Friday, January 29, 2010

Personality Disorder

Personality is seen in psychiatry to be a collection of traits and behaviours that can be traced from adolescence forward. Everyone has "personality traits". DSMIV asks examiners to record what these traits are in Axis II of the diagnosis. Broadly is the person 'odd' or "peculiear' or are they introverted or extroverted.

The traits reflect the internal defences that an individual develops to cope with the desires of the individual child and the introjected demands of adult society. Defences were the 'interpreted" mechanisms of interaction between the super ego and id. Eissenberger describes the history of this development in his thoroughly brilliant classic, "The Discovery of the Unconscious". Later these 'defences' would be more commonly called 'coping strategies" referring to how the individual interacted with the society about them.

Personality and character were terms to described the facets of the individual who 'rough' is 'smoothed' in their relationships to the external demands of the group. A defect was sort of an "unpolished' bit or indeed a coping strategy which worked well enough at a younger age or in a different social milieu but was no longer adaptive.

Personality disorders have much in common with addictions because the disorders themselves can be understood as addiction to an earlier useful 'strategy'. With alcoholism there's 'fun', 'fun and trouble' and 'trouble'. Alcohol and drugs serve to cope with the anxiety the individual feels and serves to 'self soothe'. Similiarly personality disorders reflect persistence of 'self serving ' or even 'self soothing' strategies beyond their 'do not use date'.

Borderline personality disorders act in many ways similar to the adolescent in the first phase of adolescence. Adolescence is that time of leaving home and establishing an adult family. The first phase is usually a partial or complete rejection of the parents and a move to the safety of the same sex age group. Once separated with hopefully at least an uneasy d├ętente with the past the adolescent comfortable in the new group moves on to establish a primary bond with another and moving on to form in the third phase the new nuclear unit.

It's a fact of modern and priviledged societies that childhood can be prolonged. In cultures more involved in survival the length of adolescence is not uncommonly brief, at most a year or two and the rituals of the group clearly delineated the end of childhood and the obligations and responsibilities of adulthood. In the west post modern contemporary society adolescence has extended into the 20's with the extension of education and adults living at home for lack of funds to establish a separate home.

With personality disorders there's a tendency to be somewhat surprised to see what is a normal acceptable behavior developmentally much earlier being pulled out and used in interactions in adulthood. The passive aggressive personality disorder famous for prolonged "pouts" and "chronic depressions" is reminiscient of the "terrible twos" with the child refusing to put poo poo in the potty and treating the whole issue as a kind of 'game' much to the horror of parents.

The dependent personality disorder is the 'clinger' , the child holding onto mommy's skirt and refusing to move further. They glom onto people taking hostages and calling that "love".

The antisocial personality disorder is the school yard bully who as an adult has a quick draw baton or gun if he's blue collar and quick draw lawyer if he's white collar. Wealth and status don't mean there are 'less' personality disorders but in fact wealth and status can increase the very tendency to develop and sustain personality disorders. However in the rich and powerful these are usually called "eccentricities". Only the truly rich and powerful can fully avoid growing up and live of life of childhood with it's narcissistic entitlement and utter disregard for the concerns of others.

Personality disorders are terms that are given to those who encounter the psychiatric system, the social support system, or the courts and the less resources the more likely one is to fall afowl of these societal agencies vested with powers of maintaining the peace.

Personality disorders tend to 'rub' one the wrong way. The borderline personality disorder threatens suicide a tad too easily or perhaps too often. The antisocial personality disorder would rather beat you up as to have a cup of tea. The paranoid personality disorder sees conspiracy in every action of the government, including garbage collection.

The fact is everyone is looking for love and personality disorders are usually people who didn't get it in their families. They may have got it but didn't recognize it but on the inside they look like those obese or anorexic or scarred kids whose hurt shows. Personality disorders are the hidden handicaps like learning disabilities and physical disabilities like deafness. I've told personality disorders that they'd probably have an easier life if they just wore a bandage around their head or wrapped their chest with white linen to indicate to the world that they're 'wounded'.

They're the survivors of the 'war of childhood' in which a child wants attention from their parents much as another child may long for food. Often the parents didn't get what the child seeks so can't give what they haven't got. More commonly the natural disasters and losses like deaths and calamities have disrupted the child raising process.

Paranoia is a life saving trait in a war torn zone and may well be what keeps you alive if your father or mother is an violent alcoholic. The histrionic personality disorders desire for intimacy is coupled with a fear of in depth engagement more commonly because of countless broken promises that result in that superficiality and external warmth coupled with the guarded interior.

The borderline wanting love says come hither, stay away, vacillating in between and so comfortable in being rejected that they more commonly set up a set of 'traps' and 'challenges' for any one who is considered to be let in but of course everyone or most everyone fails these "tests".

The 'coping mechanism' of the personality disorder are like 'guns' and to learn the more adaptive tools of the adult trade one has to put down the 'gun' and learn to wrestle or bargain or trade. It's terrifying to let go of a 'gun' and there's little promise of safety in a handshake or an embrace. At the merest threat one goes for the gun that might even have been tossed away.

So in times of crisis all the 'old' ways surface. And sadly drugs and alcohol make even the best of us look like "personality disorders' because chemical addictions cause a reversible brain damage with higher levels of functioning , the forebrains most human aspects of what theorists like Piaget called the realm of 'abstract thinking' and Maslow described as 'self actualization' slowly eroding giving alcohol and drugs the name, "the great eraser'. They take everything away even character.

No one is immune. It was the arrogance of the men of the age of rationalism who figured if they were captured in the female sex trade and fed heroin and cocaine then put out to work as slave prostitutes by their sociopath pimps that they the men wouldn't do this but women 'succumbed' because they had weak character.

Patton almost lost his generalship when he beat a 'shell shocked' soldier. Later research showed everyone would develop 'shell shock' if they were exposed to 220 days of a war zone necessitating the modern effective rotations. Much of the damage being done by noise and sleep deprivations. Sleep deprivation studies showed that everyone went psychotic eventually.

And the senior crack cocaine researcher in New York said that in his experience that if anyone did crack for 6 months steadily and kept doing it , they'd sell their grandmother for more crack at two years because crack changed the brain drastically.

Sometimes the treating community feels sad for the personality disorders or even those with the more offensive 'eccentricities' because the alcoholics and addicts who abstain from alcohol and drugs and join AA or NA or one of the other therapeutic communities, they have a higher success rate for recovery than those who haven't turned to drugs and alcohol to smooth the interface between themselves and society. Sober, personality disorders are treatable within the community and with therapy individually after the 'first stage' of recovery.

It's one of the amazing facts of work in addiction psychiatry but it's a place where the personality disorders are seen to disappear especially for those who enter into service, get jobs, develop altruism and humor and have gratitude for being able to pay taxes. It's a process of maturity and it begins in the addiction community with saying no to the first drink or drug.

It's harder for a mere personality disorder to 'volunteer' or 'pay taxes' or 'say no to angry outburst or running away, or to join a club. Personality disorders show most when people are in longer term relationships or in longer term jobs or when they have to change and their limitations in adaptation to change show.

The fact remains there is love and it can be found and when the 'guns' are dropped adult love is possible without the drama. Thankfully for all personality disorders are treatable conditions and not uncommonly simply 'burn out' as the individual gets 'tired' of burden of carrying all the 'baggage from the past' and having the same old same old problems always seem to be recurring.

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