Fine Line Separates Personality Quirks From Personality Disorder

Hundreds of psychiatrists attending APA’s 2002 annual meeting in Philadelphia in May packed a large room to hear a lecture by a psychiatrist renowned for his knowledge of human personality.

The psychiatrist was John Oldham, M.D., director of the New York State Psychiatric Institute and chair of the APA work group that developed the Practice Guideline for the Treatment of Borderline Personality Disorder (Psychiatric News, August 3, 2001).

Oldham warmed his audience up with the question: “What is the best journal of personality traits, styles, types, and disorders?” His answer: “The New Yorker magazine. I have a representative cartoon for every single one, and they are wonderful!” His audience broke into laughter.

The New Yorker, he continued, once ran a cartoon that showed a woman looking at her husband and asking, “Why are you the way you are?” This question, Oldham said, is of vital interest to psychiatrists. In essence, is personality inherited or is it acquired? “I think it is both,” he declared. “It is both a bit of the way we are and a bit of something we get.”

In short, personality is composed of both temperament and character, he explained. Temperament is the largely heritable contribution to personality; character is greatly impacted by life events. For instance, novelty seeking, harm avoidance, reward dependence, and persistence are temperament traits, moderately heritable, and probably not particularly influenced by environmental events, whereas self-directedness, cooperativeness, and self-transcendence are character traits that are mostly influenced by environment and only weakly, if at all, heritable.

So what is the difference between personality traits and personality disorders? “There is no bright line that distinguishes one from the other,” Oldham stated. Nonetheless, just as both genes and environment undoubtedly contribute to healthy personalities, the same is indubitably true of unhealthy ones.

Personality disorders may be more widespread than most psychiatrists realize, Oldham continued. A study published last year of some 2,000 individuals in the community suggested that the overall prevalence of personality disorders may be as high as 13 percent. What’s more, 2.4 percent of the subjects studied were found to have paranoid personality disorder, which “was surprising to me,” Oldham admitted. “We think of schizophrenia as being a 1 percent disorder. We don’t usually think of paranoid personality disorder as being twice as prevalent.”

Even more of the subjects were found to have histrionic personality disorder or obsessive-compulsive disorder, and a surprising 5 percent were discovered to have avoidant personality disorder, he said.

True, borderline personality disorder does not seem to be as widespread as the above disorders, which afflicted about 2 percent of the population, Oldham said. Yet it is the personality disorder of paramount interest to psychiatrists because individuals with borderline disorder are often very disabled.

Borderline personality disorder, he explained, lies between the neuroses and the psychoses—“You will have periodic transient fuzziness or loss of reality, but you maintain reality testing overall,” he said. Yet there are many different types of borderline disorder.

For instance,the affective type is moderately heritable and precipitated by environmental stress. The impulse dyscontrol type is also moderately heritable and triggered by stress. The aggressive type is due to a moderately heritable aggressive temperament and a reaction to early trauma. “Trauma is not inevitable in patients with borderline personality, but is common,” Oldham said.

Then there are a fourth type—the dependent type—and a fifth type in which a person has chronic feelings of emptiness and identity disturbance. “You can readily see that this last type would be a very different type of borderline patient from the impulsive, self-mutilative kind of patient,” said Oldham. “Yet they are both quite diagnosable using our DSM prototypic method.”

Psychiatric investigators are starting to get some brain-imaging and neurological information about persons with borderline personality disorder, Oldham reported. There seems to be a generalized reduction in frontal cortex metabolism, an abnormally small hippocampus, and a somewhat smaller-than-normal amygdala. There may also be a reduced integration of parietal lobe function with the rest of the brain. And persons with borderline disorders have an increased pain threshold, so that they do not seem to experience pain the same way that persons without the disorder do.

Psychiatric researchers are also learning some other interesting things about individuals with borderline personalities, Oldham pointed out. For instance, patients with borderline disorders use considerably more psychiatric residential treatment than do patients with schizotypal, avoidance, and obsessive-compulsive personalities or with major depressive disorder. The same goes for the use of medications. Also, about 8 percent of borderline patients eventually commit suicide, which is about 400 times higher than the general population. A surprising number, however, seem to do well over the long run (Psychiatric News, June 7).

“The core recommended treatment,” he said, “is psychotherapy with adjunctive symptom-targeted pharmacotherapy. We don’t recommend in the practice guideline one particular kind of psychotherapy but rather suggest that psychotherapy is the treatment of choice.”

In doing psychotherapy with borderline patients, Oldham asserted, the therapist must take an active role, whether it is a cognitive-behavioral or a psychodynamic approach. “You can’t just sit there quietly and say ‘Ummm’ whenever the patient says anything. . . .You need to say to someone, ‘Look, if I had had your early life, and if I had been traumatized, as you clearly were, I understand how hard it would be to trust me, to trust anyone in the world. I think I would have the same kinds of feelings that you have. But the world isn’t the same one you experienced when you were little. And people aren’t going to expect you to treat them with the level of mistrust that you carry around with you. And you are going to have to learn to remember that and act differently, whether you feel like it or not.’ ”

Oldham concluded, “We can’t treat these patients quickly, whatever the managed care organizations would like to say. [Yet] if we keep them in treatment for a reasonably substantial period of time, we think that there is a persuasive case that they will do better, and many of them will respond very well.” ▪