Most people have at least a few ‘out-there' relatives. And there is no better time of the year to experience the things these relatives do that qualify them as ‘out-there' than during the winter holidays (Christmas, Chanukah, Kwanzaa, Ramadan, Diwali, etc.). During this season, families tend to gather together and air out all of their abnormal behavior. If you are lucky during this time, and very quiet, you may witness a veritable sideshow of human fallibility. For instance:
- The aunt who always must be the center of attention.
- The grandmother who talks at you, not to you and treats you more like a doll than a person.
- The sister-in-law who will not assert herself despite the fact that her husband treats her badly.
- The uncle (working on his third divorce and second DWI arrest) who wants to tell you about his latest scheme for getting rich quick.
- The other uncle who rigidly insists on speaking at length about his religious beliefs, pointing out how wrong you are to persist in your evil ways.
- The hysterical and promiscuous cousin who has had string of failed relationships and who, you're pretty sure, has attempted suicide at least once.
- The niece who dresses funny and is pretty sure that the pyramids were built by UFOs.
- And of course, the nephew who chooses not to attend the gathering for his own inscrutable reasons.
Note please, in the example I've cooked up just above, that I'm talking about odd beliefs, and disturbing social mannerisms, but not necessarily about Depression, Manic states, true Obsessional behavior, or honest-to-god Psychosis. This more serious stuff, also present in our families, is not the topic of this essay. Rather, I want to call your attention to what are usually termed, “personality disorders”, or problematic, rigid personalities as you experience them in the wild. Because we are often intimately connected to people who behave in ‘abnormal' ways, (as partially illustrated above), it is helpful for us to have some understanding of how the mental health establishment understand abnormal personality.
The mental health community has long recognized that some people have rigid, fixed and very stable dysfunctional personalities that make them hard to get along with, or which interfere with their lives. The handbook that defines how mental health diagnoses are to be made, (The Diagnostic and Statistical Manual of Mental Disorders, or DSM for short), refers to such stable, rigid personality configurations as “personality disorders”.
Like most of the diagnoses described in the DSM, each personality disorder is defined as a list of symptoms, that, when present together in sufficient numbers, qualifies a patient to be diagnosed with the disorder in question. Making a diagnosis of this type is an ‘on or off' proposition. If a particular diagnosis is defined such that five out of nine possible symptoms must be met before the diagnosis can be made, then the diagnosis cannot be made if only four of the symptoms on the list are met. There is no ‘half-way' point; you either have the diagnosis or you do not.
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Many mental health professionals know that this ‘on or off' method is a crappy way to make a personality diagnosis. Personality is more accurately described as a sliding scale rather than an ‘on or off' switch. Take the personality trait of ‘friendliness' for example. You might describe someone as not-friendly, or extremely-friendly, but the chances are good that most people would show some degree of friendliness that falls in-between not-friend and extremely-friendly. Using the DSM ‘on or off' method, it is not possible to rate someone as being ‘in between' having a personality diagnosis or not. Despite the fact that the DSM forces clinicians to make binary and not dimensional diagnoses, personality diagnoses are still made, because the DSM descriptions are ‘good enough' to describe how some people habitually act.
In DSM, the personality disorders are divided into three groups (called “clusters”).
The first cluster “A” contains definitions for three personality styles which have in common their loose connection to shared reality.
Paranoid Personality Disorder is defined as a “pervasive distrust and suspiciousness of others…”. Paranoid personality disordered people often harbor suspicions (in absence of evidence) that others are plotting against them, can be preoccupied with doubt concerning other's loyalty, and may read malicious meaning into harmless remarks or events, which then may be used as justification for quick angry attacks.
Schizoid Personality Disorder is defined as a “pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings”. Truly schizoid people have little interest in human contact, sexual, emotional or otherwise, have few friends (if any) and don't appear to experience many normal human emotions.
Schizotypal Personality Disorder is defined as a “pervasive pattern of social and interpersonal deficits marked by acute (sharp) discomfort with, and reduced capacity for, close social relationships as well as by cognitive (thinking) or perceptual (sensory) distortions and eccentricities of behavior…”. While schizotypal and schizoid individuals share a common estrangement from humanity, schizotypal folks tend to tell you about their non-mainstream beliefs and experiences (UFOs, angels, ESP, out of body experiences), and may also talk in repetitive, stereotyped, round-about or otherwise odd speech.
A natural question that many people have is whether there is any relationship between schizoid, and schizotypal personality disorders and schizophrenia proper. The answer would appear to be yes (although no one fully understands how it all fits together). Schizophrenia is not really a single disease, but rather a family of diseases – some of which never fully express themselves in full flowering psychosis. Schizoid and schizotypal disorders are thought to be non-flowering members of the ‘schizofreniform' family of disorders.
Cluster “B” personality disorders group together four conditions known for their “dramatic and erratic” unpredictable qualities.
Antisocial Personality Disorder is defined as a “pervasive pattern of disregard for an violation of the rights of others”. Individuals diagnosed with ASPD often repeatedly get into legal trouble (or perform activities that would be grounds for arrest if they were caught), are deceitful towards others, act impulsively (without thinking before they act), are reckless and irresponsible, and show no remorse for actions of theirs that hurt others.
Borderline Personality Disorder is defined as a “pervasive pattern of instability of interpersonal relationships, self-image, and affects (emotions), and marked impulsivity…”. Persons diagnosed with borderline personality disorder are often preoccupied with and fear abandonment, and make desperate efforts to avoid real and imagined abandonment. They demonstrate an unstable sense of self and are prone to feelings of emptiness, show recklessness in sexual, financial, substance abuse, and other arenas, have unstable and highly reactive moods that can change from idealization to demonization in a second, and may repeatedly attempt suicide or self-mutilate by cutting or burning themselves. Borderline personality disordered people often have repetitive intense romantic affairs that blow up after a short time.
Histrionic Personality Disorder is defined as a “pervasive pattern of excessive emotionality and attention seeking”. Histrionic people tend to manipulate social situations so that they are center-stage, through the use of dramatic, theatrical behavior, sexual seductiveness, and reactive emotionality (quick to anger, quick to praise). They are also quick to pass judgment, but typically make their judgments on emotional rather than rational grounds. Some people find histrionic personality disorder medication can be helpful on their journey to treatment.
Narcissistic Personality Disorder is defined as a “pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy”. The narcissist believes in his own self-importance and expects and insists that you believe in his importance as well. The embodiment of entitlement, the narcissist expects that you will basically provide him with praise and worship. He tends to see the people around him as ‘audience members' rather than true people with needs and feelings. If you fail to go along with a narcissist, you will quickly find yourself the victim of his ridicule.
Cluster “C” personality disorders group together three personality disorders which share a common “anxious and avoidant” theme.
Avoidant Personality Disorder is defined as a “pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation…”. Avoidant personality disordered persons tend to avoid situations where they might be judged (e.g., all social situations, friendships and other intimate relationships, etc.). They are often preoccupied with being rejected or otherwise judged harshly, and as a result, are often unwilling to take social risks or assert themselves.
Dependent Personality Disorder is defined as a “pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation”. Dependent personality disordered people arrange their lives in such a way that they will avoid upsetting the person or people they are dependent on. They are typically fearful of argument, avoidant of responsibility, and sometimes willing to humiliate themselves so as to please their ‘protector'. They are quite fearful of losing their sheltering relationships, and will generally quickly move to replace a lost relationship, even when this moves them ‘out of the frying pan and into the fire' (into an even worse relationship) so to speak.
Obsessive Compulsive Personality Disorder is defined as a “pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness and efficiency.”. OCPD diagnosed people are heavy into rules and ‘right ways of doing things' so much so that the actual point of the thing they are doing gets lost in the procedures they lay upon it. They are often perfectionist, rigid, workaholic, and miserly with money. Such people are most at home within well defined social hierarchies such as the military, or bureaucratic structures. They will submit to the will of their ‘superiors' without question, but can be and merciless towards ‘subordinates'.
Last but not least, DSM provides the Not Otherwise Specified (NOS) category diagnosis for use when a personality disorder diagnosis is surely warranted, but the symptoms present don't neatly fit into any one category. Personality Disorder NOS is often tagged with multiple specifiers, noting the categories of personality disorder that are most suggested (but not quite met) by the presenting behavior. How would that look on paper? More or less like this example: “Personality Disorder NOS with Borderline and Antisocial traits”.
So these are the categories of officially sanctioned personality disorder that a mental health professional will consider if he or she is evaluating someone for the purposes of diagnosis. While these categories are not absolute by any means (and in fact, they are in cases more arbitrary than not, and based more on clinical tradition than supporting science), they do their job as a descriptive framework, allowing one clinician to talk to another about patients that one of them doesn't know personally in an intelligible way, and also providing researchers with a defined standard useful when evaluating what sorts of treatment work best for different disorders.
I'm sure that more than a few of you will easily recognize your relatives in these descriptions of the personality disorder diagnoses. In many cases, a relative will only have some of the traits of a given personality disorder I've described. In other cases, a relative will probably fit into one (or more) of the categories so well that their picture should accompany the definitions in the DSM. Who knows? Maybe you even recognize yourself in one of these categories?
While knowledge of the personality disorders can be enlightening, it also has a darker side. It is all too easy to start to make a game out of it; turning the diagnostic categories into weapons of sorts, using the act of ‘diagnosis' as a means of distancing yourself from any relationship to the people you are judging. Many people I have talked to make this sort of mistake when discussing their families: “Well, my family may be crazy”, they suggest, “But I'm not”.
In the rush to exclude one's self from family craziness, however, it is easy to lose sight of the fact that the entire idea that a set of “personality disorders” exist as discrete, ‘on or off' real-life categories is a fiction of the DSM, there for political and cultural reasons, but not really a good reflection of underlying reality. In reality, there is no line separating those with personality disorders and those without them; there are only differences in terms of how often and how rigidly people respond in dysfunctional ways.
It is important to remember that everyone acts dysfunctionally at least some of the time. Most everyone I know has felt emptiness at one time or another (particularly in the teen years), and many have at least thought of suicide. A few have done some significantly antisocial things in their day (often as kids). And who has never wanted to be the center of attention, at least in fantasy. Who has never been devastated when a relationship they were dependent on broke up. People with personality disorders are not so much ‘different' than people without them, as they have fewer possibilities for how to handle situations. Whereas non-personality disordered people can express themselves flexibly, choosing the best way to handle any given situation, personality disordered persons are rigid in their responses and too often fall back on what they always do, regardless of whether it fits (and often it does not). Where non-personality disordered people are free to experience a variety of different states of mind, personality disordered people end up being limited to the same one, over and over.
There is an old proverb that says, “People who live in glass houses should not throw stones”. For the purposes of our present discussion, I'll translate this proverb as follows, “People who have personality traits in common should not criticize or judge one another (too much)”. My major professor from graduate school used to say, “Everyone has a personality”. And because everyone does indeed have a personality; because everyone's personality (no matter how nice) ends up getting on someone's nerves at least some of the time; we are the very people who should not be criticizing one another.
Have a peaceful rest-of-the-holiday-season, and may your best hopes for the new year come true.
Mark Dombeck, Ph.D.
Note: All above quotes taken from the DSM-IV
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington DC, American Psychiatric Association, 1994.