The Iron Mask
The Common Sources of Personality Disorders

By: Dr. Sam Vaknin
 

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Do all personality disorders have a common psychodynamic source?
To what stage of personal development can we attribute this common source?
Can the paths leading from that common source to each of these disorders be charted?
Will positive answers to the above endow us with a new understanding of these pernicious conditions?
These are the four questions that this work sets out to answer, the four themes explored. A unifying theory of psychopathology has eluded the best minds for decades. This is not a grandiosity-stricken attempt to come up with such a theory. Personality disorders – however epidemiologically prevalent – still do not cover all the many-faceted manifestations of human mental illness. Moreover, finding a common source does not a theory make in the absence of clear, falsifiable, dynamics. An effort to try to find an alchemical "common source" can fast deteriorate into the compilation of inventory lists of symptoms and behaviour patterns. Sick people are very similar in many respects – but this could be misleading rather than enlightening.
 

Acute Anger

Anger is a compounded phenomenon. It has dispositional properties, expressive and motivational components, situational and individual variations, cognitive and excitatory interdependent manifestations and psychophysiological (especially neuroendocrine) aspects. From the psychobiological point of view, it probably had its survival utility in early evolution, but it seems to have lost a lot of it in modern societies. Actually, in most cases it is counterproductive, even dangerous. Dysfunctional anger is known to have pathogenic effects (mostly cardiovascular).

Most Personality Disordered people are prone to be angry. Their anger is always sudden, raging, frightening and without an apparent provocation by an outside agent. It would seem that people suffering from personality disorders are in a CONSTANT state of anger, which is effectively suppressed most of the time. It manifests itself only when the person's defenses are down, incapacitated, or adversely affected by circumstances, inner or external. We have pointed at the psychodynamic source of this permanent, bottled-up anger, elsewhere in this book ("Malignant Self Love – Narcissism Revisited" and the "Frequently Asked Questions" section). In a nutshell, the patient was, usually, unable to express anger and direct it at "forbidden" targets in his early, formative years (his parents, in most cases). The anger, however, was a justified reaction to abuses and mistreatment. The patient was, therefore, left to nurture a sense of profound injustice and frustrated rage. Healthy people experience anger, but as a transitory state. This is what sets the Personality Disordered apart: their anger is always acute, permanently present, often suppressed or repressed. Healthy anger has an external inducing agent (a reason). It is directed at this agent (coherence). Pathological anger is neither coherent, not externally induced. It emanates from the inside and it is diffuse, directed at the "world" and at "injustice" in general. The patient will identify the IMMEDIATE cause of the anger. Still, upon closer scrutiny, the cause will be found lacking and the anger excessive, disproportionate, incoherent. To refine the point: it might be more accurate to say that the Personality Disordered is expressing (and experiencing) TWO layers of anger, simultaneously and always. The first layer, the superficial anger, is indeed directed at an identified target, the alleged cause of the eruption. The second layer, however, is anger directed at himself. The patient is angry at himself for being unable to vent off normal anger, normally. He feels like a miscreant. He hates himself. This second layer of anger also comprises strong and easily identifiable elements of frustration, irritation and annoyance.

While normal anger is connected to some action regarding its source (or to the planning or contemplation of such action) – pathological anger is mostly directed at oneself or even lacks direction altogether. The Personality Disordered are afraid to show that they are angry to meaningful others because they are afraid to lose them. The Borderline Personality Disordered is terrified of being abandoned, the Narcissist (NPD) needs his Narcissistic supply sources, the Paranoid – his persecutors and so on. These people prefer to direct their anger at people who are meaningless to them, people whose withdrawal will not constitute a threat to their precariously balanced personality. They will yell at a waitress, shout at a taxi driver, or explode at an underling. Alternatively, they will sulk, feel anhedonic or pathologically bored, drink or do drugs – all forms of self-directed aggression. From time to time, no longer able to pretend and to suppress, they will have it out with the real source of their anger. They will rage and, generally, behave like lunatics. They will shout incoherently, make absurd accusations, distort facts, pronounce allegations and suspicions. These episodes will be followed by periods of sentimental sweetness and excessive flattering and submissiveness towards the victim of the latest rage attack. Motivated by the mortal fear of being abandoned or ignored, the Personality Disordered will debase and demean himself to the point of provoking repulsion in the beholder. These pendulum-like emotional swings make life with the Personality Disordered close to impossible.

Anger in healthy persons is diminished through action. It is an aversive, unpleasant emotion. It is intended to generate action in order to eradicate this uncomfortable sensation. It is coupled with physiological arousal. But it is not clear whether action diminishes anger or anger is used up in action. Similarly, it is not clear whether the consciousness of anger is dependent on a stream of cognition expressed in words? Do we become angry because we say that we are angry (=we identify the anger and capture it) – or do we say that we are angry because we are angry to start with?

Anger is induced by numerous factors. It is almost a universal reaction. Any threat to one's welfare (physical, emotional, social, financial, or mental) is met with anger. But so are threats to one's affiliates, nearest, dearest, nation, favorite football club, pet and so on. The territory of anger is enlarged to include not only the person – but all his real and perceived environment, human and non-human. This does not sound like a very adaptive strategy. Threats are not the only situations to be met with anger. Anger is the reaction to injustice (perceived injustice, it does not have to be real), to disagreements, to inconvenience. But the two sources of anger are threat (a disagreement is potentially threatening) and injustice (inconvenience is injustice inflicted on the angry person by the world).

These are also the two sources of personality disorders. The Personality Disordered is molded by recurrent and frequent injustice and he is constantly threatened both by his internal and by his external universes. No wonder that there is a close affinity between the Personality Disordered and the acutely angry person.

And, as opposed to common opinion, the angry person becomes angry whether he believes that what was done to him was deliberate or not. If we lose a precious manuscript, we are bound to become angry at ourselves, though no intent was involved. If his home is devastated by an earthquake – a person will surely rage, though no conscious mind was at work. When we perceive an injustice in the distribution of incentives or wealth or love – we become angry because of moral reasoning, whether the injustice was deliberately applied or not. We retaliate and we punish as a result of our ability to morally reason, to get even. Sometimes even moral reasoning is lacking, as in when we simply wish to alleviate our anger.

What the Personality Disordered does is: he suppresses the anger, but he has no effective mechanisms of redirecting it in order to correct the inducing conditions. His hostile expressions are not constructive – they are destructive because they are diffuse, excessive and, therefore, unclear. He does not lash out at people in order to restore his lost esteem, his prestige, his sense of power and control over his life, to recover emotionally, or to restore his well being. He rages because he cannot help it and is in a self destructive and self-loathing mode. His anger does not contain a signal, which could alter his environment in general and the behaviour of those around him, in particular. His anger is primitive, maladaptive, pent up.

Anger is a primitive, limbic emotion. Its excitatory components and patterns are shared with sexual excitation and with fear. It is cognition that guides our behaviour, aimed at avoiding harm and aversion or at minimizing them. Our cognition is in charge of attaining certain kinds of mental gratification. A prognosis, a prediction regarding the future values of the relief-gratification versus repercussions (reward to risk) ratio- these can be obtained only with the use of cognitive tools. Anger is evoked by aversive treatment, deliberately or unintentionally inflicted. Such treatment must violate either prevailing conventions regarding social interactions or some otherwise deeply ingrained sense of what is fair and what is just. The judgement of fairness or justice (namely, the appraisal of the extent of compliance with conventions of social exchange) – is also cognitive.

The angry person and the Personality Disordered both suffer from a cognitive deficit. They are unable to conceptualize, to design effective strategies and to execute them. They dedicate all their attention to the immediate and ignore the future consequences of their actions. In other words, their attention and information processing faculties are distorted, skewed in favor of the here and now, biased on both the intake and the output. Time is "relativistically dilated" – the present feels more protracted, "longer" than any future. Immediate facts and actions are judged more relevant and weighted more heavily than any remote aversive conditions. Anger impairs cognition.

The angry person is a worried person. The Personality Disordered is also excessively preoccupied with himself. Worry and anger are the cornerstones of the edifice of anxiety. This is where the knot is finally tied: people become angry because they are excessively concerned with bad things which might happen to them. Anger is a result of anxiety (or, when the anger is not acute, of fear).

The striking similarity between anger and personality disorders is the deterioration of the faculty of empathy. Angry people cannot empathize. Actually, "counter-empathy" develops in a state of acute anger. All mitigating circumstances related to the source of the anger - will be taken as meaning to devalue and belittle the suffering of the angry person. His anger will thus increase the more mitigating circumstances are brought to his attention. Judgement is altered by anger. Later provocative acts are judged to be more serious – just by "virtue" of their chronological position. All this is very typical of the Personality Disordered. An impairment of the empathic sensitivities is a prime symptom in many of them (in the Narcissistic, Schizoid and Schizotypal Personality Disordered, to mention but three).

Moreover, the aforementioned impairment of judgement (=impairment of the proper functioning of the mechanism of risk assessment) appears in both acute anger and in many personality disorders. The illusion of omnipotence (power) and invulnerability, the partiality of judgement – are typical of both states. Acute anger (rage attacks in personality disorders) is always incommensurate with the magnitude of the source of the emotion and is fuelled by extraneous experiences. An acutely angry person usually reacts to an ACCUMULATION, an amalgamation of aversive experiences, all enhancing each other in vicious feedback loops, many of them not directly related to the cause of the specific anger episode. The angry person may be reacting to stress, agitation, disturbance, drugs, violence or aggression witnessed by him, to social or to national conflict, to elation and even to sexual excitation. The same is true of the Personality Disordered. His inner world is fraught with unpleasant, ego-dystonic, discomfiting, unsettling, worrisome experiences. His external environment – influenced and molded by his distorted personality – is also transformed into a source of aversive, repulsive, or plainly unpleasant experiences. The personality Disordered explodes in rage – because he implodes AND reacts to outside stimuli, simultaneously. Because he is a slave to magical thinking and, therefore, regards himself as immune, omnipotent, omniscient and protected from the consequences of his own acts – the Personality Disordered often acts in a self destructive and self defeating manner. The similarities are so numerous and so striking that it seems safe to say that the Personality Disordered is in a constant state of acute anger.

Finally, acutely angry people perceive anger to have been the result of intentional (or circumstantial) provocation with a hostile purpose (by the target of their anger). Their targets, on the other hand, invariably regard them as incoherent people, acting arbitrarily, in an unjustified manner.

Replace the words "acutely angry" by "Personality Disordered" and the sentence would still remain largely valid.