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PERSONALITY DISORDERS
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B Behavioral
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The behavioral techniques used are principally operant conditioning and aversive conditioning The former simply emphasizes the recognition of acceptable behavior and its reinforcement with praise or other tangible rewards Aversive responses usually mean punishment, although this can range from a mild rebuke to some specific punitive responses such
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ESSENTIALS OF DIAGNOSIS
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Long history dating back to childhood Recurrent maladaptive behavior
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Table 25 3 Personality disorders: Classification and clinical findings
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Personality Disorder Paranoid Schizoid Obsessivecompulsive Histrionic (hysterical) Schizotypal Narcissistic Avoidant Dependent Antisocial Borderline Clinical Findings Defensive, oversensitive, secretive, suspicious, hyperalert, with limited emotional response Shy, introverted, withdrawn, avoids close relationships Perfectionist, egocentric, indecisive, with rigid thought patterns and need for control Dependent, immature, seductive, egocentric, vain, emotionally labile Superstitious, socially isolated, suspicious, with limited interpersonal ability, eccentric behaviors, and odd speech Exhibitionist, grandiose, preoccupied with power, lacks interest in others, with excessive demands for attention Fears rejection, hyperreacts to rejection and failure, with poor social endeavors and low self-esteem Passive, overaccepting, unable to make decisions, lacks confidence, with poor self-esteem Selfish, callous, promiscuous, impulsive, unable to learn from experience, has legal problems Impulsive; has unstable and intense interpersonal relationships; is suffused with anger, fear, and guilt; lacks self-control and self-fulfillment; has identity problems and affective instability; is suicidal (a serious problem up to 80% of hospitalized borderline patients make an attempt at some time during treatment, and the incidence of completed suicide is as high as 5%); aggressive behavior, feelings of emptiness, and occasional psychotic decompensation This group has a high drug abuse rate, which plays a role in symptoms There is extensive overlap with other diagnostic categories, particularly mood disorders and posttraumatic stress disorder
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as deprivation of privileges Extinction plays a role in that an attempt is made not to respond to inappropriate behavior, and the lack of response eventually causes the person to abandon that type of behavior Pouting and tantrums, for example, diminish quickly when such behavior elicits no reaction Dialectical behavioral therapy is a program of individual and group therapy specifically designed for patients with chronic suicidality and borderline personality disorder It blends mindfulness and a cognitive-behavioral model to address self-awareness, interpersonal functioning, affective lability, and reactions to stress
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Hospitalization is indicated in the case of serious suicidal or homicidal danger In most cases, treatment can be accomplished in the day treatment center or self-help community Antipsychotics may be required for short periods in conditions that have temporarily decompensated into transient psychoses (eg, haloperidol, 2 5 mg orally every 3 4 hours until the patient has quieted down and is regaining contact with reality) Olanzapine (25 10 mg/d) or risperidone (05 2 mg/d) may be given with lorazepam (1 2 mg orally every 4 hours as needed) In some cases, these drugs are required only for several days and can be discontinued after the patient has regained a previously established level of adjustment; they can also provide ongoing support Carbamazepine, 400 800 mg orally daily in divided doses, decreases the severity of behavioral dyscontrol Antidepressants have improved anxiety, depression, and sensitivity to rejection in some borderline patients SSRIs may have a role in reducing aggressive behavior in impulsive aggressive patients
C Psychological
Psychological intervention is best conducted in group settings Group therapy is helpful when specific interpersonal behavior needs to be improved This mode of treatment also has a place with so-called acting-out patients, ie, those who frequently act in an impulsive and inappropriate way The peer pressure in the group tends to impose restraints on rash behavior The group also quickly identifies the patient s types of behavior and helps improve the validity of the patient s self-assessment, so that the antecedents of the unacceptable behavior can be effectively handled, thus decreasing its frequency Individual therapy should initially be supportive, ie, helping the patient to restabilize and mobilize coping mechanisms If the individual has the ability to observe his or her own behavior, a longer-term and more introspective therapy may be warranted The therapist must be able to handle countertransference feelings (which are frequently negative), maintain appropriate boundaries in the relationship (no physical contacts, however wellmeaning), and refrain from premature confrontations and interpretations
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