Personality disorder

Personality disorder  

What is personality? 

Personality is defined as person’s total characteristic of emotional and behavioural traits which is apparent or expressed in daily life, and in totality it is stable and predictable. Most or all of the research and views and concept about personality disorder has been developed in western or European context. And the philosophy behind it also mostly European, and in this context other cultures has played little part. So it would be difficult to match those concepts with other or Indian or Asian cultures. 

In our day to day life we meet people with different attitudes, different way of interacting. Some are difficult to interact, some suspicious, guarded, secretive, abusive, some are quite relaxed and open about personal matters and easily approachable, some are obsessive about routines and would not go out of their way, some are quite dependent and passive and needs much support, some are avoidant.

Each person has a unique way of interacting with others, and that is consistent and it becomes evident in their early adolescence and change seldom happens despite problems with interacting with others.  

Gordon Allport, a US psychologist first indicated that each person has an inherent potential for autonomous function and growth. He said “personal dispositions” are individual traits that represent the essence of an individual’s unique personality. According to him the personality has two traits, the “central traits” are basic to individual’s personality, and the “secondary Traits” are more peripheral. There are also “common traits” are those recognized within a culture and may vary in between cultures and “cardinal traits” by which an individual may be strongly recognized.  

Maturity, according to Allport, is characterized by a capacity to relate to others with warmth and intimacy and a sense of expanded self. So according to Allport mature people have security, humour, insight, enthusiasm and zest.  

When personality disorder is considered? 

When an individual presents with difficulty in interacting with others and cause functional impairment of subjective distress then personality disorder can be diagnosed.  

What are the issues with persons having personality disorder?  

Ø      Persons having personality disorder, they have no understanding about their problem.

Ø      They present with difficulty in interacting with others.

Ø      They don’t feel any remorse or anxiety about their maladaptive or difficult behaviour.

Ø      It is a life long problem or maladaptive behaviour and it increases when the person is in stress.

Ø      They don’t take any lesson or change as result of repeated problems.

Ø      They refuse to take any help or treatment of their problem.   

Why some people are different? 

There has been no consistent reason why some people have personality disorder.  A study was done in USA involving 15,000 pairs of twins. It was found that if one of the identical twins (twins who are genetically similar and developed from one fertilized egg) has a personality disorder then the other twin will have more chance to have a personality disorder than the general population or in dizygotic twins (twins developed from two different ova and fertilized by two sperms and genetically they are not identical).  

It was also noted that schizophrenic patients have biological relatives with personality disorders. This also signifies some sort of genetic influence in personality disorder.

Depression is common in families with persons having a borderline personality disorder. Patients with avoidant personality disorder often they have high anxiety level. 

Hormonal factor:

It was found that people who exhibit impulsive behaviour has increased levels of testosterone and estrogens.  

Psychologists have different views why personality disorder happens and it is not known if those hypotheses explain the reasons with every person with personality disorder. This is not discussed because it is out of our scope.  

 Psychological defense mechanisms 

According to DSM IV the personality disorders has been classified into three broad categories and each having few different types of personality disorder. But in practical purposes personality disorder patients mostly present in a mixed form.  Each personality disorder has a cluster of defense mechanisms when those work effectively, the people with personality disorder master feeling of anxiety, depression, anger, shame, guilt and other effects.

They often view their behaviour as acceptable to them and feel no distress even though it affects others. So defense mechanisms are most effective especially in persons with personality disorders. Thus abandoning a defense mechanism increases conscious anxiety and depression, and this is the major reason that personality disordered persons are reluctant to change their behaviour.  

The important defense mechanisms are as follows: 

Fantasy: Many people who are lonely, and frightened and eccentric seek comfort and satisfaction by creating imaginary lives specially imaginary friends. Due to being dependent on fantasy they are aloof from society and other day to day activities.  

Dissociation: Dissociation or denial is replacement of unpleasant feeling by a pleasant one. They often dramatize and emotionally shallow, and histrionic in presentation. They behave at times like a careless adolescent and expose to exciting dangers, and also seductive. Often they look for appreciation of their attractiveness and courage.  

Isolation: This is a characteristic of obsessive and orderly persons. They remember the fine truth of the event but without the feeling. They are obstinate, inflexible, very restrained in stressful situation and very formal in social interaction. They are also very punctual, precise, systematic and value efficiency, orderliness, and cleanliness etc. Because of isolation they can maintain their characteristics without any anxiety. 

Splitting:Individuals with splitting divide people in to good and bad with whom he or she has ambivalent feelings thus causing a rift among care givers and in the community. 

Projection:Patients believe the unacceptable inner feelings and impulses are not their own but belongs to others.  Patients with projection are faultfinding, hyper-vigilant, over sensitive to criticism, and those who do not agree with him or those who confronts them make them enemy.  

Passive aggression: Individuals with passive aggression express aggression towards others by directing towards self such as by failure, procrastination, illness etc.  

Acting out:This happens by doing activities such as assaulting some body without any motive, or abusing a child or having sexual activity without any pleasure etc.  

 Personality disorder in different cultures 

Personality disorder diagnosis is assigned to individuals quite commonly in western countries and it has been found that in prison population some personality disorders such as antisocial, narcissistic are found in greater number than in general population.  

But in Asian countries and in India personality disorder diagnosis is not commonly assigned and in this regard there are certain differences. In western countries borderline personality disorder is commonly found than in non western cultures or in Asian and African societies.  It is not known why personality diagnoses are uncommon in non-western countries.

During my work experience in India, or in Papua New Guinea or in Bermuda and even in New Zealand Asian and African immigrants received less diagnosis of borderline personality disorder. This may be a culture bound disorder that borderline personality disorder is found more in western Caucasian or white population.  

In India and in south Asian countries probably doctors make less diagnosis of personality disorder or it’s prevalence is less or the community is more tolerant to the aberrant behaviours so they are not taken to professionals for help or screening.

Even western trained psychiatrists practicing in India finds less Borderline personality disorder (personal communication).  

As we know autonomy is cherished in western societies, so may be the dependent and passive personality disorders are more diagnosed when some body is not able to achieve independence or muster autonomy. But in India even adult children dependent on their spouse or their parents and elders, and this is easily culturally acceptable practice in the community and not pathological. 

Deliberate self harm such as slashing or minor cuts of wrists, without intention to die is not common in India. But deliberate self harm by ingesting pesticides, or harmful chemicals or medications such as paracetamol, sleeping pills, or opioid drugs as in Middle-eastern countries, is common.

Repeated slashing of wrists or forearm occurs in context of personality disorder in European countries. But in India deliberate self harm mostly occurs in the context of psychosocial adjustment problem and often impulsive in nature.    

Some of the personality disorders are described below:

Though in European or western cultures there is a big list of personality disorder, which may not be evident in India and other Asian countries, only the few important ones we come across and most important one is antisocial personality disorder. 

 Antisocial personality disorder 

According to International Classification of Diseases (tenth version) this is also known as dissocial personality disorder. These kinds of people are found more in prison population than in general community. They are also known as “sociopaths” or “psychopaths”.

This is commoner in males than females. They are not concerned about other’s feelings and shows gross and persistent irresponsibility and disregard for social norms and rules and obligations. 

They are not able to maintain a relationship though they have no problem in starting a relationship.

Their tolerance level is low, and they are impulsive thus leading to violence and aggression quite easily.

They don’t express any guilt and they don’t learn from experience or from punishment. They blame others for their actions and give plausible reasons for their actions involving the community etc.

They have elevated self appraisal and have extreme sense of entitlement.

Usually antisocial personality disorder starts in childhood or adolescence, when they present with irritability, fighting with playmates, injuring animals and mates, low frustration tolerance, beaten up by others but not learning from such incidents.

They disobey parents or elders, runaway from school, and start abusing drugs or alcohol. Though this history is common in persons with antisocial personality disorders, but it is not essential.

Sometimes they come from a disadvantaged family back ground, where father is abusive towards mother (who is passive) and children, and abuses drug or alcohol and may have criminal records. The following personality disorders are worth mentioning in western context 

 Borderline personality disorder: 

This is rarely diagnosed in India and in other developing countries and it is a sort of “culture bound syndrome” prevalent in western cultures. It is characterised by unstable and intensive interpersonal relationship, impulsive in regard to spending, sex, using drugs, reckless driving and binge eating. 

Also the have recurrent suicidal behaviour, gestures, threats and self harm attempts such as slashing of wrists and minor overdoses. Mood is unstable and fluctuates easily, and feels empty chronically.

They also have inability to control anger and get into recurrent physical fights. 

Paranoid personality disorder: 

They are characterised by distrust, and suspiciousness of others, always guarded and secretive in nature, preoccupied with doubts about untrustworthiness about friends, others. 

They are unforgiving for insults, and perceive attacks on their characters not apparent to others. They may be litigious and have outbursts of anger with small pretexts.  

Seldom they are referred to mental health services, they are not aware of their problem and so they don’t make any effort to change. And their relationship with peoples at workplace or at home has always been strained. 

 Schizoid personality disorder: 

This type disorder is also found in India and other Asian societies but they are seldom diagnosed. They present as life long pattern of socially withdrawal.  They don’t enjoy any close relationship and even the closeness of family members.

When they work or choose a hobby always they go for solitary activities. And have very few pleasured activities. They don’t have any friends and confidents except first degree relatives.

They are indifferent to praise or any criticism of others. They are emotionally cold and detached with flat affect. Usually they don’t have any sexual relationship.  

Sometimes it becomes difficult to differentiate if this is a slow onset schizophrenia or a depression or poor development of psychosocial skills.  

Narcissistic personality disorder: 

This personality disorder is characterized by increased self importance, great achievement and talents. They are preoccupied with ideal love, unlimited success, power etc.

They believe that they are special, and can be understood by special people. They need a lot of admiration. They have sense of entitlement and exploit others for their gains.

They lack understanding of others feelings, and believe that others are jealous of him or her.   

There also other personality types such as obsessive personality, dependent personality, Schizotypal personality, histrionic personality disorder etc.

Some individuals have personality types which are combination of personality types such as antisocial and narcissistic, borderline and antisocial types etc. These two personality types are more commonly found in prison population.  

Drug abuse and personality disorder:

Antisocial personality disorder individuals use drug or alcohol more than the general population. And may indulge in criminal activity such as drug trafficking, burglary, prostitution etc to finance drug habits.

 Personality disordered persons whose responsibility is it?  

Whose responsibility is if a person creates havoc in the family or in community or at work place, and has personality disorder such as antisocial personality disorder?  

Antisocial personality individuals though they have poor understanding of their problem, but due to repeated conflict with others bring the attention to the family or the community. Legal system also gets involved when the person does any criminal activity.  

Due to stress or due to drug alcohol abuse at times precipitates episodes of psychosis. Thus mental health services or psychiatric services get involved.

Usually the presentation is associated with unpredictable and unprovoked aggressive and abusive behaviour, irritable and angry or depressed mood, grandiose delusions, responding to voices or too much paranoid thoughts, not able to sleep, poor self care. Then the person gets admitted to hospital under Mental Health Act.  

After discharge from hospital it becomes difficult to continue the treatment due to poor understanding of the condition. But the antisocial behaviour continues thus causing stress in the family or in the community. They refuse to take psychotherapy and not ready to change their behaviour.  

When they get involved in violent crimes and get imprisonment, they may be motivated to participate with group or individual psychotherapy programmes in prison, such as violent offenders programs, anger management programmes, substance abuse programmes, sex offenders programmes etc.

When a longer sentence is given for a crime it may become a chance to treat the person for a longer period so that he or she can be rehabilitated in the community. But follow up of such persons in the community should be done by the probation services not by mental health services. 

In general persons with personality disorder, such as antisocial personality disorder should be taken care of by the community at large but it is unknown who would take the responsibility. When they have no other mental problem, and for any crime due to their careless and wilful behaviour should be dealt by the law. Any attempt to medicalize the bad behaviour should be discouraged.   

Antisocial personality disorder in India and other developing countries: 

The concept of personality disorder as mentioned before is mostly started in European and western countries and it has become popular in the last few decades. Mental health professionals come across more and more borderline and antisocial personality disorder individuals.  

In India the personality disorder individuals are diagnosed rarely by psychiatrists or by mental health professionals, and they are not brought to clinics, because may be people believe those are mostly bad behaviours and dealt with by social prescriptions.

Beside that apart from psychiatrist and psychologists other mental health professionals have less understanding of the issues with personality disorder. 

Management of persons having personality disorder 

Personality disorder persons are rarely referred to mental health services unless there is some deterioration of mental health, or any drug or alcohol issue or any problem with controlling impulse such as violence or gambling etc. Personality disordered persons do not agree to come to any mental health service due to having no understanding of their problems.  

For treating persons with antisocial personality disorder, the following may be important:

Psychotherapy becomes possible when they get admitted to a hospital. They do better in a self help group than in prison. To begin treatment firm limits are essential, and any kind of self destructive actions must be discouraged. The therapist finds difficult to replace control from punishment.

Involvement of family has been useful in the treatment. 

In persons with borderline personality disorder, primary problem is unstable mood, with chronic emptiness. This can be difficult to manage but medications at times help to treat depression or elevated mood or psychosis. Any kind of self harm should be discouraged and this must not be reinforced by providing attention. Splitting should also be discouraged and this can be made clear among the staffs by an agreement in the management.  

Paranoid personality disorder individuals are also difficult to treat as above. They can be helped when they have a psychotic episode or when they become involved with physical abuse or injury due to their paranoid feelings. In therapy it is very difficult to engage. If there is any delay or mistake on the part of the therapist this should be acknowledged honestly. One should not give any explanation or analysis of the feelings how they feel. The therapist should be firm and gentle when counteracting his or her views. Too much critical views may lead to discontinuation of treatment or help.  

When the stress is too much and not able to handle, some medication may be also helpful. These are anti-anxiety medications such as Lorazepam or Diazepam (both has addiction potentiality), and antipsychotic medication (Haloperidol, Risperidone or Olanzapine) are also useful. Also medications such as carbamazepine, Sodium valproate, and Lithium can be prescribed to stabilize the mood fluctuations, thus preventing crises.   

Most of the personality disorders are life long problem, and over the years individuals learn to live in society with less intensity of the symptoms or maladaptive behaviour.     

Personality change due to medical conditions 

These are not personality disorders as above but some medical conditions may precipitate personality changes and treatment of medical conditions may change it to normal state. 

After head injury, usually concussion, may present also with change in personality. They may present with depression, increased impulsive behaviour, increased aggression, sexual inappropriateness, apathy or lack of spontaneity. They may become fatigued easily and may complaint of sleep problems. There may be abuse of alcohol thus complicating the condition.  

Personality change due to abuse of anabolic steroid: 

Now abuse of anabolic steroids has become common in young generation such as high school and college students and body builders. Usually anabolic steroids are abused by young adult who play power games such as football, base ball etc. and others with low self esteem.

They usually abuse oxymetholone, soamtotropin, and stanozolol, testosterone etc. Abuse of anabolic steroids also causes personality change.

Initially it causes euphoria and hyperactivity, over the months they present with increased anger, irritability, hostility, anxiety, somatic symptoms, and have depression when they don’t use it. And there has been reports of anabolic steroid abusers committed murders and violent crimes.  

When they stop steroids they present with withdrawal symptoms such as anxiety, low mood, concerned about their bodies.  Excess use of anabolic steroids also cause liver disorder, decreases spermatogenesis, stops menstruation, acne, early balding, in men testis becomes small, gynaecomastia (enlargement of breast in men) is also common.

In young persons if started before adolescence it can cause stunted height. In severe cases there have been reports of sudden death due to heart failure.   Only treatment is to stop the steroid and may need full physical check up to find if there is any liver damage or check the heart conditions and blood lipids.