Quick Guide to the 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People with Cluster A PDs can be described as withdrawn, cold, suspicious, or irrational.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 p

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