Studies of personality disorders Antisocial and Borderline

Abstracts

OBJETIVO: Este estudo objetivou revisar, na literatura, os critérios diagnósticos e as intervenções nos transtornos de personalidade do tipo Antissocial e Borderline. MÉTODOS: Uma pesquisa manual foi realizada no acervo bibliográfico particular do autor, selecionando-se 12 referências; outra pesquisa sistematizada foi desenvolvida no período de 1990 a 2008, no mês de janeiro de 2009, na Biblioteca Virtual em Saúde, selecionando-se 23 artigos. RESULTADOS: Os achados indicaram duas abordagens - uma que classifica como doença, mas que necessita de revisão dos critérios diagnósticos e avaliação e a segunda, que classifica como problemas morais. CONCLUSÃO: Independente da abordagem é necessário que o enfermeiro aprimore seu conhecimento e compreenda a dificuldade desse sujeito ao relacionar-se adequadamente com outras pessoas; assim, é de fundamental importância que os membros da equipe de saúde analisem seus sentimentos, atitudes e reações em relação ao comportamento do cliente, uma vez que a relação com esta clientela é considerada uma das mais complexas em saúde mental.

Transtornos da personalidade; Diagnóstico; Avaliação; Princípios morais; Enfermagem psiquiátrica

REVISION ARTICLE

Marcos Hirata Soares

Assistant Professor in Psychiatric Nursing and Mental Health, Nursing Department, Centro de Ciências da Saúde, Universidade Estadual de Londrina _ UEL _ Londrina (PR), Brazil

Corresponding Author

ABSTRACT

OBJECTIVE: This study had the objective of reviewing, in the literature, the diagnostic criteria and the intervention in personality disorders, Antisocial and Borderline types.

METHODS: A manual research was performed in the author's private collection of books, selecting 12 references; other research has been systematically developed in the period 1990-2008, in January 2009, in the Virtual Health Library, selecting 23 papers.

RESULTS: Our findings indicated two approaches - one that classifies as an illness, but that needs to review the diagnostic criteria and evaluation, and the second, that classifies them as moral problems.

CONCLUSION: Regardless the type of approach, is necessary that nurses enhance their knowledge and understand the difficulty of this subject to relate properly with others; thus, it is crucial that members of the healthcare team examine their feelings, attitudes and reactions related to the client's behavior, since the relationship with this type of customer is considered one of the most complex in the mental health field.

Keywords: Personality disorders; Diagnosis; Evaluation; Morals; Psychiatric nursing

RESUMEN

OBJETIVO: Este estudio tuvo por objetivo revisar, en la literatura, los criterios diagnósticos y las intervenciones en los trastornos de personalidad del tipo Anti-social y Borderline.

MÉTODOS: Se trata de una investigación manual que fue realizada en el acervo bibliográfico particular del autor, seleccionando 12 referencias; otra investigación sistematizada fue desarrollada en el período de 1990 a 2008, en el mes de enero de 2009, en la Biblioteca Virtual en Salud, seleccionándose 23 artículos.

RESULTADOS: Los hallazgos indicaron dos abordajes - uno que los clasifica como enfermedad, pero que necesita de revisión de los criterios diagnósticos y de evaluación, y la segunda, que los clasifica como problemas morales.

CONCLUSIÓN: Independientemente del abordaje es necesario que el enfermero perfeccione su conocimiento y comprenda la dificultad de ese sujeto para relacionarse adecuadamente con otras personas; así, es de fundamental importancia que los miembros del equipo de salud analicen sus sentimientos, actitudes e reacciones en relación al comportamiento del cliente, una vez que la relación con esta clientela es considerada una de las más complejas en salud mental.

Descriptores: Trastornos de la personalidad; Diagnóstico; Evolución; Princípios morales; Enfermería psiquiátrica

INTRODUCTION

When people's personality traits are inflexible and badly adjusted, causing significantly compromised functioning or subject suffering, they constitute a class of personality disorder, characterized by bad social adaptation⁽¹⁾. Qualified as a health problem, knowledge is needed about their definition, prevalence, etiology, diagnosis and therapeutic intervention. This theory represents a considerable part of current scientific thinking on Personality Disorders (PD)⁽²⁾.

Culture influences the establishment of one's personality and is expressed through personal values. The latter are inevitably involved in PD diagnosis, as human culture will always reflect a broad scale of values, which will always interfere in clinical judgment made to diagnose PD subtypes. It is important to understand that life standards and judgments are involved in socially acceptable and culturally defined self-care levels, and also to seek a balance between individual autonomy and social control the State exercises through social and health policies.

The psychiatric paradigm, however, has been questioned throughout the Psychiatric Reform movement, and more sharply in the antipsychiatry movement, regarding its efficacy and true ability to help various types of mental disorders, like PD for example. Thus, the medicalization of difference turned into a widely debated theme that is perfectly suitable to discuss the diagnostic criteria used in type B PD, focusing on Antisocial and Borderline PD here, as there is great controversy on their classification and useful therapeutic interventions for care delivery to this type of psychic suffering⁽³⁾.

The diagnostic classification and professional practice of Antisocial and Borderline disorders display particularities that make them polemic and complex, according to the different studies analyzed, which will be presented here, departing from two basic premises aimed at debating the concepts that support the respective disorders:

- Diagnostic criteria and proposed intervention for Antisocial and Borderline PD, considered as mental disorders, but suggesting changes in diagnostic criteria, theoretical frameworks and assessment and intervention methods;

- Diagnostic criteria for Antisocial and Borderline PD, not characterizing them as mental disorders, but as moral problems, without describing clear interventions in this perspective.

Thus, it is fundamentally important for nurses and their team to reflect in depth on the themes presented here, as they are considered the most complex cases in Psychiatry and Mental Health. Within an interdisciplinary work perspective and being responsible for client care, nurses should also follow discussions and reflections on the theme.

METHODS

A non-systemized manual survey was carried out in the author's private bibliographic collection, which permitted the use of 12 references (books and papers, in addition to the 23 references from the Virtual Health Library (VHL), obtained through a systemized research carried out in January/2009, covering the period from 1990 to 2008. This long time interval was considered, as changes in views on these disorders needed to be analyzed over time.

The research used the VHL database in all sources, based on the following criteria: adult subjects, journal articles, written in English, related to the terms: Moral Principles, Social Perception/Social Values, Stereotyping, Personality Disorders, Borderline Personality Disorder, Mental Disorders, Interpersonal Relations, Personality, Social Adjustment, Legal Psychiatry, Antisocial Personality Disorder, Psychiatry, Psychology, Mental Health Services and Psychiatric Nursing. The studies that did not fit into at least two of the above listed subjects were excluded, as well as studies with infant, adolescent, female, pregnant and elderly populations.

RESULTS

The primary search resulted in 1,324 items that were individually assessed, as a secondary refinement by research topics could exclude important documents. Based on the abovementioned criteria, 23 articles were selected. Starting from the selected references, the following categories were elaborated: current classification, antisocial and Borderline personality disorders, possible etiology, epidemiology, changes in diagnostic and psychotherapeutic criteria, and diagnosis of Antisocial and Borderline personality disorders as moral problems.

DISCUSSION

The current classification of personality disorders

According to the Diagnostic and Statistical Manual of Mental Disorders⁽⁴⁾ (DSM-IV), disorders are classified in three large groups:

- Group A: Paranoid, schizoid and schizotypal personality;

- Group B: Antisocial, Borderline, Histrionic and Narcissistic Personality. Epidemiological evidence exists that this group displays the main associations between alcohol-related problems and mood disorders, which are the key to explain the high levels of violence these subjects commit⁽⁵⁾.

- Group C: Avoidant, Dependent and Obsessive-Compulsive Personality.

Another patient subgroup can exist with a combination between Borderline and Antisocial disorder, turning them even more capable of manifesting bad conducts and violence^(5-6).

Antisocial and Borderline personality disorders

Understanding these disorders as actual mental disorders, one may say that these people present deeply imbedded, inflexible and badly adjusted patterns of relationships and perception of the environment and themselves. They very frequently do not perceive their "symptoms" as harmful for themselves or others and, therefore, do not usually seek professional help, and are also considered unrecoverable in many cases. The interpersonal relation with a Personality Disorder (PD) patient can be considered a unilateral relationship, due to the inability of healthy or satisfactory interpersonal relations⁽⁷⁾.

The debate about criminality practiced by people who fit into the diagnostic criteria for these two disorders is considered highly polemic and widespread. There is no response as to the adequate place for treatment. Although the authors sustain great diagnosis and intervention difficulties, they suggest antisocial PD behavior is a mental disorder⁽⁸⁾, besides the fact that there is no scientific evidence yet to associate the violence these subjects cause as a part of the personality disorder, as the association with drugs and alcohol use is frequent. In some cases, a connection between both exists, which makes one cause the other^(6,9). In the medical-legal discussion sphere, the reformulation of laws applicable to criminal Antisocial and Borderline personality disorder patients is defended⁽¹⁰⁾.

A possible etiology

A literature review of 56 other studies⁽⁵⁾ about violence and personality disorders, among other important findings, indicates that behavioral factors in childhood and the presence of attention deficit hyperactivity disorder (ADHD) could predispose individuals to the development of personality disorders as, within the cognitive model, antisocial behavior is a phylogenetically determined strategy to facilitate survival, in which each person acts motivated by an internal control system, which regulates its perceptions and responses to the environment.

Thus, children who grow up in an environment where parents are violent tend to reproduce violent behavior when adult. This reinforces the idea that social determinants are interconnected, that is, inability to attend to basic needs, divorces, unemployment, drugs abuse and low education levels are associated with intra and extra-domestic violence, hence acting as survival responses learned at home^(5-6).

Different dysfunctional behavior problems among parents have been associated with the development of this disorder, including their low emotional sensitivity. In some cases, mothers report feeling anxious, impulsive and uncontrolled since their own childhood, suggesting that families whose parents have this disorder seem to transmit their maladjusted behaviors to their children. Thus, it is fundamental for impulsiveness, low anger control, mood instability, egocentrism, among others, to be treated early, as they interfere in fatherhood or motherhood skills⁽¹¹⁾.

Families of these patients showed the highest psychopathology rates, particularly in cases of depression, substance abuse and antisocial conducts. The quality of the family relationship, however, seems to lead towards two possible routes: contributing to the development of the specific disorder, as well as favoring a better family relationship, resulting in a better prognosis⁽¹¹⁾.

An analysis of this problem according to the theory of Interpersonal Relations⁽¹²⁾ reveals that the development of this problem is related with the experiences lives and one's ability to assess them. Although that author has not published on the application of her theory to this kind of clientele, one of her basic premises sustains that all people tend towards a positive development and need to receive unconditional positive attention. In a large majority of cases, however, people with an Antisocial or Borderline PD do not see that they have problems and, therefore, do not understand the need for therapeutic help, so that no therapeutic contract can be started in practical terms.

Epidemiology

In the general population, PD rates can range from 0.5 to 3%. In the United States, in a study among adolescent prisoners, 45% were diagnosed with ADHD. In Germany, the Antisocial and Borderline PD rates obtained in one study ranged from 27% to 85% in prisons, and similar rates were found for drugs abuse⁽⁵⁾. In North American prisons, prevalence levels of personality disorders rise up to 66%, thus related with criminal practices. These data suggest a relation between drugs use, these disorders and involvement with crimes, although no scientific proof exists yet to associate criminal conduct with the co-existence of one of these PD. However, involvement with illegal drugs is associated with criminal practices, a known fact.

As for psychotherapy, the statistics for violent episodes amounts to 1/40,000 hours of psychotherapy. This makes it more complex to truly understand the therapeutic possibilities to treat people with these diagnoses and undoes the existing prejudice regarding the complete dangerousness of people with these diagnoses⁽⁹⁾.

People with personality disorders are more susceptible to other psychiatric disorders. It is estimated that 80% of people with personality disorders suffer from other mental health problems, including depression, anxiety and harmful drugs use⁽¹³⁾.

Changes in diagnostic and psychotherapeutic criteria

A study⁽¹⁴⁾ involving 797 psychiatrists and clinical psychologists used a questionnaire called SWAP-200, with 200 personality description items, aimed at getting to know these professionals' clinical judgments. The study selected professionals with large clinical experience to decrease the risk of diagnosis difficulties, which decreased the possibilities of subjects having some signs and symptoms classified as comorbidities.

In this study⁽¹⁴⁾, it was verified that there are different empirical characteristics not included in the diagnostic criteria the DSM-IV uses to classify all PD. To give an example, Antisocial PD seems to involve certain impenetrability, sadism and a trend to manipulate other people's emotions. Despite crime-related events, there are reports on successful treatment through therapeutic and psychotherapy communities⁽⁹⁾.

The impulsiveness of Borderline PD can depend on the presence of a negative emotional state. A study involving 284 subjects diagnosed with Borderline PD⁽¹⁵⁾ suggests that people with this disorder can present a negative emotional state, which allows them to interrupt or inhibit their behavior in the presence of punishment, that is, negative emotions can be associated with increased impulsiveness among people with this disorder.

According to biosocial theory⁽¹⁶⁾, people with Borderline PD are characterized by a combination of emotional vulnerability and affective disequilibrium. Emotional vulnerability involves a low threshold for emotional response, involving intense and long-lasting responses to emotionally suggestive stimuli. Affective disequilibrium refers to the inability to control or modulate emotional experiences. Within this structure, impulsive and self-harming behavior that is generally observed in this type of disorder occurs in response to negative emotions and to the function of frequently regulating these emotions. Consequently, the presence of negative emotional states can increase the probability of impulsive behavior in these clients.

The risk of violence, a very noteworthy characteristic for this class of PD, can be understood in terms of four fundamental personality dimensions: impulse control, regulation of affection, narcissism and paranoid personality, which operate in combination and to different extents with a view to emotional regulation⁽⁶⁾.

A study that used a 100-item questionnaire to assess personality functioning, aimed at analyzed the diagnostic criteria for personality disorders, was applied to 110 community people. These questions were distributed among the following components: social avoidance, narcissism, insecurity, compulsive behavior, interpersonal disdain, mobility, anxiety, problem conduction, search for stimuli, problem identification, self-harm, rejection, shyness and hypersensitivity. The data showed a high level of internal consistency, suggesting that the results can represent larger populations and serve as a base for alterations in the diagnostic criteria for type B PD⁽¹⁷⁾.

Until then, in both studies, the need for diagnostic reformulation is mentioned as very important, suggesting that the criteria should be reviewed. Subsequent studies also suggest changes in assessment forms, but mention the need to reformulate the model, moving from criteria to dimensions.

Controversies also exist regarding diagnostic classification⁽¹⁸⁾. According to those studies, current assessment needs modification, which requires changes in classification parameters. The five-factor model is suggested, which is considered more integrative and preeminent in comparison with the current category-based model. According to this theory, personality is organized in five main large traits: trend towards neurosis, extroversion, friendliness, conscious state and opening for experiences^(18-19).

Disorders are characterized as acute dysfunctional behaviors dissipated in a relatively short period of time. The modification of assessment and classification criteria is also suggested. It is observed that some of these items, such as the ability to create and maintain interpersonal relations and self-protection from stress are also items the World Health Organization⁽²⁰⁾ appoints as mental health indicators, as well as targets of therapeutic interpersonal relationship practice⁽²¹⁾.

Therapists report more treatment failure when PD are diagnosed. They do not define, however, the actual motives involved, which can be their own inadequacy and, consequently, the inefficacy of the proposed interventions. There are signs that cognitive-behavioral therapy can be an effective method in PD treatment⁽²²⁾.

The American Psychiatric Association considers dialectic behavioral therapy as the most effective and empirically supported affective regulation treatment for this type of disorder⁽²³⁾. Dialectic logics in this disorder involves accepting patients with their current difficulties, and at the same time uses their competencies to modify maladjusted behaviors, modifying their affective regulation, stress tolerance and interpersonal relationship skills.

Diagnosis of Antisocial and Borderline disorders as moral problems

A very common term, that of social maladaptation, constitutes one of the defining characteristics of PD in general, considered a result of the conflict between moral values, culture and personality, without necessarily representing a disorder. Adapting or not to the values of culture and society does not represent a mental disorder, as the fact of being adapted by itself does not indicate the guarantee of preserved mental health either^(24-25).

The DSM-IV's classification of PD demonstrates that two different types of theoretical frameworks are followed; one with clinical syndromes and the other denoting moral aspects. In this perspective, mainly antisocial and borderline disorders, among the others in group B, can be considered more preeminently as moral problems, as their identification involves the explicit use of ethical and moral terms when compared with types A and C. As presented in DSM-IV, these disorders have more of a moral connotation⁽²⁶⁾.

The important distinction between moral values themselves and the ability to judge other people's social and moral values is the main instrument to infer on a correct clinical judgment. If the moral is merely seen as the ability to suggest certain rules, it may not be capable of perceiving that, in a way, moral values are part of people themselves, composing their identity and molding their personality. In health professionals, this interferes in the achievement of an adequate and most impartial psychiatric assessment. Current diagnostic classifications for Antisocial and Borderline PD may have a more moral than clinical connotation⁽²⁷⁾.

Judgment is the assessment of alternatives and decision-making is a process of choosing between alternatives. When a person makes a social and moral judgment, evidence and observation are assessed in the light of one's own current beliefs and knowledge. These beliefs and knowledge, in turn, can be influenced by the historical, cultural, social and economic moment itself societies are going through during that period⁽²⁷⁾.

The theory of social judgment suggests that it follows principles, such as the fact that people have a pre-existent cognitive scheme, through which they evaluate new knowledge and situations, tending to distort captured information, according to one's own prejudices. Variations in personal beliefs and attitudes result in attitudinal, personal and behavioral changes. In other words, people choose what they believe and information challenging this cognitive scheme tends to be distorted and interpreted, according to the pre-existing scheme⁽²⁷⁾.

According to the philosopher Kant⁽²⁸⁾, reason is the main balance point for life, which is why human beings should move away from immoral acts and be guided by free will. The notion that madness can be a disturbance of will, as Pinel proposes, strongly coincides with the presented Kantian concept. The cognitive scheme⁽²⁹⁾ can be considered similar with the presented reflection, between moral, will and freedom. Having autonomy means being able to establish and maintain beliefs, question one's own beliefs and act according to those in which one sees an explanation, a truth that makes sense and offers psychological comfort.

A PD diagnosis normally is not sufficient to exempt a person's acts. Accountability judgments are fundamentally judgments on the connection between an agent and an action, and these types of judgments need to be distinguished from questions regarding personal character. In other words, character cannot always be associated with inadequate acts a person commits, and the presence of a PD by itself does not justify antisocial acts⁽³⁰⁾.

People diagnosed with Borderline PD frequently present unstable interpersonal relationships, causing suffering. In this context, manipulation, a remarkable characteristic in clinical practice involving these clients, can be seen as a defense behavior for direct access to power and voice, which are not equitably available to all and, hence, could be considered a survival skill, thus permitting a possible understanding for this behavior⁽²⁹⁾. In line with this view, Evolutionary Psychology explains that behavioral responses are selected by human evolution. As an adaptive response to the environment, human behavior is genetically disseminated, in which responses are considered inadequate according to the sociocultural values of each age, society and culture⁽²⁹⁾.

On the opposite, from Kant's moral focus^(28,31), it may be wrong to classify this type of person as a mental disorder patient, considering that, in this conception, it is valid to affirm that meanness and vileness are not mental health problems. This clientele arouses different negative feelings in the mental health team, mainly among nursing professionals, who perceive some types as hostile, manipulating, uncooperative and seductive. From this perspective, badness and amorality cannot be considered illnesses^(28,31).

Mental health professionals usually believe that services cannot help patients with PD. From Kant's philosophical viewpoint, human beings are fully and irrevocably responsible for their acts, going against the classification of type B PD and also disagreeing from Evolutionary Psychology. According to this focus, moral accountability accompanies all human beings, as any live creature presents some kind of morality, which naturally develops, not permitting antisocial acts for example^(28,31).

These behavior and personality patterns are classified as problems, because society "elected" psychiatry to intervene in these moral and social problems. The origins of psychiatry in Brazil demonstrate that it was born at the heart of social medicine, as part of the medicalization project of different social, economic and cultural problems, turning them into intervention objects, i.e. into mental disorders^(32-33).

The more psychiatry expanded towards abnormality, the more social problems became the target of medical intervention, which also meant more jobs for mental health professionals. Departing from the notion of dangerousness and non-subjection to disciplinary order, which represent abnormal people, psychiatry elaborated its theory, broadening its activity area from mental illness to abnormality⁽³³⁾.

No clarity exists regarding treatment in Kant's philosophical conception. Nevertheless, more important than philosophical debates on diagnostic criteria or psychosocial constructs on mental disorders is the importance of social accountability to protect vulnerable people, thinking about a common good. Raising this awareness on people with mental disorders and their suffering is the first step to consolidate the Psychiatric Reform principles, which in turn is loaded with ethical-moral values^(31-33).

FINAL CONSIDERATIONS

Since the medicalization process of abnormality and difference started through psychiatry, much has been discussed about the true benefits of intervention and about psychiatric medicine seizing madness. The medicalization process of differences starts with a social judgment, which is imbued with a cognitive scheme, responsible for this judgment.

Antisocial and Borderline personality disorders are the most polemic diagnoses, due in a general sense to their difficult treatment and management by health professionals. The analyzed studies particularly appoint that no scientific evidence exists to attribute violent and criminal acts as parts of these disorders' psychopathology, expanding the reflection capacity of such complex concepts.

The analyzed studies also unanimously appoint changes in the criteria, theoretical frameworks, diagnostic and psychotherapeutic methods, in which changes were suggested in diagnostic criteria by including new criteria, while other studies indicated the adoption of dimensional personality assessment and cognitive-behavioral therapy for effective assessment and treatment, respectively. Several of the personality dimensions assessed in these studies are the same as the mental health indicators the World Health Organization adopts.

From the moral perspective, the analyzed studies suggested that Antisocial and Borderline personality disorders are not objects of psychiatric intervention or diagnostic classification, but moral problems, although no treatment or intervention proposal has been presented with this focus. Thus, the main theory is maintained that the mental disorders discussed here can be treated.

Considering nurses in an interdisciplinary perspective of mental health work, their knowledge on the concepts presented here is fundamental. Their responsibility in care delivery is expected to grow, along with their knowledge on the theme involving their work object, also with a view to raising awareness of their clinical supervision and their team and, finally, to stimulating further research and debate on this complex theme, involving the ethical-moral values in force in current society.

ACKNOWLEDGEMENTS

To the Scientific Dissemination Support Program-PRODICI/PROPPG/UEL.

REFERENCES

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Studies of personality disorders Antisocial and Borderline

Estudios sobre trastornos de personalidad Anti-social y Borderline

Publication Dates

• Publication in this collection
  13 Jan 2011
• Date of issue
  2010

History

• Received
  20 Jan 2009
• Accepted
  20 June 2010