PERSONALITY^GUIDED PSYCHOLOGY BOOK SERIES THEODORE MILLON, Series Editor Personality-Guided Therapy for Posttraumatic Stress Disorder George S. Everly Jr. and Jeffrey M. Lating Personality-Guided Therapy in Behavioral Medicine Robert G. Harper Personality-Guided Forensic Psychology Robert J. Craig Personality-Guided Relational Psychotherapy: A Unified Approach Jeffrey J. Magnavita Personality-Guided Cognitive-Behavioral Therapy Paul R. Rasmussen Personality-Guided Behavior Therapy Richard F. Farmer and Rosemery O. Nelson-Gray Personality-Guided Therapy for Depression Neil R. Bockian
Personality-Guided Therapy for Depression Neil R. Bockian
Series Editor Theodore Millon
AMERICAN
PSYCHOLOGICAL
ASSOCIATION
WASH I N G T O N ,
DC
Copyright © 2006 by the American Psychological Association. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, including, but not limited to, the process of scanning and digitization, or stored in a database or retrieval system, without the prior written permission of the publisher. Published by American Psychological Association 750 First Street, NE Washington, DC 20002 www.apa.org To order APA Order Department P.O. Box 92984 Washington, DC 20090-2984 Tel: (800) 374-2721; Direct: (202) 336-5510 Fax: (202) 336-5502; TDD/TTY: (202) 336-6123 Online: www.apa.org/books/ E-mail:
[email protected] In the U.K., Europe, Africa, and the Middle East, copies may be ordered from American Psychological Association 3 Henrietta Street Covent Garden, London WC2E 8LU England Typeset in Goudy by Stephen McDougal, Mechanicsville, MD Printer: Edwards Brothers, Ann Arbor, MI Cover Designer: Berg Design, Albany, NY Technical/Production Editor: Harriet Kaplan The opinions and statements published are the responsibility of the authors, and such opinions and statements do not necessarily represent the policies of the American Psychological Association. Library of Congress Cataloging-in-Publication Data Personality-guided therapy for depression / by Neil R. Bockian. p. cm. — (Personality-guided psychology) Includes bibliographical references and index. ISBN 1-59147-410-8 (alk. paper) 1. Depression, Mental—Treatment. 2. Personality disorders—Treatment. I. Title. II. Series. RC537.B58 2006 616.85'2706—dc22 British Library Cataloguing-in-Publication Data A CIP record is available from the British Library. Printed in the United States of America First Edition
2005037362
Dedicated with love to my wife Martha— my personal antidepressant and my favorite personality type.
CONTENTS
Series Foreword
ix
Preface
xi
Acknowledgments
xiii
Chapter 1.
Introduction
3
Chapter 2.
An Overview of Depression and Theoretical Models of Its Relationship to Personality Disorders
13
Chapter 3.
Depression in Paranoid Personality Disorder
41
Chapter 4.
Depression in Schizoid Personality Disorder
63
Chapter 5.
Depression in Schizotypal Personality Disorder . . . .
91
Chapter 6.
Depression in Antisocial Personality Disorder
109
Chapter 7.
Depression in Borderline Personality Disorder
135
ChapterS.
Depression in Histrionic Personality Disorder
169
Chapter 9.
Depression in Narcissistic Personality Disorder . . . .
187
Chapter 10.
Depression in Avoidant Personality Disorder
209
Chapter 11.
Depression in Dependent Personality Disorder
227
Chapter 12.
Depression in Obsessive-Compulsive Personality Disorder
247
vu
Appendix A: Emotion List—2
267
Appendix B: Expression of Personality Disorders Across the Domains of Clinical Science
271
References
273
Author Index
305
Subject Index
313
About the Author
325
viii
CONTENTS
SERIES FOREWORD
The turn of the 20th century saw the emergence of psychological interest in the concept of individual differences, the recognition that the many realms of scientific study then in vogue displayed considerable variability among "laboratory subjects." Sir Francis Galton in Great Britain and many of his disciples, notably Charles Spearman in England, Alfred Binet in France, and James McKeen Cattell in the United States, laid the groundwork for recognizing that intelligence was a major element of import in what came to be called differential psychology. Largely through the influence of psychoanalytic thought, and then only indirectly, did this new field expand the topic of individual differences in the direction of character and personality. And so here we are at the dawn of the 21st century, ready to focus our attentions ever more seriously on the subject of personality trait differences and their impact on a wide variety of psychological subjects—how they impinge on behavioral medicine outcomes, alter gerontological and adolescent treatment, regulate residential care programs, affect the management of patients with depression and posttraumatic stress disorder, transform the style of cognitive—behavioral and interpersonal therapies, guide sophisticated forensic and correctional assessments—a whole bevy of important themes that typify where psychologists center their scientific and applied efforts today. It is toward the end of alerting psychologists who work in diverse areas of study and practice that the present series, entitled Personality-Guided Psychology, has been developed for publication by the American Psychological Association. The originating concept underlying the series may be traced to Henry Murray's seminal proposal in his 1938 volume, Explorations in Personality, in which he advanced a new field of study termed personology. It took its contemporary form in a work of mine, published in 1999 under the title Personality-Guided Therapy.
The utility and relevance of personality as a variable is spreading in all directions, and the series sets out to illustrate where things stand today. As will be evident as the series' publication progresses, the most prominent work at present is found with creative thinkers whose efforts are directed toward enhancing a more efficacious treatment of patients. We hope to demonstrate, further, some of the newer realms of application and research that lie just at the edge of scientific advances in our field. Thus, we trust that the volumes included in this series will help us look beyond the threshold of the present and toward the vast horizon that represents all of psychology. Fortunately, there is a growing awareness that personality variables can be a guiding factor in all spheres of study. We trust the series will provide a map of an open country that encourages innovative ventures and provides a foundation for investigators who wish to locate directions in which they themselves can assume leading roles. Theodore Millon, PhD, DSc Series Editor
SERIES FORWORD
PREFACE
The science and practice of clinical psychology have undergone a dramatic and exciting process of change in the past century. Following Freud's explorations of the unconscious, the dialectic swung to the antithesis, the behavioral revolution of Thorndike and Watson and, later on, Skinner. Filling in the vast space since then have been many approaches. Objectrelations theorists have examined the functioning of the ego, and interpersonal theorists have studied how relationships with others impact human psychology. Client-centered, humanistic, and existential therapists as well as logotherapists have focused on human experience and questions regarding life's meaning. Systems-oriented theorists have helped us to understand dyads, families, groups, and organizations and have developed new and innovative intervention strategies. Cognitive and rational—emotive therapists have discovered a wealth of techniques designed to help the individual use reasoning to feel better. With each new theoretical innovation, the discipline of clinical psychology has found new ways to be helpful and to reach more individuals. Efforts at integration have become increasingly important. There were theoretical manuscripts integrating, for example, individual and family approaches (e.g., Wachtel & Wachtel, 1986) or psychodynamic and behavioral approaches (Arkowitz & Messer, 1984). Millon's (1969/1985) biopsychosocial model makes the case that biological, psychological, and social factors contribute to a person's overall adaptation; this approach had a substantial impact on the field. Previous efforts at integration focused mostly on the level of theory— that is, the effort was to find commonalities in different theoretical approaches or to add the strengths of one to another. With Personality-Guided Therapy (1999), Millon added the notion that the best way to integrate theories was to focus at the level of the person. Simply put, psychodynamic, behavioral, cognitive, family, humanistic, and other theories can all be used to describe XI
a single individual. From that perspective, it becomes apparent that a given individual has unconscious conflicts and behavioral tendencies and cognitions and family dynamics and experiences of conditions of worth, all of which contribute to his or her current functioning. In line with the biopsychosocial perspective, it becomes equally obvious that biological and sociological phenomena also have a substantial impact on the person. The best available picture of an individual at any given moment is a collage of all of the concepts and images contributed by each perspective. The purpose of this book is to provide a comprehensive understanding of the person with clinical depression. By taking into account personality, as represented by the personality disorders in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision; American Psychiatric Association, ZOOOa), treatments for depression are refined and made more appropriate. Along the lines of the growing and healthy interest in positive psychology, we (the author and the series editor) are also mindful to take into account strengths and positive aspects of the person. From a scientific standpoint, we see this book as part of an ongoing process. There is a synergistic flow between clinical practice and science (Soldz & McCullough, 2000). Practice leads to insights that generate hypotheses to be tested scientifically; research then informs clinical practice (Anderson, 2000). Like the developers of process-experiential therapy (Elliott, 2000) and transference-focused psychotherapy (O. F. Kemberg, Selzer, Koenigsberg, Carr, & Appelbaum, 1989; Yeomans, Clarkin, & Kernberg, 2002), we envision practice and research mutually enhancing one another, leading to many confirmations—and just as many surprises—along the way. Ultimately, our goal is to operationalize the approach and test it in randomized clinical trials. In the meantime, we invite the reader to join us in exploring this promising new approach.
PREFACE
ACKNOWLEDGMENTS
I thank the many people who made this book a possibility. First and foremost, I thank the series editor, Theodore Millon, who asked me to write the book. Ted, your faith and confidence in me have consistently exceeded my expectations of myself and inspired my best work. The dedicated and talented editors in the American Psychological Association Books Department have done a wonderful job of shepherding this project to fruition: Susan Reynolds guided me through the opening phases, and Linda McCarter has been a steadfast support for some 2 years. I also thank several gifted clinicians, my former students Don Castaldi, Mark Johns, Suzanne Richter, Michelle Rodgers, and Kelly Vinehout, all of whom provided case material; their contributions considerably enhanced the quality of this volume. In addition, I thank the anonymous reviewers, who provided feedback that dramatically improved the quality of the book while simultaneously improving the economic welfare of the coffee industry. The librarians at the Illinois School of Professional Psychology Chicago Campus deserve high praise, especially Qi Chen, who added several books to the library collection at my behest, and Fay Kallista, who tirelessly tracked down articles and interlibrary loan materials. The members of the library staff at the Adler School of Professional Psychology, Karen Drescher, Arlene Krizanic, and Michael Zellner, also provided a number of articles, some of them on an expedited basis; to them I owe my thanks as well. Hundreds of current and former students have contributed to this book through their participation in my countertransference study, their completion of their clinical research projects in areas related to this work, their questions and comments in class, and their homework assignments; from them, I have learned more than can be imagined. I appreciate the efforts of my current students and future colleagues Julia Smith and Ellyn Turer, and of former student Virginia Doyle South, who provided feedback on the initial draft. In addition, I thank Danielle Merolla, Erica XIII
Moore, and Dominika Prus, who proved to be worthy assistants during the time-pressured final phase of preparing the manuscript. My parents, Fred and Sandra, and my uncle and aunt, Alan and Barbara Brodsky, provided encouragement, emotional support, and that most precious support of all—babysitting! Special thanks go to my brother Jeffrey for what must be the most memorable portion of my writing. When a longplanned vacation together bumped up against my first draft deadline, he adapted his SUV into a traveling office, and I wrote two full chapters on the round-trip drive between Los Angeles and Death Valley. I also thank my sister-in-law, Kari, who supported our dusty adventure. I am grateful to my wife, Martha, for taking on extra responsibilities while I wrote, despite her own rapidly burgeoning career and growing opportunities. Finally, I thank my beloved children, Chaya and Yaakov, who groaned each and every time I needed to work on the book and never became the slightest bit acclimated to my need for additional time; may we always yearn to spend our moments together.
xiv
ACKNOWLEDGMENTS
Personality-Guided Therapy for Depression
1 INTRODUCTION
Depression is a thorny problem to treat. In many cases, treatment is ineffective from the start. Even when client and clinician meet with early success, relapse frequently follows. Given that millions of people suffer from the disorder, improving treatment for depression is a major priority. The premise of this book is that those individuals who have depression and either fail to make progress or experience relapse often do so because of deeply rooted, enduring patterns in numerous areas of their lives that conspire to undermine healthy and satisfactory adjustment. Personality shapes how the individual exists in the world. It is the riverbed upon which the person's emotional life flows. In order to change the direction of a complicated depression, one is well advised to intervene at the level of personality. More specifically, the very nature of the depression itself and the reason the person has become depressed is explicitly related to the individual's personality style or disorder. For example, where the person with a dependent style mourns being abandoned, the person with an antisocial personality configuration agonizes over feeling confined. Such considerations have implications for treatment. Intervention must not only address different issues but different communication styles. Thus the nurturing, supportive approach that would endear one to the dependent client would elicit denigration from the antisocial. 3
To be sure, as we have known for many years, many straightforward cases of depression are successfully treated in 20 sessions or fewer (A. T. Beck, Rush, Shaw, & Emery, 1979). Such cases are not the focus of this volume; rather, my focus is those cases that have "complications" and are likely to either fail or to relapse. Research supports the commonsense notion that individuals who have both personality disorders (PDs) and depression have more problematic recoveries (Ilardi, Craighead, & Evans, 1997). This volume provides conceptual guidelines on how to be effective in these difficult cases. Depression is influenced by behavioral problems, such as poor social skills, as well as by beliefs of personal inadequacy and ineffectiveness. Unconscious phenomena such as repression or intrapsychic fragility can impact both mood and behavior. Most depressions also involve interpersonal problems, such as family difficulties, conflicts, or withdrawal. Biological predispositions often contribute to the difficulties of depression. Personality theory serves as an excellent conceptual framework through which to understand how these various factors interact synergistically to produce problems. Similarly, personality theory provides a framework to understand many strengths an individual has that facilitate long-term recovery. It is well known that PDs are also difficult to treat. They are, by definition, long-standing and deeply ingrained. A depression may make a PD more difficult to treat, particularly in the case of those with "internalizing" personality styles who tend to be hard on themselves or intropunitive (e.g., avoidant or obsessive—compulsive) or those who are already slow and passive (e.g., schizoid or dependent). On the other hand, depression may facilitate treatment among those with "externalizing" personality styles, who might otherwise be hesitant to engage in treatment (e.g., are narcissistic or antisocial). As with the notion presented above, that taking personality into account will facilitate the treatment of depression, 1 assert that taking depression into account can improve the treatment of PDs. The aim of this volume is to provide practitioners, researchers, and students with a theoretical framework from which to approach the individual who has depression embedded within the context of a particular PD or style. Because it is based on the integration of well-grounded approaches, the current volume provides ideas that will be useful for clinicians. I am equally hopeful that the text will provide fertile ground for testable hypotheses for researchers. Indeed, this volume marks one important step in an ongoing scientific journey. Eventually, personality-guided therapy must be subject to randomized clinical trials (RCTs) to determine whether it lives up to its promise of increasing success rates and reducing relapse rates of individuals with complicated depressions. This volume is a step toward developing a treatment that is defined with sufficient precision to be manualized and thus subject to RCTs. In addition to RCTs with manualized interventions, efficacy studies with naturalistic designs are necessary to see how the therapy functions in the "real world." 4
PERSONALITY-GUIDED THERAPY FOR DEPRESSION
THERAPIST EMOTIONAL REACTIONS: COUNTERTRANSFERENCE Although it is beyond the scope of this work to cover countertransference in a comprehensive manner, looking at all of the available literature (a project of that magnitude is worthy of a book in its own right), I will make some comments on therapist emotional reactions to people with each of the PDs. Rather than exhaustively review the literature, or leave out countertransference entirely, I have chosen to report some of my own experiences, an abbreviated review of the literature, and the findings of a research project that I have undertaken for the past 7 years. Although these findings are not yet published, there have been a few presentations based on these data (Agor, Smith, & Bockiari, 2005; Bockian, 2001, 2002a, 2002b), as well as several clinical research projects (Agor, 2005; Kim, 2004; Mullen, 2004; Rodgers, 2004; Rusten, 2002; D. L. Williams, 2005). In the study, graduate students in clinical psychology were shown film clips of individuals with PDs. They were then asked to rate their emotional reactions on the basis of a 136-item adjective checklist (see Appendix A). Participants in the study also gave descriptions of the meaning of the adjectives that they endorsed. The data I am reporting came from approximately 900 such forms collected from about 250 participants. Throughout the text, this study is referred to using the presentation in which the largest portion of the data was presented (Bockian, 2002a). For the purposes of this book, the most important finding is simply the mean of the participants' ratings of their emotional reactions to the film clips. However, it is noteworthy that manipulation checks suggest that the films are adequate prototypes of the PDs they are supposed to represent. Mean ratings of the prototypicality of the film clips, and how well they represent the PD they portray, are approximately 7.5 to 8.0 on a l-to-10 scale. The main drawbacks of the research paradigm are that (a) it is not clear how similar participants' reactions would be to real clients with whom they were interacting, as opposed to film clips; (b) it is not clear how their reactions would evolve over time, as opposed to seeing just a 5- to 10-minute segment of an intake session; and (c) it relies on conscious reports entered on a self-report instrument, thus banking on the self-awareness and accuracy of the participants. The main strength of the paradigm is that the stimulus is constant, so that reactions can be aggregated across clinicians. I routinely use two strategies to deal with feelings that I have toward clients, including positive feelings, but especially negative feelings. The first step is to become aware of the nature of the feeling itself. The emotional reaction typically occurs as a "felt sense" (Gendlin, 1978)—a vague, diffuse, nonverbal feeling. I also often experience a somatic response. Identifying these experiences and then labeling them ("oh—I'm bored!") is something I find to be useful, not only in recognizing the problematic pattern in the client (e.g., schizoid PD), but also in finding ways to "sit with my feelings." INTRODUCTION
5
The process of paying attention to one's own reactions is a useful exercise, one that can be conceptualized under the rubric of mindfulness (Epstein, 1995; Kabat-Zinn, 1990, 1994). Mindfulness, which is derived from the vipassana school of Buddhist meditation, is a form of self-awareness that can be practiced on a regular basis. For therapists, engaging in regular mindfulness practice is a way of managing one's personal stress while improving one's self-awareness (Bockian, 2001, 2002b). Once the feeling has been labeled, one can simply sit with it—sitting with unpleasant feelings has deep roots in mindfulness practice. One often finds that when one is "fully present in the moment" the discomfort itself dissipates. As a client of mine once put it, "When I'm rushing around, trying to run my business, I feel like I'm going to explode. But when I stop, and return to my breath, and focus on what's happening right now, it's never that bad." Thus, sitting with boredom, just for this moment, is never that bad. One can also explore the feelings using thought records, a technique taken straight out of cognitive-behavioral therapy (CBT). Once practiced, it can be done during the session, while one is still paying attention to the client. This approach may be incompatible with a client-centered approach, or the mindfulness approach above, because it entails multitasking, and thus one is not fully present with the client. From a CBT perspective, however, I believe this would be an acceptable, and even encouraged, approach (see A. T. Beck, Freeman, 6k Davis, 2004; Ellis, 2001). As I thought about some bored feelings I had when watching a filmed simulation of a client (Fidler, 1989), I would reflect to myself, I'm feeling bored. What is the situation? He's talking about his dinner in response to the question about what he is thinking about. What is the thought connected to that boredom? He is answering my questions in ways that do not connect to other people. I don't really care about what he is going to have for dinner. 1 am interested in how he will plan his life out, what he will do now that he lost his job, and so on. I then become aware of another feeling, a slight feeling of irritation, connected to the thoughts "he should be planning out his future, he is wasting valuable time with the counselor, who is trying to do career planning with him." Once the thoughts and feelings are connected, they become rather easy to challenge. What is the client's understanding of the purpose of the sessions? Has he been educated appropriately about the reason for the referral? What does he need, from his perspective? Another direction I routinely go in when examining my emotional reactions is to imagine what it would feel like to be that person, dealing with someone who felt like I did. What if everyone—or many people—felt that way about him? What would it be like if others found me boring because I did not have intense reactions to things, or irritating because my responses were
PERSONALITY-GUIDED THERAPY FOR DEPRESSION
"off or inconsistent with expectations? Such thoughts tend to lead me toward a more empathic stance. I will then check out the validity of my assumptions by asking about his interactions with others and how others respond. Implicitly, then, I am suggesting that countertransference is generally extremely useful in helping clients. Of course, countertransference can also be so difficult to manage that it can damage the therapeutic relationship. In the chapters that follow, I outline some commonly reported countertransference reactions as well as some common pitfalls to avoid. PERSONALITY-GUIDED THERAPY Millon's personality-guided therapy (POT) approach is more than sequencing different therapies. The concept of catalytic and synergistic effects in therapy has important implications for treatment. The chapters of this book are organized to provide different approaches and findings based on theory-driven modalities. However, I hope to capture the essence of PGT in the case studies: simultaneous integration of the entirety of the person, including personality, diversity, and other unique factors, along with properly timed sequential interventions drawn from a variety of theoretical sources. From the standpoint of PGT, the treatment of PDs and depression does not constitute two separate processes. Within the medical model, on which the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision [DSM-IV-TR]; American Psychiatric Association, ZOOOa) is largely based, diseases can be separately diagnosed and treated. Thus, the individual with cancer and depression may receive radiation therapy for the cancer and pharmacotherapy for the depression, and the treatments may not react with one another. In PGT, the treatment of the PD tends to resolve the depression, and vice versa; the disorders are not truly separable. This becomes clear in many of the case studies. There is a fine example in chapter 6, in which the person has depression and antisocial PD. The client was depressed because of his hopelessness about ever being released from prison and because of his frequent placements in solitary confinement precipitated by his violent behavior. The intervention, in a sense, directly targeted the PD. The client needed to better understand his relationship to authority and how his conceptualizations overly constricted his options and choices, especially regarding his violent behavior. Once he became more in control of his violent behavior, he was no longer placed in solitary confinement, and his chances of release improved; consequently, his depression began to resolve. Treating "the depression" (e.g., with techniques that addressed typical depressogenic cognitions, such as assessments that he was worthless, "must" statements, and so on) would not have been effective, because such thoughts were too distant from the client's experience. The depression had to be treated in the INTRODUCTION
context of the person. Throughout the text, there are many sections in which I discuss methods for understanding and resolving PDs; the reader should be aware that these conceptualizations and interventions address, directly or indirectly, the individual's depression as well. The integration of well-established treatment modalities in a systematic fashion is one of the central features of PGT. In this regard, Millon (1996, 1999) has provided a guiding, comprehensive theoretical framework that integrates the work of most if not all of the major theoretical perspectives into a coherent system. It is reminiscent of the well-known Indian parable of the blind men investigating an elephant: One, grasping the leg, proclaims that the object is a tree; a second, feeling the trunk, declares it is a snake; a third, handling the tusk, believes that the elephant is a spear, and so on. The blind men then take to arguing among themselves about the true nature—or even the proper description—of the elephant (Saxe, 2002). The main point is that taken one by one, none of the descriptions adequately captures the nature of the elephant. The pointless squabbles that have permeated our discipline regarding "who is right"—psychodynamic versus behavioral perspectives being frequent competitors for this conceptual space—are, from this perspective, irresolvable. Both perspectives contain partial truths. Although highly innovative, perhaps even revolutionary in its comprehensiveness, the PGT approach has been implicit in graduate clinical psychology training. Whenever a question on a comprehensive examination has demanded that a student describe a case using more than one theoretical perspective for a client with a PD (i.e., the student could choose from among psychodynamic, client-centered, interpersonal, cognitive, family systems approaches, etc.), then an aspect of PGT was involved.
THE STATUS OF RESEARCH ON PERSONALITY-GUIDED THERAPY There is always tension about when to release scientific information. On the one hand, appropriate caution must be taken to show that a treatment has efficacy. On the other hand, to delay means that individuals who may benefit from a new treatment are denied that opportunity. PGT is a new treatment. Although its origins can be traced in various ways to Millon's writings over many years (e.g., Millon, 1969/1985, 1981, 1996), it was launched in 1999 with the publication of Millon's PersonalityGuided Therapy. To the extent that it is built on other approaches (such as cognitive-behavioral therapy, psychodynamic therapy, etc.), various aspects of the treatment are scientifically well established. It is fair to say that at this point, the treatment is in an exploratory phase, with a rich base of theory but with few empirical data. Case studies embedded in books on the topic are the only data extant that are specific to this approach (Everly & Lating, 2003; 8
PERSONALITY-GUIDED THERAPY FOR DEPRESSION
Farmer & Nelson-Gray, 2005; Harper, 2003; Magnavita, 2005; Millon, 1999; Rasmussen, 2005). Of course, as noted above, the long-term goal of the present endeavor is to lead to a manualized treatment with randomized clinical trials. Our approach is similar to that of Kernberg and his associates in the development of transference-focused psychotherapy. Initially, the group presented innovative treatment ideas based on psychodynamic theory and case material (O. F. Kernberg, Selzer, Koenigsberg, Carr, & Appelbaum, 1989). Later, the treatment was manualized (Yeomans, Clarkin, & Kernberg, 2002) and subjected to a randomized clinical trial (Clarkin, Levy, Lenzenweger, & Kernberg, 2004).
A NOTE ON MEDICATIONS A number of medications are available to treat depression; these interventions are addressed in chapter 2. PDs per se cannot be treated with medications. However, underlying dimensions, such as impulsivity and psychoticism, are amenable to medication treatment. Medications for the relevant PD will be discussed in each chapter (chaps. 3-12). One study merits consideration here, because it addressed a mixed sample that included various PDs; to avoid repetition, I review the study here and allude to it briefly throughout the text. Ekselius and von Knorring (1998) examined 400 participants with major depression whom they randomly assigned to treatment with one of two antidepressants, sertraline or citalopram, both SSRIs. A 24-week course of treatment was completed by 308 participants (i.e., 145 with sertraline, 163 with citalopram), of whom 189 (61%) had a concurrent PD. No other treatments were provided (e.g., no psychotherapy). The researchers examined 10 PDs: paranoid, schizotypal, schizoid, histrionic, narcissistic, borderline, avoidant, dependent, obsessive-compulsive, and passive-aggressive, using a structured interview. The examiners reported that they excluded antisocial and self-defeating PDs, though they did not provide an explanation for this; they did not mention aggressive-sadistic PD. Although participants were randomly assigned the different medications, the study lacked a nontreatment control group. Because they used a structured interview pre- and posttreatment, the researchers had a dimensional measure (number of criteria met) and a categorical measure (whether the person had or did not have a disorder). In the sertraline group, there was a decrease in the number of PD criteria met for each one except schizoid. There was a decrease in the percentage of individuals diagnosed with PDs with both medications. In the sertraline group, paranoid, borderline, avoidant, dependent, and obsessive-compulsive PD criteria were less common posttreatment. (Schizoid diagnoses actually increased significantly, but this was accompanied by no significant change in number of criteria met, a finding that is admittedly difficult to reconcile.) In INTRODUCTION
9
the citalopram group, there were decreases in paranoid, histrionic, borderline, avoidant, dependent, and obsessive-compulsive diagnoses. Differences between the two medications were mostly nonsignificant, except that citalopram was superior to sertraline for obsessive-compulsive PD. Most other studies, which are reviewed in later chapters, looked at medication treatment for a single disorder. Ekselius and von Knorring's (1998) approach, to give a medication and measure the impact on a number of PDs, is somewhat more efficient, in that multiple comparisons can be made simultaneously (i.e., we can see that a medication has a positive effect on many PDs, with implications that a medication may be better for one disorder than another). The study is inconclusive, however, because there was no comparison group, so we do not know for sure what would have happened without treatment. Given the slow rate of spontaneous remission of PDs, and positive findings in controlled trials with SSRIs for borderline PD and social phobia (see chaps. 7 and 10, respectively), the most likely conclusion is that the medications had at least some effect. Effect size was not formally measured but appeared to be moderate. On average, there was a remission rate of approximately 25% ("any PD" went from 59.3% to 45.5% in the sertraline group and from 63.2% to 44.8% in the citalopram group). Remission rates exceeded 50% for borderline PD (either medication), dependent PD (either medication), and histrionic PD (citalopram). The decrease in the number of criteria met for each PD ranged from 0 to 1.3; the mean decrease was less than 0.5 for Cluster A, about 0.6 to 0.7 for Cluster B, and about 0.6 to 0.8 for Cluster C, depending on the medication. The largest change was for borderline PD (sertraline = -1.2; citalopram = -1.3). Using multivariate statistics, the authors illustrated that the decreases in PD symptoms were not a function of improvement in depressive symptoms. As will be illustrated throughout the remainder of this volume, however, medication research on PD populations constitutes a hodgepodge of case studies; open-label studies; and small, brief, randomized controlled trials. Although statistically significant effect sizes have been found with many medications for many problems associated with PDs, effect sizes are consistent with using medications in an adjunctive role. Noted Soloff (1997), Medication effects are modest, at best. GAS scores in the 1989 Soloff et al. haloperidol vs. amitriptyline trial improved 14 points, to an average of 55, in the most responsive group (HAL). Similarly, the average HAMD score fell from 26 to 16 in the HAL group, still symptomatic for most drug trials in depression, (p. 339) Even for borderline PD, which has been studied more than all other PDs combined, the research base is woefully inadequate (Soloff, 2000); how much more so for other PDs, many of which lack even a single empirical study? The lack of research on the use of medications for individuals with PDs is most unfortunate. Available studies suggest high rates of medication ]0
PERSONALJTY-G UIDED THERAPY FOR DEPRESSION
use in individuals with borderline PD (see Zanarini, 2004), and it is reasonable to speculate that individuals with other PDs also receive medication at rather high rates. The clinician should not complacently assume that medications that treat Axis I disorders are also beneficial for individuals with the Axis I condition in the context of a PD. A cautionary tale is the use of benzodiazepines and tricyclic antidepressants in the treatment of individuals with borderline PD; the limited available research suggests possible disinhibition and an iatrogenic increase in impulsive aggression following use of one or both of these classes of medications (see chap. 7). Understandably, studies that assess medications for their effect on depression usually exclude PD cases, but this strategy leaves us even deeper in the dark regarding the impact of antidepressants on individuals with a PD in conjunction with a depressive disorder. I join others in the field (e.g., Coccaro, 1998; Soloff, 2000) who have called for more research in the use of medications with individuals who have PDs.
THE STRUCTURE OF THIS VOLUME To develop an integrative understanding of depression and PDs, I first looked at the research on depression itself (chap. 2). Questions regarding the epidemiology as well as the effectiveness of current treatment modalities are explored. The chapter ends with a discussion of theoretical models of the relationship between PDs and depression; I implicitly draw on these models throughout the remainder of the text. Chapters 3 through 12 cover the relationship of depression to each of the 10 PDs of DSM-IV-TR. In each of these chapters, I begin with an illustration of the phenomenon, often drawn from the arts, film, or everyday experiences. Next, I cover theoretical and empirical material from a biopsychosocial perspective, leading to three major subsections. The biological section looks at hereditary factors, neuroanatomy, neurochemistry, and medications. The psychological section considers theoretical and empirical contributions from numerous important perspectives: psychodynamic, cognitive—behavioral, client-centered and humanistic, family systems, and group therapy, with a separate section on strengths-based conceptualization and intervention. The degree of coverage is based on the available literature, so some sections are brief or absent from some chapters. The social section includes considerations of diversity such as race and ethnicity, gender, socioeconomic status, and religion. Finally, a section on treatment planning, including a case example, illustrates the integration of the various perspectives into a personality-guided approach. The demographics of all case examples have been modified to protect the privacy of the clients. Many are composite cases, which combine elements of treatment for more than one client. At the end of the section on psychological approaches in chapters 3 through 12, I asked colleagues who contributed cases to share their insights INTRODUCTION
11
as well. I have integrated the findings of selected scientific studies and theoretical manuscripts. The studies were chosen because they are directly related either to depression or the specific PD under review. Because "countertransference" is conceptualized broadly for the present purposes (i.e., to include any emotional response of the therapist), it is included in its own section rather than subsumed within the psychodynamic area. It is beyond the scope of this book to look at PDs and depression in children. Some excellent resources are available in this regard. Paulina Kernberg and her associates have provided a well-reasoned approach with rich, illustrative case material (P. Kernberg, Weiner, & Bardenstein, 2000). In addition, the reader is directed to Stanley Greenspan's developmental, individual-difference, relationship-based model. Greenspan's approach to children, although developed in the context of autism, may have potential to treat children as early as infancy to prevent PDs, or to remediate PD symptoms in children. Greenspan noted how various kinds of rigidity in early childhood may "sow the seeds" for character pathology (1997, p. 322). Although these assumptions require further testing, I believe that Greenspan's approach has potential for any child who is tending toward a PD and urge the interested reader to examine one or more of Greenspan's writings (e.g., Greenspan, 1997; Greenspan & Wieder, 1998) and the Interdisciplinary Council on Developmental and Learning Disorders Web site (http:// www.icdl.com). Finally, Nadine Kaslow and her associates have done an excellent review on the status of various approaches to treating depression in children (Kaslow, McClure, & Connell, 2002). Each chapter is largely independent of the others. Chapters 3 through 12 are arranged alphabetically within each DSM-IV-TR PD cluster (i.e., Clusters A, B, and C). With the exception of the first two (i.e., this introduction and the overview of depression), concepts and data from which are woven throughout the book, the chapters draw content only minimally from one another. I recommend reading chapters 1 and 2 first, but thereafter chapters may be read in any order.
12
PERSONALITY-GUIDED THERAPY FOR DEPRESSION
2 AN OVERVIEW OF DEPRESSION AND THEORETICAL MODELS OF ITS RELATIONSHIP TO PERSONALITY DISORDERS
Before describing the personality-guided therapy (PGT) approach to treatment, it is important to review current theories of depression, as well as the various established treatment modalities and their efficacy. In this chapter I describe the phenomenology and epidemiology of depression; then 1 enumerate the relevant treatment approaches according to the biopsychosocial model. Biological theories focus on the role of the neurotransmitter norepinephrine (NE) and serotonin in depression, and treatments include pharmacotherapy and electroconvulsive therapy (ECT). The psychological theories and interventions section considers cognitive-behavioral, interpersonal, psychodynamic, family systems, and group approaches. The section on social concerns addresses issues of diversity, such as gender, ethnicity, and socioeconomic status in understanding the person with depression. Next, I review possible relationships between depression and personality disorders (PDs) as enumerated by theory. These models of relationships, which attempt to sort out the chicken-and-egg relationship between Axis II 13
and Axis I psychopathology, are potentially useful in both research and clinical settings. For the researcher, understanding the various possible Axis I-Axis II relationships (e.g., whether a PD generally precedes a depression, or the converse) is of obvious theoretical interest, having implications not only for treatment but also for developmental theory as well as for possible refinements in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision [DSM-IV-TR]; American Psychiatric Association, ZOOOa) taxonomy. Considering the possible relationships of depression to PDs (e.g., the possibility of lingering effects of one or the other disorder) may help the clinician to think more flexibly in understanding the client's perspective.
PHENOMENOLOGY OF DEPRESSION Depression, especially in its most severe form, can be an agonizing disorder. William Styron (1992) brought his literary genius to bear on the issue of his own depression in his memoir Darkness Visible. He noted, The argument I put forth was fairly straightforward: the pain of severe depression is quite unimaginable to those who have not suffered it, and it kills in many instances because its anguish can no longer be borne. The prevention of many suicides will continue to be hindered until there is a general awareness of the nature of this pain. Through the healing process of time—and through medical intervention or hospitalization in many cases—most people survive depression, which may be its only blessing; but to the tragic legion who are compelled to destroy themselves there should be no more reproof attached than to the victims of terminal cancer, (p. 33)
He later attempted to describe the nature of the pain itself: What 1 had begun to discover is that, mysteriously and in ways that are totally remote from normal experience, the gray drizzle of horror induced by depression takes on the quality of physical pain. But it is not an immediately identifiable pain, like that of a broken limb. It may be more accurate to say that despair, owing to some evil trick played upon the sick brain by the inhabiting psyche, comes to resemble the diabolical discomfort of being imprisoned in a fiercely overheated room. And because no breeze stirs this caldron, because there is no escape form this smothering confinement, it is entirely natural that the victim begin to think ceaselessly of oblivion, (p. 50)
Finally, in a memorable quote regarding suicidal ideation, he stated, Yet in truth, such hideous fantasies, which cause well people to shudder, are to the deeply depressed mind what lascivious daydreams are to persons of robust sexuality, (p. 53)
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PERSONALfTY-GL/IDED THERAPY FOR DEPRESSION
Although his rather supportive views on suicide are not likely to be widely shared in the mental health community—nor do I support them—Styron's compelling portrayal of major depression clearly conveys its agonizing quality. There are five forms of depression listed in DSM-IV-TR that differ in intensity; chronicity; and, to some degree, etiology. Major depression, the most severe form, is characterized by depressed mood much or all of the time as well as vegetative symptoms such as disturbance of sleep, appetite, and libido. Dysthymic disorder is similar to major depression but is of lesser intensity and is, typically, longer in chronicity. DSM-IV-TR requires a minimum of 2 years to make a diagnosis, though individuals can have the disorder for many years. Adjustment disorder with depressed mood indicates a reaction to an identifiable situation with depressed mood, in excess of what would be expected within a given culture. There are also two disorders in the appendix of DSMIV-TR, with criteria provided for research purposes. One is minor depression (similar to major depression but less severe), and the other is recurrent brief depression (with multiple depressive episodes that last from 2 to 13 days). The painful nature of depression is made all the more compelling when one considers its high frequency in the population. The problem of depression ripples out to families, businesses, and society at large. To understand the scope of the problem, the next step is to examine the frequency of the disorder; further, by looking at the financial cost of the problem, we can obtain a crude estimate of the overall impact of depression.
EPIDEMIOLOGY OF DEPRESSION The National Comorbidity Survey Replication (NCSR) used face-toface household surveys performed between February 2001 and April 2003. The nationally representative sample consisted of 9,282 English-speaking participants who were at least 18 years of age. In their sample, 16.6% had had major depression and 2.5% had had dysthymic disorder at some point in their lives. This translates into approximately 33 million people in the U.S. population who had experienced major depression, 6.6 million of whom had had major depression within the past year. Projecting out to the future, the researchers estimated that by age 75, 23.2% would have had major depression, and 3.4% would have had dysthymic disorder. The median age of onset for any mood disorder (including bipolar I and II, though these account for a relatively small proportion of those with mood disorders) is 30 years old, which is much older than that for anxiety disorders (11 years), substance use disorders (20 years), and impulse control disorders (11 years). Female gender and marital disruption are risk factors for major depression (Kessler, Berglund, Demler, Jin, & Walters, 2005).
AN OVERVIEW OF DEPRESSION
15
Depression rates appear to be rising. According to the original National Comorbidity Survey (NCS) conducted from 1990 to 1992 (Kessler, 1994), 15.8% of respondents met the criteria for major depression. It must be noted, however, that somewhat different criteria were used in the two studies, with the NCS using criteria from the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R; American Psychiatric Association, 1987) and the NCSR using criteria from the fourth edition (DSMIV; American Psychiatric Association, 1994). Although the reported depression prevalence rates are quite high, Kessler et al. (2005) noted that the procedure used for the NCSR likely underestimated the actual prevalence of mental disorders. Interviews were done in a community setting, thereby eliminating some populations that are likely to have a high prevalence of disorders (e.g., the homeless or institutionalized). In addition, participants routinely underreport embarrassing behaviors. Lifetime prevalences were based on current risk factors; because the prevalence of mental illness is rising, it is likely that younger participants' lifetime risks were underestimated. The NCSR also demonstrated that depression is inadequately treated. The researchers found that only 56.8% of those with major depression and 67.5% of those with dysthymia received treatment of any kind; of those, only 37.5% (major depression) and 40.7% (dysthymia) received at least minimally adequate treatment (Wang, Lane, et al., 2005). Using evidence-based treatment guidelines, Wang, Lane, et al. (2005) defined minimally adequate treatment as appropriate medication prescription with at least four follow-up visits with a physician, or, for nonpsychotic patients, at least eight sessions with a psychiatrist or another mental health professional (e.g., a psychologist, social worker, or counselor). Overall, then, roughly three fourths of those who had depression did not receive even minimally adequate treatment. Those under the care of a mental health specialist (psychiatrist, psychologist, etc.) were far more likely to receive minimally adequate care than those under the care of a general medical doctor (52.0% vs. 14.9%). The comparable figures from the original NCS, which was conducted a decade earlier (1990-1992), indicate that only 45.8% received any treatment and that of these, 48.2% received minimally adequate treatment; thus, 78.2% failed to receive minimally adequate treatment for a mood disorder (Wang, Demler, & Kessler, 2002). Typically, there is a 6- to 8-year delay between the onset of symptoms and initiating treatment (Wang, Berglund, et al., 2005). For mental health disorders as a whole, there is a trend toward increasing treatment rates, but still only a minority of those with mental health problems receive services. In the 1980s, for example, estimates indicated that 19% of those with mental health disorders had received treatment in the past 12 months; the comparable figure was 25% in the 1990-1992 survey and 33% in the most recent survey, conducted in 2001-2003 (Wang, Berglund, et al., 2005). These disturbingly low figures are exacerbated when one con16
PERSONALITY-GUIDED THERAPY FOR DEPRESSION
siders that fewer than half of those treated received minimally adequate treatment; for example, in the most recent survey, treatment was minimally adequate for only 32.7% of those receiving care for a mental health condition. The most underserved are older adults, racial and ethnic minorities, people with low incomes, the uninsured, and those who live in rural areas. Wang, Lane, et al. (2005) concluded tersely, "Most people with mental disorders in the United States remain either untreated or poorly treated. Interventions are needed to enhance treatment initiation and quality" (p. 629). The estimated financial cost of depression as of 2000 totaled approximately $83 billion per year, an increase of nearly 8% from the 1990 estimate ($77 billion, inflation adjusted). The total figure for 2000 consisted of $26 billion (31%) for direct treatment expenses, $5 billion (7%) for costs associated with suicide, and a staggering $52 billion (62%) in workplace costs ($37 billion from absenteeism and $ 15 billion from reduced productivity while on the job; P. E. Greenberg et al., 2003). Even these enormous figures are an underestimate, because they do not account for accidents, turnover, or the impact on coworkers. Simulations have indicated that 45% to 90% of direct treatment costs are recovered in a single year through worker productivity gains; it is reasonable to expect that all of the treatment cost, or perhaps even more, could be recovered if a longer window were used (Kessler, 2002).
THEORIES OF DEPRESSION AND THEIR ASSOCIATED TREATMENTS How does a person become and remain depressed? And how does he or she recover? Biological, psychological, and social factors are essential in gaining a comprehensive understanding. Starting with the smallest unit of analysis, I explore biological factors such as neurochemical and neuroanatomical phenomena. Moving outward to a broader domain, I examine psychological aspects of depression, including intrapsychic and interpersonal manifestations. Finally, at the macro level, I integrate societal and cultural issues, such as gender role and ethnicity. Biological Factors There is a significant genetic component to depression. Sullivan et al. (cited in Wallace, Schneider, & McGuffin, 2002, pp. 174-175) conducted a review and meta-analysis of twin studies on major depression. Over 212,000 individuals were studied. Results indicated that 58% to 67% of the variance was attributable to specific environmental effects, 31% to 42% to genetic factors, and a mere 0% to 5% to shared environment among siblings. According to Thapar and McGuffin (cited in Wallace et al., 2002, p. 177), AN OVERVIEW OF DEPRESSION
17
heritability estimates (the degree to which a trait is inherited) 1 were higher (79%) for children and adolescents, which suggests that when depression starts early in life it may be a more biological condition. The largest and best available adoption study, by Wender et al. (cited in Wallace et al., 2002, p. 176), indicated a sevenfold higher likelihood of depression among those who were biologically related to a depressed person versus those who were not. A variety of biological factors are critical in depression. Under stress, NE becomes depleted, which has been associated with learned helplessness behaviors in animal studies (e.g., decreased exploratory and consummatory behaviors) and is believed to be related to learned helplessness cognitions in humans (e.g., powerlessness and hopelessness). Medications that directly enhance NE levels lead to improved functional efficiency. It is interesting to note that serotonin'enhancing medications (which do not directly effect NE) also enhance NE levels, suggesting that indirect interventions can help restore NE balance. Because of the popularity of SSRI medications, most psychologists are aware that serotonin (5-HT) depletion also increases depressive symptoms. The hypothalamic-pituitary-adrenocortical (HPA) axis, which mediates human stress responses such as the fight—flight response (W. B. Cannon, 1915, 1929/1963) and the general adaptation syndrome (Selye, 1956/1978), is also implicated in depression. Sustained elevations in cortisol lead to impaired HPA feedback inhibition and can cause the death of cells in the hippocampus. In samples of depressed individuals, 40% to 60% have elevated levels of cortisol. Increased dopamine activity, which may be induced by excessive cortisol, appears to be crucial in cases of psychotic depression (Thase, Jindal, 6k Rowland, 2002). Excess cortisol is associated with increased severity of depression, weight loss, insomnia, and increased suicidality (Thase et al., 2002). Research has yet to determine, however, if these biochemical changes cause depression or are a result of it. It is probable that causality is complex and circular; it seems reasonable to assume that similar to the relationship between temperament and the development of PDs, biological predispositions interact with environmental circumstances, enhancing or initiating biological processes related to depression. In addition, if depleted NE and serotonin are sufficient to explain the occurrence of depression, then why do antidepressant medications take weeks to produce mood changes, even though neurotransmitter levels are increased within hours (Thase et al., 2002)? Although the mechanism of action of the medications described below is presented using explanations based on neurotransmitter theory, along the lines of standard psychopharmacology texts (e.g., Stahl, 1996), the reader should be aware that there are other, and at this point unknown, reasons for the efficacy of antidepressant medications. 'The most common metric, labeled h2, is based on the difference between the frequency of a trait in fraternal versus identical twins.
18
PERSONALITY^ HIDED THERAPY FOR DEPRESSION
Medications A variety of medications have been shown in double-blind studies to ameliorate depression, (e.g., I. M. Anderson, 1998; Rudolph, 2002; Storosum et at, 2001). Historically, the first antidepressant medications developed were monoamine oxidase inhibitors (MAOIs). Drugs formerly used to fight tuberculosis were found to have an unexpected antidepressant effect. Scientists then isolated the effective compound and formulated the medications specifically as antidepressants. This discovery led to the first biological theory of depression, the monoamine hypothesis. The theory was that depletion of monoamines leads to depression. This was supported not only by the action of MAOIs (which, as their name implies, block the action of monoamine oxidase, the enzyme that breaks down monoamines, a group of neurotransmitters that include serotonin and NE, and increase the availability of monoamines) but also by findings that drugs that reduced the amounts of monoamines lead to depression (Stahl, 1996, p. 112). MAOIs, then, work by blocking the action of (inhibiting) monoamine oxidase. With less monoamine oxidase breaking down monoamines, more monoamines are available to the neurons. This increase in monoamines, the theory indicates, decreases depression. Widely used MAOIs include phenelzine (Nardil) and tranylcypromine (Parnate). Tricyclic antidepressants (TCAs) are so named because the original medications had a three-ringed chemical structure. As with MAOIs, the antidepressant qualities of TCAs were discovered while they were being used to treat another disorder, in this case schizophrenia. Though the medication was ineffective for schizophrenia, clinicians noticed during the clinical trials that their patients were becoming less depressed. TCAs quickly became popular because they were effective and the side effects were not as troublesome as those of the MAOIs. Tricyclics are still widely used but are declining in popularity because SSRIs tend to have fewer side effects. Most TCAs are available in generic form and are relatively inexpensive, which can be a big advantage in some circumstances. TCAs work by blocking the action of the reuptake pump for serotonin and NE. Because the neurotransmitters are not reabsorbed by the neurons, they remain in the synapse, the space between neurons. (Neurotransmitters leave a neuron, enter the synapse, and potentially cause the next neuron to fire.) The extra neurotransmitters in the synapse, per the monoamine hypothesis, lead to a decrease in depression. Common tricyclic compounds include amitriptyline (Elavil), desipramine (Norpramin), doxepin (Sinequan), and imipramine (Tofranil). With SSRIs, the basic mechanism of action is to block the reuptake (reabsorption) of serotonin back into the neurons, thereby leaving more serotonin available in the synapse. As with TCAs, the increased availability of synaptic monoamines underlies the antidepressant effect. SSRIs and other newer antidepressants are generally used first because of their improved side-
AN OVERVIEW OF DEPRESSION
19
effect profile relative to the older TCAs. Commonly used SSRIs include citalopram (Celexa), fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft). A number of relatively new antidepressants do not fit conveniently into any of the previous three categories (MAOI, TCA, or SSRI) and impact serotonin and NE through various mechanisms of action. Drugs in this "novel" category include amoxapine (Asendin), bupropion (Wellbutrin), maprotiline (Ludiomil), venlafaxine (Effexor), mirtazapine (Remeron), nefazodone (Serzone), and trazodone (Desyrel). Antidepressant medications have generally been found to have approximately equivalent effects on symptoms as short-term psychotherapy, with combinations of psychotherapy and antidepressant medications generally having somewhat improved efficacy (I. W. Miller & Keitner, 1996). For longterm relapse prevention, it is now known that long-term medication maintenance is often required (Gitlan, 2002). Antidepressants typically take several weeks to alleviate symptoms, although elevated levels of serotonin are available in the synaptic cleft within a few hours. Scientists have concluded that the effects of antidepressants occur as a function of complex interactions at the intracellular level. Thase et al. (2002) noted, "It is now clear that the synaptic effects of the TCAs, MAOIs, and newer antidepressants only serve to initiate a sequence or cascade of effects that culminate within cell nuclei, at the level of gene activity" (p. 201). A detailed explanation of mechanisms of action is beyond the scope of this review, but the curious reader is encouraged to peruse Stahl (1996) and Gitlan (2002). SSRIs are currently the frontline pharmacotherapy for depression in the United States. Their relatively benign side-effect profile and easy, usually once-daily, dosing encourages high compliance. Equally critical, and more so in some cases, SSRIs have much lower lethality than TCAs in overdose and are thus difficult to use as instruments of self-destruction. If one SSRI is ineffective or cannot be tolerated, most prescribers will switch to another SSRI and then, if necessary, to another drug class. The "novel" antidepressants all have different chemical structures, properties, and side-effect profiles; in essence, each is its own drug class. Some of these medications are sedating (e.g., nefaxedone and trazedone) and they may also encourage weight gain (e.g., mirtazepine), which can be therapeutic in cases that include insomnia and anorexia. The older tricyclic medications are rarely firstline medications because of unpleasant side effects (e.g., dry mouth, sedation, postural hypotension, weight gain, blurry vision, and constipation) and high lethality in overdose. They may be prescribed when cost is a consideration and, of course, when other medications have been ineffective. MAOIs are generally a third- or fourth-line treatment because of unpleasant side effects (e.g., weight gain, sexual problems, and insomnia) and dangerous interactions with foods that contain tyramine (e.g., wines and aged cheeses). Although better known 20
PERSONALITY-GUIDED THERAPY FOR DEPRESSION
for treating bipolar disorder, lithium can be useful in some cases of unipolar depression. It tends to be used rarely because of its narrow therapeutic window and its toxicity, and, thus, the requirement for routine blood work. Dysthymic disorder responds to medications in a way that is essentially identical to major depression, so the above considerations apply to both equally (Gitlan, 2002). Electroconvulsive Therapy ECT has been considered a safe and effective treatment for depression for nearly 2 decades (American Psychiatric Association, 1990; Enns & Reiss, 2001; National Institutes of Health, 1985; Pagnin, de Queiroz, Pini, & Cassano, 2004; UK ECT Review Group, 2003). Understandably, there are fears among some in the general public. The idea of passing an electrical current through the body can be frightening; further, popular depictions of the inappropriate use of ECT and images of the procedure prior to the introduction of adequate sedative medication may enhance the concerns of a potential beneficiary. Ken Kesey's One Flew Over the Cuckoo's Nest (1962/2002) and its extraordinarily popular film adaptation (Zaentz, Douglas, & Forman, 1975) portrayed ECT (without sedation) as a punishment—or even torture— used against a spirited and nonconforming patient. Such images may frighten potential patients who could benefit from an appropriate use of ECT. Psychoeducation for the client and, potentially, the family, is extremely important in cases in which ECT is the best option. Memory problems are the main side effects associated with treatment (American Psychiatric Association, 1990). For severe depressions in which several medications have been ineffective, ECT remains an important intervention. Summary and Conclusions Regarding Biological Factors Biological factors play an important role in depression. The disorder is heritable, and a number of biological models of depression have considerable scientific support. Nonetheless, those who argue that depression is a purely biological "disease" and that the best treatment is medication are flying in the face of a massive amount of data. Current scientific studies cannot validate any of the proposed biological models (e.g., serotonin depletion) as causes of depression; rather, they may be effects. As noted above, genetic studies have shown that nearly twice as much variance is accounted for by environmental factors as by genetic ones. Medication has not proved to be better than psychotherapy for treating depression; in fact, overall, studies seem to suggest that for all but the most severe depressions, psychotherapy has better efficacy (American Psychiatric Association, 2000b). Despite the existence of several classes of medications and several medications within most classes, approximately 35% to 40% of individuals do not respond to medication treatment. Data are fairly consistent with the commonsense hypothesis that psychotherapy and medications work synergistically (I. W. Miller & Keitner, AN OVERVIEW OF DEPRESSION
21
1996) and that long-term follow-up with medications and psychotherapy help prevent relapse, which is otherwise likely (Boland & Keller, 2002). Gitlan (2002), summarizing his review of psychopharmacological treatment of depression, concluded, Although antidepressants are consistently effective and the newer agents are safer and better tolerated than the older agents, the pharmacotherapy of depression still leaves much to be desired. As a first goal, it must be acknowledged that no antidepressant has been shown to be more effective than imipramine, the first agent released over 40 years ago. (p. 377) Psychological Factors Millon (1996) listed eight domains of functioning that should be considered when making a comprehensive psychological assessment, namely (a) expressive acts, (b) interpersonal conduct, (c) cognitive style, (d) selfimage, (e) object representations, (f) regulatory mechanisms, (g) morphological organization, and (h) mood and temperament. These domains roughly correspond to the major "orientations" within psychology. Expressive acts and cognitive style relate to the cognitive-behavioral school of thought. Interpersonal conduct is most closely associated with interpersonal and family systems thinking and interventions. Self-image—how one sees oneself—is relevant to all therapeutic schools of thought but is perhaps most closely associated with a client-centered approach. The next three domains are associated with psychodynamic thinking. Object representations relate to object relations theory, and regulatory mechanisms refer to Freud's ego defense mechanisms. Morphologic organization, which refers to psychic cohesion within the mind, is most closely associated with self psychology and the notion of fragmentation (Kohut, 1971, 1977; Wolfe, 1989). Finally, the mood and temperament domain refers primarily to the biological components of emotionality (mood) and personality traits (temperament). The psychology subsections of the remaining chapters in this volume cover Millon's domains, with some variations depending on the relevance to particular disorders. Of the eight domains, seven are psychological, and one is biophysical. Each of the psychological domains are considered with reference to cognitive-behavioral; client-centered, humanistic, experiential; psychodynamic; family systems; and group therapies. Below I discuss each in turn. Cognitive-Behavioral Conceptualization and Interventions Beck and his associates noted that depression is related to cognitive distortions (A. T. Beck et al, 1979). Cognitive distortions are styles of thinking that reliably produce problematic, depressogenic thoughts. For example, overgeneralization is the tendency to see one event as more representative than it really is (e.g., I'm incompetent at one thing, which means I'm incom22
PERSONALITY-GLTOED THERAPY FOR DEPRESS/ON
petent at everything). Dichotomous thinking, which is especially relevant to borderline PD, is the tendency to view everything in all-or-none terms (e.g., I'm either perfect or I'm worthless). Catastrophizing is the tendency to interpret events as being much more problematic than they really are (e.g., the student who becomes suicidal when she earns her first C; her thoughts may be, "Now I'll never get into graduate school, I'll never get a good job, and my parents will hate me"). When such thought patterns are corrected, then the depression tends to lift. Individuals with depression are likely to have a variety of depressogenic thoughts. Common thoughts among individuals with depression are, "If I try to do it, I'll just mess up"; "If I ask her out, she'll turn me down"; and "No one likes me." Underlying such automatic thoughts, especially for individuals with PDs, are core beliefs of helplessness, unlovability, and worthlessness (J. S. Beck, 2003). Often, feelings of worthlessness are reducible to one or both of the other two categories (e.g., I am worthless because I am incompetent and/or unlovable). Schemas of helplessness fit with Seligman's wellknown and well-established learned helplessness model, which can be conceptualized in a purely behavioral fashion (Seligman, 1975), and the reformulated version (Abramson, Seligman, & Teasdale, 1978), which includes helpless cognitions. In addition to the belief "I am helpless," clients may express this concept with beliefs of inadequacy, incompetence, and inferiority. The belief that one is unlovable relates to poor self-esteem and is clearly related to depressive thinking; typical core beliefs may include "I am unlovable," "I am ugly/undesirable," and "I am unwanted." A variety of behavioral interventions can also be helpful in alleviating depression. Communication skills training and assertiveness training can help clients to get their needs met more effectively. Linehan (1993) framed mindfulness meditation as a learned skill and made it a module in her dialectical behavior therapy program. In some cases, skills training can be used to help the person feel—and be—more competent, thus undermining feelings of helplessness. Physical exercise has been shown to relieve depression (Craft & Landers, 1998; Hays, 1999) and has obvious health benefits. The clinician, however, must suggest an exercise program very astutely or the chances of success are minimal. Unless the client neither watches television nor reads newspapers, he or she has undoubtedly been bombarded by messages about why we should all be exercising more. A generic, information-based approach about the benefits of exercise generally will not lead to behavior change. At best, a half-hearted "I know I should exercise more" will emerge; in such an instance, the therapist is risking being seen as an authority figure who is disappointed with the client's performance. Instead, it is essential to focus extensively on motivation. I generally do not even broach the subject of exercise for several sessions, sometimes many sessions. I like to see the depression lift partially so that I have some credibilAN OVERVIEW OF DEPRESSION
23
ity built up and motivation is not quite so difficult for the client to muster. When I do bring up exercise (unless the client does first), the discussion is embedded in the context of the client's goals. Perhaps the client's goal is to feel better, physically or emotionally (many are not aware that exercise has proven antidepressant effects, so psychoeducation can be helpful in such cases). Perhaps he or she has a goal of being healthier for another person. Often, weight loss is a goal. I have clients write down their goals and why exercise would help. Once the motivations are clear and adequate—if the motivation is not adequate, then we defer—then we can discuss specific strategies, such as the type of exercise and how that fits into the client's goals and needs. Prochaska's "stages of change" model (Prochaska et al., 1994) is extremely useful for assessing whether the client is ready for an exercise program. For the precontemplator who has no interest in an exercise program, the therapist can provide information that exercise helps depression lift and that at some point it would be useful to consider an exercise program. For the contemplator, more in-depth discussion can help the person to become aware that exercise may be worth it. During the preparation phase, one can develop specific strategies with the client, such as selecting the exercises to use, scheduling workouts, and discussing preference for exercising alone or with others. During the action phase, continued focus on motivation will remain important. Strategies such as making charts of progress toward a goal (e.g., losing a certain amount of weight or walking a certain number of miles) can be very motivating. Setting goals such as walking, running, or biking for a cause near to the person's heart can also be a great motivator; for example, setting a goal of completing a 5-mile walk for breast cancer can be motivating if the client knows someone who has or had the disease. There are books available for adjunctive bibliotherapy for exercise (e.g., Exercising Your Way to Better Mental Health, Leith, 1998; Move Your Body, Tone Your Mood: The Workout Therapy Workbook, Hays, 2002). Outcome data show clearly that cognitive-behavioral therapy (CBT) is effective. Over 80 research studies have shown that CBT is superior to placebo treatment, and it is superior to medications for all but the most severe depressions (American Psychiatric Association, 2000b). The Interpersonal Approach Coyne (1976) proposed an interactional model of depression. In contrast to work by psychodynamic theorists (e.g., Abraham 1911/1986; Freud, 1917/1986) and Beck's emerging cognitive theory (e.g., A. T. Beck, 1967), Coyne emphasized people's accurate perceptions rather than their distortions. He observed that depressed individuals have a tendency to seek reassurance. Initially, caring others in the environment wholeheartedly provide such reassurance. However, convinced that these individuals are responding
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PERSONALITY^ HIDED THERAPY FOR DEPRESSION
to his or her manipulations, the person with depression persists. Other people eventually become annoyed and send mixed messages; they provide comfort, but, in contrast to their prior, genuine encouragement, they are at least in part responding only to the demands for reassurance. A vicious circle ensues, in which demands for reassurance are met with increasing, but hidden and explicitly denied, annoyance on the part of the significant others while the person with depression becomes increasingly frustrated and perhaps hostile. As opposed to fantasized or early object loss, as emphasized by Freud, many people in the person's life are genuinely avoiding him or her in the present. If intervention occurs at this point, there is a mixture of cognitively distorted perceptions of worthlessness and accurate perceptions of real abandonment and insincerity within the depressed person's social network. The "excessive reassurance seeking" hypothesis has received research attention over the years and has generally been supported (Benazon, 2000; Coyne & Downey, 1991; Joiner, 1994; Potthoff, Holahan, & Joiner, 1995; Swann, Wenzlaff, Krull, & Pelham, 1992). Similar to Coyne, and building on themes developed by Harry Stack Sullivan and other theorists, Gerald Klerman, Myrna Weissman, and their associates developed interpersonal psychotherapy (IPT) in the 1970s (Weissman & Markowitz, 2002) as a time-limited treatment for major depression. Outcome data for IPT have been impressive; the treatment has consistently been better than placebo, has been about as effective as cognitive-behavioral therapy for most clients, and has been more effective than CBT for more severely depressed patients (for a review, see Weissman 6k Markowitz, 2002). IPT uses an unabashedly medical model approach to treatment: "In IPT, depression is defined as a medical illness, a treatable condition that is not the patient's fault" (Weissman & Markowitz, 2002, p. 406). This approach helps to reduce guilt and feelings of inadequacy on the part of the patient and facilitates a natural alliance of client and therapist against the depressive symptoms. IPT focuses on interpersonal problems in the person's current life, such as complicated bereavement, role transitions, and interpersonal deficiencies. The therapeutic relationship is designed to be positive, optimistic, and collaborative. Relatively little transference distortion is elicited in this approach, and investigation of transference phenomena is not routinely part of the treatment. The IPT therapist assists clients in pursuing their interpersonal goals. Events in clients' lives are consistently linked to their mood and symptoms. Emotionally intense events in their interpersonal lives are reenacted and role-played, and options for making different kinds of choices are considered. The treatment is designed to be brief and typically takes approximately 12 to 16 sessions. Monthly follow-up sessions provide some protection against relapse, although Weissman and Markowitz (2002) suggested that biweekly relapse prevention sessions may be more effective and should be researched.
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Client-Centered, Humanistic, and Existential Therapy Process-experiential therapy (PET) helps individuals with depression by providing them with an opportunity to focus on their internal experience. The therapeutic relationship is characterized by empathic attunement and collaboration. Although the therapist and client collaborate on goals, the relationship issues are always considered primary. Noted L. S. Greenberg, Watson, and Goldman (1998), "A form of synchrony occurs where the experience of leading and following disappears in a collaborative flowing together, as in good dancing or improvisational jazz" (p. 234). L. S. Greenberg et al. (1998) described four markers of problematic experiential states that are useful in understanding and treating depression. The first is problematic reactions, or a feeling of being puzzled by one's own emotional or behavioral responses to situations. The second is an inability to get a clear sense of one's experience. The third is a split sense of self, in which one part of the self is critical of or coercive toward the other part. Finally, individuals with depression often have "unfinished business" related to an earlier part of their lives, usually involving themes of separation, loss, or other unresolved issues. The inability of a person to get in touch with his or her own experience is treated with empathic attunement and encouragement to focus on his or her experience. The felt sense (Gendlin, 1996) is often a key concept in this regard and refers to subtle emotional and bodily experiences that can be used as doorways to deeper aspects of the self. The felt sense is something that we all experience. A good example is "that feeling that I forgot something," which, if examined even superficially, is a bodily and cognitive experience integrating thoughts ("I forgot something" and "this is bad") with somatic phenomena (e.g., a tightening in the abdominal muscles and a churning feeling in the stomach). In individuals with depression, the felt sense that something is wrong can be explored, often leading to the uncovering of feelings and thoughts that have been deeply buried under years of neglect or the exploration of thoughts and feelings that were regarded as too frightening to consider. Splits in the self, such as the critical self that berates the bad self, can be integrated using "two chair" techniques. The critical self can speak to the "bad" self, which can then, by switching chairs, answer back. Typically, the critical self can be seen for what it is—a cruel, narrow-minded bully who does not take the full picture into account. The "bad" self, meanwhile, is generally the holder of kindness, softness, and compassion and is seen to have good qualities. As the split between good and bad becomes transmuted into a split between aspects of the self that are all necessary for a completely functioning individual, the path to reintegration has been paved. L. S. Greenberg et al. (1998) described the case of "Jan," a highly self-critical, perfectionistic, and depressed woman who had unfinished business around
26
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trying to please her mother. An initial reintegration occurred in rather dramatic fashion during a two-chair interaction: Therapist:
What do you want from her (to the critic) ? [Encouraging expression of need]
Client:
I want to feel I am OK. I want to be more like her, to feel more confident.
Therapist:
[Noticing a shift in her posture and face] What are you feeling now? [Facilitating negotiation]
Client:
1 feel that the two sides have suddenly merged. It is as if the stronger person came over here and sat with me and said you're OK. (p. 245)
Unfinished business, similarly, can often be addressed through "empty chair" techniques, in which the client addresses the individual who is no longer available. L. S. Greenberg et al. (1998) argued that PET benefits from looking at aspects specific to depression rather than maintaining a strict antilabeling stance: One might. . . question the need for a differential treatment of depression, given that a therapeutic relationship characterized by attitudes of positive regard and genuine concern, as well as a form of responding that is empathic and experience centered, is helpful for different types of problems and diagnostic groups. . . . We have observed both in practice and research contexts that, during treatment of depressed people, specific types of in-session problem states or markers of underlying determinants come up more often or with greater significance, and these are embedded within specific types of depressive themes. More specifically, we found that selfcritical splits, embedded within themes of failure and lack of self-esteem, and a variety of types of lingering unresolved feelings or unfinished business with significant others, embedded within themes of dependence and loss, characterize the in-session issues that formed the focus of our treatments of depression, (p. 229)
Congruent with cognitive therapy, L. S. Greenberg et al. (1998) observed that people with depression have beliefs that they are worthless, powerless, and bad and that they experience feelings of helplessness. As with Beck's notion of "core beliefs" that are activated by current experiences, L. S. Greenberg et al. noted, "In our model, the core depressogenic weak/bad self-scheme is activated by a current emotional experience of loss or failure" (p. 232); such a notion also relates to self-psychological notions that psychopathology emerges from a damaged sense of self. Similar to the interpersonal school, they noted that social disruptions and losses elicit depressive mood. PET differs from other approaches in its focus, like all humanistic and client-centered approaches, on the natural holistic and organismic aspects of the person. The therapist focuses not only on verbal and cognitive schemas but also on bodily
AN OVERVIEW OF DEPRESSION
27
sensations such as the felt sense of an experience and subtle emotional experiences that are difficult to label. The primary mode of intervention, which is to remain empathically attuned and promote the client's attention to his or her moment-to-moment experience, differs from other approaches. Research on humanistic psychotherapy for depression has been encouraging. There is a growing body of literature on PET. Elliott, Watson, Goldman, and Greenberg (2004) reviewed 18 research studies on PET, 6 of which addressed depression. All 6 of the studies reported a positive impact on depression, with effect sizes ranging from 0.50 to 2.49 standard deviations, which represent a medium to very large effect; the mean effect size is 1.36, which is large (see Cohen, 1988). To put these findings in perspective, a brief discussion of effect size is in order. Cohen (1988) noted that an effect size of 0.8 is sufficiently large to be obvious, such as the difference, for example, between the heights of 13- and 18-year-old girls. Seen another way, a difference of this magnitude indicates that 85% of those treated are better off than those who are untreated. Three of the studies were randomized trials comparing PET to other therapies (person-centered in two studies, CBT in the third). In all three cases, PET was superior to the other conditions (a mean difference of 0.38 standard deviations, a medium-sized difference). On the basis of these studies, PET qualifies as an empirically validated treatment for depression. Ward et al. (2000) conducted a fairly large (N = 464) randomized study of client-centered counseling, CBT, and routine physician care for depression. Participants were provided with 6 to 12 sessions of psychological treatment. The study demonstrated that both psychotherapies resulted in greater reductions in depressive symptoms and more rapid remissions in depression than routine physician care, but the therapies did not differ in effectiveness from one another. Psychodynamic Therapy Psychodynamic psychotherapy is the oldest form of psychological treatment, dating back approximately 100 years. In his essay "Mourning and Melancholia," Freud (1917/1986), in his astute manner, compared the phenomenon of normal grief to the state of melancholy that we now call depression. Before considering this comparison, it is worth noting that Freud's description of melancholia, which included feelings of dejection, poor self-esteem, loss of sex drive, and appetite and sleep disturbance, was in its essence identical to a description of major depression. In addition, Freud believed that some depressions were "constitutional" (biological) and did not abide by the psychic mechanisms he described. Freud noted that melancholia differed from grief primarily in the selfdenigration and self-esteem problems of the individual with this condition. Rather than arguing, as Aaron T. Beck did later (A. T. Beck et al., 1979), that such beliefs are irrational and problematic, Freud indicated that these self-attacking statements contain more than a grain of truth: 28
PERSONALITY-GUIDED THERAPY FOR DEPRESSION
He also seems to us justified in certain other self-accusations; it is merely that he has a keener eye for the truth than other people who are not melancholic. When in his heightened self-criticism he describes himself as petty, egoistic, dishonest, lacking in independence, one whose sole aim has been to hide the weaknesses of his own nature, it may be, so far as we know, that he has come pretty near to an understanding of himself; we only wonder why a man has to be ill before he can be accessible to a truth of this kind. (Freud, 1917/1986, p. 51) With this rather backhanded compliment, Freud thus anticipated the "depressive realism" hypothesis by many years. Freud then rioted, however, that the attack on the self is invariably an attack on others, which is then redirected toward the self. The wife who proclaims that she is unworthy and cannot imagine how her husband would stay with her is really indicating her anger toward her husband and suggesting that he is inadequate in some unspecified manner. Abraham (1911/1986) extended the argument, seeing depression as a combination of defenses against underlying sadistic hostility. He suggested that the conscious experience ("I hate myself) consists of hostile feelings transformed through projection ("I hate you" becomes "you hate me" and, finally, "you hate me because I am defective"). As he noted, "In every one of these cases it could be discovered that the disease proceeded from an attitude of hate which was paralysing the patient's capacity to love" (1911/1986, p. 36). Freud hypothesized, in a rather tentative manner, that the constellation of phenomena thus observed in depression pointed to a coherent developmental pattern. He suggested that the person experiences a loss of love. Rather than withdrawing libidinal energy and attaching it to a new object, the ego withdraws the libidinal energy into the self, the narcissistic ego. The energy is then used to form an identification between the ego and the lost object. This transformation, then, is regressive in its essence; specifically, the regression is to the oral-sadistic phase, in which the merger with the object is accomplished through incorporation. This explains not only the primitive aggression associated with depression but also the phenomenon of suicide. Because the individual is identified with the object of his rage, it is possible for him to consider his own, or "its" (i.e., the object's) destruction. As noted by Freud, It is this sadism alone that solves the riddle of the tendency to suicide which makes melancholia so interesting—and so dangerous. So immense is the ego's self-love, which we have come to recognize as the primal state from which instinctual life proceeds, and so vast is the amount of narcissistic libido which we see liberated in the fear that emerges to a threat to life, that we cannot conceive how that ego can consent to its own destruction. We have long known, it is true, that no neurotic harbours thoughts of suicide which he has not turned back upon himself from murderous impulses against others.... The analysis of melancholia now AN OVERVIEW OF DEPRESSION
29
shows that the ego can kill itself only if, owing to the return of the object cathexis, it can treat itself as an object—if it is able to direct against itself the hostility which relates to an object and which represents the ego's original reaction to the external world. (Freud, 1917/1986, pp. 56-57) Thus the blurred identification between the self and the object, which is a function of the regression to a very early stage of life, allows the self to become a target of "murderous," that is, self-destructive, impulses. Thus the themes of anger turned inward, and the precursors of the depressive realism hypothesis, are present in Freud's early work on depression. Unfortunately, the empirical data supporting the psychodynamic view of depression (e.g. group designs and controlled studies) are limited (Coyne, 1976; Hollon, Thase, & Markowitz, 2002). Nonetheless, the rich history of theory and case studies is a deep well of clinical wisdom and has strongly influenced the field. Family Systems Therapy The relationship between marital problems and depression is substantial. According to a meta-analysis by Whisman (cited in Beach 6k Jones, 2002, p. 423), the correlation between depression and marital quality was -.66. Family theorists generally focus on the bidirectional nature of causality, noting that depression creates stress in the relationship and stress worsens depression, thus setting off a downward spiral. There are well-established marital and family treatments for depression using behavioral marital therapy, cognitive—behavioral marital therapy, emotion-focused therapy, and insightoriented marital therapy (for a review, see Baucom, Shoam, Mueser, Daiuto, & Stickle, 1998). According to studies by Patterson and by Patterson, Reid, and Dishion (both cited in Beach & Jones, 2002, p. 426), parent management training is effective for childhood depression. Interpersonal therapy, reviewed above, has been modified for use with couples and is called "conjoint marital therapy" (see Foley, Rounsaville, Weissman, Sholomskas, & Chevron, cited in Beach & Jones, 2002, p. 428). Available evidence suggests that the effect of marital therapy on depression is equivalent to that of individual therapy (but no better); however, it reduces marital distress more than individual treatment (Beach 6k Jones, 2002). In studies in which marital distress was not an issue, marital therapy did not confer any measured advantage. Thus, the evidence is consistent with the commonsense conclusion that marital therapy should be used in cases in which there is marital distress as well as depression; if there is no marital distress, then in most cases it would be more convenient for the depressed person to enter individual treatment. Parent training decreases symptoms in depressed children and in depressed parents simultaneously. If parent-child relationships are contributing to family stress or depression, it is an important treatment. In addition, 30
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parent training may be a less threatening way to enter treatment for families in which there are both marital distress and parent-child problems (Beach & Jones, 2002). Group Therapy A meta-analysis of 48 studies of group psychotherapy (McDermut, Miller, & Brown, 2001) showed that group psychotherapy has a substantial impact on depression. The overall effect size of treatment is 1.03; that is, the treatment group, on average, had scores 1.03 standard deviations lower than corresponding control groups, which is a large effect size. The efficacy of group treatment of depression is comparable to that of psychotherapy in general (effect size = 0.68; M. L. Smith & Glass, 1977) and individual psychotherapy for depression (effect size = 1.22; Steinbrueck, Maxwell, & Howard, 1983). CBT (e.g., Kush, 2000; Peterson & Halstead, 1998; Pidlubny, 2002) and IPT (see Klier, Muzik, Rosenblum, & Lenz, 2001; MacKenzie, 2001) have been adapted to group modalities. It is most likely that a combination of factors within the group process combine to reduce depression. Individuals can acquire new skills, such as assertiveness or problem solving, which can help them function more effectively. Cognitive-behavioral groups help clients learn to challenge their irrational or distorted beliefs. Process-oriented groups help the person to confront relationship issues in the here-and-now, a very powerful form of learning. Other available group therapies for depression include multimodal therapy (Rice, 1995), narrative therapy (Laube & Trefz, 1994) and reminiscence therapy (Bachar, Kindler, Schefler, & Lerer, 1991). Few comparisons have been performed contrasting different types of therapy. One study (Hogg & Deffenbacher, 1988) found that process group therapy and CBT were equally effective in reducing depression, and no differences were found in mechanisms of action. Group therapy has several advantages relative to individual therapy. In skills-training groups, there are opportunities to practice with peers rather than just with the therapist. In addition, during the presentation of new information, others in the group may think to ask questions that an individual may not have thought to ask. In process groups, opportunities arise that cannot occur in individual therapy, such as feedback from multiple individuals simultaneously. Perhaps the primary advantage of group psychotherapy is that it provides similar efficacy at a lower cost. Estimates suggest that group psychotherapy saves 25% to 92% of the cost of care relative to individual therapy, depending on the size of the group (see McDermut et al, 2001). Of course, group therapy is not always preferable. Individual treatment offers greater privacy, which may allow some clients to open up more. It also may help to prepare clients for group treatment. Although McDermut et al. (2001) concluded, logically, that group therapy should be the frontline treatment for depression on the basis of cost considerations, for clients with PDs exactly the reverse may be true. Many individuals with personality disorders AN OVERVIEW OF DEPRESSION
3]
are not ready for group treatment until their symptoms have partially remitted. For example, clients with paranoid and avoidant PD are often too interpersonally defensive and uncomfortable to function in a group; some individuals with narcissistic PD are unable to share attention with other group members; some individuals with schizotypal PD would come across as so strange that the group would reject them, furthering their depression. For many individuals with PDs and depression, the appropriate course of action is to provide individual treatment first; group treatment can then be used to make further progress on interpersonal and intrapsychic material. Group treatment can also be a relatively low-cost way to continue treatment for clients who require long-term work.
SOCIAL CONSIDERATIONS AND DIVERSITY Epidemiological studies in different countries have found large differences in prevalence of depression; presumably, these differences are at least partially due to differences in culture. At the times the surveys were done, depression ranged from a high of 19.0% in Lebanon to a low of 1.5% in Taiwan. The United States is intermediate, with different prevalences found in the NCS (Kessler, 1994), which surveyed participants from 1990 to 1992, and the Epidemiological Catchment Area study (Weissman, Bruce, Leaf, Florio & Holzer, 1991), which surveyed participants from 1980 to 1984. There were differences in methodology that may account for some of the differences in the findings. The NCS had a larger and more representative sample, used DSM-IV rather than DSM-IIJ-R criteria, and investigated more extensively for indications of depression than did the Epidemiological Catchment Area study. It could also be, however, that the prevalence of depression in the United States increased during the decade or so that separated the surveys. One finding that is fairly consistent is that Asian countries, such as China, japan, and Taiwan, have lower rates of depression than Western countries such as the United States, Canada, and Germany. Differences in social support may play a large role in these variances; Western culture, with its emphasis on individualism, may produce more isolation and loneliness than Eastern sociocentric cultures. In addition, Eastern cultures tend to make less of a distinction between mind and body than Western cultures; thus, what may emerge as depression in the West could be a somatic or somatization disorder in the East. Ethnographic approaches reveal a number of depression-like syndromes in other cultures that may have vastly different meanings than those attributed in the United States. For example, pena in highland Ecuador is associated with many symptoms of depression, such as "crying spells, poor concentration, anhedonia, social withdrawal, poor personal hygiene, sleep and 32
PERSONALITY-GUIDED THERAPY FOR DEPRESSION
appetite disturbance, gastrointestinal complaints, and heart pain" (Tsai &. Chentsova-Dutton, 2002, p. 470). Personal loss is generally the precipitant of pena, as it often is with depression. However, according to Tousignant and Maldonaldo (cited in Tsai & Chentsova-Dutton, 2002), pena is an appeal for payment or social reciprocity, for the incurred loss. Unlike depression in the United States, which is viewed as individual psychopathology, pena is part of the social balance in highland Ecuador. Similarly, in New Guinea, the Kaluli people are highly emotionally expressive. Grief reactions, akin to what we might view as sadness or depression in the United States, are integrated into the culture through ceremonies, rituals, and "scripted" social interactions. These expressions then become part of the social negotiations within the culture, which help individuals to get their needs met. This appears to have a strong protective effect against depression in that culture (Scheflielin, cited in Tsai & Chentsova-Dutton, 2002, pp. 469-70). As Castillo (1997) observed, In a society with dominance hierarchies, individuals at the low end of the social scale have a stigma or impaired identity imposed upon them by dominant groups. The moral career of these stigmatized individuals is compromised in interpersonal relations. The term moral career refers simultaneously to the moral status and the morale of the individual. The moral status of individuals is an indication of their perceived value in society—that is, whether they are "good" or "bad" persons as judged by the cultural definitions of morality within the context of the social dominance hierarchy. . . . When moral status is compromised in this fashion, the individual's morale or sense of self-esteem can also be negatively affected. (Goffman, 1963, p. 42)
The consequences of stigmatization fit in well with Abramson et al.'s (1978) revised learned helplessness model. The consequences of being the "wrong" race, gender, ethnicity, social class, religion, or sexual orientation are often internalized by individuals as a feeling or belief that in fact there is something wrong with them. Because these demographic characteristics are immutable or difficult to change and impact a many areas of their lives, they see their predicament as stable and global (Castillo, 1998). Thus, individuals from stigmatized or disadvantaged groups are generally more prone to depression. There is a powerful argument that the traditional social roles of women, as described, for example, by J. H. Williams (1987) and Skeggs (1997), have a significant impact on depression. Because of women's traditionally subordinate role in our culture, they are more prone to anxiety, depression, and feelings of helplessness than men. Similarly, submissiveness and fear of abandonment are more consistent with women's social role than men's. Castillo (1998) noted that women in the United States are more likely than men to experience discrimination, harassment, and poverty. Nolen-Hoeksema, Larson, and Grayson (1999) studied a community sample of over 1,100 adults AN OVERVIEW OF DEPRESSION
33
longitudinally and affirmed that "chronic strain, low mastery, and rumination were each more common in women than in men and mediated the gender difference in depressive symptoms" (p. 1061). Further, her study demonstrated that this pattern led to a vicious circle, in that depressive symptoms led to increased rumination and decreased mastery over time. These notions are consistent with the findings of a study by Lynn Collins (1998), which linked social status to the development of psychological symptoms. Collins showed her classroom students (the research participants) a film of the Stanford prison experiment (Haney, Banks, & Zimbardo, 1973). Collins put together a list of symptoms of mental disorders and had participants rate how characteristic these symptoms were of men, women, "prisoners," and "guards." What she found, as demonstrated in the ratings, was that the prisoners exhibited symptoms of depression, anxiety, and helplessness— symptoms traditionally more prevalent in women. Conversely, the guards displayed aggression, arrogance, and other symptoms of antisocial and narcissistic disorders—diagnoses given predominantly to men. What was especially ingenious about this study was that because both the guards and the prisoners were male neither gender roles nor biological sex could explain the group differences. In addition, because of randomization, explanations based on personal variables (their upbringing, family dynamics, trauma history, etc.) were ruled out. The likeliest explanation for the differences in symptoms between the prisoners and the guards is that their assigned social roles influenced their identities and behaviors. This theory fits with data that show that the prevalence of depression is relatively high among, for example, gay teens and the poor (Herrell et al., 1999; Otis & Skinner, 1996; Simons et al., 2002; van Heeringen & Vincke, 2000). However, awareness of the difference in prevalence between men and women in most mental disorders is potentially confounded by differential rates of help-seeking behavior. Women are more likely to seek psychological help for most conditions, especially for depression and anxiety. For men in our culture, asking for help is seen as a sign of weakness or dependence; for women, asking for help bears no such stigma (Tannen, 1990). It is probable that some of the difference between diagnosis rates for men and women is due to women's greater comfort in going for help, especially with a mental health issue, though it is difficult to estimate the precise magnitude of that effect. In addition, differential rates have been found not only in clinical samples, but also in epidemiological studies (Nolen-Hoeksema, 2002); these differences are more difficult to explain on the basis of self-selection for treatment. On the other hand, a study of over 2,000 referred and 1,100 nonreferred adolescents found that among mental-health-referred, but not nonreferred, adolescents, rates of depression were higher in girls than in boys (Compas et al., 1997). The authors suggested that these gender differences were apparent in only a small subset of adolescents. Further research is needed to clarify the impact of gender and the reason for the impact. 34
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People from other cultures may have vastly different experiences of distress that are shaped by their culture. Guilt, self-denigration, existential despair, and suicidal ideation have been found to be less prevalent or absent in non-Western cultures. Conversely, somatic symptoms are more pronounced in other societies. The World Health Organization Collaborative Study, which examined depression in five different countries (Canada, India, Iran, Japan, and Switzerland) found that feelings of guilt were more than twice as prevalent in the Swiss sample than in the Iranian one, and somatization was twice as high in the Iranian sample as in the Canadian one (see Sartorius et al., and Thornicroft & Sartorius, both cited in Castillo, 1998). Sociocultural upheaval can also lead to depressive symptoms. For example, the rate of completed suicides in Micronesia underwent an eightfold increase from 1960 to 1980, a period of rapid modernization accompanied by the breakdown of traditional religious and social organizations (Desjarlais, Eisenberg, Good, & Kleinman, 1995, cited in Castillo, 1997). A striking example of the difference in meaning of distress in different cultures was illustrated by Kabat-Zinn (1994): In our society, one might speak of an epidemic of low self-esteem. In conversations with the Dalai Lama during a meeting in Dharamsala in 1990, he did a double take when a Western psychologist spoke of low self-esteem. The phrase had to be translated several times for him into Tibetan, although his English is quite good. He just couldn't grasp the notion of low self-esteem, and when he finally understood what was being said, he was visibly saddened to hear that so many people in America carry deep feelings of self-loathing and inadequacy. Such feelings are virtually unheard of among the Tibetans. They have all the severe problems of refugees from oppression living in the Third World, but low self-esteem is not one of them. But who knows what will happen to future generations as they come into contact with what we ironically call the "developed world." Maybe we are overdeveloped outwardly and underdeveloped inwardly. Perhaps it is we who, for all our wealth, are living in poverty, (pp. 162-163)
In part, the Dalai Lama's perspective may reflect the difference between sociocentric and egocentric cultures. In the West, the concept of individualism permeates. We are encouraged to pursue our goals and maximize our potential; we believe in the concept of individual rights, including the right to pursue happiness. If one is not pursuing happiness, then, in Western culture, one is behaving pathologically. In sociocentric cultures, the well-being of the group is considered paramount, with individual needs being secondary. Within such a context, low self-esteem is far less comprehensible because the emphasis is not on the self in the first place. Sadness occurs, of course, but it is more likely to be a shared experience rather than a personal failing. AN OVERVIEW OF DEPRESSION
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STRENGTHS OF PATIENTS WITH DEPRESSION In my experience, individuals with depression tend to have a variety of positive qualities. Many are introspective and in touch with their feelings. I have found them by and large to be responsible—willing to take ownership of their own feelings and their impact on others. To the extent that they go overboard in that regard, it is generally easier to help depressed individuals reduce their guilt and bring their oppressive superegos into balance than it is, for example, to help poorly socialized individuals restrain their ids and develop a sense of social responsibility and guilt. Individuals with depression are generally eager to get well, which serves as a great motivation in therapy. Some studies found that depressed individuals are more realistic in their predictions than nondepressed ones, who were excessively optimistic (for a review of this research, see, e.g., Dunning & Story, 1991). This counterintuitive finding spawned a generation of research, which has generally indicated that depressed individuals are more realistic under contrived laboratory conditions but not in more realistic circumstances (Dunning & Story, 1991; Pacini, Muir, &. Epstein, 1998). Although these theories are subject to ongoing research, tentative initial conclusions suggest that depressed individuals (more than nondepressed participants) make overly optimistic estimates at the beginning of such studies, when they are under relatively little stress. Then, impairments associated with depression interfere with goal completion. Cognitive distortions similar to those noted by A. T. Beck et al. (1979), such as beliefs that one is incompetent, play an important role. Helplessness beliefs (Seligman, 1975) impair efficacy and thus render optimistic predictions inaccurate. Vicious circles (Millon, 1996), in which individuals with depression underestimate the effort required to complete a task and then initially fail, leading to further giving up, also play a role, and, similarly, positive efforts made by nondepressed individuals that are then rewarded lead to goal attainment. At this time, the depressive realism phenomenon should be considered primarily a laboratory occurrence of limited clinical utility.
THE RELATIONSHIP BETWEEN PERSONALITY DISORDERS AND DEPRESSION Seven models are most frequently cited as underlying the relationship between PDs and depression (Dolan-Sewell, Krueger, & Shea, 2001). With the exception of the independence model (which, if true at all, is not relevant to the material addressed in this volume) and perhaps the "scar" model (which does not appear to have elicited PD or depression-related studies at this time), all of the other models are implicit in conceptualizations that appear throughout this book. Each model is considered below, with some 36
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examples of how the model relates to specific depression-PD interactions that are addressed later on. Independence Model The independence model indicates that there is no relationship between Axis I and Axis II conditions. If the rate of comorbidity does not exceed the rate of chance occurrence predicted by the base rate of the disorders, that would count as supportive evidence for the independence model. For example, if a PD occurred in 10% of the population and major depression in 20% and if the comorbidity of the two disorders was 2%, that would support the independence model. In certain areas, limited support is available for the independence model. For example, a study by Petersen et al. (2002) showed that treatment-resistant depression was not related to the presence of a PD. However, for the most part, the comorbidities between depression and PDs exceed chance levels. Shea, Widiger, and Klein (1992), in their review of the literature, noted that high rates of comorbidity for PDs and depression are the norm. Citing nine studies, Shea et al. noted that in samples of depressed participants, 23% to 87% of the participants have had PDs; in most of these nine studies, the PD rate is 30% to 40%. Similarly, in the six available studies of the rates of depression in samples of individuals with PDs, the range was approximately 24% to 87%. These rates clearly exceed the amount of overlap one would anticipate on the basis of the prevalence of each disorder taken separately. Common Cause Model The common cause model applies if there is a shared element between the two disorders that causes both. The cause can be biological, psychological, environmental, or sociological. For example, a chemical imbalance in the serotonin system may underlie both depression and impulsive behavior (e.g., as seen in borderline PD; see Soloff, Kelly, Strotmeyer, Malone, & Mann, 2003; Soloff, Meltzer, Greer, Constantine, 6k Kelly, 2000). Thus, an individual with either disorder would be at risk for the other. Thus SSRIs, which are antidepressants, are useful in treating borderline PD (Rinne, van den Brink, & Luuk van Dyck, 2002). Similarly, sexual abuse may be a risk factor for both borderline PD and depression (Rose, Abramson, Hodulik, Halberstadt, & Leff, 1994; Zanarini, Gunderson, Marino, Schwartz, & Frankenburg, 1989). Techniques that facilitate healing the emotional trauma of sexual abuse would, according to this model, reduce symptoms of both disorders. Spectrum and Subclinical Model Like the common cause model, the spectrum model views one disorder as a milder version of the other disorder; in this case, the Axis II disorder AN OVERVIEW OF DEPRESSION
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would be a milder version of the Axis I disorder. There is good evidence that schizotypal PD and schizophrenia have a "spectrum" relationship, and although the evidence is not quite as strong, it appears that paranoid and schizoid PDs are part of the same spectrum (Siever, 1992). Regarding a relationship between depression and PDs, depressive PD—which is not discussed elsewhere in this volume because it is covered in the appendix of DSM-IVTR—is probably related in a spectrum fashion to major depression and dysthymic disorder. There are theories that borderline PD lies on a spectrum with bipolar disorder, based on shared features such as affective instability. Although proof of this connection is lacking, the theory led to experiments with anticonvulsants and lithium to treat borderline PD; however, this approach has had mixed success (see the section on medications in chap. 7, this volume). Predisposition—Vulnerability Model There is a possibility that having one disorder will predispose an individual to getting another disorder. In this regard, PDs, which are seen as developmentally based and having broad implications regarding the person's functioning, would be more likely to form the context into which the depression would fit. However, it is also possible that childhood depression would predispose an individual to develop a PD. A study by Daley, Hammen, Davila, and Burge (1998) is illustrative of this point. It demonstrated that the presence of a Cluster A or B PD predicted later depression in a sample of late adolescent women. The causal path consistent with Daley et al.'s analysis was that individuals with Cluster A and B PDs generated larger numbers of stressful life events, which in turn increased the likelihood of depression. The vulnerability model fit better than the pathoplasticity model (discussed below); PD did not increase the risk of depression in response to stress. Complications-Scar Model Like the vulnerability model, the complications model presumes a sequential relationship between two disorders. In this theoretical configuration, a second disorder develops in the context of the first. The first disorder remits, but the other disorder continues on, exacerbated by the effects of the original comorbid disorder; it is as if the remitted disorder left a "scar" that complicates the recovery from the lingering disorder. An example would be an individual with borderline PD who then develops depression and, after intensive treatment, no longer meets the criteria for borderline PD but is still more vulnerable to depression as a consequence of having had borderline PD. In such an instance, residual borderline PD symptoms may be the causal factor that increases the vulnerability to depression. I am not aware of any 38
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studies that support the validity of this model in specific PD-depression pairings, though it remains a theoretical possibility. Pathoplasty-Exacerbation Model In this model, the principal hypothesis is that the presence of one disorder will influence the course of another. The effects can be additive (pathoplasty) or synergistic (exacerbation). For example, depression likely increases the tendency of individuals with avoidant, schizoid, and schizotypal PDs to socially withdraw, which can then further exacerbate both conditions. A number of studies support the notion that PDs interact with depression. For example, llardi, Craighead, and Evans (1997) found that the length of remission of unipolar depression was over 7 times longer among clients who did not have PDs compared with those who did. In another study, an interaction of personality style and life events predicted depression. Specifically, the researchers predicted and found that self-critical patients were at high risk for depression relapse if they experienced adverse achievementrelated events, and dependent individuals were vulnerable to depression if they experienced negative interpersonal life events (Z. V. Segal, Shaw, Vella, & Katz, 1992). A study of the impact of PDs on cognitive therapy outcome showed that outcomes were independent of PD status but that specific paranoid and avoidant beliefs predicted poorer outcomes (Kuyken, Kurzer, DeRubeis, Beck, & Brown, 2001). Psychobiological Models In the psychobiological model, shared biological mechanisms underlie depression and PDs (though presumably different PDs will have different associations with depression). Evidence of the validity of this model is growing. For example, a recent study of 720 child and adolescent twins showed that 45% of the covariation in depression and antisocial PD were attributable to common genetic factors (O'Connor, McGuire, Reiss, Hetherington, & Plomin, 1998). Such psychobiological models are a variant of the "common cause" model discussed above, and thus the biological example given in that section applies here as well (i.e., serotonin problems in individuals with depression and impulsive PDs).
CONCLUSIONS Perhaps what is most important to consider is that these models are not mutually exclusive, and they often overlap. We do not know for certain what the relationship is between PDs and depression, but it is likely complex. StayAN OVERVIEW OF DEPRESSION
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ing with the PGT principle that integration occurs at the level of the person rather than at the level of theory, we can safely conclude that most or all of these models refer to at least some of the people, some of the time. Throughout the remainder of the book, reference will be made to these models when they fit the available data.
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3 DEPRESSION INPARANOID PERSONALITY DISORDER
The phenomenology of paranoid personality disorder (PD) is powerfully portrayed in the poem "Paranoid," written by Lisa Ochenduszko (2003) and published on the Internet. The poem is reprinted only in part, but each stanza is complete and the ellipses are in the original. In the deepest recesses and corridors of my mind, You play there . . . You run freely, gaily In my mind you make the fantasies, hollowed out screams, fearful cries . . . Denied In my mind where you hunt your prey, Your hunger ravished, eating me. . . . Destroyed In my mind or what is left of my mind, you reign as supreme. Ideal dictatorship. . .. Paranoid. . . .
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This gifted writer has portrayed the pain, emptiness, and fear that dominate the life of the person with paranoia. The frightening image of being destroyed, as if devoured from the inside, represents the internalization of the sadism to which the person was presumably subjected. The poet portrays a person who sees evil in others and has difficulty setting a boundary to keep it out ("In the deepest recesses and corridors of my mind, / You play there ... / You run freely"; "In my mind you make the fantasies").1 Although real abuse presumably occurred, in theory, there are also instances in which it is the person portrayed by the poet who feels anger or hate and then projects it onto an otherwise innocent person; this projection occurs outside of conscious awareness. Glimpses of projection appear several times in the poem. Is the feared individual able to truly "run freely" in the person's mind and to create fantasies? Or do the fantasies come, at least in part, from within? The fear of being controlled by another and the exhaustion from the defensive efforts, both so movingly portrayed, capture the essence of paranoid PD. According to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision [DSM-IV-TR]; American Psychiatric Association, 2000a), "Paranoid Personality Disorder is a pattern of distrust and suspiciousness such that others' motives are interpreted as malevolent" (p. 685). Guarded and either hostile, fearful, or both, they are among the most difficult groups to treat with psychotherapy. Their very modus operandi—trust no one—is so contrary to one of the necessary conditions of psychotherapeutic treatment that treatment often grinds to a halt after just a few sessions. There is more hope that the individual with both paranoid PD and depression will stay in treatment because the depression is distressing and increases the client's motivation to persist in treatment. It is important to distinguish paranoid PD from paranoid (delusional) disorder and from paranoid schizophrenia. Sometimes they co-occur, as in the case example at the end of this chapter, but not always. In general, I have found that people with paranoid schizophrenia and delusional disorder (but without paranoid PD) are remarkably trusting. As I have listened to elaborate tales of Federal Bureau of Investigation, Mafia, and Central Intelligence Agency conspiracies that ensnared the beleaguered client, I have often waited for the other shoe to drop—to hear the dreaded, "How do I know that you're not part of the conspiracy?"—but it never happened. Often I have found individuals with paranoid schizophrenia to be too trusting, because their psychosis often interfered with logical thinking that would have helped them to set appropriate boundaries. Nor did people with delusional disorder ever consider me part of the conspiracy. Such is not the case with individuals with paranoid PD. By definition, it is extremely difficult to establish trust. 'The poet has said in a personal communication that she was writing not about herself but about a loved one.
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EPIDEMIOLOGY In Pepper et al.'s (1995) dysthymic disorder sample, 11% had paranoid PD. In another sample of depressed clients, approximately 22% had paranoid PD (Fava et al, 1995). In a sample of 249 depressed outpatients, 5% were diagnosed with "definite" and 18% with "probable" paranoid PD (Shea, Glass, Pilkonis, Watkins, & Docherty, 1987). In a sample of 352 clients with both anxiety and depression, approximately 17% had paranoid PD, as diagnosed by structured interview (Flick, Roy-Byrne, Cowley, Shores, & Dunner, 1993). Zimmerman and Coryell (1989) studied a community sample of 797 individuals that included 143 individuals who were diagnosed with PDs. Among individuals with major depression, 1.7% met the criteria for paranoid PD. Thus the range is approximately 2% to 22%. Likely reasons for the wide range include natural sample variation, inpatient versus outpatient status, different definitions of depression (e.g., dysthymic disorder vs. major depression), and changing criteria—-for example, some studies used criteria from the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980), and others used criteria from the revised third edition (DSM-III-R; American Psychiatric Association, 1987). In regard to the converse question, among those with paranoid PD, 28.6% met the criteria for major depression (Zimmerman & Coryell, 1989). WHY DO PEOPLE WITH PARANOID PERSONALITY DISORDER GET DEPRESSED? Individuals with paranoid PD have thought patterns that generate both anxiety and depression. The fear that others cannot be trusted and that others are actively undermining one's efforts leads to anxious hypervigilance. Under such circumstances, many get worn out and sink into feelings of hopelessness and pervasive cynicism. Additional failures related to depression symptoms (such as slowed mental processing, motivational difficulties, etc.) are further attributed to external forces, such as others' malevolence. "I would be fine if not for so-and-so's interference" is a common theme. This conceptualization is consistent with the predisposition-vulnerability model, in that the paranoid PD places the person at risk for depression. It also suggests the exacerbation model because the depression and paranoia intensify one another (see chap. 2). HOW A PERSON BECOMES AND REMAINS PARANOID: THEORIES OF PARANOID PERSONALITY DISORDER AND THEIR ASSOCIATED TREATMENTS For individuals with comorbid depression and paranoid PD, it is hard to imagine a satisfactory resolution of Axis I symptoms without a concurrent PARANOID PERSONALITY DISORDER
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reduction of pathology on Axis II. The depression is likely to be tinged with anger, and difficulties with trusting a health care professional would strongly interfere with therapeutic progress in any modality. Thus, to treat the depression, trust must be established—that is, the paranoid personality pathology must recede, at least to some degree. Major theories of understanding and treating paranoid PD are presented below, with an emphasis on the individual with comorbid depression where feasible. Biological Factors Paranoid PD is part of the schizophrenia spectrum (Siever, 1992). For example, a study found that paranoid PD was twice as likely to occur in schizophrenic probands than in nonpatient controls (Baron, Gruen, &Ranier, cited in Nigg & Goldsmith, 1994). Paranoid PD appears to be intermediate between schizotypal and schizoid PDs in its genetic association to schizophrenia (for a review, see Nigg & Goldsmith, 1994). DiLalla, Carey, Gottesman, and Bouchard (1996) found that the Minnesota Multiphasic Personality Inventory Paranoia scale had a heritability estimate of 28%. Livesley, Jang, and Vernon (1998) found that suspiciousness scores had a heritability of 32.5%. In their study of the heritability of personality disorders in children and adolescents, Coolidge, Thede, and Jang (2001) found that the heritability estimate for paranoid PD was 50%. As with other personality disorders, then, paranoid PD appears to be moderately heritable. To my knowledge, there are no substantiated theories on the neurobiology of paranoid PD per se. As part of the schizophrenia spectrum (Siever, 1992), and to the extent that it is related to paranoid schizophrenia, paranoid PD involves the functioning of the dopaminergic systems. In Cloninger's theory (Cloninger, 1987), paranoid PD would presumably represent the high extreme of the "harm avoidance" dimension. Cloninger (1998) has shown that high harm avoidance is related to specific activities in the brain, such as higher levels of activity in the right amygdala (a part of the limbic system, important in processing emotions) as well as the right orbitofrontal cortex and the left medial prefrontal cortex (parts of the frontal lobes that are involved in executive functions such as planning). I know of only one empirical evaluation of medications for paranoid PD, the Ekselius and von Knorring (1998) study discussed in chapter 1. The selective serotonin reuptake inhibitors sertraline and citalopram appeared to be helpful in decreasing paranoid PD symptoms among the 84 individuals in their sample with paranoid PD. The remission rate for paranoid PD after 24 weeks of treatment was 43% for the sertraline group and 30% for the citalopram group. The sertraline group had a mean decrease of .5 criterion pre- to posttreatment; the corresponding figure for the citalopram group was .7 criterion. Unfortunately, because there was no medication-free compari44
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son group, the results of the study are inconclusive; however, given the generally persistent nature of personality disorders, the finding is noteworthy and warrants further investigation. In the absence of additional studies, it is worthwhile to consider the clinical observations provided by Joseph (1997). He divided paranoid PD into symptom clusters that are amenable to intervention with medications. Paranoia and ideas of reference can be treated with antipsychotics, such as risperidone or olanzapine (which he preferred), or other drugs, such as haloperidol, fluphenazine, or chlorpromazine. He noted that dosages are "approximately one-tenth to one-fourth of what is used for treating florid paranoia and psychoses" (p. 27). In his experience, such medications are quite effective in reducing paranoid ideation in people with paranoid PD. Joseph argued that symptoms such as such as rigid thinking and preoccupations with others' loyalty can be considered obsessional features and treated with selective serotonin reuptake inhibitors such as fluoxetine, sertraline, orparoxetine. Vigilance, guardedness, and tension may respond to anti-anxiety agents such as lorazepam, alpraxolam, and clonazepam. Anger, excessive emotional sensitivity, and irritability are a cluster of symptoms that can be treated effectively with serotonergic antidepressants or tricyclic antidepressants, with bupropion also being somewhat effective. Constricted affect, social withdrawal, and social anxiety can be conceptualized as being similar to negative symptoms of schizophrenia; Joseph noted, "They are likely to respond to low doses of risperidone or olanzapine, and, paradoxically, to serotonergic antidepressants and bupropion" (p. 30). In most cases, then, his treatment consists of long-term use of a low-dose antipsychotic and a serotonergic antidepressant, with short-term administration of a benzodiazapine. Although reasonable, Joseph's theoretical assumptions, as well as his assertions of the efficacy of particular medications for use with this population, require empirical verification. Randomized clinical trials with any medication proposed for this population are essential. Psychological Factors In the biopsychosocial model, the psychological level refers to the individual and his or her intrapsychic and interpersonal world. Important areas to consider include the person's learning history, thoughts, feelings, unconscious motivations, and relationships. Various schools of thought emphasize different aspects of the person's functioning and will be described in turn below. Millon's Theory According to Millon (1969/1985, 1981, 1996), paranoid PD is a severe "dysfunctional variant," rather than a basic personality type in its own right. Paranoid PD occurs when a personality disorder deteriorates. The basic patPARANOID PERSONALITY DISORDER
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terns that typically underlie paranoid PD (and Millon's labels for the subtypes) are narcissistic (which becomes the fanatic paranoid), sadistic (malignant), obsessive—compulsive (obdurate), avoidant (insular), and passive— aggressive-negativistic (querulous). In Millon's theory there is no developmental background that is specific to the disorder; it depends on the subtype. It is a "common endpoint" theory, in which many developmental beginnings, shaped by experience, lead to the hypervigilant mistrust seen in paranoid PD. The seeds of paranoid PD find fertile soil in narcissistic psychopathology. There is an inevitable set of beliefs that undergirds the paranoid thinking seen in this disorder: In order for someone to be undermining me, I must be important; in order for them to feel threatened by me, I must be very powerful; in order for them to feel jealous of me, I must be very special.
The arrogance that lurks just beneath the surface presentation often drives and fuels the paranoid thinking; the gratification derived from the grandiosity props up and maintains the defense, and the externalization and blame protect the person from self-reproach and further reinforce the pattern. What turns narcissism to paranoia is cold, harsh reality that fails to gratify even a modicum of the need for validation. A person with paranoid PD's perception of his or her talents and abilities are miles apart from the perceptions of others. If such individuals could simply accept their limitations and focus on activities they do adequately well, all would be copacetic; however, such is not the case. Narcissistically driven, they continue to push, feeling the constant sting of rejection. Filled with blame and condemnation, their accusations and conjectures drift further and further from reality into a quasidelusional or fully delusional form. People with avoidant origins are among those who are more constitutionally prone to paranoia. Typically shy and hypersensitive from the beginning, they consistently perceive rejection from an early age. Like their less pathological avoidant counterparts, insular paranoids were subject to harsh parental deprecation. Unlike the avoidant, however, the future paranoids found no safe quarter; withdrawal was insufficient, and persecution seemed to follow them. They lacked natural sophistication and cleverness as defenses, and thus every sling and arrow hit its mark; eventually, they came to view everyone as a potential torturer. The querulous paranoid has an originating background similar to the passive-aggressive-negativistic pattern. Millon (1996) noted that the querulous paranoid is a variant related in part to a basic negativistic pattern. These paranoids often evidence irregular infantile patterns and an uneven course of maturation, traits that often promote inconsistent and contradictory parental management. Their characteristic irritable
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affectivity may be attributed to low neurophysiological thresholds of responsivity. (p. 719) As is the case for others with basic personality patterns who deteriorate to a paranoid level of functioning, increasing mistrust is precipitated by agonizing disappointments and rejections. Fundamentally ambivalent on the selfother dimension, querulous paranoids are pushed to rely increasingly on themselves, and their resentments of others grow ever deeper. Ultimately, they become "sullen, resentful, obstructive, and peevish, openly registering feelings of jealousy, of being misunderstood, and of being cheated" (Millon, 1996, p. 720). Like individuals with sadistic PD, malignant paranoids have backgrounds of parental harassment and animosity. They acquire hostile behaviors, which are reinforced by peers (who give in to them) and parents (who inadvertently reward hostility with attention or purposefully cultivate an aggressive approach to life). Poverty may encourage a "survival of the toughest" adaptation. Millon (1996) noted, Anticipating resentment and betrayal from others, future malignant paranoids moved through life with a chip-on-the-shoulder attitude, bristling with anger and reacting before hostility and duplicity actually occurred. Resentment and antagonism were projected. Dreading being attacked, humiliated, or powerless, they learned to attack first, (pp. 717-718) As with other paranoids, harsh reality, rejection, and humiliation push them to engage in increasingly extreme defensive maneuvers. They become more angry, hostile, and hypersensitive, seeing others as more and more treacherous. Eventually, they trust almost no one and often take on delusional, persecutory beliefs. Regardless of its origin, a variety of vicious circles maintain the paranoid pattern. Perhaps most powerfully, suspicious mistrust breeds suspicious mistrust. The guarded presentation of individuals with paranoid PD elicits the belief that they are hiding something. Failure to reciprocate small trusting gestures, such as self-disclosure, by others short-circuits the rapportbuilding and trust-enabling process. Their proclivity to discharge hostility in brief bursts leads to numerous interpersonal difficulties. As noted by Millon (1996), Trapped in a timeless web of deceit and malice, their fears and angers may mount to monumental proportions. With defenses down, controls dissolved, and fantasies of doom running rampant, their dread and fury increase. A flood of frantic and hostile energies may erupt, letting loose a violent discharge, an uncontrollable torrent of vituperation and aggression, (p. 721) Obviously, the targets of such aggression typically become more actively opposed to and angry with the person with paranoid PD who attacked them.
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Finally, the delusional or quasi-delusional reconstruction of reality by persons with paranoid PD further worsens their social situation. Their suspicions often cross the line into actual accusations or, in more extreme cases, physical assault. This pattern elicits the feared animosity and vengeance that generally were not there prior to their own attacks on others. I recall an extremely paranoid client whom I knew (but never treated) when I was working at a Veterans Administration hospital who seemed to have all of these perpetuating factors. He never made any friends or even strong acquaintances on the unit. To my knowledge, he never opened up or shared any personal information with anyone. I learned from staff that in his job as a subcontractor for a private detective, he was to sit and watch people, all day long, to see if they engaged in unseemly or illegal activities. This client also had antisocial PD and, for example, would rent furniture and never pay a dime until the company came to repossess it; it is my understanding that he was also involved in the illicit drug business. He met his end by being shot to death. I do not know the circumstances, but I would suspect that his antisocial and paranoid behaviors played an important role. Regardless of the particular subtype, depression in the person with paranoid PD often reflects a sense of exhaustion—battle fatigue from a war that will not end, a surrender to the implacable foe. Once it begins, the depression itself leads to further exhaustion and hopelessness. Although this feeling of depletion is painful, it also signals the need for change and provides the impetus for growth. Cognitive-Behavioral Conceptualization and Interventions The superficial manifestations of paranoid PD are obvious— hypervigilence, suspiciousness, and mistrust. However, cognitive theory connects these surface behaviors and beliefs to a more treatable underlying selfesteem deficit: The paranoid individual's intense vigilance and defensiveness is a product of the belief that this is necessary to preserve his or her safety. If it is possible to increase the client's sense of self-efficacy regarding problem situations so that he or she is reasonably confident of being able to handle problems as they arise, then the intense vigilance and defensiveness seem less necessary. This should result in some decrease in vigilance and defensiveness that could substantially reduce the intensity of the client's symptomatology, making it much easier to address his or her cognitions through conventional cognitive therapy techniques, and making it possible to persuade him or her to try alternative ways of handling interpersonal conflicts. Therefore, the primary strategy in the cognitive treatment of [paranoid PD] is to increase the client's sense of self-efficacy before attempting to modify other aspects of the client's automatic thoughts, interpersonal behavior, and basic assumptions. (A. T. Beck, Freeman, & Davis, 2004, p. 125) 48
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For depressed clients with paranoid PD, there would typically be even greater sensitivity to threats to self-esteem. Feelings of fatigue and hopelessness can make it feel as if their usual defensive efforts are too draining, thereby tempting them to withdraw. For the client in therapy, such attempts at withdrawal have been unsuccessful, and the person may feel damaged and vulnerable. It is often easier, more efficacious, and more comfortable, then, for the client to build skills than to decrease problematic behaviors directly. Often, competing behaviors (differential reinforcement of other behaviors) can "squeeze out" the ineffective behaviors without the need for the client to use behavioral inhibition. "Don't be so suspicious," whether the message is explicit or implicit, is an ineffective approach because it requires behavioral inhibition and it does not provoke a behavior for which to provide positive reinforcement. Instead, increasing skills such as assertiveness and interpersonal communication will naturally provide contrary evidence to the client's suspicions. It is also important to work with the client on his or her cognitive interpretations, because individuals with paranoid PD routinely twist data to fit their preconceptions. Helping individuals learn Socratic dialogue, by which they she can question the evidence themselves, is an important step. It is not, however, the first step. Of all the personality disorders, and, most likely, of all the disorders in the entire DSM-IV-TR—with the possible exception of autistic disorders and reactive attachment disorder—paranoid PD presents the largest and most persistent barricade to forming a therapeutic alliance. By definition, there are profound difficulties trusting others that must become part of the therapeutic process. It is not being overly pessimistic to say that in many cases this barrier is insurmountable. Nonetheless, there are strategies to improve one's odds of success. Beck and his associates (A. T. Beck et al., 2004; A. T. Beck & Freeman, 1990) have suggested that the therapist accept the client's mistrust and ask the client to allow the therapist to build trust through actions. Most clients with paranoid PD will find that this approach will fit with their worldview, because they tend to persistently scan others' actions to determine if they are trustworthy. In addition, it is wise to start with behavioral techniques, because cognitive techniques require too much trust and self-disclosure; once a solid therapeutic alliance is formed, cognitive techniques can be introduced. Above all, within the cognitive-behavioral therapy model, it is essential to maintain a collaborative stance. Regularly checking in with clients and making sure they understand and agree with the treatment plan is a strong safeguard against potential therapy-ending misunderstandings. Finally, giving clients increased control (e.g., more homework and less frequent sessions) can help them to preserve their autonomy, which is often a prerequisite to continuing treatment. The basic cognitive-behavioral therapy relationship, which is problemfocused and less intimate than many other forms of treatment, is generally a PARANOID PERSONALITY DISORDER
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good fit for the client with paranoid PD. However, without special attention to the relationship hurdles of paranoid PD, the therapy is likely to fail. Beck and his associates (A. T. Beck et al, 2004; A. T. Beck & Freeman, 1990) have paid attention to such issues from a cognitive perspective, as alluded to above; however, the cognitively oriented therapist would be wise to peruse writings from other theoretical perspectives as well. Gabbard (1994) provided a balanced, practical, and insightful review of countertransference phenomena, written in language that is accessible to the nonpsychodynamically oriented practitioner (see the sections in this chapter on psychodynamic therapy and countertransference). Cognitive techniques can also address the quasi-delusional suspiciousness associated with paranoid PD. For approximately the past 10 to 15 years, an extremely exciting literature has been developing in the treatment of psychotic disorders using cognitive therapy. A number of research studies have demonstrated substantial reductions in delusional beliefs. This area is just now beginning to mature, with literature reviews, overviews, and books emerging to connect formerly scattered and isolated reports (Gould, Mueser, & Bolton, 2001; Haddock et al., 1998; Kingdon & Turkington, 1994). For many years, the prevailing wisdom in the field has been, "You can't talk someone out of his delusions," a saying that I still believe is largely true. However, you can train someone to talk himself out of his delusions. The primary technique, as alluded to above, is the application of Socratic dialogue. "What is the evidence for your belief?" as in all Socratic dialogue, is a basic question, but it does not go quite far enough (the delusional paranoid always has a plethora of such evidence on hand). An important extension is "What would count as evidence that your belief is incorrect?" Of course, a strong relationship must exist before such a question can even be raised. However, introducing the possibility of disconfirmation removes the delusion from the realm of tautology and places it within the empirical world. In addition to empirical disconfirmation strategies through Socratic dialogue, thought records can be introduced to work on the motivational schemas that support the beliefs. For example, the person with paranoid PD likely holds the belief, "By scanning the environment, I help myself to feel safe." Using thought records, one may determine that the more such individuals scan the environment, and the more they ruminate about safety, the less safe they feel. When the empirical and emotional pillars supporting the delusion are sufficiently weakened, the delusion itself often collapses. We lack empirical data to know for sure, but theory would indicate that the client's depression is tied to the exhausting excessive vigilance and grinding social isolation. Finding some safety within the therapeutic relationship, and ultimately beyond, is likely to provide feelings of relief as well as an antidepressant effect. Relief from depression would then enhance social functioning, promoting a positive spiral of affective and personality functioning. 50
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Client-Centered, Humanistic, and Existential Therapies Patience, validation, and unconditional positive regard are a prerequisite for developing a relationship with someone who has paranoid PD. It is worth noting, however, that the ordinary level of warmth conveyed by a client-centered therapist is likely to be seen as threatening and a form of deceitfulness, so a more businesslike approach is probably more effective at first. Ultimately, however, over an extended period of treatment, a warm relationship could be extremely healing to the depressed person with paranoid pathology. Psychodynamic Therapy According to Melanie Klein (1946/1996), paranoia is part of the normal process of development. She described the "paranoid-schizoid position" as an early developmental stage. Splitting is the primary defense mechanism used. Terrified that warm and loving feelings will be overwhelmed by hateful and aggressive feelings, infants split off and project their emotions. Too young and immature to experience the mother as a whole person, they concretely experience the mother's breast as their principal attachment. When milk flows out, they experience the "good breast," which symbolizes love and nurturance; when the breast is dry or does not gratify them, they experience it as the "bad breast," which is evil and frustrating. Stuck in this position, persons with paranoia split off and project their hostile feelings onto others, who are then seen as persecuting them. This analysis implies that the person with paranoia will reexperience the anxiety that was relieved by the projection if forced to reintegrate the projected affect; it is consistently noted clinically that individuals with paranoid PD are loathe to acknowledge their own aggressive feelings toward others. It also suggests that an important part of the phenomenon of paranoid PD is excessive early frustration relative to warm nurturance and gratification. A further implication of the paranoid-schizoid position is that the individual tends to have fleeting and unstable object relations. Months of establishing trust can be undone in an instant if the therapist (or any individual) commits a perceived injustice; the client is likely to see this as "proof that the therapist had malicious intent all along. In addition, the individual is unable to maintain a detached, observing stance. The thought that someone is trying to undermine him or her is its own proof; there is no hypothetical "as if" (e.g., "It is as if he is trying to undermine me"). Instead, slights are viewed as real and malicious rather than perceived. Perhaps the most damaging barrier against establishing relationships for the person with paranoid PD is projective identification. Projective identification has three components: (a) projection of an unacceptable impulse onto another while continuing to experience the impulse (in the paranoid patient, the projected impulse is usually aggressive); (b) viewing the individual PARANOID PERSONALITY DISORDER
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onto whom the impulse is projected as controlled by the projected impulse, and thus frightening; and (c) attempts to control the person, often in a way that provokes the feared behavior. A hypothetical example of projective identification and its capacity to undermine relationships was given by Gabbard (1994): Patient: Therapist: Patient:
I'm really angry with you because I've been sitting in the waiting room for half an hour. You told me to be here at 9:30 today. No, that's not true. I said 10 A. M. You said 9:30.
Therapist:
(a little louder and more forcefully) I said 10 o'clock. I wrote it down in my book.
Patient:
You're trying to trick me! You won't admit that you're wrong, so you try to make me think that I'm the one who's wrong.
Therapist:
(louder still) If I were wrong, I would admit it. On the contrary, I think you are the one who won't admit to being wrong, and you attribute that to me.
Patient:
I'm not going to take this harassment. I'll find another therapist! (pp. 424-425)
Projective identification involves the need to control others. But why this need? Deep down, people with paranoid PD have terrible self-esteem, believing that they are weak and ineffectual. Just as a weaker army uses a preemptive strike to capitalize on the element of surprise and maximize its effectiveness, people with paranoia believe that they are always in danger of being overwhelmed and destroyed by a superior force. Their grandiosity, then, is defensive and compensatory in nature; rather than reflecting a high selfopinion, it is a manifestation of precisely the opposite. To counter the destructive force of the projective identification, the therapist must, paradoxically, be totally open to it and accepting of it, allowing himself or herself to become a container for the negative affect. Gabbard (1994) gave an example of a better way to handle the prior situation: Patient:
I'm really angry with you because I've been sitting in the waiting room for half an hour. You told me to be here at 9:30 today.
Therapist:
Let me see if I understand you correctly. Your understanding was that you were to see me today at 9:30 instead of 10 o'clock?
Patient: Therapist:
Patient: 52
You said 9:30. I can certainly see why you might be angry at me then. Having to wait for someone for 30 minutes would make most people angry. You admit that you told me to come at 9:30?
PERSONAL/TY-G VIDEO THERAPY FOR DEPRESS/ON
Therapist:
Frankly, I don't remember saying that, but I'd like to hear more about: your recall of that conversation so I can find out what I said to give you that impression, (p. 426)
Thus, handling the client involves a persistently nondefensive, empathic, and supportive stance. Note, too, the businesslike and matter-of-fact approach taken by Gabbard above. Excessive warmth, as mentioned previously, is likely to breed suspicion and mistrust. Group Therapy Individuals with paranoid PD are not good candidates for processoriented group therapy at first. Their proclivity to elicit hostility and rejection from others is generally too strong, and they are likely to be scapegoated or otherwise rejected by the group. Rather, some progress should first be made in individual therapy; once the client is a bit more comfortable and trusting, then group approaches can be used. A psychoeducationally based skills group, however, could be considered earlier in treatment.
COUNTERTRANSFERENCE Theory and clinical observations suggest that countertransference is often a major obstacle to treatment of people with paranoid PD. Gabbard (1994) noted that "exasperation and impatience" (p. 426) often result from the relentless scrutiny by such clients. Therapists are also often tempted to burst the clients' bubble of grandiosity. Of course, to do so would typically rupture the therapeutic alliance as well. As indicated previously, projective identification requires special handling to avoid premature termination. The person with depression and paranoid PD presents the additional problem of feelings of hopelessness that can be induced in the clinician. If the therapist begins to feel hopeless, he or she must find rays of light in the darkness of the client's predicament; if this is not possible, then supervision or peer consultation is imperative. Throughout treatment, the wisest course of action is continued empathy and validation. Gabbard's (1994) illustration of how to handle projective identification, reviewed in the earlier section on psychodynamic therapy, provides an excellent illustration of how to remain empathic under trying circumstances. What little empirical research is available is consistent with clinical wisdom in the field. Graduate students who viewed a film of a therapy session with an individual simulating paranoid PD (without depression) indicated that they felt frustrated, guarded, perplexed, and fearful. The client's lack of trust, distant and suspicious demeanor, and failure to comply with an apparently reasonable request pulled forth the frustrated and confused feelings, while the client's thinly veiled hostility elicited fear and defensiveness (Bockian, 2002a). PARANOID PERSONALITY DISORDER
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In treating persons with paranoid PD, I have found it helpful to remind myself that their guarded style is usually well grounded in their experience. Many people with paranoid PD have been severely betrayed and/or sadistically abused. As the old joke goes, just because you're paranoid does not mean that they're not all out to get you.
SOCIAL CONSIDERATIONS AND DIVERSITY Individuals with certain disabilities, especially deafness, may have symptoms that would indicate paranoid PD in a hearing person. For the young child who has never had hearing but is raised in a hearing environment, watching others communicate in a manner that is inherently foreign often leads to feeling isolated and alienated. In addition, lacking many ordinary social cues, such children often believe that others are talking about them. In reality, in a culture in which difference is not well tolerated, the other children probably are often talking about them, and perhaps making fun of them, thus lending credence to suspicious feelings. The disparity between minority and majority culture was brought to the forefront during the O. J. Simpson murder trial ("Behind the Verdict," 1995). Simpson, an African American, was accused of murdering his White ex-wife. Polls in the United States showed a striking and consistent pattern: Most Whites believed Simpson was guilty, whereas most African Americans believed he was innocent. Even more interesting, a majority of African Americans (60%) believed that police often frame innocent people, com' pared with less than a fourth of Whites (Streisand, 1995). The perception that Simpson was framed gained credibility when the defense showed that one of the key witnesses, police officer Mark Fuhrman, had made racist comments that he had denied under oath. The jury, having seen an officer apparently lie under oath to help secure a conviction, experienced "reasonable doubt"—what else had the state done? Where did they get the evidence? How was the evidence safeguarded from tampering? Under a cloud of such suspicions, Simpson was acquitted. It is interesting, however, that Simpson was later convicted in civil lawsuits, thus revealing some room for interpretation regarding his innocence (MacNeil/Lehrer Productions, 1997). In short, members of minority cultures who may have been targets of racism or are intimately connected with those who have been should not be viewed as paranoid when they evidence mistrust of mainstream institutions (see Whaley, 1998). Immigrants are also at high risk for being mislabeled with paranoid PD (American Psychiatric Association, 2000a). Faced with language and other barriers and at times with hopelessly arcane immigration rules, the immigrant may become hostile or suspicious; such circumstance-related behavior should not be confused with a character disorder. Most subcultures within 54
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the United States are more sociocentric than the extremely autonomyfocused mainstream culture. However, minority experiences with racism are likely to engender a certain degree of healthy mistrust of the establishment. The potential impact of culture should not be underestimated. Castillo (1997) discussed Swat Pukhtun culture—a society in which the average male carries a gun, people are genuinely dangerous to one another, and women are kept at home as much as possible to prevent infidelity. Many people in Swat Pukhtun culture would meet the criteria for paranoid PD if judged by U.S. norms, but in fact their response to their situation is adaptive.
STRENGTHS OF PERSONS WITH PARANOID PERSONALITY DISORDER The suspiciously oriented mind is well suited to certain kinds of activities. Counterterrorists, for example, must be able to think like a terrorist, to remain hypervigilant, and to imagine possible deceptive plots that may occur. A bright and creative colleague of mine, warm and sensitive like most psychologists, nonetheless has such a cognitive proclivity. After the tragedy of 9/11 occurred, he shared with me the fact that for years, when he flew, if the pilot stepped out of the cockpit, his heart would jump into his mouth. He confided to me that he could not help but imagine the innumerable dire consequences to which the plane is subject in such moments. Had government officials or airline executives been so "paranoid," tragedy may have been averted. Another acquaintance of mine is able to imagine details of any possible contingency and make adequate preparations. For example, attacked while walking alone in a large city, he was able to frighten off his assailants because he was appropriately prepared and trained. The enormous dividing line between these healthy variants and the person with paranoid PD is the realistic nature of the planning and the lack of what cognitive therapists would call "personalization." Neither of these individuals imagines, as part of their planning or thinking, that such potential attacks are aimed specifically at undermining them; rather, they are trying to be prepared in the event of unlikely, but possible, negative human interactions. Frankly, they are the two people in the world with whom I feel most safe.
TREATMENT PLANNING: SYNERGISTIC TREATMENT The first step in creating catalytic sequences that will help the client is to establish a therapeutic bond. As noted throughout the chapter, doing so is often problematic; a patient and nondirective approach provides the greatest likelihood of success. Within a safe therapeutic relationship, cognitive techniques can help the client to challenge firmly held beliefs about others' maPARANOID PERSONALITY DISORDER
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EXHIBIT 3.1 Therapeutic Strategies and Tactics for the Prototypal Paranoid Personality STRATEGIC GOALS Balance Polarities Reduce polarity Increase polarity Counter Perpetuations Stop provocations of rejection Modify rigid minidelusions Undo self-protective withdrawals TACTICAL MODALITIES Alter inviolable self-image Moderate irascible mood Reorient cognitive suspiciousness Note. From Personality-Guided Therapy (p. 693), by T. Millon, 1999, New York: John Wiley & Sons. Copyright 1999 by John Wiley & Sons. Reprinted with permission of John Wiley & Sons, Inc.
licious intents. Behavioral techniques such as skills training can help the client to feel a greater sense of self-efficacy and thus a reduced need for hypervigilance and defensiveness. Interpersonal conceptualizations have obvious relevance, in that the client's main issue is often mistrust of others; helping the client to become aware of the patterns that maintain his or her negative mood and isolating behaviors can be very helpful (see Exhibit 3.1). Such interventions must be carefully timed; introduced too early, they will provoke defensiveness. I find that the ideal timing for helping clients to break out of such patterns is when they express frustration and ask, directly or indirectly, how they can get better. Clients who are depressed are more likely to be able to seek help in such a manner than the nondepressed person with paranoid PD. Medications can be helpful if the client becomes anxious or excessively hostile. If the client's family either participates in maintaining the behavior or bears the brunt of the client's hostilities, family therapy can help to correct those imbalances.
CASE EXAMPLE: JEAN Jean was a 15-year-old girl when her therapist, Kelly Vinehout, first saw her. The client was Caribbean American, the therapist Caucasian, and both were deaf. An incident of petty theft brought Jean to the attention of authorities. She was referred for treatment to a residential group home for the deaf and hard of hearing. Jean had a deaf sister and several hearing brothers and sisters. Her mother was addicted to drugs. Little was known about the 56
PERSONALITY-GUIDED THERAPY FOR DEPRESS/ON
father, except that he had been in and out of prison and had not been involved with the family for many years. Jean was extremely suspicious and mistrustful, far beyond what could be expected on the basis of normative deaf development or deaf culture. Her paranoia seemed to have been profoundly shaped by isolated traumatic events as well as ongoing social reinforcement. Her first memory was of being about 3 years old and being torn away from her family by the government under the auspices of the child protection division. Jean's fears were then fueled by her older sister's suspicions that the authorities were going to take away everyone in the family, put Mom in jail, lock up all the children, and so forth. With little guidance available from trustworthy adults, Jean was interpreting the world through her 3-year-old eyes and those of her frightened 4-year-old sister. The children were placed in the custody of her grandmother, who was told to not allow contact with the children's mother. However, because the mother lived close by, the children were able to sneak over for visits. This experience encouraged the belief that deceit is an ordinary part of human interactions. For Jean, raised in a home in which the mother was affectionate but routinely neglectful and poorly equipped for parenting, the seeds of paranoia fell on fertile soil. They were watered and nourished by social and interpersonal difficulties at school. Although she attended a school with deaf peers, Jean still did not fit in. Fearful when not in control, she attempted to dominate her social interactions. Although sometimes there is a submissive child around who can form a stable relationship with such a person, this did not happen for Jean; her thinly veiled hostility made it all the less likely that any of her relationships would succeed. Other children would occasionally tease her for being "bossy," not a particularly cruel barb in the world of grade school, but experienced as an infuriating and wounding slur by hypersensitive Jean. All of her relationships in school ultimately failed, leaving her isolated and lonely. On the basis of the nonverbal behavior she observed in the first session, Dr. Vinehout interpreted Jean's stealing, symbolically, as an attempt to secure desperately desired love and affection. Dr. Vinehout turned her attention to Jean's interpersonal relationships. Jean had unusually diffuse boundaries for a girl her age. Hearing children often learn about relationships in a variety of indirect ways—overhearing conversations among older children on the bus ride home, overhearing conversations among adults, and so on. In normative deaf development, children are unable to learn about such matters indirectly and thus rely on direct instruction. Jean's mother and siblings did not provide good role models, and nobody taught her about relationships. Jean tended to be intrusive in gathering information from others and guarded about sharing. Thus she helped to protect herself by minimizing her need to trust others and by gaining information that would help make others more predictable; however, few peers would tolerate that kind of inequity. PARANOID PERSONALITY DISORDER
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Further, she confused sexuality, affection, and affiliation. Jean was not yet sexually active, but Dr. Vinehout was concerned that her neediness and confusion left her vulnerable to sexual exploitation, which would have cemented her already rigid and paranoid world view. The first goal in treatment was to help Jean to understand appropriate boundaries in relationships. Dr. Vinehout used kinesthetic modeling, with a great deal of modeling and role-play, to help Jean develop more appropriate behaviors. After approximately three sessions, Jean's transference emerged in a rather direct way. The conversation went something like this (translated from the original sign language): jean:
Your hair smells just like my mother's.
Dr. Vinehout: Oh, you wish you had a mom to take care of you. jean:
Yeah, I wish you were my mom.
Dr. Vinehout: I can't be your mom, because then I couldn't be your therapist. For the same reason, I can't be your friend. Here's how it's different.
Dr. Vinehout then went on to explain the therapeutic relationship and how it worked. This kind of directness and bluntness is common and expected in deaf culture. It is also an extremely effective style with troubled adolescents, deaf or hearing, who typically see adult circumlocutions as devious. This early interaction quickly established Dr. Vinehout as someone who was relatively trustworthy, although trust had to be continuously earned throughout the course of a 3-year therapeutic relationship. It is typical for individuals in long-term treatment for PDs to bring most of their quintessential relationship issues into the room as part of the transference—countertransference enactment. In Jean's case, not surprisingly, the central issue was trust. One example was that Jean often asked to see the director of the facility ("Dr. Jones") to try to secure a desired privilege (e.g., permission to buy a bicycle). Dr. Vinehout would write a note to the director, stating the request for an appointment with the director. In Jean's mind, this meant the appointment had already been scheduled. Dr. Vinehout tried to explain that it just meant she would leave a note. Jean would then be disappointed with, and angry at, Dr. Vinehout for failing to make the appointment. So, Dr. Vinehout began to write the note to the director and a reminder note for Jean about what she had committed to do. Still, Jean would believe that someone had altered the note. Jean then got a Palm Pilot, which allowed her to encrypt the note that she wrote to herself (e.g., "Dr. Vinehout will leave a note for Dr. Jones") with a password. The following exchange would ensue: Jean:
You said you'd make an appointment for me, and then you didn't!
Dr. Vinehout: Look in your Palm Pilot. What does it say? 58
PERSONALITY-GUIDED THERAPY FOR DEPRESSION
Jean:
"Dr. Vinehout will write a note to Dr. Jones, asking for an appointment."
Dr. Vinehout: Did it say I would make the appointment? Jean:
No.
Dr. Vinehout: Do you see? Jean:
No. All that means is that someone stole my Palm Pilot and changed the note.
Dr. Vinehout: But you made the password yourself. Even if someone took your Palm Pilot, they would not know the password. Jean:
Then 1 must have dreamt the password, and someone must have stolen it from my mind.
Dr. Vinehout: No. That is not what happened. That is what we call paranoid thinking. Nobody can go into your mind and steal your dreams.
This straightforward psychoeducational intervention, repeated numerous times over the years within the context of a deep and secure therapeutic relationship, slowly but surely decreased the number of frank delusions experienced by Jean. Dr. Vinehout also provided Jean with psychoeducation about being Caribbean American in a racist culture. They discussed racial oppression and how that might impact her. Jean was receptive to these discussions. Although confrontation was helpful in a couple of key turning points in the relationship, the key to the success of the treatment was nearly constant validation. Dr. Vinehout helped to place Jean's fears in the context of her genuine experiences, accepting the reality of her ongoing and painful rejection and, more important, unconditionally accepting her as a person. Given her interpretations of events, her painful and ambivalent feelings were understandable; working through such feelings constituted the bread and butter of the twice-weekly individual sessions. In addition to individual sessions, Jean participated in group therapy twice per week. Dr. Vinehout was one of the group therapists along with a male cotherapist. Jean's participation in the group was uneven. At times, she participated well, allowing the peer group to help her process her concerns, such as whether to stay on her medications. Often, however, she was resistant and disruptive, refusing to participate. Her relationship with Dr. Vinehout served to bind her to the group, but jealousy and possessiveness of Dr. Vinehout—for example, when seeing her connect with other clients and with the cotherapist—made the group anxiety provoking. Overall, the group experience was positive for her, but it was not the place in which she made the most progress on her paranoid thinking. Jean's depression was atypical, though the manner in which it was expressed was not unusual for an adolescent, particularly one with paranoid PARANOID PERSONALITY DISORDER
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PD. She was extremely sensitive to disruptions in her fragile relationships. Rather than becoming sad and anhedonic, Jean would act out. It was predict' able that the day after a perceived slight in therapy or in a friendship relationship she would act out in an aggressive way and get into trouble. Dr. Vinehout's countertransference was unusual in relation to a paranoid client, in part because she seems to have circumvented a fair amount of the projective identification directed her way by the client and because the client tolerated identification of paranoid thinking. Typical countertransfer' ence emotions are feelings of guardedness and defensiveness, to ward off the client's attacks. Dr. Vinehout felt herself pushing away from the client in an effort to set appropriate boundaries; having tapped into the neediness and loneliness underlying the guarded defensiveness, she now had to work hard to set appropriate boundaries and keep the relationship at a healthy distance. In addition to individual and group work, Dr. Vinehout also did family work with Jean's family of origin. She met with the grandmother, uncles, and siblings, focusing primarily on two issues: interacting and communicating. With Jean present, she informed the family bluntly that they needed to know more sign language if they wished to have a relationship with Jean. This intervention helped Jean feel validated, although unfortunately, it did not get the family to learn much more sign language. Dr. Vinehout also helped the family empathize with Jean (e.g., when you sit around and chat, she feels left out and believes you are talking about her). Dr. Vinehout also worked with the family on guidelines for home visits. Jean got no supervision when she was home, which was inappropriate. Although they could not implement suggestions, they did become more aware of why the government agencies were keeping the family apart, and Jean became more understanding and accepting that such a home environment would not be good for her. By the end of the 3 years of treatment, Jean was greatly improved. She was able to function in the residential facility. The frequency of her paranoid delusional episodes had decreased. She had friendly, though somewhat superficial, relations with several of the other residents. Her relationship with the therapist was deep and rich. Although there were still episodes of mistrust, such breaches had been repaired many times, and working through them rather than having the relationship shatter was the expected outcome. Unfortunately, for systemic reasons outside the therapy realm Dr. Vinehout and Jean had to terminate. The termination process followed a predictable course, with Jean unable to process that the relationship would end and an angry confrontation in the penultimate session ("You didn't tell me we had to stop!") despite six consecutive prior sessions of addressing the issue. During the final session, Jean refused to speak with or look at Dr. Vinehout. Dr. Vinehout wrote notes to Jean, outlining the progress Jean had made over the course of treatment, the pride that she (Dr. Vinehout) felt in Jean, and reminders of Jean's plan for the future. During this final session, which consisted of Jean, Dr. Vinehout, and a staff member sitting at the dining room 60
PERSONALITY-GUIDED THERAPY FOR DEPRESSION
table, Jean refused to read the notes. Two weeks later, Dr. Vinehout received a phone call from Jean, stating she had kept the notes and was sorry that she had refused to talk to Dr. Vinehout. In conceptualizing this case from the standpoint of personality-guided therapy, it was clear that addressing the client's paranoid PD was an essential and guiding principle of the treatment. Technically, the core of the treatment was based on client-centered principles of consistent validation of the client's experience. With some clients—for example, those without personality disorders—it is possible to maintain such a stance early in treatment and then enter into a problem-solving cognitive-behavioral format; such was not the case with Jean, nor is it likely to be the case with most individuals with paranoid PD. However, building on this affirmative and validating stance, cognitive and psychoeducational techniques helped Jean to reduce some of her cognitive distortions. Early in treatment, Jean's transference was enacted and became an opportunity to build clarity and trust. Role-playing, which can be considered either a behavioral or an experiential technique, was relied on heavily to prepare Jean for the world of dating and other interpersonal relationships. The focus of much of the treatment was helping Jean establish interpersonal relationships. In conceptualizing the case, Dr. Vinehout drew on the work of Sullivan (interpersonal), Winnicott (object relations; holding environment), attachment theory, and Herman (trauma theory). Dr. Vinehout described therapy as "dancing with the affect" of the client, drawing on the client's subtle nonverbal material as the drumbeat to the music; in that regard, her work reminds me of Virginia Satir's. Synergistically, validation formed the basis of a relationship with the therapist, which then in turn became a platform from which to address other relationship issues, catalyzing the upward spiral of one good turn leading to another. However, the case also illustrates the resilience of the paranoid pattern once set into motion. Despite 3 years of intensive treatment as a relatively young woman, the client still had a good deal of paranoid psychopathology that was interfering with her functioning. She was, nonetheless, much less depressed and generally was feeling and functioning much better.
SUMMARY AND CONCLUSIONS Paranoid PD with depression is a difficult condition to treat because of problems establishing and maintaining rapport. However, in at least some cases, substantial improvements are possible. In the case of Jean, described above, a series of catalytic sequences led to considerable gains. First, the therapist established trust through bluntness and simplicity of speech as well as consistent, persistent use of physical evidence (e.g., the client taking notes in her password-protected computer). Rapport was never taken for granted, and relationship work was undertaken repeatedly. Cognitive techniques (chalPARANOID PERSONALITY DISORDER
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lenging distorted thoughts) and psychodynamic techniques (e.g., confronting the client's desire for the therapist to be her mother) led to gradual improvements in the client's functioning. Despite the "best practice" ideas and interventions reviewed above, many people with paranoid PD and depression will not be treated successfully. Many will not present for treatment, and others will not form a treatment alliance. Prognosis in such cases is guarded (pun intended). For purposes of personality-guided therapy for depression, empirical research explicitly targeting ways to establish rapport should be a priority, as well as establishing whether depression generally makes the treatment easier (e.g., because of enhanced motivation to relieve the depressive symptoms) or more difficult (e.g., with depression making it more difficult for the person to get mobilized).
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4 DEPRESSION IN SCHIZOID PERSONALITY DISORDER
A good illustration of a schizoid style of relating is shown in the portrayal of John Nash in the film A Beautiful Mind (Howard & Goldsman, 2001). Nash is a math professor, brilliant with numerical and visuospatial patterns, who seems to lack almost completely the capacity to relate to people in any way. He cannot empathize with his students when they have difficulty learning the material, nor can he discern what presentation style might help students to learn more easily or enjoy the material more. He seems to lack the desire to connect or explain. For example, in one scene, a student approaches Nash in his office with a question. He essentially dismisses her and returns to his work. After a few moments of working—a sufficient length of time to be uncomfortable—he looks up and simply observes, "You're still here." His awkward, self-absorbed style is striking, though it does not seem to bother him. Where a more narcissistic professor might disdain students for their "stupidity," the schizoid individual bears no such malice. To him, the needs of the students are merely an enigma—an enigma he may or may not be motivated to solve. Perhaps some of us have had teachers or professors who were similar—writing on the board, with their back to the class, absorbed in the material, and essentially oblivious to the people around them.
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Notably, even this prototype portrays the more sociable end of the spectrum. The choice to become a professor entails willingness to interact with others; more severely schizoid individuals, if employed, are often late-night security guards or night-shift doormen, back-room mail sorters, and employees at other jobs that entail almost no human interaction. The prototypical person with schizoid personality disorder (PD) has little desire for interpersonal contact, even with family members. Such an individual also has an impoverished cognitive style; that is, his or her understanding, especially of people, lacks richness and vitality. He or she is unable to process the numerous factors that impact people and views his or her own life in similarly simplistic terms. Impoverished cognitive style does not correlate with intelligence; a person with schizoid PD, can, like Nash, have superior abstract reasoning, visuospatial, and verbal abilities. Nonetheless, his or her inner emotional and relational world is simplistic and poorly developed. As noted above, people with schizoid PD are noted for their blandness, flatness, and the lack of desire to connect with others. According to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision [DSM-IV-TR]; American Psychiatric Association, ZOOOa), "The essential feature of Schizoid Personality Disorder is a pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings" (p. 694). Considered part of the "schizophrenic spectrum" (Siever, 1992), schizoid PD overlaps with the "negative" symptoms of schizophrenia: flat affect, lack of motivation, and social withdrawal. Like individuals with schizophrenia, individuals with schizoid PD may underachieve in social, occupational, or academic arenas. EPIDEMIOLOGY Schizoid PD is a relatively rare disorder. Community studies indicate a low prevalence of schizoid PD. A review of nine epidemiological studies indicates a median prevalence estimate of 0.6% for schizoid PD (Mattia & Zimmerman, 2001). However, the disorder is approximately 9 times as common in treatment settings. A review of eight studies suggests a prevalence rate of approximately 5% in treatment settings, with the prevalence apparently a bit higher in inpatient than outpatient settings (Widiger & Rogers, 1989). DSM-IV-TR described schizoid PD as "uncommon" in treatment settings. This low prevalence has led to a relative paucity of research. As noted by Beck and Freeman (1990), "While there have been extensive theoretical musings about the nature of the schizoid individual, little clinical research has been done on this group. . . . This is not surprising, given the reluctance of schizoid individuals to seek treatment" (p. 122). Unfortunately, little has changed in the intervening 15 years. Thus, the base of clinical lore and inter64
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vention research is not very deep, and some areas require speculation to elucidate promising, if untested, treatment avenues. In samples of individuals with depression, approximately 0% to 3% have schizoid PD. Of the 116 individuals with major depression in a study by Zimmerman and Coryell (1989), none had schizoid PD, though it is worth noting that there were few individuals with schizoid PD in the entire sample (n = 7). In Pepper et al.'s (1995) dysthymic disorder sample, 2% had schizoid PD. In Fava et al.'s (1995) sample of depressed clients, approximately 3% had schizoid PD. In a sample of 249 depressed outpatients, none were diagnosed with "definite," and 2% with "probable," schizoid PD (Shea, Glass, Pilkonis, Watkins, & Docherty, 1987). Markowitz, Moran, Kocsis, and Frances (1992) studied a sample of 34 outpatients with dysthymic disorder; none had schizoid PD. Finally, in a sample of 352 clients with both anxiety and depression, approximately 3% had schizoid PD, as diagnosed by structured interview (Flick, Roy-Byrne, Cowley, Shores, & Dunner, 1993). Minimal data are available on the prevalence of depression in individuals with schizoid PD. Zimmerman and Coryell's (1989) study, mentioned above, included a community sample totaling 797 individuals, of whom 143 were diagnosed with PDs. Among the 7 diagnosed with schizoid PD, none met the criteria for major depression.
HOW DO PEOPLE WITH SCHIZOID PERSONALITY DISORDER GET DEPRESSED? Persons with schizoid PD may become depressed when their lifestyle is too remote and detached. They may have a desire for some degree of contact, to fit in meaningfully with others in some way. The sense that life is empty, with no real purpose, is depressing to anyone (Frankl, 1959); the person with schizoid PD, with his or her barren internal world, is prone to such thoughts. In the words of A. T. Beck and Freeman (1990), although usually comfortable with a detached lifestyle, these individuals may become depressed over their awareness that they are deviants who do not fit into society. . . . They may tire of being "on the outside, looking in." Further, their belief that life is meaningless and barren can lead to or exacerbate depression, (p. 129) At times, individuals with schizoid PD may also experience depersonalization, in which they can barely experience their bodies and feel like they are just "going through the motions." Such experiences may be depressing for the individual as well. Thus, schizoid PD likely creates a vulnerability to experiencing depression. As with other PD patterns, people with schizoid PD engage in coping strategies that tend to perpetuate, or even deepen, their original personality SCHIZOID PERSONALITY DISORDER
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psychopathology. For example, their proclivity to withdraw and remain detached reduces opportunities to learn new interpersonal strategies, thus decreasing the odds that the next relationship will be meaningful and fulfilling. In addition to simple lack of contact, their cognitive impoverishment regarding emotions leads to misinterpretation and oversimplification of others' emotional lives and further reduces the odds that they will have rewarding interpersonal interactions (Millon, 1996). Over time, these strategies and proclivities may lead to a deepening of the schizoid pattern, in some cases to levels that are intolerable even to the person with the disorder. Consistent with the "exacerbation" model (see chap. 2) the patterns associated with schizoid PD and depression "feed" one another, increasing the intensity of both. Schizoid PD and depression overlap in some of their symptoms. The flat, bland presentation of the person with schizoid PD parallels anhedonia in major depression. Lethargic and insipid, such individuals already near the level of psychomotor retardation and fatigue evidenced in depression. Thus there are three symptoms (anhedonia, psychomotor retardation, and fatigue) that are shared to some degree by the two disorders. Dysthymic disorder (which has similar symptoms to major depression but at a lower level of severity and higher level of chronicity) resembles schizoid PD even more closely. It could be that some features of depression and schizoid PD share a common cause, such as brain functioning associated with lethargy and anhedonia. However, in general, people with schizoid PD are not particularly prone to either anxiety or depression. Aloof, but unconcerned about it, the typical person with schizoid PD does not seek therapy. Thus, our focus on the depressed person with schizoid PD represents a unique, and more treatable, subset.
HOW A PERSON BECOMES AND REMAINS SCHIZOID: THEORIES OF SCHIZOID PERSONALITY DISORDER Biological Factors Millon (1981) asserted that schizoid PD, like all personality disorders, has biological underpinnings. He hypothesized that individuals with schizoid PD may have a lack of neural density in the areas related to emotionality, such as portions of the limbic system. He further speculated that there may be problems in the reticular activating system, which is related to the anergia and chronic underarousal of the person with schizoid PD. These neural deficits can be a function of genetics, environmental-biological factors (e.g., anoxia during the birthing process), or environmental-psychosocial factors (e.g., an understimulating social environment). Millon (1996) noted,
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What appears most distinctive about these individuals is that they seem to lack the equipment for experiencing the finer shades and subtleties of emotional life . .. Some interpret their interpersonal passivity as a sign of hostility and rejection; it does not represent, however, an active disinterest but rather a fundamental incapacity to sense the moods that are experienced by others, (p. 218)
The above quote implies the neurological deficits previously described. Millon (1981) conjectured further about how biological and psychosocial factors may interact to deepen the biological problem: Another frankly speculative hypothesis is that a substantial number of adult schizoid personalities displayed low sensory responsivity, motor passivity, and a generally placid mood in infancy and early childhood. They may have been easy to handle and care for, but it is likely that they provided their parents with few of the blissful and exuberant responses experienced with more vibrant and expressive youngsters. As a consequence of their undemanding and unresponsive nature, they are likely to have evoked few reciprocal responses of overt affection and stimulation from their caretakers. This reciprocal deficit in sheer physical handling and warmth may have compounded the child's initial tendencies toward inactivity, emotional flatness, and general insipidity, (p. 292)
This process may be further compounded if, assuming the schizoid tendency was inherited from one or both parents, the spontaneous and persistent expression of warmth from the parents may have been lacking in any case. Research suggests individuals with schizoid PD are more likely than comparison groups to have a history of neglect (Lieberz, 1989). Genetic Factors
Genetic studies in the phenomenologically similar autistic spectrum disorders may bear fruit for understanding schizoid PD. Asperger's disorder, the core feature of which is "severe and sustained impairments in social interactions" (American Psychiatric Association, ZOOOa, p. 80), seems especially closely tied to schizoid PD. There is strong support for a genetic basis of autistic spectrum disorders using twin studies (Bailey et al, 1995; Steffenburg et al., 1989), and research is ongoing to discover specific genetic markers (Auranen et al., 2002; Buxbaum et al., 2001; Liu et al., 2001). There is also evidence of an increased rate of schizoid PD in the parents of people with autism (Narayan, Moyes, & Wolff, 1990). Schizoid PD is heritable, apparently at similar levels to other personality disorders. Like an array of thoroughly studied normal personality traits (Loehlin, 1989), PDs typically have a heritability estimate of .40 to .60. Coolidge, Thede, and Jang (2001), in an investigation of personality disorders in 112 twin pairs ages 4 to 15, found that h2 for schizoid PD was .73; the range for all personality disorders was .50 to .81. A study by Torgersen,
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Onstad, and Skre (1993) found a heritability for schizoid PD of .29. Genetic factors accounted for approximately 50% of the variance in dimensional measures such as social avoidance (Livesley, Jang, Jackson, & Vernon, 1993), restricted expression, and inhibition and for 38% of the variance in affect constriction (for a review, see Jang & Vernon, 2001). Similarly, Eysenck's extraversion construct (of which schizoid PD would represent the extreme low end) is moderately heritable (Nigg & Goldsmith, 1994). Genetic studies have generally supported the notion that schizoid PD is part of the "schizophrenia spectrum" (Siever, 1992). However, although studies of schizotypal PD have consistently linked the disorder to schizophrenia, studies examining the genetic connection between schizoid PD and schizophrenia have been somewhat inconsistent (for a review, see Nigg & Goldsmith, 1994). It is likely that schizoid PD is related to schizophrenia but not as strongly as schizotypal PD; this conceptualization is consistent with Meehl's (1990) contention that cognitive slippage is the central component of schizotypy. Medications Despite a significant effort, I could locate no specific studies on medications for schizoid PD. A study by Ekselius and von Knorring (1998; see chap. 1 for a review) found that the antidepressants sertraline and citalopram, both selective serotonin reuptake inhibitors, led to an increase in the diagnosis of schizoid PD, although there was no increase in the number of criteria met on a structured interview. I cannot explain this odd finding. The number of schizoid patients was so small (1 pre- and 6 postintervention) that one should be cautious in interpreting the results. There are some underlying dimensions or symptoms that may be amenable to psychopharmacological interventions. In the absence of further data, it is worth considering Joseph's (1997) speculations based on his clinical experience. He argued that schizoid PD is reminiscent of the negative symptoms of schizophrenia. Newer, atypical antipsychotics have the best efficacy with deficit syndromes; thus clozapine, olanzapine, sertindole, and risperidone would be the most likely to benefit people with schizoid PD. These medications may help the patient to become more sociable and emotional. Joseph conceptualized the anhedonic and low-libido features of schizoid PD as having biological underpinnings similar to those of the same symptoms in a person with depression; he recommended an energizing medication such as bupropion. As in cases of Axis I social anxiety, individuals with schizoid PD who experience anxiety in social situations may benefit from selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, or anxiolytics. Although Joseph's speculations were reasonable, they are not currently backed by scientific research. There is no substitute for appropriate empirical studies, ultimately leading to randomized clinical trials.
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Psychological Factors When considering the person's psychological functioning, important areas to consider include his or her learning history; thoughts, feelings, unconscious motivations; and relationships. The schools of thought described below (e.g., cognitive-behavioral, humanistic, psychodynamic, interpersonal, and family systems) emphasize different aspects of the person's functioning and will be described in turn. Millon's Theory According to Millon (1969/1985, 1981, 1996, 1999), individuals with schizoid PD represent the "passive-detached" type. They are thought to have a generally bland, passive nature, perhaps because of impoverished neurological substrates associated with emotion. These neural deficits in adulthood may have been caused by genetics or shaped by experience. The early experiences of people with schizoid PD are likely to be characterized as dull and colorless, although extreme withdrawal by caretakers could account for development of schizoid PD in a person who lacks a strong predisposition to the disorder. Severe difficulties in relating, such as reactive attachment disorder, that are frequently seen in children raised in neglectful or abusive orphanages exemplify the potentially profound impact of extreme environmental conditions (Hall & Geher, 2003; Wilson, 2001). At a less intense level, a temperamentally placid child, exposed to minimal "stimulus nutriment" (i.e., environmental stimulation; Millon, 1981), is at risk for developing schizoid PD. Excessively formal relationships with one's parents can have a similar effect. Deutsch (1942), describing the "as if" personality, gave the example of a child born to royalty. Raised by a variety of nannies, he had only brief and occasional contact with his parents. At that time, he was required to profess his love for them, whereupon he was dismissed. It is not surprising that this child manifested disturbed interpersonal relationships (Deutsch, 1942, cited in Millon, 1981, p. 294). The description of the person with schizoid PD in terms of Millon's domains is presented in Appendix B. Of the characteristics listed, "unengaged interpersonal conduct" and "apathetic mood/temperament" are the most salient features. Cognitive-Behavioral Conceptualization and Interventions Cognitive-behavioral therapists emphasize dysfunctional thought and behavior patterns that underlie disorders. Dysfunctional attitudes that are common to people who are categorized as having schizoid PD are listed in Exhibit 4.1. Such thoughts contribute to the individual continuing to live in a withdrawn, isolated manner. The clinician can explore for these and simi-
SCH/ZOJD PERSONALITY DISORDER
EXHIBIT 4.1
Attitudes and Assumptions Typical of a Person With Schizoid Personality Disorder * People are replaceable objects. Relationships are problematic. Life is less complicated without other people. Human relationships are just not worth the bother. It is better for me to keep my distance and maintain a low profile. * I am empty inside. * I am a social misfit. * Life is bland and unfulfilling. * Nothing is ever exciting. Note. Asterisks indicate items that suggest depression as well. From Cognitive Therapy of Personality Disorders (p. 128), by A. T. Beck and A. Freeman, 1990, New York: Guilford Press. Copyright 1990 by Guilford Press. Reprinted by permission.
lar thoughts and attitudes and then challenge them using Socratic dialogue (J. S. Beck, 1995) or disputation (Dryden & DiGiuseppe, 1990; Ellis, 1995). Dysfunctional thought records have been found to be helpful for people with schizoid PD (A. T. Beck & Freeman, 1990; A. T. Beck, Freeman, & Davis, 2004) and in depression (J. S. Beck, 1995). Not only do dysfunctional thought records challenge dysfunctional thoughts, but they also teach gradations in thinking, helping clients to overcome all-or-none thinking. Individuals with schizoid PD may believe they must always be alone, or that they never care about what happens. Dysfunctional thought records help to challenge those beliefs, often leading to awareness that such individuals do sometimes prefer to be with others or that they do sometimes care. Individuals with schizoid PD, almost by definition, lack social skills. Assuming they are depressed because they are too isolated, even given their rather minimal needs, then skill building may be extremely helpful. Liberman, DeRisi, and Mueser (1989) provided excellent guidelines, designed primarily for individuals with serious and persistent mental illness (e.g., schizophrenia and mental retardation) but adaptable to the person with schizoid PD. Excellent guidelines for couples are available in A Couple's Guide to Communication by Gottman, Notarius, Gonso, and Markman (1976); because the book is written in lay language, it can be assigned to the couple as bibliotherapy. Social skills can be taught using role-playing, in vivo exposure, and homework. Group social skills training has the obvious advantage of allowing practice with other clients rather than only the therapist. The client can also be assisted to attend to positive emotions. Individuals with either depression or schizoid PD will have a tendency to attend to negative thought patterns; an individual with both disorders will experience this even more. Homework assignments such as journaling at least one positive thought per week (at first) then per day (later on) will help the person to challenge automatic thoughts such as "life is bland and unfulfilling."
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Assertiveness training (Alberti &Emmons, 1978; M. Smith, 1975) can help depressed persons with schizoid PD to overcome their passivity and perhaps get some more of their needs met. A unique challenge with persons with schizoid PD is their perception that they have almost no needs. Selfawareness work would be useful, perhaps even essential in this regard. Meditation training (Kabat-Zinn, 1990, 1994; LeShan, 1974; Murphy & Donovan, 1997) and focusing training (Gendlin, 1978) are methods by which the individual can be taught to focus on feelings, perhaps gaining more richness to his or her rather impoverished internal environment. As discussed in chapter 2, exercise is a natural antidepressant. Naturally sluggish, depressed individuals with schizoid PD would benefit greatly from the energizing aspects of exercise, though for exactly that reason they may be unusually resistant. As always, motivation is the key. Patience on the part of the therapist is also critical; the suggestion should be well timed. One effective way to introduce the topic is to bring it up in a brainstorming session if the client asks, "What can I do about my depression?" If that does not occur, then at some point asking if the client is aware of how helpful exercise can be in reducing depression would help the exercise "precontemplator" to become a "contemplator." Sex therapy can also be useful for individuals with depression and schizoid PD. Most individuals with schizoid PD have weak sex drives, and in major depression sex can become not only uninteresting but even aversive (A. T. Beck, 1983). At such times, it is best to treat the depression and wait a bit before encouraging sexual behavior. When a clinician fails to assess the impact of depression on sexual feelings and behavior, it can have a negative impact on the therapeutic relationship, as illustrated by author William Styron (1992) in his book Darkness Visible. Styron, in the midst of a severe depression, was nearly suicidal, thoroughly anhedonic, and had great difficulties sleeping. His psychiatrist, pseudonymously referred to as "Dr. Gold," was switching medications to Nardil, after an unsuccessful trial of two other medications: Further, Dr. Gold said with a straight face, the pill at optimum dosage could have the side effect of impotence. Until that moment, although I'd had some trouble with his personality, I had not thought him totally lacking in perspicacity; now I was not at all sure. Putting myself in Dr. Gold's shoes, I wondered if he seriously thought that this juiceless and ravaged semi-invalid with the shuffle and the ancient wheeze woke up each morning from his Halcion sleep eager for carnal fun. (p. 60)
Of course, the psychiatrist was merely being ethical by informing the patient of potential side effects; nonetheless, Styron experienced the intervention as unempathic because, apparently, the physician had not sufficiently contextualized the discussion in light of the patient's ongoing experience. Keeping that cautionary tale in mind, sex therapy can be extremely useful in
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many cases in which the mildly to moderately depressed person with schizoid PD is in a relationship. Although not as interested in sex as others, individuals with schizoid PD often "don't mind" having sex, and those whose schizoid symptoms are sufficiently mild for them to be in a relationship are typically also sufficiently interested in the other person to go to at least some lengths to try to please him or her. Sex therapy can help enhance pleasure as well as sensitivity to the other person's needs—two areas in which the person with schizoid PD is likely to have problems. Several fine books are available for adjunctive bibliotherapy with sex therapy (e.g., Sexual Awareness [McCarthy & McCarthy, 1984] or The Gift of Sex [Penner & Penner, 1981]). Client-Centered, Humanistic, and Existential Therapies Client-centered, humanistic, and existential therapists eschew a diagnostic or labeling'based approach, and thus there is little, if any, clientcentered or humanistic literature specific to schizoid PD. Rather, in these approaches, the therapist would look at the ideographic aspects of the case. Nonetheless, a prototypical person with schizoid PD, coming from a background of relative neglect and often with stunted or excessively formal relationships with important others such as parents, represents almost a sine qua non of the thwarted actualizing tendency (Rogers, 1979). The clientcentered therapist would focus on creating the conditions for growth, a nonjudgmental space in which the client could explore his or her feelings, and on reengaging the actualizing tendency. If the client wished to, past relationships could be explored, which would then yield information about the conditions of worth to which the child was exposed. Client-centered therapy is somewhat passive by nature; the initiative must come from the client. Some individuals with severe schizoid PD have such problems with initiative that a modification of the therapy developed by Prouty (1994) would be helpful. Prouty labeled his approach "pretherapy" to indicate a process that would prepare a client for traditional therapy. However, his case studies suggest that the process has therapeutic effects (sometimes dramatic ones) in its own right. It was developed for individuals with severe communication problems, such as autism or severe mental retardation, and psychoses. Pretherapy uses concrete empathy, in which the therapist mirrors exact words and bodily movements to establish contact. The therapist can also simply make observations, which may help the depressed and severely schizoid client. For example, the therapist might observe, "You are sitting with your hands in your lap," or "You are remaining quiet," or "You are looking into my eyes." Such interventions can establish contact with a client with whom it is difficult to connect. Other, more dramatic techniques may be useful for the person with depression and schizoid PD. Gestalt therapy—for example, the empty chair technique—can be used to uncover any feelings regarding difficult relationships or feelings of neglect from childhood. Care should be taken not to over72
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whelm the client; unaccustomed to emotional arousal, the person could experience substantial anxiety. A solid therapeutic relationship should be established before using experiential techniques, which would thereby allow the therapist to provide support if the emotions do become overwhelming. Self-awareness techniques may be a direct and substantial form of healing for the emotional deficits of the person with schizoid PD. Mindfulness meditation (Kabat-Zinn, 1990) has been shown to be a powerful intervention to decrease depression (Kabat-Zinn et al., 1992), and participants have reported substantial improvements in their bodily and emotional selfawareness (e.g., Broadwell, 1998; Kabat-Zinn, 1990). Focusing (Gendlin, 1978) similarly induces increased body awareness, as well as self-awareness with regard to thoughts and feelings. For the depressed person with schizoid PD, these improvements can be invaluable. For clients who lack a sense of purpose, existential therapy (May, 1983b) or logotherapy (Frankl, 1983) can help in exploring the meaning of life. Based more on an attitude or philosophy than on a set of techniques, existential approaches consider the fundamental anxiety that one confronts to be existential anxiety—the awareness that our existence is finite and that there is always a threat of nonbeing or nonexistence. Frankl (1983) suggested that the client who presents with a sense of or fear of life being meaningless should be commended on having the insight and courage to confront that issue and told that many go through life "going through the motions," without ever contemplating life's meaning. The question, "What is the meaning of life?" is unanswerable; Frankl (1959) observed that it is like trying to answer the question, "What is the best color?" The answer, of course, is that it depends on the context and the person; each person must find his or her own meaning in existence. Other questions that help get at meaning in the client's life include Linehan's intervention, designed for suicidal borderline clients but broadly applicable in its underlying message. In the video Treating Borderline Personality Disorder (Linehan, 1995), a client stated that she was suicidal. Linehan replied, irreverently, "So, why don't you kill yourself right now?" For the existentialist, that is, in fact, the exact question. If life has no meaning, then why live? With the possible exception of, "Because I'm afraid it will hurt," virtually any answer addresses the meaning the client finds in life. If the client replies that it would be too painful for a relative or friend to bear, then she is living for love. If the client replies that she believes that therapy is worth a try and things may get better (as the client actually does in the video) then she is living for hope. And if she replies that she wants to live because there is one more thing she has to do, then she is living for commitment. Ultimately, commitment to something that one believes is more important— higher, if you will—than oneself is where many people find meaning. Bibliotherapy can stimulate clients in the search for meaning. Books such as Don't Sweat the Small Stuff (Carlson, 1997), The Mirack of MindfulSCHIZOID PERSONALITY DISORDER
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ness (Nhat Hanh, 1976), and Wherever You Go, There You Are (Kabat-Zinn, 1994) all are useful jumping-off points to encourage clients to look at life a bit differently. Simply assigning a client to read at least a few pages and then asking if there was anything that he or she found meaningful can lead toward the client's central concerns and hopes. Psychodynamic Therapy
In discussing schizoid PD, psychoanalytically oriented writers generally have emphasized anxiety rather than depression as more central to the disorder. Klein (1946/1996) believed splitting was the essential characteristic of the schizoid condition. In her view, in normal development the child experiences persecutory ideation, which is the projection of the child's innate aggression onto the mother or, more specifically, onto the part of the mother with which the infant has direct contact (the "bad breast"). Splitting, which Klein defined as the separation of conflicting self and object representations, is a defense against the anxiety generated by the persecutory ideation. The schizoid individual failed to resolve these conflicts and therefore remained with a narcissistic orientation, including the need to control others and the tendency to either cling to or withdraw from them. Thus the apparent absence of anxiety in the schizoid individual was an illusion; rather, as Klein (1946/1996) hypothesized, the anxiety is kept latent by the particular method of dispersal. The feeling of being disintegrated, of being unable to experience emotions, of losing one's objects, is in fact the equivalent of anxiety. This becomes clearer when advances in synthesis have been made. The great relief which a patient then experiences derives from a feeling that his inner and outer worlds have not only come more together but back to life again. At such moments it appears in retrospect that when emotions were lacking, relations were vague and uncertain and parts of the personality were felt to be lost, everything seemed to be dead. All this is the equivalent of anxiety of a very serious nature, (p. 21)
Fairbaim (1952) emphasized the early-childhood maternal relationship in the development of schizoid PD. He noted the following: (i) that in early life they gained the conviction, whether through apparent indifference or through apparent possessiveness on the part of their mother, that their mother did not really love and value them as persons in their own right; (ii) that, influenced by a resultant sense of deprivation and inferiority, they remained profoundly fixated upon their mother; (iii) that the libidinal attitude accompanying this fixation was not only characterized by extreme dependence, but also rendered highly self preservative and narcissistic by anxiety over a situation which presented itself as involving a threat to the ego; (iv) that through a regression to the attitude of the early oral phase, not only did the libidinal cathexis of an already internalized "breast-mother" become internalized, but also the 74
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process of internalization itself became unduly extended to relationship with other objects; and (v) that these resulted in general overvaluation of the internal at the expense of the external world, (quoted in Akhtar, 1987, p. 503)
As a result of these processes, these individuals take rather than give in their emotional lives. Further, emotional contacts exhaust them because they defend against their difficulties in giving by playing roles. Love itself is viewed as dangerous, a consequence of the early experiences noted above, and thus they defend against loving both themselves and others. Fairbairn (1952) further noted that those with schizoid personalities are drawn to the arts as a way of having indirect contact with others and showing the self but at a safe distance. O. F. Kernberg and colleagues (Clarkin, Yeomans, & Kernberg, 1999; O. F. Kernberg, 1967; O. F. Kernberg, Selzer, Koenigsberg, Carr, & Appelbaum, 1989; Yeomans, Clarkin, & Kernberg, 2002) included schizoid PD in a conceptualization of borderline personality organization. Like Klein and Fairbairn, Kernberg viewed splitting as the fundamental defense mechanism of the schizoid character type. Poor ego development leads to a chronic sense of unreality, which, combined with dispersal of affect, leaves the schizoid individual feeling chronically empty. Kernberg (1970) considered the schizoid personality to be a "low" level of personality organization, indicating that it is next to the psychotic range of functioning. Kernberg's "transference-focused psychotherapy" (Yeomans et al, 2002) uses the traditional analytic techniques of clarification, confrontation, interpretation, and technical neutrality. The sine qua non of his treatment, however, is analysis of the transference in the here and now. Although in his writings he generally emphasized confrontation over nurturing support, Kernberg artfully combined his confrontations with accurate and emotionally attuned statements. The following case appears, at least in this fragment, to involve a mixture of schizoid and dependent features—a person with "pure" schizoid PD as defined in DSM-IV-TR would not particularly expect or want the therapist to care. Nonetheless, the patient's startling self-absorption and lack of empathy and relationship skills are consistent with schizoid pathology. Therapist: Patient: Therapist: Patient:
Therapist:
I notice that you're making some marks on your pad whenever I speak. Yes, I'm counting how many times you talk. Why do you do that? It helps me know if you care about me. I count up the number of times you speak, and when I go home I compare that number to the last session. That's how I tell how much you're giving me. Does it matter what I say? SCHIZOID PERSONALITY DISORDER
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Patient:
Not so much. What really counts is how many times you tell me why you think I'm doing what I'm doing. Then I know you're really listening to me and concerned about me.
Therapist:
So it's very important that I care about you, and you've devised a scheme to answer that question for yourself. Can you see you're also treating what I'm saying as if it were worthless? (O. F. Kernberg et al, 1989, p. 115)
This fragment is an illustration of several key aspects of Kernberg's approach. Kernberg used both clarification and confrontation regarding the relationship between the therapist and the client (i.e., the transference) to push the client to integrate the split self and object relations implied in the interaction. Persons who have both depression and schizoid PD would presumably be those who have experienced and processed the object loss, at least partially, rather than splitting any negative emotions off completely. Depression generally entails the necessity of whole object relations. To the extent that they use neurotic defenses rather than splitting, they are more in touch with reality. Thus, although they experience more psychic pain, depressed persons with schizoid PD are likely functioning at a somewhat higher level. This conceptualization is consistent with clinical experience—individuals with schizoid PD and depression are more likely to profit from therapy than "pure," emotionally absent, prototypically schizoid individuals. In sum, the psychodynamic approach emphasizes that the superficial symptoms of schizoid PD are not to be trusted—that in fact the person's blandness is a defense against deeper anxieties. These anxieties are rooted in early trauma, particularly in relation to the mother, who is seen as withdrawing and abandoning. If one can, through appropriate analysis, resolve the inner conflicts and underlying anxieties, then the person will experience tremendous relief. The recommended treatment involves traditional psychodynamic techniques, such as technical neutrality, confrontation, and analysis of the transference. Depression, from a psychodynamic perspective, is likely to be rooted in object loss; in the case of the person with schizoid PD, a common scenario would be the withdrawal of the mother, whether because of her own problems with intimacy, physical illness, or mental disorder. Once the depression and the schizoid withdrawal are properly analyzed, the client will then become more mature, flexible, and related. It is apparent, however, that theorists from a psychodynamic perspective are talking about a somewhat different patient population. Akhtar (1987), in his review, noted the similarity of the psychodynamic interpretation of the schizoid personality and avoidant personality disorder. It could be that case studies of "schizoid" individuals reflect aspects not only of schizoid but also of avoidant and paranoid disorders. From Millon's perspective, it is certainly the case that the analysts are using the term schizoid in a different 76
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manner than he is. Millon (1996) noted that essentially, there is not much to analyze within the prototypical schizoid PD and focused on other techniques. That observation notwithstanding, it is also true that most people with PDs are better described as having admixtures of two or more personality disorders: schizoid-dependent, schizoid-avoidant, or schizoid-obsessivecompulsive. Although the person with "pure" schizoid PD may be unanalyzable, many of the schizoid subtypes would be analyzable. Thus the clinician must be careful about generalizing across different conceptualizations. Family Systems In this section, I conceptualize the situation in which the depressed person with schizoid PD is an adult and is either coming in for marital therapy with a spouse or for family therapy with his or her parents. The latter case occurs with some regularity for clients with other severe mental illnesses such as schizophrenia. The subsequent section, on children, includes family interventions in which the schizoid client is a child. There are several ways of viewing families in relation to schizoid PD: (a) The family behaviors or dynamics contributed significantly to causing the disorder, (b) the family is a victim of a primarily biological disorder and is coping with it as best they can, and (c) biology and family dynamics combined to produce the disorder (an interactionist perspective). Although the interactionist perspective is compelling, it is useful to note that all three models are partially correct and that each model will be the best explanation in a certain percentage of the cases. It is most likely that the family will view the second model—that "this is just the way he is and the way he always has been"—as the most accurate and useful. To the extent that the therapist uses one of the other two models, there is a risk of incongruence with the family, which could lead to premature termination or other problems. In cases in which there are clear biological signs, such as vegetative signs of depression and a strong history of schizoid behavior from early in life, emphasizing biological aspects of both disorders is likely to facilitate an appropriate and rapid bonding process with the therapist. In such cases, it is likely that the ultimate adjustment of the family will involve letting go of fantasies that the person with schizoid PD can be—or already is—in the average range of emotional sensitivity. The son who is disappointed with his depressed and schizoid father will feel better if he can accept his father's limitations. As mentioned previously, many clients are aware that biological factors contribute strongly to depression and will thus be comfortable with such a conceptualization. Few, however, are familiar with the concept of PDs, much less a biological component for a specific one. The risk of emphasizing biological considerations is locking the identified patient into the role of the "pathological one"; this can and should be undone by emphasizing the individual's strengths and relating to the family in a
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manner in which each individual's competencies—including those of the identified patient—are allowed to shine. The decision as to whether to share the diagnosis that the person has schizoid PD should be made on a case-by-case basis. Some basic psychoeducation, such as noting, "We now know scientifically that people are born with a wide range of abilities in sensing other people's emotions, getting emotionally involved, or getting excited about things," will suffice in many cases. In other cases, the label will provide a rallying point around which the family can get information, help, or support. If the label will disempower a family member—for example, if the person with schizoid PD is one of the parents—then it may be better to avoid using it. This stands in contrast to my approach to borderline PD, in which I virtually always share the diagnosis with the client. There is a great deal of information available on borderline PD, including several books that are written in lay language, numerous Web sites, and a national support organization. None of these are available for schizoid PD, so sharing the label does not have the same builtin practical advantages. In cases in which parents are bringing in their child with schizoid PD, sharing the diagnostic label, along with its similarity to autistic spectrum disorders, may allow the parents to tap into a crucially important social support network. A number of different patterns may emerge in a family system with parents and children in which the identified patient (the person with schizoid PD and depression) is one of the parents. From a structural perspective (Minuchin, 1974), the family is most likely to be disengaged. Boundaries are likely to be rigid between the identified patient and everyone else in the family. If the spouse has a similar character structure, then the entire family may be distant and disengaged. Marriages in which one partner has schizoid PD and depression may be dominated by feelings of being "together, but alone" (Moultrup, 1985). However, assuming the other spouse has a complementary personality, such as a more engaging temperament or dependent qualities, cross-generational boundaries may become blurred as the emotional needs of the parent are satisfied through the children. Thus, for example, the presence of a schizoid and depressed mother would encourage the oldest daughter to become parentified and provide caretaking for the other children; role reversal may also occur, in which the oldest daughter takes care of the father. If one or more of the children feel neglected, then there could be a variety of acting-out behaviors, potentially serving several functions within the family. The acting-out behavior may express rage over feelings of being neglected or may inject some purpose into the parents' lifeless marriage, thus keeping the family together. Paradoxical techniques are very powerful and should be used judiciously, but they can be effective in cases in which one spouse has schizoid PD and depression. "Prescribing the symptom" (Haley, 1963; L'Abate, Ganahl, & Hansen, 1986; Palazzoli, 1988) has been defined as telling the 78
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family to continue doing what it is already doing. If the family complies with the therapist, then they have taken a step toward collaborative work. On the other hand, if they change, then, by definition, they become unstuck. In most cases, the intervention is low risk; they are not likely to get worse from being instructed to continue their current behavior, and they may improve. The positive connotation technique, a particular form of symptom prescription, can be helpful in breaking through feelings of "stuckness" in a family (Palazzoli, 1988). Although using what is labeled a paradoxical technique, in fact the therapist is describing in an extremely straightforward fashion the function he or she believes the symptoms are playing in the family. The intervention stresses the role of each individual in the family in maintaining the family system. Thus, for example, consider a family in which there are a husband, wife, and two teenage children and in which the father has depression and schizoid PD. Consider the prototypical situation in which the wife is feeling overburdened and one or more of the children are beginning to act out, for example by breaking curfew. The therapist conceptualizes the problem as one in which there is isolation and distancing on the part of the father but poor differentiation of each member of the family, leading to painful maneuvering to attempt to establish acceptable levels of closeness with one another. The therapist might assign homework as follows: Dad, you should continue to complain about feeling depressed and continue to lie around the house as you have been doing for the past 3 weeks. This gives Mom an opportunity to feel strong and helpful and gives the children an opportunity to become more independent. This rather dramatic highlighting of the functions served by the symptoms encourages the family to consider other, less painful ways of getting their needs met. It sidesteps certain aspects of resistance because the therapist is not pushing for change. If the family "resists" and changes anyway, so much the better. If they stay the same, then they have done so at the request of the therapist and may be willing to try other experiments to resolve their problems; further, the reconceptualization of their problem, focusing on positive aspects of the symptoms, generally sparks fresh ideas for the kinds of changes to which they would be open. Family sculpture techniques (L'Abate et al., 1986; Satir, 1983) are also powerful and may be particularly helpful to the person with schizoid PD who has strong spatial abilities and spatial reasoning. Family sculpting has been defined as a method in which family members are asked to arrange one another as a living statue or tableau. Drawing upon their creative instincts, and using such nonverbal dimensions as distance, posture, visage, and gesture, the family members give concrete representation to their impressions of the family. (L'Abate et al., 1986, p. 166) SCHIZOID PERSONALITY DISORDER
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The sculpture may also be put in motion, which in many cases adds important information: Another choice at this point can be to have the sculptor put the whole sculpting in motion before verbally processing what has been sculpted. . . . With static sculpting one gets a sense of family boundaries and alliances but not the rules for traffic flow. With dynamic, or moving, sculptures one can see traffic flow and also have the chance to see action sequences repeated in time, producing a more dynamic representation of family stuckness and rigidity and family rules. (L'Abate et al., 1986, p. 180)
Reliving moments or sequences from the past or spatially representing relationship issues can be most enlightening to the client and may produce powerful insights. If even such a high-impact technique as family sculpture produces relatively little emotional impact on the person with schizoid PD, it may allow the client a clearer understanding of how his or her partner feels and thus lead to more appropriate or attentive behavior. Some people with Asperger's disorder describe a process of attending to another, consciously modeling their behaviors in order to be more accepted and acceptable (Willey, 1999). The passivity and lack of strong feelings of persons with schizoid PD can be an asset in this regard; being generally passive, they may not mind doing certain things differently, because it is "all the same" to them.
COUNTERTRANSFERENCE The literature on countertransference responses to individuals with schizoid PD is extremely limited. Giovacchini (1979) noted feelings of "existential terror," or a primitive fear of nonexistence that often led to feelings of hopelessness, with his schizoid patients (similar to modern schizoid and schizotypal PDs). Robbins (1998), referring to the "autistic position," discussed countertransference responses such as a feeling of vagueness and disconnection in response to the client's devastating isolation. Sadness, perhaps related to pity, also becomes prominent. Rosowsky and Dougherty (1998) noted how substantial feelings of disconnection, worry, and inadequacy occurred among individuals treating a man with schizoid and schizotypal traits who frequently fled his inpatient medical hospitalizations. A. T. Beck et al. (2004) noted that therapists may have a difficult time when clients have substantially different values from theirs. For example, the person with schizoid PD may have little interest in relationships; those of us who have chosen clinical psychology as a profession are likely to put relationships at a premium. A. T. Beck et al. recommended that therapists challenge their belief that their own way of looking at the world is the only valid one and to try to imagine the world from the client's perspective. 80
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In accordance with the observations above, research on graduate students suggests that they initially respond to individuals with schizoid PD with feelings of compassion and sympathy, but also pity and disconnection. Many respond with feelings of sadness or downheartedness, even when the client does not appear to be particularly depressed (Bockian, 2002a); perhaps this is related to the conflict in values discussed by A. T. Beck et al. (2004), which was reviewed above. Considerable anxiety is generated in some students, apparently because of concerns that they will not know what to say to the person and therapy will grind to a halt. Experienced therapists probably feel the same way at times, although 1 suspect many of us feel what the average person feels in response to people with schizoid PD: boredom (Millon, 1996). The dullness, the impoverished descriptions of others, and the satisfaction with a bland, colorless existence can lead to a subdued therapeutic environment, one that is nonetheless appropriate and received positively by the individual with the disorder. I also recall my work with people with brain injury. Often, other people would get angry with the person who was brain injured for being "lazy." It was clearly the case that some people with brain injury would become apathetic and unmotivated. It struck me that concepts with a strong moral valence, or ones that we might attribute to a person's self or even his or her soul, are mediated by the brain. A person who becomes apathetic after brain injury may not merely be "not trying"; it could be that the physiological apparatus that underlies motivation has been damaged. Certainly, this poses a challenge—perhaps an insurmountable one—to the physical or occupational therapist who is trying to help the person return to functioning. However, recognition of damage to the motivational system conceptually changes the therapy: Therapy consists of undertaking exercises that will help to repair the motivational system itself. In the United States, people place great value on "trying." Probably each and every one of the hundreds of millions of students who have passed through the public education system has heard, particularly in the younger grades, "Whether you do well or poorly, it's okay, as long as you tried your best." The ability to try is itself taken for granted as a lowest common denominator. If Millon's theory (Millon, 1981, 1996) about the brain structures and functioning of people with schizoid PD is correct, then their capacity to try, to be effortful, to engage in motivated behavior is itself reduced. Recognizing that the person is confronting an unusual biological challenge often helps the clinician to reduce feelings of frustration. Therapist emotional reactions can also be a wise guide regarding the therapeutic contract. Although it is often wise to reduce session length and frequency, if this is an inappropriate avoidance of a person who is truly distressed then such avoidance is a harmful countertransference that demands supervision or peer consultation. However, in many cases, it is part of an appropriate plan. Feelings of frustration can often help to guide me in this regard. The person with schizoid PD may have rather modest goals for imSCHIZOID PERSONALITY DISORDER
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provement, and change may be very slow. If the therapeutic goal in supportive or behavioral therapy, for example, involves interacting with others, and it takes the client 10 days or so to hook up with someone else, then a biweekly session will feel more fruitful to both parties than the more typical weekly sessions. Of course, there are therapies that involve no explicit or implicit demand to change (e.g., client centered and existential), and in psychodynamic therapy, there is so much material to cover from the past as well as so much to process in the transference that frequent, full-length sessions are appropriate. When working with someone with schizoid PD, collaborative goal setting is extremely important. It is all too easy to project our own needs or desires onto the person. We therapists were likely drawn to this field because we value relationships and have high levels of empathy with others. We likely see warm relationships with others as healthy, and the cooler, more detached relations of people with schizoid PD as problematic. We may therefore jump to conclusions about the nature of the problems of individuals with schizoid PD. We may view their isolation or lack of intimate relationships with others as devastating or pathological. The clients, however, may see things very differently. They may have little desire to interact with others, much less pursue close relationships. Thus we must carefully assess individuals and work with them to uncover their goals and motivations. Therapist lack of congruence with a client's goals can lead to premature termination and a negative attitude toward therapy.
SOCIAL CONSIDERATIONS AND DIVERSITY Theoretical considerations would lead to the expectation that schizoid PD is far more frequent in men than in women. Current theory indicates that men are less related than women. Levant (1995) discussed "normative male alexithymia" to indicate the frequent observation that men lack words for feelings. Although we might expect high ratios of men relative to women, as in narcissistic or antisocial PDs, current prevalence data do not indicate these differences. According to the DSM-IV-TR, there are "slightly" more men than women with schizoid PD, and they appear to be more severely impacted by it (American Psychiatric Association, ZOOOa). Perhaps, then, passivity is more acceptable and less damaging to the feminine role than to the masculine. A man who is passive, noncompetitive, and underachieving may be deemed more unacceptable, given American culture's emphasis on male dominance and achievement. American culture may be more tolerant of passivity in women. Even within the female role, however, a woman with schizoid PD may experience pressure for not being sufficiently nurturing, assuming that she dates, marries, or has children; this issue is addressed in the case study below. 82
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Low socioeconomic status is generally a risk factor for psychopathology (Dohrenwend & Dohrenwend, 1969). There is a well-known association between schizophrenia and low socioeconomic status (Eaton & Harrison, 2001), which likely generalizes, at least to some degree, to the schizophrenia spectrum. The two main theories of the etiological impact of low socioeconomic status are social causation (e.g., that poverty increases stress levels, causing psychopathology) and social selection (i.e., that psychopathology impairs productivity and leads to poverty; Dohrenwend et al., 1992). In general, both factors work simultaneously (Johnson, Cohen, Dohrenwend, Link, & Brook, 1999). For example, an impoverished individual may become depressed in part because of his poverty. Because he is unable to afford treatment, his depression worsens, and he loses his job, leading to increased poverty. It should be noted that in some cultures, what DSM-IV-TR labeled "schizoid" is considered the highest state of being. The Buddhist monk (Foulks, 1996, p. 249) or Hindu yogi (Castillo, 1997) yearn to experience a state of inner emptiness, freedom from striving, a focus on the present, and a lack of "ego" (in the sense of individual identity and the pride that goes with it), and to be free from emotions and attachments. Such individuals engage in regular meditation practice to attain such a state. I doubt that many clinicians would confuse the practiced, refined state of tranquility of the Buddhist or Hindu cleric with the inner deadness of the depressed person with schizoid PD. However, members of the Buddhist and Hindu religions may accept or even value ways of being that a practitioner from a Western perspective may see as problematic. In addition, Castillo (1997) noted that an individual is more likely to be labeled schizoid if he or she has a "stigmatized moral career": There are a number of ways that a person with a stigmatized moral career can adapt to the social environment, thus structuring personality development. For example, stigmatized persons can accept their status and "act accordingly," that is, passively accept their low status. These persons will likely have low self-esteem. They accept society's definition of them as being inferior, flawed, incapable, unworthy, inadequate, unacceptable, and so on. They internalize this stigmatized view of themselves, literally structuring it into the neural networks of their brains. These neural networks then structure their cognition of the world, (p. 42) One can easily see the origins of depression in this conceptualization. Low self-esteem and beliefs that one is inadequate are part of the diagnostic criteria for major depression and dysthymic disorder. The passivity of the individual with schizoid traits makes this "accepting" adaptation likely. As implied in the analysis above, both depression and schizoid personality disorder would be more likely to develop in hierarchical societies such as the United States (Castillo, 1997, p. 100). Some cultures have more muted forms of expression than others. For example, individuals from Scandinavian cultures tend to be more reserved than SCHIZOID PERSONALITY DISORDER
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people in the United States. Thus Scandinavian families may have a greater tolerance for the reduced emotionality associated with schizoid PD. However, Scandinavians are as sociable as Americans, and the withdrawal of the individual from family and community life would be seen as problematic. Conversely, families from highly expressive cultures (e.g., Hispanic) may have a great deal of difficulty with the schizoid individual's lack of warmth and emotionality, and the schizoid behaviors may be particularly troubling to the family. DSM-IV-TR cautioned that there are several groups that may be erroneously labeled schizoid. Individuals who move from rural to urban areas may exhibit "emotional freezing" (American Psychiatric Association, ZOOOa, p. 695) for up to several months. Similarly, immigrants may be misperceived as cold or indifferent.
STRENGTHS OF PERSONS WITH SCHIZOID PERSONALITY DISORDER When one considers the person-environment match, it is not difficult to see that there are many aspects of schizoid PD that are adaptive to certain conditions. Individuals with a low need for stimulation do well at repetitive tasks or isolated jobs that would mercilessly bore most people. Institutionalized clients with restless temperaments grow agitated and desperate; the person with schizoid features adapts extraordinarily well to institutional life. Although living in an institution may not be considered ideal, for individuals with certain kinds of problems it is the setting in which they will spend a great deal of their time. It is a sad reality that the needs of institutions to provide minimal staff-patient contact and to have maximal patient compliance with routines that are generally rather dull favors features of schizoid, dependent, and obsessive-compulsive personality disorders. There are also personality strengths inherent in schizoidal features that fall within the "normal" or positive range of functioning. Being eventempered, steady, and calm are traits that stand one in good stead in many situations. A person with schizoid PD who improves in psychotherapy can be expected to retain these positive characteristics. As noted previously, advanced meditators achieve a state of inner peace through disciplined practice, attaining a state that bears some resemblance to the person with schizoid PD's natural way of being; the client could capitalize on that proclivity in therapy.
TREATMENT PLANNING: SYNERGISTIC TREATMENT Personality-guided therapy (PGT) treatment goals flow logically from the conceptualization of the client, per Millon's theory. Because the person 84
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EXHIBIT 4.2 Therapeutic Strategies and Tactics for the Prototypal Schizoid Personality STRATEGIC GOALS Balance Polarities Increase pleasure/enhancing polarity Increase active/modifying polarity Counter Perpetuations Overcome impassive behaviors Increase perceptual awareness Stimulate social activity TACTICAL MODALITIES Energize apathetic mood Develop interpersonal involvement Alter impoverished cognitions. Note. From Personality-Guided Therapy (p. 291), by T. Millon, 1999, New York: John Wiley & Sons. Copyright 1999 by John Wiley & Sons. Reprinted with permission of John Wiley & Sons, Inc.
with schizoid PD is considered the passive-detached type, naturally, the goal is to balance the polarities by helping the client to become more active and more attached to others. Because the person is pleasure deficient, an additional goal is to increase pleasure. It is also important to undercut processes that tend to perpetuate the schizoid pattern. Vicious circles of the person with schizoid PD include (a) extreme passivity, which undermines the development of assertiveness and other appropriate skills; (b) lack of social awareness, which leads to unpleasant social interactions, thus further reducing opportunities to perceive social cues; and (c) the tendency to withdraw, which generally leads to further withdrawal. Thus, therapy should be geared toward reducing impassive behaviors, improving social awareness, and increasing social activity (see Exhibit 4.2). The long-term goals for depressed individuals with schizoid PD include increasing their activity level, enhancing pleasure, improving their social interactions and increasing their frequency, and bringing clarity to their vague cognitions so they can recognize their depression and cope with it more effectively (Bockian & Jongsma, 2001; Jongsma & Peterson, 1999). For the client with schizoid PD and depression, motivation will often be problematic; thus, the best initial interventions will be those that offer the best hope of rapid change. Behaviorally lethargic, people who have both depression and schizoid PD typically first respond best to cognitive interventions; they can challenge their negative thoughts and improve their mood while expending minimal physical energy. If the depression is not so severe that it precludes psychotherapeutic improvement, then it is best to wait for some psychological improvements to occur before introducing psychopharSCHIZOID PERSONALITY DISORDER
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macological interventions; the typical person with schizoid PD, who is not very psychologically minded, may be prone to attributing any gains made to medications and lose motivation to make psychological changes. Behavioral techniques could then be added, targeting specific social skills to improve (e.g., assertiveness), or specific antidepressive behaviors (e.g., exercise or reengaging in a favored hobby). Establishing these fundamental skills will generally be very helpful prior to attempting to repair the deeper interpersonal and structural problems the person encounters. Cognitive improvements, such as changing self-defeating thoughts, and adding skills, such as increased assertiveness, are likely to have positive interpersonal consequences. For example, the depressed person with schizoid PD may have the thought, "I am so worthless that no one would want to be with me," which may lead to neglecting a relationship ("It's just going to end anyway")- If these beliefs have been corrected with cognitive therapy, then the individual is likely to be more receptive to discussing relationship issues. Interpersonal interventions, then, can build on cognitive improvements, strengthening the person's relationships. Group and family interventions can either run concurrently with, or replace, individual treatment. As mentioned previously, group interventions have the distinct advantage of allowing the individual to practice social skills with peers. Family interventions can have positive motivational aspects as well because the therapist can provide support for beleaguered family members while supporting the client, and the family can help motivate the client to continue to come to treatment. Depth approaches, such as psychodynamic interventions, would generally be considered last because they tend to produce change more slowly and thus require greater motivation on the part of the client. The current therapist can implement psychodynamic interventions, though in some cases it would be wise to refer the client, thus allowing the transference to form anew.
CASE EXAMPLE: CANDACE AND LORENZO It is not a coincidence that most of the clients whom I saw who had schizoid PD also had histories of major psychopathology (e.g., schizophrenia or bipolar disorder). I saw them mostly when I was an intern working for the New York state psychiatric system. Their schizoid PD was never the reason that they saw themselves coming for therapy. However, in the case below, the severe Axis I psychopathology had been stabilized, leaving some Axis I depression and anxiety, and the underlying schizoid PD, as treatment issues. At the time I met her, Candace, a 42-year-old divorced White AngloSaxon Protestant woman, had had a long history of depression and schizophrenia. She had been hospitalized for schizophrenia on several occasions, but when I started seeing her as an outpatient, she was stable on medications and had not been in the hospital for a number of years. I saw her for approxi86
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mately 1 year, and she was not psychotic during that time. Candace's schizophrenia was treated with low-dose neuroleptics, and she had chronic anxiety, for which she took buspirone. She had chronic, vague feelings of sadness, which, when combined with her passivity, would meet the criteria for dysthymic disorder. Candace also met the criteria for schizoid PD. Although an intelligent woman—she had received a college education and worked as an editor—her descriptions of her relationships were quite impoverished. She had a 22-yearold daughter who was in college and whom she saw occasionally. When she would mention her daughter or say that her daughter was coming for a visit, she evinced neither excitement nor displeasure. This was her closest family relationship; she rarely mentioned her parents or other family members. Unlike most depressions, Candace's appeared to lack substantial interpersonal components. She did not describe being depressed because she felt unloved or unlovable, unwanted, or abandoned. She stated that she felt empty at times, and she also described feeling different from others. She had a history of suicidal ideation when she was in the psychiatric hospital suffering from schizophrenic symptoms. Her frightening delusions and hallucinations led her to feel hopeless that she would ever get out of the hospital or recover. Once she stopped having hallucinations, she stopped having suicidal ideation. The presenting problems at the time of referral were relationship difficulties between Candace and her boyfriend, Lorenzo. As is common in internship settings, I "inherited" the case from a prior intern, and Candace and Lorenzo were already in ongoing couples therapy; I continued, then, to see them as a couple. However, I was not insistent on seeing both members of the couple at once (Napier, 1978); if one person was sick and the other still came, I would see just that person. During those occasional individual sessions, we would refrain from talking about couple issues but rather would work on individual issues. With Candace, one of our better sessions on her depression occurred during one such session. Lorenzo was diagnosed with borderline intellectual functioning. His personality style was dramatic, and although he did not have a diagnosable personality disorder, he had features that were primarily histrionic and somewhat dependent. Lorenzo wanted much more from the relationship with Candace—marriage, as well as increased closeness and intimacy. Candace was satisfied with how things were and seemed a bit puzzled by Lorenzo's needs and desires. Thus there was a striking reversal of common American gender patterns in this case. Candace was the breadwinner, unemotional, and relatively alexithymic; Lorenzo, on the other hand, was more emotion focused and demonstrative. Candace came from a family that was formal in its structure. Dinner was eaten together at the same time each day, accompanied by polite, quiet conversation. Children were expected to be "seen and not heard." Achieve SCHIZOJD PERSONALITY DISORDER
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ment and education were emphasized. She stated that her parents cared most about her grades and that because she always did well in that area, her parents "didn't hassle her." Her meager social life was accepted as being "her decision." Lorenzo's Hispanic family was more demonstrative, openly displaying warmth and affection. There was no abuse in either family, although Lorenzo endured a moderate amount of teasing as a child. The manner in which Candace and Lorenzo were raised was consistent with their White Anglo'Saxon Protestant and Hispanic subcultures, respectively (Garcia-Preto, 1996; McGill & Pearce, 1996). However, although Lorenzo's histrionic and dependent features may have been normative within the context of an expressive, tightly knit Hispanic family, Candace's social withdrawal and aloofness were clearly beyond what would be considered appropriate within her culture. Candace's strengths included a general kindness—although not particularly empathic, she did try to be helpful to others, and she was never malicious. She was both consistent and patient with Lorenzo. She was bright, hardworking, and confident in her abilities as an editor. Though she was not warm or demonstrative, she took pride in her daughter's accomplishments and provided for the daughter's material needs. She coped very competently with her schizophrenia; she had excellent insight and was fully compliant with her medication regimen. It was interesting that the vast difference between Candace's and Lorenzo's IQs never became an issue. This was most likely because of Candace's nonstriving and "egoless" nature; she did not have a need for status that would have required her boyfriend to be highly accomplished. Candace also tended to express herself in a simple and straightforward fashion, and so Lorenzo had no difficulty understanding her. Lorenzo also demonstrated a variety of strengths. A warm and caring individual, he was able to be consistently affectionate with Candace. Without his persistence—or, put differently, if Candace were dating someone with a personality more similar to her own—the relationship likely would have drifted into isolation and separateness. Lorenzo was also able to take advantage of the programs offered through state and community facilities that provided him with work, activities, and independence. Candace was not completely detached. She preferred to have some company some of the time. She enjoyed spending time with Lorenzo but did not want him to move in and did not want to increase the amount of time they spent together (they would meet several times per week). In addition, therapy provided Candace with some measure of support that she seemed to appreciate. Treatment initially consisted primarily of cognitive interventions. Candace had beliefs such as "I am empty" and "I am odd and different" that led to feelings of depression. She was encouraged to challenge these beliefs and came up on her own with the notion that each person is unique, and who is to say what is acceptable or not? Unconditional positive regard on the part 88
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of the therapist arid Lorenzo's persistent affection were consistent reminders that she was an acceptable person. As for the belief that she was empty, her emotional reasoning (I feel empty, therefore I am empty) and her dichotO' mous reasoning ("I am empty" as opposed to "At times I feel empty") were challenged through Socratic dialogue. Over time, her belief was modified to "At times I feel empty, but I often feel fulfilled as a mother to my daughter, a girlfriend to Lorenzo, and in my job." Lorenzo had beliefs such as "Candace does not really love me or she would marry me"; "If we do not get married, that is terrible"; and "Candace must be more affectionate with me, or I cannot bear it." These beliefs were challenged against his experience and, gradually, were reframed as preferences, for example, "I would prefer it if Candace were more affectionate." The belief that Candace would marry him if she loved him was challenged, on the basis that Lorenzo would lose valuable disability benefits if the couple got married. Although marriage was highly preferable to Lorenzo, particularly given his religious upbringing, he was able to see that Candace's finances were stretched to the limit in supporting her daughter through college. After the most distressing beliefs were effectively challenged, the treatment approach shifted to become more interpersonally focused. During this phase of treatment, Lorenzo more frequently raised issues that were distressing to him. On a number of occasions, he would protest that unless Candace could be more affectionate, then perhaps they should break up. Candace was not ruffled by these threats, which did not seem to be particularly genuine. However, at least one form of affection could be improved. Sexual counseling with the couple enabled them to experience more warmth and intimacy. At that point, it became clear that Candace had reached the limits of her motivation, and probably her ability, to become warmer and more demonstrative. Although the words "schizoid personality disorder" were never used, the concept of "this is just how she is" was used as a way of discussing personality variables. As a way of helping Lorenzo to empathize, I noted that just as it was difficult for Lorenzo to reduce his desires, it was difficult for Candace to increase hers. Ultimately, it came down to a choice—"Can you accept her for who she is? Can you accept him for who he is?" They continued to stay together, and though ambivalent at times, they were more flexible, accepting, and realistic about both themselves and each other. The overall tone of the relationship had become warmer and more affectionate. Candace was less depressed, and Lorenzo was less angry and anxious. They recognized each other's strengths—that she was drawn to his emotionality and enjoyed his devotion to her, and he appreciated her patience and consistency. Although 1 did not then work with psychodynamic concepts in this case—for example by looking at unconscious motivations, early family relations, repetitions of prior patterns, and compensatory strivings—PGT prinSCHIZOID PERSONALITY DISORDER
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ciples indicate that such an approach would have been an appropriate step. Dynamically oriented therapy may have helped the couple gain further insights and enable them to achieve a better understanding of both the self and the other person (e.g., Ackerman, 1958). If it were not possible to switch from the current supportive mode to psychodynamic therapy—a real possibility, because the transference has already been shaped by supportive interventions—then an alternative would have been to add a psychodynamically oriented individual therapist for one or both members of the couple. I continued to see the couple throughout the remainder of the year, although the gains described above were mostly accomplished during the first 8 months. Given the numerous challenges that they faced—schizophrenia, depression, and borderline intellectual functioning—long-term supportive therapy was used for relapse prevention and to prevent hospitalization. After I terminated with the couple, they were transferred to a new intern.
SUMMARY AND CONCLUSIONS Schizoid PD with depression can be difficult to treat because of low energy levels and motivation. With realistic expectations regarding recovery, prognosis is reasonably good. As illustrated by the case of Candace and Lorenzo, a series of synergistic sequences led to significant improvements. Establishing trust was not particularly difficult. Cognitive techniques (challenging distorted thoughts such as Lorenzo's experiencing Candace's reserve as personal rejection) and interpersonal-family techniques (e.g., sexual counseling) led to improvements in the couple's relationship as well as decreased symptoms in each individual. For purposes of PGT for depression, empirical research on catalytic sequences, beginning with examining potential motivational strategies, would be appropriate. Research on medications may be more important with this population than with others, because motivation for change is a key ingredient for success in psychotherapy, and the lethargy that typifies individuals with schizoid PD and depression needs to be countered.
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5 DEPRESSION IN SCHIZOTYPAL PERSONALITY DISORDER
The Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision [DSM-IV-TR]; American Psychiatric Association, ZOOOa) described schizotypal personality disorder (PD) as "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" (p. 697). Individuals with schizotypal PD are seen by others as eccentric, odd, or just plain weird. They have strange, loosely connected thoughts, superstitions, and, frequently, paranoia. They may believe that they have special powers, especially clairvoyance or extrasensory perception.
PHENOMENOLOGY: THE EXPERIENCE OF SCHIZOTYPAL PERSONALITY DISORDER Interpersonally, individuals with schizotypal PD are generally withdrawn. However, the social withdrawal can occur for different reasons. People with schizotypal PD can be thought of as belonging to one of two subtypes, as
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noted by Millon (1996, 1999)—a schizotypal-avoidant type (Millon's timorous schizotypal) and a schizotypal-schizoid type (the insipid schizotypal). The timorous schizotypal individual longs to be accepted but, fearful of rejection, actively avoids others. More dysfunctional than most avoidant persons because of the additional challenge of cognitive slippage, persons belonging to this subtype have likely experienced excessive actual rejection, especially in the form of teasing as a child. Like other avoidant people, they are highly prone to depressive and anxiety disorders. The insipid schizotypal person has a generally more comfortable time of it than the timorous type; for this individual, passive and detached, rejection by others does not wound. As with other schizoid persons, however, this can lead to a lack of motivation to change and a continued pattern of poor adjustment and underachievement. Individuals with schizotypal PD as well as depression, then, are more likely to be of the timorous sort—anxious, fearful, wanting connection with others but unable to attain it, and thus always feeling as if they are "on the outside looking in." Of course, social withdrawal is also a
