Personality Disorders in Spouses
A major goal in married life is maintain a healthy personality for our spouses and our children. Happy and fulfilling marriages are dependent upon each spouse engaging in the hard work of honestly facing character weaknesses and then growing in virtues to overcome them. These weaknesses can be so strong, such as selfishness, excessive anger, controlling behaviors, insecurity and difficulty in trusting others, that grace is also necessary in order to master them.
We need courage here, not only to work on our own weaknesses, but also to ask spouses do so for the good of our marriages and our children. This chapter will present what can occur when there is failure to work adequately on developing a healthy personality in childhood, adolescence and adult life by growth in virtues, that is, a personality disorder can develop.
These personality disorders can play a significant role in the later development of major psychiatric disorders in adults and youth which is why it is so important to form our children in virtues.
Now, please be careful here in reading this chapter, because the identification of various personality weaknesses does not necessarily mean that your spouse or you have a full blown personality disorder.
A personality disorder (PD) can create significant conflicts within a spouse, marriage and family. This chapter will present information on PDs and on the important role of forgiveness in resolving the excessive anger, difficulty in trusting, fears and profound sadness from childhood emotional "wounds" with one or both parents that is present in most of these spouses. An exception would be those with a narcissistic disorders. The resolution of their anger is essential to the stabilization of the mood in these spouses.
Let's look now at a brief history of a spouse with a PD.
Louise, a 40 year old married mother with two children, had been in therapy for many years with a number of mental health professionals for the treatment of anxiety, depression, unstable interpersonal relationships, intense fears and mistrust, a poor sense of self and intense attack with episodic explosive episodes. She had been sexually abused in her latency years by an uncle and had been physically and emotionally abused by an older brother. In addition, she had felt neglected emotionally by her parents who divorced during her adolescence. She had great difficulty in mastering her anger, fears of betrayal and severe mistrust that led her to regularly overreact in anger toward her husband, Seth. She was diagnosed with a borderline personality disorder. Her difficult and demanding healing journey will be described.
We will look at the prevalence and the role of anger in what are referred to as cluster A, B and C personality disorders (PDs). In these disorders difficulties with excessive anger has been well documented both in research studies and in clinical experience. The lengthy and challenging process of helping spouses to master and resolve their angry feelings, impulses, and ideation, which lead to significant stress and impairment, will be described in this chapter. The effectiveness of psychotherapy for personality disorders has been demonstrated (Perry, J.C., et al., 1999) The use of forgiveness can enhance the healing process. The uses of the four phases of forgiveness therapy in spouses with PDs will be described.
Anger in Personality Disorders
Many personality disorder (PD) spouses have conflicts with poor impulse control, episodes of aggressive behavior, and anger attacks ( Fava, M., et al., 1993; Gould, R., et al., 1996 Millon, T. 1996), especially those within cluster B (borderline, histrionic, antisocial, and narcissistic PDs) and cluster C (avoidant, dependent, and obsessive-compulsive PDs). However, cluster A and B PDs are also, at times, associated with violent impulses and acts of aggression. The difficulty with self- and other- directed impulsive aggression in spouses with schizotypal and paranoid PD, borderline and histrionic PD, obsessive-compulsive PD, avoidant PD and antisocial PD has been attributed to reduced central serotonergic function (Coccaro, E., 1989).
Selective serotonin reuptake inhibitors (SSRI) and other medications have been shown to reduce the impulsive aggressive behaviors seen in spouses in all three personality disorder clusters (Coccaro, E., et al, 1997).
Several studies have examined co-morbidity between personality disorders and what are referred to a axis I disorders, such as depression and anxiety. Oldham, J.M., et al., (1995) reported that mood disorders co-occurred significantly with avoidant PD and anxiety disorders co-occur with borderline PD and dependent PD. Substance abuse disorders co-occur with borderline, sociopathic and histrionic personality disorders. Eating disorders co-occur significantly with personality disorders in all three clusters (schizotypal, borderline, and avoidant). Unipolar depressive disorder has been reported to co-occur with borderline, dependent, and avoidant personality disorders (Jackson, H.J., et al., 1991). Other research has shown a strong connection between substance abuse and antisocial personality disorder (Koenigsberg, H.W, 1985) and between restricting anorexics and obsessive-compulsive PD and between normal-weight bulimia and histrionic PD (Wonderlich, S.A., et al., 1990.)
Spouses with narcissistic PD and dependent PD regularly overreact in anger and aggressive behaviors when their needs are not met immediately or when they face frustrations and stresses in their lives. In marked contrast to other PD spouses, individuals with these two personality disorders often do not have significant unresolved parental anger from childhood and adolescence which is misdirected later. They manifest little empathy or understanding for others, resent giving themselves emotionally, and are obsessed with controlling their spouse and other important people in their lives. The dependent PD individual often seeks to accomplish the latter by embracing the victim/sick role.
In our clinical experience passive-aggressive anger, which is the rather sneaky covert expression of anger through irresponsibility, refusal to give oneself, lack of a cooperative attitude and silent treatment, are frequently seen in histrionic, dependent, narcissistic, and borderline PD spouses.
Louise regularly overreacted in anger to minor stresses in married and family life. Her husband, Seth, noted that her anger was often triggered when she needed to be vulnerable to others in the family, friendships and community. Slowly, he came to recognize that her traumatic childhood betrayal experiences in her childhood had made her fearful of further betrayal and that, at times, she used her anger and episodic explosions to keep others at a distance and to try to control him.
Many spouses with personality disorders report histories of childhood neglect or abuse as occurred in Louise's life. In one study persons with documented childhood abuse or neglect were shown to be more than 4 times as likely as those who were not abused or neglected to be diagnosed with personality disorders in all clusters during early adulthood (Johnson, 1999). Childhood disruptive disorders, anxiety disorders and major depression increase significantly the odds for the development of a young adult personality disorder (Kasen, 1999). Childhood conduct problems are an independent predictor of adolescent personality disorders in all three clusters (Bernstein, , 1996). Adolescents with personality disorders have been shown to be more than twice as likely as those without personality disorders to have disruptive and substance abuse disorders during early adulthood (Johnson, , 1999).
Husbands with avoidant personality disorders often have significant weaknesses in confidence often arising from a lack of affirmation from their fathers..
The excessive anger in PD spouses manifests itself early in life as conflicts in interpersonal relationships, extreme and inappropriate affectivity, impaired cognition with thoughts of revenge, and poor impulse control. In most personality disorders there is significant unresolved anger from childhood and adolescent experiences of parental neglect and abuse, especially in the borderline PD ( Zanarini, M.C., 1997).
The resolution of the anger from past disappointments and hurts resulting from neglect and abuse through the use of forgiveness can be beneficial in stabilizing the impulse control, interpersonal functioning, affectivity, and cognition in these individuals. Since the treatment of axis I conditions, such as major depression and anxiety, is often complicated by axis II personality disorders, (Reich & Green, 1990; Reich & Vasile, 1993), the resolution of the excessive anger in PD spouses can assist in the healing of their depression, anxiety and compulsive behaviors.
Cluster A Personality Disorders - Paranoid, Schizoid, and Schizotypal
Spouses with cluster A personality disorders demonstrate great difficulty in trusting, detachment, and acute discomfort in close relationships often as a result of betrayal experiences in childhood, adolescence, and adulthood. These paranoid, schizoid, and schizotypal PD spouses can be so mistrustful and defensive that they have great difficulty in admitting their anger with the exception of the paranoid client. The DSM - IV classification describes the paranoid PD client as someone who bears grudges, that is, is unforgiving of insults, injuries, or slights. Millon (1996) has described the resentment and hostility in the paranoid PD. Initially these spouses, except for the paranoid PD, do not appear to be angry. However, these individuals often harbor violent impulses for revenge against those who victimized and offended them. Under certain types of stress these isolated and withdrawn individuals can erupt in intense anger and can commit violent acts against innocent people or acts of revenge against perceived tormentors in schools, families, and communities.
Therapists often do not attempt to uncover anger in the schizoid and schizotypal client, but it should be done. Children and adolescents with these personality traits and adults with paranoid PD sometimes harbor aggressive impulses for revenge which can be misdirected with tragic consequences at innocent people. The uncovering of anger in cluster A spouses is challenging because they are so mistrustful and defensive. Role-playing an offender can facilitate this process, as can asking the spouse to begin forgiving individuals in the past identified who neglected or betrayed the spouse.
The use of forgiveness with these spouses can assist in the diminishment of their angry or violent impulses against those who have hurt them. The work phase, however, is arduous and lengthy. A major obstacle is their anger is used to distance others. The development of trust is essential in order to help these spouses learn to control their resentful feelings and angry impulses. Most of these individuals simply will not work at forgiveness until they feel safer in relationships which may take a number of years. However, if trust can be established, spouses with cluster A PDs can become y willing to employ forgiveness and derive benefit from its use.
Cluster B Personality Disorders - Antisocial (ASP), Borderline (BPD), Histrionic (HPD), Narcissistic(NPD)
Spouses with antisocial PD and borderline PD are among the angriest, regularly manifesting great difficulty in the control of their hostile feelings and impulses. Many enjoy striking out in anger at innocent people, including spouses and relatives. Initially, histrionic PD and narcissistic PD individuals are not viewed as having problems with excessive anger; however, most do. Fava, M., et al., (1993) found that the presence of anger attacks in spouses with unipolar depression was associated with higher rates of comorbid cluster B personality disorders, in particular borderline. Also, borderline personality disorder has been shown to manifest more severe anger than dysthymic controls (Snyder & Pitt, 1985) and males high in narcissism are likely to express anger physically (McCann & Biaggio, 1989). Histrionic spouses often can manifest their anger in a passive-aggressive manner, at times, through eating disorder symptomatology.
Many spouses in cluster B enjoy their ability to influence and control others with their anger and therefore are often reluctant to deal with this emotion in a healthier manner. For example, spouses with ASP often derive a sense of strength, power, and superiority through the expression of their hostility. Subsequently, there is great resistance in these spouses to the use of forgiveness. In our clinical experience less than 50% in this cluster will even consider the concept of forgiveness. Those who do decide for forgiveness usually only do so after a major difficulty occurs in their lives such as a marital separation, the loss of a loved one, serious conflicts in interpersonal relationships, disorders in children, refractory depressive or anxiety disorders, career failures, arrest, imprisonment or financial problems.
Spouses with ASP often harbor violent impulses against a parent, most often their father, and other early life offenders. Unfortunately, they regularly misdirect these impulses at spouses and others. With those who attempt to try forgiveness, the major factors are the desire to break the emotional control of an offender and the wish to be freed from the guilt arising from their hostile actions. These spouses can be asked some of the following questions in an attempt to make a decision for forgiveness: “Do you want to act like the person who abused or neglected you as a child? Do you want to be be controlled emotionally by those who hurt you? Might your hostility and powerful impulses for revenge someday backfire onto your spouse, children and on yourself?" To date no double blind psychotherapy studies have been done on the treatment of excessive anger in spouses with ASP.
Histrionic PD individuals have family backgrounds similar to those with antisocial PD (Spalt, L., 1980). They lack the ability to handle their anger effectively and are reluctant to admit their hostile feelings. Instead of honestly discussing their hurts and subsequent resentment, they often somatisize their difficulties and present themselves as victims. However, periodically, they erupt in anger attacks with highly dramatic behaviors and threats. Spouses with HPD often try to control their spouses through their hysterical eruptions in anger.
Once the anger in histrionic PD persons is uncovered, they, more than the antisocial PD spouses, become more willing to attempt the use of forgiveness. In part, this is because they do not depend upon their anger to project a strong image or identity as do those with antisocial PD.
The chapter on the selfish spouse addresses the treatment of anger in those with NPD. Children and adolescents with strong narcissistic PD traits can be extremely disruptive to marital and family life. Family members who are narcissistic are reluctant to change their insensitive, self-centered, and manipulative behaviors. However, when the opportunity presents itself, these spouses and children are encouraged to use forgiveness to control their impulsive angry outbursts.
Cluster C Personality Disorders - Avoidant, Dependent, and Obsessive-Compulsive
The anxious and fearful individuals of cluster C often experience anger attacks. Gould and his colleagues (1996) found that cluster B, cluster C and self-defeating personality traits significantly predicted the presence of anger attacks. In another study depressed spouses with anger attacks had significantly higher rates of dependent, avoidant, narcissistic, borderline, and antisocial personality disorders than depressed spouses without anger attacks. (Tedlow, J.R., et al., 1997).
In this cluster the avoidant personality disorder individual is most aware of being angry and most honest about admitting struggles with hostile feelings. In our clinical work we have found that the dependent PD often expresses anger in a passive-aggressive manner by avoiding responsibility, by acting helpless, or by embracing the sick role. The perfectionistic thinking, rigidity, and need for control in obsessive-compulsive PD result in strong resistances against anger. These individuals have great difficulty admitting their resentment and the uncovering process can be quite lengthy and challenging. Spouses with O-CPD often struggle with obsessional thought of harming others, as described in the anxious spouse chapter. Asking such spouses to make a decision to think about forgiving anyone in their past who hurt them or who is doings so in the present can result in a decrease in obsessional thoughts of harming others.
After the anger has been uncovered, most spouses with avoidant PD and obsessive-compulsive PD are willing to work at forgiving those who hurt them. However, dependent PD individuals are highly resistant to forgiving because of their belief that if they let go of their resentful feelings, they may have to change, become healthier, and act in a more responsible manner.
Forgiveness Therapy in Spouses with Borderline Personality Disorder (BPD)
Borderline PD spouses are among the angriest, most unstable and difficult spouses whom mental health professionals attempt to treat. They regularly use excessive anger and biting criticism to keep their spouses at a distance because they are so fearful of being betrayed as they were in their childhood. The importance of anger as a central affective feature of borderline PD has been emphasized in the literature (Gunderson & Singer, 1975; Snyder & Pitt, 1985). Many BPD spouses who work in therapy come to attribute their strong resentment and aggressive impulses to childhood and adolescent experiences of neglect and abuse by parents and other caretakers ( Zanarini, M.C., 1989; Zanarini et al, 1997). Wolberg, (1973) was the first mental health professional to recommend forgiveness for the anger in BPD. We recommended its use for persons with BPD in our APA Book, Helping Clients Forgive: An Empirical Guide for Resolving Anger and Restoring Hope.
These spouses, who experience an ongoing sense of abandonment, unstable relationships, a weak sense of self, chronic feelings of emptiness and loneliness, and stress- related paranoid ideation are easily angered by stresses and life events that might not provoke others. Then, they often have great difficulty in controlling their hostile feelings. Fortunately, their severe fears, intense anger and aggressive behavior do respond to a degree treatment with antidepressants and atypical anti psychotics (Fava, M., et al., 1997; Salzman, C., 1995).
BPD is diagnosed predominantly in females (about 75%), co-occurs with other personality disorders, and ranges in prevalence from 30% to 60% among clinical populations with personality disorders as reported in DSM - IV. Also, there is an increased familial risk of antisocial PD and substance abuse disorders in these spouses.
BPD spouses often meet the DSM criteria for a number of common axis I disorders, particularly major depression and substance abuse. In a study of axis I comorbidity of BPD (Zanarini, M.C., et al., 1998) anxiety disorders were almost as common as mood disorders. Also, PTSD was found to be common but not universal, and males and females were found to differ in that substance abuse disorders were significantly more common among male BPD spouses, while eating disorders were significantly more common among female spouses. Fifty-three percent of the males and 62% of the females with BPD had eating disorders. Also, the pattern of complex lifetime axis I comorbidity evidenced by borderline spouses is a useful marker for the borderline diagnosis. Seventy -five percent of borderline spouses exhibited the pattern for both a disorder of affect and a disorder of impulse. This has a strong sensitivity and specificity for the borderline diagnosis. Zanarini and colleagues (1998) concluded that a history of several axis I disorders, particularly if they had an early onset, may have a role in the development of what is commonly seen as borderline psychopathology in spouses.
BPD spouses regularly misdirect anger their spouses, especially when they have recently felt hurt, when painful memories emerges, when they want to hurt others as they have been hurt, and when they perceive their spouses do not care or give enough. Not uncommonly these spouses relate in their marriages, “I’m furious with you. Why do you talk to me that way (implying a devaluation of them)? I’d really like to hit you or throw something at you.”
In such cases it is essential to label this anger as misdirected, attempt to uncover the true offender and suggest who actually deserves the anger, which is most often a parent. The spouse should encouraged to consider the limitations of relying solely upon the expression of anger as the major way for dealing with this powerful emotion and to consider to begin working on forgiving an offender from childhood and/or a spouse. In addition, many of these spouses should be encouraged to have a evaluation for medication.
Many spouses with BPD who work at forgiveness discover enormous rage with and violent impulses toward parents and significant others as a result of feelings of neglect, abuse, or betrayal from childhood, adolescence, and adulthood. They are often motivated to begin letting go of their deep resentment to extricate themselves from the pain of the past and to help in the treatment depression or anxiety. Diminishing their resentment from childhood and adolescence can assist in stabilizing their mood and can give them a way to control their anger. However, these spouses are very fragile and have great difficulty in trusting and, under stress, can quickly relapse, misdirecting strong resentment at spouses. For those with faith, employing spiritual forgiveness can be very helpful, during which they give their anger to God frequently during the day.
Some individuals with BPD will not work on the process of forgiving an offending parent(s) and instead insist their spouses are the sole cause of their anger. They often provide a laundry list of insensitive behaviors in a spouse. When anger is consistently misdirected regularly at a spouse, it may be necessary to raise the issue of possible marital separation unless a commitment is made to work on forgiving an offending parent.
The treatment of the anger in the BPD person is one of the most challenging tasks in psychotherapy. The process of assisting these spouses in letting go of their violent and vengeful impulses from childhood, adolescence, and adulthood can take many years of treatment. The course of treatment can be stormy. Also, spouses often need to be assertive and to set clear limits. They may consider telling a spouse, “I am not your neglectful, insensitive, or abusive parent. I do not deserve your hostility.” The response might be, “Yes, you do. You don’t really care about me.” With such resistance, the spouse might reply, “I cannot allow you to treat me as you were treated by your father, your mother or significant other.” Not infrequently, spouses with BPD are unwilling to change until significant pressure is put upon them to do so.
Fortunately, some spouses are able to recognize that they are misdirecting their anger and then recommit themselves to the work of forgiveness with those who have hurt them. The most difficult aspects of the work of forgiveness for BPD spouses are reframing (understanding why their parents were neglectful or abusive), letting go of the compulsive need to control born of severe mistrust, giving up the desire for revenge and associated aggressive impulses and recognizing that they are repeating the same insensitive behaviors of an offending parent.
Initially, BPD spouses are encouraged to make a cognitive decision to try to understand an offending parent's background and commit to let go of the anger with this parent so that the chains of the past can be broken. As they grow in understanding their offenders, these spouses usually experience relief from buried aggressive fantasies and thoughts. However, the diminishment of the powerful anger in these spouses can take many years. The use of spiritual forgiveness exercises is helpful when the spouse recognizes that he/she cannot forgive.
Now let's go back and see how Louise was able to use forgiveness to help with her BPD.
Louise entered therapy at age 25 for treatment of depression and intense loneliness after the ending of a one year relationship with her boyfriend, Mike. She had been in therapy intermittently since her adolescence for depression and anxiety. Her history revealed repeated experiences of emotional neglect and sexual and physical abuse from her childhood. She had also struggled with profound feelings of worthlessness, emptiness, sadness, suspiciousness and mistrust and intense anger.
Louise was initially angry with Mike and with her uncle who had sexually abused her. Later in her therapy deep resentment emerged toward her older brother and her parents. Louise was troubled by her anger, yet believed that it was fully justified. She was interested in exploring forgiveness as a new method for dealing with her anger because she was not comfortable completely with the approach recommended by her previous therapists of releasing anger primarily through its expression. This method of handling her anger had resulted often in her feeling frustrated, guilty, and somewhat frightened of the depth and power of her inner rage. She was intelligent and intuitive and knew that she would regularly overreact in rage that Mike and others did not deserve.
Louise was asked initially to try to think of understanding and of forgiving Mike. She was aware of his weaknesses which helped her to begin this work of forgiveness. After feeling some initial relief from the pain in that relationship, she then began to think of other men who had hurt her in her life including her uncle, brother, and father and began to feel more depressed and even angrier for a period of time..
She complained of feeling completely empty, mistrustful of others and then began to direct anger at the therapist. At the end of sessions she complained of not being helped enough and even at time was reluctant to leave the office. Louise was asked to consider that she might be misdirecting anger at the therapist meant specifically for her parents, her brother and her uncle. At times she could consider this, but not always. She would then be asked to consider thinking of wanting to let go of her justified resentment.
Louise often responded, “I have been hurt so deeply I really can’t forgive them even though I know it might help me.” Since she had grown in her faith, she was comfortable thinking that she was powerless over her justifiable resentment and wanted to turn it over to God. This method of handling the rage arising from her repeated experiences of neglect and abuse in her childhood proved to be invaluable in her treatment.
The work of forgiveness with her brother, uncle and father went on for years. She felt emotional relief from the slow resolution of this justifiable resentment. However, anger attacks were not uncommon both in her personal relationships and in her therapy sessions. In an attempt to deal with her pain with her brother she was assertive with him. Unfortunately, he would not admit to being emotionally abusive of her. However, at this time she met the man she would marry and the comfort in that relationship helped her to cope with the sadness and anger toward her brother.
Her deep resentment toward her mother for not protecting her from the sexual abuse of her uncle and the emotional abuse and neglect of her brother and father emerged regularly over the course of many years of treatment. Her mother was able to apologize to Louise. She related that she had been very depressed in her marriage and had difficulty in giving herself.
Louise had difficulty in trusting the man she would later marry, Kent. As she attempted to grow in her trust in him, periodically painful memories of hurts from her childhood and adolescence would emerge which would make her fearful of being hurt further. She would then attempt to forgive those who had hurt her as a way of diminishing the influence of the emotional pain from the past.
The development of trust in her husband occurred slowly. Under stress in their relationship she could become very suspicious, fearful, irritable and critical. Louise would overreact in anger regularly, but as her trust improved, her emotional overreactions in anger lessened.
In therapy she would often relate, “I’ve never been able to trust anyone in my family. They all betrayed me. Won’t Kent also?”
The use of forgiveness in her therapy helped Louise to resolve the intense anger from her past, facilitated her growth in trust, enhanced her self esteem, helped her to control her anger and improved her ability to hope. She also found her faith helpful and, particularly, this meditation, "Lord deepen my trust in you and in Kent."
Forgiveness therapy holds many benefits for spouses with personality disorders. The resolution of their strong anger with one or both parents and other offenders from different life stages and their impulses for revenge can help to stabilize their mood, improve interpersonal relationships, enable them to gain control over their angry feelings and impulses, diminish their impulsive and self-destructive behaviors, and assist in the healing of their axis I disorders such as anxiety and depression. Forgiveness is truly good news for them.
Personality Disorders (Table 14-1)
Paranoid Personality Disorder is a pattern of distrust and suspiciousness such that others’ motives are interpreted as malevolent.
Schizoid Personality Disorder is a pattern of detachment from social relationships and a restricted range of emotional expression.
Schizotypal Personality Disorder is a pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior.
Antisocial Personality Disorder is a pattern of disregard for, and violation of, the rights of others.
Borderline Personality Disorder is a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity.
Histrionic Personality Disorder is a pattern of excessive emotionality and attention seeking.
Narcissistic Personality Disorder is a pattern of grandiosity, need for admiration, and lack of empathy.
Avoidant Personality Disorder is a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.
Dependent Personality Disorder is a pattern of submissive and clinging behavior related to an excessive need to be taken care of.
Obsessive-Compulsive Personality Disorder is a pattern of preoccupation with orderliness, perfectionism, and control.
Black, D.,W. & Larson, C.L. (1999). Bad Boys, Bad Men: Confronting antisocial personality disorder. pp. 127-144. Oxford University Press: New York
Coccaro, E . F., Astill, J. L., Herbert, J., Schut, S. C. (1990). Fluoxetine treatment of impulsive aggression in DSM-III-R personality disorders. Journal of Clinical Psychopharmacology 10, 373 - 375.
Coccaro, E. F., & Kavoussi, R. G., (1997). Fluoxetine and impulsive aggressive behavior in personality - disordered subjects. Archives of General Psychiatry, 54,1081 - 1088.
Fava, M. (1997). Psychopharmacologic treatment of pathologic aggression. Psychiatric Clinics of North America. 20: 2, 427-451.
Fava, M., Rosenbaum, J. F., Pava, J., McCarthy, M., Steingard, R., & Bouffides, E. (l993). Anger attacks in unipolar depression, Part 1. Clinical correlates and response to fluoxetine treatment. American Journal of Psychiatry, 150, 1158-1163.
Fava, M. & Rosenbaum, J. F. (1997). Anger attacks in depression. Depression and Anxiety 6, 2-6.
Gartner, J. (1992). The capacity to forgive: an object relations perspective. In M Finn & J. Garner (Eds.). Object Relations Theory and Religion, (pp. 21 -33). Westport, CT: Praeger.
Gould, R. A., Ball, R., Kaspi, S., Otto, M. W., Pollack, M. H., Shekhar, A., & Fava, M. (1996). Prevalence and correlates of anger attacks: A two site study. Journal of Affective Disorders 39, 31-38.
Gunderson, J. G., Singer, M. T., (1975). Defining borderline patients: an overview. American Journal of Psychiatry 132: 1-10.
Jackson, H. J., Whiteside, H. L., Bates, G. W., Bell, R., Rudd, R. P., & Edwards, J. (1991). Diagnosing personality disorders in psychiatric inpatients. Acta Psychiatrica Scandinavica 83: 206-213.
Kavoussi, R. J., Coccaro, E. F. (1998). Divalproex sodium for impulsive aggressive behavior in patients with personality disorders. Journal of Clinical Psychiatry 59:12, 676 - 680.
Kavoussi, R.J ., Liu, J., Coccaro, E. F. (1994). An open trial of sertraline in personality disordered patients with impulsive aggression. Journal of Clinical Psychiatry 1994:55, 137 - 141.
Kernberg, O. F. (1992). Aggression in personality disorders and perversions. New Haven, CT: Yale University Press.
Koenigsberg, H. W., Kaplan, R. D., Gilmore, M. M., & Cooper, A. M. (1985). The relationship betyween syndrome and personality disorder in DSM-III: experience with 2,462 patients. American Journal of Psychiatry 142:2, 207-212.
Markovitz, P. J., Calabrese, J. R., Schulz, S. C., & Meltzer, H. Y. (1991). Fluoxetine in the treatment of borderline and schizotypal personality disorders. American Journal of Psychiatry 148: 8, 1064 -1067.
Millon, T. (1996). Disorders of personality: DSM - IV and Beyond (2nd ed). New York, NY: Wiley.
McCann, J. T. & Biaggio, M. K. (1989). Narcissistic personality features and self-reported anger. Psychological Reports 64, 55-58.
Oldham, J. M., Skodol, A. E., Kellman, H. D., Hyler, S. E., Doidge, N., Rosnick, L., Gallaher, P. E. (1995). Comorbidity of axis I and axis II disorders. American Journal of Psychiatry 152:4, 571-578.
Reich, J. H., Green, A. I. (1990). Effect of personality disorders on outcome of treatment. Journal of Nervous and Mental Disorders 178: 592-600.
Reich, J. H., & Vasile, R. G. (1993). Effect of personality disorders on the treatment outcome of axis I conditions: an update. Journal of Nervous and Mental Disorders 181: 475-484.
Salzman, C., Wolfson, A. N., Schatzberg, A., Looper, J., Henke, R., Albanese, M., Schwartz, J., & Miyawaki, E. (1995). Effect of fluoxetine on anger in symptomatic volunteers with borderline personality disorder. Journal of Clinical Psychopharmacology 15, 23-29.
Snyder, S., & Pitt, W. M. (1985). Characterizing anger in the DSM-III borderline personality disorder. Acta Psychiatrica Scandinavica, 72(5), 464 - 469.
Spalt, L. (1980). Hysteria and antisocial personality: A single disorder. Journal of Nervous and Mental Disorders 168, 456 - 494.
Tedlow, J. R., Leslike, V. C., Keefe, B. R., Nierenberg, A. A., Rosenbaum, J. F., & Fava, M. (1997). Are anger attacks in unipolar depression a variant of panic disorder? 150th Annual Meeting of the American Psychiatric Association, San Diego, CA.
Wonderlich, S. A., Swift, W. J., Slotnick, H. B. & Goodman, S. (1990). DSM III-R personality disorders in eating-disorder subtypes. International Journal of Eating Disorders 9, 607 - 616.
Wolberg, A. R. (1973). The Borderline Patient. New York, NY: Intercontential Medical Book Co.
Zanarini, M. C., Frankenburg, F. R., Dubo, E. D., Sickel, A. E., Trikha, A., Levin, A., & Reynolds, V. (1998). Axis I comorbidity of borderline personality disorder. American Journal of Psychiatry 155, 1733 - 1739.
Zanarini, M. C., Williams, A. A., Lewis, R. E., Reich, R. B., Vera, S. C., Marino, M. F., Levin, A., Yong. L., & Frankenburg, F. R. (1997). American Journal of Psychiatry 154: 8, 1101-1106.
Zanarini, M. C., Gunderson, J. G., Marino, M. F., Schwartz, E. O., Frankenburg, F. R. (1989). Childhood experiences of borderline patients. Comprehensive Psychiatry 30: 1, 18-25.