Create a document that includes a transcript of a call from the patient’s point of view based on the information in the case study including basic personal information and reasons for seeking out psychotherapy.

Prior to beginning work on this discussion, please read Chapters 3, 4, and 17 in DSM-5 Made Easy: The Clinician’s Guide to Diagnosis; Cases 18, 19, and 20 from Case Studies in Abnormal Psychology; and Chapter 1 in Psychopathology: History, Diagnosis, and Empirical Foundations. It is recommended that you read Chapter 1 in Turning Points in Dynamic Psychotherapy: Initial Assessment, Boundaries, Money, Disruptions and Suicidal Crises.

For this discussion, you will choose from one of the three “You Decide” case studies included in Case Studies in Abnormal Psychology. The case study you choose for this discussion will also be the case study you will use for your Psychiatric Diagnosis assignment in Week Six.

In your initial post, you will take on the persona of the patient from the case study you have chosen in order to create an initial call to a mental health professional from the patient’s point of view. In order to create your initial call, evaluate the symptoms and presenting problems from the case study, and then determine how the patient would approach the first call.

Create a document that includes a transcript of a call from the patient’s point of view based on the information in the case study including basic personal information and reasons for seeking out psychotherapy. The call may be no more than 5 minutes in length. Once you have created your transcript you will create a screencast recording of the transcript using the patient’s voice. Based on the information from the case study, consider the following questions as you create your recording:

  • What would the patient say?
  • What tone of voice might he or she use?
  • How fast would the patient speak?
  • Would the message be understandable (e.g., would it be muffled, circumstantial, tangential, rambling, mumbled, pressured, etc.)?

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C H APT ER 1 7

P erso n alit y D is o rd ers

Quick Guide to the Personality Disorders

DSM -5 r e ta in s t h e 1 0 s p ecif ic p ers o nality d is o rd ers ( P D s) t h at w ere l i s te d i n D SM -IV . O f t h ese , p erh ap s 6 h av e b een

stu die d r e aso nab ly w ell a n d h av e a lo t o f s u ppo rt in th e r e se arc h c o m munity . T he r e st ( p ara n oid , s c h iz o id , h is tr io nic ,

an d d ep en den t P D s), w hile p erh ap s le ss w ell fo unded in s c ie n ce, re ta in th eir p ositio ns in th e d ia g nostic fir m am en t

becau se o f t h eir p ra ctic al u se a n d, f ra n kly , t r a d itio n.

S peak in g o f tr a d itio n, e v er s in ce D SM -III in 1 980 th e p ers o nality d is o rd ers h av e b een d iv id ed in to th re e g ro ups,

c alle d clu ste rs . H eav ily c ritic iz ed f o r a la ck o f s c ie n tif ic v alid ity , th e c lu ste rs a re p erh ap s m ost u se fu l a s a d ev ic e to

h elp u s c all t o m in d t h e f u ll s la te o f P D s.

C lu ste r A P erso n alit y D is o rd ers

P eo ple w ith C lu ste r A P D s c an b e d esc rib ed a s w ith dra w n, c o ld , s u sp ic io us, o r ir ra tio nal. ( H ere a n d th ro ughout th e

Q uic k G uid e, a s u su al, t h e l in k i n dic ate s w here a m ore d eta ile d d is c u ssio n b eg in s.)

P ara n oid . T hese p eo ple a re su sp ic io us a n d q uic k to ta k e o ff e n se . T hey o fte n h av e fe w c o nfid an ts a n d m ay re ad

h id den m ean in g i n to i n nocen t r e m ark s.

S ch iz o id . T hese p atie n ts c are little f o r s o cia l r e la tio nsh ip s, h av e a r e str ic te d e m otio nal r a n ge, a n d s e em in dif f e re n t to

c ritic is m o r p ra is e . T en din g t o b e s o lita ry , t h ey a v oid c lo se ( in clu din g s e x ual) r e la tio nsh ip s.

S ch iz o ty p al . I n te rp ers o nal r e la tio nsh ip s a re s o d if f ic u lt f o r t h ese p eo ple t h at t h ey a p pear p ecu lia r o r s tr a n ge t o o th ers .

T hey la ck clo se frie n ds an d are unco m fo rta b le in so cia l situ atio ns. T hey m ay sh ow su sp ic io usn ess, unusu al

p erc ep tio ns o r t h in kin g, e ccen tr ic s p eech , a n d i n ap pro pria te a ff e ct.

C lu ste r B P erso n alit y D is o rd ers

T hose w ith C lu ste r B P D s te n d to b e ra th er th eatr ic al, e m otio nal, a n d a tte n tio n-s e ek in g; th eir m oods a re la b ile a n d

ofte n s h allo w . T hey o fte n h av e i n te n se i n te rp ers o nal c o nflic ts .

A ntis o cia l . T he ir re sp on sib le , o fte n c rim in al b eh av io r o f th ese p eo ple b eg in s in c h ild hood o r e arly a d ole sc en ce w ith

tr u an cy, r u nnin g a w ay, c ru elty , f ig htin g, d estr u ctiv en ess, ly in g, a n d th eft. I n a d ditio n to c rim in al b eh av io r, a s a d ults

th ey m ay d efa u lt o n d eb ts o r o th erw is e b eh av e ir re sp onsib ly ; a ct r e ck le ssly o r im pu ls iv ely ; a n d s h ow n o r e m ors e f o r

th eir b eh av io r.

B ord erlin e . T hese im puls iv e p eo p le e n gag e in b eh av io r h arm fu l to th em se lv es ( s e x ual a d ven tu re s, u nw is e s p en din g,

ex cessiv e u se o f s u bsta n ces o r fo od). A ff e ctiv ely u nsta b le , th ey o fte n s h ow in te n se , in ap pro pria te a n ger. T hey fe el

em pty o r b ore d , a n d th ey f ra n tic ally tr y to a v o id a b an donm en t. T hey a re u ncerta in a b out w ho th ey a re , a n d th ey la ck

th e a b ility t o m ain ta in s ta b le i n te rp ers o nal r e la tio nsh ip s.

H is tr io n ic . O verly e m otio nal, v ag ue, a n d d esp era te f o r a tte n tio n, th ese p eo ple n eed c o nsta n t r e assu ra n ce a b out th eir

a ttr a ctiv en ess. T hey m ay b e s e lf -c en te re d a n d s e x ually s e d uctiv e.

N arc is sis tic . T hese p eo ple a re s e lf – im porta n t a n d o fte n p re o ccu pie d w ith e n vy, f a n ta sie s o f s u ccess, o r r u m in atio ns

ab out th e u niq uen ess o f th eir o w n p ro ble m s. T heir s e n se o f e n title m en t a n d la ck o f c o m passio n m ay c au se th em to

ta k e a d van ta g e o f o th ers . T hey v ig oro usly r e je ct c ritic is m a n d n eed c o nsta n t a tte n tio n a n d a d m ir a tio n.

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C lu ste r C P erso n alit y D is o rd ers

S om eo ne w ith a C lu ste r C P D w ill t e n d t o b e a n xio us a n d t e n se , o fte n o verc o ntr o lle d .

A void an t . T hese tim id p eo ple a re s o e asily w ounded b y c ritic is m th at th ey h esita te to b eco m e in volv ed w ith o th ers .

T hey m ay f e ar t h e e m barra ssm en t o f s h ow in g e m otio n o r o f s a y in g t h in gs t h at s e em f o olis h . T hey m ay h av e n o c lo se

frie n ds, a n d t h ey e x ag gera te t h e r is k s o f u nderta k in g p urs u its o uts id e t h eir u su al r o utin es.

D ep en den t . T hese p eo ple s o m uch n eed th e a p pro val o f o th ers th at th ey h av e tr o uble m ak in g in dep en den t d ecis io ns

or s ta rtin g p ro je cts ; th ey m ay e v en a g re e w ith o th ers w hom th ey k n ow to b e w ro ng. T hey fe ar a b an donm en t, fe el

h elp le ss w hen th ey a re a lo ne, a n d a re m is e ra b le w hen re la tio nsh ip s e n d. T hey a re e a sily h urt b y c ritic is m a n d w ill

e v en v olu nte er f o r u nple asa n t t a sk s t o g ain t h e f a v or o f o th ers .

O bse ssiv e– C om puls iv e . P erfe ctio nis m a n d r ig id ity c h ara cte riz e th ese p eo ple . T hey a re o fte n w ork ah olic s, a n d th ey

te n d t o b e i n decis iv e, e x cessiv ely s c ru pulo us, a n d p re o ccu pie d w ith d eta il T hey i n sis t t h at o th ers d o t h in gs t h eir w ay.

T hey h av e t r o uble e x pre ssin g a ff e ctio n, t e n d t o l a ck g en ero sity , a n d m ay e v en r e sis t t h ro w in g a w ay w orth le ss o bje cts

th ey n o l o nger n eed .

O th er C au se s o f L on g-S ta n din g C hara cte r D is tu rb an ce

P erso n alit y c h an ge d ue t o a n oth er m ed ic a l c o n dit io n . A m ed ic al c o nditio n c an a ff e ct a p atie n t’s p ers o nality f o r t h e

w ors e . T his w ould n ot q ualif y a s a P D , b ecau se i t m ay b e l e ss p erv asiv e a n d n ot p re se n t f ro m a n e arly a g e.

O th er m en ta l d is o rd ers. W hen th ey p ers is t f o r a lo ng tim e ( u su ally y ears ), a v arie ty o f o th er m en ta l c o nditio ns c an

d is to rt th e w ay a p ers o n b eh av es an d re la te s to o th ers . T his can g iv e th e ap peara n ce o f a p ers o nality d is o rd er.

E sp ecia lly g ood e x am ple s in clu de d ysth ym ia , s c h iz o phre n ia , s o cia l a n xie ty d is o rd er, a n d c o gnitiv e d is o rd ers . S om e

stu die s fin d th at p atie n ts w ith m ood d is o rd ers a re m ore li k ely to sh ow p ers o nality tr a its o r P D s w hen th ey a re

c lin ic ally d ep re sse d ; th is m ay b e e sp ecia lly tr u e o f C lu ste r A a n d C lu ste r C tr a its . P ers o nality p ath olo gy n ote d in

d ep re sse d p atie n ts s h ould b e r e ev alu ate d o nce t h e d ep re ssio n h as r e m it te d .

O th er s p ecif ie d , o r u nsp ecif ie d , p erso n alit y d is o rd er . U se o ne o f th ese c ate g orie s f o r p ers o nality d is tu rb an ces th at

d o n ot m eet t h e c rite ria f o r a n y o f t h e d is o rd ers a b ove, o r f o r P D s t h at h av e n ot a ch ie v ed o ff ic ia l s ta tu s.

I N TR O DUCTIO N

All human s (and numerous other species as well) have personality traits. These are well-ingrained ways in

which individuals experience, interact with, and think about everything that goes on around them. PDs are

collections of traits that have become rigid and work to individuals’ disadvantage, to the point that they

impair functioning or cause distress. These patterns of behavior and thinking have been present since early

adult life and have been recognizable in the patient for a long time.

Personality , and therefore PDs, should probably be thought of as dimensional rather than categorical;

this means that their components (traits) are present in normal people, but are accentuated in those with the

disorders in question. But for good reasons and bad, DSM-5 has retained the traditional categorical

structure that has been used for more than 30 years. There are promises that this will change in the coming

years; indeed, DSM-5 devotes a long portion of its Section III (material not officially approved for use) to

exploring alternative diagnostic structures. However, the experts will first have to agree as to which

dimensions to use, then how best to measure and categorize them, and then how to interpret the results. In

the meantime, we will continue to muddle along pretty much as before.

As currently defined in DSM-5, all PDs have in common the following characteristics.

Essential Features of a General Personality Disorder

There is a la stin g p atte rn o f b eh av io r a n d in te rn al e x perie n ce ( th oughts , f e elin gs, s e n sa tio ns) th at is c le arly d if f e re n t

fro m th e p atie n t’s cu ltu re . T his p atte rn in clu des p ro ble m s w ith aff e ct (ty pe, in te n sity , la b ility , ap pro pria te n ess);

c o gnitio n (h ow th e p atie n t se es a n d in te rp re ts se lf a n d th e e n vir o nm en t) ; c o ntr o l o f im puls e s; a n d in te rp ers o nal

re la tio nsh ip s. T his p atte rn i s f ix ed a n d a p plie s b ro ad ly a cro ss t h e p atie n t’s s o cia l a n d p ers o nal l if e .

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T he F in e P rin t

T he D ’s : • D ura tio n (lif e lo ng, w ith ro ots in a d ole sc en ce o r c h ild hood) • D if f u se c o nte x ts • D is tr e ss a n d d is a b ility

( w ork /e d ucatio nal, so cia l, an d pers o nal) • D if f e re n tia l dia g nosis (s u bsta n ce use , physic al illn ess, oth er m en ta l

d is o rd ers , o th er P D s, p ers o nality c h an ge d ue t o a n oth er m ed ic al c o nditio n)

The information PDs convey gives the clinician a better understanding of the behavior of patients; it can

also augment our understanding of the management of many patients.

As you read these descriptions and the accompanying vignettes, keep in mind the twin hallmarks of the

PDs: early onset (usually by late teens) and pervasive nature, such that a disorder ’s features affect multiple

aspects of work, personal, and social life.

Dia gn osin g P erso n alit y D is o rd ers

The diagnosis of PD s presents a variety of problems. On the one hand, they are often overlooked; on the

other , how ever, they are sometimes overdiagnosed (borderline PD is, in my opinion, a notorious example).

One (antisocial PD) carries a terrible prognosis; most, if not all, are hard to treat. Their relatively weak

validity suggests that no PD should be the sole diagnosis when another mental disorder can explain the

signs and symptoms that make up the clinical picture. For all of these reasons, it is a good idea to have in

mind an outline for making the diagnosis of a PD.

1. V erify the duration of the symptoms . Make sure that your patient’ s symptoms have been present at

least since early adulthood (before age 15 for antisocial PD). Interviewing informants (family,

friends, coworkers) will probably give you the most valid material.

2. V erify that the symptoms affect several areas of the patient’ s life. Specifically , are work (or school),

home life, personal life, and social life affected? This step can present real problems, in that patients

themselves often don’ t see their behavior as causing problems. (“It’ s the world that’s out of step.”)

3. Check that the patie nt fully qualifies for the particular diagnosis in question. This means checking all

the characteristics and consulting all 10 sets of diagnostic criteria. Sometimes you have to make a

judgment call. Try to be as objective as possible. As with other mental disorders, with enough

motivation you can usually force a patient into a variety of diagnoses.

4. If the patient is under age 18, make sure that the symptoms have been present for at least the past 12

months. (And be really , really sure that they aren’t due instead to some other mental or physical

disorder .) I personally prefer not making such a diagnosis at such a tender age.

5. Rule out other mental pathology that may be more acute and have greater potential for doing harm.

The flip side is that other mental disorders are also often more responsive to treatment than are PDs.

6. This is also a good time to review the generic features for any other requirements you may have

missed. Note that each patient must have two or more types of lasting problems with behavior ,

thoughts, or emotions from a list of four: cognitive, affective, interpersonal, and impulsive. (This

helps ensure that the patient’ s problems truly do affect more than one life area.)

7. Search for other PDs. Evaluate the entire history to learn whether any additio nal PD is present. Many

patients appear to have more than one PD; in such cases, diagnose them all. Perhaps more often, you

will find too few symptoms to make any diagnosis. Then you can add to your summary note

something to the ef fect: schizoid and paranoid personality traits.

8. Record all personality and nonpersonality mental diagnoses. Some examples of how this is done are

shown in the vignettes that follow .

Although you can learn the rudiments of each PD from the material I present here, it is important to note

that these abbreviated descriptions only begin to tap their rich psychopathology . If you want to make a

study of these disorders, I strongly recommend that you consult standard texts.

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C LU ST ER A P E R SO NALIT Y D IS O RDER S

The PDs included in Cluster A share behaviors generally described as withdrawn, cold, suspicious, or

irrational.

F60.0 [ 3 01.0 ] P ara n oid P erso n alit y D is o rd er

What you notice most about patients with paranoid PD (PPD) is how little they trust—and how much they

suspect—other people. The suspicions they harbor are unjustified, but because they fear exploitation, they

will not confide in those whose behavior should have earned their trust. Instead, they read unintended

meaning into benign comments and actions, and they will interpret untoward occurrences as the result of

deliberate intent. They tend to harbor resentment for a long time, perhaps forever .

These people tend to be rigid and litigious, and may have an especially urgent need to be self-suf ficient.

To others, they can appear to be cold, calculating, guarded people who avoid both blame and intimacy .

They may appear tense and have trouble relaxing during an interview . This disorder is especially likely to

create occupational difficulties: Patients with PPD are so aware of rank and power that they frequently have

trouble dealing with superiors and coworkers.

Although it is apparently far from rare (it may affect 1% of the general population), PPD rarely comes to

clinical attention. When it does, it is usu ally diagnosed in men. Its relationship (if any) to the development

of schizophrenia remains unclear, but if you find that it has preceded the onset of schizophrenia, add the

specifier (premorbid) .

Essential Features of Paranoid Personality Disorder

In m an y s itu atio ns, t h ese p atie n ts d em onstr a te t h at t h ey d is tr u st t h e l o yalty o r t r u stw orth in ess o f o th ers . B ecau se t h ey

su sp ect th at oth er peo ple w an t to deceiv e, hurt, or ex plo it th em , th ey hesita te to sh are pers o nal in fo rm atio n.

U nju stif ie d s u sp ic io ns a b out th e f a ith fu ln ess o f s p ouse o r p artn er, o r e v en th e ( m is )p erc ep tio n o f h id den c o nte n t in

e v ery day e v en ts o r s p eech , c an l e ad t o t h e b ea rin g o f g ru dges o r t o r a p id r e sp onse w ith a n ger o r a tta ck s i n k in d.

T he F in e P rin t

T he D ’s : • D ura tio n ( b eg in s in te en s o r e arly 2 0s a n d e n dure s) • D if f u se c o nte x ts • D if f e re n tia l d ia g nosis ( p hysic al

an d s u bsta n ce u se d is o rd ers ; m ood, a n xie ty , a n d p sy ch otic d is o rd ers ; p osttr a u m atic s tr e ss d is o rd er; s c h iz o ty pal a n d

sc h iz o id P D s)

C od in g N ote

If P PD p re ced es t h e o nse t o f s c h iz o phre n ia , a d d t h e s p ecif ie r ( p re m orb id ).

Dr . Schatzky

A professor of derm atology at University Hospital, Dr. Schatzky had never consulted a mental health

professional. But he was well known to the staff at the medical center and notorious among his colleagues.

One of them, Dr . Cohen, provided most of the information for this vignette.

Dr. Schatzky had been around for several years. He was known as a solid researcher and an excellent

clinician. A hard worker , he supervised fellows working on two grants and carried more than his share of

the teaching load.

One of the trainees working in his lab was a physician named Masters. He was a bright, capable young

man whose career in academic dermatology seemed destined to soar . When Dr. Masters got an offer from

Boston of an assistant professorship and his own lab space, he told Dr. Schatzky that he was sorry , but he

would leave at the end of the semester . Furthermore, he wanted to use some of their data.

Dr. Schatzky was more than upset. He responded by telling Dr. Masters that “what happened in the lab

stayed in the lab.” He wouldn’ t allow anyone to “rip him off,” and he told Dr. Masters that he would be

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blackballed if he tried to publish papers based on their findings. Furthermore, Dr. Schatzky told him to keep

away from the students until he left. This outraged the other dermatologists. Dr. Masters was one of the

most popular young teachers in the department, and the notion that he shouldn’ t have any contact with the

students seemed punitive to all and little short of an assault on academic freedom.

The other dermatologists discussed the situation in a department meeting when Dr. Schatzky was out of

town. One of the older professors had volunteered to try to persuade him to let Dr. Masters teach anyway .

Subsequently , Dr . Schatzky refused with the response, “What have I done to you?” He now seemed to think

that the other professor had it in for him.

This professor told Dr. Cohen that he wasn’ t really surprised. He’d known Dr. Schatzky since college,

and he’d always been a suspicious type. “He won’ t confide in anyone without a signed loyalty oath,” was

how the other professor put it. Dr. Schatzky seemed to think that if he said anything nice, it would

somehow be turned against him. The only person he seemed to trust complet ely was his wife, a rabbity

little creature who had probably never disagreed with him in her life.

At the meeting, someone else suggested that the department chairman should talk to him and try to “jolly

him along a bit.” But Dr. Schatzky had little sense of humor and “the longe st memory for a grudge of

anyone on the face of the planet.”

In the coll ective memory of all the staff, Dr . Schatzky had never had mood swings or psychosis, and at

department dinners, he didn’ t drink. “Never out of touch with reality , only nasty,” said Dr. Cohen.

Evaluation of Dr . Schatzky

I begin with a discla imer: From the info rmation available in this vignette, it would appear that Dr. Schatzky

had never been interviewed by a menta l health professional. Any conclusions must therefore be tentative.

Clinicians simply have no right to make definitive diagnoses of patients—or just plain people—for whom

they haven’t gathered adequate information.

That said, Dr. Schatz ky’s symptoms had apparently been quite constant and present throughout his entire

adult life (at least since college). His problems involved both his thinking and his interpersonal functioning,

which in turn led to problems with his work and personal life.

What symptoms of PPD did Dr. Schat zky have? Without cause, he suspecte d young Dr. Masters of

planning to “rip off’ his data (criterion A1). His colleagues noted his long-s tanding concerns about the

loyalty of associates (A2). He would never confide in others (A3), and he refused to let Dr. Masters teach,

which sounds a lot like holding a grudge (A5). (However , he had apparently never questioned the loyalty of

his wife, which would be another common symptom of this PD.) So we can find a total of four symptoms,

which is what’ s required for a diagnosis of PPD.

Could a non-PD diagnosis explain Dr. Schatzky’ s behavior as described? Although the information is

incomplete, drug or alcohol use appears unlikely. (It also seems unlikely that anyone of middle age could

have been taking a medication long enough to produce character disturbance that had lasted his entire adult

life.) The vignette provides no eviden ce of another medical condition . According to the information

provided, Dr. Schatzky had never had frank psychosis, such as delusional disorder or schizophrenia, and he

had no mood disorder (B).

What about other PDs? Patients with schizoid PD are cold and aloof , and as a result may appear

distrustful, but they do not have the prominent suspiciousness characteristic of patients with PPD. Patients

with schizotypal PD may have paranoid ideation, but they also appear peculiar or odd (not the case here).

And Dr. Schatzky didn’ t appear to prefer solitude. Those with antisocial PD are often cold and unfeeling,

may be suspicious, and have trouble forming interpersonal relationships. However, they rarely have the

perseverance to complete professional school, and Dr. Schatzky had no history of criminal behavior or

reckless disregard for the safety of others.

With a GAF score of 70, Dr . Schatzky’s tentative diagnosis would be as follows:

F60.0 [301.0] Paranoid personality disorder

F60.1 [ 3 01.2 0] S ch iz o id P erso n alit y D is o rd er

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People with schizoid personality disorder (SzPD) are indif ferent to the society of other people, sometimes

profoundly so. Typically , they are lifelong loners who show a restricted emotional range; they appear

unsociable, cold, and reclusive.

Patients with SzPD may succeed at solitary jobs that others find dif ficult to tolerate. They may daydream

excessively, become attached to animals, and often do not marry or even form long-lasting romantic

relationships. They do retain contact with reality , unless they develop schizophrenia. However, their

relatives are not at increased risk for that disease.

Although it is uncom monly diagnosed, SzPD is relatively common, affecting perhaps a few percent of

the general population. Men may be at greater risk than women. The following patient was the younger

brother of Lyonel Childs , whose history has been presented in connection with schizophrenia.

Essential Features of Schizoid Personality Disorder

In m an y s itu atio ns, th ese p atie n ts re m ain is o la te d a n d h av e a n arro w e m otio nal ra n ge. P re fe rrin g s o litu de in th eir

a ctiv itie s, th ey n eith er w an t n or e n jo y c lo se re la tio nsh ip s, in clu din g th ose w ith fa m il y . T hey m ay h av e n o c lo se

frie n ds, w ith th e p ossib le e x cep tio n o f r e la tiv es. I n deed , th ey e n jo y f e w a ctiv itie s, e v en s h ow in g little in te re st in s e x

w ith o th er p eo ple . E m otio nally c o ld o r d eta ch ed , t h ey s e em i n dif f e re n t t o b oth c ritic is m a n d p ra is e .

T he F in e P rin t

T he D ’s : • D ura tio n ( b eg in s in te en s o r e arly 2 0s a n d e n dure s) • D if f u se c o nte x ts • D if f e re n tia l d ia g nosis ( p hysic al

an d s u bsta n ce u se d is o rd ers , m ood a n d p sy ch otic d is o rd ers , a u tis m s p ectr u m d is o rd er, s c h iz o ty pal a n d p ara n oid P D s)

C od in g N ote

If s c h iz o id p ers o nality d is o rd er p re ced es t h e o n se t o f s c h iz o phre n ia , a d d t h e s p ecif ie r ( p re m orb id ) .

Lester Childs

“W e brought him in because of what happened to Lyonel. They seemed so much alike, and we were

worried.” Lester’s mother sat primly on the office sofa. “After Lyonel was arrested, that’s when we

decided.”

At 20, Lester Childs was in many ways a carbon copy of his older brother . Born several weeks

prematurely , he had spent his first few weeks of life in an incubator . But he gained weight rapidly and was

soon well within the norms for his age.

He walked, talked, and was toilet-trained at the usual ages. Perhaps because they both worked so hard on

the farm, or perhaps because there were no other young children for Lester and his siblings to play with, his

parents noticed nothing wrong until Lester entered first grade. Within a few weeks, his teacher had

telephoned to set up a conference.

Lester seemed bright enough, they were told; his schoolwork wasn’t in question. But his sociability was

next to nil. At recess, when the other children played dodge ball or pom-pom-p ullaway, he remained in the

classroom to color . H e seldom participated in group discussions, and he always sat a few inches back from

the others in the reading circle. When his turn for show and tell came, he stood silently in front of the class

for a few moments, then pulled a length of kite string from his pocket and dropped it onto the floor . Then he

sat down.

Most of this behavio r was quite a lot like Lyonel’ s, so the parents hadn’t been too worried. Even so, they

took him to see their family doctor, who agreed that it was probably normal for their family and that he

would “grow out of it.” But Lester never did; he only grew up. He never even participated in family

activities. At Christmas, he would open a present, take it over to a corner , and play with it by himself. Even

Lyonel never did that.

When Lester entered the room, it wa s clear that he didn’ t regard the appo intment as much of an

occasion. He wore jeans with one knee missing, tattered sneakers, and a T-shirt that at one time surely had

had sleeves. Through much of the interview , he continued to leaf through a magazine devoted to astronomy

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and math. After waiting more than a minute for Lester to say something, the interviewer began. “How are

you today?”

“I’m OK.” Lester kept on reading.

“Your mom and dad asked you to come in to see me today . Can you tell me why?”

“Not really.”

“Do you have any ideas about it?”

[Silence.]

Most of the interview went that way. Lester willingly gave information when he was directly asked, but

he seemed completely uninterested in volunteering anything. Sitting quietly, nose in his magazine, he

showed no other abnormalities or eccen tricities of behavior . His flow of speech (what there was of it) was

logical and sequential. He was fully oriented, and he scored a perfect 30 on the MMSE. His mood was

“OK”—neither too happy nor too sad. He had never used alcohol or drugs of any kind. He calmly but

emphatically denied ever hearing voices, seeing visions, or having beliefs that he was being watched,

followed, talked about, or otherwise interfered with. “I’m not like my brother ,” he said in his longest

spontaneous speech up to that point.

When asked who he was like, Lester said it was Greta Garbo—who famously wanted to be left alone. He

claimed he didn’ t ne ed friends, and he could also do without his family . Neith er did he need sex. He had

checked out the sex magazines and anatomy books. Females and males were equally boring. His idea of a

good way to spend his life was to live alone on an island, like Robinson Crusoe. “But no Friday .”

Tucking his magazine under his arm, Lester left the of fice, never to return.

Evaluation of Lester Childs

Any diagn osis of a PD requires that the difficulties be both pervasive and enduring. Although he was only

20 years old, Lester ’s problems had certainly been enduring: They were noticeable when he was 6. And as

far as we can tell, his rejection of interpersonal contact extended into every facet of his life—family , social,

and school.

Lester rejected close relationships, even with his family (criterion A1); he preferred solitary activities

(A2); he rejected the notion of having a sexual relationship with anyone (although this could conceivably

change with maturity and opportunity— A3); he had always lacked close friends (A5); his affect seemed

quite flat and detached (although this could have been an artifact of a first interview with a reluctant

interviewee—A7). In any event, Lester met at least four and possibly five diagnostic criteria (four are

required) for SzPD. These symptoms would satisfy three of the areas (cognition, affect, and interpersonal

functioning) mentioned in the generic criteria for a PD. His interest in mathematics and astronomy would

not be unusual in persons with this disorder , who typically thrive on work that others might find too lonely

to enjoy .

Could any other disorder better explain Lester’s clinical picture? Patients with depressive disorders are

often withdrawn and unsociable, but these seldom persist lifelong. Besides, Lester specifically denied

feeling depressed or lonely; any doubts on the point could be settled by asking about vegetative symptoms

of depression (changes in appetite or sleep). He also denied having symptoms (delusions and

hallucinations) that would suggest schizophr enia , and this was supported by collateral information from

his mother . There were no stereotypies or symptoms of impaired communication, as we’d expect for

autism spectrum disorder , or disturbance of consciousness of memory , as would be required for a

cognitive disorder . From the informa tion we have, he was physically healthy and did not use drugs,

alcohol, or medications (B).

What other PDs should we consider? Patients with schizotypal PD can have constricted affect and

unusual appearance. Lester’s clothing was out of keeping for most visits to a professional office but would

probably be quite usual for someone 20 years old, and he denied having any beliefs that might seem odd.

He did not voice any ideas of deep suspicion or distrust, such as might be enc ountered in paranoid PD .

Patients with avoidant PD are also isolated from other people; unlike patients with SzPD, however , they

don’ t choose this isolation, and they suf fer for it.

If Lester later developed schizophrenia , the qualifier (premorbid) would be added at that time to his

diagnosis. I find it dif ficult to place him squarely on the GAF Scale. The score of 65 is to some extent a

matter of taste, and ar guable.

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F60.1 [301.20] Schizoid personality disorder

F 21 [ 3 01.2 2] S ch iz o ty p al P erso n alit y D is o rd er

From an early age, patients with schizotypal personality disorder (StPD) have lasting interpersonal

deficiencies that severely reduce their capacity for closeness with others. They also have distorted or

eccentric thinking, perceptions, and behaviors, which can make them seem odd. They often feel anxious

when with strangers, and they have almost no close friends. They may be suspicious and superstitious; their

peculiarities of thought include magical thinking and belief in telepathy or other unusual modes of

communication. Such patients may talk about sensing a “force” or “presence,” or have speech characterized

by vagueness, digressions, excessive abstractions, impoverished vocabulary , or unusual use of words.

Patients with StPD may eventually develop schizophrenia. Many of them are depressed when they first

come to clinical attention. Their eccentric ideas and style of thinking also place them at risk for becoming

involved with cults. They get along poorly with others, and under stress they may become briefly psychotic.

Despite their odd behavior , many marry and work. This disorder occurs about as often as schizoid PD.

Essential Features of Schizotypal Personality Disorder

In m an y s itu atio ns, th ese p atie n ts te n d to b e is o la te d a n d e x hib it a n arro w e m otio nal r a n ge w ith o th er p eo ple . T hey

w ill h av e p ara n oid o r s u sp ic io us id eas, e v en id eas o f r e fe re n ce ( w hic h , h ow ev er, a re n ot h eld to a d elu sio nal e x te n t) .

T heir d re ss o r m an neris m s m ay g iv e th em a n o d d a p peara n ce, w ith a ff e ct th at is in ap pro pria te o r c o nstr ic te d ; s p eech

can b e v ag ue, i m poveris h ed , o r o verly a b str a ct. T hey m ay r e p ort s tr a n ge p erc ep tio ns o r p hysic al s e n sa tio ns, a n d t h eir

p ecu lia r b eh av io r m ay b e a ff e cte d b y m ag ic al t h in kin g o r o th er o d d b elie fs ( s u pers titio ns, a b elie f i n t e le p ath y). W ith

s e v ere s o cia l a n xie ty ( w hic h d oesn ’t i m pro ve w ith a cq uain ta n ce), t h ey t e n d t o h av e n o i n tim ate f rie n ds.

T he F in e P rin t

T he D ’s : • D ura tio n ( b eg in s in te en s o r e arly 2 0s a n d e n dure s) • D if f u se c o nte x ts • D if f e re n tia l d ia g nosis ( p hysic al

an d s u bsta n ce u se d is o rd ers , p sy ch otic d is o rd ers , m oo d d is o rd ers w ith p sy ch otic f e atu re s, a u tis m s p ectr u m d is o rd er

an d o th er n eu ro dev elo pm en ta l d is o rd ers , p ara n oid a n d s c h iz o id P D s)

C od in g N ote

If S tP D p re ced es t h e o nse t o f s c h iz o phre n ia , a d d t h e s p ecif ie r ( p re m orb id ) .

T imothy Oldham

“But it’s my baby! I don’ t care what he had to do with it!” Hugely pregnant and miserable, Charlotte

Grenville sat in the interviewer ’s offic e and wept with frustration. She was there at the request of the

presiding judge in a battle over visitation rights with her yet-unborn child.

The identi ty of the father was never in doubt. The week after her second missed period, Charlotte had

visited a gynecologi st and then called Timothy Oldham with the news. She had considered threatening to

sue him for child support, but that hadn ’t been necessary . He made good money installing carpets and had

no dependents. He offered her a generous monthly stipend, beginning immediately . But he wanted to help

rear their child. Charlotte had rejected that idea out of hand and then filed suit. With a crowded court

docket, the case had dragged on nearly as long as Charlotte’ s pregnancy.

“I mean, he’ s really weird!”

“What do you mean, ‘weird?’ Give me some examples.”

“Well, I’ve known him for the longest time—several years, anyway . He had a sister who died; he talks

about her like she’s still alive. And he does weird things. Like, when we were making love, right in the

middle he started this babble about ‘holy love’ and dedicating his seed. It put me right of f. I told him to stop

and get off, but it was too late. I mean, would you want your kid growing up with that for a father?”

“If he’s so peculiar , how did you get involved with him?”

She looked abashed. “W ell, we only did it once. And I might have been a little bit drunk at the time.”

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Timothy was not only sedate, but nearly immobile. He sat quietly in the intervi ew chair , a gangly blond

whose hair swept across his forehead nearly to his eye brows. He told his story in a dull monotone that

didn’t reveal the slightest trace of emotion.

Timothy Oldham and his twin sister, Miranda, had been orphaned when they were 4 years old. He had

no memory of his parents, other than a vague impression that they might have made their living from a

marijuana farm in northern California. The two children had been taken in by an aunt and uncle—Southern

Baptists who, he said, made the farm couple in Grant Woods’ s American Gothic look cheerful by

comparison. “That painting, it’s really them. I have a copy of it in my bedroom. Sometimes I can almost see

my uncle moving the pitchfork back and forth to signal me.”

“Is it really your uncle, and does the pitchfork really move?” the interviewer wanted to know .

“Well, it’s more of a feeling I get . . . not really . . . a sign of my Christian endeavor . . . ” Timothy’ s

voice trailed of f, but he kept gazing straight ahead.

The “Christian endeavor,” he explained, meant that everyone was put on earth for some special purpose.

His uncle always used to say that. He thought his own purpose might be to help raise the baby growing

inside Charlotte. He knew there had to be more to life than laying carpets all day .

Timothy had only a few friends, none of them close. He and Charlotte had spent no more than a few

hours together . In response to a question, he talked about his sister . Miranda and he had been

understandably close; she was the only real friend he had ever had. She died of a brain tumor when they

were 16, and Timo thy was devastated. “We were webbed together when we were born. I swore at her

graveside it would never be undone.”

With still no inflection in his voice, Timothy explained that being “webbed together” was something you

were born with. He and Miranda still were webbed. It was a Christian endeavor, and she was directing him

from beyond the grave to have a baby girl. He said that it would be having Miranda back again. He knew

that the baby wouldn’ t actually be M iranda, but said he knew it would be a girl. “It’s just one of those

feelings. But I know I’m right.”

Timothy responded in the negative to the usual questions about hallucinatio ns, delusions, abnormal

moods, substance use, and medical problems such as head injury and seizure disorders. Then he arose from

his seat and left the room without another word.

That evening Charlotte Grenville gave birth—to a healthy boy .

Evaluation of Timothy Oldham

Charlotte’s testimon y suggested that Tim othy’ s peculiarities had been present for years. Although we don’ t

know much about his school career or work, his symptoms would seem likely to affect most areas of his

life. This point should be more fully explored.

Timothy’ s schizotyp al symptoms included odd beliefs (his conviction that the baby would be his sister

returned to earth; there is no evidence that he came from a subculture where this sort of thinking was the

norm—criterion A2), illusions (the farmer in the picture waving his pitchfork—A3), constricted affect

(A6), and absence of close friends (A8). His words (“webbed together,” “Christian endeavor”) seemed

metaphorical and odd (A4). Unexplored by the interviewer were the presence of ideas of reference,

paranoid ideas, odd behavior , and excessive social anxiety. Cognitive, affective, and interpersonal

symptoms were represented here, however (see the Essential Features for a general PD earlier in this

chapter).

This evaluation turned up no indications of another mental disorder . Timothy specifically denied the

actual psychotic symptoms necessary to support a diagnosis of delusional disorder or schizophr enia .

Other conditions that could entail psychotic symptoms include mood disorders and cognitive disorders ,

but we’ve seen evidence against both (B).

Other PDs to consider would include schizoid and paranoid PDs . Eac h of these implies some degree of

social isolation, but not the eccentric thinking of StPD. Patients with any of these three Cluster A disorders

can decom pensate into brief psychoses—a trait held in common with borderline PD . Som e pa tients may

qualify for two diagnoses simultaneously: borderline PD and one of the Cluster A PDs. Patients with

avoidant PD are socially isolated, but they suffer from it and lack odd behavior and thinking. Of course, a

personality change due to another medical condition m ust be considered in those who have a severe or

chronic illness; T imothy didn’t.

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As of this evaluation , T im would receive a GAF score of 75. He hadn’ t developed schizophrenia, so we

wouldn’ t use the qualifier (premorbid) .

F21 [301.22] Schizotypal personality disorder

Z65.3 [V62.5] Litigation regarding child visitation

CLU ST ER B P E R SO NALIT Y D IS O RDER S

People with Cluster B PDs tend to be dramatic, emotional, and attention-seeking, with moods that are labile

and often shallow . They often have intense interpersonal conflicts.

F60.2 [ 3 01.7 ] A ntis o cia l P erso n alit y D is o rd er

Those with antisocial PD (ASPD) chronically disregard and violate the rights of other people; they cannot

or will not conform to the norms of society . This said, there are a number of ways in which people can

exhibit ASPD. Some are engaging con artists; others are, frankly , graceless thugs. Women (and some men)

with the disorder may be involved in prostitution. In still other individuals, the more traditional antisocial

aspects may be obscured by the heavy use (and often purveyance) of illicit drugs.

Although some of these people seem superficially charming, many are aggres sive and irritable. Their

irresponsible behavior affects nearly every life area. Besides substance use, there may be fighting, lying,

and criminal behavior of every conceiva ble sort: theft, violence, confidence schemes, and child and spouse

abuse. They may claim to have guilt feelings, but they don’t appear to feel genuine remorse for their

behavior . Although they may complain of multiple somatic problems and will occasionally make suicide

attempts, their manipulative interactions with others make it dif ficult to determine whether their complaints

are genuine.

DSM-5 criteria for ASPD specify that, beginning before age 15, the patient must have a history that

would support a diagnosis of conduct disorder; as an adult, this behavior must have continued and been

extended, with at least four ASPD symptoms.

As many as 3% of men, but only about 1% of women, have this disorder; it is found in about three-

quarters of penitentiary prisoners. It is more common among lower-socioecono mic-status populations and

runs in families; it probably has both a genetic and an environmental basis. Male relatives have ASPD and

substance-related disorders; female relatives have somatic symptom disorder and substance-related

disorders. Childhood attention-deficit/hyperactivity disorder is a common precursor, and childhood conduct

disorder is a requirement (see above).

Although treatment seems to make little difference to patients with ASPD, there is some evidence that

the disorder decreases with advancing age, as these people mellow out to become “only” substance users.

Death by suicide or homicide is the lot of others.

Generally, the diagnosis of ASPD will not be warranted if antisocial behavior occurs only in the context

of substan ce abuse. Individuals who misuse substances sometimes engage in criminal behavior, but only

when in pursuit of drugs. It is crucial to learn whether patients with possible ASPD have engaged in illicit

acts when not using substances.

Although these patients often have a childhood marked by incorrigibility , delinquency , and school

problems such as truancy , fewer than half the children with such a background eventually develop the full

adult syndrome. Therefore, we should never make this diagnosis before age 18.

Finally , ASPD is a serious disorder , with no known effective treatment. It is the refore a diagnosis of last

resort. Before making it, redouble ef forts to rule out other major mental disorders and PDs.

Essential Features of Antisocial Personality Disorder

These p atie n ts h av e a h is to ry d atin g to b efo re a g e 1 5 o f d estr o yin g p ro perty , s e rio us ru le v io la tio n, o r a g gre ssio n

ag ain st p eo p le o r a n im als ( th at is , th ey f u lf ill c rite ria f o r c o nduct d is o rd er). S in ce th en , in m an y s itu atio ns, th ey lie ,

co n, o r g iv e a n a lia s w hile e n gag in g in b eh av io rs th at m erit a rre st ( w heth er o r n ot th ey a re a ctu ally d eta in ed ). T hey

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t e n d to fig ht o r a ssa u lt o th ers , a n d g en era lly fa il to p la n th eir a c tiv itie s, re ly in g in ste ad o n th e in sp ir a tio n o f th e

im puls e . F or n one o f th is b eh av io r d o th ey s h ow r e m ors e , o th er th an f e elin g s o rry if c a u ght. T hey w ill r e fu se to p ay

th eir d eb ts o r m ain ta in s te ad y e m plo ym en t. T hey m ay i r re sp onsib ly p la ce t h em se lv es o r o th er p eo ple i n d an ger.

T he F in e P rin t

T he D ’s : • D ura tio n a n d d em ogra p hic s ( d ia g nosis c an n ot b e m ad e p rio r to a g e 1 8 ; b eh av io r p atte rn s a re e n durin g) •

D if f u se c o nte x ts • D if f e re n tia l d ia g nosis (p hy sic al a n d su bsta n ce u se d is o rd ers , b ip ola r d is o rd ers , sc h iz o phre n ia ,

o th er P D s, o rd in ary c rim in ality )

Milo T ark

Milo Tark was 23, handsome, and smart. When he worked, he earned good money installing heating and air

conditioning. He had broken into that trade when he left high school, which happened somewhere in the

middle of his 10th-grade year. Since then, he had had at least 15 different jobs; the longest of them had

lasted 6 months.

Milo was referred for evaluation after he was caught trying to con money from elderly patrons at an

ATM. The machine was one of two that served the branch bank where his mother worked as assistant

manager .

“The little devil!” his father exclaimed during the initial interview . “He was always a dif ficult one to

raise, even when he was a kid. Kinda reminded me of me, sometimes. Only I pulled out of it.”

Milo had picked a lot of fights when he was a boy . He had bloodied his first nose when he was only 5,

and the world-class spanking administered by his father had taught him nothing about keeping his fists to

himself. Later he was suspended from the seventh grade for extorting $3 and change from an 8-year -old.

When the suspension was finally lifted, he responded by ditching class for 47 straight days. Then began a

string of encounters with the police, beginning with shoplifting (condoms) and progressing through

breaking and entering (four counts) to grand theft auto when he was 15. For stealing the Toyota, he was

sent for half a year to a camp run by the state youth authority . “It was the only 6 months his mother and I

ever knew where he was at night,” his father observed.

Milo’ s time in detention seemed to have done him some good, at least initially . Although he never

returned to school, for the next 2 years he avoided arrest and intermittently applied himself to learning his

trade. Then he celebrated his 19th birthd ay by getting drunk and joining the Arm y. W ithin a few months he

was out on the street again, with a bad-conduct discharge for sharing cocaine in his barracks and assaulting

two corporals, his first sergeant, and a second lieutenant. For the next several years, he worked when he

needed cash and couldn’ t get it any other way. Not long before this evaluation, he had gotten a 16-year -old

girl pregnant.

“She was just a ditsy broad.” Milo lounged back, one leg over the arm of the interview chair. He had

managed to grow a scraggly beard, and he rolled a toothpick around in the corner of his mouth. The letters

H-A-T -E and L-O-V -E were clumsily tattooed across the knuckles of either hand. “She didn’t object when

she was gettin’ laid.”

Milo’s mo od was good now, and he had never had anything that resembled mania. There had never been

symptoms of psychosis, except for the time he was coming off speed. He “felt a little paranoid” then, but it

didn’ t last.

The ATM job was a scam thought up by a friend. The friend had read something like it in the newspaper

and decide d it would be a good way to obtain fast cash. They had never thought they might be caught, and

Milo hadn’ t considered the ef fect it would have on his mother .

He yawned and said, “She can always get another job.”

Evaluation of Milo Tark

Milo’s behavior persistently af fected all aspects of his life: school, work, family , and interpersonal relations.

By the time he was 15, he easily met criteria for conduct disorder (ASPD criterion C). Afterwards, he

moved on to full-blown adult criminali ty that persisted through his early 20s: repeated illegal acts (A1),

assaults (on Army personnel—A4), irresponsible work record (A6), impulsivity (no planning about

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breaking into the ATM—A3), and lack of remorse (toward his mother and the girl he impregnated—A7).

His symptoms touched on the areas of cognition, affect, interpersonal functioning, and impulse control (see

the description of a general PD). Of cou rse, he was now old enough (over 18—criterion B) to qualify for a

diagnosis of ASPD.

People with a manic episode or schizophr enia will sometimes engage in criminal activity, but it is

episodic and accompanied by other manic or psychotic symptoms. Milo steadfastly denied any behavior

suggesting either a mood or a psychotic disorder (D). Patients with intellectual disability may brea k the

law , either because they do not realize that it is wrong or because they are so easily influenced by others.

Although Milo didn’t do especially well in school, there is no indication that he was held back because of

low intelligence.

Because many addicted patients will do nearly anything to obtain money, substance use disorders are

important in the differential diagnosis. Milo had used cocaine and amphetami nes, but (according to him)

only briefly , and most of his antisocial behaviors were not associated with drug use. Patients with impulse-

control disorders will engage in illegal activities, but this is confined to the context of conduct disorder in

younger people and fighting or property destruction in intermittent explosive disorder . Patients with

bulimia nervosa s ometime s shoplift , but Milo had no evidence of bulimic episodes. Of course, many of

these conditions (as well as the anxiety disorders ) can be encountered as associated diagnoses in patients

with ASPD.

Career criminals whose antisocial behavior is confined to their “professional lives” may not fulfill all of

the criteria for ASPD. They may instead be diagnosed as having adult antisocial behavior , which would

be recorded as Z72.81 1 [V71.01]. It constitutes part of the dif ferential diagnosis of the PD.

With a GAF score of 35, Milo’ s complete diagnosis would be as follows:

F60.2 [301.7] Antisocial personality disorder

Z65.3 [V62.5] Arrest for ATM fraud

F60.3 [ 3 01.8 3] B ord erlin e P erso n alit y D is o rd er

Throughout their adult lives, people with borderline PD (BPD) appear unstable. They’re often at the crisis

point as regards mood, behavior , or interpersonal relationships. Many feel empty and bored; they attach

themselves strongly to others, then become intensely angry or hostile when they believe they are being

ignored or mistreated by those they depend on. They may impulsively try to harm or mutilate themselves;

these actions are expressions of anger , cries for help, or attempts to numb themselves to their emotional

pain. Although patients with BPD may experience brief psychotic episodes, these resolve so quickly that

they are seldom confused with psychoses like schizophrenia. Intense and rapid mood swings, impulsivity ,

and unstable interpersonal relationships make it dif ficult for these patients to achieve their full potential

socially , at work, or in school.

BPD runs in families. These people are truly miserable—so much so that up to 10% complete suicide.

The c o ncep t o f B PD w as d ev is e d a b out th e m id dle o f th e 2 0th c en tu ry . T hese p atie n ts w ere o rig in ally ( a n d s o m etim es

still a re ) s a id t o h over b etw een n eu ro sis a n d p sy ch osis — a “ b ord erlin e” w hose e x is te n ce i s d is p ute d b y m an y c lin ic ia n s.

A s th e c o ncep t h as e v olv ed in to a P D , it h as a ch ie v ed r e m ark ab le p opula rity , p erh ap s b ecau se s o m an y p atie n ts c an b e

sh oeh orn ed i n to i ts c ap acio us d efin itio n.

A lth ough 1 – 2% o f t h e g en era l p opula tio n m ay l e g itim ate ly q ualif y f o r a d ia g nosis o f B PD , i t i s p ro bab ly a p plie d t o a

f a r g re ate r p ro portio n o f th e p atie n ts w ho se ek m en ta l h ealth c are . It m ay still b e o ne o f th e m ost o verd ia g nose d

co nditio ns in th e d ia g nostic m an uals . M an y o f th ese p atie n ts h av e o th er d is o rd ers th at a re m ore r e ad ily tr e ata b le ; th ese

in clu de m ajo r d ep re ssiv e d is o rd er, s o m atic s y m pto m d is o rd er, a n d s u bsta n ce-re la te d d is o rd ers .

Essential Features of Borderline Personality Disorder

T hese p atie n ts e x is t in a p erp etu al c ris is o f m ood o r b eh av io r. T hey o fte n f e el e m pty a n d b ore d . D is tu rb ed id en tity

( in se cu re s e lf -im ag e) c an le ad th em to a tta ch th em se lv es s tr o ngly to o th ers a n d th en re je ct th ese s a m e p eo ple w ith

e q ual v ig or. O n th e o th er h an d, th ey m ay f ra n tic ally tr y to a v ert d ese rtio n ( it c an b e a ctu al o r f a n ta sie d ). P ro nounced

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im puls iv en ess c an l e ad t h em t o h arm o r m util a te t h em se lv es o r t o e n gag e i n o th er p ote n tia lly h arm fu l b eh av io rs , s u ch

as s e x ual in dis c re tio ns, s p en din g s p re es, e atin g b in ges, o r r e ck le ss d riv in g. A lth ough s tr e ss c an c au se b rie f e p is o des

o f d is so cia tio n o r p ara n oia , t h ese q uic k ly r e so lv e. I n te n se , r a p id m oo d s w in gs m ay y ie ld t o a n ger t h at i s i n ap pro pria te

a n d u nco ntr o lle d .

T he F in e P rin t

T he D ’s : • D ura tio n ( b eg in s in te en s o r e arly 2 0s a n d e n dure s) • D if f u se c o nte x ts • D if f e re n tia l d ia g nosis ( p hysic al

an d s u bsta n ce u se d is o rd ers , m ood a n d p sy ch otic d is o rd ers , o th er P D s)

Josephine Armitage

“I’m cutting myself !” The voice on the telephone was high-pitched and quav ering. “I’m cutting myself

right now! Ow! There, I’ve started.” The voice howled with pain and rage.

Twenty minutes later, the clinician had Josephine’ s address and her promise that she would come in to

the emergency room right away. T wo hours later, her left forearm swathed in ban dages, Josephine Armitage

was sitting in an office in the mental health department. Criss-crossing scars furrowed her right arm from

wrist to elbow . She was 33, a bit overweight, and chewing gum.

“I feel a lot better ,” she said with a smile. “I really think you saved my life.”

The clinician glanced at her nonswathed arm. “This isn’ t the first time, is it?”

“I should think that would be pretty obvious. Are you going to be terminally dense, just like my last

shrink?” She scowled and turned 90 degrees to look at the wall. “Sheesh!”

Her previous therapist had seen Josephi ne for a reduced fee, but had been unable to give her more time

when she requested it. She had responded by letting the air out of all four tires of that clinician’ s new

BMW .

Her current trouble was with her boyfriend. One of her girlfriends had been “pretty sure” she’d seen

James with another woman two nights ago. Yesterday morning, Josephine had called in sick to work and

staked out James’ s workplace so she could confront him. He hadn’ t appeared, so last evening she had

banged on the door of his apartment until neighbors threatened to call the police. Before leaving, she’d

kicked a hole in the wall beside his door . Then she got drunk and drove up and down the main drag, trying

to pick up a date.

“Sounds dangerous,” observed the clinician.

“I wa s looking for Mr. Goodbar , but no one turned up. I decided I’d have to cut myself again. It always

seems to help.” Josephine’ s anger had once again evaporated, and she had turned away from the wall.

“Life’ s a bitch, and then you die.”

“When you cut yourself, do you ever really intend to kill yourself?”

“Well, let’s see.” She chewed her gum thoughtfully . “I get so angry and depress ed, I just don’ t care what

happens. My last shrink said all my life I’ve felt like a shell of a person, and I guess that’s right. It feels like

there’ s no one living inside, so I might just as well pour out the blood and finish the job.”

Evaluation of Josephine Armitage

The first thing this clinician should do is to determine whether the behaviors reported (and observed) had

been present since Josephine’ s late teen years. From her report of the comment made by her “last shrink,”

this would seem to be the case, but it should be verified. These behaviors were pervasive: Her work was

affected (calling in sick on a whim), as were her relations with her boyfriend and her previous therapist.

Josephine had an abundance of symptoms. The entire episode of staking out James’ s apartment could be

seen as a frantic ef fort to avoid abandonment (BPD criterion A1). Even her initial moments with the present

clinician revealed some swings between idealization and devaluation (criterion A2). She showed evidence

of dangerous impulsivity (driving while under the influence of alcohol, trying to pick up a stranger—A4),

and she had made repeated suicide attempts (A5). Her mood, even within the confines of this vignette,

would seem markedly unstable and reactive to what she perceived to be the clinician’ s attitude toward her

(A6); her anger was sudden, inappropriate, and intense (A8). She agreed with a description of herself as an

“empty shell” (A7). Although patients with BPD are often described as having identity disturbance and

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occasional, brief psychotic lapses, Josephine’s vignette gives no evidence of either of these. Even so, she

had six or seven symptoms, whereas only five are required.

A long list of other mental disorders can be confused with BPD; each must be considered before settling

on this disorder as a sole (or principal) diagnosis. (This isn’t a criterion for BPD, but it is one of the generic

PD criteria, as well as one of my personal mantras.) Many patients with BPD also have major depressive

disorder or dysthymia . It’ s impo rtant to establish that suicidal behaviors, anger, and feelings of emptiness

are not experienced only during episodes of depression. Similarly , we need to know that affective instability

is not due to cyclothymic disorder . Note that the official criteria don’t mention any of these possibilities,

but they are featured in the text.

Patients with BPD can have psychotic episodes, but these tend to be brief and stress-related, and they

resolve quickly and spontaneously—all of which makes them unlikely to be con fused with schizophr enia .

The misuse of various substances c an lead to suicide behavior , instability of mood, and reduced impulse

control. Substance-r elated disorders are also often found as concomitants with BPD, and should always be

asked about carefully . Patients with somatic symptom disorder ar e often quite dramatic and may misuse

substances and make suicide attempts. Although this vignette contains no evide nce for any of these (other

than getting drunk—was this an isolated event?), the evaluating clinician would need to consider carefully

the list just given.

Patients with BPD can also show features of additional PDs. Josephine’ s presentation was dramatic,

suggesting histrionic PD . Patients with narcissistic PD are also self-centered, though they don’t have

Josephine’ s impulsivity . Patients with antisocial PD are impulsive and do not control their anger; although

some of Josephine’ s behaviors were destructive, she did not engage in overtly criminal activity .

Finally, dissociative identity disorder is sometimes encountered in patients with BPD. Further

interviewing and observation would be needed to rule out this rare condition. Assuming the verification of

Josephine’s history, her diagnosis would be as given below . I would place her GAF score at 51.

F60.3 [301.83] Borderline personality disorder

S51.809 [881.00] Lacerations of forearm

There ’s n o s u ch th in g a s a la te -lif e P D . B y d efin itio n, th e P D s a re c o nditio ns p re se n t, m ore o r le ss , f r o m th e g et- g o. I f

y ou e n co unte r a p atie n t w hose c h ara cte r s tr u ctu re a p pears to h av e c h an ged d urin g th e a d ult y ears , s e arc h f o r th e c au se

u ntil y ou fin d it. U su ally , y ou’ll tu rn u p a p ers o nality c h an ge d ue to a n oth er m ed ic al c o nditi o n, a m ood o r p sy ch otic

d is o rd er, s o m eth in g s u bsta n ce-re la te d , a c o gniti v e i s su e, o r a s e v ere a d ju stm en t d is o rd er.

F 60.4 [ 3 01.5 0] H is tr io n ic P erso n alit y D is o rd er

Patients with histrionic PD (HPD) have a long-standing pattern of extreme attention seeking and

emotionalism that seeps into all areas of their lives. These people satisfy their need to be at center stage in

two main ways: (1) Their interests and topics of conversation focus on their own desires and activities; and

(2) they continually call attention to themselves by their behavior , including speech. They are overly

concerned with physical attractiveness (of themselves and of others, as it relates to them), and they will

express themselves so extravagantly that it can seem almost a parody of normal emotionality . Their need

for approv al can cause them to be seductive, often inappropriately (even flamboyantly) so. Many lead

normal sex lives, but some will be promiscuous, and still others may be uninterested in sex.

These people are often so insecure that they constantly seek the approval of other people. Dependence

on the favor of other s may cause their moods to seem shallow or excessively reactive to their surroundings.

Low tolerance for frustration can spawn temper tantrums. They usually like to talk with mental health

professionals (it is another chance to be the center of attention), but because their speech is often vague and

full of exaggerations, they can prove frustrating to interview .

Quick to form new friendships, people with HPD are also quick to become demanding. Because they are

trusting and easily influenced, their behavior may appear inconsistent. They don’t think very analytically ,

so they may have difficulty with tasks that require logical thinking, such as doing mental arithmetic.

However , they may succeed in jobs that set a premium on creativity and imagination. Their craving for

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novelty sometimes leads to legal problems as they seek sensation or stimulation. Some have a remarkable

tendency to for get affect-laden material.

HPD has not been especially well studied, but it is reportedly quite common. It may run in families. The

classic patient is female, though the disorder can occur in men.

Essential Features of Histrionic Personality Disorder

These p atie n ts n ot o nly c ra v e th e lim elig ht, b u t a re u n hap py w hen th ey a re n o t th e f o cu s o f a tte n tio n. T hey a ctiv ely

a tte m pt to d ra w a tte n ti o n to th em se lv es w ith th eir p hysic al a p peara n ce a n d m an neris m s. T heir m an ner o f s p eak in g

m ay b e o verly d ra m atic , b ut w hat th ey s a y te n ds to b e v ag ue, la ck in g s p ecif ic ity . T hey c an b e g ush in g o r e ff u siv e

w hen e x pre ssin g th eir e m otio ns, w hic h , h ow ev er, te n d to b e s u perfic ia l a n d fle etin g. T oo o pen to s u ggestio n, to o

re ad ily i n flu en ced , t h ese p eo ple m ay i n te rp re t r e la tio nsh ip s a s b ein g i n tim ate w hen t h ey ’re n ot— ev en t o t h e e x te n t o f

beh av in g i n w ay s t h at a re i m pro perly s u ggestiv e o r s e d uctiv e.

T he F in e P rin t

T he D ’s : • D ura tio n ( b eg in s in te en s o r e arly 2 0s a n d e n dure s) • D if f u se c o nte x ts • D if f e re n tia l d ia g nosis ( p hysic al

an d s u bsta n ce u se d is o rd ers , s o m atic s y m pto m d is o rd er, o th er p ers o nality d is o rd ers )

Angela Black

Angela Black and her husband, Donald, had come for marriage counseling; as usual, they were fighting.

“He never listens to me. I might as well be talking to the dog!” Tears and mascara dripped onto the front

of Angela’ s low-cut silk dress.

“What’s th ere to listen to?” Donald retorted. “I know I irritate her, because she complains so much. But

when I ask how she’d like me to change, she can never put her finger on it.”

Angela and Donald were both 37 years old, and they had been married nearly 10 years. Already they had

been separated twice. Donald made excellent money as a corporate lawyer; Angela had been a fashion

model. She didn’ t work often any more, but her husband made enough to keep her well dressed and

comfortably shod. “I don’ t think she’s ever worn the same dress twice,” Donald grumbled.

“Yes, I have,” she snapped back.

“When? Name one time.”

“I do it all the time . Especially recently.” For several moments Angela defended herself, without ever

making a concrete statement of fact.

“Res ipsa loquitur ,” said Donald with satisfaction.

“Oh, God, Latin!” She nearly howled. “When he puts in his superior , gratuitous Latin, it makes me want

to cut my wrists!”

The Blacks agreed on one thing: For them, this was a typical conversation.

He worked late most nights and weekends, which upset her. She spent far too much money on jewelry

and clothi ng. She relished the fact that she could still attract men. “I would n’t do it if you paid more

attention to me,” she said, pouting.

“You wouldn’ t do it if you didn’ t listen to Marilyn,” he retorted.

Marilyn and Angela had been best friends since their cheerleading days in high school. Marilyn was

wealthy and independent; she didn’ t care what people thought, and behaved accordingly . Usually Angela

followed right along.

“Like the pool party last summer ,” put in Donald, “when you took off your suits to ‘practice cheers’ for

the races. Or was that your idea?”

“What would you know about it? Y ou were working late. Besides, it was only the tops.”

Evaluation of Angela Black

Angela’s personality style had a profound effect on her marriage, though the vignette hints that her other

social relationships (for example, men at the party) were affected as well. More information would be

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needed to establish that she had been this way throughout her adult life. However , it would seem unlikely

that her way of doing business with the world had developed recently .

Angela’s symptoms included a strong need to be the center of attention (HPD criterion A1) and sexual

provocation (inferred from her dancing topless—A2); excessive concern with physical appearance (A4);

dramatic emotional expression (A6); suggestibility (following the lead of her friend Marilyn—A7); and

vague speech (commented on by her husband—A5). I thought she might have expressed a touch of rapidly

shifting emotional expression (A3), too, but maybe that’s just me. Conservatively scored, she had at least

six symptoms of HPD (five are required by the DSM-5 criteria).

Her clinician should gather information adequate to determine that Angela did not have any of the major

mental disorders that commonly accompany HPD. These include somatic symptom disorder (had she

been in good physical health?) and substance-r elated disorders .

Would Angela quali fy for other PD diagnoses? She was centrally focused on herself, and she liked to be

admired. However, she lacked the sense of grandiose accomplishment that characterizes patients with

narcissistic PD . Y ou can often identify histrionic features in people with borderline PD . Angela’ s mood

was somew hat labile, but she did not report interpersonal instability, identity disturbance, transient paranoid

ideation, or other symptoms that characterize borderline patients. Her easy suggestibility might suggest

dependent PD , but she was so far from leaning on her husband for support that she actively fought with

him. W ith a GAF score of 65, I’d diagnose her as follows:

F60.4 [301.50] Histrionic personality disorder

Z63.0 [V61.10] Relationship distress with spouse

F60.8 1 [ 3 01.8 1] N arc is sis tic P erso n alit y D is o rd er

People with narcissistic PD (NPD) have a lifelong pattern of grandiosity (in behavior and in fantasy), a

thirst for admiration, and an absence of empathy . These attitudes permeate most aspects of their lives. They

regard themselves as unusually special; they are self-important individuals who commonly exaggerate their

accomplishments. (From the outset, however , we need to note that these traits constitute a PD only in

adults. Children and teenagers are naturally self-centered; in kids, narcissistic traits don’t necessarily imply

ultimate PD.)

Despite their grandiose attitudes, people with NPD have fragile self-esteem and often feel unworthy;

even at times of great personal success, they may feel fraudulent or undeserving. They remain overly

sensitive to what others think about them, and feel compelled to extract complim ents. When criticized, they

may cover their distress with a façade of icy indif ference. As sensitive as they are about their own feelings,

they have little apparent understanding of the feelings and needs of others and may feign empathy , just as

they may lie to cover their own faults.

Patients with NPD often fantasize about wild success and envy those who have achieved it. They may

choose friends they think can help them get what they want. Job performance can suffer (due to

interpersonal problems), or it can be enhanced (due to their eternal drive for success). Because they tend to

be concerned with grooming and value their youthful looks, they may become increasingly depressed as

they age.

NPD has been seldom studied. It appears to occur in under 1% of the general population; reportedly,

most patients are men. There is no info rmation about family history, environmental antecedents, or other

background material that might help us to understand these dif ficult personalities.

Essential Features of Narcissistic Personality Disorder

These p eo ple p osse ss g ra n dio sity , to geth er w ith a c ra v in g fo r a d m ir a tio n. T o g et it, th ey ty pic ally e x ag gera te th eir

o w n a b ilitie s a n d a cco m plis h m en ts . T hey te n d to b e p re o ccu pie d w ith fa n ta sie s o f b eau ty , b rillia n ce, p erfe ct lo ve,

p ow er, o r lim itle ss su ccess, a n d b elie v e th at th ey a re so u nusu al th at th ey sh ould o nly a sso cia te w ith p eo ple o r

in stitu tio ns o f r a re fie d s ta tu s. O fte n a rro gan t o r h au ghty , th ey m ay b elie v e th at o th ers e n vy th em ( th ough th e r e v ers e

m ay a ctu ally b e tr u e). L ack o f e m path y e n gag es th eir f e elin gs o f p riv ile g e in ju stif y in g th e e x plo ita tio n o f o th ers to

a ch ie v e t h eir o w n g oals .

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T he F in e P rin t

T he D ’s : • D ura tio n ( b eg in s in te en s o r e arly 2 0s a n d e n dure s) • D if f u se c o nte x ts • D if f e re n tia l d ia g nosis ( p hysic al

an d s u bsta n ce u se d is o rd ers , b ip ola r d is o rd ers , o th er p ers o nality d is o rd ers )

Berna Whitlow

“Dr . Whitlow , you’re my backup for emer gency clinic this afternoon. I’ve got to have some help from

you!” Eleanor Bondurak, a social worker at the mental health clinic, was red-faced with anger and

frustration. It wasn’ t the first time she had had dif ficulty working with this clinician.

At the age of 50, Berna Whitlow had worked at nearly every mental health clinic in the metropolitan

area. She was well trained and highly intelligent, and she read voraciously in her specialty . Those were the

qualities that had landed her job after job over the years. The qualities that kept her moving from one job to

another were known better to those who worked with her than to those who hired her. She was famous

among her colleagues for being pompous and self-centered.

“She said she wasn’ t going to take orders from me. And her attitude said for her, ‘Y ou’re nothing but a

social worker .’ ” Eleanor was now reliving the moment in a heated discussion with the clinical director.

“She said she’d talk to my boss or to you. I pointed out that neither of you was in the building at the time,

and that the patient had brought in a gun in his briefcase. So then she said I sho uld ‘write it up and submit

it,’ and she would ‘decide what action to take.’ That’ s when I had you paged.”

With the crisis over (the gun had been unloaded, the patient not dangerous), the clinical director had

dropped in to chat with Dr. Whitlow . “Look, Berna, it’s true that ordinarily the social worker sees the

patient and does a write-up before you step in. But this wasn’ t exactly an ordinary case! Especially in

emergencies, the whole team has to act together .”

Berna Whitlow was tall, with a straight nose and jutting chin that seemed to radiate authority . Her long

hair was thick and blond. She raised her chin a bit higher . “Y ou hardly need to lecture me on the team

approach. I’ve been a leader in nearly every clinic in town. I’m a superb team leader . Y ou can ask anyone.”

As she spoke, she rubbed the gold rings that encircled nearly every finger .

“But being a team leader involves more than just giving orders. It’s also about gathering information,

building consensus, caring about the feelings of oth—”

“Listen,” she interrupted, “it’s her job to work on my team. It’s my job to provide the leadership and

make the decisions.”

Evaluation of Berna Whitlow

From the material we have (which does not include a clinical interview , so our conclusions must be

tentative), Dr. Whitlow’ s personality traits would seem to have caused difficulties for many years. They

affected her life broadly , interfering with work (many jobs) and interpersonal relationships. Of course, a full

assessment would inquire about her personality as it af fected her home and social life.

Symptoms suggestive of NPD included her haughty attitude (NPD criterion A9), exaggerating her own

accomplishments (“I’m a superb team leader”—A1), insisting that she receive orders or requests only from

persons of high rank (A3), expecting obedience (from a sense of entitlement—A5), and lacking empathy

with fellow workers (A7). Five criteria are needed; affective, cognitive, and interpersonal features were

present (see the Essential Features for a general PD earlier in this chapter).

Several other PDs can either accompany or be confused with NPD. Patients with histrionic PD are also

extremely self-centered, but Dr. Whitlow was not as theatrical (although she did wear a lot of rings). As is

the case in borderline PD (and most other PDs), patients with NPD have a great deal of trouble relating to

other people. But they (including Dr. Whitlow) are not especially prone to unstable moods, suicidal

behavior , or brief psychoses under stress. Although there is a hint of the deceitful in narcissistic

exaggerations, these people lack the pervasive criminality and disregard for the rights of others that are

typical of antisocial PD .

Although dysthymia and major depressive disorder frequently accompany NPD, there is no evidence

in the vignette to support either of those diagnoses. Dr. Whitlow’ s tentative diagnosis (GAF score of 61)

would be as follows:

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F60.81 [301.81] Narcissistic personality disorder

C LU ST ER C P E R SO NALIT Y D IS O RDER S

Patients with Cluster C PDs are characteristically anxious, tense, and overcontrolled.

F60.6 [ 3 01.8 2] A void an t P erso n alit y D is o rd er

People with avoidant PD (APD) feel inadequate, are socially inhibited, and are overly sensitive to criticism.

These characteristics are present throughout adult life, and affect most aspects of daily life. (Like

narcissistic traits, avoidant traits are common in children and don’ t necessarily imply eventual PD.)

Their sensitivity to criticism and disapproval makes these people self-ef facing and eager to please others,

but it can also lead to marked social isolation. They may misinterpret innocent comments as critical; often

they refuse to begin a relationship unless they are sure they will be accepted. They will hang back in social

situations for fear of saying something foolish, and may avoid occupations that involve social demands.

Other than their parents, siblings, or children, they tend to have few close friends. Comfortable with

routine, they may go to great lengths to avoid departing from their set ways. In an interview they can appear

tense and anxious; they may misinterpret even benign statements as criticism.

Although APD has appeared in the DSMs since 1980, relevant research is still sparse. In frequency , it

occupies middle ground (about 2% of the general population) as PDs go, roughly equal for men and

women. Many such patients marry and work, although they may become depressed or anxious if they lose

their support system s. Sometimes this disorder is associated with having a disfi guring illness or condition.

APD is not often seen clinically; these patients tend to come to evaluation only when another illness

supervenes. There is considerable overlap with social anxiety disorder.

Essential Features of Avoidant Personality Disorder

These p atie n ts are so cia lly in hib ite d , are o v erly se n sitiv e to critic is m , an d fe el in ad eq uate . F eelin g th em se lv es

in fe rio r, u n ap pealin g, o r c lu m sy , th ey a re r e lu cta n t to f o rm n ew r e la tio nsh ip s. S uch p eo ple s o f e ar r id ic u le o r s h am e

th at th ey w ill o nly b eco m e in volv ed w ith o th ers if th ey c a n k n ow in a d van ce th ey w ill b e a ccep te d . O th erw is e , th eir

w orry a b out b ein g re je cte d o r c ritic iz ed (o r e m barra sse d ) o n th e jo b o r in s o cia l s itu atio ns w ill le ad th em to a v oid

n ew p urs u its .

T he F in e P rin t

T he D ’s : • D ura tio n ( b eg in s in te en s o r e arly 2 0s a n d e n dure s) • D if f u se c o nte x ts • D if f e re n tia l d ia g nosis ( p hysic al

an d s u bsta n ce u se d is o rd ers , s o cia l a n xie ty d is o rd er, p ara n oid a n d s c h iz o id P D s)

Jack W eiblich

Jack Weib lich was feeling worse when he ought to be feeling better. At least, that’s what his new

acquaintances in Alcoholics Anonymous had told him. One had reminded him that 30 days’ sobriety was

“time enough to detox every last cell” in his body . Another thought he was having a “dry drunk.”

“Whatever a ‘dry drunk’ is,” Jack obser ved later. “All I know is that after 5 we eks without alcohol, I’m

feeling every bit as bad as I did 15 years ago, before I’d ever had a drop. I’ve enjoyed hangovers more than

this!”

At age 32, Jack had a lot of hangovers to choose from. He’d had his first drink when he was only a

senior in high school. He had been a strange, lonely sort of kid who’d had a great deal of difficulty meeting

other people. While he was still in high school, he had begun to lose his hair; now, with the exception of his

eyebrows and eyelashes, he was totally bald. He was also afflicted with a sligh t, persistent nodding of his

head. “Titubation,” the neurologist had said; “don’ t worry about it.” The sight of his balding, nodding head

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in the mirror every morning looked grotesque, even to Jack. As a teenager he found it almost impossible to

form relationships; he was positive that no one could like someone as peculiar as he was.

Then one evening Jack found alcohol. “Right from the first drink, I knew I’d discovered something

important. With two beers on board, I for got all about my head. I even asked a girl out. She turned me

down, but it didn’ t seem to matter that much. I had found a life.” But the following morning, he found that

he still had his old personality . He experimented for months before he learned when and how much he

could drink and maintain a glow sufficiently rosy to help him feel well, but not too rosy to function. During

a 3-w eek period in his senior year at law school when he sobered up completely , he discovered that without

alcohol, he still had the same old feelings of isolation and rejection.

“When I’m not drinking, I don’ t feel sad or anxious,” Jack observed. “But I’m lonely and uncomfortable

with myse lf, and I feel that other people will feel the same about me. I guess that’s why I just don’ t make

friends.”

After law school, Jack went to work for a small firm that specialized in corpor ate law. They called him

“The Mole,” because he spent nearly all of every work day in the law library doing research. “I just didn’ t

feel comfortable meeting the clients—I never get along well with new people.”

The only exception to this lifestyle was Jack’ s membership in the stamp club. From his grandfather , he

had inheri ted a lar ge collection of commemorative plate blocks. When he took these to the Philatelic

Society , he thought they’d welcome him with open arms, and they did. He continued to build upon his

grandfather ’s collect ion and attended meetings once a month. “I guess I feel OK there because I don’ t have

to worry whether they’ll like me. I’ve got a great stamp collection for them to admire.”

Evaluation of Jack W eiblich

Jack’s sym ptoms were pervasive (profoundly affecting his work and social life) and had been present long

enough (since he was a teenager) to qual ify for a PD. They included the following typical APD features: He

avoided interpersonal contact (for example, with clients at the law firm—criterion A1); he felt that he was

unappealing (A6); although he joined the stamp club, he was pretty sure that his collection would be

accepted (A2); he worried a lot about being rejected (A4). Only four criteria are needed; cognitive,

occupational, and interpersonal areas were involved for Jack Weiblich (see the Essential Features for a

general PD earlier in this chapter).

Depression and anxiety are both common in patients with APD. Therefore, it is important to search for

evidence of mood disorders and anxiety disorders (especially social anxiety disorder ) in patients who

avoid contact with others. Jack stated explicitly that he felt neither sad nor anxi ous, but he admitted that he

had severe ly misused alcohol. The substance-r elated disorders also commonly bring a patient with APD

to the attention of mental health care providers.

In both APD and schizoid PD , pati ents spend most of their time alone. The difference, of course, is that

patients with APD are unhappy with their condition, whereas people with schizo id PD prefer it that way. A

somewhat more difficult differential diagnosis may be that between APD and dependent PD . (Dependent

patients avoid positi ons of responsibility , as Jack did.) Note that Jack’ s avoida nt lifestyle may have been

bound up in his twin physical peculiarities, his baldness and nodding head.

Although Jack had an alcohol use disorder , his clinician felt that it was causing him little current

difficulty and that the PD was the fundamental problem needing treatment (other clinicians might argue

with this interpretation). That’s why the PD was listed as his principal diagnosis. Of course, he didn’ t

qualify for any cour se modifiers for alcohol use disorder , because he’d only been on the wagon for 5 weeks

(p. 409); I thought his alcoholism was pretty mild, actually (and note that the PD doesn’ t enter into the

coding of the substance use disorder; see Table 15.2 in Chapter 15 ). I’d put his GAF score at 61.

F60.6 [301.82] A voidant personality disorder

F10.10 [305.00] Alcohol use disorder , mild

L63.1 [704.09] Alopecia universalis

R25.0 [781.0] Nodding of head

F60.7 [ 3 01.6 ] D ep en den t P erso n alit y D is o rd er

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Much more so than most, patients with dependent PD (DPD) feel the need for someone else to take care of

them. Because they desperately fear separation, their behavior becomes so sub missive and clinging that it

may result in others’ taking advantage of them or rejecting them. Anxiety blossoms if they are thrust into a

position of leadership, and they feel helpless and uncomfortable when they are alone. Because they

typically need much reassurance, they may have trouble making decisions. Such patients have trouble

starting projects and sticking to a job on their own, though they may do well under the careful direction of

someone else. They tend to belittle themselves and to agree with people who they know are wrong. They

may also tolerate considerable abuse (even battering).

Though it may occur commonly , this condition has not been well studied. Some writers believe that it is

dif ficult to distingui sh it from avoidant PD. It has been found more often among women than men. Bud

Stanhope , a patient with the sleep terror type of non-rapid eye movement sleep arousal disorder , also had

DPD; his history is given in an earlier chapter .

Essential Features of Dependent Personality Disorder

The n eed f o r s u pportiv e r e la tio nsh ip s d ra w s th ese p eo ple in to c lin gin g, s u bm is siv e b eh av io r a n d f e ars o f s e p ara tio n.

F ear o f d is a p pro val m ak es it h ard to d is a g re e w ith o th ers ; to g ain s u pport, th ey w ill e v en ta k e e x tr a o rd in ary s te p s,

s u ch as assu m in g unp le asa n t ta sk s. L ow se lf -c o nfid en ce pre v en ts th em fro m sta rtin g or carry in g out pro je cts

in dep en den tly ; in deed , th ey w an t o th ers to ta k e re sp onsib ility fo r th eir o w n m ajo r lif e a re as. If th ey d o m ak e e v en

ev ery day d ecis io ns, th ey r e q uir e lo ts o f a d vic e a n d r e assu ra n ce. E xag gera te d , u n re alis tic f e ars o f a b an donm en t a n d

th e n otio n t h at t h ey c an not c are f o r t h em se lv es w ill c a u se t h ese p eo ple t o f e el h elp le ss o r u nco m fo rta b le w hen a lo ne;

th ey m ay d esp era te ly s e ek a r e p la cem en t f o r a l o st c lo se p ers o nal r e la tio nsh ip .

T he F in e P rin t

T he D ’s : • D ura tio n ( b eg in s in te en s o r e arly 2 0s a n d e n dure s) • D if f u se c o nte x ts • D if f e re n tia l d ia g nosis ( p hysic al

an d s u bsta n ce u se d is o rd ers , m ood a n d a n xie ty d is o rd ers , o th er P D s)

Janet Gr eenspan

A secretar y in a lar ge Silicon Valley company , Janet Greenspan was one of the best workers there. She was

never sick or absen t, and she could do anything—she’d even had some bookkeeping experience. Her

supervisor noted that she was polite on the phone, typed like a demon, and would volunteer for anything.

When the building maintenance crew went out on strike, Janet came in early every day for a week to clean

the toilets and sinks. But still, somehow , she just wasn’t working out.

Her superv isor comp lained that Janet needed too much direction, even for simp le things—such as what

sort of paper to typ e form letters on. When she was asked what she th ought the answer should be, her

judgment was good, but she always wanted guidance anyway. Her constant need for reassurance took an

inordinate amount of her supervisor ’s time. That was why she had been referred to the company mental

health consultant for an evaluation.

At 28, Janet was slender , attractive, and carefully dressed. Her chestnut hair already showed streaks of

gray. She appeared at the doorway of the office and asked, “Where would you like me to sit?” Once she

started talking, she spoke readily about her life and her work.

She had always felt timid and unsure of herself. She and her two sisters had grown up with a father who

was affectionate but dictatorial; their mouse of a mother seemed to welcome his loving tyranny . At her

mother ’s knee, Janet had learned obedience well.

When Janet was 18, her father suddenly died; within a few months, her mother remarried and moved to

another state. Janet felt bereft and panic-stricken. Instead of beginning college, she took a job as a teller in a

bank; soon afterward, she married one of her customers. He was a 30-year -old bachelor , set in his ways,

and he soon let it be known that he preferred to make all of the couple’ s decisions himself. For the first time

in a year , Janet relaxed.

But even security bred its own anxieties. “Sometimes at night I wake up, wonde ring what I’d do if I lost

him,” Janet told the interviewer . “It makes my heart beat so fast I think it might stop from exhaustion. I just

don’ t think I could manage on my own.”

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Evaluation of Janet Gr eenspan

Janet had the follow ing symptoms of DPD: She needed considerable advice to make everyday decisions

(criterion A1); she wanted her husband to make their decisions (A2); panic-str icken when her father died

and her mother left town, she fled into an early marriage (A7); she feared being left to fend for herself, even

though she had had no indication that this was likely (A8). She even volunteer ed to clean the office toilet,

probably to secure the favor of the rest of the staff (A5). We have no evidence that she was reluctant to

disagree with others, but otherwise the criteria fit like a rubber glove. Five are needed for diagnosis. Janet

reported that she had been this way since childhood; from the history , her character traits would seem to

have affected both work and social life. Fortunately , she married someone whose need to be in char ge

matched her depend ency. Cognitive, affective, and interpersonal areas were involved (see the criteria for a

general PD).

Dependent behavior is found in several mental disorders that Janet did not appear to have, including

somatic symptom disorder and agoraphobia . The person with the secondary psychosis in what used to be

called folie à deux (or shared psychotic disorder—now it is usually diagnosed as delusional disorder ) often

has a dependent personality. Major depressive disorder and dysthymia a re impor tant in the differential

diagnosis; either of these may become prominent when patients lose those upon whom they depend. Even if

Janet had all the required physiological symptoms for generalized anxiety disorder , she would not be

given this diagnosis, because her worries were evidently limited to fears of abandonment.

Patients with DPD must be differentiate d from those with histrionic PD , who are impressionable and

easily influenced by others (but Janet did not seem to be especially attention-seeking). Other PDs usually

included in the dif ferential diagnosis are borderline and avoidant .

With a GAF score of 70, Janet’ s diagnosis would be simple:

F60.7 [301.6] Dependent personality disorder

F60.5 [ 3 01.4 ] O bse ssiv e– C om puls iv e P erso n alit y D is o rd er

People with obsessive–compulsive PD (OCPD) are perfectionistic and preoccupied with orderliness; they

need to exert interpersonal and mental control. These traits exist on a lifelong basis, at the expense of

efficiency , flexibility , and candor . However , OCPD is not just obsessive–compulsive disorder (OCD) in

miniature. Many patients with OCPD have no actual obsessions or compulsions at all, though some do

eventually develop OCD.

The rigid perfection ism of these patients often results in indecisiveness, preoccupation with detail,

scrupulosity , and insistence that others do things their way. These behaviors can interfere with their

effectiveness in work or social situatio ns. Often they seem depressed, and this depression may wax and

wane, perhaps to the point that it drives them into treatment. Sometimes these people are stingy; they may

be savers, refusing to throw away even worthless objects they no longer need. They may have trouble

expressing af fection.

Patients with OCPD are list makers who allocate their own time poorly , workaholics who must

meticulously plan even their own pleasure. They may plan their own vacations only to postpone them. They

resist the authority of others, but insist on their own. They may be perceived as stilted, stif f, or moralistic.

This condition is probably fairly common; prevalence in various studies centers around 5%. It is

diagnosed more often in males than in females, and it probably runs in families.

Essential Features of Obsessive–Compulsive Personality Disorder

These p eo ple are in te n se ly fo cu se d o n co ntr o l, o rd erlin ess, an d p erfe ctio n. T hey ca n b eco m e so ab so rb ed w ith

d eta ils , o rg an iz atio n, a n d r u le s o f a n a ctiv ity th at th ey lo se s ig ht o f its p urp ose . T hey te n d to b e r ig id a n d s tu bborn ,

perh ap s s o p erfe ctio nis tic t h at i t i n te rfe re s w ith t h e c o m ple tio n o f t a sk s. T hey c an b e o verly c o nsc ie n tio us, i n fle x ib le ,

o r s c ru pulo us a b out e th ic s, m ora ls , a n d v alu es. S om e a re w ork ah olic s; o th ers w on’t w ork u nle ss o th ers a g re e to d o

th in gs t h e p atie n ts ’ w ay. S om e m ay s a v e w orth le ss i te m s; o th ers a re s tin gy w ith t h em se lv es a n d w ith o th er p eo ple .

T he F in e P rin t

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The D ’s : • D ura tio n ( b eg in s in te en s o r e arly 2 0s a n d e n dure s) • D if f u se c o nte x ts • D if f e re n tia l d ia g nosis ( p hysic al

an d s u bsta n ce u se d is o rd ers , O CD , h oard in g d is o rd er, o th er P D s)

Robin Chatterjee

“I admit it—I’m over the top in neatness.” Robin Chatterjee straightened a fold in her sari. Born in Mumbai

and educa ted in London, Robin was a graduate student in biology . Now she spent part of her time as a

teaching assistant in biology , and the rest struggling through her own coursework at a major U.S. university .

She gazed steadily at the interviewer.

According to her preceptor , a slightly dour Scot named MacLeish who had asked her to come for the

interview , the problem wasn’t neatness. It was completing the work. Every paper she turned in was

wonderful—every fact was there, every conclusion correct, not even a misspelling. He had asked her why

she couldn ’t learn to let go of them a little sooner , “before the rats die of old age?” She had thought it funny

at the time, but it made her think.

Robin had always been orderly . Her mother had made her keep neat little lists of her chores, and the

habit stuck. Robin admitted that she became so “lost in lists” that sometimes she hardly had time to finish

her work. Her students seemed fond of her, but several had said they wished she’d give them more

responsibility . One had told Dr. MacLeish that Robin seemed afraid even to let them do their own

dissections; their methods weren’t as compulsively correct as hers were, so she’d try to do them herself.

Finally , she also admitted that nearly every night, her work habits kept her in the lab until late. It had been

weeks since she’d had a date—or any social life at all. This realization was what spurred her to follow Dr.

MacLeish’ s advice and come in for a mental health evaluation.

Evaluation of Robin Chatterjee

Although the prototype for OCPD seems a pretty good fit for Robin, she would just barely meet the official

criteria. She was workaholic and perfectionistic (OCPD criteria A3 and A2), to the point that these traits

interfered with the learning of her students. She had a great deal of difficulty delegating work—even the

students’ own dissections (A6)! And she concentrated so fiercely on her lists of tasks that she sometimes

didn’ t accomplish the tasks themselves (A1). She had had these tendencies throughout her young adult life.

Depressed mood is common in these people. The common disorders that should be looked for in a

patient with OCPD include OCD itself, major depressive disorder , and dysthymia . Robin was not

depressed and, unlike so many patients with OCPD, seemed to have no other disorder . Because she barely

met the criteria and was functioning well overall, I would place her GAF score at a relatively high 70.

F60.5 [301.4] Obsessive–compulsive personality disorder

OTH ER P E R SO NALIT Y C O NDIT IO NS

F07.0 [ 3 10.1 ] P erso n alit y C han ge D ue t o A noth er M ed ic a l C on dit io n

Some medical conditions can cause a personality change, which is defined as an alteration (usually, a

worsening) of a pa tient’ s previous personality traits. If the medical condition occurs early enough in

childhood, the change can last throughou t the person’ s life. Most instances of personality change are caused

by an injury to the brain or by some other central nervous system disorder , such as epilepsy or Huntington’ s

disease; however , sy stemic diseases that affect the brain (for example, systemic lupus erythematosis) are

also sometimes implicated.

Several sorts of personality changes commonly occur. Mood may become unstable, perhaps with

outbursts of rage or suspiciousness; other patients may become apathetic and passive. Changes in mood are

especially common with damage to the frontal lobes of the brain. Patients with temporal lobe epilepsy may

become overly religious, verbose, and lacking in a sense of humor; some may turn markedly aggressive.

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Paranoid ideas are also common. Belligerence can accompany outbursts of temper , to the extent that the

social judgment of some patients becomes markedly impaired. Use the type specifiers in the Coding Notes

to categorize the nature of the personality change.

If there is a major alteration in the structure of the brain, these personality changes will probably persist.

If the problem stems from a correctab le chemical problem, they may resolve. When severe, they can

ultimately lead to dementia, as is sometimes the case in patients with multiple sclerosis.

Essential Features of Personality Change Due to Another Medical Condition

A p hysic al i lln ess o r i n ju ry a p pears t o h av e c a u se d a p atie n t t o s u ff e r a l a stin g p ers o nality c h an ge.

T he F in e P rin t

Fro m t h eir e xp ecte d d ev elo pm en ta l p atte rn , c h ild re n w ill e x perie n ce a p ers o nality c h an ge t h at l a sts a t l e ast 1 y ear.

T he D ’s : • D ura tio n ( e n durin g) • D is tr e ss o r d is a b ility ( w ork /e d ucatio nal, s o cia l, o r p ers o nal) • D if f e re n tia l d ia g nosis

( d elir iu m , o th er p hysic al o r m en ta l d is o rd ers )

C od in g N ote s

D ep en din g o n t h e m ain f e atu re , s p ecif y t y pe:

A ggre ssiv e t y p e

A path etic t y p e

D is in hib it e d t y p e

L ab ile t y p e

P ara n oid t y p e

O th er t y p e

C om bin ed t y p e

U nsp ecif ie d t y p e

U se th e a ctu al n am e o f th e g en era l m ed ic al c o nditio n w hen y o u c o de th is d is o rd er, a n d a ls o c o de se p ara te ly th e

m ed ic al c o nditio n.

Eddie Ortway

Eddie Ortway , now age 28, had been born in central Los Angeles, where he was reared by his mother—

whenever she was neither hospitalized (for drug and alcohol use) nor jailed (for prostitution). His parents,

Eddie always suspected, had been only briefly acquainted.

Eddie avoided school whenever possible, and grew up with no role model in sight. His principal

accomplishment was learning to use his fists. By the time he was 15, he and his gang had participated in

several turf wars. He was making a name for himself as an aggressive enemy .

But Eddie was not a criminal, and the necessity for earning a living soon set him to work. With little

education and no training, he found his opportunities pretty much limited to fast food and hard labor.

Sometimes he held several jobs at a time. But, as an old probation report noted, he still had “a raging sense

of injustice.” Although he gradually stopped associating with his gang, through his middle 20s he continued

to deal aggressively with any situation that seemed to require direct action.

His 27th birthday was one of these. Eddie was delivering a pizza to an apartment building in his old

neighborhood when he encountered a teenager forcing an old woman into an alley at gunpoint. Eddie

stepped forward and for his pains received a bullet that entered his head through the left eye socket and

exited at the hairline.

He was admitted to the hospital by way of the operating room, where surgeons debrided his wound. He

never even lost consciousness and was released in less than a week. But he didn ’t return to work. The social

worker ’s report noted that Eddie’ s phys ical condition had rebounded within a month, but that he “lacked

drive.” He appeared for every scheduled job interview , but his prospective employers uniformly reported

that he “just didn’ t seem very interested in working.”

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“I needed time to recuperate,” Eddie told the interviewer . He was a good-looking young man whose hair

had begun receding from his forehead. An incisional scar ran up onto his scalp. “I still don’ t think I’m quite

ready .”

He had been recuperating for 2 years. Now he was being tested to try to learn why. Other than a slight

droop to his left eyelid, his neurological examination was completely normal. An EEG showed some slow

waves over the frontal lobes; the MRI revealed a localized absence of brain tissue.

Eddie never failed to cooperate with testing procedures, and all of the clinicians who examined him

noted that he was polite and pleasant. However, as one of them put it, “Ther e seems something slightly

mechanical about his cooperation. He complies but never anticipates, and he shows little interest in the

proceedings.”

His affect was about medium and showed almost no lability . His speech was clear, coherent, and

relevant. He denied delusions, hallucinations, obsessions, compulsions, or phobias. When asked what he

was interested in, he thought for a few seconds and then answered that he guessed he was interested in

going back home. He made a perfect score on the MMSE.

In the time since his injury , Eddie admitted, he had lived on workers’ compensation and spent most of

his time watching television. He didn’ t ar gue with anyone any more. When one examiner asked him what

he would do if he again saw someone being mugged, he shrugged and said that he thought people should

“just live and let live.”

Evaluation of Eddie Ortway

Eddie’s history and examinations presented an obvious general medical cause for his persistent personality

change (criterion A). Note that it was the physiology of trauma to the brain that produced Eddie’s

personality change. This is the explicit requirement (B) for this diagnosis, which cannot be made when

personality change accompanies a nonspecific medical condition such as severe pain.

Eddie’ s normal attention span and lack of memory deficit would rule out delirium (D) and major

neur ocognitive disorder (dementia) ; however , neuropsychological testing should be requested. A PD such

as dependent PD c oul d not explain Eddie’s condition, because his behavior represented a marke d change

from his premorbid personality (that is, the way he was until his injury). And the features of Eddie’ s

personality change were not better explained by a dif ferent physically induced mental disorder . A mood

disorder due to brain trauma would be one of several possible examples.

Besides head trauma, a variety of neurological conditions can cause personalit y change. These include

multiple sclerosis, cerebrovascular accidents, brain tumors, and temporal lobe epilepsy . Other causes of

behavioral change that could resemble a change in personality include delusional disorder , intermittent

explosive disorder , and schizophr enia . B ut Eddie’ s person ality change began abruptly after he was shot,

and he had no prior history that was consistent with any of the other disorder s mentioned (C). However ,

many other patients experience apparent personality change associated with mental disorders, including

addiction to substances.

The fact that Eddie’ s condition impaired him both occupationally and socially completed the criteria (E)

for this diagnosis. In his clinical picture, apathy (and passivity) clearly stood out as the main feature. This

determined the specific subtype. His GAF score would be a heart-breaking 55.

S06.330 [851.31] Open gunshot wound of cerebral cortex, without loss of

consciousness

F07.0 [310.1] Personality change due to head trauma, apathetic type

F60.8 9 [ 3 01.8 9] O th er S pecif ie d P erso n alit y D is o rd er

F 60.9 [ 3 01.9 ] U nsp ecif ie d P erso n alit y D is o rd er

The discus sion in DSM-5 suggests that patients who have some traits of certain PDs, but who don’t fully

meet criteria for any of them, could be listed in one of these two categories. Here’ s my problem with that

strategy: We would be branding someone who may be much less impaired than is the typical patient with a

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PD. My personal belief is that it would be better just to note in the summary the traits we’ve identified, and

not make a firm diagnosis of any sort.

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