Personality Disorder

Psychiatry is a hodge podge collection of venn diagram interconnecting overlapping diagnosis. The DSM Axial diagnostic system was an attempt to look at the various dimensions of a disorder and chart their biological psychological and sociological sources.

Axis I refers to the current and major focus of therapy whereas axis II refers to the personality traits or disorder, axis III any predominantly physical concern, axis IV social or environmental factors and Axis V the global assessment of functioning for the individual based on a scale that shows 100 as exceptionally well, below 50 as failing and lower requiring chronic social and psychological assistance or institutionalization.

Axis II, the personality disorder scale is generally speaking the least competently completed. There are many reasons but mostly 'personality' and 'character' are poorer understood today by average psychiatrists and unfortunately for the diagnostic class there are no pharmaceutical solutions to the treatment of personality. Personality disorders bring to the awareness of all that medications really predominantly manage 'symptons' and personality disorders are decidedly at greater risk for all the symptons of psychiatry but the treatment of choice is medication and psychotherapy not just medication alone.

Increasingly psychiatrists are little trained in psychotherapy, lack psychological mindedness and rely predominantly on medications for their income. There are even those psychiatrists who hold the medication pad like a cross between them and their patients.

Personality is considered to be a play of genetics and environment. The collection of coping skills that an individual leaves adolescence with were considered necessary for the individual to survive their family and early environments. They were adaptive to an extent but become decreasingly 'adaptive' over time till these habits of interaction finally fail to serve the individual in their interaction with society and they end up in the psychiatrists office with some evidence of 'dis-ease'.

Personality disorders don't just appear late in life otherwise a good clinician will consider 'organic personality disorder' which is a 'personality change' secondary to brain injury or other physically disturbing event. Generally speaking personality disorders are a "pattern of dysfunction" which can be seen in adolescence and continuing through adulthood until it culminates in need for treatment.

Usually personality disorders are more identifiable by others than by themselves. Many of the personality disorders "get under the skin" of others because it's obvious that their chronic 'coping' patterns are at the basis of the recurrent failures to achieve their ends.

Personality disorders derive mostly from the work of Dr. Carl Jung, Reich, Adler and others who looked at the complexity of the relationship of individual and society and how culture and individuals interacted.

Dr. Carl Jung made a major contribution by identifying the major division between the introvert and the extrovert. The DSM classifies these two types of personality as Cluster B for extrovert and Cluster C for introvert. Cluster A in the DSM is best described as "odd". They're the true eccentrics, the adult autistics and slightly schizophrenic sorts who muddle along without being really crazy but seem 'off' to most by their peculiar habits.

Cluster B is where the Antisocial Personality Disorder, Narcissistic Personality Disorder, Histrionic and Borderline Personality disorders are gathered. Much of the research that has helped us understand personality disorders in general has derived from the well funded research that has gone into the study of the Antisocial Personality Disorders.

The key here is 'context' and 'adaptation'. A person with the traits of 'antisocial personality disorder' might well use these positively by joining a police force or military rather than becoming a 'gang' member. Similiarly it's been said that to be a good criminal lawyer you have to have a fair measure of narcissistic personality disorder. The histrionic naturally makes a very good actress but might not be very good as a space shuttle pilot. The borderline is often similiarly described as a 'b' movie actress or actor because of the chaos that permeates their lives. They are the proverbial drama queens who become suicidal over a broken fingernail.

Cluster C personality disorders include the dependent, those who are constantly parasitically attaching themselves to others and abdicating from responsibility but then are dissatisfied by the eventual abuse that comes when the idealizations turn to devaluations. Obsessive compulsive personality disorders fit this category . Naturally if you are an accountant and obsessive compulsive your concern for detail and perfection might benefit your clients. The trouble is that the obsessive can't live with themselves worrying about their mistakes all night long.

The passive aggressive personality disorder is probably the most significant and least diagnosed of the cluster c category despite its commoness as a 'trait'. Indeed one of the ironies of psychiatry is that this field attracts more introverts than extroverts and specifically cluster c passive aggressives are forever 'punishing' extrover patients by 'punatively' labelling them as 'cluster b' personality disorders. Cluster B personality disorder in turn more commonly label cluster c personality disorders as 'those assholes". There's considerable black humor in the field of personality research and when one understands personality traits one can't help but see them in everyone and see why so commonly it's over emphasis or dependence on a 'trait' (coping mechanism) that is creating the 'problem' not so much the situation as the person in the situation will more commonly insist to all and sundry.

Now consider the paranoid. They might make a very good political or theological writer denouncing the evils and threats "out there' while never ever considering their own perceptual biases. The key thing is that this is a stable trait and that these individuals are generally functional but they're on the edge and like all the personality disorders the very characteristics that they have can cause them to 'go over the edge".

Tabloid newspapers make a heyday out of these times in these individuals lives. The histrionic 'flirting' with everyone suddenly is 'raped' and 'she/he' never saw it coming but everyone else would have described that person as a 'train wreck waiting to happen'. The obsessive compulsive one night 'break's' and finds themselves having gone from deep anxiety to chronic depression and now suicidal can't see why their life lead them to the psychiatric hospital yet those around always knew this person was 'wound too tight'.

The personality disorders have benefitted most from group therapies where their interactions with many people can be interpreted back to them. Too often in one to one therapy they simply 'discount' the 'opinion' of the therapist yet in a group it's harder to ignore a dozen others giving the same feedback.

Medications commonly are used symptomatically to help a person be able to hear advise and take in information without so much defensiveness. Anti anxiety medications, antidepressant medications and even anti psychotic medications are commonly the place where therapy begins because in crisis personality disorders are not 'open' to change. Indeed the very coping mechanisms that usually get them into the difficulties in the first place are the ways they hope to get out of the difficulty.

Hence the anxious antisocial personality disorder can't hear the 'recommendations' of the police officer because they're trying to figure out how to 'lie' their way out of this situation or 'fight' their way out. Medications can be used to reduce the anxiety and violence potential and give the person time to 'reflect' on their need to change if they don't want the same thing happening over and over again.

Increasingly the 'medicalization' of psychiatry has resulted in the 'fast food' approach to psychiatric problem solving. Hence, rather than looking at the 'why' the person has been in three relationships in which they've been beaten up or why they can't keep a job or have any long term friends, the medication approach is often solely a 'band aid' with the need for changing 'band aids' frequently or sometimes wrapping the patient up in metaphoric guaze. This is fine for 'crisis' management but the problem is that there is a need for much more.

Politically though, funding, and the approach to disease management is commonly based on addressing the 'crisis' and forgetting about the 'meaning' or the 'long term management' of whatever the 'crisis' was about. Crisis management is 'sexy'. The politicians love this sort of 'stop gap' measure but what is most commonly needed is the kind of thinking that is used in "rehabilitation medicine". Yet there is nothing 'sexy' about 'rehabilitation' or 'chronic care'.

So commonly in the present day system people were personality disorders are the most poorly treated and yet often have the greatest potential.

In the past there was great frustration in treating personality disorders for many because they didn't treat the addictions that commonly are part of the maladaptive coping armamentarium. Today it's recognized that treatment of addictions needs to precede the therapy for the personality disorders because the latter therapies of change are commonly 'anxiety' provoking and "uncovering" and encourage 'new, unknown," behaviours that increase the sense of 'vulnerability" and throw a person back to the addictive 'self soothing' behaviours if these aren't addressed first and in combination with the subsequent treatments, group and individual for the personality disorders.

Borderline personality disorder is commonly now understood to be untreated PTSD until proven otherwise. Anti social personality disorders are commonly understood today to be usually part of a 'context' where the behaviours which don't work in the 'greater society' are the very traits that permit 'survival' in the person's immediate environment. The movie, Clockwork Orange did a marvellous job of addressing the difficulties of treating an anti social individual without also treating the anti social individuals immediate 'group' and 'environment'. Passive aggressive only persist when they are not held accountable etc.

The successes in this field are so often the most gratifying for the therapists. These are usually the 'success stories' we read about where a person 'found themselves' or their 'life turned around'. It's one of the most exciting areas of psychiatry and tragically one that is often so poorly understood.