Shining a light on per­son­al­ity dis­or­der

Irish Independent - Health & Living - - MIND MATTERS - WITH PA­TRI­CIA CASEY

THE Ir­ish pub­lic is now well versed in as­pects of var­i­ous men­tal ill­nesses. Gone are the taboos that sur­rounded psy­chi­atric ill­ness in the past, when it was spo­ken of in whis­pered tones and seen as a weak­ness in­stead of be­ing viewed with com­pas­sion and un­der­stand­ing. The pub­lic knows a bit about bipo­lar dis­or­der, de­pres­sive ill­ness, and schizophre­nia. Anx­i­ety, stress and pho­bias are in their lex­i­con also, and many suf­fer with these con­di­tions.

The one ex­cep­tion to this knowl­edge is per­son­al­ity dis­or­der. What is per­son­al­ity dis­or­der, how is it di­ag­nosed, how is it treated? Surely every­body has this con­di­tion, since no­body is per­fect?

I have just been read­ing Tam­ing the Beast Within, writ­ten by my friend and men­tor Peter Tyrer from Im­pe­rial Col­lege Lon­don, an ex­pert on per­son­al­ity. It is the only book on this sub­ject for the pub­lic that I am aware of. In­ter­est­ingly, one of the few cat­e­gories of per­son­al­ity dis­or­der that peo­ple may be fa­mil­iar with is nar­cis­sis­tic per­son­al­ity dis­or­der. The other cat­e­gory recog­nised by the pub­lic is the psy­cho­pathic type, as ep­i­thets like ‘psy­cho’ are in com­mon us­age to de­pict some­body cruel and dan­ger­ous. Han­ni­bal Lecter in Si­lence of the Lambs is the pro­to­type.

To un­der­stand the con­di­tion called per­son­al­ity dis­or­der, the start­ing point is to ask ‘what is per­son­al­ity?’ One dic­tio­nary def­i­ni­tion men­tioned by Tyrer is that “it is the com­bi­na­tion of char­ac­ter­is­tics that forms an in­di­vid­ual’s dis­tinct char­ac­ter”. The traits that de­ter­mine it for the most part are con­stant over time, but they are not as rigidly fixed as psy­chi­a­trists once be­lieved. There can be some mod­i­fi­ca­tion over time with mat­u­ra­tion. These traits may be pos­i­tive or neg­a­tive, de­pend­ing on cir­cum­stances. Im­pul­siv­ity, for ex­am­ple, can be as­so­ci­ated with spon­tane­ity, which is a pos­i­tive at­tribute, but it can be neg­a­tive when it leads to im­promptu de­ci­sion-mak­ing.

Se­condly, per­son­al­ity has an im­pact on re­la­tion­ships with oth­ers — and when there are per­son­al­ity prob­lems, these will man­i­fest them­selves in in­ter­per­sonal prob­lems, not only with those close to the per­son but with oth­ers more re­mote, such as work­mates or mem­bers of the pub­lic with whom they have con­tact.

Terms like per­son­al­ity dis­or­der are still used in psy­chi­atric text­books and this sug­gests that the world is di­vided into two groups — those with nor­mal and those with ab­nor­mal per­son­al­i­ties. Re­search now shows that per­son­al­ity is on a con­tin­uum with what is re­ferred to as per­son­al­ity dis­or­der be­ing at the far end, to the ex­tent that re­la­tion­ships in gen­eral suf­fer hugely.

These prob­lems may re­late to the per­son’s con­stant de­pen­dence on oth­ers for ad­vice or support, or to their cal­lous­ness and dis­re­gard, or to their un­stint­ing rigid­ity, and so on. These traits show them­selves as both emo­tions and be­hav­iours that oth­ers iden­tify and are af­fected by. At the other end of the per­son­al­ity spec­trum are those with oc­ca­sional dif­fi­cul­ties in re­la­tion­ships, but these are short lived and self-lim­it­ing, and this is where most of us are placed.

The story of the la­bels be­gan in 1923 with the work of Ger­man psy­chi­a­trist Kurt Sch­nei­der. He iden­ti­fied 10 per­son­al­ity types based on the dom­i­nant ab­nor­mal traits in­clud­ing ob­ses­sional, de­pen­dent, im­pul­sive, and so on. In­ter­est­ingly, he did not iden­tify nar­cis­sism. These traits, or their mod­ern equiv­a­lents, are still in use to­day, although they will be largely aban­doned in the com­ing years when the World Health Or­gan­i­sa­tion pub­lishes its new clas­si­fi­ca­tion of psy­chi­atric dis­or­ders in 2020.

Per­son­al­ity is formed both from genes and from the en­vi­ron­ment. In par­tic­u­lar child­hood trauma, ne­glect or abuse, is a stres­sor that has a last­ing im­pact. The ear­lier the trauma, the more se­vere the im­pact on per­son­al­ity, po­ten­tially caus­ing a dis­or­der. It is now also recog­nised that per­son­al­ity dis­or­der can be­gin even in adult­hood. While its ori­gin may flow from events in child­hood, it is sel­dom di­ag­nosed be­fore the age of 18. One re­quire­ment, what­ever the age of di­ag­no­sis, is that the fea­tures have to be present for a min­i­mum of two years. This is to al­low for the re­al­ity that many peo­ple faced with a stres­sor may have pe­ri­ods when their emo­tions and in­ter­per­sonal re­la­tion­ships are prob­lem­atic un­til time or ther­apy heals them. Per­son­al­ity dis­or­der would not be di­ag­nosed in these in­stances.

Re­gard­ing treat­ment, there is lit­tle ev­i­dence for the ben­e­fits of med­i­ca­tion, but there is some ev­i­dence of ben­e­fit from psy­cho­log­i­cal ther­apy for the cat­e­gory known as ‘emo­tion­ally un­sta­ble per­son­al­ity dis­or­der’. Per­son­al­ity dis­or­der con­tin­ues to be a con­tro­ver­sial di­ag­no­sis since it is dif­fi­cult to de­fine and there is lim­ited ev­i­dence of the ben­e­fit of treat­ment. Tam­ing the Beast pro­vides user-friendly, ac­ces­si­ble in­for­ma­tion to those af­fected by this of­ten elu­sive and com­plex di­ag­no­sis.

Per­son­al­ity is formed both from genes and from the en­vi­ron­ment — child­hood trauma has a last­ing im­pact

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