you will take on the role of a psychology intern at a mental health facility working under the supervision of a licensed psychologist. I
Prior to beginning work on this discussion, read the assigned chapters from the text. It is highly recommended that you review each of the brief Blumenfeld (2012) video clips demonstrating the administration of a mental status examination. These are listed in the recommended resources and may require that you download Quicktime in order to view them. Although not required, these videos show the administration of a mental status exam and may prove helpful in this discussion.
Access the Barnhill (2014) DSM-5 Clinical Cases e-book in the DSM-5 library, and select one of the case studies. The case study you select must be one in which the client could be assessed using one or more of the assessment instruments discussed in this week’s reading.
For this discussion, you will take on the role of a psychology intern at a mental health facility working under the supervision of a licensed psychologist. In this role, you will conduct a psychological evaluation of a client referred to you for a second opinion using valid psychological tests and assessment procedures. The case study you select from the textbook will serve as the information provided to you from the professional who previously evaluated the client (e.g., the psychologist or psychiatrist).
In your initial post, begin with a paragraph briefly summarizing the main information about the case you selected. Evaluate and describe the ethical and professional interpretation of any assessment information presented in the case study. Devise an assessment battery for a psychological evaluation that minimally includes a clinical interview, mental status exam, intellectual assessment, observations of the client, and at least two assessment instruments specific to the diagnostic impressions (e.g., attention deficit/hyperactivity disorder, post-traumatic stress disorder, autism spectrum disorder, etc.). The assessment battery must include at least one approach to assessing your client which is different from the assessments previously administered. The assessment plan must be presented as a list of recommended psychological tests and assessment procedures with a brief sentence explaining the purpose of each test or procedure. Following the list of tests and assessment procedures you recommend for your client, compare the assessment instruments that fall within the same categories (e.g., intellectual or achievement), and debate the pros of cons of the instruments and procedures you selected versus the instruments and procedures reported by the referring professional.
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Chapter 18. Personality Disorders
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In tr o d u ctio n
Jo h n W . B arn hill, M .D .
Per so na lit y is th e end uring pa tter n of b eh avio r a nd inner ex per ience. I t u nd erlies how we
th ink , f eel , a nd a ct a nd f r a m es how we view ou rsel ves and t h e peo ple aro u nd u s. W hen we
th ink o f wh o we are, we oft en th ink o f per sona lit y a s th e cent ra l d ef ining ch ara ct er ist ic.
Psy ch iatr ist s and o th er m ent al h ea lt h pr act itio ner s spend co nsid erab le tim e th ink ing a b ou t
per sona lit y a nd t h e wa ys in wh ich d ysf unct iona l per sona lit ies cause dist ress and
d ysf unct ion in ind ivid uals and in th e peo ple aro u nd t h em . D iso rd er s of per sona lit y a re, in
so me wa ys, a s co mplex a s hum an it y, it sel f f u ll o f id iosy ncr asies, h alf – a rticu la ted co nflict s,
and u nk no wa ble co mplex ities. 8/14/2019 Psychiatry Online | DSM Library
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Lik e m any o th er co mplex sy stem s, h owev er, per sona lit ies and per sona lit y d iso rd er s tend t o
fa ll int o pa tter ns, a nd , f o r g ener atio ns, cl inicia ns and per sona lit y r esea rch ers fr o m a v a riet y
of f iel ds have sea rch ed f o r a h oly g ra il : a no solo gica l sy stem t h at is b oth sim ple to u se and
so ph istica ted eno ugh t o ca pture th e nu ances and pa ra d oxes of h um an per sona lit y.
T ra d it io na lly , t h e fiel d o f psy chiatr y h as co ncept ualiz ed per sona lit y d iso rd er s ca teg orica lly ,
a s ref lect ing d ist inct cl inica l sy nd ro m es. I n ano th er pa ra d ig m , per so na lit y d iso rd er s are
co ncept ualiz ed d im ensio nally , a s dysf unct iona l v a ria nt s of h um an per sona lit y t r a it s th at
ex ist o n a g ra d ient f r o m m ala d ap tiv e to no rm al. A s pa rt o f t h e D SM -5 d ev elopm ent
process, a t ea m o f per sona lit y r es ea rch ers ex plored m ult ipl e wa ys to inco rpo ra te both
pa ra d ig m s, a nd a s a r esu lt cr ea ted a new hyb rid ca teg orica l- d im ensio nal m od el .
Aft er v ig oro u s deb ate am ong t ea m m em ber s, t h e D SM -5 t ex t incl udes th e tr a d it io na l
categ orica l m od el o f per sona lit y d iso rd er s as wel l a s th e new hyb rid ca teg orica l-
d im ensio nal m od el . I t is th e tr a d it io na l ca teg orica l per spect ive th at is incl uded in th e m ain
b od y o f t h e tex t, wh ile th e alt er na tiv e D SM -5 m od el f o r per sona lit y d iso rd er s is descr ibed
in Sect ion III, “E mer ging M ea su res and M od el s.” This decisio n m ea ns th at t h e 10 D SM -I V
per sona lit y d iso rd er s—a nd t h eir c rit er ia—r em ain essent iall y u nch ang ed. T he pr im ary
su bst ant ive ch ang e is th at a s pa rt o f t h e rem ova l o f t h e ax ia l sy stem , t h e per sona lit y
diso rd er s are no l o ng er l ist ed sepa ra tel y f r o m o th er D SM -5 d ia gno ses.
To b et ter u nd erstand t h e sim ilarit ies and d if fer ences of t h e two m od el s, it m ay b e usef ul t o
ex plore how th e two D SM -5 d ia gno stic system s reco mmend t h at a cl inicia n assess a pa tient
wit h, f o r ex am ple, o b sessiv e-co mpu lsiv e per sona lit y d iso rd er ( O CP D). F ro m a ca teg orica l
per spect ive, t h e ind ivid ual wo uld r eceiv e a d ia gno sis of O CP D wh en cer ta in criter ia wer e
met. F ir st , t h e cl inicia n sh ou ld id ent ify a per sist ent, d ysf unct iona l pa tter n of, f o r inst ance,
per fect ionism a t t h e ex pense of f lex ibilit y. T he cl inicia n wo uld t h en ident ify a t l ea st f o u r o f
sev en specif ic sympt om atic criter ia ( pr eo ccu patio n wit h l ist s, ina bil it y t o d el eg ate ta sk s,
stubbornness, et c.) a nd sea rch f o r d iso rd er s th at m ight b e respo nsible fo r t h e sa me
sy mpt om s (a nd t h at co uld l ea d t o eit her t h e co ding o f t h e oth er d ia gno sis onl y, su ch a s
wh en sch izoph renia ca uses sympt om s ak in to t h ose fo u nd in OCP D, o r t h e co ding o f b oth
d ia gno ses, su ch a s wh en th e per son also m eet s cr iter ia f o r a no th er per sona lit y d iso rd er ).
T he new DSM -5 h yb rid m od el r es hapes th e 10 D SM -I V per sona lit y d iso rd er ca teg ories into
a r o st er o f six r ed efined ca teg orie s (a nt iso cial, a vo id ant , b ord er line, na rcissist ic, o b sessiv e-
compu lsiv e, a nd sch izoty pa l) . F or ea ch o f t h e six , t h e hyb rid m od el r eq uir es two 8/14/2019 Psychiatry Online | DSM Library
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assessm ents. T he fir st inv olv es a d et er mina tio n th at t h e ind ivid ual h as sig nifica nt
impairm ent in at l ea st t wo o f f o u r per sona lit y f u nct ioning a rea s: ident ity, sel f- d ir ect ion,
em path y, a nd int imacy . F or ea ch o f t h e six per sona lit y d iso rd er s, t h ese persona lit y specif ics
dif fer . F or ex am ple, t o q u alif y f o r O CP D, a n ind ivid ual m ight b e fo u nd t o h ave sig nifica nt
impairm ent f r o m a sense of sel f ex cessiv ely d er ived f r o m wo rk ( id ent ity) a nd f r o m r ig id ity
and st ubbornness negativ ely a ffec ting r el atio nsh ips (int imacy ).
T he new hyb rid m od el t h en req uir es an assessm ent o f per sona lit y t r a it s th at a re org aniz ed
und er f iv e bro ad t r a it d om ains. A s sh own in 18- , t h ese tr a it s and t r a it d om ains exist o n a
spect ru m ; fo r ex am ple, f o r o ne of t h e fiv e tr a it d om ains, a nt ag o nism l ies on one end o f t h e
spect ru m a nd a g reea bleness on th e oth er . T hese fiv e bro ad t r a it d om ains are new to m any
psy chiatr ist s, b u t t h ey h ave been rig oro u sl y st udied f o r sev eral d eca des wit hin aca dem ic
psy cholo gy u nd er t h e ru bric of t h e Fiv e Fact or M od el , wh ose per sona lit y d im ensio ns
include neu ro ticism , ex tr a ver sio n, a g reea bleness, co nscient iousness, a nd o penness. F or
ea ch o f t h ese persona lit y d im ensio ns, t h er e are cl ust er s of r el ated per sona lit y t r a it s.
A ppl ied t o a pa rticu la r per son, t h e Fiv e Fact or M od el ca n assig n a per cent ile sco re fo r ea ch
tr a it . F or ex am ple, t h e th eo ret ica l per son wit h O CP D m ight sco re in th e 95th per cent ile fo r
co nscient iousness and in th e 5th per cent ile fo r o penness. D SM -5 a d apt ed t h ese persona lit y
dim ensio ns and t r a it s in ord er t o m ore specif icall y f o cu s on psy chia tr ic diso rd er .
Alt e rn ativ e D SM- 5 m od el: p ath olo g ic a l p ers o n ality tr ait d om ain s
En la rg e t a b le
T went y-fiv e specif ic pa th olo gica l per sona lit y t r a it s are incl uded u nd er t h e um brel la o f t h ese
fiv e neg ativ e tr a it d om ains. F or ea ch o f t h e per sona lit y d iso rd er s, D SM -5 r eq uir es th at t h e
ind ivid ual d em onst ra te m ost o f t h e ty pica l per sona lit y t r a it s. F or e x am ple, t h e pa tient wit h
OCP D m ust d em onst ra te th e tr a it o f r ig id per fect ionism ( a n aspect o f t h e tr a it d om ain of
co nscient iousness) a s wel l a s at l e a st t wo o f t h e fo llo wing t h ree tr a it s: per severatio n (a n
aspect o f neg ativ e affect ivity), int imacy a vo id ance (a n aspect o f d et ach ment ), a nd r est rict ed
affect ivity ( a lso a n aspect o f d et ach m ent ).
T he D SM -5 h yb rid m od el a lso specif ies th at specif ic tr a it s ca n be reco rd ed ev en if no t
reco gniz ed a s pa rt o f a d ia gno sed per sona lit y d iso rd er ( e. g., h ost ilit y, a t r a it a sso ciated wit h
th e tr a it d om ain of neg ativ e affec tiv ity, co uld b e list ed a lo ng sid e an y D SM -5 d ia gno sis and
no t b e co nsid ered j u st a t r a it a sso ciated wit h, f o r inst ance, a nt iso cial per sona lit y d iso rd er ). 8/14/2019 Psychiatry Online | DSM Library
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Both o f t h e D SM -5 m od el s have ad va nt ag es and d isa dva nt ag es. T he new DSM -5 h yb rid
m od el m ight co ntrib ute to a m ore nu anced u nd erstand ing o f pa tient s, a nd it s appr oach
ta k es ad va nt ag e of d eca des’ wo rth o f per sona lit y r esea rch . I ts cu rrent co mplex ity is
d au nt ing , h owev er, ev en to sea soned cl inicia ns, a nd t h e use of a ne w system wo uld
po tent ially r ed uce th e usef ulness of ex ist ing r esea rch d ata wit hin psy ch iatr y .
T he tr a d it io na l ca teg orica l pa ra d ig m h as been critiq ued f o r ex cessiv e co morb id ity a nd
int ra d iso rd er h et er ogeneit y, a s wel l a s fo r t h e fa ct t h at o ne of t h e m ost co mmon per sona lit y
diso rd er d ia gno ses in th e pa st h as been “per sona lit y d iso rd er no t o th er wise specif ied,”
wh ich is clarif ied o nl y m arg ina lly b y t h e D SM -5 u se of “o th er specif ied” and “u nspecif ied”
per sona lit y d iso rd er s. O n th e oth er h and , t h e ca teg orica l a ppr oach is rel ativ ely
st ra ig htfo rwa rd t o u se, is fa m ilia r f r o m D SM -I V, a nd f o llo ws th e ca teg orica l st ru ct ure used
th ro u gh ou t t h e rest o f D SM -5 . I t is also t h e per sona lit y m od el incl uded in th e m ain bod y o f
th e D SM -5 t ex t a nd , a s su ch , r em ains th e Am er ica n Psy ch iatr ic Asso cia tio n’s officia l
perspect ive on per sona lit y d iso rd er s.
Su ggeste d R ead in gs
M acK inno n RA , M ich els R , B uck ley P J : T he Psy ch iatr ic Int erview in Clini cal P ra ct ice , 2 nd
E dit io n . W ash ing to n, D C , A m er ica n Psy ch iatr ic Publish ing , 2 0 06
M ich els R : Dia gno sing per sona lit y d iso rd er s . A m J Psy ch iatr y 16 9 (3): 2 4 1 – 24 3 , 2 0 12
PubM ed I D : 2 24 0 710 9
Sh ed ler J, B eck A , F ona gy P , et a l: P er so na lit y d iso rd er s in DSM -5 . A m J Psy ch iatr y
16 7 (9): 10 26 – 10 28 , 2 0 10 PubM ed I D : 2 0 826 8 53
S ko d ol A E , B end er DS , O ld h am JM , et a l: P ro po sed ch ang es in per sona lit y a nd
per sona lit y d iso rd er a ssessm ent a nd d ia gno sis fo r D SM -5 , pa rt I I : cl inica l a ppl icatio n .
Per so na l D iso rd 2(1): 2 3 – 30 , 2 0 11 PubM ed I D : 2 24 48 68 8
Sko d ol A E , Cl ark L A , B end er DS , et a l: P ro po sed ch ang es in per sona lit y a nd per sona lit y
diso rd er a ssessm ent a nd d ia gno sis fo r D SM -5 , pa rt I : d escr iption and r a tio na le . P er so na l
Diso rd 2(1): 4– 2 2 , 2 0 11 PubM ed I D : 2 24 48 68 7
W est en D , S h ed ler J, B ra d ley B , D eF ife JA : A n em pirically d er ived t a x o no my f o r
per sona lit y d ia gno sis : brid ging science and pr act ice in concept ualiz ing per sona lit y . A m J 8/14/2019 Psychiatry Online | DSM Library
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Psy ch iatr y 16 9 (3): 2 73 – 2 8 4 , 2 0 12 PubM ed I D : 2 219 35 34
Case 1 8.1 P ers o n alit y C on ic ts
L arry J. S ie ve r, M .D .
Lau ren C. Zalu da, B .A .
Fra zier A rch er wa s a 34 -y ea r-o ld sing le wh ite m an wh o ca ll ed a m ood a nd per sona lit y
diso rd er s resea rch pr ogra m b eca use an ex -fr iend h ad o nce said h e wa s “b ord er line, ” and
M r. A rch er wa nted t o l ea rn m ore ab ou t h is per sona lit y co nflict s.
During h is dia gno stic resea rch int erviews, M r. A rch er r epo rted r eg ula r, a lm ost d ail y
sit uatio ns in wh ich h e wa s su re he wa s being l ied t o o r d eceiv ed. H e wa s pa rticu la rly wa ry
o f peo ple in lea der sh ip po sitions and peo ple wh o h ad st udied psy cholo gy a nd , t h er efore,
h ad “t ra ining t o u nd erstand t h e hum an m ind ,” wh ich t h ey u sed t o m anipu la te peo ple.
Unl ike th ose aro u nd h im , M r. A rc h er b el iev ed h e did no t “d rink t h e Kool- A id ” and wa s ab le
t o d et ect m anipu la tio n and d eceit .
Mr. A rch er wa s ex tr em ely d et ail o rient ed a t wo rk , a nd h ad t r o u ble del eg ating a nd
co mpleting t a sk s. N um er ou s em plo yer s had t o ld h im t h at h e fo cu sed ex cessiv ely o n ru les,
list s, a nd sm all d et ail s, a nd t h at h e need ed t o b e m ore fr iend ly . H e h ad h el d nu mer ou s jo b s
over t h e yea rs, b u t h e wa s qu ick t o a d d , “I ’v e qu it a s oft en as I’v e been fir ed .” D uring t h e
int erview, h e def end ed h is beh avio r, a sser ting t h at u nl ike m any peo ple, h e und erstood t h e
va lu e of q u alit y o ver pr od u ct ivity. M r. A rch er’s wa riness had co ntrib uted t o h is “b ad
tem per ” and em otio na l “u ps and d owns. ” H e so cia liz ed o nl y “su per ficia lly ” wit h a h and fu l
of a cq uaint ances and co uld r eca ll t h e ex act m om ent s wh en previous “so -ca lled f r iend s and
lo ver s” had b et ra yed h im . H e spent m ost o f h is tim e alo ne.
M r. A rch er d enied a ny sig nifica nt h ist ory o f t r a u m a, a ny cu rrent o r pa st pr ob lem s wit h
subst ance use, a nd a ny h ist ory o f h ea d t r a u m a o r l o ss of co nscio usness. H e also d enied a ny
h ist ory o f m ent al h ea lt h d ia gno sis or t r ea tm ent , b u t r epo rted t h at h e fel t h e m ight h ave a
m ent al h ea lt h co nd itio n th at h ad no t y et b een dia gno sed .
On m ent al st atu s ex am ina tio n, M r. A rch er a ppea red wel l g ro om ed , co oper ativ e, a nd
o rient ed. H is speech v a ried ; at t im es he wo uld pa use th ou gh tfu lly pr ior t o a nswer ing
qu est ions, ca using h is ra te of spee ch t o b e so mewh at sl ow. H is to ne also ch ang ed 8/14/2019 Psychiatry Online | DSM Library
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significa ntly wh en he discu ssed si tu atio ns th at h ad m ad e him a ng ry , a nd m any o f h is
respo nses were leng th y, d ig ressiv e, a nd v a g u e. H owev er, h e seem ed g ener ally co her ent a nd
d id no t ev idence percept ual d iso rd er . H is affect wa s occa sionally ina ppr opr iate (e. g.,
sm iling wh ile cr ying ) b u t g ener ally co nst rict ed. H e repo rted a pa th y a s to wh ether h e liv ed
or d ied b u t d id no t r epo rt a ny a ct ive su icid al id ea tio n or h om icid al id ea tio n.
Nota b ly , M r. A rch er b eca me irrit ated a nd a rg u m ent ativ e wit h r esea rch st aff wh en he wa s
to ld t h at a lt h ou gh h e co uld r eceiv e ver bal f eed back o n his int erviews, h e co uld no t r eceiv e a
co py o f co mpleted q u est ionna ires and d ia gno stic to ols. H e co mment ed t h at h e wo uld
d ocu ment in his per sona l r eco rd s th at r esea rch st aff wer e ref using h im t h e fo rm s.
Dia g n ose s
Para no id per sona lit y d iso rd er
O bsessiv e-co mpu lsiv e per sona lit y d iso rd er
D is c u ssio n
M r. A rch er d escr ibes a l o ng -st and ing , inf lex ible, d ysf unct iona l pa tter n of d ea ling wit h t h e
wo rld . H e dem onst ra tes an end uring pa tter n of d ist ru st a nd su spicio usness. H e bel iev es
th at o th er s are ex ploit ing o r d ecei ving h im ; d ou bts th e lo ya lt y o f f r iend s; bea rs gru dges;
and r ecu rrent ly m ist ru st s th e fid elit y o f sex ual pa rtner s. T his clust er o f sy mpt om s qu alif ies
him f o r D SM -5 pa ra no id per sona lit y d iso rd er ( P PD ).
A seco nd cl ust er o f per sona lit y t r a it s rel ates to M r. A rch er’s pr eo ccupa tio n wit h
per fect ionism a nd co ntro l. H e is ex cessiv ely f o cu sed o n ru les, l ist s, a nd d et ail s. H e is
inf lex ible and u na ble to d el eg ate. I n ad d it io n to P PD , h e has D SM -5 o b sessiv e-co mpu lsiv e
per sona lit y d iso rd er ( O CP D).
F or a ny o f t h e per sona lit y d iso rd er s, it is im porta nt t o ex clude th e ph ysio lo gica l ef fect s of a
su bst ance or a no th er m ed ica l co ndit io n; neit her o f t h ese appea rs lik ely in Mr. A rch er, wh o
denied a ll su bst ance ab u se, m ed ical il lness, a nd h ea d inj ury . F urth er more, h is pa tter ns of
b eh avio r a ppea r t o b e end uring a nd no t r el ated t o eit her a m ajo r ch ang e in lif e
cir cumstance or a no th er psy chiatr ic diso rd er .
It is unsu rpr ising t h at in ad dit io n to t h e PPD a nd O CP D d ia gno ses, M r. A rch er m eet s
partia l cr iter ia f o r o th er per sona li t y d iso rd er s, incl uding sch izoty pa l, b ord er line, 8/14/2019 Psychiatry Online | DSM Library
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narcissist ic, a nd a vo id ant per sona lit y d iso rd er s. P er so na lit y d iso rd er s are fr eq uent ly
co morb id , a nd if a pa tient m eet s crit er ia f o r m ore th an one diso rd er , ea ch sh ou ld b e
reco rd ed . P PD is especia lly u nl ikely t o b e an iso la ted d ia gno sis, in either cl inica l o r
resea rch po pu la tio ns. P PD is oft e n co morb id wit h sch izoty pa l per sona lit y d iso rd er a nd /or
oth er sch izoph renia spect ru m d iso rd er s, a f ind ing a ttr ib uta b le to o ver la pping pa ra no ia-
rel ated cr iter ia. I n M r. A rch er’s ca se, h is em otio na l inst ab il it y, a nx iet y, a ng er, a nd
a rro gance are sy mpt om s oft en fo u nd in a per sona lit y cl ust er t h at in cludes bord er line
per sona lit y d iso rd er a nd na rcissis tic per sona lit y d iso rd er . B eca use of t h e rel ativ e
inf req uency o f P PD a s an “iso la ted ” diso rd er , cu rrent r esea rch is point ing t o wa rd t h e
po ssib ilit y t h at so me per sona lit y d iso rd er s, incl uding P PD , co uld b e co nso lid ated t o cr ea te
m ore incl usiv e dia gno ses. P ara no ia wo uld t h en be viewed a s a specif ier o r m od if ier f o r
oth er d iso rd er s. T hat is no t t h e sit uatio n wit h D SM -5 , h owev er, a nd P PD sh ou ld co ntinu e
to b e list ed a s a co morb id co nd itio n wh en criter ia a re m et.
A seco nd int erest ing d ia gno stic issu e rel ated t o P PD is th e co ncer n a m ong so me cl inicia ns
th at d ia gno sing P PD is ta nt am ou nt t o t r y ing t o id ent ify a n ea rly st ag e of sch izoph renia .
Ther e is genet ic, neu ro b io lo gica l, epid emiolo gica l, a nd sy mpt om atic evidence th at P PD ,
lik e sch izoty pa l per sona lit y d iso rd er , is rel ated t o sch izoph renia a n d l ies on th e
sch izoph renia spect ru m . H owev er, P PD is no t a pr ecu rso r t o sch izoph renia , a nd it s
sy mpt om s are no t ind icativ e of t h e pr od ro m al ph ase of sch izoph renia . P ro d ro m al
sch izoph renia is best ch ara ct er ized b y ea rly psy chotic sympt om s, incl uding d iso rg aniz ed
th ou gh ts and b eh avio r, wh erea s th e th ou gh t pa tter ns in PPD a re gener ally m ore sim ilar t o
th ose of d el usio nal d iso rd er a nd r el ated t h ou gh t d iso rd er s.
Su ggeste d R ead in gs
Ber man M E , F allo n A E , Co cca ro E F : The rel atio nsh ip bet ween persona lit y
psy chopa th olo gy a nd a g gressiv e beh avio r in resea rch v o lu nt eer s . J Abno rm P sy ch ol
10 7 (4): 6 51 – 6 58 , 19 98 P ubM ed I D : 9 8 30 252
B er nst ein D , U sed a D , S iev er L : Para no id per sona lit y d iso rd er , in T he D SM -I V
P er so na lit y D iso rd er s . E dit ed b y L iv esl ey WJ . N ew York , Gu ilfo rd , 19 95 , pp 4 5 – 57
K end ler K S : D ia gno stic appr oach es to sch izoty pa l per sona lit y d iso rd er : a h ist orica l
per spect ive . S ch izoph r B ull 11 (4) : 5 38 – 553 , 19 85 P ubM ed I D : 39 0937 7 8/14/2019 Psychiatry Online | DSM Library
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Kend ler K S , N ea le M C , W alsh D : E va lu ating t h e spect ru m co ncept o f sch izoph renia in th e
R osco mmon Fam ily S tu dy . A m J Psy ch iatr y 15 2 (5): 7 4 9 – 75 4 , 19 95 P ubM ed I D : 772 6 315
Siev er LJ , D avis K L : The pa th oph ysio lo gy o f sch izoph renia d iso rd er s : per spect ives fr o m
th e spect ru m . A m J Psy ch iatr y 16 1 (3): 39 8 – 413 , 2 0 04 P ubM ed I D : 14 9929 62
Siev er LJ , K oenig sberg HW , H arv ey P , et a l: Co gnit ive and b ra in fu nct ion in sch izoty pa l
per sona lit y d iso rd er . S ch izoph r R es 54 (1– 2 ): 15 7 – 16 7 , 2 0 02 P ubM ed I D : 118 539 90
T hak er GK , R oss D E , Ca ssa dy SL , et a l: S acca dic eye m ovem ent a b no rm alit ies in rel ativ es
of pa tient s wit h sch izoph renia . S ch izoph r R es 45 (3): 2 35 – 24 4 , 2 0 00 P ubM ed I D :
110 424 41
T rieb wasser J, Ch em erinsk i E , R ou sso s P , S iev er L : Para no id per sona lit y d iso rd er . J Per s
Diso rd A ugu st 2 8 , 2 0 12 [ E pu b a h ea d o f pr int ] P ubM ed I D : 2 29 28 850
Z im mer man M , Ch elm insk i I, Yo ung D : T he fr eq uency o f per sona lit y d iso rd er s in
psy chiatr ic pa tient s . P sy ch iatr Cl in North A m 31 (3): 4 0 5 – 420 , 2 0 08 P ubM ed I D :
18 638 643
C ase 1 8.2 O ddly I s o la te d
S alman Akh tar, M.D .
Gr zeg orz B uch alsk i wa s an 87-y ea r-o ld wh ite m an wh o wa s bro u gh t t o t h e psy chiatr ic
em ergency r o om ( E R ) b y pa ra m ed ics aft er t h ey h ad b een called t o h is apa rtm ent b y
neig hbors wh en th ey no ticed a n od d sm ell. A ppa rent ly , h is 90 -y ea r-o ld sist er h ad d ied
so me days ea rlier a ft er a l eng th y i llness. M r. B uch alsk i h ad d el ayed r epo rting h er d ea th f o r
sev eral r ea sons. H e had b eco me incr easing ly d iso rg aniz ed a s his sist er’s hea lt h h ad
wo rsened , a nd h e wa s wo rried t h at h is la nd lo rd wo uld u se th e apa rtm ent ’s co nd itio n as a
pr etex t f o r ev ict ion. H e had t r ied t o cl ea n up, b u t h is attem pts co nsist ed m ainl y o f m oving
it em s fr o m o ne place to a no th er . H e sa id h e wa s ab ou t t o ca ll f o r h el p wh en th e po lice and
pa ra m ed ics showed u p.
In th e ER , M r. B uch alsk i reco gniz ed t h at h is act io ns wer e od d a nd t h at h e sh ou ld h ave
ca lled f o r h el p so oner . A t t im es, h e beca me tea rfu l wh en discu ssing t h e sit uatio n and h is
sist er’s dea th ; at o th er t im es, h e seem ed a lo of, spea king a b ou t t h es e in a ca lm , f a ct ual wa y. 8/14/2019 Psychiatry Online | DSM Library
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He also wa nted t o cl arif y t h at h is apa rtm ent h ad ind eed b een a m ess bu t t h at m uch o f t h e
appa rent m ess was act ually h is la rg e co llect ion of a rticl es on bio lu m inescence, a t o pic he
had b een resea rch ing f o r d eca des .
A l icensed pl um ber , el ect ricia n, a nd l o ck sm ith, M r. B uch alsk i h ad wo rk ed u nt il a g e 65. H e
descr ibed h is la te sist er a s having b een alwa ys “a l it tle st ra ng e.” Sh e had nev er wo rk ed a nd
h ad b een married o nce, b rief ly . A sid e fr o m t h e sev eral- m ont h m arria ge, sh e and M r.
B uch alsk i h ad l iv ed in th e fa m ily’s two -b ed ro om M anh atta n apa rtm ent t h eir ent ire liv es.
Neit her o f t h em h ad ev er seen a p sy ch iatr ist .
When qu est ioned , M r. B uch alsk i st ated t h at h e had nev er h ad a r o m ant ic or sex ual
rel atio nsh ip and h ad nev er h ad m any f r iend s or so cia l co ntact s ou tsid e his fa m ily. H e
ex plained t h at h e had b een poor a nd P olish a nd h ad h ad t o wo rk a ll t h e tim e. H e had t a k en
nig ht cl asses to b et ter u nd erstand “t he st ra ng e wo rld we liv e in, ” an d h e sa id h is int ellect ual
int erest s wer e wh at h e fo u nd m ost g ra tif ying . H e sa id h e had b een u pset a s he rea liz ed t h at
h is sist er wa s dying , b u t h e wo uld ca ll it “nu mb” ra th er t h an depr essed . H e also d enied a ny
h ist ory o f m anic or psy chotic sympt om s. A ft er a n hou r wit h t h e psy chiatr ic tr a inee, M r.
B uch alsk i co nfided t h at h e hoped t h e m ed ica l sch ool m ight b e int erest ed in some of h is
pa per s aft er h is dea th . H e sa id h e b el iev ed t h at b io lu m inescent a nd g enet ic tech nolo gies
wer e on th e ver ge of a b rea kth ro u gh t h at m ight a ll o w th e sk in of a n im als and t h en hum ans
to g lo w in subtle co lo rs th at wo uld a ll o w peo ple to m ore dir ect ly r eco gniz e em otio ns. H e
had wr itten th e no tes fo r su ch t ec hno lo gy, b u t t h ey h ad g ro wn into a “wa y-to o-lo ng science
f ict ion no vel wit h l o ts of f o otno te s. ”
O n ex am ina tio n, M r. B uch alsk i wa s a t h in, el der ly m an dressed nea tly in kh ak is and
b u tto n- down shirt. H e wa s m eticu lo u s and m uch pr efer red t o d iscu ss his int erest s in
science th an his own story . H e m ad e appr opr iate ey e co ntact a nd h ad a po lit e, pl ea sant
dem eano r. H is speech wa s co her ent a nd g o al d ir ect ed. H is mood wa s “f ine, ” and h is affect
wa s appr opr iate th ou gh per haps unu suall y ch eer fu l u nd er t h e cir cumstances. H e denied a ll
sy mpt om s of psy chosis, d epr essio n, a nd m ania . A sid e fr o m h is co mm ent s ab ou t
bio lu m inescence, h e sa id no th ing t h at so und ed d el usio nal. H e wa s co gnit ively int act , a nd
h is insig ht a nd j u dgm ent wer e co nsid ered g ener all y g o od , a lt h ou gh h ist orica lly im paired in
r eg ard t o h is del ay in calling t h e po lice ab ou t h is sist er.
Dia g n osis 8/14/2019 Psychiatry Online | DSM Library
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Sch izoid per sona lit y d iso rd er
D is c u ssio n
M r. B uch alsk i’s alo of, t a cit urn, a n d a sex ual l if est yle cer ta inl y f it t h e dia gno stic criter ia f o r
sch izoid per sona lit y d iso rd er ; h is ex plana tio n th at h e has been fr iend less beca use he is
Polish a nd po or is a wea k r a tio na liz atio n fo r h is psy choso cia l d ef icit s. T he eccent ricit y o f
h is int erest in bio lu m inescence, t h e ex ag ger ated est imatio n of t h e va lu e of h is “pa pers,” and
th e fa ct t h at h e has liv ed pr etty m uch a ll h is lif e in th e fa m ily’s resid ence with h is sist er g iv e
fu rth er ev idence of h is inwa rd pr eo ccu patio n and l a ck o f so cia l eng ag em ent . T he st rik ing
po ver ty o f h is em otio na l r espo nse a t h is sist er’s pa ssing a wa y a nd h is fa il ure to m ak e any
so rt o f f u ner al a rra ng em ent s are co nf irm ato ry o f a f la ttened a ff ect iv e lif e and wea k eg o
skills. T he fa ct t h at h e is co gnit ively int act r u les ou t a g ra d u all y o ccu rring , d em ent ing
etio lo gy f o r h is wit hdra wa l a nd “c onf irm s” th e dia gno sis of sch izoid per sona lit y d iso rd er .
Su ch a d ia gno sis has a l o ng h ist ory in psy chiatr y a nd psy choana ly sis. I n psy chiatr y , it s
orig ins go b ack t o E ugen Bleu ler , wh o co ined t h e ter m sc h iz oi d in 1908 t o d escr ibe a
na tu ra l co mpo nent o f per sona lit y t h at pu lled o ne’ s attent ion to wa rd o ne’ s inner l if e and
awa y f r o m t h e ex ter na l wo rld . H e l a b el ed a m orb id ex ag ger atio n of t h is tend ency a s
“sch izoid per sona lit y.” Su ch ind ivid uals wer e descr ibed a s qu iet , su spicio us, a nd
“co mfo rta b ly d u ll.” B leu ler ’s desc ript ion wa s el ab ora ted u po n over t h e nex t cent ury , a nd
m any f ea tu res wer e ad ded t o it . T hese included so lit ary l if est yle, l o ve of b ooks, l a ck o f
ath let icism , t end ency t o wa rd a u tist ic th ink ing, po orly d ev eloped sex ualit y, a nd co ver t b u t
int ense sensit ivity t o o th er s’ em otio na l r espo nses. T his la st f ea tu re, h owev er, g o t d ro pped
fr o m t h e m ore recent po rtr a ya ls of sch izoid per sona lit y, incl uding t h e ones in DSM -I II a nd
D SM -I V. D espit e th e reser va tio ns of m any inv estigato rs (e. g., O tto K er nb erg, Jo hn
L iv esl ey, a nd m ysel f) , “l ack ing d esir e fo r cl ose rel atio nsh ips” beca me a pr im e cr iter ion fo r
th e sch izoid d ia gno sis. A m ong o th er f a ct ors th at wer e em phasiz ed wer e asex ualit y,
ind iffer ence to pr aise or cr iticism , a nh edonia , a nd em otio na l co ld ness. T he hyper sensit ivity
cr iter ion and t h e ost ensib le link t o sch izoph renia wer e assig ned, r e spect ively, t o t h e
ca teg ories of “a vo id ant ” and “sch izoty pa l” per sona lit y d iso rd er s.
W ithin psy choana ly sis, t h e sch izoid co nd itio n wa s best d escr ibed b y W . R . D . F air bair n and
H arry Gu ntrip. A cco rd ing t o t h em , int ense sensit ivity t o b oth l o ve and r ej ect ion and a
pr opensit y t o r ea dil y wit hdra w fr o m int erper sona l r el ated ness la y a t t h e co re of sch izoid
pa th olo gy. T he ind ivid ual t h us afflict ed o scil la ted b et ween wanting cl oseness and d rea ding 8/14/2019 Psychiatry Online | DSM Library
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it ; fea red t h e vig or o f h is or h er o wn need s and t h eir im pact o n oth er s; and wa s attr a ct ed t o
lit er ary a nd a rtist ic act ivities beca use th ese were avenu es of sel f- ex pressio n wit hou t d ir ect
hum an co ntact . S ch izoid per sona lit y ev olv ed f r o m o ne or m ore of t h e fo llo wing scena rio s:
1) t a nt aliz ing r ef usa l b y ea rly ca re ta k er s th at a ro u sed f r ig htening a m ou nt s of em otio na l
hung er; 2 ) ch ro nic parent al r ej ect ion, wh ich r esu lt ed in compliant a pa th y a nd l if el essness;
and 3) su stained neg lect b y pa ren ts, wh ich l ed t o r et rea t int o t h e fa nt asy wo rld .
T he ab sence of d ev elopm ental h ist ory a nd o f a ny d ata a b ou t M r. B uch alsk i’s ch ildh ood
wea kens a psy chod yna mic und ersta nd ing o f M r. B uch alsk i’s sch izoid per sona lit y. H owev er,
dev elopm ental h ist ory is no t a r eq uir ed cr iter ion fo r a d escr iptive dia gno sis; th is criter ion
is pr im aril y u til iz ed b y psy chod yn am ica lly o rient ed psy chiatr ist s. A ll in all, t h e dia gno sis of
sch izoid per sona lit y d iso rd er seem s rea sona ble fo r M r. B uch alsk i, a lt h ou gh so me m ight
arg u e in fa vo r o f a sch izoty pa l per sona lit y d iso rd er d ia gno sis giv en t h e od dit y o f h is
int erest s. I f f u rth er ex plora tio n yiel ds inf orm atio n th at q u alif ies th is pa tient f o r b oth
per sona lit y d iso rd er s, t h en both sh ou ld b e reco rd ed .
In reg ard t o o th er co morb id ities, t h e m ost l ik ely a ppea rs to b e hoard ing d iso rd er , a
d ia gno sis new to D SM -5 . M r. B uch alsk i ind icates th at h e del ayed ca lling t h e po lice aft er h is
sist er d ied b eca use he wa s wo rrie d t h at h is la nd lo rd wo uld u se th e co nd itio n of t h e
apa rtm ent a s a pr etex t f o r ev ict ion. H e descr ibes a l a rg e co llect ion of b io lu m inescence
pa per s, f o r ex am ple, a st atem ent t h at co uld m ea n a 2 -fo ot- ta ll st ack o f m anu scr ipts or a n
apa rtm ent cr am med t o t h e ceil ings wit h d eca des’ wo rth o f newspa pers, m ag azines, a nd
scr ibbled no tes, sa ved b eca use of t h eir po tent ial u sef ulness. Cl arif ying t h e pr esence of t h is
(o r a ny o th er ) co morb id co nd itio n wo uld b e cr ucia l t o t h e dev elopm ent o f a t r ea tm ent pl an
th at t r ies to m ax im ize th e lik elih ood o f ind epend ent h appiness fo r t h is pa tient .
Su ggeste d R ead in gs
Akh ta r S: S ch izoid per sona lit y d iso rd er : a sy nt hesis of d ev elopm ental, d yn am ic, a nd
d escr iptive fea tu res . A m J Psy ch oth er 41 (4): 4 9 9 – 518 , 19 87 P ubM ed I D : 332 4773
L iv esl ey WJ , W est M , T anney A : A h ist orica l co mment o n DSM -I II sch izoid a nd a vo id ant
per sona lit y d iso rd er s . A m J Psy ch iatr y 14 2 (11 ): 134 4 – 1347 , 19 85 P ubM ed I D : 39 0448 9
T rieb wasser J, Ch em erinsk i E , R ou sso s P , S iev er LJ : Sch izoid per sona lit y d iso rd er . J Per s
Diso rd 2 6 (6): 9 19 – 926 , 2 0 12 PubM ed I D : 2 32 816 76 8/14/2019 Psychiatry Online | DSM Library
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Case 1 8.3 W orrie d a n d O ddly P re o cc u p ie d
K ri st in Cad en head , M .D .
Henr y, a 19 -y ea r-o ld co lleg e so ph om ore, wa s ref er red t o t h e st udent h ea lt h cent er b y a
t ea ch ing a ssist ant wh o no ticed t h at h e appea red o d d, wo rried , a nd pr eo ccu pied a nd t h at
h is la b no teb ook wa s fil led wit h b iz arrel y t h rea tening d ra wing s.
Henr y a ppea red o n tim e fo r t h e psy ch iatr ic co nsu lt a tio n. A lt h ou gh su spicio us ab ou t t h e
rea son fo r t h e ref er ra l, h e ex plained t h at h e gener all y “f ollo wed o rd er s” and wo uld d o wh at
h e wa s ask ed . H e ag reed t h at h e had b een suspicio us of so me of h is cl assm ates, b el iev ing
th ey wer e und ermining h is ab il it ies. H e sa id t h ey wer e tel ling h is instru ct ors th at h e wa s “a
weir d g u y” and t h at t h ey d id no t wa nt h im a s a l a b pa rtner . T he ref er ra l t o t h e psy chiatr ist
wa s, h e sa id, co nfirm atio n of h is per cept ion.
Henr y d escr ibed h ow he had seen two st udent s “f lip a co in” over wh ether h e wa s gay o r
st ra ig ht. Co ins, h e asser ted , co uld o ft en pred ict t h e fu tu re. H e had o nce flipped a co in and
“h eads” had pr ed ict ed h is moth er ’s illness. H e bel iev ed h is th ou gh ts oft en came tr u e.
H enr y h ad t r a nsf erred t o t h is ou t- o f- to wn univ ersit y a ft er a n init ial y ea r a t h is lo ca l
co mmunit y co lleg e. T he tr a nsf er wa s his pa rent s’ id ea , h e sa id, a nd wa s pa rt o f t h eir a g end a
to g et h im t o b e lik e ev eryo ne else and g o t o pa rties and h ang o u t w ith g ir ls. H e sa id a ll su ch
beh avio r wa s a wa ste of t im e. A lt h ou gh t h ey h ad t r ied t o pu sh h im int o m oving int o t h e
dorm s, h e had r ef used , a nd inst ead l iv ed b y h im sel f in an off – ca mpu s apa rtm ent .
With H enr y’s per missio n, h is moth er wa s ca ll ed f o r co lla ter al inf orm atio n. S h e sa id H enr y
had b een qu iet , sh y, a nd r eser ved since childh ood . H e had nev er h ad cl ose fr iend s, h ad
nev er d ated , a nd h ad d enied wa nting t o h ave fr iend s. H e ack no wled ged f eel ing d epr essed
and a nx ious at t im es, b u t t h ese feel ing s did no t im prove wh en he wa s aro u nd o th er peo ple.
He wa s tea sed b y o th er k id s and wo uld co me hom e upset . H is moth er cr ied wh ile
ex plaining t h at sh e alwa ys fel t b ad f o r h im b eca use he nev er r ea ll y “f it in, ” and t h at sh e and
h er h usb and h ad t r ied t o co ach h im f o r y ea rs wit hou t su ccess. S h e wo ndered h ow a per son
co uld f u nct ion wit hou t a ny so cia l l if e.
Sh e ad ded t h at g h ost s, t el epa th y, a nd wit chcraft h ad f a scina ted H enr y since ju nio r h ig h
sch ool. H e had l o ng t h ou gh t t h at h e co uld ch ang e th e ou tco me of ev ent s lik e ea rth qu ak es
and h urrica nes by t h ink ing a b ou t t h em . H e had co nsist ently d enied su bst ance ab u se, a nd 8/14/2019 Psychiatry Online | DSM Library
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two d ru g scr eens had b een negativ e in th e pr ior 2 y ea rs. S h e m ent ioned t h at h er
gra nd fa th er h ad d ied in an “insa ne asy lu m ” m any y ea rs bef ore H enr y wa s born, b u t sh e did
no t k no w his dia gno sis.
On ex am ina tio n, H enr y wa s ta ll, t h in, a nd d ressed in jea ns and a T -sh irt. H e wa s aler t a nd
wa ry a nd , a lt h ou gh no nspo ntaneo us, h e answer ed q u est ions dir ect ly . H e denied f eel ing
depr essed o r co nfused . H enr y d en ied h aving a ny su icid al t h ou gh ts, pl ans, o r a ttem pts. H e
denied h aving a ny a u dit ory o r v is ual h allu cina tio ns, pa nic atta ck s, o b sessio ns,
compu lsio ns, o r ph ob ia s. H is int ellect ual sk ills seem ed a b ove aver ag e, a nd h is Mini- Ment al
S ta te Exam ina tio n sco re wa s 30 o u t o f 30 .
Dia g n ose s
Sch izoty pa l per sona lit y d iso rd er
P ara no id per sona lit y d iso rd er
D is c u ssio n
H enr y pr esent s wit h a pa tter n of so cia l a nd int erper sona l d ef icit s acco mpa nied b y
eccent ricit ies and co gnit ive dist ortio ns. T hese include del usio nal- lik e sy mpt om s (m ag ica l
th ink ing, su spicio usness, id ea s of r ef er ence, g ra nd iosit y), eccent ric int erest s, ev idence of
wit hdra wa l ( few fr iend s, a vo id anc e of so cia l co ntact ), a nd r est rict ed a ffect ( em otio na l
cold ness) . T her efore, H enr y a ppe ars to m eet cr iter ia f o r D SM -5 sch izoty pa l per sona lit y
diso rd er .
Henr y a lso su spect s th at o th er s are und ermining h im , r ea ds hid den mea ning int o b enig n
act ivities, b ea rs gru dges, a nd is over ly sensit ive to per ceiv ed a tta ck s on his ch ara ct er . I n
a d dit io n to sch izoty pa l per sona lit y d iso rd er , h e m eet s cr iter ia f o r pa ra no id per sona lit y
diso rd er . I f a n ind ivid ual m eet s cr iter ia f o r t wo per sona lit y d iso rd er s—a s is oft en th e ca se—
both sh ou ld b e reco rd ed .
Henr y, h owev er, is onl y 19 y ea rs old , a nd a per sona lit y d iso rd er d ia gno sis shou ld b e m ad e
onl y a ft er ex ploring o th er d ia gno ses th at co uld pr od u ce sim ilar sy mpt om s. F or ex am ple,
Henr y’s def icit s in socia l co mmun ica tio n and int eract io n co uld b e co nsist ent wit h a
d ia gno sis of a u tism spect ru m d iso rd er ( A SD ) wit hou t int ellect ual im pairm ent . I t is po ssib le
t h at h e had u nr epo rted sy mpt om s bey ond “sh yness” in th e ea rly d ev elopm ental per iod, 8/14/2019 Psychiatry Online | DSM Library
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and , a s wa s repo rted a b ou t H enr y, ch ildren wit h A SD co mmonl y u nd ergo sch ooly a rd
tea sing . H e and h is moth er d o no t, h owev er, r epo rt t h e so rts of r est rict ed, r epet itiv e
pa tter ns of b eh avio r, int erest s, o r a ct ivities th at a re also a h all m ark o f A SD . W ithou t t h ese,
H enr y wo uld no t b e dia gno sed o n t h e au tism spect ru m .
Henr y a lso m ay h ave a psy chiatr ic diso rd er t h at d ev elops in yo u ng a d u lt h ood , a nd h e is at
th e pea k a g e fo r t h e onset o f d epr essiv e, b ipo la r, a nd a nx iet y d iso rd er s. A ny o f t h ese can
ex acer bate basel ine persona lit y t r a it s and m ak e th em a ppea r t o b e diso rd er s, b u t H enr y
does not a ppea r t o h ave sig nifica nt d epr essiv e, m anic, o r a nx iet y sy mpt om s.
M ore lik ely in th is case wo uld b e a d ia gno sis on th e sch izoph renia spect ru m . F or H enr y t o
h ave an act ual sch izoph renia d ia gno sis, h owev er, h e wo uld need t o h ave two o r m ore of t h e
fo llo wing f iv e cr iter ia: d el usio ns, h allu cina tio ns, d iso rg aniz ed speech , g ro ssl y d iso rg aniz ed
or ca ta to nic beh avio r, a nd neg ativ e sy mpt om s. B eca use he denies hallu cina tio ns and
appea rs to b e lo gica l a nd no t t o h ave eit her o d d b eh avio r o r neg ativ e sy mpt om s, h e does
no t h ave sch izoph renia . I nst ead, h e m ay h ave del usio ns—a nd it wo uld b e usef ul t o cl arif y
th e ex tent t o wh ich h e has fix ed , f a lse bel ief s ab ou t pr ed ict ing a nd a ffect ing t h e fu tu re—b ut
h is bel ief s seem m ore biz arre th an th ose ty pica ll y seen in del usio nal d iso rd er .
Alt h ou gh H enr y cu rrent ly m ay b est f it t h e two per sona lit y d iso rd er d ia gno ses list ed a b ove,
h e m ay g o o n to d ev elop a m ore ex plicit ly psy chotic diso rd er . P sy ch iatr ic clinicia ns and
resea rch ers are pa rticu la rly int erest ed in dist ing uish ing ind ivid uals wh o pr esent a s unu sual
a s teena ger s and a re lik ely t o g o o n to d ev elop a m ore disa bling sch izoph renia f r o m t h ose
wh o pr esent sim ilarly b u t wil l no t g o o n to d ev elop a m ajo r psy chiatr ic diso rd er . A lt h ou gh
th e cu rrent a b il it y t o pr ed ict sch izoph renia is no t r o b u st , ea rly int erv ent ion co uld
su bst ant ially r ed uce th e psy cholo gica l su ffer ing a nd t h e lo ng -ter m f u nct iona l
conseq uences. T o t h at end , D SM -5 S ect ion III incl udes attenu ated psy chosis synd ro m e as
o ne of t h e co nd itio ns fo r f u rth er s tu dy. A ttenu ated psy chosis synd ro m e fo cu ses on
su bsy nd ro m al sy mpt om s, incl uding im paired insig ht a nd f u nct ionalit y, in an effo rt t o
cl arif y wh ich pa tient s are in th e pro cess of a d ecl ine into sch izoph renia a nd wh ich pa tient s
are dem onst ra ting t h e beg inning s of a m ore cr yst alliz ed per sona lit y d iso rd er .
Su ggeste d R ead in gs
Adding to n J, Co rnb la tt B A , Ca denh ead KS , et a l: A t cl inica l h ig h r isk f o r psy chosis:
ou tco me fo r no nco nverter s . A m J Psy ch iatr y 16 8 (8 ): 8 0 0 – 80 5 , 2 0 11 PubM ed I D : 8/14/2019 Psychiatry Online | DSM Library
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214 98 46 2
A hm ed AO , Gr een BA , Go od ru m N M , et a l: D oes a l a tent cl ass und erlie sch izoty pa l
per sona lit y d iso rd er ? Im plica tio ns fo r sch izoph renia . J Abno rm P sy ch ol 12 2 (2): 4 75 – 4 9 1 ,
20 13 PubM ed I D : 2 37 135 03
Fish er JE , H eller W , M iller GA : N eu ro psy cholo gica l d if fer ent iatio n of a d apt ive cr ea tiv ity
and sch izoty pa l co gnit ion . P er s Ind ivid D if 54 (1): 7 0 – 75 , 2 0 13 PubM ed I D : 2 310 974 9
C ase 1 8.4 U nfa ir n ess
Ch arle s L. S co tt, M .D .
Ik e Cr ock er wa s a 32 -y ea r-o ld m an ref er red f o r a m ent al h ea lt h ev alu atio n by t h e hum an
reso urces depa rtm ent o f a l a rg e co nst ru ct io n bu siness th at h ad b ee n his em ployer f o r 2
week s. A t h is init ial j o b int erview, M r. Cr ock er pr esent ed a s ver y m otiv ated a nd pr ovid ed
two ca rpent ry sch ool cer tif ica tio ns th at ind icated a h ig h l ev el o f sk ill a nd t r a ining . S ince his
em ploym ent b eg an, h is su per viso rs had no ted f r eq uent a rg u m ent s, a b sent eeism , po or
wo rk m ansh ip, a nd m ult ipl e er ro rs th at m ight h ave been dang erou s. W hen confro nt ed , h e
wa s repo rted ly d ism issiv e, ind icating t h at t h e pr ob lem wa s “ch eap wo od ” and “b ad
m ana gem ent ” and a d ded t h at if so meo ne go t h urt, “it ’s beca use of t h eir o wn stupid ity.”
W hen th e hea d o f h um an reso urc es met wit h h im t o d iscu ss ter min atio n, M r. Cr ock er
qu ick ly po int ed o u t t h at h e had b oth a ttent ion- def icit /hyper act ivity d iso rd er ( A D H D) a nd
b ipo la r d iso rd er . H e sa id t h at if n ot g ra nt ed a n acco mmod atio n und er t h e Am er ica ns wit h
Disa bil it ies Act , h e wo uld su e. H e d em and ed a psy chiatr ic evalu atio n.
During t h e m ent al h ea lt h ev alu atio n, M r. Cr ock er f o cu sed o n unf air ness at t h e co mpa ny
and o n how he wa s “a h el l o f a b et ter ca rpent er t h an any one th er e co uld ev er b e. ” H e
claim ed t h at h is two m arria ges had end ed b eca use of j ea lo u sy . H e sa id t h at h is wiv es wer e
“alwa ys th ink ing I wa s wit h o th er wo men, ” wh ich is wh y “t hey b oth l ied t o j u dges and g o t
rest ra ining o rd er s sa ying I ’d h it t h em .” A s “pa yb ack f o r t h e ja il t im e,” he ref used t o pa y
child su ppo rt f o r h is two ch ildren. H e had no int erest in seeing eit her o f h is two b oys
b eca use th ey wer e “little lia rs” lik e th eir m oth er s.
M r. Cr ock er sa id h e “m ust h ave been smart” beca use he had b een ab le to m ak e Cs in sch ool
d espit e sh owing u p onl y h alf t h e tim e. H e spent t im e in ju venil e hall a t a g e 14 f o r st ea ling 8/14/2019 Psychiatry Online | DSM Library
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“kid st uff, l ik e tennis shoes and wa llet s th at wer e pr act ica lly em pty.” H e lef t sch ool a t a g e 15
aft er b eing “f ra m ed f o r st ea ling a ca r” by h is pr incipa l. M r. Cr ock er po int ed o u t t h ese
hist orica l f a ct s as ev idence th at h e wa s ab le to o ver co me inj ust ice and a d ver sit y.
In reg ard t o su bst ance use, M r. C ro ck er sa id h e sm oked m arij uana a s a t eena ger a nd
st arted d rink ing a lco hol o n a “r eg ula r b asis” aft er h e fir st g o t m arried a t a g e 22. H e denied
th at u se of eit her su bst ance was a pr ob lem .
Mr. Cr ock er co ncl uded t h e int erview by d em and ing a no te fr o m t h e ex am iner t h at h e had
“b ipo la r” and “A DH D.” H e sa id t h at h e wa s “b ipo la r” beca use he had “u ps and d owns” and
g o t “m ad r ea l f a st .” M r. Cr ock er d enied o th er sy mpt om s of m ania . H e sa id h e go t d own
wh en disa ppo inted, b u t h e had “a sh ort m em ory ” and “co uld g et o u t o f a f u nk pr etty q u ick .”
M r. Cr ock er r epo rted no d if ficu lt ies in his sleep, m ood , o r a ppet ite. H e lea rned a b ou t
A D H D b eca use “both o f m y b oys go t it .” H e co ncl uded t h e int erview with a r eq uest f o r
m ed ica tio ns, a d ding t h at t h e onl y o nes th at wo rk ed wer e st im ula n ts (“a ny o f t h em ”) a nd a
specif ic sh ort- a ct ing b enz od ia zepine.
O n m ent al st atu s ex am ina tio n, M r. Cr ock er wa s a ca su all y d ressed wh ite m an wh o m ad e
rea sona ble ey e co ntact a nd wa s w ithou t a b no rm al m ovem ent s. H is speech wa s co her ent ,
go al d ir ect ed, a nd o f no rm al r a te. T her e wa s no ev idence of a ny t h ou gh t d iso rd er o r
h allu cina tio ns. H e wa s pr eo ccu pied wit h b la m ing o th er s, b u t t h ese co mment s appea red t o
r epr esent o ver va lu ed id ea s ra th er t h an del usio ns. H e wa s co gnit ively int act . H is insig ht
int o h is sit uatio n wa s po or.
T he hea d o f h um an reso urces did a b ack gro u nd ch eck d u ring t h e co urse of t h e psy chiatr ic
ev alu atio n. P hone calls rev ea led t h at M r. Cr ock er h ad b een expel led f r o m t wo ca rpent ry
tr a ining pr ogra m s and t h at b oth h is gra d u atio n cer tif ica tes had b een fa lsif ied . H e had b een
fir ed f r o m h is jo b a t o ne lo ca l co nst ru ct io n co mpa ny a ft er a f ist fig ht wit h h is su per viso r a nd
fr o m a no th er j o b a ft er a b ru pt ly l e a ving a j o b sit e. A q u ick r ev iew of t h eir r eco rd s ind icated
th at h e had pr ovid ed t h em wit h t h e sa me fa lse docu ment atio n.
Dia g n osis
A nt iso cial per sona lit y d iso rd er
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Mr. Cr ock er h as a per va siv e pa tter n of d isr egard f o r a nd v io la tio n of t h e rig hts of o th er s, a s
ind icated b y m any d if fer ent a ct io ns. H e has been arrest ed t wice fo r d om est ic vio lence—
o nce each f r o m t wo sepa ra te m arr ia ges—a nd h as spent t im e in ja il . M r. Cr ock er h as
fa lsif ied h is carpent ry cr ed ent ials a nd pr ovid es am ple ev idence of r epea ted f ig hts and
ir rit ab il it y, b oth a t wo rk a nd wit hin his rel atio nsh ips. H e dem onst ra tes lit tle or no r eg ard
fo r h ow his act io ns affect t h e sa fet y o f h is co wo rk er s. H e ref uses to see his yo u ng so ns or
pa y ch ild su ppo rt, b eca use th ey a re “little lia rs. ” H e ex hib its no r em orse fo r h ow his act io ns
neg ativ ely a ffect h is fa m ily, co wo rk er s, o r em ployer s. H e ro u tinel y q u it s jo b s and f a il s to
pl an ah ea d f o r h is nex t em ploym ent . H e m eet s all sev en of t h e sy mpt om atic criter ia f o r
D SM -5 a nt iso cial per sona lit y d iso rd er ( A PD ).
T he dia gno sis of A PD ca nno t b e m ad e unt il a g e 18 , b u t it d oes req uir e ev idence fo r co nd uct
diso rd er b ef ore ag e 15 . M r. Cr ock er’s hist ory ind icates a h ist ory o f t r u ancy , a d ju dica tio n fo r
th ef t a t a g e 14 , a nd ex pu lsio n fr o m sch ool a t a g e 15 f o r ca r t h ef t.
A t t h e end o f t h e ev alu atio n, M r. Cr ock er r eq uest s two po tent iall y a d dict ive m ed ica tio ns.
He sm oked m arij uana in hig h sch ool a nd m ay h ave beg un to d rink a lco hol h ea vil y in his
20 s. A lt h ou gh it m ight b e dif ficu lt t o el icit a n honest a cco unt o f h is su bst ance use, M r.
Cr ock er m ay ind eed h ave a co morb id su bst ance use diso rd er . S u ch a d ia gno sis would no t
affect h is dia gno sis of A PD , h owe ver , b eca use his ant iso cial b eh avio r pr ed ates his repo rted
u se of su bst ances. I n ad dit io n, h is ant iso cial a ttit udes and b eh avio rs are m anif est in
m ult ipl e set ting s and a re no t sim ply a r esu lt o f h is su bst ance ab u se (e. g., st ea ling t o pa y f o r
h is dru gs) .
M r. Cr ock er’s cl aim t h at h e has AD H D wo uld r eq uir e ev idence th at h e had so me
hyper act ive- im pulsiv e or ina ttent ive sy mpt om s th at ca used im pairm ent b ef ore ag e 12
yea rs. A lt h ou gh A D H D co uld b e a co morb id co nd itio n and co uld a cco unt f o r so me of h is
im pulsiv ity, it wo uld no t a cco unt f o r h is wid e-ra ng ing a nt iso cial b eh avio r.
T he APD d ia gno sis also r eq uir es th at t h e beh avio r no t o ccu r o nl y d u ring t h e co urse of
b ipo la r d iso rd er o r sch izoph renia . A lt h ou gh M r. Cr ock er st ates th at h e has bipo la r
d iso rd er , h e pr ovid es no ev idence th at h e has ev er b een manic (o r sch izoph renic) .
Mr. Cr ock er’s int erper sona l st yle is mark ed b y ca ll o u s disr egard f o r t h e feel ing s of o th er s
and a n arro gant sel f- a ppr aisa l. S u ch q u alit ies can be fo u nd in oth er per sona lit y d iso rd er s,
su ch a s na rcissist ic per sona lit y d iso rd er , b u t t h ey a re also co mmon in APD . A lt h ou gh 8/14/2019 Psychiatry Online | DSM Library
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comorb id ity is no t u nco mmon, in div id uals wit h na rcissist ic per sona lit y d iso rd er d o no t
exhib it t h e sa me lev els of im pulsi vit y, a g gressio n, a nd d eceit a s are pr esent in APD .
Ind ivid uals wit h h ist rio nic personalit y d iso rd er o r b ord er line persona lit y d iso rd er m ay b e
m anipu la tiv e or im pulsiv e, b u t t h eir b eh avio rs are no t ch ara ct er ist ica lly a nt iso cial.
I nd ivid uals wit h pa ra no id per sona lit y d iso rd er m ay d em onst ra te ant iso cial b eh avio rs, b u t
th eir a ct io ns tend t o st em f r o m a pa ra no id d esir e fo r r ev eng e ra th er t h an a d esir e fo r
per sona l g ain. F ina lly , peo ple wit h int ermittent ex plosiv e diso rd er a lso g et int o f ig hts, b u t
th ey l a ck t h e m any ex ploit iv e tr a it s th at a re a per va siv e pa rt o f A PD .
Su ggeste d R ead in gs
Edwa rd s D W , S co tt CL , Ya rv is R M , et a l: I m pu lsiv eness, im pulsiv e ag gress ion, per sona lit y
diso rd er , a nd spo usa l v io lence . Vio lence Vict 18 (1): 3– 14 , 2 0 03 PubM ed I D : 12 7336 16
Wyg ant D B , S el lb om M : Viewing psy chopa th y f r o m t h e per spect ive of t h e Per so na lit y
Psy ch opa th olo gy F iv e m od el : im plica tio ns fo r D SM -5 . J Per s D iso rd 2 6 (5): 7 17 – 72 6 , 2 0 12
PubM ed I D : 2 30 1334 0
Case 1 8.5 F ra g il e a n d A ngry
Fran k Y eo man s, M .D ., P h.D .
Otto K ern berg , M .D .
Ju anit a D el gad o, a sing le, u nem plo yed H ispa nic woman, so ugh t t h er apy a t a g e 33 fo r
tr ea tm ent o f d epr essed m ood , ch ro nic suicid al t h ou gh ts, so cia l iso la tio n, a nd po or per sona l
hyg iene. S h e had spent t h e pr ior 6 m ont hs iso la ted in her a pa rtm ent , l y ing in bed , ea ting
ju nk f o od , wa tch ing t el ev isio n, a nd d oing m ore onl ine shopping t h an sh e co uld a ffo rd .
M ult ipl e tr ea tm ent s had y iel ded l it tle ef fect .
Ms. D el gad o wa s th e m iddle of t h ree children in an upper -m iddle- class im migra nt f a m ily in
wh ich t h e fa th er r epo rted ly v a lu ed pr ofessio nal a ch iev em ent o ver a ll el se. S h e fel t iso la ted
th ro u gh ou t h er sch ool y ea rs and ex per ienced r ecu rrent per iods of d epr essed m ood . W ithin
her f a m ily, sh e wa s kno wn fo r a ng ry o u tb u rst s. S h e had d one wel l a ca dem ically in hig h
sch ool b u t d ro pped o u t o f co lleg e b eca use of f r u st ra tio ns wit h a r o om mate and a pr ofesso r.
S h e attem pted a ser ies of int ernsh ips and ent ry -lev el j o b s wit h t h e ex pect atio n th at sh e
wo uld r et urn to co lleg e, b u t sh e kept q u it ting b eca use “bosses are id iots. T hey co me acr oss 8/14/2019 Psychiatry Online | DSM Library
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as grea t a nd t h ey a ll t u rn ou t t o b e twist ed.” These “tra u m as” alwa ys lef t h er f eel ing t er rib le
a b ou t h er sel f ( “I ca n’t ev en succeed a s a cl er k?”) a nd a ng ry a t h er b osses (“I co uld r u n th e
pl ace and pr ob ab ly wil l”) . S h e had d ated m en wh en she wa s yo u ng er b u t nev er l et t h em g et
cl ose physica lly b eca use she beco me to o a nx ious wh en any int imacy b eg an to d ev elop.
M s. D el gad o’s hist ory incl uded cu tting h er sel f su per ficia ll y o n a nu mber o f o cca sions, a lo ng
wit h per sist ent t h ou gh ts th at sh e wo uld b e bet ter o ff d ea d. S h e sa id t h at sh e wa s gener ally
“d own and d epr essed ” bu t t h at sh e had h ad d ozens of 1- t o 2 -d ay “m ania s” in wh ich sh e
wa s ener giz ed a nd ed gy a nd pu lled a ll – nig hter s. S h e tend ed t o “cr ash ” th e nex t d ay a nd
sl eep fo r 12 h ou rs.
S h e had b een in psy chiatr ic tr ea tm ent since ag e 17 a nd h ad b een psy ch iatr ica lly
h ospit aliz ed t h ree tim es aft er o verd oses. T rea tm ent s had co nsist ed pr im aril y o f
m ed ica tio n: mood st ab il iz er s, l o w- dose neu ro lept ics, a nd a nt idepr essa nts th at h ad b een
pr escr ibed in va rio us co mbina tio ns in th e co ntex t o f su ppo rtiv e psy choth er apy .
During t h e int erview, sh e wa s a ca su all y g ro om ed a nd so mewh at u nk em pt wo man wh o wa s
cooper ativ e, co her ent , a nd g o al d ir ect ed. S h e wa s gener all y d ysph oric wit h a co nst rict ed
affect b u t d id sm ile appr opr iatel y sev eral t im es. S h e descr ibed sh am e at h er po or
per fo rm ance bu t a lso b el iev ed sh e wa s “o n Earth t o d o so mething g rea t.” Sh e descr ibed h er
fa th er a s a spect acu la r su ccess, b u t h e wa s also a “M ach iavel lia n lo ser wh o wa s alwa ys
tr y ing t o m anipu la te peo ple.” Sh e d escr ibed q u it ting j o b s beca use peo ple wer e
disr espect fu l. F or ex am ple, sh e sa id t h at wh en she wo rk ed a s a cl er k a t a d epa rtm ent st ore,
peo ple wo uld o ft en be ru de or u na ppr ecia tiv e (“a nd I wa s th er e on ly in prepa ra tio n to
b eco me a b u yer ; it wa s rid icu lo u s”) . T owa rd t h e end o f t h e init ial sessio n, sh e beca me ang ry
wit h t h e int erviewer a ft er h e gla n ced a t t h e cl ock ( “A re yo u b ored a lr ea dy?”) . S h e sa id sh e
knew people in th e neig hborh ood , b u t m ost o f t h em h ad “b eco me fr a u ds or l o ser s.” Ther e
wer e a f ew peo ple fr o m sch ool wh o wer e “F aceb ook f r iend s,” doing a m azing t h ing s all o ver
th e wo rld . A lt h ou gh sh e had no t seen th em in yea rs, sh e int end ed t o “m eet u p wit h t h em if
t h ey ev er co me back t o t o wn. ”
Dia g n osis
B ord er line persona lit y d iso rd er
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Ms. D el gad o pr esent s wit h a ffect iv e inst ab il it y, d if ficu lt y co ntro ll ing h er a ng er, u nst ab le
int erper sona l r el atio nsh ips, a n id ent ity d ist urb ance, sel f- m util ating b eh avio r, f eel ing s of
em ptiness, a nd t r a nsient , st ress- rel ated pa ra no ia. S h e m eet s cr iter ia, t h er efore, f o r D SM -5
b ord er line persona lit y d iso rd er ( B PD ).
I nd ivid uals wit h B PD o ft en present wit h d epr essiv e and /or b ipo la r sy mpt om s, a nd M s.
Del gad o is no ex cept ion. H er pr esent ing sy mpt om s incl ude a pr ed om ina ntly d epr essed
mood , d im inish ed int erest s, o ver ea ting , a ner gia , a nd ch ro nic suicid al id ea tio n. D isa bling ,
per sist ent f o r 6 m ont hs, a nd o ccu rring in th e ab sence of su bst ance u se or a m ed ica l
diso rd er , M s. D el gad o’s sy mpt om s also m eet cr iter ia f o r a D SM -5 m ajo r d epr essio n. S u ch
co morb id ity b et ween BPD a nd d epr essio n is co mmon. I t is int erest ing t o no te th at M s.
Del gad o’s pr eo ccu patio ns are accu sato ry , wh erea s th e ty pica l pr eo ccu patio n of a d epr essed
person wit hou t a per sona lit y d iso rd er is gu il ty a nd sel f- a ccu sato ry . I t wo uld b e wo rth
ex ploring t h e po ssib ilit y t h at M s. D el gad o’s depr essiv e sy mpt om s are m ore episo dic and
rea ctive th an sh e init ially r epo rts. I t a lso seem s po ssib le th at sh e qu alif ies fo r l if el ong
d epr essio n, wh ich wo uld ind icate d yst hym ic diso rd er b u t wo uld a lso po int t o wa rd a
per sona lit y d iso rd er .
M s. D el gad o r epo rts “m ania s” th at a re no t t y pica l o f so meo ne wit h b ipo la r d iso rd er . F or
ex am ple, sh e descr ibes having h ad d ozens of 1- t o 2 -d ay episo des in wh ich sh e is ener giz ed
and ed gy, f o llo wed b y a “cr ash ” an d 12 h ou rs of sl eep. T hese do no t co nform t o t h e cr iter ia
fo r b ipo la r I o r b ipo la r I I d iso rd er , in reg ard t o eit her sy mpt om s or d u ra tio n. T he
em otio na l inst ab il it y a nd a ffect st orm s of B PD ca n lo ok v er y m uch l ik e a m anic or
h ypo manic episo de, wh ich ca n lea d t o u nd erdia gno sis of B PD . E ven in th e pr esence of a
sig nifica nt m anic episo de, t h e cl inicia n sh ou ld ex plore su ch h ist orica l v a ria bles as affect ive
stab il it y, m atu rit y o f int erper sona l r el atio nsh ips, a nd st ab il it y o f wo rk , r el atio nsh ips, a nd
sel f- a ssessm ent. I f pr ob lem s are fo u nd , a B PD d ia gno sis is lik ely.
Cr iter ia f o r D SM -5 per sona lit y d iso rd er s rem ain unch ang ed f r o m t h e pr evious
cl assif icatio n sy stem . H owev er, t h e alt er na tiv e m od el f o r per sona lit y d iso rd er s, pr esent ed
in DSM -5 S ect ion III, su ggest s a m ore dim ensio nal a ppr oach , o ne in wh ich t h e int erviewer
wo uld ex plicit ly co nsid er per sona lit y f u nct ioning . T he append ix o u tlines fiv e dif fer ent t r a it
d om ains th at ex ist o n a co ntinu um . “E motio na l st ab il it y” is co ntra st ed wit h “neg ativ e
affect ivity,” fo r ex am ple, wh erea s “a nt ag o nism ” is at t h e oth er end o f t h e spect ru m f r o m
“a greea bleness” (see Tab le 18 – in th e int ro d u ct io n to t h is ch apt er). 8/14/2019 Psychiatry Online | DSM Library
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This dim ensio nal v iew of per sona lit y is co mpa tib le wit h K er nb erg’s lo ng -st and ing m od el o f
b ord er line persona lit y o rg aniz atio n (B PO ). I n ad d it io n to m eet ing t h e D SM -5 cr iter ia f o r
B PD , M s. D el gad o f it s th e cr iter ia f o r B PO —a psy cholo gica l st ru ct ure co nceiv ed a s being
ch ara ct er ized b y 1) l a ck o f a cl ea r a nd co her ent sense of sel f a nd o th er s (id ent ity d if fu sio n),
2) f r eq uent u se of pr im itiv e def ense mech anism s based o n spl itting , a nd 3) int act b u t
fr a g il e rea lit y t est ing . T he m ore int egra ted a nd r ea list ica lly co mplex t h e ind ivid ual’s
r epr esent atio ns of sel f a nd o th er s are, t h e m ore th e ind ivid ual is ab le to m od u la te and
co ntro l h is or h er em otio na l st ates and su ccessf ully int eract wit h o th er s.
M s. D el gad o d em onst ra tes ident it y d if fu sio n in her co ntra d ict ory v iews of h er sel f ( a s both
su per ior a nd ina deq uate) a nd o th er s (h er f a th er a s both spect acu la r a nd a “M ach iavel lia n
lo ser ”). H er d ef ensiv e st yle is ch ara ct er ized b y co nsist ent pr oject ion of h er h ost ile feel ing s
and per ceiv ing t h e host ilit y a s co ming f r o m o th er s. T he fr a g il it y o f h er r ea lit y t est ing , seen
in th e slig hts sh e fel t a t wo rk , h as led t o ch ro nic occu patio na l d ysf unct ion.
Beca use peo ple wit h per sona lit y d iso rd er s oft en do no t pr esent a n int erper sona l na rra tiv e
th at co nform s to t h e st ory t h at wo uld b e to ld b y o th er s, it is im porta nt t o a ttend t o t h e
pa tient ’s beh avio r in rel atio n to t h e th er apist . W ith M s. D el gad o, e v id ence of h er f r a g il it y is
seen in her sense th at t h e th er apist ’s gla ncing a t t h e cl ock m ea nt h e did no t l ik e her a nd
wa nted t o g et r id o f h er .
Su icid al t end encies are pa rt o f b oth d epr essio n and B PD . I n gener al, a cu te or ch ro nic
pa ra su icid al b eh avio r is ty pica l o f sev ere per sona lit y d iso rd er s. F urth er more, su icid alit y
ca n dev elop ab ru pt ly d u ring cr ises am ong a v a riet y o f pa tient s, b u t it is especia lly pr evalent
in peo ple—l ike M s. D el gad o—wit h a f r a g il e sense of b oth t h e wo rld a nd t h em selves.
S u ggeste d R ead in gs
Cl ark in JF , Yeo mans F E , K er nb erg OF : Psy ch oth er apy f o r B ord er line Per so na lit y :
Focu sing o n Object R el atio ns . W ash ing to n, D C , A m er ica n Psy ch iatr ic Publish ing , 2 0 06
K er nb erg OF , Yeo mans F E : B ord er line persona lit y d iso rd er , b ipo la r d iso rd er , d epr essio n,
attent ion def icit /hyper act ivity d is ord er , a nd na rcissist ic per sona lit y d iso rd er : pr act ica l
dif fer ent ial d ia gno sis . B ull M enning er Cl in 77 (1): 1– 2 2 , 2 0 13 PubM ed I D : 2 34 28 16 9
Old h am JM , S ko d ol A E , B end er DS ( ed s): Am er ica n Psy ch iatr ic Publish ing T ex tb ook o f
P er so na lit y D iso rd er s , 2 nd E dit io n . W ash ing to n, D C , A m er ica n Psy ch iatr ic Publish ing ( in 8/14/2019 Psychiatry Online | DSM Library
https://dsm-psychiatryonline-org.proxy-library.ashford.edu/doi/full/10.1176/appi.books.9781585624836.jb18 22/39
press ).
T usia ni B , T usia ni PA , T usia ni- Eng P : R em nants of a L if e on Paper . N ew York , B aro q u e
P ress , 2 0 13
C ase 1 8.6 P ain fu l S u ic id alit y
E lizab eth L . A uch in clo ss, M.D .
Karm en Fuent es wa s a 5 0 -y ea r-o ld m arried H ispa nic woman wh o pr esent ed t o t h e
psy chiatr ic em ergency r o om ( E R ) a t t h e urg ing o f h er o u tpa tient psy chiatr ist a ft er t el ling
h im t h at sh e had b een th ink ing a b ou t o ver dosing o n Advil .
In th e ER , M s. F uent es explained t h at h er b ack h ad b een “killing ” her since she fel l sev eral
d ays ea rlier a t t h e fa m ily-o wned g ro cer y st ore wh ere sh e had wo rk ed f o r m any y ea rs. T he
fa ll h ad l ef t h er d ownca st a nd d ep ressed , a lt h ou gh sh e denied o th er d epr essiv e sy mpt om s
asid e fr o m a po or m ood . S h e spo ke at l eng th a b ou t t h e fa ll a nd a b ou t h ow it r em ind ed h er
of a f a ll t h at sh e had su stained a f ew yea rs ea rlier . A t t h at t im e, sh e h ad g o ne to see a
neu ro su rg eo n, wh o t o ld h er t o r es t a nd t a k e no nst eroid al a nt i-inf la m mato ry d ru gs. S h e
descr ibed f eel ing “a band oned a nd no t ca red a b ou t” by h im . T he pa in had d im inish ed h er
ab il it y t o ex ercise, a nd sh e wa s upset t h at sh e had g ained weig ht. W hile rel ating t h e ev ent s
surro u nd ing t h e fa ll, M s. F uent es beg an to cr y.
W hen ask ed a b ou t h er su icid al co mment s, sh e sa id t h ey wer e “no b ig d ea l.” Sh e repo rted
th at t h ey wer e “just a t h rea t” aim ed a t h er h usb and t o “t ea ch h im a l esso n” beca use “he has
no co mpa ssio n fo r m e” and h ad n ot b een suppo rtiv e since th e fa ll . S h e insist ed h er
co mment s ab ou t o ver dosing d id n ot h ave oth er m ea ning . W hen her E R int erviewer
ex pressed co ncer n ab ou t t h e po ssib ilit y t h at sh e wo uld k il l h er sel f, sh e ex claim ed wit h a
sm ile, “O h wo w, I d id n’t r ea liz e it’s so ser ious. I g u ess I sh ou ld n’ t d o t h at a g ain. ” Sh e th en
sh ru gged a nd l a u gh ed . S h e went o n to t a lk a b ou t h ow “nice and sweet ” it wa s th at so m any
d oct ors and so cia l wo rk er s wa nted t o h ea r h er st ory , ca lling m any o f t h em b y t h eir f ir st
na mes. S h e wa s also so mewh at f li r ta tio us wit h h er m ale resid ent in ter viewer , wh o h ad
m ent ioned t h at sh e wa s th e “b est -d ressed wo man in th e ER .”
A cco rd ing t o h er o u tpa tient psy chiatr ist o f 3 yea rs, sh e had nev er b ef ore ex pressed su icid al
id ea tio n unt il t h is week , a nd h e wo uld b e una ble to ch eck in on her u nt il a ft er h e lef t o n
va ca tio n th e nex t d ay. M s. F uent es’ s husb and r epo rted t h at sh e ta lk ed a b ou t su icid e “lik e 8/14/2019 Psychiatry Online | DSM Library
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oth er peo ple co mplain ab ou t t h e wea th er . S h e’ s ju st t r y ing t o g et m e wo rried , b u t it d oesn’ t
work a ny more. ” H e sa id h e wo uld nev er h ave su ggest ed sh e go t o t h e ER a nd t h ou gh t t h e
psy chiatr ist h ad o ver rea cted .
Ms. F uent es init ially so ugh t o u tpa tient psy choth er apy a t a g e 47 b eca use she wa s feel ing
depr essed a nd u nsu ppo rted b y h er h usb and . D uring 3 yea rs of o u tpa tient t r ea tm ent , M s.
Fuent es had b een prescr ibed a d eq uate tr ia ls of ser tr a line, escit alo pr am , f lu oxet ine, a nd
pa ro xet ine. N one seem ed t o h el p.
M s. F uent es descr ibed b eing “a n ea rly b lo om er .” Sh e beca me sex ually a ct ive wit h o ld er
m en wh en she wa s in hig h sch ool. S h e sa id d ating h ad b een th e m ost f u n th ing sh e had ev er
done and t h at sh e m issed seeing m en “jum p th ro u gh h oops” to sl eep with h er . S h e liv ed
wit h h er 7 3- yea r-o ld h usb and . H er 2 5-y ea r-o ld so n liv ed nea rb y wit h h is wif e and y o u ng
so n. S h e descr ibed h er h usb and a s a “v ery f a m ou s” musicia n. S h e sa id t h at h e had nev er
hel ped a ro u nd t h e hou se or wit h ch ild-r ea ring a nd d id no t a ppr ecia te how much wo rk sh e
pu t int o t a k ing ca re of t h eir so n and g ra nd son.
Dia g n osis
H ist rio nic persona lit y d iso rd er
D is c u ssio n
M s. F uent es present s to t h e ER wit h d epr essio n and su icid alit y, b u t neit her o f t h ese
sy mpt om s is as pr om inent a s her o ng oing pa tter n of ex cessiv e em otio na lit y a nd a ttent ion
seek ing. H er b eh avio r wit h t h e ER st aff a nd per haps th e fa ll it sel f a ppea r t o ser ve a need f o r
attent ion and ca re, a nd b oth M s. F uent es and h er h usb and d escr ibe her ch ro nic suicid al
th rea ts as ef fo rts to pu nish a nd el icit co ncer n. F or ex am ple, t h e ER v isit wa s pr ecipit ated b y
M s. F uent es mak ing h er f ir st su icid al t h rea t in tr ea tm ent j u st a s her d oct or wa s go ing o n
va ca tio n, su ggest ing t h at sh e m ight h ave fel t l ef t o u t a nd a b and oned .
Ms. F uent es’s em otio ns shift r a pid ly b et ween tea rfu l a nd ch eer fu l, b u t sh e co nsist ently
d ism isses th e act ual t h rea t o f su icid e. I nst ead, M s. F uent es fo cu ses on her d ra m atic fa ll,
a nd o n her per cept ion th at neit her h er h usb and no r h er neu ro su rg eo n appea rs to b e
int erest ed in her su ffer ing . T hro u gh ou t h er E R v isit , sh e wa s sed uct ive wit h h er int erviewer
a nd u nu sually f r iend ly wit h st aff, ca ll ing m any o f t h em b y t h eir f ir st na mes. E ven in a b u sy
E R , f il led wit h sick , inj ured , a nd p resu mab ly u nk em pt peo ple, M s. F uent es maint ains her 8/14/2019 Psychiatry Online | DSM Library
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concer n ab ou t h er ph ysica l a ppea ra nce. S h e im plies th at h er d ress, g ro om ing , a nd weig ht
are cent ra lly im porta nt t o h er sen se of sel f- est eem , a nd t h at sh e co ntinu es to pa y cl ose
attent ion to t h eir m aint ena nce.
These ob ser va tio ns suggest t h at h er su icid alit y is no t pa rt o f a m ajo r a ffect ive diso rd er .
Inst ead, sh e has at l ea st six o f t h e eig ht sy mpt om atic criter ia f o r a D SM -5 d ia gno sis of
h ist rio nic persona lit y d iso rd er ( H PD ): d isco mfo rt wh en not t h e cen ter o f a ttent ion;
sed uct ive beh avio r; int ense bu t sh ifting a nd sh allo w em otio na lit y; th e use of ph ysica l
appea ra nce to d ra w attent ion; sel f- d ra m atiz atio n and t h ea tr ica lit y; and a t end ency t o
co nsid er r el atio nsh ips to b e m ore int imate th an th ey a re. W hile M s. F uent es does not sh ow
cl ea r ev idence of o th er cr iter ia f o r H PD , su ch a s im pressio nistic sp eech a nd su ggest ibilit y,
th ese may h ave sim ply no t b een incl uded in th e ca se repo rt.
B eca use patient s wit h H PD o ft en have co morb id so matic sympt om d iso rd er s, ca ref ul
attent ion sh ou ld b e giv en to ev alu ating t h e pa tient f o r t h ese diso rd er s. M s. F uent es has
b een episo dica lly pr eo ccu pied wit h ph ysica l d isco mfo rt, a nd f u rth er ev alu atio n m ight
dem onst ra te a m ore per va siv e an d im pairing pa tter n of ph ysica l co mplaint s or co ncer ns.
Patient s wit h H PD a lso h ave el ev ated r a tes of m ajo r d epr essiv e diso rd er . I nd eed , M s.
Fuent es shows many sig ns of d ep ressed m ood . F urth er more, M s. F uent es wa s ref er red t o
t h e ER b eca use of su icid alit y. A lt h ou gh sh e and h er h usb and m inim ize th e ser iousness of
th ese th rea ts, H PD d oes appea r t o b e asso ciated wit h a n elev ated r isk o f su icid e attem pts.
M any o f t h ese attem pts wil l b e su blet hal, b u t a v a riet y o f su icid al “g est ures” can lea d t o
ser ious harm a nd ev en sem i-accid ental d ea th . Cl inica l wo rk wit h M s. F uent es wil l inv olv e
b ala ncing t h e reco gnit ion th at h er su icid al id ea tio n ser ves th e need f o r a ttent ion wit h
awa reness th at it m ay a lso l ea d t o a ct ual sel f- h arm .
As in all psy chiatr ic assessm ents, cl inicia ns must co nsid er wh ether t h e per sona lit y issu es
are a pr ob lem b ef ore m ak ing a d ia gno sis. N orm s fo r em otio na l ex pressiv eness,
interper sona l b eh avio r, a nd st yle of d ress va ry sig nifica ntly b et ween cult u res, g end ers, a nd
a g e gro u ps, a nd it is im porta nt no t t o g ra tu it ou sl y pa th olo giz e va ria tio ns th at a re no t
acco mpa nied b y d ysf unct ion and d ist ress. A s an ex am ple of po tent ial b ia s, wo men are m ore
fr eq uent ly d ia gno sed wit h H PD d espit e po pu la tio n studies th at ind icate th at H PD is
eq ually co mmon in men and wo men.
HPD is oft en comorb id wit h o th er per sona lit y d iso rd er s. A lt h ou gh M s. F uent es has tr a it s
th at a re co mmon to o th er per sona lit y d iso rd er s, sh e does not a ppea r t o h ave a seco nd 8/14/2019 Psychiatry Online | DSM Library
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dia gno sis. F or ex am ple, M s. F uent es’s su icid al t h rea ts and d ra m atic present atio n m ight
lea d t h e ex am iner t o co nsid er b ord er line persona lit y d iso rd er . M s. F uent es does not,
h owev er, sh ow th e m ark ed inst ab il it y in int erper sona l r el atio nsh ips, ex tr em e sel f-
d est ru ct iveness, a ng ry d isr upt ions in int erper sona l r el atio nsh ips, a nd ch ro nic feel ing s of
em ptiness th at a re co mmon in bord er line persona lit y d iso rd er . W hile M s. F uent es
complains of no t r eceiv ing t h e ca re th at sh e wo uld l ik e, sh e does not m anif est t h e fea r o f
sepa ra tio n and t h e so rt o f su bm issiv e and cl ing y b eh avio r t h at a re ty pica l o f d epend ent
persona lit y d iso rd er . S im ilarly , a lt h ou gh sh e appea rs to h ave an ex cessiv e need f o r
ad m iratio n, sh e has no t d em onst ra ted t h e la ck o f em path y t h at is a ca rd ina l f ea tu re of
na rcissist ic per sona lit y d iso rd er . F ina lly , wh ile sh e dem onst ra tes so m e m anipu la tiv e
beh avio r, a s do peo ple wit h a nt iso cial per sona lit y d iso rd er , h er s is motiv ated b y a d esir e fo r
attent ion ra th er t h an so me so rt o f pr ofit .
S u ggeste d R ead in gs
Ga bbard GO : Cl ust er B per sona lit y d iso rd er s: hyst er ica l a nd h ist rio nic , in P sy ch od yna mic
Psy ch iatr y in Clinica l P ra ct ice , 4 th E dit io n . W ash ing to n, D C , A m er ica n Psy ch iatr ic
P ublish ing , 2 0 05 , pp 5 4 1 – 570
H ales R E , Yu dofsk y SC , R ob er ts L W ( ed s): The Am er ica n Psy ch iatr ic Publish ing T ex tb ook
of P sy ch iatr y , 6 th E dit io n . W ash ing to n, D C , A m er ica n Psy ch iatr ic Publish ing , 2 0 14
M acK inno n RA , M ich els R , B uck ley P J : T he hist rio nic patient , in T he Psy ch iatr ic
Int erview in Clinica l P ra ct ice , 2 nd E dit io n . W ash ing to n, D C , A m er ica n Psy ch iatr ic
P ublish ing , 2 0 06 , pp 137 – 17 6
Case 1 8.7 D is sa tis fa ctio n
R ob ert M ic h els, M .D .
Larry Go ra no v wa s a 5 7-y ea r-o ld sing le unem ployed wh ite m an wh o wa s ask ing f o r a
r ev iew of h is tr ea tm ent a t t h e psy chiatr ic clinic. H e had b een in we ekly psy choth er apy f o r 7
y ea rs wit h a d ia gno sis of d yst hym ic diso rd er . H e co mplained t h at t h e tr ea tm ent h ad b een
of l it tle hel p and h e wa nted t o m ak e su re th at t h e doct ors wer e on th e rig ht t r a ck .
Mr. Go ra no v r epo rted a l o ng -st and ing h ist ory o f l o w- gra d e depr essed m ood a nd d ecr eased
ener gy. H e had t o “d ra g ” him sel f o u t o f b ed ev ery m orning a nd r a rel y l o oked f o rwa rd t o 8/14/2019 Psychiatry Online | DSM Library
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any th ing . H e had l o st h is la st j o b 3 yea rs ea rlier , h ad b ro ken up wit h a g ir lf r iend sl ig htly
la ter , a nd d ou bted t h at h e wo uld ev er wo rk o r d ate ag ain. H e wa s em barra ssed t h at h e st ill
liv ed wit h h is moth er , wh o wa s in her 8 0 s. H e denied a ny im med iate int ent ion or pl an to
k il l h im sel f, b u t if h e did no t im prove by t h e tim e his moth er d ied , h e did no t see what h e
wo uld h ave to l iv e fo r. H e denied d ist urb ances in sleep, a ppet ite, o r co ncent ra tio n.
Cl inic reco rd s ind icated t h at M r. Go ra no v h ad b een ad h er ent t o a d eq uate tr ia ls of
flu oxet ine, escit alo pr am , ser tr a lin e, d u lo xet ine, v enl afa x ine, a nd b u pr opio n, a s wel l a s
au gm ent atio n wit h q u et iapine, a ripipr azo le, l it hiu m , a nd l ev oth yro xine. H e had so me
im provem ent in his mood wh ile ta k ing escit alo pr am b u t d id no t h ave rem issio n of
sy mpt om s. H e also h ad a co urse of co gnit ive- beh avio ra l t h er apy ea rly in his tr ea tm ent ; h e
h ad b een dism issiv e of t h e th er ap ist a nd t r ea tm ent , d id no t d o h is assig ned h om ewo rk , a nd
a ppea red t o m ak e no ef fo rt t o u se th e th er apy b et ween sessio ns. H e had nev er t r ied
psy chod yna mic psy choth er apy .
Mr. Go ra no v ex pressed f r u st ra tio n at h is la ck o f im provem ent , t h e na tu re of h is tr ea tm ent ,
and h is specif ic th er apy . H e fo u nd it “h um ilia ting ” th at h e wa s fo rced t o see tr a inees who
ro ta ted o ff h is case every y ea r o r t wo . H e fr eq uent ly f o u nd t h at t h e psy chiatr y r esid ents
wer e no t especia lly ed uca ted , cu lt u red , o r so ph istica ted , a nd f el t t h ey k new less ab ou t
psy choth er apy t h an he did . H e m uch pr efer red t o wo rk wit h f em ale th er apist s, b eca use
m en wer e “t oo co mpet itiv e and en vio us. ”
M r. Go ra no v pr eviousl y wo rk ed a s an insu ra nce bro ker . H e ex plain ed , “I t’s rid icu lo u s. I
wa s th e best b ro ker t h ey h ad ev er seen, b u t t h ey wo n’t r eh ire m e. I t h ink t h e pr ob lem is
t h at t h e pr ofessio n is fil led wit h b ig eg os, a nd I ca n’t k eep my m ou th sh ut a b ou t it .” A ft er
b eing “b la ck balled ” by insu ra nce ag encies, M r. Go ra no v d id no t wo rk f o r 5 y ea rs, u nt il h e
wa s hir ed b y a n au to m ob il e dea ler . H e sa id t h at a lt h ou gh it wa s benea th h im t o sel l ca rs, h e
wa s su ccessf ul, a nd “in no t im e, I wa s ru nning t h e pl ace. ” H e qu it w ithin a f ew mont hs aft er
a n arg u m ent wit h t h e owner . D espit e enco ura g em ent f r o m sev eral t h er apist s, M r. Go ra no v
had no t a ppl ied f o r a j o b o r pu rsu ed em ploym ent r eh ab il it atio n or v o lu nt eer wo rk ; h e
st ro ng ly v iewed t h ese opt ions as benea th h im .
Mr. Go ra no v h as “g iven up on wo men. ” H e had m any pa rtner s as a y o u ng er m an, b u t h e
gener ally f o u nd t h em t o b e una ppr ecia tiv e and “o nly in it f o r t h e fr ee mea ls. ” The
psy chiatr ic resid ent no tes ind icated t h at h e respo nded t o d em onst ra tio ns of int erest wit h
suspicio n. T his tend ency h el d t r u e in reg ard t o b oth wo men wh o h ad t r ied t o b ef riend h im 8/14/2019 Psychiatry Online | DSM Library
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and r esid ents wh o h ad t a k en an in ter est in his care. M r. Go ra no v d escr ibed h im sel f a s
so meo ne wh o h ad a l o t o f l o ve to g iv e, b u t sa id t h at t h e wo rld wa s fu ll o f m anipu la to rs. H e
sa id h e had a f ew bu ddies, b u t h is m oth er wa s th e onl y o ne he tr u ly ca red a b ou t. H e
enj oyed f ine rest au ra nt s and “f iv e-st ar h otel s,” bu t h e ad d ed t h at h e co uld no l o ng er a ffo rd
th em . H e ex ercised d ail y a nd wa s co ncer ned a b ou t m aint aining h is b od y. M ost o f h is tim e
wa s spent a t h om e wa tch ing t el ev isio n or r ea ding no vel s and b io gra ph ies.
On ex am ina tio n, t h e pa tient wa s nea tly g ro om ed , h ad sl ick ed-b ack h air , a nd wo re cl oth ing
th at a ppea red t o b e by a h ip- hop desig ner g ener all y f a vo red b y m en in th eir 2 0 s. H e wa s
coher ent , g o al d ir ect ed, a nd g ener all y co oper ativ e. H e sa id h e wa s sa d a nd a ng ry . H is affect
wa s co nst rict ed a nd d ism issiv e. H e denied a n int ent ion to k il l h im sel f b u t f el t h opel ess and
th ou gh t o f d ea th f a ir ly o ft en. H e wa s co gnit ively int act .
D ia g n osis
N arcissist ic per sona lit y d iso rd er
D is c u ssio n
W hen a pa tient pr esent s to a psy chiatr ist , sy mpt om s are gener all y t h ose aspect s of
psy chopa th olo gy t h at a re ea siest t o r eco gniz e and t o d ia gno se. A nx iet y, d epr essio n,
ob sessio ns, a nd ph ob ia s are seen similarly b y pa tient a nd d oct or a nd a re cent ra l d ef ining
ch ara ct er ist ics of m any d iso rd er s. P atient s wit h per sona lit y d iso rd er s are dif fer ent . T heir
pr ob lem s are oft en more dist ressi ng t o o th er s th an to t h e pa tient , a nd t h eir sy mpt om s are
o ft en va g u e and m ay seem seco ndary t o t h eir cent ra l issu e. W hat d et er mines th e dia gno sis
or d ef ines th e fo cu s of t r ea tm ent is no t t h e anx iet y o r d epr essio n, f o r ex am ple, b u t r a th er
wh o t h e pa tient is, t h e lif e he or sh e has ch osen to l ea d, a nd t h e pa tter n of h is or h er h um an
rel atio nsh ips.
A co ro lla ry is th at t h e pa tient ’s co mplaint s m ay b e less rev ea ling t h an th e wa y in wh ich t h ey
are m ad e. T he co nsu lt a tio n int erview with m ost pa tient s co nsist s of co llect ing inf orm atio n
and m ak ing o b ser va tio ns. T he co nsu lt a tio n wit h m ost pa tient s wh o h ave per sona lit y
diso rd er s req uir es th e cr ea tio n of a r el atio nsh ip, a nd t h en th e doct or’s ex per iencing a nd
u nd erstand ing o f t h at r el atio nsh ip. Co unt ertr a nsf erence respo nses can be im porta nt
d ia gno stic to ols, a nd t h e wa y in which t h e pa tient r el ates to t h e cl inicia n ref lect s th e
tem plate th at st ru ct ures how th e pa tient r el ates to o th er s. F or ex am ple, M r. Go ra no v’s
pr im ary co mplaint is his sad m ood . A lt h ou gh h e co uld h ave a d epr essiv e diso rd er , h e seem s 8/14/2019 Psychiatry Online | DSM Library
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to l a ck m ost o f t h e per tinent D SM -5 cr iter ia f o r a ny o f t h e depr essiv e diso rd er s. I nst ead, h is
lo w mood a ppea rs to b e a r espo nse to ch ro nic disa ppo intment . D espit e his view of h im sel f
as ta lent ed a nd a ttr a ct ive, h e is unem ployed , u nd erappr ecia ted , a nd a lo ne. E m pt y
dem ora liz atio n is a co mmon acco mpa nim ent t o per sona lit y d iso rd er a nd , a s wit h M r.
Go ra no v, is oft en unr espo nsive to ph arm aco th er apy .
Furth er , a ty pica l f o r m ost pa tient s wit h ser ious depr essio n, h e is co ncer ned a b ou t
m aint aining h is appea ra nce and h is attr a ct iveness to o th er s. H is gro om ing , cl oth es, a nd
m anner r ef lect h is und erly ing g ra nd iosit y, h is co nv ict ion th at h e is specia l a nd d eser ving o f
th e appr ecia tio n th at h e has fa il ed t o r eceiv e.
This story a b ou t M r. Go ra no v r ef lect s a t y pica l m ild t o m od er ate na rcissist ic per sona lit y
diso rd er . Cl assic fea tu res incl ude gra nd iosit y, a co nv ict ion th at h e deser ves specia l
tr ea tm ent , est ra ng em ent f r o m o th er s, a st rik ing ly d im inish ed ca pa cit y f o r em path y, a nd a n
attit ude of a rro gant d isd ain. T he depr essed a ff ect is clea rly pr esent , b u t it is seco ndary t o
h is fu nd am ent al per sona lit y psy ch opa th olo gy.
T hese patient s are dif ficu lt t o t r ea t. T hey see th eir pr ob lem a s th e fa il ure of t h e wo rld t o
r eco gniz e th eir t r u e va lu e, a nd t h ey o ft en slid e int o d epr essed , l o nel y so cia l wit hdra wa l a s
lif e pr ogresses. A t h er apeu tic allia nce req uir es mak ing co ntact wit h t h em a ro u nd t h eir
pa in, l o nel iness, a nd iso la tio n, a nd wo rk ing t o enh ance th eir pl ea su re ra th er t h an to
r eno unce th eir cl aim s on oth er s.
M r. Go ra no v is a pa tient . H e is no t j u st so meo ne wit h a so cia l a nd per sona l id ent ity wh o
happens to b e a pa tient ; b eing a p atient h as beco me cent ra l t o wh o h e is. F urth er more, h e
is a d issa tisf ied pa tient , a nd h is psy chiatr ist d oes not pr ovid e him w ith wh at h e wa nts or
feel s ent itled t o g et . I n fa ct , a s his st ory u nf old s, it is clea r t h at t h is is a f a m ilia r pr ob lem f o r
M r. Go ra no v. H e is dissa tisf ied w ith h is fr iend s, h is jo b s, a nd h is signif ica nt o th er s. L ik e his
th er apist s, t h ey h ave no t b een go od eno ugh , h ave fa il ed t o r eco gniz e his va lu e, a nd h ave
fa il ed h im .
Su ggeste d R ead in gs
Akh ta r S: T he sh y na rcissist , in Ch ang ing I d ea s in a Ch ang ing W orld : T he Rev olu tio n in
Psy ch oana ly sis. E ssa ys in Hono ur o f A rno ld Co oper . E dit ed b y S and ler J, M ich els R ,
Fona gy P . L ond on, K arna c , 2 0 00 , pp 111 – 119 8/14/2019 Psychiatry Online | DSM Library
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Cooper A M : Furth er d ev elopm ents of t h e dia gno sis of na rcissist ic per sona lit y d iso rd er , in
D iso rd er s of N arcissism : D ia gno stic, Cl inica l, a nd E m pir ical I m plica tio ns . E dit ed b y
R onning stam E F . W ash ing to n, D C , A m er ica n Psy ch iatr ic Press , 19 98 , pp 5 3 – 74
R onning stam E F ( ed ): D iso rd er s of N arcissism : D ia gno stic, Cl inica l, a nd E m pir ical
Im plica tio ns . W ash ing to n, D C , A m er ica n Psy ch iatr ic Press , 19 98
R onning stam E F , W einb erg I: Narcissist ic per sona lit y d iso rd er : pr ogress in reco gnit ion
and t r ea tm ent . F ocu s 11 (2): 16 7 – 177 , 2 0 13
C ase 1 8.8 S h yn ess
J . Ch rist op h er P erry , M .P .H. , M .D .
M ath ilda H er ber t wa s a 2 3- yea r-o ld wo man ref er red f o r psy chiatr ic co nsu lt a tio n to h el p
her “b rea k o u t o f h er sh ell.” Sh e had r ecent ly m oved t o a new city t o t a k e cl asses to b eco me
an ind ust ria l l a b t ech nicia n and h ad m oved in wit h a n old er co usin, wh o wa s also a
psy choth er apist a nd t h ou gh t sh e sh ou ld “g et o u t a nd enj oy h er y o u th .”
A lt h ou gh sh e had pr eviousl y b een pr escr ibed m ed ica tio ns fo r a nx iet y, M s. H er ber t sa id
th at h er r ea l pr ob lem wa s “sh ynes s.” Sch ool wa s dif ficu lt b eca use everyo ne was co nst ant ly
“cr iticiz ing.” Sh e avo id ed b eing ca ll ed o n in class beca use she knew she wo uld “sa y
something st upid ” and b lu sh a nd ev eryo ne would m ak e fu n of h er . S h e avo id ed spea king
u p or t a lk ing o n tel eph ones, wo rried a b ou t h ow sh e wo uld so und . S h e drea ded pu blic
spea king .
Sh e wa s sim ilarly r et icent wit h f r iend s. S h e sa id sh e had a lwa ys been a peo ple pl ea ser wh o
prefer red t o h id e her f eel ing s wit h a ch eer fu l, co mpliant , a ttent ive dem eano r. S h e had a f ew
fr iend s, wh om sh e descr ibed a s “wa rm a nd l if el ong .” Sh e fel t l o nel y a ft er h er r ecent m ove
a nd h ad no t y et m et a ny one fr o m sch ool o r t h e lo ca l co mmunit y.
S h e sa id sh e had b ro ken up wit h h er f ir st ser ious boyfr iend 2 y ea rs ea rlier . H e had init ially
b een “kind a nd pa tient ” and , t h ro u gh h im , sh e had a so cia l l if e by pr oxy. S oon aft er sh e
moved in wit h h im , h owev er, h e tu rned o u t t o b e an “a ng ry a lco holic. ” Sh e had no t d ated
since th at ex per ience. 8/14/2019 Psychiatry Online | DSM Library
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Ms. H er ber t g rew up in a m etro po lit an area wit h h er pa rent s and t h ree old er sib ling s. H er
bro th er wa s “h yper act ive and a nt iso cial” and t o ok u p ev eryo ne’ s attent ion, wh erea s her
sist ers wer e “h yper compet itiv e an d per fect .” H er m oth er wa s anx iousl y co mpliant , “l ik e
m e.” M s. H er ber t’s fa th er wa s a v er y su ccessf ul inv estment m ana ger wh o o ft en point ed o u t
wa ys in wh ich h is ch ildren did no t l iv e up to h is ex pect atio ns. H e co uld b e su ppo rtiv e bu t
tend ed t o d isr egard em otio na l u n cer ta int y in fa vo r o f a “t ou gh o pt im ism .” Tea sing a nd
co mpet itio n “sa tu ra ted ” th e hou seh old , a nd “it d id n’t h el p th at I wa s fo rced t o g o t o t h e
sa me gir ls’ sch ool wh ere m y sist ers had b een stars and wh ere ev eryo ne was rich a nd ca tty .”
S h e dev eloped a k een sensit ivity t o cr iticism a nd f a il ure.
H er pa rent s div orced d u ring h er s enio r y ea r o f h ig h sch ool. H er f a th er m arried a no th er
wo man so on th er ea ft er . A lt h ou gh sh e had pl anned t o a ttend t h e sa me el ite univ ersit y a s
h er t wo sist ers, sh e ch ose to a ttend a l o ca l co mmunit y co lleg e at t h e la st m inu te. S h e
ex plained t h at it wa s go od t o b e awa y f r o m a ll t h e co mpet itio n, a nd h er m oth er need ed t h e
su ppo rt.
M s. H er ber t’s st reng th s incl uded ex cel lent wo rk in her m ajo r, ch em istry , especia lly a ft er
o ne senio r pr ofesso r t o ok a specia l int erest . F am ily ca mping t r ips had l ed t o a m ast er y o f
ou td oor sk ills, a nd sh e fo u nd t h at sh e enj oyed b eing o u t in th e wo od s, f lex ing h er
ind epend ence. S h e also enj oyed b ab ysit ting a nd v o lu nt eer ing in an im al sh elter s, b eca use
kid s and a nim als “a ppr ecia te ev eryth ing y o u d o a nd a ren’ t m ea n.”
During t h e ev alu atio n, M s. H er ber t wa s a wel l- d ressed y o u ng wo man of sh ort st atu re wh o
was attent ive, co her ent , a nd g o al d ir ect ed. S h e sm iled a l o t, especia lly wh en ta lk ing a b ou t
th ing s th at wo uld h ave m ad e m ost peo ple ang ry . W hen th e psy chiatr ist o ffer ed a t r ia l
co mment , l ink ing M s. H er ber t’s cu rrent a nx iet y t o ex per iences with h er f a th er , t h e pa tient
a ppea red q u iet ly u pset . A ft er sev era l su ch inst ances, t h e psy chiatr ist wo rried t h at a ny
int erpr etive co mment s m ight b e ta k en as cr iticism a nd h ad t o ch eck a t end ency t o a vo id
sensit ive su bject s. E xpl icit ly d iscu ssing h is co ncer ns led b oth t h e patient a nd psy chiatr ist t o
r el ax a nd a llo wed t h e co nv ersa tio n to co ntinu e m ore pr od u ct ively.
D ia g n ose s
A vo id ant per sona lit y d iso rd er
Socia l a nx iet y d iso rd er 8/14/2019 Psychiatry Online | DSM Library
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Dis c u ssio n
M s. H er ber t’s sh yness extend s int o a per sist ent so cia l a vo id ance th at r ed uces her a b il it y t o
enj oy h er sel f. S h e und erper fo rm s a t sch ool, a nd sh e seem s to h ave ch osen her co lleg e (a
lo ca l co mmunit y co lleg e) a nd ca re er ( la b t ech nicia n) l a rg el y t o r ed uce per ceiv ed r isk a nd t o
a vo id a nx iet y. S h e feel s lo nel y b u t is una ble to m ak e co nnect ions wit h f r iend s. S h e is
st ym ied in her ef fo rts to d ate m en . S h e appea rs to h ave two D SM -5 d ia gno ses th at a re so
oft en comorb id t h at t h ey m ay b e dif fer ing co ncept ualiz atio ns of sim ilar co nd itio ns:
avo id ant per sona lit y d iso rd er ( A vP D ) a nd so cia l a nx iet y d iso rd er ( so cia l ph ob ia ).
A vP D r ef lect s a per sist ent pa tter n of so cia l inh ibitio n, f eel ing s of ina deq uacy , a nd
h yper sensit ivity t o neg ativ e ev alu atio n. I t a lso r eq uir es fo u r o r m ore of sev en criter ia,
wh ich M s. H er ber t ea sil y m eet s. S h e avo id s occu patio na l a ct ivities th at inv olv e sig nifica nt
interper sona l co ntact . F or m ost o f h er l if e, sh e has been rel uct ant t o spea k u p, f ea ring t o
d ra w criticism o r r id icu le, ev en fr o m f a m ily m em ber s. S h e avo id s being t h e cent er o f
attent ion, is sel f- d ou bting , a nd b lu sh es easil y. S h e avo id s new situatio ns. S h e is unwil ling
t o g et inv olv ed wit h peo ple unl ess she is cer ta in th at sh e wil l b e lik ed . T hese have had a
d eb ilit ating ef fect o n all a spect s of h er l if e.
Lik e m ost peo ple wit h A vP D , M s. H er ber t a lso q u alif ies fo r D SM -5 so cia l a nx iet y d iso rd er
(so cia l ph ob ia ). S h e dem onst ra tes fea r o f so cia l scr utiny a nd o f b ei ng neg ativ ely ev alu ated .
Socia l sit uatio ns are end ured , b u t b arel y, a nd h er a nx iet y is alm ost a lwa ys pr esent . S h e
appea rs sh y, sel ect s wo rk wh ere th er e wil l b e lim ited so cia l int eract io n, a nd pr efer s to l iv e
wit h f a m ily m em ber s.
M s. H er ber t d escr ibes having t h ese sympt om s fr o m a y o u ng a g e. A lt h ou gh sh yness is
commonl y r epo rted in ind ivid uals wit h A vP D a nd so cia l a nx iet y d iso rd er , m ost sh y
ch ildren do no t g o o n to r epo rt t h e so rts of issu es prevalent in peo ple wit h t h ese diso rd er s:
dim inish ed sch ool per fo rm ance, em ploym ent , pr od u ct ivity, so cio eco no mic statu s, q u alit y
of l if e, a nd o ver all wel l- b eing .
During t h e int erview, t h e psy chiatr ist sensed M s. H er ber t’s dist res s and f el t
unch ara ct er ist ica lly r est rict ed in what h e co uld a sk . I n oth er wo rd s, h e beca me awa re of a
co unt ertr a nsf erence rea ctio n in wh ich h e fea red h urting h er f eel ing s. A ft er h e sh ared h is
own concer ns th at sh e wo uld f eel cr iticiz ed b y h is co mment s, b oth t h e psy chiatr ist a nd t h e
pa tient wer e ab le to m ore co mfo rta b ly ex plore her h ist ory a nd d eepen th e th er apeu tic 8/14/2019 Psychiatry Online | DSM Library
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allia nce. A st ro ng a llia nce hel ps mitig ate dist ress and sh am e and incr eases th e lik elih ood o f
a m ore th oro u gh ex plora tio n fo r co mmon co morb id ities as wel l a s a sm ooth er t r a nsit ion
int o t r ea tm ent .
Su ggeste d R ead in gs
Per ry JC : Cl ust er C per sona lit y d iso rd er s : avo id ant , o b sessiv e-co mpu lsiv e, a nd
d epend ent , in Ga bbard ’s Trea tm ent s of P sy ch iatr ic Diso rd er s , 5 th E dit io n . E dit ed b y
Ga bbard GO . W ash ing to n, D C , A m er ica n Psy ch iatr ic Publish ing ( in press )
Sanisl ow CA , B arto lini E E , Z olo th E C : A vo id ant per sona lit y d iso rd er , in E ncy cloped ia o f
H um an Beh avio r , 2 nd E dit io n . E dit ed b y R am ach and ra n VS . S an Dieg o, CA , A ca dem ic
Press , 2 0 12 , pp 2 57 – 2 6 6
C ase 1 8.9 L ack o f S elf – C on den ce
R ay mo nd R aad , M .D ., M .P .H.
P au l S. A ppelb au m, M.D .
Nate Ir v in wa s a 31- yea r-o ld wh ite m an wh o so ugh t o u tpa tient psy chiatr ic ser vices fo r “l ack
o f sel f- co nfidence. ” H e repo rted l if el ong t r o u bles wit h a sser tiv enes s and wa s specif ically
u pset b y h aving b een “stuck ” fo r 2 y ea rs at h is cu rrent “d ea d-end ” jo b a s an ad m inist ra tiv e
assist ant . H e wish ed so meo ne would t el l h im wh ere to g o nex t so t h at h e wo uld no t h ave to
fa ce th e “b urd en” of d ecisio n. A t w ork , h e fo u nd it ea sy t o f o llo w his boss’ s dir ect ions bu t
h ad d if ficu lt y m ak ing ev en mino r ind epend ent d ecisio ns. T he sit uatio n wa s “d epr essing ,”
h e sa id, b u t no th ing new.
M r. I r v in also r epo rted d issa tisf actio n wit h h is rel atio nsh ips with w om en. H e descr ibed a
ser ies of sev eral- m ont h-lo ng r el atio nsh ips over t h e pr ior 10 y ea rs th at end ed d espit e his
doing “ev eryth ing I co uld .” H is most r ecent r el atio nsh ip had b een with a n oper a sing er. H e
repo rted h aving g o ne to sev eral o per as and t a k en sing ing cl asses to im press her , ev en
th ou gh h e did no t pa rticu la rly enj oy m usic. T hat r el atio nsh ip had r ecent ly end ed f o r
u ncl ear r ea sons. H e sa id h is mood a nd sel f- co nfidence were tied t o h is dating . B eing sing le
m ad e him f eel d esper ate, b u t d esper atio n m ad e it ev en hard er t o g et a g ir lf r iend . H e sa id h e
fel t t r a pped b y t h at spir al. S ince th e la test b rea ku p, h e had b een qu it e sa d, wit h f r eq uent
cr ying spel ls. I t wa s th is depr essio n th at h ad pr om pt ed h im t o seek t r ea tm ent . H e denied 8/14/2019 Psychiatry Online | DSM Library
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all o th er sy mpt om s of d epr essio n, incl uding pr ob lem s wit h sl eep, a ppet ite, ener gy,
su icid alit y, a nd a b il it y t o enj oy t h ing s.
Mr. I r v in init ially d enied t a k ing a ny m ed ica tio ns, b u t h e ev ent uall y r ev ea led t h at 1 yea r
earlier h is pr im ary ca re ph ysicia n h ad b eg un to pr escr ibe alpr azo la m 0 .5 m g/d ay f o r
“a nx iet y.” H is dose had esca la ted , a nd a t t h e tim e of t h e ev alu atio n, M r. I r v in wa s ta k ing 5
m g/d ay a nd g et ting pr escr iptions fr o m t h ree dif fer ent ph ysicia ns. Cu tting b ack l ed t o
a nx iet y a nd “t he sh ak es. ”
Mr. I r v in denied a ny pr ior per sona l o r f a m ily psy chiatr ic hist ory , in cluding o u tpa tient
psy chiatr ic appo intment s.
Aft er h ea ring t h is hist ory , t h e psy chiatr ist wa s co ncer ned a b ou t M r. I r v in’ s esca la ting
a lpr azo la m u se and h is ch ro nic dif ficu lt ies with ind epend ence. S h e th ou gh t t h e m ost
accu ra te dia gno sis was benz od ia zepine use diso rd er co morb id wit h a per sona lit y d iso rd er .
Howev er, sh e wa s co ncer ned a b ou t t h e neg ativ e unint ended ef fect s t h at t h ese dia gno ses
might h ave on th e pa tient , incl uding h is em ploym ent a nd insu ra nc e co ver ag e, a s wel l a s
h ow he wo uld b e dea lt wit h b y f u tu re cl inicia ns. S h e ty ped int o t h e el ect ro nic med ica l
reco rd a d ia gno sis of “a dju st m ent d iso rd er wit h d epr essed m ood .” T wo week s la ter , M r.
Ir v in’ s insu ra nce compa ny a sk ed h er h is dia gno sis, a nd sh e gave th e sa me dia gno sis.
Dia g n ose s
D epend ent per sona lit y d iso rd er
B enz od ia zepine use diso rd er
D is c u ssio n
M r. I r v in has an ex cessiv e need f o r so meo ne to t a k e ca re of h im a nd m ak e decisio ns fo r
h im . H e has dif ficu lt y m ak ing d ecisio ns ind epend ently a nd wish es t h at o th er s wo uld m ak e
th em f o r h im . H e la ck s th e co nfidence to init iate pr oject s or d o t h ing s on his own, h e
gener ally f eel s unco mfo rta b le bei ng a lo ne, a nd h e is rel uct ant t o d isa gree on ev en mino r
matter s. H e go es to a lm ost d espe ra te leng th s to seek a nd m aint ain r el atio nsh ips and t o
o b ta in suppo rt a nd nu rtu ring f r o m o th er s.
M r. I r v in, t h er efore, m eet s at l ea st six o f t h e eig ht D SM -5 cr iter ia ( o nl y f iv e are req uir ed )
fo r d epend ent per sona lit y d iso rd er. T o m eet t h e cr iter ia f o r t h e dia gno sis, t h ese patter ns 8/14/2019 Psychiatry Online | DSM Library
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must a lso f it t h e gener al cr iter ia f o r a per sona lit y d iso rd er ( i. e. , t h e sy mpt om s m ust d if fer
fr o m cu lt u ra l ex pect atio ns and b e end uring , inf lex ible, per va siv e, a nd a sso ciated wit h
dist ress and /or im pairm ent in fu nct ioning ). M r. I r v in’ s sy mpt om s m eet t h is stand ard .
F urth er more, h is sympt om s are per sist ent a nd d eb ilit ating , a nd l ie ou tsid e th e no rm al
ex pect atio ns fo r a h ea lt h y a d u lt m an of h is ag e.
M any psy chiatr ic dia gno ses can int ensif y d epend ent per sona lit y t r a it s or b e co morb id wit h
depend ent per sona lit y d iso rd er . I n th is pa tient , it is especia lly im porta nt t o co nsid er a
m ood d iso rd er , b eca use he pr esent s wit h “d epr essio n” th at h as recent ly wo rsened . S om e
pa tient s wit h m ood d iso rd er s ca n pr esent wit h sy mpt om s th at m im ic per sona lit y d iso rd er s,
so if t h is pa tient is in th e m idst o f a m ajo r d epr essiv e episo de, h is depend ent sy mpt om s
may b e co nfined t o t h at episo de. M r. I r v in, h owev er, d enies oth er sy mpt om s of d epr essio n
and d oes not m eet cr iter ia f o r a ny o f t h e depr essiv e diso rd er s.
Nota b ly , M r. I r v in is using a lpr azo la m . H e has been ta k ing t h e m ed ica tio n in incr easing
am ou nt s over a l o ng er per iod o f t im e th an wa s int end ed. T o o b ta in a n ad eq uate su ppl y, h e
get s pr escr iptions fr o m t h ree dif fe rent ph ysicia ns. H e has dev eloped t o ler ance (r esu lt ing in
d ose esca la tio n) a nd wit hdra wa l ( a s dem onst ra ted b y a nx iet y a nd sh ak es) . A ssu ming t h at
fu rth er ex plora tio n wo uld co nfirm cl inica ll y sig nifica nt im pairm en t o r d ist ress, M r. I r v in
m eet s cr iter ia f o r a b enz od ia zepine use diso rd er . Giv en his hist ory o f u se and h is tend ency
not t o b e ent irel y t r a nspa rent , it wo uld b e especia lly im porta nt t o t a ct fu lly ex plore th e
po ssib ilit y t h at h e is using o th er su bst ances, incl uding a lco hol, t o b acco , il licit d ru gs, a nd
pr escr iption dru gs su ch a s opio ids.
The psy chiatr ist in th is case fa ces a co nflict co mmon in clinica l pr act ice. D ocu ment atio n of
pa tient s’ d ia gno ses in clinica l ch arts—a nd t h eir r el ea se to t h ir d pa rties—ca n so metim es
have downst rea m ef fect s on pa tie nt s’ insu ra nce cover ag e or d isa bil it y st atu s and ca n lea d t o
st ig m atiz atio n, b oth wit hin and o u tsid e th e hea lt h ca re sy stem . Giv en th is rea lit y,
psy chiatr ist s ca n be tem pted t o r eco rd o nl y t h e lea st sev ere of sev era l d ia gno ses, o r
so metim es to r epo rt ina ccu ra te bu t pr esu mab ly l ess pejora tiv e diso rd er s. I n th is case, t h e
psy chiatr ist d oes both . A lt h ou gh t h e pa tient h as depr essed m ood , h e does not m eet cr iter ia
fo r t h e ad ju st m ent d iso rd er t h at is reco rd ed b y h is psy chiatr ist . H e d oes, h owev er, a ppea r
to m eet cr iter ia f o r b oth d epend ent per sona lit y d iso rd er a nd b enz od ia zepine use diso rd er ,
bu t neit her o f t h ese more ser ious and po tent iall y m ore st ig m atiz ing d ia gno ses is incl uded
in th e ch art o r d iscl osed t o t h e ins urer . 8/14/2019 Psychiatry Online | DSM Library
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When dia gno ses are ina ccu ra tel y r eco rd ed in med ica l ch arts, o st en sib ly f o r t h e pu rpo se of
pr otect ing pa tient s, t h is may end u p ca using h arm inst ead. S u bseq uent cl inicia ns wh o
rev iew th e reco rd s m ay l a ck cr itic al inf orm atio n reg ard ing pa tient s’ pr esent atio n and
tr ea tm ent . F or ex am ple, if M r. I r v in wer e to u rg ent ly ca ll f o r a pr escript ion of
b enz od ia zepines, a co ver ing psy chiatr ist m ight h ave no wa y o f k no wing f r o m t h e pa tient ’s
ch art a b ou t eit her t h e pa tter n of b enz od ia zepine ab u se or t h e ph ysio lo gica l d epend ence. A s
a ph ysicia n wh o int end s to “d o no h arm ,” M r. I r v in’ s psy chiatr ist h as tr ied t o sh iel d h im
fr o m st ig m a b u t h as inst ead ex po sed h im t o m ed ica l r isk .
The ph ysicia n has oth er r espo nsibilit ies bey ond t h ose to t h e pa tien t. W hen th e ph ysicia n
and pa tient a g ree to a ccept pa ym ent f r o m a n insu rer , t h e ph ysicia n m ay b e ob lig ated t o
pr ovid e to insu rer s and g o ver nm ental a g encies a r ea sona ble am ou nt o f h onest cl inica l
inform atio n. L ack o f d iscl osu re is ta nt am ou nt t o f r a u d a nd ca n be pr osecu ted . I n ad dit io n,
alt h ou gh b eing pa rt o f t h e m ed ica l pr ofessio n aff o rd s m any pr ivileg es, it a lso inv olv es
respo nsibilit ies. D ia gno stic deceit m ay seem l ik e an inno cuou s ef fo rt t o pr otect t h e pa tient ,
bu t t h e dish onest y neg ativ ely a ffect s th e repu ta tio n of t h e ent ire pr ofessio n, a r epu ta tio n
th at is int egra l t o t h e ab il it y t o r end er t r ea tm ent t o f u tu re pa tient s.
Su ggeste d R ead in gs
Appel bau m P S : Priv acy in psy chiatr ic tr ea tm ent : th rea ts and r espo nses . A m J Psy ch iatr y
15 9 (11 ): 18 09 – 18 18 , 2 0 02 PubM ed I D : 12 4112 11
Howe E : Co re et hica l q u est ions : wh at d o y o u d o wh en yo u r o b lig atio ns as a psy chiatr ist
co nflict wit h et hics? P sy ch iatr y 7(5): 19 – 2 6 , 2 0 10 PubM ed I D : 2 0 532 154
Mullins- Swea tt S N , B er nst ein DP , W idiger TA : R et ent ion or d el et io n of per sona lit y
diso rd er d ia gno ses fo r D SM -5 : a n ex per t co nsensu s appr oach . J Per s D iso rd 2 6 (5): 6 8 9 –
70 3 , 2 0 12 PubM ed I D : 2 30 13338
Case 1 8.1 0 R ela tio n sh ip C on tr o l
M ic h ae l F. Walton , M .D .
Ogd en Judd a nd h is boyfr iend , P eter K leinm an, pr esent ed f o r co upl es th er apy t o a d dress
esca la ting co nflict a ro u nd t h e issu e of m oving in to get her . M r. K leinm an descr ibed a
sev eral- m ont h-lo ng a pa rtm ent se arch t h at wa s m ad e “a go niz ing ” by M r. Ju dd’s rig id wo rk 8/14/2019 Psychiatry Online | DSM Library
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schedule and h is “end less” list o f a pa rtm ent d em and s. T hey wer e una ble to co me to a
d ecisio n, a nd ev ent ually t h ey d ecid ed t o j u st sh are M r. Ju dd’s apa rtm ent . A s M r. K leinm an
co ncl uded , “O gd en won.”
M r. Ju dd r ef used t o h ir e m over s fo r h is boyfr iend ’s bel ong ing s, ins isting o n per sona lly
pa cking a nd t a k ing a n inv ent ory o f ev ery it em in his boyfr iend ’s pl ace. W hat sh ou ld h ave
ta k en 2 d ays to ok 1 week . O nce th e item s wer e tr a nspo rted t o M r. Ju dd’s apa rtm ent , M r.
K leinm an beg an to co mplain ab ou t M r. Ju dd’s “cr azy r u les” ab ou t wh ere item s co uld b e
pl aced o n th e booksh elf, wh ich d ir ect ion th e hang ers in th e cl oset f a ced , a nd wh ether t h eir
cl oth es could b e int erming led . M oreo ver , M r. K leinm an co mplaine d t h at t h er e wa s hard ly
a ny spa ce fo r h is po ssessio ns beca use Mr. Ju dd nev er t h rew any th ing a wa y. “I ’m t er rif ied o f
lo sing so mething im porta nt ,” ad ded M r. Ju dd.
O ver t h e ensu ing week s, a rg u m ent s bro ke ou t nig htly a s th ey u npa cked b oxes and set tled
in. M ak ing m atter s wo rse, M r. Ju dd wo uld o ft en come hom e aft er 9 :0 0 o r 10 :00 p. m .,
b eca use he had a per sona l r u le to a lwa ys have a b la nk “t o-d o” list b y t h e end o f t h e day. M r.
K leinm an wo uld o ft en wake ea rly in th e m orning t o f ind M r. Ju dd g rim ly o rg aniz ing
shelves or cl oset s or so rting b ooks alph ab et ica ll y b y a u th or. T hro u gh ou t t h is pr ocess, M r.
Ju dd a ppea red t o b e wo rk ing h ard a t ev eryth ing wh ile enj oying h im sel f l ess and g et ting l ess
d one. M r. K leinm an fo u nd h im self f eel ing incr easing ly d et ach ed f r o m h is boyfr iend t h e
lo ng er t h ey l iv ed t o get her .
M r. Ju dd d enied sy mpt om s of d epr essio n and f r ee- flo ating a nx iet y. H e sa id t h at h e had
nev er ex per iment ed wit h cig aret tes or a lco hol, a d ding , “I wo uld n’ t wa nt t o f eel l ik e I wa s
ou t o f co ntro l.” H e denied a f a m ily h ist ory o f m ent al il lness. H e wa s ra ised in a t wo -pa rent
h ou seh old a nd wa s an ab ove aver ag e hig h sch ool a nd co lleg e st udent . H e wa s an onl y ch ild
and f ir st sh ared a r o om a s a co lleg e fr esh man. H e descr ibed t h at ex per ience as being
d if ficu lt d u e to “co nflict ing st yles—h e wa s a m ess and I k new th at t h ing s sh ou ld b e kept
nea t.” H e had m oved m id-y ea r in to a sing le dorm r o om a nd h ad no t l iv ed wit h a ny one unt il
Mr. K leinm an m oved in. M r. Ju dd wa s wel l l ik ed b y h is boss, ea rning r eco gnit ion as
“em ployee of t h e m ont h” th ree tim es in 2 y ea rs. F eed back f r o m co llea gu es and
su bord ina tes wa s less enthusia stic, ind icating t h at h e wa s over ly r ig id , per fect ionist ic, a nd
cr itica l.
O n ex am ina tio n, M r. Ju dd wa s a t h in man wit h ey eg la sses and g el led h air , sit ting o n a
co uch nex t t o h is boyfr iend . H e wa s m eticu lo u sl y d ressed . H e wa s co oper ativ e wit h t h e 8/14/2019 Psychiatry Online | DSM Library
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interview and sa t q u iet ly wh ile his boyfr iend spo ke, int erru pt ing o n a f ew occa sions to
co ntra d ict . H is speech wa s no rm al in ra te and t o ne. H is aff ect wa s ir rit ab le. T her e wa s no
ev idence of d epr essio n. H e denied specif ic ph ob ia s and d id no t t h ink h e had ev er
ex per ienced a pa nic atta ck . A t t h e end o f t h e co nsu lt a tio n, M r. Ju dd r em ark ed , “I k no w I’m
d if ficu lt , b u t I r ea lly d o wa nt t h is to wo rk o u t.”
D ia g n osis
O bsessiv e-co mpu lsiv e per sona lit y d iso rd er
D is c u ssio n
Co upl es tr ea tm ent wo uld pr ob ab ly f o cu s on th e rel atio nsh ip ra th er t h an on eit her o f t h e
two m en, b u t t h e ca se repo rt cl ea rly f o cu ses on M r. Ju dd’s co ntrib utio n to t h e dif ficu lt ies in
th e rel atio nsh ip. M r. Ju dd is viewed a s a co ntro ll ing , per fect ion- driv en, a nd inf lex ible
“wo rk ah olic. ” H e hold s on to b el ong ing s ex cessiv ely a nd f ind s it d if ficu lt t o int egra te new
item s int o h is apa rtm ent , spend ing h ou rs sing le- hand edly o rg aniz ing b ooks th at co uld
o th er wise ju st b e pl aced o n a b ooksh elf. H e is driv en and u na ble to d el eg ate, a nd a lt h ou gh
th ose qu alit ies can be ad apt ive in some cir cumstances, t h ey a re ca using h im d ist ress and
d ysf unct ion in reg ard t o h is sit uatio n wit h h is boyfr iend a nd wit h h is co llea gu es at wo rk .
M r. Ju dd a ppea rs to f u lf il l cr iter ia, t h er efore, f o r a D SM -5 d ia gno sis of o b sessiv e-
compu lsiv e per sona lit y d iso rd er ( O CP D).
O CP D a nd o b sessiv e-co mpu lsiv e diso rd er ( O CD ) ca n be co morb id , b u t t h e two co nd itio ns
usu ally ex ist sepa ra tel y. T he im porta nt d ist ing uish ing f a ct or is th at wh erea s O CP D is
co nsid ered a m ala d apt ive pa tter n of b eh avio r m ark ed b y ex cessiv e co ntro l a nd inf lex ibilit y,
O CD is ch ara ct er ized b y t h e pr esence of t r u e ob sessio ns and co mpu lsio ns.
Ther e ca n, h owev er, b e sig nifica nt b eh avio ra l o ver la p bet ween OCD a nd O CP D. F or
ex am ple, h oard ing b eh avio rs ca n b e co mmon to b oth d ia gno ses. I n OCP D, t h e ca use of t h e
hoard ing d iso rd er is th e need f o r o rd er a nd co mpleteness, a nd M r. Ju dd r epo rts th at h e is
“t er rif ied o f l o sing so mething im porta nt .” To co mpensa te fo r t h e fa ct t h at h is apa rtm ent is
no w sh ared wit h h is boyfr iend —and is over fu ll—M r. Ju dd wo rk s grim ly int o t h e nig ht so
t h at h is booksh elves and cl oset m aint ain th eir u su al st and ard o f ex cessiv e org aniz atio n. I n
O CD , t h e ca use of t h e hoard ing t end s to b e eit her t h e avo id ance of o ner ou s co mpu lsiv e
rit uals or o b sessio nal a nd o ft en irra tio na l f ea rs of inco mpleteness, h arm , a nd
co ntam ina tio n. T he beh avio rs are ty pica ll y u nwa nted a nd d ist ressi ng, a nd a re lik ely t o l ea d 8/14/2019 Psychiatry Online | DSM Library
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to t h e accu mula tio n of o d d d eb ris su ch a s fing erna il cl ipping s or r o tten fo od . I n hoard ing
diso rd er , a new dia gno sis in DSM -5 , t h e fo cu s is ex clusiv ely o n a p er sist ent d if ficu lt y
d isca rd ing o r pa rting wit h po ssessio ns ra th er t h an on a need f o r o rd er o r o n ob sessio ns and
co mpu lsio ns.
In reg ard t o M r. Ju dd, it wo uld b e u sef ul t o specif icall y ex plore wh ether h is hoard ing
beh avio r a ttenu ates a specif ic, pa rticu la rly d ist ressing o r int ru siv e th ou gh t, a nd t o
u nd erstand t h e ex tent o f h is accu mula tio ns. H is list -m ak ing a nd a rr a ng ing m ay b e
co mpu lsio ns and m eet cr iter ia f o r O CD if t h ey a re fo u nd no t o nl y t o b e acco mpa nied b y
tensio n and d if ficu lt y r el ax ing b u t a lso t o b e tim e-co nsu ming , d ist ressing , o ver ly r epet itiv e,
and r it ualist ic. A lt h ou gh D SM -5 e nco ura g es an effo rt t o d ist ing uish b et ween OCP D, O CD ,
and h oard ing d iso rd er , t h ese th re e diso rd er s ca n be co morb id wit h ea ch o th er .
As discu ssed in th e int ro d u ct io n to t h is ch apt er, S ect ion III o f D SM -5 o u tlines an
alt er na tiv e m od el t h at incl udes fiv e per sona lit y d iso rd er t r a it d om ains (see Tab le 18 – in th e
int ro d u ct io n to t h is ch apt er): neg ativ e aff ect ivity, d et ach ment , a nt ag o nism , d isinh ibitio n
(v s. co nscient iousness) , a nd psy choticism . S ev eral o f t h ese fa ct ors are per tinent t o a
d ia gno sis of O CP D. F or ex am ple, M r. Ju dd’s int erper sona l st yle wit h b oth h is boyfr iend
a nd h is co wo rk er s appea rs to b e m ark ed b y r ig id d et ach ment a nd r est rict ed l ev els of
int imacy . H e m anif est s sig nifica nt a m ou nt s of neg ativ e affect ivity, a s ref lect ed in his grim
per sist ence in continu ing t a sk s pa st t h e po int o f u sef ulness. F ina ll y , M r. Ju dd’s
co mpu lsiv ity per va d es th e ent ire st ory , a s m ark ed b y ex tr em e co ns cient iousness and r ig id
per fect ionism .
Su ggeste d R ead in gs
H ays P : D et er mina tio n of t h e ob sessio nal per sona lit y . A m J Psy ch iatr y 12 9 (2): 2 17 – 219 ,
19 72 P ubM ed I D : 50 410 64
L och ner C , S er eb ro P , v a n der M erwe L , et a l: Co morb id o b sessiv e-co mpu lsiv e per sona lit y
diso rd er in ob sessiv e-co mpu lsiv e d iso rd er ( O CD ) : a m ark er o f sev erity . P ro g
N eu ro psy choph arm aco l B io l P sy ch iatr y 35 (4): 10 87 – 10 92 , 2 0 11 PubM ed I D : 2 14 110 45
P int o MA , E isen J, M anceb o M , et a l: O bsessiv e-co mpu lsiv e per sona lit y d iso rd er , in
O bsessiv e-Co mpu lsiv e D iso rd er : S u bty pes and S pect ru m Co nditio ns . E dit ed b y 8/14/2019 Psychiatry Online | DSM Library
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Abra m owit z J, M cK ay D , T aylo r S. O xfo rd , U K , O xfo rd U niv ersit y P ress , 2 0 08 , pp 2 4 6 –
270
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