Systems-centred therapy (SCT) is a particular form of group therapy based on the Theory of Living Human Systems developed by Yvonne Agazarian.
The theory postulates that living human systems survive, develop, and transform from simple to complex through discriminating and integrating information. Corresponding to the small and rigorously defined set of concepts, SCT defines a set of methods, techniques and instruments. SCT practitioners use these with individuals, couples and groups to explore the experience of their differences and work with these to integrate them. Using the method of functional subgrouping, these living human systems increase their ability to see both sides of their issues and resolve them productively. The theory was first developed in Agazarian’s 1997 book, Systems-Centred Therapy for Groups, and grew out of her earlier work in group psychotherapy under the influence of such figures as W.R. Bion and John Bowlby through the further input of the general systems theory of Ludwig von Bertalanffy.
SCT explains how living human systems contain their energy within functional boundaries and direct it towards their goals: the primary goals of survival and development and the secondary goals of environmental mastery. In SCT training groups, all members work in functional subgroups rather than work alone. Subgroups work both sides of every issue in the group-as-a-whole. This practice strengthens both the therapeutic capacity of the training group and allows individual members to choose which side of the conflict has therapeutic salience for their own personal work.
Theory of Living Human Systems: An Introduction
SCT and consultation developed by Yvonne Agazarian is based on the Theory of Living Human Systems, a theory that can be applied to any living human system as small as one individual or a large group and couples, families, classrooms, committees, businesses or even nations. Thus the theory offers a set of ideas for thinking about how living human systems work that can be applied at any level.
The theory defines “a hierarchy of isomorphic systems that are energy-organizing, self-correcting and goal directed” – working on the assumption that psychic patterns will be repeated in the same form (isomorphy)at every nested level of interaction. Each of these constructs is then operationally defined with methods developed that test the hypothesis of the theory. In this way, it offers a comprehensive systems theory and methodology of practice that can be applied in clinical, organisational and educational settings. Most importantly, Agazarian’s theory of living human systems introduces the hypothesis that the single essential process by which living human systems survive, develop and transform is by discriminating and integrating differences.
Working with Differences
Differences are challenging for people, whether they are differences in opinions, beliefs, ideas, wishes, or feelings. Differences are challenging even when we find them inside of ourselves. Groups often respond to differences that are “too different” by ignoring the differences, avoiding the differences, trying to change or convert the differences or blaming, judging or scapegoating the differences. Groups that respond in these ways to differences can survive unchanged for a long time since anything that challenges the status quo does not become incorporated into the group or is rejected by the group.
Because of this tendency, Systems-centred therapists or consultants pay a lot of attention to communication within the system. They are particularly looking to reduce the defensive “noise” within the communication. Noise is defined as contradictions, (Simon and Agazarian), ambiguities and redundancies (Shannon and Weaver). This concept of noise was developed from work by Shannon and Weaver who formulated observations about the inverse relationship between noise and information transfer. By highlighting and reducing contradiction, ambiguities, and redundancies, i.e. “noise”, communication is more effective in transferring information and the system has a better chance of discriminating and integrating its differences.
According to the theory of living human systems, groups that are able to take in and use differences are able to not only survive but also develop and transform. This kind of development enables groups to use their differences as resources to find solutions to problems that are more comprehensive and responsive to the complexity of the problem. They are able to move with less difficulty toward their goals.
Functional Subgrouping
In systems-centred therapy, members are taught to manage differences and resolve conflicts by a technique called functional subgrouping. Rather than individual members working alone, functional subgrouping requires that all members of a system that are similar work together to deeply explore their similarity. When that subgroup finishes its exploration, the subgroup holding a difference begins its work, exploring their similarities with one another. Inevitably, as the members of a subgroup talk with each other, they discover differences (i.e. differences within the apparently similar) within their subgroup and also, find similarities with the other subgroup (similarities in the apparently different). By using functional subgrouping, the whole group has a better chance of integrating its differences rather than rejecting differences. When a group can make use of its differences it becomes more complex and interesting akin to the way music is enriched by harmonies or interwoven themes. The group moves from the survival of the status quo to development and transformation.
SCT clients learn through experience. By exploring one’s experience rather than explaining it, members learn to tell the difference between comprehensive understanding (words first, experience second) and apprehensive understanding (experience first, words second). Clients learn to restore the connection between their comprehensive, thinking self and their emotional, intuitive self. Learning this skill leads to “containing” the energy and gaining the knowledge that frustrations and conflicts arouse, rather than discharging, binding or constricting it in defensive symptoms. Energy in SCT is understood as the ability of the group or individual to work towards its goals.
Working with Perspectives
Another important part of the theory of living human systems is that groups function more effectively when there is the capacity to shift perspective from the perspective of the individual to the perspective of the whole group. Being able to shift perspective from seeing things from the perspective of a person in a group (or couple or family or business, etc.) to the perspective of a member of the group creates a climate of mutual work toward a common goal. Individuals who are able to make the shift from the perspective of an individual to the perspective of a member or systems-centred perspective are less likely to take personally the inevitable challenges that arise as a human system moves toward its goal. When we take things less personally, we are less likely to get bogged down in frustration, hurt feelings and unproductive arguments. When we understand ourselves in the context of the systems that we belong to and co-create – our families, schools, businesses, labour unions, political parties, churches, sports clubs – we not only participate in their tasks, we are also involved in their development: establishing the distribution of authority and the degree of trust that help these systems survive and grow. Doing this, we contribute to the system balance between innovation and continuity, and at the same time strike a balance between our own desire to learn and our want for security.
Phases of Development
The systems-centred methods which developed from the theory of living human systems offers a map of predictable phases for the development of human systems. In the first phase of development, a system comes to terms with the issues of giving and taking authority and with the authority that resides in the members. Successful management of this phase leads to cooperation between members and between members and leaders. Unsuccessful management of this phase results in members behaving defiantly or compliantly which inevitably undermines the group’s development.
In the second phase, called the intimacy phase, the group wrestles with the challenges of closeness and distance from fellow members. This is the phase of team building for workgroups and the phase in which the issues related to separation and individuation are explored in therapy groups. As the group works in this phase it explores the pull to becoming enchanted with itself or becoming disenchanted and falling into despair with no energy to do its work. Successful management of this phase allows members to gain greater access and intimacy with themselves and also to work together with others in a climate of tested and mutual trust.
In the third phase of development, the group has the opportunity to develop a greater access to its emotional and rational intelligence and develops the capacity to use that information effectively in the service of the group’s goals. The group works more efficiently as it is more able to accept the reality of the role each member plays in the group, and stays more connected to the goal of the group and the reality of the environment in which the group is working.
Successfully managing the challenges of these phases of development means that the system is capable of developing an effective distribution of authority, establishing a climate of trust, and developing the capacity for system adaptation and learning. Wheelan (2005) has shown that work groups that are more developed in their phases have increased productivity.
As Psychotherapy
The theory of living human systems has been applied to psychotherapy as well as to business, organisational and educational consultation. In its application to psychotherapy, a unique aspect of this theory is that it is equally applicable to both individual and couples psychotherapy and to group psychotherapy. SCT posits that much of a person’s suffering is related to viewing oneself only from the perspective of the individual self, a person-centred view. By developing a capacity to see oneself from the perspective of the system one is a part of, a systems-centred perspective, the psychotherapy client is able to more consciously influence their own development and the development of the systems they are a part of.
A SCT therapist uses the phases of development described in the theory of living human systems to systemically train a client to recognise states of mind that interfere with reaching the client’s goal. These interfering states of mind are referred to as defences. Two of the most common defences that bring people to psychotherapy are anxiety and depression; these are addressed in the first phase of treatment. Clients are taught how to recognise and reduce these defences so that they are freed to traverse life less painfully and more smoothly. SCT work is a partnership in which the therapist governs the structure of the therapy and clients make a series of manageable choices at different “forks in the road”. Each fork is a choice a person makes between familiar defences and experiencing the emotion, conflict or impulses that triggered the defence. The systems-centred therapist teaches the client to systematically weaken the defence, such as anxiety or tension, in a structured sequence that matches the client’s ability to choose. As each defence is undone, the client can choose to take the fork in the road away from the symptoms generated by their defensive responses, and towards discovering the conflicts, between their emotions or impulses and the fears of their emotions or impulses, that were being defended against. As SCT psychotherapy proceeds, the client acquires skills that increase their ability to undo their own defences. Through this process, clients regain their ability to use their common sense, (and existential humour!) to manage the every day conflicts between themselves and reality. Clear outcome criteria for each step are in the sequence of defence modification locates the client in the SCT treatment plan. Because each defence modification addresses a specific symptom, therapy can be delivered either continuously or chunked into modules. SCT can therefore be applied to the goals of both short-term and long-term therapy.
Criticism
Irvin D. Yalom has seen the formation of subgroups as a negative indicator in the context of group therapy.
Role suction is a term introduced in the United States by Fritz Redl in the mid-20th century to describe the power of a social group to allocate roles to its members.
W.R. Bion’s group dynamics further explored the ways whereby the group (unconsciously) allocates particular functions to particular individuals in order to have its covert emotional needs met; and the process has recently been highlighted anew within the systems-centred therapy of Yvonne Agazarian.
Among regularly occurring group roles are those of the scapegoat for the group’s troubles; the joker; the peacemaker; the critic/spokesperson for group standards; the idol, or upholder of the group ideal; and the identified patient. In mixed gender groups, women may be disproportionately pressured by role suction into playing a nurturing/peacemaker role.
The ease whereby people pick out those who play complementary games, and the psychological splitting of good and bad help fuel such role differentiation.
Behind role suction, such forces as projective identification and countertransference have been singled out as operating at an unconscious level in the group.
Role lock – confirming mutual suction into complementary roles, such as victim and abuser – is ensured by the intermeshing of projective identifications.
Wider Systems
The British anti-psychiatrists explored the theme of group suction in connection with role attribution in the family nexus, as well as with the allocations of roles in the wider social system, David Cooper suggesting that ‘there are always good or bad, loved or hated ‘mothers’ and ‘fathers’, older or younger ‘brothers’ and ‘sisters’…in any institutional structure”.
A wider variety of roles can however be found in organisational life, the person-in-role acting as a container for the (unconscious) group forces.
Role of the Therapist
Bion has described his experience as a group therapist when he “feels he is being manipulated so as to be playing a part, no matter how difficult to recognise, in somebody else’s phantasy…a temporary loss of insight, a sense of experiencing strong feelings, and at the same time a belief that their existence is quite adequately justified by the objective situation”. Bion’s work has also been used to illustrate the part played by role suction in the selection of group leaders – dependent groups favouring narcissistic leaders, the fight/flight group paranoids.
R.D. Laing considered that a central part of the therapist’s job was “not to allow himself to collude with the patients in adopting a position in their phantasy-system: and, alternatively, not to use the patients to embody any phantasy of their own” – to resist role suction. Later therapists however have explored how a measure of adaptation to patients’ role suction – a degree of role responsiveness – can be a useful element in the therapeutic use of the countertransference.
Criticism
From the point of view of systems-centred therapy, the debate relates to the interface between a personal system and the psycho-dynamics of social systems themselves.
Debate has arisen about how far the group imposes roles, and how far the individual’s own personality goes to meet the group halfway. Earl Hopper has used the term personification to challenge Redl’s concept, suggesting instead that group roles reflect the underlying personality of the individual involved. However, Kibel objects that in many cases the roles imposed are in fact ego-dystonic; with others pointing to how personal tendencies combine with group expectations with varying degrees of fit.
1924 – Anna Elisabeth (Lise) Østergaard, Danish psychologist and politician (d. 1996).
Lise Ostergaard
Anna Elisabeth “Lise” Østergaard (18 November 1924 to 19 March 1996) was a Danish psychologist and a politician in the social-democratic party.
Under Anker Jørgensen’s leadership, she was Minister without Portfolio (1977-1980) and Minister of Culture (February 1980 to September 1982). As a psychologist, she was head of psychology in Copenhagen’s Rigshospitalet (1958) as well as the first woman to become professor of clinical psychology at Copenhagen University (1963), a position she resumed after her political career ended in the mid-1980s.
Biography
Born on 18 November 1924 in Odense, Østergarrd was the daughter of Alfred Østergaard (1890-1962) and his wife Martha Kirstine Nielsen (1885–1944). She spent her first 12 years in Odense before moving with her parents to Gentofte. Although she encountered difficulties at school, she finally embarked on psychology studies at Copenhagen University. On leaving home against her father’s wishes, she paid her own way by working as a doctor’s secretary.
Psychology
After graduating in 1947, Østergaard worked as a psychologist in Norrtulls sjukhus, a children’s hospital in Stockholm. In 1949, she returned to Denmark, first spending a year in Dronning Louises Børnehospital (Queen Louise’s Children’s Hospital) before moving to the newly established children’s psychology clinic at Copenhagen University where she remained until 1954. She then entered the Rigshospitalet’s psychology department where she was appointed head psychologist in 1958, expanding her experience in clinical psychology. As a result, from 1955 to 1960 she headed a course in clinical psychology for the Dansk Psychologforening (Danish Psychologists Association) while teaching as the first woman psychologist at the university. She also took up assignments as a guest lecturer in Lund, Sweden, and Bergen, Norway.
Published in 1961, her Den psykologiske testmetode og dens relation til klinisk psykiatri (The Psychological Test Method and its Relationship to Clinical Psychiatry) raised considerable interest among psychiatrists. While working at Rigshospitalet, Østergaard treated a number of schizophrenic patients. In 1962, this led to her En psykologisk analyse af de formelle schizofrene tankeforstyrrelser (A Psychological Analysis of Formal Schizophrenic Thought Disorders), paving the way for research on the borderline between psychology and psychiatry in collaboration with the National Institute of Mental Health in the United States.
In 1963, Østergaard became the first female professor of psychology at Copenhagen University. After heading the Studenterrådgivningsklinikken (Student Advisory Clinic, 1964-1968), she established the Institut for Klinisk Psykologi (Clinical Psychology Institute) in 1968. From 1970 to 1973, she was a member of Denmark’s Unesco committee and from 1973 a member of Akademiet for de Tekniske Videnskaber (The Danish Academy of Technical Sciences).
It is taken either by mouth or by injection into a muscle. The injectable version is long-acting and lasts for about two weeks.
Common side effects include movement problems, sleepiness, dizziness, trouble seeing, constipation, and increased weight. Serious side effects may include the potentially permanent movement disorder tardive dyskinesia, as well as neuroleptic malignant syndrome, an increased risk of suicide, and high blood sugar levels. In older people with psychosis as a result of dementia, it may increase the risk of dying. It is unknown if it is safe for use in pregnancy. Its mechanism of action is not entirely clear, but is believed to be related to its action as a dopamine and serotonin antagonist.
Study of risperidone began in the late 1980s and it was approved for sale in the United States in 1993. It is on the World Health Organisation’s List of Essential Medicines. It is available as a generic medication. In 2018, it was the 159th most commonly prescribed medication in the United States, with more than 3 million prescriptions.
Medical Uses
Risperidone is mainly used for the treatment of schizophrenia, bipolar disorder, and irritability associated with autism.
Schizophrenia
Risperidone is effective in treating psychogenic polydipsia and the acute exacerbations of schizophrenia.
Studies evaluating the utility of risperidone by mouth for maintenance therapy have reached varying conclusions. A 2012 systematic review concluded that evidence is strong that risperidone is more effective than all first-generation antipsychotics other than haloperidol, but that evidence directly supporting its superiority to placebo is equivocal. A 2011 review concluded that risperidone is more effective in relapse prevention than other first- and second-generation antipsychotics with the exception of olanzapine and clozapine. A 2016 Cochrane review suggests that risperidone reduces the overall symptoms of schizophrenia, but firm conclusions are difficult to make due to very low-quality evidence. Data and information are scarce, poorly reported, and probably biased in favour of risperidone, with about half of the included trials developed by drug companies. The article raises concerns regarding the serious side effects of risperidone, such as parkinsonism.
Long-acting injectable formulations of antipsychotic drugs provide improved compliance with therapy and reduce relapse rates relative to oral formulations. The efficacy of risperidone long-acting injection appears to be similar to that of long acting injectable forms of first generation antipsychotics.
Bipolar Disorder
Second-generation antipsychotics, including risperidone, are effective in the treatment of manic symptoms in acute manic or mixed exacerbations of bipolar disorder. In children and adolescents, risperidone may be more effective than lithium or divalproex, but has more metabolic side effects. As maintenance therapy, long-acting injectable risperidone is effective for the prevention of manic episodes but not depressive episodes. The long-acting injectable form of risperidone may be advantageous over long acting first generation antipsychotics, as it is better tolerated (fewer extrapyramidal effects) and because long acting injectable formulations of first generation antipsychotics may increase the risk of depression.
Autism
Compared to placebo, risperidone treatment reduces certain problematic behaviours in autistic children, including aggression toward others, self-injury, challenging behaviour, and rapid mood changes. The evidence for its efficacy appears to be greater than that for alternative pharmacological treatments. Weight gain is an important adverse effect. Some authors recommend limiting the use of risperidone and aripiprazole to those with the most challenging behavioural disturbances in order to minimise the risk of drug-induced adverse effects. Evidence for the efficacy of risperidone in autistic adolescents and young adults is less persuasive.
Other Uses
Risperidone has shown promise in treating therapy-resistant obsessive-compulsive disorder, when serotonin reuptake inhibitors are not sufficient.
While antipsychotic medications such as risperidone have a slight benefit in people with dementia, they have been linked to higher incidences of death and stroke. Because of this increased risk of death, treatment of dementia-related psychosis with risperidone is not US Drug and Food Administration (FDA) approved.
Forms
Available forms of risperidone include tablet, oral dissolving tablet, oral solution, and powder and solvent for suspension for injection.
Adverse Effects
Common side effects include movement problems, sleepiness, dizziness, trouble seeing, constipation, and increased weight. About 9 to 20% of people gained more than 7% of the baseline weight depending on the dose. Serious side effects may include the potentially permanent movement disorder tardive dyskinesia, as well as neuroleptic malignant syndrome, an increased risk of suicide, and high blood sugar levels. In older people with psychosis as a result of dementia, it may increase the risk of dying.
While atypical antipsychotics appear to have a lower rate of movement problems as compared to typical antipsychotics, risperidone has a high risk of movement problems among the atypicals. Atypical antipsychotics however are associated with a greater amount of weight gain.
Drug Interactions
Carbamazepine and other enzyme inducers may reduce plasma levels of risperidone.
If a person is taking both carbamazepine and risperidone, the dose of risperidone will likely need to be increased.
The new dose should not be more than twice the patient’s original dose.
CYP2D6 inhibitors, such as SSRI medications, may increase plasma levels of risperidone and those medications.
Since risperidone can cause hypotension, its use should be monitored closely when a patient is also taking antihypertensive medicines to avoid severe low blood pressure.
Risperidone and its metabolite paliperidone are reduced in efficacy by P-glycoprotein inducers such as St John’s wort.
Discontinuation
The British National Formulary recommends a gradual withdrawal when discontinuing antipsychotic treatment to avoid acute withdrawal syndrome or rapid relapse. Some have argued the additional somatic and psychiatric symptoms associated with dopaminergic super-sensitivity, including dyskinesia and acute psychosis, are common features of withdrawal in individuals treated with neuroleptics. This has led some to suggest the withdrawal process might itself be schizomimetic, producing schizophrenia-like symptoms even in previously healthy patients, indicating a possible pharmacological origin of mental illness in a yet unknown percentage of patients currently and previously treated with antipsychotics. This question is unresolved, and remains a highly controversial issue among professionals in the medical and mental health communities, as well as the public.
Dementia
Older people with dementia-related psychosis are at a higher risk of death if they take risperidone compared to those who do not. Most deaths are related to heart problems or infections.
Pharmacology
Pharmacodynamics
Risperidone has been classified as a “qualitatively atypical” antipsychotic agent with a relatively low incidence of extrapyramidal side effects (when given at low doses) that has more pronounced serotonin antagonism than dopamine antagonism. Risperidone contains the functional groups of benzisoxazole and piperidine as part of its molecular structure. Although not a butyrophenone, it was developed with the structures of benperidol and ketanserin as a basis. It has actions at several 5-HT (serotonin) receptor subtypes. These are 5-HT2C, linked to weight gain, 5-HT2A, linked to its antipsychotic action and relief of some of the extrapyramidal side effects experienced with the typical neuroleptics.[46]
It was recently found that D-amino acid oxidase, the enzyme that catalyses the breakdown of D-amino acids (e.g. D-alanine and D-serine – the neurotransmitters) is inhibited by risperidone.
Risperidone acts on the following receptors:
Receptors
Description
Dopamine
This drug is an antagonist of the D1 (D1, and D5) as well as the D2 family (D2, D3 and D4) receptors, with 70-fold selectivity for the D2 family. This drug has “tight binding” properties, which means it has a long half-life and like other antipsychotics, risperidone blocks the mesolimbic pathway, the prefrontal cortex limbic pathway, and the tuberoinfundibular pathway in the central nervous system. Risperidone may induce extrapyramidal side effects, akathisia and tremors, associated with diminished dopaminergic activity in the striatum. It can also cause sexual side effects, galactorrhoea, infertility, gynecomastia and, with chronic use reduced bone mineral density leading to breaks, all of which are associated with increased prolactin secretion.
Serotonin
Its action at these receptors may be responsible for its lower extrapyramidal side effect liability (via the 5-HT2A/2C receptors) and improved negative symptom control compared to typical antipsychotics such as haloperidol for instance. Its antagonistic actions at the 5-HT2C receptor may account, in part, for its weight gain liability.
Alpha α1 Adrenergic
This action accounts for its orthostatic hypotensive effects and perhaps some of the sedating effects of risperidone.
Alpha α2 Adrenergic
Perhaps greater positive, negative, affective and cognitive symptom control.
Histamine H1
Effects on these receptors account for its sedation and reduction in vigilance. This may also lead to drowsiness and weight gain.
Voltage-Gated Sodium Channels
Because it accumulates in synaptic vesicles, Risperidone inhibits voltage-gated sodium channels at clinically used concentrations. Though this medication possesses similar effects to other typical and atypical antipsychotics, it does not possess an affinity for the muscarinic acetylcholine receptors. In many respects, this medication can be useful as an “acetylcholine release-promoter” similar to gastrointestinal drugs such as metoclopramide and cisapride.
Pharmacokinetics
Risperidone undergoes hepatic metabolism and renal excretion. Lower doses are recommended for patients with severe liver and kidney disease. The active metabolite of risperidone, paliperidone, is also used as an antipsychotic.
Society and Culture
Regulatory Status
Risperidone was approved by the FDA in 1993 for the treatment of schizophrenia. In 2003, the FDA approved risperidone for the short-term treatment of the mixed and manic states associated with bipolar disorder. In 2006, the FDA approved risperidone for the treatment of irritability in autistic children and adolescents. The FDA’s decision was based in part on a study of autistic people with severe and enduring problems of violent meltdowns, aggression, and self-injury; risperidone is not recommended for autistic people with mild aggression and explosive behaviour without an enduring pattern. On 22 August 2007, risperidone was approved as the only drug agent available for treatment of schizophrenia in youths, ages 13-17; it was also approved that same day for treatment of bipolar disorder in youths and children, ages 10-17, joining lithium.
Availability
Janssen’s patent on risperidone expired on 29 December 2003, opening the market for cheaper generic versions from other companies, and Janssen’s exclusive marketing rights expired on 29 June 2004 (the result of a paediatric extension). It is available under many brand names worldwide.
Risperidone is available as a tablet, an oral solution, and an ampule, which is a depot injection.
Lawsuits
On 11 April 2012, Johnson & Johnson (J&J) and its subsidiary Janssen Pharmaceuticals Inc. were fined $1.2 billion by Judge Timothy Davis Fox of the Sixth Division of the Sixth Judicial Circuit of the US state of Arkansas. The jury found the companies had downplayed multiple risks associated with risperidone (Risperdal). The verdict was later reversed by the Arkansas State Supreme court.
In August 2012, Johnson & Johnson agreed to pay $181 million to 36 US states in order to settle claims that it had promoted risperidone and paliperidone for off-label uses including for dementia, anger management, and anxiety.
In November 2013, J&J was fined $2.2 billion for illegally marketing risperidone for use in people with dementia.
In 2015, Steven Brill posted a 15-part investigative journalism piece on J&J in The Huffington Post, called “America’s most admired lawbreaker”, which was focused on J&J’s marketing of risperidone.
J&J has faced numerous civil lawsuits on behalf of children who were prescribed risperidone who grew breasts (a condition called gynecomastia); as of July 2016 there were about 1,500 cases in Pennsylvania state court in Philadelphia, and there had been a February 2015 verdict against J&J with $2.5 million awarded to a man from Alabama, a $1.75M verdict against J&J that November, and in 2016 a $70 million verdict against J&J. In October, 2019, a jury awarded a Pennsylvania man $8 billion in a verdict against J&J.
Names
Brand names include Risperdal, Risperdal Consta, Risperdal M-Tab, Risperdal Quicklets, and Risperlet.
Psychogenic disease (or psychogenic illness) is a name given to physical illnesses that are believed to arise from emotional or mental stressors, or from psychological or psychiatric disorders.
Background
It is most commonly applied to illnesses where a physical abnormality or other biomarker has not yet been identified. In the absence of such biological evidence of an underlying disease process, it is often assumed that the illness must have a psychological cause, even if the patient shows no indications of being under stress or of having a psychological or psychiatric disorder. Examples of diseases that are believed by many to be psychogenic include psychogenic seizures, psychogenic polydipsia, psychogenic tremor, and psychogenic pain.
There are problems with the assumption that all medically unexplained illness must have a psychological cause. It always remains possible that genetic, biochemical, electrophysiological, or other abnormalities may be present which we do not have the technology or background to identify.
The term psychogenic disease is often used in a similar way to psychosomatic disease. However, the term psychogenic usually implies that psychological factors played a key causal role in the development of the illness. The term psychosomatic is often used in a broader way to describe illnesses with a known medical cause where psychological factors may nonetheless play a role (e.g. asthma can be exacerbated by anxiety).
In psychology, emotional detachment, also known as emotional blunting, has two meanings:
One is the inability to connect to others on an emotional level; and
The other is as a positive means of coping with anxiety.
This coping strategy, also known as emotion focused-coping, is used by avoiding certain situations that might trigger anxiety. It refers to the evasion of emotional connections. Emotional detachment may be a temporary reaction to a stressful situation, or a chronic condition such as depersonalisation-derealisation disorder. It may also be caused by certain antidepressants. Emotional blunting as reduced affect display is one of the negative symptoms of schizophrenia.
Signs and Symptoms
Emotional detachment may not be as outwardly obvious as other psychiatric symptoms. Patients diagnosed with emotional detachment have reduced ability to express emotion, to empathise with others or to form powerful emotional connections. Patients are also at an increased risk for many anxiety and stress disorders. This can lead to difficulties in creating and maintaining personal relationships. The person may move elsewhere in their mind and appear preoccupied or “not entirely present”, or they may seem fully present but exhibit purely intellectual behaviour when emotional behaviour would be appropriate. They may have a hard time being a loving family member, or they may avoid activities, places, and people associated with past traumas. Their dissociation can lead to lack of attention and, hence, to memory problems and in extreme cases, amnesia. In some cases, they present an extreme difficulty in giving or receiving empathy which can be related to the spectrum of narcissistic personality disorder.
In children (ages 4-12 were studied), traits of aggression and antisocial behaviours were found to be correlated with emotional detachment. Researchers determined that these could be early signs of emotional detachment, suggesting parents and clinicians to evaluate children with these traits for a higher behavioural problem in order to avoid bigger problems (such as emotional detachment) in the future.
Causes
Emotional detachment and/or emotional blunting have multiple causes, as the cause can vary from person to person. Emotional detachment or emotional blunting often arises due to adverse childhood experiences, or to psychological trauma in adulthood.
Emotional blunting is often caused by antidepressants in particular selective serotonin reuptake inhibitors (SSRIs) used in major depressive disorder, and often as an add-on treatment in other psychiatric disorders.
Behavioural Mechanism
Emotional detachment is a behaviour which allows a person to react calmly to highly emotional circumstances. Emotional detachment in this sense is a decision to avoid engaging emotional connections, rather than an inability or difficulty in doing so, typically for personal, social, or other reasons. In this sense it can allow people to maintain boundaries, psychic integrity and avoid undesired impact by or upon others, related to emotional demands. As such it is a deliberate mental attitude which avoids engaging the emotions of others.
This detachment does not necessarily mean avoiding empathy; rather, it allows the person to rationally choose whether or not to be overwhelmed or manipulated by such feelings. Examples where this is used in a positive sense might include emotional boundary management, where a person avoids emotional levels of engagement related to people who are in some way emotionally overly demanding, such as difficult co-workers or relatives, or is adopted to aid the person in helping others.
Emotional detachment can also be “emotional numbing”, “emotional blunting”, i.e., dissociation, depersonalisation or in its chronic form depersonalisation disorder. This type of emotional numbing or blunting is a disconnection from emotion, it is frequently used as a coping survival skill during traumatic childhood events such as abuse or severe neglect. Over time and with much use, this can become second nature when dealing with day to day stressors.
Emotional detachment may allow acts of extreme cruelty and abuse, supported by the decision to not connect empathically with the person concerned. Social ostracism, such as shunning and parental alienation, are other examples where decisions to shut out a person creates a psychological trauma for the shunned party.
Reduced affect display, sometimes referred to as emotional blunting, is a condition of reduced emotional reactivity in an individual.
It manifests as a failure to express feelings (affect display) either verbally or nonverbally, especially when talking about issues that would normally be expected to engage the emotions. Expressive gestures are rare and there is little animation in facial expression or vocal inflection. Reduced affect can be symptomatic of autism, schizophrenia, depression, posttraumatic stress disorder, depersonalisation disorder, schizoid personality disorder or brain damage. It may also be a side effect of certain medications (e.g. antipsychotics and antidepressants).
Reduced affect should be distinguished from apathy and anhedonia, which explicitly refer to a lack of emotion, whereas reduced affect is a lack of emotional expression (affect display) regardless of whether emotion (underlying affect) is actually reduced or not.
Types
Constricted Affect
A restricted or constricted affect is a reduction in an individual’s expressive range and the intensity of emotional responses.
Blunted and Flat Affect
Blunted affect is a lack of affect more severe than restricted or constricted affect, but less severe than flat or flattened affect. “The difference between flat and blunted affect is in degree. A person with flat affect has no or nearly no emotional expression. He or she may not react at all to circumstances that usually evoke strong emotions in others. A person with blunted affect, on the other hand, has a significantly reduced intensity in emotional expression”.
Shallow Affect
Shallow affect has equivalent meaning to blunted affect. Factor 1 of the Psychopathy Checklist identifies shallow affect as a common attribute of psychopathy.
Brain Structures
Individuals with schizophrenia with blunted affect show different regional brain activity in fMRI scans when presented with emotional stimuli compared to individuals with schizophrenia without blunted affect. Individuals with schizophrenia without blunted affect show activation in the following brain areas when shown emotionally negative pictures: midbrain, pons, anterior cingulate cortex, insula, ventrolateral orbitofrontal cortex, anterior temporal pole, amygdala, medial prefrontal cortex, and extrastriate visual cortex. Individuals with schizophrenia with blunted affect show activation in the following brain regions when shown emotionally negative pictures: midbrain, pons, anterior temporal pole, and extrastriate visual cortex.
Limbic Structures
Individuals with schizophrenia with flat affect show decreased activation in the limbic system when viewing emotional stimuli. In individuals with schizophrenia with blunted affect neural processes begin in the occipitotemporal region of the brain and go through the ventral visual pathway and the limbic structures until they reach the inferior frontal areas. Damage to the amygdala of adult rhesus macaques early in life can permanently alter affective processing. Lesioning the amygdala causes blunted affect responses to both positive and negative stimuli. This effect is irreversible in the rhesus macaques; neonatal damage produces the same effect as damage that occurs later in life. The macaques’ brain cannot compensate for early amygdala damage even though significant neuronal growth may occur. There is some evidence that blunted affect symptoms in schizophrenia patients are not a result of just amygdala responsiveness, but a result of the amygdala not being integrated with other areas of the brain associated with emotional processing, particularly in amygdala-prefrontal cortex coupling. Damage in the limbic region prevents the amygdala from correctly interpreting emotional stimuli in individuals with schizophrenia by compromising the link between the amygdala and other brain regions associated with emotion.
Brainstem
Parts of the brainstem are responsible for passive emotional coping strategies that are characterized by disengagement or withdrawal from the external environment (quiescence, immobility, hyporeactivity), similar to what is seen in blunted affect. Individuals with schizophrenia with blunted affect show activation of the brainstem during fMRI scans, particularly the right medulla and the left pons, when shown “sad” film excerpts. The bilateral midbrain is also activated in individuals with schizophrenia diagnosed with blunted affect. Activation of the midbrain is thought to be related to autonomic responses associated with perceptual processing of emotional stimuli. This region usually becomes activated in diverse emotional states. When the connectivity between the midbrain and the medial prefrontal cortex is compromised in individuals with schizophrenia with blunted affect an absence of emotional reaction to external stimuli results.
Prefrontal Cortex
Individuals with schizophrenia, as well as patients being successfully reconditioned with quetiapine for blunted affect, show activation of the prefrontal cortex (PFC). Failure to activate the PFC is possibly involved in impaired emotional processing in individuals with schizophrenia with blunted affect. The mesial PFC is activated in aver individuals in response to external emotional stimuli. This structure possibly receives information from the limbic structures to regulate emotional experiences and behaviour. Individuals being reconditioned with quetiapine, who show reduced symptoms, show activation in other areas of the PFC as well, including the right medial prefrontal gyrus and the left orbitofrontal gyrus.
Anterior Cingulate Cortex
A positive correlation has been found between activation of the anterior cingulate cortex and the reported magnitude of sad feelings evoked by viewing sad film excerpts. The rostral subdivision of this region is possibly involved in detecting emotional signals. This region is different in individuals with schizophrenia with blunted affect.
Diagnoses
Schizophrenia
Patients with schizophrenia have long been recognized as showing “flat or inappropriate affect, with splitting of feelings from events … feelings seem flat instead of being in contact with what is going on”. One study of flat affect in schizophrenia found that “flat affect was more common in men, and was associated with worse current quality of life” as well as having “an adverse effect on course of illness”.
The study also reported a “dissociation between reported experience of emotion and its display” – supporting the suggestion made elsewhere that “blunted affect, including flattened facial expressiveness and lack of vocal inflection … often disguises an individual’s true feelings.” Thus, feelings may merely be unexpressed, rather than totally lacking. On the other hand, “a lack of emotions which is due not to mere repression but to a real loss of contact with the objective world gives the observer a specific impression of ‘queerness’ … the remainders of emotions or the substitutes for emotions usually refer to rage and aggressiveness”. In the most extreme cases, there is a complete “dissociation from affective states”.
Another study found that when speaking, individuals with schizophrenia with flat affect demonstrate less inflection than normal controls and appear to be less fluent. Normal subjects appear to express themselves using more complex syntax, whereas flat affect subjects speak with fewer words, and fewer words per sentence. Flat affect individuals’ use of context-appropriate words in both sad and happy narratives are similar to that of controls. It is very likely that flat affect is a result of deficits in motor expression as opposed to emotional processing. The moods of display are compromised, but subjective, autonomic, and contextual aspects of emotion are left intact.
Post-Traumatic Stress Disorder
Post-traumatic stress disorder (PTSD) was previously known to cause negative feelings, such as depressed mood, re-experiencing and hyperarousal. However, recently, psychologists have started to focus their attention on the blunted affects and also the decrease in feeling and expressing positive emotions in PTSD patients. Blunted affect, or emotional numbness, is considered one of the consequences of PTSD because it causes a diminished interest in activities that produce pleasure (anhedonia) and produces feelings of detachment from others, restricted emotional expression and a reduced tendency to express emotions behaviourally. Blunted affect is often seen in veterans as a consequence of the psychological stressful experiences that caused PTSD. Blunted affect is a response to PTSD, it is considered one of the central symptoms in post-traumatic stress disorders and it is often seen in veterans who served in combat zones. In PTSD, blunted affect can be considered a psychological response to PTSD as a way to combat overwhelming anxiety that the patients feel. In blunted affect, there are abnormalities in circuits that also include the prefrontal cortex.
Assessment
In making assessments of mood and affect the clinician is cautioned that “it is important to keep in mind that demonstrative expression can be influenced by cultural differences, medication, or situational factors”; while the layperson is warned to beware of applying the criterion lightly to “friends, otherwise [he or she] is likely to make false judgments, in view of the prevalence of schizoid and cyclothymic personalities in our ‘normal’ population, and our [US] tendency to psychological hypochondriasis”.
R.D. Laing in particular stressed that “such ‘clinical’ categories as schizoid, autistic, ‘impoverished’ affect … all presuppose that there are reliable, valid impersonal criteria for making attributions about the other person’s relation to [his or her] actions. There are no such reliable or valid criteria”.
Differential Diagnosis
Blunted affect is very similar to anhedonia, which is the decrease or cessation of all feelings of pleasure (which thus affects enjoyment, happiness, fun, interest, and satisfaction). In the case of anhedonia, emotions relating to pleasure will not be expressed as much or at all because they are literally not experienced or are decreased. Both blunted affect and anhedonia are considered negative symptoms of schizophrenia, meaning that they are indicative of a lack of something. There are some other negative symptoms of schizophrenia which include avolition, alogia and catatonic behaviour.
Closely related is alexithymia – a condition describing people who “lack words for their feelings. They seem to lack feelings altogether, although this may actually be because of their inability to express emotion rather than from an absence of emotion altogether”. Alexithymic patients however can provide clues via assessment presentation which may be indicative of emotional arousal.
“If the amygdala is severed from the rest of the brain, the result is a striking inability to gauge the emotional significance of events; this condition is sometimes called ‘affective blindness'”. In some cases, blunted affect can fade, but there is no conclusive evidence of why this can occur.
1896 – Lev Vygotsky, Belarusian-Russian psychologist and philosopher (d. 1934).
People (Deaths)
2014 – Patrick Suppes, American psychologist and philosopher (b. 1922).
Lev Vygotsky
Lev Semyonovich Vygotsky (17 November 1896 to 11 June 1934) was a Soviet psychologist, known for his work on psychological development in children. He published on a diverse range of subjects, and from multiple views as his perspective changed over the years. Among his students was Alexander Luria and Kharkiv school of psychology.
He is known for his concept of the zone of proximal development (ZPD): the distance between what a student (apprentice, new employee, etc.) can do on their own, and what they can accomplish with the support of someone more knowledgeable about the activity. Vygotsky saw the ZPD as a measure of skills that are in the process of maturing, as supplement to measures of development that only look at a learner’s independent ability.
Also influential are his works on the relationship between language and thought, the development of language, and a general theory of development through actions and relationships in a socio-cultural environment.
Vygotsky is the subject of great scholarly dispute. There is a group of scholars who see parts of Vygotsky’s current legacy as distortions and who are going back to Vygotsky’s manuscripts in an attempt to make Vygotsky’s legacy more true to his actual ideas.
Patrick Suppes
Patrick Colonel Suppes (17 March 1922 to 17 November 2014) was an American philosopher who made significant contributions to philosophy of science, the theory of measurement, the foundations of quantum mechanics, decision theory, psychology and educational technology. He was the Lucie Stern Professor of Philosophy Emeritus at Stanford University and until January 2010 was the Director of the Education Programme for Gifted Youth also at Stanford.
Personality disorders (PD) are a class of mental disorders characterised by enduring maladaptive patterns of behaviour, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the individual’s culture.
These patterns develop early, are inflexible, and are associated with significant distress or disability. The definitions may vary somewhat, according to source, and remain a matter of controversy. Official criteria for diagnosing personality disorders are listed in the fifth chapter of the International Classification of Diseases (ICD) and in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM).
Personality, defined psychologically, is the set of enduring behavioural and mental traits that distinguish individual humans. Hence, PDs are defined by experiences and behaviours that deviate from social norms and expectations. Those diagnosed with a PD may experience difficulties in cognition, emotiveness, interpersonal functioning, or impulse control. In general, PDs are diagnosed in 40-60% of psychiatric patients, making them the most frequent of psychiatric diagnoses.
PDs are characterised by an enduring collection of behavioural patterns often associated with considerable personal, social, and occupational disruption. PDs are also inflexible and pervasive across many situations, largely due to the fact that such behaviour may be ego-syntonic (i.e. the patterns are consistent with the ego integrity of the individual) and are therefore perceived to be appropriate by that individual. In addition, people with personality disorders often lack insight into their condition and so refrain from seeking treatment. This behaviour can result in maladaptive coping skills and may lead to personal problems that induce extreme anxiety, distress, or depression and result in impaired psychosocial functioning. These behaviour patterns are typically recognised by adolescence, the beginning of adulthood or sometimes even childhood and often have a pervasive negative impact on the quality of life.
While emerging treatments, such as dialectical behaviour therapy, have demonstrated efficacy in treating PDs, such as borderline personality disorder, PDs are associated with considerable stigma in popular and clinical discourse alike. Despite various methodological schemas designed to categorise PDs, many issues occur with classifying a personality disorder because the theory and diagnosis of such disorders occur within prevailing cultural expectations; thus, their validity is contested by some experts on the basis of inevitable subjectivity. They argue that the theory and diagnosis of PDs are based strictly on social, or even sociopolitical and economic considerations.
Personality disorder is a term with a distinctly modern meaning, owing in part to its clinical usage and the institutional character of modern psychiatry. The currently accepted meaning must be understood in the context of historical changing classification systems such as DSM-IV and its predecessors. Although highly anachronistic, and ignoring radical differences in the character of subjectivity and social relations, some have suggested similarities to other concepts going back to at least the ancient Greeks. For example, the Greek philosopher Theophrastus described 29 ‘character’ types that he saw as deviations from the norm, and similar views have been found in Asian, Arabic and Celtic cultures. A long-standing influence in the Western world was Galen’s concept of personality types, which he linked to the four humours proposed by Hippocrates.
Such views lasted into the eighteenth century, when experiments began to question the supposed biologically based humours and ‘temperaments’. Psychological concepts of character and ‘self’ became widespread. In the nineteenth century, ‘personality’ referred to a person’s conscious awareness of their behaviour, a disorder of which could be linked to altered states such as dissociation. This sense of the term has been compared to the use of the term ‘multiple personality disorder’ in the first versions of the DSM.
Physicians in the early nineteenth century started to diagnose forms of insanity involving disturbed emotions and behaviours but seemingly without significant intellectual impairment or delusions or hallucinations. Philippe Pinel referred to this as ‘ manie sans délire ‘ – mania without delusions – and described a number of cases mainly involving excessive or inexplicable anger or rage. James Cowles Prichard advanced a similar concept he called moral insanity, which would be used to diagnose patients for some decades. ‘Moral’ in this sense referred to affect (emotion or mood) rather than ethics, but it was arguably based in part on religious, social and moral beliefs, with a pessimism about medical intervention so social control should take precedence. These categories were much different and broader than later definitions of personality disorder, while also being developed by some into a more specific meaning of moral degeneracy akin to later ideas about ‘psychopaths’. Separately, Richard von Krafft-Ebing popularised the terms sadism and masochism, as well as homosexuality, as psychiatric issues.
The German psychiatrist Koch sought to make the moral insanity concept more scientific, and in 1891 suggested the phrase ‘psychopathic inferiority’, theorised to be a congenital disorder. This referred to continual and rigid patterns of misconduct or dysfunction in the absence of apparent mental retardation or illness, supposedly without a moral judgement. Described as deeply rooted in his Christian faith, his work established the concept of personality disorder as used today.
20th century
In the early 20th century, another German psychiatrist, Emil Kraepelin, included a chapter on psychopathic inferiority in his influential work on clinical psychiatry for students and physicians. He suggested six types:
Excitable;
Unstable;
Eccentric;
Liar;
Swindler; and
Quarrelsome.
The categories were essentially defined by the most disordered criminal offenders observed, distinguished between criminals by impulse, professional criminals, and morbid vagabonds who wandered through life. Kraepelin also described three paranoid (meaning then delusional) disorders, resembling later concepts of schizophrenia, delusional disorder and paranoid personality disorder. A diagnostic term for the latter concept would be included in the DSM from 1952, and from 1980 the DSM would also include schizoid, schizotypal; interpretations of earlier (1921) theories of Ernst Kretschmer led to a distinction between these and another type later included in the DSM, avoidant personality disorder.
In 1933 Russian psychiatrist Pyotr Borisovich Gannushkin published his book Manifestations of Psychopathies: Statics, Dynamics, Systematic Aspects, which was one of the first attempts to develop a detailed typology of psychopathies. Regarding maladaptation, ubiquity, and stability as the three main symptoms of behavioural pathology, he distinguished nine clusters of psychopaths: cycloids (including constitutionally depressive, constitutionally excitable, cyclothymics, and emotionally labile), asthenics (including psychasthenics), schizoids (including dreamers), paranoiacs (including fanatics), epileptoids, hysterical personalities (including pathological liars), unstable psychopaths, antisocial psychopaths, and constitutionally stupid. Some elements of Gannushkin’s typology were later incorporated into the theory developed by a Russian adolescent psychiatrist, Andrey Yevgenyevich Lichko, who was also interested in psychopathies along with their milder forms, the so-called accentuations of character.
In 1939, psychiatrist David Henderson published a theory of ‘psychopathic states’ that contributed to popularly linking the term to anti-social behaviour. Hervey M. Cleckley’s 1941 text, The Mask of Sanity, based on his personal categorisation of similarities he noted in some prisoners, marked the start of the modern clinical conception of psychopathy and its popularist usage.
Towards the mid 20th century, psychoanalytic theories were coming to the fore based on work from the turn of the century being popularized by Sigmund Freud and others. This included the concept of character disorders, which were seen as enduring problems linked not to specific symptoms but to pervasive internal conflicts or derailments of normal childhood development. These were often understood as weaknesses of character or wilful deviance, and were distinguished from neurosis or psychosis. The term ‘borderline’ stems from a belief some individuals were functioning on the edge of those two categories, and a number of the other personality disorder categories were also heavily influenced by this approach, including dependent, obsessive-compulsive and histrionic, the latter starting off as a conversion symptom of hysteria particularly associated with women, then a hysterical personality, then renamed histrionic personality disorder in later versions of the DSM. A passive aggressive style was defined clinically by Colonel William Menninger during World War II in the context of men’s reactions to military compliance, which would later be referenced as a personality disorder in the DSM. Otto Kernberg was influential with regard to the concepts of borderline and narcissistic personalities later incorporated in 1980 as disorders into the DSM.
Meanwhile, a more general personality psychology had been developing in academia and to some extent clinically. Gordon Allport published theories of personality traits from the 1920s – and Henry Murray advanced a theory called personology, which influenced a later key advocate of personality disorders, Theodore Millon. Tests were developing or being applied for personality evaluation, including projective tests such as the Rorshach, as well as questionnaires such as the Minnesota Multiphasic Personality Inventory. Around mid-century, Hans Eysenck was analysing traits and personality types, and psychiatrist Kurt Schneider was popularising a clinical use in place of the previously more usual terms ‘character’, ‘temperament’ or ‘constitution’.
American psychiatrists officially recognised concepts of enduring personality disturbances in the first Diagnostic and Statistical Manual of Mental Disorders in the 1950s, which relied heavily on psychoanalytic concepts. Somewhat more neutral language was employed in the DSM-II in 1968, though the terms and descriptions had only a slight resemblance to current definitions. The DSM-III published in 1980 made some major changes, notably putting all personality disorders onto a second separate ‘axis’ along with mental retardation, intended to signify more enduring patterns, distinct from what were considered axis one mental disorders. ‘Inadequate’ and ‘asthenic’ personality disorder’ categories were deleted, and others were expanded into more types, or changed from being personality disorders to regular disorders. Sociopathic personality disorder, which had been the term for psychopathy, was renamed Antisocial Personality Disorder. Most categories were given more specific ‘operationalised’ definitions, with standard criteria psychiatrists could agree on to conduct research and diagnose patients. In the DSM-III revision, self-defeating personality disorder and sadistic personality disorder were included as provisional diagnoses requiring further study. They were dropped in the DSM-IV, though a proposed ‘depressive personality disorder’ was added; in addition, the official diagnosis of passive-aggressive personality disorder was dropped, tentatively renamed ‘negativistic personality disorder.’
International differences have been noted in how attitudes have developed towards the diagnosis of personality disorder. Kurt Schneider argued they were ‘abnormal varieties of psychic life’ and therefore not necessarily the domain of psychiatry, a view said to still have influence in Germany today. British psychiatrists have also been reluctant to address such disorders or consider them on par with other mental disorders, which has been attributed partly to resource pressures within the National Health Service, as well as to negative medical attitudes towards behaviours associated with personality disorders. In the US, the prevailing healthcare system and psychanalytic tradition has been said to provide a rationale for private therapists to diagnose some personality disorders more broadly and provide ongoing treatment for them.
Epidemiology
The prevalence of personality disorder in the general community was largely unknown until surveys starting from the 1990s. In 2008 the median rate of diagnosable PD was estimated at 10.6%, based on six major studies across three nations. This rate of around one in ten, especially as associated with high use of services, is described as a major public health concern requiring attention by researchers and clinicians.
The prevalence of individual personality disorders ranges from about 2% to 3% for the more common varieties, such as schizotypal, antisocial, borderline, and histrionic, to 0.5-1% for the least common, such as narcissistic and avoidant.
A screening survey across 13 countries by the WHO using DSM-IV criteria, reported in 2009 a prevalence estimate of around 6% for personality disorders. The rate sometimes varied with demographic and socioeconomic factors, and functional impairment was partly explained by co-occurring mental disorders. In the US, screening data from the National Comorbidity Survey Replication between 2001 and 2003, combined with interviews of a subset of respondents, indicated a population prevalence of around 9% for personality disorders in total. Functional disability associated with the diagnoses appeared to be largely due to co-occurring mental disorders (Axis I in the DSM).
A UK national epidemiological study (based on DSM-IV screening criteria), reclassified into levels of severity rather than just diagnosis, reported in 2010 that the majority of people show some personality difficulties in one way or another (short of threshold for diagnosis), while the prevalence of the most complex and severe cases (including meeting criteria for multiple diagnoses in different clusters) was estimated at 1.3%. Even low levels of personality symptoms were associated with functional problems, but the most severely in need of services was a much smaller group.
Personality disorders (especially Cluster A) are also very common among homeless people.
There are some sex differences in the frequency of personality disorders which are shown below (type of PD/predominant gender):
Paranoid personality disorder: Male.
Schizoid personality disorder: Male.
Schizotypal personality disorder: Male.
Antisocial personality disorder: Male.
Borderline personality disorder: Female.
Histrionic personality disorder: Female.
Narcissistic personality disorder: Male.
Avoidant personality disorder: Male.
Dependent personality disorder: Female.
Depressive personality disorder: Female.
Passive–aggressive personality disorder: Male.
Obsessive-compulsive personality disorder: Male.
Self-defeating personality disorder: Female.
Sadistic personality disorder: Male.
Classification
The two relevant major systems of classification are:
The ICD system is a collection of numerical codes that have been assigned to all known clinical disease states, which provides uniform terminology for medical records, billing, and research purposes. The DSM defines psychiatric diagnoses based on research and expert consensus, and its content informs the ICD-10 classifications. Both have deliberately merged their diagnoses to some extent, but some differences remain. For example, ICD-10 does not include narcissistic personality disorder as a distinct category, while DSM-5 does not include enduring personality change after catastrophic experience or after psychiatric illness. ICD-10 classifies the DSM-5 schizotypal personality disorder as a form of schizophrenia rather than as a personality disorder. There are accepted diagnostic issues and controversies with regard to distinguishing particular personality disorder categories from each other.
General Criteria
Both diagnostic systems provide a definition and six criteria for a general personality disorder. These criteria should be met by all personality disorder cases before a more specific diagnosis can be made.
The ICD-10 lists these general guideline criteria:
Markedly disharmonious attitudes and behaviour, generally involving several areas of functioning, e.g. affectivity, arousal, impulse control, ways of perceiving and thinking, and style of relating to others;
The abnormal behaviour pattern is enduring, of long standing, and not limited to episodes of mental illness;
The abnormal behaviour pattern is pervasive and clearly maladaptive to a broad range of personal and social situations;
The above manifestations always appear during childhood or adolescence and continue into adulthood;
The disorder leads to considerable personal distress but this may only become apparent late in its course;
The disorder is usually, but not invariably, associated with significant problems in occupational and social performance.
The ICD adds: “For different cultures it may be necessary to develop specific sets of criteria with regard to social norms, rules and obligations.”
In DSM-5, any personality disorder diagnosis must meet the following criteria:
An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:
Cognition (i.e. ways of perceiving and interpreting self, other people, and events).
Affectivity (i.e. the range, intensity, lability, and appropriateness of emotional response).
Interpersonal functioning.
Impulse control.
The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
The enduring pattern is not better explained as a manifestation or consequence of another mental disorder.
The enduring pattern is not attributable to the physiological effects of a substance (e.g. a drug of abuse, a medication) or another medical condition (e.g. head trauma).
In ICD-10
Chapter V in the ICD-10 contains the mental and behavioural disorders and includes categories of personality disorder and enduring personality changes. They are defined as ingrained patterns indicated by inflexible and disabling responses that significantly differ from how the average person in the culture perceives, thinks, and feels, particularly in relating to others.
The specific personality disorders are: paranoid, schizoid, dissocial, emotionally unstable (borderline type and impulsive type), histrionic, anankastic, anxious (avoidant) and dependent.
Besides the ten specific PD, there are the following categories:
Other specific personality disorders (involves PD characterised as eccentric, haltlose, immature, narcissistic, passive-aggressive, or psychoneurotic).
Personality disorder, unspecified (includes “character neurosis” and “pathological personality”).
Mixed and other personality disorders (defined as conditions that are often troublesome but do not demonstrate the specific pattern of symptoms in the named disorders).
Enduring personality changes, not attributable to brain damage and disease (this is for conditions that seem to arise in adults without a diagnosis of personality disorder, following catastrophic or prolonged stress or other psychiatric illness).
In ICD-11
In the proposed revision of ICD-11, all discrete personality disorder diagnoses will be removed and replaced by the single diagnosis “personality disorder”. Instead, there will be specifiers called “prominent personality traits” and the possibility to classify degrees of severity ranging from “mild”, “moderate”, and “severe” based on the dysfunction in interpersonal relationships and everyday life of the patient.
There are six prominent personality traits/patterns categorised by the ICD-11:
Negative affectivity (“tendency to experience a broad range of negative emotions.”).
Detachment (“tendency to maintain interpersonal distance (social detachment) and emotional distance (emotional detachment).”).
Dissociality (“disregard for the rights and feelings of others, encompassing both self-centredness and lack of empathy.” Equivalent to the DSM-5 classification of antisocial personality disorder.).
Disinhibition (“tendency to act rashly based on immediate external or internal stimuli (i.e., sensations, emotions, thoughts), without consideration of potential negative consequences.”).
Anankastia (“narrow focus on one’s rigid standard of perfection and of right and wrong, and on controlling one’s own and others’ behaviour and controlling situations to ensure conformity to these standards.” Equivalent to the DSM-5 classification of obsessive-compulsive personality disorder.),
Borderline pattern (“pattern of personality disturbance is characterised by a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity”. Equivalent to the DSM-5 classification of borderline personality disorder.),
In DSM-5
The most recent fifth edition of the Diagnostic and Statistical Manual of Mental Disorders stresses that a personality disorder is an enduring and inflexible pattern of long duration leading to significant distress or impairment and is not due to use of substances or another medical condition. The DSM-5 lists personality disorders in the same way as other mental disorders, rather than on a separate ‘axis’, as previously.
DSM-5 lists ten specific personality disorders: paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent and obsessive-compulsive personality disorder.
The DSM-5 also contains three diagnoses for personality patterns not matching these ten disorders, but nevertheless exhibit characteristics of a personality disorder:
Personality change due to another medical condition – personality disturbance due to the direct effects of a medical condition.
Other specified personality disorder – general criteria for a personality disorder are met but fails to meet the criteria for a specific disorder, with the reason given.
Unspecified personality disorder – general criteria for a personality disorder are met but the personality disorder is not included in the DSM-5 classification.
Personality Clusters
The specific personality disorders are grouped into the following three clusters based on descriptive similarities:
Cluster A (Odd or Eccentric Disorders)
Cluster A personality disorders are often associated with schizophrenia: in particular, schizotypal personality disorder shares some of its hallmark symptoms with schizophrenia, e.g., acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behaviour. However, people diagnosed with odd-eccentric personality disorders tend to have a greater grasp on reality than those with schizophrenia. Patients suffering from these disorders can be paranoid and have difficulty being understood by others, as they often have odd or eccentric modes of speaking and an unwillingness and inability to form and maintain close relationships. Though their perceptions may be unusual, these anomalies are distinguished from delusions or hallucinations as people suffering from these would be diagnosed with other conditions. Significant evidence suggests a small proportion of people with Cluster A personality disorders, especially schizotypal personality disorder, have the potential to develop schizophrenia and other psychotic disorders. These disorders also have a higher probability of occurring among individuals whose first-degree relatives have either schizophrenia or a Cluster A personality disorder.
Paranoid personality disorder: characterised by a pattern of irrational suspicion and mistrust of others, interpreting motivations as malevolent.
Schizoid personality disorder: lack of interest and detachment from social relationships, apathy, and restricted emotional expression.
Cluster B (Dramatic, Emotional or Erratic Disorders)
Antisocial personality disorder: pervasive pattern of disregard for and violation of the rights of others, lack of empathy, bloated self-image, manipulative and impulsive behaviour.
Borderline personality disorder: pervasive pattern of abrupt emotional outbursts, altered empathy, instability in relationships, self-image, identity, behaviour and affect, often leading to self-harm and impulsivity.
Narcissistic personality disorder: pervasive pattern of superior grandiosity, need for admiration, and a perceived or real lack of empathy. In a more severe expression, narcissistic personality disorder may show evidence of paranoia, aggression, psychopathy, and sadistic personality disorder, which is known as malignant narcissism.
Cluster C (Anxious or Fearful Disorders)
Avoidant personality disorder: pervasive feelings of social inhibition and inadequacy, extreme sensitivity to negative evaluation.
Obsessive-compulsive personality disorder: characterised by rigid conformity to rules, perfectionism, and control to the point of satisfaction and exclusion of leisurely activities and friendships (distinct from obsessive-compulsive disorder).
Other Personality Types
Some types of personality disorder were in previous versions of the diagnostic manuals but have been deleted. Examples include sadistic personality disorder (pervasive pattern of cruel, demeaning, and aggressive behaviour) and self-defeating personality disorder or masochistic personality disorder (characterised by behaviour consequently undermining the person’s pleasure and goals). They were listed in the DSM-III-R appendix as “Proposed diagnostic categories needing further study” without specific criteria. The psychologist Theodore Millon and others consider some relegated diagnoses to be equally valid disorders, and may also propose other personality disorders or subtypes, including mixtures of aspects of different categories of the officially accepted diagnoses.
Millon’s Description
Psychologist Theodore Millon, who has written numerous popular works on personality, proposed the following description of personality disorders:
Type of Personality Disorder
Description
Paranoid
Guarded, defensive, distrustful and suspicious. Hypervigilant to the motives of others to undermine or do harm. Always seeking confirmatory evidence of hidden schemes. Feel righteous, but persecuted. Experience a pattern of pervasive distrust and suspicion of others that lasts a long time. They are generally difficult to work with and are very hard to form relationships with. They are also known to be somewhat short-tempered.
Schizoid
Apathetic, indifferent, remote, solitary, distant, humourless, contempt, odd fantasies. Neither desire nor need human attachments. Withdrawn from relationships and prefer to be alone. Little interest in others, often seen as a loner. Minimal awareness of the feelings of themselves or others. Few drives or ambitions, if any. Is an uncommon condition in which people avoid social activities and consistently shy away from interaction with others. It affects more males than females. To others, they may appear somewhat dull or humourless. Because they don’t tend to show emotion, they may appear as though they don’t care about what’s going on around them.
Schizotypal
Eccentric, self-estranged, bizarre, absent. Exhibit peculiar mannerisms and behaviours. Think they can read thoughts of others. Preoccupied with odd daydreams and beliefs. Blur line between reality and fantasy. Magical thinking and strange beliefs. People with schizotypal personality disorder are often described as odd or eccentric and usually have few, if any, close relationships. They think others think negatively of them.
Antisocial
Impulsive, irresponsible, deviant, unruly. Act without due consideration. Meet social obligations only when self-serving. Disrespect societal customs, rules, and standards. See themselves as free and independent. People with antisocial personality disorder depict a long pattern of disregard for other people’s rights. They often cross the line and violate these rights.
Borderline
Unpredictable, egocentric, emotionally unstable. Frantically fears abandonment and isolation. Experience rapidly fluctuating moods. Shift rapidly between loving and hating. See themselves and others alternatively as all-good and all-bad. Unstable and frequently changing moods. People with borderline personality disorder have a pervasive pattern of instability in interpersonal relationships.
Histrionic
Hysteria, dramatic, seductive, shallow, egocentric, attention-seeking, vain. Overreact to minor events. Exhibitionistic as a means of securing attention and favours. See themselves as attractive and charming. Constantly seeking others’ attention. Disorder is characterised by constant attention-seeking, emotional overreaction, and suggestibility. Their tendency to over-dramatise may impair relationships and lead to depression, but they are often high-functioning.
Narcissistic
Egotistical, arrogant, grandiose, insouciant. Preoccupied with fantasies of success, beauty, or achievement. See themselves as admirable and superior, and therefore entitled to special treatment. Is a mental disorder in which people have an inflated sense of their own importance and a deep need for admiration. Those with narcissistic personality disorder believe that they are superior to others and have little regard for other people’s feelings.
Avoidant
Hesitant, self-conscious, embarrassed, anxious. Tense in social situations due to fear of rejection. Plagued by constant performance anxiety. See themselves as inept, inferior, or unappealing. They experience long-standing feelings of inadequacy and are very sensitive of what others think about them.
Dependent
Helpless, incompetent, submissive, immature. Withdrawn from adult responsibilities. See themselves as weak or fragile. Seek constant reassurance from stronger figures. They have the need to be taken care of by a person. They fear being abandoned or separated from important people in their life.
Obsessive-Compulsive
Restrained, conscientious, respectful, rigid. Maintain a rule-bound lifestyle. Adhere closely to social conventions. See the world in terms of regulations and hierarchies. See themselves as devoted, reliable, efficient, and productive.
Depressive
Sombre, discouraged, pessimistic, brooding, fatalistic. Present themselves as vulnerable and abandoned. Feel valueless, guilty, and impotent. Judge themselves as worthy only of criticism and contempt. Hopeless, suicidal, restless. This disorder can lead to aggressive acts and hallucinations.
Passive-Aggressive (Negativistic)
Resentful, contrary, sceptical, discontented. Resist fulfilling others’ expectations. Deliberately inefficient. Vent anger indirectly by undermining others’ goals. Alternately moody and irritable, then sullen and withdrawn. Withhold emotions. Will not communicate when there is something problematic to discuss.
Sadistic
Explosively hostile, abrasive, cruel, dogmatic. Liable to sudden outbursts of rage. Gain satisfaction through dominating, intimidating and humiliating others. They are opinionated and closed-minded. Enjoy performing brutal acts on others. Find pleasure in abusing others. Would likely engage in a sadomasochist relationship, but will not play the role of a masochist.
Self-Defeating (Masochistic)
Deferential, pleasure-phobic, servile, blameful, self-effacing. Encourage others to take advantage of them. Deliberately defeat own achievements. Seek condemning or mistreatful partners. They are suspicious of people who treat them well. Would likely engage in a sadomasochist relationship.
Additional Factors
In addition to classifying by category and cluster, it is possible to classify personality disorders using additional factors such as severity, impact on social functioning, and attribution.
Severity
This involves both the notion of personality difficulty as a measure of subthreshold scores for personality disorder using standard interviews and the evidence that those with the most severe personality disorders demonstrate a “ripple effect” of personality disturbance across the whole range of mental disorders. In addition to subthreshold (personality difficulty) and single cluster (simple personality disorder), this also derives complex or diffuse personality disorder (two or more clusters of personality disorder present) and can also derive severe personality disorder for those of greatest risk.
Dimensional System of Classifying Personality Disorders
Level of Severity
Description
Definition by Categorical System
0
No personality disorder
Does not meet actual or subthreshold criteria for any personality disorder.
1
Personality difficulty
Meets sub-threshold criteria for one or several personality disorders.
2
Simple personality disorder
Meets actual criteria for one or more personality disorders within the same cluster.
3
Complex (diffuse) personality disorder
Meets actual criteria for one or more personality disorders within more than one cluster.
4
Severe personality disorder
Meets criteria for creation of severe disruption to both individual and to many in society.
There are several advantages to classifying personality disorder by severity:
It not only allows for but also takes advantage of the tendency for personality disorders to be comorbid with each other.
It represents the influence of personality disorder on clinical outcome more satisfactorily than the simple dichotomous system of no personality disorder versus personality disorder.
This system accommodates the new diagnosis of severe personality disorder, particularly “dangerous and severe personality disorder” (DSPD).
Effect on Social Functioning
Social function is affected by many other aspects of mental functioning apart from that of personality. However, whenever there is persistently impaired social functioning in conditions in which it would normally not be expected, the evidence suggests that this is more likely to be created by personality abnormality than by other clinical variables. The Personality Assessment Schedule gives social function priority in creating a hierarchy in which the personality disorder creating the greater social dysfunction is given primacy over others in a subsequent description of personality disorder.
Attribution
Many who have a personality disorder do not recognise any abnormality and defend valiantly their continued occupancy of their personality role. This group have been termed the Type R, or treatment-resisting personality disorders, as opposed to the Type S or treatment-seeking ones, who are keen on altering their personality disorders and sometimes clamour for treatment. The classification of 68 personality disordered patients on the caseload of an assertive community team using a simple scale showed a 3 to 1 ratio between Type R and Type S personality disorders with Cluster C personality disorders being significantly more likely to be Type S, and paranoid and schizoid (Cluster A) personality disorders significantly more likely to be Type R than others.
Presentation
Comorbidity
There is a considerable personality disorder diagnostic co-occurrence. Patients who meet the DSM-IV-TR diagnostic criteria for one personality disorder are likely to meet the diagnostic criteria for another. Diagnostic categories provide clear, vivid descriptions of discrete personality types but the personality structure of actual patients might be more accurately described by a constellation of maladaptive personality traits.
Impact on Functioning
It is generally assumed that all personality disorders are linked to impaired functioning and a reduced quality of life (QoL) because that is a basic diagnostic requirement. But research shows that this may be true only for some types of personality disorder.
In several studies, higher disability and lower QoL were predicted by avoidant, dependent, schizoid, paranoid, schizotypal and antisocial personality disorder. This link is particularly strong for avoidant, schizotypal and borderline PD. However, obsessive-compulsive PD was not related to a compromised QoL or dysfunction. A prospective study reported that all PD were associated with significant impairment 15 years later, except for obsessive compulsive and narcissistic personality disorder.
One study investigated some aspects of “life success” (status, wealth and successful intimate relationships). It showed somewhat poor functioning for schizotypal, antisocial, borderline and dependent PD, schizoid PD had the lowest scores regarding these variables. Paranoid, histrionic and avoidant PD were average. Narcissistic and obsessive-compulsive PD, however, had high functioning and appeared to contribute rather positively to these aspects of life success.
There is also a direct relationship between the number of diagnostic criteria and quality of life. For each additional personality disorder criterion that a person meets there is an even reduction in quality of life.
Issues
In the Workplace
Depending on the diagnosis, severity and individual, and the job itself, personality disorders can be associated with difficulty coping with work or the workplace – potentially leading to problems with others by interfering with interpersonal relationships. Indirect effects also play a role; for example, impaired educational progress or complications outside of work, such as substance abuse and co-morbid mental disorders, can plague sufferers. However, personality disorders can also bring about above-average work abilities by increasing competitive drive or causing the sufferer to exploit his or her co-workers.
In 2005 and again in 2009, psychologists Belinda Board and Katarina Fritzon at the University of Surrey, UK, interviewed and gave personality tests to high-level British executives and compared their profiles with those of criminal psychiatric patients at Broadmoor Hospital in the UK. They found that three out of eleven personality disorders were actually more common in executives than in the disturbed criminals:
Histrionic personality disorder: including superficial charm, insincerity, egocentricity and manipulation
Narcissistic personality disorder: including grandiosity, self-focused lack of empathy for others, exploitativeness and independence.
Obsessive-compulsive personality disorder: including perfectionism, excessive devotion to work, rigidity, stubbornness and dictatorial tendencies.
According to leadership academic Manfred F.R. Kets de Vries, it seems almost inevitable that some personality disorders will be present in a senior management team.
In Children
Early stages and preliminary forms of personality disorders need a multi-dimensional and early treatment approach. Personality development disorder is considered to be a childhood risk factor or early stage of a later personality disorder in adulthood. In addition, in Robert F. Krueger’s review of their research indicates that some children and adolescents do suffer from clinically significant syndromes that resemble adult personality disorders, and that these syndromes have meaningful correlates and are consequential. Much of this research has been framed by the adult personality disorder constructs from Axis II of the Diagnostic and Statistical Manual. Hence, they are less likely to encounter the first risk they described at the outset of their review: clinicians and researchers are not simply avoiding use of the PD construct in youth. However, they may encounter the second risk they described: under-appreciation of the developmental context in which these syndromes occur. That is, although PD constructs show continuity over time, they are probabilistic predictors; not all youths who exhibit PD symptomatology become adult PD cases.
Versus Mental Disorders
The disorders in each of the three clusters may share with each other underlying common vulnerability factors involving cognition, affect and impulse control, and behavioural maintenance or inhibition, respectively. But they may also have a spectrum relationship to certain syndromal mental disorders:
Paranoid, schizoid or schizotypal personality disorders may be observed to be premorbid antecedents of delusional disorders or schizophrenia.
Borderline personality disorder is seen in association with mood and anxiety disorders, with impulse-control disorders, eating disorders, ADHD, or a substance use disorder.
Avoidant personality disorder is seen with social anxiety disorder.
Versus Normal Personality
The issue of the relationship between normal personality and personality disorders is one of the important issues in personality and clinical psychology. The personality disorders classification (DSM-5 and ICD-10) follows a categorical approach that views personality disorders as discrete entities that are distinct from each other and from normal personality. In contrast, the dimensional approach is an alternative approach that personality disorders represent maladaptive extensions of the same traits that describe normal personality.
Thomas Widiger and his collaborators have contributed to this debate significantly. He discussed the constraints of the categorical approach and argued for the dimensional approach to the personality disorders. Specifically, he proposed the Five Factor Model of personality as an alternative to the classification of personality disorders. For example, this view specifies that Borderline Personality Disorder can be understood as a combination of emotional lability (i.e. high neuroticism), impulsivity (i.e. low conscientiousness), and hostility (i.e. low agreeableness). Many studies across cultures have explored the relationship between personality disorders and the Five Factor Model. This research has demonstrated that personality disorders largely correlate in expected ways with measures of the Five Factor Model and has set the stage for including the Five Factor Model within DSM-5.
In clinical practice, individuals are generally diagnosed by an interview with a psychiatrist based on a mental status examination, which may take into account observations by relatives and others. One tool of diagnosing personality disorders is a process involving interviews with scoring systems. The patient is asked to answer questions, and depending on their answers, the trained interviewer tries to code what their responses were. This process is fairly time-consuming.
As of 2002, there were over fifty published studies relating the five factor model (FFM) to personality disorders. Since that time, quite a number of additional studies have expanded on this research base and provided further empirical support for understanding the DSM personality disorders in terms of the FFM domains. In her seminal review of the personality disorder literature published in 2007, Lee Anna Clark asserted that “the five-factor model of personality is widely accepted as representing the higher-order structure of both normal and abnormal personality traits”.
The five factor model has been shown to significantly predict all 10 personality disorder symptoms and outperform the Minnesota Multiphasic Personality Inventory (MMPI) in the prediction of borderline, avoidant, and dependent personality disorder symptoms.
Research results examining the relationships between the FFM and each of the ten DSM personality disorder diagnostic categories are widely available. For example, in a study published in 2003 titled “The five-factor model and personality disorder empirical literature: A meta-analytic review”, the authors analysed data from 15 other studies to determine how personality disorders are different and similar, respectively, with regard to underlying personality traits. In terms of how personality disorders differ, the results showed that each disorder displays a FFM profile that is meaningful and predictable given its unique diagnostic criteria. With regard to their similarities, the findings revealed that the most prominent and consistent personality dimensions underlying a large number of the personality disorders are positive associations with neuroticism and negative associations with agreeableness.
Openness to Experience
At least three aspects of openness to experience are relevant to understanding personality disorders: cognitive distortions, lack of insight (means the ability to recognise one’s own mental illness here) and impulsivity. Problems related to high openness that can cause problems with social or professional functioning are excessive fantasising, peculiar thinking, diffuse identity, unstable goals and nonconformity with the demands of the society.
High openness is characteristic to schizotypal personality disorder (odd and fragmented thinking), narcissistic personality disorder (excessive self-valuation) and paranoid personality disorder (sensitivity to external hostility). Lack of insight (shows low openness) is characteristic to all personality disorders and could help explain the persistence of maladaptive behavioural patterns.
The problems associated with low openness are difficulties adapting to change, low tolerance for different worldviews or lifestyles, emotional flattening, alexithymia and a narrow range of interests. Rigidity is the most obvious aspect of (low) openness among personality disorders and that shows lack of knowledge of one’s emotional experiences. It is most characteristic of obsessive-compulsive personality disorder; the opposite of it known as impulsivity (here: an aspect of openness that shows a tendency to behave unusually or autistically) is characteristic of schizotypal and borderline personality disorders.
Causes
Currently, there are no definitive proven causes for personality disorders. However, there are numerous possible causes and known risk factors supported by scientific research that vary depending on the disorder, the individual, and the circumstance. Overall, findings show that genetic disposition and life experiences, such as trauma and abuse, play a key role in the development of personality disorders.
Child Abuse
Child abuse and neglect consistently show up as risk factors to the development of personality disorders in adulthood. A study looked at retrospective reports of abuse of participants that had demonstrated psychopathology throughout their life and were later found to have past experience with abuse. In a study of 793 mothers and children, researchers asked mothers if they had screamed at their children, and told them that they did not love them or threatened to send them away. Children who had experienced such verbal abuse were three times as likely as other children (who did not experience such verbal abuse) to have borderline, narcissistic, obsessive-compulsive or paranoid personality disorders in adulthood. The sexually abused group demonstrated the most consistently elevated patterns of psychopathology. Officially verified physical abuse showed an extremely strong correlation with the development of antisocial and impulsive behaviour. On the other hand, cases of abuse of the neglectful type that created childhood pathology were found to be subject to partial remission in adulthood.
Socioeconomic Status
Socioeconomic status has also been looked at as a potential cause for personality disorders. There is a strong association with low parental/neighbourhood socioeconomic status and personality disorder symptoms. In a 2015 publication from Bonn, Germany, which compared parental socioeconomic status and a child’s personality, it was seen that children who were from higher socioeconomic backgrounds were more altruistic, less risk seeking, and had overall higher IQs. These traits correlate with a low risk of developing personality disorders later on in life. In a study looking at female children who were detained for disciplinary actions found that psychological problems were most negatively associated with socioeconomic problems. Furthermore, social disorganisation was found to be inversely correlated with personality disorder symptoms.
Parenting
Evidence shows personality disorders may begin with parental personality issues. These cause the child to have their own difficulties in adulthood, such as difficulties reaching higher education, obtaining jobs, and securing dependable relationships. By either genetic or modelling mechanisms, children can pick up these traits. Additionally, poor parenting appears to have symptom elevating effects on personality disorders. More specifically, lack of maternal bonding has also been correlated with personality disorders. In a study comparing 100 healthy individuals to 100 borderline personality disorder patients, analysis showed that BPD patients were significantly more likely not to have been breastfed as a baby (42.4% in BPD vs. 9.2% in healthy controls). These researchers suggested this act may be essential in fostering maternal relationships. Additionally, findings suggest personality disorders show a negative correlation with two attachment variables: maternal availability and dependability. When left unfostered, other attachment and interpersonal problems occur later in life ultimately leading to development of personality disorders.
Genetics
Currently, genetic research for the understanding of the development of personality disorders is severely lacking. However, there are a few possible risk factors currently in discovery. Researchers are currently looking into genetic mechanisms for traits such as aggression, fear and anxiety, which are associated with diagnosed individuals. More research is being conducted into disorder specific mechanisms.
Research shows a malfunctioning inner brain: hippocampus up to 18% smaller, a smaller amygdala, malfunctions in the striatum-nucleus accumbens and the cingulum neural pathways connecting them and taking care of the feedback loops on what to do with all the incoming information from the multiple senses; so what comes out is anti-social – not according to what is the social norm, socially acceptable and appropriate.
Management
Specific Approaches
There are many different forms (modalities) of treatment used for personality disorders:
Individual psychotherapy has been a mainstay of treatment. There are long-term and short-term (brief) forms.
Family therapy, including couples therapy.
Group therapy for personality dysfunction is probably the second most used.
Psychological-education may be used as an addition.
Self-help groups may provide resources for personality disorders.
Psychiatric medications for treating symptoms of personality dysfunction or co-occurring conditions.
Milieu therapy, a kind of group-based residential approach, has a history of use in treating personality disorders, including therapeutic communities.
The practice of mindfulness that includes developing the ability to be non-judgementally aware of unpleasant emotions appears to be a promising clinical tool for managing different types of personality disorders.
There are different specific theories or schools of therapy within many of these modalities. They may, for example, emphasize psychodynamic techniques, or cognitive or behavioural techniques. In clinical practice, many therapists use an ‘eclectic’ approach, taking elements of different schools as and when they seem to fit to an individual client. There is also often a focus on common themes that seem to be beneficial regardless of techniques, including attributes of the therapist (e.g. trustworthiness, competence, caring), processes afforded to the client (e.g. ability to express and confide difficulties and emotions), and the match between the two (e.g. aiming for mutual respect, trust and boundaries).
Response of Patients with Personality Disorders to Biological and Psychosocial Treatments
Cluster
Evidence for Brain Dysfunction
Response to Biological Treatments
Response to Psychosocial Treatments
A
Evidence for relationship to schizophrenia; otherwise none known.
Schizotypal patients may improve on antipsychotic medication; otherwise not indicated.
Poor. Supportive psychotherapy may help.
B
Evidence for relationship to bipolar disorder; otherwise none known.
Antidepressants, antipsychotics, or mood stabilizers may help for borderline personality; otherwise not indicated.
Poor in antisocial personality. Variable in borderline, narcissistic, and histrionic personalities.
C
Evidence for relationship to generalized anxiety disorder; otherwise none known.
No direct response. Medications may help with comorbid anxiety and depression.
Most common treatment for these disorders. Response variable.
Challenges
The management and treatment of personality disorders can be a challenging and controversial area, for by definition the difficulties have been enduring and affect multiple areas of functioning. This often involves interpersonal issues, and there can be difficulties in seeking and obtaining help from organisations in the first place, as well as with establishing and maintaining a specific therapeutic relationship. On the one hand, an individual may not consider themselves to have a mental health problem, while on the other, community mental health services may view individuals with personality disorders as too complex or difficult, and may directly or indirectly exclude individuals with such diagnoses or associated behaviours. The disruptiveness that people with personality disorders can create in an organisation makes these, arguably, the most challenging conditions to manage.
Apart from all these issues, an individual may not consider their personality to be disordered or the cause of problems. This perspective may be caused by the patient’s ignorance or lack of insight into their own condition, an ego-syntonic perception of the problems with their personality that prevents them from experiencing it as being in conflict with their goals and self-image, or by the simple fact that there is no distinct or objective boundary between ‘normal’ and ‘abnormal’ personalities. There is substantial social stigma and discrimination related to the diagnosis.
The term ‘personality disorder’ encompasses a wide range of issues, each with a different level of severity or disability; thus, personality disorders can require fundamentally different approaches and understandings. To illustrate the scope of the matter, consider that while some disorders or individuals are characterised by continual social withdrawal and the shunning of relationships, others may cause fluctuations in forwardness. The extremes are worse still: at one extreme lie self-harm and self-neglect, while at another extreme some individuals may commit violence and crime. There can be other factors such as problematic substance use or dependency or behavioural addictions. A person may meet the criteria for dissociative identity disorder (formerly “multiple personality disorder”) diagnoses and/or other mental disorders, either at particular times or continually, thus making coordinated input from multiple services a potential requirement.
Therapists in this area can become disheartened by lack of initial progress, or by apparent progress that then leads to setbacks. Clients may be perceived as negative, rejecting, demanding, aggressive or manipulative. This has been looked at in terms of both therapist and client; in terms of social skills, coping efforts, defence mechanisms, or deliberate strategies; and in terms of moral judgments or the need to consider underlying motivations for specific behaviours or conflicts. The vulnerabilities of a client, and indeed a therapist, may become lost behind actual or apparent strength and resilience. It is commonly stated that there is always a need to maintain appropriate professional personal boundaries, while allowing for emotional expression and therapeutic relationships. However, there can be difficulty acknowledging the different worlds and views that both the client and therapist may live with. A therapist may assume that the kinds of relationships and ways of interacting that make them feel safe and comfortable have the same effect on clients. As an example of one extreme, people who may have been exposed to hostility, deceptiveness, rejection, aggression or abuse in their lives, may in some cases be made confused, intimidated or suspicious by presentations of warmth, intimacy or positivity. On the other hand, reassurance, openness and clear communication are usually helpful and needed. It can take several months of sessions, and perhaps several stops and starts, to begin to develop a trusting relationship that can meaningfully address a client’s issues.
Phenacetin (acetophenetidin, N-(4-ethoxyphenyl)acetamide) is a pain-relieving and fever-reducing drug, which was widely used following its introduction in 1887.
It was withdrawn from medicinal use as dangerous from the 1970s (e.g. withdrawn in Canada in 1973, and by the US Food and Drug Administration (FDA) in 1983).
Brief History
Phenacetin was introduced in 1887 in Elberfeld, Germany by German company Bayer, and was used principally as an analgesic; it was one of the first synthetic fever reducers to go on the market. It is also known historically to be one of the first non-opioid analgesics without anti-inflammatory properties.
Prior to World War One, Britain imported phenacetin from Germany. During the war, a team including Jocelyn Field Thorpe and Martha Annie Whiteley developed a synthesis in Britain.
Known Mechanism of Action
Phenacetin’s analgesic effects are due to its actions on the sensory tracts of the spinal cord. In addition, phenacetin has a depressant action on the heart, where it acts as a negative inotrope. It is an antipyretic, acting on the brain to decrease the temperature set point. It is also used to treat rheumatoid arthritis (subacute type) and intercostal neuralgia.
In vivo, one of two reactions occur. Usually Phenacitin’s ether is cleaved to leave paracetamol (acetaminophen), which is the clinically relevant analgesic. A minority of the time the acetyl group is removed from the amine, producing carcinogenic P-Phenetidine. This reaction is quite rare, however, as evidenced by the fact that the drug was on the market for almost 100 years before a statistical link was established, when Canada, followed by the United States, withdrew it from the market.
Preparation
The first synthesis was reported in 1878 by Harmon Northrop Morse.
Phenacetin may be synthesized as an example of the Williamson ether synthesis: ethyl iodide, paracetamol, and anhydrous potassium carbonate are heated in 2-butanone to give the crude product, which is recrystallised from water.
Uses
Phenacetin was widely used until the third quarter of the twentieth century, often in the form of an A.P.C., or “aspirin-phenacetin-caffeine” compound analgesic, as a remedy for fever and pain. An early formulation (1919) was Vincent’s APC in Australia.
In the United States, the FDA ordered the withdrawal of drugs containing phenacetin in November 1983, due to its carcinogenic and kidney-damaging properties. It was also banned in India. As a result, some branded, and previously phenacetin-based, preparations continued to be sold, but with the phenacetin replaced by safer alternatives. A popular brand of phenacetin was Roche’s Saridon, which was reformulated in 1983 to contain propyphenazone, paracetamol and caffeine. Coricidin was also reformulated without phenacetin. Paracetamol is a metabolite of phenacetin with similar analgesic and antipyretic effects, but the new formulation has not been found to have phenacetin’s carcinogenicity.
Phenacetin has been used as a cutting agent to adulterate cocaine in the UK and Canada, due to the similar physical properties.
Due to its low cost, phenacetin is used for research into the physical and refractive properties of crystals. It is an ideal compound for this type of research.
In Canada phenacetin is used as a laboratory reagent, and in a few hair dye preparations (as a stabiliser for hydrogen peroxide). While it is considered a prescription drug, no marketed drugs contain phenacetin.
Safety
Phenacetin, and products containing phenacetin, have been shown in an animal model to have the side effect and after-effect of carcinogenesis. In humans, many case reports have implicated products containing phenacetin in urothelial neoplasms, especially urothelial carcinoma of the renal pelvis. Phenacetin is classified by the International Agency for Research on Cancer (IARC) as carcinogenic to humans. In one prospective series, phenacetin was associated with an increased risk of death due to urologic or renal diseases, death due to cancers, and death due to cardiovascular diseases. In addition, people with glucose-6-phosphate dehydrogenase deficiency may experience acute haemolysis, or dissolution of blood cells, while taking this drug. Acute haemolysis is possible in the case of patients who develop an IgM response to phenacetin leading to immune complexes that bind to erythrocytes in blood. The erythrocytes are then lysed when the complexes activate the complement system.
Chronic use of phenacetin is known to lead to analgesic nephropathy characterized by renal papillary necrosis. This is a condition which results in destruction of some or all of the renal papillae in the kidneys. It is believed that the metabolite p-phenetidine is at least partly responsible for these effects.
One notable death that can possibly be attributed to the use of this drug was that of the aviation pioneer Howard Hughes. He had been using phenacetin extensively for the treatment of chronic pain; it was stated during his autopsy that phenacetin use may have been the cause of his kidney failure.
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