Personality Disorders
Lecture: Personality Disorders. Fernandez’s “You don’t Count” and “The Fourth of July” pgs 143-146. Also pages 22-57
Additional Readings:
1. Sims’s Chapter 21
http://www.psycom.net/depression.central.borderline.html (Links to an external site.)
http://mentalhelp.net/poc/center_index.php?id=8 (Links to an external site.)
There have been a couple of students who are very worried about the Tests. As I mentioned before, this is a difficult course with significant amount of material, and thus the exams are not easy tasks. Some students are able to do very well on them, but others, being good students as well, tend to struggle.
I am not sure where the mystery is, and in addition to the things I have already shared and done for the class, I can’t do much more. Still, I want to remind you that the total class grade is the result of various tasks and activities, and not only your Tests are important.
Also, you can drop (or not take) one exam and you would only have 3 exams to count for final grade. In short, it is too early to panic. Finally, you do have to manage your expectations; an “A” in Psychopathology is not easy or even common, although in the same vein, if a student stick with the class, and does the work, a C or even a B is realistic.
Having said that, I will be posting the Reviews ahead of time with a few Test questions for you to practice and feel more confident for next one.
Well, we have covered already a significant portion of the most typical disorders you will encounter in psychopathology.
In addition to this week’s topic (personality disorders) the other one major category of disorders will be the psychotic disorders. All of them will make the bulk of the work of a practicing clinician. Obviously, that will not include those who are involved with children, or in the practice of neuropsychology, both of which are specialty areas in Clinical Psychology.
That does not mean you may not see those cases in general practice, but in principle any complicated child case or Neuro case you will refer to a specialist. The trend today, in contrast to the time when I was trained, is more and more specialization, and if you are planning to go into this field, it will probably be what you would do. Those areas may include things such as addictive disorders, eating disorders, trauma, relationships, sexual disorders, pain management, sleep disorders, etc.
I hope that thus far, you have become aware of the importance of a good assessment, and a good grasp of major areas in psychopathology. The next step, and a crucial one if you are going to practice, is the ability to connect with your patient and understand his or her dilemma as they bring this or that problem to you.
Diagnoses are only your starting point, a ball park orientation to the main symptoms the patient is presenting to you; from there you need to recreate a narrative in which both of you could work towards a resolution of the patient’s problems. Along with this awareness is the need to understand the role of culture in the presentation of the symptoms as well as in the interpretation we make of what ails the person.
Each patient is unique in the way they suffer and the meaning of that suffering in their lives. Sometimes a practical goal of therapy may be the elimination of the particular problem, let’s say Panic Disorder, but other times, it may mean the incorporation and acceptance of issues or events they can’t change such as childhood abuse or chronic illness.
On these, the problems you can’t solve and the pain you can’t take away, you have to work with your patient in adaptation to the lingering impact of their conditions to their lives. Here is the area when Psychology is most lacking, and Philosophy and even Religion may be a potent ally in your efforts at helping your patient. In the book that I wrote, I address some of these issues, which I consider extremely important to understand and succor your patients.
This week!
Now, turning our attention to the topic for this week. This is a very interesting area and one that is constantly in the news!
Think about the people who make the news, from criminals to celebrities, how many of them do you think you could be diagnosed with a personality disorder?
Now all of us have our own “quirks” , and all of us have a personality (I hope!). However, most of us would not probably be diagnosed with a disordered personality because one has to have a “maladaptive pattern of dysfunction” and it has to extend to our thinking, feelings and behaviors, as well as to our relationship to other people.
The Five-Factor theory has been very popular in the last few years. Remember this acronym: OCEAN and you will remember it.
O=Openness to experience, C=Conscientiousness E= Extroversion A= Agreeableness N=Neuroticism.
The history of personality theory is fascinating going back to ancient Greeks. If interested read upon the humor theory as it relates to personality, interesting!
Personality disorders are now grouped on 3 basic major groups or cluster. This is important to remember:
Cluster A= Those odd or eccentric (Think “paranoid” very bad “geeks” called schizoids and schizoptypal)
Cluster B= The “drama queens and kings” , emotional types or “erratic”; that is the histrionic, borderline, narcissistic and anti-socials.
Cluster C=The anxious types avoidant, dependent, OC folks.
Despite the neat categories the trend is going towards developing a “dimensional model” which it was initially slated to go into effect in the DSM5, but it did not quite make it; I’m sure it will be added in the next version.
Ok these are the points I would like to emphasize and I want you to learn.
For this week and looking ahead:
1. Read Chapter 10 from our Textbook.
2. Read Sims’s Chapter 21 and Fernandez’s “You don’t Count” (see below) and “The Fourth of July” pgs 143-146. Also pages 22-57
Class Participation: This is a Borderline Personality Disorder patient I treated earlier in my career. There were also other issues such as alcohol, depression, etc, but the dynamics of the patient-therapist relationship were very interesting as well. As with many patients one would treat in therapy, this young woman had multiple issues, all connected to her basic personality style.
She was a long-term therapy case, unfortunately unless you are in private practice it would be hard to do these days; we all want quickies! But quickies do not work with these patients and the steady, strenuous, and consistent work is what really works. I hope you enjoy it.
You don’t Count!
I was sitting in front of a young, angry, tearful and disheveled young woman who had presented herself to our clinic to get help with depression, poor sleep and failing grades. She was a second year college student, who over the last few months had become increasingly depressed and unable to focus on her studies or anything else for that matter.
She started to tell me her story. She had been a model and at one time was making good money from it. She had money, fashionable clothes and she was able to travel widely in pursue of her career goals.
In one of her travels, she had met an older man, a successful businessman, and they started a long term relationship. Their story was as passionate as it was romantic. They had been to many places, but her favorite was Venice. She had very distinct memories of the days they had spent there; she was a princess enraptured in the fantasy of a life time. Something however, went wrong, and their idyllic castle came crashing down.
What followed was a series of very short term relationships, always seeking to fill an emptiness no man was ever able to fill. Then, she started drinking and using drugs, she abandoned her career, and eventually became more and more depressed, hopeless and suicidal. As she was telling me her story, she became increasingly frustrated and verbally aggressive. Her ire was directed to men; they were pigs; insensitive, uncaring, abusive. I began to feel very uncomfortable, and not having enough experience at this point in my life, I did not know what to do. I wanted to help her, but I wasn’t sure how. I also realized that her rage was getting to me, making me unease and unsure.
Attempting to bring down the intensity of her motional barrage I tried to inject humor by noting that if all men were pigs, what chance I had to help her, since as she could notice, I was a man. She looked at me sardonically and with a sharp remark shoot me down and said: – You don’t count!
I let her talk for almost the whole hour, and by the end, at the risk of looking silly, I told her this was a good session (I doubted) and I would be delighted to see her again (false!). To my surprise, she assented and made a follow up appointment. What followed was several weeks, which became months of fairly intense therapy.
We revisit her past (poor relationships with parents), her present (she needed to assume responsibility over her choices) and her future (what kind of life she expected to have). I tolerated her anger, supported her suffering and always encouraged her to see herself different, to learn to forgive and to accept the inevitable blows of life and her own “imperfect” human condition.
As time passed, her mood improved and her ability to regain control of her life significantly changed for the better. She started to do well in her classes and appeared happier with her life. She also began to change in another aspect.
This disheveled and tearful woman I had met several months ago, was turning into a great looking, attractive and very well-dressed young woman. Among my peers there was an increased interest to see “Luis’ Pretty Patient” and several of them would make a point to come across the clinic’s waiting room to take a peek at this beautiful lady.
The tone of our sessions also changed. There was little anger now, but a lot more flirtation. She made a few remarks about developing a friendship, becoming close, having outside sessions.
In Christmas, she wanted to give me a very expensive present, which I declined; I was not allowed to receive gifts from patients, I said. This became a difficult phase in our treatment. Once again, this young woman was challenging my abilities and testing the limits of my role as a Psychotherapist. Then one summer day, she came to session dressed in a fine linen white dress; she looked stunning. As we walked into the therapy room, she asked me to switch places, which I found peculiar.
But not having a reason to object I told her that was fine. She sat on the chair I typically used, which was exactly in front of a window through which light came into the room. This was a calculated effort at seduction; the sunlight behind her revealed her naked figure and she knew it! I don’t recall that session very well.
I only remember feeling extremely uncomfortable and ashamed, I babbled a few words here and there and she had complete control of the session and of me. Right after she left, I contacted my clinical supervisor, who heard my distressed and my expressed discouragement of ever being an ineffective Clinician; I was tempted and lost control of the session. My clinical supervisor, an older very experience Psychologist was very receptive and sympathetic towards me.
He gave me a clinical sound advice about counter-transference, how to handle it and to use it for the patient’s benefit. Most importantly, as I was leaving, in a very sympathetic manner said:- Don’t worry Luis, I have had this same experience before, just learn from it, and remember it is not about you!
Next session, I brought up the subject with her. She was a beautiful woman and easy to like. I felt she had done this because she really wants to be desired and loved by someone she admires and feels grateful for his help, but I was the wrong man.
I was her doctor, and my job was to help her not hurt her as other men had done in her life; I was committed to be different. This was a turning point for her and for our therapy. Now things began to move more rapidly and we began working towards termination.
When the final day came, she brought a small present I could not refuse. I was leaving to start my career and she had brought a very nice planner with my initials engraved in it. She told me she wanted me to remember her and use this calendar in my first year as a practicing Psychologist, then with a mischievous look on her face she added-Are you sure you don’t want to have a couple of drinks with me before you leave?
I smiled back to her and said- Laura, you know if we go out for a drink neither one of us will be doing the right thing, let’s leave it where it is now. She burst out laughing and said – I know Doc, I know.
I never saw her again, but I heard years later she had married and had a couple of kiddos, for all accounts she was a happy woman.
