Welcome back to DIRT FROM THE ROOTS, your monthly blog for discovering new perspectives on interesting, insightful, and obscure topics within the mental health and psychology fields. Today, we discuss a section of the DSM that has seen a lot of detrimental consequences from lack of public psychoeducation in personality disorders.
TOPIC OF THE MONTH
PERSONALITY DISORDERS
"It is as if my life were magically run by two electric currents: joyous positive and despairing negative — whichever is running at the moment dominates my life, floods it."
— Sylvia Plath
We will make a shift to end the summer from covering developmental disorders into another category of the DSM in mental illness. If you recall from the prior two months, developmental disorders are defined by their root being genetic, while mental illness is typically derived from maladaptive environmental influence such as trauma, ongoing chronic conditions, and/or similar factors. While this could be genetic, it is hard to determine whether something such as a personality disorder was biological or due to the very nature of being in an environment where a parent is showing symptoms. And of course, underlying developmental disorders will absolutely play into presentation of mental illness should an individual experience symptoms from multiple diagnoses.
While mental illness is more broad, we will today solely focus on personality disorders. I will begin by giving the caveat that these disorders are some of the most difficult to manage, and more so than most conditions can become extremely stressful on the individuals that are consistently interacting with the affected person. While understanding of these disorders are continuing to grow rapidly, it is important to remember that they also represent one of the most challenging conditions that the mental health community faces. It is also important to understand that while the symptoms associated with these conditions are very real, many times the actual titles have been weaponized against people, and therefore the simple action of using labels of “personality disorder” can creating discomfort and even trauma response with some individuals. While we will use these labels for categorization process, it is paramount to remember that symptoms, not diagnosis, are what we focus on.
WHAT IS A PERSONALITY DISORDER?
The challenge of treating and managing personality disorders begins at the very definition, which can most loosely be described as “long lasting patterns of maladaptive thoughts, feelings, and behaviors that cause disruption in functioning and relationships”. Just looking at this sentence, we can see that there are not any particularly defined issues, and it is not too hard to see how this wording can be very easily interpreted in judgmental or narrow-minded ways. While personality disorders can be exorbitantly obvious to third-party observers, this is not particularly considerate of the actual experience of the affected individuals and overlooks the fact that this is likely how that individual has always operated in the world– imagine if you were told the way you were was “bad” and therefore were expected to change overnight without any coping mechanisms available! On top of this, most personality disorders (particularly severe ones) are believed to be derived from extreme, unprocessed trauma– as if it was hard enough for a human to be reflective and introspective, this layer of trauma must be seen as near-impenetrably thick as a barrier in the case of personality disorder development. Unfortunately, these diagnoses specifically can certainly lead to more harm than help when labeled.
All of this together, and individuals with personality disorders are amongst the least likely mental health conditions to seek treatment. Whether the individual is unaware, defensive, sensitive, or fears the stigma around the diagnosis, there are a plethora of rationales for this to occur.
WHAT ARE THE PERSONALITY DISORDERS?
While personality disorders fall under a broad categorization, the actual DSM conditions vary greatly. The way that we organize these conditions is in three “clusters” of personality disorders based on similar features. I will first list out the 10 most prominent disorders and delve into each cluster further.
As far as personality disorders go, surprise, surprise!-- much further research is needed.
Cluster A
defining features: odd and eccentric thinking/behavioral patterns
Paranoid Personality Disorder
Schizoid Personality Disorder
Schizotypal Personality Disorder
Cluster B
defining features: erratically emotional and unpredictable thoughts and behavioral patterns
Borderline Personality Disorder
Narcissistic Personality Disorder
Histrionic Personality Disorder
Antisocial Personality Disorder
Cluster C
defining features: anxious and fearful thoughts and behavioral patterns
Avoidant Personality Disorder
Obsessive-Compulsive Personality Disorder
Dependent Personality Disorder
CLUSTER A: ISSUES WITH PERCEPTION
As mentioned last month, cluster A personality disorders are most commonly mistaken for autism or learning disabilities, but hold firm distinctions. Given their etymology, you may not be surprised that this cluster has the most genetic links, as all three have shown evidence of connection to schizophrenia.
In the case of Paranoid Personality Disorder, your initial guess of symptoms might be most in line with the actual condition as compared to the others: PPD displays frequent paranoia in the form of unjustified suspicion or fear of malevolent intent of others. Individuals with this disorder are often extremely anchored in their beliefs, and may restrict life to large-scale proportions due to paranoia. Of all personality disorders, this has also received the most critical challenge to existence, as some believe that the paranoia is due to either schizophrenia or just one piece of a larger unresolved traumatic response condition.
Schizoid Personality Disorder is perhaps the opposite of a cluster B disorder: it is defined by great preference of being alone over social interaction, limited range of emotional expression (often creating a cold, disengaged presentation towards others), little or no interest in sex or intimacy, and inability to pick up on social cues or experience pleasure. A commonly reported perception from individuals who identify is that they view themselves as the “observers” in life, rather than feeling actively in it. Interestingly, research has suggested that there are certain individuals who display these symptoms but others who seem to mask them (aka appear socially adept) but still feel most safe in their internal world. Those diagnosed with SzPD actually tend to report feeling comfortable in that position, making this one of the least likely conditions to seek treatment. Continuing with the cluster A theme, more genetic than environmental links have been suggested as a root cause.
Schizotypal Personality Disorder is, put most simply, one of the most intriguing presentations of humanity that we have categorized to this point. Those affected by the PD might experience extremely odd and eccentric ways of speaking, dressing, and behaving socially. There are frequent symptoms of what can be described as “magical thinking”-- the idea that one can influence people and events with their thoughts. Additionally, individuals with Schizotypal may experience odd perceptual experiences, including hearing voices, unwarranted suspicions, and the belief that certain incidents or experiences have secret or special messages only intended for the affected individual. Along with all this is a common feature of social hesitance/avoidance as well as inappropriate emotional reactions. While again, there is a link to the “schizophrenic spectrum” of cluster A causes, Schizotypal has shown to have more environmental roots than the other two. Schizotypal has shown frequent comorbidity with depression and social phobias, but has also been described as the “easiest condition to identify, hardest to treat” given that a typical reaction for these individuals in psychotherapy is to believe that they are just eccentric or nonconformist, and are vulnerable to conflating therapeutic goals with their own magical thinking components.
While cluster A disorders are in no way less serious as a condition, there is reason to believe that these individuals do not seek treatment because, more so than the other two clusters, their quality of life may not be particularly affected, specifically for Schizoid Personality Disorder. Given the internalized perceptions and socially-avoidant characteristics of cluster A features, this cluster is also less likely to create outward problematic dynamics with others involved in the individual’s life.
CLUSTER B: ISSUES WITH RELATIONSHIPS
As may be inferred by "issues with relationships", cluster B personality disorders can have much more influence on the individuals around the person with the diagnosis than most conditions. Cluster B personality disorders are largely believed to be rooted in responses to extreme trauma, though genetic factors are not to be dismissed entirely. The challenges associated with both possessing and interacting with cluster B personality disorders are not too surprising when given the most common features of these 4 conditions are struggles with empathy, inappropriate, volatile, and sometimes violently erratic emotional responses, and great difficulty in reflection on why or how the individual’s behaviors affect others. Related or not, another common feature is self-sabotage.
Antisocial personality Disorder is perhaps the most infamous of all: what we would colloquially describe as a “sociopath” more or less refers to this disorder. Typically predicated by Conduct Disorder in adolescence, ASPD is defined as disregard for others’ feelings, safety, wellbeing, needs, and rights. ASPD individuals may or may not experience their own personal emotions, but the key feature is lack of awareness or remorse for others perceptions. Individuals are often recklessly impulsive, and there is strong correlation with addiction and criminality amongst those affected. Unsurprisingly, this condition is extremely hard to treat given lack of motivation to make any changes, but perhaps surprisingly to some, ASPD is not indicative that the individual has malevolent intentions. Individuals with ASPD will commonly have one or few friends, and many accounts report finding other non-empathetic based ways to appreciate symbiotic relationships. The concept of someone being a “psychopath” would be partially supported by ASPD, but it is important to note that no such official diagnosis of “psychopathy” (nor sociopathy) exists in earnest.
Narcissistic Personality Disorder is a challenger to ASPD as far as notoriety, likely due to narcissism being a fairly common personality trait that can be seen acutely. NPD is taking acute narcissism and applying it to all realms of life: someone with the disorder will display a feeling of specialness and attitude that they are more important than others. Those with NPD will commonly be arrogant, exaggerate personal accomplishments, and hold belief that they should constantly be praised, admired, and fawned upon. On the other hand, individuals with NPD often disregard the wants and needs of others, have unreasonable and unrealistic expectations of them, can often manipulate or take advantage of others, and often believe others are envious of them. This disorder is commonly seen deriving from one of two extremes in childhood: either extreme unprocessed trauma such as sexual abuse or extreme overglorification and coddling of the individual can lead to development of the condition. Treatment of NPD is most complicated by the difficulty of the individual seeing the isolated issue; typically clients seeking treatment will trend towards focus on comorbid conditions rather than NPD, and there is no clear evidence suggesting psychotherapy as an effective treatment option for the condition itself.
Histrionic Personality Disorder may exist as the least defined of all 10 listed here, as symptoms are almost entirely overlapping with other cluster B presentations and individuals typically present as very high-functioning both socially and cognitively. HPD is defined most prominently by attention seeking behaviors and use of manipulative strategies to draw that attention. The condition is traditionally also associated with seductive behaviors or overt sexuality, as well as extreme difficulty in accountability and controlling impulse. Individuals that display histrionic traits are commonly proud of the way they present, generally perceive relationships as more intimate than the reality, and are more likely to blame others for faults, making psychotherapy a largely ineffective option. Some research indicates that 2/3rds of individuals with HPD also qualify for ASPD, with emphasis on the “sexual” presentation being a potential differentiator. As has been found in many different conditions, sexism may play a part in looking at HPD as an isolated condition when it is actually just a subform of ASPD most commonly seen in women. Another way of looking at differences may exist in self perception, as individuals with ASPD are more likely to be aware of their lack of remorse while HPD individuals may continually deflect these issues to the faults of others.
And finally Borderline Personality Disorder, perhaps the most stigmatized diagnosis in all of mental health and also the PD which I have had the most personal experience working with. Through both anecdotal and research-based experiences, I can tell you that the most common professional answer I have gotten to how to manage BPD has unfortunately been simply to “not work with it”. Borderline personality disorder can be most broadly described as intense emotional reaction to abandonment, and though this is an accurate statement, it overlooks the presentation. An individual with borderline most prominently will have “splitting” tendencies– more popularly known as “black-and-white” thinking– where an individual will trend towards seeing a situation as either all bad or all good with disregard for any form of nuance. Reactions to these extremes often present as inappropriate or “over the top” emotional, which can be extremely risk-taking and often out of control, leading to dangerous, traumatizing or abusive situations. Individuals with BPD are also at 400% higher risk of suicide than general population, report chronic feelings of emptiness and insatiability, and commonly report very unstable self-perceptions. A common description from individuals with BPD involves the idea of “having no emotional skin”, meaning even the slightest concern or inconvenience can be perceived as a traumatically harmful attack and warrants an equally harsh and rageful response. While the other 3 cluster B disorders do not necessarily present chronically, a unique feature of BPD is the “Jekyll and Hyde” dynamic in which a person with borderline personality may display as a seemingly entirely different personality until threat of abandonment occurs, creating a shift into a very defensive and emotionally erratic state. BPD is strongly correlated with abuse in childhood (particularly sexual), but has a fuzzy perception around genetics. While there is an enormous jump in percentage when looking at BPD individuals with BPD parents, it is hard to separate genetics from the nature of the condition creating a traumatic childhood.
DBT or Dialectical Behavioral Therapy was created for Borderline Personality disorder, and in current day exists as not only the best treatment option for BPD, but for most conditions in mental health. “Dialectical” means “concerned with or acting through opposing forces”, and encourages the marriage of both extremes in the case of splitting. A simplified way to look at DBT is “emotions lead to thoughts lead to behaviors”, and the focus is on while we cannot control our emotions or thoughts, we can identify them in tandem and intervene on our decision to behave in the typical way as response. Though very difficult, there has been many cases of recovery and greatly improved management of the condition.
As will be covered shortly, an additional consideration of Cluster B is that these disorders are very susceptible to negatively impact those involved in the lives of affected individuals, making the very low frequency of seeking treatment even more challenging.
CLUSTER C: ISSUES WITH SECURITY
In cluster C personality disorders, our main feature is based around fear, anxiety and avoidance. While this may appear to be similar to Cluster A from a social perspective, the difference is that Cluster C disorders often possess more awareness (and therefore distress) about their barriers to functioning while Cluster A disorders may be more comfortable with their disconnect as there is not as much motivation to present “typically”.
In the case of Avoidant Personality Disorder, we may best define the condition by what it is not: it is not autism, as individuals with APD could be described as being socially deterred due to hyperawareness of social norms and fear of how they will be perceived for breaking them. It is not Schizoid Personality Disorder, as individuals with APD actually desire social connection so intensely that it is creating debilitating anxiety through idealization and fear that they are unworthy of social connections. Presentationwise, an individual with APD may appear very shy, have great fear of embarrassment, ridicule and disapproval, and take measures to avoid social contact both in personal and professional settings. There is high comorbidity with other anxiety disorders such as phobias and panic disorder, as well as PTSD which may be a leading root cause. Individuals with APD are correlated with higher rates of substance misuse, particularly in the case of mediating social anxiety. While environment may determine intensity, there is reason to believe that having a withdrawn or shy social affect may have genetic links. There are (particularly compared to other PDs) reasonably effective treatment benefits in psychotherapy. So long as the therapist is able to retain trust and avoid judgment, there have been significant improvements in APD presentation due to cognitive, dialectical, and exposure therapy strategies.
Dependent Personality Disorder is described as a “pervasive dependence on other people”. While this is most commonly seen in the form of “codependent relationships”, further symptoms include extreme challenge in making decisions for self, detrimental passivity or submissive behaviors, and avoidance of any responsibilities. Individuals with DPD may present as overly “clingy” and unhealthily engaged within relationships, completely helpless and despaired when not in a relationship, and lack confidence to trust their own decisions without excessive approval or validation from outside sources. Aside from the obvious barriers that exist with a lack of self-autonomy, individuals with DPD are at high risk of remaining in abusive situations due to fear. Unlike any other listed condition, there is not any evidence suggesting a genetic predisposition to DPD, as it is almost entirely linked to trauma and parenting styles that are extremely overprotective or authoritarian. This condition is also considered to be reasonably treatable with psychotherapy, as empowerment and building of independence skills can show marked improvement.
Finally, we have Obsessive Compulsive Personality Disorder, the most common Personality Disorder seen in the US. Though they can be comorbid, this is NOT referring to OCD, the anxiety disorder, which focuses on intrusive thoughts that lead to compulsions. OCPD is differentiated by the root cause being extreme perfectionism (rather than intrusive thoughts) and instead of perceiving compulsions as “egodystonic”, or unwanted and involuntary as OCD does, the symptoms are seen as “egosyntoic”, indicating the person perceives symptoms as necessary and rational. As would be implied by perfectionism, individuals with OCPD are rigid and inflexible about order, rules, detail, procedures, morality, and similar facets. Individuals with OCPD display these same behaviors in other realms, often hyperfocusing on conscientiousness, constricted emotional response, and extreme caution in both social and transactional situations. We also commonly see “workaholic” tendencies, or more broadly that the individuals adhere to a constant choice of productive or ritualistic behaviors over relationships, rest and recreation. There are both genetic and environmental links to OCPD, though one of the more common links appears to be a failure to develop secure attachments in early childhood. The condition is obviously comorbid with OCD, but also commonly seen in individuals on the autism spectrum and connected to eating and feeding disorders, which also stem from a need to control and perfectionism. OCPD has shown most improvement when utilizing CBT and exposure therapy methods, with a goal of reducing neuroticism.
Cluster C personality disorders may be most responsive to treatment in comparison to the other two clusters, but this is in no way looking at the issues with less severity or validity to others.
INDIVIDUALS AFFECTED BY PERSONALITY DISORDERS
And finally, my experience as a professional has included far more people affected by other individuals with personality disorder traits than seeing people with the actual disorders. There is great risk of trauma and confusion around the disorder, particularly if the individual is a parent or partner. In a very dichotomous situation, we must consider both sides: the person with the personality disorder is surely struggling and has great reason to act the ways that they may behave, but the affected individual may actually be experiencing as much or more trauma from receiving the harmful end of unmanaged symptoms within the disorder.
While the unfortunate reality is that we as outsiders cannot do any work for the other person, the main challenges of managing a loved one with a personality disorder come from the lack of awareness that this behavior is not normal, the difficulty of expressing needs and boundaries to someone who does not seem to be taking them into consideration, and disillusionment that may lead to gaslighting and other manipulative behaviors that chronically affect those around the person with the disorder. It is crucial to not only recognize that this condition may be showing symptoms, but also to recognize that the nature of the disorder may work in ways that redirects blame or responsibility to those around them. If this becomes presented as an expected or typical behavior that the loved one takes accountability for, it can create large issues in functioning and expectation.
Perhaps the most reported way that clients have discovered that someone in their life has a personality disorder comes through the idea of “situations which become extremely intense in reality, but cannot be adequately explained in summary”. More or less, the idea of something “breaking down” for a person with a PD is often seen as “well, I get sad sometimes too” instead of recognizing that something small and seemingly insignificant can lead to 10+ hours of traumatic response which puts those around them in a hypervigilance and wary of further escalation.
SO WHAT CAN BE DONE HERE?
So we’ve gotten through all disorders and… there is not much resolution. If anything, you may feel more concerned about these conditions– and to some degree, that’s probably a desired outcome. I sometimes view personality disorders as the culprit of many “unidentified, unsolvable mysteries” where humans act very irrational without outward reason to do so, as well as situations where people can’t identify what is going on with someone but just “have a weird feeling”-- the perfect storm of mental health stigma, ease of denial and whatever emotional layer the observer is feeling is sure to create a convoluted scenario.
But the truth is that these disorders are much more manageable than once thought, which is a large part of the stigma. Though like anything, we may not see a solution to “fix” or “correct” a person affected by a personality disorder, but recovery and certainly management of the condition is showing more positive results than expected. If you are affected by someone witha personality disorder, finding some kind of professional help may prove to be extremely effective and validating in a way that may not be very common amongst casual conversations. If you feel you may have a personality disorder, exploring that may be the most terrifying but also most helpful first step that can be taken.
A word of advice: going online to see other perspectives on personality disorders is extremely risky. While there will assuredly be helpful validation and strategy, this specific corner of the internet is ripe with extremely, extremely biased perspectives from all extant angles. A person suffering from a condition may find comfort in seeing others with their perspective, but may also read terribly traumatic accusations and judgmental perceptions from other sources, particularly those who are affected and have not processed or do not understand what has happened to them. On the other side, loved ones are just as likely to find accounts of DBT strategies that may be effective as they are to find a full-on philippic about how individuals with personality disorders require an exorcism as they are convinced this is a demonic possession. The truth is that we have dangerously low public awareness on personality disorders, and therefore finding opinions online is even more vulnerable to misinformation and emotional responses than the already high risk.
CONCLUSION
So while these “personality disorder” titles hold great infamy, controversy, and notoriety in modern day society, the best way to view them is simple as this: all of these symptoms are being caused by some root– genetic, traumatic, or otherwise– and these symptoms are absolutely inhibiting life in general. Seems basic enough. But to manage these symptoms, we are first going to have to battle our own perceptions, the social construct, and perhaps even our life schemas depending on how long the interactions have been occurring. The overwhelming nature of rewiring these very ingrained ideas makes the treatment of personality disorders seem much more daunting than other conditions, but we must realize that this same perspective is how any human on earth can grow or adapt to life on earth from a psychological level as well.
In utmost honesty, there are very few things in mental health that I can say are truly optimistic, but one is that in the case of mental illness (including personality disorders), there does seem to be a correlation between aging and symptom severity lessening. Though the work absolutely must be done, I have experienced people who have been at full severity of personality disorder barriers than now live managed, fulfilling lives. Though outlook is assuredly perceived amongst the most bleak of mental health conditions, this also provides the most opportunity for more progress to be made in treatment.
WHAT’S COOKING FOR NEXT MONTH
DEPRESSION
Next month, Nick will discuss a topic that gained more recent public attention in depression, and explains how recent studies may be misinterpreted as well as critical in understanding the condition.
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