There exists an important distinction between a personality style and a personality disorder. A personality style does not cause significant distress nor does it interfere generally with occupational or social functioning, whereas a personality disorder does have these effects. We can consider personality disorders according to a categorical or dimensional perspective. The categorical perspective posits that the disorder is either present or absent in an individual. That is, even if certain criteria are present in an individual, unless a threshold number of criteria are met and for the prescribed period of time, the disorder cannot be diagnosed, and thus is not present. The dimensional model of personality alternatively suggests that personality traits are, in and of themselves, neither adaptive nor maladaptive; neither are they normal nor pathological. Rather, these traits are presumed to be possessed by everyone, albeit differing in expression or degree and reflecting the synergy of multiple traits. The difference in whether a composite of traits, or trait profile, defines a style or a disorder often depends on variables that exist outside the individual. The dimensional model of personality allows each trait to be envisioned as lying along a continuum, which assumes its presence and describes its relative quantity. Although personality as a construct implies compelling stability, the profile of individual traits, its expression, and whether it becomes identified as a "style" or a "disorder" is informed by an equally compelling capacity for change. This potential for flexibility has significant and special relevance to the care of individuals with personality disorders.
Stage models of psychosocial development consider the context in which the personality is expressed. Developmental theorists additionally have emphasized the relevance of stage-related tasks—what the individual is being asked to do at specific stages of psychosocial development (see Erikson, 1982; Kegan, 1982; Levinson, Darrow, Klein, Levinson, & McKee, 1978). Successful adaptation can thus be defined as the successful negotiation of the psychosocial tasks required at each life stage. Using context and tasks, including roles and relationships, as referents, an individual may be diagnosed with a personality disorder at one stage in life, yet not be so diagnosed while at another stage, even as he or she exhibits the same personality trait profile.
The individual with a personality disorder, because of a limited response repertoire and lack of response flexibility, often has great difficulty in negotiating novel tasks. This is especially relevant to the older adult. For example, the loss of a spouse may mean that the individual needs to learn and perform tasks that the lost spouse had historically performed. Someone with a Dependent Personality Disorder might become overwhelmed and flooded with anxiety at the prospect of doing things alone without support and direction. Conversely, the move from one's home to a more institutionalized setting (e.g., an assisted living facility) can mean being freed from assuming responsibility for certain instrumental activities of daily living. Control is a reciprocal of responsibility. Assuming responsibility is threatening to the dependent personality, whereas loss of control is threatening to the obsessive-compulsive personality.
A change in the individual's context provides a novel frame for the expression of his personality traits. He will be asked to be successful at new or different tasks and can be expected to meet them in a way that is usual for him, consistent with his personality style. Or she will be asked to perform different roles, and will also do this in a way that is usual for her, consistent with her personality style. The prevailing directives here are those of homeostasis and self-constancy.
Homeostasis refers to the tendency of the individual to return to a baseline of functioning, to what feels right and comfortable to him or her. It is the process of reequilibration toward an individual's center. This process is naturally upset when an individual is thrown off his or her center by a change perceived as significant, whether the change required is initiated from in or outside the individual.
Older adults are called on to make many changes in response to changes in their health, functional status, and social and occupational domains. These many requirements for change have been referred to as the vicissitudes of old age as well as the meaning of the slogan "old age is not for sissies." However, also in older age, an individual's ability to regulate, self-correct, and re-center is also challenged. Resources such as energy, money, and time might become limited. On the other side of the equation are the qualities of wisdom, including the strength of survivorship and the ability to draw from and generalize from past experience. Well-functioning, psychologically healthy individuals at any age have a "deep bench"—a broad repertoire of responses to apply to novel situations—as well as the ability to choose and apply those which are most appropriate. Those with personality disorders, however, have both a narrow repertoire of responses and also are impaired in their ability to identify appropriate responses. These deficiencies are reflected in problems with affect regulation, distance regulation, core vulnerabilities, and reliance on primitive defenses (discussed earlier in Chapter 10).
Self-constancy refers to the need, throughout life, to do whatever it takes to continue to "feel like me." This need to feel like oneself is a response to the question raised often by frustrated care providers or others in close relationship with the individual with a personality disorder: "If he sees how angry he makes people by being that way, and how they avoid him, why doesn't he stop doing that?" We offer two responses to this type of inquiry. First, if what an individual "does" (i.e., thinks, acts, or feels) does not achieve what it is intended to, the tendency is for him or her to do it again and again, but louder, faster, and/or harder. Second, even if the behavior is met with an objectively negative response, it is the response that an individual usually gets and therefore it "feels like me" and reinforces their self-constancy, which is especially needed during times of change.
Intimate relationships with others both reflect and affect the expression of personality pathology. Any change or loss of others who have performed significant functions for the individual with a personality disorder is likely to be reflected through an exaggeration of his or her maladaptive traits. Having functioned as "auxiliary selves," these significant others attenuated the expression of the personality disorder in three major ways. First, they may have served to bind the expression of pathology (e.g., by distracting an individual from acting out his distress). Second, they may have served as a buffer between the individual and others, thereby reducing the opportunity for the display of pathology. This function offers a secondary gain of reducing the feedback (reinforcement) of the maladaptive traits. Third, they may have served to bolster the individual's more adaptive traits, thereby selectively inhibiting the expression of the reciprocal maladaptive ones (see Chapter 10 for an elaboration on these functions).
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