I finally have time to get back to this weekly blog. I’ve actually missed doing it as it gave me an opportunity to think about how psychiatric diagnoses have helped me build story characters.
Starting off with Borderline Personality Disorder, I think it’s safe to say that this is one of the most challenging diagnoses for any clinician. Borderlines are characterized by a severe and pervasive fear of abandonment; they’ll stop at nothing to ensure that the people in their lives stay connected. About 75% of persons with this disorder are female. Self mutilation and multiple suicide attempts, that are more attention-getting gestures than true suicide attempts, are common. Despite the fact that the Borderline doesn’t really want to die, they often miscalculate; thus, this group suicides at a rate roughly ten times greater than the general population. Medications are fairly ineffective treating this disorder. There are some newer, highly structured, psychotherapeutic interventions that have shown some promise, though.
The most distinctive characteristic of persons with BPD is their hypersensitivity to rejection and their preoccupation with abandonment. Unfortunately, their perception of whether or not another cares for them involves unrealistic levels of availability and validation. So, the individual with BPD alternatively idealizes, then devalues, others. In storybook land, this could be a supporting character who is uber–demanding, constantly upping the emotional ante to get their needs met.
As a personal aside, the very few suicides I’ve had in my practice over the years have all carried this diagnosis. They are difficult to treat because they do not trust easily, so the development and maintenance of a therapeutic alliance is a perpetual challenge.
Narcissistic Personality Disorders aren’t any easier to treat than Borderlines, but at least they lack the lethal element. Narcissists actually make great antagonists. They’re the ones with an elevated sense of their own importance, a sense of entitlement, and fantasies of unlimited success/power/brilliance. They can be haughty and arrogant. They also tend to be interpersonally exploitive, lack empathy and are envious of others. I can think of lots of storybook antagonists who fit that bill: Joffrey in the Fire and Ice Series, Saruman in LOTR, Ambrose in Rothfuss’s Name of the Wind, to name but a few.
Narcissists hardly ever come into psychotherapy. The idea that they would even need to consider fixing anything about themselves is anathema to them. Underneath the bravado, though, is brittleness. In depth work, they train practitioners to be wary of too much confrontation with this disorder (assuming you’d ever see one in your practice!) because the theory is once you’ve pulled their covers, there’s no ego strength beneath to shore them up.
Another thing to keep in mind is that the personality disorders rarely occur singly. Generally individuals have traits from more than one of these disorders. So, Joffrey was also an antisocial personality disorder, as was Saruman. The Diagnostic and Statistical Manual of Mental Disorders (we’re on the fourth edition at the moment) defines a personality disorder as “an enduring pattern of inner experience and behavior that deviates markedly from the expectation of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment”.
In plain speak, what this means is that personality disorders see the world in a way that diverges from most of the rest of us. The more severe disorders have their roots in very early childhood (age 0-3). And, clinicians (who often do not agree on much) agree that all of these disorders begin prior to age 5.
Today’s blog is getting too long to finish the last two disorders. However, I’d be more than glad to entertain any questions about this series so far.