Is it a disorder or just a bad patch?

Personality disorders are not always what we think. Sometimes it may just be a stage of development that an individual got “stuck” in. Local clinical psychologist Maika Eysselein, and occupational therapist Liesel Vermaak, explain.

The series Game of Thrones captures so well the complexity of the human character, giving us glimpses into the world of personality disorders. As viewers, our perception of these personalities is ever-changing.

As people's stories unfold and their lives are lived, their personalities change.

For a long time distinct categories of diagnosing “malfunctioning” personality were used. Diagnoses would be made using these “categories”.

However, it becomes difficult to treat or support someone when one day they fit the diagnosis of a particular personality disorder perfectly, and the next day not at all.

Alternative approaches to understanding the complexities of personality are more helpful. If we understand personality as a complex, living organism which consists of many different qualities and parts, we will better understand people's “fluctuating character”.

We are born with a certain temperament - introversion/extroversion, for example. Yet, environmental factors determine the level of functioning we can develop, or they leave us stuck in inadequate patterns of managing ourselves in relation to our environment.



PATTERN OF NEED

For example: A young child whose parent only communicates love when s/he is being exceptional, may develop a pattern of needing to focus on him- or herself to excel at all times.

Or, a young child whose parent is fragile and in whom they can't trust to maintain theirsafety, may develop a pattern of manipulative control.

Another example is a young child whose parent is over-bearing and intrusive, which leaves the child struggling to build his or her own ideas making it difficult for him or her to competently enter the adult world.

Another contributor to the development of personality is the experience of extreme stress and trauma. They necessitate exceptional ability to cope.

Such exceptional ability to cope is only possible when we have matured through exceptional safe-keeping by our caretakers.

Personality has the potential to develop – as the brain does too – right into adulthood. Hence trauma at an early age is often associated with personality dysfunction in adulthood. Instead of moving along the continuum of personality growth, a traumatised individual potentially freezes in one spot on the continuum, unable to move along by themselves.

On the other hand, an individual has the potential to move up the continuum if conditions are favourable and if treatment is optimized for the particular person. Differentiation between clinical disorder and personality is necessary. If we understand personality as undergoing a developmental “freeze”, ideal treatment should enable growth and empowerment.

Pharmacological treatment of personality is mostly symptom-management and we utilise it eagerly because of the intensity of our patient's suffering. However, if pharmacological treatment “only” manages symptoms, aren't we leaving the person “frozen”, right where they are – just at milder temperatures?

It is not an illness to be cured but a developmental challenge to be outgrown.

Relying on medication as only form of treatment has the potential of complicating the patient's situation further. It numbs the discomfort just enough for the client to not have to change in their personality.



MISDIAGNOSIS

Misdiagnosis has significant consequences too. What happens to those who struggle with personality difficulties and get diagnosed with bipolar disorder?

In occupational therapy across all fields of interest we assess and treat people across their lifespan having challenges in their occupational areas and role performance. In occupational therapy in mental health, when an individual appears to show irregular improvements in function with repeated relapses and life crises, and in the absence of significant clinical pathology, a personality disorder may be involved.

Personality traits are the enduring patterns of perceiving and relating to oneself and one's environment in a wide range of social and personal contexts. When one's personality traits become rigid, maladaptive and cause functional impairment or subjective distress, we find a personality disorder.

Personality has been described on a continuum, with traits in clusters, and the level of personality functioning on a continuum.

Occupational therapists would like to assist the individual in becoming more functional in all areas of life and facilitate appropriate ways of coping with and reducing stress.

A good question in dealing with personality disorders is: “What is the motivational level driving this person's action?” And that answer will describe how to engage this person in an effective therapeutic process.

The assessment of the motivational level of the person allows the “just right” challenge to be determined.

The Vona du Toit Model of Creative Ability describes various levels of motivation and action. For each motivational drive there is a correlating action that results in an experience with the internal and external environment of the person. The stages of motivation and action initially follow a developmental sequence, however, are not rigidly demarcated at any moment in time.

There is a fluid fluctuation on a continuum, and treatment is aimed to restore creative ability to the highest level of functioning where the person has the ability to present the self freely, without anxiety, limitations or inhibitions.

Prognosis is poor when looking at personality disorder from a medical perspective and more hopeful when approaching it from a fluid perspective.

The therapeutic environment also exerts pressure on the person to find alternative responses, and elements facilitated by the therapist or clinician may include:

• Validation. Non-judgmental engagement and focus on their strengths.

• Dialectics. This is a philosophical perspective, a way of discovering what is true by considering opposite theories. Dialectics highlights what is missing, is there another solution, find the grey while honouring the “black” and “white”.

• Group work. The way a person interacts with others in the outside world will be the same way the person treats and acts towards others in the group.

• Consultation. Therapists and clinicians benefit from engaging with colleagues and develop skills to manage personality disorders. Watch for transference and counter-transference.



THERAPY

Occupational therapy aims to amongst others improve insight and judgment into emotions, cognitions and behaviours; ability to form meaningful interpersonal relationships and to apply more appropriate ways of coping with stress and anxiety (stop self injury / destructive behaviours).

Dialectic behavioural therapy (DBT) theory addresses four critically important skills that can reduce the symptoms of personality disorder.

Distress tolerance will help the person cope better with painful events by building up resilience and give new ways to soften the effects of upsetting circumstances.

Mindfulness will help the person experience more fully the present moment while focusing less on the painful experiences from the past or frightening possibilities in the future.

Emotional regulation skills help the person to recognize more clearly what the feeling is, and then to observe each emotion without becoming overwhelmed by it.

Interpersonal effectiveness provides new tools to express beliefs and needs, and set limits and negotiate solutions to problems, all while protecting relationships and treating others with respect.

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