Personality Disorders - Use and Abuse of Differential Diagnoses
The differential diagnoses in the personality disorders section of the Diagnostic and Statistical Manual (DSM) contain many overlaps and culture-bound artefacts.
The categorical (non-dimensional) taxonomy leads to multiple diagnoses (co-morbidity) in the same patient.
By: Dr. Sam Vaknin
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The DSM IV-TR is a linear, descriptive (phenomenological), and bureaucratic. It is "medical", "mechanic-dynamic", and "physical" - akin to the old taxonomies in Botany and Zoology. It ignores life circumstances, biological and psychological processes, and lacks an overarching conceptual and exegetic framework. Moreover, the DSM is heavily influenced by fashion, prevailing social mores and lores, and by the legal and business environment.
The classification of Axis II personality disorders - deeply ingrained, maladaptive, lifelong behavior patterns - in the Diagnostic and Statistical Manual, fourth edition, text revision [American Psychiatric Association. DSM-IV-TR, Washington, 2000] - or the DSM-IV-TR for short - has come under sustained and serious criticism from its inception in 1952.
The DSM IV-TR adopts a categorical approach, postulating that personality disorders are "qualitatively distinct clinical syndromes" (p. 689). This is widely doubted. Even the distinction made between "normal" and "disordered" personalities is increasingly being rejected. The "diagnostic thresholds" between normal and abnormal are either absent or weakly supported.
The polythetic form of the DSM's Diagnostic Criteria - only a subset of the criteria is adequate grounds for a diagnosis - generates unacceptable diagnostic heterogeneity. In other words, people diagnosed with the same personality disorder may share only one criterion or none.
The DSM fails to clarify the exact relationship between Axis II and Axis I disorders and the way chronic childhood and developmental problems interact with personality disorders;
The differential diagnoses are vague and the personality disorders are insufficiently demarcated. The result is excessive co-morbidity (multiple Axis II diagnoses);
The DSM contains little discussion of what distinguishes normal character (personality), personality traits, or personality style (Millon) - from personality disorders;
The DSM does not incorporate personality disorders induced by circumstances (reactive personality disorders, such as Milman's proposed "Acquired Situational Narcissism"). Nor does it efficaciously cope with personality disorders that are the result of medical conditions (such as brain injuries, metabolic conditions, or protracted poisoning);
The DSM suffers from a dearth of documented clinical experience regarding both the disorders themselves and the utility of various treatment modalities;
Numerous personality disorders are "not otherwise specified" - a catchall, basket "category";
Cultural bias is evident in certain disorders (such as the Antisocial and the Schizotypal);
The emergence of dimensional alternatives to the categorical approach is acknowledged in the DSM-IV-TR itself:
An alternative to the categorical approach is the dimensional perspective that Personality Disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another (p.689)
The following issues - long neglected in the DSM - are likely to be tackled in future editions as well as in current research:
The longitudinal course of the disorder(s) and their temporal stability from early childhood onwards
The genetic and biological underpinnings of personality disorder(s)
The development of personality psychopathology during childhood and its emergence in adolescence
The interactions between physical health and disease and personality disorders
The effectiveness of various treatments - talk therapies as well as psychopharmacology.
1. The Concept of "Disease"
We are all terminally ill. It is a matter of time before we all die. Aging and death remain almost as mysterious as ever. We feel awed and uncomfortable when we contemplate these twin afflictions. Indeed, the very word denoting illness contains its own best definition: dis-ease. A mental component of lack of well being must exist SUBJECTIVELY. The person must FEEL bad, must experience discomfiture for his condition to qualify as a disease. To this extent, we are justified in classifying all diseases as "spiritual" or "mental".
Is there any other way of distinguishing health from sickness - a way that does NOT depend on the report that the patient provides regarding his subjective experience?
Some diseases are manifest and others are latent or immanent. Genetic diseases can exist - unmanifested - for generations. This raises the philosophical problem or whether a potential disease IS a disease? Are AIDS and Hemophilia carriers - sick? Should they be treated, ethically speaking? They experience no dis-ease, they report no symptoms, no signs are evident. On what moral grounds can we commit them to treatment? On the grounds of the "greater benefit" is the common response. Carriers threaten others and must be isolated or otherwise neutered. The threat inherent in them must be eradicated. This is a dangerous moral precedent. All kinds of people threaten our well-being: unsettling ideologists, the mentally handicapped, many politicians. Why should we single out our physical well-being as worthy of a privileged moral status? Why is our mental well being, for instance, of less import?
Moreover, the distinction between the psychic and the physical is hotly disputed, philosophically. The psychophysical problem is as intractable today as it ever was (if not more so). It is beyond doubt that the physical affects the mental and the other way around. This is what disciplines like psychiatry are all about. The ability to control "autonomous" bodily functions (such as heartbeat) and mental reactions to pathogens of the brain are proof of the artificialness of this distinction.
It is a result of the reductionist view of nature as divisible and summable. The sum of the parts, alas, is not always the whole and there is no such thing as an infinite set of the rules of nature, only an asymptotic approximation of it. The distinction between the patient and the outside world is superfluous and wrong. The patient AND his environment are ONE and the same. Disease is a perturbation in the operation and management of the complex ecosystem known as patient-world. Humans absorb their environment and feed it in equal measures. This on-going interaction IS the patient. We cannot exist without the intake of water, air, visual stimuli and food. Our environment is defined by our actions and output, physical and mental.
Thus, one must question the classical differentiation between "internal" and "external". Some illnesses are considered "endogenic" (=generated from the inside). Natural, "internal", causes - a heart defect, a biochemical imbalance, a genetic mutation, a metabolic process gone awry - cause disease. Aging and deformities also belong in this category.
In contrast, problems of nurturance and environment - early childhood abuse, for instance, or malnutrition - are "external" and so are the "classical" pathogens (germs and viruses) and accidents.
But this, again, is a counter-productive approach. Exogenic and Endogenic pathogenesis is inseparable. Mental states increase or decrease the susceptibility to externally induced disease. Talk therapy or abuse (external events) alter the biochemical balance of the brain. The inside constantly interacts with the outside and is so intertwined with it that all distinctions between them are artificial and misleading. The best example is, of course, medication: it is an external agent, it influences internal processes and it has a very strong mental correlate (=its efficacy is influenced by mental factors as in the placebo effect).
(continued below)
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The very nature of dysfunction and sickness is highly culture-dependent. Societal parameters dictate right and wrong in health (especially mental health). It is all a matter of statistics. Certain diseases are accepted in certain parts of the world as a fact of life or even a sign of distinction (e.g., the paranoid schizophrenic as chosen by the gods). If there is no dis-ease there is no disease. That the physical or mental state of a person CAN be different - does not imply that it MUST be different or even that it is desirable that it should be different. In an over-populated world, sterility might be the desirable thing - or even the occasional epidemic. There is no such thing as ABSOLUTE dysfunction. The body and the mind ALWAYS function. They adapt themselves to their environment and if the latter changes - they change. Personality disorders are the best possible responses to abuse. Cancer may be the best possible response to carcinogens. Aging and death are definitely the best possible response to over-population. Perhaps the point of view of the single patient is incommensurate with the point of view of his species - but this should not serve to obscure the issues and derail rational debate.
As a result, it is logical to introduce the notion of "positive aberration". Certain hyper- or hypo- functioning can yield positive results and prove to be adaptive. The difference between positive and negative aberrations can never be "objective". Nature is morally-neutral and embodies no "values" or "preferences". It simply exists. WE, humans, introduce our value systems, prejudices and priorities into our activities, science included. It is better to be healthy, we say, because we feel better when we are healthy. Circularity aside - this is the only criterion that we can reasonably employ. If the patient feels good - it is not a disease, even if we all think it is. If the patient feels bad, ego-dystonic, unable to function - it is a disease, even when we all think it isn't. Needless to say that I am referring to that mythical creature, the fully informed patient. If someone is sick and knows no better (has never been healthy) - then his decision should be respected only after he is given the chance to experience health.
All the attempts to introduce "objective" yardsticks of health are plagued and philosophically contaminated by the insertion of values, preferences and priorities into the formula - or by subjecting the formula to them altogether. One such attempt is to define health as "an increase in order or efficiency of processes" as contrasted with illness which is "a decrease in order (=increase of entropy) and in the efficiency of processes". While being factually disputable, this dyad also suffers from a series of implicit value-judgments. For instance, why should we prefer life over death? Order to entropy? Efficiency to inefficiency?
Health and sickness are different states of affairs. Whether one is preferable to the other is a matter of the specific culture and society in which the question is posed. Health (and its lack) is determined by employing three "filters" as it were:
- Is the body affected?
- Is the person affected? (dis-ease, the bridge between "physical" and "mental illnesses)
- Is society affected?
In the case of mental health the third question is often formulated as "is it normal" (=is it statistically the norm of this particular society in this particular time)?
We must re-humanize disease. By imposing upon issues of health the pretensions of the accurate sciences, we objectified the patient and the healer alike and utterly neglected that which cannot be quantified or measured - the human mind, the human spirit.
Read "The Myth of Mental Illness"
2. Psychology as Storytelling
Storytelling has been with us since the days of campfire and besieging wild animals. It serves a number of important functions: amelioration of fears, communication of vital information (regarding survival tactics and the characteristics of animals, for instance), the satisfaction of a sense of order (justice), the development of the ability to hypothesize, predict and introduce theories and so on.
We are all endowed with a sense of wonder. The world around us in inexplicable, baffling in its diversity and myriad forms. We experience an urge to organize it, to "explain the wonder away", to order it in order to know what to expect next (predict). These are the essentials of survival. But while we have been successful at imposing the structures of our mind on the outside world we are less successful when we try to cope with our internal universe.
The relationship between the structure and functioning of our (ephemeral) mind, the structure and modes of operation of our (physical) brain and the structure and conduct of the outside world have been the subject matter of heated debate for millennia. Broadly speaking, there were (and still are) two schools of thought:
There are those who, for all intents and purposes, identify the substrate (brain) with its product (mind). Some of them postulate the existence of a lattice of preconceived, inborn categorical knowledge about the universe the vessels into which we pour our experience to be molded.
Others regard the mind as a black box. While it is possible in principle to know its input and output, it is impossible, again in principle, to understand its internal functioning and management of information. Pavlov coined the word "conditioning", Watson adopted it and invented "behaviorism", Skinner came up with "reinforcement". But they all ignored the psychophysical question: what IS the mind and HOW is it linked to the brain?
The other camp fancies itself more "scientific" and "positivist". It speculates that the mind (whether a physical entity, an epiphenomenon, a non-physical principle of organization, or the result of introspection) has a structure and a limited set of functions.
They argue that a "user's manual" for the mind could be composed, replete with engineering and maintenance instructions. The most prominent of these "psychodynamists" was, of course, Freud. Though his disciples (Adler, Horney, the object-relations lot) diverged wildly from his initial theories they all shared his belief in the need to "scientify" and objectify psychology.
Freud a medical doctor by profession (Neurologist) and Josef Breuer before him came with a theory regarding the structure of the mind and its mechanics: (suppressed) energies and (reactive) forces. Flow charts were provided together with a method of analysis, a mathematical physics (dynamics) of the mind.
But this was a mirage. An essential part was missing: the ability to test the hypotheses derived from these "theories". Still, their theories sounded convincing and, surprisingly, had great explanatory power. But - non-verifiable and non-falsifiable as they were they could not be deemed to be scientific.
Psychological theories of the mind are metaphors of the mind. They are fables and myths, narratives, stories, hypotheses, conjunctures. They play (exceedingly) important roles in the psychotherapeutic setting but not in the laboratory. Their form is artistic, not rigorous, not testable, less structured than theories in the natural sciences.
The language used in psychological theories is literary, polyvalent, rich, effusive, and fuzzy in short, metaphorical. They are suffused with value judgments, cultural preferences, fears, post facto and ad hoc constructions. None of this has methodological, systematic, analytic and predictive merits.
Still, these theories are powerful descriptive instruments, admirable constructs of the mind. As such, they are bound to satisfy some needs. Their very existence proves it.
Peace of mind is an essential need, which was neglected by Maslow in his famous hierarchy of needs. People sacrifice material wealth, resist temptation, ignore opportunities, and sometimes risk themselves and others just to attain this bliss.
People prefer inner equilibrium to outer homeostasis. It is the fulfillment of this overriding need that psychological theories cater to. In this, they are no different than other collective narratives (myths, for instance).
In some respects, though, there are striking differences:
First, psychology is desperately trying to link up to reality and to scientific discipline by employing observation and measurement and by organizing its results and presenting them using the language of mathematics. This does not atone for its primordial sin: that its subject matter is ethereal, ephemeral and inaccessible. Still, it lends it an air of credibility and rigorousness.
Second, while historical narratives are "blanket" narratives psychology is "tailored" or "customized". A unique narrative is invented for every patient (client) in which s/he is the protagonist (hero or anti-hero). This mass customization seems to reflect an age of increasing individualism.
True, the "language units" used in therapy (large chunks of denotates and connotates) are one and the same for every "user". In psychoanalysis, the therapist is likely to always make use of the tripartite structure of Id, Ego, Superego. But these are language elements and need not be confused with the plots. Each client, each person, and his own, unique, irreplicative, plot.
To qualify as a "psychological" plot, the narrative must be:
- All-inclusive (anamnetic) It must encompass, integrate and incorporate all the facts known about the protagonist.
- Coherent It must be chronological, structured and causal.
- Consistent Self-consistent (its subplots cannot contradict one another or go against the grain of the main plot) and consistent with the observed phenomena (both those related to the protagonist and those pertaining to the rest of the universe).
- Logically compatible It must not violate the laws of logic both internally (the plot must abide by some internally imposed logic) and externally (the Aristotelian logic which is applicable to the observable world).
- Insightful (diagnostic) It must inspire in the client a sense of awe and astonishment which is the result of seeing something familiar in a new light or the outcome of seeing a pattern emerging out of a big body of data. The insights must appear to be a logical conclusion of the development of the plot.
- Aesthetic The plot must be both plausible and "right", beautiful, not cumbersome, not awkward, not discontinuous, smooth and so on.
- Parsimonious The plot must employ the minimum numbers of assumptions and entities in order to satisfy all the above conditions.
- Explanatory The plot must explain the behavior of other characters, the hero's decisions and behavior, and why events unfolded the way that they did.
- Predictive (prognostic) The plot must possess the ability to predict future events, the future behavior of the hero and of other meaningful figures and the inner emotional and cognitive dynamics.
- Therapeutic With the power to induce change (whether it is for the better, is a matter of contemporary value judgments and fashions).
- Imposing The plot must be regarded by the client as a useful organizing principle of his life's events past, present, and future.
- Elastic The plot must possess the intrinsic abilities to self organize, reorganize, assimilate emerging order, accommodate new data comfortably, avoid rigidity in its modes of reaction to attacks from within and from without.
In all these respects, a psychological plot is a theory in disguise. Scientific theories must satisfy most of the same conditions. But the equation is flawed. The important elements of testability, verifiability, refutability, falsifiability, and repeatability are all missing. No experiment could be designed to test the statements within the plot, to establish their truth-value and, thus, to convert them to theorems.
There are four reasons to account for this shortcoming:
- Ethical To substantiate a theory experiments would have to be conducted on the patient and others. To achieve the necessary result, the subjects must be ignorant of the fact that they are being experimented upon (in double blind experiments) or remain in the dark regarding what the experimenters want to achieve. Some experiments may involve unpleasant or even traumatic experiences. This is ethically unacceptable.
- The Psychological Uncertainty Principle The current position of a human subject can be fully known. But both treatment and experimentation influence the subject and void this knowledge. The very processes of measurement and observation influence the subject and change him or her.
- Uniqueness Psychological experiments are, therefore, bound to be unique. They cannot be repeated elsewhere and at other times even if they involve the SAME subjects. This is because the subjects are never really the same due to the above-mentioned psychological uncertainty principle. Repeating the experiments with other subjects adversely affects the scientific value of the results.
- The undergeneration of testable hypotheses Psychology does not generate a sufficient number of hypotheses, which can be subjected to scientific testing. This has to do with the fabulous (=storytelling) nature of psychology. In a way, psychology has affinity with some private languages. It is a form of art and, as such, is self-sufficient. If structural, internal constraints and requirements are met a statement is deemed true even if it does not satisfy external scientific requirements.
So, what are plots good for? They are the instruments used in the procedures which induce peace of mind (even happiness) in the client. This is done with the help of a few embedded mechanisms:
- The Organizing Principle Psychological plots offer the client an organizing principle, a sense of order and ensuing justice, of an inexorable drive toward well defined (though, perhaps, hidden) goals, the ubiquity of meaning, being part of a whole. They strive to answer the "whys" and "hows". Plots are dialogic. The client asks: "why do I suffer from (here follows a syndrome)". Then, the plot is spun: "You are like this not because the world is whimsically cruel but because your parents mistreated you when you were very young, or because a person important to you died, or was taken away from you when you were still impressionable, or because you were sexually abused and so on". The client is calmed by the very fact that there is an explanation to that which until now monstrously taunted and haunted him, that he is not the plaything of vicious gods, that his discomfort has a label, that there is someone to blame (helpfully focusing his diffused anger) and, that, therefore, his belief in order, justice and their administration by some supreme, transcendental principle (or being) is restored. This sense of "law and order" is further enhanced when the plot yields predictions which come true (either because they are self-fulfilling prophesies or because some real "law" has been discovered).
- The Integrative Principle The client is offered, through the plot, access to the innermost, hitherto inaccessible, recesses of his mind. He feels that he is being reintegrated, that "things fall into place". In psychodynamic terms, his energy is released to do productive and positive work, rather than to be channeled distorted and destructive forces.
c. The Purgatory Principle In most cases, the client feels sinful, debased, inhuman, decrepit, corrupting, guilty, punishable, hateful, alienated, strange, mocked and so on. The plot offers him absolution. Like the highly symbolic story of the Savior the client's sufferings expurgate, cleanse, absolve, and atone for his sins and handicaps. A feeling of hard won achievement accompanies the spinning of a successful plot. The client sheds layers of functional, maladaptive clothing. This is inordinately painful. The client feels dangerously naked, precariously exposed. He then assimilates the plot offered to him, thus enjoying the benefits emanating from the previous two principles and only then does he develop new mechanisms of coping. Therapy is a mental crucifixion and resurrection and atonement for the sins. It is highly religious with the plot in the role of the scriptures from which solace is gleaned.
(continued below)
This article appears in my book, "Malignant Self-love: Narcissism Revisited"
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3. Personality Disorders - An Overview
All personality disorders are interrelated, at least phenomenologically - though we have no Grand Unifying Theory of Psychopathology. We do not know whether there are and what are the mechanisms underlying mental disorders. At best, mental health professionals record symptoms (as reported by the patient) and signs (as observed).
Then, they group them into syndromes and, more specifically, into disorders. This is descriptive, not explanatory science. Sure, there are a few etiological theories around (psychoanalysis, to mention the most famous) but they all failed to provide a coherent, consistent theoretical framework with predictive powers.
Patients suffering from personality disorders have many things in common:
- Most of them are insistent (except those suffering from the Schizoid or the Avoidant Personality Disorders). They demand treatment on a preferential and privileged basis. They complain about numerous symptoms. They never obey the physician or his treatment recommendations and instructions.
- They regard themselves as unique, display a streak of grandiosity and a diminished capacity for empathy (the ability to appreciate and respect the needs and wishes of other people). They regard the physician as inferior to them, alienate him using umpteen techniques and bore him with their never-ending self-preoccupation.
- They are manipulative and exploitative because they trust no one and usually cannot love or share. They are socially maladaptive and emotionally unstable.
- Most personality disorders start out as problems in personal development which peak during adolescence and then become personality disorders. They stay on as enduring qualities of the individual. Personality disorders are stable and all-pervasive not episodic. They affect most of the areas of functioning of the patient: his career, his interpersonal relationships, his social functioning.
- The typical patients is unhappy. He is depressed, suffers from auxiliary mood and anxiety disorders. He does not like himself, his character, his (deficient) functioning, or his (crippling) influence on others. But his defences are so strong, that he is aware only of the distress and not of the reasons to it.
- The patient with a personality disorder is vulnerable to and prone to suffer from a host of other psychiatric problems. It is as though his psychological immunological system has been disabled by his personality disorder and he falls prey to other variants of mental illness. So much energy is consumed by the disorder and by its corollaries (example: by obsessions-compulsions, or mood swings), that the patient is rendered defenceless.
- Patients with personality disorders are alloplastic in their defences. They have an external locus of control. In other words: they tend to blame the outside world for their mishaps. In stressful situations, they try to pre-empt a (real or imaginary) threat, change the rules of the game, introduce new variables, or otherwise influence the world out there to conform to their needs. This is as opposed to autoplastic defences (internal locus of control) typical, for instance, of neurotics (who change their internal psychological processes in stressful situations).
- The character problems, behavioural deficits and emotional deficiencies and lability encountered by patients with personality disorders are, mostly, ego-syntonic. This means that the patient does not, on the whole, find his personality traits or behaviour objectionable, unacceptable, disagreeable, or alien to his self. As opposed to that, neurotics are ego-dystonic: they do not like who they are and how they behave on a constant basis.
- The personality-disordered are not psychotic. They have no hallucinations, delusions or thought disorders (except those who suffer from the Borderline Personality Disorder and who experience brief psychotic "microepisodes", mostly during treatment). They are also fully oriented, with clear senses (sensorium), good memory and a satisfactory general fund of knowledge.
The Diagnostic and Statistical Manual [American Psychiatric Association. DSM-IV-TR, Washington, 2000] defines "personality" as:
" enduring patterns of perceiving, relating to, and thinking about the environment and oneself exhibited in a wide range of important social and personal contexts."
Click here to read the DSM-IV-TR (2000) definition of personality disorders.
The international equivalent of the DSM is the ICD-10, Classification of Mental and Behavioural Disorders, published by the World Health Organization in Geneva (1992).
Click here to read the ICD-10 diagnostic criteria for the personality disorders.
Each personality disorder has its own form of Narcissistic Supply:
- HPD (Histrionic PD) Sex, seduction, "conquests", flirtation, romance, body-building, demanding physical regime;
- NPD (Narcissistic PD) Adulation, admiration, attention, being feared;
- BPD (Borderline PD) The presence of their mate or partner (they are terrified of abandonment);
- AsPD (Antisocial PD) Money, power, control, fun.
Borderlines, for instance, can be described as narcissist with an overwhelming separation anxiety. They DO care deeply about not hurting others (though often they cannot help it) but not out of empathy. Theirs is a selfish motivation to avoid rejection. Borderlines depend on other people for emotional sustenance. A drug addict is unlikely to pick up a fight with his pusher. But Borderlines also have deficient impulse control, as do Antisocials. Hence their emotional lability, erratic behaviour, and the abuse they do heap on their nearest and dearest.
4. An Example of a Unifying Approach
We are all narcissists at an early stage of our lives. As infants, we feel that we are the centre of the universe, omnipotent and omniscient. Our parents, those mythical figures, immortal and awesomely powerful, are there only to protect and serve us. Both self and others are viewed immaturely, as idealisations.
Inevitably, the inexorable processes and conflicts of life grind these ideals into the fine dust of the real. Disappointments follow disillusionment. When these are gradual and tolerable, they are adaptative. If abrupt, capricious, arbitrary, and intense, the injuries sustained by the tender, budding self-esteem, are irreversible.
Moreover, the empathic support of the caretakers (the Primary Objects, the parents) is crucial. In its absence, self-esteem in adulthood tends to fluctuate, to alternate between over-valuation (idealisation) and devaluation of both self and others.
Narcissistic adults are the result of bitter disappointments, of radical disillusionment with parents, role models, or peers. Healthy adults accept their limitations (the boundaries of their selves). They accept disappointments, setbacks, failures, criticism and disillusionment with grace and tolerance. Their sense of self-worth is constant and positive, minimally affected by outside events, no matter how severe.
The common view is that we go through the stages of a linear development. We are propelled forward by various forces: the Libido (force of life) and the Thanatos (force of death) in Freud's tripartite model, Meaning in Frenkel's work, socially mediated phenomena (in both Adler's thinking and in Behaviourism), our cultural context (in Horney's opera), interpersonal relations (Sullivan) and neurobiological and neurochemical processes, to mention but a few schools of developmental psychology.
In an effort to gain respectability, many scholars attempted to propose a "physics of the mind". But these thought systems differ on many issues. Some say that personal development ends in childhood, others during adolescence. Yet others say that development is a process which continues throughout the life of the individual.
Common to all these schools of thought are the mechanics and dynamics of the process of personal growth. Forces inner or external facilitate the development of the individual. When an obstacle to development is encountered, development is stunted or arrested but not for long. A distorted pattern of development, a bypass appears.
Psychopathology is the outcome of perturbed growth. Humans can be compared to trees. When a tree encounters a physical obstacle to its expansion, its branches or roots curl around it. Deformed and ugly, they still reach their destination, however late and partially.
Psychopathologies are, therefore, adaptative mechanisms. They allow the individual to continue to grow around obstacles. The nascent personality twists and turns, deforms itself, is transformed until it reaches a functional equilibrium, which is not too ego-dystonic.
Having reached that point, it settles down and continues its more or less linear pattern of growth. The forces of life (as expressed in the development of the personality) are stronger than any hindrance. The roots of trees crack mighty rocks, microbes live in the most poisonous surroundings.
Similarly, humans form those personality structures which are optimally suited to their needs and outside constraints. Such personality configurations may be abnormal but their mere existence proves that they have triumphed in the delicate task of successful adaptation.
Only death puts a stop to personal growth and development. Life's events, crises, joys and sadness, disappointments and surprises, setbacks and successes all contribute to the weaving of the delicate fabric called "personality".
When an individual (at any age) encounters an obstacle to the orderly progression from one stage of development to another he retreats at first to his early childhood's narcissistic phase rather than circumvent or "go around" the hindrance.
The process is three-phased:
(1) The person encounters an obstacle
(2) The person regresses to the infantile narcissistic phase
(3) Thus recuperated, the person confronts the obstacle again.
While in step (2), the person displays childish, immature behaviours. He feels that he is omnipotent and misjudges his powers and the might of the opposition. He underestimates challenges facing him and pretends to be "Mr. Know-All". His sensitivity to the needs and emotions of others and his ability to empathise with them deteriorates sharply. He becomes intolerably haughty with sadistic and paranoid tendencies.
Above all, he then demands unconditional admiration, even when he does not deserve it. He is preoccupied with fantastic, magical, thinking and daydreams his life away. He tends to exploit others, to envy them, to be edgy and explode with unexplained rage.
People whose psychological development is obstructed by a formidable obstacle mostly revert to excessive and compulsive behaviour patterns. To put it succinctly: whenever we experience a major life crisis (which hinders our personal growth and threatens it) we suffer from a mild and transient form of the Narcissistic Personality Disorder.
This fantasy world, full of falsity and hurt feelings, serves as a springboard from which the rejuvenated individual resumes his progress towards the next stage of personal growth. This time around, faced with the same obstacle, he feels sufficiently potent to ignore it or to attack it.
In most cases, the success of this second onslaught is guaranteed by the delusional assessment that the obstacle's fortitude and magnitude are diminished. This, indeed, is the main function of this reactive, episodic, and transient narcissism: to encourage magical thinking, to wish the problem away or to enchant it or to tackle and overcome it from a position of omnipotence.
A structural abnormality of personality arises only when recurrent attacks fail constantly and consistently to eliminate the obstacle, or to overcome the hindrance. The contrast between the fantastic world (temporarily) occupied by the individual and the real world in which he keeps being frustrated is too acute to countenance for long without a resulting deformity.
This dissonance - the gap between grandiose fantasy and frustrating reality - gives rise to the unconscious "decision" to go on living in the world of fantasy, grandiosity and entitlement. It is better to feel special than to feel inadequate. It is better to be omnipotent than psychologically impotent. To (ab)use others is preferable to being (ab)used by them. In short: it is better to remain a pathological narcissist than to face harsh, unyielding reality.
Not all personality disorders are fundamentally narcissistic. Yet, I think that the default, when growth is stunted by the existence of a persistent obstacle, is remission to the the narcissistic phase of early personal development. I further believe that this is the ONLY default available to the individual: whenever he comes across an obstacle, he regresses to the narcissistic phase. How can this be reconciled with the diversity of mental illnesses?
"Narcissism" is the substitution of a False Self for the True Self. This, arguably, is the predominant feature of narcissism: the True Self is repressed, relegated to irrelevance and obscurity, left to degenerate and decay. In its stead, a psychological structure is formed and projected unto the outside world the False Self.
The narcissist's False Self is reflected at him by other people. This "proves" to the narcissist that the False Self indeed exists independently, that it is not entirely a figment of the narcissist's imagination and, therefore, that it is a legitimate successor to the True Self. It is this characteristic which is common to all psychopathologies: the emergence of false psychic structures which usurp the powers and capacities of the previous, legitimate and authentic ones.
Horrified by the absence of a clearly bounded, cohesive, coherent, reliable, and self-regulating self the mentally abnormal person resorts to one of the following solutions, all of which involve reliance upon fake or invented personality constructs:
- The Narcissistic Solution The True Self is replaced by a False Self. The Schizotypal Personality Disorder also largely belongs here because of its emphasis on fantastic and magical thinking. The Borderline Personality Disorder (BPD) is a case of a failed narcissistic solution. In BPD, the patient is aware that the solution that she opted for is "not working". This is the source of her separation anxiety (fear of abandonment). This generates her identity disturbance, her affective and emotional lability, suicidal ideation and suicidal action, chronic feelings of emptiness, rage attacks, and transient (stress related) paranoid ideation.
- The Appropriation Solution This is the appropriation, or the confiscation of someone else's self in order to fill the vacuum left by the absence of a functioning Ego. While some Ego functions are available internally others are adopted by the "appropriating personality". The Histrionic Personality Disorder is an example of this solution. Mothers who "sacrifice" their lives for their children, people who live vicariously, through others all belong to this category. So do people who dramatise their lives and their behaviour, in order to attract attention. The "appropriators" misjudge the intimacy of their relationships and the degree of commitment involved, they are easily suggestible and their whole personality seems to shift and fluctuate with input from the outside. Because they have no Self of their own (even less so than "classical" narcissists) the "appropriators" tend to over-rate and over-emphasise their bodies. Perhaps the most striking example of this type of solution is the Dependent Personality Disorder.
- The Schizoid Solution These patients are mental zombies, trapped forever in the no-man's land between stunted growth and the narcissistic default. They are not narcissists because they lack a False Self nor are they fully developed adults, because their True Self is immature and dysfunctional. They prefer to avoid contact with others (they lack empathy, as does the narcissist) in order not to upset their delicate tightrope act. Withdrawing from the world is an adaptive solution because it does not expose the patient's inadequate personality structures (especially his self) to onerous and failure bound tests. The Schizotypal Personality Disorder is a mixture of the narcissistic and the schizoid solutions. The Avoidant Personality Disorder is a close kin.
- The Aggressive Destructive Solution These people suffer from hypochondriasis, depression, suicidal ideation, dysphoria, anhedonia, compulsions and obsessions and other expressions of internalised and transformed aggression directed at a self which is perceived to be inadequate, guilty, disappointing and worthy of nothing but elimination. Many of the narcissistic elements are present in an exaggerated form. Lack of empathy becomes reckless disregard for others, irritability, deceitfulness and criminal violence. Undulating self-esteem is transformed into impulsiveness and failure to plan ahead. The Antisocial Personality Disorder is a prime example of this solution, whose essence is: the total control of a False Self, without the mitigating presence of a shred of True Self.
Perhaps this common feature the replacement of the original structures of the personality by new, invented, mostly false ones is what causes one to see narcissists everywhere. This common denominator is most accentuated in the Narcissistic Personality Disorder.
The interaction, really, the battle, between the struggling original remnants of the personality and the malignant and omnivorous new structures can be discerned in all forms of psychic abnormality. The question is: if many phenomena have one thing in common should they be considered one and the same, or, at least, caused by the same?
I say that the answer in the case of personality disorders should be in the affirmative. I think that all the known personality disorders are forms of malignant self-love. In each personality disorder, different attributes are differently emphasised, different weights attach to different behaviour patterns. But these, in my view, are all matters of quantity, not of quality. The myriad deformations of the reactive patterns collectively known as "personality" all belong to the same family.
Also Read
More about Other Personality Disorders - in the Open Site Encyclopedia
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