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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.
requires vigilance!
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:
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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?
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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).
- 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.
Situation: Patient arrives late; persists with dramatic storytelling; breaks into sobs when therapist redirects to agenda setting.
Emotion: Frustrated / Disappointed / Uncertain / Embarrassed
Automatic thought(s): This patient will never get it! / We are making no progress using cognitive therapy. / I don’t know what to do next. I must be ineffective with this approach.
Rational response: Contempt on my part will not help, so I could avoid such eternalized judgments and be more sympathetic. She is showing more skill in labeling affect, and identifying thoughts. Also, I’m focusing on the importance of making a list when her obvious priority is interpersonal support. I need to respect her values, help her learn to define problems, and not give up. Just because I feel uncertain does not mean I am ineffective, or have committed any shameful action. My discomfort comes from believing all patients must change quickly, and if they don’t, it’s my fault. Does it make sense that an effective therapist “never” feels uncertain? I can brainstorm some options to try next.
sick
Paranoid individuals have a strong tendency to blame others for interpersonal problems, usually can cite many experiences which seem to justify their convictions about others, are quick to deny or minimize their own problems, and often have little recognition of the ways in which their behavior contributes to their problems. Thus, when an assessment is based on the client’s self-report, it can easily appear that the client’s suspicions are justified or that the problems are due to inappropriate actions by others. In addition, because the characteristics of paranoia are understood to some extent by most laymen, paranoid individuals are likely to recognize that others consider them to be paranoid, and to realize that it is prudent to keep their thoughts to themselves. When this is the case, indications of paranoia tend to emerge only gradually over the course of therapy and may easily be missed.
Often it is easiest to identify paranoid individuals by watching for characteristics other than blatantly unrealistic suspicions. Table 6.2 presents a number of possible signs of a paranoid personality style which may be early indications of PPD. Individuals with PPD are typically quite vigilant, tend to interpret ambiguous situations as threatening, and are quick to take precautions against perceived threats. They frequently are perceived by others as argumentative, stubborn, defensive, and unwilling to compromise. They also may manifest some of the characteristics they perceive in others, being seen by others as devious, deceptive, disloyal, hostile, and malicious.
Thus, antisocial patients’ automatic thoughts and reactions are frequently distorted by self-serving beliefs that emphasize immediate, personal satisfactions and minimize future consequences. The underlying belief that they are always right makes it unlikely that they will question their actions. Patients may vary in the degree of trust or mistrust they have in others, but they are unlikely to seek guidance or advice on any particular course of action. A person with ASPD who wants something will take it without either understanding the possible consequences or manifesting concern about possible consequences.
For example, the therapist noticed that magazines were disappearing from his waiting room, and he suspected Randy, his ASPD patient. He checked that the magazines were there prior to Randy’s session. Afterward they were gone. Asking Randy at the following session about the missing magazines, Randy at first vigorously denied the action. He then switched to the position that he must have inadvertently taken them. But, he reasoned, the magazines were there for the patients, and as a patient he was then justified in taking “his” magazine home to read. Thus, the behaviors of individuals with ASPD tend to elicit negative responses from others without awareness or concern that what he was doing was stealing from someone who was trying to help him.
Because the problems that they manifest are generally chronic and ego-syntonic, the patients themselves are often baffled by the responses of others and unable to see how present circumstances arose. For example, Randy was genuinely astounded that the therapist made such a “big deal” about a “stupid” magazine. Further, even after Randy offered to pay for the magazines, the therapist still saw a need for discussion of the behavior. Typically, the patient with ASPD will see the locus of the difficulties that they encounter in dealing with other people or tasks as external and independent of their behavior, viewing themselves as victims of unfair, prejudiced, or hostile systems.
Given that other people hold the key to survival in the world, histrionic patients tend to also hold the basic belief that it is necessary to be loved by everyone for everything one does. This leads to a very strong fear of rejection. Even entertaining the notion that rejection is possible is extremely threatening to these individuals, because this reminds the patient of his or her tenuous position in the world. Any indication of reje tion at all is devastating, even when the person doing the rejecting was not actually that important to the patient. Feeling inadequate yet desperate for approval as their only salvation, people with HPD cannot relax and leave the acquisition of approval to chance. Instead, they feel constant pressure to seek this attention in the ways they have learned are ef- fective, often by fulfilling an extreme of their sex-role stereotype. Female histrionics (as well as some of the males) seem to have been rewarded from an early age for cuteness, physical attractiveness, and charm rather than for competence or for any endeavor requiring systematic thought and planning. The more “macho” male histrionics have learned to play an extreme masculine role, being rewarded for virility, toughness, and power rather than interpersonal competence or problem-solving ability. Understandably, then, both male and female histrionics learn to focus attention on the playing of roles and “performing” for others.
People with a HPD view themselves as sociable, friendly, and agreeable, and, in fact, they are often perceived as very charming at the beginning of a relationship. However, as the relationship continues, the charm seems to wear thin and they gradually are seen as overly demanding and in need of constant reassurance. Given that being direct involves the risk of rejection, they often use more indirect approaches such as manipulation to try to gain attention but will resort to threats, coercion, temper tantrums, and suicide threats if more subtle methods seem to be failing.
Histrionic people are so concerned about eliciting external approval that they learn to value external events over their own internal experience. With so little focus on their own internal life, they are left without any clear sense of identity apart from other people and see themselves primarily in relation to others. In fact, their own internal experience can feel quite foreign and uncomfortable to them and at times they actively avoid self-knowledge, not knowing how to deal with it. Having some vague sense of the superficial nature of their feelings may also encourage them to shy away from true intimacy with another person for fear of being “found out.” Because they have paid little attention to their own in- ternal resources, they have no idea how to respond when depth is required in a relationship. Thus, their relationships tend to be very shallow, superficial, and based on role playing.
helpful