Personality disorder is among the most controversial topics in mental health. Personality itself is a rather slippery concept, and deciding where to draw the line between “normal” and disturbed personality is even slipperier. The fact that personality disorders often seem to have a greater impact on other people than on the person with the disorder makes them even more contentious.
Personality is usually defined as an individual’s typical way of thinking, feeling and behaving. The word comes from the Latin persona, meaning “mask,” referring to what actors in classical theatre once wore to play different characters. We now think about personality as our psychological uniqueness, closely related to our sense of self or identity. It is usually described as a particular set of enduring characteristics or traits.
Every one of us has a distinctive combination of these traits. Personality researchers have identified as many as 4500 trait words in the English language, such as sociable, curious, callous, irresponsible, optimistic, immoral, warm and impulsive. But, you might ask, are there really so many ways people differ from one another? Or is there, perhaps, a limited number of basic personality types or dimensions amid all this complexity?
Sure enough, many attempts have been made to distil personality down to a more manageable number. The psychologist Raymond Cattell, a pioneer, applied sophisticated statistical techniques to construct a set of sixteen factors, each on a continuum stretching between two poles. Your position on each continuum, such as reserved–warm, shy–bold, relaxed–tense and serious–lively, summarises your unique personality. For example, someone might be very low on the reserved–warm factor, average on the shy–bold factor, well above average on the relaxed–tense factor, and slightly above average on the serious–lively factor.
Although boiling 4500 distinct words down to sixteen basic personality factors was an impressive feat, other psychologists found that number to still be unwieldy. Over time, researchers suggested that an even more basic set of five personality factors lurked beneath these sixteen, unimaginatively dubbed the Big Five: neuroticism, extraversion, openness, agreeableness and conscientiousness. This has become the pre-eminent model of personality structure, and as we shall see, it sheds light on the concept of personality disorder.
Once we appreciate that personality factors fall on a spectrum, we must grapple with the question of when a personality pattern crosses the boundary from normal to problematic, or even whether such a boundary exists at all. If we fall at the extreme end of one or more of the Big Five factors, we may tend to think, feel and behave in ways that cause problems in our everyday lives. For example, if we score extremely highly on neuroticism, we are likely to suffer storms of negative emotion and self-criticism that will adversely affect our close relationships, capacity to work and sense of general wellbeing.
If we are extremely low on agreeableness, on the other hand, we will tend to distrust and act in a hostile way towards others, leading to conflict with them and social rejection. If we are extremely low on extraversion, we are bound to be painfully shy and isolated, unable to reach out for the social connections that all of us need and incapable of developing interpersonal skills.
Mental health professionals adopt a pragmatic position in diagnosis: if we show longstanding inflexible, maladaptive patterns of functioning that adversely affect our lives in the spheres of family and general social relationships, work and recreation, then the possibility of our personality being dysfunctional arises.
We ourselves have reservations about the term “personality disorder” since it has often been used in a derogatory and stigmatising way. Mental health professionals are obliged to understand why people behave the way they do, and not to trivialise or dismiss their problems with a throwaway label. It is regrettable that these attitudes prevail given that people with personality problems are vulnerable to a full range of mental illnesses and are candidates for treatment, and stigma can affect their response to treatment.
Interest in types of problematic personalities goes back to ancient Greece. The Greek philosopher Theophrastus, in the fourth century BCE, described no fewer than twenty-nine troublesome types, including the flatterer, the grumbler, the boor, the buffoon, the tactless and the patron of rascals.
More objective and methodical efforts were only initiated in the early nineteenth century. People who showed a pattern of behaviour that suggested the absence of a conscience — that is, lying, stealing, assaulting, even killing, without remorse — were the first to be studied. In 1835, James Prichard, an English physician, postulated that what he called “moral insanity” might represent an illness, related to an aberrant moral centre in the brain. He included among its features “angry and malicious feelings, which arise without provocation” and elicit “the greatest disgust and abhorrence.” It later came to be called “psychopathic personality.”
It may strike you as questionable to define such behaviour as a psychiatric condition rather than as a moral failing or a criminal propensity. This thorny question has confronted both the mental health and the legal systems for many years: are people labelled as psychopathic responsible for their actions? That is, do people who kill without remorse deserve punishment or medical treatment?
The “psychopath” was soon joined by many other categories of problematic personality, culminating in the 1920s when a renowned German psychiatrist, Kurt Schneider, grasped the nettle and attempted to bring order to the chaos. Some of the ten personality disorders he identified have continued to be applied in the sphere of mental health, particularly by the American Psychiatric Association, which groups them into three clusters.
We examine each of the ten disorders in our new book, but for the moment let’s familiarise ourselves with the clusters and their underlying themes:
• Cluster A is marked by odd, eccentric behaviour: schizoid, paranoid and schizotypal personalities.
• Cluster B is typified by dramatic, explosive, emotional and erratic behaviour: histrionic, antisocial, narcissistic and borderline personalities.
• Cluster C is characterised by anxious and fearful behaviour: avoidant, dependent and obsessive-compulsive personalities.
Although these three clusters are helpful for getting a general sense of the personality patterns, the specific conditions remain somewhat controversial for a few reasons. They have no distinctive biological features, such as unique patterns of genes or brain chemistry, their causes remain unclear, the boundaries between them are blurred, and a person may satisfy the diagnostic criteria for more than a single disorder.
Because personality exists on a spectrum, determining whether someone’s personality problems are severe enough to warrant a diagnosis is often a source of disagreement among clinicians. How many personality disorders exist is hotly debated and will no doubt continue to remain controversial. Moreover, even in the modern era, some have already been ditched. The proposed “self-defeating personality disorder” is one example, removed on the grounds that it might be inappropriately applied to survivors of domestic violence.
Given this plethora of reservations, some influential systems for classifying personality problems, such as the World Health Organization’s ICD-11, have dispensed entirely with the idea of distinct personality disorders. Instead, personality disorder is diagnosed according to one or more problematic traits, and is deemed mild, moderate or severe depending on how much the traits disrupt a person’s life (being called, for example, “moderate personality disorder with detachment” or “severe personality disorder with negative affectivity and disinhibition”).
Although it is clear from our comments that distinguishing between personality disorders is a conundrum, mental health professionals need a workable framework. Such a system enables people whose personalities cause them difficulties to receive professional treatment.
Roughly one in ten adults, both men and women, meet the diagnostic criteria of a personality disorder. The rate jumps to one in three among those who have other psychiatric conditions, such as depression, anxiety and substance use. And about two-thirds of people with a personality disorder also have at least one of these conditions.
In the general population, the prevalence of specific personality disorders is around 1 to 2 per cent. Rates tend to decline with age, although middle-aged adults with a past diagnosis may continue to lead troubled lives. Although early signs of a problematic personality can be observed among children and adolescents, mental health professionals are reluctant to apply a diagnosis to them since these features may be a manifestation of another psychiatric disorder.
The factors that lead to personality disorders are complex and imperfectly understood. Studies of identical and fraternal twins point to a substantial genetic component. Interestingly, genetic influences overlap a great deal with the genetic factors underpinning the Big Five factors of (high) neuroticism, (low) agreeableness and (low) extraversion.
Biological factors besides genetic influences are also implicated. Although research findings tend to be inconsistent and hard to summarise, abnormalities in specific chemical messengers in the brain (neurotransmitters) and in the size or activity of certain brain regions have been detected.
Narcissistic individuals, for example, have been found to have smaller brain structures associated with empathy. And in those with an avoidant personality, the amygdala, a structure involved in fear and anxiety, appears to be more reactive in social situations. Problematic personality traits can also emerge after physical damage to the brain, caused, for instance, by tumours, head injuries or the emergence of dementia.
Psychoanalytically oriented theorists assert that problematic personalities are mostly psychological in origin. Sigmund Freud and Erik Erikson, among others, posit that conflicted interactions between children and their carers can create problematic ways of coping and relating. For example, a deep lack of trust might result when the child’s need for consistent care is not met. A tendency to blame others or seek attention in response to conflict as a child might become the foundation for paranoid and histrionic personalities, respectively. When parents fail to be empathically attuned to their infants, their children may fail to develop a stable sense of self, paving the way for borderline or narcissistic patterns of personality.
A related approach, based on John Bowlby’s attachment theory, proposes that children who do not develop a stable emotional bond with their carers are vulnerable to personality disturbance in adulthood. Maltreatment in childhood, particularly physical and sexual abuse, are noteworthy risk factors for certain types of personality disorders.
People with problematic personalities may seek professional help but just as often are urged to do so by distraught relatives or friends at a time of crisis such as a family or workplace conflict, breakdown of a key relationship, or excessive substance use.
Offences such as physical assault, drink driving and shoplifting may lead to the police or courts initiating the process. An impulsive overdose or self-inflicted bodily lacerations are often the route to clinical attention for people with borderline personalities; they tend to present repeatedly in this way. Alternatively, help may be sought for psychiatric difficulties associated with a problematic personality. The failure of a psychiatric disorder to respond to treatment may indicate a previously undetected problematic personality.
Less dramatically, a person may request help from a mental health professional for persistent low morale, anxiety, self-doubt, failed relationships, preoccupation with bodily symptoms, or other personal difficulties that they feel unable to change. An unrecognised personality disorder may also reveal itself in the wake of a failure to engage in treatment, a clash with a therapist, or even a threat of litigation.
Mental health professionals aim to capture as complete a picture as possible of a patient’s past and present life. An account of childhood and early relationships within the family (and with significant others) is at the heart of the inquiry, as are methods typically used to deal with the challenges and demands of life.
This emphasis on gathering information about multiple aspects of the person’s life contrasts with a more symptom-focused approach typical of a discrete mental illness. Personality difficulties are not like such illnesses: they are woven into a way of being in the world, encompassing how the person relates to others, and their self-esteem, coping styles, motivations and aspirations.
Pinpointing a specific personality disturbance requires learning about a person’s lifelong patterns of thinking, feeling and behaviour. For example, a severely depressed executive in charge of a large company may be utterly reliant on his family and on professional staff for even the most trivial decision. Such reliance could well constitute a longstanding feature of a dependent personality disorder, but could also be a feature of a troubled mood state, or could be a combination of both. Talking with him alone may not yield enough information to reach the correct diagnosis. Since we are not always the most objective observers of ourselves, the views of parents, siblings and friends are invaluable.
As you can see, assessing personality to ascertain if it is disordered is challenging to say the least. A thorough evaluation by highly skilled mental health professionals is essential, and even then, doubts may remain. Questionnaires to identify personality disorders have been available for many years but are of limited utility, in part because respondents tend to have limited and often distorted insight into the nature of their personality and its problems. •
This is an edited extract from Troubled Minds: Understanding and Treating Mental Illness, published by Scribe ($35).
