It is rare that personality problems are the chief complaint of a patient presenting for treatment. Instead, difficulties with depression, anxiety, or external situations compel the patient into treatment. Personalitydisordered patients will often see the difficulties they encounter in dealing with other people as generally independent of their own behavior or input. They will frequently describe being victimized by others or, more globally, by “the system.” Such patients are apt to have little idea about how they got to be the way they are, how they contribute to their own problems, or how to change. Other patients are very much aware of the self-defeating elements of their problems (e.g., overdependence, inhibition, and excessive avoidance) but remain unaware of the personality aspects or the role of personal volition in change.

The typical dysfunctional beliefs and maladaptive strategies expressed in personality disorders make individuals susceptible to life experiences that impinge upon their cognitive vulnerability. Thus, the dependent personality disorder is characterized by a sensitivity to loss of love and help; the narcissistic by trauma to self-esteem; the histrionic by failure to manipulate others to provide attention and support. The cognitive vulnerability is based on beliefs that are extreme, rigid, and imperative. We speculate that these dysfunctional beliefs have originated as the result of the interaction between the individual’s genetic predisposition and exposure to undesirable influences from other people and specific traumatic events.

Among the basic components of the personality organization are sequences of different kinds of schemas that operate analogously to an assembly line. For purposes of simplification, these structures may be viewed as operating in a logical linear progression. For example, exposure to a dangerous stimulus activates the relevant “danger schema,” which begins to process the information. In sequence, then, the affective, motivational, action, and control schemas are activated. The person interprets the situation as dangerous (cognitive schema), feels anxiety (affective schema), wants to get away (motivational schema), and becomes mobilized to run away (action or instrumental schema). If the person judges that running away is counterproductive, he or she may inhibit this impulse (control schema).

In Axis I disorders, a specific mode becomes hypervalent and leads, for example, to preoccupation with loss, danger, or combat. In the case of depression, a chain reaction is set up: cognitive → affective → motivational → motor. In personally meaningful situations, the interpretation and the affect feed into the “effector loop” or action system. For instance, after her interpreting a rejection, a sad expression would sweep across Sue’s face. This process, which occurred automatically, might have served phylogenetically as a form of communication—as a distress signal, for example. Concomitantly, “action schemas” were triggered: Her own particular strategy for dealing with rejection was activated, and she experienced an impulse to go into the next room and ask Tom to reassure her. She was mobilized to act according to her stereotyped strategy. At this point, she might or might not yield to her impulse to run to Tom.

Self-appraisals and self-evaluations are important methods by which people can determine whether they are “on course.” Whereas selfappraisal may simply represent observations of the self, self-evaluation implies making value judgments about the self: good–bad, worthwhile– worthless, lovable–unlovable. Negative self-evaluations are found overtly in depression but may operate in a more subtle fashion in most of the personality disorders.

In normal functioning, this system of self-evaluations and self-directions operates more or less automatically. People may not be aware of these self-signals unless they specifically focus their attention on them. These cognitions may then be represented in a particular form labeled “automatic thoughts” (Beck, 1967). As noted earlier, these automatic thoughts become hypervalent in depression, and they are expressed in notions such as “I am worthless” or “I am undesirable.”

The self-evaluations and self-instructions appear to be derived from deeper structures: namely, the self-concepts or self-schemas. In fact, exaggerated negative (or positive) self-concepts may be the factors that move a person from being a “personality type” into having a “personality disorder.” For example, the development of a rigid view of the self as helpless may move a person from experiencing normal dependency wishes in childhood to “pathological” dependency in adulthood. Similarly, an emphasis on systems, control, and order may predispose a per- son to a personality disorder in which the systems become the master instead of the tool—namely, obsessive–compulsive personality disorder.

Even though this disorder is not included in DSM-IV-TR, we have found that a significant number of patients have behaviors and beliefs indicative of this disorder. Individuals with passive–aggressive personality disorder have an oppositional style, which belies the fact that they do want to get recognition and support from authority figures. The chief problem is a conflict between their desire to get the benefits conferred by authorities on the one hand and their desire to maintain their autonomy on the other. Consequently, they try to maintain the relationship by being passive and submissive, but, as they sense a loss of autonomy, they are inclined to resist or even to subvert the authorities.

Self-view: They may perceive themselves as self-sufficient but vulnerable to encroachment by others. (They are, however, drawn to strong figures and organizations because they crave social approval and sup-port. Hence, they are frequently in a conflict between their desire for attachment and their fear of encroachment.)

View of others: They see others—specifically, the authority figures— as intrusive, demanding, interfering, controlling, and dominating, but at the same time capable of being approving, accepting, and caring.

Beliefs: Their core beliefs have to do with notions such as “Being controlled by others is intolerable,” “I have to do things my own way,” or “I deserve approval because of all I have done.”

Their conflicts are expressed in beliefs such as “I need authority to nurture and support me” versus “I need to protect my identity.” (The same kind of conflicts are often expressed by borderline patients.) The conditional belief is expressed in terms such as “If I follow the rules, I lose my freedom of action.” Their instrumental beliefs revolve around postponing action that is expected by an authority, or complying superficially but not substantively.

Threat: The main threat or fears revolve around loss of approval and abridgement of autonomy.

Strategy: Their main strategy is to fortify their autonomy through devious opposition to the authority figures while ostensibly courting the favor of the authorities. They try to evade or circumvent the rules in a spirit of covert defiance. They are often subversive in the sense of not getting work done on time, not attending classes, and so on—ultimately self-defeating behavior. Yet, on the surface, because of their need for approval, they may seem to be compliant and cultivate the goodwill of the authorities. They often have a strong passive streak. They tend to follow the line of least resistance; they often avoid competitive situations and are interested more in solitary pursuits.

Affect: Their main affect is unexpressed anger, which is associated with rebellion against an authority’s rules. This affect, which is conscious, alternates with anxiety when they anticipate reprisals and are threatened with cutting off of “supplies.”

The key words for obsessive–compulsives are “control” and “should.” These individuals make a virtue of justifying the means to achieve the end to such an extent that the means becomes an end in itself. To them, “orderliness is godliness.”

Self-view: They see themselves as responsible for themselves and others. They believe they have to depend on themselves to see that things get done. They are accountable to their own perfectionistic conscience. They are driven by the “shoulds.” Many of the people with this disorder have a core image of themselves as inept or helpless. The deep concern about being helpless is linked to a fear of being overwhelmed, unable to function. In these cases, their overemphasis on systems is a compensation for their perception of defectiveness and helplessness.

View of others: They perceive others as too casual, often irresponsible, self-indulgent, or incompetent. They liberally apply the “shoulds” to others in an attempt to shore up their own weaknesses.

Beliefs: In the serious obsessive–compulsive disorder, the core beliefs are “I could be overwhelmed,” “I am basically disorganized or disoriented,” “I need order, systems, and rules in order to survive.” Their conditional beliefs are “If I don’t have systems, everything will fall apart,” “Any flaw or defect in performance will produce a landslide,” “If I or others don’t perform at the highest standards, we will fail,” “If I fail in this, I am a failure as a person,” “If I have a perfect system, I will be successful/happy.” Their instrumental beliefs are imperative: “I must be in control,” “I must do virtually anything just right,” “I know what’s best,” “You have to do it my way,” “Details are crucial,” “People should do better and try harder,” “I have to push myself (and others) all the time,” “People should be criticized in order to prevent future mistakes.” Frequent automatic thoughts tinged with criticalness are “Why can’t they do it right?” or “Why do I always slip up?”

Threats: The main threats are flaws, mistakes, disorganization, or imperfections. They tend to “catastrophize” that “things will get out of control” or that they “won’t be able to get things done.”

Strategy: Their strategy revolves around a system of rules, standards, and “shoulds.” In applying rules, they evaluate and rate other people’s performance as well as their own. In order to reach their goals, they try to exert maximum control over their own behavior and that of others involved in carrying out their goals. They attempt to assert control over their own behavior by “shoulds” and self-reproaches, and over other people’s behavior by overly directing, or disapproving and punishing them. This instrumental behavior amounts to coercing and slave driving themselves or others.

Affect: Because of their perfectionistic standards, these individuals are particularly prone to experience regrets, disappointment, and anger toward themselves and others. The affective response to their anticipation of substandard performance is anxiety or anger. When serious “fail- ure” does occur, they may become depressed.

The key word for narcissistic personality disorder is “self-aggrandizement.”

Self-view: The narcissistic personalities view themselves as special and unique—almost as princes or princesses. They believe that they have a special status that places them above ordinary people. They consider themselves superior and entitled to special favors and favorable treatment; they are above the rules that govern other people.

View of others: Although they may regard other people as inferior, they do not do this in the same sense as do the antisocial personalities. They simply see themselves as prestigious and as elevated above the average person; they see others as their vassals and potential admirers. They seek recognition from others primarily to document their own grandiosity and preserve their superior status.

Beliefs: The core narcissistic beliefs are as follows: “Since I am special, I deserve special dispensations, privileges, and prerogatives,” “I’m superior to others and they should acknowledge this,” “I’m above the rules.” Many of these patients have covert beliefs of being unlovable or helpless. These beliefs emerge after a significant failure and form core elements in the patients’ depression.

The conditional beliefs are, “If others don’t recognize my special status, they should be punished,” “If I am to maintain my superior status, I should expect others’ subservience.” On the other hand, they have negatively framed beliefs such as, “If I’m not on top, I’m a flop.” Thus, when they experience a significant defeat, they are prone to a catastrophic drop in self-esteem. The instrumental belief is, “Strive at all times to demonstrate your superiority.”

Strategy: Their main plans revolve around activities that can reinforce their superior status and expand their “personal domain.” Thus, they may seek glory, wealth, position, power, and prestige as a way of continuously reinforcing their superior image. They tend to be highly competitive with others who claim an equally high status and will resort to manipulative strategies to gain their ends.

Unlike the antisocial personality, they do not have a cynical view of the rules that govern human conduct; they simply consider themselves exempt from them. Similarly, they do regard themselves as part of society, but at the very top stratum.

Affect: Their main affect is anger when other people do not accord them the admiration or respect to which they believe they are entitled, or otherwise thwart them in some way. They are prone to becoming depressed, however, if their strategies are foiled. For example, psychothera- pists have treated several “inside traders” on Wall Street who became depressed after their manipulations were discovered and they were publicly disgraced. They believed that by tumbling from their high position, they had lost everything.

People with obsessive–compulsive personality, in marked contrast to histrionics, “miss the forest for the trees.” These persons focus so much on details that they miss the overall pattern; for example, a person with this disorder may decide on the basis of a few flaws in another person’s performance that the other person has failed, even though the flaws may have simply represented some variations in an overall successful performance. Further, in contrast to histrionics, people with obsessive–compulsive personality disorder tend to minimize subjective experiences. Thus, they deprive themselves of some of the richness of life and of access to feelings as a source of information that enhances the significance of important events

As defined by the fourth edition of the Diagnostic and Statistical Manual of the Mental Disorders (DSM-IV; American Psychiatric Association, 1994), a personality disorder is “an enduring pattern of inner ex- perience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment” (p. 633). The pattern is manifested in two (or more) of the following areas: (1) cognition (i.e., ways of perceiving and interpreting self, other people, and events), (2) affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response), (3) interpersonal functioning, and (4) impulse control.

Given this definition, clinicians should keep two critical questions in mind when determining whether a personality disorder diagnosis is warranted:

1. Do the relevant inner experiences and behaviors represent inflexible, pervasive, and long-standing patterns and not just tran- sient or episodic effects related to a patient’s current psychiatric state?

2. Do these long-standing patterns create significant distress or significantly impair functioning across multiple domains (e.g., so- cial and occupational)?

Such judgments are ultimately left to the clinician as no distinct cutting points have been proposed or identified empirically to establish the boundaries between pathological and normal personality, between personality disorders and Axis I disorders, or between the various personality disorders themselves (Zimmerman, 1994).

1. The patient believes therapy is a passive or magical process. As part of the clinical picture, some Axis II patients see both problems and solutions as external to themselves. They may appear to be highly motivated, but their motivation is to simply absorb some curative effect from being around the therapist. Some believe that it is the therapist’s job to do all the work, with little or no input from them, and they hope to gain both insight and behavioral change from the remarkable observations and directions that the therapist will provide. They may idealize or flatter the therapist initially but easily become defensive or disenchanted with the expectations of productive therapy.

Clinical Example: Carolyn, a 40-year-old housewife with no children, entered therapy to “figure herself out” after a friend recommended cognitive ther- apy as a productive alternative to psychoanalysis. She had a history of recurrent depression and a personality disorder combining narcissistic and dependent features. After thorough explanation of the parameters of cognitive therapy and the importance of patient involvement, Carolyn remained vague about pinpointing any problems or goals, telling the therapist, “I expect you to figure that out.” The homework of planning one or two items for the session agenda was explicitly assigned several times, and each time Carolyn returned for the following ses- sion without anything for the agenda but a pleasantly stated redirection of the session agenda to the therapist. When gently prompted for greater participation in the session structure, Carolyn became defensive and scolded the therapist for not meeting her expectations for advice and instructions.