Professional Documents
Culture Documents
Personality-Guided Therapy
for Depression
Neil R. Bockian
AMERICAN
PSYCHOLOGICAL
ASSOCIATION
WASH I N G T O N ,
DC
Copyright 2006 by the American Psychological Association. All rights reserved. Except
as permitted under the United States Copyright Act of 1976, no part of this publication
may be reproduced or distributed in any form or by any means, including, but not limited
to, the process of scanning and digitization, or stored in a database or retrieval system,
without the prior written permission of the publisher.
Published by
American Psychological Association
750 First Street, NE
Washington, DC 20002
www.apa.org
To order
APA Order Department
P.O. Box 92984
Washington, DC 20090-2984
Tel: (800) 374-2721; Direct: (202) 336-5510
Fax: (202) 336-5502; TDD/TTY: (202) 336-6123
Online: www.apa.org/books/
E-mail: order@apa.org
In the U.K., Europe, Africa, and the Middle East, copies may be ordered from
American Psychological Association
3 Henrietta Street
Covent Garden, London
WC2E 8LU England
Typeset in Goudy by Stephen McDougal, Mechanicsville, MD
Printer: Edwards Brothers, Ann Arbor, MI
Cover Designer: Berg Design, Albany, NY
Technical/Production Editor: Harriet Kaplan
The opinions and statements published are the responsibility of the authors, and such
opinions and statements do not necessarily represent the policies of the American
Psychological Association.
Library of Congress Cataloging-in-Publication Data
Personality-guided therapy for depression / by Neil R. Bockian.
p. cm. (Personality-guided psychology)
Includes bibliographical references and index.
ISBN 1-59147-410-8 (alk. paper)
1. Depression, MentalTreatment. 2. Personality disordersTreatment.
I. Title. II. Series.
RC537.B58 2006
616.85'2706dc22
British Library Cataloguing-in-Publication Data
A CIP record is available from the British Library.
Printed in the United States of America
First Edition
2005037362
CONTENTS
Series Foreword
ix
Preface
xi
Acknowledgments
xiii
Chapter 1.
Introduction
Chapter 2.
13
Chapter 3.
41
Chapter 4.
63
Chapter 5.
91
Chapter 6.
109
Chapter 7.
135
ChapterS.
169
Chapter 9.
187
Chapter 10.
209
Chapter 11.
227
Chapter 12.
247
vu
267
271
References
273
Author Index
305
Subject Index
313
325
viii
CONTENTS
SERIES FOREWORD
The turn of the 20th century saw the emergence of psychological interest in the concept of individual differences, the recognition that the many
realms of scientific study then in vogue displayed considerable variability
among "laboratory subjects." Sir Francis Galton in Great Britain and many
of his disciples, notably Charles Spearman in England, Alfred Binet in France,
and James McKeen Cattell in the United States, laid the groundwork for
recognizing that intelligence was a major element of import in what came to
be called differential psychology. Largely through the influence of psychoanalytic thought, and then only indirectly, did this new field expand the topic of
individual differences in the direction of character and personality.
And so here we are at the dawn of the 21st century, ready to focus our
attentions ever more seriously on the subject of personality trait differences
and their impact on a wide variety of psychological subjectshow they impinge on behavioral medicine outcomes, alter gerontological and adolescent
treatment, regulate residential care programs, affect the management of patients with depression and posttraumatic stress disorder, transform the style
of cognitivebehavioral and interpersonal therapies, guide sophisticated forensic and correctional assessmentsa whole bevy of important themes that
typify where psychologists center their scientific and applied efforts today.
It is toward the end of alerting psychologists who work in diverse areas
of study and practice that the present series, entitled Personality-Guided Psychology, has been developed for publication by the American Psychological
Association. The originating concept underlying the series may be traced to
Henry Murray's seminal proposal in his 1938 volume, Explorations in Personality, in which he advanced a new field of study termed personology. It took its
contemporary form in a work of mine, published in 1999 under the title Personality-Guided Therapy.
SERIES FORWORD
PREFACE
The science and practice of clinical psychology have undergone a dramatic and exciting process of change in the past century. Following Freud's
explorations of the unconscious, the dialectic swung to the antithesis, the
behavioral revolution of Thorndike and Watson and, later on, Skinner. Filling in the vast space since then have been many approaches. Objectrelations theorists have examined the functioning of the ego, and interpersonal theorists have studied how relationships with others impact human
psychology. Client-centered, humanistic, and existential therapists as well
as logotherapists have focused on human experience and questions regarding
life's meaning. Systems-oriented theorists have helped us to understand dyads,
families, groups, and organizations and have developed new and innovative
intervention strategies. Cognitive and rationalemotive therapists have discovered a wealth of techniques designed to help the individual use reasoning
to feel better. With each new theoretical innovation, the discipline of clinical
psychology has found new ways to be helpful and to reach more individuals.
Efforts at integration have become increasingly important. There were
theoretical manuscripts integrating, for example, individual and family approaches (e.g., Wachtel & Wachtel, 1986) or psychodynamic and behavioral approaches (Arkowitz & Messer, 1984). Millon's (1969/1985)
biopsychosocial model makes the case that biological, psychological, and social factors contribute to a person's overall adaptation; this approach had a
substantial impact on the field.
Previous efforts at integration focused mostly on the level of theory
that is, the effort was to find commonalities in different theoretical approaches
or to add the strengths of one to another. With Personality-Guided Therapy
(1999), Millon added the notion that the best way to integrate theories was
to focus at the level of the person. Simply put, psychodynamic, behavioral,
cognitive, family, humanistic, and other theories can all be used to describe
XI
PREFACE
ACKNOWLEDGMENTS
I thank the many people who made this book a possibility. First and
foremost, I thank the series editor, Theodore Millon, who asked me to write
the book. Ted, your faith and confidence in me have consistently exceeded
my expectations of myself and inspired my best work. The dedicated and
talented editors in the American Psychological Association Books Department have done a wonderful job of shepherding this project to fruition: Susan Reynolds guided me through the opening phases, and Linda McCarter
has been a steadfast support for some 2 years. I also thank several gifted clinicians, my former students Don Castaldi, Mark Johns, Suzanne Richter,
Michelle Rodgers, and Kelly Vinehout, all of whom provided case material;
their contributions considerably enhanced the quality of this volume. In addition, I thank the anonymous reviewers, who provided feedback that dramatically improved the quality of the book while simultaneously improving
the economic welfare of the coffee industry. The librarians at the Illinois
School of Professional Psychology Chicago Campus deserve high praise, especially Qi Chen, who added several books to the library collection at my
behest, and Fay Kallista, who tirelessly tracked down articles and interlibrary
loan materials. The members of the library staff at the Adler School of Professional Psychology, Karen Drescher, Arlene Krizanic, and Michael Zellner,
also provided a number of articles, some of them on an expedited basis; to
them I owe my thanks as well. Hundreds of current and former students have
contributed to this book through their participation in my countertransference study, their completion of their clinical research projects in areas related to this work, their questions and comments in class, and their homework assignments; from them, I have learned more than can be imagined. I
appreciate the efforts of my current students and future colleagues Julia Smith
and Ellyn Turer, and of former student Virginia Doyle South, who provided
feedback on the initial draft. In addition, I thank Danielle Merolla, Erica
XIII
Moore, and Dominika Prus, who proved to be worthy assistants during the
time-pressured final phase of preparing the manuscript.
My parents, Fred and Sandra, and my uncle and aunt, Alan and Barbara Brodsky, provided encouragement, emotional support, and that most
precious support of allbabysitting! Special thanks go to my brother Jeffrey
for what must be the most memorable portion of my writing. When a longplanned vacation together bumped up against my first draft deadline, he
adapted his SUV into a traveling office, and I wrote two full chapters on the
round-trip drive between Los Angeles and Death Valley. I also thank my
sister-in-law, Kari, who supported our dusty adventure. I am grateful to my
wife, Martha, for taking on extra responsibilities while I wrote, despite her
own rapidly burgeoning career and growing opportunities. Finally, I thank
my beloved children, Chaya and Yaakov, who groaned each and every time I
needed to work on the book and never became the slightest bit acclimated to
my need for additional time; may we always yearn to spend our moments
together.
xiv
ACKNOWLEDGMENTS
1
INTRODUCTION
The process of paying attention to one's own reactions is a useful exercise, one that can be conceptualized under the rubric of mindfulness (Epstein,
1995; Kabat-Zinn, 1990, 1994). Mindfulness, which is derived from the
vipassana school of Buddhist meditation, is a form of self-awareness that can
be practiced on a regular basis. For therapists, engaging in regular mindfulness practice is a way of managing one's personal stress while improving one's
self-awareness (Bockian, 2001, 2002b).
Once the feeling has been labeled, one can simply sit with itsitting
with unpleasant feelings has deep roots in mindfulness practice. One often
finds that when one is "fully present in the moment" the discomfort itself
dissipates. As a client of mine once put it, "When I'm rushing around, trying
to run my business, I feel like I'm going to explode. But when I stop, and
return to my breath, and focus on what's happening right now, it's never that
bad." Thus, sitting with boredom, just for this moment, is never that bad.
One can also explore the feelings using thought records, a technique
taken straight out of cognitive-behavioral therapy (CBT). Once practiced,
it can be done during the session, while one is still paying attention to the
client. This approach may be incompatible with a client-centered approach,
or the mindfulness approach above, because it entails multitasking, and thus
one is not fully present with the client. From a CBT perspective, however, I
believe this would be an acceptable, and even encouraged, approach (see
A. T. Beck, Freeman, 6k Davis, 2004; Ellis, 2001). As I thought about some
bored feelings I had when watching a filmed simulation of a client (Fidler,
1989), I would reflect to myself,
I'm feeling bored. What is the situation? He's talking about his dinner in
response to the question about what he is thinking about. What is the
thought connected to that boredom? He is answering my questions in
ways that do not connect to other people. I don't really care about what
he is going to have for dinner. 1 am interested in how he will plan his life
out, what he will do now that he lost his job,
and so on. I then become aware of another feeling, a slight feeling of irritation, connected to the thoughts "he should be planning out his future, he is
wasting valuable time with the counselor, who is trying to do career planning
with him."
Once the thoughts and feelings are connected, they become rather easy
to challenge. What is the client's understanding of the purpose of the sessions? Has he been educated appropriately about the reason for the referral?
What does he need, from his perspective?
Another direction I routinely go in when examining my emotional reactions is to imagine what it would feel like to be that person, dealing with
someone who felt like I did. What if everyoneor many peoplefelt that
way about him? What would it be like if others found me boring because I did
not have intense reactions to things, or irritating because my responses were
"off or inconsistent with expectations? Such thoughts tend to lead me toward a more empathic stance. I will then check out the validity of my
assumptions by asking about his interactions with others and how others
respond.
Implicitly, then, I am suggesting that countertransference is generally
extremely useful in helping clients. Of course, countertransference can also
be so difficult to manage that it can damage the therapeutic relationship. In
the chapters that follow, I outline some commonly reported countertransference reactions as well as some common pitfalls to avoid.
PERSONALITY-GUIDED THERAPY
Millon's personality-guided therapy (POT) approach is more than sequencing different therapies. The concept of catalytic and synergistic effects
in therapy has important implications for treatment. The chapters of this
book are organized to provide different approaches and findings based on
theory-driven modalities. However, I hope to capture the essence of PGT in
the case studies: simultaneous integration of the entirety of the person, including personality, diversity, and other unique factors, along with properly
timed sequential interventions drawn from a variety of theoretical sources.
From the standpoint of PGT, the treatment of PDs and depression does
not constitute two separate processes. Within the medical model, on which
the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision
[DSM-IV-TR]; American Psychiatric Association, ZOOOa) is largely based,
diseases can be separately diagnosed and treated. Thus, the individual with
cancer and depression may receive radiation therapy for the cancer and pharmacotherapy for the depression, and the treatments may not react with one
another. In PGT, the treatment of the PD tends to resolve the depression,
and vice versa; the disorders are not truly separable. This becomes clear in
many of the case studies. There is a fine example in chapter 6, in which the
person has depression and antisocial PD. The client was depressed because of
his hopelessness about ever being released from prison and because of his
frequent placements in solitary confinement precipitated by his violent behavior. The intervention, in a sense, directly targeted the PD. The client
needed to better understand his relationship to authority and how his
conceptualizations overly constricted his options and choices, especially regarding his violent behavior. Once he became more in control of his violent
behavior, he was no longer placed in solitary confinement, and his chances
of release improved; consequently, his depression began to resolve. Treating
"the depression" (e.g., with techniques that addressed typical depressogenic
cognitions, such as assessments that he was worthless, "must" statements,
and so on) would not have been effective, because such thoughts were too
distant from the client's experience. The depression had to be treated in the
INTRODUCTION
context of the person. Throughout the text, there are many sections in which
I discuss methods for understanding and resolving PDs; the reader should be
aware that these conceptualizations and interventions address, directly or
indirectly, the individual's depression as well.
The integration of well-established treatment modalities in a systematic fashion is one of the central features of PGT. In this regard, Millon
(1996, 1999) has provided a guiding, comprehensive theoretical framework
that integrates the work of most if not all of the major theoretical perspectives into a coherent system. It is reminiscent of the well-known Indian parable of the blind men investigating an elephant: One, grasping the leg, proclaims that the object is a tree; a second, feeling the trunk, declares it is a
snake; a third, handling the tusk, believes that the elephant is a spear, and so
on. The blind men then take to arguing among themselves about the true
natureor even the proper descriptionof the elephant (Saxe, 2002). The
main point is that taken one by one, none of the descriptions adequately captures the nature of the elephant. The pointless squabbles that have permeated
our discipline regarding "who is right"psychodynamic versus behavioral
perspectives being frequent competitors for this conceptual spaceare, from
this perspective, irresolvable. Both perspectives contain partial truths.
Although highly innovative, perhaps even revolutionary in its comprehensiveness, the PGT approach has been implicit in graduate clinical psychology training. Whenever a question on a comprehensive examination
has demanded that a student describe a case using more than one theoretical
perspective for a client with a PD (i.e., the student could choose from among
psychodynamic, client-centered, interpersonal, cognitive, family systems
approaches, etc.), then an aspect of PGT was involved.
Farmer & Nelson-Gray, 2005; Harper, 2003; Magnavita, 2005; Millon, 1999;
Rasmussen, 2005). Of course, as noted above, the long-term goal of the present
endeavor is to lead to a manualized treatment with randomized clinical trials. Our approach is similar to that of Kernberg and his associates in the
development of transference-focused psychotherapy. Initially, the group presented innovative treatment ideas based on psychodynamic theory and case
material (O. F. Kernberg, Selzer, Koenigsberg, Carr, & Appelbaum, 1989).
Later, the treatment was manualized (Yeomans, Clarkin, & Kernberg, 2002)
and subjected to a randomized clinical trial (Clarkin, Levy, Lenzenweger, &
Kernberg, 2004).
A NOTE ON MEDICATIONS
A number of medications are available to treat depression; these interventions are addressed in chapter 2. PDs per se cannot be treated with medications. However, underlying dimensions, such as impulsivity and
psychoticism, are amenable to medication treatment. Medications for the
relevant PD will be discussed in each chapter (chaps. 3-12).
One study merits consideration here, because it addressed a mixed sample
that included various PDs; to avoid repetition, I review the study here and
allude to it briefly throughout the text. Ekselius and von Knorring (1998)
examined 400 participants with major depression whom they randomly assigned to treatment with one of two antidepressants, sertraline or citalopram,
both SSRIs. A 24-week course of treatment was completed by 308 participants (i.e., 145 with sertraline, 163 with citalopram), of whom 189 (61%)
had a concurrent PD. No other treatments were provided (e.g., no psychotherapy). The researchers examined 10 PDs: paranoid, schizotypal, schizoid,
histrionic, narcissistic, borderline, avoidant, dependent, obsessive-compulsive,
and passive-aggressive, using a structured interview. The examiners reported
that they excluded antisocial and self-defeating PDs, though they did not
provide an explanation for this; they did not mention aggressive-sadistic
PD. Although participants were randomly assigned the different medications,
the study lacked a nontreatment control group. Because they used a structured interview pre- and posttreatment, the researchers had a dimensional
measure (number of criteria met) and a categorical measure (whether the
person had or did not have a disorder).
In the sertraline group, there was a decrease in the number of PD criteria met for each one except schizoid. There was a decrease in the percentage
of individuals diagnosed with PDs with both medications. In the sertraline
group, paranoid, borderline, avoidant, dependent, and obsessive-compulsive
PD criteria were less common posttreatment. (Schizoid diagnoses actually
increased significantly, but this was accompanied by no significant change in
number of criteria met, a finding that is admittedly difficult to reconcile.) In
INTRODUCTION
the citalopram group, there were decreases in paranoid, histrionic, borderline, avoidant, dependent, and obsessive-compulsive diagnoses. Differences
between the two medications were mostly nonsignificant, except that
citalopram was superior to sertraline for obsessive-compulsive PD.
Most other studies, which are reviewed in later chapters, looked at
medication treatment for a single disorder. Ekselius and von Knorring's (1998)
approach, to give a medication and measure the impact on a number of PDs,
is somewhat more efficient, in that multiple comparisons can be made simultaneously (i.e., we can see that a medication has a positive effect on many
PDs, with implications that a medication may be better for one disorder than
another). The study is inconclusive, however, because there was no comparison group, so we do not know for sure what would have happened without
treatment. Given the slow rate of spontaneous remission of PDs, and positive
findings in controlled trials with SSRIs for borderline PD and social phobia
(see chaps. 7 and 10, respectively), the most likely conclusion is that the
medications had at least some effect. Effect size was not formally measured
but appeared to be moderate. On average, there was a remission rate of approximately 25% ("any PD" went from 59.3% to 45.5% in the sertraline
group and from 63.2% to 44.8% in the citalopram group). Remission rates
exceeded 50% for borderline PD (either medication), dependent PD (either
medication), and histrionic PD (citalopram). The decrease in the number of
criteria met for each PD ranged from 0 to 1.3; the mean decrease was less
than 0.5 for Cluster A, about 0.6 to 0.7 for Cluster B, and about 0.6 to 0.8 for
Cluster C, depending on the medication. The largest change was for borderline PD (sertraline = -1.2; citalopram = -1.3). Using multivariate statistics,
the authors illustrated that the decreases in PD symptoms were not a function of improvement in depressive symptoms.
As will be illustrated throughout the remainder of this volume, however, medication research on PD populations constitutes a hodgepodge of
case studies; open-label studies; and small, brief, randomized controlled trials. Although statistically significant effect sizes have been found with many
medications for many problems associated with PDs, effect sizes are consistent with using medications in an adjunctive role. Noted Soloff (1997),
Medication effects are modest, at best. GAS scores in the 1989 Soloff et
al. haloperidol vs. amitriptyline trial improved 14 points, to an average
of 55, in the most responsive group (HAL). Similarly, the average HAMD score fell from 26 to 16 in the HAL group, still symptomatic for most
drug trials in depression, (p. 339)
Even for borderline PD, which has been studied more than all other
PDs combined, the research base is woefully inadequate (Soloff, 2000); how
much more so for other PDs, many of which lack even a single empirical
study? The lack of research on the use of medications for individuals with
PDs is most unfortunate. Available studies suggest high rates of medication
]0
use in individuals with borderline PD (see Zanarini, 2004), and it is reasonable to speculate that individuals with other PDs also receive medication at
rather high rates. The clinician should not complacently assume that medications that treat Axis I disorders are also beneficial for individuals with the Axis
I condition in the context of a PD. A cautionary tale is the use of benzodiazepines and tricyclic antidepressants in the treatment of individuals with borderline PD; the limited available research suggests possible disinhibition and
an iatrogenic increase in impulsive aggression following use of one or both of
these classes of medications (see chap. 7). Understandably, studies that assess
medications for their effect on depression usually exclude PD cases, but this
strategy leaves us even deeper in the dark regarding the impact of antidepressants on individuals with a PD in conjunction with a depressive disorder. I join
others in the field (e.g., Coccaro, 1998; Soloff, 2000) who have called for
more research in the use of medications with individuals who have PDs.
11
as well. I have integrated the findings of selected scientific studies and theoretical manuscripts. The studies were chosen because they are directly related either to depression or the specific PD under review. Because "countertransference" is conceptualized broadly for the present purposes (i.e., to include
any emotional response of the therapist), it is included in its own section
rather than subsumed within the psychodynamic area.
It is beyond the scope of this book to look at PDs and depression in
children. Some excellent resources are available in this regard. Paulina
Kernberg and her associates have provided a well-reasoned approach with
rich, illustrative case material (P. Kernberg, Weiner, & Bardenstein, 2000).
In addition, the reader is directed to Stanley Greenspan's developmental,
individual-difference, relationship-based model. Greenspan's approach to children, although developed in the context of autism, may have potential to
treat children as early as infancy to prevent PDs, or to remediate PD symptoms in children. Greenspan noted how various kinds of rigidity in early
childhood may "sow the seeds" for character pathology (1997, p. 322). Although these assumptions require further testing, I believe that Greenspan's
approach has potential for any child who is tending toward a PD and urge the
interested reader to examine one or more of Greenspan's writings (e.g.,
Greenspan, 1997; Greenspan & Wieder, 1998) and the Interdisciplinary
Council on Developmental and Learning Disorders Web site (http://
www.icdl.com). Finally, Nadine Kaslow and her associates have done an excellent review on the status of various approaches to treating depression in
children (Kaslow, McClure, & Connell, 2002).
Each chapter is largely independent of the others. Chapters 3 through
12 are arranged alphabetically within each DSM-IV-TR PD cluster (i.e.,
Clusters A, B, and C). With the exception of the first two (i.e., this introduction and the overview of depression), concepts and data from which are woven throughout the book, the chapters draw content only minimally from
one another. I recommend reading chapters 1 and 2 first, but thereafter chapters may be read in any order.
12
2
AN OVERVIEW OF DEPRESSION
AND THEORETICAL MODELS OF ITS
RELATIONSHIP TO PERSONALITY
DISORDERS
and Axis I psychopathology, are potentially useful in both research and clinical
settings. For the researcher, understanding the various possible Axis I-Axis
II relationships (e.g., whether a PD generally precedes a depression, or the
converse) is of obvious theoretical interest, having implications not only for
treatment but also for developmental theory as well as for possible refinements in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.,
text revision [DSM-IV-TR]; American Psychiatric Association, ZOOOa) taxonomy. Considering the possible relationships of depression to PDs (e.g., the
possibility of lingering effects of one or the other disorder) may help the
clinician to think more flexibly in understanding the client's perspective.
PHENOMENOLOGY OF DEPRESSION
Depression, especially in its most severe form, can be an agonizing disorder. William Styron (1992) brought his literary genius to bear on the issue
of his own depression in his memoir Darkness Visible. He noted,
The argument I put forth was fairly straightforward: the pain of severe
depression is quite unimaginable to those who have not suffered it, and it
kills in many instances because its anguish can no longer be borne. The
prevention of many suicides will continue to be hindered until there is a
general awareness of the nature of this pain. Through the healing process
of timeand through medical intervention or hospitalization in many
casesmost people survive depression, which may be its only blessing;
but to the tragic legion who are compelled to destroy themselves there
should be no more reproof attached than to the victims of terminal cancer, (p. 33)
14
Although his rather supportive views on suicide are not likely to be widely
shared in the mental health communitynor do I support themStyron's
compelling portrayal of major depression clearly conveys its agonizing
quality.
There are five forms of depression listed in DSM-IV-TR that differ in
intensity; chronicity; and, to some degree, etiology. Major depression, the most
severe form, is characterized by depressed mood much or all of the time as
well as vegetative symptoms such as disturbance of sleep, appetite, and libido. Dysthymic disorder is similar to major depression but is of lesser intensity
and is, typically, longer in chronicity. DSM-IV-TR requires a minimum of 2
years to make a diagnosis, though individuals can have the disorder for many
years. Adjustment disorder with depressed mood indicates a reaction to an identifiable situation with depressed mood, in excess of what would be expected
within a given culture. There are also two disorders in the appendix of DSMIV-TR, with criteria provided for research purposes. One is minor depression
(similar to major depression but less severe), and the other is recurrent brief
depression (with multiple depressive episodes that last from 2 to 13 days).
The painful nature of depression is made all the more compelling when
one considers its high frequency in the population. The problem of depression ripples out to families, businesses, and society at large. To understand
the scope of the problem, the next step is to examine the frequency of the
disorder; further, by looking at the financial cost of the problem, we can
obtain a crude estimate of the overall impact of depression.
EPIDEMIOLOGY OF DEPRESSION
The National Comorbidity Survey Replication (NCSR) used face-toface household surveys performed between February 2001 and April 2003.
The nationally representative sample consisted of 9,282 English-speaking
participants who were at least 18 years of age. In their sample, 16.6% had had
major depression and 2.5% had had dysthymic disorder at some point in
their lives. This translates into approximately 33 million people in the U.S.
population who had experienced major depression, 6.6 million of whom had
had major depression within the past year. Projecting out to the future, the
researchers estimated that by age 75, 23.2% would have had major depression, and 3.4% would have had dysthymic disorder. The median age of onset
for any mood disorder (including bipolar I and II, though these account for a
relatively small proportion of those with mood disorders) is 30 years old,
which is much older than that for anxiety disorders (11 years), substance use
disorders (20 years), and impulse control disorders (11 years). Female gender
and marital disruption are risk factors for major depression (Kessler, Berglund,
Demler, Jin, & Walters, 2005).
AN OVERVIEW OF DEPRESSION
15
siders that fewer than half of those treated received minimally adequate
treatment; for example, in the most recent survey, treatment was minimally adequate for only 32.7% of those receiving care for a mental health
condition. The most underserved are older adults, racial and ethnic minorities, people with low incomes, the uninsured, and those who live in
rural areas. Wang, Lane, et al. (2005) concluded tersely, "Most people with
mental disorders in the United States remain either untreated or poorly
treated. Interventions are needed to enhance treatment initiation and quality" (p. 629).
The estimated financial cost of depression as of 2000 totaled approximately $83 billion per year, an increase of nearly 8% from the 1990 estimate
($77 billion, inflation adjusted). The total figure for 2000 consisted of $26
billion (31%) for direct treatment expenses, $5 billion (7%) for costs associated with suicide, and a staggering $52 billion (62%) in workplace costs ($37
billion from absenteeism and $ 15 billion from reduced productivity while on
the job; P. E. Greenberg et al., 2003). Even these enormous figures are an
underestimate, because they do not account for accidents, turnover, or the
impact on coworkers. Simulations have indicated that 45% to 90% of direct
treatment costs are recovered in a single year through worker productivity
gains; it is reasonable to expect that all of the treatment cost, or perhaps
even more, could be recovered if a longer window were used (Kessler, 2002).
THEORIES OF DEPRESSION
AND THEIR ASSOCIATED TREATMENTS
How does a person become and remain depressed? And how does he or
she recover? Biological, psychological, and social factors are essential in gaining a comprehensive understanding. Starting with the smallest unit of analysis, I explore biological factors such as neurochemical and neuroanatomical
phenomena. Moving outward to a broader domain, I examine psychological
aspects of depression, including intrapsychic and interpersonal manifestations. Finally, at the macro level, I integrate societal and cultural issues, such
as gender role and ethnicity.
Biological Factors
There is a significant genetic component to depression. Sullivan et al.
(cited in Wallace, Schneider, & McGuffin, 2002, pp. 174-175) conducted a
review and meta-analysis of twin studies on major depression. Over 212,000
individuals were studied. Results indicated that 58% to 67% of the variance
was attributable to specific environmental effects, 31% to 42% to genetic
factors, and a mere 0% to 5% to shared environment among siblings. According to Thapar and McGuffin (cited in Wallace et al., 2002, p. 177),
AN OVERVIEW OF DEPRESSION
17
18
Medications
A variety of medications have been shown in double-blind studies to
ameliorate depression, (e.g., I. M. Anderson, 1998; Rudolph, 2002; Storosum
et at, 2001). Historically, the first antidepressant medications developed were
monoamine oxidase inhibitors (MAOIs). Drugs formerly used to fight tuberculosis were found to have an unexpected antidepressant effect. Scientists
then isolated the effective compound and formulated the medications specifically as antidepressants. This discovery led to the first biological theory of
depression, the monoamine hypothesis. The theory was that depletion of
monoamines leads to depression. This was supported not only by the action
of MAOIs (which, as their name implies, block the action of monoamine
oxidase, the enzyme that breaks down monoamines, a group of neurotransmitters that include serotonin and NE, and increase the availability of
monoamines) but also by findings that drugs that reduced the amounts of
monoamines lead to depression (Stahl, 1996, p. 112). MAOIs, then, work by
blocking the action of (inhibiting) monoamine oxidase. With less monoamine oxidase breaking down monoamines, more monoamines are available to
the neurons. This increase in monoamines, the theory indicates, decreases
depression. Widely used MAOIs include phenelzine (Nardil) and tranylcypromine (Parnate).
Tricyclic antidepressants (TCAs) are so named because the original
medications had a three-ringed chemical structure. As with MAOIs, the
antidepressant qualities of TCAs were discovered while they were being used
to treat another disorder, in this case schizophrenia. Though the medication
was ineffective for schizophrenia, clinicians noticed during the clinical trials
that their patients were becoming less depressed. TCAs quickly became popular because they were effective and the side effects were not as troublesome as
those of the MAOIs. Tricyclics are still widely used but are declining in popularity because SSRIs tend to have fewer side effects. Most TCAs are available
in generic form and are relatively inexpensive, which can be a big advantage
in some circumstances. TCAs work by blocking the action of the reuptake
pump for serotonin and NE. Because the neurotransmitters are not reabsorbed by the neurons, they remain in the synapse, the space between neurons. (Neurotransmitters leave a neuron, enter the synapse, and potentially
cause the next neuron to fire.) The extra neurotransmitters in the synapse,
per the monoamine hypothesis, lead to a decrease in depression. Common
tricyclic compounds include amitriptyline (Elavil), desipramine (Norpramin),
doxepin (Sinequan), and imipramine (Tofranil).
With SSRIs, the basic mechanism of action is to block the reuptake
(reabsorption) of serotonin back into the neurons, thereby leaving more serotonin available in the synapse. As with TCAs, the increased availability of
synaptic monoamines underlies the antidepressant effect. SSRIs and other
newer antidepressants are generally used first because of their improved side-
AN OVERVIEW OF DEPRESSION
19
effect profile relative to the older TCAs. Commonly used SSRIs include
citalopram (Celexa), fluoxetine (Prozac), paroxetine (Paxil), and sertraline
(Zoloft).
A number of relatively new antidepressants do not fit conveniently
into any of the previous three categories (MAOI, TCA, or SSRI) and impact
serotonin and NE through various mechanisms of action. Drugs in this "novel"
category include amoxapine (Asendin), bupropion (Wellbutrin), maprotiline
(Ludiomil), venlafaxine (Effexor), mirtazapine (Remeron), nefazodone
(Serzone), and trazodone (Desyrel).
Antidepressant medications have generally been found to have approximately equivalent effects on symptoms as short-term psychotherapy, with
combinations of psychotherapy and antidepressant medications generally
having somewhat improved efficacy (I. W. Miller & Keitner, 1996). For longterm relapse prevention, it is now known that long-term medication maintenance is often required (Gitlan, 2002).
Antidepressants typically take several weeks to alleviate symptoms, although elevated levels of serotonin are available in the synaptic cleft within
a few hours. Scientists have concluded that the effects of antidepressants
occur as a function of complex interactions at the intracellular level. Thase
et al. (2002) noted, "It is now clear that the synaptic effects of the TCAs,
MAOIs, and newer antidepressants only serve to initiate a sequence or cascade of effects that culminate within cell nuclei, at the level of gene activity"
(p. 201). A detailed explanation of mechanisms of action is beyond the scope
of this review, but the curious reader is encouraged to peruse Stahl (1996)
and Gitlan (2002).
SSRIs are currently the frontline pharmacotherapy for depression in
the United States. Their relatively benign side-effect profile and easy, usually once-daily, dosing encourages high compliance. Equally critical, and more
so in some cases, SSRIs have much lower lethality than TCAs in overdose
and are thus difficult to use as instruments of self-destruction. If one SSRI is
ineffective or cannot be tolerated, most prescribers will switch to another
SSRI and then, if necessary, to another drug class. The "novel" antidepressants all have different chemical structures, properties, and side-effect profiles; in essence, each is its own drug class. Some of these medications are
sedating (e.g., nefaxedone and trazedone) and they may also encourage weight
gain (e.g., mirtazepine), which can be therapeutic in cases that include insomnia and anorexia. The older tricyclic medications are rarely firstline medications because of unpleasant side effects (e.g., dry mouth, sedation, postural
hypotension, weight gain, blurry vision, and constipation) and high lethality
in overdose. They may be prescribed when cost is a consideration and, of
course, when other medications have been ineffective. MAOIs are generally
a third- or fourth-line treatment because of unpleasant side effects (e.g., weight
gain, sexual problems, and insomnia) and dangerous interactions with foods
that contain tyramine (e.g., wines and aged cheeses). Although better known
20
for treating bipolar disorder, lithium can be useful in some cases of unipolar
depression. It tends to be used rarely because of its narrow therapeutic window and its toxicity, and, thus, the requirement for routine blood work. Dysthymic disorder responds to medications in a way that is essentially identical
to major depression, so the above considerations apply to both equally (Gitlan,
2002).
Electroconvulsive Therapy
ECT has been considered a safe and effective treatment for depression
for nearly 2 decades (American Psychiatric Association, 1990; Enns & Reiss,
2001; National Institutes of Health, 1985; Pagnin, de Queiroz, Pini, &
Cassano, 2004; UK ECT Review Group, 2003). Understandably, there are
fears among some in the general public. The idea of passing an electrical
current through the body can be frightening; further, popular depictions of
the inappropriate use of ECT and images of the procedure prior to the introduction of adequate sedative medication may enhance the concerns of a potential beneficiary. Ken Kesey's One Flew Over the Cuckoo's Nest (1962/2002)
and its extraordinarily popular film adaptation (Zaentz, Douglas, & Forman,
1975) portrayed ECT (without sedation) as a punishmentor even torture
used against a spirited and nonconforming patient. Such images may frighten
potential patients who could benefit from an appropriate use of ECT.
Psychoeducation for the client and, potentially, the family, is extremely important in cases in which ECT is the best option. Memory problems are the
main side effects associated with treatment (American Psychiatric Association, 1990). For severe depressions in which several medications have been
ineffective, ECT remains an important intervention.
Summary and Conclusions Regarding Biological Factors
Biological factors play an important role in depression. The disorder is
heritable, and a number of biological models of depression have considerable
scientific support. Nonetheless, those who argue that depression is a purely
biological "disease" and that the best treatment is medication are flying in
the face of a massive amount of data. Current scientific studies cannot validate any of the proposed biological models (e.g., serotonin depletion) as causes
of depression; rather, they may be effects. As noted above, genetic studies
have shown that nearly twice as much variance is accounted for by environmental factors as by genetic ones. Medication has not proved to be better
than psychotherapy for treating depression; in fact, overall, studies seem to
suggest that for all but the most severe depressions, psychotherapy has better
efficacy (American Psychiatric Association, 2000b). Despite the existence
of several classes of medications and several medications within most classes,
approximately 35% to 40% of individuals do not respond to medication treatment. Data are fairly consistent with the commonsense hypothesis that psychotherapy and medications work synergistically (I. W. Miller & Keitner,
AN OVERVIEW OF DEPRESSION
21
23
ity built up and motivation is not quite so difficult for the client to muster.
When I do bring up exercise (unless the client does first), the discussion is
embedded in the context of the client's goals. Perhaps the client's goal is to
feel better, physically or emotionally (many are not aware that exercise has
proven antidepressant effects, so psychoeducation can be helpful in such
cases). Perhaps he or she has a goal of being healthier for another person.
Often, weight loss is a goal. I have clients write down their goals and why
exercise would help. Once the motivations are clear and adequateif the
motivation is not adequate, then we deferthen we can discuss specific strategies, such as the type of exercise and how that fits into the client's goals and
needs.
Prochaska's "stages of change" model (Prochaska et al., 1994) is extremely useful for assessing whether the client is ready for an exercise program. For the precontemplator who has no interest in an exercise program,
the therapist can provide information that exercise helps depression lift and
that at some point it would be useful to consider an exercise program. For the
contemplator, more in-depth discussion can help the person to become aware
that exercise may be worth it. During the preparation phase, one can develop
specific strategies with the client, such as selecting the exercises to use, scheduling workouts, and discussing preference for exercising alone or with others.
During the action phase, continued focus on motivation will remain important. Strategies such as making charts of progress toward a goal (e.g., losing a
certain amount of weight or walking a certain number of miles) can be very
motivating. Setting goals such as walking, running, or biking for a cause near
to the person's heart can also be a great motivator; for example, setting a goal
of completing a 5-mile walk for breast cancer can be motivating if the client
knows someone who has or had the disease. There are books available for
adjunctive bibliotherapy for exercise (e.g., Exercising Your Way to Better Mental
Health, Leith, 1998; Move Your Body, Tone Your Mood: The Workout Therapy
Workbook, Hays, 2002).
Outcome data show clearly that cognitive-behavioral therapy (CBT)
is effective. Over 80 research studies have shown that CBT is superior to
placebo treatment, and it is superior to medications for all but the most severe depressions (American Psychiatric Association, 2000b).
The Interpersonal Approach
Coyne (1976) proposed an interactional model of depression. In contrast to work by psychodynamic theorists (e.g., Abraham 1911/1986; Freud,
1917/1986) and Beck's emerging cognitive theory (e.g., A. T. Beck, 1967),
Coyne emphasized people's accurate perceptions rather than their distortions. He observed that depressed individuals have a tendency to seek reassurance. Initially, caring others in the environment wholeheartedly provide
such reassurance. However, convinced that these individuals are responding
24
to his or her manipulations, the person with depression persists. Other people
eventually become annoyed and send mixed messages; they provide comfort,
but, in contrast to their prior, genuine encouragement, they are at least in
part responding only to the demands for reassurance. A vicious circle ensues,
in which demands for reassurance are met with increasing, but hidden and
explicitly denied, annoyance on the part of the significant others while the
person with depression becomes increasingly frustrated and perhaps hostile.
As opposed to fantasized or early object loss, as emphasized by Freud, many
people in the person's life are genuinely avoiding him or her in the present. If
intervention occurs at this point, there is a mixture of cognitively distorted
perceptions of worthlessness and accurate perceptions of real abandonment
and insincerity within the depressed person's social network. The "excessive
reassurance seeking" hypothesis has received research attention over the years
and has generally been supported (Benazon, 2000; Coyne & Downey, 1991;
Joiner, 1994; Potthoff, Holahan, & Joiner, 1995; Swann, Wenzlaff, Krull, &
Pelham, 1992).
Similar to Coyne, and building on themes developed by Harry Stack
Sullivan and other theorists, Gerald Klerman, Myrna Weissman, and their
associates developed interpersonal psychotherapy (IPT) in the 1970s
(Weissman & Markowitz, 2002) as a time-limited treatment for major
depression. Outcome data for IPT have been impressive; the treatment
has consistently been better than placebo, has been about as effective as
cognitive-behavioral therapy for most clients, and has been more effective
than CBT for more severely depressed patients (for a review, see Weissman
6k Markowitz, 2002). IPT uses an unabashedly medical model approach to
treatment: "In IPT, depression is defined as a medical illness, a treatable condition that is not the patient's fault" (Weissman & Markowitz, 2002, p. 406).
This approach helps to reduce guilt and feelings of inadequacy on the part of
the patient and facilitates a natural alliance of client and therapist against
the depressive symptoms.
IPT focuses on interpersonal problems in the person's current life, such as
complicated bereavement, role transitions, and interpersonal deficiencies. The
therapeutic relationship is designed to be positive, optimistic, and collaborative. Relatively little transference distortion is elicited in this approach, and
investigation of transference phenomena is not routinely part of the treatment.
The IPT therapist assists clients in pursuing their interpersonal goals.
Events in clients' lives are consistently linked to their mood and symptoms.
Emotionally intense events in their interpersonal lives are reenacted and
role-played, and options for making different kinds of choices are considered.
The treatment is designed to be brief and typically takes approximately 12 to
16 sessions. Monthly follow-up sessions provide some protection against relapse, although Weissman and Markowitz (2002) suggested that biweekly
relapse prevention sessions may be more effective and should be researched.
AN OVERVIEW OF DEPRESSION
25
26
trying to please her mother. An initial reintegration occurred in rather dramatic fashion during a two-chair interaction:
Therapist:
What do you want from her (to the critic) ? [Encouraging expression of need]
Client:
Therapist:
[Noticing a shift in her posture and face] What are you feeling
now? [Facilitating negotiation]
Client:
Congruent with cognitive therapy, L. S. Greenberg et al. (1998) observed that people with depression have beliefs that they are worthless, powerless, and bad and that they experience feelings of helplessness. As with Beck's
notion of "core beliefs" that are activated by current experiences, L. S. Greenberg
et al. noted, "In our model, the core depressogenic weak/bad self-scheme is
activated by a current emotional experience of loss or failure" (p. 232); such a
notion also relates to self-psychological notions that psychopathology emerges
from a damaged sense of self. Similar to the interpersonal school, they noted
that social disruptions and losses elicit depressive mood. PET differs from
other approaches in its focus, like all humanistic and client-centered approaches, on the natural holistic and organismic aspects of the person. The
therapist focuses not only on verbal and cognitive schemas but also on bodily
AN OVERVIEW OF DEPRESSION
27
sensations such as the felt sense of an experience and subtle emotional experiences that are difficult to label. The primary mode of intervention, which is
to remain empathically attuned and promote the client's attention to his or
her moment-to-moment experience, differs from other approaches.
Research on humanistic psychotherapy for depression has been encouraging. There is a growing body of literature on PET. Elliott, Watson, Goldman,
and Greenberg (2004) reviewed 18 research studies on PET, 6 of which addressed depression. All 6 of the studies reported a positive impact on depression, with effect sizes ranging from 0.50 to 2.49 standard deviations, which
represent a medium to very large effect; the mean effect size is 1.36, which is
large (see Cohen, 1988). To put these findings in perspective, a brief discussion of effect size is in order. Cohen (1988) noted that an effect size of 0.8 is
sufficiently large to be obvious, such as the difference, for example, between
the heights of 13- and 18-year-old girls. Seen another way, a difference of this
magnitude indicates that 85% of those treated are better off than those who
are untreated. Three of the studies were randomized trials comparing PET to
other therapies (person-centered in two studies, CBT in the third). In all three
cases, PET was superior to the other conditions (a mean difference of 0.38
standard deviations, a medium-sized difference). On the basis of these studies,
PET qualifies as an empirically validated treatment for depression.
Ward et al. (2000) conducted a fairly large (N = 464) randomized study
of client-centered counseling, CBT, and routine physician care for depression. Participants were provided with 6 to 12 sessions of psychological treatment. The study demonstrated that both psychotherapies resulted in greater
reductions in depressive symptoms and more rapid remissions in depression
than routine physician care, but the therapies did not differ in effectiveness
from one another.
Psychodynamic Therapy
Psychodynamic psychotherapy is the oldest form of psychological treatment, dating back approximately 100 years. In his essay "Mourning and Melancholia," Freud (1917/1986), in his astute manner, compared the phenomenon of normal grief to the state of melancholy that we now call depression.
Before considering this comparison, it is worth noting that Freud's description of melancholia, which included feelings of dejection, poor self-esteem,
loss of sex drive, and appetite and sleep disturbance, was in its essence identical to a description of major depression. In addition, Freud believed that
some depressions were "constitutional" (biological) and did not abide by the
psychic mechanisms he described.
Freud noted that melancholia differed from grief primarily in the selfdenigration and self-esteem problems of the individual with this condition.
Rather than arguing, as Aaron T. Beck did later (A. T. Beck et al., 1979),
that such beliefs are irrational and problematic, Freud indicated that these
self-attacking statements contain more than a grain of truth:
28
29
shows that the ego can kill itself only if, owing to the return of the object
cathexis, it can treat itself as an objectif it is able to direct against itself
the hostility which relates to an object and which represents the ego's
original reaction to the external world. (Freud, 1917/1986, pp. 56-57)
Thus the blurred identification between the self and the object, which is a
function of the regression to a very early stage of life, allows the self to become a target of "murderous," that is, self-destructive, impulses. Thus the
themes of anger turned inward, and the precursors of the depressive realism
hypothesis, are present in Freud's early work on depression.
Unfortunately, the empirical data supporting the psychodynamic view
of depression (e.g. group designs and controlled studies) are limited (Coyne,
1976; Hollon, Thase, & Markowitz, 2002). Nonetheless, the rich history of
theory and case studies is a deep well of clinical wisdom and has strongly
influenced the field.
Family Systems Therapy
The relationship between marital problems and depression is substantial. According to a meta-analysis by Whisman (cited in Beach 6k Jones,
2002, p. 423), the correlation between depression and marital quality was
-.66. Family theorists generally focus on the bidirectional nature of causality, noting that depression creates stress in the relationship and stress worsens depression, thus setting off a downward spiral. There are well-established
marital and family treatments for depression using behavioral marital therapy,
cognitivebehavioral marital therapy, emotion-focused therapy, and insightoriented marital therapy (for a review, see Baucom, Shoam, Mueser, Daiuto,
& Stickle, 1998). According to studies by Patterson and by Patterson, Reid,
and Dishion (both cited in Beach & Jones, 2002, p. 426), parent management training is effective for childhood depression. Interpersonal therapy,
reviewed above, has been modified for use with couples and is called "conjoint marital therapy" (see Foley, Rounsaville, Weissman, Sholomskas, &
Chevron, cited in Beach & Jones, 2002, p. 428).
Available evidence suggests that the effect of marital therapy on depression is equivalent to that of individual therapy (but no better); however,
it reduces marital distress more than individual treatment (Beach 6k Jones,
2002). In studies in which marital distress was not an issue, marital therapy
did not confer any measured advantage. Thus, the evidence is consistent
with the commonsense conclusion that marital therapy should be used in
cases in which there is marital distress as well as depression; if there is no
marital distress, then in most cases it would be more convenient for the depressed person to enter individual treatment.
Parent training decreases symptoms in depressed children and in depressed parents simultaneously. If parent-child relationships are contributing to family stress or depression, it is an important treatment. In addition,
30
parent training may be a less threatening way to enter treatment for families
in which there are both marital distress and parent-child problems (Beach &
Jones, 2002).
Group Therapy
A meta-analysis of 48 studies of group psychotherapy (McDermut, Miller,
& Brown, 2001) showed that group psychotherapy has a substantial impact
on depression. The overall effect size of treatment is 1.03; that is, the treatment group, on average, had scores 1.03 standard deviations lower than corresponding control groups, which is a large effect size. The efficacy of group
treatment of depression is comparable to that of psychotherapy in general
(effect size = 0.68; M. L. Smith & Glass, 1977) and individual psychotherapy
for depression (effect size = 1.22; Steinbrueck, Maxwell, & Howard, 1983).
CBT (e.g., Kush, 2000; Peterson & Halstead, 1998; Pidlubny, 2002)
and IPT (see Klier, Muzik, Rosenblum, & Lenz, 2001; MacKenzie, 2001)
have been adapted to group modalities. It is most likely that a combination
of factors within the group process combine to reduce depression. Individuals
can acquire new skills, such as assertiveness or problem solving, which can
help them function more effectively. Cognitive-behavioral groups help clients learn to challenge their irrational or distorted beliefs. Process-oriented
groups help the person to confront relationship issues in the here-and-now, a
very powerful form of learning. Other available group therapies for depression include multimodal therapy (Rice, 1995), narrative therapy (Laube &
Trefz, 1994) and reminiscence therapy (Bachar, Kindler, Schefler, & Lerer,
1991). Few comparisons have been performed contrasting different types of
therapy. One study (Hogg & Deffenbacher, 1988) found that process group
therapy and CBT were equally effective in reducing depression, and no differences were found in mechanisms of action.
Group therapy has several advantages relative to individual therapy. In
skills-training groups, there are opportunities to practice with peers rather
than just with the therapist. In addition, during the presentation of new information, others in the group may think to ask questions that an individual
may not have thought to ask. In process groups, opportunities arise that cannot occur in individual therapy, such as feedback from multiple individuals
simultaneously. Perhaps the primary advantage of group psychotherapy is
that it provides similar efficacy at a lower cost. Estimates suggest that group
psychotherapy saves 25% to 92% of the cost of care relative to individual
therapy, depending on the size of the group (see McDermut et al, 2001).
Of course, group therapy is not always preferable. Individual treatment
offers greater privacy, which may allow some clients to open up more. It also
may help to prepare clients for group treatment. Although McDermut et al.
(2001) concluded, logically, that group therapy should be the frontline treatment for depression on the basis of cost considerations, for clients with PDs
exactly the reverse may be true. Many individuals with personality disorders
AN OVERVIEW OF DEPRESSION
3]
are not ready for group treatment until their symptoms have partially remitted. For example, clients with paranoid and avoidant PD are often too interpersonally defensive and uncomfortable to function in a group; some individuals with narcissistic PD are unable to share attention with other group
members; some individuals with schizotypal PD would come across as so
strange that the group would reject them, furthering their depression. For
many individuals with PDs and depression, the appropriate course of action
is to provide individual treatment first; group treatment can then be used to
make further progress on interpersonal and intrapsychic material. Group treatment can also be a relatively low-cost way to continue treatment for clients
who require long-term work.
33
longitudinally and affirmed that "chronic strain, low mastery, and rumination were each more common in women than in men and mediated the gender difference in depressive symptoms" (p. 1061). Further, her study demonstrated that this pattern led to a vicious circle, in that depressive symptoms
led to increased rumination and decreased mastery over time.
These notions are consistent with the findings of a study by Lynn Collins
(1998), which linked social status to the development of psychological symptoms. Collins showed her classroom students (the research participants) a
film of the Stanford prison experiment (Haney, Banks, & Zimbardo, 1973).
Collins put together a list of symptoms of mental disorders and had participants rate how characteristic these symptoms were of men, women, "prisoners," and "guards." What she found, as demonstrated in the ratings, was that
the prisoners exhibited symptoms of depression, anxiety, and helplessness
symptoms traditionally more prevalent in women. Conversely, the guards
displayed aggression, arrogance, and other symptoms of antisocial and narcissistic disordersdiagnoses given predominantly to men. What was especially ingenious about this study was that because both the guards and the
prisoners were male neither gender roles nor biological sex could explain the
group differences. In addition, because of randomization, explanations based
on personal variables (their upbringing, family dynamics, trauma history, etc.)
were ruled out. The likeliest explanation for the differences in symptoms
between the prisoners and the guards is that their assigned social roles influenced their identities and behaviors. This theory fits with data that show
that the prevalence of depression is relatively high among, for example, gay
teens and the poor (Herrell et al., 1999; Otis & Skinner, 1996; Simons et al.,
2002; van Heeringen & Vincke, 2000).
However, awareness of the difference in prevalence between men and
women in most mental disorders is potentially confounded by differential
rates of help-seeking behavior. Women are more likely to seek psychological
help for most conditions, especially for depression and anxiety. For men in
our culture, asking for help is seen as a sign of weakness or dependence; for
women, asking for help bears no such stigma (Tannen, 1990). It is probable
that some of the difference between diagnosis rates for men and women is
due to women's greater comfort in going for help, especially with a mental
health issue, though it is difficult to estimate the precise magnitude of that
effect. In addition, differential rates have been found not only in clinical
samples, but also in epidemiological studies (Nolen-Hoeksema, 2002); these
differences are more difficult to explain on the basis of self-selection for treatment. On the other hand, a study of over 2,000 referred and 1,100 nonreferred
adolescents found that among mental-health-referred, but not nonreferred,
adolescents, rates of depression were higher in girls than in boys (Compas et
al., 1997). The authors suggested that these gender differences were apparent
in only a small subset of adolescents. Further research is needed to clarify the
impact of gender and the reason for the impact.
34
People from other cultures may have vastly different experiences of distress that are shaped by their culture. Guilt, self-denigration, existential despair, and suicidal ideation have been found to be less prevalent or absent in
non-Western cultures. Conversely, somatic symptoms are more pronounced
in other societies. The World Health Organization Collaborative Study, which
examined depression in five different countries (Canada, India, Iran, Japan,
and Switzerland) found that feelings of guilt were more than twice as prevalent in the Swiss sample than in the Iranian one, and somatization was twice
as high in the Iranian sample as in the Canadian one (see Sartorius et al., and
Thornicroft & Sartorius, both cited in Castillo, 1998). Sociocultural upheaval
can also lead to depressive symptoms. For example, the rate of completed
suicides in Micronesia underwent an eightfold increase from 1960 to 1980, a
period of rapid modernization accompanied by the breakdown of traditional
religious and social organizations (Desjarlais, Eisenberg, Good, & Kleinman,
1995, cited in Castillo, 1997).
A striking example of the difference in meaning of distress in different
cultures was illustrated by Kabat-Zinn (1994):
In our society, one might speak of an epidemic of low self-esteem. In
conversations with the Dalai Lama during a meeting in Dharamsala in
1990, he did a double take when a Western psychologist spoke of low
self-esteem. The phrase had to be translated several times for him into
Tibetan, although his English is quite good. He just couldn't grasp the
notion of low self-esteem, and when he finally understood what was being said, he was visibly saddened to hear that so many people in America
carry deep feelings of self-loathing and inadequacy.
Such feelings are virtually unheard of among the Tibetans. They have
all the severe problems of refugees from oppression living in the Third
World, but low self-esteem is not one of them. But who knows what will
happen to future generations as they come into contact with what we
ironically call the "developed world." Maybe we are overdeveloped outwardly and underdeveloped inwardly. Perhaps it is we who, for all our
wealth, are living in poverty, (pp. 162-163)
In part, the Dalai Lama's perspective may reflect the difference between
sociocentric and egocentric cultures. In the West, the concept of individualism permeates. We are encouraged to pursue our goals and maximize our
potential; we believe in the concept of individual rights, including the right
to pursue happiness. If one is not pursuing happiness, then, in Western culture, one is behaving pathologically. In sociocentric cultures, the well-being
of the group is considered paramount, with individual needs being secondary. Within such a context, low self-esteem is far less comprehensible because the emphasis is not on the self in the first place. Sadness occurs, of
course, but it is more likely to be a shared experience rather than a personal
failing.
AN OVERVIEW OF DEPRESSION
35
37
would be a milder version of the Axis I disorder. There is good evidence that
schizotypal PD and schizophrenia have a "spectrum" relationship, and although the evidence is not quite as strong, it appears that paranoid and schizoid PDs are part of the same spectrum (Siever, 1992). Regarding a relationship between depression and PDs, depressive PDwhich is not discussed
elsewhere in this volume because it is covered in the appendix of DSM-IVTRis probably related in a spectrum fashion to major depression and dysthymic disorder. There are theories that borderline PD lies on a spectrum
with bipolar disorder, based on shared features such as affective instability.
Although proof of this connection is lacking, the theory led to experiments
with anticonvulsants and lithium to treat borderline PD; however, this approach has had mixed success (see the section on medications in chap. 7, this
volume).
PredispositionVulnerability Model
There is a possibility that having one disorder will predispose an individual to getting another disorder. In this regard, PDs, which are seen as
developmentally based and having broad implications regarding the person's
functioning, would be more likely to form the context into which the depression would fit. However, it is also possible that childhood depression would
predispose an individual to develop a PD.
A study by Daley, Hammen, Davila, and Burge (1998) is illustrative of
this point. It demonstrated that the presence of a Cluster A or B PD predicted later depression in a sample of late adolescent women. The causal
path consistent with Daley et al.'s analysis was that individuals with Cluster
A and B PDs generated larger numbers of stressful life events, which in turn
increased the likelihood of depression. The vulnerability model fit better
than the pathoplasticity model (discussed below); PD did not increase the
risk of depression in response to stress.
Complications-Scar Model
Like the vulnerability model, the complications model presumes a sequential relationship between two disorders. In this theoretical configuration, a second disorder develops in the context of the first. The first disorder
remits, but the other disorder continues on, exacerbated by the effects of the
original comorbid disorder; it is as if the remitted disorder left a "scar" that
complicates the recovery from the lingering disorder. An example would be
an individual with borderline PD who then develops depression and, after
intensive treatment, no longer meets the criteria for borderline PD but is still
more vulnerable to depression as a consequence of having had borderline
PD. In such an instance, residual borderline PD symptoms may be the causal
factor that increases the vulnerability to depression. I am not aware of any
38
studies that support the validity of this model in specific PD-depression pairings, though it remains a theoretical possibility.
Pathoplasty-Exacerbation Model
In this model, the principal hypothesis is that the presence of one disorder will influence the course of another. The effects can be additive (pathoplasty)
or synergistic (exacerbation). For example, depression likely increases the tendency of individuals with avoidant, schizoid, and schizotypal PDs to socially
withdraw, which can then further exacerbate both conditions.
A number of studies support the notion that PDs interact with depression. For example, llardi, Craighead, and Evans (1997) found that the length
of remission of unipolar depression was over 7 times longer among clients
who did not have PDs compared with those who did. In another study, an
interaction of personality style and life events predicted depression. Specifically, the researchers predicted and found that self-critical patients were at
high risk for depression relapse if they experienced adverse achievementrelated events, and dependent individuals were vulnerable to depression if
they experienced negative interpersonal life events (Z. V. Segal, Shaw, Vella,
& Katz, 1992). A study of the impact of PDs on cognitive therapy outcome
showed that outcomes were independent of PD status but that specific paranoid and avoidant beliefs predicted poorer outcomes (Kuyken, Kurzer,
DeRubeis, Beck, & Brown, 2001).
Psychobiological Models
In the psychobiological model, shared biological mechanisms underlie
depression and PDs (though presumably different PDs will have different
associations with depression). Evidence of the validity of this model is growing. For example, a recent study of 720 child and adolescent twins showed
that 45% of the covariation in depression and antisocial PD were attributable to common genetic factors (O'Connor, McGuire, Reiss, Hetherington,
& Plomin, 1998). Such psychobiological models are a variant of the "common cause" model discussed above, and thus the biological example given in
that section applies here as well (i.e., serotonin problems in individuals with
depression and impulsive PDs).
CONCLUSIONS
Perhaps what is most important to consider is that these models are not
mutually exclusive, and they often overlap. We do not know for certain what
the relationship is between PDs and depression, but it is likely complex. StayAN OVERVIEW OF DEPRESSION
39
ing with the PGT principle that integration occurs at the level of the person
rather than at the level of theory, we can safely conclude that most or all of
these models refer to at least some of the people, some of the time. Throughout the remainder of the book, reference will be made to these models when
they fit the available data.
40
3
DEPRESSION INPARANOID
PERSONALITY DISORDER
The phenomenology of paranoid personality disorder (PD) is powerfully portrayed in the poem "Paranoid," written by Lisa Ochenduszko (2003)
and published on the Internet. The poem is reprinted only in part, but each
stanza is complete and the ellipses are in the original.
In the deepest recesses and corridors of my mind,
You play there . . .
You run freely,
gaily
In my mind you make the fantasies,
hollowed out screams,
fearful cries . . .
Denied
In my mind where you hunt your prey,
Your hunger ravished,
eating me. . . .
Destroyed
In my mind or what is left of my mind,
you reign as supreme.
Ideal dictatorship. . ..
Paranoid. . . .
41
This gifted writer has portrayed the pain, emptiness, and fear that dominate the life of the person with paranoia. The frightening image of being
destroyed, as if devoured from the inside, represents the internalization of
the sadism to which the person was presumably subjected. The poet portrays a person who sees evil in others and has difficulty setting a boundary
to keep it out ("In the deepest recesses and corridors of my mind, / You play
there ... / You run freely"; "In my mind you make the fantasies").1 Although
real abuse presumably occurred, in theory, there are also instances in which
it is the person portrayed by the poet who feels anger or hate and then
projects it onto an otherwise innocent person; this projection occurs outside of conscious awareness. Glimpses of projection appear several times in
the poem. Is the feared individual able to truly "run freely" in the person's
mind and to create fantasies? Or do the fantasies come, at least in part,
from within? The fear of being controlled by another and the exhaustion
from the defensive efforts, both so movingly portrayed, capture the essence
of paranoid PD.
According to the Diagnostic and Statistical Manual of Mental Disorders
(4th ed., text revision [DSM-IV-TR]; American Psychiatric Association,
2000a), "Paranoid Personality Disorder is a pattern of distrust and suspiciousness such that others' motives are interpreted as malevolent" (p. 685). Guarded
and either hostile, fearful, or both, they are among the most difficult groups
to treat with psychotherapy. Their very modus operanditrust no oneis
so contrary to one of the necessary conditions of psychotherapeutic treatment that treatment often grinds to a halt after just a few sessions. There is
more hope that the individual with both paranoid PD and depression will
stay in treatment because the depression is distressing and increases the client's
motivation to persist in treatment.
It is important to distinguish paranoid PD from paranoid (delusional)
disorder and from paranoid schizophrenia. Sometimes they co-occur, as in
the case example at the end of this chapter, but not always. In general, I have
found that people with paranoid schizophrenia and delusional disorder (but
without paranoid PD) are remarkably trusting. As I have listened to elaborate tales of Federal Bureau of Investigation, Mafia, and Central Intelligence
Agency conspiracies that ensnared the beleaguered client, I have often waited
for the other shoe to dropto hear the dreaded, "How do I know that you're
not part of the conspiracy?"but it never happened. Often I have found
individuals with paranoid schizophrenia to be too trusting, because their psychosis often interfered with logical thinking that would have helped them to
set appropriate boundaries. Nor did people with delusional disorder ever consider me part of the conspiracy. Such is not the case with individuals with
paranoid PD. By definition, it is extremely difficult to establish trust.
'The poet has said in a personal communication that she was writing not about herself but about a
loved one.
42
EPIDEMIOLOGY
In Pepper et al.'s (1995) dysthymic disorder sample, 11% had paranoid
PD. In another sample of depressed clients, approximately 22% had paranoid
PD (Fava et al, 1995). In a sample of 249 depressed outpatients, 5% were
diagnosed with "definite" and 18% with "probable" paranoid PD (Shea, Glass,
Pilkonis, Watkins, & Docherty, 1987). In a sample of 352 clients with both
anxiety and depression, approximately 17% had paranoid PD, as diagnosed
by structured interview (Flick, Roy-Byrne, Cowley, Shores, & Dunner, 1993).
Zimmerman and Coryell (1989) studied a community sample of 797 individuals that included 143 individuals who were diagnosed with PDs. Among
individuals with major depression, 1.7% met the criteria for paranoid PD.
Thus the range is approximately 2% to 22%. Likely reasons for the wide range
include natural sample variation, inpatient versus outpatient status, different
definitions of depression (e.g., dysthymic disorder vs. major depression), and
changing criteria-for example, some studies used criteria from the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III;
American Psychiatric Association, 1980), and others used criteria from the
revised third edition (DSM-III-R; American Psychiatric Association, 1987).
In regard to the converse question, among those with paranoid PD, 28.6%
met the criteria for major depression (Zimmerman & Coryell, 1989).
WHY DO PEOPLE WITH PARANOID PERSONALITY
DISORDER GET DEPRESSED?
Individuals with paranoid PD have thought patterns that generate both
anxiety and depression. The fear that others cannot be trusted and that others are actively undermining one's efforts leads to anxious hypervigilance.
Under such circumstances, many get worn out and sink into feelings of hopelessness and pervasive cynicism. Additional failures related to depression symptoms (such as slowed mental processing, motivational difficulties, etc.) are
further attributed to external forces, such as others' malevolence. "I would be
fine if not for so-and-so's interference" is a common theme. This conceptualization is consistent with the predisposition-vulnerability model, in that
the paranoid PD places the person at risk for depression. It also suggests the
exacerbation model because the depression and paranoia intensify one another (see chap. 2).
HOW A PERSON BECOMES AND REMAINS PARANOID:
THEORIES OF PARANOID PERSONALITY DISORDER
AND THEIR ASSOCIATED TREATMENTS
For individuals with comorbid depression and paranoid PD, it is hard to
imagine a satisfactory resolution of Axis I symptoms without a concurrent
PARANOID PERSONALITY DISORDER
43
son group, the results of the study are inconclusive; however, given the generally persistent nature of personality disorders, the finding is noteworthy
and warrants further investigation.
In the absence of additional studies, it is worthwhile to consider the
clinical observations provided by Joseph (1997). He divided paranoid PD
into symptom clusters that are amenable to intervention with medications.
Paranoia and ideas of reference can be treated with antipsychotics, such as
risperidone or olanzapine (which he preferred), or other drugs, such as haloperidol, fluphenazine, or chlorpromazine. He noted that dosages are "approximately one-tenth to one-fourth of what is used for treating florid paranoia
and psychoses" (p. 27). In his experience, such medications are quite effective in reducing paranoid ideation in people with paranoid PD. Joseph argued that symptoms such as such as rigid thinking and preoccupations with
others' loyalty can be considered obsessional features and treated with selective serotonin reuptake inhibitors such as fluoxetine, sertraline, orparoxetine.
Vigilance, guardedness, and tension may respond to anti-anxiety agents such
as lorazepam, alpraxolam, and clonazepam. Anger, excessive emotional sensitivity, and irritability are a cluster of symptoms that can be treated effectively with serotonergic antidepressants or tricyclic antidepressants, with
bupropion also being somewhat effective. Constricted affect, social withdrawal, and social anxiety can be conceptualized as being similar to negative
symptoms of schizophrenia; Joseph noted, "They are likely to respond to low
doses of risperidone or olanzapine, and, paradoxically, to serotonergic antidepressants and bupropion" (p. 30). In most cases, then, his treatment consists of long-term use of a low-dose antipsychotic and a serotonergic antidepressant, with short-term administration of a benzodiazapine. Although
reasonable, Joseph's theoretical assumptions, as well as his assertions of the
efficacy of particular medications for use with this population, require empirical verification. Randomized clinical trials with any medication proposed
for this population are essential.
Psychological Factors
In the biopsychosocial model, the psychological level refers to the individual and his or her intrapsychic and interpersonal world. Important areas
to consider include the person's learning history, thoughts, feelings, unconscious motivations, and relationships. Various schools of thought emphasize
different aspects of the person's functioning and will be described in turn
below.
Millon's Theory
According to Millon (1969/1985, 1981, 1996), paranoid PD is a severe
"dysfunctional variant," rather than a basic personality type in its own right.
Paranoid PD occurs when a personality disorder deteriorates. The basic patPARANOID PERSONALITY DISORDER
45
terns that typically underlie paranoid PD (and Millon's labels for the subtypes) are narcissistic (which becomes the fanatic paranoid), sadistic (malignant), obsessivecompulsive (obdurate), avoidant (insular), and passive
aggressive-negativistic (querulous).
In Millon's theory there is no developmental background that is specific to the disorder; it depends on the subtype. It is a "common endpoint"
theory, in which many developmental beginnings, shaped by experience, lead
to the hypervigilant mistrust seen in paranoid PD.
The seeds of paranoid PD find fertile soil in narcissistic psychopathology. There is an inevitable set of beliefs that undergirds the paranoid thinking seen in this disorder:
In order for someone to be undermining me, I must be important; in
order for them to feel threatened by me, I must be very powerful; in order
for them to feel jealous of me, I must be very special.
The arrogance that lurks just beneath the surface presentation often drives
and fuels the paranoid thinking; the gratification derived from the grandiosity props up and maintains the defense, and the externalization and blame
protect the person from self-reproach and further reinforce the pattern. What
turns narcissism to paranoia is cold, harsh reality that fails to gratify even a
modicum of the need for validation. A person with paranoid PD's perception
of his or her talents and abilities are miles apart from the perceptions of
others. If such individuals could simply accept their limitations and focus on
activities they do adequately well, all would be copacetic; however, such is
not the case. Narcissistically driven, they continue to push, feeling the constant sting of rejection. Filled with blame and condemnation, their accusations and conjectures drift further and further from reality into a quasidelusional or fully delusional form.
People with avoidant origins are among those who are more constitutionally prone to paranoia. Typically shy and hypersensitive from the beginning, they consistently perceive rejection from an early age. Like their less
pathological avoidant counterparts, insular paranoids were subject to harsh
parental deprecation. Unlike the avoidant, however, the future paranoids
found no safe quarter; withdrawal was insufficient, and persecution seemed
to follow them. They lacked natural sophistication and cleverness as defenses,
and thus every sling and arrow hit its mark; eventually, they came to view
everyone as a potential torturer.
The querulous paranoid has an originating background similar to the
passive-aggressive-negativistic pattern. Millon (1996) noted that
the querulous paranoid is a variant related in part to a basic negativistic
pattern. These paranoids often evidence irregular infantile patterns and
an uneven course of maturation, traits that often promote inconsistent
and contradictory parental management. Their characteristic irritable
46
47
Finally, the delusional or quasi-delusional reconstruction of reality by persons with paranoid PD further worsens their social situation. Their suspicions often cross the line into actual accusations or, in more extreme cases,
physical assault. This pattern elicits the feared animosity and vengeance that
generally were not there prior to their own attacks on others.
I recall an extremely paranoid client whom I knew (but never treated)
when I was working at a Veterans Administration hospital who seemed to
have all of these perpetuating factors. He never made any friends or even
strong acquaintances on the unit. To my knowledge, he never opened up or
shared any personal information with anyone. I learned from staff that in his
job as a subcontractor for a private detective, he was to sit and watch people,
all day long, to see if they engaged in unseemly or illegal activities. This
client also had antisocial PD and, for example, would rent furniture and never
pay a dime until the company came to repossess it; it is my understanding
that he was also involved in the illicit drug business. He met his end by being
shot to death. I do not know the circumstances, but I would suspect that his
antisocial and paranoid behaviors played an important role.
Regardless of the particular subtype, depression in the person with paranoid PD often reflects a sense of exhaustionbattle fatigue from a war that
will not end, a surrender to the implacable foe. Once it begins, the depression itself leads to further exhaustion and hopelessness. Although this feeling of depletion is painful, it also signals the need for change and provides
the impetus for growth.
Cognitive-Behavioral Conceptualization and Interventions
The superficial manifestations of paranoid PD are obvious
hypervigilence, suspiciousness, and mistrust. However, cognitive theory connects these surface behaviors and beliefs to a more treatable underlying selfesteem deficit:
The paranoid individual's intense vigilance and defensiveness is a product of the belief that this is necessary to preserve his or her safety. If it is
possible to increase the client's sense of self-efficacy regarding problem
situations so that he or she is reasonably confident of being able to handle
problems as they arise, then the intense vigilance and defensiveness seem
less necessary. This should result in some decrease in vigilance and defensiveness that could substantially reduce the intensity of the client's
symptomatology, making it much easier to address his or her cognitions
through conventional cognitive therapy techniques, and making it possible to persuade him or her to try alternative ways of handling interpersonal conflicts. Therefore, the primary strategy in the cognitive treatment of [paranoid PD] is to increase the client's sense of self-efficacy
before attempting to modify other aspects of the client's automatic
thoughts, interpersonal behavior, and basic assumptions. (A. T. Beck,
Freeman, & Davis, 2004, p. 125)
48
For depressed clients with paranoid PD, there would typically be even
greater sensitivity to threats to self-esteem. Feelings of fatigue and hopelessness can make it feel as if their usual defensive efforts are too draining,
thereby tempting them to withdraw. For the client in therapy, such attempts at withdrawal have been unsuccessful, and the person may feel damaged and vulnerable.
It is often easier, more efficacious, and more comfortable, then, for the
client to build skills than to decrease problematic behaviors directly. Often,
competing behaviors (differential reinforcement of other behaviors) can
"squeeze out" the ineffective behaviors without the need for the client to use
behavioral inhibition. "Don't be so suspicious," whether the message is explicit or implicit, is an ineffective approach because it requires behavioral
inhibition and it does not provoke a behavior for which to provide positive
reinforcement. Instead, increasing skills such as assertiveness and interpersonal communication will naturally provide contrary evidence to the client's
suspicions. It is also important to work with the client on his or her cognitive
interpretations, because individuals with paranoid PD routinely twist data to
fit their preconceptions. Helping individuals learn Socratic dialogue, by which
they she can question the evidence themselves, is an important step.
It is not, however, the first step. Of all the personality disorders, and,
most likely, of all the disorders in the entire DSM-IV-TRwith the possible
exception of autistic disorders and reactive attachment disorderparanoid
PD presents the largest and most persistent barricade to forming a therapeutic alliance. By definition, there are profound difficulties trusting others that
must become part of the therapeutic process. It is not being overly pessimistic to say that in many cases this barrier is insurmountable. Nonetheless,
there are strategies to improve one's odds of success.
Beck and his associates (A. T. Beck et al., 2004; A. T. Beck & Freeman,
1990) have suggested that the therapist accept the client's mistrust and ask
the client to allow the therapist to build trust through actions. Most clients
with paranoid PD will find that this approach will fit with their worldview,
because they tend to persistently scan others' actions to determine if they are
trustworthy. In addition, it is wise to start with behavioral techniques, because cognitive techniques require too much trust and self-disclosure; once a
solid therapeutic alliance is formed, cognitive techniques can be introduced.
Above all, within the cognitive-behavioral therapy model, it is essential to
maintain a collaborative stance. Regularly checking in with clients and making
sure they understand and agree with the treatment plan is a strong safeguard
against potential therapy-ending misunderstandings. Finally, giving clients
increased control (e.g., more homework and less frequent sessions) can help
them to preserve their autonomy, which is often a prerequisite to continuing
treatment.
The basic cognitive-behavioral therapy relationship, which is problemfocused and less intimate than many other forms of treatment, is generally a
PARANOID PERSONALITY DISORDER
49
good fit for the client with paranoid PD. However, without special attention
to the relationship hurdles of paranoid PD, the therapy is likely to fail. Beck
and his associates (A. T. Beck et al, 2004; A. T. Beck & Freeman, 1990)
have paid attention to such issues from a cognitive perspective, as alluded to
above; however, the cognitively oriented therapist would be wise to peruse
writings from other theoretical perspectives as well. Gabbard (1994) provided a balanced, practical, and insightful review of countertransference phenomena, written in language that is accessible to the nonpsychodynamically
oriented practitioner (see the sections in this chapter on psychodynamic
therapy and countertransference).
Cognitive techniques can also address the quasi-delusional suspiciousness associated with paranoid PD. For approximately the past 10 to 15 years,
an extremely exciting literature has been developing in the treatment of
psychotic disorders using cognitive therapy. A number of research studies
have demonstrated substantial reductions in delusional beliefs. This area is
just now beginning to mature, with literature reviews, overviews, and books
emerging to connect formerly scattered and isolated reports (Gould, Mueser,
& Bolton, 2001; Haddock et al., 1998; Kingdon & Turkington, 1994). For
many years, the prevailing wisdom in the field has been, "You can't talk
someone out of his delusions," a saying that I still believe is largely true.
However, you can train someone to talk himself out of his delusions. The
primary technique, as alluded to above, is the application of Socratic dialogue. "What is the evidence for your belief?" as in all Socratic dialogue, is
a basic question, but it does not go quite far enough (the delusional paranoid always has a plethora of such evidence on hand). An important extension is "What would count as evidence that your belief is incorrect?" Of
course, a strong relationship must exist before such a question can even be
raised. However, introducing the possibility of disconfirmation removes
the delusion from the realm of tautology and places it within the empirical
world. In addition to empirical disconfirmation strategies through Socratic
dialogue, thought records can be introduced to work on the motivational
schemas that support the beliefs. For example, the person with paranoid
PD likely holds the belief, "By scanning the environment, I help myself to
feel safe." Using thought records, one may determine that the more such
individuals scan the environment, and the more they ruminate about safety,
the less safe they feel. When the empirical and emotional pillars supporting the delusion are sufficiently weakened, the delusion itself often
collapses.
We lack empirical data to know for sure, but theory would indicate that
the client's depression is tied to the exhausting excessive vigilance and grinding social isolation. Finding some safety within the therapeutic relationship,
and ultimately beyond, is likely to provide feelings of relief as well as an
antidepressant effect. Relief from depression would then enhance social functioning, promoting a positive spiral of affective and personality functioning.
50
51
I'm really angry with you because I've been sitting in the waiting room for half an hour. You told me to be here at 9:30 today.
No, that's not true. I said 10 A. M.
You said 9:30.
Therapist:
Patient:
You're trying to trick me! You won't admit that you're wrong,
so you try to make me think that I'm the one who's wrong.
Therapist:
Patient:
I'm not going to take this harassment. I'll find another therapist! (pp. 424-425)
I'm really angry with you because I've been sitting in the waiting room for half an hour. You told me to be here at 9:30 today.
Therapist:
Patient:
Therapist:
Patient:
52
Therapist:
Frankly, I don't remember saying that, but I'd like to hear more
about: your recall of that conversation so I can find out what I
said to give you that impression, (p. 426)
COUNTERTRANSFERENCE
Theory and clinical observations suggest that countertransference is
often a major obstacle to treatment of people with paranoid PD. Gabbard
(1994) noted that "exasperation and impatience" (p. 426) often result from
the relentless scrutiny by such clients. Therapists are also often tempted to
burst the clients' bubble of grandiosity. Of course, to do so would typically
rupture the therapeutic alliance as well. As indicated previously, projective
identification requires special handling to avoid premature termination. The
person with depression and paranoid PD presents the additional problem of
feelings of hopelessness that can be induced in the clinician. If the therapist
begins to feel hopeless, he or she must find rays of light in the darkness of the
client's predicament; if this is not possible, then supervision or peer consultation is imperative. Throughout treatment, the wisest course of action is
continued empathy and validation. Gabbard's (1994) illustration of how to
handle projective identification, reviewed in the earlier section on psychodynamic therapy, provides an excellent illustration of how to remain empathic under trying circumstances.
What little empirical research is available is consistent with clinical
wisdom in the field. Graduate students who viewed a film of a therapy session with an individual simulating paranoid PD (without depression) indicated that they felt frustrated, guarded, perplexed, and fearful. The client's
lack of trust, distant and suspicious demeanor, and failure to comply with an
apparently reasonable request pulled forth the frustrated and confused feelings, while the client's thinly veiled hostility elicited fear and defensiveness
(Bockian, 2002a).
PARANOID PERSONALITY DISORDER
53
the United States are more sociocentric than the extremely autonomyfocused mainstream culture. However, minority experiences with racism are
likely to engender a certain degree of healthy mistrust of the establishment.
The potential impact of culture should not be underestimated. Castillo
(1997) discussed Swat Pukhtun culturea society in which the average male
carries a gun, people are genuinely dangerous to one another, and women are
kept at home as much as possible to prevent infidelity. Many people in Swat
Pukhtun culture would meet the criteria for paranoid PD if judged by U.S.
norms, but in fact their response to their situation is adaptive.
55
EXHIBIT 3.1
Therapeutic Strategies and Tactics for the Prototypal Paranoid Personality
STRATEGIC GOALS
Balance Polarities
Reduce polarity
Increase polarity
Counter Perpetuations
Stop provocations of rejection
Modify rigid minidelusions
Undo self-protective withdrawals
TACTICAL MODALITIES
Alter inviolable self-image
Moderate irascible mood
Reorient cognitive suspiciousness
Note. From Personality-Guided Therapy (p. 693), by T. Millon, 1999, New York: John Wiley & Sons.
Copyright 1999 by John Wiley & Sons. Reprinted with permission of John Wiley & Sons, Inc.
licious intents. Behavioral techniques such as skills training can help the
client to feel a greater sense of self-efficacy and thus a reduced need for
hypervigilance and defensiveness. Interpersonal conceptualizations have
obvious relevance, in that the client's main issue is often mistrust of others;
helping the client to become aware of the patterns that maintain his or her
negative mood and isolating behaviors can be very helpful (see Exhibit 3.1).
Such interventions must be carefully timed; introduced too early, they will
provoke defensiveness. I find that the ideal timing for helping clients to break
out of such patterns is when they express frustration and ask, directly or indirectly, how they can get better. Clients who are depressed are more likely to
be able to seek help in such a manner than the nondepressed person with
paranoid PD. Medications can be helpful if the client becomes anxious or
excessively hostile. If the client's family either participates in maintaining
the behavior or bears the brunt of the client's hostilities, family therapy can
help to correct those imbalances.
father, except that he had been in and out of prison and had not been involved with the family for many years.
Jean was extremely suspicious and mistrustful, far beyond what could
be expected on the basis of normative deaf development or deaf culture. Her
paranoia seemed to have been profoundly shaped by isolated traumatic events
as well as ongoing social reinforcement. Her first memory was of being about
3 years old and being torn away from her family by the government under the
auspices of the child protection division. Jean's fears were then fueled by her
older sister's suspicions that the authorities were going to take away everyone
in the family, put Mom in jail, lock up all the children, and so forth. With
little guidance available from trustworthy adults, Jean was interpreting the
world through her 3-year-old eyes and those of her frightened 4-year-old sister. The children were placed in the custody of her grandmother, who was
told to not allow contact with the children's mother. However, because the
mother lived close by, the children were able to sneak over for visits. This
experience encouraged the belief that deceit is an ordinary part of human
interactions.
For Jean, raised in a home in which the mother was affectionate but
routinely neglectful and poorly equipped for parenting, the seeds of paranoia
fell on fertile soil. They were watered and nourished by social and interpersonal difficulties at school. Although she attended a school with deaf peers,
Jean still did not fit in. Fearful when not in control, she attempted to dominate her social interactions. Although sometimes there is a submissive child
around who can form a stable relationship with such a person, this did not
happen for Jean; her thinly veiled hostility made it all the less likely that any
of her relationships would succeed. Other children would occasionally tease
her for being "bossy," not a particularly cruel barb in the world of grade school,
but experienced as an infuriating and wounding slur by hypersensitive Jean.
All of her relationships in school ultimately failed, leaving her isolated and
lonely.
On the basis of the nonverbal behavior she observed in the first session,
Dr. Vinehout interpreted Jean's stealing, symbolically, as an attempt to secure desperately desired love and affection. Dr. Vinehout turned her attention to Jean's interpersonal relationships. Jean had unusually diffuse boundaries for a girl her age. Hearing children often learn about relationships in a
variety of indirect waysoverhearing conversations among older children
on the bus ride home, overhearing conversations among adults, and so on. In
normative deaf development, children are unable to learn about such matters indirectly and thus rely on direct instruction. Jean's mother and siblings
did not provide good role models, and nobody taught her about relationships. Jean tended to be intrusive in gathering information from others and
guarded about sharing. Thus she helped to protect herself by minimizing her
need to trust others and by gaining information that would help make others
more predictable; however, few peers would tolerate that kind of inequity.
PARANOID PERSONALITY DISORDER
57
Further, she confused sexuality, affection, and affiliation. Jean was not yet
sexually active, but Dr. Vinehout was concerned that her neediness and confusion left her vulnerable to sexual exploitation, which would have cemented
her already rigid and paranoid world view. The first goal in treatment was to
help Jean to understand appropriate boundaries in relationships. Dr. Vinehout
used kinesthetic modeling, with a great deal of modeling and role-play, to
help Jean develop more appropriate behaviors.
After approximately three sessions, Jean's transference emerged in a
rather direct way. The conversation went something like this (translated
from the original sign language):
jean:
Dr. Vinehout: Oh, you wish you had a mom to take care of you.
jean:
Dr. Vinehout: I can't be your mom, because then I couldn't be your therapist.
For the same reason, I can't be your friend. Here's how it's different.
You said you'd make an appointment for me, and then you didn't!
Jean:
No.
No. All that means is that someone stole my Palm Pilot and
changed the note.
Dr. Vinehout: But you made the password yourself. Even if someone took your
Palm Pilot, they would not know the password.
Jean:
Then 1 must have dreamt the password, and someone must have
stolen it from my mind.
Dr. Vinehout: No. That is not what happened. That is what we call paranoid
thinking. Nobody can go into your mind and steal your dreams.
59
table, Jean refused to read the notes. Two weeks later, Dr. Vinehout received
a phone call from Jean, stating she had kept the notes and was sorry that she
had refused to talk to Dr. Vinehout.
In conceptualizing this case from the standpoint of personality-guided
therapy, it was clear that addressing the client's paranoid PD was an essential
and guiding principle of the treatment. Technically, the core of the treatment was based on client-centered principles of consistent validation of the
client's experience. With some clientsfor example, those without personality disordersit is possible to maintain such a stance early in treatment
and then enter into a problem-solving cognitive-behavioral format; such
was not the case with Jean, nor is it likely to be the case with most individuals with paranoid PD. However, building on this affirmative and validating
stance, cognitive and psychoeducational techniques helped Jean to reduce
some of her cognitive distortions. Early in treatment, Jean's transference was
enacted and became an opportunity to build clarity and trust. Role-playing,
which can be considered either a behavioral or an experiential technique,
was relied on heavily to prepare Jean for the world of dating and other interpersonal relationships. The focus of much of the treatment was helping Jean
establish interpersonal relationships. In conceptualizing the case, Dr. Vinehout
drew on the work of Sullivan (interpersonal), Winnicott (object relations;
holding environment), attachment theory, and Herman (trauma theory).
Dr. Vinehout described therapy as "dancing with the affect" of the client,
drawing on the client's subtle nonverbal material as the drumbeat to the
music; in that regard, her work reminds me of Virginia Satir's. Synergistically, validation formed the basis of a relationship with the therapist, which
then in turn became a platform from which to address other relationship
issues, catalyzing the upward spiral of one good turn leading to another. However, the case also illustrates the resilience of the paranoid pattern once set
into motion. Despite 3 years of intensive treatment as a relatively young
woman, the client still had a good deal of paranoid psychopathology that was
interfering with her functioning. She was, nonetheless, much less depressed
and generally was feeling and functioning much better.
61
lenging distorted thoughts) and psychodynamic techniques (e.g., confronting the client's desire for the therapist to be her mother) led to gradual improvements in the client's functioning.
Despite the "best practice" ideas and interventions reviewed above, many
people with paranoid PD and depression will not be treated successfully. Many
will not present for treatment, and others will not form a treatment alliance.
Prognosis in such cases is guarded (pun intended). For purposes of personality-guided therapy for depression, empirical research explicitly targeting ways
to establish rapport should be a priority, as well as establishing whether depression generally makes the treatment easier (e.g., because of enhanced
motivation to relieve the depressive symptoms) or more difficult (e.g., with
depression making it more difficult for the person to get mobilized).
62
4
DEPRESSION IN SCHIZOID
PERSONALITY DISORDER
A good illustration of a schizoid style of relating is shown in the portrayal of John Nash in the film A Beautiful Mind (Howard & Goldsman,
2001). Nash is a math professor, brilliant with numerical and visuospatial
patterns, who seems to lack almost completely the capacity to relate to people
in any way. He cannot empathize with his students when they have difficulty
learning the material, nor can he discern what presentation style might help
students to learn more easily or enjoy the material more. He seems to lack
the desire to connect or explain. For example, in one scene, a student approaches Nash in his office with a question. He essentially dismisses her and
returns to his work. After a few moments of workinga sufficient length of
time to be uncomfortablehe looks up and simply observes, "You're still
here." His awkward, self-absorbed style is striking, though it does not seem to
bother him. Where a more narcissistic professor might disdain students for
their "stupidity," the schizoid individual bears no such malice. To him, the
needs of the students are merely an enigmaan enigma he may or may not
be motivated to solve. Perhaps some of us have had teachers or professors
who were similarwriting on the board, with their back to the class, absorbed in the material, and essentially oblivious to the people around them.
63
Notably, even this prototype portrays the more sociable end of the spectrum.
The choice to become a professor entails willingness to interact with others;
more severely schizoid individuals, if employed, are often late-night security
guards or night-shift doormen, back-room mail sorters, and employees at other
jobs that entail almost no human interaction.
The prototypical person with schizoid personality disorder (PD) has
little desire for interpersonal contact, even with family members. Such an
individual also has an impoverished cognitive style; that is, his or her understanding, especially of people, lacks richness and vitality. He or she is unable
to process the numerous factors that impact people and views his or her own
life in similarly simplistic terms. Impoverished cognitive style does not correlate with intelligence; a person with schizoid PD, can, like Nash, have
superior abstract reasoning, visuospatial, and verbal abilities. Nonetheless,
his or her inner emotional and relational world is simplistic and poorly
developed.
As noted above, people with schizoid PD are noted for their blandness,
flatness, and the lack of desire to connect with others. According to the
Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision
[DSM-IV-TR]; American Psychiatric Association, ZOOOa), "The essential
feature of Schizoid Personality Disorder is a pervasive pattern of detachment
from social relationships and a restricted range of expression of emotions in
interpersonal settings" (p. 694).
Considered part of the "schizophrenic spectrum" (Siever, 1992), schizoid PD overlaps with the "negative" symptoms of schizophrenia: flat affect,
lack of motivation, and social withdrawal. Like individuals with schizophrenia, individuals with schizoid PD may underachieve in social, occupational,
or academic arenas.
EPIDEMIOLOGY
Schizoid PD is a relatively rare disorder. Community studies indicate a
low prevalence of schizoid PD. A review of nine epidemiological studies indicates a median prevalence estimate of 0.6% for schizoid PD (Mattia &
Zimmerman, 2001). However, the disorder is approximately 9 times as common in treatment settings. A review of eight studies suggests a prevalence
rate of approximately 5% in treatment settings, with the prevalence apparently a bit higher in inpatient than outpatient settings (Widiger & Rogers,
1989). DSM-IV-TR described schizoid PD as "uncommon" in treatment settings. This low prevalence has led to a relative paucity of research. As noted
by Beck and Freeman (1990), "While there have been extensive theoretical
musings about the nature of the schizoid individual, little clinical research
has been done on this group. . . . This is not surprising, given the reluctance
of schizoid individuals to seek treatment" (p. 122). Unfortunately, little has
changed in the intervening 15 years. Thus, the base of clinical lore and inter64
vention research is not very deep, and some areas require speculation to elucidate promising, if untested, treatment avenues.
In samples of individuals with depression, approximately 0% to 3% have
schizoid PD. Of the 116 individuals with major depression in a study by
Zimmerman and Coryell (1989), none had schizoid PD, though it is worth
noting that there were few individuals with schizoid PD in the entire sample
(n = 7). In Pepper et al.'s (1995) dysthymic disorder sample, 2% had schizoid
PD. In Fava et al.'s (1995) sample of depressed clients, approximately 3%
had schizoid PD. In a sample of 249 depressed outpatients, none were diagnosed with "definite," and 2% with "probable," schizoid PD (Shea, Glass,
Pilkonis, Watkins, & Docherty, 1987). Markowitz, Moran, Kocsis, and Frances
(1992) studied a sample of 34 outpatients with dysthymic disorder; none had
schizoid PD. Finally, in a sample of 352 clients with both anxiety and depression, approximately 3% had schizoid PD, as diagnosed by structured interview (Flick, Roy-Byrne, Cowley, Shores, & Dunner, 1993).
Minimal data are available on the prevalence of depression in individuals with schizoid PD. Zimmerman and Coryell's (1989) study, mentioned
above, included a community sample totaling 797 individuals, of whom 143
were diagnosed with PDs. Among the 7 diagnosed with schizoid PD, none
met the criteria for major depression.
65
psychopathology. For example, their proclivity to withdraw and remain detached reduces opportunities to learn new interpersonal strategies, thus decreasing the odds that the next relationship will be meaningful and fulfilling.
In addition to simple lack of contact, their cognitive impoverishment regarding emotions leads to misinterpretation and oversimplification of others' emotional lives and further reduces the odds that they will have rewarding interpersonal interactions (Millon, 1996). Over time, these strategies
and proclivities may lead to a deepening of the schizoid pattern, in some
cases to levels that are intolerable even to the person with the disorder. Consistent with the "exacerbation" model (see chap. 2) the patterns associated
with schizoid PD and depression "feed" one another, increasing the intensity
of both.
Schizoid PD and depression overlap in some of their symptoms. The
flat, bland presentation of the person with schizoid PD parallels anhedonia
in major depression. Lethargic and insipid, such individuals already near the
level of psychomotor retardation and fatigue evidenced in depression. Thus
there are three symptoms (anhedonia, psychomotor retardation, and fatigue)
that are shared to some degree by the two disorders. Dysthymic disorder (which
has similar symptoms to major depression but at a lower level of severity and
higher level of chronicity) resembles schizoid PD even more closely. It could
be that some features of depression and schizoid PD share a common cause,
such as brain functioning associated with lethargy and anhedonia.
However, in general, people with schizoid PD are not particularly prone
to either anxiety or depression. Aloof, but unconcerned about it, the typical
person with schizoid PD does not seek therapy. Thus, our focus on the depressed person with schizoid PD represents a unique, and more treatable,
subset.
66
What appears most distinctive about these individuals is that they seem
to lack the equipment for experiencing the finer shades and subtleties of
emotional life . .. Some interpret their interpersonal passivity as a sign of
hostility and rejection; it does not represent, however, an active disinterest but rather a fundamental incapacity to sense the moods that are
experienced by others, (p. 218)
This process may be further compounded if, assuming the schizoid tendency was inherited from one or both parents, the spontaneous and persistent expression of warmth from the parents may have been lacking in any
case. Research suggests individuals with schizoid PD are more likely than
comparison groups to have a history of neglect (Lieberz, 1989).
Genetic Factors
67
Onstad, and Skre (1993) found a heritability for schizoid PD of .29. Genetic factors accounted for approximately 50% of the variance in dimensional measures such as social avoidance (Livesley, Jang, Jackson, & Vernon,
1993), restricted expression, and inhibition and for 38% of the variance in
affect constriction (for a review, see Jang & Vernon, 2001). Similarly,
Eysenck's extraversion construct (of which schizoid PD would represent
the extreme low end) is moderately heritable (Nigg & Goldsmith, 1994).
Genetic studies have generally supported the notion that schizoid PD is
part of the "schizophrenia spectrum" (Siever, 1992). However, although
studies of schizotypal PD have consistently linked the disorder to schizophrenia, studies examining the genetic connection between schizoid PD
and schizophrenia have been somewhat inconsistent (for a review, see Nigg
& Goldsmith, 1994). It is likely that schizoid PD is related to schizophrenia but not as strongly as schizotypal PD; this conceptualization is consistent with Meehl's (1990) contention that cognitive slippage is the central
component of schizotypy.
Medications
Despite a significant effort, I could locate no specific studies on medications for schizoid PD. A study by Ekselius and von Knorring (1998; see chap.
1 for a review) found that the antidepressants sertraline and citalopram, both
selective serotonin reuptake inhibitors, led to an increase in the diagnosis of
schizoid PD, although there was no increase in the number of criteria met on
a structured interview. I cannot explain this odd finding. The number of
schizoid patients was so small (1 pre- and 6 postintervention) that one should
be cautious in interpreting the results.
There are some underlying dimensions or symptoms that may be amenable to psychopharmacological interventions. In the absence of further data,
it is worth considering Joseph's (1997) speculations based on his clinical experience. He argued that schizoid PD is reminiscent of the negative symptoms of schizophrenia. Newer, atypical antipsychotics have the best efficacy
with deficit syndromes; thus clozapine, olanzapine, sertindole, and risperidone
would be the most likely to benefit people with schizoid PD. These medications may help the patient to become more sociable and emotional. Joseph
conceptualized the anhedonic and low-libido features of schizoid PD as having biological underpinnings similar to those of the same symptoms in a person with depression; he recommended an energizing medication such as
bupropion. As in cases of Axis I social anxiety, individuals with schizoid PD
who experience anxiety in social situations may benefit from selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, or anxiolytics.
Although Joseph's speculations were reasonable, they are not currently backed
by scientific research. There is no substitute for appropriate empirical studies, ultimately leading to randomized clinical trials.
68
Psychological Factors
When considering the person's psychological functioning, important
areas to consider include his or her learning history; thoughts, feelings, unconscious motivations; and relationships. The schools of thought described
below (e.g., cognitive-behavioral, humanistic, psychodynamic, interpersonal,
and family systems) emphasize different aspects of the person's functioning
and will be described in turn.
Millon's Theory
According to Millon (1969/1985, 1981, 1996, 1999), individuals with
schizoid PD represent the "passive-detached" type. They are thought to have
a generally bland, passive nature, perhaps because of impoverished neurological substrates associated with emotion. These neural deficits in adulthood may have been caused by genetics or shaped by experience. The early
experiences of people with schizoid PD are likely to be characterized as dull
and colorless, although extreme withdrawal by caretakers could account for
development of schizoid PD in a person who lacks a strong predisposition to
the disorder. Severe difficulties in relating, such as reactive attachment disorder, that are frequently seen in children raised in neglectful or abusive
orphanages exemplify the potentially profound impact of extreme environmental conditions (Hall & Geher, 2003; Wilson, 2001). At a less intense
level, a temperamentally placid child, exposed to minimal "stimulus nutriment" (i.e., environmental stimulation; Millon, 1981), is at risk for developing schizoid PD.
Excessively formal relationships with one's parents can have a similar
effect. Deutsch (1942), describing the "as if" personality, gave the example
of a child born to royalty. Raised by a variety of nannies, he had only brief
and occasional contact with his parents. At that time, he was required to
profess his love for them, whereupon he was dismissed. It is not surprising
that this child manifested disturbed interpersonal relationships (Deutsch,
1942, cited in Millon, 1981, p. 294).
The description of the person with schizoid PD in terms of Millon's
domains is presented in Appendix B. Of the characteristics listed, "unengaged
interpersonal conduct" and "apathetic mood/temperament" are the most salient features.
Cognitive-Behavioral Conceptualization and Interventions
Cognitive-behavioral therapists emphasize dysfunctional thought and
behavior patterns that underlie disorders. Dysfunctional attitudes that are
common to people who are categorized as having schizoid PD are listed in
Exhibit 4.1. Such thoughts contribute to the individual continuing to live in
a withdrawn, isolated manner. The clinician can explore for these and simi-
EXHIBIT 4.1
lar thoughts and attitudes and then challenge them using Socratic dialogue
(J. S. Beck, 1995) or disputation (Dryden & DiGiuseppe, 1990; Ellis, 1995).
Dysfunctional thought records have been found to be helpful for people
with schizoid PD (A. T. Beck & Freeman, 1990; A. T. Beck, Freeman, &
Davis, 2004) and in depression (J. S. Beck, 1995). Not only do dysfunctional
thought records challenge dysfunctional thoughts, but they also teach gradations in thinking, helping clients to overcome all-or-none thinking. Individuals with schizoid PD may believe they must always be alone, or that they
never care about what happens. Dysfunctional thought records help to challenge those beliefs, often leading to awareness that such individuals do sometimes prefer to be with others or that they do sometimes care.
Individuals with schizoid PD, almost by definition, lack social skills.
Assuming they are depressed because they are too isolated, even given their
rather minimal needs, then skill building may be extremely helpful. Liberman,
DeRisi, and Mueser (1989) provided excellent guidelines, designed primarily
for individuals with serious and persistent mental illness (e.g., schizophrenia
and mental retardation) but adaptable to the person with schizoid PD. Excellent guidelines for couples are available in A Couple's Guide to Communication by Gottman, Notarius, Gonso, and Markman (1976); because the book
is written in lay language, it can be assigned to the couple as bibliotherapy.
Social skills can be taught using role-playing, in vivo exposure, and homework. Group social skills training has the obvious advantage of allowing practice with other clients rather than only the therapist.
The client can also be assisted to attend to positive emotions. Individuals with either depression or schizoid PD will have a tendency to attend to
negative thought patterns; an individual with both disorders will experience
this even more. Homework assignments such as journaling at least one positive thought per week (at first) then per day (later on) will help the person to
challenge automatic thoughts such as "life is bland and unfulfilling."
70
Of course, the psychiatrist was merely being ethical by informing the patient
of potential side effects; nonetheless, Styron experienced the intervention as
unempathic because, apparently, the physician had not sufficiently
contextualized the discussion in light of the patient's ongoing experience.
Keeping that cautionary tale in mind, sex therapy can be extremely useful in
71
many cases in which the mildly to moderately depressed person with schizoid
PD is in a relationship. Although not as interested in sex as others, individuals with schizoid PD often "don't mind" having sex, and those whose schizoid
symptoms are sufficiently mild for them to be in a relationship are typically
also sufficiently interested in the other person to go to at least some lengths
to try to please him or her. Sex therapy can help enhance pleasure as well as
sensitivity to the other person's needstwo areas in which the person with
schizoid PD is likely to have problems. Several fine books are available for
adjunctive bibliotherapy with sex therapy (e.g., Sexual Awareness [McCarthy
& McCarthy, 1984] or The Gift of Sex [Penner & Penner, 1981]).
Client-Centered, Humanistic, and Existential Therapies
Client-centered, humanistic, and existential therapists eschew a diagnostic or labeling'based approach, and thus there is little, if any, clientcentered or humanistic literature specific to schizoid PD. Rather, in these
approaches, the therapist would look at the ideographic aspects of the case.
Nonetheless, a prototypical person with schizoid PD, coming from a background of relative neglect and often with stunted or excessively formal relationships with important others such as parents, represents almost a sine qua
non of the thwarted actualizing tendency (Rogers, 1979). The clientcentered therapist would focus on creating the conditions for growth, a
nonjudgmental space in which the client could explore his or her feelings,
and on reengaging the actualizing tendency. If the client wished to, past
relationships could be explored, which would then yield information about
the conditions of worth to which the child was exposed.
Client-centered therapy is somewhat passive by nature; the initiative
must come from the client. Some individuals with severe schizoid PD have
such problems with initiative that a modification of the therapy developed
by Prouty (1994) would be helpful. Prouty labeled his approach "pretherapy"
to indicate a process that would prepare a client for traditional therapy. However, his case studies suggest that the process has therapeutic effects (sometimes dramatic ones) in its own right. It was developed for individuals with
severe communication problems, such as autism or severe mental retardation, and psychoses. Pretherapy uses concrete empathy, in which the therapist
mirrors exact words and bodily movements to establish contact. The therapist can also simply make observations, which may help the depressed and
severely schizoid client. For example, the therapist might observe, "You are
sitting with your hands in your lap," or "You are remaining quiet," or "You
are looking into my eyes." Such interventions can establish contact with a
client with whom it is difficult to connect.
Other, more dramatic techniques may be useful for the person with
depression and schizoid PD. Gestalt therapyfor example, the empty chair
techniquecan be used to uncover any feelings regarding difficult relationships or feelings of neglect from childhood. Care should be taken not to over72
whelm the client; unaccustomed to emotional arousal, the person could experience substantial anxiety. A solid therapeutic relationship should be established before using experiential techniques, which would thereby allow
the therapist to provide support if the emotions do become overwhelming.
Self-awareness techniques may be a direct and substantial form of healing for the emotional deficits of the person with schizoid PD. Mindfulness
meditation (Kabat-Zinn, 1990) has been shown to be a powerful intervention to decrease depression (Kabat-Zinn et al., 1992), and participants have
reported substantial improvements in their bodily and emotional selfawareness (e.g., Broadwell, 1998; Kabat-Zinn, 1990). Focusing (Gendlin,
1978) similarly induces increased body awareness, as well as self-awareness
with regard to thoughts and feelings. For the depressed person with schizoid
PD, these improvements can be invaluable.
For clients who lack a sense of purpose, existential therapy (May, 1983b)
or logotherapy (Frankl, 1983) can help in exploring the meaning of life. Based
more on an attitude or philosophy than on a set of techniques, existential
approaches consider the fundamental anxiety that one confronts to be existential anxietythe awareness that our existence is finite and that there is
always a threat of nonbeing or nonexistence. Frankl (1983) suggested that
the client who presents with a sense of or fear of life being meaningless should
be commended on having the insight and courage to confront that issue and
told that many go through life "going through the motions," without ever
contemplating life's meaning. The question, "What is the meaning of life?"
is unanswerable; Frankl (1959) observed that it is like trying to answer the
question, "What is the best color?" The answer, of course, is that it depends
on the context and the person; each person must find his or her own meaning in existence.
Other questions that help get at meaning in the client's life include
Linehan's intervention, designed for suicidal borderline clients but broadly
applicable in its underlying message. In the video Treating Borderline Personality Disorder (Linehan, 1995), a client stated that she was suicidal. Linehan
replied, irreverently, "So, why don't you kill yourself right now?" For the
existentialist, that is, in fact, the exact question. If life has no meaning, then
why live? With the possible exception of, "Because I'm afraid it will hurt,"
virtually any answer addresses the meaning the client finds in life. If the
client replies that it would be too painful for a relative or friend to bear, then
she is living for love. If the client replies that she believes that therapy is
worth a try and things may get better (as the client actually does in the video)
then she is living for hope. And if she replies that she wants to live because
there is one more thing she has to do, then she is living for commitment.
Ultimately, commitment to something that one believes is more important
higher, if you willthan oneself is where many people find meaning.
Bibliotherapy can stimulate clients in the search for meaning. Books
such as Don't Sweat the Small Stuff (Carlson, 1997), The Mirack of MindfulSCHIZOID PERSONALITY DISORDER
73
ness (Nhat Hanh, 1976), and Wherever You Go, There You Are (Kabat-Zinn,
1994) all are useful jumping-off points to encourage clients to look at life a
bit differently. Simply assigning a client to read at least a few pages and then
asking if there was anything that he or she found meaningful can lead toward
the client's central concerns and hopes.
Psychodynamic Therapy
Therapist:
75
Patient:
Not so much. What really counts is how many times you tell me
why you think I'm doing what I'm doing. Then I know you're
really listening to me and concerned about me.
Therapist:
So it's very important that I care about you, and you've devised
a scheme to answer that question for yourself. Can you see you're
also treating what I'm saying as if it were worthless? (O. F.
Kernberg et al, 1989, p. 115)
This fragment is an illustration of several key aspects of Kernberg's approach. Kernberg used both clarification and confrontation regarding the
relationship between the therapist and the client (i.e., the transference) to
push the client to integrate the split self and object relations implied in the
interaction.
Persons who have both depression and schizoid PD would presumably
be those who have experienced and processed the object loss, at least partially, rather than splitting any negative emotions off completely. Depression generally entails the necessity of whole object relations. To the extent
that they use neurotic defenses rather than splitting, they are more in touch
with reality. Thus, although they experience more psychic pain, depressed
persons with schizoid PD are likely functioning at a somewhat higher level.
This conceptualization is consistent with clinical experienceindividuals
with schizoid PD and depression are more likely to profit from therapy than
"pure," emotionally absent, prototypically schizoid individuals.
In sum, the psychodynamic approach emphasizes that the superficial
symptoms of schizoid PD are not to be trustedthat in fact the person's
blandness is a defense against deeper anxieties. These anxieties are rooted in
early trauma, particularly in relation to the mother, who is seen as withdrawing and abandoning. If one can, through appropriate analysis, resolve the
inner conflicts and underlying anxieties, then the person will experience
tremendous relief. The recommended treatment involves traditional psychodynamic techniques, such as technical neutrality, confrontation, and analysis of the transference. Depression, from a psychodynamic perspective, is likely
to be rooted in object loss; in the case of the person with schizoid PD, a
common scenario would be the withdrawal of the mother, whether because
of her own problems with intimacy, physical illness, or mental disorder. Once
the depression and the schizoid withdrawal are properly analyzed, the client
will then become more mature, flexible, and related.
It is apparent, however, that theorists from a psychodynamic perspective are talking about a somewhat different patient population. Akhtar (1987),
in his review, noted the similarity of the psychodynamic interpretation of
the schizoid personality and avoidant personality disorder. It could be that
case studies of "schizoid" individuals reflect aspects not only of schizoid but
also of avoidant and paranoid disorders. From Millon's perspective, it is certainly the case that the analysts are using the term schizoid in a different
76
manner than he is. Millon (1996) noted that essentially, there is not much
to analyze within the prototypical schizoid PD and focused on other techniques. That observation notwithstanding, it is also true that most people
with PDs are better described as having admixtures of two or more personality disorders: schizoid-dependent, schizoid-avoidant, or schizoid-obsessivecompulsive. Although the person with "pure" schizoid PD may be
unanalyzable, many of the schizoid subtypes would be analyzable. Thus the
clinician must be careful about generalizing across different conceptualizations.
Family Systems
In this section, I conceptualize the situation in which the depressed
person with schizoid PD is an adult and is either coming in for marital therapy
with a spouse or for family therapy with his or her parents. The latter case
occurs with some regularity for clients with other severe mental illnesses
such as schizophrenia. The subsequent section, on children, includes family
interventions in which the schizoid client is a child.
There are several ways of viewing families in relation to schizoid PD:
(a) The family behaviors or dynamics contributed significantly to causing
the disorder, (b) the family is a victim of a primarily biological disorder and is
coping with it as best they can, and (c) biology and family dynamics combined to produce the disorder (an interactionist perspective). Although the
interactionist perspective is compelling, it is useful to note that all three
models are partially correct and that each model will be the best explanation
in a certain percentage of the cases.
It is most likely that the family will view the second modelthat "this
is just the way he is and the way he always has been"as the most accurate
and useful. To the extent that the therapist uses one of the other two models,
there is a risk of incongruence with the family, which could lead to premature termination or other problems. In cases in which there are clear biological signs, such as vegetative signs of depression and a strong history of schizoid behavior from early in life, emphasizing biological aspects of both disorders
is likely to facilitate an appropriate and rapid bonding process with the therapist. In such cases, it is likely that the ultimate adjustment of the family will
involve letting go of fantasies that the person with schizoid PD can beor
already isin the average range of emotional sensitivity. The son who is
disappointed with his depressed and schizoid father will feel better if he can
accept his father's limitations. As mentioned previously, many clients are
aware that biological factors contribute strongly to depression and will thus
be comfortable with such a conceptualization. Few, however, are familiar
with the concept of PDs, much less a biological component for a specific one.
The risk of emphasizing biological considerations is locking the identified
patient into the role of the "pathological one"; this can and should be undone by emphasizing the individual's strengths and relating to the family in a
77
79
The sculpture may also be put in motion, which in many cases adds important information:
Another choice at this point can be to have the sculptor put the whole
sculpting in motion before verbally processing what has been sculpted.
. . . With static sculpting one gets a sense of family boundaries and alliances but not the rules for traffic flow. With dynamic, or moving, sculptures one can see traffic flow and also have the chance to see action
sequences repeated in time, producing a more dynamic representation of
family stuckness and rigidity and family rules. (L'Abate et al., 1986,
p. 180)
COUNTERTRANSFERENCE
The literature on countertransference responses to individuals with schizoid PD is extremely limited. Giovacchini (1979) noted feelings of "existential terror," or a primitive fear of nonexistence that often led to feelings of
hopelessness, with his schizoid patients (similar to modern schizoid and
schizotypal PDs). Robbins (1998), referring to the "autistic position," discussed countertransference responses such as a feeling of vagueness and disconnection in response to the client's devastating isolation. Sadness, perhaps related to pity, also becomes prominent. Rosowsky and Dougherty (1998)
noted how substantial feelings of disconnection, worry, and inadequacy occurred among individuals treating a man with schizoid and schizotypal traits
who frequently fled his inpatient medical hospitalizations.
A. T. Beck et al. (2004) noted that therapists may have a difficult time
when clients have substantially different values from theirs. For example, the
person with schizoid PD may have little interest in relationships; those of us
who have chosen clinical psychology as a profession are likely to put relationships at a premium. A. T. Beck et al. recommended that therapists challenge their belief that their own way of looking at the world is the only valid
one and to try to imagine the world from the client's perspective.
80
In accordance with the observations above, research on graduate students suggests that they initially respond to individuals with schizoid PD
with feelings of compassion and sympathy, but also pity and disconnection.
Many respond with feelings of sadness or downheartedness, even when the
client does not appear to be particularly depressed (Bockian, 2002a); perhaps
this is related to the conflict in values discussed by A. T. Beck et al. (2004),
which was reviewed above. Considerable anxiety is generated in some students, apparently because of concerns that they will not know what to say to
the person and therapy will grind to a halt. Experienced therapists probably
feel the same way at times, although 1 suspect many of us feel what the average person feels in response to people with schizoid PD: boredom (Millon,
1996). The dullness, the impoverished descriptions of others, and the satisfaction with a bland, colorless existence can lead to a subdued therapeutic
environment, one that is nonetheless appropriate and received positively by
the individual with the disorder.
I also recall my work with people with brain injury. Often, other people
would get angry with the person who was brain injured for being "lazy." It was
clearly the case that some people with brain injury would become apathetic
and unmotivated. It struck me that concepts with a strong moral valence, or
ones that we might attribute to a person's self or even his or her soul, are
mediated by the brain. A person who becomes apathetic after brain injury
may not merely be "not trying"; it could be that the physiological apparatus
that underlies motivation has been damaged. Certainly, this poses a challengeperhaps an insurmountable oneto the physical or occupational
therapist who is trying to help the person return to functioning. However,
recognition of damage to the motivational system conceptually changes the
therapy: Therapy consists of undertaking exercises that will help to repair
the motivational system itself. In the United States, people place great value
on "trying." Probably each and every one of the hundreds of millions of students who have passed through the public education system has heard, particularly in the younger grades, "Whether you do well or poorly, it's okay, as
long as you tried your best." The ability to try is itself taken for granted as a
lowest common denominator. If Millon's theory (Millon, 1981, 1996) about
the brain structures and functioning of people with schizoid PD is correct,
then their capacity to try, to be effortful, to engage in motivated behavior is
itself reduced. Recognizing that the person is confronting an unusual biological challenge often helps the clinician to reduce feelings of frustration.
Therapist emotional reactions can also be a wise guide regarding the
therapeutic contract. Although it is often wise to reduce session length and
frequency, if this is an inappropriate avoidance of a person who is truly distressed then such avoidance is a harmful countertransference that demands
supervision or peer consultation. However, in many cases, it is part of an
appropriate plan. Feelings of frustration can often help to guide me in this
regard. The person with schizoid PD may have rather modest goals for imSCHIZOID PERSONALITY DISORDER
81
provement, and change may be very slow. If the therapeutic goal in supportive or behavioral therapy, for example, involves interacting with others, and
it takes the client 10 days or so to hook up with someone else, then a biweekly session will feel more fruitful to both parties than the more typical
weekly sessions. Of course, there are therapies that involve no explicit or
implicit demand to change (e.g., client centered and existential), and in psychodynamic therapy, there is so much material to cover from the past as well
as so much to process in the transference that frequent, full-length sessions
are appropriate.
When working with someone with schizoid PD, collaborative goal setting is extremely important. It is all too easy to project our own needs or
desires onto the person. We therapists were likely drawn to this field because
we value relationships and have high levels of empathy with others. We likely
see warm relationships with others as healthy, and the cooler, more detached
relations of people with schizoid PD as problematic. We may therefore jump
to conclusions about the nature of the problems of individuals with schizoid
PD. We may view their isolation or lack of intimate relationships with others
as devastating or pathological. The clients, however, may see things very
differently. They may have little desire to interact with others, much less
pursue close relationships. Thus we must carefully assess individuals and work
with them to uncover their goals and motivations. Therapist lack of congruence with a client's goals can lead to premature termination and a negative
attitude toward therapy.
83
people in the United States. Thus Scandinavian families may have a greater
tolerance for the reduced emotionality associated with schizoid PD. However,
Scandinavians are as sociable as Americans, and the withdrawal of the individual from family and community life would be seen as problematic. Conversely, families from highly expressive cultures (e.g., Hispanic) may have a
great deal of difficulty with the schizoid individual's lack of warmth and emotionality, and the schizoid behaviors may be particularly troubling to the family.
DSM-IV-TR cautioned that there are several groups that may be erroneously labeled schizoid. Individuals who move from rural to urban areas
may exhibit "emotional freezing" (American Psychiatric Association, ZOOOa,
p. 695) for up to several months. Similarly, immigrants may be misperceived
as cold or indifferent.
EXHIBIT 4.2
Therapeutic Strategies and Tactics for the Prototypal Schizoid Personality
STRATEGIC GOALS
Balance Polarities
Increase pleasure/enhancing polarity
Increase active/modifying polarity
Counter Perpetuations
Overcome impassive behaviors
Increase perceptual awareness
Stimulate social activity
TACTICAL MODALITIES
Energize apathetic mood
Develop interpersonal involvement
Alter impoverished cognitions.
Note. From Personality-Guided Therapy (p. 291), by T. Millon, 1999, New York: John Wiley & Sons.
Copyright 1999 by John Wiley & Sons. Reprinted with permission of John Wiley & Sons, Inc.
85
macological interventions; the typical person with schizoid PD, who is not
very psychologically minded, may be prone to attributing any gains made to
medications and lose motivation to make psychological changes. Behavioral
techniques could then be added, targeting specific social skills to improve
(e.g., assertiveness), or specific antidepressive behaviors (e.g., exercise or reengaging in a favored hobby). Establishing these fundamental skills will generally be very helpful prior to attempting to repair the deeper interpersonal
and structural problems the person encounters.
Cognitive improvements, such as changing self-defeating thoughts, and
adding skills, such as increased assertiveness, are likely to have positive interpersonal consequences. For example, the depressed person with schizoid
PD may have the thought, "I am so worthless that no one would want to be
with me," which may lead to neglecting a relationship ("It's just going to end
anyway")- If these beliefs have been corrected with cognitive therapy, then
the individual is likely to be more receptive to discussing relationship issues.
Interpersonal interventions, then, can build on cognitive improvements,
strengthening the person's relationships. Group and family interventions can
either run concurrently with, or replace, individual treatment. As mentioned
previously, group interventions have the distinct advantage of allowing the
individual to practice social skills with peers. Family interventions can have
positive motivational aspects as well because the therapist can provide support for beleaguered family members while supporting the client, and the
family can help motivate the client to continue to come to treatment. Depth
approaches, such as psychodynamic interventions, would generally be considered last because they tend to produce change more slowly and thus require greater motivation on the part of the client. The current therapist can
implement psychodynamic interventions, though in some cases it would be
wise to refer the client, thus allowing the transference to form anew.
mately 1 year, and she was not psychotic during that time. Candace's schizophrenia was treated with low-dose neuroleptics, and she had chronic anxiety, for which she took buspirone. She had chronic, vague feelings of sadness,
which, when combined with her passivity, would meet the criteria for dysthymic disorder.
Candace also met the criteria for schizoid PD. Although an intelligent
womanshe had received a college education and worked as an editorher
descriptions of her relationships were quite impoverished. She had a 22-yearold daughter who was in college and whom she saw occasionally. When she
would mention her daughter or say that her daughter was coming for a visit,
she evinced neither excitement nor displeasure. This was her closest family
relationship; she rarely mentioned her parents or other family members.
Unlike most depressions, Candace's appeared to lack substantial interpersonal components. She did not describe being depressed because she felt
unloved or unlovable, unwanted, or abandoned. She stated that she felt
empty at times, and she also described feeling different from others. She
had a history of suicidal ideation when she was in the psychiatric hospital
suffering from schizophrenic symptoms. Her frightening delusions and hallucinations led her to feel hopeless that she would ever get out of the hospital
or recover. Once she stopped having hallucinations, she stopped having suicidal ideation.
The presenting problems at the time of referral were relationship difficulties between Candace and her boyfriend, Lorenzo. As is common in internship settings, I "inherited" the case from a prior intern, and Candace and
Lorenzo were already in ongoing couples therapy; I continued, then, to see
them as a couple. However, I was not insistent on seeing both members of
the couple at once (Napier, 1978); if one person was sick and the other still
came, I would see just that person. During those occasional individual sessions, we would refrain from talking about couple issues but rather would
work on individual issues. With Candace, one of our better sessions on her
depression occurred during one such session.
Lorenzo was diagnosed with borderline intellectual functioning. His
personality style was dramatic, and although he did not have a diagnosable
personality disorder, he had features that were primarily histrionic and somewhat dependent. Lorenzo wanted much more from the relationship with
Candacemarriage, as well as increased closeness and intimacy. Candace
was satisfied with how things were and seemed a bit puzzled by Lorenzo's
needs and desires. Thus there was a striking reversal of common American
gender patterns in this case. Candace was the breadwinner, unemotional,
and relatively alexithymic; Lorenzo, on the other hand, was more emotion
focused and demonstrative.
Candace came from a family that was formal in its structure. Dinner
was eaten together at the same time each day, accompanied by polite, quiet
conversation. Children were expected to be "seen and not heard." Achieve SCHIZOJD PERSONALITY DISORDER
87
ment and education were emphasized. She stated that her parents cared most
about her grades and that because she always did well in that area, her parents "didn't hassle her." Her meager social life was accepted as being "her
decision." Lorenzo's Hispanic family was more demonstrative, openly displaying warmth and affection. There was no abuse in either family, although
Lorenzo endured a moderate amount of teasing as a child. The manner in
which Candace and Lorenzo were raised was consistent with their White
Anglo'Saxon Protestant and Hispanic subcultures, respectively (Garcia-Preto,
1996; McGill & Pearce, 1996). However, although Lorenzo's histrionic and
dependent features may have been normative within the context of an expressive, tightly knit Hispanic family, Candace's social withdrawal and aloofness were clearly beyond what would be considered appropriate within her
culture.
Candace's strengths included a general kindnessalthough not particularly empathic, she did try to be helpful to others, and she was never
malicious. She was both consistent and patient with Lorenzo. She was bright,
hardworking, and confident in her abilities as an editor. Though she was not
warm or demonstrative, she took pride in her daughter's accomplishments
and provided for the daughter's material needs. She coped very competently
with her schizophrenia; she had excellent insight and was fully compliant
with her medication regimen. It was interesting that the vast difference between Candace's and Lorenzo's IQs never became an issue. This was most
likely because of Candace's nonstriving and "egoless" nature; she did not
have a need for status that would have required her boyfriend to be highly
accomplished. Candace also tended to express herself in a simple and straightforward fashion, and so Lorenzo had no difficulty understanding her.
Lorenzo also demonstrated a variety of strengths. A warm and caring
individual, he was able to be consistently affectionate with Candace. Without his persistenceor, put differently, if Candace were dating someone with
a personality more similar to her ownthe relationship likely would have
drifted into isolation and separateness. Lorenzo was also able to take advantage of the programs offered through state and community facilities that provided him with work, activities, and independence.
Candace was not completely detached. She preferred to have some
company some of the time. She enjoyed spending time with Lorenzo but
did not want him to move in and did not want to increase the amount of
time they spent together (they would meet several times per week). In addition, therapy provided Candace with some measure of support that she
seemed to appreciate.
Treatment initially consisted primarily of cognitive interventions.
Candace had beliefs such as "I am empty" and "I am odd and different" that
led to feelings of depression. She was encouraged to challenge these beliefs
and came up on her own with the notion that each person is unique, and who
is to say what is acceptable or not? Unconditional positive regard on the part
88
89
ciples indicate that such an approach would have been an appropriate step.
Dynamically oriented therapy may have helped the couple gain further insights and enable them to achieve a better understanding of both the self and
the other person (e.g., Ackerman, 1958). If it were not possible to switch
from the current supportive mode to psychodynamic therapya real possibility, because the transference has already been shaped by supportive interventionsthen an alternative would have been to add a psychodynamically
oriented individual therapist for one or both members of the couple.
I continued to see the couple throughout the remainder of the year,
although the gains described above were mostly accomplished during the
first 8 months. Given the numerous challenges that they facedschizophrenia, depression, and borderline intellectual functioninglong-term supportive
therapy was used for relapse prevention and to prevent hospitalization. After
I terminated with the couple, they were transferred to a new intern.
90
5
DEPRESSION IN SCHIZOTYPAL
PERSONALITY DISORDER
The Diagnostic and Statistical Manual of Mental Disorders (4th ed., text
revision [DSM-IV-TR]; American Psychiatric Association, ZOOOa) described
schizotypal personality disorder (PD) as "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 behavior" (p. 697). Individuals with schizotypal PD are seen
by others as eccentric, odd, or just plain weird. They have strange, loosely
connected thoughts, superstitions, and, frequently, paranoia. They may believe that they have special powers, especially clairvoyance or extrasensory
perception.
91
noted by Millon (1996, 1999)a schizotypal-avoidant type (Millon's timorous schizotypal) and a schizotypal-schizoid type (the insipid schizotypal). The
timorous schizotypal individual longs to be accepted but, fearful of rejection,
actively avoids others. More dysfunctional than most avoidant persons because of the additional challenge of cognitive slippage, persons belonging to
this subtype have likely experienced excessive actual rejection, especially in
the form of teasing as a child. Like other avoidant people, they are highly
prone to depressive and anxiety disorders. The insipid schizotypal person has
a generally more comfortable time of it than the timorous type; for this individual, passive and detached, rejection by others does not wound. As with
other schizoid persons, however, this can lead to a lack of motivation to change
and a continued pattern of poor adjustment and underachievement. Individuals with schizotypal PD as well as depression, then, are more likely to be of the
timorous sortanxious, fearful, wanting connection with others but unable to
attain it, and thus always feeling as if they are "on the outside looking in." Of
course, social withdrawal is also associated with depression alone, so a person
with either subtype of schizotypal PD with comorbid depression is likely to be
quite withdrawn. The depressive thoughts are also often moderated, if you will,
by the person's cognitive dysfunction. For example, in the case example at
the end of the chapter, the client presented with quasi-delusional thoughts
(e.g., Demons are stealing my clothing) rather than a more direct expression
of dysphoric affect (e.g., "I feel helpless and vulnerable").
EPIDEMIOLOGY
The prevalence of schizotypal PD, according to DSM-IV-TR, is 3.0%
in the general population. According to a meta-analysis of nine communitybased studies by Mattia and Zimmerman (2001), the prevalence of schizotypal
PD is 1.8%. At least one study (Maier, Lichtermann, Klingler, Heun, 6k
Hallmayer, 1992) noted that schizotypal PD was diagnosed more frequently
in men, although that hypothesis was not statistically tested. Approximately
one half of individuals with schizotypal PD have a history of major depression (American Psychiatric Association, 2000a; Siever, 1992).
Of the 116 individuals with major depression in a study by Zimmerman
and Coryell (1989), 12.9% had schizotypal PD. In Pepper et al.'s (1995) dysthymic disorder sample, 4% had schizotypal PD. In another sample of depressed clients, approximately 3% had schizotypal PD (Fava et al., 1995). In
a sample of 249 depressed outpatients, fewer than 1% were diagnosed with
"definite," and 1% with "probable," schizotypal PD (Shea, Glass, Pilkonis,
Watkins, & Docherty, 1987). Among individuals with major depression,
65.2% met the criteria for schizotypal PD. In a sample of 352 clients with
both anxiety and depression, approximately 2.3% had schizotypal PD, as diagnosed by structured interview (Flick, Roy-Byrne, Cowley, Shores, & Dunner,
92
1993). The range, then, is virtually none (fewer than 1%) to nearly two
thirds (66.3%) of individuals with depression having schizotypal PD. Likely
reasons for the enormous range include natural sample variation, inpatient
versus outpatient status, different definitions of depression (e.g., dysthymic
disorder vs. major depression), and changing criteriafor example, some
studies used criteria from the third edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-III; American Psychiatric Association,
1980), and some used criteria from the revised third edition (DSM-III-R;
American Psychiatric Association, 1987). Further research clarifying the
overlap of depression and schizotypal PD is warranted. There are fewer data
on the prevalence of depression in a sample of individuals with PDs, although
the findings are more consistent. Zimmerman and Coryell (1989) studied a
community sample of 797 individuals, which included 143 individuals who
were diagnosed with personality disorders. Among those with schizotypal
PD, 65.2% met the criteria for major depression. A study that included 86
clients with schizotypal PD found that 66.3% had major depression
(McGlashin et al., 2000).
WHY DO PEOPLE WITH SCHIZOTYPAL PERSONALITY
DISORDER GET DEPRESSED?
Depression in people with schizotypal PD is likely to be precipitated by
major cognitive problems associated with the personality disorder. The person with schizotypal PD is highly prone to feelings of depersonalization. As
stated by Millon (1981),
The deficient or disharmonious affect of schizotypals deprives them of
the capacity to experience events as something other than flat and lifeless phenomena. They suffer a sense of vapidness in a world of cold and
washed-out objects. Moreover, schizotypals feel themselves to be more
dead than alive, insubstantial, foreign, and disembodied. As existential
phenomenologists might put it, they are threatened by "nonbeing."
(p. 413)
93
the case with the person who has schizotypal PD, who is likely to simply feel
vulnerable, overwhelmed, and frightened.
Although social withdrawal is pervasive among people with schizotypal
PD, an excess of detachment is depressing. Most of us, even the more sociable among us, have experienced a desire for privacy after a period of intensive social interaction or a desire to "get out there" after a period of
reclusiveness; similarly, the person with schizotypal PD has a threshold that
produces discomfort when exceeded. For most people with schizotypal PD,
considerable anxiety accompanies an amount of social interaction that most
people would consider normal or even sparse, whereas depression is likely to
ensue when isolation becomes excessive.
Minnesota Multiphasic Personality Inventory Scale 8, Schizophrenia,
contains a substantial number of items that essentially measure social alienation. As in schizophrenia, social alienation is a major component of
schizotypal PD. People with schizotypal PD were often odd or different from
an early age and experienced substantial peer rejection as children. This feeling of being odd, different, or an outcast is often depressing and can lead to
depression later in life.
Social disengagement itself can predispose one to a generally poor adjustment and put one at risk for a variety of disorders, including depression.
As noted by P. Kernberg, Weiner, and Bardenstein (2000),
Teacher reports from the beginning of the Danish High-Risk Study (Olin
et al., 1997) confirm that children later diagnosed with [schizotypal PD]
were seen as passive and socially unengaged, hypersensitive to criticism,
and nervously reactive to events; they did not show social anxiety until
adulthood. This research suggests that social anxiety develops as a consequence of the passivity and hypersensitivity that reduces children's
socializing opportunities. Their particular traits may also render them
ill-prepared to acquire behaviors for mastering the challenges of adulthood for sexuality, intimacy, job, and autonomy and separation, (p. 231)
Consistent with the "vulnerability" model of the relationship between
Axis I and Axis II, there are several ways in which schizotypal PD appears to
make the person more susceptible to depression when under stress (see chap.
2). In addition, to the extent that depression leads to further withdrawal and
isolation, the two disorders intensify one another, consistent with the "exacerbation" model.
The first of Millon's two subtypes of schizotypal PD, the insipid type, is
mainly a mixture of schizotypal and schizoid features. In such cases, the person has extremely limited emotions and thus would be less prone to depression. The second type, the timorous type, is primarily a mixture of schizotypal
and avoidant features. Such individuals present as touchy, overstimulated,
and hypersensitive. They are prone to anxiety and depressive disorders. For
the person with avoidant features, there is usually a strong desire to be ac94
cepted by others and profound feelings of humiliation and rejection. For the
individual who also has schizotypal features, this feeling of oddness,
differentness, and rejection was typically reified through early experiences of
persistent peer rejection. Often difficulties in clear and rational thinking and
the tendency to slip into quasi-delusional and paranoid states only exacerbate depressive feelings and complicate treatment.
HOW A PERSON BECOMES AND REMAINS SCHIZOTYPAL:
THEORIES OF SCHIZOTYPAL PERSONALITY DISORDER
Biological Factors
Schizotypal PD shares with schizophrenia symptoms of oddness, eccentricity, and cognitive slippage. Meehl (1962, 1990) labeled this underlying
dimension schizotaxia. Meehl's 1962 hypothesis that schizotaxia has a substantial genetic component has been supported by a variety of studies. Studies have also shown that schizotypal PD is biologically related to schizophrenia, thus justifying the conceptualization of schizotypal PD as part of the
"schizophrenia spectrum" disorders (Siever, 1992).
A number of studies have shown that schizotypal PD is at least moderately heritable. Genetic factors accounted for approximately 50% of the variance in dimensional measures such as social avoidance (Livesley, Jang, Jackson, &. Vernon, 1993), restricted expression, and inhibition and for 38% of the
variance in affect constriction (for a review, see Jang & Vernon, 2001). Family
studies have shown an increased rate of schizotypal PD (or its symptoms) in
biological relatives of schizophrenics (vs. adoptive relatives), and, conversely,
the rate of schizophrenia in relatives of individuals with schizotypal PD is higher
than in the general population (for a review, see Tyrka et al., 1995).
According to a review by Siever et al. (1998), studies have shown that
individuals with schizotypal PD have a variety of cognitive dysfunctions that
are similar to those of individuals with schizophrenia but lower in severity.
Executive function, visuospatial working memory, verbal memory, and sustained attention are all impaired. Studies have shown that similar to individuals with schizophrenia, people with schizotypal PD have an excess of
dopamine (Siever et al., 1991). Fukuzako, Kodama, and Fukuzako (2002)
found phospholipid abnormalities in the left temporal lobe. A magnetic resonant imaging (MRI) and positron-emission tomography study demonstrated
that a schizotypal PD group was in between a schizophrenic group and a
normal control group in metabolic rates in the prefrontal area while performing a verbal learning task (Buchsbaum et al., 2002).
Neuroanatomical Features
Like individuals with schizophrenia (though to a lesser degree), individuals with schizotypal PD have increased ventricular volume and asymmeSCHIZOTYPAL PERSONALITY DISORDER
95
try relative to normal controls (Buchsbaum et al., 1997), research participants with other personality disorders (Siever et al., 1995), and research participants with a variety of non-schizophrenia-spectrum disorders (T. D. Cannon et al., 1994). Neuroanatomical differences include substantial (21%)
decreased left Heschl's gyrus volume (Dickey et al., 2002), which is related
to problems with logical memory. Similar to medication-naive schizophrenic
subjects, a sample of individuals with schizotypal PD had reduced caudate
nucleus size relative to matched nonpsychiatrically disordered controls; reduced caudate nucleus size is related to problems in working memory (Levitt
et al., 2002). An MRI study showed that temporal lobe size is smaller in
individuals with schizotypal PD than in normal controls (Downhill et al.,
2001); the authors interpreted their findings to indicate that gray matter loss
in the temporal lobes, with intact white matter connectivity, relates to the
psychopathological symptoms of schizotypal PD. The corpus callosum of
schizotypal PD samples had reduced volume and a different shape from those
of normal controls, suggesting reduced connectivity in the brains of individuals with schizotypal PD (Downhill et al., 2000). There is evidence that
there are prenatal neurodevelopmental abnormalities, based on the discovery of minor physical anomalies that are known to originate prenatally, studied cross-sectionally in a group of schizotypal research participants relative
to a nondisordered comparison group (Weinstein, Diforio, Schiffman, Walker,
& Bonsall, 1999) and longitudinally in a schizotypal PD sample (E. F. Walker,
Logan, & Walder, 1999). Using MRI and positron-emission tomography scans,
Shihabuddin et al. (2001) showed that a sample of participants with
schizotypal PD had reduced volume and increased metabolism of the putamen relative to both schizophrenic and control participants. According to
the authors, "These alterations in volume and activity may be related to the
sparing of patients with [schizotypal PD] from frank psychosis" (p. 877).
A reasonable summary of the biological literature is that schizotypal PD is
similar to schizophrenia but milder in degree.
Medications
Preliminary evidence has suggested that several dimensions of schizotypal
PD can be addressed with medications. Schulz, Schulz, and Wilson (1988)
provided a review of medications for schizotypal PD, including some older
studies of pseudoneurotic schizophrenia (a forerunner of schizotypal PD).
The authors reviewed three studies that contained pseudoneurotic schizophrenia samples: The study by Klein (cited in Schulz et al., 1988) was doubleblind and placebo controlled; the study by Hedberg, Houck, and Glueck (cited
in Schulz et al., 1988) was double-blind but not placebo controlled; and the
study by Aono et al. (cited in Schulz et al., 1988) was an open trial. As
expected, neuroleptics decreased psychotic-like symptoms; surprisingly, they
helped with depression as well. Also surprisingly, the effects of antidepressants were not limited to affective symptoms; indeed, in one study, the
96
97
and social inadequacy. When life forces them to interact with others for
survival, they easily become overwhelmed, to which they typically respond
by "blanking out" or with a burst of poorly modulated aggression. At times,
they become frankly psychotic. Any of these reactions furthers their social
alienation and decreases the probability of stable, positive structures in their
daily lives.
The description of the person with schizotypal PD in terms of Millon's
domains is presented in Appendix B. Of the features listed, cognitive disturbance and social withdrawal are the most prominent.
Cognitive-Behavioral Conceptualization and Interventions
Cognitivebehavioral therapists note the elevated importance of a sound
therapeutic relationship with the person with schizotypal PD. Their proclivity to paranoid thinking and difficulties with social interactions can easily
sweep away the therapeutic relationship early in treatment. Only after a therapeutic bond is established, through copious active listening and clearly understanding the client's point of view, can cognitive-behavioral therapy
(CBT) technically begin.
A recent and rapidly growing area in the cognitive-behavioral literature is the treatment of psychotic disorders using CBT. At this point, studies
have debunkedor at least refinedthe old saying that "you can't talk people
out of their delusions." CBT has been effective in decreasing the frequency
of delusions and the firmness of conviction with which they are held (Haddock et al., 1998; Kingdon & Turkington, 1994). The technique for doing so
is to challenge a delusion just like any other belief, especially using thought
records and Socratic dialogue. So although "you can't talk a man out of his
delusions," one might say that you can show him how to talk himself out of
them. Behavioral experiments, carefully structured so that they can provide
evidence for or against a belief, are an integral and essential part of the treatment. In retrospect, much treatment for depression is similar. The belief of
the bright but depressed college student that she is "stupid" is similar to
a nonbizarre delusional belief. Thus methods that are used with quasidelusional and delusional beliefs will pave the ground for treating depressive
ideation, and vice versa.
Accustomed to trusting their feelings and intuitions, clients with
schizotypal PD need to learn to evaluate evidence. Common thoughts experienced by people with schizotypal PD include believing they are dead, believing that they or someone else is possessed by the devil or evil spirits, and
paranoid thoughts such as "1 cannot trust my mother." Instructing the client
to gather the appropriate evidence and evaluating that evidence during the
session can challenge such thoughts.
A. T. Beck, Freeman, and Davis (2004) noted that common core beliefs among individuals with schizotypal PD include "I am different and abSCHJZOTYPAL PERSONALfTY DISORDER
99
normal" and paranoid ideas such as "people are cruel." They may have ambivalence about these beliefs, on the one hand recognizing that they are a
source of distress but on the other hand thinking that their beliefs keep them
safe. Working through this ambivalence with a cost-benefit analysis and
behavioral experiments can help the individual to make informed choices
regarding behavior change.
Client-Centered, Humanistic, and Existential Therapies
From the standpoint of psychodynamic theory, schizotypal PD is a somewhat more severe manifestation of schizoid personality phenomena. Please
see chapter 6, this volume, for further discussion.
Family Systems
There is little if any literature on the family treatment of individuals
with schizotypal PD. However, a variety of family interventions have been
helpful for people with schizophrenia; many aspects of such treatments apply
directly to schizotypal PD, and others can be used with minimal modification. Behavioral family therapy (BFT; see studies by C. M. Anderson,
Hogarthy, & Reiss, and Falloon, Boyd, McGill, Razani, Moss, & Gilderman,
both cited in Razali, Hasanah, Khan, & Subramaniam, 2000) involves family psychoeducation regarding schizophrenia, social skills training, and communication skills training, all of which are widely accepted and effective
treatments for schizophrenia. For ethnic minorities, culturally modified family therapy uses culturally sensitive explanations of schizophrenia, medication, and social skills training and had better long-term effectiveness in a
Malay population than BFT (Razali et al, 2000).
Perhaps the most researched family intervention for schizophrenia is
that described in the "expressed emotion" (EE) literature. High EE is charac100
terized by a great deal of criticism of the identified patient, excessive involvement in the patient's life, and high expressed hostility. High EE has
been shown to be a predictor of relapse (psychosis and hospitalization) in
schizophrenia (e.g., see Hooley & Licht, 1997). Reduction of EE using family
behavior therapy to reduce criticism, hostility, and overinvolvement led to
dramatic reductions in relapse. BFT has been used successfully as an intervention in high-EE families (Falloon et al., cited in Razali et al., 2000; Hahlweg
& Wiedemann, 1999); to the extent that a family with a person with
schizotypal PD has high EE, BFT is likely to be helpful.
Family theorists noted that double-bind communication patterns occurred in families with a schizophrenic member (Watzlawick, Beavin, & Jackson, 1967). Double-binds refer to messages that contain a directive at one
level and a counterdirective at another level and that block escape. A classic
example is the "be spontaneous" paradox. If a wife orders her husband to "be
spontaneous," then if he acts in a spontaneous fashion he is doing so under
her direction and therefore is not truly spontaneous; if he does not do so,
then he is openly defiant. Watzlawick et al. (1967) hypothesized that the
husband in this situation becomes psychotic to escape from the bind. Initially, Watzlawick et al. believed that double-binds from the parents caused
schizophrenia in the child, but the theory was quickly modified to note the
circular nature of the interactions, in which participants with and without
schizophrenia would double-bind one another (see Burbach, 1996). Modern
theorists have noted that a biological predisposition is necessary (but not
sufficient) to cause schizophrenia, and the same can be said for schizotypal
PD. When double-binds do occur, they are typically emotionally destructive,
whether or not they cause psychosis. The way to break a double-bind is to
address the underlying paradox through assertiveness and related means. For
example, instructing the client to say, "When you tell me to be spontaneous,
you put me in a no-win situation. I can't be spontaneous by command. How
am I supposed to do that?" requires a response from the other person that will
help to break the bind. The identified patient can also be instructed to own
his or her experience and share itfor example, "When you order me to 'be
spontaneous,' I feel trapped and manipulated." In this way, the context is
shifted from a struggle for power to a discussion of feelings. A third way out is
to directly confront the underlying power issue (e.g., "I understand you want
me to be spontaneous, but that's not my goal"). This brings the power struggle
out into the open where it can be directly addressed.
Group Therapy
Group social skills training can be especially helpful because the client
can get feedback from peers rather than from the therapist alone. An important caveat for persons with schizotypal PD is that they must be socially appropriate enough to bond with the group and to avoid peer rejection. A former
client of mine, "Pat," who had schizotypal PD, attended a group I ran. This
SCHIZOTYPAL PERSONALITY DISORDER
101
group, a psychoeducation group for individuals with spinal cord injury, rarely
included individuals with severe psychopathology, and due to the heavy dose
of structure in the group, rarely elicited excessively intense emotions. We
were discussing anger management, and I asked about how various individuals handled their anger. One said he counted to 10; another, that he rarely
got angry; and a third said he yelled. Pat noted that when he got angry with
his brother, he ran him over with a car. The room fell into a stunned, tight
silence. I began to wonder if Pat was not only schizotypal, but actually schizophrenic. I pulled Pat from the group and began to see him in individual therapy.
The main theme of the brief therapy was reality orientation. Most group
therapy clients of mine, however, including those with schizotypal PD, have
not alienated themselves in this manner and have profited from the generally accepting and nonjudgmental tenor of the group.
COUNTERTRANSFERENCE
The literature on countertransference responses to individuals with
schizotypal PD is extremely limited. As discussed in chapter 4, this volume,
on schizoid PD, Giovacchini (1979) noted feelings of "existential terror," or
a primitive fear of nonexistence, which often led to feelings of hopelessness
with his schizoid patients (similar to modern schizoid and schizotypal PDs).
Robbins (1998) referring to the "autistic position," discussed countertransference responses such as a feeling of vagueness and disconnection in response to the client's devastating isolation. Sadness, perhaps related to pity,
also becomes prominent.
Students describing their emotional reaction to individuals with
schizotypal PD checked off words such as curious, bewildered, weird, perplexed,
disconnected, and pity. Such reactions are consistent with schizotypal pathology (Bockian, 2002a). The individual is eccentric and strange, and tends to
elicit odd feelings from the therapist. Such feelings can go in the direction of
feeling curiousfor example, about the experience of the client or the meaning of the loosely connected ramblingsor the therapist may experience
feelings of pity, seeing the person's strangeness as being fundamentally sad.
Many people simply cannot relate to these clients' quasi-delusional statements nor to their stiff or awkward style; feelings of disconnection may then
result.
In working with individuals with schizotypal PDor with a psychotic
disorder, for that matterI find it helpful to view their statements as metaphors, interpreting them as poems or allegories. For example, a client has a
delusion that he is being followed by beings from another planet. The meaning of that will vary from person to person, but there are a number of likely
scenarios: The person feels invaded, intruded on, but also important (important enough that the beings chose him as a target). Translating from the
102
103
mean scores on the Schizotypal scale were very low. The most likely interpretation was that moderate scores on the Schizotypal scale were associated
with the improvements in quality of life; hypothetically, this may be due to
improved creativity. Imaginativeness and openness to alternative perspectives are likely to be strengths in many people with Schizotypal PD, especially
those with a mild case.
SYNERGISTIC TREATMENT
Millon (1999) suggested modest goals for the individual with schizotypal
PD, given their significant impairments. Establishing a relationship based on
unconditional positive regard is essential as a foundation for other approaches
and is healing in its own right. Often, practical advice and reassurance is
warranted and can further deepen the trust in the relationship. Once the
relationship is firmly established, cognitive interventions can decrease the
quasi-delusional distortions the person experiences. Psychopharmacological
interventions may be helpful as well in that regard and may also be useful in
anxiety management with the timorous schizotypal subtype. As noted above,
the client's eccentricities can elicit rejection, which can be iatrogenic; however, with adequate assessment and preparation, the group experience can be
particularly healing in this population. Individuals with schizotypal PD often
benefit from interpersonal contact that is nonthreatening and structured, as
is often found in group interventions. Millon did not specifically recommend
psychodynamic approaches as part of the synergistic sequencing; however, in
this population, strong transference reactions can develop, which must be
addressed. The porous line between reality and fantasy makes individuals
with schizotypal PD particularly prone to distorted beliefs about the therapist. Further, the relative lack of outside relationships can heighten the importance of the therapeutic relationship. Psychodynamic theory is particularly useful in providing a conceptual map for traversing this potentially tricky
terrain. Family interventions are often indispensable in creating a supportive
structure that will allow the person to function outside of therapy. Millon's
recommended strategic goals and tactical modalities are listed in Exhibit 5.1.
CASE EXAMPLE: HOPE
Technically, the case that follows would be diagnosed "personality
change secondary to a medical condition [stroke]." That being said, the personality that resulted from the change would best be described as schizotypal
PD. There was a substantial depression as well, which interacted with the
schizotypal features to create a marked clinical presentation. To date, this
client is the most prototypical example I have seen of someone with depression and schizotypal PD.
104
EXHIBIT 5.1
105
noticed that I felt sad, heavy, and helpless, and I experienced a strong urge to
rescue her. This is a common gut reaction I have noticed within myself when
I encounter a client with depression, especially if the person has a tendency
toward dependency. With clients who are more classically psychotic (e.g.,
those who have schizophrenia), I often experience confusion and a struggle
to create coherence. Hope, however, was more in the schizotypal range of
functioningshe was having illusions, rather than frank hallucinations; she
probably did see shadows or vague movements on the ground but interpreted
them to be demons. Behavioral eccentricities emerged in the course of treatment, as will be seen below.
I believed, then, that the best way to initially conceptualize the case
was major depression with mood-congruent delusions in the context of
schizotypal PD. Because the belief in spirits is common in Hope's African
culture of origin, the content of her thoughts was not particularly bizarre
(L. Black, 1996). Interpreted as if they were poems or dreams, the experiences she shared seemed to indicate feelings of vulnerability and helplessness
as she wrestled with forces outside her control. I believed that the intervention I provided should help her to feel empowered and in control and should
help to increase her feelings of independence. Working collaboratively with
her, I directed her feelings of dependency and reliance toward her faith, as I
believed that her reliance on God was a strength in this case.
My initial intervention could be conceptualized as behavioral or as paradoxical. At one level, I was providing a simple directive, a homework assignment. At another level, I was placing her in a therapeutic double-bind, in
which I challenged her to eliminate her symptoms within the framework of
her interpretation of her experience; the model on which 1 was drawing was
Ericksonian hypnosis. Within the session, I said to her,
Hope, you and I both know that spirits such as the ones you describe feed
on misery and find the presence of joy intolerable. If you bring about
within yourself a feeling of happiness the devils will leave you alone.
What are some of the things that make you happy?
The primary activities that gave her joy were praying and attending
church. "That is great," I said to her, "because you and I both know that the
devils are powerless compared with the overwhelming power of God." I suggested that she "pray for happiness and inner peace in addition to your usual
prayers." In addition to assigning the client this homework, I contacted her
family to see if they could help get Hope to some of her meetings.
Over the course of the next few sessions (I was seeing her twice per
week), Hope's mood rapidly improved, and the frequency with which she
saw the "devils" rapidly declined. Staff reportedsome with amusement
and others with irritationthat Hope at times was praying in loud, fervent
songs. She also began to preach, to no one in particular. She reported success in attaining joy, especially when she sang out to the Lord with all her
106
heart. Within approximately 3 weeks she was delusion free. She was freely
talking about her feelings, such as difficulties adjusting to the nursing
home and frustrations regarding insufficient time with her family. It is
worth noting that unlike her belief in spirits, her decision to pray loudly
and preach from her bed would be considered eccentric or inappropriate
within her subcultures (African American and Baptist), thus the schizotypal
diagnosis.
A variety of family and community interventions were also extremely
helpful. I interacted with Hope's oldest daughter fairly regularly; she visited
Hope about once every 2 weeks. I helped make arrangements for Hope to go
to her religious meetings, working with lay leadership in the community and
with her family. Still, Hope only got to go about once per month, though
that made a huge difference in her life. At one point, Hope lost weight, was
looking pale, and appeared to me to be dying. I checked with her physician,
who confirmed that she was having difficulty staying hydrated and was not
doing well; death at any time was not out of the question. Working with her
oldest daughter, we arranged to have as many family members as possible
come to visit. Her brother flew in from Africa to surprise her, and probably a
total of a dozen family members came to visit. As the family members visited,
I could see the life pouring into her body. She fully recovered and regained
her prior level of health.
Hope continued to wrestle with difficulties maintaining her grip on
reality throughout treatment. Under stress, she would become delusional
again, and, when more distressed, she would occasionally become frankly
psychotic. She had a hallucination that a large, terrifying devil was standing
menacingly at the foot of her bed, leaning over her in an intimidating and
threatening manner. Repeating the intervention for her to pray and to engender joy in her life was helpful. The larger, more intimidating figure may
have represented death, fused with guilt. At that time, she was having an
erotic transference and may have had guilt about her sexual feelings. Thus,
the therapy began to move into areas most thoroughly addressed by psychodynamic theory. 1 have noticed that strong transference reactions often occurred in my nursing home clients; their lives were often understimulating,
and thus the therapy took on a higher level of prominence. Her feelings for
me represented, at least in part, unresolved feelings that she had about a man
she had wanted to marry but from whom she was kept apart, primarily for
racial reasons. I also represented an idealized father image, because her true
father was neglectful and philandering and was thrown out of the house by
her mother. Over time, after gleaning a variety of meanings regarding her
prior relationships, our bond became more reality based.
We terminated more because I was leaving the setting than because of
a natural termination time. Hope was in therapy with me for about 2 years,
and probably could have gone on for at least a year more. Termination was
done over a period of several months and ultimately went smoothly.
SCHIZOTYPAL PERSONALITY DISORDER
107
108
6
DEPRESSION IN ANTISOCIAL
PERSONALITY DISORDER
So apt at capturing the essence of human nature, Shakespeare illuminated the character of the scheming lago, who, speaking of Othello, declares,
I follow him to serve my turn upon him:
We cannot ail be masters, nor all masters
Cannot be truly follow'd. You shall mark
Many a duteous and knee-crooking knave
That, doting on his own obsequious bondage
Wears out his time, much like his master's ass,
For naught but provender; and, when he's old, cashier'd:
Whip me such honest knaves . . .
In following him I follow but myself;
Heaven is my judge, not I for love and duty,
But seeing so for my peculiar end. (Shakespeare, 1972, pp. 1171-1172)
The bard delineated the hallmarks of what we now call the antisocial personality disorder (PD): being self-centered and manipulative. People with this
disorder view the world as a savage place divided into exploiters and the
exploitedand they choose and vigorously pursue membership in the former
group. Although it is often tied to violent criminal behavior, especially on
109
the lower socioeconomic rungs, the passage illustrates how sociopathy can
penetrate the highest social echelons. lago also has elements of narcissistic
PD, as will be discussed in a later chapter.
and vulnerabilities of others, taking advantage of this sensitivity to manipulate and control. However, they typically evidence a marked deficit in selfinsight and rarely exhibit foresight" (p. 464). Therapists often observe this
phenomenon during therapy sessions, experiencing themselves a feeling of
vulnerability and invasion when working with such clients.
EPIDEMIOLOGY
Community estimates indicate that antisocial PD occurs in approximately 3% of males and 1% of females. In clinical settings, the prevalence is
approximately 3% to 30%, whereas in substance abuse and forensic settings
the prevalence is generally even higher (American Psychiatric Association,
ZOOOa).
In a sample of depressed clients, approximately 3% had antisocial PD
(Fava et al., 1995). Markowitz, Moran, Kocsis, and Frances (1992) studied a
sample of 34 outpatients with dysthymic disorder; none had antisocial PD. In
a sample of 249 depressed outpatients, none were diagnosed with "definite"
and 2% were diagnosed with "probable" antisocial PD (Shea, Glass, Pilkonis,
Watkins, & Docherty, 1987). In Pepper et al.'s (1995) dysthymic disorder
sample, 4% had antisocial PD. Of the 116 individuals with major depression
in a study by Zimmerman and Coryell (1989), 7.8% had antisocial PD. In a
sample of 352 clients with both anxiety and depression, approximately 2%
had antisocial PD, as diagnosed by structured interview (Flick, Roy-Byrne,
Cowley, Shores, & Dunner, 1993). In the depressed samples reviewed, then,
approximately 0% to 8% had antisocial PD. Beginning with the portion of
the sample in which antisocial PD was reported, Zimmerman and Coryell
(1989) found that 34.6% had depression.
HOW DO PEOPLE WITH ANTISOCIAL PERSONALITY
DISORDER GET DEPRESSED?
Impulsive and acting-out behaviors tend to protect individuals with
antisocial PD from depression. When they do get depressed, it is often because they have been constrained in some way, usually by the legal system.
Individuals with other psychiatric problems, such as schizophrenia, may become depressed in inpatient psychiatric settings once their psychosis is in
remission. On the spinal cord injury unit, some clients had fears of reprisals
from others. To some degree, their fears were probably justified; others whom
they had harmed may have been eager to pay them back. To some degree,
these fears were also probably a projection of their own hostile feelings. Because they are impulsive and often have comorbid substance abuse, however,
depressed individuals with antisocial PD are at high risk for suicide (Links,
Gould, & Ratnayake, 2003). Unlike most PDs, which create a vulnerability
ANTISOCIAL PERSONALITY DISORDER
I11
road worker whose anterior and medial frontal cortex was damaged by a spike
through his head. Gage underwent massive personality changes, most notably an increase in aggression and impulsivity. Since then, formal studies have
documented that dysfunction and reduced levels of activity in the frontal
region are associated with aggression, impulsivity, and criminal behavior (see
Siever et al., 1998).
Heritability
Nigg and Goldsmith (1994) reviewed studies that used the Psychopathic
Deviate scale (Scale 4) of the Minnesota Multiphasic Personality Inventory.
Studies of normal twins yielded a heritability of approximately 56%; similarly, a study of twins raised apart yielded a heritability estimate of 61% on
the same scale (DiLalla, Carey, Gottesman, & Bouchard, 1996). Loehlin,
Willerman, and Horn (1987) administered the Minnesota Multiphasic Personality Inventory to mothers who were giving up their children for adoption; years later, they tested the adopted children at about the same age as
the mother when she was tested. The correlation between the scores was .27,
which suggests a heritability of .54; by comparison, the correlations with
adoptive relatives were negligible (.02, .07, and .01 for adoptive siblings,
fathers, and mothers, respectively). A study using the Dimensional Assessment of Personality Pathology Callousness Scale yielded a heritability of 56%,
whereas stimulus seeking had a heritability estimate of 40% (Jang, Livesley,
Vernon, & Jackson, 1996). Studies of conduct problems have yielded heritability estimates of 61% (Coolidge, Thede, &. Jang, 2001) and 49% (Livesley,
Jang, & Vernon, 1998), although surprisingly, a different study found a heritability estimate for conduct disorder of zero (Livesley, Jang, Jackson, &
Vernon, 1993). A meta-analysis by McCartney, Harris, and Bernieri (1990)
showed a higher interclass correlation for monozygotic twins (.49) than dizygotic twins (.29) on aggression. The sum of the evidence suggests that antisocial PD and antisocial traits are moderately heritable, as is the case with
the other PDs.
Medications
Theoretical work reviewed above has indicated that serotonergic pathways in the frontal area are implicated in impulsive aggression, thus suggesting that selective serotonin reuptake inhibitors would be effective in reducing acting-out behavior. Studies done with individuals with borderline PD
have borne out these predictions in open trials (Markovitz &. Wagner, 1995),
uncontrolled studies (Silva et al., 1997), and a double-blind, placebocontrolled study (Rinne, van den Brink, & Luuk van Dyck, 2002). Such
studies should be replicated with individuals with antisocial PD.
Some preliminary investigations have been done with atypical
antipsychotics for antisocial PD. Hirose (2001) presented a case study in
which treatment with risperidone led to reduced aggression and impulsivity.
ANTISOCIAL PERSONALITY DISORDER
113
genetics or shaped by experience. The early experiences of people with antisocial PD are likely to be characterized by conflict. Noted Millon (1981),
The primary experiential agent for this pattern is likely to be parental
rejection, discontent, or hostility. This reaction may be prompted in part
when the newborn infant, for constitutional reasons, proves to be "cold,"
sullen, testy, or otherwise difficult to manage. It does not take too long
for a child with a disposition such as this to be stereotyped as a "miserable, ill-tempered, and disagreeable little beast." Once categorized in this
manner, reciprocal negative feelings build up into a lifelong cycle of parent-child feuding, (p. 208)
During infancy, from birth through 1 year of age, this hostile relationship is already beginning to take root. By early childhood, these children are
already rebelling and, feeling unsafe, are relying on themselves for protection. As they mature into grade school and adolescence, they increasingly
develop a deviant, outsider identity, distancing themselves from the counsel
of others who may be older and wiser.
Evidence from the Environmental Risk Longitudinal Twin study
(Trouton, Spinath, & Plomin, 2002; see also Jaffee et al, 2004) supports and
extends Millon's theory regarding the early manifestations of the antisocial
pattern and the environmental sequelae. This study examined over 1,100
twins drawn from, a registry of over 15,900 twins born in England and Wales
in 1994 and 1995. Families in which mothers were 20 years of age and younger
were selected because maternal youth is associated with risk for problematic
outcomes. Children were followed from approximately age 5 to age 7. Researchers found that corporal punishment was genetically mediated but that
physical abuse was not, indicating that abuse was due to factors that differed
among families. The genetically mediated factors that underlie corporal punishment, however, were also correlated with antisocial behavior. Overall,
then, children with certain genetically mediated characteristics (e.g., oppositional, aggressive, and coercive behaviors) are more likely to be spanked;
physical discipline, in turn, increases the risk of antisocial behavior.
Abuse, however, is added on, coming more from other family factors
(e.g., parental characteristics; Jaffee, Caspi, Moffitt, Polo-Thomas, et al.,
2004). In terms of environmental risk factors, abuse has been shown by
Cicchetti and Manly to be a risk factor for antisocial behavior (cited in Jaffee,
Caspi, Moffitt, Polo-Thomas, et al., 2004). The longitudinal twin study quoted
from below suggests in the strongest possible way that abuse plays a causal
role. Jaffee, Caspi, Moffitt, and Taylor (2004) ruled out numerous alternative explanations to support their conclusion. They noted,
We found that (a) physical maltreatment prospectively predicted antisocial outcome, (b) physical maltreatment bore a dose-response relation
to antisocial outcome, (c) physical maltreatment was followed by the
emergence of new antisocial behavior, (d) children's maltreatment vic-
115
timization was not influenced by genetic factors, (e) the effects of physical maltreatment remained significant after controlling for parents' history of antisocial behavior, and (f) the effect of physical maltreatment
was significant after controlling for any genetic transmission of antisocial behavior, although genetic factors accounted for approximately half
of the association between physical maltreatment and children's antisocial behavior. (Jaffee, Caspi, Moffitt, & Taylor, 2004, p. 50)
Maternal negative expressed emotions are also a risk factor for later
antisocial behavior and, on the basis of similar logic, also appear to play a
causal role. Mothers who made negative comments (e.g., "she is horrible")
and who had an overall negative tone (e.g., more negative comments than
positive ones) were more likely to demonstrate antisocial behavior concurrently and prospectively, controlling for genetic factors; the researchers also
statistically eliminated the possibility that the negative expressed emotions
were purely a function of the effects of the child's behavior on the parents,
using longitudinal analyses (Caspi et al., 2004).
Scientists are beginning to identify genotypes that moderate the relationship between environment and antisocial behavior. One study, which
followed participants from birth to adulthood, examined over 500 men at
age 26. They found that a gene-impacting monoamine oxidase A had a moderating effect; high levels of this enzyme reduced the likelihood of antisocial
behavior occurring in the presence of maltreatment (Caspi et al., 2002).
A variety of factors serve to perpetuate the antisocial PD pattern. The
person with antisocial PD's anticipation of distrust elicits genuine distrust
from others, thus initiating a cycle of mutual misgivings. Their proclivity for
being provocative elicits hostility from others, justifying their worldview that
others are cruel and vindictive. Finally, their weak intrapsychic control leads
to the direct venting of angry feelings or to impulsive behavior; thus, they are
continually in difficult legal and interpersonal situations, perpetuating their
view of the world as hostile and unjust (Millon, 1999).
The description of the antisocial PD prototype in terms of Millon's
domains is presented in Appendix B. Of the features listed, "irresponsible,"
"acting-out,'' and "impulsive" are the most salient.
Cognitive-Behavioral Conceptualization and Interventions
Individuals with antisocial PD are prone to a variety of automatic
thoughts that flow from their cognitive schemas and core beliefs. Automatic
thoughts include, "I cannot let him get the better of me"; "It doesn't matter,
I'll just get high"; and "I'm going to get what I want (regardless of what happens to anyone else)." A. T. Beck, Freeman, and Davis (2004) described six
categories of cognitive distortions that typify the antisocial prototype:
1. Justification"Wanting something or wanting to avoid something justifies my actions."
J 16
117
always given smoking privileges. As part of the behavioral contract, I scheduled in four smoking sessions per day. This provided a real incentive for him
to participate in the process. In that case, a nurse complained that although
the client was the abusive one, it was the staff who had to make all of the
behavioral changes. Although that was not quite truethere were numerous behavioral consequences that were initiated by the patient's behavior
I could understand her point. Most of the behavioral changes were mediated
by restructuring the patient's environment, which meant changing staff behaviors. I replied that she was right and that in a perfect world, the client's
immoral and problematic behaviors could be changed in a direct way. However, the only way to change his behaviors was to change his environment
namely, our behaviors. Because we were the ones drawing salaries, and it was
incumbent on us to rehabilitate the patient (including psychological rehabilitation) as part of our mission, we would have to go first. However, I reassured her that if about 100 years of behavioral theory had merit, then his
behaviors should follow shortly. Once they did, I never had to deal with that
complaint again when contracts were written for other clients.
Individuals with antisocial PD tend to also be receptive to cost-benefit
analysis interventions, which provide structured ways to look at long-term
and short-term benefits of a particular action. Because they are interested in
having their short-term needs gratified, there is an incentive to participate.
By looking in a structured way at typical interactions, the client will often
come to see how a little bit of planning can yield greater gratification in the
long term (A. T. Beck et al., 2004; A. T. Beck & Freeman, 1990 ).
Psychodynamic Therapy
118
COUNTERTRANSFERENCE
The client with antisocial PD, like the client with narcissistic PD, routinely rejects the therapeutic relationship. In such a circumstance, the therapy
often stalls; the therapist often responds with feelings of helplessness. Ironically, despite such feelings, therapists may take excessive responsibility for
the client's behavior, perhaps as a function of omnipotence fantasies. When
the client acts out, the therapist may then feel responsible and thus guilty
(Strasburger, 1986). Helpless feelings may also induce the belief that treatment is futile (Lion, 1978; Meloy, 1988).
Many therapists see themselves as nurturing and kindhearted; such characteristics are often devalued by the person with antisocial PD. To the extent that the therapist accepts the client's feelings, the therapist experiences
devaluation and invalidity, which produces feelings such as worthlessness,
depression, anger, and shame (Strasburger, 1986). These clients' lack of emotional nuance and subtlety may also be disconcerting to therapists, disrupting their normal ways of relating and leaving them feeling unbalanced.
Therapists will often reject, hate, or wish to destroy clients with antisocial PD because of their immoral behavior and the powerful reactions the
clients elicit. In psychodynamic theory, one might say that the clinician's
superego is activated against the id-driven behaviors of the client (Meloy,
119
1988; Strasburger, 1986). For example, when a client has raped someone, the
therapist may fantasize about the client receiving castration as therapy or the
death penalty as punishment. Though this is not the venue to discuss the
appropriate severity of punishment for crimes, it is clear that such fantasies
represent great anger and likely hatred as well. The therapist must be comfortable with these emotions, which are not unnatural, and use them in the
service of the therapy; consultation with colleagues can be important in such
cases.
Therapists often feel manipulated by individuals with antisocial PD;
indeed, such clients can pull for special treatment. Therapists must understand their motives for "bending" their usual practices. Usually, changing
one's standard practice is a bad idea, because therapists can inadvertently
reinforce clients' erroneous belief that it is other people's inflexibility or misunderstanding that is the problem rather than their own dysfunctional behavior (A. T. Beck et al., 2004).
One emotional reaction therapists often have to the antisocial client is
fear of assault or harm. This is a realistic fear and should be honored. Existing
data suggest that attacks on therapists are fairly common; for example, Guy,
Brown, and Poelstara (1990) found that nearly 40% of psychologists have
been physically attacked on one or more occasion. It appears that "serious"
attacks (in which the psychologist misses 1 or more days from work) are
rather rare, with 3% of psychiatrists and 1% of psychologists reporting such
attacks (Reid & Kang, 1986). Several leading theorists have noted that therapists may defend against the anxiety of real danger by psychological denial
(Gabbard & Coyne, 1987; Meloy, 1988; Strasburger, 1986). Lion and Leaff
(1973) asserted that such beliefs and defenses are disturbingly common; they
noted, "Denial is the most ubiquitous defense against anxiety generated by a
violent patient. ... to face the issue of dangerousness is very threatening to
the physician . . . the therapist's human vulnerability emerges" (p. 105). I
know of several cases in which sociopathic clients have assaulted therapists.
In one particularly disturbing case, a therapist who was in denial about the
dangerousness of a patient used harsh confrontational techniques on a psychiatrically hospitalized and still unstable sociopathic man; to make matters
worse, the therapist had a student with her. When the patient, who stood
approximately 6 feet, 2 inches tall, became assaultive, the confronting therapist fled, followed by her student; the patient was able to catch, beat, and
injure the student. It is essential to take appropriate measures to assure therapist safety, especially maintaining physical superiority (i.e., having sufficient
staff of sufficient strength and with appropriate training to safely and quickly
control a patient). Our discipline must confront denial in our students, our
colleagues, and ourselves. Sometimes, this denial is related to a belief that
our "special relationship" with a client is a sufficient safeguard. Instead, careful attention to verbal and nonverbal cues and awareness of the client's motivation and capacity for self-control are better indicators; in addition, sys120
temic issues (e.g., safety protocols that are in place in a hospital or clinic) are
key. With appropriate precautions, however, fear of assault need not and
should not dominate the treatment or lead to intimidation of the therapist.
Research on graduate students' responses to filmed vignettes of individuals with antisocial PD suggested that they initially respond to these individuals with feelings of curiosity, sadness, and pity; they also feel alarmed,
irritated, fearful, afraid, and angry (Bockian, 2002a; see the description of
the study in chap. 1, this volume). Informal discussions with the study participants have indicated that the pity they felt was mostly related to characteristics specific to the client portrayed in the film vignette (Wohl, 1996); he
appeared to have a low IQ and, given his history of violence, rather meager
prospects for the future, even if he were able to turn his life around. The
person portrayed elicited somewhat more compassion than most, because he
was treated, apparently successfully, and was making the film vignette as a
way of thanking his therapists.1 Consistent with the literature reviewed above,
the feelings of anger and irritation were generated by his sociopathic behavior, such as his violence, especially his violence toward women. Feelings of
alarm and fear were realistic responses to the client's propensity for violence
and extremely marginal internal controls.
In reflecting on my own work with individuals with antisocial PD, there
are a few whom I liked, but mostly I felt wary, guarded, and suspicious. Even
with those who were "nice," I was generally waiting for the other shoe to
drop, such as a request to collude against other members of the treatment
team. I used to try getting in touch with their abuse history as a way of stoking my feelings of compassion; in my experience, this was worse than futile.
All had been abused, and all responded with denial ("It wasn't so bad" or "I
deserved it") or withdrawal from any of my expressions of compassion. Perhaps accepting compassion was interpreted by the client as a form of inferiority in a hierarchical relationship. It is also possible that despite my conscious
efforts to avoid it, I would slip into feeling pity, from which most people
shrink (whether they have antisocial PD or not).
Instead, I now do the work internally. I imagine that the person was
abused and is responding the best way he or she knows how. I pay attention
to any somatic responses I am having, such as leaning forward, leaning back,
or tightness in the stomach; usually, I experience tension of some kind when
there are dominance issues (e.g., if I am being insulted or drawn into a power
struggle). 1 then work hard to sidestep such conflicts, knowing from experience that they are futile; as noted in prior examples, I do this by providing
suggestions and stating, "It is up to you if you choose to do what I suggest." I
challenge my beliefs using cognitive techniques. For example, if a client then
does not take my suggestions, I have thoughts such as, "He should do as I
'The interested reader can view the film clip of this discussion in the antisocial PD case on the video
Diagnosis According to the DSM-IV (Wohl, 1996).
121
suggest, his life is a mess, and that is his only way out of trouble." This belief
can be challenged on numerous grounds: Getting out of trouble may not be
his goal; he may consciously or unconsciously crave the structure of his present
setting. Also, it really is his life, and it only affects me to the extent that I
invest some part of myself in him; I need to return to neutral. What am I
getting out of his doing what I suggest? Let it go. Further, what does the
behavior mean to him? There are people who have sacrificed their lives for a
cause. Patrick Henry is a hero for having given his life for his country. We
admire him, because we admire his cause. To individuals with antisocial PD,
any cause for which they are willing to give their lives invariably seems fool'
ish to me, from my perspective, but to the person with the disorder, it is all
important. (This dynamic can be found in the case example in chap. 7, this
volume, on borderline PD. The patient literally risked his life by failing to
comply with his routine medical care. Eventually, I understood that he be'
lieved that to be under the control of another was worse than death. In his
mind, he was behaving like Patrick Henry.) In such circumstances, one can
challenge the meaning of control; for example, working through administrative channels to control the nurses' behaviors rather than cursing at them
may be an acceptable substitute behavior. One can also challenge the client's
black-and-white thinking that he or she must be in control of everything at
every minute. Such a change would involve giving trust, something with
which the individual has had horrible experiences. Such challenges to my
beliefs help me to stay focused and recognize how difficult it is for that person
to behave in a manner that would meet my expectations.
In most cases, I am accustomed to reframing the belief that large changes
can occur in therapy. Not to be unduly pessimistic, but I believe that a superego must be developed during a certain sensitive period. One cannot put
yeast in the dough, leave it on a shelf for 25 years, put it in the oven, and
expect to get bread. Thus, in the case of the individual with antisocial PD, I
can be more satisfied with small changes. However, I do believe that if these
small changes are sufficient to get the person into a dramatically different
environment, great change can occur. For example, if the client gets into a
stable relationship with a genuinely caring and drug-free individual, then the
changes that can occur over long periods of time with a significant other
providing corrective emotional experiences on a daily basis can be almost
miraculous. In my clinical experience, life events outside of psychotherapy
that unfold over a number of years are often crucial to the client's ability to
make major changes.
123
You know, when you yell, scream, or curse at a nurse, the hospital labels that verbal abuse. And the hospital is required by law
to provide an abuse-free environment for its employees. So the
minute you start cursing out a nurse, the entire resources of the
hospital will be directed at getting you to stop. No matter how
high they have to escalate, they'll keep going. Is that what you
want, to be battling the whole hospital?
Client:
Therapist:
It's true. It's not fair for you to have to wait a long time for your
care. But cursing them out just gets you in trouble, and it doesn't
get you what you want. Hey, do you really want to bust her?
Client:
How?
ANTISOCIAL PERSONALITY DISORDER
125
Therapist:
Client:
Therapist:
Client:
Therapist:
Client:
Therapist:
Client:
Therapist:
Client:
But that's their job! I shouldn't have to thank them for doing
their job. They're getting paid for that.
Therapist:
You and I both know that people should do their jobs well
whether they get thanked or not. I'm just telling you, that's what
makes them tick. You have to stick with it a few times for it to
work, but if you try it, you'll see. It's up to you; it doesn't make
any difference to me.
126
with the client (e.g., "What, I have to do Jill's job now, too? Talk to Jill, and
see what she says. If you're still not happy, there are other things we can do").
In the entire process, the client was moving toward a position of working within and through the system rather than working outside of it. If that
lesson sinks inand it did in most though not all casesit is the most powerful lesson of all. I also taught clients to "manipulate" in a sophisticated
rather than a crude fashion. Many of us will say "thank you" to a nurse who
helps us because, well, we actually feel grateful. This is too much to hope for
in the early treatment of individuals with antisocial PD. In fairness to the
clients, their upbringing was probably miserable and punitive, and thus to
get to true gratitude will at a minimum take time or may never occur. If the
client changes from manipulating cruelly and harmfully to kindly and productively, I'll take that deal.
My slight derogation of the nurses was also strategic. To say that as a
whole they were a good and kind group was so outside the client's realm of
experience that it could not even be processed. That they were "a bunch of
do-gooders" says the same thing, though it was framed by the client as indicating that they were suckers or manipulators. Nonetheless, the client received and integrated the powerful message that he could work with these
people on their own terms; could get a certain amount of what he wanted;
and the nurses would be so happy, they'd come back for more!
The final piece of the intervention is among the most important. I withdrew my investment in the client's decision, keeping him in charge and maintaining my role as a consultant. If I had become an authority figure, our
alliance would have been shattered.
The overall functioning of the system was crucial in these instances. Jill
McDonald (not her real name) truly was phenomenal at resolving conflicts
and understanding the perspective of both parties. Nursing staff, with excellent uniformity, followed through on setting boundaries. It should be noted
that as human beings, the nurses were responsive to ordinary reinforcements,
and the clients' hostile behaviors did elicit passiveaggressive behaviors from
some nurses. However, on the whole, the nurses really were goodhearted and
responded well to a few "thank you"s. Poorly functioning systems with deeply
entrenched hostility and political divisions may not have done so well with
such interventions.
In terms of catalytic sequences, then, I would recommend an integrated
cognitivebehavioral/systemic approach as illustrated by the above when
possible. Environmental contingencies, when controllable, can provide a
context for behavioral change. Although accurate empathy and unconditional positive regard are building blocks for the relationship, warmth, at
least in my experience, is not. A warm, sensitive male is viewed as weak by
the typical person with antisocial PD and may arouse homophobia; I have
found that being warm with them is tantamount to a request for premature
termination. My experience base with these clients is almost exclusively in
ANTISOCIAL PERSONALITY DISORDER
12 7
EXHIBIT 6.1
Therapeutic Strategies and Tactics for the Prototypal Antisocial Personality
STRATEGIC GOALS
Balance Polarities
Shift focus more to needs of others
Reduce impulsive acting-out
Counter Perpetuations
Reduce tendency to be provocative
View affection and cooperation positively
Reverse expectancy of danger
TACTICAL MODALITIES
Offset heedless, shortsighted behavior
Motivate interpersonally responsible conduct
Alter deviant cognitions
Note. From Personality-Guided Therapy (p. 474), by T. Millon, 1999, New York: John Wiley & Sons.
Copyright 1999 by John Wiley & Sons. Reprinted with permission of John Wiley & Sons, Inc.
male-male relationships. Other arrangements are likely to elicit very different responses. I have female students who have acted warmly with male antisocial clients and obtained excellent results, though in all of the cases I can
recall there was a rapid erotic transference that had to be resolved before
further progress could be made. It is also noteworthy, then, that the procedure I have outlined may need to be modified for female therapists or clients.
Guidelines for treatment goals were summarized by Millon (1999; see
Exhibit 6.1). As noted, it is critical to balance the self-other polarity by
shifting more toward others' needs and to decrease the "active" end of the
active-passive dimension by reducing impulsive acting out. It is essential to
block activities that perpetuate the antisocial pattern, such as clients' tendency to be provocative and their proclivity to view cooperation as problematic. The clinician needs to intervene to reduce shortsighted behavior, irresponsible conduct, and distorted cognitions.
128
ral, though he had the full spectrum of symptoms that qualified him for a
diagnosis of major depression: He was not eating and had lost weight, was
lethargic and apathetic, and had feelings of hopelessness. Joe also clearly met
the criteria for antisocial PD. He had a lengthy juvenile record (e.g., truancy,
vandalism, and violent behaviors). Joe was a gang member and had moved
up to a high level on the hierarchy. He thrived on the excitement and sadistic pleasure of the gang fights. He would continue to beat his victims after
they were unconscious. Later on, Joe was involved in extensive criminal activity but was never convicted because he or his gang members were consistently able, through the threat of physical violence, to intimidate people
into dropping the charges against him. Once that started to happen, Joe began to feed off the feelings of invincibility and power, and his grandiosity
began to soar. Freed from what minimal constraints he previously had had,
his behavior became increasingly daring. He developed a scheme to rob other
gangs by dressing up as police, busting into their houses, and taking money
and stolen goods; this activity was highly lucrative. His luck ran out when he
decided to hit a major gang a second time; this time around they were prepared, and a gunfight ensued. Joe accidentally shot and killed a young child
and was charged with the crimes for which he was presently incarcerated.
Joe's older brother, younger sister, and his mother were also involved in
gangs. His father, who had been absent from the home for years, was a pimp.
His mother was killed in a gang fight. In his mind, his mother's gang did not
retaliate adequately for her death. Plotting the best path for revenge, he
dropped out of school at 16, joined a rival gang, and figured out the best way
to hurt others.
During his 1st year in the penitentiary, Joe wanted to attain the high
rank that he had held in his street gang. To "prove his worth," he engaged in
dozens of violent incidents, incurring multiple prison charges. He quickly
became unmanageable within the institutional structure. Prison authorities
cracked down and broke up the gangs within the prison. Their main weapon
was the use of solitary confinement. Repeatedly placed in solitary confinement, Joe became increasingly morose. It was at this time that he attempted
suicide and was offered treatment.
The therapist, Don Castaldi, connected with him through empathy and
validation. He provided the client with an opportunity to discuss his situation and vent his anger. From the client's perspective, it was easy to understand how difficult it was to be sent to solitary confinement so often. Dr.
Castaldi would make statements such as, "I can imagine how awful it must
feel to be sent to secure lockup"; "It is understandable that you are angry
when you get sent to solitary so often"; and "It must be frustrating to get sent
to solitary so often, while others do not." The key was to validate the feelings, not necessarily the cognitive interpretation of the inequities and "unfairness" that are a function of externalization of blame.
129
of the treatment into an old and all-too-familiar pattern for Joe, someone
using him for personal gain. Dr. Castaldi discussed the case with a colleague,
who noted how much pressure to succeed this case was generating. Looking
at the issues allowed Dr. Castaldi to get a greater sense of perspective. He
focused on becoming more mindful and viewing Joe as a person rather than a
"project," which helped him to regain his balance.
Simultaneously, Joe was experiencing something of an identity crisis.
No longer invested in creating an illegal empire, he was not sure what to do
or who he was. He began to identify with the African American subculture
and focus on issues of racial oppression. Other African American prisoners
also started to pressure him about seeing a White therapist, which strained
the therapeutic relationship with Dr. Castaldi. Joe began to feel conflicted
about being open and vulnerable with his "oppressor." Dr. Castaldi, on the
other hand, felt frustrated with Joe's distorted and separatist interpretation
of Martin Luther King Jr.'s work and with Joe's focus on fighting racism as an
excuse for violence. Joe increasingly asked difficult questions relating to Dr.
Castaldi's assessment of him as a person. This culminated in the following
exchange:
Joe:
Dr. Castaldi:
Joe:
Dr. Castaldi:
Joe:
Dr. Castaldi:
Joe:
Dr. Castaldi's genuineness had an enormous impact on Joe, who suddenly realized that life could be very different. Dr. Castaldi's recognition and
validation of Joe's physical strength seemed reassuring in that context. They
were able to discuss the impact of racism and social class in a more productive and collaborative way so that Joe could integrate his own behaviors with
the impact of racism and social class to create a more realistic picture of his
life and his situation. He began to show remorse, demonstrating feelings for
the young boy who had been killed by his stray bullet and acknowledging
that he had stolen that child's opportunity to experience life. At about this
time, other gang members were beginning to testify against him in court. Joe
ANTISOCIAL PERSONALITY DISORDER
J 31
began to state that he wanted to "honor the memory of the child" by turning
state's evidence. Dr. Castaldi noted that there were several elements in his
decision, including genuine feelings for the child as well as self-serving interests (e.g., avoiding life in prison). It was difficult to assess just how far Joe had
come in developing a conscience or superego, but it appeared that he had
developed at least a minimal or preliminary concept of and experience with
guilt and remorse. His basic self-serving approach was still dominant, and as
he appeared to be transitioning from a deviant to a more mainstream set of
values and convictions, Dr. Castaldi was struck by how Joe was able to give
up "the code," that is, the gang values that he presumably had held all his
life. After testifying, Joe was transferred to another prison where he apparently served 5 years and was released; Joe had viewed testifying as "being in
the spotlight" and had enjoyed the narcissistic gratification. At their last
contact, Joe told Dr. Castaldi that he would miss their conversations; Dr.
Castaldi said he believed that Joe had great potential and wished him the
best. Dr. Castaldi believed that the main impact of therapy had been the
opportunity for Joe to internalize a positive relationship as well as Joe's ability and decision to take advantage of this opportunity. Treatment had lasted
approximately 1 year.
In sum, then, Dr. Castaldi followed the principles of personality-guided
therapy by modifying his approach to Joe on the basis of Joe's personality
style. The initial connection with Joe was established through a relationship
style that is possibly unique to the treatment of individuals with antisocial
PD: The therapist was empathic and validating but not particularly warm or
nurturing. The therapist then used cognitive and interpersonal techniques
and theory, which helped the client to develop a different understanding of
his relationships on the ward. His choice of how to deliver the message about
how he was being "played" by other inmates, which was a gut-level therapeutic intervention, was consistent with dialectical behavior therapy (Linehan,
1993) and paradoxical communication concepts (Watzlawick, Weakland, &
Fisch, 1974). Behavioral techniques are implicit in prison life, because there
is a system of rewards and punishments to enhance compliance with ward
routines. However, the impact of the behavioral consequences was entirely
contingent on the client's conceptualization of the consequences; thus, in
this case, cognitive work was essential in complementing the behavioral plan.
Once the client did some basic reframing, however, the behavioral consequences began to have their intended effect.
The second major turning point in the case, the client's confrontation
of the therapist regarding the client's superior strength and the way the therapist handled it, is an excellent example of the powerful impact of therapist
genuineness (Rogers, 1979). Psychodynamic thinking also impacted the analysis of this powerful transference response on the part of the client. His reaction to feeling vulnerable (i.e., to threaten, assert power, and take control)
was met in a different and therapeutic way. Presumably, Joe was anticipating
13 2
posturing, defensiveness, or power plays by Dr. Castaldi; when the latter reacted with honesty and empathy, it smashed his assumptions about the nature and potential of relationships.
The amelioration of Joe's depression occurred naturally as a consequence
of attending to the environmental and relationship issues that accompany
antisocial PD. The Axis I and Axis II conditions were treated as a unified
whole rather than as two separate conditions. As Joe's behaviors, cognitions,
and relationships changed, the depression dissipated.
13 3
7
DEPRESSION IN BORDERLINE
PERSONALITY DISORDER
I Feel
I feel the whirlwind twisting inside me
a great tornado tears me apart.
I feel the hate burning inside
fire and darkness blackens my soul.
I feel the fear squeezing my heart
incredible terror separates me from the world.
I feel the emptiness deep as a well
the huge black hole forever swallows me.
I feel the pain
need to die.
Insufferable punishment
can no longer live.
Brooke Bergan
'I am delighted to report that Brooke now describes herself as completely healed, through a
combination of psychotherapy and intensive prayer, and she is now a professional writer (Brooke
Bergan, personal communication, August 8, 2005). She requested that the following poem be
included here to provide a complete picture of her recovery: "To My Father, God: / "Let my days start
in Your presence / for just an hour or two / or all day long, for all I want / is to remain in You. / "I've
wandered over rocky roads / and always in the end / I've ended up back in Your arms / my broken
heart you mend. / "For in this life trials will come / but in and through them all / Your loving arms will
draw me on / to Heaven where I belong."
135
EPIDEMIOLOGY
Borderline is the most frequent of all PDs. According to the DSM-IVTR, 30% to 60% of individuals within personality disorder samples have a
borderline diagnosis. Borderline PD is estimated to exist in 2% of the general
population, 10% of individuals seen in outpatient clinics, and 20% of inpatients (American Psychiatric Association, 2000a, p. 708).
In a sample of depressed clients, approximately 16% had borderline PD
(Fava et al., 1995). Of the 116 individuals with major depression in a study
by Zimmerman and Coryell (1989), 6.9% had borderline PD. In Pepper et
al.'s (1995) dysthymic disorder sample, 24% had borderline PD. In a sample
of 249 depressed outpatients, 2% were diagnosed with "definite" and 8%
with "probable" borderline PD (Shea, Glass, Pilkonis, Watkins, & Docherty,
1987). In a sample of 352 clients with both anxiety and depression, approximately 14% had borderline PD as diagnosed by structured interview (Flick,
Roy-Byrne, Cowley, Shores, & Dunner, 1993). Thus the frequency of borderline PD in samples of individuals with depression ranges from 2% to 24%.
Likely reasons for the wide range include natural sample variation, inpatient
versus outpatient status, different definitions of depression (e.g., dysthymic
disorder vs. major depression), and changing criteria (e.g., some studies used
criteria from the third edition of the Diagnostic and Statistical Manual of Mental Disorders [American Psychiatric Association, 1980], and some used criteria from the revised third edition [American Psychiatric Association, 1987]).
Starting with borderline PD and looking at depression, a study that
included 175 clients with borderline PD found that 70.9% had major depression (McGlashin et al., 2000). Zimmerman and Coryell (1989) studied a
136
See chapter 2 for further discussion of theoretical models of relationships between Axis 1 and Axis II
disorders.
13 7
Positron-emission tomography scans on several samples have demonstrated reduced activity in the brains of adults with borderline PD, particularly in the orbital-frontal region (Goyer, Andreason, et al, 1994; Goyer,
Konicki, & Schulz, 1994). Studies by Soloff et al. (2000) with a sample of
people with borderline PD demonstrated reduced response to the serotonin
agonist fenfluramine relative to a placebo control. Using positron-emission
tomography scans and magnetic resonance imaging, Ley ton et al. (2001) also
found lower levels of brain activity near the frontal lobe area and differences
in the serotonin-rich areas of the brain, concluding that low serotonin synthesis capacity in the relevant pathways of the brain may promote impulsive
behavior in individuals with borderline PD. As seen in chapter 6, this volume, brain-scan studies have shown that individuals who have difficulty with
impulse control and aggression have reduced levels of activity in their brains
in a number of key locations. This effect held up whether one used lifetime
history of impulsive-aggressive acts or current impulsivity on an assigned
task to define impulsivity. Increases in aggression are associated with low
level of activity in the frontal cortex as well as reduced activity in several
areas within the limbic system. Although further research is necessary, these
preliminary results imply that memory and integration of sensory and emotional material are implicated in the difficulties experienced by people with
borderline PD.
Similarly, studies using computerized tomography scans have demonstrated interesting neuroanatomical differences between individuals with and
without borderline PD that correspond to clinical presentation. For example,
J 38
one study showed that when compared with controls, while controlling for
overall brain volume, people with borderline PD had a 16.0% smaller hippocampus and a 7.5% smaller amygdala (Driessen et al, 2000). The hippocampus plays an important role in memory, and the amygdala relates to a
variety of emotional processes.
Neuropsychological studies of individuals with borderline PD also provide highly useful and suggestive findings. O'Leary and Cowdry (1994) reviewed four neuropsychological studies done on people with borderline PD.
They concluded that people with borderline PD demonstrate difficulties with
visual discrimination and filtering and difficulties with recall of complex
material. There also appear to be problems in visuomotor integration and
figural memory. Neurological examinations and electroencephalogram studies have shown a high rate of subtle neurological dysfunction in individuals
with borderline PD (Zanarini, Kimble, & Williams, 1994). These problems
are generally in the mild to moderate range and are diffuse; thus they are
subtle and could easily be missed without testing.
Individuals with borderline PD have been found to have difficulty with
both verbal and visual memory, especially with regard to complex material.
Difficulty with recall of complex material may make it difficult for people
with borderline PD to learn from their experiences. We do not yet know
whether individuals with borderline PD have difficulty with retrieval, recall,
or both. Processing problems can also impact an individual's self-image.
O'Leary and Cowdry (1994) noted that "such a memory deficit may contribute to difficulties borderline patients experience in maintaining a continuous sense of self and using the past to respond to present events and predict
future consequences" (p. 147).
Thus, brain functioning and learning style may contribute to many of
the difficulties that we see in borderline PD. A number of the findings are
consistent with borderline psychopathology. Poor filtering often leads to confusion, which may contribute to excessive dependence on others and poor
boundaries. Diffuse neuropsychological dysfunction may be related to dissociation and other neurocognitive functions. Sluggish functioning of the serotonergic systems, imbalances in the cholinergic and noradronergic systems,
anatomical deficiencies in the amygdala, and dysfunction in the limbic system may lead a person to be extremely vulnerable to impulsivity and affective dysregulation. Deficiencies in the hippocampus may contribute to memory
problems. Many of the distortions people with borderline PD evince may be
seen as a function of neurological dysfunction. Splitting, for example, can be
seen as a problem of recall especially in evidence under conditions of high
emotional arousal.
A natural question is whether the neurological problems are primary
and cause borderline PD, whether borderline behavior causes neurological
impairment (e.g., through substance misuse and head injury associated with
high-risk behavior), or whether the problem is best explained by a third variBORDERLINE PERSONALITY DISORDER
J39
Medications that impact serotonin generally have had salubrious effects on individuals with borderline PD. Markovitz and Wagner's (1995) open
trial investigation of venlafaxine with 39 patients demonstrated decreases in
self-injurious behavior, somatic complaints, and Symptom Checklist90
scores. Silva et al. (1997) did an uncontrolled 7-week trial of fluoxetine with
35 patients that showed decreases in depression, impulsivity, and overall psychiatric symptoms and an increase in Global Assessment of Functioning
scores. Sertraline and citalopram appear to have decreased borderline symptomatology in an uncontrolled study (Ekselius & von Knorring, 1998; see
chap. 1, this volume). Rinne et al.'s (2002) double-blind placebo-controlled
study of 38 women demonstrated that fluvoxamine produces substantial decreases in rapid mood shifts, though aggression and impulsivity were not improved.
Anticonvulsants have had mixed results, de la Fuente and Lostra's (1994)
double-blind, placebo-controlled trial of carbamazepine with 20 inpatients
showed no improvement on the Symptom Checklist90, Brief Psychiatric
Rating Scale, and an acting-out scale, and 2 participants in the medication
group dropped out because of dramatic acting-out behavior (wrist cutting
and physical violence). An 8-week, open-label trial (Stein, Simeon, Frenkel,
Islam, 6k Hollander, 1995) of valproate with 8 patients found that there was
overall improvement in about half the cases. Impulsivity, irritability, anger,
anxiety, and rejection sensitivity showed modest improvements. Stein et al.
(1995) concluded that valproate may have "limited efficacy" in treating borderline PD. Hollander and his associates (Hollander et al., 2001; Hollander,
Swann, Coccaro, Jiang, & Smith, 2005, in two small randomized controlled
trials with divalproex sodium, found decreased aggression, irritability, depression, impulsive aggression, and suicidality as well as improved global impression. In a study that was unique in that it focused on immediate effects,
Philipsen et al. (2004) administered clonidine to 14 female participants and
took ratings after 30, 60, and 120 minutes. There were significant decreases
in inner tension, dissociative symptoms, and urge to commit self-injurious
behavior; the effects were strongest after 30 to 60 minutes.
Atypical antipsychotic medications have also shown promise in treating symptoms of borderline PD. Case studies have illustrated marked improvements in some individuals. Khouzam and Donnelly (1997) noted remission of extreme impulsivity and self-mutilation using risperidone, and
Szigethy and Schulz (1997) found that a client with borderline PD and dysthymia responded to a combination of risperidone and fluvoxamine. Treat140
141
group (from 41 to 55). Enough studies are available that meta-analysis should
be considered to evaluate the costs and benefits of various treatments. All of
the findings should be interpreted with caution: Medication studies of individuals with borderline PD are marked by high dropout rates, and large placebo effects are also often seen in controlled studies. Most of the studies
reviewed are small and uncontrolled; even in this best-studied of PDs, the
research on medications is woefully inadequate. Adequately sized randomized clinical trials should be conducted on each medication used with this
group. Researchers and clinicians should be sobered by paradoxical findings
with widely used medications: Individuals with borderline PD may not have
the expected improvements and may even get worse with particular drugs.
Psychological Factors
Millon's Theory
Borderline PD, in Millon's conceptualization, is a "dysfunctional," or
extreme, variant of dependent, histrionic, and passiveaggressive PDs. As
such, the etiology, including biological underpinnings and psychosocial experiences, is related to the subtype. The more dependent types generally have
more sluggish temperaments and a history of being overnurtured (with the
inevitable meta-message that the child is incompetent and requires care).
The more histrionic types have highly active temperaments and were reinforced for performing for their parents and others. The passive-aggressive
(negativistic) types tend to have moody, irascible temperaments and were
raised with parental inconsistency. In all cases, repeated failures of their attempts to cope with the world have led to increasing desperation. Rather
than flexibly adapting to the environment, however, the person with incipient borderline PD tends to recycle the same coping efforts but at a higher or
more extreme level of intensity. Eventually, the individual engages in extreme behaviors much of the time. Overall, Millon viewed mundane, oftrepeated patterns in the environment (such as ongoing parental inconsistency) as more central to the development of PDs than dramatic but
time-limited traumatic events (such as a single episode of sexual abuse).
The fundamental feature, as seen in Millon's tridimensional model,
is that there is ambivalence on all three dimensions (active-passive, painpleasure, and selfother), which emerges as a near-constant state of ambivalence and tension. This is not true of all people with PDs. The person with
dependent PD can feel comfortable in an environment in which he is consistently nurtured and supported; similarly, the individual with narcissistic PD
can feel comfortable if interacting with one or more admirers. Not so with
borderline PD. A persistently nurturing other person will tend to elicit fears
of engulfment; however, anything less than complete devotion at every moment elicits abandonment terror. Similarly, the person with borderline PD
tends to alternate between passively hoping for attention and affection from
BORDERLINE PERSONALITY DISORDER
J 43
others and actively seeking to have his or her emotional needs met. Millon
(1996) described this polarity conflict as signifying "the intense ambivalence
and inconsistency that characterizes the borderline, their emotional vacillation, their behavioral unpredictability, as well as the inconsistency they manifest in their feelings and thoughts about others" (p. 660).
The description of borderline PD in terms of Millon's eight domains is
given in Appendix B. Of these domains, paradoxical interpersonal conduct,
uncertain self-image, and split morphologic organization are most central
and salient (Millon, 1999, p. 645).
Psychodynamic Therapy
Psychodynamic formulations of borderline PD focus on a variety of developmental and constitutional factors that interact to form the disorder.
The term borderline is derived from the conceptualization of Stern (1938)
that there is a group of clients who seem to dwell at the boundarythe "borderline"between psychosis and neurosis. It is important to note that Stern's
initial interest in this area stemmed from the fact that there were people who
seemed like they should be amenable to analysis who in fact did very poorly.
Comparing psychoanalytic treatment with a necessary surgery, Stern stated,
"A negative therapeutic reaction is nevertheless inevitable; in some, the reaction is extremely unfavorable, and, cumulatively, may become dangerous;
patients may develop depression, suicidal ideas, or make suicide attempts"
(Stem, 1986, p. 59).
The word inevitable is chilling in this context; classical psychoanalysis
is not recommended for this population. However, with some modest modifications from psychoanalysis, psychodynamic methods are effective. The
theories described below draw primarily on object relations theory. Thus, the
key issue is not the relationships with real people, such as the mother, but
rather the individual's internal representation of the mother and, perhaps
even more germanely, the relationship of various parts of the self (part'Self)
to various parts of the other (part-objects). Thus, for example, the person with
borderline PD may see him- or herself as a denigrated, abused self in relation
to a sadistic, abusive other; both this self and this other are really part-self
and part-object relations.
O. F. Kernberg and colleagues used the concept of "borderline personality organization" rather than borderline PD (Clarkin, Yeomans, & Kemberg,
1999; O. F. Kemberg, 1967/1986a; O. F. Kemberg, Selzer, Koenigsberg, Carr,
& Appelbaum, 1989). Borderline personality organization is conceptualized
as a level of functioning rather than a categorical conception. Theoretically
derived from the interplay of psychodynamic processes related to how the
developing child handles an excess of aggressive libidinal energy, borderline
personality organization includes features of not only borderline but also narcissistic, schizoid, schizotypal, paranoid, histrionic, antisocial, and dependent PDs (Clarkin et al., 1999; O. F. Kernberg, 1967/1986a). Excess aggres144
145
"libidinal withdrawal" from the child, frustrating the child's separationindividuation process. The most common pattern occurs when the mother
discourages separation, instead encouraging dependency and clinging. The
mother, according to Masterson, is generally a person with borderline PD
herself who has her own problems with separation anxiety. The child's attempts to individuate provoke extreme anxiety in the mother, which in turn
elicits caretaking behavior from the child. Another pattern is for the child to
regress and cling to the mother, failing to individuate, thus gratifying the
mother's emotional needs. Alternatively, the mother may withdraw, unable
to handle the child's dependency needs.
For Masterson, like Kemberg, the key to understanding the individual
with borderline PD was understanding the part-self and part-object relations
that compose the psyche. The mother is divided into two part-objects as a
function of splitting. There is the rewarding object relations unit, which is
the all-good object, and the withdrawing object relations unit, which is all
bad (hostile, withdrawing, and rejecting). The child can defend against
feelings of abandonment in one of two ways. The first way is to project the
rewarding unit onto others (including the therapist) while internalizing
the withdrawing unit. This leads to clinging subordination. The second
path is to project the withdrawing unit onto others while the rewarding
unit is internalized. Others are thus seen as hostile, critical, and distancing.
The client avoids thoughts and feelings that interfere with this defense,
primarily through denial, and psychotherapeutic progress once again grinds
to a halt.
Abandonment depression, and the defenses built around it, for
Masterson, constitute the heart of borderline psychopathology. Masterson
called this pattern the "borderline triad: separation-individuation leads to
depression which leads to defense" (Masterson, 1981, p. 133). Like Kernberg,
Masterson recommended confrontation as the path through which to break
this stalemate. The purpose of the confrontation is to "render the functioning of the split object relations unit/pathologic ego alliance ego alien"
(p. 136). That is, clients must experience their perceptions of others as partobjects (e.g., as entirely hostile, withdrawing, bad, or good), as something
foreign and in need of repair rather than as a necessary and adaptive response
to reality. Stated Masterson, "The clinging transference calls for the confrontation of the denial of destructive behavior . . . while the distancing
transference calls for the confrontation of the negative, hostile projections,
usually on the therapist" (1981, p. 137).
Confrontation, when effective, thus increases anxiety, because clients
become aware of conflicts that were formerly suppressed, denied, or defended
against through acting out. When they recognize that these defenses are selfdestructive, they control their behavior, thus experiencing the abandonment
depression. This promotes a healing cycle: "There results a circular process,
sequentially including resistance, confrontation, working through the feel146
147
EXHIBIT 7.1
Maladaptive Ways of Thinking Learned in Early Childhood
by People With Borderline Personality Disorder
Early maladaptive schemas
Abandonment/instability
Mistrust/abuse
Emotional deprivation
Defectiveness/shame
Dependence/incompetence
Undeveloped self
Insufficient self-control/selfdiscipline
Subjugation
Punitiveness
Possible expression
I worry that people I feel close to will leave or
abandon me.
I have been physically, emotionally, or sexually
abused by important people in my life.
Most of the time, I haven't had someone to nurture
me, share himself or herself with me, or care
deeply about everything that happens to me.
I am unworthy of the love, attention, and respect of
others.
I do not feel capable of getting by on my own in
everyday life.
I feel that I do not really know who I am or what I
want.
I often do things impulsively that I later regret.
I feel that I have no choice but to give in to other
people's wishes, or else they will retaliate or
reject me in some way.
I'm a bad person who deserves to be punished.
Note. Based on the Young Schema Therapy Questionnaire, Short Form and Long Form, adapted from
Cognitive Therapy for Personality Disorders: A Schema-Focused Approach (3rd ed., pp. 12-16), by J. E.
Young, 1999, Sarasota, FL: Sarasota Professional Resource Press, and personal communication from
the author, May 3, 2002. Reprinted by permission of Jeffrey E. Young. Reproduction without written
consent of the author is prohibited.
logical parallel of the psychodynamic construct of splitting, all-or-none thinking is seen as having broad-reaching implications:
Since dichotomous thinking can produce extreme emotional responses
and actions and can produce abrupt shifts from one extreme mood to
another, it could be responsible to a considerable extent for the abrupt
mood swings and dramatic shifts in behavior that are a hallmark of BPD.
(A. T. Beck & Freeman, 1990, p. 187)
A. T. Beck and Freeman (1990) further noted that relationship issues
with the therapist will be much more prominent for people with borderline
PD than for those with other disorders. A. T. Beck et al. (2004) recommended
some specific strategies for fostering a relationship with the person with borderline PD:
The therapist actively breaks through the detachment of the patient, is
actively involved in crises, soothes the patient when sad, and brings in
him- or herself as a person. . . . This approach almost necessarily provokes difficult feelings in the patient, based on core schemas, which is
good because these can be subsequently be addressed in therapy. Thus,
this "reparenting" approach is considered an essential ingredient of the
treatment, (p. 202)
148
149
punished or told her interests are bad or wrong; conversely, the boy who is
told he should be able to control his emotions and that his yearning for
nurturance is a show of weakness is also being invalidated. Consistent invalidation leads to confusion and poor self-esteem. As is emphasized below, borderline PD results when the biologically vulnerable individual is raised in a
persistently invalidating environment.
The concept of invalidation explains the finding that sexual abuse is
common among people with borderline PD. Sexual abuse is the ultimate
invalidation. The victim's well-being is irrelevant to the abuser, who is gratifying his or her needs. As described by Linehan (1993),
Sexual abuse, as it occurs in our culture, is perhaps one of the clearest
examples of extreme invalidation during childhood. In the typical case
scenario of sexual abuse, the person being abused is told that the molestation or intercourse is "OK," but that she [or he] must not tell anyone
else. The abuse is seldom acknowledged by other family members, and if
the child reports the abuse she [or he] risks being disbelieved or blamed,
(pp. 53-54)
Emotional Vulnerability Versus Self-Invalidation. Returning to the polarity model, Linehan (1993)defined emotional vulnerability as ongoing and
extreme emotional sensitivity, intense emotional reactions, and the experience of persistent negative emotional reactions. She compared this with the
physical hypersensitivity of the burn patient:
The net effect of these emotional difficulties is that borderline individuals are the psychological equivalent of third-degree burn patient. They
simply have, so to speak, no emotional skin. Even the slightest touch or
movements can create immense suffering. Yet, on the other hand, life is
movement. Therapy, at its best, requires both movement and touch. Thus,
both the therapist and the process of therapy itself cannot fail to cause
intensely painful emotional experiences for the borderline patient.... it
is the experience of their own vulnerability that sometimes leads borderline individuals to extreme behaviors (including suicidal behaviors), both
to try to take care of themselves and to alert the environment to take
better care of them. (p. 69)
Linehan believed that emotional vulnerability is the core feature of borderline PD, with many of the other symptoms making sense as an attempt to
cope with it. Excessive emotional arousal, such as feelings of depression, interferes with cognitive functioning and behavioral responses that would facilitate coping. Attempts to regulate painful emotions are the precursors of
impulsive behaviors, such as drug or alcohol use and unprotected sex, which
then lead to further problems. Attempts to modulate emotions through social interactions can lead to excessive dependency and concomitant fears of
abandonment. Thus, emotional vulnerability becomes a focal point around
which many borderline symptoms make sense. This tendency toward affective
150
Predictablythough uncomfortably, for the therapistthe patient responds to the invalidating (therapy) environment with anger, depression,
BORDERLINE PERSONALITY DISORDER
151
To resolve these dilemmas, the patient must learn self-acceptance, compassion, and self-soothing and accept gradual change, and the therapist must
be keenly attuned to messages regarding invalidation and rapidly shift between validation and change strategies.
Active Passivity Versus Apparent Competence. Active passivity is
Linehan's eye-catching phrase that captures the phenomenon of demanding
clinginess and neediness seen in people with borderline PD. It is something
of a hybrid between the passivity of the dependent, who waits and hopes for
support, and the activity of the histrionic, who provides entertainment in
"exchange" for nurturance. The likely experiential history of people experiencing active passivity is a history of failure when they attempt to cope actively with situations (i.e., learned helplessness), presumably accompanied
by at least some instances of soothing by others. Biologically hypersensitive
individuals who lack the capacity to self-soothe, are unable to tolerate their
current distress, and have a history of failing when they make active efforts
to cope may desperately turn to others to rescue them. According to Linehan
(1993), "A passive self-regulation style is probably a result of the individual's
temperamental disposition as well as the individual's history of failing in
attempts to control both negative affects and associated maladaptive behavior" (p. 79). Gender roles also contribute in that women tend to learn to use
emotion-focused coping and see the "self in relationship" (Gilligan, 1988)
within the context of a patriarchal culture. To the extent that people see
rescue by other individuals as the only way to manage their lives, they will
tend to experience frantic fear of abandonment.
Apparent competence refers to the behavior of a person who is competent in some areas while behaving completely inappropriately at times. The
individual's competence, for example, at work, may belie substantial deficits
in other areas. Others are surprised, perhaps even shocked, when a person
who appears to be a typical colleague suddenly has a "meltdown" or behaves
inappropriately for no apparent reason. Linehan (1993) explained this phenomenon as occurring because of (a) a lack of stimulus generalization, (b) a
failure on the part of the person with borderline PD to communicate his or
15 2
J 53
To do so, the therapist is advised to help clients to process their grief, and
encourage them to know that they can survive the inherent stress of doing
so, while providing concrete grieving strategies or skills. Simultaneously, or
in rapid alternation, the therapist must validate the client's persistent sense
of crisis.
Client-Centered, Humanistic, and Existential Therapies
An important theoretical perspective within the client-centered and
humanistic therapy domain is Margaret Warner's (2000) "fragile process."
Given the antilabeling orientation of most humanistically oriented therapists, it is relatively difficult to find theoretical work on PDs from that perspective. However, assuming that Linehan's (1993) theory about the invalidating environment is correct, it is likely that a therapeutic approach based
on validation and unconditional positive regard would be effective; the one
outcome study I could find (Eckert & Wuchner, 1996) indicated results comparable to those of dialectical behavior therapy (Linehan, 1993) and transference-focused therapy (Clarkin et al, 1999). Warner defined fragile process
as follows:
"Fragile" process is a style of process in which clients have difficulty modulating the intensity of core experiences, beginning or ending emotional
reactions when socially expected, or taking the points of view of other
people without breaking contact with their own experience. Clients in
the middle of a fragile process often feel particularly high levels of shame
and self-criticism about their experience. (Warner, 2000, p. 145)
Integrating fragile process with developmental theory, especially attachment theory, Warner (2000) hypothesized that individuals who are prone to
fragile process are insecurely attached. Individuals with insecure attachment
to adult figures find that high arousal leads to emotional overload and disorganization, which neither they nor their caregivers are able to soothe. As
children they would thus often feel either fearful (because they could not be
soothed) or angry (if they expected the caregiver to help and were disappointed or frustrated). As infants they would either constantly seek out attachments to find sustaining nurturance or self-protectively withdraw from
others.
The dilemma throughout life, then, is that if persons with fragile process (like persons with borderline PD) express their feelings, they are often
misunderstood; if they withdraw, they feel empty. As Warner (2000) put it,
Clients who have a fragile style of processing often experience their lives
as chaotic or empty. If clients with high-intensity fragile process choose
to stay connected with their experience in personal relationships, they
are likely to feel violated and misunderstood a great deal of the time.
When they express their feelings, others in their lives are likely to see
them as unreasonably angry, touchy, and stubborn. These others are likely
BORDERLINE PERSONALITY DISORDER
155
Warner (2000) noted that there are pitfalls for the therapist treating
people with fragile process:
The client may be able to talk about feelings of rage at the therapist and
very much want them understood and affirmed. Yet, therapist comments
to explain the situation or disagree with the client will be felt as attempts
by the therapist to annihilate his experience, (p. 150)
COUNTERTRANSFERENCE
Several theorists have indicated that countertransference responses to
individuals with borderline PD tend to be similar because of the powerful
pull of the disorder. (Gabbard & Wilkinson, 1994; O. F. Kernberg, 1975,
1967/1986a; O. F. Kernberg et al., 1989; Meissner, 1988). Therapists frequently respond with feelings of worthlessness, depression, guilt, anxiety, and
self-doubt when, because of the client's splitting, the therapist is devalued
and rejected; such devaluation can also, understandably, lead to anger, rage,
and a desire by the therapist to terminate therapy (Adler, 1985; Gabbard 6k
Wilkinson, 1994; O. F. Kernberg et al., 1989; Meissner, 1982). As will be
discussed later in the chapter on narcissistic PD (chap. 9, this volume), such
156
feelings are generated as a function of therapists' narcissistic needs: Therapists are typically invested in being validated by clients' appreciation and by
their progress in therapy. For similar reasons, when they cannot live up to
their clients' magical expectations, therapists often feel frustrated, depleted,
ashamed, and impotent and doubt their own competence (Adler, 1985; O. F.
Kernberg, 1975; Meissner, 1982, 1988).
Therapists may experience rescue fantasies or engage in rescuing behaviors in which the therapist gives the client increasing amounts of time
and reassurance (Adler, 1985; Gabbard & Wilkinson, 1994). This is especially true with clients who are victims of sexual abuse. Gabbard and
Wilkinson (1994) suggested that the rescuer role unfolds in a predictable
pattern. Initially, therapists take extraordinary measures to show patients
that they care and to try to undo parental harm. However, the needs of the
client form a bottomless pit; eventually, the therapist begins to feel like a
victim rather than a rescuer. The authors noted, "Clinicians who treat borderline patients with a history of sexual abuse must never forget that an abusive parent has been internalized and thus exists as an introject ready to be
activated at the drop of a hat" (p. 55). The pattern can escalate further if
therapists try to hide their irritation by redoubling their efforts to show that
they care. Gabbard and Wilkinson suggested that the therapist break the
cycle by frankly acknowledging his or her own limits.
Cognitive therapists have noted that clients with borderline PD often
distort therapists' statements. For example, through magnification, the client
may see therapist suggestions aimed at increasing autonomy as threats of
abandonment; through selective abstraction, the client may see only the negative in a therapeutic intervention. These cognitive distortions may lead to
powerful feelings of frustration and hopelessness on the part of therapists.
Clinicians may have thoughts such as, "There is nothing 1 can do to help this
patient," and "1 must be tough and detached to prove I cannot be manipulated" (Layden, Newman, Freeman, & Morse, 1993, pp. 122-123). In addition to consultation, cognitive theorists have suggested the use of thought
records3 for therapists to challenge their countertransference responses
(A. T. Beck et al., 2004; Layden et al., 1993).
Individuals with borderline PD may become explicitly or implicitly seductive, which can arouse sexual feelings in the therapist (Searles, 1986).
Gabbard and Wilkinson (1994) cited several empirical studies that suggest
that borderline PD is a risk factor for therapist sexual acting out. This issue is
'Dysfunctional thought records are a standard cognitive therapy technique that has only recently been
suggested for self-care ot the therapist as well as for use with clients. The technique involves making
columns labeled, for example, "situation," "emotion," "automatic thought," "rational response," and
"outcome." In the situation in which a person with borderline PD threatens suicide, the therapist may
feel angry and have the automatic thought, "She is trying to manipulate me." A rational response
might be, "Whether or not she is trying to get me to do something using extreme measures, she is in
emotional pain," which leads to lower anger and increased compassion.
15 7
the concomitant increase in diagnoses; however, there are also forces at work
that are genuinely increasing the number of new cases. Because our genetics
have not changed appreciably, social changes appear to be the most likely
causal factors. One could say that if we were to design a society most likely to
create borderline PD among its citizens, our current American society would
be almost ideal.
Millon (1987) outlined a series of social factors that have contributed
to this increasing prevalence. We live in a world of rapid technological and
sociological change, the pace of which is constantly accelerating. In our highly
mobile society, it is becoming less likely that children will grow up in one
stable environment, in one home, in one city, or even in one family. Formerly stable institutions such as religious institutions and marriage are no
longer so stable. Participation in religious institutions is down (Clark, 2000;
Hadaway & Marler, 1993; C. Smith, Denton, & Paris, 2002). More than
50% of marriages end in divorce, and second marriages have an even higher
failure rate. The breakup of parents makes it more difficult for the developing child to internalize stable role models. Further, it is not uncommon for a
divorcing couple to line up on opposite sides of a courtroom, with each side
painting itself as all good and the other as all bad. The developing child can
internalize this kind of real-life splitting.
Many women with children are now engaged in full-time careers, but
few fathers have chosen to stay home with their children. Today, children
are often raised by a patchwork of "others," including day-care workers,
babysitters, and aides working in early education programs. Extended kinship networks, although still a positive and stabilizing force in African American, Asian American, and Latino subcultures (Sue & Sue, 2003), have had a
declining role in White majority culture. Working parents often come home
relatively late, exhausted from workday demands. They have difficulty spending the few precious moments they have with their children providing firm,
consistent discipline. Instead, they often assuage their guilt by being lax or
lavishing the child with gifts.
Television and other video media also have a profound impact on personality development. Role models and heroes have become increasingly violent, unstable, and outwardly sexual. Emotional shallowness and instability
often dominate TV programs. Problems develop and are resolved in 30 to 60
minutes, often as a result of a dramatic 2-minute confrontation. The sincere
expression of feelings and the negotiations that constitute real conflict resolution do not happen on TV. It is reasonable to theorize that as our children
watch television they are learning how to be impulsive, cynical, sexually
unrestrained, explosively angry, and melodramaticthat is, more borderline.
According to Millon (1987),
TV may be nothing but simple pablum for those with comfortably internalized models of real human relationships, but for those who possess a
BORDERLINE PERSONALITY DISORDER
159
Alienated from family and community life, people experience emptiness, loneliness, and meaninglessnessfoundations of the borderline personality. The answer promoted by powerful forces within our culture is to
buy more to feel better. Of course, material items never really fill the void, so
people continue to experience the emptiness and the drive to fill it. Explained
Cushman (1990), the U.S. national character was once one that valued community; it is now a nation that values spending and consuming. Where it was
once a society of creators, it is now a society of consumers, impulsive, cynical, depressed, and increasingly enraged by simply waitingon the road, in
line, and online.
Finally, the increasing prevalence of sexual abuse (Sedlak & Broadhurst,
1996) is likely a contributing factor in the increasing prevalence of borderline PD. The causal role of sexual abuse in borderline PD is complex. We do
know that not all individuals who have been sexually abused develop borderline PD, and not all people with borderline PD have been sexually abused.
Zanarini et al. (1998) have shown that borderline PD cannot be reduced to
complex posttraumatic stress disorder. Nonetheless, borderline symptoms
logically relate to sexual abuse. In addition to Linehan's (1993) observations
about the connection between invalidation and sexual abuse, those who have
been sexually abused commonly use defenses that are also used by people
with borderline PD. Dissociation (to mentally escape from the abuse) and
splitting (to allow one to have a relationship with the abuser) are associated,
respectively, with DSM-IV-TR's diagnostic Criteria 9 and 2 for borderline
PD. Low self-esteem, a common concomitant of abuse, often leads to depen160
dency and fear of abandonment (Criterion 1), suicidal feelings (Criterion 5),
and depression (Criterion 6). Thus, unless proven otherwise, it is wise to
assume that sexual abuse plays a contributing role in borderline PD, and that
as rates of abuse rise, so will rates of borderline PD.
On the topic of sexual abuse, it is important to note that therapists may
erroneously blame families or assume that family members were abusive when
in fact the family members are often the greatest source of support to the
person with borderline PD. Gunderson, Berkowitz, and Ruiz-Sancho (1997)
put it this way:
I [John Gunderson] was a contributor to the literature that led to the
unfair vilification of the families and the largely unfortunate efforts at
either excluding or inappropriately involving them in treatment. So it is
with some embarrassment that I now find myself presenting a treatment
that begins with the expectation that families of borderline individuals
are important allies of the treaters and that largely finesses the whole
issue of whether they had anything to do with the origins of psychopathology. . . . The parents generally saw the families as much healthier
than did the borderline offspring. Much of the preceding literature about
the families of borderline patients derived solely from reports provided
by the borderline patients, and rarely included the families' perspective,
(p. 449)
Thus, we must exercise caution in our assumptions about families and be
open to an inclusive approach when appropriate.
161
EXHIBIT 7.2
Therapeutic Strategies and Tactics for the Prototypal Borderline Personality
STRATEGIC GOALS
Balance Polarities
Reduce conflict between active-passive polarities
Reduce conflict between pain-pleasure polarities
Reduce conflict between self-other polarities
Counter Perpetuations
Reduce capricious emotionality
Moderate inconsistent attitudes
Adjust unpredictable behaviors
TACTICAL MODALITIES
Stabilize paradoxical interpersonal conduct
Rebuild unstable self-image
Steady labile moods
Note. From Personality-Guided Therapy (p. 655), by T. Millon, 1999, New York: John Wiley & Sons.
Copyright 1999 by John Wiley & Sons. Reprinted with permission of John Wiley & Sons, Inc.
163
tines; he smoked in bed, creating a fire risk, and refused his routine bowel
care, which could lead to hypertensive crisis and death. These behaviors appeared manipulative to the staff and created a great deal of anger on the part
of some staff; other staff believed his requests were reasonable. As is typical
in cases of borderline PD, there was countertransferential anger and pity as
well as substantial splitting among staff. Doug was also being withdrawn from
methadone, about which he was ambivalent.
There were a number of factors that I considered in conceptualizing
this complex case. First and foremost, I wanted to understand how the client's
personality was integral to the difficulties he was experiencing. With his violent and desultory history, the client superficially appeared to have a prototypical antisocial PD. However, the melange of reactions among the staff led
me to consider borderline PD in addition, which turned out to be his primary
diagnosis. This led to predictable vicious circles (Millon, 1996) that exacerbated existing problems. Not surprisingly, Doug's abuse was eliciting feelings
of demoralization, helplessness, and dysphoria among some nurses while bringing out anger and frustration among others. Blocked from active aggression
by their professional role and their moral values, many engaged in passiveaggressive behavior (e.g., being slow to answer his call bell). Such responses
fueled Doug's indignation and strengthened his rationale (or, more accurately, his rationalization) for the "necessity" of the abusive behavior. Many
on the staff experienced feelings of anger, frustration, and helplessness; as a
group, nursing staff wanted the patient transferred to another facility to escape his irritating presence. Transfer was not an option in this case; moreover, if he were to be adequately rehabilitated, behavior change was essential, and merely passing him along would not be helpful to the patient or to
the new facility.
I further conceptualized the problem with abuse and the staffs response
to it as being akin to that of a dysfunctional family. There was a central
treatment team, consisting of the physicians, head nurses, psychologist, and
social worker. The nursing staff, who were hierarchically lower than the treatment team, were the ones being abused. As in many dysfunctional families,
unhealthy alliances were formed. Nurses who were being abused were angry.
Several of those who got along well with Doug, on the other hand, experienced pride and blamed the abused nurses' lack of skill for their fate. Initially, I felt angry with Doug for his abusive behaviors, though my emotional
reaction evolved over time.
It was essential to pull the team together into a consistent stance. Drawing on Bateson's (1972) concept that changes in one part of a system can
reverberate and lead to changes elsewhere in the system, I met with the "family
members" (the treatment team, all three shifts of nurses, and the client)
separately to facilitate differentiation (Bowen, 1966) and empowerment.
Minuchin's (1974) theory suggests that intergenerational boundaries and
hierarchies must be clear and appropriate in a healthy family. Thus, for ex164
165
Future research clarifying the nature of the relationship between borderline PD, depression, and suicidal behavior would be extremely helpful.
The person with depression and borderline PD appears to be at higher risk
for suicidal behavior than those with either condition alone (e.g., Friedman
et al., 1983), though additional research is necessary. In addition, research
on combinations of synergistic interventions would be useful in clarifying
the impact of different interventions and their timing; such studies may also
shed light on conceptualization of the treatment of borderline PD.
167
8
DEPRESSION IN HISTRIONIC
PERSONALITY DISORDER
There is such a thing in this state of Louisiana as the Napoleonic code, according to which whatever belongs to my wife is
also mineand vice versa.
Blanche:
My, but you have an impressive judicial air! [She sprays herself
with her atomizer; then playfully sprays him with it. He seizes the
atomizer and slams it down on the dresser. She throws back her head
and laughs.]
Stanley:
If I didn't know that you was my wife's sister I'd get ideas about
you. (T. Williams, 1953/1974, pp. 40-41)
There is almost palpable tension as one can sense the tragedy that will unfold
from her relentless poor judgment.
170
EPIDEMIOLOGY
According to the DSM-IV-TR, histrionic PD occurs in approximately
2% to 3% of the general population. In inpatient and outpatient settings,
histrionic PD has a prevalence of approximately 10% to 15%.
A number of studies have investigated the prevalence of histrionic
PD in depressed samples. Of the 116 individuals with major depression in a
study by Zimmerman and Coryell (1989), 9.5% had histrionic PD. In Pepper et al.'s (1995) dysthymic disorder sample, 14% had histrionic PD. In
another sample of depressed clients, approximately 3% had histrionic PD
(Fava et al, 1995). In a sample of 249 depressed outpatients, 4% were diagnosed with "definite" and 9% with "probable" histrionic PD (Shea, Glass,
Pilkonis, Watkins, & Docherty, 1987). Markowitz, Moran, Kocsis, and
Frances (1992) studied a sample of 34 outpatients with dysthymic disorder;
12% had histrionic PD. In a sample of 352 clients with both anxiety and
depression, approximately 11% had histrionic PD as diagnosed by structured interview (Flick, Roy-Byrne, Cowley, Shores, 6k Dunner, 1993). Thus,
in depressed samples, approximately 3% to 14% had histrionic PD. Conversely, looking at the rate of depression in individuals with histrionic PD,
Zimmerman and Coryell studied a community sample of 797 individuals
that included 143 individuals who were diagnosed with personality disorders. Among those with histrionic PD, 45.8% met the criteria for major
depression.
171
Reward dependence was defined by Cloninger (1998) as "a heritable predisposition for facility in the development of conditioned reward, particularly social cues" (p. 72). High reward dependence is related to elevated activity in the thalamus, which is consistent with the theory that serotonergic
projections from the thalamus to the median raphe nuclei play an important
role in social communication (Cloninger, 1998). Thus, science is gaining
preliminary understanding of some of the activity in the brain associated
with histrionic PD.
Heritability
173
with their lives, they, rarely feel the need to schedule such time on a
regular basis, (p. 230)
The authors found that this technique often provides a way for clients to
manage their depression long after termination.
Psychodynamic Therapy
Individuals with histrionic PD are often drawn to partners with obsessive-compulsive features. It is from such relationships that the phrase "opposites attract" seems to draw much of its strength. Prototypically, the histrionic woman is attracted to the stability of the obsessivecompulsive man.
His ability to stay focused on tasks, dedicated to long-term goals, and stoic in
the face of adversity is overwhelmingly appealing. Conversely, the obsessive-compulsive man feels like the "strong one" in the relationship, making
him feel like a "real man," sometimes for the first time. When he is with her,
his self-doubts vanish; in patiently listening to her and supporting her, he
feels strong and good. Through her, he is able to experience emotionality,
spontaneity, and fun. Each derives vicarious emotional satisfaction from the
other. To a certain extent, the attraction is based not on similarity and mutual interests but rather on the prospect of making each individual in the
partnership whole, to fill in a "missing piece" (Sperry & Maniacci, 1998).
In many such relationships, over time the poor differentiation and unrealistic expectations on the part of the person with histrionic PD of what
the relationship can provide create a tremendous strain and lead to significant depression and other problems in one or both partners (Sperry &
Maniacci, 1998). The histrionic wife is disappointed with her "stick-in-themud" husband, who is too involved with his work to pay attention to her,
and too "boring" for her even when they are together. His indecisiveness
makes him seem "weak" to her, and she may become castrating or provocative. She may flirt with other men in front of him, secretly hoping to provoke
HISTRIONIC PERSONALITY DISORDER
175
176
Group Therapy
Individuals with histrionic PD are in some ways naturals for group treatment. There is a concern, given that it is an explicit criterion in DSM-IVTR, that clients will feel uncomfortable if they are not the center of attention in a group. If a group norm is established that everyone will have an
opportunity to participate, and if clients see that their contributions are valued even when their problems are not the main topic of conversation, then
they can gain valuable perspective. Their people-pleasing proclivities tend
to facilitate rapid joining with the group (though their need for constant
attention puts them at risk for becoming monopolizers). Further, sometimes
they can see in others what they resist seeing in themselves, or they can hear
from a peer what they cannot process from the therapist. Psychodrama is a
technique that may be particularly well suited to individuals with histrionic
PD. It gives them a role to play, whether their problems are the focus of
attention or not. It also takes advantage of their attraction to theatrics. Perhaps surprisingly, a search on PsycINFO for "psychodrama and histrionic
personality disorder" yielded only one hit, an article entitled "Psychodrama
With the Hysteric" (Clayton, 1973).
COUNTERTRANSFERENCE
Similar to clients with borderline PD, individuals with histrionic PD
can pull powerfully for therapists to play the role of "rescuer." Rather than
being pulled into such a role, therapists are well advised to examine their
thoughts and motivations and continue to encourage a collaborative relationship (A. T. Beck et al., 2004). Therapists who do get drawn in are likely
to find, at some point, that they feel manipulated and thus frustrated and
angry. In addition, the client's meager and superficial inner world can be
frustrating to therapists as well and lead to feelings of hopelessness. For example, a case report indicated that a client with histrionic PD had almost no
awareness of any thoughts that took place in association with a panic attack
other than "I'm going to faint." The therapist had thoughts such as "Why
bother with this? Nothing sinks in. It won't make a difference" (A. T. Beck
et al., 2004, p. 228). Therapists in such situations must challenge their
thoughts and will often benefit from consultation.
Additional information regarding countertransference with histrionic
PD can be gleaned from the psychodynamic literature on the hysterical personality, a similar but somewhat less severe variant. Lionells (1986) noted
that therapists often experience anger, contempt, and frustration in response
to clients' manipulations. Feelings of sexual attraction are common because
of clients' (unconscious) seductiveness (Berger, 1971; Eriksson, 1962; Farber,
1961; O. F. Kernberg, 1992; Lionells, 1986; Muslin & Gill, 1978).
177
According to DSM-IV-TR, studies have found that histrionic PD occurs more frequently in women but that the ratio is no higher than the ratio
of women to men in the sample as a whole. Although noting that the disorder may be expressed differently in women and men, the DSM-IV-TR provided no guidance on how to avoid gender stereotypes that may lead to improper diagnosis and seemed to imply that gender bias is not a problem. A
growing body of literature, however, has suggested that clinicians tend to see
women as more histrionic and that there are diagnostic biases that favor
diagnosing women with histrionic PD (K. G. Anderson, Sankis, & Widiger,
2001; Erickson, 2002; Garb, 1997; Sprock, 2000). Clinicians should exercise
caution in carefully attending to whether the behaviors are causing distress
or functional impairments in the individual before applying the histrionic
label, particularly for women. It does appear, however, that the field is making progress in reducing gender bias, primarily through making the criteria
more gender neutral; in the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1987),
histrionic PD was described as being diagnosed much more frequently in
women than in men.
179
EXHIBIT 8.1
Long-Term Goals for Histrionic Personality Disorder
1.
2.
3.
4.
5.
6.
7.
8.
Reduce focus on gaining attention from others, while strengthening self-awareness and self-image.
Decrease manipulative actions designed to gain attention from others.
Form genuine social relationships.
Decrease seductive behavior and excessive use of physical appearance to secure attention.
Stabilize erratic moods and dramatic displays of emotion.
Reorient flighty cognitive style, increasing attention to relevant detail.
Improve self-esteem.
Decrease suggestibility.
Note. From The Personality Disorders Treatment Planner (pp. 169-170), by N. R. Bockian and A. E.
Jongsma, 2001, New York: John Wiley & Sons. Reprinted with permission of John Wiley & Sons, Inc.
EXHIBIT 8.2
Therapeutic Strategies and Tactics for the Prototypal Histrionic Personality
STRATEGIC GOALS
Balance Polarities
Diminish manipulative actions
Moderate focus on others
Counter Perpetuations
Reverse external preoccupations
Kindle genuine social relationships
Acquire in-depth knowledge
TACTICAL MODALITIES
Decrease interpersonal attention seeking
Stabilize fickle moods
Reduce dramatic behaviors
Reorient flighty cognitive style
Note. From Personality-Guided Therapy (p. 408), by T. Millon, 1999, New York: John Wiley & Sons.
Copyright 1999 by John Wiley & Sons. Reprinted with permission of John Wiley & Sons, Inc.
tend to produce change more slowly and thus require greater motivation on
the part of the client; in addition, the capacity to introspect may be built up
through other methods, which would then permit a psychodynamic approach
to proceed more efficiently. The current therapist can implement psychodynamic interventions, though in some cases it would be wise to refer the client, thus allowing the transference to form anew. Throughout any form of
treatment, the client's reaction to the therapist (transference) and the
therapist's reaction to the client (countertransference) can be effectively
monitored by using psychodynamic concepts (see Exhibit 8.2).
181
tines, which were indeed quite funny. She was prone to use humor as a way to
relieve tension, which was a great strength for her; however, it also distracted
her from getting around to deeper issues that might help her to work through
the anxiety. I made it a point to remember what we were discussing before
she went into her comedy mode. 1 would enjoy the show for a few minutes
and then I would remind her of where we were and encourage her to continue to process what we had been discussing. At the end of therapy, 1 asked
her what had been most helpful to her; she responded, in essence, that I gave
her space to joke around but always brought her back to the issue at hand.
Despite her numerous strengths, including a high IQ and strong interpersonal skills, Miko was prone to distractibility and a fragmented presentation
common to people with histrionic PD.
What was initially essential in treatment, of course, was to deal with
the problems related to her sexual assault. Like many victims, Miko largely
blamed herself. She felt deeply ashamed, believing that she had been "dirtied" and that she would bring disgrace to her family. Although not especially
prone to guilt generally, she felt guilty about being raped, implying that it
was her fault. Dealing with such issues can be rather tricky. To say it was not
her fault and there was nothing she could have done would have alleviated
guilt at the expense of increasing fear; if she truly believed that, then she
could never feel safe. Conversely, to say that there was something she should
have done would have increased guilt and shame. Her guilt feelings were
challenged using cognitive techniques, particularly Socratic dialogue. As we
reviewed the evidence, it became clearer to Miko that she had not asked for
this to happen and that it really was not her fault. I also explicitly stated, in
no uncertain terms, that Henry was wrong and that nothing that Miko did
warranted what had happened; this was important, because later we would
be investigating issues (such as how to stay safe, or her personality characteristics) that could be misinterpreted as blaming or internalized as self-blame.
Miko's feelings of shame and guilt subsided as these new beliefs became more
habitual. Simultaneously, we focused several months of therapy on the issue
of how to stay safe. She took numerous practical precautions, such as getting
to know men well before she would be alone with them; avoiding being out
alone late at night; and, most meaningfully to her, avoiding alcohol. One
issue that we discussed was to pay attention to whether a man objectified
women. Miko noticed, in retrospect, that Henry objectified women and that
generally his relationships lacked a meaningful personal quality. Miko avoided
men with these characteristics.
Miko initially could garner little social support from her family because
she did not want to tell them what happened. When I asked Miko to describe
her childhood, she stated that "everything was great" and her parents were
"wonderful." I found myself struggling to get a sense of what her experiences
were as a child, because her descriptions tended to be very broad and lacking
in detail. Although I could not quite understand how her relationships with
HISTRIONIC PERSONALITY DISORDER
183
her family members could be so good and yet she could not tell them about
her sexual assault, I attributed this to cultural issues. In Japanese culture,
shame is an extremely powerful emotion and plays a central role in society.
Loss efface can be considered worse than death, as illustrated by the ancient
seppuku1 ritual, in which a samurai (warrior) commits suicide to preserve his
honor. We discussed the issue on a number of occasions over several weeks; I
neither encouraged nor discouraged her from discussing it with her parents.
She ultimately decided to tell them; although shocked and pained, they were
supportive and helpful, and Miko felt relieved.
Miko's personality was extremely important to working through her
depression. We were able to draw on her outgoing nature and sense of humor
to help to reestablish feelings of pleasure and the sense of approval that she
enjoyed. Later in therapy, we would work on her need for approval and help
her to be more independent; this could be conceptualized as helping her to
balance out Millon's self-other dimension.
Miko's depression was largely related to her shame and guilt feelings
about the sexual assault. Through the interventions described above, her
depression began to subside, and the symptoms receded substantially within
approximately a dozen sessions. Her mood lifted, her appetite returned, and
her energy level increased. Her posttraumatic stress disorder symptoms were
more resilient. I treated these symptoms mostly by talking about her experiences, which functioned as an informal kind of systematic desensitization.
We also used coping strategies, such as deep breathing and relaxation. Slowly,
her symptoms subsided, but even after 18 months of treatment, there were
still occasional nightmares and anxiety symptoms related to the assault. It
should be noted that this case was treated prior to the development of eye
movement desensitization and reprocessing therapy (Shapiro, 2001) or else
that treatment would have been considered.
As the depression lifted, we spent more time on interpersonal and characterological issues. Miko had a variety of interpersonal difficulties that continued to motivate her to stay in therapy. Broadly speaking, her relationships
were characterized by an excessive need to please coupled with an excessive
need for reassurance, which was evidenced primarily in her long-term intimate relationships (e.g., her 2-year relationship with her boyfriend). There
was also a pattern of seductiveness, which was more evident in her relationships with me and with strangers. Two interactions were helpful in correcting her internalized schemas. Early in therapy, Miko mentioned that when
she had terminated with her prior therapist she brought him a gift and suggested that they begin dating. She told me that the therapist turned her down
on the grounds that they were of different religions and there would be problems raising the children. I am not a "blank slate" therapist, so I am certain
'Seppuku is also known as ham kiri, which has been mispronounced "hari kari" in English (Seppuku,
n.d.).
184
that Miko saw the look of astonishment on my face. I informed her that
dating relationships between therapist and client, even after termination,
were unethical because they typically harmed the client and undid a lot of
the good done by therapy. After that, slowly, Miko got less and less dressed
up for each session. Her seductiveness (e.g., through body language) also
lessened. Confronting her former therapist's inappropriate response had an
impact similar to a transference comment, but because it was less direct, it
was much easier technically. A second incident occurred in which Miko
went to rent a video from a video store. The young man behind the counter
told her to take the tape without paying for it, and to just bring it back the
next day. I asked Miko for her interpretation of why he had done so. She had
not really thought about it. Shrugging her shoulders, she said, "I guess because he's a nice guy." Using a typical cognitive challenge, 1 noted, "Then,
do you think he gives free tapes to everyone?" Despite numerous attempts to
come up with an alternative hypothesis, Miko was at a loss. Finally, I suggested, "Do you think he may have been attracted to you?" She looked astonished but could think of no other explanation. We were then able to discuss
signals that she might be sending out. The conceptual framework was that it
is great to be attractive, but it is important to be able to modulate it or else
one winds up either starved for affection or with constant unwanted attention. Her attitude changed quickly. Formerly, she saw herself as not pretty
enough and, at a deeper level, undesirable, perhaps even unlovable. Her insecurities drove subtle but near constant strivings for approval. Taking seriously the possibility that she was attractive, she consciously used these same
skills to attract men. I remember feeling somewhat bad for these young men
because Miko was more interested in experimenting with her skills than in
having a relationship with them (she had broken up with her boyfriend but
was not quite ready to reenter the dating world at that time). I felt relieved
that Miko needed only a few weeks of experimenting to see that she was able
to attract a great majority of those toward whom she showed interest. Equally
if not more important was to find the "off switch," which she also accomplished rather readily. Therapy continued for a number of months thereafter;
having gotten past many of her fears and insecurities, she was ready for deeper,
more meaningful, more intimate relationships than in the past. We continued to work on helping her to have more complete, assertive, and healthy
relationships. At the time of termination, Miko no longer met the criteria
for any Axis I or Axis II disorders and was generally functioning in a healthy
manner.
In sum, I used a series of catalytically sequenced interventions. Cognitive work helped her to get past her initial depressive shame. Further cognitive and behavioral interventions helped her to desensitize from her trauma
symptoms. A method akin to analysis of transference, albeit indirect, created
a significant correction of her beliefs about the therapeutic relationship and
her awareness of boundaries in relationships. The event at the video store
HISTRIONIC PERSONALITY DISORDER
185
allowed her to gain insight into the effect of her actions on others. By the
end of treatment, she was treating others in a more mature manner, driven
by healthy desires for intimacy rather than unhealthy strivings for reassurance. The therapy involved concepts drawn from cognitive, behavioral, interpersonal, and object relations conceptualizations.
186
9
DEPRESSION IN NARCISSISTIC
PERSONALITY DISORDER
187
(American Psychiatric Association, ZOOOa). In Pepper et al.'s (1995) dysthymic disorder sample, 4% had narcissistic PD. Markowitz, Moran, Kocsis, and
Frances (1992) studied a sample of 34 outpatients with dysthymic disorder;
6% had narcissistic PD. Of the 116 individuals with major depression in a
study by Zimmerman and Coryell (1989), 7.8% had narcissistic PD. In another sample of depressed clients, approximately 11% had narcissistic PD
(Fava et al., 1995). In a sample of 352 clients with both anxiety and depression, approximately 6% had narcissistic PD as diagnosed by structured interview (Flick, Roy-Byrne, Cowley, Shores, & Dunner, 1993). Thus, in depressed
samples, approximately 4% to 11% had narcissistic PD. Zimmerman and
CoryelPs (1989) study had no individuals with narcissistic PD; to my knowledge, no studies have assessed the frequency of depression in a sample of
individuals with narcissistic PD.
WHY DO PEOPLE WITH NARCISSISTIC PERSONALITY
DISORDER GET DEPRESSED?
Individuals with narcissistic PD often become depressed when their fantasies of unlimited success or admiration from others do not materialize. Noted
Millon(1999),
Dysthymic disorder is perhaps the most common symptom disorder seen
among narcissists. Faced with repeated failures and social humiliations,
and unable to find some way of living up to their inflated self-image,
narcissists may succumb to uncertainty and dissatisfaction, losing selfconfidence, and convincing themselves that they are, and perhaps have
always been, fraudulent and phony, (p. 244)
Drawing on psychodynamic and object relations perspectives, O. F.
Kernberg (cited in Millon, 1999) described the mixture of fear, rage, and feelings of failure that constitute depression in the individual with narcissistic PD:
For them, to accept the breakdown of the illusion of grandiosity means
to accept the dangerous, lingering awareness of the depreciated self
the hungry, empty, lonely primitive self surrounded by a world of dangerous, sadistically frustrating and revengeful objects, (p. 244)
Thus narcissistic PD appears to be a factor that increases one's vulnerability to depression. As with antisocial PD, however, it is likely that there is
a "reverse exacerbation" of sorts, in that individuals with narcissistic PD and
depression are likely more amenable to treatment than those with narcissistic PD alone (see chap. 2, this volume, for a discussion of theoretical models
of the relationship between Axis I and Axis II disorders).
Depression in narcissistic PD can alternate between being hostile and
being withdrawn and sullen. Often individuals compose themselves by returning to grandiose fantasies. If they can attain some level of success, then
NARCISSISTIC PERSONALITY DISORDER
189
the depression may dissipate. If not, however, reality continues to hit hard;
repeated failures reignite the depression. Tending to blame others, persons
with narcissistic PD may at times appear paranoid as they attempt to find an
excuse for failing to live up to their own virtually unreachable expectations.
190
anticonvulsants (e.g., carbamazepine or valproate). To the extent that persons with narcissistic PD show paranoia (e.g., feeling envious and believing
others are envious of them), Joseph suggested that antipsychotic medications such as risperidone, olanzapine, or sertindole are efficacious. When the
individual with narcissistic PD becomes depressed, Joseph recommended mood
stabilizers, selective serotonin reuptake inhibitors, or a combination thereof.
It is not clear from a theoretical standpoint that manic grandiosity and
narcissistic grandiosity are linked. According to Millon's (1996) theory, most
individuals with narcissistic PD are passive and calm unless insulted. Biological research would help to clarify the neuroanatomical and neurochemical correlates of narcissistic PD, leading to potential medication strategies.
Whether confirming Joseph's (1997) hypotheses or evaluating new ones, randomized clinical trials are necessary to verify the effectiveness of medication
treatment for symptoms of narcissistic PD.
Psychological Factors
Within the biopsychosocial model (Millon, 1969), psychological considerations fall midway between the "micro" level biological factors (which
involve considerations at the molecular level) and the "macro" level social
factors (which involve interactions of entire cultures, often including hundreds of millions of people). The psychological approaches reviewed in the
following sections attend to behavioral, cognitive, affective, unconscious,
and interpersonal aspects of the person's functioning.
Millon's Theory
Within his theoretical framework, Millon considered the narcissist to
be the passive, self-oriented type. Narcissists are variable along the painpleasure dimension, which is thus not entered specifically into the formulation of the personality. They are passive in that they expect to have their
desires met without having to put forth any effort. The self-orientation indicates an independent style, not relying on others for gratification. Millon
(1981) described the characteristics as follows:
Narcissism signifies that these individuals overvalue their personal worth,
direct their affections toward themselves rather than others, and expect
that others will not only recognize but cater to the high esteem in which
narcissists hold themselves. . . . Narcissistic individuals are benignly arrogant . . . they operate on the fantastic assumption that their mere desire is justification for possessing whatever they seek. (pp. 158-159)
It is Millon's belief that narcissism results from early and excessive positive regard from the child's parents. The parents view the child as marvelolusly superior and talented, regardless of his or her actual accomplishments.
NARCISSISTIC PERSONALITY DISORDER
191
EXHIBIT 9.1
Conceptualization of Narcissistic Personality Disorder: A Comparison of
Millon (1981, 1996) and O. F. Kernberg (1986b, 1986c)
Millonian narcissist (secure narcissist)
Core belief
I am perfect
I am great
I am superior to others
I am worthless
I am an imposter
Experiential history
Automatic thoughts
Putting forth effort is beneath me.
Others should recognize my superiority
and reward me for it.
J 93
194
and object images. The destruction of the external object image entails the
destruction of appropriate self images, leaving a feeling of emptiness. The
inability to experience others as real and whole objects implies inadequate
mirroring of the grandiose fantasies of the narcissist; in order to be admired,
one must have relationships with real people.
Idealized people, on whom these patients seem to "depend," regularly
turn out to be projections of their own aggrandized self concept... . His
attitude toward others is either deprecatoryhe has extracted all he needs
and tosses them asideor fearfulothers may attack, exploit, and force
him to submit to them. At the bottom of this dichotomy lies a still deeper
image of the relationship with external objects, precisely the one against
which the patient has erected all these other pathological structures. It is
the image of a hungry, enraged, empty self, full of impotent anger at
being frustrated, and fearful of a world which seems as hateful and revengeful as the patient himself. (O. F. Kernberg, 1970/1986b, pp. 218219)
Heinz Kohut's (1971) theory of narcissism is based on his clinical observations of numerous narcissistic clients. His theory differs from the others
in that he saw narcissistic needs and endeavors as constituting a separate line
of development, an essential and normal part of the growth process. Pathological narcissism, then, is a fixation to a point of development; the phaseappropriate conflicts, as with any fixation, remain unresolved and are thus
neurotically acted out or repeated (Kohut, 1971; see also O. F. Kernberg,
1986a, 1986b, 1986c). The trauma that causes the fixation is generated by
the parents:
As can be regularly ascertained, the essential genetic trauma is grounded
in the parents' own narcissistic fixations, and the parent's narcissistic
needs contribute decisively to the child's remaining enmeshed within
the narcissistic web of the parent's personality . .. (Kohut, 1983, p. 186)
Kohut (1971) refused to actually describe behavioral and diagnostic
attributes of narcissists. He maintained that the only reliable criterion for
diagnosis is the spontaneous emergence of one of the narcissistic transferences. Others, however, have gleaned characteristics from throughout Kohut's
work and have suggested the following criteria:
Sexually, they may report perverse fantasies or lack of interest in sex;
socially, they may experience work inhibitions, difficulty in forming and
maintaining relationships, or delinquent activities; and personally, they
may demonstrate a lack of humor, little empathy for others' needs and
feelings, pathologic lying, or hypochondriacal preoccupations.... Reactive increase in grandiosity because of perceived injury to self-esteem
may appear in increased coldness, self-consciousness, stilted speech, and
even hypomanic-like episodes. (Akhtar & Thomson, 1982, p. 14)
195
For Kohut, however, the critical feature was the type of transference
manifest within therapy. He stated that there are two basic kinds of transferences that indicate narcissistic disorders (see Kohut, 1971). The first is the
idealizing transference, in which the client sees the therapist as all good and
perfect, re-creating the relationship with the idealized parental "imago"
the unrealistic image of perfection through which the infant or young child
views his or her parents.
The second kind of transference, or mirror transference, is the reactivation of the grandiose self, that is, the undifferentiated omnipotence of infancy.
The mirror transference constitutes the therapeutic revival of the developmental stage in which the child attempts to retain a part of the original, all-embracing narcissism by concentrating perfection and power upon
a grandiose self and by assigning all imperfections to the outside. (Kohut,
1983, pp. 187-188)
There are three specific types of mirror transference: (a) merger (through
the extension of the grandiose self); (b) alter-ego or twinship; and (c) the mirror transference in the narrower sense, which is the one most often referred to
by Kohut. In the merger transference, the analyst is not experienced as a
separate entity but rather as a part of the analysand. This notion is similar to
Kernbergian notions of the transference, and in fact a case of O. F. Kernberg's
(1986c) illustrates the phenomenon dramatically. Kernberg had pointed out
some disparities between the content of the client's discussions and his tone
of voice. "The patient first had a startled reaction, and after I finished talking, he said that he had not been able to listen attentively to what 1 was
saying, but that he had all of a sudden become aware of my presence" (O. F.
Kernberg, 1986c, p. 279). The failure to even acknowledge the existence of
others except perhaps to bolster one's own self-esteem is a highly narcissistic
reaction.
In the twinship transference, the analysand sees the analyst as a separate person but one very much like him- or herself. Meissner, reviewing Kohut,
stated,
At a somewhat less primitive level of organization [than the merger transference], the activation of the grandiose self leads to the experiencing of
the narcissistic object as similar to, and to that extent a reflection of, the
grandiose self. In this variant, the object as such is preserved but is modified by the subject's perception of it to suit his narcissistic needs. This
form of transference is referred to as alter-ego or twinship transference.
Clinically, dreams and fantasies referring to such alter-ego or twinship
relationship with the analyst may be explicit. (Meissner, 1986, p. 417)
This is less archaic than the merger transference, but is still a primitive way
of relating; it is rarely seen, even among narcissists.
The mirror transference in the narrower sense is the most thoroughly
discussed by Kohut (1971) and thus presumably the most common or impor196
tant. In this case the analyst is experienced clearly as a separate person but
only considered important when he or she is "mirroring," or confirming, the
analysand's grandiose notions of him- or herself. It is the reenactment of "the
gleam in the mother's eye, which mirrors the child's exhibitionistic display"
(Kohut, 1971, p. 116). It is through the re-creation of this critical phase of
development that Kohut believed the corrective reconstruction process can
take place.
Narcissists do have relations with objects. However, according to Kohut
(1971), the objects only have significance insofar as they are seen as extensions of the self. Kohut thus labeled these "self-objects," inasmuch as the self
and the object are largely fused. Obviously, seeing others as a part of oneself
involves a great deal of denial or distortion, thus impairing the reality-testing
capabilities of the individual.
Family Systems
Couples in which both partners have narcissistic PD have unique vulnerabilities that can be addressed in couples therapy. Kalogjera et al. (1998)
described an approach based on Kohut's self psychology. In broad terms, the
problem of the narcissistic couple is that they fail to meet each other's selfobject needs, thus reactivating old wounds from childhood. Mirroring selfobject needs include the need for healthy attention from a significant other,
such as empathy and attentive listening. Twinship self-object needs include
shared interests and the need for mutually gratifying physical contact. Idealizing self-object needs include the desire for respect and the capacity to see
good and wonderful qualities in the other person. However, individuals with
narcissistic PD tend to be self-absorbed and provide insufficiently for the
partner's self-object needs in all three domains. When injured, each withdraws or rages at the other, perpetuating a cycle of wounding and of empathic failure. Kalogjera et al. illustrated the phenomenon with the following vignette:
In a conjoint marital session, Bob expressed his feelings of disappointment and hurt that his father did not accept his advice regarding a
legal matter. This was particularly painful to Bob, in light of the fact
that he is an expert in this field. This is one of the few instances in
which Bob was able to be open regarding his feelings about his family.
He was expecting an empathic and validating response from Kathy.
Instead, she looked at him in an icy manner and, in a cold tone, stated,
"I don't think that should be affecting you anymore." At that point,
Bob became visibly angry; he turned toward the therapist and, in an
agitated voice, shouted, "Would you want to be married to a woman
like this?" (p. 220)
Correcting the problem in relatedness requires that the therapist address, and show the couple how to redress, multiple levels of empathic failure simultaneously; in addition, it is necessary for the therapist to reenerNARCISSISTIC PERSONALITY DISORDER
197
gize the feelings of hope and optimism that formed the initial attraction
and idealization of the couple. Over time, this idealization is often worn
away (de-idealization), and desires for reparations emerge in their stead
(the curative fantasy).
As often happens in these cases, both members of the couple are
wounded simultaneously. The therapist must address their needs without
siding with either member of the couple, or, more accurately, siding with
both equally and simultaneously. Kalogjera et al.'s (1998) case illustration
is highly instructive:
Therapist (T): Bob, you felt very hurt . . . you very much wanted Kathy to
know how you felt about your painful interactions [rejection]
with your father. You hoped Kathy would understand your pain
and help you deal with it. (The therapist empathically expresses the
identification of the narcissistic injury, the unfulfilled selfobject needs
for mirroring and twinship, and recognition of curative fantasy.)
Bob:
T:
Kath^:
Note how the therapist simultaneously addressed both members of the couple
to prevent further narcissistic wounding and to promote an alliance. The
therapy continued:
T:
198
tion of idealizing self object failure and further weakening of the curative fantasy, and defensive withdrawal from the relationship), (p.
231)
After approximately 18 months of treatment, the couple was functioning much better. They were freer and more open and loving with one another and laughed together more, and their sex life became satisfying again.
They had worked through many of their hurt feelings, and, in the process,
each member of the couple experienced a dramatic reduction in narcissistic
symptoms.
L. S. Benjamin (1996a) recommended a similar approach. Couples work
can facilitate recognition of the narcissistic pattern, which can be a tricky
balancing act; it would be easy to fall into a position that would be seen as
blaming one member of the couple or the other. For example, noting, "You
tried to do something special and felt unappreciated by her" feeds the narcissistic husband by making his wife the villain, whereas stating, "Each person
in the couple contributes to the problem; let's look at what each of you is
doing" fails to validate the narcissistic client and is too far from his worldview.
Stating instead, for example, "You have been trying to make things work
well, and you feel just devastated to hear that they aren't going as perfectly as
you thought" allows the recognition of problematic aspects of the narcissistic
pattern, positively framed, and avoids blame.
Individuals with narcissistic PD also often pair with individuals with
dependent PD. For further discussion of the dependent-narcissistic couple,
see chapter 12 of this volume.
COUNTERTRANSFERENCE
Therapists frequently have difficult emotional reactions when treating
individuals with narcissistic PD. Therapists have narcissistic needs, among
them the need to be acknowledged by the client, perhaps even appreciated,
and another the need to see the client make progress to validate our perceptions of ourselves as competent therapists (Ivey, 1995; Kohut, 1971). Clients
with narcissistic PD can be maximally frustrating to both of those needs.
According to psychodynamic theory, their psychic structure is designed specifically to avoid acknowledging the contribution of others and to maintain
the fantasy that they are completely self-sufficient. The withdrawal of the
client leads to feelings of boredom, and his or her grandiosity pulls for feelings of anger and punitiveness. As was discussed in the chapter on antisocial
PD, the therapist will be drawn to reject clients when they act in an infantile
manner (e.g., relentlessly demanding attention and admiration like a 2-yearold). Analytically oriented thinkers relate this to the internal developmental process of the therapist, who rejected (or, more technically, whose superego rejected) the infantile self as part of maturation (Cooper, 1959/1986);
NARCISSISTIC PERSONALITY DISORDER
199
with him my role in therapy and made some efforts to correct what I am
certain were distortions on his part. The session felt empty and unsatisfying.
Many years later, in preparing a lecture on narcissistic PD, I had a fantasy of
a conversation that might have been:
Client:
Therapist:
I'm wondering, did you consider how I might feel when you said
that?
Client:
Isn't that your job? If you can't take it, you shouldn't be a counselor.
Therapist:
Client:
Therapist:
No.
Do you think that might have something to do with the difficulties you are having with your girlfriend?
Thus one possible approach to countertransference is to use it as a sensitive antenna to identify the transferencein this case, devaluation tinged
with entitlement and aggression. What has happened in the here and now
can then be related to the client's presenting complaint. If the client's presenting problem is relationship orientedand it often isthen when you as
therapist feel devalued, it is an opportunity to share how, within the context
of the client's goals, the comment is devaluing. Such "transference comments"
are likely to be effective only if a therapeutic relationship has been established in which the client has felt validated and understood, at least to some
degree.
201
the gender gap in narcissistic PD is the impact of male privilege and patriarchy on mental functioning.
Anthropologist Richard Castillo (1997) would agree with such an interpretation. In discussing gender differences in narcissistic PD, he observed,
The symptoms of narcissistic personality disorder appear to be more likely
to occur in societies that are hierarchical and egocentric, for example,
the United States. It is likely that persons with this disorder will belong
to one or more dominant groups in social hierarchies, (p 106)
He further noted that the disorder is less likely to occur in egalitarian cultures, such as the Senoi Temiar of Malaysia, and to be adaptive in extremely
egocentric cultures such as the Swat Putkhtun of northern Pakistan. For the
typical clinician in the United States, the major subcultures of interest are
Euro-American, Asian, Hispanic, Native American, and African American.
It is likely that more sociocentric cultures such as those of Japan and China
are less likely to produce narcissistic pathology. Hierarchies within Hindu
culture may produce behaviors that appear to be narcissistic but are considered acceptable within the culture (e.g., the superior behavior of the Brahman relative to the obsequious behavior of an untouchable). Machismo in
Hispanic culture may also produce "false positives" for narcissistic PD in
what are considered acceptable behaviors within the culture. White EuroAmericans may be more prone to take privilege for granted and to not recognize that their expectations may be considered excessive from the standpoint
of other, less empowered groups (Castillo, 1997).
STRENGTHS OF PERSONS WITH
NARCISSISTIC PERSONALITY DISORDER
Traits that are seen in mild, subclinical, or normal-range narcissism
entail many features that are highly valued in Western culture. Confidence
is valuable in nearly any circumstance. Most individuals who have accomplished great achievements have a belief in themselves that is along the dimension of narcissistic PD. The belief that one's ideas are sufficiently valuable that others should invest time, energy, or money in supporting their
actualization is a prerequisite to accomplishment. To a certain degree, what
separates healthy self-valuation from pathological narcissism is the understanding that ordinarily, regardless of one's ability, one must work hard to
achieve one's goals (Bockian, 1990).
TREATMENT PLANNING: SYNERGISTIC TREATMENT
Because the person with narcissistic PD is considered the passiveindependent type, the logical goal is to balance the polarities by helping the
202
EXHIBIT 9.2
Therapeutic Strategies and Tactics for the
Prototypal Narcissistic Personality
STRATEGIC GOALS
Balance Polarities
Stimulate active-modifying
Encourage other focus
Counter Perpetuations
Undo insubstantial illusions
Acquire discipline and self-controls
Reduce social inconsiderations
TACTICAL MODALITIES
Moderate admirable self-image
Dismantle interpersonal exploitation
Control haughty behavior
Diminish expansive cognitions
Note. From Personality-Guided Therapy (p. 443), by T. Millon, 1999, New York: John Wiley & Sons.
Copyright 1999 by John Wiley & Sons. Reprinted with permission of John Wiley & Sons, Inc.
client to become more active and more attached to others. Several proclivities lead to the perpetuation of the narcissistic pattern; these tendencies must
be undermined in order to make progress. The client's illusions of superiority
interfere with actual efforts to accomplish anything. Failure to gain desperately desired admiration because of genuine lack of accomplishment or underachievement leads to further fantasy rather than redoubled efforts; this
cycle leads to depression and other mental deterioration. Impulsive rage alienates these individuals from others, and thus from the support that may help
them to reach their goals. Another mechanism of social alienation is withdrawal into fantasies of unlimited success. Once social isolation occurs, the
feedback necessary to help ground the individual in reality is undermined,
and he or she begins to slide increasingly down the slippery slope of illusion,
delusion, and self-boosting fantasy. Thus, therapy should be geared to reduce
illusions of superiority, increase the person's self-control, and decrease social
alienation (see Exhibit 9.2). The long-term goals for depressed individuals
with narcissistic PD, then, include encouraging them to set goals; increase
activity level; and decrease arrogance, entitlement, and exploitation and
helping them to gain control over their rage and to recognize their depression and cope with it more effectively (Bockian & Jongsma, 2001; Jongsma
6k Peterson, 1999).
The most effective treatment arranges catalytic sequences that synergize
and build on one another. For the client with narcissistic PD and depression,
motivation will often be problematic; thus the best initial interventions will
NARCISSISTIC PERSONALITY DISORDER
203
be those that offer the best hope of rapid change. Alternately querulous,
irritable, and showing bravado, people who have both depression and narcissistic PD will typically first respond best to a humanistic approach (validation) to establish a strong working alliance. A delicate balance often arises
between "feeding the narcissism" and providing appropriate validation. Reflecting back true statements that do not directly confirm the more grandiose claims works well (e.g., "It sounds like you have a number of accomplishments of which to be proud"), as does validating the feelings (e.g., "It must be
very painful to feel so misunderstood so often"). Then, as recommended by
Millon (1999), one may explore the client's developmental history with the
goal of gaining insight into the meaning of the client's behaviors and attitudes. Cognitive and behavioral interventions can then help to functionally
improve behavior and mood. If the depression is not so severe that it precludes psychotherapeutic improvement, then it is best to wait for some psychological improvements to occur before introducing psychopharmacological interventions; individuals with narcissistic PD can lose motivation to
make psychological changes once the immediate crisis is resolved. Some,
however, are more connected to the psychotherapy; the opportunity to have
undivided attention from another person is often appealing to the individual
with narcissistic PD. In that regard, long-term psychodynamic or psychoanalytic therapy can be comfortably accepted. Family therapy can help the individual to correct patterns of exploitiveness and derogatory communication
in marital and parent-child relationships. Group therapy can be extremely
helpful in correcting interpersonal patterns, though there are two cautions:
The narcissistic client often flees in the face of confrontations that threaten
to explode his or her illusions, and there is a risk of the person becoming a
monopolizer in the group. If those two factors can be managed, then prospects are reasonably good. Ultimately, if it is impossible to challenge the
illusions, then the therapy has failed, so it is incumbent on the group therapist to find a balance between support and confrontation within the group.
205
lieve his anxiety. Dr. Johns used the model from dialectical behavior therapy
(Linehan, 1993), in which phone calls could be used to reinforce coping
skills, but if the phone call became lengthy, then an additional session was
scheduled. This model worked well, and between-session phone calls gradually diminished over time. Once rapport had been adequately established,
cognitive techniques (A. T. Beck et al., 2004) were used to correct Tomas's
cognitive errors, particularly his black-and-white thinking.
There was a powerful pull for Dr. Johns to align with the wife and children and immediately push for the client to have greater empathy. To do so
too early would have been a therapeutic error. The therapeutic relationship
had to be solid before such work could be undertaken. Nonetheless, mindfulness meditation training (which has been shown to increase empathy levels)
enhanced Dr. Johns's ability to sit with his own pain and thereby be more
available to listen to Tomas. Later in therapy, after Tomas comprehended
clearly that Dr. Johns understood and validated him and there was a strong
therapeutic bond, direct interventions to help the client to put himself in his
wife's and children's shoes was undertaken. There was progress in that area,
which, though extremely slow, was a positive development for the client.
The main breakthrough in the case came when Dr. Johns suggested the
use of the empty chair technique to help Tomas resolve the internalized split
between his idealized and devalued self. Dr. Johns instructed the client to sit
in a chair and have the "good self" talk to the "bad self," with the encouragement that they somehow find a way to come to terms with one another and
develop a working relationship with each other. The good self was the
straight, married-with-two-children, "perfect" (stereotypic) American male.
The bad self was the gay, porn-watching adulterer. As the conversation
evolved between the two, it became clear that the good self was also overbearing, judgmental, rigid, and insufferable, a manifestation of a domineering superego. The bad self was gentle, vulnerable, fallible but forgivable, and
tender (and considerably more fun and likable). Apparently, the bad self was
not all bad, nor was the good self all good. Given that the underlying need
was to be loved (for which the need to be admired had been substituted but
could never really fill the void), the good self would have to come to terms
with the bad self. The bad self was the lovable one and offered the best hope
of salvation.
Much of the client's depression was a function of his internalized homophobia. Raised Catholic, in a culture that promoted strong, stereotypically
masculine roles, he had intense negative images of homosexuality. Being gay
was associated with sinfulness, unmanliness, and worthlessness. As he developed a more affirmative and increasingly integrated gay identity, his depression lessened.
Countertransferentially, Dr. Johns often experienced feelings of irritation and frustration and, at times, exasperation. Tomas tried to build himself
up at the expense of others, which went against Dr. Johns's values. The de206
valuation was at times directed at Dr. Johns, which elicited anger. Dr. Johns
would attend closely to his own emotional reactions and then confront Tomas
in the here and now, thus helping him to recognize how his behaviors and
attitudes impacted other people. To reduce guilt and minimize projection of
blame and responsibility as well as Tomas's own anger and resentment for
being criticized, Dr. Johns would normalize Tomas's behavior within the context of his narcissistic PD or the problems he was confronting in his life.
Although not excusing or condoning the behavior, Dr. Johns's method neutralized the potentially overwhelming affect and made the underlying issues
more approachable.
Deep down, what Tomas feared the most was looking at the inner sense
of emptiness that haunted him. Slowly, he came closer to getting in touch with
those feelings. The mindfulness work was critical in that regard, because emptiness from a Buddhist perspective is not frightening; it is a crucial part of
reality and, indeed, a necessary step in the path toward enlightenment.
In sum, then, guided by Tomas's personality and his need for unconditional positive regard, therapy started by using a humanistic approach, using
empathy and validation and examining the client's thwarted actualizing tendency. The emphasis then shifted to cognitivebehavioral interventions to
challenge Tomas's beliefs about himself and others. As his self-image improved, he became better able to tolerate more intensive self-exploration.
Sensitivity to issues related to sexual orientation, ethnicity, and religion were
crucial to understanding Tomas's depression. The use of mindfulness meditation helped him tolerate his negative affect sufficiently to engage in the therapeutic process. The use of the empty chair technique then allowed him to
increase self-awareness and more thoroughly integrate aspects of self that he
had previously abhorred or tried to ignore or destroy. Thus, therapies were
combined synergistically, with a trusting relationship forming the foundation on which challenge could be tolerated; mindfulness-based stress reduction enhanced Tomas's insight and distress tolerance, which allowed deeper
explorations of his issues with his therapist. Psychodynamic theory was helpful in examining the transferencecountertransference interactions and understanding his self-development of and the dynamics underlying his interpersonal relationships, as well as helping to integrate his internalized parental
images and childhood experiences into his present reality. As a function of
the positive relationship with the therapist, modeling, and active and persistent skill building, Tomas slowly became more empathic. At this writing,
group therapy or couples work are possibilities for helping him to further
reduce his narcissistic proclivities. Further goals of treatment include increasing his ability to self-validate and decreasing his addictive proclivities (e.g.,
to relationships, sex, drugs, and food), which he was using to fill the void he
was experiencing, as well as ameliorating the subsequent excessive admiration seeking, multiple sex partners, procrastination regarding priorities like
finding a meaningful job, and sidestepping his role as parent.
NARCISSISTIC PERSONALITY DISORDER
207
208
10
DEPRESSION IN AVOIDANT
PERSONALITY DISORDER
209
Laura is a tragic figure, because it seems clear as the drama unfolds that Laura
could make a fine companion if only she could escape her demons.
EPIDEMIOLOGY
According to the Diagnostic and Statistical Manual of Mental Disorders
(4th ed., text revision [DSM-IV-TR]; American Psychiatric Association,
2000a), avoidant PD has a prevalence of 0.5% to 1.0% in the community. In
outpatient clinics, the corresponding rate is approximately 10.0%. Avoidant
PD is fairly prevalent in samples of depressed individuals. In a sample of 10Z
individuals with recurrent depression, Pilkonis and Frank (1988) found that
the prevalence of avoidant PD was 30.4%- Of the 116 individuals with major
depression in a study by Zimmerman and Coryell (1989), 6.9% had avoidant
PD. In Pepper et al.'s (1995) dysthymic disorder sample, 16% had avoidant
PD. In Fava et al.'s (1995) sample of depressed clients, approximately 26%
had avoidant PD. In a sample of 249 depressed outpatients, 13% were diagnosed with "definite" and 34% with "probable" avoidant PD (Shea, Glass,
Pilkonis, Watkins, 6k Docherty, 1987). Markowitz, Moran, Kocsis, and Frances
(1992) studied a sample of 34 outpatients with dysthymic disorder; 32% had
avoidant PD. In a sample of 352 clients with both anxiety and depression,
approximately 27% had avoidant PD, as diagnosed by structured interview
(Flick, Roy-Byrne, Cowley, Shores, 6k Dunner, 1993). Thus, in the currently
available studies on depressed samples, between 13% and 32% have comorbid
avoidant PD. Likely reasons for the fairly wide range include natural sample
210
variation, inpatient versus outpatient status, different definitions of depression (e.g., dysthymic disorder vs. major depression), and changing criteria
(e.g., some studies used criteria from the third edition of the Diagnostic and
Statistical Manual of Mental Disorders [American Psychiatric Association, 1980],
and some used criteria from the revised third edition [American Psychiatric
Association, 1987]).
Fewer data are available on the frequency of depression in avoidant PD
samples, but the two extant studies are consistent with each other. A study of
157 clients with avoidant PD found that 81.5% had major depression
(McGlashin et al., 2000). Zimmerman and Coryell (1989) studied a community sample of 797 individuals, which included 143 individuals who were
diagnosed with PDs. Among those with avoidant PD, 80% met the criteria
for major depression.
2I1
Deltito and Stam (1989) discussed a series of four case studies of individuals with avoidant PD, most of whom had concurrent anxiety disorders
on Axis I. Three responded well to a monoamine oxidase inhibitor (MAOI;
tranylcypromine; phenelzine) and 1 to an SSRI (fluoxetine); these cases were
reportedly representative of 20 similar patients whom the authors and their
associates treated in their clinic. Their treatment was based on the notion
that avoidant PD is similar to social phobia and would respond to similar
medications. Although their study lacked rigorous methodology, their findings were generally encouraging. Ekselius and von Knorring (1998; see chap.
1 of this volume for a further description of the study) surveyed 106 individuals with avoidant PD at baseline. The SSRIs sertraline and citalopram ap212
213
excellent tolerability, safety, and positive outcomes in research. I must confess surprise at the recommendation to use buspirone at several points in the
algorithm, given the weak research findings.
Davidson (2003) noted that social phobia's approximately 35% to 65%
response rate indicates that many patients do not respond to medications;
even those who do generally have only a partial response. He recommended
research on combinations of medications and on brain mechanisms that may
provide keys to more effective treatments. To these excellent suggestions, I
add that research on combined pharmacotherapy and psychotherapy would
be in order. Finally, it is essential that more research be done on medication
for avoidant PD itself; the studies with individuals with social phobia can
only be considered useful beginnings toward finding medication treatments
for avoidant PD.
Psychological Factors
Millon's Theory
According to Millon (1969/1985, 1981, 1996, 1999), individuals with
avoidant PD represent the "active-detached" type. They separate from others and do so in a purposeful and intentional way. Individuals with avoidant
PD are thought to have an active, anxious, insecure nature, perhaps as a
result of excessive neurological (limbic) substrates associated with painful
emotion. These neural differences in adulthood may have been caused by
genetics or shaped by experience. The early experiences of people with
avoidant PD are likely to be characterized as anguished when hypersensitive
children are routinely told they are no good. As Millon (1996) stated,
Normal, attractive, and healthy infants may encounter parental devaluation, malignment, and rejection. Reared in a family setting in which
they are belittled, abandoned, and censured, these youngsters will have
their natural robustness and optimism crushed, and acquire in its stead
attitudes of self-depreciation and feelings of social alienation, (p. 279)
self-protective in intent, increases their encounters with hurtful stimuli; indeed, they may find rejection where most would not even notice a passing
negative emotion. Another person's bad day is experienced personally as a
barge full of rejection, even if it has little to do with the avoidant person's
behaviors. The internal use of cognitive distraction also interferes with their
ability to think clearly and thus engage in comfortable conversation, thereby
deepening their already disturbing level of alienation. Thus the individual
tends to remain isolated and fearful over time or, in many cases, becomes
more avoidant and distressed over time.
The description of the person with avoidant PD in terms of Millon's
domains is presented in Appendix B. "Aversive interpersonal conduct" and
"alienated self-image" are the most prominent features.
Cognitive-Behavioral Conceptualization and Interventions
Individuals with avoidant PD have a number of troubling cognitions
that can lead to withdrawal and depression. Beliefs in their own worthlessness, inadequacy, and unlovability predominate. Intermediate beliefs such
as, "If I interact with others, then I will humiliate myself; "Only by staying
away from others can I remain safe"; and "If I can't be with others that accept
me completely, then I am better off alone" undergird the avoidant pattern.
Similarly, intermediate beliefs such as "If I get to know others, they will reject me"; "I'm so lonely I can't stand it"; and "Things will never get better,
because I am too defective for anyone to like or love" steer the individual
toward depression. These underlying beliefs, which emerge after a period of
exploration, underlie the automatic thoughts that occur spontaneously and
are readily seen in therapy. Typical automatic thoughts for the person with
avoidant PD include "If I talk to her, she won't like me"; "If I speak up in
class, I will make a fool of myself; and "I give upI can't go on this way."
Viewed in this light, the enormous covariation between avoidant PD and
depression becomes sensible: The same core beliefs often underlie both.
A. T. Beck and Freeman (1990) observed that a personal history of
rejection, particularly by close significant others, provides a powerful learning history that establishes the avoidant pattern. Parental rejection is, understandably, particularly hard on a child. They noted,
Avoidant patients must make certain assumptions to explain the negative interactions: "I must be a bad person for my mother to treat me so
badly," "I must be different or defectivethat's why I have no friends,"
"If my parents don't like me, how could anyone?" (p. 261)
Through the error of overgeneralization, children then learn to withdraw socially, fearing rejection. They interpret rejection from others as proof
of their differentness, unlovability, and inadequacy. Believing the negative
messages, they become highly self-critical. They may describe themselves as
AVOIDANT PERSONALITY DISORDER
215
boring, stupid, and unattractive. As a function of these self-critical proclivities, individuals with avoidant PD are particularly sensitive to thoughts about
depression that enhance and deepen their negative mood. They are likely to
have thoughts such as "It is terrible to feel badly as I do" and "Other people
rarely feel depressed or embarrassed."
Avoidant PD is somewhat similar to paranoid PD in that forming a
therapeutic relationship generates considerable anxiety on the part of the
person with this disorder, and early in treatment, there is a substantial risk of
premature termination. Clients may flee after admitting to a flaw, believing
that the therapist now knows how defective they are and will therefore reject
them for therapy. It is important to screen for these thoughts by asking openended questions about the thoughts and feelings of the client, such as "How
did it feel when you told me that?" and "What thoughts are going through
your head?" Once the relationship is formed, it tends to be very strong, because, as previously noted, attaining an accepting relationship is extremely
rewarding for the person with avoidant PD. Standard cognitive and behavioral techniques are generally effective. Skill building is often essential. It
has been my experience that a person with avoidant PD often does relatively
well within the safe confines of the therapeutic relationship but is extremely
awkward in day-to-day social situations. Large quantities of role-play and
practice are often helpful. A. T. Beck, Freeman, and Davis (2004) further
recommended role play with rejecting and critical others from the past, which
often results in substantial reconceptualizations of the client's history. They
gave the following example:
Mother:
Jane:
Mother:
Jane:
Mother:
Jane:
Mother:
216
Jane:
I wish you didn't get so mad at me. I'm only a kid. I wish you
would get mad at Daddy, instead. He's the one who left. I'm the
one who's staying with you.
Mother:
Jane: I'm really sorry, Mommy. I wish you didn't feel so bad. Then
maybe you wouldn't yell at me so much.
Mother:
By seeing her mother simultaneously through her adult eyes and the eyes of a
6-year-old child, Jane came to understand a new interpretationthat her
mother's problems caused much of the shaming and that Jane herself was just
a typical child. It was no longer automatic for Jane to assume that she was
bad and wrong. The therapy continued with considerable work challenging
Jane's belief that she was unlikable and building a new schema, namely, that
she was likable to at least some people.
In addition to role-play, Socratic dialogue helps to challenge clients'
negative beliefs about themselves. Thought records, similarly, reinforce the
habit of challenging negative thoughts and replacing distorted beliefs with
more realistic ones. As the underlying core beliefs of inadequacy, worthlessness, and unlovability are assuaged, both the avoidant PD and the depression
resolve.
Psychodynamic Therapy
The withdrawal from social life by the person with avoidant PD is, in
broad terms, an effort to manage anxiety. The origins of this anxiety vary
from case to case. However, in many cases, it appears to be rooted in shame.
Unlike guilt, which is experienced by the individual when wishes or actions
conflict with the constrictions imposed by the superego, shame is experienced when the individual fails to live up to the ego ideal. In general, individuals with avoidant PD use repression and other high-level defenses and
do not show identity diffusion;1 thus they can be seen as being organized at
the neurotic, as opposed to borderline or psychotic, level of personality
functioning. As such, the individual with avoidant PD would be expected
to form a relationship with the therapist somewhat more easily than the
borderline, paranoid, or schizoid client, a prediction that fits well with clinical experience.
Gabbard (1994) recommended warm and empathic support coupled
with firmly suggesting to clients that they expose themselves to feared social
situation to become more aware of the specific fantasies that they have. These
fantasies often lead to associations with childhood experiences that have
important etiological significance. He gave a case example of a 24-year-old
woman who had intense fears in social situations. Because she was very pretty,
she got asked out often but relied on alcohol to soothe her anxieties sufficiently for her to cope and to help her to open up. During one session, when
'Identity diffusion indicates a changeable and unstable sense of self, often manifested by frequent
changes in appearance, social group, and vocational and avocational activities.
217
she was particularly quiet, he asked her if she was concerned about how he
would respond if she were to share her thoughts and feelings. She replied that
she was extremely afraid of losing control of her emotions, anticipating that
the therapist would shame her and accuse her of being like a baby. This
brought back memories of her harsh and critical father, who not only shamed
her for having emotions but also for receiving positive recognition of any
kind (accusing her of being a "show-off"). Thus, the client not only feared
criticism but also was frightened by her (normal) exhibitionistic desires and
her need for affirmation. As she worked through her difficulties with these
issues, she found that she was able to go out and enjoy herself without becoming inebriated.
COUNTERTRANSFERENCE
When individuals with avoidant PD enact their avoidance within the
therapyfor example, by canceling appointments or avoiding anxietyprovoking material, therapists often feel frustrated.
Typical thoughts about the avoidant patient may include the following:
"The patient isn't trying." "She won't let me help her." "If I try really
hard, she'll drop out of therapy anyway." "Our lack of progress reflects
poorly on me." "Another therapist would do better." The therapist thinking these types of thoughts may begin to feel helpless, unable to assist the
patient in effecting significant change. (A. T. Beck et al., 2004, p. 316)
pull for pity is highly informative; it suggests that others in the client's environment feel the same way and often that individuals with avoidant PD feel
sorry for themselves. Such hypotheses can be easily checked. For example, at
some point, when someone treats these clients well, they will likely hypothesize that the other person was nice "because she felt sorry for me." The role
of pity in the client's life can then be discussed openly. Once I find the origins of my feelings of pityusually an understandable reaction to the person
describing a highly pained existenceI can challenge the thoughts with
Socratic questioning. "Is the situation really hopeless? Is it possible that by
changing her behaviors she can elicit different responses? Does she have any
strengths that would be appealing to anyone? Can at least some of her avoidant
behaviors be turned around? Don't Vicious circles' tend to work in reverse,
in that, just as failure breeds failure, success breeds success?" Now, with a
more neutral stance, I am able to help the person consider some additional
possibilities.
The most frustrating part of the disorder is the cognitive avoidance.
The individual is sincere and motivated but cannot endure the pain of selfexploration long enough to get anything done. In such circumstances, I remember Marsha Linehan's (1993) simile regarding persons with borderline
PDthey are like burn patients and have no "emotional skin." Imagine being so hypersensitive that to talk about one's deficits that may need correction is like a torrent of humiliating criticism. Imagine having a background
in which your internalized significant others are "vexatious" internalized tormentors waiting to be unleashed by the slightest provocation. If this is true
for the person who has avoidant PD, it is all the more true for the individual
who concurrently has comorbid depression. When I empathize with the person more intensely, I am better able to be patient and to recognize that we
may need to take very small steps. The average person with a PD needs at
least a year or two of treatment, and maybe this person needs more. So, each
session, if we make a fraction of a percent of the total improvement we are
hoping to attain, we are doing fine. As I discuss in the chapter on antisocial
PD (chap. 6, this volume), it is often important for therapists to check on
their own motivations for wanting a patient to make progress at a certain
rate; if the client can wait, then so can I. Breathe in, breathe out.
219
especially young women, are taught to behave deferentially. Such individuals should not be diagnosed with avoidant PD (Castillo, 1997) for this reason
alone. DSM-IV-TR noted that difficulties with acculturation following immigration may falsely appear to be avoidant PD.
STRENGTHS OF PERSONS WITH
AVOIDANT PERSONALITY DISORDER
Individuals with avoidant PD or features are often attracted to, or adept
at, poetry or other artistic endeavors. Their hypersensitivity often shades
into finely attuned and acute attention to subtle nuances of feeling. Such
individuals may do well with journaling or expressive arts therapy.
Avoidant behavior is a part of everyone's experience. Who among us
has not stopped to "lick their wounds" after a painful breakup and avoided
dating or other forms of social contact for a period of time? Though this
pattern goes too far in avoidant PD, when used appropriately, avoidance is
part of the repertoire of useful coping patterns.
TREATMENT PLANNING: SYNERGISTIC TREATMENT
Personality-guided therapy treatment goals flow logically from the
conceptualization of the client, per Millon's (1996, 1999) theory. The person with avoidant PD is considered the active-detached type, so naturally
the goal is to balance the polarities by helping the client to become less
active and more attached to others. Because the person is hypersensitive to
pain, an additional goal is to decrease pain and increase pleasure. It is also
important to undermine processes that tend to perpetuate the avoidant pattern. As noted above, vicious circles of persons with avoidant PD include
social detachment, suspicious and fearful behavior, hypersensitivity to rejection, and cognitive self-distraction. Therefore, therapy should be geared to
reduce their fears, attune their internal cognitions, and increase social activity (see Exhibit 10.1). The long-term goals for depressed individuals with
avoidant PD include increasing their activity level, enhancing pleasure, improving their social interactions and increasing their frequency, and bringing focus to their distracted cognitions to help them recognize their depression and cope with it more effectively (Bockian & Jongsma, 2001; Jongsma
& Peterson, 1999).
Individuals with avoidant PD have substantial difficulties with trust.
Establishing a trusting relationship is no small task, although in general, prospects for success are good if the therapist is patient and supportive and if the
therapist takes the important step of checking in frequently with the client
to make sure that there are no cognitive distortions that could interfere with
the therapeutic relationship. Judith S. Beck (1995) recommended a review
220
EXHIBIT 10.1
Therapeutic Strategies and Tactics for the Prototypical Avoidant Personality
STRATEGIC GOALS
Balance Polarities
Diminish anticipation of pain
Increase pleasure/enhancing polarity
Counter Perpetuations
Reverse social detachment
Diminish suspicious/fearful behavior
Moderate perceptual hypersensitivity
Undo intentional cognitive interference
TACTICAL MODALITIES
Adjust alienated self-image
Correct aversive interpersonal conduct
Remove vexatious objects
Note. From Personality-Guided Therapy (p. 319), byT. Millon, 1999, New York: John Wiley & Sons.
Copyright 1999 by John Wiley & Sons. Reprinted with permission of John Wiley & Sons, Inc.
at the end of the session asking if the client has any questions or needs any
clarifications. Specifically asking during the session, "Did anything bother
you?" has a good chance of eliciting distorted thoughts that the therapist was
judging the client harshly. Whenever making any suggestions for a change in
behavior, the therapist should be aware that the client could interpret what
was said as form of rejection. One technique that can be helpful in such
circumstances is to make a "compliment sandwich" when providing feedback to the avoidant client. The therapist can compliment the client, then
provide criticism or suggestions, then compliment again. For example, one
could say,
You did a great job paying attention to your feelings while you were so
uncomfortable meeting with your boss. I wonder if you would like to try
some assertiveness techniques. I think you have the ability to do it, if you
feel ready.
When this suggestion is framed in the context of his or her strengths, even
the person with avoidant PD would be unlikely to feel rejected. Conversely,
a more unfettered and, ordinarily, effective statement such as "You seemed
to feel uncomfortable; perhaps some assertiveness techniques would help,"
could trigger a surprising cascade of thoughts, such as the following:
I knew I should have stood up for myself. Now he thinks I'm weak. He
probably doesn't even want to do therapy with someone as weak as me.
I'm too much work for any therapist. It's hopeless. I shouldn't come back
next week. He'll be happier with me off his caseload.
AVOIDANT PERSONALITY DISORDER
221
Clients with both depression and avoidant PD are at particularly high risk for
such distortions. Regardless of therapist orientation, the initial relationship
with the person with avoidant PD should resemble Rogers's (1979) approach:
warmth, empathy, and unconditional positive regard. Persistent support early
in therapy generally secures the therapeutic relationship, which, once established, tends to be very solid; having an accepting other in their lives is generally greatly needed and appreciated by individuals with avoidant PD.
Once the relationship is established, a variety of approaches can be
used either separately and sequentially or in a more parallel and simultaneous fashion. Typically, clients can explore the roots of their difficulties
while also participating in cognitive exercises to challenge some of their cognitive distortions and behavioral techniques to become engaged with other
people. Group therapy can be particularly helpful for individuals with avoidant
PD, particularly if the group is free from hostile and attacking members and
instead is composed of others who are supportive and interested in being
supported. The group can provide a safe intermediate environment between
the therapy environment and the "real world," a place where the client can
ask for feedback from others, who are unlikely to be as harsh as his or her own
inner critic. In cases where the family is unwittingly promoting the avoidant
pattern, family therapy may be useful to help clients to gain more intimacy in
their marriage or other close relationships and to help family members to
better understand the client's worldview.
Improvements in any areacognitive, behavioral, or interpersonal
are likely to lead to a positive cascade of improvements that are isomorphic
to but move in the opposite direction from the "vicious circle." For example,
changes in the client's belief from "I am defective" to "I am a person who has
some flaws and some strengths" changes the likelihood that the client will
risk having a relationship with another person. If the relationship goes well,
that is likely to lead to a reduction in depression, a further willingness to risk
being in a relationship, and a further change in beliefs (e.g., reduced beliefs
of defectiveness, increased beliefs of being worthwhile).
222
223
224
his father. He had deep-seated feelings of rage about the abuse he had suffered at his father's hands and feelings of resentment about how his dad was
still controlling his life (e.g., by pressuring him to choose a particular major).
First, Jordan wrote a letter to his father, which was processed with Dr. Rodgers
and never sent. He then confronted his father verbally over the issue of his
current need for independence. His father was warm and supportive, stating
that he "only wanted him [Jordan] to be happy." This shocked Jordan. Though
happy that his father was supportive, he was confused, because it shattered
his all-bad image of his father, and he would thus need to reintegrate a new
image.
Throughout the therapy, Jordan had largely avoided the topic of how
being Korean influenced him. He had pretty much all White friends and
never got involved in any of the Asian activities on campus. However, as his
self-image improved, he became more interested in his Asian heritage and
what that meant to him. Dr. Rodgers disclosed to him that she was half Japanese, which greatly facilitated his opening up and exploring these topics.
Jordan made a great deal of progress working through his internalized racism.
Toward the end of therapy, in what was a huge step for him, Jordan did ask a
girl on a datearid got rejected. However, he was able to frame the asking
itself as a success. He asked a second girl out on a date and this time was
accepted. He began to date occasionally, and one of the girls he asked out
was Asian.
At the end of the spring term, as is common in college counseling centers, it was time to terminate. Because Dr. Rodgers would not be returning
the next year, the therapy could not continue in the same manner in the fall.
With his improved self-image and social skills, Jordan was ready for group
therapy, and collaboratively, they decided that Jordan would join a therapy
group at the counseling center. In addition to being an opportunity to learn
more about how others perceived him, the group was led by an Asian therapist who could potentially act as a role model.
In sum, the therapy consisted of initial cognitive-behavioral interventions, which provided relatively rapid reduction of depressive symptoms. The
therapy was also informed by self psychology and psychodynamic theory,
particularly in the analysis of the transference and the countertransference
as they coevolved in treatment. Jordan's improvements prepared him for a
wider range of treatment options, particularly group therapy, and if he was
interested, in psychodynamic therapy. Sensitivity to cultural diversity issues
facilitated further self-image improvements. Jordan's depression was completely remitted at the end of this 9-month, 25-session treatment, and his
avoidant PD symptoms were dramatically reduced. Further therapy would
have been useful in continuing to resolve his relationship difficulties with
his father, looking at his issues with his mother, and continuing to strengthen
his self-confidence and social skills.
225
226
11
DEPRESSION IN DEPENDENT
PERSONALITY DISORDER
Substitute "dependent PD" for "borderline PD," and the description fits almost perfectly; the difference is that people with dependent PD do not project
hostile intentions onto others. The underlying fear of death if not protected
by a powerful other, however, is shared.
Phenomenologically, individuals with dependent PD are passive and
clingy. Generally, the conscious and ostensible reason for their dependent
behaviors is poor self-esteem and low self-confidence. Their motto is, "I can't
possibly do it; if I try do to it I'll only mess it up. Could you do it for me?
Please?" The hope is that someone will take care of them and nurture them.
In return, they offer unparalleled loyalty. In its milder form, it is not alto227
gether a bad arrangement for the partner, and some individuals with dependent features settle comfortably into a stable subordinate relationship with
another individual. The "ideal" marriage of the not-so-distant past, with the
working husband and the adoring wife, had some of these qualities. The division of power was never quite as neat as it appeared on the surface, however,
and the feminist movement of the 1960s changed that prototypical relationship pattern. However, dependent PD goes much further. The incompetence
becomes more global. The strain on the partner to make more and more
decisions, so that even the most minor decisions require his or her input, takes
its toll. The "supermom" prototype is the woman who works, takes care of the
children, and cleans the house; the mom with dependent PD would be one
who struggles in all of those domains. Even if she has no job outside the house,
she feels unable to take care of the children (because she is unable to assert
adequate authority) and in fact demonstrates incompetence in childrearing
and even in housekeeping ("It's so hard"). Constant demands for reassurance
add to the strain on the partner. Understandably, many partners bum out,
bringing about the most feared consequence of all: abandonment.
For men with dependent PD, or even features of it, the disorder seems
to be even more disruptive. In Western culture, there really is little place for
a dependent male. For the most part, men are uncomfortable taking subordinate roles and are expected to be wage earners. I am reminded of the case of
a Hispanic couple in which the man had dependent PD. He achieved pseudoindependence by starting his own business, but unable to set limits with his
employees, he was never able to earn much money. Warm and nurturing, he
would have been a very good stay-at-home dad, though he would have needed
to learn a bit more about boundaries with the children. Mom had no such
difficulty; her character was a combination of obsessive-compulsive, histrionic, and aggressive features. A hardheaded business manager, she was working her way up the ladder in a medium-sized corporation. Given their culturally defined gender roles, the couple could not simply fall into a comfortable
pattern. Both struggled mightily to fit into a pattern that was against both of
their natures: He had to be the "strong one" and the wage earner; she had to
be the subordinate wife. In recent generations among Americanized couples,
however, more flexible gender roles are possible. It is becoming more common for the wife to work and the husband to stay at home; this becomes
particularly likely when the woman is the better educated or higher earning
of the two.
EPIDEMIOLOGY
According to the Diagnostic and Statistical Manual of Mental Disorders
(4th ed., text revision; American Psychiatric Association, 2000a), dependent PD is among the most prevalent of the PDs in mental health clinics.
228
According to a quantitative review by Mattia and Zimmerman (2001), dependent PD has a prevalence of approximately 2.2% in community samples.
In a sample of 102 individuals with recurrent depression, Pilkonis and
Frank (1988) found that the prevalence of dependent PD was 15.7%. Of the
116 individuals with major depression in a study by Zimmerman and Coryell
(1989), 3.4% had dependent PD. In Pepper et al.'s (1995) dysthymic disorder sample, 9% had dependent PD. Markowitz, Moran, Kocsis, and Frances
(1992) studied a sample of 34 outpatients with dysthymic disorder; 21% had
dependent PD. In Fava and associates' sample of depressed clients, approximately 12% had dependent PD (Fava et al., 1995). In a sample of 249 depressed outpatients, 6% were diagnosed with "definite" and 20% with "probable" dependent PD (Shea, Glass, Pilkonis, Watkins, & Docherty, 1987).
Finally, in a sample of 352 clients with both anxiety and depression, approximately 8% had dependent PD as diagnosed by structured interview (Flick,
Roy-Byrne, Cowley, Shores, & Dunner, 1993). Thus, in currently available
studies of depressed samples, approximately 3% to 21% have dependent PD.
Viewed from the opposite directionstarting with individuals with dependent PDfewer data are available. Zimmerman and Coryell (1989) studied
a community sample of 797 individuals, which included 143 individuals who
were diagnosed with PDs. Among individuals with dependent PD, 28.6%
met the criteria for major depression.
A meta-analytic review of 18 studies indicates that women are 40%
more likely to be diagnosed with dependent PD than men (cited in Bornstein,
2005). This careful, well-reasoned review considered four possible causes of
the gender gap. The first is sampling bias, which refers to the collection of
nonrepresentative samples; if the prevalence of dependent PD is high in females in some samples but not others and the former group of samples are
disproportionately represented in population estimates, then a gender difference would be reported erroneously. Because the gender difference is robust
across settings, however, it is unlikely that nonrepresentative sampling could
have caused the observed difference. The second possibility is diagnostic bias,
which refers to a clinician's misdiagnosis based on his or her preconceptions.
Bornstein (2005) ruled out this possibility as well. Three available studies,
one of which had a sample of over 1,000 psychiatrists, psychologists, and
social workers, presented written simulated cases that differed only by gender. In all of the studies, women were not more likely to be diagnosed with
dependent PD; indeed, in one of the studies the male participants were diagnosed as having dependent PD in 52% of the cases, as opposed to 39% in the
female cases, and in the other two studies the diagnostic rate was about the
same. The third model, criterion sex bias, would be applicable if the criteria
themselves were inappropriately sex linked; an extreme example would be
criteria linked to the menstrual cycle or other female-only characteristics. It
is difficult to get empirical evidence on the topic because more subtle forms
of criterion sex bias will always be in the eyes of the beholder. On the basis of
DEPENDENT PERSONALITY DISORDER
229
Reich's (1990a, 1990b) work, Bornstein reasoned that if the diagnostic criteria are biased, then one would expect to find that the men diagnosed with the
disorder would be more pathological and probably would have different demographics; if men and women diagnosed with dependent PD have similar demographics and overall levels of pathology, then the criteria are probably performing appropriately. Several studies have shown that men and women
diagnosed with dependent PD have similar demographics and overall levels
of psychopathology; thus the sex-biased criteria model seems unlikely.
Finally, there is the self-report bias model, which is the theory that men
and women vary substantially in their willingness to acknowledge or disclose
dependency-related behaviors and attitudes. A substantial body of evidence
indicates that gender differences emerge more strongly as the face validity of
the measure increases (cited in Bornstein, 2005). Bornstein conducted a largescale meta-analysis of sex differences in dependency (cited in Bornstein, 2005),
analyzing 97 studies. Results indicated clearly that on self-report tests, such
as the Millon Clinical Multiaxial InventoryIII (MCMI-III; Millon, 1994)
and the Minnesota Multiphasic Personality Inventory, there was a positive
correlation between femininity and dependency and a negative correlation
between masculinity and dependency; although Millon did not report a combined effect size, it appeared to be moderate in magnitude.1 The opposite was
true, however, for projective measures; men scored higher on projective dependency scales than did women.2 Concluded Bornstein, "It may be that
men and women have comparable underlying dependency needs, but women
are more willing than men to acknowledge these needs when asked" (2005,
p. 11).
Overall, then, Bornstein (2005) logically concluded that there is gender difference in diagnosis of dependent PD and that it is due at least in part
to differences in self-report tendencies between men and women. He recommended using multiple assessment techniques (e.g., self-report plus projective tests) to minimize this bias. Other hypothesized sources of bias seem
unlikely.
230
231
thalamus to the median raphe nuclei play an important role in the reward
dependence dimension. Thus one would expect to see these biological patterns in the individual with dependent PD.
Heritability
An uncontrolled trial by Ekselius and von Knorring (1998) has suggested that the SSRIs sertraline and citalopram were associated with statistically significant decreases in dependent PD diagnosis rates and symptoms
among the 61 individuals with dependent PD in their sample (see chap. 1,
this volume, for a further description of the study). The remission rate for
dependent PD after 24 weeks of treatment was 61% for the sertraline group
and 57% for the citalopram group. The sertraline group had a mean decrease
of 0.9 criterion pre- to posttreatment; the corresponding figure for the
citalopram group was 1.0 criterion. Unfortunately, because there was no
medication-free comparison group, the results of the study are inconclusive;
however, given the long-standing nature of personality disorders, the finding
is promising and warrants further investigation. A study by D. W. Black,
Monahan, Wesner, Gabel, and Bowers (1996) was less encouraging, indicating a lack of response by participants with dependent PD symptoms to
fluoxetine. Other than that, there appear to be no studies of medications
used with dependent PD.
Given the paucity of available data, it is worth considering the suggestions by Joseph (1997) based on his clinical experience. Joseph noted that
the clinging behavior of the person with dependent PD may include aspects
of anxiety (e.g., fear of abandonment) and depression (e.g., difficulty coping
with loss). Thus, he asserted that individuals with dependent PD often respond to medications that are helpful with anxiety and depression. In his
recommendations, Joseph (1997) noted,
The first-line medications for depression and anxiety in modern psychiatric practice are the serotonergic antidepressants, venlafaxine,
mirtazapine, and nefazodone because of their favorable side effect profiles and their effectiveness in the treatment of anxiety. However, all
antidepressants including MAOIs, trazodone, [tricyclic antidepressants]
and bupropion, should be effective. In addition to antidepressant treatment, patients with Dependent Personality Disorder may benefit from
232
adjunctive treatment using antianxiety medications, either on a standing basis, or preferably, on a [given as needed] schedule, (p. 1^0)
Joseph further noted that many people with dependent PD present with dysthymia or dysthymic symptoms and thus may benefit from long-term pharmacotherapy.
There is an obvious need for studies that investigate whether dependent symptoms can be alleviated with medications. Given its nascent stage
of development, our understanding of the biology of dependent PD could be
greatly facilitated by basic science, presumably related to biological studies of
attachment in general. In addition, given the high prevalence of depressive
disorders and dependent PD and their moderate overlap, there is a great need
for studies that assess the effectiveness of pharmacotherapy in individuals
with both disorders. Ultimately, randomized clinical trials are necessary to
establish the efficacy of various medications for symptoms of dependent PD.
Psychological Factors
Milloris Theory
According to Millon's (1996) tridimensional system, dependent PD
represents the passive-dependent adaptation. Unlike the active-dependent
(histrionic) types, who use their charm or appearance to get their needs met,
the passive-dependent individual waits and hopes, dreaming that a rescuer
will magically appear.
The presumed developmental history of the person who develops dependent PD is that of a temperamentally placid, passive child. Although
many individuals who develop psychopathology have histories of neglect,
the opposite is generally true of budding dependents. Significant others such
as parents rush in to fill the void left by the person's natural passivity. Potential incompetence becomes actualized as opportunities to grow and learn from
mistakes are turned away. Reduced competence leads to further overprotection and further incompetence. Although burdened with feelings of helplessness and skill deficits, this kind of experiential history tends to imbue the
individual with an unshakable sense of optimism, a belief that others tend to
be good and helpful rather than undermining and malevolent, and basic trust
in others. Even among those who are depressed and thus currently pessimistic, this underlying optimism is generally a resource waiting to be tapped.
Millon's (1996) domain descriptions are provided in Appendix B. Of
the domains, submissive interpersonal conduct and inept self-image are the
most salient.
Cognitive-Behavioral Conceptualization and Interventions
From a cognitive perspective, individuals with dependent PD have a
number of beliefs that tend to interfere with their functioning. Ideas such as
DEPENDENT PERSONALITY DISORDER
233
"I need help making a decision" and "I can't stand being alone" shape much
of the individual's adaptation to the world. Helplessness schemas (Young,
1999) are often triggered by depression in the individual with dependent PD.
Dichotomous and global styles of thinking, such as believing "I am incompetent," can be challenged with great effectiveness using Socratic dialogue (e.g.,
"Are you incompetent at everything? Is there anything at all that you do
adequately, or even partly adequately?"). Under such questioning, it is rare
that even an extremely dependent and moderately depressed person cannot
find an area of partial competence. Depressions that are so severe that one
cannot even imagine anything positive about oneself may benefit from early
psychopharmacological interventions to facilitate availability to the therapeutic process; in contrast to many clients with PDs, premature termination
is rarely a cause for concern in the person with dependent PD.
A. T. Beck and Freeman (1990) astutely noted that
[dependent PD] can be conceptualized as stemming from two key assumptions. First, these individuals see themselves as inadequate and helpless, and therefore unable to cope with the world on their own . . . Second, they conclude that the solution to the dilemma of being inadequate
in a frightening world is to try to find someone who seems to be able to
handle life and who will protect and take care of them. (p. 290)
In other words, the individual with dependent PD has the core beliefs "I am
helpless" and "I am inadequate" and the intermediate beliefs "Only if I can
find someone to take care of me will I be okay," and "If I can't find someone
to take care of me, it's awful." Directly confronting and dispelling negative
core beliefs can have far-reaching consequences for a wide array of behaviors
and attitudes. If the client no longer believes that he or she is helpless, which
acts as a pillar supporting an entire building of beliefs, then hundreds of specific automatic thoughts can be rapidly changed. In the case of dependent
PD, skill building can in fact challenge the core belief directly. Significant
changes, especially in the client's depression, can occur after only a dozen or
so sessions (see the case example at the end of this chapter). As with all PDs,
however, treatment can easily take a year or two before the PD can be considered adequately treated.
A variety of behavioral techniques can be very helpful to the person
with dependent PD. For example, dependent PD can be seen as an extreme
form of underassertion; thus, assertiveness training can be beneficial. The
therapist should not assume that problem-solving and decision-making skills
have been learned but are being ignored for emotional reasons; in fact, it is
likely that the client has not mastered these important skills and would benefit greatly from learning them.
Client-Centered, Humanistic, and Existential Therapies
Client-centered therapy provides a nurturing environment for the person with dependent PD. By its firm, nondirective stance, client-centered
234
Freud (1940/1969) discussed the oral phase as a normal part of development. In addition to nourishment, the infant derives sensual gratification
while nursing. Throughout the first 18 months of life, the developing child
focuses a great deal of libidinal energy on the oral area, putting objects in the
mouth, sucking the thumb and pacifiers, and so on. When the child is frustrated during the oral phase, there is a negative kind of orality, associated
with sarcasm and feelings of pessimism. Overindulgence, on the other hand,
leads to much more positive feelings. Abraham (1911/1986) discussed how
overindulgence during the oral phase of development leads to the formation
of a dependent character. In a later work, Abraham (1924/1983) stated,
According to my experience we are here concerned with persons in whom
the sucking was undisturbed and highly pleasurable. They have brought
with them from this happy period a deeply rooted conviction that everything will always be well with them. They face life with an imperturbable
optimism which often does in fact help them to achieve their aims. But
we also meet with less favourable types of development. Some people are
dominated by the belief that there will always be some kind persona
representative of the mother, of courseto care for them and give them
everything they need. This optimistic belief condemns them to inactivity, (p. 131)
Gabbard (1994), however, noted that this narrow view of the relationship
between early life events and later character pathology is no longer widely
held in psychodynamic circles. He suggested it is more essential that a pattern of dependency be fostered throughout all phases of development, and
that parents consistently communicate that independence is dangerous.
To my knowledge, psychodynamic theorizing regarding dependent PD
has been modest. I assume that this is because dependency issues respond
well to traditional psychodynamic and psychoanalytic techniques. Although
splitting defenses and borderline pathology, for example, presented the therapeutic community with a tremendous challenge, dependency issues are considered a routine part of much psychodynamic treatment; dependency during psychoanalysis does not necessarily imply dependent psychopathology,
because it is a phase of treatment that is relatively common among many
analysands. More extreme dependency, then, does not necessarily demand a
different approach to treatment. Thus, although dependent PD is relatively
common, it has generated less research and scholarly interest than, for example, borderline and narcissistic PDs.
DEPENDENT PERSONALITY DISORDER
235
Family Systems
Often, individuals with dependent PD are attracted to people with narcissistic PD as partners. In many ways, it is a perfect fit. The individual with
narcissistic PD (usually a male) needs to be admired, likes to feel like the
strong one, and has fantasies of unlimited success; the person with dependent PD (usually a female), low in self-esteem, tends to fawn, wants someone
strong to take care of her, and tends to gullibly believe what others tell her.
Couples in which one person has a mildly dependent style and the other a
mildly narcissistic style often do very well. When each person is at the PD
level, however, the relationship typically becomes problematic. Often, the
narcissistic husband becomes derogatory toward his wife, believing that
she is "beneath" him. The very subservience he craves makes her appear
inadequate and useless. He may get involved in an affair with someone
"more worthy"prettier, more accomplished, or higher in social status.
Even in the absence of an affair, his lack of empathy can, over time, be
emotionally devastating for his wife. Dependent pathology, likewise, can
create enormous marital strain. The low self-esteem and instrumental incompetence of the wife can be draining to even the most selfless husband,
much less to one with narcissistic pathology; no matter how much he nurtures, her craving for care will make his efforts seem inadequate.3 Placing
another person into the position of always having to be the strong one and
falling apart if he ever shows neediness can be difficult for anyone; for someone with narcissistic problems, the pattern may be a painful reenactment of
childhood experiences.
Nurse (1998) recommended a structured treatment based on Millon's
(1996) theory. Clients present for treatment, often with one of the issues
enumerated above. The MCMI-III is administered to each client. In addition
to work on the couples issues that have brought them to treatment, the uniqueness of each individual is emphasized, on the basis of the assessment. The second session is then an individual one, which is used to provide feedback from
the MCMIIII assessment. When the couple comes back together for the
next session, they are asked to share what they learned about themselves.
With the dependent-narcissistic couple, two of Millon's (1996) polarities are particularly out of balance: the self (individuation)-other (nurturance)
dimension and the passive (accommodation)-active (modification) dimension. On the former, the narcissistic member of the dyad is too self-focused,
whereas the dependent member is too other-focused. Thus the therapist needs
to encourage the dependent client to individuate and to become more assertive and more self-reflective. The narcissistic client, conversely, benefits from
empathy training and encouragement to focus on the other person's needs.
'Individuals with dependent PD usually have a degree of actual incompetence, the result of a history
of overprotection and reliance on others, which then tends to be exaggerated in their own minds as
extreme incompetence and helplessness.
236
On the latter dimension, both are too passive and need to be moved to a
place of increased activity.
COUNTERTRANSFERENCE
As in the case of histrionic and borderline PDs, individuals with dependent PD can elicit rescuer fantasies and behavior. Noted A. T. Beck, Freeman, and Davis (2004),
The temptation to rescue the [dependent PD] patient is particularly strong,
and it can be very easy either to accept the patient's belief in his or her
own helplessness or try to rescue the patient out of frustration with slow
progress. Unfortunately, attempts at rescuing the patienr are incompatible with the goal of increasing the patient's autonomy and selfsufficiency, (p. 279)
The manner in which the person with dependent PD calls for rescuing
is somewhat different from that of clients with other PDs. In borderline PD,
the client often threatens or engages in self-destructive behavior (especially
suicidal gestures and attempts), which elicits rescuing responses. Persons with
histrionic PD have a flighty, scattered presentation that leads the therapist
to believe that they are unable to think through problems for themselves;
additionally, their dramatic, seductive behavior impels the therapist to play
the hero. Persons with dependent PD present themselves as incompetent
and pathetic, which prompts the therapist to want to solve their problems for
them (A. T. Beck et al., 2004). The therapist ultimately can become frustrated with the client's passivity and dependency (Bornstein, 2005) and may
entertain thoughts that the client truly is incompetent or even stupid or that
the client is feigning incompetence for effect (A. T. Beck et al., 2004). Therapists may experience pleasurable feelings of power in response to the patient's
submissiveness (Bornstein, 2005). Of course, such beliefs and feelings must
be examined.
Research on graduate students has shown that they typically feel sad,
pitying, and depressed in response to a film of someone simulating dependent PD. Participants have noted that they believed the client's life was very
restricted and seemed unfulfilling, which accounted for much of their sadness and pity. They typically also have an urge to rescue the client, which is
consistent with the sad, pitying reaction. Participants also felt curious, and
they found themselves leaning forward with interest. One of the films drew a
frustrated, angry, irritated response. In that particular film, the client was
involved in what appeared to be an abusive relationship but would not talk
to the therapist unless the presumed perpetrator was in the room. This atypical scenario, in which the dependent transference on the therapist was blocked
by an obsessive attachment to a significant other, left the therapists in trainDEPENDENT PERSONAL/TV DISORDER
237
ing feeling unable to be helpful and thus frustrated; they were irritated with
the client for not taking better care of herself and angry at the presumably
abusive boyfriend (Bockian, 2002a; see chap. 1, this volume, for a further
description of this study).
For better or for worse, and probably like many other clinicians, I respond positively to clients whose dependency needs drive them to be cooperative and eager to see me. I often feel a powerful urge to rescue themI
call that "being on my horse," the image of the knight in shining armor racing off to protectively slay the dragon for another person. I want to take away
their pain, right away. Once I experience such feelings, I typically look for
related thoughts and challenge them using cognitive techniques:
Is she really so fragile? Can she tolerate some discomfort in order to achieve
her long-term goals? Do others respond in the same way? How would I
feel if everyone around me viewed me as being in need of rescuing? Would
I wear out my welcome?
By exploring my thoughts in this way, I usually can "get off the horse"that
is, get away from the rescuing stance and come to a more balanced assessment of the person.
After this preliminary positive reaction, with clients whose dependency
issues are more severe and persistent I often feel burdened and drained. Some
clients, unintentionally and unconsciously, have a vampiric quality, draining
my energy to support themselves. In such cases, I often experience discomfort
and a desire to get away. Once again, using self-awareness and cognitive strategies, I pay attention to what 1 am feeling and imagine what it would be like to
be that person. Desperate for support, they probably experience persistent rejection; after all, if I, in my role as a paid, professional support person, feel
drained, imagine how the person who is a "volunteer" must feel! Feeling more
compassionate, I am then able to explore my hunches and usually do find
that the person does indeed persistently feel rejected and alone.
I have, however, observed a strongly different reaction in a number of
my students. Among those who have somewhat obsessive-compulsive personality styles and have strong values that a person must be "productive,"
individuals with dependency issues arouse strong judgmental thoughts. Students who are highly independent often find the dependent client annoying
and pitiful. I encourage them to explore their reactions in light of their personal and cultural values.
cultures. Castillo (1997) gave the example of Japanese society; in that culture, children are taught "the nail that stands out gets hammered down"
(p. 107). In many such cultures, unlike the United States, adolescents are not
expected to make important life decisions (e.g., which college to attend). Such
behaviors and attitudes should not be considered features of dependent PD,
particularly if they are not problematic in the person's subculture.
As noted above, more females acknowledge dependency and are diagnosed with dependent PD than males. Willingness to acknowledge dependency is likely impacted by cultural factors, such as differential acceptability
of expressing reliance on another for men and women. Communitarian cultures tend to tolerate dependent behavior more than independent cultures;
for example, Bornstein and Languirand (cited in Bornstein, 2005) found that
adolescents and young adults in India and Japan demonstrated higher levels
of self-reported dependency than similar populations in North America. They
concluded, "Studies indicate that gender role norms can have a powerful
impact on women's and men's willingness to acknowledge underlying dependency needs" (Bornstein, 2005, p. 8).
239
240
EXHIBIT 11.1
Therapeutic Strategies and Tactics for the Prototypal Dependent Personality
STRATEGIC GOALS
Balance Polarities
Stimulate active/modifying polarity
Encourage self-focus
Counter Perpetuations
Reduce self-depreciation
Encourage adult skills
Diminish clinging behaviors
TACTICAL MODALITIES
Correct submissive interpersonal conduct
Enhance inept self-image
Acquire competence behaviors
Note. From Personality-Guided Therapy (p. 377), by T. Millon, 1999, New York: John Wiley & Sons.
Copyright 1999 by John Wiley & Sons. Reprinted with permission of John Wiley & Sons, Inc.
241
nursing homes that overrides all other considerations: loneliness. Most residents in nursing homes spend a good deal of time alone or, if with others,
sitting in front of a television set together. Certainly, the nursing home made
substantial efforts, providing trips to local restaurants, bringing in entertain'
ment frequently, and so on. Nonetheless, mobility impairments and cognitive impairments limited certain kinds of activities, and many residents had
difficulty energizing themselves to participate in activities. Loneliness is so
pervasive in nursing homes that the opportunity to spend a chunk of time
with a cognitively intact person who will provide one with warm, supportive
contact is very appealing. Because of the relatively sparse activities between
sessions, transference tends to be intensified. In contrast to the situation of
clients in typical outpatient settings, family contact does not occur daily.
The sheer quantity of time spent with the therapist, at 50 to 100 or so minutes per week, rivals the amount of time spent with family (which occurs for
longer periods of time but less frequently). Contact with other nursing home
residents occurs frequently, but in many cases such others are activity partners, and the relationships often lack substantial depth or intimacy. These
factors were generally true in Elisa's case, as elaborated below.
Elisa was the youngest of three siblings. Her oldest brother, Martin, was
married and had two children. The middle brother, Erik, never married. Elisa
had been married to Jack for approximately 3 years. They had a daughter,
Caroline, about 2 years into the marriage. Elisa described the marriage as
being a very good one. Unfortunately, when Caroline was just a year old,
Jack died of a heart attack. Erik moved in and helped to raise Caroline. Elisa
never remarried, and she and Erik continued to live together for many years.
However, Erik's health had recently begun to fail. He was spending more
time in the hospital than out and was no longer able to help Elisa in her dayto-day activities. Thus, Elisa had moved into the nursing home.
In terms of countertransference, I generally liked Elisa. I found myself
feeling the typical emotions I feel with many people with dependent PD:
nurturing, rescuing, and concerned. This "rescuer" reaction is a reliable sign
for me that the individual has dependency issues and helps to clarify several
aspects of the client's situation. In this case, one was that she presented herself as being fragile, as if her pain would break her. A moment's reflection
revealed that in fact this was a woman who had coped with a great deal of
pain in her life, including several psychiatric hospitalizations as well as the
death of her husband and both parents. She had had copious family support
throughout her life, which was extremely helpful to her in surviving these
difficulties. Reflecting on these facts and being aware that my role was to
help her balance the dependence-independence (other-self) polarity, which
was currently excessively tilted toward dependence, helped me to "get off the
horse"that is, regain my footing and help her to become more independent rather than simply helping her transfer her dependency from someone
else onto me.
242
I also more than occasionally felt bored during our sessions and had
thoughts about how we would fill the 50 minutes we had together. These are
generally reliable signs for me that the person has schizoid features. The blandness, lack of emotional intensity, and lack of drama tend to leave me feeling
a bit bored; relative to what one might expect from someone who fits the
"pure" dependent prototype, Elisa's emotional reactions were muted, and she
was more self'focused. With some clients with schizoid PD, there are difficulties in finding clear, collaboratively developed goals, which can create a
sense of futility for both therapist and client; this was not a problem in Elisa's
treatment. The feeling of struggling to keep the conversation going, however, speaks to the client's overall passivity and to my own distaste for long
periods of silence during therapy sessions.
It cannot be ruled outin fact, I believe it is most likelythat medications strongly contributed to Elisa's emotional flatness or bluntness. Thus
she may not have been schizoid in Millon's (1996) sense, in which there is
an underlying defect in emotional processing. Rather, medications, especially
lithium and low-dose neuroleptics, may have made her appear relatively flat
or, over time, may have induced a degree of blandness that would not otherwise have been present. It is also important to note that Elisa felt best when
with others and uncomfortable when alone, which, in and of itself, virtually
rules out schizoid PD proper. Given the mix of features, Elisa would best fit
Millon's "ineffectual" subtype of dependent PD.
Elisa was referred to me because she was feeling "nervous" and "down."
She had a number of specific concerns. Her main concern was for her brother
Erik, on whom she relied and who was extremely ill.
Elisa specifically requested hypnosis because a friend of hers had had
hypnosis with good effect. The use of hypnosis with people with psychotic
disorders can be tricky, and one must use good judgment and appropriate
precautions. Because she had asked for hypnosis, turning her down because
of her history would inevitably carry a meta-message that she was too sick
and too damaged to receive the treatment she saw as best, perhaps even magical. I checked with staff and with her records and saw that she had been
stable on medications for a long time, at least a year with no psychotic episodes. Because I generally work with light trance and had rarely encountered
any untoward effects, I decided to work with her hypnotically.
The hypnosis that I used with Elisa was similar to that used by Yapko
(2001) in the treatment of depression. It was primarily cognitive-behavioral
in its theoretical underpinnings. I would induce a state of trance using standard techniques. I would then have her imagine situations in which she would
become anxious or depressed, and we would then "build in" coping strategies. I would suggest that when she felt bad (either "nervous" or "down") a
variety of coping strategies would "automatically" come to mind. These coping strategies had been collaboratively constructed prior to the session. They
included going for a walk, talking to a friend, calling a family member, and so
DEPENDENT PERSONALITY DISORDER
243
on. Elisa reported a powerful relaxation response during the session; I also
observed rapid eye movements, suggesting that she achieved good depth of
trance. The intervention was highly effective, and her use of various coping
strategies increased dramatically.
Encouraged by Elisa's success with this relatively structured intervention, I implemented a permissive imagery intervention, which allowed her to
go to a special place that she found comforting. This, too, was successful,
helping to reduce Elisa's anxiety without provoking any abreactions, regressions, psychotic phenomena, or other problems.
Elisa's free-floating anxietyher vague nervousness for which she had
no awareness of an immediate causeabated within a few sessions. That in
and of itself was a substantial improvement in her emotional condition. However, her reality-based fears regarding her brother's health, her fears about
her ability to survive if he died, and her underlying depression regarding the
loss she was potentially facing were issues that required further intervention.
In addition to the hypnosis, which we continued as part of the therapy
for much of the treatment, Elisa and I began to do a good deal of cognitive
restructuring. I helped her to challenge her beliefs regarding the thoughts
that left her feeling depressed and anxious. At times, Elisa engaged in all-ornone thinking. For example, after her brother moved out of the house, she
was fearful that her possessions would be discarded by the realtors or that the
house would be sold and she would not have an opportunity to retrieve her
possessions. She was overwhelmed by feelings of helplessness and spent a
great deal of time worrying and ruminating. Using cognitive techniques, we
were able to assess the likelihood of her fears coming true. We examined the
evidencestatements from her brother, from the real estate agents, and so
on. We assessed whether these people were trustworthy on the basis of her
experience. Once she was reassured that the items were not likely to be discarded, we were able to explore the meanings she attributed to her possessions. Some of them, such as her wedding album, had a great deal of emotional significance, as an attachment to her long-lost husband. Other items,
such as some articles of clothing, lacked sentimental significance and were
left at home because she did not have room in the nursing home. Although
the sale of the house itself was an obvious symbol of a decision to permanently reside in a nursing home, the attachment to the clothing, in part,
represented the assumption that someday she would return home. It is probably hard for most middle-class individuals to accept that all of their worldly
possessions would fit in the small closet and few drawers available in a semiprivate nursing home room, and that was true for Elisa. However, it was also
true that she lived simply and was able to work through the loss of the home.
It helped greatly that Elisa truly enjoyed living in the nursing home. The
relationships suited her, and the nurses who helped her monitor her medications were a source of security and comfort. If her brother were not with her,
she in fact would be lonely living at home.
244
After about 15 to 20 sessions, Elisa would have been ready for a tapering of sessions. However, at about that time, there was a crisis. Her brother's
health took a severe turn for the worse. I spoke with Erik, who had been
transferred to the same nursing home as Elisa. He was in bad shape medicallyhe was emaciated, pale, and weak. He was also severely depressed.
I made an appointment to see him to treat his depression, but I never got
to keep it. Within a week, he had been transferred to a hospital, where he
expired.
Elisa was, of course, devastated. She cried frequently throughout the
day. Her face was drawn, and she had a pained expression constantly. Although this was an expected grief reaction, given the closeness of the relationship, I was a bit concerned because, given her bipolar disorder, it was not
clear how Elisa would respond biochemically. Because Elisa was not only
grieving for a loved one but experiencing the loss as a threat to her existence
and her way of life, I conceptualized her reaction as grief but likely to be
complicated by depression. We increased session frequency to twice per week.
With increased support, she did relatively well. Within a few weeks, the
deepest grief had lifted. She had transferred much of her dependency needs
to the nursing home. Reassured that she would be okay, she was able to experience the loss of Erik as a deeply saddening event but not a threatening one.
After approximately 1 year of treatment, we were able to comfortably
terminate by reducing session frequency. Elisa was moving to a new nursing
home to be near her daughter's family.
245
sess the relationship between childhood precursors of dependent PD and associated theory-derived risk factors (e.g., perceived incompetence and overprotective parenting style) would be an invaluable contribution. In the context of these improved understandings, theory regarding the interaction
between and concomitant development of depression and dependent PD
would be more meaningful.
246
12
DEPRESSION IN OBSESSIVECOMPULSIVE PERSONALITY
DISORDER
247
ing profits rise on a ledger sheet and implies that any activities just for fun are
a waste of time. Mr. Banks's discussions with the happy-go-lucky chimney
sweep, Bert, prompt him to question his choices; when Mr. Banks loses his
job (at the bank) he reconsiders his values and begins spending joyful leisure
time with his family. Despite the film's focus on magical Mary, it is actually
Mr. Banks who undergoes the most dramatic transformation and learns to
balance his life in a satisfying way.
names of the disorders should be different to avoid misleading users of DSMIV-TR into thinking there is a relationship between the disorders. In this
chapter, I differentiate between them by using the two separate terms indicated earlier in this paragraph.
EPIDEMIOLOGY
According to DSM-IV-TR, obsessive-compulsive PD has a prevalence
of approximately 1% in the general population and 3% to 10% in mental
health clinics; it occurs approximately twice as often in males as in females.
An excess of occurrence in males was also found in a sample of individuals
who had both obsessive-compulsive PD and depression (Carter, Joyce, Mulder,
Sullivan, & Luty, 1999). Mattia and Zimmerman's (2001) quantitative literature review showed that among the six studies that attempted to measure
the prevalence of obsessivecompulsive PD in the community, the median
prevalence was 4.3%; these studies used criteria from the third edition of the
Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980) and the revised third edition (DSM-III-R; American Psychiatric Association, 1987).
In a sample of 102 individuals with recurrent depression, Pilkonis and
Frank (1988) found that the prevalence of obsessive-compulsive PD was
18.6%. Of the 116 individuals with major depression in a study by Zimmerman
and Coryell (1989), 4.3% had obsessive-compulsive PD. In Pepper et al.'s
(1995) dysthymic disorder sample, 4% had obsessive-compulsive PD. In
another sample of depressed clients, approximately 30% had obsessivecompulsive PD (Fava et al., 1995). In a sample of 249 depressed outpatients,
13% were diagnosed with "definite" and 39% with "probable" obsessivecompulsive PD (Shea, Glass, Pilkonis, Watkins, & Docherty, 1987). In a
sample of 352 clients with both anxiety and depression, approximately 20%
had obsessive-compulsive PD, as diagnosed by structured interview (Flick,
Roy-Byrne, Cowley, Shores, & Dunner, 1993). A study of 622 participants
with anxiety disorders found that 15.4% of individuals with major depression (and, by definition, at least one anxiety disorder) had obsessivecompulsive PD, which was the second most frequent Axis II condition among
those with depression (Dyck et al., 2001). The range, then, is approximately
4% to 20%, or as many as 39% if one includes those classified as "probable."
Likely reasons for the wide range include natural sample variation, inpatient
versus outpatient status, different definitions of depression (e.g., dysthymic disorder vs. major depression), and changing criteria (e.g., some studies used DSMIII criteria and some used DSM-III-R criteria); further studies of the prevalence of obsessive-compulsive PD in depressed samples are warranted.
Conversely, fewer studies examined the frequency of depression in PD samples.
Zimmerman and Coryell studied a community sample of 797 individuals,
OBSESSIVE-COMPULSIVE PERSONALITY DISORDER
249
which included 143 individuals who were diagnosed with personality disorders. Among those with obsessive-compulsive PD, 31.3% met the criteria
for major depression. Another large study that included 153 clients with obsessive-compulsive PD found that 75.8% had major depression (McGlashin
et al., 2000).
WHY DO PEOPLE WITH OBSESSIVE-COMPULSIVE
PERSONALITY DISORDER GET DEPRESSED?
Increased perfectionism is associated with higher levels of current depression (Hewitt & Flett, 1991a, 1991b, 1993) and increased levels of chronicity in depression (Hewitt, Flett, Ediger, Norton, & Flynn, 1998), as well
as suicidality (Adkins & Parker, 1996; Hewitt, Newton, Flett, & Callander,
1997). Structural equation modeling of the relationship between perfectionism and coping (Dunkley, Blankstein, Halsall, Williams, & Winkworth, 2000)
is consistent with explanations for these findings based on Lazarus's cognitive appraisal theory (Lazarus & Folkman, 1984). Perfectionism increases
stress at the level of cognitive appraisal because the person evaluates nearly
all performance as inadequate. In addition, perfectionists often see their selfworth as tied to their performance, thus increasing the experience of pressure. Attempting to reach goals that always seem unattainable may impact
secondary appraisal, the belief that one has the resources to cope with a problem, leading to feelings of helplessness (Flett, Russo, & Hewitt, 1994). Further, perfectionism appears to interfere with coping, because perfectionists
often engage in dysfunctional coping such as disengagement and denial
(Dunkley, Blankstein, Halsall, Williams, & Winkworth, 2000). The strongest and most consistent finding is that individuals who have high levels of
self-oriented perfectionism (in which the person is perfectionistic regarding
both personal and work or achievement standards) and who encounter problems in achievement are highly prone to depression (Hewitt &L Flett, 1991a,
1991b, 1993; Hewitt, Flett, & Ediger, 1996; Z. V. Segal, Shaw, Vella, & Katz,
1992). Socially prescribed perfectionism (in which the person is concerned
about what others will think if he or she is not perfect) is associated with
poorer problem solving, thus indicating poorer coping (Flett, Hewitt,
Blankstein, Solnik, & Van Brunschot, 1996). Individuals with higher achievement-related beliefs have been found to have depressive emotions and cognitions, specifically, "feelings of failure, self-hate, self-blame, anhedonia, guilt,
irritability, loss of interest in others, and hopelessness" (Persons, Burns, Perloff,
& Miranda, 1993, p. 518).
There is also a substantial literature relating rumination to depression.
Individuals who ruminate about their depression remain depressed more severely and for a greater duration than those who distract themselves (NolenHoeksema, 1991). In addition, a ruminative style has been found to predict
depression from 30 days to 18 months later (for a review, see Spasojevic &
250
251
group, the results of the study are inconclusive; however, given the persistent
nature of PDs, the finding is promising and warrants further investigation.
In the absence of further data, it is worthwhile to consider Joseph's
(1997) observations based on his clinical experience. He noted that characteristics such as preoccupation with details, overconscientiousness, and hoarding money are obsessional features, whereas perfectionism, excessive devotion to productivity, and requiring others to submit to one's exact way of
doing things are compulsive features. He found that treatments that are effective for obsessions and compulsions (per Axis I OCD) are effective with
Axis II obsessive-compulsive PD. Joseph contended that the likelihood of
treatments being effective for obsessive-compulsive PD is encouraging, requiring lower doses and having a higher likelihood of success than Axis I
OCD. Although clomipramine, serotonergic antidepressants, venlafaxine,
and nefazodone are potentially effective treatments, serotonergic antidepressants are usually tried first because of their relatively benign side effect
profile.
Unfortunately, in the absence of sufficient studies, we simply do not
know what medications are effective for people with obsessive-compulsive
PD. In addition, I have substantial reservations about Joseph's argument that
OCD and obsessive-compulsive PD lie on a continuum. The comorbidity of
OCD and obsessive-compulsive PD is moderate; DSM-IV-TR noted that a
majority of people with OCD do not meet the criteria for obsessive-compulsive PD. It is not clear that the two disorders, despite their shared name, have
much in common (American Psychiatric Association, ZOOOa, p. 462; Millon,
1996). It may be that various antidepressants, antianxiety agents, and other
medications are effective with individuals with obsessivecompulsive PD,
but even if that were established, it is not clear that it is for the reasons
hypothesized by Joseph. Empirical studies, ultimately leading to randomized
controlled clinical trials, are needed to explore what medications are helpful
in this population.
Psychological Approaches
Within the biopsychosocial model (Millon, 1969), psychological factors are intermediate between biological considerations (e.g., chemical and
electrical reactions) and sociocultural issues (which may involve interactions of hundreds of millions of people). The psychological approaches reviewed in the following sections attend to behavioral, cognitive, affective,
unconscious, and interpersonal aspects of the person's functioning.
Millon's Theory
According to Millon (1981, 1996) the compulsive personality is the
"passive-ambivalent" type. Millon preferred the use of "compulsive" personality, rather than DSM-IV-TR's "obsessive-compulsive," to avoid confusion
OBSESSIVE-COMPULSIVE PERSONALITY DISORDER
253
with the Axis I disorder. The ambivalence refers to whether to rely on the
self or on others. The compulsive character, in contrast, attempts to bind the
ambivalence by appealing to rules and authority, following an external set of
standards rather than listening to his or her conflicted inner voice. Though
adaptive in some ways, this resolution comes at a high price:
These individuals manifest extraordinary consistency, a rigid and unvarying uniformity in all significant settings. They accomplish this by
repressing urges toward autonomy and independence. They comply with
the strictures and conform to the rules set down by others. Their restraint, however, is merely a cloak with which they deceive both themselves and others; it serves also as a straitjacket to control intense resentment and anger
Inwardly, they churn with defiance like the antisocial
personality; consciously and behaviorally, they submit and comply like
the dependent. (Millon, 1996, p. 506)
Yearning to assert themselves but not daring to, individuals with compulsive PD absorb themselves in daily routines and minutiae. At times, there
are opportunities for the indirect expression of hostility, such as being judgmental toward those who do not comply strictly with society's rules, righteous indignation toward individuals who violate religious requirements, and
so on. Direct expressions of anger in response to an individual, however, are
almost unthinkable.
Millon (1996) asserted that individuals with obsessive-compulsive PD
were raised with extensive use of punishment and miserly amounts of praise.
Parents would sternly condemn the child for any "mistakes," but behavior
rarely if ever exceeded expectations or earned any reward. Consistent with
the observation that individuals with obsessive-compulsive PD are indecisive, Millon noted that they become attuned to what they must not do but
often are not aware of what they ought to do. More recent empirical data are
consistent with this theory. An investigation of current clients' perceptions
of their bond with their parents indicated that individuals with obsessivecompulsive PD reported low parental care and high overprotection (Nordahl
& Stiles, 1997).
Appendix B lists Millon's description of obsessive-compulsive PD in
terms of the eight domains. Of the features listed, constricted cognitive style,
respectful interpersonal conduct, and disciplined expressive behavior are the
most salient (Millon, 1999, p. 529).
Cognitive-Behavioral Conceptualization and Interventions
Cognitive-behavioral therapists target thoughts such as "I must avoid
mistakes to be worthwhile," "Mistakes are intolerable," and "Failure is intolerable" (A. T. Beck & Freeman, 1990, p. 315; A. T. Beck, Freeman, & Davis,
2004, p. 328). Many of Ellis's "musterbatory" statements (Ellis, 1993), such
as "When I do not perform well, and win others' approval, as at all times I
254
should, ought, and must, I am an inadequate person" (Ellis, 1997, p. 19), fall
into the category of obsessive-compulsive thinking. Underlying many of these
beliefs is the cognitive error of all-or-none thinking: One is either perfect or
worthless, a success or a failure. Such beliefs can be treated with dysfunctional thought records and/or Socratic dialogue. The emphasis of the intervention will depend on the client's motivation. For the highly motivated
client, thought records have the advantage of replacing ruminative thoughts
with productive activity and establishing constructive habits through repetition. Often, individuals with obsessive-compulsive PD or features must be
taught to limit the amount of material they document, selecting a few thoughts
to challenge; some, using all-or-none thinking, believe they must document
every thought or the exercise has been done improperly. Conversely, there
are individuals with obsessive-compulsive PD who are concerned that therapy
will be a waste of time or that they do not have time in their genuinely busy
schedules to add homework. In such cases, 1 often start with Socratic dialogue, which does not require homework. Once the client has become familiar with Socratic dialogue, we can use it to challenge the idea that he or she
does not have time to do homework. The main argument for homework is
that it makes the therapy go more quickly and efficiently (efficiencyhow
appealing!), it can often be very brief (with practice, doing a thought record
on one or two thoughts takes only a few minutes), and it can help establish
habits that will be necessary for long-term maintenance of gains. If clients
understand the benefits of homework and still decline, that is, of course,
their prerogative.
The therapeutic relationship with individuals with obsessivecompulsive PD is likely to be formal and businesslike. In cognitive-behavioral therapy, this is an acceptable position, because many of the techniques
can be applied in a rather straightforward manner. The main challenge, however, is to be sure that the individual understands the benefits of treatment
(because they often deny the relevance of emotions) and remains motivated
to continue treatment. This is less likely to be a problem for depressed individuals with obsessive-compulsive PD because they are aware of their distress, or that something is awry. Once the depression lifts, motivation to
continue to treat characterological issues is often modest or nonexistent. To
avoid premature termination (thus leaving the client at high risk for relapse)
it is important, at some point, to bring in how dysfunctional schemas relate
to the client's depression. Timing is important, because if the client feels
blamed in early sessions, he or she may leave treatment. A natural progression is for the therapist to note how distressing the client's circumstances are
(e.g., feeling overwhelmed with work) and provide some ways to address this
(e.g., relaxation training), followed by looking at ways to reduce the workload
(e.g., assertiveness), and finally letting go of perfectionistic standards. The
therapeutic goals have subtly shifted from an external orientation (e.g., "The
supervisor is working me too hard") to an intermediate level ("Maybe I can
OBSESSIVE-COMPULSIVE PERSONALITY DISORDER
255
Such children become filled with rage over minor disruptions in routine.
Their attempt to maintain control is deleterious to both family and peer
relationships. Intervention consists of confronting the defenses against the
underlying rage, fear, and anxiety.
The goals of treatment for obsessive-compulsive PD were concisely
stated by P. Kernberg et al. (2000):
Psychodynamic treatment of [obsessive-compulsive PD] seeks to transform maladaptive automatic, ego-syntonic behavior and thought processes compatible with the patient's sense of self into ego-dystonic or
incompatible behavior and thought processes that the patient can readily
identify, recognize as maladaptive, and then resolve. Psychodynamic
approaches focus on the conflict underlying and giving rise to the [obsessive-compulsive PD] trait, toward helping the patient deal with the unacceptable wish and fear in direct, adaptive ways. (p. 123)
257
to the doctor's opinion about what to do next and blaming the doctor for
not doing better, (p. 248)
Clinicians must be prepared for ambivalence and anxiety-driven maneuvering. The symptoms can be confronted directly in the here and now or
can be connected to earlier object relations, particularly with the parents.
Family Systems
Individuals with obsessive-compulsive PD often partner with individuals
with histrionic PD. For a discussion of the histrionic/obsessive-compulsive
couple, see chapter 9, this volume, on histrionic PD.
Group Therapy
Individuals with obsessivecompulsive PD can be difficult to treat in
group therapy. They tend to align with the therapist, deny that they have
any problems, and shut out any emotions, thereby failing to process their
emotions in a group formatand perhaps disrupting the group process. Nonetheless, psychodynamically informed expressive-supportive therapy was found
to be effective for a group of individuals with obsessive-compulsive PD. Barber Morse, Krakauer, Chittams, and Crits-Cristoph (1997) found that at the
end of 52 weeks of treatment, 85% of the patients in group therapy no longer
met the criteria for the disorder; depression and other problems were ameliorated as well. In theory, other expressive techniques could be useful to break
through the obsessive-compulsive person's emotional deadlock. Experiential techniques that re-create emotionally intense experiences could potentially help the individual to connect with some emotional experiences. There
is a risk that the individual can become highly anxious if overstimulated, so
therapeutic judgment must be exercised in weighing the costs and benefits of
treatment. My impression is that in most cases of obsessivecompulsive PD
not just some features, but the full-blown diagnosable disorderit would be
best to defer group therapy until the client has made some progress in individual or family therapy. If the individual can be better described as having a
mixed obsessive-compulsive and dependent PDa fairly common
subvariantthen prospects are better (Bockian, 1990). Such individuals are
more compliant, less stubborn, less filled with doubt, and more trusting. This
combination allows the client to more easily take advantage of the group
process.
COUNTERTRANSFERENCE
Individuals with obsessive-compulsive PD typically present material in
a dry, unemotional way, which elicits feelings of boredom. Their excessive
focus on details, which can slow progress substantially, can be exasperating
258
to clinicians. They may also make efforts to control therapy sessions, thereby
provoking frustration from clinicians (A. T. Beck et al., 2004).
Research was conducted on graduate students, in which they rated their
emotions in response to a video of an interview between a clinician and a
client simulating obsessive-compulsive PD (Bockian, 2002a; see chap. 1, this
volume, for a further description of the study). The issues noted by A. T.
Beck et al. (2004) and reviewed above were supported and extended. Findings suggest that participants responded to individuals with obsessivecompulsive PD in three discernable patterns. One pattern was frustration
(irritation and exasperation), presumably in response to the client's focus on
detail and emotional constriction. Another pattern was to express compassion (empathy, sadness, and pity); the empathic feelings were probably related to general therapeutic feelings, whereas the pitying feelings appeared
to be related to comparisons that participants made between the client's current constricted emotional life and a more "ideal" emotional and related way
that he could be. Finally, the third pattern of emotional response was feelings of disconnection (guardedness and dullness), which also appeared to be
related to the client's nonrelational and unemotional style.
Depending on the severity of the disorder, these emotions resonate well
with my own experience of treating people with obsessive-compulsive PD.
In the case of Ronald, presented below, I felt extremely disconnected and at
times frustrated. With others with obsessive- compulsive PD, I have at times
felt pity because their lives seemed so regimented and constricted as to be
no fun at all; this has been particularly true of individuals with obsessivecompulsive PD and depression. As noted in earlier chapters in this book, pity
is a potentially problematic countertransference, and I take a variety of precautions and countermeasures to resolve such feelings (see the countertransference section of chap. 11, this volume, on avoidant PD).
Maintaining a connection can be a real challenge with a person with
obsessive-compulsive PD, particularly if one is feeling irritated, disconnected,
or dull (bored). Patience is often the key. Working through problems slowly
and methodically is suited to the individual's style. Internally, I try to stay
present in the moment and to continuously empathize with the client. Sometimes, I am able to maintain my patience, but the client's wears thin. Whether
it is the therapist, the client, or both who are struggling, supervision or peer
consultation (for the therapist) can be very helpful.
259
261
EXHIBIT 12.1
sexual counseling may be helpful for an excessively constricted client. Psychodynamic interventions also can be helpful, because these individuals are
able to focus on the details of their experience; interpretation can then help
them to synthesize what they experience as countless unique phenomena
into a more cogent whole. An overview of a personality-guided approach to
obsessivecompulsive PD is provided in Exhibit 12.1.
263
At the time, my typical result using hypnosis for pain was a 33% to 66% reduction on self-rated
pain.
264
Ronald's progress with his pain provided a natural challenge to his helplessness belief. His feelings of efficacy improved, and his confidence grew. He
was somewhat less depressed. However, his beliefs that he was worthless could
not be sufficiently challenged in this intervention.
The pain management work provided an entree into treatment in this
case. By the end of the 10 weeks, we had a solid working alliance that I
believe would have laid the groundwork for addressing Ronald's problematic
behaviors and attitudes. A great deal more time would have been required,
however, to challenge his feelings of worthlessness and the probable secondary gain from hospitalization. To the extent that he did improve, taking advantage of his personality strengths (e.g., diligence) and being patient with
his personality problems (e.g., rigidity) were important to his progress.
265
APPENDIX A:
EMOTION LIST2
Age
Gender
Date
Use the following scale: 1=1 did not respond this way at all, to 5 = I felt
this very much
1. Angry
2. Hostile
3. Animosity
4. Hatred
5. Exasperated
6. Manipulated
7. Revulsion
8. Repulsion
9. Happy
10. Contented
11. Joyful
12. Gladdened
13. Hopeful
14. Confident
15. Reassured
16. Expectant
17. Attracted
18. Charmed
19. Infatuated
20. Enamored
21. Fascinated
22. Curious
23. Amused
24. Sad
25. Unhappy
26. Melancholy
267
27. Downhearted
28. Morose
29. Dispirited
30. Despondent
31. Depressed
32. Dejected
33. Blue
34. Heavy
35. Downcast
36. Energized
37. Enlivened
38. Excited
39. Inspired
40. Encouraged
41. Frustrated
42. Suffocated
43. Drained
44. Sucked dry
45. Pent-up
46. Belittled
47. Ashamed
48. Embarrassed by
49. Embarrassed for
50. Humiliated
51. Pity
52. Compassion
53. Sympathy
54. Empathy
55. Understanding
56. Connected
57. Emotional
identification
58. Responsible for
59. Protective
60. Rescuing
61. Burdened
62. Guilty
63. Appeasing
64. Trying to please
65. Deferential
66. Frightened
67. Fearful
68. Afraid
69. Apprehensive
268
APPENDIX A
70. Defensive
71. Guarded
72. Alarmed
73. Threatened
74. Scared
75. Intimidated
76. Terrified
77. Anxious
78. Nervous
79. Distressed
80. Dreading
81. Agitated
82. Irritated
83. Bored
84. Dull
85. Apathetic
86. Wearied
87. Fatigued
88. Tired
89. Worn out
90. Sleepy
91. Confused
92. Perplexed
93. Baffled
94. Bewildered
95. Weird
96. Odd
97. Surreal
98. Disconnected
99. Disconcerted
100. Flustered
101. Overwhelmed
102. Confounded
103. Dismayed
104. Edgy
105. Tenuous
106. "Walking on
eggshells"
107. Like/Liking
108. Dislike
Tension in the:
109. neck
110. shoulders
111. back
112.throat
113. leg
114. arm
115. other
125. other
APPENDIX A
269
271
Constricted
"c
o
O
Deferential
Secretive
Paradoxical
Provocative
Eccentric
Spasmodic
Defensive
ncompatible
Unalterable
Inviolable
CD
CC
CD
c
g
E
15
"5.
V)
0)
o
w
!
CO
CD
O)
en
CO
X
LLJ
to
O
O
73
C
-o
ragmente
Inverted
"D.
cy>
Inelastic
O)
o:
Suspicious
o 15
co E
CD
"c
Melancholic
Anguished J
Apathetic
Mood/
emperament
Callous
Insouciant
Distraught or
insentient
Dysphoric
Irritable
Solemn
Irascible
-CD
Paranoid
Uncertain
Capricious
Borderline
Chaotic
Estranged
CO
Q.
Divergent
Autistic
Eruptive
o
CD
.bJ
Schizotypa
Discredited
Undeserving
Spurious
Disjointed
Inchoate
Depleted
Diffident
CO
Abstinent
Vacillating
Discontented
"o
15
o
Resentful
D)
c
o
CD
Negativisti
Concealed
Conscientious
"5
o
Respectful
Debased
Disciplined
CO
Pernicious
Combative
c
g
Autonomous
differentia
CD
Skeptical
Deviant
Dogmatic
O>
Abrasive
Irresponsible
Impulsive
Precipitate
CO
Rational!.,
'2
15
E
c
1o
o
X
Compulsiv
Contrived
Admirable
O)
UL
!c
Expansive
Exploitive
c
g
Dissoci;
Attentionseeking
CO
c
g
Antisocial
Shallow
Gregarious
Submissive
Incompetent
u_
o
.CD
Sadistic
Immature
Defenseless
CD
Disconsolate
Intellectua
CO
UCO
0
CO
Q.
Narcissist!
Forsaken
Worthless
Pessimistic
'5
CD
TO
CO
CD
>,
a
c
Histrionic
Vexatious
Alienated
'c ">
Distracted
0
Q.
CD
Aversive
co
(0
Complacent
w E
O)
0)
Impoverished
_N
Dependent
Unengaged
DC
HJ
Impassive
o IA
c
g
a
LL
Depressive
p-1
E 0
Avoidant
CO
CO
P =
Schizoid
CO
orpholog
rganizatic
O
p^
U
Regula
Mechan
O
Object
presentatio
CO
Expressive Interpersonal
Acts
Conduct
co
Domain/
Disorder
H
.y
'o
c
o
'co
c
g
o
O
CO
CD
'Q
ol
C7> o
C<2 V)
T 03
2 oa
CO >,
"O _0>
O CO
.85
REFERENCES
Abraham, K. (1983). The influence of oral eroticism on character-formation. In
T. Millon (Ed.), Theories of personality and psychopathology (3rd ed., pp. 128133). New York: Holt, Rinehart & Winston. (Original work published 1924)
Abraham, K. (1986). Notes on the psycho-analytical investigation and treatment of
manic-depressive insanity and allied conditions. In J. C. Coyne (Ed.), Essential
papers on depression (pp. 31-47). New York: New York University Press. (Original work published 1911)
Abraham, K. (1997). Contributions to the theory of the anal character. In D. J. Stein
& M. H. Stone (Eds.), Essential papers on obsessive-compulsive disorder (pp. 370392). New York: New York University Press. (Original work published 1953)
Abramson, L. Y., Seligman, M. E. P., &. Teasdale, J. D. (1978). Learned helplessness
in humans: Critique and reformulation. Journal of Abnormal Psychology ,87, 4974.
Ackerman, N. W. (1958). The psychodynamics of family life. Oxford, England: Basic
Books.
Adkins, K. K., & Parker, W. (1996). Perfectionism and suicidal preoccupation, journal of Personality, 64, 529-543.
Adler, G. (1985). Borderline psychopathology and its treatment. New York: Jason
Aronson.
Agor, W. D. (2005). Emotional response patterns as a clinical indicator for personality
disorders: The passive aggressive personality. Unpublished manuscript.
Agor, W. D., Smith, J., & Bockian, N. R. (2005, August). Emotional response patterns
as a clinical indicator for personality disorders: The passive aggressive personality. Poster
presented at the Annual Convention of the American Psychological Association, Washington, DC.
Akhtar, S. (1987). Schizoid personality disorder: A synthesis of developmental, dynamic, and descriptive features. American journal of Psychotherapy, 41, 499
518.
Akhtar, S. (1992). Broken structures: Severe personality disorders and their treatment.
London: Jason Aronson.
Akhtar, S., & Thomson, J. A., Jr. (1982). Overview: Narcissistic personality disorder. American Journal of Psychiatry, 139, 1220.
Alberti, R., & Emmons, M. (1978). Your perfect right. San Luis Obispo, CA: Impact
Publishers.
American Psychiatric Association. (1980). Diagnostic and statistical manual of mental
disorders (3rd ed.). Washington, DC: Author.
American Psychiatric Association. (1987). Diagnostic and statistical manual of mental
disorders (3rd ed., rev.). Washington, DC: Author.
273
REFERENCES
275
276
REFERENCES
Bornstein, R. F. (1996). Sex differences in dependent personality disorder prevalence rates. Clinical Psychology: Science and Practice, 3, 1-12.
Bornstein, R. F. (2005). The dependent patient: A practitioner's guide. Washington,
DC: American Psychological Association.
Bowen, M. (1966). The use of family theory in clinical practice. Comprehensive Psychiatry, 7, 345-374.
Broadwell, S. E. (1998). The effects of mindfulness meditation training on medical residents. Unpublished manuscript.
Brody, E. M., & Farber, B. (1996). The effects of therapist experience and patient
diagnosis on countertransference. Psychotherapy, 33, 372-380.
Buchsbaum, M. S., Nenadic, I., Hazlett, E. A., Spiegal-Cohen, J., Fleischman, M. B.,
Akhavan, A., et al. (2002). Differential metabolic rates in prefrontal and temporal Brodmann areas in schizophrenia and schizotypal personality disorder.
Schizophrenia Research, 54, 141-150.
Buchsbaum, M. S., Yang, S., Hazlett, E., Siegel, B. V., Germans, M., Haznedar, M.,
et al. (1997). Ventricular volume and asymmetry in schizotypal personality disorder and schizophrenia assessed with magnetic resonance imaging. Schizophrenia Research, 27, 45-53.
Burbach, F. R. (1996). Family based interventions in psychosisan overview of, and
comparison between, family therapy and family management approaches, journal of Mental Health, 5,111-134.
Buxbaum, J. D., Silverman, ]. M., Smith, C. ]., Kilifarski, M., Reichert, J., Hollander,
E., et al. (2001). Evidence for a susceptibility gene for autism on chromosome 2
and for genetic heterogeneity. American Journal of Human Genetics, 68, 15141520.
Cagno, S. (2001). Quetiapina e disturbo borderline di personalita: Un'esperienza
clinica: Trattamento di un breve episodio psicotico [Quetiapine and borderline
personality disorder: A clinical experience: Treatment of a short psychotic episode]. Rivistadi Psichiatria, 36, 344-348.
Cannon, T. D., Mednick, S. A., Parnas, J., Schulsinger, F., Praestholm, J., &
Vestergaard, A. (1994)- Developmental brain abnormalities in the offspring of
schizophrenic mothers: II. Structural brain characteristics of schizophrenia and
schizotypal personality disorder. Archives of General Psychiatry, 51, 955-962.
Cannon, W. B. (1915). Bodily changes in pain, hunger, fear, and rage; an account of
recent researches into the function of emotional excitement. New York: Appleton.
Cannon, W. B. (1963). Bodily changes in pain, hunger, fear and rage (2nded.). Oxford,
England: Harper &. Row. (Original work published 1929)
Carlson, R. (1997). Don't sweat the small stuff (and it's all small stuff). New York:
Hyperion.
Carter,]. D., Joyce, P. R., Mulder, R. T., Sullivan, P. F., &Luty, S. E. (1999). Gender
differences in the frequency of personality disorders in depressed outpatients.
Journal of Personality Disorders, 13, 67-74.
REFERENCES
277
Caspi, A., McClay, J., Moffitt, T. E., Mill, J., Martin, J., Craig, I. W., et al. (2002,
August 2). Role of genotype in the cycle of violence in maltreated children
[Electronic version]. Science, 5582, 851-854.
Castillo, R. (1997). Culture and mental illness: A client-centered approach. New York:
Brooks/Cole.
Castillo, R. J. (1998). Meanings of madness. Pacific Grove, CA: Brooks/Cole.
Charney, D. S., Nelson, J. C., &Quinlan, D. M. (1981). Personality traits and disorder in depression. American journal of Psychiatry, 138, 1601-1604
Chengappa, K. N. R., Baker, R. W., & Sirri, C. (1995). The successful use of clozapine
in ameliorating severe self mutilation in a patient with borderline personality
disorder. Journal of Personality Disorders, 9, 76-82.
Chengappa, K. N. R., Ebeling, T., Kang, J. S., Levine, J., & Parepalty, H. (1999).
Clozapine reduces severe self-mutilation and aggression in psychotic patients
with borderline personality disorder. Journal of Clinical Psychiatry, 60, 477-484Chodoff, P. (1974). The diagnosis of hysteria: An overview. The American journal of
Psychiatry, 131, 1073-1078.
Choi, N. (2004). Sex role group differences in specific, academic, and general selfefficacy. Journal of Psychology, 138, 149-159.
Clark, W. (2000). Patterns of religious attendance. Canadian Social Trends, 59,
23-27.
Clarkin, J. F., Levy, K. N., Lenzenweger, M. F., & Kernberg, O. F. (2004). The Personality Disorders Institute/Borderline Personality Disorder Research Foundation Randomized Control Trial for Borderline Personality Disorder: Rationale,
methods, and patient characteristics. Journal of Personality Disorders, 18, 52-72.
Clarkin, ]. F., Yeomans, F. E., 6k Kernberg, O. F. (1999). Psychotherapy for borderline
personality. New York: Wiley.
Clayton, G. M. (1973). Psychodrama with the hysteric. Group Psychotherapy and
Psychodrama, 26(3-4), 31-46.
Cloninger, C. R. (1987). A systematic method for clinical description and classification of personality variants. A proposal. Archives of General Psychiatry, 44, 573588.
Cloninger, C. R. (1998). The genetics and psychobiology of the seven-factor model
of personality. In K. R. Silk (Ed.), Biological and neurobehavioral studies of borderline personality disorder (pp. 63-92). Washington, DC: American Psychiatric
Press.
Coccaro, E. F. (1998). Clinical outcome of psychopharmacologic treatment of borderline and schizotypal personality disordered subjects. Journal of Clinical Psychiatry , 59(Suppl. 1), 30-35.
Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale,
NJ: Erlbaum.
Colgan, P. (1987). Treatment of dependency disorders in men: Toward a balance of
identity and intimacy, journal of Chemical Dependency Treatment, 1, 205-227.
Collins, L. (1998). Illustrating feminist theory: Power and psychopathology. Psychology of Women Quarterly, 22, 97-112.
Compas, B. E., Oppedisano, G., Connor, ]. K., Gerhardt, C. A., Hinden, B. R.,
Achenbach, T. M., et al. (1997). Gender differences in depressive symptoms in
278
REFERENCES
279
280
REFERENCES
Eckert, J., & Wuchner, M. (1996). Long-term development of borderline personality disorder. In R. Hutterer, G. Pawlowsky, P. F. Schmid, & R. Stipsits (Eds.),
Client-centered and experiential psychotherapy: A paradigm in motion (pp. 213-233)
New York: Peter Lang.
Ekselius, L., &. von Knorring, L. (1998). Personality disorder comorbidity with major
depression and response to treatment with sertraline or citalopram. International
Clinical Psychopharmacology, 13, 205-211.
Elliot, R. (2000).Origins of process-experiential therapy: A personal case study in
practice-research integration. In S. Soldz & L. McCullough (Eds.), Reconciling
empirical knowledge and clinical experience: The art and science of psychotherapy
(pp. 33-49). Washington, DC: American Psychological Association.
Elliott, R., Watson, J. C, Goldman, R. N., & Greenberg, L. S. (2004). Learning
emotion-focused therapy. Washington, DC: American Psychological Association.
Ellis, A. (1993). Reflections on rational-emotive therapy. Journal of Consulting and
Clinical Psychology, 61, 199-201.
Ellis, A. (1995). Thinking processes involved in irrational beliefs and their disturbed
consequences. Journal of Cognitive Psychotherapy, 9, 105-116.
Ellis, A. (1997). Using rational-emotive behavior therapy techniques to cope with
disability. Professional Psychology: Research and Practice, 28, 17-22.
Ellis, A. (2001). Rational and irrational aspects of countertransference. Journal of
Clinical Psychology, 57, 999-1004.
Enns, M. W., & Reiss, J. P. (2001). Electroconvulsive therapy. Retrieved February 21,
2006, from http://www.cpa-apc.org/publications/position_papers/therapy.asp
Epstein, M. (1995). Thoughts without a thinker. New York: Basic Books.
Erickson, K. B. (2002). Psychologist gender and sex bias in diagnosing histrionic and
narcissistic personality disorders. Dissertation Abstracts International: B. The Physical Sciences and Engineering, 62(106), 4781. (UMI No. 3029930)
Eriksson, E. H. (1962). Reality and actuality. Journal of the American Psychoanalytic
Association, 10, 451-474.
Everly, G. S., & La ting, J. M. (2003). Personality-guided therapy for posttraumatic stress
disorder. Washington, DC: American Psychological Association.
Fairbairn, W. R. D. (1952). An object relations theory of personality. New York: Basic
Books.
REFERENCES
281
Fisher, S., & Greenberg, R. P. (Eds.) (1978). The scientific evaluation of Freud's theories and therapy: A book of readings. New York: Basic Books.
Flett, G. L, Hewitt, P. L, Blankstein, K. R., Solnik, M., & Van Brunschot, M. (1996).
Perfectionism, social problem-solving ability, and psychological distress. Journal of Rational-Emotive and Cognitive-Behaviour Therapy, 14, 245-274.
Flett, G. L., Russo, F., & Hewitt, P. L. (1994). Dimensions of perfectionism and
constructive thinking as a coping response. Journal of Rational-Emotive and Cognitive-Behaviour Therapy, 12, 163-179.
Flick, S. N., Roy-Byrne, P. P., Cowley, D. S., Shores, M. M., & Dunner, D. L. (1993).
DSMI1IR personality disorders in a mood and anxiety disorders clinic: Prevalence, comorbidity, and clinical correlates. Journal of Affective Disorders, 27,
71-79.
Forehand, R., & Kotchick, B. A. (1996). Cultural diversity: A wake-up call for parent training. Behavior Therapy, 27, 187-206.
Foulks, E. F. (1996). Culture and personality disorders. InJ. E. Mezzich, A. Kleinman,
H. Fabrega, & D. L. Parron (Eds.), Culture and Psychiatric Diagnosis: A DSM-IV
perspective (pp. 243-252). Washington, DC: American Psychiatric Press.
Frankenburg, F. R., & Zanarini, M. C. (1993). Clozapine treatment of borderline
patients: A preliminary study. Comprehensive Psychiatry, 34, 402-405.
Frankenburg, F., &. Zanarini, M. C. (2004). The association between borderline personality disorder and chronic medical illnesses, poor health-related lifestyle
choices, and costly forms of health care utilization. Journal of Clinical Psychiatry,
65, 1660-1665.
Frankl, V. (1959). Man's search for meaning. New York: Simon &. Schuster.
Frankl, V. E. (1983). Meaninglessness: A challenge to psychologists. In T. Millon
(Ed.), Theories of personality and psychopathology (pp. 256-263). New York: Holt,
Rinehart &. Winston.
Freud, S. (1959). Character and anal eroticism. In E. Jones (Ed.), Sigmund Freud:
Collected papers (Vol. 2, pp. 45-50). New York: Basic Books. (Original work
published 1908)
Freud, S. (1969). An outline of psycho-analysis (J. Strachey, Trans.). New York: Norton.
(Original work published 1940)
Freud, S. (1986). Mourning and melancholia. In ]. C. Coyne (Ed.), Essential papers
on depression (pp. 48-63). New York: New York University Press. (Original
work published 1917)
Freyd, J. J., Putnam, F. W., Lyon, T. D., Becker-Blease, K. A., Cheit, R. E., Siegel, N.
B., & Pezdek, K. (2005, April 22). The science of child sexual abuse. Science,
308, 501.
Friedman, R. C, Aronoff, M. S., Clarkin, J. F, Corn, R., & Hurt, S. W. (1983).
History of suicidal behavior in depressed borderline inpatients. American Journal of Psychiatry, 140, 1023-1026.
Fukuzako, H., Kodama, S., & Fukuzako, T. (2002). Phosphorus metabolite in temporal lobes of subjects with schizotypal personality disorder. Schizophrenia Research, 58, 201-203.
282
REFERENCES
REFERENCES
283
Gottman, J., Notarius, C., Gonso, J., & Markman, H. (1976). A couple's guide to
communication. Champaign, IL: Research Press.
Gould, R. A., Mueser, K. T., &Bolton, E. (2001). Cognitive therapy for psychosis in
schizophrenia: An effect size analysis. Schizophrenia Research, 48, 335-342.
Goyer, P. F., Andreason, P. J., Semple, W. E., Clayton, A. H., King, A. C., ComptonToth, B. A., et al. (1994). Positron-emission tomography and personality disorders. Neuropsychopharmacology, 10, 21-28.
Goyer, P. F., Konicki, P. E., & Schulz, S. C. (1994). Brain imaging in personality
disorders. In K. R. Silk (Ed.), Biological and neurobehavioral studies of borderline
personality disorder (pp. 109-125). Washington, DC: American Psychiatric Press.
Greenberg, P. E., Kessler, R. C., Birnbaum, H. G., Leon, S. A., Lowe, S. W., Berglund,
P. A., & Corey-Lisle, P. K. (2003). The economic burden of depression in the
United States: How did it change between 1900 and 2000? Journal of Clinical
Psychiatry, 64, 1465-1475.
Greenberg, L. S., Watson, J. C., & Goldman, R. (1998). Process-experiential therapy
of depression. In L. S. Greenberg, ]. C. Watson, & G. Lietaer (Eds.), Handbook
of experiential psychotherapy (pp. 227-248). New York: Guilford Press.
Greenspan, S. I. (1997). De<velopmentally based psychotherapy. Madison, CT: International Universities Press.
Greenspan, S. L, & Wieder, S. (1998). The child with special needs. Reading, MA:
Perseus Publishing.
Gunderson, J. G., Berkowitz, C., & Ruiz-Sanchez, A. (1997). Families of borderline
patients: A psychoeducational approach. Bulletin of the Menninger Clinic, 61,
446-457.
Guy, J. D., Brown, C. K., & Poelstra, P. L. (1990). Who gets attacked? A national
study of patient violence directed at psychologists in clinical practice. Professional Psychology: Research and Practice, 21, 493-495.
Hadaway, C. K., & Mailer, P. L. (1993). What the polls don't show: A closer look at
U.S. church attendance. American Sociological Review, 93, 741-752.
Haddock, G., Tarrier, N., Spaulding, W., Yusupoff, L., Kinney, C., & McCarthy, E.
(1998). Individual cognitive-behavior therapy in the treatment of hallucinations and delusions: A review. Clinical Ps^cholog^ Review, 18, 821-838.
Hahlweg, K., & Wiedemann, G. (1999). Principles and results of family therapy in
schizophrenia. European Archives of Psychiatry and Clinical Neuroscience,
249(SuPPl. 4), 108-115.
Haley, ]. (1963). Strategies of psychotherapy. New York: Gruen & Stratton.
Hall, S. E. K., & Geher, G. (2003). Behavioral and personality characteristics of
children with reactive attachment disorder, journal of Psychology, 137, 145162.
Haney, C., Banks, C., & Zimbardo, P. (1973). Interpersonal dynamics in a simulated
prison. International Journal of Criminology and Penology, 1, 69-97.
Harper, R. G. (2003). Personality-guided therapy in behavioral medicine. Washington,
DC: American Psychological Association.
284
REFERENCES
Hart, S. D., Dutton, D. G., & Newlove, T. (1993). The prevalence of personality
disorder among wife assaulters. Journal of Personality Disorders, 7, 329-341Hayes, J. A., & Gelso, C. J. (2001). Clinical implications of research on countertransference: Science informing practice, journal of Clinical Psychology, 57,10411051.
Hays, K. F. (1999). Working it out: Using exercise in psychotherapy. Washington, DC:
American Psychological Association.
Hays, K. F. (2002). Move your body, tone your mood: The workout therapy workbook.
Oakland, CA: New Harbinger Publications.
Herrell, R., Goldberg, J., True, W. R., Ramakrishran, V., Lyons, M., Eisen, S., &.
Tsuang, M. T. (1999). Sexual orientation and suicidality: A co-twin control
study in adult men. Archives of General Psychiatry, 56, 867-874.
Hewitt, P. L, & Flett, G. L. (1991a). Dimensions of perfectionism in unipolar depression, journal of Abnormal Psychology, 100, 98-101.
Hewitt, P. L., & Flett, G. L. (1991b). Perfectionism in the self and social contexts:
Conceptualization, assessment, and association with psychopathology. journal
of Personality and Social Psychology, 60, 456470.
Hewitt, P. L., & Flett, G. L. (1993). Dimensions of perfectionism, daily stress, and
depression: A test of the specific vulnerability hypothesis, journal of Abnormal
Psychology, 102, 58-65.
Hewitt, P. L., Flett, G. L., & Ediger, E. (1996). Perfectionism and depression: Longitudinal assessment of a specific vulnerability hypothesis, journal of Abnormal
Psychology, 105, 276-280.
Hewitt, P. L., Flett, G. L., Ediger, E., Norton, G. R., & Flynn, C. A. (1998). Perfectionism in chronic and state symptoms of depression. Canadian journal of
Behavioural Science, 30, 234-242.
Hewitt, P. L., Newton, ]., Flett, G. L., & Callander, L. (1997). Suicide ideation in
adolescent psychiatric patients: Perfectionism and hopelessness. Journal of Abnormal Child Psychology, 25, 95-101.
Hirose, S. (2001). Effective treatment of agression and impulsivity in antisocial personality disorder with risperidone. Psychiatry and Clinical Neurosdences, 55,161163.
Hirschfeld, R. M. A. (1997). Pharmacotherapy of borderline personality disorder.
Journal of Clinical Psychiatry, 58, 48-52.
Hogg, J. A., & Deffenbacher, J. L. (1988). A comparison of cognitive and interpersonal-process group therapies in the treatment of depression among college students. Journal of Counseling Psychology, 35, 304-310.
Hollander, E., Allen, A., Lopez, R. P., Bienstock, C. A., Grossman, R., Siever, L. J.,
et al. (2001). A preliminary double-blind, placebo-controlled trial of divalproex
sodium in borderline personality disorder. Journal of Clinical Psychiatry, 62, 199203.
Hollander, E., Swann, A. C., Coccaro, E. F., Jiang, P., & Smith, T. B. (2005). Impact
of trait impulsivity and state aggression on divalproex versus placebo response
REFERENCES
285
REFERENCES
Joiner, T. E. (1994). Contagious depression existence, specificity to depressed symptoms, and the role of reassurance seeking. Journal of Personality and Social Psychology, 67, 287-296.
Jongsma, A. E., & Peterson, L. M. (1999). The complete adult psychotherapy treatment
planner. New York: Wiley.
Joseph, S. (1997). Personality disorders: Neu> symptom-focused drug therapy. Binghamton,
NY: Haworth Medical Press.
Kabat-Zinn, J. (1990). Full catastrophe living. New York: Delta Books.
Kabat-Zinn, J. (1994). Wherever you go, there you are: Mindfulness meditation in everyday life. New York: Hyperion.
Kabat-Zinn, J., Massion, A. O., Kristeller, J., Peterson, L. G., Fletcher, K. E., Pbert,
L., et al. (1992). Effectiveness of a meditation-based stress reduction program in
the treatment of anxiety disorders. American Journal of Psychiatry, 149, 936943.
Kalogjera, I. J., Jacobson, G. R., Hoffman, G. K., Hoffman, P., Raffe, I. H., White,
H. C., & Leonard-White, A. (1998). The narcissistic couple. In J. Carlson &
L. Sperry (Eds.), The disordered couple (pp. 207-238). Bristol, PA: Brunner/Mazel.
Kaslow, N. J., McClure, E. B., & Connell, A. M. (2002). Treatment of depression in
children and adolescents. In I. H. Gotlib & C. L, Hammen (Eds.), Handbook of
depression (pp. 441-464). New York: Guilford Press.
Kernberg, O. F. (1967). Borderline personality organization. Journal of the American
Psychoanalytic Association, 15, 641-685.
Kernberg, O. F. (1970). Psychoanalytic classification of character pathology. Journal
of the American Psychoanalytic Association, 18, 800-822.
Kernberg, O. F. (1975). Borderline conditions and pathological narcissism. New York:
Jason Aronsori.
Kernberg, O. F. (1986a). Borderline personality organization. In M. H. Stone (Ed.),
Essential papers on borderline disorders: One hundred years at the border (pp. 279319). New York: New York University Press. (Original work published 1967)
Kernberg, O. F. (1986b). Factors in the psychoanalytic treatment of narcissistic personalities. In A. P. Morrison (Ed.), Essential papers on narcissism (pp. 213-244).
New York: New York University Press. (Original work published 1970)
Kernberg, O. F. (1986c). Further contributions to the treatment of narcissistic personalities. In A. P. Morrison (Ed.), Essential papers on narcissism (pp. 245-292).
New York: New York University Press. (Original work published 1974)
Kernberg, O. F. (1990). Countertransference. In R. Langs (Ed.), Classics in psychoanalytic technique (Rev ed., pp. 207-216). Northvale, NJ: Jason Aronson. (Original work published 1965)
Kernberg, O. F. (1992). Antisocial and narcissistic personality disorders. Aggression in
personality disorders and perversions. New Haven, CT: Yale University Press.
Kernberg, O. F., Selzer, M. A., Koenigsberg, H. W., Carr, A. C., & Appelbaum,
A. H. (1989). Ps;ychod;ynamic psychotherapy of borderline patients. New York: Basic Books.
REFERENCES
287
REFERENCES
289
Lieberz, K. (1989). Children at risk for schizoid disorders. Journal of Personality Disorders, 3, 329-337.
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press.
Linehan, M. M. (1995). Treating borderline personality disorder: The dialectical approach
[Video]. New York: Guilford Publications.
Links, P. S., Gould, B., & Ratnayake, R. (2003). Assessing suicidal youth with antisocial, borderline, or narcissistic personality disorder. Canadian Journal of Psychiatry, 48, 301-310.
Lion, L. S. (1978). Psychological effects of jogging: A preliminary study. Perceptual
and Motor Skills, 47, 1215-1218.
Lion, J. R., & Leaff, L. A. (1973). On the hazards of assessing character pathology, in
an outpatient setting: A brief clinical note. Psychiatric Quarterly, 47, 104-109.
Lionells, M. (1986). A reevaluation of hysterical relatedness. Contemporary Psychoanalysis, 22, 570-597.
Liu, ]., Nyholt, D. R., Magnussen, P., Parano, E., Pavone, P., Geschwind, D., et al.
(2001). A genomewide screen for autism susceptibility loci. American Journal of
Human Genetics, 69, 327-340.
Livesley, W. ]., Jackson, D., & Schroeder, M. (1989). A study of the factorial structure of personality pathology. Journal of Personality Disorders, 3, 292-306.
Livesley, W. ]., Jang, K. L., Jackson, D. N., & Vernon, P. A. (1993). Genetic and
environmental contributions to dimensions of personality disorder. American
Journal of Psychiatry, 150, 1826-1831.
Livesley, W. J., Jang, K. L., &. Vernon, P. A. (1998). Phenotypic and genetic structure of traits delineating personality disorder. Archives of General Psychiatry, 55,
941-948.
Loehlin, J. C. (1989). Partitioning environmental and genetic contributions to behavioral development. American Psychologist, 44, 1285-1294.
Loehlin, J. C., Willerman, L., & Horn, J. M. (1987). Personality resemblance in
adoptive families: A 10-year follow-up. Journal of Personality and Social Psychology, 53, 961-969.
Lyubomirsky, S., &Nolen-Hoeksema, S. (1993). Self-perpetuating properties of dysphoric rumination. Journal of Personality and Social Psychology, 65, 339349.
MacKenzie, K. R. (2001). Interpersonal psychotherapy group (IPT-G) for depression. Journal of Psychotherapy Practice and Research, 10, 46-51.
MacNeil/Lehrer Productions. (1997). Oppression and malice: February 5, 1997 transcript. Retrieved April 5, 2006, from http://www.pbs.org/newshour/bb/law/
february97/simp_2-5.html
Magnavita, J. J. (2005). Personality-guided relational psychotherapy: A unified approach.
Washington, DC: American Psychological Association.
Maier, W., Lichtermann, D., Klingler, R., Heun, R., & Hallmayer, J. (1992).
Prevalences of personality disorders (DSM-III-R) in the community. Journal of
Personality Disorders, 6, 187-196.
290
REFERENCES
March, J., & Mulle, K. (1998). OCD in children and adolescents: A cognitive-behavioral
treatment manual. New York: Guilford Press.
Markovitz, P. J. (2004). Recent trends in the pharmacotherapy of personality disorders, journal of Personality Disorders, 18, 90-101.
Markovitz, P. J., Calabrese, J. R., Schulz, S. C., & Meltzer, H. Y. (1991). Fluoxetine
in the treatment of borderline and schizotypal personality disorders. American
Journal of Psychiatry, 148, 1064-1067.
Markovitz P. ]., & Wagner, S. C. (1995). Venlafaxine in the treatment of borderline
personality disorder. Psychopharmacology Bulletin, 31, 773-777.
Markowitz, J. C., Moran, M. E., Kocsis, J. H., & Frances, A. (1992). Prevalence and
comorbidity of dysthymic disorder among psychiatric outpatients, journal of
Affective Disorders, 24, 63-71.
Marshall, R. D., & Schneier, F. R. (1996). An algorithm for the pharmacotherapy of
social phobia. Psychiatric Annals, 26, 210-216.
Martin, H. B. (2004). Gender differences in emotional response toward a male with borderline personality disorder. Unpublished manuscript.
Mason, P. T., &Kreger, R. (1998). Stop walking on eggshells: Taking your life back when
someone you care about has borderline personality disorder. Oakland, CA: New
Harbinger.
Masterson, ]. (1981). The narcissistic and borderline disorders. New York: Brunner/
Mazel.
Mattia, J. I., &. Zimmerman, M. (2001) Epidemiology. In W. J. Livesley (Ed.), Handbook of personality disorders (pp. 107-123). New York: Guilford Press.
May, R. (1983a). The discovery of being: Writings in existential psychology. New York:
Norton.
May, R. (1983b). Existential psychology. In T. Millon (Ed.), Theories of personality
and psychopathology (pp. 263-271). New York: Holt, Rinehart & Winston.
McCarthy, B., & McCarthy, E. (1984). Sexual awareness. New York: Carroll & Graf.
McCartney, K., Harris, M. J., & Bernieri, F. (1990). Growing up and growing apart:
A developmental meta-analysis of twin studies. Psychological Bulletin, 107, 226237.
McDermut, W., Miller, I. W., & Brown, R. A. (2001). The efficacy of group psychotherapy for depression: A meta-analysis and review of the empirical literature.
Clinical Psychology: Research and Practice, 8, 98-116.
McGill, D. W., & Pearce, J. K. (1996). American families with English ancestors
from the Colonial era: Anglo Americans. In M. McGoldrick, J. Giordano, &
J. K. Pearce (Eds.), Ethnicity and family therapy (2nd ed., pp. 451-466). New
York: Guilford Press.
McGlashin, T. H., Grilo, C. M., Skodol, A. E., Gunderson, J. G., Shea, M. T., Morey,
L. C,, et al. (2000). The collaborative longitudinal personality disorders study:
Baseline Axis-I/11 and II/II diagnostic co-occurrence. Acta Psychiatrica
Scandinavica, 102, 256-264REFERENCES
291
McHenry, S. S. (1994). When the therapist needs therapy: Characterological countertransference issues and failures in the treatment of the borderline personality
disorder. Psychotherapy, 31, 557-570.
Mclntyre, S. M., & Schwartz, R. C. (1998). Therapists' differential countertransference reactions toward clients with major depression or borderline personality
disorder. Journal of Clinical Psychology, 54, 923-931.
McPherson, S. (1996). The spaces between birds: Mother/daughter poems, 1967-1995.
Hanover, NH: University Press of New England/Wesleyan University Press.
McWilliams, N. (1994). Psychoanalytic diagnosis: Understanding personality structure
in the clinical process. New York: Guilford Press.
Meehl, P. E. (1973). Schizotaxia, schizotypy, and schizophrenia. In P. E. Meehl (Ed.),
Psychodiagnosis: Selected papers (pp. 135-155). Minneapolis: University of Minnesota Press. (Original work published 1962)
Meehl, P. E. (1978). Theoretical risks and tabular asterisks: Sir Karl, Sir Ronald, and
the slow progress of soft psychology. Journal of Consulting and Clinical Psychol'
ogy,46, 806-834.
Meehl, P. E. (1990). Toward an integrated theory of schizotaxia, schizotypy, and
schizophrenia, journal of Personality Disorders, 4, 1-99.
Meissner, W. W. (1982). Notes on countertransference in borderline conditions.
International journal of Psychoanalytic Psychotherapy, 9, 89-123.
Meissner, W. W. (1986). Narcissistic personalities and borderline conditions: A differential diagnosis. In A. P. Morrison (Ed.), Essential papers on narcissism (pp.
403-447). New York: New York University Press. (Original work published
1979)
Meissner, W. W. (1988). Treatment of patients in the borderline spectrum. Northvale,
NJ: Jason Aronson.
Meloy, J. R. (1988). The psychopathic mind: Origins, dynamics, and treatment. Northvale,
NJ: Jason Aronson.
292
REFERENCES
Millon, T. (1987b). On the genesis and prevalence of the BPD. Journal of Personality
Disorders, 1,354-372.
Millon, T. (1994). Millon Clinical Multiaxial InventoryIII. Minneapolis, MN: National Computer Systems.
Millon, T. (1999). Personality-guided therapy. New York: Wiley.
Millon, T. (with Davis, R. D.). (1996). Disorders of personality: DSM-IV and beyond
(2nd ed.). New York: Wiley.
Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press.
Moultrup, D. J. (1985). Alone together. In A. S. Gurman (Ed.), Casebook of marital
therapy (pp. 229-252). New York: Guilford Press.
Mullen, K. B. (2004) Therapist emotional reactions as a diagnostic indicator for schizptypal
personality disorder. Unpublished manuscript
Murphy, M., &. Donovan, S. (1997). The physical and psychological effects of meditation: A review of contemporary research with a comprehensive bibliography, 19311996 (2nd ed.). Sausalito, CA: Institute of Noetic Sciences.
Muslin, H., & Gill, M. (1978). Transference in the Dora case. Journal of the American
Psychoanalytic Association, 26, 311328.
Nagy, J., & Szatmari, P. (1986). A chart review of schizotypal personality disorders
in children. Journal of Autism and Developmental Disorders, 16, 351-367.
Napier, A. Y. (with Whitaker, C. A.). (1978). The family crucible. New York: Harper
&. Row.
Narayan, S., Moyes, B., & Wolff, S. (1990). Family characteristics of autistic children: A further report. Journal of Autism and Developmental Disorders, 20, 523535.
National Institutes of Health. (1985). Electroconvulsive therapy. NIH Consensus
Statement Online, 5, 1-23.
Nhat Hanh, T. (1976). The miracle ofmindfulness. Boston: Beacon Press.
Nigg, J. T., & Goldsmith, H. H. (1994). Genetics of personality disorders: Perspectives from personality and psychopathology research. Psychological Bulletin, 115,
346-380.
Nolen-Hoeksema, S. (1991). Responses to depression and their effects on the duration of depressive episodes. Journal of Abnormal Psychology, 100, 569582.
Nolen-Hoeksema, S. (2002). Gender differences in depression. In I. H. Gotlib &.
C. L. Hammen (Eds.), Handbook of depression (pp. 492-509). New York: Guilford
Press.
Nolen-Hoeksema, S., Larson, ]., & Grayson, C. (1999). Explaining the gender difference in depressive symptoms. Journal of Personality and Social Psychology, 77,
1061-1072.
Nordahl, H. M., & Stiles, T. C. (1997). Perceptions of parental bonding in patients
with various personality disorders, lifetime depressive disorders, and healthy
controls. Journal of Personality Disorders, 11, 391-402.
REFERENCES
293
Nurse, R. (1998). The dependent/narcissistic couple. InJ. Carlson & L. Sperry (Eds.),
The disordered couple (pp. 315-331). Bristol, PA: Brunner/Mazel,.
Ochenduszko, L. (2003, March 29). Paranoid. Message posted with the screen name
"WoundedAngel" to http://www.allpoetry.com/Poem/211128
O'Connor, T. G., McGuire, S., Reiss, D., Hetherington, E. M., & Plomin, R. (1998).
Co-occurrence of depressive symptoms and antisocial behavior in adolescence:
A common genetic liability. Journal of Abnormal Psychology, 107, 27-37.
O'Leary, K., & Cowdry, R. (1994). Neuropsychological testing results in borderline
personality disorder. In K. R. Silk (Ed.), Biological and neurobehavioral studies of
borderline personality disorder (pp. 127-157). Washington, DC: American Psychiatric Press.
Otis, M. D., & Skinner, W. F. (1996). The prevalence of victimization and its effect
on mental well-being among lesbian and gay people, journal of Homosexuality,
30, 93-121.
Pacini, R., Muir, F., & Epstein, S. (1998). Depressive realism from the perspective of
cognitive-experiential self-theory, journal of Personality and Social Psychology,
74, 1056-1068.
Pagnin, D., de Queiroz, V., Pini, S., & Cassano, G. B. (2004). Efficacy of ECT in
depression: A meta-analytic review. Journal of ECT, 20, 13-20.
Palazzoli, M. S. (1988). The work of Mara Selvini Palazzoli (M. Selvini, Ed., & A. J.
Pomerans, Trans.). Lanham, MD: Jason Aronson.
Paniagua, F. A. (1994). Assessing and treating culturally diverse clients: A practical guide.
London: Sage.
Pavlov, I. P. (1963). Lectures on conditioned reflexes (Vol. 1). Oxford, England: International. (Original work published 1928)
Penner, C., & Penner, J. (1981). The gift of sex. Waco, TX: Word Books.
Pepper, C. M., Klein, D. N., Anderson, R. L., Riso, L. P., Ouimette, P. C., & Lizardi,
H. (1995). Axis II comorbidity in dysthymia and major depression. American
journal of Psychiatry, 152, 239-247.
Persons, J. B., Burns, D. D., Perloff, J. M., & Miranda, J. (1993). Relationships between symptoms of depression and anxiety and dysfunctional beliefs about
achievement and attachment. Journal of Abnormal Psychology, 102, 518-524.
Petersen, T., Hughes, M., Papakostas, G. I., Fava, M., Rosenbaum, J. F., &Nierenberg,
A. A. (2002). Treatment-resistant depression and Axis II comorbidity. Psychotherapy and Psychosomatics, 71, 269-274.
Peterson, A. L., & Halstead, T. S. (1998). Group cognitive behavior therapy for
depression in a community sample: A clinical replication series. Behavior Therapy,
29, 3-18.
Philipsen, A., Richter, H., Schmahl, C., Peters, J., Riisch, N., Bohus, M, & Lieb, K.
(2004). Clonidine in acute aversive inner tension and self-injurious behavior in
female patients with borderline personality disorder. Journal of Clinical Psychiatry, 65, 1414-1419.
294
REFERENCES
REFERENCES
295
Rosenbaum, J. F., & Pollock, R. A. (1994)- The psychopharmacology of social phobia and comorbid disorders. Bulletin of the Menninger Clinic, 58(2, Suppl. A),
67-83.
Rosowsky, E., & Dougherty, L. M. (1998). Personality disorders and clinician responses. Clinical Gerontologist, 18, 31-42.
Rudolph, R. L. (2002). Achieving remission from depression with venlafaxine and
venlafaxine extended release: A literature review of comparative studies with
selective serotonin reuptake inhibitors. Acta Psychiatrica Scandinavica, 106(Suppl.
415), 106-129.
Rusten, M. (2002). Emotional reaction to histrionic personality disorder: An investigation
of diagnostic utility. Unpublished manuscript.
Satir, V. (1983). Conjoint family therapy (3rd ed.). Palo Alto, CA: Science & Behavior Books.
Saxe, J. G. (2002). The blind men and the elephant. Retrieved July 6, 2003, from http://
www.noogenesis.com/pineapple/blind_men_etephant.html
Scarciglia, P., Gherardelli, S., Tarsitani, L, & Biondi, M. (2004). Stati alterati di
coscienza in un disturbo schizotipico di personalita: Un caso clinico trattato
con olanzapine [Impairments of consciousness in a schizotypal personality disorder: A clinical case treated with olanzapine] [English Abstract]. Rivista di
Psichiatria, 39, 270-276.
Schuldberg, D. (2000-2001). Six subclinical spectrum traits in normal creativity.
Creativity Research Journal, 13, 5-16.
Schulz, S. C., Camlin, K. L., Berry, S. A., & Jesberger, ]. A. (1999). Olanzapine
safety and efficacy in patients with borderline personality disorder and comorbid
dysthymia. Biological Psychiatry, 46, 1429-1435.
Schulz, S. C., Schulz, P. M., & Wilson, W. H. (1988). Medication treatment of
schizotypal personality disorders. Journal of Personality Disorders, 2, 1-13.
Searles, H. F. (1986). My work with borderline patients. Northvale, NJ: Jason Aronson.
Sedlak, A. J., & Broadhurst, D. D. (1996). Executive summary of the Third National
Incidence Study of Child Abuse and Neglect. Retrieved November 19, 2003, from
http://nccanch.acf.hhs.gov/pubs/statsinfo/nis3.cfm
Seedat, S., & Stein, M. B. (2004). Double-blind, placebo-controlled assessment of
combined clonazepam with paroxetine compared with paroxetine monotherapy
for generalized social anxiety disorder. Journal of Clinical Psychiatry, 65, 244248.
Segal, D. L., Hook, J. N., &. Coolidge, F. L. (2001). Personality dysfunction, coping
styles, and clinical symptoms in younger and older adults. Journal of Clinical
Geropsychology, 7, 201-212.
Segal, Z. V., Shaw, B. F., Vella, D. D., & Katz, R. (1992). Cognitive and life stress
predictors of relapse in remitted unipolar depressed patients: Test of the congruency hypothesis. Journal of Abnormal Psychology, 101, 26-36.
Seligman, M. E. (1975). Helplessness: On depression, development, anddeath. Oxford,
England: Freeman.
296
REFERENCES
Seligman, M. E. P., & Csikszentmihalyi, M. (2000). Positive psychology: An introduction. American Psychologist, 55, 5-14.
Selye, H. (1978). The stress of life (Rev. ed.). Oxford, England: McGraw-Hill. (Original work published 1956)
Selye, H., & Weider, A. (1953). The general-adaptation-syndrome in its relationships to neurology, psychology, and psychopathology. In A. Weider (Ed.), Contributions toward medical psychology: Theory and psychodiagnostic methods (2 vols.,
pp. 234-274). Oxford, England: Ronald Press.
Seppuku. (2005). In Wikipedia. Retrieved September 10, 2005, from http://
en.wikipedia.org/wiki/Seppuku
Serban, G., & Siegel, S. (1984). Response of borderline and schizotypal patients to
small doses of thiothixene and haloperidol. American journal of Psychiatry, 141,
1455-1458.
Shakespeare, W. (1972). The works of William Shakespeare. Roslyn, NY: Walter J.
Black.
Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures (2nd ed.). New York: Guilford Press.
Shea, M. T., Glass, D. R., Pilkonis, P. A., Watkins, J., &. Docherty, J. P. (1987).
Frequency and implications of personality disorders in a sample of depressed
outpatients, journal of Personality Disorders, 1, 27-42.
Shea, M. T., Pilkonis, P. A., Beckham, E., Collins, J. F., Elkin, I., Sotsky, S. M., &
Docherty, J. P. (1990). Personality disorders and treatment outcome in the NIMH
treatment of depression collaborative research program. American Journal of Psychiatry, 147, 711-718.
Shea, M. T., Widiger, T. A, & Klein, M. H. (1992). Comorbidity of personality
disorders and depression: Implications for treatment, journal of Consulting and
Clinical Psychology, 60, 857-868.
Shihabuddin, L, Buchsbaum, M. S., Hazlett, E. A., Silverman, J., New, A., Brickman,
A. M., et al. (2001). Striatal size and relative glucose metabolic rate in schizotypal
personality disorder and schizophrenia. Archives of General Psychiatry, 58, 877884.
Siever, L. (1992). Schizophrenia spectrum personality disorders. American Psychiatric
Press Review of Psychiatry, 11, 25-42.
Siever, L. J., Amin, F., Coccaro, E. F., Bernstein, D., Kavoussi, R. J., Kalus, O., et al.
(1991). Plasma homovanillic acid in schizotypal personality disorder. American
journal of Psychiatry, 148, 1246-1248.
Siever, L. ]., New, A. S., Kirrane, R., Novotny, S., Koenigsberg, H., & Grossman, R.
(1998). New biological research strategies for personality disorders. In K. R.
Silk (Ed.), Biology of personality disorders (pp. 27-61). Washington, DC: American Psychiatric Press.
Siever, L. J., Rotter, M,, Losonczy, M., Song, L. G., Mitropoulou, V., Trestman, R.,
et al. (1995). Lateral ventricular enlargement in schizotypal personality disorder. Psychiatry Research, 57, 109-118.
REFERENCES
297
REFERENCES
REFERENCES
299
Streisand, B. (1995, October 9). Any justice for all? U.S. News and World Report,
119, 46-50.
Styron, W. (1992). Darkness visible: A memoir of madness. New York: Random House.
Sue, D. W., & Sue, D. (2003). Counseling the culturally diverse: Theory and practice
(4th ed.). New York: Wiley.
Swann, W. B., Jr., & Bosson, J. K. (1999). The flip side of the reassurance-seeking
coin: The partner's perspective. Psychological Inquiry, 10, 302-304.
Swann, W. B., Wenzlaff, R. M., Krull, D. S., & Pelham, B. W. (1992). Allure of
negative feedback: Self-verification strivings among depressed persons. Journal
of Abnormal Psychology, 101, 293-306.
Swanston, H. Y., Plunkett, A. M., O'Toole, B. I., Shrimpton, S., Parkinson, P. N., &
Gates, R. K. (2003). Nine years after child sexual abuse. Child Abuse and Negleet, 27, 967-984.
Szigethy, E. M., & Schulz, S. C. (1997). Risperidone in comorbid borderline personality disorder and dysthymia. journal of Clinical Psychopharmacology, 17, 326327.
Tannen, D. (1990). You just don't understand: Women and men in conversation. New
York: Ballantine.
Thase, M. C., Jindal, R., & Howland, R. H. (2002). Biological aspects of depression
(pp. 192-218). In I. H. Gotlib & C. L. Hammen (Eds.), Handbook of depression.
New York: Guilford Press.
Torgersen, S., Lygren, S., Oien, P. A., Sker, I., Onstad, S., Edvardsen, J., et al. (2000).
A twin study of personality disorders. Comprehensive psychiatry, 1, 416-425.
Torgersen, S., Onstad, S., & Skre, I. (1993). "True" schizotypal personality disorder:
A study of co'twins and relatives of schizophrenic probands. American journal of
Psychiatry, 150, 1661-1667.
Torgersen, S., Skre, I., Onstad, S., Evardsen, J., & Kringlen, E. (1993). The psychometric-genetic structure of DSM111R personality disorder criteria. Journal of
Personality Disorders, 7, 196-213.
Trouton, A., Spinath, F. M., & Plomin, R. (2002). Twins Early Development Study
(TEDS): A multivariate, longitudinal genetic investigation of language, cognition and behavior problems in childhood. Twin Research, 5, 444-448.
Tsai, ]. L., & Chentsova-Dutton, Y. (2002). Understanding depression across cultures. In I. H. Gotlib & C. L. Hammen (Eds.), Handbook of depression (pp. 467491). New York: Guilford Press.
Tyrka, A. R., Cannon, T. D., Haslam, N., Mednick, S. A., Schulsinger, F., Schulsinger,
H., & Parnas, J. (1995). The latent structure of schizotypy: 1. Premorbid indicators of a taxon of individuals at risk for schizophrenia-spectrum disorders. Journal of Abnormal Psychology, 104, 173-183.
UK ECT Review Group. (2003). Efficacy and safety of electroconvulsive therapy in
depressive disorders: A systematic review and meta-analysis. Lancet, 361, 799-
300
REFERENCES
van Heeringen, C., &. Vincke, ]. (2000). Suicidal acts and ideation in homosexual
and bisexual young people: A study of prevalence and risk factors. Social Psychiatry and Psychiatric Epidemiology, 35, 494-499.
Vuksic-Mihaljevic, Z., Mandic, N., Barkic, ]., & Mrdjenovic, S. (1998). Countertransference in the treatment of borderline personality disorder. European Journal of Psychiatry, 12, 50-58.
Wachtel, E. F., & Wachtel, P. L. (1986). Family dynamics in individual psychotherapy:
A guide to clinical strategies. New York: Guilford Press.
Waldeck, T. L., & Miller, L. S. (2000). Social skills deficits in schizotypal personality
disorder. Psychiatry Research, 93, 237-246.
Walker, E. F., Logan, C. B., & Walder, D. (1999). Indicators of neurodevelopmental
abnormality in schizotypal personality disorder. Psychiatric Annals,29, 132-136.
Walker, T., Thomas, ]., & Allen, T. S. (2003). Treating impulsivity, irritability, and
aggression of antisocial personality disorder with quetiapine. International Journal of Offender Therapy and Comparative Criminology, 47, 556-567.
Wallace, ]., Schneider, T., & McGuffin, P. (2002). Genetics of depression. In I. H.
Gotlib & C. L. Hammen (Eds.), Handbook of depression (pp. 169-191). New
York: Guilford Press.
Wang, P. S., Berglund, P., Olfson, M., Pincus, H. A., Wells, K. B., & Kessler, R. C.
(2005). Failure and delay in initial treatment contact after first onset of mental
disorders in the National Comorbidity Survey Replication. Archives of General
Psychiatry, 62, 603-613.
Wang, P. S., Demler, O., & Kessler, R. C. (2002). Adequacy of treatment for serious
mental illness in the United States. American Journal of Public Health, 92, 9298.
Wang, P. S., Lane, M., Olfson, M., Pincus, H. A., Wells, K. B., & Kessler, R. C.
(2005). Twelve-month use of mental health services in the United States: Results from the National Comorbidity Survey Replication. Archives of General
Psychiatry, 62, 629-640.
Ward, E., King, M., Lloyd, M., Bower, P., Sibbald, B., Farrelly, S., et al. (2000).
Randomised controlled trail of non-directive counseling, cognitivebehaviour
therapy, and usual general practitioner care for patients with depression: I. Clinical effectiveness. British Medical Journal, 321, 1383-1388.
Warner, M. (2000). Person-centered psychotherapy at the difficult edge: A developmentally based model of fragile and dissociated process. In D. Mearns &
B. Thome (Eds.), Person-centered therapy today: New frontiers in theory and practice (pp. 144-171). London: Sage.
Watzlawick, P., Beavin, ]. H., & Jackson, D. D. (1967). Pragmatics of human communication: A study of interactional patterns, pathologies, and paradox.es. New York:
Norton.
Watzlawick, P., Weakland, J. H., & Fisch, R. (1974). Change: Principles of problem
formation and problem resolution. Oxford, England: Norton.
REFERENCES
301
Weinstein, D. D., Diforio, D., Schiffman, J., Walker, E., & Bonsall, R. (1999). Minor
physical anomalies, dermatoglyphic asymmetries, and cortisol levels in adolescents with schizotypal personality disorder. American Journal of Psychiatry, 156,
617-623.
Weissman, M. M., Bruce, M. L., Leaf, P. ]., Florio, L. P., & Holzer, C, III. (1991).
Affective disorders. In L. N. Robins & D. A. Regier (Eds.), Psychiatric disorders
in America (p. 45). New York: Free Press.
Weissman, M. M., & Markowitz, ]. C. (2002). Interpersonal psychotherapy for depression. In I. H. Gotlib & C. L. Hammen (Eds.), Handbook of depression (pp.
405-421). New York: Guilford.
Whaley, A. L. (1998). Cross-cultural perspective on paranoia: A focus on the Black
American experience. Psychiatric Quarterly, 69, 325-344Whiffen, V. E., & Macintosh, H. B. (2005). Mediators of the link between childhood sexual abuse and emotional distress: A critical review. Trauma, Violence
& Abuse, 6, 24-39.
Whitley, B. E. (1983). Sex-role orientation and self-esteem: A critical meta-analytic
review. Journal of Personality and Social Psychology, 44, 765-778.
Whitley, B. E. (1985). Sex-role orientation and psychological well-being: Two metaanalyses. SexRoks, 12, 207-225.
Widiger, T. A., & Rogers, J. H. (1989). Prevalence and comorbidity of personality
disorders. Psychiatric Annak, 19, 132-136.
Willey, L. H. (1999). Pretending to be normal: Living with Asperger's syndrome. London: Jessica Kingsley Publishers.
Williams, D. L. (2005). Therapist emotional response to patients diagnosed with depressive personality disorder. Unpublished manuscript.
Williams, J. H. (1987). Psychology of women: Behavior in a biosocial context (3rd ed.).
New York: Norton.
Williams, T. (1974). A streetcar named Desire. New York: Penguin. (Original work
published 1953)
Williams, T. (1999). The glass menagerie. New York: New Directions. (Original work
published 1945)
Williamson, R. C. (1976). Socialization, mental health, and social class: A Santiago
sample. Social Psychiatry, 11, 69-74Wilson, S. L. (2001). Attachment disorders: Review and current status. Journal of
Psychology, 135,37-51.
Winnicott, D. W. (1949). Hate in the counter-transference. The International Journal
of Psycho-Analysis, 30, 69-74.
Wohl, I. (1996). Diagnosis according to the DSM-IV (Program 3) [Motion picture].
(Available from Films for the Humanities and Sciences, Princeton, NJ 085432053.)
Wolfe, B. (1989). Heinz Kohut's self psychology: A conceptual analysis. Psychotherapy:
Theory, Research and Practice, 6, 187-198.
302
REFERENCES
REFERENCES
303
AUTHOR INDEX
Abraham, K, 24, 29, 235, 256
Abramson, L. Y., 23, 33, 37
Ackerman, N. W., 90
Adkins, K. K., 250
Adler.G., 156,157
Agor, W. D., 5
Akhtar, S., 75, 76, 118, 195
Alberti, R., 71
Alloy, L. B., 251
American Psychiatric Association, xii, 7,14,
16, 21, 24, 42, 43, 54, 64, 67, 82,
84,91-93,110,111,136,170,179,
189, 204, 210, 211, 228, 248, 249,
253
Anderson, I. M., 19
Anderson, ]., 97
Anderson, K. G., 179
Anderson, T., xii
Andreason, P. ]., 138
Anson, C. A., 264
Appelbaum, A. H., xii, 9, 75, 119, 144
Arkowitz, H., xi
Aronoff, M. S., 137
Auranen, M., 67
Bachar, E., 31
Bailey, A., 67
Baker, R. W., 141
Bandura, A., 147
Banks, C., 34, 123,201
Barber,]. P., 258
Bardenstein, K. K., 12, 175, 257
Basoff.E. S., 124
Bateson, G., 164
Baucom, D. H., 30
Beach, S. R. H., 30, 31
Beavin,]. H., 101
Beck, A. T., 4, 6, 22, 24, 28, 36, 39, 48-50,
64,65,70,71,80,81,99,112, 116,
118, 120, 147-149, 157, 166, 174,
176, 192-194, 200, 206, 215, 216,
218, 234, 237, 240, 254, 259
Beck, J. S., 23, 70, 117,220
Benazon, N. R., 25
Benjamin, ]., 252
Benjamin, L. S., 178, 199,257
305
AUTHOR INDEX
Eaton, W., 83
Ebeling, T., 141
EckertJ., 155
Ediger, E., 250
Ekselius, L, 9,10,44, 68,140,172,190, 212,
232, 252
Elliott, R., xii, 28
Ellis, A., 6, 70, 254, 255
Emery, G., 4
Emmons, M., 71
Epstein, M., 6
Epstein, S., 36
Erickson, K. B., 179
Eriksson, E. H., 176
Evans, D. D., 4, 39
Evardsen, J., 252
Everly, G. S., 9
307
308
AUTHOR INDEX
309
310
AUTHOR INDEX
311
312
AUTHOR INDEX
SUBJECT INDEX
Assault, fear of, 120-121
Assertiveness training, 23, 49, 71, 234
Attention deficit disorder, 114
Atypical antipsychotics, 97, 113, 140-142
Autistic spectrum disorders, 67
Avoidant paranoid PD, 45
Avoidant PD, 209-226
biological factors of, 212-214
case example of, 222-225
and countertransference, 218-219
with depression, 211
epidemiology of, 210-211
and group therapy, 32
and paranoid PD, 216
phenomenology of, 210
psychological factors of, 214-218
and social considerations/diversity, 219
220
strengths of patients with, 220
synergistic treatment for, 220-222
theories of, 212-218
Axis I-Axis II relationships, 14, 37-38
313
314
SUBJECT /NDEX
Cortisol, 18
Coryell, W., 249-250
Cost-benefit analysis, 118
Cost (of depression), 17
Countertransference, 5-7
and antisocial PD, 119-122
and avoidantPD, 218-219
and borderline PD, 156-158
and dependent PD, 237-238
and histrionic PD, 177-178
and narcissistic PD, 199-201
and obsessivecompulsive PD, 258259
and paranoid PD, 50, 53-54, 60
and schizoid PD, 80-82
and schizotypal PD, 102-103
A Couple's Guide to Communication
(Gottman, Notarius, Gonso, and
Markman), 70
Couples therapy, 176, 180, 261
Coyne, ]. C., 24
Crisis, unrelenting, 153154
Criterion sex bias, 229
Cushman, P., 159
Dalai Lama, 35
Danish High-Risk Study, 94
Darkness Visible (William Styron), 14, 71
Davis, D. D., 237
Deafness, 54, 56-58
Decubitus ulcer, 263
Delusional disorder, 42
Delusions, challenging, 99
Denial, 120
Dependency, 137, 230, 239
Dependent PD, 227-246
biological factors of, 231-233
and borderline PD, 227
case example of, 241245
and Countertransference, 237-238
with depression, 230231
epidemiology of, 228-230
and narcissistic PD, 236
phenomenology of, 227228
psychological factors of, 233237
rescue responses elicited by, 237, 242
and social considerations/diversity, 238239
strengths of patients with, 239
synergistic treatment for, 240-241
theories of, 231-237
Depersonalization, 65, 93
Depression, 13-40
315
316
SUBJECT INDEX
317
SUBJECT INDEX
319
Notarius, C., 70
Novelty seeking, 172
Nurse, R, 236
Nursing homes, 241-242
Obdurate paranoid PD, 45
Object representations, 22, 51
Obsessive-compulsive disorder (OCD) (Axis
I), 248-249, 253
Obsessive-compulsive paranoid PD, 45
Obsessive-compulsive PD (Axis II), 247-265
biological factors of, 251-252
case example of, 262265
and countertransference, 258-259
with depression, 250-251
epidemiology of, 249-250
heritability of, 252
and histrionic PD, 175-176
medications for, 252-253
phenomenology of, 248249
psychological factors of, 253-258
and social considerations/diversity, 259260
strengths of patients with, 260-261
synergistic treatment for, 261262
theories of, 251-258
OCD. See Obsessive-compulsive disorder
(Axis I)
Ochenduszko, Lisa, 41-42
The Odd Couple (Neil Simon), 248
Olanzapine, 45, 68, 97, 141, 191
One Flew Over the Cuckoo's Nest (Ken Kesey),
21
Orbital frontal region, 112, 138
Othello (William Shakespeare), 187-188
Overdose, 20
Overgeneralization, 22-23
Paradoxical technique, 174-175
Paranoid (delusional) disorder, 42
"Paranoid" (Lisa Ochenduszko), 41
Paranoid PD, 41-62
biological factors of, 44-45
case example of, 56-61
and countertransference, 53-54
depression with, 43
epidemiology of, 43
and group therapy, 32
psychological factors of, 45-53
and social considerations/diversity, 5455
strengths of patients with, 55
320
SUBJECT (NDEX
Psychobiological models, 39
Psychodynamic therapy, 28-30
for antisocial PD, 118-119
for avoidant PD, 217-218
for borderline PD, 144
for dependent PD, 235, 240
for histrionic PD, 175
and narcissistic PD, 194-197
for obsessive-compulsive PD, 256-257
for paranoid PD, 51-53
for schizoid PD, 74-77
Psychoeducation
about paranoid PD, 59
about schizoid PD, 78
about schizotypal PD, 100
Psychoses, 45
Psychotic depression, 18
Putamen, 96
Querulous paranoid PD, 45-46
Quetiapine, 114, HI
Racism, 55, 59
Randomized clinical trials (RCTs), 4
Reassurance, seeking, 24-25
Recurrent brief depression, 15
Regulatory mechanisms, 22
Relationship issues, 148
Remeron, 20
Repetition compulsion, 147
Rescue responses, 237, 242
Reticular activating system, 66
Reversible MAOIs, 213
Reward dependence, 172, 231-232
Right orbitofrontal cortex, 44
Risperidone, 45, 68, 97, 98, 113, 140, 141,
191
Robbins, A., 80, 102
Rogers, C. R., 256
Rosowsky, E., 80
Sadistic paranoid PD, 45
Safety, 120-121
Sampling bias, 229
Scandinavian cultures, 83-84
Scar model. See Complications-scar model
Schema-focused cognitive therapy, 147
Schema therapy, 147, 148
Schizoid (term), 76-77
Schizoid PD, 63-90
attitude/assumptions typical of, 70
biological factors of, 66-68
321
Serotonins, 18-20
and borderline PD, 138
and impulsive aggression, 112
and obsessive-compulsive PD, 251-253
Sertindole, 68, 191
Sertraline, 9, 10
for avoidantPD, 212-213
for borderline PD, 140
for dependent PD, 232
and histrionic PD, 172, 173
and narcissistic PD, 190
and obsessive-compulsive PD, 252
for paranoid PD, 44
and schizoid PD, 68
Serzone, 20
SES (socioeconomic status), 83
Sex bias, 229
Sex therapy, 7172
Sexual abuse, 37, 137, 150, 157-158, 160161
Sexual assault, 182-184
Sexual counseling, 261, 262
Shakespeare, William, 109, 187
Simon, Neil, 248
Simpson, O. J., 54
Sinequan, 19
Skills training, 56, 100, 101-102, 176
Skills-training groups, 31
Social alienation, 94
Social anxiety, 213
Social causation, 83
Social disengagement, 94
Social phobia, 213
Social selection, 83
Social status, 34
Sociocentric cultures, 35, 238-239
Sociocultural upheaval, 35
Socioeconomic status (SES), 83
Socratic dialogue, 49, 50, 70
Sodium valproate, 114
Soloff, P. H., 142
Somatic response, 5
Somatic symptoms, 35
Somatization, 223, 248
Spearman, Charles, ix
Spectrum model, 3738
Sperry, L., 176
Split sense of self, 2627
Splitting, 74-76, 139, 145
SSRIs, 9-10, 18-20
and antisocial PD, 113
for avoidantPD, 212-213
322
SUBJECT INDEX
76, 145
Tranylcypromine, 19
Trazodone, 20
Wales, 115
Warner, Margaret, 155-156
Weiner, A. S, 175,257
Wellbutrin, 20
Wherever You Go, There You Are (]. KabatZinn), 74, 100
White matter, 96
Wilkinson, S. M, 157
Williams, Tennessee, 169
Women
with avoidant PD, 211
with dependent PD, 211
role of, 33-34
World Health Organization Collaborative
Study, 35
Worthlessness, 23
Yoga, 180
Young, ]., 147
Zimmerman, M., 249-250
SUBJECT INDEX
323
Neil Bockian, PhD, is a professor at the Adler School of Professional Psychology in Chicago, Illinois. He is the author of more than 40 professional
publications and presentations in the areas of personality disorders, behavioral medicine, and rehabilitation psychology. He was the lead author on
The Personality Disorders Treatment Planner and New Hope for People With
Borderline Personality Disorder. Dr. Bockian's interests include empirical studies of countertransference, personality disorder prevention, the integration
of personality with Axis I disorders, and the study of Axis II conditions in
medical disorders. In addition to his professorial duties, he has a part-time
private practice; he integrates hypnosis, meditation, and neurofeedback into
his clinical work. Dr. Bockian lives with his wife and two children in Chicago, Illinois.
325