Magazine article Clinical Psychiatry News

What's in a Personality?

Magazine article Clinical Psychiatry News

What's in a Personality?

Article excerpt

A few years ago, I wrote a column about renaming borderline personality disorder ("'Borderline' Label Needs a New Name," The Psychiatrist's Toolbox, July 2004, p. 30) and I received a great deal of mail on the subject. I still can't understand why, after all these years, that we still call people "borderline."

Getting back to personality disorders in general, they are a complicated part of psychiatric problems, diagnosis, and treatment. After all, they are a part of who a person is, rather than a disorder that waxes and wanes, as we see often in those that fit Axis I definitions.

So much depends on differentiating personality disorders from personality styles and getting at the source of the discomfort felt by the person experiencing these all-encompassing, usually lifetime problems.

When the disorder or style no longer works and coping skills in vocational, social, or interpersonal areas become stressful with increased anxiety and depression, a person will come into psychotherapy. Remember, though, that real scientific data are sparse on personality disorders, so the therapists' subjectivity has a large impact on determining what is pathologic and what is not.

When Problems Are Multilayered

When we incorporate the notion of multiple facets in a personality, we get multiple personality problems rolled up into one person. Then, further complicating these issues are the endless therapeutic approaches to treatment.

For example, hard-driving, well-organized, demanding, perfectionistic people who tend to function in terms of "my way or the highway" may, indeed, be that--or they may have an obsessive-compulsive personality disorder as assessed by a therapist. Then again, they may be extremely ambitious and dedicated to their particular belief system.

When we add how self-centered and adverse to criticism they are, a dimension of narcissism enters the clinical picture. Or they may be simply comfortable in their own skin and adverse to people second-guessing them. If they are uncomfortable in their style or make other people uncomfortable, and they are anxious or depressed over this and search out help, do they have a disorder or a style?

Should these "disorders" be separated under a group umbrella, or should clinicians have the tools to evaluate personality issues, disorders, or styles on an individual basis and develop a codified treatment plan?

It's an interesting dilemma for us in mental health, especially in the current era of managed care, when diagnosis and treatment need to be codified with specific criteria and again codified with specific treatment approaches. Here we have a set of disorders, which for the most part, have neither a scientific basis nor clear treatment approaches. Yet these disorders are so much a part of a general lifestyle of a person that just creating a set of disorders around styles seems difficult, let alone asking for reimbursement. It's no wonder the insurance companies are resistant to paying for such problems.

As psychiatrists, we know only too well that these personality disorders and styles can lead to social, vocational, and interpersonal problems and may indeed need therapeutic interventions. Many times the interventions restore the person to a better level of functioning and lead to lifestyle changes that have a profoundly positive effect on personality change.

In medicine, we treat overeating (and subsequent obesity) and smoking, which themselves are not illnesses but are serious, life-threatening problems. So it's not that unusual to treat a problem that is not specifically defined as an illness or even a disorder.

In my experience, most patients with personality disorders make the first appointment for psychotherapy because of an anxiety-related problem or depression or other "mental fallout" tied to a serious loss such as job loss, divorce, or collapse of an investment (Arch. …

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