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Social and therapeutic environments such as day hospitals, halfway houses, and self-help communities utilize peer pressures to modify the self-destructive behavior The patient with a personality disorder often has failed to profit from experience, and difficulties with authority impair the learning experience The use of peer relationships and the repetition possible in a structured setting of a helpful community enhance the behavioral treatment opportunities and increase learning When problems are detected early, both the school and the home can serve as foci of intensified social pressure to change the behavior, particularly with the use of behavioral techniques

The behavioral techniques used are principally operant conditioning and aversive conditioning The former simply emphasizes the recognition of acceptable behavior and its reinforcement with praise or other tangible rewards Aversive responses usually mean punishment, although this can range from a mild rebuke to some specific punitive responses such

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Personality Disorder Paranoid Schizoid Obsessivecompulsive Histrionic (hysterical) Schizotypal Narcissistic Avoidant Dependent Antisocial Borderline Clinical Findings Defensive, oversensitive, secretive, suspicious, hyperalert, with limited emotional response Shy, introverted, withdrawn, avoids close relationships Perfectionist, egocentric, indecisive, with rigid thought patterns and need for control Dependent, immature, seductive, egocentric, vain, emotionally labile Superstitious, socially isolated, suspicious, with limited interpersonal ability, eccentric behaviors, and odd speech Exhibitionist, grandiose, preoccupied with power, lacks interest in others, with excessive demands for attention Fears rejection, hyperreacts to rejection and failure, with poor social endeavors and low self-esteem Passive, overaccepting, unable to make decisions, lacks confidence, with poor self-esteem Selfish, callous, promiscuous, impulsive, unable to learn from experience, has legal problems Impulsive; has unstable and intense interpersonal relationships; is suffused with anger, fear, and guilt; lacks self-control and self-fulfillment; has identity problems and affective instability; is suicidal (a serious problem up to 80% of hospitalized borderline patients make an attempt at some time during treatment, and the incidence of completed suicide is as high as 5%); aggressive behavior, feelings of emptiness, and occasional psychotic decompensation This group has a high drug abuse rate, which plays a role in symptoms There is extensive overlap with other diagnostic categories, particularly mood disorders and posttraumatic stress disorder

as deprivation of privileges Extinction plays a role in that an attempt is made not to respond to inappropriate behavior, and the lack of response eventually causes the person to abandon that type of behavior Pouting and tantrums, for example, diminish quickly when such behavior elicits no reaction Dialectical behavioral therapy is a program of individual and group therapy specifically designed for patients with chronic suicidality and borderline personality disorder It blends mindfulness and a cognitive-behavioral model to address self-awareness, interpersonal functioning, affective lability, and reactions to stress

Hospitalization is indicated in the case of serious suicidal or homicidal danger In most cases, treatment can be accomplished in the day treatment center or self-help community Antipsychotics may be required for short periods in conditions that have temporarily decompensated into transient psychoses (eg, haloperidol, 2 5 mg orally every 3 4 hours until the patient has quieted down and is regaining contact with reality) Olanzapine (25 10 mg/d) or risperidone (05 2 mg/d) may be given with lorazepam (1 2 mg orally every 4 hours as needed) In some cases, these drugs are required only for several days and can be discontinued after the patient has regained a previously established level of adjustment; they can also provide ongoing support Carbamazepine, 400 800 mg orally daily in divided doses, decreases the severity of behavioral dyscontrol Antidepressants have improved anxiety, depression, and sensitivity to rejection in some borderline patients SSRIs may have a role in reducing aggressive behavior in impulsive aggressive patients

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