Personality Disorders
Edited by ROBERT E. FEINSTEIN
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Library of Congress Cataloging-in-Publication Data
Names: Feinstein, Robert E., editor.
Title: Personality disorders / [edited by] Robert E. Feinstein. Other titles: Primer on.
Description: New York, NY : Oxford University Press, [2022] | Series: Primer on series | Includes bibliographical references and index.
Identifiers: LCCN 2021031225 (print) | LCCN 2021031226 (ebook) | ISBN 9780197574393 (pb) | ISBN 9780197574416 (epub) | ISBN 9780197574423
Subjects: MESH: Personality Disorders
Classification: LCC RC554 (print) | LCC RC554 (ebook) | NLM WM 190 | DDC 616.85/81—dc23
LC record available at https://lccn.loc.gov/2021031225
LC ebook record available at https://lccn.loc.gov/2021031226
DOI: 10.1093/med/9780197574393.001.0001
This material is not intended to be, and should not be considered, a substitute for medical or other professional advice. Treatment for the conditions described in this material is highly dependent on the individual circumstances. And, while this material is designed to offer accurate information with respect to the subject matter covered and to be current as of the time it was written, research and knowledge about medical and health issues is constantly evolving and dose schedules for medications are being revised continually, with new side effects recognized and accounted for regularly. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulation. The publisher and the authors make no representations or warranties to readers, express or implied, as to the accuracy or completeness of this material. Without limiting the foregoing, the publisher and the authors make no representations or warranties as to the accuracy or efficacy of the drug dosages mentioned in the material. The authors and the publisher do not accept, and expressly disclaim, any responsibility for any liability, loss, or risk that may be claimed or incurred as a consequence of the use and/or application of any of the contents of this material.
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Editorial Note
Dear Reader,
Robert E. Feinstein, MD Thank you for purchasing this primer on personality disorders. In this volume, Dr. Feinstein, as editor and expert in the field, recruited other international experts in personality constructs and disorders in order to provide a single source covering what are sometimes difficult and mystifying individuals to manage in our clinical practices. This book therefore introduces to early-stage and other practitioners the current evidence about how to conceptualize personality disorders, make diagnoses under current classification systems, and the multifactorial approach to management necessary for best outcomes. Although personality disorders are common and commonly comorbid in psychiatric and other mental health practices, they are often not well understood. This book, then, addresses this important knowledge gap. We believe you will find it to be exceptionally informative and helpful to you in your work.
This volume is part of the Oxford University Press “Primer On” series; I am honored to lead this series since 2016 and was particularly pleased to join an already successful venture. The “Primer On” ’ series has been designed specifically to support psychiatry residents, earlystage practicing psychiatrists, psychology graduate students, and other interested medical trainees and practitioners. Specifically, in this series we have asked international experts to create books that focus on a specific set of conditions to provide the basic science and clinical tools to diagnose, treat and manage these major psychiatric disorders. We have also expanded the scope of the series to provide this audience information and guidance to major aspects of mental health care practices. With these considerations in mind, each volume is written with an eye toward early-stage practitioners to present current evidence and recommendation in a format that is user-friendly and informative. These texts complement other resources, such as the Oxford American Psychiatry Library, by offering more comprehensive basic and clinical knowledge so that psychiatric and other trainees can better understand these disorders in ways that will prepare them for clinical practice and fellowships (and to take board exams). As they are released, each volume will be available in print, e-book, and Oxford Medicine Online (http://oxfordmedicine.com/). We have aimed to make these affordable books that bridge handbooks and more lengthy and expensive highly specialized textbooks. I hope you enjoy this text!
Best wishes Steve Strakowski, MD
Vice Dean of Research
Associate Vice President, Regional Mental Health Dell Medical School, University of Texas at Austin Series Editor
Preface ix
Acknowledgments xi
Contributors xiii
I. OVERVIEW
1. The Personality Syndromes 3 Jonathan Shedler
2. Levels of Personality Organization: Theoretical Background and Clinical Applications 33 Eve Caligor, John F. Clarkin, and Julia F. Sowislo
3. Pathways Between Psychological Trauma and the Development of Personality Disorders 59 Valerie Rosen, Gregory Fonzo, Emily Rosen, and Alex Preston
4. Integrating Clinical and Empirical Approaches to Personality: The Shedler-Westen Assessment Procedure (SWAP) 87 Jonathan Shedler
II. MULTI-THEORETICAL TREATMENTS OF PERSONALITY DISORDERS
5. Crossing the Alphabet Divide: Navigating the Evidence for DBT, GPM, MBT, ST, and TFP for BPD 111 Kenneth N. Levy, Benjamin N. Johnson, and Haruka Notsu
6. The Big 6: Evidence-based Therapies for the Treatment of Personality Disorders 137 Robert E. Feinstein
7. Managing Patients with Personality Disorders in Medical Settings 179 Robert E. Feinstein
8. Transference-focused Psychotherapy 213 Christopher Green and Frank Yeomans
9. Mentalization-based Treatment 237
Robert P. Drozek and Jonathan T. Henry
10. Cognitive-behavioral Therapy 259
Matthew W. Southward, Stephen A. Semcho, and Shannon Sauer-Zavala
11. Dialectical Behavior Therapy 283
Sheila E. Crowell, Parisa R. Kaliush, Robert D. Vlisides-Henry, and Nicolette Molina
12. Schema Therapy 313
Anja Schaich, Eva Fassbinder, and Arnoud Arntz
13. Good Psychiatric Management (GPM) for Borderline Personality Disorder 339
Richard G. Hersh, Benjamin McCommon, Emma Golkin, and Jennifer Sotsky
14. Employing Psychodynamic Process-oriented Group Psychotherapy with Personality Disorders 363
Kenneth M. Pollock and Robert E. Feinstein
15. Psychopharmacology of Personality Disorders 393
Tawny L. Smith and Samantha M. Catanzano
III. PERSONALITY DISORDERS
16. Paranoid Personalities (Vigilant Style) 421
Royce Lee and Edwin Santos
17. Some Thoughts about Schizoid Dynamics 441 Nancy McWilliams
18. Antisocial Personalities 459
Glen O. Gabbard
19. Borderline Personality Disorder 473
Curtis C. Bogetti and Eric A. Fertuck
20. Histrionic Personality Disorder 501 Michelle Magid and Isadora Fox
21. Narcissistic Personality Disorder 523
Alyson A. Gorun, Benjamin A. Scherban, and Elizabeth L. Auchincloss
22. Avoidant Personality Disorder 545
Len Sperry and Gerardo Casteleiro
23. Dependent Personalities 565
Robert F. Bornstein and Adam P. Natoli
24. Obsessive-compulsive Personality Disorder 589 Cynthia Playfair
25. Masochistic/Self-defeating Personality Styles 613
Robert Alan Glick and Brenda Berger
Preface
Much has been written about personality disorders (PDs) and their treatments over the last 120 years. This began with descriptions of the PDs and psychoanalytic treatment early in the last century and progressed to the modern era of diverse conceptualization and treatments for patients with PDs (see Chapter 14 for a brief history). The PDs were diagnostically codified using the multiaxial system of the Diagnostic and Statistical Manual of Mental Diseases (DSM) III in 1980 and the DSM-IV in 1994. The multiaxial system, listing the PDs on Axis II, signaled the importance of treating the PDs in their own right as well as the importance of treating the PDs as comorbid disorders affecting the treatment and outcomes of other major mental conditions (Axis I disorders).
PDs have estimated worldwide prevalence rates of 12.6 percent, making them a cluster of very common disorders.1 Psychosocial functioning of patients with PDs compared to patients with other mental disorders reveals that patients with PDs are more likely to be without partners, unemployed, disabled, and demonstrating significant impairments in social, occupational, leisure, and global functioning.2 Patients with PDs have a more significant disability than the disability caused by any Axis I disorder, including major depressive disorder.2 While PDs significantly affect the treatment and outcome of depression, bipolar disorder, eating disorders, addiction, and so on, treatments of these and other common mental disorders have no ability to modify personality functioning and have no helpful impacts on the treatment of PDs. However, since the 1990s there has been an explosion of many effective treatments for PDs.
The “Big Six,” as I call them, are major evidence-based treatments for borderline personality disorders (BPDs). These treatments include transference-focused psychotherapy (TFP), mentalization-based treatment (MBT), cognitive behavioral therapy (CBT) for PDs, dialectical behavior therapy (DBT), schema therapy (ST), and good psychiatric management (GPM). There are now data from meta-analyses and some RCTs (see Chapter 5) that reveal these treatments are likely equally effective. This suggests that despite very different theoretical perspectives espousing treatment superiority, it may be that common factors across these approaches account for similar outcomes (see chapter 6). While the Big Six have much in common, it is also the case that each treatment has unique features that could be incorporated or borrowed from one evidencebased therapy (EBT) to another to improve therapeutic responsiveness to the needs of individual patients. The book explores this possibility.
While developed to treat BPD, these EBTs are also currently broadening their scope to see if these diverse psychotherapeutic modalities are also useful for the treatment of other PDs and other conditions. The data on the effectiveness of this approach, for all the
1 Volkert J, Gablonski TC, Rabung S. Prevalence of personality disorders in the general adult population in Western countries: systematic review and meta-analysis. Br J Psychiatry. 2018: 213(6):709–715.
2 Skodol AE. Impact of personality pathology on psychosocial functioning. Curr Opin Psychol 2018: 1(21):33–38.
PDs, remain to be determined by further research. For clinicians, despite this current limitation, the authors of each chapter were encouraged travel in these uncertain waters recommending their treatment approach based on some evidence, the clinical literature, and/or their own expertise, when no clear definitive evidence for specific treatments for each of the PDs is available.
Many chapters in the book were written or co-authored by master clinicians and/ or researchers and their students. This collaboration was intentionally encouraged, as I hoped it would make this book read more as a “how to understand” and “how to do psychotherapy” with patients suffering with PDs, rather than as a textbook on the PDs.
The book is divided into three sections.
Section 1 provides an overview of the diagnosis, assessment, clinical, and research approaches to working with PDs. It reviews prototypic personality syndromes, levels of personality organization, pathways from trauma to PDs, and a psychodynamic, integrated clinical and empirical approach to working with patients who have PDs.
Section II reviews multi-theoretical approaches to treatment of PDs. It covers six evidenced-based treatments designed to treat BPD, management of PDs in medical settings, psychopharmacology, and group therapy for the PDs. These diverse viewpoints help readers understand current theories about the origin and nature of the personality and how one can apply these principles to everyday care and treatment of patients.
Section III covers 10 major specific PDs, written from diverse theoretical perspectives. It is chock full of clinical illustrations and the wisdom from master clinicians when evidence-based treatment approaches are not yet known.
This book was written by 51 authors, representing diverse multi-theoretical viewpoints. I am especially appreciative of the good-natured and productive dialogue that emerged with all authors during the editorial process. I cannot thank the authors enough for their wonderful collaborative efforts and contributions.
It was very important to the editor and authors that this book contains theory and practices which could be widely applied to the treatment of our many patients who suffer with PDs. We hope that the book is comfortably accessible for use by mental health students, psychiatric residents, psychologists, social workers, faculty, and the widest scope of health professionals.
I am eager to know your reaction and comments about this work, as this kind of dialogue was the energy source for this book. Your reaction will ultimately determine the book’s usefulness.
Robert E. Feinstein, MD, Editor
Acknowledgments
I am very appreciative of my personal cyberspace editor Richard Carlin from New Jersey, whom I have never met in person because of Covid-19. His smarts, efficiencies, and detailed editing for style, formatting, and consistency was invaluable.
As in all my writing, I am exceeding grateful to my wife Marilyn for her encouragement, comments, and edits on my own chapters in this book.
I would also like to thank Oxford’s Primer Series editor, Steven Strakowski, and all those working at Oxford University Press for offering me the opportunity and for ultimately making this publication possible.
Contributors
Prof. Dr. Arnoud Arntz, PhD Department of Clinical Psychology University of Amsterdam Amsterdam, The Netherlands
Elizabeth L. Auchincloss, MD Professor and Vice-chair, Education Department of Psychiatry
Weill-Cornell Medical College New York, NY, USA
Aaron Stern MD, PhD Professor of Psychodynamic Psychiatry Department of Psychiatry
Weill-Cornell Medical College New York, NY, USA
Brenda Berger, PhD
Clinical Assistant Professor of Medical Psychology in Psychiatry
Columbia University Center for Psychoanalytic Training and Research Columbia University New York, NY, USA
Curtis C. Bogetti, BS Doctoral Student Department of Psychology
The City College of New York, City University of New York New York, NY, USA
Robert F. Bornstein, PhD Professor
Derner School of Psychology Adelphi University Garden City, NY, USA
Eve Caligor, MD
Clinical Professor of Psychiatry
Columbia University Vagelos College of Physicians and Surgeons
New York, NY, USA
Gerardo Casteleiro, PhD Adjunct Professor
Clinical Mental Health Counseling Program
Florida Atlantic University
Boca Raton, FL, USA
Samantha M. Catanzano, PharmD, BCCP
Clinical Assistant Professor College of Pharmacy
The University of Texas Austin, TX, USA
John F. Clarkin, PhD
Clinical Professor of Psychology in Psychiatry
New York Presbyterian Hospital-Weill Medical College of Cornell University White Plains, NY, USA
Sheila E. Crowell, PhD
Associate Professor Department of Psychology, Department of Psychiatry Department of Obstetrics and Gynecology University of Utah Salt Lake City, UT, USA
Robert P. Drozek, LICSW
Therapist and Supervisor, Mentalizationbased Treatment Clinic, McLean Hospital Teaching Associate, Department of Psychiatry, Harvard Medical School Belmont, MA, USA
Eva Fassbinder, MD Department of Psychiatry and Psychotherapy Christian-Albrechts-University Kiel Niemannsweg, Kiel, Germany
Robert E. Feinstein, MD Professor of Psychiatry Department of Psychiatry
Donald and Barbara Zucker School of Medicine at Northwell/Hofstra
Zucker Hillside Hospital Long Island, NY, USA
xiv Contributors
Eric A. Fertuck, PhD
Associate Professor Department of Psychology
The City College of New York, City University of New York
New York, NY, USA
Gregory Fonzo, PhD
Assistant Professor Department of Psychiatry and Behavioral Sciences
Dell Medical School, University of Texas Austin, TX, USA
Isadora Fox, DNP, APRN, PMHNP-BC, APRN-BC
Doctor of Nursing Practice
Austin PsychCare Austin, TX, USA
Glen O. Gabbard, MD Clinical Professor
Department of Psychiatry
Baylor College of Medicine Houston, TX, USA
Robert Alan Glick, MD Professor of Clinical Psychiatry, Columbia University
Former Director of the Columbia University Center for Psychoanalytic Training and Research
New York, NY, USA
Emma Golkin, MD Fellow, Public Psychiatry Department of Psychiatry Columbia University/New York State Psychiatric Institute New York, NY, USA
Alyson A. Gorun, MD
Assistant Professor Department of Clinical Psychiatry
Weill-Cornell Medical College
New York, NY, USA
Christopher Green, MD Private Practice
New York, NY, USA
Jonathan T. Henry, MD, PhD
Medical Director, Addiction Treatment Program
Department of Psychiatry
Jesse Brown Veterans Administration Medical Center
Chicago, IL, USA
Richard G. Hersh, MD
Special Lecturer
Columbia University College of Physicians and Surgeons
New York, NY, USA
Benjamin N. Johnson, MS Doctoral Student Department of Psychology
The Pennsylvania State University University Park, PA, USA
Parisa R. Kaliush, MS Department of Psychology
University of Utah Salt Lake City, UT, USA
Royce Lee, MD
Associate Professor Department of Psychiatry and Behavioral Neuroscience
University of Chicago Chicago, IL, USA
Kenneth N. Levy, PhD Associate Professor Department of Psychology
The Pennsylvania State University University Park, PA, USA
Michelle Magid, MD, MBA President, Austin Psychcare, PA
Associate Professor University of Texas Dell Medical School Austin, TX, USA
Adjunct Associate Professor
Texas A&M Health Science Center
Bryan, TX, USA
Benjamin McCommon, MD
Assistant Clinical Professor Department of Psychiatry
Columbia University College of Physicians and Surgeons
New York, NY, USA
Nancy McWilliams, PhD
Visiting Full Professor
Graduate School of Applied and Professional Psychology
Rutgers University Piscataway, NJ, USA
Nicolette Molina, BA PhD Student Department of Psychology University of Utah Salt Lake City, UT, USA
Adam P. Natoli, PhD Assistant Professor Department of Psychology and Philosophy
Sam Houston State University Huntsville, TX, USA
Haruka Notsu, MS Doctoral Student Department of Psychology
Pennsylvania State University University Park, PA, USA
Cynthia Playfair, MD
Private Practice, Affiliate Faculty, University of Texas at Austin, Dell Medical School Department of Psychiatry Supervising and Training Psychoanalyst, Center for Psychoanalytic Studies Houston, TX, USA
Kenneth M. Pollock, PhD, CGP
Clinical Associate Professor (retired) Department of Psychiatry New York Medical College Valhalla, NY, USA
Former Director of Group Psychotherapy Training Westchester Medical Center Poughkeepsie, NY, USA
Alex Preston, MD
Resident
Department of Psychiatry
University of Arkansas for Medical Sciences Little Rock, AR, USA
Emily Rosen, MD
Resident
Department of Psychiatry and Behavioral Sciences
George Washington University Washington, DC, USA
Valerie Rosen, MD Associate Professor Department of Psychiatry and Behavioral Sciences
Dell Medical School, The University of Texas at Austin
Seton Mind Institute Austin, TX, USA
Edwin Santos Research Intern Department of Psychiatry and Behavioral Neurosciences
Biological Sciences Division The University of Chicago Chicago, IL, USA
Shannon Sauer-Zavala, PhD Assistant Professor Department of Psychology University of Kentucky Lexington, KY, USA
Anja Schaich, Dr. rer. hum. biol. / MSc Psychotherapist Department of Psychiatry and Psychotherapy University of Lübeck
Ratzeburger Allee, Lübeck, Germany Department of Psychiatry and Psychotherapy, Christian-Albrechts-University Kiel, Niemannsweg, Kiel, Germany
Benjamin A. Scherban, MD Resident Psychiatrist New York Presbyterian Hospital New York, NY, USA
Stephen A. Semcho, MS Graduate Researcher Department of Psychology University of Kentucky Lexington, KY, USA
Jonathan Shedler, PhD Clinical Professor
Department of Psychiatry University of California, San Francisco San Francisco, CA, USA
Tawny L. Smith, PharmD, BCPP
Associate Professor Department of Psychiatry and Behavioral Sciences
Dell Medical School, The University of Texas Austin, TX, USA
Jennifer Sotsky, MD
Consultation-Liaison Fellow
Columbia University Irving Medical Center
New York, NY, USA
Matthew W. Southward, PhD
Postdoctoral Scholar
Department of Psychology University of Kentucky Lexington, KY, USA
Julia F. Sowislo, PhD
Instructor of Psychology in Psychiatry
Department of Psychiatry
New York Presbyterian Hospital-Weill Medical College of Cornell University Westchester Division
White Plains, NY, USA
Len Sperry, MD, PhD
Clinical Professor
Department of Psychiatry and Behavioral Medicine
Medical College of Wisconsin Milwaukee, WI, USA Professor Clinical Mental Health Counseling Program
Florida Atlantic University
Boca Raton, FL, USA
Robert D. Vlisides-Henry, MS PhD Candidate Department of Psychology University of Utah Salt Lake City, UT, USA
Frank Yeomans, MD, PhD
Clinical Associate Professor Department of Psychiatry
Weill-Cornell Medical College New York, NY, USA
Diagnosis as Pattern Recognition
Each personality syndrome discussed in this chapter is represented by a paragraphlength description called a diagnostic prototype, which describes the personality syndrome in its “ideal” or pure form.4,14–15 These diagnostic prototypes are evidence based. They were derived empirically, based on a national sample of N = 1,201 patients described by their clinicians using the Shedler-Westen Assessment Procedure (SWAP). They reflect empirically observable characteristics of actual patients, not just theoretical conjecture.
Naturally occurring diagnostic groupings were identified using statistical clustering methods, which largely confirmed the personality syndromes described in the clinical literature. The SWAP items (descriptive statements) that best describe each personality syndrome were likewise identified empirically, then arranged as paragraphs to create the diagnostic prototypes.4 (The SWAP instrument is described in Chapter 4, Integrating Clinical and Empirical Approaches to Personality: The Shedler-Westen Assessment Procedure (SWAP). The instrument is available at https://swapassessment.org.)
The diagnostic prototypes have the advantage of being empirically based and also preserving the richness and complexity of accrued clinical knowledge. To make a personality diagnosis, a clinician rates the overall resemblance or match between a patient and a diagnostic prototype from 0 (no match) to 5 (very good match). Higher scores indicate more resemblance to the diagnostic prototype and more severity. The diagnostic prototypes are presented in Boxes 1.1 to 1.10 and the rating scale is included with each prototype. If categorical diagnosis is desired for compatibility with the DSM-5 or International Classification of Diseases (ICD-10) diagnostic system, scores of 4 and 5 indicate a personality disorder diagnosis, and a score of 3 indicates traits or features of a disorder. Thus, if a patient receives a score of 5 for narcissistic personality and 3 for obsessivecompulsive personality, the categorical (DSM format) diagnosis is narcissistic personality disorder with obsessive-compulsive traits.
The premise of this approach is that a configuration or pattern of interrelated psychological characteristics defines a personality syndrome, not the presence or absence of separate characteristics. Recognizing a personality syndrome is pattern recognition, much as recognizing a face depends on pattern recognition, not tabulating separate features.4,14,15
Prototype matching provides reliable and valid diagnoses and works with the cognitive decision processes of clinicians, which rely on pattern recognition. It systematizes what expert clinicians already do in practice. In a consumer-preference study, psychologists and psychiatrists preferred this method of personality diagnosis to the DSM diagnostic system and to dimensional trait models of personality.16
Developing a Treatment Focus
In recent years, many clinicians have been trained to focus on presenting problems and DSM Axis I disorders (such as depression or generalized anxiety) and view them as encapsulated conditions separate from personality. Treatments that target specific DSM disorders implicitly assume all patients with a given DSM diagnosis have the “same”
condition and will respond to the same interventions. Clinicians learn the hard way that things are rarely so simple.
Most often, the problems that bring people to mental health treatment are not encapsulated problems. They are woven into the fabric of their lives. They are embedded in, and inseparable from, the person’s characteristic patterns of thinking, feeling, behaving, coping, defending, and relating to others: in other words, personality. This is true whether or not the person has a diagnosable “personality disorder.” The patient needs the clinician to grasp something psychologically systemic about who they are, not just what disorders they have, to help them understand why they are repeatedly vulnerable to certain kinds of suffering and how to change it.
Meaningful and lasting change generally comes not from focusing on symptoms, but on the personality patterns that underlie them. Knowledge of personality styles provides a map of the personality terrain that expert clinicians navigate. Thus, each personality syndrome is not just description, but shorthand for the broad strokes of a clinical case formulation that can provide a treatment focus and address the underlying causes of many patients’ suffering. The penultimate section of this chapter, Personality and Clinical Case Formulation, revisits this topic.
The Personality Syndromes
This section describes the major personality syndromes as understood by clinical theorists and confirmed by empirical research. The diagnostic prototypes and rating scales in Boxes 1.1 to 1.10 can be used for day-to-day clinical diagnosis.
Depressive Personality
Despite its omission from the DSM, depressive personality is the most common personality syndrome seen in clinical practice.2 It is a personality syndrome in every sense of the term: an enduring pattern of psychological functioning evident by adolescence and encompassing the full spectrum of personality processes.
People with depressive personalities are chronically vulnerable to painful affect, especially feelings of inadequacy, sadness, guilt, and shame. They have difficulty recognizing their needs, and when they do recognize them, they have difficulty expressing them. They are often conflicted about allowing themselves pleasure. They may seem driven by an unconscious wish to punish themselves, either by getting into situations destined to cause pain or depriving themselves of opportunities for enjoyment. A psychologically insightful observer might describe the person as their own worst enemy.
Where there is an enemy, there is often anger and aggression. One underlying psychological theme in depressive personality is internal attacks against the self. The person is angry, defends against experiencing anger, and instead directs it at themselves in the form of self-criticism, self-deprivation, and self-punitiveness. The relevant SWAP item is, “Has trouble acknowledging or expressing anger toward others and instead becomes depressed, self-critical, self-punitive, etc.” In short, the person treats themselves like someone they despise.
Clinicians can easily miss the patient’s anger and aggression because people with depressive personalities tend to be overtly agreeable and put others’ needs first,
including the clinician’s needs. If psychotherapy is to bring about meaningful psychological change, anger must be recognized, experienced, and explored in the therapy relationship.
A second psychological theme involves separation, rejection, and loss. The person may be preoccupied with, and painfully vulnerable to, disruptions in interpersonal relationships. They fear being abandoned and left unprotected and uncared for. As a result, they avoid interpersonal conflict and have difficulty asserting themselves. Undue people-pleasing and helpfulness protect against disapproval or rejection. In psychotherapy, they suppress legitimate criticisms and dissatisfactions for fear of hurting the clinician’s feelings or damaging the therapy relationship. Instead of communicating their needs and wants, they accept what is offered and make do. This can lead to a relationship dynamic in which the clinician thinks things are going swimmingly and the patient does without, thereby recreating the patient’s dysfunctional relationship pattern in the therapy relationship.
This pattern may have roots in relational disruption or insufficient emotional availability of a caretaker in early development, leaving the person feeling emotionally empty and incomplete, and believing their deprivation was caused by their own badness. Some patients have a pervasive sense that someone or something essential to their well-being has been lost and can never be recovered. These feelings can crystalize around, and be amplified by, subsequent experiences of loss. Rewards and pleasures that are realistically available may be experienced as a pale shadow of what was lost or could have been. Such patients may need the clinician’s help to mourn what has been lost before they can invest emotionally in what life can offer now.
For some patients with depressive personalities, themes of unconscious anger and self-attack predominate. For others, themes of separation and loss predominate. These themes have been discussed in the clinical and research literature in terms of introjective (self-critical) and anaclitic (dependent) depression.17,18 Both themes may be present in any blend.
Depressive personality is the most common personality style among people drawn to the mental health professions.19 Clinical practitioners have endless opportunity to care for others instead of themselves, be unduly helpful, and fault themselves for falling short of unrealistic, self-imposed standards.
See Box 1.1, p. 8 for the depressive personality prototype.
Anxious-Avoidant Personality
The term “Avoidant Personality Disorder” is used by the DSM and is more familiar to clinicians, but the hyphenated term “anxious-avoidant” more accurately and telegraphically conveys the essence of this personality syndrome.
People with anxious-avoidant personalities are, first and foremost, anxious. Anxiety pervades their experience of themselves and their world. They ruminate and dwell on perceived dangers and past mistakes. Their predominant emotions are anxiety, shame, and embarrassment. They defend against sources of anxiety by avoidance. The problem is that the sources of anxiety are everywhere, including within. Ultimately, avoidant responses become bars in a psychological prison, constricting and limiting freedom of thought, feeling, choice, and action. As a result, people with anxious-avoidant personalities lead constricted lives and tend to adhere to familiar routines. Despite their avoidant
