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Primary Personality Disorders
by Stuart Sorensen – RMN
There are many different types of personality disorder. These can be broadly categorised into two discrete types called primary and secondary personality disorders (Lyttle J. 1992). Secondary personality disorders are essentially neurotic in nature and are generally more distressing for the sufferer than for those around them. Primary personality disorders tend to be most distressing for the people associated with sufferers. These are often termed antisocial or psychopathic personality disorders and it is this group of disorders which is the focus of this handout.
There are three classifications of primary personality disorder:
Let’s begin by examining the formation or aetiology of primary personality disorder.
Mainstream psychological theory divides human behavior into two broad categories called adaptive and maladaptive. These can also be described as functional and dysfunctional. Simply put adaptive behavior works and is not generally disruptive either for the protagonist or those around them. Maladaptive behavior can be extremely disruptive and tends to be distressing.
Both patterns of behavior, adaptive and maladaptive are learned by trial and error. If we grow up in a society which rewards adaptive behavior we learn to behave in adaptive ways. On the other hand if our upbringing is characterized by manipulation, emotional blackmail, violence or a host of other maladaptive behaviors then those are what we learn. Incidentally it is often a mistake to assume that primary personality disorders are automatically the result of ‘bad parenting’.
People can be influenced by a wide range of sub-cultures during their formative years and learn their social skills from a wide variety of sources including friends, social culture and the media. As a rule knowledge of the aetiology of personality disorder is a useful diagnostic and preventative tool but it is usually unhelpful as a basis of blame attribution. Making parents feel guilty after the damage has been done helps nobody and can cause resentments which de-rail the therapeutic process. It is often useful to share this information with parents in order to prevent the formation of personality disorders in their children but not once the personality has become fixed. Also, it must be said, parenting is often completely irrelevant.
Put simply, people’s personalities are shaped by their experiences. If we grow up in a loving environment where we are encouraged to feel safe and to explore our world without fear of condemnation we develop into confident people with high self-esteem. If on the other hand we are not valued as children and not taught the value of others we grow up with poor self-esteem and little concern for those around us.
Whatever our upbringing and personality type it is generally accepted that the personality ‘fixes’ during the third decade of life (the twenties). After this time it is difficult and arguably impossible to alter a personality in any meaningful way. In some cases people with a milder form of primary personality disorder can be helped to behave more adaptively but not to actually change their personality. Research has demonstrated that even this limited degree of success can only be achieved with long term therapeutic intervention lasting one year or more in a dedicated therapeutic community. Attempting to ‘treat’ primary personality disorders in any other type of environment tends to create disruptions, jeopardizes other patients in many cases and serves little or no useful purpose. Medium or high-grade primary personality disorders do not appear to be amenable to change at all after this age.
The ICD-10 is the diagnostic reference book for mental and behavioral disorders and is accepted throughout Europe. It describes primary personality disorder as Dissocial personality disorder (World Health Organization – 1992) and lists the traits of this personality disorder as follows:
"(a) callous unconcern for the feelings of others;
(b) gross and persistent attitude of irresponsibility and disregard for social norms, rules and obligations;
(c) incapacity to maintain enduring relationships, though having no difficulty in establishing them;
(d) very low tolerance to frustration and a low threshold for discharge of aggression, including violence;
(e) incapacity to experience guilt or to profit from experience, particularly punishment;
(f) marked proneness to blame others, or to offer plausible rationalizations, for the behavior that has brought the patient into conflict with society."
In order to make the diagnosis of Dissocial Personality Disorder at least three of these traits must be present and enduring over time. Let’s look at how these personality traits interact to create the pattern of behavior typical of this disorder.
Callous unconcern for the feelings of others can be defined as lack of conscience and comes from the inability to empathize with others. This effectively removes the normal social barriers associated with respect for other people. The dissocial personality disordered person will quite literally ride roughshod over anyone in order to get what they want and will be incapable of feeling any remorse or even understanding right and wrong in the normal way. Hence the characteristic gross and persistent attitude of irresponsibility and disregard for social norms, rules and obligations. It also explains the incapacity to maintain enduring relationships although their typically charming front means that they have no difficulty in establishing them.
These people crave stimulation and are easily bored. This is why they have a very low tolerance to frustration which combined with their inability to empathize explains their low threshold for discharge of aggression, including violence.
Dissocial personality disorders are characterized by marked proneness to blame others, or to offer plausible rationalizations…. To put it another way they do not generally accept responsibility for their misconduct which is another reason why those around them tend to suffer. Their plausibility often results in innocent bystanders being blamed for offences in which they had no part and friendships can be destroyed. Dissocials are particularly dangerous with regard to vulnerable people such as the disabled or mentally ill who are often unable to recognize or withstand their behavior.
Finally their incapacity to experience guilt or to profit from experience, particularly punishment is the reason for their resistance to treatment. This is partly because they experience stimuli less intensely than other people do. Put another way they feel pain less and don’t experience any emotions as intensely either. That’s why they’re so easily bored and in part explains their need to engineer dramatic (and often extremely disruptive) situations. Such situations may be said to ‘punctuate the emptiness’ caused by their high stimuli threshold.
Many people are drawn into what has come to be known as the savior fantasy in relation to these people and will patiently endure a range of unpleasant circumstances in an attempt to put them back on ‘the right track’. An excellent source of information about the sort of strategies used by dissocials in these situations is GAMES PEOPLE PLAY (Berne E. – 1964).
So what can we do?
In any behavioral disorder it is vital to draw firm and consistent boundaries. This is very different from the usual stance people take when dealing with others. As a rule in our society 'no' tends to mean 'no - unless you can persuade me otherwise'. With psychopaths 'no' must be absolute. And it must be consistently maintained throughout the team.
Psychopaths tend to play one person off against another and will use your friends and colleagues to emotionally blackmail you by gaining their support with plausible explanations for their behavior. Typically they will explain how hard they are trying and how difficult it is to cope with their problems - particularly when that callous nurse (you) won't give them any slack. Then comes the trump card: 'How can anyone expect me to get better when the nurse (you) treats me so unfairly?' Students are vulnerable because they are not yet used to this sort of manipulation and regularly get hurt emotionally by strategies such as these.
The same is true of the patient's parents and associates, which is why they often visit the ward to verbally attack the staff. These people often complain officially about staff. Be aware that these people generally are doing precisely what they believe to be right and are only fighting against the perceived injustice the psychopathic patient has persuaded them of. Incidentally this is why nurses on psychiatric wards are so insistent that the approach is consistent and that the rationale is well documented. Psychopaths are dangerous people to the inexperienced.
Perhaps the greatest skill in dealing with dis-social personalities is assertiveness. See the related handout in this series. Assertiveness skills help you keep boundaries and avoid the manipulation and emotional blackmail.
Relatives find it extremely difficult to understand and deal appropriately with psychopathic family members. This is understandable and certainly not a reason to dismiss or otherwise under-value them or their experience. Just as you had no knowledge of psychopathy before you began your training - neither can they be expected to. They are generally reasonable people faced with a bewildering situation and doing the best they can. It is often possible to help them by teaching assertiveness but don't call it that - most parents and relatives prefer to think of it in the popular guise of 'tough love'. The message is the same. Essentially it's important to help them understand their personal rights and also to accept that the psychopath is an adult. However bizarre their relatives' behavior may be, however destructive or offensive it is the psychopath's own responsibility. Relatives have no need to feel responsible. Incidentally they don't need to run around after the psychopath either although that is often extremely hard for relatives to hear and the message often fails to get through at all.
Those who do take this message on board often find that the psychopathic relative will eventually learn to leave them alone but this may result in total separation. This is no different from a bereavement resulting from death of a loved on. For that reason it is inappropriate to try to 'force' the relative into an assertive position. The resulting separation may be too hard for them to cope with. It is enough to help them recognize the issues. Anything further must remain their own choice.
You, however, have a professional responsibility and, excluding personal acquaintances and relatives, have a duty to maintain a professional distance. This is not simply an archaic instruction which has no basis in reality. This is a vital part of your care, not only for the psychopathic patient but also for the other vulnerable patients in your charge. The therapeutic relationship involves many difficult things which have nothing to do with 'ordinary' life outside hospital. Psychiatric nurses simply cannot afford to let psychopathic patients manipulate them.
This short handout will not make you an expert but it will help you keep yourself emotionally secure. It will also help you to protect the vulnerable mentally ill patients in your care. Please feel free to discuss any or all of the issues raised with your mentor on the ward. Enjoy your placement.
Berne E. (1964)
Games People Play
Lyttle J. (1992)
World Health Organization (1992)
The ICD-10 Classification of Mental and Behavioural Disorders
Compliments of Stuart Sorensen – RMN
Copyright © Patty Fleener, M.S.W. All rights reserved.