Personality Disorders (intermission).

Forgive the lull in posts here about personality disorders. I am scheduled to deliver my talk this Friday. I’m directing my efforts towards creating a visually pleasing presentation and discussing the information as coherently as possible.

It doesn’t matter how many times I’ve presented something in front of a large group of people. I still feel nervous before every talk.

Consult-Liaison Education Medicine

Personality Disorders (IX): Definition and Etiology of the Dependent Type.

There is very little data about dependent personality disorder. Psychoanalytic theorists have discussed their ideas about how this condition comes about, but there are few papers that discuss the reasons why it develops and what to do about it.

We’ll go through the DSM-4 criteria for it first:

A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

Yikes. Would you have ever guessed that “clinging” would become a diagnostic criterion?

(1) has difficulty making everyday decisions without an excessive amount of advice and reassurance from others

The thought is that the person will make the “wrong” decision or that the decision will displease other people. The decisions, though, may not appear complicated to most people. (“Which cereal should I eat? You’re not going to be mad if I eat the Cookie Crisp, right? But maybe I should go with Lucky Charms. Which do you think will taste better?”)

(2) needs others to assume responsibility for most major areas of his or her life

Again, this suggests a lack of trust in oneself to make the “right” decisions. (“Which job should I apply for? Where should I live? What kind of food should I eat?”)

(3) has difficulty expressing disagreement with others because of fear of loss of support or approval. Note: Do not include realistic fears of retribution.

Perhaps this is also a fear of abandonment (see borderline personality disorder). Also note that this criterion includes a caveat about excluding “realistic fears”, whereas in borderline personality disorder, the excessive efforts apply to either “real or imagined” abandonment.

(I suppose it is noteworthy that this criterion refers to “expressing disagreement” and the borderline criterion refers to “excessive efforts”, though both are driven by “fear”.)

(4) has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy)

Insecurity is all a matter of degree. Again, this difficulty with initiative must impair function, affect relationships, etc. Conversations like

“Where do you want to eat?”
“I don’t know, where do you want to eat?”

don’t count.

(5) goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant

Doormat” is not a clinical term, but this is what often comes to mind.

(6) feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself

This is an interesting criterion because it comments directly on emotions rather than behaviors. Sometimes we think people feel uncomfortable or helpless, though they actually feel neither. Sometimes people do feel uncomfortable and helpless, though their behaviors don’t suggest this at all.

(7) urgently seeks another relationship as a source of care and support when a close relationship ends

This criterion, as with the last one, should be taken in conjunction with the other criteria for this diagnosis.

(8) is unrealistically preoccupied with fears of being left to take care of himself or herself

Fear underpins this diagnosis and drives the behaviors that seem like “clinging”.[1. One must be careful when assuming intentions from behaviors alone. You might see me eating a sack of cookies (behavior) and assume that I lack control (intention). I might actually be eating a sack of cookies (behavior) because I hadn’t eaten all day or I don’t want to share my cookies with other people. Maybe the sack is no longer full of cookies, but I am eating quickly because I am running late. The sack may not have cookies inside. You get my point.]

Here is a paper that reports some studies that describe possible etiologies of dependent personality disorder. Some authors found a relationship between “infantile feeding experiences and later dependency”, though the data is inconsistent and subject to the mothers’ reporting bias.

When people studied interactions between infants and parents and parenting styles, they found that parents who are overprotective and authoritarian may have children who ultimately develop dependent personality disorder.

The author correctly notes that parental behavior may actually reinforce dependent behaviors in children and vice versa. If the parent derives some benefit (psychological or otherwise) from a child who shows dependent behaviors, the parent may actually increase the authoritarian and overprotective behavior because the parent “likes” the reactions. This may drive the child to demonstrate even more of these behaviors. And on and on it goes.

These observations are in direct contrast to other hypothesizes about dependent personality disorder (for which there is no data, but only speculation): Some argue that children who lose their parents at an early age (due to death, adoption, etc.) are more likely to develop dependent personality disorder. Others argue that children who have chronic physical illness are also more likely to develop this condition.

One major component to consider is “fit”.[2. To learn more about “fit”, read about attachment theory.] We don’t choose our parents or our children. Sometimes, there just isn’t a “good fit” between parents and children. Some parents are anxious, which leads to overprotectiveness and authoritarian behavior. This may increase the likelihood that the child will develop dependent personality disorder or traits. If the child had different parents, he might have a different temperament as an adult. To be clear, many children do have anxious parents and never develop this condition.

And that’s all I got for dependent personality disorder. Next up is how to manage (not treat!) these conditions in settings like shelters and supportive housing. I shan’t let that task daunt me.

Consult-Liaison Education Medicine

Personality Disorders (VIII): The Definition of Borderline.

If you haven’t read the proposed etiologies of borderline personality disorder first, please do so. An understanding of its causes makes the criteria seem less… judgmental and harsh.

Following is the definition of borderline personality disorder according to DSM-4.

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

The authors here focus on instability, not only when interacting with others, but also with oneself and one’s emotions.

(1) frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

The vast majority of people don’t want to experience abandonment. “Frantic”, given the context, is open to interpretation. Upon reading this, you may think of multiple, desperate phone calls filled with promises that cannot be kept. These efforts, however, can also refer to someone who abruptly stays in bed and doesn’t acknowledge any communications from the outside world. “Frantic efforts” are not required to be loud.

(2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

“Alternating between extremes of idealization and devaluation” is often described as something like this:

January 15: “I love my doctor—she’s the best doctor I’ve ever had. She is smart and really understands what I’m talking about. Don’t see anyone else in that clinic; no one else there is as good as she is.”

February 1: “My doctor is terrible. She thinks she’s really good, but she’s not. I’m not sure why they let her graduate from medical school—she doesn’t know what she’s doing and her bedside manner is crap. I would not recommend her to my worst enemy.”

Recall the concept of “all good/all bad”.[1. This “all good/all bad” concept comes from object relations theory. Object relations is not my forte; I’m much too concrete.] That is reflected here.

(3) identity disturbance: markedly and persistently unstable self-image or sense of self

Recall the experiences of invalidation children may experience while growing up. If you are regularly told that your thoughts, emotions, and behaviors are “wrong”, you, too, might have doubts about who you are, what you feel, and what you do.

(4) impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

This might speak to heightened “emotional sensitivity” (more intense emotions that last a longer period of time), which is considered a biological cause of this condition.

People also often confuse these behaviors with the hypo/mania described in bipolar disorder.

(5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

This criterion was already mentioned twice before we got here! This is why some people use the mental shortcut of, “Well, she’s always trying to kill herself, so she must be borderline”.[2. Try this exercise if you work in health care: Describe your patients as people instead of medical conditions. No, he’s not “the liver cancer in bed seven”, he’s “Mr. Smith, the man diagnosed with liver cancer”. Yes, emotional distance can be useful, but if you habitually think of your patients as diagnoses, that might lead you to treat your patients as if they weren’t people.] Like many shortcuts, this can lead you to the wrong conclusion.

Remember that Little Suzie learned that people seemed to only really understand her internal distress when she did things like injure herself. This is the best way she knows how to get her emotional needs met. This is a skills deficit. (To be clear, you could say that “she’s manipulative”, but we all manipulate each other all the time. I’m arguably manipulating you right now with these words. We often use the word “manipulative” when the manipulation isn’t skillful. People would do something different if they could in that moment.)

(6) affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)

This again refers to the “emotional sensitivity” discussed above in criterion 4. People also confuse this with mood fluctuations seen in bipolar disorder.

(7) chronic feelings of emptiness

This can be related to the “identity disturbance” described in criterion 3 above.

(8) inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

(I encourage all to use the word “inappropriate” with caution. What is “inappropriate” strongly depends on the context.)

This, too, refers to “emotion sensitivity” and the impulsivity that may result from it.

(9) transient, stress-related paranoid ideation or severe dissociative symptoms

This criterion explains the psychotic symptoms that can accompany borderline personality disorder. Some will recall the the name “borderline” came about because some theorists argued that these individuals are on the “borderline” between neurosis and psychosis.

Dissociation can be a skillful way of coping with stress. An extreme example is someone dissociating while getting raped. A more common example is someone dissociating a bit while at the dentist. Dissociation becomes a problem when it affects function (like dissociating while at a job interview).

Again, recall that a personality disorder is an “enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment”. People who work in health care settings often start using the word “borderline” to describe someone who they feel annoyed and frustrated with. That’s unfair. Words matter.

Next up is dependent personality disorder… for which there is sparse data.

Consult-Liaison Education Medicine

Personality Disorders (VII): Where Does the Borderline Variety Come From?

Though I finished my last post with questions about treatment for antisocial personality disorder, I am going to change course and instead discuss the other two personality disorders for my talk first. (I ultimately cannot discuss specific treatments for each condition, partly because some of the conditions unfortunately do not have evidence-based treatments, but also because some of the treatments overlap.)

Much of the literature discusses the treatment of borderline personality disorder, though few discuss etiologies of this condition. As with antisocial personality disorder, there is evidence that children who experience abuse or neglect are at higher risk of developing borderline personality disorder. There are more ideas than evidence about the development of this condition.

There are two major hypotheses (one from the behavioral school of thought, the other from the psychodynamic school) about the etiology of borderline personality disorder.

Marsha Linehan, who developed dialectical behavior therapy, argues that borderline personality disorder develops as a consequence of two factors. The first is biological: Some individuals are just genetically programmed to experience more emotional sensitivity—meaning more intense emotions that last a longer period of time—than the “average” person. Impulse control (now considered a heritable trait) is often a challenge for these individuals as well.

The second factor is environmental: Individuals with borderline personality disorder often grow up in invalidating environments. These two factors combined can result in children never learning the skills to regulate their own emotions.

When I am teaching these concepts in person, I usually draw a graph that shows the hypothesized difference between how the “average” (whatever that even means) person experiences an emotional response and how someone with borderline personality disorder experiences an emotional response. The point is to see that people with borderline personality disorder are often overwhelmed by emotions, which can result in impulsive behavior.

All human beings, when overwhelmed, can behave in ways that are impulsive. Think about the last time you were really stressed out. Maybe you spoke too soon, did something you now regret, or didn’t behave the way you and others expect you to behave.

Now imagine having those experiences throughout the day.

When I describe invalidation, I usually share the example of “Little Suzie” who draws a picture of a horse. She is pleased with her drawing and shows it to her parents. She expects that they will feel pleasure from this drawing, too.

They don’t recognize it’s a horse.

“It doesn’t even look like an animal,” they comment. “Why are you proud of this?”

Little Suzie naturally begins to cry because she was proud of her drawing. Upon seeing this, her parents reply, “Why are you crying? You’re too sensitive. There is nothing to be sad about. Stop being silly and stop crying.”

As this happens repeatedly to Little Suzie she learns that her internal experiences are “wrong”. The messages she receives from the external world consistently contradict the messages she receives from her internal world. Thus, she learns to distrust or disbelieve her internal experiences.

There are rare moments, though, when the world seems to “agree” with her internal experiences when she engages in certain behaviors (like cutting her skin; suddenly, people tell Suzie things like, “Wow—you must be feeling really bad if you cut your wrist like that!”). She thus learns that the one way she can receive emotional validation is when she demonstrates behaviors like trying to kill herself.

Both the behavioral and psychodynamic formulations (see below) comment that sexual abuse is a risk factor for the development of borderline personality disorder. You can imagine that sexual abuse is a highly invalidating event (“I know this feels good to you, too… but don’t tell anybody…”).

Psychodynamic formulations (Otto Kernberg focused on this condition) argue that borderline personality disorder originates when toddlers become alarmed about the potential of their mothers disappearing. He argued that these individuals are “repeatedly reliving an early infantile crisis in which they fear that attempts to separate from their mother will result in her disappearance and abandonment of them”.[1. From Gabbard’s Psychodynamic Psychiatry in Clinical Practice, page 434.] Kernberg has also argued that these individuals have problems integrating stable, constant ideas/constructions about people (and themselves) in their own minds, which results in these individuals believing that people are either all good or all bad, rather than a mixture of the two.

Bateman and Fonagy have argued that borderline personality disorder comes about because these individuals “have a great deal of difficulty appreciating and recognizing that perceived states of oneself and others are fallible and subjective and are representations of reality that reflect only one of a range of possible perspectives”.[2. From Gabbard’s Psychodynamic Psychiatry in Clinical Practice, page 436.] This is similar to the view above about people being either all good or all bad. It is difficult to consider different viewpoints when you’re experiencing an intense emotion.

And… that’s really about it in terms of how borderline personality disorder comes about. People with borderline personality disorder often die from self-injury (whether inadvertently or not) and, unfortunately, many people assume that these individuals don’t need or want help. It is unfortunate that we don’t know enough about this condition to help prevent it from occurring, but at least we know information to help treat it when it presents.

We’ll go over DSM-4 diagnostic criteria next.

Consult-Liaison Education Medicine

Personality Disorders (VI): Where Does the Antisocial Variety Come From?

Now that we know how the DSM defines antisocial personality disorder, let’s see what the literature[1. Unfortunately, there isn’t a lot of data for many psychiatric conditions and phenomena. This frustrates clinicians and patients alike.] says about its causes.

One paper that argues that children whose mothers are experiencing depression are more likely to demonstrate antisocial behaviors. This is a “nurture” proposal, as mothers experiencing depression may not have more difficulties with the role of parenting. This can result in more stress for the family.[2. This, along with many of the other studies discussed here, harkens back to the “schizophrenogenic mother“, which is controversial.]

The authors also argue that genetics accounts for about one-third of the association between mother and child antisocial behaviors. This is the “nature” proposal, as the data suggests that treating depression in mothers alone does not prevent the development of antisocial behaviors.

Do note that the study looked at kids at ages five and seven. We have no idea how many of these kids ultimately demonstrate symptoms consistent with conduct disorder. Recall that a diagnosis of conduct disorder (by age 15) must precede a diagnosis of antisocial personality disorder (earliest at age 18).

Here’s a paper that discusses childhood spanking and a possible relationship with antisocial behavior. (Again, this paper does not comment on the the development of conduct disorder.) The authors interviewed parents and asked them if they spanked their children in the past week. According to the paper, the more parents spanked their children, the more likely the children were to develop antisocial behaviors. The authors conclude, “When parents use corporal punishment to reduce [antisocial behaviors], the long-term effect tends to be the opposite.”

It’s not clear if the interview also screened for other events occurring in the home, including substance use, violence between the parents/caregivers, education, etc.

There’s evidence that children who “experienced substantiated child abuse and/or neglect from 1967 to 1971 in a Midwestern metropolitan county area” were, as adults, significantly more likely to demonstrate symptoms of antisocial personality disorder. These diagnoses came from a two-hour interview… which, again, generally isn’t how personality disorders are diagnosed in clinical practice. (Rarely do psychiatrists get two hours with clients and, as previously noted, personality disorders are usually diagnosed after working with a client over time.)

Here’s an argument that male children born to women with severe nutritional deficiency were more likely to develop antisocial personality disorder. The authors concluded that the risk was highest if the mother experienced “nutritional deficiency” (famine) during the first and second trimesters.

During famine and war, there are numerous relevant factors that may affect this: People can get really ill (dysentery, tuberculosis, etc.). People experience both physiological and psychological stress during these times. It may not be nutritional deficiency alone that results in antisocial personality disorder. (Furthermore, the results of this paper would suggest that populations in North Korea and Somalia should have a higher incidence of antisocial personality disorder, which does not appear to be the case.)

So, hopefully, we now have more empathy for individuals with antisocial traits or personality disorder. They often had crappy things happen to them while they were growing up. As a result of their personal histories, could they have developed ways of coping that may have worked well in the past, but don’t work so well now (and may instead be construed as antisociety)?

Next: What can we do about this? How can we help these individuals?