Personality Disorder Part 3
Personality Disorders, part 3
Hello, people! In last week’s blog, we talked about the cause of personality disorders, sort of the nature versus nurture debate, and how both genetics and environment play a role in developing these disorders. We also discussed some of the requirements for diagnosis: how the maladaptive behaviors or personality traits must be relatively stable over time and consistent across situations; that they must cause significant impairment in self and interpersonal functioning; and that they cannot be a result of the direct effects of a substance or general medical condition. Each of the ten disorders has its own set of diagnostic criteria based on the various signs and symptoms typically exhibited. And that’s what we’ll be getting into today- the signs and symptoms of personality disorders.
As I mentioned before, the DSM-5 allocates each of the ten personality disorders to one of three groups or clusters, A, B, or C, based on similar characteristics and symptoms. Many people with one personality disorder also have signs and symptoms of at least one additional personality disorder, and it is usually within the same cluster. I should note that it’s not necessary to exhibit all the signs and symptoms listed for a disorder to be diagnosed. So let’s get started on the first cluster.
Cluster A Personality Disorders
These are characterized by odd, eccentric thinking or behavior. They include paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder.
Paranoid Personality Disorder
PPD is defined by mistrust and suspicion so intense that it permeates thought patterns and behavior, interfering with daily functioning. A person with PPD feels very wary of others, believing that they want to harm them. They are always on guard for signs that someone is trying to threaten, mistreat, or deceive them. No matter how unfounded their beliefs, they may repeatedly question the faithfulness, honesty, or trustworthiness of the people around them, whether they are friends, family, spouse, and/ or lovers. They may be defensive or sarcastic, which may elicit a hostile response from others. This response, in turn, then seems to confirm their original suspicions, reinforcing their beliefs. When they perceive they’re being persecuted, rejected, or slighted, they’re likely to respond with hostility, angry outbursts, and/ or controlling behavior; and they often deflect any blame onto others. Their fearful and distrustful perceptions make forming and maintaining close relationships very difficult. In addition, they’re often able to find and exaggerate the negative aspects of any situation or conversation, which also strains relationships. These qualities affect their ability to function at home, work, and school. Because of these symptoms, the condition often results in social withdrawal, tenseness, irritability, and lack of emotion.
Common PPD symptoms include:
-Suspecting, without justification, that others are trying to exploit, harm, or deceive them.
-Doubting or obsessing on the lack of loyalty or trustworthiness of family, friends, and acquaintances.
-Refusing to confide in people for fear that any information they divulge will be used against them.
-Becoming detached or socially isolated
-Interpreting hidden, malicious, demeaning, or threatening subtext or meanings in innocent gestures, events, or conversations.
-Having trouble working with others, being argumentative and defensive.
-Being overly sensitive to perceived insults, criticism, or slights.
-Quickly feeling anger, snapping to judgment, and holding grudges.
-Responding to imagined attacks on their character with anger, hostility, or controlling behavior.
-Repeatedly suspecting, without basis, their romantic partner or spouse of infidelity.
-Having trouble relaxing due to an inability to let their guard down.
PPD affects approximately 1 to 5 percent of people worldwide, though I’ve seen estimates of up to 10 percent. It often first appears in early adulthood, and is more common in men than women. Research suggests it may be most prevalent in those with a family history of schizophrenia. Despite being one of the most common personality disorders, PPD can be difficult to detect until symptoms progress from mild to more severe. This is because most people behave in mistrustful, suspicious, or hostile ways at some point in their lives without warranting a diagnosis of PPD. Spotting the signs can be further complicated as it often occurs with another mental health problem, such as an anxiety disorder, obsessive-compulsive disorder (OCD), substance abuse, or depression. When people with PPD have other diagnoses, it can compound their PPD symptoms. For example, depression and anxiety affect mood, and shifts in mood can make someone with PPD more likely to feel paranoid and isolated.
Professional treatment can help someone with PPD manage symptoms and improve their daily functioning. But due to the very nature of the disorder, most people with PPD don’t seek help, as they don’t see their suspicious behavior as unusual or unwarranted. Rather, they see it as rational. They are defending themselves against the bad intentions and deceptive, untrustworthy activities of those around them. As far as they’re concerned, their fears are justified, and any attempts to change how they think only confirms their suspicions that people are “out to get them” in some way. In addition, their intense suspicion and mistrust of others often includes mental health professionals. They question their motives in trying to help, and it can take a fair amount of time to build enough trust so they feel comfortable confiding in them and following their advice.
Schizoid Personality Disorder
The term “schizoid” indicates a natural tendency to direct attention toward one’s inner life and away from the external world. Please note that while their names sound alike, and they might have some similar symptoms, schizoid personality disorder is not the same thing as schizophrenia. People with schizoid PD tend to be distant, detached, aloof, and more prone to introspection. They often choose to be alone, and have little to no desire for social or sexual relationships. In addition to being indifferent to other people, they are also indifferent to social norms and conventions. They seem to not care about external praise or criticism, and commonly demonstrate a lack of emotional response. They are generally “loners” who prefer solitary activities. Many people with schizoid personality disorder are able to function fairly well, although they tend to choose jobs that allow them to work alone, such as night security officers, library, or lab workers.
A competing theory about people with schizoid PD is that they are in fact highly sensitive with a rich inner fantasy life. That they experience a deep longing for intimacy, but find initiating and maintaining close relationships too difficult or distressing, and as a result, choose to retreat into their inner world, which they create with vivid detail.
Common Schizoid PD symptoms include:
-Lack of interest in social or personal relationships, preferring to be alone
-Limited range of emotional expression
-Inability to take pleasure in most activities
-Inability to pick up normal social cues
-Difficulty relating to others
-Appearance of being cold or indifferent to others
-Little or no interest in intimacy or in having sex with another person
-May commonly daydream and/or create vivid fantasies of complex inner lives.
-Often reclusive, organize life to avoid contact with other people
Available statistics suggest that between 3 to 4 percent of the general population has schizoid PD, though it’s very difficult to accurately assess the prevalence, because people with schizoid PD rarely present for medical attention. This is because they generally function so well, and their preferences have few or no negative legal or societal consequences. Schizoid PD usually begins in late adolescence or early adulthood, affects men more often than women, and is more common in people who have close relatives with schizophrenia.
Schizotypal Personality Disorder
STPD is characterized by oddities of appearance, behavior, and speech, unusual perceptual experiences, and anomalies of thinking similar to those seen in schizophrenia. People with STPD have a higher than average probability of developing schizophrenia, and the condition used to be called “latent schizophrenia.” Their anomalies of thinking can include odd beliefs, suspiciousness, obsessive ruminations, and magical thinking, which is being overly superstitious or thinking of themselves as psychically powerful. An example may be believing that they have a “sixth sense” or thinking that speaking of the devil can make him appear. This may lead them to develop what are called ideas of reference- the false belief or intuition that occurrences, events, or details in the world relate or refer directly to themselves. People with STPD generally don’t understand how relationships form, or the impact of their behavior on others. They may react oddly in conversations, not respond, or talk to themselves. They have difficulty with responding appropriately to social cues, often misinterpret people’s motivations and behaviors, and develop significant distrust of others. This can cause excessive social anxiety, and can lead them to fear social interaction, thinking that other people are harmful. While people with STPD and people with schizoid PD both avoid social interaction, people with STPD do so because they fear others, whereas people with schizoid PD do so simply because they have no desire to interact with others, or find interacting with them too difficult.
Schizotypal personality disorder typically includes five or more of these signs and symptoms:
-Being a loner and lacking close friends outside of the immediate family
-Limited or inappropriate emotional responses, “flat emotions”
-Persistent and excessive social anxiety, tendency to be stiff and awkward when relating to others
-Very uncomfortable with intimacy
-Commonly misinterpret events, ie feeling that something has a direct personal offensive meaning, when it is actually harmless or inoffensive
-Distorted perceptions or odd perceptual experiences, ie mistaking noises for voices, hearing a voice whisper their name, or sensing an absent person’s presence
-Peculiar, eccentric, or unusual thinking, beliefs, or mannerisms
-Suspicious or paranoid thoughts and constant doubts about the loyalty of others
-Belief in special powers, such as mental telepathy or superstitions
-Dressing in peculiar ways, such as wearing oddly matched clothes or appearing unkempt
-Peculiar style of speech: highly variable, this may include unusual patterns of speaking, rambling oddly during conversations, vague speech, or speaking in excessive detail, in metaphors, or in an overly elaborate manner.
The prevalence of STPD ranges from approximately 1 to 4 percent of the population, and is more common in men than in women. STPD occurs more often in relatives of patients with schizophrenia or another Cluster A personality disorder. In fact, people that have an immediate family member with STPD can be as much as 50 percent more likely to develop it, as compared to people without that family history. People with STPD typically disagree with the suggestion their thoughts and behavior are disordered, and seek medical attention for depression or anxiety as opposed to the disorder. While it is typically diagnosed in early adulthood, some signs and symptoms, such as increased interest in solitary activities, or a high level of social anxiety, may be seen in the teen years. These children may also underperform in school, or appear socially out of step with peers, and this may result in teasing or bullying. STPD is likely to endure across the entire lifespan, though treatment, such as medications and therapy, can improve symptoms. Without treatment, individuals with STPD are at high risk for having major difficulty with work and relationships.
That’s the end of Cluster A personality disorders. Next week, we’ll cover Cluster B.
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The Dangers Of Alcohol
As an addiction specialist, I see patients abusing substances of all kinds. Today I’d like to talk about alcohol. It is so ingrained and accepted in our society. Pop culture would have you believe that you can’t have any fun or lead a fulfilling life without alcohol. During nearly every commercial break on television, there is an advertisement for alcohol, full of smiling people having the time of their lives like they’re on a permanent vacation. As a matter of fact, as I write this, I have a television on in the background, and there was just a commercial for a Mexican beer. It was a fiesta, with women in bright costumes dancing around and people cheering and cheersing with cold cervezas. The message: you’re clearly missing out if your life doesn’t resemble the lives of these people, but if you drink their beer, your life can be as awesome as theirs.
Fermented grain, fruit juice and honey have been used to make alcohol for thousands of years. Even early Greek writings warned of the perils of alcohol. In our modern world, the dangers of alcohol are well studied and well known. Despite this fact, alcohol is the most common drug used and abused by people. Here are some sobering facts and figures: an estimated 15 million Americans suffer from alcoholism, and nearly 90,000 people die from alcohol-related causes annually, making alcohol the third leading preventable cause of death in the United States. 40% of all car accident deaths in the United States involve alcohol, claiming approximately 10,000 lives a year. According to the Institute of Alcohol Studies, consuming larger amounts of alcohol can cause more than 60 different health issues and hundreds of physical conditions.
Day in and day out, I witness the ravages of alcoholism, and it’s not pretty. Alcohol in any amount affects every part of a person, inside and out. It’s just a matter of degrees.
What are these effects? Let’s start with the outward appearance. While drinking moderately may not have immediate disadvantages, over time you’ll start to notice them- especially when you look in the mirror. Drinking alcohol dehydrates you, which makes hair follicles dry and brittle and more likely to cause hair to fall out. What hair you have will look crispy with split ends. Heavy alcohol use can lead to permanent damage to the health of your hair. It can also cause hormonal issues like increased estrogen, which can cause problems with hair growth and loss, particularly in men.
Drinking too much also dehydrates and deprives the skin of vital vitamins and nutrients. Instead of being soft and hydrated, your skin will begin to look cracked and wrinkled. This will leave others thinking you may be older than you actually are. Excess alcohol also alters blood flow to the skin, leaving an unhealthy appearance for days.Alcohol can also cause your face to look pale, bloated and puffy.Sometimes the blood vessels on your face burst and the capillaries break, causing a chapped look. Not only can your face become red, but the tiny blood vessels in your eyes become irritated and rupture, causing bloodshot eyes. Not cute.
Over time, drinking heavily can have other, more permanent, detrimental effects on your skin. Rosacea, a skin disorder that starts with a tendency to blush and flush easily is linked to alcohol consumption. Continued alcohol consumption can eventually lead to a condition called rhinophyma, a facial disfigurment that is a subtype of rosacea, where large, red, pus-filled bumps develop on the face, commonly on the cheeks, chin, and especially the nose, where it can cause severe bulbous distortion. If you have rosacea, I strongly urge that you google rhinophyma and that you don’t drink.
Let’s not forget that alcohol is fattening, high in empty calories. A couple of gin and tonics and a pint of beer equal about the same calories as a big fast food burger. You might be surprised to find out what the junk food calorie equivalents are for your favorite drinks. Alcohol also bloats your stomach. “Beer belly” is real people, but not only caused by beer. And then there’s cellulite; many believe the toxins in alcohol contribute to its build up.
A less often discussed result of drinking heavily is B.O. Yes, the bad odor emanating from the body after a long night of drinking is directly related to the alcohol seeping from it. According to the Institute of Alcohol Studies, over 10 percent of alcohol consumed leaves the body unused through your sweat, breath, and urine. While pretty much everyone can smell it, non-drinkers are generally especially susceptible to the odor. And it is gross. Keep that in mind the next time you wake up after a bender. Your body odor could leave a lasting impression.
Let’s move from external effects of alcohol and go inside the body, starting with the brain. Obviously, when you’re drunk, your brain is impaired. There is loss of inhibitions, confused or abnormal thinking, and poor decision-making. But I want you to understand the chronic effects of alcohol on the brain and cognition, the long term effects. So, how does alcohol impact cognitive ability? Clearly, the impact is directly related to the frequency and quantity of alcohol consumed.
Occasional and moderate drinkers:
– Memory impairment
– Impaired decision-making
Heavy and/or chronic drinkers:
– Diminished gray matter in the brain
– Inability to think abstractly
– Loss of visuospatial abilities
-Loss of attention span
In general, heavy alcohol use causes the brain to shrink. Any alcohol use causes clouded thinking, slow thought process or delays in cognition. If you drink at night – even two drinks – the next day, your thoughts aren’t as fluid, you’re not as clear, you’re not as creative. Alcohol use changes behavior. You may develop psychological issues, personality issues. It is well established in the mental health field that alcohol consumption can exacerbate underlying mental health disorders. People become more irritable, anxious, and depressed when they drink. So why do it? People use it as a coping skill. It lowers inhibitions, gives “liquid courage” and allows us to do things we wouldn’t normally do. Some people use it to keep a job they hate, or to stay in a miserable marriage. It numbs pain, it’s an escape hatch for the psyche. It becomes a solution to a problem, or a way to mask the problem. Just as we are all different, the way alcohol affects us all differently.
The following factors have been shown to influence how alcohol impacts a person’s brain functioning over time:
-The volume a person drinks
-How often a person drinks
-The age at which drinking began
-The number of years a person has been drinking
-The person’s sex, age, and genetic factors
-Whether the person’s family has a history of alcoholism
-Whether the person was exposed to alcohol as a fetus
-The person’s general health
One of the biggest problems with alcohol that I see is trauma, people getting hurt. When you drink alcohol, your decision making is impaired. The brain that usually protects you is suddenly impaired, so you fall, you fight, you drive a car recklessly, and your coordination is off. You’re going to fall or make a bad decision and get hurt. So many accidents and deaths are attributed to alcohol. It’s especially disturbing because they’re preventable.
There is no bodily system that alcohol does not affect. What are other physical dangers of alcohol? Drinking alcohol increases the risk of cancers of the mouth, esophagus, pharynx, larynx, liver, and breast. The common thing that everyone understands is liver damage with alcohol. It causes fatty liver and cirrhosis of the liver which eventually kills you. There are a host of digestive problems with alcohol consumption: peptic ulcers, bleeding ulcers, diarrhea, pancreatic cysts/disease/failure. Alcohol can lead to diabetes, a compromised immune system, lung infections, stroke, and heart disease. It can be associated with memory issues, learning disorders, and neurological problems, where you have numbness in your arms and legs, lack of coordination, and slurred speech.
Alcohol plays a role in other issues as well. Family problems, legal problems, and social problems. One of the biggest concerns with drinking frequently is (or should be) dependency, becoming an alcoholic. Right now, I’m sure almost 100% of you are thinking ‘I‘d never become an alcoholic.’ There’s a television show called Intervention that documents the trials, tribulations, lifestyles, and consequences of alcoholics and drug addicts. None of them planned on becoming alcoholics back when they drank socially or just had a few drinks at night. The great news is that if you never make alcohol a part of your life, guess what? You’ll NEVER have to be an alcoholic or deal with all of the issues that come with it. I can’t stress enough how strongly you should take this to heart.
By now I’m certain that you understand the ravages and damages of alcohol use and abuse. But the dangers are minimized and we’re desensitized to it by pop culture; it’s so ubiquitous that we accept it as a part of life. If you tell someone that you don’t drink, they look at you like you have three heads. It is ingrained in every aspect of our society in terms of weddings, funerals, bars, restaurants, hotels, public events, private events, and clubs.
Have you ever noticed how glorified alcohol is? They put it in these beautiful bottles. I admire alcohol bottles. The artistry and sculpture of the bottles…they’re just beautiful. They look like there must be something very good inside, so you want to find out. When you go to a restaurant, the first question is always, “Would you like a drink?” Now, children’s birthday parties even serve drinks to the adults. If it’s so safe, why don’t we serve it to children? It’s because we know it’s poison, we know it’s dangerous, but it’s minimized. It’s socially acceptable. I’m not for prohibition; I think there is a place for alcohol in our society, but it shouldn’t be so glorified and so easily accessible. We need to acknowledge it’s dangers and be more restrictive with it. Take all-you-can drink mimosa or bloody mary brunches or happy hours for example, where drinks are two-for-one. These things encourage drunkenness, and then people leave with alcohol-induced poor decision skills and car keys in hand. These sorts of events need to be seriously restricted. There should be no event where we encourage people to get drunk. We should not condone its overuse or extoll its virtues.
With all of that said, how does an individual stop drinking alcohol? It’s a simple theory. You make a decision to stop, and then you stop. There is no other way. If you’re not in control of stopping, then who is? I’ve spent more than thirty years medically detoxing and working with people with alcohol and drug addictions, and I assure you that there is no other way to stop other than the person making the decision to stop and living with it. I’m not saying it is easy, especially with alcohol all around us in grocery stores, restaurants, on television, on billboards…it is everywhere. But it can be done. I see it every day, people living fulfilling lives without alcohol. If you want to be one of those people living without alcohol, make an appointment. I can help you. I talk more about this in my books, A Chance to Change and Tales from the Couch, both available on Amazon.Learn More