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Personality disorder

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Personality disorders pertain to the afflictions persons suffer from including: feelings and traits of being dramatic, emotional, erratic, odd, eccentric anxious, and/or fearful. Personality disorders have been a long lasting affliction for centuries and the studying of the causes and proper treatment are still being developed in our modern scientific community. Suffering from such disorders are in no part blame worthy to the mentally ill person(s) afflicted by them. If you or a loved one appear to have similar tendencies, contacting specialists or finding support is the first step to recovery and management.

History of Diagnostics and Studies of Personality Disorders

Philippe Pinel "manie sans delire"

If you were to truly trace the history behind the development of psychiatric observations concerning the cases of those with personality disorders, an obvious beginning would be Philippe Pinel. Before Pinel’s inquiry different types of mental illnesses were categorized as delirium or mania. These included melancholy (referring to depression), delusions (Strong but false beliefs about what is taking place or who one is), and psychoses (loss of contact with reality). In the 18th century however, French psychiatrist Philippe Pinel, developed a the term “insanity without delusions”, though in French it reads "manie sans delire"[1]. Philippe Pinel’s observations of some of his patients were that they behaved irrationally but were still aware of reality and how their behavior appeared to others. He documented them, becoming one of the first to attempt to describe their conditions. [2]Some of his observations of the patients were a lack of impulse control, frustration that would develop often into rage, and common incidents of violent actions. He noted that these patients did not suffer from delusions or psychoses [3].

A British physician employed to the Bristol Infirmary in the United States published a work in 1835. The piece was titled Treaties on Insanity and Other Disorders of the Mind. In the work he coined the term “moral insanity”. This, as he wrote on page six of the work, was “a morbid perversion of the natural feelings, affections, inclinations, temper, habits, moral dispositions, and natural impulses without any remarkable disorder or defect of the intellect or knowing or reasoning faculties and in particular without any insane delusion or hallucination”. He also claimed that a tendency to thievery, eccentric attitudes and actions, consistent anger, social afflictions, and obvious signs of depression were indicators as to having moral insanity. The term moral insanity was often used even after more defined classifications of particular afflictions [4].

By the late 1800’s however an increasing number of psychiatrists and physicians became uncomfortable with the term moral insanity. Henry Maudsley, a physician who also took interest in the behavioral studies, commented, "(It is) a form of mental alienation which has so much the look of vice or crime that many people regard it as an unfounded medical invention”. A German doctor named J. L. A. Koch attempted to change the term through his book Die Psychopatischen Minderwertigkeiter. The term he opted for was “psychopathic inferiority”. In this he did not include the mentally ill or intellectually challenged, but focused upon those who displayed consistent patterns of misconduct and dysfunction of various degrees in their lifetime. He later changed the term from psychopathic inferiority to “psychopathic personality”[5].

In the early 1900’s psychiatrists and physicians still had a focus more towards describing the mentally ill’s actions and disturbances rather than treatment. Most of the recorded data from their sessions would point towards a diagnosis of a personality disorder. At the time though these observations were considered to be early stages of more severe disorders such as Bipolar disorder (referred to as manic depression)[6]. In 1910, E. Kraepelin wrote of six more categories of psychopathic personalities in this textbook Lehrbuch der Psychiatrie (translated to Clinical Psychiatry: a textbook for students and physicians). They were labeled as “excitable, unstable, eccentric, liar, swindler, and quarrelsome”. Still the focus remained on anti-social behavior and annoying people tended to be labeled as psychopathic[7].

In the 1920’s and throughout the 1930’s, a psychiatrist name Sigmund Freud, with a group of associates, inquired into theories of the causes of personality disorders. [8]. Many of his theories revolved around the area of psychoanalysis, which focused upon unconscious attributes to personality [9]. Freud explained that the mental process was divided among three components: Id, Ego, and Superego. Id was a reference to the array of instinctual impulses that sought out instant gratification. Ego was a term that described the governing functions whose presumed intention was to keep control of the Id in prevention of indulgence and balance the relationship between Id and Superego. Superego was one’s “moral values and self-critical attributes”. In his theory, Freud perceived that the cause of anxiety was the conflicts between the three components. The Ego would attempt to reduce anxiety through the reliance of “defense mechanisms”[10]. Psychoanalysis is also used as a form of therapy. Psychoanalytic treatment show how unconscious factors affect their relationships and behavior, traces them back to the origins, shows the individual how they have changed, and helps individuals to better cope with the reality[11].

Sigmund Freud the 'father of psychology

In the 1950’s the definitions of “character disorders” were widely accepted and the focus in the psychiatric community shifted to more severe forms of illness for those who were out of touch with reality. They were not seen as a legitimate mental illness though, instead they were often seen as rebellious and deviant activity as a product of their upbringing or weakness. Some patients undergoing psychoanalysis became worse in their disorder. The term “border line” came from this where the patients whose diagnosis were seen as on the border between psychoses (disorders characterized by suspended reality testing, example: Schizophrenia) and neuroses (disorders characterized by anxiety arising from the conflict among the Id, Ego, and Superego). Character disorders became a formal diagnosis when the first issues of the Diagnostic and Statistical Manual of Mental Disorders (DSM) was published in the 1950’s. The purpose of the original DSM was to clarify and dissipate any confusions within the psychiatric community pertaining to diagnostic systems and to define character disorders, they being patterns of behavior that were not connected to anxiety or stress in the patient’s life. The DSM had relied heavily on Freud’s theories[12].


A Scottish psychiatrist known as Sir David Henderson published a book in 1939, titled Psychopathic States and described within the three variations of psychopaths. He wrote of them that there were: Aggressive psychopaths, who were “violent, suicidal, and prone to substance abuse”, passive and inadequate psychopaths who were “over-sensitive, unstable and hypochondriacal (abnormally anxious about their health)”, and creative psychopaths who were all afflicted individuals that managed to become famous or infamous. There were also introverts (schizoid) and pathological liars that were under the “passive and inadequate” category [13].

Published in 1968, DMS II described personality disorders as, "group of disorders is characterized by deeply ingrained, maladaptive patterns of behavior that are perceptibly different in quality from psychotic and neurotic symptoms". In 1980 the DSM III was published and unlike past editions, there foundation was based on practices and no longer reliant on Freudian theories, removing them altogether. They replaced them with measurable factors. During the duration of the 1970’s and 1980’s, Freud’s theories and psychoanalysis were being discredited and declining in popularity whereas the cognitive-behavioral model (emphasis on the observable, behavioral manifestations of disorders) and the medical model (cataloging pathological symptoms and their biological causes) in psychology were becoming popular. As a result of this and the continuing tests, studies, theories and so on, those suffering from personality disorders are no longer considered morally weak or willfully misbehaved, but are seen as persons suffering from legitimate troubling disorders that can often be successfully treated.[14].

Types of Disorders

For a case to be considered a personality disorder, it must correlate with one or more of the defining traits of such a disorder. They are distorted thinking patterns, problematic emotional response, over/under-regulated impulse control, and interpersonal difficulties.[15] Distorted thinking patterns, also known as cognitive distortions are patterns of thinking that skews the person’s view of reality such as the world, themselves, and others, in a negative and unrealistic way.[16]Problematic emotional response involve rigid response systems that more often than not are inappropriate emotional reactions to situations and circumstances. Over/under-regulated impulse control is as one might expect: either being overly controlling over impulses of any kind, or being too loose and giving in easily. Interpersonal difficulties are issues in social relations and behaviors.

Though there are many variations within the category of personality disorders, they are generally grouped into three different classes. The first of these is Class A. A Class A disorder includes the characteristics of being “odd or eccentric”. Examples of these being Paranoid personality disorder, Schizoid personality disorder, Schizotypal personality disorder, and more. The second class, Class B, is for disorders known to be “Dramatic, Emotional, or Erratic”. Examples of these would be Antisocial/psychopath personality disorder, Borderline personality disorder, Histrionic personality disorder, and Narcissistic personality disorder. The final grouping of disorders is Class C. A Class C disorder is “Anxious and Fearful”. Three common disorders that are in this class are Avoidant personality disorder, Dependent personality disorder, and Obsessive-compulsive personality disorder. The example of all three classes correlates with The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). [17]

Common features of a Class A diagnoses are social awkwardness and social withdrawal and are most afflicted by distorted thinking. A person afflicted with Paranoid personality disorder demonstrates a person who is dominated by the distrust and suspicions against other individuals. They often assume that people are either going to harm them, humiliate them, or use them to their advantage. They protect themselves, keep their distance, attack and lash out at those they see as a threat, hold grudges, display obsessive jealousy and are argumentative. They focus on negative memories and perceive a threat of danger or malice in harmless actions and discussions. They are often dominated by distrust and jealousy so they do not make close relationships or confide in others easily. People with Schizoid Personality Disorder are found to be those who hold an extensive pattern of detachment from social affiliations and limited ranges of emotional aspects. They tend to be isolated. Traits that are common are a disinterest in human contact and relationships, limited pleasure in life, and an appearance of disinterest in both negative and positive comments such as praise or criticism. They are often referred to as “loners”. They often miss social cues or distinctions that give them the appearance of being inept at social interactions. Their limited emotional range restricts them from returning gestures like smiles or nods. Presently this condition is rare. An individual suffering from Schizotypal Personality Disorder is characterized by social and interpersonal restrictions. Similarly to Schizoid Personality Disorder patrons, they are uncomfortable in social interactions and tend to be isolated. The difference between the two is that Schizotypal Personality Disorder patrons also suffer from “eccentric behavior and cognitive distortions”. Some examples of which that are common are: noticing things other do not see, seeing shadows that do not exist, believing they have the ability to read minds, or that others steal their thoughts. This condition appears more often in families that have a history of Schizophrenia diagnoses. The two are theorized to share DNA similarities.[18].

Class B contains these conditions: Borderline Personality Disorder, Narcissistic Personality Disorder, Histrionic Personality Disorder, and Antisocial Personality Disorder. They are characterized by over/under impulse control and emotional irregularities. Those suffering from Antisocial Personality Disorders disregard rights of others and have hostile and aggressive tendencies. Children suffering from this (known as Conduct Disorder in juvenile stages) may abuse or kill animals, or be reckless with objects like setting things aflame. They place themselves often in dangerous and risky environments often without regard for consideration to consequences. They do not often feel real remorse. Those suffering from this disorder have often been categorized as those who have most impacted society because of their actions (more so in a negative life). Narcissistic Personality Disorder pertains to problems involving people having a strong sense of entitlement based upon their view of their own self-worth. This causes them to be disrespectful, belittling to others, shallow in superficial relationships, and manipulative in the search of gaining that which they desire. Borderline Personality Disorder is the most studied personality disorders. Those suffering from this experience powerful and sudden emotions and moods that shifts swiftly. “They generally have a hard time calming down once they have become upset,” writes Mark Dombeck, “As a result, they frequently have angry outbursts and engage in impulsive behaviors such as substance abuse, risky sexual liaisons, self-injury, overspending, or binge eating”. They often see situations as either all-good or all-bad and their emotions change suddenly without warning [19].

Class C comprises of the Avoidant, Dependent, and Obsessive-Compulsive Personality Disorders, all of which being categorized by their shared quality of high anxiety. Avoidant Personality Disorder pertains to those who suffer from social inhabitation, sensitivity to negative feedback, and senses of being inadequate. Their main fear generally is being ridiculed, insulted, scolded, rejected, and criticized by other humans. They fundamentally believe they are not “good enough” and unlikeable. The feelings of being social inept and unwanted cause extreme anxiety in social events or interactions; they are often seen as “shy”. Dependent Personality Disorder refers simply to the unhealthy extremity of dependency to the protection and help of others. This is generally affiliated with the fear of losing other people’s support. Persons with Obsessive-Compulsive Personality Disorder focus upon rules, structure, regulations, and order. Their perfectionist tendencies along with the inflexibility of their manner making completing a task nearly impossible, and they are unwilling to have others do it for they will most likely not do the task properly.[20].

Treatments

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Medications may help stabilize conditions

Simone Hoermann noted," It is important to remember that everyone can exhibit some of these personality traits from time to time. To meet the diagnostic requirement of a personality disorder, these traits must be inflexible; i.e., they can be repeatedly observed without regard to time, place, or circumstance. Furthermore, these traits must cause functional impairment and/or subjective distress. Functional impairment means these traits interfere with a person's ability to functional well in society. The symptoms cause problems with interpersonal relationships; or at work, school, or home. Subjective distress means the person with a personality disorder may experience their symptoms as unwanted, harmful, painful, embarrassing, or otherwise cause them significant distress. Richer, more detailed descriptions of these disorders are found in the section describing the four core features of personality disorders" [21].That being said, many conditions can be treated and managed. The four recommended are Self-Help, Medication, Hospitalization, and Psychotherapy.

Psychotherapy begins with the patient contracting not to commit suicide (signing an actual agreement). Suicidal tendencies are usually monitored during the duration of treatment and extreme cases are recommended for hospitalization and medication. Dialectical Behavior therapy, developed by Marsha Linehan, is seen as of late to be the most successful method to use. It teaches patients to learn tactics to manage themselves in certain situations as well as their emotions through emotional regulation and reconstructing of thought and action patterns. Phillip W. Long, M.D. also notes that: “The therapeutic alliance should form within the patient’s real experiences with the therapist and with the treatment. The therapist must be able to tolerate repeated episodes of primitive rage, distrust, and fear. Uncovering is to be avoided in favor of bolstering of ego defenses, in order to eventually allow the patient to be less anxious about potential fragmentation and loss. The goals of therapy should be in terms of life gains toward independent functioning, and not complete restructuring of the personality.”[22]

Hospitalization should be used only in severe cases or when immediate care is needed. It is costly, but having partial-hospitalization or day treatment programs are helpful. Self-Help treatments are uncommon in the professional community but can be helpful in the encouragement and development of social interactions and skills. There are several support groups for people suffering from different personality disorders throughout the world. Encouragement of developing coping skills and social relationships will most often be beneficial and sometimes is in correspondence with their therapist. [23]

The subject of medicating is a very controversial topic. For more severe cases, medication generally is recommended, but not necessarily for more minor afflictions. Antidepressants and antianxiety drugs can be applied usefully when appropriate.[24]

Video

Christian lecturer on personality and disorders of the psyche.

References

  1. Vaknin, Sam. The History of Personality Disorders Personality Disorders Revisited. Web. 12 January 2014 (visited).
  2. Hoermann, Simone. Zupanick, Corrine. Dombeck, Mark. The History of the Psychiatric Diagnostic System MentalHelp.net. Web. 6 December 2013 (updated).
  3. Vaknin, Sam. The History of Personality Disorders Personality Disorders Revisited. Web. 12 January 2014 (visited).
  4. Vaknin, Sam. The History of Personality Disorders Personality Disorders Revisited. Web. 12 January 2014 (visited).
  5. Vaknin, Sam. The History of Personality Disorders Personality Disorders Revisited. Web. 12 January 2014 (visited).
  6. Hoermann, Simone. Zupanick, Corrine. Dombeck, Mark. The History of the Psychiatric Diagnostic System MentalHelp.net. Web. 6 December 2013 (updated).
  7. Vaknin, Sam. The History of Personality Disorders Personality Disorders Revisited. Web. 12 January 2014 (visited).
  8. Hoermann, Simone. Zupanick, Corrine. Dombeck, Mark. The History of the Psychiatric Diagnostic System MentalHelp.net. Web. 6 December 2013 (updated).
  9. Rana, Himmat. Sigmund Freud Psychology History. Web. May 1997
  10. Hoermann, Simone. Zupanick, Corrine. Dombeck, Mark. The History of the Psychiatric Diagnostic System MentalHelp.net. Web. 6 December 2013 (updated).
  11. Rana, Himmat. Sigmund Freud Psychology History. Web. May 1997
  12. Hoermann, Simone. Zupanick, Corrine. Dombeck, Mark. The History of the Psychiatric Diagnostic System MentalHelp.net. Web. 6 December 2013 (updated).
  13. Vaknin, Sam. The History of Personality Disorders Personality Disorders Revisited. Web. 12 January 2014 (visited)
  14. Hoermann, Simone. Zupanick, Corrine. Dombeck, Mark. The History of the Psychiatric Diagnostic System MentalHelp.net. Web. 6 December 2013 (updated).
  15. Hoermann, Simone. Zupanick, Corrine. Dombeck, Mark. The Ten Personality Disorders: Cluster A MentalHelp.net. Web. 6 December 2013 (updated).
  16. Kelly, Owen. Cognitive Distortions Obsessive-Compulsive Disorder. Web. 24 March 2011 (updated).
  17. Unknown. Personality Disorders Psychology One. Web. 10 March 2012 (updated).
  18. Hoermann, Simone. Zupanick, Corrine. Dombeck, Mark. The Ten Personality Disorders: Cluster A MentalHelp.net. Web. 6 December 2013 (updated).
  19. Hoermann, Simone. Zupanick, Corrine. Dombeck, Mark.DSM-5: The Ten Personality Disorders: Cluster B MentalHelp.net. Web. 6 December 2013 (updated).
  20. Hoermann, Simone. Zupanick, Corrine. Dombeck, Mark. DSM-5 The Ten Personality Disorders: Cluster C MentalHelp.net. Web. 6 December 2013 (updated).
  21. Hoermann, Simone. Zupanick, Corrine. Dombeck, Mark. The History of the Psychiatric Diagnostic System MentalHelp.net. Web. 6 December 2013 (updated).
  22. Grohol, John M. Borderline Personality Disorder Treatment Psych Central. Web. 15 January 2013 (updated).
  23. Grohol, John M. Borderline Personality Disorder Treatment Psych Central. Web. 15 January 2013 (updated).
  24. Grohol, John M. Borderline Personality Disorder Treatment Psych Central. Web. 15 January 2013 (updated).

Other mental illnesses