When Sleep Eludes

INSOMNIA comes in many forms and has many causes - from side effects of prescription medication, alcohol, coffee, vanilla [yes, it’s a stimulant], physical illness, depression or anxiety, negative emotions like guilt or anger, to excitement, diet, disturbance of usual sleep patterns, physical discomfort, allergies [e.g. to invisible pollens], or concrete disturbances like noise.  Add a long et cetera to the list!

Forms of Insomnia:  Difficulty falling asleep, Disturbed sleep, Nightmares or night terrors, Inability to access Deep Sleep, Too deep and too long sleep periods, Interruption of [+- 90 minutes] sleep cycles, Medical problems like Sleep Apnea;  Early Waking.

The pattern of someone’s particular sleep disturbance can often suggest the cause/s and thus the best solutions.  Unfortunately too many people become dependant on drugs [prescription, alcohol, other drugs or even starchy foods] in order to get enough rest while sleeping.  Except during times of trauma [physical, emotional, societal] it should not be necessary to use chemicals in order to get a great night’s sleep. 

Ironically, the same “rules” for having good sleep experiences generally have applied over many centuries and in different cultures, despite great changes in environmental or social circumstances or demands.  For instance, if you wouldn’t have felt restful if a troupe of actors came to perform Macbeth in your bedroom in 1620, you also will be unlikely to sleep well if you watch television in the bedroom in the 21^st century! 

Most cases of insomnia can be easily cured by simple changes in our lifestyle or thinking habits!

That would of course imply that we have to give up the immediate gratification type of comfort or stimulation for the longer-term benefits of great sleep.

If you believe you have sleeping problems or a sleeping disorder, it is a useful first step to note patterns of disturbance and possible correlation to patterns of behaviour or state of mental or physical well-being or discomfort.  Many times you will then be able to correct the problem appropriately [and without drugs!] but sometimes it may be necessary to consult a health professional like a Clinical Psychologist or a Doctor, or even to be assessed at a Sleep Laboratory, to find the best solution for the problem. 

Specialised techniques like Hypnosis or relaxation exercises are very useful adjuncts to any other methods to alleviate or manage sleep disturbance. 

More about types/forms of sleep disturbance and their causes:

First, unless you are quite sure that the cause is purely psychological or in your life style, it is always wise to rule out possible medical causes, then rule out possible substance causes [including prescribed medication], as sleep disturbances could be an early warning system that there is a physical problem that needs attention.

We can test for lifestyle causes by changing the things we are doing according to the list later in this article for at least 10 days, consistently:  If our sleep improves significantly, then we no longer have a problem!  If not, consult a physician who may also require some blood tests, if medical conditions [like thyroid malfunction or hormonal problems] are suspected.  Please note that while conditions like Sleep Apnea may have lifestyle causes [like being overweight and/or using too much alcohol] they can be life threatening conditions that need medical intervention until the lifestyle changes have positive results over time;  some conditions require medical management for life.

Medical conditions that may be misdiagnosed on initial inspection as Psychological, include Thyroid malfunction, Hormonal imbalance [in men also, not just the stereotyped women’s states of PMS, pregnancy or menopause! – for instance, low testosterone could contribute to high anxiety and sleeplessness in men].  It is important to treat the medical condition rather than its “psychological” symptoms only.

Conditions like diabetes, high or low blood pressure, kidney malfunction, sinusitis, digestive system problems, etc, etc, may also cause or contribute significantly to sleep disturbances.  The medication used to treat these and other disorders [like cancer, or allergies] can frequently be a cause of sleep disturbance, for instance, many medications used for high blood pressure can cause “restless legs” [also found in diabetes] that interferes with sleep.  Spinal injuries, especially if high in the spine, can cause interference with sleep due to conditions like spasticity of the limbs or “high tonus” [tension state] of skeletal muscles generally.  Acute and chronic pain can interfere with sleep.

Patterns of Sleep Disturbance and emotional arousal:  Generally difficulty falling asleep, or frequent waking [once medical causes are ruled out] appear to be related to stimulant/excitement chemical states of the brain [like anxiety or excitement], and early waking with inability to resume sleep appears to be associated with depressed chemical states of the brain [like depression or grief].

Lifestyle causes of sleep disturbances:

Diet:  Eating a heavy meal  or meat late at night;  eating too much meat at supper, eating dairy products at/after supper if you are sensitive to them;  garlic, onions, vanilla, alcohol, caffeine [including in chocolate, tea, soft drinks, some food energy supplements], acidic fruits, MSGs [Monosodium Glutamate found as taste enhancer in many “fast” foods like potato crisps, pizza, sauces, Chinese food and most soya sauces, fish or chicken batter at fast food vendors, gravy or basting at many steak houses, some commercial salad dressings];  too low or too high blood sugar, etc.

Distraction/Stimulation: 
1] Every authority on sleep disturbances states that “The bedroom should be used for sleep, rest and sex only”.  Add to that meditative exercises or spiritual rituals like praying.
2] Do not read in bed.  Read on a chair, seated [not slumped/lying down], under good light somewhere else in or out of the bedroom.
3] Except if you are bed-ridden no one should have a TV or PC in the bedroom;  if you are renting a single room, then do not watch or work from your bed.  Lying down should be associated with rest, sleep, and sex/comfortable togetherness only.  We form “habit” brain pathways with repeated action and the brain gets confused when it has opposing pathways associated with the same situation [e.g. being in bed] – it does not know whether to sleep or not, which leads to sleep disturbance.
4] Some forms of meditation can actually stimulate the brain:  we need alpha states to rest:  do not play eg Beta state generator CDs/MP3s etc late at night.  Do not play arousing music or engage in arousing reading/Tv etc [eg thrillers] before going to bed/sleep.
5] As far as possible, keep regular times to fall asleep or wake up.  The Reptilian centre of our brain becomes anxious when patterns are interrupted frequently, and will assume a watchful-wakeful state.
6] Do not over-sleep or sleep late to “make up” for sleep lost through late night activities.  This affects your sleep-waking cycle.  Rather “catch up” with shorter rest or sleep sessions [“siesta” or “forty winks” are sufficient to replenish energy till the next “normal” sleep time.]
6] Do not exercise vigorously within 2-3 hours before bed time [certain yoga or gentle stretching exercises may be acceptable – always test to see if it makes a difference].
7] Create a “settling down” period of at least 30 minutes before attempting sleep.  This can include calm music, rubbing on body lotion, prayer/visualisation, affirmations of peaceful, positive thoughts, etc.
8] Use self-hypnosis/relaxation/autogenic training exercises if you feel alert/ anxious/ depressed/ irritable/ aroused at bed time, or if you are in physical discomfort like pain.

Hypnosis recordings can be extremely helpful in combating both sleep disorders and their causes, whether physical like pain or illness, or psychological like anxiety or depression.  A properly qualified Clinical Hypnotherapist [i.e. someone like a psychologist/psychiatrist who is qualified not only in hypnosis but also in the neurology and physiology affecting sleep] is recommended although there are also very good commercial sleep-hypnosis products available on the internet. PLEASE READ THE ARTICLES ON HYPNOSIS ON THIS SITE before you buy a product or see a hypnotist as here could be dangers if the hypnotist is not adequately trained or experienced.  Always ask for credentials before submitting to any form of treatment!

Disruptive Emotions or Thinking:

There is by now overwhelming evidence, especially since research by Cogitive-Behavioral and Brain scientists in the last half of the 20^th century and later, that any form of mental or physical distress can be exacerbated and often even caused by incorrect/dysfunctional habits of thinking or behaving.

Many people frequently sleep very little when they’re involved with something fun or stimulating, and feel fine [though I would recommend that this practice is limited to “occasional” sleep deprivation!].  Suddenly if we can’t sleep due to physical or mental discomfort, we tend to “catastrophise” [i.e. give it more power to disrupt us than necessary or real]…  People say “I had ONLY 5 hours’ sleep last night;  I MUST be tired and today therefore WILL be terrible!”  [So many thinking errors in one statement!] Rather say “I’m so happy and excited that I had a FULL five hours’ sleep and am looking forward to a wonderful day, full of positive energy, and a great night’s sleep thereafter!”

Use phrases like “I’m looking forward to a wonderful night’s rest, and a positive, glorious day tomorrow!” or “I’m welcoming this being awake and am grateful for the wonderful, restorative sleep I will soon enter…” etc, to plant seeds for good outcome in your mind.

Dr Wayne Dyer recommends that we use two verbal techniques to help us be at peace:
- Repeat words like Serenity, Calm, Peace, Joy, Tranquillity, Abundance [etc] until you feel good
- Say “I want to feel good!”, followed by “I intend to feel good!”

Remember, your words [and thoughts] create your reality!

To learn more about this, read books on positive thinking, or watch the commercially available DVD of The Secret.

There are also many “releasing” techniques:  Find a therapist or life coach who is trained and experienced to help you to release whatever habits or experiences are interfering with good sleep.  Most of us really do not need medication in order to have fantastic sleep!  If insomnia is interfering with your ability to be happy and successful, it’s certainly worth the investment to see someone competent who can help you professionally.  When people prioritise health, all other aspects of their lives tend to improve dramatically also, at little or no further cost.

-          Please also read the article ‘Difficult People” new on web site.

Toxic implies poisonous, dangerous, distressing to the equilibrium of Self and Others, damaging, infectious, debilitating, sapping strength, interfering with healthy [“normal”] functioning…

Now be careful:  Don’t judge!  The most dangerous thing about toxic people is their frequent lack of insight into their own toxicity and their judgment of Others as Toxic or bad!  A recent episode of the sitcom Two and a Half Men demonstrated the total denial a toxic person can have of his/her own toxicity, beautifully:  The dysfunctional mother of the two anti-heroes reports that she went to a funeral of a woman who was so critical, judgmental, pedantic, self-centred and un-empathic [read “Narcissistic Personality Disorder!] that nobody else went to her funeral.  Her sons finally revealed that her fate was likely to be similar since her personality was identical!

Personality Disorders

Personality Disorders are sets of dysfunctional patterns of behaviour that are usually caused by repeated failures of Significant Others to meet childhood needs appropriately, and these symptoms cause significant distress in relationships with Self or Others at personal, social, work, intimate and family level.  Such Disorders [or PDs] may only be diagnosed in adulthood [i.e. usually after 20 years of age] and the diagnosis may be made only by a clinician, like a Psychiatrist or Clinical Psychologist.  No, your conviction that your mother-in-law is the world’s most toxic Narcissist, is not legal or valid, and may have you sued for character defamation!

There is a list of the diagnosable PD’s on the web site, but do remember

[a] all people have some measure of defensive dysfunctional traits, and most of them are not PD’s;

[b] unless you have said clinical qualification and the person is not in close relationship to you, you are not qualified – or objective enough – to make the diagnosis;

[c] and also not objective or qualified to diagnose yourself.

That being said, since the symptoms are generally caused by very early and chronic interpersonal failures, the chief defense mechanisms are Denial [I’m not like that, thank Goodness!] and Projection [But she/he/all others are!] and Splitting [If you’re not 100% validating everything I say and do, you’re obviously betraying me and must be shunned/won back/punished…!]  So perhaps if we get some inkling that we just may have some of the dysfunctional traits ourselves, there is already potential for growth in that we could come out of Denial.

1:  Fatal Poisoning: Antisocial Personalities

It’s not usually appropriate to talk about degrees of dysfunctionality among the PD’s as all of them cause severe distress at personal, social or work level.  But from a therapeutic perspective the Antisocial Personality Disorder can be the most damaging as it is highly resistant to any intervention:  People can have decades of different kinds of therapy and yet remain as toxic as at the start.  And while other poisons usually cause from moderate to severe illness in relationships, Antisocial PD frequently causes complete destruction of the Other’s sense of self, or even their life.  Previously this category was termed Psychopath [as in the famous movie Psycho], later Sociopath and since 1994, Antisocial PD.  Typical are career criminals, from those who create child pornography to drug pedlars and mass murderers.

The most common Antisocial traits are a complete absence of Empathy for others [people and animals], coupled with compelling deceit and manipulation, and frequently a sadistic enjoyment of others’ pain [as seen in the movie The Silence of the Lambs].  In childhood, symptoms of an inability to feel empathy for others, plus sadism towards animals may predict that a person would have strong Antisocial traits in adulthood, or even the Disorder, if effective and long-term therapeutic intervention is not given early enough.

Criteria for diagnosis include any 3 or more recurrent traits of the following [traits from age 15, but PD is never diagnosed before age 18]:

-          Repeated criminal / illegal acts

-          Deceitfulness / lying / conning others for personal gain

-          Impulsivity & Immediate gratification no matter what

-          Repeated physical violence [breaking things, hurting animals or people]

-          Reckless, disregarding own or others’ safety

-          Consistent irresponsibility [e.g. in relationships, with others’ money or possessions, or at work]

-          Complete lack of empathy or remorse [often, lack of any “real” emotions except pleasure]

Plus history of Repeated acts of Conduct Disorder with onset before age 15.

2:   Violent bouts of illness, sometimes causing death: Narcissistic Personalities

I’ll give more information on the other PD’s at later occasions – probably by adding more articles on the web site – but now also want to talk a little bit about the Narcissistic Personality Disorder [NPD].  Please again remember that everyone of us has Narcissistic traits, and that there are Functional ones, like healthy ambition, good interpersonal judgment, self-respect and self-confidence, as well as the Dysfunctional ones, which I’ll discuss in brief [in no particular order].

Grandiosity:  No matter what you’ve achieved, experienced, or where you’ve holidayed, the Narcissist has done better!  They have a grandiose sense of self-importance and feel superior to everyone else, from Nobel Prize winners to mere Therapists, and are thus highly resistant to therapy:  they’ll go to sessions but keep “proving” how wrong you are and how much they know better!  This is also reflected in other relationships and the critical, judgmental, arrogant and perfectionist attitude is a major stressor in, for instance spouse abuse or emotional abuse in general – whether derogating your child, or being obnoxious to a waiter in a restaurant.  Their “victims” report that it feels like the Narcissist is always on the look-out to catch them doing something wrong, or being slightly imperfect in some way, and this “fault” is then catastrophied and focussed on and punished in humiliating and extreme ways.

Entitlement:  Why should the Narcissist have to wait in a queue like mere other human beings?  Why should the doctor, teller, therapist, spouse, or nurse in a hospital not be instantly available at the moment their need is felt, the bell is rung for attention, or the person is called.  Talk about Immediate Gratification!  While this immediate gratification need is normally in the form of service or attention from others [including pets], Narcissists also frequently have substance addiction disorders, which tends to further impair their insight and judgment, and to escalate their pathology to dangerous levels.

Lack of Empathy:  Or sometimes Fake empathy:  if they believed they lacked empathy, they would have to admit to a flaw, so they deny that possibility to themselves, and research “how to be empathic” [as they research and challenge anything else in order never to be caught of guard], and act as empathic people are supposed to act – sometimes.  Their words may sound empathic but their body language may at the same time be threatening, rejecting or denigrating. Basically their chief defense [against chronic early failures of empathy or positive attention from Significant Others] mechanism is total self-absorption and they are unwilling or unable to recognise and deal with needs or feelings of Others.

According to the DSM [Diagnostic and Statistical Manual of Mental Disorders, internationally used for clinical diagnosis], people with any five of the following [chronic or daily] personality traits, either have “Narcissistic Personality traits” [shown as +, ++, or +++ depending on severity and impact on others] or a full-blown Narcissistic Personality Disorder…  Now, remember that we ALL display many of these traits some of the time or in specific situations, without them being our main, only, or chronic defenses!

-          Grandiose sense of self-importance

-           Preoccupied with fantasies of unlimited power, success, beauty, brilliance or ideal love

-          Believes s/he is special/unique and can only be understood by or be associated with others who are “the best” in any field

-          Demands or invites excessive admiration

-          Sense of entitlement

-          Exploits others to achieve his/her own goals

-          Lacks empathy

-          Believes others are envious of him/her, yet also envies [and often denigrates] success of others

-          Arrogant, haughty behaviours and attitudes

Impact on Relationships:

Borderline Personality Disorder [BPD] can be as destructive to Self and Others in relationships [in fact, commonly more directedly self-destructive than NPD or Antisocial PD] and its defensive causes are usually as early as in the previously discussed PD’s, resulting in equally primitive defensive mechanisms [e.g. Splitting, Projection, Denial].  And people with strong BPD traits cause massive havoc in relationships too, but I will discuss that Disorder on its own elsewhere [BPD sufferers are often overwhelming, so it’s not just a matter of physical space here!]

For now, let’s just consider the common effects of Antisocial PD and Narcissistic PD on relationships. 

Very often we find some sort of abuse of Others with both, and it’s difficult for the lay person to differentiate causal factors:  Is the person abusive because of anti-social tendencies, or because of a deeply repressed terror of being abandoned, or losing control? [Or are they on a continuum of similar dysfunction?]

It’s important to understand that when there is abuse in a relationship – financial, power, social, emotional, sexual, verbal, and especially if its already escalated to physical violence [breaking objects, smashing doors or walls, or physically attacking or threatening to injure others or animals] – it is highly unlikely that a few weeks or even months of couples’ counselling/therapy will create lasting levels of greater harmony.

Unfortunately, the converse is true.  Even when there is some behaviour change on the part of the abusive partner, it may be manipulative [conscious or unconscious] or a False Self formation* underneath which parts of the personality build up resentment and rebellion against the therapist as authority figure, often resulting in higher levels of control and abuse if the person feels that the partner is gaining self-esteem and confidence.

It is never safe to be in any form of relationship with the Antisocial Personality:  even if you’re part of their “gang” and have similar behaviours, you are never safe [“blood in, blood out”]. And there really is no safe way to remain in an intimate relationship with a Narcissistic Personality, not while they’re either not yet in therapy, or even for many years while they are in therapies of various kinds.  While the traits remain, the danger is high, and the behaviours are likely to escalate or at least recur, despite remorseful promises and apparent acts of contrition, that may last for months. Only when a mental health professional can assure you that it’s safe, should you consider being in a close relationship with formerly abusive people.

If you suspect that your romantic or business partner/s may be Narcissists, the only way you can be relatively safe from some form of abuse in the relationship, is to insist on regular [i.e. at least once a week, and probably in terms of years rather than months] couples therapy as well as individual therapy for the abuser.  And maybe the therapist is a religious counsellor or social worker or guru, but, because of the power dynamic and primitive defenses, without some authority figure to whom there is accountability, most clinicians appear to hold little hope for good prognosis.

In other words, if there is ever any form of abuse [psychological or physical, or at any other level, especially if recurrent], get professional help, and urgently!  Do not delay until the co-dependency and the behaviours are so fixed that it’s extremely difficult to find an antidote for the “poison”.

Conversely, if you recognise the traits at toxic level in yourself, it is very important to commit to the right kind of psychotherapy as soon as possible, understanding that the long-term investment of time and money is worth it, as the gains are safer and happier relationships with yourself and Others at all levels of your life, which in turn promotes financial and physical well-being.

*See C20 psychoanalyst Donald W Winnicott’s essays on the formation of the defensive False Self structures

         - Please also see article on “Toxic People” on this web site

Unfortunately it is true that every one of us – even the most saintly – has some character traits that irritate some other people!  The good news is that it’s not always the fault of the person who is perceived to be irritating:  for instance, a “Type A Personality” may benefit from having some traits of more peaceful and joyful people that s/he finds highly annoying because they may not behave rashly enough to suit his/her needs for immediate gratification.  So, the person described as “difficult” may not be as problematic interpersonally as the one who describes him/her in such terms.Traits are considered to be dysfunctional if they interfere significantly with our optimal functioning in our personal life [e.g. causing depression, anxiety, addictions], our social life [e.g. our ability to function effectively socially or in intimate or family relationships], or our work life [e.g. in concentration, or in relationships at work].

Character or personality traits are qualities we all have, in various combinations.  They can be adaptive or functional, like certain life skills:  An accountant needs to be precise in her work, but hopefully not in exact in the way she arranges her flowers every day.  That would be bordering on maladaptive or dysfunctional behaviour, and may be traits or indicative of a fixed and invasive Personality Disorder which generally can affect people around her negatively or lead to arguments or rejection.

Traits are called ego-syntonic if we are proud of them and wish to keep them, despite others not believing we should indulge in them, or despite their interference with our optimal functioning as described above [e.g. "I like being aggressive: it gets me what I want"].  Traits that we ourselves recognise as dysfunctional or negative are termed ego-dystonic [e.g. "I would like to stop being addicted to cocaine because I realise it's harming me and my family"].

Certain clusters of traits appear to occur in set patterns and are always dysfunctional. These clusters are diagnosed only in adults [i.e. people over 20] and are well researched so that reasonably accurate conclusions can be drawn as to their causes and how they affect an individual and his/her life.  We can even predict with reasonable validity when a teenager who displays these clusters is likely to develop them into the fixed patterns of behaviour called Personality Disorders, by the time s/he reaches adulthood.

Although a person must fulfil all the criteria to be diagnosed with a Personality Disorder [and only a professional with clinical certification, like a psychiatrist or a clinical psychologist, may make such diagnoses!], some adults have enough of the traits to make their or others’ lives a misery – hence “difficult people”.

The following PDs [Personality Disorders] are stipulated in the current Diagnostic and Statistical Manual of the Psychiatric Disorders [DSM].  There are also other proposed categories [e.g. Depressive PD] that are being researched and may be added later.

CLUSTER A                                     CLUSTER B                         CLUSTER C

PARANOID PD                                ANTISOCIAL PD                 AVOIDANT PD

SCHIZOID PD                                  BORDERLINE PD                DEPENDENT PD

SCHIZOTYPAL PD                          HISTRIONIC PD                  OBSESSIVE-COMPULSIVE PD

                                                       NARCISSISTIC PD              PD NOS [Not Otherwise Specified]

Personality traits are not chosen as an act of will, and they are not signs of “madness”, though they may make people feel “mad, bad, or sad” if the traits are strong! [with prevalence of the traits notated as ++ or +++].  “Madness” [or psychosis] implies that an individual is frequently and grossly out of touch with reality, and no longer generally able to function effectively in his/her life - personally, socially or occupationally.  Even persons with “text book” PDs, tend to function quite well in some of these areas most of the time, and – except for Antisocial PDs – are usually not hospitalised or institutionalised [eg in forensic settings] – unless there is a specific symptom or threat such as attempted suicide.

Even for certifiable “madness” [psychosis – see below], there is always a Cause or Etiology.  The old psychotherapy cliché “It’s all my mother’s fault” is not as inappropriate as most of us would prefer it to be, especially if we are a parent or a caregiver! But the failure to make an individual feel safe and wanted in the world is often caused by peers, or by other authority figures or caregivers than the mother.  

Defense / Coping mechanisms are the infant’s and the young child’s attempt to ward off perceived terror / anxiety in repeated early situations that suggest to the person that s/he is in danger of abandonment / rejection / annihilation that would end in the destruction of the integrity of the Self.  Such defense mechanisms are not “genetic”, although symptoms could be similar: Being born with brain damage, for instance, may predispose a person to act out violently, similar to someone with Antisocial PD, or to have severe mood swings like someone with Borderline PD;  however, the cluster of symptoms and etiology is what allows us to differentiate between various mental disorders, according to a Differential Diagnosis.

Other disorders now clearly associated with brain damage [eg low brain matter density and resultant enlarged ventricles] include psychotic disorders, like the schizophrenias [typically demonstrating symptoms like auditory hallucinations or various delusions], and these may be aggravated by inadequate parenting. 

“Psychotic / psychosis” implies an inability to stay primarily in objective reality.  We might all like to call our mother-in-law or boss a “Devil”, but when we actually believe her/him to be Beelzebub, horns and tail and pit of sulphur and all, we are diagnosed as “psychotic”.  Psychosis may usually be indicated in any of three categories: 

[1] Not being orientated to Person [who I am], Place [where I am], Time [when is this] or Situation [what is happening]. 

[2] Hallucinations [seeing or hearing or smelling or tasting or feeling things that are not there as if they are, or vice versa, not experiencing them when they are present], or Illusions [experiencing distortions in sensory perceptions, such as “walls bending in on me”]. 

[3] Delusions [fixed beliefs that are not real to objective others, eg "I can fly off the roof", or "There is a snake in my belly and it's eating me up inside"].  Note that such psychotic symptoms are commonly associated with people who do not have a general psychotic illness but who are intoxicated by drugs, and they can also occur in certain cultural milieu such as “mass hysteria” and a “calling to be a spiritual healer”, without indicating a fixed psychotic disorder.

NB: Note that psychiatric disorders are diagnosed according to an Exclusion principle, i.e. first eliminate possible medical causes of symptoms, then possible substance causes, then genetic, etc…   And diagnoses are based on patterns or clusters of symptoms, not on a single symptom.  [This means, Gents, that a woman who is pregnant and has mood swings because her hormones are not balanced, may NOT primarily be diagnosed as "Borderline" because of the one symptom;  it is however possible to be both Borderline PD and pregnant.]

While people with PDs may have certain symptoms that appear delusional [such as the belief "I am the greatest person on earth and therefore deserve special treatment" in Narcissism, or "I am helpless and can't do anything for myself" in Dependent PD] or hallucinatory [such as the body dysmorphia associated with some eating disorders], the person with a PD moves generally in the world of objective reality, with short lapses into unreality [often described as micropsychotic episodes] from which s/he can usually emerge without medication or any overt intervention.

PDs are resistant to therapy:  How can one be expected easily to give up the very habit/s one unconsciously believes are the only defense that wards off one’s annihilation?  For the first part of the 20^th century Freud and his followers generally de-selected people for analysis if they suffered serious deficits such as found in the PDs.  Even in face-to-face psychoanalytic therapy it could take many years of thrice or twice a week therapy for the PD to abate sufficiently for people to live more peacefully with others and themselves.  Speedier results have been reported with modern integrated therapies that include techniques like Hypnosis or EMDR, but the danger of causing collapse if the defenses are too quickly overwhelmed, is significant, and such work should only be attempted by licensed and experienced or supervised clinical psychotherapists.

Remember that PDs are formed after repeated and continuous failures of caregivers to provide a safe, accepting, welcoming, non-intrusive yet stimulating, caring environment, with appropriate freedom and boundaries, over time.  And none of us are taught this art in schools!  We learn our parenting skills from the often inadequate role-modelling by our own parents, early teachers and other caregivers.  And if there is a severe enough failure to provide such a safe and nurturing environment by even one “big person” [such as being emotionally abused by a teacher or sexually molested by a family member], not even the best efforts of relatively good parents may be sufficient to ward off severe defensive traits or even disorders of the personality.

Half a century ago British psychoanalyst Donald W Winnicott coined the phrase “good-enough mother”, which can be extrapolated to good-enough parents, father, nanny, teacher, etc.  Different behaviours are required of good-enough parents in the child’s different developmental stages [for instance, not still breastfeeding the seventeen year old may be a good idea].  An infant psychologically needs a great deal more eye contact and physical holding than a teenager, as another instance.  Modern psychotherapists generally believe that optimal provision of a child’s emotional needs should include unconditional love / positive regard, freedom from intrusion and neglect, and appropriate boundary setting for his/her behaviour, and some add optimal frustration, which stretches his/her resourcefulness without being overwhelming.

When parents / significant others repeatedly fail in one or more of these areas, the child is likely to develop such strong defenses against unconscious fears of being hurt / annihilated / abandoned / rejected, that the formation of a PD defensive structure is likely.

So, generally “difficult” people can become “nicer” people if they get a chance to have these basic developmental needs consistently met at some stage in their life, for instance in therapy.  In interaction it nay be useful to remember that the “difficult” behaviour in any specific moment points to a fear of a perceived threat:  If Alex suddenly becomes bombastic / grandiose/ arrogant, it’s likely that someone has done something [or Alex believes in fantasy  that this has been done!] to make her/him feel small, powerless, disrespected, ignored, diminished, worthless, unheard… [for instance, in ignoring his/her contribution to a discussion].

The answer to the question of how to change his/her defensive behaviour seems obvious:  to acknowledge that s/he is worth some positive regard.  Similarly, if Ashley is acting in an over-controlling manner, it is likely that more structure or safeguards are necessary in the situation/s that evoke the behaviour.  But such “therapeutic” responses are hard to sustain in practice with a “difficult” person, who may often have the effect on others to suggest or make them feel “mad, bad, or sad”!

Some specific examples of various PD’s are discussed in the 2009 monthly Selfgrow newsletter, to which you can subscribe on this web site.  There are also various internet News groups that focus on specific Personality Disorders.

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