Cluster A

Patients diagnosed with Cluster A disorders are least likely to benefit from therapeutic interventions based upon their behavioral styles, which often involve greater isolation and higher levels of what might be termed "eccentric" behavior. Therapy to them might seem very threatening and be interpreted as an invasion of privacy (Beck et al., 2004; Magnavita, 1997; Millon, 1999; Millon & Davis, 2000).

Schizoid PD and Schizotypal PD

There is little evidence of co-occurring Axis I disorders among patients diagnosed with schizoid PD (SPD), because most of these patients display few emotions and prefer few, if any, interpersonal relationships (Beck et al., 2004; Magnavita, 1997; Millon, 1999; Millon & Davis, 2000). Much of the behavioral and cognitive pattern of the individual with SPD parallels that of depression. They have a "profound defect in the ability to form social relationships and an underresponsiveness to all forms of stimulation" (Millon, 1999, p. 283). Furthermore, Millon states, "They tend to choose interests and vocations that will allow them to maintain their social detachment" (p. 283). The significant difference is that for the individual with SPD, the pattern is a way of life, whereas for the depressed patient, it is an interruption in life.

Dan, age 68, met the criteria for SPD but came to therapy having self-labeled himself as "depressed." He had sought therapy over the past 40 years for periods ranging from 6 months to 7 years. Dan claimed that the therapy helped him, but he was unable to describe what help he gained in the therapy(s). Over the years he had taken a broad range of antidepressants with no effect. One therapist labeled him as having "untreatable depression." It was clear that Dan's personality problems were the core of his view of his own depression. When his most recent therapist asked Dan whether he had ever heard the term "schizoid," Dan said that he had not. The treatment question was whether this approach would be helpful or open a can of worms. Could Dan's depression possibly be addressed without addressing the schizoid personality pattern? The therapist decided that it would be useful to open this particular can of worms. He shared the DSM criteria with Dan and discussed the nature of personality styles and disorders. Dan sat with DSM-IV-TR on his lap and read and reread the entry. He responded, "That's me. That is surely me. So all of these years it wasn't my fault that I couldn't get rid of my depression. They [previous therapists] were treating my broken leg by trying to put a cast on my arm." Dan could identify the problems he wanted to deal with by differentiating between the depression and SPD.

Similar to SPD, the inability to relate to others and the interpersonal problems associated with schiozotypal PD (SchPD) contribute to overall depressive symptoms (Beck et al., 2004; Magnavita, 1997; Millon & Davis, 2000). The SchPD pattern, which is the most eccentric of the group, can often mask the depression, whereas the depression can exacerbate the eccentricity of the individual with SchPD. The depressive has what might be termed a "minor thought disorder," wherein the individual misinterprets his/her reality. For example, the individual may strongly believe, "Nobody likes me," regardless of data to the contrary. The individual with SchPD may have ideas of reference relating to the motives, actions, or thoughts of others.

Paranoid PD

The patient with paranoid PD (PPD) is similar to both the patient with SPD and to that with SchPD. Depression is common among paranoid patients, as they tend to have low self-esteem and use fear responses and behaviors as a means to cover up depression (Millon & Davis, 2000). As a means of coping with their fears, patients with PPD typically isolate themselves when they feel shame and humiliation. These perceptions then contribute to the overall depressive state and the depressive-like pattern (Beck et al., 2004; Magnavita, 1997; Millon, 1999; Millon & Davis, 2000). The members of this diagnostic group rarely choose to seek therapy, inasmuch as they have strongly held beliefs regarding the untrustworthiness of others. The very idea of unburdening themselves to another person is antithetical to their deepest core beliefs. They are often referred by family members, or by an employer within the context of an employee assistance program.

Lester Jensen was referred for five "counseling" sessions because of his "constant down mood and problems getting along with his coworkers." He had worked in the same drafting room at an architectural firm for the past 7 years. There were six other men who worked in the room. Mr. Jensen insisted on being addressed formally by his coworkers and stated that he was "not friends with any of the people at work." He sat with his drafting table facing the wall, so that he would not have to see the other men. "I know that they talk about me. They make fun of me. They steal my ideas, so I tell them off on a regular basis." He also was clear that he would not be self-disclosing with the therapist, as he knew that the therapist was going to tell the managers at his firm everything that was said in the sessions. The therapist took the tack that there were ways that Mr. Jensen could get these people off of his back, so that he could have his privacy. The therapist used the five sessions to outline specific behaviors that Mr. Jensen could perform that might have the effect of keeping others at bay and maintaining his privacy (and safety), without injuring his position at work.

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