Personality Disorders
Personality disorders are characterized by patterns of perceiving, reacting, and relating that are relatively inflexible and socially maladaptive.
Everyone has characteristic patterns of perceiving and relating to other people and events (personality traits). Put another way, people tend to cope with stresses in an individual but repetitive style. For example, some people respond to a troubling situation by seeking someone else's help, whereas others prefer to deal with problems on their own. Some people minimize problems; others exaggerate them. Regardless of their usual style, however, mentally healthy people are likely to try an alternative approach if their first response is ineffective.
In contrast, people with personality disorders are rigid and tend to respond inappropriately to problems, to the point that relationships with family, friends, and coworkers are affected. These maladaptive responses usually begin in adolescence or early adulthood and do not change over time.
People with personality disorders are unaware that their thought or behavior patterns are inappropriate; thus they tend not to seek help on their own. Instead, they may be referred by their friends, their family, or a social agency because their behavior is causing difficulty for others. When they do seek help on their own, usually because of troubling symptoms (for example, anxiety, depression, or substance abuse), they tend to believe their problems are caused by other people or by circumstances beyond their control.
Personality disorders are grouped into three clusters. Cluster A personality disorders involve odd or eccentric behavior; cluster B, dramatic or erratic behavior; and cluster C, anxious or inhibited behavior.
 See the sidebar Consequences of Personality Disorders.
Cluster A: Odd or Eccentric Behavior
Paranoid Personality: People with a paranoid personality are distrustful and suspicious of others. They suspect on the basis of little or no evidence that others are out to harm them, and they may retaliate at any time. This behavior often leads to rejection by others, which seems to justify their original feelings. They are generally cold and distant in their relationships.
People with a paranoid personality often take legal action against others, especially if they feel righteously indignant. They are unable to see their own role in a conflict. Although they usually work in relative isolation, they may be highly efficient and conscientious.
Sometimes people who already feel alienated because of a defect or handicap (such as deafness) are more likely to suspect that other people have negative ideas or attitudes toward them. Such heightened suspicion, however, is not evidence of a paranoid personality unless it involves wrongly attributing malevolence to others.
Schizoid Personality: People with a schizoid personality are introverted, withdrawn, and solitary. They are emotionally cold and socially distant. They are most often absorbed with their own thoughts and feelings and are fearful of closeness and intimacy with others. They talk little, are given to daydreaming, and prefer theoretical speculation to practical action. Fantasizing is a common coping mechanism (defense mechanism).
Schizotypal Personality: People with a schizotypal personality, like those with a schizoid personality, are socially and emotionally detached. In addition, they display oddities of thinking, perceiving, and communicating similar to those of people with schizophrenia (see Section 7, Chapter 107). Although schizotypal personality is sometimes found in people with schizophrenia before they become ill, most adults with a schizotypal personality do not develop schizophrenia.
Some people with a schizotypal personality show signs of magical thinking--that is, they believe that a particular thought or action can control something or someone. For example, a person may believe that he can cause harm to others by thinking angry thoughts. People with a schizotypal personality may also have paranoid ideas.
Cluster B: Dramatic or Erratic Behavior
Histrionic (Hysterical) Personality: People with a histrionic personality conspicuously seek attention, are dramatic and excessively emotional, and are overly concerned with appearance. Their lively, expressive manner results in easily established but often superficial and transient relationships. Their expression of emotions often seems exaggerated, childish, and contrived to evoke sympathy or attention (often erotic or sexual) from others.
People with a histrionic personality are prone to sexually provocative behavior or to sexualizing nonsexual relationships. However, they may not really want a sexual relationship; rather, their seductive behavior often masks their wish to be dependent and protected. Some people with a histrionic personality also are hypochondriacal and exaggerate their physical problems to get the attention they need.
Narcissistic Personality: People with a narcissistic personality have a sense of superiority, a need for admiration, and a lack of empathy. They have an exaggerated belief in their own value or importance, which is what therapists call "grandiosity." They may be extremely sensitive to failure, defeat, or criticism. When confronted by a failure to fulfill their high opinion of themselves, they can easily become enraged or severely depressed. Because they believe themselves to be superior in their relationships with other people, they expect to be admired and often suspect that others envy them. They believe they are entitled to having their needs met without waiting, so they exploit others, whose needs or beliefs they deem to be less important. Their behavior is usually offensive to others, who view them as being self-centered, arrogant, or selfish. This personality disorder typically occurs in high achievers, although it may also occur in people with few achievements.
Antisocial Personality: People with an antisocial personality (previously called psychopathic or sociopathic personality), most of whom are male, show callous disregard for the rights and feelings of others. Dishonesty and deceit permeate their relationships. They exploit others for material gain or personal gratification (unlike narcissistic people, who exploit others because they think their superiority justifies it).
Characteristically, people with an antisocial personality act out their conflicts impulsively and irresponsibly. They tolerate frustration poorly, and sometimes they are hostile or violent. Often they do not anticipate the negative consequences of their antisocial behaviors and, despite the problems or harm they cause others, do not feel remorse or guilt. Rather, they glibly rationalize their behavior or blame it on others. Frustration and punishment do not motivate people with an antisocial personality to modify their behaviors or improve their judgment and foresight but, rather, usually confirm their harshly unsentimental view of the world.
People with an antisocial personality are prone to alcoholism, drug addiction, sexual deviation, promiscuity, and imprisonment. They are likely to fail at their jobs and move from one area to another. They often have a family history of antisocial behavior, substance abuse, divorce, and physical abuse. As children, many were emotionally neglected and physically abused. People with an antisocial personality have shorter life expectancies than the general population. The disorder tends to diminish or stabilize with age.
Borderline Personality: People with a borderline personality, most of whom are women, are unstable in their self-image, moods, behavior, and interpersonal relationships. Their thought processes are more disturbed than those of people with an antisocial personality, and aggression is more often turned against the self. They are more angry, more impulsive, and more confused about their identity than are people with a histrionic personality. Borderline personality becomes evident in early adulthood, but prevalence decreases with age.
People with a borderline personality often were neglected or abused as children. Consequently, they feel empty, angry, and deserving of nurturing. They have far more dramatic and intense interpersonal relationships than people with cluster A personality disorders. When they feel cared for, they appear lonely and waiflike, often needing help for past mistreatment, depression, substance abuse, and eating disorders. However, when they fear being abandoned by a caring person, their mood shifts dramatically and is frequently expressed as inappropriate and intense anger. This shift in mood is accompanied by extreme changes in their view of the world, themselves, and others--things are black or white, good or evil, but never neutral.
People with a borderline personality who feel abandoned and alone may wonder whether they actually exist (that is, they do not feel real). They can become desperately impulsive, engaging in reckless promiscuity or substance abuse. At times they are so out of touch with reality that they have brief episodes of psychotic thinking, paranoia, and hallucinations.
People with a borderline personality are commonly seen by primary care doctors. Additionally, borderline personality is the most common personality disorder treated by therapists, because people with the disorder relentlessly seek someone to care for them. However, after repeated crises, vague unfounded complaints, and failures to comply with therapeutic recommendations, caretakers--including doctors--often become very frustrated with them and view them as help-rejecting complainers.
Cluster C: Anxious or Inhibited Behavior
Avoidant Personality: People with an avoidant personality are overly sensitive to rejection, and they fear starting relationships or anything new. They have a strong desire for affection and acceptance but avoid intimate relationships and social situations for fear of disappointment and criticism. Unlike those with a schizoid personality, they are openly distressed by their isolation and inability to relate comfortably to others. Unlike those with a borderline personality, they do not respond to rejection with anger; instead, they withdraw and appear shy and timid. Avoidant personality is similar to generalized social phobia (see Section 7, Chapter 100).
Dependent Personality: People with a dependent personality routinely surrender major decisions and responsibilities to others and permit the needs of those they depend on to supersede their own. They lack self-confidence and feel intensely insecure about their ability to take care of themselves. They often protest that they cannot make decisions and do not know what to do or how to do it. This behavior is due partly to a belief that others are more capable and partly to a reluctance to express their views for fear of offending the people whom they need. People with other personality disorders often have aspects of a dependent personality, but these traits are usually hidden by the more dominant traits of the other disorder. Sometimes adults with prolonged illnesses develop a dependent personality.
Obsessive-Compulsive Personality: People with an obsessive-compulsive personality are preoccupied with orderliness, perfectionism, and control. They are reliable, dependable, orderly, and methodical, but their inflexibility makes them unable to adapt to change. Because they are cautious and weigh all aspects of a problem, they have difficulty making decisions. They take their responsibilities seriously, but because they cannot tolerate mistakes or imperfection, they often have trouble completing tasks. Unlike the mental health disorder called obsessive-compulsive disorder (see Section 7, Chapter 100), obsessive-compulsive personality does not involve repeated, unwanted obsessions and ritualistic behavior.
People with an obsessive-compulsive personality are often high achievers, especially in the sciences and other intellectually demanding fields in which order and attention to detail are desirable. However, their responsibilities make them so anxious that they can rarely enjoy their successes. They are uncomfortable with their feelings, with relationships, and with situations in which they lack control or must rely on others or in which events are unpredictable.
Diagnosis
A doctor bases the diagnosis of a personality disorder on a person's history, specifically, repetitive displays of maladaptive thought or behavior patterns. These patterns tend to become apparent because the person stubbornly resists changing them despite their negative consequences. In addition, a doctor is likely to notice the person's inappropriate use of mental coping mechanisms (defense mechanisms). Although everyone unconsciously uses coping mechanisms, people with personality disorders use them in immature and maladaptive ways, such that it interferes with their daily functioning.
 See the table Common Coping Mechanisms.
Treatment
Personality traits take many years to develop, thus the treatment of maladaptive traits takes many years as well. No short-term treatment can cure a personality disorder, although some changes may be accomplished faster than others. For example, drug therapy or reduction of environmental stresses can quickly relieve symptoms such as anxiety and depression. Behavioral changes can occur within a year; interpersonal changes take longer. For example, for a person with a dependent personality, a behavioral change might be to stop stating that he cannot make decisions; the interpersonal change might be to interact with others in a workplace or family setting in such a way that he actually seeks out or at least accepts some decision-making responsibilities.
Although treatments differ according to the type of personality disorder, some general principles apply to all treatments. Because the person with a personality disorder usually does not see a problem with his own behavior, he must be confronted with the harmful consequences of his maladaptive thoughts and behaviors. To do this, a therapist needs to repeatedly point out the undesirable consequences of the person's thought and behavior patterns. Sometimes the therapist finds it necessary to set limits on behavior (for example, the person might be told that he cannot raise his voice in anger but instead must use a regular speaking voice). The involvement of family members is helpful and often essential because they can act in ways that either reinforce or diminish the person's problematic behavior or thoughts. Group and family therapy, group living in designated residential settings, and participation in therapeutic social clubs or self-help groups can all be valuable in helping to change socially undesirable behaviors.
Psychotherapy (talk therapy) remains the cornerstone of most treatments and usually must continue for more than 1 year to effect change in a person's maladaptive behavior or interpersonal patterns. In the context of an intimate, cooperative, nonexploitative doctor-patient relationship, the person can begin to understand the sources of his distress and recognize his maladaptive behavior. Psychotherapy can help him more clearly recognize the attitudes and behaviors that lead to interpersonal problems, such as dependency, distrust, arrogance, and manipulativeness.
For some people with personality disorders, primarily those that involve maladaptive attitudes, expectations, and beliefs (such as narcissistic or obsessive-compulsive personality), psychoanalysis (see Section 7, Chapter 98) is recommended and is usually continued for at least 3 years. Behavior therapy (see Section 7, Chapter 98) is helpful in changing behaviors such as recklessness, social isolation, lack of assertiveness, and temper outbursts. Behavioral change is most important for people with a borderline, antisocial, or avoidant personality. However, people with an antisocial or paranoid personality are rarely successfully treated by any therapy.
Drug therapy is sometimes appropriate for people with a personality disorder who have depression, phobia, or panic disorder. However, drugs usually provide only limited relief. In contrast, the feelings of anxiousness and sadness that result from a personality disorder are rarely satisfactorily relieved by drugs. Drug therapy for people with a borderline personality is frequently complicated by misuse of the drugs or by suicide attempts.
|
