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Is a personality disorder a brain disease?
Posted Mar 04, 2020
Personality disorders (PDs) are mental disorders defined as problematic, lasting patterns of behavior, thinking, and inner experience exhibited across many social contexts—but, importantly, not all contexts. This latter point is seldom appreciated. The patterns are in fact often dependent on specific types of interactions and situations with certain other people, and may completely disappear at other times. People who exhibit symptoms of one of the more severe disorders, borderline personality disorder (BPD), are well known for creating arguments between doctors and nurses on hospital wards by acting sweet around one set of them, while acting horribly around the other set (the infamous staff split).
With the exception of Cluster A disorders, described below, they are likely not brain diseases but problems with functioning, especially in relationships with others, and in my opinion the behavior patterns are learned responses. Because the behavior can be quite extreme, some people and clinicians think they simply must be brain diseases, but the neuroscience does not support that. That the behaviors appear and disappear depending on social context shows this; real brain diseases like Alzheimer's are not like that. Furthermore, findings on fMRI studies and heritability studies, often cited to “prove” that PDs are brain diseases, are misleading or fraudulent. Readers can follow the links here to understand how.
Another odd characteristic of PDs is that there can be over a hundred different combinations of traits that all lead to the same diagnosis. Some traits may even seem contradictory. Narcissistic personality disorder requires at least five of nine different characteristics—any five— or any six, seven, eight, or all nine. One trait is an excessive need for admiration, but another is “takes advantage of others.” It is hard to think of a worse way to gain people’s admiration to make them feel used.
A patient can also simultaneously show symptoms of several different PDs in any possible combination. One study showed that once someone is diagnosed with BPD, they also qualify, on average, for 1.6 other PDs. Any other ones.
The traits that make up PDs are said to be maladaptive. This means they cause problems for the intimates of the involved individuals, but also, in the long run, are self-destructive or self-defeating for the person with the disorder. Over the short run, these traits may be used to solve certain types of interpersonal problems, but the “solution” does not last and prevents the use of better ways to resolve ongoing problems.
PDs were at one time thought by psychiatry to be different from all other psychiatric disorders. They were placed on a separate “axis” from other disorders, Axis II. Of course, all human behavior involves the brain, but as I have argued, PDs are likely “functional” or behavioral disorders. For this reason, I was in favor of keeping Axis II. However, because insurance companies often refused to authorize treatment for them—despite that they can be highly disabling and require extensive therapy—Axis II was eliminated. (Psychiatry does not consider causation in describing its diagnoses, because the true “causes” of almost all of them are not known for certain).
As mentioned, the personality disorders are subdivided into “clusters” that have common themes. The first, Cluster A, consists of disorders that are usually a prelude to more serious brain conditions such as schizophrenia, and probably have little in common with the PDs in the other two “clusters.” For this reason, I believe that they should not have been classified as personality disorders in the first place, and they will not be discussed further here.
The most serious personality disorders are seen in Cluster B, the “dramatic” disorders. Antisocial PD, the most difficult to treat, is characterized by disrespect and disregard for the rights of others, often leading to criminal behavior. They rarely come to therapy voluntarily.
BPD is currently the most common. I have noticed a marked increase in its prevalence since I was in training back in the mid-1970s, which makes me think it is related to ongoing developments and changes in our culture. It is also seen much less commonly in traditional cultures.
People with BPD often react with strong anger or panic to seemingly minor slights. This has led some psychiatrists to believe that BPD is a variation of bipolar disorder, but good evidence says otherwise. People with BPD are impulsive, self-destructive, and may cut themselves or engage in other self-injurious behaviors. They often worry about being abandoned by loved ones. A history of overt physical or sexual child abuse is a feature in the backgrounds of many of them, although certainly not all of them.
Cluster C personality disorders exhibit highly prevalent anxiety or fearfulness. Those with avoidant PD, for example, are socially inhibited, feel inadequate, and are hypersensitive to negative evaluations by others. They constantly worry about what other people think about them,
Because of their now-you-see-it, now-you-don't nature, a variety of information must be taken into account to make an accurate PD diagnosis. Good clinicians specifically ask about some of the more severe symptoms and behavior in a good psychiatric diagnostic interview, which includes a complete history of the patient’s upbringing and relationships over the course of their lives—things asked about less and less recently. Often it takes more than one session for the clinician to see the patterns. A patient’s behavior with the doctor and with the staff also provides clues. Interviews with the patient’s significant others may reveal important information, although they may at times be just as misleading as patients sometimes are.