Mental health articles

OF mental health care and mentally ill



There is a group of behaviours that, although seen in normal healthy interactions,are taken to extremes or carried out in an inappropriate manner by those with personality disorder. These are:

• always being nice to everyone

• ignoring one’s own needs and putting everyone else first

• never letting people know if they upset you

• becoming overinvolved in other people’s problems

• developing close relationships in a rushed or superficial way.

There is also another group of behaviours that range from frantic attempts tocontrol or avoid situations to paradoxical behaviours designed to take the sting outof a situation by making it happen before it occurs.

Frantic or hysterical reactions to real or imagined rejection or abandonment For example, one client swallowed her husband’s car keys when she became convincedhe would leave her after they had an argument. Another clung to his legs as heattempted to leave screaming that she would kill herself if he left.

Apologising inappropriately and taking the blame for others to avoid confrontationor its consequences A female client who had been abused and undermined formany years by her husband not only stayed with him but covered up for him andmade excuses for his behaviour always saying it was her fault or that she had madehim hit her.

Shooting yourself in the foot A male client panicked so much if he enjoyedanything that he would sabotage anything he enjoyed because he was convinced that he would lose it in the end.

Testing out This is where clients provoke rejection in order to prove to themselves that they are right in their suspicions that they are going to be rejected. They often push and push at friends, family or professionals in order to prove that their fears of rejection are correct.

Anyone who they fear may reject or abandon them will be subjected to a series of tests where they will provoke the very rejection they fear. Unfortunately, these fears and beliefs appear to be so ingrained that no amount of acceptance, toleranceor evidence is sufficient to offer reassurance, and this ‘testing out process’ often continues unabated.

A more problematic form of this that is seen in antisocial personality disorder iswhen the client purposely behaves in an antisocial or objectionable manner. Thisappears to be an attempt to gain control over the rejection, for example if youintentionally make people dislike or reject you, it can take the sting out of therejection as you do not have to face the heartache of being disliked or rejectedwhen you are attempting to be accepted or liked.

Testing fate In extreme circumstances, clients will sometimes indulge in dangerousdeath-defying behaviour. One client, when very distressed, would play chickenon the road with trucks. Her reasoning was ‘Well, if I die, I don’t care; if Idon’t die, that means I’m supposed to carry on.’ Often the highly dangerousnature of these behaviours creates a state of high arousal and excitement thatdistracts the person from the distress of the trigger situation. These dysfunctionalresponses to emotional distress are the key to understanding personality disorder.The sheer terror and extreme distress that can suddenly overwhelm a person with personality disorder is the primary cause of most of the problems experienced bythis group.

These highly emotional states can be triggered very suddenly and at these timesthe person may feel totally out of control. They develop patterns of behaviourto cope with these emotional overload situations. Self-harm, suicide, violence –anything is better than having to face the emotion.

Often people with personality disorder feel that they have no choice in thesesituations. They are out of control and need someone else to keep them safe andhelp them regain control. In some extreme cases, the person dissociates themselvesfrom the situation so completely that they are unaware of what they are doing.Sometimes, after the event they will have no memory of what has happened.

Black-and-white thinking The world is a really inconsistent place. People havegood and bad moods; they may do and say nice things one moment and bad thingson another occasion. For people with personality disorder, this is really confusingbecause these inconsistencies do not fit with the way they perceive the world. Thisleads to a process known as ‘splitting’, where everything gets divided into extremesand only one extreme is perceived at any one time.

Making judgements becomes very difficult as the judgement will not be madein a balanced way but will depend on which extreme is being perceived at thatmoment. This in turn may mean that the judgement will change when the perceptionchanges. People with this problem are often aware that they have difficulty makingjudgements and learn not to trust their own judgement as a result.

Black-and-white thinking does not just apply to people; it can apply to anything.For example, Angela, a client with borderline personality disorder, could not understandhow she could believe anything good about herself without becoming horrendouslyarrogant; as she really hated the idea of being arrogant, she refused to believeanything good about herself.

This leads to a bizarre perception of the world. Everything is black or white andwhat was once black can become white, but by the time it does the client cannotremember how it appeared when it was black and it may then switch back again.This inconsistent perception leads to feelings of insecurity and confusion. It is verydifficult to live in a world that changes all the time, and making decisions becomesimpossible.

Splitting This term is used to describe the process where people with personalitydisorder split off different parts of their own personality. In extreme cases, thissplitting is so extreme that the person may have no memory of what they have beendoing in one mode when they are in another. In the US, this is sometimes seenas ‘multiple personality disorder’. However, these ‘personalities’ are incompletefragments of personality rather than complete and distinct personalities in themselves.In the UK, the same presentation is seen as dissociation in a fragmentedpersonality. Either way, treatment is aimed at consolidating the various aspects intoone complete person. The scenario below provides an example.

This apparent contradiction was interpreted by some staff as proof that she wasbeing manipulative and that her need was not genuine. In reality, there was nocontradiction, as Sue had automatically switched to a different mode, one whichwas necessary to attend the interview that was important to her. This splitting isnot under the conscious control of the client and can be as confusing to the personsuffering from this symptom as it is to their family and carers.

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