Last week, I described "personality" as the unique way in which each person interprets the world and responds to it. We looked at the ways in which personality, especially temperament, is genetically determined. We noted the ways in which character traits, which are more changeable, interact with temperament. Defense mechanisms, which determine how each person handles unacceptable impulses or thoughts, give an added dimension to personality. Intelligence is an important individual characteristic, but does not change personality style very much. Each personality is a unique "fingerprint" resulting from a combination of these characteristics. Like fingerprints, even though no two are exactly the same, personalities can be sorted into types. Today, we'll begin looking at the ways in which personality can contribute to mental health problems. When personality becomes disordered, it can cause psychiatric symptoms all by itself.

Personality disorders are extreme personality styles. Like fun-house mirrors, these disorders cause distorted views of people and events. When someone's perception of others is distorted, her responses are apt to be inappropriate as well. In this way, personality disorders disrupt thoughts, emotions, behavior, self image, and relationships. Personality disorders last for years, untreated, and create a broad range of difficulties. They are not easy to overcome. Although the symptoms of personality disorder may mimic the symptoms of other disorders, they do not respond well to medicines used to treat those other conditions. Mental health professionals group personality disorders together into three categories, or "clusters." Broadly, the disorders of Cluster A may be described as odd or eccentric. Those of Cluster B are dramatic or emotional. Cluster C disorders are anxious or fearful. Today, we'll look at the Cluster A Personality Disorders - Paranoid, Schizoid, and Schizotypal.

Paranoid Personality Disorder causes someone to interpret the world as a dangerous and hostile place. A person with this disorder is very distrustful. He does not take people or events at face value, but is always looking to uncover the real truth, the hidden motive. These people assume that others are out harm them, even without evidence for it. Honest mistakes are seen as attempted rip-offs and harmless jokes as demeaning insults. Projection is the chief defense mechanism of paranoia. Using projection, the person attributes her own unacceptable impulse or feeling to others. (" I don't want to attack you. You want to attack me!", or, "I'm not jealous. People are out to get me because they're jealous of me!") People with Paranoid Personality Disorder often believe that another person, or organization, has wronged them permanently. They may believe that they were swindled in a business deal, or that some government agency has changed or destroyed records in order to prevent them from getting something. They are preoccupied with doubts about the loyalty of their friends and associates. These people guard their personal information carefully and may refuse to answer questions, assuming that the information will be used against them somehow.

People with this disorder respond angrily to the perception that others are out to do them wrong. They may become preoccupied with ideas of revenge. They may wage an endless struggle to correct some perceived injustice and attempt to enlist attorneys, physicians and others to assist them in their quest for the "missing records" or their goal of suing some government official, bank, or business. Although these individuals have a great deal of difficulty cooperating with others, they may band together in cults with a few others who share their simplistic and stereotypic view of the world.

Schizoid Personality Disorder, also part of the odd and eccentric group, is less colorful. These people show a pattern of social detachment. They show little emotion. People with this disorder greatly prefer to be by themselves. They are "loners" who prefer mechanical activities, like working with computers or doing math games. They have little interest in sex and do not pursue romantic relationships. People with Schizoid Personality Disorder may appear cold and aloof, and may not care what others think of them. People with this disorder often go against the grain of social expectations. They may not return social gestures like smiles, nods, or greetings. Despite the outward appearance of being bland or empty, people with this disorder often have a rich and elaborate fantasy life. Withdrawal from the social world is the principal defense mechanism of Schizoid Personality Disorder. Even though they shrink from human interaction, these folks may be very self-critical and very keen observers of the human condition.

Schizotypal Personality Disorder is the third member of the odd or eccentric cluster of personality disorders. People with Schizotypal Personality Disorder perceive connections between unrelated events. Their thinking is magical and superstitious. They may be preoccupied with the paranormal or believe that they have power to see the future or to control the future with thoughts or rituals. Some people with this personality disorder may believe that they can "sense" the presence of others, or read their minds. They may have unusual perceptions, such as hearing a voice murmuring their name.

Unlike schizoid people, schizotypal personalities want relationships, but have a great deal of trouble making it happen. This personality disorder causes someone to be anxious in social situations and to be very aware that he does not "fit in". Although most of us have some anxiety at meeting new people, our anxiety gets better as the meeting goes on. This is not true for people with Schizotypal Personality Disorder. Their anxiety gets worse. Others notice right away that schizotypal people are odd. These folks have difficulty adhering to social conventions. They may avoid eye contact. They dress haphazardly and without regard for any known style or fashion. Their clothing may be mismatched, dirty, or poorly sized. Schizotypal people often use strange words or use common words in unusual ways. There has been some debate about whether Schizotypal Personality Disorder is simply a mild form of Schizophrenia. There is general agreement, however, that it is a true personality disorder, stable and predictable, not fluctuating and progressive.

Last week, I quoted Dr. William Osler as having said, "It's as important to know what kind of patient has the disease as to know what kind of disease the patient has." You can see how that applies, for example, to depression. Anyone can develop Major Depressive Disorder. However, the individual's personality style often determines the treatment and its outcome. Imagine a depressed woman with Paranoid Personality Disorder. She is wary of her doctor. He must be up to something. Why is he asking her all these personal questions? The doctor seems nice, but maybe he's just pretending to be nice so he can trick her into taking medicine to "control her mind". Now, imagine a woman with the same degree of depression, but with Schizoid Personality Disorder. She might want to take antidepressant medicine but might not want to see a therapist. She might find it repellant to share her thoughts and feelings. She might be puzzled by her therapist's questions and really have little to say about herself. Finally, a depressed woman with Schizotypal Personality Disorder might disagree with her doctor about why she is depressed. She may believe that her depression is caused by food additives, solar radiation, or people who are sending out "bad vibes". If she agrees to take medicine, she will see connections between the medicine and unrelated events. In therapy, she will feel anxious and misunderstood. She may tell her therapist long-winded rambling stories having no connection to her depression. Mental health professionals who focus only on symptoms, and who use a one-size-fits-all approach to interacting with their patients, will quickly run afoul of these strong personality undertows, and the treatment will founder. Next week we'll take a look at more personality disorders - the emotional and dramatic group.

Dr. Dingley is a psychiatrist at Evergreen Behavioral Services in Farmington. He may be contacted at adingley@fchn.org.