Assessment and Treatment of Personality Disorders: A Behavioral Perspective.

According to traditional diagnostic viewpoints represented in the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision; American Psychiatric Association, 2000), a personality disorder is: "an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment" (p. 685). We review issues relevant to a behavioral perspective and the DSM-IV-TR approach to personality disorders below, followed by assessment and treatment issues for personality disorders (both at the nomothetic and idiographic levels), and examples of borderline and avoidant personality disorders. A central thesis of this paper is that a behavioral approach to assessment and treatment can compliment and expand upon a diagnostic approach, for example, by targeting covarying response classes characteristic of the different personality disorders. The concept of "personality" has historically been eschewed by behaviorists, who focus on external (i.e., environmental), rather than internal, causes of behavior. The purpose of this paper is to present our view that basic behavioral principles can be successfully applied to personality disorders, which have been conceptualized by many as "characterological" in nature and that a behavioral view can fully integrate the DSM concept of personality disorders. Hayes et al. (2006) supported this emphasis on behavior theory by noting that a focus on basic behavioral treatment principles (not just the techniques themselves) makes it easier to confront a wide array of clinical problems. Although one such treatment package for personality disorders does exist, it is designed only for borderline personality disorder. Further, some personality-disordered clients show resistance to the structure of a manualized treatment, leaving much room for uncertainty in the treatment of this population. It is our position that a focus on basic behavioral assessment and treatment principles can aid greatly in clinical decision-making for clients with personality disorders. As this population presents unique and difficult clinical challenges, this approach is likely to be successful in the absence of readily available treatment packages. The Relationship between Behavioral Assessment and the DSM system Prior to presenting a behavioral view on the assessment of personality disorders, we describe the relationship between behavioral assessment and the DSM system. It is our contention that recent versions of the DSM can be useful to behavioral assessors. This viewpoint has been presented previously, in relation to psychopathology in general (Nelson & Barlow, 1981; Nelson-Gray & Paulson, 2004). Behavioral assessment and psychiatric diagnosis developed on two parallel tracks. Behavioral assessment began informally, as a means of quantifying outcome measures while behavior therapy or behavior modification initially demonstrated its efficacy. The various series of case studies that demonstrated the effectiveness of specific behavior therapy techniques included outcome measures, showing changes in particular target behaviors (e.g., Eysenck, 1976; Ullmann & Krasner, 1965). Even when the case study dealt with a classic diagnosable disorder (e.g., depression), behavior therapists were content with selecting a few salient target behaviors to demonstrate improvements that resulted from behavioral interventions (e.g., very slow speech rate in a chronically depressed man; Robinson & Lewinsohn, 1973). In these early case studies utilizing behavior therapy, no mention was made of formal diagnosis or of changes in covarying behaviors that comprise the diagnostic syndrome. Eventually, behavioral assessment developed as a discipline in its own right, with this stated goal: "The goal of behavioral assessment is to identify meaningful response units and their controlling variables for the purposes of understanding and of altering behavior" (Nelson & Hayes, 1979, p. …