Chapter II Personality And Its Disorders

Chapter II Personality And Its Disorders

Few things are as debated in the field of modern psychology as the concept of personality. Indeed the existence of personality is itself the subject to debate. Scientists have debated the role of genetics, health, social class, gender and many other dimensions in human behavior. Perhaps what we think of as personality is nothing more than how we behave in a given circumstance. Since circumstances vary, such thinking goes, there is no consistent personality.

Nevertheless, there is enough consensus however to offer the following description of personality:

Personality is a group of consistent ways that an individual interacts with himself and with others. It is a collection of expectations and habits of action that each of us develops in order to deal meet individual needs.

From this perspective, a personality disorder may be thought of as ineffective personal expectations and behavioral habits. In other words it is a group of habits that fail to help us get what we want in life. This chapter will briefly describe the evolution of personality and explain what is meant by personality disorder.

The Evolution Of Personality

Central to any model of personality is that all human behavior is purpose driven. The forward urge of life is constant from the moment of conception through death. From the perspective of biology, such purpose driven behavior is directed towards the imperative of survival at all costs. Even self destructive behaviors such as suicide or drug use at a deep level is intended to protect the individual from seemingly greater threats such as pain or abandonment.

The evolution of human personality is sequential in nature. Completion of one developmental stage leads to the next stage. This process begins with birth and continues into young adulthood when our personality reaches a plateau.

Of most relevance to borderline personality disorder are two fundamental factors in personality development: temperament and parenting. These two factors alone account for most of the personality related habits that either make us or break us.

The Influence Of Temperament

Fundamental to our survival in the world is the ability to make sense of what is happening in the world around us. Raw data is taken in through the sensory organs, the eyes, tongue, ears, skin, and nose. Impulses are sent along nerves to the brain where they are identified and processed. The brain then responds as it sees fit based on the circumstances.

Linking the mind and the sensory organs is the central nervous system. Much more than passive conduits of electrochemical information, the structures of the central nervous system add their own twist to the information flowing back and forth between the outside world and the mind. Like the strings of a piano that the shape the impulses of the pianist and the listener, the CNS either amplifies or curtail the impulses. This influence is often referred to temperament.

Temperament refers to how our nervous system interacts with the environment. Neuroscientists think of temperament as a ‘hard-wired’ facet of who we are. For the most part, the temperament that we are born with, is the temperament that we will live with for the remainder of our days. Without much consciousness or thought, many of us possess nervous systems that smoothly flow with the give and take of the environment around us. The process that begins with nervous system activation by outside stimuli and then ending with relaxation runs smoothly and efficiently.

Some of us however have a more difficult time. Even as newborns, the interface between temperament and environment is uneven. Infants with such temperaments may be easily “upended” by even slight changes in their environment. Their nervous systems may become so excited that the process of attaining equilibrium is much more protracted than a less excitable infant.

Built upon temperament are the first skills and expectations of the growing infant. Skills such as the ability to grasp for a desired object or to persevere in the face of frustration are first manifest in the first year of life. With time and experience, new skills and expectations are laid upon the previous layer. This process continues throughout childhood, adolescence, and early adulthood.

For the child with an easy going temperament, skills acquisition is fairly easy. There are ups and downs and difficult moments but overall, the child becomes adept at getting his many physical and social needs met. The world for this child is an inviting place filled with ever widening vistas. He or she develops a repertoire of skills and expectations that allow full participation in this world. The child’s easy going temperament allows him or her to concentrate on the tasks of growth without becoming distracted by the comings and goings of the world.

Such is not the case for the child with a difficult temperament. Even as infants, life was difficult. As they grow they continue to feel disjointed in the world. The skills and expectations that they develop are more often intended to be protective of the fragile peace that they can carve out for themselves. While their more easy going friends are comfortably exploring and mastering their world, these kids are retreating into a cocoon of safety and predictability. This cocoon often becomes a significant part of their personality. Children with such high maintenance temperaments spend a great deal of effort in warding off distress that they have little energy left to explore and conquer the world.

Parenting And Personality Development

While temperament provides the first foundation of personality development, the most influential factors lie outside the child. Chief among them is the relationship between the parent and child. It is even no exaggeration to say that parenting style has the capacity to shape the child’s future.

When a child emerges into the world, it knows nothing. Philosophers (including the Rabbis in Pirkay Avos) have long described the mind of the new-born child as resembling a ‘blank slate’. While the neonate certainly experiences sensations of distress and pleasure, it lacks the understanding to make any sense of them. It is only the input of those in the outside world that can help make sense of such confusion.

At first, it is the parents’ responses to the child that provide direction. Holding, diaper changing, feeding, singing, and so forth offer some coherence. The parent and baby together learn which inner sensation goes with which response. With the leaps and bounds of brain and language development during the first years of life, the child is able to use verbal and non-verbal language to label his or her own inner sensations.

Their extraordinary role in early development makes the parent into the center of the child’s world. The parent is the most important and powerful determinant of how things are and how they should be. Philosophers and psychologists alike describe the parent as a god-like figure in the mind of the child. Whatever a child learns from observing the parent will remain a dominant part of the child’s awareness for rest of his or her days. Such knowledge includes everything from how to tie one’s shoes to how to deal with social rejection.

Beyond the how-to knowledge imparted by the parent is who-am-I knowledge that shapes the child’s expectations and behavior. The core beliefs about who we are and what we can do originate with how parents interact with us. By the time a child enters school, he or she has already developed some rudimentary curiosity about his or her place in their expanding world.

While the child’s curiosity is motivates learning about the world, it naturally leads to confusion about themselves. Examples of confusion include whether the child is lovable, smart, talented, forgivable, and capable. This confusion is quite distressing. The child automatically looks to his or her parents, as they are the ones who have always made the world understandable.

The answers that the parent offers will become the unquestioned truth for the child. The desperation with which the child seeks answers means that whatever the parent answers will be accepted deeply into the child’s psyche. If the parents communicates through his or her words and actions that the child is lovable, likable, smart, capable, and so on then the child will believe that that to be the case even in the face of difficulties. And if, rachaman litzlan, the parent communicates with his or her actions that the child doesn’t measure up, then the child will accept that to be the case even when he or she succeeds in school or in career. The consequence of this will be a child who lacks the confidence necessary to take the risks of personal growth. Such lack of confidence leaves the child deeply confused and unable to adapt to the changing terrain of his or her social and physical development.

Psychologists refer to the feedback loop between parent and child as validation. Through the psychological process of validation the child is able to form a personal identity. Personality development is highly influenced by the quality of the parent’s validation of the child. This influence is reflected in the beautiful words of the poet and educator, Dorothy Law Holte:

If a child lives with criticism,
 he learns to condemn.

If a child lives with hostility,
 he learns to fight.

If a child lives with ridicule,
 he learns to be shy.

If a child lives with shame,
 he learns to feel guilty.

If a child lives with tolerance, 
he learns to be patient.

If a child lives with encouragement, 
he learns confidence.

If a child lives with praise,
 he learns to appreciate.

If a child lives with fairness, 
he learns justice.

If a child lives with security,
 he learns to have faith.

If a child lives with approval, 
he learns to like himself.

If a child lives with acceptance and friendship,
 he learns to find love in the world.

Without continuous and consistent validation of the child’s feelings, fears, struggles, weaknesses, capacities, and dreams the child will grow into adulthood full of self doubt. No amount of intellect, easy-going temperament, health or any other “lucky break” can make up for the consequences of such self doubt.

From Personality To Personality Disorder
Until now the discussion has focused on normal, healthy personality development. While it may seem that possessing a difficult temperament and having been parented in a poorly validating environment would be a recipe for disaster, the fact is that most with such backgrounds live very satisfying lives. This is because there are many forces in our social environment positive circumstances that make up for any deficits. Such forces may include a helpful teacher or a good friend who comes into our lives at the right time. Whatever it is, most of us are given the chance to develop into people who can thrive in our adulthood even when our childhoods have been difficult.

People who develop borderline personality disorder and other personality disorders don’t get these lucky breaks. Sometimes their temperament and degree of parental invalidation are so extreme that their development is interrupted. The developing child remains stuck in earlier levels of growth, afraid and unable to develop new skills so that he or she can keep up with others and with the world. Consider these examples:

Devora, Aged 24
Devora returned home from a job interview in a foul mood. Her mother, distressed by Devora’s anger tried to comfort her. This set Devora off even more. She screamed at her mother and demanded that she leave her alone. Later on, when it seemed that Devora had calmed down, her mother inquired about the interview, Devora related that it had gone poorly. When Devora’s mother confronted her daughter about the earlier outburst, Devora stated that the mother was “bugging me”.

Discussion
Disappointment is difficult for everybody, including young children. It is not uncommon for an eight or nine year old to storm into the house of apartment after a difficult day and yell at his or her family members. Aggression in this age group is to be expected as it allows a child, who lacks the problem solving and self soothing skills of an adult, to regain a sense of mastery. In a young adult however aggression is no longer an acceptable way to deal with frustration. By the time one reaches adulthood, it is expected that one can manage the feelings that come with frustration without lashing out at others.

Alex, aged 24
Alex was due for his six month performance review at the accounting firm where he worked. He was quite nervous since he felt that his supervisor didn’t like him. That the supervisor was cold and standoffish to everyone in the department was lost on Alex. He just assumed that the supervisor was planning on firing him from his probationary employment. Alex was therefore quite surprised when the supervisor told him that he was eligible for permanent employment.

Discussion
Young children relate to the world through their own inner experience. In the vast majority of children, the ability to recognize that others may think and feel different than he or she does, only comes with further cognitive development. They automatically assume that what they feel or think is true for others. This tendency is referred to as projection. If he or she is scared then the other child is scared. If he or she is angry then the other child is angry.

While projection in a child is perfectly normal, in a young adult however projection is highly limiting. Projection leads people to interact with others in ways that are inaccurate. A husband who projects his own happiness onto his wife, won’t notice that she is sad and in need of his reassurance. By the time one reaches adulthood, it is expected that one can separate out his or her own thoughts from those of others.

In essence, a personality disorder can be thought of as a repertoire of problem solving kills and expectations that fail to meet the individual’s current needs. While these skills and expectations may have been useful or developmental understandable in earlier stages, they no longer are. The failure to “upgrade” the skill set is the consequence of avoidance to learning new skills and the deep confusion caused by parental validation.

The discrepancies between the skills acquisition of psychological development and physical maturation are manifest in many ways. In fact, almost all of us to some minor degree fail to be fully “grown up” at different times in our lives. It is only when such immaturity or lack of skills is manifest often and significantly gets in the way of an enjoyable life that it is considered a personality disorder.

The DSM-IV lists nine different personality disorders. They are:
Paranoid Personality Disorder
Schizoid Personality Disorder
Schizoptypal Personality Disorder
Antisocial Personality Disorder
Borderline Personality Disorder
Histrionic Personality Disorder
Narcissistic Personality Disorder
Avoidant Personality Disorder
Dependent Personality Disorder
Obsessive Compulsive Personality Disorder

Each of these personality disorders is organized around a central theme. For example, someone with dependent personality disorder exhibits excessive dependency on others; he or she cannot seem to act independently. Someone with obsessive compulsive personality disorder (NOT obsessive compulsive disorder or OCD) is excessively obsessed with order as well as collecting things even when doing so undermines other dimensions of his or her own life such as social relationships or career. Someone with antisocial personality disorder has little regard for the feelings and rights of others.

It is important to note that borderline personality disorder is different from other personality disorders in four ways. First of all, individuals with borderline personality disorder often suffer from other, highly treatable, psychiatric disorders. Such disorders are clinical depression, any of the bipolar disorders such a bipolar I or bipolar II, and post-traumatic stress disorder (P.T.S.D.).

Furthermore individuals with borderline personality disorder often exhibit characteristics of other personality disorders. This is especially the case with antisocial personality disorder, histrionic personality disorder, dependent personality disorder, and narcissistic personality disorder.

The third difference between those with borderline and those with other personality disorders is that individuals with borderline live in a great amount of inner pain. People with personality disorders are usually quite untroubled by their habits and idiosyncracies. It is other who are frustrated by them. People with borderline however usually live in an unremitting state of fear, rejection, chaos, and misery.

Finally, unlike those with other personality disorder, individuals with borderline personality disorder are significantly more likely to improve with treatment.

There are many, many resources that explain each of these personality disorders. For those looking for the authoritative book on the subject, The Diagnosis and Treatment of DSM-IV Personality Disorders, by Len Sperry, M.D., Ph.D. is an excellent place to start.



How One Is Diagnosed With A Personality Disorder

Fewer aspects of professional psychology and psychiatry are fraught with more inconsistency than personality disorders. Have ten clinicians evaluate someone for a personality disorder and there may very well be ten different opinions. Yet as surprising as such confusion may seem, psychological diagnosis is very difficult. After all, objective tests such as a biopsies and x-rays have not been developed for psychological diagnosis.

Instead, clinicians must draw upon highly subjective exams of psychological and social functioning to accurately diagnosis any psychological disorder. Still, diagnosis is part of the process of repair and healing. Accurate diagnosis can point the way towards a much brighter future.

In the best case diagnostic scenarios a large amount of data is first collected about the person seeking assistance. Data collection begins with a complete medical evaluation to determine how the person’s health may be contributing to his or her psychological difficulties. The person is then tested for difficulties with memory, attention, and perception processing since deficits in these areas can understandably undermine psychological and social adjustment.

Exhaustive psychological interviews are conducted with the person. These inventories evaluate how he or she interacts with others, manages stress and fears, and how they self comfort. Self-report questionnaires that assess personality traits such as hostility, depression, impulsivity, and anxiety are administered. Family members and others are interviewed for their experiences with the person and his or her difficulties. This mass of data is then analyzed to determine the factors that cause the difficulties in question.

Such an exhaustive diagnostic process is always helpful. Yet it is often not practical for a number of reasons. For one thing, the expense is often not covered by insurance (although ironically far more expensive diagnostic tests such as MRI’s are commonly covered). Furthermore, patients and their families often do not know to ask for psychological assessment when seeking assistance. When exhaustive diagnostics cannot be performed, a competent professional should be sought for consultation. Such a professional will most likely advanced training and supervised work experience in the treatment of individuals with personality disorders. They must also be willing to invest the time of understanding the patient and his or her social background.

Regrettably, these procedures are only rarely performed. Poorly trained and confused professionals often give many people a seat-of-the-pants diagnosis. Such diagnoses often are inaccurate to the extent that time, money, and hope is squandered on the wrong treatments. That such diagnoses are made in such cavalier ways shows a fundamental lack of respect for the patient, his or her family, and ultimately for the clinician himself.

Returning To Peace: Some Introductory Thoughts

Borderline Personality Disorder.

Incurable.
Untreatable.
Impossible.

These are the typical reactions of many mental health professionals to the condition known as borderline personality disorder. People with borderline are considered the most difficult to treat. Their seemingly unpredictable mood swings, frequent intense outbursts, and fragile sense of self can cause many otherwise competent professionals to throw up their hands.

Of course, the individuals with the disorder are just as baffled as the professionals. So many precious lives are controlled by inscrutable inner forces. Therapy, medication, hospitalization after hospitalization, folk healing. Nothing seems to help.

Some find temporary relief in self destructive behaviors such as drug use, behavioral addictions like sex and shopping. Others find self mutilation able to calm their inner turmoil. Obviously the toll on family life, work, career, social relationships, and spirituality is heavy. It is little wonder that people with borderline personality will try anything to stop their intense suffering.

In the last fifteen years however the situation has improved. With the publication of Cognitive Therapy Of Borderline Personality Disorder, psychologist Marsha Linehan ushered in a significant, new perspective on borderline. Dialectical Behavioral Therapy, a system of treatment for people with borderline that Linehan developed, created hope that people a system of treatment for people with borderline that Linehan developed, created hope that people could live without all the agony.

Furthermore, developments in psychopharmacology (the use of medication to treat psychological conditions), psychotherapy, and educational psychology have given sufferers of borderline and their families reason for real optimism. As a psychotherapist trained in the DBT method and having thousands of hours of experience treating adults with borderline personality disorder, I have witnessed the dramatic turning around of wounded lives. The time for hope has arrived.

Returning To Peace is intended to get the good news about borderline personality disorder out. Returning To Peace brings together the latest scientific understanding of borderline personality disorder with tried and true techniques for finding a way through the chaos. Most importantly, readers will find reason for a new optimism about a disorder that for too long has been shrouded in shame and confusion.

Why A Special Book For Torah Observant Jewry?

When it comes to recovery from borderline, the Torah observant Jew has some unfair advantages.

Allow me to explain:

For many years, religion was viewed with contempt by many of the greats of psychology. Understandably, religion responded with distrust of professional psychology. The result were two "sides" who despite their many common aspirations, would not learn from each other.

Over the years however this feud thawed. This has been especially the case among Torah observant Jewry. More and more frum people and communities have turned to the mental health community. It is no longer difficult to find superbly trained, compassionate b'nay Torah for the gamut of mental health problems. This should be a source of great pride to us all.

Just as the religious have turned to psychology, psychology has taken a fresh look at religion. In the last fifteen years, psychological researchers have flocked to the religious to understand the many psychological benefits of religious faith and practice. The most well known of these scientists are Martin Seligman and the late M. Scott Peck.

Most ironic however is the integration of religious spiritual practices into psychology. Prayer, loving kindness, faith, and spirit are all accepted parts of this new psychology. What was once rejected is now embraced. Go figure!

Thus I was hardly surprised when I began learning about cognitive therapy or reading Dr. Linehan's Cognitive Therapy Of Borderline Personality Disorder. In fact the more I integrated their techniques into my clinical practice the more I realized how close many of the most basic dimensions of Yiddishkeit were being 'copied' in these scientifically validated treatments. Davening and chessed were examples of 'opposite actions'. The mitzva of tochacha and other interpersonal mitzvos paralled the 'DEAR MAN' technique. The many brachos that we say throughout the day makes mindfulness practice come like a snap. In fact, it began to dawn on me that a spirited Torah observant lifestyle offers a kind of unfair advantage. And when it comes to borderline personality disorder one needs every advantage.

About The Title

Over the last fifteen years, I've worked with hundreds of adults with borderline. When I include the children, parents, spouses, teachers, and coworkers of people with borderline, it is safe to say that I have encountered thousands. Through individual psychotherapy, group therapy, and family treatment I've become intimately familiar with borderline. The more I sit with people and listen to them, the more I learn about the disorder and the real people who suffer with it. And while I would never misrepresent myself as a true insider, I've been able to form a most personal view of borderline personality disorder.

So what have I learned about this disorder? What have I learned about the very real people who intensely suffer as a result of borderline? Perhaps the most significant realization is that people with borderline want more than anything to live in peace. The person with borderline often lives conflict with their world. Harmony and comfort are states so rarely experienced!

Hence, the title of the book that you hold in your hands. Returning To Peace flows from my heart directly to your heart with one goal in mind: to help you find a measure of peace.

What FrummyDBT is all about

Hey there people. About a year ago, a mentor of mine encouraged me to write a book about borderline personality disorder (BPD). It seems that in this age of blogging, it made sense to publish my thoughts and writings on this “gigantic” topic as they are come to mind. While it is my plan to ultimately publish my ideas as book, frummydbt will serve as a first draft.

BPD has been a professional and personal interest of mine for many years. As a young therapist in the early nineties, I worked at a facility that was one of the first on the east coast of the United States to have fully integrated dialectical behavioral therapy (DBT) into the services offered there. DBT is a treatment system designed by Marsha Linehan based on her fascinating understanding of borderline. The DBT system worked for many of our patients and I’ve been hooked on it ever since.

As a personal interest, borderline has fascinated me ever since I learned about it in my university days. Borderline has certainly shaped the lives of many people who I know and love. What’s more is that I’ve made peace with the very real possibility that I’ve exhibited some borderline traits over the years. Good therapy, loving relationships, and mazal have for the most part helped me stay in the land of the living even when my self destructive personality traits have wanted to undo me.

On a deeper level in fact, I’ve come to believe in fact that it is my borderline traits that are my most prized possessions. As a trained hypnotherapist and as a committed Jew, I’ve learned that “symptoms” and “problems” are often invitations to creativity and deeper spiritual connection. When I saw how DBT and other disciplines could transform the liabilities of personality disorders, I realized that my unstable moods, my seeming endless identity confusion, suicidal fantasies, and other painful aspects of who I am were in fact potential assets! My life is filled, thank God, with great joy and power now, which I believe is connected to my own BPD.