By Annie Murphy Paul, published on March 1, 2005 - last reviewed on August 20, 2012
They call him "the Shark."
Bill, a 26-year-old lawyer, is proud of his nickname and the ruthlessness that inspired it. Confident and charming, he can also be arrogant, manipulative and deceptive—though he sees nothing wrong with these qualities, useful as they are in winning cases and attracting women. Lately, however, Bill's character has been landing him in trouble. He's begun abusing cocaine. He can't resist the temptations of strip clubs and casinos. He's already been married and divorced twice. Even his successful career has been endangered by his habit of propositioning female coworkers. Bill is bothered enough that he pays a visit to a psychologist's office. There he's told that he has an "antisocial" personality: He consistently, and often unscrupulously, places his own interests above those of others. Bill's antisocial tendencies pervade his entire way of being—just as someone with a narcissistic personality can't see past his own grandiosity or someone with an obsessive-compulsive personality can't lift her eyes from her meticulous, exacting tasks.
The idea that human nature can be refracted through personality traits—distinct clusters of thoughts and feelings that color all of a person's actions—has been around a long time. But it is gaining new momentum. For one thing, it gives us a high-definition picture of human character and its variety. It also encourages renewed appreciation for the diversity of influences on behavior, from genes to lifestyles. As a result, the new view of personality heralds a revolution in how we view disorder, marking a shift away from rigid categories of pathology to a more organic sense of the way individuals fit in their world. After all, aren't lawyers supposed to be aggressive? Aren't, say, actors almost universally narcissistic? Aren't accountants and copy editors rewarded for their compulsive attention to detail?
For many years, serious problems of character and personality were believed to be relatively rare. What's more, they were regarded as virtually untreatable—and bereft of any benefit or utility. Personality disorders were sequestered on their own island of pathology.
But a flood of new theories, surveys and techniques is sweeping aside the old assumptions about problematic personalities. Dysfunctional personalities actually appear to be quite common, affecting more than 30 million Americans—about one person in seven. This increased awareness of the prevalence of personality problems is stimulating breakthroughs in understanding and treating them, as well as a dawning realization that what we call mental illness might once have had, and may still serve, highly adaptive functions. Most surprising of all, researchers are accumulating evidence that the line between normal and abnormal personality is much more subtle than anyone imagined. Which may mean that our conception of mental illness is due for a revision—and that we "normal" people are all just a little bit crazy. From Quirk to Quagmire Central to the emerging perspective is a distinction between personality styles and personality disorders. Any specific pattern of thinking and feeling may be expressed as a healthy, though perhaps quirky, personality style, or it may be expressed more floridly as a clinically diagnosable personality disorder. Psychologists recognize 10 different personality types that, when manifest in intense form, represent 10 distinct personality disorders.
People with an avoidant personality, for example, may be homebodies who like routine and cherish a few intimates, or they may shun people for fear of rejection and avoid risk-taking or new activities for fear of the humiliation of failure. The former have an avoidant personality style, the latter an avoidant personality disorder. Likewise, people with a histrionic personality may merely enjoy attention and be entertainingly dramatic, although able to cede the stage to others when appropriate. Those with histrionic personality disorder insist on being the center of attention and have emotional problems as well; their feelings are shallow and ever-shifting, and they may have difficulty intimately connecting with others.
So what's the difference between a personality disorder and a personality style? One gauge is, simply, extremity: The personality disordered think, feel and act in ways that are at the outer edge of what most people experience. A second guideline is inflexibility. Says Randolph Nesse, a psychiatrist at the University of Michigan: "Most of us are angry sometimes and loving sometimes, nice sometimes and mean sometimes. But people with personality disorders keep doing the same things over and over again.
Their emotional palette isn't varied; it's monochromatic." They get stuck, unable to respond fluidly to changing circumstances. Their daily functioning is also impaired. A clinician evaluating someone for a personality disorder would ask two key questions: Has the patient's personality contributed to a loss of relationships? Has it contributed to career failure? Thomas Widiger, a University of Kentucky psychologist who diagnosed Bill the Shark, adds a subjective measure: How much distress is a person feeling as a result of his personality problems? If these distinctions seem less black-and-white than shades of gray, they are. And in fact, many psychologists are shifting from the old you-have-it-or-you-don't perspective on personality disorders (the "categorical" model) to the more nuanced "dimensional" model. In it, personality is located along a continuum, with healthy personality traits at one end, personality disorders at the other—and innumerable gradations in between.
The dividing line between normal and abnormal becomes much less important in the new dimensional model, and some proponents refuse to recognize one at all. "I don't think it is useful to draw a line," declares Johns Hopkins University psychiatrist Gerald Neustadt. "What is the purpose of having a diagnosis? Ultimately, it's to treat people, to help them. So when someone comes to you with a problem in the personality domain, you try to understand his traits and how they are getting him into trouble." What counts most is recognizing that the patient's difficulty does indeed lie within the "personality domain," says Neustadt. Problems of personality are different in nature from other kinds of mental disorder, such as a sudden onset of depression or anxiety. Character disorders are more deeply rooted, broader and more encompassing—and more intractable, because they are so intimately related to a person's very self.
But the implications of the new work on personality disorders go far beyond parochial diagnostic matters. It represents a sea of change in how we view psychological health and illness. As Thomas Widiger says, "The patterns found in personality disorders really are traits that are distributed throughout the population, and we all have them to greater or lesser degree." The new research suggests that psychopathology is not alien and unfamiliar but rather recognizably human, an extension of what we all experience. That could soften the stigma that still attaches to mental illness.
Just as we may see something of ourselves in the volatile diva or the misanthropic recluse, we may also embrace the extreme, the flagrant, the florid in our own characters. The new work on personality disorders might allow us to rescue an array of traits and behaviors—the high spirits of a borderline personality, the single-minded intensity of an obsessive-compulsive—from the "pathological" category in which they've been deposited and reclaim them as rich additions to healthy human variety.
Personality disorders contribute an important insight to reformulated ideas of mental health: Context is everything. Behavior that creates havoc in one situation may be celebrated in another, and finding the right niche may mean—for any one of us—the difference between psychological health and sickness. From this perspective, personality problems are not burdens we carry wherever we go but latent vulnerabilities that are exacerbated by specific environments. They are also potential assets.
Randolph Nesse offers an example. "Imagine a very dramatic woman—in DSM language, a 'histrionic' individual. If she goes to work for an accounting company, chances are she'll have lots of trouble, because she's more interested in impressions than details and because she's likely to be more impulsive and more emotionally expressive than the others who work there. She gets thrown out of the job, gets really depressed and shows up at the office of a therapist, who says, 'It's your personality that's the problem; you have a personality disorder.' Now imagine that same woman in the artistic world, where her attributes are actually an advantage. She'd be doing beautifully, would not show up at a psychologist's office and would not be diagnosed with a personality disorder. Yet this is the same person with the same constellation of traits—just two different contexts." The importance of specialized niches turns up again in investigations of the origins of personality disorders. One provocative notion emerging from evolutionary psychology is that many of the behaviors found in personality disorders—perverse as they may appear to us now—originated as adaptations necessary for survival.
And in fact, looking closely, it's not hard to see the germ of something useful in what on the surface appear to be self-defeating patterns of behavior. Avoidant personality disorder, for example, may be a holdover from a time when strangers posed a very real danger. "The insecurity and nervousness avoidant people feel about approaching others was in some contexts very adaptive," says Widiger. "It helped them develop a sense of caution about entering risky situations and risky relationships." Likewise, obsessive-compulsive personality disorder may be an exaggerated version of the directed and diligent efforts that helped some of our human ancestors thrive. The perfectionism, productivity and skinflint approach to money that characterizes this disorder may be remnants of organizing and hoarding behaviors that prepared communities for times of scarcity, Nesse speculates.
Conversely, some personality patterns may have rewarded the individual at a cost to the larger community. Stealing, cheating and manipulating got for some people what they couldn't obtain by more legitimate means, which may explain why researchers have found a small but stable population of individuals with antisocial personality disorder in societies all over the world. Such personality quirks have persisted because extreme behavior can still work to an individual's advantage. "One of the features of narcissism is enormous confidence and self-esteem," observes Widiger. "It takes a degree of narcissism to continue despite failures and setbacks, and narcissists quite often have very successful careers." People with dependent personality disorder may suffer for their exquisite sensitivity to relationships, says Nesse, "but I bet they make really good friends" and have stronger social networks as a result.
That personality disorders once had their uses could explain why they are so prevalent today. The first survey of such conditions conducted in this country concluded that about one in ten Americans suffers from a personality disorder. A much larger survey, based on interviews of more than 43,000 people, released by the National Institutes of Health, put the number at 15 percent—or almost one-sixth of the population. Obsessive-compulsive personality disorder is the most common, affecting about 8 percent of all adults; next come paranoid personality disorder at 4.4 percent and antisocial personality disorder at 3.6 percent. Just 0.5 percent was diagnosed with dependent personality disorder, in which a person needs excessive reassurance from others and fears functioning on his or her own.
Personality disorders may afflict 50 percent or more of people currently receiving treatment for any mental health condition. "Most patients who seek assistance are suffering from the difficulties of long-standing maladaptive attitudes and coping styles, essentially what have come to be labeled personality disorders," notes personality researcher-clinician Theodore Millon. "Dysfunctions of personality have become omnipresent" in therapy practices, he says. Millon thinks personality disorders "will outstrip all other areas of psychological and psychiatric practice in the coming decade."
Not long ago, diagnosis of a personality disorder carried a grim outlook. By and large, the only treatment available was long-term psychoanalysis. To eliminate troublesome behaviors, it was believed, you needed to change the underlying traits on which the very structure of personality had been built, day in and day out, through a person's countless interactions with the world. The few who qualified for such demanding therapy didn't necessarily benefit from it. Therapists' general attitude toward these illnesses, says psychiatrist Len Sperry of the Medical College of Wisconsin, was one of "dread and hopelessness."
Gone, along with that approach to treatment, is the Freudian view that inner conflicts arising in childhood are the sole cause. The emerging perspective acknowledges that personality, both normal and abnormal, is a complex interaction of forces inside and outside the individual—biological, psychological and social.
The antisocial personality of Bill the Shark, for example, may have originated in a genetic predisposition to aggressiveness expressed biochemically in low levels of the neurotransmitter serotonin. This inborn temperament might have been aggravated by hostile or irresponsible parenting manifest as Bill was growing up. Bill's antisocial tendencies may have reached full expression and reinforcement in social environments—casinos, strip clubs, law firms—that permitted and even encouraged combative behavior.
New treatments chip away at each element of the biopsychosocial roots of personality disorders. Drugs like selective serotonin reuptake inhibitors may act on the biochemical imbalances. Interpersonal and psychodynamic therapies take on the psychological component of the disorder, encouraging the individual to reflect on his past experiences to help release their hold on current behavior. Cognitive-behavioral and dialectical exercises (in which the person learns to challenge his own impulses) seek to shift the pattern of external rewards and punishments in favor of more controlled and constructive conduct. The new integrative paradigm, Sperry reports, has transformed clinicians' attitudes from hopelessness to optimism. From the start, Bill the Shark's antisocial personality traits presented special challenges. He "had little desire for psychological growth or moral self-improvement," Widiger notes, and his glib cockiness made genuine rapport difficult to achieve. Widiger instead took advantage of Bill's ambitious and competitive nature by challenging him to come up with ways to limit his drug use and his gambling. Using approaches borrowed from cognitive-behavioral therapy, psychologist and patient devised personal mantras that Bill would repeat to himself when faced with a temptation. "These mantras might have sounded superficial to others," Widiger acknowledges, but to Bill "they were effective, meaningful, even inspirational."
Widiger made a concerted effort not to react with judgment or disapproval when Bill regaled him with tales of his unsavory exploits. As Bill grew more comfortable, he was able to examine the roots of his behavior, coming to terms with his parents' failings and considering ways to rectify his own. Though still far from sensitive or empathetic, Bill began to recognize how hurtful his actions were to himself and to others. His essential nature was not changed by therapy, says Widiger, but he was able to smooth "the rougher edges of his personality."
Len Sperry uses an identical metaphor to describe the treatment of patients like Bill. "The clinician working with personality-disordered individuals is not a carpenter who rebuilds a structure," he notes, "but is rather like a cabinetmaker who sands down and takes the rough edges off." Ultimately, he adds, the goal is to turn a personality disorder into a personality style—to help the personality-disordered patient become a functioning, healthy human being, with quirks and idiosyncrasies intact. A person, that is, a lot like you and me.