My new patient, a middle-aged man, sat in the chair opposite mine and stated in a somewhat aggrieved tone: “Hey doc, I hear you specialize in treating personality disorders. My partner looked on the internet and said that I am a narcissist and that there is not much hope for me. What do you think?”
Patients seeking help after self-diagnosing with personality disorders is not an uncommon experience for me as a clinician. Over about the past decade or so, I have observed the trend toward either self-diagnosis or diagnosis by a family member or partner.
A parallel trend has occurred in medical practices whereby patients approach their physicians and request a prescription for their anxiety or depression after watching ads about medications.
The movement toward amateur diagnosing has been fueled in part by access to the internet, along with an explosion of information regarding mental health issues and personality disorders. These sometimes compelling stories grab our attention with themes of betrayal, criminality, sexual acting-out, substance abuse, exploitation of partners, and a multitude of ways people with personality disorders make life difficult for those around them.
True or imagined tales of people with personality disorders are popular, and presented regularly in magazines such as Psychology Today. While psychiatrists and psychologists were once reluctant to diagnose public figures whom they had not met personally, now such diagnoses are common and sometimes even encouraged as a professional or social duty.
In one paper, a group of 27 psychiatrists and mental health professionals published their assessment of Donald Trump, based on publicly available speeches and behaviors. Their consensus was made public: he was considered to be a malignant narcissist, which refers to someone whose extreme level of narcissism crosses the boundary into an antisocial personality disorder.
Public access to information about personality disorders is not all bad. Many who have been suffering silently, or who have lived with those who suffer from the disorder, may now find ways to get the help they need. The primary danger inherent in this trend is in using pathological labeling as a tool to hurt others.
In one case, a man who suffered from severe childhood trauma was told by his wife that her therapist (never having met him) diagnosed him as suffering from borderline personality disorder. She went on to divulge this information in front of their adult children at the dinner table, where they proceeded to search on their cell phones and ultimately agreed with the diagnosis. This was extremely disturbing to my patient who felt labeled with a stigmatizing diagnosis in a shaming and public way.
However, some people feel a sense of relief in discovering they have a condition that others also have, and for which evidence-based treatments exist.
Personality Disorders and Trauma
I have specialized in the treatment of personality disorders for over three decades. I have learned what I consider to be the most critical commonality among these patients: almost every patient I have evaluated and/or treated has suffered from early traumatic experiences in childhood or adolescence. And yet, most medical and mental health clinicians do not recognize or acknowledge the prevalence of trauma most of the time.
Trauma as the root cause and pathway to most psychological and many physical disorders has been known and subsequently “forgotten” in waves through the generations. We don’t want to believe that parents and adults mistreat, abuse, neglect, and fail to protect those entrusted to their care.
We all want to look away as it is much too painful for us to bear witness. Consider, also, the worldwide trafficking in children that goes on not only in third world countries but in our own first world communities. It’s important that we open our eyes to the lifelong effects of childhood trauma.
How Trauma Leads to Personality Dysfunction
Trauma is a developmental disruption that often crystallizes patterns of adaptation, erodes one’s sense of safety and trust, and alters the way that information is processed. Strategies that were once adaptive responses to adversity may become fixed and increasingly maladaptive as we age. Patterns of self-other relationships and also the ways we treat ourselves become entrenched, exaggerated, and self-perpetuating.
Thus, the non-metabolized trauma becomes part of our operating system, which comprises the encoded internal beliefs that we carry about ourselves and others, such as “I can trust,” “I can rely on others,” or “I am bad,” “I deserve to suffer.”
Along with the encoded cognitions that we adopt from the way we are treated, we have feelings that, if not processed productively, result in defenses which further distort the information processing system. The ability to grow, learn from mistakes, and thrive are curtailed and instead vicious cycles dominate one’s interactions with the world.
What Can We Do If Someone We Love Shows Signs of Personality Dysfunction?
If someone you love displays signs of a personality disorder, it is imperative they see a medical or mental health provider. It is almost always the case that patients will not initially report a history of trauma unless trust has been established, and they are asked directly. I have treated many patients who have told me that they suffered severe abuse and were in treatment with other providers but were never asked about their history of traumatic events.
Often such patients are offered regimes of psychotropic medication and labeled in ways that make them feel worse. For those seeking treatment for themselves or family members, it is important that labeling and diagnosing mental disorders are not used in a shaming or stigmatizing manner.
Personality can change: neuroscience has shown that our brains are capable of neuroplasticity, so that when traumatic events of the past are faced and processed, we can achieve new ways of interacting with others and develop compassion for their own inner self.
- Lee, B. X. (2019). Summary of the Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President by Brandy X. Lee. Scorpio Digital Press.
- Magnavita, J. J. (2018). “The Treatment of Trait and Narcissistic Personality Disturbances,” in Herman, A. D., Brunell, A. B., & Foster, J. D. (Eds.). Handbook of Trait Narcissism: Key Advances, Research Methods, and Controversies (pp. 471-479) New York: Springer.
- Magnavita, J. J. (2005). Personality-Guided Relational Therapy: A Unified Approach. Washington, DC: American Psychological Association.
- Magnavita, J. J. (2010). Evidence-Based Treatment of Personality Dysfunction: Principles, Methods, and Processes. Washington, DC: American Psychological Association.
- van der Kolk, B. (2014). The body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. New York: Penguin Books.