Rep36 Understanding Personality Disorder

2. Origins of personality disorder

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Healthy or normal personality functioning is
characterised by the following:
I
ego identity (integration of self concept and
concept of significant others);
I
ego strength (control of affects and impulses);
I
an integrated and mature superego
(internalised social values); and
I
effective management of libidinal and
aggressive impulses.
Personality disorders reflect developmental
Dave
Dave initially sought help from his GP for anxiety problems following the loss of his job. He was
offered a short-term treatment focusing on anxiety management. The therapist became
increasingly concerned at Dave’s social isolation and chronic obsessional washing and began to
question the regular appearance of bruising to Dave’s arms and face. Dave was asked about any
experiences of violent conflict but disclosed this was a pattern of self-harm he used to relieve
tension. Following this disclosure, the focus of treatment changed to reducing self-harming
behaviour. Unfortunately, shortly after this change in focus Dave attempted to hang himself
resulting in hospital admission. On review it appeared the self-harming behaviour had helped to
control overwhelming feelings of self-hatred, which had precipitated the suicide attempt. 
Whilst in hospital Dave was observed to sleep very little, to over control his eating and then
binge eat, to be at times appeasing and other times confrontational and to become easily aroused
in situations of conflict. When medically examined, it also became apparent that Dave was
regularly cutting his arms and stomach. The ward staff had difficulty managing Dave’s behaviour
as, despite attempts to address his behaviour, Dave continued to engage in his eating and cutting
behaviour. This resulted in Dave using increasingly secretive means to continue with these behaviours.
The ward staff became exasperated with his behaviour, with some staff supportive of Dave and
others hostile to him. This resulted in situations of conflict between the staff and Dave, during
which staff were threatened and intimidated by Dave’s highly aroused and confrontational manner. 
At this point a psychological assessment of Dave was sought. Dave was initially hostile and
suspicious of this process and refused to engage in any discussion of his aggressive behaviour or
problems with eating and self-harm. Over time the assessment allowed Dave the opportunity to
explore his life experiences and the impact of these on how he currently felt. Personality testing
augmented this. Dave began to trust the assessor, whom he considered was attempting to
understand him, was honest with him and gave him clear, unambiguous messages. Through this
process, an initial formulation of Dave’s difficulties revealed an individual who had been
emotionally neglected by two parents who were focussed on their own career development. Dave
was left with a number of carers and there appeared to be no consistent or predictably warm
figure he could trust. He became a withdrawn child who was ostracised and bullied at school. Dave
formed a close and loving attachment to his older sister who died in a road traffic accident when
Dave was 13 years old. Dave left home at 15 and formed a relationship with an older woman,
whom he considered to be loving and protective. Over time it became apparent this woman was a
controlling and emotionally abusive person and Dave became physically abusive of this woman
before deciding to leave the relationship. The personality testing indicated Dave would attempt to
avoid intimacy because it was associated with rejection and conflict. However, he continued to
desire closeness and protection from others. Therefore, he was drawn to form relationships with
people who could support and protect him. He would please and placate these people to ensure
himself of enduring support and protection, which left him open to abuse. Dave was also
hypervigilant to rejection within relationships and if he perceived himself to be let down or
betrayed could become emotionally or physically aggressive. 
Dave considered the assessment process helped him to understand himself. The assessment was
useful in negotiating a care plan with Dave, professionals in the community and a local specialist
personality disorder service. Dave recognised the need to address a number of complex issues
including interpersonal relationships, self-harm and violence to others. Dave trusts those he is working
with as they provide a consistent and reliable response to him within clear negotiated boundaries. He
finds the process difficult and at times becomes withdrawn and rejecting of services, but the consistent
support helps him to return to services and continue to work towards a more stable lifestyle.

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failures in one or more of these areas.
Kernberg’s concept of Borderline Personality
Organisation (which includes all of the DSM-IV
cluster A and B disorders: see Section 1.1) is
characterised by identity diffusion (i.e. confused
ego identity), primitive internal defensive
operations such as idealised object
representations (i.e. seeing specific people as
faultless), denial or splitting (i.e. seeing people
or relationships as all good or all bad), and
varying degrees of superego disorganisation.
Failures of mature development are seen in
distortions in interpersonal relations and the
control of emotional impulses, pathological rage
being central to borderline disorders. 
Psychoanalytic psychotherapy for personality
disorders takes a variety of individual and group
forms (Bateman & Fonagy, 2001; Clarkin,
Yeomans & Kernberg, 1999). A common goal is
to change those characteristics of the individual’s
internalised object relations that lead to
repetitive maladaptive behaviours and long-term
emotional and cognitive disturbances. This is
achieved through identifying the dominant
object-relations emerging in the transference,
that is, the reactivation in therapy of internalised
relationships based on early experience (Clarkin
et al
., 1999).