Personality Disorder: Concepts and Treatment
The Concept of Personality
The term personality represents a person’s enduring characteristics manifesting as behaviour in various circumstances. Personality disorder differs from mental illness. The behaviours that define personality exist throughout adult life. On the other hand, the state that defines a mental condition differs from the individual’s earlier, normal state. However, it is worth noting that a disordered personality can also develop as a consequence of traumatic experiences, e.g. emotional or sexual abuse.
The Importance of Assessing Personality
Assessing personality is significant in psychology and psychiatry for several reasons. Different types of personalities tend to predispose to certain psychiatric conditions and may illuminate the psychiatric symptoms. Moreover, they may also impact how a person reacts to the treatment and determine strategies for forming an effective therapeutic relationship.
Type of personality (e.g. obsessional) can shape unusual features of a psychiatric condition (e.g. overthinking and inhibition in depression), particularly when personality traits become inflated due to a disorder. Therefore, the underlying psychiatric diagnosis can be muddled if the clinician does not assess a patient’s personality.
Personality as a Predisposition
Personality can predispose to mental health conditions by affecting a person’s response to stressful circumstances. For example, adverse events are more likely to result in an anxiety disorder in a worrier, an individual with an anxious personality who tends to worry about minor problems.
Structures of Personality
There are two main structures of personality, one of which is character and the other temperament. Temperament is the inborn predisposition to behave in a particular way. Historically, the notion of temperament was part of the concept of the four humours and their corresponding temperaments. Sanguine (ruled by their own pleasure to live), choleric (feels powerful and demonstrates it), melancholic (doubts and ruminations direct the person) and phlegmatic (the person lacks any efforts to feel happy and lives without pleasure). On the other hand, the character is a constellation of habits, a disposition developed through learning and experience.
Childhood and Personality Development
The Freudian theory of psychosexual development underlines childhood experiences during the first five years of life. Furthermore, Freud claimed that people must successfully accomplish five critical phases of libido progression to develop a healthy personality. Failure or fixation at particular stages elucidated particular characteristics of adult personality.
Jung saw personality development as a permanent course, with “individuation” as its ultimate objective. His theories are particularly relevant to later-life disorders. Jung presented the notions of “introversion” and “extraversion”.
Erikson has outspread Freud’s theory of psychosexual development. His eight stages of development sustained into late adulthood, with each phase being a conflict, e.g. “trust versus mistrust”, which individuals must resolve. Erikson accentuated the importance of the teenage years.
Attachment Theory
Bowlby (1951) highlighted the critical impact of maternal deprivation on personality. He posited that a reliable connection was necessary for functional, secure attachment and that a secure attachment promoted healthy relationships and mental health in later life. Conversely, insecure attachments often lead to the inability to form relationships in later life.
Abnormal Personality: the Concept and Diagnoses
Some personalities may appear clearly abnormal—for example, paranoid traits of being overly suspicious, sensitive, and mistrustful. However, fulfilling the complete diagnostic criteria of paranoid personality disorder is rarely possible. Depending on the intensity of trait expression, personality can be seen as a set of particular traits, personality difficulty or personality disorder.
Moreover, the newest categorisation of the WHO-issued International Classification of Diseases (ICD) eliminates all types of personality disorders except for a general explanation of personality disorders. This diagnosis can be further detailed as mild, moderate or severe. In addition, personality trait domains (disinhibition, detachment, anankastia, dissociality and negative affectivity) specify a personality.
Therapists may also indicate a borderline pattern qualifier. All personality disorders, particularly severe ones, encompass a borderline personality organisation (BPO). The BPO includes (1) identity confusion, (2) the use of immature defence mechanisms and 3) unstable reality.
On the other hand, the valid diagnostic criteria of the APA-issued Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), is still ‘’clustering’’ personality disorders into three groups clustered together by specifying similarities:
- cluster A: schizotypal, schizoid, paranoid.
- cluster B: narcissistic, histrionic, borderline, antisocial.
- cluster C: obsessive-compulsive, dependent, avoidant
All personality disorder diagnoses must meet the main criteria for a personality disorder as follows:
- ● The distinctive and long-lasting patterns of behaviour deviate noticeably from the cultural standard in more than one of the following areas: ways of connecting to others, control of urges and gratification, cognition, and emotionality.
- ● The behaviour is rigid and dysfunctional in wide-ranging situations.
- ● Causing distress to others and self.
- ● The presentation is stable and enduring, typically starting in late childhood or teenage years.
- ● The behaviour does not result from another mental condition, illness or brain injury.
Personality Disorder Treatment
One of the most critical services clinicians can offer for a patient with a personality disorder is a frank yet tactful sharing of their opinion on what is happening. However, individuals with a personality disorder may not see any issues in their personalities, even though their professional life, interpersonal relationships and marriage suffer. Often, hitting “rock bottom” in their career or personal life may encourage them to seek help.
A formal diagnosis of a personality disorder is generally not offered before the age of 18. However, signs and symptoms indicative of the disorder can be recognised at an earlier stage.
Individuals with personality disorders may have to try various therapists and therapy approaches until they discover an effective combination for their needs.
Personality Disorder Treatment: Supportive Psychological Therapy
Psychological therapeutic support has been the foundation of treating personality disorders. Mental health professionals usually work on distressing symptoms of a personality disorder using long-term psychotherapy (talk therapy), such as CBT, DBT, schema-focused therapy, psychodynamic psychotherapy, etc. Psychological support can achieve modest but valuable improvement by providing a consistent and safe point of reference. Improvement dynamics vary from patient to patient. In some people with a personality disorder, treatment progress is evident in several months. Sometimes, however, it may take years to start improving.
Personality Disorder Treatment: Pharmacological Therapy
No specific pharmacological treatment exists for a personality disorder per se. Yet, psychiatrists may prescribe psychiatric medication if a comorbid condition (e.g. depression, any type of anxiety disorder) is present. Furthermore, meta-analytical research evidence indicates that psychiatric pharmacological interventions could have favourable effects on facets of borderline personality disorder (BPD), such as emotional instability and uncontrollable impulses. Similarly, psychiatric medications may alleviate symptoms of schizotypal personality disorder. However, psychotherapeutic techniques (e.g. CBT, DBT) are essential to address borderline core symptoms. The BPD core symptomatology includes identity disruption, fear of rejection and abandonment and feelings of emptiness.
Bibliography
- ICD-11 Personality Disorders: A Psychodynamic Perspective on Personality Functioning – DOI: 10.3389/fpsyt.2021.654026
- Transference-Focused Psychotherapy – DOI: 10.1093/med/9780197574393.003.0008
- Personality and Personality Disorder – DOI: 10.1093/med/9780198747437.001.0001
- Assessment of Personality – DOI: 10.1093/med/9780199696758.001.0001
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