Stigma and Personality Disorders

Last week I delivered a lecture on personality disorders to a group of nurse practitioners students. I am always excited to teach this subject, as the class is always lively and well-attended. Students have many "war stories" about interesting encounters with clients with personality disorders. I have had my fair share of memorable interactions, and I used to dread my time with these clients. Thanks to personal and professional growth, I welcome clients with personality disorders to my practice. Working with these clients is rewarding, as their recovery can be impactful to both them and their families.

It is estimated that 9% of adults have a personality disorder. The word personality comes from the Greek "persona," meaning a theatrical mask. Countless theories have attempted to explain the genesis of human personality. I subscribe to the works of Bandura (operant learning) and Rogers (Humanistic Theory) to understand personality. I also have learned that personality dysfunction is often genetic and often the cause or the result of generational trauma.

Personality disorders are associated with worsened psychiatric outcomes. Clients with personality disorders die sooner and have worsened medical co-morbidities. Studies have shown that clients with personality disorders neglect to care for their medical needs, such as taking insulin and blood pressure medications and following up with aftercare instructions. There are three clusters of personality disorders; clusters A, B, and C. Cluster A includes conditions of oddity such as schizotypal personality. Cluster B consists of dramatic conditions, an example being borderline personality disorder. Finally, cluster C includes anxious disorders, for example, obsessive-compulsive personality disorder.

Cluster B personality disorders often get the brunt of societal stigma, as these individuals repeatedly violate the rights of others or cause chaos in their interactions with the healthcare system. Healthcare providers, in particular, often have difficulty accepting that personality disorder is a mental illness like major depression, schizophrenia, or bipolar disorder. Research has demonstrated that the brains of clients with personality disorders are wired differently compared to their non-PD counterparts. Besides the biological data that classifies PD as a mental illness, practically no one wakes up and says, "I want to create chaos in my life today!" These clients suffer considerably as a result of their actions. Humans do not want to suffer. That is not in our nature.

This rationale seems straightforward; however, for years, I could not wrap my brain around this idea. It was until I worked in the outpatient environment and followed clients for years that I realized that these clients are more complicated than this polarized view I had developed. These clients were once children. Many of them are victims of physical or sexual abuse. Often they are exposed to maladaptive coping from a young age. They had as much control over their personality development as I have control over putting down my favorite frosted donut (LOL). This awaking allowed me to develop genuine positive regard for my clients with personality disorders. I began to accept the nature of the illness and not allow others' stigma to influence my relationship with clients.

With this newfound epiphany, clients started to respond better to treatment. I began to look forward to my work with PD clients, and the number of crisis appointments lessened. I tolerated the highs and the lows. I accepted the outbursts and setbacks. The clients began to see I had genuine empathy for their predicament. The positive regard and trust I built created an opening for treatment. As I finish this blog, I am throwing down a challenge for all my healthcare provider readers: change your thinking about personality disorders. Be open to the idea that this is a mental illness and not choice-driven behavior. Develop positive regard for all of your clients. These clients deserve better.