Personality Disorders

CHAPTER 17

Personality Disorders

Quick Guide to the Personality Disorders

DSM-5 retains the 10 specific personality disorders (PDs) that were listed in DSM-IV. Of these, perhaps 6 have been studied reasonably well and have a lot of support in the research community. The rest (paranoid, schizoid, histrionic, and dependent PDs), while perhaps less well founded in science, retain their positions in the diagnostic firmament because of their practical use and, frankly, tradition.

Speaking of tradition, ever since DSM-III in 1980 the personality disorders have been divided into three groups, called clusters. Heavily criticized for a lack of scientific validity, the clusters are perhaps most useful as a device to help us call to mind the full slate of PDs.

Cluster A Personality Disorders

People with Cluster A PDs can be described as withdrawn, cold, suspicious, or irrational. (Here and throughout the Quick Guide, as usual, the link indicates where a more detailed discussion begins.)

Paranoid . These people are suspicious and quick to take offense. They often have few confidants and may read hidden meaning into innocent remarks.

Schizoid . These patients care little for social relationships, have a restricted emotional range, and seem indifferent to criticism or praise. Tending to be solitary, they avoid close (including sexual) relationships.

Schizotypal . Interpersonal relationships are so difficult for these people that they appear peculiar or strange to others. They lack close friends and are uncomfortable in social situations. They may show suspiciousness, unusual perceptions or thinking, eccentric speech, and inappropriate affect.

Cluster B Personality Disorders

Those with Cluster B PDs tend to be rather theatrical, emotional, and attention-seeking; their moods are labile and often shallow. They often have intense interpersonal conflicts.

Antisocial . The irresponsible, often criminal behavior of these people begins in childhood or early adolescence with truancy, running away, cruelty, fighting, destructiveness, lying, and theft. In addition to criminal behavior, as adults they may default on debts or otherwise behave irresponsibly; act recklessly or impulsively; and show no remorse for their behavior.

Borderline . These impulsive people engage in behavior harmful to themselves (sexual adventures, unwise spending, excessive use of substances or food). Affectively unstable, they often show intense, inappropriate anger. They feel empty or bored, and they frantically try to avoid abandonment. They are uncertain about who they are, and they lack the ability to maintain stable interpersonal relationships.

Histrionic . Overly emotional, vague, and desperate for attention, these people need constant reassurance about their attractiveness. They may be self-centered and sexually seductive.

Narcissistic . These people are self-important and often preoccupied with envy, fantasies of success, or ruminations about the uniqueness of their own problems. Their sense of entitlement and lack of compassion may cause them to take advantage of others. They vigorously reject criticism and need constant attention and admiration.

Cluster C Personality Disorders

Someone with a Cluster C PD will tend to be anxious and tense, often overcontrolled.

Avoidant . These timid people are so easily wounded by criticism that they hesitate to become involved with others. They may fear the embarrassment of showing emotion or of saying things that seem foolish. They may have no close friends, and they exaggerate the risks of undertaking pursuits outside their usual routines.

Dependent . These people so much need the approval of others that they have trouble making independent decisions or starting projects; they may even agree with others whom they know to be wrong. They fear abandonment, feel helpless when they are alone, and are miserable when relationships end. They are easily hurt by criticism and will even volunteer for unpleasant tasks to gain the favor of others.

Obsessive–Compulsive . Perfectionism and rigidity characterize these people. They are often workaholics, and they tend to be indecisive, excessively scrupulous, and preoccupied with detail They insist that others do things their way. They have trouble expressing affection, tend to lack generosity, and may even resist throwing away worthless objects they no longer need.

Other Causes of Long-Standing Character Disturbance

Personality change due to another medical condition . A medical condition can affect a patient’s personality for the worse. This would not qualify as a PD, because it may be less pervasive and not present from an early age.

Other mental disorders. When they persist for a long time (usually years), a variety of other mental conditions can distort the way a person behaves and relates to others. This can give the appearance of a personality disorder. Especially good examples include dysthymia, schizophrenia, social anxiety disorder, and cognitive disorders. Some studies find that patients with mood disorders are more likely to show personality traits or PDs when they are clinically depressed; this may be especially true of Cluster A and Cluster C traits. Personality pathology noted in depressed patients should be reevaluated once the depression has remitted.

Other specified, or unspecified, personality disorder . Use one of these categories for personality disturbances that do not meet the criteria for any of the disorders above, or for PDs that have not achieved official status.

INTRODUCTION

All humans (and numerous other species as well) have personality traits. These are well-ingrained ways in which individuals experience, interact with, and think about everything that goes on around them. PDs are collections of traits that have become rigid and work to individuals’ disadvantage, to the point that they impair functioning or cause distress. These patterns of behavior and thinking have been present since early adult life and have been recognizable in the patient for a long time.

Personality, and therefore PDs, should probably be thought of as dimensional rather than categorical; this means that their components (traits) are present in normal people, but are accentuated in those with the disorders in question. But for good reasons and bad, DSM-5 has retained the traditional categorical structure that has been used for more than 30 years. There are promises that this will change in the coming years; indeed, DSM-5 devotes a long portion of its Section III (material not officially approved for use) to exploring alternative diagnostic structures. However, the experts will first have to agree as to which dimensions to use, then how best to measure and categorize them, and then how to interpret the results. In the meantime, we will continue to muddle along pretty much as before.

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

Essential Features of a General Personality Disorder

There is a lasting pattern of behavior and internal experience (thoughts, feelings, sensations) that is clearly different from the patient’s culture. This pattern includes problems with affect (type, intensity, lability, appropriateness); cognition (how the patient sees and interprets self and the environment); control of impulses; and interpersonal relationships. This pattern is fixed and applies broadly across the patient’s social and personal life.

The Fine Print

The D’s: • Duration (lifelong, with roots in adolescence or childhood) • Diffuse contexts • Distress and disability (work/educational, social, and personal) • Differential diagnosis (substance use, physical illness, other mental disorders, other PDs, personality change due to another medical condition)

The information PDs convey gives the clinician a better understanding of the behavior of patients; it can also augment our understanding of the management of many patients.

As you read these descriptions and the accompanying vignettes, keep in mind the twin hallmarks of the PDs: early onset (usually by late teens) and pervasive nature, such that a disorder’s features affect multiple aspects of work, personal, and social life.

Diagnosing Personality Disorders

The diagnosis of PDs presents a variety of problems. On the one hand, they are often overlooked; on the other, however, they are sometimes overdiagnosed (borderline PD is, in my opinion, a notorious example). One (antisocial PD) carries a terrible prognosis; most, if not all, are hard to treat. Their relatively weak validity suggests that no PD should be the sole diagnosis when another mental disorder can explain the signs and symptoms that make up the clinical picture. For all of these reasons, it is a good idea to have in mind an outline for making the diagnosis of a PD.

1.  Verify the duration of the symptoms. Make sure that your patient’s symptoms have been present at least since early adulthood (before age 15 for antisocial PD). Interviewing informants (family, friends, coworkers) will probably give you the most valid material.

2.  Verify that the symptoms affect several areas of the patient’s life. Specifically, are work (or school), home life, personal life, and social life affected? This step can present real problems, in that patients themselves often don’t see their behavior as causing problems. (“It’s the world that’s out of step.”)

3.  Check that the patient fully qualifies for the particular diagnosis in question. This means checking all the characteristics and consulting all 10 sets of diagnostic criteria. Sometimes you have to make a judgment call. Try to be as objective as possible. As with other mental disorders, with enough motivation you can usually force a patient into a variety of diagnoses.

4.  If the patient is under age 18, make sure that the symptoms have been present for at least the past 12 months. (And be really, really sure that they aren’t due instead to some other mental or physical disorder.) I personally prefer not making such a diagnosis at such a tender age.

5.  Rule out other mental pathology that may be more acute and have greater potential for doing harm. The flip side is that other mental disorders are also often more responsive to treatment than are PDs.

6.  This is also a good time to review the generic features for any other requirements you may have missed. Note that each patient must have two or more types of lasting problems with behavior, thoughts, or emotions from a list of four: cognitive, affective, interpersonal, and impulsive. (This helps ensure that the patient’s problems truly do affect more than one life area.)

7.  Search for other PDs. Evaluate the entire history to learn whether any additional PD is present. Many patients appear to have more than one PD; in such cases, diagnose them all. Perhaps more often, you will find too few symptoms to make any diagnosis. Then you can add to your summary note something to the effect: schizoid and paranoid personality traits.

8.  Record all personality and nonpersonality mental diagnoses. Some examples of how this is done are shown in the vignettes that follow.

Although you can learn the rudiments of each PD from the material I present here, it is important to note that these abbreviated descriptions only begin to tap their rich psychopathology. If you want to make a study of these disorders, I strongly recommend that you consult standard texts.

CLUSTER A PERSONALITY DISORDERS

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

F60.0 [301.0] Paranoid Personality Disorder

What you notice most about patients with paranoid PD (PPD) is how little they trust—and how much they suspect—other people. The suspicions they harbor are unjustified, but because they fear exploitation, they will not confide in those whose behavior should have earned their trust. Instead, they read unintended meaning into benign comments and actions, and they will interpret untoward occurrences as the result of deliberate intent. They tend to harbor resentment for a long time, perhaps forever.

These people tend to be rigid and litigious, and may have an especially urgent need to be self-sufficient. To others, they can appear to be cold, calculating, guarded people who avoid both blame and intimacy. They may appear tense and have trouble relaxing during an interview. This disorder is especially likely to create occupational difficulties: Patients with PPD are so aware of rank and power that they frequently have trouble dealing with superiors and coworkers.

Although it is apparently far from rare (it may affect 1% of the general population), PPD rarely comes to clinical attention. When it does, it is usually diagnosed in men. Its relationship (if any) to the development of schizophrenia remains unclear, but if you find that it has preceded the onset of schizophrenia, add the specifier (premorbid).

Essential Features of Paranoid Personality Disorder

In many situations, these patients demonstrate that they distrust the loyalty or trustworthiness of others. Because they suspect that other people want to deceive, hurt, or exploit them, they hesitate to share personal information. Unjustified suspicions about the faithfulness of spouse or partner, or even the (mis)perception of hidden content in everyday events or speech, can lead to the bearing of grudges or to rapid response with anger or attacks in kind.

The Fine Print

The D’s: • Duration (begins in teens or early 20s and endures) • Diffuse contexts • Differential diagnosis (physical and substance use disorders; mood, anxiety, and psychotic disorders; posttraumatic stress disorder; schizotypal and schizoid PDs)

Coding Note

If PPD precedes the onset of schizophrenia, add the specifier (premorbid).

Dr. Schatzky

A professor of dermatology at University Hospital, Dr. Schatzky had never consulted a mental health professional. But he was well known to the staff at the medical center and notorious among his colleagues. One of them, Dr. Cohen, provided most of the information for this vignette.

Dr. Schatzky had been around for several years. He was known as a solid researcher and an excellent clinician. A hard worker, he supervised fellows working on two grants and carried more than his share of the teaching load.

One of the trainees working in his lab was a physician named Masters. He was a bright, capable young man whose career in academic dermatology seemed destined to soar. When Dr. Masters got an offer from Boston of an assistant professorship and his own lab space, he told Dr. Schatzky that he was sorry, but he would leave at the end of the semester. Furthermore, he wanted to use some of their data.

Dr. Schatzky was more than upset. He responded by telling Dr. Masters that “what happened in the lab stayed in the lab.” He wouldn’t allow anyone to “rip him off,” and he told Dr. Masters that he would be blackballed if he tried to publish papers based on their findings. Furthermore, Dr. Schatzky told him to keep away from the students until he left. This outraged the other dermatologists. Dr. Masters was one of the most popular young teachers in the department, and the notion that he shouldn’t have any contact with the students seemed punitive to all and little short of an assault on academic freedom.

The other dermatologists discussed the situation in a department meeting when Dr. Schatzky was out of town. One of the older professors had volunteered to try to persuade him to let Dr. Masters teach anyway. Subsequently, Dr. Schatzky refused with the response, “What have I done to you?” He now seemed to think that the other professor had it in for him.

This professor told Dr. Cohen that he wasn’t really surprised. He’d known Dr. Schatzky since college, and he’d always been a suspicious type. “He won’t confide in anyone without a signed loyalty oath,” was how the other professor put it. Dr. Schatzky seemed to think that if he said anything nice, it would somehow be turned against him. The only person he seemed to trust completely was his wife, a rabbity little creature who had probably never disagreed with him in her life.

At the meeting, someone else suggested that the department chairman should talk to him and try to “jolly him along a bit.” But Dr. Schatzky had little sense of humor and “the longest memory for a grudge of anyone on the face of the planet.”

In the collective memory of all the staff, Dr. Schatzky had never had mood swings or psychosis, and at department dinners, he didn’t drink. “Never out of touch with reality, only nasty,” said Dr. Cohen.

Evaluation of Dr. Schatzky

I begin with a disclaimer: From the information available in this vignette, it would appear that Dr. Schatzky had never been interviewed by a mental health professional. Any conclusions must therefore be tentative. Clinicians simply have no right to make definitive diagnoses of patients—or just plain people—for whom they haven’t gathered adequate information.

That said, Dr. Schatzky’s symptoms had apparently been quite constant and present throughout his entire adult life (at least since college). His problems involved both his thinking and his interpersonal functioning, which in turn led to problems with his work and personal life.

What symptoms of PPD did Dr. Schatzky have? Without cause, he suspected young Dr. Masters of planning to “rip off’ his data (criterion A1). His colleagues noted his long-standing concerns about the loyalty of associates (A2). He would never confide in others (A3), and he refused to let Dr. Masters teach, which sounds a lot like holding a grudge (A5). (However, he had apparently never questioned the loyalty of his wife, which would be another common symptom of this PD.) So we can find a total of four symptoms, which is what’s required for a diagnosis of PPD.

Could a non-PD diagnosis explain Dr. Schatzky’s behavior as described? Although the information is incomplete, drug or alcohol use appears unlikely. (It also seems unlikely that anyone of middle age could have been taking a medication long enough to produce character disturbance that had lasted his entire adult life.) The vignette provides no evidence of another medical condition. According to the information provided, Dr. Schatzky had never had frank psychosis, such as delusional disorder or schizophrenia, and he had no mood disorder (B).

What about other PDs? Patients with schizoid PD are cold and aloof, and as a result may appear distrustful, but they do not have the prominent suspiciousness characteristic of patients with PPD. Patients with schizotypal PD may have paranoid ideation, but they also appear peculiar or odd (not the case here). And Dr. Schatzky didn’t appear to prefer solitude. Those with antisocial PD are often cold and unfeeling, may be suspicious, and have trouble forming interpersonal relationships. However, they rarely have the perseverance to complete professional school, and Dr. Schatzky had no history of criminal behavior or reckless disregard for the safety of others.

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

F60.0 [301.0] Paranoid personality disorder

F60.1 [301.20] Schizoid Personality Disorder

People with schizoid personality disorder (SzPD) are indifferent to the society of other people, sometimes profoundly so. Typically, they are lifelong loners who show a restricted emotional range; they appear unsociable, cold, and reclusive.

Patients with SzPD may succeed at solitary jobs that others find difficult to tolerate. They may daydream excessively, become attached to animals, and often do not marry or even form long-lasting romantic relationships. They do retain contact with reality, unless they develop schizophrenia. However, their relatives are not at increased risk for that disease.

Although it is uncommonly diagnosed, SzPD is relatively common, affecting perhaps a few percent of the general population. Men may be at greater risk than women. The following patient was the younger brother of Lyonel Childs, whose history has been presented in connection with schizophrenia.

Essential Features of Schizoid Personality Disorder

In many situations, these patients remain isolated and have a narrow emotional range. Preferring solitude in their activities, they neither want nor enjoy close relationships, including those with family. They may have no close friends, with the possible exception of relatives. Indeed, they enjoy few activities, even showing little interest in sex with other people. Emotionally cold or detached, they seem indifferent to both criticism and praise.

The Fine Print

The D’s: • Duration (begins in teens or early 20s and endures) • Diffuse contexts • Differential diagnosis (physical and substance use disorders, mood and psychotic disorders, autism spectrum disorder, schizotypal and paranoid PDs)

Coding Note

If schizoid personality disorder precedes the onset of schizophrenia, add the specifier (premorbid).

Lester Childs

“We brought him in because of what happened to Lyonel. They seemed so much alike, and we were worried.” Lester’s mother sat primly on the office sofa. “After Lyonel was arrested, that’s when we decided.”

At 20, Lester Childs was in many ways a carbon copy of his older brother. Born several weeks prematurely, he had spent his first few weeks of life in an incubator. But he gained weight rapidly and was soon well within the norms for his age.

He walked, talked, and was toilet-trained at the usual ages. Perhaps because they both worked so hard on the farm, or perhaps because there were no other young children for Lester and his siblings to play with, his parents noticed nothing wrong until Lester entered first grade. Within a few weeks, his teacher had telephoned to set up a conference.

Lester seemed bright enough, they were told; his schoolwork wasn’t in question. But his sociability was next to nil. At recess, when the other children played dodge ball or pom-pom-pullaway, he remained in the classroom to color. He seldom participated in group discussions, and he always sat a few inches back from the others in the reading circle. When his turn for show and tell came, he stood silently in front of the class for a few moments, then pulled a length of kite string from his pocket and dropped it onto the floor. Then he sat down.

Most of this behavior was quite a lot like Lyonel’s, so the parents hadn’t been too worried. Even so, they took him to see their family doctor, who agreed that it was probably normal for their family and that he would “grow out of it.” But Lester never did; he only grew up. He never even participated in family activities. At Christmas, he would open a present, take it over to a corner, and play with it by himself. Even Lyonel never did that.

When Lester entered the room, it was clear that he didn’t regard the appointment as much of an occasion. He wore jeans with one knee missing, tattered sneakers, and a T-shirt that at one time surely had had sleeves. Through much of the interview, he continued to leaf through a magazine devoted to astronomy and math. After waiting more than a minute for Lester to say something, the interviewer began. “How are you today?”

“I’m OK.” Lester kept on reading.

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

“Not really.”

“Do you have any ideas about it?”

[Silence.]

Most of the interview went that way. Lester willingly gave information when he was directly asked, but he seemed completely uninterested in volunteering anything. Sitting quietly, nose in his magazine, he showed no other abnormalities or eccentricities of behavior. His flow of speech (what there was of it) was logical and sequential. He was fully oriented, and he scored a perfect 30 on the MMSE. His mood was “OK”—neither too happy nor too sad. He had never used alcohol or drugs of any kind. He calmly but emphatically denied ever hearing voices, seeing visions, or having beliefs that he was being watched, followed, talked about, or otherwise interfered with. “I’m not like my brother,” he said in his longest spontaneous speech up to that point.

When asked who he was like, Lester said it was Greta Garbo—who famously wanted to be left alone. He claimed he didn’t need friends, and he could also do without his family. Neither did he need sex. He had checked out the sex magazines and anatomy books. Females and males were equally boring. His idea of a good way to spend his life was to live alone on an island, like Robinson Crusoe. “But no Friday.”

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

Evaluation of Lester Childs

Any diagnosis of a PD requires that the difficulties be both pervasive and enduring. Although he was only 20 years old, Lester’s problems had certainly been enduring: They were noticeable when he was 6. And as far as we can tell, his rejection of interpersonal contact extended into every facet of his life—family, social, and school.

Lester rejected close relationships, even with his family (criterion A1); he preferred solitary activities (A2); he rejected the notion of having a sexual relationship with anyone (although this could conceivably change with maturity and opportunity—A3); he had always lacked close friends (A5); his affect seemed quite flat and detached (although this could have been an artifact of a first interview with a reluctant interviewee—A7). In any event, Lester met at least four and possibly five diagnostic criteria (four are required) for SzPD. These symptoms would satisfy three of the areas (cognition, affect, and interpersonal functioning) mentioned in the generic criteria for a PD. His interest in mathematics and astronomy would not be unusual in persons with this disorder, who typically thrive on work that others might find too lonely to enjoy.

Could any other disorder better explain Lester’s clinical picture? Patients with depressive disorders are often withdrawn and unsociable, but these seldom persist lifelong. Besides, Lester specifically denied feeling depressed or lonely; any doubts on the point could be settled by asking about vegetative symptoms of depression (changes in appetite or sleep). He also denied having symptoms (delusions and hallucinations) that would suggest schizophrenia, and this was supported by collateral information from his mother. There were no stereotypies or symptoms of impaired communication, as we’d expect for autism spectrum disorder, or disturbance of consciousness of memory, as would be required for a cognitive disorder. From the information we have, he was physically healthy and did not use drugs, alcohol, or medications (B).

What other PDs should we consider? Patients with schizotypal PD can have constricted affect and unusual appearance. Lester’s clothing was out of keeping for most visits to a professional office but would probably be quite usual for someone 20 years old, and he denied having any beliefs that might seem odd. He did not voice any ideas of deep suspicion or distrust, such as might be encountered in paranoid PD. Patients with avoidant PD are also isolated from other people; unlike patients with SzPD, however, they don’t choose this isolation, and they suffer for it.

If Lester later developed schizophrenia, the qualifier (premorbid) would be added at that time to his diagnosis. I find it difficult to place him squarely on the GAF Scale. The score of 65 is to some extent a matter of taste, and arguable.

F60.1 [301.20] Schizoid personality disorder

F21 [301.22] Schizotypal Personality Disorder

From an early age, patients with schizotypal personality disorder (StPD) have lasting interpersonal deficiencies that severely reduce their capacity for closeness with others. They also have distorted or eccentric thinking, perceptions, and behaviors, which can make them seem odd. They often feel anxious when with strangers, and they have almost no close friends. They may be suspicious and superstitious; their peculiarities of thought include magical thinking and belief in telepathy or other unusual modes of communication. Such patients may talk about sensing a “force” or “presence,” or have speech characterized by vagueness, digressions, excessive abstractions, impoverished vocabulary, or unusual use of words.

Patients with StPD may eventually develop schizophrenia. Many of them are depressed when they first come to clinical attention. Their eccentric ideas and style of thinking also place them at risk for becoming involved with cults. They get along poorly with others, and under stress they may become briefly psychotic. Despite their odd behavior, many marry and work. This disorder occurs about as often as schizoid PD.

Essential Features of Schizotypal Personality Disorder

In many situations, these patients tend to be isolated and exhibit a narrow emotional range with other people. They will have paranoid or suspicious ideas, even ideas of reference (which, however, are not held to a delusional extent). Their dress or mannerisms may give them an odd appearance, with affect that is inappropriate or constricted; speech can be vague, impoverished, or overly abstract. They may report strange perceptions or physical sensations, and their peculiar behavior may be affected by magical thinking or other odd beliefs (superstitions, a belief in telepathy). With severe social anxiety (which doesn’t improve with acquaintance), they tend to have no intimate friends.

The Fine Print

The D’s: • Duration (begins in teens or early 20s and endures) • Diffuse contexts • Differential diagnosis (physical and substance use disorders, psychotic disorders, mood disorders with psychotic features, autism spectrum disorder and other neurodevelopmental disorders, paranoid and schizoid PDs)

Coding Note

If StPD precedes the onset of schizophrenia, add the specifier (premorbid).

Timothy Oldham

“But it’s my baby! I don’t care what he had to do with it!” Hugely pregnant and miserable, Charlotte Grenville sat in the interviewer’s office and wept with frustration. She was there at the request of the presiding judge in a battle over visitation rights with her yet-unborn child.

The identity of the father was never in doubt. The week after her second missed period, Charlotte had visited a gynecologist and then called Timothy Oldham with the news. She had considered threatening to sue him for child support, but that hadn’t been necessary. He made good money installing carpets and had no dependents. He offered her a generous monthly stipend, beginning immediately. But he wanted to help rear their child. Charlotte had rejected that idea out of hand and then filed suit. With a crowded court docket, the case had dragged on nearly as long as Charlotte’s pregnancy.

“I mean, he’s really weird!”

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

“Well, I’ve known him for the longest time—several years, anyway. He had a sister who died; he talks about her like she’s still alive. And he does weird things. Like, when we were making love, right in the middle he started this babble about ‘holy love’ and dedicating his seed. It put me right off. I told him to stop and get off, but it was too late. I mean, would you want your kid growing up with that for a father?”

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

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

Timothy was not only sedate, but nearly immobile. He sat quietly in the interview chair, a gangly blond whose hair swept across his forehead nearly to his eye brows. He told his story in a dull monotone that didn’t reveal the slightest trace of emotion.

Timothy Oldham and his twin sister, Miranda, had been orphaned when they were 4 years old. He had no memory of his parents, other than a vague impression that they might have made their living from a marijuana farm in northern California. The two children had been taken in by an aunt and uncle—Southern Baptists who, he said, made the farm couple in Grant Woods’s American Gothic look cheerful by comparison. “That painting, it’s really them. I have a copy of it in my bedroom. Sometimes I can almost see my uncle moving the pitchfork back and forth to signal me.”

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

“Well, it’s more of a feeling I get . . . not really . . . a sign of my Christian endeavor . . . ” Timothy’s voice trailed off, but he kept gazing straight ahead.

The “Christian endeavor,” he explained, meant that everyone was put on earth for some special purpose. His uncle always used to say that. He thought his own purpose might be to help raise the baby growing inside Charlotte. He knew there had to be more to life than laying carpets all day.

Timothy had only a few friends, none of them close. He and Charlotte had spent no more than a few hours together. In response to a question, he talked about his sister. Miranda and he had been understandably close; she was the only real friend he had ever had. She died of a brain tumor when they were 16, and Timothy was devastated. “We were webbed together when we were born. I swore at her graveside it would never be undone.”

With still no inflection in his voice, Timothy explained that being “webbed together” was something you were born with. He and Miranda still were webbed. It was a Christian endeavor, and she was directing him from beyond the grave to have a baby girl. He said that it would be having Miranda back again. He knew that the baby wouldn’t actually be Miranda, but said he knew it would be a girl. “It’s just one of those feelings. But I know I’m right.”

Timothy responded in the negative to the usual questions about hallucinations, delusions, abnormal moods, substance use, and medical problems such as head injury and seizure disorders. Then he arose from his seat and left the room without another word.

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

Evaluation of Timothy Oldham

Charlotte’s testimony suggested that Timothy’s peculiarities had been present for years. Although we don’t know much about his school career or work, his symptoms would seem likely to affect most areas of his life. This point should be more fully explored.

Timothy’s schizotypal symptoms included odd beliefs (his conviction that the baby would be his sister returned to earth; there is no evidence that he came from a subculture where this sort of thinking was the norm—criterion A2), illusions (the farmer in the picture waving his pitchfork—A3), constricted affect (A6), and absence of close friends (A8). His words (“webbed together,” “Christian endeavor”) seemed metaphorical and odd (A4). Unexplored by the interviewer were the presence of ideas of reference, paranoid ideas, odd behavior, and excessive social anxiety. Cognitive, affective, and interpersonal symptoms were represented here, however (see the Essential Features for a general PD earlier in this chapter).

This evaluation turned up no indications of another mental disorder. Timothy specifically denied the actual psychotic symptoms necessary to support a diagnosis of delusional disorder or schizophrenia. Other conditions that could entail psychotic symptoms include mood disordersand cognitive disorders, but we’ve seen evidence against both (B).

Other PDs to consider would include schizoid and paranoid PDs. Each of these implies some degree of social isolation, but not the eccentric thinking of StPD. Patients with any of these three Cluster A disorders can decompensate into brief psychoses—a trait held in common with borderline PD. Some patients may qualify for two diagnoses simultaneously: borderline PD and one of the Cluster A PDs. Patients with avoidant PD are socially isolated, but they suffer from it and lack odd behavior and thinking. Of course, a personality change due to another medical condition must be considered in those who have a severe or chronic illness; Timothy didn’t.

As of this evaluation, Tim would receive a GAF score of 75. He hadn’t developed schizophrenia, so we wouldn’t use the qualifier (premorbid).

F21 [301.22] Schizotypal personality disorder
Z65.3 [V62.5] Litigation regarding child visitation

CLUSTER B PERSONALITY DISORDERS

People with Cluster B PDs tend to be dramatic, emotional, and attention-seeking, with moods that are labile and often shallow. They often have intense interpersonal conflicts.

F60.2 [301.7] Antisocial Personality Disorder

Those with antisocial PD (ASPD) chronically disregard and violate the rights of other people; they cannot or will not conform to the norms of society. This said, there are a number of ways in which people can exhibit ASPD. Some are engaging con artists; others are, frankly, graceless thugs. Women (and some men) with the disorder may be involved in prostitution. In still other individuals, the more traditional antisocial aspects may be obscured by the heavy use (and often purveyance) of illicit drugs.

Although some of these people seem superficially charming, many are aggressive and irritable. Their irresponsible behavior affects nearly every life area. Besides substance use, there may be fighting, lying, and criminal behavior of every conceivable sort: theft, violence, confidence schemes, and child and spouse abuse. They may claim to have guilt feelings, but they don’t appear to feel genuine remorse for their behavior. Although they may complain of multiple somatic problems and will occasionally make suicide attempts, their manipulative interactions with others make it difficult to determine whether their complaints are genuine.

DSM-5 criteria for ASPD specify that, beginning before age 15, the patient must have a history that would support a diagnosis of conduct disorder; as an adult, this behavior must have continued and been extended, with at least four ASPD symptoms.

As many as 3% of men, but only about 1% of women, have this disorder; it is found in about three-quarters of penitentiary prisoners. It is more common among lower-socioeconomic-status populations and runs in families; it probably has both a genetic and an environmental basis. Male relatives have ASPD and substance-related disorders; female relatives have somatic symptom disorder and substance-related disorders. Childhood attention-deficit/hyperactivity disorder is a common precursor, and childhood conduct disorder is a requirement (see above).

Although treatment seems to make little difference to patients with ASPD, there is some evidence that the disorder decreases with advancing age, as these people mellow out to become “only” substance users. Death by suicide or homicide is the lot of others.

Generally, the diagnosis of ASPD will not be warranted if antisocial behavior occurs only in the context of substance abuse. Individuals who misuse substances sometimes engage in criminal behavior, but only when in pursuit of drugs. It is crucial to learn whether patients with possible ASPD have engaged in illicit acts when not using substances.

Although these patients often have a childhood marked by incorrigibility, delinquency, and school problems such as truancy, fewer than half the children with such a background eventually develop the full adult syndrome. Therefore, we should never make this diagnosis before age 18.

Finally, ASPD is a serious disorder, with no known effective treatment. It is therefore a diagnosis of last resort. Before making it, redouble efforts to rule out other major mental disorders and PDs.

Essential Features of Antisocial Personality Disorder

These patients have a history dating to before age 15 of destroying property, serious rule violation, or aggression against people or animals (that is, they fulfill criteria for conduct disorder). Since then, in many situations, they lie, con, or give an alias while engaging in behaviors that merit arrest (whether or not they are actually detained). They tend to fight or assault others, and generally fail to plan their activities, relying instead on the inspiration of the impulse. For none of this behavior do they show remorse, other than feeling sorry if caught. They will refuse to pay their debts or maintain steady employment. They may irresponsibly place themselves or other people in danger.

The Fine Print

The D’s: • Duration and demographics (diagnosis cannot be made prior to age 18; behavior patterns are enduring) • Diffuse contexts • Differential diagnosis (physical and substance use disorders, bipolar disorders, schizophrenia, other PDs, ordinary criminality)

Milo Tark

Milo Tark was 23, handsome, and smart. When he worked, he earned good money installing heating and air conditioning. He had broken into that trade when he left high school, which happened somewhere in the middle of his 10th-grade year. Since then, he had had at least 15 different jobs; the longest of them had lasted 6 months.

Milo was referred for evaluation after he was caught trying to con money from elderly patrons at an ATM. The machine was one of two that served the branch bank where his mother worked as assistant manager.

“The little devil!” his father exclaimed during the initial interview. “He was always a difficult one to raise, even when he was a kid. Kinda reminded me of me, sometimes. Only I pulled out of it.”

Milo had picked a lot of fights when he was a boy. He had bloodied his first nose when he was only 5, and the world-class spanking administered by his father had taught him nothing about keeping his fists to himself. Later he was suspended from the seventh grade for extorting $3 and change from an 8-year-old. When the suspension was finally lifted, he responded by ditching class for 47 straight days. Then began a string of encounters with the police, beginning with shoplifting (condoms) and progressing through breaking and entering (four counts) to grand theft auto when he was 15. For stealing the Toyota, he was sent for half a year to a camp run by the state youth authority. “It was the only 6 months his mother and I ever knew where he was at night,” his father observed.

Milo’s time in detention seemed to have done him some good, at least initially. Although he never returned to school, for the next 2 years he avoided arrest and intermittently applied himself to learning his trade. Then he celebrated his 19th birthday by getting drunk and joining the Army. Within a few months he was out on the street again, with a bad-conduct discharge for sharing cocaine in his barracks and assaulting two corporals, his first sergeant, and a second lieutenant. For the next several years, he worked when he needed cash and couldn’t get it any other way. Not long before this evaluation, he had gotten a 16-year-old girl pregnant.

“She was just a ditsy broad.” Milo lounged back, one leg over the arm of the interview chair. He had managed to grow a scraggly beard, and he rolled a toothpick around in the corner of his mouth. The letters H-A-T-E and L-O-V-E were clumsily tattooed across the knuckles of either hand. “She didn’t object when she was gettin’ laid.”

Milo’s mood was good now, and he had never had anything that resembled mania. There had never been symptoms of psychosis, except for the time he was coming off speed. He “felt a little paranoid” then, but it didn’t last.

The ATM job was a scam thought up by a friend. The friend had read something like it in the newspaper and decided it would be a good way to obtain fast cash. They had never thought they might be caught, and Milo hadn’t considered the effect it would have on his mother.

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

Evaluation of Milo Tark

Milo’s behavior persistently affected all aspects of his life: school, work, family, and interpersonal relations. By the time he was 15, he easily met criteria for conduct disorder (ASPD criterion C). Afterwards, he moved on to full-blown adult criminality that persisted through his early 20s: repeated illegal acts (A1), assaults (on Army personnel—A4), irresponsible work record (A6), impulsivity (no planning about breaking into the ATM—A3), and lack of remorse (toward his mother and the girl he impregnated—A7). His symptoms touched on the areas of cognition, affect, interpersonal functioning, and impulse control (see the description of a general PD). Of course, he was now old enough (over 18—criterion B) to qualify for a diagnosis of ASPD.

People with a manic episode or schizophrenia will sometimes engage in criminal activity, but it is episodic and accompanied by other manic or psychotic symptoms. Milo steadfastly denied any behavior suggesting either a mood or a psychotic disorder (D). Patients with intellectual disability may break the law, either because they do not realize that it is wrong or because they are so easily influenced by others. Although Milo didn’t do especially well in school, there is no indication that he was held back because of low intelligence.

Because many addicted patients will do nearly anything to obtain money, substance use disorders are important in the differential diagnosis. Milo had used cocaine and amphetamines, but (according to him) only briefly, and most of his antisocial behaviors were not associated with drug use. Patients with impulse-control disorders will engage in illegal activities, but this is confined to the context of conduct disorder in younger people and fighting or property destruction in intermittent explosive disorder. Patients with bulimia nervosa sometimes shoplift, but Milo had no evidence of bulimic episodes. Of course, many of these conditions (as well as the anxiety disorders) can be encountered as associated diagnoses in patients with ASPD.

Career criminals whose antisocial behavior is confined to their “professional lives” may not fulfill all of the criteria for ASPD. They may instead be diagnosed as having adult antisocial behavior, which would be recorded as Z72.811 [V71.01]. It constitutes part of the differential diagnosis of the PD.

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

F60.2 [301.7] Antisocial personality disorder
Z65.3 [V62.5] Arrest for ATM fraud

F60.3 [301.83] Borderline Personality Disorder

Throughout their adult lives, people with borderline PD (BPD) appear unstable. They’re often at the crisis point as regards mood, behavior, or interpersonal relationships. Many feel empty and bored; they attach themselves strongly to others, then become intensely angry or hostile when they believe they are being ignored or mistreated by those they depend on. They may impulsively try to harm or mutilate themselves; these actions are expressions of anger, cries for help, or attempts to numb themselves to their emotional pain. Although patients with BPD may experience brief psychotic episodes, these resolve so quickly that they are seldom confused with psychoses like schizophrenia. Intense and rapid mood swings, impulsivity, and unstable interpersonal relationships make it difficult for these patients to achieve their full potential socially, at work, or in school.

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

The concept of BPD was devised about the middle of the 20th century. These patients were originally (and sometimes still are) said to hover between neurosis and psychosis—a “borderline” whose existence is disputed by many clinicians. As the concept has evolved into a PD, it has achieved remarkable popularity, perhaps because so many patients can be shoehorned into its capacious definition.

Although 1–2% of the general population may legitimately qualify for a diagnosis of BPD, it is probably applied to a far greater proportion of the patients who seek mental health care. It may still be one of the most overdiagnosed conditions in the diagnostic manuals. Many of these patients have other disorders that are more readily treatable; these include major depressive disorder, somatic symptom disorder, and substance-related disorders.

Essential Features of Borderline Personality Disorder

These patients exist in a perpetual crisis of mood or behavior. They often feel empty and bored. Disturbed identity (insecure self-image) can lead them to attach themselves strongly to others and then reject these same people with equal vigor. On the other hand, they may frantically try to avert desertion (it can be actual or fantasied). Pronounced impulsiveness can lead them to harm or mutilate themselves or to engage in other potentially harmful behaviors, such as sexual indiscretions, spending sprees, eating binges, or reckless driving. Although stress can cause brief episodes of dissociation or paranoia, these quickly resolve. Intense, rapid mood swings may yield to anger that is inappropriate and uncontrolled.

The Fine Print

The D’s: • Duration (begins in teens or early 20s and endures) • Diffuse contexts • Differential diagnosis (physical and substance use disorders, mood and psychotic disorders, other PDs)

Josephine Armitage

“I’m cutting myself!” The voice on the telephone was high-pitched and quavering. “I’m cutting myself right now! Ow! There, I’ve started.” The voice howled with pain and rage.

Twenty minutes later, the clinician had Josephine’s address and her promise that she would come in to the emergency room right away. Two hours later, her left forearm swathed in bandages, Josephine Armitage was sitting in an office in the mental health department. Criss-crossing scars furrowed her right arm from wrist to elbow. She was 33, a bit overweight, and chewing gum.

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

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

“I should think that would be pretty obvious. Are you going to be terminally dense, just like my last shrink?” She scowled and turned 90 degrees to look at the wall. “Sheesh!”

Her previous therapist had seen Josephine for a reduced fee, but had been unable to give her more time when she requested it. She had responded by letting the air out of all four tires of that clinician’s new BMW.

Her current trouble was with her boyfriend. One of her girlfriends had been “pretty sure” she’d seen James with another woman two nights ago. Yesterday morning, Josephine had called in sick to work and staked out James’s workplace so she could confront him. He hadn’t appeared, so last evening she had banged on the door of his apartment until neighbors threatened to call the police. Before leaving, she’d kicked a hole in the wall beside his door. Then she got drunk and drove up and down the main drag, trying to pick up a date.

“Sounds dangerous,” observed the clinician.

“I was looking for Mr. Goodbar, but no one turned up. I decided I’d have to cut myself again. It always seems to help.” Josephine’s anger had once again evaporated, and she had turned away from the wall. “Life’s a bitch, and then you die.”

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

“Well, let’s see.” She chewed her gum thoughtfully. “I get so angry and depressed, I just don’t care what happens. My last shrink said all my life I’ve felt like a shell of a person, and I guess that’s right. It feels like there’s no one living inside, so I might just as well pour out the blood and finish the job.”

Evaluation of Josephine Armitage

The first thing this clinician should do is to determine whether the behaviors reported (and observed) had been present since Josephine’s late teen years. From her report of the comment made by her “last shrink,” this would seem to be the case, but it should be verified. These behaviors were pervasive: Her work was affected (calling in sick on a whim), as were her relations with her boyfriend and her previous therapist.

Josephine had an abundance of symptoms. The entire episode of staking out James’s apartment could be seen as a frantic effort to avoid abandonment (BPD criterion A1). Even her initial moments with the present clinician revealed some swings between idealization and devaluation (criterion A2). She showed evidence of dangerous impulsivity (driving while under the influence of alcohol, trying to pick up a stranger—A4), and she had made repeated suicide attempts (A5). Her mood, even within the confines of this vignette, would seem markedly unstable and reactive to what she perceived to be the clinician’s attitude toward her (A6); her anger was sudden, inappropriate, and intense (A8). She agreed with a description of herself as an “empty shell” (A7). Although patients with BPD are often described as having identity disturbance and occasional, brief psychotic lapses, Josephine’s vignette gives no evidence of either of these. Even so, she had six or seven symptoms, whereas only five are required.

A long list of other mental disorders can be confused with BPD; each must be considered before settling on this disorder as a sole (or principal) diagnosis. (This isn’t a criterion for BPD, but it is one of the generic PD criteria, as well as one of my personal mantras.) Many patients with BPD also have major depressive disorder or dysthymia. It’s important to establish that suicidal behaviors, anger, and feelings of emptiness are not experienced only during episodes of depression. Similarly, we need to know that affective instability is not due to cyclothymic disorder. Note that the official criteria don’t mention any of these possibilities, but they are featured in the text.

Patients with BPD can have psychotic episodes, but these tend to be brief and stress-related, and they resolve quickly and spontaneously—all of which makes them unlikely to be confused with schizophrenia. The misuse of various substances can lead to suicide behavior, instability of mood, and reduced impulse control. Substance-related disorders are also often found as concomitants with BPD, and should always be asked about carefully. Patients with somatic symptom disorder are often quite dramatic and may misuse substances and make suicide attempts. Although this vignette contains no evidence for any of these (other than getting drunk—was this an isolated event?), the evaluating clinician would need to consider carefully the list just given.

Patients with BPD can also show features of additional PDs. Josephine’s presentation was dramatic, suggesting histrionic PD. Patients with narcissistic PD are also self-centered, though they don’t have Josephine’s impulsivity. Patients with antisocial PD are impulsive and do not control their anger; although some of Josephine’s behaviors were destructive, she did not engage in overtly criminal activity.

Finally, dissociative identity disorder is sometimes encountered in patients with BPD. Further interviewing and observation would be needed to rule out this rare condition. Assuming the verification of Josephine’s history, her diagnosis would be as given below. I would place her GAF score at 51.

F60.3 [301.83] Borderline personality disorder
S51.809 [881.00] Lacerations of forearm

There’s no such thing as a late-life PD. By definition, the PDs are conditions present, more or less, from the get-go. If you encounter a patient whose character structure appears to have changed during the adult years, search for the cause until you find it. Usually, you’ll turn up a personality change due to another medical condition, a mood or psychotic disorder, something substance-related, a cognitive issue, or a severe adjustment disorder.

F60.4 [301.50] Histrionic Personality Disorder

Patients with histrionic PD (HPD) have a long-standing pattern of extreme attention seeking and emotionalism that seeps into all areas of their lives. These people satisfy their need to be at center stage in two main ways: (1) Their interests and topics of conversation focus on their own desires and activities; and (2) they continually call attention to themselves by their behavior, including speech. They are overly concerned with physical attractiveness (of themselves and of others, as it relates to them), and they will express themselves so extravagantly that it can seem almost a parody of normal emotionality. Their need for approval can cause them to be seductive, often inappropriately (even flamboyantly) so. Many lead normal sex lives, but some will be promiscuous, and still others may be uninterested in sex.

These people are often so insecure that they constantly seek the approval of other people. Dependence on the favor of others may cause their moods to seem shallow or excessively reactive to their surroundings. Low tolerance for frustration can spawn temper tantrums. They usually like to talk with mental health professionals (it is another chance to be the center of attention), but because their speech is often vague and full of exaggerations, they can prove frustrating to interview.

Quick to form new friendships, people with HPD are also quick to become demanding. Because they are trusting and easily influenced, their behavior may appear inconsistent. They don’t think very analytically, so they may have difficulty with tasks that require logical thinking, such as doing mental arithmetic. However, they may succeed in jobs that set a premium on creativity and imagination. Their craving for novelty sometimes leads to legal problems as they seek sensation or stimulation. Some have a remarkable tendency to forget affect-laden material.

HPD has not been especially well studied, but it is reportedly quite common. It may run in families. The classic patient is female, though the disorder can occur in men.

Essential Features of Histrionic Personality Disorder

These patients not only crave the limelight, but are unhappy when they are not the focus of attention. They actively attempt to draw attention to themselves with their physical appearance and mannerisms. Their manner of speaking may be overly dramatic, but what they say tends to be vague, lacking specificity. They can be gushing or effusive when expressing their emotions, which, however, tend to be superficial and fleeting. Too open to suggestion, too readily influenced, these people may interpret relationships as being intimate when they’re not—even to the extent of behaving in ways that are improperly suggestive or seductive.

The Fine Print

The D’s: • Duration (begins in teens or early 20s and endures) • Diffuse contexts • Differential diagnosis (physical and substance use disorders, somatic symptom disorder, other personality disorders)

Angela Black

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

“He never listens to me. I might as well be talking to the dog!” Tears and mascara dripped onto the front of Angela’s low-cut silk dress.

“What’s there to listen to?” Donald retorted. “I know I irritate her, because she complains so much. But when I ask how she’d like me to change, she can never put her finger on it.”

Angela and Donald were both 37 years old, and they had been married nearly 10 years. Already they had been separated twice. Donald made excellent money as a corporate lawyer; Angela had been a fashion model. She didn’t work often any more, but her husband made enough to keep her well dressed and comfortably shod. “I don’t think she’s ever worn the same dress twice,” Donald grumbled.

“Yes, I have,” she snapped back.

“When? Name one time.”

“I do it all the time. Especially recently.” For several moments Angela defended herself, without ever making a concrete statement of fact.

“Res ipsa loquitur,” said Donald with satisfaction.

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

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

He worked late most nights and weekends, which upset her. She spent far too much money on jewelry and clothing. She relished the fact that she could still attract men. “I wouldn’t do it if you paid more attention to me,” she said, pouting.

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

Marilyn and Angela had been best friends since their cheerleading days in high school. Marilyn was wealthy and independent; she didn’t care what people thought, and behaved accordingly. Usually Angela followed right along.

“Like the pool party last summer,” put in Donald, “when you took off your suits to ‘practice cheers’ for the races. Or was that your idea?”

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

Evaluation of Angela Black

Angela’s personality style had a profound effect on her marriage, though the vignette hints that her other social relationships (for example, men at the party) were affected as well. More information would be needed to establish that she had been this way throughout her adult life. However, it would seem unlikely that her way of doing business with the world had developed recently.

Angela’s symptoms included a strong need to be the center of attention (HPD criterion A1) and sexual provocation (inferred from her dancing topless—A2); excessive concern with physical appearance (A4); dramatic emotional expression (A6); suggestibility (following the lead of her friend Marilyn—A7); and vague speech (commented on by her husband—A5). I thought she might have expressed a touch of rapidly shifting emotional expression (A3), too, but maybe that’s just me. Conservatively scored, she had at least six symptoms of HPD (five are required by the DSM-5 criteria).

Her clinician should gather information adequate to determine that Angela did not have any of the major mental disorders that commonly accompany HPD. These include somatic symptom disorder (had she been in good physical health?) and substance-related disorders.

Would Angela qualify for other PD diagnoses? She was centrally focused on herself, and she liked to be admired. However, she lacked the sense of grandiose accomplishment that characterizes patients with narcissistic PD. You can often identify histrionic features in people with borderline PD. Angela’s mood was somewhat labile, but she did not report interpersonal instability, identity disturbance, transient paranoid ideation, or other symptoms that characterize borderline patients. Her easy suggestibility might suggest dependent PD, but she was so far from leaning on her husband for support that she actively fought with him. With a GAF score of 65, I’d diagnose her as follows:

F60.4 [301.50] Histrionic personality disorder
Z63.0 [V61.10] Relationship distress with spouse

F60.81 [301.81] Narcissistic Personality Disorder

People with narcissistic PD (NPD) have a lifelong pattern of grandiosity (in behavior and in fantasy), a thirst for admiration, and an absence of empathy. These attitudes permeate most aspects of their lives. They regard themselves as unusually special; they are self-important individuals who commonly exaggerate their accomplishments. (From the outset, however, we need to note that these traits constitute a PD only in adults. Children and teenagers are naturally self-centered; in kids, narcissistic traits don’t necessarily imply ultimate PD.)

Despite their grandiose attitudes, people with NPD have fragile self-esteem and often feel unworthy; even at times of great personal success, they may feel fraudulent or undeserving. They remain overly sensitive to what others think about them, and feel compelled to extract compliments. When criticized, they may cover their distress with a façade of icy indifference. As sensitive as they are about their own feelings, they have little apparent understanding of the feelings and needs of others and may feign empathy, just as they may lie to cover their own faults.

Patients with NPD often fantasize about wild success and envy those who have achieved it. They may choose friends they think can help them get what they want. Job performance can suffer (due to interpersonal problems), or it can be enhanced (due to their eternal drive for success). Because they tend to be concerned with grooming and value their youthful looks, they may become increasingly depressed as they age.

NPD has been seldom studied. It appears to occur in under 1% of the general population; reportedly, most patients are men. There is no information about family history, environmental antecedents, or other background material that might help us to understand these difficult personalities.

Essential Features of Narcissistic Personality Disorder

These people possess grandiosity, together with a craving for admiration. To get it, they typically exaggerate their own abilities and accomplishments. They tend to be preoccupied with fantasies of beauty, brilliance, perfect love, power, or limitless success, and believe that they are so unusual that they should only associate with people or institutions of rarefied status. Often arrogant or haughty, they may believe that others envy them (though the reverse may actually be true). Lack of empathy engages their feelings of privilege in justifying the exploitation of others to achieve their own goals.

The Fine Print

The D’s: • Duration (begins in teens or early 20s and endures) • Diffuse contexts • Differential diagnosis (physical and substance use disorders, bipolar disorders, other personality disorders)

Berna Whitlow

“Dr. Whitlow, you’re my backup for emergency clinic this afternoon. I’ve got to have some help from you!” Eleanor Bondurak, a social worker at the mental health clinic, was red-faced with anger and frustration. It wasn’t the first time she had had difficulty working with this clinician.

At the age of 50, Berna Whitlow had worked at nearly every mental health clinic in the metropolitan area. She was well trained and highly intelligent, and she read voraciously in her specialty. Those were the qualities that had landed her job after job over the years. The qualities that kept her moving from one job to another were known better to those who worked with her than to those who hired her. She was famous among her colleagues for being pompous and self-centered.

“She said she wasn’t going to take orders from me. And her attitude said for her, ‘You’re nothing but a social worker.’ ” Eleanor was now reliving the moment in a heated discussion with the clinical director. “She said she’d talk to my boss or to you. I pointed out that neither of you was in the building at the time, and that the patient had brought in a gun in his briefcase. So then she said I should ‘write it up and submit it,’ and she would ‘decide what action to take.’ That’s when I had you paged.”

With the crisis over (the gun had been unloaded, the patient not dangerous), the clinical director had dropped in to chat with Dr. Whitlow. “Look, Berna, it’s true that ordinarily the social worker sees the patient and does a write-up before you step in. But this wasn’t exactly an ordinary case! Especially in emergencies, the whole team has to act together.”

Berna Whitlow was tall, with a straight nose and jutting chin that seemed to radiate authority. Her long hair was thick and blond. She raised her chin a bit higher. “You hardly need to lecture me on the team approach. I’ve been a leader in nearly every clinic in town. I’m a superb team leader. You can ask anyone.” As she spoke, she rubbed the gold rings that encircled nearly every finger.

“But being a team leader involves more than just giving orders. It’s also about gathering information, building consensus, caring about the feelings of oth—”

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

Evaluation of Berna Whitlow

From the material we have (which does not include a clinical interview, so our conclusions must be tentative), Dr. Whitlow’s personality traits would seem to have caused difficulties for many years. They affected her life broadly, interfering with work (many jobs) and interpersonal relationships. Of course, a full assessment would inquire about her personality as it affected her home and social life.

Symptoms suggestive of NPD included her haughty attitude (NPD criterion A9), exaggerating her own accomplishments (“I’m a superb team leader”—A1), insisting that she receive orders or requests only from persons of high rank (A3), expecting obedience (from a sense of entitlement—A5), and lacking empathy with fellow workers (A7). Five criteria are needed; affective, cognitive, and interpersonal features were present (see the Essential Features for a general PD earlier in this chapter).

Several other PDs can either accompany or be confused with NPD. Patients with histrionic PD are also extremely self-centered, but Dr. Whitlow was not as theatrical (although she did wear a lot of rings). As is the case in borderline PD (and most other PDs), patients with NPD have a great deal of trouble relating to other people. But they (including Dr. Whitlow) are not especially prone to unstable moods, suicidal behavior, or brief psychoses under stress. Although there is a hint of the deceitful in narcissistic exaggerations, these people lack the pervasive criminality and disregard for the rights of others that are typical of antisocial PD.

Although dysthymia and major depressive disorder frequently accompany NPD, there is no evidence in the vignette to support either of those diagnoses. Dr. Whitlow’s tentative diagnosis (GAF score of 61) would be as follows:

F60.81 [301.81] Narcissistic personality disorder

CLUSTER C PERSONALITY DISORDERS

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

F60.6 [301.82] Avoidant Personality Disorder

People with avoidant PD (APD) feel inadequate, are socially inhibited, and are overly sensitive to criticism. These characteristics are present throughout adult life, and affect most aspects of daily life. (Like narcissistic traits, avoidant traits are common in children and don’t necessarily imply eventual PD.)

Their sensitivity to criticism and disapproval makes these people self-effacing and eager to please others, but it can also lead to marked social isolation. They may misinterpret innocent comments as critical; often they refuse to begin a relationship unless they are sure they will be accepted. They will hang back in social situations for fear of saying something foolish, and may avoid occupations that involve social demands. Other than their parents, siblings, or children, they tend to have few close friends. Comfortable with routine, they may go to great lengths to avoid departing from their set ways. In an interview they can appear tense and anxious; they may misinterpret even benign statements as criticism.

Although APD has appeared in the DSMs since 1980, relevant research is still sparse. In frequency, it occupies middle ground (about 2% of the general population) as PDs go, roughly equal for men and women. Many such patients marry and work, although they may become depressed or anxious if they lose their support systems. Sometimes this disorder is associated with having a disfiguring illness or condition. APD is not often seen clinically; these patients tend to come to evaluation only when another illness supervenes. There is considerable overlap with social anxiety disorder.

Essential Features of Avoidant Personality Disorder

These patients are socially inhibited, are overly sensitive to criticism, and feel inadequate. Feeling themselves inferior, unappealing, or clumsy, they are reluctant to form new relationships. Such people so fear ridicule or shame that they will only become involved with others if they can know in advance they will be accepted. Otherwise, their worry about being rejected or criticized (or embarrassed) on the job or in social situations will lead them to avoid new pursuits.

The Fine Print

The D’s: • Duration (begins in teens or early 20s and endures) • Diffuse contexts • Differential diagnosis (physical and substance use disorders, social anxiety disorder, paranoid and schizoid PDs)

Jack Weiblich

Jack Weiblich was feeling worse when he ought to be feeling better. At least, that’s what his new acquaintances in Alcoholics Anonymous had told him. One had reminded him that 30 days’ sobriety was “time enough to detox every last cell” in his body. Another thought he was having a “dry drunk.”

“Whatever a ‘dry drunk’ is,” Jack observed later. “All I know is that after 5 weeks without alcohol, I’m feeling every bit as bad as I did 15 years ago, before I’d ever had a drop. I’ve enjoyed hangovers more than this!”

At age 32, Jack had a lot of hangovers to choose from. He’d had his first drink when he was only a senior in high school. He had been a strange, lonely sort of kid who’d had a great deal of difficulty meeting other people. While he was still in high school, he had begun to lose his hair; now, with the exception of his eyebrows and eyelashes, he was totally bald. He was also afflicted with a slight, persistent nodding of his head. “Titubation,” the neurologist had said; “don’t worry about it.” The sight of his balding, nodding head in the mirror every morning looked grotesque, even to Jack. As a teenager he found it almost impossible to form relationships; he was positive that no one could like someone as peculiar as he was.

Then one evening Jack found alcohol. “Right from the first drink, I knew I’d discovered something important. With two beers on board, I forgot all about my head. I even asked a girl out. She turned me down, but it didn’t seem to matter that much. I had found a life.” But the following morning, he found that he still had his old personality. He experimented for months before he learned when and how much he could drink and maintain a glow sufficiently rosy to help him feel well, but not too rosy to function. During a 3-week period in his senior year at law school when he sobered up completely, he discovered that without alcohol, he still had the same old feelings of isolation and rejection.

“When I’m not drinking, I don’t feel sad or anxious,” Jack observed. “But I’m lonely and uncomfortable with myself, and I feel that other people will feel the same about me. I guess that’s why I just don’t make friends.”

After law school, Jack went to work for a small firm that specialized in corporate law. They called him “The Mole,” because he spent nearly all of every work day in the law library doing research. “I just didn’t feel comfortable meeting the clients—I never get along well with new people.”

The only exception to this lifestyle was Jack’s membership in the stamp club. From his grandfather, he had inherited a large collection of commemorative plate blocks. When he took these to the Philatelic Society, he thought they’d welcome him with open arms, and they did. He continued to build upon his grandfather’s collection and attended meetings once a month. “I guess I feel OK there because I don’t have to worry whether they’ll like me. I’ve got a great stamp collection for them to admire.”

Evaluation of Jack Weiblich

Jack’s symptoms were pervasive (profoundly affecting his work and social life) and had been present long enough (since he was a teenager) to qualify for a PD. They included the following typical APD features: He avoided interpersonal contact (for example, with clients at the law firm—criterion A1); he felt that he was unappealing (A6); although he joined the stamp club, he was pretty sure that his collection would be accepted (A2); he worried a lot about being rejected (A4). Only four criteria are needed; cognitive, occupational, and interpersonal areas were involved for Jack Weiblich (see the Essential Features for a general PD earlier in this chapter).

Depression and anxiety are both common in patients with APD. Therefore, it is important to search for evidence of mood disorders and anxiety disorders (especially social anxiety disorder) in patients who avoid contact with others. Jack stated explicitly that he felt neither sad nor anxious, but he admitted that he had severely misused alcohol. The substance-related disorders also commonly bring a patient with APD to the attention of mental health care providers.

In both APD and schizoid PD, patients spend most of their time alone. The difference, of course, is that patients with APD are unhappy with their condition, whereas people with schizoid PD prefer it that way. A somewhat more difficult differential diagnosis may be that between APD and dependent PD. (Dependent patients avoid positions of responsibility, as Jack did.) Note that Jack’s avoidant lifestyle may have been bound up in his twin physical peculiarities, his baldness and nodding head.

Although Jack had an alcohol use disorder, his clinician felt that it was causing him little current difficulty and that the PD was the fundamental problem needing treatment (other clinicians might argue with this interpretation). That’s why the PD was listed as his principal diagnosis. Of course, he didn’t qualify for any course modifiers for alcohol use disorder, because he’d only been on the wagon for 5 weeks (p. 409); I thought his alcoholism was pretty mild, actually (and note that the PD doesn’t enter into the coding of the substance use disorder; see Table 15.2in Chapter 15). I’d put his GAF score at 61.

F60.6 [301.82] Avoidant personality disorder
F10.10 [305.00] Alcohol use disorder, mild
L63.1 [704.09] Alopecia universalis
R25.0 [781.0] Nodding of head

F60.7 [301.6] Dependent Personality Disorder

Much more so than most, patients with dependent PD (DPD) feel the need for someone else to take care of them. Because they desperately fear separation, their behavior becomes so submissive and clinging that it may result in others’ taking advantage of them or rejecting them. Anxiety blossoms if they are thrust into a position of leadership, and they feel helpless and uncomfortable when they are alone. Because they typically need much reassurance, they may have trouble making decisions. Such patients have trouble starting projects and sticking to a job on their own, though they may do well under the careful direction of someone else. They tend to belittle themselves and to agree with people who they know are wrong. They may also tolerate considerable abuse (even battering).

Though it may occur commonly, this condition has not been well studied. Some writers believe that it is difficult to distinguish it from avoidant PD. It has been found more often among women than men. Bud Stanhope, a patient with the sleep terror type of non-rapid eye movement sleep arousal disorder, also had DPD; his history is given in an earlier chapter.

Essential Features of Dependent Personality Disorder

The need for supportive relationships draws these people into clinging, submissive behavior and fears of separation. Fear of disapproval makes it hard to disagree with others; to gain support, they will even take extraordinary steps, such as assuming unpleasant tasks. Low self-confidence prevents them from starting or carrying out projects independently; indeed, they want others to take responsibility for their own major life areas. If they do make even everyday decisions, they require lots of advice and reassurance. Exaggerated, unrealistic fears of abandonment and the notion that they cannot care for themselves will cause these people to feel helpless or uncomfortable when alone; they may desperately seek a replacement for a lost close personal relationship.

The Fine Print

The D’s: • Duration (begins in teens or early 20s and endures) • Diffuse contexts • Differential diagnosis (physical and substance use disorders, mood and anxiety disorders, other PDs)

Janet Greenspan

A secretary in a large Silicon Valley company, Janet Greenspan was one of the best workers there. She was never sick or absent, and she could do anything—she’d even had some bookkeeping experience. Her supervisor noted that she was polite on the phone, typed like a demon, and would volunteer for anything. When the building maintenance crew went out on strike, Janet came in early every day for a week to clean the toilets and sinks. But still, somehow, she just wasn’t working out.

Her supervisor complained that Janet needed too much direction, even for simple things—such as what sort of paper to type form letters on. When she was asked what she thought the answer should be, her judgment was good, but she always wanted guidance anyway. Her constant need for reassurance took an inordinate amount of her supervisor’s time. That was why she had been referred to the company mental health consultant for an evaluation.

At 28, Janet was slender, attractive, and carefully dressed. Her chestnut hair already showed streaks of gray. She appeared at the doorway of the office and asked, “Where would you like me to sit?” Once she started talking, she spoke readily about her life and her work.

She had always felt timid and unsure of herself. She and her two sisters had grown up with a father who was affectionate but dictatorial; their mouse of a mother seemed to welcome his loving tyranny. At her mother’s knee, Janet had learned obedience well.

When Janet was 18, her father suddenly died; within a few months, her mother remarried and moved to another state. Janet felt bereft and panic-stricken. Instead of beginning college, she took a job as a teller in a bank; soon afterward, she married one of her customers. He was a 30-year-old bachelor, set in his ways, and he soon let it be known that he preferred to make all of the couple’s decisions himself. For the first time in a year, Janet relaxed.

But even security bred its own anxieties. “Sometimes at night I wake up, wondering what I’d do if I lost him,” Janet told the interviewer. “It makes my heart beat so fast I think it might stop from exhaustion. I just don’t think I could manage on my own.”

Evaluation of Janet Greenspan

Janet had the following symptoms of DPD: She needed considerable advice to make everyday decisions (criterion A1); she wanted her husband to make their decisions (A2); panic-stricken when her father died and her mother left town, she fled into an early marriage (A7); she feared being left to fend for herself, even though she had had no indication that this was likely (A8). She even volunteered to clean the office toilet, probably to secure the favor of the rest of the staff (A5). We have no evidence that she was reluctant to disagree with others, but otherwise the criteria fit like a rubber glove. Five are needed for diagnosis. Janet reported that she had been this way since childhood; from the history, her character traits would seem to have affected both work and social life. Fortunately, she married someone whose need to be in charge matched her dependency. Cognitive, affective, and interpersonal areas were involved (see the criteria for a general PD).

Dependent behavior is found in several mental disorders that Janet did not appear to have, including somatic symptom disorder and agoraphobia. The person with the secondary psychosis in what used to be called folie à deux (or shared psychotic disorder—now it is usually diagnosed as delusional disorder) often has a dependent personality. Major depressive disorder and dysthymia are important in the differential diagnosis; either of these may become prominent when patients lose those upon whom they depend. Even if Janet had all the required physiological symptoms for generalized anxiety disorder, she would not be given this diagnosis, because her worries were evidently limited to fears of abandonment.

Patients with DPD must be differentiated from those with histrionic PD, who are impressionable and easily influenced by others (but Janet did not seem to be especially attention-seeking). Other PDs usually included in the differential diagnosis are borderline and avoidant.

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

F60.7 [301.6] Dependent personality disorder

F60.5 [301.4] Obsessive–Compulsive Personality Disorder

People with obsessive–compulsive PD (OCPD) are perfectionistic and preoccupied with orderliness; they need to exert interpersonal and mental control. These traits exist on a lifelong basis, at the expense of efficiency, flexibility, and candor. However, OCPD is not just obsessive–compulsive disorder (OCD) in miniature. Many patients with OCPD have no actual obsessions or compulsions at all, though some do eventually develop OCD.

The rigid perfectionism of these patients often results in indecisiveness, preoccupation with detail, scrupulosity, and insistence that others do things their way. These behaviors can interfere with their effectiveness in work or social situations. Often they seem depressed, and this depression may wax and wane, perhaps to the point that it drives them into treatment. Sometimes these people are stingy; they may be savers, refusing to throw away even worthless objects they no longer need. They may have trouble expressing affection.

Patients with OCPD are list makers who allocate their own time poorly, workaholics who must meticulously plan even their own pleasure. They may plan their own vacations only to postpone them. They resist the authority of others, but insist on their own. They may be perceived as stilted, stiff, or moralistic.

This condition is probably fairly common; prevalence in various studies centers around 5%. It is diagnosed more often in males than in females, and it probably runs in families.

Essential Features of Obsessive–Compulsive Personality Disorder

These people are intensely focused on control, orderliness, and perfection. They can become so absorbed with details, organization, and rules of an activity that they lose sight of its purpose. They tend to be rigid and stubborn, perhaps so perfectionistic that it interferes with the completion of tasks. They can be overly conscientious, inflexible, or scrupulous about ethics, morals, and values. Some are workaholics; others won’t work unless others agree to do things the patients’ way. Some may save worthless items; others are stingy with themselves and with other people.

The Fine Print

The D’s: • Duration (begins in teens or early 20s and endures) • Diffuse contexts • Differential diagnosis (physical and substance use disorders, OCD, hoarding disorder, other PDs)

Robin Chatterjee

“I admit it—I’m over the top in neatness.” Robin Chatterjee straightened a fold in her sari. Born in Mumbai and educated in London, Robin was a graduate student in biology. Now she spent part of her time as a teaching assistant in biology, and the rest struggling through her own coursework at a major U.S. university. She gazed steadily at the interviewer.

According to her preceptor, a slightly dour Scot named MacLeish who had asked her to come for the interview, the problem wasn’t neatness. It was completing the work. Every paper she turned in was wonderful—every fact was there, every conclusion correct, not even a misspelling. He had asked her why she couldn’t learn to let go of them a little sooner, “before the rats die of old age?” She had thought it funny at the time, but it made her think.

Robin had always been orderly. Her mother had made her keep neat little lists of her chores, and the habit stuck. Robin admitted that she became so “lost in lists” that sometimes she hardly had time to finish her work. Her students seemed fond of her, but several had said they wished she’d give them more responsibility. One had told Dr. MacLeish that Robin seemed afraid even to let them do their own dissections; their methods weren’t as compulsively correct as hers were, so she’d try to do them herself. Finally, she also admitted that nearly every night, her work habits kept her in the lab until late. It had been weeks since she’d had a date—or any social life at all. This realization was what spurred her to follow Dr. MacLeish’s advice and come in for a mental health evaluation.

Evaluation of Robin Chatterjee

Although the prototype for OCPD seems a pretty good fit for Robin, she would just barely meet the official criteria. She was workaholic and perfectionistic (OCPD criteria A3 and A2), to the point that these traits interfered with the learning of her students. She had a great deal of difficulty delegating work—even the students’ own dissections (A6)! And she concentrated so fiercely on her lists of tasks that she sometimes didn’t accomplish the tasks themselves (A1). She had had these tendencies throughout her young adult life.

Depressed mood is common in these people. The common disorders that should be looked for in a patient with OCPD include OCD itself, major depressive disorder, and dysthymia. Robin was not depressed and, unlike so many patients with OCPD, seemed to have no other disorder. Because she barely met the criteria and was functioning well overall, I would place her GAF score at a relatively high 70.

F60.5 [301.4] Obsessive–compulsive personality disorder

OTHER PERSONALITY CONDITIONS

F07.0 [310.1] Personality Change Due to Another Medical Condition

Some medical conditions can cause a personality change, which is defined as an alteration (usually, a worsening) of a patient’s previous personality traits. If the medical condition occurs early enough in childhood, the change can last throughout the person’s life. Most instances of personality change are caused by an injury to the brain or by some other central nervous system disorder, such as epilepsy or Huntington’s disease; however, systemic diseases that affect the brain (for example, systemic lupus erythematosis) are also sometimes implicated.

Several sorts of personality changes commonly occur. Mood may become unstable, perhaps with outbursts of rage or suspiciousness; other patients may become apathetic and passive. Changes in mood are especially common with damage to the frontal lobes of the brain. Patients with temporal lobe epilepsy may become overly religious, verbose, and lacking in a sense of humor; some may turn markedly aggressive. Paranoid ideas are also common. Belligerence can accompany outbursts of temper, to the extent that the social judgment of some patients becomes markedly impaired. Use the type specifiers in the Coding Notes to categorize the nature of the personality change.

If there is a major alteration in the structure of the brain, these personality changes will probably persist. If the problem stems from a correctable chemical problem, they may resolve. When severe, they can ultimately lead to dementia, as is sometimes the case in patients with multiple sclerosis.

Essential Features of Personality Change Due to Another Medical Condition

A physical illness or injury appears to have caused a patient to suffer a lasting personality change.

The Fine Print

From their expected developmental pattern, children will experience a personality change that lasts at least 1 year.

The D’s: • Duration (enduring) • Distress or disability (work/educational, social, or personal) • Differential diagnosis (delirium, other physical or mental disorders)

Coding Notes

Depending on the main feature, specify type:

Aggressive type

Apathetic type

Disinhibited type

Labile type

Paranoid type

Other type

Combined type

Unspecified type

Use the actual name of the general medical condition when you code this disorder, and also code separately the medical condition.

Eddie Ortway

Eddie Ortway, now age 28, had been born in central Los Angeles, where he was reared by his mother—whenever she was neither hospitalized (for drug and alcohol use) nor jailed (for prostitution). His parents, Eddie always suspected, had been only briefly acquainted.

Eddie avoided school whenever possible, and grew up with no role model in sight. His principal accomplishment was learning to use his fists. By the time he was 15, he and his gang had participated in several turf wars. He was making a name for himself as an aggressive enemy.

But Eddie was not a criminal, and the necessity for earning a living soon set him to work. With little education and no training, he found his opportunities pretty much limited to fast food and hard labor. Sometimes he held several jobs at a time. But, as an old probation report noted, he still had “a raging sense of injustice.” Although he gradually stopped associating with his gang, through his middle 20s he continued to deal aggressively with any situation that seemed to require direct action.

His 27th birthday was one of these. Eddie was delivering a pizza to an apartment building in his old neighborhood when he encountered a teenager forcing an old woman into an alley at gunpoint. Eddie stepped forward and for his pains received a bullet that entered his head through the left eye socket and exited at the hairline.

He was admitted to the hospital by way of the operating room, where surgeons debrided his wound. He never even lost consciousness and was released in less than a week. But he didn’t return to work. The social worker’s report noted that Eddie’s physical condition had rebounded within a month, but that he “lacked drive.” He appeared for every scheduled job interview, but his prospective employers uniformly reported that he “just didn’t seem very interested in working.”

“I needed time to recuperate,” Eddie told the interviewer. He was a good-looking young man whose hair had begun receding from his forehead. An incisional scar ran up onto his scalp. “I still don’t think I’m quite ready.”

He had been recuperating for 2 years. Now he was being tested to try to learn why. Other than a slight droop to his left eyelid, his neurological examination was completely normal. An EEG showed some slow waves over the frontal lobes; the MRI revealed a localized absence of brain tissue.

Eddie never failed to cooperate with testing procedures, and all of the clinicians who examined him noted that he was polite and pleasant. However, as one of them put it, “There seems something slightly mechanical about his cooperation. He complies but never anticipates, and he shows little interest in the proceedings.”

His affect was about medium and showed almost no lability. His speech was clear, coherent, and relevant. He denied delusions, hallucinations, obsessions, compulsions, or phobias. When asked what he was interested in, he thought for a few seconds and then answered that he guessed he was interested in going back home. He made a perfect score on the MMSE.

In the time since his injury, Eddie admitted, he had lived on workers’ compensation and spent most of his time watching television. He didn’t argue with anyone any more. When one examiner asked him what he would do if he again saw someone being mugged, he shrugged and said that he thought people should “just live and let live.”

Evaluation of Eddie Ortway

Eddie’s history and examinations presented an obvious general medical cause for his persistent personality change (criterion A). Note that it was the physiology of trauma to the brain that produced Eddie’s personality change. This is the explicit requirement (B) for this diagnosis, which cannot be made when personality change accompanies a nonspecific medical condition such as severe pain.

Eddie’s normal attention span and lack of memory deficit would rule out delirium (D) and major neurocognitive disorder (dementia); however, neuropsychological testing should be requested. A PD such as dependent PD could not explain Eddie’s condition, because his behavior represented a marked change from his premorbid personality (that is, the way he was until his injury). And the features of Eddie’s personality change were not better explained by a different physically induced mental disorder. A mood disorder due to brain trauma would be one of several possible examples.

Besides head trauma, a variety of neurological conditions can cause personality change. These include multiple sclerosis, cerebrovascular accidents, brain tumors, and temporal lobe epilepsy. Other causes of behavioral change that could resemble a change in personality include delusional disorderintermittent explosive disorder, and schizophrenia. But Eddie’s personality change began abruptly after he was shot, and he had no prior history that was consistent with any of the other disorders mentioned (C). However, many other patients experience apparent personality change associated with mental disorders, including addiction to substances.

The fact that Eddie’s condition impaired him both occupationally and socially completed the criteria (E) for this diagnosis. In his clinical picture, apathy (and passivity) clearly stood out as the main feature. This determined the specific subtype. His GAF score would be a heart-breaking 55.

S06.330 [851.31] Open gunshot wound of cerebral cortex, without loss of consciousness
F07.0 [310.1] Personality change due to head trauma, apathetic type

F60.89 [301.89] Other Specified Personality Disorder

F60.9 [301.9] Unspecified Personality Disorder

The discussion in DSM-5 suggests that patients who have some traits of certain PDs, but who don’t fully meet criteria for any of them, could be listed in one of these two categories. Here’s my problem with that strategy: We would be branding someone who may be much less impaired than is the typical patient with a PD. My personal belief is that it would be better just to note in the summary the traits we’ve identified, and not make a firm diagnosis of any sort.

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