by Dr Dennis Trent, Chartered Clinical Psychologist Midlands Psychological Services
Of all mental disorders Personality Disorders are probably the most misunderstood.
Many times I have read psychiatric reports in which the psychiatrist has said that the person does not have a mental illness, it just a personality or behavioural disorder. Like the majority of mental problems, personality disorders are, in most cases, the result of non-medical issues. There are a few examples where a disease or head trauma can alter or affect a person’s personality, however in the main the personality is developed over time and the person’s interpretation of their experiences.
It is the perception of the experience rather than the experience itself that can cause an event to be seen as either positive or negative. That is why two people can experience the same event and have completely different reactions to it. So what does this mean for a personality disorder? The answer is that it helps us to understand why two people can be raised in a dysfunctional environment and one will develop a personality disorder while the other either does not or develops a completely different personality disorder.
Children need to trust their environment and those in it. In many ways, their lives depend on those around them. If that environment is unstable or chaotic, it becomes difficult to trust, as in its most basic form, trust allows a child to predict the future. If the environment is unstable, that is the child cannot predict the actions of others in the environment, or if the limits applied to the child are constantly changing, the need to continually test those limits becomes imperative. One of the hallmarks of abused children is their inability to play since they are always testing those limits to see if they are in the same place they were moments ago.
To say that events help form the self-concept is much like saying the sun is hot; most people accept that as a given. We tend to gain much of our sense of who and what we are from the way people react and respond to us. A child learning to walk makes many mistakes with no adverse effect on their self-concept. As the child grows older the acceptance or rejection of others through approval, disapproval or ridicule of those efforts will contribute strongly to how children view themselves and the world around them. The children that are constantly treated like an object are highly likely to begin to see themselves as objects. This can easily expand to others to the point that everyone is viewed as an object.
Objects are unique in that they have no intrinsic value; rather they have the value others place on them. Children who see themselves as objects will often rely on others to gain a sense of acceptance. The problem arises in that people will only accept what they believe to be true. If there is no perception of worth of the child by the child, they will enlist others to say that they are worthy only to ultimately reject that and go on to try to get someone else to value them.
Child abuse comes in the form of physical abuse, sexual abuse, emotional abuse and neglect. While most people are quite clear in what constitutes physical and, recently, sexual abuse, the role of neglect and emotional abuse are less recognised. In all cases, it is easy to see that the main concern of the abuser is not the child, but is filling a need in the abuser. In virtually every case the child is viewed as an object.
The easiest way to understand how this affects the child as that child becomes an adult is to picture a standard round goldfish bowl. Let the goldfish represent the person and the bowl is the personality. It is the thing that allows the goldfish to interact with the world around it while remaining safe within that world. The life events that we all experience over the course of our lives tends to coat the inside of the bowl, much like a goldfish bowl that is not regularly cleaned. If the predominant colour of that coating is pink, the fish will see the world in shades of pink and the world will see the fish in shades of pink. Likewise, if the predominant colour of that coating is blue, the fish will see the world in shades of blue and the world will see the fish in shades of blue.
The problem arises in that if the fish were to be shown a pink card while living in a blue bowl, it is likely to say that is pink as it is the same as it has always seen,
but the pink it sees is not the same shade as those outside the bowl would see since it is pink seen through a blue filter. It is because of this that most people with a personality disorder do not recognise that they have a personality disorder since the world looks the same as it always has and there is nothing to give an alternate view. Even if told there is a filter, since it has built up over the course of the person’s life, there is no understanding of the true colour of pink as it has always been seen through a blue filter. There is, therefore, no real reason for a person to doubt their assumption of what pink really looks like. That coating exists for all of us and determines how we see the world. The degree to which it enhances or limits our world view is determined by how we perceive the events which have occurred throughout our lives. There is an old adage that says that everything seen in abnormal psychology can be seen in normal psychology. It only becomes a disorder when it affects our daily living and the manner in which we interact with the world around us and others in that world to the point that it causes a marked deviation from the expectations of the individual’s culture. This must occur in cognition, that is the way in which people perceive and interpret
themselves, other people or events; affect, or the range, intensity lability and appropriateness of emotional responses; interpersonal functioning; and impulse control. Because of its nature, it is long-standing, inflexible and pervasive, and leads to clinically significant impairment in social, occupational or other important areas of functioning.
In that sense, while many with personality disorders know right from wrong, it tends to be an academic knowledge and is not something that may impact on the person’s decision to act. While a personality disorder can be singularly present, it can also be present along with other disorders including other personality disorders. Since a personality disorder is the result of the coating or lense through which the world is viewed and that coating can be composed of an infinite number of experiences, there are an infinite variations in personality disorders. Having said that, the most recent publication, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, or DSM-5, put out by the American Psychiatric Association groups them into three main clusters. Cluster A includes Paranoid Personality Disorder, or a basic distrust and suspiciousness of others, Schizoid Personality Disorder, or a pattern of detachment from social relationships, and Schizotypal Personality Disorder, or an acute discomfort with close relationships along with eccentricities in behaviour.
Cluster B includes Antisocial Personality Disorder, a disregard and violation of the rights of other, Borderline Personality Disorder, instability of interpersonal relationships and self-image, Histrionic Personality Disorder, excessive emotionality and attention seeking, and Narcissistic Personality Disorder, grandiosity and a need for admiration. Cluster C includes Avoidant Personality Disorder, social inhibition and feelings of inadequacy, Dependant Personality Disorder, submissive and clinging behaviour, and Obsessive-Compulsive Personality Disorder, a preoccupation with orderliness and perfection. It also includes space for those which do not easily fall into any of the above categories. When the International Classification of Mental and Behavioural Disorders, Eleventh Edition (ICD-11) is published by the World Health Organisation it is likely to have slightly different names and classifications, but is likely to be generally similar to DSM-5.
While not extensive in detail, the above gives an idea of the breadth of personality disorders which may occur. It also becomes clear that personality disorders
have wide ranging impacts on the lives of those who have then as well as those around them. In that sense, when the nature of a personality disorder is understood, it can help to explain how and why a person acts in a given situation. Clearly, almost by definition, an individual with a personality disorder is
unlikely to act in a situation impacted on by that disorder in the same way that someone without such a disorder would act.
To understand how and why a person with a personality disorder acts in a certain way, it is necessary to have a clear view of the events that have lead to the establishment of that disorder. Equally, an assessment of the likelihood of change is necessary when assessing any considered intervention or risk posed by someone with a personality disorder. Although they have a long duration and a low efficacy, the treatment of personality disorders is viable in many cases. The treatment of such conditions is, in the long run, less expensive than the consequences of non-treatment.