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21
FOCUS, VOL. 3, No. 3
1
CLINICAL SYNTHESIS   |   July 01, 2005 
Quick Reference for Personality Disorders
FOCUS 2005;3:368-371.
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Copyright 2005 American Psychiatric Association
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Table 1.  Prognostic Factors in Borderline Personality Disorder
Poor PrognosisGood Prognosis
Parental brutality/incest (+Stone 1990)High IQ (+McGlashan 1985; +Stone 1990)
Greater affective instability (+McGlashan 1992)Absence of narcissistic entitlement (+Plakun 1991)
Magical thinking (+McGlashan 1992)Absence of parental divorce (+Plakun 1991)
Impulsivity and substance abuse (+Links et al. 1993)
Comorbid schizotypal, antisocial, or paranoid features (+Links et al. 1998; +McGlashan 1986; +Stone 1993)
Presence of maternal psychopathology (+Paris et al. 1988)
Family history of mental illness (+Paris et al. 1988)
Note: Reference list is at the end of this section.
Source:Gabbard GO: Psychodynamic Psychiatry in Clinical Practice, 4th ed. Washington, DC, American Psychiatric Publishing, 2005, p 434
 
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Table 2.  Medication Strategies for Borderline Personality Disorder Target Symptoms
Affective-DysregulationImpulsive-BehavioralCognitive-Perceptual
SSRISSRILow-dose antipsychotic
Low-dose antipsychoticLow-dose antipsychoticSSRI
ClonazepamaLithium carbonate
MAOIbMAOIb
LithiumCarbamazepine
Divalproex
Naltrexonec
MAOI=monoamine oxidase inhibitor; SSRI=selective serotonin reuptake inhibitor
a Do not use alprazolam, as it may result in disinhibition.
b MAOIs should be used with considerable caution because of dietary restrictions.
c If self-mutilation and/or alcohol abuse is present.
Source:Gabbard GO: Psychodynamic Psychiatry in Clinical Practice, 4th ed. Washington, DC, American Psychiatric Publishing, 2005, p 447 (based on Gabbard 2000 and Soloff 1998)
 
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Figure 1. : A Psychobiological Model of Personality Disorder
Source:
Gabbard GO: Psychodynamic Psychiatry in Clinical Practice, 4th ed. Washington, DC, American Psychiatric Publishing, 2005, p. 443 (based on Cloninger et al., 1993)

 
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Table 3.  Varieties of Narcissistic Transference
Need for admiration and affirmation from the therapist
Idealization of the therapist
Assumption of twinship between therapist and patient
Proneness to feel shamed and humiliated by the therapist
Contempt and devaluation toward the therapist, often related to envy
Denial of the therapist’s autonomy
Omnipotent control of the therapist
Insistence on exclusive dyadic relatedness that does not allow for a third party
Use of the therapist as a sounding board without empathy for the therapist’s experience
Denial of dependency on the therapist
Inability to accept help from the therapist
Source:Gabbard GO: Psychodynamic Psychiatry in Clinical Practice, 4th ed. Washington, DC, American Psychiatric Publishing, 2005, p 503
 
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Table 4.  DSM-IV-TR Personality Clusters, Specific Types, and Their Defining Clinical Features
ClusterTypeCharacteristic Features
AOdd or eccentric
ParanoidPervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent
SchizoidPervasive pattern of detachment from social relationships and restricted range of expression of emotions in interpersonal settings
SchizotypalPervasive 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
BDramatic, emotional, or erratic
AntisocialHistory of conduct disorder before age 15; pervasive pattern of disregard for and violation of the rights of others; current age at least 18
BorderlinePervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity
HistrionicPervasive pattern of excessive emotionality and attention seeking
NarcissisticPervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy
CAnxious or fearful
AvoidantPervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation
DependentPervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation
Obsessive-compulsivePervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control at the expense of flexibility, openness, and efficiency
Source:Skodol AE: Manifestations, clinical diagnosis, and comorbidity, in The American Psychiatric Publishing Textbook of Personality Disorders. Edited by Oldham JO, Skodol AE, Bender DS. Washington, DC, American Psychiatric Publishing, 2005, chapter 4, p 60 (adapted from DSM-IV-TR, p 685)
 
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Table 5.  Dialectical Behavior Therapy Skills Training Modules
I.Mindfulness
  • Focusing on the moment
  • Awareness without judgment
II.Distress tolerance
  • Crisis survival strategies
  • Radical acceptance of reality
III.Emotion regulation
  • Observe and identify emotional states
  • Validate and accept one’s emotions
  • Decrease vulnerability to negative emotions
  • Increase experience of positive emotions
IV.Interpersonal effectiveness
  • Assertiveness training
  • Cognitive restructuring
  • Balancing objectives with maintaining relationships and self-esteem
Source:Stanley B, Brodsky BS: Dialectical behavior therapy, in The American Psychiatric Publishing Textbook of Personality Disorders. Edited by Oldham JO, Skodol AE, Bender DS. Washington, DC, American Psychiatric Publishing, 2005, chapter 19, p 312
 
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+QuickReffig2outlined.jpeg
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Figure 2. : Dialectical Behavior Therapy: Two-Pronged Approach
Source:
Stanley B, Brodsky BS: Dialectical behavior therapy, in The American Psychiatric Publishing Textbook of Personality Disorders. Edited by Oldham JO, Skodol AE, Bender DS. Washington, DC, American Psychiatric Publishing, 2005, chapter 19, p. 311

+
Cloninger CR, Srvakic DM, Pryzbeck TR: A psychobiological model of temperament and character. Arch Gen Psychiatry  1993; 50:975—990
 
+
Gabbard GO: Combining medication with psychotherapy in the treatment of borderline personality disorder, in Psychotherapy and Personality Disorders (Review of Psychiatry Series; Oldham JM and Riba MB, series eds.), vol 19. Edited by Gunderson JG, Gabbard GO. Washington, DC, American Psychiatric Press,  2000, pp 65—90
 
+
Links PS, Heslegrave R, vanReekum R: Prospective follow-up study of borderline personality disorder: prognosis, prediction of outcome, and axis II comorbidity. Can J Psychiatry  1998; 43:265—270
 
+
Links PS, Mitton JE, Steiner M: Stability of borderline personality disorder. Can J Psychiatry  1993; 38:255—259
 
+
McGlashan TH: Prediction of outcome in BPD, in The Borderline: Current Empirical Research. Edited by McGlashan TH. Washington, DC, American Psychiatric Press,  1985, pp 61—98
 
+
McGlashan TH: The Chestnut Lodge Follow-up Study, III: long-term outcome of borderline personalities. Arch Gen Psychiatry  1986; 43:20—30
 
+
McGlashan TH: The longitudinal profile of BPD: contributions from the Chestnut Lodge Follow-up Study, in Handbook of the Borderline Diagnosis. Edited by Silver D, Rosenbluth M. Madison, CT, International Universities Press,  1992
 
+
Paris J, Nowlis D, Brown R: Developmental factors in the outcome of borderline personality disorder. Compr Psychiatry  1988; 29:147—150
 
+
Plakun EM: Prediction of outcome in borderline personality disorder. J Personal Disord  1991; 5:93—101
 
+
Soloff PH: Algorithms for pharmacological treatment of personality dimensions: symptom-specific treatments for cognitive-perceptual, affective, and impulse-behavioral dysregulation. Bull Menninger Clin  1998; 62:195—214
 
+
Stone MH: Long-term outcome in personality disorders. Br J Psychiatry  1993; 162:299—313
 
+
Stone MH: The Fate of Borderline Patients: Successful Outcome and Psychiatric Practice. New York, Guilford,  1990
 

Figure 1.

A Psychobiological Model of Personality Disorder

Source:Gabbard GO: Psychodynamic Psychiatry in Clinical Practice, 4th ed. Washington, DC, American Psychiatric Publishing, 2005, p. 443 (based on Cloninger et al., 1993)

Figure 2.

Dialectical Behavior Therapy: Two-Pronged Approach

Source:Stanley B, Brodsky BS: Dialectical behavior therapy, in The American Psychiatric Publishing Textbook of Personality Disorders. Edited by Oldham JO, Skodol AE, Bender DS. Washington, DC, American Psychiatric Publishing, 2005, chapter 19, p. 311
Anchor for JumpAnchor for Jump
View Large | Add to My POL
Table 1.  Prognostic Factors in Borderline Personality Disorder
Poor PrognosisGood Prognosis
Parental brutality/incest (+Stone 1990)High IQ (+McGlashan 1985; +Stone 1990)
Greater affective instability (+McGlashan 1992)Absence of narcissistic entitlement (+Plakun 1991)
Magical thinking (+McGlashan 1992)Absence of parental divorce (+Plakun 1991)
Impulsivity and substance abuse (+Links et al. 1993)
Comorbid schizotypal, antisocial, or paranoid features (+Links et al. 1998; +McGlashan 1986; +Stone 1993)
Presence of maternal psychopathology (+Paris et al. 1988)
Family history of mental illness (+Paris et al. 1988)
Note: Reference list is at the end of this section.
Source:Gabbard GO: Psychodynamic Psychiatry in Clinical Practice, 4th ed. Washington, DC, American Psychiatric Publishing, 2005, p 434
Anchor for JumpAnchor for Jump
View Large | Add to My POL
Table 2.  Medication Strategies for Borderline Personality Disorder Target Symptoms
Affective-DysregulationImpulsive-BehavioralCognitive-Perceptual
SSRISSRILow-dose antipsychotic
Low-dose antipsychoticLow-dose antipsychoticSSRI
ClonazepamaLithium carbonate
MAOIbMAOIb
LithiumCarbamazepine
Divalproex
Naltrexonec
MAOI=monoamine oxidase inhibitor; SSRI=selective serotonin reuptake inhibitor
a Do not use alprazolam, as it may result in disinhibition.
b MAOIs should be used with considerable caution because of dietary restrictions.
c If self-mutilation and/or alcohol abuse is present.
Source:Gabbard GO: Psychodynamic Psychiatry in Clinical Practice, 4th ed. Washington, DC, American Psychiatric Publishing, 2005, p 447 (based on Gabbard 2000 and Soloff 1998)
Anchor for JumpAnchor for Jump
View Large | Add to My POL
Table 3.  Varieties of Narcissistic Transference
Need for admiration and affirmation from the therapist
Idealization of the therapist
Assumption of twinship between therapist and patient
Proneness to feel shamed and humiliated by the therapist
Contempt and devaluation toward the therapist, often related to envy
Denial of the therapist’s autonomy
Omnipotent control of the therapist
Insistence on exclusive dyadic relatedness that does not allow for a third party
Use of the therapist as a sounding board without empathy for the therapist’s experience
Denial of dependency on the therapist
Inability to accept help from the therapist
Source:Gabbard GO: Psychodynamic Psychiatry in Clinical Practice, 4th ed. Washington, DC, American Psychiatric Publishing, 2005, p 503
Anchor for JumpAnchor for Jump
View Large | Add to My POL
Table 4.  DSM-IV-TR Personality Clusters, Specific Types, and Their Defining Clinical Features
ClusterTypeCharacteristic Features
AOdd or eccentric
ParanoidPervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent
SchizoidPervasive pattern of detachment from social relationships and restricted range of expression of emotions in interpersonal settings
SchizotypalPervasive 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
BDramatic, emotional, or erratic
AntisocialHistory of conduct disorder before age 15; pervasive pattern of disregard for and violation of the rights of others; current age at least 18
BorderlinePervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity
HistrionicPervasive pattern of excessive emotionality and attention seeking
NarcissisticPervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy
CAnxious or fearful
AvoidantPervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation
DependentPervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation
Obsessive-compulsivePervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control at the expense of flexibility, openness, and efficiency
Source:Skodol AE: Manifestations, clinical diagnosis, and comorbidity, in The American Psychiatric Publishing Textbook of Personality Disorders. Edited by Oldham JO, Skodol AE, Bender DS. Washington, DC, American Psychiatric Publishing, 2005, chapter 4, p 60 (adapted from DSM-IV-TR, p 685)
Anchor for JumpAnchor for Jump
View Large | Add to My POL
Table 5.  Dialectical Behavior Therapy Skills Training Modules
I.Mindfulness
  • Focusing on the moment
  • Awareness without judgment
II.Distress tolerance
  • Crisis survival strategies
  • Radical acceptance of reality
III.Emotion regulation
  • Observe and identify emotional states
  • Validate and accept one’s emotions
  • Decrease vulnerability to negative emotions
  • Increase experience of positive emotions
IV.Interpersonal effectiveness
  • Assertiveness training
  • Cognitive restructuring
  • Balancing objectives with maintaining relationships and self-esteem
Source:Stanley B, Brodsky BS: Dialectical behavior therapy, in The American Psychiatric Publishing Textbook of Personality Disorders. Edited by Oldham JO, Skodol AE, Bender DS. Washington, DC, American Psychiatric Publishing, 2005, chapter 19, p 312
+
+
Cloninger CR, Srvakic DM, Pryzbeck TR: A psychobiological model of temperament and character. Arch Gen Psychiatry  1993; 50:975—990
 
+
Gabbard GO: Combining medication with psychotherapy in the treatment of borderline personality disorder, in Psychotherapy and Personality Disorders (Review of Psychiatry Series; Oldham JM and Riba MB, series eds.), vol 19. Edited by Gunderson JG, Gabbard GO. Washington, DC, American Psychiatric Press,  2000, pp 65—90
 
+
Links PS, Heslegrave R, vanReekum R: Prospective follow-up study of borderline personality disorder: prognosis, prediction of outcome, and axis II comorbidity. Can J Psychiatry  1998; 43:265—270
 
+
Links PS, Mitton JE, Steiner M: Stability of borderline personality disorder. Can J Psychiatry  1993; 38:255—259
 
+
McGlashan TH: Prediction of outcome in BPD, in The Borderline: Current Empirical Research. Edited by McGlashan TH. Washington, DC, American Psychiatric Press,  1985, pp 61—98
 
+
McGlashan TH: The Chestnut Lodge Follow-up Study, III: long-term outcome of borderline personalities. Arch Gen Psychiatry  1986; 43:20—30
 
+
McGlashan TH: The longitudinal profile of BPD: contributions from the Chestnut Lodge Follow-up Study, in Handbook of the Borderline Diagnosis. Edited by Silver D, Rosenbluth M. Madison, CT, International Universities Press,  1992
 
+
Paris J, Nowlis D, Brown R: Developmental factors in the outcome of borderline personality disorder. Compr Psychiatry  1988; 29:147—150
 
+
Plakun EM: Prediction of outcome in borderline personality disorder. J Personal Disord  1991; 5:93—101
 
+
Soloff PH: Algorithms for pharmacological treatment of personality dimensions: symptom-specific treatments for cognitive-perceptual, affective, and impulse-behavioral dysregulation. Bull Menninger Clin  1998; 62:195—214
 
+
Stone MH: Long-term outcome in personality disorders. Br J Psychiatry  1993; 162:299—313
 
+
Stone MH: The Fate of Borderline Patients: Successful Outcome and Psychiatric Practice. New York, Guilford,  1990
 
+
+

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