CBT for Personality Disorders

Henck van Bilsen, Brian Thomson

• Publisher: SAGE Publications Ltd
• Year: 2011
• Print ISBN: 9781849202947, 9781849202930
• eBook ISBN: 9781446241653
• Edition: 1
• Topic: Psychologie
• Subtopic: Kognitive Psychologie & Kognition

This key new text on CBT for personality disorders offers a unique trainee guide to this complex area. The book provides a practical, hands-on overview of the treatment strategies for working with personality disorders, linking these with the theory of both cognitive and behavioural approaches. Covering the full range of personality disorders, this is the most rounded and introductory guide yet. Key content includes:

- therapist self-care; avoiding pitfalls

- holding the CBT line in challenging circumstances, across a range of multi-disciplinary settings

- exploration of the therapeutic relationship and engagement strategies

- reflections on the evidence for CBT and personality problems

- chapter introductions and summaries, key learning points and reflective questions

- case examples and vignettes.

This book is an important resource for anyone wishing to use their CBT training with clients presenting personality disorders.

1

PERSONALITY DISORDERS OR NOT

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In this chapter you will:

• Get an introduction to the concept of personality disorders.
• Receive information about diagnostic criteria for personality disorders.
• Be introduced to a transdiagnostic perspective on personality disorders.
• Be asked to contemplate whether a dichotomous approach (classification ICD, DSM) is the preferred approach or whether a continuum (transdiagnostic perspective) is a more helpful perspective.

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The International Classification of Mental and Behavioural Disorders (ICD–10) defines a personality disorder as: ‘a severe disturbance in the characterological condition and behavioural tendencies of the individual, usually involving several areas of the personality, and nearly always associated with considerable personal and social disruption’. The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–IV) defines a personality disorder as: ‘an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time and leads to distress or impairment’. There are nine categories of personality disorder in ICD–10, while the DSM system proposes three broad clusters of personality disorders. Studies indicate a prevalence of 10–13 per cent of the adult population in the community (APA, 2000).

What is a Personality Disorder?

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This is where the debate begins. Dobbert (2007) states that those with personality disorders have traits that cause them to feel and behave in socially distressing ways, typically resulting in discord and instability in many aspects of their lives. Depending on the specific disorder, these personalities are generally described in negative terms such as hostile, detached, needy, antisocial or obsessive. The assumption here is that the problem feelings and behaviours are the result of an underlying issue (a disorder) and that the disorder ‘explains’ the problem feelings and behaviours.

While many other psychological disorders fluctuate in terms of symptom presence and intensity, as with normal personality, personality disorders typically remain relatively constant throughout life, although they do vary in severity from individual to individual (Dobbert 2007). This is again an interesting statement. It means that the disorder is still there but at times it will be less visible or obvious (but how do we know it is still there if we can’t see it?).

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (APA, 2000), personality disorders can be categorised into three main groupings or clusters: cluster A encompasses odd or eccentric behaviours; cluster B encompasses those with dramatic, emotional, or erratic behaviour; and finally cluster C, encompasses those with anxious, fearful behaviour.

Cluster A is described in DSM-IV-TR as encompassing the following types of personality disorder: schizoid, paranoid and schizotypal.

Individuals with schizoid personality disorder (SPD) are detached from interpersonal relationships and show a marked restriction in the range of emotions they express. Those with SPD may be perceived by others as sombre and aloof, and often are referred to as ‘loners’. According to the DSM system, to qualify for a diagnosis the person should at least demonstrate four of the following symptoms:

• Wishes not to have or to enjoy close relationships, family included.
• Prefers solitary activities and life.
• Has little or no interest in sex with other people.
• Has little or no pleasure when doing activities.
• Few if any close friends, other than first-degree relatives.
• Is indifferent to criticism or praise.
• Displays flattened affect, emotional coldness, or detachment.

People with a paranoid personality disorder (PPD) are typically distrustful and suspicious of others. Although they are prone to unjustified angry or aggressive outbursts when they perceive others as disloyal or deceitful, those with PPD more often come across as emotionally ‘cold’ or excessively serious. According to the DSM system, to qualify for a diagnosis the person should at least demonstrate four of the following symptoms:

• Believes without reason that others are exploiting, harming, or trying to deceive her/him.
• Has unjustified doubts about friends’/associates’ loyalty or trustworthiness.
• Believes without reason that if she/he confides in others this information will somehow be used against her/him.
• Finds hidden demeaning or threatening meanings in harmless remarks or events.
• Is unforgiving and bears grudges.
• Believes without reason that people are out to attack his/her character or reputation and is quick to react with anger.
• Believes without reason in the infidelity of their sexual partner.

People with schizotypal personality disorder have a need for isolation and display odd, outlandish, or paranoid beliefs. In social situations, they may behave inappropriately or not interact with others at all, or they may talk to themselves. According to the DSM system, to qualify for a diagnosis the person should at least demonstrate five of the following symptoms:

• Ideas of reference.
• Magical thinking or odd beliefs, not consistent with the culture’s norms, and influences behaviour.
• Odd perceptual experiences.
• Odd thinking or speech.
• Suspiciousness or paranoid.
• Narrowed or inappropriate affect.
• Eccentric, odd, or peculiar behaviour/appearance.
• Few or no close friends or confidants, not including first-degree relatives.
• Excessive social anxiety.

Cluster B includes the following types of personality disorders: antisocial, borderline, narcissistic and histrionic personality disorder.

A person with an antisocial personality disorder has a lack of empathy for the suffering of others and does not appear to have a conscience, has difficulty controlling impulses and manipulative behaviours. According to the DSM system, to qualify for a diagnosis the person should display from the age of fifteen a disregard for and violation of the rights of others, those rights considered normal by the local culture, as indicated by at least three of the following:

A	Repeated acts that could lead to arrest.
B	Conning for pleasure or profit, repeated lying, or the use of aliases.
C	Failure to plan ahead or being impulsive.
D	Repeated assaults on others.
E	Reckless when it comes to their own or others’ safety.
F	Poor work behaviour or failure to honour financial obligations.
G	Rationalising the pain they inflict on others.

Research has shown that individuals with antisocial personality disorder are also indifferent to the threat of physical pain and punishment in general, displaying no indications of fear when threatened (Millon et al., 1998; Hare, 1999).

Someone with a borderline personality disorder (BPD) will find it challenging to regulate emotions. This emotional instability results in dramatic and abrupt shifts in mood, impulsivity, poor self-image and tumultuous interpersonal relationships. They are highly sensitive to rejection, and the resulting fear of abandonment may result in frantic efforts to avoid being left, with as a consequence suicide threats and attempts to force others not to abandon them.

Those suffering from BPD are also prone to other impulsive behaviours, such as excessive spending, binge eating, risky sex, and drug and alcohol abuse. They often exhibit additional psychiatric problems, particularly bipolar disorder, depression, anxiety and other personality disorders. Symptoms typically begin in early adulthood and, once present, can interfere with relationships, work performance, long-term planning and the individual’s sense of self-identity.

According to DSM-IV-TR, to be diagnosed with BPD a patient must have a pervasive pattern of instability of interpersonal relationships, self-image and affect, marked by impulsivity beginning by early adulthood, as indicated by five (or more) of the following criteria:

• Frantic efforts to avoid real or imagined abandonment.
• Pattern of unstable and intense interpersonal relationships.
• Identity disturbance: markedly and persistently unstable self-image.
• Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
• Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour.
• Affective instability due to a marked reactivity of mood (extreme changes in mood typically lasting a few hours and only rarely more than a few days).
• Chronic feelings of emptiness.
• Inappropriate, intense anger or difficulty in controlling anger.
• Transient, stress-related paranoid ideation or severe dissociative symptoms.

A person with a narcissistic personality disorder (NPD) will demonstrate in behaviour, attitudes and thoughts grandiosity, need for admiration and lack of empathy. They tend to be extremely self-absorbed, intolerant of others’ perspectives, insensitive to others’ needs and indifferent to the effect of their own egocentric behaviour.

According to DSM-IV-TR, a patient must exhibit five or more of the following traits in order to be diagnosed with NPD:

• Grandiose sense of self-importance.
• Preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
• Belief that he or she is ‘special’ and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
• Need for excessive admiration.
• Sense of entitlement.
• Takes advantage of others to achieve his or her own ends.
• Lack of empathy.
• Envious of others or believes that others are envious of him or her.
• Arrogant, haughty behaviours or attitudes.

Individuals with histrionic personality disorder exhibit a pervasive pattern of excessive emotionality and attempt to get attention in unusual ways, such as bizarre appearance or speech. With rapidly shifting, shallow emotions, histrionics can be extremely theatrical, and constantly need to be the centre of attention.

According to DSM-IV-TR, a patient must exhibit at least five of the following traits:

• Uncomfortable if not the centre of attention.
• Interaction with others in an inappropriately provocative or seductive manner.
• Shallow and rapid changing of emotion.
• Uses appearance to draw attention.
• Speech that lacks detail and is excessively impressionistic.
• Theatrical, self-dramatisation, or out of proportion expression of emotion.
• Easily influenced, suggestible.
• Perceives ordinary and social relationship as intimate.

Cluster C includes obsessive compulsive, avoidant and dependent personality disorder.

People suffering from obsessive-compulsive personality disorder are focused on order and perfection. As a consequence their lack of flexibility interferes with their ability to get things done, and to enjoy life in general. Little is accomplished because, whatever the task, for the obsessive-compulsive, it is never right or good enough. These individuals become mired in detail and are often unable to see the big picture; a literal example of not being able to see the forest for the trees. The standards set for themselves and others are impossibly high, and they are prone to damage personal relationships by being critical of those who don’t live up to their standards. There are few moral grey areas for someone with this personality disorder: things are either right or wrong, with no room for compromise. (Dobbert, 2007).

According to DSM-IV-TR, a patient must exhibit at least four of the following traits:

• Marked preoccupation with details, lists, order, organisation, rules, or schedules.
• Marked perfectionism that interferes with the completion of the task.
• Excessive devotion to work.
• Excessive devotion ...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• About the Authors
• Introduction
• 1 Personality disorders or not
• 2 CBT in the front-line
• 3 The process of CBT: from symptoms to problems and goals, moving on to formulation
• 4 Socialising the client to CBT, identifying problems and goals, and treatment evaluation
• 5 Structuring sessions: from agenda setting to homework
• 6 Interventions for (lasting) change
• 7 Engagement strategies
• 8 Reflection on CBT as a psychological therapy for personality disorders
• 9 Pitfalls for the therapist
• References
• Index