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How To Diagnose People You Don’t Like With Personality Disorders

Welcome to the wonderful world of Psychiatry.

A place where there are all sorts of amazing diagnoses to give people who rub you the wrong way. A place where people aren’t just assholes, they’re Narcissistic. They’re not just dramatic and self-indulgent, they’re Histrionic. They’re not just emotionally labile and needy, they’re Borderline.

Now, I’m not necessarily a fan of needlessly labeling people with personality disorders, and I do think psychiatrists tend to diagnose people with personality disorders just because they’re difficult to deal with. At the same time, though, having a framework can help you understand people who have semi-pathological traits and characteristics and can actually make it more tolerable to cope with these people.

For example, say your boss is a real jerk who’s always giving you a hard time, and all you can think is “Hey, this guy’s a jerk.” But if you understand he has traits of Narcissistic Personality Disorder, you start to see certain small interactions with him as part of a larger pattern of psychopathology, which can help you realize not to take stuff he says or does so personally, because he has a different way of interacting with the world than you. Make sense?

So let’s get into the nitty gritty. The diagnostic bible of psychiatry is the Diagnostic and Statistical Manual (DSM), which is constantly being updated and revised. We are currently on version IV (so DSM-IV), although version V is in the works and supposedly will reframe how we diagnose personality disorders. So the following is accurate as of now, but may change when the new version of the Manual comes out.

There are 3 “Clusters” of personality disorders in the DSM-IV.

  1. Cluster A – People with odd or eccentric characteristics. Includes Paranoid Personality Disorder, Schizoid Personality Disorder, and Schizotypal Personality Disorder.
  2. Cluster B – People who are dramatic, emotional or impulsive. Includes Antisocial Personality Disorder, Borderline Personality Disorder, Narcissistic Personality Disorder and Histrionic Personality Disorder.
  3. Cluster C – People who are highly anxious and fearful. Includes Dependent Personality Disorder, Avoidant Personality Disorder and Obsessive-Compulsive Personality Disorder.

Now I’m just going to focus on the Cluster B disorders because people with these disorders tend to be the most difficult to deal with. Someone with Schizotypal Personality Disorder will just sit in their room by themselves reading subversive books and ordering prayer rocks online, but a raging narcissist can make your life a living hell.

Narcissistic Personality Disorder

Perhaps my favorite disorder to diagnose in people who are difficult to deal with. Anytime you interact with someone who acts entitled, demanding and superior probably has narcissistic personality traits, if not the full blown disorder. As with all personality disorders, the different between someone with a mild case of asshole-ism versus the full-blown personality disorder is that someone with the personality disorder has such severe characteristics that they are impaired in interpersonal interactions and daily life.

Per the DSM IV, Narcissistic Personality Disorder is diagnosed when someone meets 5 (or more) of the following 9 criteria:

  1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
  2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
  3. Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
  4. Requires excessive admiration.
  5. Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations.
  6. Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends.
  7. Lacks empathy:  is unwilling to recognize or identify with the feelings and needs of others.
  8. Is often envious of others or believes that others are envious of him or her.
  9. Shows arrogant, haughty behaviors or attitudes.

People with Narcissistic Personality Disorder can be extremely frustrating to deal with and will test the very ends of your patience. It’s key to realize they are operating from a very specific place – one where they are the center of the universe. You’re not going to be able to convince them that they’re not, so don’t waste your energy trying. Unsurprisingly, Narcissists aren’t usually too eager to seek treatment for their condition from a psychiatrist or therapist.

Borderline Personality Disorder

You know that friend you have who’s emotionally needy and clingy one minute, and then pushing you away the next? The type of person who loves you one day and hates you the next? Who’s afraid you’ll leave them but then leaves you first? Who crumples into a pile of tears at a moment’s notice and cuts as a way to cope with emotional pain? Yeah, that friend of yours just might have Borderline Personality Disorder.

Per the DSM IV, Borderline Personality Disorder is diagnosed when there is pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following:

  1. Frantic efforts to avoid real or imagined abandonment.
  2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
  3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
  4. Impulsivity in at least two areas that are potentially self-damaging (eg, spending, sex, substance abuse, reckless driving, binge eating).
  5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
  6. Affective instability/marked reactivity of mood.
  7. Chronic feelings of emptiness.
  8. Inappropriate, intense anger or difficulty controlling anger.
  9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Borderline Personality Disorder is just as frustrating for the person who has it as it is for the person who’s dealing with the person who has it. It is very common for people with BPD to have a history of childhood abuse, leading to feelings of severe insecurity and fear of abandonment. They’re so afraid of being abandoned that they lash out at others as a way to protect themselves from feeling hurt. They “split,” meaning they put people in categories of all good and all bad. When you’re in their good graces, they love you. But when you’re not… watch out. It’s a complicated disorder often treated with a combination of medications and therapy. It’s much more common in women, but men can have it too.

Histrionic Personality Disorder

It’s hard to miss someone with Histrionic Personality Disorder. She’s usually female, loud, dramatic and attention seeking. She’s sexually provocative way past the point of appropriateness. You may have talked to her at a party or two, but don’t feel like you could ever have a deep or meaningful conversation with her.

The DSM IV describes Histrionic Personality Disorder as a pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following:

  1. Is uncomfortable in situations in which he or she is not the center of attention.
  2. Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.
  3. Displays rapidly shifting and shallow expression of emotions.
  4. Consistently uses physical appearance to draw attention to self.
  5. Has a style of speech that is excessively impressionistic and lacking in detail.
  6. Shows self-dramatization, theatricality, and exaggerated expression of emotion.
  7. Os suggestible, i.e., easily influenced by others or circumstances.
  8. Considers relationships to be more intimate than they actually are.

People with Histrionic Personality Disorder feel a compulsive need to be the center of attention. They might look like they’re in a constant state of performing. It can be difficult to have a meaningful friendship or relationship with this type of person.

Antisocial Personality Disorder

When people think of the word “antisocial,” they probably think of a loner-type of person who is shy, doesn’t have a lot of friends, and sits at home playing World of Warcraft instead of trying to find a girlfriend. Antisocial Personality Disorder, though, is a totally different ballgame.

People with ASPD are your run-of-the-mill sociopaths and serial killers. They are often criminals, breaking the law with little regard for social norms or rules. They can be charming and manipulative, but lack empathy when they hurt others.

According to the DSM IV, a person meets criteria for Antisocial Personality Disorder when there is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by 3 (or more) of the following:

  1. Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest.
  2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.
  3. Impulsivity or failure to plan ahead.
  4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
  5. Reckless disregard for safety of self or others.
  6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.
  7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.

In order to be diagnosed with this disorder a person must be at least 18 years old and have had evidence of behavioral problems before the age of 15 (someone who is younger than 18 but displays similar behavior would be diagnosed with Conduct Disorder. For example, there’s a good change that kid running around your neighborhood setting fires and torturing small animals may grow up to have Antisocial Personality Disorder.

The Concept of Countertransference – It’s Not Just About Them, It’s About You

One of the things we learn in psychiatry is that when a person with a certain personality invokes a strong reaction in us, is helps give us insight into what their issues are but also tells us a lot about ourselves.

Instead of just talking about liking or disliking a person, we talk about countertransference. Countertransference is how a therapist or psychiatrist feels toward a patient, but more broadly can be used to describe how anyone feels toward anyone else. They key is, when you feel a strong reaction toward someone, it tells you something important about yourself.

So before you go out and start gleefully diagnosing all sorts of people with the above personality disorders, keep in mind a couple of things. One, it’s a tough thing for psychiatrists to get right, and we train for years to be able to accurately diagnose people with mental disorders. Two, despite how I titled this post, it’s better to use this information as a way to better understand and tolerate others than to use it as a way to judge. And don’t forget – if all you do is go around judging people, then you’re probably the asshole.

Happy diagnosing!

***

Image by One From Rome

Comments

  1. It’s also fun to diagnose people who appear on reality TV Shows with these personality disorders!

  2. HAHA! Great twist at the end, Elana. I’m so glad I waited until the END of the post before I started to use the information you posted here. I have one question – did you type this all from the top of your head? Cause that would be crazy. It was funny, I was just speaking with a buddy of mine who recently broke up with his girlfriend, and he thinks she has a personality disorder. Your post couldn’t have come out at a better time. I’m definitely sending this to him!

    • Haha yeah I had to throw that in at the end so the post would have the right message! I didn’t type the diagnostic criteria from my head – I got that directly from a psychiatry textbook. I’m definitely not that smart :-). Hope your friend finds the post helpful!

  3. Perfect, clear and to the point. LOVED the last line. Sooo funny.
    I am going to send this to a friend who is best friends with my wife of 36yrs. I’ve known this friend since I was 5. I am now 57.
    A dear heart who has all the knowledge of our past is prone to diagnosing. She has always been a bit focused that way. Sometimes for good and sometimes because we think she is just a bit like her father, an admitted hypochondriac. HA! Each expressing that with a smile.

    • Thanks for the comment – I think I’ve always been a diagnoser at heart too… probably why I went into medicine :-). Hope your friend enjoys the post!

      • Anonymous says:

        HOLY CRAP! Just saw the ukelele song and had to wipe the tears from my eyes. Being a goofy-ass who loves to jump into the lighter side of irony, that was just great.
        (The Dr. with the pen….. what up with that?) Oh man, the humor in that song.
        So glad you chose your field.
        BTW, Still haven’t heard from our friend….. wondering if she caught the part about tolerance and my personal fave, Zen and the art of not being an asshole.
        And yes, we’ve all walked in that parade.

  4. I hate having to admit my flaws, but I’m pretty sure I have a personality disorder. I think I fall into the Histrionic category as well as the Antisocial category. I used to think everyone was out to get me, but then realized I’m the one who is crazy. I have done some really crappy things to people and I wish I could take it all back, but I can’t. Since I have come to my senses, I have been trying my best to not make those kinds of mistakes anymore. I’m successful about half of the time. I probably still exhibit this behavior currently and not even know I’m doing it for the other half. Very frustrating. I am not looking for any pity, I’m just trying to figure out why I even act like this in the first place. I will gladly take any advice or criticism, good or bad. I am truly trying to be a better person for the sake of my entire family and friends and mostly for myself. Thanks.

    • Hey Erin, thanks for your comment – it’s not easy to post a question like that on a blog. I want to say first that the fact you recognize you have a problem in how you interact with others puts you ahead of 99% of people with personality disorders (which I’m not sure you have). Most people lack this type of insight, and think the problem is with everyone else instead of themselves. Because you recognize that there is a problem, but just need help understanding why it’s there and learning how to act differently, I think you would do really well in therapy. Have you thought about seeing a therapist? Most therapists have a sliding scale option for people who can’t afford full price or who don’t have insurance. Kudos to you for taking steps to improve yourself.

  5. I really need to give this page to the psychologist (she was fellow btw) from Johns Hopkins Hospital who diagnosed me with NPD years ago – basically for saying things like wanting to be well off and date hot guys AFTER she asked me what I wanted out life…I think I initially mentioned concerns over my mother and family being happy and healthy…and wanting to get a decent education and be a productive member of society bla bla…duh…what’s so bad about that? Every gal wants that. Especially a hot guy.

    I think she probably didn’t like the way I was acting WHILE being a geeky looking girl. And boy was I geeky lookin chick. Geeky people…geeky girls are not supposed to have the same attitude and expectations like a cheer leader or say Marsha Brady or a Lindsay Lohan ….while bitching about life. Right whatever. But NPD? A morbidly narcissitic personality? I lack empathy? I love and need constant attention?? Really? Every page of her notes were conveying a morbid narcissistic quality about my life….while a lot of what we talked about was left out of the notes. I was never told of this diagnosis until I found an old letter sent to MY INSURANCE company from Johns Hopkins that said I had NPD and that I acted like I was “adorable”. I was mortified. I even gave my medical records info to teachers since I had testing anxiety issues that I believe was associated with my OCD. I wanted to sue these people for not telling me while I was sending out my medical information with out knowing my diagnosis or the full extent of it …..and the more I read sites like these, the more I want to file a suit against this hospital. And I think I will. Hope this make sense since I was narcissistically ranting my ass off. Okay, off my nar’cy soap box. Chow.

  6. People rant and complain…and if you don’t relate or like the person for it for whatever reason, it’s pretty easy for ANY of us to label the person as being arrogant and unfair. It’s just a way of competing but not a very smart way of doing so.

    • Yes, this would involve not having a lot of self-awareness. Hopefully you read my entire post and therefore understand that I’m not recommending thoughtlessly diagnosing others with personality disorders.

  7. …and one more thing the DSM constantly states that those who “suffer” from NPD tend to intellectualize their diagnosis especially if they disagree with the diagnosis.
    Um. Well..yeah, if someone diagnosed YOU as such, how would you respond? And why is it that there is hardly any discussion over this issue? We all intellectualize and debate over issues that concern us or that we may not agree with. Whether we’re narcissistic ass hats or not (like some eh, medical professionals out there who get a way with misdiagnosing and mistreating A LOT) , OF COURSE IT’S HUMAN NATURE to intellectualize or debate something we feel strong about or disagree with.

  8. Thanks Elana,

  9. I’d write more but I seem to be an antisocial asshole (at times). Aint self awareness a kick in the jewels…

  10. LOL! I think your material is great! I’ve only read a couple of articles. I originally saw your piece on HP about Buddha in our lives and your mention of when you changed your path from surgery to psychiatry. I was struck by that because I am a surgeon, but I took every elective I could in psychiatry! The only area I couldn’t reach with a knife :-)

    Feel free to look at my site, or not, but I’ll be back to read more.

    Thank you!

    Dr. J

    • Hey Dr. J! Thanks for the compliment. Even though psychiatry and surgery seem so different I think there’s got to be a similar personality type that is attracted to both, because I know so many people who switched from one to the other, or medical students who are debating about the two. I think psychiatrists get into the mind with their metaphorical knife :-)

  11. Just reading the title of this post made me smile…
    In the end, it always seems to me to come down to perceptions one has, and I loved that your proviso at the end discouraged people from ‘judging’ – so easily and often done.
    Thanks for a great post.

  12. I just read your article here on personality disorders and it hit home. I just broke up my girlfriend because of the way she was treating me. Her behavior was so terrible that I could not take it anymore. She would be all loving to me one day and then another day she would be cold as ice for no apparent reason. She had no remorse for the way she treated me and made no effort to even apologize for being rude and disrespectful. I did not know this at that time but her behavior fits perfectly with BPD.

  13. I think I fit into one of these. That being said, I feel I need to point out that these classifications are not flaws (IMO).
    They are called disorder’s not flaws. A personality thats out of the order or not the same as the majority of people is not flawed and should not be condemned.

    I think it’s dangerous for people to comprehend this as a list of dysfunctional or unideal personalities. Who is to say what personality is ideal anyway? Such interpretations may be what leads to the self harm and/or other negative behaviours.

    As far as I can see these are just a list of personality types that are not the norm.
    I never want to have a normal personality. I believe that we only get one life, and I don’t want to waste it being the same as everyone else.
    To be unique and creative an individual needs to have a personality that is out of step with the mainstream or in Dis-Order.

    • By definition, to be diagnosed with a personality disorder a person’s personality traits need to impair their ability to form healthy relationships and function in everyday life (such as at work). People with personality disorders can make themselves miserable and the people around them miserable.

      So, I guess I would disagree with you that someone who can’t function in life or form healthy relationships is just “out of the mainstream.”

  14. I ran across your blog while looking for information on how to cope with ending a friendship with a person who I think is a BP. Among the most obvious things I noticed were – he was abused as a child, has abandonment issues (which he does recognize), is extremely manipulative, sees everything as either “right” or “wrong” (this is what actually got me intrigued to research on different personality types as I had never really run across someone so adamant about there being absolutely NO gray areas in life!) and he has a history of reckless sexual encounters and failed relationships (including friendships – 45 years old and has never had a best friend or even a close friend). I tried to be there for him. I really did, but the love/hate he displayed to me (splitting) and the verbal abuse was just too much for me to handle. I finally decided a “no contact” email was the best way to go and I made a clean break. I feel pity for him as he basically pushes people away to the point where they have to leave for the sole purpose of self preservation. Naturally, he thinks everyone “abandons” him. He will always hold a special place in my heart, but I just cannot stay in contact with someone so committed to sabotaging the relationship. I do have a question if you don’t mind. Is it common for a BP to use splitting and sabotage in the relationship every time they reveal even the slightest vulnerability? That was a pattern with him. I notice that he would be highly emotional and open up to me – and the next day when I would follow up and ask how he was feeling? BOOM! He would suddenly try to distance himself or act like no emotional vulnerability had ever happened.

    • anonymous says:

      This is a late reply, but I have BPD and it’s common for someone to open up to you then shut you out later. Why? Because we’re terrified of you thinking less of us for putting all our cards on the table but we want to be able to have somebody to confide in just like any other normal person does. Just normal people probably don’t despise themselves for having feelings.

  15. Hello, im kyle, and im scared what i read just now about cluster b: Narcissistic Personality Disorder
    i have friend that has exact attitude like that, how can i help her? pls i am willing to help my best friend, she didnt know that i doubt about her attitudes.,

    Pls help me to help her, send me an email. Thanks!

    • put histrionic frauds in prison says:

      Read more. the person you think is your best friend does not value you and will take you on a rollercoaster ride. they will blame you in the end. So unless youre codependent or something just cut all and i mean all contact. not as bad as npd or god the dreaded predator hpd. those ppl do it all on purpose with lies and mindgames then .. respectively. npd dont care or hpd play the victim after mind raping the world around them. but bpd is less on purpose and more about their own instability and nearly split personality draining you of your lifes energy. run from them all

  16. Hi there! I know this is somewhat off topic
    but I was wondering if you knew where I could get a captcha plugin for my
    comment form? I’m using the same blog platform as yours and I’m having trouble finding one?
    Thanks a lot!

Trackbacks

  1. […] sources, Elana Miller, the Zen Psychiatrist, has even written about the humorous aspects of figuring out the mental diagnoses of the people you find most difficult or don’t like. (It’s actually a fun and productive article – all tongue in […]

  2. […] sources, Elana Miller, the Zen Psychiatrist, has even written about the humorous aspects of figuring out the mental diagnoses of the people you find most difficult or don’t like. (It’s actually a fun and productive article – all tongue in […]

  3. […] How to Diagnose People You Don’t Like with Personality Disorders. I hate how I came across her site (it was shared via FaceBook because of her cancer post), but I’ve fallen in love with her and her loving-but-real approach to the world. […]

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