At the end of a long, dark hallway, almost walled off by the bricks of an annex building, the office of José Luis Carrasco (Cáceres, 63 years old), head of Psychiatry and creator and director of the Personality Disorders Unit of the Clinical Hospital San Carlos de Madrid suddenly opens to the light. Behind the large window located behind his work table, the spotless blue sky of a May morning and the green of the trees draw—in contrast with the bricks—an almost bucolic setting. To the left of the desk, a large bookshelf looks strangely uncluttered. Just about twenty books on psychiatry and personality disorders, the specialty to which Carrasco has dedicated more than 30 years of his career. Among those volumes, displayed with the cover facing front, his last book, Personality and its disorders (Arpa, 2024), in which the psychiatrist invites readers to an informative introduction to the science of personality, a branch that three decades ago, he confesses, “was almost like science fiction.”
“Before, psychiatry was in charge of very clear illnesses: severe depression, schizophrenia, bipolar disorders… but what were called psychopathies—which were anomalous personalities—had always been considered something unmedical,” explains Carrasco. which recognizes that thanks to the gradual entry of these disorders into the field of medicine and psychiatry in recent decades, much progress has been made in understanding their causes, their neurobiology, and the psychological and family factors that produce them. , and treatments.
Ask. He writes in the introduction that we use the word “personality” with “an astonishing naturalness, without realizing that, after the concept of God, it is the “most formidable and unattainable that exists.”
Answer. It is a very strong concept. When we rate someone by their personality, it is actually as if we are rating their entire being, their entire essence. That, if we think about it, is as complex as the idea of God itself. And we do it quite a bit and very lightly when it comes to rating someone’s personality. Just through an encounter, a comment or an action we already say that “this person is neurotic” or that “that person has an obsessive personality.” We label a person’s personality based on a reaction or an act, a momentary manifestation of their personality at a specific moment and in a specific context, and from there we always behave with that person based on that label. . That is a mistake, because it is a prejudice that prevents us from seeing that person in another way. Getting to know someone’s personality takes a long time.
Q. Would you dare to define the concept of personality?
R. I would define it as the characteristics, mechanisms and components of the human being that enable them to be a person. That is, being an individual who has the capacity to decide, which is what currently differentiates us from animals. Within psychiatry we could speak of personality as the tendency to be, to feel, to interpret the world and to relate to others in a certain way. But it is a trend, it is not something that enslaves us.
Q. Can we say that personality, therefore, is fluid?
R. Today we know that personality is not a fixed thing, but rather it is a living entity, it is more of a being than an entity. So yeah, it flows. Yes, it is true that it does not flow from white to black, but it is flowing, it is not always the same, because it depends on the traits, which would be the foundations of the personality, but also on the interaction of those traits with the environment. We could say that genetics lays the foundations of personality, but the foundations are nothing if the building does not later take shape through interactions with the environment, through epigenetics. In harmony between biology and environment is how personality flows.
Q. Do we all share the same personality traits?
R. The personality is like a temple that is being built. We all have the same columns that act as support, which are the traits (emotional sensitivity, extroversion and introversion, sensation seeking, impulsivity, interpersonal sensitivity, etc.), but those columns can be more or less fat, thin, tall or short . Starting from that basis, a temple that is built with balanced columns will have more consistency. However, if it is built with all the thick columns on one side and the thin ones on the other and some columns taller than others, the temple can hold, but at the slightest windstorm or earthquake it will collapse. Exactly the same is what would happen to the personality.
Q. A graphic example of the latter?
R. If the traits are out of adjustment, there can be very big contradictions. For example, a person may have the trait of being a highly developed sensation seeker, but at the same time they also have a trait whereby they are very afraid of something happening to them. This will cause him to be in conflict with himself, he may become blocked and in the blockage feel bad (“I’m worthless, I’m a coward”). Or let’s say a boy who is a sensation seeker and who, however, has a very strict family that tells him no, that he has to study to be a mathematician and an orderly and balanced man. That is, being the complete opposite of what his biology asks of him. In the end it is easy for that boy to end up dropping out of school and smoking joints because he gets bored, because he has not been allowed to flow where he needs to go.
Jaime Villanueva
Q. I said before that personality flows in the harmony between biology and the environment.
R. Exact. The thing is that if there is no harmony and a child, for example, does not reach the reference or the idea of him that he feels his parents have, it is easy for him to begin to get overwhelmed because he does not reach it, because it is not what is expected of him, and That’s when the personality gets sick. You have to let the trait flow, because the trait is never bad. The bad thing is when you try to put a dam on the trait and make a person be different from what they are. It happens a lot with impulsive kids. Maybe they have a brother capable of studying for ten hours straight, but they can’t be like that. As parents we have to understand this and let them flow, because they may be good at many other things, but you cannot try to make them have a trait that they do not have. What happens if we force it in that sense? The boy will begin to think that he is a disappointment, that he is worthless, his self-esteem will begin to fall and he may end up developing a personality disorder.
Q. To what extent does the parents’ gaze, attachment, and the development of children’s personality condition?
R. The emotional nutrition of parents is essential for the building. In the end, the essence of the personality building is the experience of oneself, the image that I have of myself, the esteem that I have towards myself; and that has been created through the eyes of the parents, their smile, what the world has given us back from our actions. It is in this return that we create our image and our self-esteem, which is something that we do not bring as standard. If we have not generated a semi-consistent self-image and self-esteem (because there is a lot of disparity between what we are and the ideal that we feel our parents expect) we are approaching a personality disorder. That is why one of the key recommendations of the book is that we must help the building grow towards where it needs to grow, let it flow. If it can be improved a little, fine; but without comparing, for example, a son with his brother or with his friend, because that sends a message that we would like it to be different. The key to protecting against personality disorders is loving attention and trust (which form a secure attachment with parents), unconditional love, “I like the way you are.”
Q. Where is the border between a very impulsive, narcissistic or hypersensitive personality and personality disorder?
R. Basically, a person with a personality disorder cannot stand independently, they need a kind of crutch, a protective figure. The case of an emotionally hypersensitive person who can succeed academically and professionally, who can have a partner and who, although he suffers more or less, is autonomous, we would not classify it as a disorder. The disorder has a functional qualification: that is, this person, if left alone, does not function or does so by abusing others (that is, being a narcissist or psychopath) or by clinging to whatever, usually narcissists or psychopaths. And another key aspect is that the identity of the person with a personality disorder is not formed. When we explore, you realize that they are people without purpose, who are going nowhere and who get tangled in interpersonal situations until you deal with them.
Q. The pandemic has caused an outbreak of mental health disorders. Has it also happened in the case of personality disorders?
R. A lot. There has been an exponential increase, more than doubling. It has happened in general with all disorders that have to do with behavior and personality. We don’t know exactly why that was. Partly due to confinement, which forced kids to spend a lot of time with their parents without the disconnection that relationships with peers entail. Even more so for the most impulsive. And then it has also affected the probably global feeling of meaninglessness. Feeling that there are no prospects, many have entered symptomatic loops of self-harm, discouragement…
Q. There is also a lot of talk about social networks.
R. Social media is not bad per se, but put in the hands of vulnerable people they are doing a lot of harm. Think that we have kids forming their self-image in comparison to the ideal images they see on the networks. They have tremendous cocoa in the formation of their identity.
Q. The environment plays a role in the development of personality disorders. Also in recovery?
R. Yes. Invalidation of the patient’s discomfort is very common. Since these disorders do not have very bizarre symptoms such as delusions or hallucinations, it seems that they are things of life, that they are not diseases, and one tends to think that the person is forcing the situation a little or that they do not want to get out of it. But it’s not true. The patient is as he is because he cannot be otherwise, but it is more difficult for family members and society to understand him. That’s why it’s easy to invalidate discomfort with comments like “nothing’s wrong with you,” “with everything we’ve done to make you happy, how do you do this to us?” or advice like “be reasonable” or “think about the future.”
Q. Do we lack empathy with people who suffer from a personality disorder?
R. Yes Yes. They produce a kind of automatic reaction of rejection and annoyance in us. We must be taught to identify the disorder, to empathize and to accept. When people with a personality disorder are given a good welcome, they automatically have less of a personality disorder and over time they stop being so. Foster care greatly improves the disorder, at least in borderline personality disorders, which are the majority.
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