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Using DSM-5 and ICD-11 Personality Traits in Clinical Treatment

Bo Bach and Jennifer Presnall-Shvorin

This chapter provides a guideline for how maladaptive personality traits may inform treatment planning and therapy for individuals with personality problems and disorders. As reviewed elsewhere in this handbook, both the DSM-5 and ICD-11 have moved towards dimensional trait models of personality disorders that are substantially coherent with the universal Five-Factor Model of Personality (see Table 19.2). Importantly, the DSM-5 and ICD-11 trait domains have been replicated across different cultures (e.g., Bach, Sellbom, Kongerslev, et al., 2017; Lotfi, Bach, Amini, & Simonsen, 2018; Pires, Sousa Ferreira, & Gonçalves, 2017). Accordingly, this chapter primarily will focus on maladaptive traits according to the DSM-5 Section III and the ICD-11, which we anticipate will provide considerable worldwide utility for using those new diagnostic systems in treatment planning.

As therapists, we wish to maximize the possibility of successful outcomes in treatment while minimizing unnecessary discomfort and negative effects, which can be challenging when working with personality disordered patients. On one hand, we want to enable treatment compliance and motivate energetic patient efforts. On the other hand, we want to address the core issues that are driving the clinical problems. Our goal in this chapter is to discuss how to consider personality traits in the service of accommodating both of these needs in a clinical setting.

The last 70 years of research on individual differences suggest that personality trait assessment should be included in treatment planning independent of therapeutic framework (Allport, 1961; Cattell, 1943; Eysenck, 1947; Harkness & Lilienfeld, 1997). In the absence of personality trait formulations, therapists may misunderstand that signs and symptoms conceptualized as “presenting complaints” or “targets of treatment” may be manifestations of maladaptive personality traits. The essential role of traits in conceptions of disordered personality is already recognized in the DSM-IV/5 definition of personality disorder as characterized by inflexible and maladaptive traits. However, DSM-IV/5 personality disorder categories are implicitly composed of heterogeneous trait configurations (Bach, Anderson, & Simonsen, 2017; Morey, Benson, & Skodol, 2016; Presnall, 2013). Each DSM-IV/5 personality disorder category appears to be a compound assortment of maladaptive personality traits, which essentially complicates empirically based treatment (Lynam & Widiger, 2001). For example, when treating borderline personality disorder, we do not know for sure whether we are dealing with separation/abandonment anxiety, aggression/hostility, or impulsivity/risk taking. Thus, for a more meaningful and more focused treatment, we need to direct our attention to the homogeneous building blocks of personality psychopathology, or traits (Widiger & Clark, 2000). Accordingly, it should be obvious that therapies for personality disorders would focus on managing and treating specific maladaptive traits instead of heterogeneous categories. In other words, therapists should treat specific problems (e.g., emotional lability) and not diagnoses (e.g., borderline personality disorder). In addition to a large body of research showing that traits influence our reactions to events in general (Kotov, Gamez, Schmidt, & Watson, 2010; Roberts, Kuncel, Shiner, Caspi, & Goldberg, 2007), it has also been shown that traits shape our responses to treatment (Bagby, Gralnick, Al-Dajani, & Uliaszek, 2016). Importantly, a systematic review of the literature shows that traits are not only robust predictors of important life outcomes, but appear to be amenable to intervention (Roberts, Luo, et al., 2017). However, most current treatments barely mention this matter. Instead, the psychodynamic and cognitive behavior therapy literature usually refers to enduring features of attachment styles, defense mechanisms, schemas, and self–other narratives, which are either manifestations of or otherwise associated with traits (e.g., Bach & Bernstein, 2019; Fossati et al., 2015; Granieri et al., 2017; Hopwood, Schade, Krueger, Wright, & Markon, 2013).

As summarized in Table 19.1, personality traits can be used in treatment in a number of ways (Bagby et al., 2016; Harkness & Lilienfeld, 1997).

Table 19.1Six ways mental health care may benefit from considering patient traits

1.	Provide a context for establishing a favorable treatment alliance with the patient
2.	Guide therapists in tailoring treatment to personality
3.	Provide a framework for understanding basic traits that are hardwired (and should be accepted) versus maladaptive trait expressions that are changeable (and should be treated)
4.	Improve the patient’s self-knowledge, insight, and motivation for treatment
5.	Promote psychoeducation about how personality traits serve to maintain symptoms
6.	Encourage patients to broaden their desired treatment goals beyond symptom improvement

The recommendations for DSM-5 and ICD-11 informed treatment presented in this chapter are generally supported by research derived from universal five-factor traits (Widiger & Costa, 2013), the Dimensional Assessment of Personality Pathology (Livesley, 2003), the Schedule for Nonadaptive and Adaptive Personality (Clark, 1993), and the Minnesota Multiphasic Personality Inventory – Personality Psychopathology 5 (Harkness & McNulty, 2006), which all describe different aspects and levels of the Five-Factor Model (Widiger & Simonsen, 2005). In recent years, hundreds of studies have provided empirical support for the DSM-5 traits (Al-Dajani, Gralnick, & Bagby, 2016; Miller, Sleep, & Lynam, 2018) as measured with the Personality Inventory for DSM-5 (PID-5; Krueger, Derringer, Markon, Watson, & Skodol, 2012). Essentially, all of the aforementioned measures have shown substantial convergence with the DSM-5 and ICD-11 trait domains (Anderson et al., 2013; Bach, Sellbom, Skjernov, & Simonsen, 2018; Bastiaens et al., 2016; Clark et al., 2015; Gore & Widiger, 2013; Oltmanns & Widiger, 2018). However, not all the specific ideas discussed below have been empirically validated, such as how to structure a therapeutic alliance with a patient characterized by detachment.

Pre-Treatment Assessment of Traits

Before a therapist can take traits into account, there must be an appropriate and feasible method of trait assessment. In regards to the maladaptive traits described in DSM-5 and ICD-11, we recommend using at least one of several approaches. First, the PID-5 may be employed as a self-report form (Krueger et al., 2012) or informant report form (Markon, Quilty, Bagby, & Krueger, 2013). Likewise, the ICD-11 traits may be measured using the Personality Inventory for ICD-11 (PiCD; Oltmanns & Widiger, 2018). Another solution is to use a simple algorithm for deriving the five ICD-11 domains from PID-5 trait facets (Bach, Sellbom, Kongerslev, et al., 2017). For a more thorough assessment, the patient may be administered the Structured Clinical Interview for DSM-5 – Alternative Model of Personality Disorder – Module II (SCID-AMPD; Skodol, First, Bender, & Oldham, 2018), which may also yield the five ICD-11 domains by using the aforementioned algorithm for that purpose (Bach, Sellbom, Kongerslev, et al., 2017). Finally, the traits may simply be rated by the therapist based on observations, unstructured questions, and/or other clinical information (Morey, Krueger, & Skodol, 2013). We refer to Miller et al. (2018) for an updated empirical review of the maladaptive traits described in DSM-5 Section III, and to Bach, Markon, Simonsen, and Krueger (2015) and Bach and First (2018) for clinical illustrations.

Which Aspects of Traits Should We Seek to Change?

An important distinction in this chapter is that traits should not be confused with the impairment they may cause, which is consistent with the well-known distinction by Allport (1961) that personality is something and personality does something. This also aligns with McCrae and Costa’s (1995) distinction between basic tendencies and characteristic adaptions. For example, a patient who is prone to becoming anxious (i.e., trait anxiousness) could fashion many alternative adaptations in his or her everyday life to avoid or temporarily reduce anxiety, including social withdrawal, substance or alcohol use, self-help reading, exercise, or meditation. A similar distinction has been proposed by Leising and Zimmermann (2011), who describe personality dispositions that may become problematic as separate from the possible negative consequences of those personality patterns. For example, an individual may have a trait disposition to experience fear that results in frequently feeling stressed out and becoming socially isolated. Likewise, in the DSM-5 Section III system (American Psychiatric Association [APA], 2013) and the ICD-11 system (World Health Organization [WHO], 2019), personality disorders are conceptualized in terms of both stylistic traits and their related functional impairment/severity. Accordingly, a patient may have prominent features of negative affectivity, which may involve mild impairment in self and interpersonal functioning (e.g., some distress without serious dysfunction) or severe impairment in self and interpersonal functioning (e.g., hatred, self-harm, and/or psychotic-like perceptions under stress). Finally, this is comparable to the rationale provided in the Sociogenomic Trait Intervention Model (STIM), which focuses on changing trait-related states in a way that ensures the changes are enduring. However, only if these state changes become internalized, extended, and automatic would they qualify as changes in traits (Roberts, Hill, & Davis, 2017).

A basic clinical principle is that traits tend to be resistant to change, whereas characteristic adaptations or functional impairment may be less resistant to change. Therefore, treatment should target what personality does to the patient (i.e., characteristic adaptions), as we cannot really change what it is (i.e., basic tendencies). Not even 20 years on the couch can turn a high anxiousness Woody Allen-like character into a low anxiousness person. Instead, the patient may be helped to find new adaptive ways of coping that fits her or his traits, which offers better potential for constructive growth and more healthy relationships. In other words, one must learn to live well with oneself. Accordingly, the patient’s level of impairment may be elucidated in terms of how much the traits impact the patient’s ability to live a fulfilling life. In line with this, traits are important to address because their maladaptive expressions influence the clinical portrait. For example, emotional lability, anxiousness, and impulsivity affect how the patient responds to stress, challenges, and daily tasks. Clinical practice should therefore focus attention on understanding the traits while changing their consequences. This is consistent with Wachtel’s (1973) suggestion that psychotherapeutic interventions should be targeted toward the choices of current environmental stimuli, rather than toward the underlying dispositions. From this perspective, lasting therapeutic change usually depends on modulating the impact of the traits and not getting rid of them, which will be further explained in the following.

How Therapists May Benefit from Considering Patient Traits

As summarized in Table 19.1, psychotherapists may make use of patient trait information in several ways. In this section, we provide guidelines for how to use traits to establish a favorable treatment alliance, improve self-knowledge and insight for patients (including therapeutic assessment), and inform psychoeducation as well as the focus and implementation of treatment.

Using Traits to Establish a Favorable Treatment Alliance

As a precondition of effective treatment of the patient’s problems, the therapist must establish a favorable alliance with the patient (Martin, Garske, & Davis, 2000). Most therapists intuitively adapt their personal style to the patient’s personality traits. However, once a framework of personality traits is established, the therapist can do this more consciously and with more confidence (Gartstein, Putnam, Aron, & Rothbart, 2016). For each of the five DSM-5 and ICD-11 trait domains, we therefore present a tailored approach to forming the alliance in the “Guidelines for Specific Trait Domains.”

Personality Traits as a Source of Self-Knowledge and Insight

It is vital for patients to understand their own self, as one must learn to live well with oneself (Gartstein et al., 2016). For example, individuals who acknowledge their own weaknesses and accurately perceive how others view them appear to be more liked by others (e.g., Oltmanns, Gleason, Klonsky, & Turkheimer, 2005). In other words, the insights gained from personality assessment may potentially improve relationships, which are often impaired among those with personality disorders.

The approach of collaborative therapeutic assessment is ideally suited for promoting self-knowledge (Fischer & Finn, 2008). In this procedure, patients can first be asked to identify questions about themselves that they would like the assessment to address. Subsequently, the test results can be used to answer the patient’s questions after the assessment while also discussing the accuracy of the test profile and its interpretations. For example, are the traits demonstrated in everyday life and how? This approach not only relies on the validity/accuracy of the test results but also takes advantage of the profile as a framework for discussion of the patient’s mental health issues in general. As a particularly powerful achievement, therapeutic assessment may also help patients develop a more compassionate understanding of themselves.

Using Traits in Psychoeducation

When working with traits, an essential goal is to help patients accept that traits are part of their biological heritage – and therefore something they must own – without conveying the idea that traits cannot be changed into something more adaptive. Personality traits are not fate, and knowing about them can actually lead to greater freedom. As previously emphasized, the patient must learn to live well with oneself. This balanced communication with the patient is achieved by educating the patient about how the environment influences traits, so that the patient understands that it is possible to adjust the way traits are expressed. Some aspects of traits are mostly hardwired, whereas others are more changeable. A particularly useful way of building this acceptance is to encourage patients to identify ways in which their traits may be beneficial (e.g., Figure 19.4 and Figure 19.6). As a part of this process, the therapist must teach the patient about what traits actually look like “in action.” The most common traits probably emerged sometime in human history because they involved an adaptive advantage. They helped our remote ancestors solve adaptive problems in their environment and survive long enough to pass on their genes. For example, the disinhibition facet of impulsivity (see Figure 19.4) may have served as a productive feature when adaptive (e.g., quickly hunting down an animal) and a problematic feature when maladaptive (e.g., neglecting long-term consequences). This way of presenting the information suggests that traits are not naturally maladaptive; instead, they are only maladaptive when individuals have learned to express them in ways that cause dysfunction or lack the flexibility that applies to adaptive trait functioning (Livesley, 2003). Taken together, this kind of psychoeducation often facilitates change in and of itself. The patient does not have to change a global quality that he or she feels is a fundamental part of the self, but rather more specific aspects of his or her behavior.

Even apparently problematic traits such as emotional lability and anxiousness can be useful. For example, a male patient with high levels of depressivity and anxiousness that led to periods of misery and dysphoria learned to be more tolerant of these feelings when he recognized that they contributed to his work. He was an aspiring artist, and the despair and melancholy added a dimension to his paintings that was not present when his mood was less depressed. Previously, he feared the feelings of melancholy and dejection, and whenever his mood dropped, he would ruminate over problems instead of taking advantage of it. Once he realized that the feelings could be used creatively, he ruminated less and painted more, which in return had the impact of moderating his sadness.

As another example, a troubled writer and poet had extremely labile moods and was unsteady in her productivity due to emotional lability, impulsivity, eccentricity, and some unusual beliefs and experiences. Like the previous patient, she feared mood changes, but she also feared alienation and exclusion from society because of her way of being. She therefore regularly told herself that she could not handle this life and therefore had to kill herself. She did not attempt to kill herself, but used self-harm as a way of coping with the pain and disillusion. After some time, her emotional lability settled enough for her to realize that her vulnerable traits, eccentric style, and unusual perceptions actually helped her write peculiar but impressive avant-garde literature that was highly recognized among intellectuals. Consequently, instead of feeling despair, she began to appreciate the freshness, depth, spontaneity, and originality that her personality added to life. This development helped her to tolerate her emotional lability, which indirectly had a settling effect that reduced the impairment caused by this lability.

Finally, it is generally easier to acknowledge the adaptive significance of traits when the context is taken into account because traits are context-dependent. Therefore, a particular trait may be valuable in some situations but not in others. For example, the trait domain of detachment may be problematic in social situations (e.g., at parties), but it could be useful in other settings in which it is an advantage to be self-reliant, cool headed, capable of self-absorption, and have little need for interpersonal contact (e.g., an academic researcher or a “HGV” truck driver). Understanding this usefulness of otherwise maladaptive traits helps therapists and patients not to evaluate traits in all-or-none terms.

Using Traits to Inform Focus of Treatment

Psychotherapists need to work with traits in two ways. First, treatment must be tailored to fit patients’ salient traits in addition to their psychopathology and presenting problems. For example, patients with trait features of negative affectivity as well as antagonism/dissociality and/or disinhibition are usually “too reactive.” Consequently, an important task for therapists is to contain their behavior and reduce their reactivity by teaching them to both tolerate and regulate it. The opposite applies to patients with features of detachment and anankastia, as these patients are less emotionally responsive. Thus, the therapeutic task is to increase their emotional activity and liberty while also accepting their trait nature.

Secondly, as previously emphasized, treatment needs to focus on changing maladaptive traits into more adaptive traits, without seeking to get rid of the basic traits. Accordingly, treatment should focus on modulating trait expression by helping the patient to find more healthy or constructive ways to express or manage basic traits. Such management or modulation particularly makes sense when we look at how the environment influences trait expression. In other words, the environment may amplify or reduce the expression of the genetic trait dispositions (Livesley, 2003). This premise implies that it is possible to change the expression of maladaptive traits by modifying the environment. Accordingly, it may reduce maladaptive trait behavior in some patients if they are encouraged to evade certain situations and relationships that evoke these behaviors. Therapists often do this intuitively; for example, by helping patients to detect and prevent risk situations for self-harm such as spending too much time alone. This approach involves understanding that the highly emotionally labile patient will probably always be emotionally labile and experience mood swings, although the magnitude of these swings may be dampened by teaching the patient how to regulate emotions. Likewise, the detached patient with restricted affectivity and intimacy avoidance is unlikely to become even modestly extraverted and attention-seeking, but may be helped to feel more comfortable in relating to other people. A concrete implication of this approach is that some patients may benefit from receiving help in finding or generating environments that allow them to express their core traits in more functional and satisfying ways. This strategy particularly applies to patients at the extreme end of a trait continuum. For example, detached patients are best helped by encouraging them to create a fulfilling way of living that is consistent with their basic stylistic traits and needs, rather than attempting to modify traits that are “hardwired” and extremely resistant to change.

Guidelines for Specific DSM-5 and ICD-11 Trait Domains

In this section, we provide ideas for the treatment of specific trait domains in the DSM-5 Section III and the ICD-11 models of personality disorders, including negative affectivity, detachment, antagonism/dissociality, disinhibition, anankastia, and psychoticism. As shown in Table 19.2, the DSM-5 and ICD-11 trait domains are highly concordant and align with maladaptive extremes of universal five-factor traits. Based on a comprehensive review of the literature, it is assumed that the first two domains of negative affectivity (high neuroticism) and detachment (low extraversion) are most amenable to treatment (Roberts, Luo, et al., 2017).

Table 19.2Alignment among DSM-5, ICD-11, and FFM traits

DSM-5	ICD-11	FFM
Negative Affectivity	Negative Affectivity	High Neuroticism
Detachment	Detachment	Low Extraversion
Antagonism	Dissociality	Low Agreeableness
Disinhibition	Disinhibition	Low Conscientiousness
(low Disinhibition)	Anankastia	High Conscientiousness
Psychoticism	(Schizotypal/Dissociation)	High Openness

Negative Affectivity

This domain is essentially the same as elevated neuroticism and comprises the opposite pole of emotional stability. It is not a coincidence that negative affectivity is presented here as the first domain, as it may lead to a number of obvious consequences including emotional crises, deliberate self-harm, and suicidality (Livesley, 2003). Patients with negative affectivity are typically characterized by anxiousness, emotional lability, low self-esteem, and depressivity, as well as their interpersonal (e.g., submissiveness) and behavioral (e.g., avoidance or self-harm) manifestations. The emotional dysregulation and anxiousness related to negative affectivity tend to disrupt cognition in the form of perseveration, separation insecurity, and suspiciousness, and interfere with interpersonal behavior in the form of hostility and submissiveness (APA, 2013; WHO, 2019). Consistent with the WHO characterization of non-specific psychological distress, negative affectivity is associated with elevated levels of emotional suffering that are shared with a wide range of disorders (without being specific to any single disorder) and predict a range of mental and physical problems and may tax one’s ability to cope (Phillips, 2009).

Whereas negative affectivity is a component of nearly all personality disorders (with perhaps the exception of schizoid and antisocial/psychopathy), the presentation of the facets of negative affectivity may differ. The facet of anxiousness may appear as social anxiousness, evaluation apprehension, and distrust-related anxiety as seen in avoidant and schizotypal disorders. Emotional lability and depressivity may be confined to affective dysregulation and feelings of shame and hopelessness, as seen in borderline personality disorder. The facet of hostility may manifest as the reactive anger of narcissistic personality disorder, dysregulated anger of borderline personality disorder, or the intimidating rage of antisocial personality disorder. The overall goal of treating negative affectivity is to help the patient find more adaptive expressions of this trait as illustrated in Figure 19.1.

Figure 19.1

From maladaptive to adaptive expression of negative affectivity

Establishing a Therapeutic Relationship

The patient with prominent features of negative affectivity may also be characterized as the neurotic patient around whom many of the technical features of classic psychoanalysis were developed. Due to transference, the patient tends to link such neurotic features to the therapist: “Does the therapist really care about me or think about me between sessions?” Trait facets of submissiveness and separation insecurity in particular may influence the patient–therapist relationship. Depending on the configuration of counter-transference, the therapist may be overly nursing (“come to me, and let me soothe you”) or sadistic/abusive (“get it together, pantywaist”).

A more contemporary approach to building a successful alliance with patients characterized by negative affectivity involves (1) educating the patient about his or her willingness to experience anxiety and (2) encouraging the patient to regard the relationship with the therapist as simply providing more examples of how the patient is constantly scanning for cues of threats to self-esteem. In line with most traditional therapeutic approaches, the therapist aims to reduce such anxiety because it interferes with healthy information processing. For example, in response to a therapist’s casual statement that a patient’s suit is well tailored, the patient may anxiously wonder whether the therapist is saying “you need disguise because you are fat.” Accordingly, interventions aimed at reducing the influence of anxiety and related difficulties may involve the therapist listening to how the patient listens to or perceives other’s remarks (i.e., “listening to listening”).

Treatment Goals for Negative Affectivity

Because emotional distress has historically been a chief component in patients’ presenting complaints, virtually all modes of psychotherapy target aspects of negative affectivity to some degree (Widiger & Trull, 1992). For example, traditional Beckian cognitive therapy targets negative automatic thinking and beliefs often related to emotional disorders (Beck, 1983), dialectical behavior therapy targets emotional dysregulation (Linehan & Dexter-Mazza, 2008), acceptance and commitment therapy focuses on acceptance of negative affect (Hayes, 2004), and compassion focused therapy targets problematic cognitions and emotions related to anxiety, anger, trauma, shame, and self-criticism by means of compassionate mind training (Gilbert, 2014). Transference-focused psychotherapy assumes that enhanced emotional control results from the resolution of structural impairments to personality that involve fragmented object relationships that are addressed in the context of the interaction between therapist and patient (Clarkin, Yeomans, & Kernberg, 2006). Mentalization based treatment assumes that emotion regulation increases with improved mentalizing capacity and epistemic trust (Bateman & Fonagy, 2016). Finally, schema therapy assumes that emotional suffering is reduced by fostering emotional fulfillment of the patient’s inner “vulnerable child,” including modification of underlying schemas, such as defectiveness and vulnerability to harm, through corrective emotional experiences (Young, Klosko, & Weishaar, 2003).

An implicit or explicit aim for most therapies seems to be to change the patient from anxious to non-anxious or mistrustful to trusting (e.g., Beck, Davis, & Freeman, 2015; Linehan & Dexter-Mazza, 2008). However, it may be false advertisement to claim that increased awareness of automatic appraisals will eventuate in the extinction of thoughts associated with negative affectivity. In fact, the single greatest misconception that patients (and many therapists) hold about therapy is that a high negative affectivity person can be turned into a low negative affectivity person. Instead, genetically influenced traits of negative affectivity may be modified by environmental manipulation, but only within certain limits. Accordingly, the patient can learn to identify and deal with automatic appraisals in a healthier manner. For example, he or she can learn to select new adaptations to the experience of anxiety or sadness. Yet, as previously mentioned, this is not the same as turning a Woody Allen-like patient with prominent negative affectivity into a patient with low negative affectivity. Figure 19.1 illustrates how the negative affectivity facet of emotional lability potentially may be expressed in a more adaptive manner. In general, it has been suggested that patients with negative affectivity may benefit from treatment that focuses more globally on emotion regulation and stress management skills (Bagby et al., 2016; Barlow, Sauer-Zavala, Carl, Bullis, & Ellard, 2014). Below, we present some examples of specific approaches and techniques that may be utilized to target problems related to negative affectivity.

The Unified Protocol is a specific transdiagnostic cognitive-behavioral approach designed for a range of emotional disorders that share the underlying trait of negative affectivity (Barlow et al., 2011), including mood and anxiety disorders and avoidant and borderline personality disorders (Sauer-Zavala, Bentley, & Wilner, 2016). The Unified Protocol approach targets negative affectivity by extinguishing distress in response to the experience of strong emotions. As illustrated in Figure 19.2, reduction of aversive reactions to emotions by improving tolerance is thought to lead to less reliance on the maladaptive, avoidant emotion-regulation strategies that exacerbate symptoms. In the end, this is expected to lead to fewer negative emotions (Barlow et al., 2011; Sauer-Zavala et al., 2016). In other words, improvement of negative reactions to emotional stimuli reduces the intensity and frequency of forthcoming experiences and is thereby thought to enhance the adaptivity of negative affectivity.

Figure 19.2

A rationale for focusing on negative affectivity in the treatment of emotional disorder

Patients with prominent features of negative affectivity are not just chronically unhappy, anxious, or worried, but can easily be pushed over the edge when things actually do go wrong in their lives. Because of this chronic state of reactivity to challenging events, mindfulness-based treatment has been identified as an intervention that may be of particular value for helping individuals with negative affectivity cope with such challenges (Drake, Morris, & Davis, 2017). Accordingly, the patient is trained in practicing mindfulness by consciously, curiously, and acceptingly focusing attention on present thoughts, feelings, and bodily sensations without judgment or efforts to avoid or fight these experiences. In practice, patients are encouraged not to judge aspects of negative affectivity as negative, but to instead take a gentle, inquisitive attitude, which reduces racing thoughts, rumination, and worry (Dimidjian & Linehan, 2008) and changes the impact of negative emotions and sensations on the patient. Drake and colleagues (2017) found that even patients with the highest levels of negative affectivity can learn to cope with challenging life situations by drawing on mindfulness-based coping strategies. In other words, mindfulness may be viewed as a learned trait or skill that explains why some individuals with negative affectivity are less distressed than others. Mindfulness also comprises an essential part of the Unified Protocol and dialectical behavioral therapy.

The emotional lability facet of negative affectivity is a core feature of borderline personality disorder (Bach, Sellbom, Bo, & Simonsen, 2016), and involves instability of mood and emotions, including emotions that are intense, easily aroused, and/or out of proportion to circumstances. Patients experiencing emotional lability may often use maladaptive coping strategies, such as substance abuse, binge eating, self-harm, or other behaviors that function to avoid or suppress emotions. Dialectical behavioral therapy was developed to address this core feature by enhancing emotion regulation skills in terms of distress tolerance, acceptance, and mindful awareness (Linehan & Dexter-Mazza, 2008).

The depressivity facet of negative affectivity also deserves particular psychotherapeutic attention. This facet involves feelings of being down, hopeless, miserable, and pessimistic about the future, along with pervasive guilt or shame, inferiority, and suicidal ideation or behavior. Compassion focused therapy may be an efficient treatment to address the shame and self-criticism in patients with high levels of depressivity by helping the patient feel safe and practice self-compassion as the antithesis to self-criticism (Gilbert, 2014).

The anxiousness facet of negative affectivity typically also includes a somatic component (e.g., muscle tension and rapid heart rate), which may be targeted by means of relaxation and stress-reduction methods, including breathing exercises and neuromuscular progressive relaxation.

Interpersonal facets of negative affectivity, such as submissiveness, separation insecurity, and hostility, may be targeted using assertiveness training to change the environmental reinforcers that maintain self-defeat, anxiety, and depressivity (Millon, Grossman, Millon, Meagher, & Ramnath, 2004). As illustrated in Figure 19.3, this may be conceptualized as an assertive balance between submissiveness at one maladaptive pole and hostility at another maladaptive pole. The goal of this approach is to train patients to take care of their own needs in an adaptive manner by being sufficiently compliant when most appropriate, and saying no or protesting when most appropriate.

Figure 19.3

Fostering assertiveness ensures more adaptive expression of negative affectivity

In general, negative affectivity is substantially related to most maladaptive schemas of emotional disorders as defined in the schema therapy model (Bach & Bernstein, 2019; Schmidt, Joiner Jr., Young, & Telch, 1995; Thimm, 2010). For example, the facet of separation insecurity aligns with the schema of abandonment, whereas the facet of submissiveness aligns with the schema of subjugation (Bach & Bernstein, 2019). Due to such schemas, patients with negative affectivity are likely to feel vulnerable, lonely, abandoned, distressed, and deprived from having their emotional needs met, which are sustained by the absence of healthy coping strategies. Consequently, patients with prominent features of negative affectivity may benefit from the schema-focused approaches used in schema therapy, such as enhancement of the patient’s healthy adult function that must protect and soothe the vulnerable part of the patient (where negative affect and related schemas are experienced).

Detachment

This domain is essentially associated with extremely low extraversion (i.e., maladaptive introversion), and patients with such features may describe themselves as shy, introverted, avoidant, or a “loner.” Others may view them as cold, unsociable, unexcitable, and uninterested. Detachment is typically characterized by facets of withdrawal, restricted affectivity, anhedonia, intimacy avoidance, and sometimes suspiciousness (APA, 2013; WHO, 2019). In terms of low FFM extraversion, this typically involves low levels of warmth, gregariousness, excitement seeking, positive emotion, and activity (Costa & McCrae, 1992). Patients with detachment may initiate therapy due to feeling as if they are missing out on something in life; however, they will likely be reticent to aggressively pursue interpersonal interactions or novel activities. They may have a select few friends, acquaintances, or colleagues who have expressed concern, distress, or frustration with their detached, withdrawn, and unassertive behavior, contributing external pressure that leads to treatment-seeking. The overall goal of treating detachment is to help the patient find more adaptive expressions of this trait as illustrated in Figure 19.4.

Figure 19.4

From maladaptive to adaptive expression of detachment

Establishing a Therapeutic Relationship

Therapists like to be appreciated by their patients and to obtain a sense of progress and personal competency from sessions. Such appreciation and progress is often mirrored in the facial expressions of positive affectivity. Consequently, patients with prominent features of detachment (i.e., restricted affectivity) tend to frustrate therapists’ own “narcissistic” needs for appreciation and approval. Even insightful and psychologically sharp observations by the therapist may not trigger any facial markers of interest, and therapist jokes seem to fall flat. Thus, unless the therapist takes these trait features into account, he or she may get upset or disappointed with such patients. The worst case of such therapeutic narcissism may cause the therapist to have unexplained rage at the difficult patient who fails to appreciate how brilliant the therapist is. In such cases, it is important for therapists to understand that patients are not to be used as “positive feedback machines.” Instead, a good and healthy alliance with the patient should begin with a decision by the therapist not to use the patient to meet his or her own narcissistic needs. Furthermore, the therapist must also understand that a low level of positive affectivity does not mean that the patient is psychologically flat or that his or her life is intellectually poor (Harkness & McNulty, 2006).

Therapies vary in the extent to which they require the patient or therapist to speak and interact. A patient with prominent features of detachment is often a person of few words. Depending on the therapeutic and theoretical framework, this may be misinterpreted as a deficit or as a sign that a more talkative and happy part inside the patient is “repressed” or has been “shut down.” Eventually, such approaches to the detached patient may result in early dropout. Likewise, highly enthusiastic healthcare staff should not “get in the face” of the detached patient in an attempt to make the patient more engaged in social activities. Staff may misinterpret the lack of response from the detached patient as disrespect and start “pushing” the patient to get a response, until the patient eventually does react! Such mechanisms of detached personality warrant particular consideration when working with forensic and substance use patients (Harkness & McNulty, 2006).

Treatment Goals for Detachment

Individual therapists can assist patients in setting appropriate goals and expectations, understanding the nature of detachment and the responses it evokes in others, and clarifying the specific negative impact of detachment in patients’ lives. Figure 19.4 shows how the detachment facet of withdrawal potentially may be expressed in a less maladaptive manner. Therapy with patients characterized by detachment may target related core beliefs involving a lack of interest in relationships, mistrust, independence, and interpersonal ambivalence (Hopwood et al., 2013).

Behavioral therapy and skills training, including approaches such as behavioral activation (Lejuez, Hopko, Acierno, Daughters, & Pagoto, 2011), could also serve a primary role in treating patients with detachment. In order to begin behavioral therapy, it is critical to understand the specific deficits of detachment that are most detrimental to the patient’s successful functioning, as well as the reinforcers that are maintaining maladaptive behaviors. Typical social reinforcers (such as attention or physical touch) are unlikely to be effective for patients with detachment, so it is imperative that the therapist and the patient work together to determine what will foster more adaptive behaviors of detachment. In the case of a therapy such as behavioral activation, this includes the consideration of values before moving into the determination of activities to be undertaken as part of the therapy.

Finally, and perhaps most important, patients with low hedonic capacity due to detachment may feel secondary guilt because they do not feel what they are “supposed” to feel about social interactions. Therefore, a primary intervention may be to help detached patients feel more comfortable being who they are. This involves the therapist understanding the patient, and then helping the patient understand, appreciate, and accept him- or herself (Fischer & Finn, 2008). This trait also has implications for the treatment environment in general. In certain cases, it may be best to help the patient feel safe by means of familiar “isolation” from too much social stimuli and enthusiasm. This is consistent with Nidotherapy-based management of schizoid personality disorders (Tyrer, 2002).

Antagonism or Dissociality

This domain is associated with extremely low agreeableness, and is probably the domain that therapists would most prefer to avoid. Facets of this domain include callousness, manipulativeness, deceitfulness, grandiosity, attention seeking, hostility, and sometimes low submissiveness and low anxiousness (APA, 2013; WHO, 2019). In terms of low FFM agreeableness, this domain typically involves lack of altruism, compliance, modesty, and tendermindedness (Costa & McCrae, 1992). The overall goal of treating antagonism/dissociality is to help the patient find more adaptive expressions of this trait as illustrated in Figure 19.5.

Figure 19.5

From maladaptive to adaptive expression of antagonism/dissociality

Establishing a Therapeutic Relationship

From the outset of therapy, patients presenting with antagonism or dissociality will be resistant to therapists’ efforts to establish rapport, will oppose most forms of assessment, will be frequently evasive or dishonest, and will explain that other people are the cause of their problems. They may be referred through the justice system or by their employer, or may be seeking therapy in order to obtain some secondary gain (e.g., lawsuit settlement and child custody). However, if accompanied by features of negative affectivity, the antagonism/dissociality may be an externalizing voice of something more vulnerable inside the patient that longs for understanding, comfort, and stability (Bach & Bernstein, 2019).

Within the therapeutic relationship, these patients may engage in the same manipulation, dishonesty, arrogance, and defiance that they exhibit in other relationships. Therapists must therefore avoid engaging in power struggles or responding defensively when challenged; this must be combined with a healthy dose of skepticism. There is a constant tension between the therapist attempting to model trust, straightforwardness, and empathy, while remaining alert to the patient’s dishonesty and manipulativeness. Therapists who are considering initiating treatment with individuals low in agreeableness should reflect upon their ability to confront unpleasant behaviors without defensiveness or moral judgment (Harkness & McNulty, 2006).

A patient high on this domain may attempt to dominate and control the therapist. By predicting such domination tactics to the patient, the therapist may equalize the relationship. If the patient subsequently attempts to control and dominate, this will only reveal the therapist’s expertise. The therapist can also try to sublimate or contain the patient’s need for control within the therapy by identifying options and giving choices to the patient. Explicit attempts to share control with the patient also addresses the potential counter-transferential revenge-based impulses to control and dominate the patient.

To establish a working alliance with the patient, it is essential to show insight and sensitivity to the patient’s worldview. Finding an appropriate balance between advocating changes and validating the patient is a constant clinical task. Patients high on antagonism/dissociality are typically highly competitive and may seek to outperform others, especially when the trait facet of grandiosity applies to the patient. Therefore, “morally correct” confrontations in which mutuality and cooperativeness are seen as morally superior may threaten the alliance. The patient may simply be prone to view the therapist as naïve and uncool.

Treatment Goals for Antagonism/Dissociality

Therapists must maintain realistic expectations regarding treatment outcomes for this domain, which is highly consistent with the treatment of antisocial and narcissistic personality disorders. Although such individuals may seem resistant to intervention, they are not untreatable (Behary & Dieckman, 2012; Bernstein, Arntz, & de Vos, 2007; Ronningstam, 2010; Salekin, 2002). Therapeutic techniques, such as cognitive-behavioral or interpersonal therapy, should employ rational and utilitarian arguments that focus on the benefits of prosocial behavior. For example, if a patient is self-centered, defiant, and arrogant and struggling to obtain employment, the therapist should illustrate why altruism, compliance, and modesty would be attractive to an employer.

If episodes of recent aggression or antagonistic behavior are presented in the clinical session, the therapist can acknowledge the benefits of using aggression before a more comprehensive analysis of the costs. Afterwards, the therapist can move on with psychoeducation about interpersonal influence and management theory as more useful alternatives to mere aggression: the mafia boss Tony Soprano meets Abraham Maslow. Consequently, a reasonable goal for therapy can be structured around the patient first developing an awareness of the costs of using an antagonistic/dissocial strategy (Harkness & McNulty, 2006; Livesley, 2003). Then, the therapist can treat the patient as having a skill deficit by training in more appropriate strategies of interpersonal influence. Figure 19.5 shows how the antagonism/dissociality facet of callousness potentially may be expressed in a less maladaptive manner. If the aforementioned approach succeeds and a quality alliance is established, the therapist can move on with more in-depth treatment of characterological features by means of schema therapy (Behary & Dieckman, 2012; Bernstein et al., 2007), mentalization based treatment (Bateman & Fonagy, 2016), or transference focused therapy (Stern, Diamond, & Yeomans, 2017), among others.

Antisocial and narcissistic personality disorders can be said to comprise severe forms of antagonism/dissociality, and modified versions of schema therapy have been developed for such features (Behary & Dieckman, 2012; Bernstein et al., 2007). The schema therapy model for psychopathy only addresses aspects that are thought to be linked with insecure attachment styles and/or trauma, and not solely innate neurobiological factors (Bernstein et al., 2007). The treatment typically focuses on schemas related to insufficient self-control and a sense of having special rights, which are also related to frequently acting cruel and selfish. This is further accentuated by excessive reference to others for admiration as an attempt to regulate one’s own self-esteem. Moreover, antagonistic individuals often experience anger when their needs are not met, which may be expressed as highly demanding and hostile behavior. As an attempt to maintain social dominance and a sense of superiority, they may strategically bully, dominate, or hurt others. Finally, antagonistic individuals may also be extremely alert to potential threats to social dominance or superiority (Bach & Bernstein, 2019). Essentially, the schema therapist must confront and bypass antagonistic overcompensating modes (e.g., “predator mode” and “self-aggrandizer mode”), gain access to an underlying vulnerable or angry part of the patient, and enhance the patient’s healthy adult functions (Young et al., 2003).

Disinhibition

This domain is essentially associated with low conscientiousness. Patients with such features are typically characterized by facets of irresponsibility, impulsivity, distractibility, risk taking, and lack of perseveration and ability to follow rules (APA, 2013; WHO, 2019). In terms of low conscientiousness, this domain typically involves low ability to keep order, low dutifulness, low self-discipline, low competence, and low achievement striving (Costa & McCrae, 1992). The overall goal of treating disinhibition is to help the patient find more adaptive expressions of disinhibition as illustrated in Figure 19.6.

Figure 19.6

From maladaptive to adaptive expression of disinhibition

Establishing a Therapeutic Relationship

Establishing an alliance with the disinhibited patient can be tricky, but is doable when offering the patient a real understanding of the disinhibited personality. Disinhibited patients are not likely to have sought therapy under their own motivation. Instead, a family member or friend may have called for the appointment and transported the patient to therapy (assuming treatment is not compulsory due to legal concerns). They may appear unkempt, although not necessarily unclean. When describing the nature of their problems, they may be vague and unfocused, which makes it difficult to write up a focused case-formulation and treatment plan.

The therapist should avoid acting like a school principal or an authoritarian parent, which may only be obnoxious to the patient. Instead, remember that spontaneity and novelty will be attractive to the patient, whereas triviality and predictability may drive the patient away. Be prepared to listen to and tolerate greater risk taking and less awareness of long-term consequences. Seek to build a relationship with the patient around the goal of helping him or her to live with a disinhibited personality, rather than shaming the patient into inhibition or anankastia (Harkness & McNulty, 2006).

Treatment Goals for Disinhibition

Behavioral therapy is one obvious treatment for problems related to disinhibition (Safren, 2006). The therapist should identify what is rewarding or punishing for the patient, which must be strong enough to effectively change the likelihood that a behavior will take place. The patient and therapist should then discuss the patient’s behaviors that are creating the most severe negative consequences, which will serve as the first behavioral targets. In addition to directly modifying behaviors, the therapist should assist the patient in changing her or his environment to create an effective reward and punishment system that is naturally maintained by the environment, keeping in mind that feelings of mastery and accomplishment are unlikely to be effective reinforcers for these patients. Figure 19.6 shows how the disinhibition facet of impulsivity potentially may be expressed in a less maladaptive manner.

Family systems therapy may also be an appropriate option for the treatment of disinhibition (Brown, 1999). Families and friends will have established ways of interacting with the patient, which are likely to play a role in maintaining behavior. For example, some families treat the patient as the “scapegoat.” Positive changes in the patient are viewed skeptically by the family and the system functions most smoothly when the patient can be blamed for negative situations. The therapist will work with the family to identify these patterns of interaction, and to change possible reinforcers that have served to maintain the patient’s behaviors.

A primary goal of treating maladaptive disinhibition is to help the patient learn to live with a disinhibited personality. In many clinical settings, a disinhibited personality may be equated with ADHD, which is consistent with research showing that disinhibition facets of distractibility and impulsivity capture ADHD (Sellbom, Bach, & Huxley, 2018; Smith & Samuel, 2017). In any case, this involves helping the patient find safer and more healthy adaptations that still fit with the patient’s need for excitement, risk taking, and novelty. However, there are currently no known interventions for turning high disinhibition into low disinhibition, which should also be kept in mind when planning the treatment. Overall, the therapist should help the patient realize how this hardwired feature of disinhibition consistently influences various aspects of life, including relationships, financial problems, short time horizon, distractibility, alcohol- and drug use, and boredom. Such a personality-based case conceptualization might help the patient understand the underlying disposition and life pattern (Sellbom et al., 2018). After some time, the patient can start to appreciate and distinguish features of disinhibition from the adaptations he or she has developed. This has a clear advantage over a pathological diagnostic formulation. Consistent with clinical management of ADHD, patients with disinhibition may benefit form learning certain skills for everyday life as if they had ADHD (Safren, 2006).

Anankastia

This domain is essentially associated with maladaptive low disinhibition and maladaptive high conscientiousness, which causes the patient to have extremely high standards of thought and behavior and a tendency to rigidly persevere around conventionality and organization. Patients with such features are typically characterized by aspects of rigid perfectionism along with emotional and behavioral constraint, including concern with following rules and meeting obligations, deliberativeness, rigid perseveration, stubbornness, and rigid control of emotional expression (WHO, 2019). In terms of maladaptive high FFM conscientiousness, this domain may involve excessive orderliness, dutifulness, achievement striving, and self-discipline (Costa & McCrae, 1992). Anankastia is substantially associated with obsessive-compulsive personality disorder, which in the ICD-10 is labeled F60.5 anankastic personality disorder. Sometimes individuals with narcissistic personality disorder may also demonstrate the acclaim-seeking aspect of maladaptive high achievement-striving, which is consistent with Millon’s bureaucratic compulsive subtype of obsessive-compulsive personality disorder (Millon et al., 2004). The overall goal of treating anankastia is to help the patient find more adaptive expressions of perfectionism as illustrated in Figure 19.7.

Figure 19.7

From adaptive to maladaptive expression of anankastia

Establishing a Therapeutic Relationship

The overwhelming preoccupation with orderliness, perfectionism, and control of their lives, emotional expressions, and relationships means that most types of treatment are going to be, at best, difficult. Treatment options that do not fit within the patient’s scheme will likely be quickly rejected rather than attempted. Treatment is complicated if patients do not accept that they are anankastic, or believe that their thoughts or behaviors are in some sense correct and therefore should not be changed. However, patients with anankastia who do decide to initiate therapy are likely to be successful, as they will be diligent about completing homework, consistent in their attendance, and are unlikely to prematurely terminate treatment (Harkness & McNulty, 2006).

Anankastic patients may be most comfortable with clearly structured therapy. Therefore, the anankastic patient may also respond better with specific goals and an active therapist providing direction, guidance, sets of rules, and reasonable advice. In other words, therapists should strive to be on time, remember the plan, and keep the structure of the session. In that way, the therapist creates a common “tradition” for a patient who yearns to be traditional. Moreover, homework helps structure the therapeutic work outside the session. However, after a positive alliance has been established, it may be worthwhile to tone down the structure and predictability in order to help the patient become a bit more tolerant of imperfection, flexibility, and emotional spontaneity in relationships. Accordingly, therapist mistakes and insufficiencies may cause ruptures in therapy that eventually reveal important issues that should be dealt with.

Treatment Goals for Anankastia

Because the domain of anankastia is somewhat the opposite of disinhibition, the target of treatment is also somewhat the opposite, as it would actually help most anankastic patients to have some more disinhibition. Thus, a reasonable clinical target is to help the patient find healthy adaptations for an anankastic or highly conscientious personality. Some patients with anankastia may recognize that their disordered personality is leading to negative life consequences and will identify those as the target for therapy. Others may seek therapy in order to treat the consequences themselves, such as neglected and failed relationships or physical and emotional exhaustion.

One important aspect of treatment is to have patients examine and properly identify feeling states, rather than just intellectualizing or distancing themselves from their emotions. Patients characterized by anankastia often are not in touch with their emotional states as much as their thoughts. It may be helpful to lead the patient away from describing situations, events, and daily happenings and instead talk about how these elements made the patient feel. Although a group therapy modality may be helpful and effective, most people with anankastia will not be able to withstand the minimum social contact necessary to gain a healthy group dynamic. They may quickly become ostracized by the group for pointing out other people’s deficits and “wrong-headed” ways of doing things. In such settings, the anankastic patient may also take the role as the wise co-therapist (Gabbard & Newman, 2007; Simon, 2015).

Because of its organization, straightforward approach, and homework component, cognitive behavioral treatment is likely to appeal to patients with anankastia. In the cognitive portion, therapists can assist anankastic patients in examining their faulty beliefs regarding perfection, order, and control. Behaviorally, the therapist should make strong use of shaping within the context of homework assignments (Simon, 2015).

Psychodynamic therapy may also be effective in treating anankastia, focusing on early dynamics that may have established or maintained their preoccupation with order, perfection, and achievement and how these dynamics are continuing in adult life. Analytically, the patient would ultimately be working to reshape and quiet an over-active superego (Gabbard & Newman, 2007).

Schema therapy has been shown to be an effective treatment for Cluster C personality disorders, including the obsessive-compulsive type (Arntz, 2012; Hopwood & Thomas, 2014), and, thus, might also be particularly effective in the treatment of anankastia. The schema therapist may target the unrelenting standards schema as a driving force behind the anankastic style. Moreover, the therapist and the patient may analyze whether the anankastic personality is a manifestation of an internalized demanding authority (i.e., an echo of demanding parental messages from upbringing that are still very dominant in the patient’s life) or a perfectionistic over-controller coping mode. In the former, the patient may feel that the only right way to be is to be perfect or high-achieving, keep everything in order, strive for high status, be humble, put others’ needs before one’s own, or be efficient and avoid wasting time. Such anankastic features often involve extreme conscientiousness, including excessive standards and responsibility, which therefore also implicate a self-sacrifice schema and a compliant surrenderer coping mode. Consequently, the patient typically feels that it is wrong to express feelings or to act spontaneously. The maladaptive anankastia may also be a product of a perfectionistic over-controller mode, however, which may have been developed to protect the self from a perceived or real threat (e.g., misfortune, criticism, losing control) by means of perseveration and extreme control. In either case, the target of schema therapy is to understand the patient’s real needs and help him or her to have them met in an adaptive manner. This involves building up a more flexible healthy adult mode (i.e., a new internalized “good” parent) that can outmatch the dysfunctional modes related to anankastia and “take care” of an underlying vulnerable child mode in an authentic manner (Arntz, 2012).

The aforementioned therapeutic approaches may be further strengthened using compassion-focused therapy (Gilbert, 2014) focusing on exchanging self-criticism (i.e., internalized critical/demanding authority) with self-compassion (i.e., acceptance and compassion from an internalized “good” authority). Moreover, modified versions of dialectical behavior therapy for obsessive-compulsive personality features and disorders of emotional over-control target the rigidity, inhibited emotional expression, and stubbornness characterizing anankastic features (Lynch, Hempel, & Dunkley, 2015; Miller & Kraus, 2007). Finally, the previously mentioned STIM has been adapted to a specific treatment approach for problems related to Conscientiousness (Roberts, Hill, & Davis, 2017).

Psychoticism

Historically, factor analysis of personality structure has yielded a fifth domain entitled unconventionality, openness, oddity, or psychoticism (Chmielewski, Bagby, Markon, Ring, & Ryder, 2014). Accordingly, the variance comprised by this domain may appear somewhat diverse, including features ranging from unusual/creative perspectives on life to psychotic-like experiences. This domain includes facets such as cognitive and perceptual dysregulation, eccentricity, and unusual beliefs and experiences. In terms of extremely high FFM openness, this domain may involve having an extraordinary imagination along with the ability to fantasize, show interest in abstractions and aesthetics, have original ideas, and think in different ways. The overall goal of treating psychoticism is to help the patient find more adaptive expressions of psychotic-like features as illustrated in Figure 19.8.

Figure 19.8

From maladaptive to adaptive expressions of psychoticism

Establishing a Therapeutic Relationship

First of all, patients with high psychoticism should be recognized for the adaptations they’ve achieved under the extraordinary conditions of being prone to schizotypal, psychotic-like, quasi-psychotic, or dissociative features, including depersonalization (e.g., feeling like a robot not in control of own speech or movements) and derealization (e.g., feelings of being alienated from or unfamiliar with surroundings). For example, patients with psychoticism must manage social interaction even though they do not experience the world like most others do. The ability to trust their own perceptions, something most people take for granted, may fail. Additionally, patients with psychoticism may be seen by others as odd, bizarre, mad, or strange, which may have led to alienating and discouraging experiences. Thus, the therapist should highlight and encourage the healthy functioning of the patient, including the social adaptation that has been achieved despite deviating cognitions and perceptual dysregulation. Praising this achievement may form an important basis for a working alliance (Harkness & McNulty, 2006). The therapist must also keep in mind that a patient with elevated psychoticism, according to interview-ratings or self-report, has acknowledged that his or her thinking and perception are unusual. Consequently, the patient might also be prepared to talk about psychoticism. However, many therapists have fears about the malignancy of the topic (e.g., latent delusions), which may weaken the alliance with and reinforce the alienation of the patient.

Treatment Goals for Psychoticism

Miscommunication and misperception are enemies of good social functioning. Therefore, it can be beneficial to provide the patient with skills in reality checking, emotion recognition, and separating fact from beliefs. For example, it may be helpful for the patient if the therapist frequently checks what the patient got out of a certain communication during the therapy session. Moreover, the therapist can help the patient make good decisions about communicating with others about unusual thinking (Harkness & McNulty, 2006), which may include social cognition training (Henderson, 2013).

In cases where facets of unusual beliefs and experiences and eccentricity are predominant due to schizotypal features, it may be useful to take advantage of existing treatment approaches for schizotypal and related disorders. For example, cognitive therapy may adjust distorted thought patterns and give the patient a set of coping skills to alleviate tension and anxiety in social situations (Renton & Mankiewiecz, 2015). This also may include targeting core beliefs, schemas, and modes related to mistrust, isolation, and alienation that are thought to be associated with psychotic or pre-psychotic features (Bach & Bernstein, 2019; Hopwood et al., 2013).

In cases where the perceptual dysregulation facet is predominant due to dissociative phenomena or transient psychotic-like episodes in borderline personality disorder, a trauma-focused approach to dissociation and/or complex posttraumatic stress disorder might be relevant (Kulkarni, 2017). It has been suggested that therapist awareness of the frequency and severity of dissociation in borderline personality disorder is essential to safety planning in relation to suicidal risk management (Korzekwa, Dell, & Pain, 2009). Thus, as a potential suicidal or parasuicidal risk factor, perceptual dysregulation may explicitly reflect intrusive traumas that are linked to dissociation or psychotic-like experiences in some patients (Bach & Fjeldsted, 2017). The mercurial nature of emotions associated with psychotic-like experiences in borderline personality disorder has also been the subject of the mindfulness and emotion regulation components of dialectical behavior therapy (Linehan & Dexter-Mazza, 2008). These techniques may target the perceptual dysregulation facet of psychoticism, and could potentially be applied to unusual beliefs and experiences. In particular, the observing and describing skills of mindfulness may assist patients with psychoticism in thinking more concretely, and the emotion regulation skills focusing on reducing emotional vulnerability (i.e., basic self-care skills with an emphasis on balance, including treat physical illness, balance eating, avoid mood-altering drugs, balance sleep, get exercise, and build mastery) may be effective for treating perceptual dysregulation and associated sensitivity.

Conceptualizing and Treating Patients with Multiple Traits

The least sophisticated way of interpreting and using personality traits in treatment is to take one trait domain or facet at a time and only consider what that particular feature indicates about the patient. Such a simplistic approach forfeits the more finely detailed information that would be derived from an integrative and multidimensional view of all trait domains and facets in combination.

Consider, for instance, two patients for whom negative affectivity constitutes the most prominent feature. One patient may be characterized by a secondary trait of antagonism/dissociality, and thus exhibit externalizing anger or overcompensating grandiosity due to vulnerability related to dysregulated emotions or self-esteem. By contrast, the second patient may be characterized by a secondary trait of detachment, suggesting that the negative affectivity may be coped with through internalizing features of depressivity, withdrawal, and anxiousness (which looks very different from the first patient). Accordingly, the ideal way of using a trait system in treatment is to allow any one finding to be adjusted and expanded by any other finding. Taken together, the clinical implications of secondary traits are vital and may have substantial consequences for treatment planning and targets of treatment.

Although this is a goal worth striving for, those who evaluate personality traits as a part of treatment planning operate in a way that represents a compromise between the simplistic interpretations based on single-trait elevations and the ideal report that takes into account every prominent trait dimension at the same time. At times, one may have a clear idea of how the meaning and clinical implications of one trait is altered by the presence of another trait. Those who routinely evaluate and use the trait system have ready-made interpretations and solutions for treatment planning. An interpretation that included the two most prominent traits is most appropriate when only two traits are elevated or when there is a sizeable gap between the scores obtained on the second highest trait and the third. Therapists using trait subfacets, such as the 25 facets of the DSM-5 Section III trait system, should typically take into consideration the three most prominent facets (a “top three” interpretation). However, some elements of the fourth or the fifth elevations are occasionally added in cases where those traits or facets offer information that appears to be of particular relevance for treatment planning.

As previously explained, the categorical personality disorders are mostly composed of different constellations of overlapping trait domains (APA, 2013). For example, a constellation of negative affectivity and detachment captures avoidant personality disorder, which may therefore be treated using approaches for this diagnostic category (e.g., Arntz, 2012). The same applies to a constellation of antagonism/dissociality and disinhibition capturing antisocial personality disorder (e.g., Bateman & Fonagy, 2016; Bernstein et al., 2007), as well as psychoticism and detachment capturing schizotypal personality disorder (e.g., Renton & Mankiewiecz, 2015). Pure detachment can be treated as schizoid personality disorder (Renton & Mankiewiecz, 2015), and pure anankastia can be treated as obsessive-compulsive personality disorder (e.g., Simon, 2015). However, anankastia with detachment as a secondary trait may be treated as a puritanical or inhibited type, anankastia with negative affectivity may be treated as a conscientious or worried type, and anankastia with antagonism/dissociality may be treated as a bureaucratic, narcissistic, or sadistic type (Millon et al., 2004). In many cases, the presence of anankastia may also be considered a protective factor in terms of the orderliness and ability to work on demanding tasks found in low disinhibition. Borderline personality disorder is more complex and heterogeneously comprised of different potential domains. Some milder cases may only be characterized by negative affectivity in terms of emotional lability, separation insecurity, anxiousness, and depressivity, whereas some more severe cases may be characterized by the same negative affectivity features accompanied by disinhibition (e.g., impulsivity), antagonism/dissociality (e.g., hostility), and psychoticism (e.g., perceptual dysregulation). As evident from the aforementioned trait content, different configurations of borderline personality disorder have substantial implications for treatment planning and targets of treatment. Problems such as self-injury or suicidal behavior are more challenging to deal with in the latter case. In general, the presence of secondary psychoticism, reflective of chaotic thinking, dissociation, or alienation, may indicate severe distress and is very likely to be trauma-related. This particularly applies to combinations of negative affectivity and psychoticism.

Sometimes, patients also have very divergent facet scores within the same domain. Consider, for example, one male patient who has been prone to impulsive outbursts and cheeky actions since childhood, often resulting in humiliating and shameful reprimands from authorities and sometimes resulting in physical abuse from his stepfather and mother. Although he cannot help being verbally impulsive on different occasions, he is also very anxious about what will happen. Consequently, his score on impulsivity is very high, while his score on risk taking is very low. This constellation has clinical implications in terms of focusing on how to accept and regulate his innate impulsivity, while simultaneously dealing with his learned shame and fear of wrongdoing that causes him to be tense and afraid of taking any risks in social situations.

Conclusion

This chapter provided an overview of how the empirically derived trait dimensions included in DSM-5 and ICD-11 may be useful for establishing a favorable treatment alliance, increasing the patient’s self-knowledge, providing psychoeducation, planning realistic treatment goals, and matching therapy to the patient’s personality. A conclusive key message is that practitioners should not treat traits per se but the maladaptive expressions of traits. We encourage therapists to start working from this trait perspective and suggest that future developments of evidence-based psychotherapy manuals are tailored to the empirically derived trait domains described in this chapter. Such an approach could include more attention to the homogeneous building blocks of pathological traits (e.g., emotional lability) than to the heterogeneous categories of specific mental disorders (e.g., borderline personality disorder). So far, this has already been initiated with the Unified Protocol targeting a range of emotional disorders that are driven by underlying traits of negative affectivity, including avoidant, dependent, and borderline personality disorder features. Likewise, future randomized controlled trials should evaluate the clinical significance of focusing on these domains in contrast to the traditional heterogeneous diagnostic categories.

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