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Personality-Guided Therapy for Posttraumatic Stress Disorder
George S. Everly Jr. and Jeffrey M. Lating
Personality-Guided Therapy in Behavioral Medicine
Robert G. Harper
Personality-Guided Forensic Psychology
Robert J. Craig
Personality-Guided Relational Psychotherapy: A Unified Approach
Jeffrey J. Magnavita
Personality-Guided Cognitive-Behavioral Therapy
Paul R. Rasmussen
Personality-Guided Behavior Therapy
Richard F. Farmer and Rosemery O. Nelson-Gray
Personality-Guided Therapy for Depression
Neil R. Bockian

Personality-Guided Therapy
for Depression
Neil R. Bockian

Series Editor Theodore Millon






Copyright 2006 by the American Psychological Association. All rights reserved. Except
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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
British Library Cataloguing-in-Publication Data
A CIP record is available from the British Library.
Printed in the United States of America
First Edition


Dedicated with love to my wife Martha

my personal antidepressant and my favorite personality type.


Series Foreword






Chapter 1.


Chapter 2.

An Overview of Depression and Theoretical

Models of Its Relationship to Personality


Chapter 3.

Depression in Paranoid Personality Disorder


Chapter 4.

Depression in Schizoid Personality Disorder


Chapter 5.

Depression in Schizotypal Personality Disorder . . . .


Chapter 6.

Depression in Antisocial Personality Disorder


Chapter 7.

Depression in Borderline Personality Disorder



Depression in Histrionic Personality Disorder


Chapter 9.

Depression in Narcissistic Personality Disorder . . . .


Chapter 10.

Depression in Avoidant Personality Disorder


Chapter 11.

Depression in Dependent Personality Disorder


Chapter 12.

Depression in Obsessive-Compulsive Personality




Appendix A: Emotion List2


Appendix B: Expression of Personality Disorders Across the

Domains of Clinical Science




Author Index


Subject Index


About the Author





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.

The utility and relevance of personality as a variable is spreading in all

directions, and the series sets out to illustrate where things stand today. As
will be evident as the series' publication progresses, the most prominent work
at present is found with creative thinkers whose efforts are directed toward
enhancing a more efficacious treatment of patients. We hope to demonstrate,
further, some of the newer realms of application and research that lie just at
the edge of scientific advances in our field. Thus, we trust that the volumes
included in this series will help us look beyond the threshold of the present
and toward the vast horizon that represents all of psychology. Fortunately,
there is a growing awareness that personality variables can be a guiding factor in all spheres of study. We trust the series will provide a map of an open
country that encourages innovative ventures and provides a foundation for
investigators who wish to locate directions in which they themselves can
assume leading roles.
Theodore Millon, PhD, DSc
Series Editor



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

a single individual. From that perspective, it becomes apparent that a given

individual has unconscious conflicts and behavioral tendencies and cognitions and family dynamics and experiences of conditions of worth, all of which
contribute to his or her current functioning. In line with the biopsychosocial
perspective, it becomes equally obvious that biological and sociological phenomena also have a substantial impact on the person. The best available
picture of an individual at any given moment is a collage of all of the concepts and images contributed by each perspective.
The purpose of this book is to provide a comprehensive understanding
of the person with clinical depression. By taking into account personality, as
represented by the personality disorders in the Diagnostic and Statistical Manual
of Mental Disorders (4th ed., text revision; American Psychiatric Association, ZOOOa), treatments for depression are refined and made more appropriate. Along the lines of the growing and healthy interest in positive psychology, we (the author and the series editor) are also mindful to take into account
strengths and positive aspects of the person.
From a scientific standpoint, we see this book as part of an ongoing
process. There is a synergistic flow between clinical practice and science (Soldz
& McCullough, 2000). Practice leads to insights that generate hypotheses to
be tested scientifically; research then informs clinical practice (Anderson,
2000). Like the developers of process-experiential therapy (Elliott, 2000)
and transference-focused psychotherapy (O. F. Kemberg, Selzer, Koenigsberg,
Carr, & Appelbaum, 1989; Yeomans, Clarkin, & Kernberg, 2002), we envision practice and research mutually enhancing one another, leading to many
confirmationsand just as many surprisesalong the way. Ultimately, our
goal is to operationalize the approach and test it in randomized clinical trials.
In the meantime, we invite the reader to join us in exploring this promising
new approach.



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

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



Personality-Guided Therapy for Depression


Depression is a thorny problem to treat. In many cases, treatment is

ineffective from the start. Even when client and clinician meet with early
success, relapse frequently follows. Given that millions of people suffer from
the disorder, improving treatment for depression is a major priority.
The premise of this book is that those individuals who have depression
and either fail to make progress or experience relapse often do so because of
deeply rooted, enduring patterns in numerous areas of their lives that conspire to undermine healthy and satisfactory adjustment. Personality shapes
how the individual exists in the world. It is the riverbed upon which the
person's emotional life flows. In order to change the direction of a complicated depression, one is well advised to intervene at the level of personality.
More specifically, the very nature of the depression itself and the reason the person has become depressed is explicitly related to the individual's
personality style or disorder. For example, where the person with a dependent style mourns being abandoned, the person with an antisocial personality configuration agonizes over feeling confined. Such considerations have
implications for treatment. Intervention must not only address different issues but different communication styles. Thus the nurturing, supportive approach that would endear one to the dependent client would elicit denigration from the antisocial.

To be sure, as we have known for many years, many straightforward cases

of depression are successfully treated in 20 sessions or fewer (A. T. Beck, Rush,
Shaw, & Emery, 1979). Such cases are not the focus of this volume; rather, my
focus is those cases that have "complications" and are likely to either fail or to
relapse. Research supports the commonsense notion that individuals who have
both personality disorders (PDs) and depression have more problematic recoveries (Ilardi, Craighead, & Evans, 1997). This volume provides conceptual
guidelines on how to be effective in these difficult cases.
Depression is influenced by behavioral problems, such as poor social
skills, as well as by beliefs of personal inadequacy and ineffectiveness. Unconscious phenomena such as repression or intrapsychic fragility can impact
both mood and behavior. Most depressions also involve interpersonal problems, such as family difficulties, conflicts, or withdrawal. Biological predispositions often contribute to the difficulties of depression. Personality theory
serves as an excellent conceptual framework through which to understand
how these various factors interact synergistically to produce problems. Similarly, personality theory provides a framework to understand many strengths
an individual has that facilitate long-term recovery.
It is well known that PDs are also difficult to treat. They are, by definition, long-standing and deeply ingrained. A depression may make a PD more
difficult to treat, particularly in the case of those with "internalizing" personality styles who tend to be hard on themselves or intropunitive (e.g., avoidant
or obsessivecompulsive) or those who are already slow and passive (e.g.,
schizoid or dependent). On the other hand, depression may facilitate treatment among those with "externalizing" personality styles, who might otherwise be hesitant to engage in treatment (e.g., are narcissistic or antisocial).
As with the notion presented above, that taking personality into account
will facilitate the treatment of depression, 1 assert that taking depression into
account can improve the treatment of PDs.
The aim of this volume is to provide practitioners, researchers, and
students with a theoretical framework from which to approach the individual
who has depression embedded within the context of a particular PD or style.
Because it is based on the integration of well-grounded approaches, the current volume provides ideas that will be useful for clinicians. I am equally
hopeful that the text will provide fertile ground for testable hypotheses for
researchers. Indeed, this volume marks one important step in an ongoing
scientific journey. Eventually, personality-guided therapy must be subject to
randomized clinical trials (RCTs) to determine whether it lives up to its
promise of increasing success rates and reducing relapse rates of individuals
with complicated depressions. This volume is a step toward developing a
treatment that is defined with sufficient precision to be manualized and thus
subject to RCTs. In addition to RCTs with manualized interventions, efficacy studies with naturalistic designs are necessary to see how the therapy
functions in the "real world."



Although it is beyond the scope of this work to cover countertransference in a comprehensive manner, looking at all of the available literature (a
project of that magnitude is worthy of a book in its own right), I will make
some comments on therapist emotional reactions to people with each of the
PDs. Rather than exhaustively review the literature, or leave out countertransference entirely, I have chosen to report some of my own experiences,
an abbreviated review of the literature, and the findings of a research project
that I have undertaken for the past 7 years. Although these findings are not
yet published, there have been a few presentations based on these data (Agor,
Smith, & Bockiari, 2005; Bockian, 2001, 2002a, 2002b), as well as several
clinical research projects (Agor, 2005; Kim, 2004; Mullen, 2004; Rodgers,
2004; Rusten, 2002; D. L. Williams, 2005). In the study, graduate students in
clinical psychology were shown film clips of individuals with PDs. They were
then asked to rate their emotional reactions on the basis of a 136-item adjective checklist (see Appendix A). Participants in the study also gave descriptions of the meaning of the adjectives that they endorsed. The data I am
reporting came from approximately 900 such forms collected from about 250
participants. Throughout the text, this study is referred to using the presentation in which the largest portion of the data was presented (Bockian, 2002a).
For the purposes of this book, the most important finding is simply the mean
of the participants' ratings of their emotional reactions to the film clips. However, it is noteworthy that manipulation checks suggest that the films are
adequate prototypes of the PDs they are supposed to represent. Mean ratings
of the prototypicality of the film clips, and how well they represent the PD
they portray, are approximately 7.5 to 8.0 on a l-to-10 scale.
The main drawbacks of the research paradigm are that (a) it is not clear
how similar participants' reactions would be to real clients with whom they
were interacting, as opposed to film clips; (b) it is not clear how their reactions would evolve over time, as opposed to seeing just a 5- to 10-minute
segment of an intake session; and (c) it relies on conscious reports entered on
a self-report instrument, thus banking on the self-awareness and accuracy of
the participants. The main strength of the paradigm is that the stimulus is
constant, so that reactions can be aggregated across clinicians.
I routinely use two strategies to deal with feelings that I have toward
clients, including positive feelings, but especially negative feelings. The first
step is to become aware of the nature of the feeling itself. The emotional
reaction typically occurs as a "felt sense" (Gendlin, 1978)a vague, diffuse,
nonverbal feeling. I also often experience a somatic response. Identifying
these experiences and then labeling them ("ohI'm bored!") is something I
find to be useful, not only in recognizing the problematic pattern in the client (e.g., schizoid PD), but also in finding ways to "sit with my feelings."

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
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.
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

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.


There is always tension about when to release scientific information.
On the one hand, appropriate caution must be taken to show that a treatment has efficacy. On the other hand, to delay means that individuals who
may benefit from a new treatment are denied that opportunity.
PGT is a new treatment. Although its origins can be traced in various
ways to Millon's writings over many years (e.g., Millon, 1969/1985, 1981,
1996), it was launched in 1999 with the publication of Millon's PersonalityGuided Therapy. To the extent that it is built on other approaches (such as
cognitive-behavioral therapy, psychodynamic therapy, etc.), various aspects
of the treatment are scientifically well established. It is fair to say that at this
point, the treatment is in an exploratory phase, with a rich base of theory but
with few empirical data. Case studies embedded in books on the topic are the
only data extant that are specific to this approach (Everly & Lating, 2003;


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 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

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


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.


To develop an integrative understanding of depression and PDs, I first
looked at the research on depression itself (chap. 2). Questions regarding the
epidemiology as well as the effectiveness of current treatment modalities are
explored. The chapter ends with a discussion of theoretical models of the
relationship between PDs and depression; I implicitly draw on these models
throughout the remainder of the text.
Chapters 3 through 12 cover the relationship of depression to each of
the 10 PDs of DSM-IV-TR. In each of these chapters, I begin with an illustration of the phenomenon, often drawn from the arts, film, or everyday
experiences. Next, I cover theoretical and empirical material from a
biopsychosocial perspective, leading to three major subsections. The biological section looks at hereditary factors, neuroanatomy, neurochemistry, and
medications. The psychological section considers theoretical and empirical
contributions from numerous important perspectives: psychodynamic, cognitivebehavioral, client-centered and humanistic, family systems, and group
therapy, with a separate section on strengths-based conceptualization and
intervention. The degree of coverage is based on the available literature, so
some sections are brief or absent from some chapters. The social section includes considerations of diversity such as race and ethnicity, gender, socioeconomic status, and religion. Finally, a section on treatment planning, including a case example, illustrates the integration of the various perspectives
into a personality-guided approach. The demographics of all case examples
have been modified to protect the privacy of the clients. Many are composite
cases, which combine elements of treatment for more than one client.
At the end of the section on psychological approaches in chapters 3
through 12, I asked colleagues who contributed cases to share their insights


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.




Before describing the personality-guided therapy (PGT) approach to

treatment, it is important to review current theories of depression, as well as
the various established treatment modalities and their efficacy. In this chapter I describe the phenomenology and epidemiology of depression; then 1
enumerate the relevant treatment approaches according to the biopsychosocial
model. Biological theories focus on the role of the neurotransmitter norepinephrine (NE) and serotonin in depression, and treatments include pharmacotherapy and electroconvulsive therapy (ECT). The psychological theories
and interventions section considers cognitive-behavioral, interpersonal, psychodynamic, family systems, and group approaches. The section on social
concerns addresses issues of diversity, such as gender, ethnicity, and socioeconomic status in understanding the person with depression.
Next, I review possible relationships between depression and personality disorders (PDs) as enumerated by theory. These models of relationships,
which attempt to sort out the chicken-and-egg relationship between Axis II

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.

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)

He later attempted to describe the nature of the pain itself:

What 1 had begun to discover is that, mysteriously and in ways that are
totally remote from normal experience, the gray drizzle of horror induced
by depression takes on the quality of physical pain. But it is not an immediately identifiable pain, like that of a broken limb. It may be more accurate to say that despair, owing to some evil trick played upon the sick
brain by the inhabiting psyche, comes to resemble the diabolical discomfort of being imprisoned in a fiercely overheated room. And because no
breeze stirs this caldron, because there is no escape form this smothering
confinement, it is entirely natural that the victim begin to think ceaselessly of oblivion, (p. 50)

Finally, in a memorable quote regarding suicidal ideation, he stated,

Yet in truth, such hideous fantasies, which cause well people to shudder,
are to the deeply depressed mind what lascivious daydreams are to persons of robust sexuality, (p. 53)



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
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.

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).



Depression rates appear to be rising. According to the original National

Comorbidity Survey (NCS) conducted from 1990 to 1992 (Kessler, 1994),
15.8% of respondents met the criteria for major depression. It must be noted,
however, that somewhat different criteria were used in the two studies, with
the NCS using criteria from the revised third edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-III-R; American Psychiatric Association, 1987) and the NCSR using criteria from the fourth edition (DSMIV; American Psychiatric Association, 1994).
Although the reported depression prevalence rates are quite high, Kessler
et al. (2005) noted that the procedure used for the NCSR likely underestimated the actual prevalence of mental disorders. Interviews were done in a
community setting, thereby eliminating some populations that are likely to
have a high prevalence of disorders (e.g., the homeless or institutionalized).
In addition, participants routinely underreport embarrassing behaviors. Lifetime prevalences were based on current risk factors; because the prevalence
of mental illness is rising, it is likely that younger participants' lifetime risks
were underestimated.
The NCSR also demonstrated that depression is inadequately treated.
The researchers found that only 56.8% of those with major depression and
67.5% of those with dysthymia received treatment of any kind; of those, only
37.5% (major depression) and 40.7% (dysthymia) received at least minimally adequate treatment (Wang, Lane, et al., 2005). Using evidence-based
treatment guidelines, Wang, Lane, et al. (2005) defined minimally adequate
treatment as appropriate medication prescription with at least four follow-up
visits with a physician, or, for nonpsychotic patients, at least eight sessions
with a psychiatrist or another mental health professional (e.g., a psychologist, social worker, or counselor). Overall, then, roughly three fourths of those
who had depression did not receive even minimally adequate treatment. Those
under the care of a mental health specialist (psychiatrist, psychologist, etc.)
were far more likely to receive minimally adequate care than those under the
care of a general medical doctor (52.0% vs. 14.9%). The comparable figures
from the original NCS, which was conducted a decade earlier (1990-1992),
indicate that only 45.8% received any treatment and that of these, 48.2%
received minimally adequate treatment; thus, 78.2% failed to receive minimally adequate treatment for a mood disorder (Wang, Demler, & Kessler,
2002). Typically, there is a 6- to 8-year delay between the onset of symptoms
and initiating treatment (Wang, Berglund, et al., 2005).
For mental health disorders as a whole, there is a trend toward increasing treatment rates, but still only a minority of those with mental health
problems receive services. In the 1980s, for example, estimates indicated that
19% of those with mental health disorders had received treatment in the
past 12 months; the comparable figure was 25% in the 1990-1992 survey and
33% in the most recent survey, conducted in 2001-2003 (Wang, Berglund,
et al., 2005). These disturbingly low figures are exacerbated when one con16


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).

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),


heritability estimates (the degree to which a trait is inherited) 1 were higher

(79%) for children and adolescents, which suggests that when depression
starts early in life it may be a more biological condition. The largest and best
available adoption study, by Wender et al. (cited in Wallace et al., 2002,
p. 176), indicated a sevenfold higher likelihood of depression among those
who were biologically related to a depressed person versus those who were not.
A variety of biological factors are critical in depression. Under stress,
NE becomes depleted, which has been associated with learned helplessness
behaviors in animal studies (e.g., decreased exploratory and consummatory
behaviors) and is believed to be related to learned helplessness cognitions in
humans (e.g., powerlessness and hopelessness). Medications that directly
enhance NE levels lead to improved functional efficiency. It is interesting to
note that serotonin'enhancing medications (which do not directly effect NE)
also enhance NE levels, suggesting that indirect interventions can help restore NE balance. Because of the popularity of SSRI medications, most psychologists are aware that serotonin (5-HT) depletion also increases depressive symptoms.
The hypothalamic-pituitary-adrenocortical (HPA) axis, which mediates human stress responses such as the fightflight response (W. B. Cannon,
1915, 1929/1963) and the general adaptation syndrome (Selye, 1956/1978), is
also implicated in depression. Sustained elevations in cortisol lead to impaired
HPA feedback inhibition and can cause the death of cells in the hippocampus.
In samples of depressed individuals, 40% to 60% have elevated levels of cortisol. Increased dopamine activity, which may be induced by excessive cortisol,
appears to be crucial in cases of psychotic depression (Thase, Jindal, 6k Rowland,
2002). Excess cortisol is associated with increased severity of depression, weight
loss, insomnia, and increased suicidality (Thase et al., 2002).
Research has yet to determine, however, if these biochemical changes
cause depression or are a result of it. It is probable that causality is complex
and circular; it seems reasonable to assume that similar to the relationship
between temperament and the development of PDs, biological predispositions interact with environmental circumstances, enhancing or initiating
biological processes related to depression. In addition, if depleted NE and
serotonin are sufficient to explain the occurrence of depression, then why do
antidepressant medications take weeks to produce mood changes, even though
neurotransmitter levels are increased within hours (Thase et al., 2002)? Although the mechanism of action of the medications described below is presented using explanations based on neurotransmitter theory, along the lines
of standard psychopharmacology texts (e.g., Stahl, 1996), the reader should
be aware that there are other, and at this point unknown, reasons for the
efficacy of antidepressant medications.
'The most common metric, labeled h2, is based on the difference between the frequency of a trait in
fraternal versus identical twins.



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-



effect profile relative to the older TCAs. Commonly used SSRIs include
citalopram (Celexa), fluoxetine (Prozac), paroxetine (Paxil), and sertraline
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


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,
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,


1996) and that long-term follow-up with medications and psychotherapy

help prevent relapse, which is otherwise likely (Boland & Keller, 2002).
Gitlan (2002), summarizing his review of psychopharmacological treatment of depression, concluded,
Although antidepressants are consistently effective and the newer agents
are safer and better tolerated than the older agents, the pharmacotherapy
of depression still leaves much to be desired. As a first goal, it must be
acknowledged that no antidepressant has been shown to be more effective than imipramine, the first agent released over 40 years ago. (p. 377)
Psychological Factors
Millon (1996) listed eight domains of functioning that should be considered when making a comprehensive psychological assessment, namely
(a) expressive acts, (b) interpersonal conduct, (c) cognitive style, (d) selfimage, (e) object representations, (f) regulatory mechanisms, (g) morphological organization, and (h) mood and temperament. These domains roughly
correspond to the major "orientations" within psychology. Expressive acts
and cognitive style relate to the cognitive-behavioral school of thought. Interpersonal conduct is most closely associated with interpersonal and family
systems thinking and interventions. Self-imagehow one sees oneselfis
relevant to all therapeutic schools of thought but is perhaps most closely
associated with a client-centered approach. The next three domains are associated with psychodynamic thinking. Object representations relate to object relations theory, and regulatory mechanisms refer to Freud's ego defense
mechanisms. Morphologic organization, which refers to psychic cohesion
within the mind, is most closely associated with self psychology and the notion of fragmentation (Kohut, 1971, 1977; Wolfe, 1989). Finally, the mood
and temperament domain refers primarily to the biological components of
emotionality (mood) and personality traits (temperament).
The psychology subsections of the remaining chapters in this volume
cover Millon's domains, with some variations depending on the relevance to
particular disorders. Of the eight domains, seven are psychological, and one
is biophysical. Each of the psychological domains are considered with reference to cognitive-behavioral; client-centered, humanistic, experiential; psychodynamic; family systems; and group therapies. Below I discuss each in
Cognitive-Behavioral Conceptualization and Interventions
Beck and his associates noted that depression is related to cognitive
distortions (A. T. Beck et al, 1979). Cognitive distortions are styles of thinking that reliably produce problematic, depressogenic thoughts. For example,
overgeneralization is the tendency to see one event as more representative
than it really is (e.g., I'm incompetent at one thing, which means I'm incom22


petent at everything). Dichotomous thinking, which is especially relevant to

borderline PD, is the tendency to view everything in all-or-none terms (e.g.,
I'm either perfect or I'm worthless). Catastrophizing is the tendency to interpret events as being much more problematic than they really are (e.g., the
student who becomes suicidal when she earns her first C; her thoughts may
be, "Now I'll never get into graduate school, I'll never get a good job, and my
parents will hate me"). When such thought patterns are corrected, then the
depression tends to lift.
Individuals with depression are likely to have a variety of depressogenic
thoughts. Common thoughts among individuals with depression are, "If I try
to do it, I'll just mess up"; "If I ask her out, she'll turn me down"; and "No one
likes me." Underlying such automatic thoughts, especially for individuals
with PDs, are core beliefs of helplessness, unlovability, and worthlessness
(J. S. Beck, 2003). Often, feelings of worthlessness are reducible to one or
both of the other two categories (e.g., I am worthless because I am incompetent and/or unlovable). Schemas of helplessness fit with Seligman's wellknown and well-established learned helplessness model, which can be conceptualized in a purely behavioral fashion (Seligman, 1975), and the
reformulated version (Abramson, Seligman, & Teasdale, 1978), which includes helpless cognitions. In addition to the belief "I am helpless," clients
may express this concept with beliefs of inadequacy, incompetence, and inferiority. The belief that one is unlovable relates to poor self-esteem and is
clearly related to depressive thinking; typical core beliefs may include "I am
unlovable," "I am ugly/undesirable," and "I am unwanted."
A variety of behavioral interventions can also be helpful in alleviating
depression. Communication skills training and assertiveness training can help
clients to get their needs met more effectively. Linehan (1993) framed mindfulness meditation as a learned skill and made it a module in her dialectical
behavior therapy program. In some cases, skills training can be used to help
the person feeland bemore competent, thus undermining feelings of
Physical exercise has been shown to relieve depression (Craft & Landers,
1998; Hays, 1999) and has obvious health benefits. The clinician, however,
must suggest an exercise program very astutely or the chances of success are
minimal. Unless the client neither watches television nor reads newspapers,
he or she has undoubtedly been bombarded by messages about why we should
all be exercising more. A generic, information-based approach about the
benefits of exercise generally will not lead to behavior change. At best, a
half-hearted "I know I should exercise more" will emerge; in such an instance, the therapist is risking being seen as an authority figure who is disappointed with the client's performance.
Instead, it is essential to focus extensively on motivation. I generally do
not even broach the subject of exercise for several sessions, sometimes many
sessions. I like to see the depression lift partially so that I have some credibilAN OVERVIEW OF DEPRESSION


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
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



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.



Client-Centered, Humanistic, and Existential Therapy

Process-experiential therapy (PET) helps individuals with depression
by providing them with an opportunity to focus on their internal experience.
The therapeutic relationship is characterized by empathic attunement and
collaboration. Although the therapist and client collaborate on goals, the
relationship issues are always considered primary. Noted L. S. Greenberg,
Watson, and Goldman (1998), "A form of synchrony occurs where the experience of leading and following disappears in a collaborative flowing together,
as in good dancing or improvisational jazz" (p. 234).
L. S. Greenberg et al. (1998) described four markers of problematic
experiential states that are useful in understanding and treating depression.
The first is problematic reactions, or a feeling of being puzzled by one's own
emotional or behavioral responses to situations. The second is an inability to
get a clear sense of one's experience. The third is a split sense of self, in which
one part of the self is critical of or coercive toward the other part. Finally,
individuals with depression often have "unfinished business" related to an
earlier part of their lives, usually involving themes of separation, loss, or other
unresolved issues.
The inability of a person to get in touch with his or her own experience
is treated with empathic attunement and encouragement to focus on his or
her experience. The felt sense (Gendlin, 1996) is often a key concept in this
regard and refers to subtle emotional and bodily experiences that can be used
as doorways to deeper aspects of the self. The felt sense is something that we
all experience. A good example is "that feeling that I forgot something,"
which, if examined even superficially, is a bodily and cognitive experience
integrating thoughts ("I forgot something" and "this is bad") with somatic
phenomena (e.g., a tightening in the abdominal muscles and a churning feeling
in the stomach). In individuals with depression, the felt sense that something is wrong can be explored, often leading to the uncovering of feelings
and thoughts that have been deeply buried under years of neglect or the
exploration of thoughts and feelings that were regarded as too frightening to
Splits in the self, such as the critical self that berates the bad self, can be
integrated using "two chair" techniques. The critical self can speak to the
"bad" self, which can then, by switching chairs, answer back. Typically, the
critical self can be seen for what it isa cruel, narrow-minded bully who
does not take the full picture into account. The "bad" self, meanwhile, is
generally the holder of kindness, softness, and compassion and is seen to
have good qualities. As the split between good and bad becomes transmuted
into a split between aspects of the self that are all necessary for a completely
functioning individual, the path to reintegration has been paved. L. S.
Greenberg et al. (1998) described the case of "Jan," a highly self-critical,
perfectionistic, and depressed woman who had unfinished business around



trying to please her mother. An initial reintegration occurred in rather dramatic fashion during a two-chair interaction:

What do you want from her (to the critic) ? [Encouraging expression of need]


I want to feel I am OK. I want to be more like her, to feel more



[Noticing a shift in her posture and face] What are you feeling
now? [Facilitating negotiation]


1 feel that the two sides have suddenly merged. It is as if the

stronger person came over here and sat with me and said you're
OK. (p. 245)

Unfinished business, similarly, can often be addressed through "empty chair"

techniques, in which the client addresses the individual who is no longer
L. S. Greenberg et al. (1998) argued that PET benefits from looking at
aspects specific to depression rather than maintaining a strict antilabeling stance:
One might. . . question the need for a differential treatment of depression, given that a therapeutic relationship characterized by attitudes of
positive regard and genuine concern, as well as a form of responding that
is empathic and experience centered, is helpful for different types of problems and diagnostic groups. . . . We have observed both in practice and
research contexts that, during treatment of depressed people, specific types
of in-session problem states or markers of underlying determinants come
up more often or with greater significance, and these are embedded within
specific types of depressive themes. More specifically, we found that selfcritical splits, embedded within themes of failure and lack of self-esteem,
and a variety of types of lingering unresolved feelings or unfinished business with significant others, embedded within themes of dependence and
loss, characterize the in-session issues that formed the focus of our treatments of depression, (p. 229)

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



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:


He also seems to us justified in certain other self-accusations; it is merely

that he has a keener eye for the truth than other people who are not
melancholic. When in his heightened self-criticism he describes himself
as petty, egoistic, dishonest, lacking in independence, one whose sole
aim has been to hide the weaknesses of his own nature, it may be, so far
as we know, that he has come pretty near to an understanding of himself;
we only wonder why a man has to be ill before he can be accessible to a
truth of this kind. (Freud, 1917/1986, p. 51)
With this rather backhanded compliment, Freud thus anticipated the "depressive realism" hypothesis by many years.
Freud then rioted, however, that the attack on the self is invariably an
attack on others, which is then redirected toward the self. The wife who
proclaims that she is unworthy and cannot imagine how her husband would
stay with her is really indicating her anger toward her husband and suggesting that he is inadequate in some unspecified manner. Abraham (1911/1986)
extended the argument, seeing depression as a combination of defenses against
underlying sadistic hostility. He suggested that the conscious experience ("I
hate myself) consists of hostile feelings transformed through projection ("I
hate you" becomes "you hate me" and, finally, "you hate me because I am
defective"). As he noted, "In every one of these cases it could be discovered
that the disease proceeded from an attitude of hate which was paralysing the
patient's capacity to love" (1911/1986, p. 36).
Freud hypothesized, in a rather tentative manner, that the constellation of phenomena thus observed in depression pointed to a coherent developmental pattern. He suggested that the person experiences a loss of love.
Rather than withdrawing libidinal energy and attaching it to a new object,
the ego withdraws the libidinal energy into the self, the narcissistic ego. The
energy is then used to form an identification between the ego and the lost
object. This transformation, then, is regressive in its essence; specifically, the
regression is to the oral-sadistic phase, in which the merger with the object is
accomplished through incorporation. This explains not only the primitive
aggression associated with depression but also the phenomenon of suicide.
Because the individual is identified with the object of his rage, it is possible
for him to consider his own, or "its" (i.e., the object's) destruction. As noted
by Freud,
It is this sadism alone that solves the riddle of the tendency to suicide
which makes melancholia so interestingand so dangerous. So immense
is the ego's self-love, which we have come to recognize as the primal
state from which instinctual life proceeds, and so vast is the amount of
narcissistic libido which we see liberated in the fear that emerges to a
threat to life, that we cannot conceive how that ego can consent to its
own destruction. We have long known, it is true, that no neurotic harbours
thoughts of suicide which he has not turned back upon himself from
murderous impulses against others.... The analysis of melancholia now


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,


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


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.


Epidemiological studies in different countries have found large differences in prevalence of depression; presumably, these differences are at least
partially due to differences in culture. At the times the surveys were done,
depression ranged from a high of 19.0% in Lebanon to a low of 1.5% in
Taiwan. The United States is intermediate, with different prevalences found
in the NCS (Kessler, 1994), which surveyed participants from 1990 to 1992,
and the Epidemiological Catchment Area study (Weissman, Bruce, Leaf,
Florio & Holzer, 1991), which surveyed participants from 1980 to 1984.
There were differences in methodology that may account for some of the
differences in the findings. The NCS had a larger and more representative
sample, used DSM-IV rather than DSM-IIJ-R criteria, and investigated
more extensively for indications of depression than did the Epidemiological Catchment Area study. It could also be, however, that the prevalence of
depression in the United States increased during the decade or so that separated the surveys.
One finding that is fairly consistent is that Asian countries, such as
China, japan, and Taiwan, have lower rates of depression than Western countries such as the United States, Canada, and Germany. Differences in social
support may play a large role in these variances; Western culture, with its
emphasis on individualism, may produce more isolation and loneliness than
Eastern sociocentric cultures. In addition, Eastern cultures tend to make less
of a distinction between mind and body than Western cultures; thus, what
may emerge as depression in the West could be a somatic or somatization
disorder in the East.
Ethnographic approaches reveal a number of depression-like syndromes
in other cultures that may have vastly different meanings than those attributed in the United States. For example, pena in highland Ecuador is associated with many symptoms of depression, such as "crying spells, poor concentration, anhedonia, social withdrawal, poor personal hygiene, sleep and


appetite disturbance, gastrointestinal complaints, and heart pain" (Tsai &.

Chentsova-Dutton, 2002, p. 470). Personal loss is generally the precipitant
of pena, as it often is with depression. However, according to Tousignant and
Maldonaldo (cited in Tsai & Chentsova-Dutton, 2002), pena is an appeal for
payment or social reciprocity, for the incurred loss. Unlike depression in the
United States, which is viewed as individual psychopathology, pena is part of
the social balance in highland Ecuador. Similarly, in New Guinea, the Kaluli
people are highly emotionally expressive. Grief reactions, akin to what we
might view as sadness or depression in the United States, are integrated into
the culture through ceremonies, rituals, and "scripted" social interactions.
These expressions then become part of the social negotiations within the
culture, which help individuals to get their needs met. This appears to have
a strong protective effect against depression in that culture (Scheflielin, cited
in Tsai & Chentsova-Dutton, 2002, pp. 469-70).
As Castillo (1997) observed,
In a society with dominance hierarchies, individuals at the low end of
the social scale have a stigma or impaired identity imposed upon them
by dominant groups. The moral career of these stigmatized individuals is
compromised in interpersonal relations. The term moral career refers simultaneously to the moral status and the morale of the individual. The
moral status of individuals is an indication of their perceived value in
societythat is, whether they are "good" or "bad" persons as judged by
the cultural definitions of morality within the context of the social dominance hierarchy. . . . When moral status is compromised in this fashion,
the individual's morale or sense of self-esteem can also be negatively
affected. (Goffman, 1963, p. 42)

The consequences of stigmatization fit in well with Abramson et al.'s

(1978) revised learned helplessness model. The consequences of being the
"wrong" race, gender, ethnicity, social class, religion, or sexual orientation
are often internalized by individuals as a feeling or belief that in fact there
is something wrong with them. Because these demographic characteristics
are immutable or difficult to change and impact a many areas of their lives,
they see their predicament as stable and global (Castillo, 1998). Thus, individuals from stigmatized or disadvantaged groups are generally more prone to
There is a powerful argument that the traditional social roles of women,
as described, for example, by J. H. Williams (1987) and Skeggs (1997), have
a significant impact on depression. Because of women's traditionally subordinate role in our culture, they are more prone to anxiety, depression, and
feelings of helplessness than men. Similarly, submissiveness and fear of abandonment are more consistent with women's social role than men's. Castillo
(1998) noted that women in the United States are more likely than men to
experience discrimination, harassment, and poverty. Nolen-Hoeksema,
Larson, and Grayson (1999) studied a community sample of over 1,100 adults


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.


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



In my experience, individuals with depression tend to have a variety of
positive qualities. Many are introspective and in touch with their feelings. I
have found them by and large to be responsiblewilling to take ownership
of their own feelings and their impact on others. To the extent that they go
overboard in that regard, it is generally easier to help depressed individuals
reduce their guilt and bring their oppressive superegos into balance than it is,
for example, to help poorly socialized individuals restrain their ids and develop a sense of social responsibility and guilt. Individuals with depression
are generally eager to get well, which serves as a great motivation in therapy.
Some studies found that depressed individuals are more realistic in their
predictions than nondepressed ones, who were excessively optimistic (for a
review of this research, see, e.g., Dunning & Story, 1991). This counterintuitive finding spawned a generation of research, which has generally indicated that depressed individuals are more realistic under contrived laboratory conditions but not in more realistic circumstances (Dunning & Story,
1991; Pacini, Muir, &. Epstein, 1998). Although these theories are subject to
ongoing research, tentative initial conclusions suggest that depressed individuals (more than nondepressed participants) make overly optimistic estimates at the beginning of such studies, when they are under relatively little
stress. Then, impairments associated with depression interfere with goal
completion. Cognitive distortions similar to those noted by A. T. Beck et al.
(1979), such as beliefs that one is incompetent, play an important role. Helplessness beliefs (Seligman, 1975) impair efficacy and thus render optimistic
predictions inaccurate. Vicious circles (Millon, 1996), in which individuals
with depression underestimate the effort required to complete a task and
then initially fail, leading to further giving up, also play a role, and, similarly,
positive efforts made by nondepressed individuals that are then rewarded
lead to goal attainment. At this time, the depressive realism phenomenon
should be considered primarily a laboratory occurrence of limited clinical


Seven models are most frequently cited as underlying the relationship
between PDs and depression (Dolan-Sewell, Krueger, & Shea, 2001). With
the exception of the independence model (which, if true at all, is not relevant to the material addressed in this volume) and perhaps the "scar" model
(which does not appear to have elicited PD or depression-related studies at
this time), all of the other models are implicit in conceptualizations that
appear throughout this book. Each model is considered below, with some


examples of how the model relates to specific depression-PD interactions

that are addressed later on.
Independence Model
The independence model indicates that there is no relationship between Axis I and Axis II conditions. If the rate of comorbidity does not
exceed the rate of chance occurrence predicted by the base rate of the disorders, that would count as supportive evidence for the independence model.
For example, if a PD occurred in 10% of the population and major depression
in 20% and if the comorbidity of the two disorders was 2%, that would support the independence model. In certain areas, limited support is available
for the independence model. For example, a study by Petersen et al. (2002)
showed that treatment-resistant depression was not related to the presence
of a PD. However, for the most part, the comorbidities between depression
and PDs exceed chance levels. Shea, Widiger, and Klein (1992), in their
review of the literature, noted that high rates of comorbidity for PDs and
depression are the norm. Citing nine studies, Shea et al. noted that in samples
of depressed participants, 23% to 87% of the participants have had PDs; in
most of these nine studies, the PD rate is 30% to 40%. Similarly, in the six
available studies of the rates of depression in samples of individuals with PDs,
the range was approximately 24% to 87%. These rates clearly exceed the
amount of overlap one would anticipate on the basis of the prevalence of
each disorder taken separately.
Common Cause Model
The common cause model applies if there is a shared element between
the two disorders that causes both. The cause can be biological, psychological, environmental, or sociological. For example, a chemical imbalance in the
serotonin system may underlie both depression and impulsive behavior (e.g.,
as seen in borderline PD; see Soloff, Kelly, Strotmeyer, Malone, & Mann, 2003;
Soloff, Meltzer, Greer, Constantine, 6k Kelly, 2000). Thus, an individual with
either disorder would be at risk for the other. Thus SSRIs, which are antidepressants, are useful in treating borderline PD (Rinne, van den Brink, & Luuk
van Dyck, 2002). Similarly, sexual abuse may be a risk factor for both borderline PD and depression (Rose, Abramson, Hodulik, Halberstadt, & Leff, 1994;
Zanarini, Gunderson, Marino, Schwartz, & Frankenburg, 1989). Techniques
that facilitate healing the emotional trauma of sexual abuse would, according to this model, reduce symptoms of both disorders.
Spectrum and Subclinical Model
Like the common cause model, the spectrum model views one disorder
as a milder version of the other disorder; in this case, the Axis II disorder


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
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


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).

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


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.




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,
In my mind you make the fantasies,
hollowed out screams,
fearful cries . . .
In my mind where you hunt your prey,
Your hunger ravished,
eating me. . . .
In my mind or what is left of my mind,
you reign as supreme.
Ideal dictatorship. . ..
Paranoid. . . .


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.



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).
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).
For individuals with comorbid depression and paranoid PD, it is hard to
imagine a satisfactory resolution of Axis I symptoms without a concurrent


reduction of pathology on Axis II. The depression is likely to be tinged with

anger, and difficulties with trusting a health care professional would strongly
interfere with therapeutic progress in any modality. Thus, to treat the depression, trust must be establishedthat is, the paranoid personality pathology must recede, at least to some degree. Major theories of understanding
and treating paranoid PD are presented below, with an emphasis on the individual with comorbid depression where feasible.
Biological Factors
Paranoid PD is part of the schizophrenia spectrum (Siever, 1992). For
example, a study found that paranoid PD was twice as likely to occur in schizophrenic probands than in nonpatient controls (Baron, Gruen, &Ranier, cited
in Nigg & Goldsmith, 1994). Paranoid PD appears to be intermediate between schizotypal and schizoid PDs in its genetic association to schizophrenia (for a review, see Nigg & Goldsmith, 1994).
DiLalla, Carey, Gottesman, and Bouchard (1996) found that the Minnesota Multiphasic Personality Inventory Paranoia scale had a heritability
estimate of 28%. Livesley, Jang, and Vernon (1998) found that suspiciousness scores had a heritability of 32.5%. In their study of the heritability of
personality disorders in children and adolescents, Coolidge, Thede, and Jang
(2001) found that the heritability estimate for paranoid PD was 50%. As
with other personality disorders, then, paranoid PD appears to be moderately
To my knowledge, there are no substantiated theories on the neurobiology of paranoid PD per se. As part of the schizophrenia spectrum (Siever,
1992), and to the extent that it is related to paranoid schizophrenia, paranoid PD involves the functioning of the dopaminergic systems. In Cloninger's
theory (Cloninger, 1987), paranoid PD would presumably represent the high
extreme of the "harm avoidance" dimension. Cloninger (1998) has shown
that high harm avoidance is related to specific activities in the brain, such as
higher levels of activity in the right amygdala (a part of the limbic system,
important in processing emotions) as well as the right orbitofrontal cortex
and the left medial prefrontal cortex (parts of the frontal lobes that are involved in executive functions such as planning).
I know of only one empirical evaluation of medications for paranoid
PD, the Ekselius and von Knorring (1998) study discussed in chapter 1. The
selective serotonin reuptake inhibitors sertraline and citalopram appeared to
be helpful in decreasing paranoid PD symptoms among the 84 individuals in
their sample with paranoid PD. The remission rate for paranoid PD after 24
weeks of treatment was 43% for the sertraline group and 30% for the
citalopram group. The sertraline group had a mean decrease of .5 criterion
pre- to posttreatment; the corresponding figure for the citalopram group was
.7 criterion. Unfortunately, because there was no medication-free compari44


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
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


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



affectivity may be attributed to low neurophysiological thresholds of

responsivity. (p. 719)
As is the case for others with basic personality patterns who deteriorate to a
paranoid level of functioning, increasing mistrust is precipitated by agonizing disappointments and rejections. Fundamentally ambivalent on the selfother dimension, querulous paranoids are pushed to rely increasingly on themselves, and their resentments of others grow ever deeper. Ultimately, they
become "sullen, resentful, obstructive, and peevish, openly registering feelings of jealousy, of being misunderstood, and of being cheated" (Millon, 1996,
p. 720).
Like individuals with sadistic PD, malignant paranoids have backgrounds
of parental harassment and animosity. They acquire hostile behaviors, which
are reinforced by peers (who give in to them) and parents (who inadvertently reward hostility with attention or purposefully cultivate an aggressive
approach to life). Poverty may encourage a "survival of the toughest" adaptation. Millon (1996) noted,
Anticipating resentment and betrayal from others, future malignant paranoids moved through life with a chip-on-the-shoulder attitude, bristling
with anger and reacting before hostility and duplicity actually occurred.
Resentment and antagonism were projected. Dreading being attacked,
humiliated, or powerless, they learned to attack first, (pp. 717-718)
As with other paranoids, harsh reality, rejection, and humiliation push them
to engage in increasingly extreme defensive maneuvers. They become more
angry, hostile, and hypersensitive, seeing others as more and more treacherous. Eventually, they trust almost no one and often take on delusional, persecutory beliefs.
Regardless of its origin, a variety of vicious circles maintain the paranoid pattern. Perhaps most powerfully, suspicious mistrust breeds suspicious
mistrust. The guarded presentation of individuals with paranoid PD elicits
the belief that they are hiding something. Failure to reciprocate small trusting gestures, such as self-disclosure, by others short-circuits the rapportbuilding and trust-enabling process. Their proclivity to discharge hostility
in brief bursts leads to numerous interpersonal difficulties. As noted by
Millon (1996),
Trapped in a timeless web of deceit and malice, their fears and angers
may mount to monumental proportions. With defenses down, controls
dissolved, and fantasies of doom running rampant, their dread and fury
increase. A flood of frantic and hostile energies may erupt, letting loose
a violent discharge, an uncontrollable torrent of vituperation and aggression, (p. 721)
Obviously, the targets of such aggression typically become more actively opposed to and angry with the person with paranoid PD who attacked them.



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)


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
The basic cognitive-behavioral therapy relationship, which is problemfocused and less intimate than many other forms of treatment, is generally a


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
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.


Client-Centered, Humanistic, and Existential Therapies

Patience, validation, and unconditional positive regard are a prerequisite for developing a relationship with someone who has paranoid PD. It is
worth noting, however, that the ordinary level of warmth conveyed by a
client-centered therapist is likely to be seen as threatening and a form of
deceitfulness, so a more businesslike approach is probably more effective at
first. Ultimately, however, over an extended period of treatment, a warm
relationship could be extremely healing to the depressed person with paranoid pathology.
Psychodynamic Therapy
According to Melanie Klein (1946/1996), paranoia is part of the normal process of development. She described the "paranoid-schizoid position"
as an early developmental stage. Splitting is the primary defense mechanism
used. Terrified that warm and loving feelings will be overwhelmed by hateful
and aggressive feelings, infants split off and project their emotions. Too young
and immature to experience the mother as a whole person, they concretely
experience the mother's breast as their principal attachment. When milk
flows out, they experience the "good breast," which symbolizes love and
nurturance; when the breast is dry or does not gratify them, they experience
it as the "bad breast," which is evil and frustrating. Stuck in this position,
persons with paranoia split off and project their hostile feelings onto others,
who are then seen as persecuting them. This analysis implies that the person
with paranoia will reexperience the anxiety that was relieved by the projection if forced to reintegrate the projected affect; it is consistently noted clinically that individuals with paranoid PD are loathe to acknowledge their own
aggressive feelings toward others. It also suggests that an important part of
the phenomenon of paranoid PD is excessive early frustration relative to
warm nurturance and gratification.
A further implication of the paranoid-schizoid position is that the individual tends to have fleeting and unstable object relations. Months of establishing trust can be undone in an instant if the therapist (or any individual)
commits a perceived injustice; the client is likely to see this as "proof that
the therapist had malicious intent all along. In addition, the individual is
unable to maintain a detached, observing stance. The thought that someone
is trying to undermine him or her is its own proof; there is no hypothetical
"as if" (e.g., "It is as if he is trying to undermine me"). Instead, slights are
viewed as real and malicious rather than perceived.
Perhaps the most damaging barrier against establishing relationships for
the person with paranoid PD is projective identification. Projective identification has three components: (a) projection of an unacceptable impulse onto
another while continuing to experience the impulse (in the paranoid patient, the projected impulse is usually aggressive); (b) viewing the individual


onto whom the impulse is projected as controlled by the projected impulse,

and thus frightening; and (c) attempts to control the person, often in a way
that provokes the feared behavior. A hypothetical example of projective identification and its capacity to undermine relationships was given by Gabbard

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.


(a little louder and more forcefully) I said 10 o'clock. I wrote it

down in my book.


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.


(louder still) If I were wrong, I would admit it. On the contrary,

I think you are the one who won't admit to being wrong, and
you attribute that to me.


I'm not going to take this harassment. I'll find another therapist! (pp. 424-425)

Projective identification involves the need to control others. But why

this need? Deep down, people with paranoid PD have terrible self-esteem,
believing that they are weak and ineffectual. Just as a weaker army uses a
preemptive strike to capitalize on the element of surprise and maximize its
effectiveness, people with paranoia believe that they are always in danger of
being overwhelmed and destroyed by a superior force. Their grandiosity, then,
is defensive and compensatory in nature; rather than reflecting a high selfopinion, it is a manifestation of precisely the opposite.
To counter the destructive force of the projective identification, the
therapist must, paradoxically, be totally open to it and accepting of it, allowing himself or herself to become a container for the negative affect. Gabbard
(1994) gave an example of a better way to handle the prior situation:

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.


Let me see if I understand you correctly. Your understanding

was that you were to see me today at 9:30 instead of 10 o'clock?



You said 9:30.

I can certainly see why you might be angry at me then. Having
to wait for someone for 30 minutes would make most people
You admit that you told me to come at 9:30?



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)

Thus, handling the client involves a persistently nondefensive, empathic,

and supportive stance. Note, too, the businesslike and matter-of-fact approach
taken by Gabbard above. Excessive warmth, as mentioned previously, is likely
to breed suspicion and mistrust.
Group Therapy
Individuals with paranoid PD are not good candidates for processoriented group therapy at first. Their proclivity to elicit hostility and rejection from others is generally too strong, and they are likely to be scapegoated
or otherwise rejected by the group. Rather, some progress should first be made
in individual therapy; once the client is a bit more comfortable and trusting,
then group approaches can be used. A psychoeducationally based skills group,
however, could be considered earlier in treatment.

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).


In treating persons with paranoid PD, I have found it helpful to remind

myself that their guarded style is usually well grounded in their experience.
Many people with paranoid PD have been severely betrayed and/or sadistically abused. As the old joke goes, just because you're paranoid does not
mean that they're not all out to get you.


Individuals with certain disabilities, especially deafness, may have symptoms that would indicate paranoid PD in a hearing person. For the young
child who has never had hearing but is raised in a hearing environment,
watching others communicate in a manner that is inherently foreign often
leads to feeling isolated and alienated. In addition, lacking many ordinary
social cues, such children often believe that others are talking about them.
In reality, in a culture in which difference is not well tolerated, the other
children probably are often talking about them, and perhaps making fun of
them, thus lending credence to suspicious feelings.
The disparity between minority and majority culture was brought to
the forefront during the O. J. Simpson murder trial ("Behind the Verdict,"
1995). Simpson, an African American, was accused of murdering his White
ex-wife. Polls in the United States showed a striking and consistent pattern:
Most Whites believed Simpson was guilty, whereas most African Americans
believed he was innocent. Even more interesting, a majority of African
Americans (60%) believed that police often frame innocent people, com'
pared with less than a fourth of Whites (Streisand, 1995). The perception
that Simpson was framed gained credibility when the defense showed that
one of the key witnesses, police officer Mark Fuhrman, had made racist comments that he had denied under oath. The jury, having seen an officer apparently lie under oath to help secure a conviction, experienced "reasonable
doubt"what else had the state done? Where did they get the evidence?
How was the evidence safeguarded from tampering? Under a cloud of such
suspicions, Simpson was acquitted. It is interesting, however, that Simpson
was later convicted in civil lawsuits, thus revealing some room for interpretation regarding his innocence (MacNeil/Lehrer Productions, 1997). In short,
members of minority cultures who may have been targets of racism or are
intimately connected with those who have been should not be viewed as
paranoid when they evidence mistrust of mainstream institutions (see Whaley,
Immigrants are also at high risk for being mislabeled with paranoid PD
(American Psychiatric Association, 2000a). Faced with language and other
barriers and at times with hopelessly arcane immigration rules, the immigrant may become hostile or suspicious; such circumstance-related behavior
should not be confused with a character disorder. Most subcultures within


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.


The suspiciously oriented mind is well suited to certain kinds of activities. Counterterrorists, for example, must be able to think like a terrorist, to
remain hypervigilant, and to imagine possible deceptive plots that may occur. A bright and creative colleague of mine, warm and sensitive like most
psychologists, nonetheless has such a cognitive proclivity. After the tragedy
of 9/11 occurred, he shared with me the fact that for years, when he flew, if
the pilot stepped out of the cockpit, his heart would jump into his mouth. He
confided to me that he could not help but imagine the innumerable dire
consequences to which the plane is subject in such moments. Had government officials or airline executives been so "paranoid," tragedy may have
been averted. Another acquaintance of mine is able to imagine details of any
possible contingency and make adequate preparations. For example, attacked
while walking alone in a large city, he was able to frighten off his assailants
because he was appropriately prepared and trained. The enormous dividing
line between these healthy variants and the person with paranoid PD is the
realistic nature of the planning and the lack of what cognitive therapists
would call "personalization." Neither of these individuals imagines, as part of
their planning or thinking, that such potential attacks are aimed specifically
at undermining them; rather, they are trying to be prepared in the event of
unlikely, but possible, negative human interactions. Frankly, they are the
two people in the world with whom I feel most safe.


The first step in creating catalytic sequences that will help the client is
to establish a therapeutic bond. As noted throughout the chapter, doing so is
often problematic; a patient and nondirective approach provides the greatest
likelihood of success. Within a safe therapeutic relationship, cognitive techniques can help the client to challenge firmly held beliefs about others' maPARANOID PERSONALITY DISORDER


Therapeutic Strategies and Tactics for the Prototypal Paranoid Personality
Balance Polarities
Reduce polarity
Increase polarity
Counter Perpetuations
Stop provocations of rejection
Modify rigid minidelusions
Undo self-protective withdrawals
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.


Jean was a 15-year-old girl when her therapist, Kelly Vinehout, first saw
her. The client was Caribbean American, the therapist Caucasian, and both
were deaf. An incident of petty theft brought Jean to the attention of authorities. She was referred for treatment to a residential group home for the
deaf and hard of hearing. Jean had a deaf sister and several hearing brothers
and sisters. Her mother was addicted to drugs. Little was known about the


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
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
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.


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):

Your hair smells just like my mother's.

Dr. Vinehout: Oh, you wish you had a mom to take care of you.

Yeah, I wish you were my mom.

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.

Dr. Vinehout then went on to explain the therapeutic relationship and

how it worked. This kind of directness and bluntness is common and expected in deaf culture. It is also an extremely effective style with troubled
adolescents, deaf or hearing, who typically see adult circumlocutions as devious. This early interaction quickly established Dr. Vinehout as someone who
was relatively trustworthy, although trust had to be continuously earned
throughout the course of a 3-year therapeutic relationship.
It is typical for individuals in long-term treatment for PDs to bring most
of their quintessential relationship issues into the room as part of the transferencecountertransference enactment. In Jean's case, not surprisingly, the
central issue was trust. One example was that Jean often asked to see the
director of the facility ("Dr. Jones") to try to secure a desired privilege (e.g.,
permission to buy a bicycle). Dr. Vinehout would write a note to the director, stating the request for an appointment with the director. In Jean's mind,
this meant the appointment had already been scheduled. Dr. Vinehout tried
to explain that it just meant she would leave a note. Jean would then be
disappointed with, and angry at, Dr. Vinehout for failing to make the appointment. So, Dr. Vinehout began to write the note to the director and a
reminder note for Jean about what she had committed to do. Still, Jean would
believe that someone had altered the note. Jean then got a Palm Pilot, which
allowed her to encrypt the note that she wrote to herself (e.g., "Dr. Vinehout
will leave a note for Dr. Jones") with a password. The following exchange
would ensue:

You said you'd make an appointment for me, and then you didn't!

Dr. Vinehout: Look in your Palm Pilot. What does it say?




"Dr. Vinehout will write a note to Dr. Jones, asking for an


Dr. Vinehout: Did it say I would make the appointment?



Dr. Vinehout: Do you see?


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.

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.

This straightforward psychoeducational intervention, repeated numerous

times over the years within the context of a deep and secure therapeutic
relationship, slowly but surely decreased the number of frank delusions experienced by Jean.
Dr. Vinehout also provided Jean with psychoeducation about being
Caribbean American in a racist culture. They discussed racial oppression
and how that might impact her. Jean was receptive to these discussions.
Although confrontation was helpful in a couple of key turning points
in the relationship, the key to the success of the treatment was nearly constant validation. Dr. Vinehout helped to place Jean's fears in the context of
her genuine experiences, accepting the reality of her ongoing and painful
rejection and, more important, unconditionally accepting her as a person.
Given her interpretations of events, her painful and ambivalent feelings were
understandable; working through such feelings constituted the bread and
butter of the twice-weekly individual sessions.
In addition to individual sessions, Jean participated in group therapy
twice per week. Dr. Vinehout was one of the group therapists along with a
male cotherapist. Jean's participation in the group was uneven. At times, she
participated well, allowing the peer group to help her process her concerns,
such as whether to stay on her medications. Often, however, she was resistant and disruptive, refusing to participate. Her relationship with Dr. Vinehout
served to bind her to the group, but jealousy and possessiveness of Dr.
Vinehoutfor example, when seeing her connect with other clients and
with the cotherapistmade the group anxiety provoking. Overall, the group
experience was positive for her, but it was not the place in which she made
the most progress on her paranoid thinking.
Jean's depression was atypical, though the manner in which it was expressed was not unusual for an adolescent, particularly one with paranoid


PD. She was extremely sensitive to disruptions in her fragile relationships.

Rather than becoming sad and anhedonic, Jean would act out. It was predict'
able that the day after a perceived slight in therapy or in a friendship relationship she would act out in an aggressive way and get into trouble.
Dr. Vinehout's countertransference was unusual in relation to a paranoid client, in part because she seems to have circumvented a fair amount of
the projective identification directed her way by the client and because the
client tolerated identification of paranoid thinking. Typical countertransfer'
ence emotions are feelings of guardedness and defensiveness, to ward off the
client's attacks. Dr. Vinehout felt herself pushing away from the client in an
effort to set appropriate boundaries; having tapped into the neediness and
loneliness underlying the guarded defensiveness, she now had to work hard
to set appropriate boundaries and keep the relationship at a healthy distance.
In addition to individual and group work, Dr. Vinehout also did family
work with Jean's family of origin. She met with the grandmother, uncles, and
siblings, focusing primarily on two issues: interacting and communicating.
With Jean present, she informed the family bluntly that they needed to know
more sign language if they wished to have a relationship with Jean. This
intervention helped Jean feel validated, although unfortunately, it did not
get the family to learn much more sign language. Dr. Vinehout also helped
the family empathize with Jean (e.g., when you sit around and chat, she feels
left out and believes you are talking about her). Dr. Vinehout also worked
with the family on guidelines for home visits. Jean got no supervision when
she was home, which was inappropriate. Although they could not implement suggestions, they did become more aware of why the government agencies were keeping the family apart, and Jean became more understanding and
accepting that such a home environment would not be good for her.
By the end of the 3 years of treatment, Jean was greatly improved. She
was able to function in the residential facility. The frequency of her paranoid
delusional episodes had decreased. She had friendly, though somewhat superficial, relations with several of the other residents. Her relationship with
the therapist was deep and rich. Although there were still episodes of mistrust, such breaches had been repaired many times, and working through
them rather than having the relationship shatter was the expected outcome.
Unfortunately, for systemic reasons outside the therapy realm Dr. Vinehout
and Jean had to terminate. The termination process followed a predictable
course, with Jean unable to process that the relationship would end and an
angry confrontation in the penultimate session ("You didn't tell me we had
to stop!") despite six consecutive prior sessions of addressing the issue. During the final session, Jean refused to speak with or look at Dr. Vinehout. Dr.
Vinehout wrote notes to Jean, outlining the progress Jean had made over the
course of treatment, the pride that she (Dr. Vinehout) felt in Jean, and reminders of Jean's plan for the future. During this final session, which consisted of Jean, Dr. Vinehout, and a staff member sitting at the dining room


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.


Paranoid PD with depression is a difficult condition to treat because of
problems establishing and maintaining rapport. However, in at least some
cases, substantial improvements are possible. In the case of Jean, described
above, a series of catalytic sequences led to considerable gains. First, the therapist established trust through bluntness and simplicity of speech as well as
consistent, persistent use of physical evidence (e.g., the client taking notes
in her password-protected computer). Rapport was never taken for granted,
and relationship work was undertaken repeatedly. Cognitive techniques (chalPARANOID PERSONALITY DISORDER


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).




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.


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
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.
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.


Persons with schizoid PD may become depressed when their lifestyle is
too remote and detached. They may have a desire for some degree of contact,
to fit in meaningfully with others in some way. The sense that life is empty,
with no real purpose, is depressing to anyone (Frankl, 1959); the person with
schizoid PD, with his or her barren internal world, is prone to such thoughts.
In the words of A. T. Beck and Freeman (1990),
although usually comfortable with a detached lifestyle, these individuals
may become depressed over their awareness that they are deviants who
do not fit into society. . . . They may tire of being "on the outside, looking in." Further, their belief that life is meaningless and barren can lead
to or exacerbate depression, (p. 129)
At times, individuals with schizoid PD may also experience depersonalization,
in which they can barely experience their bodies and feel like they are just
"going through the motions." Such experiences may be depressing for the
individual as well. Thus, schizoid PD likely creates a vulnerability to experiencing depression.
As with other PD patterns, people with schizoid PD engage in coping
strategies that tend to perpetuate, or even deepen, their original personality


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,


Biological Factors
Millon (1981) asserted that schizoid PD, like all personality disorders,
has biological underpinnings. He hypothesized that individuals with schizoid PD may have a lack of neural density in the areas related to emotionality,
such as portions of the limbic system. He further speculated that there may
be problems in the reticular activating system, which is related to the anergia
and chronic underarousal of the person with schizoid PD. These neural deficits can be a function of genetics, environmental-biological factors (e.g.,
anoxia during the birthing process), or environmental-psychosocial factors
(e.g., an understimulating social environment). Millon (1996) noted,



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)

The above quote implies the neurological deficits previously described.

Millon (1981) conjectured further about how biological and psychosocial factors may interact to deepen the biological problem:
Another frankly speculative hypothesis is that a substantial number of
adult schizoid personalities displayed low sensory responsivity, motor
passivity, and a generally placid mood in infancy and early childhood.
They may have been easy to handle and care for, but it is likely that they
provided their parents with few of the blissful and exuberant responses
experienced with more vibrant and expressive youngsters. As a consequence of their undemanding and unresponsive nature, they are likely to
have evoked few reciprocal responses of overt affection and stimulation
from their caretakers. This reciprocal deficit in sheer physical handling
and warmth may have compounded the child's initial tendencies toward
inactivity, emotional flatness, and general insipidity, (p. 292)

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

Genetic studies in the phenomenologically similar autistic spectrum

disorders may bear fruit for understanding schizoid PD. Asperger's disorder,
the core feature of which is "severe and sustained impairments in social interactions" (American Psychiatric Association, ZOOOa, p. 80), seems especially closely tied to schizoid PD. There is strong support for a genetic basis of
autistic spectrum disorders using twin studies (Bailey et al, 1995; Steffenburg
et al., 1989), and research is ongoing to discover specific genetic markers
(Auranen et al., 2002; Buxbaum et al., 2001; Liu et al., 2001). There is also
evidence of an increased rate of schizoid PD in the parents of people with
autism (Narayan, Moyes, & Wolff, 1990).
Schizoid PD is heritable, apparently at similar levels to other personality disorders. Like an array of thoroughly studied normal personality traits
(Loehlin, 1989), PDs typically have a heritability estimate of .40 to .60.
Coolidge, Thede, and Jang (2001), in an investigation of personality disorders in 112 twin pairs ages 4 to 15, found that h2 for schizoid PD was .73;
the range for all personality disorders was .50 to .81. A study by Torgersen,



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.
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.



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-



Attitudes and Assumptions Typical of a Person

With Schizoid Personality Disorder
* People are replaceable objects.
Relationships are problematic.
Life is less complicated without other people.
Human relationships are just not worth the bother.
It is better for me to keep my distance and maintain a low profile.
* I am empty inside.
* I am a social misfit.
* Life is bland and unfulfilling.
* Nothing is ever exciting.
Note. Asterisks indicate items that suggest depression as well. From Cognitive Therapy of Personality
Disorders (p. 128), by A. T. Beck and A. Freeman, 1990, New York: Guilford Press. Copyright 1990 by
Guilford Press. Reprinted by permission.

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."



Assertiveness training (Alberti &Emmons, 1978; M. Smith, 1975) can

help depressed persons with schizoid PD to overcome their passivity and perhaps get some more of their needs met. A unique challenge with persons
with schizoid PD is their perception that they have almost no needs. Selfawareness work would be useful, perhaps even essential in this regard. Meditation training (Kabat-Zinn, 1990, 1994; LeShan, 1974; Murphy & Donovan,
1997) and focusing training (Gendlin, 1978) are methods by which the individual can be taught to focus on feelings, perhaps gaining more richness to
his or her rather impoverished internal environment.
As discussed in chapter 2, exercise is a natural antidepressant. Naturally sluggish, depressed individuals with schizoid PD would benefit greatly
from the energizing aspects of exercise, though for exactly that reason they
may be unusually resistant. As always, motivation is the key. Patience on the
part of the therapist is also critical; the suggestion should be well timed. One
effective way to introduce the topic is to bring it up in a brainstorming session if the client asks, "What can I do about my depression?" If that does not
occur, then at some point asking if the client is aware of how helpful exercise
can be in reducing depression would help the exercise "precontemplator" to
become a "contemplator."
Sex therapy can also be useful for individuals with depression and schizoid PD. Most individuals with schizoid PD have weak sex drives, and in major depression sex can become not only uninteresting but even aversive
(A. T. Beck, 1983). At such times, it is best to treat the depression and
wait a bit before encouraging sexual behavior. When a clinician fails to
assess the impact of depression on sexual feelings and behavior, it can have
a negative impact on the therapeutic relationship, as illustrated by author
William Styron (1992) in his book Darkness Visible. Styron, in the midst of
a severe depression, was nearly suicidal, thoroughly anhedonic, and had
great difficulties sleeping. His psychiatrist, pseudonymously referred to as
"Dr. Gold," was switching medications to Nardil, after an unsuccessful trial
of two other medications:
Further, Dr. Gold said with a straight face, the pill at optimum dosage
could have the side effect of impotence. Until that moment, although
I'd had some trouble with his personality, I had not thought him totally
lacking in perspicacity; now I was not at all sure. Putting myself in Dr.
Gold's shoes, I wondered if he seriously thought that this juiceless and
ravaged semi-invalid with the shuffle and the ancient wheeze woke up
each morning from his Halcion sleep eager for carnal fun. (p. 60)

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



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


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

In discussing schizoid PD, psychoanalytically oriented writers generally

have emphasized anxiety rather than depression as more central to the disorder. Klein (1946/1996) believed splitting was the essential characteristic of
the schizoid condition. In her view, in normal development the child experiences persecutory ideation, which is the projection of the child's innate
aggression onto the mother or, more specifically, onto the part of the mother
with which the infant has direct contact (the "bad breast"). Splitting, which
Klein defined as the separation of conflicting self and object representations,
is a defense against the anxiety generated by the persecutory ideation. The
schizoid individual failed to resolve these conflicts and therefore remained
with a narcissistic orientation, including the need to control others and the
tendency to either cling to or withdraw from them.
Thus the apparent absence of anxiety in the schizoid individual was an
illusion; rather, as Klein (1946/1996) hypothesized, the anxiety
is kept latent by the particular method of dispersal. The feeling of being
disintegrated, of being unable to experience emotions, of losing one's
objects, is in fact the equivalent of anxiety. This becomes clearer when
advances in synthesis have been made. The great relief which a patient
then experiences derives from a feeling that his inner and outer worlds
have not only come more together but back to life again. At such moments it appears in retrospect that when emotions were lacking, relations were vague and uncertain and parts of the personality were felt to
be lost, everything seemed to be dead. All this is the equivalent of anxiety of a very serious nature, (p. 21)

Fairbaim (1952) emphasized the early-childhood maternal relationship

in the development of schizoid PD. He noted the following:
(i) that in early life they gained the conviction, whether through apparent indifference or through apparent possessiveness on the part of their
mother, that their mother did not really love and value them as persons
in their own right; (ii) that, influenced by a resultant sense of deprivation and inferiority, they remained profoundly fixated upon their mother;
(iii) that the libidinal attitude accompanying this fixation was not only
characterized by extreme dependence, but also rendered highly self preservative and narcissistic by anxiety over a situation which presented
itself as involving a threat to the ego; (iv) that through a regression to
the attitude of the early oral phase, not only did the libidinal cathexis of
an already internalized "breast-mother" become internalized, but also the


process of internalization itself became unduly extended to relationship

with other objects; and (v) that these resulted in general overvaluation
of the internal at the expense of the external world, (quoted in Akhtar,
1987, p. 503)

As a result of these processes, these individuals take rather than give in

their emotional lives. Further, emotional contacts exhaust them because they
defend against their difficulties in giving by playing roles. Love itself is viewed
as dangerous, a consequence of the early experiences noted above, and thus
they defend against loving both themselves and others. Fairbairn (1952) further noted that those with schizoid personalities are drawn to the arts as a
way of having indirect contact with others and showing the self but at a safe
O. F. Kernberg and colleagues (Clarkin, Yeomans, & Kernberg, 1999;
O. F. Kernberg, 1967; O. F. Kernberg, Selzer, Koenigsberg, Carr, &
Appelbaum, 1989; Yeomans, Clarkin, & Kernberg, 2002) included schizoid
PD in a conceptualization of borderline personality organization. Like Klein
and Fairbairn, Kernberg viewed splitting as the fundamental defense mechanism of the schizoid character type. Poor ego development leads to a chronic
sense of unreality, which, combined with dispersal of affect, leaves the schizoid individual feeling chronically empty. Kernberg (1970) considered the
schizoid personality to be a "low" level of personality organization, indicating that it is next to the psychotic range of functioning.
Kernberg's "transference-focused psychotherapy" (Yeomans et al, 2002)
uses the traditional analytic techniques of clarification, confrontation, interpretation, and technical neutrality. The sine qua non of his treatment, however, is analysis of the transference in the here and now. Although in his
writings he generally emphasized confrontation over nurturing support,
Kernberg artfully combined his confrontations with accurate and emotionally attuned statements. The following case appears, at least in this fragment, to involve a mixture of schizoid and dependent featuresa person
with "pure" schizoid PD as defined in DSM-IV-TR would not particularly
expect or want the therapist to care. Nonetheless, the patient's startling
self-absorption and lack of empathy and relationship skills are consistent
with schizoid pathology.


I notice that you're making some marks on your pad whenever

I speak.
Yes, I'm counting how many times you talk.
Why do you do that?
It helps me know if you care about me. I count up the number of
times you speak, and when I go home I compare that number to
the last session. That's how I tell how much you're giving me.
Does it matter what I say?



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.


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
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


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



manner in which each individual's competenciesincluding those of the

identified patientare allowed to shine.
The decision as to whether to share the diagnosis that the person has
schizoid PD should be made on a case-by-case basis. Some basic
psychoeducation, such as noting, "We now know scientifically that people
are born with a wide range of abilities in sensing other people's emotions,
getting emotionally involved, or getting excited about things," will suffice in
many cases. In other cases, the label will provide a rallying point around
which the family can get information, help, or support. If the label will
disempower a family memberfor example, if the person with schizoid PD is
one of the parentsthen it may be better to avoid using it. This stands in
contrast to my approach to borderline PD, in which I virtually always share
the diagnosis with the client. There is a great deal of information available
on borderline PD, including several books that are written in lay language,
numerous Web sites, and a national support organization. None of these are
available for schizoid PD, so sharing the label does not have the same builtin practical advantages. In cases in which parents are bringing in their child
with schizoid PD, sharing the diagnostic label, along with its similarity to
autistic spectrum disorders, may allow the parents to tap into a crucially important social support network.
A number of different patterns may emerge in a family system with
parents and children in which the identified patient (the person with schizoid PD and depression) is one of the parents. From a structural perspective
(Minuchin, 1974), the family is most likely to be disengaged. Boundaries are
likely to be rigid between the identified patient and everyone else in the
family. If the spouse has a similar character structure, then the entire family
may be distant and disengaged. Marriages in which one partner has schizoid
PD and depression may be dominated by feelings of being "together, but alone"
(Moultrup, 1985). However, assuming the other spouse has a complementary personality, such as a more engaging temperament or dependent qualities, cross-generational boundaries may become blurred as the emotional needs
of the parent are satisfied through the children. Thus, for example, the presence of a schizoid and depressed mother would encourage the oldest daughter to become parentified and provide caretaking for the other children; role
reversal may also occur, in which the oldest daughter takes care of the father.
If one or more of the children feel neglected, then there could be a variety of
acting-out behaviors, potentially serving several functions within the family.
The acting-out behavior may express rage over feelings of being neglected or
may inject some purpose into the parents' lifeless marriage, thus keeping the
family together.
Paradoxical techniques are very powerful and should be used judiciously, but they can be effective in cases in which one spouse has schizoid
PD and depression. "Prescribing the symptom" (Haley, 1963; L'Abate,
Ganahl, & Hansen, 1986; Palazzoli, 1988) has been defined as telling the


family to continue doing what it is already doing. If the family complies

with the therapist, then they have taken a step toward collaborative work.
On the other hand, if they change, then, by definition, they become unstuck.
In most cases, the intervention is low risk; they are not likely to get worse
from being instructed to continue their current behavior, and they may
improve. The positive connotation technique, a particular form of symptom
prescription, can be helpful in breaking through feelings of "stuckness" in a
family (Palazzoli, 1988). Although using what is labeled a paradoxical technique, in fact the therapist is describing in an extremely straightforward
fashion the function he or she believes the symptoms are playing in the
family. The intervention stresses the role of each individual in the family
in maintaining the family system. Thus, for example, consider a family in
which there are a husband, wife, and two teenage children and in which
the father has depression and schizoid PD. Consider the prototypical situation in which the wife is feeling overburdened and one or more of the
children are beginning to act out, for example by breaking curfew. The
therapist conceptualizes the problem as one in which there is isolation and
distancing on the part of the father but poor differentiation of each member of the family, leading to painful maneuvering to attempt to establish
acceptable levels of closeness with one another. The therapist might assign
homework as follows:
Dad, you should continue to complain about feeling depressed and continue to lie around the house as you have been doing for the past 3 weeks.
This gives Mom an opportunity to feel strong and helpful and gives the
children an opportunity to become more independent.
This rather dramatic highlighting of the functions served by the symptoms
encourages the family to consider other, less painful ways of getting their
needs met. It sidesteps certain aspects of resistance because the therapist is
not pushing for change. If the family "resists" and changes anyway, so much
the better. If they stay the same, then they have done so at the request of the
therapist and may be willing to try other experiments to resolve their problems; further, the reconceptualization of their problem, focusing on positive
aspects of the symptoms, generally sparks fresh ideas for the kinds of changes
to which they would be open.
Family sculpture techniques (L'Abate et al., 1986; Satir, 1983) are also
powerful and may be particularly helpful to the person with schizoid PD who
has strong spatial abilities and spatial reasoning. Family sculpting has been
defined as
a method in which family members are asked to arrange one another as a
living statue or tableau. Drawing upon their creative instincts, and using
such nonverbal dimensions as distance, posture, visage, and gesture, the
family members give concrete representation to their impressions of the
family. (L'Abate et al., 1986, p. 166)


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)

Reliving moments or sequences from the past or spatially representing

relationship issues can be most enlightening to the client and may produce
powerful insights. If even such a high-impact technique as family sculpture
produces relatively little emotional impact on the person with schizoid PD,
it may allow the client a clearer understanding of how his or her partner feels
and thus lead to more appropriate or attentive behavior. Some people with
Asperger's disorder describe a process of attending to another, consciously
modeling their behaviors in order to be more accepted and acceptable (Willey,
1999). The passivity and lack of strong feelings of persons with schizoid PD
can be an asset in this regard; being generally passive, they may not mind
doing certain things differently, because it is "all the same" to them.

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.


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


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.


Theoretical considerations would lead to the expectation that schizoid
PD is far more frequent in men than in women. Current theory indicates that
men are less related than women. Levant (1995) discussed "normative male
alexithymia" to indicate the frequent observation that men lack words for
feelings. Although we might expect high ratios of men relative to women, as
in narcissistic or antisocial PDs, current prevalence data do not indicate these
According to the DSM-IV-TR, there are "slightly" more men than
women with schizoid PD, and they appear to be more severely impacted by it
(American Psychiatric Association, ZOOOa). Perhaps, then, passivity is more
acceptable and less damaging to the feminine role than to the masculine. A
man who is passive, noncompetitive, and underachieving may be deemed more
unacceptable, given American culture's emphasis on male dominance and
achievement. American culture may be more tolerant of passivity in women.
Even within the female role, however, a woman with schizoid PD may experience pressure for not being sufficiently nurturing, assuming that she dates,
marries, or has children; this issue is addressed in the case study below.


Low socioeconomic status is generally a risk factor for psychopathology

(Dohrenwend & Dohrenwend, 1969). There is a well-known association
between schizophrenia and low socioeconomic status (Eaton & Harrison,
2001), which likely generalizes, at least to some degree, to the schizophrenia
spectrum. The two main theories of the etiological impact of low socioeconomic status are social causation (e.g., that poverty increases stress levels, causing psychopathology) and social selection (i.e., that psychopathology impairs
productivity and leads to poverty; Dohrenwend et al., 1992). In general, both
factors work simultaneously (Johnson, Cohen, Dohrenwend, Link, & Brook,
1999). For example, an impoverished individual may become depressed in
part because of his poverty. Because he is unable to afford treatment, his
depression worsens, and he loses his job, leading to increased poverty.
It should be noted that in some cultures, what DSM-IV-TR labeled
"schizoid" is considered the highest state of being. The Buddhist monk (Foulks,
1996, p. 249) or Hindu yogi (Castillo, 1997) yearn to experience a state of
inner emptiness, freedom from striving, a focus on the present, and a lack of
"ego" (in the sense of individual identity and the pride that goes with it), and
to be free from emotions and attachments. Such individuals engage in regular meditation practice to attain such a state. I doubt that many clinicians
would confuse the practiced, refined state of tranquility of the Buddhist or
Hindu cleric with the inner deadness of the depressed person with schizoid
PD. However, members of the Buddhist and Hindu religions may accept or
even value ways of being that a practitioner from a Western perspective may
see as problematic.
In addition, Castillo (1997) noted that an individual is more likely to
be labeled schizoid if he or she has a "stigmatized moral career":
There are a number of ways that a person with a stigmatized moral career
can adapt to the social environment, thus structuring personality development. For example, stigmatized persons can accept their status and
"act accordingly," that is, passively accept their low status. These persons will likely have low self-esteem. They accept society's definition of
them as being inferior, flawed, incapable, unworthy, inadequate, unacceptable, and so on. They internalize this stigmatized view of themselves,
literally structuring it into the neural networks of their brains. These
neural networks then structure their cognition of the world, (p. 42)
One can easily see the origins of depression in this conceptualization.
Low self-esteem and beliefs that one is inadequate are part of the diagnostic
criteria for major depression and dysthymic disorder. The passivity of the
individual with schizoid traits makes this "accepting" adaptation likely. As
implied in the analysis above, both depression and schizoid personality disorder would be more likely to develop in hierarchical societies such as the
United States (Castillo, 1997, p. 100).
Some cultures have more muted forms of expression than others. For
example, individuals from Scandinavian cultures tend to be more reserved than


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.


When one considers the person-environment match, it is not difficult
to see that there are many aspects of schizoid PD that are adaptive to certain
conditions. Individuals with a low need for stimulation do well at repetitive
tasks or isolated jobs that would mercilessly bore most people. Institutionalized clients with restless temperaments grow agitated and desperate; the person with schizoid features adapts extraordinarily well to institutional life.
Although living in an institution may not be considered ideal, for individuals with certain kinds of problems it is the setting in which they will spend a
great deal of their time. It is a sad reality that the needs of institutions to
provide minimal staff-patient contact and to have maximal patient compliance with routines that are generally rather dull favors features of schizoid,
dependent, and obsessive-compulsive personality disorders.
There are also personality strengths inherent in schizoidal features that
fall within the "normal" or positive range of functioning. Being eventempered, steady, and calm are traits that stand one in good stead in many
situations. A person with schizoid PD who improves in psychotherapy can be
expected to retain these positive characteristics. As noted previously, advanced meditators achieve a state of inner peace through disciplined practice, attaining a state that bears some resemblance to the person with schizoid PD's natural way of being; the client could capitalize on that proclivity in


Personality-guided therapy (PGT) treatment goals flow logically from
the conceptualization of the client, per Millon's theory. Because the person


Therapeutic Strategies and Tactics for the Prototypal Schizoid Personality
Balance Polarities
Increase pleasure/enhancing polarity
Increase active/modifying polarity
Counter Perpetuations
Overcome impassive behaviors
Increase perceptual awareness
Stimulate social activity
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.

with schizoid PD is considered the passive-detached type, naturally, the goal

is to balance the polarities by helping the client to become more active and
more attached to others. Because the person is pleasure deficient, an additional goal is to increase pleasure. It is also important to undercut processes
that tend to perpetuate the schizoid pattern. Vicious circles of the person
with schizoid PD include (a) extreme passivity, which undermines the development of assertiveness and other appropriate skills; (b) lack of social awareness, which leads to unpleasant social interactions, thus further reducing
opportunities to perceive social cues; and (c) the tendency to withdraw, which
generally leads to further withdrawal. Thus, therapy should be geared toward
reducing impassive behaviors, improving social awareness, and increasing
social activity (see Exhibit 4.2). The long-term goals for depressed individuals with schizoid PD include increasing their activity level, enhancing pleasure, improving their social interactions and increasing their frequency, and
bringing clarity to their vague cognitions so they can recognize their depression and cope with it more effectively (Bockian & Jongsma, 2001; Jongsma
& Peterson, 1999).
For the client with schizoid PD and depression, motivation will often
be problematic; thus, the best initial interventions will be those that offer
the best hope of rapid change. Behaviorally lethargic, people who have both
depression and schizoid PD typically first respond best to cognitive interventions; they can challenge their negative thoughts and improve their mood
while expending minimal physical energy. 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 psychopharSCHIZOID PERSONALITY DISORDER


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.


It is not a coincidence that most of the clients whom I saw who had
schizoid PD also had histories of major psychopathology (e.g., schizophrenia
or bipolar disorder). I saw them mostly when I was an intern working for the
New York state psychiatric system. Their schizoid PD was never the reason
that they saw themselves coming for therapy. However, in the case below,
the severe Axis I psychopathology had been stabilized, leaving some Axis I
depression and anxiety, and the underlying schizoid PD, as treatment issues.
At the time I met her, Candace, a 42-year-old divorced White AngloSaxon Protestant woman, had had a long history of depression and schizophrenia. She had been hospitalized for schizophrenia on several occasions,
but when I started seeing her as an outpatient, she was stable on medications
and had not been in the hospital for a number of years. I saw her for approxi86


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


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
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


of the therapist arid Lorenzo's persistent affection were consistent reminders

that she was an acceptable person. As for the belief that she was empty, her
emotional reasoning (I feel empty, therefore I am empty) and her dichotO'
mous reasoning ("I am empty" as opposed to "At times I feel empty") were
challenged through Socratic dialogue. Over time, her belief was modified to
"At times I feel empty, but I often feel fulfilled as a mother to my daughter, a
girlfriend to Lorenzo, and in my job."
Lorenzo had beliefs such as "Candace does not really love me or she
would marry me"; "If we do not get married, that is terrible"; and "Candace
must be more affectionate with me, or I cannot bear it." These beliefs were
challenged against his experience and, gradually, were reframed as preferences, for example, "I would prefer it if Candace were more affectionate."
The belief that Candace would marry him if she loved him was challenged,
on the basis that Lorenzo would lose valuable disability benefits if the couple
got married. Although marriage was highly preferable to Lorenzo, particularly given his religious upbringing, he was able to see that Candace's
finances were stretched to the limit in supporting her daughter through
After the most distressing beliefs were effectively challenged, the treatment approach shifted to become more interpersonally focused. During this
phase of treatment, Lorenzo more frequently raised issues that were distressing to him. On a number of occasions, he would protest that unless Candace
could be more affectionate, then perhaps they should break up. Candace was
not ruffled by these threats, which did not seem to be particularly genuine.
However, at least one form of affection could be improved. Sexual counseling with the couple enabled them to experience more warmth and intimacy.
At that point, it became clear that Candace had reached the limits of
her motivation, and probably her ability, to become warmer and more demonstrative. Although the words "schizoid personality disorder" were never
used, the concept of "this is just how she is" was used as a way of discussing
personality variables. As a way of helping Lorenzo to empathize, I noted
that just as it was difficult for Lorenzo to reduce his desires, it was difficult
for Candace to increase hers. Ultimately, it came down to a choice"Can
you accept her for who she is? Can you accept him for who he is?" They
continued to stay together, and though ambivalent at times, they were more
flexible, accepting, and realistic about both themselves and each other.
The overall tone of the relationship had become warmer and more affectionate. Candace was less depressed, and Lorenzo was less angry and anxious. They recognized each other's strengthsthat she was drawn to his
emotionality and enjoyed his devotion to her, and he appreciated her patience and consistency.
Although 1 did not then work with psychodynamic concepts in this
casefor example by looking at unconscious motivations, early family relations, repetitions of prior patterns, and compensatory strivingsPGT prinSCHIZOID PERSONALITY DISORDER


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.


Schizoid PD with depression can be difficult to treat because of low
energy levels and motivation. With realistic expectations regarding recovery, prognosis is reasonably good. As illustrated by the case of Candace and
Lorenzo, a series of synergistic sequences led to significant improvements.
Establishing trust was not particularly difficult. Cognitive techniques (challenging distorted thoughts such as Lorenzo's experiencing Candace's reserve
as personal rejection) and interpersonal-family techniques (e.g., sexual counseling) led to improvements in the couple's relationship as well as decreased
symptoms in each individual.
For purposes of PGT for depression, empirical research on catalytic sequences, beginning with examining potential motivational strategies, would
be appropriate. Research on medications may be more important with this
population than with others, because motivation for change is a key ingredient for success in psychotherapy, and the lethargy that typifies individuals
with schizoid PD and depression needs to be countered.




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


Interpersonally, individuals with schizotypal PD are generally withdrawn.
However, the social withdrawal can occur for different reasons. People with
schizotypal PD can be thought of as belonging to one of two subtypes, as


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").

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,


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).
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)

Anyone who persistently experienced such thoughts and feelings would

likely experience depression and anxiety. Schizotypal PD and major depression with psychotic features can interact with negative synergy. As illustrated in the case study below, a woman whose clothing was being stolen or
misplaced in a nursing home developed the delusion that demons were stealing her clothing. Her depression, which was in part related to the loss of
control, stimulation, and freedom associated with living in a nursing home,
rapidly deteriorated from an adjustment disorder to a major depression with
psychotic features. Conversely, paranoid ideation can also be depressing.
Although anger and self-righteous indignation can sometimes help the person with paranoid personality disorder to ward off depression, such is rarely


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.
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


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.
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


monoamine oxidase inhibitor tranylcypromine was more efficacious than

triflurophenazine in reducing overall symptoms (Hedberg et al., cited in Schulz
et al., 1988); in another study, imipramine reduced symptoms more than
chlorpromazine (Klein, cited in Schulz et al., 1988). The Aono et al. (cited
in Schulz et al., 1988) study demonstrated that the antidepressant amoxapine
seemed to be effective for both psychotic and neurotic symptoms.
Schulz et al. (1988) reviewed four later studies that examined the effects of neuroleptic medication prescribed in low doses, as well as antidepressant medications in their usual therapeutic dosage. Unfortunately for our
present purposes, most of the samples were a mixture of individuals with
borderline PD and schizotypal PD. The studies were modest in size (17-52
participants) but were either double-blind or single blind. The four studies
taken together support the low-dose neuroleptic strategy, with at least one
study demonstrating similar improvements in participants regardless of diagnosis (e.g., borderline PD, schizotypal PD, or both). Neuroleptics generally
outperformed tricyclic antidepressants (which had equivocal results and made
some participants considerably worse).
Later studies defined schizotypal PD participants more precisely and
used newer medications. Preliminary findings with atypical antipsychotics
are encouraging. Scarciglia, Gherardelli, Tarsitani, and Biondi (2004) presented a case study that demonstrated a reduction in dissociative episodes
using olanzapine. Keshavan, Shad, Soloff, and Schooler (2004) performed a
26-week open-label trial of olanzapine with 11 participants; they found significant improvements in psychosis, depression, and overall functioning.
Koenigsberg et al. (2003) performed a 9-week randomized clinical trial of
risperidone with 25 participants. As assessed by the Positive and Negative
Syndrome Scale, negative schizophrenic symptoms began to remit by Week
3, and a reduction in positive symptoms had occurred by Week 7.
Newer antidepressants may also be helpful. One study has shown that
depressive symptoms remit with fluoxetine treatment (Markovitz, Calabrese,
Schulz, &. Meltzer, 1991); however, these results should be interpreted with
caution because the study was uncontrolled, and the small sample (N = 22)
was a mixture of individuals with borderline and schizotypal PDs. Jensen and
Anderson (1989) found in their 39-day open-label trial that the tricyclic antidepressant amoxapine helped to reduce schizophrenia-like and depressive symptoms in the five schizotypal PD participants in their sample. It is not clear if
amoxapine is superior to imipramine in treating schizotypal PD symptoms, if
the high percentage of borderline PD individuals in the Soloff et al. (1986)
study led to different results, or if Jensen and Andersen's (1989) miniscule
sample (N = 5) was too small to detect iatrogenic effects. In all, the evidence
above supports, albeit tentatively, Joseph's (1997) concise conclusion:
Strictly from a symptomatic approach, schizotypal personality disorder
can be considered a mild form of schizophrenia with the same characterSCH/ZOTYPAL PERSONALITY DISORDER


istics except that psychotic thought, perceptual, and affective symptoms

are mild; hence the personal, social, and occupational deterioration are
proportionately less severe. . . . Since the difference is quantitative and
not qualitative, the treatment employs similar medications, the primary
difference being in the dose size. (pp. 58-59)
Joseph (1997) provided a case illustration of a 50-year-old woman who
had schizotypal PD and depressed mood. Her symptoms included poor
memory, poor concentration, ideas of reference, obsessive ruminations, and
insomnia. She was treated with fluoxetine, risperidone, temazepam, and psychotherapy. Noted Joseph, "The patient reported almost complete resolution of most symptoms, and felt that she should have started this treatment
25 years ago" (p. 62).
Psychological Factors
In the biopsychosocial model, the psychological level falls between the
highly individual biological level and the large-scale sociocultural level. Psychological factors include the person's learned behaviors, beliefs, emotions,
unconscious strivings, and interpersonal relationships. Several established
lines of thought emphasize different aspects of the person's experience, and
will be described in turn below.
Millon's Theory
Millon conceptualized schizotypal PD as a more severe, "decompensated" variant of the schizoid or avoidant PDs. Thus, in terms of Millon's
tripolar theory, the person with schizotypal PD may appear to be passively
detached or actively detached. In contrast to the less severe counterparts of
the disorder, people with schizotypal PD also have instabilities on the painpleasure dimension. Where the person with schizoid PD has a deficiency in
both pain and pleasure and the person with avoidant PD has an excess of
pain sensitivity, the individual with schizotypal PD has weakness along the
pain-pleasure dimension such that the two poles may reverse (pleasure is
experienced as painful). As Millon (1999) stated,
In essence, this signifies that none of the survival motives and aims of
the schizotypal have a firm grounding. Rather, they are feeble in their
intensity and focus, and can be easily reversed or distorted in their usual
objectives and goals. The figure portrays their rather ineffectual existence, as well as the meaningless and eccentric character of their activities. Possessing little spark or drive, these individuals become increasingly estranged from social conventions, (p. 617)
Thus, persons with schizotypal PD tend to drift in a downward spiral.
Their social withdrawal leads to insufficient stimulation, lack of checks and
balances on quasi-delusional thinking, and thus further autistic reasoning


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


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

Client-centered therapy would be a natural fit for someone with

schizotypal PD and depression. Feelings of alienation are likely to be prominent, and a consistent, empathic approach is a powerful remedy for such
feelings. Existential therapy may also be extremely useful for depressed clients with schizotypal PD. As they grapple with feelings of emptiness and
meaninglessness, a therapy that specifically addresses purpose in life could be
a powerful antidote (Frankl, 1983; May, 1983b). For the clinician who is not
specifically existentially oriented, assigning the client a book to read such as
Don't Sweat the Small Stuff (Carlson, 1997), The Miracle ofMindfulness (Nhat
Hanh, 1976), or Wherever You Go, There You Are (Kabat-Zinn, 1994) is a
useful starting point. Simply assigning the client to read a few pages and then
asking if there was anything that he or she found meaningful can lead into a
productive discussion of how to find or create meaning in one's life.
Psychodynamic Therapy

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


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.

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
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


client's beliefs to the likely underlying meanings and understanding those

underlying meanings generally shifts my emotional reactions from a felt sense
of weirdness, and perhaps a bit of anxiety, to a sense of empathy. The underlying meanings are usually common, shared human reactions. Who among
us has not felt intruded on at one time or another? Or wished that we were
esteemed, or a bit more important than we probably are? Incidentally, as I
look back on the days when I would directly share my insights with clients, I
now consider this a clinical error on my part. Their beliefs were concrete
they were being followed by aliens! The most direct approach was to ask how
it felt for the person to establish a sense of connection; it can be helpful to
guess ("It must be frightening to you"). Unlike strange cognitive distortions,
the underlying emotions are usually quite understandable. At that point, an
empathic bond is generally readily established.


As noted by Rollo May (1983a) and Victor Frankl (1983), modern life
leaves people vulnerable to the struggle to find meaning in their existence.
Traditional societies, through their more intense community involvements
and religious beliefs, are unlikely to engender the belief that life is meaningless (Castillo, 1997). In technological societies constructed of tens or hundreds of millions of people, the belief that society would go on pretty much
identically whether one participates or not can lead to thinking that one's
contribution is trivial and that there is no purpose in one's existence. American society's great strength is its valuing the potential of each individual, but
this individualism comes at a cost: If each individual is going in his or her
own direction, it is difficult to find secure collections of individuals sharing
meaning systems. If this feeling of ennui is relatively widespread among
healthy, high-functioning, and privileged members of our society, imagine
how much more difficult life is for the individual with constitutional proclivities for cognitive slippage who is isolated from others; subject to peer
rejection; and, in many cases, not highly productive at work.


A number of studies have found a positive connection between
schizotypal personality and creativity (Cox & Leon, 1999; Kinney, 20002001; Schuldberg, 2000-2001). A surprising positive relationship was discovered between the Schizotypal scale of the Millon Clinical Multiaxial InventoryIII (Millon, 1994) and quality of life (Bockian, Dill, Fidanque, &
Lee, 1999). On examining the data, Bockian et al. (1999) found that the


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.
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.
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.



Therapeutic Strategies and Tactics for the

Prototypal Schizotypal Personality
Balance Polarities
Stabilize erratic pain-pleasure polarities
Stabilize erratic self-other polarities
Counter Perpetuations
Prevent social isolation
Undo excessive dependency
Reduce fantasy preoccupations
Alter eccentric behaviors
Reverse autistic cognitive style
Reconstruct estranged self-image
Note. From Personality-Guided Therapy (p. 627), by T. Millon, 1999, New York: John Wiley & Sons.
Copyright 1999 by John Wiley & Sons. Reprinted with permission of John Wiley & Sons, Inc.

Hope was a 68-year-old divorced mother of six grown children. She

grew up in an African nation and had been residing in the United States for
approximately 40 years. A number of months before I began to see her, Hope
had had a stroke or similar episode. This event led to her transition from
community residence with her granddaughter to living in a nursing home.
Christian throughout her life, following the stroke she became a Baptist and
was "reborn." Since that time, according to her daughter, she was extremely
religious. Her memory was somewhat impaired and thus some of the details
in her history were sketchy.
I had no difficulty connecting with Hope; unlike many people with
schizotypal PD, she was interested in having a relationship with me and with
her family members. I have often found that in nursing homes, because of the
understimulating and often isolating environment, clients are eager for a relationship. Simply providing an opportunity to talk about her concerns established a comfortable therapeutic rapport. Hope's initial complaint to me
was that she was seeing "devils," shadowy spirits that would hide in corners
or under her bed. She claimed that they were stealing her clothes and otherwise tormenting her. Sadly, Hope's clothing was disappearing and needed to
be replaced by the nursing home; staff believed that in fact the clothing was
being stolen. Nonetheless, several diagnostic possibilities jumped to mind.
Psychosis secondary to stroke and its attendant brain damage? Schizophrenia? Schizotypal PD? Atypical psychosis?
Hope's voice was sad and pleading as she reported her story, and I felt a
distinct cry for help. Paying attention to my emotional reactions to her, 1


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


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
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.



As illustrated in the case of Hope, a personality-guided conceptualization, followed by a catalytic sequence of interventions, led to substantial
improvements. The interplay of her depression and her vulnerability to quasidelusional ideas as a function of her schizotypal PD meant that both problems had to be treated simultaneously. After establishing rapport, an individual intervention based primarily on paradoxical techniques helped to
improve the client's mood and decrease her quasi-psychotic experiences; indeed, one might say that the client's willingness to act in an odd manner
(singing in a public setting) enhanced her recovery. Understanding of her
culture and of what her experience meant to her was particularly critical in
this case and shaped the nature of the paradoxical interventions. Family interventions, cognitive interventions to challenge her irrational beliefs, and
psychodynamic conceptualizations to understand and ultimately confront
issues in the client-therapist relationship (the transference-countertransference dynamics) were integrated in accordance with her schizotypal personality. Emphasizing her strengths helped to enhance her relationships within
her family and led to long-term more positive functioning. Notably, medications were not necessary in this case; it is not necessary to automatically refer
for medications in these cases, though, of course, medications should be used
as a resource when indicated.
Per the above discussion, I suggest that key areas for research include
studies that look at the catalytic arrangement of interventions based on personality-guided principles. It may be necessary to evaluate subtypes independently (e.g., Millon's distinction between the schizotypal with avoidant vs.
schizoid features). Medication research is important, not only to find more
effective medication agents but also to assess which cases may not need medication intervention.




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

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.


People with antisocial PD tend to be impulsive and tough. In more
severe cases, conscience is entirely lacking; in virtually all cases, conscience
is extremely deficient. As the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision [DSM-IV-TR]; American Psychiatric Association, ZOOOa) put it,
The essential feature of Antisocial Personality Disorder is a pervasive
pattern of disregard for, and violation of, the rights of others that begins
in childhood or early adolescence and continues into adulthood, (p. 701)
Among those who are violent, most use violence instrumentally. There
was an appropriate category in the revised third edition of the Diagnostic and
Statistical Manual of Mental Disorders (American Psychiatric Association, 1987)
for those who use violence for sadistic pleasure; however, with the elimination of aggressive-sadistic personality disorder in the fourth edition (American Psychiatric Association, 1994), the closest category in DSM-IV-TR is
antisocial PD. People with this disorder are often, for example, manipulators,
con men, or parasites who fleece others of their savings or live off others
without any thought of reciprocation. Much of my experience with individuals with antisocial PD has been with drug dealers and substance abusers who
sustained spinal cord injuries from their high-risk behavior (e.g., being shot
during a drug deal or having a car accident while driving under the influence). Establishing rapport was a challenge, although I found this to be workable'within the hospital setting. In chapter 7, this volume, on borderline PD,
I describe the case of an individual who had a mixture of borderline and
antisocial features. The therapy went well, because we were able to control
the contingencies shaping his behavior effectively; in that case, the behaviors generalized well postdischarge, and he changed his life in a positive way.
In purer cases of antisocial PD, I have been able to achieve substantial changes
using similar methods during clients' hospital stays, but few of these changes
tended to be internalized, and my sense was that these clients were quick to
revert to their old ways. Establishing rapport with this help-rejecting population can be difficult; methods to effectively establish a preliminary rapport
are discussed later in this chapter.
Individuals with antisocial PD often have a peculiar kind of empathy.
Noted Millon (1996), "Antisocials tend to be finely attuned to feelings, moods,


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.
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,
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.
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


to depression, in the case of antisocial PD there is a unique Personality x

Environment interaction (antisocial PD plus constraint) that increases not
only the likelihood of depression but, more important, its lethality. Such a
conceptualization is consistent with the "pathoplasty" model of interaction
between the Axis I and Axis II conditions. Another unusual feature of antisocial PD is that the presence of depression appears to improve treatment
outcomes, as reported by Woody, McLellan, Luborsky, and O'Brien (cited in
A. T. Beck, Freeman, & Davis, 2004, p. 12); this is a kind of reverse "exacerbation" model of the interaction between antisocial PD and depression (see
chap. 2, this volume, for a discussion of the theoretically possible relationships between depression and personality disorders).


Antisocial PD and its youthful counterpart, conduct disorder, are the
most thoroughly researched of all the PDs with regard to causality. Research
reviewed below provides detailed estimates of genetic versus environmental
contributions. In addition, a considerable amount of theory has been generated in an effort to understand the thoughts and behaviors of this enigmatic
group. Perhaps this is due to our natural fascination with the "criminal mind,"
or the cost to society, both economic and emotional, associated with antisocial acts. In addition to considering individuals with criminal behavior, this
section will consider the broader issues associated with the active self-oriented person.
Biological Factors
The biological mechanisms underlying antisocial PD features, such as
impulsivity and aggression, are related to serotonergic activity in the brain.
Coccaro (1998) reviewed some 30 studies demonstrating a relationship between serotonin levels and impulsive aggression. Serotonin levels, as measured by cerebrospinal fluid metabolites, demonstrated an inverse relationship with impulsive aggression. Low serotonin levels were associated with,
among other indicators of impulsive aggression, violent suicide attempts,
impulsive arson, violent assaults, and lifetime history of aggression. Pharmacologic challenge studies demonstrated reduced response to serotonergic
agents in individuals with impulsive aggression. Platelet studies suggested an
inverse correlation between the number of serotonin-binding sites and impulsive aggression.
Activity level in the frontal lobes, such as the orbital frontal region, has
been shown in a variety of studies to be associated with impulsive aggression.
Perhaps the most famous case is that of Phineas Gage, a 19th-century rail112


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).

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.
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.


T. Walker, Thomas, and Allen (2003) studied 4 participants using quetiapine;

like Hirose, they noted reductions in aggression, impulsivity, hostility, irritability, and rage reactions.
In the absence of further studies, it is worthwhile to consider the clinical observations of Joseph (1997). He argued that antisocial PD can be conceptualized as falling along a number of dimensions, some of which are amenable to intervention with medications and others of which are not. Joseph
noted that impulsivity may indicate attention deficit disorder or hypomania.
As is well known, attention deficit disorder can be treated with stimulants
(e.g., methylphenidate), bupropion, or various other medications, and hypomania responds to lithium, carbamazepine, sodium valproate, and so on. As
discussed above, irritability and anger respond to serotonergic medications;
if those medications are not effective, antipsychotics or benzodiazepines can
be tried. Unfortunately, as Joseph noted, treatment is often unsuccessful; in
part, this is due to the numerous symptoms of the disorder that medication
cannot reduce. Criminal behavior, exploitive conduct, irresponsibility, and
deficient conscience are, and may always be, beyond the reach of pharmacological intervention. He recommended working with patients, their families,
and the courts to develop realistic expectations of what medications can and
cannot do in these cases. That being said, Joseph noted that medications can
be very helpful in some cases, especially if the antisocial features are intertwined with paranoid ideation; in such cases, antipsychotic medication can
make an enormous difference.
Although Joseph's (1997) recommendations are rational, his hypotheses are not a substitute for ongoing theory building and empirical investigations. Scientific studies must be performed to assess the efficacy of medications with antisocial PD. Until a solid base of randomized clinical trials of
various medications has been created, the usefulness of various medications
will remain in doubt.
Psychological Factors
The biopsychosocial model (Millon, 1969) indicates that a person's biological makeup, psychological experiences, and social (e.g., cultural, ethnic,
and religious) environment all contribute vital information for understanding an individual. Each element of this model will be reviewed in the following sections.
Millon s Theory
According to Millon (1969, 1981, 1996, 1999), individuals with antisocial PD are the "active-independent" type. They are thought to have a
generally active, impulsive nature, perhaps because of inadequacies in the
"pain" center of the brain and densely branched neuronal networks in centers that regulate anger. These neural problems may have been caused by


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-



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


2. Thinking is believing"My thoughts and feelings are completely

accurate, simply because they occur to me."
3. Personal infallibility"I always make good choices."
4. Feelings make facts"1 know I'm right, because I feel right
about what I do."
5. The impotence of others"The views of others are irrelevant
to my decisions, unless they directly control my immediate
6. Low impact consequences"Undesirable consequences will not
occur or will not matter to me." (p. 175)
As noted previously, most people with antisocial PD are prone to depression when they are constrained. For such individuals, their beliefs typically include thoughts such as "I am trapped," "I will never get out of here,"
"I've gone too far this time," "I can't possibly survive this horrible place long
enough to get free." I have also seen similar thoughts in individuals with
substance addiction; often, in a sudden burst of insight, they realize they are
in a prison just as real as one with walls and bars. The chemical slave driver
dictates their every behavior, from theft to prostitution to losing jobs to living on the streets. Perhaps they have tried drug rehabilitation and it has
failed, or perhaps the thought of asking for help is worse than dying. A patient of mine (see the case example in chap. 7, this volume), while having
such thoughts, injected his veins with battery acid in an attempt to die. I
remember shuddering with revulsion when I heard about his choice of method,
as if the only way to destroy himself would be to consume and obliterate
himself from the inside out. The distorted beliefs of both the depressed and
nondepressed individual with antisocial PD can be challenged using standard cognitive techniques, such as Socratic dialogue and thought records
(J. S. Beck, 1995).
Behavioral contracting is another technique that I have found to be
helpful in my work with individuals with antisocial PD (Bockian, 1994). I
have never used individual contracts (i.e., contracts that just involve patients contracting with themselves, such as agreeing to reward themselves
for behaviors associated with quitting smoking). Instead, all of the contracts
I have done have involved individuals with antisocial PD as they are involved in a system and details of how they would interact with one another.
Most of these have been contracts to reduce or eliminate verbal or physical
abuse. It is a fundamental tenet of behavioral contracting that everyone must
think the contract is fair, which can be quite challenging when one party has
issues of entitlement. Nonetheless, I believe I was always able to find common ground on which to agree. Even individuals with severe antisocial PD
recognize that a hospital will not agree to allow them to abuse staff, particularly in writing. I always made sure that there was something in it for the
patient. For example, in one case, the client was concerned that he was not


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

Psychodynamic theory can be helpful in understanding the inner world

of persons with antisocial PD. Their internalized objects are generally malevolent and perceived as hurtful and exploitive. Akhtar (1992), in his summary of a large psychodynamic literature, stated succinctly,
Most psychoanalytic investigators agree that the core antisocial character results largely from a severely traumatized childhood, with much actual injustice being suffered by the growing child. Internalization of abnormal parental superegos or unconscious parental encouragement of
the child's delinquency are other common background factors. Disappointment in primary objects, humiliation and suffering, internalization
of abnormal norms, and/or corruption by parents are various factors that
work with the child's own age-specific distortions and fantasy elaborations, (pp. 229-230)

These factors lead to a severe disturbance in the clients' internalized objects

as well as in their interactions with others.
Nonetheless, the use of psychodynamic treatment techniques in cases
of true antisocial PD is generally futile. Millon (1999) noted that there are



few intrapsychic mechanisms on which patient and therapist can draw in

such cases. He concluded,
There is a widespread pessimism as to whether intrapsychic therapy can
produce significant changes within the antisocial . . . psychodynamic
approaches tend to be difficult to undertake because antisocials are not
apt to internalize therapeutic "insights" without external controls or interventions, even if they stay in treatment for more than a few sessions. If
severe limits are put on the antisocial personality (such as in highly controlled incarceration settings), anxiety and depression may lead some
patients to be more amenable to change. Almost any other treatment
orientation would have a greater (if limited) chance at success given the
antisocial's lack of insight and low tolerance for boredom or slowly progressive changes, (p. 480)

O. F. Kernberg, Selzer, Koenigsberg, Carr, and Appelbaum (1989) were

more succinct, stating simply in a footnote that their treatment, which at the
time was called expressive therapy, is contraindicated in cases of antisocial PD
(p. 8). That Kernberg, who successfully opened the door for psychodynamic
treatment of borderline and other severe personality disorders, was so blatantly pessimistic about treatment of individuals with antisocial PD is a powerful indication that other therapies should be used in such cases.

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,



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
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).



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.


Antisocial PD occurs approximately 3 times as frequently in males as in
females (DSM-IV-TR, p. 704), a finding for which there are a variety of


explanations. There could be genetic, hormonal, or other biological factors

that account for the difference. Males, more than females, may be given
messages that it is acceptable to express anger. In addition, there could be
diagnostic bias. Many males are labeled antisocial who would probably be
better conceptualized as borderline (Dutton, 1998; Hart, Dutton, & Newlove,
1993). If men with borderline PD express their rages by hitting others, if drug
use is their form of impulsive behavior, and if they then get into drug-related
legal problems, the behavioral line between borderline PD and antisocial PD
becomes thin. Nonetheless, the underlying biological and psychological factors can be different, even diametrically opposed. Individuals with borderline PD are hypersensitive in a variety of domains; individuals with antisocial PD tend to be hyposensitive. The emotional force of an intervention
that will merely touch a person with antisocial PD will be experienced by the
person with borderline PD as a hammer blow. People with borderline PD
may be prone to shame and guilt, unlike those with antisocial PD. Perhaps
most important, individuals with borderline PD are relationship oriented and
are more capable of forming a therapeutic alliance. My advice is that a clinician should carefully rule out borderline PD on any male diagnosed with
antisocial PD. I have observed that failing to recognize borderline pathology
in men with antisocial features has done a good deal of harm. Borderline PD
is more treatable, and therefore misdiagnosis leads to lost opportunities for
As noted previously, features of antisocial and narcissistic PDs were
induced in randomly selected college-aged men in the famous Stanford prison
experiment (Haney, Banks, & Zimbardo, 1973). Collins (1998) extended
this finding by having college student participants rate behaviors as either
masculine or feminine; consistently, the guard behaviors (dominance, aggression) were rated as masculine, whereas prisoner behaviors (depression,
anxiety) were rated as feminine. Because all of the participants were the
same gender and were randomly assigned, the only plausible explanation for
the differences in behavior was social role. Collins concluded that social dominance tends to elicit arrogance and oppressive behavior, whereas social status inferiority elicits feelings of helplessness, depression, and anxiety. Although not a conclusive study, Collins's findings lend weight to the notion
that at least part of the explanation of the gender gap in antisocial PD is the
impact of male privilege and patriarchy on mental functioning.
The issue of masculinity is crucial when treating males with antisocial
PD. The culture of psychotherapy promotes a number of values: introspection, vulnerability, processing feelings, self-awareness, and open communication. These are feminine-typical strengths. Male strengths include task focus, courage, expressing opinions, assertiveness, and team play (Bockian,
1999). Individuals with antisocial PD often have several of these strengths.
The most important idea I try to keep in mind is that it is not necessary to
change the client's masculine traits to have a good outcome. He does not


have to become sensitive, sentimental, or highly introspective. The research

literature teaches us that androgynous individuals are no better adjusted than
individuals who are highly masculine (Basoff & Glass, 1982; Choi, 2004;
Whitley, 1983, 1985). Thus, it is incumbent on us to accept various aspects
of the client's approach to the world that may not match our own.
Instead, it is wise for the therapist to take advantage of potential masculine strengths to engage processes that are necessary for therapy. For example, honesty is essential. When the client says something honest that leaves
him vulnerable, I acknowledge him by saying something like, "That took a
lot of guts to admit that you made a mistake. Now we can get to work. Let's
roll up our sleeves." Here, I engage courage in the service of honesty and
vulnerability, task focus, and teamwork. An intervention I did with Doug, a
patient with borderline PD (see the case example in chap. 7, this volume),
was an attempt to gain honor among thieves, so to speak. He was breaking
some rules on the unit and was saying he would not do it again. I asked him
to "give me his word as a man" that he would no longer engage in the behaviors, which he did. When he repeated the behaviors (which I partially expected despite the hope that he would change), I said to him, in a surprised
and disappointed tone of voice, "You gave me your word as a man, and then
you broke it? It'll be quite some time before I trust you again." Doug had a
mixture of borderline and antisocial features, so a "pure" antisocial might
have responded differently, but after that intervention, he worked hard to
earn my trust. I had provided him with a challenge and an opportunity. He
could be a man; in an institution such as a hospital, one is treated like a child
in many ways. He rose to the occasion.
Antisocial PD is more likely to occur in cultures that are hierarchically
arranged. Extremely common thoughts among individuals with antisocial
PD include "I'm not getting my fair share"; "Why should he have it and not
me?"; and "I want it, so I'm going to get it." Disparities in wealth and status
provide targets for the antisocial agenda.


If they can be channeled for the good, many characteristics of antisocial PD are adaptive and even admirable. The ability to be charming and to
create a sense of trustif one follows through with trustworthy behaviors
constitutes an extremely important set of social skills. The aggressiveness of
the antisocial person, when sublimated, is a positive trait. The "aggressive"
athlete is usually admired above all others, and to call someone an aggressive
businessperson or salesperson is generally a compliment. Subclinical or
normal-range antisocial features are often present in some of the most successful people in our society.



In working with the depressed person with antisocial PD, it is extremely
important to establish a therapeutic relationship. There are a variety of ways
to do so, which have been outlined elsewhere (Bockian & Jongsma, 2001),
though it should be noted that none of these strategies is entirely effective.
Conceptually, I consider the client as having no superego, and thus I must
work entirely through the ego and the id. Depression is a positive prognostic
sign because it will provide motivation for the person to change. The depressed person with antisocial PD, unlike the "pure," nondepressed antisocial person, is confronted with the thought, "This ain't working." Perhaps he
has gotten caught by the police doing something illegal and is now in prison,
or perhaps he is court-ordered into treatment, or perhaps he is in a mental
institution, and it bothers him. I then frame our relationship as one in which
I am a consultant who will help the client to achieve his goals, within reason.
On the spinal cord injury unit, I worked on numerous occasions with
patients who were verbally or even physically abusive with staff. What I found
fascinating was the underlying rationalization. The client usually framed the
situation as one in which the nurse was not doing her job (e.g., by not bringing his water immediately or by insisting that he do something for himself).
He would then experience something akin to an obligation to correct her
shortcomings. (Presumably, this was a reenactment of his childhood experience through identification with the aggressor, though I rarely confirmed
this assumption.) Once I ferreted out the meaning of the behavior, assuming
that the client did interpret the problem as being that he was getting poor
service, I would say something like the following to the client:

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?


That is so unfair. Why should I have to wait for 20 minutes just

to get a glass of water? Why do I have to sit here with my f
hair in my f
ing eyes just because Jane [the nurse] is on her
coffee break.7 And why don't they leave my brush where I can
reach it? They do it just to piss me off. They're just trying to get
under my skin.


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?







Talk to Jill McDonald. She's the patient advocate. She talks to

the chief of staff. Your complaint will go to Jane's bosses' bosses'
Does that really work?
I've seen it work 100 times.
That might be all right. How do I contact her?
I'll tell her today that you want to see her. She usually sees patients within a day or two. By the way, you know you can have
these nurses eating out of your hand, don't you?
What do you mean?
They became nurses in order to help people. They're a bunch of
do-gooders. It's really easy to get them to do what you want.


All you have to do is throw in a couple of "thank you"s after

they give you your care.


But that's their job! I shouldn't have to thank them for doing
their job. They're getting paid for that.


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.

Such an intervention, when combined with specific behaviors on the

part of nurses, was successful with 7 of the 8 abusive patients that I saw on the
spinal cord injury unit; the 8th patient was a person with multi-infarct dementia. The essential behavior on the part of nursing staff, when they were
abused, was to state, "That is abuse. I will return when you can behave appropriately." The nurse would then leave the room. Thus the antisocial
individual's desire for instrumental control was undermined.
In the above intervention, 1 took into account a number of conceptual
issues. One was to work within the client's worldview. In the us-and-them
battle for control, I helped the client to see that he was isolated and badly
outgunned (which was why we, the staff, had to present a united front). I
then offered him a potentially powerful allythe chief of staff of the hospitalwho was more powerful than the entire force against whom the client
was fighting. I validated the portion of the client's position that was reasonable (it was not right for him to have to wait an excessive length of time for
treatment). By telling him to complain, I implied that he had just cause. Of
course, it was not my call either way. If the client had asked me if I thought
he was rightwhich none ever didI would simply have shared this fact



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

12 7

Therapeutic Strategies and Tactics for the Prototypal Antisocial Personality
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
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.


At the time that he was seen by his therapist, Joe, a 25-year-old African
American man, was incarcerated on charges of murder and home invasion.
He was being held in secure custody, 23-hour lockup, in solitary confinement. At the time of the initial evaluation, Joe was extremely depressed. He
had attempted suicide by hanging himself using his bedsheet; it was accidental that he was found and cut down. His suicide attempt prompted the refer-



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.



Having established a working alliance, Dr. Castaldi set out to reframe

the client's behavior and his role in the power hierarchy of the prison subculture. He asked the client, "You're a smart guy, but you're always the one
getting pitched [put in solitary]. Why is that?" The client noted that others
would start up with him, and he "had to show them who's boss." The therapist wanted to challenge the client's concrete and short-sighted notions of
challenge and control and to highlight the consequence of getting "put in
the hole" over the momentary power of winning the fight. He took a bit of a
risk by using a confrontational and irreverent (Linehan, 1993) style. He stated,
"Oh, so you're the entertainment." Enraged, Joe terminated the session.
After about a week, however, Joe sent a message requesting another
session with Dr. Castaldi. Joe asked what was meant by the comment about
being the entertainment. Dr. Castaldi explained that some of the inmates
were intentionally, though indirectly, provoking Joe by sending others to
press his buttons. By responding predictably, Joe was turning over his power
and allowing himself to be used, that is, manipulated like a puppet. Joe could
not deny the accuracy of the description, and his worldview changed radically in that moment; he no longer wanted to dance to their tune. However,
it was not clear to Joe how he could save face. He was able to internalize that
not fighting was being strong and smart. This kind of "cost-benefit" analysis,
which involved evaluating actions in terms of his personal gain and loss, was
congruent with his personality style. He began to covet the instigator role
instead, seeing if he could get others to dance to his tune. In fact, he was able
to wrest some control in that manner. His fighting decreased substantially.
And because other prisoners were not as easily provoked or sadistic as Joe,
and were less damaging fighters, there was a dramatic reduction in the overall violence on the ward. Joe, working behind the scenes, gained power among
the inmates. At this time, the staff sergeant began to communicate with Joe
to get a feel for the emotional tone of the unit, which instigated a process of
inmates' respecting one another's areas of expertise and power. Once he was
no longer being sent to the hole and began feeling more in control, Joe's
depression and hopelessness dissipated.
Joe was now able to plan more effectively and think more abstractly.
True, he was using his skills to be manipulative, but he was doing so in a
manner that was causing far less social harm and personal distress. At this
point, Joe was looking forward to his sessions and consistently was waiting to
meet Dr. Castaldi at the appointed time.
Dr. Castaldi noted, in retrospect, that he began to feel narcissistic gratification from treating this case. He felt himself getting drawn into being
invested in certain outcomes, such as behavioral and attitudinal improvements. Here was this "impossible" client, with whom he was having astonishing "success." Other staff members in the prison were taking note of him,
and his prestige was rising. Suddenly, but inevitably, the therapist's prestige
on the unit was tied to Joe's behaviors. Subtly, this was shifting the dynamics


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
Dr. Castaldi:
Dr. Castaldi:


You know, I could kill you if I wanted to.

Yes, I know.
Does that intimidate you?
It would, but I know that you are working toward becoming a
better you, and that killing me would blow everything you've
worked toward, so that reduces my fear. If I'm frightened I can't
do my best work with you, so I really kind of let it go.
You said that so easily.

Dr. Castaldi:

Whether you can defeat me in a fight is not very important to

who I am. It's just the truth.


I've had to think about whether I could take someone or they

could take me every day of my life. I can't even imagine any
other way of thinking.

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

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.


Treating the person with antisocial PD starts with some extraordinary
challenges in establishing rapport, the difficulty of which is second only to
the treatment of clients with paranoid PD. Clients with both depression and
antisocial PD are usually somewhat more amenable to treatment because
they want some kind of change, and the therapist may be able to help. Extreme bluntness and an appeal to the client's self-interest while making modest
demands often suffice to establish a starting place; warmth and compassion,
central with treating other disorders, is usually an error with this population.
Synergistic and catalytic sequences for the person with antisocial PD
can then follow. Cognitive and behavioral strategies aimed at securing desirable consequences are usually a good place to start. Once the trust is established, interpersonal strategies may be useful. Psychodynamic approaches are
useful for conceptualization, and the skilled use of confrontation can be essential to success; it should be noted, however, that few individuals with
antisocial PD have much patience for the thorough efforts required in many
analytical approaches. As illustrated by the case of Joe, genuineness and transparency were keys to the client's breakthrough, as was an understanding of
the transference and countertransference.
Future research should focus on an empirical analysis of ways of establishing rapport in this population to validate the growing clinical lore on the
topic; many therapeutic interventions fail because they cannot get past this
first step. Brain research also seems to be a particularly promising avenue;
findings may lead to early intervention strategies or medication interventions. Finally, the empirical analysis of the arrangement and integration of
psychotherapeutic approaches, including synergistic and catalytic sequences,
requires further empirical investigation.


13 3

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


It is difficult to convey the emotional distress experienced by individuals with borderline personality disorder (PD). The disorder has the dubious
distinction of having the highest rate of suicidal and parasuicidal behavior of
any PD. Poetry and artwork can help to convey the anguish of those with the
disorder. The poem above is by a young woman who had borderline PD,
Brooke Bergan; she was in high school when she wrote it.1

'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."


This poem illustrates the severe emotional dysregulation, the "swirling

tornado" that consumes her, and the accompanying suffering, which she experiences or interprets as punishment. The fire produces burning (blackening) heat, but no light; it cannot push out the darkness. Fire and darkness
coexist within her, representing the split she feels. She experiences hate,
terror, and fearher anger cannot protect her and perhaps only increases
her feeling of vulnerability. In the end, everything is swallowed up by emptiness and the desire to end her pain through death. Her wildly fluctuating
emotions lead to relationship disruptions, fueling abandonment fears that
further her emotional dysregulation.
Borderline PD was described in the Diagnostic and Statistical Manual of
Mental Disorders (4th ed., text revision [DSM-IV-TR]; American Psychiatric Association, ZOOOa) as follows: "The essential feature of Borderline Personality Disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early
adulthood and is present in a variety of contexts" (p. 706)

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


community sample of 797 individuals, which included 143 individuals who

were diagnosed with PDs. Among individuals with borderline PD, 61.5%
met the criteria for depression. According to a literature review on the frequency of comorbid conditions with borderline PD, 24% to 87% of individuals with borderline PD have affective disorders as well (Shea, Widiger, &
Klein, 1992).
The reasons for depression among individuals with borderline PD are
self-evident, because they are partially incorporated into the definition of
the syndrome. Affective lability, which includes depressed mood, is one of
the criteria for borderline PD. Consistent with the "psychobiological" model
of the relationship between Axis I and Axis II, it may be that common biological factors partially underlie each disorder. The typical lifestyle of individuals with borderline PD only exacerbates the likelihood of depression.
They deeply desire love and affection, but their erratic and unstable behaviors practically preclude the possibility of stable attachments. Although alcohol and illicit drug use may temporarily stave off painful affect, both the
biological and psychological effects of substance abuse are depressogenic.
Interpersonal dependency issues can be related to intense feelings of helplessness, which leads to depression (Seligman, 1975); in addition, clinging
dependency can bum out relationships, leading to further distress. Individuals with borderline PD also have copious anger and rage, which can be directed against the self as a flood of recriminations (Millon, 1999). Thus borderline PD creates a vulnerability to depression, and further, each disorder
exacerbates the intensity of the other. It is also reasonable to speculate that
not only constitutional factors but also psychological events may predispose
a person to both borderline PD and depression. For example, there is a relatively high rate of sexual abuse reported by individuals with both disorders
(Danielson, de Arellano, Kilpatrick, Saunders, & Resnick, 2005; Freyd et al.,
2005; Swanston et al., 2003; Whiffen & Macintosh, 2005; Zanarini, 1997).2
Borderline PD plus depression is a particularly dangerous combination.
In one study, 92% of individuals with depression and borderline PD had a
lifetime history of at least one suicide attempt. This rate was significantly
higher than individuals with depression alone or with depression and a
comorbid Axis II diagnosis other than borderline. Approximately 31% of
the suicide attempts were rated as having a "severe" (e.g., cut throat) or "extreme" (e.g., coma) level of lethality (Friedman, Aronoff, Clarkin, Corn, &.
Hurt, 1983).

See chapter 2 for further discussion of theoretical models of relationships between Axis 1 and Axis II


13 7


Biological Factors
A number of biological factors have been shown to be related to incidences of borderline PD.

Borderline PD appears to be moderately heritable. In one study, a factor

labeled "emotional dysregulation," which corresponds to borderline PD, had
a heritability estimate of 52% (Jang, Vernon, & Livesley, 2000). Coolidge,
Thede, and Jang (2001), in their sample of children and adolescents, found
that the heritability of borderline PD is 76%. A study using the Dimensional
Assessment of Personality Pathology found that affective lability has a heritability of 38.4%, and identity problems have a heritability of 39.7%. Silk
(2000), in his review of the literature, estimated that the overall heritability
of borderline PD is approximately 50% (pp. 66-67).
Neurological and Neuropsychological Findings

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


able (e.g., physical or sexual abuse, which leads to neurological impairment).

At this time, there is insufficient evidence to answer the etiological question
definitively. The various models are not exclusive, and any or all of them
may be relevant in any given case.

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


ment with clozapine led to a dramatic decrease in self-injurious behavior

after failed attempts with various other medications (Chengappa, Baker, &
Sirri, 1995); similarly, a client with obsessive-compulsive disorder and borderline PD "improved considerably" with clozapine following failed attempts
with numerous other medications (Steinert, Schmidt-Michel, & Kaschka,
1996). Cagno (2001) reported a case in which there were decreased psychotic symptoms, improved treatment compliance, and an improved "sense
of purpose" (p. 344) in a client treated with quetiapine. Hilger, Barnas, and
Kasper (cited in Markovitz, 2004) reported on 2 clients whose self-injurious
behavior was eliminated at 6-month follow-up (Case 1) and 8-month follow-up (Case 2) following treatment with quetiapine. Self-injurious behavior was also reduced in 2 clients using olanzapine (Hough, 2001).
Group designs have also generally demonstrated improvements using
atypical antipsychotics. In an uncontrolled clozapine study with blind raters,
Frankenburg and Zanarini (1993) found that there were global improvements
in functioning and decreases in psychopathology. Chengappa, Ebeling, Kang,
Levine, and Parepally (1999) used clozapine with 7 female inpatients and
found decreases in self-mutilation, seclusion, use of as-needed anxiolytics,
and injuries to staff and peers; in addition, global functioning ratings increased substantially. Another clozapine study investigated 12 borderline PD
inpatients with severe psychotic symptoms; there were decreases in overall
psychiatric symptoms and depression and improved global functioning
(Bendetti, Sforzird, Colombo, Marrei, & Smeraldi, 1998). Parker (cited in
Markovitz, 2004) treated 8 severe borderline PD patients using clozapine;
hospitalizations were substantially reduced, leading to over $36,000 in reduced hospital costs per patient on average. Using risperidone with 15 borderline PD patients, Roca et al. (cited in Markovitz, 2004) demonstrated a
reduction in impulsive aggression and a 13-point improvement on the Global Assessment of Functioning. An 8-week study of 9 patients with olanzapine
demonstrated statistically significant improvements in many areas, including psychoticism, depression, interpersonal sensitivity, anger, global functioning, and overall symptomatology (Schulz, Camlin, Berry, & Jesberger,
1999). Bogenschutz and Numberg (2004) completed a randomized clinical
trial of olanzapine. Forty participants were evenly divided between the drug
and placebo conditions. Relative to the placebo condition, the olanzapine
group demonstrated improvements on borderline PD symptoms and clinical global impression; weight gain was noted as a side effect. Zanarini and
Frankenburg (cited in Markovitz, 2004) completed a double-blind, placebocontrolled study of olanzapine with 28 nondepressed women with borderline PD. Nineteen were assigned to the drug condition, and 9 were controls. The researchers found decreases in global symptoms and improvements
in global functioning. On the basis of his review of the literature, Markovitz
(2004) concluded, "There is a growing body of evidence to support the
efficacy of the atypical antipsychotics in decreasing impulsivity, aggresBORDERLINE PERSONALITY DISORDER


sion, self-injurious behavior, and affective instability in [borderline PD]"

(p. 93).
Soloff (2000) recommended conceptualizing the individual with borderline PD as having difficulties that lie along four dimensions: cognitiveperceptual problems, affective dysregulation, impulsive-behavioral dyscontrol,
and interpersonal psychopathology. Soloff constructed an algorithm of treatment recommendations on the basis of his comprehensive review of the literature. Cognitive-perceptual disturbances such as suspiciousness, paranoia,
and thought disorder are treated primarily with low-dose neuroleptics, switching to an atypical neuroleptic if the former has inadequate efficacy and adding an SSRI or monoamine oxidase inhibitor for affective symptoms. For
affective dysregulation, including depression, anger, anxiety, and lability, an
SSRI is the first line of treatment; a low-dose neuroleptic can be added for
anger, and clonazepam for anxiety. If these are insufficiently effective, other
medications to try include valproate, lithium, or carbamazepine. Impulsive
aggression, including bingeing and self-injurious behavior, is also primarily
treated with SSRIs, followed by lithium, monoamine oxidase inhibitors,
valproate, and carbamazepine, depending on the exact symptoms and response. The use of SSRIs for affective dysregulation and impulsivity was based
on the theoretical work (presented above) on serotonergic insufficiency in
people with borderline PD and other affective-behavioral dysregulation problems. Interpersonal psychopathology (problems in interpersonal relationships)
is not directly treated with medications (except as it is impacted by the other
three dimensions) and falls within the domain of psychotherapy (Soloff, 1998).
Others who reviewed the literature reached similar conclusions (Coccaro,
1998; Hirschfeld, 1997).
It should be noted that two studies have investigated the use of essential fatty acids as a form of treatment. Zanarini and Frankenberg (2003) did
an 8-week double-blind randomized trial of ethyl-eicosapentaenoic acid versus placebo with 30 women with borderline PD. They found that the supplements decreased aggression and depression. A randomized controlled trial of
essential fatty acids plus a vitamin and mineral supplement with 231 incarcerated young adults demonstrated that those in the active treatment group
were approximately 26% less likely to be reported for antisocial behavior and
had fewer rule violations than those in the placebo condition (Gesch,
Hammond, Hampson, Eves, & Crowder, 2002). These nutritional supplements are extremely low risk compared with medications and have had promising results; further investigation is warranted.
Although dramatic case studies are encouraging, it is not clear that the
newer medications lead to improvements that are, on average, much better
than those obtained with older medications. For example, Global Assessment Scale scores in Frankenburg and Zanarini's (1993) study of clozapine
yielded approximately a 12-point improvement (from 31 to 43), which is
similar to Soloff et al.'s (1989) 14-point improvement in their haloperidol


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

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


sion can be caused by constitutional factors or by childhood frustration. The

individual then defends against the aggressive impulses using splitting and
related defenses.
Splitting occurs in normal development as a way of experiencing the
positive and negative aspects of significant others in the environment. Newborns coo in the presence of a warm, loving mother and wail when the mother
is unable to immediately provide for their needs. In normal development,
children at some point integrate whole views of others, so they recognize that
the father who is nurturing at one time is still the same person as the one who
is withholding at another. However, when children have a massive excess of
aggressive libidinal energy, good internalized objects are at risk of being completely overwhelmed by negative object representations. In other words, if one
were to see the other person, say the mother, as a whole, she would be invested
with a massive amount of hostile, aggressive energy and a relatively small amount
of loving, nurturing energy and hence would be seen as essentially all bad.
Splitting, then, protects the fragile internalized good objects from being overwhelmed by the aggressive, malevolent bad object representations.
Splitting, being the primary defensive operation to cope with excess
aggression, elicits several other defensive maneuvers. Primitive idealization,
one side of splitting, occurs when external objects are seen as all good. Omnipotent control is overvaluation of the self and is related to devaluation,
which is deflation of others. As seen in chapter 3, this volume, on paranoid
PD, projective identification is a three-part process: (a) projection of an unacceptable impulse onto another while continuing to experience the impulse;
(b) viewing the individual onto whom the impulse is projected as under the
sway of the projected impulse, and thus frightening; and (c) attempts to control the person, often in a way that provokes the feared behavior. An example of projective identification is the client who repeatedly and with thinly
veiled hostility accuses the therapist of being angry with her; eventually, the
therapist does in fact become irritated and angry, "confirming" the client's
suspicions. Denial, according to Kernberg (see Yeomans, Clarkin, &. Kernberg,
2002), is not so much denial of the existence of a perception, thought, or
feeling but rather the splitting off of the emotion so that the phenomenon is
seen as emotionally irrelevant.
Kernberg (see Yeomans et al., 2002) recommended the traditional analytic techniques of clarification, confrontation, interpretation, and technical neutrality (placing oneself equidistant from the id, ego, and superego in
helping the client to resolve conflicts). The sine qua non of his treatment,
however, is analysis of the transference in the here and now; in fact, he recently labeled his therapy transference focused psychotherapy, Transference focused psychotherapy has been manualized to promote consistent use in different settings (Yeomans et al., 2002).
Masterson (1981) had a different perspective. Rather than emphasizing
the child's internalized aggression, he saw the primary problem as the mother's


"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


ings of abandonment (withdrawing part unit), further resistance (rewarding

part unit) and further confrontation, which leads in turn to further working
through" (Masterson, 1981, p. 137).
According to Masterson, borderline clients do not have transference in
the classical sense, because transference requires whole-object relations. Instead, they engage in transference acting out. The concept is similar to Freud's
repetition compulsion, in which events are repeated not in memory but in behavior. Just as the resolution to the repetition compulsion is interpretation,
which releases repressed memories, the resolution to transference acting out
is confrontation in the transference, which brings awareness of the meaning
of the behavior. This allows the client to increasingly perceive the therapist
as a whole object, which permits working through. As Masterson stated, "The
more he invests in the therapist as a real object, the more he turns to therapy
to work through his feelings of abandonment rather than to the rewarding
unit/pathologic ego alliance to relieve them" (1981, p. 151).
Masterson's and Kernberg's conceptualizations are similar in a number
of ways, especially in the area of technique. Both emphasize confrontation,
especially confrontation of the transference, as the path to resolution of borderline psychopathology. Both use rather traditional psychoanalytic techniques (e.g., technical neutrality). The main differences are their etiological
assumptions, with Kernberg emphasizing excess aggression and Masterson
emphasizing maternal unavailability.
Cognitive-Behavioral Conceptualization and Interventions
Cognitive-behavioral therapy for borderline PD is built primarily on
the notion that people who have the disorder are prone to a variety of beliefs
that are then logically related to their emotions. The acquisition of these
beliefs and behaviors is generally thought to follow the principles of social
learning (e.g., Bandura, 1977), reinforcement (e.g., Skinner, 1953), and associational learning (e.g., Pavlov, 1963). The relationship that is encouraged between client and therapist is that of teacher and student who engage
in "collaborative empiricism" to shine the light of reason on the client's potentially irrational beliefs.
Young's (1987) work with schemas, originally labeled "schema-focused
cognitive therapy" (see also A. T. Beck & Freeman, 1990) and now known
as "schema therapy" (Young, Klosko, & Weishaar, 2003) examines typical
beliefs held by people with PDs, including borderline PD. Young explicated
typical beliefs that persist in people with borderline PD. By educating clients
about schemas, the therapist can align with the client against the maladaptive schema. Examples of schemas that typify borderline PD are listed in
Exhibit 7.1.
Beck and his associates (A. T. Beck & Freeman, 1990; A. T. Beck,
Freeman, & Davis, 2004) have argued that dichotomous (all-or-none) thinking plays an important role in borderline PD pathology. The phenomenoBORDERLINE PERSONALITY DISORDER


Maladaptive Ways of Thinking Learned in Early Childhood
by People With Borderline Personality Disorder
Early maladaptive schemas
Emotional deprivation
Undeveloped self
Insufficient self-control/selfdiscipline

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
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
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)


People with borderline PD are also likely to have intense emotional

reactions that appear to be highly inappropriate to the situation. The structured, task-focused nature of cognitive-behavioral therapy tends to minimize what analysts would call "transference" with most clients; however, individuals with borderline PD are likely to have strong emotional reactions
that are not a direct function of the therapist's behavior. From a cognitivebehavioral perspective, transference can be viewed as stimulus generalization from a previous relationship to the current one, or, as A. T. Beck and
Freeman (1990) rioted, applying previously held general beliefs rather than
responding to the therapist as an individual. The therapist must be prepared
to help the client to unpack the meaning of these intense reactions based on
prior experiences and strongly held beliefs.
Other aspects of borderline pathology also interfere with the development of a productive cognitive-behavioral therapeutic relationship. Identity confusion interferes with setting goals, because the individual often experiences rapidly shifting agendas. The fear of intimacy can provoke
discomfort, premature termination, or acting out even with the modest intimacy typically seen in cognitive-behavioral therapy. Fear of and anticipation of rejection can lead to premature termination.
The establishment and continued maintenance of a positive therapeutic relationship provides the context in which the client can be provided
with skills training in particular areas of deficit (such as assertiveness and
other relationship skills) and encouraged to engage in behavioral experiments.
The goal is to persistently identify the client's beliefs, particularly those that
may be distorted or irrational, and challenge these beliefs against reality.
Dialectical Behavior Therapy Theory

Perhaps it is fitting, given the paradoxical nature of borderline PD, that

a treatment developed specifically to address it is, in its essence, designed to
address paradox. According to Linehan (1993), dialectical behavior therapy
is so named because Linehan saw the principal issues involved in borderline
PD as the resolution of diametrically conflicting tendencies (thesis and diathesis) that must be brought to resolution (synthesis). Drawing on Zen Buddhism, Linehan viewed the synthesis as transcending the rational, similar to
a Zen koan (paradox). The resolution to the polarities, rather than a rational
solution, is an experience. The prototypical dilemmas are explained below.
The Invalidating Environment. Before attending to the polarities underlying Linehan's model, it is important to address critical developmental
precursors to borderline PD. One, according to Linehan (1993), is the "invalidating environment." Invalidation indicates that significant others are
sending messages that one's feelings, thoughts, and perceptions are not real
or do not matter. Such invalidation, according to Linehan, can contribute to
the development of borderline PD. Examples include the girl whose interests
in mechanical pursuits do not fit society's gender stereotyping and who is


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


dysregulation is largely biological, whereas its counterpart, self-invalidation, is

predominately learned.
Self-invalidation indicates a tendency on the part of the individual to
respond with shame, guilt, and intropunitiveness to environmental stimuli.
Often, self-invalidation leads to depression. The combination of emotional
vulnerability and self-invalidation leads to a vicious circle for clients. Unable to internally regulate their emotions, they turn to others to help stabilize their emotions. However, the extreme emotions of the person with borderline PD are beyond the empathic scope of the typical friend and even of
many therapists. Isn't it natural enough, for example, if the individual is literally suicidal over a breakup with a lover of a few months, to say, "C'mon,
now, pull yourself together, there are lots offish in the sea," and so on? When
the individual repeatedly fails to respond to typical reassurances, others often get burnt out; frustrated; and, ultimately, rejecting. This pattern, noted
in depression under the rubric of "excessive reassurance seeking" (see chap.
3, this volume), is exacerbated in the case of the person with borderline PD,
who finds such responses powerfully invalidating. Although the helper may
be attempting to convey the message, "You're fine, you just need some perspective," the message received is, "My feelings don't count, my reality is not
real to you, you don't understand how bad I feel." The person with borderline
PD may then make an extreme gesture, such as a suicide attempt, out of
desperation ("I feel terrible and no one can help me") or in an effort to prove
the severity of his or her despair ("You didn't think 1 was desperate, but I
really was"). Thus, attempts to regulate emotions generally lead to further
invalidation. The dialectical dilemma for clients, then, given their tendency
toward black-and-white thinking, is to vacillate between recognizing their
emotional vulnerability (thereby blaming others for their lack of understanding) or believing the messages from the invalidating environment ("You are
fine, you just need to pull yourself together") and feeling guilty, shameful,
and inadequate. Simultaneously, the therapist finds that it is difficult to avoid
invalidating the patient. Linehan (1993) gave a number of examples:
Common instances of invalidation include the therapist's offering or insisting on an interpretation of behavior that is not shared by the patient;
setting firm expectations for performance over what the patient can (or
believes she can) accomplish; treating the patient as less competent than
she actually is; failing to give the patient the help that would be given if
the therapist believed the patient's current perspective to be valid; criticizing or otherwise punishing the patient's behaviors; ignoring important communications or actions of the patient; and so on. Suffice it to
say that in most therapy relationships (even good ones) a fair amount of
invalidation is common, (p. 76)

Predictablythough uncomfortably, for the therapistthe patient responds to the invalidating (therapy) environment with anger, depression,


anxiety, or avoidance (including suicide attempts or dropping out of therapy).

The patient can feel invalidated whether the therapist is aiming for change
or for acceptance:
In reviewing how a particular interaction went wrong or why some goal
was not reached, if the therapist in any way implies that the patient could
improve performance the next time, the patient is likely to respond that
the therapist must be assuming that the patient has been wrong all along
and that the invalidating environment is right.... On the other hand, if
the therapist uses a non-change oriented tacticlistening to the patient
or sympathetically validating the patient's responsesthen the patient
is likely to panic at the prospect that life will never improve. (Linehan,
1993, p. 77)

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


her vulnerability clearly because he or she has learned to inhibit emotional

expression as a form of coping, and (c) variations in competence based on
perceived support (when people with borderline PD are with a supportive
individual, or believe they are in a secure, supportive relationship, they do
relatively wellwhich means that they will function deceptively well during therapy sessions). A leading advocate for people with borderline PD shared
a story that illustrated the phenomenon of apparent competence perfectly.
She was in her office, where a woman with borderline PD, who happened to
be a physician, was raging at her. In the midst of the outburst, the physician's
pager went off. She calmly went to the phone, called the hospital, and gave
advice and a prescription for her patient. She then hung up the phone and
resumed her tirade (V. Porr, personal communication, May, 28, 2003). Certainly, one could understand why many observers would conclude that the
rage was not real or was put on for effect. However, according to Linehan's
theory, such an interpretation would be in most cases both inaccurate and
harmful. Rather, the individual with borderline PD exhibited apparent competencethe skills she had acquired to remain calm and cool in her role as
physician did not: generalize to her interpersonal role with the advocate. In
fact, she was in a state of substantial emotional dysregulation. Unfortunately,
then, this apparent competence leads to a vicious circle, in which incompetence is seen by others as a lack of effort, "playing games," or manipulation;
because this interpretation is different from the client's viewpoint, it perpetuates the invalidating environment.
The dialectical dilemma for clients on this polarity is that to the extent
they have difficulty regulating their own emotions and thus rely on others,
the more ashamed they feel, because of our independence-oriented, dependency-shunning culture. Therefore, individuals attempt to inhibit their emotional responses, thus perpetuating the myth that they are able to regulate
their emotions just like anyone else. When they inevitably fail to control
their emotions, they swing from guilt (because they failed) to anger (because
others do not understand). In either case, emotional dysregulation ensues,
including extreme attempts at regulation (such as suicide attempts). The
dialectical dilemma for therapists is that if they see only the client's competence, they will invalidate his or her true skill deficits. Further, by aligning
themselves with the apparent competence they risk attributing failures to
"resistance," which can undermine the therapeutic relationship. Alternatively, if the therapist aligns excessively with the active passivitywhich is
easy enough to clo by simply empathizing with the clientthen the client
will not optimally improve; the therapy may even become paralyzed. The
best solution is to flexibly alternate support and challenge, going back and
forth, in many cases, within a single session.
Unrelenting Crisis Versus Inhibited Grieving. People with borderline PD
tend to go from one crisis to the next. Linehan (1993) explained this as
being caused by a combination of low stress tolerance and poor coping skills.

J 53

An initial problem may leave the person feeling overwhelmed; he or she

then is unable to resolve the problem sufficiently. This emotional state makes
further problems more overwhelming, leading to yet another crisis. This process becomes a vicious circle of unending crisis and feelings of desperation.
Inhibited grieving "refers to a pattern of repetitive, significant trauma and loss,
together with an inability to fully experience and personally integrate or resolve these events" (Linehan, 1993, p. 89). Studies show that approximately
two thirds to three quarters of people with borderline PD have a history of
being abused sexually; thus, a majority of people with borderline PD are coping with trauma-related symptoms (Linehan, 1993, pp. 52-53). The problem, as Linehan saw it, is that these individuals are unable to regulate their
emotions well enough to handle normal grieving; if they were to process the
loss they would "fall apart." The person with borderline PD fears processing
emotions that were so overwhelming that he or she would become dysfunctional (e.g., curl up in a fetal position for hours)and has, most likely, experienced such emotions. Therefore, like many people with posttraumatic stress
disorder, the individual avoids contact with any reminders of the stressors,
both external and internal. This strategy is only partially successful, because
reminders are common in the environment (especially in interpersonal relationships), and mental representations based on the traumatic events influence many aspects of the person's life. What unfolds, then, is a chronic, partial grieving, with frequent emotional dysregulation. I recently supervised an
evaluation of a case in which a client with borderline PD and a history of
severe physical abuse (e.g., broken bones) described her experience with psychodrama treatment. As she relived and reexperienced her past, she became
so anxious that she felt persistent panic and feelings of desperation. The
ensuing panic disorder created significant disruptions in her functioning and
required a variety of psychological and pharmacological interventions. Thus,
in working through a traumatic past, the person with borderline PD may
require substantial support to avoid an intolerable worsening of symptoms.
The dialectical dilemma for clients is that they cannot avoid exposure
to loss and trauma cues because there are too many (e.g., aspects of many
relationships are partial reminders of abuse experiences). Further, they cannot inhibit their grief reactions indefinitely as they go from crisis to crisis.
Their efforts to escape feelings of emptiness and desperation, such as drinking, speeding, unprotected sex, and so on, provoke further crises. Their coping strategies lead to a vicious circle of mood swings and impulsive behavior.
The dialectical dilemma for the therapist, on the other hand, is, as noted by
Linehan (1993), to
balance his or her response to the oscillating nature of the patient's
distresssometimes expressed as acute crisis and overwhelming affect,
and at other times presented as complete inhibition of affective responding. An intense reaction by the therapist at either extreme may be all
that is needed to push the patient to the other extreme, (p. 93)


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
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


to become angry and rejecting in return, reinforcing clients' sense that

there is something fundamentally poisonous about their existence.
Clients who continue to express their feelings are likely to have ongoing
volatile relationships or a succession of relationships that start out well
and then go sour. If, on the other hand, they give up on connecting or
expressing their personal reactions they are likely to feel frozen or dead
inside. Many alternate, holding in their reactions while feeling increasingly uncomfortable and then exploding with rage at those around them,
(p- 152)

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)

So what is the proper intervention for persons with fragile process?

Warner (2000) stressed that it is essential to try to understand them from
their own perspective. One error that therapists frequently make with people
in general, and especially those with fragile process, is to assume that they
have words for their feelings. Often, they do not. People with fragile process
often act out their feelings (e.g., by taking drugs, self-mutilating, or attempting suicide). If clients are struggling for words, therapists need to support
them through it and avoid the temptation to guess or hypothesize about their
feelings. A comment such as "something about that feels uncomfortable, but
you're not quite clear what it is" is often effective and will allow the person
with fragile process to continue to explore his or her experience (Warner,
2000, p. 153). If the therapist fills the space by putting words into the person's
mouth, the client will often feel misunderstoodthis being the core problem for people with borderline PD.

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


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

especially powerful if the client is a victim of incest or sexual abuse. As noted

above, abuse victims pull for powerful rescuer fantasies on the part of the
therapist and for special treatment; in the context of multiple boundary transgressions, the risk of sexual acting out increases (Gabbard &. Wilkinson, 1994).
Empirical research is fairly consistent with the clinical observations
described above. The responses of therapists and therapists-in-training to
video vignettes of individuals with borderline PD have indicated that the
participants felt interested (curious, amused, fascinated) and angry (frustrated,
irritated, exasperated), as well as "disconnected" and "sad" and experienced
"compassion." Participants also mentioned "leaning back" body language.
Herein we can see the ambivalence of therapists. The data can be interpreted in one of two ways: Either some therapists had positive feelings (interested, compassionate) and others had negative ones (angry, disconnected),
or participants had mixed reactions to the highly variable presentations portrayed in the vignettes. Either way, the ambivalence is notable in the countertransference, even based on brief (5- to 10-minute) presentations (Bockian,
2002a; see chap. 1, this volume, for additional details of the study). An empirical study of 155 psychotherapists' (3-27 years of experience) reactions to
an audiotaped interview with a client with major depression or borderline
PD demonstrated that the clients with borderline PD were seen as more dominant and hostile, whereas individuals with major depression were perceived
as more submissive and friendly; participants also saw individuals with major
depression as being more likely to benefit from treatment and more likely to
have a positive outcome. Brody and Farber (1996) studied 336 therapists'
responses to written clinical vignettes of individuals with borderline PD, depression, and schizophrenia. Borderline PD was associated primarily with a
negative countertransference, including feelings of irritation, frustration, and
anger and lower ratings of liking the client in the vignette; on the positive
side, consistent with the Bockian (2002a) study, therapists were as interested
in the clients with borderline PD as they were in the clients with depression
and schizophrenia. Holmqvist (2000) performed a study of 143 patients and
124 staff, generating 3,605 feeling checklists. Borderline personality organization (O. F. Kernberg, 1975), a construct related to borderline PD, was related to increased aggressive feelings and decreased relaxed feelings in staff.
Thus the small but growing empirical literature is validating the clinical literature demonstrating that themes of hostility, irritation, anger, and frustration are important; further empirical work is needed to investigate themes
such as boundary violations, rescuer fantasies and behaviors, helplessness,
and hopelessness.


Borderline PD appears to be increasing in frequency. This may be explained, in part, by clinicians' increasing awareness of Axis II disorders and


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


world of diffuse values and standards, or one in which parental precepts

and norms have been discarded, the impact of these "substitute" prototypes is especially powerful, even idealized and romanticized. And what
these characters and story plots present to vulnerable youngsters are the
stuff of which successful half-hour "life stories" must be composed to capture the attention and hold the fascination of their audiencesviolence,
danger, agonizing dilemmas, and unpredictability, each expressed and
resolved in an hour or lessprecisely those features of social behavior
and emotionality that come to characterize the affective and interpersonal instabilities of the [person with borderline PD]. (p. 365)

Another phenomenon pervading American culture that encourages the

development of borderline personality behaviors is the "empty self." According to Cushman (1990),
It is a self that seeks the experience of being continually filled up by
consuming goods, calories, experiences, politicians, romantic partners
and empathic therapists in an attempt to combat the growing alienation
and fragmentation of its era. This response has been implicitly prescribed
by a post-World War II economy that is dependent on the continual
consumption of nonessential and quickly obsolete items and experiences,
(pp. 600-601)

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.


From any theoretical orientation, both the poem presented at the beginning of this chapter and the one below illustrate the intense suffering of
people with borderline PD. However, it is equally clear that the poems and
artwork presented in this chapter are the products of exceptionally sensitive
and intuitive individuals. As clinicians, we tend to focus on psychopathologyfinding out what is wrong so that we can help fix it. However, there is
a growing movement to more fully integrate "positive psychology" (Seligman
& Csikszentmihalyi, 2000) into our formulations. To ignore the power of the
human spirit; the resiliency within all people; and, perhaps above all, the
power of love, would be to paint only half the picture. We must fight within
ourselves the tendency to split away and disregard the strengths that exist in
these admittedly highly vulnerable individuals. The following poem is an
illustration of the power of love between mother and child. According to the
poet, Lauren Fechhelm (personal communication, December 11, 2002), the
angel is her mother, who stayed with her and saw her through a terrifying
psychotic episode.


The Face of an Angel

When tough times set in, you were by my side.
I know my agony broke your heart. . .
And when you thought things were getting better,
1 told you 1 did not want to live.
But you did not want to believe,
You would not believe,
Because you could not bear to see me in pain again.
Despairing, you still comforted your sobbing child . . .
Because you were my angel.
Demons swirled about my head
and skeletons danced on my bedbut you stayed.
And I was ashamed.
To you I owe my life,
My sanity,
And my dignity.
And thanks to you I will do great things with my life.
A life that I once thought would never be.
How can I ever repay you?
1 will find a way, because when I look at your face,
I see the face of an angel. (L. Fechhelm, personal communication, 2001)

Is the angel-mother the "idealized part-object?" Is there evidence of

"poor differentiation" in the poet's difficulty being separated from her mother?
Perhaps. But what is more important is the universal human quality of the
experiencethe experience of love, gratitude, and triumph over severe adversity. This poem stands as a reminder of the strength and love that can
exist in these families, love strengthened rather than weakened by shared
The therapist must first establish a working alliance with the person
with borderline PD, which can entail significant challenges. Millon (1999)
recommended starting with a supportive, nonconfrontational approach, using behavioral approaches to make some initial gains. Linehan (1993) and
O. F. Kemberg et al. (1989) emphasized providing appropriate structure. Once
rapport is established, behavioral interventions can be combined with medications if anxiety or depression are relatively severe. Cognitive interventions
can help reduce irrational beliefs. Millon (1999) then recommended considering group and, later, family approaches to further enhance the client's interpersonal functioning.
Treatment planning should attend to tangibly addressing the client's
distressing symptoms. For example, an objective might be for the client to
"report a reduction in feelings of emptiness and depersonalization"; appropri162


Therapeutic Strategies and Tactics for the Prototypal Borderline Personality
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
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.

ate therapeutic interventions for this problem include mindfulness exercises

such as "teach the client to increase his/her body awareness through an assigned exercise" and "explore aspects of the client's life that provide a sense
of meaning, purpose, or mission" (Bockian & Jongsma, 2001, pp. 84, 90).
The therapy should have a persistent theme of attending to the client's underlying ambivalence, reflected in the conflicts in Millon's (1999) three polarities (see Exhibit 7.2).


The following is a synopsis of a case that I have discussed in greater
detail in an earlier work (Bockian, 1994). Doug was 42 years old when I saw
him on a spinal cord injury long-term rehabilitation unit. He was a Caucasian male of German and Irish background. A substance abuser at age 12, he
left home at 16 and was addicted to heroin by age 18. He had spent 9 of the
11 years before I saw him in prison on a variety of charges related to a drugaddiction lifestyle (e.g., theft, assault, drug sales, and possession of illegal
weapons). He had a long history of depression and suicide attempts. After
falling off a railing, he sustained a spinal cord injury between the 6th and 7th
cervical vertebrae; he thus had approximately 50% use of his arms, limited
use of his fingers, and complete paralysis below the chest.
The main problem that led to Doug's referral was verbal and physical
abuse toward staff. He was also dangerously noncompliant with hospital rouBORDERLINE PERSONALITY DISORDER


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


ample, in a family with young children, the parents need to be in charge,

setting rules and guidelines. Family pathology can undermine this framework; for example, in families in which one or both of the parents is an alcoholic, the oldest child is often "parentified," or given responsibilities (such as
getting the younger children fed and off to school) that are ordinarily reserved for parents. Because parentified children lack full parental authority
and, because of their youth, typically lack adequate parenting skills, systems
that contain parentified children are generally chaotic. In this case, I conceptualized issues of boundaries and hierarchy as central to the difficulties
that were occurring. As alluded to above, nurses were functioning almost as
"parentified children," given responsibilities to care for the client but inadequate power to effect necessary changes; further, lacking adequate mental
health training, they were not equipped to deal with this complex client's
abusive behavior. I believed that it was necessary to provide the nurses with
the tools they needed to handle the abuse problem and to have the treatment team give them the support they needed. I applied to the central administration of the hospital to institute a "zero tolerance for abuse" policy,
which was passed quickly. This provided institutional support for the next
intervention, which was to have nurses inform an abusive client (specifically
Doug, in this case) that if he was abusive the nurse would inform him that his
behavior was abuse and leave the room. Simultaneously, we instituted a behavioral contract that specified consequences for problematic behavior (e.g.,
abuse and smoking behavior).
Within a week or two, Doug's problematic behavior had dropped from
30 episodes a month to about 4, and even the episodes that did occur were
less problematic. There was no abusive behavior, and the occasional treatment refusals were more appropriate and less a function of acting out. By the
end of 2 months, when he was discharged, he was on such good terms with
the nurses that he bought them pizza to thank them for their care for him.
The staffs emotional reaction to him, of course, changed substantially, with
most having a positive feeling for him. After the abusive behavior stopped, I
also felt more positive, with feelings of respect, amusement (he could be
quite funny), and compassion (he had some difficult situations to confront)
being most prominent.
Culturally, the most relevant factors were not his gender or Euro-American origins but rather prison culture. His refusal to comply with hospital
routines symbolized his tenacious refusal to accept subordinate status. In
prison, accepting subordinate status entailed a variety of forms of physical,
mental, and sexual abuse that Doug, understandably, fought off. Using cognitive techniques, I was able to help Doug process the nature of his inappropriate generalization from prison culture to hospital culture.
In sum, then, in this case I identified vicious circles and problematic
interactions, conceptually guided by personality constructs (borderline and
antisocial). Initially, I used a combination of behavioral and family techBORDERLINE PERSONALITY DISORDER


niques to help bring a chaotic situation under control. Afterward, aware of

culturally relevant factors, I was able to discern some of the motives for the
client's behavior, and challenge them using cognitive-behavioral therapy.
From a personality-guided therapy perspective, what is notable in this case
are the synergistic and catalytic sequences of interventions, guided by the
personality dynamics of the client, and the interpersonal sequelae thus entailed. One area that would have been worth exploring, in retrospect, was
Doug's neuropsychological status. It is likely that he had neuropsychological
deficits, whether he was born with them or acquired them through violence,
substance abuse, or head trauma (e.g., the fall that broke his neck). Such
factors may have contributed to misperceptions, poor judgment, and impulsivity. Although there was a good outcome in this case, knowing his neuropsychological status could have helped us to fine-tune his postdischarge adjustment through both rehabilitation and disability accommodation. Further, one
of the biggest problems Doug had is that for many years he had been treated as
someone with antisocial PD when really he primarily had borderline PD. Discriminating between the two disorders, by understanding the reason for the
acting-out behavior, was very important in optimizing treatment. Consistent
with the major tenets of this chapter, correctly identifying Doug's primary personality pattern led to appropriate and attuned interventions. Doug was labile and impulsive. In my experience, those who viewed him as callous and
manipulative related to him poorly and were not helpful; conversely, in a
case of "pure" antisocial PD, failing to identify the client's manipulations can
be highly problematic and can undermine the relationship.


Treating depression in the context of a person with borderline PD is a
significant challenge. The characteristic style of the individual interferes with
the therapeutic relationship unless active measures are taken to promote an
appropriate one. Leading psychodynamic theorists (Clarkin et al, 1999) and
cognitive-behavioral/dialectical behavior therapists (A. T. Beck et al., 2004;
Linehan, 1993) have agreed that providing structure (e.g., on ways to handle
session length, session frequency, billing, suicidal behavior, etc.) is one of
the keys to success with this population.
Personality-guided therapy principles indicate that catalytic sequences
of interventions will be most effective. Linehan's (1993) integration of cognitive, behavioral, and mindfulness strategies is a good illustration of this
principle. In the case illustration, the arrangement of interventions in a manner that provided a sense of safety"family" interventions to create appropriate boundaries followed by interpersonal strategies to enhance relationships and cognitive strategies to challenge Doug's erroneous beliefsled to
substantial change in a relatively brief period of time.


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.




As the name of the disorder suggests, histrionic features abound in

the world of theater and film. The exaggerated behaviors of actors and
actresses on talk shows and in other venues generally illustrate subclinical
and healthy-range histrionic features. In most cases, people are amused and
entertained by their antics, thus illustrating the more positive aspects of
such characteristics. Most television shows, with their 30- or 60-minute
formats; brief, dramatic confrontations; and artificially rapid problem resolutions are veritable instruction manuals on how to have a histrionic personality disorder (PD).
In its more severe form, histrionic PD is often painful to individuals,
especially as they approach and surpass middle age. The emotional roller
coaster, the lack of stable relationships, and the unfillable craving for attention wear on them. As they age, the once charming and seductive flirtations
become less effective and are at times even grotesque. The character Blanche
DuBois, from the play A Streetcar Named Desire (T. Williams, 1953/1974),
illustrates some of the more tragic aspects of histrionic PD. Her attempt to
create an illusion based on appearances ultimately failed, whereas a simpler,
more honest approach may have allowed her to develop the relationships she

desired. Her history of seductiveness led to her inability to hold on to her

teaching position. Her instrumental incompetence (e.g., mismanaging the
family fortune) and life strategy"I have always depended on the kindness
of strangers"contributed to her tragic demise. The following scene illustrates Blanche's inappropriate seductiveness with Stanley, her sister's brutish
husband. Stanley believes that Blanche has inherited money that she is hiding from him.

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.


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.]


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.


Histrionic PD has been defined in the Diagnostic and Statistical Manual
of Mental Disorders (4th ed., text revision [DSMIVTR]; American Psychiatric Association, ZOOOa) as "a pervasive pattern of excessive emotionality
and attention-seeking behavior" (p. 711). The individual with histrionic PD
tends to be dramatic, seductive, and flirtatious. The individual often is shallow, focusing on superficialities; a heterosexual woman with histrionic PD
may describe the type of car a man drives, the way he wears his hair, or the
way he dresses rather than his personal qualities as critical elements in a
Depressed persons with histrionic PD express their depressive symptoms in dramatic terms. Another notable phenomenon is that with their
rapidly shifting emotions, individuals with histrionic PD may be in tears one
moment and then, when discussing a new topic, seem fine. This should not
be misconstrued as faking depression to attain sympathy in a manipulative,
conscious way. Typically, they are genuinely experiencing distressing sadness. The easy distractibility and quasi-dissociative inner experience of persons with histrionic PD, however, make it possible for them to isolate affects
within the session. If the therapist guides the topic back to the distressing
material, the depressive affect reliably reemerges.



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


People with histrionic PD become depressed for a variety of reasons.
Interpersonal rejection is extremely difficult for most people with histrionic
PD to take. Their flightiness and shallow object relations mean that their
depression may be short-lived if they can find another relationship, which
entails a risk of premature termination of therapy. Millon (1999) noted that
dysthymia among individuals with histrionic PD is often associated with their
feelings of inner emptiness; extremely other-oriented, individuals with histrionic PD experience a sense of aimlessness and purposelessness when inbetween relationships with others. Given that the rates of depression appear
to be higher for individuals with histrionic PD than in the general population, it appears that histrionic PD creates a vulnerability to depression (see
chap. 2, this volume, for further discussion of theoretical models of the relationship between depression and Axis II disorders).




Biological Factors
According to Cloninger (1987), histrionic PD would be described as
involving high novelty seeking, low harm avoidance, and high reward dependence. High novelty seeking is related to complex interactions among
dopaminergic systems within the brain. Noted Cloninger (1998),
Mesolimbic and mesofrontal dopaminergic projections have been shown
to play a crucial role in incentive activation of each aspect of novelty
seeking. Dopamine depleting lesions in the nucleus accumbens or the
ventral tegmentum lead to neglect of novel environmental stimuli and
reduce both spontaneous activity and investigative behavior. (Cloninger,
1998, p. 71)

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.

The heritability of histrionic PD appears to be similar to that of other

PDs. Coolidge, Thede, and Jang (2001) found a heritability of .79 for histrionic PD in their study of child and adolescent twins. A meta-analysis by
McCartney, Harris, and Bernieri (1990) showed a higher interclass correlation for monozygotic twins (.51) than dizygotic twins (.19) on a measure of
the normal trait, sociability. Livesley, Jang, and Vernon (1998) found that
the Dimensional Assessment of Personality Pathology measure of affective
lability, a dimension relevant in many people with histrionic PD, had a heritability of 38.4%. DiLalla, Carey, Gottesman, and Bouchard (1996) found
the following heritability on Minnesota Multiphasic Personality Inventory
scales, which are partially related to the histrionic PD prototype: Hysteria:
26%; Masculinity/Femininity: 36%; Hypomania: 55%.

To my knowledge, the only empirical study that specifically addressed

the use of medications with individuals with histrionic PD was Ekselius and
von Knorring's (1998) uncontrolled trial of the selective serotonin reuptake
inhibitors sertraline and citalopram (see chap. 1, this volume). The study
had mixed results. In the citalopram group, 8 of 13 individuals with histri172


onic PD in their sample (61.5%) achieved remission after 24 weeks of treat'

ment, which was statically significant; however, in the sertraline group, only
1 of 9 achieved remission, a statistically nonsignificant decrease. Both the
sertraline group and the citalopram group had a mean decrease of 0.2 criterion pre- to posttreatment, which was statistically nonsignificant. Unfortunately, because there was no medication-free comparison group, the results
of the study are inconclusive.
In the absence of further scientific data, it is worthwhile to consider the
conceptualization provided by Joseph (1997) on the basis of clinical observation. He argued that there are three symptom clusters that respond to medications that are relevant to histrionic PD. The first is the individuals' heightened emotional sensitivity, sensitivity to rejection, and irritability. These
symptoms, he asserted, respond to serotonergic antidepressants venlafaxine,
or nefazodone. (For the depressed person with histrionic PD, selective serotonin reuptake inhibitors can serve a dual purpose.) The second symptom
cluster relates to the high energy level and scattered presentation of people
with histrionic PD, conceptualized as hypomanic symptoms; appropriate
medications are mood stabilizers such as lithium, valproate, or carbamazepine.
Finally, the proclivity of individuals with histrionic PD to jump from topic to
topic and their lack of focus may be neurologically related to attention deficit disorder. In such cases, stimulants (e.g., methylphenidate) or bupropion
would be indicated. Joseph's (1997) observations, though insightful and rational, must be backed by science. Empirical studies leading to randomized
clinical trials are necessary to verify the appropriateness of various medications for histrionic PD.
Psychological Factors
Millon's Theory
According to Millon's (1996) tripolar model, histrionic PD represents
the "active-dependent" prototype. Unlike the passive-dependent type (dependent PD), who waits and hopes for attention and nurturance, persons
with histrionic PD demand attention. They use a variety of tools and strategies, including energy and charm on the positive end to demandingness and
melodrama on the more negative end, to obtain the attention they crave.
In terms of their presumed pathogenic background, Millon (1981) noted
that the child is born with an active temperament and is likely to engage
energetically with the environment. Parents and other significant figures reward the child for performing and may discourage instrumental competence.
The child is rewarded for being charming, engaging, and cute. Thus the child
learns to derive nurturance and support by performing for others.
A description of the histrionic prototype in terms of Millon's domains
is given in Appendix B. Fickle mood and attention seeking are the most
prominent features of the disorder.


Cognitive-Behavioral Conceptualization and Interventions

Individuals with histrionic PD are prone to hold a number of different
beliefs that are associated with their dramatic yet dependent behaviors. They
may have automatic thoughts such as, "I want him to notice me," and "I'm
bored!" Intermediate beliefs would include, "Unless I am the center of attention, it is awful," and "I will only do something if it's fun." A. T. Beck, Freeman, and Davis (2004) noted the underlying core belief, "I am inadequate
and unable to handle life on my own" (p. 225). This belief and many of the
corresponding intermediate beliefs and automatic thoughts are depressogenic
as well. In addition, confusion about their identity may emerge in thoughts
such as, "As long as I do what I feel like doing in the moment everything will
be fine," and, perhaps most important, "I don't mind, I'll just go along with
what everyone else wants to do." Identity confusion is often emotionally
painful and can contribute to depressed mood.
Such individuals often engage in emotional reasoningthat is, believing
that a feeling is strong evidence that something is true. For example, depressed individuals with histrionic PD may be prone to thinking, "If I feel
like a failure, then it means that I am a failure." DSM-IV-TR described their
thinking as "global and impressionistic"; in cognitive terms, this indicates
that they are likely to make the error of overgeneralization. For example,
they may see one rejection as evidence that they will always be rejected.
Similarly, individuals with histrionic PD are prone to dichotomous thinkingfor example, seeing others as "good" or "rotten."
The client needs to learn to challenge these beliefs. Socratic dialogue
and thought records can be helpful to persons with histrionic PD, helping
them to relate their feelings to their thoughts. The capacity to think clearly,
logically, and persistently is a great gift that cognitive therapy can offer the
often flighty or disjointed person with histrionic PD. Of the behavioral techniques, assertiveness training can be especially helpful in countering manipulative behaviors (such as tantrums) and in helping the individual to know
his or her genuine needs. Problem-solving skills can also be useful in helping
the individual to achieve genuine competence and self-satisfaction.
A. T. Beck and Freeman (1990) suggested the use of a paradoxical technique for the treatment of depression in histrionic PD:
For patients who feel reluctant to give up the emotional trauma in their
lives and insist that they have no choice but to get terribly depressed and
upset, it can be useful to help them gain at least some control by learning
to "schedule a trauma." Patients can pick a specific time each day (or
week) during which time they will give in to their strong feelings (of
depression, anger, temper tantrum, etc.). Rather than being overwhelmed
when such feelings occur, they learn to postpone the feelings to a convenient time and keep them within an agreed-upon time frame. This often
has a paradoxical effect. When patients learn that they can indeed "schedule depression" and stick to the time limits without letting it interfere


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

According to P. Kernberg, Weiner, and Bardenstein (2000), histrionic

PD represents the extreme end of the hysterical personality type and thus
falls within the borderline level of personality organization. The hysterical
personality is in the neurotic range of functioning. In recommending psychodynamic treatment, they noted that
the optimal treatment is psychoanalytic or expressive psychoanalytic
psychotherapy to resolve the conflicts around dependence and sexual
inhibitions due to guilt over incestuous wishes. Addressing issues of rivalry and envy affecting friendship and love relationships are also goals
of treatment, (p. 107)

The critical intervention is the confrontation of the transference in the here

and now.
Family Systems

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


a strong, rescuing reaction; instead, he rationalizes and withdraws. Seeing

this as more evidence that he does not care, she becomes increasingly provocative (e.g., by having an affair) or despairs and becomes depressed or
suicidal. The husband, meanwhile, becomes increasingly angry at the acting-out wife, ultimately feeling completely exploited. If the wife instead is
suicidal or depressed, the husband is more likely to feel burdened and overwhelmed.
Sperry and Maniacci (1998) described three phases in treating the histrionic-obsessive couple. The first phase is to establish a working alliance. It
is useful to establish the expectation that neither person in the couple is
"crazy" or "the mentally ill one" (a label often self-applied by the suicidal or
depressed histrionic partner). Instead, the explicit therapeutic expectation is
that each individual will take responsibility for his or her contribution to the
extant problem. By maintaining this neutral stance, the therapist conveys
reassurance to the histrionic partner, reducing her fears of abandonment,
and also eliminates mental illness as an excuse to act out. Discussing family of-origin issues can also help make confusing patterns understandable.
The second phase is rebalancing the couple relationship. Histrionicobsessive couples typically present with imbalances in boundaries, power,
and intimacy. Problems in boundaries and power respond well to structural
and strategic therapy, and communication and family-of-origin approaches
can be used to improve intimacy.
The third phase is modifying each partner's individual dynamics. In
general, in this phase, the goal is to help each partner to become more honest, forthright, and assertive. Noted Sperry and Maniacci (1998),
Both the histrionic and the obsessive partners are often dishonest in their
attempts to control each other. She misrepresents facts, dishonestly seduces, and exaggerates her feelings, while he pretends he has no personal
needs or desires, or that he is not bothered by her behavior. In addition,
she pretends utter helplessness, feigns illness, threatens suicide, and finds
other unfair means of exerting enormous pressure on him. He, for his
part, resorts to passiveaggressive tactics, such as physical and emotional
withdrawal, avoidance of feelings, procrastination, and indecisiveness.
(p. 197)

Numerous techniques are available to help the clients improve; Sperry

and Maniacci (1998) mentioned cognitive-behavioral couples therapy and
Adlerian couples therapy. Once clients make adequate changes in their selfconcept and their expectations of the relationship, there are substantial improvements in the relationship.
In some cases a fourth phase, skills training, is necessary. In such cases,
skills training is usually done concurrently with the second phase, rebalancing the couple.



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).

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).



A study I performed with psychotherapy graduate students showed that

the most prominent feelings in response to a filmed representation of histrionic PD were amusement, curiosity, irritation, fascination, embarrassment
for the client, empathy, and energy; participants also found themselves "leaning forward" and "leaning back" (Bockian, 2002a; see also chap. 1, this volume, for a description of the study). It appears that there were two main
emotional reactions, one of which was positively tinged (feeling amused,
curious, empathetic, and energized and leaning forward) and the other negatively tinged (feeling irritated and embarrassed for and leaning back). Informally, through class discussions, it appeared that women sometimes felt competitive with a woman portrayed as a seductive histrionic, and some felt angry
("That is the kind of girl who'll steal your boyfriend!"); this is consistent
with psychodynamic theory (P. Kernberg et al., 2000) and L. S. Benjamin's
(1996a) interpersonal theory. Gender appeared to play a role; informal discussions suggested that students were less judgmental of a histrionic man
who was sexually promiscuous than of a woman who alluded to being an
exotic dancer (but who was not sexually promiscuous). Although sexual attraction was not listed as one of the top 10 items, it is a possible response to
I generally enjoy people with histrionic PD. 1 enjoy the show. I just
make sure to track the person and bring him or her back to the topic at hand,
and it generally works out. Many have a well-developed sense of humor,
which is a strength. When the PD is severe and the individual is chaotic,
scattered, and extremely dramatic, the countertransference becomes more
challenging; I tend to experience frustration, or the thoughts, "Why don't
you give it a rest!" and "Just get real!" In such cases, I use the cognitive approach alluded to previously: I ask myself, "What is it like to be that person?
What would it be like if others did not take me seriously? If people could not
follow my scattered thoughts? If I had little access to my personal history?
What would it be like if others were irritated with me when I wanted so badly
to be liked?" This kind of analysis usually leads to improved empathy.


In making a diagnosis of histrionic PD, one should be careful to take
into account gender and cultural norms regarding behaviors such as flirtation, dress, and attention seeking. What is considered excessively flirtatious
for women, for example, may be considered acceptable for men. In some
cultures, such as Hispanic culture, louder forms of dress and more dramatic
behaviors may be socially acceptable or even admirable. DSM-IV-TR explicitly listed "macho" behavior as a potential sign of histrionic PD in men;
obviously, within Hispanic culture, macho behaviors are not considered to
be pathological (Castillo, 1997).


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.


The strengths associated with histrionic features are a sense of liveliness, the ability to have fun and to provide fun for others, and sociability.
Often, such individuals can be charming and charismatic, which is a great
strength if appropriately channeled. Some aspects of histrionic PD are helpful for a variety of professions, most notably the entertainment field, but also
sales, teaching, and any other profession that involves engaging others'


Because the person with histrionic PD is considered the active-dependent type, then naturally, the goal is to balance the polarities by helping the
client to become less hyperactive, less demanding, more independent, and
more self-focused. It is also important to undercut processes that tend to
perpetuate the histrionic pattern. Vicious circles of the person with histrionic PD include (a) failure to integrate experiences because of their external
preoccupation; (b) massive repression, which undermines their ability to learn
from experience; and (c) superficial relationshipsmoving from person to
person precludes their developing deeper and more meaningful relationships,
further interfering with their ability to learn from experience. Thus, therapy


Long-Term Goals for Histrionic Personality Disorder

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.

should be geared to reduce their external preoccupation, deepen their social

relationships, and expand their depth of knowledge (including their selfawareness and awareness of relationship histories). The long-term goals for
individuals with histrionic PD are listed in Exhibit 8.1. In addition, goals
based on their depression would include being able to recognize their depression and cope with it more effectively (Bockian & Jongsma, 2001; Jongsma
& Peterson, 1999).
The path to effective treatment is to assemble catalytic sequences that
synergize and build on one another. For clients with histrionic PD and depression, helping to stabilize their excessive emotionality would generally be
the most appropriate first step; if too labile, the client is unlikely to be able to
process potentially helpful interventions. Behavioral skills, such as relaxation
training, and cognitive interventions, such as Socratic dialogue, will further
help to stabilize the individual. Once an alliance is formed, antidepressant
medication can be considered. Prone to believe in quick fixes, individuals
with histrionic PD may lose motivation for treatment if medications are introduced too quickly, so the clinician should carefully consider the timing of
psychopharmacological interventions. Mindfulness meditation (Kabat-Zinn,
1990; Linehan, 1993) is an intervention that could potentially have extremely
powerful and direct effects on histrionic symptoms such as difficulties with
introspection and focusing. Although sitting meditation may be difficult for
clients who are restless or who have attention-deficit/hyperactivity disorder
symptoms, movement-based meditation (e.g., yoga) can be substituted or
added to attain similar results more comfortably. A combined meditation
and yoga program has also been shown to have powerful effects on depression, comparable to the effects of psychotherapy (J. J. Miller, Fletcher, &
Kabat-Zinn, 1995). Family and couple therapy can help to break reinforcement of histrionic patterns that others may unwittingly be providing. Group
therapy can be especially powerful for people with histrionic PD, with psychodrama being a potentially excellent fit (Clayton, 1973). Depth approaches,
such as psychodynamic interventions, would generally come last because they


Therapeutic Strategies and Tactics for the Prototypal Histrionic Personality
Balance Polarities
Diminish manipulative actions
Moderate focus on others
Counter Perpetuations
Reverse external preoccupations
Kindle genuine social relationships
Acquire in-depth knowledge
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).


At the time that I saw her, Miko, a Japanese American woman who was
self-referred for treatment, was 23 years old. Her long black hair was meticulously brushed, and her makeup was attractively applied. She wore a brightcolored dress, part of a well-coordinated outfit. Her eye makeup made her
lashes look long and full and gave her a wide-eyed appearance. A part-time
aerobics instructor, Miko was very fit. Overall, her appearance was very attractive. Miko had recently graduated from a state university and was an
extraordinarily active woman. In addition to holding a full-time job, she was
a part-time actress in a comedy troupe and, until shortly before she began
therapy, was a cocktail waitress. She worked diligently at improving her im-



provisation comedy skills and dreamed of being a professional actress some

Although composed while she provided routine intake information,
when asked what brought her to the clinic, she became tense and fidgety.
Although her eye contact had initially been unusually good, she glanced all
around the room. Finally, with tears starting to form in her eyes, she half
blurted, half choked out, "I was raped." Tears were now flowing down her
cheeks, but she remained silent. She accepted the tissue I offered her gratefully, and she then related what had happened.
Miko had been working her usual shift as a cocktail waitress. That night,
there was a celebration after work. She had had three beers over a 2-hour
period, and, with her rather small frame, she was "pretty tipsy, but not drunk."
She knew that driving was not a good idea. The bartender, Henry, offered to
drive her home, and she accepted. Instead of taking her back to her home,
Henry took her back to his apartment. He then forced her to have oral sex
with him, threatening her with violence if she did not comply. She remembered him initiating sexual contact, and then she blacked out, unable to
remember anything further about that night. She woke up the next morning
in her bed. The next day Miko quit her job at the bar.
Miko reported difficulty in her day-to-day activities. She had problems
sleeping, being plagued by troubling dreams about the event. When she was
not engaged in highly absorbing activities, her mind would drift to the rape;
driving was especially difficult, and she had to pull off to the side of the road
to compose herself several times per week. In addition to the obvious posttraumatic stress disorder or rape trauma syndrome symptoms, Miko was experiencing a major depressive episode. She had depressed mood much of the
day, feelings of shame, and loss of appetite.
Rapport was established quickly and without much difficulty. Miko's
symptoms were very distressing, and she was eager to get well. Her Millon
Clinical Multiaxial InventoryII score demonstrated a prominent elevation on the Histrionic scale, with a secondary elevation on the ObsessiveCompulsive scale and a tertiary elevation on the Dependent scale. Her
strengths were her liveliness and vivaciousness (which became more apparent as the depression lifted), her determination, and her commitment to
being a good employee and a good actress. Her main weaknesses were her
interpersonal naivete and her lack of self-awareness.
My initial emotional reactions to Miko were feelings of sympathy and
compassion and feelings of sexual attraction. These are fairly common responses that I have to individuals with histrionic PD or features. I wondered
to myself if others felt this way and, more specifically, if her attractiveness to
me was part of a general pattern of seductiveness. The therapy ultimately
presented opportunities to evaluate this issue. In terms of transference, Miko
initially demonstrated a strong need for approval and a strong proclivity to
be entertaining. At times, she would bring in material from her comedy rou182


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


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,


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
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


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.


A variety of interventions can be helpful for depressed individuals with
histrionic PD. Cognitive and behavioral interventions can help to reign in
their flighty and impulsive proclivities. Goal setting can also be important,
because the depression can evaporate temporarily if the client secures a new
paramour or finds an exciting new situation, thus leading to premature termination. As illustrated in the case of Miko, psychodynamic factors such as
awareness of transference and countertransference feelings can be important
in guiding the therapy. The client's interpersonal style and modifications thereof
also are crucial in this highly "other-oriented" population. Self-awarenessenhancing interventions, whether through traditional psychological approaches or through specific mindfulness training, are often central to the
treatment. These interventions, arranged in a synergistic fashion, can help
the person with histrionic PD (or features of the disorder) to alleviate depressive symptoms and live a deeper, more satisfying life.
We need more research in a variety of areas. Differences in countertransference reactions of male and female therapists to histrionic clients,
especially those who are seductive, would be useful in providing appropriate
guidelines for therapists and supervisors. Clinical psychology as a science
needs to further investigate the integration of psychotherapeutic approaches,
including synergistic and catalytic sequences. Finally, psychodrama may be a
particularly useful approach with this population; research in that area would
facilitate appropriate treatment and referral as well as enhance awareness of
potential pitfalls.




The nefarious character lago from Shakespeare's Othello demonstrates

the devastating effect of unbridled narcissism combined with ruthless sociopathy. In Act 1, Scene 1, lago vents his rage when he is not selected as
Othello's officer:
But he [Othello], as loving his own pride and purposes,
Evades them, with a bombast circumstance
Horribly stuff d with epithets of war:
And, in conclusion, nonsuits
My mediators; for Certes, says he,
I have already chose my officer.

And what was he?

Forsooth, a great arithmetician,
One Michael Cassio, a Florentine,
A fellow almost damn'd in a fair wife;
That never set a squadron in the field,
Nor the division of a battle knows
More than a spinster; unless the bookish theoretic,
Wherein the toged consuls can propose
As masterly as he: mere prattle without practice
Is all his soldiership. (Shakespeare, 1972, p. 1171)


In this brief passage, lago evidences feelings of entitlement, and projection

of his own narcissistic proclivities onto Othello. He denigrates Cassio, in
thinly veiled jealousy of the latter's advancement. This specious reasoning
that he, lago, is entitled to promotion because of his superioritybecomes
the rationalization for his scheme to advance his position by undermining
Individuals with narcissistic personality disorder (PD) are prototypically haughty, arrogant, and grandiose. They are generally less active than
lago, prone to fantasy rather than actual aggression. What is striking about
the phenomenology of narcissistic PD is not only how it impacts the person
with the disorder but how it impacts others. When teaching, I ask my students to share experiences they have had with people who have characteristics of individuals with each of the PDs. I am consistently struck by the pained
look of individuals who are children of narcissistic mothers or fathers. Derogation and consistent inability to ever satisfy the narcissist have been persistent themes. Equally interesting are the numerous stories of individuals who
dated people with narcissistic PD just once, disappointedthough amused
at their dates' nonstop focus on themselves, inability to engage in a give-andtake conversation, or the crude and bombastic attempts to impress. Although
these individuals were often good-looking, wealthy, well-appointed, and initially intriguing, it soon became evident that having a relationship with one
of them would be not only undesirable but insufferable.
A colleague of mine (Suzanne Richter, personal communication, February 21, 2002) has provided a striking example of the impact of narcissistic PD
on a child, even long into adulthood. The client, a woman in her 30s with a
husband and two children, had been recently diagnosed with breast cancer and
was preparing to undergo a mastectomy. Although she knew her mother was
typically self-involved, she was hoping that her mother would at least be somewhat supportive under such extreme circumstances. When she informed her
mother about her diagnosis and impending surgery, her mother responded,
"Oh. Anyway, how do you like my dress that I'm wearing to the opera?" and
stood up to provide a quick fashion show. The client was crushed. Perhaps the
mother believed that she was helping by taking her daughter's mind off such a
painful topic. Nonetheless, the empathic failure in this case is remarkable.
Estimates indicate that the prevalence of narcissistic PD is less than 1%
in the general population and is about 2% to 16% in clinical populations


(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.
Individuals with narcissistic PD often become depressed when their fantasies of unlimited success or admiration from others do not materialize. Noted
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


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.


Biological Factors
To my knowledge, there have been no studies of the neurobiology of
grandiosity, arrogance, lack of empathy, or other narcissistic traits.1 Millon
(1996) noted that the biological mechanisms of narcissistic PD were not
known. Other factors, such as heritability and medications, have received at
least some attention.

As with other PDs, narcissistic PD appears to be moderately heritable.

In their study of the heritability of PDs in children and adolescents, Coolidge,
Thede, and Jang (2001) found that narcissistic PD had a heritability of 66%.
Livesley, Jang, and Vernon's (1998) twin study found that narcissism had a
heritability of 43.6%.
Almost no studies have assessed the use of medications for individuals
with narcissistic PD. The Ekselius and von Knorring (1998) study reviewed
in chapter 1 of this volume included 37 individuals with narcissistic PD.
Results were generally discouraging. Neither sertraline nor citalopram were
associated with statistically significant reductions in diagnosed rates of narcissistic PD. The citalopram group decreased by a mean of 0.5 criterion preto posttreatment, which was significant; the sertraline group, however, decreased by a mean of only 0.2 criterion, which was nonsignificant. D. W.
Black, Monahan, Wesner, Gabel, and Bowers (1996) found that narcissistic
traits were not impacted by fluvoxamine, relative to placebo.
Given the extremely limited available data, it is appropriate to consider the hypotheses developed by Joseph (1997) on the basis of his clinical
experience. He argued that the features of narcissistic PD, such as grandiosity, feelings of entitlement, and arrogance, can be conceptualized as symptoms of hypomania and thus treated with medications such as lithium and
'On the basis of her clinical experience, Mary Francis Schneider (personal communication, January 3,
2006) has speculated that the empathic failure associated with narcissistic PD falls along the autistic
spectrum. Although there is no empirical support for her theory at this time, I believe it is worthy of



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.


This aggrandizing attitude is internalizedlearnedby the future narcissist.

Further, their parents' doting models the subservience that persons with narcissistic PD come to expect from all with whom they interact (Millon, 1981).
Millon's (1981) view is in marked contrast to analytic viewpoints exemplified by O. F. Kernberg (1970/1986b) and Kohut (1971). Kernberg and Kohut
saw narcissism as a defense against underlying feelings of worthlessness, emptiness, and boredom. One of Millon's subtypes, the compensatory, appears to be
similar to the analytic description of narcissism. This subtype is a mixture of
narcissistic and passive-aggressive/negativistic features (Bockian, 1990).
Millon's domain-level descriptions of narcissistic PD are given in Appendix B. Of the domains, the exploitive interpersonal conduct and admirable self-image are the most salient.
Cognitive-Behavioral Conceptualization and Interventions
Individuals with narcissistic PD are prone to thoughts such as "I am
superior" and "Others should cater to my needs." Depending on their personal history, their core beliefs tend to vary. Millon's (1981) prototype would
be an individual who has a deep well of parental overvaluation on which to
draw. For such individuals, the core beliefs match the automatic thoughts,
and they genuinely believe they are superior; in the case of persons with
narcissistic PD and depression, they are typically perplexed by reality's failure to demonstrate this obvious truth. The prototype is someone born to
royalty, who would, naturally, expect to be treated deferentially by his or her
subjects. Individuals who fit in with modern psychodynamic formulations,
such as those of O. F. Kernberg (1970/1986b) and Kohut (1971), would have
substantially different profiles. Although superficially grandiose, underneath
they harbor beliefs about inadequacy and worthlessness. Exhibit 9.1 outlines
the thought processes of the two basic subgroups of narcissists. What is remarkable is that individuals with such different experiential histories can have such
a similar superficial manifestation, yet it is clear from case material that this is
in fact the empirical reality. Although not present in conscious awareness,
for insecure narcissists the fear is that they are imposters and are not truly
superior; this trepidation often lurks in the shadows of their awareness.
A. T. Beck, Freeman, and Davis (2004) noted that there are three key
targets in treating someone with narcissistic PD: (a) increasing goal attainment and exploring the meaning of success; (b) improving empathy and awareness of others' rights; and (c) enhancing self-esteem and beliefs about selfworth. Breaking down grandiose expectations into more achievable steps can
be extremely useful in treating the person with narcissistic PD. Dysfunctional
thought records can be used to challenge all-or-none thinking such as, "Unless I'm the star of the show I'm a total failure." Problem-solving discussions
can help to undo inappropriate behavior, by, for example, replacing fantasy
with concrete steps toward goal attainment. Beliefs about self can be gently
and supportively challenged when there is sufficient rapport; for example,


Conceptualization of Narcissistic Personality Disorder: A Comparison of
Millon (1981, 1996) and O. F. Kernberg (1986b, 1986c)
Millonian narcissist (secure narcissist)

Analytic narcissist (O. F. Kernberg;

Kohut, 1971; insecure narcissist)

Core belief
I am perfect
I am great
I am superior to others

I am worthless
I am an imposter
Experiential history

Excessive praise, especially for aspects Being put down, neglected

of the self that do not require effort
(e.g., praise for being handsome,
pretty, or cute)
High expectations
Intermediate beliefs
If someone stands in my way, he
should be destroyed.
If others don't recognize my greatness,
it is because they are fools.

I'll show them.

If I make an effort and fail, that would be
If I am not superior, then I'm horrible,
because the average person is a
If others don't recognize my superiority,
then they are idiots.

Automatic thoughts
Putting forth effort is beneath me.
Others should recognize my superiority
and reward me for it.

I am better than any of these people.

They are a bunch of stupid losers,

the strategy of emphasizing what might be gained by a more accepting stance

toward criticism can facilitate growth (A. T. Beck et al., 2004).
A. T. Beck and his associates (A. T. Beck et al., 2004; A. T. Beck &
Freeman, 1990) recommended some alternative beliefs that can be used as
goals or benchmarks for the individual with narcissistic PD. Reframing grandiose narcissistic beliefs into more realistic ones can be extremely beneficialfor example, "I can be ordinary and be happy"; "One can be human,
just like everyone else, and still be special"; "Relationships are experiences,
not status symbols" (A. T. Beck et al., 2004, p. 266); and "To let the evaluations of others control my moods makes me dependent on them and out of
control" (A. T. Beck & Freeman, 1990, p. 249).
Other techniques can also be aimed at the various difficulties that constitute narcissistic PD. For example, hypersensitivity to criticism (that triggers narcissistic rage) can be treated with systematic sensitization. Fantasies
of unlimited success can be altered using imagery work; for example, a fanNARCISSISTJC PERSONALITY DISORDER

J 93

tasy of being a star of a Broadway show can be replaced with an image of

starring (or even having a secondary role) in a local theater production. Such
images should focus on deriving pleasure from the activity itself, not only
from the applause or the "glory." Finally, extensive use of role play and imaginal
work can help the client to improve his or her empathic capabilities (A. T.
Beck & Freeman, 1990).
Psychodynamic Therapy
Underlying narcissistic grandiosity, according to O. F. Kernberg (1970/
1986b), is a defect of early object relations. He argued that severe narcissism
does not reflect simply a fixation in early narcissistic stages of development
and a simple lack of the normal course of development toward object love but
that it is characterized by the simultaneous development of pathological forms
of self-love and pathological forms of object love (O. F. Kernberg, 1970/1986b,
p. 216). As shall be seen later, this is exactly opposite Kohut's (1971) argument that narcissistic disorders are indeed fixations in a narcissistic period.
O. F. Kernberg (1970/1986b) asserted that what happens in the case of
the narcissist is a "refusion" of the self and the object after the establishment
of functional ego boundaries. The ideal self, ideal object, and actual self are
fused into one internalized image. Thus, according to Kernberg,
It is as if they [narcissists] were saying, "I do not need to fear that I will be
rejected for not living up to the ideal of myself which alone makes it
possible for me to be loved by the ideal person I imagine would love me.
That ideal person and my ideal image of that person and my real self are
all one, and better than the ideal person whom I wanted to love me, so
that I do not need anybody else any more." In other words, the normal
tension between actual self on the one hand, and ideal self and ideal
object on the other, is eliminated by the building up of an inflated self
concept within which the actual self and the ideal self and ideal object
are confused. (O. F. Kernberg, 1970/1986b, p. 217)
O. F. Kernberg (1970/1986b) also stated that narcissists very often have
backgrounds in which the parental figures are chronically cold with underlying aggressive feelings. The child may be used to fulfill the parents' narcissistic ambitions to be brilliant or great. The child often occupies a critical role
in such families, being either an only child or considered to be one with
special talents or intelligence. The situation thus fosters a need to defend
against envy to live up to high expectations. Once set into motiononce
the real and idealized self and object images have been fusedthe pattern
becomes "extremely effective in perpetuating a vicious circle of self-admiration, depreciation of others, and eliminating all actual dependency" (O. F.
Kernberg, 1970/1986b, p. 220).
O. F. Kernberg (1970/1986b) saw the narcissist as feeling deeply rooted
emptiness, rage, and fear as a consequence of the pathological fusion of self



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)



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
In the twinship transference, the analysand sees the analyst as a separate person but one very much like him- or herself. Meissner, reviewing Kohut,
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


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.)


Uhhuh (visible diminution of signs of anger).

Kathy, for you Bob seemed preoccupied with his relationship
with his father ... it felt as if his father was more important to
him than you and your marriage. (Again, the therapist empathzcalfy
identifies narcissistic injury and unfulfilled selfobject needs for mirroring and twinship . . .)
Yeh (she nods her agreement), (p. 231)

Note how the therapist simultaneously addressed both members of the couple
to prevent further narcissistic wounding and to promote an alliance. The
therapy continued:


Bob and Kathy (addressing both together, to provide mirroring for

them as a couple and twinship by joining them, thereby enhancing
cohesion of the marital bond), due to feeling deeply hurt, you have
not been able to understand and meet each other's needs (empathic attunement and identification of selfobject failure). You did
not feel safe, and you both withdrew from each other (identification of the defensive reaction to fear of narcissistic injury). Since
you perceived each other as uncaring and blaming, a lot of
resentment has built up in both of you (identification of a source
of de-idealization and subsequent development of narcissistic rage).
The risk for both of you was being hurt and yet not being heard
again (repetition of traumatization from childhood mirroring
selfobject failures). As a consequence it became very difficult to
invest emotionally in your partner and in your future (identification of destruction of curative fantasy). Your marriage became
less important, and you started to have doubts about your commitment to i t . . . you both withdrew from each other (identifica-


tion of idealizing self object failure and further weakening of the curative fantasy, and defensive withdrawal from the relationship), (p.
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
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.

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);


cognitively oriented theorists note the disappointment of the therapist whose

patient does not change and who attributes the problem to his own incompetence (A. T. Beck et al., 2004).
Ironically, the client's defensive structure pulls for anger, rejection, and
neglect, precisely the situations and feelings they were designed to avoid. It
is natural, though countertherapeutic, for the therapist to reject the client in
kind (Cooper, 1959/1986; O. F. Kernberg, 1970/1986b, 1974/1986c; Kohut,
1971). Similarly, the client's arrogant, haughty attitudes and criticism of the
therapist can interfere with the therapist developing empathy for the client
(A. T. Beck et al., 2004). Such emotions are difficult to handle and are at
odds with the self-concept of most therapists. Conversely, the therapist must
be careful not to be drawn into the client's aggrandizing comments (e.g.,
compliments and flattery), which can lead to collusion to avoid change or be
a cover for the client's covetousness of the therapist's positive qualities or
possessions (A. T. Beck et al., 2004).
Empirical studies support the kinds of reactions that have been reported
in the literature. Betan, Heim, Conklin, and Westen (2005) collected a countertransference questionnaire from 181 clinicians; the instructions were to
include clients that they had seen for at least eight sessions. Thirteen of the
clients who were rated had narcissistic PD. The authors noted, "Clinicians
reported feeling anger, resentment and dread in working with narcissistic
personality disorder patients; feeling devalued and criticized by the patient;
and finding themselves distracted, avoidant, and wishing to terminate treatment" (Betan et al., 2005, p. 894). A study of responses to a filmed vignette
of an individual with narcissistic PD indicated that therapist trainees were
most likely to feel fear (indicated by response choices fearful, guarded, alarmed,
and afraid) and anger (angry, frustrated); other likely emotions were indicated
by single items (curious, pity, sad, dislike). Informal discussions with participants indicated that the fear was that the client would either verbally attack
the therapist or "lose it" in a fit of rage, and anger was generated by the
client's supercilious and devaluing attitude (Bockian, 2002a; see chap. 1 for
further details of this study).
I recall experiencing several such feelings and entrapments with a person I treated early in my training. The client was a law student and thus had
access to the counseling center where I was an extern. Strikingly handsome,
he was able to quickly attract and seduce women; however, there was one
woman whom he desired but with whom he had numerous get-togethers and
breakups. He was genuinely perplexed by his inability to maintain a relationship with her, or, more accurately, by her lack of sustained interest in him.
During one of our sessions, he said to me, "You don't say very much." I made
some neutral comment, such as "Tell me more about that." He responded, "If
I had to pay you, I would just set up a mirror and talk to myself." I felt wounded
by his devaluing comment and, internally, withdrew into intellectualization
("My, how interesting, is this a mirroring transference?"). I then discussed


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:

If I had to pay you, I would just set up a mirror and talk to



I'm wondering, did you consider how I might feel when you said


Isn't that your job? If you can't take it, you shouldn't be a counselor.


You're a law student. It was a yes or no question; please just

answer yes or no. Did you consider how I might feel when you
made your comment?


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


As noted in chapter 3, features of antisocial and narcissistic PDs were
induced in randomly selected college-aged men in the famous Stanford prison
experiment (Haney, Banks, & Zimbardo, 1973). Collins (1998) extended
this finding by having college student participants rate behaviors as either
masculine or feminine; consistently, the guard behaviors (dominance, aggression) were rated as masculine, whereas prisoner behaviors (depression,
anxiety) were rated as feminine. Because all of the participants were the
same gender and were randomly assigned, the only plausible explanation for
the differences in behavior was social role. Social dominance, then, tends to
elicit arrogance and oppressive behavior, whereas social status inferiority elicits
feelings of helplessness, depression, and anxiety. Thus, one explanation of


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).
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).
Because the person with narcissistic PD is considered the passiveindependent type, the logical goal is to balance the polarities by helping the


Therapeutic Strategies and Tactics for the
Prototypal Narcissistic Personality
Balance Polarities
Stimulate active-modifying
Encourage other focus
Counter Perpetuations
Undo insubstantial illusions
Acquire discipline and self-controls
Reduce social inconsiderations
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


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.


At the beginning of therapy, Tomas, a Hispanic man, was 38 years old.
At that time, he was married and had two children, ages 6 and 9. Tomas had
experienced homosexual urges since childhood. He began to visit pornographic Web sites, and finally, he began to have affairs with men. He was
caught, which precipitated a divorce; shortly thereafter he began therapy. At
the time that he presented for treatment, he was depressed, anxious, and
Early in the treatment, Tomas wondered if he might be narcissistic.
Reviewing the criteria in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision; American Psychiatric Association, ZOOOa) with


the therapist, Mark Johns, in a collaborative fashion allowed the client to

recognize that the label fit. Recognition of the narcissistic pattern and insights into its nature and origins became a key feature of treatment.
Tomas was raised by two alcoholic parents. Although affectionate when
sober, they were often emotionally neglectful. Forced to rely on himself, he
always yearned for someone to fill his emotional hunger, to provide for his
natural needs for mirroring and validation, and to care for him. His selfesteem was badly damaged, and he fit best into the "compensatory narcissist"
conceptualization; his attempts at self-inflation were an effort to hide his
underlying doubts and fears about his worthiness. He became preoccupied
with fantasies of ideal love and supreme beauty and was consumed by concerns about his looks, weight, attractiveness to others and his desperate search
for the ideal partner. Initially, Tomas believed that his attraction to men was
temporary, a phase or just an expression of curiosity. As it became clearer
that his primary sexual orientation was toward men, it precipitated a personal crisis. He felt dirty, guilty, and shameful.
Tomas had remarkably little empathy for his wife's position. His main
focus was on his own suffering, and he was perplexed that she was not supportive and understanding of the deep pain he was experiencing and had
been experiencing throughout most of his life. Once divorced, he would share
with her the intimate details of his sexual liaisons. His empathy was so poor
that he did not fathom how hurtful this might be to her. Although his actions may have appeared to have a sadistic tinge, he did not appear to get
satisfaction from hurting her or to be attempting to control her through intimidation. In part, his "sharing" was driven by a self-focus on his own pain
without adequate consideration of his ex-wife's needs. Despite the circumstances of their relationship, he felt entitled to her support. Ironically, although he had rejected his ex-wife, he felt even more rejected by her. He was
covetous of her admiration, and his projection of his own negative feelings
about himself led him to attempt to prove to her that he was attractive and
desirable by boasting, if you will, about his relationships. His difficulties with
empathy extended to his relationship with his children as well. Although he
cared about them, their genuine needs were trumped by his concern for his
image; he was primarily concerned about how his actions would make him
look in the eyes of others or about how his children's behaviors would reflect
on him.
The initial phase of therapy focused on validating Tomas's experience.
The process of coming out and developing a gay identity is typically fraught
with difficulties. Dr. Johns focused on the struggles that the client experienced and on his personal sense of pain. Tomas was taught mindfulness meditation, emotional regulation techniques, and distress tolerance (Kabat-Zinn,
1990; Linehan, 1993) as ways of coping with his pain. Like many individuals
with narcissistic PD, Tomas initially had poor boundaries. He would call Dr.
Johns very frequently, sometimes more than once per day, primarily to reNARCISSISTIC PERSONALITY DISORDER


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.



When treating individuals with narcissistic PD, maintaining rapport is
often a substantial challenge. Blithely supporting the narcissist's grandiosity
all but abandons any hope of therapeutic progress, whereas confrontation
undertaken precipitously can undermine a fragile bond. Managing countertransference is often the most difficult problem the therapist faces. In my
experience, concurrent mild to moderate depression generally facilitates
motivation, thus adding to the probability of therapeutic success. All of these
elements were demonstrated in the case of Tomas. Initially, the focus was
validation in order to secure the relationship. As the therapy evolved, Dr.
Johns managed his countertransference using mindfulness-based techniques;
when he (Dr. Johns) was more centered, he was able to compassionately
confront the client's grandiosity and lack of empathy. Tomas's depression
and PD resolved in concert with one another.
Depression in narcissistic PD requires a great deal of further research.
Little is known about the biology of narcissistic PD, even though its heritability appears to be similar to that of other PD. Understanding the basic
neurological mechanisms associated with the disorder may lead to improve'
ments in both psychotherapy and medication management. Although I have
argued that mild to moderate depression facilitates psychotherapeutic intervention with individuals with narcissistic PD, further research is needed to
verify this hypothesis as well as to confirm other aspects of the relationship
between depression and narcissistic PD.




The phenomenon of avoidant personality disorder (PD) is brilliantly

captured in Tennessee Williams's (1945/1999) The Glass Menagerie. The
character Laura is so painfully shy that she is practically homebound; when
she does go out, she does not interact with others. Desperately yearning for
affection but believing that she is unlovable because of a disability, she interacts mostly with her somewhat overbearing and formerly very popular mother.
Laura has relatively few lines, her attitude being conveyed largely by her
fragile demeanor and wilting body language. A perceptive high school acquaintance, her date for the evening that her brother arranges for her (and
apparently her first date ever) summarizes her difficulties:
You know what I judge to be the trouble with you? Inferiority complex!
... A lack of confidence in yourself as a person. . . . For instance that
clumping you thought was so awful in high school. You say that you even
dreaded to walk into class. You see what you did? You dropped out of
school, you gave up an education because of a clump, which as far as I
know was practically non-existant [sic]! A little physical defect is what
you have. Hardly noticeable, even! Magnified a thousand times by your
imagination! (T. Williams, 1945/1999, pp. 80-81)


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.


The individual with avoidant PD is characterized by a painful evasion
of others for fear of rejection. Persons with avoidant PD play an emotional
game of hide and seek, believing that as soon as their inner experience is
known, they will be rejected because of their fundamental inadequacy. There
is a profoundly hopeless feeling generated by such a belief. How can there be
cause for optimism? To the extent that they are accepted, it is because they
have managed to hide their real self from the other person; thus such acceptance cannot possibly feel safe, much less gratifying. In their minds, relationships hang by gossamer threads, waiting to be swept away. Often, the person
prefers to strike preemptively, leaving a relationship before he or she can be
rejected. Unlike the unemotional schizoid pattern, the avoidant pattern entails a yearning for relationships. People with avoidant PD suffer the torment
of Tantalus, in which gratification is always in sight but just out of reach.

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



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.


Given their attitudes and beliefs, it is not surprising that people with
avoidant PD get depressed; what is remarkable is that they have moments
that are depression free. More than with most psychological conditions, persons with avoidant PD are trapped in a no-win situation. If they connect to
others, they get rejected, whereas if they stay alone, they pine for a relationship. Weak and atrophied social skills make genuine connections difficult.
Also, the belief that "to know me is to reject me" can serve as a nearly insurmountable barrier to interpersonal association, especially without treatment.
In many cases, even relationships within the nuclear family are poor; as a
result, the option of remaining comfortably connected to one's family of origin for positive social ties is often undesirable or even detrimental. Avoidant
PD thus increases one's vulnerability to depression. In addition, depression
and avoidant PD exacerbate one another; the depressed and avoidant person
is all the more likely to withdraw, thus feeling even more depressed. It is also
possible that depression, even after it remits, leaves the person vulnerable to
increased avoidant behavior (e.g., in an effort to avoid the pain of rejection),
which would be consistent with the "complications-scar" model (see chap.
2, this volume, for discussion of theoretical relationships between depression
and Axis II disorders).
One particularly painful period for a woman with avoidant PD is the
point at which the ticking of the biological clock grows loud. In her 30s and
realizing that she has never really dated effectively, the prospects of marrying
and having children begin to fade. The thought of her loneliness continuing
indefinitely without any hope of receiving the fantasized unconditional love
from a child can be overwhelming.




Biological Factors
Avoidant PD, conceptually, is almost synonymous with high levels of
Cloninger's (1988) harm avoidance dimension. A series of studies of animals
and humans have demonstrated the biological mechanisms underlying harm
avoidance behavior. The evidence suggests that opposing processes in the
serotonergic and dopaminergic systems originating in the brain stem and
midbrain underlie avoidant behavior (Cloninger, 1998). Cloninger noted
that individuals who are high in both novelty seeking and harm avoidance
will experience approach-avoidance conflicts. According to Millon (1996),
individuals with avoidant PD have an underlying desire to be accepted (unlike those with schizoid PD) and are thus prone to approachavoidance conflicts. Behaviorally, however, they are consistently inhibited (unlike, e.g.,
the passive-aggressive/negativistic type).

Avoidant PD and related traits appear to be moderately heritable. A

study by Livesley, Jang, and Vernon (1998), using the Dimensional Assessment of Personality Pathology, found that the Rejection Sensitivity scale
had a heritability of 36%, and the Social Avoidance scale had a heritability
of 38.4%. Coolidge, Thede, and Jang's (2001) study of children and adolescents found a heritability of 61% for avoidant PD. A meta-analysis by
McCartney, Harris, and Bernieri (1990) showed a higher interclass correlation for monozygotic twins (.51) than for dizygotic twins (.19) on sociability,
a dimension on which avoidant PD presumably represents the extreme low
end. DiLalla, Carey, Gottesman, and Bouchard (1996) found that the Minnesota Multiphasic Personality Inventory Social Introversion scale has a heritability of 34%.

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


peared to be helpful in decreasing avoidant PD symptoms. The remission

rate for avoidant PD after 24 weeks of treatment was 27% for the sertraline
group and 22% for the citalopram group; both reductions were statistically
significant. Both the sertraline and the citalopram groups had a mean decrease of 0.6 criteria pre- to posttreatment, which was statistically significant. Unfortunately, because there was no medication-free comparison group,
the results of the study are inconclusive; however, given the generally persistent nature of PDs, the finding is noteworthy and warrants further investigation. Seedat and Stein (2004) treated 28 individuals with generalized social
anxiety, 23 of whom had avoidant PD. In a double-blind, placebo-controlled
study, they tested whether adding clonazepam to a regimen of paroxetine
was superior to paroxetine alone. Adding clonazepam did not produce statistically significant improvement, though the authors noted that the findings
pointed in the right direction, and a larger sample may have yielded a significant improvement result. Reich, Noyes, and Yates (1989) conducted a study
to examine the efficacy of alprazolam on avoidant personality traits in social
phobia patients. For 9 of 14 patients, six of the measured avoidant traits
improved with treatment; however, all traits, with the exception of avoiding
social or occupational activities requiring interpersonal contact, returned to
baseline levels after treatment was discontinued.
Unlike the published research on medications for avoidant PD, the literature on medication for social anxiety and social phobia is substantial. Given
the significant overlap in phenomenology between these disorders and
avoidant PD (Rosenbaum & Pollock, 1994), it is worthwhile to consider the
relevant studies. A literature review of over 20 placebo-controlled medication trials for social phobia (Davidson, 2003) reported that the MAOI
phenelzine is effective in about 60% to 70% of cases and was superior to
placebo in all of the studies reviewed; however, potentially dangerous side
effects make it desirable to try other medications first. Reversible MAOIs
such as moclobemide and brofaromine were considered "promising" but had
less consistent findings than phenelzine and have limited availability in the
United States. SSRIs were superior to placebo and were effective in about
43% to 70% of cases. Benzodiazapines were more effective than placebo,
though they were generally considered a second-line treatment because of
drug dependence, difficulties with withdrawal, and a limited spectrum of positive effects. Other medications, such as tricyclic antidepressants, buspirone,
and beta blockers, were found to be either ineffective or of limited use.
On the basis of the literature, Marshall and Schneier (1996) have constructed an algorithm for medication treatment of social phobia. They recommend starting with an SSRI; if there is no response, they suggest switching to clonazepam, but if there is a partial response, one can augment with a
benzodiazapine or buspirone. If there is no response to clonazepam, they recommend using an MAOI, but if there is a partial response, they suggest adding an MAOI or buspirone. The prominent position of SSRIs is due to their


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)

Of course, the temperamentally irritable and hypersensitive child is more

likely to elicit such rejection from well-meaning but ill-prepared parents and
will be more easily devastated by their rejection. Difficulties in early parentchild interactions will predispose the child to further difficulties when he or
she engages with peers. As rejection piles on rejection, the child internalizes
a damaged and worthless self-image.
Once the avoidant pattern is set in motion, various processes contribute to its self-perpetuation. The choice to withdraw from others socially means
that individuals with antisocial PD are deprived of the opportunity to learn
how to interact more effectively with others. Their fears of others and the
suspicion that others will not only reject but also humiliate them naturally
beget distrust. Their proclivity to scan the environment for threats, though


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


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:




[played by the therapist] You're no good! I wish you were never

born! The only reason your father left us was that he didn't
want you.
Don't say that, Mommy. Why are you so angry?
I'm angry because you're such a bad child.
What did I do that was so bad?
Everything. You're a burden. You're too much to take care of.
Your father didn't want you around.
I'm sad Daddy left. Are you sad, too?
Yes. Yes, I am. I don't know how we're going to get by.


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.


I know. I know. It wasn't really your fault. Daddy isn't living up

to his responsibilities.


Jane: I'm really sorry, Mommy. I wish you didn't feel so bad. Then
maybe you wouldn't yell at me so much.

I guess I do yell at you because I'm unhappy, (pp. 313-314)

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
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.



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.
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)

Challenging such thoughts, of course, would be critical to the success of the

Research on graduate students' and clinicians' responses to filmed vignettes of individuals with avoidant PD supports and extends the patterns
observed by A. T. Beck et al. (2004). Participants initially responded to individuals with avoidant PD by feeling perplexed, disconnected, and frustrated,
which appear to be responses to the cognitive avoidance of the client and to
his or her reticence in trying new strategies to connect with others. In addition, participants reported feelings of pity and feeling responsible for the person. The individual's apparent fragility seemed to pull strongly for such feelings. Many participants felt sad, downhearted, or melancholy, which was a
straight empathic response to the depression and sadness evident in the individuals portrayed in the vignettes used in the study (Bockian, 2002a; see
chap. 1, this volume, for further description of this study).
Like the participants in the study, the emotion with which I must frequently grapple when dealing with individuals with avoidant PD is pity. The
clients are generally terribly sad and distressed, they feel completely hopeless, and they effectively convey that hopelessness to the therapist. Nonetheless, pity is not only a nontherapeutic stance but also an iatrogenic one.
When I feel it, I vigorously search for its origins and actively reframe it. The


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
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.


Avoidant PD may be viewed as a sign of a "stigmatized moral career"
(see chap. 3, this volume). Individuals who are lower on the social hierarchy
may feel inadequate and handle those feelings through social avoidance. Thus,
avoidant PD is more likely to occur in hierarchical societies such as the United
States. In some individuals from non-Western societies, however, the behavior may have a very different meaning. For example, people from India,


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.
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.
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


Therapeutic Strategies and Tactics for the Prototypical Avoidant Personality
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
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.


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).


Jordan was 20 years old when he was seen by Michelle Rodgers in a
college counseling center for depression, which was impacting his academic
work. He was born in Korea, and his family immigrated to the United States
when Jordan was approximately 7 years old. His parents made a middle-class
living as shopkeepers. Jordan was very hesitant to come to therapy, believing
that it was a sign of weakness. When he started therapy, Jordan had lost his
appetite, had great difficulty sleeping, and had significant suicidal ideation.
Because of the severity of his depressive symptoms, Dr. Rodgers considered a



referral to psychiatry for a medication evaluation, but Jordan was adamantly

Jordan had numerous thoughts that were consistent with his depression, colored by the context of his avoidant PD. Tall, athletic, and handsome, Jordan had never dated despite a strong desire to do so. His automatic
thoughts were, "If I ask her out she'll reject me," and "If people get to know
me, they won't like me." The underlying core beliefs were feelings of worthlessness and unlovability. Although he was a bright student on academic
scholarship at a top university, he still felt stupid and useless. He engaged in
a great deal of dichotomous thinking and was prone to making
overgeneralizations. For example, because he was rejected by some people,
he believed he would be rejected by all people, and if he was not acceptable
to everyone, then he was worthless. Dr. Rodgers initiated cognitive therapy,
both on the general principles of personality-guided therapy and also because cognitive-behavioral therapy tends to be more acceptable to Asians
than insight-oriented approaches (Paniagua, 1994).
Dr. Rodgers initially used mood logs and thought records to help Jordan
build a mood vocabulary and to track variations in mood that would stand as
evidence against his belief that he felt miserable all the time. Jordan had an
extremely limited emotional vocabulary, what Levant (1995, 1998) would
have called "normative male alexithymia." This was shaped in part by his
gender and in part: by his culture; in Korean culture, it is more acceptable to
describe somatic experiences rather than emotional ones (Paniagua, 1994).
In the United States, we might call this somatization, but, from an Asian
perspective, Westerners inappropriately "psychologize" what are really somatic concerns (Domino & Lin, 1991). However, given that Jordan's goal
was to adjust to mainstream culture on a U.S. university campus, some emotion-focused work was highly appropriate. Simultaneously, Dr. Rodgers was
aware that acculturation, intergenerational distress associated with differential acculturation levels of the client relative to his parents, and internalized
racism appeared to be major issues for this young man, and they would be
addressed later in the therapy.
In addition to mood logs, thought records, and corresponding Socratic
dialogue, Dr. Rodgers assigned books on self-esteem and assertiveness as bibliotherapy. Jordan read the books with great interest. Role-play helped him
to implement the relevant behaviors. He first tried some assertiveness with
his friends (e.g., asserting where he wanted to go out rather than just going
along with the group). Rather than the expected rejection, his friends expressed pleasure in knowing where he stood. This experience was one of several crucial turning points for Jordan, who started to dismantle his automatic
thoughts about others. He also began to recognize that he in fact did have
some friends, counter to his notion that he was completely isolated and,
thereby, completely unlovable.



Having made some significant gains, the therapy became increasingly

focused on where Jordan's behaviors originated and how his beliefs developed and unfolded. Jordan's experiential history fit well with what would be
expected on the basis of his current beliefs and avoidant functioning. His
father had a problem with alcohol and was routinely abusive, critical, and
demeaning toward Jordan. Although Asians use a more stern disciplinary
style than Americans and are more prone to use physical discipline (Forehand & Kotchick, 1996), the father's drunken rages were abusive even within
that context. Both parents worked almost constantly; thus there was little
emotional support available from either. Although his father stopped drinking after being diagnosed with a heart condition and his behavior changed
dramatically for the better, a great deal of damage had already been done.
Incidentally, because of his experiences with his father's drinking, Jordan
chose to be abstinent.
Jordan's transference evolved over the course of treatment. Initially, he
saw Dr. Rodgers as an authority figure and deferentially tried to please her. A
mirroring transference then developed, which allowed Jordan to receive muchneeded validation that he had never attained as a child. He then began to
idealize Dr. Rodgers, at which time he began to take psychology courses,
considered changing his major to psychology, and considered becoming a
therapist. Later in the therapy, he seemed to relate to her as he did to his
older sister. Although his sister took care of him, she also had a tendency to
direct his life, engendering feelings of affection but also resentment on Jordan's
part. When the client began to work on issues involving dating, the transference became somewhat erotically tinged, although never to a degree that it
became a significant source of resistance, and these feelings resolved on their
own without the need for confrontation.
In general, Dr. Rodgers experienced Jordan as likable, because he was
very kindhearted, but often experienced frustration with him. Her countertransference also entailed the belief that the client was fragile, which she
challenged internally and found was not true. The principal areas of frustration involved Jordan's cognitive avoidance, which was manifest in his failure
to do homework and his proclivity to be stubborn. On one occasion Dr.
Rodgers shared her frustration with Jordan. He became enragedhis hands
were trembling, his face was flushed, and he could barely get his words out.
Dr. Rodgers worked through the feelings by listening, and by validating how
it was natural to feel angry given his perspective. She then confronted some
of the distortions in Jordan's beliefs that gave rise to his anger. This intervention helped to model a path through which Jordan could resolve his own
emotional difficulties. The honest expression of feelings did not impair the
relationship or entail rejection; rather, it strengthened the relationship and
expressed trust. This intervention paved the way for confrontations with his
sister, which also went well. Jordan then realized that he needed to confront



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
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.




Individuals with avoidant PD, if the therapist attends appropriately to
the client's hypersensitivities, usually can form an appropriate therapeutic
bond; in that regard, prognosis is more hopeful than with some other PDs
(e.g., paranoid). My clinical experience corresponds to the available epidemiological data, which suggest that nearly all individuals with avoidant PD
present with depression (80% had major depression; presumably, at least some
if not most of the remaining 20% had minor depression, dysthymic disorder,
or adjustment disorder with depressed mood). Thus when I treat someone
with avoidant PD, depression is a routine consideration.
Treating depressed individuals with avoidant PD first involves establishing rapport, which can be tricky, especially if the client evidences cognitive avoidance. As illustrated in the case example, forming a true therapeutic alliance can emerge deep into the treatment, when there is sufficient
trust for the client to challenge his beliefs about the therapist's opinion of
him. As in the case study, cultural considerations often play a crucial role in
the therapist's understanding of the client and thus in his or her ability to
become and to stay connected. Dr. Rodgers's understanding of her own emotional response to Jordan, and her ability to process this crucial information
with him, also led to a turning point in the case. Thus, although the interventions were primarily cognitive-behavioral, psychodynamic, self psychology, and interpersonal considerations were keys to bringing the case to a
successful conclusion.
There are many areas to research in the treatment of comorbid avoidant
PD and depression. Biologically, there may be causal links between the two
disorders, which warrant exploration. For example, there may be biological
factors unique to the avoidant-depressed combination, which, if discovered,
would lead to more effective medication regimens. Psychologically, it would
be helpful to find out, using prospective studies, what psychological factors
lead to avoidant PD. Although current models emphasize rejecting and critical parenting; as illustrated by the case example, it could be that there are
distortions in recall (e.g., the person with avoidant PD may misjudge his or
her parents retrospectively). Such studies may also uncover a subset of individuals with avoidant PD who lack depressive symptoms, allowing comparisons between the depressed and nondepressed groups; given that nearly all
individuals with avoidant PD present to clinics with depression, such comparisons are currently impractical.




The phenomenon of dependent personality disorder (PD) was eloquently

described by Paul Mason and Randy Kreger (1998):
Imagine the terror that you would feel if you were a 7-year-old, lost and
alone in the middle of Times Square in New York City. Your mom was
there a second ago, holding your hand. Suddenly the crowd swept her
away and you can't see her anymore. You look around frantically, trying
to find her. Menacing strangers glare back at you . . . This is how people
with [borderline PD] feel nearly all the time. (p. 27)

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.

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.


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


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


The primary distinguishing reasons for depression among individuals
with dependent PD are fear of abandonment and actual abandonment. To
'Bornstcin (2005) reported 10 effect sizes; the median value was approximately d = .44- Cohen's d is
the number of standard deviations of difference between the groups. Therefore, on self-report tests,
women scored higher than men by about four tenths of a standard deviation, which is considered a
medium magnitude.
Bornstein (2005) reported that the effect size was small (d = .11) but statistically significant; on
projective tests dependency scores for men were higher than those for women by about one tenth of a
standard deviation.



empathize with the dependent client, it is necessary to imagine, as noted in

the beginning of this chapter, the intensity of the belief that one's very life
depends on the beneficence of others. Often, such beliefs are subconscious or
preconscious, although in at least some cases clients have full awareness of
their fears. The passage from Mason and Kreger (1998), quoted above, about
the terror of a lost child may be a metaphor, but I have seen cases in which
the intensity of such a belief is manifest. I once treated a person with a bluecollar job who was being hit by her husband. She would not leave him on the
basis of the following argument: "My husband hits me, but if I left him, I
could only afford to live in a neighborhood that is so dangerous that I would
probably be killed." It is possible that she was correct, but I believe it is more
likely that her beliefs were distorted and betrayed an underlying dependency;
she earned more money than others I knew who managed to live in reasonably safe conditions.
The relationship between dependent PD and depression, given the
conceptualization above, becomes apparent; the belief that one is helpless
has long been known to underlie feelings of depression (Seligman 1975). In
addition, object loss often leads to depression, particularly in a predisposed
individual (Blatt, 1974; Blatt, Shahar, & Zurhoff, 2002; Freud, 1917/1986).
As demonstrated in empirical research (see the section on epidemiology,
above) depression frequently overlaps with dependent PD. Thus dependent
PD creates a vulnerability to depression. In addition, depression and dependent PD likely exacerbate one another; for example, the person with dependent PD generally clings so hard that rejection becomes likely, thus increasing rejection and dependency needs synergistically (see chap. 2, this volume,
for further discussion of the relationship between depression and Axis II disorders).


Biological Factors
According to Cloninger's (1987) model, individuals with dependent
PD would be low on novelty seeking, high on harm avoidance, and high on
reward dependence. This theory suggests several patterns that are important
in the development and maintenance of dependent PD. Dopamine depletion is related to low novelty seeking; for example, individuals at risk for
Parkinson's disease have low levels of novelty seeking (Cloninger, 1998).
High harm avoidance is related to higher levels of activity in the right
amygdala, the right orbitofrontal cortex, and the left medial prefrontal cortex. 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 the reward
dependence dimension. Thus one would expect to see these biological patterns in the individual with dependent PD.

Limited available evidence suggests that dependent PD is moderately

heritable, at a level similar to other personality disorders. A study by Coolidge,
Thede, and Jang (2001) found that dependent PD had a heritability of .61
in a sample of children and adolescents. Livesley et al. (1998), using the
Dimensional Assessment of Personality Pathology, found a heritability
of 33.6% on the submissiveness scale and 43.6% heritability for insecure

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


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


"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


therapy implicitly forces the client to make decisions and differentiate in a

healthy way. Though making decisions and differentiating may be uncomfortable for the client at times, the supportive stance of the therapist and the
proclivity of the dependent client to form strong attachments and thus stay
in therapy bode well for the ultimate success of treatment.
Psychodynamic Therapy

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.


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.



On the latter dimension, both are too passive and need to be moved to a
place of increased activity.

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


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.


In many subcultures, polite and deferential behavior is considered appropriate. Many cultures, especially those of Asia, are sociocentric. Independent decision making is less common than in highly autonomous Western


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).


Individuals with mild dependent PD symptoms manifest a variety of
strengths. As noted previously, such individuals tend to be optimistic. They
are trusting and trustworthy and thus tend to engender trusting relationships. They tend to be kindhearted, and when the disorder is not severe they
tend to give in addition to receiving help. Individuals with dependent PD
features are very well suited to situations in which it is appropriate to receive
help passively (such as receiving some types of medical care) or to seek it
actively (such as attending a professor's office hours). As mentioned previously, individuals with dependent PD tend to be extremely loyal, which facilitates reciprocal loyalty and closeness with others. Institutional living,
though less than ideal, may be required in cases of severe physical or mental
disability; in such cases, being passive and submissive, unfortunately, tends
to be highly adaptive. Bornstein (2005), on the basis of numerous studies,
described strengths in individuals with healthy dependency. Individuals with
healthy dependency are sensitive to social cues, including verbal and nonverbal communication. They have high levels of insight and integrate therapist feedback into their self-concept, leading to positive change. The friendships of individuals with healthy dependency are characterized by openness
and flexibility, and their romantic relationships are marked by mature intimacy and open communication. At work, they are congenial, cooperative,
and focused on the needs of the group. Finally, as parents, they use an authoritative style and set limits in an appropriate, flexible manner.



Unlike the situation with many of the other PDs, developing a therapeutic bond with individuals with dependent PD requires relatively little
special effort. Unless the therapist actively pushes the person away (e.g., because of discomfort with dependency or premature efforts to force independence on the client), then the client will naturally bond with the therapist,
falling into a help-seeking role. A. T. Beck et al. (2004) pointed out that
allowing such dependency to form is not problematic early in treatment as
long as it is clear that the long-term goal is for the client to be able to help
him- or herself. Cognitive and behavioral interventions can be used simultaneously to challenge the client's view of him- or herself as incompetent.
Through skills training and use of thought records and Socratic dialogue,
individuals with dependent PD will tend to become more competent and to
recognize their abilities. The process of increasing independence can occur
within the therapy; while initially providing structure, the therapist can require increasing input from the client in setting agendas and determining
therapeutic activities. Interpersonal conceptualizations are almost always
necessary or implied with the person with dependent PD because they define
themselves in relation to others rather than as independent beings. Clientcentered therapy, with its firm nondirective stance, would also require that
the client structure the session and thus become more independent. Once
the client has gained some improved competence, group therapy interventions can further reduce the dependence on the therapist and provide an
opportunity to try new behaviors (e.g., assertiveness) in a relatively safe environment. Because the client is unlikely to flee from therapy, psychopharmacologic interventions can be implemented early to help reduce depressive
affect. Psychodynamic interventions can also help to deepen the client's selfunderstanding and understanding of the impact of early childhood events
especially helpful is the confrontation of the dependent transference. The
key to successful treatment, regardless of the theory used in understanding
the person or the particular intervention used, is maintaining a warm but
firm stance that the client find a way to be competent and to feel successful.
It is important to note that a wise and realistic overall goal of treatment
is to bring the person with dependent PD to a state of healthy dependency,
rather than autonomy. Noted Bornstein (2005),
When working with a dependent patientespecially one who is extremely
clinging and insecureit is easy to overemphasize autonomy at the expense of healthy dependency. Although increasing autonomous functioning is an important goal of clinical work with dependent patients,
autonomy is most adaptive when it is expressed in flexible, situationappropriate ways and combined with a willingness to seek help and support from other people, (p. 147)



Therapeutic Strategies and Tactics for the Prototypal Dependent Personality
Balance Polarities
Stimulate active/modifying polarity
Encourage self-focus
Counter Perpetuations
Reduce self-depreciation
Encourage adult skills
Diminish clinging behaviors
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.

As seen in the section of this chapter on the strengths of dependent

PD, there is a positive place for individuals with healthy dependent traits.
Guidelines for conceptualizing and implementing the personality-guided
paradigm are provided in Exhibit 11.1.


When I started seeing Elisa, she was a 68-year-old widow who was living in a nursing home. She was a Caucasian Protestant of mixed northern
European descent. At that time, Elisa had mixed features of anxiety and depression. She had a history of being diagnosed with both schizophrenia and
bipolar disorder for many years. She took lithium and a small amount of a
low-dose neuroleptic, and she was stable on her medications. From time to
time I reported side effect problems (e.g., a tremor in the hand) to her psychiatrist, but in general she tolerated the medications well. Although 1 saw
some evidence of mood swings, I never observed any overt schizophrenic
The initial phase of treatment was intended to establish rapport, which
occurred readily using active listening and reflecting and other techniques
that originated in the client-centered tradition. I have found rapport building to be unusually easy in nursing homes. Despite the image of older adults
as therapy avoidant, seeing therapy as being something for "crazy people"
and as a severe encroachment on their independence, there is a factor at



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.


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


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.


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
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.


The principles of personality-guided therapy indicate a catalytic sequence that simultaneously addresses depression and the relevant PD. The
illustrative case in this chapter drew on synergistic combinations of a variety
of treatments. Client-centered techniques were used to establish a connection. Once the alliance was formed, cognitive-behavioral techniques helped
the client to improve her skills and her self-image. Hypnosis in this case had
a somewhat paradoxical flavor; although the client was passive during the
hypnosis sessions, virtually all of the suggestions were designed to help her
increase her activity level, coping, and competence. As she became more
competent and less needy, her interpersonal relationships improved. Ultimately, her depression lifted, she became more able to enjoy her time with
her family, and they were better able to enjoy their time with her.
There are many areas that require further research in examining the
relationship between dependency and depression. Biological information,
including basic neurological mechanisms underlying the disorders as well as
the effectiveness of medications, require further elaboration. Prospective studies assessing how dependent PD develops, and cross-sectional studies to asDEPENDENT PERSONALITY DISORDER


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.




The phenomenon of obsessive-compulsive personality is whimsically

illustrated in the Disney children's movie Mary Poppins (Stevenson, 1964/
2004) in the character of Mr. Banks. Preoccupied with order and productivity, he is ruining his relationship with his children. The song "A British Bank"
summarizes his philosophy:
A British bank is run with precision
A British home requires nothing less!
Tradition, discipline, and rules
must be the tools
Without themdisorder! Chaos!
Moral disintegration!
In short, we have a ghastly mess!1

The song goes on to describe, with blithe indifference to reality, how

the children (approximately 9 and 6 years old) should get excited about see'From "A British Bank (The Life I Lead)" from Walt Disney's Mary Poppins. Words and music by
Richard M. Sherman and Robert B. Sherman. Copyright 1963 by Wonderland Music Company, Inc.
Copyright renewed. All rights reserved. Used by permission.


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.


According to the Diagnostic and Statistical Manual of Mental Disorders
(4th ed., text revision [DSM-IV-TR]; American Psychiatric Association,
The essential feature of Obsessive-Compulsive Personality Disorder is a
preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency,
(p. 725)
Individuals with obsessivecompulsive personality disorder (PD) are
noted for their rigidity, orderliness, attention to rules, and attention to details. They generally deny emotional experience, perhaps not wanting to appear weak to others but, more likely, pushing the emotional experience out
of their own awareness. Unlike the schizoid client, who appears to be largely
unable to experience emotions, persons with obsessive-compulsive PD appear to be channeling emotions or shutting them down. Perhaps as a consequence of their inability or unwillingness to experience or deal with their
emotions, they tend to be more vulnerable to somatization disorder (e.g.,
hypochondriasis; Garyfallos et al, 1999), which thus allows individuals to
express a variety of emotions under the safe rubric of medical illness. Illness
can allow them to be nurtured by others without asking for nurturance or can
excuse them from work when their "internalized taskmaster" would never
allow them an idle moment. Neil Simon's play The Odd Couple (1966), which
also was made into a movie and a long-running TV series, turned Felix Unger,
a highly prototypical, tragicomic person with obsessive-compulsive PD, into
something of a cultural icon. Felix had essentially every symptom of the disorderexcessive neatness and orderliness, excessive attention to detail, high
and rigid moral standards, and even somatization in the form of allergies.
Despite the similarity in names, there is no clear relationship between
Axis I obsessive-compulsive disorder (OCD), and Axis II obsessivecompulsive PD. Hoarding, and perhaps miserly spending, are shared by the
two disorders. Empirically, findings have been mixed as to whether there is a
relationship or not (Spitzer 6k Dieter, 1997). Millon (1999) argued that the


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.

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,


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).
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 &


Alloy, 2001). The mechanism by which rumination works appears to be that

individuals who ruminate tend to believe that they are increasing their selfawareness and thus avoid pleasurable distracting activities (Lyubomirsky &
Nolen-Hoeksema, 1993).
Individuals with obsessive-compulsive PD manifest tight control to
prevent the expression of anger. Prone to restraint and guilt, they turn their
anger inward against the self (Millon, 1999, p. 243). Thus individuals with
obsessive-compulsive PD generally fit very well with this traditional psychodynamic interpretation of depression. In addition, the internalization of the
harsh, punitive parent creates a painful inner world. Although "perfect" behavior can sometimes stave off the inner critic, it always lurks in the background. Any slipwhich is, of course, inevitablecreates a flood of selfrecrimination. This is often experienced as depression.
I have also observed clinically that people with obsessive-compulsive
PD are prone to feeling overwhelmed when their orderly lives are thrown off
by uncontrollable events. Primarily, this manifests as anxiety, which is usually denied or rationalized. However, if the uncontrollable event involves
loss or failure, depression often ensues. Consistent with the "vulnerability"
model (see chap. 2, this volume) obsessive-compulsive PD appears to increase an individual's susceptibility to depression.


Biological Factors
Although a good deal has been written about biological underpinnings
of impulsivity, aggression, emotional dysregulation, and thought disorder,
there has been little research on biological factors underlying the excessive
behavioral inhibition and cognitive rigidity seen in obsessive-compulsive
PD. Preliminary evidence in one study suggests that obsessive-compulsive
PD features may be related to serotonergic function. However, it is not a
simple relationship; insufficient serotonin has been linked to impulsive aggression, but it does not appear to be the case that excess serotonin is related
to behavioral inhibition. Instead, it may be that increased serotonergic receptor sensitivity plays a role, as noted by Hollander, Decaria, Niescu, et al.
(cited in Stein et al., 1996). In one small study, biological research supported
psychodynamic theorizing that obsessive-compulsive PD has a component
of hostilityhostility scores were higher in the obsessive-compulsive PD
patients than in a mixed PD comparison groupwhich may emerge as impulsive aggression. Impulsive aggression scores, in turn, were associated with
reduced plasma prolactin response to fenfluramine, whereas hostility scores


were associated with blunted response to fenfluramine; these findings are

similar to those found with impulsive groups such as individuals with borderline or antisocial PDs (Stein et al., 1996). Further research is needed in this
area to clarify the nature of neurotransmitter processing in individuals with
obsessivecompulsive PD.
Obsessive-compulsive PD appears to be moderately heritable. Jang et
al. (1996) performed a principal component analysis of the 18 scales of the
Dimensional Assessment of Personality Disorders. One of the factors,
Compulsivity, is closely related to obsessive-compulsive PD. The researchers found a heritability of 44%. Torgersen, Skre, Onstad, Evardsen, and
Kringlen (1993) factor-analyzed the Structured Interview for DSM-III-R
Personality Disorders with a sample of index twins, co-twins, siblings, and
parents and found that the Perfectionism factor had a heritability of 30%.
Clifford et al. (in Nigg & Goldsmith, 1994) found that the heritability of
obsessionality using the Leyton Obsessional Inventory yielded heritability
estimates of .46 for males and .62 for females. A study by Coolidge et al.
(2001) examined a sample of 70 monozygotic and 42 dizygotic twin pairs,
ages 4 to 15, using the Coolidge Personality and Neuropsychological Inventory for Children. The heritability of obsessive-compulsive PD was 77%.
One contrary finding was by Torgerson and Psychol (cited in Nigg & Goldsmith, 1994), who failed to find heritability of obsessivecompulsive traits in
a mostly community twin sample; however, the scale used to measure obsessive-compulsive traits was developed for the study and had unknown psychometric properties. In a molecular genetic study, a link has been found
between persistence (i.e., being hardworking, ambitious, andperfectionistic)
and two genes, one of which is related to enzymatic activity and the other to
serotonergic function (J. Benjamin et al., 2000). Thus it appears that obsessive-compulsive PD has heritability comparable to other PDs, and some preliminary molecular genetic work is assessing possible gene loci of associated
An uncontrolled trial with the selective serotonin reuptake inhibitors
sertraline and citalopram had mixed results (Ekselius & von Knorring, 1998;
for a further description of the study, see chap. 1, this volume). The remission rate for obsessive-compulsive PD after 24 weeks of treatment was 33%
for the sertraline group (ns) and 45% for the citalopram group (p < .01). The
sertraline group had a mean decrease of 0.6 criterion pre- to posttreatment;
the corresponding figure for the citalopram group was 1.1 criteria (p < .001
for both). Unfortunately, because there was no medication-free comparison


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
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


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


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


do something about it by talking to her") to a more internal focus ("It doesn't

have to be perfect").
Rumination is often a serious problem for depressed individuals with
obsessive-compulsive PD. Techniques such as thought stopping and distraction can be effective in such cases. In addition, worrying can be contained by
suggesting "worry periods" during the day, which will help the client to let go
of worries at other times.
Client-Centered, Humanistic, and Existential Therapies
Although there is little humanistic client-centered literature specific to
obsessive-compulsive PD per se, the experiential background of the person
with obsessive-compulsive PD is a classic example of what Rogers would call
"conditions of worth" (see Rogers, 1979). Millon (1996) described the
overcontrolling parenting style that predisposes one to obsessivecompulsive
They learn what they must not do, so as to avoid negative reinforcements.
. . . Compulsives learn to heed parental restrictions and rules; for them,
the boundaries of disapproved behaviors are rigidly set. However, as a
function of experiencing mostly negative injunctions, they have little
idea of what is approved; they seem to know well what they must not do,
but do not know so well what they can do. (p. 531)
In theory, a form of therapy that emphasizes consistent unconditional
positive regard would be a direct antidote to the persistent negative attention such individuals received as children. It is likely that the person with
obsessive-compulsive PD would chafe at the unstructured nature of the treatment and would initially impose his or her own structure but would gradually
come to appreciate the persistent open and accepting stance of the therapist.
Psychodynamic Therapy
There is a long history of treatment of obsessive-compulsive PD with
psychodynamic therapy. What we now call obsessivecompulsive PD is akin
to the "anal character" (Abraham, 1953/1997; Freud, 1908/1959) based on
Freud's anal phase of development; that is, the problem of the obsessivecompulsive person is thought to be rooted in fixation at the anal phase of
development. This fixation can be caused by excessive libidinal energy affixed to the anus (anal eroticism) or to issues relating to toilet training. More
relevant than toilet training per se are the associated symbolic meanings that
are being learned by the child or negotiated between parent and child, namely,
dirtiness versus cleanliness, learning self-control, the ability of the child to
defy his or her parents (e.g., by expelling or withholding urine or feces), and
so on.
According to psychodynamic theory, superficial compliant behavior is
a cover for underlying hostility:


The traits of overcontrol and inhibition of expression of aggression are

clinically observed to be compensatory defenses against the underlying
sadistic thoughts and fantasies. The underbelly of pleasurably charged
raw aggression is readily seen in the play and dreams of [obsessivecompulsive PD] children, in dramatic contrast to their constricted behavior in public. (P. Kernberg, Weiner, & Bardenstein, 2000)

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)

P. Kernberg et al. gave the example of a child who is refusing to go to a party

because it will be "boring"; the goal of psychodynamic therapy would be to
help the child become aware of the underlying fear (e.g., of rejection) or rage
(e.g., against those who would reject him) and also to let go of the denial of
feelings (i.e., saying that it will be boring, with no apparent involvement of
feelings as opposed to being overwhelmed with emotion). Typical defensive
operations among individuals with obsessivecompulsive PD include reaction formation, isolation of affect, rationalization, and displacement.
(P. Kernberg et al., 2000, p. 123)
Transference issues often reflect the ambivalence of the client regarding dominance and submission. The therapeutic relationship is generally
impacted by the client's character pathology. L. S. Benjamin (1996a) gave a
fine example:
A patient was very slow to recognize that he was depressed. He thought
he could stay "on top of" the problem if only he could get things better
organized. But the signs of depression persisted, and suddenly one day
the patient admitted he was depressed. Then he was willing to take the
prescription, but looked it up in the [Physicians Desk Reference] in order
to be aware of possible side effects. The depression continued. The patient sent the doctor reprints on recent studies of antidepressants and
questioned the prescription. The patient expressed frustration that the
right medication had not been found. He alternated between deferring



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

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



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.


The excess of males with obsessive-compulsive PD is consistent with
male dominance in the social hierarchy of Western cultures (Castillo, 1997).
Individuals with obsessive-compulsive PD tend to be obsequious toward superiors and demanding of subordinates and are thus highly aware of domi-



nance hierarchies. In certain cultures, obsessivecompulsive characteristics

may be seen as strengths, particularly by the religiously devout, among whom
scrupulous attention to the details of religious observance may be seen as
right and appropriate behavior. In the United States, religious behavior that
might appear to be symptomatic of obsessive-compulsive PD may be normative within that reference group. For example, Galanti (cited in Castillo,
1997) described a case of an Orthodox Jewish man who brought his wife to
the hospital while she was in active labor on the Sabbath. According to the
requirements of halacha (Jewish law), he could not purchase food in the cafeteria, handle money, or operate electrical devices (e.g., push the button on
the elevator or turn on the TV). These same rules would be followed by any
Orthodox Jew, regardless of personality type, and therefore do not indicate
obsessivecompulsive PD symptoms.
Obsessivecompulsive PD appears to be one of the more prevalent PDs
in populations of older adults (Devanand et al., 2000). Dimensional ratings
suggest that although overall personality and clinical dysfunction is lower in
older adults than in younger adults, older adults have elevations on obsessive-compulsive PD scales (D. L. Segal, Hook, & Coolidge, 2001). It is not
clear, however, whether these findings are due to cohort effects (e.g., values
more prevalent in prior generations), whether people tend to become more
obsessive-compulsive as they age, or if they can be accounted for by other
factors (e.g., economic considerations or other circumstances that differentially impact older adults). Longitudinal research would be necessary to clarify
these issues.


Individuals with obsessive-compulsive personality style or features have
a variety of strengths. Diligence, persistence, and a proclivity to work hard
toward one's goals are highly desirable characteristics in U.S. culture, as are
being organized, efficient, and productive. Witticisms from Ben Franklin
dating back over 200 years capture these values (e.g., "early to bed and early
to rise . . ."). A variety of awards recognize achievement and symbolize our
admiration for individuals who have been successful. In most cases, such levels cannot be achieved by talent alone; hard work is necessary. Depressed
individuals with obsessive-compulsive PD can draw on those strengths during the process of recovery. It is reliably true that the most detailed charts
and most scrupulous tracking of behavioral assignments will occur in the
somewhat obsessive-compulsive client.
Research using the Millon Clinical Multiaxial InventoryII (MCMIII; Millon, 1987a) has shown that when individuals have a primary elevation
on the Obsessive-Compulsive scale and a secondary elevation on the Nar260


cissistic scale, the overall profile tends to be in the nonpathological range;

this finding suggests that the obsessive-compulsive tendency toward hard
work and humility, combined with a belief in one's own ideas, is a relatively
healthy pattern. It is interesting to note that when the Narcissistic scale was
primary and the Obsessive-Compulsive scale was secondary, the entire profile had a variety of elevations and was moderately pathological; perhaps if
one is not willing to put in the work to back up one's ideas, problems begin to
surface. Thus in some (though not all) cases of obsessive-compulsive personality, there are healthy feelings of humility. In addition, a combination of
histrionic and obsessivecompulsive features was related to low overall
MCMI-II elevations, indicating a relatively healthy adjustment. A capacity
to be outgoing and fun loving while also being able to work hard and maintain moral boundaries is a very adaptive combination (Bockian, 1990). These
personality styles (combinations of adaptive obsessive-compulsive, histrionic,
and narcissistic features) seem common in professionals. A certain amount
of obsessive-compulsive style is necessary for the rigors of training and maintaining proficiency; a presentational flair is important for teachers, professors, and trial attorneys, among others; and confidence is helpful for achieving success in nearly any profession.


As with most treatment of individuals with PDs, there are challenges to
the establishment of a therapeutic bond with the person with obsessivecompulsive PD; this is less prominent when depression is simultaneously
present, because the client is unlikely to deny that there is a problem. A
client-centered approach emphasizing warmth, unconditional positive regard, and accurate empathy facilitates the formation of a therapeutic alliance. Consistent with the client's personality, formulation of goals should
begin as soon as possible, preferably in the first session. Behavioral techniques such as relaxation training and thought stopping can provide relatively quick relief from tension and enhance motivation to comply further
with treatment. The behavioral interventions blend well with cognitive and
interpersonal approaches. Cognitive interventions can be extremely helpful
and highly ego syntonic for the client, who generally believes that all problems have a rational solution. Interpersonal therapy can help clients to address issues that arise with others in their environments; often, they will see
their problems as being a function of others' demands, so interpersonal
conceptualizations are also likely to fit well with their worldview. Medications should be introduced judiciously, because early relief from pharmacological agents may facilitate premature termination. Couples interventions
can be essential, especially in the case of the obsessive-compulsive/histrionic marriage (as illustrated in chap. 8, this volume), and in some cases,



Therapeutic Strategies and Tactics for the

Prototypal Compulsive Personality
Balance Polarities
Identify and stabilize self-other conflict
Encourage decisive action
Counter Perpetuations
Loosen pervasive rigidity
Reduce preoccupation with rules
Moderate guilt and self-criticism
Alter constricted cognitive style
Adjust perfectionistic behaviors
Brighten solemn-downcast mood
Note. From Personality-Guided Therapy (p. 535), by T. Millon, 1999, New York: John Wiley & Sons.
Copyright 1999 by John Wiley & Sons. Reprinted with permission of John Wiley & Sons, Inc.

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.


The following case uses personality-guided therapy in a behavioral medicine setting. There are some advantages and limitations to treatment of PDs
in this setting. Some patients respond extremely rapidly to therapy, in part
because of the medical crisis that sometimes creates a strong motivation for
change and in part because of unique relationships that are available in medical
cases. The availability of a large number of patient-staff contacts in the medical setting can provide a context for rapid change (see, e.g., the case example
in chap. 7, this volume). In the case below, Ronald experienced egosyntonic personality and depressive symptoms and probably never would have
seen me were it not for the urging of a fellow hospitalized patient; relationships among patients can be another powerful catalyst for change. However,
when change does not occur rapidly, there is often little opportunity to extend treatment. Ronald was discharged once his medical treatment was done,
which gave us about 10 weeks to work together.


Ronald was a 38-year-old married Army veteran when I saw him. He

had paraplegia and used a wheelchair to ambulate. Ronald was admitted to
the spinal cord injury service for a decubitus ulcer, which is caused by excessive duration of pressure on the tissues under the pelvic bones. Individuals
with spinal cord injury usually must spend some time out of their wheelchairs
to take pressure off of sensitive areas. I did a routine intake with Ronald, who
had a number of difficulties, described below. After the intake, he was not
interested in psychotherapy. However, Ronald was experiencing chronic pain
secondary to his spinal cord injury; he was referred to me by a fellow spinallyinjured veteran whom I had treated for a pain problem using hypnosis.
On intake, I learned that Ronald worked approximately 60 hours per
week, five 12-hour days, including over an hour commute by car in each
direction. Ironically, Ronald worked as a paralegal for a law firm that handled
numerous disability rights lawsuits under the Americans with Disabilities
Act; thus, one would have thought they would be understanding of his special needs. Nonetheless, from Ronald's perspective, his boss was demanding,
and Ronald did not dare even ask for a lighter work schedule or other accommodations. It is likely, however, given Ronald's obsessive tendencies, that
his work took him far longer than it should have. Ronald was anxious that he
would lose his job if he made any waves.
Ronald's relationship with his wife seemed rather cold and distant. His
Italian American background made his behaviors and attitudes more striking, because that subculture is generally characterized by warmth, closeness,
and emotional expressiveness (Giordano & McGoldrick, 1996). He identified mainly as an American and did not seem to draw much from his Italian
Hospitalization seemed extremely comfortable to Ronald. He remained
in bed, uncomplaining, reading his newspaper and appearing quite content.
It appeared that Ronald was getting the rest and nurturance that was sorely
lacking in other areas of his life.
Ronald's primary defense mechanism was intellectualization. Perhaps
the most striking aspect of the case occurred during our first session, at which
I discussed his medical condition with him. Decubiti (also known as "pressure sores") have a large behavioral component; they can almost always be
prevented through behavioral interventions, such as pushing on armrests every
few minutes to allow blood flow to the tissue beneath the hip pointers and
avoiding excessive sitting times. Ronald's response sounded as if I were talking about another person. "How interesting," he commented as I provided
psychoeducation, including a discussion of consequences that most clients
consider dire. Without adequate pressure relief, the tissue dies; surgical corrections usually work the first time but become progressively more likely to
fail. Ultimately, the damage cannot be healed, and the patient can no longer
ambulate in a wheelchair, effectively rendering him or her bedbound and,
implicitly, either homebound or institutionalized. Ronald's expression did


not change at all; he had no apparent emotional reaction. If he had heard

any of this information before, he did not say so. I actually felt a chill go
through my bodya kind of instinctive recoiling from the deadness and disconnection from affect; though it is difficult to put into words what I was
experiencing, it might best be described as a momentary kind of existential
Ronald had two core beliefs underlying his cognitions, namely, the beliefs that he was helpless and worthless. Unpacking the meaning of these
beliefs was complex as a result of the stigmatizing impact of spinal cord
injury. Ronald believed that he could not get a new job because of the
stigma against individuals with spinal cord injury. Sadly, it is clear that
there is discrimination against individuals with spinal cord injury in the
workplace, as seen in the 76% unemployment rate (compared with 39%
preinjury) documented by the Annual Report for Model SCI Care Systems
(cited in Krause & Anson, 1997). Ronald's belief had a strong potential
basis in reality. However, Ronald would not perform the behavioral experiment of trying to get a new job. Also, individuals who experience the stigma
of spinal cord injury who are not particularly prone to depression (e.g.,
externalizers) become angry rather than depressed. "If only they would give
me a chance" or "It is unfair and illegal" are their usual battle cries. This was
not Ronald's response. He internalized the negative feelings, becoming dysthymic. The worthlessness belief fed the helplessness beliefs; it is as if he
were saying,
Because I am worthless, no one would want to hire me. I cannot stand up
to anyone, because I am powerless and have nothing to offer. All I can
do is work as hard as I can to try to show that I have some value.

Ronald's response was consistent with Castillo's (1997) conceptualization of

the conforming response to a stigmatized moral career. Unfortunately, Ronald
was not motivated to challenge these beliefs. He did not see them as modifiable; rather, he saw them simply as reality.
Though somewhat skeptical, Ronald was more open to viewing his pain
as something that could be modified. I saw him weekly for hypnotic sessions.
Although the literature generally shows no correlation between personality
and hypnotizability, in this case the client's rigidity and difficulty "letting
go"which I saw as components of his obsessive-compulsive PDslowed
progress in hypnosis. However, as compensation, Ronald was diligent in doing his homework, practicing with tapes of our hypnotic sessions. After approximately seven or eight sessions, he experienced about a 25% reduction
in his pain experience. Although this was a below-average result,2 it was still
a substantial improvement for him.

At the time, my typical result using hypnosis for pain was a 33% to 66% reduction on self-rated


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.


As demonstrated in the case example, working with depressed individuals with obsessivecompulsive PD often requires a good deal of patience.
Fortunately, if a good therapeutic bond is established, such clients can be
very persistent. It is critical to establish initial rapport, which involves carefully titrating warmth and genuineness with the client's need for distance.
Cognitive-behavioral approaches often fit well with these individuals' desire
for tangible, task focused interventions. Later, humanistic or psychodynamic
approaches, focusing on the "here and now" of the therapeutic relationship,
can enhance progress. Family systems therapy may be essential when the
client's rigidity distances significant others.
A substantial amount of additional research is needed for obsessivecompulsive PD and its relationship with depression. Biological factors in
obsessive-compulsive PD are poorly understood; of course, then, interactions
between obsessive-compulsive PD and depression are even less understood.
Medication interventions for obsessive-compulsive PD are in their infancy;
little empirical work has been done, and I have significant reservations about
existing theory. Prospective studies assessing how obsessivecompulsive PD
develops, and cross-sectional studies to assess the relationship between childhood precursors of it and associated theory-derived risk factors (e.g., the correlation between perfectionism and being exposed to a demanding parenting
style) would be a major contribution. Further work should also explore the
nature of the interaction between depression and obsessivecompulsive PD,
such as whether depression improves motivation for treatment and how improvements in one disorder lead to improvements in the other.






Code (1st initial of first name and last 4 of SS#)

Religion (circle one): Protestant, Catholic, Jewish, Muslim, Hindu, Buddhist,
Race/Ethnicity (circle one: White, African American, Hispanic, Asian,
Native American, other).
Clinical Experience: Number of years of full-time experience, master's level
or above, excluding practica, doing psychotherapy or diagnostic work (use
fractions if necessary)
Number of years of practicum experience you have (use fractions if necessary)
Have you seen this film clip before? Yes No
Please rate how much you experienced each of the following emotions in response to
the client you encountered. In common language, you might say "the client 'made
me feel
.'" You might think of this as how strongly a client "pulls for" a
particular emotion. If you can explain why you felt a particular emotion/emotions,
or can provide clarification of what you were imagining or other contextual information, please do so on the back of the form.

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

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
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



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
107. Like/Liking
108. Dislike
Tension in the:
109. neck
110. shoulders
111. back

113. leg
114. arm
115. other

116. Feeling choked or

unable to breathe
117. Heart rate
118. Sexual arousal
Pain or ache in the;
119. neck
120. shoulders
121. back
122. throat
123. leg
124- arm

125. other

126. Leaning forward

127. Leaning back
128. Arms crossed
129. Legs crossed
Heavy feeling in the:
130. neck
131. shoulders
132. back
133. throat
134. leg
135. arm
136. other

Explanation of emotional response: if you can, please provide an explanation

or context for the emotions you felt, or add any other information.
Please add any additional words, and how strongly you felt this way, here.






































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o IA


E 0


P =







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