Applying CT with Mixed Personality Disorder (or more than one personality disorder)

Note: This query raises a number of important issues. I'll be responding in several separate posts as time permits and I would encourage others to chime in as well.

Linda writes: "You have indicated that Cognitive Therapy conceptualizes each personality disorder differently with different treatment implications. This makes it difficult to use with mixed personality disorders." I guess my first response is that therapy with clients who meet DSM criteria for "Mixed Personality Disorder" (i.e. who combine features of several different personality disorders) and with clients who qualify for more than one personality disorder diagnosis is difficult no matter therapeutic approach you use.

One can use a therapeutic approach which does not differentiate between different personality disorders. This is simpler than a more differentiated approach but it runs the risk of overlooking meaningful commonalities among individuals who share the same diagnosis.

Another alternative is to take a purely idiographic approach in which one ignores diagnostic labels and bases intervention on a good evaluation and an individualized formulation. This approach has advantages but it has the drawback that one is "starting from scratch" with each client. If time and cost were no obstacle this approach might be ideal but if we can learn from previous experience with clients who are similar and learn from the available research, this may aid intervention.

A third option is to take a "cookbook" approach where a set treatment protocol is developed for a given diagnosis and then is applied when treating anyone who qualifies for that diagnosis. This ignores individual differences and does not work as well as a more sophisticated approach.

My preference is to take a "prototypal" approach where we try to identify meaningful commonalities among individuals who share a given diagnosis, history, or problem. Once we have developed an understanding of the typical individual with Antisocial Personality Disorder (or any other diagnosis) we can use this understanding to facilitate intervention but we still need to develop an individualized understanding of this individual and his or her problems. When an individual combines features of several personality disorders or meets criteria for more than one diagnosis, it is particularly important to develop an individualized formulation.

I agree that developing an individualized conceptualization of each client is difficult but what alternative makes more sense (or works better)? General principles for applying CT with personality disorders have been proposed which apply across diagnoses (see my subsequent post), however, my experience has been that there are significant differences between individuals with different personality disorder diagnoses and that interventions which are usually appropriate for individuals with one diagnosis may be inappropriate or irrelevant for the typical individual with a different diagnosis.

In Jarrad's case, if his diagnoses of Antisocial Personality Disorder (ASPD) and Generalized Anxiety Disorder (GAD) are accurate, then my understanding of what is "typical" with these disorders would give me a starting place. However, I would start with a good assessment, particularly since Jarrad's "obsessive" thoughts of self-harm and of harming others don't seem to be consistent with either of his current diagnoses. Also, since the case description thus far doesn't reveal many signs of GAD but does include the mention of significant social anxiety, I would wonder if the diagnosis of GAD is accurate.

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