The Crazy Inside All of Us – Part 1: Personality Disorders

Have you ever noticed that everyone around you is crazy? I certainly have, especially now. When you really get to know someone, you get to peer into his or her deepest-darkest thoughts. Some people wear their crazy on the outside. Others take it with them to the grave. The reality is that our craziness represents a shared experience by all of us. We are all primates with primal urges and desires. We all have thoughts everyday that we are not proud of and most of us would agree that we are much more selfish than we lead on to our co-humans. Most of us would probably be a lot healthier if we came to terms with our crazy and discussed it more openly.

The crazy is certainly coming out in society as I am writing this. Pandemic lock downs, police shootings, massive protests, tear gassing citizens, and everything else happening right now are a lot to take in! In Part 2 of this article we will talk about coping or defense mechanisms, defined as unconscious strategies people use to defend themselves against anxiety provoking, unacceptable thoughts, emotions, or impulses. There is a lot of pent-up energy in all of us at this time. We are even seeing groups of people expressing pent-up energy that has been stored over years, and even generations of mistreatment and oppression.

Many people are familiar with psychiatric and developmental disorders. Most individuals understand, or are at least are familiar with things like depression, anxiety, bipolar depression, schizophrenia, autism spectrum disorders, and substance abuse disorders. But many of us may be less familiar with personality disorders. We have all met people with bad personalities or personality problems. This article is going to help put some labels on these personality problems. By understanding these maladaptive personality traits, we can better recognize them both in others and ourselves. Recognition is the first step to bettering oneself. I view personality disorders as a spectrum of disease, which all of us have some connection to. Our very own crazy!

Introduction

Personality is defined psychologically as a set of long lasting behavioral and mental traits that distinguish us from one another as individual people. But our personalities do not live in isolation. They are part of an environment, which consists of other people with distinct personalities, the greater society with all of its ideas and opinions, as well as the natural world that houses both our society and us. When a person is able to play nicely with other people and their ideas fit in well with societal norms, we often describe such a person as having a “good” personality. However “good” is not really intrinsic to their personality, but rather, representative of the “good” fit between such a personality and its surroundings. In contrast, “bad” personalities often represent a “bad” fit.

A personality disorder is defined by the DSM5 (Diagnostic and Statistical Manual of Mental Disorders, 2013) as enduring maladaptive patterns of behavior and thinking that are present in many different contexts within an individual’s life. Furthermore and very importantly, these maladaptations must significantly deviate from those accepted by the individual's culture. These maladaptations typically cause the individual some degree of distress and disability. The maladaptive patterns of a personality disorder must not be better explained by a psychiatric illness, developmental stage, or the effects of a substance such as an illicit drug.

Approximately 5-20% of people in most societies are thought to have a personality disorder. Among those with mental health illnesses, rates can be over 50%. While most of us do not have a diagnosable personality disorder, all of us can recognize some of the below mentioned traits in ourselves. That is, if we are brave enough to be honest with ourselves. The DSM5 lists 10 discrete personality disorders. However, individuals can have combinations or parts of each of these personality disorders leading to a large array of presentations as diverse as the personalities themselves. Many people have a predisposition to these disorders because of their genetics. However they are also considered to be acquired maladaptive behaviors, with a significant portion learned from our environment, beginning very early in childhood.

Let's review all 10 of the currently diagnosable personality disorders. While you read, think about people you have met, fictional characters, and public personalities that might fit into one or several of these personality disorders. If you want to make yourself a better person, think about the personality disorder that most describes yourself. Then think about how you might change your behavior in order to achieve a more fulfilling life.

The Odd People (Paranoid, Schizoid, and Schizotypal)

Paranoid Personality Disorder

(Adolf Hitler, Nazi Germany)

This disorder is characterized by mistrust of others and society. They are often paranoid that people are trying to harm or wrong them, that intimate partners are cheating on them, and tend to have many conspiratorial explanations for things. As a result, they are often withdrawn and emotionally detached. They regularly hold grudges and do not trust other people. In spite of their emotional detachment, they are often very sensitive to setbacks and insults.

These traits make it hard for people to function in society and to have meaningful relationships. As such, this personality disorder can be quite debilitating. It has significant symptoms that overlap with schizophrenia, perhaps the most severe mental health disorder.

Patients have told me they do not smoke marijuana because it makes them paranoid. “I smoked and then went around the whole house and shut all the blinds because I thought people were watching me. I peaked through cracks in the blinds to keep an eye on what was outside repeatedly. Nothing was out there”. There are others who say it makes them social. We are such interesting creatures. But remember, these personality disorders must exist in the absence of drug use and cannot be explained by other mental health disorders.

Paranoia strikes deep. We have all felt it. When it starts to control your every action it is a problem. Some degree of paranoia is healthy though, as it protects us from those who really are trying to harm us.

Schizoid Personality Disorder

(Dexter Morgan, Dexter series [not the killing part, just his personality])

Schizoids are hermits. They prefer to be solitary and do not enjoy close relationships with others. They are often emotionally flat, indifferent to praise or criticism, take pleasure in few if any activities, and do not follow social norms. They may seem autistic but often are more able to recognize reality than individuals with severe autism spectrum disorders. This is a fairly rare personality disorder and due to their withdrawn nature, most people are unlikely to meet them. I think we all feel a little Schizoid sometimes, but for most only on a bad day.

Schizotypal Personality Disorder

(Possibly Doc Brown, Back to the Future)

This personality disorder very closely resembles an attenuated or less severe version of schizophrenia. Schizotypal people are often odd, disorganized, struggle profoundly with interpersonal relationships, and have what most people would describe as distorted or odd thinking. Their thinking is often very magical in nature, believing in paranormal and supernatural phenomena. They often have ideas of reference, believing that events in their life are somehow connected and represent a greater, and often negative meaning. They also have bodily illusions, thinking things like part or all of their body is not their own or that they do not really exist.

It is hard for me not to think about Lord of the Rings, Harry Potter, Star Wars, and other fantasy epics when I think about these individuals. Surely we all share some of this preoccupation with greater meanings and magical explanations. However, those who are not able to pull back into reality are greatly debilitated from a societal functioning standpoint.

The Dramatic People (Antisocial, Borderline, Histrionic, and Narcissistic)

Antisocial Personality Disorder

(The Joker, Batman Movies)

These individuals often have a complete disregard for the rights of others. They typically have poor moral values and no sense of conscience. As a result, they are frequently involved in crimes and often demonstrate aggressive behavior toward others. In childhood they are often involved in fights, conflicts with parents, cruelty toward animals, and poor academic performance. Later in life they struggle to perform in the workplace, are involved in abusive relationships, and frequently become involved with crime. While only about 5% of people are thought to suffer from some degree of antisocial personality disorder, studies on incarcerated men have shown rates as high as 80%.

People with personality disorders are often very difficult to help. Those with antisocial personality disorder are particularly difficult, with some believing that many individuals cannot be cured of their negative behavioral and thought patterns. This disorder disproportionately affects those from low socioeconomic status. This is not surprising to me as the amount of crime, illicit drug use, and dog-eat-dog mentality seem much more common in areas of oppression.

All of us wrong one another throughout our lifetimes. We need to stop. The world is already a rough place as is. When we do something good for others we make the world a better place. I have found that every time I give something selflessly, I almost always get back more than I gave in the first place. Early intervention, likely in childhood, is probably key to helping such people.

Borderline Personality Disorder

(Norma Bates, Psycho)

One of the most terrifying things a patient can tell me, after only exchanging a few encounters with them, is that I am “the best doctor they have ever had”. They then often go on to say the last doctor they had was horrible. This is called splitting, and it is a red flag.

Those with borderline personality disorder are terrified of being abandoned, they have very poor self-image, are impulsive, have uncontrolled emotions, and often exhibit self-damaging behavior. They view things as either all good or all bad, which is highlighted by my point above, and referred to in psychiatry as splitting. They often lack a sense of identity and deal with any perceived rejection very poorly. These individuals have suicide rates much higher than the normal population.

We have all met someone like this. They latch onto others, eventually feel let down by them, and then explode emotionally. When we feel down or defeated, many of us may act a little borderline ourselves.

Histrionic Personality Disorder

(Anakin Skywalker, just prior to his fall to Darth Vader, Star Wars; Most reality TV show people)

Ever met someone that has to be the center of attention at all times? These individuals are often dramatic, seductive, and exaggerate their behaviors and appearance in the hopes of drawing attention. Sounds like all the major media outlets doesn’t it?!

Most of us are fairly aware and annoyed with these people. By definition they make themselves known. Women are disproportionately affected by this disorder.

In my opinion, the world is getting crazier every day. Advertisements have to work harder than ever to draw our attention. News outlets compete for our eyes and ears by drawing on fear tactics with shock and awe maneuvers. Sometimes it is nice to take a step back. Turn off the news, turn off social media, and go on a peaceful walk. Primates like to make a lot of noise, even when nothing is happening.

Narcissistic Personality Disorder

(Maui, Disney’s Moana, though he is a demigod, so he might actually be better…)

The narcissist believes they are the greatest, smartest, and most beautiful person. Sometimes such individuals truly believe they are profoundly special. Others feel a deep sense of inferiority and hide behind their narcissistic tendencies. In either case they exhibit grandiosity, feeling that they have nearly unlimited power, intelligence, beauty, or love.

Such individuals may lack empathy, and often exploit relationships for their own benefit. They have an excessive need for admiration. While many personality types struggle in their careers, some personality disorders are disproportionately represented in positions of power. Presidents, politicians, business leaders, professional athletes, and celebrities are highly successful individuals. Narcissistic traits (sometimes even disorders) can be very common in these highly successful people. At some point in our lives, many of us have felt this heightened sense of importance. An enduring expression of these traits is what defines narcissistic and other personality disorders.

When people are in positions of power, it is not uncommon for them to mistreat or psychologically torment those underneath them. If you are in a position of power over others, I encourage you to be very thoughtful about your actions. Do not take out your own feelings of inadequacy on those working underneath you. If your boss mistreats you in unproductive ways, look for a new job or transfer, but also realize that mental health or personality disorders are likely playing a big role. It is often not you, but them who has an issue. This will be explained more thoroughly when we talk about defense mechanisms in Part 2.

The Anxious People (Avoidant, Dependent, and Obsessive Compulsive)

Avoidant Personality Disorder

(Possibly Charlie Brown, from Peanuts cartoon)

Unlike Schizoid individuals, those with avoidant personality disorder strongly desire intimacy with others. However, because they are so afraid and anxious regarding rejection, they avoid social situations, intimate relationships, and occupations with interpersonal contact. They are preoccupied with rejection and view themselves as socially inept or lacking. Being rejected as a child by parents or peer groups is strongly linked to this disorder. However many individuals suffer from this disorder in the absence of such an event.

All of us feel alone at times. Most of us are desperate for social intimacy and acceptance. Reach out to other people and allow yourself to be vulnerable. Do not worry about being cool or being rejected. Instead worry about being a good person that wants to help others and you will find acceptance.

I know so many people who say things like “I wish I could be friends with that person” but never actually take the risk of introducing themselves and asking to hang out. We all need to open up. While sometimes we will be rejected, the overall benefit of putting yourself out there greatly outweighs the risk. If someone rejects you, it is his or her loss!

I always tell people that I am the richest man I know because I have been blessed with such wonderful friends.

Dependent Personality Disorder

(Buster, Arrested Development)

These individuals depend on others to take care of them and make decisions for them. They require constant reassurance, have difficulty initiating their own projects and activities, and are unable to assume responsibility in their own life. They feel uncomfortable and helpless when alone and are always anxious about being left. Such individuals are very clingy and will go to extraordinary lengths to try and maintain their dependent relationship.

Dependent people are too anxious and unsure of themselves to live life on their own. They rely on their dependents for reassurance. After failures in my own life, I have certainly felt this way, I believe many people have. To some degree, most of us depend on others. However, any healthy person should be able to stand alone on his or her own two feet and face the adversity that life relentlessly brings.

Obsessive-Compulsive (OC) Personality Disorder

(Possibly Steve Jobs, Apple Co-founder)

Orderliness, perfectionism, and control are the characteristics, which define this disorder. OC persons need to control their environment as well as the people within it. As such, they are often inflexible and dislike any unpredictable events. Such individuals may be very tight with money. Their need for control often comes at the expense of efficiency and leads to unhealthy interpersonal relationships. While there is some overlap with obsessive-compulsive disorder, this is considered by most to be a distinct entity.

Like those with narcissistic personality disorder, OC individuals can often be found in positions of power. Their disorder can create serious disharmony in the workplace. I have personally worked under such an individual and it was not something I would like to do again. With proper insight and behavioral interventions, some of the attributes of this disorder can be positive in certain situations, for instance organizational skills.

Discussion

Every person has a unique personality, defined by his or her enduring patterns of behavior and thinking. This means your mom was right, you are unique, just like everybody else. When an individual’s personality does not match up with societal norms, we view them as odd or out of place. Psychiatrists have categorized severe forms of mismatch under the diagnosis of personality disorder.

However, people should remember that parts of every personality disorder can have benefits. For example, narcissism lends itself to a certain degree of confidence. Many people could use more confidence in their lives. Obsessive-compulsive personality disorder lends itself to meticulous organization. Many of us could benefit from improved organization. Even a person with a schizoid personality, that enjoys being alone, can derive some benefit, particularly during a pandemic with stay at home orders. While personality disorders can be debilitating, they often represent extreme examples of what can be very beneficial traits. So we cannot view them as all bad. Remember viewing anything as all bad or all good is called splitting, a key manifestation of the particularly debilitating, borderline personality disorders as well as Sith Lords (Dark Side) from Star Wars.

Those with personality disorders are outliers. Remember that outliers contribute significantly to diversity within a population of people. From a scientific perspective, diversity is good, as it gives our species a survival advantage (this will be a discussion for a future blog). Even what are widely considered negative traits, may prove beneficial in some situations.

Keep in mind that personality disorders are not static. They change over time within a given population of people. They are also highly dependent on the local culture, ideas, and accepted norms. It is somewhat shameful to admit, but homosexuality was listed as a personality disorder in the first Diagnostic and Statistical Manual of Mental Health Disorders, 1952. I must say, I am oftentimes embarrassed to be a physician. Especially when considering some of the horrible things my predecessors have done. This includes things like experimenting on minorities and children as well as calling homosexuality a personality disorder.

Most of us do not have a diagnosable personality disorder. But if we are honest with ourselves, all of us have expressed at least some of the negative characteristics listed above, at some point in our lives. All of us do things we are not proud of and make mistakes. Those who can react to their shortcomings and mistakes in a positive manner are able to continually better themselves, as well as our society.

Remember that most people with personality disorders will have a mix of the above mentioned, ten discrete personality disorders. Psychiatric illness and substance abuse are also common among those with personality disorders, further complicating the picture. One characteristic, which unites all personality disorders, is immature responses to stressful situations, emotions, thoughts, and impulses. People’s unconscious and self-preserving responses to stress are referred to as coping or defense mechanisms. Some mechanisms are healthy, allow us to become better people, and live healthy lives. Other coping mechanisms are considered harmful to self and society. In Part 2 of “The Crazy Inside All of Us” we are going to discuss defense mechanisms!

Author

William Brandenburg, MD, owner of Wonder Medicine clinic and full time rural hospitalist.

Editor

Karlee Brandenburg, RN-BSN, owner of Wonder Medicine.

Conflict of Interest

This article promotes Wonder Medicine clinic, which the author and editor own.

Disclaimer

This article was written for educational purposes only. It is not intended to serve as formal medical advice. Please talk with your healthcare provider if you are having a medical problem.

References

• Diagnostic and Statistical Manual of Mental Disorders 1, 2, 3, 4, and 5. American Psychiatric Association.

• Guze S. Criminality and Psychiatric Disorders. Oxford University Press. New York. 1976.

• World Health Organization, Personality Disorders.

• Wikipedia

• Personal experience treating and dealing with crazy people

• The crazy that lives inside me!