Personality disorder

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Personality disorders are a type of mental disorder defined by the American Psychiatric Association (DSM-5) as "an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment."

Both genetic predispositions and environmental factors (e.g. childhood sexual/emotional abuse or neglect) can play a role in the development of personality disorders. In a sense, they can be thought of as coping mechanisms taken to the extreme. It is not uncommon for someone to have more than one personality disorder at the same time.

Personality disorders often inhibit a person's ability to function successfully in society, but are, by and large, not harmful to society (with certain exceptions). Megalomania, fear of interaction, belief that one is destined to be something "great", trouble with relationships, and unstable self-image are all aspects that can lead to a diagnosis of "personality disorder".

Cluster A Disorders[edit]

Cluster A personality disorders (usually considered to be the black sheep or the least common of the official 10 personality disorders) involve eccentricity and psychosocial alienation. They are often thought to exist on a spectrum with schizophrenia, with which each shares symptoms, and first-degree relatives of schizophrenics have higher rates of Cluster A traits when compared to the general population.^[1]

Paranoid Personality Disorder[edit]

Paranoid personality disorder (PPD) involves an extreme suspicious belief or a conspiracy theory that other people, world governments, or central banks are going to try to harm people with PPD, but that is relatively impervious to evidence to the contrary.

Paranoid personality disorder can be distinguished from paranoid schizophrenia in that a person who suffers from paranoid personality disorder does not suffer from hallucinations or other false stimuli that reinforce their paranoia; they simply have a mindset that sees potential danger in everything.^{[citation needed]} While paranoid personality disorder can and often does lead to similar anti-social and abusive antics as narcissistic personality disorder or antisocial personality disorder, the underlying thought processes behind the harmful behavior are quite different. Where narcissists feel entitled to take whatever they want and psychopaths and sociopaths are apathetic to the harm they cause to others, paranoiacs tend to lash out in what they see as self-defense, seeking to neutralize any potential threat with extreme prejudice.^{[citation needed]}

Schizoid Personality Disorder[edit]

Schizoid personality disorder (SzPD) is characterized by inhibited emotions and a preference for being solitary. Someone with SzPD may be very aloof, unemotional, and uninterested in making any friends or becoming lovers with anyone very much, kind of similar to a classic autistic person (not a person with Asperger's syndrome), despite schizoid PD being a psychiatric disorder and autism being a neurological disorder.

Schizotypal Personality Disorder[edit]

Schizotypal personality disorder (StPD) is characterized by extreme, eccentric behavior and beliefs that are considered abnormal within a person's culture. It can resemble schizophrenia, and some genes that are strongly associated with schizophrenia are also expressed in people with StPD.^[2] People with StPD may realize that they are experiencing delusions of seeing ghosts and magic, or they may be unsure and decide to follow along with them "just in case." Their odd mannerisms may be perplexing to other people, and they may have severe paranoia. They often have few if any close interpersonal relationships.

Merely believing in supernatural beings or things is not enough to meet criteria for StPD: these beliefs must be culturally inappropriate. For example, if an adult who was born and raised Lutheran in Minnesota thought that his neighbor was trying to kill him via the evil eye, that might be consistent with StPD. But the same belief in someone from Ethiopia, where belief in the evil eye is very common,^[3] would not signify mental illness.

Although StPD shares delusions and hallucinations with schizophrenia, StPD rarely presents as full-blown psychosis and other common symptoms of schizophrenia, like catatonia or avolition, are absent or just mild in StPD. Treatment is different too: while antipsychotic drugs are cornerstones for treating schizophrenia, psychotherapy is the first-line treatment for StPD^[4], with a few small studies suggesting that low-dose antipsychotics might help as an adjunct to therapy^[5]. Because StPD is less debilitating than schizophrenia, and because antipsychotics can cause severe side effects like diabetes, obesity, and Parkinson's-like symptoms^[6], the risks of prescribing a medication to a patient with StPD may outweigh the potential benefits.

Cluster B Disorders[edit]

Cluster B personality disorders all involve dramatic, destructive traits (usually considered to be the most popular or the most common of the official 10 personality disorders). While they are not the commonest personality disorders in the general population — that would be Cluster C — they are the disorders most commonly seen in clinical settings.^[7]

Antisocial personality disorder[edit]

“”When we look back upon what has been recorded of Alcibiades, we are led to suspect that he had the gift of every talent except that of using them consistently to achieve any sensible aim or in behalf of any discernible cause.

—Hervey M. Cleckley[8]

Antisocial personality disorder (AsPD or APD) is defined by consistent disregard for social norms or other people's rights; those with it are often called "sociopaths" or "psychopaths." People with AsPD show little concern for others, experience shallow emotions, are often irritable or aggressive, and feel little if any remorse for their actions. They are often irresponsible, impulsive, prone to boredom, and have an unusually high need for stimulation; they sometimes take irrational risks to keep themselves amused, with little concern for even their own safety. This relative lack of fear means that the threat of punishment does little to deter them. They are also prone to lying, stealing, and sadism. Symptoms tend to peak during the late teenage years and early 20s. They sometimes improve on their own by a person's 40s.^[9] The disorder's disregard for others' rights makes people with it likelier to become criminals. It is estimated that 60-80% of some prison populations consist of people who suffer from AsPD.

People with AsPD are sometimes difficult to spot. Those who learn to read social cues can use superficial charm and feigned emotions to blend in, and can become successful as charlatans, shysters, and con artists. Those who learn social skills and suppress their impulsivity sometimes rise very high in political or corporate life, as their lack of scruples enables them to cross lines that their competitors wouldn't. "Psychopathic leadership" is recognized as a serious problem in politics and workplaces.^[10]

AsPD and "psychopathy" are sometimes used interchangeably, but psychopathy is often considered a somewhat different entity that accounts only for AsPD's most extreme cases. The distinction is less about a patient's observed behaviors, and more about whether said behaviors are caused by some innate brain defect (psychopathy), or arose during childhood in response to terrible living conditions (milder AsPD). The word "sociopath" is sometimes used colloquially to describe people with AsPD who lack psychopathy, but it seldom appears in contemporary scientific literature.^{[note 1]} Two illustrative fictional cases are Marlo Stanfield from The Wire and Tony Soprano: Tony is hailed as a realistic depiction of someone who developed AsPD in response to trauma, while Marlo's frigid brutality is more in line with psychopathy.

While the psychopathy-AsPD distinction is accepted and used in neurological and psychological research,^[11] things are murkier in clinical settings. UpToDate distinguishes between the two entities,^[12] but the DSM-5 doesn't recognize psychopathy.^{[note 2]}

Like many diagnoses, the term has been abused in the past. From 1917 to 1990, U.S. immigration law banned gay people from entering the country, on the grounds that they were psychopaths. Congress intended the term "psychopathic personality" to designate homosexuals as well as people having psychopathic disorders, as that term is generally understood.^[13]

The Athenian statesman and military leader Alcibiades, whose life was extensively documented by his contemporaries Plato, Xenophon, and Thucydides, is often cited as an excellent historical example of AsPD due to his repeated aggression, fearlessness, risk-taking, impulsivity, irresponsibility, and disloyalty: traits that enabled flashes of brilliant success, but prevented him from staying in power anywhere for long.^[14][15]

Borderline personality disorder[edit]

Borderline Personality Disorder (BPD) involves intense emotions and fear of abandonment. People with BPD may go to drastic lengths to avoid abandonment (real or perceived) and experience tumultuous emotions. These include a profound feeling of emptiness, depression, furious outbursts, fear, shame, and more.^[17] People with BPD may act in extreme, manipulative, or otherwise inappropriate ways, and may lack the self-awareness to realize that this is wrong.

The prevailing theory about people with BPD is that their perceptions (e.g. splitting, regarding a person as all good or all bad) and resulting behavior toward those they have devalued is the result of subconscious defense mechanisms, rather than the kind of purposeful malice exhibited by those with AsPD. Indeed, many sufferers of BPD have lost companionship and friendships due to doing what they simply believed was the right thing or what they had to do, even if lying or other sorts of destructive behavior is involved.^{[note 3]}

Randi Kreger's Stop Walking on Eggshells and Splitting alleges that BPD can be a reason why people make false allegations of rape and domestic violence, although there is no evidence to support this and there are some people who suffer from BPD who can actually be victims of such things. Rates of false allegations of rape are the same as any other crime.^[18] Dana Becker argues, "the BPD diagnosis has been used in court to institutionalize and/or medicate women involuntarily, deny them custody of their children, and have their parental rights terminated. Women diagnosed as having BPD have also frequently been discredited as witnesses in court cases involving rape or sexual abuse."^[19]

Some people have voiced concerns about BPD being over-diagnosed in order to dismiss angry or unhappy women.^{[note 4]} Quinn Capes-Ivy argues, "could that 'inappropriate anger' be not a disordered way of thinking, but valid female rage against a world which devalues women and things which are thought of as 'traditionally feminine'?"^[20] BPD was described by Gillian Proctor as "the latest example of a historical tendency to explain away as 'madness' the strategies some women use to survive oppression and abuse."^[21] Jennifer Reimer argues, "the portrayal of 'borderline women' in films in the late 1980s and early 1990s, such as Fatal Attraction, and Single White Female, as well as books like I Hate You, Don’t Leave Me, played a significant role in the stigmatization of so-called 'borderline' women."^[22]

Some men's rights writers, such as Paul Elam, aka a MGTOW asshole, argue that people with BPD know what they are doing and often enjoy it, saying to never "breed with a BPD woman."^[23] This has generated some push back, with people arguing that it is dehumanizing and unkind to talk about women with BPD this way.^[24]

More recent studies have provided evidence that BPD is at least partly hereditary in origin and has measurable biological effects that could challenge its classification as a personality disorder. Specifically, people with BPD have been found to show a combination of unusually high levels of activity within the amygdala^[25] and reduced prefrontal cortex activity, which would result in disproportionate emotional responses that cannot be regulated effectively.

BPD is often confused with bipolar disorder; the similar initials don't help. Both disorders share symptoms of impulsivity, self-destructive behavior, and suicidality, but BPD lacks empathy and experiences a chronic state of inner emptiness, while bipolar disorder retains capacity for empathy and has no narcissism; still, patients are often misdiagnosed. BPD actually shares more in common with Narcissistic and Antisocial personality disorders than it does with with bipolar disorder.^[26] Unfortunately, the treatment for each disorder is quite different. Bipolar disorder is a mood disorder, and medication is a backbone of treatment. For BPD, medications are of little help, and treatment depends on therapy.

Histrionic Personality Disorder[edit]

Histrionic personality disorder (HPD) involves a need to be the center of attention. Someone with HPD may go to great lengths to be an attention-seeker by being seductive and flamboyant, and act as if they were performing on a stage at all times. Someone with HPD might have unrealistic dreams centered on commanding others' attention, such as succeeding in Hollywood or on Broadway. In their personal lives, this translates into dramatic, often inappropriate behaviors. In healthcare settings, they may test doctors' boundaries by acting seductively.^[27] Compared to the rest of Cluster B, HPD is relatively understudied, perhaps because it doesn't involve the aggressive and self-destructive behavior that the rest of the cluster demonstrates.

Narcissistic Personality Disorder[edit]

Narcissistic personality disorder (NPD) involves being highly self-centered and entitled. Patients classically show an arrogant affect and an inflated sense of self-importance, which often conceals profound private fears of worthlessness. This leads people with NPD to seek emotional validation from others (often called "supply") in unhealthy, often abusive, ways.

This search for validation manifests as an unhealthy preoccupation with social status, expecting excessive admiration for one's accomplishments (real or imagined), grandiose and often unrealistic goals for reaching the top of life's hierarchy (such as via entertainment, business, or politics), and manipulative behavior. Bigotry may be common, since this gives the narcissist an easy way to feel superior to others.^{[note 5]}

People in a narcissist's life who recognize and begin resisting a narcissist's manipulation are often discarded and replaced with new sources of "supply". Like all victims of emotional abuse, people who have suffered at a pathological narcissist's hands may develop PTSD, anxiety, and depression. Children of narcissists are at risk of adopting aspects of NPD themselves, to cope with their parents' unrealistic expectations and a lack of unconditional love.

Wolters-Kluwer's UpToDate recommends subdividing NPD into overt, covert, and malignant subtypes. Overt NPD manifests with the classic loud, attention-hungry behavior. Covert NPD shares the overt type's dreams of unlimited success, but these are held privately; it may resemble clinical depression, and takes longer to diagnose. Malignant narcissism, which can be either overt or covert, features antisocial traits and absent empathy.^[28] However, the DSM-5 doesn't make these distinctions.

A possible example of the grandiose narcissist is Donald Trump, with a likely malignant narcissist being Adolf Hitler; covert narcissism, as its name suggests, is harder to identify in public figures. A few possible cases in popular culture are the grandiose Jimmy McNulty and Stringer Bell from The Wire plus virtually every member of the Lannister family from Game of Thrones, the covert Walter White from Breaking Bad, and the malignant Dennis Reynolds from It's Always Sunny in Philadelphia.

People often conflate the word "narcissist" with "abuser", like how "psychopath" is conflated with "serial killer". The truth is that not every abuser has NPD, that not every narcissist behaves like the classic aggressive abuser (people with covert NPD more often show passive-aggressive behavior), and that not all narcissists lack empathy.^{[note 6]} NPD is no joke: The condition is very unpleasant to live with, as one constantly seeks external validation to prop up a pathologically unstable self-image. NPD also carries a high risk of suicide, and patients with NPD who attempt suicide tend to choose deadlier methods.^[29]

"Narcissist" is also one of the most overused terms in psychiatry: it's safe to say that anyone who uses the term does not like whomever they're talking about, making the term relatively meaningless, thanks in no small part to YouTubers like Doctor Ramani.^[30] This is unfortunate, because NPD, for all the harm that it causes, is a serious mental illness.

There is little research on whether or how NPD might be treated. People with it are less likely to even seek treatment; NPD is often diagnosed when a patient is referred for a different problem, like suicidality, or if a spouse demands that the patient see a therapist. Therapies that were designed for BPD have recently begun being adapted for NPD, with some studies showing promising results,^[31] but no method has been proven to be superior or reliable. NPD makes building a therapeutic alliance hard, and it is difficult for patients with this disorder to accept that their distress is of their own making.^[32]

Some experts have analyzed Donald Trump's behavior and suggested that he is very likely to have NPD.^[33][34] Critics have pointed out the iffy ethics of armchair diagnosing public figures,^[35] and argued that people with mental disorders might not appreciate being compared to Donald Trump.^{[36][37][note 7]}

Gender issues with BPD and AsPD[edit]

Three-quarters of those diagnosed with borderline personality disorder are female. There is some speculation that because of gender stereotypes, a person manifesting certain thought and behavior patterns (e.g. impulsivity, inappropriate anger, paranoia, refusing to distinguish fiction from reality, hypocrisy, lying, reckless disregard for safety of self and others) is more likely to be diagnosed with BPD if female and antisocial personality disorder if male. A distinction sometimes drawn between BPD and AsPD is that those with BPD "act in" by harming themselves mostly, while those with AsPD "act out" by harming others.^[38] Though that doesn't preclude the former from acting violent towards others or the latter from committing self-harm, of course, as illustrated by murderer and alleged kitten killer Luka Magnotta, a young male adult diagnosed with borderline personality disorder.

With regard to the criteria, a major distinction between BPD and AsPD is the AsPD requirement "there is evidence of Conduct Disorder with onset before age 15 years." There is sometimes comorbidity between BPD and AsPD,^[39] and men who physically abuse women often have borderline and antisocial traits.^[40] According to the DSM, another difference between BPD and AsPD is that people with BPD are manipulative to gain the concern and nurturance of caregivers, while people with AsPD are manipulative to gain power, profit, or some other material gratification. Also, people with AsPD tend to be less emotionally unstable and more aggressive than people with BPD.

Anakin Skywalker of the Star Wars prequel trilogy is often held up as an instructive example of how BPD presents in males.^[41] As for females, the show Crazy Ex Girlfriend is about a woman with BPD.^[42] Interestingly, the show just started off with the main character being... odd, to say the least, but going with whatever behavior would make for the silliest song for a musical sitcom. In the later seasons, they brought an actual psychiatrist to consult and determined that the lead character fits the criteria of having BPD to the letter.

Cluster C Disorders[edit]

Cluster C personality disorders are characterized by fear.

Avoidant Personality Disorder[edit]

People with avoidant personality disorder (AvPD) avoid social situations due to feelings of inferiority and feelings of not being accepted by anyone. They tend to be overly sensitive about what people think of them. They also believe in the best of everyone having some good in them or they even believe that treating some abusers as people will make them become civilized human beings. However, most dramatic people never want to change to suppress their malicious behavior to treat others with empathy and to respect others' social boundaries, and if they did, they will revert to their old self. AvPD is often confused with social anxiety disorder, which has many symptoms, such as trembling, dizziness, fast heartbeat, dry mouth, excessive sweating, and shortness of breath, that makes it different from AvPD.

Dependent Personality Disorder[edit]

People with dependent personality disorder (DPD) rely on other people to take care of them and make decisions for them in order to feel secure. They will always say "yes" or "I agree" to follow everything of what they are told by their caretaker or ruler to avoid feeling alone or abandoned (not exactly the same reason as people with BPD). Furthermore, they choose to never have an opinion of their own to disagree or say "no", and they never choose to look at both sides of the story to see who is telling the truth or not. Otherwise speaking, they always believe what one person (mostly a dramatic abuser) says to them as their only source of news, instead of other sources that are logical or factual. Although an abuser harasses a victim, people with DPD will act like "good cops" by covering up every conflict that happens between them to deceive the general public that the world is all shines and rainbows, allowing an abuser to continue on getting away with hurting others.

Obsessive Compulsive Personality Disorder[edit]

People with obsessive-compulsive personality disorder (OCPD) feel the need to micromanage things. They believe in perfectionism, orderliness, and rules. They are also a workaholic (a word derived from "alcoholic"), meaning they almost never spend time on vacations with family members or friends and they always strive to achieve 100% correct on their assignment in their own way at work or school. Sometimes, they are even very strict by forcing others to work near endlessly at the cost of their freedom and human bond experience with one another. Many people confuse OCPD a lot with OCD (obsessive-compulsive disorder), which is an anxiety or mental disorder that involves with repetitive behavior (e.g. frequent handwashing, checking on the door 5 times if it's locked or not, aligning objects to make right angles) that OCPD lacks.

External links[edit]

• DSM-IV list of personality disorders
• 10 Personality Disorders
• Asshole personality disorder, inexplicably missing from the DSM

Notes[edit]

References[edit]