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Old 01-22-11, 10:51 PM
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On Personality and Personality Disorders

Personality Disorders and Personality

In order to understand personality disorders, we must first understand what they are a disorder of, that is, we must first understand personality. Personality is a relatively stable construct. There are many different approaches to defining personality. The most prevalent, perhaps, is trait theory. Trait theory describes personality along a variety of continuous scales. The most common, and empirically supported, take on personality is the "Big Five" approach, also known as the OCEAN model. These major traits are Openness to Novelty, Conscientiousness, Extraversion, Agreeableness, and Neuroticism. It is believed that these five dimensions can adequately map a personality for clinical purposes.

What it is critical to understand is that personality is very, very stable over time. Personality begins its development genetically, where it is influenced heavily by temperament, a separate concept distinct from, though related to, personality. It is then strongly, strongly influenced by very early childhood experiences, with the most important events occurring between ages 0-2. While there are further crises that refine personality, it is largely set in stone by the end of the first three major life crises, as defined by Erikson: trust vs. mistrust, autonomy vs. shame and doubt, and initiative vs. guilt. With these three developmental crises met, the rest of development is largely determined.

Early personality development is described by several researchers and theorists, and is a very complex time. I will not be able to address the entirety of personality development in this thread. However, I will hit on some major concepts of personality development that are critical to the etiology of psychopathology.

Sigmund Freud first described early personality development with his drive theory and the stages of psychosexual development. The most pertinent three are the oral, anal, and phallic (oedipal) stages. These stages correlate almost exactly with the previously mentioned Eriksonian stages. While many psychologists have moved away from the use of psychosexual terms, American culture still makes reference to old psychoanalytic terms, calling people "anal" when they are especially restricted. To help clarify these terms, I will describe their use. An "anal fixation" is when an adult is seen as having regressed to the anal stage of development, which can be either retentive or anal expulsive. Oral, similarly, can be either aggressive or passive. While we have largely moved away from these original descriptions of the stages in the mainstream of psychology (except for the most stalwart of Freudian classical analysts), these stages merit discussion simply because they are the foundation of other theories of childhood development.

The most important derivation of psychosexual development are Erikson's stages of development, which have been previously mentioned. I will describe the first three stages in the next paragraph, as well as describing the structural theory developments taking place. Structural theory describes the internal psychological structures that comprise a person's self. These structures are the Id, which operates on the pleasure principle, the Ego, which operates on the reality principle, and the Superego, a portion of the ego that can best be described as the conscience. The Id wants instant gratification of desires. It is essentially hedonistic. Because hedonism is not adaptive or realistic, we develop an Ego to regulate the Id, to decide what should and should not be pursued, and to defend against anxiety. The Superego develops as a result of our parents teaching us societally acceptable behavior. It punishes the Ego and Id for acting in socially maladaptive ways with it's primary weapon: guilt. The development of these structures will be described in the subsequent paragraphs.

The first crisis that a child must face is that of trust vs. mistrust. This crisis is experienced between the ages of birth to one or one and a half years old. During this crisis, the child must determine whether or not he or she trusts the world and believes he or she is safe, or distrusts the world and believes that it is a fundamentally harsh and cruel place. While temperament has some influence here, the most critical influence is that of the mother. If the mother is nurturing and provides nourishment and, most importantly, love and affection, the child will likely resolve the crisis by learning to trust the world. This is a key stage of development. During this stage, the Id rules king. There is no ego to keep its desires in check. Towards the end of this stage, the Ego develops as the child edges into the autonomy (anal) stage. The ego develops in order to regulate the impulses of the Id as the child realizes that instant gratification of needs is not realistic.

The second crisis that a child faces is that of autonomy vs. shame and doubt. This takes place from ages 1.5 to 3 or 4. During this stage, the child must resolve whether or not he or she acts autonomously and freely, or if his or her behaviors are inhibited by doubt and shame. Resolution of this crisis determines whether a child will act freely and express his or her agency, or will be inhibited by feelings of doubt. Failing to resolve this crisis with autonomy leads to a person who is fearful and hesitant to act and make decisions. This is when the ego most fully develops, as it determines if it is able to act on its own. At the same time, another process is taking place, called separation-individuation, which I will describe in a few paragraphs.

The third crisis is that of Initiative vs. Guilt, taking place around ages 4-6. During this stage, a child learns if he or she can take the initiative to seek out desires and act with the agency he or she has recently developed with the development of the ego, or if he or she will be inhibited by the development of an overly strong Superego. As the child ages, he or she is exposed to social norms and generally acceptable behaviors. This morphs into the Superego, a portion of the ego partially conscious, mostly unconscious, that inhibits us from negative behaviors.

Another critical and simultaneously occurring process is that of separation-individuation, described by Hungarian psychoanalyst Margaret Mahler. Mahler describes two phases, the symbiotic phase and the separation-individuation phase. During the symbiotic phase, the child is attached to the mother, aware of the mother but not aware of the self, without a self-conception. The next phase is that of separation-individuation. Separation is the distinction made between the mother and the self, a learning that they are not one unit. Individuation then refers to the development of the Ego and subsequently of the Self.

Separation-individuation is divided into three stages: hatching, practicing, and rapprochement. Hatching begins about five or six months after birth. The child becomes aware of the world and, while remaining oriented to the mother, begins to see that there is more to the world than simply the mother. After this, from about 9 months to 1.5 years (and corresponding to the beginning of the autonomy vs. shame and doubt stage of Erikson's model), the child begins to wander and explore, but always returns very quickly to the mother. During rapprochement (and exactly corresponding to the Autonomy stage), the child searches out the world, entering a crisis of staying with the mother or becoming more independent, and finally resolving either to act independently or act with shame and doubt.

The final important conception necessary to understand the etiology of personality disorders is Melanie Klein's object relations theory. In psychoanalytic literature, an "object" is an internalization, an internal representation of a person. Klein describes the two concepts, and then two "positions."

The first concept is the concept of "unconscious phantasy" (spelled such to differentiate it from fantasy, a Freudian defense). The Phantasy is characterized by the development of a mental world, allowing for the eventually development of contact with reality. The next concept is projective identification. This is a process where the Freudian defense projection is applied to "bad part objects" (I will describe part objects in the next paragraph), that is, the Ego has developed and is utilizing a defense where anxiety is projected onto external objects. At the same time, good characteristics are internalized (introjected) by the ego to create a concept of positive self-worth.

There are also two positions, which establish the names for personality disorders which I will discuss in a reply to this post. You will recognize the names of the positions because they are intrinsically linked to personality disorders with which many of you are already familiar.

The first position is the paranoid-schizoid position. In this position, the child is characterized by the ego defense of splitting. Objects are separated into part objects - there are two breasts, the "good breast" which answers to needs and responds to the child's desires, and the "bad breast," a hallucinated aspect of the phantasy that encompasses the bad. The child introjects aspects of the good breast while projecting aspects of the bad breast onto real things. In this position, the ego is terrified of impending destruction. It splits (splitting is a primitive defense mechanism) the bad from the good, then projects the bad out in order to control the mental environment.

The second position is the depressive position. In this position, the child begins to integrate that the good and bad breast are representations of the same object. The child learns that one object can be good or bad. In integrating the good breast and the bad breast, the child represents that there is one mother. In representing that there is one mother, there is a separation, called the "primal split," where the child realizes that he or she is not the same object as the mother. This is a critical stage of development as it allows for the construction of a concept of self.

In the next post, I will describe how these processes lead to the etiology of several personality disorders.
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Old 01-22-11, 11:05 PM
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Re: On Personality and Personality Disorders

The "cluster B" catergory fascinates me - maybe more than it should.
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Old 01-22-11, 11:11 PM
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Re: On Personality and Personality Disorders

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The "cluster B" catergory fascinates me - maybe more than it should.
Me too. I just last night started wondering whether I want to dedicate my practice to borderline personality disorder. It would certainly keep my work interesting and challenging. Personality disorders in general fascinate me, as they are all grounded in a rich psychoanalytic tradition.
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Old 01-22-11, 11:22 PM
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Re: On Personality and Personality Disorders

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Me too. I just last night started wondering whether I want to dedicate my practice to borderline personality disorder. It would certainly keep my work interesting and challenging. Personality disorders in general fascinate me, as they are all grounded in a rich psychoanalytic tradition.

Totally. There must be a smidge of shameful entertainment value that I gain from it to string my interest along - but mainly it's so tragic. I can't imagine a worse hell than what "CB" afflicted folks experience - particularly borderline. It calls on the best part of good people to fix it - an you just don't want to accept that it's unsolvable (incurable). It's almost maddening to think about. Emotionally, it doesn't compute.

What scholars do you think are the best writers on the subject?
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Old 01-22-11, 11:26 PM
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Re: On Personality and Personality Disorders

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Totally. There must be a smidge of shameful entertainment value that I gain from it to string my interest along - but mainly it's so tragic. I can't imagine a worse hell than what "CB" afflicted folks experience - particularly borderline. It calls on the best part of good people to fix it - an you just don't want to accept that it's unsolvable (incurable). It's almost maddening to think about. Emotionally, it doesn't compute.

What scholars do you think are the best writers on the subject?
this says pills can help some parts of it
http://www.ncbi.nlm.nih.gov/pubmed/19636254
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Old 01-22-11, 11:46 PM
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Re: On Personality and Personality Disorders

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Originally Posted by Mignon View Post
What scholars do you think are the best writers on the subject?
I'm admittedly not well versed in the scholars, and it's been a long time since I've studied personality disorders as disorders themselves outside the psychoanalytic tradition. The work of Margaret Mahler is hugely important in the understanding of symbiotic-psychotic individuals. Melanie Klein's work defines borderline personality disorder, as I will demonstrate in the next post. Freud and Janet spoke wonderfully to hysteria, now known as conversion disorder and histrionic personality disorder.

Personally, I strongly recommend the book Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process by Nancy McWilliams as an excellent crash course in psychoanalytic constructions of personality. It is dense, and requires some background in psychodynamics, but it is a wonderful resource. The original post of this thread, and some additional reading expanding on Klein and Mahler's work, should be sufficient to "get" the book.

I should also mention that Sigmund and Anna Freud's work on the description of ego defenses is probably the single most important contribution to the field of ego psychology, and a solid understanding of ego defenses can inform a practitioner to identify psychodynamic processes and thus give him or her an invaluable weapon in identifying the neuroses of a client.
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Old 01-22-11, 11:53 PM
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Re: On Personality and Personality Disorders

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this says pills can help some parts of it
http://www.ncbi.nlm.nih.gov/pubmed/19636254
Things like that are hopeful for patients who are just done with it all. But isn't a trademark of that B cluster group a conviction of self superiority (persistant denial that anything to do with them is in need of fixing)?

I don't know, I get my PD information from shady internet summaries, but that's what keeps coming up. That is, my impression is that treatment compliance would be a rare thing, since the diagnosed patient would "comply" with treatment under duress. People who lack a conscience (APD) do not wish to acquire one, as it is viewed as a complicating weakness (I've read).

Interesting thread!
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Old 01-22-11, 11:56 PM
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Re: On Personality and Personality Disorders

As I described in the other thread, with a personality disorder the dysfuntion is usually ego syntonic, meaning it is fundamental to the way the ego works and the client will not identify anything as wrong with that mode of operation. For a narcissist, the problem is "other people don't recognize how great I am." For the borderline, it is "other people hate me." For the histrionic, "nobody understands how ______ I am." And for the antisocial, other people don't matter.
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Old 01-22-11, 11:59 PM
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Re: On Personality and Personality Disorders

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Originally Posted by Mignon View Post
Totally. There must be a smidge of shameful entertainment value that I gain from it to string my interest along - but mainly it's so tragic. I can't imagine a worse hell than what "CB" afflicted folks experience - particularly borderline. It calls on the best part of good people to fix it - an you just don't want to accept that it's unsolvable (incurable). It's almost maddening to think about. Emotionally, it doesn't compute.

What scholars do you think are the best writers on the subject?
For various reasons I was researching BPD a few weeks ago, and watching youtube videos made by people who have BPD were quite painful to watch. I tend to have a visceral response to raw and/or intense emotion and those videos were loaded with it.
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Old 01-23-11, 12:02 AM
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Re: On Personality and Personality Disorders

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Originally Posted by KMiller View Post
As I described in the other thread, with a personality disorder the dysfuntion is usually ego syntonic, meaning it is fundamental to the way the ego works and the client will not identify anything as wrong with that mode of operation. For a narcissist, the problem is "other people don't recognize how great I am." For the borderline, it is "other people hate me." For the histrionic, "nobody understands how ______ I am." And for the antisocial, other people don't matter.
With that in mind - while it seems like an advance to have pharmaceuticals improve PD symptoms - who but someone who doesn't have a PD would comply?

Is my thought.
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Old 01-23-11, 12:12 AM
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Re: On Personality and Personality Disorders

It's been pointed out to me that the use of the term "mother" doesn't accurately represent the situation. For the purposes of modernization, you're welcome to replace "mother" with "primary caregiver" or "person filling the mother role." Remember that the "mother object" is an internalization, and that any primary caregiver can fill that role. The language used in psychoanalysis is sometimes archaic.

In essence, assume when I say "mother" that I mean "the mental representation of the generally accepted conception of a mother in Western culture to the child."
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Old 01-23-11, 12:16 AM
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Re: On Personality and Personality Disorders

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Originally Posted by Fortune View Post
For various reasons I was researching BPD a few weeks ago, and watching youtube videos made by people who have BPD were quite painful to watch. I tend to have a visceral response to raw and/or intense emotion and those videos were loaded with it.

Yeah I feel you - but I just want to clarify that by "entertainment value" I mean reading clinical write ups / summarized case histories about certain PDs in a removed way. It "entertains" my curiosity and attraction to difficult (considered unsolvable) puzzles, I guess? I don't want readers to think that by "entertainment value" I mean glee / delight. Far from it. Just clarifying for other readers.
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Old 01-23-11, 12:22 AM
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Re: On Personality and Personality Disorders

do most cluster Bs end up in treatment by circumstances like, ultimatums by family members, forced by a court or something, or seeking treatment for a axis 1 type disorder?


how do most patients with ego systonic PDs end up making their way to docs?
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Old 01-23-11, 12:23 AM
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Re: On Personality and Personality Disorders

or are some bad enough to get committed?
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Old 01-23-11, 12:25 AM
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Re: On Personality and Personality Disorders

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do most cluster Bs end up in treatment by circumstances like, ultimatums by family members, forced by a court or something, or seeking treatment for a axis 1 type disorder?


how do most patients with ego systonic PDs end up making their way to docs?

I don't know, but I've read more than once (in half jest) that people around the cluster B PD afflicted seek counseling / treatment / diagnoses eventually.
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