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 ...

Let's Play Spot the Personality Disorder

In a recent blog post, I discussed narcissism in the context of its proposed downsizing from the DSM-5 as a stand-alone “categorical” diagnosis to one of many “core impairments” in a dimensional schema of “personality functioning.” Personality is complex, and clinicians have a hell of a time trying to sort out what is going on. To give you an idea, I have prepared a little quiz:

Following are symptoms taken from the four DSM-IV “Cluster B” personality disorders: Antisocial, Borderline, Histrionic, Narcissistic.  See if you can match the symptom to the disorder. Answers and commentary further down:

1 "Is uncomfortable in situations in which he or she is not the center of attention."

2 "Requires excessive admiration."

3 "Impulsivity or failure to plan ahead."

4 "Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating)."

5 "A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation."

6 "Considers relationships to be more intimate than they actually are."

7 "Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another."

8 "Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others."

9 "Displays rapidly shifting and shallow expression of emotions."

10 "Identity disturbance: markedly and persistently unstable self image or sense of self."

11 "Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations."

12 "Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations."

13 "Shows arrogant, haughty behaviors or attitudes."

14 "Irritability and aggressiveness, as indicated by repeated physical fights or assaults."

15 "Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)."

Answers

1 Histrionic

2 Narcissistic

3 Antisocial

4 Borderline

5 Borderline

6 Histrionic

7 Antisocial

8 Narcissistic

9 Histrionic

10 Borderline

11 Narcissistic

12 Antisocial

13 Narcissistic

14 Antisocial

15 Borderline

Commentary

I think you get the point. Namely, we have a preponderance of overlapping symptoms that defy easy categorization. Yes, we all sort of know what a narcissist is, for instance, but some of the features are strikingly close to histrionic and borderline, which in turn appears to be the female twin of the more male antisocial, which yet in turn can be difficult to distinguish in certain respects from narcissism. Enough, already!

I’d be interested in how well or how badly you fared, and other sundry opinions. Please give me feedback in the comments below. Confession: In the course of assembling this quiz, I couldn’t keep track of the correct answers, myself. I was obliged to keep rechecking and rechecking again ... and again.

Obviously, we need a lot more clarity in the next DSM. But will the new dimensional system only result in far more confusion?

Much more to come ...

Judging Amy - Follow-up

In my previous two blog pieces, I recounted the adventures and misadventures of the fictional Amy, who clearly evidenced personality issues that operated both to her advantage and disadvantage. My point was that before we congratulate ourselves in not being like Amy, it would be far more useful, instead, to acknowledge that we have a lot more in common with people like her than we would care to admit.

In short, we need to be thinking in terms of WE, rather than THEM vs US.

A lot of attention is paid to managing our illness - such as bipolar or depression or anxiety - but what tends to hold us back in life are our unresolved personality issues. I got to observe this close-up in my years of attending and facilitating DBSA support groups. I strongly suspected in some individuals an undiagnosed personality disorder in play, but more often than not I saw myself looking in the mirror at my own personal shortcomings.

We get fearful, we feel threatened, we get overwhelmed. We may flip out, we may become avoidant. We overreact, we under-react. In desperation, it seems, as a way of dealing with a world that seems to be increasingly aligned against us, we restructure our own reality. Call it Me World, where we are no longer hold ourselves accountable, or as accountable.

This may allow us to hold onto our sanity for a little while, but the catch is the real world doesn't buy into our reality.

What psychiatry categorizes as personality disorders sheds invaluable light on what is going on with us, but with this major caveat:

Personality disorders are by no means definitive. The DSM method of separating out and categorizing various personality disorders creates the misleading impression of identifying (and thereby labeling and stigmatizing) an individual by the so-called disease at the expense of understanding the person. The reality is different degrees of symptom severity and overlap, which the next DSM is likely to address, probably in the form of a "dimensional" schema to coexist with its categories.

Okay, now a quick traverse of the four best-known - and closely-related - personality disorders, which the DSM groups together as Axis II, Cluster B:

Borderline Personality Disorder

Freud's successors came up with this term to describe what they saw as problem patients bordering on psychotic. Emotionally unstable is a far more accurate description. Nevertheless, the label borderline stuck, together with the legacy of borderline individuals being regarded as problem patients. Sympathetic hospital staff have been known to turn on individuals in distress once they have been handed this diagnosis.

Borderline made its official debut in the DSM-III of 1980, but on the surface is very difficult to distinguish from bipolar. Unofficially, psychiatry is guided by the common stereotype of the moody and often hysterical teenage girl (or people who act like one) who may have abandonment issues, act impulsively, and engage in destructive behavior such as cutting. Twice as many females are diagnosed with the illness, possibly because problem males better fit the stereotype of antisocial personality disorder.

People living with someone who exhibits borderline tendencies typically describe the relationship as akin to walking on eggs: one minute all love and light, the next a hateful explosion or the sullen silent treatment. A borderline meltdown tends to have its roots in the individual’s lack of ability to handle the stress of any given social situation. Thus it can occur without warning. This tends to contrast with bipolars behaving badly, which typically flows in slower cycles.

Antisocial Personality Disorder

Serial killers generally fall into this class, but the diagnostic criteria is wide enough to include your abusive boss or scheming co-worker, or for that matter your brother who borrows your car and returns it without refilling the tank. According to the old joke, poor people with antisocial disorder are in prison, middle class individuals with this disorder are in therapy, and rich people with the label are CEOs. These are your classic sociopaths, out for number one, with no regard for others. “I’d walk over my own grandmother to re-elect Richard Nixon,” Watergate conspirator Chuck Colson once bragged. He wasn’t joking. He authored an “enemies list” of real and imagined political opponents to be singled out for special treatment, such as FBI harassment and tax audits.

Typically, men are three times more likely than women to receive the diagnosis, leading to a strong suspicion of gender stereotyping between borderline and antisocial. A female who is emotionally overwhelmed and angry may throw a hissy fit. A male in a similar state may throw a punch.

Narcissistic Personality Disorder

We are not simply talking about over-inflated egos. Rather, the narcissist sees him or herself at the center of his or her own personal universe, with everyone else relegated to bit players assigned to specific minor roles. Dare to intrude reality into this individual's fantasy world and brace yourself for a narcissistic rage.

Histrionic Personality Disorder

Most of us enjoy being the center of attention, but people like Tom Cruise tend to go about it by jumping on Oprah’s couch. Those inclined toward displays of excessive emotionality also hate it when the spotlight turns to someone else, even a loved one. “Poor me” may also feature in their routine.

Mind vs Brain

The DSM-I of 1952 interpreted behavior as "determined by inherent personality patterns, the social setting, and the stresses of interpersonal relations" and tended to give far less weight to "the precipitating organic impairment.” This separation of the mind from the brain had far-reaching effects. With the advent of biological psychiatry, personality disorders became the poor relation of psychiatry. The ground-breaking DSM-III of 1980 had the effect of highlighting "Axis I" illnesses such as bipolar, depression, schizophrenia, and anxiety (all with obvious biological underpinnings) at the expense of ghettoizing the personality disorders into "Axis II."

Of all things, biological psychiatry is rescuing personality disorders from past and current neglect. The "stresses of interpersonal relations," for instance, are turning up on brain scans in ways that are screaming, "major paradigm shift."

More later ...