Personality Disorders Part 2

Dependent PD, Histrionic PD, & Borderline PD

Dependent Personality Disorder Overview

A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation; Dependency involves motivational, cognitive, affective, and behavioral components

• Motivational — A need for guidance and protection from others

• Cognitive — The belief that they are weak and ineffectual and that others are powerful and capable

• Affective — Feeling anxious and fearful when required to act independently

• Behavioral — Will seek support, guidance, and reassurance from others

Individuals with DPD will often have one person in their lives whom they depend on — the “dependee”

Dependent PD Descriptors

Must exhibit at least five of the following characteristics

1. Difficulty making decisions without advice and reassurances from others

2. Needs others to assume responsibility for his/her life

3. Difficulty disagreeing with others because of fear of loss of support or approval

4. Difficulty doing things on their own

5. Goes to excessive lengths to gain nurturance and support from others

6. Feels helpless when alone

7. Urgently seeks another close relationship at the end of another relationship

8. Unrealistically preoccupied with fears of being alone

Other Factors in DPD

Comorbidity — Associated with higher rates of eating disorders, depressive, and anxiety disorders

Gender Issues — More diagnosed in women, BUT disorder’s prevalence is much more balanced for men and women

Cultural Differences — Important to consider role of culture since there are differences in dependency and autonomy

Treatment for a Client with Dependent PD

Focus on identifying issues that underline a client’s beliefs about abandonment and separation

• Therapist must be careful not to foster dependency during course

• Recommended to look at marital relationship (spouse can be overprotective, infantilizing, or domineering)

Histrionic Personality Disorder Overview

A pervasive pattern of excessive emotionality and attention-seeking behavior

• Core characteristics include egocentricity, seductiveness, theatrical emotionality, frequent use of denial, and a vague cognitive style

• Tend to be impulsive and have a great difficulty delaying gratification

Histrionic PD Descriptors

Must exhibit at least five of the following characteristics

1. Uncomfortable when not the center of attention

2. Interactions are often inappropriately seductive or provocative

3. Rapidly shifting and shallow emotions

4. Uses physical appearance to draw attention to self

5. Excessively and theatrical expression of emotion

6. Easily influenced by others

7. Considers relationships to be more intimate than they really are

Other Factors of HPD

Comorbidity — High with anxiety disorders, dissociative disorders, dysthymia, and major depression

• Approximately 66% of persons with this disorder also meet criteria for ASPD

  • Suggestions that HPD/ASPD may be gender-typed alternative expressions of the same underlying personality structure

    • Both seen as highly manipulative (one active intimidation vs seductive flirtation)

Treatment for a Client with Histrionic PD

Therapy often focuses on showing the client the long term impact of their behavior (usually short-term gains) and teaching more appropriate ways of negotiating/satisfying their needs

• Often present in treatment for relationship problems

Borderline Personality Disorder Overview

A pervasive pattern of instability of interpersonal relationships, self-image, and affect as well marked impulsivity

• Common signs are chronic suicidality, intense love-hate relationships, self-mutilation, and frequent mood fluctuations

Three Major Clinical Features/Areas of BPD

1. Impulsivity — Often a response to dysphoric feelings; Impulsive actions like suicidal attempts, self-mutilation, and substance abuse

2. Affectivity — Intense emotions, moods changing rapidly and drastically (dysphoria, anger, emptiness, mild euphoria, and anxiety — different from mood fluctuations in bipolar disorder)

3. Cognitive — Often experience paranoid thinking or transient psychotic symptoms like hearing voices and visual hallucinations (different from psychotic disorder); Some xp feelings of dissociation or depersonalization

Age of Onset of BPD

Particularly prominent in early adulthood with beginnings in adolescence; By middle age most individuals no longer meet criteria/have acute symptoms

Borderline PD Descriptors

Must exhibit at least five of the following characteristics

1. Frantic efforts to avoid real or imagined abandonment

2. A pattern of unstable, intense interpersonal relationships that are marked by fluctuations between idealization and devaluation

3. Unstable self-image or sense of self

4. Impulsivity in at least 2 areas that are potentially self-damaging (spending, sex, substance abuse, binge eating)

5. Recurrent suicidal behavior, gestures, or threats of self-mutilating behavior

6. Affective instability (usually lasting a few hours and only rarely more than a few days)

7. Chronic feelings of emptiness

8. Inappropriate intense anger or difficulty controlling anger

9. Transient paranoid thoughts or dissociative symptoms

Other Factors in BPD

Consider the diagnosis when the presentation involves a number of different clusters of clinical symptoms (anxiety, depression, substance abuse)

• Half of all individuals with a history of recurrent suicide admissions meet criteria for BPD

• More diagnosed in women; however, may be a function of help-seeking behavior in women

• Comorbidity — Very high with MDD, bipolar disorder, and substance abuse disorders

• No casual link supported in research, but many individuals have history of childhood sexual abuse

Treatment for a Client with BPD

Treatment often combines therapy and medication

• Therapists working with clients must have a strong amount of empathy and patience while maintaining strong boundaries

• Pharmacological Treatment — Mood stabilizers to improve impulsivity and rage as well as low dose antipsychotic medications for those who show signs of transient psychotic symptoms during times of stress

• Therapy Approach — Dialectical Behavior Therapy (DBT); Focuses on first diminishing suicidal behavior, second on therapy interfering behaviors, followed by a focus on gaining insight into impact of own behavior, regulating emotions, and addressing past traumatic events