Personality Disorders

DSM personality disorders are fascinating and controversial because they suggest that a person’s personality--by nature multifaceted, unique, and shaped by experience--can be maladaptive and inappropriate to the point that it constitutes a disorder. According to the DSM, a personality disorder is an enduring, inflexible, and pervasive pattern of experience and behaviour that deviates markedly from the expectations of the person’s culture; is manifested in terms of cognition, emotion, interpersonal functioning, and impulse control and leads to significant distress or impairment. The ten DSM personality disorders are divided into three clusters.

Odd or Eccentric: A person with a schizoid personality is a loner, detached or aloof, with a restricted range of emotions. A person with a paranoid personality is distrustful and suspicious, and frequently and unjustifiably perceives others as deceitful or disloyal. A person with antisocial personality disorder is popularly known as a psychopath or sociopath: manipulative and lacking in empathy or conscience. A person with a schizotypal personality is odd or eccentric, with unusual or peculiar beliefs or behaviour.

Dramatic, Emotional, or Erratic:  Borderline personality disorder is characterized by emotional instability, poor self-image, dramatic shifts in mood, fear of abandonment, and tumultuous interpersonal relationships. A person with a narcissistic personality is grandiose, selfish, entitled, and intolerant, with a strong need for admiration. A person with a histrionic personality is theatrical, flashy, emotional, and uncomfortable when not the centre of attention.

Fearful or Avoidant: A person with an avoidant personality fears criticism, avoids social interaction, and is risk-adverse and sensitive to rejection. A person with a dependent personality is needy and submissive, very sensitive to criticism or disapproval, and needs a lot of reassurance and help making decisions. A person with an obsessive-compulsive personality is focused on efficiency and productivity, and may be considered a perfectionist or a workaholic.

Each personality disorder is described by 7 to 9 traits, most of which are not independently pathological. Lots of people people are, for example, impulsive and fail to plan ahead, or show restraint within intimate relationships out of fear of shame or ridicule, without having an antisocial or avoidant personality disorder, respectively. Further, a personality disorder is not necessarily immediately obvious. You could be dating someone for three months before you realize that he is intolerant of your opinions, expects special treatment from waiters and customer service representatives, and frequently and tangentially mentions his Harvard PhD in conversation with strangers–-helping explain why he has a hard time sustaining a relationship.

Therapists can use a strong or otherwise unusual personal reaction to a given client as a clue to the possibility of a personality disorder, and can convert the reaction into a therapeutic intervention by telling the client about it (e.g., “I feel personally responsible for your well-being to an unusual extent” or “I feel like nothing I could do would allow me to gain your trust”). If the client says it’s not the first time he or she has received that particular feedback, the therapist can ask something like, “What do you think it’s like for others to feel so much responsibility for you?” or “How has your difficulty with trust affected your marriage?” to help the client gain insight about how his or her personality impacts his or her relationships.

Personality disorders don’t come out of nowhere, and can constitute a valid response to a maladaptive early environment. If you were consistently misled and betrayed as a child, paranoia is a reasonable response. If you were an adored and overprotected child who was never criticized and who never faced a tough decision or problem on her own, dependence is to be expected. The emotional instability and fear of abandonment common among individuals with borderline personality disorder are the natural outcomes of alternating abuse, invalidation, and neglect. This developmental perspective on personality disorders can be validating for clients and helpful in maintaining patience and empathy in therapists who work with people with personality disorders. The therapist’s job is then to guide the client to an understanding of the impact of the behaviour pattern on the client’s current relationships and to help the client replace dysfunctional patterns with more adaptive and appropriate behaviour.