought that the main reason for this was that her parents were embarrassed by the overdose as both were health professionals and known locally. Over the next years of her adolescence, Jane began to cut herself with her father’s razor and discovered that this relieved some of the tension she experienced. Her scars went undiscovered as she cut herself on her thighs and upper arms, parts of her body she never uncovered. During this time, Jane described frequent spells of low mood but she sought no help. In her early twenties, following the end of a brief relationship, she took another overdose of paracetamol. Following admission to Accident and Emergency, she was referred to a psychiatrist. He diagnosed depression and began treating her with antidepressants. She found these relatively helpful at first but gained a significant amount of weight, adding to her feelings of worthlessness and self-disgust. Between the ages of twenty-four and thirty-three she had taken a further three overdoses, two of which had required medical treatment. Her liver was now damaged as a result of paracetamol overdose. She had been treated with antidepressants off and on for over ten years when she was referred for cognitive therapy. Her diagnosis was changed to one of Borderline Personality Disorder at the age of twenty-eight.

Mental status Jane presented as a medium height, overweight, woman who looked older than her thirty-three years. Although she seemed withdrawn or shy at first, she became quite angry and hostile, then tearful and remorseful during the same session. Her mood was changeable but overall appeared to be low. Her thinking was clear and she gave a coherent account of herself.

Family and social history There was no definite history of mental illness in the family. Her mother was still alive, aged seventy, and was described as being critical and overbearing particularly towards the patient. Her father was described as having been quiet and rather weak, allowing her mother to dominate. Both parents were nurses and worked full time when she was young. Her father had been in a relatively senior management post when he died of a heart attack, aged fifty-seven. The family lived in a small modest house in an estate near the local hospital. The family was Catholic and church going was regular.

158 At the age of fourteen she took an overdose. She felt she was unpopular at school due to being teased by her classmates for being overweight and unattractive. Her mother also put pressure on her to be slim “like her other sisters” and her father was disapproving of her lack of interest in her studies and impatient about her difficulties at school. Jane thought she was different from other girls at school, a fact that was emphasised by her mother repeatedly commenting to her that other girls were going out with boys when they should be at home studying. Both her parents compared Jane to her older sisters and brother who were thought of as being more able students, good at sports and popular. She said she felt miserable as an adolescent as there was often tension at home when she was a child as her parents argued a lot. She tried to gain her mother’s affection by carrying out household duties but was only given more chores as a result. She felt unappreciated and used by her parents. Her mother preferred the children to come straight home from school and discouraged extra curricular activities, except those involving church activities. Although Jane had no close friends at school, she had some friends through a church group she attended. According to Jane, her early development was normal though she thought she was not as academically able as her older sisters and brother. She had difficulty with arithmetic and spelling at school and had to have extra tuition for these subjects in primary school. She struggled academically at secondary school but completed her education at age seventeen with just enough exam passes to get entry into nursing college. She was unsure about her decision to become a nurse but wanted her parents’ approval and as they were both nurses, she chose this option. Her years at nursing college were amongst her happiest. She was able to excel in the practical ward-based work and coped reasonably well with her studies. She lived in the nurse’s accommodation and, for the first time, was able to make friends through work. She had no boyfriends until she formed a relationship with a foreign doctor whom she did not know was married. This was her first and only sexual relationship. She ended the relationship when she realised he was married. She felt used by him and took a serious overdose with the intention of killing herself because she thought she would never be able to develop enough trust to form another relationship. She stole the medication that she took in overdose from her workplace and when this was discovered she was disciplined and charged with theft. She resigned from her training at this point and never worked again. She was referred to psychiatry at this point. Jane had two older married sisters, both of whom were teachers and lived locally. One of her sisters had two daughters. Her older brother was divorced, worked in sales, and lived in another part of the country. She was currently unemployed and on a low income.

Medical history Birth and early development was normal. The patient had liver damage as a result of paracetamol overdose. She was obese and complained of stiffness and sore joints.

Treatment history Cognitive behaviour therapy (CBT) is a relatively brief, time limited structured therapy. It has been adapted for the treatment of personality disorder and can be delivered over a twelve-month period to good effect. In Jane’s case, therapy continued over a slightly longer period. The therapist saw Jane weekly for one hour at the beginning of therapy and then fortnightly for a period of six months. Sessions were then continued monthly for another nine months until the end of therapy when sessions were weekly for four weeks. Cognitive behaviour therapy relies heavily on case formulation – a description of a person’s presenting problems that explains the processes that cause and maintain the problems, guided by a theoretical model. The first CBT sessions involved identifying Jane’s current problems, the relationship between her thinking, mood and behaviour and the possible underlying psychological mechanism accounting for her problems. Jane’s main problems were deliberate self-harm, mainly cutting herself on a daily basis, feelings of anger at some staff in the team whom she thought had

159 treated her badly, guilt at having made an official complaint against a member of staff, low mood, social isolation, and being overweight. She held several key core beliefs about herself and others. These beliefs were “I am no good,” and “nobody could like me“ and “other people will use me and let me down.” Jane’s behaviour was characterised by self-neglect and punishment. Not only did she mutilate her body through cutting, she also scalded herself with hot water from time to time. She either did not eat properly or gorged herself on fatty foods and spent large parts of her day either trying to sleep or watching television. She found no pleasure in activities and her daily routine was unstructured. Her past history suggested that Jane’s beliefs about herself and others had developed as a result of her childhood and adolescent experience. Her mother, in particular, had been critical of her, comparing her negatively with others, including her sisters and brother. Her low self-worth had arisen from her family’s attitude to her, the lack of affection and lack of appreciation shown to her, her inability to control her weight and her difficulties at school. Her self-punitive and self-negligent behavioural strategies resulted from her sense of worthlessness. Her beliefs that others would use her or let her down were also directly related to her experience with her family and her past relationship and had led to her avoiding social contact so that she might not be hurt. The formulation was discussed with Jane at the end of the fourth session and she seemed satisfied that it fitted her. Although no direct intervention had taken place during the assessment phase of therapy to reduce self-harm, this had decreased in frequency over the five-week period. This appeared to be due to her having been listened to carefully by the therapist and her feeling validated and understood. Given Jane’s longstanding connections with the team and her likely need for psychiatric and nursing input in the future, it seemed appropriate to then discuss what had led to her complaint. It appeared that Jane had thought that several members of the nursing staff had ganged up against her and had stopped responding to her in a positive way. She had been making regular night–time calls to the emergency services and the team had decided not to follow-up these distress calls, even though she had threatened to kill herself. The therapist decided with Jane that she would investigate the allegations and brought the findings back to the next session. Apparently Jane’s calls had been so frequent they had been regarded as a nuisance rather than as genuine crisis calls and in addition, she had made several silent calls that had been traced back to her phone number. From the formulation, it was clear that Jane might interpret the behaviour of staff who were not responding to her calls as her being let down by others. When asked about her interpretation of their behaviour, she confirmed this prediction and added that the nursing staff were paid to help people like her, not ignore her when she threatened to kill herself. The team formed Jane’s main contact with people and she was able to admit that she had become dependent on this contact, hence her anger at their non-response. Therapy focussed on helping Jane to view of her behaviour from the standpoint of a member of staff, then attempting to get her to think of more effective ways of getting help when she needed it. Jane described how she had felt isolated from others and alone with her distress and she did not know what to do about this. She cut herself either as a way of relieving the tension she experienced or distracting herself from the painful feelings she experienced. The therapist then focussed on what could she do instead of cutting herself. Gentle emphasis was placed on when she did cope without cutting or overdosing by asking about these occasions and making a note of them. Slowly Jane built up some ideas about what she could do instead of cutting. The therapist was attempting to build up Jane’s strategies for self-nurture here, rather than Jane’s overdeveloped strategies of self-punishment and neglect that led to self-harm. Jane decided her main self-nurturing strategy was to lie on the sofa with a blanket around her and watch a video of her favourite television programme. If this was too difficult because of the strength of her distressing feelings, she would try to do something less harmful to herself but distracting, such as running very cold water over her arms or legs. In addition, the therapist explored the types of activities Jane had done in the past that gave her pleasure and discovered that she was a keen embroiderer and had been good at art at school. Motivating Jane to begin these tasks again could have been problematic. She might resist if she thought it might imply

160 she was more able than she thought herself to be and therefore less needy of help from the team. The therapist instead gently explored why Jane had stopped doing things she previously enjoyed and what she had got out of these activities in the past, whilst acknowledging the difficulties of taking steps to make more positive changes when she still felt so low. Over the following four months, therapy focussed on building up Jane’s repertoire of behavioural strategies that were self-nurturing such as eating regular healthier meals, sleeping only at night, slowly increasing her activities in her home and through the local authority she attended a day time art class. Her belief, “I am worthless” was weakened by building up an alternative belief, namely, “I am okay”. Evidence for this new belief came from her artistic abilities, her reduction in self-harm, and that she had intrinsic worth as an individual and had survived a rather emotionally deprived and critical family upbringing. Her belief that others would let her down was founded in evidence from her past. However, over her time in therapy, she and the therapist worked on a historical record that emphasised other relationships she had in her past with people that had not let her down or used her. These included friends from the church group and nursing friends, one of whom she met again. Although she was never able to fully trust that others would not let her down, she did take the risk of getting to know new people through her art class on the basis that she would at least feel less isolated, even if some people might let her down. Jane had to learn to take the development of relationships more slowly and to be less intense with others so that she did not overwhelm them with her problems and risk alienating them. The most significant change was in her relationship with her mother. She had been visiting her mother every Sunday before therapy began and had found this resulted in her feeling angry and humiliated in response to her mother’s negative comments. Having gone into the pros and cons of contact with her mother, she reduced the number of visits to her mother and took the initiative in inviting her mother to her home instead, along with her nieces. Taking control in this way, and asserting herself with her mother, was a great relief to Jane and raised her self-esteem hugely. Her relationship with her nieces also proved to be satisfying. Rather surprisingly for Jane, her mother appeared to be impressed by her ability to engage her young nieces in play and activities. At the end of therapy, Jane was less isolated, had more contact with others, had more structured days, was able to find pleasure in activities and was not cutting herself. She was still at risk of feeling low but managed these occasions by telephoning people she knew or using her “lying on the couch with a video” strategy.

Differential diagnosis The case illustrates an individual with a diagnosis of borderline personality disorder. The patient described may also have met criteria for a diagnosis of major depressive disorder at various times.

Editorial comment This clinical vignette describes the treatment of a borderline patient using cognitive therapy. The patient shows a number of symptoms and behavioural problems typical of BPD. The patient self- lacerates, she has taken an overdose in the past, and shows affective instability. Interestingly, she can be withdrawn and shy but also can become sensitive, leading to rapid expression of anger and hostility and other mood fluctuations. This usually means that therapists have to be extremely careful within their treatment if they are not to stimulate a negative therapeutic reaction. The treatment with cognitive therapy starts with a more intensive treatment of weekly sessions which are then reduced to fortnightly and then to monthly until the end of therapy when sessions were offered weekly again for 4 weeks. This is an interesting phasic treatment approach to BPD. Reducing the level of contact over the whole treatment is replaced by an increase towards the end of therapy. Many people may worry that this would create increasing dependency on the therapist just at the time when the patient was trying to gain some independence. However, this appears not to have occurred in this case.

161 A further learning point from this vignette is that it is unclear whether some of the change that appears to have occurred is related to the interventions or is possibly part of the non-specific effects of good therapy. This applies to all the other clinical vignettes. It remains unclear whether the interventions that we actually make and many believe are useful to aid the change in patients are actually the causes of that change. One aspect in the treatment of borderline patients is that maintaining a positive therapeutic alliance and repairing therapeutic raptures is likely to be as integral to change as any specific intervention, such as identifying core beliefs, mapping schemas, or making transference interpretations. Again, it should also be noted that this cognitive therapy was provided over the longer term rather than the shorter term.

162 CASE 5: Ellen: Borderline Personality Disorder Country of origin: Canada Author: Joel Paris

Identifying data The patient is an 18-year old woman attending school who referred herself to a psychiatrist.

Presenting complaint Suicidal ideas.

History of present illness Ellen’s best friend Carla recently committed suicide by jumping off a bridge. The two were very close; Carla had wanted them to commit suicide together, but Ellen refused. Since the suicide, however, Ellen felt an increasing compulsion to join Carla in death. Ellen was living with her older sister and brother-in-law, having been taken away from her parents by a social agency several years previously. Ellen was currently obtaining high marks in school. However, she was cutting her wrists repetitively to deal with emotional dysphoria. At the same time, Ellen was obsessed with a fantasy world in which she imagined herself living on another planet with an entirely different group of people. She heard their voices speaking to her from time to time, and sometimes believed she could join these people if she were dead. At the same time, Ellen realized that these ideas and experiences were imaginary.

Mental status Ellen was a pleasant and intelligent adolescent who spoke with a certain eloquence and smiled a great deal, but was uncomfortable with her own feelings. Her inner emotions were described as intense but transitory, depending on events during the course of a day. Her preoccupation with suicide seemed to provide some hope of escape, as did her fantasy world, about which she was not truly delusional.

Family and social history Ellen was the youngest of 3 children who had been born to her mother, each by different men. The mother had long been a severe alcoholic, and had been seen in psychiatry for suicide attempts. When Ellen was an infant, her mother was unable to care for her, and the father, who was described as a strange, paranoid man, had left the home. Ellen was placed with an elderly woman who raised her for the next five years. When the foster mother died, Ellen lived with her mother for several years. However, this situation proved to be chaotic, and Ellen ran away. After jumping off a balcony, Ellen was evaluated in child psychiatry. For a time, Ellen also stayed with her father (around the age of eleven), but this placement led to at least one episode of incest with full intercourse. Ellen was again evaluated by a social agency, leading to her placement with her sister.

Medical history No history of serious medical illnesses.

Course and treatment history Ellen spent the next two years in psychotherapy. Her course was chaotic and troubled, and she had a psychiatric hospitalization for threatened suicide, as well as a medical hospitalization for an overdose. In spite of her chronic suicidality, she continued to do well in school. Ellen was treated almost entirely with psychotherapy, once or twice a week. Most of the issues in the therapy concerned her feelings about her chaotic past, her guilt about the death of Carla, and

163 her difficult relationship with her sister and mother. Ellen had many crises, and her attachment to the therapist was expressed on one occasion by carving his name on her wrist. Although she was being seen regularly, Ellen had difficulty maintaining a connection with the therapist between sessions, which she dealt with by writing a large number of letters to him, which she eventually deposited in his office. At the same time, Ellen was concerned that the therapist would behave towards her as her father had, and expressed relief that this was not happening. On the anniversary of Carla’s death, Ellen became more suicidal, and was briefly admitted to a psychiatric ward. The main benefit of hospitalization was that a psychologist on the ward conducted family therapy with her sister and brother-in-law, helping them to work out their interpersonal conflicts. At this point, Ellen was prescribed a low dose neuroleptic (trifluoperazine 5mg), which she took for 3 months. She then took an overdose of her medication, leading to a brief medical admission. After that, no further pharmacotherapy was prescribed. By the end of the 2-year period of treatment, Ellen was more stable in her emotional responses, had stopped cutting herself, and no longer felt suicidal. Moreover, she no longer thought about her fantasy world, or had any further pseudo-hallucinations. However, Ellen’s impulsivity and dependency expressed themselves in the manner in which she terminated this course of therapy. After starting a relationship with a new boyfriend, Ellen left treatment angrily when the therapist asked her questions about why she was getting involved so quickly. Most probably, Ellen felt ready for more autonomy, but could not work through a formal termination. Ellen called the therapist back two years later, asking for the return of the packet of letters she had left with him. By that time, she was attending university and still involved with the same boyfriend. Ellen was interviewed for a follow-up study of borderline personality disorder at age 26. She was working, and was in a stable marriage (with the same man). There were no psychiatric symptoms, and Ellen attained the highest GAF score (80) of any subject in the 15-year follow-up study. At age 31, Ellen returned for a further course of sessions with the same therapist, which lasted for another l8 months. By that time she had given birth to two young daughters. She was primarily concerned that she might damage them as her mother had damaged her. If anything, Ellen now functioned as a “super-mother” whose constant activity was designed to avoid any disaster. Her own mother, still actively alcoholic, was back in her life, and Ellen felt she had to take care of her. Most of the therapeutic work consisted of helping her to establish better boundaries in that relationship. In doing so, she became less anxious about her management of her own family. Ellen also showed resourcefulness in becoming involved in activities outside the family. She worked part-time for a printing company, and was also involved activities at the neighbourhood school. Ellen came back once more for a shorter course of therapy (about 6 months) at age 35. At this time, the discussion focused more on her feelings about men. Her father was dying, and she had borne a third child, this time a son. She was also concerned about her husband, who had been treated for pericarditis, and who worried her by his heavy use of marijuana. At the time of the last follow-up interview, in 1999, Ellen was 38 and happy with her marriage and her children. Her husband had become successful in business, although Ellen continued to be upset about his cannabis dependence. While her mother continues to drink, she is no longer creating a great deal of trouble. Ellen’s main regret at this point is that she has not been able to launch a career. She has a BA and wants to use her brain, and might go back to school when her son is in first grade. Ellen now experienced no symptoms at all, with the exception of mood swings that she describes as being of manageable proportions.

Differential diagnosis

164 As with other borderline patients, Ellen showed extensive Axis I comorbidity. At various times, she at least met criteria for major depressive disorder and for brief psychotic episode. However, the overall course of the illness could only be accounted for by a personality disorder diagnosis.

Editorial comment This admirably clear and succinct case discussion, demonstrates the common behavioural problem of self-laceration and suicide attempts which are found in borderline patients. Around 60-70% of borderline patients self-harm or attempt suicide. During the course of treatment, the patient had to be hospitalised for threatened suicide. This is a common reason for hospitalisation of borderline patients. It is important to note that it may be necessary to admit a patient as a result of an acute suicidal episode but, in general, psychiatric hospital admission does not reduce the long-term risk of borderline patients. Further, the risk of suicide of borderline patients appears to lessen when they are in treatment. The greatest risk occurs when a patient has experienced a series of failed treatments. This leads them to give up eventually. At the point of which they feel life is no longer worth living and they are not being offered further treatment, they may make a serious suicide attempt, which of course may be successful. The author also states that this patient had difficulty maintaining the connection with the therapist between sessions. She dealt with this by writing a large number of letters to him. This contact between patient and therapist between sessions is another feature that therapists have to manage during the treatment of BPD. In terms of mentalization, our view would be that patients with BPD have difficulty in retaining an image and inner feeling of their therapist having them in mind. When they lose that experience in their mind, they react as if “out of sight is out of mind” and have to contact the therapist in some way. Patients may telephone constantly, seeking out the voice of the therapist or write to her/him or even turn up at the consulting room. Therapists need to have ways of managing this aspect of treatment. The patient terminated therapy impulsively, at the point at which she started a relationship with a new boyfriend. She appears to have reacted with some over sensitivity and perhaps paranoid reaction when the therapist asked her questions about her rapid level of involvement with the boyfriend. Over- sensitivity is very common in BPD and results from difficulties in understanding the motivation behind the question. This is an example of a failure of mentalization within the context of attachment relationships which we consider a core feature of BPD. Despite this breakdown in the therapeutic relationship the patient returned to therapy at a later time with the same therapist which is often a hallmark of sensitively given treatment. Overall, this vignette illustrates a successful treatment with psychotherapy over a long period of time.

165 CASE 6: Peter: Narcissistic Personality Disorder Country of origin: The Netherlands Author: R.E. Abraham

Identifying data The patient is a 42-year-old man who after successful treatment for alcohol abuse was referred to a private psychiatrist for further treatment.

Presenting complaint Symptoms of depression which did not respond to anti-depressant medication.

History of present illness Until a year and a half ago, the patient was a town councillor in a provincial town and chairman of the regional chapter of a green party. Following his arrest during a police raid on a brothel in the capital, the executive committee of the party forced him to resign from both positions. He protested vehemently against his removal, which he felt to be totally undeserved. He told his story to the media, and asked for legal advice, but without success. “Those small-minded people who’d always had it in for me finally got their way”. Some months later he began to suffer from depression and his already considerable consumption of alcohol increased still further, so that he was often drunk all day. It was at this point that he was admitted for clinical treatment for a period of three months. He then stopped drinking, although he felt this was ridiculous. He did so mainly to demonstrate that he is not an alcoholic. In his view, the treatment hasn’t changed anything. He still finds the present situation unacceptable, but he can’t see any way out. He feels empty and restless. He lies on the couch all day or watches TV. When the children get home, he withdraws into his study and plays “stupid” computer games for four or five hours at a stretch. He has no other activities. No weight changes have been recorded, but there has been some loss of libido. There is no history of mood disorders, and the patient has never been treated by a psychiatrist. Nor have any severe mood disorders been recorded in the family. A cousin suffered from depression for a time, but did not receive treatment.

Mental status Appearance conforms to actual age. Wiry build, sharp profile and shoulder-length curly hair. Presents a healthy appearance. Clothing is “artistic”, including a striking long, red scarf. In conversation the patient is self-assured, easily irritated, and quick to make devaluating remarks. Consciousness is clear, but the patient is occasionally preoccupied. When asked, he indicates that his thoughts sometimes wander, and that he finds it difficult to concentrate during “these kind of discussions”. Orientation and memory appear undisturbed. There are no perceptual or conceptual disturbances, with the exception of a marked preoccupation with the dead-end situation in which he finds himself. His mood is somewhat apathetic, but above all dysphoric. The feelings of the therapist are a mixture of irritation and compassion: “I feel powerless. All this man wants is for someone to undo the injustice which has been done to him”. And “It’s a shame, really. He’s clearly a man with many qualities”.

Family and social history The patient is the elder of two children. His sister is two years younger.

166 When the patient was five years old, the father, who worked for a large multinational, was appointed regional director in Indonesia. His mother remained behind because she did not want to leave her family, and while in Indonesia his father entered into a new relationship. Financially, he always saw that the family was well taken care of, but he never returned to Holland. The patient didn’t meet his father until he was at university and doing an internship in London, where his father had settled. He described him as man with class, who although he was amiable and generous, didn’t know how to deal with his son and kept the contact between them to a minimum. The mother had led a somewhat sheltered life. “She called my father a traitor, but she never made anything of her own life”. Where the children were concerned, she was over-protective, which he had always found irritating. “My sister is the spitting image of my mother. I have no contact with her”. There are no details pertaining to the patient’s birth and childhood, except that he was always ahead of his age. The patient went through elementary school and secondary school without difficulty. He was regarded as the life of the party, but always felt like an outsider. “They borrowed money from me and cribbed from me during exams. Outside of that, they didn’t like me very much. Thought I was sort of arrogant”. In his last year of secondary school he fell in love with the prettiest girl in school. She liked him, but refused to have sex with him, so he broke off their relationship. At law school it was the same story. He got high marks without having to work for them. He had a great many acquaintances, but no friends. He was also an excellent tennis player. In his third year at university he was elected president of the student body. In that same year he entered into a relationship with a freshman , a girl who worshipped him. They also had a sexual relationship. At the end of his fourth year, he resigned as president in order to take up an internship abroad. “That really threw me for a loss. As president, I was really somebody. Everybody wanted to know me, and suddenly that was all over. I was glad to get away”. After graduation his father helped him get a job with a top law firm. A few years later he became the youngest partner in the history of the firm. Meanwhile he and his girlfriend had married, since “she was counting on it”. They had two children, a daughter who is doing well and a son with only average abilities. He left the upbringing of the children to his wife, since ‘she didn’t have anything else to do.’ After that, boredom set in. “I was in my mid-thirties and I had everything: house, career, wife”. At work he was respected for his accomplishments, but he didn’t really belong. “I have a lot of acquaintances and business associates, but I don’t know how to make friends. And I don’t really need them. You end up having to listen to somebody when it’s not convenient for you”. Through his work he became involved with the green party. After having successfully represented them in a number of court cases, they asked him to become their regional chairman. He accepted. “Not that I’m particularly interested in the environment, but it sounded like an interesting job and I was already away from home a lot”. It was during this period that he started drinking heavily and visiting brothels. At home, sex was no longer exciting. “She’s a sweet girl, but that’s about it. Prostitution is a jungle. You’re a hunter searching out his prey in a world full of danger”. When he was offered the position of alderman three years ago, he accepted, and had his firm buy him out. “They were glad to get rid of me. Not that my work wasn’t good. But my extracurricular activities didn’t exactly reflect the firm’s image”. With regard to his arrest, he admits that it was his own fault. “I knew there were a lot of illegal women there and that the place had already been raided by the police. But that was part of the kick. Besides, those women couldn’t go to the police without giving themselves away”.

167 When asked about his present situation, he says his wife has indicated that she wants to give it another try. “In a way I’m glad, but on the other hand I despise her for taking the easy way out. And I’m not sure it’s what I want myself”.

Treatment history The therapist proposed that, to begin with, they could arrange for a limited number of sessions. When the patient asked what good that would do, he explained that it is often easier to get things straight in your own mind when you have to explain your reasons to someone else. The patient felt that this might be helpful. However, the proposed frequency - once every two weeks - was unacceptable. “I don’t want to go on that long”. The therapist agreed to weekly appointments. After two sessions he regretted having been so accommodating. The talks were extremely difficult. The client was not prepared to explore his situation, let alone his feelings, and blamed the therapist for the impasse. “I don’t why the hell I’m here. I’ve told you everything. There’s no use going through it all again. It won’t change anything. What kind of therapy is this anyway? And besides, there’s nothing you can do for me”. The therapist found himself dreading the following appointment. He felt powerless and was starting to wonder whether his proposal had been realistic. When the patient opened the third session by saying “Well, have you come up with anything?” he realized that he had been manoeuvred into the position of the underdog, and that the top dog was ruthlessly confronting him with his incompetence. He answered, “I get the impression that you’re not giving yourself, or me, a chance. I understand that you are deeply hurt and all you can do is lash out at everything and everyone, including yourself”. “That’s true”, the patient replied. “The same thing went through my mind a while back. But what else can I do?” “I can’t tell you,” the therapist answered. “But you are an intelligent and creative person, with no shortage of ideas. You’ve demonstrated this on many occasions”. During the rest of that session the patient talked about various possibilities which he had considered and why he felt they wouldn’t work. But his attitude was clearly less dismissive. The next time things again went wrong. It was as if the previous exchange had never taken place. “Talk doesn’t solve problems”. When the therapist said that he sounded angry and helpless, the patient denied this. But at the end of the session, the patient did say that he had called a former business acquaintance and made an appointment to meet. This meeting did not produce results. The patient apparently thought that everyone would be delighted to welcome him into the firm, but his friend only said that he would “look around”. Although the therapy sessions were still difficult, the patient did appear willing to talk about what he might do. One thing was clear: he wanted more than anything to regain his position in public life. This meant that on each occasion he came to the conclusion that the talks were useless because he couldn’t get what he wanted. The therapist confined himself to the remark that he had his heart set on that type of function, and rejected all other options. Indirectly the grandiose nature of his self-image also came up. For example, in referring to a TV documentary over the British aristocracy, the patient remarked that that kind of life would suit him quite well. Gradually the patient’s attitude was becoming less destructive. It was noteworthy that he never failed to keep his appointments, even though he had repeatedly described them as ‘useless’ or ‘unhelpful’. But that suddenly changed when the therapist announced that in a month’s time he would be unavailable for a period of three weeks. The patient responded to this by saying that he wanted to conclude the treatment at that time. He then cancelled his next appointment, and later wrote a letter saying that he was otherwise occupied in the coming weeks, and that he regarded the course of treatment as terminated. Some nine months later he wrote to the therapist, who ‘must be curious’ to know how things were with him. He lived alone in the capital and was now assistant director and head buyer for a

168 foundation which imported goods from developing countries. He said that wherever he went he was greeted as a king because he presided over the purse-strings. He said nothing about his wife and children. Nor did he indicate how he felt about the treatment.

Diagnosis and differential diagnosis With the exception of the preoccupation with wish-fulfilling fantasies, the patient meets the criteria of the narcissistic personality disorder. His attention to his appearance, the occasionally exaggerated nature of his verbal presentation and his sexual behaviour are characteristics which fit the histrionic personality disorder. The total absence of regret or guilt about what he has done to his wife and children may be seen as antisocial. Unfortunately, it is not clear why he broke off the treatment - in other words, how the therapist’s announcement concerning his coming absence had affected him.

Editorial comment The case of Peter presents a more typical description of a narcissistic personality – successful and influential struggling with boredom, loneliness, and feeling outside. He also showed risky behaviour, which was atypical and dissociated from his regular life style and functioning. In treatment he was distant and positioning himself out of reach of help, expecting the therapist to do the work towards meaning and change, and blaming the therapist when this did not happen. The therapist’s interventions, i.e., to acknowledge both the patient’s strengths, his creativity and intelligence, and his accompanying destructive tendencies towards himself as well as the therapist who tried to help him, proved useful as it diminished the patient’s destructiveness and built motivation to participate in the therapy. The dialectic between the patient’s low self-esteem and self- nullifying attitude, and his special expectations and grandiose wishes was well represented in the treatment. The therapist showed ability to both tolerate strong countertransference of dread, threat, and powerlessness, and to be honest and concerned, well aware of the risk for enactment and projective identification, i.e., to act on the patients negative attitude, blame and rejection. This example shows some of the challenges involved in treating the narcissistic patient in psychodynamic or psychoanalytic psychotherapy.

169 CASE 7: Carmen: Histrionic Personality Disorder Country of origin: Chile Author: Sergio Valdivieso Fernández

Introduction This case illustrates a histrionic personality disorder with a negative response to psychotherapy.

Identifying data The patient is a 25-year-old female Psychology student, who is in her last term at university and is currently looking for a hospital in which to finish her clinical training. She was evaluated by a psychoanalyst and referred for dynamic psychotherapy.

Presenting complaint Depression, difficulties in dealing with interpersonal relationships, and vocational dissatisfaction.

History of present illness The subject says that she had her first panic attack in 1993, when she was in her last year at school, and that she was referred to a psychiatrist who diagnosed phobic attacks. Carmen attributes the onset of her crises to the fact that her boyfriend at the time (Toño) was being treated for panic attacks and that she had become “influenced” by this. She started a course of psychotherapy that lasted for a year, and helped her to overcome family difficulties, especially those existing with her mother. In spite of this, she says that she was never the same again, that she felt insecure and pessimistic. In part, she blames this on her six year relationship with Toño, with whom she maintained an extremely conflictive courtship because of her family’s refusal to accept him. She says that she idealised him to a fault that he was always on her mind, that she believed she would love him for ever; the relationship was extremely turbulent and was interrupted on various occasions, when she felt enormously anxious, guilty and angry... The relationship finally came to an end in 1998, when she went through a depressive episode that required treatment with Fluoxetine, which she has kept up intermittently until now, although she has been extremely inconsistent with her medication owing to her ambivalent feelings regarding the treatment. She still dreams about Toño; she dreams that he has another girlfriend, and rejects her. She says that she has also had stormy relationships with two other boyfriends that she broke up with them and then felt so lonely that she tried to get them back “at any price”. On her first appointment, she was in a clear state of depression, she wanted to die, felt that she was wasting her life, that she had no motivation whatsoever towards university and her career. She believes that she is suffering from pathological bereavement, and that she needs to work on her problem in order to recover her identity. She wants something powerful, she approves of the psychoanalytical approach, and her parents are willing to give her economic support.

Family and social history From the information she gives us we can see that her parents have seven children and she is the third child in the family, with two older brothers. The father is a gyneco-obstetrician who she describes as being very kind, caring, irritable, hard-working, affectionate, and sensitive, with a depressive personality, and who has sceptical feelings regarding psychotherapy. Her mother is a journalist, who has received some training in family counselling and who acts as the father’s surgical nurse. She describes her as being traditional, rather impulsive, sarcastic, with extremely idealised fantasies about Carmen; they have a close but conflictive relationship. Carmen feels a lot of pressure from her mother, who has always been extremely strict. Carmen feels that her mother is intrusive and opinionated because of her categorical statements. When confronted with how contradictory it

170 is for her to be so close to her mother, in spite of her invasiveness, she says that in spite of everything she feels close to her and feels that her mother understands her. When Carmen was three years old, her father travelled to Europe on a scholarship for a year and her mother followed, and returned with a new brother. Her parents left her with some uncles, and she recalls that she came to call her uncle “daddy”. She recalls that she was extremely sensitive during her school years, that she suffered when her mates laughed at other people, and that this led her to break off with her best friends and feel extremely lonely. She has done well at university, she has a friend she trusts, but says that she often felt rejected without really knowing why.

Mental status She was on time for her first appointment, looking like a teenager, with slightly grungy clothes, no makeup, tousled and badly tinted hair, and a bottle of mineral water in her hand; an attractive woman with an expression of discontent on her face. She quickly took over the interview, had no difficulty in telling her story, giving the impression of taking the interview in her stride and treating the interviewer with enormous familiarity. Carmen feared my diagnosis, she herself believed her condition to be borderline, and used psychological jargon (“I have a lot of narcissistic features, primitive aspects, idealisation, lack of values, I am full of aggressive affections and have a death pulsion”). In spite of the seriousness of the diagnosis and of the fact that she herself is a psychologist, she gave her symptoms in a superficial (dissociated) way. When she said goodbye she placed her hand on my face in a gesture of excessive proximity.

Treatment history Carmen’s analyst referred to me for psychoanalysis. When discussing the case, the diagnosis was a histrionic and borderline personality disorder, with good prognosis owing to the fact that the patient was intelligent, did not present self destructive behaviour, was not involved in substance abuse and was motivated by psychotherapy. A four times a week couch analysis was agreed upon. As we will see, this was not an appropriate decision. We will now describe the main features of her therapy, including some verbatim dialogues and the therapist’s reactions vis-à-vis the clinical material. The analysis was marked by persistent tardiness and absenteeism on the part of Carmen, which affected the continuity of the treatment in spite of all her interpretative efforts. Her interpersonal relationships were intense and ambivalent, which in the analysis appeared as a permanent contradiction between her manifest wish for treatment and the many lapses on her part. These manifestations were present in other relationships in her life, and especially in her relationship with her mother, who she considers to be narcissistic, cold and envious, incapable of giving support and care, but who is the person she resorts to permanently in case of conflict or problems. For example, on one occasion when her mother told her that she had been irresponsible with a very important appointment to obtain a place for her clinical training, the patient was extremely angry and blamed herself for going to a person (her mother) who was envious of her. The following dialogue bears evidence of the patient’s intensely contradictory feelings:

Analyst: “You called your mother?” Carmen: I was just there and, well, I told her this morning that I needed support, my mother is not a source of support, she is not a container, but I always go to her. Analyst: I think that with that call you wanted to tell your mother “Don’t worry. I didn’t do well”, as you fear success and performing better than your mother. Carmen: To say that is really too much. I daren’t think that, that I am afraid of my mother’s envy... It just might be. It might be real... there are very dark sides to my relationship with my mother.... A friend of mine and I analysed each other, and have worked on that hypothesis together: anger at my mother, my mother used to say that I was the prettiest, my mother is Narcissistic and I boycott her Narcissism and want her to fail, or I might even protect her Narcissism so that she does

171 not shine less than I do ... there is a really complex relationship with my mother, there is a lot of love but also a tendency to feel anger towards her, the other approach that is related to her. Analyst: In what sense? Carmen: My mother nurtured my feelings when I began to have doubts about things. She studied counselling to get to know herself, my mother must have been sad and had little insight about it. When I was small I remember my mother crying over the death of her father, I went to her and she told me that she had never gone through with her bereavement. When I was small I knew I was going to be a psychologist. (She cried) Analyst: Why are you sad? Carmen: I remember her crying, her father died when she was two years old, when my mother’s sister got married, my mother cried during the wedding, in a new act of bereavement for the death of her father. Yesterday, I was speaking to my younger sister about my admired and undervalued mother. Analyst: You feel anger, grief, and guilt because she suffered a lot. Carmen: She had a distant and cold mother, she told me that my father gave her all the love she had lacked. Analyst: I was thinking that your sorrow for her might include the sorrow you feel for yourself, and ask yourself if you will ever have a partner, an analyst that might give you what you need, just as she does. Carmen: I have had a good life, loving father, decent mother, I haven’t suffered that much in my life.

The dialogue shows infantile (borderline) features in the patient. Although she knows that her mother does not help her, her affective dependency leads her to go to her in a gesture of dissociation and infantilisation. At the same time, we see the emergence of fear of maternal envy and identification with her mother’s bereavement, which reflects the patient’s precarious identity and strong affective dependence. As happens in Carmen’s analysis, she shows self destructive behaviour in terms of her work and other relationships. She knows she has to find a place for her clinical training, but has still not done so because she has not taken the initiative, or has not turned up or has been late for her appointments. During this period she has established a relationship with a schizophrenic patient with actively psychotic features. This relationship has no future, and combines masochistic elements and omnipotent fantasies of saving him. In one of the sessions she says:

Carmen: I don’t know if I want to give up José Antonio, I like to be with him, I don’t want to leave him; I’d hate to lose him, I don’t want to lose him. Analyst: You can’t leave José Antonio because you need to feel close to someone, you need to feel loved. Carmen: I need him, but he’s not the person that makes me feel really loved, he’s not demonstrative, he’s even rude to me. Analyst: There’s also the need to feel a common cause with the disabled because you feel disabled Carmen: I love him, it doesn’t matter if he doesn’t love me. He has an illness that is eating through him. Analyst: How serious is this illness? Carmen: Serious and even more serious if he becomes more introspective. My being his friend has given him a feeling of self-esteem, it has woken him up. As he lacks self-esteem, I feel a need to call him, to invite him, to fill him with life, and this is working out, there has been a change. He’s asleep and has to be woken up. And I’d love it if he woke me up, but I always reach a certain point, there are many things I don’t know about him and things I am not aware of, and many silences and vacuums. I hang on to what I know, to what I take to be the truth.

172 Analyst: I was thinking that this could reflect your situation with me here, your silences, what you don’t know about me, but also about the positive side, the hope to awaken potentials, as you said at the beginning of the session. (When she arrived, she said that she was feeling well). Carmen: Yes, I hope for development, I have gone on with this because I believe in it, the good has prevailed over the bad.

This material clearly shows that Carmen has rescue fantasies that she projects on to her partners. I have also come to believe that she consorts with pathological environments in order to attain a clear differentiation, to be sure of the meaning of psychosis and know that she is not psychotic, because she fears that analysis might show that she is psychotic. Furthermore, she tests me as a father figure because I feel an ethical dilemma, “Should I favour the schizophrenic patient and his recovery with a healthier partner, or should I protect Carmen by telling her to leave José Antonio?” When we take up the subject again in subsequent sessions, she says that she likes the way in which we have talked about José Antonio; “I don’t expect you to tell me to become involved, indirectly it is quite clear, in the sense that you had opened my eyes with that test, the blood test, that involved Clozapine, it was just naming something that I already knew. That was the role you played and there was no judgement on your part. The part you played was extremely important to me.” Finally, Carmen’s capacity to fantasise was outstanding, she brought multiple dreams to the sessions and gave vivid images of the different conflicts that worried her. Despite all my efforts to interpret her resistance, the analysis did not go well because, as has been mentioned before, of her tendency to act by means of tardiness and absenteeism. What was tricky in Carmen’s case was the amount of dreams and associations that gave the impression of in- depth psychological work, while her behaviour reflected the exact opposite. After a period of eight months, the analyst decided that a change of therapy was necessary; weekly sessions should be brought down from four to three, face to face therapy was required, together with a combination of clarification and confrontation, allowing for a certain degree of idealisation of the therapist and a slower and more progressive development of the therapeutic connection. She was referred to a colleague.

Differential diagnosis The patient fulfils the histrionic personality disorder pattern, including seductive inappropriate behaviour, superficial emotional expression, suggestibility, and a belief that her relationships are more intimate than they really are. To this we must also add a tendency toward dissociative language, a wealth of fantasy and features of infantile dependence. On the other hand, she fulfils the criteria for a borderline personality disorder, such as efforts to avoid being left alone, identity alteration and a chronic feeling of emptiness. The only element that is missing for a full borderline personality disorder is a tendency to more aggressive impulsive behaviour, the absence of suicidal behaviour and impulsiveness. The differential diagnosis would also include a depressive-masochistic personality, as she has a very negative concept of herself, she is pessimistic, presents chronic disphoria and exposes herself to ill treatment and failure. Nonetheless, it is necessary to bear in mind that she is being treated for major depression.

Editorial comment This case illustrates the difficulties of treating patients with infantile histrionic features. Carmen approached psychoanalysis with high motivation. She was intelligent, had no history of impulsiveness or major self-destructive behaviour, and in addition to all this, was training to be a psychologist. However, during the course of the treatment there was evidence of a severe resistance to therapy. Although the patient provided dreams and thoughts, and understood the interpretations, she made no progress in the therapy. In the case of patients of this kind, it would seem that the use of more confrontation would be more recommendable

173 CASE 8: Patrick: Avoidant Personality Country of origin: Scandinavia Author: Anonymous

Identifying data Upon referral, the patient was a 35 year old, unmarried data technician. He was referred to a specialized treatment program for personality disorders from an out-patient drug addiction service. His personality pathology was considered more devastating than his substance abuse.

Presenting complaint Low self esteem, loneliness, sense of emptiness, suicidal ideation, social isolation, substance abuse, general dissatisfaction with life.

History of present illness Present complaints had been chronic in nature, dating back to childhood. He recalled having daily suicidal thoughts for several years in his early youth. Around the age of 30, he started using amphetamine and cannabis as a means of overcoming his chronic depression. He soon became dependent on drugs on a daily basis. In desperation over this additional problem, he made an attempt to commit suicide. Eventually he told a medical doctor about his drug problems and was referred to a drug addiction service. He received counselling and supportive psychotherapy as well as pharmacotherapy. However, antidepressants did not have any effect on his dysphoria.

Assessments The assessment procedures at the unit for personality disorders included structural interviews and several self report tests. On axis I he fulfilled the criteria for dysthymic disorder and drug abuse in partial remission, but not panic disorder or social phobia. His avoidant behaviour was more prominent than his level of experienced anxiety. On axis II he fulfilled all seven criteria for avoidant personality disorder and an additional seven criteria spread across other personality disorders. The most prominent feature was a pervasive fear of being ridiculed when interacting with others. At the time of assessment he had been on sick leave for 10 months due to his mental problems. His GAF (Global Assessment of Functioning, DSM-IV) score for social functioning was 49 (not being able to work, social isolation), and 54 for symptoms (depressed mood). His total score (GSI) on the symptom checklist (SCL-90R) was 1.63, and his total score on interpersonal problems (IIP-C) was 2.11.

Family and social history His family was seriously affected by substance abuse. His father developed alcoholism at an early age, and his mother drug addiction later in life. His father managed for many years to maintain a social facade. However, due to his drinking, he was eventually fired from his job. Shortly thereafter his parents were divorced. Deprived of his social position and family, his father committed suicide when Patrick was 21. His mother lived somewhat longer. However, her later years were increasingly affected by her drug abuse and a deterioration of social functioning. She died suddenly due to a head injury. Patrick recalled a family atmosphere of anger, distrust and fear. Episodes of fierce quarrelling between his parents were followed by periods of icy silence. Neither he nor his mother was beaten by his father, but he was often ridiculed for being weak and vulnerable. He never dared speak up against his father, and he could not recall any relaxed and warm moments of being with his father. Mother was more available, although he experienced her as being preoccupied with her own

174 sufferings and misfortune. His best friend and supporter, in fact his surrogate mother, was an aunt who lived close by. She died in an accident when he was 28. He recalled that he realized at the age of 5-6 that his parents hated each other. The hatred struck him with terror and he learned at the same age to shut out his own feelings in order to survive and withdraw to solitary activities. He became insecure and shy at an early age, and he hardly dared to invite his comrades home for fear of his father’s condition. His insecurity and fear was aggravated by being made a scapegoat at school and due to the lack of parental support. Feeling depressed and worthless, he had little motivation for school work and received mediocre grades. Suicide as a solution to his miserable life seemed tempting. In his life history narrative presented at the treatment unit, he wrote that he “lost his vitality and lust for life long before puberty”. His self contempt was also fuelled by the fact that he never managed to get a girlfriend during his school years. However, he was supported by at least one stable friend, a more self assertive young man who adopted him as a sort of confidant. He moved to the city instead of completing college, took some courses in mechanics and drifted along with several kinds of jobs, none of which gave him any satisfaction. He eventually resorted to illegal drugs in order to feel alive.

Medical history Birth and early development proceeded normally. The patient has never suffered any serious illnesses.

Treatment history At the time he was admitted to the unit for personality disorders, all members of his close family were dead due to tragic circumstances. He hardly had any contact with his extended family, and his network consisted of two friends who also abused illegal drugs. He was on long-term sick leave. However, the treatment at the drug addiction unit had made him optimistic and motivated for further treatment and he appeared with optimistic expectations. The treatment goals he described for himself were 1) becoming more self-assertive, and 2) getting more involved with people. He gave the impression of being a nice man, full of the best intentions. However, the therapists experienced his compliance to be coloured by submission. They felt it was as though he wished to reassure them that he would not become an emotional burden to them. A nice guy. He was not on any medication. In this group-based treatment program lasting for 20 weeks, he was a regular, but somewhat detached participant. He seldom spoke in the large group, but was more involved in the small psychotherapy group. In the problem solving group, his passive avoidance as well as a stubborn claim for justice became apparent. The therapists encountered a series of problems related to passivity: He postponed most of his obligations, resisted sorting out practical affairs, did not pay his bills and avoided contacting people who could be helpful. And he never raised these issues as problem areas for the psychotherapy group. When he repeatedly told about relapses into drug abuse during weekends, it was with some regret and shame. However, emotional turmoil was not his melody. He never accused the therapists of showing too little concern and not being helpful enough, as many other patients would do as weekends approached. In the art therapy group he elaborated on themes from his childhood, mostly related to experiences with his father. He could be moved by emphatic comments from fellow patients and the art therapist, but his customary state of self was that of emotional detachment, physical tension and intellectualising comments on his own as well as the life stories of fellow patients. However, he stubbornly pursued one theme: He wanted assistance from the social worker to apply for a new education which should be paid by the state health and social security funds. This was the topic about which his angry assertiveness surfaced. He claimed that his depressions during school age had prevented him from reaching his educational potential and that the community was to blame for not having done anything. In this way, he felt society owed him something. After having completed the 20 week treatment, he reported that he was somewhat less depressed, had regained some hope for the future, did not feel as lonely and isolated

175 as before, was not troubled by thoughts of suicide, and was motivated for the continuation treatment consisting of group psychotherapy 1 1/2 hours a week. In the absence of the extended peer group and therapist support from the personality unit, he relapsed somewhat during the first period in the out-patient group. He resorted to intermittent drug abuse and was absent from several group meetings. However, he slowly became a regular group member, albeit mostly as a passive listener who seldom engaged in the heated discussions in the group and seldom took any initiative to speak about his life experiences. He was a passenger, rather than a member of the crew. After half a year of seemingly therapeutic impasse, things started to change. First, he succeeded in his efforts to get state funding for occupational retraining as a TV-technician. The school provided the necessary structure to his hitherto empty life. It provided him also with social challenges that could be discussed in the group. Secondly, he experienced an emotional breakthrough in a group session when he was moved to tears by some emotional validating remarks by one of the group therapists. It felt novel, strange, and good as well as provoking anxiety. In the aftermath of this session he experienced bouts of crying and sadness while at home. These emotional breakthroughs were followed by glimpses of novel world experiences where colours, sounds and smell took on an intensity and realness he never had experienced before. He came to realize in an almost shocking way how he, as long as he could remember, had “walked in a valley of shadows”. He decided to intensify his therapy and, supported by the group therapists, he engaged in weekly individual sessions as well with another therapist. He consented to regular communication between the group therapist and the individual therapist. He now entered a phase of sadness and mourning, new initiatives and occasional relapses. He recalled multiple childhood events, how he had dulled himself and shut out all feelings. Supported by the group, he contacted members of his extended family. He told of new expectations, but also of new disappointments and relapses of flight into substance euphoria. He told of bouts of anger toward his father and how he had hit the wall in his apartment in blind rage. However, in the group he seldom dared to show his anger. By the end of this phase, he was acknowledged by the group for his new initiatives, his progress at school and his new emotional involvement. After a year and a half in the continuation therapy, he suddenly won a considerable amount of money in a lottery. He was exhilarated since he had lived for so long on a minimal health pension and had acquired some debt which he hesitated to qualify. There followed a phase where he was engaged in the struggle of other group members, but more withdrawn with respect to own life experiences. After another half a year, at the end of a group session, he remarked that he was broke again. Nobody mentioned the issue in the next session until one of the therapists commented on the theme and the collective avoidance. Patrick then told his story about how the money “just slowly disappeared” in what seemed to be a steady over-consumption rather than any manic maldisposition. His story also revealed how he fairly early had perceived how his economic first class behaviour would lead to a collapse sooner or later. However, he continued on. One of the group therapists asked why he had not brought this theme to the group. He could not give any good answers. The therapist continued and asked the group what would most likely have happened if he had shared it. Several members replied that they would have asked for some action to stop the luxurious spending. He then replied angrily: “Yes, exactly, and I don’t want anybody to interfere with my private affairs that way”. Again, the group was stunned. “But hey, private affairs? What’s going on with you? Isn’t this group therapy?” He was perplexed. “Yes ..., but …, well I have always had some difficulties with money and I hated it when my mother asked me to pay my bills. Usually it made me just wait for the next reminder.” This session led to a new phase in his therapy. The group was now more confronting. He was no longer seen only as a victim of misbehaving parents, or the idealized successful group member doing progress in affect consciousness and social adaptation. He was challenged as to his hidden anger and stubbornness, avoidance and not taking full responsibility for his life. He responded with anger in the group, toward group members and the male therapist. He defended himself with the

176 right to enjoy life now since he had been so deprived in his childhood. There surfaced grandiose fantasies of what he could have achieved if it hadn’t been for the wounds he had suffered from the humiliations and terror at home. When spending money, he could experience a silent victory over his parents, classmates and teachers who never believed in him. When refusing to pay his bills, he could express his contempt toward society, to which he owed nothing. There followed new episodes of cannabis misuse, anger and counterattacks in the group, but also new episodes of sadness and mourning. Eventually, other topics surfaced. He finished school, found a new job, and in his termination phase he movingly summed up the fundamental ways in which he had changed during therapy, changes that he had not foreseen, and for which he was immensely grateful. He was interviewed for a follow-up study five years after termination from the day treatment program. By then, he no longer fulfilled the criteria for avoidant personality disorder. His GSI (SCL- 90R) was 0.32, IIP-C was 0.68, GAF (symptoms) was 76 and GAF (function) was 70. He enjoyed working as a technician in a privately owned TV company. He had found a hobby in fishing and used that as a reason to visit his home region and share wildlife with some of his cousins. He had fallen in love last year and relapsed into cannabis misuse when his girlfriend broke off the relationship. However, he had contacted his previous therapist and felt he could cope after five sessions. He could still feel lonely and he missed having a family of his own. However, he believed he still had a chance of meeting someone with whom he could share his life.

Editorial comment Patrick was a lonely isolated person. He fulfilled all seven criteria of avoidant personality disorder as well as features of other personality disorders. It is not uncommon that avoidant personality disorder comorbid with other personality disorder such as dependent, borderline personality disorder, and the Cluster A personality disorders. Patrick had been suffering from dysthymic disorder and drug abuse in partial remission. Although avoidant personality disorder also tends to comorbid with mood disorders and anxiety disorders, sometimes it is difficult to differentiate the symptoms due to avoidant personality disorder and depressive symptoms. In the case of Patrick, symptoms such as insecurity and shyness at an early age in relating others could be due to not only personality disorder but also depression. In clinical settings we should be keep in mind these two possibilities. Symptoms of Patrick have greatly improved by the group-based treatment program. Evidence has shown that both individual psychotherapy and group psychotherapy are effective for avoidant personality disorder. In his case, sportive confrontation by group members to stop a luxurious spending made him realize that he was one of the group members, which help him to have a sense of belongingness and to interact with other people more effectively.

177 CASE 9: Saskia: Avoidant Personality Disorder Country of origin: The Netherlands Author: M.M. Thunnissen

Identifying data and presenting complaints The patient is a 38-year old woman who fears death since she got cervical cancer eight years before. She has feelings of insecurity, anxiety to fail or to be rejected, mood changes. Outpatient treatment with a psychologist had insufficient results and now she is referred for a three-month inpatient psychotherapy program.

History of present illness Since she got cervical cancer eight years ago, Saskia has lost her trust in her body, and with every unusual physical sensation in her body she fears that the cancer has relapsed. Besides this, she has a deep feeling of inadequacy and fear of being rejected. She has problems in trusting people, is on her guard, and built a wall around her to prevent being hurt. Her mood changes rapidly, from feeling scared or sad, too cheerful. There are no problems with sleeping or eating.

Mental status She presents, dressed in a hippie-outlook, together with her husband who also wears clothes from the sixties-fashion and has a pigtail. She impresses as distant and defensive in her firm and obstinate presentation, although she admits to feeling inferior and anxious underneath. There are no signs of delusions or thinking disorders. Concentration and memory are slightly impaired. Her affect is dysphoric; she never has the feeling of being good enough and is easily disappointed in herself and others; she is inclined to react fiercely. She radiates “don’t touch me”, and “attack is the best defence”.

Family and social history She has one brother, two years elder. Both parents are still alive, father is 69 and mother 68. She was born on the day John F. Kennedy was shot, and her parents attributed a special meaning to this coincidence: from that moment on, her birth was connected to the death of a person whom she didn’t know but who was much more important than she was. From her youth on, Saskia was scared of suffering and dying. Her father was an insecure and anxious man, obsessed by death and suffering, afraid in social relationships. Her mother was more sociable, but also superficial and not very nurturing. In a material sense everything was possible (music- and ballet lessons), but emotionally the atmosphere was cold and characterised by fights and an unsafe atmosphere. From his puberty, her brother was negative, manipulative and destructive, verbally and physically. Her parents couldn’t handle him and often gave in, at her expense. Her brother finally got a high managerial position, but didn’t do very well in relationships: he is now divorcing for the third time. During her puberty, Saskia felt more and more left alone, became convinced she always had to struggle for what she needed – and always lost this struggle. She finished high school and started a study at the university (archaeology and art history), but couldn’t finish this because her parents refused to support her financially longer than four years (she needed another two years). They didn’t approve of her choice of study and wanted to give the money to her brother. She still considers this as a major injustice and as a confirmation that she has nothing to say and always loses. She finished a secretary training, which she didn’t like; since then had many different jobs like cleaning and working in a shop. She now lives from social support and has no idea what kind of work she would like to do for living.

178 She had a long-term relationship between the age of 18 and 29 years, and after one year of several sexual relationships, she started, upon her 30th year, again a long-term relationship with a man, working in the construction industry. They are not living together but have a satisfying emotional relationship; neither of them wants children. Since her operation for cervical cancer, sexual contact is difficult and painful; otherwise their physical relationship is satisfying.

Medical history Birth and early development were normal; she was a quiet baby and seldom cried. When she was 30 years old, she was diagnosed with cervical cancer and part of the ovaries and uterus were removed. Since then, she has physical complaints: pain in the lower part of her body, pain with intercourse, irregular menstrual cycle and partly insensitivity of her belly. She can still have children, although with difficulty, but she doesn’t want them. Since the operation all controls are ok, although she worries every year about it. At intake she feels tired, dizzy and sweaty; she has heart palpitations, a dry mouth, pain in her head and intestines. She uses homeopathic medication, drinks alcohol only if she goes out for dinner, doesn’t smoke or use drugs and eats healthy: vegetarian and biological.

Psychodynamic diagnosis Saskia is the youngest of two. Because of the behavioural problems of her elder brother, there were a lot of fights and tension in her family, and Saskia felt neglected, unloved, ridiculed if she showed her vulnerabilities and retreated as a reaction. She seems to have identified with her father, an insecure and anxious man, who had problems showing his feelings. She avoids work activities with pressure, challenge and interpersonal contacts; is anxious about being criticised or rejected or failing. She sees herself as inadequate and inferior, which she hides behind a strong presentation, to prevent being attacked and feeling hurt. Inside, she still feels very angry and sad. Getting cancer at the age of 30 years reinforced her feelings of insecurity.

DSM-IV classification Axis 1: generalised anxiety disorder, 300.02 Axis 2: avoidant personality disorder, 301.82 Axis 3: status after cervix carcinoma and surgery; somatic tension complaints. No current medication. Axis 4: no work, bad relationship with her brother, insecurity for the yearly cancer controls Axis 5: 65 (current) –65 (past year)

Differential diagnosis This patient shows four items of avoidant personality disorder: she avoids interpersonal relationships out of fear of criticism or rejection; she is reserved in intimate relationships out of fear of being humiliated, is preoccupied with rejection in social situations, sees herself as inadequate and inferior. She also has one item of paranoid personality disorder: anxiety that others will manipulate or cheat her; two items of dependent PD: lack of self-confidence and unrealistic fear of being left alone, and two items of obsessive-compulsive PD: perfectionism and excessively consciousness. On Axis I she shows a Generalized Anxiety Disorder especially around her physical condition. The fact that she got cervix cancer, eight years before, has been the trigger for both the Axis I as the Axis II condition; but despite positive yearly controls she still felt anxious to get cancer again. The Generalized Anxiety Disorder was treated with psychotherapy, which was not effective. This could be caused by the underlying personality disorder. A more intensive inpatient group-program was advised to treat the personality pathology.

Hospital course and treatment history

179 After two intake sessions and a whole day session in which she gets acquainted with the inpatient program and the therapists, she is admitted in the Centre for Psychotherapy, in the three-month inpatient program. In the first week of her stay she makes her treatment contract, which is aimed at changing her avoidant coping style, starting to feel her emotions instead of translating them in somatic complaints, and getting close to others. In the first weeks of the treatment she is suspicious and anxious, and defends herself by hiding behind a cold facade. She tries to find a place in the group by taking care of others, who experience her as over-doing and suffocating. She discovers how anxious and inadequate she feels inside, and step by step she can show some of these feelings. She enjoys the creative and psychomotor therapy, although she puts more emphasis on performing instead of experiencing; she doesn’t want to make a single mistake. She starts to feel anger and sadness, for example when friends cancel an appointment in the weekend or when group members finish their treatment and leave. She discovers that she is inclined to resist these feelings by taking care of herself badly or translating her negative emotional feelings into negative somatic feelings. She experiences a big gap between the world in the psychotherapeutic centre and the weekends with her partner at home. She is afraid that her relationship will be scrutinised and criticised in the therapy. She starts having dreams about the cervix operation, eight years ago: she sees knives, entering her vagina, breasts and eyes and discusses in the group therapy the impact of the surgery. She learns to differentiate her anxieties: she is afraid to be close, partly from fear of being rejected, and partly from fear of intimacy and fear of being left alone. Halfway through the treatment, she feels stuck in resistance, anger and jealousy; she feels unable to ventilate her feelings, gets memories from both her parents and her brothers who rejected her instead of supporting her, and feels not strong enough to deal with these feelings. She gets sleeping problems and doubts about the progress in her treatment. She still avoids discussing her relationship in the therapy, and presents this relationship as all- positive. Then she has a sexual-coloured dream of a monster with tentacles on her body that strokes her and gives her sexual pleasure, and finally she discusses in a realistic way the good and bad things of her relationship. She decides to change the LAT-relationship into living together with her friend, and to give more attention to feeling, dressing and acting like a woman her age. At the end of the program after three months, she feels changed in a fundamental way. She feels she left her past – the painful memories of her youth and the cervix surgery- behind her. Her avoiding coping style has changed: she can tolerate intimacy in social relationships, doesn’t fear rejection or criticism all the time. She can experience her own feelings and doesn’t need to translate them any more in somatic complaints; she takes better care of herself, feels less inferior. She got closer to her partner, and decided to live together with him.

Follow-up Her symptom level decreased clearly: her Global Severity Index GSI (0-4) decreased from 2.7 at admission to 0.46 at discharge form the inpatient program; after 12 months it was 0.37 and at 24 months 1.1. At that time she and her partner had started a psychotherapeutic treatment because of sexual problems. Three years after the inpatient program Saskia describes as the main benefit of the inpatient psychotherapy her ability to handle intimate relationships. She is going to marry her boyfriend and has a few intimate friends by whom she feels respected and with whom she feels at home. She doesn’t avoid or suppress her feelings as much as she did, and sometimes she finds it hard to handle feelings of anxiety or anger. Superficial relationships are sometimes difficult to her; for example, she feels irritated by gossiping or racist attitudes of colleagues at her work, and she doesn’t always succeed in changing the style of conversation. She doesn’t have a paid job yet; she works as a

180 volunteer in a playgroup for young children, and gives voluntary courses in art history. She hopes to find a paid job in the future.

Editorial Comments This case is supposed to be an avoidant (APD) and obsessive-compulsive (OCD) personality disorder. Symptoms such as that she expects rejection, had problems in social contacts, especially with authorities, is afraid to be close, and find superficial relationships to be more difficult to her could be symptoms of an APD, but also of a social phobia or even only symptoms without conforming a complete syndrome. Obsessive-compulsive personality is even less guaranteed, with scattered symptoms such as that she is a perfectionist and doesn't want to make a single mistake. A lot of the history of the case may be irrelevant, secondary or difficult to associate with the acquisition or maintenance of the patient’s problem. There is much information about her parents and her brother. There are even some comments about the father of her father. Some information is reiterative. There is also a lot of information about her kind of living. However, information is lacking about more relevant issues, particularly those supposed to be linked to the problem (as acquisition or maintenance factors). There are many inferences not justified, such as, e.g., “...to disguise her own unsafe and anxious feelings by taking care of others.” There are no clear symptoms, or at least they are not described in a systematic way, to diagnose a personality disorder. The follow-up assessment three years later was significant. However, during this follow-up it is said that “she feels much more anxious than before --a side effect which she hadn't foreseen before starting therapy.” This is probably an expected outcome because the problem was not well assessed and diagnosed and the therapy applied was not adequate.

181 CASE 10: Sally: Dependent Personality Disorder Country of origin: USA Author: James Reich

Identifying data The patient is a 27 year old white female administrative assistant who until a physical injury was employed by a large medical organization. She was initially seen because pain from the medical condition appeared to her treating physicians to be causing emotional problems. She was then referred for psychiatric evaluation.

Presenting complaint Sally presented with depression secondary to pain, but was also in fairly deep psychic distress over her inability to work. Specifically she missed being a part of the workplace, which until her injury had been a great source of pleasure.

History of present illness Sally is a high school graduate who to casual external appearances seemed to be well adjusted. Although capable of going to college after high school she decided she preferred to enter the work force. After several jobs at different companies in the clerical area she took a job at a large medical services organization. This was work she enjoyed. Important to her also was the feeling of being part of a professional friendly group. In her initial employment people were polite, professional and reasonable. The organization provided training which she did well at. She preferred, however, not to advance to administration. Her job went well; she received good reviews and was well liked. However, her work required much use of the computer and data entry. She gradually began to develop pain in her wrists. At first she ignored the pain or tried to treat it with over the counter medications. However, eventually she realized that she should seek out medical attention. Physicians diagnosed a potential carpal tunnel syndrome. Sally reported the problem to her superiors at work. The organization had a procedure for this situation. Her workspace was evaluated and ergonomic equipment was brought in for her. It was recommended that she follow the work restrictions suggested by her physicians. It was at this point that she began to have conflicts with her superiors at work. Her immediate superiors continually urged her to work past her work limitations and praised her profusely when she did. Although Sally told her supervisors that working beyond her limitations caused her pain, she tended to do so at her supervisor’s encouragement. Although this resulted in pain Sally felt gratification of being part of the group again and having people pleased with her. This pattern resulted in recurrent flare ups of her wrist pains. This required medical leaves at times. When she returned to work her superiors were suspicious as to the reality of her physical symptoms. They again and again encouraged her to work beyond her work limitations. Although she had received strong advice from her physicians not to do so, she frequently did , which caused more pain. Her physicians suggested possibly changing her line of work. Sally however, had never experienced such a feeling of pleasure as she did in her position within her job. The feeling of being part of something and needed was extremely powerful. She felt that if her superiors understood her pain, which she explained to them, they would understand her need to follow her work restrictions. Sally continued to work. Her superiors continued to encourage her to work beyond her limitations and she did. Her carpal tunnel condition worsened and eventually required surgery. Upon recovery from surgery Sally made her strongest efforts to stay within her work restrictions. After a period of time, however, she could no longer resist the pressures of her superiors and worked as if

182 she was not injured. The damage to her wrists this time was not reparable by surgery and Sally was left in significant daily pain, with significant orthopaedic limitations and unable to work. Sally’s feelings were complex. She felt betrayed by her superiors and co-workers at work, but also could not fail to stop constantly blaming herself for what she now saw as her “stupidity” for not having prevented the situation herself. The loss of work created a devastating loss of structure. She developed significant depressive symptoms. Physicians working with her to rehabilitate her from her orthopaedic condition referred her for psychiatric evaluation.

Mental status Sally presented as a woman who appeared her stated age. She was dressed casually for the interview and was adequately groomed. She wore wrist splints on both wrists and appeared to be in some pain when she used her hands. Affect was appropriate to mood. She appeared depressed and a bit anxious. Concentration was fair. She made good attempts to answer questions, but at times seemed distracted by pain or low energy. She denied hallucinations and there were no signs of delusions of the somatic, paranoid or religious type.

Family and social history There is no family history of mental illness. Her mother is a homemaker and her father an accountant. Although they may have been a bit overprotective, it appeared she had a healthy middle class environment for her upbringing. She was not mistreated.

Medical history Birth and early development were normal. The patient has never suffered any serious illnesses up to the current problems. Extensive medical records indicate well documented difficulties with the wrists diagnosed by appropriate medical tests. A bilateral chronic pain syndrome had developed at this time.

Course and treatment history By the time Sally came into treatment it was too late to effect a cure of her orthopaedic difficulties and chronic pain. She would never work again. She was treated with antidepressants and psychotherapy with modest success. Therapy largely consisted of mourning the loss of her physical function and adjusting to her current level of disability.

Differential diagnosis and formulation Sally demonstrates the key aspect of Dependent personality, the need to please others even at the expense to herself. People with these traits (as people with other personality traits) can make a good adjustment if they find an environment congenial to their personality. Sally unfortunately failed to do so. Differential diagnosis on Axis I would include the depressive and anxiety disorders. However, none of these symptoms were present prior to her physical injuries. In the personality disorders we must consider other disorders in the “anxious cluster.” Avoidant personality does not fit as there was no excessive shyness. Negativistic (Self defeating) does not fit as there is no evidence in any area of her life that she was deliberately setting herself up for failure. Although compulsive personality traits may have been present we do not have prior evidence that they were dysfunctional prior to her injuries and probably fitted into the workplace well.

Editorial comment The case of Sally illustrates a key dynamic of dependent personality disorder: the inability to set limits on others’ requests, even when those requests are excessive or unreasonable. In Sally’s case, her unquestioning compliance with the productivity demands of her supervisors at work led to permanent injury, and - somewhat ironically - to the loss of the very same relationships she worked so hard to maintain.

183 The degree to which Sally’s self-destructive passivity and compliance at work stemmed from her early experiences within the family is unclear, but her parents’ overprotectiveness likely played some role in the etiology of her personality pathology. Research confirms that overprotective and authoritarian parenting, alone or in combination, often lead to excessive interpersonal dependency in offspring. Although Sally’s depression and anxiety were secondary to her work-related injuries, these comorbidity patterns are characteristic of dependent personality disorder. These two Axis I syndromes--along with somatisation disorder and eating disorders--often co-occur with dependent personality disorder at higher-than-expected rates.

184 CASE 11: Brian: Obsessive-Compulsive Personality Disorder Country of origin: Australia Author: Janine Stevenson

Identifying data The patient is a 42-year-old single male, who lives with his parents. He has been unemployed for some time. He presented to the anxiety disorders clinic at a major teaching hospital, because of concerns regarding his long-term unemployment.

Presenting complaints Procrastination and perfectionism.

History of present illness Brian was referred at the insistence of his parents as he had not been out of the house for some time. His last job had been as a police officer. However, he had lost his job because he had been taking inordinate amounts of time to complete reports. Over the years Brian had had several jobs, all of which he left or had been dismissed from because he had taken so long to complete tasks. Brian tended to procrastinate when making decisions or carrying out plans. On weekends, when the family planned to visit the grandparents Brian would start packing on Friday afternoon, but on many occasions did not finish the packing until Sunday, by which time it was too late to go. Brian spent long periods of time in the bathroom, would take half an hour to wash his hands-first washing the tap, then his hands, then the tap again. He took two years to build the front fence, making sure that it was done absolutely perfectly. He would measure the distance between palings over and over again, to make sure they were equally spaced. When he inherited a property from an uncle, he took so long to make a decision about selling it, that the property had been vandalised and rendered virtually worthless. Brian had scheduled his days so rigidly, that he became angry if a family member interfered with his routine. This routine also made it difficult for him to go out and look for job. In fact, it totally prevented him from doing so. Brian also had many worries. He would worry about the economy, whether the world could sustain itself, the effect of the drought on farmers, whether his father would catch cold at work and whether he would get through his daily routine. This would also prevent Brian from going out and enjoying himself. He had no friends, no social activities and no hobbies. Brian was also concerned about his own physical health. He would visit doctors frequently complaining of minor physical symptoms. He would complain of cracking noises in the shoulder, abdominal pain, backache, and various other maladies. Eventually, his parents complained to the family GP, who referred Brian to the anxiety disorders clinic of a large teaching hospital.

Mental status Brian presented as a well groomed middle-aged man dressed in jeans and T-shirt, wearing working boots and with short cropped hair. He was somewhat nervous, but cooperative and friendly. He sat on the edge of his seat, sometimes rocking, and displaying multiple tics. His speech was rapid and clipped and his manner of speech quite circumstantial. His mood was neutral, though his affect was restricted. His thought processes were quite rigid, and his attitudes fixed. He would argue about the finest points. He did not see any of his behaviour as abnormal, but agreed that it was interfering with his ability to obtain work. There was no evidence of delusions or hallucinations or other psychotic phenomena.

185 Family history and personal history Brian’s grandma was said to have had mental problems of an indeterminate nature. His father was preoccupied with neatness, was an angry man, who abused alcohol. His mother was said to be very overprotective, keeping him home from school as a young boy at the slightest concern. Brian had a younger brother, who also lived at home. He went to work and had a girlfriend. Brian’s parents were comfortably off, owning the local cinema. Brian has always lived with his parents, although he has not spoken to his father since his twenties, as his father used to beat him. He has a good relationship with his mother. Brian did reasonably well at school and developed normally. His schoolwork was meticulously neat, and he was well liked by his teachers. He spent his spare time outside with friends. He started out dating normally, but soon became disenchanted. After leaving school, Brian has had 30 or 40 jobs, mostly factory work. The longest he has lasted in a job has been one week, often only one day. He has kept the same group of friends since school, but made no new ones. He has no really intimate friends, and has not had a girlfriend for over 10 years. On two or three occasions, he attended technical College, but never completed a course. His hobbies include bike riding, walking, and reading. He has no forensic history. His parents describe his personality as shy, becoming angry and frustrated at any change in his routine.

Medical history Brian had previously received counselling on two occasions in 1989 and 1997 after being referred by his GP. In 1997-98 he attended the anxiety clinic on two or three occasions, receiving a diagnosis of OCD. He was then referred to a group, which dealt with sufferers of OCD. Brian had no significant medical history. He would take no medications, being afraid of side- effects. In his twenties, Brian had dabbled in recreational drugs such as marijuana and LSD. He described himself as a moderate drinker.

Treatment course Treatment involved a mixture of analytically oriented psychotherapy, supportive therapy and cognitive behavioural measures. Brian came to therapy twice-weekly. He was very punctual and never missed a session; he talked freely, and in great detail. The initial part of therapy mainly dealt with family relationships. Brian did not speak to his father at all, and saw him as very aloof and critical. However, he appeared to be extremely close to his mother. In the afternoons when she was resting he would lie next to her on the bed, usually at her request. He would talk about this relationship as if he was talking about his girlfriend. In phone calls to Brian's mother she also saw no peculiarities about this relationship. They necessarily spent a lot of time together, due to Brian's unemployment. The family as a whole, however, found Brian's behaviour very frustrating and annoying. He would occupy the bathroom for long periods of time, take a long time in eating a meal or in organising himself to go out. When the time came to leave the sessions Brian would often not be ready. He would continue talking and delaying even when the therapist was standing at the door, with his hand on the doorknob. His speech was very circumstantial and elaborate, and it often took him a long while to come to the point. He would argue with the therapist and point out minor discrepancies in what the therapist was saying. However, he was conscientious and eager to make his life easier. He would describe the complex rituals needed to prepare for anything. And how he would become frustrated, if he felt he got something wrong. Brian did like company but expected high standards of his friends. He was critical of imperfections, told his family how to eat and would make them do tasks over and over again to get it right. Understandably, they were quite angry about this. Also in therapy, he would tell his therapist

186 how to arrange his room and would comment if things were out of place. He expected the therapy sessions to follow the same format each time and was intolerant of changes. He dealt with his employment difficulties by blaming others. While still in therapy he obtained a job, but this lasted only one month. He retried the police force, which was successful for a time. But when working for the drug squad, he needed to wash his arms in Lysol to kill the germs after handling offenders. This resulted in Brian's losing the skin on his arms from his fingers to his elbows. He retired sick. His tics were not a worry to him but as they annoyed others he felt embarrassed. He would move his head in a circular motion, shrug his shoulders, and circle his wrists. He was often not aware of even doing this, and there was little success in extinguishing these tics, though they did decrease over time. CBT was used to deal with his lateness and its effect on others. The family was also included at this point in time to help them deal with Brian's behaviour. Family sessions were arranged at monthly intervals over a period of six months and this was ultimately quite successful in helping Brian fit in better with the family. Much time was spent giving practical advice, using a government rehabilitation program that supported the client in obtaining and keeping a job. Brian eventually obtained work as a librarian, which utilised his obsessionality, and they found him a reliable and responsible worker. Brian remained in that job some years. (The rehabilitation service was able to help Brian in the task of making a decision, which Brian found very hard. He would ruminate and procrastinate over a decision often until a job was given to someone else). Brian also had problems with intimacy. Eventually he did find a girlfriend in the young woman at the library, but leisure activities had to wait for all work tasks to be done. When talk of a more permanent relationship was broached, he told the young lady that she could never replace his mother, who confirmed this to her causing some consternation and eventual break-up. It was apparent that Brian also found great difficulty in expressing emotions, and also in recognising emotions in others. After 18 months in therapy, Brian experienced an episode of major depression. He was hospitalised and treated with clomipramine, which was used with success. After two years Brian began to decrease the frequency of sessions. He was coping better and decided to return and study law, keeping his job in the library part-time. Some years later he returned to see the therapist again, to give him an update on progress. He had married, although the relationship seemed to be one where his wife became a “mother” to him. They had two children, Brian described himself as not being much good with kids, but better able to relate to them as they grew up. His obsessionality had lessened, but never quite disappeared. He was better able to recognise emotions, but still not good at expressing them.

Differential diagnosis Obsessive compulsive personality disorder is characterised by people who are preoccupied with details rules, lists, order and organisation, people who are inflexible rigid and stubborn. Brian was certainly all these things. He did have rituals and repetitive behaviours, but he did not resist these. He did not experience intrusive thoughts, impulses or images, and did not think his behaviour was unreasonable. His anxieties were related to his lifestyle and life’s difficulties, so he did not fulfil criteria for OCD, however, his major depression responded very quickly to clomipramine, which has also been found useful in OCD. And this did prove of benefit to him. Eventually he settled into a lifestyle that suited him and he adapted to take into account his personality style.

Editorial comment This case was diagnosed as an obsessive compulsive personality disorder (OCPD) and many of the symptoms described seem to justify this diagnostic. Typical symptoms described were that he had been taking inordinate amounts of time to complete reports, he took two years to build the front fence, making sure that it was done absolutely perfectly or had scheduled his days so rigidly, that he

187 became angry if a family member interfered with his routine. In the section on treatment more symptoms characteristic of the disorder such as “expected high standards of his friends” or “he was critical of imperfections” are described (these descriptions would be better included at the beginning of the case). This type of personality fitted well with the only job he maintained for years. So, the author tells us that the patient obtained work as a librarian, which utilized his obsessionality, and they found him a reliable and responsible worker. This case describes symptoms closely related to the main diagnosis of OCPD and the description is focused to the main characteristics relevant to the disorder. Therapy seems more successful because the diagnostic is based on an adequate assessment of the main symptoms of the disorder.

188 CASE 12: Gregorio: Mixed Personality Disorder Country of origin: Italy Author: Andrea Fossati

Identifying data Gregorio is currently a 33 year old unemployed man who lives in a small village in Northern Italy. He was initially seen 10 years ago when he asked for psychiatric treatment on a voluntary basis; shortly afterwards he was referred to the author of the present case for an additional psychotherapeutic treatment.

Presenting complaint Intrusive thoughts and images, compulsive behaviours, alcohol abuse, ideas of reference, paranoid ideation, social isolation, sense of self-worthlessness.

History of present illness When Gregorio was eighteen years old and was working as a skilled worker, he suddenly started doubting if his work was accurate or not. Although he recognized these thoughts as irrational, he started spending a lot of time controlling his artefacts. Soon these compulsive controls took so much time that he could not finish his work. During the same period, Gregorio also started controlling repeatedly the disposition of objects within his room, became preoccupied with contamination, was continuously annoyed by intrusive sexual images, was preoccupied with doubts concerning almost everything (for instance, he was constantly preoccupied with the doubt of not saying all he meant to say when he talked to someone), had to look persistently at people in order to be sure to maintain their images in his memory, and became progressively preoccupied with accumulation (in particular, videotapes). In a sense, this was a reappearance of a previous disorder; in fact, during the elementary school Gregorio had severe achievement problems because he was absorbed in controlling repeatedly the alignment of the letters on a page and in repeating several times words or numbers in his head. These childhood symptoms seemed to recover spontaneously when Gregorio was fourteen year old. After their (re-)appearance in adulthood, in a few months these symptoms forced Gregorio to stop working. When he was seen for the first time at San Raffaele-Turro Hospital, it had been four years that Gregorio was unable to work, and he had just received a disability pension. These psychopathological aspects interacted deeply with other long lasting features of Gregorio. Since he can remember, Gregorio describes himself as a young boy, and later a young man easy to bear grudges and to perceive attacks to his reputation; however, he rarely reacted with overt aggressive behaviour to these perceived attacks. Rather, he is typically used to silently brood over revenge fantasies, being unable to forgive or even forget what he considered to be an offence. Accordingly, Gregorio describes himself as “…someone who prefers to stay on his own, on guard… You know, doctor, all you say can be used against you… The less people know of you, the less they can damage you, do prefer that other people mind their own business, and not my own business”. He reported that he was always annoyed and frightened when he saw people talking while looking at him: “…I became very angry some minutes ago while I was waiting for you in the waiting room; there were a guy and a girl that were talking to each other and laughing… a couple she looked at me and then started laughing… I got mad; I started thinking, how do these foolish people dare to make fun of me? It was as during my school days… when I saw my school fellows laughing I always thought that they were talking behind my back… I never got them in the act of the crime; anyway, I do not want to see all those mobsters anymore”. Although the fear that people can notice compulsive behaviours is frequently observed among subjects suffering from obsessive-compulsive disorder, Gregorio’s ideas of reference and distrust,

189 substantially worsened this aspect, and gave it a somewhat “persecutory” meaning. Moreover, long lasting ideas of reference and acute feelings of shame related to obsessive-compulsive symptoms became part of a vicious circle in which shame feelings increased the frequency and intensity of the ideas of reference, and, in turn, ideas of reference boosted the shame feelings related to obsessive- compulsive symptoms. He started fearing that people could notice his behaviour, and this thought increased the severity of the Gregorio’s usual feeling that unknown people was staring at him in a derogatory way or that was making secretly fun of him. In turn, these symptoms led Gregorio to impose further restrictions to his already poor social interactions. During the consultation, Gregorio said that he was distressed by his “shyness” and his “fears”. For instance, he reported that making new friends or starting social interactions have always been distressful experiences for him; Gregorio also stated that he is greatly concerned with what people can think about him and how they can judge him. Gregorio has a deeply rooted judgmental attitude towards himself and frequently makes harsh comments on his person (for instance, “I am not an ill person, I am just a plain moron”). Gregorio complained of being unable to confide his feelings and thoughts to anybody – with the partial exception of his mother and his older brother – because of the “fear of being cheated and betrayed. Gregorio said that “I can trust only my family… all other people at a first glance may look nice and polite, but they are there only to take advantage of you or to cheat you”. These “fears” led Gregorio to adopt peculiar strategies, which ended in other vicious circles of obsessive symptoms and long term suspiciousness. For instance, when he was going to the pub with his older brother – because of his suspiciousness and social anxiety he was unable to tolerate other people’s presence if he was not accompanied by a family member - he had to spend a lot of money “otherwise, people surely start thinking that I am a beggar or the barman might get mad at me, and hit me or kick me in front of all customers”. This effort of being the “perfect client” at the pub, the severe anxiety arising in the social contexts, and the extreme distress related to the intrusive thoughts and compulsive “rituals” soon led Gregorio to develop a severe alcohol abuse, which was the third chief complaint of Gregorio when he asked for a psychiatric consultation. To make things worst, Gregorio started a ritualized way of drinking; he said that he could drink only triplets, i.e., if he drank a pint of beer, he had to drink two more pints of beer, and so on. When Gregorio was admitted for the first time to our hospital he was drinking 15-18 pints of beer daily.

Mental status Gregorio presented as a tall, markedly overweight young man. He looked grim and aloof; however, his affect was not blunted. Although he rarely smiled during the interview, he seemed anxious or manifested anger at times. His mood was neutral. He did not display any sign of mental confusion, and did not display any indication of delusions or hallucinations. None of his thinking was clearly delusional, although he was markedly suspicious and had frequent ideas of reference. His speech was circumstantial and included a lot of irrelevant details. Sometimes, the meaning of his words was somewhat vague and obscure; for instance, he said that he was frightened by a supernatural being that he called “the presence”. When the interviewer asked him if this “presence” was something like a ghost or a devil he said: “You are completely wrong. The presence is neither a ghost nor a devil, and this is the reason why it frightens me. You can exorcise evil spirits, but what can be done in the case of the presence… The presence is something that I cannot see; I can only feel it when it comes near to me… I can only ask my mother to stay near the door of my room to protect me”. These “presences” were frightening Gregorio from his early childhood; since then Gregorio’s mother had to stand guard – particularly when Gregorio took his daily shower - to avoid that the “presences” come too close to him. Gregorio says that he is not superstitious, although he has since late childhood had a very strong interest in magic, UFO's, and paranormal activities. He says that he does not believe in magicians, but he is able to recognize those people who have the powers: “…I was sixteen when I saw her for the first time… (Gregorio is talking about a famous sensitive who worked in Milan) I was watching her program at the TV when I felt her power near me… I know

190 that you are thinking that I am mad; I know that doctors believe in science, but there are ancient sciences that have a different approach to reality… Any time I came to her office, I felt the power to release from her mind… It was great… I told you, I am not superstitious but I felt clearly that she was able to read through my mind”. Since then, Gregorio went once a week to the sensitive’s office to get “consultations”; this caused friction with his older brother and his mother who considered these encounters a waste of time and money.

Family and social history Gregorio is the younger of two German brothers. His father died of gastric cancer when Gregorio was fourteen years old. His mother is a seventy year old woman who is described as “meticulous” and a “worrier”. Gregorio’s older brother received a diagnosis of Generalized Anxiety Disorder, and one of his female cousins was diagnosed as having Obsessive-Compulsive Disorder. Gregorio’s father was a specialized worker who is described as “anxious”, “silent” and “devoted to family”; he did not ever drink, but he smoked heavily (80 cigarettes/day). Gregorio and his family lived in a small house in a northern Italian village; they lived respectably, although modestly. After the father’s death, Gregorio’s family sustained an economic breakdown. His mother, who up to that time had been a housewife, had to start working as an hourly paid home help; Gregorio had to stop studying and began to work in the same factory in which his brother worked. According to his mother and his older brother, Gregorio has always been a loner. They describe him as an introverted, distrustful child, easy to bear grudges and to react with anger even to the slightest jokes. During elementary school, Gregorio had severe achievement problems because when he was eight year old, he became completely absorbed in controlling repeatedly the alignment of the letters on a page and in repeating several times words or numbers in his head. Gregorio was not popular among his peers and never had any close friends. As an adolescent, he did not get on well with his colleagues. Although he was a steady worker, and he was much appreciated for his scrupulous devotion to work, he found it difficult to make friends. He was very touchy and he got offended for nothing; with the exception of his older brother and a couple of his brother’s friends, he had no other social contact during childhood and adolescence. Although he was interested in having sexual experiences, Gregorio had no girlfriends until he was twenty two years old, when he started dating a young woman. He met her during his first admission to our hospital (they were admitted to the same Unit); the young woman suffered from an Obsessive-Compulsive Disorder which was mainly characterized by obsessions of contamination. The relationship lasted only a few months. Gregorio did not feel any deep emotion for her and he was disappointed by the young girl’s refusal of physical intimacy; moreover, he started thinking that the young girl’s parents were organizing a plot against him. Up to now, Gregorio had no other affective relationship. In a sense, Gregorio always lived with his family; indeed, he is still living in his family house. However, he always lived alone in a separate room, spending the majority of his time there. At best, he was with his parents and his brother only for lunch and dinner. When Gregorio was asked if there is something wrong with his family he said “…No, I love them! They have always done their utmost for me. Simply, after a while I am uncomfortable to have them near me… I told you, I have always preferred to stay on my own… I prefer calling them when I need something; you know, my mother lives downstairs, and my older brother lives within reach…”. Since he had to stop working because of the severity of his symptoms, Gregorio depends completely on his mother and his brother for money; although he receives a small disability pension, he prefers that his mother administers it.

Medical history Birth and early development were normal. Currently Gregorio suffers gall stones and adiposis hepatica; notwithstanding his alcohol abuse and his heavy cigarette smoking (Gregorio has smoked 40-60 cigarettes/day since he was fourteen year old), he never suffered any other serious illness.

191

Hospital course and treatment history Gregorio entered an integrated treatment program that included a standard psychiatric treatment for his intrusive thoughts and compulsive behaviours, a psychotherapeutic treatment of his dysfunctional personality features, and a program for treating alcohol abuse. The program included weekly meetings of the different clinicians who were following Gregorio in treatment in order to coordinate the therapeutic interventions, and to obtain an up-to-date and detailed clinical picture of Gregorio’s clinical course. Gregorio came for psychiatric treatment every two weeks. He was initially prescribed clomipramine 250 mg/day; because of his poor response, fluvoxamine 300 mg/day was tried; although the response was satisfactory, severe adverse side effects imposed to change the treatment strategy. Then, a combined treatment based on both fluvoxamine and clomipramine was tried, but the results were unsatisfactory. Gregorio’s poor response to pharmacological treatments and difficulties to adhere to the cognitive-behavioural program when at home ended in several hospital admissions (eight in ten years) due to the flare-up of obsessive-compulsive symptoms. Currently, Gregorio’s pharmacological treatment is based on paroxetine 60 mg/day, clomipramine 125 mg/day, and risperidone 1 mg/day. This treatment was weakly effective in controlling some obsessive-compulsive symptoms, although Gregorio’s life is still severely impaired by these symptoms. The alcohol abuse treatment – which lasted two years - was effective in helping Gregorio to control his drinking behaviour. Gregorio initially came for treatment twice in a week; he received individual support psychotherapy and psycho-educational treatment, and cognitive group therapy for alcohol abuse/dependence disorder. However, group therapy was dismissed soon after the beginning of the alcohol abuse treatment program because Gregorio found it excessively distressful to interact with 8-10 persons for forty five minutes. However, he kept following the individual treatment plan for roughly two years, although his frequency was not regular. Since then Gregorio remained sober for most of the time, with the exception of sporadic drinking episodes. Gregorio also attended long-term, cognitively-oriented individual psychotherapy sessions that were scheduled once a week. This cognitively-oriented treatment focused mainly on the implicit (that is, “unconscious” although not in the psychoanalytic sense) cognitive schemas that sustained Gregorio’s suspiciousness and ideas of reference; in particular, Gregorio’s attributional style – that is, his personal system of causal inferences and perceived reasons an event has occurred – was one of the major targets of the therapeutic interventions. Gregorio became gradually more and more aware of his tendency to attribute to others his own negative feelings about himself, and able to disentangle his own affective states from other people’s signals in the interpersonal contexts. Although his cognitive style remained interpretative, Gregorio became more aware of his cognitive schemas and more willing to change them; in turn, this reduced the frequency and severity of his ideas of reference and made him slightly less distrustful. Despite these slight improvements in some of his symptoms, during the years Gregorio became progressively overwhelmed by intrusive ideas and images whenever he was outside of his home. For instance, at the outpatient clinic, as well as at the hospital unit where he was hospitalized, Gregorio met several female nurses and psychiatrists; these professional encounters started intrusive mental images with sexual content, which caused compulsive behaviours, such as to accumulating – either by buying them or recording them – hundreds of movies that contained sexual scenes. Unfortunately, the worsening of obsessive symptoms that Gregorio observed when he was outside his home interacted with Gregorio’s tendency to social isolation and withdrawal. Indeed, he started reducing the frequency of his contacts with the clinicians that were following him in treatment, in order to avoid outside world stimuli that could increase the severity of his obsessive symptoms. For this reason, one year ago Gregorio informed his psychiatrist and his psychotherapist that he did not want to come anymore to the hospital; rather, he wanted to remain shut up in his house. Currently, Gregorio is still living shut up in his house for most of his time (he gets out for a

192 couple of hours twice-three times in a year), but he regularly calls on the telephone once a week his psychotherapist, and once every other week his psychiatrist.

Differential diagnosis The case of Gregorio illustrates the need for a multiaxial perspective. Gregorio clearly met the DSM-IV criteria for an Axis I diagnosis of Obsessive-Compulsive Disorder. Although the alcohol abuse was somewhat secondary to the obsessive-compulsive symptoms, it was severe enough to warrant treatment and an additional diagnosis of Alcohol Abuse Disorder (he never displayed any alcohol dependence symptoms). Gregorio neither suffered from mood disorder, nor manifested psychotic signs or symptoms that were suggestive of schizophrenia, delusional disorder, schizoaffective disorder, schizophreniform disorder or brief psychotic disorder. The average IQ level excluded that mental retardation could explain some of Gregorio’s abnormal behaviours and cognitions. Gregorio manifested several long-lasting features that were already evident his childhood, were present in several context, could not be better accounted for as manifestations of other mental disorders, and caused him both distress and impairment in social functioning. These long lasting features formed clear patterns of behaviours and inner experiences that involved cognition, interpersonal functioning, and to a lesser extent affectivity. All these characteristics suggest the presence of one or more personality disorder diagnoses. Indeed, Gregorio is suspicious without sufficient basis of being harmed or deceived by other, reads threatening meanings in benign events, persistently bears grudges, and perceives attacks on his reputation in irrelevant comments; all these features indicate that a Paranoid Personality Disorder diagnosis may accurately describe some of Gregorio’s psychopathology. Gregorio’s social anxiety was not related to fear of other people’s judgments; rather, it was explained by Gregorio’s paranoid fears of being harmed or attacked by others. Gregorio was severely limited in his social interactions by ideas of reference; he also showed frequent illusions – such as feeling “ the presence” coming near him – that influenced his behaviour (although he could criticize them), as well as magical thinking. Gregorio never had any close friends and manifested an odd way of thinking. These characteristics, as well as his paranoid ideation, clearly indicated the presence also of an axis II diagnosis of Schizotypal Personality Disorder. Although Gregorio showed a pervasive pattern of detachment from social relationships, he did not show the restricted range of emotions that is needed to diagnose Schizoid Personality Disorder.

Editorial comment This case is diagnosed with obsessive-compulsive disorder (OCD), but also with three more (personality) disorders. The more documented disorders have to do with OCD (intrusive thoughts and compulsive rituals), and some symptoms of paranoid (“I am unable to forgive or forget the insults that I suffered,” “I can trust only my family”) and schizotypal disorders (“had frequent ideas of reference,” “he was frightened by a supernatural being that he called “the presence”). Although the author says that the patient manifested several long-lasting features that were already evident in his childhood (referring to the possible antecedents of a personality disorder), the main symptoms beginning in childhood seem to be related not to a personality disorder but to the OCD, which is the disorder usually present in the life of the patient. The diagnostic of avoidant personality disorder (APD) is not guaranteed by the symptoms described by the author, given that the schizotypal disorder can explain many symptoms similar to those included in the APD. Treatment does not seem very successful because currently the patient “is still living shut up in his house for most of his time.” Maybe the secondary gains of receiving a disability pension and being cared by his mother has aided, although not explained the failure of most interventions. It seems that there have to be some important maintaining factors which have been not grasped in the assessment of this case.

193 CASE 13: John: Antisocial Personality Disorder Country of origin: The Netherlands Author: H. Groen

Identifying data The patient is a 27 year old male who committed murder when he was 17. He stayed in a high- security hospital during 10 years and he started aftercare treatment.

Presenting Complaints He had no direct complaints but felt paranoia, walking around in the big city. He came to the therapist because he had to, forced by the rules of the Ministry of Justice.

History He was the second son of a good looking couple. His parents were operating in the centre of the restaurant world in a big city. He was a very important figure in his mother’s life, as he reported. She trusted him and told him a lot about her personal feelings. That was because his father was never there and his older brother wasn’t too bright. He was intelligent and did well at primary school, the first 4 years. He didn’t know what happened but for some reason a group at school started teasing him. He felt helpless and wasn’t able to defend himself. He, his mothers little hero and helper, powerless at school. At home he had to be strong. Especially because of the fact that the marriage of his parents was not too good. His father had a girl friend and his mother felt betrayed and angry. She told him about her frustrations and loneliness. He realized, as he told during therapy, that his problems at school were minor details in the perspective of his mother’s problems. He felt weak at school not able to stop the teasing and the beating at some times. At home he felt strong, competing with his father and winning mother’s favourite. At the end of primary school his father’s relationship with a girlfriend ended, and suddenly his father was back at home, more than ever before. That had a couple of other reasons, too. He made a fortune, because he sold his restaurant for a very good price. This was also important because of his physical complaint (heart failure). Working very hard was no longer possible. So back at home, very rich, with physical complaints, he and his wife found each other again. John was no longer very interesting for his mother. She was nice to him and gave him what he wanted: toys, clothing etc. But she otherwise left him alone. His father was nice to him too: he felt guilty about not being there for a long time. So he took his son to clubs and sport-stadiums with his drinking friends. John found it very interesting, being a part of his father’s world. It never occurred to him that it might be strange, going to (adult) clubs, being in the beginning of his adolescence. At home his mother took care of his father, she felt very worried about him and his way of living. They spend a lot of time together and they were rather intimate, also in the presence of John. John went to school, because he was very intelligent and he did not have to work very hard. He was rather popular because he had it all. Beautiful clothes, nice bike, always money and good looking. Also his charm towards the girls appeared to be important, though he was shy when sexuality played a role. He told that despite the fact that he wasn’t teased anymore he felt insecure and never at ease. In contacts with girls, very early for his age, he felt very small. During those days he decided to go to a karate school. One of the main reasons was his fear to feel powerless again. Still there was no possibility to talk about all these things at home: his mother was nice to him, his father too. He got all he wanted and mom and dad were together again and having fun. His

194 father was happy getting the attention from his wife he wanted and needed. A happy family with a happy son. John did well at school, did well with his karate but developed a secret world. He met Dave at the karate school and Dave took him to expensive disco clubs. Even John’s money wasn’t enough to party that wild. He felt good in the new environment, got into contact with the criminal milieu and because he was strong, smart and not afraid he was accepted. Finally a group of his own. He was only 16 years old at the time. It was told that a crippled man had a lot of money and jewellery. Dave and John decided to rob the man. It meant not only a lot of money but also a great status in his new peer-group. A group with a lot of people who liked him because of what he showed and what he was. They found the old man at home and they forced him to tell where they could find the money and the jewellery. Because he wasn’t cooperating too well, John became very angry and started kicking with hands and feet. He became incredible angry at the man and he could not stop any more. He told that he did not understand where all the anger came from. Dave became afraid but did not want to leave the house without money: He had promised his older girl-friend a glorious evening. They searched the house and finally found the money. They left the house leaving the man who died afterwards as forensic research showed They spend the money at high speed in the milieu and of course a police man took notice of it. They were arrested and John was send to prison for 2 years and after these two years to a high security hospital for treatment of his diagnosed anti-social personality disorder.

Treatment course Part 1: The admission to the high security hospital was not easy for him. He simply did not understand why. He had to be punished but treatment was out of the question. Nothing wrong with him!! He felt betrayed also by his father and mother. They continued their lives and visited him rarely. The staff of the hospital tried really hard to relate to him but whatever they did he did not react positively. With the other patients he did not relate either. One of the reasons was the fact that he almost finished high-school and al the others at the most finished primary school. It seemed he made a decision: no more teasing ever and never part of a strange group again. Admitting this position was far too vulnerable. He became paranoid towards the staff and the other patients. He reacted very often with lots of anger. At such moments he had to be locked in. He appeared to be right: staff is not to be trusted and the others did not help him. After 6 years (!) a new male psychotherapist touched something important. This therapist did not try to relate but confronted him very sober and simple with the fact that the way he behaved would lead to 5 or 10 more years in hospital. The therapist said: “if that is what you want, be clear, because it is important for me to know what to talk with you about. Is it your future in the hospital or your future outside the hospital”? After 3 weeks he made another appointment and they started working together. Every time again the vital question was: “Does it help your future?” He surprised many others by behaving that well and many did not trust him. But he showed good behaviour focused on his way out. One of his dreams was to become a scuba diver (teacher) and was able to follow the relevant courses. Finally, after almost 10 years, he was allowed into society again.

Part 2:

195 For the follow up of his treatment he was send to a psychotherapist of the out- patient forensic clinic. This man continued the attitude of his colleague in the hospital but made a very important intervention: John felt very insecure, now living in the big city after 10 years in the hospital. He felt paranoid and thought he was not able to relate to anyone. A zero, he was. But as the therapist and John agreed upon, something strange was going on: he was teaching a group of eight adults the scuba diving. Those eight adults trusted him. So something inside him was trustworthy or eight adults were eight fools. The therapist explained to him, using little notes, a lot about the internal conflict, the impossible position he had during his childhood and other themes related to his biography. Every time again asking whether talking about these themes was important for his future, every time again relating to his slowly growing positive self esteem. Inside was a small voice: maybe I am meaningful to other, maybe I am somebody. During the therapy, the therapist related behaviour, interpersonal behaviour, cognitions and internal objects. The anchor point was his self (esteem) and the trustworthiness he was able to generate. Using the Millon framework appeared to be very helpful in this complicated process. Sometimes it was very difficult because he still felt attracted to the criminal milieu where he felt safe as he did not in the normal world. Also because he felt ashamed about his past. His growing self esteem and his insight in his internal processes made it possible to look at himself as a murderer. He cried very softly for the first time and felt guilty and ashamed. He stated to understand that the anger in those days was related to his impossible situation; the anger in the therapy was never towards the therapist but got words towards his father and mother. Sometimes his driving was dangerous, his anger directed to other drivers. After one year he got a girlfriend: good looking intelligent and from a stable family. They had their fights but they went well. She started to come with him to the therapy and told about his anger. She could understand very well the difference between angriness at her and the anger not connected to the interpersonal space: anger from inside. They moved to the south and stopped therapy. At the end, it appeared, he had kept all the little notes from the psychotherapist. He had used them to explain himself towards his girl friend and her parents. After two years he made contact again and proudly told he was doing well and had a son. He was working as a sports teacher for disabled children. He felt meaningful towards his wife and his son. His father had died and his mother tried to connect again. He was proud that he kept a distance: he was a grown up man with his own family.

Differential Diagnosis Though he killed someone very brutally, though he was diagnosed as an anti-social personality disorder, though he behaved as a psychopath, it appeared that the biography was of a vital meaning for a good multi-conceptual diagnosis, understanding and treatment. Directed by his behaviour a superficial diagnosis was made easy. But, looking sharply at his biography we can see his behaviour is strongly influenced by his traumas at school, by the conflict between his position at home and at school. His self-esteem was fractured and it became worse because at home he failed: he was not his mother’s little helper: as in a John Lennon song: “Mother I loved you, but you never loved me”. Mother went back to his father, she had used him. Growing older: there was still a lot of puppy pain, defended by a roaring lonely wolf. Al the anger exploded and he killed another helpless human being. His anti-social behaviour got a context and became understandable by acknowledging the consequences of the role he got at home, the impossible conflict between his position at home and at school and the immense anger because of the fact it became clear his mother used him and his father never saw him as his child e.g. he looked adult movies with him.

196 When he met the psychotherapist who acknowledged his autonomy on a respectful way a major change became possible. For the first time in his life he was able to go for himself, not reacting on the others, using him (his parents), teasing him (his school mates, his fellow patients, the staff of the hospital). In this safe therapy context it was no longer necessary to react as an abused and neglected child. He was able to feel attached to the therapists: step by step. His mother never accepted him as a young man and used him, his father used him and ignored him, his school-mates teased him and he felt terrible alone and lousy. From this case we can learn that using the Millon domains (behaviour, interpersonal behaviour, cognitions etc.) therapy of anti-socials can be possible and successful. As long as we agree upon the fact that the axis 2 Anti-social personality disorder diagnosis is too superficial and stigmatizing. The DSM diagnosis is based on behaviour only and this case shows that the interpersonal, cognitive and psychodynamic history had to be taken into account for this successful therapy.

Editorial comment Being criminal is something other than having an antisocial/dissocial personality disorder. This case illustrates that while the patient is attracted to the criminal milieu, he is becoming aware of and struggling with his personality deficiencies as being the primary cause of his criminality. His stable, secure childhood attachment to his mother, in the absence of the father, was distorted in early adolescence. When his unfaithful, seductive father returned to the family, the patient was shut off, and he became more lonely and mistrustful toward the world around him. His “new” wealthy parents bought him things as substitutes for emotional contact. Materialism became a defence against his insecurity and threat of feeling powerless. Participating in karate, frequenting expensive nightclubs, and being part of the criminal groups made him feel strong and important. He was charming and tried to deny his inner life and feelings. He wasn’t aware of his strong feelings of anger, hatred and envy, which were expelled in the robbery of the old crippled man. In therapy, his best protection from his feelings of guilt and insecurity was outbursts of anger and projection. After a long therapeutic process, he was able to feel sorry, guilty, and ashamed. The genuine feelings paved the way for a more mutual relationship and for the capability of being a father and husband. The case also illustrates that when doing psychotherapy with antisocial/dissocial personality disorder patients, you need a broader reference than the descriptive approach in a classification system.

197 CASE 14: Sergio: Antisocial/Dissocial Personality Disorder Country of origin: Uruguay Author: Danilo Rolando

Identifying data The patient is a 22-year-old male, of medium height and robust constitution, wearing long hair tied at the back. He has worked as a computer program salesperson. He had been under psychiatric care for some weeks before he was referred to a psychotherapist. His father had taken him to the doctor's office “because he was getting into trouble everywhere”.

Chief complaints Depressed mood, irritability, impulsive and aggressive behaviour.

History of present illness Since his mother’s death, 8 months before, he has been showing an exacerbation of his temper disorders, exhibiting marked irritability and aggressive and impulsive behaviour towards his father, his brother (5 years younger) and strangers at the street or night clubs where he usually goes. The patient makes an idealization out of violence, regarding it as a sign of manhood. He once had a fight at a nightclub and was beaten, after which he planned revenge against his offender, taking profit of his acquaintance to a narcotic’s brigade police officer. He has also had outburst reactions towards his teacher at the gastronomy lessons he was taking, as well as with his classmates. Regarding his mother’s death, while he cannot make a precise point, he criticizes his father: “my father was perseverant in work issues, but helpless about my mother's condition at the ICU. A strongest person would have been necessary to make clear what was going on. She had become septic; she was hospitalized; there was malpractice; she was given a medication that was bad for her and she was not asked about it. She had a heart arrest and she survived, but then died a few days later”. Six years before, his mother had had a kidney extirpation because of a malignant tumour, and died due to a further complication related to her disease. Somehow, he deals with the fantasy of his mother’s suicide, and gives a “psychological explanation”: “it was the effect or her father’s death”. “She could not bear it; grief affected her so much”. His grandfather had died two years before. He had been hospitalized because of a tumour, and the patient had gone on a trip to a seaside resort in Brazil with his girlfriend. When he came back, he found out that his grandfather had a spread cancer, and that his mother had had a psychiatric hospitalization. His grandfather died a month after that. Although these events seem connected, he does not exhibit affects like sorrow, remorse or guilt. He remembers having received accusations from relatives, and having felt observed by others. “My mother’s death changed our lives. Mine, in terms of outbursts and instability, and my brother’s in terms of guilt”. “Luckily, I had made my mother happy returning home a few months before she died”. He used to have a girlfriend (called Giovanna), with whom he had lived for a while. His mother did not like her due to her apparent promiscuous sexual behaviour, and because of her being three years older than him, and having harsh and abusive manners. He tells that living together “suffocated” them, and that they burned out “because I was out of job, there was no money, and because of drugs. We both smoked marihuana. She smoked harder”. They lived for a while with Giovanna’s sister and his boyfriend, who was convicted for drug traffic a short time later. “Big Brother-like life” of both couples was not comfortable for Giovanna (referring to television reality shows).

198 He then had another girlfriend, Estela, (-accepted by his mother-, who was a teacher, good mannered and about his age), but after his mother’s death, she left him because of having lost affection towards him, and rejecting Sergio’s aggressive behaviour. (He reports an episode in which with Estela present, he verbally offends his 82-year-old grandmother – with whom he lives- in a cruel way, because she “believed she saw her own daughter in Estela“). Sergio reports that he “was not really in love with Estela, and that he “was only interested on her sexually”. “When I needed her most, she was not there. She is not my best pal; she gets scared at my reactions, she cannot stand them. Instead, Giovanna came back when she knew that my mum was in a coma. She is loving and a good pal”. “Now I think I am going back to Giovanna, though I don’t know whether to get more involved with her or to keep a more distant relationship”. Actually, Giovanna is the one who doubts whether to start it over or not: “she wants an adult life, separate from my family, but that is not possible for me, because I am out of work, and because I need to be at home and play a role there: cook for my brother and pal for my father, who has only a few friends” He describes Giovanna as a woman having the same personality traits as his mother had: “emotionally unstable, nervous, stubborn, and possessive. She gives me no emotional stability. She puzzles me. She is unstable in making a decision about coming back together. So many braking-ups and good moments... She is not giving me much; just the support of a friend. We are twin souls, but we cannot live together; we are both explosive. My father is concerned about us wasting time arguing. He loves Giovanna; now they play chess together. Mum would not have let her approach him”. They have sex when she goes to his place, but he wants to have sex with other women. “I have a good day with her, and the following with another woman; I don’t know if I love her. You don’t do such a thing when you love. She cannot break off me; for me it is easier”. “I have no future as a man. I have a dream: having a son and grandson for my father, and, I would have liked, for my mother”. As he gets frustrated with Giovanna, he feels very attracted by a classmate, “a mixture of a porno Italian actress and an angel”. He says his mother “sent it for him from heaven”, but he quickly realized that she was more “nuts” than he was. She suffered from phobias and used to say she had been “psychologically raped”. “I don’t want to have hopes; everything gets lost”. “I cannot find anything that drives me; that is why I search for women”. With this and other girls, he intends to elicit jealousy in Giovanna.

Past personal history Some years before, he had needed psychiatric care “for the bad impression I had when I learnt that an uncle of mine was homosexual”. He had been suspicious about the issue before, but had denied it. He reports behaviour disorders in his teens (between 15 and 17 years old), but underestimates them. He used to smoke marihuana with his friends, and to steal things from wealthy people who were members of the same sports club they attended. “My mother used to worry; she was aware in those years; she was not taking pills. I was going on a lark all the time, searching for women with my friends”. He recalls an episode when he went off to a seaside resort 300 kilometres away, and did not telephone his family for 3 days. This caused great anguish in his mother, who reported him to the police as a missing person. “She was over- concerned about me. For her, I was the black sheep of the family”. He says he had been obese until adolescence, but then lost weight exercising (martial arts). He occasionally had self-induced vomiting with the same purpose. During his childhood, he had been diagnosed with minimal brain dysfunction and given Ritalin. He finished primary school, but did not complete high school. He did not finish a marketing course either. He then worked as a computers program salesperson for a while, at the same

199 company where his father used to work. He was dismissed due to physical aggression to a co- worker. By the time the treatment took place, he was taking gastronomy lessons of secondary level, and his father was very concerned about him getting a job. The patient has quitted having job interviews because he cannot tolerate the frustration of repeated rejection.

Mental status He has the appearance of a teenager. He wears blue jeans and sportswear. His hair is long and tied at the back. He is very anxious and talks all the time. He complains about his depressed mood, and his lack of concentration and motivation. He reports feeling confused, devastated, disorganized, and full of pessimistic attitudes towards life: “something is missing inside me, so that I have no drive; I feel empty”. His thought process is coherent, with neither formal disturbances nor pathologic contents (no delusions or hallucinations).

Family and social history Sergio says that he had left home “escaping from family problems”; there used to be very violent arguments between his parents; “my mother used to quarrel with everybody; she got upset when the music was loud; we didn’t get along with each other; she was very jealous at Giovanna, and that’s why she didn’t accept her. During the last few years my father used to treat my mother badly, and I stopped him”. She was on medication and her husband said she was crazy. They had frequent arguments about money problems. His father became violent, though he only intended to hit her once. “He was an absent father. He used to spend all day at work; that situation led me to psychotherapy during childhood”. He reports that since his mother died, he has taken over a father’s role at home, especially with his brother. He is critical about this issue, but at the same time he feels he has to do it, since his father does not: “he is away working all day and is very prone to outbursts; since mum died, the house is full of friends of Fernando’s (his brother); they stay late, they mess up the whole place, they play music; limits need to be stated for them; besides, I am the cook, the one who tries to deal with household savings, and they just go and take stuff away from the fridge, making themselves at home”. Sergio has practically no friends. Instead, he has some acquaintances, which are only by chance or from his neighbourhood. One of his friends made him various tattoos (one with an octopus shape on a leg, and a bracelet on an arm). He took his best friend to the psychiatrist “because he has not been able to get over his father’s death. He has been hospitalized several times, but he doesn’t want to maintain treatment”. He also shows another example of pretended “altruism” helping a neighbour who was depressed because he had broke up with his girlfriend. “I played the role of therapist, and they got back together. He is very interested, and I was surprised he did not ask for anything in return”. He was actually looking forward to getting closer to this boy’s sister, whom he had dated once or twice before. He regards having “a good relationship” with his father although he says they have always “lacked communication”. Lately, they have been having harsh arguments where he demands “hardness” from his father. “Since my grandfather’s death, I only see sad things”. He feels unstable, and intends to be alone or sometimes with other people to forget. “This family has been tearing apart for years”. “After my grandfather’s death I could keep on working, but my mother’s death has been more devastating. I have a great instability and a pessimistic attitude towards life; everything makes me upset”.

200 He tells that at home he has always been “the caring one”, formerly with his mother, now with his brother. Nevertheless, he regards himself as a bad example for his brother since he smokes marihuana. Drugs offer him relief, “disconnecting me from problems”. Despite this, he affirms he is able to moderate his consumption: “I have never had an actual habit.” His mother had been a consumer of psychoactive medication and was sometimes hospitalized because of overdose. He admits a link between his own addictive behaviour and that of his mother: “I am just like my mother. She used to grab pills when any problem came up, or call the emergency service instead. We were both very family-bound”.

Diagnosis DSM: Axis I: Anxiety Disorder. Axis II: The clinical diagnosis was Borderline Personality Disorder with antisocial features This patient’s personality traits fulfil DSM criteria BDP: “A pervasive pattern of instability of interpersonal relationships and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the items”.

In this patient, the following DSM-IV items are remarkable: Item 2: “A pattern of unstable and intense interpersonal relationships”…, as observed in his coupling relationships and regarding parental characters. He practically lacks friends. He shows troubles in establishing deep and lasting affective relationships, which always turn unstable. Item 3: “identity disturbance”… It is evident in this patient with his immature way of assuming his roles (not being able to assume adult ones), and deep feelings of emptiness (he says he feels “confused, devastated, disorganized, full of pessimistic reactions towards life” … “something is missing inside me, so that I feel discouraged, I feel empty”). Item 4: “impulsivity in at least two areas”…. This patient has shown frequent impulsive and explosive reactions, typically borderline, as well as drug consumption episodes (of alcohol and marihuana), as an acting-out (he grabs drugs as a relief, to “disconnect from problems”, pointing out that he has never been an addict). He has also been involved in impulsive acting-outs in his sexual performance. Item 6: “affective instability due to a marked reactivity of mood”… The patient has shown dysphoric depression, irritability and chronic anxiety. Item 7: “chronic feelings of emptiness”, seen before. Item 8: “inappropriate, intense anger, or difficulty controlling anger” Throughout the patient’s history, episodes of uncontrolled anger are found in different situations: arguments with his father, with his sister, with his girlfriend, with job-mates, with unknown people at the street or at the pubs where he usually goes.

The patient also shows antisocial personality traits, as indicated by: Some of the his relationship features, apart from the typical instability of the borderline patient, show that they are shallow, cold, careless (occasionally including an amount of cruelty), and exploitative in his sexual relationships. Lack of empathy. Irresponsible work behaviour: he rejected job offers regarding them as second range, according to his aptitudes (self-inflation), while his family was undergoing economic needs. He has also been unstable in his academic performance. Lack of feelings of anguish, guilt and remorse. Disregard of others.

201 - “impulsivity and aggressiveness, as indicated by repeated physical fights or assaults” (item 7 of Criterion A from DSM-IV for antisocial personality disorder): some of the aggressive acts of the patient have antisocial features (e.g. those in which he idealizes violence as a sign of manhood, or when he plans to obtain help from a policeman of his acquaintance to get his offenders beaten. The feelings of rejection that his aggressive behaviour elicits (e.g. his girl friend finished with their relationship). Past history of conduct disturbances before adolescence: getaways from home, thefts and marihuana consumption (considering that these disorders could be secondary to his drug consumption).

During childhood, he had been diagnosed with attention-deficit/hyperactivity disorder, being then treated with Ritalin (typical past illness of antisocial and borderline personalities). The fact that he had shown temper and behaviour disorders before adolescence, tells us about the permanent nature of his personality disorder, although those have increased with grief. From a psychopathological point of view, he shows a borderline personality organization, characterized by identity diffusion and primitive defence mechanisms (mainly splitting), with reality judgment preserved. Severe super-ego pathology is also evident in this patient. Symptoms described by him as depressed mood, apathy, and lack of interests, are permanent, and appear as more related to a habitual behaviour style than to depression. Feelings of emptiness, boredom and inability to project himself to the future, correspond to the identity disorders related to his personality traits (borderline, antisocial). This patient was studied with the Millon test (MCMI-III) for personality disorder. In this case, desirability index was rather high (71), making results controversial. Anyway, he scored high for Antisocial Disorder (82), and also for Passive-Aggressive Disorder (83), Depressive Disorder (78), Aggressive/Sadistic Disorder (73), and Borderline Disorder (71). In Axis I, he scored high for anxiety (94), Bipolar Disorder (77), alcohol dependence (75), dysthymia (72), and lower for drug dependency (66).

Millon test: Axis III: he does not show remarkable pathology. Axis IV: conflictive family situations for various years, (recent death of his mother, family disturbance, academic and job problems). Axis V: impaired functioning in several areas.

Treatment This patient was on medication, namely venlafaxine and clonazepam. The attending psychiatrist found it useful to augment current treatment with supportive psychotherapy, as she saw him depressed and showing risky aggressive acting-outs. A male therapist who was psycho-dynamically oriented carried out psychotherapy. A series of interviews with the patient and his father took place. Treatment consisted of a supportive therapeutic listening, and pointed at achieving a greater “bearing in mind” of his non-elaborated grief. Therapeutic work was focused on these aspects, based upon pointing-outs and confrontations, intending to articulate affects, thoughts, and life events, without getting into other pathologic issues, involving very few psychoanalytic interpretations, considering the failures in the patient’s symbolic development. The insufficient development of an observer ego and of the super-ego, the scarce introspection skills, the severe pathology of object relationships, the presence of antisocial traits, the high potential for severe acting-outs and the lack of motivation, determined the impossibility to carry out a classic and deep psychoanalytic psychotherapy.

202 All along the treatment, the patient referred to his problems: he was depressed, irritable, or could not control his aggressive impulses, and used to act them out often. He said he found it hard to concentrate, and had lost interest (for example in surf, which was one of his favourite hobbies). More often than not, his reports included references to his mother’s death, without being able to connect his emotions, feelings and behaviour. His speech could seem guilty to the observer, but he never admitted guilt feelings: “life changed for everybody at home; I am mere instability and outburst; my brother blames himself”. His main defences were those of denial, projection and impulse acting (primitive defences). Occasionally, he would apply to manic defences: he got drunk with friends and women. Although he was rather socially withdrawn, he was always looking forward to get involved with a girl, but only in a superficial way. He used to say he loved his former girlfriend, whom he did not want to lose, but in fact, he showed inability to love. She stood by him but was reluctant to starting over the relationship. They attempted, but all of a sudden, they were arguing and yelling at each other. Reports regarding his relationship with Giovanna, illustrate the type of object relationships he sets up quite well. It is the kind of relationship where he is interested in the other giving everything necessary to fulfil his needs, in a narcissistic way, with strong sadistic traits. Mixed and disjointed self and object images, show the strong dissociation and splitting of his psychical functioning. Going ahead in psychotherapy, approached him to depressive feelings, which caused him to show resistance reactions: “sometimes I get upset with God – though I don’t believe in him much - why did he take away such a good woman as my mother? He could have taken me, the one who drove everybody crazy”. Three months after beginning treatment (which lasted 5 months on the whole), an important inflection was noticed, in terms of connecting his manifestations with his mother’s loss: “I find myself very unstable, related to what happened to my mother”; “those tremendous days I underwent when my mother was at the ICU come to my mind. Depression is increasing. I am sad about being so sad.” The therapist shows him that he should not be scared at being sad, because it is a normal status for such a situation like his. In addition, his aggressive reactions had diminished to some extent: “now I neither yell nor break things, and I am not in a bad temper, but my mood is variable”. Medication doses could be reduced. He says he has improved with medication and therapy. He adds that in consecutive appointments he has been feeling more comfortable and able to talk about everything.

Editorial comment As seen in this case, Attention Deficient Disorder - with or without hyperactivity - is often seen in the childhood of antisocial/dissocial personalities. Sergio also had behavioural problems in adolescence and was treated with amphetamine-like drugs (Ritalin), due to a diagnosis of a minimal brain dysfunction. Also, he was raised in a stressful family milieu with a lot of tension between his parents. His father was often absent and when present was often yelling at or rejecting his nervous drug, addicted mother. Later, the patient also turned to drugs for relief and he became addicted to marihuana. In the mental examination, the patient demonstrated a mixed clinical picture of different personality disorders, most prominently antisocial and borderline. Both depression and substance abuse often occur as comorbid disorders in these patients, which decreases the likelihood of rapid symptom remission and better rehabilitation. Sergio was treated with anti-depressive and sedative medication, which apparently reduced the risk of aggressive outbursts and stabilized his mood. Supportive, psychodynamic oriented psychotherapy led to some insight which helped him work through some of his depressive feelings caused by the loss of his mother. This case illustrates patients with this difficult combination of antisocial and borderline personality disorders, as well as comorbid syndromes, might benefit from a combination of pharmacotherapy and psychotherapy.

203 CASE 15: Marcel: Dissocial Personality Disorder Country of origin: Romania Author: Mircea Dehelean

Identifying Data The patient is a 46-year-old male presently unemployed. He has a disability pension and is married without children. He is referred by the GP for an alcohol withdrawal state without delirium.

Presenting complaint Marcel has some subjective complaints (insomnia, nausea) associated with tremor and sweating, related to the alcohol withdrawal state. He firmly sustains that he never had any psychological or psychiatric problems except a short and mild depressive episode in the past. He recognizes that sometimes is irritable, impulsive or even aggressive with others like anyone else. He also admits some difficulties in maintaining good and longstanding relationships with other people, including members of his own family. Despite the fact that he has very few constant friends, he is convinced that his attitude toward others is a natural one.

History of present illness The first clinical expression of his primary mental disorder appeared around age of 10 years with frequent social misconduct in a variety of situations: at home, at school or among his companions of an anomic group organized by him as leader. He had disturbed relations with members of his family, with his classmates and with teachers at school. He was involved alone or within his group of friends in many fights beating weaker boys without having any consideration about the consequences of his behaviour on his victims (pain, bruises and so on). He took great pleasure in fighting and harming others. At school he had very poor results and finished only 5 classes. Because of frequent absenteeism, little concern for learning and lack of elementary discipline he finished only 5 classes in 9 years. At home he lied or deceived his parents. He stole and sold for his own profit various objects. He spent most of the day away from home. When he did return home, it was very late in the night. Sometimes, when he managed to remain unobserved at closing time, he slept in public institutions (churches, cinemas) or cemeteries. He is very proud of his “courageous adventures” when he “operated” with his gang as a thief in the street, in buses or tramways, never to be caught by the police. He also stole from his neighbours’ gardens often with a reckless temerity. Once he was very close to death by drowning in a rural type fountain. From his many escapades he sometimes was brought back home by police. Marcel proved to be very skilled in offering a good explanation to avoid sanctions. These were rare and without any durable benefits. His father sent him to a child psychiatrist when he was 10 years old and Marcel was diagnosed having a conduct disorder. The recommended psychotherapy was never accomplished because of the patient’s lack of compliance and the father’s lack of implication. When at 16 years old he got his first employment (as unskilled worker in a factory), he was dismissed a month later because of lack of interest in doing a good work, impulsivity and tense relationships with co-workers resulting in many conflicts. In the following years he obtained several unskilled jobs never to remain employed more than 1-3 months, as a consequence of his misconduct (in a state of impulsive reaction he destroyed all the fragile objects from the factory’s warehouse, some other times he stole some products to sell them for his own profit). He tells that the sound of broken glass causes him great pleasure and a wish to repeat such an enjoyable experience. Often he tried to impress people by producing a superficial bleeding on his thorax and arms with a blade or a knife to obtain benefits or to avoid sanction. This manipulative act is deliberately committed and often profitable for him (he is referred by police to a medical unit and from there to a psychiatric hospital).

204 Some antisocial acts are impulsive, others are performed in cold blood without any concern about other people. All his deceitful acts are executed without any remorse, pity or mercy for others and are associated with the pride of being a clever winner. He always considered himself as a worthy man who deserves everything by any means. Moreover, he thinks that the rules and the laws are for ordinary people and not for himself, who is a special case. The sense of duty, of responsibility didn’t have for him any meaning. He used his qualities of being a charming and convincing man to obtain what he wanted, but if necessary he also used force and verbal or physical violence. The first period of his patho-biography (1977-1987) is characterized by impulsivity and a constant social misconduct. In the second period of his psychiatric history (1987-1991), on a background of dissocial personality appear several mild depressive episodes treated and well remitted with common antidepressants (especially tetracyclics such as Maprotiline and Mianserin) associated with moderate doses of Neuleptil. In this period the alcohol use became more frequent and excessive. The antisocial behaviour and the alcohol abuse increased his social problems. In the third period of his patho-biography (1991-2004), the social misconduct persists. After a late marriage with a woman with bipolar disorder whom he met in a psychiatric hospital, he took advantage of one of her hospitalizations to sell her house and the goods inside without her knowledge. He spent all this money on his own profit. Surprisingly, he succeeded after a serious conflict with her, to normalize the relations with his wife, who continued to support him despite his bad character. Moreover, he changed his own last name into his wife’s last name to avoid being prosecuted for his misconduct. In this period, the main general pathological problem became gastric and hepatic consequences of chronic alcoholism and the onset of some withdrawal states without delirium, which determined hospital admissions. Since age of 21 he was admitted several times in a rural or urban psychiatric hospital, presently being supervised monthly in an outpatient facility of a University Psychiatric Clinic. Because of his lack of insight, egosyntony and a very low compliance he systematically refused any psychotropic or psychotherapeutic treatment. His hospital admissions were based only on medical or legal problems.

Mental status The patient was admitted in hospital without psychomotor agitation or any behaviour problems. During the hospitalization his behaviour was normal. He is a good-looking man and sociable, making a good impression to the investigator. The sensorium was normal. He was well oriented for time, place, situation, and person. Insomnia was present especially during the first period of the night. Cognitive functions such as attention, perception and memory were normal. The assessed IQ was 109. Mood appears to be normal, the past depressive episodes have had fully remitted. Affects and the expression of emotions appear to be also normal. An inflated self-esteem was noteworthy. The patient considers that from psychological perspective he is entirely healthy, within the frame of normality. He may be “different”, but in a positive way. The patient’s past medical records, the data offered by significant informants about the lack of insight and egosyntonic attitude of the patient towards his systematic and harmful misbehaviour, corroborated with observations provided by the medical staff and other patients during hospitalization put into light the patient’s habitual abnormal traits of character. In this respect the patient has severe moral abnormalities: irresponsibility, incapacity to feel pity, mercy, guilt or remorse toward other people. He is callous, prone to be deceitful and manipulative in order to gain personal profit or pleasure by any means. The sense of grandiosity, the self centred attitude results in a disregard of the feelings and rights of others or in a lack of concern for the social demands, common rules and laws without any concern about possible negative consequences for himself.

205 Irritability leads the patient to reckless impulsive acts, lacking volitional control on impulses. He has a very low tolerance to frustration. Aggressive antisocial behaviours result from both “warm” impulsive acts and from “in cold blood” deliberated acts as well, the latter being prevalent.

Family and social history Family history: The patient’s father, mother and elder brother have chronic alcoholism. His mother suffered also from a Somatisation Disorder and was repeatedly hospitalized. Because she left the family (by divorce) when the patient was 2 years old, she contributed only genetically to the deviant personogenesis (as a vulnerability factor) of his son. The father (a skilled manual worker) might have contributed both genetically and environmentally (through education). Despite the fact that he was the sole supporting parent (mother left the family and the town), he had little implication in his education, being pedagogically incompetent. After the divorce, he had to rear 3 little children but his involvement in their education was low. The psychological familial ambiance was characterized by conflicts because both of the father’s alcoholism and the patient’s early life misbehaviour. School problems : The patient has a poor cultural background. He graduated only 5 classes of an elementary school and this in 9 years with modest results. He manifested absenteeism, indifference for learning, lack of discipline, misbehaviour toward classmates and defiance toward teachers. Military service was not carried out because of his previous diagnosis of conduct disorder, which was changed in early adulthood in a personality disorder. Job history: At age of 16 he was employed as an unskilled worker. He couldn’t maintain a job more than 1-3 months (he had about 36 employments) because of his misconduct (lassitude, bad work, conflicts, impulsive destructiveness, delinquent behaviour and manipulative self harm). After some hospitalizations he managed to obtain a disability pension of small amount (because he worked effectively only few years), insufficient for a decent self-support, which incited the patient to obtain money by immoral or illegal means. Sexual and emotional history: The patient started precociously his sexual life, which was non discriminative, excepting short relations that provided him material profit. No affective implication could be traced throughout his sexual relations. However he didn’t have any kind of abnormal sexual activity. Marital status: He chose to marry in a woman whom he met during a hospital admission (his wife has Bipolar Disorder and is 20 years older than him). Their marriage is without children. He deceived his own wife selling her house with all that was inside without her knowledge and permission, spending all money. However, he succeeded to conciliate with her and maintain her support. Marcel considers that he deservers everything from her without any obligation of reciprocity. Interpersonal relationships: The patient has the ability to make friends easy because of his charming, captive behaviour, when he considers that this could be profitable for him. However, these relationships are of short duration because of his deceitful behaviour toward others. He is incapable of a normal social adjustment in any collectivity. Legal and criminal problems : From childhood till now his misbehaviour shows many delinquent aspects. In most of the cases he succeeded in escaping sanctions by various manipulative behaviours or by finding a scapegoat. He was always pluri-delinquent but never committed a severe criminal act. Only two times he was sanctioned with a short period detention. Pathological habits : He became a chronic alcoholic with harmful consequences (medical illness related to alcohol systematic abuse) and with a syndrome of dependence with withdrawal state but without delirium. He smokes moderately and never used other substances, which determine dependence.

Medical history Birth and early development were normal. According to medical records, in childhood Marcel had respiratory infections. He recollects that at age of 7 he suffered a head trauma apparently without

206 consequences in the future. He also had a viral acute hepatitis type A. The most important organic medical problems were generated by his chronic alcoholism: alcoholic hepatitis, gastritis, and cardiomiopathy, the latter being also a consequence of his hypertension.

Hospital course and treatment history From 1971 till now, the patient had many hospitalizations in a rural psychiatric hospital and two in a University Psychiatric Clinic. Between 1971 and 1987 he was admitted in psychiatric hospitals compulsory (demands from police and juridical authorities) or referred by emergency room doctors because of his self-mutilating behaviour in front of the police (to escape possible penal sanctions). Therapeutically he was non compliant and refused any psychotherapeutic treatment because he was always considered to have a perfect mental health. Between 1987 and 1991 he was hospitalized for some depressive episodes, dissocial personality being only a background. The patient received tetracyclic antidepressant medication. Between 1991 and 2004 the main problem was the chronic alcoholism superimposed on the background of his dissocial personality disorder. The treatment was directed only for the acute manifestations of his chronic alcoholism, especially for the withdrawal states.

Differential diagnosis This case of Dissocial/Antisocial Personality Disorder has in common with other conditions such as: Adult Antisocial Behaviour (listed in the DSM IV at “Other Conditions That May Be a Focus of Clinical Attention”) and Conduct Disorder prolonged in adult life, the antisocial behaviour, but Marcel presents also the general criteria for a personality disorder (e.g. enduring inflexible and pervasive pattern across a broad range of personal and social situations). The absence of severe criminal behaviour with important forensic implications in this case of Dissocial Personality Disorder is a distinctive aspect between this personality disorder and the (old or new) concept of “Psychopath”. Marcel’s diagnostic of Dissocial/Antisocial Personality Disorder should be differentiated from other related Personality Disorders (Cluster B of DSM IV) with which it shares some common traits: impulsivity, unstable relationships and self-mutilating behaviour shared with Borderline Personality Disorder, inflated self-esteem shared with Narcissistic Personality Disorder, and a persistent manipulative behaviour (according to ICD-10) shared with Histrionic Personality Disorder. The inflexible and pervasive pattern of disregard for the feelings and the rights of others, for rules and obligations and incapacity to experience guilt and proneness to blame others clearly differentiates Marcel’s Dissocial Personality Disorder from other Personality Disorders.

Editorial comment This case illustrates almost all the diagnostic criteria for ICD-10 Dissocial Personality Disorder and DSM-IV Antisocial Personality Disorder. Despite the large diversity of its behavioural and personologic features, this case doesn’t display the severity of the nuclear-forensic type called the “psychopath” type The numerous hospitalizations were motivated by a tendency to escape from the legal consequences of his misbehaviour (self-mutilation when police arrives) and by depressive episodes or alcohol withdrawal states or alcoholic hepatitis. The patient never accepted that his real psychological problems are a consequence of a pathologic personality. Almost all of the diagnostic criteria for antisocial/dissocial personality disorders are present in this vignette. Marcel’s numerous hospitalizations were a result of an attempt, to escape from the legal consequences of his misbehaviour (self-mutilation when the police arrived) and by depressive episodes, alcohol withdrawal states or alcoholic hepatitis. The patient never accepted that his real psychological problems were a result of a pathological personality. The history of his illness includes the characteristics of an antisocial/dissocial prototype: divorced parents, emotional neglect by the only caregiver (the father), and social misconduct (fighting, stealing, destructiveness, poor school

207 performance, prolonged absences from home, adventurous escapades, etc.) He felt superior to and looked down on others, rules, and the law. He was cold-blooded, without remorse of the pain he caused other people. He never maintained a job for a longer period of time and he never completed an education. He exploited his twenty year older mentally ill wife. Because alcohol had a sedative, anti- depressive, problem-denying effect on him, he became an alcoholic with severe organic medical problems and dependency. This case illustrates that many antisocial/dissocial personalities manage to keep denying their personal difficulties or failure for years. It also illustrates how they have the power to control others through threats, cunning and charm.

208 CASE 16: Mr. M: Antisocial Personality Disorder Country of origin: Canada Author: Paul Links & Yvonne Bergmans

Identifying data This patient is a 55 year old male on social assistance, staying in a one room boarding home at the time of referral. Approximately three years prior to his referral, he had an iliostomy following bowel surgery. He was initially referred by his psychiatrist as a potential candidate for a group intervention designed for people with recurrent suicide attempts and participation in an antidepressant drug trial

Presenting complaint Mr. M. presented for his first scheduled appointment in the crisis department, reporting that he was locked out of his boarding home. His personal belongings, medications and ostomy supplies are still in the building. He went to the emergency shelter last night and reports he was denied a bed until he signed forms for permission to release information regarding his medical status. He reported that he was also told he had to have a community support worker in place before he would be considered for a bed. He took great offence to being treated this way, wondering why it was that he was being treated “unfairly” stating that “108 other guys don’t have to go through this. It’s just new rules for me.” In reminding him of the purpose of our meeting, he stated, “yeah she’s just stupid and trying to get rid of me. She says I’m just depressed. No kidding. I have a lot to be depressed about!’ ”. He stated, “I’m so afraid of myself right now, I’m afraid I’ll hurt someone else before I hurt myself, feeling really volatile”. He feels everyone is using his “health” as an issue to deny him access to what he needs.

History of present illness Mr. M. wanted to be admitted to hospital in order to ‘sort it all out. "The patient characterized himself as being a risk to himself and others. He reports currently being in “dire straights” and “going to kill [him]self”. He states he does not want to live; he only wants to be dead. Suicide attempts began in the past three years and he relates it specifically to his physical pain and his perception of not getting help. He lives with a non specified bowel disorder which has rendered him an iliostomy, left him with kidney and bladder trouble and he describes being unable to eat without severe and painful ramifications for a few days afterward. He reports that nothing has been found to give him any relief. He carries a great deal of anger toward the medical profession yet ultimately is still looking for help. He is unable to identify or articulate “the need”. He reports he is not afraid to die, just to die alone. He has attempted suicide four times in the past year, including overdosing twice and cutting his ostomy off. He identifies his major stressors as frustration around his medical issues and lack of control around the eating and pain issues. “I can’t control my life for even 30 minutes now” he states. He later identified being angry with life, having once been independent as a truck driver and helicopter pilot, making $150,000 per year now getting $547 a month to live on. He says he is angry with the world with lots of complaints. Mr. M. described recurrent thoughts of harming others. Although, he has almost constant ideation about hurting others; he has not been physically violent for the last ten years. Although the patient first reported that he felt depressed, he has changed this to saying that he mainly feels angry. His appetite remains poor mainly related to his bowel problems. If he is free of pain, he can sleep at night; although, he reports taking hours to fall asleep most nights. His energy and interest are not labelled as problems. The patient has asked for an antidepressant in the past but his psychiatrist has not prescribed any given there may be a question of liver and kidney dysfunction. The patient reported a long history of flashbacks dating back to his time in Vietnam, stating that when they occur, he is safest in “a rubber room”, isolated from everyone, with a substantial

209 dose of diazepam to get through it. He reports finding himself cowering in bushes and ditches trying to stay away from the onslaught of visual flashbacks. He avoids any material that reminds him of his war experience and he was unable to watch almost any action oriented television show. He reports frequently feeling anxious, “jumpy”, and described being hypervigilant when around other men. Mr. M. reported being alive for a variety of reasons. He states he is stubborn. Each time he has attempted to end his life, he has been found. He reports feeling like he can’t walk out in front of a streetcar as it wouldn’t be fair to do that to the driver who would have to live with having hit and killed someone. He notes he has given up his license as he knows he’s at risk of road rage and “doesn’t want to kill the innocent bystander”. He later reported that his license was taken away after his stroke.

Past psychiatric history Mr. M.’s psychiatrist identified that Mr. M. has a long history of psychopathic behaviour including experiences in Sing Sing and Viet Nam. He engages in a great deal of ‘acting out’ behaviour, overdoses, and stabbing his ostomy stump. The patient and the psychiatrist identified these behaviours as suicide attempts as the patient reported suicidal intent with each act. The patient described having been in a psychiatric facility only once for 17 months in Boston for heroin and alcohol addiction after coming home from Vietnam. He reports he has not used either substance in 25 years and substituted work for the addiction. Since becoming ill 5 years ago, he has not been able to work. His surgery for the bowel disorder occurred in 1999. He reports being diagnosed with antisocial personality disorder during his time with VA services, noting “of course I’m angry, look at what’s gone on in my life!” He then identifies anger for him as “frustration, fear, and pain”. The patient also notes that he has been diagnosed with post traumatic stress disorder and has received almost every type of psychotropic medication for his symptoms. He describes emotionally escalating where “everything is mentally blocked out” at those times and identifies that he has no control nor memory of what goes on during those times. He states that he will self injure in order to get away from that emotional plateau.

Family and social history Mr. M. reports being given up for foster care at the age of 5 while his twin brother remained with his mother. He remains angry about this. His understanding is that he “was too much to handle for her.” As a child, he was repeatedly in trouble with the police, frequently ran away from his foster homes, and had a history of fighting and being truant from school. Mr. M. insisted he has a university education in fine arts. Previous notes indicate that he can “be a man of skill and finesse, knowing how to do, and actually doing “fine needlepoint”. This piece of the history can not be verified. During his adolescence, Mr. M. claims he rode with the Hell’s Angel’s for many years, and states that he quit because he’s “getting too old for that”. He is clear that he has maintained contact with the group, “just in case [he] needs them”. He remains in contact with his aging mother who lives out of town. He denies any current contact with his brother whom he states has defrauded him. He refused to comment on his biological father except to say that his father was a criminal and was incarcerated for many years. Mr. M. was raised in the Jehovah’s Witness faith and stated he raised his two children in the same tradition. He identified serving 10 years in prison for manslaughter yet refused to provide details. He reports that his first wife and their baby were killed in a car accident by a drunk driver and angrily points out that he was sentenced to jail for a longer period of time for his behaviour in the courtroom during sentencing than the driver who killed his family. He refused to speak of his second wife, except for noting that they had two children together, neither of whom he is in contact with. He states he does not know what his son does for a living and states his daughter is doing a

210 PhD. in mathematics somewhere in the USA. He is not clear where she is. He believes his ex-wife has poisoned his children against him. He reports that he was a marine helicopter pilot during the Vietnam War doing two and a half tours of duty, reporting that he completed over 1500 missions despite being told not to. He tearfully noted that at the age of 21, he thought he was “invincible”, “a hotshot”, “the best and most decorated officer in the U.S. marines…” but then asked “and for what?” He states he owns five rigs which run out of Sacramento, California, However, he claims that he has no connection to those running the business and does not draw any salary from them despite them using his vehicles. He reports owning property and horses in a town just outside of the city, and has given the property over to friends who will take care of it for him as he states they “needed a place to stay more than I do”.

Medical history Iliostomy- surgery performed 3 yrs ago following bowel obstruction. The patient also had a history of hospitalizations for two myocardial infarctions and one minor stroke.

Mental status Mr. M’s manner is brusque with an angry and sarcastic tone. He sits huddled in a corner with his baseball cap over his eyes, slightly malodorous, his outdoor coat on despite the heat in the room, arms and legs crossed, not able to make eye contact unless he is making a demand or challenging statement. He is generally uncooperative when he is experiencing high affect, and he refers to professionals as “assholes, bimbo’s and jerks”. He is able to respond best to firm limits set with a logical consequence such as, “People often feel scared when they feel threatened. If you continue to swear and threaten in that manner, your concerns will likely not be heard and attended to.” He endorses feeling angry and depressed. However, the prominent affect is anger. His speech varies in rate and tone depending on his level of anger. He endorses suicidal and homicidal ideation but with no clear intent and no particular target for his aggression. He denies paranoid or grandiose ideation. The patient does not endorse altered perceptions. His thought form is normal. He is oriented and his sensorium is grossly intact. He demonstrates a good vocabulary and some superficial understanding of his problems. However, from history, he can be impulsive and act without thinking about the consequences.

Treatment history Although Mr. M indicated wanting to enter into group therapy, at the time of initial presentation, was not a good candidate for group therapy. It was agreed that he would be followed individually for 5 months by a group therapist in order to provide group readiness skills. He attended each of his weekly sessions, on time and regularly. He also accessed the therapist when needing support, going to the emergency room for medical concerns related to his bowel disorder. Initial sessions were primarily crisis based, often revolving around housing, obtaining medical supplies given that some of the necessary materials needed for his medical condition were not covered by social assistance, or “support-need translation” during emergency room presentations. The initial goals of therapy were to develop an alliance with this patient and to reflect to him how his behaviour was the predecessor to rejection by healthcare providers. Another goal was to more clearly state the need of a hospital visit in words versus behaviour as it was consistently documented in the chart how abusive this man was toward staff. It was also observed that emergency room staff, upon hearing Mr. M was on his way, would attribute his arrival exclusively to their bad luck and being on shift that day. His initial work consisted of identifying his fear of doctors and the defensive posturing he took when in contact with them, leaving them feeling battered and abused, and his feeling that his needs were not addressed, and he was once again “rejected”. He often lamented that “rules change

211 when I’m there”, believing that the treatment he was receiving was substandard to what others were receiving. He also began to identify the intensity of the emotions he was experiencing, even if he was unable to name the specific emotions. Crisis team staff were informed of his “scale of intensity” thus creating a more common language between Mr. M. and emergency room staff. There were joint sessions with his psychiatrist and case conferences with shelter/housing agencies and other social service agencies to find a “safer” place for Mr. M. to live. He was able to identify that he did not trust anyone, and agreed to establish ground rules for behaviour without trust between committed care providers, with the recognition that each behaviour was a choice and each choice had an effect. Mr. M. refused to fire his group therapist despite having fired every other care provider. When asked why this was the case, he only commented, “I think my first girlfriend was named_” At interaction 23, within 4 months, Mr. M. was able to report an interaction with a care provider that went well, identifying that he had not been abusive, he had asked intelligent questions, shown respect and had the same shown for him in return. Reporting this he identified that he would like to try the group intervention beginning in a month, stating he would “try his best”.

Editorial comment This case demonstrates that personality disorders often show lots of comorbidity. This patient meets the criteria for both the antisocial/dissocial, narcissistic and borderline personality disorders and for Post Traumatic Stress Disorder (PTSD) and substance abuse. As in this case, some of the antisocial traits and behaviours tend to “burn out” over time. The patient demonstrated little physical aggressiveness and his substance abuse disorder was in remission by the time he entered treatment. These patients are at increased risk for suicidal behaviour compared to the general population. However, the clinician, when making decisions about the treatment setting that best meets the patients’ needs, must remember that these patients might confer a risk of harm to other vulnerable psychiatric patients. These patients are difficult to engage and often expect to be dismissed or rejected. They quickly close off communication and their reactivity often precludes them from getting their needs met. Once Mr. M developed some trust with the therapist, he was able to modify his encounters with health care staff and increase his chances of having his needs met.

212 CASE 17: Alejandro: Borderline Personality Disorder Country of origin: Argentina Author: Claudia Astorga

Identify data Twenty-year old male patient, Alejandro, comes from a rural area. He worked as a farmer. He was sent to psychiatric treatment by a judge because he had had some legal problems: he had injured a neighbour.

Presenting complaint Social withdrawal, irritability, feeling of incomprehension from society.

History of present illness He was working with his neighbour Raúl, who was a family friend. They lived in neighbouring farms and their families were close friends. As a child, and because of his mother’s illness, he was left in charge of Irma, Raúl’s wife. Once Alejandro had an argument with Raúl, while they were working. Raúl fired Alejandro, owing him some money. That afternoon, Alejandro felt really disgusted, angry, resentful since he thought Raúl’s decision had been unjust. However, he told his parents – as he usually did – what had happened but he did not tell them about his inner feelings/ mood. He watched TV with his brothers and had dinner. Afterwards, once it was dark, he went to bed. He could not stop thinking about the episode and felt distressed. He knew these kinds of episodes had happened before but more vigorously. It happened when he faced embarrassing situations, some of them of a social type. That night, he got up barefoot, went across the field, walked into his neighbour’s house and injured Raul and his wife. He was arrested and sent for treatment.

Mental status Alejandro seems to be an ordinary man for his age, with the characteristics of any young farmer. Quiet, shy, he answers the questions properly, though unwillingly. He seems to be somehow anxious, trying to hide his anxiety and all his feelings. His mood is a little depressive and he is able to talk about the history of his family and about his past life – but only saying what he considers proper. He does not show any sign of hallucination and his thoughts show overestimated ideas.

Family and social history There is no evidence of mental illness in the history of his family, except for his grandfather on his mother’s side, who is alcoholic and aggressive. The relation among the members of the family is good. It is a humble family, in which the parents make an effort to give welfare and education to his children. Because they live in a rural area far away from school, when the time came for Alejandro to go to secondary school, he was sent to a remote city, where he lived during the term. He remembers those days as traumatic ones: he did not make friends, he felt isolated because of the countryside and he had problems to adapt himself to the place. Besides, he says his teachers discriminated him, although he was an average student. This was the cause for him to run away from the place. The same happened in a second attempt to finish school. The family group is made of four brothers with no difficulties.

Medical history Birth and early development were normal. The patient has never suffered from any serious illness.

Hospital course and treatment history

213 Sent by the judge, Alejandro was treated in a Security Neuropsychiatry Institute, not in a private surgery. During the first month of treatment, Alejandro was seen twice a week and later only once. The method used was supportive therapy, and it did not involve psychoanalytic interpretation. Most unfortunately, it was impossible to be in close contact with the family because they lived far away and because of their economic situation. However, his mother spoke twice. She said that, since he was a child, Alejandro had been quiet and introvert and that he had few friends and had a difficulty in meeting new people. He had a girlfriend in a nearby town, with whom he had a distant relationship. He was calm but when he became angry he shouted, though he never became physically aggressive. He had a good family relationship, although he sometimes argued with his father because Alejandro wanted him to act more sternly with the family. The other members of the family considered Alejandro to be too serious and quiet. He had done odd jobs without problems. In the sessions, Alejandro showed a cooperative attitude, though rather controlled. He spoke about the history of his family and while doing this he revealed strict moral and ethical concepts. He said he was angry with the person he had injured. He even admitted, after some sessions, that “that man deserved such a punishment”. At that time, the treatment focused in making Alejandro understand that his rigid attitude would not let him adapt. After some time, he started to show a dysphoric mood because he felt badly when he was together with his mates. So as to change this situation, Alejandro was asked to do some tasks, such as working in the orchard and cleaning. His mood improved only a little. At the same time, the idea that his mates discriminated him became stronger and that he could not get in contact with them since their attitudes were really different to what he thought was correct. He felt lonely, tough he preferred being alone. The therapist understood this situation as pre-delirium and it was decided to give Alejandro a small dose of neuroleptics: olanzaoina 5 mg per day. The medication improved the clinic condition and the thinking notoriously. This allowed him to have a better interpersonal relationship and a better predisposition with the therapist. His relationship with his family also improved: now he phoned them twice a week. During the sessions of the therapy, he became critical of his old behaviour and he admitted his aggressiveness towards his neighbour was excessive.

Differential diagnosis The patient does not show a schizophrenic disorder since this is characterized by psychotic symptoms, from which he does not suffer. He does not present hallucinations, disorganized speech, uncontrolled behaviour, or severe negative symptoms. As regards the source of the thinking, it was more of an overestimated type than a delusive one. A paranoid disorder was discarded although, at the moment of the crisis, the ideas became mini-delusive. A Borderline Disorder is discarded because in our case there is no instability or tumultuous behaviour.

Editorial comment This patient is interesting because the diagnosis remains in doubt. The patient commits an impulsive violent act after he felt unfairly treated. This appears to be out of character to some extent. However, the past history suggests that he did show angry outbursts. It is implied that the patient shows a level of over control in that he is shy, quiet and retiring with his peer group. His family members consider him to be too serious and quiet. He also shows rigid thinking patterns. This level of control of mind and behaviour is exhausting for patients and it is unsurprising that when provoked this patient breaks down and becomes verbally aggressive and, on the occasion reported, physically aggressive. It is possible that this man shows a narcissistic rigidity in which he is very sensitive to others’ actions against him. When he was sacked by his employer who was a family friend, the blow to his self-esteem and the inner hurt, may have led to revenge fantasies. The author points out that there is some evidence of a paranoid disorder and there are traits of schizoid

214 personality disorder. However, it may also be important to consider narcissistic features if treatment is to be adequately focused.

215 CASE 18: Anna Z: Borderline Personality Disorder Country of origin: Serbia and Montenegro Author: Dusica Lecic-Tosevski

Identifying data Anna Z., 29 year old student of philosophy was hospitalized in Personality Disorders Unit of the University Psychiatric Clinic. Hospitalization was suggested by the professor of psychiatry who at the time supervised the inpatient treatment of her mother because of chronic depression with hypochondriasis. The professor observed “an intense pathological symbiosis between mother and daughter, with immense mutual destructiveness”.

Presenting complaints Mood oscillation, problems with interpersonal relationships, pressure in the head and a diffuse fear, as well as the academic inhibition.

History of present illness Before referred to me, Anna was in psychotherapy with a psychologist for about ten years, and hospitalized many times. That treatment was interrupted due to a growing conflict which she developed with that therapist. Ever since the childhood she had a lot of problems. As a child she was treated by a child psychiatrist for a few years for temper tantrums. Sometimes she feels excitement and euphoria and “a dance of her whole body”. At other times she is depressed and cannot move. Anna has very bad relationship with her parents, especially the mother who is blackmailing her by threatening that she would die. Anna felt guilty because of many things – because of her parents’ divorce, because her mother is to be put in a house for old people (which she wished strongly), because she was “not good enough to be loved” (her father’s words). She was obsessed by death and believed that she would die on her birthday that year. Number seven had special importance for her. Seven years ago on her birthday her aunt died, and her best girlfriend died seven years after she had met her. Seven years later she met me “which must have some importance”. She had fears of many things, a “vacuum fear” in her head. She frequently masturbates but is frigid, with painful intercourses, feeling that her body is disintegrating during it. Some of her boyfriends were drug addicts and one of them died of AIDS. Occasionally she smoked marihuana. She falls in love quickly, lately with unavailable, beautiful men, actors or ballet dancer. She is intrusive, sends them letters and phones to them at the most awkward times. Anna described herself as immature, sensitive, narcissistic person, with a need to attract attention. She believed her thoughts were powerful, and felt either superior or inferior. Slowly she was transforming into her mother, and in the mirror often saw her reflexion. She was taking diazepam uncontrollably, often combined with alcohol.

Family and social history Anna’s parents met during their inpatient psychiatric treatment at the same hospital. Mother, a commercialist, was treated for depression, which lasted her whole later life, with associated phobia of malignant diseases. Her father, a well known literary critic was treated because of “Kafkian’s dilemmas”. They married soon afterwards since her mother got pregnant. The marriage was very bad from the beginning and lasted 13 years, when they divorced. Mother was disappointed giving birth to Anna, since she was expecting a son, and used to say that ”she brought another sufferer into the world”.

216 Her parents lived a bohemian life, leaving her to the care of her grandfather in a province, when she was two years old. Her grandfather both loved and beat her; he was cruel like her father, but “a little warmer”. Once when she was thus punished by her grandfather she did not speak for a whole month, just made some drawings. She loved her aunt, father’s sister. That aunt was treated for twenty years in many psychiatric hospitals, as a suicidal hysterical personality, with psychotic decompensations of a schizophreniform type (this was confirmed by a medical chart). Mother retired when Anna was four, due to her psychiatric illness. Anna cannot describe her - she hates her and longs for her, she could kill her, and feels guilty because of it. She thinks that her mother never loved her, but only manipulated her by repeated stories that she would have committed suicide had she not been born. “Father is an intellectual” (Anna says it with an ironic tinge), “an emotional invalid, intellectual monster, with developed spirit, but retarded soul”. He beat her when she was small (mother did, too), and cannot show any feelings. He rejects to meet her and does not help her although she is very poor. He only expected from her to study. When she would speak about her problems he would suggest reading Kafka, or overcoming everything "by Hesse’s humour". During her childhood "she was an impossible child”, aggressive or withdrawn, with frequent temper tantrums. She studied philosophy, which she now finds meaningless. She has two exams before graduation, but has fear of graduating. She used to work as a journalist for the youth radio, and occasionally wrote texts for some journals.

Mental status Anna always wears trousers, with "I don’t care” looks. She talks fast and much, with a lot of foreign words, as if wishing to leave impression. The whole interactional field of the first few interviews was overwhelmed with a story of having been jeopardized by her parents and feeling of anger towards them, people who never accepted and loved her. Her interpersonal relations are intense and unstable, which she instantly manifested quickly entering into the transference, demanding this therapist to rescue her from threatening death. Her emotions are changing quickly - she speaks about her "awful melancholia" and obsessive thoughts smiling, with rather indifferent looks. The persons she mentions are either ideal (me or her lost friend) or worthless and devalued (her mother and ex-therapist). Thus she can’t experience ambivalence, but splits the object images. She never had delusions or hallucinations (reality testing had been always intact). Affective resonance was preserved.

Diagnosis Diagnosis of borderline personality disorder (BPD) with infantile, histrionic traits was not difficult to make (she was understood that way in previous psychotherapy, too). Diagnosis was confirmed by various tests (Diagnostic Interview for Borderlines – Revised (DIB-R), Structured Interview for Personality Disorders (SIDP) and Millon Clinical Multiaxial Inventory (MCMI). MCMI has shown prominent dependent, histrionic, narcissistic, passive- aggressive and borderline dimensions. Anxiety and dysthymia were the most prominent clinical scales. Anna had structural characteristics necessary for BPD: diffuse identity, primitive defence mechanisms cantered around splitting and intact reality testing. Anna is emotionally labile, with a combination of dependent and exhibitionistic traits. She cannot control her impulses in conflict situations. She is pseudo hypersexual and sexually inhibited Anna is pseudo promiscuous, which is probably a regressive defence against her genital fears. Thus, preoedipal and oedipal situation are united in this girl, with fusion of libidinal and aggressive impulses, which is shown by flooding of all erotic contacts by "swallowing", control and overreacting. Her histrionism is also seen in the following: vaginal anaesthesia; contacts with unavailable men; falling in love at the first sight; infantile, oral-aggressive behaviour; brief encounters by which she remains locked in her eternal suffering, boredom, emptiness and worthlessness.

217 Her relationship with mother (her wish for autonomy and separation, with intense need for a continuous contact and emotional gratification - "I want to separate from her, and I need her badly"), showed unmasked, reactivated conflict during rapprochement subphase and only touched but not adequately used the road to self and object constancy. She manifested diffuse identity which was shown by contradictory personality attributes - she perceives self and others in a contradictory manner (she is superior, Nichean, and creative, and immediately afterwards ugly, negative and evil). She cannot adequately describe her relations with others, so that persons she talks about look like human caricatures. Anna impulsively makes decisions, just to change them soon afterwards. Her self-esteem oscillates and she has ego-syntonic impulsivity (drugs, alcohol), which are manifestations of her splitting. She splits the external world into all good and all bad, with sudden and complete change of her attitude towards herself and others. Anna has tendency to experience external objects as omnipotent figures of incredible power, by the mechanism of primitive idealization (therapist is powerful, will rescue her, lead her ”to the light and wisdom”), which I understood as a manifestation of a primitive protective fantasy and a projection of an ideal split-off object into me. She is also “powerful” - she can predict events, her thoughts come true, she knows the day of her death (omnipotent self-experience, as a defence of helplessness, negative self-concept, i.e. her bad, real, false self). Anna is thus protected from her intrapsychic conflict, but her ego is weak. She cannot tolerate anxiety; her behaviour is impulse-ridden (she drinks alcohol, talks on the phone for hours, takes a lot of benzodiazepines) and does not have sublimatory channels. She also has polysymptomatic neurosis, and thus, in my view, fits into a classical Kernberg’s description of borderline personality organization.

Medical history When entered treatment Anna had no serious somatic illnesses. Later in life she developed diabetes mellitus, anaemia, and myomatous uterus for which she had to be operated upon.

Hospital course and treatment history Anna expected from treatment to become less hysterical, less aggressive, to learn to make adequate relationships with men and to separate from her parents. During her eight weeks stay at the Clinic, the modified psychoanalytical psychotherapy was applied three times weekly, and after that, once a week at the Outpatient Clinic. She was treated by SSRI medication (Floxetine), but she was not compliant, and would rather take Diazepam. After the resistance I felt at the beginning because of her intrusive and controlling behaviour, I felt empathy for her experiences and her infantile helplessness. I tried to maintain a neutral, quiet stance, without anxiety which she had shifted into me, as well as not to be drawn into her chaos and confusion. However, I have not been successful many times. I was aware how strongly she had been trying to symbiotically fuse with me (from the first days she put some demands to me and tried to seduce me by saying how special I was). Anna felt safe and protected in the hospital, near me, she said. She feared leaving and going back home were she was to be alone, without her mother who in the meantime has been hospitalized at the psychiatric hospital for the elderly. Soon after the beginning of treatment she "felt very well", and talked to everyone about it, especially to her father whom she phoned after a long time. The communication with me "has shaken her" (she said I confronted her pseudo- intellectuality). I focused my attention on her behaviour more than on the words which were between her and me like the fences, and which were coloured by intellectual interpretations and bizarre, contradictory communication. Soon she distorted the meaning of my comments, to which I reacted clarifying what was said, and confronting the distortions. She idealized me, and has been doing it during the course of many years calling me her “guru”, her “friend”, bringing me gifts and writing letters. But, she would easily feel hurt and would become

218 aggressive whenever I confronted her contradictions and chaos, or coming late to the session. Then I was either her father who criticizes her, or mother who never understood her. I felt that she has developed strong narcissistic transference, in which I was put into a role of a protective, magic archaic self-object, with narcissistic fantasies of her power. "My Om, my Absolute, and mantra are words: no one can do me any harm, no one can threaten me", which she repeated with my image. Before she used to do it with the image of her friend who died - her idealizing transference by this clearly unveiled a defence against her hostile feelings towards me. "I need you so badly; it would be awful if you rejected me. You have taken all my defences, when you confronted me with my theories, and distant emotions. I want to get in touch with myself..." After the first two outpatient sessions she did not appear for a month. When she came she said: "I am one of many to you; you smile to everyone the same way". She brought me drama which she wrote with the dedication: “To my guru”. Drama was written “in Becket’s manner” and was full of emptiness and absurd movements. When she would miss a session, she would appear handing out a gift, a chocolate, or a book, like a small guilty child. Since I have not been fulfilling her unconscious expectations to reject her, she would say how she experienced intense fear and not feeling her body. “She did not deserve attention and acceptance since she was evil and dirty”. She would often come with a medical report showing how she had toothache, rhinitis, or “heart problems”. The latter was a manifestation of panic attacks which she often had. She would ask me could she get an ischemic injury - she was smiling when confronted, partly aware that this behaviour is an identification with her mother and a symbolic expression of her need for attention and care. Two days after she had finished her drama, her mother died ("I was right to be afraid of finishing things - something bad always happens"). Mother was buried at the hospital graveyard, without family present at the funeral. After that she began to feel hope saying that in encounter with me “her bad destructive self will die and she will live a new life”. She met a new boyfriend who soon became her husband and became orgasmic. After intense treatment of 40 sessions, Anna disappeared for two years. Meanwhile she developed a severe form of insulin dependent diabetes mellitus. She seemed satisfied with this development, since she now had a real problem. Finally people had to believe her and pay attention to her. She was very poor, and had to sell her apartment and buy a small wooden summer house near the river, in order to be able to live and buy necessary medication. Soon her marriage became disharmonious since she could not tolerate her husband’s daughter from the previous marriage. Her husband was a passive-dependent unsuccessful painter who obtained money by selling jewellery which he made. She was provided a medical testimony which gave her a modest disability pension. Her complaints were much milder and she was preoccupied with her somatic illness. Her chief complaint was insomnia, which was actually a sleep inversion, since she liked to sleep during the day. Her pattern of coming back into treatment and leaving it has become habitual. When she finally appeared again last year, 13 years after the beginning of treatment, she developed severe anaemia due to haemorrhage caused by myomatous uterus, for which she had to be operated upon. During the second round of the treatment, when she asked to “start again an intense psychotherapy”, I suggested supportive treatment on PRN basis. Structuring her life was focus of the treatment. She decided to continue her studies and succeeded in passing and examination after 10 years.

Differential diagnosis The case clearly indicates a diagnosis of a severe personality disorder. This type of personality is now classified as borderline personality disorder, but could be also diagnosed as both histrionic personality disorder and borderline personality disorder, according to DSM-IV and ICD-10 nomenclature. The patient was socially and professionally incapacitated, but has never developed

219 psychotic symptoms, so schizophrenic disorder should be excluded. She did have depressive episodes in her past and they can be expected in the future, when dual diagnosis should be made.

Editorial comment There are some immediate things that are clear from this vignette. It is notable that the patient was with a psychiatrist for 10 years and hospitalised many times. This is an extremely long treatment, which was eventually interrupted due to conflict that developed with the therapist. It is possible that continuous treatment for so long may harm borderline patients. They are extremely sensitive to therapy interventions and can become over involved with therapist and dependent on seeing them. The result can be that they become trapped in therapy with very little progress being made. A learning point is always to consider whether or not your patient is showing development outside the therapy. Patients may appear to be using therapy within treatment appropriately but in fact their lives outside are not changing at all. This suggests that the therapy is being used to structure their life but not used as developmental process. The author points out that modified psychoanalytic psychotherapy was applied 3 times weekly with this patient. The term “modified” is important. It is unclear how it was modified but in general terms many therapists consider all therapeutic interventions have to be of a modified form with borderline patients. It is also notable that this patient showed sporadic attendance. This is common with borderline patients and therapists have to be able to manage non-attendance in order to prevent a therapy breaking down. Interestingly, the patient had intensive treatment of around one year (40 sessions). The patient then did not attend for 2 years. However, she did return. It is notable that this patient behaved like many borderline patients. She came for treatment but then left but then returned and left again. It is important that therapists allow patients to leave in a manner in which they can return to therapy at some point without it being humiliating.

220 CASE 19: John: Schizoid Personality Disorder Country of origin: Denmark Author: Morten Kjølbye

Identifying data John is a 23 years old man. Despite extraordinary intelligence John was not able to complete or participate in any educational program, and is unemployed at the moment. He was referred from his GP to individual psychotherapy, and was seen for evaluation at The Clinic for Personality Disorder.

Presenting complaint John’s main complaint was an inability to concentrate and a tendency to be socially isolated. He therefore felt that he was old before his age, and felt that he was tired and senile. He wanted to have a normal life with a family and friends, but thought that he was rootless, aggressive and felt that other people thought that he was peculiar or odd. He felt that he was outside relationships and that other people exploited him, because he had special gifts and talents in computer management.

Family and social history John is the eldest of two sons and grew up under unstable and chaotic circumstances. His parents were never married and hardly ever stayed together. He never had a stable relationship with his father, and later thought that his father did not manage the responsibility as a father. His paternal grandfather had died in a concentration camp during the Second World War and had been taken by the Germans in the middle of the night. The grandmother never talked about her husband. John describes his father as a violent man with a bad temper. He would often leave the house in a rage and return after several days. For long periods he would disappear completely and return as nothing had happened. The mother was sweet but non-caring. She was often not at home working, and the patient and his four years younger brother was handed over to different maids. John remembers one particular with affection, but she was driven from the house by an enraged father. John claims that his first recollection in life is from his first year of life. He remembers the feeling of lying in a cradle and being choked. From the age of about three he remembers that he did not mind if the other children played with his toys, but when he took them back, he was surprised that they made a fuss about it. He went to various schools because his parents moved around. He was thought of as a lonely wolf and did not participate in the social life or games of sports with his peers. From around the age of thirteen he became interested in computers and was quite advanced in his understanding of mathematics. He became exceedingly isolated with his computer as his sole companion.

History of present illness Since his early childhood John has not been interested in playing with his brother or his peers. He has preferred solitary activities, and from puberty he became absorbed in computers. Around his eighteens birthday John began to have the idea that there was something wrong with him, that he was different from other young men, because he was not interested in sex or girls. He compensated by telling that he wanted to have a family, but in fact he was not interested in it at all. He was fare more interested in his internal world inhabited with aggressive figures. He became more and more isolated and began indulging in aggressive fantasy, reading extremely violent cartoons and watching macabre videos.

221 During school class he was often absent minded being absorbed in his own thoughts and fantasies. He did not bother about his teachers complaints and was also indifferent to the praise from his mathematics teacher. His school mates soon learned to let him be. At the psychiatric interview he explained that he has two close friends, but on further elaboration it turned out that one friend was living in another city, and that they only met two or three times a year. During their meeting they went to the cinema and saw two or three films together. The other friend was a neighbour with whom he played on the Internet. They actually seldom met, but participated in the same game with other players on the Internet. Recently John developed a computer program that could play the Internet game for him, so that he did not have to sit in front of the screen all the time. In fact he did not interact in the computer contact because his computer program won all the battles for him. John complained that he was not able to concentrate so that he could read a book and told that he often got caught up in his own associations and could, so to speak, wake up after half an hour of internal fantasy. He was not able to use these fantasies as a resource to solve problems.

Mental status At the assessment interview in the outpatient clinic John presented himself as a small, lean young man. During the interview he was quite emotional distant and seldom looked at the interviewer. Occasionally it was difficult to follow his thoughts, and it was quite characteristic of him that he either generalized his problems or quickly denied them after telling about them. The interviewer sensed some hostility from the way the patient answered the questions in the interview, but when confronted with this he quickly denied and withdrew further from the contact, and began to talk about his preoccupation with his computer and that he longed for a normal life He said that he longed for emotional contact, but he demonstrated in the interview considerably difficulties in being in contact. It was quite hard for ham to describe his feelings, and he was also quite out of touch with what happens in the interview. In the SCID-II interview John disclosed some avoidant traits such as a preoccupation with being criticized in social contact, some obsessive-compulsive traits as a preoccupation with details, an excessive devotion to work and an inability to enjoy leisure and a reluctance to work in cooperation, because he wanted things done “my way”. He also showed some narcissistic traits being preoccupied with his own ingenious and fulfilled the diagnostic criteria for Schizoid Personality Disorder, in that he was not able to enjoy close relationship and laced close friends, always chose solitary activity, was not interested in sex and showed emotional coldness and detachment in the interview. The patient has never suffered from hallucination or thought disorder or any serious physical illness.

Treatment history The patient was offered individual psychotherapy and accepted this. After a few sessions he did not turn up for several appointments. After several letters he came to the next session but then began to come late for the succeeding sessions. He was a bit confused, could not find the therapist’s office or said that he had fallen to sleep and therefore had missed the bus. After working with the patient’s resistance towards therapy in the next half year, the patient began to come more regularly and began to talk about his aggressive thoughts and his preoccupation with sadistic fantasies. This was quite terrifying for the patient, but after some time he became more confident and relaxed in the psychotherapeutic relationship. John was put on narcoleptics as an attempt to reduce his aggression, but soon quit this treatment because he complained of being in a mental restraint jacket. He is coming steadily to the psychotherapy sessions, but can for long periods be quite detached.

222 Differential diagnosis The primarily differential diagnoses are Schizotypal and Avoidant Personality Disorder. In the latter case John’s wish to have a close family was perceived as a defence rather than a genuine wish for close interpersonal relationship, and in the former case John did not show ideas of reference or odd beliefs or thinking.

Editorial comment This is an interesting and informative vignette on a rather typical case of schizoid personality disorder. The strength is the detailed description of items in the biography and social history which are quite specific for the development of schizoid personality stiles. Especially the difficulties how to establish a stable relationship to significant others like father and mother are very impressive in the childhood of John. These problems even go further back to the grant parents and the distortion of their lives during World War II. Such hidden burden as well as the insufficient qualities of the mother regarding the binding behaviour are plausible ethiopathogenetic forerunners of John’s deficiencies in establishing close relationships. Some questions could be formulated concerning the discussion of differential diagnosis. Often it is regarded as unusual that a person with schizoid personality disorders complains by himself or herself to be isolated. Many schizoid patients, in the contrary, claim to be quite satisfied with their loneliness. In addition it sounds quite unusual that John utters the wish to have a family. Also in this respect schizoid persons usually accept their situation or even deny any desire for closer relationships. If John says that he longed for emotional contact, this might have been already the result of some reflection on his situation induced by interventions of the GP or other persons with therapeutic intentions. In summary the considerations on the differential diagnosis are convincing that it is more a schizotype than an avoidant personality disorder John suffers from.

223 CASE 20: Jim: Narcissistic and Antisocial Personality Disorder Country of origin: Netherlands (Dutch Surinam) Author: T.M.J. Huygen

Identifying data The patient is a 28 year old black male (of Surinam descent) who is already for several years an in- patient of a state forensic clinic. In July 1997 he has been convicted for death threats towards his ex girl friend and arson: he set fire to her apartment, jeopardizing the lives of twelve people living in the same building which had to be evacuated. The court sentenced him to 18 months imprisonment (with deduction of the period of preventive custody) and subsequent involuntary psychiatric treatment in a state forensic clinic (legal frame: “TBS” = patient was put at the pleasure of the government). Because of a relatively long period of preventive custody the treatment could commence already in August 1997. Jim appealed against the sentence; this appeal was rejected by the court in 2000.

Presenting complaint Jim has never had any psychological or psychiatric complaints.

History of present illness In the year 1993 at the age of 17 Jim meets Elsa, then 14 years of age; she is the victim in the present case. In that period of time Jim had been expelled of school because of frequent truancy. He hung out with youth gangs, indulging in a criminal life style and often having large sums of money to his disposal. Jim remembers the relationship to have been pleasant at first. He was able to pamper Elsa financially and went out with her a lot. Elsa remembers Jim to have been nice and considerate in this early phase. The relationship deteriorated when Elsa announced she was pregnant and subsequently chose to have an abortion without conferring with Jim. He was deeply offended by this, thought of it as murder and had wanted to have a say in the matter. Conflicts started to increase from this point – the beginning of 1994 – onward. Often Jim would give her expensive presents after a row which he would reclaim at later rows. Elsa remembers Jim to have changed gradually: he became closed and Elsa had difficulty reading his moods. She suspected him of having other affairs and confronted him with this. In the ensuing row she was beaten by Jim for the first time. From that time on Elsa became afraid of him because she could no longer connect with him during his aggressive outbreaks. As a result she decided to leave him. Jim went trough a lot of trouble to try to re-establish the relationship, visited her daily and cried many tears, hoping to mollify her into taking him back. Eventually Elsa gave in to his pleading but remained fearful of his potential aggressiveness. Late 1995 the relationship came to a permanent end. Both are convinced to have taken the initiative as to this decision. Some weeks after that the criminal acts took place. First Jim threatened Elsa to throw a bomb in her house. Instead, he poured gasoline in her hallway – choosing to pour it in the pattern of a single number that was significant to them both – and set fire to it. In the pre-trial psychiatric and psychological evaluation the criminal acts were explained as having stemmed from narcissistic rage. It stated that the relationship with the victim fulfilled Jim’s need for security. Furthermore, the relationship had deepened because Elsa had set limits where Jim’s mother had never done so. Precisely in this dependent relationship Jim had been highly vulnerable. The narcissistic hurt after the breaking up had been great. Threatening the victim did not have the result Jim desired: Elsa refused to re-establish the relationship. Soon after this Jim set fire to Elsa’s house.

224 Previous convictions: Jim had been convicted earlier by juvenile court for attempted rape, violence and death threats. Noteworthy is that Jim during his pre-trial evaluation denied all allegations at first, only to admit to them when he heard that certain private forensic clinics would be out of his reach because they would only treat patients who had owned up to their criminal acts. Only then he confesses to have set fire to Elsa’s house, adding that he had been under the influence of alcohol.

Mental status Jim is a well built black male, well groomed and wearing clean clothes. He has a certain charm but often chooses to be derisive and mocking. Orientation and attention are without fault. His intelligence appears to be at least average. There are no psychotic features of any kind. His mood is neutral with a tendency to dysfori, though he is well able to make derogatory jokes with an arrogant laugh. His general behaviour on the ward is marked by a strong need for affection, attention, admiration and acknowledgement by staff and fellow-patients. When these needs are not met, he shows himself to be a self conceited man with a poorly developed conscience. When faced with possible problems, Jim doesn’t avoid these, but, on the contrary, seeks an active role to undo his sense of narcissistic hurt. He has a tendency to fantasize about his superior talents and future successes. His actual relationships with other people are of a shallow character and usually aimed at fulfilment of his needs and wishes. Jim has shown no aggressive behaviour, but when cornered or slighted, he seeks refuge in verbal “offensive defence”, choosing to be as insulting and despising as possible within the social rules set on the ward.

Family and social history Jim’s parents are both from Surinam; Jim was born there. Both parents had earlier relationships from which several children were born. Jim was the fourth and youngest from his parents’ relationship. Mother decided to emigrate with her children to Holland when Jim was a one year old baby, leaving Jim’s father because of his infidelity. In the years that followed mother appears to have physically abused her children on a regular basis, causing the eldest children to run away from home. Two of them were placed in foster families, Jim and his sister Lucia were allowed to stay with mother. According to mother, Jim was a normal, lively child that functioned without problems in the family. She denies to have spoilt him, but admits with a smile that her daughters are of a different opinion. On primary school Jim shows serious behaviour problems, which result in getting him sent to a special school for children with severe educational problems. The headmaster remembers Jim to have been aggressive, impulsive, threatening to fellow-pupils and neglectful of his self-care (torn clothes, insufficient hygiene). Mother, when interviewed about this period of time, minimalizes her son’s problems. She feels she had no part in them, and stresses that she kept her son indoors as much as possible after school hours for fear of wrong influences. She did not think social contacts to be of any importance to him. When Jim is twelve, he meets a 54-year old man, Mr. Green, on the soccer club of which he is a member; Jim is a talented soccer player. This man tried to support and care for Surinam boys like Jim that were having problems at home. Jim decided to move in with this man. Mother reacted by filling some plastic bags with Jim’s belongings and declaring that he needn’t return to her. The Council for Child Protection tried to prevent Jim’s moving in with Mr. Green – who was a known paedophile – but these efforts failed because of Jim’s refusal to cooperate. Jim states never to have been sexually abused by Mr. Green but admits having witnessed sexual abuse by Mr. Green of some other boy.

225 Jim’s school teacher provides the information that Jim, together with two other boys, sexually harassed a girl from their own class when he is thirteen. Jim however claims no recollection of this. The period of secondary school can be described as a chain of failures. Jim is sent to several schools but fails to maintain himself on any of them. Because of repeated behavioural problems similar to those in primary school he is expelled from each and everyone of them. When Jim is seventeen, he is found guilty twice for sexual assault, rape threats and life threats to a girl from his class. The court however released him on probation, and ordered him to follow a course about victims, which he did with little attention. After leaving school Jim has no regular job, but he does have substantial sums of money to his disposal. He says to have gotten this from family and friends running hash shops and brothels, for which he sometimes would have to transport clients or girls, or would have to be temporary caretaker of apartments. Jim uses alcohol and marihuana in moderate quantities on a daily basis. At this age Jim meets Elsa (see under History of present illness).

Medical history Jim has had no physical complaints or any somatic problems. On admittance he appeared healthy. Physical examination and routine checks revealed no pathology of any kind.

Hospital course and treatment history During his stay in the clinic (a stay which lasted for almost three years) Jim has shown quite different patterns of behaviour. The first nine months were marked by conflicts with the treatment team, trespassing of ward rules (using soft drugs, smuggling a mobile phone into the clinic) and his fending off any form of treatment. Jim was consequently confined to his room for longer periods of time. During these months the findings of the pre-trial psychiatric and psychological evaluation could be corroborated. Jim showed indeed seriously narcissistic and antisocial patterns of behaviour, a grandiose sense of self-importance and a heightened sensitivity to narcissistic injury. After nine months the treatment team concluded that therapeutically little else was possible than offering Jim a simple nursing programme consisting of letting him spend most of his time on the ward, with the daily possibility of doing sports and having walks in the closed courtyard. There were too many impediments to consider a useful therapeutic programme. Jim lacked any problem-awareness, experienced no sense of any suffering and did not invest into efforts to change, all the more so after – to his evident disappointment and against his unrealistic expectations – the court decided to prolong his detention 1 for another two years. After this court decision, however, Jim’s behaviour showed a slow but unmistakable positive change. At first this could be recognized as superficial over adaptiveness, as Jim often resorted to his attitude of sarcastic “offensive defence”. As time progressed, however, a more structural change became visible. Jim’s behavioural problems disappeared to the background, he chose to be more constructive and appeared sensitive to therapeutic interventions. In the fall of 1999 he started sessions with a psychotherapist to work through his life history and analyse the dynamics and risk factors concerning the offences he was convicted for. He showed himself motivated for this endeavour and committed himself to the arduous task of writing down all that seemed relevant in this respect. Jim showed remarkable openness about his acts and appeared well able to reflect on his motives and internal dynamics. He made obvious progress in taking responsibility and in reaching insight into the mechanisms behind his behaviour. Jim followed a treatment programme on aggression and anger, and showed eagerness to learn new cognitive ways to control his aggressive impulses. During the part called Moral Reasoning (about making choices in moral dilemmas) it was noteworthy that Jim often had divergent points of view, mainly caused by his strong clan loyalty to his family and friends and his subsequent

1 In the Dutch juridical system the TBS-measure is reviewed by the court every two years; the court usually follows the advice given by the clinic as to prolong it for another two years or not. In this case the court followed the clinic’s advice to prolong the measure.

226 unwillingness ever to betray them. Jim nevertheless showed an open attitude to fellow-group- members and the therapists, and was prepared to take positive contributions into account. All in all he was experienced as an active and pleasant participant. These positive developments led to a gradual increase of freedom of movement and, after some time, to periods of leave outside the clinic, at first supervised, but later on without supervision. A transfer to a resocialization unit was considered and eventually – with some team members having severe doubts despite Jim’s apparently stable progress – decided upon. After his transfer to his new unit, however, things started to go less well. Jim was allowed a fair amount of freedom and was expected to show sustained responsibility in matters of ward discipline and social rules. Old behavioural problems began to surface again: Jim became nonchalant in living up to appointments with the nursing staff and lied about his whereabouts. He showed increasingly manipulative behaviour and was at some day suspected of having smuggled soft drugs onto the ward. He wrote an open anonymous letter – in twisted hand writing – to the head of the clinic accusing an innocent fellow-patient (and his family!) of this, which at first caused a chilling buzz of suspicion around the clinic. Graphological examination, however, showed Jim to be the only possible author, which – when confronted with this – he vehemently and indignantly denied. Because of these negative and ominous developments Jim was transferred back to his old ward. After this he showed a chain of offence related behaviours: kindling ill feelings and hostility between fellow-patients, exploiting other people’s vulnerabilities for his own advantage, striving for dictatorial leadership within his peer group and showing a generally derogatory and mocking attitude to the nursing staff. His position among fellow-patients gradually became dubious. Although he was still able to impress them with his verbal sarcasm and rebellious leadership, more and more patients sought to distance themselves from him. Jim himself – sensing his increasingly threatened position – requested after some weeks for a transfer to another clinic, which the treatment team – seeing no more possibilities for Jim’s treatment – endorsed. The head of the clinic subsequently decided in favour of Jim’s request. Some months after Jim left the clinic, he submitted a complaint at the Medical Disciplinary Council, accusing the clinic psychiatrist and the head consultant of harmful negligence, and claiming substantial financial damages. The case is still under the Council’s scrutiny and will involve a formal hearing in about two months. An earlier attempt by the Council to settle the matter amiably was met by Jim’s stern refusal to reach any agreement whatsoever.

Editorial comment The case of Jim is one of impulsive violent reactions to rejections and boundaries, and to other threats to the vulnerable narcissistic self-esteem. Primitive entitlement and super-ego deficiencies were occasionally counterbalanced by grandiose fantasies and temporary adaptive behaviour at the perspective of gaining privileges. The patient’s primitive and impulsive responses to expectations and responsibility show his severe character disorder and lack of genuine ability for responsibility and concern. His long history of violence, deceitful and criminal behaviour, and interpersonal manipulativeness, proved to be not possible to change with treatment in a forensic clinic. The patient show more impulsivity and extreme affect dysregulation, with lack of moral and structural integration. He seems driven either by efforts to gain power, control or privileges or by enraged entitled exploitativeness. In my opinion, he does not seem to have the internal organization of focused narcissistic rage, but more of indiscriminative and revengeful violence.

227 CASE 21: Borderline Personality Disorder Country of origin: Brazil Author: Marco Aurélio Baggio

Identifyin data Júlio is a 36-year-old businessman of Spanish origin who is involved in a non-marital relationship with Eliane. He has three teenage children from his first marriage.

Presenting complaint He complains of despondency, fatigue, a desire to abandon everything, and incapacity to deal with his business and his affective life. He has expressed a desire to quit smoking and gambling, and admits to having been addicted to Bingo in the past.

History of present illness His disturbance has accompanied him since he was a child. He considered himself to be weak, inadequate, and inferior in comparison with his friends. He developed a verbal aptitude, which gave him some compensation by earning him a reputation for being “intelligent”. With some degree of embarrassment, he related his growing difficulties of becoming sexually aroused with his partner. He also felt morally guilty whenever he procured the services of prostitutes.

Mental status His mental status was marked by constant vacillation and indecision. In general, he regretted what he had done. He always seemed to have had an equivocal attitude. He lived immersed in a state of intense diffuse anguish that permeated his entire being. His gait was slow and tottering as if he were an old man. It appeared as though he were carrying the world on his shoulders.

Family and social history Of humble descent, his parents immigrated to Brazil when he was 3 years old. His father was a travelling salesman, slightly worn out by life. His mother was an angry housewife, harsh and dissatisfied, always complaining and giving orders to everyone. She was a self-absorbed, unpleasant person who tyrannized her husband, her mother-in-law, and her four children, including Júlio, who was the second child. The family atmosphere was oppressive and sombre.

Medical history Júlio presented chronic gastritis and severe headaches when pressured. Seven years ago, the first articular symptoms of uraemia appeared, arising from obesity. He drank many cups of coffee everyday. Palpitations and cardiac arrhythmia occasionally occurred. On four occasions, he presented panic episodes with outbreaks of generalized anxiety and a fear of dying. Once, having experimented with cocaine in a social gathering, he manifested signs of a bad trip, which left him particularly frightened.

Course of treatment He sought psychiatric treatment with one request: “I want to make a general change in my manner of being. For the first time, I want to treat myself seriously. I didn’t take seriously the other treatments that I started and then dropped.” During three years, Júlio attended three psychotherapeutic sessions per week. He took antidepressant medication – fluoxetine – 40 mg/day and penfluridol – 20 mg per week. In each session, he presented a different set of complaints and infirmities. During the analytic hour, he described an extensive list of situations that were almost always unfavourable to him. He

228 felt unhappy, victimized by a hard, insensitive world. He yearned for his girlfriend to handle of his business, resolve disputes, and take care of him and the house. He wanted to live in a quiet country house where he could have every comfort but without bigger expenses. He liked being invited by his friends, but soon took issue with them, becoming quarrelsome, and afterwards, he felt attacked and scorned. His elderly mother made unreasonable demands. He attempted to help her with a smile on his lips, but with hate in his heart. In the face of awkward situations or those that required him to take a firm position, he hesitated and frequently regressed, adopting attitudes that were quite childish. Sometimes, he was the bold entrepreneur, but soon he became the worried store clerk. Charming in the social circuit, he was querulous, whining, and unpleasant with close friends. Little by little, some of them began to distance themselves from him. He attached himself easily to a new friend or employee. He broke off with women who were interested in him and soon had nothing more to do with them. He complained of dizziness and episodes of depersonalization. When confronted with painful situations, he fled from them in tears. Incapable of persisting or maintaining efforts in his tasks, he dismissed any proposal that anyone made as being preposterous. He was always on the look out for someone who was disposed to take care of him and his business. He seemed to be ready to jump into the lap of the first person who was prepared to carry him. He projected a certain aspect of “major abandonment” that served as a kind of credit card to move and induce others to take care of him. He was unable to maintain the necessary effort in his work or in the projects he started. He soon became tired of or bored with them and abandoned them. Often, he became fascinated with someone, a writer, friend, artist, or public figure, who then became a role model. Suddenly, he became disillusioned with them, one by one, and at such times, his inelegant comments could be cruel. He presented himself before the media as a successful businessman, but in his sessions, he exposed his true feelings: “I’m a fake, a phoney, a lazy guy.” At other times, he lamented: “Nothing ever goes right for me. I’m jinxed”. Repeatedly, he went back to recall the poverty of his childhood. Then, the grotesque image of his restrictive mother appeared, always degrading and discrediting him. A child whose exuberance had been restrained turned into a fearful, timid, and guilt-ridden boy. An exhausted, silent, negligent father was hardly an appealing male figure for the young Júlio to adopt as a reference. Various life experiences throughout his youth left him with feelings of bitterness and failure. Ordinarily a calm person with a faintly cynical smile, Júlio was given to raptus of hatred or outbursts of rage, at which times he lost his composure. Unpredictable in his attitudes, his behaviour was governed by extreme dissonance: on one hand, he could be affectionate and charming; then without apparent reason, he could be unpleasant, caustic, and mean. His economic and financial life bordered on the chaotic. He was always on the brink of bankruptcy. In half of the sessions, he presented himself as being in intense suffering, as though he were attempting a form of constant “psychic bloodletting”. For Júlio, the small and medium misfortunes of everyday life – an omission, a separation, a delay, a failure to meet someone, or frustration in general – were seen as being unbearable. Frequently, he took them as being a form of persecution or a personal offence. He did not learn from experience, but kept making the same mistakes over and over again. His world was tumultuous and he felt as though he was in the middle of a constant conflict that was never resolved. Once, he expressed his feeling that he was living on a fast roller coast. His life seemed to be stationed in a “stable instability”. When faced with pressure, his psychism became disorganized, regressing, entering tilt . In this situation, he resembled a small, defenceless animal, trapped in a corner. In a psychiatrist, he looked

229 for a redeemer, a Saviour who would resolve for him, in one swift stroke, everything that complicated his life. Júlio presented a particular tendency to adopt the path of suffering and error. “I love to suffer,” often slipped out of his mouth. During the psychoanalytic process, myriad personalities began to emerge on the scene. Sometimes, two or three “personas” appeared in the same session. These multiple egoic states that alternated in the setting are, in my judgment, a pathognomic sign from which one may diagnose a borderline configuration of the psychic character. Another typical finding is that such personalities have already drawn three or more previous psychiatric diagnoses. Júlio had been an “infantile hysteric”, a “pre-psychotic”, a “schizoaffective”, an “atypical melancholic”, and a “weak-willed psychopathic personality”. In addition to the incapacity to grieve by reason of not accepting the castration that life imposes on everyone, Júlio carried a darkness in his internal world, which manifested itself in his disaster fantasies and arose, tenebrous, in his frequent nightmares. Whenever there was opportunity to explore a subject, a certain feeling, or a situation, the patient tended to slip around it, simply changing register. He quickly changed the subject and the ‘outfit’ as if he were a skilful actor. A heavy depositor of unresolved problems, Júlio looked for someone who would accept the role of being a loyal and generous depository. Finally, the manifestation of his desire was soon inundated by anguish tinted with doubts. This almost always resulted in hesitation or paralysis. His improvement was slow, replete with progress and regression, as is typical in these cases. An elevated humanistic investment was made by a therapeutic couple. Júlio made progress regarding the stabilization of his mood. The clarity of his internal world markedly improved. He buried his mother, first literally and, afterwards, symbolically. He managed to resolve many of his quarrels in life. He decided to turn over the administration of his business to a competent professional and concentrate instead on something he did very well: sales. When it came to selling his shop’s products, he was unbeatable. After three years of standard, well-established psychoanalytic and psychiatric treatment, the client still presented numerous, kaleidoscopic complaints. Although he had made expressive improvements in many areas of his life, he complained that the treatment was slow, painful, and expensive. Above all, he complained that his garish attempts to become a new man had not been met. In the following years, every so often, Júlio came back to therapy for a short period of a few weeks. This allowed him to discharge large portions of his problematic, after which he became more acute and even more diligent in taking charge of his own life. These short periods of therapy over the subsequent years had the property of being true emotional, intellectual, and existential fuelling stations for the client. Gradually, we became friends.

Differential diagnosis The depressed patient suffers primordial attacks on his or her mood. The schizoid remains retracted from the warmer human relationships. The deviant tends to structure himself around the choice of evil and wickedness in misconduct. The psychopathic personality acts in an intrusive and malign manner, committing a series of antisocial acts. The psychotic schizophrenic presents specific, typical delirious and hallucinatory experiences Now, the borderline personality presents a mutant kaleidoscope of all the psychopathologies in a variety of grievances, “personas”, and performances that mimic a number of clinical pictures without ever consolidating itself into one of them. Such mutability is another pathognomonic sign for making a diagnosis of the borderline personality construction.

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Final considerations The psychiatric treatment of borderline personality is slow, laborious, and intensive. Psychoanalysis is useful, especially when accompanied by psychopharmacotherapy. The therapeutic results are measured in terms of psychic improvement and not in terms of cure. In my experience, the borderline construction of the psychic character occurs in the period prior to the establishment of the oedipal complex. They are people who habitually had a good level of intimacy with their parents during the first year of life, but, soon afterwards, they lacked the necessary affective parental support to fully live their second, third, and subsequent years of life. Thus, they became timid children, inhibited in their psychomotor initiatives on one hand, and restrained in their erotic fantasies and infantile aggressions on the other. Between the first and third of life, they had to develop a false “I” – an artificial “I” – to confront the untimely demands of an adverse family environment. The borderline personality grows up without the possibility of hating or loving with ease and fullness. Having had its psychosexual development disturbed, the forming personality wanders toward the countless possibilities of pre-Oedipal ordination. Seeing that he is prevented from living with joy and fervour, the borderline will plot a course toward any one of the frontiers that his survival need impels him. The frontiersman is anyone who lacks a cutting instrument, which, in psychoanalysis, we call castration, an essential instrument for separating contents and feelings, making his selection and hierarchization possible in terms of desirability and value. In this way, the borderline personality remains stuck in a boiling soup of primal psychic components that can only be arranged in a more integrated and healthy manner at great cost. In short, the work of clinical psychiatry with borderline patients is still in the experimental field of trial and error. I close this clinical vignette by alerting those who may be interested that urban civilization, capitalism, and the media have contributed to the dissolution of the ties and stability of the traditional family. This is a powerful factor that determines the fate of tens of millions of children, causing the development of their individuality to be afflicted and distorting, assuming some of the varied forms of borderline personality.

Editorial comment This vignette discusses the treatment of patient from psychoanalytic perspective. The treatment was interesting and the author discusses many of the potential developmental problems that may have contributed to the patient’s problems. The patient demonstrates many of the dysthymic symptoms and anxiety symptoms associated with borderline personality disorder. The patient also shows some features of dependent personality disorder, which perhaps needs to be taken into account in the treatment. It is unclear from the clinical vignette what types of interventions were given by the therapist. This lack is very common in the clinical descriptions given about the psychoanalytic treatment of borderline patients. A fully developed theoretical view is provided but limited information about the actual interventions used. Nevertheless, it is clear from the vignette that the therapist and patient developed a positive therapeutic alliance and that this may have contributed to the slow improvement of the patient. A learning point here is that, in order to treat borderline patients, it is extremely important to maintain the therapeutic process over the longer-term.

231 CASE 22 Marcello: Avoidant Personality Disorder Country of origin: Italy Author: Marco Pellegrini

Identifying Data Marcello is currently a 38 year old man who lives in a town in Northern Italy. He works as cook. He was referred for alcohol abuse to the Alcohol Dependence Unit where he attended a 15-day inpatient detoxification program followed by a six month day-hospital treatment for alcohol dependence. During the first week of treatment, he has also been referred for Axis-II assessment.

Presenting Complaint Alcohol abuse, panic attacks, anxiety

History of Present Illness The first episode of panic attacks occurred ten years before and lasted about six months. During the attacks the patient presented a clinical picture characterized by: palpitations, sweating, sensations of shortening of breathe, feeling of choking, depersonalisation, feelings of going crazy. The cognitive component of these attacks also included pessimistic worries and fear that his wife betrayed him. The clinical picture developed suddenly and lasted from 20 to 40 minutes. He had 4-5 attacks per day, which severely distressed him. Nevertheless, he never developed phobic avoidance or situation or places. He never showed depression or elated mood, and did not manifest any psychotic sign or symptom. At the time of the onset, Marcello was not consuming psychotropic substances or drugs. The attacks remitted spontaneously without any pharmacological or psychological treatment. However, five years later, when his wife confessed her recent affair with another man, they reappeared. At that point, Marcello was overwhelmed by attacks and pessimistic thoughts, and started thinking that he would never recovered; to make things even worse, Marcello was plagued by severe insomnia. Although he was sad about the marital conflict, he was not overtly depressed. Thus, he visited a psychiatrist who prescribed him fluoxetine 40 mg/day. But after a few weeks he asked the psychiatrist to stop the treatment because attacks did not decrease in frequency and intensity and his sleep disturbances increased. This threw Marcello in utter despair; he considered this failure as evidence that no therapy was available for his disorder; his worst worries were becoming real. One day, one of his colleagues noticed that Marcello rarely talked, often did not eat, and frequently abandoned the kitchen for a few minutes. At lunch, his colleague invited him to drink a glass of wine to feel better. Marcello was not used to drinking; however, he decided to give his colleague’s suggestion a chance. As a matter of fact, Marcello felt better and since then he started drinking 33cl of wine at lunch. Marcello had the impression that his work performance improved. But his sleep disturbances and pessimistic thoughts continued. Marcello increased alcohol assumption. During the last four months before present assessment he drank 1 ½ litres of wine and 2 cans of beer per day. Although he was able to continue to work, his clinical picture got worse. In fact, psychological and physical withdrawal symptoms came up. From the psychological point of view, the patient started suffering from feelings of jumpiness, shakiness, irritability, emotional volatility with rapid emotional changes, fatigue and difficulty with thinking clearly. Physically, headaches, nausea, vomiting, and loss of appetite appeared.

Mental Status Marcello presents himself as a tall slim man. Although he was quite anxious during all the interview session, he had a collaborative attitude towards the interviewer and he politely answered all questions, even when he was asked to clarify the circumstances of his wife recent affair. His speech

232 was clear and no sign of formal thought disorder was observed. He did not display any sign of mental confusion, delirium or psychotic features.

Family and Social History Marcello is fourth of seven siblings. He has three brothers and three sisters. According to Marcello, his youngest brother has drinking problems. His mother died of pancreatic cancer when he was nine years old. His father recently died of pulmonary emphysema. After his mother’s death he lived with his uncle’s family for six months. Afterwards he returned to his nuclear family. He describes himself as a very shy child. To make the idea clearer to the interviewer, he told about his vivid memory of something that occurred during his second year of primary school. As usual, his father had brought him to school. But, as soon as Marcello was left alone in front of the school he decided to go home. According to Marcello, whenever his teacher closed the door of the classroom, he always thought that it was like a “prison door closing”. He added that his shyness generally decreased when the situation and people became familiar. But he never could be more confident with his teacher, despite the fact he was his neighbour. He could not get very familiar with his siblings too, with which he usually felt embarrassed and could hardly talk, especially about his private feelings and concerns. During the interview, the patient emphasised that despite his shyness until he was nine year old he was convinced to be “one of the best in the world”. But this statement contrasted with his highly inhibited behaviour as well as with the progressive deterioration of his self-image; as he grew up as a shy, introverted adolescent, he started to think that he was not as good, interesting, attractive, etc. as the other guys. He usually did not go to parties; when he did it, he preferred “confounding myself with the wall”, because he thought he had nothing interesting to say, and found it too difficult to meet previously unknown co-eds. He suffered from his social isolation and desired to make new friends, but he said that “the fear of saying or doing something embarrassing was so intense that I could not say a word”. He is still a shy, quiet man. During the interviews he was afraid to stare at the interviewer, and frequently felt ashamed for “all the silly things I am saying”. Marcello described his father’s attitude towards himself when he was a child as very apprehensive. After compulsory school, Marcello followed a professional course for electricians, but he never could find a job because “previous work experience was always required”. Then, he started working with his oldest brother as manual worker. He also worked as a skilled worker in textile industry until his current job as cook. He does not complain about his job, even if his greatest interest is in Electronics, which is his favourite hobby. Marcello has been married for eighteen years and he has a seventeen year old son. He met his wife during a holiday in Northern Italy. For few years he spent half the time working in Southern Italy and half the time in Northern Italy with his girlfriend. After marriage his wife reached him in Southern Italy, but according to Marcello, his parents-in-law “forced him” to come to Northern Italy and assured that they would helped him job seeking. Marcello initially found a job, which unfortunately was in a city 100 km from the town where he lived with his wife. In this way, he could stay with his family only during week-ends. Afters few years he found his present job. He has always been afraid that his wife would betray him. Marcello adds that his wife did not do anything to dissipate his suspicions. In fact, at the time they were not married, whenever he returned to Southern Italy to work, his wife had dates with other men. Nonetheless, Marcello always forgave his wife because he was convinced to be too unattractive and boring to fully satisfy her. To get things worse, two years before the referral, his wife confessed a brief affair with another man. This initiated his last severe episode of panic attacks. About his relationship with his son, Marcello does describe himself as an authoritative father. On the contrary, he is worried about his son’s behaviour. The son spends a lot of time playing with computer and does not frequent his technical school of web design, but he does not seem to be able to confront his son with his responsibilities.

Hospital Course

233 During the day-hospital treatment for alcohol dependence, Marcello had to follow several group sessions. Despite his shyness and his intense feelings of embarrassment, Marcello positively valued this experience. The Alcohol Dependence Unit therapists agreed with the patient’s judgement, reporting that he was able to progressively disclose about his drinking problems with other patients and with therapists. On the contrary, he always found it very difficult to share his private affairs with other group members.

Differential Diagnosis The clinical picture characterized by intense anxiety, palpitations, sweating, sensation of shortening of breathe, feeling of choking, depersonalisation, the frequency, duration, and severity of attacks, and the absence of any other axis I disorder that could explain clinical manifestations, strongly suggests a diagnosis of Panic Attack Disorder. Although the alcohol dependence started as an attempt to cope with the panic attacks, it became rapidly so severe and problematic in itself to warrant an additional axis I diagnosis of Alcohol Dependence. Although he was extremely preoccupied with other people’s judgements, Marcello never displayed any sign of suspiciousness or paranoid ideation; he never showed magical thinking or recurrent illusions. He was also appropriate in his behaviour and thinking (i.e., he did not show any sign of oddness either in behaviour or thinking). Marcello has always been preoccupied with fears of betrayal, but he can hardly be described as jealous. He never controlled his wife; rather, he seems to justify her attitudes. Marcello is likely to forgive the offences. He has very few friends, but he is not socially isolated. Actually, he desires to have friends and start new relationships, but he is paralysed by a sense of embarrassment and low self-confidence. With the exception of the intense anxiety attacks, Marcello’s affective reactions are in the normal range (e.g., he sometimes gets angry with his son for his laziness, but he never raises his voice or throws things). Notwithstanding the low self- esteem, Marcello’s identity is integrated, with no major changes in sexual orientation or life goals. His romantic relationships have always been deep and intense, but highly stable and long-lasting. He complains of feeling sad, but he never reports feelings of emptiness; his life is difficult, but also full of meaning. All these features led to excluding a co-diagnosis of Paranoid, Schizotypal, Schizoid, or Borderline Personality Disorder. The difficulties to get involved with people unless certain of being liked, the restraint in relationships because of fears of being ridiculed, the preoccupations with being criticized in social situations, and a low self-esteem that is centred on being socially inept and unappealing are long-lasting features characterizing Marcello’s everyday life; moreover they can not be considered as a consequence of his drinking behaviour, Panic Attack Disorder or any mood or psychotic syndrome. As a whole, these considerations strongly suggest an axis II diagnosis for Avoidant Personality Disorder.

Editorial Comment Marcello, a 38 year old man, was very shy and introverted as a child and adolescent. As an adult he is socially isolated and highly inhibited despite his desire to have friends because of his low self-esteem. Despite his desire to have new friends, he is paralyzed by a sense of embarrassment and low self- esteem when he tries to start new relationships. These features support the diagnosis of avoidant personality disorder which is characterized by a pervasive pattern of social inhibition, feeling of inadequacy or inferiority, and hypersensitivity to negative evaluation. Marcello was suffering from panic disorder for ten years. Avoidant personality disorder often comorbids with anxiety disorder as well as mood disorder. These patients tend to use alcohol and/or other substance to relieve their psychological pain as a self-treatment which leads to substance use disorder. Marcello never could find a job until he started working with his brother as manual worker. He also has difficulty with his wife. Patients with avoidant personality disorder often have difficulty in interpersonal relationships which usually leads QOL problems such as difficulty of job finding and marital problems

234 CASE 23: Erik: Narcissistic Personality Disorder Country of origin: Norway Author: Merete Johansen

Identifying data Erik was a man in his early thirties when he was referred to a specialized treatment program for personality disorders. The referring therapist had treated him individually for approximately 3 years. Reason for referral was stated as severe personality dysfunction, following an acute psychiatric hospitalisation.

Presented complaints Interpersonal problems, recurrent depressions, chronic uneasiness/anxiousness and psychosomatic symptoms.

History of present illness Erik’s history of complaints started when he was a child. He characterized his childhood as being unhappy. His family moved quite often, and he recalled being lonely, especially during the years when his younger brother suffered from severe asthma. At the age of twenty-two he was depressed and unhappy for a long time following a break-up with a girlfriend. His depression was characterized by anxiety, fatigue and somatic complaints. He wasn’t able to continue his studies for several months. When he was 27 he had disagreements with colleagues at work. He resigned following an argument with his boss. A new depressive episode brought him in contact with a psychiatrist. It took two years for him to recover. Five months prior to the referral, Erik’s job as TV reporter was threatened. The firm was in a bad financial position, he was told. He lost his work, became depressed, and suffered several panic attacks. After a few weeks he contacted his former therapist, who agreed to continue the therapy they recently had terminated. The therapist found him quite disorganized, and he was subsequently hospitalized because of suicidal ideations. At the emergency ward he received anti-depressive and mood stabilizing medication in addition to supportive psychotherapy. According to the staff his behaviour was clinging and regressive, interrupted by explosive outbursts of rage. Gradually his symptoms of anxiety faded, but he became excessively concerned with somatic symptoms such as breathing difficulties, numbness in legs and arms, vertigo, back-pain and abdominal pain. A physician examined him, but no somatic illnesses were uncovered in the examinations and tests. When his therapist in the emergency ward suggested day hospital treatment, Erik accepted this suggestion on the basis of realizing that his somatic symptoms were connected to depression and anxiety. He also wanted to explore whether group therapy was a suitable treatment for his interpersonal problems.

Family and social history There is no history of mental disorders in the family. However, Erik’s grandfather was characterized as emotionally unstable. He had high ambitions, was a perfectionist and quite successful in his career. Erik’s father was given a similar character sketch. He was a businessman who travelled a lot. During some early years of Erik’s childhood his mother was occupied with his younger brother. His mother was described as the opposite of his father’s strong character. She kept a low profile toward her husband. Erik recalled that this often made him frustrated and angry. He felt less connected with her and his younger brother, and characterized the relationship with his mother as emotionally distant. As early as at the age of 4 his father started training him in sports and preparing him for school. During childhood his father continued to coach him regularly to become very good at different sports. Through this Erik felt that his father gave him attention, and he felt more attached

235 to him. When he was a child he felt lonely when his father was away. His mother often left him with his uncle when she was in hospital looking after his younger brother. Erik rarely played with other children, became lonely, and focused on striving for good results at school. Compared to his classmates he was a serious child. The family moved several times and Erik had difficulties making friends. At high school he felt lonely, but girls considered him charming and attractive, and he had several short romantic relationships before he met a girl he fell in love with at the age of 20. This romantic relationship lasted a few years. After the break-up of this relationship he became depressed, and experienced his first panic attacks. He finished university studies with good grades. He had some shorter romantic relationships, but did not become deeply attached to anyone for several years. His first job at the age of 24 was as a reporter with a TV company. He was quite successful at work, and was given a senior position after a short time with the firm.

Mental status and assessments At the assessment interview before starting the intensive day treatment program Erik presented himself as a good looking and impressively knowledgeable and articulated man. However, his complaints were presented somewhat covertly, and he was ambivalent with regard to the role of a patient in a psychiatric unit. The assessment procedures included structural interviews and several self-report tests, which he hesitated to take part in. On DSM-IV axis-I, he fulfilled the criteria for recurrent depressive disorder, somatoform disorder and panic disorder without agoraphobia. On axis-II he fulfilled 5 criteria for narcissistic personality disorder, and additionally 10 criteria scattered on other personality disorders. The most prominent features were a grandiose sense of self-importance and a sense of entitlement. At assessment he had been on sick leave for 5 months due to his mental problems. His GAF (Global Assessment of Functioning, DSM-IV) score for social functioning was 48 (not able to work, social isolation), and for symptoms 54 (depressed mood). His total score (GSI) on the symptom checklist (SCL-90R) was 1.69, and his total score on interpersonal problems (IIP-C) was 1.63.

Medical history Birth and early development was normal. He had never suffered any serious illnesses.

Treatment history Upon admission to the day treatment unit he had been in a close relationship to a woman for two years. The relationship was dominated by disagreements and conflicts, and she had talked about leaving him. The couple rented a rather expensive apartment, and he received financial support from his father. His treatment goals for himself were based on the realization that his problems were related to his interpersonal difficulties. He wanted to do something about these problems, and hoped the treatment could help him recover from depression and solve the problems in his love life. The group therapy based intensive day treatment program, 4 days a week, lasted for 22 weeks. The treatment consisted of different types of group therapies, including small group psychotherapy, art therapy, cognitive therapy and large group therapy. Erik participated regularly, with the exception of one week when he decided to go to Spain with a friend to see a soccer match between Real Madrid and Liverpool. Early in the therapy he was supposed to present his family and social history to his small group. He focused on the complex relationship with his father. He also told about how he often felt guilty when joining his father in devaluating the mother. After he told about this in the small group, he reacted with panic attacks and stress related dissociative symptoms. His story was meant to be talked about in the group setting, but a feeling of being disloyal toward his parents overwhelmed Erik. He experienced intense feelings of guilt for telling the group about his parents. “Every time I tried talking with my mother about these things, she always burst into tears”.

236 Following this event a feeling of distrust toward the group and group therapy emerged. He became angry, and accused the therapists for not being able to cope with the situation. He wanted guarantees about confidentiality from therapists and the fellow patients. The group tried to support him and calm him down. He gradually became a somewhat detached member of his group. His loyalty to the parents, especially his father, appeared to be very strong. He also claimed that his father had changed. He insisted that something must be wrong with himself. He could not understand or cope with the ambivalence toward his father. Despite the unit’s regular policy of not supplementing the group therapy with individual sessions, Erik received individual supportive sessions every second week in the first part of his treatment period. His administrative therapist made this decision. At a clinical conference this became an issue. There were several quite divergent attitudes among staff members. The staff perceived this action as his therapist’s counter- transference reaction of wanting to protect him. After some discussion the team concluded that Erik should continue the treatment program without individual supportive sessions. Erik became regressive, appealing to the therapists’ caring and protection and said he felt abandoned by the therapist and not taken seriously. He claimed that he was not able to sleep alone at home, since his girlfriend was temporarily staying with her parents. He alternated between states of grandiosity and childish regression. He doubted the unit’s capacity to help him. He turned hostile to both of the group therapists and some of the patients in his small group and expressed distrust of the unit and of the whole hospital. In the large group this sometimes resulted in explosive outbursts of rage. He seemed driven by despair, and was not receptive to interventions other than supportive understanding. This emotional instability was followed by prolonged passivity and avoidance in the groups. However, in the group therapy he could also seem to be caring, with the ability to verbally express understanding of his fellow patients. At other times he tended to dominate the group’s attention. This attitude could generate irritated comments from some fellow patients, while others admired him and went along with his criticisms of the unit’s policies. He received reactions on focusing on the unit’s policies instead of his own treatment goals. At one point he expressed the need to be admitted to the emergency ward. He felt isolated and detached from the group, and questioned the meaning of the therapy. He considered dropping out of the program. He worried about how to manage real life, “out there, at work”. In the groups he mentioned several difficult experiences in work situations. He tended not to listen to feedback from group members, but ruminated over himself in negative ways. He especially worried about anyone finding out that he was doubt-ridden about himself, deeply envious of others, chronically bored, corruptible, unable to love, forgetful of details, and inattentive to objective aspects of events. In the art therapy he portrayed his dreams and wishes of becoming a famous artist. He was also preoccupied with what he missed, and what he could have done if he had been able to follow his own ways and wishes. His paintings were abstract, and filled with pale, harmonic colours. He never managed to portray his emotional turbulence through the pictures. In the small group he changed focus during the last part of the treatment, away from the interpersonal problems he experienced in the here and now. He started to focus on his relationship to his girlfriend and private life outside the groups. He maintained that this was the only way he could make use of therapy at this point, and he would rather not talk about his relationship with the group. At home he also felt isolated. He was still suffering from restlessness, problems concentrating and social withdrawal. He started to talk about the problems he experienced in his close relationship: “I don’t understand myself or the situation between her and me. At first she was the only woman I wanted. She was mature, calm and wise. She was my shelter and a woman I admired. Now she irritates me. She is not what I dreamed of. I don’t like her body, she is fat. And I don’t like the way she dresses. Sometimes it’s better that she is not there. Our relationship is better when we only talk on the phone”. He preferred to live like a prince in a castle, among rich, beautiful people, and his woman should be rich, beautiful, warm and preoccupied with him and his special needs. He dreamt about

237 being married to a woman who had not previously had other men. He wanted to be the most special man to her. When he told the group about this he was crying and revealed a feeling of deep shame: “Often when I’m with my girlfriend I cannot avoid these thoughts, and feel disgust and anger toward her. The feeling becomes so strong, and I can’t even stand her touching me”. Erik asked for help with this and also revealed that he longed to have his own family. He felt an agonizing envy toward his married friends who also had children. He felt disappointed, desperate and pessimistic about not being able to cope with this in the future. In the groups he told of how his girlfriend got irritated and frustrated about his feelings, and had threatened to leave him. She had told him that she would not put up with everything from him, especially not the negative characteristics of her as a person. He realised that he appreciated her defining some limits for his attacks on her, because he needed her to be strong, not weak and accepting of everything he said. Erik and his girlfriend planned a trip to a resort in Brazil. He finally realized that he was afraid of committing himself to more therapy and of feeling the deepest pain again. Toward the end of the treatment he got a job offer, a position in a prestigious TV company. He became very frustrated and afraid of losing this opportunity if he continued treatment (outpatient group psychotherapy) arranged by the unit. He was afraid his new colleagues could discover that he was a patient at a psychiatric hospital. Devaluation of the therapists and the treatment program followed several outbursts of anger and frustration. In the groups he was experienced as monopolizing and dominating, and he was nearly subjected to a collective rejection by the fellow patients. At this time he felt exhausted and devastated by the recurring experiences in the group therapy. He decided to contact his former therapist, who agreed to start individual therapy again. Erik looked forward to returning to the ‘real world’. He claimed that the current treatment only represented another “digging around in the pain”, without giving him anything in return that he could make use of. He felt he had become worse during the treatment. Before he left he wanted to have the information in his medical file deleted. For this purpose he sought legal aid from his lawyer. He was concerned that someone could find out about his psychiatric problems, and he was afraid this would harm his career, stopping him from becoming a famous TV reporter.

Editorial comment The case of Erik highlights several features of the narcissistic patient, first the importance of the structure provided by his work as a TV reporter for his ability to function. When Erik lost his job he became increasingly symptomatic, e.g., depressed, disorganized, suicidal and explosively enraged. It is possible to assume that Erik’s work provided important sources of narcissistic self-esteem support, such as being admired and in the centre of attention, working rather independently and being involved but with a distance of a fixed role and task as a reporter, and being able to pursue a fantasy of being or becoming famous and recognized. The second feature relates to the narcissistic patients regressive, negative and distrustful reactions to intensive treatment. Such treatment may involve a substantial threat to their self-esteem, caused by the requirement of close involvement, giving up of control and internal mastering, and facing situations and feelings that they normally can not master – e.g., revealing conflicts, facing shortcomings and regulating accompanying feelings, such as guilt, shame, envy and ambivalence. The case example also highlights the challenge in treatment of the narcissistic patient, to help the patient to contain a painful tumultuous treatment experience, and to make a personal meaning and learning objective out of such experience that can assist the patient out in the real world and in the future. Understanding why situations trigger rage, disappointment, shame and fear, and applying strategies to regulate self-esteem and strong feelings are important parts of intensive group program with narcissistic patients .

238 CASE 24: Mary: Borderline Personality Disorder Country of origin: Italy Author: Cesare Maffei

Identifying data The patient is a 31 years old female, she had a degree in law, however she has always worked discontinuously. She was initially seen because of severe self-mutilating behaviours.

Presenting complaint Impulsive behaviours in multiple areas: self-cutting, binge eating, substance abuse.

Mental status Mary appeared as a good-looking young woman, plump, with a “puppet face”, due to a stereotyped emotional expressiveness. She used to behave like a very gentle person, apparently very interested in her interlocutor. She rarely spoke spontaneously, her answers were short, and often they seemed a kind way to control the interpersonal distance (“I tell you what I imagine you are expecting from me”). Attention, perception and memory seemed to be intact. Her mood seemed mostly neutral, slightly fatuous. Reality testing was unimpaired.

Family and social history Both her mother and her father are still living, retired and in good physical health. She has a brother, 33 years old. Her mother could suffer from Obsessive-Compulsive Disorder, her father has schizoid personality traits, and non-better specified impulsive behaviours are referred to her brother. Mary was a preterm baby (8 months), who showed conduct abnormalities since childhood. She describes physical fights with her brother during the adolescence, a great ‘coldness’ in the relationship with her father and an ambivalent relationship with her mother. She attacked her mother, considering her “the cause of her problems”, however she pretended to be protected as a little girl, having her mother under her whole physical and mental control when she was in difficulty Her social relationships are described as very poor, she did not have close friends or confidants during her life, except one or two persons. She had one stable love affair during her whole life, however, she had many “one night” sexual relationships since her adolescence. Mary was a good student. After her school-leaving exam in languages with a good scoring, she obtained her university degree in Law taking her nine years, although her already severe psychopathological suffering. She then had many intermittent works as office worker, generally giving them up because of her psychopathology.

Medical history Birth and early physical development were normal. She has never suffered from any severe illness. Mary had early conduct problems (4-7 years), characterized by frequent physical fights with pairs. At age 7, onset of compulsions concerning the need of having her things in a particular order, and repeated doubts (i.e. “open-closed”: doors, windows, etc.), subsequently sporadically present during the whole clinical history. At age 11, onset of self-injuring behaviour (She started to beat her arms with a stick, making her subcutaneous veins “to burst”). At about age 15, onset of self-cutting behaviour (concerning even her face, using wood slivers), justified to her family as accidents. This symptom, becoming progressively more severe, remained for the whole clinical history. In the last few years onset of burns, more and more severe, and self-cutting behaviours (Mary

239 uses razor blades, knifes, pieces of glass, etc.): the object of these behaviours is mainly her left forearm. In September 1998, she was subjected to surgery for a large cutaneous self-transplant, because of third-degree burns that she herself worsened using knifes or irons. At age 16-17, onset of contamination ideas. Progressive organisation of an eating disorder with features of Anorexia Nervosa, that Mary ‘explains’ as avoiding behaviour, aiming at reducing her anxiety, due to contamination obsessions about food. She refers the idea that food could ‘stop’ in her intestine, that food is “dirty”, and so on. Remark of amenorrhea from 17 to 18 years of age. In the same period, binge eating appeared (she also ate frozen meat), always followed by misuse of laxatives. This symptom worsened progressively, since November 1998 when Mary used 80-160 gr. (every two or three days) of Senna leaves, spending about $ 170 a week to buy different kinds of laxatives. Moreover, she drank 6-7 lt. a day of saline solutions to induce vomiting and to better “wash” her intestine. Psychoactive drug abuse started at age 24-25 with chlordemetildiazepam, administered by her mother. This symptom worsened over time, with a need of increasing amounts of anxiolytic and hypnotic drugs. She also used neuroleptics (chlorpromazine, haloperidol, levomepromazine) as hypnotics and ‘not to think’. To obtain these drugs, Mary acted antisocial behaviours, such as theft of prescription pads of her physicians and their falsification. At the end of 1998, she “drunk bottles” of levomepromazine 100- 200 mg/die and chlordemetildiazepam The clinical history of Mary is also characterized by suicidal behaviours, or gestures, using drugs: two of them required hospitalization in November 1998.

Treatment history Mary met a psychiatrist for the first time at age 24, in September 1992, when she was admitted in a psychiatric ward, after a self-cutting behaviour. She was discharged after being diagnosed as Borderline Personality Disorder and benzodiazepines were prescribed. During the next seven months Mary became an outpatient of a territorial unit but she then gave up her therapy, reporting no benefits. In 1993 she was hospitalized, diagnosed as Bipolar Disorder and treated with lithium, haloperidol and chlorpromazine (Mary started to misuse it). She refused ECT, and self-discharged after about three weeks. Starting from that period, Mary refused to meet psychiatrists during four years. In 1996, at age 28, she met a homeopathic physician who prescribed her levomepromazine that she added to the previous drugs she misused. In 1997, Mary went to the Neurological Division of our Department because of insomnia: she was treated using mianserine and benzodiazepines. She gave up the therapy because she felt worse. At the end of 1997, Mary’s mother had some talks with me and she accepted to contact the unit for eating disorders, however she refused to be hospitalized and the routine therapeutic programme and she undertook an out-patient programme, with intermittent clinical examinations and no psychiatric drug treatment (substance abuse conducts were still present). She received a diagnosis of Anorexia and Bulimia Nervosa. In October 1998, Mary accepted to be hospitalized, however she self-discharged after only three days. A severe escalation of self-mutilating behaviours with multiple and sensational self-cutting injuries followed. After one of these performances, during which she acted a self-cut of her left forearm of about 20 cm. of length, in a restroom of our Department, she was admitted to a psychiatric ward. She remained two months: she was treated with clozapine and had talks with me. She also met a social worker, in order to find a new job and a home. A binge eating with laxative abuse was promptly acted in coincidence with the patient’s planned discharge. She continued her treatment as outpatient in a Day-Hospital setting. The results of clozapine treatment were excellent, with global progress of the whole symptomatology (i.e. Mary stopped self-

240 cutting behaviours and reduced the laxative substances abuse) and the frequent physical examinations in order to check clozapine adverse effects were used to improve her compliance. Notwithstanding the good results obtained with pharmacological treatment, she had a serious adverse effect (agranulocytosis) and clozapine had to be discontinued. A new treatment, first with risperidone then with olanzapine was started, with satisfying results. Mary showed slow and progressive improvement, and her behaviour seemed to be the best obtained in the last seven years: just one self-injuring act during the two months admission and end of substance and laxative abuse. Only eating problems were still relevant. Mary said she was now able to better control her impulsivity. She planned to begin psychotherapy.

Comments on psychotherapy My therapeutic relationship with Mary begun with a particular event: she was found in a restroom of our Department, bleeding. She cut her left forearm provoking a severe injury of about 20 cm. The surgeon sutured her forearm and few hours later she had a talk with me: she said that she needed help, she couldn’t go back home, she asked to be hospitalized. She said that she could “sleep on the stairs”, but she had to remain in the hospital. She was hospitalized and seemed very happy and grateful. Two days later, she told me that and the psychiatrist of the ward that she wanted go home. She was cool and contemptuous. She said: “I can’t stay here, I don’t like this place, it suffocates me! Let me go home, I made a mistake, you can’t help me, I can do by myself, I have to live my life, I have to be free...” She was like a machine, she repeated these phrases a number of times and seemed unable to listen to my words. I stopped her shouting: “you want go home, ok, however I know that you will come back bleeding, with your forearm bleeding... and you will repeat the same scene...please, help me...I can’t tolerate you when you look like a mass of bleeding rags... If you will show me it, I will drive out you...do what you want!” I left the room. She remained and few days later she told me that the true reason she wanted to be free was different. While in the ward she had to eat and couldn’t buy and use laxatives. At the end of the talk we decided together to try to “normalize” her relationship with food, step by step. She increased food intake in a relatively satisfying way, however she avoided using laxatives. Her psychiatrist told me that, in his opinion, Mary secretly ate. She was always plump, even when she refused food. At the end of her hospitalization period, Mary was helped by our social worker to find a new job. She decided that it was too early to live by herself and went home: she lived at home only partially, in fact she was given hospitality by a girl she had known in the ward. She started talks with me, once a week, in order to plan a psychotherapeutic treatment. We began this programme in February 1999, when she left the ward. We evaluated the possibility of a psychotherapeutic intervention: this was the goal of our talks. She was compliant, she rarely was missing. However, it was a difficult task. To summarize, each talk was easily foreseeable: - She starts saying “I’m well, and you?” - When I ask her if she has something to add she says “You know everything about me, but if you want I can tell you more” and starts to speak. She seems to want show that everything is going well, even if gives me to understand that everything doesn’t work - When I comment upon it, she says that I am right, however she minimizes saying “it doesn’t matter, since my life is senseless” - Sometimes she suspects she is dangerous: probably that is the reason she often says “how are you?” This fact is more complex: it seems that if she says “I’m well”, even if it is not true, she reassures herself that her interlocutor is well. She has to lie, in order to protect her interlocutor’s health, in a magical way. - She often gives me to understand, or overtly says, that she is still alive because “you and doctor B. (her psychiatrist) exist: the goal of my life is to stay with you...when I am near you I feel

241 good... but you don’t need me as I need you... so I can’t be happy...however I have to be satisfied...I am not so important...I am a disaster”, and so on - During the talk she is always quiet and laughing - Her words are often apparently self-ironic, also when she describes her suffering. She seems to see herself suffering from outside and to mock herself: contemporarily she mocks me trying to help her - She seems more serious when she speaks about her insomnia: night and death seem to be equivalent. She can’t sleep (alone) because she fears dying, however she fears dying even when she is awake. (Probably she avoids it by eating, but it is not clear) - She injuries her body because “physical suffering is better than mental suffering”. When she tries to describe her mental suffering, she seems unable to find adequate words. Sometimes she says that she feels herself “unfit for life” - Sometimes it seems to me that I live a situation like this: I drink a cup of tea with a lady suffering from cancer, in a final stage. It is evident that she is near to die, however she tells me that her main problem is the worsening quality of tea. I see her cancer, but I can’t see it, paradoxically. Sometimes she injuries herself, cutting a slice of a cake: however she says “don’t worry...what about your tea?” It became clear that it was very difficult to define a therapeutic project and a therapeutic contract because Mary was very shifty. She apparently asked for help, but contemporarily she implicitly refused it. Starting from the previously mentioned episode, when she was bleeding on the stairs asking for hospitalization, a contract on the control of impulsive self-damaging behaviours was presented as inalienable in order to begin a true psychotherapy: she accepted. A psychotherapeutic work was begun: its characteristics were supportive and sometimes more expressive. It lasted about two years, continuously: sometimes it was necessary to hospitalize Mary for her alimentary behaviour, while self-cutting and impulsive medication intake improved. To summarize, the effect of psychotherapy was to reduce abnormal behaviours and to make Mary more aware of the “emptiness” of her life: no identity, no human relationships, no project, no future. During this period, her parents were helped to better understand and manage their problems with Mary: they had periodical meetings with a family therapist. Two years later, Mary understood that she had to be “closer to reality”, in other words that she had to face with people, with common life, with shared rules. She agreed that a therapeutic community could be a good beginning: living with other people, together, day by day and learn to share something. Moreover, her mother started to refuse their pathological relationship and said that Mary had to live far from home. Consequently, she started this new experience.

Diagnostic features Mary was diagnosed using a semistructured interview, SCID-II, as a severe Borderline Personality Disorder, with Schizotypal traits as pointed out by: 1. Marked affective instability, chronic feelings of emptiness, boredom, and uselessness of living. 2. Impulsivity in multiple areas (substance abuse, suicidal behaviour, binge eating) often related to perception of impending separation or rejection in interpersonal relationships or used to ‘interrupt’ the feelings of emptiness. Severe self-mutilating behaviours consciously acted in order to reduce anxiety. 3. Unstable and chaotic interpersonal relationships. 4. Intense and excessive anger with difficulty in controlling it. Frequent displays of temper and aggressive acts against objects, self and (rarely) others. 5. Transient psychotic-like symptoms during time of stress with consequently behavioural abnormalities and acute subjective suffering. The patient shows episodes of depersonalization characterized by feelings of detachment and estrangement from herself, pseudo-hallucinations, paranoid ideation, etc. that never assumed the form of a real delusion

242 or hallucination and with spontaneous resolution depending on environmental circumstances.

Moreover, eccentric features schizotypal-like, are used as continuous ways of reality explanations, probably according to familiar environment (her mother). Classical odd beliefs such as superstitiousness, paranormal phenomena, ‘astral influences’ and magical thinking pointed out since childhood and showed a good response to low clozapine dose, stopping to influence the patient’s behaviour.

Differential diagnosis Mary seems to have some core features of Borderline Personality Disorders, mainly different aspects of impulsivity. Self-destructive behaviours, substance abuse, severe problems with food are evident and continuous aspects of her personality psychopathology. Schizotypal cognitive features are diagnosed, however they do not seem so important. It could be supposed that the patient also shows narcissistic characteristics: she has a grandiose image of herself, also when she punishes herself. She seems to provoke pain to herself and deny the value of it. Her behaviour is masochistic and what she lives is an omnipotent triumph on herself: she kills herself laughing. Her interpersonal behaviour seems to show histrionic features: even if she is not openly seductive, however she is manipulative, emotionally superficial and unstable, and always the centre of attention.

Editorial comment There is no doubt that this patient shows many of the characteristics of borderline personality disorder. It is notable that in her treatment history, benzodiazepines were prescribed. An important learning point is that these are rarely indicated and probably contra-indicated in BPD. The patient also has a diagnosis of bipolar disorder. The comorbidity of BPD and bipolar disorder may arise simply because of the overlapping set of criteria. The differential diagnosis can be difficult in some patients and an increasing number of patients with BPD are being given the diagnosis. This may be an artefact and a result of external factors, for example reimbursement of treatment for bipolar disorder but not BPD in managed care systems. This patient also demonstrates some evidence that severe self-mutilating behaviours may respond to atypical anti psychotic medication. Small studies have suggested Clozapine may be helpful in severe self-mutilation. This patient experienced serious side effects (agranulosytosis) and so was given other atypical anti psychotic medication with reasonable results. The detail of the psychotherapeutic intervention is helpful. This shows what therapist actually did. It is notable that the therapist was reasonably active which is a therapist’s stance, which is being increasingly recommended in the treatment of BPD. The key appears to be striking a balance between being active and inactive without being overly active or excessively quiet.

243 CASE 25: Francisc: Anxious/Avoidant Personality Disorder Country of origin: Romania Author: Aurel Nirestean

Identifying data The patient is a 42 years old male, a worker in industrial environment referred to hospital admission by family members .

Complaints Permanent apprehension and avoidant behaviour, obsessive thoughts, compulsions, impulsivity, social isolation, the sensation of seeing persons and things unnoticed by others and of hearing voices unheard by others, concentration difficulties, insomnia, libido loss, sexual impotence.

History of the illness Ever since childhood the patient resented to leave for school, complaining about cephalalgia, stomach-ache, vomiting and diarrhoea, and treated accordingly for gastritis and enteritis. He disliked waking up in the morning feeling more tired than the evening before. His status would often be so severe that his mother would allow him to stay home, this leading to the disappearance of symptoms within the same day, only to be resumed during the following morning. The patient recounts that when the teacher was checking the roll and he might have been solicited for an answer, he would feel his hands cold and perspiring, the forehead hot as if from fever and an intense feeling of uneasiness which ended only when the teacher would close the roll. When he was listened to in classes his thoughts were rambling away and was incapable of giving coherent answers. During classes and religious services when his movements were restrained for fear of disturbing the others, he felt like scratching of leaving his place. Considering that the patient is overweight, he accuses strong and persistent feelings of lack of self-trust, inferiority and fear of failure in interpersonal relationships which he avoids for fear of rejection and disapproval. He recounts that he would often sit on a bench watching the children playing football, longing to join in but feeling blocked by numerous fantasies which overwhelmed him: he dreaded miss-kicking the ball, the inability to run due to obesity or that the others would leave the match resenting his presence. The patient underlines the difficulty of deciding to get involved, the need of consent from authoritative or trustworthy people. Their presence in the middle of that activity would represent an ideal situation and would perfectly suit his desires. This behavioural pattern is also to be met in his professional and family attitude. He worked as a lathe man, a job for which he had no previous training and this would induce a state of unsafeness and uneasiness, would make him incapable of performing correctly because he would anticipate his failure and make mistakes, which in turn led to penalties from the management. Although he had cared for his future wife for a long time, due to the fear of being rejected, he had never expressed his feelings until she confessed her appreciation and desire to marry him. At the age of 20 while performing his military service he had two successive parasuicidal attempts, the first through medical ingestion of painkillers and the latter through electrocution, with no critical repercussions as he consulted a doctor immediately. Mention has to be made that he failed to disclose to the doctors his autolytic intention in both situations pretending they were accidental, dreading the thought of assuming responsibility. The patient was therefore not evaluated psychiatrically and performed the rest of the military service without any major incidents. Three years later while working as a lathe man the patient presented another parasuicidal attempt through medicine ingestion as a result of a minor incident - he was professionally warned for spare part execution errors at the workplace. He was referred for admission by the family and presented generalised anxiety, negative anticipations, avoidant behaviour, marked ambivalence,

244 anhedonia, difficulties of attention focussing and impaired fixation memory, severe insomnias, depersonalization phenomena. Post hospital release he followed an anxiolytic treatment for several months but eventually interrupted medication. Another two hospital admissions follow at the age of 29 and 35 respectively, for major depressive episodes, the former with an autolytic medical attempt. Both depressive episodes were established against a painful fear and unsafe experience in the professional environment where he misapprehended his dismissal for incompetence and self-devaluating feelings and guilt in the family life. Then he followed the prescribed medication and underwent no hospitalization up to the age of 42. Meanwhile he took sedatives and hypnotics. At the age of 42 he was hospitalized at his wife’s initiative, alerted by a much more complex symptomatology than the previous ones as well as by the patient’s threats of committing suicide if he had to carry on the same stressful professional activity. The patient was complaining about intense fright obsessive, self- and hetero-aggressive ideas, compulsions, social isolation, the feeling of being haunted, of seeing people and animals, and hearing voices which the others failed to discern, severe difficulties in making decisions and focussing attention, severe insomnias, disorders of sexual dynamics. The Personality Assessment Schedule Test together with the DSM criteria were used in establishing the diagnosis of personality disorder of the anxious/avoidant type, and the Y- BOCS scale – Yale Brown Obsessive Compulsive Schedule confirmed psychometrically the obsessive-compulsive disorder.

Mental status Our patient is a tall man with hyperstenic built and hyperaemic countenance, who always has a dignified attitude and very well-groomed outfit. The overall impression is that of excessive timidity and maximum self-control especially due to uncertain smile - which suggests both the need of communication and at the same time irony - and to the slow and simplified gestures suggesting an excessive pedantry and increased self-control. Communication within the therapeutic relationship is relatively difficult and damaged by the patient’s indecision, assiduous tendencies and lack of trust in the process of commenting his problems. For a couple of days he refused to cooperate directly with the medical staff, but handed in to the psychiatrist several sheets of neatly spelled papers, containing a minute description of the history of his disease and all the current complaints, including the detailed description of his sexual dysfunction and disturbed marital relationship. At the level of self-conscience and environment he presents phenomena of depersonalization and derealisation, whereas at the perceptive level he presents visual and auditory hallucinations: “sees” and “hears” people and animals which the others cannot perceive, criticizes these phenomena triggering intense anxiety, and fights them. He presents selective hyperprosexia and hypermnesis on obsessive cognitions with a low attention focus and fixation hipomnesis for the other preoccupations and activities. The patient has a slow discourse, interrupted by numerous breaks which suggest different obsessive themes, of being followed – by „the supervisors at the workplace”, on the street he feels haunting looks” – of relationship – assigns to the others a critical attitude of himself and anticipates being ridiculed or rejected - or self- or hetero-aggressive themes accompanied by obsessive representations and checks, or compulsions. He recounts the presence of “forcing”, tormenting suicidal intentions through defenestration, jumping out of transportation means or veinsections, as well as wife and children homicide. These thoughts recurring especially at night or in moments of inactivity, are in sharp contrast with his profoundly religious ideas, and induce a severe anxiety which he fights by repeated counts according to several algorithms, prayer and religious songs. He needs to verify periodically whether the family is still alive and that his aggressive states are mere representations of his tormented mind without any correspondent in real life. He has uncontrollable drives of swearing, of uttering obscenities, of repeatedly washing his hands and of periodically checking whether the gas, the water or electricity have been turned off. The patient presents spatial and social phobias since childhood – fear of darkness, of heights, of deep water, of starting a conversation, of being remarked and of blushing, to which other phobias

245 have recently added: fear of extreme poverty, mess, sickness, death, and intermittently, phobia of himself. The basic mood is affectively colourless, “suppressed” by the permanent self-censorship, with a low interest and involvement in activities; this background highlights anxiety, anhedony, ambivalence and ambitendency. Active social avoidance is present with minimum interpersonal relations, fatigability, asthenia, lack of appetite, severe insomnia. Extremely bothering is the lack of libido and early ejaculation, and considers his sexual intercourse with his wife a “burden” and a “duty” although he is affectionate to her and feels quasi-constant guilt for his entire behaviour. The parent’s family is described by the patient as relatively harmonious, dominated by the mother’s personality, who is rigid, hyper protective and fearsome, preoccupied by an education with powerful moral and religious basis. She was a housewife with a major role in her three children’s education, our patient being the youngest. The father, a worker who spent his entire day working is poorly outlined, and apparently uninvolved in the family life. The patient can hardly state to which member he feels to be mostly attached and considers himself to have equidistant relations to his parents and brothers. A certain tension is perceived when he speaks about his sister who had been treated for paranoid schizophrenia since adolescence, and who after the parents’ death would live with the patient and his wife. With reference to the school years, the patient admits it was an anguished period due to the permanent freight and accompanying symptoms – cephalalgia, perspirations, diarrhoea, and fever – whenever he had to perform an activity to distinguish him in front of his colleagues. He had poor results in school, attended only eight years of gymnasium and a training course in the turnery. He considers the lack of pleasure in performing an activity to be characteristic of his personality, due to intrapsychologic tension, unsafeness and negative anticipations. Different activities become attractive to a certain extent only after recurrent practice and familiarization through repetition. He got married at the age of 25, “due to his wife”, has two children and considers his family an extremely important support for him. Five years ago he renounced the catholic religion of the parental family and adopted the Pentecostal cult to which his wife belonged and considers this to be a turning point in his life as well as a spiritual evolution.

Medical history We consider that the patient’s birth and early development were normal. He had no accidents or cranial and cerebral traumas nor did he undergo any surgeries. From the age of 44 he is known as suffering of ischemic heart disease, essential arterial hypertension, obesity and dislipidemia and follows the prescribed treatments.

Treatment history Our patient, suffering of anxious/avoidant personality disorder since young age, presents recurrent admissions to hospital every year since the age of 42, for obsessive-compulsive and depressive relapses. Ever since the therapy began, the patient refused to participate in psychoanalysis of family therapies, expressing his preference for the drug-based treatment which he followed meticulously. He was treated with Fluoxetin 40 mg/day, Risperidon 6-8 mg/day and symptomatic medication with symptomatology remissions. Initially, the severity and complexity of the obsessive-compulsive panel imposed the patient’s retirement as most of the complaints were present and exacerbated within the professional environment. Evolution under treatment was favourable and after a year the patient insisted to be reintegrated in part-time professional activity, which he considered to be beneficial, conferring him the feeling of being useful and facilitating the development of interpersonal relations. During hospitalization, the medical treatment was completed with different psychotherapeutic techniques, according to the patient’s availability and the peculiarities of the clinical panel. Supportive psychotherapy based on psychodynamic concept and the implementation of a therapeutic alliance was helpful in preventing maladaptative defences of avoidance, inhibition, fear

246 of rejection and strengthening the mechanisms of coping used in the development of interpersonal relations. Awareness and insight oriented techniques assisted him in acquiring the level of understanding and accepting his own situation as well as the others’ problems. Behavioural techniques supported him in the control of compulsions and social avoidance, the subject managing to participate to different social meetings with friends and performances. During the depressive episodes he attended group meetings with symptomatology improvement. A subject approached with therapeutic difficulty was the problem of sexual dynamics, initially of phychogenic nature, subsequently associating an organic component due to somatic pathology and established medication. These deteriorated the difficulties of communication within the marital relationship and exacerbated the patient’s feelings of inferiority.

Differential diagnosis Phenomenological overlapping to a certain extent with the social phobia, the anxious/avoidant personality disorder is different from it through its long-term chronologic evolution beginning in childhood, as well as through the fact that selectively, the avoidant behaviour addresses interpersonal relationships rather than the respective social relations. Unlike the avoidant personality, the schizoid lacks any desire of communication and implication into interpersonal relationships since he is hardly preoccupied by the fear of rejection or group disapproval. Dependent personalities present a more marked fear of being abandoned than avoidant personalities and they search for attachment in interpersonal relationships. The well-established obsessive-compulsive disorder in our patient’s case poses no problems of differential diagnosis with other forms of anxious disorders or with schizophrenia.

Editorial comment The case presented here is diagnosed with avoidant personality disorder (APD) and obsessive compulsive disorder (OCD). There seems to be clear symptoms for diagnosing OCD. Regarding APD, symptoms such as permanent apprehension and avoidant behaviour, fear of disturbing the others, feelings of lack of self-trust, fear of failure in interpersonal relationships which he avoids for fear of rejection and disapproval, and social isolation seems usual if this type of disorder, as are also typical of social phobia, generalized type (SP). The author tries to differentiate both, but reasons such as “the symptoms appeared in childhood” does not guarantee APD diagnostic since one third of the social phobia also begin in childhood. A further reason to differentiate both disorders, “the avoidant behaviour addresses interpersonal relationships rather than the respective social relations” does not seem clear at all. No mention of traumatic interpersonal situations in childhood, characteristic of APD and SP A more relevant differential diagnosis should have been made with schizotypal personality disorder (STPD), since both disorders share some symptoms. Symptoms such as visual and auditory hallucinations: “sees” and “hears” people and animals which the others cannot perceive, depersonalization and derealisation, basic mood is affectively colourless, lack of pleasure in performing an activity, lack of trust in the process of commenting his problems, on the street he feels haunting looks are typical of STPD. Furthermore, his sister had been treated for paranoid schizophrenia since adolescence, which might support the presence of a SRPD. There are some inferences or comments by the author not justified, such as that the need of communication, typical APD is inferred from an “uncertain smile” or that “structural anxiety as well as moral rigor in the case of the above-presented patient maintain and augment each other and motivate both persistence of manifestations and resistance to treatment.” Treatment was confusing and without any systematic guide.

Note: There seems to be some confusion with the age of the patient through the case.

247 CASE 26: Lola: Borderline Personality Disorder Country of origin: Spain Authors: Esperanza Gómez Gazol and Antonio Perez Urdaniz

Identifying data The patient is a 29 year old good looking Spanish female, separated, no children. She is a computer technician who comes to our city after having lived in several cities and countries: Madrid, London, Belgium, Amsterdam, Los Angeles, Ibiza ......

Present complain She comes to our outpatient clinic, accompanied by her boyfriend and her boyfriend's mother, complaining of symptoms of anxiety and apathy. She states that the present economic and relational problems have triggered the complaint, although she recognized that she has always had many "ups and downs"

History of present illness Lola was born in a large city of southern Spain; she is the 3 rd of three siblings. Her family ran a family business, a small printing company. When she was 19 the family company went bankrupt and she was very affected by the economic and family hardships that the bankruptcy originated; then she decided to move to Madrid to look for a job. She started working as a waitress to support herself and continued studying computer graphic design, but after a few months she quit her studies and decided to concentrate in her job and in having fun. During the weekends she went out dancing, drinking, dating..... Then she had her first anxiety crisis, she went to a psychiatrist who prescribed Alprazolam and she was put in psychotherapy, but after a few sessions she met an English young man and decided to go to live with him to London, to look for news horizons. In London she started working as a go-go dancer in a disco and increased her abuse of alcohol and started using hashish and marihuana. When she was still 20 years old, she was diagnosed of panic attacks with agoraphobia and she was put in treatment with Sertraline and Alprazolam, but refused to do some psychotherapy as she was suggested. She had a terrible quarrel with her boyfriend because she caught him in bed with another woman, this prompted a suicide gesture by taking a pill overdose. She was admitted to a psychiatry unit for ten days but after discharge she refused to do the follow-up treatment telling the psychiatrist that she was going to Amsterdam with another boyfriend to rest and recuperates herself. She was very optimistic about this possibility and expected to initiate a new period in her life. In Amsterdam she started working in a Computer Firm as an apprentice and continued her computer formation. She did also occasional work as waitress, she made many friends and she refers that in about a year she moved seven times of apartment, according her "impulses" and the highs and lows of her sentimental life. During some periods she increased her amount of drinking and started consuming cocaine, her way of life became more and more accelerated and chaotic, she went to several therapists but didn't like any of them. She began to have intense feelings of wanting to go away and impulses to escape she started having binge eating episodes almost daily. She asked for sick leaves at job often pretending to be ill, what was no true, risking to be fired from her job, and she used these sick leaves periods to travel to France, Germany, Belgium, Portugal, and Italy. At that time Lola increased her manipulative behaving using people in function of the benefits she could get from them: money, presents, travelling, housing..... Approximately after living one year in Amsterdam, in one of her trips to Belgium, she decided no to return to Amsterdam and remain in Belgium where found a job with a family taking care of

248 the house and kids, but two months later she also got tired of this job, she said that she got terribly homesick of Spain and left just leaving a goodbye note to the family and even leaving part of her belongings. When she returned to Spain she staying in Madrid for a few months where she repeated her usual way of life, sporadic jobs, sporadic sexual relations, sporadic visits to her psychiatrists. Then she met a group of American young people, fell in love with one of them, and decided to go to live with him to Los Angeles, Ca. She was 22 years old. When they arrived to Los Angeles they got married and she started working in a computer firm. Initially the relation was very good, her husband was a 28 years ago Mexican -American, who worked as a security guard. But after a while the relation got stormy and plenty of breakings and reconciliations. He wanted to have children soon, bur she wanted to delay it, saying that "she was not ready for that" to the frustration of her husband. Eventually they separated although they continued their stormy relationship. They travelled to Mexico; she abused alcohol and benzodiazepines according to her ups and downs, and only worked in the periods of separation from her husband. She was somehow reserved about this four years period of her life, which finished when again she got very homesick of Spain and decided to come back. She was 26 years ago. When Lola returned to Spain she went to the island of Ibiza and worked making craftsmanship. She manufactured ceramics, necklaces, rings...and sold them herself to the tourists in a small shop. Her business was going reasonably well, she was an Imipramine 75 and Alprazolam 0.5 on a demand. The quiet life she had in the island seemed to be good for her in the beginning, she didn't drink much, she didn't have a boyfriend, and it seemed that she was settling down. But after two years in Ibiza, at the age of 28, she began to have derealisation -depersonalization crisis. She refereed she was like afraid of staying in an island all her life she felt like isolated from the world. Then she met a Spanish family from our town who was on vacations in Ibiza and started a friendship with a son of the family, and decided to leave Ibiza an to go to live with him and his family, since this new boyfriend, 25 years old, was still a student and was living with his parents. The family of his boyfriend accepted her well, specially the boyfriend's mother, who had a friendly relation with her. During this eight month period the family of her boyfriend supported her economically. She was looking for a job but didn't like, any of the jobs offered to her and refused several offers. The boyfriend's family got increasingly worried about her and finally her boyfriend and his mother of her boyfriend brought her to the psychiatry outpatient clinic.

Mental status The patient is a 29 years old woman, attractive, extrovert, verbal, polite.... she dressed in a casual manner and wears a mini skirt. She is in a low mood and refers preoccupation for not finding a suitable job and being a burden for her boyfriend's family. She recognizes to be very anxious, to feel agoraphobic in public places, to have many ups and downs and bouts of impulsivity that caused her to have binge eating. Lola says he has abandoned hers hobbies like art and sports and that she is feeling "real bad".

Social and family history Lola is the 3 rd of three siblings, her mother suffered from panic attacks and her father from alcohol dependence one of her brothers suffers from anxiety and depression. The family of Lola ran a small family business a printing company, she wanted to study computer graphic design in order to work with her family. Because of the refereed family illness the relations within the family were quite unstable, Lola’s stormy temperament and rebelliousness didn't facilitate things.

249 But the worse problems arrived when the family firm went bankrupt, this aggravated the family conflicts as well as the paternal abuse of alcohol, and prompted Lola to leave home and go to Madrid to life her life. The life of Lola is a long list of sentimental and job changes. Her sentimental relations are very passionate bur unstable and both her sentimental life and her job reared show a high degree of impulsiveness and instability. Though her life she has consumed several drugs although she didn't get dependent of them. She was scared of the depersonalization- derealisation attacks produced by some drugs specially cocaine.

Medical history She doesn’t refer any medical problem.

Clinical course and treatment history Lola came by herself to the second interview, she said that she wanted to clarify some points that she didn’t want to mention in the previous visit. She referred that she was very worried by the reactions she was having after consuming cocaine, she said that she experienced moments of great anxiety for followed by sensations of strangeness, unreality regarding the place where she is or what she is living and even regarding herself. These symptoms of depersonalization - derealisation are brief and related to the use of cocaine. She is also worried because she initiated in the use of cocaine her present boyfriend. She was very pleased with her present boyfriend Juan, but she didn't like living in her parents’ house. She persuaded Juan to rent an apartment for them but they didn't have the money to pay for it, so her boyfriend's parents helped them economically and she started looking for a job. She had four job offers, some of them even well paid, but she didn't like anyone of them, she was contradictory on one hand she wanted to work but on the other hand she didn't. She started having a growing feeling of wanting to get away, to go to another city to find a job, but she was contradictory in everything she made. We include a little dialog of this session to illustrate her degree of emotional instability and impulsiveness: Lola: Do you want me to tell you what I did a few days ago? I was feeling very sad and alone, and I decided to adopt a dog so I went to the pet- shop and I saw a wonderful puppy, bur he had a little brother, so I adopted the two of them. I couldn't stand to separate them, they had suffered a lot, do you understand? Therapist: and what else happened? Lola: I did not even remembered that my landlady had told me that she did not allow animals in my apartment, so this very evening I told Juan that we were moving to another apartment, and we did the moving I packed up my belongings very quickly but it took us a while, because after buying the dogs, in the way back home, I had bought many nice things for the doggies, food, toys, houses...very nice things. Therapist: So, where are you living now? Lola: Well, first I moved my things to Juan parent's house because it was too late to find an apartment the same day, so we spend a couple of day with friends, and yesterday we found another apartment, it's a little far, but they let me have the dogs. Juan has been very helpful he is good to me.... the doggies are so nice, but they give a lot of work and demanded a lot attention, but Juan is so helpful.... Therapist: what do you think all that means? Lola: I don't know maybe I should have thought better, tomorrow I have a job interview and if I get the job I will have to leave the dogs alone because I will not have free time to take care of them... I didn't know everything is very confusing I can not control myself...I do not think about what I do. I do everything without thinking I didn't think I do everything wrong ....I'm a disaster (she cries).

250 THIRD INTERVIEW: Lola missed the next two appointments, and then her boyfriend’s mother came. She was very worried and gave us the following information. One week ago, Lola had gone to Madrid to look for a job, Juan went with her. Juan's mother said that Lola made it very clear to Juan that she didn't want a formal relation with him, although she loved him very much, she told him than everyone has to do his/her own life. Juan had abandoned his studies in the University in the middle of the academic year, was living in Madrid with friends of him, because Lola didn't want to live with him any longer. Juan doesn't have a job, and his mother was very worried, she said that Juan has never been like that, that he was responsible and hardworking, and blames Lola for this change. She said that Lola is very irresponsible, changing and impulsive, and states that his son is a good boy and hopes that Lola will completely leave him soon. She was also very worried because Juan and Lola didn't have any money she send Juan some money but she was afraid that the money will end up in Lola’s hands, and shows anger that Lola for not working in months while she had worked in the past, and while she was offered several jobs... She tries to keep in touch by telephone with Juan and with Lola but Juan is very reserved and doesn't say much, and Lola soon stops answering her phone calls.

Diagnosis and treatment The patient presents an unstable way of living and a wide variety of symptoms, anxiety attacks, abuse of alcohol, abuse of drugs, depressive episodes, depersonalization- derealisation, binge eating...... This shows a pattern of emotional instability, impulsiveness, and messy social relations, produced by a borderline personality disorder. The diagnosis is a severe borderline personality disorder which causes a very unstable way of living and a variety of Axis I pathology. She is a very resourceful person she has travelled a lot and despite of her pathology she always was able to survive. We passed the complete form of the IPDE to the patient. She cooperated very well, was very verbal, and we obtained the following scores.

PERSONALITY DISORDER NUMBER DIMENSIONA RESULT OF L SCORE CRITERIA 301.0 PARANOID 0 3 NEGATIVE 301.20 SCHIZOID 0 2 NEGATIVE 301.22 SCHIZOTYPAL 1 4 NEGATIVE 301.7 ANTISOCIAL 1 7 NEGATIVE 301.83 BORDERLINE 5 14 POSITIVE 301.50 HISTRIONIC 2 8 NEGATIVE 301.81 NARCISSISTIC 0 2 NEGATIVE 301.82 AVOIDANCE 1 3 NEGATIVE 301.6 DEPENDENT 2 7 NEGATIVE 301.4 OBSESSIVE COMPULSIVE 0 2 NEGATIVE 301.9 NO SPECIFIC 0 0 NEGATIVE

The initial treatment was: Paroxetine 20 mg 1-0-0 Alaprazolam 0.5 mg 1/2-1/2-1/2 Topiramate 50mg 0-0-1

And also we tried to initiate some counselling about her living situation but we didn't have the time, and the chance to do a proper follow-up.

251

Editorial comment The case of Lola illustrates two important features of pathological dependency. First, although Lola was formally diagnosed with borderline personality disorder, it is clear from her relationship history that strong underlying dependency needs play a key role in her current difficulties. Second, it is noteworthy that Lola’s problematic dependency was largely secondary to her alcohol and drug use. Although diagnosticians have long recognized that dependent personality disorder often co-occurs with substance use disorders, only recently have clinical researchers shown that in most cases increases in dependent behaviour follow (rather than precede) substance use disorder diagnoses. Like many highly dependent people, Lola is conflicted regarding her competing dependency and autonomy urges. In her familial and romantic relationships she alternates between relatively long periods of excessive dependency and short-lived episodes of tenuous self-reliance. Her ambivalence in this area emerged quite clearly in her impulsive purchase of a puppy, which appeared to be prompted by an urge to nurture and care for something even more helpless than she. Even here, however, Lola’s well-intentioned behaviour led to conflicts with her romantic partner and renewal of old family interaction patterns as she turned from partner to parents for nurturance, comfort, and financial support.

252 CASE 27: Paranoid Personality Disorder Country of origin: Argentina Author: Nestor Koldobsky

Identifying data RP male, 55 years old, married two children (male 35, married; female, 32, married), two grandchildren.

Exhibited complaints The patient came to the consultation with his wife. The principal complaints were sadness, anguish, anhedonia, interest decay, and ruin ideation related to his job situation (an apparent high risk to be fired).

History of present illness As the depressive symptomatology was improving – the same symptomatology had been seen in other critical life situations in which the severity was evaluated by RP through a real or imaginary perception– elements showing a permanent presence of pride related to the quality, rhythm and results of his work began to appear. Pride traits joined to arrogance had been present from his adolescence. In many occasions the patient reacted with manifest rage when his work was criticized. When those comments from clients and work mates were analyzed in therapeutic situation, it was proved that not always the critics were wrong, undue or had the intention to devaluate the patient (“narcissistic hurt”?). To approach his work tasks he behaved throughout obsessive mechanisms, but they were not always related to the concept of responsibility, but to the internal need to face the possibility to be criticized and devaluated by rivals, clients and work mates. The last two years RP became mentally aggravated for work place problems. There were continuous thefts of tapestry, expensive decoration, pieces and furniture. He manifested that those illegal behaviours offended his creditability, but not only that: for more than two years he had been expectant trying to see how this situation could affect him. This expectation has had not only an adaptative or self-defence object to him, but he has also for a long time been hyper vigilant, tense, anguished, waiting with fear to be accused as actor, partner or even having thoughts about being intentionally implicated.

Family and social history The patient came to his first consultation with his wife, who suffered from a severe heart insufficiency and was a good, submissive partner, caring for her husband. The son was being treated for depression and violent frequent behaviours, which generated him neither remorse nor guilt. The early personal history was not clear. He built up a middle class family, having lived since marrying in a workers’ neighbourhood with friendly and sharing-in-common people, but RP was always respectful, distant, solitary, untruthful, isolated from neighbours. His job was that one of an upholsterer.

Mental status and assessment Mentally active, with an adequate intellectual level, he has always shown himself alert, analyzing the therapist’s questions, writings, attitudes, expressions, and taking care before answering each question. The history was told in a clear, coherent style, but focusing the attention only on a depressive symptomatology, being reticent to comment about his permanent distrust, fear and apprehension. The symptomatology had always been present since his early years, but being increased during the last two years. There were no delusional ideas, but only distrustful

253 overestimated ones. His affect expression was restrained, and all his acts were studied and controlled. At his second or third consultation, he was given a copy of the self auto-evaluation MCMI III test to be answered. At that moment he suffered an extremely emotional reaction (anxiety, anguish and fear) and ran away from the office. For a long time he was unable to come to the next appointment according to the contract treatment. When he finally came, he looked slightly embarrassed, and explained that because of both the contents of the questions and the distrust the material had produced on him, he had not been able to control his emotional reactions and, therefore, escaped.

Medical history Patient suffering from bronchial chronicle disease (20-30 cigarettes per day). Being affected by two or three annual severe pulmonary infectious episodes. Suffering from hypertension, controlled by salt free diet and amilodarona.

Differential Diagnosis RP did not have a flexible, creative and adaptive conduct, but a pathological personality. There were characteristic traits, especially distrust, which had been present since his adolescence. This trait influenced his behaviour, which was rigid, non-adaptive, affecting his self and his interpersonal relationships. RP had a pathological personality, distrust being the principal permanent trait. RP’s diagnosis was considered to be PPD. It is necessary to differentiate delusional disorder from PPD: in the former there are fixed pathological ideas, while in the latter there is only overestimated ideation. RP did not present delusional ideation but overestimated untruthful ideation. The patient has not had paranoid schizophrenia because hallucinations, primary thinking, and thinking course alterations were not present. The paranoid defensive attitude was related to his perception that he would be attacked, accused or fired. Many times the paranoid patients have defensive crisis that are related to their perception that they will be attacked (as it happened with the test material presentation to RP). It is necessary to differentiate these reactions from those of the evasive and dependent PD’s, where the attack is on the self-esteem, and from the borderline, where the reactions are related to the impulsivity and the affective instability. Sensibility is the base of the jealous attitude and distrust of PPD. As at first consultation RP’s diagnosis was DDM, a differential DDM with psychotic features diagnosis was required. RP did not have congruent or incongruent mood psychotic features, as there were no delusional ideas, but only overestimated ideation which had not depressive themes and pre- existed to the depressive state.

DSM IV diagnosis Axe I: DDM Axe II: Paranoid Personality Disorder (PPD); Obsessive-Compulsive traits. Axe III: Bronchial chronicle disease by high tobacco consumption. Hypertension. Axe IV: Difficulties regarding work environment and tasks. Other psychosocial and environmental problems, real or imaginarily perceived. Axe V: 50, severe social and occupational functional impairment.

Treatment history It is known that Cluster A personality disorders (DSM IV) patients ask for treatment with great difficulty or never at all. Generally the consultation is done because of crisis situations and/or because of comorbid pathology. It has been considered that the consultation period motivates those patients for treatment (in this case major depression). It is of enormous importance that this period (crisis or comorbidity presentation) is used to establish an adequate therapeutic alliance. The therapeutic alliance got deeper with RP, not only because of the kindness, understanding and

254 sincerity that the therapists tried to provide in the early treatment period, but because of the fact that the patient was alleviated from the depressive symptoms, which produced him an enormous personal suffering. This suffering was related not only to the disadvantage and impotence that he had felt at his labour place, but also to the fact that he perceived the disease, the depression, as a factor that increased the vulnerability to the external pressure that was taking place in that moment (there was a mixture between ideas of depressive contents with a tendency to a chronic suspicion and distrust). When RP was proposed to take a health license at work, he read thoroughly the therapist’s certificate. Then he insistently asked if the work license, which he accepted with pleasure because he did not feel well, would not cause him any harm. In order to prevent an administrative transgression which might harm him, the therapist asked RP if he was included in a license regime. He answered that it was not the administrative aspect that worried him, but the possibilities to offer new elements allowing others to disqualify him. At the beginning of the treatment his wife was suggested to be present in order to get him to feel more comfortable and confident, and so she was on many appointments. RP was habitually so authoritarian. His way of thinking and his beliefs were imposed as “universal truths” to the family members and environmental people. As the treatment advanced, his narcissism and personal pride (superior in this case to a healthy self esteem) got down, and he became much more dependent on his wife and family. RP’s suspicion and distrust never was technically confronted (early confrontation). As suspicion and distrust occurred not only within his job conflict, but within his neighbourhood as well, in spite of having lived there for many years, he was relatively isolated. Suspicion and distrust appeared many times during the evaluation and treatment stage: labour license certificate, medication prescription or propositions for him; all these situations were sieved by doubt and distrust. RP often asked the therapist an exhausting interrogation, which sometimes made him feel tired, anxious and raged – contra transference reactions. RP was managed with great patience, not only knowing that he was getting fond of the therapist, but also this being confirmed by his satisfaction expressions – PPD usually behaves honestly– and for some of his wife’s comments. Therapy went on slowly and progressively. It was suggested that work license would benefit the patient and that pharmacological indications would contribute to humour recovery. Strengthening on his personality was insisted. The pharmacological treatment was that one specific for a major depression, but when the paranoid mechanism appeared, low doses of atypical neuroleptics were added (for PPD risperidone, olanzapine, quetiapine were used). At this treatment level, the therapist validated the patient’s suffering, adhered neither to RP’s doubts, nor distrust and hypersensitivity, but did not oppose actively to them. In this therapeutic moment the therapist focused on all the negative consequences that the situation had brought to the patient and went on suggesting him that even if the situation persisted, adopting an isolated and hidden attitude would not be adequate. The patient was intended to take conscience that those conducts only would contribute others to lack consideration of his personal values and abilities, in special those related to his work quality. He was suggested that treatment would help him recover his mental strength. Once RP was relieved from sadness and anguish, he recovered a good somatic and humour state. The flow of fondness was deeper. During license time, he was promoted physical and mental activities and free time usage (walking for his hypertension, accompanying his wife for her cardiopathy, caring her and helping to confront the illnesses fears, going shopping, visiting their children and helping them with their grandchildren entertainment). The adequate use of free time replaced the permanent time loss sensation. The reappearance of positive affects and the decrease of the anguish and tension levels were stimulated. At the beginning of the treatment, with the argument to put distance from the unjust situations for which he suffered a lot, we supported the stopping of the obsessive-ruminative mechanism of ideation. When he got that, he became much quiet. He looked less overwhelmed, less tense. In that stage we began to make it prominent that even though the problems continued, he could get the possibility to live with them within a healthier pattern and with a lower suffering for him and his family. The therapist validated the possibility that attitude change could be due to being far from the stress situations. It was emphasized that in other holiday times during the last years, he

255 had not been detached from bad thinking or suffering, as he was able to in this present moment. RP agreed. After many months, he could maintain a lower preoccupation state, but never with total unconcern. He was better humoured, had lower irritability, and more insertion in his environment. Talking about the possibility of getting back to work had begun. This proposition produced an anxiety decompensation, for the fear of the situation at work place, but when he was proposed to return to work, he showed a strengthened personality, that prepared him for the challenge of getting back to a potential hostile place. There is a persisting doubt about the attitude of other people, but it is not with the previous intensity. The interrelationship aspects have been worked on in connection with establishing an emphatic relation with neighbours, neighbourhood, and some friends. During that period the comprehension about the existence of other people’s affective flows and attachment intentions was strengthened and some beliefs were re-elaborated about own and other behaviours that occur within the process of interrelationship. When RP surpassed the feeling of insecurity to returning to his job he accepted to go. At that moment the therapist increased the frequency of appointments, and without confrontation, he was intended to accept to participate with his coworkers, using an example as if they were “a separate couple that do not decide to leave home”. Once he accepted this consideration, the therapist began to make him differentiate what behaviours, in the labour realm, objectively referred badly to him, from those that were in relation to corruption mechanisms which had not the interest to alien him. It was stimulated that the patient differentiated and took distance from the authentic risk, in connection with his deep analysis and evaluation of the facts. Thinking derivate from paranoids became more diffuse. It was permanently stimulating RP’s self-esteem, enhancing his values and the real quality of his work. Some months later, when possibilities to patient decompensation in suspicion, hyper vigilance, and self reference lowered, retirement was proposed, being his age and administratively possible. At the same time RP was motivated to begin new activities.

Therapeutic strategies 1. Taking care of the development of the therapeutic alliance 2. Supporting and treating the emotional consequences of the personal perceptions of other persons attitudes 3. Stimulating the accept of his self efficiency and an adequate self evaluation through the correct evaluation of the results of his work and production 4. Modify the feelings, real or perceived, to be attacked, diminished or disregarded at word 5. In the case of zeal, stimulate to confront zeal, fighting for the things he likes, “not submit to the lions” 6. Enhance the abilities to confront anxiety and interpersonal problems 7. Get a real perception of the intentions and conduct of the others 8. Develop and increase conscience of the point of view of the others

Editorial comment This case illustrates several important dilemmas which arise when addressing paranoid personality disorder, as well as personality disorders in general. The first issue relates to the presence of comorbidity between major depression, the possibility of dysthymic disorder, and the personality disorder. The differentiation is difficult to make, given that an ongoing air of suspiciousness and hypersensitivity to criticism can produce a chronically dysphoric state, which may vary in intensity. Response to treatment often helps discriminate between a specific Axis I disorder, in this case major depression and/or dysthymia, and the personality disorder itself. It does not appear in this case, however, that specific antidepressant medications produced significant change in the patient’s state. While over time there was specific improvement in the dimensions of both mood and affect, it is unclear whether this reflected a responsiveness to pharmacologic treatment for depression or to psychotherapeutic treatment for the personality disorder itself. Further, since we know from recent

256 large scale studies (such as the Step D Study in the United States,) that only about one-third of patients with significant depression respond to initial pharmacotherapeutic intervention, we are still left with the difficulty of differentiating personality disorder versus depression in this case. Another very important issue relates to diagnostic criteria one uses to make a diagnosis, and the overlap between criteria for various personality disorders. For example, in this case, the tendency toward grandiosity, reflected in ICD-10, Criteria F: “Tendency to experience excessive self- importance, manifest in a persistent self-referential attitude” appropriately reflects the underlying hypothesis about the role of grandiosity in the psychological constellation of individuals with paranoid personality disorder. Using a self-psychological psychoanalytic understanding, one might suggest that paranoid personality reflects an inadequate maturation of early developmental grandiosity. Thus, the symptoms of hypersensitivity to criticism, excessive vigilance regarding such criticism, suspiciousness of others, emotional distancing, and chronic dysphoria, could all relate to excessive vulnerability due to the persistence of infantile grandiosity. This connection is illustrated through the patient’s response to the therapist’s work with him over time. Responding to the therapist’s nonjudgmental, empathic approach, the patient’s paranoid personality disorder symptomatology diminished over time (even though it never totally disappeared.). One could hypothesize that the improvement was related to appropriate nurturance of the patient’s narcissistic deficits, even though it is unclear whether these deficits were substantially altered through the course of treatment. One could argue that it was the therapist serving in a “self-object” function, in which the therapist provided psychological sustenance for the underlying narcissistic defect that allowed the patient’s symptoms to decrease and his functional capacities to improve. Knowing of the difficulty in engaging patients with paranoid personality in a psychotherapeutic process, one must admire the sensitive way in which the therapist was able to maintain and build a therapeutic alliance which had a clear therapeutic benefit for the patient. A more general message from this case regards the possible role of this type of therapeutic intervention in patients with any personality disorder. One could hypothesize that whatever the etiologic origins of a specific individual’s personality disorder that the “holding” aspects of a long term therapeutic alliance would serve to ameliorate, to some extent, the developmental deficit and result in a higher level of functioning with diminished experience of distress.

257 CASE 28 Jane: Obsessive-Compulsive Personality Disorder Country of origin: Kenya Author: J.M. Mburu

Identifying data The patient is 30 year-old female married two years ago, a mother of one-year-old son, employed as secretary in busy sales department. Her husband who initially wanted some marital counselling referred her to psychiatric clinic for assessment following their counsellor’s recommendation.

Presenting complaint The husband explained that his wife, Jane was rather difficult to live with; she has no room for flexibility, cannot tolerate changes and always wanted things done her way. The husband indicated that apart from one other person whom Jane went to school with she has not been able to retain most friends. Their marital relationship has lately been strained by this behaviour and he desperately wanted mental disorders ruled out or found and treated since he wanted to salvage his marriage.

History of presenting complaints During courtship, which lasted for barely six months, the husband had noticed some characteristics in his fiancé that he could now recall though initially he did not pay much attention to them. For example preoccupation with punctuality, ever careful not to mess things up and at times she was indecisive since she had doubts about issues, which ordinarily would be agreed upon quickly.

Mental Status Jane had good grooming and appeared calm and was spontaneous in her speech. She described her self as irritable and tearful especially if her husband didn’t follow her instructions and although she was not hostile that time, along the interview she developed anger and accused her husband of being unreasonable. Thought process was so rigid and could not be swayed easily, however there were no delusions, and she did not have perceptual disturbances. Her cognitions were intact except for her insight where she indicated that it was the husband who was a problem and not she. At this juncture it was suggested that a second session be arranged where the relatives will be interviewed as well

Personal History Parents revealed that the prenatal and postnatal periods were not unusual compared with other siblings. However, they did notice at six years, that Jane was rather concerned with tidiness and often fought with her younger sister who would often disorganize her well arranged room. Otherwise she grew well and had no major illness, but school reports cited her as an obedient and neat girl. She completed school, and trained in secretarial courses. However, unlike her two younger sisters she was the last to marry. During the third session, Purity, a childhood friend and former classmate accompanied Jane since she had previously been involved in mediating between the couple and was a trusted friend to them. Purity narrated the following: “I met my neighbour Jane during our pre-school age and we became friends. She remained a close and faithful friend of mine all through primary school. Unfortunately, we didn’t do many things together because of the heavy tasks imposed on us by our parents at this age. Time came to go to high school and we happened to go to the same girl’s boarding school.

258 Jane reported to school before me. On my arrival, I found that Jane had not settled down despite having reported to the school one week earlier than I. She was still struggling to accommodate to the new environment. It was so difficult for her to adapt to the new changes. Jane was feeling so upset now that she had to change from her old routine of life at home and change to a new routine in a boarding school. Jane was so rigid in her views and so inflexible that she was so uncomfortable with the new changes in her life. Jane was always very punctual in every area, be it in class, going for meals, going to bed or for other activities like games. She was so punctual that she could not understand why other people would be late. She would really get annoyed with the people who were late. Due to her punctuality, Jane was chosen to be one of the prefects while still in form one and so she became the time-keeper (bell ringer) in the school. Having acquired the role of a prefect, she really made good use of her position to try and enforce punctuality on others. She was so preoccupied with punctuality that she even punished those who were late for example, for meals or for games for instance, by asking them to kneel down for sometime. She was harsh at judging people, especially concerning lateness. On conversing with her about punctuality and punishment of latecomers, she told me that she really feared being late for fear of being judged harshly so when others are late, they should also be judged harshly because rules should not be broken. Jane was very careful to observe all the school rules to the letter; she would always show some kind of disgust for those who broke school rules. She would actually never talk to any of the so-called “school criminals”, not even offer them a greeting. Jane was always careful to do the right things, at the right time, at the right place and with the right people. Her moral standards were so high and so exaggerated that whenever she did wrong, she was so preoccupied with the guilty feelings that she would become so upset for such a long time. She would consequently enjoy nothing for a couple of days. Instead she would really be distressed because of her wrong deeds. I had an opportunity to be in the same dormitory with Jane. Being a close friend of mine, I would always pass by her cube to say hallo in the mornings. What surprised me was that Jane had never woken up after me in her entire secondary school life. I would always find her awake, having made her bed already and very busy dressing. She would wake up very early, tidy her bed, tidy her cube and put everything in order. She was very neat such that she got offended if you entered her room with dirty shoes or littered her room with papers. She was just too smart. She would always dress very smartly. If her skirt got a dirty spot somewhere, she would keep looking at it so many times that she had to go back to the dormitory to change or and remove the spot. Jane would always make a list of the things she intended to do that day every morning. She kept making changes on that list as the day progressed such that she would end up not doing most of the things. She had a very neat study timetable but she kept uttering it everyday such that some of her sleep time was spent on making a new study timetable hence didn’t have much time to study and thus could not perform well in her academics. She was so concerned with trivial details that she never got anything important done for example, she was very busy drawing lines on her books to make them neat such that she could not get enough time for study hence the poor performance. Jane was very sensitive to criticism. She had such undue concern for other people’s opinions. Every break time, she kept asking me whether her clothes looked neat and clean. Whenever we were given some homework in class she would always seek the opinion of so many people before she did her homework. She would fear making a mistake; so she spent so much time getting other peoples answers and trying to judge which answer is right among the many such that she would end up not finishing her homework at times. This would put her into trouble, which really distressed her. Jane was so indecisive. In case she was faced with a decision to make; she would move from one person to another seeking for advice and consulting others so that there was always a delay in the decision-making. Due to her nature of delayed decision-making, she had very few friends, since you could not decide anything substantial together with her. You could never tell when she was

259 happy or when she was informal that people feared to joke with her. She was also very mean in all respects. She could hardly enjoy giving or receiving gifts, hence could not make many friends. People perceived her to be very judgmental because she was such a perfectionist. Jane was such an organized lady. She would really organize her things so well. Every closing day, Jane would make a schedule of where and how to spend the holiday. She was so preoccupied with organization. If she keeps her cup on the right side of the table and the plate on the left side, you could not alter this order otherwise you would collide with her. She was such an orderly lady. If you happened to visit her room, you could not disorganize her things or just put things anywhere else, otherwise she would sit you down to tell you how she organizes her things and how the order of her room should be like. This behaviour persisted all through our school life and it was so inflexible in Jane’s life. You could not try to change any of her behaviours because they were so rigid in her I got married at 23 years but she did so at 30 and although several boys approached her, relationships were short-lived and very fragile. Due to long standing contact with Jane I learned that the boys easily got tired of her due to rigidity and perfectionist patterns. I hope that Jane has outlived her childhood behaviours, and of course when the current husband really fell in love with her we all encouraged the marriage. But they have been constantly quarrelling over trivial things as I have now learnt .She says the husband doesn’t get home at the prescribed time, he throws his socks, shoes trousers all over the place, never makes the bed to her satisfaction, that he disorganizes the order of tooth brushes set in the bathroom. He has been accused of being a disorganized person and irresponsible although he doesn’t seem to understand why she is so irritated by such trivial matters and in any case he thinks he doesn’t do any of these things in a manner most other men don’t. He has been upset by the fact that although the baby is well she constantly takes him for medical check ups incurring heavy bills. She is now threatened with sacking at her work place due to inability to complete tasks in good time, although the employer says she was initially a good organizer but now she achieves minimal, except making schedules and remaking them. Workmates find her difficult to relate to.

Management Other treatment sessions were arranged. Behaviour therapy was done in which the husband was constantly encouraged to be patient, learn her likes and dislikes with hope that since he is more flexible it would be easy for him to adjust and accommodate her. Since she was irritable, constantly feeling rejected and tearful at times with sense of hopelessness, antidepressants were prescribed. Within two months of psychotherapy and pharmaco therapy, significant changes were recorded. The husband yielded to her demands with limitations, her temperament was much better and although her rigidity persisted, the intensity of irritability reduced with less frequent quarrels in the house. Long-term supportive psychotherapy was recommended for the couple.

Editorial comment In this case of obsessive-compulsive personality disorder (OCPD) from Kenya, we see the classic clinical presentation of rigidity, moral superiority, punctuality, self-doubt, and perfectionism that undermines task completion. Another significant feature of this case is that Jane first came to attention when her husband persuaded her that she needed to go to a psychiatric clinic for assessment. Often the family members of a person with OCPD are far more distressed by the patient’s behaviour than the patient herself is. Similarly, much of the symptomatology was explicated by a childhood friend and former classmate who had made observations over Jane’s lifetime about the behaviours causing difficulty for Jane. The difficulties in interpersonal relationships that the patient has encountered throughout her life are common in cases of OCPD. Others find the

260 inflexibility, insistence on punctuality and tidiness, and the “holier than thou” attitude to be irritating and thus may avoid the patient with these traits. In this vignette, the patient is treated with behaviour therapy and antidepressants. It should be clarified that we are lacking rigorous randomized controlled trials of the application of behaviour therapy to obsessive-compulsive personality disorder, and there are no placebo-controlled studies demonstrating that antidepressants are helpful for the condition. By contrast, the combination of behaviour therapy and a selective serotonin reuptake inhibitor is efficacious for obsessive- compulsive disorder (OCD). There are randomized controlled trials using psychodynamic therapy and cognitive therapy for Cluster C personality disorders, and both modalities appear to be efficacious for the anxious cluster of personality disorders, including obsessive-compulsive personality disorder.

261 CASE 29 AB: Borderline Personality Disorder Country of origin: India Author: J.K. Trivedi & Dishanter Goel

Identifying data The patient AB is 24 years old unmarried girl, 8 th semester medical student belonging to a middle socio-economic status family.

Presenting complaints Emotional outbursts, frequent changes in emotions (currently depressed) and self injurious behaviour.

History of Present Illness Miss AB was in school in class XI (16 years old), when she started feeling that nobody can understand her emotions and needs, and nobody can be as ‘emotional’ as she is. She would feel frustrated and feel that she has been wronged by her parents & siblings and they could never understand her feelings. She would frequently have emotional outbursts; during which she would shout or hurl things at her siblings and sometimes over her mother. During these episodes of frustration’ she would also harm herself like slashing her wrists or consuming 8-10 “sleeping pills”. She admits that she never had intentions to die but it was just out of ‘anger’ that she committed such type of behaviour. She always had a feeling of emptiness. During this period she fell into relationship with one of her old friends and got involved with him physically. She had strong emotions for him and felt that he is the one who can fill her long emptiness, but after completion of school, she started preparing for premedical entrance examinations and broke up from that guy. During her preparations, she got involved with another guy (P) but she left him also after she got through the premedical examination. In the early years of her medical college, she found many girl friends but slowly distanced from most of them, as she would have outbursts of anger on any one of them and would shout on them. She would never follow anybody’s suggestions and wanted to live life her own way. There is also history of her going on ‘shopping sprees’ and spending thousands of rupees in a single day which was excessive considering her modest background. All her girl friends noticed that she had many broken friendships even with girls who were even very close to her. She would insult and devaluate the girls whom she used to praise whole heartedly. She got involved with a boy in her first year, who was considered to be a man of bad character, but she argued that ‘she likes taking risks. She got so emotionally involved with him that she wanted to marry him, but one day they had a fight and their relationship was broken. All the while her self injurious behaviour continued and she consumed tablets of Benzodiazepines twice when she fought with the guy during their relationship. During her 3 rd year, (P) came back to her life when she herself called him up and asked him to meet her. They got involved physically despites the fact that (P) was married by now. After 3-4 months (P) refused to keep any more contacts with her, as he was married man. She broke many articles in her room and slashed her wrists. After 6 months, she fell in love with a guy (RM), who was also one of her friends, and proposed him but he refused. She had fears that she will be abandoned by him and she started calling him up, 3-4 times a day, and would apologize to him again and again. She admits that she has always had such feelings of abandonment regarding her family members, girl friends or boy friends, and she always try to keep her relationships but they are ultimately lost. This boy tried to maintain a distance form her, but she would call him up at midnight and apologize to him. He changed his phone number, but she got it somehow. She wrote him letters by her blood and consumed

262 benzodiazepines twice and slashed her wrists twice when he didn’t respond to her calls, though she says that “I don’t want him to love me, but I don ’t want to lose his friendship”. The second time she slashed her wrists, she was referred to Department of Psychiatry for evaluation.

Fa mily and Social History AB belongs to middle socio-economic family. Her father is a bank clerk and earns Rs. 10,000/- per month. He is a modest man and is busy with his work. Her mother is a house wife. She is a social lady. None of her other children complain that she has been a ‘bad’ mother, but they praise that despite having chronic heart and joint problems, she has always done her best for her children. She has two elder brothers, one of whom is married and working and was 7 years elder to AB so he was not much close to the patient and never need to share her emotions. The other brother always tried to be supportive to the patient, but she would shout at him during her emotional outbursts and frequently she would accuse him of not being a good brother.

Medical History Birth and development were normal. The patient has never suffered serious illness.

Mental Status AB was good looking girl. She complained of depressed mood, loss of interest in pleasurable activities, easy fatigability, guilt feelings, depressed sleep, decreased concentration and worthlessness. She had been having such feelings for the past 10 days. She feels that she gets happy or sad very easily and then she has difficulty in controlling her emotions. She feels that she gets angry very easily and during her emotional outbursts, she can not control her behaviour. Sometimes, she has had self injurious behaviour, but she never has real intentions to kill herself and she always knew that she is not going to die by slashing her wrists superficially or ingesting some tablets of Benzodiazepines. She has high morals and philosophical ideas. She confirms that she always had a feeling of emptiness and burden and that was because no one at her home or amongst her friends ever understood her. She never got the love or care of her parents and they were not supportive to her. Her brothers were busy in their lives and they never had the time to share her problems. Whenever she tries to get close to someone, she is always deceived and the one whom she used to idealize turns out to be a “devil”.

Managemen t AB came for therapy weekly for 4 months. The method of therapy was Dialectical Behaviour Therapy (DBT). Throughout the session, the patient was regular and cooperative with the therapist. The second brother of the patient was the only family member, who visited the therapist during the duration of therapy. The first two sessions was dedicated to building therapeutic alliance with the patient. Some of her maladaptive behaviours were discussed and counter views to such behaviours were presented to the patient. After some persuasion, she accepted that some of her behaviours are maladaptive. Then the diagnosis was revealed and discussed with the patient. The 3 rd and the 4 th sessions targeted the self injurious behaviour of the patient and she was told about coping skills and anger management. She was advised not to repeat such behaviour in future. She was taught relaxation exercises and was advised to routinely carry them out. She was also given home work assignments which included maintaining an automatic thought diary, where she would mention the situation, her emotional reaction to the situation, automatic thought which came to her mind, her behavioural responses to it, was there anything wrong in it, according to her, and can she think of a better response.

263 Further sessions included a 15 minute review of her home work at the start of the sessions. Next 4 sessions strengthened the concepts of mindfulness, distress tolerance, emotional regulation and interpersonal effectiveness. Anger management was also included. The patient started showing improvement in her emotional outbursts and learned to overpower her emotional outbursts and anger. She stopped harming herself and realised that it is maladaptive. She let RM go and realised that if he does not want to get involved in a relationship, then she can not win him forcibly. She realised she should acknowledge her well-wishers and should lower her expectations. She realised that each time idealistic attitude cannot work in real life and various instances of her own life were quoted as examples, to make her understand this. Next 4 sessions also targeted the above issues with some more success. When the emotional regulation was satisfactory achieved, the maladaptations in her self image were targeted. Next 6 sessions aimed at improving her interpersonal relations and self image, while strengthening the concepts learned in the previous sessions slight changes occurred in her interpersonal relations and concepts about self, while her schemas, and philosophies about life, were completely unmoved. Therapy was discontinued due to the examinations of the patient, after which she left the town and expressed her inability to attend weekly sessions. AB came for follow-up, one year after that and told the therapist that she is able to control her emotions most of time, barring one incidence in the past one year, when she tried to call RM again and he refused to talk to her. She felt intense frustration and consumed 10 tablets of Alprazolam after that. She realised next morning that it was wrong to do so and tried to control her emotions after that, more intensely. The perception of self, philosophies, feeling of emptiness, interpersonal relations and feeling that she has never been understood by others, did not change much.

Editorial comment Ms. AB shows many of the features typical of borderline personality disorder, including emotional outbursts in which she shouts or throws things, self-harm episodes involving slashing her wrists or consuming 8-10 hypnotics, feelings of emptiness, and fears of abandonment. In addition, she has the characteristic pattern of relationships so commonly seen in BPD, including a tendency to idealize persons with whom she is close, only to subsequently devalue them because they turn out to be “devils”. This mode of object relations is part of the intrapsychic structure of the patient, accompanied by defences of idealization ad devaluation. Hence the internal world is projected onto the external world. The patient’s actual behaviour places interpersonal pressure on those in her environment to conform to what is being projected onto them. This pattern is often referred to as projective identification. While Ms. AB denies suicidal intent, some patients with BPD do become suicidal in addition to having self-injurious behaviour, and in each case a careful assessment must be made of suicide risk. The patient received four months of weekly dialectical behaviour therapy (DBT), which is one of the empirically validates therapies, in addition to mentalization-based therapy, for borderline personality disorder. However, she did not continue the therapy long enough to obtain its full effects. The patient discontinued the therapy because of her examinations and then left town without resuming treatment elsewhere. Borderline personality disorder is a condition characterized by problematic compliance with treatment, and dropout from therapy or non-compliance with medication are common phenomena in the course of treatment.

264 CASE 30 Mr FA: Narcissistic Personality Disorder Country of origin: Pakistan Authors: H.R. Chaudhry & Mirrat Gul Butt

Identifying data The patient Mr FA is 21 years old unmarried male, educated up till Matriculation, unemployed and belonging to a middle socio-economic status family. Informants: Father, Brother and paternal uncle, all are reliable and well informed.

Presenting complaints According to father he never bothered about others emotions, has grandiose behaviour, selfish, manipulative, he take himself intelligent, like excess of admiration and if anybody pin points his mistakes he started fighting and arguing with him and always talk high of him. According to patient nobody understands him, he has high level of thinking; he is smart, attractive and well dressed that’s why his family members and other people are jealous of him.

History of Present Illness As reported by Mr FA, three years ago he made a male friend. The male friend was attracted towards his style, smartness and his brilliance of doing his work. After 1-½ years of their friendship the patient tried o have physical relationship with him. That person initially hesitated but later agreed to it as the patient persuaded him to do so. After 3 to 4 months of his relationship his friend asked him to end the sexual activity but he refused, he shouted and abused his friend. So his friend left him. He became very upset. He left going to the shop or meeting people he started remaining destructive and aggressive at home. He became over demanding and argued that nobody can ever understand him. As tried to harm himself. He said every body is jealous of him, as he is brilliant, sharp, active and smart person. He was very upset, highly aggressive and manipulative at home therefore his paternal uncle and his father brought to the hospital.

Personal History Birth and development were normal. The patient has never suffered serious illness. According to his father and his paternal uncle the patients is stubborn since childhood. As he was the first son after two daughters therefore he finds himself authoritative and man of the house. He never takes others emotions seriously and selfishly takes advantage of others. Since his childhood if he likes anything he wants to take that by fair or unfair means and if anybody admires and praises him he loves him. Although he has only done matriculation but he has inflated self- esteem. And be friends with him. He became jealous of people easily if anybody is praising the other and claims that other people were jealous of him. He easily became disturbed and irritated when anything happens against his will. Since his teenage became aggressive on minor issues and destructive. He shouts a lot and beats his younger siblings and elder sisters as he said they did not obey him being the eldest son. In his childhood and in his teenage too he was taken to a psychiatrist for his aggressive and manipulative behaviours. He was given medications for few months but showed no improvement. No record of that period available. According to the patient he was the most beautiful child in his childhood. Everyone loved him and appraised him for his beauty and his different acts. He said that during his academic life he was very intelligent and easily understood each and every thing, what the teacher said. The teachers also appraised him very much, but he got bored of studies and started playing mental activity games, like chess and cards in which he always succeeded. He said that in his family whatever problem has occurred he solve it when nobody could solve it. According to the patient he was a “master mind”.

265 He always felt him far greater in his qualities among the rest of his mates. He was not an academically intelligent person but was sure that what ever he thought he can do that. He was the first son after two daughters that are why his parents pampered him very much. His family environment was always tense. He said that he was friendly with his selective friends. He was self-centered person but enjoyed the company of those people who gave him preference on others. He ran his father’s shop according to his will and very brilliantly. He was very rigid and aggressive person.

Family and Social History The patient belongs to a middle socio- economic family. He lives under a nuclear family system. He has six siblings and his birth order is 3rd. His father is 47 years old, educated up till matriculation. He works in Wapda as Incharge of Grid station. He earns 15,000/ per month He also owns an electronic goods shop, which was earlier run by the patient for about two years, and now since one year his younger son runs it. His father has his strict rules and regulations. He is not friendly towards any of his child, as reported by the patient. But listens to patient’s suggestion mostly. His mother is 43 years old. She is an illiterate woman. According to the patient his parents has very conflicting relationship since his child hood. His eldest sister has done F.A. she is 24 years old and she did sewing and embroidery work at home. The patient hates her as she disobeys him and responds back to him harshly. The second sister has also done F.A. she is a quite person and took care of his things. He likes her. Then comes his number and after him there is a brother who is educated up till middle and is 20 years old. He runs his father’s shop. The patient hates him as according to him “he knew nothing about the market values a customs, he has no style to sell the things; he is not intelligent enough to run any business”. Then he has sisters of 19 and 16 years old, a brother of 18 years old and who are privately doing matriculation. The patient’s paternal uncle also has the same problem of anger and aggression, which seems to be a role model for him. Since 15 years, he is on medicine. His brother too is a psychiatric patient and is taking medicine as he has been diagnosed suffering from depression.

Mental Status Mr FA was anxious and irritable during the first meeting, he complained of depressed mood, he was irritated by the family as he reported that nobody understands him and he has high intelligence, looks, from his all family members that’s why they are jealous of him and try to overpower him. He was very talkative and rigid in his views. He avoids eye-to-eye contact during the session. He is very defensive in talking about anything openly. His tone was very rigid. Mood and energy level was subjectively very depressed and objectively stubborn, rigid and argumentative. No abnormality of thought and perception could be elicited. Mr FA was a young man, wearing neat and clean dress. The patient has a small height and thin structure and his front tooth is turned inwards. He was wearing eyeglasses. Rapport was built very gradually with him. No obsessions, perceptual disturbances or thought disturbances were reported. He was oriented well about time, place & person. His concentration attention was impaired, as he could not perform well on serial seven tests. His memory, abstract thinking, judgment were intact. Insight was partially present.

Management Mr FA came for therapy weekly for 3 months. The modalities used for the therapy were Behaviour Therapy (BT), Cognitive Behaviour Therapy (CBT), Rational Emotive Behaviour Therapy (BT) and Family Counselling. Throughout the sessions, the patient was regular and in time. His father, brother and paternal uncle visited the therapist during the duration of therapy.

266 In the initial two sessions the patient has rigid tone and aggressive mood and was unwilling to share his personal issues with the therapist. Supportive technique is used for a healthy rapport building. The patient remained quite much defensive during the first two sessions. The detailed history was taken from the patient and deep breathing was taught to him to relax him. The discussion was done regarding his maladaptive patterns, but he tried to justify them by saying that his family always provoked him and made him angry. A distraction technique of pillow punching and rubber band technique were taught to him to control his reoccurring thoughts and aggression. In the 3rd and 4th sessions the patient gradually became more open and told his problem of homosexuality. Sex education was given to him regarding his misconceptions about sexual acts. 16 Progressive Muscles Relaxation was taught to him to make him relax. He rated himself restless at above 100% and after the exercise he found himself relaxed at 50%. The relaxation exercise is given as homework assignment to do twice in a day. In the 5th and 6th sessions, feedback is taken relaxation exercise by him. He was asked to do the relaxation exercise in the session to confirm whether he was doing it properly or not. He was given a daily activity chart to make him active and involve in some work Beck Depression Inventory showed his severe depression and House Tree Person (a projective test) shows his defensive, complex and aggressive nature. His paternal uncle came with him in this session. MMPI was administered on him. Homework assignment is given to make a list of his strengths and weakness. Minnesota Multiphasic Personality Inventory showed invalid results. In 7th and 8th sessions he didn’t bring the assignment with him so it was made in the session. The list of his life goals is made in this session. The emotional fire drill (a technique of (Rational Emotive Behaviour Therapy) is done in this session. Rational Emotional Imagery was done to control his anger on the people around him. He controlled his anger on people but not on his family. Rotters Incomplete Sentence Blank was administered on him. RISB results showed that he is highly maladjusted in his environment. ABC model of Rational Emotive Behaviour Therapy was taught to him to develop insight. But his rigid thinking always became a hindrance. His father was psychoeducated came in this session. In 9th and 10th sessions, Disputing is done on his irrational beliefs about his boy friend and himself. 3 levels of Thought Stopping and Reframing Technique were done in this session. He seemed to be very relaxed and understanding. Ratings are taken around his problematic areas in which there is a marked difference and betterment around his major problem or reoccurring thoughts of his friend. Forceful self-statements are taught to him. Encouragement and counselling is done in this session. In 11th and 12th sessions his improvement was noted. The patient reported that he has seen his boy friend but it does not disturb him. He was taught the 4th level of Thought Stopping Technique. He said that since few days he has started thinking about having relationship with the opposite sex and wanted to settle down in his life. So counselling is done in this session. For further improvement in his behaviour towards sexual practices Problem solving techniques are taught to him and other distraction techniques were taught to him to control his anger. His father brought an issue that he wanted to have a hold on the shop and run it alone. Family counselling was done and an agreement was signed that he will be allowed to run the shop not alone but in the guidance of his father and brother and if he could not follow the suggestions he has to do some other work. Post ratings were taken in this session.

POST ASSESSMENT: Formal – BDI = 12 mild depression. Informal Ratings

Problem areas Pre Ratings Post ratings

267 Depressive feelings 10 6 Anger 9 5 Anxiety feelings 8 5 Negative Thoughts 10 5 Irritation 9 5 Restlessness 9 5 Sleep disturbance 8 4 Hopelessness 9 5 Recurrent thoughts 9 5 Self image 8 5

Pre and post informal subjective ratings of the patient and their graphical representation.

PRE-RATING

15

10 Series1 5 Figures 0 ABCDEFGHIJK Problemetic Areas

POST-RATINGS

8 6 4 Series1

Figures 2 0 ABCDEFGHIJ Problemetic Areas

In 13th session the patient came with his father that they have not let him run the shop. The father told the reason that he became manipulative again and again at the shop, which affected their work. It was decided with the consent of the patient that his father will find another job for him which is suitable for him and which suits his personality. Counselling with the patient and his family was done in this session. In the 14th and 15th sessions Counselling was done. Emphasis was given on follow-ups sessions and maintenance of the therapeutic works.

LIMITATIONS: The environment of the patient is same in which the patient has to survive. For family psycho education only the father and the brother of the patient were available. The patient’s mother and sisters did not come to the therapist.

268 The patient has personality problem therefore the chances of relapse are high. His manipulative behaviour and his grandiosity and his self image has slightly improved but his selfishness always made to manipulate others people rights.

RECOMMENDATIONS: To arrange family counselling and especially counselling of the mother and sisters with whom the patient lives and fights. It would be better for patient if he make a habit of disputing his irrational beliefs by making them more rational and practical and to continue follow up sessions. Self-help literature about bolstering self-esteem and getting what they want out of life can be given to him. Literature regarding his illness can also be given to him to improve his insight.

Editorial Comment Mr. FA is a relatively young man who apparently since early childhood has shown significant signs of narcissistic disorder, e.g., stubbornness, admiration seeking, aggressive behaviour and entitled, exploitative behaviour. However, he also had real assets and special features, being firstborn son, beautiful and intelligent, for which he was both admired, spoiled and envied. Obviously, at early age, he developed a sense of superiority, unrealistic expectations of other’s subordination and adherence to him and intense aggressive reactions if that does not happen. This case example highlights the difficulties for a young man with relatively severe narcissistic features to find a meaningful track in adult life, including work and intimate relationships. Despite being intelligent and educated, his unrealistic expectations and overvaluation of his own capability, combined with emotional dysregulation and proneness to aggressive, manipulative and demanding interpersonal behaviour, makes adjustment to work environment and attachment to other people difficult. As Mr. FA lives with his family and is expected to work in the family business, a family treatment approach including psychoeducation and consultations focusing on management of conflicts, boundaries, and interaction/collaboration, seems beneficial. A cognitive behavioural approach is appropriate, especially since Mr. FA presented with limited ability for insight. It is most important to help Mr. FA to identify, understand and modulate his anger and aggressive/hostile reactions. Other areas relates to ability to work, concentrate and stay focused, and pursue tasks towards assigned goals. Such focus will help the patient to evaluate realistic and unrealistic experiences of himself, and modulate unrealistic superiority towards more realistic self-appraisal. This example highlights the limitations with short term interventions and points to the necessity with long-term treatment of narcissistic patients independent of treatment modality.

269 CASE 31 Anja: Borderline Personality Disorder Country of origin: Germany Authors: Gabriele Partscht & Sabine C. Herpertz

Identifying Data We discuss the case of a 21 year old female patient who is in her 6th semester of training to become a hotel manager. After initial treatment, her primary care physician suggested to contact the university department of psychiatry for detoxication from alcohol and sedativa. Following detoxication, the patient was advised to undergo an in-patient psychotherapy treatment. The patient presented herself for the treatment a few weeks later and completed it after 10 weeks of inpatient and 2 further weeks of day-treatment.

Presenting Complaint Rapidly rising mood shifts, self-image of being worthless, instable interpersonal relationships, impulsiveness with self-damaging behaviours (alcoholism, drug abuse [benzodiazepines], self- mutilations through cutting, promiscuity)

History of Present Illness Per the patient’s report, first symptoms trace back to the beginning of adolescence (12 years), when she started with dating young men. Anja has been drinking alcohol (cocktails and schnapps), first irregularly. At the age of 14, she began self-mutilations through cutting her arms. During the same period of time the patient developed an anorexia nervosa for which she underwent outpatient treatment over six months. After that, Anja gave up restricted eating and did not “cut herself” anymore but consumed more and more alcohol on a regular basis ending up with 1-2 bottles of wine or half a bottle of vodka per day. She had noticed alcohol withdrawal symptoms. Due to the alcohol abuse the patient experienced problems at her school, skipped lessons and finally was downgraded. Starting at the age of 12 Anja spent less and less time at home but in the company of older and frequently alternating boyfriends. During the last two years she experienced cardiac pains and difficulty in breathing connected with considerable anxiety. A medical check-up did not reveal any physical condition and the symptoms were assessed to be related to panic attacks which usually occurred in situations of fear of being abandoned. Anja started to self-medicate with high doses of benzodiazepines and increased her daily alcohol intake. She avoided public transportation and lost social contacts. She began her self-mutilating behaviour again. As long as she could remember Anja experienced rapidly rising and changing mood shifts every day. She was hardly able to describe the quality of her aversive emotions, which were accompanied by states of intense tension. She often experienced feelings of emptiness. Self- mutilations and alcohol abuse occurred in states of unbearable tension and were often triggered by the fear of being abandoned. She could not easily refuse pleas and requests, and rapidly felt guilty and responsible. She was troubled by feelings of pervasive insufficiency and inferiority and reported to have suicidal ideas. Due to constant fears of being rejected and left alone, the patient tried to please her partners, subordinated and deprecated herself to “be and do what is expected” of her. She was not able to deal with even minimal criticism or rejections and separated from friends and boyfriends as soon as those occurred.

Mental Status She was an attractive woman who styled herself extravagantly. She appeared to be mistrustful, insecure and withdrawn at first glance, but opened up soon after. She then presented her complaints and interpersonal difficulties frankly, sometimes using an impressionistic style of speaking. Her communication style was thoroughly ironic and superimposed. She presented intense psychomotoric

270 tension without experiencing dissociative states. She reported about chronic feelings of emptiness, irritability, lack of emotional stability with an incapability to control anger or other intensive emotions. An inability to precisely identify and name her emotions was noticeable. A dichotomous way of thinking interacted with mood shifts. The patient reported an unstable but persistently negative self-image and suffered from instable interpersonal relationships. She experienced panic attacks and exhibited an increasing pattern of avoiding public situations. Neither disturbance of orientation, attention, or memory nor signs of content-related or formal disturbances in the patient’s thinking nor perception was detected. No acute suicidality.

Family and Social History Anja did not recall any medical or psychiatric diseases within her family. She reported not to remember details of the first 10 years of her life. Her mother had owned a restaurant, but works now as a waitress. Her father is an insurance agent working for a financial consulting company. The patient was 14 years old when her parents divorced, and she continued to live with the mother and her new partner. Anja had little contact with her father and half-sister. Her dominating memory is that of being alone, feeling abandoned and rejected by her family. She found her boyfriends to be her surrogate family. In her early years, the patient enjoyed school and took over functions such as class representative. She also participated in dance and recitation competitions and enjoyed some hobbies (volleyball, ballet, dancing). Beginning at age 11, she started to skip school, got drunk frequently and therefore had to repeat two school years. She earned a secondary school certificate and began a vocational training to become a hotel manager. She was in her 6 th semester, when she started her in-patient treatment. Anja became sexual active at age 12. She fostered sexual relationships with mostly older men and frequently changed partners and made some money by table-dance. At 18 years of age she moved in with a 12 year older man. During this relationship she as well as her partner had multiple affairs. Due to alcohol excess and physical disputes she left her boyfriend shortly before she started therapy and moved in with her mother. Separating from her boyfriend made her situation even more critical and motivated her to seek for therapy.

Medical History Birth and early childhood development were regular. The patient has been suffering from asthma bronchiale since age 12. She had performed one detoxification from alcohol and sedativa with obvious vegetative withdrawal symptoms over two weeks. Six months of psychiatric outpatient treatment because of anorexia nervosa at the age of 12, no psychiatric/psychotherapeutic treatment since then.

Hospital course and treatment history Anja’s psychotherapy lasted 12 weeks. The treatment program was based on the Dialectical Behaviour Therapy (DTB) by M. Linehan. All weeks were needed for the first stage treatment which focuses on severe behavioural problems, i.e. different modes of self-harming behaviour and their interaction with an incapability to regulate emotions. The following treatment goals were set: Reduction of self-harming behaviours (self-mutilation, alcohol abuse) by learning and using skills Increased capability to identify, modulate and adequately communicate emotions Increase of self-acceptance and self-esteem The nature of the DBT was discussed with the patient and her commitment was obtained. A well-structured treatment contract regulated how to deal with self-mutilations and alcohol or drug abuse during the inpatient treatment process: an increased frequency of self-mutilations, self- mutilation requiring surgery as well as the consumption of alcohol or drugs would lead to an admonishment. After three admonishments the patient would be discharged and her treatment terminated. Furthermore, the treatment contract included general rules on how to deal with self-

271 mutilations. Self-mutilation would lead to a two-hour time-out as well as a behaviour analysis which would be presented first to the therapy group and later to the individual therapist. According to the DBT-Program the therapy setting comprised the following therapeutical methods: Skills-training (twice a week), theme-focused group therapy (once a week), perception training (once a week), body therapy (once a week), ergo-therapy (twice a week), individual therapy (once a week), homework- group (once a week), and two evening events (in groups of 8 - 9 patients). During the first weeks of inpatient treatment Anja, although she had high expectations of the therapy, was mostly passive, pessimistic and critically observing the group therapies. She spoke in an ironical or even sarcastic way about herself and her feelings. She reported strong craving of alcohol and after five weeks showed a relapse in drinking followed by an admonishment. Maintaining a clear dialectical stance in the therapeutic interaction in this situation allowed Anja to make the important interpersonal experience that she was strongly expected to give up drinking by her therapist but at the same time was accepted in all her problems and deficiencies and was not rejected (as she had been convinced to experience similar to previous relationships). She began to trust the therapist and medical team and from now on started a strong therapeutic alliance. Within this difficult phase of treatment the individual therapist and the whole team strongly profited from an external supervisor. With great commitment Anja practiced skills in states of aversive tension, especially in stress tolerance. She exposed herself to intense tactile stimuli, learnt how to strongly activate her muscles and made the experience that tension decreased without mutilating herself. She started to also apply these skills when craving and somatic symptoms occurred. Symptoms such as difficulty in breathing, abdominal discomfort and vertigo partially decreased. To allow a better dealing with functional physical trouble, cognitive procedures were applied such as “thought-stops” and the use of alternative phrases (in case of tachykardia and heart trouble: “I feel my heart beating, I am alive”). Further on, Anja acquired skills to better identify and regulate her emotions. She learnt the basic emotional qualities and their autonomic and mimic correlates. She analyzed her emotions through “feeling protocols” and became able to attentively perceive her emotions without evaluating them. She was proud to find out that she was able to reduce emotional arousal by means of breathing exercises. She became aware that aversive emotions were induced by negative automatic thoughts and interpersonal myths (“When I care for myself, I hurt others”. “I have to exert all my strength to prevent that anyone thinks badly about me.”), which repeatedly supported her bad self-image. Using cognitive restructuring procedures she was taught how to monitor her thought patterns and she more and more succeeded to develop inner guidelines for when to trust and when to suspect interpersonal interpretations. Correspondingly, her therapist cared to validate her interpersonal experiences on the one hand and to initiate new perspectives on the other hand. A number of individual therapy sessions were spent to focus on her individual needs and how to express those needs. She became more and more competent to modulate or suppress activated maladaptive cognitive schemes and emotional processes. However, she remained to have trouble to accept positive feelings as well as to trust her growing interpersonal skills. Regarding her style of communication, Anja was able to give up her forced smile. She also opened up and changed her ironic/sarcastic manner of speaking into more authentic and clear communications. Among the patients she felt enabled to express her desires and requests and started to transfer this experience to her private life. She also learnt to accept criticism of the other patients and to maintain relationships even when frustrated. Additional strategies which targeted at the comorbid substance abuse disorder were integrated in the therapy program. Alcohol abuse was identified as a self-harming mechanism which served to cope with unbearable tension and to avoid aversive emotions. Typical situational triggers were analyzed which bared the risk of relapse. During the last two weeks of her treatment, the patient agreed to participate in expositional exercises by using public transport. She planned to continue her vocational training and therefore needed to use a city bus. As the expectance of discharge revived fears of rejection and abandonment, Anja eagerly accepted a half-day in-patient treatment for two further weeks to bridge

272 the time between her discharge and the beginning of the following individual out-patient therapy. During these two weeks, she practised new skills to enhance self-esteem. Over four weeks the patient accepted to take 20 mg cipramile which we had prescribed to reduce affective instability and panic attacks. Although no side-effects occurred, the patient discontinued medication, four weeks before discharge, however, without experiencing deterioration of complaints.

Differential Diagnosis Due to the typical symptoms presented by the patient, we diagnosed a borderline personality disorder according to DSM and ICD nomenclatures with further dependent and slightly histrionic (style of speech, seeking for approval) traits. The leading symptoms were as follows: emotional instability with marked and abrupt shifts from baseline mood to irritability and anxiety, lack of control of anger, self-mutilative behaviour together with further impulsive modes of self-harming behaviours, intense fear of being abandoned. In addition, she had a typical self-image of being worthless and bad. She further exhibited a dependent interpersonal style in partnerships, e.g. gave up wishes and needs in order to get other people to like her. A full-blown dependent personality disorder was not present as she did not feel helpless or needed others for her daily life or wanted them to take responsibility for her or to make her decisions.

Editorial Comment Anja, the patient presented in this vignette, illustrates the clinical observation that Axis I comorbidity frequently accompanies borderline personality disorder. Indeed, Axis I conditions, such as eating disorders, chemical dependency, anxiety disorders or mood disorders are so common as Axis I conditions associated with borderline personality disorder, that the treating clinician must generally combine treatments for Axis I disorders with the standard approaches to borderline personality disorder. This case actually demonstrates how alcohol and benzodiazepines may serve as self- medication to deal with unbearable internal states, such as emptiness, anxiety, depression, or excessive tension. Many of these unbearable states are initiated by a fear of being abandoned, and this case is no exception. Clinicians should explore abandonment fears when symptomatic behaviours are increasing, as these fears often lie at the core of the patient’s distress, even though they themselves might not easily identify such fears. Longstanding clinical tradition suggests that borderline personality disorder is unlikely to respond to psychotherapeutic efforts unless the substance abuse problems are also treated. In this case, the authors integrated addiction treatment with the dialectical behaviour therapy. They stressed that continued use of alcohol or unprescribed medications could potentially lead to the patient’s discharge from treatment. This type of limit setting may be essential in developing a treatment alliance with such patients. However, the clinicians also combined the expectation of sobriety with acceptance of the patient and her problems. Patients with borderline personality disorder need some balance of validation and expectation of change to gain maximum benefit from treatment. The authors also note in passing that the individual therapist and the team strongly profited from an external supervisor. This point cannot be made strongly enough. Clinicians often find themselves confused and emotionally distressed in the treatment of BPD patients, and having an external supervisor or consultant may help them maintain optimal judgment about what is best for the patient.

273 Curriculum Suggestions – Module III

The case vignettes are best used for group discussions in classrooms or in workshops. The following questions should be addressed:

1. Are the diagnoses justified? Compare traits, behaviour and symptoms described in the vignette to the diagnostic criteria in ICD-10 and DSM-IV. Does the patient actually fulfil the criteria for the diagnosis under which it is classified in the module? The diagnostic criteria in DSM-IV and ICD-10 are found in the appendix

2. What do you think of the way the assessment were done (diagnostic instruments) and how available information were interpreted? See Module I for further information on assessment and in module II for an overview of diagnostic instruments

3. Does the case vignette differ from the prototype of that specific disorder as described in module II? Read the text in module II for the corresponding disorder

4. What is your opinion of how the treatment was organized and coined? For more information of treatment recommendation see module I (general information) and in module II for more specific guidelines

5. Does the case remind you of specific controversies or important scientific questions? For example: how do we separate borderline personality disorder from bipolar disorder or depression? Find more information in reference list for each disorder of how to get access to these issues

6. Compare the different case vignettes under same diagnosis. What are the similarities and what are the differences? Do you see any trans-cultural differences in how the patients present themselves, their symptoms or how treatment is invented?

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