What's in a personality?

When Problems Are Multilayered 

When we incorporate the notion of multiple facets in a personality, we get multiple personality problems rolled up into one person. Then, further complicating these issues are the endless therapeutic approaches to treatment.

For example, hard-driving, well-organized, demanding, perfectionistic people who tend to function in terms of “my way or the highway” may, indeed, be that—or they may have an obsessive-compulsive personality disorder as assessed by a therapist. Then again, they may be extremely ambitious and dedicated to their particular belief system.

When we add how self-centered and adverse to criticism they are, a dimension of narcissism enters the clinical picture. Or they may be simply comfortable in their own skin and adverse to people second-guessing them. If they are uncomfortable in their style or make other people uncomfortable, and they are anxious or depressed over this and search out help, do they have a disorder or a style?

Should these “disorders” be separated under a group umbrella, or should clinicians have the tools to evaluate personality issues, disorders, or styles on an individual basis and develop a codified treatment plan?

It's an interesting dilemma for us in mental health, especially in the current era of managed care, when diagnosis and treatment need to be codified with specific criteria and again codified with specific treatment approaches. Here we have a set of disorders, which for the most part, have neither a scientific basis nor clear treatment approaches. Yet these disorders are so much a part of a general lifestyle of a person that just creating a set of disorders around styles seems difficult, let alone asking for reimbursement. It's no wonder the insurance companies are resistant to paying for such problems.

As psychiatrists, we know only too well that these personality disorders and styles can lead to social, vocational, and interpersonal problems and may indeed need therapeutic interventions. Many times the interventions restore the person to a better level of functioning and lead to lifestyle changes that have a profoundly positive effect on personality change.

In medicine, we treat overeating (and subsequent obesity) and smoking, which themselves are not illnesses but are serious, life-threatening problems. So it's not that unusual to treat a problem that is not specifically defined as an illness or even a disorder.

In my experience, most patients with personality disorders make the first appointment for psychotherapy because of an anxiety-related problem or depression or other “mental fallout” tied to a serious loss such as job loss, divorce, or collapse of an investment (Arch. Gen. Psychiatry 2007;64:433–40). Once the anxiety or mood changes have been resolved, the individual's personality issues surface and the patterns of behavior that have brought the “house down” appear.

To illustrate how challenging and complicated treatment can be, I'd like to describe a patient with obsessive-compulsive, narcissistic, and dependent personality styles, traits, and disorders rolled up into one—with differing intensities operating in variable modes at various times. This is a more clinically realistic scenario than the one-dimensional DSM labels.

Some years ago, I treated a 32-year-old man who controlled both his work and social worlds to the extreme. He drove his friends up the walls. He couldn't find a lady friend willing to hang in there for more than 2 or 3 months, because he was so busy that he failed to return her calls promptly.

Of course, he firmly believed that he should be cared for and understood by the current “other” and that his friends needed to help him get in more social situations and invited to more parties.

He almost got married once, but the woman didn't understand that his job was more important than hers. She also proved unwilling to recognize how tired he was at the end of a day or week.

Essentially, this is what we see in the world of treatment: “I need to see a shrink to work things out. My girl dumped me, the managing partner thinks I'm very difficult and demanding to first-year people, and the secretarial staff, whom I evaluate, doesn't like my expectations on reading my e-mails at once. The managing partner doesn't get it. I should have his job. I don't know how he got there!”

My cognitive-behavioral approach uses the learning, philosophizing, and action (LPA) technique that I developed years ago to help people overcome psychological problems. This technique is applicable to some of the problems we call personality disorders.

Identifying Why Problems Exist 

First, I need to help the person understand why he is really there. The learning phase offers an understanding that he might have a problem, based on the patient's current presence in my office. I would like him to learn that I'm on his side to help him feel better. I try to teach a therapeutic alliance as well as develop one.

I want the patient to understand that, as we go through the therapeutic process and discuss what goes on in his life, I will be pointing things out that he may not like or agree with. Rather than debate it, as is his tendency, I would like us to think about the issues and challenge some of the thoughts that, in turn, will challenge the behaviors that get him into difficulty.

With this learning process in place, someone who really senses he is in trouble but is resistant with ego syntonic features as his behavior pattern—behavior not distressful to him but potentially disastrous to others—starts to understand his purpose in needing help. It makes the process go a lot faster, and I'm certain that treating a personality disorder doesn't always take years, as so much of the literature suggests.

The literature, of course, is based more on traditional therapeutic understanding than on cognitive-behavioral methods of treatment.

As the learning phase progresses, we can examine how issues in life are dealt with in a maladaptive way using automatic thoughts (which are usually unconscious but accessible and can lead to difficult situations) and belief systems that fit a person's comfort zone. What really goes on is a learning dialogue between the therapist and patient (“Talk Therapy: East Meets West,” The Psychiatrist's Toolbox, April 2006, p. 28).

Integrated into this is the philosophizing phase, where I like to go over the ideas of Dr. Wilhelm Reich, who helped advance our understanding of personality and personality styles.

Therapeutically, we can take that wonderful time shuttle back to the patient's early learning—linking the philosophy and the learning. As the patient feels comfortable in this relearning and philosophizing about how he got to be where he is, we can then move into the action phase of the LPA technique, looking for change. CHANGE is that great, elusive concept in talk psychotherapy. What is it, and how do we measure it? I believe its evaluation is a two-way street. The therapist and patient need to agree that things are better and that life is going well. Outside validation adds a third dimension in assessing change.

Once we can establish that he is demanding, controlling, overly self-involved, and needs nurturing, in many instances we can then develop an action-based therapeutic strategy. Skills can be taught to challenge thoughts, which in turn will challenge behaviors, hopefully leading to better levels of functioning in the patient's work and social worlds.

The patient who is feeling and doing better is using the operational behavioral technique, which helps these changes become a permanent part of the personality—thus moving away from the disorders. This is very hard work as you engage in complicated dialogues of a person's learned behavior and current maladaptive behavior.

Staying Focused on the Goal 

Our aim is to illicit CHANGE. As in, “If you get a chance to check your e-mails today, I would appreciate it,” instead of “I want those e-mails checked every 10 minutes—or else.” Furthermore, if the patient realizes that making a phone call reporting that he'll be late, even though he sees no purpose in doing so, then things will improve socially.

Many patients with personality disorders have great strengths. It is equally important to find clear ways to bring these strengths into the therapeutic setting.

Not all personality disorders are the same, so therapeutic outcomes will vary and may include failure. But it's important to get away from the one-size-fits all, it-takes-forever-to-get-these-people-better mentality, and from the need to spend years analyzing resistance.

We learn certain family and social myths growing up. If the myths are faulty, our belief systems may be equally faulty. Helplessness or overly controlling behavior as a learned myth, for example, can lead to an ego syntonic dependent personality or an obsessive-compulsive personality.

In addition, if a child is applauded rather than redirected after negative behavior—such as pressing every button in an elevator of a 40-story building and getting this reaction from the parents: “He's such an intelligent, inquisitive child,” and if this inappropriate feedback is ongoing—we can begin to see the genesis of the narcissistic personality. What's important to know is that these personality disorders and styles can be challenged and changed in the right therapeutic setting—in much less time than traditional psychotherapies suggest.

In future columns, I will discuss additional treatment options for specific combinations of personality disorders. Let me know what you think about treating personality disorders, and I will try to pass these along to my readers.