Rep36 Understanding Personality Disorder

References 
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raise that person’s own awareness of their
behaviours, thoughts and emotions. This is the
core of formulation: a sophisticated, detailed
and dynamic understanding of a person as an
individual, and its process directly informs
interventions to generate positive change.
Formulation is necessary in addition to
diagnosis; while diagnosis is a useful starting
point, providing baseline information about type
and level of disorder, it is inflexible and
impersonal and therefore limited in its utility in
individuals with personality disorder difficulties.
Formulation goes beyond diagnosis through the
generation of a working model based on an
assessment of the range of personality traits
presented and a linked set of hypotheses that are
addressed in the course of a systemic response to
the needs presented.
Clare
Clare is a 34-year old woman who is married to James. She works as a care assistant in a nursing
home for older people though she only does the night shift. She used to work in a bank and was
doing very well there until she decided to leave because she felt so unhappy about being around
her colleagues. When her line manager asked her why she was so unhappy that she wanted to
leave, she told her that it was because she felt so afraid that she was doing things wrong and that
her colleagues were criticising her and didn’t care to associate with her. Her line manager pointed
out that she did not associate with them, that she seemed to make a point of keeping herself to
herself. Clare had nothing to say in response and looked very unhappy indeed.
James was becoming increasingly more concerned about Clare’s social withdrawal. She had always
been a very shy and introverted woman. He liked that because he was a quiet, shy man himself. They
never had a fancy lifestyle, but now Clare was refusing to go to the small local pub with him on a
Friday evening, their habit all their married life until recently. When he asked why, she told him that
she was worried people were looking at her and that she didn’t feel as good as or as interesting as
the other women who were there. When James asked Clare if she thought she might be depressed,
as she had been for several months after the death of her mother when she was 28-years old, she said
that she wasn’t. She was fine when she was on her own and when she was at work in the nursing
home, with only one or two people to talk to at a time whom she never felt judged her. But James
was unhappy because he felt their lives were becoming very restricted and dull. He felt himself
becoming irritable with Clare and feeling envious of his friends who went to parties and on holiday.
Over the space of several months, James convinced Clare that her shyness and desire for
solitude were worse than they had ever been and that they might be responsible for some of the
irritability that he had been experiencing towards her. James convinced Clare to come with him to
their GP, just so that they could talk it over with an independent person who might be able to
help. James explained to the GP how Clare had changed in the last few years and how their plans
at the time of their marriage – to work and travel and eventually have children – were falling by
the wayside because Clare was having increasing difficult being around people. He told the GP
that he worried that she might not want to be around him for very much longer. Clare began to
cry and was able to tell the doctor that she too was worried by her increasing and debilitating
shyness and that she too missed their friends and their former activities and worried for their future. 
Clare’s doctor arranged for her to visit a clinical psychologist for an assessment prior to the
recommendation of treatment. The psychologist asked Clare to tell her what it felt like to be her
and how who she was now was different from the person she was 10 years ago and from the person
she was as an adolescent. The psychologist asked her to tell her about how she met James and
what she liked and disliked about him. She asked about Clare’s health and her employment, her
upbringing and her family, and she also asked her about her thoughts about the future. She asked
whether Clare was anxious and whether she had ever had a panic attack, and she asked if she was
worried about leaving the house alone or being in crowded places. 
As a result of Clare’s responses to the questions posed, the psychologist was able to rule out
panic disorder and agoraphobia. The psychologist thought that instead Clare could be depressed,
or she could have characteristics of avoidant personality disorder, or both. Clare was obviously a
bright young woman and she had no physical worries, and while she had lost her mother, the
remainder of her family were close and there was no conflict there that was adding to Clare’s

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