Personality Disorders

Hello people, I hope everyone had a great holiday weekend! Did everyone set off a bunch of fireworks? Did you grill some burgers or dogs, have some baked beans, and a scoop of potato salad? Top it off with some apple pie? Me neither. Can I just ask, why do people shoot off fireworks on Saturday day, like before the sun sets? Are they testing them to see if they’re loud enough? Just wondering. Maybe they can’t wait. Anyhoo, last week, we talked about Antisocial Personality Disorder, the first Cluster B personality disorder, the dramatic and erratic disorders. If you recall, ASPD is the official diagnostic term for the colloquial terms sociopathy and psychopathy. That’s the big takeaway. So this week, we’ll be continuing with the Cluster B’s with Borderline Personality Disorder. 

Borderline Personality Disorder

BPD is also sometimes called Emotionally Unstable Personality Disorder, or EUPD, but I prefer Borderline. It always reminds me of that 80’s song. BPD is the most commonly diagnosed personality disorder, and was so called, because it was thought to lie on the “borderline” between neurotic disorders (meaning anxiety disorders) and psychotic disorders, such as schizophrenia and bipolar disorder. BPD is characterized by difficulties in regulating emotion. People with BPD experience big mood swings, and they feel a great sense of instability and insecurity. They feel emotions very intensely, often for extended periods of time, and it’s generally harder for them to return to a stable baseline after an emotionally triggering event. This difficulty can lead to impulsivity, poor self-image, and intense emotional responses to stressors. Struggling with self regulation and having a poor self-image essentially equates to a lack of a sense of self, and as a result, they often experience feelings of emptiness and extreme fears of abandonment, whether these are real or just perceived. They generally have a pattern of instability in their relationships, and there can be violence involved, especially in response to criticism. These unstable personal relationships often involve “splitting,” where the person alternates between idealization “I’m so in love!” and devaluation “I hate him!” Suicidal threats and acts of self-harm are common, and this is how and why many people with BPD frequently come to medical attention. Extreme stress responses can lead to dissociative feelings, meaning they feel disconnected from their thoughts or themselves, have “out of body” type feelings, potentially even psychotic episodes. They basically check out, and may not remember these events well afterwards. 

BPD signs and symptoms may include:

-Impulsive behaviors that can have dangerous outcomes, such as excessive spending, unsafe sex, reckless driving, gambling, overuse of substances, and binge eating

-Distorted and unstable self-image affecting moods, values, opinions, goals, and relationships

-Wide mood swings, often as a reaction to interpersonal stress

-Unstable and intense relationships

-Suicidal behavior or threats of self-injury

-Intense fear of being alone or abandoned, may be real or imagined

-Periods of intense depressed mood, irritability, or anxiety lasting a few hours to a few days

-Ongoing feelings of emptiness

-Frequent, intense displays of anger, often followed by shame and guilt

-Stress-related paranoia that comes and goes; when stress is severe, it can lead to brief psychotic episodes

It has been suggested that BPD often results from childhood sexual abuse, and that it is more common in women, in part because women are more likely to suffer sexual abuse. However, some argue that BPD is more common in women simply because women presenting with angry and promiscuous behavior tend to be labeled with it, whereas men presenting with similar behaviors tend instead to be labeled with ASPD, Antisocial PD. More recent research seems to back this up. Women are more likely to receive the diagnosis, because it is commonly thought of as a “female” disorder, even though there’s no such thing. In fact, of the estimated 1.4 percent of the adult U.S. population with BPD, nearly 75 percent of them are women.

Histrionic Personality Disorder

HPD is characterized by a pattern of excessive emotion and attention seeking. People with HPD generally like to be the center of attention at all times, and may actually be uncomfortable when they’re not. They often use physical appearance to draw attention to themselves, are often flirtatious, and can employ exaggerated or rapidly shifting emotions as a means to reach this goal. The surprise is that they usually lack a sense of self-worth, and they depend on attracting this attention to seek the approval of others in order to boost their wellbeing. They often seem to be dramatizing or playing a part in a bid to be seen and heard. The word “histrionic” is derived from the Latin histrionicus, meaning “pertaining to the actor.” People with HPD may take great care of their appearance, and behave in a manner that is overly charming or inappropriately seductive. Because they crave excitement, they tend to act on impulse and are easily suggestible, and they may place themselves at risk of an accident, or fall prey to exploitation. Their dealings with others often seem insincere or superficial, and in the long term, this can adversely impact their social and romantic relationships. They find this to be especially distressing, as they are very sensitive to criticism and rejection, and they react very poorly to loss or failure. It can result in a vicious cycle in which the more rejected they feel, the more histrionic they become, and the more histrionic they become, the more rejected they feel. Achieving any emotional or sexual intimacy may be difficult, and they may play a victim role, potentially without being aware of it. They may also try to control their partner using seduction or emotional manipulation, while becoming very dependent on them. They tend to be too trusting, especially of authority figures who they think may be able to solve all their problems. They often think relationships are closer and more intimate than they really are. They crave novelty and tend to bore easily, so they may change jobs and friends frequently. Delayed gratification is very frustrating to them, so their actions are often motivated by obtaining immediate satisfaction. 

HPD signs and symptoms may include:

-Constantly seeking attention

-Into instant gratification

-Excessively emotional, dramatic, or sexually provocative to gain attention

-Excessive concern with physical appearance

-Speaks dramatically with strong opinions, but few facts or details to back them up

-Makes rash decisions

-Easily influenced by others

-Shallow, rapidly changing emotions

-Believes relationships with others are closer than they really are

-Gullible and easily influenced by others

-Excessively sensitive to criticism or disapproval

-Low tolerance for frustration, easily bored by routine, often beginning projects without finishing them or skipping from one event to another

-Self-centered, rarely showing concern for others

-Good social skills, but use them to manipulate others, to be the center of attention

The estimated prevalence of HPD is less than 2 percent of the general population. It is usually evident by early adulthood, and is diagnosed more often in women than in men, but this may simply reflect the higher prevalence of women in clinical settings. There is a clear tendency for HPD to run in families, which suggests a genetic susceptibility, but the child of a parent with the disorder might simply be repeating learned behavior. Other environmental factors that might be involved include a lack of criticism or punishment as a child, and unpredictable attention given to a child by his or her parent(s), which tends to lead to confusion about what types of behavior earn parental approval.

Narcissistic Personality Disorder

NPD is characterized by an extreme feeling of self-importance, a sense of entitlement, and a need to be admired. The person is envious of others, and expects them to be the same of him. They typically lack empathy, and readily lie, exploit, or take advantage of others to achieve aims. To others, they may seem self-absorbed, controlling, intolerant, selfish, and/ or insensitive. If they feel ridiculed or obstructed, they can become very angry and even vengeful. Fueled by a belief that they’re special, and more important than others, they can have a reaction called “narcissistic rage,” which can have disastrous consequences for all involved. It’s human nature to be aware of and express our own needs, as well as want others to be aware of our abilities and achievements. These aren’t bad things, but people with NPD take this to the extreme. At the heart of it, they have fragile self-esteem, so they rely on others to recognize their worth and their needs. They are generally unhappy and disappointed when they’re not given the praise or special favors they believe they deserve. This can cause problems in all areas of life, work

school, and relationships. People with NPD usually put themselves on a pedestal, where they can look down on others and direct them, as they believe they are better than. They exaggerate their own talents and accomplishments, while downplaying those of others. They are usually preoccupied by power, success, and beauty, and may engage in impulsive behaviors, such as risky sex and gambling, in their pursuits of these goals.

NPD signs and symptoms may include:

-Fantasies about power, success, and attractiveness

-Entitled, conceited, snobby

-Exaggeration of achievements or talents

-Expectation of constant praise and admiration

-Exaggeration of intimacy with others, especially those with wealth or VIP status

-React negatively to criticism

-Show great charm but quickly become irritated or angry

-Talking at length about their own concerns but lacking interest in those of others

-Show aggression when faced with a threat to their ego

-Resent the successes of other people

-Arrogant, dismissive, or unaware of other people’s needs

-Perceived superiority that covers a deep seated insecurity

-Unreasonable expectations of favors and advantages

-Envy of others accompanies belief that others envy them

-Unfulfilling relationships; become unhappy, angry, and confused when things don’t go their way

-Typically have ongoing issues with work, school, relationships, finances, alcohol, substances

Research indicates that NPD affects 6.2 percent of the U.S. population, and is much more common in men than women, affecting 7.7 percent of men and 4.7 percent of women. There may be cultural influences associated with NPD, but this may be a stereotype. Diagnosing NPD specifically can be challenging, as the features tend to have so much overlap with other disorders. In addition, a person with NPD may not recognize that problems in their life stem from their own behavior, and they may blame others instead. Narcissists can be especially difficult to deal with. I’ve done a lot of family counseling for it, but the person with the diagnosis must accept it to make headway. Some NPD traits may appear similar to confidence, but healthy confidence and NPD aren’t the same thing. People who have healthy self-esteem are usually humble, while people with NPD, by definition, never are. It takes a lot of work on the patient’s part to modify behavior, but it can be done with sufficient motivation.

That’s the end of Cluster B Personality Disorders. Next week, we’ll tackle Cluster C disorders. 

I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon. 

Thank you and be well people!

MGA