Tag: Psychology

The final personality disorder in the current diagnostic system is Obsessive-Compulsive Personality Disorder (OCPD). First, I’ll explain why OCPD is not the same as Obsessive-Compulsive Disorder (OCD).

In OCD, someone’s obsessions and compulsions are entirely subjective, and individual to them. While the person knows their obsessions and fears are irrational, they feel forced to listen to those fears. At the core of OCD are ingrained if-then loops: if the person does not listen to those fears, something bad will happen to them or people they care about. If the person carries out their compulsions – either activities or rituals of specific thoughts – then they have briefly stopped those negative things from happening

As a stereotypical example, consider a person with OCD whose particular obsession and compulsion centres on locking doors. The person may need to spend an hour checking that every door in their house is locked before leaving, to prevent the overwhelming consequences of leaving one unlocked. However, they will not think differently of their family members for being able to leave after checking once. They may envy their family for being free from that worry and may feel guilty over how the time spent checking intrudes upon other family members.

In OCPD, the person’s rules and beliefs are not subjective and personal. They see their rules and methods as “objectively” correct, regardless of how complex, rigid or time consuming their approach may appear to others. Someone with OCPD who had specific rules about the correct location of every item in their house would require everyone else to abide by those rules exactly. If a housemate wanted to do things differently, the person with OCPD would see them as incorrect, illogical, or even morally wrong.

Dependent Personality Disorder was introduced in the first version of the DSM in 1952. Originally, it was seen as a subtype of an now-unused condition named “Passive-Aggressive Personality Disorder”, but it was quickly changed to being a separate condition.

The core symptom of DPD is a person’s belief that they are unable to function independently. A person with DPD is compelled to rely excessively on either one person (often a significant other) or multiple people (such as a close group of friends) to help them navigate most or all parts of their life. This reliance is not out of laziness, nor a wish to delegate responsibility. Instead, it is to escape a primal fear of inability. A person with DPD sees the world as a cold, dangerous place, and usually believes that they are deficient and unable to survive on their own. Therefore, they will seek out others who they view as stronger and more capable to help them navigate through life. They are terrified of losing that support or angering their support network, as they believe they cannot function alone.

The DSM-5 describes DPD as a pervasive and excessive need to be taken care of, which leads to submissive and clinging behaviour and fears of separation. To be diagnosed with DPD, someone needs to have at least 5 of these criteria:

• They have difficulty making everyday decisions without excessive advice and reassurance from others
• They need others to assume responsibility for most major areas of his or her life
• They struggle to disagree with others because they fear a loss of support or approval.
• They have difficulty initiating projects or doing things on their own. because they lack self-confidence in their own judgment or abilities (Not because of lacking motivation/energy etc)
• They go to extremes to get nurture and support from others, even to the point of volunteering for uncomfortable or dangerous situations
• They feel uncomfortable or helpless when alone, as they are convinced they cannot care for themselves
• They must urgently seek out new relationships to provide care and support when a relationship ends
• They are unrealistically preoccupied with fears about being left to take care of themself alone

Today we move on to the Cluster C personality disorders, which are known as the “anxious” or “fearful” disorders. The first of these is Avoidant Personality Disorder (AvPD).

In 1911, Swiss psychiatrist Bleuler wrote about people who shied away from most social contact and activities. Bleuler is better-known for coining the words schizophrenia and schizoid, and he interpreted people’s avoidance through that lens; he assumed severe social avoidance was part of an unnoticed type of schizophrenia. However, this opinion was not widely accepted, and within ten years others described severe social avoidance as a separate condition.

AvPD is leagues beyond being shy and introverted. Instead, it is a deep-rooted and severe fear of rejection and criticism which impacts almost every aspect of a person’s life. While someone with AvPD will want to connect with and develop friendships with others, their fear of being criticised and disapproved of can be so painful that they are unable to take part in social activities. Their self-loathing and feelings of inferiority may be so strong that they assume others would not want to interact with them. As a result, they often interpret neutral statements as containing hidden rejections or reminders of their perceived social inability, which reinforces their perception of being socially inadequate.

The DSM-5 describes AvPD as a widespread pattern of being inhibited around people, feeling inadequate, and being very sensitive to any negative judgements. To be diagnosed with AvPD, someone must meet 4 of these criteria:

• They avoid occupational activities that involve significant interpersonal contact because they fear criticism, disapproval, or rejection.
• They are unwilling to get involved with people unless they can be certain of being liked.
• They show restraint within close relationships because of the fear of being shamed or ridiculed
• They are preoccupied with being criticized or rejected in social situations.
• They are inhibited in new social situations because they feel inadequate
• They seem themselves as socially inept, personally unappealing, or inferior to others
• They are unusually reluctant to take personal risks or to engage in new activities in case they embarass themseleves.

Today’s topic, Borderline Personality Disorder, is perhaps the third most argued-about psychiatric disorder (with first and second place going to Dissociative Identity Disorder and ADHD/ADD).

One of the many contentious points is its name. When the DSM was first developed during the 1950s, psychiatrists divided mental health issues into “neurotic” and “psychotic”. People with “neurotic” illnesses were in distress but still aware of reality and that they were ill, while people with “psychotic” illnesses were detached from reality and often unaware that they were ill. Borderline personality disorder received its name because psychiatrists saw the symptoms as being on the border of both categories. However, that method of categorising mental health conditions is no longer used, so “borderline” now doesn’t mean anything. It can also be actively unhelpful, because people can assume it means that someone is on the border of having a mental health condition and not having one. The ICD-10 instead uses the name “Emotionally Unstable Personality Disorder”, which better reflects the condition’s core symptom.

A person with EUPD experiences much more intense and changeable emotions than a typical person, and the overwhelming nature of those emotions underpins the other EUPD symptoms. To be diagnosed with EUPD in the DSM-5, someone must meet 5 of the 9 criteria:

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The term “Narcissism” comes from the Greek myth of Narkissos, a demigod famed for his beauty. Although everybody admired Narkissos, he scorned and rejected everyone who loved him. Eventually Nemesis, the goddess of revenge, led Narkissos to a pool of water where he fell in love with the image he saw. When Narkissos realised the image was himself, and understood that he could never love anyone else in the same way, he died.

Psychologists first used the word narcissism to mean vanity and self-admiration. Now, people often call an arrogant or over-confident person a narcissist. But the disorder covers far more areas than vanity or confidence. The DSM-5 describes Narcissistic PD as a pattern of having an unrealistic sense of greatness or uniqueness, a need for admiration, and a lack of empathy. The person needs to have at least 5 of the following criteria:

• They have a grandiose sense of self-importance. They exaggerate their achievements and talents, and they expect to be recognized as superior without reason.
• They are preoccupied with fantasies of unlimited success, power, brilliance, or beauty, or of ideal love.
• They believe they are “special” and unique, and that they can only be understood by other special, high-status people.
• They require excessive admiration.
• They have a sense of entitlement. They expect especially favourable treatment or automatic obedience to their expectations.
• They take advantage of others to achieve their own goals.
• They lack empathy and are unwilling to recognize or identify others’ feelings and needs.
• They are envious of others, and believe others are envious of them.
• They are arrogant and haughty to others.

The word histrionic comes from the Latin word “histrio”, which means both “actor” and “excessively dramatic or emotional”. People with HPD struggle to be genuinely intimate in relationships, so often maintain relationships through acting out a role. Yet they are skilled at setting up situations which force specific emotions from others, often by using their appearance to attract others. Their reliance on seduction can generate many shallow friendships but spark distrust from longer-term friends or partners.

In the DSM-5 Histrionic Personality Disorder is a long-term pattern of being excessively emotional, dramatic, and attention-seeking, which is true across multiple areas of life. To be diagnosed with HPD, a person must meet 5 or more of these criteria:

• They are uncomfortable whenever they are not the center of attention
• They use inappropriate sexually seductive or provocative behavior to interact with others
• They express rapidly shifting and shallow emotions
• They consistently use their physical appearance to draw attention
• They speak in an excessively impressionistic way which lacks detail
• They are dramatic and theatrical, showing exaggerated expressions of emotion
• They are suggestible – easily influenced by others or circumstances
• They consider relationships to be more intimate than they actually are

The general PD criteria mentioned in the first post must also apply. “A person needs to have a collection of unusual behaviours and traits which affects a large portion of their everyday life. Those behaviours and traits must start before early adulthood. They need to cause negative consequences for the person, who should be upset by or annoyed at those behaviours.”

However, someone with HPD generally won’t see their actions as dysfunctional. “Rapidly shifting emotions” applies to how a person views other people and external situations, not themselves; even if a person with HPD tires of a friend or partner, or suddenly quits a job they enjoyed the previous week, they will keep a good image of themselves. Another criteria is “distorted views of relationships”, which is also found in BPD. Yet while someone with BPD can alternate between pulling people closer and pushing people away to protect them, a person with HPD will solely pull others to them.

Because someone with HPD does not perceive any issues with their actions, they usually seek assistance due to a conflict with someone else such as a relationship breakup. As someone with HPD considers relationships to be stronger than they actually are, a break-up will be a severe shock, especially if they believed they were being a perfect partner. They may feel intensely depressed after relationships end, and may feel victimised by the breakup; noticing this pattern can flag up HPD.

Many sources discuss HPD using the same exemplar character: Scarlett O’Hara from Gone With The Wind. Although Scarlett’s main motivation is the good cause of protecting her homestead and herself from further traumatic experiences, she is unable to realise when she has gone too far in reaching a goal. She is an expert manipulator who makes multiple men fall for her despite being unsure of her feelings for them. She desires to be the centre of attention, without caring how she gets there- she interrupts a conversation on war merely to call it trivial.  While often appearing highly social, intelligent and functional in everyday life, she can also enter a very self-centered, almost infantile mode.

This character demonstrates many of the traits associated with HPD. However, it is important to remember that the character was written decades before the idea of HPD, or the DSM itself, was developed.

Psychological Criticisms of HPD

HPD is one of the conditions where friends and family may experience greater distress than the person themselves. Although the DSM specifies that histrionic traits need to cause functional impairment such as job problems or an inability to maintain relationships in order to be diagnosed as HPD, conditions diagnosed mostly through observable behaviour still raise questions about how to ensure psychiatric diagnoses are fair and useful tools rather than judgemental reactions to individual differences.

This complaint is especially relevant for HPD because people with it do not often experience as many negative consequences as people with some other PDs. Although many people with Antisocial PD receive criminal convictions, and some (though not all) people with Borderline PD experience frequent hospitalizations, these events are rarely part of HPD.

Another criticism of HPD is over gender bias. HPD has very similar criteria to Borderline PD and Narcissistic PD. HPD differs mostly because it does not feature suicidal behaviour (a common Borderline PD trait) or envious and jealous behaviour (a Narcissistic PD trait). As a result, some researchers argue that HPD and NPD could be male and female sides of the same disorder rather than two separate diagnoses.

However, >75% of people diagnosed with NPD are male, while about 75% of people diagnosed with HPD are female. The HPD criteria sound like an exaggerated version of negative female stereotypes; being overly emotional and relying on appearance or physical appeal are often seen as female traits. Similarly,  seductive behaviour is shown almost entirely by female characters in media, which biases people’s idea of what that behaviour looks like.

Finally HPD is under-researched; possibly because people with HPD keep a lower profile in regards to legal and medical services, or because people with HPD are unlikely to volunteer themselves for treatment or research into it. This lack of research means the potential causes, triggers, and treatments for HPD are even less clear than for other PDs.