What is Stress? There are some rather elaborate and erudite definitions of stress that may technically cover what the term means but do little to advance the understanding of what stress is. Stated simply, stress is change. Anything that causes change in a person’s daily routine is stressful. Anything that causes change in a person’s health is stressful.

Whenever a person experiences a change in his/her life there is an associated stress factor called a stressor. Stressors can be positive or negative and sometimes both.

Examples of stressors

1. DEATH OF SPOUSE 2. DIVORCE 3. MENOPAUSE 4. SEPARATION FROM LIVING PARTNER 5. JAIL TERM OR PROBATION 6. DEATH OF CLOSE FAMILY MEMBER OTHER THAN SPOUSE 7. SERIOUS PERSONAL INJURY OR ILLNESS 8. MARRIAGE OR ESTABLISHING LIFE PARTNERSHIP 9. FIRED AT WORK 10. MARITAL OR RELATIONSHIP RECONCILIATION 11. RETIREMENT 12. CHANGE IN HEALTH OF IMMEDIATE FAMILY MEMBER 13. WORK MORE THAN 40 HOURS PER WEEK 14. PREGNANCY OR CAUSING PREGNANCY 15. SEX DIFFICULTIES 16. GAIN OF NEW FAMILY MEMBER 17. BUSINESS OR WORK ROLE CHANGE 18. CHANGE IN FINANCIAL STATE 19. DEATH OF A CLOSE FRIEND (not a family member) 20. CHANGE IN NUMBER OF ARGUMENTS WITH SPOUSE OR PARTNER 21. MORTGAGE OR LOAN FOR A MAJOR PURPOSE 22. FORECLOSURE OF MORTGAGE OR LOAN 23. SLEEP LESS THAN 8 HOURS PER NIGHT 24. CHANGE IN RESPONSIBILITIES AT WORK 25. TROUBLE WITH IN-LAWS, OR WITH CHILDREN 26. OUTSTANDING PERSONAL ACHIEVEMENT 27. SPOUSE BEGINS OR STOPS WORK 28. BEGIN OR END SCHOOL 29. CHANGE IN LIVING CONDITIONS (visitors in the home, Change in roommates, remodeling house) 30. CHANGE IN PERSONAL HABITS (diet, exercise, Smoking, etc.) 31. CHRONIC ALLERGIES 32. TROUBLE WITH BOSS 33. CHANGE IN WORK HOURS OR CONDITIONS 34. MOVING TO NEW RESIDENCE 35. PRESENTLY IN PRE-MENSTRUAL PERIOD 36. CHANGE IN SCHOOLS 37. CHANGE IN RELIGIOUS ACTIVITIES 38. CHANGE IN SOCIAL ACTIVITIES (more or less than before) 39. MINOR FINANCIAL LOAN 40. CHANGE IN FREQUENCY OF FAMILY GET-TOGETHERS 41. VACATION 42. PRESENTLY IN WINTER HOLIDAY SEASON 43. MINOR VIOLATION OF THE LAW

It is an obvious that stress exists in people’s lives on a daily basis. But the human body likes homeostasis (or equilibrium) so when it encounters a stressor it strives to resolve the stressor and return to homeostasis. A stressor is either an external or internal stressor.

• An external stressor is any change in an individual’s life that is the result of a factor occurring outside of that individual’s body, such as a threat, challenge or task.

• An internal stressor occurs inside an individual’s body, such as a thought process, perception or worry that acts as a stimulus or provocation disrupting homeostasis.

The Stress Cycle

When a stressor has stimulated the body or the mind there is a response. This response is called the stress cycle and it is has four main components:

Stressor: A stressor manifests that alters an individual’s homeostasis.

Stress reaction: An emotional and/or a physical disruption in normal functioning of the affected body systems.

Strain: The struggle to regain homeostasis and to overcome the effects of a stressor.

Stress coping: The process of dealing with the stress reaction by one of many different methods ranging from action steps in problem solving to reframing interpretations of events and circumstances.

Types of Stress

There are seven categories of stress:

1. Eustress: Positive stress 2. Distress: Negative stress 3. Overload: Unrealistic expectations and punitive interpersonal responses by self

or others to accomplish too much in too little time. 4. Arousal: A Physical and emotional excitation alerting the body for action (heart

pounding, adrenaline rush) to meet a physical or cognitive challenge. 5. Physical stress: The body is often subjected to physical stress like exercise,

sports and hard physical labor, which in some cases can be eustress or distress. 6. Environmental stress: This form of stress occurs with exposure to a change of

altitude, climate, or pollution in the atmosphere. Even extreme temperature changes from hot to cold or vice versa can strain the human adaptation processes.

7. Emotional stress: This form of stress includes all of the cognitive and behavioral causes and outcomes that strain our coping mechanisms.

Differing from the types of stress are some of the unique aspects of stressors, such as:

1. Stimulation: A sound, sight or thought, which requires a response to relieve some disruption, (e.g. an alarm followed by emergency response).

2. Challenge: A special kind of a stressful circumstance that is motivating, initiates growth, strength, maturity and development and conditioning to succeed.

3. Overload: When the prolonged demands of numerous stressors accumulate beyond capacity, the reaction may be to feel a burden that is crushing or consuming.

4. External demands: When the external assignments or expectations are excessive. These might be goals/quotas with harsh consequences to follow if they are not met.

5. Internal demands: Internal pressures based upon unrealistic expectations of what one can or "should" do.

Most people experience stress cycles repeatedly during a routine day without experiencing any negative effects. Unusual stressors can task any person’s ability to cope and any person’s ability to cope may lessen to the point that stressors previously managed become detrimental.

Physiologic Effects of Stress

(Medicine has been studying the effects of stress for years and as with most research, some results concur with other research while some results challenge every aspect of similar research. As an example, it has been long accepted that there was a direct link between increased stress and heart disease. Recent research is disproving that link and pointing out that there were obvious fallacies in the conclusions of a relationship by noting that researchers failed to adjust for or eliminate other life-style factors such as diet, smoking and alcohol use. As a result, alleging that stress causes heart disease has as much scientific credibility as saying that blonde hair causes low intelligence. In time, properly conducted research may prove that such a link exists, but until valid scientific research is done and subjected to peer review, view all research with a healthy skepticism

As the years progress and the research continues, the controversy persists in determining a standard for measuring objective test results and rating the impairment caused by stress. Part of the problem is that individuals do not respond to stressors in the same way. While one individual may experience diarrhea and insomnia, another individual may experience constipation and fatigue, yet both are experiencing similar stressors. In fact, the more knowledgeable one becomes about the research in this area the more one might become convinced that a definitive answer may not be found in this lifetime.

Fortunately, this is not an issue in determining the veracity of a claim. If the researchers all agree that an elevated test result indicates impairment and the only controversy is consistency between the ranges in the test results and the degree of impairment, then it can be stated, without controversy, that the absence of an elevated test result indicates no impairment).

Every medical specialty diagnoses stress-related disorders. “Recent studies” suggest that 70 to 80 percent of all medical care is rooted in a stress-related condition. Understanding the physiologic effects of stress requires becoming familiar with the Autonomic Nervous System (ANS) and the Endocrine System. All researchers agree that stress affects hormones and it is the Autonomic Nervous System (ANS) that stimulates the production of the hormones and it is the Endocrine System that produces these hormones.

The ANS is part of the peripheral nervous system and it controls many organs and muscles within the body cavity. In most situations, we are unaware of the workings of the ANS because it functions in an involuntary, reflexive manner. The ANS regulates:

• Muscles o In the skin (around hair follicles; smooth muscle) o Around blood vessels (smooth muscle) o In the eye (the iris; smooth muscle) o In the stomach, intestines and bladder (smooth muscle) o The heart (cardiac muscle)

• Glands

The ANS is divided into three parts:

• The sympathetic nervous system • The parasympathetic nervous system • The enteric nervous system

1. Sympathetic nervous system: This part is responsible for preparing the body to meet stress. Its responses include: increased heart rate, increased blood pressure, and respiratory rate accelerating. The sympathetic nervous system also stimulates endocrine glands like the adrenal gland and thyroid to produce hormones. Adrenaline, noradrenaline and cortisol are some of the hormones produced by the adrenal cortex during the stress response.

2. Parasympathetic nervous system: This portion is responsible for the relaxation response and brings the body back to the relaxed stage. If the sympathetic reactions are comparable to the accelerator of the car then the parasympathetic responses are like the brakes.

3. Enteric nervous system: This portion of the ANS regulates the activity of the digestive system, including bile production, motility in the small and large intestines as well as sphincter control in diarrhea and vomiting.

Reference Chart

The Autonomic Nervous System Structure Sympathetic Stimulation Parasympathetic

Stimulation Iris (eye muscle) Pupil Dilation Pupil Constriction

Salivary Glands Saliva production reduced Saliva production increased

Oral/Nasal Mucosa Mucus production reduced Mucus production increased

Heart Heart rate and force increased Heart rate and force decreased

Lung Bronchial muscle relaxed Bronchial muscle contracted

Stomach Peristalsis reduced Gastric juice secreted; motility increased

Small Intestine Motility reduced Digestion increased

Large Intestine Motility reduced Secretions and motility increased

Liver Increased conversion of glycogen to glucose

Kidney Decreased urine secretion Increased urine secretion

Adrenal medulla Norepinephrine and epinephrine secreted

Bladder Wall relaxed Sphincter closed

Wall contracted Sphincter relaxed

When the body is challenged by almost anything that happens to us, from getting out of bed in the morning or running up a flight of stairs or having to stand up and give a talk, the brain activates the autonomic nervous system (ANS), the involuntary system of nerves which controls and stimulates the output of two hormones, cortisol from the adrenal cortex and adrenalin from the adrenal medulla. These two hormones and the activity of the ANS help us cope: the ANS and the adrenalin keep us alert by increasing our heart rate and blood pressure and quickly mobilizing energy reserves. In contrast, cortisol works more slowly, helps replenish energy supplies and, at the same time, helps us to remember important things. For example, cortisol readies our immune system to handle any threat -- bacterial/viral or injury. Another aspect of cortisol action is called "containment." Many physiological systems are pitted against one another so that neither system can get out of control. The initial, first line response to many noxious or pathogenic agents is normally "contained" by circulating levels of cortisol. This is why we take corticoids for an inflammation or skin irritation. Cortisol also contains acquired immune responses, and this is particularly useful when those responses are harmful, such as in an allergy or an autoimmune disorder.

All of these adaptive responses are described by the term "allostasis" which means "maintaining stability, or homeostasis, through change. The body actively copes with a challenge by expending energy and attempting to put things right. Most of the time it succeeds but the real problems arise when the systems involved in allostasis don't shut off when not needed or don't become active when they are needed. The way our bodies work presents us with a paradox: what can protect can also damage. This is called "allostatic load." It's the price the body has to pay for either doing its job less efficiently or simply being overwhelmed by too many challenges. For our metabolism, the overactivity of the ANS and increased cortisol secretion produce elevated levels of sugar in the blood ("hyperglycemia"). As little as a week of inadequate sleep, say 75% of normal, can raise evening levels of blood sugar. If prolonged, what can result is a rise of insulin, the hormone manufactured by the pancreas to control sugar metabolism. If this situation goes on for a long time, continued hyperactivity of the ANS and elevated cortisol will lead the body down the path to Type 2 diabetes. Elevated levels of cortisol, as in depressive illness, are also linked to gradual demineralization of bone. For the cardiovascular system, the elevation of ANS activity, combined with hyperglycemia and too much insulin ("hyperinsulinemia") promote both hypertension and harmful metabolic conditions, as blood cholesterol rises and HDL drops. This one-two punch accelerates hardening of the arteries ("arteriosclerosis"). Blood pressure surges seem particularly important. Among monkeys living in social hierarchies, the dominant males show accelerated atherosclerosis when the hierarchy is unstable and they have to continuously fight for their position. Treating these animals with beta blockers, pharmaceuticals used to control blood pressure, prevented the increased atherosclerosis. While acute stress actually improves our brain's attention and increases our capacity to store important and life-protecting information, for example, a source of danger, chronic stress dampens our ability to keep track of information and places. Chronic stress does this by impairing excitability of nerve cells and by promoting atrophy of nerve cells in the hippocampus, a region of the brain that is important for spatial and verbal memory. For the immune system, which is controlled by the nervous system and by circulating hormones, chronic stress suppresses the ability of the immune system to do its job. This, once again, is in contrast to acute stress. Acute stress actually helps the immune system handle a pathogen by causing immune cells to move out of the bloodstream and into tissues where they are needed. Chronic stress, however, impairs not only the ability of the immune system to relocate immune cells but also the ability of those cells to do their job of recognizing and responding to the pathogenic agent. But what happens when the body cannot mount an adequate response to an acute stress? Clearly, many of the good things that stress hormones do will not occur, like enhancing memory, replenishing energy reserves or moving immune cells to where they are needed. One other consequence, seen most clearly in the immune system, is that systems that are normally "contained" by cortisol become hyperactive. In the immune system, we find inflammatory agents (cytokines) and self-generated responses ("autoimmune") are no longer contained by circulating cortisol. As a result, disorders like arthritis and autoimmune diseases, for example, lupus, become worse. One

treatment for such disorders, as we will discuss later on, is to treat the patient with cortisone or another glucocorticoid steroid. Besides regulating the endocrine system and the ANS and exerting a powerful influence on the immune system, the brain is the master organ for our behavior. And our behavior can help us or hurt us in various ways. The most obvious way is to get us out of danger by flight or conciliation or to increase danger by confrontation or by risk-taking behaviors like driving recklessly. Another role of behavior is via health-damaging activities, e.g., smoking, drinking or eating too much of the wrong things, or health promoting behaviors such as exercise and eating a healthful diet. In other words, when we are under stress, it's important whether we reach for the bag of potato chips or go for a swim or a jog. Eating a rich diet and drinking alcohol feed into the allostatic load -- they increase the levels of these stress mediators and, thus, make hypertension and insulin resistance, among other consequences, more likely. Individuals may differ in their health and well-being because they differ in behavioral and neuroendocrine adaptive mechanisms, that is, the ways in which their hormone and nervous systems react. You might, compared to a friend, have higher or lower allostatic load, not only because you are subjected to different degrees of life stressors but because you are "wired" differently and have had different life experiences that make you react in different ways.

People with long-term histories of persistent and relatively small elevations or deficiencies in stress hormone levels may show accelerated progress toward pathophysiology and disease. In the case of excess hormone production, these disorders include atherosclerosis, obesity, type 2 diabetes and cognitive impairment. For relative hormone insufficiency, the pathophysiology includes autoimmune and inflammatory disorders, chronic pain and chronic fatigue.

Psychological Effects of Stress

It is a rarity to have a legitimate stress claim based on psychological symptoms alone. The reason is simple: by the time a claim is processed, the cause of the legitimate psychological stress and its stress response has passed. A good benchmark is this: if the claimant’s symptoms persist, the etiology of the complaint is based in another psychiatric disorder.

The most likely disorders are Personality Disorders. A personality disorder is defined as deeply ingrained patterns of behavior that are pervasive and maladaptive, resulting in significant impairment in social, employment or education activities.

It is important to note that most people have some personality traits of one or more personality disorders. The distinction is that these traits are not pervasive nor do they cause significant impairment. It is also worth noting that most of us know at least one person with a personality disorder. It is also common for individuals to have symptoms of more than one personality disorder, with one disorder being more prominent.

In reviewing a claim, it is important to look for an Axis Diagnosis provided by the therapist. If the therapist has provided an Axis II diagnosis, it is almost a certainty that this diagnosis is the origin of the claim. An Axis Diagnosis is a consistent format used in psychiatry and will appear like this:

Axis I: Clinical Disorders

This includes:

o Disorders usually diagnosed in infancy, childhood or adolescence (Autism, ADHD, Etc.) o Delirium, dementia and other cognitive disorders (Dementias, Alzheimer’s Disease, etc.) o Mental disorders due to a general medical condition o Substance-related disorders (such as alcohol or drugs) o Schizophrenia and other psychotic disorders o Mood disorders (Depression, Bipolar) o Anxiety disorders o Somatoform disorders (Conversion Disorder, Hypochondriasis, etc.) o Factitious disorders o Dissociative disorders (Dissociative Identity Disorder, etc.) o Sexual and gender identity disorders o Eating disorders (Anorexia, Bulimia, etc.) o Sleep disorders (Insomnia, Sleep Terrors, etc.) o Impulse-control disorders (Intermittent Explosive Disorder, Kleptomania, etc.) o Adjustment disorders

Axis II: Personality Disorders and Mental Retardation

Examples:

o Paranoid personality disorder o Borderline personality disorder o Antisocial personality disorder o Dependent personality disorder o Mental retardation

Axis III: General Medical Condition

Listed here are general medical (physical) concerns that may have a bearing on understanding the client’s mental disorder, or in the management of the client’s mental disorder

Axis IV: Psychosocial and Environmental Problems

o Problems with the primary support group (divorce, abuse, deaths, births, etc.) o Problems related to social environment (retirement, living alone/friendships, etc.) o Educational problems (illiteracy, academic problems, conflict with teachers, etc.) o Occupational problems (unemployment, difficult work conditions, job dissatisfaction, etc.) o Housing problems (homelessness, unsafe neighborhood, problems with neighbors, etc.) o Economic problems (poverty, insufficient finances, etc.) o Problems with access to health care services (inadequate health care, transportation to health

care, health insurance, etc.) o Problems related to interaction with the legal system/crime (arrest, incarceration, or victim of crime,

etc.) o Other psychosocial and environmental problems (Disasters, problems with health care providers,

etc.)

Axis V: Global Assessment of Functioning

This is a number from 1-100 that reflects the caregiver’s judgment of the overt level of functioning. A general outline of the levels is: 100: No symptoms

90: Minimal symptoms, good functioning

80: Transient symptoms that are expected reactions to psychosocial stressors

70: Mild symptoms OR some difficulty in social occupational or school functioning

60: Moderate symptoms OR moderate difficulty in social, occupation or school functioning

50: Serious symptoms OR any serious impairment in social occupational or school functioning

40: Some impairment in reality testing or communication OR major impairment in several areas such as work or school, family relations, judgment, thinking or mood

30: Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communication or judgment OR inability to function in almost all areas

20: Some danger of hurting self or others OR occasionally fails to maintain minimal personal hygiene OR gross impairment in communication

10: Persistent danger of severely hurting self or others OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death

Personality Disorders

Antisocial Personality Disorder

Symptoms

This disorder is characterized by a long-standing pattern of a disregard for other people's rights, often crossing the line and violating those rights. This pattern of behavior has occurred since age 15 (although only adults 18 years or older can be diagnosed with this disorder) and consists by the presence of the majority of these symptoms:

• Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest

• Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure

• Impulsivity or failure to plan ahead • Irritability and aggressiveness, as indicated by repeated physical fights or assaults • Reckless disregard for safety of self or others • Consistent irresponsibility, as indicated by repeated failure to sustain consistent work

behavior or honor financial obligations • Lack of remorse, as indicated by being indifferent to or rationalizing having hurt,

mistreated, or stolen from another

Introduction

Both professionals and laypeople often misunderstand antisocial personality disorder. Confused with the popular terms, "sociopath" or "psychopath," someone who suffers from this disorder can be discriminated against within the mental health system, because of the symptoms of their disorder. Because there is usually a pervasive lack of remorse, and many time any feelings at all, they are assumed not to have any real feelings by many professionals. This can lead to difficulties within treatment.

Psychotherapy is nearly always the treatment of choice for this disorder; medications may be used to help stabilize mood swings or specific and acute Axis I concurrent diagnoses. There is no research that supports the use of medications for direct treatment of antisocial personality disorder, though.

Psychotherapy

As with most personality disorders, individuals with this disorder rarely seek treatment on their own, without being mandated to therapy by a court or significant other. Court referrals for assessment and treatment for this disorder are likely the most common referral source. A careful and thorough assessment will ensure that the person that the person has antisocial personality disorder. This can often be confused with simple criminal activity (all criminals do not have this disorder), adult antisocial behavior, and other activities, which do not justify the personality disorder diagnosis. As with a thorough assessment of any suspected personality disorder, formal psychological testing should be considered invaluable.

Because many people who suffer from this disorder will be mandated to therapy, sometimes in a forensic or jail setting, motivation on the patient's part may be difficult to find. In a confined setting, it may be nearly impossible and therapy should then focus on alternative life issues,

such as goals for when they are released from custody, improvement in social or family relationships, learning new coping skills, etc. In an outpatient setting, the focus of therapy can also be on these types of issues, but a part of the therapy should be devoted to discussing the antisocial behavior and feelings (or lack thereof). Common in the population who suffer from antisocial personality disorder is the lack of connections between feelings and behaviors. Helping the client draw those lines between the two may be beneficial.

Threats are never an appropriate motivating factor in any sort of treatment, and least of all with this disorder. If the only way to motivate the patient is to threaten to report their noncompliance with therapy to the courts or warden, it is highly unlikely the clinician will make any type of gains within therapy anyway. It is appropriate, however, to try and help the individual with this disorder find good reasons that they may want to work on this problem further. For instance, ensuring that they not come into contact with the court system again, be incarcerated, have to submit themselves to additional psychological examinations, etc.

Effective psychotherapy treatment for this disorder is limited. It is likely, though, that intensive, psychoanalytic approaches are inappropriate for this population. Approaches the reinforce appropriate behaviors and attempting to make connections between the person's actions and their feelings may be more beneficial. Emotions are usually a key aspect of treatment of this disorder. Patients often have had little or no significant emotionally rewarding relationships in their lives. The therapeutic relationship, therefore, can be one of the first ones. This can be very scary for the client, initially, and it may become intolerable. A close therapeutic relationship can only occur when a good and solid rapport has been established with the client and he or she can trust the therapist implicitly.

Trust brings up the issue of confidentiality, since often the patient with antisocial personality disorder is mandated to therapy. This means that the clinician may have to occasionally report on the patient's progress in therapy. While this can usually be done in a very general way which reveals no significant details of the content of therapy, it is still an important issue for the client. He or she may be suspicious and distrustful of the clinician at first, since it will be unclear as to who has the highest priority -- the patient or the court. This fear can only be alleviated with an honest disclosure as to what the therapist will reveal to the courts, and with time, as the client learns that what he says in the therapy session does not become common knowledge. The limitations of therapy should be discussed with the patient up-front, in a clear and matter-of-fact manner, so there are no misunderstandings later.

The content of therapy should focus on the patient's emotions (or lack thereof). As the individual learns to experience various emotional states, one of the first may be depression. The client will likely be unfamiliar with the feelings associated with depression, and so it is beneficial for the clinician to be supportive and empathetic to the individual during this time. Reinforcing any emotions, outside of anger or frustration, is usually beneficial. Experiencing intense affect is usually a sign of progress in therapy. Staying on "safe issues," and discussing more real-life concerns, while one way of treating this disorder, is not likely to be as effective in long term behavioral change as an approach emphasizing the discovery and labeling of appropriate emotional states.

People who have antisocial personality disorder often experience difficulties with authority figures. The therapist should usually take a neutral stance in this matter, since it is a firmly held belief by the client. The clinician should avoid arguments and taking sides on authority issues and those who hold authority over the client. Their moral and ethical makeup may leave a lot to be desired as well. While this may be an appropriate topic for discussion in therapy, it will also likely be one of little progress. Usually one of the more effective ways for a person with this disorder to learn to change their ineffective behaviors is to have to face up to the

consequences of their behavior. This sometimes means dealing with courts and jails, but it can also eventually be a motivating factor in the client's treatment.

Other modalities of psychotherapy, such as group and family therapy, can be helpful. Often people with this disorder find themselves in a group setting, because they aren't given any treatment choices. This is usually not conducive to their treatment, since in most groups, the individual can remain emotionally-closed and has little reason to share with others. It also doesn't help that these groups are often made up of people suffering from a wide range of mental disorders. Groups which are devoted exclusively to this disorder, though rare, are the best choice. In such a group, the patient is given a greater reason to contribute and share with others. Care must be utilized by group leaders to ensure the group doesn't become a "How-to" course in criminal behavior. Family therapy can be helpful to increase education and understanding among family members. Families often misunderstand and are confused about the cause of the antisocial behaviors and the idea that it is a mental disorder. Phillip W. Long, M.D. adds, "This confusion, guilt, the temptation to make restitution for the patient's criminal acts, and the frustrations of working with someone who is seen to be quite ill but who will not be treated should all be discussed openly with family members."

While there are many theories, as with all personality disorders, research has found little significant causative factors.

Hospitalization

Rarely is inpatient care appropriate or necessary for this personality disorder. Like most personality disorders, most people will go through their lives with little realization of the difficulty they have. In this case, though, the person is more likely to be seen as a criminal and have a history of difficulties with the law. Loss of freedom may be more of a motivating factor than in other personality disorders, so some specialized treatment facilities have started to treat people with this disorder.

As with any treatment, the focus on feelings and connecting antisocial behavior to appropriate feeling states is appropriate. Since inpatient programs tend to be more intensive and expensive, they are rarely sought out by the patient themselves. Community follow-up and support, either by the hospital or professionals, or with the use of self-help support groups, is imperative to maintaining treatment gains.

Medications

Medications should only be utilized to treat clear, acute and serious Axis I concurrent diagnoses. No research has suggested that any medication is effective in the treatment of this disorder.

Self-Help

The medical profession often overlooks self-help methods for the treatment of this disorder because very few professionals are involved in them. Groups can be especially helpful for people with this disorder, if they are tailored specifically for antisocial personality disorder. Individuals with this disorder typically feel more at ease in discussing their feelings and behaviors in front of their peers in this type of supportive modality. Leaders of such self-help support groups, though, must be wary of individuals who come to group just to brag about their exploits and who may seek to use the group inappropriately. Usually a group can be very helpful and beneficial to most people with this disorder, once they overcome their initial fears and hesitation to join such a group. Many support groups exist within communities throughout

the world that are devoted to helping individuals with this disorder share their commons experiences and feelings.

Avoidant Personality Disorder

Symptoms

This disorder is characterized by a long-standing and complex pattern of feelings of inadequacy, extreme sensitivity to what other people think about them, and social inhibition. It typically manifests itself by early adulthood and includes a majority of the following symptoms:

• avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection

• is unwilling to get involved with people unless certain of being liked • shows restraint within intimate relationships because of the fear of being shamed or

ridiculed • is preoccupied with being criticized or rejected in social situations • is inhibited in new interpersonal situations because of feelings of inadequacy • views self as socially inept, personally unappealing, or inferior to others • is unusually reluctant to take personal risks or to engage in any new activities because

they may prove embarrassing

Treatment

Psychotherapy As with most personality disorders, the treatment of choice is psychotherapy. While individual therapy is usually the preferred modality, group therapy can be useful if the client can agree to attend enough sessions. Because of the basic components of this disorder, though, it is often difficult to have the individual attend group therapy early on in the therapeutic process. It is a modality to consider as the patient approaches termination of individual treatment, if additional therapy seems necessary and beneficial to the client. Individuals who suffer from this disorder typically have poor self-esteem and issues surrounding any type of social interactions. They often see only the negative in life and have difficulty in looking at situations and interactions in an objective manner. This can also interfere with their self-report when they present for an initial evaluation, which can lead to important life history and medical information being missed (because the patient deems it and him or herself too unimportant to bother). It is necessary to take a more detailed evaluation than usual, while doing so in a relatively unobtrusive fashion. The clinician should be sensitive to nonverbal cues of the client during this session, to evaluate when information is being withheld. This is essential to making a differential diagnosis with similar-looking but vitally different disorders, such as someone who suffers from schizoid or borderline personality disorder. As with other personality disorder, the individual is not likely to present him or herself to therapy unless something has gone wrong in their life with which their dysfunctional personality style cannot adequately cope. As with other personality disorders, psychotherapy is usually most effective when it is relatively short-term and oriented toward finding solutions to specific life problems. While self-esteem issues will undoubtedly present themselves in treatment, serious self-enhancement is unlikely. The negative self-valuation is a life-long, pervasive cognition not conducive to regular methods of increasing one's self-esteem. As with all therapy, a solid therapeutic relationship founded with good rapport and listening to the client is important to the therapist's effectiveness. Forming initial rapport is likely to be more difficult with someone who has this disorder, since early termination is often an issue. Once rapport is formed, therapy is usually quite stable,

unless issues are brought up which are extremely difficult for the client to deal with. Care should be used by the clinician in exploring new material, therefore. Termination of therapy is an important issue as well, because a successful ending to therapy and the therapeutic relationship reinforces the possibility of new relationships. Medications As with all personality disorders, medications should only be prescribed for specific and acute Axis I diagnoses or problems suffered by the individual. Anti-anxiety agents and antidepressants should be prescribed only when there is a clear Axis I diagnosis in conjunction with the personality disorder. Physicians should resist the temptation to over-prescribe to someone with this disorder, because they often present with complaints of anxiety in social situations or a feeling of disconnectedness with their feelings. The anxiety in this instance is clearly situationally related and medication may actually interfere with effective psychotherapeutic treatment. Self-Help Such approaches would likely not be very effective because a person with this disorder is likely to avoid attending such sessions, due to increased anxiety and difficulty interacting socially.

Borderline Personality Disorder Symptoms

A person who suffers from this disorder has labile interpersonal relationships characterized by instability. This pattern of interacting with others has persisted for years and is usually closely related to the person's self-image and early social interactions. The pattern is present in a variety of settings (e.g., not just at work or home) and often is accompanied by a similar lability (fluctuating back and forth, sometimes in a quick manner) in a person's affect, or feelings. Relationships and the person's affect may often be characterized as being shallow. A person with this disorder may also exhibit impulsive behaviors and exhibit a majority of the following symptoms:

• frantic efforts to avoid real or imagined abandonment. • a pattern of unstable and intense interpersonal relationships characterized by

alternating between extremes of idealization and devaluation • identity disturbance: markedly and persistently unstable self-image or sense of self • impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex,

substance abuse, reckless driving, binge eating) • recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior • affective instability due to a marked reactivity of mood (e.g., intense episodic

dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)

• chronic feelings of emptiness • inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of

temper, constant anger, recurrent physical fights) • transient, stress-related paranoid ideation or severe dissociative symptoms

Treatment

Introduction Borderline personality disorder is experienced in individuals in many different ways. Often, people with this disorder will find it more difficult to distinguish between reality from their own misperceptions of the world and their surrounding environment. While this may seem like a type of delusion disorder to some, it is actually related to their emotions overwhelming regular cognitive functioning. People with this disorder often see others in "black-and-white" terms. Depending upon the circumstances and situation, for instance, a therapist can be seen as being very helpful and caring toward the client. But if some sort of difficulty arises in the therapy, or in the patient's life, the person might then begin characterizing the therapist as "bad" and not caring about the client at all. Clinicians should always be aware of this "all-or-nothing" lability most often found in individuals with this disorder and be careful not to validate it. Therapists and doctors should learn to be a "rock" when dealing with a person who has this disorder. That is, the doctor should offer his or her stability to contrast the client's lability of emotion and thinking. Many professionals are turned-off by working with people with this disorder, because it draws on many negative feelings from the clinician. These occur because of the client's constant demands on a clinician, the constant suicidal gestures, thoughts, and behaviors, and the possibility of self-mutiliating behavior. These are sometimes very difficult items for a therapist to understand and work with.

Psychotherapy is nearly always the treatment of choice for this disorder; medications may be used to help stabilize mood swings. Controversy surrounds overmedicating people with this disorder. Psychotherapy Like with all personality disorders, psychotherapy is the treatment of choice in helping people overcome this problem. While medications can usually help some symptoms of the disorder, they cannot help the patient learn new coping skills, emotion regulation, or any of the other important changes in a person's life. An initially important aspect of psychotherapy is usually contracting with the person to ensure that they do not commit suicide. Suicidality should be carefully assessed and monitored throughout the entire course of treatment. If suicidal feelings are severe, medication and hospitalization should be seriously considered. The most successful and effective psychotherapeutic approach to date has been Dialectical Behavior Therapy. Research conducted on this treatment have shown it to be more effective than most other psychotherapeutic and medical approaches to helping a person to better cope with this disorder. It seeks to teach the client how to learn to better take control of their lives, their emotions, and themselves through self-knowledge, emotion regulation, and cognitive restructuring. It is a comprehensive approach that is most often conducted within a group setting. Because the skill set learned is new and complex, it is not an appropriate therapy for those who may have difficulty learning new concepts. Like all personality disorders, borderline personality disorder is intrinsically difficult to treat. Personality disorders, by definition, are long-standing ways of coping with the world, social and personal relationships, handling stress and emotions, etc. that often do not work, especially when a person is under increased stress or performance demands in their lives. Treatment, therefore, is also likely to be somewhat lengthy in duration, typically lasting at least a year for most. Other psychological treatments that have been used, to lesser effectiveness, to treat this disorder include those which focus on social learning theory and conflict resolution. These types of solution-focused therapies, though, often neglect the core problem of people who suffer from this disorder -- difficulty in expressing appropriate emotions (and emotional attachments) to significant people in their lives due to faulty cognitions.

Providing a structured therapeutic setting is important no matter which therapy type is undertaken. Because people with this disorder often try and "test the limits" of the therapist or professional when in treatment, proper and well-defined boundaries of your relationship with the client need to be carefully explained at the onset of therapy. Clinicians need to be especially aware of their own feelings toward the patient, when the client may display behavior which is deemed "inappropriate." Individuals with borderline personality disorder are often unfairly discriminated against within the broad range of mental health professionals because they are seen as "trouble-makers." While they may indeed need more care than many other patients, their behavior is caused by their disorder.

Hospitalization Hospitalization is often a concern with people who suffer from borderline personality disorder because they so often visit hospital emergency rooms and are sometimes seen on inpatient units because of severe depression. People with this disorder often present in crisis at their local community mental health center, to their therapist, or at the hospital emergency room. While an emergency room is an immediate source of crisis intervention for the patient, it is a costly treatment and regular visits to the E.R. should be discouraged. Instead, patients should be encouraged to find additional social support within their community (including self-help support groups), contact a crisis hotline, or contact their therapist or treating physician directly. Emergency room personnel should be careful not to treat the person with borderline personality disorder in blind conjunction with another set of therapists or doctors who are treating the patient for the same problem at another facility. Every attempt should be made to contact the client's attending physician or primary therapist as soon as possible, even before the administration of medication which may be contraindicated by the primary treatment provider. Crisis management of the immediate problem is usually the key component to effective treatment of this disorder when it presents in a hospital emergency room, with discharge to the patient's usual care provider. Inpatient treatment often takes the form of medication in conjunction with psychotherapy sessions in groups or individually. This is an appropriate treatment option if the person is experiencing extreme difficulties in living and daily functioning. It is, however, relatively rare to be hospitalized in the U.S. for this disorder. Long-term care of the person suffering from borderline personality disorder within a hospital setting is nearly never appropriate. The typical inpatient stay for someone with borderline personality disorder in the U.S. is about 3 to 4 weeks, depending upon the person's insurance. Since this treatment is so expensive, it is getting more difficult to obtain. Results of such treatment are also mixed. While it is an excellent way of helping stabilize the client, it is usually too short a time to attain significant changes within the individual's personality makeup. Good inpatient care facilities for this disorder should be highly structured environments that seek to expand the individual's independence. Partial hospitalization or a day treatment program is often all that's needed for people who suffer from borderline personality disorder. This allows the individual to gain support and structure from a safe environment for a short time, or during the day, and returning home in the evening. In times of increased stress or difficulty coping with specific situations, this type of treatment is more appropriate and healthier for most people than full inpatient hospitalization. Medications

During brief reactive psychoses, low doses of antipsychotic drugs may be useful, but they are usually not essential adjuncts to the treatment regimen, since such episodes are most often self-limiting and of short duration.

It is, however, clear that low doses of high potency neuroleptics (e.g., haloperidol) may be helpful for disorganized thinking and some psychotic symptoms. Depression in some cases is amenable to neuroleptics. Neuroleptics are particularly recommended for the psychotic symptoms mentioned above, and for patients who show anger which must be controlled. Dosages should generally be low and the medication should never be given without adequate psychosocial intervention."

Antidepressant and anti-anxiety agents may be appropriate during particular times in the patient's treatment, as appropriate. For example, if a client presents with severe suicidal

ideation and intent, the clinician may want to seriously consider the prescription of an appropriate antidepressant medication to help combat the ideation. Medication of this type should be avoided for long-term use, though, since most anxiety and depression is directly related to short-term, situational factors that will quickly come and go in the individual's life. Self-Help The medical profession often overlooks self-help methods for the treatment of this disorder because very few professionals are involved in them. Encouraging the individual with borderline personality disorder to gain additional social support, however, is an important aspect of treatment. Many support groups exist within communities throughout the world that are devoted to helping individuals with this disorder share their commons experiences and feelings. Patients can be encouraged to try out new coping skills and emotion regulation with people they meet within support groups. They can be an important part of expanding the individual's skill set and develop new, healthier social relationships.

Dependent Personality Disorder Symptoms

This personality disorder is characterized by a long-standing need for the person to be taken care of and a fear of being abandoned or separated from important individuals in his or her life. This pervasive fear leads to "clinging behavior" and usually manifests itself by early adulthood. It includes a majority of the following symptoms:

• has difficulty making everyday decisions without an excessive amount of advice and reassurance from others

• needs others to assume responsibility for most major areas of his or her life • has difficulty expressing disagreement with others because of fear of loss of support

or approval. • has difficulty initiating projects or doing things on his or her own (because of a lack of

self-confidence in judgment or abilities rather than a lack of motivation or energy) • goes to excessive lengths to obtain nurturance and support from others, to the point

of volunteering to do things that are unpleasant • feels uncomfortable or helpless when alone because of exaggerated fears of being

unable to care for himself or herself • urgently seeks another relationship as a source of care and support when a close

relationship ends • is unrealistically preoccupied with fears of being left to take care of himself or herself

Treatment

Introduction Individuals with dependent personality disorder are usually quite needy, for attention, valuation, and social contact. Clients with disorder usually don't present in a dramatic fashion, but will often make repeated requests for attention to their complaints, whether these complaints are about their lifestyle, social relationships, lack of meaning in life, medical, or education. People who suffer from this disorder are often outwardly compliant with clinicians' suggestion for treatment, and will usually be passive in their overall treatment, no matter what form it takes. However, real gains in therapy may not be made easily, because the client's compliance (due to the disorder) is often only surface-deep. While the individual may be one of the easiest to see week after week or month after month in therapy, they may also be one of the most difficult because of their strong need for constant reassurance and support. Dependency upon the clinician specifically and therapy in general should be carefully monitored and avoided. Psychiatrists and physicians should be aware that individuals with dependent personality disorder will often present with a number of physical or somatic complaints. While appropriate medications need to be prescribed for these as necessary, the clinician should carefully monitor medication intake and maintenance to ensure the patient is not abusing it. Physical complaints should not be minimized or dismissed, as is often the case with someone who suffers from this disorder, but they must not also be encouraged. A simple, matter-of-fact approach works best in this case. Clinicians in general should be wary of the therapeutic relationship with a person suffering from dependent personality disorder. The needs of the individual can be great and overwhelming at times, and the patient will often try to test the limits of the frame set for therapy. Burnout among therapists treating this disorder is common, because of the client's demands for constant reassurance and attention, especially between therapy sessions. A clear

explanation at the onset of therapy about how treatment is to be conducted, including a discussion of appropriate times and needs for contacting the clinician in-between sessions, is vitally important. While rapport and a close, therapeutic relationship must be established, the boundaries in therapy must also be constantly and clearly delineated. Psychotherapy As with all personality disorders, psychotherapy is the treatment of choice. Treatment is likely to be sought by individuals suffering from this disorder when stress or other complications within their life have led to decreased efficiency in life functioning. As with all other personality disorders as well, they may present with a clear Axis I diagnosis and the personality disorder may only become apparent after a few sessions of therapy. The most effective psychotherapeutic approach is one which is focuses on solutions to specific life problems the patient is presently experiencing. Long-term therapy, while ideal for many personality disorders, is contra-indicated in this instance since it reinforces a dependent relationship upon the therapist. While some form of dependency will exist no matter the length of therapy, the shorter the better in this case. Termination issues will likely be of extreme importance and will virtually be a litmus test of how effective the therapy has been. If the individual cannot end therapy successfully and move on to become more self-reliant, it should not be seen as a therapeutic failure. Rather, the individual was not likely seeking life-changing therapy in the first instance but instead solution-focused therapy. Examining the client's faulty cognitions and related emotions (of lack of self-confidence, autonomy versus dependency, etc.) can be an important component of therapy. Assertiveness training and other behavioral approaches have been shown to be most effective in helping treat individuals with this disorder. Group therapy can also be helpful, although care should be utilized to ensure that the patient doesn't use groups to enhance existing or new dependent relationships. Challenging dependent relationships the client has with others that may be unhealthy for the client should generally be avoided at the onset of therapy. As therapy progresses, these challenges can occur but must be done carefully; restraint must be used if the individual is not ready to give up these unhealthy relationships. Termination of therapy with a person who has this disorder is an extremely important issue to consider. While termination should always be a joint decision between the clinician and the client, people with this disorder often don't know "how much is enough" therapy. The therapist, therefore, may need to prod the patient toward ending therapy. As the end of therapy approaches, the patient is likely to re-experience feelings of insecurity, lack of self-confidence, increased anxiety and perhaps even depression. This can be typical of individuals with this disorder terminating therapy and should be treated appropriately. The clinician should not allow the patient to use these new symptoms, though, as a way of prolonging the current therapy. The goal is to end a relationship at an agreed-upon time and way. The client should be reinforced for the positive gains made in therapy and encouraged to explore their new-found autonomy or improved management of their anxious feelings. Medications As with all personality disorders, medications should only be prescribed for specific problems suffered by the individual. Sedative drug abuse and overdose is common in this population and should be prescribed with additional caution. Anti-anxiety agents and antidepressants should be prescribed only when there is a clear Axis I diagnosis in conjunction with the personality disorder. Physicians should resist the temptation to overprescribe to someone with this disorder, because they often present with multiple physical complaints or anxiety. The anxiety in this instance is clearly situationally-related and medication may actually interfere with effective psychotherapeutic treatment.

Giving any individual with a personality or mental disorder a placebo drug for its perceived value by the patient is ethically questionable. Doctors rarely have need to prescribe a vitamin or other non-psychoactive substance unless a patient's medical condition clearly indicates it. When such a prescription is made, it should be made with the clear understanding what it is being prescribed for. Any indirect suggestion that such a medication will help an individual overcome their feelings of insecurity, inadequacy, need for dependence, etc. should be avoided. A medication should not be prescribed because of its "magical" effects, and more expensive medications should not be prescribed over less-expensive medications just because they are "newer." Prescriptions should always be written for a specific medication because of the research suggesting its effectiveness with the patient's specific medical complaint or diagnosed mental disorder and avoidance of intolerable side-effects. Self-Help The medical profession often overlooks self-help methods for the treatment of this disorder because very few professionals are involved in them. Suggesting such a support group later in treatment, to help put some of their new skill sets to use in a group setting, may be helpful. Many support groups exist within communities throughout the world that are devoted to helping individuals with this disorder share their commons experiences and feelings. Individuals should likely avoid using a support group as the only means of treatment for this disorder, since it is likely to encourage additional dependent relationships.

Histrionic Personality Disorder Symptoms

A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. is uncomfortable in situations in which he or she is not the center of attention 2. interaction with others is often characterized by inappropriate sexually seductive or

provocative behavior 3. displays rapidly shifting and shallow expression of emotions 4. consistently uses physical appearance to draw attention to self 5. has a style of speech that is excessively impressionistic and lacking in detail 6. shows self-dramatization, theatricality, and exaggerated expression of emotion 7. is suggestible, i.e., easily influenced by others or circumstances 8. considers relationships to be more intimate than they actually are

Treatment

Psychotherapy Individuals who suffer from this disorder are usually difficult to treat for a multitude of reasons. As with most personality disorders, people present for treatment only when stress or some other situational factor within their lives has made their ability to function and cope effectively impossible. They are, however (unlike other people who suffer from personality disorders), much quicker to seek treatment and exaggerate their symptoms and difficulties in functioning. Because they also tend to be more emotionally needy, they are often reluctant to terminate therapy. Psychotherapy, as with most personality disorders, is the treatment of choice. Group and family therapy approaches are generally not recommended, since the individual who suffers from this disorder often draws attention to themselves and exaggerates every action and reaction. People with disorder often come across as "fake" or shallow in their interpersonal relationships with others. Patients often are express all feelings with the same depth of emotion, unaware of the subtleties of their own emotional states and of the vast range available to them. Therapy should generally be supportive and good rapport will usually be easily established with the patient early on. Clinicians may often find themselves placed in a "rescuer" role, in which the therapist will be asked to constantly reassure and rescue the client from daily problems. Every problem is usually expressed in a dramatic fashion. Many times the therapist will be perceived as sexually attractive to the patient. Boundary issues in relationships and a clear delineation of the therapeutic framework are relevant and important aspects of therapy. Approaches that take advantage of matter-of-fact and realistic assessment of situations and problems can also be important. Solution-focused therapy is often appropriate with this client. Most therapy approaches should not be focused on the long-term, personality change of the individual, but rather short-term alleviation of difficulties within the person's life. Few people could afford the time or cost required to "cure" someone of this disorder. This should be explicitly stated up-front at the onset of therapy to dismiss any thoughts the client may have of a "magical" cure for this disorder. Suicidal behavior is often apparent in a person who suffers from histrionic personality disorder. Suicidality should be assessed on a regular basis and suicidal threats should not be ignored or dismissed. Suicide sometimes occurs when all that was intended was a gesture, so all such thoughts and plans should be taken with the same seriousness as with any other disorder. A

suicide contract should be established to specify under what conditions the therapist may be contacted in case the client feels like hurting him or herself. Self-mutilation behavior may also be present in this disorder and should also be taken seriously as an issue of importance to discuss within therapy. Therapists will find that taking a somewhat skeptical stance within therapy to be useful, due to the usual exaggeration of events and problems by the patient. By following a line of reasoning to its logical conclusion, the client can usually discover the unrealistic expectations and fears associated with many behaviors and thoughts. Since many people who have histrionic personality disorder will emphasize attractiveness ("style over substance") in their lives and relationships, discussing alternatives and trying out new behaviors may be helpful. The therapist can also help by pointing out, in session, when the client is using shallow criteria in which to judge another. The patient should eventually look to be able to do this themselves throughout their lives. Insight- and cognitive-oriented approaches are generally largely ineffective in treatment of this disorder and should be avoided. People with this disorder are often incapable of examining unconscious motivations and their own thoughts to a degree where it is helpful. While these approaches can be a part of a larger treatment plan, they should not be the focus. Helping the client to examine interactions from a more objective point of view and emphasizing alternative explanations for behavior is likely to be more effective. Examining and clarifying a client's emotions are also important components of therapy. Clinicians will often experience reactions to treating this disorder, because of the dramatic nature of the patient. Because of this possibility, therapists should be more attuned to their own feelings within the therapy setting and ensure that they are treating the patient fairly and with respect. As with Borderline Personality Disorder, individuals with histrionic personality disorder often find themselves discriminated against by mental health professionals because of the symptoms of their disorder. Clinicians and patients should be aware of this possible discrimination. Medications As with most personality disorders, medications are not indicated except for the treatment of specific, concurrent Axis I diagnoses. Care should be given when prescribing medications to someone who suffers from histrionic personality disorder, though, because of the potential for using the medication to contribute to self-destructive or otherwise harmful behaviors. Self-Help There are not any self-help support groups or communities that we are aware of that would be conducive to someone suffering from this disorder. Such approaches would likely not be very effective because a person with this disorder is likely to be very dramatic in their interactions with others, coming across as "artificial" or shallow.

Narcissistic Personality Disorder

Symptoms

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)

2. is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

3. believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)

4. requires excessive admiration 5. has a sense of entitlement, i.e., unreasonable expectations of especially favorable

treatment or automatic compliance with his or her expectations 6. is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own

ends 7. lacks empathy: is unwilling to recognize or identify with the feelings and needs of

others 8. is often envious of others or believes that others are envious of him or her 9. shows arrogant, haughty behaviors or attitudes

Treatment

Medical Treatment Hospitalization The hospitalization of patients with severe Narcissistic Personality occurs frequently. For some, such as those who are quite impulsive or self-destructive, or who have poor reality-testing, this is the result of Axis I symptoms which are overlaid upon the personality disorder. Hospitalizations should be brief, and the treatment specific to the particular symptom involved. Another group of patients for whom hospitalization is indicated, provided long-term residential treatment is available, are those who have poor motivation for outpatient treatment, fragile object relationships, chronic destructive acting out, and chaotic life-styles. An inpatient program can offer an intensive milieu which includes individual psychotherapy, family involvement, and a specialized residential environment. The structure is physically and emotionally secure enough to sustain the patient with severe ego weakness throughout the course of expressive, conflict-solving psychotherapy. Small staff-patient groups within the wards, as well as large community meetings, at which feelings are shared and patients' comments taken seriously by staff, and constructive work assignments, recreational activities, and opportunities to sublimate painfully conflictual impulses make the hospital a "holding" environment rather than merely a containing one. The ultimate goals are of effecting a better integrated internal world, more cohesive and modulated self-object representation, and a self-concept less vulnerable to narcissistic injury.

Psychosocial Treatment Basic Principles Narcissistic patients try to sustain an image of perfection and personal invincibility for themselves and attempt to project that impression to others as well. Physical illness may shatter this illusion, and a patient may lose the feeling of safety inherent in a cohesive sense of self. This loss precipitates a panicky sensation that "my world is falling to pieces," and the patient feels a sense of personal fragmentation. The histrionic patient's idealization of the physician stands in contrast to the narcissistic patient's frequent contemptuous disregard for the physician, who is denigrated in a defensive effort to maintain a sense of superiority and mastery over illness. Only the most senior physician in a prestigious institution is deemed worthy of respect as the frightened patient seeks an external reflection of his or her own fragile grandeur in the doctor. More junior members of the health care team may be the targets of derision as the patient seeks to establish hierarchical dominance in order to counter the shame and fear triggered by illness. Health care professionals must convey a feeling of respect and acknowledge the patient's sense of self-importance so that the patient can reestablish a coherent sense of self, but they must at the same time avoid reinforcing either pathologic grandiosity (which may contribute to denial of illness) or weakness (which frightens the patient). An initial approach of support followed by step-by-step confrontation of the patient's vulnerabilities may enable the patient to deal with the implications of illness with feelings of greater subjective strength. The increased self-confidence may reduce the patient's need to attack the health care team in a misguided effort at psychologic self-preservation and eases the pressure to provide perfect care, since the patient's antagonistic feeling of entitlement (defined by DSM-III as an "expectation of special favors without assuming reciprocal responsibilities") is reduced. Many of the treatment principles and approaches discussed for this disorder apply as well to Borderline Personality Disorder. The individual with narcissistic and related personality disorders is likely to present with Axis I symptoms and disorders at various times in his or her life. These should be treated as described elsewhere. Caution should be observed, however, not to overdiagnose psychotic decompensation as Schizophrenia unless all DSM-III criteria are apparent. The same caveat applies to the pharmacologic treatment of depressive symptoms in the absence of clinical signs of Major Affective Disorder. When treating presenting symptoms and Axis I disorders in patients with Narcissistic Personality Disorder and other similar conditions, attention should be paid to the consequences of removing symptoms in a patient whose underlying character is primitive and or fragile. Some clinicians, suggest that the grandiosity and tendency to idealize and devalue should be interpreted as defensive maneuvers when aspects of early conflictual relationships are played out in adult life. Other clinicians, posit that the emergence of the patient's grandiosity and tendency to idealize the therapist should initially be viewed supportively. To help the individual develop stronger self-esteem regulation, the therapist then gradually points out the realistic limitations of patient and therapist alike while also offering an empathic ambience to cushion patients in their efforts to accept and integrate these experiences. Unfortunately, much research will be required to validate the description and course of narcissistic personality disorder before further research can answer which techniques bring about a better response to treatment. Individual Psychotherapy Most psychiatrists will, as a practical matter, treat most of their severely narcissistic patients for symptoms related to crises and relatively external Axis I diagnoses, rather than in an effort

to address the personality disorder itself. The therapist must be aware of the importance of narcissism to the contiguity of the patient's psyche, refrain from confronting the need for self-aggrandizement, and help the patient use his or her narcissistic characteristics to reconstitute an intact self-image. Positive transference and therapeutic alliance should not be relied upon, since the patient may not be able to acknowledge the real humanness of the therapist but may have to see him/her as either superhuman or devalued. Those patients who do not terminate treatment after symptom relief has been obtained may wish help for some of the problems related to their personality disorder, such as interpersonal difficulties or depression. The therapist must have a good understanding of the principles of the narcissistic personality style, both for interpretation to the patient and for use in combating countertransference. Goals for ordinary psychotherapy should not be too great, since the source of these patients' difficulties lies deep in pathological development. Group Therapy The goals are to help the patient develop a healthy individuality (rather than a resilient narcissism) so that he or she can acknowledge others as separate persons, and to decrease the need for self-defeating coping mechanisms. The first step toward developing a working alliance is empathy with the surprise and hurt that the patient experiences as a result of confrontations within the group. The external structuring group therapy provides can control destructive behavior in spite of ego weakness. In groups, the therapist is less authoritative (and less threatening to the patient's grandiosity); intensity of emotional experience is lessened; and regression is more controlled, creating a better setting for confrontation and clarification. Outpatient analytic-expressive group therapy requires a concomitant individual relationship for most patients, which should be somewhat supportive. The need for this additional support, the likelihood of the patient's leaving the group at the first sign of psychic insult, and proneness to disorganized thinking are all found more often in the Borderline patient. The patient with a Narcissistic Personality Disorder does not appear so vulnerable to separation anxieties as the Borderline patient, but is instead involved in issues centered around maintaining a sense of self-worth

Obsessive-Compulsive Personality Disorder Symptoms

A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

1. is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost

2. shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met)

3. is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity)

4. is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification)

5. is unable to discard worn-out or worthless objects even when they have no sentimental value

6. is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things

7. adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes

8. shows rigidity and stubbornness

Treatment

Introduction Individuals who suffer from this personality disorder often are characterized by their lack of openness and flexibility in not only their daily routines, but also with interpersonal relationships and expectations. The overwhelming preoccupation with orderliness, perfectionism and control of their lives and relationships means that most types of treatment are going to be, at best, difficult. Treatment options that do not fit within the client’s cognitive schema will likely be quickly rejected rather than attempted. Individuals who suffer from this disorder have difficulty in incorporating new and changing information into their lives, so new learning takes place only over a great deal of time and with as much effort on both the clinician's and client's part. Their ability to work with others is equally affected, since they see the world as black and white -- their way of doing things and the wrong way of doing things. Naturally, this faulty logic will also be translated into their therapeutic relationship with the clinician and their treatment. It is therefore unlikely the clinician will have much success in using techniques or treatment modalities which haven't first been approved by the patient for use. Sometimes this may be done simply by stating the effectiveness of a given treatment for a specific problem, citing relevant research studies. More often, though, this technique won't be effective. When this disorder is combined with the presentation of a medical illness, physicians should expect a logical and coherent presentation of troubling symptoms with little emotionality attached to their physical discomfort. Treatment is most effective when the nature of the disease process is first discussed with the individual, as well as typical and accepted treatments. A physician in this instance is best sticking with the facts of the presenting problem and underlying disorder rather than offering vague impressions of their opinion. Since

the individual with this disorder tends to be meticulous and concerned with details, the treatment regimen --once accepted -- will likely be adhered to rigorously, without incident. Psychotherapy As with most personality disorders, individuals seek treatment for items in their life that have become overwhelming to their existing coping skills. These skills may be somewhat limited, in the first place, because of their disorder. While they may be generally effective enough in most instances to shield the client from stress and emotional difficulties, during times of increased stress, work pressure, family problems, etc. the underlying disorder will become more evident in day-to-day behaviors. As with most personality disorders, treatment is often focused on short-term symptom relief and the support of existing coping mechanisms while teaching new ones. Long-term or substantive work on personality change is usually beyond most clinician's skill levels, and patient's budgets. Obsessive-compulsive personality disorder is especially resistant to such changes, because of the basic makeup of this disorder. Short-term therapy will be most likely to be beneficial when the patient's current support system and coping skills are examined. Those skills that are not currently working could be reinforced with additional skill sets. Social relationships can also be examined, reinforcing strong, positive relationships while having the client re-examine negative or harmful relationships. One important aspect is to try and have the individual examine and properly identify their feeling states, rather than just intellectualizing or distancing themselves from their emotions. This can be accomplished through a variety of techniques, such as feeling identification (e.g., the "feeling faces") at the onset of every therapy session. Homework might include writing feelings down in a journal, especially as they notice them. Proper identification and realization of feelings can bring about much change in and of itself. Individuals suffering from obsessive-compulsive personality disorder often are not in touch with their emotional states as much as their thoughts. Leading the client away from describing situations, events, and daily happenings and to talking about how such situations, events and daily happenings made them feel may be helpful. Sometimes the patient may complain he or she doesn't remember or know how he or she felt at the time; the journal becomes a useful tool at this point. Therapy with people who have this disorder can sometimes be trying, since they can see the world in a very "all-or-nothing" manner. Beck's cognitive therapy doesn't seem to be all that effective in treatment, and cognitive approaches in general probably aren't useful in this case. Clinicians must be willing to undergo verbal attacks on their professionalism and knowledge, as such skepticism about a therapist's treatment approach from the client with this disorder can be expected. Clinicians should also be careful about engaging the client within these verbal attacks or intellectual discussions, as they continue to distance the patient from his or her feelings. And take the focus off of the client and onto unrelated matters (e.g., a therapist's professional training). Most people who suffer from this personality disorder (and the different, but related, obsessive-compulsive disorder) lead relatively normal lives, may have a family, friends, and work regularly. Clinicians should be careful not to overgeneralize psychopathology and look to change aspects of the patient's personality he or she is not ready or willing to change. This means, in effect, that if the way they relate to others in their environment (which a clinician might characterize as a personality disorder) is working for them, a clinician should not seek to change it 180 degrees without the client's purposeful consent. Therapy will most often be most effective when it focuses on correcting short-term difficulties currently being experienced. It

will become increasingly less effective when the goal of therapy is complex, long-term personality change. Although a group therapy modality may be helpful and an effective treatment option, most people who suffer from this disorder will not be able to withstand the minimum social contact necessary to gain a healthy group dynamic. They may quickly become ostracized by the group for pointing out other people's deficits and "wrong-headed" ways of doing things. Hospitalization Hospitalization is rarely needed for people who suffer from this disorder, unless an extreme or severe stressor or stressful life event occurs which increases the compulsive behaviors to an extent where regular daily activites are halted or present possible risks of harm to the patient. Hospitalization may also be needed when the obsessive thoughts do not allow the individual to conduct any usual activities, paralyzing them in bed or with their accompanying compulsive behaviors. Medications In most cases, medication for this disorder is not indicated unless the individuals is also suffering from a clearly delineated Axis I diagnosis as well. However, newer medications such as Prozac, an SRRI, have been approved for the treatment of obsessive-compulsive disorder and may provide some relief to individuals with the personality disorder. Long-term use, though, is rarely indicated, appropriate, or beneficial. Self-Help The medical profession often overlooks self-help methods for the treatment of this disorder because very few professionals are involved in them. Support groups, though, offer an excellent adjunct to continuing medication check-ups once a month, and a way to gain emotional and social support through the community. These groups also allow others to ensure the client is doing well and promotes the client's independence and stability. Many support groups exist within communities throughout the world that are devoted to helping individuals with this disorder share their commons experiences and feelings. Such support groups are recommended to individuals suffering from this disorder, especially if they have found therapy unhelpful or too expensive.

Paranoid Personality Disorder Symptoms

A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

• suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her

• is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates

• is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her

• reads hidden demeaning or threatening meanings into benign remarks or events • persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights • perceives attacks on his or her character or reputation that are not apparent to others

and is quick to react angrily or to counterattack • has recurrent suspicions, without justification, regarding fidelity of spouse or sexual

partner

Treatment

Psychotherapy As with most personality disorders, psychotherapy is the treatment of choice. Individuals with paranoid personality disorder, however, rarely present themselves for treatment. It should not be surprising, then, that there has been little outcome research to suggest which types of treatment are most effective with this disorder. It is likely that a therapy that emphasizes a simple supportive, client-centered approach will be most effective. Rapport building with a person who has this disorder will be much more difficult than usual because of the paranoia associated with the disorder. Early termination, therefore, is common. As the therapy progresses, the patient will likely begin to trust the clinician more and more. The client then will likely begin disclosing some of his or her more bizarre paranoid ideation. The therapist must be careful to balance being objective in therapy and with regards to these thoughts, and of raising the suspicions of the client that he or she is not trusted. It is a difficult balance to maintain, even after a good working rapport has been established. During times when the patient is acting upon his paranoid beliefs, the therapist's loyalties and trust may be called into question. Care must be used not to challenge the client too firmly or risk the individual leaving therapy permanently. Control issues should be dealt with in much a similar manner, with great care. Since the paranoid beliefs are delusion and not based in reality, arguing them from a rational point of view is useless. Challenging the beliefs is also likely to result in more frustration on both the part of the therapist and client, too. All clinicians and mental health personnel who come into contact with the individual who suffers from paranoid personality disorder should be more keenly aware of being straight-forward with this individual. Subtle jokes are often lost on them and allusions to information about the client not received directly from the client's mouth will raise a great deal of suspicion. Therapists should typically avoid trying to have the patient sign a release of information for information not essential to the current therapy. Items in life that usually wouldn’t give most people a second thought can easily become the focus of attention to this client, so care must be exercised in discussions with the client. An honest, concrete approach will likely gain the most results, focusing on current life difficulties which has brought the

client into therapy at this time. Clinicians should generally not inquire too deeply into the client's life or history, unless it's directly relevant to clinical treatment. Long-term prognosis for this disorder is not good. Individuals who suffer from this disorder often remain afflicted with prominent symptoms of it throughout their lifetime. It is not uncommon to see such people in day treatment programs or state hospitals. Other modalities, such as family or group therapy, are not recommended. Medications Medications are usually contraindicated for this disorder, since they can arouse unnecessary suspicion that will usually result in noncompliance and treatment dropout. Medications that are prescribed for specific conditions should be done so for the briefest time period possible to bring the condition under management. An anti-anxiety agent, such as diazepam, is appropriate to prescribe if the client suffers from severe anxiety or agitation where it begins to interfere with normal, daily functioning. An anti-psychotic medication, such as thioridazine or haloperidol, may be appropriate if a patient decompensates into severe agitation or delusionsal thinking which may result in self-harm or harm to others. Self-Help There are not any self-help support groups or communities that we are aware of that would be conducive to someone suffering from this disorder. Such approaches would likely not be very effective because a person with this disorder is likely to be mistrustful and suspicious of others and their motivations, making group help and dynamics unlikely and possibly harmful.

Schizoid Personality Disorder Symptoms A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

• neither desires nor enjoys close relationships, including being part of a family • almost always chooses solitary activities • has little, if any, interest in having sexual experiences with another person • takes pleasure in few, if any, activities • lacks close friends or confidants other than first-degree relatives • appears indifferent to the praise or criticism of others • shows emotional coldness, detachment, or flattened affectivity

Treatment

Psychotherapy While there are many suggested treatment approaches one could make for this disorder, none of them are likely to be easily effective. As with all personality disorders, the treatment of choice is individual psychotherapy. However, people with this disorder are unlikely to seek treatment unless they are under increased stress or pressure in their life. Treatment will usually be short-term in nature to help the individual solve the immediate crisis or problem. The patient will then likely terminate therapy. Goals of treatment most often are solution-focused using brief therapy approaches. The development of rapport and a trusting therapeutic relationship will likely be a slow, gradual process that may not ever fully develop as in seeing people with other disorders. Because people who suffer from this disorder often maintain a social distance with people in their lives, even those close to them, the clinician should work to help ensure the client's security in the therapeutic relationship. Acknowledging the client's boundaries are important and the therapist should not look to confront the client on these types of issues. Long-term psychotherapy should be avoided because of its poor treatment outcomes and the financial hardships inherent in length therapy. Instead, psychotherapy should focus on simple treatment goals to alleviate current pressing concerns or stressors within the individual's life. Cognitive-restructuring exercises may be appropriate for certain types of clear, irrational thoughts that are negatively influencing the patient's behaviors. The therapeutic framework should be clearly defined at the onset. Stability and support are the keys to good treatment with someone who suffers from schizoid personality disorder. The therapist must be careful not to "smother" the client and be able to tolerate some possible "acting-out" behaviors . Group therapy may be an alternative treatment modality to examine, although it is usually not a good initial treatment choice. A person who suffers from this disorder who is assigned to group therapy at the onset of therapy will likely terminate treatment prematurely because he or she will be unable to tolerate the effects of being in a social group. If, however, the person is graduating from individual to group therapy, they may have enough minimal social skills and abilities to tolerate group much better. People who suffer from this disorder see little to no reason for social interactions and often will be quite quiet in group, contributing little to others and offering little of themselves. This is to be expected and the individual who has schizoid personality disorder should not be pushed into participating more fully group until he or she is ready and on their own terms. Group leaders must be careful to help protect the

individual from criticism from other group members for their lack of participation. Eventually, if the group can tolerate the initially-silent member with this disorder, the individual may gradually participate more and more, although this process will be very slow and drawn out over months. Clinicians should be wary of too much isolation and introspection on the part of the patient. The goal is not to keep the individual in therapy as long as possible (although they may appreciate, if not fully utilize, therapy). As in group therapy, the individual who suffers from this disorder may engage in long periods of not talking and silence in session. These may be difficult to bear for the clinician. Phillip W. Long, M.D., also notes that the patient may eventually, "reveal a plethora of fantasies, imaginary friends, and fears of unbearable dependency - even of merging with the therapist. Oscillation between fear of clinging to the therapist may be followed by fleeing through fantasy and withdrawal." These types of feelings must be normalized by the clinician and brought into proper focus in the therapeutic relationship. Medications Medication is usually not an issue for someone who suffers from this disorder, unless they also have an additional Axis I disorder, such as major depression. Most patients show no additional improvement with the addition of an antidepressant medication, though, unless they are also suffering from suicidal ideation or a major depressive episode. Long-term treatment of this disorder with medication should be avoided; medication should be prescribed only for acute symptom relief. Additionally, prescription of medication may interfere with the effectiveness of certain psychotherapeutic approaches. Consideration of this effect should be taken into account when arriving at a treatment recommendation. Self-Help The medical profession often overlooks self-help methods for the treatment of this disorder because very few professionals are involved in them. The social network provided within a self-help support group can be a very important component of increased, higher life functioning and a decrease in an inability to function in the face of unexpected stressors. A supportive and non-invasive group can help a person who suffers from schizoid personality disorder overcome fears of closeness and feelings of isolation. Many support groups exist within communities throughout the world that are devoted to helping individuals with this disorder share their commons experiences and feelings. Patients can be encouraged to try out new coping skills and learn that social attachments to others don't have to be fraught with fear or rejection. They can be an important part of expanding the individual's skill set and develop new, healthier social relationships.

Schizotypal Personality Disorder Symptoms

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, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

• ideas of reference (excluding delusions of reference) • odd beliefs or magical thinking that influences behavior and is inconsistent with

subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or "sixth sense"; in children and adolescents, bizarre fantasies or preoccupations)

• unusual perceptual experiences, including bodily illusions • odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or

stereotyped) • suspiciousness or paranoid ideation • inappropriate or constricted affect • behavior or appearance that is odd, eccentric, or peculiar • lack of close friends or confidants other than first-degree relatives • excessive social anxiety that does not diminish with familiarity and tends to be

associated with paranoid fears rather than negative judgments about self

Treatment

Psychotherapy As with most personality disorders, schizotypal personality disorder is best treated with some form of psychotherapy. Individuals with this disorder usually distort reality more so than someone with Schizoid Personality Disorder. As with Delusional Disorder and Paranoid Personality Disorder, the clinician must exercise care in therapy to not directly challenge delusional or inappropriate thoughts. A warm, supportive, and client-centered environment should be established with initial rapport. As with Avoidant Personality Disorder, the individual lacks an adequate social support system and usually avoids most social interactions because of extreme social anxiety. The patient often reports feelings of being "different" and not "fitting in" with others easily, usually because of their magical or delusion thinking. There is no simple solution to this problem. Social skills training and other behavioral approaches that emphasize the learning of the basics of social relationships and social interactions may be beneficial. While individual therapy is the preferred modality at the onset of therapy, it may be appropriate to consider group therapy as the client progresses. Such a group should be for this specific disorder, though, which may be difficult to form or find in smaller communities. Medications Medication can be used for treatment of this disorder's more acute phases of psychosis. These phases are likely to manifest themselves during times of extreme stress or life events with which they cannot adequately cope. Psychosis is usually transitory, though, and should effectively resolve with the prescription of an appropriate anti-psychotic.

Self-Help There are not any self-help support groups or communities that we are aware of that would be conducive to someone suffering from this disorder. Such approaches would likely not be very effective because a person with this disorder is likely to be mistrustful and suspicious of others and their motivations, making group help and dynamics unlikely and possibly harmful.