Hey everyone. Welcome to this hour of Mental Health Month. Upon checking my notes, I realized I’ve completely skipped the week of the 18th, where we cover Somatic disorders, eating disorders, and depressive disorders, and went straight into the last week which covers Gender Dysphoria, Neurodevelopmental disorders, and personality disorders. So, I’m switching things around a little.
Yesterday we talked about Gender Dysphoria, the meaning of tolerance, and the realities of biological humans–that is, a brain can indeed develop specifically toward a different sex than the sex of the body. Today, we’re going to talk about Personality Disorders. Tomorrow we will cover Substance-Related and addictive Disorders. The following week will be Somatic disorders, eating disorders, and depressive disorders. We will include Neurodevelopmental disorders on the last day of the month so no one feels left out.
If you want to share an experience you’ve had with any of the above conditions, or even ones we’ve already talked about, feel free to contact me here or on my social media (profiles below).
Now, we come to my favorite section of the DSM-5, with one of the only disorders that has been characteristically diagnosed unreliably–that is, psychologists often come to same conclusions on other disorders but can never quite agree who has this one– and with little to no genetic influence detected. I’m, of course, talking about Borderline Personality Disorder. We’ll get to that shortly. 761
Because personality disorders widely controversial, the DSM constructs this section completely differently. First they describe personality disorders, clinically, as a discrepancy between a persons inner experience/behavior and the expectations of their culture. This is stable over time and generates impairment.
Then, they mention because of the “complexity” of the review process (this is a fancy way of saying because research that correlates these labels with “disordered brains” are inconclusive and scarce), they have split the personality disorder section into two. The second section updates what was in the DSM-4-TR, and the third section has a “proposed research model” for diagnosis and conceptualization.
Personality disorders are separated into clusters still. Cluster “A” disorders are:
Paranoid Personality Disorder: this includes someone with a “pervasive distrust” of others. People’s motives are perceived as malevolent and the individual has a preoccupation with doubts about people’s loyalty, and trustworthiness. There is a constant level of perceiving personal attacks where attacks are not intended and believe that others are exploiting them. This cannot occur during schizophrenia or any other psychotic disorder, including Bipolar mania. They may, however, experience brief psychotic episodes that last minutes or hours. I’ve always thought of this disorder as a miniature schizophrenia.
Schizoid Personality Disorder: This one is actually less harmful in terms of relationships because the person does not form close relationships and has no desire to do so. Not quite sure why that’s a problem. But, they have restricted range of expressed emotions and chooses solitary activities. They may be indifferent to praise or criticism and has a flattened affect. I’ve always thought of this disorder as the negative symptoms of schizophrenia, plus one.
Schizotypal Personality Disorder: This includes issues with close relationships as well but includes cognitive distortions, ideas of references but NOT delusions of reference, odd beliefs, bodily illusions and odd thinking. Paranoid ideation and constricted affect are also included. This cannot occur during the course of other psychotic disorders either, and is probably more of a mini schizophrenia than Paranoid Personality. People often seek treatment for the anxiety and depression rather than their thoughts or behaviors and they may experience psychotic episodes that last minutes to hours.
Cluster “B” Personality Disorders are the ones everyone wants to get their hands on.
And by hands on I mean “grasp an understanding of.”
And when I say Cluster B personality disorders, I really mean just the first two. The others no one seems to mention very often.
Antisocial Personality Disorder: This is not sociopathy. Sociopath isn’t even the correct word. Psychopath is. But that’s not who these people really are. We’ll talk about The Dark Triad next month. It’ll be great fun.
Those diagnosed with Antisocial PD do share some things with clinical psychopaths though, and that is their unyielding disregard for other’s natural rights. This includes breaking the law remorselessly, lying, conning, and being otherwise deceitful for fun or personal gain. It also includes impulsivity, aggressiveness, disregard for other’s safety, and irresponsibility. People must be 18 years old before this diagnosis is concluded and must have evidence of a conduct disorder before 15 years of age. None of these criteria can occur during schizophrenia episodes or bipolar episodes.
Borderline Personality DIsorder: This is the controversial one. It’s described as instability of relationships, self-image, and affects, with a sprinkle of impulsivity and efforts to avoid real/imagined abandonment. Individuals may also be impulsive with self-damaging activities, like reckless driving or spending, binge eating, substance abuse. There may be reoccurring self-mutilation and emotional instability around irritability and anxiety that lists a few hours and rarely more than a few days. Feels of emptiness, intense anger, and severe dissociative symptoms may also occur.
The dissociative symptoms should give a clue to what is one of the number one correlations with this disorder.
75% of diagnoses are female. And with every clinician learning that statistic, more females are likely to be diagnosed with it than actually have it. Across cultures as well, according to the DSM, it is often misdiagnosed.
Histrionic Personality Disorder: Not a commonly heard one, but in reading the description you might think you know someone with this personality type.
These individuals are attention seeking excessively, and very emotional. They need to be the center of attention and are often seductive. They have rapidly shifting expressions of emotions and their speech lacks detail. Everything is a theatrical display.
Narcissistic Personality Disorder: The second of the Dark Triad, which we will talk about next month. This is a pattern of serious grandiosity, fantastical or in behavior, and a need for admiration. There is a severe lack of empathy and these individuals generally want to be recognized as superior without reason. They are obsessed with fantasies of unlimited power, love, beauty, and success. An individual may believe they are inherently “special” and are insanely entitled. They are arrogant and envious.
50-75% are male. Again, these numbers also make it more likely they will be diagnosed with this.
Cluster C Personality Disorders are on the softer end of the spectrum. Softer not in intensity, but in personality. These are the people certain Cluster B types would take advantage of easily.
Avoidant Personality Disorder: This is someone who feels inadequate and hypersensitive to criticism, so much so that they avoid anything that may make them feel inadequate. This includes social gatherings, work, and any other interpersonal situations.
Dependent Personality Disorder: These individuals have a pervasive need to be taken care of. This may lead to serious submissiveness and clinging behavior. They fear making others feel bad, and so they will not disagree with people. Initiating projects on their own is hard, and seeks another relationship as comfort when another relationship ends.
Obsessive-Compulsive Personality Disorder: This is kind of like the umbrella diagnosis of OCD, but more inclined toward only orderliness, perfectionism, interpersonal control, and lists. They really like lists, rules, and organization. Money will be hoarded in case of catastrophe and they may be inflexible about morality, ethics, and values.
There are other personality disorders that may be due to medical conditions or are unspecified/otherwise specified.
Well, what isn’t up with Borderline Personality?
It’s been the hot button in clinical psychology because of the intensity of emotions these individuals feel. It often results in some psychologists refusing to treat people diagnosed with these conditions. Two out of my six therapists have told me some version of a “horror story” of an anonymous someone diagnosed with BPD who stormed out of an appointment or blew up in anger and then stormed out of an appointment.
I feel this attaches a very negative connotation to this set of experiences. Everyone expects the outbursts, the sudden changes, the unruly emotions, and so when they happen it’s just more affirmation that the individual is out of control. Self-expectations and other’s expectations can play a huge role in behavior, even in those with this condition.
The problem is, psychologists actually really struggle in diagnosing this. Back in my research course I learned that studies showed psychologists are quite confident when they make the diagnosis, but when other psychologists evaluate the same patient, they often don’t come to the same conclusion. This is in comparison to someone with narcissistic personality disorder, where most psychologists came to the conclusion that that diagnosis was fit for that person. This could be for many reasons: the background of the psychologist, the presentation of the person, the interpretations of the psychologist. It could also be, though, that this condition presents varying experiences and that makes it harder to recognize patterns.
Borderline Personality usually comes with a decent set of childhood trauma. This article from 2017 talks about how childhood trauma can affect biological systems that are then connected to the development of borderline personality. This article from 2014 talks about Complex PTSD (which is not a DSM diagnosis) and Borderline personality. CPTSD overlaps a lot with Borderline, and so these researchers question the scientific integrity of CPTSD and the role of trauma in BPD.
It could be that we’ve had it wrong this whole time, that BPD is not in fact a personality “disorder”, but instead a trauma response condition. This switch would require absolute links between BPD and trauma, the likes of which would match with PTSD, and right now we have no absolute links for any mental health anything. So let’s not hold our breaths.
The point is, the experience of BPD are very real. The label and possible cause mean nothing when someone’s life is turned upside down, when relationships are constantly crumbling, when someone blames themselves constantly for “not being normal.”
Let me re-frame: the possible cause is important in the sense that it could change how treatment is approached. But it is not more important than affirming people’s experiences. Right now treatment for BPD includes therapies in which the individual learns to recognize, label, and acknowledge when their emotions are exaggerated, and medications normally meant for other conditions. There are no medications registered solely for the treatment of BPD.
People often see this as a hopeless diagnosis. Because of this, I encourage people to read personal stories from people diagnosed with this condition so you can see that many of these individuals are creative, vibrant, determined, beautiful people in many ways. There’s one personal story and one more here to get you started.
Well, one’s in the DSM-5 and the other is a checklist, for starters.
Psychopaths often lead pretty normal lives. The likelihood that you will see them in a therapists office or in the cell of a jail getting diagnosed with something is very, very slim. They are charming people, do very well in life, and no, they are NOT only serial killers. That’s romanticized Hollywood bullshit. They will manipulate, remain remorseless, and often create an abundance of wealth for themselves. C.E.O’s can score quite high on the psychopath checklist.
People with Antisocial Personality have trouble leading normal lives and can find themselves in trouble. They may be erratic and rage-prone, which can catch quite a lot of attention.
Criminals, like gang-members, are not necessarily psychopaths or antisocial. The DSM mentions that Antisocial may be misdiagnosed if someone is fighting for what they believe to be is their survival. Often gangs are comprised of people who feel close to the other members and consider them family, people who believe they are fighting for “the principle of the matter”, for honor, for integrity, for power. They know their lifestyle inflicts violence and fear, but believes there is no other way to live. They are willing to die for their street family.
That is the opposite of antisocial. It is criminal, but not abnormal given the circumstance.
Some people with antisocial personality are also psychopaths. Some people who are psychopaths are serial killers. Both overlaps are rare.
You are safe.
If anyone watches SBSK on Youtube with Chris, they did an interesting interview with someone diagnosed as Antisocial. You can watch it here. Again, sociopath is a clinically incorrect term.
Please. Stop using it.
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