Psychiatric Annals

TREATMENTS REDUCING PERSONALITY DISORDERS 

Treating the Emotional Dysregulation Cluster of Traits

W John Livesley, MB, ChB, PhD, FRCPC

Abstract

Empirical research indicates that a few broad dimensions such as emotional dysregulation, social avoidance and withdrawal, antisocial behavior, and compulsivity underlie the personality disorders.1*3 These dimensions cut across categories of disorder and their occurrence explains the substantial overlap among personality diagnoses. The broadest and probably most prevalent dimension is emotional dysregulation, which represents the extremes of the normal personality dimension of neuroticism.

Although the traits forming these dimensions form the basic scaffolding of personality disorder and the DSM-IV defines personality disorder as maladaptive traits, most current treatments do not discuss specific interventions to treat maladaptive traits. They seem to assume that trait-based behavior can be changed using standard interventions. Specific interventions also seem to be neglected because most treatments focus on either global disorders or specific behaviors. The psychodynamic tradition, for example, largely concentrates psychopathology assumed to underlie specific disorders such as borderline personality and narcissism. Cognitive behavioral approaches on the other hand tend to focus on specific maladaptive behaviors and cognitions. Trait constructs lie somewhere in the middle of this range; they are more general man specific behaviors but more specific than global diagnoses.

There are, however, good reasons for developing strategies to manage maladaptive traits as part of a comprehensive treatment of personality disorder. Traits such as anxiousness, affective lability, and impulsivity influence a range of clinically significant behavior and predispose to Axis I disorders such as anxiety, mood, and substance abuse disorders. A further reason for focusing on traits is that they have a genetic basis. This, along with evidence that traits change little over the adult life span,4 suggests that there may be limits to which traits can be changed using traditional methods. An implication of these findings is that a more productive strategy for managing maladaptive traits would be to help individuals to adapt to their traits and use them effectively rather that attempt to make fundamental changes in the trait stracture of personality.

THE STRUCTURE AND ORIGINS OF EMOTIONAL DYSREGULATION

Factor analyses of personality disorder traits and the diagnostic criteria for DSM personality disorders consistently identify a broad factor variously labeled asthenia and emotional dysregulation.1'3 The factor is typically defined by traits such as anxiousness that includes ruminative worry, guilt proneness, and indecisiveness, and affective lability including instable affects, labile anger, and hypersensitivity. This emotional core is associated with dependency as indicated by submissiveness and insecure attachment, cognitive dysregulation - the tendency for cognitions to become disorganized under stress - and socia] avoidance. The factor is relatively broad and includes traits that cover most DSM diagnoses including the Cluster B diagnoses, dependent personality disorder, and some individuals with more avoidant features. However, the factor most closely resembles borderline personality disorder.

This combination of traits forms a self-sustaining structure. High levels of anxiousness and affective lability reinforce each other and may lead to escalating dysphoric states that culminate in impulsive acts. These qualities also influence the other traits in the cluster. Anxiousness inevitably leads to fearfulness in interpersonal relationships and hence to tendencies to act submissively and to be apprehensive in social situations. At the same time these behaviors are likely to increase emotional arousal. Anxiousness is also likely to exacerbate tendencies for thinking to become disorganized. And, disorganized thinking and information processing is likely to lead to a further reduction in control over feelings and impulses.

There appears to be a strong biological underpinning to these behaviors; the traits defining emotional dysregulation, like all personality traits, are highly heritable. The heritability of the overall cluster is 0.53 and the heritabilities of specific traits are: anxiousness 0.44; affective lability 0.45; submissiveness 0.45; insecure attachment 0.48;…

Empirical research indicates that a few broad dimensions such as emotional dysregulation, social avoidance and withdrawal, antisocial behavior, and compulsivity underlie the personality disorders.1*3 These dimensions cut across categories of disorder and their occurrence explains the substantial overlap among personality diagnoses. The broadest and probably most prevalent dimension is emotional dysregulation, which represents the extremes of the normal personality dimension of neuroticism.

Although the traits forming these dimensions form the basic scaffolding of personality disorder and the DSM-IV defines personality disorder as maladaptive traits, most current treatments do not discuss specific interventions to treat maladaptive traits. They seem to assume that trait-based behavior can be changed using standard interventions. Specific interventions also seem to be neglected because most treatments focus on either global disorders or specific behaviors. The psychodynamic tradition, for example, largely concentrates psychopathology assumed to underlie specific disorders such as borderline personality and narcissism. Cognitive behavioral approaches on the other hand tend to focus on specific maladaptive behaviors and cognitions. Trait constructs lie somewhere in the middle of this range; they are more general man specific behaviors but more specific than global diagnoses.

There are, however, good reasons for developing strategies to manage maladaptive traits as part of a comprehensive treatment of personality disorder. Traits such as anxiousness, affective lability, and impulsivity influence a range of clinically significant behavior and predispose to Axis I disorders such as anxiety, mood, and substance abuse disorders. A further reason for focusing on traits is that they have a genetic basis. This, along with evidence that traits change little over the adult life span,4 suggests that there may be limits to which traits can be changed using traditional methods. An implication of these findings is that a more productive strategy for managing maladaptive traits would be to help individuals to adapt to their traits and use them effectively rather that attempt to make fundamental changes in the trait stracture of personality.

THE STRUCTURE AND ORIGINS OF EMOTIONAL DYSREGULATION

Factor analyses of personality disorder traits and the diagnostic criteria for DSM personality disorders consistently identify a broad factor variously labeled asthenia and emotional dysregulation.1'3 The factor is typically defined by traits such as anxiousness that includes ruminative worry, guilt proneness, and indecisiveness, and affective lability including instable affects, labile anger, and hypersensitivity. This emotional core is associated with dependency as indicated by submissiveness and insecure attachment, cognitive dysregulation - the tendency for cognitions to become disorganized under stress - and socia] avoidance. The factor is relatively broad and includes traits that cover most DSM diagnoses including the Cluster B diagnoses, dependent personality disorder, and some individuals with more avoidant features. However, the factor most closely resembles borderline personality disorder.

This combination of traits forms a self-sustaining structure. High levels of anxiousness and affective lability reinforce each other and may lead to escalating dysphoric states that culminate in impulsive acts. These qualities also influence the other traits in the cluster. Anxiousness inevitably leads to fearfulness in interpersonal relationships and hence to tendencies to act submissively and to be apprehensive in social situations. At the same time these behaviors are likely to increase emotional arousal. Anxiousness is also likely to exacerbate tendencies for thinking to become disorganized. And, disorganized thinking and information processing is likely to lead to a further reduction in control over feelings and impulses.

There appears to be a strong biological underpinning to these behaviors; the traits defining emotional dysregulation, like all personality traits, are highly heritable. The heritability of the overall cluster is 0.53 and the heritabilities of specific traits are: anxiousness 0.44; affective lability 0.45; submissiveness 0.45; insecure attachment 0.48; cognitive dysregulation 0.49; and social avoidance 0.52.5

Environmental Effects

Although traits have a substantial genetic component, environmental factors have an approximately equal influence. An understanding of the way the environment influences the way traits are expressed provides the basis for an approach to change. The environment appears to affect the degree to which a genetic predisposition is expressed. The same genetic loading for a trait such as anxiousness is unlikely to produce the same level of the trait in all individuals. For example, a child with a given genetic predisposition may show less anxiousness if raised by caregivers who help the child to learn ways to manage anxiety and more anxiousness if raised in an abusive environment. The dampening and amplifying effects of the environment suggests that one strategy for managing maladaptive traits is to modulate the degree to which the trait is expressed with biological and behavioral interventions.

The environment also influences the way a trait is expressed. Not all individuals with the same degree of submissiveness, for example, act in the same way. Some ways of expressing the trait will be more adaptive than others. This suggests that a second strategy for managing trait-related behavioral problems is to promote more adaptive trait expression.

A third implication for treatment comes from the realization that trait expression can be modified by environmental factors. Traits require a congenial environment to be expressed. To take an obvious example, sociability can only be expressed in social situations. This suggests that rather than seeking to change traits, we help patients to identify situations and opportunities for them to express their basic tendencies constructively. To convert these ideas into actual interventions we need to understand a little more about the structure of traits.

The Structure of Traits

A complex chain of biological and psychological events links genetic predisposition to actual behavior. IXiring development, genetic predispositions in interaction with the environment establish bio-psychological systems - the biological and psychological mechanisms that underlie trait-based behavior. These structures link information from the environment to overt behavior. The biological component consists of neural networks and transmitter systems. For example, impulsive-aggression appears to be related to the serotonin system.6'7 Psychologically, these structures consist of cognitive-affective processes that influence how events are perceived and initiate response tendencies leading to trait-based behavior. This suggests, at least theoretically, that pharmacological and behavioral interventions may have a role in modifying trait behavior, a contention supported by evidence that the selective serotonin reuptake inhibitors reduce hostility and impulsivity in patients with borderline personality disorder and increase cooperation and decrease angry hostility in normal individuals.8

Behavioral traits consist of cognitions, associated emotions, response tendencies, and overt acts. The cognitive component involves beliefs and expectations that influence trait arousal and expression. For example, the cognitions associated with anxiousness and affective lability consist of beliefs about how threatening the world is, the efficacy with which one is able to deal with threats, and one's ability to tolerate affect and control emotions. These beliefs influence how events are perceived and increase the likelihood that the individual will act in a fearful and emotional way. The actual behaviors involved will differ according to the individuals learning experiences. With affective traits, the emotional component is the salient feature although the cognitive component is still important. With traits such as submissiveness or impulsivity the cognitive component may have greater significance. This structure accounts for much of the stability of traits: the different components reinforce each other. To change maladaptive traits we need to modify this structure. The cognitive component is probably most readily accessible and amenable to cognitive restructuring.

TREATMENT STRATEGIES

Although many interventions are likely to be useful in managing the behaviors and symptoms associated with the emotional dysregulation cluster of traits and their consequences, it is also useful to use interventions designed specifically to address the trait component. Ideas that traits are enduring qualities that the individual has to learn to use adaptively and that the environment influences the range and mode of trait expression suggest four strategies for working with the traits:9 (1) increase acceptance and tolerance; (2) attenuate trait expression through the acquisition of strategies to regulate and control trait-based behavior; (3) promote more adaptive trait expression; and (4) promote the creation of environments that are compatible with the individual's salient traits.

Increase Acceptance and Tolerance

If individuals are to learn how to use their traits adaptively, they need to accept and tolerate these qualities. Although most people are comfortable with their traits, many individuals being treated for personality disorder express considerable dissatisfaction with their personal qualities, so that it is common for anxious patients with labile affects to berate themselves for having these characteristics and spend considerable time wishing that they were different.

Psycho-Education. Tolerance and acceptance may be promoted by explaining that traits are part of the individual's biological heritage while indicating that this does not mean that they cannot be changed. Orange can be presented in terms of working to find ways to reduce the frequency and intensity of trait expression and express traits in ways that do not cause problems. This approach is often motivating because it emphasizes that it is not necessarily necessary to change basic traits but rather to find more useful ways to express them.

Identify Adaptive Features. It is easier to accept one's traits when their potential value is recognized. Most traits evolved because they offered a selective advantage to our remote ancestors. Many of these advantages also apply to the contemporary situation. This suggests that traits are not mtrinsically maladaptive: problems occur because the individual has learned to express them in rigid and maladaptive ways.

Acceptance and tolerance is built by encouraging patients to consider the potential benefits of their traits. With some traits these advantages are readily apparent. Moderate levels of compulsivity, for example, are valuable because modern society needs people who are conscientious, orderly, and attentive to detail. Similar considerations apply to most traits. Even apparently problematic traits such as affective lability and anxiousness may also be useful. Many emotionally labile individuals value the vividness and spontaneity that these qualities bring to their lives and the way that they contribute to creativity. Recognition of these benefits often makes it easier to accept and manage mood changes. One patient who was engaged in a creative profession initially hated her mood swings and ruminated about them in ways that exacerbated the problem. As the swings became less extreme due to other interventions she began to recognize that moderate mood changes contributed to her creativity. As a result she began to use them to generate ideas and feared them less and less· This had a further modulating effect because she no longer thought in ways that increased the intensity of her moods.

Attenuate Trait Expression

This strategy derives from the recognition that environmental factors act by influencing the degree to which a genetic predisposition is expressed. The goal is to reduce the frequency and intensity of trait expression by restructuring the way triggering events are perceived, modifying amplifying factors, teaching skills to regulate and control trait expression by enhancing competing behaviors, and using medication to modulate the expression of specific traits.

Restructuring Triggering Situations. Traits are activated by situations that are interpreted as relevant to the trait. For example, behaviors associated with anxiousness are triggered by perceptions of threat, which suggests that the frequency of anxious behavior would be reduced if fewer threatening situations were encountered.

This can be achieved in two ways. The simplest is to avoid situations that are considered threatening. This happens when trauma leads to avoidance of situations associated with the traumatic events. Although this causes additional problems, there are situations when avoidance may be a useful way to gain control over problem behavior. For example, patients with strong needs for stimulation and excitement engage in maladaptive thrill seeking because they seek out situations with extensive opportunities to act in this way. Hence early in treatment it may be useful to draw attention to person-environment interaction and encourage patients to avoid such situations until more control is acquired.

More lasting attenuation in trait expression is achieved by helping patients reframe the way triggering situations are perceived. Instead of interpreting a wide range of situations as relevant to a given trait, some situations may come to be seen differently. For example, individuals with high levels of anxiousness may learn to see previously threatening situations as less threatening by challenging and restructuring catastrophic thinking. Or individuals who are highly sensitive to rejection may be helped to recognize that many of the situations that they perceived as indicative of rejection can be understood in different ways. In effect, the patient learns to be more discriminating in the way situations are perceived.

Modifying Amplifying Cognitions. Extreme and frequent expression of affective traits such as affective lability and anxiousness often occurs because emotional arousal activates thinking that amplifies distress. Patients often rununate about problems or events that evoke strong feelings and undermine coping with catastrophic thinking or telling themselves that they cannot tolerate these feelings, that these things should not happen, and that life is unfair. More adaptive responses would be to use problem solving to resolve the situation or distraction and self-sootning to reduce distress. Anxiety and dysphoria may be modulated by restructuring these thoughts and by helping the individual to develop self-soothing skills.

Similar maladaptive thoughts increase the frequency of expression of other traits. For example, the submissive individual may use a variety of automatic thoughts that increase the probability of acting submissively or undermine the ability to be assertively. Ought and should statements such as "I ought to help people if they ask" or "I should always try to take care of people" increase the chances of acting submissively. A similar situation occurs when the individual is afraid of the consequences of refusing even unreasonable requests because of a fear of retaliation and the other person being angry. Statements such as "I cannot cope with people being mad at me" or "It's not nice to get people mad" undermine attempts to be assertive. A reduction in submissiveness requires changes to these dysfunctional thoughts. Other traits in the emotional dysregulation cluster, such as social apprehensiveness, involve similar modes of thought that increase maladaptive responses.

Enhancing Incompatible Behaviors. The example of submissiveness raises the possibility of modulating trait expression by promoting the development of incompatible or complementary behavior, in this case by teaching assertiveness skills. People rely on trait-based behaviors when they lack the skills required to act differently. Submissive individuals can be taught assertive behaviors that do not cause additional interpersonal problems. Similar opportunities exist for modulating social apprehensiveness through social skill training and teaching interpersonal communication skills. Finally, relaxation training may also be considered a way to teach alternative responses to stressful situations that are incompatible with strong emotions.

Medication. Medication may be useful in modulating some traits and associated symptoms.10"12 A rationale is provided by evidence that specific neurotransmitter systems mediate trait expression6 and medication modifies trait expression in normal individuals.8 Two components of emotional dysregulation are potential targets for pharmacological intervention: (1) the emotional core of affective lability and anxiousness and the impulsive behavior that is often associated with intense dysphoria; and (2) cognitive dysregulation.

The selective serotonin reuptake inhibitors are usually recommended as first line agents to treat affective lability.11'12 The evidence suggests that aggression, irritability, impulsivity including selfharming behavior, and mood symptoms respond to these agents. It is less convincing that they affect affective lability per se. Although most studies have been conducted on borderline personality disorder, there is no reason to assume that affective features associated with other personality patterns will not respond to the same agents.

There is perhaps stronger evidence of the benefits of neuroleptics in treating the quasi-psychotic symptoms and other perceptual and cognitive symptoms associated with cognitive disorganization. Again most studies have been conducted on patients with borderline personality disorder. Low doses of these agents are useful in managing the perceptual-cognitive features of cognitive disorganization, namely confused and disorganized thinking, transient psychotic episodes, and quasipsychotic features such as paranoid ideation and pseudo-hallucinations.nAl Low doses of atypical neuroleptics may also be useful in managing hypersensitivity, a trait that is often associated with affective lability. Many patients feel overwhelmed by any form of stimulation, including experiences, feelings, and everyday events. This sensitivity leads to strong reactions to events that increase reactive behavior, leading to further affective distress. A low dose of an atypical neuroleptic often helps to dampen hypersensitivity sufficiently for patients to reflect on their experiences rather than struggle to contain them. For more details on medication in the management of maladaptive traits and personality disorder see Reich, "Drug Treatment of Personality Disorder Traits," (page 590).

Promote More Adaptive Trait Based Behavior

A third strategy for treating emotional regulation is to replace maladaptive responses progressively with more adaptive alternatives. The strategy is based on the idea that the environment influences the behaviors through which a trait is manifested. These changes are achieved through interventions to challenge and modify the maladaptive schemata that contribute to maladaptive expressions of traits and strengthening more adaptive schemata and behavior.

The acquisition of more adaptive trait-based behavior requires modification to maladaptive schemata that mediate maladaptive behavior using cognitive interventions. Clinically significant traits are identified and the maladaptive schemata associated with these traits are explored and challenged.

Change is more likely to be achieved when restructuring of maladaptive schemata is combined with behavioral change. Maladaptive dependency behavior, for example, may be approached in this way. In fact, most treatments do this without explicitly acknowledging the process. Dependency incorporates two separate behaviors: anxious attachment and submissiveness. These traits involve feared loss or separation from attachment figures and caregivers, problems with assertiveness, subservience, and need for advice and reassurance. These traits are strongly associated with the emotional dysregulation pattern although they may occur in the absence of extreme scores on other traits defining the pattern as occurs with DSM-FV dependent personality disorder.

For these patients, crises including self-harm often serve multiple functions, including satisfying the need for care and support. Although some clinicians are tempted to respond in a way that does not satisfy these needs, an approach based on the recognition that these needs are grounded in heritable traits would adopt a graded approach to change in which the patient would be encouraged to find progressively more adaptive ways to meet these needs. This may start by encouraging the patient to seek help before a full-blown crisis state develops. To do this it may be necessary to restructure such beliefs as: "People have to be coerced to provide help," 'Tt is not possible to ask for help directly/' and "I should not need help." It also involves helping patients to identify more effective ways of getting the care and attention that they think they need. It will also be recognized that there are also opportunities here to challenge ideas that they cannot manage alone and hence modulate the frequency of trait expression.

Modification in behavior may involve changing how patients ask for help in crises by telling someone close to them that problems are brewing, and asking for support. Later in treatment, the relationship between these traits and episodes of abuse and victimization may be explored to help the patient recognize how dependent careseeking behavior may lead to abuse. This provides further opportunities to learn how to seek help and reassurance in ways that elicit collaboration rather than control and do not leave the patient open to exploitation. These dependency behaviors often include the need to look after others. Again rather than relinquish the need to help others, the patient may learn how to do this without neglecting his or her own needs and in ways that enhance self-worth rather than diminish it.

Select and Create Conducive Environments

A final strategy for managing maladaptive traits is to help individuals to find or create environments that allow them to express their basic traits in adaptive ways and to make constructive use of their personality characteristics. The idea of modifying the environment to match the individual's personality differs from the emphasis that psychotherapy usually places on helping people to adjust to their environment. Although most interventions discussed thus far also focus on changing maladaptive behavior and the internal structures and processes that contribute to these acts, it is also useful to help individuals to select environments that support adaptive rather than maladaptive action and to create life styles and personal worlds that allow them to express their personality in ways that are rewarding and fulfilling.

Although more adaptive behavior may be increased by avoiding some situations and seeking out others, the environment has a more fundamental influence on behavior and personality. Much of the consistency and coherence of personality is maintained by external structures in the environment. These structures were initially shaped by personality processes; once established, however, they support and maintain the individual's characteristic behavior patterns. Hence an important part of helping patients to forge a more coherent sense of self is helping them to create personal worlds that are coherent with their personality.

Some therapists may disrniss this idea as too supportive or simply social engineering. However, the approach is a natural consequence of empirical studies of the stability of personality and an understanding of the way individuals create environments that are conducive to their personality. People do not just respond passively to the environment but rather shape and create the manimate and animate environment to which they relate. Willi refers to this aspect of the environment as the personal niche.13 Once established, the niche provides the structure that organizes action and the opportunity to express and satisfy various abilities, interests, needs, and traits. We can think of the niche as a structure in the environment that people create over time that sustains and nurtures their interests, offers opportunities to express their basic nature, and provides opportunities for fulfillment and growth.

When individuals have extreme levels of a trait or lack the resources for extensive therapeutic work, radical change is difficult to achieve. Under these circumstances we may need to think about how to help them to find a life situation that is rewarding. This may involve helping highly labile individuals to find supportive situations and relationships that do not trigger the extremes of emotional expression but rather contain their reactivity. Similarly, individuals at the extremes of dependency and submissiveness who feel obliged to submit to other people's demands may need help finding situations that allow them to express these traits without be exploited or overwhelmed, as in this vignette:

Mary was in early middle age when she sought treatment for long-standing depressive symptoms and selfmutilation that were part of an emotional dysregulation pattern that included strong dependency and submissiveness leading to frequent demands for care and attention and a powerful need to care for others. Over the years, she had spent most of her time caring for lier aging parents, her own large family, and her even larger extended family. These traits and their associated behaviors became entrenched and she saw herself as someone who never said no and was always available to help. The sense of caring for others was an important part of her identity that contributed to self-esteem. It was not something that she wanted to change radically, although she recognized that compulsive care giving contributed to dysthymic symptoms.

Altlwugh Mary went spent considerable time and effort meeting her family's needs, she ivas made to feel a failure and that she was selfish and uncaring. At times, she felt exhausted by their demands but always felt that she should respond. On these occasions, her moods became unstable and site often engaged in parasuicidal acts. In therapy, Mary began to understand the nature of her dependency and submissiveness and how these traits increased the problems ioith affective lability and anxiousness. She also recognized how her actions contributed to her mood symptoms and feelings of worthlessness. However, she did not think that she could change these behaviors. She thought they were an important part of her nature and she valued the way she was able to help people and the way everyone turned to her for help. Attempts were made to modulate the intensity of the care giving and submissiveness using some of the methods discussed earlier but it was also recognized that there were limits to which change could be achieved because these traits were well established and Mary was not motivated to change them extensively. Attention focused on helping iter to find situations that allowed her to care for others in a more controlled and contained manner that did not lead to her becoming exhausted. She began volunteering to assist at residential homes far the elderly and found this activity satisfying. The work also placed constraints on the amount of spent care giving. Eventually, site began working in the residence on a part-time basis. This increased her sense of self-worth and allowed her to feel that she could refuse to more unreasonable demands of her family because site was working taking care of needy people.

Mary was helped to create a personal niche that allowed her to express highly submissive and dependent traits and a compulsive need to care for others in more adaptive ways. The vignette also illustrates that rather than seeking change to bring about major changes in maladaptive traits, it may often be more useful to think it terms of helping individuals use these traits more effectively. The creation of personal niches that are containing and rewarding is especially important in managing vulnerable individuals and those with traits at the extremes of range of variation with limited capacity for change.

CONCLUSION

When treating patients with personality pathology is it useful to complement traditional approaches with a specific focus on maladaptive traits. Traite are an organizing construct in personality. They have a similar role in treatment in that they focus attention on specific problems. The trait approach also offers an alternative perspective on treatment by acting as a reminder of the limits of change and the value of thinking about ways to help individuals to use their personalities constructively rather than simply focusing on changing them.

When maladaptive traits such as the emotional dysregulation cluster are part of a clinical presentation of personality disorder, specific interventions to manage and modulate maladaptive traits need to be used in the context of careful attention to the treatment relationship and the establishment of a collaborative alliance. Without this foundation, the intervention strategy is likely to be of limited benefit.

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10.3928/0048-5713-20021001-08

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