Introduction
Extant epidemiologic studies and laboratory research consistently demonstrate that aggression is a developmentally salient behavior, which is mostly triggered by situational factors such as the presence of violent cues, parental conflict and divorce, poverty, provocation, and the quality of parent-child relations (Bettencourt et al. 751).
Another strand of existing literature (e.g., Daffern et al. 430; Fossati et al. 24; Latalova & Praske 239) demonstrates that aggression, in its form and scope, is a widespread symptom in a number of disorders and syndromes of psychiatric concern, particularly maladaptive personal functioning and personality disorder.
However, there still remains a dearth in literature with regard to the particular correlates of aggression that are exhibited in people with personality disorders, and if aggressive behavior is a precondition of personality disorder.
Through a critical analysis of several personality disorders classified under the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th edition), such as borderline personality disorder, antisocial personality disorder, avoidant personality disorder, narcissistic personality disorder and obsessive-compulsive personality disorder, this paper aims to demonstrate that aggression against self or against others is a core component of personality disorders.
Understanding Aggression & Personality Disorder
Considerable research conducted over several decades has attempted to investigate the reasons for exhibiting aggressive behavior in patients suffering from personality disorders (Daffern et al. 426), but no conclusive results seem forthcoming in a number of fronts, in large part due to the problems encountered in categorizing personality disorders (Nelson-Gray et al. 12).
In other fronts, however, studies have been conclusive on the relationship between aggression and personality disorders, and the influence that aggressive behavior impacts on personality disorders and vise-versa (Reidy et al. 415).
Many academics and practitioners believe that aggressive behavioral orientation on the part of individuals with personality disorders stands in the way of attaining effective treatment and management of these disorders (Nouvion et al. 554) and, as such, it is of essence to come up with strategies and modalities for purposeful intervention with regard to eliminating or reducing aggression in this group of the population. The following section aims to seek a better understanding of the concept of aggression within the broader context of personality disorders.
Aggression
Aggression literature continues to elicit increased attention from academics and practitioners, primarily because of the many negative consequences associated with the concept in the broad fields of psychology and psychiatry. Aggression has been described as “…overt behavior involving intent to inflict noxious stimulation or to behave destructively towards another organism or object” (Latalova & Prasko 240).
Aggression, according to these particular authors, is different from anger, which is perceived as an emotional state that fluctuates from mild irritation to passionate range and is a common precursor to overt aggressive behavior. The variations notwithstanding, there exists compelling evidence to the fact that aggressive behaviors embody significant challenges to the successful integration into society of individuals with personality disorders and other psychiatric disorders, not mentioning that an aggressive orientation presents significant management issues for care providers (Crocker et al. 652).
Some paradigms to studying aggression divide aggressive behavior into discrete subtypes depending upon the scope and the context of the aspects concerned. Although the nomenclature of these subtypes often varies, research demonstrates that some individuals exhibit more than one subtype of aggression (Nouvion et al. 552) and that associations often exist among the various subtypes of aggression (Reidy et al. 415).
Overall, an aggressive orientation exhibited by an individual may distinctively be described as being reactive or proactive. A meta-analytic review of psychology and psychiatric literature (e.g., Nouvion 552; Reidy et al. 416; Latalova & Praske 240) demonstrates that reactive aggressive behavior occurs in response to aggravations or threats, or discernments of threats, while proactive aggressive behavior is deliberate, planned and goal-oriented.
Consequently, while reactive aggressive behavior tends to be emotional, impulsive, hostile and perpetuated with high autonomic arousal and minimal behavioral control, proactive aggressive behavior is perpetuated with low autonomic arousal and a high degree of behavioral control.
Studies have found that proactive aggressive behavior is closely correlated to personality disorders and other psychiatric disorders than reactive aggressive behavior (Nouvion et al. 553). In one such study cited by these authors, some researchers found that proactive aggression exhibited by 12-year olds premeditated their levels of delinquency, oppositional defiant disorder (ODD) and conduct disorder (CD) by the time the teenagers reached age 15.
In yet another study also reported by these authors, researchers found that “…proactive males, compared with reactive males, were more prone to externalizing problems (aggression, unruliness) in childhood and adjustment problems (noncompliance, conduct problems) in adolescence, and that proactive males and females had poorer achievement in school and were heavy users of alcohol as adults” (553).
To drive the point home, another study also cited by the same authors found proactive aggression to be positively correlated with a multiplicity of personality and behavioral disorders, such as antisocial personality disorder and disruptive behavior diagnosis. These findings aptly demonstrate that aggressive behavior is a fundamental component of personality disorders.
Consequently, it can be argued that proactive aggression is a uniquely discernible form of aggressive behavior with significant clinical implications for individuals with preexisting condition for personality disorder (Nouvion et al. 553).
To provide some more insights into this issue, academics and practitioners have acknowledged that “…individuals displaying reactive aggression may be differentiated from individuals displaying proactive aggression on measures of personality and psychopathology, as well as in histories of aggression, and type and severity of aggressive behaviors committed” (Fossati et al. 22).
However, both proactive and reactive forms of aggression have been noted to either lead to aggression against self or aggression against others (Reidy et al. 415). As noted in psychological literature, the two subsets of violence “…share certain underlying neurobiological mechanisms, but their impact on clinical care, patient’s environment, and legal involvement are different” (Latalova & Prasko 239).
Unlike aggression against self, which is ultimately viewed as a form of self-injurious behavior, aggression against others not only endangers care providers, family members and other patients, but may also carry legal penalties for the perpetrator (Bowins 155), as well as increased risk for victimization in job settings and criminalization (Crocker et al 652).
Some researchers argue from the perspective that aggression causes negative ramifications on interpersonal relations, which in turn triggers or aggravates personality disorders in individuals experiencing the noted interpersonal strain (DiGiuseppe et al. 67).
In such a scenario, aggressive behavioral orientation, arising from such factors as family discord, couple distress and parent-child conflict, becomes the triggering agent for personality disorder and other behavioral and cognitive impairments, including irrationality, poor judgment, and engaging in risky and erratic behavior.
Personality Disorders
According to traditional diagnostic perspectives embodied in the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision), a personality disorder is described as “…an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has onset in adolescence or early childhood, is stable over time, and leads to distress or impairment” (Nelson-Gray et al 7).
Personality disorders are complex and highly challenging, not only for the individuals concerned but also the society, health institutions and caregivers, mainly due to the fact that only a limited number of treatment therapies are supported by research.
In terms of prevalence, one study demonstrates that the most common personality disorder is “…the obsessive-compulsive personality disorder, followed by passive-aggressive, avoidant, borderline, and histrionic personality disorder” (Torgersen 626).
While these disorders represent a cluster of the most common personality disorders, it is imperative to mention that the rarest personality disorders within the general population include antisocial, schizoid, dependent, and sadistic personality disorders. However, it is essential to note that prevalence rates may vary depending on the geographical context and population (Roberts et al. 225).
The following sections aim to look at the inter-linkages between the sampled personality disorders and the prevalence of aggression. The sections will also incorporate findings from an interview with an expert psychiatrist about the perceived relationship between aggression and personality disorders.
Aggression and Antisocial Personality Disorder (ASPD)
Debate still rages as to what this entity really represents, with some researchers arguing that there is an actual defect in sociopaths while others argue “…that antisocial behavior is an adaptive trait providing an enhanced ability to acquire recourses through deceit” (Bowins 158). However, the DSM-IV acknowledges that antisocial personality disorder (ASPD) is typified by a persistent disrespect for, and infringement on, other people’s rights and freedoms (Reidy et al. 415).
The present criteria for ASPD, as elucidated in DSM-IV, encompass a behavioral blueprint that is initiated before age 15, and consist of three of the following behaviors: repeated criminal acts, deceitfulness, impulsiveness, repeated fights or assaults, disregard and disrespect for the security of others, irresponsibility, and lack of remorse (Moeller & Dougherty 6).
It is imperative to note that ASPD is a comparatively common personality disorder afflicting the general population, with available statistics demonstrating that an estimated 3 percent of men and 1 percent of women successfully meet the DSM-IV criteria for ASPD (Moeller & Dougherty 6).
Interestingly, the prevalence of ASPD is much higher in selected populations, such as violent offenders incarcerated in prisons and patients in alcohol or substance abuse treatment programs, suggesting a strong correlation between ASPD and aggressive behavior. Contract killers, who are often extremely aggressive individuals but having the capacity to hide or encapsulate emotions, fall into this category of antisocial individuals (Bowins 159)
One study seems to suggest that dysregulated and uncontrollable aggression, may it be proactive or reactive, is a hallmark of ASPD (DiGiuseppe 69). However, another study suggests that “…detachment from, and indifference to, the feelings and welfare of others is a hallmark of this condition” (Bowins 158).
The variations notwithstanding, research has demonstrated that individuals presenting with ASPD “…are prone to develop an overt antisocial pathway characterized by an escalation from minor aggressive (e.g., bullying, annoying others) to serious violent behaviors (e.g., gang fighting, physical assault)” (DiGiunta et al. 874).
Another study demonstrated that individuals “…with histories of behaviors associated with ASPD were more aggressive than were people without such histories” (Moeller & Dougherty 7). In yet another study, it was demonstrated that adolescent male parolees exhibiting three or more of mentioned ASPD symptoms exhibited higher aggressive behavior than did adolescent female parolees with no symptoms of ASPD.
Based on these sentinel studies, it could be authoritatively argued that there is a positive correlation between ASPD and aggression and that ASPD does, in fact, increase aggressive behavior in humans. The findings, more than anything else, exemplify the fact that individuals who are likely to engage in aggressive behavior are more likely to have an elaborate and readily available personality disorder (Bettencourt et al. 753)
An interview with a psychiatrist in a local counseling center for individuals exhibiting disordered behavior demonstrated that it is often difficult to treat clients with a personality disorder, primarily because such individuals may not necessarily display insight that their behaviors deviate from societal norms.
As a matter of fact, the psychiatrist confided in me that an individual presenting with ASPD might not be conscious of the fact that others within the social setup regard his behavior as excessively calculating and self-serving; rather, he may view his behavior as an absolutely normal attempt to get ahead of his peers.
It, therefore, becomes extremely important for caregivers to look into other possessive behavioral orientations, such as heightened aggression, to make a correct diagnosis of ASPD and other personality disorders (Nouvion et al. 560).
Aggression and Borderline Personality Disorder
Borderline personality disorder (BPD) is included within Cluster B (erratic-emotional-dramatic) of Axis II personality disorders and is typified by the DSM-IV-TR “…as a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts” (Nelson-Gray et al 26).
BPD is typified by volatility and dysfunction in affective, behavioral, and interpersonal spheres of the individual, leading to impulsive and self-destructive behaviors in the event of the individual reaching extreme affective instability. These episodes are typically succinct and reactive and entail intense fluctuations between angry and depressed states (Reidy et al. 417).
Available literature demonstrates that “…patients with borderline personality disorder, mainly with impulsive-behavioral dyscontrol symptoms, exhibit impulsive aggression, self-mutilation, or self-damaging behavior (e.g., promiscuous sex, substance abuse, reckless spending)” (Latalova & Prasko 239).
Another strand of existing literature demonstrates that individuals with BPD exhibit “…emotional/affective dysregulation (e.g., labile mood, anger, negative affect), interpersonal difficulties (e.g., sensitivity to perceived threats of abandonment or rejections), impulsivity (e.g., self-injury or sexual promiscuity), and cognitive dysregulation (e.g., dissociation in responses to stress, unstable self-image)” (Nelson-Gray et al 27). Interestingly, nearly all of these behavioral orientations are positively correlated with aggression (Daffern et al. 427), implying that aggression may be an innate constituent of BPD.
Extant research demonstrates that BPD has high comorbidity with substance use and alcohol disorders, Bipolar Disorder, and Antisocial Personality Disorder, implying that patients suffering from BPD are at elevated risk of demonstrating violent or aggressive behavior (Latalova & Prasko 239). In yet another study, it was reported that “…women with borderline personality disorder demonstrated more aggressive responses than did women without the disorder” (Moeller & Dougherty 8).
To reinforce this perspective, another study found that a self-report of BPD aspects in middle childhood was distinctively linked to instructor-reported relational aggression (aggression displayed to damage or destroy relationships) even after controlling other extraneous variables such as physical aggression and depressive symptomatology (Reidy et al. 415).
Moving on, psychological and psychiatric literature has proved that patients with BPD are also known to present with manifold problems in a therapeutic setting, such as placid forms of therapy interfering behavior to violent suicidal gestures and aggressive episodes (Nelson-Gray et al. 30). Consequently, these research findings related to BPD and aggression demonstrate that aggressive behavior is indeed a central component of personality disorder.
More important, these findings underscore the fact that particular personality characteristics appear to envisage divergent patterns of aggressive behavior (Bettencourt et al. 751). These views are consistent with Anderson and Bushman’s (2002) general aggression model, which posits that certain character traits predispose individuals to high levels of aggressive behavior (Bettencourt et al. 753).
Aggression & Narcissism
A growing body of literature demonstrates that narcissism is innately and positively correlated with aggression and hostility, with studies revealing that highly narcissistic individuals might be particularly sensitive to experiencing “slights” from others and that high narcissism is often expressed with high aggressive behavior when there is an inherent ego threat (DiGiuseppe 69).
One study reports that “…narcissists have an inflated sense of self-worth and self-love without a strong set of beliefs that support this sense of superiority” (Bettencourt et al. 758). By virtue of the fact that this group of the population experiences unbalanced self-esteem, they are exceptionally sensitive to personal slights, such as insult and positive censure.
Consequently, narcissistic individuals tend to exhibit aggressive behavior in ego-threatening situations, primarily because of their perceived culpability to threats to the self-concept. Indeed, a number of researchers have acknowledged that factors that contain or control aggression in the general population seem to be totally absent or are deficient in narcissist individuals (Bettencourt et al. 758).
Moving on, several psychological and psychiatric-oriented studies have demonstrated “…that narcissism predicts aggressive behavior in situations involving provocation” (Bettencourt et al. 758). This finding is particularly important to the cause of the present paper as it implies that narcissism and the level of provocation positively interact to influence aggressive behavior.
The psychiatrist interviewee supported this line of thought when he admitted that narcissist individuals often become angry, irritated and exceedingly impatient when confronted with a challenge that seems to challenge their self-worth and self-concept as they perceive such challenges as actual provocations to their capabilities. Indeed, the psychiatrist confided in me that individuals are exhibiting narcissistic orientations and challenging to treat due to their misrepresentation of facts and experiences.
This view has been corroborated in the literature, with one study noting that individuals presenting with narcissism are the most difficult to treat as any comment that these individuals may misinterpret as a personal slight generates the so-called narcissistic injury, activating intense aggressive behavior and frequently, a failure to progress with therapy (Bowins 157).
In yet another study, “…overt narcissism has been linked to aggression in response to an external threat to one’s self-esteem” (Fossati et al. 21). Extending these finding, a study conducted by Barry et al. (2007) cited by these authors demonstrated that in moderately to extremely aggressive children, overt narcissistic predisposition appeared to forecast both proactive (i.e., unprovoked, goal-setting) and reactive types of aggression.
This is an important finding which sets the stage for the exposition of the fact that aggression is indeed a central component of personality disorders as it implies that narcissists can indeed perpetuate unprovoked aggression. It is imperative to note that this finding underlines the commonly accepted assertion that individuals presenting with narcissists predispositions are only reactively aggressive (Reidy et al. 415). Indeed, other studies have found that narcissist individuals are not prone to displaced aggression irrespective of provocation (Reidy et al. 419).
Aggression & Avoidant Personality Disorder
Avoidant personality disorder is incorporated within Cluster C (fearful-anxious) regimen of the Axis II personality disorders and is typified by the DSM-IV-TR “…as a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early childhood and present in a variety of contexts” (Nelson-Gray et al 31).
A growing body of literature assumes the position that avoidant personality disorder cannot in any meaningful be differentiated from social phobia due to the huge amount of symptom overlap and recurrent co-occurrence of social phobia and avoidant personality disorder (Nelson-Gray et al 31). However, these particular authors acknowledge that clients with avoidant personality disorder are often expected “…to present with other Axis I anxiety disorders, other personality disorders (especially dependent personality disorder), and mood disorders” (31).
It is important to note that individuals suffering from avoidant personality disorder often mostly present to therapists or to the psychiatric counselors as cautious, detached, distrustful and potentially aggressive, primarily due to their extreme and often unfounded fears of receiving negative evaluation and hypersensitivity to criticism (Nelson-Gray et al. 33).
This view is reinforced by the interviewee, who suggested that he had experienced instances when clients turn aggressive when confronted with the reality of receiving a negative evaluation in a clinical or therapy setting.
Apart from the aggressive confrontations, the psychiatrist confided in me that groups of the population presenting with avoidant personality disorder are more likely to engage in cancellation of appointments at the last minute, shifting from one therapist to the other, coming late for therapy sessions, and failing to do homework, ostensibly because of their fears to receive negative evaluation as well as their hypersensitivity to criticism.
Aggression & Schizoid Personality Disorder
Extant literature demonstrates that individuals exhibiting Schizoid Personality Disorder (SPD) “…lead very limited lives and demonstrate some degree of psychosis when under significant stress, thus reinforcing the perspective that it is a variant of schizophrenia” (Bowins 163). This particular author contends that individuals with this type of disorder extend isolation to the extreme, not mentioning that they exhibit the tendency to over-apply the juvenile classical defense of schizoid fantasy.
The criteria for schizoid personality disorder under the DSM-IV diagnostic tool include a pervasive pattern of detachment from social and interpersonal relationships, as well as limited range of expression of emotions and other feelings in interpersonal settings, initiating in early adulthood and presenting in a multiplicity of contexts.
In particular, individuals with schizoid personality disorder must present four or more of the following symptoms: neither desires nor takes pride in forming close interpersonal relationships, including being part of a family; take pride in choosing and fulfilling solitary responsibilities and activities; exhibit little, if any, interest in having sexual experiences with another individual; derives pleasure in few, if any, activities; lack close friends or confidants other than their immediate relatives; appear unresponsive to the praise or criticism of others, and; exhibit emotional coldness, detachment, or compressed affectivity (Parpottas 46).
It is imperative to note that schizoid personality disorder “…does not occur exclusively during the course of schizophrenia, a mood disorder with psychotic features, another psychotic disorder, or a pervasive developmental disorder, and is not due to the direct physiological effects of a general medical condition” (Parpottas 46).
The description notwithstanding, numbers of researchers and practitioners believe that a relationship exists between this group of the population and aggressive and violent behavior (Loza & Hanna 340). However, other researchers believe that there exists a paucity of research on the association between schizoid personality disorder and aggressive behavior, although a positive correlation seems highly probable (Loza & Hanna 340).
Indeed, a number of symptoms associated with the syndrome, such as lack of interpersonal and social ties, detachment and unresponsiveness, have been positively correlated with aggressive behavior in past studies (Bowins 165). Hypochondriac, introverted, solitariness, and aloofness, according to available literature, are traits that either enhance or triggers aggressive behavior in individual with personality disorder (Loza & Hanna 341).
It, therefore, follows that people suffering from a schizoid personality disorder may indeed demonstrate aggression against self or others by virtue of the fact that they exhibit symptoms that have long being known to increase incidences of aggression. However, as noted by Parpottas, conclusive findings are yet to be attained in this area.
Aggression & Obsessive-Compulsive Personality Disorder
In the psychological and psychiatric literature, obsession-compulsion is usually perceived as a set of personality characteristics that would not naturally be as extreme as to constitute a personality disorder; however, a disorder materializes when characteristics or behaviors become rigid, maladaptive, and occasion impaired functioning or subjective distress (Mudrack 491; Torres et al. 863).
This view is premised on the view that many individuals undeniably possess varying levels of obsessive-compulsive characteristics without necessarily being impaired or prejudiced by these traits. As a matter of fact, obsessions and compulsions are evidently perceived as constituents of the regular repertoire of human behavior.
In their extreme form, however, obsessions and compulsions have caused inflexibility, extreme skepticism, a damaging “…superego (believing that one is more ethical than others, suspicious of pleasure, guided by conscience, and conscientious, dependable, and reliable), and perseverance (suggesting a pattern of dogged persistence, hard work, and tenacity” (Mudrack 491).
In job-related context, a manager exhibiting this type of personality disorder may become extremely ‘bossy’, always reprimanding employees for not realizing often unachievable or untenable objectives (Torres et al. 864). Cases abound of teachers who beat their students for not dressing to their expectations, or for not attaining marks that the teachers consider as satisfactory.
The psychiatrist interviewee confided in me that such projection of aggressiveness on the part of teachers might be as a direct consequence of Obsessive-compulsive disorder, though such teachers may never be aware that they are suffering from the disorder.
Through the beatings, the teachers may engage in self-harm behavior (e.g., losing their jobs for going against the set rules and regulations) or may internalize a predisposition to harm others (e.g., physically injuring the students). Both ways, it can be argued that aggressiveness – either proactive or reactive – is a critical component of personality disorders.
Conclusion
From this critical discussion and analysis, there is compelling evidence to suggest that aggression is a fundamental component in many of the personality disorder classified under the DSM-IV and its successor – the DSM-IV-TR – diagnostic manuals.
It has been found that, with the exception of schizoid personality disorder, aggression is deeply entrenched in behavioral orientations of individuals with personality disorders discussed in this paper, which include antisocial personality disorder, borderline personality disorder, narcissism, avoidant personality disorder, and obsessive-compulsive personality disorder.
Opinion still remains on whether aggression forms a critical constituent of schizoid personality disorder (Loza & Hanna 340), but there is a strong indication that the symptoms associated with this condition are known to trigger or aggravate aggressive behavior.
This analysis provides important implications for clinical, psychological and psychiatric practice by virtue of the fact that practitioners and therapists can develop a centralized treatment strategy aimed at reducing aggressive orientations in the treatment and management of the discussed personality disorders.
By treating aggression in this group of the population, doctors and therapists will stand a better position not only to assist the individuals concerned reinforce their cognitive and emotional faculties towards full recovery, but also ensure that these individuals do not present a threat, either to themselves or to other members of society.
What’s more, the analysis shed’s light on a number of issues that could inarguably assist society in the handling and understanding of individuals with the discussed personality disorders, particularly in terms of handling their aggressive predispositions. However, further research is needed to be able to separate the particular correlates of aggression in individuals with personality disorder and how such correlates could be addressed to reduce disorder burden.
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