Personality Disorders

WHAT ARE PERSONALITY DISORDERS?

Many people struggle with problems that are not as easy to define or treat as some of the others listed on this website. These difficult problems affect nearly every aspect of a person’s life. They influence the person’s actions and behaviors, interfere with the person’s relationships and career, and alter the way in which the person thinks about himself or herself and the world. Due to this pervasive nature, these problems are officially referred to as personality disorders.¹

There are ten personality disorders that will be described below: paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent, and obsessive-compulsive.¹ It’s estimated that almost 15 percent of all adults in the United States, or almost thirty-one million people, struggle with personality disorders,² and these long-term problems are often the cause of general unhappiness and disability in a person’s life.³

Personality disorders often begin forming as early as childhood or adolescence. As a result, the habitual behaviors and thoughts of an adult can be very inflexible and resistant to change. People struggling with these problems might recognize the various difficulties caused by their personality style, but they usually seek help for the treatment of other problems, such as depression, or at the urging of family members or friends; or, in the case of antisocial personality disorder, they might be forced into treatment by the legal system.

In general, personality disorders are probably caused by a combination of biological and social factors. Some studies have shown that personality disorders have a strong chance of being passed on in families due to influential genetic traits.^4-7 Other studies have linked the development of various personality disorders to factors such as brain dysfunction,^8-15 childhood experiences of depression and anxiety,^16-18 parental depression,¹⁹ parenting styles,^20-25 childhood temper and activity levels,^26-29 a history of being abused or neglected,^30-39 having a family member with schizophrenia,⁴⁰ poverty,^{3, 41} and nutritional deficits.^42-44 Certain personality disorders can also be learned by children and adolescents while watching the behaviors of their parents⁴⁵ and friends.^{41, 46, 47}

One influential branch of psychological treatment also proposes that personality disorders develop as a result of cognitive schemas. According to cognitive behavioral therapy, schemas are strongly held core beliefs that a person has about himself or herself, others, and the world, and these schemas cause the person to focus on certain types of experiences and emotions while ignoring others.⁴⁸ In essence, schemas act as a filter through which a person views his or her life. For example, a man with a schema of defectiveness believes that he is incapable of doing anything correctly. Therefore, he won’t take risks, he’ll rely on others for constant reassurance, and he’ll usually associate with people who confirm his feelings of defectiveness. Schemas like these begin early in childhood and are very difficult to change, even if they make a person’s life very difficult. In each section below, the specific schema associated with each personality disorder will be highlighted. Then, at the end of this review of personality disorders, a brief description will be given of the cognitive behavioral therapy for the treatment of personality disorders.

Paranoid Personality Disorder

People who have paranoid personality disorder are very mistrustful of others and their motives, even when there is little or no evidence to support their suspicions.1 They’re also constantly on the lookout for being attacked, injured, or tricked by other people,⁴⁸ including friends, family, and coworkers. People with this problem might even suspect that friends and family members are plotting to hurt them.

According to cognitive behavioral therapy, the schema of a person who has paranoid personality disorder might be something like “Other people are always looking to take advantage of me (or hurt me),” and as a result, the person thinks, “I always have to be on guard.”⁴⁸

People with this problem are always questioning the loyalty of others, and any deviation from 100 percent loyalty is interpreted as a betrayal. As a result, people with paranoid personalities often have damaged family relationships, few close friends, and few social interactions. They also hold grudges, are extremely jealous, get angry when they think they’ve been insulted, and often try to control other people’s lives.¹

Many people with paranoid personality disorder also suffer with other problems, such as drug and alcohol addictions,⁴⁹ depression, dysthymia, bipolar disorder, panic disorder, social phobia, specific phobia, and generalized anxiety disorder.^50-52

It’s estimated that almost 2 to 6 percent of the general adult population, or approximately nine million adults in the United States, struggle with paranoid personality disorder,^{3, 53} with women reporting the problem more frequently than men.²

Schizoid Personality Disorder

People who have schizoid personality disorder aren’t interested in seeking social contacts or relationships and often prefer to be alone.¹ They also aren’t concerned about receiving either approval or criticism from others and show little emotional reaction to other people and events.⁵⁴

According to cognitive behavioral therapy, the schema of a person who has schizoid personality disorder might be something like “I don’t need close relationships with others because they only interfere with my life,” and as a result, the person thinks, “I’m better off remaining alone.”⁴⁸

A person with this problem might be described as very shy, reclusive, or even unfriendly—despite how the person really feels. People struggling with schizoid personality disorder don’t necessarily dislike other people. Sometimes they just doesn’t know how to interact with others⁵⁵ or feel extremely uncomfortable when they try to interact.⁴⁸ Either way, they usually avoid unnecessary contact with other people and prefer having a job that requires little contact with other people, and if they do have relationships, they’re probably not very intimate. The word “schizoid” comes from the Greek prefix schizo, meaning “split.” Here, “schizo” applies to the way these people disconnect from other people.

Many people with this type of personality disorder also struggle with bipolar disorder, depression, dysthymia, panic disorder, generalized anxiety disorder, or social phobia,^{1, 50, 56} as well as drug and alcohol problems.^{49, 57, 58} Additionally, there appears to be a strong link between schizoid personality disorder and the development of problems such as schizophrenia^{1, 59, 60} and homelessness.⁶¹

In a large study of adults in the United States, it was estimated that 3 percent of the population, or almost seven million people, had schizoid personalities, with men and women being affected equally.²

Schizotypal Personality Disorder

People with schizotypal personality disorder have difficulties forming and maintaining relationships, exhibit odd behavior that doesn’t fit in with cultural norms, and often have strange or suspicious types of thoughts.¹

According to cognitive behavioral therapy, the schema of a person who has schizotypal personality disorder might be something like “I don’t know how to fit in with other people,” and as a result, the person thinks, “I need to be different in order to be noticed.”⁴⁸

Unlike people with schizoid personality disorder, those struggling with a schizotypal personality may want to have closer relationships. However, they may not have the social skills to form those types of relationships, or they may feel very uncomfortable when trying to create relationships. As a result, people with schizotypal personality disorder often have few social contacts. Part of this problem might be related to the eccentric behavior they often exhibit. People with schizotypal personality disorder frequently dress and behave in ways that appear odd, eccentric, or unconventional. In addition, they often claim to have magical powers and psychic abilities, or believe that common events are caused by them or have special meaning for them.

Many people with schizotypal personality disorder also struggle with anxiety and depression, as well as brief psychotic episodes that are often caused by stress.¹

It’s estimated that schizotypal personality disorder occurs in almost 3 percent of the general population.¹

Antisocial Personality Disorder

People who have antisocial personality disorder manipulate and abuse others for their own purposes and show little or no consideration for the needs and safety of others.¹

According to cognitive behavioral therapy, the schema of a person who has antisocial personality disorder might be something like “The world is made up of aggressors and victims,” and as a result, the person thinks, “I have to take advantage of them before they take advantage of me.”⁴⁸

People with this type of personality disorder can be violent, impatient, egotistical, and easily agitated, and they often show little regret for hurting other people. Plus, they have little regard for rules and the law, which often puts them at risk for being arrested. People with this problem often think that others aren’t as smart as they are and therefore deserve to be manipulated. For these reasons, people with this problem has few close friends or romantic relationships.

Obviously, the issue most frequently related to this problem is breaking the law. In surveys at prisons, the rates of antisocial personality problems among men have ranged from approximately 33 to 62 percent of the population.^62-66 Similarly, the rates for women in prison have ranged from almost 12 to 60 percent of the population.^65-69

People with antisocial personalities are also at a higher risk of dying from unnatural causes. In one long-term study, people with this type of personality were almost four times as likely to die unexpectedly when compared with other people.⁷⁰ Among the many reasons for this likelihood are an increased risk for suicide,^{71, 72} an increased risk for accidents,⁷³ and an increased risk of experiencing a violent death.⁷⁴

Many people with antisocial personalities also struggle with social phobia, specific phobia, post-traumatic stress disorder, panic disorder, generalized anxiety disorder, depression, bipolar disorder,^{50, 56, 75, 76} alcohol and drug problems,⁴⁹ or gambling addictions.⁷⁷

In a large study of adults in the United States, it was estimated that almost 4 percent of that population, or almost eight million people, had antisocial personalities, with men being affected more often than women.²

Borderline Personality Disorder

People who have borderline personality disorder suffer frequent, uncontrollable, and painful mood swings.^{1, 78} They also experience great difficulty forming and maintaining relationships, have problems controlling their spontaneous and reckless behaviors, and experience fluctuating ideas about who they are.¹

According to cognitive behavioral therapy, the schema of a person who has borderline personality disorder might be something like “Other people will always leave me (or hurt me),” and as a result, the person thinks, “I need to do whatever it takes to make them stay (or accept me).”⁴⁸

The overall theme of this disorder is rapid and unpredictable change in a person’s thoughts, moods, behaviors, relationships, and beliefs.^{79, 80} Very often, these rapid changes are caused by recurring fears of being criticized or deserted by other people, or by the actions of other people that feel like criticism, such as small disagreements or changes in plans. In response to these types of situations, a person with borderline personality disorder can suddenly feel very sad, nervous, or angry, and might engage in some type of self-harming behavior, like self-mutilation, unsafe sexual activity, or suicidal acts.⁸¹

Of all the problems related to borderline personality, the most severe is suicide. It’s estimated that as many as 75 percent of the people with this problem will attempt to kill themselves at some point,⁸² and as many as 10 percent eventually will take their own lives.^83-85 In addition, many people with borderline personality disorder suffer with depression, dysthymia, post-traumatic stress disorder, eating disorders, social phobia, specific phobia, panic disorder, or drug and alcohol problems.^{58, 86, 87} Males suffering from borderline personality disorder seem to be more likely to develop drug or alcohol problems than female sufferers. But female sufferers appear to be more likely to develop bulimia, anorexia, and other eating disorders.^{87, 88} People with borderline personality disorder also frequently suffer with chronic medical conditions such as fibromyalgia, chronic fatigue syndrome, obesity, diabetes, hypertension, arthritis, and back pain.⁸⁹

Studies have estimated that approximately 1 to 5 percent of the general population is affected by borderline personality disorder.^{3, 53, 90, 91} Many studies report that almost 75 percent of the people diagnosed with this problem are women.^{91, 92} However, this striking outcome isn’t always found,⁸⁸ and a few researchers have uncovered evidence that some mental health care professionals diagnose women with borderline personality disorder more frequently than men, even when both sexes have the same symptoms.^{93, 94} (Click here for more information on borderline personality disorder and treatment using dialectical behavior therapy.)

Histrionic Personality Disorder

People who have histrionic personality disorder are constantly striving to be the center of attention and often act in very dramatic ways in order to get that attention.¹

According to cognitive behavioral therapy, the schema of a person who has histrionic personality disorder might be something like “Other people have to admire me in order for me to feel valued (or loved),” and as a result, the person thinks, “If I’m not interesting enough, they won’t like me.”⁴⁸

People with this type of personality disorder might dress and behave in a sexually seductive manner in order to get attention. They might talk and behave in a very grandiose way, as if they were in a performance. Or they might give gifts to others in order to gain their immediate attention. People with histrionic personalities also display emotions that change very quickly and often feel superficial. For example, they might treat a person they’ve just met like an old friend, and then react very dramatically when the person doesn’t return their affections. When people with histrionic personality disorder aren’t getting the admiration they need from others, they may make a scene in order to get that attention, acting overly hurt or upset.

People with histrionic personality disorder also struggle with strained relationships, suicidal behaviors, depression, or other personality disorders.¹

It has been estimated that approximately 3 percent of the general population struggles with histrionic personality disorder.¹

Narcissistic Personality Disorder

People who have narcissistic personality disorder believe that they have many exceptional characteristics and deserve to be admired by others; plus, they often lack sympathy and compassion for others.¹

According to cognitive behavioral therapy, the schema of a person who has narcissistic personality disorder might be something like “Since I’m superior to others, I deserve special privileges,” and as a result, the person thinks, “If others don’t serve me, I’ll punish them.”⁴⁸

People who have this style of personality are often preoccupied with their own success, intelligence, and attractiveness. It’s very important to them that others see them as influential, talented, beautiful, intelligent, and persuasive.^{95, 96} People with this problem think that they are entitled to special attention from others. They also believe that they can only be truly understood by other people like them and that they should only associate with other people of high status. People with narcissistic personalities consider other people to be of lesser standing than they are, and so they will criticize others for their faults, act enviously of their successes, and take advantage of others to get their own needs met.

There appear to be two different types of people with narcissistic personality disorder: those who are outgoing in social situations and those who are not.⁹⁷ Those who are outgoing like to show off and be the focus of attention. These people put a lot of time into preparing their appearance and expect others to pay them compliments; if they don’t get complimented, they become offended or angry.⁹⁸ Those who aren’t outgoing like to keep to themselves. They become upset when they’re criticized, so they put great effort into protecting themselves from disapproval.

Due to the characteristics associated with this type of personality disorder, it’s often very hard for people with a narcissistic personality to maintain romantic relationships.⁹⁹ Many people with narcissistic personality problems also suffer with bipolar disorder,^{100, 101} depression,¹ or anxiety problems.⁸⁶ There’s also a danger of developing problems with substance abuse,^{102, 103} gambling addiction,¹⁰⁴ or eating disorders.^{105, 106} However, the greatest threat for people with narcissistic personalities is the possibility of suicide.⁷² It’s been observed that suicide attempts can arise very quickly and without warning in people with this problem,⁷² possibly resulting from a sudden injury to the person’s self-esteem.¹⁰⁷

It’s been estimated that narcissistic personality disorder affects approximately 1 to 3 percent of the general population,^{1, 3, 53, 108} with men being diagnosed with the problem 50 to 75 percent more often than women.^{1, 109}

Avoidant Personality Disorder

People who have avoidant personality disorder are very sensitive to criticism and judgment from others, so they tend to stay away from social interactions.¹

According to cognitive behavioral therapy, the schema of a person who has avoidant personality disorder might be something like “I’m defective (or unlovable),” and as a result, the person thinks, “I have to keep others at a distance so they don’t discover my faults.”⁴⁸

People with this problem want to have relationships with others, but they are often critical of their own social skills and self-worth. They think that they are defective or somehow substandard in comparison to others. And so they are constantly aware of social situations in which they might be evaluated, criticized, humiliated, or rejected. This often prevents them from meeting or interacting with others, unless they can be sure that they will be accepted and liked. It also prevents them from engaging in activities in society and at work where they might be exposed to criticism. As a result, they might be described by others as shy, loners, or introverted.

In many ways, this problem is very similar to social phobia, and some experts think that they are actually different descriptions of the same problem.1 (Click here for more information on social phobia.)

In addition to having few close relationships, people who have avoidant personalities also struggle with problems at work, depression, anxiety, or other personality disorders.¹

It’s estimated that approximately 1 percent of the general population has avoidant personality disorder.¹

Dependent Personality Disorder

People with dependent personality disorder are unable to make decisions without the constant assistance and approval of others, so they constantly rely on others to take care of them and make decisions for them.¹

According to cognitive behavioral therapy, the schema of a person who has dependent personality disorder might be something like “I’m completely helpless,” and as a result, the person thinks, “I’ll always need someone to assist me.”⁴⁸

People who have this problem often find it difficult to make even simple day-to-day decisions without the help of others, such as what clothes to wear, what to eat, and where to go. Those struggling with dependent personalities think that they’re not good enough or smart enough to make those decisions for themselves. Plus, they’re afraid that if they do something wrong, they’ll be abandoned by others. As a result, they’re constantly trying to please others by seeking approval, volunteering for unwanted chores, and not disagreeing.

Despite their best efforts to please other people, many people with dependent personality disorder still do not have many close, satisfying relationships in which their own needs are met.¹¹⁰ People with this type of personality are also in danger of experiencing problems such as depression, dysthymia, bipolar disorder, panic disorder, generalized anxiety disorder, bulimia, and social phobia.50, 56, 86, 111 There’s also an increased risk of suicide among people with dependent personalities.¹¹² Other studies have found relatively strong relationships between dependent personality disorder and alcohol and drug problems, especially for men.^{49, 57}

It’s estimated that approximately 1 to 2 percent of the general adult population, or approximately one million people in the United States, have a dependent personality, with women developing the problem more often than men.^{2, 3, 53}

Obsessive-Compulsive Personality Disorder

People who have obsessive-compulsive personality disorder are very concerned with maintaining order and control, achieving perfection, and following rules.¹

According to cognitive behavioral therapy, the schema of a person who has obsessive-compulsive personality disorder might be something like “Everything has to be done perfectly,” and as a result, the person thinks, “I have to be in control of everything in order to prevent any errors from occurring.”⁴⁸

People with this problem are so preoccupied with these issues that they often fail to complete tasks because they cannot do so perfectly. People with obsessive-compulsive personality disorder might be described as very conscientious students or workers, but they often have trouble getting projects completed on time because they must follow their own step-by-step procedures or constantly revise whatever they’re working on. They also find it very difficult to delegate work to others unless they can control the quality of work that’s being performed. This need for perfection interferes with a person’s social activities and relationships, since these things are put on hold until unfinished projects are completed. People with this type of personality are equally unbending when it comes to following moral principles and the rules of law. They believe that others should behave as they do, and they get very upset or angry when other people don’t follow the rules of society.

In severe cases of obsessive-compulsive personality disorder, a person might collect and hide things, fearing that he or she might need them in the future. For example, a person might collect old, valueless objects like newspapers or junk found on the street. In other cases, the person might hide all of his or her money and live a miserly lifestyle, fearing that one day he or she might need the money during a catastrophe.

People with obsessive-compulsive personalities also struggle with anxiety disorders, such as generalized anxiety disorder and phobias.¹ This type of personality disorder also shares traits with an anxiety disorder with a similar name, obsessive-compulsive disorder, but the latter problem involves intrusive thoughts that a person attempts to neutralize with compulsive behaviors. (Click here for more information on obsessive-compulsive disorder.)

It’s estimated that approximately 1 percent of the general population struggles with obsessive-compulsive personality disorder.¹

COGNITIVE BEHAVIORAL THERAPY FOR PERSONALITY DISORDERS

Cognitive behavioral therapy (CBT) is a form of treatment that combines elements of both cognitive therapy and behavior therapy. Cognitive therapy examines the way people’s thoughts about themselves, others, and the world affect their mental health. Behavior therapy investigates the way people’s actions influence their own lives and their interactions with others. By combining the two, CBT examines the way people can change their thoughts and behaviors in order to improve their lives.

Due to the long-standing nature of personality disorders, treating them with CBT is often difficult, complex, and time-consuming. It’s generally best for the person to work with a mental health care professional. However, the recommended CBT interventions aren’t much different than those used in the treatment of depression and anxiety,⁴⁸ so a person might be likely to make some progress using these techniques in a self-help approach. The steps, therefore, are highlighted below with links to further instructions.

The CBT treatment of personality disorders is often composed of eleven steps:⁴⁸

Conduct an assessment and provide education
Get reactivated in life
Challenge and correct self-defeating thoughts
Practice relaxation techniques
Practice visualization techniques
Use imagery to confront feared situations
Engage in real-life exposure to feared situations
Practice effective communication skills
Develop emotion regulation skills
Develop specific coping skills
Prevent relapse

The first step of the CBT treatment for personality disorders is to conduct an assessment of the person’s symptoms in order to verify that he or she is struggling with a personality disorder and not some other similar problem. However, this can be a lengthy process. Very few people—if any—come to therapy complaining of a problem with their “personality.” Most of the time, people struggling with these problems will seek help for related difficulties, such as depression and anxiety. Then, during the assessment process, longer-standing problems like personality disorders might be discovered. This usually occurs when people reveal the different kinds of thoughts they are having (as is highlighted below, in the section titled “Challenge and Correct Self-Defeating Thoughts”). In the case of personality disorders, these thoughts often point toward a common schema. Then the themes of a person’s behaviors might confirm the presence of a personality disorder.

Although personality disorders are officially recognized mental health problems, many mental health care professionals won’t use labels such as “paranoid” or “schizoid” to describe the problem. Instead, most CBT professionals address the pattern of rigid thoughts and behaviors associated with each disorder, with the goal of creating more flexible and adaptive coping abilities.

During the assessment process, it’s also important for the person to understand that CBT is a collaborative treatment, as well as an active form of treatment that requires him or her to do work outside of the therapy session.

2. Get Reactivated in Life

One of the initial steps of the CBT treatment for personality disorders is to help people begin scheduling pleasurable activities back into their lives. Many people with these problems often isolate themselves from the rest of the world and avoid fun and interesting activities, which, ironically, only serves to deepen their problems. One of the most important initial steps of treatment, therefore, is to get people reactivated in life and help them stop avoiding activities. This can be done in many ways, but using a schedule to plan and record activities is often helpful and motivating. (Click here for instructions on how to plan an activity schedule.)

3. Challenge and Correct Self-Defeating Thoughts

Perhaps the most important step of the CBT treatment for personality disorders is to challenge and correct self-defeating thoughts. These thoughts are often the cause of distressing feelings. At the most observable level are automatic thoughts, critical thoughts that people think and say to themselves that sabotage success and happiness. Two examples of automatic thoughts might be “I don’t deserve anything good happening to me” and “Why bother trying? I’m just going to fail.” A person can be either aware or completely unaware of having a thought like this. However, in both cases the result is that the person feels sad, anxious, or hopeless. (Click here for information on identifying automatic thoughts.)

Much of the CBT treatment for personality disorders will be spent identifying and reevaluating these types of thoughts. This can be done with the use of a thought record. The thought record helps the person look for evidence that both supports and contradicts these thoughts. Then, most importantly, it helps the person create a more balanced thought. For example, if the person had the thought “Why bother trying? I’m just going to fail,” the thought record would offer evidence of this thought being true and examples of it not being true in the person’s life.

The thought record also helps the person identify different types of cognitive distortions, unhelpful thinking styles that generate those automatic thoughts. For example, overgeneralizing involves making broad negative conclusions about life based on limited situations, and minimizing and magnifying involve discounting the positive and enlarging the negative aspects of life. (Click here for information on identifying cognitive distortions.)

By evaluating the evidence and cognitive distortions, the goal of the thought record is to help the person find a new, balanced thought and ease feelings of sadness, anxiety, and hopelessness. In this example, perhaps a more balanced thought would be “Even though I don’t do everything perfectly, I’m still capable of doing most things pretty well.” And instead of feeling excessively sad, such as 8 on a scale of 1 to 10, perhaps this newer thought will help the person feel less sad, say only a 5 out of 10. (Click here for instructions on using a thought record.)

As the work on challenging automatic thoughts continues, a person using a thought record will usually begin to notice common themes among his or her thoughts. These themes often point to deeper, more firmly entrenched schemas, or core beliefs, that make a person more vulnerable to feelings of frustration, loneliness, and sadness. These schemas include thoughts like “I’m a failure,” “I’m worthless,” and “I’m unlovable.” When these schemas are encountered, they too need to be challenged and modified using the thought record and other techniques. (Click here for instructions on challenging core beliefs.)

4. Practice Relaxation Techniques

For most people, changing long-standing habits is very difficult and therefore very stressful and anxiety provoking. Relaxation exercises can help reverse some of these effects, but more importantly, they can also prepare a person to confront those changes in a much healthier way. For example, suppose a woman’s relationship with her husband has been problematic. For the last few years, she has avoided dealing with the conflicts, and as a result she has developed many physical symptoms of stress, such as tight muscles and high blood pressure. Practicing relaxation techniques in a consistent way can help ease these problems. In addition, they can also help if she chooses to address the relationship issues with her husband. Relaxation techniques can prepare a person for confronting stressors and help the person deal with problems in a more effective way.

Typically, relaxation exercises begin with building body awareness to help people scan their bodies for signs of stress and muscles tension. (Click here for instructions on building body awareness.)

Next, it’s very important to learn proper breathing techniques. Many people who are under stress breathe in a very constricted way. Some of them breathe very rapidly. Either of these types of breathing can make a person more vulnerable to stress. Learning proper breathing technique, using long, slow breaths, can help a person relax quickly and easily. (Click here for instructions on proper breathing techniques.)

Progressive muscle relaxation is also a very important exercise. Many people experience stress as muscle tension. Progressive muscle relaxation helps people relax the entire body. Then, once this basic technique is established, people can learn to relax even more quickly by using cue-controlled relaxation and other rapid relaxation techniques. (Click here for instructions on using muscle relaxation techniques.)

Meditation is also helpful for many people. Learning how to stay focused in the present moment is a healthy alternative to being overwhelmed by stress-provoking thoughts. Meditation, or mindfulness, can take many forms, none of which have to be spiritual. People can learn to be mindful of their breathing, to meditate while walking or eating, or to use visualization to meditate. (Click here for instructions on building meditation and mindfulness skills.)

Effective relaxation also includes developing good nutritional habits and engaging in healthy physical exercise. Therefore, the person should make time in his or her life to address these issues, too. (Click here for instructions on developing good nutritional habits and physical exercise regimens.)

5. Practice Visualization Techniques

Visualization techniques use the power of the imagination to help people relax and create mental space for evaluating stressful situations. Techniques such as special-place visualization can help people relax by imagining a safe place in their mind, where they can completely relax. (Click here for instructions on using visualization and special-place techniques.)

Self-hypnosis is a very effective tool for relaxing and giving oneself powerful suggestions for dealing with stressful situations, such as “I will be calm, confident, and in control.” Self-hypnosis can also be used for coping with anxiety, fear, muscle tension, and pain. (Click here for instructions on using self-hypnosis.)

Autogenics is a form of self-hypnosis that can help people quickly relax by giving themselves suggestions that promote feelings of heaviness and warmth throughout the body. (Click here for instructions on using autogenics.)

Once a person has learned both relaxation and visualization techniques, it’s often helpful to combine the two in order to create an even more relaxing experience. (Click here for instructions on how to combine relaxation and visualization techniques.)

6. Use Imagery to Confront Feared Situations

One of the next steps in the CBT treatment of personality disorders might be to use mental imagery to desensitize the person to feared situations. In this context, desensitization means learning to relax while confronting the situation instead of allowing the situation to provoke anxiety, fear, and avoidance. However, in this intermediate stage of treatment, the person confronts the feared situation in his or her imagination rather than in real life. This allows the person more control over the situation and offers opportunities to practice relaxation techniques and other coping skills. For example, a person who struggles with obsessive-compulsive personality disorder has great difficulty tolerating mistakes and imperfection. In this step of the CBT treatment, the person can imagine himself or herself making mistakes and then using relaxation techniques and coping thoughts to deal with the situation. Similarly, a person with dependent personality disorder can imagine himself or herself coping with decision-making situations, and a person with borderline personality disorder can imagine coping with being alone.

The desensitization process begins with making a hierarchy, a graded list of situations that cause fear and anxiety. For example, a person with obsessive-compulsive personality disorder might experience mild distress when making mistakes at home, moderate distress when making mistakes at work, and severe distress when making mistakes in public. The purpose of the hierarchy is to allow the person to confront the least anxiety-provoking situations first and to build on his or her initial success by confronting situations that provoke increasingly greater levels of anxiety.

Imagery desensitization begins with ten to fifteen minutes of relaxation, including diaphragmatic breathing, progressive muscle relaxation, and special-place visualization. Then the person imagines the details of the anxiety-provoking scene, as if he or she were in that scene at that moment. As the person’s anxiety level begins to rise, he or she continues using relaxation skills and periodically imagines being in the safe place he or she has created. With practice, the anxiety-provoking scene will eventually lose its strength and the person will no longer react to it with such intense feelings of distress. This technique is also frequently used in the CBT treatment of phobias. (Click here for information on using imagery desensitization.)

7. Engage in Real-Life Exposure to Feared Situations

After a person has successfully practiced imagery desensitization, the next step in the CBT treatment of personality disorders might be to begin confronting feared situations in real life. This is often the most important and powerful step in the entire treatment, because successfully confronting feared situations can help change a person’s schema. Exposing oneself to feared situations takes courage and commitment, but without this step the personality disorder cannot be treated effectively.

As in the previous step, the person creates a hierarchy of feared situations, or continues using the same hierarchy. For this step, the person might create in-between steps that make the exposure exercises more realistic. For example, a man with a fear of making mistakes at home might purposely make small mistakes before purposely making bigger mistakes. As strange as it might sound to make mistakes on purpose, the goal is to show the person that his life won’t end in catastrophe because of it.

During the live exposure process, there are two ways a person can engage in the procedure. The first is to engage in the feared situation until the person’s anxiety rises to a moderate level, then temporarily retreat from the situation and use relaxation skills to reduce the anxiety before reengaging with the situation. Temporarily retreating from the feared situation is different than avoiding the situation, which is what people with personality disorders typically do. The point of this stage of treatment is to continue strengthening the person’s relaxation skills and perceived control of the situation by temporarily disengaging from the situation and using the previously learned coping skills. Then the person returns to engaging with the feared situation, rather than running away from it.

The second way to approach the skill of live exposure requires a stronger commitment to the process, but sometimes this second approach is even more effective than the first. The second approach is to stay in the feared situation beyond the point when it causes moderate anxiety and to tolerate the higher level of anxiety until it eventually diminishes, which might take as long as fifteen to forty-five minutes. Using either strategy, the person should continue to repeatedly engage with each situation until it no longer provokes significant feelings of distress. Then the person is ready to move up to the next situation on the hierarchy. Both imagery desensitization and live exposure must be practiced regularly in order for the treatment to be effective. (Click here for information about conducting real-life exposure exercises.)

8. Practice Effective Communication Skills

For many people with personality disorders, one of the core problems is a lack of effective communication skills. This is actually good news, because effective communication skills are easy to learn; they just take practice. Among the skills that are often needed are effective listening skills, nonverbal communication skills (body language), conversational skills, job-interviewing skills, social and dating skills, and public speaking skills. (Click here for instructions on effective communication skills.)

Assertive skills training can also help people learn to communicate more effectively, get their needs met in an appropriate way, stop being passive or aggressive, and set appropriate boundaries. Assertiveness isn’t a trait with which people are born; it’s a skill that must be learned. And learning how to communicate in an effective way can often make the difference between suffering in a stressful situation and getting one’s needs met in a healthy way. (Click here for instructions on using assertive communication skills.)

9. Develop Emotion Regulation Skills

Emotion regulation skills serve a number of different purposes. They help people identify their emotions more clearly and easily, and help them cope with painful emotions instead of getting overwhelmed by them. They can also help people reduce their vulnerability to overwhelming emotions, increase their experiences of positive emotions, and learn to be mindful of emotions without judging them. Emotion exposure techniques can help people learn not to fear their feelings. Learning to do the opposite of emotional urges blocks ineffective, emotion-driven responses to situations. And, finally, problem-solving skills can help people develop coping strategies for events that trigger difficult emotions. (Click here for instructions on how to use emotion regulation skills.)

10. Develop Specific Coping Skills

For many people struggling with personality disorders, learning coping skills to deal with specific difficulties can be very helpful. Problem-solving skills can help people who feel like they don’t know what to do in many situations by helping them to identify and select healthy solutions to difficult, anxiety-provoking situations. The steps to problem solving include defining the problem, outlining the desired goals, brainstorming possible solutions, evaluating the possible consequences, putting the chosen plan into action, and evaluating the results. (Click here for instructions on problem solving.)

Learning how to set goals can be a valuable skill for someone struggling with issues of uncertainty and self-doubt. For example, a person dealing with obsessive-compulsive personality disorder might lose sight of what the original goal was while working on a project. Goal setting can help get that person back on track. This is accomplished by exploring the person’s values, which are like compass points that steer a person’s life in a particular direction. After identifying their values, people can create goals that move them toward those values. (Click here for instructions on developing values and goals.)

Learning how to budget one’s time can be a great help for people who feel stressed-out because they’ve taken on too many tasks. Creating a time log and evaluating which tasks can realistically be accomplished often helps people organize their time more effectively. (Click here for instructions on time management.)

And, finally, skills for managing job stress can help people cope with stressors that arise in the workplace. There are eight steps to managing stress in the workplace: identify the symptoms of the stress, identify the sources of stress, identify how the person generally responds to those stressors, set goals to respond more effectively, develop motivation, change the way the person thinks about the stressor, learn how to negotiate, and learn how to pace activities.

11. Prevent Relapse

Finally, the last step of the CBT treatment for personality disorders is preventing relapse after treatment is complete. The key to relapse prevention is for the person to continue using the cognitive and behavioral skills learned in treatment and to recognize the early signs of returning difficulties in order to take steps to prevent relapse. And when needed, people should always consider seeking additional help from medical and mental health care professionals.

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