Our understanding of personality disorder is limited. What is it? What symptoms does it present? Why does it happen? How do you define it? How does the sufferer cope with it and how does his environment cope with it? Why does something like this exist in mankind, affecting personal and social situations of those who suffer from it and those who do not?
Fundamentals of personality disorder
In personality disorder there is need and suffering What does a person with personality disorder feel and think? What image does he have of himself and what meaning does he have of the world? To what extent does he access his own and other people’s thoughts? Does he recognize his feelings and thoughts as incorrect?
Imagine a person living with the expectation of rejection, with a personal history of maladaptive behaviors. In a job interview, unable to read the friendly attitude of the interviewer, he interprets contempt, his apparent competence shifts to an attitude of active passivity accompanied by feelings of anger and emotional pain, and finally self-invalidation. He refuses the job without finishing the interview before being judged. Why? If we look for the functionality of this behavior, we could consider that it is a way to avoid the evaluation to which he feels subjected and with it the emotional pain he suffers. To do so, he invalidates the interviewer and excludes himself before the interviewer may reject him. In the short term it is a useful behavior. We can therefore try to understand the behavior of the personality disorder in terms of its function, not its form.
The dilemma we find then, between the perceived functionality of the pattern of thoughts and maladaptive behaviors and the expectations of the culture of the environment, leading to uncertainty, which places us in a cognitive inconsistency, an emotional dysregulation or a behavioral unpredictability from which derives by psychological cause a behavior (although functional from the perspective of people with personality disorder) a behavior I say, incorrect in reference to the context where it develops, generating in the sufferer significant limitations in their ability to manage life, suffering and vulnerability.
What is personality?
The widespread use of the term personality reveals a significant ambiguity that makes a majority definition impossible.
In spite of this significant diversity, definitions coincide in considering firstly, the totality of manifest behavior as well as private experience; secondly, the persistence and permanence of its characteristics; thirdly, the singularity of the unique character of each person; and finally, the usefulness of categorization to describe, explain and reliably predict behaviors based on a hypothetical construct of behavior that we call personality.
Personality models look for cause-effect relationships in the physiological, psychological or sociocultural that move between the inherited and the learned, and determine a habitual behavior or way of being, encompassing both the manifest behavior and the cognitive and emotional experience. This pattern of behavior involves an ingrained lifestyle that affects the way of interpreting reality, thinking, feeling and acting with a consistent behavior that is forged between the inherited temperament, and the unique character, consciously determined, acquired throughout life by the experiences and social and cultural influences, product of the integration of the processes of each person.
The value of personality
In spite of the objective of describing people reliably by assigning them the category of definitive, personality in its dynamic and evolutionary condition, presents a transituational consistency and open to the incorporation of knowledge and opinions, open to rational debate and therefore susceptible to present different behaviors, as the concrete situation in which it develops changes, and innovative according to the new variables involved. Therefore, its value transcends from the private sphere to human interactions, since the integration of temperament -conceived as genetic inheritance-, biography -or personal history of what we do and what happens to us in life-, and character -as a learned part of the behavior forged in education, family and immediate environment-, this sum understood as personality, is the basis of the social competence of a human being (De Waele and Harre, 1976).
The personality pathway
The route to reach this social competence of the mature personality, which determines people’s behavior patterns, requires defeating automatic thoughts with the help of rational interpretation; to achieve this, rational interpretation confers meaning to feelings; these gain emotional credit and the empirical support of experience with actions; then, actions train habit by integrating knowledge, capacity and desire; and finally, habit shapes the character that defines personality.
What about mental disorder?
The second concept that needs to be explained is that of disorder. A mental disorder is characterized by a significant alteration in cognitive state, emotional regulation or overt behavior, reflecting dysfunction of psychological, biological or developmental processes (DSM-5). The term is used to indicate behaviors identifiable by a group of recognizable symptoms that interfere with the activity of the organism (ICD-10).
We do not currently understand mental disorders as natural classifications, since they do not exist in reality as such. The categories we use are constructs that help us to understand the general laws that regulate abnormal behavior due to psychological causes and guide us in dealing with the problems of psychopathological personality disorder. Therefore, there are no diseases, there are people in whom mechanisms of self-image construction, definition of personal and social identity, emotional interpretation, attribution of meaning to the world, problem-solving strategies, social attribution, interpersonal relationships, in short, there are people who require individualized psychological attention.
What is personality disorder?
When people extend their particular maladjustment to several of these contexts of inner life and social life, limiting their capacity and causing their discomfort and that of those around them, we are dealing with personality disorder. The criteria accepted by the DSM for personality disorder is the permanent pattern of internal experience and behavior apart from the culture of the environment that causes significant discomfort and deterioration in family, social and occupational activity.
Nature of personality disorder
We are far from understanding the nature of the relationship between personality traits and personality disorder. Several models propose personality traits as a vulnerable factor for personality disorder or vice versa. Others propose the existence of a mutual influence with a continuity derived from the dependence on innate temperamental factors (Gutierrez, 1996), the basis of the learned character that defines personality. Dimaggio and Semerari trace personality disorder back to a cognitive or emotional deficit of metarepresentation of the self, which affects the way in which the person organizes emotions and the system of meanings of his inner world, his belonging to the world and relationships with others.
For its part, the etiology of personality disorder, although complex and undefined, describes among its causes:
(a) Genetic vulnerability factors due to the influence of genetic inheritance acting both at the individual level and in association with abnormal environmental factors.
b) Alteration of neurotransmitters involved in the regulation of impulses, aggression and affect, which could contribute to excessive response to stress and emotional hypersensitivity in interpersonal relationships.
c) Neurobiological dysfunction describing evidence of structural and functional deficits in key brain areas for the regulation of affect, attention, self-control and executive function, and scientific evidence regarding brain structures involved in the relational disturbance component (Stanley and Siever, 2010).
d) Psychosocial factors and contextual characteristics tend to be considered predisposing facilitators of personality dysfunction.
e) Attachment processes derived from insecure or disorganized attachment relationships that suggest a failure in the development of mentalization capacity. (Mirapeix, Vázquez, Gómez, & Artal, 2017).
Despite the certainty about the involvement of these areas in the construction of the self and the construction of perceived reality, we do not have a complete understanding of the brain that connects it to the foundation of personality.
Types of personality disorder
Personality disorders are complex to assess. It requires the detection of a broad and heterogeneous set of traits, symptoms, and behaviors, an assessment of the duration and inflexibility of symptoms, and the evaluation of how they produce emotional distress and functional impairment in various life domains. (Mirapeix, Vázquez, Gómez, & Artal, 2017).
Unstable patterns of maladaptive thinking and behaviors, also called incorrect or unhealthy behaviors, fall into three clusters:
Cluster A personality disorders.
Hardly undergo variation throughout life, characterized by a persistence of eccentric and bizarre thoughts and behaviors, with especially problematic social situations due to mistrust and malicious interpretation, introversion and low sociability, including schizoid personality disorder (mistrust), schizotypal personality disorder and paranoid personality disorder.
Cluster B personality disorders
With a tendency to decline in middle age, characterized by emotionally unpredictable and extreme thoughts and behaviors, affective lability and disruptive behavior. They include borderline personality disorder, antisocial personality disorder, histrionic personality disorder and narcissistic personality disorder.
Cluster C personality disorders
With presence of neuroticism, characterized by dominant thoughts and behaviors of anxiety and fear with high dependence and neuroticism and predominant use of denial, rationalization, avoidance and inhibition such as avoidant personality disorder, dependent personality disorder and obsessive-compulsive personality disorder. Additionally there is the category of depressive personality disorder, characterized by difficulty in pleasure, and passive-aggressive disorder, determined by intrapsychic conflicts.
Diagnosis and treatment of personality disorder
The DSM and ICD typology constructs help us to establish a diagnosis of personality disorder which, after overcoming the resistance to assessment of those who suffer from it, requires evaluation of manifest behavior, cognition, impulse control and interpersonal relationships (there are various instruments according to the DSM-4 and ICD-10 diagnostic criteria).
Following Quiroga and Erraste, there is no empirically proven treatment to treat all personality disorders in general, the most widely accepted treatment of choice being psychotherapy, where there is a specific psychotherapeutic management strategy for the different personality disorders. In behavioral and cognitive therapies, problem solving and crisis management, cognitive restructuring and training in skills framed in the therapeutic alliance have been important elements.
From the pharmacological point of view, the various treatments used to date have been aimed exclusively at symptomatological control. The best results have been obtained in those that reduce impulsivity in crisis situations and in those that stabilize mood.
In any case, we have already expressed that there are no diseases, there are people with personality disorder who, as Millon explains, require combined modalities strategically designed in a sequential manner, therefore, we add, personalized. In accordance with the laws of human functioning that must be attended to in a systematic way, Millon himself proposes as basic dimensions the purpose of personal existence, the mode of adaptation, the interest in survival and offspring and the personal styles for representing life experiences in the form of personal meanings.
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Living with personality disorder
Coping with the daily complications of personality disorder involves an ongoing effort to get to know oneself and learn to manage the bad days. The person with personality disorder lives in a persistent discrepancy between private experience and what society describes as appropriate behavior. This discordance reinforces beliefs, dysfunctional assumptions and inappropriate behaviors from which the motivational context of the personality disorder is generated.
The suffering of the person with personality disorder can be found in the testimony of Anna, diagnosed with borderline personality disorder:” …for me it is a big problem not to have emotional stability, my sudden mood swings make people not know how to treat me and to move away…I avoid the suffering by cutting the relationship before they leave me…society is mediocre…I would not like to be as simple as others…I begin to understand what is wrong with me…However I continue and will continue to think that I do not fit in this society” (Frías, A. Living with borderline disorder. pp.109-110 ).
The effects of this deregulation of emotions in their significance, leads to functional strategies from the perspective of the person with personality disorder, and yet maladaptive and unexpected in quality and degree in the context. At the same time it interferes with the maintenance of the sense of self, the purpose of which is to establish emotional consistency, stable ideation and behavioral predictability over time and in similar situations.
Returning to Anna’s case, we find that she presents an inability to inhibit mood-dependent maladaptive behaviors or to initiate mood-independent behaviors of the current moment, necessary to set long-term goals. Anna suffers. She has before her a long therapeutic road of validation and change in which to understand herself and learn psychosocial thinking and behavioral skills (discomfort tolerance, emotion regulation, self-awareness, interpersonal effectiveness, etc.) until she accepts and adapts to the normal stresses of daily life.
The environment observes how the person suffering from the personality disorder becomes a risk to himself, to the family and to relationships. They tend initially to claim normality, an apparently simple behavioral learning that is socially taken for granted. “It’s simple, just change the behavior, you can do it”…but it’s not, each crisis leaves us reeling, fragile as a reed fearful of the future.
The family oscillates between understanding maladaptive behavior, allowing itself to be manipulated by fear of reaction, and criticism that leads to increased conflict, living in exhaustion. Uncertainty opens the way to new problems, their consequences and the persistence of the behaviors. These undermine the helping mood of family members and the tension of coping leads to states of anxiety and depression.
The way of relating to people with personality disorder begins with understanding: understanding that they act functionally according to their particular way of seeing the world, they act as they know how; understanding that their objective is not to hurt, that the conflict is not personal, that its function is to reinforce the behavior; understanding the suffering of maladaptive behavior; understanding that they face a long therapeutic path of self-knowledge and learning of normalized psychosocial skills. Assimilating this philosophy is important because it determines the attitude of helping to change, which is an essential component of the relationship of family members with those suffering from personality disorder.
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Dimaggio, G. y Semerari, A., (2008). Los trastornos de personalidad [Personality disorders]. Biblioteca de psicología, Desclée de Brouwer, Bilbao.
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Mirapeix, C., Vázquez, J., Gómez, A., y Artal, J., (2017). Abordaje integrador del Trastorno Límite de la Personalidad [Integrative approach to Borderline Personality Disorder]. Servicio de Psiquiatría del Hospital Universitario Marqués de Valdecilla y CIBERSAM, Santander.
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