Obsessive–Compulsive Personality Disorder

A person who has an obsessive–compulsive personality sees life from the inside of a pressure cooker. It is a pressure cooker often constructed from the patient’s own set of perfectionistic goals and demands. In short, these patients are hard on themselves. Driven by an internal sense that any failure is an ultimate failure, they help to form the army of workaholics who both love and resent their work. In a sad sense, these people frequently function under a covert belief system that they must prove themselves worthy of being loved. Thus there is no time for fun, and they often appear too serious for their own good while presenting a somewhat cool and distant exterior.

They tend to control their anxiety through the use of an abstract and overly intellectualized style of thinking. Deep inside, there seems to be a fear that they are about to lose control. Consequently, life becomes a series of contests that are won through discipline and endless lists and work schedules. Patients with an obsessive–compulsive personality truly show their colors when they produce a splendidly paradoxical “schedule for play.” Even free time is a commodity to be well spent. Moreover, major decisions rapidly become major hurdles, because the patient becomes terrified of the prospect of making a wrong decision. Life is viewed as a long corridor of one-way doors few of which lead to “success.” It is a costly lifestyle, filled with stress. It is a way of life in which tears may not be shown but are felt nevertheless.

Dependent Personality Disorder

As with the previous disorder, a person with a dependent personality views the world as a place fraught with potential disaster; however, the resultant anxiety is handled in a different fashion. The compulsive person throttles the anxiety by fiercely attempting to control all possible situations, including the behaviors of others. The passive-aggressive individual mutes the anxiety by saying, “I never expected much from this lousy show anyway.” In contrast, the dependent personality runs from the anxiety, straight into the arms of some unsuspecting surrogate parent. Life is spent hunting for this savior. White knights are not the inhabitants of fairy tales; they are the invited dinner guest.

These patients are exquisitely sensitive to rejection, but they are willing to risk humiliation if the reward is eventual safety. Consequently, they are often warm and giving, bordering precariously on the cusp of obsequiousness. They are more than willing to bend to the needs of others; indeed, they thrive on the chance to prove their irreplaceable devotion by doing just about anything they are asked to do. They can be coerced to do things they find to be objectionable, or even illegal, if such activities are necessary to be accepted or loved. They invented the concept of bending to peer pressure.

Having a fear of showing anger, because it could result in rejection, they display their anger passively by making mistakes, procrastinating, or “forgetting” to do requested tasks. Because they view themselves as weak and ineffectual, they do not want to make decisions. Moreover, their intensely low self-esteem traps them into a fear that they could not make it on their own. This type of person is often unable to leave the spouse-abuser, and his or her unfortunate answer to insecurity is the safety of interpersonal dependency.

Avoidant Personality Disorder

Affection and love are two conditions that people with an avoidant personality hope for desperately. Unfortunately these goals remain mere dreams, because these patients suffer from such low self-esteem that they dare not risk making an attempt at friendship. If ever there were people who followed the credo “Any club that would accept me, I wouldn’t want to belong to,” it is this group of patients. Like people with dependent personalities, they feel inadequate, but their low self-esteem seems laced with a more brutal self-ridicule. These people do not generally trust themselves and essentially become socially phobic. Unlike the person with a dependent personality, they frequently appear aloof and cool, so as to protect themselves from the rejection they feel is a future certainty. They also tend to alienate other people with self-denigrating comments such as, “You probably don’t want me along, but can I come to the movies too?” Such testing comments beg for a statement of acceptance from their targets, who may quickly tire of providing reassurance.

Their timid demeanor may provoke ridicule from bullies and those predisposed to cruelty. Moreover, they do not search for the “white knight” so valued by people with dependent personalities, because they would not even dare to address such a figure if found. It is a lonely existence. These are the patients who live in cities for years without making an effort to secure a friendship unless they feel absolutely certain that rejection will not occur. Every night is lost in the anonymity of online exchanges or in the white flickering of television characters, who have no method of inflicting pain and who will reliably show up for the next date.

Schizoid Personality Disorder

The person presenting with a schizoid personality structure represents the classic picture of the quiet loner. If one were to picture an animal analogue, some type of mollusk comes to mind – a creature that is slow moving, has limited ability to reach out, yet is more than capable of living a shell-like existence, content to function as an isolated unit. There is a blandness to the world of these patients, both in their internal and external worlds. They tend to form few relationships and prefer the role of a wallflower. Emotions run neither high nor deep. Tenderness tends to be neither felt nor sought. They exhibit a relatively bland indifference to what others may think of them. Their lack of affective color may suggest the cool stamp of one looking down from the pedestal of superiority. This is seldom the case. In actuality, their “colorless” quality represents a muted palette. These people tend to lack both the need and the social skills to actively engage other people.

On the surface, they may sound somewhat like people with avoidant personalities. But the avoidant personality is a hotbed of anxious emotions stirred by a perpetual duel with predicted humiliation. A person with an avoidant personality actively avoids people, whereas a person with a schizoid personality effortlessly glides through people with a minimum of contact. There is no fear of rejection because there is no desire for acceptance.

Some mention should be made of another diagnosis with which the schizoid disorder is sometimes associated, but which, in my opinion, shares little overt resemblance, except with regard to the spelling of their names. A person with a schizotypal personality disorder (which we will examine in detail in a few pages), like a person with a schizoid personality, may also have few friends and appear somewhat aloof and distant. But patients with a schizotypal personality disorder are generally, but not always, rejection sensitive, much more like a person with an avoidant personality. Moreover, their world is seldom bland. On the contrary, it is extremely active, rich with bizarre and idiosyncratic emotions and conceptualizations, a bit like a dream on feet. Furthermore, the diagnosis of the schizotypal personality seems to be related to schizophrenia and people with such personality traits may later develop this psychotic disorder. Indeed, in the DSM-5, the schizotypal personality disorder is viewed as being part of the schizophrenia spectrum as well as being a personality disorder.

In contrast, there appears to be no striking relationship between the person with a schizoid personality and the occurrence of schizophrenia. Indeed the person with a schizoid personality disorder is not generally prone to micropsychotic episodes, as seen in schizotypal personality disorders.

Antisocial Personality Disorder

A person with an antisocial personality is a chameleon. At times he or she may appear somewhat withdrawn like a person with a schizoid personality disorder, but more frequently the person appears actively involved with others. With certain people this individual may appear belligerent and nasty. On a different night or with a different person, he or she may be the epitome of charm. The reason for the deftness in style lies primarily in the fact that these patients are participating in a continual game in which other individuals exist as pieces to be manipulated and utilized as deemed fit.

As a result, people with antisocial personalities are frequently at odds with the law and are noted for lying, cheating, drug fencing, job hopping, and paternity suits. They can be particularly nasty on the web, wrapping their cruelty in the anonymity of a false internet identity. Sex is a one-night affair, and the word “responsibility” is not listed in their dictionary. At their worst, these patients may be cruel, sadistic, and violent (a sub-category of this disorder is referred to in the literature as “sociopathy”). It has been suggested that they seldom feel anxiety and certainly infrequently feel the anxiety born from guilt. Indeed, they live a life in which a superego seems to have never set foot in their psyche. In a surprising sense, these people frequently see their problems as arising from flaws in other people, as opposed to their own inadequacies. They have an almost uncanny knack at convincing others to give them yet another chance, leaving people to feel convinced that “this time is really different.” It isn’t.

Obnoxious as these patients may sound, Vaillant makes the humanizing point that, in reality, they probably do, or at least did at some point, feel pain.⁴ Indeed, their amoral behaviors and worldview probably are, at least in part, a reflection of defenses developed to deflect relatively intense pain. For instance, the apparent callousness of their relationships may in some cases represent a defense, protecting the patient from a fear of being engulfed by intense dependency needs. Ironically, people with an antisocial personality may very well be as entrapped as their victims, their distancing defenses taking them so far from human emotion that they may appear as monsters. But in the last analysis, they are all too human.

Histrionic Personality Disorder

There are probably few people who are as exhilarating to be around as a histrionic person “on a good day” and few as miserable to encounter as an unhappy one “on a bad day.” On this adult see-saw, these patients attempt to live life as a child, hoping to find a perch on Daddy or Mommy’s knee. The world is seen through the eyes of an Impressionist painter, popping an occasional hallucinogen. They do not look at details and seldom remember them. The past is a blur of impressionistic images. Whereas the person dealing with an obsessive–compulsive personality collects the world in neat categories and cages, the histrionic patient gleefully unlocks the doors of any cages within sight.

These patients feel little responsibility and demonstrate an unnerving sense of devil-may-care. With a forced eviction lying only days ahead, the histrionic patient may be focusing attention on landing a date with someone he or she met in a pick-up bar or encountered in a risqué chat room. Somehow or another a new apartment is supposed to simply materialize in the meantime. Their impulsive nature is often also manifested in flirtatiousness and even promiscuity. They are frequently drawn to people who are already attached or sought by someone else.

There is no doubt that life is exciting for them, because they view themselves as if their life were part of a movie. They tend to demand center stage, and if lucky enough to be good-looking or talented, they may well end up center stage. Their life is a long string of over-reactions, tantrums, and lost loves. Many a Hollywood train-wreck is pulled by the locomotive of an underlying histrionic personality. Fascinating people to read about; painful people to befriend.

Beneath the dramatics is a fragile self-esteem that is easily crushed. Behind the glamour, intense feelings of inferiority and neediness hide. They are powerfully dependent upon the applause of others for their own sense of self-worth. Keenly sensitive to rejection, they are constantly searching for reassurance and praise. People are manipulated to achieve these needs, and a person with a histrionic personality can little afford to empathize with the needs of those who may lie in his or her way.

Mild suicidal behaviors without intent to die are not uncommon. But these suicidal behaviors may be followed several days later by a bright smile if “Mr. or Mrs. Right” has entered the picture. This ability to change moods rapidly, depending on environmental circumstances, is a hallmark feature. Like a child throwing a tantrum, one needs only to distract a person with a histrionic personality in order to make things better. Somehow, there is tragedy in all this glamour. Adults were not made to live as children.

Narcissistic Personality Disorder

As mentioned earlier, this category seems to house two rather distinctive types, which, for want of a better title, can be referred to as the stable and unstable variants. In the stable variant, the patient’s narcissism appears to be well rooted. These patients actually view themselves as superior and frequently enjoy their own company. In contrast to this picture, with the unstable variant, the narcissism appears more as a defensive front, a type of pseudo-narcissism. With these patients, the grandiosity is more of a charade, hiding an intensely frightened ego.

Let us look at people with a stable narcissistic personality first. To these patients, other people exist as objects, whose reason for existence is to comfort the patient. A person with this type of narcissism finds it difficult to view others as having needs. The world revolves around one god, and the god is “I.”

Like a small child, the stable narcissist’s views of others may rapidly change from idealizing to denigrating. Mother is great if she buys the toy airplane and is a hated object if she denies the purchase. People with a stable narcissism are often the product of a spoiled upbringing, in which sharing was not common. Consequently, they never develop the ability to think of other’s needs. It simply does not cross their minds.

Naturally, few people locked into a narcissistic perspective are born with the abundance of talents and skills they feel they have. Daddy’s little girl may merely be another average kid to the rest of the world. To deflect this painful realization, these patients may preoccupy themselves with grandiose fantasies. On the other hand, some people with a stable narcissistic personality structure, especially if talented, may be reasonably happy, although they may be difficult to get along with. Problems arise if, for whatever reason, adulation and subservience do not come their way. In such instances, they may pout, stomp about, become depressed, and/or turn to inappropriate substance use for comfort.

In contrast, a person with an unstable narcissistic personality tends to live in a much more hostile world. The sense of ego is actually poorly developed, and life is a constant threat. There lurks an incipient feeling of annihilation and a piercing feeling that the individual is truly worthless. This is defended against by the production of a grandiose style, not unlike that seen in the person with a histrionic personality. But the stakes are high, and these patients are easily wounded. Their defense may consist of a vicious rage, and they can turn on a friend in moments. Few people are trusted and bitterness becomes a way of life.

They are constantly fleeing humiliation, while gloating over the embarrassment of others. If dinner is not on the table on time, then one may find it angrily thrown on the floor. Tantrums and rages become second nature. They expect to be at the head of the line, and when this does not happen, a scene is to be expected. They are almost impossible to please and are prone to severe depressive episodes when their needs are not met. Their personality structure is quite primitive, and they are prone to micropsychotic episodes. People with unstable narcissism are often not successful in life, because their behavior prevents advancement, while their mood swings make consistent work difficult. In some instances, they may demonstrate reasonably good impulse control in public or on the job, but display their more primitive qualities in their intimate relationships such as with their spouse or their therapist.

Unlike the stable narcissist, the unstable narcissist is frequently sad and angry. Every day is a battlefield. They pretend to be Napoleon, but deep in their hearts they know they are a sham. Worse yet, they unconsciously fear that others will recognize the sham as well.

Borderline Personality Disorder

The person coping with a borderline personality structure experiences life as if there were no sense of inner self. If one could feel inanimate, like a piece of clothing hanging forlornly in a closet, then one can begin to appreciate the hollowness that haunts these people. Like the clothing, they feel empty unless filled by the presence of others. Like the clothing, they depend on others to give meaning to life. Consequently, they often intensely dislike being alone, because it can lead to sensations of impending annihilation and destruction. As a friend leaves the apartment, they may literally feel empty, as if a part of themselves were now absent.

Their need for others is so great that they cannot understand how anyone who really cares about them could leave them alone. Thus their dependency quickly becomes a hostile one as they resent the pain that others inflict upon them. When they feel slighted, they can rapidly escalate into rages, throwing glasses, breaking furniture, and screaming profanities. In this sense, they are unpredictable. Because they are so exquisitely sensitive to being hurt, friends and lovers may quickly tire of apologizing, eventually growing angry themselves. A high level of interpersonal stress is the standard price required to befriend these patients.

Without the presence of others, these patients frequently view life as colorless and boring. Consequently, coupled with their intense feelings of weakness and self-loathing, they may ceaselessly seek stimulation using drugs, sex, and eating to satisfy their feelings of emptiness. Their impulsive behaviors unfortunately may bring them into contact with superficial people, who promptly proceed to abuse them, thus fulfilling their worst fears. Fear of abandonment becomes a nagging companion, stoked by the fact that their unpredictable behavior and manipulative attitude frequently result in actual rejection.

Their thinking often has a black/white quality to it, in which they have problems seeing the grey both in situations and in the actions of others. This can result in a tendency to “catastrophize,” seeing problems and relationships as disastrous or untenable. Their catastrophizing tendency is frequently accompanied by an inability to soothe or comfort themselves without the help of another person.

Suicidal thought arises almost with a predictability. It may be coupled with a tendency to use self-cutting and other forms of non-lethal self-harm such as burning themselves with cigarette butts and matches, striking themselves, or head banging. When cutting themselves, they frequently feel no pain. The self-cutting seems to serve as a surprisingly reliable method for relieving their feelings of intense pain or anger. Such episodes often follow an argument or perceived slight. These periods of analgesia, while cutting themselves, probably represent fleeting periods of psychotic depersonalization. Other common micropsychotic processes include derealization and paranoia.

In the last analysis, these patients face a harsh world, over which they feel they have little control. The picture is further darkened by the sense that they themselves are also out of control. They represent the stuff of which soap operas are made. They are “the glass people,” delicate to touch, easily broken, and dangerous when shattered.

Schizotypal Personality Disorder

Like the person with a borderline personality, the individual with a schizotypal personality seems to lack a core. This person also is stalked by a rather unsettling sensation that he or she is somehow empty. This blandness becomes an invitation to an in-pouring of vivid fantasy and psychotic-like process. The world becomes peopled with clairvoyant messages, ghost-like presences, magical hunches, and secretive glances. Like a child withdrawn into a world peopled with pretend playmates, the person with a schizotypal personality silently retreats from life. Unlike a person with a schizoid personality described earlier, a person struggling with a schizotypal personality disorder is frequently sensitive to rejection. This person wants contact but does not know how to make it. There is a desperate quality here, in which the eccentric professor finds more solace in his books than with others of his species. They may find that the only safe place to fulfill their needs for intimacy lies in the addictive world of massively multiplayer online gaming (MMO). Here in the world of MMOs they find it easier to befriend an avatar than the human who created it. One of my adolescent patients would spend endless days running with stray dogs in the woods near his house. Apparently, they were kinder companions than the children at his school. Moreover, he was “the king” of his dogs, whereas he was merely “the dog boy” at his school. Thus these fantasy wanderings may provide a firmer sense of self-esteem to these patients.

Because of the withdrawal into their private worlds, these patients may develop idiosyncratic ways of thinking and using words, tending to become metaphoric and vague. There may have been a tiny bit of schizotypal flair to the oddness of Emily Dickinson. Unfortunately, these traits may result in further problems with socialization, as reflected by Ms. Dickinson suggesting to her guest that he choose between a glass of wine or a rose from the garden. With the right guest, this eccentric gesture is endearing; with the wrong guest, it is puzzling if not downright bizarre. When stressed, the person with a schizotypal personality may decompensate into micropsychotic episodes including delusions and hallucinations. And as part of the schizophrenia spectrum, people with this personality disorder can be more likely to develop schizophrenia itself, or they may have relatives afflicted by it. In a sense, this individual lives life from “the inside of the bottle,” peering at others as if watching a different species, worried that someone may poke a finger or two into his or her private world.

Paranoid Personality Disorder

The world of the person with a paranoid personality is blanketed by a thick covering of restless worrying. Probably more than any other disorder discussed so far, these patients see the world as a hostile environment. These patients have never evolved the ability to trust other people. As a consequence, they are suspicious and guarded by nature. They scour their interactions with others for the subtlest hints of deception, often ignoring the bigger picture as they fixate on a slip of the tongue or an errant look. They tend to be over-controlling and prone to intense jealousy.

Their paranoid ideation, except during micropsychotic episodes, is not delusional in quality, but nevertheless, they seem driven by it. It is as if they feed on their own concerns. One is left with the feeling that without their fears, they would feel awkward and without purpose.

Their defensive guardedness has generally arisen to protect them from a deep-rooted sense of inferiority. Moreover, they fear that their weaknesses will leave them vulnerable to attack. In response, they become haughty, finding it extremely difficult to admit mistakes. All new faces represent potential enemies, not potential friends. Everything needs to be checked out. By way of illustration, during an initial interview one of my patients suddenly produced a notebook in which he began vigorously scribbling down our dialogue. He related that, “I’m just keeping a record so that people on the outside know what’s going on in here.”

It is a lonely existence. It is also one in which delusional thinking can erupt, because the paranoid patient’s isolation prevents him or her from receiving corrective opinions from others. It is further complicated by their tendency to see their own unacceptable impulses in other people instead of in themselves (a psychodynamic defense known as projection). They are consequently prone to misattribute their own hostility to others. Their brief delusional micropsychotic breaks are often accompanied by tremendous feelings of rage and indignation. These patients are also predisposed to more severe psychiatric disorders, such as a paranoid delusional disorder. In the final analysis, they are exquisitely unhappy. In a true sense, they lead tortured lives, because everywhere that they look they see men with inquisitor’s hoods. Ironically, it is the hands of their own projections that weave such ominous raiments.

Passively Scouting for Clues to Personality Dysfunction

Throughout the interview, the clinician has the opportunity to reflect upon both the patient’s words and actions. In this way, without actively searching for clues to personality dysfunction, the astute clinician frequently picks up on a variety of hints as to which disorders may be worth pursuing in more detail.

In this regard, the clinician can focus on the patient’s observable behaviors and style of interaction (signal signs) or on the patient’s reported complaints (signal symptoms). Both areas are rich with implication, providing pertinent clinical hints that point toward the personality diagnoses or traits that are most likely present. Keep in mind that the presence of signal signs or signal symptoms does not indicate that a personality disorder (or even a specific personality criterion) is present. They merely indicate that it is worth looking for a particular disorder or trait historically in the available timeframe.

Signal Signs

Since personality disorders represent long-standing patterns of behavior, it is not unusual for patients to reveal some of their pathologic behaviors during the interview itself. This does not always occur, but it frequently does. I am consistently amazed by the regularity with which these signal signs occur in the first 5 to 8 minutes of the interview, during the scouting period. This early appearance of characteristic defensive behaviors may result from the patient’s anxiety stimulated by meeting a clinician. This self-system anxiety probably triggers many of the most ingrained defenses of the patient.

In Chapter 3 (see pages 68–97) we discussed the mnemonic PACE as representing the mental activities of the clinician during the scouting period. If the reader will recall, the “A” stands for an assessment of the patient’s mental state and behaviors. An important part of this assessment process is the clinician’s careful openness to the presence of signal signs (observable behaviors). Signal signs may also appear during any subsequent phase of the interview as well.

The signal signs represent behaviors suggestive of specific personality disorders that may warrant further investigation. As noted earlier, they do not indicate that the patient necessarily has these disorders, because these behaviors may be present in personality disorders other than the ones listed or in people without character pathology at all, sometimes caused by state-dependent factors such as the presence of bipolar disorder or schizophrenia. But what the signal signs do suggest is the increased likelihood that a particular disorder may be present and may be worth exploring later in the interview, perhaps while eliciting the social history.

Each clinician could probably develop a long list of signal signs gleaned from experience. In this chapter, I am sharing some of those that have been most useful for me. Many others exist, and I am not attempting an exhaustive study here. The following observations are derived from clinical experience and do not represent research-validated data. Nevertheless, I think that they provide a useful jumping-off point for clinicians who are attempting to master the art of delineating a differential diagnosis regarding personality.

One of the more peculiar signal signs is the presence of comments made by the patient during the interview about the interview itself or the interviewer. Most patients do not make such process comments, because they are inhibited by the newness of the situation and do not want to do something that is wrong. I remember a young man who was being interviewed by a student in front of a group of fellow students. The patient had a dramatic intensity and related several times that he was an extremely sensitive individual. It has been said that if one has a good trait, one never needs to tell others about it. Such was the case with this “sensitive” patient, for in the middle of the interview he turned to the obviously struggling interviewer saying, “You sure seem to be having a lot more trouble with this interview than me.” If the clinician was not feeling awkward enough already, then this statement certainly pulled out a few more beads of sweat.

This practice of commenting on the process of the interview, frequently in a somewhat caustic fashion, is often a dead giveaway that the clinician is speaking with a person exhibiting one of the following four disorders: an antisocial personality, a narcissistic personality, a histrionic personality, or a borderline personality (it may also manifest in people with passive-aggressive traits).

A somewhat-related behavior that can signal the presence of personality dysfunction arises when the patient makes some type of unwarranted complaint during the interview itself. These complaints may be coupled with demands of a subtle nature and sometimes of a not-so-subtle nature. For example, a patient may walk in the door for the first appointment announcing that he or she does not intend to sit in the waiting room so long the next time. Or the patient may begin, “You really should get better parking arrangements for your patients, although I’m sure you’ve already looked into this matter before” (topped off with a pleasant smile). Such behaviors are often the “window dressings” of a person with one of the following disorders: a narcissistic personality, a borderline personality, a paranoid personality, or an antisocial personality.

At the other extreme, one may encounter patients who seems a little too pleased with the clinician. These are the patients who make sexual innuendoes or references throughout the interview. This may consist of overly frank discussions of sexual adventures or overt offers for a date or the request of a telephone number. In other instances, the patient may turn on the charm with phrases such as, “Well, I’ve always seemed to be fairly attractive to the opposite sex, as I’m sure you’ve found to be true for yourself.” These types of comments represent signal signs consistent with the following: an antisocial personality, a histrionic personality, and a narcissistic personality. If the innuendoes become more lewd or intrusive, one should become even more alert to the possible presence of an antisocial personality structure. I have found that males with an antisocial personality disorder will not infrequently use this type of sexual innuendo for putting female interviewers on-guard as a means of attempting to control the interview.

This type of behavior is similar to the patient who presents with a dramatic bravado. The patient may be boldly dressed in bright colors or a sinewy scarf. If male, the patient may be encased in clothing so tight that one cannot help but notice he is a gold card member at the local gym and has the muscles to prove it. If female, provocative clothing and sexual innuendo may rule the day. The patient is frequently quite enthralled with the very act of talking about the history of the present illness while animatedly gesturing. Such patients may rapidly become tearful and even more rapidly shut off the tears when the clinician embarks on a new line of questioning. These types of behaviors should serve as an indication that one may be in the presence of a person with a histrionic personality or a borderline personality.

Another type of signal sign consists of the patient who appears child-like and helpless. These patients may speak with a quiet meekness, accompanied by an earnest attempt to please the interviewer with statements such as, “Is this what you wanted to hear?” As one would suspect, such behaviors are often the trademarks of a dependent personality structure. Such helplessness is sometimes also seen episodically in people with histrionic personalities and with borderline personalities.

As a final example of a signal sign, we turn to those patients who become openly manipulative during the interview itself. They may attempt to make the clinician grant them a request or make a condemnation of another clinician. For instance, the patient may say, “My current therapist is very bossy. Don’t you think that is strange for a therapist?” The patient then waits anxiously for the clinician to make a disparaging comment that will undoubtedly be fired as a verbal salvo at the therapist in question. Other types of manipulations may consist of various methods of controlling the interview or bargaining with the clinician, such as, “Look it’s getting late, if we must talk let’s do it quickly and I need a cigarette first.” Once again, we’ve hit the province of disorders such as the borderline personality, the histrionic personality, and the narcissistic personality. Such “sighing compliance” may also mark a person presenting with passive-aggressive traits. (See Figure 14.1 for a summary of signal signs)