Personality Disorders

Variation in personality is a normal and natural aspect of humanity. More extreme variations are sometimes labelled as eccentric, adaptive and even brilliant. However, when these variations negatively effect the client or others, there is utility in grouping various personality types and subsequently providing tailored approaches based on experience and research. As with other groupings, personality disorders often do not neatly fit in one category or another. In addition, a diagnostic label should only be used if the cluster of symptoms deviates significantly from others in cultural groupings and is causing problems. Those with personality disorders can often trigger strong reactions from staff. Understanding and managing these reactions may improve client outcomes, as well as increase staff morale, and reduce conflict within and between staff. Understanding the meaning behind a diagnosis of personality disorder may improve common language and understanding required in multi-disciplinary approaches. Some personality disorders are more likely to coexist with substance use (eg anti-social, borderline and dependent personality disorders). While facilitating significant change in personality may be beyond the scope of most health and welfare workers, successful drug interventions are more likely when personality factors are incorporated into treatment plans.
Contents Categories Aetiology Treatment Caution in uncovering negative emotional states Identify and manage your reaction Use supervision Specialist therapy Family Involvement Table of Personality Disorders
Categories
The DSM-lV describes ten disorders which fall into three categories: Cluster A Eccentric or odd behaviour: Paranoid, schizoid and schizotypal personality disorders Cluster B Dramatic, erratic and emotional behaviour: Borderline, antisocial, narcissistic and histrionic personality disorders Cluster C Anxious, fearful, and/or constricted behaviour: Obsessive-compulsive, avoidant and dependent personality disorders
Aetiology
Most theories about the development of personality disorders stress the use of maladaptive coping strategies to cope with life problems. These problems may be severe, prolonged and experienced early in life (eg ongoing child sexual abuse). As the coping strategies tend to avoid rather than deal with issues, chronic underlying stress states develop which call for even more of the same maladaptive strategies. As unresolved issues mount, so does general life chaos. In this context, substance use may provide yet another maladaptive coping strategy which also increases the range and depth of overall problems. As these coping strategies become in-grained, certain developmental tasks are poorly achieved. This results in personalities which often evoke strong reactions in others thus reinforcing and maintaining the personality disorder and associated chaos. In addition some theorists suggest a bio-social predisposition to certain personality disorders (eg borderline personality disorder). This theory hypothesise an autonomic nervous system which over-reacts to low levels of stress and takes longer than normal to return to normal baseline states. This mechanism is likely to also predispose to increased substance use.
Treatment
Caution in uncovering underlying negative emotional states As most personality disorders are the manifestation of long-term protection against stress and anxiety states, be cautious of uncovering deep emotional states, particularly if unsupported or when undergoing detoxification. Doing so may increase anxiety and exacerbate negative symptoms associated with personality disorder and possibly increase the likelihood of relapse into maladaptive defence mechanisms such as excessive drug use. Identify and manage your reaction Personality disorders often trigger a range of issues within self. These reactions can threaten professional conduct with the client and other staff. Use good communication skills between staff as well as with the client. Set clear boundaries and limits and stick to them. Use supervision Supervision will help to see own reactions and maintain professional conduct. Where treatment is not progressing, supervision may help ensure all that can be done is being done (which is the criteria for staff success). Specialist therapy Specialist therapy may be indicated for some personality disorders, particularly when there are concurrent symptoms such as self-harm or very aggressive behaviour. These treatments should generally only be carried out under close supervision of someone experienced in these treatments such as a clinical psychologist or psychiatrist. Family Involvement Family members may require support as clients in their own right. Where children are involved, a careful assessment of child safety may be required, generally by someone specifically trained in this area such as a child protection worker. Family and significant others may have extensive experience in dealing with maladaptive behaviours and can be a key resource in both assessment and ongoing treatment if appropriately engaged and involved in case management.
Table of Personality Disorders The table below provides a brief sketch of personality disorders. While the staff reaction column is based on the author's previous experience rather than hard research, it is provided to stimulate consideration of possible reactions and management of these reactions.
Personality Disorder (PD)	Symptoms	Likely Staff Reaction	Approach
Paranoid PD	OVERLY: suspicious, mistrustful, conspiracy theories. hold grudges, sensitive to criticism	Defensive, anger, sarcasm	Do not argue the point. Use empathy rather than hunt for detail Keep professional distance Be open and straightforward
Schizoid/Schizotypal PD	Detached, solitary, emotionally cold, eccentric (eg superstitious, telepathic) vague speech	Emotional distance, frustration at not getting through	Respect withdrawal and distance but 'hang in there'. Continue to be there after the client expects you to give up
Borderline PD	Poor interpersonal relationships - people seen as either wonderful or terrible. Hates being alone, impulsive and moody. May have self-harm, eating disorders, depression Often previously abused with post traumatic stress disorder (PTSD)	Staff splitting: may feel like the only one who 'really understands' (if being flattered) while others feel resentful (if they are being devalued). Danger of crossing client/counsellor boundaries	Work with here & now problems using structured problem solving approach, rather than issues in the past. High level communication with other staff. Maintain client/counsellor boundaries & limits. Specialist therapy such as Dialectical Behaviour Therapy & Cognitive Behavioural Therapy helpful
Narcissistic PD	Self absorbed, need to be constantly admired, lack of empathy with others, arrogant, May over flatter counsellor or criticise if total attention not given	Staff splitting as with Borderline PD. Feeling hurt and angry or flattered & charmed.	Similar to Borderline PD Set time limits with client Remain professional Recognise own narcissistic issues
Antisocial PD	History of conduct disorder in adolescents Disregard for the rights of others Unlawful, lying, impulsive, aggressive, irresponsible, lack of remorse, reckless with self and others. May be charismatic and corrupting	Vicarious excitement & admiration of exploits Loathing at lack of conscience Attempts to control may result in aggression	Resist temptation to collude or reinforce anti-social behaviour. Reframe hurtful exploits in a matter-of-fact manner as hurtful and not glamorous. Focus on resolving immediate problems.
Histrionic PD	Attention seeking and over-emotional, dramatic. Over-use of metaphor & flowery language Easily falls in love (with counsellor)	Impatient or frustrated when difficulty in getting to the point or Engrossed with poetic style .	Maintain boundaries and use clarifying statement often.
Obsessive-Compulsive PD	Perfectionist, rigid, in control, no spontaneity Irritable or angry when their order is threatened Depressed if they can't meet their own expectations	Irritated by lack of flexibility Frustrated counselling when client is over-inclusive and pedantic about detail. Battle to over-come their obsession with control	Work with underlying feelings, particularly feelings of hostility and anger (care with worker and client safety)
Avoidant PD	Distant social relationships (although unlike Schizoid PD, these would like intimate relationships but fear rejection). May be anxious and depressed	Withdrawal as client is quiet and withdrawn	Respect distance, but continue to be available. Cognitive therapy helpful in challenging negative beliefs about social situations and people.
Dependent PD	Rely on others to make decisions, care for and control them Submissive and require constant reassurance Rarely disagree for fear of loss of relationship Ask the counsellor for all the answers Severe depression may accompany relationship disharmony	Counsellor does all the talking and advice giving Cut off from client for fear of being consumed by their dependence	Resist giving advice or cutting-off. Rather use a problem solving or solution focused brief therapy approach and congratulate client success. Dependence is a key feature of addiction. Motivational therapy, 12 step programs and cognitive behavioural therapy may all be useful.