Category: Education

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.

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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?

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In casual parlance, the term “antisocial” can mean “shy” or “introverted”, as in, “No, I’m not going to that party… I’m feeling antisocial.”

The word “antisocial” in clinical settings, however, is an abbreviation for the condition of Antisocial Personality Disorder, which has nothing to do with shyness or introversion.

Here is how DSM-4 defines Antisocial Personality Disorder:

A. There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following:

Think of “antisocial” as referring specifically to “antisociety”. (This is why people opine that Hannibal Lecter and Volde—uh, He-Who-Must-Not-Be-Named—have antisocial personality disorder. Do also note that the terms “psychopaths” and “sociopaths” refer to an extreme form of antisocial personality disorder, but not all individuals with this condition are violent serial killers. People who work in mental health often quip that there are some people with antisocial personality disorder who do quite well for themselves in government and CEO positions.)

We’ll talk more about the “occurring since age 15 years” part in criterion C below.

(1) failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest

This criterion, when taken alone, is problematic. By definition, Galileo Galilei and Mahatma Gandhi would have been on their way to a diagnosis of antisocial personality disorder.

I repeat this often here, perhaps more so to remind myself: (1) Context matters, and (2) This is how psychiatry can become an agent of social control.

(2) deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure

This, paired with criterion A7 (“lack of remorse”), is often cited for this diagnosis.

(3) impulsivity or failure to plan ahead

This is a matter of degree. (We all, occasionally, are impulsive and don’t plan ahead.) The outcomes of the impulsivity and failure to plan ahead also matters. Generally, this criterion can result in the behaviors described in the rest of the diagnosis.

(4) irritability and aggressiveness, as indicated by repeated physical fights or assaults

The modifier of “repeated physical fights or assaults” strongly suggests that this is not primarily an emotional condition; it is a behavioral condition. That “failure to conform to social norms with respect to lawful behaviors” refers to this.

(5) reckless disregard for safety of self or others

Individuals with this condition can be dangerous. They often die by violent means (such as suicide and homicide).

(6) consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations

Our culture values consistent work behavior and financial responsibility. This is why such behavior is considered “antisociety”.

(7) lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

This is arguably the most compelling (and most often cited) criterion for antisocial personality disorder. Most people, regardless of which culture they belong to, feel some regret, shame, or guilt upon breaking a social contract. These individuals do not.

B. The individual is at least age 18 years.

A person must be a legal adult.

C. There is evidence of Conduct Disorder with onset before age 15 years.

By definition, Conduct Disorder is the predecessor of Antisocial Personality Disorder. DSM-4 defines Conduct Disorder as “a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated. The specific behaviors characteristic of Conduct Disorder fall into one of four categories: aggression to people and animals, destruction of property, deceitfulness or theft, or serious violation of rules.” The authors are arguing that Antisocial Personality Disorder doesn’t just come out of the blue. A pattern was already in motion.

D. The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic Episode.

This is a corollary to the previous criterion. Schizophrenia and a Manic Episode are considered “episodic” (yes, even schizophrenia). As you may recall, personality disorders are considered “chronic“.

You can now see why it can be challenging to work with people with antisocial personality disorder. To help us avoid automatic reactions of disdain for these individuals, we’ll next learn why people might develop this condition.

Now that we are familiar with the three clusters of personality disorders, let us begin with cluster A. The first is paranoid personality disorder.

A few things to keep in mind when discussing paranoid personality disorder:

1. Medical professionals seldom see people with this condition in clinical settings. Individuals with paranoid personality disorder generally don’t want to see us, so we have few opportunities to learn about and from them. Because of this, there is limited data on this condition and what interventions (if any) are useful.
2. Paranoid personality disorder (as with most personality disorders) is considered “egosyntonic”. This is the fancy way of saying that people with this condition don’t find their thoughts, behaviors, or emotions distressing. No conflict exists between who they believe they “should be” and who they actually “are”.
3. DSM adopts a fairly behavioral approach when describing symptoms of this condition. The authors make no attempt to explain why certain thoughts and behaviors came to be.[1. To be clear, there are many psychiatrists (most of whom have a psychodynamic perspective) who have attempted to explain the underpinnings of personality disorders, though these explanations are difficult to validate. It is difficult to apply the scientific method to the “unconscious”.] Again, this explains why the diagnostic criteria are something like “ordering from a Chinese menu”.

Here are the verbatim DSM-4 diagnostic criteria for paranoid personality disorder:

A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

You can already see why these individuals often lead solitary lives.

(1) suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her

These suspicions are generally within the realm of possibility. For example, someone with this condition might worry, “I don’t trust my boss—he says everything is fine, but I know he’s looking for reasons to fire me. I do my work like I should and he knows it. He just wants me out of here.”

Contrast that with someone who says, “I don’t trust my boss—he says everything is fine, but I know he’s trying to steal all of my bones. Every payday, I see how he looks at me. He thinks he’s God: He wants to use one of my ribs so he can create something new.”

(2) is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates

“You got me a birthday gift? Why? What am I supposed to do with this restaurant gift certificate? Are you regifting? Did the health department give this place a low rating? You don’t even like sushi—are you hoping that I’ll get sick?”

(3) is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her

“When is your birthday?”

“Why do you need to know that?”

“So I can send you a gift.”

“Or so you can steal my identity. I’m onto you.”

(4) reads hidden demeaning or threatening meanings into benign remarks or events

“I hope you have a happy birthday.”

“What do you mean by that? Is something going to happen the next day that will make me unhappy?”

(5) persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights

“He calls himself my ‘friend’. It’s convenient how he forgot that my stomach didn’t feel good after that meal at the sushi restaurant three years ago.”

(6) perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack

“I hope you have a happy birthday.”

“Are you saying that I’m not a happy person? Who are you to judge? I don’t see you smiling all the time—you got pretty pissed off the other day when that bird crapped on your car. Don’t tell me to be happy when you get bent out of shape over how your car looks.”

(7) has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner

“My boss invited me and my girlfriend to the holiday party. Why did he invite her? What is she going to do with him?”

DSM also inserts a (long) caveat about cultural differences:

Some behaviors that are influenced by sociocultural contexts or specific life circumstances may be erroneously labeled paranoid and may even be reinforced by the process of clinical evaluation. Members of minority groups, immigrants, political and economic refugees, or individuals of different ethnic backgrounds may display guarded or defensive behaviors due to unfamiliarity (e.g., language barriers or lack of knowledge of rules and regulations) or in response to the perceived neglect or indifference of the majority society. These behaviors can, in turn, generate anger and frustration in those who deal with these individuals, thus setting up a vicious cycle of mutual mistrust, which should not be confused with Paranoid Personality Disorder. Some ethnic groups also display culturally related behaviors that can be misinterpreted as paranoid.

Every individual, however, has his own individual culture. It’s not difficult to imagine that someone of the cultural “majority” who experienced chronic trauma and mistreatment could still demonstrate behaviors consistent with paranoid personality disorder.

Certain conditions must be ruled out before one receives a diagnosis of paranoid personality disorder. These include paranoia due to drugs (like methamphetamine), medical conditions, or schizophrenia. Personality disorders are uncommon conditions and should be “diagnoses of exclusion”.

According to DSM-4, somewhere between 0.5% and 2.5% of the general population meet criteria for a diagnosis of paranoid personality disorder. According to this article, 4.4% of adults in the US meet criteria for paranoid personality disorder. (Please recall that personality disorders should not be diagnosed from a single meeting… like a survey.) Many sources indicate that men are more likely to meet criteria for paranoid personality disorder, though I have not seen any research data to support this.

Paranoid personality disorder is one of the few diagnoses that has been listed in DSM since its first version (1952), though my understanding is that it is not in DSM-5. Hopefully DSM-5 will explain this omission (though I suspect it is due to the dearth of research data about this condition).

When I actually present this topic formally, I anticipate I will only superficially cover cluster A personality disorders (with the possible exception of schizotypal personality disorder). In many ways, these conditions are not relevant to the work of the audience.

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