5. DISORDERS OF PSYCHOGENIC ORIGIN
Disordered patterns of behavior characterized by relatively fixed and inflexible lifelong reactions to stress. Individuals may show repetitive, maladaptive, and frequently self-defeating patterns of behavior, inadequate handling of impulses, or restricted and inappropriate feelings. The individual has a limited variety of responses to stress, and in the face of failure to cope may show anxiety, denial, or psychotic behavior. In the absence of environmental frustration, he tends to show little anxiety or mental or emotional symptoms, and the behavior patterns are said to be "ego syntonic," i.e., they are felt by the person to be "normal" and "right." Thus, such a person rarely seeks help because of his own anxiety and discomfort; more often he is referred by a family or society with whom he is unable to live in harmony. If the patient seeks help, it usually follows environmental frustrations and he shows typical neurotic symptoms and conflicts.
The maladaptive behavior patterns seen in personality disorders tend to be exaggerations of mechanisms used at times by, most people. Diagnosis of personality disorders is based on behavioral manifestations and patterns and need not reflect a subjective sense of conflict or distress. Frequently, though, one recognizes low self-esteem, paucity or relative superficiality of intimate relationships, difficulty in sustaining interests, low frustration tolerance, difficulty in postponing gratification, and inability to learn from experience.
The causes of these disorders are unknown, but constitutional factors may play a role in some instances (schizoid, cyclothymic, antisocial personalities), In general, it is assumed that patterns of response are a result of early experiences and conditioning, and that early interpersonal relationships are important in establishing modes of defense and their rigidity.
1. Paranoid personality: These people tend to be hypersensitive, with an underlying suspicion of others and their motivations. They are often rigid and inflexible in behavior and react poorly to criticism or suggestions for change. They feel isolated and project onto others harmful motives and blame for misfortune. It is assumed that these traits are the person's ways of dealing with feelings about himself which he regards as unacceptable, demeaning, or dangerous. Often the suspicious attitude leads to aggressive feelings and/or behavior, with resultant further isolation. The individual's sense of self-adequacy and self-esteem seems particularly impaired.
Often the behavior of these people is designed to, prove their adequacy, while their sense of worthiness becomes exaggerated and is accompanied by belittlement of others. In many spheres: they may be highly efficient and conscientious, though, lacking flexibility. Positions of power and recognition may be achieved, but frequently at the expense of the ability to relax and to maintain a sense of humor. Often their suspiciousness and hostility bring about rejection by others, which seems to justify their original feelings, but they are unable to see their own part in this cycle. They may be litigious, especially when they feel a sense of righteous indignation.
2. Cyclothymic personality: Behavior is frequently characterized by alternating and recurrent states of depression or elation. While elated, these persons feel active and outgoing; are ambitious, optimistic, and enthusiastic; and may show high levels of energy. At such times they are gregarious and capable of attracting friends who may find them fascinating though unpredictable or eccentric. Periods of depression are characterized pessimism, low levels of energy, and a sense of hopelessness and worry. Moods of cheerfulness and sadness are part of normal behavior and no doubt there is a continuum with cyclothymic personalities. However, with a cyclothymic disorder, the mood swings are precipitated more by internal than external events, tend to be more intense, and are apt to be cyclic. At times there is not a regular swing from high to low moods but, rather, a more sustained depression or euphoria. It is uncertain whether the cyclothymic personality disorder lies on a continuum with manic-depressive illness or is a different entity.
3. Schizoid personality: These persons are oversensitive, withdrawn, seclusive, and shy, and avoid close or prolonged relationships. They may be characterized as eccentric and their thinking as "autistic" (somewhat idiosyncratic but without loss of reality testing). Daydreaming is common, with difficulty in expressing feelings, and detachment. The range of adaptive responses is limited and withdrawal is the main reaction to stress. Often they develop highly stylized and distinct interests which further separate them from their peers, and, in general, their attention is directed to asocial endeavors.
4. Explosive personality: This pattern is characterized by sudden, tantrum-like outbursts of rage or verbal or physical aggressiveness. Despite guilty and regretful feelings, these individuals are unable to control their outbursts. They are easily excited by environmental frustrations. Recently, questions have been raised as to whether underlying minor organic brain changes predispose to this explosiveness.
5. Obsessive-compulsive personality: Patterns of behavior are characterized by concern for perfection and orderliness, conformity to social norms, and high personal standards of conscience. Persons with this reaction have difficulty dealing with ambiguous situations; need to define, compartmentalize, and conceptualize problems; and also show some rigidity, inhibition, and difficulty in relaxing. There is a drive to control the situation, and to reduce ambiguity. When faced with new, uncertain, and complex situations, they display anxiety. The quality of compulsiveness is in tune with Western cultural standards, and when the disorder is not too marked these people are often capable of high levels of achievement, especially in the sciences and academic fields where order is desirable. On the other hand, they often feel a sense of isolation and difficulty with interpersonal relationships in which one must rely on others and in which one's feelings are less under strict control and events are less predictable.
6. Hysterical (histrionic) personality: This pattern is characterized by dramatic and attention-seeking behavior, excitability, emotional instability and over-reactivity, self-centeredness, and a provocativeness or sexualization of nonsexual relationships often combined with sexual frigidity or fears. Though superficially self-assured, such people have major doubts as to their identity and goals. Their difficulty in expressing genuine feelings further prevents intimate relationships. Such relationships are affected by the individual's seemingly insatiable need for affection. Behind their sexually seductive behavior lies a child-like wish for nonsexual affection and protection.
7. Asthenic personality: This category is characterized by lack of enthusiasm, low energy and capability, difficulty in developing a broad sense of enjoyment and pleasure, and a poor response to even small physical or emotional stresses. These persons never seem to mobilize resources to meet distress and, as a result, feel helplesswishing they could do more but seemingly unable to feel up to doing it.
8. Antisocial personality: This pattern, formerly referred to as "sociopathic," includes those whose behavior is repetitively in conflict with social mores. Delinquent behavior is not the sole pattern, but is accompanied by impulsiveness, irresponsibility, either a low sense of guilt or guilt that appears only after an event, callousness toward others, and a superficiality of emotional involvement. These people seem to have a keen capacity for rationalizing and explaining their behavior as a consequence of another's. They also show little foresight. Onset is usually before age 12 to 15. Typical childhood symptoms are theft, lack of discipline, and truancy together with habit disturbances such as enuresis, sleepwalking, and nail-biting. As adults they have continued problems with school, poor work records, and unstable marital histories, besides showing belligerency, social isolation, sexual deviations, and frequently excessive alcohol or drug use. They also complain of anxiety and somatic complaints. The disorder is preponderant in males; there is some evidence to believe that there is a "maturing out" of the disorder between ages 30 and 40, followed by a decrease in gross antisocial behavior.
9. Passive-aggressive personality: This group is subdivided into passive, passive-aggressive, and aggressive types. The passive type is characterized by helplessness, indecisiveness, and a clinging dependency even when given support from others. Such passivity may serve to gain attention and affection, to avoid responsibility, and/or to control others covertly. Passive-aggressive behavior is characterized by obstinacy, inefficiency, procrastination, and sullenness, often disguised under a superficial compliance. Frequently these people agree to perform a task and then proceed to subtly undermine its completion with complaints and passive obstructionism. The aggressive type is characterized by sullenness, tantrum-like behavior, provocativeness, and argumentativeness, especially with those in authority. Such behavior usually serves to deny or conceal marked dependency needs. The behavior is maladaptive in that, ironically, it drives others away and prevents the individual from receiving even a normal amount of support.
10. Inadequate personality: The term describes individuals whose response to any form of stress seems ineffectual. Their behavior shows poor judgment, ineptness, lack of energy, poor long-range planning, and poor performance. Incentive is lacking, especially to achieve culturally desired levels. These people are marginally involved in social relationships, tend to drift, and take non-demanding jobs. There is no evidence for physical or mental defects. However, there does seem to be some social value-judgment essential to this diagnosis, since those diagnosed as inadequate personalities tend to be in the lower socioeconomic level on the other hand, this may reflect early social, cultural, and experiential deprivation which, together with the repeated experience of failure, leads to passive styles of behavior. Often these people are welfare recipients or reside in institutions.
11. Sexual deviations: This category refers to those who repetitively and somewhat compulsively direct their sexual interests toward objects other than the opposite sex, toward sexual acts not associated with intercourse, or toward intercourse only when associated with stylized behavior (e.g., sexual sadism). The term carries a moral connotation and is somewhat related to cultural norms. However, it is believed that this behavior reflects at least developmental difficulties, if not psychopathology, and that "deviant" sexual behavior is an attempt to achieve some sexual gratification while avoiding fears associated with usual adult sexual practices.
While specific [techniques] of treatment and problems encountered with the various diagnostic groups may differ, several general concepts may be considered. Motivation for therapy often comes from someone other than the person involved, for reasons which the person feels are foreign to him or through events by which he feels he is being 'victimized. Treatment is tedious and prolonged; results are undramatic. Commonly, therapeutic gains are made only in the setting of a relationship with another person which must be flexible and reassuring, usually requiring more activity than passivity. Patients need to be confronted with the way their behavior affects other people and the kind of impact they have on others. Frequently, limits on behavior need to be set and reality issues dealt with. It is often necessary to involve families, as group pressure seems to be effective. Group and family treatment, group living situations, therapeutic social clubs, milieu hospital therapy-all can be valuable in treatment. The patient's self-esteem must be supported while his maladaptive modes of behavior are confronted. It is also important that those undertaking treatment be aware of the treatment difficulties and avoid the disappointment, annoyance, and moral judgments that tend to creep in.
Source: Merck Manual,
12th Edition, 1972, pp. 1378 - 1382