Unlike me, many people are uncomfortable with the idea of personality disorders. The term itself does the concept no favours, as it can sound like a judgement on someone’s entire being, or alternatively, like an excuse for undesirable behaviour. Even so, most people would be able to identify an acquaintance or two whose personality is extreme enough in one way or another that it goes beyond “normal”, or to state that without that particular vapid word, causes problems for themselves or others. Beyond this, mental health workers also find the notion problematic in several ways. Nonetheless, for simplicity’s sake I’m going to start with the “classic” view of the nature of specific personality disorders, before going on to look at the problems psychiatrists and others perceive with it. Well not quite yet: I want to bring something up first.
In this post, I mention in passing that I’m not always keen on D’s. By this I mean the tendency to add “disease” or “disorder” to something, which when abbreviated turns into a D. For instance, ADHD. To be honest I don’t like either D in that initialism. During my training it was borne in upon me that if one is to respect one’s client one should divorce the disorder from the person in front of you, or rather, sitting at an angle of approximately 137.5o. It’s better to talk about someone with disordered eating than someone with an eating disorder. This is similar to referring to someone adjectivally rather than substantivally (is that a word), so someone is “theist” or “atheist” as opposed to “A theist” or “AN atheist”. Hence I would perhaps be better referring to someone as having a disordered personality rather than having a personality disorder, but there’s another problem there. An autistic person might prefer to be called that rather than a person with autism because it’s an important part of her identity. Likewise, someone might identify with a personality disorder, but there is a way of externalising them which I will come to later. Back to the main point.
There are said to be ten personality disorders, along with a couple of other combinations of personality traits which could also qualify, such as Machiavellian personality which is part of the “Dark Triad”. There’s also, as there so often is, “not otherwise specified”, which is the diagnosis of elimination at the end of such categorisations as the DSM and possibly ICD (can’t remember). Leaving those aside, there is a “classic” set of categories which can then be split into smaller diagnoses: anxious, emotional/impulsive and eccentric. Cluster A is the third of these: schizoid, schizotypal and paranoid. The first two of these reflect a recurrent problem I perceive with psychiatric nomenclature, that concepts are often appalingly badly and confusingly named. Cluster B is the second, including antisocial, histrionic, borderline and narcissistic. Once again, the failure of nomenclature makes itself felt in the term “borderline”, which is probably usually or almost always misunderstood by outsiders, and for this reason is sometimes relabelled “emotionally unstable”. Finally, cluster C comprises the obsessive-compulsive, avoidant and dependent disorders, so to speak.
Cluster B is the most notorious, because it includes features of the Dark Triad. This is psychopathy (more on that in a moment: it’s one form of antisocial personality disorder), narcissism and machiavellianism, which as I’ve said has been considered by some to be a personality disorder in itself. It’s notable, incidentally, that two of those are named after someone, although of course one is mythical, because these people are harmfully self-centred. Narcissism is said to involve an excessive sense of self-importance, need for admiration and lack of empathy, all masking a deeper lack of self-esteem. I personally believe there’s a gender bias in the criteria for this, because one of the questions on a typical questionnaire asks about how important one feels one’s appearance is and how much time is spent on grooming, which I believe would typically differ between women and men, and then the question arises of why a man shouldn’t spend so much time on that. It also doesn’t work particularly well as a way of identifying narcissism, because for example people who have breast enhancements or cosmetic surgery on their noses may be body dysmorphic instead, and that’s definitely not the same thing. It’s very common for Donald Trump to be identified as a narcissist by both mental health professionals and the general public. Antisocial personality is rather complex in its relationships with the outside world. It covers psychopaths and sociopaths, and although the term is deprecated I prefer the word “psychopath” because it’s easier for most people to understand. Psychopaths are born, sociopaths made. Either way, a person with antisocial, also known as “dyssocial”, personality disorder lacks empathy, is manipulative, agressive, disregards the rights of others (that needs rewording for non-rights based language – isn’t aware of duties and obligations), lacks remorse and tends to be impulsive and break the law. I find this unsatisfactory. Not all psychopaths are impulsive. If they are, it may be to do with their lack of prudence, because prudence is, in a sufficiently deep-thinking person, fairly similar to having a conscience. There is, of course, a high proportion of people in prison who are psychopathic, but the world is also run by psychopaths who are not in prison and don’t even have criminal records. Also, although there’s a large overlap between ethical behaviour and legal behaviour, there are many situations where they’re opposites, and you can’t always follow your conscience without breaking the law. Psychopaths can be useful, because for example they may make better surgeons, but perhaps the biggest problem with this society and many others is that psychopathy leads to success. Ultimately this means our leaders in industry and politics are mainly psychopathic. Neither psychopathy and its allied states nor narcissism are likely to be pursued by the person concerned as diagnoses, but they do tend to be made in a criminal setting – that is, you get arrested, profiled as a psychopath before being arrested or diagnosed by professionals treating your victims or investigating their murder or manslaughter. Broadening focus to the Dark Triad in general, there’s also machiavellianism (not sure of the capitalisation but since I’ve written “narcissism” with a small N, there you go – looks wrong though), which is manipulative, callous and indifferent to morality, in other words a caricature of Machiavelli. It probably goes without saying that Machiavellianism (all right then!) is another trait common in successful politicians and business leaders. Machiavellianism differs from the others in that it involves alexithymia – not being able to understand emotions. Theoretically, psychopaths can understand emotion quite well and in fact use it to manipulate people, so it isn’t that they lack empathy but have a different attitude towards it. Both psychopaths and Machiavellians are basically people who act on their ethical scepticism. Ethical scepticism, probably more commonly known as moral skepticism, is the belief that no ethical views are valid, i.e. that there is no right or wrong. Bertrand Russell was a moral skeptic, but didn’t act on it and was in fact a very active social campaigner. The difference is when you actually put it into practice in your life.
It’s probably worth mentioning at this point that my own father is a psychopath, i.e. officially diagnosed as one by people working within the police and judicial system. I mention this not to be vindictive but to illustrate a wider point I wish to make later.
The other two in this cluster are borderline and histrionic. I’ll deal with borderline personality disorder (BPD) first. BPD people may have mood swings, worry about abandonment, are “thin-skinned”, self-harm, end their lives, have a weak sense of identity, are impulsive, have a sense of inner emptiness, are intensely angry, tend to dissociate or become paranoid under duress and have difficulty maintaining relationships. These criteria tend to be stronger when they’re younger but not everyone changes. I can’t let this pass without a rant about the name. WHAT WERE THEY THINKING‽ Calling it “borderline personality disorder” makes it sound either like it’s a mild personality disorder or that it’s a combination of different personality disorders and comes across as terminally vague. It got this name because it was considered at the time to be on the edge of being psychotic, which it isn’t. As a name, it’s now entrenched and used all over the place, so although “emotionally unstable personality disorder” is another, newer, title for the diagnosis, it doesn’t seem likely to catch on. This name is a disaster. It’s been said that the character Faith in ‘Buffy’ is a good example of BPD. You might be noticing, incidentally, that I’m not talking about causes or treatment in this post at all, but this is already going to be pretty long so I don’t want to wade into that too much. Dialectical Behavioural Therapy, though, is used with people who are “emotionally unstable.”
It should probably be noted at this point that dissociative personality has been mentioned here, which is seen as another personality disorder but which some people “own” as an aspect of their identity.
The other one in this cluster is histrionic personality disorder. These are people who dramatise things, often as a way of making them seem realer to themselves. I wouldn’t consider myself to be diagnosable with this at all but I know that I tend to do this too, so I can empathise quite well with this aspect and I am widely acknowledged to be a drama queen. Besides this, people with histrionic personality disorder seek attention, flirt, dress or behave provocatively (I never flirt, so I really am not this), are rash, easily influenced by others, are seen as drama queens and feel they have to entertain others. They may also use language in such a way that they’re difficult to pin down. Looking at this list, with which I’m not massively familiar, it seems to me that there are a few lines of paid work where most of these things would be an asset, notably acting, dancing and stand-up comedy. People with this disorder tend to use “thou” earlier than most others would – this doesn’t work in English nowadays of course because we only have one word for “you”, but I mean something like “Du” or “tu”. They tend to be extrovert, and attach very quickly. I also do this, but I never use “tu” when I speak French, so the situation for me is that I find it easy to empathise with this but don’t consider myself to be this kind of person. These people sound like they might be fun to be around, though perhaps wearing, but it isn’t fun to be them because, for example, they tend to feel ignored and place a higher value on relationships with people who only regard them as acquaintances, so they can be easily hurt. It’s probably clear that BPD and histrionic personality disorder have a lot in common, and that histrionic personality disorder is somewhat like narcissism too, and this begins to reveal one of the problems with this way of thinking about personality disorders.
Then there’s cluster C. This includes Avoidant, Obsessive-Compulsive and Dependent Personality Disorders, associated with anxiety and fear. Avoidant is the “nicest” personality disorder in a way, and although I have definite avoidant tendencies, certainly more than average, it doesn’t seem to constitute an issue in the way it would for someone diagnosable with the condition, partly because I tend to be quite sociable, but I do know a couple of people quite well with this diagnosis. It’s often abbreviated to AvPD. Such people are sensitive and discouraged by criticism, avoid personal relationships, avoid social activities and feel inferior to others. Dependent is somewhat similar, and involves not feeling adequate to function in an “adult” way, being indecisive, having others assume responsibility for your life, not being confident and thinking of everyone else as more capable than you are. Again, although I don’t know that anyone I’ve encountered has this as an official diagnosis, I do know people like this and I can see tendencies in myself, though more weakly than with histrionic personality disorder and much more so than AvPD. However, as with all of these I don’t think I qualify for any diagnosis of this nature. This is mainly about empathy.
Obsessive-Compulsive Personality Disorder needs to be distinguished from obsessive-compulsive behaviour, and in fact with this and several others yet to be mentioned, there’s a correspondence between a specific mental health issue and a personality disorder. Obsessive-compulsive people may stick to a rigid schedule, refuse to delegate, are workaholics, have unrealistically high standards for themselves and others, worry about mistakes and become anxious when things don’t seem perfect. They also think their own way is best. This again is a potentially marketable and socially useful set of traits, for instance in medical professions. The difference between OCPD and OCD is that the latter are neurotic, i.e. they have insight into their issues and wish they didn’t have them, whereas the former are “at peace” with them and may not understand that it’s okay for others not to be like that. This means that, like some of the Cluster B diagnoses, these people are unlikely to seek help.
Finally, there’s Cluster A: schizoid, schizotypal and paranoid. Here again the failure of psychiatric conditions to be sensibly labelled arises. It isn’t helpful to call two quite dissimilar personality types by such similar names, and the very use of the word “schizophrenia” led to a persistent popular confusion of the condition with dissociation for many decades. Conversely, clearly the word “paranoia” was considered too useful and so it was renamed the vague-sounding “delusional disorder”. I don’t know what’s wrong with their naming conventions, but it’s a serious problem. Anyway, starting with what is apparently still called Paranoid Personality Disorder, this is persistent distrust and suspicion starting by early adulthood, and can be remembered by the mnemonic SUSPECT:
- Suspicious of others
- Unforgiving
- Suspects partner is unfaithful, therefore controlling in relationships.
- Perceived attack.
- Enemy or friend?
- no Confiding in others.
- Threats always perceived.
Compliments may be interpreted as sarcastic or manipulative. The world is unsafe to them. They do feel the need for emotional closeness and therefore have relationships, and can be perceived by others in positive ways, at least initially. Their distrust often leads to them not seeking help and it’s therefore probably underdiagnosed. It’s important to note that paranoia itself, i.e. the problem now described as “delusional disorder”, is not like this in a crucial way. I tend to think people who are paranoid are mainly unlucky with their experiences in such a way that it’s led to them having non-bizarre but poorly corroborated beliefs about the world, which are usually threatening in nature. Studies show that people who are paranoid as a mental condition as opposed to the personality disorder usually think mainly in similar ways to most other people with the exception that they jump to conclusions. Someone with paranoid personality disorder as opposed to paranoia need not have been unlucky with their experiences. They just are like that, at least as adults. I don’t deny that they’re likely to have a history explaining how they’ve become like this, but it isn’t an episode that they’ve talked themselves into. I also suspect that this is another personality type which can lead to successful careers.
Schizoid people are loners who are comfortable with being that way. They don’t express their emotions much, don’t feel the need for companionship, aren’t interested in sexual relationships and these people are basically hermits. It can be confused with autism by outsiders. Schizoid people are not, however, always asexual. They’re often interested in sexual arousal but don’t connect it with intimacy. They’re emotionally cold and indifferent to criticism and praise alike. Again, schizoid people don’t seek diagnosis or help, but their family and acquaintances might. Autistics would tend to have less varied interests and have desires for relationships rather than a lack of interest. Although I’m in no way schizoid, it’s also true that I’ve only recently realised that many people don’t consider hermits to be well-adjusted people. To my mind, this doesn’t seem to be a personality disorder at all because it’s harmless and only distressing to the family if they don’t reach a stage of acceptance.
Finally among Cluster A is schizotypal. This has been seen as the precursor of schizophrenia itself. Schizotypals are eccentric, perceive and think oddly and are uncomfortable with close relationships. This is across the board by the way: they’re uncomfortable with all relationships in all contexts. They have most of the following characteristics: odd social interaction such as not making eye contact, difficulty picking up on social cues, ideas of reference (thinking everything is about them in a cognitive rather than emotional way), knight’s move thinking (such as supposing that the way cellophane looks on a cigarette packet means it’s sending messages about them to the police), odd beliefs which are unlike social norms (this is incidentally the main reason religion is not a mental illness), belief in the great significance of the paranormal, circumlocutory and impenetrable use of language, excessive social anxiety which does not improve with repeated exposure, and bodily illusions. They also have few close friends but, unlike schizoid people, are not happy about that. The kind of beliefs they have may have similiarities to the kind of things I mentioned I believed as a child here. Brain scans show that they tend to have reduced grey matter, i.e. the cell bodies of neurones in the brain as opposed to the white matter of the connections, and the incidence of this personality type is about the same as bipolar disorder, so it’s surprising that it isn’t talked about more. The neurological characteristics found suggest that it may be on the schizophrenic spectrum as a kind of “high-functioning” schizophrenia similar to how Aspergers might be seen as “high-functioning” autism (bearing in mind that this is not a good way of describing it). As such, schizophrenics might change on anti-psychotic medication but this is because it reduces the positive symptoms of the condition such as hallucinations and delusions, but it doesn’t tend to alter these people’s outlook much because many of the manifestations of their personality resemble its negative symptoms such as poverty of speech and flatness of affect. And in the interests of full disclosure, this is in fact the personality disorder I score most highly on when I’ve done the rather inaccurate and poorly-administered questionnaires available online. I suspect that people who are schizotypal have managed to go through life without having encountered the kind of stresses which would trigger a full-blown psychotic episode in them, and that the threshold for this varies person to person.
This post has rather got away from me, so next time I’ll criticise the classical model of personality disorders I’ve just outlined, but that’s it for today.
A Box Of Chocolates 