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Personality Disorders Personality disorders are
patterns of perceiving, reacting, and relating to other people and events
that are relatively inflexible and that impair a person's ability to function
socially. ·
Behavior
may be odd or eccentric, dramatic or erratic, or anxious or inhibited. ·
Doctors
consider the diagnosis when inappropriate thinking or behavior is repeated
despite negative consequences. ·
Drugs
do not change people's personality traits, but psychotherapy may help people
recognize their problem and change their socially undesirable behaviors. Everyone has characteristic patterns of perceiving and relating
to other people and events (personality traits). That is, people tend to cope
with stresses in an individual but consistent way. For example, some people
respond to a troubling situation by seeking someone else's help; others
prefer to deal with problems on their own. Some people minimize problems;
others exaggerate them. Regardless of their usual style, however, mentally
healthy people are likely to try an alternative approach if their first
response is ineffective. In contrast, people with a personality disorder are rigid and
tend to respond inappropriately to problems, to the point that relationships
with family members, friends, and coworkers are affected. These maladaptive
responses usually begin in adolescence or early adulthood and do not change
over time. Personality disorders vary in severity. They are usually mild and
rarely severe. Most people with a personality disorder are distressed about
their life and have problems with relationships at work or in social
situations. Many people also have mood, anxiety, substance abuse, or eating
disorders. People with a personality disorder are unaware that their
thought or behavior patterns are inappropriate; thus, they tend not to seek
help on their own. Instead, they may be referred by their friends, family
members, or a social agency because their behavior is causing difficulty for
others. When they seek help on their own, usually because of the life
stresses created by their personality disorder, or troubling symptoms (for
example, anxiety, depression, or substance abuse), they tend to believe their
problems are caused by other people or by circumstances beyond their control. Until fairly recently, many psychiatrists and psychologists felt
that treatment did not help people with a personality disorder. However,
specific types of psychotherapy (talk therapy), sometimes with drugs, have
now been shown to help many people. Choosing an experienced, understanding
therapist is essential.
Personality disorders are
grouped into three clusters. Cluster A personality disorders involve odd or
eccentric behavior; cluster B, dramatic or erratic behavior; and cluster C,
anxious or inhibited behavior.
Cluster A: Odd or
Eccentric Behavior Paranoid Personality: People with a paranoid personality are
distrustful and suspicious of others. Based on little or no evidence, they
suspect that others are out to harm them and usually find hostile or
malicious motives behind other people's actions. Thus, people with a paranoid
personality may take actions that they feel are justifiable retaliation but
that others find baffling. This behavior often leads to rejection by others,
which seems to justify their original feelings. They are generally cold and
distant in their relationships. People with a paranoid personality often take legal action
against others, especially if they feel righteously indignant. They are
unable to see their own role in a conflict. They usually work in relative
isolation and may be highly efficient and conscientious. Sometimes people who already feel alienated because of a defect
or handicap (such as deafness) are more likely to suspect that other people
have negative ideas or attitudes toward them. Such heightened suspicion,
however, is not evidence of a paranoid personality unless it involves wrongly
attributing malice to others. Schizoid Personality: People with a schizoid personality are
introverted, withdrawn, and solitary. They are emotionally cold and socially
distant. They are most often absorbed with their own thoughts and feelings
and are fearful of closeness and intimacy with others. They talk little, are
given to daydreaming, and prefer theoretical speculation to practical action.
Fantasizing is a common coping (defense) mechanism. Schizotypal Personality: People with a schizotypal personality,
like those with a schizoid personality, are socially and emotionally
detached. In addition, they display oddities of thinking, perceiving, and
communicating similar to those of people with schizophrenia (see Schizophrenia and Delusional Disorder: Schizophrenia).
Although schizotypal personality is sometimes present in people with
schizophrenia before they become ill, most adults with a schizotypal
personality do not develop schizophrenia. Some people with a schizotypal personality show signs of magical
thinking—that is, they believe that their thoughts or actions can control something
or someone. For example, people may believe that they can harm others by
thinking angry thoughts. People with a schizotypal personality may also have
paranoid ideas. Cluster B: Dramatic or Erratic Behavior Histrionic (Hysterical) Personality: People with a histrionic personality
conspicuously seek attention, are dramatic and excessively emotional, and are
overly concerned with appearance. Their lively, expressive manner results in
easily established but often superficial and transient relationships. Their
expression of emotions often seems exaggerated, childish, and contrived to
evoke sympathy or attention (often erotic or sexual) from others. People with a histrionic personality are prone to sexually
provocative behavior or to sexualizing nonsexual relationships. However, they
may not really want a sexual relationship; rather, their seductive behavior
often masks their wish to be dependent and protected. Some people with a
histrionic personality also are hypochondriacal and exaggerate their physical
problems to get the attention they need. Narcissistic Personality: People with a narcissistic personality
have a sense of superiority, a need for admiration, and a lack of empathy.
They have an exaggerated belief in their own value or importance, which is
what therapists call grandiosity. They may be extremely sensitive to failure,
defeat, or criticism. When confronted by a failure to fulfill their high
opinion of themselves, they can easily become enraged or severely depressed.
Because they believe themselves to be superior in their relationships with
other people, they expect to be admired and often suspect that others envy
them. They believe they are entitled to having their needs met without
waiting, so they exploit others, whose needs or beliefs they deem to be less
important. Their behavior is usually offensive to others, who view them as
being self-centered, arrogant, or selfish. This personality disorder
typically occurs in high achievers, although it may also occur in people with
few achievements. Antisocial Personality: People with an antisocial personality
(previously called psychopathic or sociopathic personality), most of whom are
male, show callous disregard for the rights and feelings of others.
Dishonesty and deceit permeate their relationships. They exploit others for
material gain or personal gratification (unlike narcissistic people, who
exploit others because they think their superiority justifies it). Characteristically, people with an antisocial personality act
out their conflicts impulsively and irresponsibly. They tolerate frustration
poorly, and sometimes they are hostile or violent. Often they do not
anticipate the negative consequences of their antisocial behaviors and,
despite the problems or harm they cause others, do not feel remorse or guilt.
Rather, they glibly rationalize their behavior or blame it on others.
Frustration and punishment do not motivate them to modify their behaviors or
improve their judgment and foresight but, rather, usually confirm their
harshly unsentimental view of the world. People with an antisocial personality are prone to alcoholism,
drug addiction, sexual deviation, promiscuity, and imprisonment. They are
likely to fail at their jobs and move from one area to another. They often
have a family history of antisocial behavior, substance abuse, divorce, and
physical abuse. As children, many were emotionally neglected and physically
abused. People with an antisocial personality have a shorter life expectancy
than the general population. The disorder tends to diminish or stabilize with
age. Borderline Personality: People with a borderline personality,
most of whom are women, are unstable in their self-image, moods, behavior,
and interpersonal relationships. Their thought processes are more disturbed
than those of people with an antisocial personality, and their aggression is
more often turned against the self. They are angrier, more impulsive, and
more confused about their identity than are people with a histrionic
personality. Borderline personality becomes evident in early adulthood but
becomes less common in older age groups. People with a borderline personality often report being
neglected or abused as children. Consequently, they feel empty, angry, and
deserving of nurturing. They have far more dramatic and intense interpersonal
relationships than people with cluster A personality disorders. When they
fear being abandoned by a caring person, they tend to express inappropriate
and intense anger. People with a borderline personality tend to see events
and relationships as black or white, good or evil, but never neutral. When people with a borderline personality feel abandoned and
alone, they may wonder whether they actually exist (that is, they do not feel
real). They can become desperately impulsive, engaging in reckless promiscuity , substance abuse, or self-mutilation. At
times they are so out of touch with reality that they have brief episodes of
psychotic thinking, paranoia, and hallucinations. People with a borderline personality commonly visit primary care
doctors. Borderline personality is also the most common personality disorder
treated by therapists, because people with the disorder relentlessly seek
someone to care for them. However, after repeated crises, vague unfounded
complaints, and failures to comply with therapeutic recommendations,
caretakers—including doctors—often become very frustrated with them and view
them erroneously as people who prefer complaining to helping themselves. Cluster C: Anxious or Inhibited Behavior Avoidant Personality: People with an avoidant personality are
overly sensitive to rejection, and they fear starting relationships or
anything new. They have a strong desire for affection and acceptance but
avoid intimate relationships and social situations for fear of disappointment
and criticism. Unlike those with a schizoid personality, they are openly
distressed by their isolation and inability to relate comfortably to others.
Unlike those with a borderline personality, they do not respond to rejection
with anger; instead, they withdraw and appear shy and timid. Avoidant
personality is similar to generalized social phobia (see Anxiety Disorders: Social Phobia). Dependent Personality: People with a dependent personality
routinely surrender major decisions and responsibilities to others and permit
the needs of those they depend on to supersede their own. They lack
self-confidence and feel intensely insecure about their ability to take care
of themselves. They often protest that they cannot make decisions and do not
know what to do or how to do it. This behavior is due partly to a reluctance
to express their views for fear of offending the people they need and partly
to a belief that others are more capable. People with other personality
disorders often have traits of a dependent personality, but the dependent
traits are usually hidden by the more dominant traits of the other disorder.
Sometimes adults with a prolonged illness or physical handicap develop a
dependent personality. Obsessive-Compulsive Personality: People with an obsessive-compulsive
personality are preoccupied with orderliness, perfectionism, and control.
They are reliable, dependable, orderly, and methodical, but their inflexibility
makes them unable to adapt to change. Because they are cautious and weigh all
aspects of a problem, they have difficulty making decisions. They take their
responsibilities seriously, but because they cannot tolerate mistakes or
imperfection, they often have trouble completing tasks. Unlike the mental
health disorder called obsessive-compulsive disorder (see Anxiety Disorders: Obsessive-Compulsive Disorder (OCD)),
obsessive-compulsive personality does not involve repeated, unwanted
obsessions and ritualistic behavior. People with an obsessive-compulsive personality are often high
achievers, especially in the sciences and other intellectually demanding
fields that require order and attention to detail. However, their
responsibilities make them so anxious that they can rarely enjoy their
successes. They are uncomfortable with their feelings, with relationships,
and with situations in which they lack control or must rely on others or in
which events are unpredictable. Some personality types are not classified as disorders. Passive-Aggressive (Negativistic)
Personality: People
with a passive-aggressive personality behave in ways that appear inept or
passive. However, these behaviors are actually ways to avoid responsibility
or to control or punish others. People with a passive-aggressive personality
often procrastinate, perform tasks inefficiently, or claim an implausible
disability. Frequently, they agree to perform tasks they do not want to
perform and then subtly undermine completion of the tasks. Such behavior
usually enables them to deny or conceal hostility or disagreements. Cyclothymic Personality: People with cyclothymic personality
alternate between high-spirited buoyancy and gloomy pessimism. Each mood
lasts weeks or longer. Mood changes occur regularly and without any
identifiable external cause. Many gifted and creative people have this
personality type (see Mood Disorders: Cyclothymic Disorder). Depressive Personality: This personality type is characterized
by chronic moroseness, worry, and self-consciousness. People have a
pessimistic outlook, which impairs their initiative and disheartens others. To
them, satisfaction seems undeserved and sinful. They may unconsciously
believe their suffering is a badge of merit needed to earn the love or
admiration of others. A doctor bases the diagnosis of a personality disorder on a
person's history, specifically, on repetition of maladaptive thought or
behavior patterns. These patterns tend to become apparent because the person
tenaciously resists changing them despite their negative consequences. In
addition, a doctor is likely to notice the person's immature and maladaptive
use of mental coping mechanisms, which interferes with their daily
functioning. A doctor may also talk with people who interact with the person. Relief of anxiety, depression, and other distressing symptoms
(if present) is the first goal. Drug therapy can help. Drugs such as
selective serotonin reuptake inhibitors (SSRIs) can help both depression and
impulsivity. Anticonvulsant drugs can help reduce impulsive, angry outbursts.
Other drugs such as risperidone Some Trade Names However, drug
therapy does not generally affect the personality traits themselves. Because
these traits take many years to develop, treatment of the maladaptive traits
may take many years as well. No short-term treatment can cure a personality
disorder, although some changes may be accomplished faster than others.
Behavioral changes can occur within a year; interpersonal changes take
longer. For example, for people with a dependent personality, a behavioral
change might be to stop stating that they cannot make decisions; the
interpersonal change might be to interact with coworkers or family members in
such a way that they actually seek out or at least accept some
decision-making responsibilities. Although treatments differ according to the type of personality
disorder, some general principles apply to all treatments. Because people
with a personality disorder usually do not see a problem with their own
behavior, they must be confronted with the harmful consequences of their
maladaptive thoughts and behaviors. Thus, a therapist needs to repeatedly
point out the undesirable consequences of their thought and behavior
patterns. Sometimes the therapist finds it necessary to set limits on
behavior (for example, people might be told that they cannot raise their
voice in anger). The involvement of family members is helpful and often
essential because they can act in ways that either reinforce or diminish the
problematic behavior or thoughts. Group and family therapy, group living in
designated residential settings, and participation in therapeutic social
clubs or self-help groups can all be valuable in helping to change socially
undesirable behaviors. Because personality disorders are particularly difficult to
treat, choosing a therapist with experience, enthusiasm, and an understanding
of the person's areas of emotional sensitivity and usual ways of coping is
important. Kindness and direction alone do not change personality disorders.
Psychotherapy is the cornerstone of most treatments and usually must continue
for more than a year to change a person's maladaptive behavior or
interpersonal patterns. In the context of an intimate, cooperative doctor-patient
relationship, people can begin to understand the sources of their distress
and recognize their maladaptive behavior. Psychotherapy can help them more
clearly recognize the attitudes and behaviors that lead to interpersonal
problems, such as dependency, distrust, arrogance, and manipulativeness. For maladaptive behaviors, such as recklessness, social
isolation, lack of assertiveness, or temper outbursts, group therapy and
behavior modification, sometimes within a day hospital or residential setting,
are effective. These behaviors can be changed in months. Participation in
self-help groups or family therapy can also help change maladaptive
behaviors. Dialectical behavioral therapy is effective for borderline
personality disorder. This therapy involves weekly individual psychotherapy
and group therapy as well as telephone contact with therapists between
scheduled sessions. It aims to help people understand their behaviors and
teach them problem solving and adaptive behaviors. Psychodynamic therapy is also
effective for people with borderline or avoidant personality disorder. These
therapies help people with a personality disorder think about the effects
their behaviors have on others. For some people with personality disorders,
primarily those that involve maladaptive attitudes, expectations, and beliefs
(such as narcissistic or obsessive-compulsive personality), psychoanalysis
(see Overview of Mental Health Care: Psychotherapy)
is recommended and is usually continued for at least 3 years. Last full review/revision May 2006 by John G. Gunderson, MD http://www.merck.com/mmhe/sec07/ch105/ch105a.html
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