comerabpsych9e

16.2 “Dramatic” Personality Disorders

The cluster of “dramatic” personality disorders includes the antisocial, borderline, histrionic, and narcissistic personality disorders. The behaviors of people with these problems are so dramatic, emotional, or erratic that it is almost impossible for them to have relationships that are truly giving and satisfying.

These personality disorders are more commonly diagnosed than the others. However, only the antisocial and borderline personality disorders have received much study, partly because they create so many problems for other people. The causes of the disorders, like those of the odd personality disorders, are not well understood. Treatments range from ineffective to moderately effective.

Antisocial Personality Disorder

Sometimes described as “psychopaths” or “sociopaths,” people with antisocial personality disorder persistently disregard and violate others’ rights (APA, 2013). Aside from substance use disorders, this is the disorder most closely linked to adult criminal behavior. DSM-5 stipulates that a person must be at least 18 years of age to receive this diagnosis; however, most people with antisocial personality disorder displayed some patterns of misbehavior before they were 15, including truancy, running away, cruelty to animals or people, and destroying property.

antisocial personality disorder A personality disorder marked by a general pattern of disregard for and violation of other people’s rights.

Robert Hare, a leading researcher of antisocial personality disorder, recalls an early professional encounter with a prison inmate named Ray:

Notorious disregard In 2009, financier Bernard Madoff was sentenced to 150 years in prison after defrauding thousands of investors, including many charities, of billions of dollars. Given his overwhelming disregard for others and other such qualities, some clinicians suggest that Madoff displays antisocial personality disorder.

In the early 1960s, I found myself employed as the sole psychologist at the British Columbia Penitentiary…. I wasn’t in my office for more than an hour when my first “client” arrived. He was a tall, slim, dark-haired man in his thirties. The air around him seemed to buzz, and the eye contact he made with me was so direct and intense that I wondered if I had ever really looked anybody in the eye before. That stare was unrelenting—he didn’t indulge in the brief glances away that most people use to soften the force of their gaze.

Without waiting for an introduction, the inmate—I’ll call him Ray—opened the conversation: “Hey, Doc, how’s it going? Look, I’ve got a problem. I need your help. I’d really like to talk to you about this.”

Eager to begin work as a genuine psychotherapist, I asked him to tell me about it. In response, he pulled out a knife and waved it in front of my nose, all the while smiling and maintaining that intense eye contact.

Once he determined that I wasn’t going to push the button, he explained that he intended to use the knife not on me but on another inmate who had been making overtures to his “protégé,” a prison term for the more passive member of a homosexual pairing. Just why he was telling me this was not immediately clear, but I soon suspected that he was checking me out, trying to determine what sort of a prison employee I was….

From that first meeting on, Ray managed to make my eight-month stint at the prison miserable. His constant demands on my time and his attempts to manipulate me into doing things for him were unending. On one occasion, he convinced me that he would make a good cook … and I supported his request for a transfer from the machine shop (where he had apparently made the knife). What I didn’t consider was that the kitchen was a source of sugar, potatoes, fruit, and other ingredients that could be turned into alcohol. Several months after I had recommended the transfer, there was a mighty eruption below the floorboards directly under the warden’s table. When the commotion died down, we found an elaborate system for distilling alcohol below the floor. Something had gone wrong and one of the pots had exploded. There was nothing unusual about the presence of a still in a maximum-security prison, but the audacity of placing one under the warden’s seat shook up a lot of people. When it was discovered that Ray was the brains behind the bootleg operation, he spent some time in solitary confinement.

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Once out of “the hole,” Ray appeared in my office as if nothing had happened and asked for a transfer from the kitchen to the auto shop—he really felt he had a knack, he saw the need to prepare himself for the outside world, if he only had the time to practice he could have his own body shop on the outside…. I was still feeling the sting of having arranged the first transfer, but eventually he wore me down.

Soon afterward I decided to leave the prison to pursue a Ph.D. in psychology, and about a month before I left Ray almost persuaded me to ask my father, a roofing contractor, to offer him a job as part of an application for parole.

Ray had an incredible ability to con not just me but everybody. He could talk, and lie, with a smoothness and a directness that sometimes momentarily disarmed even the most experienced and cynical of the prison staff. When I met him he had a long criminal record behind him (and, as it turned out, ahead of him); about half his adult life had been spent in prison, and many of his crimes had been violent…. He lied endlessly, lazily, about everything, and it disturbed him not a whit whenever I pointed out something in his file that contradicted one of his lies. He would simply change the subject and spin off in a different direction. Finally convinced that he might not make the perfect job candidate in my father’s firm, I turned down Ray’s request—and was shaken by his nastiness at my refusal.

Before I left the prison for the university, I took advantage of the prison policy of letting staff have their cars repaired in the institution’s auto shop—where Ray still worked, thanks (he would have said no thanks) to me. The car received a beautiful paint job and the motor and drivetrain were reconditioned.

With all our possessions on top of the car and our baby in a plywood bed in the backseat, my wife and I headed for Ontario. The first problems appeared soon after we left Vancouver, when the motor seemed a bit rough. Later, when we encountered some moderate inclines, the radiator boiled over. A garage mechanic discovered ball bearings in the carburetor’s float chamber; he also pointed out where one of the hoses to the radiator had clearly been tampered with. These problems were repaired easily enough, but the next one, which arose while we were going down a long hill, was more serious. The brake pedal became very spongy and then simply dropped to the floor—no brakes, and it was a long hill. Fortunately, we made it to a service station, where we found that the brake line had been cut so that a slow leak would occur. Perhaps it was a coincidence that Ray was working in the auto shop when the car was being tuned up, but I had no doubt that the prison “telegraph” had informed him of the owner of the car.

(Hare, 1993)

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Previous Identity

Antisocial personality disorder was referred to as “moral insanity” during the nineteenth century.

Like Ray, people with antisocial personality disorder lie repeatedly (APA, 2013). Many cannot work consistently at a job; they are absent frequently and are likely to quit their jobs altogether (Hengartner et al., 2014). Usually they are also careless with money and frequently fail to pay their debts. They are often impulsive, taking action without thinking of the consequences (Millon, 2011). Correspondingly, they may be irritable, aggressive, and quick to start fights. Many travel from place to place.

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Recklessness is another common trait: people with antisocial personality disorder have little regard for their own safety or for that of others, even their children. They are self-centered as well, and are likely to have trouble maintaining close relationships. Usually they develop a knack for gaining personal profit at the expense of other people. Because the pain or damage they cause seldom concerns them, clinicians commonly say that they lack a moral conscience (see Table 16-2 below). They think of their victims as weak and deserving of being conned, robbed, or even physically harmed (see PsychWatch below).

How do various institutions in our society—business, government, science, religion—view lying? How might such views affect lying by individuals?

Surveys indicate that 3.6 percent of adults in the United States meet the criteria for antisocial personality disorder (Sansone & Sansone, 2011). The disorder is as much as four times more common among men than women.

Because people with this disorder are often arrested, researchers frequently look for people with antisocial patterns in prison populations (Pondé et al., 2014; Black et al., 2010). It is estimated that at least 40 percent of people in prison meet the diagnostic criteria for this disorder (Naidoo & Mkize, 2012). Among men in urban jails, the antisocial personality pattern has been linked strongly to past arrests for crimes of violence (De Matteo et al., 2005). The criminal behavior of many people with this disorder declines after the age of 40; some, however, continue their criminal activities throughout their lives (APA, 2013).

Table : table: 16-2Annual Hate Crimes in the United States

Group Attacked	Number of Reported Incidents
Racial/ethnic groups	4,119
LGBT* groups	1,318
Religious groups	1,166
Groups with disability	102
*Widely accepted acronym for Lesbian, Gay, Bisexual, and Transgender people
Information from: U.S. Department of Justice, Federal Bureau of Investigation, 2013, 2012

Popular sociopaths Television audiences seem to love characters with the symptoms of antisocial personality disorder. Legendary character Tony Soprano of The Sopranos (above) had hardly left our screens when he was replaced in the hearts of television viewers everywhere by the equally legendary Walter White of Breaking Bad (below).

Studies and clinical observations also indicate that people with antisocial personality disorder have higher rates of alcoholism and other substance use disorders than do the rest of the population (Brook et al., 2014; Reese et al., 2010). Perhaps intoxication and substance misuse help trigger the development of antisocial personality disorder by loosening a person’s inhibitions. Perhaps this personality disorder somehow makes a person more prone to abuse substances. Or perhaps antisocial personality disorder and substance use disorders both have the same cause, such as a deep-seated need to take risks. Interestingly, drug users with the personality disorder often cite the recreational aspects of drug use as their reason for starting and continuing it.

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It appears that children with conduct disorder and an accompanying attention-deficit/hyperactivity disorder have a heightened risk of developing antisocial personality disorder (APA, 2013; Black et al., 2010). These two childhood disorders, which you will read about in Chapter 17, often bear similarities to antisocial personality disorder. Like adults with antisocial personality disorder, children with a conduct disorder persistently lie and violate rules and other people’s rights, and children with attention-deficit/hyperactivity disorder lack foresight and judgment and fail to learn from experience. Intriguing as these observations may be, however, the precise connection between the childhood disorders and antisocial personality disorder has been difficult to pinpoint.

How Do Theorists Explain Antisocial Personality Disorder?Explanations of antisocial personality disorder come from the psychodynamic, behavioral, cognitive, and biological models. As with many other personality disorders, psychodynamic theorists propose that this one begins with an absence of parental love during infancy, leading to a lack of basic trust (Meloy & Yakeley, 2010; Sperry, 2003). In this view, some children—the ones who develop antisocial personality disorder—respond to the early inadequacies by becoming emotionally distant, and they bond with others through the use of power and destructiveness. In support of the psychodynamic explanation, researchers have found that people with this disorder are more likely than others to have had significant stress in their childhoods, particularly in such forms as family poverty, family violence, child abuse, and parental conflict or divorce (Kumari et al., 2014; Martens, 2005).

Many behavioral theorists have suggested that antisocial symptoms may be learned through modeling, or imitation (Gaynor & Baird, 2007). As evidence, they point to the higher rate of antisocial personality disorder found among the parents of people with this disorder (APA, 2013; Paris,2001). Other behaviorists have suggested that some parents unintentionally teach antisocial behavior by regularly rewarding a child’s aggressive behavior (Kazdin, 2005). When the child misbehaves or becomes violent in reaction to the parents’ requests or orders, for example, the parents may give in to restore peace. Without meaning to, they may be teaching the child to be stubborn and perhaps even violent.

Can you point to attitudes and events in today’s world that may trivialize people’s needs? What impact might they have on individual functioning?

Hardly a new disorder A worker attaches a tag that translates as “Killer of a Wife” to a wax-covered head at the Lombroso Museum in Turin, Italy. Hundreds of such heads, taken from prisons throughout Europe, line the museum’s shelves, each with the tags like “Ladro” (“Thief”) or “Omicida” (“Murderer”). The display comes from nineteenth-century psychiatrist Cesare Lombroso’s crude but pioneering research into the nature of criminal and related antisocial behavior.

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The cognitive view says that people with antisocial personality disorder hold attitudes that trivialize the importance of other people’s needs (Elwood et al., 2004). Such a philosophy of life, some theorists suggest, may be far more common in our society than people recognize (see Figure 16-3). Cognitive theorists further propose that people with this disorder have genuine difficulty recognizing points of view or feelings other than their own (Herpertz & Bertsch, 2014).

Figure 16.3: figure 16-3
Are some cultures more antisocial than others?
In a cross-cultural study, teenagers were asked to write stories describing how imaginary characters would respond to various conflicts. About one-third of the respondents from New Zealand, Australia, NorthernIreland, and the United States described violent responses, compared with fewer than one-fifth of the respondents from Korea, Sweden, and Mexico. (Information from: Archer & McDaniel, 1995.)

Finally, studies suggest that biological factors may play an important role in antisocial personality disorder. Researchers have found that antisocial people, particularly those who are highly impulsive and aggressive, have lower serotonin activity than other people (Thompson, Ramos, & Willett, 2014; Patrick, 2007). As you’ll recall (see page 300), both impulsivity and aggression also have been linked to low serotonin activity in other kinds of studies, so the presence of this biological factor in people with antisocial personality disorder is not surprising.

Other studies indicate that individuals with this disorder display deficient functioning in their frontal lobes, particularly in the prefrontal cortex (Liu et al., 2014; Thompson et al., 2014). Among other duties, this brain region helps people to plan and execute realistic strategies and to have personal characteristics such as sympathy, judgment, and empathy. These are, of course, all qualities found wanting in people with antisocial personality disorder.

In yet another line of research, investigators have found that people with antisocial personality disorder often feel less anxiety than other people, and so lack a key ingredient for learning (Blair et al., 2005). This would help explain why they have so much trouble learning from negative life experiences or tuning in to the emotional cues of others. Why should people with antisocial personality disorder experience less anxiety than other people? The answer may lie once again in the biological realm. Research participants with the disorder often respond to warnings or expectations of stress with low brain and bodily arousal, such as slow autonomic arousal and slow EEG waves (Thompson et al., 2014; Perdeci et al., 2010). Perhaps because of the low arousal, they easily tune out threatening or emotional situations, and so are unaffected by them.

It could also be argued that because of their physical underarousal, people with antisocial personality disorder would be more likely than other people to take risks and seek thrills. That is, they may be drawn to antisocial activity precisely because it meets an underlying biological need for more excitement and arousal. In support of this idea, as you read earlier, antisocial personality disorder often goes hand in hand with sensation-seeking behavior.

Treatments for Antisocial Personality DisorderTreatments for people with antisocial personality disorder are typically ineffective (Millon, 2011; Meloy & Yakeley, 2010). Major obstacles to treatment include the individuals’ lack of conscience, desire to change, or respect for therapy (Colli et al., 2014; Kantor, 2006). Most of those in therapy have been forced to participate by an employer, their school, or the law, or they come to the attention of therapists when they also develop another psychological disorder (Agronin, 2006).

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PsychWatch

Mass Murders: Where Does Such Violence Come From?

On December 14, 2012, a young man entered the Sandy Hook Elementary School in Newtown, Connecticut, and killed 26 people—20 of them young children—in a shooting rampage. In the months prior to this massacre, gunmen killed 12 moviegoers at a Batman movie in Colorado, 6 churchgoers at a Sikh temple in Wisconsin, and 5 workers at a sign company in Minnesota. In 2014, a young man went on a rampage near the campus of the University of California, Santa Barbara, killing 6 people and injuring 13 others. Listening to some of the psychologists and psychiatrists interviewed immediately after these events, you might conclude that the mental health field has a clear understanding of why individuals commit mass murders and has effective treatments for those capable of such acts. In fact, that is not the case. The clinical field has offered various theories about mass murderers, but enlightening research and effective interventions have been elusive (Montaldo, 2014; Friedman, 2013; Ferguson et al., 2011).

What do we know about mass killings? We know they involve, by definition, the murder of four or more people in the same location and at around the same time. FBI records also indicate that, on average, mass killings occur in the United States every 2 weeks, 75 percent of them feature a lone killer, 67 percent involve the use of guns, and most are committed by males (Hoyer & Heath, 2012).

We also know that despite appearances, the number of mass killings is not on the rise overall (O’Neill, 2012). What is increasing, however, are certain kinds of mass killings. So-called pseudocommando mass murders, for example, are on the rise. A pseudocommando mass murderer “kills in public during the daytime, plans his offense well in advance, and comes prepared with a powerful arsenal of weapons. He has no escape planned and expects to be killed during the incident” (Knoll, 2010). Similarly, “autogenetic” (self-generated) massacres, in which individuals kill people indiscriminately to fulfill a personal agenda, seem be on the rise (Bowers et al., 2010; Mullen, 2004).

Unthinkable Family members of students at the Sandy Hook Elementary School in Connecticut react with fear, disbelief, and horror during the immediate aftermath of the killing rampage at the school.

Theorists have suggested a number of factors to help explain pseudocommando, autogenetic, and other mass killings, including the availability of guns, bullying behavior, substance abuse, the proliferation of violent media and video games, dysfunctional homes, contagion effects, and mental illness. In fact, regardless of one’s position on gun control, media violence, or the like, almost everyone, including most clinicians, believes that mass killers typically suffer from a mental disorder (Archer, 2012). Which mental disorder? On this, there is little agreement. Each of the following has been suggested:

Antisocial, borderline, paranoid, or schizotypal personality disorder
Schizophrenia or severe bipolar disorder
Intermittent explosive disorder—an impulse-control disorder featuring repeated, unprovoked verbal and/or behavioral outbursts (Coccaro, 2012)
Severe disorder of mood, stress, or anxiety

Although these and yet other disorders have been proposed, none has received clear support in the limited research conducted on mass killings. On the other hand, several variables have emerged as a common denominator across the various studies: severe feelings of anger and resentment, feelings of being persecuted or grossly mistreated, and desires for revenge (Knoll, 2010). That is, regardless of which psychological disorder a mass killer may display, he usually is driven by this set of feelings. For a growing number of clinical researchers, this repeated finding suggests that research should focus less on diagnosis and much more on identifying and understanding these particular feelings.

Clearly, clinical research must expand its focus on this area of enormous social concern. Granted it is a difficult problem to investigate, partly because so few mass killers survive their crimes, but the clinical field has managed to gather useful insights about other elusive areas. And, indeed, in the aftermath of the horrific massacre of so many innocent children in the Newtown shooting rampage, a wave of heightened determination and commitment seems to have seized the clinical community (Archer, 2012).

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Character Ingestion

As late as the Victorian era, many English parents believed babies absorbed personality and moral uprightness as they took in milk. Thus, if a mother could not nurse, it was important to find a wet nurse of good character

(Asimov, 1997)

Some cognitive therapists try to guide clients with antisocial personality disorder to think about moral issues and about the needs of other people (Beck & Weishaar, 2011; Weishaar & Beck, 2006; Beck et al., 2004). In a similar vein, a number of hospitals and prisons have tried to create a therapeutic community for people with this disorder, a structured environment that teaches responsibility toward others (Harris & Rice, 2006). Some patients seem to profit from such approaches, but it appears that most do not. In recent years, clinicians have also used psychotropic medications, particularly atypical antipsychotic drugs, to treat people with antisocial personality disorder. Some report that these drugs help reduce certain features of the disorder, but systematic studies of this claim are still needed (Brown et al., 2014; Thompson et al., 2014; Silk & Jibson, 2010).

Borderline Personality Disorder

People with borderline personality disorder display great instability, including major shifts in mood, an unstable self-image, and impulsivity (APA, 2013). These characteristics combine to make their relationships very unstable as well (Paris, 2010, 2005). Some of Ellen Farber’s difficulties are typical:

borderline personality disorder A personality disorder characterized by repeated instability in interpersonal relationships, self-image, and mood and by impulsive behavior.

Ellen Farber, a 35-year-old, single insurance company executive, came to a psychiatric emergency room … with complaints of depression and the thought of driving her car off a cliff. An articulate, moderately overweight, sophisticated woman, Ms. Farber appeared to be in considerable distress. She reported a 6-month period of increasingly persistent dysphoria and lack of energy and pleasure. Feeling as if she were “made of lead,” Ms. Farber had recently been spending 15–20 hours a day in her bed. She also reported daily episodes of binge eating, when she would consume “anything I can find.” … She reported problems with intermittent binge eating since adolescence, but these had recently increased in frequency, resulting in a 20-pound weight gain….

She attributed her increasing symptoms to financial difficulties. Ms. Farber had been fired from her job two weeks before…. She claimed it was because she “owed a small amount of money.” When asked to be more specific, she reported owing $150,000 to her former employers and another $100,000 to various local banks…. From age 30 to age 33, she had used her employer’s credit cards to finance weekly “buying binges,” accumulating the $150,000 debt. She … reported that spending money alleviated her chronic feelings of loneliness, isolation, and sadness. Experiencing only temporary relief, every few days she would impulsively buy expensive jewelry, watches, or multiple pairs of the same shoes….

In addition to lifelong feelings of emptiness, Ms. Farber described chronic uncertainty about what she wanted to do in life and with whom she wanted to be friends. She had many brief, intense relationships with both men and women, but her quick temper led to frequent arguments and even physical fights. Although she had always thought of her childhood as happy and carefree, when she became depressed, she began to recall [being abused verbally and physically by her mother].

(Spitzer et al., 1994, pp. 395–397)

Like Ellen Farber, people with borderline personality disorder swing in and out of very depressive, anxious, and irritable states that last anywhere from a few hours to a few days or more (see Table 16-3 below). Their emotions seem to be always in conflict with the world around them. They are prone to bouts of anger, which sometimes result in physical aggression and violence (Scott et al., 2014). Just as often, however, they direct their impulsive anger inward and inflict bodily harm on themselves. Many seem troubled by deep feelings of emptiness.

Table 16.1: table: 16-3Comparison of Personality Disorders

	Cluster	Similar Disorders	Responsiveness to Treatment
Paranoid	Odd	Schizophrenia; delusional disorder	Modest
Schizoid	Odd	Schizophrenia; delusional disorder	Modest
Schizotypal	Odd	Schizophrenia; delusional disorder	Modest
Antisocial	Dramatic	Conduct disorder	Poor
Borderline	Dramatic	Depressive disorder; bipolar disorder	Moderate
Histrionic	Dramatic	Somatic symptom disorder; depressive disorder	Modest
Narcissistic	Dramatic	Cyclothymic disorder (mild bipolar disorder)	Poor
Avoidant	Anxious	Social anxiety disorder	Moderate
Dependent	Anxious	Separation anxiety disorder; Moderatedepressive	disorder
Obsessive-compulsive	Anxious	Obsessive-compulsive disorder	Moderate

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Personality disorders—at the movies In the 1999 film Girl, Interrupted, based on a best-selling memoir, Susanna Kaysen (left, played by actress Winona Ryder) is befriended by Lisa Rowe (played by Angelina Jolie) at a mental hospital. Kaysen received a diagnosis of borderline personality disorder at the hospital, while Rowe’s diagnosis was antisocial personality disorder. However, Rowe’s rages, dramatic mood shifts, impulsivity, and other symptoms were actually more characteristic of a borderline picture than were Kaysen’s.

Borderline personality disorder is a complex disorder, and it is fast becoming one of the more common conditions seen in clinical practice. Many of the patients who come to mental health emergency rooms are people with this disorder who have intentionally hurt themselves. Their impulsive, self-destructive activities may range from alcohol and substance abuse to delinquency, unsafe sex, and reckless driving (Kienast et al., 2014; Coffey et al., 2011). Many engage in self-injurious or self-mutilation behaviors, such as cutting or burning themselves or banging their heads (Bracken-Minor & McDevitt-Murphy, 2014; Chiesa, Sharp, & Fonagy, 2011). As you saw in Chapter 9, such behaviors typically cause immense physical suffering, but those with borderline personality disorder often feel as if the physical discomfort offers relief from their emotional suffering. It may serve as a distraction from their emotional or interpersonal upsets, “snapping” them out of an “emotional overload” (Sadeh et al., 2014; Stanley & Brodsky, 2005). Many try to hurt themselves as a way of dealing with their chronic feelings of emptiness, boredom, and identity confusion. Scars and bruises also may provide them with a kind of concrete evidence of their emotional distress (Paris, 2010, 2005). Many theorists believe that borderline patterns are more severe among people who injure themselves (Whipple & Fowler, 2011).

Suicidal threats and actions are also common (Amore et al., 2014; Zimmerman et al., 2014; Leichsenring et al., 2011). Studies suggest that around 75 percent of people with borderline personality disorder attempt suicide at least once in their lives; as many as 10 percent actually commit suicide. It is common for people with this disorder to enter clinical treatment by way of the emergency room after a suicide attempt.

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Whither “Borderline”?

In 1938 the term “borderline” was introduced by psychoanalyst Adolph Stern. He used it to describe patients who were more disturbed than “neurotic” patients, yet not psychotic (Bateman, 2011; Stern, 1938). The term has since evolved to its present usage.

People with borderline personality disorder frequently form intense, conflict-ridden relationships in which their feelings are not necessarily shared by the other person. They may come to idealize another person’s qualities and abilities after just a brief first encounter. They also may violate the boundaries of relationships (Lazarus et al., 2014; Skodol et al., 2002). Thinking in dichotomous (black-and-white) terms, they quickly feel rejected and become furious when their expectations are not met; yet they remain very attached to the relationships (Berenson et al., 2011). In fact, they have recurrent fears of impending abandonment and frequently engage in frantic efforts to avoid real or imagined separations from important people in their lives (Gunderson, 2011; Sherry & Whilde, 2008). Sometimes they cut themselves or carry out other self-destructive acts to prevent partners from leaving.

People with borderline personality disorder typically have dramatic identity shifts. Because of this unstable sense of self, their goals, aspirations, friends, and even sexual orientation may shift rapidly (Westen et al., 2011; Skodol, 2005). They may also occasionally have a sense of dissociation, or detachment, from their own thoughts or bodies (Zanarini et al., 2014). Indeed, at times they may have no sense of themselves at all, leading to the feelings of emptiness described earlier.

According to surveys, 5.9 percent of the adult population display borderline personality disorder (Zanarini et al., 2014; Sansone & Sansone, 2011). Close to 75 percent of the patients who receive the diagnosis are women (Gunderson, 2011). The course of the disorder varies from person to person. In the most common pattern, the person’s instability and risk of suicide peak during young adulthood and then gradually wane with advancing age (APA, 2013; Hurt & Oltmanns, 2002). Given the chaotic and unstable relationships characteristic of borderline personality disorder, it is not surprising that the disorder tends to interfere with job performance even more than most other personality disorders do (Hengartner et al., 2014).

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Letting It Out

Expression of Anger Only 23 percent of adults report openly expressing their anger (Kanner, 2005, 1995). Around 39 percent say that they hide or contain their anger, and 23 percent walk away to try to collect themselves.

The Myth of Venting Contrary to the notion that “letting off steam” reduces anger, angry participants in one study acted much more aggressively after hitting a punching bag than did angry participants who first sat quietly for a while (Bushman et al., 1999).

How Do Theorists Explain Borderline Personality Disorder?Because a fear of abandonment tortures so many people with borderline personality disorder, psychodynamic theorists have looked once again to early parental relationships to explain the disorder (Gabbard, 2010). Object relations theorists, for example, propose that an early lack of acceptance by parents may lead to a loss of self-esteem, increased dependence, and an inability to cope with separation (Caligor & Clarkin, 2010; Sherry & Whilde, 2008).

Research has found that this is consistent with the early childhoods of people with borderline personality disorder. In many cases, when they were children, their parents neglected or rejected them, verbally abused them, or otherwise behaved inappropriately (Martín-Blanco et al., 2014). Their childhoods were often marked by multiple parent substitutes, divorce, death, or traumas such as physical or sexual abuse. Indeed, research suggests that early sexual abuse is a common contributor to the development of borderline personality disorder (Newnham & Janca, 2014; Huang, Yang, & Wu, 2010). Indeed, children who experience such abuse are four times more likely to develop the disorder than those who do not (Zelkowitz et al., 2001). At the same time, it is important to recognize that the vast majority of people with histories of physical, sexual, or psychological abuse do not go on to develop borderline personality disorder (Skodol, 2005).

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Road Ragers Part 1

15%	Percentage of drivers who yell out obscenities when upset by other motorists
14%	Motorists who have shouted at or had a honking match with another driver in the past year
7%	Motorists who “give the finger” when upset by other drivers
7%	Drivers who shake their fists when upset by other drivers
2%	Motorists who have had a fist fight with another driver
(Information from: OFWW, 2004; Kanner, 2005, 1995; Herman, 1999)

Borderline personality disorder also has been linked to certain biological abnormalities, such as an overly reactive amygdala, the brain structure that is closely tied to fear and other negative emotions, and an underactive prefrontal cortex, the brain region linked to planning, self-control, and decision making (Mitchell et al., 2014; Richter et al., 2014; Stone, 2014). Moreover, people with borderline personality disorder who are particularly impulsive—those who attempt suicide or are very aggressive toward others—apparently have lower brain serotonin activity (Soloff et al., 2014; Herpertz, 2011). Some, although not all, studies have tied this lower activity to an abnormality of the 5-HTT gene (the serotonin transporter gene) (Amad et al., 2014; Ni et al., 2006). As you may recall, this gene also has been linked to major depressive disorder, suicide, aggression, and impulsivity (see page 223). In accord with these various biological findings, close relatives of those with borderline personality disorder are five times more likely than the general population to have the same personality disorder (Amad et al., 2014; Torgersen, 2000, 1984; Kendler et al., 1991).

Troubled princess Admired by millions during her short life, particularly for her numerous charitable efforts and humane acts, Princess Diana also had a range of psychological problems that she herself disclosed in books and interviews. Diagnosing and explaining her problems has become a common practice—both inside and outside the clinical field—since her death in 1997. Her self-cutting, possible borderline personality functioning, and disordered eating behaviors have received the most attention.

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A number of theorists currently use a biosocial theory to explain borderline personality disorder (Neacsiu & Linehan, 2014; Rizvi et al., 2011). According to this view, the disorder results from a combination of internal forces (for example, difficulty identifying and controlling one’s emotions, social skill deficits, abnormal neurotransmitter reactions) and external forces (for example, an environment in which a child’s emotions are punished, ignored, trivialized, or disregarded). Parents may, for instance, misinterpret their child’s intense emotions as exaggerations or attempts at manipulation rather than as serious expressions of unsettled internal states. According to the biosocial theory, if children have intrinsic difficulty identifying and controlling their emotions and if their parents teach them to ignore their intense feelings, they may never learn how properly to recognize and control their emotional arousal, how to tolerate emotional distress, or when to trust their emotional responses (Herpertz & Bertsch, 2014; Lazarus et al., 2014; Gratz & Tull, 2011). Such children will be at risk for the development of borderline personality disorder. This theory has received some, but not consistent, research support (Gill & Warburton, 2014).

Note that the biosocial theory is similar to one of the leading explanations for eating disorders. As you saw in Chapter 11, theorist Hilde Bruch proposed that children whose parents do not respond accurately to the children’s internal cues may never learn to identify cues of hunger, thus increasing their risk of developing an eating disorder (see pages 359–360). Small wonder that a large number of people with borderline personality disorder also have an eating disorder (Gabriel & Waller, 2014; Rowe et al., 2010). Recall, for example, Ellen Farber’s dysfunctional eating pattern.

Finally, some sociocultural theorists suggest that cases of borderline personality disorder are particularly likely to emerge in cultures that change rapidly. As a culture loses its stability, they argue, it inevitably leaves many of its members with problems of identity, a sense of emptiness, high anxiety, and fears of abandonment. Family units may come apart, leaving people with little sense of belonging. Changes of this kind in society today may explain growing reports of the disorder (Millon, 2011; Paris, 2010, 1991).

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Road Ragers Part 2

67%	Percentage of young adult drivers who consider themselves aggressive drivers
30%	Percentage of elderly drivers who consider themselves aggressive drivers
59%	Percentage of drivers with children who say they are likely to respond aggressively to a traffic altercation
45%	Percentage of drivers without children who say they are likely to respond aggressively to a traffic altercation
66%	Percentage of all annual traffic fatalities caused by aggressive driving
(Information from: National Highway Traffic Safety Administration, 2010)

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Treatments for Borderline Personality DisorderIt appears that psychotherapy can eventually lead to some degree of improvement for people with borderline personality disorder (Omar et al., 2014; Neville, 2014). It is, however, extraordinarily difficult for a therapist to strike a balance between empathizing with the borderline client’s dependency and anger and challenging his or her way of thinking (Goodman, Edwards, & Chung, 2014; Gabbard, 2010). Given the emotionally draining demands of clients with borderline personality disorder, some therapists refuse to treat such people. The wildly fluctuating interpersonal attitudes of clients with the disorder can also make it difficult for therapists to establish collaborative working relationships with them (Colli et al., 2014; Goodman et al., 2014). Moreover, clients with borderline personality disorder may violate the boundaries of the client–therapist relationship (for example, calling the therapist’s emergency contact number to discuss matters of a less urgent nature) (Colli et al., 2014; Gutheil, 2005).

Traditional psychoanalysis has not been effective with people with borderline personality disorder (Doering et al., 2010). The clients often experience the psychoanalytic therapist’s reserved style and encouragement of free association as suggesting disinterest and abandonment. The clients may also have difficulty tolerating interpretations made by psychoanalytic therapists and see them as attacks.

Contemporary psychodynamic approaches, such as relational psychoanalytic therapy (see page 67), in which therapists take a more supportive and egalitarian posture, have been more effective than traditional psychoanalytic approaches. In approaches of this kind, therapists work to provide an empathic setting within which borderline clients can explore their unconscious conflicts and pay particular attention to their central relationship disturbance, poor sense of self, and pervasive loneliness and emptiness (Goodman et al., 2014; Gabbard, 2010, 2001; Muran et al., 2010). Research has found that contemporary psychodynamic treatments sometimes help reduce suicide attempts, self-harm behaviors, and the number of hospitalizations and bring at least some improvement to those with the disorder (Neville, 2014; Clarkin et al., 2010, 2001).

Over the past two decades, an integrative treatment for borderline personality disorder, called dialectical behavior therapy (DBT), has been receiving considerable research support and is now considered the treatment of choice in many clinical circles (Neacsiu & Linehan, 2014; Linehan et al., 2006, 2002, 2001). DBT, developed by psychologist Marsha Linehan, grows largely from the cognitive-behavioral treatment model (see MediaSpeak below). It includes a number of the same cognitive and, at the same time, behavioral techniques that are applied to other disorders: homework assignments, psychoeducation, the teaching of social and other skills, modeling by the therapist, clear goal setting, reinforcements for appropriate behaviors, ongoing assessment of the client’s behaviors and treatment progress, and collaborative examinations by the client and therapist of the client’s ways of thinking (Neacsiu & Linehan, 2014; Rizvi et al., 2011).

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In Their Words

“Anger is a brief lunacy.”

Horace, Roman poet

DBT also borrows heavily from the humanistic and contemporary psychodynamic approaches, placing the client–therapist relationship itself at the center of treatment interactions, making sure that appropriate treatment boundaries are adhered to and providing an environment of acceptance and validation of the client. Indeed, DBT therapists regularly empathize with their borderline clients and with the emotional turmoil they are experiencing; locate kernels of truth in the clients’ complaints or demands; and examine alternative ways for them to address valid needs.

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MediaSpeak

The Patient as Therapist

By Benedict Carey, The New York Times, June 23, 2011

Learning from within Psychologist Marsha Linehan drew from her own psychological struggles to develop dialectical behavior therapy.

Marsha M. Linehan, 68 … told her story in public for the first time last week….

Dr. Linehan … was driven by a mission to rescue people who are chronically suicidal, often as a result of borderline personality disorder, an enigmatic condition characterized in part by self-destructive urges. “I honestly didn’t realize at the time that I was dealing with myself,” she said. “But I suppose it’s true that I developed a therapy that provides the things I needed for so many years and never got.”

She learned the central tragedy of severe mental illness the hard way, banging her head against the wall of a locked room.

Marsha Linehan arrived at the Institute of Living on March 9, 1961, at age 17, and quickly became the sole occupant of the seclusion room on the unit known as Thompson Two, for the most severely ill patients. The staff saw no alternative: The girl attacked herself habitually, burning her wrists with cigarettes, slashing her arms, her legs, her midsection, using any sharp object she could get her hands on.

The seclusion room … had no such weapon. Yet her urge to die only deepened….

“I was in hell,” she said. “And I made a vow: when I get out, I’m going to come back and get others out of here.” …

It took years of study in psychology—she earned a Ph.D. at Loyola in 1971—before she found an answer. On the surface, it seemed obvious: She … accepted herself as she was…. That basic idea—radical acceptance, she now calls it—became increasingly important as she began working with patients, first at a suicide clinic in Buffalo and later as a researcher….

Dr. Linehan was closing in on two seemingly opposed principles that could form the basis of a treatment: acceptance of life as it is, not as it is supposed to be; and the need to change, despite that reality and because of it….

She chose to treat people with a diagnosis that she would have given her young self: borderline personality disorder….

Yet even as she climbed the academic ladder, moving from the Catholic University of America to the University of Washington in 1977, she understood from her own experience that acceptance and change were hardly enough…. She relied on therapists herself, off and on over the years, for support and guidance….

Dr. Linehan’s own emerging approach to treatment—now called dialectical behavior therapy, or D.B.T.—would also have to include day-to-day skills…. She borrowed some of these from other behavioral therapies and added elements, like opposite action, in which patients act opposite to the way they feel when an emotion is inappropriate; and mindfulness meditation….

In studies in the 1980s and ‘90s, researchers at the University of Washington and elsewhere tracked the progress of hundreds of borderline patients at high risk of suicide who attended weekly dialectical therapy sessions. Compared with similar patients who got other experts’ treatments, those who learned Dr. Linehan’s approach made far fewer suicide attempts, landed in the hospital less often and were much more likely to stay in treatment. D.B.T. is now widely used for a variety of clients, including juvenile offenders….

What might be the positives and negatives—for both clinician and client—when a theorist or therapist focuses primarily on people whose problems are similar to his or her own?

Most remarkably, perhaps, Dr. Linehan has reached a place where she can stand up and tell her story, come what will. “I’m a very happy person now.” … “I still have ups and downs, of course, but I think no more than anyone else.”

June 23, 2011, “Lives Restored: Expert on Mental Illness Reveals Her Own Fight” by Benedict Carey, From The New York Times, 6/23/2011, © 2011 The New York Times. All rights reserved. Used by permission and protected by the copyright laws of the United States. The printing, copying, redistribution, or retransmission of this content without express written permission is prohibited.

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DBT is often supplemented by the clients’ participation in social skill-building groups (Roney & Cannon, 2014). In these groups, clients practice new ways of relating to other people in a safe environment and receive validation and support from other group members.

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Dealing with Anger

Women are 2.5 times more likely than men to turn to food as a way to calm down when angry.
According to surveys, men are 3 times more likely than women to use sex as a way to calm down when angry.
Women are 56 percent more likely than men to “yell a lot” when angry.
Men are 35 percent more likely than women to “seethe quietly” when angry.

(Zoellner, 2000)

DBT has received more research support than any other treatment for borderline personality disorder (Neacsiu & Linehan, 2014; Roepke et al., 2011). Many clients who receive DBT become more able to tolerate stress; develop new, more appropriate, social skills; respond more effectively to life situations; and develop a more stable identity. They also have significantly fewer suicidal behaviors and require fewer hospitalizations than those who receive other forms of treatment (Klein & Miller, 2011). In addition, they are more likely to remain in treatment and to report less anger, more social gratification, improved work performance, and reductions in substance abuse (Rizvi et al., 2011).

Antidepressant, antibipolar, antianxiety, and antipsychotic drugs have helped calm the emotional and aggressive storms of some people with borderline personality disorder (Black et al., 2014; Knappich et al., 2014; Martinho et al., 2014). However, given the numerous suicide attempts by people with this disorder, the use of drugs on an outpatient basis is controversial (Gunderson, 2011). Additionally, clients with the disorder have been known to adjust or discontinue their medication dosages without consulting their clinicians. Many professionals believe that psychotropic drug treatment for borderline personality disorder should be used largely as an adjunct to psychotherapy approaches, and indeed many clients seem to benefit from a combination of psychotherapy and drug therapy (Omar et al., 2014; Soloff, 2005).

Histrionic Personality Disorder

People with histrionic personality disorder, once called hysterical personality disorder, are extremely emotional—they are typically described as “emotionally charged”—and continually seek to be the center of attention (APA, 2013). Their exaggerated moods and neediness can complicate life considerably, as we see in the case of Lucinda:

histrionic personality disorder A personality disorder characterized by a pattern of excessive emotionality and attention seeking. Once called hysterical personality disorder.

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What Is the Difference Between an Egoist and an Egotist?

An egoist is a person concerned primarily with his or her own interests. An egotist has an inflated sense of self-worth. A boastful egotist is not necessarily a self-absorbed egoist.

Unhappy over her impending divorce, Lucinda decided to seek counseling. She arrived at her first session wearing a very provocative outfit, including a revealing blouse and extremely short skirt. Her hair had been labored over, and she had on an excessive amount of makeup—very carefully applied.

When asked to discuss her separation, Lucinda first insisted that the therapist call her Cindy, saying, “All my close friends call me that, and I like to think that you and I will become very good friends here.” She said that her husband, Morgan had suddenly abandoned her—”probably brainwashed by some young trollop.” She proceeded to describe their break-up in a theatrical manner. Over a span of five minutes, her voice ranged from whispers to cries of agony and back again to whispers; she waved her arms dramatically while making some points and sat totally still while making others; and she moved back and forth from a curled-in-a-ball sitting position to a standing position marked by pacing. She seemed to be on center stage—except, of course, she was alone talking to a therapist whom she was meeting for the first time.

Lucinda said that when Morgan first told her that he wanted a divorce, she did not know whether she could go on. The pain was palpable. After all, they had been so “incredibly and irrevocably” close, and he had been so very devoted to her. He had always taken such wonderful care of her, always placed her first. She was his everything.

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She said that initially she even had thoughts of doing away with herself. But, of course, she knew that she had to pull herself together. So many people needed her to be strong. So many people relied on her, particularly her “dear friends” and her sister. She had deep and special relationships with them all, relationships that had to be nurtured. Right now, her inner circle was rallying around her—supporting her, caring for her, even feeding her when she was too weak to feed herself. But she knew that soon she must go back to taking care of their needs.

The therapy discussion returned to the divorce itself. She told the therapist that without Morgan she would now need a man to take care of her—emotionally and every other way. She asked the therapist if she looked like a 30-year-old woman. When he declined to answer, she said, “I know you’re not supposed to say.”

When the therapist attempted to steer the conversation back to Morgan, Lucinda became petulant and asked, “Do we really need to talk about that abusive lout?” Pressed on the word “abusive,” Lucinda replied that she was referring to “mental cruelty.” Morgan had, after all, called her inadequate and worthless throughout their marriage and told her that everything good in her life had been due to him. When her therapist pointed out that this seemed to contradict the rosy picture she had just painted of Morgan and their married life, she quickly changed the subject, stating that she thought she was running out of time to have a child. She said her life would be “absolutely ruined” if she did not have a child by the age of 32.

As the session came to a close, Lucinda’s therapist suggested that it might be useful for him to meet with Morgan. She loved the idea, saying, “Then he’ll know the competition he has!”

When he met with Morgan a few days later, the therapist heard a very different story than the one presented by Lucinda. Morgan said, “I really loved Cindy—still do—but she was always flying off the handle at the slightest thing, telling me I’m no good or that I didn’t care about her. She would often complain that I spent too much time at work—keep in mind that I never work more than 30 hours a week—and too little time attending to her and her needs. I never wanted anyone but her, and I have no plans to become involved with anyone else. But I just can’t take life with her anymore. It’s too draining.”

The real surprise for the therapist came when Morgan described Lucinda’s social life. He said that she had virtually no close friends. The “dear and special” friendships she had spoken of during her therapy session were really just casual relationships—relationships of only a few months or so. As for her sister, Lucinda and she might talk on the phone once a month and get together in person twice a year. Yes, Morgan said, she did always talk about how close she was to other people and how much others wanted and needed her, but he never saw any evidence of it. He acknowledged that she drew a lot of attention from people. But he believed that there was a simple explanation for that. “Look at the way she dresses,” he noted, “and consider her never-ending flirtatious behavior. That will certainly get people’s attention, keep them around for a while. But she confuses this kind of attention with deep and lasting interest by others.”

People with histrionic personality disorder are always “on stage,” using theatrical gestures and mannerisms and grandiose language to describe ordinary everyday events. Like chameleons, they keep changing themselves to attract and impress an audience, and in their pursuit they change not only their surface characteristics—according to the latest fads—but also their opinions and beliefs. In fact, their speech is actually scanty in detail and substance, and they seem to lack a sense of who they really are.

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Approval and praise are their lifeblood; they must have others present to witness their exaggerated emotional states. Vain, self-centered, demanding, and unable to delay gratification for long, they overreact to any minor event that gets in the way of their quest for attention. Some make suicide attempts, often to manipulate others (APA, 2013; Lambert, 2003).

People with histrionic personality disorder may draw attention to themselves by exaggerating their physical illnesses or fatigues. They may also behave very provocatively and try to achieve their goals through sexual seduction. Most obsess over how they look and how others will perceive them, often wearing bright, eye-catching clothes. They exaggerate the depth of their relationships, considering themselves to be the intimate friends of people who see them as no more than casual acquaintances. Often they become involved with romantic partners who may be exciting but who do not treat them well.

This disorder was once believed to be more common in women than in men, and clinicians long described the “hysterical wife” (Anderson et al., 2001). Research, however, has revealed gender bias in past diagnoses (APA, 2013; Fowler et al., 2007; Ford & Widiger, 1989). When evaluating case studies of people with a mixture of histrionic and antisocial traits, clinicians in several studies gave a diagnosis of histrionic personality disorder to women more than men. Surveys suggest that 1.8 percent of adults have this personality disorder, with males and females equally affected (APA, 2013; Sansone & Sansone, 2011).

Transient hysterical symptoms These avid Harry Potter fans expressed themselves with exaggerated emotionality and lack of restraint at the midnight launch of one of the books in the series. Similar reactions, along with fainting, tremors, and even convulsions, have been common at concerts by musical idols dating back to the 1940s. Small wonder that expressive fans of this kind are regularly described as “hysterical” or “histrionic” by the press—the same labels applied to the personality disorder that is marked by such behaviors and symptoms.

How Do Theorists Explain Histrionic Personality Disorder?The psychodynamic perspective was originally developed to help explain cases of hysteria (see Chapter 10), so it is no surprise that psychodynamic theorists continue to have a strong interest in histrionic personality disorder. Most psychodynamic theorists believe that as children, people with this disorder had cold and controlling parents who left them feeling unloved and afraid of abandonment (Horowitz & Lerner, 2010; Bender et al., 2001). To defend against deep-seated fears of loss, the children learned to behave dramatically, inventing crises that would require other people to act protectively.

Cognitive explanations look instead at the lack of substance and extreme suggestibility that people with histrionic personality disorder have. Cognitive theorists see these people as becoming less and less interested in knowing about the world at large because they are so self-focused and emotional. With no detailed memories of what they never learned, they must rely on hunches or on other people to provide them with direction in life (Blagov et al., 2007). Some cognitive theorists also believe that people with this disorder hold a general assumption that they are helpless to care for themselves, and so they constantly seek out others who will meet their needs (Weishaar & Beck, 2006; Beck et al., 2004).

Sociocultural, particularly multicultural, theorists believe that histrionic personality disorder is produced in part by cultural norms and expectations. Until recently, our society encouraged girls to hold on to childhood and dependency as they grew up. The vain, dramatic, and selfish behavior of the histrionic personality may actually be an exaggeration of femininity as our culture once defined it (Fowler et al., 2007). Similarly, some clinical observers claim that histrionic personality disorder is diagnosed less often in Asian and other cultures that discourage overt sexualization and more often in Hispanic American and Latin American cultures that are more tolerant of overt sexualization (Patrick, 2007; Trull & Widiger, 2003). Researchers have not, however, investigated this claim systematically.

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In Their Words

“The hysterical find too much significance in things. The depressed find too little.”

Mason Cooley, American aphorist

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Treatments for Histrionic Personality DisorderPeople with histrionic personality disorder are more likely than those with most other personality disorders to seek out treatment on their own (Tyrer et al., 2003). Working with them can be very difficult, however, because of the demands, tantrums, and seductiveness they are likely to deploy. Another problem is that these clients may pretend to have important insights or to change during treatment merely to please the therapist. To head off such problems, therapists must remain objective and maintain strict professional boundaries (Colli et al., 2014; Blagov et al., 2007).

Cognitive therapists have tried to help people with this disorder to change their belief that they are helpless and also to develop better, more deliberate ways of thinking and solving problems (Beck & Weishaar, 2014; Weishaar & Beck, 2006; Beck et al., 2004). Psychodynamic therapy and various group therapy formats have also been used (Horowitz & Lerner, 2010). In all these approaches, therapists ultimately aim to help the clients recognize their excessive dependency, find inner satisfaction, and become more self-reliant. Clinical case reports suggest that each of the approaches can be useful. Drug therapy appears less successful except as a means of relieving the depressive symptoms that some patients have (Bock et al., 2010; Grossman, 2004; Koenigsberg et al., 2002).

Narcissistic Personality Disorder

People with narcissistic personality disorder are generally grandiose, need much admiration, and feel no empathy with others (APA, 2013). Convinced of their own great success, power, or beauty, they expect constant attention and admiration from those around them. Frederick, the man whom we met at the beginning of this chapter, was one such person. So is Steven, a 30-year-old artist, married, with one child:

narcissistic personality disorder A personality disorder marked by a broad pattern of grandiosity, need for admiration, and lack of empathy.

Steven came to the attention of a therapist when his wife insisted that they seek marital counseling. According to her, Steve was “selfish, ungiving and preoccupied with his work.” Everything at home had to “revolve about him, his comfort, moods and desires, no one else’s.” She claimed that he contributed nothing to the marriage, except a rather meager income. He shirked all “normal” responsibilities and kept “throwing chores in her lap,” and she was “getting fed up with being the chief cook and bottlewasher, tired of being his mother and sleep-in maid.”

On the positive side, Steven’s wife felt that he was basically a “gentle and good-natured guy with talent and intelligence.” But this wasn’t enough. She wanted a husband, someone with whom she could share things. In contrast, he wanted, according to her, “a mother, not a wife”; he didn’t want “to grow up, he didn’t know how to give affection, only to take it when he felt like it, nothing more, nothing less.”

Steve presented a picture of an affable, self-satisfied and somewhat disdainful young man. He was employed as a commercial artist, but looked forward to his evenings and weekends when he could turn his attention to serious painting. He claimed that he had to devote all of his spare time and energies to “fulfill himself,” to achieve expression in his creative work….

His relationships with his present co-workers and social acquaintances were pleasant and satisfying, but he did admit that most people viewed him as a “bit self-centered, cold and snobbish.” He recognized that he did not know how to share his thoughts and feelings with others, that he was much more interested in himself than in them and that perhaps he always had “preferred the pleasure” of his own company to that of others.

(Millon, 1969, pp. 261–262)

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In Their Words

“To love oneself is the beginning of a lifelong romance.”

Oscar Wilde, An Ideal Husband (1895)

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In the Greek myth, Narcissus died enraptured by the beauty of his own reflection in a pool, pining away with longing to possess his own image. His name has come to be synonymous with extreme self-involvement, and indeed people with narcissistic personality disorder have a grandiose sense of self-importance. They exaggerate their achievements and talents, expecting others to recognize them as superior, and often appear arrogant. They are very choosy about their friends and associates, believing that their problems are unique and can be appreciated only by other “special,” high-status people. Because of their charm, they often make favorable first impressions, yet they can rarely maintain long-term relationships (Campbell & Miller, 2011).

Why do people often admire arrogant deceivers—art forgers, jewel thieves, or certain kinds of “con” artists, for example?

Like Steven, people with narcissistic personality disorder are seldom interested in the feelings of others. They may not even be able to empathize with such feelings (Baskin-Sommers et al., 2014; Roepke & Vater, 2014; Ritter et al., 2011). Many take advantage of other people to achieve their own ends, perhaps partly out of envy; at the same time they believe others envy them. Though grandiose, some react to criticism or frustration with bouts of rage, humiliation, or embitterment (APA, 2013; Campbell & Miller, 2011; Rotter, 2011). Others may react with cold indifference. And still others become extremely pessimistic and filled with depression. They may have periods of zest that alternate with periods of disappointment (Ronningstam, 2011).

As many as 6.2 percent of adults display narcissistic personality disorder, up to 75 percent of them men (APA, 2013; Sansone & Sansone, 2011). Narcissistic-type behaviors and thoughts are common and normal among teenagers and do not usually lead to adult narcissism (APA, 2013) (see MindTech below).

How Do Theorists Explain Narcissistic Personality Disorder?Psychodynamic theorists more than others have theorized about narcissistic personality disorder, and they again propose that the problem begins with cold, rejecting parents. They argue that some people with this background spend their lives defending against feeling unsatisfied, rejected, unworthy, ashamed, and wary of the world (Roepke & Vater, 2014;Ronningstam, 2011;Bornstein, 2005). They do so by repeatedly telling themselves that they are actually perfect and desirable, and also by seeking admiration from others. Object relations theorists—the psychodynamic theorists who emphasize relationships—interpret the grandiose self-image as a way for these people to convince themselves that they are totally self-sufficient and without need of warm relationships with their parents or anyone else (Celani, 2014; Diamond & Meehan, 2013). In support of the psychodynamic theories, research has found that children who are abused or who lose parents through adoption, divorce, or death are at particular risk for the later development of narcissistic personality disorder (Kernberg, 2010, 1992, 1989). Studies also show that people with this disorder do indeed earn relatively high shame and rejection scores on various scales and believe that other people are basically unavailable to them (Ritter et al., 2014; Bender et al., 2001).

A number of cognitive-behavioral theorists propose that narcissistic personality disorder may develop when people are treated too positively rather than too negatively in early life. They hold that certain children acquire a superior and grandiose attitude when their “admiring or doting parents” teach them to “overvalue their self worth,” repeatedly rewarding them for minor accomplishments or for no accomplishment at all (Millon, 2011; Sperry, 2003).

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MindTech

Selfies: Narcissistic or Not?

In the art world, people have been drawing self-portraits for centuries. In recent years, however, digital technology has ushered in the era of the selfie, a cousin to the self-portrait. Safe to say, just about every cell phone user has taken a selfie. In fact, more than 90 percent of all teens have now posted a photo of themselves online (Pew Research Foundation, 2014). These self-photos have created such a stir that the word “selfie” was elected “Word of the Year 2013” by the Oxford English Dictionary.

As the selfie phenomenon has grown, opinions about selfies have intensified. It seems like people either love them or hate them. This is true in the field of psychology as well. Some psychologists view taking selfies as a form of narcissistic behavior, while others view them more positively.

First, the negative perspective. Many sociocultural theorists see a link between narcissistic personality disorder and “eras of narcissism” in society (Paris, 2014). They suggest that social values in society break down periodically, producing generations of self-centered, materialistic youth. Some of these theorists consider today’s selfie generation a perfect example of a current era of narcissism. This theory has gained a large following, but it is not supported by research. One team of researchers, for example, found no relationship at all between how many selfies people post and how high they score on a narcissism personality scale (Alloway, 2014; Alloway et al., 2014).

This lack of support for the narcissism viewpoint does not mean that selfies, especially repeated selfie behaviors, are completely harmless. Sherry Turkle (2013), an influential technology psychologist, believes that the near- reflexive instinct to photograph oneself may limit deeper engagements with the environment or experiencing events to their fullest (Eisold, 2013). Turkle also suggests that people who post an endless stream of selfies are often seeking external validation of their self-worth, even if that pursuit may not rise to a level of clinical narcissism.

Psychologists also observe that posting too many “selfies” may alienate those who view the poster’s social media profile (Miller, 2013). Studies have found, for example, that people often take a negative view of friends and family members who excessively post photos to their Facebook sites (Houghton, 2013).

What other trends in behavior—digital or otherwise—might suggest that our society is currently in an era of narcissism?

On the positive side, a number of psychologists believe that the criticisms and concerns about the selfie movement have been overstated. Media psychologist Pamela Rutledge (2013) views selfies as an inevitable by-product of “technology-enabled self-expression.” She believes that selfie behaviors are simply confusing to individuals of a predigital generation. Moreover, she concludes that the selfie trend, for digital natives, can enhance explorations of identity, help identify one’s interests, develop artistic expression, help people craft a meaningful narrative of their life experiences, and even reflect more realistic body images (for example, posting “selfies” without makeup). In therapy, selfies can serve as a springboard to discuss issues that clients are reluctant to broach on their own (Sifferlin, 2013).

In short, like other technological trends you’ve read about, the selfie phenomenon has received mixed grades from psychology researchers and practitioners so far.

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Many sociocultural theorists see a link between narcissistic personality disorder and “eras of narcissism” in society (Paris, 2014; Campbell & Miller, 2011). They suggest that family values and social ideals in certain societies periodically break down, producing generations of young people who are self-centered and materialistic and have short attention spans. Western cultures in particular, which encourage self-expression, individualism, and competitiveness, are considered likely to produce such generations of narcissism. In fact, one worldwide study conducted on the Internet found that respondents from the United States had the highest narcissism scores, followed, in descending order, by those from Europe, Canada, Asia, and the Middle East (Foster, Campbell, & Twenge, 2003).

What specific features of Western society may be contributing to today’s apparent rise in narcissistic behavior?

Treatments for Narcissistic Personality DisorderNarcissistic personality disorder is one of the most difficult personality patterns to treat because the clients are unable to acknowledge weaknesses, to appreciate the effect of their behavior on others, or to incorporate feedback from others (Campbell & Miller, 2011). The clients who consult therapists usually do so because of a related disorder such as depression (APA, 2013; Piper & Joyce, 2001). Once in treatment, the clients may try to manipulate the therapist into supporting their sense of superiority. Some also seem to project their grandiose attitudes onto their therapists and develop a love-hate stance toward them (Colli et al., 2014; Shapiro, 2004).

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Portrait in Vanity

King Frederick V, ruler of Denmark from 1746 to 1766, had his portrait painted at least 70 times by the same artist, Carl Pilo.

(Shaw, 2004)

Psychodynamic therapists seek to help people with this disorder recognize and work through their basic insecurities and defenses (Diamond & Meehan, 2013; Messer & Abbass, 2010). Cognitive therapists, focusing on the self-centered thinking of such individuals, try to redirect the clients’ focus onto the opinions of others, teach them to interpret criticism more rationally, increase their ability to empathize, and change their all-or-nothing notions (Beck & Weishaar, 2014; Weishaar & Beck, 2006; Beck et al., 2004). None of the approaches have had clear success, however (Paris, 2014; Dhawan et al., 2010).