HIV and Personality Disorders High Risk Behavior and Disease Susceptibility

Personality disorders are more common among those infected with Human Immunodeficiency Virus (HIV), with borderline personality being one of the most frequent. For example, Perkins, Davidson, Leserman, Liao, and Evans (1993) found a higher prevalence of personality disorder among HIV-positive than HIV-negative subjects, with borderline the principal diagnosis. Later studies have supported this finding. In a longitudinal study, Jacobsberg, Frances, and Perry (1995) discovered that almost two-fifths of subjects who tested seropositive could be diagnosed with a personality disorder. Among subjects who did not know their HIV status, significantly more HIV-positive than HIVnegative subjects could be diagnosed as borderlines. Others have found that personality disorders and other serious mental conditions may impair self-assessment of risk and reduce the effectiveness of educational programs (Knox, Boaz, Friedrich, & Dow, 1994).

Why would HIV and personality disorder go together? Personality disorders are often linked to impulsivity, and impulsivity is linked to high-risk behaviors. By definition, impulsive individuals fail to think through the consequences of their actions. Borderlines, for example, are famous for sudden shifts of emotion and impulsive actions, including spending sprees and heavy alcohol and substance abuse. Moreover, impulsivity is linked to unprotected sex and multiple sexual partners, a principal way through which HIV is spread. Likewise, a significantly greater proportion of subjects with antisocial personality disorder engage in needle sharing than those without antisocial personality disorder.

Further research will be necessary to test additional hypotheses linking the personality disorders with HIV infection. For example, it is possible that some narcissistic personalities feel a special sense of invulnerability or that they are "above" using a condom. Dependent personalities might be reluctant to refuse a partner who desires unprotected sex. Individuals with sadistic traits might deliberately infect others. Antisocials might lie about their sexual history or HIV status. Because casual sex is common in our society, those who practice it are obliged to size up their partners for traits that might be linked to high-risk behaviors.

models and learned to depend on sex-role stereotypic compliments—physical attractiveness for histrionics and manliness for antisocials—as the basis for their self-esteem. In general, they are especially sensitive to external sources of reward and move impulsively and capriciously from one engaging item to the next. Thus oriented to the external world, they fail to develop a solid self-identity that might anchor them during periods of stress. As a consequence, they are always on unsure footing, constantly on edge, never quite sure who will provide the attention and stimulation they desperately require. Periods of brooding, dejection, and hopelessness alternate with simulated euphoria as they shift from acknowledging to denying their condition.

The Petulant Borderline

The petulant borderline is mixed with the negativistic (passive-aggressive) personality. When even more dyscontrol is added to the active-ambivalence of the negativist, the result is someone who is even more unpredictable, restless, irritable, impatient, complaining, disgruntled, stubborn, sullen, pessimistic, resentful, and envious of the happiness and success of others. They resent those on whom they depend and hate those to whom they must plead for love. In contrast to other borderline subtypes, most petulants have seldom had their needs satisfied on a regular basis and have never felt secure in their relationships. Stubborn and demanding, they openly register their disappointments.

Unable to find comfort with others, they may become increasingly bitter and discontent, caught between two pathological extremes. At times, they express feelings of worthlessness and futility, become highly agitated or deeply depressed, express self-condemnation, and develop delusions of guilt. At other times, their habitual negativism becomes completely irrational, driving them into rages in which they distort reality, make excessive demands of others, and viciously attack those they see as having trapped them and forced them into intolerable conflicts. Their moods become a way of threatening others that further trouble is coming unless something is done. However, following these wild outbursts, petulants turn their hostility inward and become remorseful, plead for forgiveness, and promise to behave and make up for their transgressions. Alternatively, they may express fatigue and somatic disorders as a means of milking others' attention while burdening them at the same time. As children, they are likely to have felt mishandled and cheated, perhaps caught in a power struggle between caretakers who used the child as a pawn. For them, affection was never free of conflictful feelings.

Consider the case of Georgia (see Case 14.2). Elizabeth, who has come to the university counseling center seeking help and advice on coping with a problem parent, describes her mother, Georgia. Georgia synthesizes many of the characteristics of the borderline and negativistic personalities. For example, she vacillates between blaming Elizabeth and smothering her, an example of the borderline traits, devaluation and idealization. Consistent with the tendency of the negativist to try to recapture ideal love, Georgia adored Harold, her husband, early in their marriage but later became disenchanted, asserting that everything he did for her was never right or never enough. Indeed, in her more petulant moments, Georgia will tell you that no one has ever appreciated her—another characteristic of the negativistic personality but here synthesized with the unstable relationships characteristic of the borderline. Her social contact with the surrounding neighborhood, throwing tantrums and alienating others, provides even more evidence. Moreover, Georgia's vocational history is typical of the negativist, in that some minor problem that apparently stands as a symbol of her mistreatment gets blown out of proportion, leading to indignation and loss of employment. However, her anger and inability to find a meaningful direction in life are also characteristic of the identity disturbance, unstable affect, and sudden inappropriate anger of the borderline. In fact, intense expressed anger, more anger than would ordinarily be attributed to a passive-aggressive person, is one of the defining characteristics of the case.

Given her history, Georgia appears caught in an unresolvable conflict that prevents finding a single, stable course of action. She desperately wants affection and approval from the significant others in her life, yet she seems unsure how to ask for them. Moreover, she is deeply resentful but fears asserting her anger. As a result, Georgia finds herself in a constant state of turmoil. First, she tries to be ingratiating and acquiescent,

Elizabeth, age 21, presented at the university counseling center seeking professional help related to problems at home. Her mother, Georgia, has a long history of psychological problems, and is now going through a difficult period.1

Georgia believes that she has never been appreciated by anyone, including her own mother, husband, children, and employers. Georgia was the middle child in a family of moderate means. The second daughter of three children, she was always compared unfavorably to her older sister, an excellent student and now a prominent attorney. In contrast, Georgia was an average student, although her teachers felt she could do much better. In fact, Georgia was the "black sheep" of the family, who never lived up to her mother's expectations. She recalls her mother saying over and over again during their many arguments, "I should have abandoned you when I realized what a lousy kid you were."

Georgia married Elizabeth's father, Harold, whom she apparently adored, the summer after their high school graduation. In the early years, Harold did everything for Georgia, but somehow, it was never right or never enough, and her attitude toward him changed. Harold, a solid individual by Elizabeth's account, sees Georgia as a troubled soul who "can't get her life together." Elizabeth and her younger brother avoid their mother as much as possible. "Sometimes she shifts, like between blaming you one minute and smothering you with love the next," Elizabeth says. "She can't make up her mind whether to love you or hate you. It's ridiculous."

Georgia's erratic behavior has had a similar outcome both socially and vocationally. She makes a good first impression, but her numerous part-time jobs always end the same way, with Georgia seizing on some minor problem and voicing an angry indignance over the way she was treated. Social contacts had the same course. "She alienated everyone in our neighborhood," Elizabeth stated. "Some people she'd piss off, others felt smothered by her needi-ness, and some got both. Over and over again, she'd make friends, then throw a tantrum, and call them and cuss them. Whenever she's excluded from community activities, she gets mad because she swears they're talking about how to keep her out."

Presently, Georgia is being seen twice a week for treatment of depression. According to Elizabeth, her history includes threats of suicide, though she has never actually gone further. Currently, she is very angry that Harold refuses to use part of the children's college fund to finance a month-long stay at a Caribbean resort, and says she will no longer speak to him. In response, Harold is simply exasperated.

1 Numbers mark aspects of the case most consistent with DSM criteria, and do not necessarily indicate that the case "meets" diagnostic criteria in this respect.

Borderline Personality Disorder DSM-IV Criteria

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

(2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

(3) identity disturbance: markedly and persistently unstable self-image or sense of self

(4) impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

(5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

(6) affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days)

(7) chronic feelings of emptiness

(8) inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

(9) transient, stress-related paranoid ideation or severe dissociative symptoms

Reproduced with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright 1994 American Psychiatric Association.

but when this fails, she explodes with accusations that she is unloved and unappreciated. With her hopes dashed, Georgia quickly becomes increasingly hostile. Her resentments are then turned inward, creating guilt and a sense of worthlessness.

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