Robert Rhoton PsyD

Psychological Health and Wellness

Robert.rhoton@aztraumatherapy.com

In the past mental health professionals have attributed personality disorders to some internal deficit (hole in the head theory) and not attributes of the situation or biological reactions. This made diagnosing and adequately treating people who suffer from personality disorders very difficult. What are the short falls or problems with this thought process?

The causes of personality disorders are controversial.

Some believe that personality disorders are caused by early experiences that prevented the development of normal thought and behavior patterns.

Others believe that biological or genetic influences are the root cause of personality disorders.

The truth is likely a combination of genetic predisposition and environmental variables contributing to the development of personality disorders.

1. Since we can not change genetics or impact it much with our current science, it is of little practical value when looking at helpful intervention to even consider genetics.

2. We can focus on environmental factors and the resulting behaviors and patterned actions that create problems in the lives of individual and those that they are relating to

Paranoid Affective Hypomanic Depressive Schizoid Explosive Obsessive-

compulsive Historonic Dependent

Anti-social Narcissistic Avoidant Borderline Passive-aggressive *Sadistic **Anankastic

Prenatally, those things that interrupt or interfere with the development of the child, for instance parental drug addiction, high levels of stress being experienced by the mother, poor prenatal care, over-activity during pregnancy, and emotional instability of the mother.

The mind/brain is assumed to be multifaceted, with semi-autonomous specialized subsystems operating in parallel. The component subsystems highlight their own parts of the representational tableau, which includes the:phenomenological experiencethe actionsthe preferences the memories of the person.

A number of component systems have been identified each with its distinctive functions

The mind can be likened to a chamber orchestra: Each subsystem or instrument contributes its own special qualities to the melody and harmonies, providing an unparalleled complexity and richness. The music maybe altered when individual instruments are either muted or amplified.

Reasoning and logic as a “COOL” system

Emotions, instinct and survival behavior as a “HOT” system

The “cool” hippocampal memory system records, in an unemotional manner, well-elaborated autobiographical events, complete with their spatial-temporal context. The cool system is cognitive and complex, informationally neutral, subject to control processes, and integrated. Cool-system memories are narrative, recollective, and episodic. The person knows that the events occurred in his personal past, and there is no sense of reliving or of mistaking the memory for a current percept.

The “hot” amygdala system responds to unintegrated fragmentary fear-provoking features of events, which become hooked directly to fear responses. The hot system is direct, quick, highly emotional, inflexible, and fragmentary. Hot-system memories are stimulus-driven and entail a sense of reliving rather than like recollections.

The two systems should operate in parallel, with the cool system encoding the contextual panorama and the hot system contributing a “highlighting” of emotional aspects of the experience.

When the systems are not working in parallel then the visual, auditory, kinesthetic, emotional and recognition of environmental feedback is skewed.

At traumatic levels of stress, the cool system becomes dysfunctional, while the hot system becomes hyper-responsive.

This means that the encoding under such conditions should be fragmentary rather than replete, and coherent.

At high levels of stress the individual will focus selectively and, at traumatic levels, exclusively, on the survival/instinctual evoking features that are peculiar to the hot system.

Highly stressed children oft experience irrational fears, fragmented memories, and dissociated experience.

Children that experience high levels of stress fail to integrate traumatic experiences into the narrative of their lives. Children initially perceive such experiences differently than do normal children under non-traumatic conditions

Children process the stress at a somatosensory level rather than autobiographically. Van der Kolk (1994)

Executive functioning is a term psychologists have chosen to use over the last decade to identify some of the highest levels of functioning of the brain.

Executive functioning, involves a combination of interrelated functions that produce purposeful, goal-directed, problem-solving initiating:

Executive functions:InhibitingShiftingPlanningOrganizingself-monitoringemotional controlworking memory

There are five general environmental factors that contribute to the Personality Disorders besides, poor care, poor nutrition, prolonged hospitalization, separation from caregiver, serious accidents and all forms of abuse. These are factors that interrupt and interfere with normal social-emotional development:

Based on the work of Jeffery E. Young Schema Therapy: A Practitioner's Guide 

1.  ABANDONMENT /  INSTABILITY2. MISTRUST / ABUSE3. EMOTIONAL DEPRIVATION

Deprivation of Nurturance:  Absence of attention, affection, warmth, or companionship.

Deprivation of Empathy:  Absence of understanding, listening, self-disclosure, or mutual sharing of feelings from   others.

Deprivation of Protection:  Absence of strength, direction, or guidance from others.

4. DEFECTIVENESS / SHAME 5. SOCIAL ISOLATION / ALIENATION

Childhood trauma can grow when the child’s expectation for needed security, safety, stability, nurturance, empathy, sharing of feelings, acceptance, and respect are not be met in a predictable

It can be damaging to the personality formation when there is a lack of predictability and security, safety, stability, nurturance, acceptance, and respect .

DEPENDENCE / INCOMPETENCE VULNERABILITY TO HARM OR ILLNESS  ENMESHMENT  /  UNDEVELOPED SELF   FAILURE - The belief that one has

failed,  will inevitably fail, or is fundamentally inadequate . Often involves beliefs that one is stupid, inept, untalented, ignorant, lower in status, less successful than others, etc.

Trauma can occur when the child has expectations about themselves and the environment that interfere with their perceived ability to separate, survive, function independently, or perform successfully.

Typical family origin is enmeshed, undermining of confidence, overprotective, or failing to reinforce child for performing competently outside the family

Deficiency in internal limits, responsibility to others, or long-term goal-orientation. Leads to difficulty respecting the rights of others, cooperating with others, making commitments, or setting and meeting realistic personal goals.

Typical family origin is characterized by permissiveness, overindulgence, lack of direction, or a sense of superiority -- rather than appropriate confrontation, discipline,  and  limits in relation to taking responsibility, cooperating in a reciprocal manner, and setting goals.

An excessive focus on the desires, feelings, and responses of others, at the expense of the child’s own needs -- in order to gain love and approval, maintain one's sense of connection, or avoid retaliation.  Usually involves suppression and lack of awareness regarding one's own emotions and natural inclinations.

Typical family origin is based on conditional acceptance: children must suppress important aspects of themselves in order to gain love, attention, and approval.  

An excessive emphasis on suppressing the child's spontaneous feelings, impulses, and choices OR on meeting rigid, internalized rules and expectations about performance and ethical behavior -- often at the expense of happiness, self-expression, relaxation, close relationships, or health.

Typical family origin is grim, demanding, and punitive: performance oriented, duty and perfectionism are highly prized values, following rules, hiding emotions, and avoiding mistakes dominate over warm relationships, pleasure, joy, and relaxation.  

Pervasive themes or patterns that have their origins in early adverse experiences, are elaborated over the course of a lifetime, and are dysfunctional to a significant degree

EMS’s are comprised of cognitions, emotions, and memories; they drive maladaptive behaviors.

EMS’s distort one’s perception of the self, others, and the world. They are self-perpetuating and self-defeating.

EMS form a set of dynamic injunctions that have a compelling or inhibiting quality to them.

Abandonment Mistrust & Abuse Emotional

Deprivation Defectiveness Social Isolation Dependence Vulnerability Enmeshment Approval-Seeking

• Failure• Subjugation• Self-Sacrifice• Unrelenting

Standards• Negativity• Entitlement• Insufficient

Self-Control• Overcontrol• Punitiveness

Toxic frustration of needs

Traumatization, victimization, mistreatment

Over-indulgence

Selective internalization or identification

Temperament or neurobiology can play a role

When patterned and habituated family behavior and interactions interrupt or interfere with the normal developmental (emotional, psychological, cognitive and social) processes --- this can be designated a traumagenic family structure

Traumagenic families are generally transmitting an intergenerational family culture that distorts, interferes with or interrupts normal human developmental processes

Psychological trauma in early childhood can have a tremendous negative impact as it can distort the infant, toddler or young child’s social, emotional, neurological, physical and sensory development. This is especially true of young children who have experienced multiple and/or chronic, adverse interpersonal events through the child’s care giving system.

The symptoms and behavioral characteristics can be categorized into seven domains

Domain OneAttachment - Uncertainty about the reliability and predictability of the world, problems withboundaries, distrust and suspiciousness, social isolation, difficulty attuning to other people'semotional states and points of view, difficulty with perspective taking and difficulty enlisting otherpeople as allies.

Domain TwoBiology - Sensorimotor

developmental problems, problems with coordination, balance, body tone,

difficulties localizing skin contact, hypersensitivity to physical contact, analgesia, somatization, increased medical problems

Domain ThreeAffect or emotional regulation - easily-

aroused high-intensity emotions, difficulty with emotional

self-regulation, difficulty describing feelings and internal experience, chronic and pervasive

depressed mood or sense of emptiness or deadness, chronic suicidal preoccupation, over-inhibition or excessive expression of anger and difficulty communicating wishes and desires.

Domain FourDissociation - distinct alterations

in states of consciousness, amnesia, depersonalization and derealization and two or more distinct states of consciousness, with impaired memory for state based events.

Domain FiveBehavioral control - poor modulation

of impulses, self-destructive behavior, aggressive behavior, sleep disturbances, eating disorders, substance abuse, oppositional behavior, excessive compliance, pathological self-soothing behaviors, difficulty understanding and complying with rules and communication of traumatic past by reenactment in day-to-day behavior or play (sexual, aggressive, etc.).

Domain SixCognition - difficulties in attention

regulation and executive functioning, problems focusing on and

completing tasks, difficulty planning and anticipating, learning difficulties, problems with language development, lack of sustained curiosity, problems with processing novel information, constancy, problems understanding own contribution to what happens to them, problems with orientation in time and space, acoustic and visual perceptual problems, impaired comprehension of complex visual-spatial patterns

Domain SevenSelf-concept - lack of a continuous and

predictable sense of self, low self-esteem, feelings of shame and guilt, generalized sense of being ineffective in dealing with one's environment, belief that one has been permanently damaged by the trauma, poor sense of separateness, disturbances of body image and shame and guilt

They are often socially isolated, and have little emotional and financial support.

Depression is a common factor in caregivers.

They are prone to use the same abusive techniques with their own children, that they hated as children.

They often show limited insight into the complexity of emotional and psychological needs and have a limited understanding of effective relationships.

They are at high risk to become overwhelmed and frustrated, and engage in hostile interactions to force compliance.

Parents who do not understand these issues often attribute their child's misbehavior to willfulness on the child's part, a conscious intention to cause the parent aggravation and frustration.

They often experience high levels of stress and discord in their lives, often as a result of the chaotic and unhealthy environments in which they live.

May have substance abuse problems and show high levels of marital discord and violence.

Substance abuse generally exacerbates stress, and stress is more likely to occur after a partner has been using substances. As a result, the children experience high levels of anxiety and become overloaded."

The children often feel responsible for the stress, and experience intense feelings of helplessness and powerlessness

There is inconsistent structure, support, and affection for extended and unpredictable periods of time. "Interrupted parenting" or a "wavering commitment" to parenting is most harmful.

Sometimes children show extreme difficulty bonding with the parent and feeling safe with them

While there may be no overt negative interactions, there is generally limited positive interaction.

Use of power control strategies (e.g., threats, demands, disapproval), and fail to respond positively to good behavior.

Problem solving decreases with more negative, controlling, and punitive behaviors.

Likely to show hostility, be demanding and rigid, and respond critically to the child.

Family shows poor conflict resolution skills

Executive functions:InhibitingShiftingPlanningOrganizingself-monitoringemotional controlworking memory

5 irritable, uncooperative and difficult to redirect. Started counseling for 10 months – no improvement

9 killed the neighbors dog with a hammer. Struck the dog approximately 70 times. Entered counseling a second time for 2 years and medication– no improvement

10 expelled for fighting, had 22 fights in the four grade

11 arrested for possession and consumption of alcohol

12 expelled and sent to an alternative school for bring and brandishing a knife at school

13 ran away from home (gone for 3 weeks) 13 broke his brother’s jaw (10) with a

baseball bat for touching a video game. Put on probation and started counseling a third time.

14 violated probation by destroying property. Took a pipe to a neighbor’s car who had called him a name. Goes to detention for 30 days

16 meets a girl (14) at the movies and rapes her in the stairwell theater exit. Punches her several times and kicked her in the stomach because she wouldn’t consent to sodomy. Stole her clothes and left her naked and bruised in the stairwell.

Arrested detained until 18.

How do you make sense of Jason’s behaviors now?

How would you need to approach someone with the environmental influences and domain deficits?

Janel ; a 41 female that lived alone save for a cat that had adopted her several years before. She had 2 or 3 friends that she considered close to her, but only talked with or seen them occasionally, about 5 times a year. She enjoyed her family though she lived a great distance (4 hours by plane from them), but would make frequent phone calls, those calls were characterized as being short, under 10 minutes. When she had family coming to see her, she would feel anxious, have trouble eating and felt a good many mystery pains. She would never initiate a conversation when out in public, and when

others would engage her, she would be extraordinarily polite and pleasant, and try to withdraw from the conversation as soon as possible. Has a phobia about large public gathering places, avoids malls, and subway stations. Once walked 22 blocks in the snow to avoid using the bus. She feels very lonely, but feels that she has to live the way she does to obtain security and safety. Even when she fantasizes about a different life, all of her fantasies avoid anything that might be upsetting. As a profession, she is a copy editor for large publishing company, and actually has to interact with others at work very seldomly

36 year old Hispanic male Veteran with a history of heroin addiction, depression and incarceration

Hostile, belligerent, mistrustful Frequent altercations with other clients

(e.g. while waiting in line for methadone), fights with strangers (e.g., while working as street vendor, threw a hammer that broke a car window, nearly injuring a child)

Had some capacity for remorse, but these behaviors were “ego-syntonic” – they felt like justifiable responses to provocations

Began methadone maintenance, stopped using heroin

Depression improved after taking antidepressant medication

Participated in regular group psychotherapy

However, his aggressive behavior persisted, even after staff repeatedly enforced consequences for his behavior

Finally kicked out of program after caught stealing VA property, which he had been selling on the street

A history of severe physical and emotional abuse

Beatings by his father occurred nearly every day, often with hard objects, frequently leaving him with bruises or marks. From 3-14 had father inflicted injuries including, broken arm (3 times), concussion, dislocated shoulder, broken hand, 6 broken ribs.

He was frequently yelled and screamed at, called names, insulted and belittled by both of his parents

Enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts

behavior that deviates markedly from the expectations of the individual’s culture

Social information processing skills deficits

Aggressive cognitive responses Children who had been physically

harmed by an adult during the first five years of life were 4 times more likely to engage in externalizing (acting out) behaviors by the 4th or 5th grade.

Children raised in Traumagenic homes 2.5 more likely to engage in acting out with high risk behaviors

What is the likelihood of problem behaviors if one has both physical abuse and traumagenic family structure?

These deficits include tendencies:1. to be distracted from relevant

social cues, 2. to presume hostile intent on the

part of peers, 3. to choose aggressive responses

to situations, 4. to view aggression as leading to

successful outcomes.

Those with personality disorders generate less competent (constructive, problem resolving) and more aggressive responses to negative or aversive behavior and may not be able to generate more competent responses.

Patients typically come for therapy with presenting problems other than personality problems

They require more work within the session

Longer duration of treatment Greater strain on the therapist’s skills

and patience Greater difficulty in treatment

compliance

A strong relationship exists between the cognitive patterns on the one hand and the affective and behavioral patterns on the other

Victim Stance1. Blame others for not meeting

responsibilities2. Blames others for their inappropriate

behavior3. Always have a ready excuse4. Fight for the right to be a victim5. Resist efforts to appropriately solve

problems that are causing them distress6. Focus away from assuming responsibility

Sense of Injustice

1. View normal expectations as unfair2. Refuses to follow “unfair” directions3. Refuse to meet “unfair”

expectations4. Complain that the consequences

for any of their actions that bring negative feed back or correction is unfair

Uniqueness (Grandiosity)1. Claim that they are different or unique

and should have a different set of rules and expectations

2. Demand others understand them3. Accuse others of not understanding them

or making adequate efforts to understand them

4. Focus on how they are not understood rather than resolving problems or conflicts

One way boundaries1. Demands respect and privacy in

inappropriate ways2. Violates others privacy3. No reciprocity in respecting the rights of

person or property4. Behaves suspiciously and then becomes

enraged when those behaviors are questioned

Overthrow or defeat rules

1. Sees rules, guidelines, and restrictions as obstacles that must be overcome

2. Manipulate others by being charming or compliant in order to avoid being held accountable to the rules

3. Focus on one-way rights (seeing their own rights and not the rights of others)

Pride in Negativity

1. Enjoy showing off their knowledge of negative or inappropriate things

2. Gets power from negative behavior or ideas

3. Places high value on learning and knowing things that are hurtful, hateful, evil or demeaning to others

Anger that is instrumental

1. Loses control to get their own way2. Trains others to avoid them when angry

or else3. Claim that they “lost control” after and

aggresssive, destructive or abusive incident

4. Uses anger to have power in a situation5. Others become timid and “walk on

eggshells” when they have to discuss problems or responsibilities

One way training

1. Uses inappropriate behavior to train others to give in to them

2. Uses inappropriate behavior when their wishes are opposed or resisted

3. Resists attempts to problem-solve and be re-directed

One Way Role Models

1. Models self after negative peers, neighbors, the famous “bad” people

2. Adopts behaviors of negative role models

3. Act non-responsively to or directly reject positive role models

Wishing1. Has unrealistically high opinion of their own

skills and abilities2. Talks about how things will be but avoids

goal setting or commitments designed to achieve goals

3. Acts as if talking about it is the same as doing it

4. Constantly put off activities or tasks which are perceived as “responsibilities”

5. Respond with anger when pressed to perform in a timely manner

Casing (or) Sizing Up1. Size people up for how much power

they have and respond differently based on their view of that power

2. Reacts negatively to or dominates those that appear to have less power

3. Act charming toward those with more power

4. Resist developing relationships with those that might be more powerful than they or threaten their power

Dishonesty and misinformation1. Use omission and vagueness to confuse or

avoid2. Pretend to have misunderstood3. Keep secrets for no apparent reason4. Tell others what they think the other wants

to hear5. Say yes and agree to avoid further feedback6. Act confused when challenged on an

inappropriate comment or behavior

False Apologies

1. Apologizes without acknowledging actual wrong doing

2. Blame others while apologizing3. Say “I’m sorry” without taking

responsibility

Turnaround

1. Put others on the defensive when they are clearly wrong

2. Put others on the spot so that they wind up explaining themselves rather than focusing on resolving a problem

3. Use statements like “you don’t love me” “you don’t trust me” “ you don’t appreciate me” as away to avoid dealing with an issue and deflect away

Partialization

1. Do incomplete work and feel like that should be good enough

2. Expect full rewards for partial completion

3. Acts angry when reminded of full expectations of responsibility

4. Enraged when denied a reward for a minimal efforts or partial completion

SafetySelf-regulationSelf-processing and Self-

assessmentExperience integration and

reorientationRelational engagementPositive affect enhancement

SafetyInternal SafetyRelational SafetyPhysiological SafetyTherapeutic Safety

Self-regulationAffective, Behavioral, SomaticSelf-soothing capacityHealthy appropriate self-expressions

Impulse control Modulation of emotional states

Self-processing and Self-assessmentIncrease effective use of executive functions

Increase effective planning and execution

Develop a coherent narrative about the self

Increase future orientation

Experience integration and reorientation► Understanding of triggers►Containing emotions►Differentiating the degrees of emotional response needed►Incorporate experience into history

Relational engagementBuild relational capacity in significant relationships

Attunement to significant others

Routines, and rituals

Positive affect enhancementΨIncrease creativityΨImaginationΨPleasure and JoyΨCompetenceΨMastery

Schema Therapy  A Practitioner's Guide (2006) Guilford Press . Jeffrey E. Young, Janet S. Klosko, and Marjorie E. Weishaar

The Abusive Personality: Violence and Control in Intimate Relationships by Donald G. Dutton

 When Your "Perfect Partner" Goes Perfectly Wrong: Loving Or Leaving The Narcissist In Your Life by Mary Jo Fay

 Social and Personality Development by David R. Shaffer  Reinventing Your Life: The Breakthough Program to End

Negative Behavior...and Feel Great Again by Jeffrey E. Young, Janet S. Klosko, and Aaron T. Beck 

 Treatment Utilization by Patients With Personality Disorders. Am J Psychiatry 158:295-302, February 2001

 The disorders of personality. Handbook of personality: Theory and research. Millon, Theodore Pervin, Lawrence A. (Ed). (1990). Handbook of personality: Theory and research. (pp. 339-370). New York, NY, US: Guilford Press. xiv, 738 pp.

You are welcome to contact the presenter through e-mail at Robert.Rhoton@aztraumatherapy.com or through the Psychological Health and Wellness website www.psychologicalhealthandwellness.com if you want additional information.