- People with personality disorders are often portrayed as monsters, but even the borderline and narcissistic are rarely as malignant as on TV.
- Some say the cause of personality disorders is unknown, however, a closer look points to early relational complications and some genetics.
- Even if not interested in personality disorders, clinicians likely encounter them more often than they think, and would do well to study them.
Personality disorders (PDO) are amongst the most misunderstood and stigmatized psychological conditions. Part of this reason is that the ones that lend themselves to entertainment are characterized by aggressive and dramatic activity, and, at that, caricatured for effect. It's a rare day that you meet someone with borderline personality disorder who's so venomous as Glen Close's character in Fatal Attraction, or a narcissist so malignant as Leonardo DiCaprio's role in The Wolf on Wall Street.
Unfortunately, such characters suggested to popular culture that this is what PDO means, and any mention of "personality disorder," nevermind the aforementioned two, creates a conditioned recoil response in many. Further, the stigma can be perpetuated by providers who magnify the challenges that PDOs often bring to their work, for it's indeed flustering if it's not a population you're prepared to work with. Frequently, I've found, it's the providers' flustered reactivity, such as suggesting the patient can control themselves at the moment if they want to (Linehan, 2006; Shannon, 2019) or that their difficult presentation is personal, that makes it more difficult than it needs to be, and the patient is deemed "untreatable."
Besides the myth of being untreatable, three other ideas about personality pathology persist that contribute to the stigma and lack of treatment of such individuals, perpetuating the hopeless, negative view of them.
1. The cause of personality disorders is unknown. If you've ever casually perused online material about personality disorders, you've encountered the erroneous statement, "Scientists still aren't sure what causes personality disorders."
This makes it sound like PDOs spontaneously appear, adding mystery to an already stigmatized population, and enhancing the perception they're unable to be effectively worked with. It's as if it's expected that researchers will someday find, lurking in the neuropsychiatric depths, some as-yet-undiscovered, damaged circuitry akin to a pinball machine-like mechanism that's gone haywire, and that the combination of damaged obstacles being bounced off of it dictates this or that personality disorder.
This seeming want for discovery of an absolute, universal cause suggests hope for some myopic vision of a purely physiological basis for the conditions. This way, it could be treated with a pill or surgery, similar to how the serotonin panacea theory took over depression, and we know how that went. If nothing else since that epoch in psychiatry, we've learned that the recipe for depression is a more complicated, varying set of experiential and genetic ingredients than originally believed.
In terms of personality, it's a similar etiology, perhaps best summarized by personality expert Dr. Joseph Shannon (2019). He illustrated that personality consists of two things: A) inherited items, or traits, the collection of traits being one's temperament, and B) learned experiences, called habits, the collection of which is termed an individual's character.
A disorder of personality, therefore, is the meeting of the waters of genetic vulnerability, such as a propensity for anxiety and impulsivity, encountering some unsettling early life experience that shapes one's core schema about themselves, others, and how the world operates. This becomes crystallized into a pervasive baseline pattern of inflexible, maladaptive ways of relating. While not everyone's troubling early relational experience is identical, different personality disorders tend to have similar types of early relational conflicts that set things in motion. For example:
- People with borderline personality disorder invariably have an encounter with some form of abandonment or other event(s) that lead them to identifying as a victim and having hypersensitivity to further abandonment. High anxiety festers at the slightest sign of potential abandonment, engendering, with the encouragement of amygdalar hypersensitivity, a highly impulsive retreat or attack, depending on the nuances of the individual's lens of the situation.
- Those with dependent personalities seem to share a background of growing up in environments where there was learned helplessness; perhaps independent thinking wasn't allowed, or was even punished. Being alone is thus anxiety/depression-provoking because they can't make their own decisions/provide for themselves, and therefore feel compelled to cling to people who can provide for them, even if, sometimes, it means sacrificing well-being or morals.
2. Personality disorders are largely untreatable. As vexing and interpersonally challenging as some PDOs can be, the uninitiated may think, "There's no helping these people!" The fact is, people with personality pathology have been successfully treated from the time of the classic Victorian Austria analysts to modern interventions. A thorough synopsis may be found in Millon (2011), where he discusses the successful work of early practitioners across all personality pathologies.
Today, there is plenty of evidence that PDOs are indeed treatable beyond tenuous stability. We need only to look at the work of modern analysts like Nancy McWilliams (2013) and Stuart Yudofsky (2005); cognitive/behavioral oriented practitioners such as Aaron Beck (2015), and Marsha Linehan with her DBT (e.g., Bedics et al., 2015; Choi-Kain et al., 2017); and the work done in borderline-specific hospital units such as McLean in Boston.
The catch is, given personality isn't something episodic, or a phase of life matter, the work is time-consuming and energy-intensive, requiring a lot of patience on the part of the practitioner. Though "coping skills and medications" may ostensibly help some PDOs, it is tenuous stability at best, for the core schema leading to the pervasive interpersonal behavior has not been reprogrammed. It's akin to having to constantly remember different commands to override programmatic malfunctions on a personal computer, rather than updating the software or correcting the programming script.
Practitioners with low frustration tolerance may be their own worst enemy in trying to work with personality pathology, no matter how interested they may be. As detailed in #1, above, clearly, working with personality disorders requires a detailed understanding of the relational conflicts behind the presentation and a time investment.
3. If I'm not interested in PDOs, I don't need to know about them. Given the stigma of PDOs even within mental health care, it's not unusual for practitioners to shy away from seeking direct work with this spectrum. If anything, it's been my experience that such clinicians find it sufficient to just be able to recognize PDOs in order to refer elsewhere.
The problem is, the ones most people tend to recognize are the cluster Bs (i.e., antisocial, borderline, histrionic, and narcissistic), given they stand out because of their penchant for drama and moodiness. If clinicians do attempt to hang on and work with them, the focus is solely on managing the effects of the personality (e.g., moodiness, reactivity, and self-destructive activity) rather than helping them learn to more effectively relate, contributing, at best, to the above-mentioned tenuous stability.
The bigger problem is that "cluster Bs" are only four of the many personality disorders. Most clinicians, it seems, don't recognize that they are in fact encountering PDOs much more often than they may realize.
Consider that estimates of people in the United States who meet full criteria for at least one PDO is roughly between 12% to 15% (e.g., APA, 2011; Volkert, et al., 2018). Add to this that many more present pervasive traits and characteristics of PDOs but don't meet strict criteria. Across the spectrum, then, estimates are believed to be that at least 20% (Shannon, 2019) of people have some level of significant personality pathology. Now, consider that people with personality pathology tend to experience significant anxiety, depression, moodiness, or anger, which are amongst the chief complaints of people seeking therapy, and you can see how the concentration of personality-related pathology in a general clinical setting would be significant.
While many clinicians easily recognize cluster B personalities, what about "less popular" ones such as the cluster A (i.e., paranoid, schizoid, schizotypal), and cluster C (i.e., avoidant, dependent, obsessive-compulsive) not to mention problematic personalities not mentioned in the later DSM editions, like the passive-aggressive, depressive, and self-defeating? These individuals often harbor significant anxiety, depression, and relationship complications.
It may seem, for example, that someone ostensibly meets criteria for social anxiety disorder, and this becomes the focus of treatment. However, the case is particularly more challenging than the therapist is used to. Perhaps the patient seems very passive and thus struggles with relating and communicating to the therapist. Perhaps the therapist notes there's more than the "performance anxiety" of the garden variety social angst, and realizes a "flavor" of self-deprecation and/or negative self-evaluation in comparison to others that is driving the social inhibitions. These are not unusual indicators of, respectively, the schizoid and avoidant personalities.
What is driving the "social phobia" for the schizoid is, as noted in 10 Core Beliefs of Personality Disorders, their core schema of, "The world, especially dealing with emotions and other people, is overwhelming. I can't juggle all the stimulation; an insular life, unplugged of emotion, is much more manageable." The avoidant's perspective is, "I'm so inept, undesirable, and stupid that no one would ever want to be with me. My undesirable characteristics are irrepressible and easily detected, and therefore I'll always be seen as 'less-than.'" Thus, dismantling the social inhibitions will require restructuring these lenses through which they view life.
Clearly, successful intervention will need more than social skills building and exposure therapy, and all clinicians would do well to gain some level of competency in identifying and working with matters of personality.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed, text revision).
Beck, A., Davis, D., & Freeman, A. (2015). Cognitive therapy of personality disorders (3rd ed.) Guilford Press.
Bedics, J. D., Atkins, D. C., Harned, M. S., & Linehan, M. M. (2015). The therapeutic alliance as a predictor of outcome in dialectical behavior therapy versus nonbehavioral psychotherapy by experts for borderline personality disorder. Psychotherapy, 52(1), 67–77. https://doi.org/10.1037/a0038457
Choi-Kain, L.W., Finch, E.F., Masland, S.R., Jenkins, J.A., & Unruh, B.T. (2017). What works in the treatment of borderline personality disorder. Current Behavioral Neuroscience, 4, 21–30. https://doi.org/10.1007/s40473-017-0103-z
Linehan, M. in Lichtenstein, B. (2006). Back from the edge. Lichtenstein Creative Media.
McWilliams, N. (2013). Psychoanalytic diagnosis: Understanding personality structure in the clinical process (2nd ed.). Guilford.
Millon, T. (2011). Disorders of personality: Introducing a DSM/ICD spectrum from normal to abnormal (3rd ed). Wiley.
Shannon, J. (2019, October 25). Character flaws: How to understand and navigate relationships with high conflict clients. Brattleboro Retreat, Brattleboro, Vermont.
Volkert, J., Gablonski, T., & Rabung, S. (2018). Prevalence of personality disorders in the general adult population in Western countries: Systematic review and meta-analysis. The British Journal of Psychiatry, 213(6), 709-715. doi:10.1192/bjp.2018.202
Yudofsky, S. (2005). Fatal flaws: Navigating destructive relationships with people with disorders of personality and character. American Psychiatric Publishing.