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People often ask me what exactly...

Posted Sep 29 2008 10:07pm

People often ask me what exactly is a personality disorder in the clinical sense. Since I was a diagnostic clinician for 5 years I will try to explain this without being too clinical. But feel free to ask questions if I’m not clear.

We used the DSM IV (Diagnostic and Statistical Manual of Mental Disorders) to make clinical diagnoses but I think there is another book for Europe and the rest of the world. In the US we used the DSM and we would have to diagnose 5 axes. The evaluation form would ask for it as well as the insurance company so you had to evaluate the 5 axes.

Axis I is clinical disorders, learning disorders, developmental disorders. When I was practicing, there needs to be something on Axis I. Usually when I was evaluating in the ER it was Major Depressive Episode. That was the most common but also schizophrenia, anxiety disorder, panic disorder, bipolar, ADHD. If you really don’t want to saddle someone with a diagnosis or don’t really have one, Adjustment Disorder NOS would be the general diagnosis (NOS stands for not otherwise specified).

Axis II is Personality Disorders. Borderline, Narcisstic, Paranoid, Schizoid, Obsessive Compulsive, Histrionic (I think there are 12-15 personality disorders). In most people this would be N/A.

Axis III is medical if you have a medical condition.

Axis IV is any psycho/social factors affecting the diagnosis

Axis V is global assessment functioning on a scale of 1-100

So Axis I are very common disorders.

Personality Disorders

Axis II is fairly uncommon but characterized by the fact that they are so ingrained in the person and difficult to treat.

However, there are different “clusters” of personality disorders so it’s best to think of them that way. The first cluster is paranoid and schizoid (not the same as schizophrenic which is an Axis I diagnosis).

The second cluster is histrionic, narcissistic, borderline, antisocial.

The third cluster is the OCD and dependent and avoidant personalities.

The one that affects relationships the most is the second cluster.Borderline personalities were the ones that showed up most in my practice and this is characterized by impulse control difficulty, stormy relationships, pushing people away though afraid of being alone, frequent and dramatic mood changes, manipulative behavior

Narcisstic personalities tend to have an inflated sense of self, does not respond well to criticism, criticizes others, manipulates, inability to emphathize with others, attention seeking.

From the DSM:

The clinical criteria is: A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following:

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
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)
3. requires excessive admiration
4. has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations
5. is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends
6. lacks empathy: is unwilling to recognize or identify with the feelings and needs of others
7. is often envious of others or believes that others are envious of him or her
8. shows arrogant, haughty behaviors or attitudes

Personality disorders, especially cluster 2, are very difficult to overcome and make the partner of the person who has them pretty miserable.

NOTE: Approx 75% of those with NPD are male. NPDs make up about 2-15% of the clinical population (people actively seeking services from mental health providers) and about 1% of the general population. Although “narcissistic defense mechansims” might be common (having some of the criteria), having true NPD is much less common.

Axis II Cluster 2 personalities tend to abuse the people they are in relationships with. For the life of me I don’t understand why the DSM doesn’t list abuse of others as a criteria for NPDs. I would bet the house that every narcissist abuses almost everyone in their life.

Partners of Narcissists

I tend to disagree with studies I’ve read that healthy, stable people can find themselves in relationships with narcissists or borderlines. Most healthy people would intuitively RUN from relationships with these people. I can see how someone can “seem” to have it altogether but has unfinished business or some other self-doubt that attracts a narcissist or borderline and the doubt grows and grows as a result of the treatment/abuse by the narcissist.

But the most common partner of a narcissist or borderline is someone who is a perennial victim or martyr. Another common partner of a narcissist is someone who gets their self worth from the narcissist’s self-aggrandizing. In other words the narcissist thinks he or she is something special and the partner wants to be with someone special therefore they will be someone special. (complicated to describe).

Most partners of people with personality disorders are very codependent. I define them as “ clinically codependent ” (my term) even though there is no codependent term in clinical diagnosis this is my word for someone who needs aggressive intervention.

I find there are those who are everyday codependent, people who can read Codependent No More, go to a few CODA meetings, become very aware of their codep traits and change them.

Clinical codependents
need more rigorous intervention. Therapy, tough love, and a complete withdrawal from the person with a personality disorder. If someone has been sucked into a relationship with a person with a personality disorder, especially cluster 2 personality disorder, my recommended first line of treatment is GET AWAY FROM THEM AND STAY AWAY FROM THEM. Otherwise you’re never going to get well.

As discussed on the comments in another thread, I read the book The Wizard of Oz and Other Narcissists. I do find it dangerous that she suggests therapy with people who have NPD but she seems to waver throughout the book as to whether she wants to address people with TRUE NPD (evaluated as having an Axis II diagnosis) and people who have “narcissistic defense mechanisms.” I was a clinician and trained in the DSM and had trouble keeping straight what she was talking about.

A true NPD is not only going to be immune to couples therapy but I would bet my house that in 99 percent of the cases they use the therapy against their partner and maybe even against the therapists. I’ve seen therapists manipulated by narcissists and borderlines more times than I care to recount.

When I worked in Emergency Psychiatric Services our evaluations always commented on the person’s “insight” meaning their ability to understand their own problems. When a person has an Axis II, esp cluster 2, diagnosis, it was fairly usually to see “lacks insight” on their eval. A person who lacks insight cannot change because they don’t know how to change. My experience with NPDs is they don’t want to change and if they did, they wouldn’t know where to begin.

Borderlines and narcissists, especially narcissists, do not give up their victims easily. They do not respond well to rejection and it is part of the overblown sense of self that causes them to reel someone back in. It has NOTHING TO DO with any “feelings” they have toward their victim because they don’t have any (I don’t care WHAT they say, the feelings are NOT PRESENT.) Borderlines tend to manipulate the people back into their lives with stormy drama. I spent a lot of time in the ER with borderlines who were making a very lighthearted attempt at “suicide” which was mostly a histrionic effort to reel someone in their life back in after the person had announced they had had enough.


Most narcissists will make you believe it is ALL YOUR FAULT. It is RARELY about them. The world is wrong not them. Most of the time they keep their victim in one place with blame and a constant erosion of any self-worth the victim might muster. Occasionally they will say they love you and they are sorry but as a last resort.

If they say they are sorry or they love you or they care it is merely part of the game. BELIEVE NONE OF IT. Narcissists are PATHOLOGICAL LIARS and will say whatever they have to in order to keep their victim where they want her (or him but most [around 80 percent] narcissists are men).

Getting out is not easy but it really has to be done if you ever hope to have even a semblence of happiness. As I’ve said in other posts about getting way from your abuser, make sure you have a PLAN and you can stay SAFE. Abusers often kill or severely harm the person trying to leave. PLEASE TALK TO A DOMESTIC ABUSE SPECIALIST OR CALL THE 800 NUMBERS HERE: 1 800 799 SAFE which is 1 800 799 7233.

Also read Staying Safe by the National Domestic Violence Helpline:

Borderline Personality Disorder is actually easier to treat. Borderlines are difficult personalities and when they are in a lot of pain can be difficult to be around. But compared to an NPD a BPD is a walk in the park.

When I was a clinician about 75 percent of my population were borderlines and I found most of them to be incredibly likable people. Most were women who had cutting issues which is fairly common among borderlines. They can be very manipulative and when they are in the throes of their rejecting behavior, they can be quite frustrating.

I believe that my adoptive mother was borderline and I adapted some of her push me/pull me personality when I was younger. Through therapy and insight I was able to see it for what it was and stop it but sometimes partners or children of borderlines take on their maladaptive traits.

I get a lot of questions about NPD but not many about BPD. If you want more information about borderlines, let me know.

Stay Safe All!!!

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COMMENTS ARE CLOSED ON THIS THREAD. Please continue threads on Personality Disorders II

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