Rachel McMurray, MA, LMFT specializes in working with cluster B personality disorders and other related specialties. As a reminder, cluster B refers to antisocial personality disorder, borderline personality disorder, histrionic personality disorder, and narcissistic personality disorder. If you’d like to learn more about these diagnoses, please see this article for an overview. Rachel shared that the cluster B types are the personality disorders she’s most well-versed in because they’re the most common in society and, more importantly, they are the ones who have the highest likelihood of coming into treatment. Those in the other clusters are less likely to present for therapy for various reasons. The following is the first part of my interview with Rachel (the second and third parts of this interview will be posted over the next two weeks). I hope you find the article informative and meaningful whether you’re a therapist, family member/friend of an individual with a personality disorder, or simply an interested reader!
Ashleigh: What would you want the public to know about personality disorders in general?
Rachel: This is controversial but my number one thing is that they’re not caused by trauma, especially not childhood trauma. There are different theories of thought and treatment models that say otherwise, but I am going with the most recent research and my experiences. I might get some backlash, so I’ll qualify my statements a bit. Most of my knowledge is based on consistent exposure to loved ones with personality disorders, my clinical experience over the past fifteen years, and trainings, especially those conducted by Dr. Gregory Lester, PhD. I like his work because he presents the knowledge he’s gained from a practitioner perspective and I find that really useful. He synthesizes massive amounts of literature as well as the most current research and assembles it into a format that clinicians can easily understand and then use. He has conducted more trainings on this subject than anyone else in the world and the DSM-5 committee consulted with him about personality disorders before their most recent updated publication.
Also, I really want people to know that personality disorders are not considered curable, but are treatable, that this is not a population to be written off and/or vilified. I’ll explain the difference. Unlike mood and anxiety disorders which are ego-dystonic, personality disorders are ego-syntonic. Meaning, for example, that someone with narcissistic personality disorder is a narcissist vs. someone who is afflicted by a disease/illness called narcissism. This is not something happening to the person, it is the person, and this is why it cannot be cured. The only personality disorder that is not treatable is antisocial personality disorder because the individual does not care about the consequences of their behaviors and therefore is not generally motivated to change. Most people with the other three Cluster B disorders want to change (to various extents) because they see the significant negative consequences/losses (family, friends, work, etc.) that result from how they operate in the world; they suffer as a result of these consequences whether or not they admit they are at fault. Individuals with antisocial personality disorder do not tend to care about these types of consequences and thus are less likely to voluntarily seek treatment.
Another thing is that it’s important to look beneath the surface of their stories, to find a balance between believing everything or nothing. This is a population that is often experienced as manipulative and seen as deceptive or disingenuous. For example, it’s common for individuals with borderline personality disorder to fabricate things, but not necessarily totally make things up. Instead, they will exaggerate things because they experience it a certain way. For example, one of my clients referred to her mother as abusive and weeks later told me why she thought this. She experienced being dropped off (appropriately) for her first day of kindergarten as a traumatic abandonment. She was surprised that I did not clearly see this as abuse and twenty minutes later in session, she altered aspects of the story to make it seem as if her mother behaved heartlessly. In sum, the client experienced her mother as heartless, she wanted me to understand her feelings, she changed the facts to match. They tend to be aware of the exaggerated nature of their stories initially, but if they tell it enough times it becomes difficult to remember what is real and what isn’t. It ends up becoming part of their narrative which is aligned with the dissociative, sometimes psychotic quality of the disorder itself.
Ashleigh: What do you think is the biggest misconception about personality disorders?
Rachel: As I said before, it doesn’t look like they result from trauma as previously thought. Personality disorders are genetic and neurologically based. Worldwide, the presentation is the same, regardless of culture, socioeconomic status, etc., which strongly supports the genetic/neurological theory. You can see distinct differences in the brain scans of individuals with personality disorders in certain types of scans. For example, only about 20% of individuals diagnosed with borderline personality disorder have trauma in their history. They are born this way and often their thoughts/feelings lead to behaviors that can result in traumatic experiences, or they experience normative events as traumatic and relay the events as traumas like my client did.
Personality disorders tend to present early on in development; the average age of presentation is five years old. This aligns with Freud’s stages of psychosexual development, Piaget’s developmental model, and the idea that our core beliefs about self, the world, others and the future are formed by age six. It is a misconception that you have to wait to diagnose until the individual is 18. The only exception to this is antisocial personality disorder, which requires that the client is at least 18 years of age. That said, for developmental reasons I rarely diagnose before adolescence.
I also want to clarify some of the terminology. Like, the term borderline itself refers to the line between psychosis and neurosis, which differs from how the term is often interpreted. People think of something being borderline to mean mild, like if something is “borderline problematic.” The psychosis part meaning that the person has psychotic, delusional, fantasy and dissociative elements to contend with, and simultaneously suffers from neurotic qualities such as anxiety and mood disturbance. They have dysphoric moods that will last from a few hours to a few days before they shift, which is very different than the presentation of bipolar disorder. This is another common misconception, as something people often confuse for bipolar disorder for borderline personality disorder and likewise often confuse narcissistic personality disorder with antisocial personality disorder. Differential diagnosis is very important here.
Ashleigh: Which factors do you think influence the development of a personality disorder?
Rachel: Nothing. You can have cases where they had/have nearly perfect parenting and a great life, but still, the person has a raging personality disorder and experience a lot of chaos and destruction. I’ve worked with lovely families, but they can’t solve it. Marsha Linehan created DBT and shared that rather than coming from a family with a lot of trauma, she was the trauma in her family. Of course, there are cases where trauma is involved, but it doesn’t cause a personality disorder. If there are other factors besides genetics or neurological variability, we don’t have conclusive data supporting that thesis at this time.
Ashleigh: What are the most common comorbid conditions that people with personality disorders tend to face?
Rachel: Antisocial personality disorder tends to be comorbid with ADHD, as you might imagine in terms of the impulse control aspect as well as the hyper-focus on their needs/interests (which in this case might be drugs, money, and serial killing, etc.). With addictive disorders, antisocial, borderline, and narcissistic personality disorder are very common. Bulimia and other forms of eating disorders are comorbid with borderline personality because they’re so susceptible to environmental emphases on body-image and a sense of self. To explain further, it’s like having a map without lines connecting the dots. Borderline personality disorder is also associated with dysthymia, which is an ongoing, relatively mild depressive state. Factitious disorders and hypochondriasis are also common with borderline personality disorder and histrionic personality disorder. Major depressive disorder is common with borderline and narcissistic personality disorders.