Use and Abuse of Differential Diagnoses
The DSM IV-R is a linear, descriptive (phenomenological), and bureaucratic. It is "medical", "mechanic-dynamic", and "physical" - akin to the old taxonomies in Botany and Zoology. It ignores life circumstances, biological and psychological processes, and an overarching conceptual and exegetic framework. Moreover, the DSM is heavily influenced by fashion, prevailing social mores and lores, and by the legal and business environment.
The DSM IV-TR is a linear, descriptive (phenomenological), and bureaucratic. It is "medical", "mechanic-dynamic", and "physical" - akin to the old taxonomies in Botany and Zoology. It ignores life circumstances, biological and psychological processes, and lacks an overarching conceptual and exegetic framework. Moreover, the DSM is heavily influenced by fashion, prevailing social mores and lores, and by the legal and business environment.
The classification of Axis II personality disorders - deeply ingrained, maladaptive, lifelong behavior patterns - in the Diagnostic and Statistical Manual, fourth edition, text revision [American Psychiatric Association. DSM-IV-TR, Washington, 2000] - or the DSM-IV-TR for short - has come under sustained and serious criticism from its inception in 1952.
The DSM IV-TR adopts a categorical approach, postulating that personality disorders are "qualitatively distinct clinical syndromes" (p. 689). This is widely doubted. Even the distinction made between "normal" and "disordered" personalities is increasingly being rejected. The "diagnostic thresholds" between normal and abnormal are either absent or weakly supported.
The polythetic form of the DSM's Diagnostic Criteria - only a subset of the criteria is adequate grounds for a diagnosis - generates unacceptable diagnostic heterogeneity. In other words, people diagnosed with the same personality disorder may share only one criterion or none.
The DSM fails to clarify the exact relationship between Axis II and Axis I disorders and the way chronic childhood and developmental problems interact with personality disorders;
The differential diagnoses are vague and the personality disorders are insufficiently demarcated. The result is excessive co-morbidity (multiple Axis II diagnoses);
The DSM contains little discussion of what distinguishes normal character (personality), personality traits, or personality style (Millon) - from personality disorders;
A dearth of documented clinical experience regarding both the disorders themselves and the utility of various treatment modalities;
Numerous personality disorders are "not otherwise specified" - a catchall, basket "category";
Cultural bias is evident in certain disorders (such as the Antisocial and the Schizotypal);
The emergence of dimensional alternatives to the categorical approach is acknowledged in the DSM-IV-TR itself:
"An alternative to the categorical approach is the dimensional perspective that Personality Disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another" (p.689)
The following issues - long neglected in the DSM - are likely to be tackled in future editions as well as in current research:
The longitudinal course of the disorder(s) and their temporal stability from early childhood onwards
The genetic and biological underpinnings of personality disorder(s)
The development of personality psychopathology during childhood and its emergence in adolescence
The interactions between physical health and disease and personality disorders
The effectiveness of various treatments - talk therapies as well as psychopharmacology.
1. The Concept of "Disease"
We are all terminally ill. It is a matter of time before we all die. Aging and death remain almost as mysterious as ever. We feel awed and uncomfortable when we contemplate these twin afflictions. Indeed, the very word denoting illness contains its own best definition: dis-ease. A mental component of lack of well being must exist SUBJECTIVELY. The person must FEEL bad, must experience discomfiture for his condition to qualify as a disease. To this extent, we are justified in classifying all diseases as "spiritual" or "mental".
Is there any other way of distinguishing health from sickness - a way that does NOT depend on the report that the patient provides regarding his subjective experience?
Some diseases are manifest and others are latent or immanent. Genetic diseases can exist - unmanifested - for generations. This raises the philosophical problem or whether a potential disease IS a disease? Are AIDS and Hemophilia carriers - sick? Should they be treated, ethically speaking? They experience no dis-ease, they report no symptoms, no signs are evident. On what moral grounds can we commit them to treatment? On the grounds of the "greater benefit" is the common response. Carriers threaten others and must be isolated or otherwise neutered. The threat inherent in them must be eradicated. This is a dangerous moral precedent. All kinds of people threaten our well-being: unsettling ideologists, the mentally handicapped, many politicians. Why should we single out our physical well-being as worthy of a privileged moral status? Why is our mental well being, for instance, of less import?
Moreover, the distinction between the psychic and the physical is hotly disputed, philosophically. The psychophysical problem is as intractable today as it ever was (if not more so). It is beyond doubt that the physical affects the mental and the other way around. This is what disciplines like psychiatry are all about. The ability to control "autonomous" bodily functions (such as heartbeat) and mental reactions to pathogens of the brain are proof of the artificialness of this distinction.
It is a result of the reductionist view of nature as divisible and summable. The sum of the parts, alas, is not always the whole and there is no such thing as an infinite set of the rules of nature, only an asymptotic approximation of it. The distinction between the patient and the outside world is superfluous and wrong. The patient AND his environment are ONE and the same. Disease is a perturbation in the operation and management of the complex ecosystem known as patient-world. Humans absorb their environment and feed it in equal measures. This on-going interaction IS the patient. We cannot exist without the intake of water, air, visual stimuli and food. Our environment is defined by our actions and output, physical and mental.
Thus, one must question the classical differentiation between "internal" and "external". Some illnesses are considered "endogenic" (=generated from the inside). Natural, "internal", causes - a heart defect, a biochemical imbalance, a genetic mutation, a metabolic process gone awry - cause disease. Aging and deformities also belong in this category.
In contrast, problems of nurturance and environment - early childhood abuse, for instance, or malnutrition - are "external" and so are the "classical" pathogens (germs and viruses) and accidents.
But this, again, is a counter-productive approach. Exogenic and Endogenic pathogenesis is inseparable. Mental states increase or decrease the susceptibility to externally induced disease. Talk therapy or abuse (external events) alter the biochemical balance of the brain. The inside constantly interacts with the outside and is so intertwined with it that all distinctions between them are artificial and misleading. The best example is, of course, medication: it is an external agent, it influences internal processes and it has a very strong mental correlate (=its efficacy is influenced by mental factors as in the placebo effect).
The very nature of dysfunction and sickness is highly culture-dependent. Societal parameters dictate right and wrong in health (especially mental health). It is all a matter of statistics. Certain diseases are accepted in certain parts of the world as a fact of life or even a sign of distinction (e.g., the paranoid schizophrenic as chosen by the gods). If there is no dis-ease there is no disease. That the physical or mental state of a person CAN be different - does not imply that it MUST be different or even that it is desirable that it should be different. In an over-populated world, sterility might be the desirable thing - or even the occasional epidemic. There is no such thing as ABSOLUTE dysfunction. The body and the mind ALWAYS function. They adapt themselves to their environment and if the latter changes - they change. Personality disorders are the best possible responses to abuse. Cancer may be the best possible response to carcinogens. Aging and death are definitely the best possible response to over-population. Perhaps the point of view of the single patient is incommensurate with the point of view of his species - but this should not serve to obscure the issues and derail rational debate.
As a result, it is logical to introduce the notion of "positive aberration". Certain hyper- or hypo- functioning can yield positive results and prove to be adaptive. The difference between positive and negative aberrations can never be "objective". Nature is morally-neutral and embodies no "values" or "preferences". It simply exists. WE, humans, introduce our value systems, prejudices and priorities into our activities, science included. It is better to be healthy, we say, because we feel better when we are healthy. Circularity aside - this is the only criterion that we can reasonably employ. If the patient feels good - it is not a disease, even if we all think it is. If the patient feels bad, ego-dystonic, unable to function - it is a disease, even when we all think it isn't. Needless to say that I am referring to that mythical creature, the fully informed patient. If someone is sick and knows no better (has never been healthy) - then his decision should be respected only after he is given the chance to experience health.
All the attempts to introduce "objective" yardsticks of health are plagued and philosophically contaminated by the insertion of values, preferences and priorities into the formula - or by subjecting the formula to them altogether. One such attempt is to define health as "an increase in order or efficiency of processes" as contrasted with illness which is "a decrease in order (=increase of entropy) and in the efficiency of processes". While being factually disputable, this dyad also suffers from a series of implicit value-judgments. For instance, why should we prefer life over death? Order to entropy? Efficiency to inefficiency?
Health and sickness are different states of affairs. Whether one is preferable to the other is a matter of the specific culture and society in which the question is posed. Health (and its lack) is determined by employing three "filters" as it were:
Is the body affected?
Is the person affected? (dis-ease, the bridge between "physical" and "mental illnesses)
Is society affected?
In the case of mental health the third question is often formulated as "is it normal" (=is it statistically the norm of this particular society in this particular time)?
We must re-humanize disease. By imposing upon issues of health the pretensions of the accurate sciences, we objectified the patient and the healer alike and utterly neglected that which cannot be quantified or measured - the human mind, the human spirit.
Read "The Myth of Mental Illness"
2. Psychology as Storytelling
Storytelling has been with us since the days of campfire and besieging wild animals. It served a number of important functions: amelioration of fears, communication of vital information (regarding survival tactics and the characteristics of animals, for instance), the satisfaction of a sense of order (justice), the development of the ability to hypothesize, predict and introduce theories and so on.
We are all endowed with a sense of wonder. The world around us in inexplicable, baffling in its diversity and myriad forms. We experience an urge to organize it, to "explain the wonder away", to order it in order to know what to expect next (predict). These are the essentials of survival. But while we have been successful at imposing our mind's structures on the outside world – we have been much less successful when we tried to cope with our internal universe.
The relationship between the structure and functioning of our (ephemeral) mind, the structure and modes of operation of our (physical) brain and the structure and conduct of the outside world have been the matter of heated debate for millennia. Broadly speaking, there were (and still are) two ways of treating it:
There were those who, for all practical purposes, identified the origin (brain) with its product (mind). Some of them postulated the existence of a lattice of preconceived, born categorical knowledge about the universe – the vessels into which we pour our experience and which mold it. Others have regarded the mind as a black box. While it was possible in principle to know its input and output, it was impossible, again in principle, to understand its internal functioning and management of information. Pavlov coined the word "conditioning", Watson adopted it and invented "behaviourism", Skinner came up with "reinforcement". But all ignored the psychophysical question: what IS the mind and HOW is it linked to the brain?
The other camp was more "scientific" and "positivist". It speculated that the mind (whether a physical entity, an epiphenomenon, a non-physical principle of organization, or the result of introspection) – had a structure and a limited set of functions. They argued that a "user's manual" could be composed, replete with engineering and maintenance instructions. The most prominent of these "psychodynamists" was, of course, Freud. Though his disciples (Adler, Horney, the object-relations lot) diverged wildly from his initial theories – they all shared his belief in the need to "scientify" and objectify psychology. Freud – a medical doctor by profession (Neurologist) and Bleuler before him – came with a theory regarding the structure of the mind and its mechanics: (suppressed) energies and (reactive) forces. Flow charts were provided together with a method of analysis, a mathematical physics of the mind.
But this was a mirage. An essential part was missing: the ability to test the hypotheses, which derived from these "theories". They were all very convincing, though, and, surprisingly, had great explanatory power. But - non-verifiable and non-falsifiable as they were – they could not be deemed to possess the redeeming features of a scientific theory.
Psychological theories of the mind are metaphors of the mind. They are fables and myths, narratives, stories, hypotheses, conjunctures. They play (exceedingly) important roles in the psychotherapeutic setting – but not in the laboratory. Their form is artistic, not rigorous, not testable, less structured than theories in the natural sciences. The language used is polyvalent, rich, effusive, and fuzzy – in short, metaphorical. They are suffused with value judgements, preferences, fears, post facto and ad hoc constructions. None of this has methodological, systematic, analytic and predictive merits.
Still, the theories in psychology are powerful instruments, admirable constructs of the mind. As such, they are bound to satisfy some needs. Their very existence proves it.
The attainment of peace of mind is a need, which was neglected by Maslow in his famous rendition. People will sacrifice material wealth and welfare, will forgo temptations, will ignore opportunities, and will put their lives in danger – just to reach this bliss of wholeness and completeness. There is, in other words, a preference of inner equilibrium over homeostasis. It is the fulfillment of this overriding need that psychological theories set out to cater to. In this, they are no different than other collective narratives (myths, for instance).
In some respects, though, there are striking differences:
Psychology is desperately trying to link up to reality and to scientific discipline by employing observation and measurement and by organizing the results and presenting them using the language of mathematics. This does not atone for its primordial sin: that its subject matter is ethereal and inaccessible. Still, it lends an air of credibility and rigorousness to it.
The second difference is that while historical narratives are "blanket" narratives – psychology is "tailored", "customized". A unique narrative is invented for every listener (patient, client) and he is incorporated in it as the main hero (or anti-hero). This flexible "production line" seems to be the result of an age of increasing individualism. True, the "language units" (large chunks of denotates and connotates) are one and the same for every "user". In psychoanalysis, the therapist is likely to always employ the tripartite structure (Id, Ego, Superego). But these are language elements and need not be confused with the plots. Each client, each person, and his own, unique, irreplicable, plot.
To qualify as a "psychological" plot, it must be:
All-inclusive (anamnetic) – It must encompass, integrate and incorporate all the facts known about the protagonist.
Coherent – It must be chronological, structured and causal.
Consistent – Self-consistent (its subplots cannot contradict one another or go against the grain of the main plot) and consistent with the observed phenomena (both those related to the protagonist and those pertaining to the rest of the universe).
Logically compatible – It must not violate the laws of logic both internally (the plot must abide by some internally imposed logic) and externally (the Aristotelian logic which is applicable to the observable world).
Insightful (diagnostic) – It must inspire in the client a sense of awe and astonishment which is the result of seeing something familiar in a new light or the result of seeing a pattern emerging out of a big body of data. The insights must be the logical conclusion of the logic, the language and of the development of the plot.
Aesthetic – The plot must be both plausible and "right", beautiful, not cumbersome, not awkward, not discontinuous, smooth and so on.
Parsimonious – The plot must employ the minimum numbers of assumptions and entities in order to satisfy all the above conditions.
Explanatory – The plot must explain the behaviour of other characters in the plot, the hero's decisions and behaviour, why events developed the way that they did.
Predictive (prognostic) – The plot must possess the ability to predict future events, the future behaviour of the hero and of other meaningful figures and the inner emotional and cognitive dynamics.
Therapeutic – With the power to induce change (whether it is for the better, is a matter of contemporary value judgments and fashions).
Imposing – The plot must be regarded by the client as the preferable organizing principle of his life's events and the torch to guide him in the darkness to come.
Elastic – The plot must possess the intrinsic abilities to self organize, reorganize, give room to emerging order, accommodate new data comfortably, avoid rigidity in its modes of reaction to attacks from within and from without.
In all these respects, a psychological plot is a theory in disguise. Scientific theories should satisfy most of the same conditions. But the equation is flawed. The important elements of testability, verifiability, refutability, falsifiability, and repeatability – are all missing. No experiment could be designed to test the statements within the plot, to establish their truth-value and, thus, to convert them to theorems.
There are three reasons to account for this shortcoming:
Ethical – Experiments would have to be conducted, involving the hero and other humans. To achieve the necessary result, the subjects will have to be ignorant of the reasons for the experiments and their aims. Sometimes even the very performance of an experiment will have to remain a secret (double blind experiments). Some experiments may involve unpleasant experiences. This is ethically unacceptable.
The Psychological Uncertainty Principle – The current position of a human subject can be fully known. But both treatment and experimentation influence the subject and void this knowledge. The very processes of measurement and observation influence the subject and change him.
Uniqueness – Psychological experiments are, therefore, bound to be unique, unrepeatable, cannot be replicated elsewhere and at other times even if they deal with the SAME subjects. The subjects are never the same due to the psychological uncertainty principle. Repeating the experiments with other subjects adversely affects the scientific value of the results.
The undergeneration of testable hypotheses – Psychology does not generate a sufficient number of hypotheses, which can be subjected to scientific testing. This has to do with the fabulous (=storytelling) nature of psychology. In a way, psychology has affinity with some private languages. It is a form of art and, as such, is self-sufficient. If structural, internal constraints and requirements are met – a statement is deemed true even if it does not satisfy external scientific requirements.
So, what are plots good for? They are the instruments used in the procedures, which induce peace of mind (even happiness) in the client. This is done with the help of a few embedded mechanisms:
The Organizing Principle – Psychological plots offer the client an organizing principle, a sense of order and ensuing justice, of an inexorable drive toward well defined (though, perhaps, hidden) goals, the ubiquity of meaning, being part of a whole. It strives to answer the "why’s" and "how’s". It is dialogic. The client asks: "why am I (here follows a syndrome)". Then, the plot is spun: "you are like this not because the world is whimsically cruel but because your parents mistreated you when you were very young, or because a person important to you died, or was taken away from you when you were still impressionable, or because you were sexually abused and so on". The client is calmed by the very fact that there is an explanation to that which until now monstrously taunted and haunted him, that he is not the plaything of vicious Gods, that there is who to blame (focussing diffused anger is a very important result) and, that, therefore, his belief in order, justice and their administration by some supreme, transcendental principle is restored. This sense of "law and order" is further enhanced when the plot yields predictions which come true (either because they are self-fulfilling or because some real "law" has been discovered).
The Integrative Principle – The client is offered, through the plot, access to the innermost, hitherto inaccessible, recesses of his mind. He feels that he is being reintegrated, that "things fall into place". In psychodynamic terms, the energy is released to do productive and positive work, rather than to induce distorted and destructive forces.
The Purgatory Principle – In most cases, the client feels sinful, debased, inhuman, decrepit, corrupting, guilty, punishable, hateful, alienated, strange, mocked and so on. The plot offers him absolution. Like the highly symbolic figure of the Savior before him – the client's sufferings expurgate, cleanse, absolve, and atone for his sins and handicaps. A feeling of hard won achievement accompanies a successful plot. The client sheds layers of functional, adaptive clothing. This is inordinately painful. The client feels dangerously naked, precariously exposed. He then assimilates the plot offered to him, thus enjoying the benefits emanating from the previous two principles and only then does he develop new mechanisms of coping. Therapy is a mental crucifixion and resurrection and atonement for the sins. It is highly religious with the plot in the role of the scriptures from which solace and consolation can be always gleaned.
3. Personality Disorders - An Overview
All personality disorders are interrelated, in my view, at least phenomenologically. We have no Grand Unifying Theory of Psychopathology. We do not know whether there are – and what are – the mechanisms underlying mental disorders. At best, mental health professionals register symptoms (as reported by the patient) and signs (as observed). Then, they group them into syndromes and, more specifically, into disorders. This is descriptive, not explanatory science. Sure, there are a few theories around (psychoanalysis, to mention the most famous) but they all failed miserably at providing a coherent, consistent theoretical framework with predictive powers.
Patients suffering from personality disorders have many things in common:
Most of them are insistent (except those suffering from the Schizoid or the Avoidant Personality Disorders). They demand treatment on a preferential and privileged basis. They complain about numerous symptoms. They never obey the physician or his treatment recommendations and instructions.
They regard themselves as unique, display a streak of grandiosity and a diminished capacity for empathy (the ability to appreciate and respect the needs and wishes of other people). They regard the physician as inferior to them, alienate him using umpteen techniques and bore him with their never-ending self-preoccupation.
They are manipulative and exploitative because they trust no one and usually cannot love or share. They are socially maladaptive and emotionally unstable.
Most personality disorders start out as problems in personal development which peak during adolescence and then become personality disorders. They stay on as enduring qualities of the individual. Personality disorders are stable and all-pervasive – not episodic. They affect most of the areas of functioning of the patient: his career, his interpersonal relationships, his social functioning.
The patient is not happy, to use an understatement. He is depressed, suffers from auxiliary mood and anxiety disorders. He does not like himself, his character, his (deficient) functioning, or his (crippling) influence on others. But his defences are so strong, that he is aware only of the distress – and not of the reasons to it.
The patient with a personality disorder is vulnerable to and prone to suffer from a host of other psychiatric disturbances. It is as though his psychological immunological system has been disabled by the personality disorder and he falls prey to other variants of mental sickness. So much energy is consumed by the disorder and by its corollaries (example: by obsessions-compulsions), that the patient is rendered defenceless.
Patients with personality disorders are alloplastic in their defences. In other words: they tend to blame the external world for their mishaps. In stressful situations, they try to pre-empt a (real or imaginary) threat, change the rules of the game, introduce new variables, or otherwise influence the external world to conform to their needs. This is as opposed to autoplastic defences exhibited, for instance, by neurotics (who change their internal psychological processes in stressful situations).
8. The character problems, behavioural deficits and emotional deficiencies and instability encountered by the patient with personality disorder are, mostly, ego-syntonic. This means that the patient does not, on the whole, find his personality traits or behaviour objectionable, unacceptable, disagreeable, or alien to his self. As opposed to that, neurotics are ego-dystonic: they do not like who they are and how they behave on a constant basis.
The personality-disordered are not psychotic. They have no hallucinations, delusions or thought disorders (except those who suffer from a Borderline Personality Disorder and who experience brief psychotic "microepisodes", mostly during treatment). They are also fully oriented, with clear senses (sensorium), good memory and general fund of knowledge.
The Diagnostic and Statistical Manual (DSM) – IV-TR (2000) defines "personality" as: "...enduring patterns of perceiving, relating to, and thinking about the environment and oneself... exhibited in a wide range of important social and personal contexts."
It defines personality disorders as:
"A. An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual's culture. This pattern is manifested in two (or more) of the following areas:
Cognition (i.e., ways of perceiving and interpreting self, other people, and events);
Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response);
Interpersonal functioning;
Impulse control.
B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.
F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug abuse, a medication) or a general medical condition (e.g., head trauma)."
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, fourth edition, text revision (DSM IV-TR). Washington, DC: American Psychiatric Association.
4. An Example of a Unifying Approach
We are all narcissists at an early stage of our lives. As infants, we feel that we are the centre of the universe, omnipotent and omniscient. Our parents, those mythical figures, immortal and awesomely powerful, are there only to protect us. Both self and others are viewed immaturely, as idealisations. Inevitably, the inexorable processes and conflicts of life erode them and grind the ideal into the fine dust of the real. Disappointments follow disillusionment. If gradual and tolerable – they yield adaptation. If abrupt, capricious, arbitrary, and intense – the injuries sustained by the tender, budding, self-esteem, are irreversible. Moreover, the empathic support of the caretakers (the Primary Objects, the parents) is crucial. In its absence, the self-esteem in adulthood will tend to fluctuate, to alternate between over-valuation (idealisation) and devaluation of both the self and others. Narcissistic adults are the result of bitter disappointment, of radical disillusionment with their parents. Healthy adults accept their self-limitations (=the limitations, the boundaries, of their selves). They accept disappointments, setbacks, failures, criticism and disillusionment with grace and tolerance. Their self-esteem is constant and positive, not affected by outside events, no matter how severe.
The common view is that we go through the stages of a linear development. We are propelled forward by forces: the libido (force of life) and Thanatos (force of death) in Freud's thinking, Meaning in Frenkel's, socially mediated phenomena (Adler, Behaviorism), cultural context (Horney), interpersonal relations (Sullivan) and neurobiological and neurochemical forces, to mention but a few schools of developmental psychology. In an effort to gain respectability, psychologists constructed a "physics of the mind".
These thought systems differ on many issues. Some said that personal development ends in childhood, others – during adolescence. Yet others said that development is a process which continues throughout the life of the individual. Common to all these schools of thought are the mechanics and dynamics of the process. Forces – inner or external – facilitated the development of the individual. When an obstacle to development is encountered, development is stunted or arrested – but not for long. A distorted pattern of development, a bypass appears. Hence, psychopathological conditions are the outcomes of disturbed growth. Humans can be compared to trees. When a tree encounters a physical obstacle to its growth – its branches or roots curl around it. Yet, deformed and ugly, they still reach their destination, however late and partially. Psychopathologies are adaptive mechanisms. They allow the individual to continue to grow around the disturbing factor. The personality twists and turns, deforms itself, is transformed – until it reaches a functional equilibrium, which is not too ego-dystonic. There it settles down and continues its more or less linear pattern of growth. But the thrust is clear: onwards. Adaptation above all, growth at any price, straight or deformed, it doesn't really matter. The forces of life (as expressed in the development of the personality) are stronger than any hindrance. The roots of trees crack mighty rocks, microbes live in the most poisonous surroundings – humans form the personality structure which is best suited to their needs and outside constraints. Such a personality structure may be abnormal – but it has mostly triumphed in the delicate task of successful adaptation.
I believe that people do engage in linear growth and development and that, these are driven by both internal and external forces. I also believe that only death puts a stop to personal growth and development. Life events, crises, joys and sadness, disappointments and surprises, setbacks and successes – all contribute to the weaving of the delicate fabric called "personality". Where I differ from customary views is in what I believe constitutes a reaction to disturbances, hindrances and obstacles to personal growth.
I think that when an individual (at any age) encounters an obstacle to the orderly progression from one stage of development to another – he retreats to the narcissistic phase rather than circumvent or "go around" the hindrance. The process is three-stepped: (1) The person encounters an obstacle; (2) The person regresses to the infantile narcissistic phase; and (3) The person recuperates and moves back from the narcissistic phase to attack the obstacle again. While in step (2), the person displays childish, immature behaviours. He feels that he is omnipotent and misjudges his powers and the powers of his opponents and opposition. He underestimates challenges facing him and pretends to be "Mr. Know-All". His sensitivity to the needs and emotions of others and his ability to empathise with them deteriorates sharply. He becomes intolerably haughty and arrogant, with sadistic and paranoid tendencies. Above all, he then seeks unconditional admiration, even when he does not deserve it. He is preoccupied with fantastic, magical, thinking and daydreams his life away. He tends to exploit others, to envy them, to be edgy and explode with unexplained rage. People who undergo a psychological development crisis brought on by an insurmountable obstacle – mostly revert to excessive and compulsive behaviour patterns. To put it succinctly: whenever we experience a major life crisis (which hinders our personal growth and threatens it) – we suffer from a mild and transient form of the Narcissistic Personality Disorder.
This fantasy world, full of falsity and feelings hurt, serves as a springboard. It is from there that the individual can resume his progress towards the next stage of personal growth. Faced with the same obstacle, he feels (falsely) sufficiently potent to ignore it or to attack it. In most cases, success is guaranteed by the very unrealistic assessment of the fortitude and magnitude of the obstacle. The main function of the episodic or transient NPD is this: to encourage the individual to engage in magical thinking, to wish the problem away or to enchant it or to tackle and overcome it from a position of omnipotence.
A structural abnormality of personality arises only when recurrent attacks fail constantly and consistently to eliminate the obstacle, or to overcome the hindrance. The contrast between the fantastic world (temporarily) occupied by the individual and the real world in which he keeps being frustrated – is too acute to countenance for long. The dissonance gives rise to the unconscious "decision" to go on living in the world of fantasy, grandeur, grandiosity and entitlement. It is better to feel special than to feel inadequate. It is better to be omnipotent than psychologically impotent. To (ab)use others is preferable to being (ab)used by them. In short: it is better to remain a pathological narcissist than to face the harsh unyielding realities.
Not all psychopathologies are narcissistic in character and not all personality disorders are narcissistic. Yet, I think that the default (in case of growth stunted by an obstacle) is the narcissistic phase of personal development. I further believe that this is the ONLY default available to the individual: whenever he comes across an obstacle, he regresses to the narcissistic phase. How can this be reconciled with the diversity of psychopathologies/personality disorders?
We must define "narcissism" more broadly as the substitution of a False Self for the True Self. This, arguably, is the predominant feature of narcissism: the True Self is repressed and suppressed, relegated to irrelevance and obscurity, left to degenerate and fossilise. In its stead, a psychological structure is formed and projected unto the outside world – the False Self. The False Self is reflected to the narcissist by other people. This "proves" to him that the False Self has an independent existence, that it is not entirely a figment of his imagination and, therefore, that it is a legitimate heir to the True Self. It is this characteristic which unites all psychopathologies: the emergence of false psychic structures which usurp the powers and capacities of the previous, legitimate and authentic structures.
Horrified by the absence of a clearly bounded, cohesive, coherent, reliable, and self-regulating self – the mentally abnormal person resorts to one of the following solutions, all of which involve reliance upon fake or invented personality elements:
The Narcissistic Solution – The substitution of the True Self with a False Self. The narcissistic solution is the subject of this book. The Schizotypal Personality Disorder largely belongs here because of its emphasised fantastic and magical thinking. The Borderline Personality Disorder is a case of a failed narcissistic solution. In BPD, the patient is aware (at least unconsciously) that the solution that he adopted is "not working". This is the source of his anxiety (something is fuzzily wrong, or a foreboding sense, a premonition is present), of his fear of abandonment (by the solution). This generates his identity disturbance, his affective instability, suicidal ideation and suicidal action, chronic feelings of emptiness, rage attacks, and transient (stress related) paranoid ideation.
The Appropriation Solution – This is the appropriation, the confiscation of someone else's self in order to fill the vacuum left by the absence of a functioning Ego. While some of the Ego functions are available – the others are assumed and adopted by the "appropriating personality". The Histrionic Personality Disorder is an example of this solution. Mothers who "sacrifice" their lives for their children, people who live vicariously, through others – all belong to this category. So do people who dramatise their lives and their behaviour, in order to attract attention. The "appropriators" misjudge the intimacy of their relationships and the degree of commitment involved, they are easily suggestible and their whole personality seems to shift and fluctuate with input from the outside. Because they have no Self of their own (even more so then narcissists) – the "appropriators" tend to over-rate and over-emphasise their bodies. Perhaps the most striking example of this type of solution is the Dependent Personality Disorder.
The Schizoid Solution – These patients are mental zombies, trapped forever in the no-man's land between stunted growth and the narcissistic default. They are not narcissists because they lack a False Self – nor are they fully developed adults, because their True Self is immature and dysfunctional. They prefer to avoid contact with others (they lack empathy, as the narcissist does) in order not to upset their delicate tightrope act. Withdrawing from the world is an adaptive solution because it does not expose the inadequate personality structures (especially the self) to onerous – and failure bound – tests. The Schizotypal Personality Disorder patient is a mixture of the narcissistic and the schizoid solutions. The Avoidant Personality Disorder is a close kin.
The Aggressive Destructive Solution – These people suffer from hypochondriasis, depression, suicidal ideation, dysphoria, anhedonia, compulsions and obsessions and other expressions of internalised and transformed aggression directed at a self which is perceived to be inadequate, guilty, disappointing and worthy of nothing but elimination. Many of the narcissistic elements are present in an exaggerated form. Lack of empathy becomes reckless disregard for others, irritability, deceitfulness and criminal violence. Undulating self-esteem is transformed into impulsiveness and failure to plan ahead. The Antisocial Personality Disorder is a prime example of this solution, whose essence is: the total control of a False Self, without the mitigating presence of a shred of True Self.
Perhaps this common feature – the replacement of the original structures of the personality by new, invented, mostly false ones – is what causes one to see narcissists everywhere. This common denominator is most accentuated in the Narcissistic Personality Disorder. The interaction, really, the battle, between the struggling original remnants of the personality and the malignant and omnivorous new structures – can be discerned in all forms of psychic abnormality. The question is: if many phenomena have one thing in common – should they be considered one and the same?
I say that the answer in the case of personality disorders should be in the affirmative. I think that all the known personality disorders are forms of malignant self-love. In each personality disorder, different attributes are differently emphasised, different weights attach to different behaviour patterns. But these, in my view, are all matters of quantity, not of quality. The myriad heads of the deformation of the reactive patterns collectively known as "personality" – all belong to the same medusa.
The classification of Axis II personality disorders - deeply ingrained, maladaptive, lifelong behavior patterns - in the Diagnostic and Statistical Manual, fourth edition, text revision [American Psychiatric Association. DSM-IV-TR, Washington, 2000] - or the DSM-IV-TR for short - has come under sustained and serious criticism from its inception in 1952.
The DSM IV-TR adopts a categorical approach, postulating that personality disorders are "qualitatively distinct clinical syndromes" (p. 689). This is widely doubted. Even the distinction made between "normal" and "disordered" personalities is increasingly being rejected. The "diagnostic thresholds" between normal and abnormal are either absent or weakly supported.
The polythetic form of the DSM's Diagnostic Criteria - only a subset of the criteria is adequate grounds for a diagnosis - generates unacceptable diagnostic heterogeneity. In other words, people diagnosed with the same personality disorder may share only one criterion or none.
The DSM fails to clarify the exact relationship between Axis II and Axis I disorders and the way chronic childhood and developmental problems interact with personality disorders;
The differential diagnoses are vague and the personality disorders are insufficiently demarcated. The result is excessive co-morbidity (multiple Axis II diagnoses);
The DSM contains little discussion of what distinguishes normal character (personality), personality traits, or personality style (Millon) - from personality disorders;
A dearth of documented clinical experience regarding both the disorders themselves and the utility of various treatment modalities;
Numerous personality disorders are "not otherwise specified" - a catchall, basket "category";
Cultural bias is evident in certain disorders (such as the Antisocial and the Schizotypal);
The emergence of dimensional alternatives to the categorical approach is acknowledged in the DSM-IV-TR itself:
"An alternative to the categorical approach is the dimensional perspective that Personality Disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another" (p.689)
The following issues - long neglected in the DSM - are likely to be tackled in future editions as well as in current research:
The longitudinal course of the disorder(s) and their temporal stability from early childhood onwards
The genetic and biological underpinnings of personality disorder(s)
The development of personality psychopathology during childhood and its emergence in adolescence
The interactions between physical health and disease and personality disorders
The effectiveness of various treatments - talk therapies as well as psychopharmacology.
1. The Concept of "Disease"
We are all terminally ill. It is a matter of time before we all die. Aging and death remain almost as mysterious as ever. We feel awed and uncomfortable when we contemplate these twin afflictions. Indeed, the very word denoting illness contains its own best definition: dis-ease. A mental component of lack of well being must exist SUBJECTIVELY. The person must FEEL bad, must experience discomfiture for his condition to qualify as a disease. To this extent, we are justified in classifying all diseases as "spiritual" or "mental".
Is there any other way of distinguishing health from sickness - a way that does NOT depend on the report that the patient provides regarding his subjective experience?
Some diseases are manifest and others are latent or immanent. Genetic diseases can exist - unmanifested - for generations. This raises the philosophical problem or whether a potential disease IS a disease? Are AIDS and Hemophilia carriers - sick? Should they be treated, ethically speaking? They experience no dis-ease, they report no symptoms, no signs are evident. On what moral grounds can we commit them to treatment? On the grounds of the "greater benefit" is the common response. Carriers threaten others and must be isolated or otherwise neutered. The threat inherent in them must be eradicated. This is a dangerous moral precedent. All kinds of people threaten our well-being: unsettling ideologists, the mentally handicapped, many politicians. Why should we single out our physical well-being as worthy of a privileged moral status? Why is our mental well being, for instance, of less import?
Moreover, the distinction between the psychic and the physical is hotly disputed, philosophically. The psychophysical problem is as intractable today as it ever was (if not more so). It is beyond doubt that the physical affects the mental and the other way around. This is what disciplines like psychiatry are all about. The ability to control "autonomous" bodily functions (such as heartbeat) and mental reactions to pathogens of the brain are proof of the artificialness of this distinction.
It is a result of the reductionist view of nature as divisible and summable. The sum of the parts, alas, is not always the whole and there is no such thing as an infinite set of the rules of nature, only an asymptotic approximation of it. The distinction between the patient and the outside world is superfluous and wrong. The patient AND his environment are ONE and the same. Disease is a perturbation in the operation and management of the complex ecosystem known as patient-world. Humans absorb their environment and feed it in equal measures. This on-going interaction IS the patient. We cannot exist without the intake of water, air, visual stimuli and food. Our environment is defined by our actions and output, physical and mental.
Thus, one must question the classical differentiation between "internal" and "external". Some illnesses are considered "endogenic" (=generated from the inside). Natural, "internal", causes - a heart defect, a biochemical imbalance, a genetic mutation, a metabolic process gone awry - cause disease. Aging and deformities also belong in this category.
In contrast, problems of nurturance and environment - early childhood abuse, for instance, or malnutrition - are "external" and so are the "classical" pathogens (germs and viruses) and accidents.
But this, again, is a counter-productive approach. Exogenic and Endogenic pathogenesis is inseparable. Mental states increase or decrease the susceptibility to externally induced disease. Talk therapy or abuse (external events) alter the biochemical balance of the brain. The inside constantly interacts with the outside and is so intertwined with it that all distinctions between them are artificial and misleading. The best example is, of course, medication: it is an external agent, it influences internal processes and it has a very strong mental correlate (=its efficacy is influenced by mental factors as in the placebo effect).
The very nature of dysfunction and sickness is highly culture-dependent. Societal parameters dictate right and wrong in health (especially mental health). It is all a matter of statistics. Certain diseases are accepted in certain parts of the world as a fact of life or even a sign of distinction (e.g., the paranoid schizophrenic as chosen by the gods). If there is no dis-ease there is no disease. That the physical or mental state of a person CAN be different - does not imply that it MUST be different or even that it is desirable that it should be different. In an over-populated world, sterility might be the desirable thing - or even the occasional epidemic. There is no such thing as ABSOLUTE dysfunction. The body and the mind ALWAYS function. They adapt themselves to their environment and if the latter changes - they change. Personality disorders are the best possible responses to abuse. Cancer may be the best possible response to carcinogens. Aging and death are definitely the best possible response to over-population. Perhaps the point of view of the single patient is incommensurate with the point of view of his species - but this should not serve to obscure the issues and derail rational debate.
As a result, it is logical to introduce the notion of "positive aberration". Certain hyper- or hypo- functioning can yield positive results and prove to be adaptive. The difference between positive and negative aberrations can never be "objective". Nature is morally-neutral and embodies no "values" or "preferences". It simply exists. WE, humans, introduce our value systems, prejudices and priorities into our activities, science included. It is better to be healthy, we say, because we feel better when we are healthy. Circularity aside - this is the only criterion that we can reasonably employ. If the patient feels good - it is not a disease, even if we all think it is. If the patient feels bad, ego-dystonic, unable to function - it is a disease, even when we all think it isn't. Needless to say that I am referring to that mythical creature, the fully informed patient. If someone is sick and knows no better (has never been healthy) - then his decision should be respected only after he is given the chance to experience health.
All the attempts to introduce "objective" yardsticks of health are plagued and philosophically contaminated by the insertion of values, preferences and priorities into the formula - or by subjecting the formula to them altogether. One such attempt is to define health as "an increase in order or efficiency of processes" as contrasted with illness which is "a decrease in order (=increase of entropy) and in the efficiency of processes". While being factually disputable, this dyad also suffers from a series of implicit value-judgments. For instance, why should we prefer life over death? Order to entropy? Efficiency to inefficiency?
Health and sickness are different states of affairs. Whether one is preferable to the other is a matter of the specific culture and society in which the question is posed. Health (and its lack) is determined by employing three "filters" as it were:
Is the body affected?
Is the person affected? (dis-ease, the bridge between "physical" and "mental illnesses)
Is society affected?
In the case of mental health the third question is often formulated as "is it normal" (=is it statistically the norm of this particular society in this particular time)?
We must re-humanize disease. By imposing upon issues of health the pretensions of the accurate sciences, we objectified the patient and the healer alike and utterly neglected that which cannot be quantified or measured - the human mind, the human spirit.
Read "The Myth of Mental Illness"
2. Psychology as Storytelling
Storytelling has been with us since the days of campfire and besieging wild animals. It served a number of important functions: amelioration of fears, communication of vital information (regarding survival tactics and the characteristics of animals, for instance), the satisfaction of a sense of order (justice), the development of the ability to hypothesize, predict and introduce theories and so on.
We are all endowed with a sense of wonder. The world around us in inexplicable, baffling in its diversity and myriad forms. We experience an urge to organize it, to "explain the wonder away", to order it in order to know what to expect next (predict). These are the essentials of survival. But while we have been successful at imposing our mind's structures on the outside world – we have been much less successful when we tried to cope with our internal universe.
The relationship between the structure and functioning of our (ephemeral) mind, the structure and modes of operation of our (physical) brain and the structure and conduct of the outside world have been the matter of heated debate for millennia. Broadly speaking, there were (and still are) two ways of treating it:
There were those who, for all practical purposes, identified the origin (brain) with its product (mind). Some of them postulated the existence of a lattice of preconceived, born categorical knowledge about the universe – the vessels into which we pour our experience and which mold it. Others have regarded the mind as a black box. While it was possible in principle to know its input and output, it was impossible, again in principle, to understand its internal functioning and management of information. Pavlov coined the word "conditioning", Watson adopted it and invented "behaviourism", Skinner came up with "reinforcement". But all ignored the psychophysical question: what IS the mind and HOW is it linked to the brain?
The other camp was more "scientific" and "positivist". It speculated that the mind (whether a physical entity, an epiphenomenon, a non-physical principle of organization, or the result of introspection) – had a structure and a limited set of functions. They argued that a "user's manual" could be composed, replete with engineering and maintenance instructions. The most prominent of these "psychodynamists" was, of course, Freud. Though his disciples (Adler, Horney, the object-relations lot) diverged wildly from his initial theories – they all shared his belief in the need to "scientify" and objectify psychology. Freud – a medical doctor by profession (Neurologist) and Bleuler before him – came with a theory regarding the structure of the mind and its mechanics: (suppressed) energies and (reactive) forces. Flow charts were provided together with a method of analysis, a mathematical physics of the mind.
But this was a mirage. An essential part was missing: the ability to test the hypotheses, which derived from these "theories". They were all very convincing, though, and, surprisingly, had great explanatory power. But - non-verifiable and non-falsifiable as they were – they could not be deemed to possess the redeeming features of a scientific theory.
Psychological theories of the mind are metaphors of the mind. They are fables and myths, narratives, stories, hypotheses, conjunctures. They play (exceedingly) important roles in the psychotherapeutic setting – but not in the laboratory. Their form is artistic, not rigorous, not testable, less structured than theories in the natural sciences. The language used is polyvalent, rich, effusive, and fuzzy – in short, metaphorical. They are suffused with value judgements, preferences, fears, post facto and ad hoc constructions. None of this has methodological, systematic, analytic and predictive merits.
Still, the theories in psychology are powerful instruments, admirable constructs of the mind. As such, they are bound to satisfy some needs. Their very existence proves it.
The attainment of peace of mind is a need, which was neglected by Maslow in his famous rendition. People will sacrifice material wealth and welfare, will forgo temptations, will ignore opportunities, and will put their lives in danger – just to reach this bliss of wholeness and completeness. There is, in other words, a preference of inner equilibrium over homeostasis. It is the fulfillment of this overriding need that psychological theories set out to cater to. In this, they are no different than other collective narratives (myths, for instance).
In some respects, though, there are striking differences:
Psychology is desperately trying to link up to reality and to scientific discipline by employing observation and measurement and by organizing the results and presenting them using the language of mathematics. This does not atone for its primordial sin: that its subject matter is ethereal and inaccessible. Still, it lends an air of credibility and rigorousness to it.
The second difference is that while historical narratives are "blanket" narratives – psychology is "tailored", "customized". A unique narrative is invented for every listener (patient, client) and he is incorporated in it as the main hero (or anti-hero). This flexible "production line" seems to be the result of an age of increasing individualism. True, the "language units" (large chunks of denotates and connotates) are one and the same for every "user". In psychoanalysis, the therapist is likely to always employ the tripartite structure (Id, Ego, Superego). But these are language elements and need not be confused with the plots. Each client, each person, and his own, unique, irreplicable, plot.
To qualify as a "psychological" plot, it must be:
All-inclusive (anamnetic) – It must encompass, integrate and incorporate all the facts known about the protagonist.
Coherent – It must be chronological, structured and causal.
Consistent – Self-consistent (its subplots cannot contradict one another or go against the grain of the main plot) and consistent with the observed phenomena (both those related to the protagonist and those pertaining to the rest of the universe).
Logically compatible – It must not violate the laws of logic both internally (the plot must abide by some internally imposed logic) and externally (the Aristotelian logic which is applicable to the observable world).
Insightful (diagnostic) – It must inspire in the client a sense of awe and astonishment which is the result of seeing something familiar in a new light or the result of seeing a pattern emerging out of a big body of data. The insights must be the logical conclusion of the logic, the language and of the development of the plot.
Aesthetic – The plot must be both plausible and "right", beautiful, not cumbersome, not awkward, not discontinuous, smooth and so on.
Parsimonious – The plot must employ the minimum numbers of assumptions and entities in order to satisfy all the above conditions.
Explanatory – The plot must explain the behaviour of other characters in the plot, the hero's decisions and behaviour, why events developed the way that they did.
Predictive (prognostic) – The plot must possess the ability to predict future events, the future behaviour of the hero and of other meaningful figures and the inner emotional and cognitive dynamics.
Therapeutic – With the power to induce change (whether it is for the better, is a matter of contemporary value judgments and fashions).
Imposing – The plot must be regarded by the client as the preferable organizing principle of his life's events and the torch to guide him in the darkness to come.
Elastic – The plot must possess the intrinsic abilities to self organize, reorganize, give room to emerging order, accommodate new data comfortably, avoid rigidity in its modes of reaction to attacks from within and from without.
In all these respects, a psychological plot is a theory in disguise. Scientific theories should satisfy most of the same conditions. But the equation is flawed. The important elements of testability, verifiability, refutability, falsifiability, and repeatability – are all missing. No experiment could be designed to test the statements within the plot, to establish their truth-value and, thus, to convert them to theorems.
There are three reasons to account for this shortcoming:
Ethical – Experiments would have to be conducted, involving the hero and other humans. To achieve the necessary result, the subjects will have to be ignorant of the reasons for the experiments and their aims. Sometimes even the very performance of an experiment will have to remain a secret (double blind experiments). Some experiments may involve unpleasant experiences. This is ethically unacceptable.
The Psychological Uncertainty Principle – The current position of a human subject can be fully known. But both treatment and experimentation influence the subject and void this knowledge. The very processes of measurement and observation influence the subject and change him.
Uniqueness – Psychological experiments are, therefore, bound to be unique, unrepeatable, cannot be replicated elsewhere and at other times even if they deal with the SAME subjects. The subjects are never the same due to the psychological uncertainty principle. Repeating the experiments with other subjects adversely affects the scientific value of the results.
The undergeneration of testable hypotheses – Psychology does not generate a sufficient number of hypotheses, which can be subjected to scientific testing. This has to do with the fabulous (=storytelling) nature of psychology. In a way, psychology has affinity with some private languages. It is a form of art and, as such, is self-sufficient. If structural, internal constraints and requirements are met – a statement is deemed true even if it does not satisfy external scientific requirements.
So, what are plots good for? They are the instruments used in the procedures, which induce peace of mind (even happiness) in the client. This is done with the help of a few embedded mechanisms:
The Organizing Principle – Psychological plots offer the client an organizing principle, a sense of order and ensuing justice, of an inexorable drive toward well defined (though, perhaps, hidden) goals, the ubiquity of meaning, being part of a whole. It strives to answer the "why’s" and "how’s". It is dialogic. The client asks: "why am I (here follows a syndrome)". Then, the plot is spun: "you are like this not because the world is whimsically cruel but because your parents mistreated you when you were very young, or because a person important to you died, or was taken away from you when you were still impressionable, or because you were sexually abused and so on". The client is calmed by the very fact that there is an explanation to that which until now monstrously taunted and haunted him, that he is not the plaything of vicious Gods, that there is who to blame (focussing diffused anger is a very important result) and, that, therefore, his belief in order, justice and their administration by some supreme, transcendental principle is restored. This sense of "law and order" is further enhanced when the plot yields predictions which come true (either because they are self-fulfilling or because some real "law" has been discovered).
The Integrative Principle – The client is offered, through the plot, access to the innermost, hitherto inaccessible, recesses of his mind. He feels that he is being reintegrated, that "things fall into place". In psychodynamic terms, the energy is released to do productive and positive work, rather than to induce distorted and destructive forces.
The Purgatory Principle – In most cases, the client feels sinful, debased, inhuman, decrepit, corrupting, guilty, punishable, hateful, alienated, strange, mocked and so on. The plot offers him absolution. Like the highly symbolic figure of the Savior before him – the client's sufferings expurgate, cleanse, absolve, and atone for his sins and handicaps. A feeling of hard won achievement accompanies a successful plot. The client sheds layers of functional, adaptive clothing. This is inordinately painful. The client feels dangerously naked, precariously exposed. He then assimilates the plot offered to him, thus enjoying the benefits emanating from the previous two principles and only then does he develop new mechanisms of coping. Therapy is a mental crucifixion and resurrection and atonement for the sins. It is highly religious with the plot in the role of the scriptures from which solace and consolation can be always gleaned.
3. Personality Disorders - An Overview
All personality disorders are interrelated, in my view, at least phenomenologically. We have no Grand Unifying Theory of Psychopathology. We do not know whether there are – and what are – the mechanisms underlying mental disorders. At best, mental health professionals register symptoms (as reported by the patient) and signs (as observed). Then, they group them into syndromes and, more specifically, into disorders. This is descriptive, not explanatory science. Sure, there are a few theories around (psychoanalysis, to mention the most famous) but they all failed miserably at providing a coherent, consistent theoretical framework with predictive powers.
Patients suffering from personality disorders have many things in common:
Most of them are insistent (except those suffering from the Schizoid or the Avoidant Personality Disorders). They demand treatment on a preferential and privileged basis. They complain about numerous symptoms. They never obey the physician or his treatment recommendations and instructions.
They regard themselves as unique, display a streak of grandiosity and a diminished capacity for empathy (the ability to appreciate and respect the needs and wishes of other people). They regard the physician as inferior to them, alienate him using umpteen techniques and bore him with their never-ending self-preoccupation.
They are manipulative and exploitative because they trust no one and usually cannot love or share. They are socially maladaptive and emotionally unstable.
Most personality disorders start out as problems in personal development which peak during adolescence and then become personality disorders. They stay on as enduring qualities of the individual. Personality disorders are stable and all-pervasive – not episodic. They affect most of the areas of functioning of the patient: his career, his interpersonal relationships, his social functioning.
The patient is not happy, to use an understatement. He is depressed, suffers from auxiliary mood and anxiety disorders. He does not like himself, his character, his (deficient) functioning, or his (crippling) influence on others. But his defences are so strong, that he is aware only of the distress – and not of the reasons to it.
The patient with a personality disorder is vulnerable to and prone to suffer from a host of other psychiatric disturbances. It is as though his psychological immunological system has been disabled by the personality disorder and he falls prey to other variants of mental sickness. So much energy is consumed by the disorder and by its corollaries (example: by obsessions-compulsions), that the patient is rendered defenceless.
Patients with personality disorders are alloplastic in their defences. In other words: they tend to blame the external world for their mishaps. In stressful situations, they try to pre-empt a (real or imaginary) threat, change the rules of the game, introduce new variables, or otherwise influence the external world to conform to their needs. This is as opposed to autoplastic defences exhibited, for instance, by neurotics (who change their internal psychological processes in stressful situations).
8. The character problems, behavioural deficits and emotional deficiencies and instability encountered by the patient with personality disorder are, mostly, ego-syntonic. This means that the patient does not, on the whole, find his personality traits or behaviour objectionable, unacceptable, disagreeable, or alien to his self. As opposed to that, neurotics are ego-dystonic: they do not like who they are and how they behave on a constant basis.
The personality-disordered are not psychotic. They have no hallucinations, delusions or thought disorders (except those who suffer from a Borderline Personality Disorder and who experience brief psychotic "microepisodes", mostly during treatment). They are also fully oriented, with clear senses (sensorium), good memory and general fund of knowledge.
The Diagnostic and Statistical Manual (DSM) – IV-TR (2000) defines "personality" as: "...enduring patterns of perceiving, relating to, and thinking about the environment and oneself... exhibited in a wide range of important social and personal contexts."
It defines personality disorders as:
"A. An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual's culture. This pattern is manifested in two (or more) of the following areas:
Cognition (i.e., ways of perceiving and interpreting self, other people, and events);
Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response);
Interpersonal functioning;
Impulse control.
B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.
F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug abuse, a medication) or a general medical condition (e.g., head trauma)."
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, fourth edition, text revision (DSM IV-TR). Washington, DC: American Psychiatric Association.
4. An Example of a Unifying Approach
We are all narcissists at an early stage of our lives. As infants, we feel that we are the centre of the universe, omnipotent and omniscient. Our parents, those mythical figures, immortal and awesomely powerful, are there only to protect us. Both self and others are viewed immaturely, as idealisations. Inevitably, the inexorable processes and conflicts of life erode them and grind the ideal into the fine dust of the real. Disappointments follow disillusionment. If gradual and tolerable – they yield adaptation. If abrupt, capricious, arbitrary, and intense – the injuries sustained by the tender, budding, self-esteem, are irreversible. Moreover, the empathic support of the caretakers (the Primary Objects, the parents) is crucial. In its absence, the self-esteem in adulthood will tend to fluctuate, to alternate between over-valuation (idealisation) and devaluation of both the self and others. Narcissistic adults are the result of bitter disappointment, of radical disillusionment with their parents. Healthy adults accept their self-limitations (=the limitations, the boundaries, of their selves). They accept disappointments, setbacks, failures, criticism and disillusionment with grace and tolerance. Their self-esteem is constant and positive, not affected by outside events, no matter how severe.
The common view is that we go through the stages of a linear development. We are propelled forward by forces: the libido (force of life) and Thanatos (force of death) in Freud's thinking, Meaning in Frenkel's, socially mediated phenomena (Adler, Behaviorism), cultural context (Horney), interpersonal relations (Sullivan) and neurobiological and neurochemical forces, to mention but a few schools of developmental psychology. In an effort to gain respectability, psychologists constructed a "physics of the mind".
These thought systems differ on many issues. Some said that personal development ends in childhood, others – during adolescence. Yet others said that development is a process which continues throughout the life of the individual. Common to all these schools of thought are the mechanics and dynamics of the process. Forces – inner or external – facilitated the development of the individual. When an obstacle to development is encountered, development is stunted or arrested – but not for long. A distorted pattern of development, a bypass appears. Hence, psychopathological conditions are the outcomes of disturbed growth. Humans can be compared to trees. When a tree encounters a physical obstacle to its growth – its branches or roots curl around it. Yet, deformed and ugly, they still reach their destination, however late and partially. Psychopathologies are adaptive mechanisms. They allow the individual to continue to grow around the disturbing factor. The personality twists and turns, deforms itself, is transformed – until it reaches a functional equilibrium, which is not too ego-dystonic. There it settles down and continues its more or less linear pattern of growth. But the thrust is clear: onwards. Adaptation above all, growth at any price, straight or deformed, it doesn't really matter. The forces of life (as expressed in the development of the personality) are stronger than any hindrance. The roots of trees crack mighty rocks, microbes live in the most poisonous surroundings – humans form the personality structure which is best suited to their needs and outside constraints. Such a personality structure may be abnormal – but it has mostly triumphed in the delicate task of successful adaptation.
I believe that people do engage in linear growth and development and that, these are driven by both internal and external forces. I also believe that only death puts a stop to personal growth and development. Life events, crises, joys and sadness, disappointments and surprises, setbacks and successes – all contribute to the weaving of the delicate fabric called "personality". Where I differ from customary views is in what I believe constitutes a reaction to disturbances, hindrances and obstacles to personal growth.
I think that when an individual (at any age) encounters an obstacle to the orderly progression from one stage of development to another – he retreats to the narcissistic phase rather than circumvent or "go around" the hindrance. The process is three-stepped: (1) The person encounters an obstacle; (2) The person regresses to the infantile narcissistic phase; and (3) The person recuperates and moves back from the narcissistic phase to attack the obstacle again. While in step (2), the person displays childish, immature behaviours. He feels that he is omnipotent and misjudges his powers and the powers of his opponents and opposition. He underestimates challenges facing him and pretends to be "Mr. Know-All". His sensitivity to the needs and emotions of others and his ability to empathise with them deteriorates sharply. He becomes intolerably haughty and arrogant, with sadistic and paranoid tendencies. Above all, he then seeks unconditional admiration, even when he does not deserve it. He is preoccupied with fantastic, magical, thinking and daydreams his life away. He tends to exploit others, to envy them, to be edgy and explode with unexplained rage. People who undergo a psychological development crisis brought on by an insurmountable obstacle – mostly revert to excessive and compulsive behaviour patterns. To put it succinctly: whenever we experience a major life crisis (which hinders our personal growth and threatens it) – we suffer from a mild and transient form of the Narcissistic Personality Disorder.
This fantasy world, full of falsity and feelings hurt, serves as a springboard. It is from there that the individual can resume his progress towards the next stage of personal growth. Faced with the same obstacle, he feels (falsely) sufficiently potent to ignore it or to attack it. In most cases, success is guaranteed by the very unrealistic assessment of the fortitude and magnitude of the obstacle. The main function of the episodic or transient NPD is this: to encourage the individual to engage in magical thinking, to wish the problem away or to enchant it or to tackle and overcome it from a position of omnipotence.
A structural abnormality of personality arises only when recurrent attacks fail constantly and consistently to eliminate the obstacle, or to overcome the hindrance. The contrast between the fantastic world (temporarily) occupied by the individual and the real world in which he keeps being frustrated – is too acute to countenance for long. The dissonance gives rise to the unconscious "decision" to go on living in the world of fantasy, grandeur, grandiosity and entitlement. It is better to feel special than to feel inadequate. It is better to be omnipotent than psychologically impotent. To (ab)use others is preferable to being (ab)used by them. In short: it is better to remain a pathological narcissist than to face the harsh unyielding realities.
Not all psychopathologies are narcissistic in character and not all personality disorders are narcissistic. Yet, I think that the default (in case of growth stunted by an obstacle) is the narcissistic phase of personal development. I further believe that this is the ONLY default available to the individual: whenever he comes across an obstacle, he regresses to the narcissistic phase. How can this be reconciled with the diversity of psychopathologies/personality disorders?
We must define "narcissism" more broadly as the substitution of a False Self for the True Self. This, arguably, is the predominant feature of narcissism: the True Self is repressed and suppressed, relegated to irrelevance and obscurity, left to degenerate and fossilise. In its stead, a psychological structure is formed and projected unto the outside world – the False Self. The False Self is reflected to the narcissist by other people. This "proves" to him that the False Self has an independent existence, that it is not entirely a figment of his imagination and, therefore, that it is a legitimate heir to the True Self. It is this characteristic which unites all psychopathologies: the emergence of false psychic structures which usurp the powers and capacities of the previous, legitimate and authentic structures.
Horrified by the absence of a clearly bounded, cohesive, coherent, reliable, and self-regulating self – the mentally abnormal person resorts to one of the following solutions, all of which involve reliance upon fake or invented personality elements:
The Narcissistic Solution – The substitution of the True Self with a False Self. The narcissistic solution is the subject of this book. The Schizotypal Personality Disorder largely belongs here because of its emphasised fantastic and magical thinking. The Borderline Personality Disorder is a case of a failed narcissistic solution. In BPD, the patient is aware (at least unconsciously) that the solution that he adopted is "not working". This is the source of his anxiety (something is fuzzily wrong, or a foreboding sense, a premonition is present), of his fear of abandonment (by the solution). This generates his identity disturbance, his affective instability, suicidal ideation and suicidal action, chronic feelings of emptiness, rage attacks, and transient (stress related) paranoid ideation.
The Appropriation Solution – This is the appropriation, the confiscation of someone else's self in order to fill the vacuum left by the absence of a functioning Ego. While some of the Ego functions are available – the others are assumed and adopted by the "appropriating personality". The Histrionic Personality Disorder is an example of this solution. Mothers who "sacrifice" their lives for their children, people who live vicariously, through others – all belong to this category. So do people who dramatise their lives and their behaviour, in order to attract attention. The "appropriators" misjudge the intimacy of their relationships and the degree of commitment involved, they are easily suggestible and their whole personality seems to shift and fluctuate with input from the outside. Because they have no Self of their own (even more so then narcissists) – the "appropriators" tend to over-rate and over-emphasise their bodies. Perhaps the most striking example of this type of solution is the Dependent Personality Disorder.
The Schizoid Solution – These patients are mental zombies, trapped forever in the no-man's land between stunted growth and the narcissistic default. They are not narcissists because they lack a False Self – nor are they fully developed adults, because their True Self is immature and dysfunctional. They prefer to avoid contact with others (they lack empathy, as the narcissist does) in order not to upset their delicate tightrope act. Withdrawing from the world is an adaptive solution because it does not expose the inadequate personality structures (especially the self) to onerous – and failure bound – tests. The Schizotypal Personality Disorder patient is a mixture of the narcissistic and the schizoid solutions. The Avoidant Personality Disorder is a close kin.
The Aggressive Destructive Solution – These people suffer from hypochondriasis, depression, suicidal ideation, dysphoria, anhedonia, compulsions and obsessions and other expressions of internalised and transformed aggression directed at a self which is perceived to be inadequate, guilty, disappointing and worthy of nothing but elimination. Many of the narcissistic elements are present in an exaggerated form. Lack of empathy becomes reckless disregard for others, irritability, deceitfulness and criminal violence. Undulating self-esteem is transformed into impulsiveness and failure to plan ahead. The Antisocial Personality Disorder is a prime example of this solution, whose essence is: the total control of a False Self, without the mitigating presence of a shred of True Self.
Perhaps this common feature – the replacement of the original structures of the personality by new, invented, mostly false ones – is what causes one to see narcissists everywhere. This common denominator is most accentuated in the Narcissistic Personality Disorder. The interaction, really, the battle, between the struggling original remnants of the personality and the malignant and omnivorous new structures – can be discerned in all forms of psychic abnormality. The question is: if many phenomena have one thing in common – should they be considered one and the same?
I say that the answer in the case of personality disorders should be in the affirmative. I think that all the known personality disorders are forms of malignant self-love. In each personality disorder, different attributes are differently emphasised, different weights attach to different behaviour patterns. But these, in my view, are all matters of quantity, not of quality. The myriad heads of the deformation of the reactive patterns collectively known as "personality" – all belong to the same medusa.
Narcissistic Personality Disorder
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