How are Personality Disorders the same or different from other Psychiatric Disorders like Major Depressive Disorder, Panic Disorder, Schizophrenia?
To address this question requires defining a Personality Disorder and then exploring the term’s history.
What is a Personality Disorder?
The standard dictionary definition of “Personality Disorder” is:
PERSONALITY DISORDERS (plural), Merriam-Webster Dictionary, (term): any of various psychological disorders that are characterized by persistent inflexible or impaired patterns of thought and behavior that usually cause difficulties in forming and maintaining interpersonal relationships and in meeting the daily demands of one's personal and work life and that typically become apparent during adolescence or early adulthood
Then, Merriam-Webster dictionary throws in a: NOTE: Personality disorders are typically accompanied by three types of presentations: intense and unstable emotions, eccentric and odd behavior, or extreme fear or nervousness. (I think the NOTE is in reference to the very the first definition of Personality Disorder, which was recorded in 1919 in the USA). So, Personality Disorder has been around for more than 100 years.
The American Psychological Association has a definition of Personality Disorder. Packed with information, it is probably more than you want to read. I copy it below as I will refer to it frequently in this entry:
Personality Disorder (PD). [the numbering is mine. Bolding is partially mine. Note: Each personality disorder (narcissistic, borderline…) has its own entry in the APA dictionary.
…disorders involving pervasive patterns of perceiving, relating to, and thinking about the environment and the self that interfere with long-term functioning of the individual and are not limited to isolated episodes. DSM–IV–TR recognizes 10 specific personality disorders organized within three clusters: Cluster A includes 1. paranoid, 2. schizoid, and 3. schizotypal; Cluster B includes 4. antisocial, 5. borderline, 6. histrionic, and 7. narcissistic; and Cluster C includes 8. avoidant, 9. dependent, and 10. obsessive-compulsive; each disorder has its own entry in the dictionary. These constructs emerged from different theoretical perspectives of the early 20th century. They do not, however, exhaust the list of possible clinically significant maladaptive personality traits, and many of the DSM–IV–TR disorders are themselves often difficult to diagnose reliably; indeed, research has shown that many people diagnosed with a PD qualify for more than one. Conversely, personality disorder not otherwise specified, a residual category included within the DSM–IV–TR classification, is a highly common PD diagnosis in clinical settings, applied to patients whom clinicians determine to have a personality disorder but who do not meet the diagnostic criteria for any of the 10 disorders within the classification. DSM–5 retains the same clusters of disorders, as well as the same diagnostic criteria for them, but includes, for “further study,” a new model for PD classification, proposing impaired personality functioning and pathological personality traits as the main criteria for identifying the presence of a personality disorder.
Previous “After the Session Blog” entries have described specific personality disorders including Borderline Personality Disorder (671 views) and Narcissistic Personality Disorder (51 views). Views of entries rarely exceed 100; except for Borderline Personality Disorder at 671 views. This high number is puzzling. It could NOT be due to a single viewer because the counter only marks unique views. Perhaps an error, but I doubt it.
Why so many views? Perhaps the puzzling nature of the issue is a curiosity. Perhaps it is people experiencing borderline personality disorder, themselves, who are seeking answers. Who knows. People reliably diagnosed with Borderline Personality Disorder are an elusive group, tough to interact with, even tougher to live with and to treat.
Most of my personal, “Treatment Failures”, are with this disorder. My definition of a treatment failure is that whatever happens in psychotherapy, the person’s trajectory, mistakes, set-backs, keep re-emerging and it is as if therapy never occurred. This is a treatment failure, and, in my experience, rare. People almost always change (in good ways) as a consequence of therapy. Why is it rare? Because people who come enter therapy, no matter how bad off they may be, are ready to change, and therapy provides a structure for change. Real change is very hard on your own, although it can be done.
THE HISTORY OF PERSONALITY DISORDER
The history of personality disorder is wrapped up in the history of personality (c 371 to c 287 BC, Theophrastus who was a contemporary to Plato). Further, the history of personality is wrapped up in the history of temperaments (551-479 BCE - Confucius). The previous sentence is packed with assumptions. I won’t unpack it here because it would take the entire entry to do so. It is important at this juncture to appreciate the long background legacy of “Personality Disorders.”
Psychiatry, as a medical science, appeared, roughly, the end of the 18th Century. Most historians converge around Philippe Pinel (1745-1826) as the author of a personality disorder in psychiatric nosology. This nosology (or classification) was in his seminal written work, Traite medico-philosophique stir l'alienation mentale ou la rnanie (English: There is not a direct English translation for this work, but it means: “The History of Mental Illness”).
Pinel was frustrated that the varieties of mental illness were all lumped into one or two classifications of “mania” which was, back then, an essential state of agitation. To be sure, almost everyone with mental illness was agitated in one form or another, but Pinel argued that people could be agitated and not have mental illness; and that people could have mental illness and not be agitated (this latter point is where personality disorders appeared). The evolving history of personality disorder spans France, Russia, and Germany. It is eventually Emil Kraepelin, a German Psychiatrist, (Germany, 1856-1926) who introduced personality types into modern psychiatric classification, under the term “psychopathic personalities.”
Kraepelin stressed the existence of overlap between pathological conditions and personal features encountered in normal people. He noted that the limit between pathological and normal is arbitrary.
It was Sigmund Freud (1856-1939), Karl Abraham, and Wilhelm Reich who created a psychoanalytic approach designed to addressed what they called faulty personality. For example, Freud established a connection between character traits and childhood experiences. He described patients who are especially “orderly, parsimonious and obstinate” as Obsessive Compulsive Personality Disorder.
It was here that Personality Disorders, as a classification scheme, jumped to the United States by way of Raymond Bernard Cattell (1905-1998) who was using statistics to classify people (with and without mental illness) into groups or clusters (this is probably where the term Cluster A, B, and C came from). Personality Disorders became a subgroup of disorders within Personality in general. So, the two ways of thinking are intermingled (for better or worse). Note, today, a contemporary personality assessment, the NEO-PI (Neuroticism - pathological; Extroversion - normal; Openness to Experience -normal Personality Inventory), reflects this intermingling.
As it has evolved into the 20th and 21st Centuries up to today, other political, social, and medical factors have impacted personality disorder definitions and causes. But, suffice this description to note that personality disorders have been part of the human condition for nearly as long as human beings have had the written word.
How are Personality Disorders Different than other Mental Health Disorders?
People with bona-fide Personality Disorder (PD) - it doesn’t matter what kind of PD it is - have a unique way of presenting themselves in therapy. For example, I have seen in the past 6 years only one or two person with clear diagnostic features of Avoidant Personality Disorder. Why? Because such individuals are “Avoidant” and they have been “Avoidant” from as early as they can remember. If I was a child psychologist, a parent might bring this kind of child client into therapy, but it is still unlikely. Why? Because one or both parents are likely “Avoidant” as well. The life and lifestyle of an “Avoidant” personality disordered person is spent avoiding others and probably self denigrating for doing so. I hope I am making myself very clear here.
I have abstracted from the internet (because I’ve never personally had a specific case like this of an avoidant personality disorder, diagnosed Vaknin, S. (2009, October 1). The Avoidant Patient - A Case Study, HealthyPlace. October 16 from: https://www.healthyplace.com/personality-disorders/malignant-self-love/avoidant-patient-a-case-study
Case Study: Gladys, Avoidant Personality Disorder (picture is exemplary of 26 year old, and taken from public domain, unrelated to case)
Gladys is a 26 year-old single female who is a clerical worker at a large company, she was born in a rural town, parents are still married, she has three siblings, Gladys is the youngest child among the siblings. She was an average performer in school, graduated high school, attended college, but dropped out before she completed her degree.
…I would like to be normal" - says Gladys and blushes purple…She prefers reading books and watching movies with her elderly mother to going out with her work colleagues…She has no friends that she can recall. How long has she been working with these people? Eight years in the same firm…
Does she have a boyfriend? I must be mocking her. Who would date an ugly duckling, plain secretary like her?…"Please, doctor…no need to lie to me just to make me feel better…
"I am a social cripple. I can't work with other people. I declined a promotion to avoid working in a team." Her boss thought highly of her until she turned his offer down…
I ask her to describe how she thinks she is being perceived by others. "Shy, timid, lonely, isolated, invisible, quiet, reticent, unfriendly, tense, risk-averse, resistant to change, reluctant, restricted, hysterical, and inhibited."… When asked if she talks with her mother, Gladys says, “no, we don’t have anything in common.”
Major Depression with Avoidant Features and Alcoholism: Jacob (picture is exemplary of 63 year old male, and taken from public domain, unrelated to case)
Jacob is a 63 year old divorced male with a history of Major depressive disorder and Alcohol use disorder. He lives alone and reports many failed relationships, leaving him, by his own report, feeling isolated and worthless, at least for the last 10 years or so. He reports cycles of binge drinking “I want to be alone, I can’t face other people.”…His physical health has deteriorated leading to multiple hospital admissions for alcohol related issues. Jacob’s motivation for change is unclear…
He grew up in England and in his late 20’s immigrated to New Zealand. He currently lives alone in a small town…He is twice divorced and has three children. He has regular contact with one of his daughters, Jane, by telephone…his many failed relationships…leave him depressed, especially when they end…an ex high school teacher, he is retired…An avid reader he likes to go mountain biking when he can. He has not engaged in these activities in the last few months as his alcohol consumption has increased…Notes indicate Jacob has been depressed since his divorce from wife just over 20 years ago. He is prescribed Citalopram 30mg and Zopiclone 7.5mg by his General Practitioner. His depression appears secondary to his alcohol use because the depression still remains even in abstinent periods of his life.
These are two extremely different cases, but there is also some similarities among these two clients. For one, both clients do not want to be alone. The first case, is a clear example of Avoidant Personality Disorder. It seems from this case that the motivation to “Avoid” is central in this person’s life (even so far as a defining feature of her character and makeup). Even though Gladys dislikes the idea of being alone and feeling inferior because she is alone and isolated, she chooses to be alone, she almost avoids other people at great cost, sometimes, to her own financial and personal wellbeing. Gladys clearly generates her own isolation, ostensibly, to avoid others, and she has done this for as far back as she can remember. The second case, Jacob, it seems that avoidance is a consequence of his poor life choices and his affective nature. He is not trying to avoid others, he just can’t manage himself in a way that allows others to remain close to him. His depression and alcoholism push people away. Avoidance is not the central feature of Jacob’s case, but it is prominent. Visible in his negative affect, it probably played a role in instigating his alcohol use. You get a different feeling of avoidance in Jacob’s story. Avoidance here is almost a natural consequence for getting into trouble and being ostracized from the world, being in public and becoming intoxicated. Jacob does interact with his daughter, whereas in the case of Gladys, she watches television with her mother, but in Gladys’s case you don’t get the sense that Gladys interacts or even really cares about her mother. Mother is simply a benign presence, no more or less, for Gladys, than the furniture in the room.
In both instances, and for different reasons, these individuals did not “cause” their psychopathology, but they played a role in it. They indulged it, so-to-speak. They “gave in” to those familiar niggling urges they knew would take them down unfortunate life pathways. Stated another way, they are both victims of something, something larger than themselves, but then again, they are both making choices for themselves, with some valence towards making poor choices. Their efforts to cope with the negative, almost overpowering, force of pathology that operates within them is not working. This force is psychopathology, and, I believe, runs in all people both the well adjusted and poorly adjusted. For some, it is prominent and life altering. For others, it is in the background, almost non-existent, until the individual faces stress or life turbulence (See “After the Session Blog”, Turbulence, February 13, 2021).
Psychopathology is qualitatively different for Avoidant Personality Disorder than for Major Depressive Disorder (MDD) per se. Even though he is older, suffering from addiction, and somewhat more jaded by life experience, the prognosis for Jacob is better than for Gladys. Why? Because the disorder Gladys experiences is wedged deep in the center of her essential make-up. She sees everything through the lens of avoidance, and this feature of her will not change.
Can Personality Disorders be Explained Biologically?
The answer to this question is YES and NO. In an earlier entry, I describe the neurological underpinnings of Borderline Personality Disorder (See “After the Session Blog”, Borderline Personality Disorder, October 23, 2021).
For example there is compelling evidence for a biological underpinning in the symptom of emotional dysregulation for Cluster C personality disorders (Avoidant, Dependent, Obsessive-Compulsive) implicating the neurotransmitters dopamine and serotonin.
It is without question that individuals with Personality Disorders have distinct historical patterns in the areas of:
Genetics
Neurochemistry abnormalities (dopamine, serotonin, Gaba)
Childhood Trauma (Particularly Verbal Abuse, Sexual Abuse, Physical Abuse)
Over-reactive Temperament (This group might be considered the “highly reactive child” syndrome.
Early Peer Group Factors (both positive and negative). There is no study of this, but it would be interesting to evaluate whether children from military families (in transition) have a greater propensity, say, for Personality Disorder than children from homes and with peers in highly stable non-transitioning (no moves during childhood) family situations.