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Sorting Out the Storms. Differentiating Personality Disorders Among Sex Addicts and Co-Addicts Kenneth M. Adams, Ph.D., CSAT The Challenge.

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sorting out the storms

Sorting Out the Storms

Differentiating Personality Disorders Among Sex Addicts and Co-Addicts

Kenneth M. Adams, Ph.D., CSAT

the challenge
The Challenge
  • Underlying personality disorders (PD) influence responsiveness to treatment and capacity for taking responsibility and rebuilding trust
  • Need to differentiate PD for sex addiction (SA)
  • Many sex addicts have underlying personality disorders
  • Different manifestations of SA occur due to the particular PD
the challenge continued
The Challenge Continued
  • Each PD has a different “emotional agenda” that is encoded in the sexual behavior
  • Inconsistent treatment outcomes occur when the addiction model is applied to all cases has if they were the same
  • Co-addicts also differ in treatment outcomes depending on their own underlying PD
  • Must differentiate PD’s from PTSD in co-addict
personality disorders
Personality Disorders
  • Deeply embedded pattern of psychological characteristics- PD’s are “stuck” in traits
  • Largely unconscious, cannot be eradicated easily
  • Biology (temperament) and attachment experiences produce patterns
  • Traits ego-syntonic- feel familiar, personal & normal-therapist and client often differ on goals
  • Traits wax and wane under stress (Mays, 2009)
  • DSM IV vs DSM V, use of SDI
  • Will review NPD and ASD, addicts/DPD and BPD co-addicts and differential diagnosis
  • Emotional agenda and transference and counter transference issues addressed
  • Movie clips – warning!
narcissistic personality disorder
Narcissistic Personality Disorder
  • Entitlement
  • Overvaluation of self (extreme grandiosity)
  • Exhibitionism
  • Interpersonal exploitation
  • Cognitive ineffectiveness
  • Ethics zeal
  • Rage and emptiness in response to criticism
  • Devaluation and idealization (Mays, D. 2009)
narcissistic sex addicts
Narcissistic Sex Addicts
  • Emotional agenda: to be adored and center of attention
  • Insatiable need for admiration and reassurance of their fragile self
  • Sexually compulsive to act out entitlement to the attention, recognition, and validation they crave
  • Sexual gratification is temporary, expect special treatment
  • Seductive role sex, paying for sex-power, trading, exploitive sex –trust
  • Loyalty is to self, others are sexually expendable
  • Not aware of others, will exploit sexually (unaware)
differential diagnosis
Differential Diagnosis
  • NPD SA’s display compulsive cycle and some remorse/distress vs. those with NPD only, lack evidence of cycle, use others as needed
  • High functioning vs. fragile vs. grandiose/malignant narcissist
  • HPD, BPD, and ASD lack extreme grandiosity
  • NPD not as reckless, criminal, impulsive, self-abusive, or afraid of abandonment
  • OCD are perfectionist, NPD believe they are “prefect”
  • Relationship seeking? Yes, when insecure. Treatment seeking? Yes, when injured (Mays, D., 2009)
  • Strong idealized transference of the perfect therapist (shopping around), expect same in return
  • May withdraw angrily if not reciprocated
  • Therapist may idealize in their counter – transference and fail to confront
  • Therapist may mistake grandiosity as stability and interpret too quickly
  • Need long term relationship to be able to gently confront
  • Focus on entitlement, grandiosity, and lack of recognition of others
  • Role-play empathy, amends, 12 steps very helpful here
antisocial personality disorder
Antisocial Personality Disorder
  • Preoccupation with CONTROL (getting “over” on people), insist on being right, rarely concede
  • Aggression, anticipate hostility, easily provoked
  • Rebelliousness
  • Predatory behaviors
  • Deceit
  • Lack of remorse
  • Achievement (Mays, D, 2009)
other apd traits not in dsmiv
Other APD Traits not in DSMIV
  • Lack of empathy
  • Externalization of blame
  • Imperviousness to consequences
  • Sadism
  • Tendency to manipulate others’ emotions (Schedler, 2004)
psychopathy hare 1993
Psychopathy (Hare, 1993)
  • Aggressive narcissism
  • Chronic emotional detachment
  • Chronic lying
  • Asocial
  • Cognitive problems
  • Psychopaths differ from APD DSM-IV in that APD is described in terms of behaviors, psychopaths have core traits of extreme self-centeredness, exploitation, indifference to others’ feelings, willingness to hurt others for one’s own purpose (Stone in Mays)
antisocial sex addicts
Antisocial Sex Addicts
  • The sexually addicted APD are concerned with sexual power
  • Often sexually exploitive and have substance abuse issues
  • Paying for sex-commercial, exploitive sex-trust, children, and force, seductive role sex
  • Lack empathy and remorse
differential diagnosis1
Differential Diagnosis
  • Most addicts lie, may show lack of remorse – must wait for period of abstinence and elimination of double life to determine APD
  • NPD glib, superficial, exploitive but not usually aggressive or history of conduct disorder
  • Borderline manipulative, but to gain nurturance
  • Psychopaths not typically impulsive or aggressive, also more aggressive narcissism in psychopaths
  • Not treatment seeking, not relationship seeking except to exploit
  • Make sure treatment isn’t being used to placate
  • APD are always trying to control therapy
  • ABD will want therapist to advocate for them
  • Therapist may offer nurturance rather than limits
  • Firm, rigid limits needed, treatment team must work together
  • Poor treatment outcomes, 12-step may help
other personality disorders and sexual addiction
Other Personality Disorders and Sexual Addiction
  • OCD- emotional agenda is wanting to know correct way and avoid blame, moralistic about sexual matters, prone to shameful acting-out (submission-domination, pain exchange, paying for sex commercial)
  • Avoidant PD (social anxiety)- emotional agenda is to avoid being hurt, rejected at all costs, prone to cybersex, fantasy-masturbation, teen sites
other personality disorders and sexual addiction continued
Other Personality Disorders and Sexual Addiction Continued
  • Histrionic PD- emotional agenda is to illicit care from powerful person by being attractive, entertaining, ill, prone to flirtation, fantasy, masturbation, little follow thru
  • Dependent PD- emotional agenda is to assure love and protection from powerful person at any cost by being submissive, prone to excessive fantasy, masturbation, seductive role sex, excessive dependency, female SA’s
dependent personality disorder
Dependent Personality Disorder
  • Need for attachment
  • Dependency on approval
  • Submissiveness and feelings of inadequacy
  • Depressive affect
  • Naïve and uncritical (Mays, D., 2009)
dpd co addict
DPD Co-Addict
  • Struggle to take care of self in face of betrayal
  • Naively believe lies and rationalizations
  • Can declare more loyalty and devotion in the face of hurt
  • May resist treatment if putting relationship “on the line” is called for implicitly or explicitly
  • Will enable addict, submissive at times
  • Shows history of dependency in other relationships
  • Will organize around victim feelings and fail to acknowledge their attachment to having someone powerful “take care” of them
differential diagnosis2
Differential Diagnosis
  • DPD emotional agenda is to have a powerful person take care of them because they are unable to care for themselves- “if I’m submissive, I will be nurtured and taken care of “
  • Definitely relationship seeking
  • Avoidant PD feel inadequate and need reassurance, but more skittish about attaching and becoming dependent
  • Borderlines rage, DPD submit
  • Sex addiction cycle must be present for SA diagnosis
  • Co-addict who do not have underlying DPD will show initial dependency but will be able to rally and declare and back up non-negotiables
  • Treatment seeking, therapist may mistake compliance with agreement
  • Compliant, see therapist as powerful, can create dependency on therapist
  • Therapist needs to encourage independence on part of client
  • Submissiveness may give false appearance of treatment alliance (Mays)
  • Addicts will struggle to surrender their attachment to addiction
  • Co-addicts will struggle to create non-negotiables and to give up relationship to addict if needed, go slow
  • Therapists must show self care (keeping time, etc.)
borderline personality disorder
Borderline Personality Disorder
  • Affective instability
  • Behavioral difficulties
  • Cognitive problems
  • Co-morbidity
  • Treatment seeking
bpd sex addicts
BPD Sex Addicts
  • Emotional agenda is to the search for the perfect union with someone that will finally meet all their needs for nurturance, dependency, and support with sexual acting-out organized around this
  • Multiple partners, promiscuity, pain exchange, submissive-domination, compulsive masturbation, trading sex, paying for sex-commercial, exhibitionism (dancing), other
  • Sex is used to reward and punish regarding issues of attachment, separation, and abandonment
  • Sexually impulsive
  • Act outside of orientation for increased high
bpd co addict
BPD Co-Addict
  • Emotional agenda is to the search for the perfect union with someone that will finally meet all their needs for nurturance, dependency, and support
  • Prone to seduction by exploitive or calculating seducer
  • Extreme reactivity and dysregulation in face of betrayal- punishing, abusive
  • “Cluster” memory disturbance- “injustice collecting” in attempt to protect
  • Reactivity persists in face of addicts recovery well over one year
  • Common therapist error is to mistake BPD for acute PTSD and encourage anger and victimizing assimilation as the only focus of treatment, can over use trauma model
differential diagnosis3
Differential Diagnosis
  • Most co-addicts have some degree of PTSD and look like BPD, must use history for BPD diagnosis
  • BPD will often have multiple addictions
  • Rule out mood disorder
  • Histrionic shows attention seeking, but not self destructiveness
  • Dependent will also fear abandonment but become submissive rather than enraged
  • Definitely relationship seeking
  • Idealization of therapist followed by disillusionment and increasing demands, manipulation, threats
  • Containment of reactions on part of client and therapist
  • Firm boundaries
  • Assess suicide potential-if acute, hospitalize
  • Psychiatric evaluation
  • 12 step groups may be helpful
  • Therapist must not overindulge anger or victimized feelings in wake of betrayal
  • Discourage rehearsal of past wounds
  • Therapist own trauma may complicate and prejudice
treatment prognosis of personality disorders
Treatment Prognosis of Personality Disorders
  • According to Mays, those most amenable (which doesn’t guarantee outcome) are: BPD, OCD, DPD, Avoidant
  • Untreatable PD’s: Salvageable- APD with good character and arrogant NPD; Unsalvageable-Psycopathy with narcissism, Sadistic APD
treatment markers of long term compliance and change
Treatment Markers of Long – Term Compliance and Change
  • Takes responsibility
  • Shows empathy
  • Authentic remorse
  • Reflective
  • Committed to treatment w/o leverage
  • Values personal growth over image management
  • Humility
  • Committed to course greater than self