Decision Making and Personality Disorders

Decision Making and Personality Disorders

 

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Decision Making and Personality Disorders

Article in Journal of Cognitive Psychotherapy · April 2002

DOI: 10.1891/jcop.16.2.209.63991

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Robert L Leahy

Weill Cornell Medical College

68 PUBLICATIONS 1,246 CITATIONS

Journal of Cognitive Psychotherapy: An International Quarterly, Vol. 16, No. 2, 2002

  

Decision Making and Personality Disorders

Robert L. Leahy

American Institute for Cognitive Therapy, and Weill-Cornell University Medical College, New York

 Individuals with different personality disorders are hypothesized to approach deci- sion making with a variety of concerns related to their perception of their general efficacy, information demands, risk aversion, and utility of gains and losses. A vari- ation of modern portfolio theory is employed to examine decision-making in a clin- ical population of adult patients. Variations along personality dimensions were related to a number of decision-making concerns and strategies. The implications of these findings are examined in the clinical treatment of personality disorders.

 

Keywords: personality disorder; decision making; obsessive-compulsive disorder

The cognitive model of personality disorders has emphasized the thematic content of personal schemas—that is, habitual patterns or biases in viewing the self and others. For example, Beck and Freeman (1990) propose that the avoidant personality views the self as vulnerable to depreciation and rejection, and views others as critical and demeaning. According to this model, avoidant individu- als utilize strategies to either avoid or compensate for their schematic vulnerability. For example, persons with avoidant characteristics tend to avoid evaluative situa- tions and avoid unpleasant thoughts. In addition, Millon and his colleagues (Davis & Millon, 1999; Millon, Davis, Millon, Escovar, & Meagher, 2000) maintain that avoidant individuals compensate for a lack of interpersonal rewards by developing a rich fantasy life. A similar conceptual model has been advanced by Young (1990), who argued that personality might be understood as the persistence of early mal- adaptive schemas for which the individual utilizes avoidant, compensatory, and schema-maintaining strategies. Thus, individuals who view themselves as “defective” may avoid situations that are challenging or that could lead to rejection, could compensate by deferring to others, or might pursue experiences that maintain the schema, such as self-defeating relationships.

 

Review of Portfolio Theory

I have advanced a model of decision-making based on how individuals compute their current and future resources, their ability to tolerate risk, their regret orientation, and their perception that they can replicate behaviors with a long duration (Leahy, 1997, 1999, 2001). Pessimistic decision-making is based on a “portfolio theory.” Portfolio theory suggests that individuals with a pessimistic “portfolio” believe that they have low current and future resources, low ability to predict and control outcomes, low util- ity for gains and high disutility for losses, high stop-loss rules for quitting early, high regret, and high demands for information. In contrast, an optimistic “portfolio” includes the assumption that one has considerable current and future resources, con- siderable ability to predict and control outcomes, high value for positives, low disutil- ity or suffering for losses, the ability to tolerate loss, and low demands for information. Individuals with manic or overly optimistic and grandiose portfolio theories tend to overestimate current and future resources, predictability, control, and hedonic value, while underestimating potential costs and risks (Leahy, 1997, 1999, 2001).

Portfolio theory of decision-making may help us expand our understanding of the phenomenology of different personality disorders. This theoretical model of decision-making proposes that individuals differ in their assessment of current and future resources in five ways: (a) in interpersonal and task-oriented domains, (b) in estimates of predictability and control, (c) in perceived utility of gains and losses and how they are defined, (d) in tolerance of risk, and (e) in demand for information before making decisions. Evidence of the relationship between these various dimen- sions and depression was found in a recent study (Leahy, 2001). A pessimistic port- folio theory was supported by the finding that, of the 25 dimensions of decision-making, 21 were significantly related to depression and 19 were signifi- cantly associated with risk-aversion.

 

Portfolio Theory and Personality Disorders

Decision-making models may be especially important in understanding the differ- ent personality disorders. Some individuals with personality disorders are assumed to be highly avoidant and indecisive; others are viewed as impulsive; others may require considerable information prior to making a decision; and others may not enjoy the benefits of rewards. For example, persons with Avoidant Personality Disorder (APD) are characterized by low self-esteem, sensitivity to rejection, and demands for guarantees before entering into a relationship. The portfolio decision- making model suggests that these individuals will be low in current and future self- efficacy, have high information demands before making a decision to change, high stop-loss criteria (i.e., quitting early), internalization of negatives, and lack of gen- eralization of positives.

Dependent Personality Disorder (DPD) is characterized by the reliance on others for decisions and resources as a reflection of lower self-efficacy. Consequently, per- sons with DPD have a tendency to stay in bad situations or relationships simply to maintain security and to avoid abandonment. These individuals are also seen as risk- averse and are likely to rely on others for important decisions. As a corollary of their dependency, they are often inclined to blame others when things do not work out.

Individuals with Obsessive-Compulsive Personality Disorder (OCPD) tend to have relatively intact self-efficacy, but are viewed as indecisive and risk-averse. Typically, they require considerable information before making a decision. Self-defeating individuals often reject positive outcomes, blame others for their failures, and quit early. These individuals might be reasonably expected to have low self-efficacy.

Paranoid Personality Disorder (PPD) is characterized by distrust and blame of others, which has been viewed as symptomatic of either inflated self-esteem or as a defensive avoidance of low self-esteem (Zigler & Glick, 1984, 1988). Zigler and Glick have offered a model of paranoia that stressed the dynamics of self-protective externalization of blame to avoid self-criticism. According to Zigler and Glick’s model, individuals with paranoid personalities are more likely to blame others if things do not work out and are expected to blame themselves as well. They could be characterized by a pessimistic model of decision-making—that is, low self-efficacy, high information demands, low generalization of success, and high generalization of failure.

Persons with Histrionic Personality Disorder (HPD) are characterized by their lack of self-awareness or insight, their need to impress others, and their impulsivi- ty. Thus, these individuals are more likely to be risk-takers, or even risk-lovers, unlike the other personalities described here.

Individuals with Narcissistic Personality Disorder (NPD) are characterized by their lack of empathy and their grandiose sense of themselves, often devaluing or blaming others for their problems. However, psychodynamic models of narcissism (Kernberg, 1974, 1975, 1998a, 1998b) emphasize the emptiness of the interior lives of these individuals, such that they may “mask” their privately experienced low self- esteem with grandiose public displays of their worthiness. Thus, evaluation of how persons with NPD regard their decision-making processes may cast some light on our understanding of their perceptions of self-change and self-efficacy. A similar model has been advanced as a “schema-focused” model by Young and Flanagan (1998), suggesting that those with narcissistic personalities use grandiosity to pro- tect against “injured” or “defective” aspects of the self. In the present study, I inves- tigated the perception of self-efficacy and decision processes in patients who varied in narcissistic characteristics.

Borderline Personality Disorder (BPD) is characterized by unstable affect, feelings of emptiness, chaotic interpersonal experiences, self-destructive behav- ior, and self-loathing. Individuals with BPD can be risk-averse or risk-seekers, depending on their volatile moods. However, it is generally expected that they possess low self-efficacy, a tendency to blame others, a general sense of helpless- ness and hopelessness, and a high degree of procrastination. Linehan’s (1993) dialectical-behavioral model of BPD emphasizes the multiple facets of the bor- derline personality (e.g., relentless crises, feelings of emptiness, difficulty modu- lating affect, hopelessness, and anger). The current study on decision processes allows us to examine how these factors may be reflected in portfolio theories or decision strategies.

Finally, Antisocial Personality Disorder (APD) is characterized by a lack of con- cern for the rights of others as well as difficulty assessing negative outcomes. Individuals diagnosed with APD, lacking empathy, often present with a history of cruelty toward others and violations of the law. Their self-esteem may remain intact, since their standards of conduct for themselves leave little capacity for guilt. These individuals generally have low frustration tolerance, leading them to give up early, and they are expected to blame others. Given their impulsive nature, we would expect higher risk-taking behavior from these individuals.

 

 

METHOD

In order to explore the relationship between personality disorders and the decision- making model of portfolio theory, 101 adult patients in a private practice clinic were asked to complete a variety of self-report forms including the Beck Depression Inventory (BDI; Beck & Steer, 1987), Beck Anxiety Inventory (BAI; Beck & Steer, 1990), Symptom Checklist-90-revised (SCL-90-R; Derogatis, 1977), Locke Wallace Marital Adjustment Test (Locke & Wallace, 1959), and a 25- item Decision Questionnaire (Leahy, 2001). The Structured Clinical Interview for DSM-III-R (SCID-II; Spitzer, Williams, Gibbon, & First, 1990) was administered by staff psychologists. The SCID-II was used as a measure of personality disorder. Rather than classify individuals categorically as avoidant, dependent, or other per- sonality disorders, it was decided to score individuals dimensionally on each scale. The rationale was that many individuals often simultaneously score high on sever- al personality disorders (Livesley, 1998; Livesley, Schroeder, Jackson, & Jang, 1994; Millon et al., 2000).

There is no a priori basis on which to decide that one categorization of a per- sonality disorder should take precedence over another. There is also little rationale for using an arbitrary “cut-off” point for a personality disorder, since individual variation would be lost in such a categorical system. By using a dimensional rather than categorical approach, more of the data can be utilized, with an evaluation of the same individual along a variety of personality dimensions. However, one con- sequence of using a dimensional scoring system is the necessity of recognizing that we are describing variations in a personality trait or style and not fixed categories of individuals.

 

RESULTS AND ANALYTIC COMMENTARY

Individual correlations were calculated for scores on each personality disorder on the SCID-II and the 25 dimensions of the Decision Questionnaire that assesses the various portfolio dimensions described earlier. The means and standard deviations for the scores on the different personality disorders are shown in Table 1 and the cor- relations between scores on the personality dimensions and the decision question- naire dimensions are shown in Table 2. In addition, factor scores were derived for the 25 decision-making dimensions, which yielded four factors: Self-efficacy, Discouragement, Unpredictability, and Risk Aversion. For the sake of brevity, I will limit my discussion to several personality disorders, excluding discussion of the data on schizoid, schizotypal, passive-aggressive, and anti-social personality characteristics.

 

Avoidant, Dependent, and Self-Defeating Personality Disorders

According to Millon and others (Davis & Millon, 1999; Millon et al., 2000), avoidant individuals are characterized by low self-esteem, sensitivity to rejection, and caution when approaching others. Dependent individuals also are expected to have low self-esteem, but their focus is on concerns regarding abandonment, presumably because they believe that they cannot provide for their own needs. Self- defeating personalities also are expected to have low self-esteem, to view rewards as unsatisfying and to become anxious when things improve. We examined some of these issues by correlating scores on the SCID-II, using it as a dimensional scale rather than as a categorical measure. Thus, patients could score relatively higher or lower on each of the personality scales for the DSM-III-R.

Decision dimensions were significantly correlated with avoidant, dependent and self-defeating personality. Eighteen of 25 dimensions were correlated for avoidant and dependent scales, and 19 of 25 decision dimensions were correlated for self- defeating personality characteristics. Substantial similarities between these three per- sonality disorders were observed in the correlation matrix between the decision-making dimensions and personality disorders (see Table 2). Individuals in these groups generally believed that they had few resources in current and future rela- tionships, at work or in personal relationships. All believed that they had little abili- ty to control and predict outcomes. Dependent Personality Disorder and self-defeating personality type were related to self-blaming if things did not work out. All three personality types were less likely to take credit for positives, all pre- dicted that negatives would continue and be generalized, and all quit early. Individuals with Avoidant Personality Disorder and self-defeating personalities tend- ed to have a high threshold for defining positives and a low threshold for defining negatives. They procrastinated and felt the need to build consensus before making decisions. Examination of the relationship between the factor scores and these per- sonality dimensions suggested that Avoidant and Dependent Personality Disorders are related to Discouragement (r = .373, p < .01; r = .245, p < .05, respectively), and Unpredictability (r = .333, p < .01; r = .229, p < .05, respectively). Self-defeating per- sonality type was also related to Discouragement (r = .343, p < .01) and Unpredictability (r = .422, p < .01).

 

TABLE 1. Means and Standard Deviations of the SCID-II Personality Dimensions

Personality Dimension M SD
Avoidant 2.98 2.12
Dependent 2.42 1.92
Obsessive Compulsive 4.79 2.02
Passive-Aggressive 2.65 2.09
Self-Defeating 3.64 2.57
Paranoid 2.45 1.73
Schizoid 1.35 1.12
Schizotypal 1.37 1.26
Histrionic 1.97 1.63
Narcissistic 4.56 2.59
Borderline 4.02 2.60
Antisocial 0.88 1.36
N = 101.

 

TABLE 2. Correlation Matrix of Decision-Making Dimensions and Personality Disorders 

I have little to offer in a
relationship .339** .290** .136 .181 .405** .240* .137 .131 -.004 .161 .275** .132
at work or school -.188 -.306** -.033 -.072 -.302** -.166 -.228* -.223* -.172 .020 -.228* -.181
I have many sources of reward
in my life -.338** -.349** -.173 -.149 -.353** -.280** -.056 -.020 -.150 -.077 -.261* .015
I expect that in the future my
relationships will improve -.191 -.416** .035 -.071 -.306** -.150 -.123 -.159 .012 .109 -.032 -.030
I expect that in the future my
skills and abilities
will improve -.217* -.295** .019 -.132 -.231* -.072 -.021 -.122 .046 .110 .046 .049
I expect that in the future I will have
many rewarding experiences -.276** -.425** .059 .006 -.286** -.114 -.080 -.084 .020 .098 -.142 -.035

 

I have many skills and abilities

Most things in life seem

turn out the way I’d like -.362** -.255* .091 -.047 -.236* -.183 .020 -.033 .013 -.009 -.325** .006
I don’t mind taking risks -.117 -.233* -.060 -.177 -.077 .092 .242* .089 .216* .022 .066 .195
I focus much of my time and energy on
trying to achieve positive things     -.208* -.308** -.103 -.060 -.216* -.127 -.040 -.057 -.158 .086 -.225* -.123
avoiding negative things                  .206 .107 .140 .103 .020 .061 -.085 -.152 .063 .305** -.005 -.127
enjoy it that much                            .493** .123 .252* .168 .501** .366** .138 .102 .239* .245* .339** .133

 

unpredictable                        .294**   .295**  -.070   .225*                                  .368**   .322**   .156       -.116                                                      .150                                                             .281**  .329**   .195 I am usually able to make things

 

I spend much of my time and energy When I achieve something, I do not

I take credit for my achievements

I blame myself if things don’t

-.251* -.317** .067 -.092 -.526** -.106 -.150 -.237* -.006 -.114 -.067 .053
work out .206 .209* .121 .138 .341** .285** .088 -.095 .054 .380** .391** -.028
I blame others if things don’t
work out .093 .260* .008 -.103 .034 .187 .092 .080 .098 -.006 .078 .201
I am very cautious .157 .131 .246* .189 .080 -.038 -.113 -.057 -.026 .064 -.059 -.077
If I don’t get what I want immediately,
I doubt that I’ll ever get it                                                     .345** .513** -.049 .107 .418** .282** .198 .285** .260* .097 .276** .156
I get discouraged more easily
than others                                                     .453** .350** -.032 .192 .371** .476** .208 .212* .246* .191 .404** .330**
If something doesn’t work out,
I tend to think other things won’t
work out                                                     .594** .403** .132 .338** .484** .343** -.060 .015 .001 .327** .277* -.064
If something does work out, I think
other things will work out                                                     -.233* -.013 .101 -.099 -.189 -.063 .031 -.156 -.079 .061 -.179 .112
When things improve, I have a hard
time seeing the improvement                                                     .443** .198 .154 .138 .513** .267* .154 .180 .245* .166 .260* -.067
A small negative change often seems
like a big negative change                                                     .411** .219* .069 .104 .300** .337** .134 .005 .211 .150 .228* .014
I need to know for certain
that something will work
out before I try it                                                     .368** .098 .256* .197 .183 .082 -.175 -.044 .045 .239* .159 -.151
I often wait a long time before I do
things to help myself                                                     .294** .307** .220* .209 .473** .226* .123 .344** .268* .237* .505** .285**
I feel it is important for me to
convince others or myself that
my decisions are correct                                                     .225* .337** .388** .116 .233* .097 -.168 -.169 .100 .305** .086 -.075

Note. Two-tail tests.

*p < .05. **p < .01.

 

It was interesting to observe how the avoidant and dependent personalities dif- fered. Dependency was related to risk-aversion, but avoidance was not related to risk. Those with avoidant personality characteristics also reported that they did not derive much pleasure from positive events, and were less likely to generalize posi- tives when they did occur. The reliance that persons with Dependent Personality Disorder have on others was supported by the finding that they are more likely to blame others if things do not work out. Those with Avoidant Personality Disorder reported that they demand more information before making decisions-a finding con- sistent with the meaning of “avoidance.” Self-defeating personality type was asso- ciated with being less likely to maximize positives, less likely to generalize positives when they did occur, and high demands for information.

These findings are consistent with a schematic model (Beck & Freeman, 1990), which suggests that people with dependent and avoidant personality characteristics view themselves as incompetent and weak, respectively. These individuals utilize a “pessimistic portfolio” that is based on their low estimation of current and future rewards, low perceived personal efficacy, and a hesitant style of decision making.

Obsessive-Compulsive Personality Disorder

Individuals with Obsessive-Compulsive Personality Disorder (OCPD) were assumed to have relatively intact self-esteem, but to have difficulty making deci- sions. OCPD was not significantly related to most of the decision dimensions, except for those associated with caution, waiting, and information demands. OCPD was related to deriving little pleasure from positives. OCPD was significantly relat- ed to the decision factor, Risk-Aversion (r = .284, p < .01). These data support the view that persons with OCPD inhibit their impulsivity and have higher demands or requirements for information before making decisions. However, the current study did not support Millon and his colleagues’ (2000) view that these individuals are inclined to blame themselves or others because of their relatively greater emphasis on rules and responsibility. The data reported here imply that individuals with OCPD demonstrate their conscientiousness by demanding more information, and perhaps this is a manifestation of their reassurance-seeking tendencies. These data suggest that OCPD individuals are better characterized by self-doubt, caution, and demands for information than by rule-seeking attitudes.

Paranoid Personality Disorder

The cognitive model of paranoia stresses the “moralistic” and “control” dimen- sions of the paranoid personality. Zigler and Glick’s (1984, 1988) model of para- noia views the paranoid style of distrust and grandiosity as a cognitive defense against feeling low self-esteem and the perception that they will be rejected and fail. Paranoid Personality Disorder (PPD) was related to viewing oneself as having few positive resources in current relationships and few resources in general. In addition, PPD was related to low predictability, blaming oneself, receiving low pleasure from positives, having a low threshold for defining negatives, a high threshold for defining positives, quitting early, and generalizing negatives. Thus, individuals with PPD believe that they will not be effective in producing positive events (which they do not much enjoy when they are achieved), and that negative events will only continue. They scored relatively high on procrastination. Thus, paranoia is a constellation in which the individual is pessimistic, views him or her- self as less likely to predict outcomes, has a hard time seeing positives (but sees negatives easily), procrastinates, and self-blames. PPD was significantly correlated with the decision factors of Discouragement (r = .393, p < .01) and Unpredictability (r = .259, p < .01).

 

Histrionic Personality Disorder

According to the cognitive model, individuals with Histrionic Personality Disorder (HPD) tend to view their selves in terms of glamour and impressive display. Millon and colleagues (2000) suggest that persons with histrionic characteristics use a dramatic and demanding appearance and behavior to obtain rewards and attention from others, but that the interior self is empty and prone to depression. Rewards for the histrionic person would seem to be temporary, always requiring a new dramatic display to promote further self-aggrandizement. Millon suggests that these individuals lack insight, which may result in their inability to develop a self-critical reflection. Only a few of the decision dimensions were related to histrionic personality characteristics.

Interestingly, individuals with HPD viewed themselves as more likely to take risks. In addition, they tended to derive less pleasure from positives, were more likely to predict negatives, more likely to quit early, had a high threshold for defining positives, and procrastinated more. Persons with HPD scored higher on the decision factor of Discouragement (r = .274, p < .01). These data are consistent with Millon’s view of the person with histrionic traits as lacking self-reflection and the ability to delay gratification. They are easily frustrated, give up, and demand a lot to reward themselves. Interestingly, there was no significant relationship between measures of perceived competence, or current and future resources, and histrionic personality characteristics. Consistent with Millon’s view, these individ- uals are not suffering from a self-critical voice and are willing to take risks to achieve their transitory goals.

 

Narcissistic Personality Disorder

The cognitive model of Narcissistic Personality Disorder (NPD) stresses the inflat- ed and grandiose schema about the self. However, other formulations, such as that of Millon (Millon et al., 2000) and Kernberg (Kernberg & Senia, 1995), emphasize the view that individuals with narcissistic personalities experience a sense of empti- ness and meaninglessness—indeed, feelings of worthlessness. They attempt to com- pensate for these feelings of emptiness by inflating their self-views and surrounding themselves with admiring and deferent need-gratifiers. Persons with NPD may have difficulty deriving any lasting pleasure and satisfaction, both because of feelings of emptiness and because nothing quite lives up to their grandiose expectations.

The data in the present study indicate that narcissism is unrelated to perceptions of present and future resources—that is, individuals with narcissistic personality characteristics do not view themselves as lacking self-efficacy in the present or future. However, NPD was related to six decision factors: (a) low predictability of future events, (b) attempts to minimize negatives, (c) generalizing negatives, (d) high demands for certainty, (e) procrastination and (f) the need to build consensus. However, persons with NPD tended to blame themselves when things did not work out. They also scored higher on the decision factor of Unpredictability (r = .282, p < .01). Thus, the view of narcissistic personality that emerges from these data is of someone who is generally pessimistic, anhedonic, and indecisive. Essentially, this is someone who tries to avoid making mistakes, perhaps because self-criticism will follow.

 

Borderline Personality Disorder

No study of personality disorders would be complete without some description of the borderline personality. These individuals are characterized by instability in every area of their lives, with such variability that Beck and Freeman did not even describe their core schemas in their book on personality disorders. In the current study, Borderline Personality Disorder (BPD) was related to the perception of few current resources but unrelated to the perception of future resources. Thus, for those with BPD, although events may vary from day to day, the current situation always seems bad. Individuals with BPD believe that they cannot predict or control future out- comes, they predict and generalize negatives, and they place less emphasis on max- imizing positives. They do not take pleasure from positives, they have a high threshold for defining positives, a low threshold for defining negatives, and they blame themselves when things do not work out. Persons with BPD frequently claim that they procrastinate.

The overall view of borderline personality is of an individual who believes that he or she has few resources, little personal efficacy, is anhedonic, and highly self-criti- cal. Higher scores on BDP were related to higher scores on the decision factor of Discouragement. This is consistent with Linehan’s view that these individuals often believe that they are incompetent and have difficulty deriving pleasure from events.

 

CLINICAL IMPLICATIONS

 

Avoidant, Dependent, and Self-Defeating Personality Disorders

The decision model appears to describe many of the characteristics of avoidant, dependent and self-defeating personality types. As noted earlier, 18 of 25 dimensions were significantly correlated for avoidant and dependent, and 19 of 25 dimensions correlated with self-defeating personality. The decision model, based on portfolio theory, appears to be a good description of how these individuals contemplate decisions. These individuals believed that they had few current or future resources, little control or predictability of outcomes, were less likely to take credit for positives, more likely to predict and generalize negatives, and more likely to quit early. We develop a picture of those with avoidant and dependent personality traits as believing that they have low competence, are easily discouraged, lack self-control, and crave predictability.

Clinical implications from this study suggest that these patients need to be assist- ed in improving their general level of social competence and to learn to take credit for their positive achievements. Their general pessimism about negative outcomes may be reinforced by their tendency to quit early or to procrastinate before helping themselves. Clinical interventions include training in persistence, examining the costs and benefits of giving up early, and graded task assignments. These hesitant patients can be helped to recognize the opportunity costs in waiting for additional information. Hesitancy may reduce the opportunities for reward. The data also indicated that Dependent Personality Disorder was related to risk-aversion and blaming others. Clinical interventions should focus on self-care and self-reliance, rather than depending on others, and should encourage the dependent patient to collaborate in assigning homework. Reassurance seeking should be discouraged in the therapeutic relationship, lest the patient come to believe that only the therapist or someone else can really help him.

The data on self-defeating personality type mirrored many of the findings for avoidant and dependent personalities. Self-defeating and avoidant personalities were less likely to define a positive and more likely to define a negative. These individuals manifest an inhibited and hesitant style in confronting change—often not seeing positive change when it is there. They are more likely to see marginal negative changes as major setbacks. Self-defeating personality characteristics were also related to the decision factors of not maximizing positives and requiring high demands for information. These hesitant individuals may appear to others as “masochistic,” but they may actually be employing a “risk-management” style that they believe keeps them from being disappointed. For example, one patient with self-defeating personality characteristics believed that her pessimism and tendency to question any positive change were good methods to avoid being disappointed and ending up as a “fool.” Her belief was that looking for the dark center of the cloud, rather than the silver lining, allowed her to avoid investing too much of herself into something that would not work out. A case conceptualization that stressed the role of hedging and self-fulfilling negative prophecies allowed her to make therapeutic improvements.

 

Obsessive-Compulsive Personality Disorder

As indicated above, patients with OCPD do not have a general impairment in self- esteem nor do they manifest a tendency to blame others. Many individuals with OCPD believe that they are highly competent, and they maintain high standards of which they are proud. However, they do have high demands for information before making decisions, and tend to utilize waiting and caution as decision strategies. Clinical interventions that can be useful with these individuals focus on their demand for certainty by examining the costs and benefits of passing up timely opportunities to demand “perfect” information. Contrary to a common perception of these patients as self-critical, there was no evidence of this in the present study. OCPD individuals were inhibited in making decisions primarily because of their requirement for more complete information. Many of these individuals have exces- sive standards of responsibility, based on hindsight bias and the need to know for sure (see Leahy, 2001). Examining information demands and utilizing the double standard is a helpful tool with which to explore the unrealistic information require- ments that are demanded. Some individuals with OCPD can recognize that many of their better decisions (e.g., choosing to purchase real estate or to make a commit- ment in a relationship) have been made with incomplete information. Goals with these individuals are to help them make timelier, less conflicted decisions, and to abandon the desire to make perfect decisions in an uncertain world.

 

Paranoid Personality Disorder

Data from this study offer support for the model of paranoia advanced by Zigler and Glick (1984, 1988). According to this model, paranoia is a defensive response to an underlying depression, such that the person with paranoia wards off depression by bolstering the ego with a sense of grandiosity and deflects self-blame by blaming others. Although we do not need to utilize a “defensive dynamic” model, the cur- rent data do indicate that persons with PPD tend to blame themselves and others, and see themselves as having low self-efficacy. These individuals also show indi- cations of pessimism and procrastination. Although many clinicians find it difficult to work with patients with paranoid personality characteristics, establishing a trust- ing and collaborative working relationship is essential with any patient with any paranoid qualities, especially those with delusions (see Alford & Beck, 1994; Haddock et al., 1998).

The underlying depressive features of those with paranoid personality features suggest that the collaborative alliance should focus on enhancing these patients’ sense of personal self-efficacy. This can be accomplished through behavioral acti- vation, social skills training, or by modifying the self-perceptions toward the posi- tives that do exist. The cautious and inhibited style of decision-making often reflects fears that they will be taken advantage of or hurt by others. This decision-making style needs to be carefully modified toward encouraging prudent, but not risky, deci- sion-making. All-or-nothing definitions of “trust,” a tendency to personalize others’ behaviors, “mind-reading” negative intentions, and failing to perceive one’s own contributions to the creation of conflict are important targets for change. The often hostile and provocative behaviors of these individuals should not blind the clinician from recognizing that this apparent “attack” mode may mask underlying depression and low self-esteem (Young, 1990; Zigler & Glick, 1988).

 

Histrionic Personality Disorder

The view of individuals with Histrionic Personality Disorder (HPD) as being impul- sive was supported in the present study. Along with Antisocial Personality Disorder, persons with histrionic symptoms were more likely to report taking risks. These indi- viduals also showed a lack of persistence (i.e., they tended to give up easily). Individuals with HPD predicted negative outcomes, were less likely to see a positive as a “real” positive, and reported frequent procrastination. Their generally poor self- direction and self-discipline is reflected in high risk-taking, lack of persistence, and a tendency to derive little pleasure from positives. However, they rarely endorsed items related to low self-esteem, such as having few current or future resources that they might control. These data reinforce a view of persons with HPD as having little self-reflection and self-direction. This relative lack of self-direction suggests that the clinician could profitably focus on (a) helping the patient become more aware of risky and impulsive decisions and (b) call attention to the necessity of developing plans that are well thought-out—giving due consideration for both the short- and long-term consequences. Many individuals with Histrionic Personality Disorder have chaotic and emotionally labile relationships—ones that begin and end with high intensity interactions. Some have serious financial problems—often the result of their inability to plan and save, and sometimes because of capricious spending habits. Clinicians can assist these patients to recognize the need to rely on well thought-out plans, rather than emotions and seductive displays, and help the patient to develop more rational decision-processes, tolerance of frustration, and emotional regulation.

 

Narcissistic Personality Disorder

Contrary to the psychoanalytic or “schema-focused” eclectic view that persons with Narcissistic Personality Disorder (NPD) experience intrapsychic suffering as a result of a deflated, empty self (see Kernberg, 1975; Kernberg, 1998a; Young & Flanagan, 1998), the data reported here do not suggest impairments in their per- ceived ability to control current or future resources—that is, essentially, self-effica- cy. Nor did those with NPD present with an exaggerated view of their abilities. Narcissism was related to an inhibited style of decision-making—that is, low pre- dictability, high demands for information, procrastination, minimization of nega- tives, generalizing negatives, and a need to build a consensus before making decisions. What might account for this inhibited, almost compulsive, style of deci- sion-making? Persons with NPD tended to blame themselves when things did not work out, which suggests that they may be highly prone to regret. Thus, these indi- viduals may utilize an inhibited and pessimistic style of decision-making to avoid feeling regret.

Many patients with NPD perform at levels less than their potential might suggest because they have a strong fear of failure. In particular, they fear that others will humiliate them if things do not work out. In any case, these data suggest that the cli- nician can assist the patient in making progress by examining pessimistic assump- tions—that is, “I need to know for certain,” and “If I don’t know for certain, then it won’t work out.” Practice in small steps toward longer-term goals, rather than reliance on the “big hand,” may help the patient experiment with progress. One patient with NPD felt trapped because he believed that he could not take an “ordi- nary” job lest it reflect his failure and humiliation. He found it helpful to look at a so-called ordinary job as the first step in a procession of more challenging jobs in the future. Indeed, taking an “ordinary” job was reframed by the therapist as a chal- lenge to enhance his ability to practice being “ordinary”—a task that both he and the therapist viewed as very demanding.

 

Borderline Personality Disorder

Individuals with Borderline Personality Disorder (BDP) generally utilize a pes- simistic decision strategy. Data from the current study suggest that the clinician should help clarify patients’ views of their current situations and lack of emphasis on achieving positives. These patients, often characterized by lives that consist of unrelenting crises (Linehan, 1993), do not perceive themselves as able to predict or control events and do not take pleasure from positives. Therapists can assist patients in “competency tracking”—that is, monitoring any positive behavior and positive outcome and in learning to compartmentalize or place negative outcomes in per- spective. For example, the tendency of persons with BDP to count any negative as a big negative, to generalize negatives, and to blame themselves can be countered using the following techniques:

  1. Offset negatives with
  2. View negatives along a continuum to gain perspective of degrees of negativ-
  3. Utilize the double-standard technique to ask whether such a negative by another would be viewed as so
  4. Help recognize that one can correct and change one’s own behavior without condemning
  5. Establish reasonable standards of behavior, such that one is not held entirely blameworthy for all negative

 

The present study found that individuals with BPD view the current situation as bad, but are neutral about the future, which suggests that they are “engulfed” by their current field of experience. Several techniques may be utilized to help them recognize that the present is not overwhelming:

  1. Emotional regulation and cognitive distancing techniques, such as mindful- ness training and radical acceptance (see Linehan, 1993; Teasdale, 1999).
  2. The continuum technique (discussed above) to place current events in per- spective.
  3. Diversifying one’s perception of other positives that are available to offset any current
  4. Examining past catastrophic and all-or-nothing predictions to determine why they were not
  5. Discouraging reliance on emotional reasoning and encourage reliance on facts and how a theoretical “reasonable” person might see
  6. Writing short narratives that describe how the current situation can be resolved in a positive

 

 

SUMMARY

 

This study suggests that persons with different personality disorders vary in their approach to making decisions. Decision dimensions that reflect perception of resources (current and future), predictability, control, regret, threshold for defining outcomes, and demands for certainty are related to personality dimensions. Other models of personality disorders emphasize the underlying dynamics that mold the personality or stress the cognitive content of schemas. However, the current decision model provides an empirical basis for describing how individuals who are high and low on various personality dimensions view decision-making.

The portfolio model suggests that individuals utilize different criteria in making decisions. There are 25 dimensions of a “pessimistic portfolio,” with factors related to self-efficacy, discouragement, unpredictability, and risk-aversion. The portfolio model allows us to examine how different individuals define positive or negative changes, whether they enjoy or excessively suffer the experience of change, and what value they place on information, predictability, and control. The correlational nature of the present study does not allow the prediction of different personality dis- orders based on their decision-making strategies, nor does it allow us to examine the causal relationships between personality disorders and decision-making. However, important differences did arise in the empirical investigation of personality dimen- sions and portfolio concerns. The pessimistic portfolio closely mapped onto many of the decision criteria for diagnosing Avoidant, Dependent, and Borderline Personality Disorders. Individuals with these disorders generally appear to utilize very pessimistic portfolio strategies, having perceptions of low current and future access to rewards, high information demands, quick stop-loss or quitting rules, and less enjoyment of gains. They are more likely to suffer negatives and have high information demands.

The data on OCPD were revealing in that they supported the view of individuals with OCPD as inhibited and cautious, but not as lacking in self-esteem. Especially interesting are the data on paranoid personalities, which suggest an underlying neg- ative portfolio view of the self, having low self-efficacy, being easily discouraged, and cautious about change. Persons with Histrionic Personality Disorder reported a preference for risk, low frustration tolerance, and a tendency to quit easily. Finally, the findings relevant to those with Narcissistic Personality Disorder did not support the commonly held view that these individuals are masking low self-esteem, but rather that they are afraid of making mistakes.

The approach taken here was largely empirical and not guided by any one theo- ry of personality. Future research should attempt to replicate these data, possibly applying other measures of personality disorder with a different sample. However, these findings do suggest important differences among the various personality dis- orders that may help clinicians understand how different patients perceive them- selves as capable of making positive change.

 

 

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Acknowledgment. I would like to thank Jessica Hirsch, Lisa Wu, Anthony Papa, and Randye

  1. Semple for their assistance in collecting and analyzing the data.

 

Offprints. Requests for offprints should be directed to Robert L. Leahy, PhD, American Institute for Cognitive Therapy, 136 East 57th Street, Suite 1101, New York, NY 10022. E- mail: Leahy@cognitivetherapynyc.com

 

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