Evolving PACT Through Deepening Understanding of Personality Disorders

By Nicole McGuffin, PsyD, LPC, BCN
PACT Level 3 Therapist

There is confusion about personality disorders. According to the DSM-5 (APA, 2013) a list of pathological symptoms and traits categorize a diagnosis of Narcissistic Personality Disorder (NPD). The DSM-5 narrowly classifies this group of people by grandiosity, needing admiration, having entitlement, and lacking empathy. These traits are critical in the understanding of NPD. However, this route struggles to capture issues of self and affect regulation including feeling inferior, low self-esteem, vulnerability and inferiority, emptiness, fearing boredom, emotional distress, affective reactivity, and rage (Caligor & Stern, 2020). 

Section III of the DSM-5 (2013) introduces The Alternative Model for Personality Disorders (AMPD). Its requirements include both personality functioning impairments and pathological trait elevation. It covers a broader range and is more inclusive of characteristic difficulties in identity, self-direction, empathy, intimacy, grandiosity, and attention seeking. Another framework to understand NPD is within the framework of Object Relations Theory (Caligor & Stern, 2020). This framework examines core structural features of identity consolidation, object relations (sensing needs of others) defensive operations, aggression, moral functioning, and reality testing. 

The field’s issues in defining narcissistic personality disorder creates confusion and controversy in researchers and clinicians alike (Caligor & Stern, 2020). This complicates assessment and treatment planning. With a deeper understanding of personality disorders, PACT clinicians can increase effectiveness and augment healing in couples with issues originating from relational trauma that manifests as personality disorders.

Personality disorders have a fairly high prevalence rate of 12.16% in the general population of Western countries (Volkert, Gablonski, & Rabung, 2018). There are a low number of available epidemiological studies available because diagnosis is complex and resource intensive. Personality disorders have a similar prevalence to physical health conditions such as low back pain and chronic respiratory diseases (12% & 7%), and are more prevalent than diabetes and cardiovascular disease (3%), and more prevalent than depression and anxiety disorders (6%) (Volkert). 

What is a personality disorder? 

Elinor Greenberg, PhD (2016) begins her notable book with the statement “Nobody is a Borderline. Nobody is a Narcissist. Nobody is a Schizoid...when we diagnose, we are describing a pattern...never a person. All people are unique. Labels, however well intended, cannot do justice to human complexity.” So what is a personality disorder? Greenberg describes personality disorders as a broad and pervasive set of problems thought to begin in infancy and early childhood that are stable throughout life. They affect many aspects of personality including identity, thinking, behaviors, and expectations from others. She prefers the term personality adaptations instead of disorder because it’s a creative adaptation to environmental challenges from difficult childhood situations. She shares a set of difficulties affecting both the sense of self and interpersonal relationships. Understanding these patterns when working with couples assists in both assessment and treatment planning.

• They lack a realistic, integrated notion of themselves and others

Adaptations to the personality create tendencies to view the self and others in both polarized and extreme ways. People are viewed as both all good or all bad, both special and unique, or worthless and defective. When the view changes of someone from someone as an all-good person, instead of seeing the reality of having both good and bad, they rescind their initial view to one of all-bad.

• They lack object constancy.

When frustration naturally occurs in relationships the ability to hold a positive emotional tie to the person when feeling angry, frustrated, or disappointed is lacking. Love and adoration quickly turns to disappointment and hatred. Also, when someone is not in the person’s everyday life, it can be difficult to remember their face and they literally become out-of-mind.

• The ability to see others realistically is severely limited by past unmet needs for appropriate parenting.

When needs are unmet from the past, one presses to fulfill them in the present with other people. Past unmet needs are projected on others. They assign the roles to others and become disappointed when others do not meet these needs. They also may miss indications that their expectations are inappropriate. 

• They are continually searching for a special someone who will do for them what their parents did not, so that they can resume their interrupted emotional growth.

Searching for restoration, repair, and parenting to heal early wounds, the client deeply desires a relationship that is positive, intense, one-on-one with a person who can characterize the primary caregiver of earlier years. This gets confusing for an individual who believes they are searching for adult romantic love when in actuality they are unconsciously hoping for a replication of the glorified and idealized parent-child relationship. They account for this desire by telling themselves they are searching for a partner, companion, or mentor. They are largely unaware of the desire.

• They now fully identify with their false self and believe that it represents a true and complete picture of who they are.

 Awareness of feelings and authentic expression of the self has been inhibited for so long that client’s believe the constructed false self is in actuality their real self. The false self is comprised of the adaptations to their early environment to stay attached to their primary caregivers including disconnecting, pleasing, inhibiting aspects, and doing anything that may displease caregivers. This false self inhibits further emotional and mental growth. Spontaneity is lost as behaviors that mirror early childhood patterns continue. Underlying this false self may be an ache of something missing and of emptiness. 

What is the psychobiological manifestation of personality disorders? 

The psychobiological pathology of borderline and narcissistic personality disorders share the common feature of a deficiency in affect regulation (Schore, 2016). When stress increases, the less evolved limbic system struggles with the mitigation of the stress. Also, because the dual circuit orbitofrontal system is compromised, symbolic representations are not accessible which is important for self-soothing and repair functions encoded in the evocative memory. Shame is imprinted in the internal representations of the self, and regulation is impaired.

How do personality disorders develop? 

Many factors have been identified in the etiology of personality disorders such as genetic, biological, trauma, problematic interactions with parents (Fruzzetti, Shenk, Hoffman, 2005). However for the purpose of this writing, the developmental psychopathology of personality disorders is simplified to create a birds-eye-view for the reader. 

Borderline Personality Disorder is a socioemotional pathology with difficulties in maintaining relationships socially, affect regulation, abandonment depression, repeated expression of emotion, depression, with a compromised ability to regulate shame (Schore, 2016). It develops from a failure of good-enough attachment and bonding, lack of delight in the child, and the unavailability of the primary caregiver to emotionally regulate, upregulate, and empathize. There is a lack of secure attachment to both parents. The result is an inability to process data and sustain internalized images, or a “holding introject” as a source of self-soothing. In stress, it’s difficult to hold a sense of self and relate to significant others. These experiences imprint into the limbic system.

Narcissistic Personality Disorder is a failure in self-regulation that originated in the practicing period. Regulation of the mood is dependent on what is happening externally. Shame, a key affect of the disorder is defended against grandiosity, lack of empathy, unreasonable entitlement, and rage. This personality structure was not arrested before the rapprochement crisis and deflation of infantile grandiosity, and omnipotence did not occur creating a hyperaroused state (Schore, 2016). The child was objectified with parents projecting their own idealized self onto the child while failing to provide “enough realistic positive and negative evaluation to support some degree of tension between the actual self and the idealized self” (Broucek, 1991). 

Authors Caligor and Stern (2020) present NPD in an object relations theory framework, which is helpful to understand (Table adopted from Caligor & Stern).

Core Structural Features of Narcissistic Personality Disorder

Identity Failure of normal identity consolidation; presence of compensatory grandiose self-structure, which may provide sense of self that has some stability and specificity; in contrast, sense of others is vague, superficial; variable capacity to invest in long-term goals; affect regulation tied to self-valuation

Object Relations: Limited sense of the needs of the other, independent of the needs of the self; superficial, transactional relationships may be overtly exploitative; problems with intimacy; boredom

Defensive Operations: Predominantly splitting-based/dissociative defenses — in particular, idealization and devaluation, dissociation, projection, denial

Aggression: Variable depending on severity, but prominent in psychological functioning

Moral Functioning: Pathology of value systems and moral functioning reflected in childlike values (fame, glamour, wealth), shame over guilt, often with moral lacunae, possibly with frank antisocial features

Reality Testing: Denial of realities that challenge grandiosity, potentially resulting in gross distortion of reality

Envisioning PACT’s Future

My vision for PACT centers on deepening our clinicians’ understanding of personality disorders so that even further healing of relational trauma is possible through the PACT model. PACT clinicians informed in personality disorders can better meet couples needs utilizing established PACT interventions for superior care. 

Personality structure and internal working models of attachment have been shown to be relatively stable throughout one’s life. However, Bowlby used the term working model because attachment can be changed. And, “the developing mind does not have to become fixed with one pattern of traits or another...and an individual does not have to settle for some innate temperament or personality that is unchangeable” (Siegel, 2020). Personality structure illustrates patterns of self-regulation. Secure relationships interact with the brain to influence who we are.

The Bridge to Action 

1. Deepen and expand the PACT curriculum for understanding personality disorders and how these disorders look in the consulting room. An addition to Masterson’s impactful books, include Elinor Greenberg’s book (2016) Borderline, Narcissistic, and Schizoid Adaptations: The Pursuit of Love, Admiration, and Safety.
2. Create a research study demonstrating the efficacy of PACT and showing specific changes. This research study will strengthen the theory, methodologies, and spur future studies on the importance of PACT and healing personality structure through secure and safe relationships. Continual research will measure the progress we are making. 
3. Create resources for clinicians to understand, identify, and work with personality disorders. These can include reading lists and trainings, such as Masterson’s Psychoanalytic Approach to the Treatment of Personality Disorders to deepen understanding and efficacy in the consulting room. Resources can also include white papers and bulleted lists of best practices to keep in mind with each adaptive pattern.
4. PACT was created on the foundation of attachment theory, arousal regulation, and developmental neuroscience. These key tenants can continue to be explored with the vast literature written on each topic. Each pillar supports the relational healing of personality structure in a relational dyadic context. Each can be expanded in PACT trainings for clinicians.

Deepen clinician understanding of personality disorders to further heal relational trauma through the PACT model. Establish a module on relational trauma in PACT training that teaches clinicians how to break generational issues that chronically traumatize individuals and their families. This will reward both individuals and the collective family to heal the most difficult relationships and prevent an impact on generations to come. 

To further this vision, the PACT Institute must create roles, systems, and structures to support the process. Clinicians will celebrate accomplishments by witnessing the positive change within healing relationships so their clients’ children and future generations have the opportunity to break the cycle of trauma and live healthier lives.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Bowlby, J. (1988). A Secure Base: Clinical applications of attachment theory. Routledge.

Broucek, F.J. (1991). Shame and the Self. Guilford Press.

Caligor, E. & Stern, B. (2020). Diagnosis, classification, and assessment of  narcissistic personality disorder within the framework of object relations theory. Journal of Personality Disorders, 34, 104-121.

Egan, S.J., Haley, S., & Rees, C.S. (2020). Attitudes of clinical psychologists towards clients with personality disorders. Australian Journal of Psychology. 
https://doi.org/10.1111/ajpy.12068

Fruzzetti, A., Shenk, C., Hoffman, P. (2005). Family interaction and the development of borderline personality disorder: A transactional model. Development and Psychopathology 17, 1007-1030. https://doi.org/10.1017/S0954579405050479

Greenberg, E. (2016). Borderline, Narcissistic, and Schizoid Adaptations:  The pursuit of love, admiration, and safety. Greenbrooke Press.

Schore, A. (2016). Affect Regulation and the Origin of the Self: The neurobiology of emotional development. Routledge.

Siegel, D. (2020). The Developing Mind: How relationships and the brain interact to shape who we are. The Guilford Press.

Volkert, J., Gablonski T., Rabung, S. (2018). Prevalence of personality disorders in the general adult population in western countries: Systematic review and meta-analysis. The British Journal of Psychiatry 213, 709-715. 
https://doi.org/10.1192/bjp.2018.202