Introduction
As the above quotation illustrates, for ages humans have enthusiastically attempted to classify each other. Such behavior seems to represent a trademark of the species, for better or worse. In previous centuries, cheirologists attempted to determine the currents of personality in the physical characteristics of the hand. Today, cheirology has been appropriately relegated to the niche of the historically curious – an intellectual antique of sorts.
However, personality theory remains as intriguing today as it did for the cheirologists of the 18th century. On the one hand, tremendous advances have been made in understanding both the normal and abnormal aspects of personality development. On the other hand, much remains to be learned. To be successful in the art of personality assessment, it is important to understand the limitations of current conceptualizations. It is also of value to be familiar with some of the controversies surrounding personality disorders and the systems developed for categorizing them.
Taking into consideration both the presence of these controversies and the fact that there are 10 specific personality disorders in the DSM-5, we will utilize a slightly different approach in the following chapters than was used when we explored mood disorders and psychotic process. Rather than attempt the exhaustive task of representing each diagnosis by a separate clinical presentation, smaller clinical illustrations will be liberally used to delineate diagnostic principles that may be generalizable to any personality disorder.
The emphasis will remain on practical techniques and strategies, brought to life with clinical illustrations, sample questions, and excerpts from initial interviews. My aim here is to acknowledge the controversies and nuances of these diagnoses while simultaneously developing a user-friendly approach for arriving at a differential diagnosis regarding personality dysfunction. My goal is to provide psychiatric residents and graduate students in social work, nursing, clinical psychology, and counseling with the practical tools to effectively and sensitively arrive at a personality disorder diagnosis in the real world of everyday practice as experienced in community mental health centers, hospitals, and private practices.
To achieve this goal, two chapters are devoted to the art of uncovering personality dysfunction and the complexities of differential diagnosis. A third, and final, chapter will explore the fascinating phenomenology and psychodynamics that ultimately drive the behaviors of the people who carry these enigmatic diagnoses.
In this chapter, Personality Disorders: Before the Interview Begins – Core Concepts, we will be introduced to the theoretical aspects regarding personality disorders that most directly impact upon our ability to effectively uncover them during an initial interview, including basic definitions, the pros and cons of making personality diagnoses, and the etiology of personality dysfunction. In Chapter 14, Personality Disorders: How to Sensitively Arrive at a Differential Diagnosis, practical interviewing techniques and strategies for sensitively performing a differential diagnosis will be addressed in a comprehensive fashion. The set of chapters on personality disorders concludes with Chapter 15, Understanding and Effectively Engaging People With Difficult Personality Disorders: The Psychodynamic Lens. It will be in this chapter that our diagnostic illustrations will step out of the pages of this book to become fully realized people, whom we will meet, interact with, and care for in our counseling centers, inpatient units, and emergency rooms.
The Mystery of Personality Disorders Revealed: Core Principles and Definitions
In Search of a Definition
The Gestalt of Personality Dysfunction
To achieve a better feel for how personality dysfunction presents and is experienced by both the patient and the clinician, let us begin by looking at an exchange in an initial interview between a therapist and a person coping with significant personality dysfunction. As is commonly seen with personality dysfunction, the problematic perceptions, attitudes, and behaviors shadow the patient across time zones, locations, and interpersonal relationships. They impact upon almost every person with whom they develop a relationship, sometimes even with a total stranger encountered on a subway or in a bar, or even in a chat room on the internet. On the day of this interview, they would quickly make themselves known to the unsuspecting initial interviewer – me. We will refer to the patient as Mr. Fellows and begin by examining his history, which will then be complemented by a re-creation of a brief bit of dialogue from the interview itself.
Mr. Fellows was referred for outpatient psychotherapy. He had originally been seen in the emergency room with a subsequent referral for possible group therapy. After attending two group sessions, he left because “the therapist spent too much time listening to all those screwball people. And he was also an inexperienced therapist, that’s for sure. I just didn’t like him.”
Mr. Fellows presented in a dirty plaid shirt encased by an unkempt army jacket. He was short in stature with a balding head from which his black hair sprouted. His hair had clearly met a comb, but the liaison had been a brief one. He quickly conveyed a feeling that he did not really want to be in the room. His handshake was overly firm and then suddenly weak as if purposely avoiding prolonged contact. He had entered the room sporting a jaunty cap, which was a little worse for wear, and had now found itself in his lap, a plaything for his fidgeting hands.
With regard to his history he had come from a tough neighborhood, and he had seldom felt at home there. “I didn’t belong there, I’m a sensitive guy, and I felt things those other kids could never feel. But I beat it.” He related having a very high IQ, and he indeed appeared quite knowledgeable and well read. However, he had always encountered intermittent problems in school. He had frequently been involved in arguments with teachers and tended to be a loner. He had had no problems with the law and seemed strongly opposed to violence and criminal activity. He considered taking drugs to be bad, yet he hesitantly admitted to drinking problems in the past.
He had never liked his father, who considered him to be a complete failure and had beaten him in the past. Over the years he had lost contact with most of his family, and he was generally not welcome in their homes.
He viewed himself as talented, especially with regard to writing. Indeed, he had been working on a novel for years. He also boasted of his ability to protect others, as well as himself, from violence. To this point he always carried a small canister of pepper spray with him.
Despite his abhorrence of physical conflict, he reported a life-long history of “finding the nearest argument.” Apparently he often tended to dominate conversations, because “in all honesty I’m smarter than most of the people I meet.” In short, he had developed the rather nifty habit of alienating people almost upon first contact. I would prove to be no different. The following dialogue occurred during the early phases of the body of the interview:
Pt.: That last therapist was a real loser. And I really don’t see much sense in group therapy anyway. In fact, if I really look at this realistically, I don’t really need any help at this time.
Clin.: With that idea in mind what were some of your reasons for coming in for an evaluation today? Apparently you had been referred for outpatient psychotherapy.
Pt.: In the first place I don’t really like psychotherapists. I don’t think you guys really know what you’re doing anyway. I mean I had seen a therapist off and on for 6 or 7 years. He was okay, but he charged more than he was worth. What you need to do for me today is to write a note saying that for medical reasons I need to live in a new halfway house. The one I’m at is situated in too dangerous a neighborhood. And that’s all I need or want from you.
Mr. Fellows was clearly not meant for public relations work. At least he quickly got to his point. In the next session, when he was reminded that further evaluation was needed before I could legitimately address his request, he became actively hostile and commented, “You don’t give a damn do you, Doctor! For all you care, I could be mugged tomorrow, and it would be no sweat off your back. I hope someday you’re being murdered and when you call the police, they say further inquiry will be necessary before we respond to your call!” His words were said with such vehemence and disdain that I felt a twinge of fear.
With regard to diagnosis, further interviewing revealed that Mr. Fellows met the criteria for a narcissistic personality disorder. He also displayed antisocial, borderline, and paranoid traits. Indeed, a rule-out secondary diagnosis was “other specified personality disorder” (i.e., mixed personality features: antisocial, borderline, and paranoid traits). Concerning other psychiatric diagnoses, he was still having intermittent problems with excessive alcohol use, although he had not been drinking for several months.
Subsequent therapy revealed that throughout his life Mr. Fellows had suffered from an intense feeling of vulnerability. The question, “Am I really worth loving?” was a rather constant companion, a shadow from which he could not step away, no matter how hard he tried to inflate his self-esteem. He developed a series of defenses to protect himself from this pain, including a sense of entitlement, a tendency to put others down, fantasies and preoccupations with grandiosity, and a coolness in interpersonal contacts. This coolness could serve to protect him from the danger of imminent rejection, a rejection that had first surfaced in the form of abuse from his father.
We are now beginning to perceive the subtle workings of disordered personality structure. In these conditions, the individual develops a series of defenses that can temporarily and in certain circumstances protect them from significant pain. Unfortunately, these same defenses become rigid and limited in number. The patient is left with a defensive structure that is inflexible and frequently ineffective in decreasing pain in the long term; in fact, often it creates new pains (in the form of lost friends, shattered marriages, and blown job opportunities).
Mr. Fellow’s cool indifference and his tendency to put others down may indeed protect him from the potential pain of losing a loving figure, but, ironically, it will also prevent him from ever developing such a relationship in the first place. Mr. Fellows does not know how to function otherwise, and therein lies the tragedy of the situation. The intensity of the loneliness and self-loathing can be enormous. Mr. Fellows is not choosing to have a personality disorder. It has bloomed inside him, a product of his environment, pains, and psychological limitations.
This point is important for the clinician, because it serves to reframe the irritating and sometimes, if one is frank, obnoxious behaviors that some people with personality disorders display in response to their pain and anxiety. Such a realization can help to decrease angry countertransference feelings, while serving to increase a sense of compassion. For instance, the same Mr. Fellows who was initially so patently rude and demanding, would later cry from his sense of loss during the termination phase of his time-limited psychotherapy with me, a mere 12 sessions after our initial handshake.
The story of Mr. Fellows also highlights another, easily missed point. The key to understanding adult psychopathology lies in an understanding of childhood and adolescent development. An adult psychiatrist cannot work in an intellectual vacuum, as if adult patients spontaneously appeared at 18 years of age. Many critical therapeutic interactions parallel parent–child behaviors and feelings. Indeed, these patients can quickly arouse parental responses in the clinician even during the initial interview. If unaware of these psychodynamic concerns, initial interviewers can inadvertently disrupt blending.
DSM-5 Definitions of a Personality Disorder
With these ideas in mind let us look at the definition of a personality disorder (or character disorder, as it has sometimes been described in the past) as viewed in the DSM-5:
A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.1
The actual diagnostic criteria2 are as follows:
Personality Disorders as Reflections of the Social History
The DSM-5 insists that the pathological feelings and behaviors to be used as diagnostic criteria must be consistent and persistent over time. From the perspective of an interviewer, this fact emphasizes that a personality disorder is a historical diagnosis. The critical criteria for making the diagnosis lie in the patient’s history, not in the patient’s behavior in the interview itself. The patient’s immediate behavior in the interview often provides important clues to underlying psychopathology, as it did with Mr. Fellows, but the criteria for establishing the diagnosis lie in historical evidence, for the onset must be traced back to adolescence or young adulthood. In a sense, a personality disorder leaves historical artifacts. These artifacts are often buried in the patient’s social history.
The nature of these artifacts varies significantly, but one of two elements will be present: (1) either the patient’s rigid defenses result in behaviors/feelings/consequences that are disturbing to other people, and/or (2) the patient’s rigid defenses result in behaviors/feelings/consequences that are unsettling to the patient. By way of illustration, a person with an antisocial personality may steal the life savings of an employer who trusted the patient implicitly. The patient may have no regrets about such actions, but clearly the patient’s behavior will have had a disastrous effect on the employer. Such behaviors are called ego-syntonic, because they do not disturb the patient.
At the other extreme, a person with an avoidant personality may shun almost all social contact while living in a self-imposed interpersonal exile. This behavior may not really harm anyone else per se but results in significant personal distress. These types of behaviors are referred to as ego-dystonic, because they directly create subjective pain in the patient and are viewed by the patient as a problem. Some patients show a combination of ego-dystonic and ego-syntonic symptoms. Moreover, some ego-syntonic behaviors may morph into ego-dystonic behaviors as the patient begins to realize the damaging consequences of their behaviors to themselves over the course of time.
In patients who display primarily ego-syntonic behaviors, an important issue arises. These patients frequently are not strongly invested in receiving help, because their behaviors are not disturbing to them. Family members, lawyers, or employers may have pressured such patients into therapy; consequently, these patients may be unusually difficult to engage, both in the initial interview and in subsequent therapy. Thus, if an interviewer happens to be functioning as a consultant or triage agent, the presence of primarily ego-syntonic behaviors may suggest that the interviewer should ultimately recommend that an experienced staff member be responsible for ongoing therapy as opposed to a trainee.
But whether ego-syntonic or ego-dystonic, the behavioral manifestations of a personality disorder tend to result in specific types of dysfunctional interpersonal patterns within parental, sibling, dating, marital, employment, and friendship relationships. Consequently, as mentioned earlier, the historical evidence of a disordered personality is usually reflected in the patient’s social history. To an experienced interviewer, the social history is like a snowfield, in which the characteristics of the patient’s personality dysfunction can be read in the tracks criss-crossing its surface.
Thus the social history is not merely a sterile recording of “what job was held when,” but represents a sensitive mirror in which the reflections of a personality disorder may first appear to the alert clinician. Stated even more boldly, a totally normal social history, if accurately related by the patient, is not consistent with a personality disorder. Somewhere along the line, the pathologic personality traits will disrupt interpersonal relationships.
From the DSM-5 definitions we can see that when performing a differential diagnosis in the initial interview, the clinician must actively search for consistent patterns of behavior, demonstrated from adolescence or early adulthood onward, without major disruption of these patterns. In this regard, Mr. Fellows serves as a suitable illustration. His defensive patterns appeared early in his life. His social history was littered with weak relationships, a poor job history, an unending string of arguments, and a maladaptive grandiosity. These behaviors were consistent over time and were undeniably crystallized by late adolescence.
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