Please go away, go somewhere else. Please fly back home where you will be at least 1000 miles away. Please never come back.
These are some of the common sentiments that people may have towards individuals with personality disorders. Sentiments held by family, friends, and often even their treatment providers. Addiction treatment of individuals with personality disorders is usually very difficult. They frequently irritate and wear down the people that are trying their best to work with them. Many clinicians conclude that they just like to self-sabotage and just don’t want to get better. They are almost always misunderstood. None of this is conducive to a strong recovery, yet this scenario repeats itself almost every day in treatment settings all over the country. So what is it about personality disorders? Why are they so difficult to deal with?
The biggest challenge that faces individuals with personality disorders is the fact that most people, including themselves, have little to no knowledge about them. A personality disorder is defined as an enduring pattern of perceiving, relating to, and thinking about one’s self and one’s environment that creates a substantial degree of dysfunction and interferes with long-term functioning. The dysfunction often creates a substantial degree of dysfunction and distress for the individual, which increases the vulnerability to substance abuse. Addiction frequently develops and the enduring behavior patterns predictably trigger relapses. Multiple treatment failures usually follow, with the individual being written off as poorly motivated or “not ready”. The unfortunate circumstance here is that this population rarely receives the specialized care needed to get better. Effective care requires attention and consideration for the specific needs of the different personality disorders.
There are a variety of different personality disorders with certain typified dysfunctional behavior patterns. The grouping that is most frequently encountered in addiction treatment settings is what is referred to as “Cluster B”. Cluster B includes the Narcissistic, Borderline, Histrionic, and Antisocial personality disorders. Many people exhibit certain traits of each of these personalities, but individuals with a complete constellation of the specific traits will meet criteria for having a full disorder. Each of these disorders has specific considerations with regards to how it affects addiction and recovery.
Narcissistic Personality Disorder is exemplified by a preoccupation with the self, a heightened sense of self-worth, selfishness, devaluation of others, and a strong emphasis on prestige, power, and vanity. Narcissists are usually seen as arrogant, self-absorbed, and tend to be dismissive of others. They may be high functioning and can achieve extraordinary levels of success. Some of the same traits that helped them achieve such success in other facets of life may actually impede them in recovery. Narcissists often have difficulty taking direction in treatment settings, especially from lower level staff. They are sensitive to criticism and may reject any therapeutic feedback that may resemble such. Perceived slights or disrespect may lead to an impulsive abandonment of treatment, which almost invariably ends in relapse. Their behavior and demeanor may create conflicts with other patients, especially when they are dismissive. These behaviors can be very disruptive, garner most of the attention, and typically distract clinicians from the deeper- rooted problems. The consequence of this is that without addressing the deeper problems, most of the behaviors and thought patterns that contributed to the development of the addiction will simply continue. Knowledge of and sensitivity to these tendencies will help keep the patient engaged in treatment and allow more opportunity to address the deeper issues. Individual psychotherapy for an extended period of time is the treatment that is most effective. It is also important to be able to separate between full scale Narcissistic Personality Disorder and the rather common sub-syndromal trait clusters. The repetitive self-gratification of drug use will contribute to a certain degree of self-absorption and selfishness that resembles narcissism. These individuals usually lack many of the other traits and will not be as disruptive in this regard.
Borderline Personality Disorder is widely regarded as one of the most disruptive and difficult conditions in all of psychiatry. This disorder is characterized by severe emotional instability, rapid and extreme mood shifts, chaotic relationships, unrelenting crises, an unstable sense of identity, “black and white” thinking, chronic suicidal ideation, and intentional self-injury. Substance abuse is a common complication; often the result of failed attempts to regulate mood. Addiction actually worsens the mood instability, creating a vicious cycle of attempted mood suppression and relapse. The intensity of the mood shifts is very difficult to tolerate, which is why the risk of relapse is so high. They are often seen as the “impossible patients” on inpatient units and leaving against medical advice is common. Conventional treatment systems, including 12-step models, do not work well with this disorder and in some cases can worsen emotional trauma. Dialectical Behavioral Therapy (DBT) is the treatment of choice for Borderline Personality Disorder, whether addiction is present or not. Unless the personality elements are thoroughly addressed, the prognosis can be poor. This disorder can be the most disabling of the cluster B disorders.
Less disabling than Borderline Personality Disorder but still problematic is Histrionic Personality Disorder. This condition is characterized by a pattern of excessive emotionality and attention-seeking behavior, an excessive need for approval, inappropriately seductive behavior, dramatic expression with an impressionistic style, and manipulative behavior to help meet their needs. The extroverted behavior often mixes with substances of abuse, with addiction frequently developing. Individual psychotherapy is the most important modality of treatment for this disorder, usually with an emphasis on Cognitive Behavioral Therapy (CBT).
The cluster B disorder that is most lacking in established and effective treatment is Antisocial Personality Disorder. Individuals with this disorder, commonly referred to as “sociopaths”, are characterized by a severe lack of consideration for the rights and feelings of others, disregard for social norms and rules, difficulty maintaining enduring relationships despite relative ease in establishing them, a low frustration tolerance with a heightened capacity for aggression, and a notable deficiency in the ability to experience guilt. The impulsivity and novelty seeking of this population often leads to drug use. There is growing data on deficits in the dorsolateral prefrontal cortex of this population, which would further predispose them to substance abuse and the development of addiction. The difficulty in following rules interferes with many treatment initiatives. The involvement in criminal behavior often pulls them back into the drug world, resulting in relapses and potential legal consequences. The criminal justice system is one of the more common final destinations for these individuals. Most of the inmates in any prison meet full criteria for Antisocial Personality Disorder, with estimates as high as 75% of the population. Not everyone with a criminal history should be considered a sociopath though, especially considering how frequently illegal behaviors are involved with addiction. Well-established boundaries and frequent limit setting are fundamental requirements for trying to treat this population. Treatment failure is common with this disorder. The absence of a correct diagnosis and the related therapeutic considerations contribute to this.
Accurate diagnosis requires careful analysis of a thorough clinical history as well as ongoing observation by a treating therapist or psychiatrist. Following the patient’s behavior over time gives the best picture of pathological behaviors in different situations and contexts. Awareness of a co-existing personality disorder is as important to the patient as it is to the clinical team. Many patients express a certain degree of relief and new found hope once they gain a greater understanding of themselves and their behavioral tendencies. Clinicians are better equipped to treat their patients if they can account for the myriad personality driven behaviors that may complicate treatment. This requires additional education and training on the part of the professional. In treatment settings where time may be limited, communication with prior treating clinicians is essential. Simply reviewing medical records rarely yields as much valuable information as would a phone call to the most recent outpatient therapist. When a willing patient with insight into their personality disorder engages a well informed and prepared clinical team, the prospect of a successful outcome is optimized.
Raul J Rodriguez MD is the founder and medical director of the Delray Center for Healing, an outpatient center that specializes in the treatment of addiction, eating disorders, personality disorders, and treatment resistant depression. The Delray Center for Healing is located in downtown Delray Beach, Florida. More information is available at www.delraycenter.com.