Introduction

Personality means the characteristic and behaviour that make up a person’s adjustment to life and includes major traits, interests, values, self-concept, abilities, drives and emotional patterns.

Personality traits are the enduring, subjective patterns of perceiving and relating to oneself and one’s environment in a wide range of social and personal contexts. In the well-adjusted person, these behavioural patterns should be relatively stable, predictable and consistent.

When personality traits become inflexible, maladaptive and rigidly pervasive and deviate from cultural standards, it can be said that a personality disorder exists. Furthermore, there is functional impairment which affects at least two of the following areas – cognition, affect, interpersonal functioning and impulse control. The key factor of personality disorders is often anger and the expression or introversion of anger.

Personality disorders have an onset in adolescence or early adult life and continue throughout life. Behavioural patterns interfere with a person’s functioning causing significant impairment in the social and occupational spheres. This chapter addresses occupational therapy intervention, which is an integral part of a multidisciplinary approach to assisting the individual to be more functional in daily life.

Personality disorders are seen in 10–20% of the general population (Robertson et al. 2001). The person with a personality disorder is clinically less impaired than those with other mental health disorders but is functionally more disabled. Superficially, a person with a personality disorder may present as stable, have a relatively good job and is seemingly competent and appearing to cope with life. On closer examination, however, there are deeply ingrained maladaptive behavioural patterns operational with no feelings of anxiety about his/her behaviour. This is compounded by signs that are alloplastic (blame is put on others) and ego syntonic (they believe their behaviour is right). That person is much more likely to have reduced insight, refuse or ignore psychiatric help, point out the therapist’s problems and persist in fixed behavioural patterns (the locus of control is external). This behaviour perpetuates those problems for which they seek assistance and causes scepticism from colleagues in other disciplines on the competence of psychiatric treatment (Robertson et al. 2001; Kaplan & Sadock 2003). He/she can create extreme discord both at home and in the inpatient setting. As a result, people with personality disorders are associated with poor treatment outcomes as these disorders are so time-consuming.

The occupational therapist requires a good understanding of this condition because behind a facade of seemingly coping and competent behaviour is a person who may have all or a combination of the following problems:

• Struggles to cope with stressful situations
  
• Is lonely and isolated
  
• Has fluctuating labile moods
  
• Has poor self-concept with low self-esteem
  
• Is unable to cope with responsibility, problem-solving, decision-making
  
• Feels inadequate
  
• Has reduced social skills (especially assertiveness skills)
  
• Struggles to form mature relationships

As can be taken from the aforementioned points, this group of clients exhibits a wide range of impairments and disabilities in performing their roles in society. It is established that their problems may relate to crime and alcohol and drug abuse with relationship problems leading to elevated levels of separation, divorce and child custody hearings. Due to reduced coping skills precipitated during extreme times of stress, these clients frequent emergency rooms and crisis clinics and utilise telephonic counselling services.

Long-term prognosis can be poor with a revolving door syndrome of repeated hospital admissions. Contributing factors are the reduced potential for insight with an inability to self-regulate behaviour and co-morbidity with reduced support systems as relationships may be inadequate, superficial, abusive, conflictual, ambivalent or turbulent. There is impaired occupational functioning with either a fluctuating or chaotic work record or conflicting/discordant/awkward work relationships. However, some features such as aggression become less apparent as the person enters middle age (Galder et al. 1996).

Conversely, some individuals have a good prognosis with excellent work histories, supportive networks and willingness for therapy.

This chapter aims to give a broad outline of personality disorders and to clarify issues surrounding them. It will provide different models, strategic skills, dynamic therapeutic interventions, theoretical frameworks and specified techniques that will enhance the quality and proficiency of occupational therapy.

Using an eclectic approach in which different theories and models are studied, the occupational therapist becomes equipped with knowledge so that intervention by occupational therapy is given from a solid foundation.

What is a personality disorder?

Diagnosis of personality disorders is either based on DSM-5 (American Psychiatric Association (APA) 2013) or using the ICD-10 classification (World Health Organisation (WHO) 2010). The World Health Organisation classification (2010) makes a basic differentiation between organic personality disorders, enduring personality changes derived from catastrophic experience, habit and impulse disorders, gender identity and sexual disorders and personality abnormalities that reflect a residue from some mental illness, as well as outlines nine specific personality types (Rutter & Taylor 2002; WHO 2010).

The DSM-5 (APA 2013) system uses a single axis and combines the first three axes outlined in the past Diagnostic and Statistical Manuals. This is because the DSM-5 removes the arbitrary boundaries between personality disorders and other mental disorders. The hybrid model used for the DSM-5 retains six personality types which are described by a specific pattern of impairments or traits. Thus, the paranoid, schizoid, histrionic and dependent personality disorders are not described in the DSM-5 (APA 2013):

• Borderline personality disorder
  
• Obsessive–compulsive personality disorder
  
• Avoidant personality disorder
  
• Schizotypal personality disorder
  
• Antisocial personality disorder
  
• Narcissistic personality disorder

There is also a diagnosis of Personality Disorder – Trait Specified (PD-TS) that is considered with a personality disorder where the criteria for a specific type are not fully met.

For the purposes of this chapter, the focus will be solely on the three clusters described by Du (2013), taking into consideration the DSM-5 changes earlier:

1. Cluster A – odd or eccentric disorders
   
   
   
   1. Schizotypal disorder: shows odd behaviour of unnatural thinking
   
   
2. Cluster B – dramatic, emotional or erratic disorders
   
   
   
   1. Antisocial disorder: does not care about the law or the rights of others.
      
   2. Borderline disorder: thinking is extreme on either end and lack of stability in relationships, identity and behavioural patterns.
      
   3. Narcissistic disorder: pervasive patterns of grandiosity, need for attention and a lack of empathy for others.
   
   
3. Cluster C – anxious or fearful disorders
   
   
   
   1. Avoidant disorder: lack of social drive, low self-esteem and extremely sensitive to criticism
      
   2. Obsessive–compulsive personality disorder: shows a strict conformity to rules, moral codes and order

The occupational therapist analyses the person’s ethnic, cultural and social background to ascertain if symptomatology is not an expression of habits, customs, cultural adaptations and belief, rather than a disorder. For example, during times of the death of someone, histrionic manifestations that are out of character may occur. Relevant pointers include attitudes to illness, religious beliefs and moral standards (Galder et al. 1996). Certain cultures may enforce submission to authority and contribute to development of a personality disorder (Robertson et al. 2001).

Gender distribution differs among the personality disorders. Predominantly in men, there are the antisocial and obsessive–compulsive personality disorders. The avoidant, borderline personality disorders are seen more frequently in women (Robertson et al. 2001). Sexual identity disturbances are clinically observed to suggest homosexuality with the male borderline person and with the woman presenting with antisocial personality disorder features. However, social stereotyping is contraindicated.

Understanding the aetiology and development of personality disorders

Personality disorders result from an interaction of genetic with upbringing factors (Galder et al. 1996). Incorporation of both genetic and constitutional factors in the causation of personality disorders has been well documented (Kaplan & Sadock 2003).

The occupational therapist should look at a combination of these four separate theoretical frameworks:

1. Dynamic model – is based on internal organising psychology resulting from conflict experienced in early life, with emphasis on developmental factors.
   
2. Trait model – this considers all possible personality types with interpersonal behaviour as the core.
   
3. Biological model – personality is ascribed to genetic or biological predispositions.
   
4. Sociological model – regards personality being shaped by social circumstances, and pathology is based on deviance from social norms and harm to society.

Freud (Boeree 2009) believed that fixation at a stage of development led to a certain personality type, for example, an oral fixation contributed towards dependency and an anal fixation led to obsessive–compulsive personality traits (Robertson et al. 2001).

The basic cause appears to be faulty childhood rearing resulting more from the parents’ attitude than their actions. Onset is at an early age and is precipitated by parental neglect, rejection and loss or lack of adequate parental models for identification. The results manifest in late adolescence, when behaviour becomes a fixed, pathological way of coping with life.

Genetic factors such as the XYY chromosome appearance, the abnormal EEGs and a high threshold for emotional stimulation are the complex components of the antisocial personality disorder. There is an etiological correlation of borderline personality disorder with childhood sexual abuse (Rutter & Taylor 2002). Children with borderline intelligence are at risk for personality disorders (Kaplan & Sadock 2003). The most clear-cut finding from family studies is the association of schizophrenia and schizotypal personality in the biological relatives (Robertson et al. 2001; Rutter & Taylor 2002).

Knowledge of background history is the basis for understanding the dynamics for therapeutic intervention. Conditions such as temporal lobe epilepsy, thyroid and other hormonal changes and diabetes may strongly impact on personality changes (S. Zilesnick, pers. comm.).

According to Galder et al. (1996), assessment to determine personality disorder should be validated by four sources:

1. Client’s own description of personality
   
2. Client’s behaviour during the interview
   
3. Client’s account of behaviour in a variety of past circumstances
   
4. Views of relatives and friends with the consent of the client

Clinical developments lean towards the psychiatrist informing and educating the clients on their personality type and traits so as to consolidate therapy and compliance in all therapies. As there are distortions of emotional control, psycho-education and even discussion of clinical signs, especially with the Cluster B and C disorders, can have a very positive effect in understanding behaviours and their impact on relationships both within the home and work contexts (S. Zilesnick & M. Vuirli, pers. comm.). This means if the client knows his/her condition, it in itself can be therapeutic as it puts into perspective behaviour that may well be confusing. This helps understand the aetiology of maladaptive responses as the client often does not have a preconception of his/her condition (S. Zilesnick, pers. comm.). The possibility of change is greater when there is cognitive understanding for lack of control, fixed behavioural patterns and/or self-mutilating behaviours. This creates the beginning of intellectual insight prior to the consolidated development of emotional insight.

However, psycho-education with Cluster B and C clients is contraindicated as there is already a distortion of thinking present, which would be counter-effective in any therapy (S. Zilesnick, pers. comm.).

Common defence mechanisms

The occupational therapist needs to understand the defence mechanisms used by the person with a personality disorder, that is, the unconscious mental processes that the ego uses to resolve conflicts.

Models of treatment intervention and teamwork

Treatment usually takes place in a psychiatric unit, clinic or outpatient department. The person with a personality disorder settles quicker within the contained environment of the hospital. Combined therapies in a rehabilitation facility where the multidisciplinary team has a unified treatment approach and a shared frame of reference are recommended. Family involvement and early establishment of supportive networks are essential for success. Post-discharge should look at maintaining support and containment through case management, ongoing review, self-help groups and ongoing individual or group therapy.

Behavioural approaches

Because it is difficult to change personality structure and stereotypical behavioural responses to stress, many theorists opt for a behavioural approach to teach appropriate responses in stressful situations. It is a long-term process consisting of operant behaviour (positive feedback for appropriate behaviour and ignoring negative behaviour), which allows experience of feelings of well-being and success by participating in positive tasks, even if they are not always continually reinforced (classic conditioning). Occupational therapy interventions such as relaxation and assertiveness training are behavioural in essence, and by observing appropriate behaviour in all social settings, the avoidant persons can practise new skills.

Dialectical behaviour therapy

Linehan (1993, 2007) found that cognitive behavioural treatment was the best procedure for borderline personality disorders and expanded this theory to create a model called dialectical behaviour therapy (DBT), which includes skills training based on biosocial and psychosocial theories. Dialectics refers to both the fundamental nature of reality and persuasive dialogue/relationships and refers to the treatment approach the therapist adopts to effect change.

With persons with personality disorders, there is an interrelatedness of stresses and processes, and new skills need to be learnt simultaneously to effect change. Thus, the occupational therapist may need to teach self-regulation skills, for example, assertiveness, together with skills for positively influencing the environment, namely, stress management in the workplace.

As reality is not static and requires change in acquiring skills, there may be positive validation and a shift in others’ opinions. It is a dynamic model of intervention and may benefit other personality disorders.

Cognitive behavioural approaches

Cognitive therapy is used to treat symptoms and abnormal behaviours which persist because of the way the client thinks about them. Behavioural therapy is used to treat symptoms and behaviour because of actions taken to relieve distress. Because thought and action often occur together, a cognitive behavioural approach is used (Galder et al. 1996). Most cognitive behavioural therapies require specialised training; less complex procedures can be accomplished by a competent occupational therapist such as anxiety management and relaxation techniques (Scott et al. 1989). Clinical experience has shown that obsessive–compulsive disorders benefit most from this approach. The teaching of assertive skills by the occupational therapist is useful for avoidant personalities.