Why is Spotting the Personality Disorder So Damned Hard?

In my last piece, Let's Play Spot the Personality Disorder, I posted a quiz asking readers to match the four DSM-IV Cluster B personality disorders (antisocial, borderline, histrionic, narcissistic) to 15 DSM symptoms. Now try matching these DSM descriptions to the same list of disorders:

1 “A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts ...”

2 “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 ...”

3 “There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years ...”

4 “A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts ...”

Easy, right? Here's the answers:

1 Histrionic, 2 Borderline, 3 Antisocial, 4 Narcissism.

But if this quiz was so easy, why was the last one so difficult? Here’s the explanation. The DSM descriptions are basically assigning colors to various illnesses, much like different houses: Green, blue, yellow, orange. The symptoms are the paint, and here we run into problems. Green is a combination of blue and yellow, yellow is present in three of the paints, and all use white as a base (I won’t even get into the issue of the various tints).

Thus, for example, these two interchangeable symptoms (antisocial and borderline, respectively):

• "Irritability and aggressiveness, as indicated by repeated physical fights or assaults."
• "Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)."

It gets worse. The DSM-IV symptom checklist for narcissism mentions nothing about anger or aggression, but a review of the literature brings up the phenomenon of “narcissistic rage” (against those who poke holes in their ego).

Obviously, the narcissist is living in a world of self-delusion (“believes that he or she is ‘special’ and unique”), but so is someone living with borderline (“identity disturbance”, “alternating between extremes of idealization and devaluation”), and histrionic (“considers relationships to be more intimate than they actually are”). Likewise, further reading reveals that those with antisocial have difficulty separating out fantasy from reality.

Here, we’re looking at the white paint of a fundamental failure in perception, of people living in universes of their own imaginations, with highly distorted views of themselves and the people around them. Something is obviously not processing right in the cortical areas of the brain.

Then there is all the blue and yellow paint from the emotional areas:

“Impulsivity in at least two areas” (borderline), “impulsivity or failure to plan ahead” (antisocial), “uncomfortable in situations ...” (histrionic), “often envious of others” (narcissistic).

So, failure in perception meets runaway emotion. Or, it could be a deficit of emotion:

“Shallow expression of emotion” (histrionic), “chronic feelings of emptiness” (borderline),  “lack of remorse, as indicated by being indifferent ...” (antisocial), “lacks empathy” (narcissistic).

Either way you look at it, we’re talking about an emotional thermostat set way too high or too low, or one that’s simply on the fritz. Thus, faulty perception meets unregulated emotion. Worlds collide, strange behavior happens. In a reasonably operational brain, the thinking areas pick up that something is amiss, and we work at changing our behavior. But here we’re dealing with “a pervasive pattern” rather than a mere episode, which puts us back in the realm of faulty perception. Again and again, the individual fails to come to terms with his or her thoughts and actions. Thus:

“Preoccupied with fantasies ...” (narcissistic), “rationalizing having hurt ...” (antisocial), “Is suggestible” (histrionic), “paranoid ideation” (borderline).

Avoid these people like the plague, you think. Not so fast. If you happen to believe that the narcissist in your presence walks on water, then the two of you will get along just fine - until, perhaps, you start noticing that your new boon companion is wearing wet clothes.

Conversely, someone with borderline may think it is you who walks on water (and who are you to question their good judgment?) - that is, until he or she decides you are really the Antichrist, after all. Meanwhile, who isn’t drawn to a histrionic enchanter or enchantress? - at least until we start thinking with our brains again. And, of course, chances are you will be profusely thanking that very charming (but antisocial!) individual you have just handed over your entire life savings to.

And there you are - the “normal” one in this relationship - left to pick up the pieces, humiliated, mystified, abused, jilted, duped, conned, and perhaps much worse. These people definitely need therapy, but - thanks to them - you may need it more. But where does the therapist start? We may know a “classic” narcissist or borderline when we see one, but personality - much less life - is never that simple.

Diagnostic psychiatry can no more explain the reality of personality than theology can explain God. At best, psychiatry (and theology) can come up with an approximation of reality, based on what we know at the time. Clearly, a better approximation is needed. The people working on the DSM-5 recognized that, too.

Much more to come ...