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.
- Cluster A – People with odd or eccentric characteristics. Includes Paranoid Personality Disorder, Schizoid Personality Disorder, and Schizotypal Personality Disorder.
- Cluster B – People who are dramatic, emotional or impulsive. Includes Antisocial Personality Disorder, Borderline Personality Disorder, Narcissistic Personality Disorder and Histrionic Personality Disorder.
- 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:
- Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
- Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
- 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).
- Requires excessive admiration.
- Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations.
- Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends.
- Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
- Is often envious of others or believes that others are envious of him or her.
- 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:
- Frantic efforts to avoid real or imagined abandonment.
- A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
- Identity disturbance: markedly and persistently unstable self-image or sense of self.
- Impulsivity in at least two areas that are potentially self-damaging (eg, spending, sex, substance abuse, reckless driving, binge eating).
- Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
- Affective instability/marked reactivity of mood.
- Chronic feelings of emptiness.
- Inappropriate, intense anger or difficulty controlling anger.
- 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:
- Is uncomfortable in situations in which he or she is not the center of attention.
- Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.
- Displays rapidly shifting and shallow expression of emotions.
- Consistently uses physical appearance to draw attention to self.
- Has a style of speech that is excessively impressionistic and lacking in detail.
- Shows self-dramatization, theatricality, and exaggerated expression of emotion.
- Os suggestible, i.e., easily influenced by others or circumstances.
- 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:
- Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest.
- Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.
- Impulsivity or failure to plan ahead.
- Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
- Reckless disregard for safety of self or others.
- Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.
- 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.
Image by One From Rome