Personality Disorders
Khenu Singh
Herbert Ochitill
Personality is a complex matter, and there is no consensus on how to define it, even in its maladaptive and disordered forms. One thing is clear, however—disordered personality and certain personality traits affect every aspect of the experience of human immunodeficiency virus (HIV) disease and its treatment. Certain personality traits and disorders increase risk behaviors related to both infection and transmission of the HIV virus. Thus certain personality structures, especially borderline and antisocial personality disorders, are significantly more prevalent in HIV-positive individuals. Personality affects the personal meaning of having HIV infection, as well as coping with the illness and its treatment. The patient’s experience of caregivers, providers, and others in the interpersonal milieu is also shaped by personality. The larger sociocultural responses to HIV and high-risk subcultures are often experienced in unique ways patients with personality disorder (PD). Personality affects aspects of medical care from compliance with medical care, including potentially life-saving interventions, to the treatment relationship itself. Even seasoned mental health providers struggle with intense, sometimes hateful, countertransference feelings. Clearly, the interface of personality and HIV disease is an area that every practitioner needs to be familiar with, whether medical or psychiatric providers or leaders involved in policy-making and public health systems of care.
Models of Personality
Most authors consider personality to involve intelligence, temperament, and character with temperament reflecting biologic contributions and character reflecting social and cultural shaping.1 In regard to maladaptive personality structure, there is some controversy between dimensional and categorical approaches. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) uses categorical constructs with which most clinicians are familiar. However, DSM-V Prelude Project workgroup on personality and relational issues continues to consider the merits of a dimensional approach. DSM aside, there are other categorical approaches to disordered personality from the psychoanalytic tradition, including Otto Kernberg’s concept of the borderline personality organization, which subsumes the DSM-IV borderline, narcissistic, and antisocial personality disorders.
A thorough review of various theories of personality is beyond the scope of this chapter. We review the major temperament and character traits, to provide a conceptual framework
and to set the context for studies that reference specific personality traits. Though there are multiple conceptual models, some authors feel these can be reduced to four temperament traits: (a) fearfulness or high harm avoidance, (b) impulsivity or high novelty seeking, (c) social detachment or low reward dependence, and (d) compulsiveness or persistence. The DSM-IV personality disorder clusters relate to these four traits in the following manner: cluster A (social detachment or low reward-dependence), cluster B (impulsivity or high novelty-seeking), and cluster C (fearfulness or high harm avoidance).1
and to set the context for studies that reference specific personality traits. Though there are multiple conceptual models, some authors feel these can be reduced to four temperament traits: (a) fearfulness or high harm avoidance, (b) impulsivity or high novelty seeking, (c) social detachment or low reward dependence, and (d) compulsiveness or persistence. The DSM-IV personality disorder clusters relate to these four traits in the following manner: cluster A (social detachment or low reward-dependence), cluster B (impulsivity or high novelty-seeking), and cluster C (fearfulness or high harm avoidance).1
In addition to temperament, there are three major character dimensions described in the literature: (a) self-directedness, (b) cooperativeness, and (c) self-transcendence.1 Self- directedness includes the concept of locus of control that has been shown to relate to the extent of involvement with health care.2 Cooperativeness relates to a sense of being involved in human experience and society and has implications in regard to the interpersonal field, including social support networks and providers. Finally, self-transcendence relates to a sense of being involved in the universe as a whole, expanding the boundaries of self to take on broader life perspectives, and discovering meaning in one’s life. This correlates with coping with a chronic illness and the existential issues related to death and dying, issues examined later in this chapter.
Personality models can more broadly be classified as two types: the social-cognitive and the trait-dispositional.3 The social-cognitive model relates to plans, goals, strategies, and overall narratives that inform behavior and are situated within a larger social context. Neurotic conflict and complex are also included here as significant aspects of personality structure. These social-cognitive or narrative aspects of personality are unique, shaped by particular aspects of relationship and life experience not readily reduced to categorical personality disorders. Trait-dispositional models refer to personality dimensions, as outlined previously. These once competing theories are now considered to be complementary by clinicians and theoreticians in the field of personality.
Thus there are multiple ways to conceptualize both normal and disordered personality— dimensional, categorical, and narrative/social-cognitive approaches are among these. Our focus will be on those personality traits, as well as DSM-IV personality disorders that have been described in the literature on HIV and personality and noted in the clinical experience of those working with patients with HIV.
Epidemiologic Perspectives
Almost by definition, the DSM cluster B PDs are associated with an increase in risk-related behaviors. Borderline patients are more impulsive (including impulsive sexual behaviors), and antisocial patients are both more impulsive and less harm-avoidant (i.e., less fearful of consequences). These features suggest an increased prevalence of these personality disorders in HIV-positive samples. This is supported by the literature, which shows a higher rate of PD in HIV-positive individuals, with the largest constituents being the cluster B PDs, especially borderline (BPD) and antisocial (ASPD).4,5 As we know from clinical practice, comorbidities are common between various Axis II PDs, yet this is not a feature mentioned in the HIV-related studies reviewed. Also, studies offer little about the prevalence and experience of individuals with other PDs, traits, and styles and how these relate to infection with HIV.
Diagnosis of Personality Disorder in the HIV-Positive Population
Clinical experience of HIV care providers reveals that though they describe the “difficult” patient, they have a hard time diagnosing PD or maladaptive personality traits. Mental health clinicians also may struggle in making PD diagnoses, because diagnosis can be complicated
by numerous factors in the HIV-positive population, including drug-using and gay subcultures. In gay and drug-using patients, there are also barriers to contacting family members and other individuals, who ordinarily can provide useful longitudinal history helpful in assessing the patient’s personality structure. Often, stabilization of drug addiction is necessary before a firm diagnosis can be made.
by numerous factors in the HIV-positive population, including drug-using and gay subcultures. In gay and drug-using patients, there are also barriers to contacting family members and other individuals, who ordinarily can provide useful longitudinal history helpful in assessing the patient’s personality structure. Often, stabilization of drug addiction is necessary before a firm diagnosis can be made.
There are specific challenges of diagnosing DSM-IV BPD in the gay context, raising questions such as: (a) rating sexual impulsivity within certain gay lifestyles, where contact may move quickly to sexual acts; (b) assessing impulsive substance use in the gay club culture, where it may be more a cultural norm; and (c) assessing instability of self-image, which can be a consequence of the difficult coming-out process for gay and bisexual individuals.6 Initially, these specific high-risk behaviors can be targeted; often, more sustained and longitudinal contact with the patient allows accurate assessment of underlying personality disorder and maladaptive traits.
HIV-related cognitive disorder may decrease memory and affect self-appraisal, impeding diagnostic assessment. Patients with active legal entanglements and extensive drug histories may minimize or deny their legal history or drug use, masking historical facts useful for diagnosis. They may also limit access to useful sources of collateral history out of similar fears. Relational ties may have declined so severely that no access to collateral sources is possible. Gay patients with HIV may be estranged from their families, sometimes rejected by them after coming out or disclosing their HIV infection status. Even when these patients are still connected with them, they may resist provider contact with family members and other sources of collateral history out of shame and concern for stigmatization, fearing disclosure of their HIV status, drug use, or gay lifestyle.
Personality, Maladaptive Behavior, and Illness Response
Personality and High-Risk Behaviors
The main HIV transmission categories relate to high-risk sexual and drug-related behaviors, behaviors that are increased in certain PD populations. The DSM ASPD and BPD, as well as the traits of high novelty-seeking (high impulsivity) and low harm avoidance (low fearfulness), have been linked with high-risk behaviors. As well, with narcissistic pathology, low self-esteem and defensive grandiosity can reduce the perceived risk of infection and thus the barrier to high-risk behavior.
When compared to non–PD controls at risk for HIV infection, patients with ASPD have been shown to have increased needle-sharing, decreased needle-cleaning, more needle-sharing partners, and higher self-reported rates of intravenous drug use. These patients have a larger number of sexual partners, higher rates of prostitution, and higher rates of risky sexual behavior, including anal sex.5 Thus, not only are these patients at high risk for infection, with multiple sexual and needle-sharing partners, as well as higher rates of prostitution, they also pose a significant risk to others in the community.
In studies of personality traits, novelty-seeking has been related to high-risk sexual behavior. Novelty-seeking was related to high-risk sexual behaviors, including number of sex partners or frequency of unprotected sexual intercourse—through its correlation with alcohol use in gay and bisexual men, this further and promotes high-risk sexual behaviors.7
The highest transmission category for women does not relate to intravenous drug use or same-sex sexual activity, but to heterosexual sexual activity. Women with narcissistic spectrum pathology who have low self-esteem sometimes try to bolster this low sense of self by adopting a rescuing role with drug-abusing HIV-positive males, which gives them a sense of narcissistic
gratification (by feeling like heroic martyrs) and is a response to an extremely rigid and self- deprecating ego ideal. These factors are proposed to make sense of those seronegative women who sustain relationships with HIV-infected partners, placing themselves at high risk.6
gratification (by feeling like heroic martyrs) and is a response to an extremely rigid and self- deprecating ego ideal. These factors are proposed to make sense of those seronegative women who sustain relationships with HIV-infected partners, placing themselves at high risk.6
Personality and Psychological Experience of Infection
HIV infection is a significant life experience for anyone affected. There is the specific impact of HIV disease and related medical sequelae, as well as the complex experience of dealing with a chronic illness. Issues can arise in relation to the patient’s self-perception and the response from family, friends, and the larger society of which they are part. There are existential questions in regard to meaning and death. This experience is unique for everyone dealing with HIV disease, yet there are particular issues that are common with patients with PD.
Patients with narcissistic pathology and with other disorders of the self, including BPD, can experience the diagnosis of serious illness most intensely. For those using primitive defenses, especially splitting, this may contribute to increased denial of illness and medication nonadherence. Because AIDS affects various systems of the body, including visible and stigmatizing AIDS-specific lesions such as Kaposi’s sarcoma, this can be especially fragmenting for those with preexisting narcissistic vulnerabilities. To illustrate, a colleague described a patient who had severe narcissistic pathology and developed visible Kaposi’s lesions during the progression of his HIV disease. The resulting narcissistic injury was so fragmenting that he committed suicide.
Like a child, the very ill individual yearns for omniscient and omnipotent caregivers to fulfill idealized self-object needs.8 For patients who experienced prior abuse, they may vacillate between help-seeking and help-rejecting behaviors. This reflects primitive aspects of the psyche acting to prevent patients from being retraumatized as they were by their early attachment figures.9 Thus, as self-object ties are disrupted, the resulting destabilization of the self can be experienced as a recapitulation of the inadequate early environment. In these states of heightened dependency, there can be a triggering of old fears of being neglected/abandoned, mistreated/abused, or even narcissistically used by caregivers who need the child to be sick and dependent. A failure of the early self-object environment may be rationalized as a fault of the patient, such that AIDS can even be experienced as a “just retribution for being fundamentally bad.”8
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