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MH Psychotherapy Note

posted 2021-06-19, updated 2022-04-20

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PT REPORT

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ASSESSMENT

[checkbox name="DPF" value="-- PASSIVE-DETACHED PERSONALITY FEATURES --"][conditional field="DPF" condition="(DPF).is('-- PASSIVE-DETACHED PERSONALITY FEATURES --')"]

The Pt has only a limited need for companionship and social support. Pt feels most comfortable, most free, and most themselves when alone. For this reason, Pt generally prefers to live and work in the relative calm and reassurance of social isolation without concern of boredom or loneliness. Pt is regarded as self-contained and self-sufficient, their self is their inner sanctum, where they are independent of the emotional and social worlds. As a dispassionate observer of life, the Pt rarely gets excited about anything. Their even-tempered calm frees them from noisy social attachments but also makes the Pt intellectually aware of details others would easily miss. In relationships, the Pt needs alone time and seldom becomes as intimately involved as their partners would prefer. In work, the Pt functions efficiently but not as team players.

The Pt has only a minimal need to give and receive affection or to become involved with others emotionally. For this reason, Pt tends to have few relationships and does not develop strong ties to others. Instead, Pt is viewed as seen as calm, placid, untroubled, and easygoing but also as possibly being socially awkward or indifferent to the feelings of others. Pt is a private person who enjoys being
alone, only rarely expressing inner thoughts and feelings. Ever unobtrusive, the Pt works quietly and methodically behind the scenes, content to remain in the background.

Is typically viewed as an introvert - caught up in the joy of mentation. Others often see them as lacking in spontaneity and vitality. Though the Pt is comforted by the quiet and solitude of an asocial lifestyle, the Pt possesses the capability to relate to others when necessary. Pt usually selects solitary activities resulting in social isolation. Pt prefers minimal to no contact when engaged in an activity, yet, is willing and able to productively interact when necessary to accomplish a goal. Sexuality is generally an undesirable and unexplored realm for the Pt.

Pt can become engaged in certain hobbies or interests. Has some acquaintances and can sometimes find enjoyment from being part of a small social group. Pt is capable of productively receiving feedback and changing their behavior accordingly if needed. Is even-tempered with some range of emotion and is capable of experiencing a degree of pleasure and sadness. However, under duress, the Pt struggles to form secure, satisfying attachments to others. To preserve self-esteem, Pt tends to favour passive avoidance, remains in the background of social life, is quietly and unobtrusive at work, is rarely noticed, and is generally unmoved by emotional stimuli.

[checkbox value="- Presents with depressive features: slow personal tempo, low activation level, and the absence of vigorous and energetic action. Easily fatigued, with only weak motoric expressiveness. Struggles to rouse themselves to meet responsibilities, pursue the simplest pleasures, or behave with spontaneity. Interpersonally, presents as quiet, somewhat colourless, and vaguely dependent way of relating, and mildly dyphoric. Struggles to initiate activities, seems to have few interests, preferring a simple, repetitive, and dependent lifestyle|- Presents with avoidant features: represses all desires and emotions as they yield only anguish and disillusionment. Some behavioral eccentricities, autistic thinking, and depersonalization. Solitude seeking, aimless drifting on the periphery of society.|-- Presents with schizotypal features: frequently stares off into space, seems dreamy and distant as if avoiding a mundane world, inattentive and disengaged from the affairs of life. Somewhat obliviousness to the surroundings and appears preoccupied internally with nothing at all. Feels like a disembodied observer - viewing themselves from the outside, detached not only from the real world but also from their own thoughts and feelings, from their imagination and fantasies, and from their own corporeal bodies, as well. Has an ethereal attitude and only a
residual physical presence.|- Presents with compulsive features: isolated, emotionally detached, and solemn. Emotionally constricted; avoiding feelings through structured settings comfortable patterns of existence, also some features of a conflict between autonomy versus obedience, only weakly if at all."]

Psychological defenses include: depersonalization, derealization, false self, Distancing, Autistic withdrawal. Intellectualization. Isolation of affect.[/conditional]

[checkbox name="APF" value="-- ACTIVE-DETACHED PERSONALITY FEATURES --"][conditional field="APF" condition="(APF).is('-- ACTIVE-DETACHED PERSONALITY FEATURES --')"]

Pt is a sensitive person, generally comfortable in familiar surroundings and thrives within the context of a small group of trusted intimates. Pt is deeply concerned about the feelings and opinions of others and need their approval to flourish. Interpersonally, Pt is courteous and restrained. Pt avoids ambiguity, instead preferring situations where the expectations of others are well known and easily
confirmed. Pt is hesitant to readily reveal themselves to others; shares their
thoughts and dreams only after some time and only when they feel safe. Because Pt is a very private person, may self-disclose too infrequently to deepen their relationships, frustrating others to the point that a real sense of intimacy is lost. Is hyper-alert to criticism and prefers to deal with others cautiously. Pt is highly aware of goings-on in their surroundings and are ever on the outlook for potential threats to their safety or esteem. Pt is sensitive to social indifference
and rejection, feel unsure of themselves, and are unusually wary in new social
or interpersonal situations, especially with strangers. Ill at ease and self-conscious, they Pt anticipates difficulties in relationships and fears embarrassment.

[checkbox value="- Presents with negativisitic features: Pt is in conflict over the longing for intimacy versus the fear of vulnerability that naturally ensues in a close relationship with another. Is ambivalent about themselves and others. Pt idealizes close friends and companions, but should their sense of autonomy be threatened, is quick to undermine or humiliate them. Pt easily drawn into 'interpersonal guerilla warfare.' If not withdrawn into isolation, is experienced as petulant and sulking. Prone to attacking others for failing to recognize their needs for affection, but accuse those who offer nurturance of seeking to compromise their independence. Disposed to anticipate disappointments and fearful of facing others openly, Pt may strike out indirectly by obstructing their actions and misrepresenting their wishes. Pt reports feeling misunderstood, unappreciated, and demeaned, and their mood can be erratic. Under slight pressures, however, the Pt's pacific surface quickly gives way to impulsive hostility. Unable to orient emotions and thoughts logically, they may at times become lost in personal irrelevancies and autistic asides, further alienating them from others. Relating to such individuals, undoubtedly, is an arduous process, requiring far more patience than most people are likely to offer. This interpersonal strategy, fulfills the Pt's circular struggle; it vilifies others and discourages their closeness (keeping them safe from harm), yet ensures the Pt's unwanted isolation.|- Presents with paranoid features: Pt incorporates features of the paranoid personality, but exhibits greater reality contact. That is, Pt is well aware of personal shortcomings but will attribute them as much to the maneuverings of others as to themselves. Often seems high-strung and prickly, vigilant to signs of rejection and abuse, and excessively wary of the motives of others. Pt's pervasive apprehensiveness is often accompanied by intense and labile moods that feature prolonged periods of edginess and self-deprecation. My impression is that Pt strongly expects that others will be rejecting and disparaging but alternates between the profound gloom that often accompanies the basic detached personality pattern and the irrational projection of the paranoid. Either way, their usual strategy is a protective withdrawal that maintains a safe distance from all emotional involvement. Retreating defensively, some become more and more remote from others and from needed sources of support. At times expresses guilt and contrition, while feeling misunderstood, unappreciated, and demeaned by others. Paranoid traits makes it difficult to contain their anger toward anyone who has been unsupportive, critical, or disapproving. As the self-esteem approaches collapse, Pt tends to take on more severe paranoid features and comes to believe that their 'pathetic self' is the product of covert actions by others to undermine them or make them inhibit themselves. Paranoid defenses makes it easier to believe that others are the cause of their inadequacy, an external attribution, than to believe that they are naturally inadequate, an internal attribution.|-- Presents with schizotypal features: frequently stares off into space, seems dreamy and distant as if avoiding a mundane world, inattentive and disengaged from the affairs of life. Somewhat obliviousness to the surroundings and appears preoccupied internally with nothing at all. Feels like a disembodied observer - viewing themselves from the outside, detached not only from the real world but also from their own thoughts and feelings, from their imagination and fantasies, and from their own corporeal bodies, as well. Has an ethereal attitude and only a residual physical presence.|- Presents with compulsive features: isolated, emotionally detached, and solemn. Emotionally constricted; avoiding feelings through structured settings comfortable patterns of existence, also some features of a conflict between autonomy versus obedience, only weakly if at all."]

Psychological defenses include: depersonalization, derealization, false self. Distancing. Autistic withdrawal. Intellectualization. Isolation of affect.[/conditional]

Treatment Goals

As Pt presents with fears around intimacy and a hypersensitivity to rejection and ridicule, they tend to engage in self-imposed isolation and social withdrawal. Furthermore, Pt tends to hide and contain feelings of inner despair for fear that overt expressions of such weakness and suffering might render them even more vulnerable to social ridicule, humiliation, and rejection. Moreover, the pervasive sense of unease and disquiet is what is most observable about this Pt. They evince a constant timorous and restive state, overreacting to innocuous experiences, hesitant about relating to events that may prove personally problematic, and anxiously judging these events as signifying ridicule or rejection from others. The speech
is generally slow and constrained. Pt exhibits frequent hesitations, aborted or fragmentary thought sequences, and occasional confused and irrelevant digressions. Physical behaviors tend to be highly controlled or underactive, although
marked with periodic bursts of fidgety and rapid staccato movements. Overt expressions of emotion are typically kept in check, but this underresponsiveness belies deep tension and disharmony. Pt exerts great restraint, not only in controlling anxiety, but in controlling feelings of confusion and in subduing the upsurge of anger.

From a cognitive-behavioural framework the Pt has a tendency to view things pessimistically -- that is, contempt directed at the self, fear and suspicion of others, and a sense of future despair. Next is the limited opportunity the Pt has for experiencing reinforcing events. Characteristically, Pt tends to be inflexible, confined to a small range of potentially reinforcing experiences.

Pt demonstrates heightened pain sensitivity in social milieus, and generates low internal pleasure such that reinforcers are often ineffectual. Deficits arise from self-protective restraint. The coping style employed by the Pt is not a matter of choice. It is the principal, and perhaps only, means the Pt has found effective in warding off the painful humiliation experienced at the hands of others. Discomforting as social alienation may be, it is less distressing than the anguish of extending themselves to others, only to be rebuffed or ridiculed. Distance guarantees a measure of safety; trust only invites disillusion.

Reinforcers:

Defensive narrowing precludes corrective experiences
Preoccupations relive painful past - intensifies social estrangement
Suspicious and Fearful Behavior - evokes reciprocal disaffection
Weakness attracts humiliaters
Rebuff reinforces aversiveness
Emotional-Perceptual Hypersensitivity
Sensitive to derogatory events
Scanning elevates threats into fears
Sensitivity deepens plight
Cognitive Interference - intrusive fears fragment and derail thoughts
Social communication becomes tangential and irrelevant

Goals:

Diminish anticipation of pain
Increase pleasure/enhancing
Counter Perpetuations
Reverse social detachment
Diminish suspicious/fearful behavior
Moderate perceptual hypersensitivity
Undo intentional cognitive interference
Tactical Modalities
Adjust alienated self-image
Correct aversive interpersonal conduct
Remove vexatious objects

Behavioral Techniques

Self-monitoring withdrawal behavior to help clarify their inclination to avoid certain people or social situations.
Keep a log of their self-deprecatory statements and physiological arousal.
Behavioral rehearsal to improve assertiveness and behavioral fluidity
Anxiety-management training can be very helpful.
Hierarchical grading of social tasks in regard to anxiety-provoking potential.

Interpersonal Techniques

Explore the Pt’s long-term maladaptive patterns, eschewing statements or actions that expose their hypersensitivities.
Refusing to support avoidance and encouraging assertive behavior.

Cognitive Techniques

Help patient discover thinking errors committed in everyday life that contribute to their dysphoria and self-defeating behaviors.
Increase the Pt's tolerance for what they perceive as emotionally upsetting relationships or events.
Enable the Pt to recognize that difficulties in close relationships do not result in devastation and abandonment. Particularly disclosure fantasies of negative retribution.

Psychodynamic Techniques

Consider Pt's avoidant behaviour as being driven by the shame of not measuring up to one’s ego ideal, of being weak, defective, even disgusting. Childhood memories are analyzed to clarify the roots of avoidance. Explore the underlying elements of the past that have led to feelings of rejection and shame.

Explore excessive self-reflection.

[checkbox name="ADPF" value="-- AMBIVALENT-DETACHED PERSONALITY FEATURES --"][conditional field="ADPF" condition="(ADPF).is('-- AMBIVALENT-DETACHED PERSONALITY FEATURES --')"]

Pt has an idiosyncratic style, marching to the beat of a unique drummer, nourished by a unique belief system that contributes to an unconventional or even eccentric lifestyle. Requires few intimate relationships and is instead an independent seeker of what is interesting and unusual, often being drawn to the extrasensory, supernatural, occult, or mystical.

Pt is highly open to new experiences and novel interpretations of conventional ideas and is curious about alternative abstract formulations of the old and common. Often, the Pt is highly aware of the reactions of others but nevertheless draw inspiration from internal sources. As such, consensual social reality is not the basis of the Pt's self-esteem. Instead, the subjective world of their own unique experiences is what the Pt believes and value. If experience supports the existence of the supernatural or ESP, then objective, scientific proof is not required. Is an experimentalists who seeks the limits of knowledge and of emotional and spiritual experience.

[checkbox value="- Presents with depressive and dependent features: is notably insensitive to feelings, indifferent to the external world, and appears drab, unmotivated, apathetic, inexpressive, sluggish, and joyless. Tends to experience their mind and body as separate or decoupled. Struggles with deep feelings of emptiness. Feels like an automaton without meaning or purpose. Consciousness seems to float, unconnected to the physical world, as if lost in some dimension between being and nonbeing. Cognitive processes seem obscure, vague, and tangential. Symptoms of depersonalization are frequent. Social communications are responded to minimally or with inappropriate affect or peculiar ideas or in a circumstantial and confused manner. Speech is monotonous, listless, or even inaudible at times. In some cases, depressive and dependent features may also be present. Struggles to interchange ideas and feelings with others, and therefore appears fixed and undeveloped, continuing, therefore, in their disjointed, amorphous, and affectless state. Restricted in social experiences, seems to have a marked paucity of social skills - finds it difficult to relate socially, which perpetuate a vicious circle
that fosters their isolation and accentuates social inadequacies and cognitive
deficiencies.|- Presents with negativisitic features: restrained, isolated, apprehensive, guarded, and socially shrinking. Apathy and indifference are used protectively to damp down sensitivities, feelings, and desires. Drawn to strange signs and omens through which protective guidance can be obtained and malicious events controlled or averted. Focused on irrelevant details that would escape the ordinary person and develop superstitious behaviors or rituals. Has a rich fantasy life that seems to include perceptions that are normally beyond the five senses, creating an inner world populated by magical fantasies, illusions, telepathic relationships, and other odd thoughts that provide an existence more significant and rewarding than that found in reality. Excessively apprehensive, particularly in social encounters, exhibiting agitation and an anxious watchfulness. Exhibits a distrust of others and a suspiciousness about their motives that rarely recede despite familiarity. Bedeviled with feelings of low self-esteem, incompetence, and a marked distrust of others leading to protectively keeping distance from others, walling off from society, and insulating feelings."]

Psychological defenses include: depersonalization, derealization, false self. Distancing. Autistic withdrawal. Intellectualization. Isolation of affect.[/conditional]

[checkbox name="DPF" value="-- PASSIVE DEPENDENT PERSONALITY FEATURES --"][conditional field="DPF" condition="(DPF).is('-- PASSIVE DEPENDENT PERSONALITY FEATURES --')"]

When functioning well at their baseline, Pt is capable of genuine empathy for others, possessing a tremendous capacity for sustained unconditional love. Is among the most trusting people, with a modest, uncritical, gentle demeanor that communicates almost unquestioned acceptance. Pt is easy to please and demands little from others. Pt sets realistic standards for approval and is always encouraging of their mates and loved ones. Has deep reservoirs of goodwill and is genuinely pleased by the good fortunes of others.

Pt is gracious even to those whom they may dislike. Despite the high esteem in which the Pt is held, the more people value them, the more humble they become. Generally charitable in giving of themselves, the Pt tends to put a positive light on all life events and stress the virtues and good they find in others.

Pt tends to seek out the opinion of others, weighs the advantages and disadvantages, but makes the decision based on their own analysis. Is generally comforted by the support of others and enjoys their company but can perform adequately without it. Pt generally prefers interpersonal harmony but is able to speak up when necessary and hold their ground. Capable of functioning autonomously but prefers to work in close proximity to others. Pt is considerate and occasionally self-sacrificing, keeping the best interest of others foremost in mind. Pt prefers the company of others but can enjoy occasional solitude. Pt can be nostalgic about lost intimacy but does not immediately seek to merge with another. Pt enjoys the affection of others as expressed through thoughtfulness but is not terrified of abandonment.

However, under duress, the Pt tends to fuse their own identity with that of others. Struggles to be alone with a tendency towards enmeshment with others because the idea of separation causes intense anxiety.

[checkbox value="- Presents with avoidant features: lives a symbiotic existence sustained by institutional rewards and requirements. Possesses an underlying apprehensiveness that overlies a lack of initiative and an anxious avoidance of autonomy. Easily disconcerted and experiences a general sense of dread and foreboding. Vulnerable to separation anxiety and greatly fear loss of support and nurturance. Sometimes expresses abandonment fears through outbursts of anger directed at those who fail to appreciate needs for security and safety. Preferring institutional security, has a pattern of withdrawing from social encounters, as such, loneliness and isolation are commonly experienced. Attempts to be pleasant and agreeable, which masks underlying tension, sadness, and guilt. Outwardly quiet and affable in the face of difficulties, but underneath is overwhelmed by fears of abandonment and isolation.|- Presents with masochistic features: submissive, agreeable, and hungry for affection, nurturance, and security. Fears of abandonment lead Pt to be overly compliant and obliging. Can be socially gregarious and charming at times. Typically gracious, neighborly, benevolent, and compliant in their relationships with others, preferring to avoid conflict and seek harmony even at the expense of their internal values and beliefs. Tends to be preoccupied with external approval, at the expense of cultivating a real inner identity. Feels bolstered by submerging or allying themselves with the abilities and virtues of others, creating a feeling of shared competence. Demonstrates a naïve attitude toward life’s problems - maintaining an air of pleasantry and good spirits, denying disturbing emotions and cover inner conflicts with various distractions. Critical thinking is not a strong point. Having had others support them, seems underdeveloped or immature in some areas. Generally self-sacrificing and readily adopts the role of inferior or subordinate. Tends to avoid self-assertion and happy to leave responsibilities in the hands of others. Resembles the masochistic personality. All that seems to matter is that others like them, are pleased by them, and are willing to accept their smiles and goodwill as sufficient. However. their agreeableness is designed to encourage others to take control, thereby compensating for their feelings of incompetence. Struggles to follow through on adult responsibilities and often feel helpless whenever autonomy or initiative is required. The loss of a significant source of support or identification may prompt severe depression. Open displays of guilt, illness, anxiety, and depression are common and serve the purpose of deflecting criticism and transforming threats of disapproval or abandonment into support and sympathy.|- Presents with regressive features: has a childlike quality, struggling to take on adult activity and responsibility. Appears underdeveloped, inexperienced, and unsophisticated. Lacks ambition and energy, which makes the expectancies of adulthood overwhelming and frightening. Passive and easygoing with under-developed competencies or confidence in their own abilities. Adult roles appear somewhat distasteful or frightening. Generally pleasant and sociable as long as they are permitted to remain pre-adult in their preferences and activities. Feels challenged when others begin to expect more or demand that they mature and get down to the business of life. May appear irresponsible and neglectful at times.|- Presents with schizoid features: Exhibits a general lack of vitality, low energy level, fatigability, and weakness in expressiveness and spontaneity. Struggles with anhedonia poorly able to experience pleasurable emotions in great depth. Tends to shun social relationships. Generally seeks an untroubled life completely free of responsibility, though mainly because of a lack of drive. Often tunes out life’s demands. Reality avoidant at times, appearing to sleepwalk through life, half disengaged and half dependent. They typically do not want to engage in anything or think too deeply, and thus exhibits a certain fatalism that allows them to
ignore difficulties. Tends to externalise this fatalism, which betrays an underlying assumption that nothing ever changes on the basis of their efforts, justifying their lack of drive and desire to act on their own behalf.|- Presents with depressive features: idealization and identification are the major themes. Attachment concerns with a tendency towards merging. Identity forfeiture. Denial of unique personal potentials as independence is fought against. Through fusion, a sense of significance, emotional stability, and purpose in life is secured. Life is performed in the service of extending the status and significance of others, be it a person or an institutional entity. Because of this fusion, Pt may adopt values and attitudes that are different from their ordinary preferences. Self confidence is derived through assuming the qualities of the persons or institutions with whom they have identified. A feeling of significance is derived through fusion with their idealized others. By deriving their identity through external sources, they make themselves extremely vulnerable to loss - risking depression and anxiety through loss of attachment."]

Psychological defenses include: introjection, idealization, denial.

Treatment Goals:

Encourage self-focus
Counter Perpetuations
Reduce self-depreciation
Encourage adult skills
Diminish clinging behaviors
Correct submissive interpersonal conduct
Enhance inept self-image
Acquire competence behaviors

Behavioural interventions:

Anxiety hierarchy of independent and assertive behaviors for gradual
implementation.
Role-playing and modeling for skills development
Anxiety-reducing skills, such as breathing techniques and deep muscle relaxation
Anxiety tolerance.
Assertiveness training.
Limited sessions.

Cognitive interventions:

Challenge unrealistic expectations.
Challenge polarized thinking around loved versus alone.
Socratic questions around self-image.
Two-chair work of dealing with an adversary.

Analytic:

Explore the defense against hostility
Explore trauma avoidance
Shine a light on introjective tendencies (parroting, emulating and mirroring)[/conditional].

[checkbox name="ADP" value="-- ACTIVE DEPENDENT PERSONALITY FEATURES --"][conditional field="ADP" condition="(ADP).is('-- ACTIVE DEPENDENT PERSONALITY FEATURES --')"]

When functioning well at their baseline, the Pt is generally friendly, expressive, and sociable. Pt tends to experience life through sensation and a sense of the romantic. Is highly intuitive, trusts others easily and readily gets involved in relationships. Seems to be be popular and naturally know how to make others like them. Is warm, lively, dramatic, energizing, and occasionally provocative. Pt presents with an outgoing style; enjoys compliments and praise without depending on them. Enjoys entertaining others, yet can relinquish the floor and become part of the audience. Is comfortable with aspects of physical attraction by way of style, body consciousness, fashion, and presenting themselves well. Pt is more constructive in qualifying and detailing appraisals, given their authenticity of emotion. Pt is capable of making their own decisions, even at the expense of attention and approval. Pt is anchored to a solid sense of self, allowing for a sense of continuity over time and insight into the nature of personal relationships.

However, under duress, Pt over-relies on a blanket sexual allure or promise. Is prone to being fickle with rapidly shifting moods. Compliments and praise never seem to be enough; Pt must be the center of attention at all times.

Pt tends to be cognitively global, diffuse, and impressionistic. Seems to be constantly engaged in dramatic and theatrical expression. Is easily swayed by the influences of others. Considers relationships to be more friendly or intimate than they really are. Pt seems unable to hold a point and explore it in depth, tending to digress from one superficiality to the next, as a means of avoiding conflict or unpleasant emotions. Pt easily gets to know others but quickly becomes bored with them.

[checkbox value="- Presents with histrionic features: Overly romantic and attention seeking. Chameleon-like on social demand, and changing to suit audience and
circumstance. Sense of self is subordinated to the requirements of the social economy. Style is valued to the exclusion of substance.|- Presents with capricious features: strong dependency issues. Tends to sexualize relationships prematurely. Indulgent and struggles with frustration tolerance. Inner emptiness compensated through being the center of attention and by persistent sensation seeking. Occasional primitive regressions into fantasy. Given the lack of identity formation, the Pt's attachment to significant others is highly dependent and demanding. Constant reassurance seeking to maintain their stability and vacillate between over-compliance and profound depression when approval is not forthcoming. Emotions change quickly, easily, and unpredictably, running the gamut from intense love to intense rage to intense guilt, all of which may be expressed simultaneously. Can be agreeable but rapidly shifts to sullen or petulant the next. Tends to complain that they are either unloved or treated unfairly, attitudes that quickly escalate into tantrums when anyone disagrees. - Presents with narcissistic features: radiates attractiveness, charm, playfulness, verve, and intensity. More than just bubbly or perky, the Pt is interpersonally cheerful, optimistic, spontaneous, and impulsively expressionistic, often without regard to future consequences. Driven by a need for excitement and stimulation, the Pt is easily infatuated, attaching themselves to one person after another in quick succession. Behaviorally, their movements are quick and animated. Ideas often flow so quickly and tends to infect others with their excitement. Tends to face around, getting things done, starting projects, and persuading others to join them with an energy and friendliness. Prone to gratifying momentary whims without completing much of anything.|- Presents with compulsive features: is desperate for approval and therefore prone to continually compliment, praise, flatter, and commend. Struggles to tolerate indifference in others. When disagreements do occur, the Pt immediately begin smoothing things over, even compromising their own desires or paints themselves as innocent victims caught in a cruel world. Struggles with feelings of emptiness, the guilt of the compulsive, and the inferiority and helplessness of the dependent. Struggles with feelings of being a problematic person who is unloved and inadequate. Others tend to see the Pt as a pleaser; ever alert to any subtle means whereby appreciation and approval might be secured. Internalized condemning parental voices rain down from on high with criticism and admonishment. Rather than conforming the Pt moves to appease: goodwill and kind gestures in return for anger and hostility.|- Presents with negativistic features: intensely moody and emotionally variable. Generally is friendly and sociable, but is easily bored, needing external stimulation, and impulsive sensation-seeking. Hypersensitive to criticism, intolerant of frustration, and socially immature—characteristics that ensure that the good times won’t last. Pt alternates between periods of extreme emotional excitement and impulsive acting-out, followed by fits of anger that transition to depressive-like symptoms of fatigue and sleep and eating pattern changes. With a fragmented sense of self, is vulnerable to unmoderated displays of raw and rapidly changing emotions. Easily loses control, reacting with storm and turbulence to even minor provocations. Deprived of attention, they may search frantically for approval, becoming contentious, dejected, or hopeless when it is not readily forthcoming.|- Presents with anti-social features: tends to make a good first impression and seem sociable and sincere, exhibiting spontaneity and charm. However, tends to be manipulative, violates social conventions, breaks promises, shatters loyalties, behaves irresponsibly, with eruptions of of anger and physical confrontation. They often seem to enjoy conflict, gaining a degree of gratification or amusement from the excitement and tension thereby produced."]

Psychological defenses include: repression, splitting, sexualization, dissociation, and projection.

Treatment goals:

Diminish manipulative actions
Moderate focus on others
Reverse external preoccupations
Kindle genuine social relationships
Acquire in-depth knowledge
Decrease interpersonal attention-seeking
Stabilize fickle moods
Reduce dramatic behaviors
Reorient Flighty Cognitive Style

Behavioural:

Relaxation training
Problem-solving strategies
Assertiveness training
Tolerate existential anxiety

Interpersonal:

Warm sympathy toward their observing ego
Examine dysfunctional patterns
Explore alternate behaviours
Firm clear-cut boundaries

Cognitive:

Reinforce assertive and competent responses
Link thoughts to behaviours
Identify distortions
Identify their authentic wants and needs
Build self-concept: make a list of things they know about themselves e.g. favorite colors and foods
Handling rejection

Psychoanalytic:

Reveal hidden needs for dependency
Explore the transference drama[/conditional]

[checkbox name="AmDP" value="-- AMBIVALENT DEPENDENT PERSONALITY FEATURES --"][conditional field="AmDP" condition="(AmDP).is('-- AMBIVALENT DEPENDENT PERSONALITY FEATURES --')"]

Pt is continually seeking out new opportunities for life fulfillment with little regard for common sense limits and emotional / personal safety. Pt demonstrates a pattern of seemingly perpetual activity and pursuit of interests, often drawing others into these endeavors more as an afterthought than by design. Pt appears to have a vulnerability to discomfort coming from any form of passivity, whether that be appropriate rest or stagnation of activity.

The energy and self-assured entrepreneurial attitude characteristic of hypomanic individuals places them in leadership roles where their less desirable, uninhibited and meddlesome tendencies are tolerated. Although their drivenness may drive
others away, their exuberance and people-seeking skills are counterbalancing assets. Questionable judgment in social, sexual and financial spheres may hurt their loved ones and irritate associates.

Relative to their peers, Pt typically has more drive and energy, more self-confidence, increased social and physical activity, happy mood, faster thinking. However, darker features include: more irritable and impatient, distractible attention, foolish business ventures, imprudent driving, increased consumption of coffee, cigarettes, and alcohol.

While highly positive when circumstances are favourable, Pt is prone to decompensation when not briskly stimulated. Pt can continue to function quite successfully as long as they limit and focus their extraordinary energies and good moods. It is when they begin to become too high-spirited and impetuous that difficulties arise. They act intrusively with others, come up with scattered ideas, are insensitive to the rights of their colleagues and family members. At this point their exuberance takes on a preclinical form.

[checkbox value="- Presents with histrionic features: The dominant characteristic of this Pt is their cheerfulness and buoyancy, their desire to enjoy life, to follow the pleasure principle, to experience events in a jovial manner, to be carefree and happy-go-lucky.

If events and experiences are not immediately gratifying and mirthful, Pt is ready to pick up and move on to something else that may be. To be in the company of others who are similarly inclined or receptive to them dominates their aspirations. Pt is a social entertainer. Nothing is more wonderful and exulting than to be in the company
of people open to their cheerful glibness. Pt tends to race from one person to another, constantly seeking a jubilant and gleeful response to their entreaties. Social conviviality is their goal. Pt frequently will attempt in their small personal world to engage in clever chit-chat, jokes, shocking commentaries, and
outrageous humor. Blithe and frivolous, the Pt keeps their attention focused on the
superficial and cheerful aspects of life. Unfortunately, in the rush to maintain a euphoric and animated life, the Pt struggles to become fully accomplished in any single realm. To settle down, concentrate, and expend effort seems more than they can tolerate. Superficiality and good spirits are all that they desire. Pt is a great entertainer, with ideas moving in a lightning fast, almost frenzy-like fashion, from one topic to another. Pt struggles to focus their attention and concentrate; all sorts of creative ideas and plans are generated to keep those around them in a buoyant and convivial mood.

Personal relationships tend to be superficial, however, with minimal affective resonance achieved with others. In Pt's effort to maintain their bustling activity, their interpersonal superficiality and inattentiveness to the interests of others
comes to the fore. Caring little for durable relationships, for anything and anyone, means the Pt struggles to acquire a genuine degree of warmth and intimacy with others. Moreover, the Pt is a poor conversationalist, and generally fails to reciprocate the affairs and concerns of those they relate to. They continually interrupt others, keep the flow of conversation centered on the primacy of their own wishes, and seek to maintain the tone of repartee upbeat and cheerful.| - Presents with Narcissistic features: Pt has an an entrepreneurial spirit, full of eagerness, liveliness, vitality, and optimism. Pt is an enthusiastic promoter of ideas and plans. They are passionate and effusive in their pursuit of their goals, evidencing at times an irrepressible spirit that drives them to pursue one implausible venture after another. Pt champions numerous amusements, as well as numerous ways of engaging others to pursue and promote them. Their passion and ebullience, however, is typically short-lived they leap from one passing exciting venture to another.

Many naïve persons are drawn to the Pt's enterprises and gambles because enthusiasm is infectious. Unfortunately Pt is too readily bored, lacking the staying power and consistency necessary to complete projects. Ideas emerge quickly in full form, but not necessarily thoughtfully or sensitive to practicalities. Getting serious
or detail-oriented is not their forte. Excited by variety, novelty, and change, their consistency consists of inconsistency. The best part of the Pt's life is in anticipating what might be, not in everyday mundane realities. It may well be that they are too frightened of stopping, of looking inward. Each idea springs anew as they run away from the thought of any finality or closure. When they do work, they do so in spurts, resisting any event or action that may slow them down. Any
experience they judge as drudgery, prosaic, or ordinary is avoided like the plague.

As noted, Pt tends to throw themselves into their world with tremendous vitality and ardor. They indulge in anything that may come to mind with such immediacy and fervor that it invariably leads to a constant flow of fresh possibilities, again and again, faster and more. A problem that arises, of course, is that they become enamoured with transient anticipations, with what they enthusiastically look forward to. As a consequence, they lose touch with what lies presently before them. Their immediate
environment fails to take hold and cannot therefore be fully satisfying. They always seem to be looking to tomorrow, the next event, not that which exists in front of them now. Life is what they want to do or what they must acquire. What they have in
hand is never enough -- it’s only what may be that can be satisfying, so they believe.| - Presents with Anti-Social features: What is considered exuberant at one level of functioning decompensates into a turbulent level
of malfunctioning. What we see is a pattern of
heedless behavior, scattered thinking, and brash
and impetuous actions and moods. They appear
desperately impetuous, engaging in careless and
unmindful behaviors, acting impulsively and
abruptly as they generate irresponsible and
harebrained schemes. In their effort to keep
functioning while they seek to deny the pressure
of an upsurging depression, they race
wildly, almost completely out of control. Their
actions, thoughts, and moods become erratic
and unpredictable; their behaviors and emotions
become akin to the manic breakdown of
compulsive personalities.
Within the space of a few minutes, moods
and actions may shift rapidly from one extreme
to the other, swinging from jubilance one second
to tearful remorse the next. Scattered among
these unpredictable shifts may also be seen
moments of precipitate hostility. Careless and
unmindful of what they say, their behavior
becomes increasingly irresponsible. Interspersed
among their devil-may-care outlook are previously
repressed outbursts of momentary anger
and fearful anxiety. One moment they may feel
the most joyous and excited of moods, the next
they throw themselves into a deep sense of
sadness and loneliness. It is during these

[checkbox name="PIP" value="-- PASSIVE INDEPENDENT PERSONALITY FEATURES --"][conditional field="PIP" condition="(PIP).is('-- PASSIVE INDEPENDENT PERSONALITY FEATURES --')"]

Pt has high positive self-regard, having a faith in their abilities. Pt aims high and battles to succeed. Ambitious and likes to lead. Pt is ambitious, assumes leadership roles, and enjoys being central to others.

[checkbox value="- Presents with antisocial features: success tends to come at the expense of the needs of others. Legal boundaries are optional. Opportunistic. Contempt of victims. Limited super ego development and lacking internalized moral prohibition. Frequently disregards the rights of others. Self esteem is derived through humiliating and dominating others. Joy is obtained by gaining the trust of others and then outwitting or swindling them. Indifferent to truth. Masks antisocial attitudes through through a veneer of politeness and civility. When challenged, displays an attitude of nonchalance or cool strength. Victim blames. Relationships are utilitarian. Preys on the weak and vulnerable, enjoying their dismay and anger.|- Presents with negativistic features: wounded in early life, compensates with an illusion of superiority. Striving to fulfill aspirations of status, recognition, and prestige. Feels privileged and empowered by virtue of pseudo achievements. Entitlement bears little relation to reality. Exceedingly sensitive to the reactions of others, noting every critical judgment and feeling slighted by every sign of disapproval, compensating through a façade of superiority. Struggles with procrastination for fear of evaluation. When threatened with reality, becomes defensive, arrogant and dismissive.|- Presents with histrionic features: defined by the game of erotic seduction they play with objects of their affection. Entices and tempts the emotionally needy and naïve, while fulfilling their own hedonistic desires and sexual appetites. Not inclined toward genuine intimacy. Enjoys being desired by many rather than one. , Desires the warm affection of a genuine relationship, but feels restless and unsatisfied in a relationship. Sexual conquests are 'victories' to gratify power needs. Substantial body narcissism, attending scrupulously to physical appearance, clothes, and other external attributes.|- Presents with elitist features: Self-assured to the point of arrogance. Ill-suited to subordinate positions. Cultivates a facade of success to amplify a superior self-image. Fears being ordinary. Stands as a race apart from ordinary human beings. Revels in displays of power. Fixated on prestige. Tends to flaunt symbols of status and achievement. Craves recognition and engages heavily in self-promotion."]

Psychological defenses include: grandiosity, rationalization, fantasy, denial, repression, splitting, devaluation.[/conditional]

[checkbox name="AIP" value="-- ACTIVE INDEPENDENT PERSONALITY FEATURES --"][conditional field="AIP" condition="(AIP).is('-- ACTIVE INDEPENDENT PERSONALITY FEATURES --')"]

Demonstrates a capacity for self-sufficiency, ambition, competitiveness, and a constructive pursuit of individuality and self-determination. Unconventional; Pt does things their own way and is willing to take the consequences, regardless of how others might judge them. Sometimes flirts with legal boundaries in pursuit
of their own goals and desires. Rather than accept customary responsibilities, they see themselves as independent or creatively autonomous.

[checkbox value="- Presents with anti-social features: Somehow feels that life has not given them 'their due'. Envious of those who have received the bounty of a good life, Pt is driven by a desire for retribution to take what destiny has refused them. Whether through deceit or destruction, their goal is compensation for the emptiness of life. Pleasure lies in taking control of the property and possessions of others. Seems to have an enormous drive for revenge, manipulating others like pawns in a power game. Deeply insecure about their power and status, never feeling that they’ve been compensated for life’s impoverishments. Prone to ostentatious or wasteful displays of materialism and conspicuous consumption. Has little compassion for or guilt about the effects of their behavior. Remains forever dissatisfied and insatiable.|- Presents with narcissistic features: motivated by the desire to defend and extend a reputation of bravery and toughness. Behaviours are designed to ensure that others notice them and accord them the respect that they deserve. Hypersensitive to the possibility of belittlement. Feels they are someone significant, not to be easily dismissed, treated with indifference, taken lightly, or pushed around. Whenever their status or ability is slighted, Pt erupts with ferocious intensity, posturing, and threatening until rivals back down. Being tough and assertive is essentially a defensive act intended to prove their strength and guarantee a reputation of indomitable courage.|- Presents with histrionic features: risk taking is intended to impress others with a front of courageous indifference to potentially painful consequences. Pt wishes others to see them as unaffected by what almost anyone else would surely experience as dangerous or frightening. Pt seems unfazed by the possibility of gambling with death or serious injury. Risk is proactively sought as its own reward, a means of feeling stimulated and alive, not a means of material gain. This defends against the sense of feeling trapped by the responsibility and boredom of everyday life. Irresponsible with actions and their fails to consider the consequences for their own life, or the lives of others, as they pursue ever more daring challenges.|- Presents with schizoid features: Pt known to drift along at the margins of society, scavenging whatever slim resources they come across. Self perception is that they are jinxed or doomed and desire only to exist at the edge of a world that would almost certainly reject them. Mired in self-pity. Pt has dropped out of society to become a gypsy-like wanderer. Pt has little regard for their personal safety or comfort, and tends to drift from one setting to another as homeless person. Pt's sense of 'being no place' likely signifies alienation from self and others. Often appears vaguely disconnected from reality and lacks any clear sense of self-identity. Known to misuse substances and occasionally acts out.|- Presents with sadistic features: is frequently belligerent, rancorous, vicious, malignant, brutal, callous, vengeful, and vindictive. Behaviours are charged with a hateful and destructive defiance of conventional social life. Having paranoid features, Pt anticipates betrayal and punishment leading to a strike-first attitude. Rather than merely issue verbal threats, however, Pt secure their boundaries with a cold-blooded ruthlessness that avenges every mistreatment they believe others have inflicted on them in the past. Tender emotions are a sign of weakness. Goodwill and kindness are perceived as weakness at best or a deeper ply to manipulate them at worse. Displays a chip-on-the-shoulder attitude and a willingness to confirm a strong self-image by victimizing those too weak to retaliate or those whose terror might prove particularly entertaining. Pt is an expert at the art of posturing and enjoy pressuring their opponents until they cower and withdraw. Makes few concessions and generally prefers to escalate confrontations as far as necessary, backing down only when clearly outgunned."]

Psychological defenses include: Narcissism, grandiosity, rationalization, minimization, acting out, splitting, devaluation.[/conditional]

[checkbox name="PP" value="-- AMBIVALENT INDEPENDENT PERSONALITY FEATURES --"][conditional field="PP" condition="(PP).is('-- AMBIVALENT INDEPENDENT PERSONALITY FEATURES --')"]

When functioning well at their baseline, the Pt is able to adapt to the realistic demands of the environment. Is very comfortable working and existing in dangerous and often unpredictable contexts. Has an earthy realism about life and people. Is highly adaptive to the vicissitudes of life.

Pt is highly independent, values their freedom, and is sensitive to issues of power, authority, and domination. Pt is suitably cautious and reserved in dealing with others and enters relationships only after careful consideration. Pt not only listens to what others say but also pick up subtle meanings and expectations at multiple levels. Pt does not shy away from problematic or highly conflictual situations.

Where criticism is concerned Pt is not easily intimidated, and will readily defend what they see as inalienable rights. Fidelity and loyalty are among the Pt's highest values, and they thrive when communication is direct and nonthreatening. Pt's keen nose for conspiracy serves them well. Pt prefers to remain somewhat distant until others can be carefully appraised. Pt places a premium on fidelity, frankness, openness, and honesty; is more open to the evidence; and does not alienate others on the basis of suspicion alone. Pt has a close knit circle of trusted friends but nevertheless, but plays their cards closely with those who are only acquaintances.

However, under duress, Pt often believes, without adequate foundation, that others are attempting to harm, exploit, or deceive. Pt frequently suspects, with no adequate foundation, that close friends or associates have been disloyal. Pt is extremely reticent about sharing confidential information with others for fear that it will be used against them. Pt interprets benign communications as containing hidden threats or demeaning messages.

Pt nurses grudges and rarely forgives an insult and perceives attacks where none are intended. Moreover, Pt responds almost reflexively with angry counterattacks. Pt tends to implode intimate relationships as they perceive their significant other has been unfaithful.

[checkbox value="- Presents with Narcissistic features: Pt frequently comes across as arrogant, pretentious, and expansive and maintains an air of contempt toward others. Pt tends to run hard into reality, resulting in narcissistic wounds. With self-image of perfection shattered, Pt often seeks to reestablish lost pride through extravagant claims and intricate fantasies. By endowing themselves with illusory powers, Pt sees self as a type of superheroes or demigod, ready to prevail against an evil universe. Having assumed a grandiose identity, Pt attempts to offset the collapse of self-esteem produced by objective reality. As such, presents themselves as a holy saint, inspired leader, or talented genius. Elaborate schemes may be devised by which to deliver the world from sin, lead the planet to world peace, solve long-standing scientific problems, or create utopian societies. Occasionally, their plans are sufficiently detailed to draw at least passing interest. Pt attributes failures to interference to intangible powers, perhaps secret government agencies that have conspired to preserve the status quo. Projection, righteous indignation, and a sense of omnipotence combine to create a defensive armor in this Pt. Having a crushed sensed of self-worth, and unwilling to face reality, Pt retreats deeper inside a private world of fantasy, creating a compensatory universe in which they can assume their former station, fulfill previous ambitions, and salvage their existence."]

[checkbox value="- Presents with sadistic features: Pt has expectations that they will be on the receiving end of others aggressions. Highly sensitive to power issues, the Pt's strategy is to dominate others before they can dominate them. Frequently intimidating and belligerent, the Pt seems to possess a ruthless desire to avenge past wrongs and triumph over others. Even when they are alone, the long list of perceived wrongs apparently done to them constantly rises into their awareness, thus keeping a potential for aggression close to the surface. Pt reports their actual efforts at abusing and terrorizing others routinely backfire, which leads them to seek retribution more through fantasy than action. Although these setbacks are wrought by their own hand, as their chip-on-the-shoulder attitude toward others provokes abundant antagonism. As the Pt becomes more isolated, left to ruminate over this self-created perpetual cycle of interpersonal hostility, they tend to cogitate on the perceived malicious nature of their hostile environment, complete with the venomous individuals who inhabit it. Via the intrapsychic mechanism of projection, Pt attributes their own acrimony to others, ascribing to them all of the enmity they feel within themselves. As the line between objective antagonism and imagined hostility grows thin, the belief that others are intentionally persecuting them may take on almost delusional proportions. Pt therefore feels the need to protect their autonomy against any and all outside influence is a defining feature of this variant because nothing is so valuable and so vulnerable to them as their sense of self-worth. The malevolence they perceive emanating from others is neither casual nor random but designed to intimidate, offend, undermine their self-esteem, control their thoughts, and weaken their will. They are ever alert against their darkest fears: Others will make them soft and yielding, forced to submit to authority, or worse, tricked into surrendering their self-determination."]

[checkbox value="- Presents with compulsive features: Pt presents as rigid, perfectionistic, grim, humorless, tense, overcontrolled, small-minded, peevish, legalistic, and self-righteous. Pt has a posture of unabashed self-assertion. They actively rebel against any and all external constraints in a maladaptive effort to regain their sense of perceived control and overturn injustices previously doled out on them. While they do continue to seek clarity from imposed rules and regulations, they are now the imposers of a system that is used to attack others, usually through either legal action or the setting of impossible rules that cannot realistically be followed. Other caught in the Pt's crosshairs are despised for their weakness, their sloppiness and lack of regard for disciplined behavior, their failure to live an organized life, and their hypocrisy.

Despite these assertions of nonconformity and dominance, however, the Pt is not likely to eschew deep-seated feelings of guilt and fear of retribution. Further,
although they may appear to function normally much of the time, they possess tightly
compartmentalized persecutory delusions. It is not unusual for the Pt to project their anger onto others—thereby creating the perception of hostile intent from innocuous or absent signals."]

[checkbox value="- Presents with negativistic features: characteristics such as discontentment, pessimism, stubbornness, vacillation, and vengefulness which amplify into overt hostility and forthright delusions. This result manifests in tones of faultfinding, sullenness, resentfulness, contentiousness, jealousy, and insistence on being forever wronged or cheated. Pt eschews relationships, instead giving up their quests for affection and adopting a contrived stance of autonomy and self-determination, renouncing their social needs yet harboring a cloaked sense of dejection. While they state their newfound independence with vengeful fury, the Pt remains deeply troubled by interpersonal discontentedness and feelings of indecisiveness, with hidden feelings vacillating between desiring the company of others and feeling repulsed by them. As envy mounts, the Pt often complains that the achievements of others reflect unfair advantages or preferential treatment. Grumbling turns to anger and spite as their fantasies of being taken advantage of accrete ever more injustices. Legal action against those who have wronged them is common, as are erotic delusions because the Pt does still seek affection even while refusing it. This is done via the intrapsychic projection mechanism, whereby the Pt comes to believe that the feelings of the self are actually emanating from others. Thus, by projecting their own desires onto others, it becomes 'them' who make lewd remarks or otherwise suggest sexual intentions. Accusations of infidelity, deceit, and betrayal are often made against innocent relatives and friends, a further synthesis of the negativistic and paranoid patterns."]

- Presents with avoidant features: Pt often presents as moody, apprehensive, and hypersensitive to criticism, especially where their worth and achievements are concerned. Extremely vulnerable, Pt often seeks solace in self-focused ways. For example, they may engage in abstruse intellectual activities to enhance their self-esteem or indulge in drugs and alcohol to calm their fears. Especially fearful of shame and humiliation, the Pt seeks to defend themselves against both real and imagined dangers. More than most, they seek to protect themselves from a world both threatening and destructive. As such, the Pt tends to isolate themselves for long periods of time, a means of keeping the inevitable judgments of others out of their lives. Pt has an unusually strong fear of being controlled. They not only seek to prevent external influence but also desire to rely solely on their own conclusions
and beliefs. Unwilling to check their thoughts against consensual reality, the Pt seems frequently out of touch with the surrounding world, and often loses the
ability to distinguish fantasy from reality. Having fears of shame and humiliation, an important component of both the paranoid and avoidant patterns, the Pt easily inflates to full-blown conspiracies.

Psychological defenses include: projection, reaction formation, rationalisation, splitting, devaluation, displacement, grandiosity, omnipotent fantasy.[/conditional]

[checkbox name="PCP" value="-- PASSIVE CONFLICTED PERSONALITY FEATURES --"][conditional field="PCP" condition="(PCP).is('-- PASSIVE CONFLICTED PERSONALITY FEATURES --')"]

Pt is characterized by a dedication to hard work, deeply held convictions
of conscience and moral principle, a need to do things perfectly and in a socially
approved manner, perseverance in pursuits, preference for orderliness and detail, cautious consideration of alternatives before acting, and the need to save or collect things. At times the Pt presents as proper, conventional, orderly, and perfectionistic. Pt respects tradition and authority; upholding established rules and standards, and follow regulations closely. Pt seldom exhibits spontaneity and can be rather rigid and inflexible in relationships. Pt tends to be intolerant of deviance and tend to be judgmental of those who are not as earnest. Ever diligent in their responsibilities, others perceive Pt as highly dependable and industrious.

[checkbox value=" Presents with dependent features: Pt exhibits a conforming dependency, compliance to rules and authority, and a willing submission to the wishes, values, expectations, and demands of others. Pt's self-image is considerate, thoughtful, and cooperative. Has a strong sense of duty, which masks underlying feelings of personal inadequacy. As such, Pt tends to minimize their accomplishments, underplay their abilities, and grade their success in terms of how well the expectations of others are fulfilled. Though other will describe Pt as earnest, hardworking, and thorough, these characteristics compensate for deep feelings of self-doubt and hesitation and serve to keep them in the good graces of those they rely on for esteem. Pt holds fast to the belief that they will be cared for, valued, and loved in direct proportion to their hard work and monumental accomplishments. This belief structure comes with a significant liability; Pt fears that failure to perform perfectly will provoke both abandonment and condemnation, which creates considerable inner sensations of tension and guilt. So dreadful is the thought of making mistakes or taking even the smallest risk that they perpetually rework their efforts, never attaining a true sense of satisfaction for a job well done, all the while feeling perennially anxious over their perceived inadequacy to handle any unanticipated hitch. Dependent features gives rise to a distinct submissive interpersonal manner with superiors and an air of propriety and restraint with all others. This is in direct conflict with intense contrary feelings that frequently lurk beneath this veneer, and on occasion, these more primitive qualities sneak through their tightly controlled coping skills. Their occasional experience with such security breaches teaches them to hold even tighter to self-control, thereby creating an existence that is over-organized, devoid of spontaneity, and dramatically upset by any deviation in routine. The Pt experiences aggression as a private battle and is usually masked by a front of equanimity and social agreeableness.|- Presents with paranoid features: Pt experience a deep ambivalence between obedience and defiance, which they resolve through sublimation, reaction
formation, and displacement. When Pt sublimates this conflict seem more normal, whereas displacement of aggression makes them seem more forceful, versus reaction formation which translates their aggression into self-righteous fury. Metaphorically the drives and aggressive impulses are so strong, yet so strongly reacted against, that these individuals seek the armor of God’s righteousness to purify, transform, and contain them. Pt feels the persistent press of irrational and repugnant
aggressive and sexual drives and adopt an ascetic and austere lifestyle to prohibit
their dark impulses and fantasies. Their hostility is likely to be vented through
vicious displacements, which usually identify a common enemy or seek to scapegoat
the weak. Dichotomous thinking reinforces these urges: In their mind, the world is composed of the all good and the all bad, us versus them, the justified and the unjust, the saved and the sinners, along with the saints etc. Pt is reviled by perceived moral laxity, and tends to use their wrath as a 'vengeful sword' of righteousness bestowed with a sacred mandate to dispel sin and iniquity. Pt seems generally pleased to be this instrument through which justice is administered.
With puritanical leanings, Pt naturally gravitate toward radical fundamentalism, as the literalism inherent in such beliefs creates a clear picture, not only of who deserves punishment, but who deserves absolute punishment. Thus, injustice is made just and Pt is free of any residual guilt. Pt is viewed as harsh, demanding,
abrasive, irritating, prudish, and exceptionally straitlaced.|- Presents with narcissistic features: Pt is allied with traditional values, established authorities, and formal organizations. Pt wholeheartedly embraces the order and structure inherent in recognized institutions, authorities, and social mores. Pt flourishes in an organizational setting, feeling comforted, strengthened, and empowered by clearly defined superior and subordinate relationships, definite roles, and known expectations and responsibilities. Pt uses highly developed and formalized external structures to compensate for the internal sense of ambivalence and indecisiveness that plagues them. Pt presents with fused identity to the system as a means of achieving place, purpose, and protection, which frees Pt from any anxiety related to making independent decisions. Pt's superiors know them as trustworthy, diligent, and faithfully committed to the goals and values of the institution, which fortifies their self-esteem and gives them a direction. Without the organization Pt would feel lost or aimless in life. Punctual and meticulous, they adhere to the work ethic like worker ants in a colony, appraising their own and others’ tasks with black-and-white efficiency, as done or not done. The status gained by their alliance with their “greater cause” offers the Pt a modicum of pride and self-importance. Pt is deeply committed to all of the trifling and inconsequential directives of their beloved institution. Pt gains a sense of status by fusing their identity with a much larger force and becoming an indispensable part of this important structure. At a moderately disordered level, the Pt's rigid adherence to policies and rules makes them seem officious, high-handed, close-minded, and petty. At a severely disordered level, the Pt may use their knowledge of the rules, effectiveness with red tape, and ingratiating attitude with superiors to terrorize subordinates or anyone else who crosses their path without paying them the proper dues and respect.|- Presents with Schizoid features: Pt's miserliness takes on an almost symbolic significance. Ever wary of the possibility of loss, Pt is selfish and keeps a tight, self-protective grip on everything they possess, lest it somehow be wrested from them. The Pt's identification lies with the security value of material goods. Having been deprived of so many wishes and desires in childhood, the Pt nurtures and protects what little they have, ever suspicious that others might scavenge their few prized possessions. Pt draws sharp boundaries and behaves with an unnecessary stinginess. In effect, their behavior says, 'What is mine is mine, and what is yours is yours. 'Pt is self-sufficient to a fault, disallowing anyone who may potentially deprive them of their resources and acting as if any loss in their nest egg could not be replenished. Pt's miserliness likely masks a deeper need. By effectively shutting out anyone else from permeating their world of possessions, they are, in effect, guarding against any discovery of the barrenness of their attainments and competencies. In keeping an air of propriety and privacy, they stave off any possible unearthing of their dreaded rebellious urges or irrational anger.|- Presents with negativistic features: Pt appears on the surface to be maintaining a controlled and austere front but struggles incessantly with a desire to conform to the wishes or agendas of others one minute and the desire to subvert others and assert their own interests the next. When expected to act decisively, the Pt tends to vacillate and procrastinate, feels tormented and confused, becomes cautious and timid, and use complex rationales to delay making decisions as long as possible. Unable to crystallize their own identity and feeling wave upon wave of ambivalence, the Pt tends to express their dissatisfaction by becoming exhausted, grumpy, and discontent. Pt is perpetually overwhelmed by the conflict between the will and better decisions; their existential experience is that of being caught between a rock and hard place. Painfully aware of their inner impulses, the Pt engages in a form of self-torture; an act of punitive resolution that symbolically undoes that which bedevils them. In this context, the obsessions and compulsions that emerge signify a futile attempt to control that which is illogical, irrational, or even abstract about themselves and their desires. Generally, the more extreme the obsessions and compulsions, the more the Pt's routine coping skills are failing. The Pt's inner ambivalence is the inability to confront what is upsetting to them, and outward behaviors such as compulsions are an outlet for their contradictory feelings. At times, the Pt sees themselves as driven by ego-alien forces, perhaps demons. Helpless, in their perspective, to escape the clutches of corruption, the more decompensated the Pt may come to feel as though they are on the edge of psychic dissolution."]

Psychological defenses include: isolation of affect, reaction formation, displacement, undoing.[/conditional]

[checkbox name="MPD" value="-- MASOCHISTIC CONFLICTED PERSONALITY FEATURES --"][conditional field="MPD" condition="(MPD).is('-- MASOCHISTIC CONFLICTED PERSONALITY FEATURES --')"]

Pt seems to live to serve and to be helpful to others. When allowed to give selflessly of themselves, everything is right with the world. Forever putting others above themselves, the Pt has a reputation for being kind, considerate, and charitable. Always forgiving, Pt believes that people should be accepted and appreciated for who and what they are, not judged harshly by some extrinsic
or legalistic standard. Although Pt willingly shoulders the burdens of life for
those they love, they feel uncomfortable when their good deeds are singled out for
praise, honestly believing that no thanks or recognition is necessary.

[checkbox value="- Presents with avoidant features: Pt appear to actively and repetitively search for circumstances that lead to suffering or even destruction. From the outside, the Pt seems gratified by misfortune, failure, or humiliation, preferring instead to be disgraced, victimized, or even ruined. Driven by a 'success neurosis,' they experience favorable outcomes as producing anxiety and guilt, not pleasure and happiness. Rather than suffer success, the Pt searches out failure or punishment, subtly reversing their good fortune. Seemingly striving hard for accomplishment, they either stop just short of its attainment or manufacture some means of proving themselves unable to follow through. Covertly, Pt is likely gratified by their own defeat. Fearing things will suddenly turn sour, the Pt would rather be pitied as an unfortunate victim of circumstance than as someone who had striven hard but failed. Failure may bring on a sense of relief that they must no longer live up to some standard.|- Presents with negativistic features: Pt is known to give constantly of themselves. However, Pt is unable to let go of their attachments. Instead, becoming so indispensable and self-sacrificing that others are unable to withdraw from them without feeling incredibly cruel. It is as if others become entrapped and dominated by a dependency driven by the fulfillment of their every need. Through ostentatious sacrifices, Pt seems driven to intrude into the daily affairs of their children, spouses, friends, and peers, meddling in activities, romance, occupation, and anywhere else they can obtain a foothold. Ostensibly their altruistic acts create grounds for inducing guilt in others, which may be used to prevent them from distancing or ending the relationship. Mates are overprotected and jealously guarded, bribed for love, and controlled through guilt.|- Presents with depressive features: Pt tends to mope around complaining of their terrible condition but telegraphs a bind for others 'don’t let my suffering make you worry about me; do what is best for you.' In other words in one voice, they disavow any need for assistance and explain that they do not want to burden others, yet present themselves as having suffered the slings and arrows of outrageous misfortune. Pt tends to make others who comes to their aid feel emotionally drained and guilty; as if moving on with his or her own life was an abandonment. Hypochondriacal defenses may come to the fore when no other method of gaining love and dependence seems available. Pt presents as a sorrowful invalid, a genuine but self-created suffering that forces others to be caring and nurturing. The Pt's discomforts are merely an instrumentality designed to secure pity and assistance.|- Presents with histrionic features: Pt seems proudly unselfish and self-sacrificial. Self-denial, asceticism, and stoic tolerance of adversity are seen as noble and righteous, a sign of purity and saintliness, the glorification of misery. Sacrificing themselves completely to others or for some meritorious cause is open for public view. If others withdraw their attention or distance their emotional bond, Pt tends to complain that they are ungrateful and thoughtless and should remember they have been faithful and giving. Superficial altruism may occasionally give way to self-congratulatory pride, and past good deeds may be used to justify a sense of being entitled to emotional support from others. Even when they get their way, however, a low sense of self-worth continues to lurk just below the surface, a consciousness that the appreciation of others is manipulated rather than genuine."]

Psychological defenses include: repression, undoing, narcissistic, autistic fantasy.[/conditional]

[checkbox name="ACPD" value="-- AMBIVALENT CONFLICTED PERSONALITY FEATURES --"][conditional field="ACPD" condition="(ACPD).is('-- AMBIVALENT CONFLICTED PERSONALITY FEATURES --')"]

Pt lives a roller coaster life; frequent ups and downs are the rule, and attachment is the central theme in all relationships. There is a desire always to be involved in a passionate romantic relationship. Pt tends to express emotionally rather than logically, showing their feelings with spontaneity and creativity. Socially, Pt is lively and engaging, with an open mind toward experimenting with various roles and value systems. Pt seeks closeness with their partners, like a merging of souls but
even more intensely. Pt expects the same from others and quickly becomes hurt whenever the same desire is not forthcoming. Pt is sensitive to anything
that might impact the quality of attachment in their relationships. Pt prone to reading more into behaviors and events than is warranted but can take a more realistic and complex perspective on their relationships. Pt diminishes self-uncertainty by being more experimental and curious about alternative lifestyles, roles, and value systems. Pt is somewhat sensation-seeking, but in ways that primarily add to the richness of experience rather than subtract from it. Pt tends to be spontaneous and emotionally intense and only occasionally overreacts or over-dramatizes. Pt actively pursue social venues and creative pursuits that help make life entertaining. Pt tends to be emotionally intense but nevertheless
able to step back and see the effects of their moods on others.

[checkbox value="- Presents with avoidant and dependent features: The Pt tends to
pursue a strategy of submissive attachment to one or two significant others. Avoidance of competition, loyalty, and humility but also masochistic subordination and at times parasitic clinginess. By exclusively relying on a single someone, Pt is prone to 'putting all their eggs in one basket.' This leads to fearing that their lifeline is threatened, their world is chronically destabilized. Consequently, the Pt is ever preoccupied with their lack of security, mainly their own helplessness, self-doubt, and lack of self-sufficiency. To reinforce their relationships, the Pt admits to clinging tenaciously to whoever is available, merging their own identity
into that of their partner. Given such profound needs, they are easily panicked by a sense of isolation or aloneness and easily feel depressed and powerless. Simple responsibilities at times seem monumental, everything feels like a burden, and life somehow always seems empty and heavy. When feelings of futility intensify, the Pt may regress to a state of marked depression or infantile dependency, requiring others to tend to them as if they were infants. Generally stable in moods, these tendencies tend to emerge when the Pt senses that their interpersonal
pacts have been violated too often—that others have 'selfishly failed' to supply promised rewards of affection. At times of feeling resentful and angry, the Pt no longer believes that conformity will forestall desertion. Instead, they feel coerced into submission and betrayed—emotions that periodically break through normal controls. Because anger is not only inconsistent with their self-image but also alienates or provokes those on whom they depend, intense negative feelings are experienced as dangerous. In response, the Pt may swing to the opposite pole, becoming excessively preoccupied with self-reproach. Self-mutilation and suicidal attempts, symbolic acts of self-desertion, may be used to control their resentment
or as punishment for anger.|- Presents with histrionic or anti-social features: Unless constantly receiving attention, the Pt becomes increasingly seductive, impulsive, capricious, and irresponsible. Pt prone to becoming behaviorally hyperactive and cognitively scattered, exhibiting a dysregulation of positive affects that includes frenetic gaiety, frantic gregariousness, and irrational and superficial excitement. At times, Pt loses all sense of propriety and judgment. Frequently fails to plan ahead or heed the consequences of their actions as they struggle to free themselves from social constraints. Pt experiences many disappointments, and goes for extended periods of time without the security they
crave, which leads to states of hopelessness and depression. Family background seems to have endorsed drama, a desire for stimulus variety, and an intolerance of boredom. Pt models and has learned to depend on sex-role stereotypic compliments as the basis for their self-esteem. In general, the Pt is sensitive to external sources of reward and moves impulsively and capriciously from one engaging item to the next. Thus oriented to the external world, the Pt seems to have failed to develop a solid self-identity that might anchor them during periods of stress. As a consequence, the Pt is always on unsure footing, constantly on edge, never quite sure who will provide the attention and stimulation they desperately require. Periods of
brooding, dejection, and hopelessness alternate with simulated euphoria as the Pt
shifts from acknowledging to denying their condition of security and attachment.|- Presents with negativistic features: Pt can be unpredictable, restless, irritable, impatient, complaining, disgruntled, stubborn, sullen, pessimistic, resentful, and envious of the happiness and success of others. Pt expresses resentment towards those on whom they depend and seem to hate those to whom they must plead for love. It is as if the Pt has seldom had their needs satisfied on a regular basis and have never felt secure in their relationships. Stubborn and demanding, they openly register their disappointments. Unable to find comfort with others, the Pt becomes increasingly bitter and discontent, caught between two pathological extremes. At times, they express feelings of worthlessness and futility, become highly agitated or deeply depressed, express self-condemnation, and develop delusions of guilt. At other times, their habitual negativism becomes completely irrational, driving them into rages in which they distort reality, make excessive demands of others, and viciously attack those they see as having trapped them and forced them into intolerable conflicts. The Pt's moods become a way of threatening others that further trouble is coming unless something is done. However, following
these wild outbursts, the Pt turns their hostility inward and become remorseful, plead for forgiveness, and promise to behave and make up for their transgressions. The Pt may express fatigue and somatic disorders as a means of milking others’ attention while burdening them at the same time. Affection has never been free of conflictful feelings.- Presents with masochistic features: Pt's self-destruction serves the needs of a comorbid masochistic pattern. Pt is perpetually unable to find a comfortable niche with others. The masochistic traits cause the Pt to turn inward, where destructive feelings can be expressed upon the self. Underneath, there is both a desire for independence and a genuine fear of autonomy. To control these oppositional tendencies, the Pt struggles to present a façade of self-restraint and self-sacrifice. Ever deferential and ingratiating, Pt bends over backwards to impress their superiors with their conformity, all the while denying their dependencies and becoming even more conflicted. At times, these antagonisms give rise to public displays and bitter complaints about being treated unfairly, of expecting to be disillusioned and disapproved by others, and of no longer being appreciated for their diligence, submissiveness, and self-sacrifice. With the persistence of ambivalent feelings, the Pt tends to somatize into physical symptoms as more subtle means of discharging negative feelings prove self-defeating, tension and depression mount beyond tolerable limits. Pt is known to accuse others of despising them, seeking to destroy their worth, and plotting to abandon them. As a result makes inordinate demands for attention and reassurances. Pt at times threatens to commit suicide and thereby 'save' others the energy of destroying them slowly. The Pt perpetuates their pathology by deliberately putting themselves in positions of excessive vulnerability, making themselves so dependent and clingy that others could only become exasperated, resulting in a predictable abandonment cycle."]

Psychological defenses include: splitting, acting out, primitive denial, idealizing, devaluing, regression.[/conditional]

[checkbox name="AAPD" value="-- ACTIVE CONFLICTED PERSONALITY FEATURES --"][conditional field="AAPD" condition="(AAPD).is('-- ACTIVE CONFLICTED CONFLICTED PERSONALITY FEATURES --')"]

Pt tends towards conforming to the expectations of others, but would like to put their own personal stamp on their productions. Makes substantial contributions but enjoys receiving due credit. Is able to get along with others, becoming
resistant only when sensing a sense of entitlement from others. Is able to
use protest constructively without exaggerating faults. Does not begrudge others
their good fortune, but may become quickly disappointed if their own efforts are not appropriately rewarded. Is conscious of the distribution of rewards in life but is nevertheless able to take initiative to better their own situation. Can vacillate between defiance and expressions of remorse but does not act out so extremely that such expressions are necessary.

[checkbox value="- Presents with dependent features: Pt demonstrates indirect resistance to the expectations of others that it has become an almost defining feature of their personality. Sensitive to situations that assume the Pt's compliance and thus value the individual as a means to an end, not as a unique human being. Pt avenges themselves mainly in roundabout and covert ways that undercut and frustrate anyone who would take them for granted or demand a certain level of performance. The exact methods vary but include procrastination, dawdling, stubbornness, forgetfulness, and intentional inefficiency. Fearful of expressing resentments directly, the Pt fulfills obligations with foot-dragging slowness and inconsistent performance. May engage in feigned incompetence or exhausting requests for help may be used to frustrate others. Given a looming deadline or the need to perform at unusually high levels, somatic complaints may be used passive-aggressively as a means of excusing them from work, thus increasing the level of tension for everyone else.|- Presents with sadistic features: Pt remains caught in the conflict between their own agenda and a loyalty to others, but has become more overtly and intentionally contentious and quarrelsome nonetheless. Get so torn by conflict that every request or expectation feels like a major burden. Past experience has led Pt to expect that even their most conscientious performances are likely to be evaluated with disappointment and derision. Is so jaded that they have deep doubts about whether life will work out or whether happiness is even possible at all. Certain that loyalty and the tender emotions are only a sad illusion created to conceal the perverse cruelty of human nature. Has a 'damned if you do and damned if you don’t' attitude. As such, minor frictions tend to exacerbate into major confrontations and power struggles. Pt derives a special joy in spotting inconsistencies in the behaviors or ethical standards of anyone who would require something from them. Known to construct arguments that amplify observed contradictions and shove these squarely in the face of their antagonists, just for the sadistic pleasure of undermining their self-confidence and watching them squirm. Takes the moral high ground and dogmatically insist that others are either hypocritical or mentally defective. When pressed, even such indirect oppositionality may give way to contemptuous fault-finding and outright insults. Generally experienced as abrasive.|- Presents with depressive features: Pt is prone to griping. Attacks emotionally through annoying complaints, thinly cloaked criticisms, and unsubtle digs. It feels as if the Pt is fighting a war of attrition designed to wear down the enemy. Is constantly disapproving, as if purposely seeking some thin rationale by which to be negative and faultfinding. Happy to point out imperfections, pick at old wounds, work others into a state of irritation, and then complain further that their concerns have not been properly addressed. Tends to exaggerate trivial concerns. self image is paradoxically as an ambassador of goodwill, who has become exasperated with the problem at hand, perhaps struggling with the inefficiency or ineptitude of those around them, especially those who give the orders. Pt cultivates the image of being more competent than their superiors, whose recognized status and authority they deeply resent.|- Presents with capricious features: Pt is distinguished by unstable and rapidly fluctuating emotions and attitudes. At times presents as affectionate, predictable, interesting, even charming, but then suddenly become irritable, oppositional, and disagreeable. Or, at times presents as self-assured, decisive, and competent, only to abruptly regress to a clinging dependency. Or they may be pleased with themselves one moment, only to become angry and depressed the next. Torn by conflict, the Pt's thoughts seem to flow freely in almost any direction, putting them at the mercy of rapidly changing emotions. Emotions are expressed directly and primitively, untransformed by a cohesive self-structure that might give direction to behavior. Tantrums are common. Unable to fathom the source of such shifts, others find them aversive, if only because their emotional maelstroms are difficult to understand."]

Psychological defenses include: projection, rationalization, regression, reaction formation, splitting, displacement, grandiosity.[/conditional]

[checkbox name="SCPD" value="-- SADISTIC CONFLICTED PERSONALITY FEATURES --"][conditional field="SCPD" condition="(SCPD).is('-- SADISTIC CONFLICTED PERSONALITY FEATURES --')"]

Pt seems to enjoy the power to direct and intimidate, to evoke obedience and respect. Tough and unsentimental, Pt makes an effective leaders by assigning tasks and coercing performance from subordinates. Although others see Pt as impulsively aggressive and stubborn, for example, Pt tends to of themselves as energetic, assertive, and realistic. Pt uses an imposing physical presence as a means of pulling for respect in interpersonal transactions. Pt enjoys an image
of strength and holds this as part of their self-image. Pt is authoritative,
not authoritarian. Pt feels gratified only where punishment was administered and justice was served. Pt seeks to expose deception in others. Cultivates power and uses it for a greater good. Pt creates rules and expect them to be followed, though within reasonable limits. Pt admires the potential of strength and its various symbols to evoke respect.

[checkbox value="- Presents with capricious features: Pt is distinguished for sudden eruptions of uncontrollable rage, frequently vented against members of their own family as safe targets. Pt generally copes competently until some unknown threshold is reached, after which they react instantaneously with abusive defiance and possibly physical violence. These displays of aggression are not used instrumentally to dominate others, but instead release pent-up feelings of frustration or humiliation. Pt is hypersensitive to feelings of betrayal, or they may be deeply frustrated by the futility and hopelessness of life.|- Presents with negativistic features: Pt known to be physically assaultive, and overwhelms their victims by unrelenting criticism, forceful anger, and vulgar and bitter tirades. Pt seems to relish the act of menacing and brutalizing others in the most unmerciful and inhumane ways. Pt derives a deep satisfaction from creating suffering, observing its effects, and reflecting on their actions. Violence may be employed intentionally to inspire terror and intimidation. Resistance only seems to stimulate them more. Often calculating and cool, Pt is selective in their choice of victims, identifying scapegoats who are easily intimidated and unlikely to react with violence in return. Pt enjoys dramatizing their surly behavior.|- Presents with compulsive features: Pt presents as if they are society’s sadistic superego, vested in punishment for its own sake, unable to be appeased. Like military sergeants, certain cops, university deans, and the harsh judge all feel that they have the right to control and punish others. Cloaked within a socially sanctioned role, the Pt safely metes out condemnation in the name of justice with such extraordinary force that their deeper motives are clear. Ever seeking to make themselves seem important, these sticklers for rules search out those guilty of some minor trespass, make them cower before the power of their position, and then punish them with a righteous indignation that reeks of repressed anger and personal malice. Despite their responsibility to be fair and balanced, the Pt is unable to put limits on the emotions that drive their vicious behaviors.|- Presents with avoidant features: Pt is insecure, even cowardly leading to their creating an image of strength, a sense of mutual ensured destruction. It is as if their aggressive hostility is a counterphobic act, designed to master their own inner fearfulness, while sending a message of strength to others that they will not be intimidated. Pt's displays of courage serve to divert and impress the audience with a façade of potency that says, 'I will not be pushed around.' Neither naturally mean-spirited nor intrinsically violent, Pt caricatures the swaggering tough-guy or petty tyrant. It is therefore likely they employ aggression instrumentally against others who seem threatening and abusive. That is, fearful of real danger, they strike first, hoping to induce a measure of fearfulness that forestalls further antagonisms."]

Psychological defenses include: projection, splitting, disavowel, narcissistic, denial.[/conditional]

Pt is unable to achieve an internalized ideal: [checkbox value="that others must always be there for me|everyone should be completely honest|that people should completely understand me|I should be completely lovable|I should be part of a loving community|I should be completely competent at everything|I should be able to handle anything that life brings|I should be completely independent|I should completely measure up to others|I am entitled to special privileges|I should be in complete control|I should be free to completely express myself|I must suppress my wants and needs|the needs of others are more important|I must always be approved of|life should be completely fair and equal|spontaneity is the essence of life|if I can't achieve perfection, there's no point trying|people who make mistakes need to be punished"]. Falling short of this ideal, the Pt maintains their self-esteem through
[textarea default=""]

[checkbox value="Acceptance of the situation that has been causing anxiety.|Acting out with socially undesirable behaviours.|Anticipating potentially stressful events by mentally preparing and rehearsing for it.|Altruistically acting in a way to neutralise potential threats from others.|Avoiding situations that create anxiety rather than confronting or addressing it.|Converting their anxiety into a physical complaint.|Denial of their feelings and previous actions to avoid guilt and anxiety.|Displacing their actual feelings into an acceptable substitute behaviour.|Dissociating from the world and entering into a more tolerable alerted state of consciousness."]

[comment memo="What is their current overall level of functioning out of 100?"]
Global functioning: [checkbox name="variable_43" value="91 – 100 No symptoms. Superior functioning in a wide range of activities|81 – 90 Absent or minimal symptoms, good functioning in all areas|71 – 80 If symptoms are present, they are transient and expected reactions to psychosocial stressors.|61 – 70 Some mild symptoms, but generally functioning pretty well.|51 – 60 Moderate difficulty in everyday functioning.|41 – 50 Serious impairment in everyday functioning.|31 – 40 Some impairment in reality testing or communication and major impairment in several areas.|21 – 30 Behaviour is considerably influenced by poor reality testing; an inability to function in almost all areas of life.|11 – 20 Some danger of hurting self or others; occasionally fails to maintain minimal personal hygiene; gross impairment in communication.|1 – 10 Persistent danger of severely hurting self or others; persistent inability to maintain minimal personal hygiene or serious suicidal act with clear expectation of death.|0 Inadequate information"].

ACTION

[comment memo="What action did you take based on current suicide risk?"]
Risk: [checkbox value="No need for further action today|I reminded the patient of their calling MHAL 1800011511 if needed, and urged them to present to the ED or call 000 in a crisis|Pt and I agreed to a harm minimization approach by removing access to lethal means|and I further discussed their risks with their parent"]

Progress: [checkbox name="variable_45 value="excellent|good|fair|poor|negligible"]

PLAN

[textarea default="Next apt. "]

Clinical interview with Pt -
for the purpose of

PT REPORT

OBSERVATIONS
Pt is a young adult mid-aged adult older adult young teen older teen child male female. Reasonably Not well Meticulously kempt + ++ +++, average weight overweight underweight + ++ +++.
Posture relaxed rigid stooped confident aggressive tense slumped + ++ +++
Movement unremarkable odd / peculiar slowed repetitive restless agitated tremorous + ++ +++
Attention: no concerns - attended well seemed unaware inattentive distractible hyper-vigilant scattered concentration preoccupied confused focused on irrelevancies + ++ +++
Engagement: no concerns - engaged well avoided eye contact fixed staring glaring at author tense facial expression dependent and needy dramatic and exaggerating concerns passive and difficult to engage uninterested silly and joking around resistant critical and verbally combative hostile and threatening sarcastic and taunting irritable fatuous flirtatious demanding threatening guarded paranoid defensive and resistant manipulative argumentative + ++ +++
Mood reported & affect observed: euthymic dysphoric anxious angry apathetic ashamed prideful sad irritable hostile pessimistic depressed manic euphoric neutral with commensurate affect with incongruent affect tearful affect labile affect restricted affect blunted affect flat affect + ++ +++
Speech: spontaneous normal RTV abnormal RTV clear and articulate selectively mute mute loud laconic verbose quiet pressured rambling babbling incongruent with mood and current circumstances + ++ +++
Thinking: logical linear rigid and concrete personalizing persecutory indecisive unrealistic difficulties of reference magical ideas of influence distorted pseudologica fantastica memory difficulties provided unnecessary detail (circumstantial) wandered between many topics (tangential) jumped from one idea to another (loose associations) racing thoughts (flight of ideas) abruptly changed topic or stopped mid-sentence (thought blocking) tended to loop or repeat themes (obsessive) stuck on over-valued ideas (preoccupations) + ++ +++
Orientation: no concerns AH reported VH reported poor judgement poor reality testing poor insight complete denial + ++ +++
Stressors disclosed without prompting: nil self-esteem parenting spouse money school physical health energy sleep body weightshape eating food housing employment mood family work grief and loss illness transitions legal peers relationship + ++ +++
Suicide risk: .

ASSESSMENT

-- PASSIVE-DETACHED PERSONALITY FEATURES --

The Pt has only a limited need for companionship and social support. Pt feels most comfortable, most free, and most themselves when alone. For this reason, Pt generally prefers to live and work in the relative calm and reassurance of social isolation without concern of boredom or loneliness. Pt is regarded as self-contained and self-sufficient, their self is their inner sanctum, where they are independent of the emotional and social worlds. As a dispassionate observer of life, the Pt rarely gets excited about anything. Their even-tempered calm frees them from noisy social attachments but also makes the Pt intellectually aware of details others would easily miss. In relationships, the Pt needs alone time and seldom becomes as intimately involved as their partners would prefer. In work, the Pt functions efficiently but not as team players.

The Pt has only a minimal need to give and receive affection or to become involved with others emotionally. For this reason, Pt tends to have few relationships and does not develop strong ties to others. Instead, Pt is viewed as seen as calm, placid, untroubled, and easygoing but also as possibly being socially awkward or indifferent to the feelings of others. Pt is a private person who enjoys being
alone, only rarely expressing inner thoughts and feelings. Ever unobtrusive, the Pt works quietly and methodically behind the scenes, content to remain in the background.

Is typically viewed as an introvert - caught up in the joy of mentation. Others often see them as lacking in spontaneity and vitality. Though the Pt is comforted by the quiet and solitude of an asocial lifestyle, the Pt possesses the capability to relate to others when necessary. Pt usually selects solitary activities resulting in social isolation. Pt prefers minimal to no contact when engaged in an activity, yet, is willing and able to productively interact when necessary to accomplish a goal. Sexuality is generally an undesirable and unexplored realm for the Pt.

Pt can become engaged in certain hobbies or interests. Has some acquaintances and can sometimes find enjoyment from being part of a small social group. Pt is capable of productively receiving feedback and changing their behavior accordingly if needed. Is even-tempered with some range of emotion and is capable of experiencing a degree of pleasure and sadness. However, under duress, the Pt struggles to form secure, satisfying attachments to others. To preserve self-esteem, Pt tends to favour passive avoidance, remains in the background of social life, is quietly and unobtrusive at work, is rarely noticed, and is generally unmoved by emotional stimuli.

- Presents with depressive features: slow personal tempo, low activation level, and the absence of vigorous and energetic action. Easily fatigued, with only weak motoric expressiveness. Struggles to rouse themselves to meet responsibilities, pursue the simplest pleasures, or behave with spontaneity. Interpersonally, presents as quiet, somewhat colourless, and vaguely dependent way of relating, and mildly dyphoric. Struggles to initiate activities, seems to have few interests, preferring a simple, repetitive, and dependent lifestyle - Presents with avoidant features: represses all desires and emotions as they yield only anguish and disillusionment. Some behavioral eccentricities, autistic thinking, and depersonalization. Solitude seeking, aimless drifting on the periphery of society. -- Presents with schizotypal features: frequently stares off into space, seems dreamy and distant as if avoiding a mundane world, inattentive and disengaged from the affairs of life. Somewhat obliviousness to the surroundings and appears preoccupied internally with nothing at all. Feels like a disembodied observer - viewing themselves from the outside, detached not only from the real world but also from their own thoughts and feelings, from their imagination and fantasies, and from their own corporeal bodies, as well. Has an ethereal attitude and only a
residual physical presence. - Presents with compulsive features: isolated, emotionally detached, and solemn. Emotionally constricted; avoiding feelings through structured settings comfortable patterns of existence, also some features of a conflict between autonomy versus obedience, only weakly if at all.

Psychological defenses include: depersonalization, derealization, false self, Distancing, Autistic withdrawal. Intellectualization. Isolation of affect.

-- ACTIVE-DETACHED PERSONALITY FEATURES --

Pt is a sensitive person, generally comfortable in familiar surroundings and thrives within the context of a small group of trusted intimates. Pt is deeply concerned about the feelings and opinions of others and need their approval to flourish. Interpersonally, Pt is courteous and restrained. Pt avoids ambiguity, instead preferring situations where the expectations of others are well known and easily
confirmed. Pt is hesitant to readily reveal themselves to others; shares their
thoughts and dreams only after some time and only when they feel safe. Because Pt is a very private person, may self-disclose too infrequently to deepen their relationships, frustrating others to the point that a real sense of intimacy is lost. Is hyper-alert to criticism and prefers to deal with others cautiously. Pt is highly aware of goings-on in their surroundings and are ever on the outlook for potential threats to their safety or esteem. Pt is sensitive to social indifference
and rejection, feel unsure of themselves, and are unusually wary in new social
or interpersonal situations, especially with strangers. Ill at ease and self-conscious, they Pt anticipates difficulties in relationships and fears embarrassment.

- Presents with negativisitic features: Pt is in conflict over the longing for intimacy versus the fear of vulnerability that naturally ensues in a close relationship with another. Is ambivalent about themselves and others. Pt idealizes close friends and companions, but should their sense of autonomy be threatened, is quick to undermine or humiliate them. Pt easily drawn into 'interpersonal guerilla warfare.' If not withdrawn into isolation, is experienced as petulant and sulking. Prone to attacking others for failing to recognize their needs for affection, but accuse those who offer nurturance of seeking to compromise their independence. Disposed to anticipate disappointments and fearful of facing others openly, Pt may strike out indirectly by obstructing their actions and misrepresenting their wishes. Pt reports feeling misunderstood, unappreciated, and demeaned, and their mood can be erratic. Under slight pressures, however, the Pt's pacific surface quickly gives way to impulsive hostility. Unable to orient emotions and thoughts logically, they may at times become lost in personal irrelevancies and autistic asides, further alienating them from others. Relating to such individuals, undoubtedly, is an arduous process, requiring far more patience than most people are likely to offer. This interpersonal strategy, fulfills the Pt's circular struggle; it vilifies others and discourages their closeness (keeping them safe from harm), yet ensures the Pt's unwanted isolation. - Presents with paranoid features: Pt incorporates features of the paranoid personality, but exhibits greater reality contact. That is, Pt is well aware of personal shortcomings but will attribute them as much to the maneuverings of others as to themselves. Often seems high-strung and prickly, vigilant to signs of rejection and abuse, and excessively wary of the motives of others. Pt's pervasive apprehensiveness is often accompanied by intense and labile moods that feature prolonged periods of edginess and self-deprecation. My impression is that Pt strongly expects that others will be rejecting and disparaging but alternates between the profound gloom that often accompanies the basic detached personality pattern and the irrational projection of the paranoid. Either way, their usual strategy is a protective withdrawal that maintains a safe distance from all emotional involvement. Retreating defensively, some become more and more remote from others and from needed sources of support. At times expresses guilt and contrition, while feeling misunderstood, unappreciated, and demeaned by others. Paranoid traits makes it difficult to contain their anger toward anyone who has been unsupportive, critical, or disapproving. As the self-esteem approaches collapse, Pt tends to take on more severe paranoid features and comes to believe that their 'pathetic self' is the product of covert actions by others to undermine them or make them inhibit themselves. Paranoid defenses makes it easier to believe that others are the cause of their inadequacy, an external attribution, than to believe that they are naturally inadequate, an internal attribution. -- Presents with schizotypal features: frequently stares off into space, seems dreamy and distant as if avoiding a mundane world, inattentive and disengaged from the affairs of life. Somewhat obliviousness to the surroundings and appears preoccupied internally with nothing at all. Feels like a disembodied observer - viewing themselves from the outside, detached not only from the real world but also from their own thoughts and feelings, from their imagination and fantasies, and from their own corporeal bodies, as well. Has an ethereal attitude and only a residual physical presence. - Presents with compulsive features: isolated, emotionally detached, and solemn. Emotionally constricted; avoiding feelings through structured settings comfortable patterns of existence, also some features of a conflict between autonomy versus obedience, only weakly if at all.

Psychological defenses include: depersonalization, derealization, false self. Distancing. Autistic withdrawal. Intellectualization. Isolation of affect.

Treatment Goals

As Pt presents with fears around intimacy and a hypersensitivity to rejection and ridicule, they tend to engage in self-imposed isolation and social withdrawal. Furthermore, Pt tends to hide and contain feelings of inner despair for fear that overt expressions of such weakness and suffering might render them even more vulnerable to social ridicule, humiliation, and rejection. Moreover, the pervasive sense of unease and disquiet is what is most observable about this Pt. They evince a constant timorous and restive state, overreacting to innocuous experiences, hesitant about relating to events that may prove personally problematic, and anxiously judging these events as signifying ridicule or rejection from others. The speech
is generally slow and constrained. Pt exhibits frequent hesitations, aborted or fragmentary thought sequences, and occasional confused and irrelevant digressions. Physical behaviors tend to be highly controlled or underactive, although
marked with periodic bursts of fidgety and rapid staccato movements. Overt expressions of emotion are typically kept in check, but this underresponsiveness belies deep tension and disharmony. Pt exerts great restraint, not only in controlling anxiety, but in controlling feelings of confusion and in subduing the upsurge of anger.

From a cognitive-behavioural framework the Pt has a tendency to view things pessimistically -- that is, contempt directed at the self, fear and suspicion of others, and a sense of future despair. Next is the limited opportunity the Pt has for experiencing reinforcing events. Characteristically, Pt tends to be inflexible, confined to a small range of potentially reinforcing experiences.

Pt demonstrates heightened pain sensitivity in social milieus, and generates low internal pleasure such that reinforcers are often ineffectual. Deficits arise from self-protective restraint. The coping style employed by the Pt is not a matter of choice. It is the principal, and perhaps only, means the Pt has found effective in warding off the painful humiliation experienced at the hands of others. Discomforting as social alienation may be, it is less distressing than the anguish of extending themselves to others, only to be rebuffed or ridiculed. Distance guarantees a measure of safety; trust only invites disillusion.

Reinforcers:

Defensive narrowing precludes corrective experiences
Preoccupations relive painful past - intensifies social estrangement
Suspicious and Fearful Behavior - evokes reciprocal disaffection
Weakness attracts humiliaters
Rebuff reinforces aversiveness
Emotional-Perceptual Hypersensitivity
Sensitive to derogatory events
Scanning elevates threats into fears
Sensitivity deepens plight
Cognitive Interference - intrusive fears fragment and derail thoughts
Social communication becomes tangential and irrelevant

Goals:

Diminish anticipation of pain
Increase pleasure/enhancing
Counter Perpetuations
Reverse social detachment
Diminish suspicious/fearful behavior
Moderate perceptual hypersensitivity
Undo intentional cognitive interference
Tactical Modalities
Adjust alienated self-image
Correct aversive interpersonal conduct
Remove vexatious objects

Behavioral Techniques

Self-monitoring withdrawal behavior to help clarify their inclination to avoid certain people or social situations.
Keep a log of their self-deprecatory statements and physiological arousal.
Behavioral rehearsal to improve assertiveness and behavioral fluidity
Anxiety-management training can be very helpful.
Hierarchical grading of social tasks in regard to anxiety-provoking potential.

Interpersonal Techniques

Explore the Pt’s long-term maladaptive patterns, eschewing statements or actions that expose their hypersensitivities.
Refusing to support avoidance and encouraging assertive behavior.

Cognitive Techniques

Help patient discover thinking errors committed in everyday life that contribute to their dysphoria and self-defeating behaviors.
Increase the Pt's tolerance for what they perceive as emotionally upsetting relationships or events.
Enable the Pt to recognize that difficulties in close relationships do not result in devastation and abandonment. Particularly disclosure fantasies of negative retribution.

Psychodynamic Techniques

Consider Pt's avoidant behaviour as being driven by the shame of not measuring up to one’s ego ideal, of being weak, defective, even disgusting. Childhood memories are analyzed to clarify the roots of avoidance. Explore the underlying elements of the past that have led to feelings of rejection and shame.

Explore excessive self-reflection.

-- AMBIVALENT-DETACHED PERSONALITY FEATURES --

Pt has an idiosyncratic style, marching to the beat of a unique drummer, nourished by a unique belief system that contributes to an unconventional or even eccentric lifestyle. Requires few intimate relationships and is instead an independent seeker of what is interesting and unusual, often being drawn to the extrasensory, supernatural, occult, or mystical.

Pt is highly open to new experiences and novel interpretations of conventional ideas and is curious about alternative abstract formulations of the old and common. Often, the Pt is highly aware of the reactions of others but nevertheless draw inspiration from internal sources. As such, consensual social reality is not the basis of the Pt's self-esteem. Instead, the subjective world of their own unique experiences is what the Pt believes and value. If experience supports the existence of the supernatural or ESP, then objective, scientific proof is not required. Is an experimentalists who seeks the limits of knowledge and of emotional and spiritual experience.

- Presents with depressive and dependent features: is notably insensitive to feelings, indifferent to the external world, and appears drab, unmotivated, apathetic, inexpressive, sluggish, and joyless. Tends to experience their mind and body as separate or decoupled. Struggles with deep feelings of emptiness. Feels like an automaton without meaning or purpose. Consciousness seems to float, unconnected to the physical world, as if lost in some dimension between being and nonbeing. Cognitive processes seem obscure, vague, and tangential. Symptoms of depersonalization are frequent. Social communications are responded to minimally or with inappropriate affect or peculiar ideas or in a circumstantial and confused manner. Speech is monotonous, listless, or even inaudible at times. In some cases, depressive and dependent features may also be present. Struggles to interchange ideas and feelings with others, and therefore appears fixed and undeveloped, continuing, therefore, in their disjointed, amorphous, and affectless state. Restricted in social experiences, seems to have a marked paucity of social skills - finds it difficult to relate socially, which perpetuate a vicious circle
that fosters their isolation and accentuates social inadequacies and cognitive
deficiencies. - Presents with negativisitic features: restrained, isolated, apprehensive, guarded, and socially shrinking. Apathy and indifference are used protectively to damp down sensitivities, feelings, and desires. Drawn to strange signs and omens through which protective guidance can be obtained and malicious events controlled or averted. Focused on irrelevant details that would escape the ordinary person and develop superstitious behaviors or rituals. Has a rich fantasy life that seems to include perceptions that are normally beyond the five senses, creating an inner world populated by magical fantasies, illusions, telepathic relationships, and other odd thoughts that provide an existence more significant and rewarding than that found in reality. Excessively apprehensive, particularly in social encounters, exhibiting agitation and an anxious watchfulness. Exhibits a distrust of others and a suspiciousness about their motives that rarely recede despite familiarity. Bedeviled with feelings of low self-esteem, incompetence, and a marked distrust of others leading to protectively keeping distance from others, walling off from society, and insulating feelings.

Psychological defenses include: depersonalization, derealization, false self. Distancing. Autistic withdrawal. Intellectualization. Isolation of affect.

-- PASSIVE DEPENDENT PERSONALITY FEATURES --

When functioning well at their baseline, Pt is capable of genuine empathy for others, possessing a tremendous capacity for sustained unconditional love. Is among the most trusting people, with a modest, uncritical, gentle demeanor that communicates almost unquestioned acceptance. Pt is easy to please and demands little from others. Pt sets realistic standards for approval and is always encouraging of their mates and loved ones. Has deep reservoirs of goodwill and is genuinely pleased by the good fortunes of others.

Pt is gracious even to those whom they may dislike. Despite the high esteem in which the Pt is held, the more people value them, the more humble they become. Generally charitable in giving of themselves, the Pt tends to put a positive light on all life events and stress the virtues and good they find in others.

Pt tends to seek out the opinion of others, weighs the advantages and disadvantages, but makes the decision based on their own analysis. Is generally comforted by the support of others and enjoys their company but can perform adequately without it. Pt generally prefers interpersonal harmony but is able to speak up when necessary and hold their ground. Capable of functioning autonomously but prefers to work in close proximity to others. Pt is considerate and occasionally self-sacrificing, keeping the best interest of others foremost in mind. Pt prefers the company of others but can enjoy occasional solitude. Pt can be nostalgic about lost intimacy but does not immediately seek to merge with another. Pt enjoys the affection of others as expressed through thoughtfulness but is not terrified of abandonment.

However, under duress, the Pt tends to fuse their own identity with that of others. Struggles to be alone with a tendency towards enmeshment with others because the idea of separation causes intense anxiety.

- Presents with avoidant features: lives a symbiotic existence sustained by institutional rewards and requirements. Possesses an underlying apprehensiveness that overlies a lack of initiative and an anxious avoidance of autonomy. Easily disconcerted and experiences a general sense of dread and foreboding. Vulnerable to separation anxiety and greatly fear loss of support and nurturance. Sometimes expresses abandonment fears through outbursts of anger directed at those who fail to appreciate needs for security and safety. Preferring institutional security, has a pattern of withdrawing from social encounters, as such, loneliness and isolation are commonly experienced. Attempts to be pleasant and agreeable, which masks underlying tension, sadness, and guilt. Outwardly quiet and affable in the face of difficulties, but underneath is overwhelmed by fears of abandonment and isolation. - Presents with masochistic features: submissive, agreeable, and hungry for affection, nurturance, and security. Fears of abandonment lead Pt to be overly compliant and obliging. Can be socially gregarious and charming at times. Typically gracious, neighborly, benevolent, and compliant in their relationships with others, preferring to avoid conflict and seek harmony even at the expense of their internal values and beliefs. Tends to be preoccupied with external approval, at the expense of cultivating a real inner identity. Feels bolstered by submerging or allying themselves with the abilities and virtues of others, creating a feeling of shared competence. Demonstrates a naïve attitude toward life’s problems - maintaining an air of pleasantry and good spirits, denying disturbing emotions and cover inner conflicts with various distractions. Critical thinking is not a strong point. Having had others support them, seems underdeveloped or immature in some areas. Generally self-sacrificing and readily adopts the role of inferior or subordinate. Tends to avoid self-assertion and happy to leave responsibilities in the hands of others. Resembles the masochistic personality. All that seems to matter is that others like them, are pleased by them, and are willing to accept their smiles and goodwill as sufficient. However. their agreeableness is designed to encourage others to take control, thereby compensating for their feelings of incompetence. Struggles to follow through on adult responsibilities and often feel helpless whenever autonomy or initiative is required. The loss of a significant source of support or identification may prompt severe depression. Open displays of guilt, illness, anxiety, and depression are common and serve the purpose of deflecting criticism and transforming threats of disapproval or abandonment into support and sympathy. - Presents with regressive features: has a childlike quality, struggling to take on adult activity and responsibility. Appears underdeveloped, inexperienced, and unsophisticated. Lacks ambition and energy, which makes the expectancies of adulthood overwhelming and frightening. Passive and easygoing with under-developed competencies or confidence in their own abilities. Adult roles appear somewhat distasteful or frightening. Generally pleasant and sociable as long as they are permitted to remain pre-adult in their preferences and activities. Feels challenged when others begin to expect more or demand that they mature and get down to the business of life. May appear irresponsible and neglectful at times. - Presents with schizoid features: Exhibits a general lack of vitality, low energy level, fatigability, and weakness in expressiveness and spontaneity. Struggles with anhedonia poorly able to experience pleasurable emotions in great depth. Tends to shun social relationships. Generally seeks an untroubled life completely free of responsibility, though mainly because of a lack of drive. Often tunes out life’s demands. Reality avoidant at times, appearing to sleepwalk through life, half disengaged and half dependent. They typically do not want to engage in anything or think too deeply, and thus exhibits a certain fatalism that allows them to
ignore difficulties. Tends to externalise this fatalism, which betrays an underlying assumption that nothing ever changes on the basis of their efforts, justifying their lack of drive and desire to act on their own behalf. - Presents with depressive features: idealization and identification are the major themes. Attachment concerns with a tendency towards merging. Identity forfeiture. Denial of unique personal potentials as independence is fought against. Through fusion, a sense of significance, emotional stability, and purpose in life is secured. Life is performed in the service of extending the status and significance of others, be it a person or an institutional entity. Because of this fusion, Pt may adopt values and attitudes that are different from their ordinary preferences. Self confidence is derived through assuming the qualities of the persons or institutions with whom they have identified. A feeling of significance is derived through fusion with their idealized others. By deriving their identity through external sources, they make themselves extremely vulnerable to loss - risking depression and anxiety through loss of attachment.

Psychological defenses include: introjection, idealization, denial.

Treatment Goals:

Encourage self-focus
Counter Perpetuations
Reduce self-depreciation
Encourage adult skills
Diminish clinging behaviors
Correct submissive interpersonal conduct
Enhance inept self-image
Acquire competence behaviors

Behavioural interventions:

Anxiety hierarchy of independent and assertive behaviors for gradual
implementation.
Role-playing and modeling for skills development
Anxiety-reducing skills, such as breathing techniques and deep muscle relaxation
Anxiety tolerance.
Assertiveness training.
Limited sessions.

Cognitive interventions:

Challenge unrealistic expectations.
Challenge polarized thinking around loved versus alone.
Socratic questions around self-image.
Two-chair work of dealing with an adversary.

Analytic:

Explore the defense against hostility
Explore trauma avoidance
Shine a light on introjective tendencies (parroting, emulating and mirroring).

-- ACTIVE DEPENDENT PERSONALITY FEATURES --

When functioning well at their baseline, the Pt is generally friendly, expressive, and sociable. Pt tends to experience life through sensation and a sense of the romantic. Is highly intuitive, trusts others easily and readily gets involved in relationships. Seems to be be popular and naturally know how to make others like them. Is warm, lively, dramatic, energizing, and occasionally provocative. Pt presents with an outgoing style; enjoys compliments and praise without depending on them. Enjoys entertaining others, yet can relinquish the floor and become part of the audience. Is comfortable with aspects of physical attraction by way of style, body consciousness, fashion, and presenting themselves well. Pt is more constructive in qualifying and detailing appraisals, given their authenticity of emotion. Pt is capable of making their own decisions, even at the expense of attention and approval. Pt is anchored to a solid sense of self, allowing for a sense of continuity over time and insight into the nature of personal relationships.

However, under duress, Pt over-relies on a blanket sexual allure or promise. Is prone to being fickle with rapidly shifting moods. Compliments and praise never seem to be enough; Pt must be the center of attention at all times.

Pt tends to be cognitively global, diffuse, and impressionistic. Seems to be constantly engaged in dramatic and theatrical expression. Is easily swayed by the influences of others. Considers relationships to be more friendly or intimate than they really are. Pt seems unable to hold a point and explore it in depth, tending to digress from one superficiality to the next, as a means of avoiding conflict or unpleasant emotions. Pt easily gets to know others but quickly becomes bored with them.

- Presents with histrionic features: Overly romantic and attention seeking. Chameleon-like on social demand, and changing to suit audience and
circumstance. Sense of self is subordinated to the requirements of the social economy. Style is valued to the exclusion of substance. - Presents with capricious features: strong dependency issues. Tends to sexualize relationships prematurely. Indulgent and struggles with frustration tolerance. Inner emptiness compensated through being the center of attention and by persistent sensation seeking. Occasional primitive regressions into fantasy. Given the lack of identity formation, the Pt's attachment to significant others is highly dependent and demanding. Constant reassurance seeking to maintain their stability and vacillate between over-compliance and profound depression when approval is not forthcoming. Emotions change quickly, easily, and unpredictably, running the gamut from intense love to intense rage to intense guilt, all of which may be expressed simultaneously. Can be agreeable but rapidly shifts to sullen or petulant the next. Tends to complain that they are either unloved or treated unfairly, attitudes that quickly escalate into tantrums when anyone disagrees. - Presents with narcissistic features: radiates attractiveness, charm, playfulness, verve, and intensity. More than just bubbly or perky, the Pt is interpersonally cheerful, optimistic, spontaneous, and impulsively expressionistic, often without regard to future consequences. Driven by a need for excitement and stimulation, the Pt is easily infatuated, attaching themselves to one person after another in quick succession. Behaviorally, their movements are quick and animated. Ideas often flow so quickly and tends to infect others with their excitement. Tends to face around, getting things done, starting projects, and persuading others to join them with an energy and friendliness. Prone to gratifying momentary whims without completing much of anything. - Presents with compulsive features: is desperate for approval and therefore prone to continually compliment, praise, flatter, and commend. Struggles to tolerate indifference in others. When disagreements do occur, the Pt immediately begin smoothing things over, even compromising their own desires or paints themselves as innocent victims caught in a cruel world. Struggles with feelings of emptiness, the guilt of the compulsive, and the inferiority and helplessness of the dependent. Struggles with feelings of being a problematic person who is unloved and inadequate. Others tend to see the Pt as a pleaser; ever alert to any subtle means whereby appreciation and approval might be secured. Internalized condemning parental voices rain down from on high with criticism and admonishment. Rather than conforming the Pt moves to appease: goodwill and kind gestures in return for anger and hostility. - Presents with negativistic features: intensely moody and emotionally variable. Generally is friendly and sociable, but is easily bored, needing external stimulation, and impulsive sensation-seeking. Hypersensitive to criticism, intolerant of frustration, and socially immature—characteristics that ensure that the good times won’t last. Pt alternates between periods of extreme emotional excitement and impulsive acting-out, followed by fits of anger that transition to depressive-like symptoms of fatigue and sleep and eating pattern changes. With a fragmented sense of self, is vulnerable to unmoderated displays of raw and rapidly changing emotions. Easily loses control, reacting with storm and turbulence to even minor provocations. Deprived of attention, they may search frantically for approval, becoming contentious, dejected, or hopeless when it is not readily forthcoming. - Presents with anti-social features: tends to make a good first impression and seem sociable and sincere, exhibiting spontaneity and charm. However, tends to be manipulative, violates social conventions, breaks promises, shatters loyalties, behaves irresponsibly, with eruptions of of anger and physical confrontation. They often seem to enjoy conflict, gaining a degree of gratification or amusement from the excitement and tension thereby produced.

Psychological defenses include: repression, splitting, sexualization, dissociation, and projection.

Treatment goals:

Diminish manipulative actions
Moderate focus on others
Reverse external preoccupations
Kindle genuine social relationships
Acquire in-depth knowledge
Decrease interpersonal attention-seeking
Stabilize fickle moods
Reduce dramatic behaviors
Reorient Flighty Cognitive Style

Behavioural:

Relaxation training
Problem-solving strategies
Assertiveness training
Tolerate existential anxiety

Interpersonal:

Warm sympathy toward their observing ego
Examine dysfunctional patterns
Explore alternate behaviours
Firm clear-cut boundaries

Cognitive:

Reinforce assertive and competent responses
Link thoughts to behaviours
Identify distortions
Identify their authentic wants and needs
Build self-concept: make a list of things they know about themselves e.g. favorite colors and foods
Handling rejection

Psychoanalytic:

Reveal hidden needs for dependency
Explore the transference drama

-- AMBIVALENT DEPENDENT PERSONALITY FEATURES --

Pt is continually seeking out new opportunities for life fulfillment with little regard for common sense limits and emotional / personal safety. Pt demonstrates a pattern of seemingly perpetual activity and pursuit of interests, often drawing others into these endeavors more as an afterthought than by design. Pt appears to have a vulnerability to discomfort coming from any form of passivity, whether that be appropriate rest or stagnation of activity.

The energy and self-assured entrepreneurial attitude characteristic of hypomanic individuals places them in leadership roles where their less desirable, uninhibited and meddlesome tendencies are tolerated. Although their drivenness may drive
others away, their exuberance and people-seeking skills are counterbalancing assets. Questionable judgment in social, sexual and financial spheres may hurt their loved ones and irritate associates.

Relative to their peers, Pt typically has more drive and energy, more self-confidence, increased social and physical activity, happy mood, faster thinking. However, darker features include: more irritable and impatient, distractible attention, foolish business ventures, imprudent driving, increased consumption of coffee, cigarettes, and alcohol.

While highly positive when circumstances are favourable, Pt is prone to decompensation when not briskly stimulated. Pt can continue to function quite successfully as long as they limit and focus their extraordinary energies and good moods. It is when they begin to become too high-spirited and impetuous that difficulties arise. They act intrusively with others, come up with scattered ideas, are insensitive to the rights of their colleagues and family members. At this point their exuberance takes on a preclinical form.

-- PASSIVE INDEPENDENT PERSONALITY FEATURES --

Pt has high positive self-regard, having a faith in their abilities. Pt aims high and battles to succeed. Ambitious and likes to lead. Pt is ambitious, assumes leadership roles, and enjoys being central to others.

- Presents with antisocial features: success tends to come at the expense of the needs of others. Legal boundaries are optional. Opportunistic. Contempt of victims. Limited super ego development and lacking internalized moral prohibition. Frequently disregards the rights of others. Self esteem is derived through humiliating and dominating others. Joy is obtained by gaining the trust of others and then outwitting or swindling them. Indifferent to truth. Masks antisocial attitudes through through a veneer of politeness and civility. When challenged, displays an attitude of nonchalance or cool strength. Victim blames. Relationships are utilitarian. Preys on the weak and vulnerable, enjoying their dismay and anger. - Presents with negativistic features: wounded in early life, compensates with an illusion of superiority. Striving to fulfill aspirations of status, recognition, and prestige. Feels privileged and empowered by virtue of pseudo achievements. Entitlement bears little relation to reality. Exceedingly sensitive to the reactions of others, noting every critical judgment and feeling slighted by every sign of disapproval, compensating through a façade of superiority. Struggles with procrastination for fear of evaluation. When threatened with reality, becomes defensive, arrogant and dismissive. - Presents with histrionic features: defined by the game of erotic seduction they play with objects of their affection. Entices and tempts the emotionally needy and naïve, while fulfilling their own hedonistic desires and sexual appetites. Not inclined toward genuine intimacy. Enjoys being desired by many rather than one. , Desires the warm affection of a genuine relationship, but feels restless and unsatisfied in a relationship. Sexual conquests are 'victories' to gratify power needs. Substantial body narcissism, attending scrupulously to physical appearance, clothes, and other external attributes. - Presents with elitist features: Self-assured to the point of arrogance. Ill-suited to subordinate positions. Cultivates a facade of success to amplify a superior self-image. Fears being ordinary. Stands as a race apart from ordinary human beings. Revels in displays of power. Fixated on prestige. Tends to flaunt symbols of status and achievement. Craves recognition and engages heavily in self-promotion.

Psychological defenses include: grandiosity, rationalization, fantasy, denial, repression, splitting, devaluation.

-- ACTIVE INDEPENDENT PERSONALITY FEATURES --

Demonstrates a capacity for self-sufficiency, ambition, competitiveness, and a constructive pursuit of individuality and self-determination. Unconventional; Pt does things their own way and is willing to take the consequences, regardless of how others might judge them. Sometimes flirts with legal boundaries in pursuit
of their own goals and desires. Rather than accept customary responsibilities, they see themselves as independent or creatively autonomous.

- Presents with anti-social features: Somehow feels that life has not given them 'their due'. Envious of those who have received the bounty of a good life, Pt is driven by a desire for retribution to take what destiny has refused them. Whether through deceit or destruction, their goal is compensation for the emptiness of life. Pleasure lies in taking control of the property and possessions of others. Seems to have an enormous drive for revenge, manipulating others like pawns in a power game. Deeply insecure about their power and status, never feeling that they’ve been compensated for life’s impoverishments. Prone to ostentatious or wasteful displays of materialism and conspicuous consumption. Has little compassion for or guilt about the effects of their behavior. Remains forever dissatisfied and insatiable. - Presents with narcissistic features: motivated by the desire to defend and extend a reputation of bravery and toughness. Behaviours are designed to ensure that others notice them and accord them the respect that they deserve. Hypersensitive to the possibility of belittlement. Feels they are someone significant, not to be easily dismissed, treated with indifference, taken lightly, or pushed around. Whenever their status or ability is slighted, Pt erupts with ferocious intensity, posturing, and threatening until rivals back down. Being tough and assertive is essentially a defensive act intended to prove their strength and guarantee a reputation of indomitable courage. - Presents with histrionic features: risk taking is intended to impress others with a front of courageous indifference to potentially painful consequences. Pt wishes others to see them as unaffected by what almost anyone else would surely experience as dangerous or frightening. Pt seems unfazed by the possibility of gambling with death or serious injury. Risk is proactively sought as its own reward, a means of feeling stimulated and alive, not a means of material gain. This defends against the sense of feeling trapped by the responsibility and boredom of everyday life. Irresponsible with actions and their fails to consider the consequences for their own life, or the lives of others, as they pursue ever more daring challenges. - Presents with schizoid features: Pt known to drift along at the margins of society, scavenging whatever slim resources they come across. Self perception is that they are jinxed or doomed and desire only to exist at the edge of a world that would almost certainly reject them. Mired in self-pity. Pt has dropped out of society to become a gypsy-like wanderer. Pt has little regard for their personal safety or comfort, and tends to drift from one setting to another as homeless person. Pt's sense of 'being no place' likely signifies alienation from self and others. Often appears vaguely disconnected from reality and lacks any clear sense of self-identity. Known to misuse substances and occasionally acts out. - Presents with sadistic features: is frequently belligerent, rancorous, vicious, malignant, brutal, callous, vengeful, and vindictive. Behaviours are charged with a hateful and destructive defiance of conventional social life. Having paranoid features, Pt anticipates betrayal and punishment leading to a strike-first attitude. Rather than merely issue verbal threats, however, Pt secure their boundaries with a cold-blooded ruthlessness that avenges every mistreatment they believe others have inflicted on them in the past. Tender emotions are a sign of weakness. Goodwill and kindness are perceived as weakness at best or a deeper ply to manipulate them at worse. Displays a chip-on-the-shoulder attitude and a willingness to confirm a strong self-image by victimizing those too weak to retaliate or those whose terror might prove particularly entertaining. Pt is an expert at the art of posturing and enjoy pressuring their opponents until they cower and withdraw. Makes few concessions and generally prefers to escalate confrontations as far as necessary, backing down only when clearly outgunned.

Psychological defenses include: Narcissism, grandiosity, rationalization, minimization, acting out, splitting, devaluation.

-- AMBIVALENT INDEPENDENT PERSONALITY FEATURES --

When functioning well at their baseline, the Pt is able to adapt to the realistic demands of the environment. Is very comfortable working and existing in dangerous and often unpredictable contexts. Has an earthy realism about life and people. Is highly adaptive to the vicissitudes of life.

Pt is highly independent, values their freedom, and is sensitive to issues of power, authority, and domination. Pt is suitably cautious and reserved in dealing with others and enters relationships only after careful consideration. Pt not only listens to what others say but also pick up subtle meanings and expectations at multiple levels. Pt does not shy away from problematic or highly conflictual situations.

Where criticism is concerned Pt is not easily intimidated, and will readily defend what they see as inalienable rights. Fidelity and loyalty are among the Pt's highest values, and they thrive when communication is direct and nonthreatening. Pt's keen nose for conspiracy serves them well. Pt prefers to remain somewhat distant until others can be carefully appraised. Pt places a premium on fidelity, frankness, openness, and honesty; is more open to the evidence; and does not alienate others on the basis of suspicion alone. Pt has a close knit circle of trusted friends but nevertheless, but plays their cards closely with those who are only acquaintances.

However, under duress, Pt often believes, without adequate foundation, that others are attempting to harm, exploit, or deceive. Pt frequently suspects, with no adequate foundation, that close friends or associates have been disloyal. Pt is extremely reticent about sharing confidential information with others for fear that it will be used against them. Pt interprets benign communications as containing hidden threats or demeaning messages.

Pt nurses grudges and rarely forgives an insult and perceives attacks where none are intended. Moreover, Pt responds almost reflexively with angry counterattacks. Pt tends to implode intimate relationships as they perceive their significant other has been unfaithful.

- Presents with Narcissistic features: Pt frequently comes across as arrogant, pretentious, and expansive and maintains an air of contempt toward others. Pt tends to run hard into reality, resulting in narcissistic wounds. With self-image of perfection shattered, Pt often seeks to reestablish lost pride through extravagant claims and intricate fantasies. By endowing themselves with illusory powers, Pt sees self as a type of superheroes or demigod, ready to prevail against an evil universe. Having assumed a grandiose identity, Pt attempts to offset the collapse of self-esteem produced by objective reality. As such, presents themselves as a holy saint, inspired leader, or talented genius. Elaborate schemes may be devised by which to deliver the world from sin, lead the planet to world peace, solve long-standing scientific problems, or create utopian societies. Occasionally, their plans are sufficiently detailed to draw at least passing interest. Pt attributes failures to interference to intangible powers, perhaps secret government agencies that have conspired to preserve the status quo. Projection, righteous indignation, and a sense of omnipotence combine to create a defensive armor in this Pt. Having a crushed sensed of self-worth, and unwilling to face reality, Pt retreats deeper inside a private world of fantasy, creating a compensatory universe in which they can assume their former station, fulfill previous ambitions, and salvage their existence.

- Presents with sadistic features: Pt has expectations that they will be on the receiving end of others aggressions. Highly sensitive to power issues, the Pt's strategy is to dominate others before they can dominate them. Frequently intimidating and belligerent, the Pt seems to possess a ruthless desire to avenge past wrongs and triumph over others. Even when they are alone, the long list of perceived wrongs apparently done to them constantly rises into their awareness, thus keeping a potential for aggression close to the surface. Pt reports their actual efforts at abusing and terrorizing others routinely backfire, which leads them to seek retribution more through fantasy than action. Although these setbacks are wrought by their own hand, as their chip-on-the-shoulder attitude toward others provokes abundant antagonism. As the Pt becomes more isolated, left to ruminate over this self-created perpetual cycle of interpersonal hostility, they tend to cogitate on the perceived malicious nature of their hostile environment, complete with the venomous individuals who inhabit it. Via the intrapsychic mechanism of projection, Pt attributes their own acrimony to others, ascribing to them all of the enmity they feel within themselves. As the line between objective antagonism and imagined hostility grows thin, the belief that others are intentionally persecuting them may take on almost delusional proportions. Pt therefore feels the need to protect their autonomy against any and all outside influence is a defining feature of this variant because nothing is so valuable and so vulnerable to them as their sense of self-worth. The malevolence they perceive emanating from others is neither casual nor random but designed to intimidate, offend, undermine their self-esteem, control their thoughts, and weaken their will. They are ever alert against their darkest fears: Others will make them soft and yielding, forced to submit to authority, or worse, tricked into surrendering their self-determination.

- Presents with compulsive features: Pt presents as rigid, perfectionistic, grim, humorless, tense, overcontrolled, small-minded, peevish, legalistic, and self-righteous. Pt has a posture of unabashed self-assertion. They actively rebel against any and all external constraints in a maladaptive effort to regain their sense of perceived control and overturn injustices previously doled out on them. While they do continue to seek clarity from imposed rules and regulations, they are now the imposers of a system that is used to attack others, usually through either legal action or the setting of impossible rules that cannot realistically be followed. Other caught in the Pt's crosshairs are despised for their weakness, their sloppiness and lack of regard for disciplined behavior, their failure to live an organized life, and their hypocrisy.

Despite these assertions of nonconformity and dominance, however, the Pt is not likely to eschew deep-seated feelings of guilt and fear of retribution. Further,
although they may appear to function normally much of the time, they possess tightly
compartmentalized persecutory delusions. It is not unusual for the Pt to project their anger onto others—thereby creating the perception of hostile intent from innocuous or absent signals.

- Presents with negativistic features: characteristics such as discontentment, pessimism, stubbornness, vacillation, and vengefulness which amplify into overt hostility and forthright delusions. This result manifests in tones of faultfinding, sullenness, resentfulness, contentiousness, jealousy, and insistence on being forever wronged or cheated. Pt eschews relationships, instead giving up their quests for affection and adopting a contrived stance of autonomy and self-determination, renouncing their social needs yet harboring a cloaked sense of dejection. While they state their newfound independence with vengeful fury, the Pt remains deeply troubled by interpersonal discontentedness and feelings of indecisiveness, with hidden feelings vacillating between desiring the company of others and feeling repulsed by them. As envy mounts, the Pt often complains that the achievements of others reflect unfair advantages or preferential treatment. Grumbling turns to anger and spite as their fantasies of being taken advantage of accrete ever more injustices. Legal action against those who have wronged them is common, as are erotic delusions because the Pt does still seek affection even while refusing it. This is done via the intrapsychic projection mechanism, whereby the Pt comes to believe that the feelings of the self are actually emanating from others. Thus, by projecting their own desires onto others, it becomes 'them' who make lewd remarks or otherwise suggest sexual intentions. Accusations of infidelity, deceit, and betrayal are often made against innocent relatives and friends, a further synthesis of the negativistic and paranoid patterns.

- Presents with avoidant features: Pt often presents as moody, apprehensive, and hypersensitive to criticism, especially where their worth and achievements are concerned. Extremely vulnerable, Pt often seeks solace in self-focused ways. For example, they may engage in abstruse intellectual activities to enhance their self-esteem or indulge in drugs and alcohol to calm their fears. Especially fearful of shame and humiliation, the Pt seeks to defend themselves against both real and imagined dangers. More than most, they seek to protect themselves from a world both threatening and destructive. As such, the Pt tends to isolate themselves for long periods of time, a means of keeping the inevitable judgments of others out of their lives. Pt has an unusually strong fear of being controlled. They not only seek to prevent external influence but also desire to rely solely on their own conclusions
and beliefs. Unwilling to check their thoughts against consensual reality, the Pt seems frequently out of touch with the surrounding world, and often loses the
ability to distinguish fantasy from reality. Having fears of shame and humiliation, an important component of both the paranoid and avoidant patterns, the Pt easily inflates to full-blown conspiracies.

Psychological defenses include: projection, reaction formation, rationalisation, splitting, devaluation, displacement, grandiosity, omnipotent fantasy.

-- PASSIVE CONFLICTED PERSONALITY FEATURES --

Pt is characterized by a dedication to hard work, deeply held convictions
of conscience and moral principle, a need to do things perfectly and in a socially
approved manner, perseverance in pursuits, preference for orderliness and detail, cautious consideration of alternatives before acting, and the need to save or collect things. At times the Pt presents as proper, conventional, orderly, and perfectionistic. Pt respects tradition and authority; upholding established rules and standards, and follow regulations closely. Pt seldom exhibits spontaneity and can be rather rigid and inflexible in relationships. Pt tends to be intolerant of deviance and tend to be judgmental of those who are not as earnest. Ever diligent in their responsibilities, others perceive Pt as highly dependable and industrious.

Presents with dependent features: Pt exhibits a conforming dependency, compliance to rules and authority, and a willing submission to the wishes, values, expectations, and demands of others. Pt's self-image is considerate, thoughtful, and cooperative. Has a strong sense of duty, which masks underlying feelings of personal inadequacy. As such, Pt tends to minimize their accomplishments, underplay their abilities, and grade their success in terms of how well the expectations of others are fulfilled. Though other will describe Pt as earnest, hardworking, and thorough, these characteristics compensate for deep feelings of self-doubt and hesitation and serve to keep them in the good graces of those they rely on for esteem. Pt holds fast to the belief that they will be cared for, valued, and loved in direct proportion to their hard work and monumental accomplishments. This belief structure comes with a significant liability; Pt fears that failure to perform perfectly will provoke both abandonment and condemnation, which creates considerable inner sensations of tension and guilt. So dreadful is the thought of making mistakes or taking even the smallest risk that they perpetually rework their efforts, never attaining a true sense of satisfaction for a job well done, all the while feeling perennially anxious over their perceived inadequacy to handle any unanticipated hitch. Dependent features gives rise to a distinct submissive interpersonal manner with superiors and an air of propriety and restraint with all others. This is in direct conflict with intense contrary feelings that frequently lurk beneath this veneer, and on occasion, these more primitive qualities sneak through their tightly controlled coping skills. Their occasional experience with such security breaches teaches them to hold even tighter to self-control, thereby creating an existence that is over-organized, devoid of spontaneity, and dramatically upset by any deviation in routine. The Pt experiences aggression as a private battle and is usually masked by a front of equanimity and social agreeableness. - Presents with paranoid features: Pt experience a deep ambivalence between obedience and defiance, which they resolve through sublimation, reaction
formation, and displacement. When Pt sublimates this conflict seem more normal, whereas displacement of aggression makes them seem more forceful, versus reaction formation which translates their aggression into self-righteous fury. Metaphorically the drives and aggressive impulses are so strong, yet so strongly reacted against, that these individuals seek the armor of God’s righteousness to purify, transform, and contain them. Pt feels the persistent press of irrational and repugnant
aggressive and sexual drives and adopt an ascetic and austere lifestyle to prohibit
their dark impulses and fantasies. Their hostility is likely to be vented through
vicious displacements, which usually identify a common enemy or seek to scapegoat
the weak. Dichotomous thinking reinforces these urges: In their mind, the world is composed of the all good and the all bad, us versus them, the justified and the unjust, the saved and the sinners, along with the saints etc. Pt is reviled by perceived moral laxity, and tends to use their wrath as a 'vengeful sword' of righteousness bestowed with a sacred mandate to dispel sin and iniquity. Pt seems generally pleased to be this instrument through which justice is administered.
With puritanical leanings, Pt naturally gravitate toward radical fundamentalism, as the literalism inherent in such beliefs creates a clear picture, not only of who deserves punishment, but who deserves absolute punishment. Thus, injustice is made just and Pt is free of any residual guilt. Pt is viewed as harsh, demanding,
abrasive, irritating, prudish, and exceptionally straitlaced. - Presents with narcissistic features: Pt is allied with traditional values, established authorities, and formal organizations. Pt wholeheartedly embraces the order and structure inherent in recognized institutions, authorities, and social mores. Pt flourishes in an organizational setting, feeling comforted, strengthened, and empowered by clearly defined superior and subordinate relationships, definite roles, and known expectations and responsibilities. Pt uses highly developed and formalized external structures to compensate for the internal sense of ambivalence and indecisiveness that plagues them. Pt presents with fused identity to the system as a means of achieving place, purpose, and protection, which frees Pt from any anxiety related to making independent decisions. Pt's superiors know them as trustworthy, diligent, and faithfully committed to the goals and values of the institution, which fortifies their self-esteem and gives them a direction. Without the organization Pt would feel lost or aimless in life. Punctual and meticulous, they adhere to the work ethic like worker ants in a colony, appraising their own and others’ tasks with black-and-white efficiency, as done or not done. The status gained by their alliance with their “greater cause” offers the Pt a modicum of pride and self-importance. Pt is deeply committed to all of the trifling and inconsequential directives of their beloved institution. Pt gains a sense of status by fusing their identity with a much larger force and becoming an indispensable part of this important structure. At a moderately disordered level, the Pt's rigid adherence to policies and rules makes them seem officious, high-handed, close-minded, and petty. At a severely disordered level, the Pt may use their knowledge of the rules, effectiveness with red tape, and ingratiating attitude with superiors to terrorize subordinates or anyone else who crosses their path without paying them the proper dues and respect. - Presents with Schizoid features: Pt's miserliness takes on an almost symbolic significance. Ever wary of the possibility of loss, Pt is selfish and keeps a tight, self-protective grip on everything they possess, lest it somehow be wrested from them. The Pt's identification lies with the security value of material goods. Having been deprived of so many wishes and desires in childhood, the Pt nurtures and protects what little they have, ever suspicious that others might scavenge their few prized possessions. Pt draws sharp boundaries and behaves with an unnecessary stinginess. In effect, their behavior says, 'What is mine is mine, and what is yours is yours. 'Pt is self-sufficient to a fault, disallowing anyone who may potentially deprive them of their resources and acting as if any loss in their nest egg could not be replenished. Pt's miserliness likely masks a deeper need. By effectively shutting out anyone else from permeating their world of possessions, they are, in effect, guarding against any discovery of the barrenness of their attainments and competencies. In keeping an air of propriety and privacy, they stave off any possible unearthing of their dreaded rebellious urges or irrational anger. - Presents with negativistic features: Pt appears on the surface to be maintaining a controlled and austere front but struggles incessantly with a desire to conform to the wishes or agendas of others one minute and the desire to subvert others and assert their own interests the next. When expected to act decisively, the Pt tends to vacillate and procrastinate, feels tormented and confused, becomes cautious and timid, and use complex rationales to delay making decisions as long as possible. Unable to crystallize their own identity and feeling wave upon wave of ambivalence, the Pt tends to express their dissatisfaction by becoming exhausted, grumpy, and discontent. Pt is perpetually overwhelmed by the conflict between the will and better decisions; their existential experience is that of being caught between a rock and hard place. Painfully aware of their inner impulses, the Pt engages in a form of self-torture; an act of punitive resolution that symbolically undoes that which bedevils them. In this context, the obsessions and compulsions that emerge signify a futile attempt to control that which is illogical, irrational, or even abstract about themselves and their desires. Generally, the more extreme the obsessions and compulsions, the more the Pt's routine coping skills are failing. The Pt's inner ambivalence is the inability to confront what is upsetting to them, and outward behaviors such as compulsions are an outlet for their contradictory feelings. At times, the Pt sees themselves as driven by ego-alien forces, perhaps demons. Helpless, in their perspective, to escape the clutches of corruption, the more decompensated the Pt may come to feel as though they are on the edge of psychic dissolution.

Psychological defenses include: isolation of affect, reaction formation, displacement, undoing.

-- MASOCHISTIC CONFLICTED PERSONALITY FEATURES --

Pt seems to live to serve and to be helpful to others. When allowed to give selflessly of themselves, everything is right with the world. Forever putting others above themselves, the Pt has a reputation for being kind, considerate, and charitable. Always forgiving, Pt believes that people should be accepted and appreciated for who and what they are, not judged harshly by some extrinsic
or legalistic standard. Although Pt willingly shoulders the burdens of life for
those they love, they feel uncomfortable when their good deeds are singled out for
praise, honestly believing that no thanks or recognition is necessary.

- Presents with avoidant features: Pt appear to actively and repetitively search for circumstances that lead to suffering or even destruction. From the outside, the Pt seems gratified by misfortune, failure, or humiliation, preferring instead to be disgraced, victimized, or even ruined. Driven by a 'success neurosis,' they experience favorable outcomes as producing anxiety and guilt, not pleasure and happiness. Rather than suffer success, the Pt searches out failure or punishment, subtly reversing their good fortune. Seemingly striving hard for accomplishment, they either stop just short of its attainment or manufacture some means of proving themselves unable to follow through. Covertly, Pt is likely gratified by their own defeat. Fearing things will suddenly turn sour, the Pt would rather be pitied as an unfortunate victim of circumstance than as someone who had striven hard but failed. Failure may bring on a sense of relief that they must no longer live up to some standard. - Presents with negativistic features: Pt is known to give constantly of themselves. However, Pt is unable to let go of their attachments. Instead, becoming so indispensable and self-sacrificing that others are unable to withdraw from them without feeling incredibly cruel. It is as if others become entrapped and dominated by a dependency driven by the fulfillment of their every need. Through ostentatious sacrifices, Pt seems driven to intrude into the daily affairs of their children, spouses, friends, and peers, meddling in activities, romance, occupation, and anywhere else they can obtain a foothold. Ostensibly their altruistic acts create grounds for inducing guilt in others, which may be used to prevent them from distancing or ending the relationship. Mates are overprotected and jealously guarded, bribed for love, and controlled through guilt. - Presents with depressive features: Pt tends to mope around complaining of their terrible condition but telegraphs a bind for others 'don’t let my suffering make you worry about me; do what is best for you.' In other words in one voice, they disavow any need for assistance and explain that they do not want to burden others, yet present themselves as having suffered the slings and arrows of outrageous misfortune. Pt tends to make others who comes to their aid feel emotionally drained and guilty; as if moving on with his or her own life was an abandonment. Hypochondriacal defenses may come to the fore when no other method of gaining love and dependence seems available. Pt presents as a sorrowful invalid, a genuine but self-created suffering that forces others to be caring and nurturing. The Pt's discomforts are merely an instrumentality designed to secure pity and assistance. - Presents with histrionic features: Pt seems proudly unselfish and self-sacrificial. Self-denial, asceticism, and stoic tolerance of adversity are seen as noble and righteous, a sign of purity and saintliness, the glorification of misery. Sacrificing themselves completely to others or for some meritorious cause is open for public view. If others withdraw their attention or distance their emotional bond, Pt tends to complain that they are ungrateful and thoughtless and should remember they have been faithful and giving. Superficial altruism may occasionally give way to self-congratulatory pride, and past good deeds may be used to justify a sense of being entitled to emotional support from others. Even when they get their way, however, a low sense of self-worth continues to lurk just below the surface, a consciousness that the appreciation of others is manipulated rather than genuine.

Psychological defenses include: repression, undoing, narcissistic, autistic fantasy.

-- AMBIVALENT CONFLICTED PERSONALITY FEATURES --

Pt lives a roller coaster life; frequent ups and downs are the rule, and attachment is the central theme in all relationships. There is a desire always to be involved in a passionate romantic relationship. Pt tends to express emotionally rather than logically, showing their feelings with spontaneity and creativity. Socially, Pt is lively and engaging, with an open mind toward experimenting with various roles and value systems. Pt seeks closeness with their partners, like a merging of souls but
even more intensely. Pt expects the same from others and quickly becomes hurt whenever the same desire is not forthcoming. Pt is sensitive to anything
that might impact the quality of attachment in their relationships. Pt prone to reading more into behaviors and events than is warranted but can take a more realistic and complex perspective on their relationships. Pt diminishes self-uncertainty by being more experimental and curious about alternative lifestyles, roles, and value systems. Pt is somewhat sensation-seeking, but in ways that primarily add to the richness of experience rather than subtract from it. Pt tends to be spontaneous and emotionally intense and only occasionally overreacts or over-dramatizes. Pt actively pursue social venues and creative pursuits that help make life entertaining. Pt tends to be emotionally intense but nevertheless
able to step back and see the effects of their moods on others.

- Presents with avoidant and dependent features: The Pt tends to
pursue a strategy of submissive attachment to one or two significant others. Avoidance of competition, loyalty, and humility but also masochistic subordination and at times parasitic clinginess. By exclusively relying on a single someone, Pt is prone to 'putting all their eggs in one basket.' This leads to fearing that their lifeline is threatened, their world is chronically destabilized. Consequently, the Pt is ever preoccupied with their lack of security, mainly their own helplessness, self-doubt, and lack of self-sufficiency. To reinforce their relationships, the Pt admits to clinging tenaciously to whoever is available, merging their own identity
into that of their partner. Given such profound needs, they are easily panicked by a sense of isolation or aloneness and easily feel depressed and powerless. Simple responsibilities at times seem monumental, everything feels like a burden, and life somehow always seems empty and heavy. When feelings of futility intensify, the Pt may regress to a state of marked depression or infantile dependency, requiring others to tend to them as if they were infants. Generally stable in moods, these tendencies tend to emerge when the Pt senses that their interpersonal
pacts have been violated too often—that others have 'selfishly failed' to supply promised rewards of affection. At times of feeling resentful and angry, the Pt no longer believes that conformity will forestall desertion. Instead, they feel coerced into submission and betrayed—emotions that periodically break through normal controls. Because anger is not only inconsistent with their self-image but also alienates or provokes those on whom they depend, intense negative feelings are experienced as dangerous. In response, the Pt may swing to the opposite pole, becoming excessively preoccupied with self-reproach. Self-mutilation and suicidal attempts, symbolic acts of self-desertion, may be used to control their resentment
or as punishment for anger. - Presents with histrionic or anti-social features: Unless constantly receiving attention, the Pt becomes increasingly seductive, impulsive, capricious, and irresponsible. Pt prone to becoming behaviorally hyperactive and cognitively scattered, exhibiting a dysregulation of positive affects that includes frenetic gaiety, frantic gregariousness, and irrational and superficial excitement. At times, Pt loses all sense of propriety and judgment. Frequently fails to plan ahead or heed the consequences of their actions as they struggle to free themselves from social constraints. Pt experiences many disappointments, and goes for extended periods of time without the security they
crave, which leads to states of hopelessness and depression. Family background seems to have endorsed drama, a desire for stimulus variety, and an intolerance of boredom. Pt models and has learned to depend on sex-role stereotypic compliments as the basis for their self-esteem. In general, the Pt is sensitive to external sources of reward and moves impulsively and capriciously from one engaging item to the next. Thus oriented to the external world, the Pt seems to have failed to develop a solid self-identity that might anchor them during periods of stress. As a consequence, the Pt is always on unsure footing, constantly on edge, never quite sure who will provide the attention and stimulation they desperately require. Periods of
brooding, dejection, and hopelessness alternate with simulated euphoria as the Pt
shifts from acknowledging to denying their condition of security and attachment. - Presents with negativistic features: Pt can be unpredictable, restless, irritable, impatient, complaining, disgruntled, stubborn, sullen, pessimistic, resentful, and envious of the happiness and success of others. Pt expresses resentment towards those on whom they depend and seem to hate those to whom they must plead for love. It is as if the Pt has seldom had their needs satisfied on a regular basis and have never felt secure in their relationships. Stubborn and demanding, they openly register their disappointments. Unable to find comfort with others, the Pt becomes increasingly bitter and discontent, caught between two pathological extremes. At times, they express feelings of worthlessness and futility, become highly agitated or deeply depressed, express self-condemnation, and develop delusions of guilt. At other times, their habitual negativism becomes completely irrational, driving them into rages in which they distort reality, make excessive demands of others, and viciously attack those they see as having trapped them and forced them into intolerable conflicts. The Pt's moods become a way of threatening others that further trouble is coming unless something is done. However, following
these wild outbursts, the Pt turns their hostility inward and become remorseful, plead for forgiveness, and promise to behave and make up for their transgressions. The Pt may express fatigue and somatic disorders as a means of milking others’ attention while burdening them at the same time. Affection has never been free of conflictful feelings.- Presents with masochistic features: Pt's self-destruction serves the needs of a comorbid masochistic pattern. Pt is perpetually unable to find a comfortable niche with others. The masochistic traits cause the Pt to turn inward, where destructive feelings can be expressed upon the self. Underneath, there is both a desire for independence and a genuine fear of autonomy. To control these oppositional tendencies, the Pt struggles to present a façade of self-restraint and self-sacrifice. Ever deferential and ingratiating, Pt bends over backwards to impress their superiors with their conformity, all the while denying their dependencies and becoming even more conflicted. At times, these antagonisms give rise to public displays and bitter complaints about being treated unfairly, of expecting to be disillusioned and disapproved by others, and of no longer being appreciated for their diligence, submissiveness, and self-sacrifice. With the persistence of ambivalent feelings, the Pt tends to somatize into physical symptoms as more subtle means of discharging negative feelings prove self-defeating, tension and depression mount beyond tolerable limits. Pt is known to accuse others of despising them, seeking to destroy their worth, and plotting to abandon them. As a result makes inordinate demands for attention and reassurances. Pt at times threatens to commit suicide and thereby 'save' others the energy of destroying them slowly. The Pt perpetuates their pathology by deliberately putting themselves in positions of excessive vulnerability, making themselves so dependent and clingy that others could only become exasperated, resulting in a predictable abandonment cycle.

Psychological defenses include: splitting, acting out, primitive denial, idealizing, devaluing, regression.

-- ACTIVE CONFLICTED PERSONALITY FEATURES --

Pt tends towards conforming to the expectations of others, but would like to put their own personal stamp on their productions. Makes substantial contributions but enjoys receiving due credit. Is able to get along with others, becoming
resistant only when sensing a sense of entitlement from others. Is able to
use protest constructively without exaggerating faults. Does not begrudge others
their good fortune, but may become quickly disappointed if their own efforts are not appropriately rewarded. Is conscious of the distribution of rewards in life but is nevertheless able to take initiative to better their own situation. Can vacillate between defiance and expressions of remorse but does not act out so extremely that such expressions are necessary.

- Presents with dependent features: Pt demonstrates indirect resistance to the expectations of others that it has become an almost defining feature of their personality. Sensitive to situations that assume the Pt's compliance and thus value the individual as a means to an end, not as a unique human being. Pt avenges themselves mainly in roundabout and covert ways that undercut and frustrate anyone who would take them for granted or demand a certain level of performance. The exact methods vary but include procrastination, dawdling, stubbornness, forgetfulness, and intentional inefficiency. Fearful of expressing resentments directly, the Pt fulfills obligations with foot-dragging slowness and inconsistent performance. May engage in feigned incompetence or exhausting requests for help may be used to frustrate others. Given a looming deadline or the need to perform at unusually high levels, somatic complaints may be used passive-aggressively as a means of excusing them from work, thus increasing the level of tension for everyone else. - Presents with sadistic features: Pt remains caught in the conflict between their own agenda and a loyalty to others, but has become more overtly and intentionally contentious and quarrelsome nonetheless. Get so torn by conflict that every request or expectation feels like a major burden. Past experience has led Pt to expect that even their most conscientious performances are likely to be evaluated with disappointment and derision. Is so jaded that they have deep doubts about whether life will work out or whether happiness is even possible at all. Certain that loyalty and the tender emotions are only a sad illusion created to conceal the perverse cruelty of human nature. Has a 'damned if you do and damned if you don’t' attitude. As such, minor frictions tend to exacerbate into major confrontations and power struggles. Pt derives a special joy in spotting inconsistencies in the behaviors or ethical standards of anyone who would require something from them. Known to construct arguments that amplify observed contradictions and shove these squarely in the face of their antagonists, just for the sadistic pleasure of undermining their self-confidence and watching them squirm. Takes the moral high ground and dogmatically insist that others are either hypocritical or mentally defective. When pressed, even such indirect oppositionality may give way to contemptuous fault-finding and outright insults. Generally experienced as abrasive. - Presents with depressive features: Pt is prone to griping. Attacks emotionally through annoying complaints, thinly cloaked criticisms, and unsubtle digs. It feels as if the Pt is fighting a war of attrition designed to wear down the enemy. Is constantly disapproving, as if purposely seeking some thin rationale by which to be negative and faultfinding. Happy to point out imperfections, pick at old wounds, work others into a state of irritation, and then complain further that their concerns have not been properly addressed. Tends to exaggerate trivial concerns. self image is paradoxically as an ambassador of goodwill, who has become exasperated with the problem at hand, perhaps struggling with the inefficiency or ineptitude of those around them, especially those who give the orders. Pt cultivates the image of being more competent than their superiors, whose recognized status and authority they deeply resent. - Presents with capricious features: Pt is distinguished by unstable and rapidly fluctuating emotions and attitudes. At times presents as affectionate, predictable, interesting, even charming, but then suddenly become irritable, oppositional, and disagreeable. Or, at times presents as self-assured, decisive, and competent, only to abruptly regress to a clinging dependency. Or they may be pleased with themselves one moment, only to become angry and depressed the next. Torn by conflict, the Pt's thoughts seem to flow freely in almost any direction, putting them at the mercy of rapidly changing emotions. Emotions are expressed directly and primitively, untransformed by a cohesive self-structure that might give direction to behavior. Tantrums are common. Unable to fathom the source of such shifts, others find them aversive, if only because their emotional maelstroms are difficult to understand.

Psychological defenses include: projection, rationalization, regression, reaction formation, splitting, displacement, grandiosity.

-- SADISTIC CONFLICTED PERSONALITY FEATURES --

Pt seems to enjoy the power to direct and intimidate, to evoke obedience and respect. Tough and unsentimental, Pt makes an effective leaders by assigning tasks and coercing performance from subordinates. Although others see Pt as impulsively aggressive and stubborn, for example, Pt tends to of themselves as energetic, assertive, and realistic. Pt uses an imposing physical presence as a means of pulling for respect in interpersonal transactions. Pt enjoys an image
of strength and holds this as part of their self-image. Pt is authoritative,
not authoritarian. Pt feels gratified only where punishment was administered and justice was served. Pt seeks to expose deception in others. Cultivates power and uses it for a greater good. Pt creates rules and expect them to be followed, though within reasonable limits. Pt admires the potential of strength and its various symbols to evoke respect.

- Presents with capricious features: Pt is distinguished for sudden eruptions of uncontrollable rage, frequently vented against members of their own family as safe targets. Pt generally copes competently until some unknown threshold is reached, after which they react instantaneously with abusive defiance and possibly physical violence. These displays of aggression are not used instrumentally to dominate others, but instead release pent-up feelings of frustration or humiliation. Pt is hypersensitive to feelings of betrayal, or they may be deeply frustrated by the futility and hopelessness of life. - Presents with negativistic features: Pt known to be physically assaultive, and overwhelms their victims by unrelenting criticism, forceful anger, and vulgar and bitter tirades. Pt seems to relish the act of menacing and brutalizing others in the most unmerciful and inhumane ways. Pt derives a deep satisfaction from creating suffering, observing its effects, and reflecting on their actions. Violence may be employed intentionally to inspire terror and intimidation. Resistance only seems to stimulate them more. Often calculating and cool, Pt is selective in their choice of victims, identifying scapegoats who are easily intimidated and unlikely to react with violence in return. Pt enjoys dramatizing their surly behavior. - Presents with compulsive features: Pt presents as if they are society’s sadistic superego, vested in punishment for its own sake, unable to be appeased. Like military sergeants, certain cops, university deans, and the harsh judge all feel that they have the right to control and punish others. Cloaked within a socially sanctioned role, the Pt safely metes out condemnation in the name of justice with such extraordinary force that their deeper motives are clear. Ever seeking to make themselves seem important, these sticklers for rules search out those guilty of some minor trespass, make them cower before the power of their position, and then punish them with a righteous indignation that reeks of repressed anger and personal malice. Despite their responsibility to be fair and balanced, the Pt is unable to put limits on the emotions that drive their vicious behaviors. - Presents with avoidant features: Pt is insecure, even cowardly leading to their creating an image of strength, a sense of mutual ensured destruction. It is as if their aggressive hostility is a counterphobic act, designed to master their own inner fearfulness, while sending a message of strength to others that they will not be intimidated. Pt's displays of courage serve to divert and impress the audience with a façade of potency that says, 'I will not be pushed around.' Neither naturally mean-spirited nor intrinsically violent, Pt caricatures the swaggering tough-guy or petty tyrant. It is therefore likely they employ aggression instrumentally against others who seem threatening and abusive. That is, fearful of real danger, they strike first, hoping to induce a measure of fearfulness that forestalls further antagonisms.

Psychological defenses include: projection, splitting, disavowel, narcissistic, denial.

Pt is unable to achieve an internalized ideal: that others must always be there for me everyone should be completely honest that people should completely understand me I should be completely lovable I should be part of a loving community I should be completely competent at everything I should be able to handle anything that life brings I should be completely independent I should completely measure up to others I am entitled to special privileges I should be in complete control I should be free to completely express myself I must suppress my wants and needs the needs of others are more important I must always be approved of life should be completely fair and equal spontaneity is the essence of life if I can't achieve perfection, there's no point trying people who make mistakes need to be punished. Falling short of this ideal, the Pt maintains their self-esteem through

Acceptance of the situation that has been causing anxiety. Acting out with socially undesirable behaviours. Anticipating potentially stressful events by mentally preparing and rehearsing for it. Altruistically acting in a way to neutralise potential threats from others. Avoiding situations that create anxiety rather than confronting or addressing it. Converting their anxiety into a physical complaint. Denial of their feelings and previous actions to avoid guilt and anxiety. Displacing their actual feelings into an acceptable substitute behaviour. Dissociating from the world and entering into a more tolerable alerted state of consciousness.

What is their current overall level of functioning out of 100?
Global functioning: 91 – 100 No symptoms. Superior functioning in a wide range of activities 81 – 90 Absent or minimal symptoms, good functioning in all areas 71 – 80 If symptoms are present, they are transient and expected reactions to psychosocial stressors. 61 – 70 Some mild symptoms, but generally functioning pretty well. 51 – 60 Moderate difficulty in everyday functioning. 41 – 50 Serious impairment in everyday functioning. 31 – 40 Some impairment in reality testing or communication and major impairment in several areas. 21 – 30 Behaviour is considerably influenced by poor reality testing; an inability to function in almost all areas of life. 11 – 20 Some danger of hurting self or others; occasionally fails to maintain minimal personal hygiene; gross impairment in communication. 1 – 10 Persistent danger of severely hurting self or others; persistent inability to maintain minimal personal hygiene or serious suicidal act with clear expectation of death. 0 Inadequate information.

Factors inmpacting on recovery: nothing of note is not very motivated to change lacks a strong education background experiences significant work stress has housing problems has an over-burdening debt experiences economic disadvantage is not very psychologically minded lack meta-cognitions has very poor insight lives in a difficult social environment has financial stress over-identifies with sick role has ongoing legal problems has background of childhood adversity has history of victimization is unemployed has problems related to upbringing has chronic medical problems is pregnant is very religious has discord with family has discord with most people has extreme beliefs has personality instability has significant lifecycle transition difficulties has substance misuse concerns has low self-efficacy has sexual difficulties has medication adherence and compliance problems has rigid psychological defenses has relationship problems has feelings of hopelessness is unaware of problem is denying of the problem has secondary gains from the sick role has no motivation to change.

ACTION

What action did you take based on current suicide risk?
Risk: No need for further action today I reminded the patient of their calling MHAL 1800011511 if needed, and urged them to present to the ED or call 000 in a crisis Pt and I agreed to a harm minimization approach by removing access to lethal means and I further discussed their risks with their parent

Worked with Pt to tolerate distress learn relaxation skills learn mindfulness and meta-cognitive skills develop greater insight decrease over-eating behaviours increase eating and calories decrease ETOH misuse endure withdrawal of substances feel more hopeful about the future improve sleep enhance a sense of self-efficacy increase psychological knowledge become more assertive adhere to recommended medical treatment enhance problem-solving skills modify distorted cognitions and beliefs become motivated to treat MH concerns improve medication adherence and compliance feel enhanced self-agency

Progress: excellent good fair poor negligible

PLAN

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