Personality Disorder

I don’t really like the term “personality disorder” as it suggests an enduring condition whereas the evidence is many personality dysfunctions soften or resolve fully over several years.

A personality dysfunction describes a failure during childhood years to develop in one    or both of these areas                                                                                                                                                – good emotional control                                                                                                                                                      – use interpersonal relationships in a non- purely self interested way                                                    So for example Borderline Personality people typically have problems modulating anger and sadness . Paranoid Personality people deal with anxiety by constantly finding threat where there may be none.  Antisocial Personality people  deal with society from the point of view of what they can take from it; hence their frequent criminality. Narcissistic personality people feel other people are just there to help them achieve greatness.

The cause of personality dysfunction? About 55% genetic about 45% rearing environment.  There is an interplay called epigenetics. In epigenetics a parent could grow up with alcoholic parents and the result could be that a gene could be turned on in his future children that made them more prone to criminality.  Many people with personality dysfunction come from toxic home environments where affection has been unavailable or conditionally given.  There is also in some personality dysfunctions ( antisocial and borderline) higher rates of sexual abuse and neglect.  Underlying the personality dysfunction are brain changes – for example in Borderlines there is a heightened emotional responsivity to facial images suggesting anger.

There is also the problem of the cycle of repetition. Normally when we do something and it doesn’t work out we problem solve and then try a new method .  But Personality Dysfunction people are great at banging their heads repeatedly against  the brick wall to see if it moves!  Sexual abuse begets further rape experiences. Self-cutting begets more self-cutting . Drug taking binges begets more drug taking binges and so on. Great  patience is required in waiting for them to realise its time to stop and move on.   Its a hang-over from childhood-young children don’t problem solve.

MANAGEMENT 

The bottom line of managing personality dysfunction is that treatment goes no where till you have a relationship. By relationship I mean a shared agreement on what the goal of therapy is and how to get there.  Because personality dysfunction people often blow hot and cold about treatment the therapists tries to counter this by setting up a schedule which he hopes is doeable for the patient (technically called “the frame”). Forming a relationship properly can take say three months – its not quick. Sometimes there’s seduction involved – antisocial personalities may want things rather than treatment ( letters for Court, letters for social security).

A word about comorbidity. Many personality disorder patients are unhappy people and are initially referred by family doctors for treatment of depression. Treating with medication before one has a relationship is unwise and just results in non-compliance or over-dose.  I don’t generally find antidepressants very useful.  Mood stabilisers  such as Depakote (Epilim) and Topiramate can be useful.   Zyprexa , an antipsychotic, has anti-anger and anti-paranoid properties and so can be useful.  N-acetyl Cysteine has PTSD treatment and anti-addiction properties  and may be useful.  Generally medication is best sorted  early on and then not fiddled with.  Fibromyalgia is a common medical  condition. Anorexia may be an additional psychiatric comorbidity.

One issue that often comes up is the “ see what their doing to me “cycle. In this the patient recurrently evokes the ”blood is thicker than water” argument  and goes to the toxic family and gets punished for it and then reverts to depression or self-injury as a consequence.  As a child one is stuck with one’s family . As an adult you have a choice and can vote with your feet.

Treating a person with personality dysfunction is to some extent like coaching a team of novice child  footballers – you have to attend to all the players needs,  stay confident about the teams progress, and communicate that back to them when they are losing.

 

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