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Personality Disorders

P R I M E R S O N P SYC H IAT RY Stephen M. Strakowski, MD, Series Editor Published and Forthcoming Titles: Anxiety Disorders edited by Kerry Ressler, Daniel Pine, and Barbara Rothbaum Autism Spectrum Disorders edited by Christopher McDougle Schizoprehnia and Psychotic Spectrum Disorders edited by S. Charles Schulz, Michael F. Green, and Katharine J. Nelson Mental Health Practice and the Law edited by Ronald Schouten Borderline Personality Disorder edited by Barbara Stanley and Antonia New Trauma and Stressor-​Related Disorders edited by Frederick J. Stoddard, Jr., David M. Benedek, Mohammed R. Milad, and Robert J. Ursano Depression edited by Madhukar H. Trivedi Bipolar Disorder edited by Stephen M. Strakowski, Melissa P. Del Bello, Caleb M. Adler, and David E. Fleck Public and Community Psychiatry edited by James G. Baker and Sarah E. Baker Substance Use Disorders edited by F. Gerard Moeller and Mishka Terplan Personality Disorders edited by Robert E. Feinstein

Personality Disorders Edited by R O B E RT E . F E I N ST E I N

1

3 Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries.

Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America. © Oxford University Press 2022 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above.

You must not circulate this work in any other form and you must impose this same condition on any acquirer.

Library of Congress Cataloging-​in-​Publication Data Names: Feinstein, Robert E., editor.

Title: Personality disorders /​[edited by] Robert E. Feinstein.

Other titles: Primer on.

Description: New York, NY : Oxford University Press, [2022] | Series: Primer on series | Includes bibliographical references and index.

Identifiers: LCCN 2021031225 (print) | LCCN 2021031226 (ebook) | ISBN 9780197574393 (pb) | ISBN 9780197574416 (epub) | ISBN 9780197574423 Subjects: MESH: Personality Disorders Classification: LCC RC554 (print) | LCC RC554 (ebook) | NLM WM 190 | DDC 616.85/​81—​dc23 LC record available at https://​lccn.loc.gov/​2021031225 LC ebook record available at https://​lccn.loc.gov/​2021031226 DOI: 10.1093/​med/​9780197574393.001.0001 This material is not intended to be, and should not be considered, a substitute for medical or other professional advice. Treatment for the conditions described in this material is highly dependent on the individual circumstances.

And, while this material is designed to offer accurate information with respect to the subject matter covered and to be current as of the time it was written, research and knowledge about medical and health issues is constantly evolving and dose schedules for medications are being revised continually, with new side effects recognized and accounted for regularly. Readers must therefore always check the product information and clinical procedures with the most up-​to-​date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulation. The publisher and the authors make no representations or warranties to readers, express or implied, as to the accuracy or completeness of this material. Without limiting the foregoing, the publisher and the authors make no representations or warranties as to the accuracy or efficacy of the drug dosages mentioned in the material. The authors and the publisher do not accept, and expressly disclaim, any responsibility for any liability, loss, or risk that may be claimed or incurred as a consequence of the use and/​or application of any of the contents of this material.

1 3 5 7 9 8 6 4 2 Printed by Marquis, Canada

Editorial Note Dear Reader, Robert E. Feinstein, MD Thank you for purchasing this primer on personality disorders. In this volume, Dr. Feinstein, as editor and expert in the field, recruited other international experts in personality constructs and disorders in order to provide a single source covering what are sometimes difficult and mystifying individuals to manage in our clinical practices. This book therefore introduces to early-​stage and other practitioners the current evidence about how to conceptualize personality disorders, make diagnoses under current classification systems, and the multifactorial approach to management necessary for best outcomes. Although personality disorders are common and commonly comorbid in psychiatric and other mental health practices, they are often not well understood. This book, then, addresses this important knowledge gap. We believe you will find it to be exceptionally informative and helpful to you in your work.

This volume is part of the Oxford University Press “Primer On” series; I am honored to lead this series since 2016 and was particularly pleased to join an already successful venture. The “Primer On” ’ series has been designed specifically to support psychiatry residents, early-​ stage practicing psychiatrists, psychology graduate students, and other interested medical trainees and practitioners. Specifically, in this series we have asked international experts to create books that focus on a specific set of conditions to provide the basic science and clinical tools to diagnose, treat and manage these major psychiatric disorders. We have also expanded the scope of the series to provide this audience information and guidance to major aspects of mental health care practices. With these considerations in mind, each volume is written with an eye toward early-​stage practitioners to present current evidence and recommendation in a format that is user-​friendly and informative. These texts complement other resources, such as the Oxford American Psychiatry Library, by offering more comprehensive basic and clinical knowledge so that psychiatric and other trainees can better understand these disorders in ways that will prepare them for clinical practice and fellowships (and to take board exams). As they are released, each volume will be available in print, e-​book, and Oxford Medicine Online (http://​oxfordmedicine.com/​). We have aimed to make these affordable books that bridge handbooks and more lengthy and expensive highly specialized textbooks. I hope you enjoy this text!

Best wishes Steve Strakowski, MD Vice Dean of Research Associate Vice President, Regional Mental Health Dell Medical School, University of Texas at Austin Series Editor

Contents Preface Acknowledgments Contributors

ix xi xiii

I . OV E RV I EW 1. The Personality Syndromes Jonathan Shedler

3

2. Levels of Personality Organization: Theoretical Background and Clinical Applications Eve Caligor, John F. Clarkin, and Julia F. Sowislo

33

3. Pathways Between Psychological Trauma and the Development of Personality Disorders Valerie Rosen, Gregory Fonzo, Emily Rosen, and Alex Preston

59

4. Integrating Clinical and Empirical Approaches to Personality: The Shedler-​Westen Assessment Procedure (SWAP) Jonathan Shedler

87

I I . M U LT I - T H E O R E T IC A L T R E AT M E N T S O F P E R S O NA L I T Y D I S O R D E R S 5. Crossing the Alphabet Divide: Navigating the Evidence for DBT, GPM, MBT, ST, and TFP for BPD Kenneth N. Levy, Benjamin N. Johnson, and Haruka Notsu

111

6. The Big 6: Evidence-​based Therapies for the Treatment of Personality Disorders Robert E. Feinstein

137

7. Managing Patients with Personality Disorders in Medical Settings Robert E. Feinstein

179

8. Transference-​focused Psychotherapy Christopher Green and Frank Yeomans

213

9. Mentalization-​based Treatment Robert P. Drozek and Jonathan T. Henry

237

10. Cognitive-​behavioral Therapy Matthew W. Southward, Stephen A. Semcho, and Shannon Sauer-​Zavala

259

viii

Contents

11. Dialectical Behavior Therapy Sheila E. Crowell, Parisa R. Kaliush, Robert D. Vlisides-​Henry, and Nicolette Molina

283

12. Schema Therapy Anja Schaich, Eva Fassbinder, and Arnoud Arntz

313

13. Good Psychiatric Management (GPM) for Borderline Personality Disorder Richard G. Hersh, Benjamin McCommon, Emma Golkin, and Jennifer Sotsky 14. Employing Psychodynamic Process-​oriented Group Psychotherapy with Personality Disorders Kenneth M. Pollock and Robert E. Feinstein 15. Psychopharmacology of Personality Disorders Tawny L. Smith and Samantha M. Catanzano

339

363 393

I I I . P E R S O NA L I T Y D I S O R D E R S 16. Paranoid Personalities (Vigilant Style) Royce Lee and Edwin Santos

421

17. Some Thoughts about Schizoid Dynamics Nancy McWilliams

441

18. Antisocial Personalities Glen O. Gabbard

459

19. Borderline Personality Disorder Curtis C. Bogetti and Eric A. Fertuck

473

20. Histrionic Personality Disorder Michelle Magid and Isadora Fox

501

21. Narcissistic Personality Disorder Alyson A. Gorun, Benjamin A. Scherban, and Elizabeth L. Auchincloss

523

22. Avoidant Personality Disorder Len Sperry and Gerardo Casteleiro

545

23. Dependent Personalities Robert F. Bornstein and Adam P. Natoli

565

24. Obsessive-​compulsive Personality Disorder Cynthia Playfair

589

25. Masochistic/​Self-​defeating Personality Styles Robert Alan Glick and Brenda Berger

613

Index

631

Preface Much has been written about personality disorders (PDs) and their treatments over the last 120 years. This began with descriptions of the PDs and psychoanalytic treatment early in the last century and progressed to the modern era of diverse conceptualization and treatments for patients with PDs (see Chapter 14 for a brief history). The PDs were diagnostically codified using the multiaxial system of the Diagnostic and Statistical Manual of Mental Diseases (DSM) III in 1980 and the DSM-​IV in 1994. The multiaxial system, listing the PDs on Axis II, signaled the importance of treating the PDs in their own right as well as the importance of treating the PDs as comorbid disorders affecting the treatment and outcomes of other major mental conditions (Axis I disorders).

PDs have estimated worldwide prevalence rates of 12.6 percent, making them a cluster of very common disorders.1 Psychosocial functioning of patients with PDs compared to patients with other mental disorders reveals that patients with PDs are more likely to be without partners, unemployed, disabled, and demonstrating significant impairments in social, occupational, leisure, and global functioning.2 Patients with PDs have a more significant disability than the disability caused by any Axis I disorder, including major depressive disorder.2 While PDs significantly affect the treatment and outcome of depression, bipolar disorder, eating disorders, addiction, and so on, treatments of these and other common mental disorders have no ability to modify personality functioning and have no helpful impacts on the treatment of PDs. However, since the 1990s there has been an explosion of many effective treatments for PDs. The “Big Six,” as I call them, are major evidence-​based treatments for borderline personality disorders (BPDs). These treatments include transference-​focused psychotherapy (TFP), mentalization-​based treatment (MBT), cognitive behavioral therapy (CBT) for PDs, dialectical behavior therapy (DBT), schema therapy (ST), and good psychiatric management (GPM). There are now data from meta-​analyses and some RCTs (see Chapter 5) that reveal these treatments are likely equally effective. This suggests that despite very different theoretical perspectives espousing treatment superiority, it may be that common factors across these approaches account for similar outcomes (see ­chapter 6). While the Big Six have much in common, it is also the case that each treatment has unique features that could be incorporated or borrowed from one evidence-​ based therapy (EBT) to another to improve therapeutic responsiveness to the needs of individual patients. The book explores this possibility.

While developed to treat BPD, these EBTs are also currently broadening their scope to see if these diverse psychotherapeutic modalities are also useful for the treatment of other PDs and other conditions. The data on the effectiveness of this approach, for all the

1 Volkert J, Gablonski TC, Rabung S. Prevalence of personality disorders in the general adult population in Western countries: systematic review and meta-​analysis. Br J Psychiatry. 2018: 213(6):709–​715.

2 Skodol AE. Impact of personality pathology on psychosocial functioning. Curr Opin Psychol.

2018: 1(21):33–​38.

x

Preface

PDs, remain to be determined by further research. For clinicians, despite this current limitation, the authors of each chapter were encouraged travel in these uncertain waters recommending their treatment approach based on some evidence, the clinical literature, and/​or their own expertise, when no clear definitive evidence for specific treatments for each of the PDs is available.

Many chapters in the book were written or co-​authored by master clinicians and/​ or researchers and their students. This collaboration was intentionally encouraged, as I hoped it would make this book read more as a “how to understand” and “how to do psychotherapy” with patients suffering with PDs, rather than as a textbook on the PDs. The book is divided into three sections.

Section 1 provides an overview of the diagnosis, assessment, clinical, and research approaches to working with PDs. It reviews prototypic personality syndromes, levels of personality organization, pathways from trauma to PDs, and a psychodynamic, integrated clinical and empirical approach to working with patients who have PDs. Section II reviews multi-​theoretical approaches to treatment of PDs. It covers six evidenced-​based treatments designed to treat BPD, management of PDs in medical settings, psychopharmacology, and group therapy for the PDs. These diverse viewpoints help readers understand current theories about the origin and nature of the personality and how one can apply these principles to everyday care and treatment of patients.

Section III covers 10 major specific PDs, written from diverse theoretical perspectives. It is chock full of clinical illustrations and the wisdom from master clinicians when evidence-​based treatment approaches are not yet known.

This book was written by 51 authors, representing diverse multi-​theoretical viewpoints. I am especially appreciative of the good-​natured and productive dialogue that emerged with all authors during the editorial process. I cannot thank the authors enough for their wonderful collaborative efforts and contributions.

It was very important to the editor and authors that this book contains theory and practices which could be widely applied to the treatment of our many patients who suffer with PDs. We hope that the book is comfortably accessible for use by mental health students, psychiatric residents, psychologists, social workers, faculty, and the widest scope of health professionals.

I am eager to know your reaction and comments about this work, as this kind of dialogue was the energy source for this book. Your reaction will ultimately determine the book’s usefulness.

—​Robert E. Feinstein, MD, Editor

Acknowledgments I am very appreciative of my personal cyberspace editor Richard Carlin from New Jersey, whom I have never met in person because of Covid-​19. His smarts, efficiencies, and detailed editing for style, formatting, and consistency was invaluable.

As in all my writing, I am exceeding grateful to my wife Marilyn for her encouragement, comments, and edits on my own chapters in this book.

I would also like to thank Oxford’s Primer Series editor, Steven Strakowski, and all those working at Oxford University Press for offering me the opportunity and for ultimately making this publication possible.

Contributors Prof. Dr. Arnoud Arntz, PhD Department of Clinical Psychology University of Amsterdam Amsterdam, The Netherlands Elizabeth L. Auchincloss, MD Professor and Vice-chair, Education Department of Psychiatry Weill-Cornell Medical College New York, NY, USA Aaron Stern MD, PhD Professor of Psychodynamic Psychiatry Department of Psychiatry Weill-​Cornell Medical College New York, NY, USA Brenda Berger, PhD Clinical Assistant Professor of Medical Psychology in Psychiatry Columbia University Center for Psychoanalytic Training and Research Columbia University New York, NY, USA Curtis C. Bogetti, BS Doctoral Student Department of Psychology The City College of New York, City University of New York New York, NY, USA Robert F. Bornstein, PhD Professor Derner School of Psychology Adelphi University Garden City, NY, USA Eve Caligor, MD Clinical Professor of Psychiatry Columbia University Vagelos College of Physicians and Surgeons New York, NY, USA

Gerardo Casteleiro, PhD Adjunct Professor Clinical Mental Health Counseling Program Florida Atlantic University Boca Raton, FL, USA Samantha M. Catanzano, PharmD, BCCP Clinical Assistant Professor College of Pharmacy The University of Texas Austin, TX, USA John F. Clarkin, PhD Clinical Professor of Psychology in Psychiatry New York Presbyterian Hospital-​Weill Medical College of Cornell University White Plains, NY, USA Sheila E. Crowell, PhD Associate Professor Department of Psychology, Department of Psychiatry Department of Obstetrics and Gynecology University of Utah Salt Lake City, UT, USA Robert P. Drozek, LICSW Therapist and Supervisor, Mentalization-​ based Treatment Clinic, McLean Hospital Teaching Associate, Department of Psychiatry, Harvard Medical School Belmont, MA, USA Eva Fassbinder, MD Department of Psychiatry and Psychotherapy Christian-Albrechts-University Kiel Niemannsweg, Kiel, Germany Robert E. Feinstein, MD Professor of Psychiatry Department of Psychiatry Donald and Barbara Zucker School of Medicine at Northwell/Hofstra Zucker Hillside Hospital Long Island, NY, USA

xiv

Contributors

Eric A. Fertuck, PhD Associate Professor Department of Psychology The City College of New York, City University of New York New York, NY, USA Gregory Fonzo, PhD Assistant Professor Department of Psychiatry and Behavioral Sciences Dell Medical School, University of Texas Austin, TX, USA

Jonathan T. Henry, MD, PhD Medical Director, Addiction Treatment Program Department of Psychiatry Jesse Brown Veterans Administration Medical Center Chicago, IL, USA Richard G. Hersh, MD Special Lecturer Columbia University College of Physicians and Surgeons New York, NY, USA

Isadora Fox, DNP, APRN, PMHNP-BC, APRN-​BC Doctor of Nursing Practice Austin PsychCare Austin, TX, USA

Benjamin N. Johnson, MS Doctoral Student Department of Psychology The Pennsylvania State University University Park, PA, USA

Glen O. Gabbard, MD Clinical Professor Department of Psychiatry Baylor College of Medicine Houston, TX, USA

Parisa R. Kaliush, MS Department of Psychology University of Utah Salt Lake City, UT, USA

Robert Alan Glick, MD Professor of Clinical Psychiatry, Columbia University Former Director of the Columbia University Center for Psychoanalytic Training and Research New York, NY, USA Emma Golkin, MD Fellow, Public Psychiatry Department of Psychiatry Columbia University/​New York State Psychiatric Institute New York, NY, USA Alyson A. Gorun, MD Assistant Professor Department of Clinical Psychiatry Weill-​Cornell Medical College New York, NY, USA Christopher Green, MD Private Practice New York, NY, USA

Royce Lee, MD Associate Professor Department of Psychiatry and Behavioral Neuroscience University of Chicago Chicago, IL, USA Kenneth N. Levy, PhD Associate Professor Department of Psychology The Pennsylvania State University University Park, PA, USA Michelle Magid, MD, MBA President, Austin Psychcare, PA Associate Professor University of Texas Dell Medical School Austin, TX, USA Adjunct Associate Professor Texas A&M Health Science Center Bryan, TX, USA Benjamin McCommon, MD Assistant Clinical Professor Department of Psychiatry Columbia University College of Physicians and Surgeons New York, NY, USA

Contributors Nancy McWilliams, PhD Visiting Full Professor Graduate School of Applied and Professional Psychology Rutgers University Piscataway, NJ, USA Nicolette Molina, BA PhD Student Department of Psychology University of Utah Salt Lake City, UT, USA Adam P. Natoli, PhD Assistant Professor Department of Psychology and Philosophy Sam Houston State University Huntsville, TX, USA Haruka Notsu, MS Doctoral Student Department of Psychology Pennsylvania State University University Park, PA, USA Cynthia Playfair, MD Private Practice, Affiliate Faculty, University of Texas at Austin, Dell Medical School Department of Psychiatry Supervising and Training Psychoanalyst, Center for Psychoanalytic Studies Houston, TX, USA Kenneth M. Pollock, PhD, CGP Clinical Associate Professor (retired) Department of Psychiatry New York Medical College Valhalla, NY, USA Former Director of Group Psychotherapy Training Westchester Medical Center Poughkeepsie, NY, USA

xv

Valerie Rosen, MD Associate Professor Department of Psychiatry and Behavioral Sciences Dell Medical School, The University of Texas at Austin Seton Mind Institute Austin, TX, USA Edwin Santos Research Intern Department of Psychiatry and Behavioral Neurosciences Biological Sciences Division The University of Chicago Chicago, IL, USA Shannon Sauer-​Zavala, PhD Assistant Professor Department of Psychology University of Kentucky Lexington, KY, USA Anja Schaich, Dr. rer. hum. biol. /​ MSc Psychotherapist Department of Psychiatry and Psychotherapy University of Lübeck Ratzeburger Allee, Lübeck, Germany Department of Psychiatry and Psychotherapy, Christian-Albrechts-University Kiel, Niemannsweg, Kiel, Germany Benjamin A. Scherban, MD Resident Psychiatrist New York Presbyterian Hospital New York, NY, USA Stephen A. Semcho, MS Graduate Researcher Department of Psychology University of Kentucky Lexington, KY, USA

Alex Preston, MD Resident Department of Psychiatry University of Arkansas for Medical Sciences Little Rock, AR, USA

Jonathan Shedler, PhD Clinical Professor Department of Psychiatry University of California, San Francisco San Francisco, CA, USA

Emily Rosen, MD Resident Department of Psychiatry and Behavioral Sciences George Washington University Washington, DC, USA

Tawny L. Smith, PharmD, BCPP Associate Professor Department of Psychiatry and Behavioral Sciences Dell Medical School, The University of Texas Austin, TX, USA

xvi

Contributors

Jennifer Sotsky, MD Consultation-​Liaison Fellow Columbia University Irving Medical Center New York, NY, USA Matthew W. Southward, PhD Postdoctoral Scholar Department of Psychology University of Kentucky Lexington, KY, USA Julia F. Sowislo, PhD Instructor of Psychology in Psychiatry Department of Psychiatry New York Presbyterian Hospital-​Weill Medical College of Cornell University Westchester Division White Plains, NY, USA Len Sperry, MD, PhD Clinical Professor Department of Psychiatry and Behavioral Medicine Medical College of Wisconsin Milwaukee, WI, USA Professor Clinical Mental Health Counseling Program Florida Atlantic University Boca Raton, FL, USA

Robert D. Vlisides-​Henry, MS PhD Candidate Department of Psychology University of Utah Salt Lake City, UT, USA Frank Yeomans, MD, PhD Clinical Associate Professor Department of Psychiatry Weill-​Cornell Medical College New York, NY, USA

I

OV E RV I EW

1

The Personality Syndromes Jonathan Shedler

Key Points • Personality refers to an individual’s characteristic patterns of thought, feeling, behavior, motivation, defense, interpersonal functioning, and ways of experiencing self and others.

• Clinical knowledge accrued over generations has given rise to a taxonomy of familiar personality syndromes.

• Personality syndromes exist on a continuum of functioning from healthy to severely disturbed. There is no discontinuity between normal and pathological personality.

• Understanding personality syndromes requires an understanding of underlying personality processes such as inner conflicts, defenses, and motives.

• A diagnostic prototype is provided for each personality syndrome, which describes the syndrome in its “ideal” or pure form.

• A practical diagnostic method based on pattern recognition is provided, whereby clinicians consider the overall resemblance between patients and diagnostic prototypes.

• The personality constructs provide the broad strokes of clinical case formulations. They can explain and contextualize presenting symptoms and disorders.

• Each personality syndrome is a distinct pathway to depression and requires a different treatment focus. © 2021 by Jonathan Shedler, PhD

Introduction Personality is not about what disorders you have but about who you are. It refers to a person’s characteristic patterns of thought, feeling, behavior, motivation, defense, interpersonal functioning, and ways of experiencing self and others. All people have personalities and personality styles.

4

Overview

While there are as many personalities as people, clinical knowledge accrued over generations has given rise to a taxonomy of familiar personality styles or types. Most people, whether healthy or troubled, fit somewhere in the taxonomy. Empirical research over the past two decades has confirmed the major personality types and their core features.1–​5 Most clinical theorists do not view the personality types as inherently disordered.

They are generally discussed in the clinical literature as personality types, styles, or syndromes—​not “disorders.” Each exists on a continuum of functioning from healthy to severely disturbed. The term “disorder” is best regarded as a linguistic convenience for clinicians, denoting a degree of extremity or rigidity that causes significant dysfunction, limitation, or suffering. One can have, for example, a narcissistic personality style without having narcissistic personality disorder.

The same personality dynamics give rise to both strengths and weaknesses. A person with a healthy narcissistic personality style has the confidence to dream big dreams and pursue them; they can be visionaries, innovators, and founders. A person with a healthy obsessive-​compulsive style excels in areas requiring precise, analytic thinking; they may be successful engineers, scientists, or academics. A person with a healthy paranoid style looks beneath the surface and sees what others miss; they may be investigative journalists or brilliant medical diagnosticians. Our best and worst qualities are often cut from the same psychological cloth.

Many psychodynamically influenced clinicians accept the broad outlines of an organizing framework proposed by Otto Kernberg,6,7 which combines the concept of personality type with a “severity dimension” reflecting level of personality organization (healthy, neurotic, borderline, psychotic).8–​9 For example, we can speak of a patient with narcissistic personality organized at a neurotic level or at a borderline level. The approach presented here is consistent with this framework. (For discussion of levels of personality organization, see Chapter 2, Levels of Personality Organization: Theoretical Background and Clinical Applications.)

The recognition that personality styles exist on a continuum of functioning was undercut by the Diagnostic and Statistical Manual of Mental Disorders10 (DSM) beginning with the publication of DSM-​III.11 To shoehorn personality styles discussed in the clinical literature into a categorical taxonomy of disorders, the framers of the DSM described them in pathological form, in some cases ratcheting up the severity to the point of caricature.3,4 The DSM also disregarded the underlying personality processes at the core of the personality styles, such as internal conflict, defenses, and motives. It focused instead on outward behavior and readily observable symptoms. Thus, the DSM borrowed terminology and concepts from the clinical, chiefly psychoanalytic literature (obsessive-​ compulsive, narcissistic, paranoid, and so on) but disconnected them from the larger body of clinical knowledge.

Clinicians who are expert in treating personality have a working knowledge of personality syndromes that is richer, deeper, and more complex than the depictions in the DSM8,9,12,13 and in some cases diverges from it.3 This chapter provides an overview of the personality syndromes as understood by expert clinicians and verified by empirical research. The descriptions provided here go beyond overt behavior and symptoms and address the personality processes that underlie them. For many patients, they can provide roadmaps for effective treatment.

The Personality Syndromes

5

Diagnosis as Pattern Recognition Each personality syndrome discussed in this chapter is represented by a paragraph-​ length description called a diagnostic prototype, which describes the personality syndrome in its “ideal” or pure form.4,14–​15 These diagnostic prototypes are evidence based. They were derived empirically, based on a national sample of N = 1,201 patients described by their clinicians using the Shedler-​Westen Assessment Procedure (SWAP).

They reflect empirically observable characteristics of actual patients, not just theoretical conjecture.

Naturally occurring diagnostic groupings were identified using statistical clustering methods, which largely confirmed the personality syndromes described in the clinical literature. The SWAP items (descriptive statements) that best describe each personality syndrome were likewise identified empirically, then arranged as paragraphs to create the diagnostic prototypes.4 (The SWAP instrument is described in Chapter 4, Integrating Clinical and Empirical Approaches to Personality: The Shedler-​Westen Assessment Procedure (SWAP). The instrument is available at https://​swapassessment.org.)

The diagnostic prototypes have the advantage of being empirically based and also preserving the richness and complexity of accrued clinical knowledge. To make a personality diagnosis, a clinician rates the overall resemblance or match between a patient and a diagnostic prototype from 0 (no match) to 5 (very good match). Higher scores indicate more resemblance to the diagnostic prototype and more severity. The diagnostic prototypes are presented in Boxes 1.1 to 1.10 and the rating scale is included with each prototype.

If categorical diagnosis is desired for compatibility with the DSM-​5 or International Classification of Diseases (ICD-​10) diagnostic system, scores of 4 and 5 indicate a personality disorder diagnosis, and a score of 3 indicates traits or features of a disorder.

Thus, if a patient receives a score of 5 for narcissistic personality and 3 for obsessive-​ compulsive personality, the categorical (DSM format) diagnosis is narcissistic personality disorder with obsessive-​compulsive traits.

The premise of this approach is that a configuration or pattern of interrelated psychological characteristics defines a personality syndrome, not the presence or absence of separate characteristics. Recognizing a personality syndrome is pattern recognition, much as recognizing a face depends on pattern recognition, not tabulating separate features.4,14,15 Prototype matching provides reliable and valid diagnoses and works with the cognitive decision processes of clinicians, which rely on pattern recognition. It systematizes what expert clinicians already do in practice. In a consumer-​preference study, psychologists and psychiatrists preferred this method of personality diagnosis to the DSM diagnostic system and to dimensional trait models of personality.16

Developing a Treatment Focus In recent years, many clinicians have been trained to focus on presenting problems and DSM Axis I disorders (such as depression or generalized anxiety) and view them as encapsulated conditions separate from personality. Treatments that target specific DSM disorders implicitly assume all patients with a given DSM diagnosis have the “same”

6

Overview

condition and will respond to the same interventions. Clinicians learn the hard way that things are rarely so simple.

Most often, the problems that bring people to mental health treatment are not encapsulated problems. They are woven into the fabric of their lives. They are embedded in, and inseparable from, the person’s characteristic patterns of thinking, feeling, behaving, coping, defending, and relating to others: in other words, personality. This is true whether or not the person has a diagnosable “personality disorder.” The patient needs the clinician to grasp something psychologically systemic about who they are, not just what disorders they have, to help them understand why they are repeatedly vulnerable to certain kinds of suffering and how to change it.

Meaningful and lasting change generally comes not from focusing on symptoms, but on the personality patterns that underlie them. Knowledge of personality styles provides a map of the personality terrain that expert clinicians navigate. Thus, each personality syndrome is not just description, but shorthand for the broad strokes of a clinical case formulation that can provide a treatment focus and address the underlying causes of many patients’ suffering. The penultimate section of this chapter, Personality and Clinical Case Formulation, revisits this topic.

The Personality Syndromes This section describes the major personality syndromes as understood by clinical theorists and confirmed by empirical research. The diagnostic prototypes and rating scales in Boxes 1.1 to 1.10 can be used for day-​to-​day clinical diagnosis.

Depressive Personality Despite its omission from the DSM, depressive personality is the most common personality syndrome seen in clinical practice.2 It is a personality syndrome in every sense of the term: an enduring pattern of psychological functioning evident by adolescence and encompassing the full spectrum of personality processes.

People with depressive personalities are chronically vulnerable to painful affect, especially feelings of inadequacy, sadness, guilt, and shame. They have difficulty recognizing their needs, and when they do recognize them, they have difficulty expressing them.

They are often conflicted about allowing themselves pleasure. They may seem driven by an unconscious wish to punish themselves, either by getting into situations destined to cause pain or depriving themselves of opportunities for enjoyment. A psychologically insightful observer might describe the person as their own worst enemy.

Where there is an enemy, there is often anger and aggression. One underlying psychological theme in depressive personality is internal attacks against the self. The person is angry, defends against experiencing anger, and instead directs it at themselves in the form of self-​criticism, self-​deprivation, and self-​punitiveness. The relevant SWAP item is, “Has trouble acknowledging or expressing anger toward others and instead becomes depressed, self-​critical, self-​punitive, etc.” In short, the person treats themselves like someone they despise.

Clinicians can easily miss the patient’s anger and aggression because people with depressive personalities tend to be overtly agreeable and put others’ needs first,

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including the clinician’s needs. If psychotherapy is to bring about meaningful psychological change, anger must be recognized, experienced, and explored in the therapy relationship.

A second psychological theme involves separation, rejection, and loss. The person may be preoccupied with, and painfully vulnerable to, disruptions in interpersonal relationships. They fear being abandoned and left unprotected and uncared for. As a result, they avoid interpersonal conflict and have difficulty asserting themselves. Undue people-​pleasing and helpfulness protect against disapproval or rejection. In psychotherapy, they suppress legitimate criticisms and dissatisfactions for fear of hurting the clinician’s feelings or damaging the therapy relationship. Instead of communicating their needs and wants, they accept what is offered and make do. This can lead to a relationship dynamic in which the clinician thinks things are going swimmingly and the patient does without, thereby recreating the patient’s dysfunctional relationship pattern in the therapy relationship.

This pattern may have roots in relational disruption or insufficient emotional availability of a caretaker in early development, leaving the person feeling emotionally empty and incomplete, and believing their deprivation was caused by their own badness. Some patients have a pervasive sense that someone or something essential to their well-​being has been lost and can never be recovered. These feelings can crystalize around, and be amplified by, subsequent experiences of loss. Rewards and pleasures that are realistically available may be experienced as a pale shadow of what was lost or could have been. Such patients may need the clinician’s help to mourn what has been lost before they can invest emotionally in what life can offer now.

For some patients with depressive personalities, themes of unconscious anger and self-​attack predominate. For others, themes of separation and loss predominate. These themes have been discussed in the clinical and research literature in terms of introjective (self-​critical) and anaclitic (dependent) depression.17,18 Both themes may be present in any blend.

Depressive personality is the most common personality style among people drawn to the mental health professions.19 Clinical practitioners have endless opportunity to care for others instead of themselves, be unduly helpful, and fault themselves for falling short of unrealistic, self-​imposed standards.

See Box 1.1, p. 8 for the depressive personality prototype.

Anxious-​Avoidant Personality The term “Avoidant Personality Disorder” is used by the DSM and is more familiar to clinicians, but the hyphenated term “anxious-​avoidant” more accurately and telegraphically conveys the essence of this personality syndrome.

People with anxious-​avoidant personalities are, first and foremost, anxious. Anxiety pervades their experience of themselves and their world. They ruminate and dwell on perceived dangers and past mistakes. Their predominant emotions are anxiety, shame, and embarrassment. They defend against sources of anxiety by avoidance. The problem is that the sources of anxiety are everywhere, including within. Ultimately, avoidant responses become bars in a psychological prison, constricting and limiting freedom of thought, feeling, choice, and action. As a result, people with anxious-​avoidant personalities lead constricted lives and tend to adhere to familiar routines. Despite their avoidant

8

Overview

Box 1.1 Depressive Personality Prototype Summary statement: Individuals with depressive personality are prone to feelings of depression and inadequacy, tend to be self-​critical or self-​punitive, and may be preoccupied with concerns about abandonment or loss.

Individuals who match this prototype tend to feel depressed or despondent and to feel inadequate, inferior, or a failure. They tend to find little pleasure or satisfaction in life’s activities and to feel life has no meaning. They are insufficiently concerned with meeting their own needs, disavowing or squelching their hopes and desires to protect against disappointment. They appear conflicted about experiencing pleasure, inhibiting feelings of excitement, joy, or pride. They may likewise be conflicted or inhibited about achievement or success (e.g., failing to reach their potential or sabotaging themselves when success is at hand). Individuals who match this prototype are generally self-​critical, holding themselves to unrealistic standards and feeling guilty and blaming themselves for bad things that happen. They appear to want to “punish” themselves by creating situations that lead to unhappiness or avoiding opportunities for pleasure and gratification. They have trouble acknowledging or expressing anger and instead become depressed, self-​critical, or self-​punitive. They often fear that they will be rejected or abandoned, are prone to painful feelings of emptiness, and may feel bereft or abjectly alone even in the presence of others. They may have a pervasive sense that someone or something necessary for happiness has been lost forever (e.g., a relationship, youth, beauty, success).

5 very good match (patient exemplifies this disorder; prototypical case)

Diagnosis

4 good match (patient has this disorder; diagnosis applies) 3 moderate match (patient has significant features of this disorder)

Features

2 slight match (patient has minor features of this disorder) 1 no match (description does not apply)

defenses, anxiety still leaks out through a variety of channels, which can include somatic symptoms and concerns.

People with anxious-​avoidant personalities are fearfully avoidant not only of the external, interpersonal world but also their own internal world. The former is manifested in social avoidance, self-​consciousness, and social awkwardness. The latter is manifested in inhibition and constriction of emotional life and desire. They are motivated to avoid perceived harm, not to pursue their desires.

The challenge in psychotherapy is that patients with anxious-​avoidant personality are avoidant in psychotherapy, too. They are likely to steer clear of difficult topics, change the subject when their thoughts lead in disturbing directions, and fend off the clinician’s efforts to explore psychological experience beyond the most familiar, well-​worn grooves.

This creates a dilemma for clinicians: If they don’t confront avoidant defenses, therapy will accomplish little; if they do, the patient may quit or shut down. Effective treatment involves a balancing act of support and confrontation. The clinician should help and

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Box 1.2 Anxious‐avoidant Personality Prototype Summary statement: Individuals with anxious‐avoidant personality are chronically prone to anxiety, are socially anxious and avoidant, and attempt to manage anxiety in ways that limit and constrict their lives.

Individuals who match this prototype are chronically anxious. They tend to ruminate, dwelling on problems or replaying conversations in their minds. They are more concerned with avoiding harm than pursuing desires, and their choices and actions are unduly influenced by efforts to avoid perceived dangers. They are prone to feelings of shame and embarrassment. Individuals who match this prototype tend to be shy and self‐conscious in social situations and to feel like an outcast or outsider. They are often socially awkward and tend to avoid social situations because of fear of embarrassment or humiliation. They tend to be inhibited and constricted and to have difficulty acknowledging or expressing desires. They may adhere rigidly to daily routines, have trouble making decisions, or vacillate when faced with choices. Their anxiety may find expression through a variety of channels, including panic attacks, hypochondriacal concerns (e.g., excessive worry about normal aches and pains), or somatic symptoms in response to stress (e.g., headache, backache, abdominal pain, asthma).

5 very good match (patient exemplifies this disorder; prototypical case)

Diagnosis

4 good match (patient has this disorder; diagnosis applies) 3 moderate match (patient has significant features of this disorder)

Features

2 slight match (patient has minor features of this disorder) 1 no match (description does not apply)

support the patient to put words to previously unarticulated feelings and fantasies. When they respond to situations (both inside and outside therapy) with fearful avoidance, they should be pressed for details about the presumed dangers (“And what would happen then?”) so they can be examined in the light of day. When a secure working alliance is established, the clinician should encourage the patient to face feared situations and experiences in incremental steps. See Box 1.2 for the anxious-​avoidant personality prototype.

Dependent‐Victimized Personality The term “Dependent Personality Disorder” is used by DSM, but the hyphenated term “dependent-​victimized” communicates a core feature of the personality syndrome: the tendency to put oneself in harm’s way. People with this personality syndrome are drawn to relationships in which they are mistreated, exploited, or abused.

People with dependent-​victimized personalities are characterized by intense dependency, leading them to subordinate their needs to those of others in order to maintain desperately needed attachments. This leaves them vulnerable to mistreatment and exploitation. The person experiences the attachment relationship as essential to their