ARCHIVED - The Human Face of Mental Health and Mental Illness in Canada 2006
CHAPTER 6 PERSONALITY DISORDERS
What Are Personality Disorders?
Personality disorders cause enduring patterns of inner experience and behavior that deviate from the expectations of society. These disorders are pervasive, inflexible and stable over time and lead to distress or impairment.Footnote 1
"Personality is seen today as a complex pattern of deeply imbedded psychological characteristics that are largely non- conscious and not easily altered, which express themselves automatically in almost every area of functioning."Footnote 2
Personality characteristics or traits are expressed on a continuum of social functioning. Personality disorders reflect personality traits that are used inappropriately and become maladaptive.Footnote 3 To some degree, this classification is arbitrary.
Some deviations may be quite mild and interfere very little with the individual's home or work life. Others may cause great disruption in both the family and society. Specific situations or events trigger the behaviours of a personality disorder. In general, individuals with a personality disorder have difficulty getting along with others and may be irritable, demanding, hostile, fearful or manipulative.
Personality disorders exist in many forms.Footnote 4 (Table 1-1) Classification of personality disorders is arbitrary. Each person is unique and can display mixtures of patterns.
- Difficulty getting along with other people. May be irritable, demanding, hostile, fearful or manipulative.
- Patterns of behaviour deviate markedly from society's expectations and remain consistent over time.
- Disorder affects thought, emotion, interpersonal relationships and impulse control.
- The pattern is inflexible and occurs across a broad range of situations.
- Pattern is stable or of long duration, beginning in childhood or adolescence.
|Borderline Personality Disorder||Instability in interpersonal relationships, self- image and affect, and marked impulsivity.|
|Antisocial Personality Disorder||Disregard for, and violation of, the rights of others.|
|Histrionic Personality Disorder||Excessive emotionality and attention seeking.|
|Narcissistic Personality Disorder||Grandiosity, need for admiration and lack of empathy.|
|Avoidant Personality Disorder||Social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.|
|Dependent Personality Disorder||Submissive and clinging behaviour related to an excessive need to be taken care of.|
|Schizoid Personality Disorder||Detachment from social relationships and a restricted range of emotional expression.|
|Paranoid Personality Disorder||Distrust and suspiciousness in which others' motives are interpreted as malevolent.|
|Obsessive-Compulsive Personality Disorder||Preoccupation with orderliness, perfectionism and control.|
|Schizotypal Personality Disorder||Acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behaviour.|
How Common Are Personality Disorders?
Canadian data on the prevalence of personality disorders is lacking. United States estimates of the prevalence of diagnosis of any personality disorder, however, range from 6% to 9%, depending upon the criteria used for definition.Footnote 5
Epidemiological studies most often measure and report antisocial personality disorder. A 1991 Ontario survey estimated that the one-year prevalence rate of antisocial personality disorder in the general population was 1.7%.Footnote 6 An Edmonton study in the 1980s found that 1.8% of the population had an antisocial personality disorder in the six-month period prior to the survey and 3.7% reported having had a personality disorder at some point in their lives.Footnote 7 Footnote 8
Impact of Personality Disorders
Who Develops a Personality Disorder?
Studies have shown that men tend to be diagnosed more often than women with anti- social personality disorder (3% versus 1%)Footnote 9 while women are more often diagnosed with borderline personality disorder (representing approximately 75% of cases).Footnote 10 This gender difference may be related to men's and women's differential social experiences, socialization effects and professional labelling bias.
Ideally, data from a population survey would provide information on the age and sex distribution of individuals with personality disorders. At the present time, however, hospitalization data provide the best available description of individuals with personality disorders. These data have limitations, however: most people with personality disorders if treated, are treated in the community rather than in hospitals, unless they show suicidal behaviour; and individuals with borderline personality disorder have higher rates of admission than other disorders because of their high rate of suicidal behaviour.
In 2002/03, hospitalizations for personality disorders were most frequent between the ages of 15 and 50 years. (Figure 6-1) In this age group, women were hospitalized more often than men. The hospitalization rate among young women 15-19 years old was nearly triple the rate of young men in the same age group.
What Are the Effects of Personality Disorders?
Although personality disorders usually onset in adolescence or early adulthood, they can also become apparent in mid-adulthood. To some extent, timing depends on the type of personality disorder and the situation or events surrounding the individual. For example, borderline personality disorder usually peaks in adolescence and early adulthood and then becomes less prominent by mid-adulthood. On the other hand, narcissistic personality disorder may not be identified until middle age when the individual experiences the sense of loss of opportunity or faces personal limitations.
Since personality disorders usually develop in adolescence or early adulthood, they occur at a time when most people develop adult relationship skills, complete their education and establish careers. The result of the use of maladaptive behaviours during this life stage has implications that extend for a lifetime.
A history of alcohol abuse, drug abuse, sexual dysfunction, generalized anxiety disorder, bipolar disorder, obsessive-compulsive disorder, depressive disorders, eating disorders, and suicidal thoughts or attempts often accompany personality disorders.Footnote 11 Footnote 12 Research has shown that up to one-half of prisoners have antisocial personality disorder. This is because of its associated behavioural characteristics, such as substance abuse, violence and vagrancy, which lead to criminal behaviour.Footnote 13 Other social consequences of personality disorders include:
- Spousal violence;
- Child maltreatment;
- Poor work performance;
- Suicide; and
Personality disorders have a major effect on the people who are close to the individual. The individual's fixed patterns make it difficult for them to adjust to various situations. As a result, other people adjust to the individual. This creates a major strain on all relationships among family and close friends and in the workplace. At the same time, when those around the individuals with the personality disorder do not adjust, they can become angry, frustrated, depressed or withdrawn. This establishes a vicious cycle of interaction, causing the individuals to persist in the maladaptive behaviour until their needs are met.
Stigma Associated with Personality Disorders
Since the behaviours shown in some personality disorders remain close to what is considered "normal", others often assume that the individuals can easily change their behaviour and solve the interpersonal problem. When the behaviour persists, however, it may be perceived as a lack of will or willingness to change. The fixed nature of the trait is poorly understood by others.
Causes of Personality Disorders
Personality disorders likely result from the complex interplay of genetic and environmental factors. Genetic factors contribute to the biological basis of brain function and to basic personality structure. This structure then influences how individuals respond to and interact with life experiences and the social environment. Over time, each person develops distinctive patterns or ways of perceiving their world and of feeling, thinking, coping and behaving.
Individuals with personality disorders may have impaired regulation of the brain circuits that control emotion. This difficulty, combined with psychological and social factors such as abuse, neglect or separation, puts an individual at higher risk of developing a personality disorder. Strong attachments within the family or a supportive network of people outside the family, in the school and in the community help an individual develop a strong sense of self-esteem and strong coping abilities. Opportunities for personal growth and for developing unique abilities can enhance a person's self-image. This supportive environment may provide some protection against the development of a personality disorder.
Diagnoses of borderline personality disorder tend to be highly correlated with experiences of early childhood physical and sexual abuse and with addictions in women.Footnote 14
For biologically predisposed individuals, the major developmental challenges that are a normal part of adolescence and early adulthood—separation from family, self-identity, and independence—may be the precipitating factors for the development of the personality disorder. This may explain why personality disorders usually onset in these years.
Treatment of Personality Disorders
The greatest challenge in treating personality disorders is that the problem is often unrecognized by the individual. They often blame others for relationship problems. Intensive individual and group psychotherapy, combined with anti-depressants and mood stabilizers, can be at least partially effective for some people. Difficulties arise from both the persistence of symptoms and the negative impact of these symptoms on the therapeutic relationship.
Individuals with borderline personality disorder have more frequent hospitalizations, use outpatient psychotherapy more often, and make more visits to emergency rooms than individuals with other personality disorders.Footnote 15
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