Personality and Borderline Problems

Personality disorders are one of the most difficult diagnoses and take multiple visits to understand the extent of the problem. You do not get a borderline diagnosis in the first office visit. It takes months and a multitude of factors to see how a personality is pathological.

Furthermore, there’s no medication approved for what I like to call the 7 deadly sins; laziness, lust, greed, overindulgence, bitterness, pride, and envy. Overall, “the deadly sins” are just an easier way to frame the difficulty of treating certain toxic personality traits.

The greatest problem consists of knowing how certain personalities can lead to an overwhelmingly dysfunctional life, serious crimes, or other offenses…This is easily one of the main reasons why it’s important to recognize and treat personality disorders and not just turn a blind eye.

Even if it takes years, continue to offer the patient hope or seek additional help. Just to be clear, the standard of treatment includes consistent psychotherapy (DBT), and once again there are no F.D.A.-approved medications to treat personality disorders but they may treat other conditions i.e. depression, OCD.

An Overview of Personality Disorders

• Over a third (39.0%) of respondents with any personality disorder and 42.4% of respondents with borderline personality disorder reported receiving mental health treatment at some time in the past 12 months. -NIMH
• A borderline personality disorder is a serious mental disorder marked by a pattern of instability in moods, behavior, self-image, and functioning. These experiences often result in impulsive actions and unstable relationships. A person with a borderline personality disorder may experience intense episodes of anger, depression, and anxiety that may last from only a few hours to days.
• Other categories also include: paranoid, schizoid apathetic, schizotypal, antisocial, histrionic, narcissistic, avoidant, dependent, obsessive-compulsive, depressive, passive-aggressive (Negativistic), sadistic self-defeating (masochistic)

According to the Diagnostic and Statistical Manual of Mental Disorders 5th Revision (DSM-5), a personality disorder can be diagnosed if there are significant impairments in self and interpersonal functioning together with one or more pathological personality traits.

In addition, these features must be (1) relatively stable across time and consistent across situations, (2) not better understood as normative for the individual’s developmental stage or socio-cultural environment, and (3) not solely due to the direct effects of a substance or general medical condition.

The DSM-5 lists 10 personality disorders and allocates each to one of three groups or “clusters”: A, B, or C.

1. Cluster A (Odd, bizarre, eccentric)
   • Paranoid PD, Schizoid PD, Schizotypal PD
2. Cluster B (Dramatic, erratic)
   • Antisocial PD, Borderline PD, Histrionic PD, Narcissistic PD
3. Cluster C (Anxious, fearful)
   • Avoidant PD, Dependent PD, Obsessive-compulsive PD

I also read somewhere; WEIRD, WILD, & WORRIED -already in ABC order

10 Types of Personality Disorders

There are a lot of overlapping factors to consider with personality disorders such as anxiety but overall a visually competent person can make these diagnoses tricky. For instance, in some mental disorders, you can immediately tell something is wrong; attire, mannerisms, or speech. However, with personality disorders, these people may have great jobs such as a doctor, an engineer, or politicians so what makes these diagnoses difficult is how they appear “fine” or some consider manipulative until there’s a crisis or they get angry. When something goes wrong, even if it’s insignificant, everything around them is affected, and usually for the worse. I’m generally speaking but here’s some great info  describing specific personality disorders by a psychiatrist:

1. Paranoid Personality Disorder: Cluster A is comprised of paranoid, schizoid, and schizotypal personality disorders. A paranoid personality disorder is characterized by a pervasive distrust of others, including even friends, family, and partners. As a result, this person is guarded, suspicious, and constantly on the lookout for clues or suggestions to validate his fears. He also has a strong sense of personal rights: He is overly sensitive to setbacks and rebuffs, easily feels shame and humiliation, and persistently bears grudges. Unsurprisingly, he tends to withdraw from others and struggle with building close relationships. The principal ego defense in paranoid PD is a projection, which involves attributing one’s unacceptable thoughts and feelings to other people. A large, long-term twin study found that paranoid PD is modestly heritable and that it shares a portion of its genetic and environmental risk factors with schizoid PD and schizotypal PD.
2. Schizoid Personality Disorder: The term “schizoid” designates a natural tendency to direct attention toward one’s inner life and away from the external world. A person with schizoid PD is detached and aloof and prone to introspection and fantasy. He has no desire for social or sexual relationships, is indifferent to others and to social norms and conventions, and lacks emotional response. A competing theory about people with schizoid PD is that they are in fact highly sensitive with a rich inner life: They experience a deep longing for intimacy but find initiating and maintaining close relationships too difficult or distressing, and so retreat into their inner world. People with schizoid PD rarely present to medical attention because, despite their reluctance to form close relationships, they are generally well functioning and quite untroubled by their apparent oddness.
3. Schizotypal Disorder: Schizotypal PD is characterized by oddities of appearance, behavior, and speech, unusual perceptual experiences, and anomalies of thinking similar to those seen in schizophrenia. These later can include odd beliefs, magical thinking (for instance, thinking that speaking of the devil can make him appear), suspiciousness, and obsessive ruminations. People with schizotypal PD often fear social interaction and think of others as harmful. This may lead them to develop so-called ideas of reference — that is, beliefs or intuitions that events and happenings are somehow related to them. So whereas people with schizotypal PD and people with schizoid PD both avoid social interaction, with the former it is because they fear others, whereas with the latter it is because they have no desire to interact with others or find interacting with others too difficult. People with schizotypal PD have a higher than average probability of developing schizophrenia, and the condition used to be called “latent schizophrenia.”
4. Antisocial Personality Disorder: Cluster B is comprised of antisocial, borderline, histrionic, and narcissistic personality disorders. Until psychiatrist Kurt Schneider (1887-1967) broadened the concept of personality disorder to include those who “suffer from their abnormality,” personality disorder was more or less synonymous with an antisocial personality disorder. Antisocial PD is much more common in men than in women and is characterized by a callous unconcern for the feelings of others. The person disregards social rules and obligations, is irritable and aggressive, acts impulsively, lacks guilt, and fails to learn from experience. In many cases, he has no difficulty finding relationships — and can even appear superficially charming (the so-called “charming psychopath”) — but these relationships are usually fiery, turbulent, and short-lived. As antisocial PD is the mental disorder most closely correlated with crime, he is likely to have a criminal record or a history of being in and out of prison.
5. Borderline Personality Disorder: In borderline PD (or emotionally unstable PD), the person essentially lacks a sense of self and, as a result, experiences feelings of emptiness and fears of abandonment. There is a pattern of intense but unstable relationships, emotional instability, outbursts of anger and violence (especially in response to criticism), and impulsive behavior. Suicidal threats and acts of self-harm are common, for which reason many people with borderline PD frequently come to medical attention. Borderline PD was so-called because it was thought to lie on the “borderline” between neurotic (anxiety) disorders and psychotic disorders, such as schizophrenia and bipolar disorder. It has been suggested that borderline personality disorder often results from childhood sexual abuse and that it is more common in women, in part because women are more likely to suffer sexual abuse. However, feminists have argued that borderline PD is more common in women because women presenting with angry and promiscuous behavior tend to be labeled with it, whereas men presenting with similar behavior tend instead to be labeled with antisocial PD.
6. Histrionic Personality Disorder: People with histrionic PD lack a sense of self-worth and depend on attracting the attention and approval of others for their wellbeing. They often seem to be dramatizing or “playing a part” in a bid to be heard and seen. Indeed, “histrionic” derives from the Latin histrionics, “pertaining to the actor.” People with histrionic PD may take great care of their appearance and behave in a manner that is overly charming or inappropriately seductive. As they crave excitement and act on impulse or suggestion, they can place themselves at risk of accident or exploitation. Their dealings with others often seem insincere or superficial, which in the longer term can adversely impact their social and romantic relationships. This is especially distressing to them, as they are sensitive to criticism and rejection and react badly to a loss or failure. A vicious circle may take hold in which the more rejected they feel, the more histrionic they become — and the more histrionic they become, the more rejected they feel. It can be argued that a vicious circle of some kind is at the heart of every personality disorder and, indeed, every mental disorder.
7. Narcissistic Personality Disorder: In narcissistic PD, the person has an extreme feeling of self-importance, a sense of entitlement, and a need to be admired. He is envious of others and expects them to be the same as him. He lacks empathy and readily lies and exploits others to achieve his aims. To others, he may seem self-absorbed, controlling, intolerant, selfish, or insensitive. If he feels obstructed or ridiculed, he can fly into a fit of destructive anger and revenge. Such a reaction is sometimes called “narcissistic rage” and can have disastrous consequences for all those involved.
8. Avoidant Personality Disorder: Cluster C is comprised of avoidant, dependent, and anankastic personality disorders. People with avoidant PD believe that they are socially inept, unappealing, or inferior, and constantly fear being embarrassed, criticized, or rejected. They avoid meeting others unless they are certain of being liked and are restrained even in their intimate relationships. Avoidant PD is strongly associated with anxiety disorders, and may also be associated with actual or felt rejection by parents or peers in childhood. Research suggests that people with avoidant PD excessively monitor internal reactions, both their own and those of others, which prevents them from engaging naturally or fluently in social situations. A vicious circle takes hold in which the more they monitor their internal reactions, the more inept they feel, and the more inept they feel, the more they monitor their internal reactions.
9. Dependent Personality Disorder: characterized by a lack of self-confidence and an excessive need to be looked after. This person needs a lot of help in making everyday decisions and surrenders important life decisions to the care of others. He greatly fears abandonment and may go through considerable lengths to secure and maintain relationships. A person with dependent PD sees himself as inadequate and helpless, and so surrenders his personal responsibility and submits himself to one or more protective others. He imagines that he is at one with these protective other(s), whom he idealizes as competent and powerful, and towards whom he behaves in a manner that is ingratiating and self-effacing. People with dependent PD often end up with people with a cluster B personality disorder, who feed on the unconditional high regard in which they are held. Overall, people with dependent PD maintain a naïve and child-like perspective and have limited insight into themselves and others. This entrenches their dependency, leaving them vulnerable to abuse and exploitation.
10. Anankastic (Obsessive-Compulsive) Personality Disorder: Anankastic PD is characterized by an excessive preoccupation with details, rules, lists, order, organization, or schedules; perfectionism so extreme that it prevents a task from being completed; and devotion to work and productivity at the expense of leisure and relationships. A person with anankastic PD is typically doubting and cautious, rigid and controlling, humorless, and miserly. His underlying anxiety arises from a perceived lack of control over a world that eludes his understanding, and the more he tries to exert control, the more out of control he feels. As a consequence, he has little tolerance for complexity or nuance and tends to simplify the world by seeing things as either all good or all bad. His relationships with colleagues, friends, and family are often strained by the unreasonable and inflexible demands that he makes upon them.

–Psychology Today

Etiology of Symptoms

The main concern with people having personality problems is the risk of harming themselves or others. Aggression and violence are related to impulsive and obsessive-compulsive disorders, which are also found in personality disorders. Aggressive behaviors are primarily involved with the dopamine/reward circuits like addictions or compulsive-seeking behaviors. Treatment is possible by regulating the dopamine pathways, with the use of antipsychotics (for aggression) or SSRIs to treat the compulsivity.

-Stahl, 2013

 

Key Points and Features

• As with all diagnoses, rule out any other causes such as substance use, brain injury…etc.
• Personality disorders respond better to psychotherapy and support rather than with medications alone.
• These patients are usually very alert and orientated to name, date, location, or in other words, mentally competent and have the right to REFUSE medications or treatment, thus emotional support/therapy is the most important.

Additional Information and Resources 

• Borderline Personality Disorder– Medline Plus: Medical Encyclopedia
• Famous People with BPD
• Personality Disorders– Medline Plus: Medical Encyclopedia
• Veterans Crisis Line
• Tips for Family and Caregivers To help a friend or relative with the disorder:
  • Offer emotional support, understanding, patience, and encouragement—change can be difficult and frightening to people with a borderline personality disorder, but it is possible for them to get better over time
  • Learn about mental disorders, including borderline personality disorder, so you can understand what the person with the disorder is experiencing
  • Encourage your loved one who is in treatment for a borderline personality disorder to ask about family therapy
  • Seek counseling for yourself from a therapist. It should not be the same therapist that your loved one with a borderline personality disorder is seeing

–National Institute of Mental Health Information

The Mayo Clinic also has a great description of personality disorders & check out Related Websites and Additional Help for Borderline Personalities