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Psychiatry Online

The American Psychiatric Association (APA) has updated its Privacy Policy and Terms of Use , including with new information specifically addressed to individuals in the European Economic Area. As described in the Privacy Policy and Terms of Use, this website utilizes cookies, including for the purpose of offering an optimal online experience and services tailored to your preferences.

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Special Report: Antisocial Personality Disorder—The Patient in Need Often Overlooked

  • Donald W. Black , M.D.

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The view of many mental health professionals is that people with antisocial personality disorder are untreatable. This conclusion is clearly premature because of the lack of relevant research on medications and psychotherapy to guide treatment decisions.

Graphic: Person walking under flat arches

Antisocial personality disorder (ASPD) is psychiatry’s forgotten disorder. Despite its enormous cost to individuals, families, and society, few clinicians diagnose ASPD, let alone offer treatment, and few researchers investigate it. Clinicians and researchers have largely distanced themselves from the disorder, perhaps in sympathy with family members and friends who react similarly.

Psychiatry has wrestled with the problem of chronic antisocial behavior for more than 200 years. While the terms and definitions used have shifted over the years, they all describe recurrent, serial misbehavior. People with ASPD rebel against authority, resist all norms, and push the limits of acceptable behavior. Nineteenth century British physician William Pritchard used the term moral insanity to describe people who willfully engage in antisocial conduct. His use of the term moral was prescient considering that many people he described appeared to lack a moral compass, perhaps ASPD’s most disturbing aspect.

Poorly understood even by psychiatrists and psychologists, ASPD was given one of the best definitions by the Donald Goodwin, M.D., and Samuel Guze, M.D., in the book Psychiatric Diagnosis . They described ASPD as “a pattern of socially irresponsible, exploitative, and guiltless behavior manifested by disturbances in many areas of life including family relations, schooling, work, military service, and marriage.” Behaviors include criminal acts and failure to conform to the law, failure to sustain consistent employment, manipulation of others for personal gain, and failure to develop or sustain stable interpersonal relationships.” Symptoms fall along a spectrum of severity and range from relatively mild at one end—for example, lying, cheating—to very serious at the other—for example, rape and murder (see table). Other important attributes include lack of empathy for others, lack of remorse, and failure to learn from the negative results of one’s behavior.

Work by Lee Robins, Ph.D., and others in the 1950s and 1960s strongly influenced the ASPD criteria created for DSM-III in 1980. They have since been refined for subsequent DSM editions, but they remain true to Robins’ vision of a chronic behavioral disorder beginning in childhood. DSM-5 criteria require that a person have three or more of seven pathological personality traits (for example, deceitfulness, impulsivity, irritability or aggressiveness, recklessness, and irresponsibility). The person must be 18 years or older and meet criteria for conduct disorder prior to age 15. Schizophrenia and mania have been ruled out as a cause of the symptoms. ASPD is the only disorder in DSM-5 with an age requirement. While the criteria were criticized from the outset for ignoring psychological components of the disorder, Robins argued that a focus on behavioral symptoms would lead to greater diagnostic reliability.

Comorbid Disorders Common

Common and culturally universal, surveys in the United States and United Kingdom show that 2% to 5% of the general adult population in the United States meet the criteria for lifetime ASPD. Prevalence in men is from 2 to 7 times that in women, depending on the sample surveyed and assessment method used. The disorder rarely occurs by itself; usually it is associated with high rates of substance use disorders, mood and anxiety disorders, attention-deficit/hyperactivity disorder (ADHD), pathological gambling, and other personality disorders (borderline and narcissistic personality disorders). Rates of suicidal behavior and completed suicide are elevated.

The following vignette illustrates many of the typical symptoms of ASPD and how they affected one of our patients over a lifetime. The patient had been admitted to the University of Iowa Psychopathic Hospital (now Psychiatric Hospital) in the 1950s and was followed up over 30 years later in the 1980s (see Donald W. Black, M.D., and Nancy C. Andreasen, M.D., Ph.D., Introductory Textbook to Psychiatry, Seventh Edition , APA Publishing, 2020).

Case Study 1

Burton, age 18 years, was admitted for evaluation of antisocial behavior at the request of his adoptive parents. His early childhood had been chaotic and abusive. His alcoholic father had married five times and abandoned his family when Burton was 6 years old. Because his mother had a history of incarceration and was unable to care for him, Burton was placed in foster care until he was adopted at age 8. As a child, Burton lied, cheated at games, shoplifted, and stole money from his mother’s purse. He was sent to a juvenile reformatory at age 16. While there, he slashed another boy with a razor blade in a fight. In the hospital, the psychiatrists interviewed Burton and his adoptive parents, conducted an encephalogram (deemed normal), and measured his IQ at 112. He showed no interest in psychotherapy, insulted staff members, and left abruptly after a 16-day stay. He was described as “unimproved” on discharge.

Psychiatric and Medical Comorbidity of ASPD

Psychiatric comorbidity among individuals with ASPD is associated with negative outcomes such as high service use, poor treatment response, and reoffending.

Individuals with ASPD often meet criteria for comorbid internalizing and externalizing conditions, including mood disorders, substance use disorders, and ADHD.

ASPD shares transdiagnostic features (e.g., anger, impulsivity) with a range of psychiatric disorders, highlighting the need to thoroughly assess for comorbid conditions to best inform clinical care and risk management strategies.

Comorbid personality disorders present in about one-half of individuals with ASPD. The borderline, narcissistic, and histrionic types are more common than other personality disorders.

A history of aggressive behavior and recklessness increases the odds of developing comorbid medical conditions (e.g., traumatic brain injury, sexually transmitted diseases).

Source: Patrick T. McGonigal, M.A., et al., Chapter 4, Textbook of Antisocial Personality Disorder , APA Publishing, 2022.

Burton was followed up 30 years later at age 48. Burton, appearing old and haggard, was living in an impoverished neighborhood in a nearby community. He admitted to more than 20 arrests and five felony convictions on charges ranging from attempted murder and armed robbery to driving while intoxicated. He had spent more than 17 years in prison. Burton reported nine hospitalizations for alcohol detoxification, the most recent occurring earlier that year. Burton had never held a full-time job and had lived in six states; he had moved more than 20 times in 10 years. Burton’s common-law marriage was described as unsatisfactory, and he admitted committing spousal abuse. He occasionally attended Alcoholics Anonymous meetings but otherwise did not socialize. When asked, Burton admitted that he had not yet settled down and still got a “charge out of doing dangerous things.”

Longitudinal studies show that ASPD is worse early in its course but that its symptoms lessen with advancing age. While the older antisocial person may be less troublesome to families and society, improvement follows many years of behavioral symptoms that have stunted educational and work achievement, thereby limiting the person’s potential and contributing to unstable relationships and family discord. The following case vignette is illustrative.

Case Study 2

Mr. C, age 28, was admitted to the University of Iowa Psychiatric Hospital for evaluation of “lack of drive and ambition” and inability to find security and happiness, but the doctors quickly noted his history of stealing, absenteeism from work, and inability to hold a job as suggestive of an underlying ASPD.

Mr. C grew up in a two-parent, solidly middle-class home. His misbehaviors started around age 5 years, when he first ran away from home. At age 6, he started a fire in a shed, and by age 11, he was regularly stealing money from his mother’s purse. Mr. C managed to finish high school with middling grades and started college, but he would skip classes and eventually dropped out. At age 20, he broke into a local drugstore but tripped an alarm and was caught. A guilty plea led to his first jail sentence. Mr. C joined the army where he served six years; however, he was court-martialed for stealing money from a superior officer’s trousers and was dishonorably discharged from the service. After the discharge, he returned home and married after a brief courtship. His wife knew nothing of his past. The family moved to California (he and his wife had one child by then) seeking new opportunities but failed to find work, and in a quixotic move, he stole a car with the plan to drive back to Iowa. He was quickly apprehended, pleaded guilty, and received probation. His criminal career continued, mainly involving breaking and entering, to supplement, he said, his meager income from his work as an unskilled laborer.

At the hospital, a physical examination showed only obesity and mild hypertension, and Mr. C’s mental status was deemed normal. He was offered individual and group psychotherapy, a standard approach at the time, and remained five months. At discharge, he was thought to have a “poor” prognosis.

Mr. C was followed up at age 65. By then, he was living in a small apartment in a small rural community. He reported that he was lonely, as his wife had passed away, and he was estranged from his three children. He had a part-time job with an insurance agency and had worked there for 25 years. In the intervening decades, Mr. C claimed only an additional two arrests, but his “rap sheet,” which was public information, revealed a much different story, with multiple arrests and incarceration for mainly minor nonviolent offenses. Mr. C felt that the lengthy psychiatric hospitalization had helped him grow as a person and that he had genuinely improved, attributing much of that to the influence of his loving wife. He reported regular church attendance and socialized with his neighbors.

Genetic, Neurobiological, and Environmental Causes

Considered a multidetermined disorder, not unlike schizophrenia or hypertension, the cause of ASPD is thought to involve both genetic vulnerability and environmental events. Early family, twin, and adoption studies have suggested a heritable component, yet exactly what is inherited and how the disorder is transmitted remain unclear, even as newer genetic methodologies are being applied.

Competing theories suggest that ASPD results from the consequences of a neurodevelopmental insult, chronic underarousal, or deficient cognitive processing. Roles have been proposed for the neurotransmitter serotonin and the hormone testosterone, each known to mediate aggression, and, in the case of serotonin, impulsivity.

Numerous structural brain imaging studies have been conducted on individuals with ASPD, examining a wide range of brain regions. Overall, studies have documented that ASPD likely has a neurobiological basis involving structural brain abnormalities, with key impairments commonly found in the prefrontal and temporal cortices. These findings are bolstered not only by results derived from functional imaging studies but also from neuropsychological studies that document executive functioning deficits in populations of individuals with ASPD. Indicators for limbic dysfunction that are associated with ASPD can be observed early in life. Accumulating evidence also suggests that structural brain abnormalities are able to improve the prediction of ASPD when considered alongside psychosocial risk factors for antisocial behavior, are influenced by both genetic and social environmental factors, and can help to account for why males have higher rates of ASPD.

A review of imaging studies, however, suggests that there is a diversity of findings in individuals with ASPD. Future studies that account for psychiatric comorbidity and other confounding effects may help to reduce some of the observed heterogeneity in these structural imaging findings. More neurobiological testing in prospective longitudinal studies, as well as the inclusion of female subjects and larger samples in structural MRI studies of ASPD, can also help advance our understanding of the neurobiological underpinnings of this personality disorder.

Gene-Environment Interplay in Antisocial Personality Disorder

Family studies confirm that antisocial behavior not only runs in (within) families but also runs across families through the coupling of antisocial individuals.

Twin studies confirm that the contribution of genetic and environmental factors to antisocial behavior shifts in importance from childhood to adulthood.

Twin studies have shown that the main causes of comorbidity between antisocial behavior disorders and psychiatric and addictive disorders are shared genetic risk factors.

Twin and adoption studies provide examples of how genetic risk for antisocial behavior is associated with both greater exposure to a high-risk environment and greater sensitivity to a high-risk environment.

Twin studies of pairs discordant for a putative environmental risk or protective factor have provided incisive tests about whether a risk or protective factor might potentially be causally related to antisocial behavior.

Source: Wendy S. Slutske, Ph.D., Christal N. Davis, M.A., Chapter 7, Textbook of Antisocial Personality Disorder , APA Publishing, 2022.

Likewise, environmental events that could be involved in the onset or maintenance of antisocial behavior include childhood abuse, poor parenting, and disturbed peer relationships. A history of childhood abuse occurs at high rates in antisocial persons, many of whom visit the abuse on their own children, thus perpetuating an intergenerational cycle of abuse. Erratic or inappropriate parental discipline and inadequate supervision have all been linked to antisocial behavior. Many antisocial persons grow up in households where one or both parents were antisocial, unable to effectively monitor their child’s behavior, set rules and ensure that they are obeyed, check on the child’s whereabouts, or steer the child away from troubled playmates. Disturbed peer relationships (the “birds of a feather” phenomenon) are often overlooked as a possible contributing factor but are present in the history of most antisocial persons. Unhealthy relationships often take root during the elementary school years and reward aggressive behavior, in the process encouraging gang membership in which troubled youth can gain a sense of belonging.

An unresolved question concerns the matter of whether frontal lobe dysfunction in antisocial populations is due to head injury, disrupted prenatal development, or other causes, such as neurological illness.

Antisocial persons are overrepresented in psychiatric clinics and hospitals, though rarely seek care for their ASPD (and are likely unaware that they have it). Instead, they typically seek care for co-occurring depression, substance misuse, problems relating to marital maladjustment, anger and irritability, and/or suicidal behavior. Because there are no diagnostic tests, the ASPD diagnosis rests on the person’s history of chronic and repetitive behavioral problems dating back to childhood or early adolescence. The differential diagnosis includes other personality disorders (especially narcissistic and borderline personality disorders), substance use disorders, psychotic and mood disorders, intermittent explosive disorder, and medical conditions that might cause violent outbursts (for example, temporal lobe epilepsy).

Psychosocial Factors

Psychosocial factors do not fully determine the emergence of antisocial behavior, and neither do biological factors. The antisocial syndrome has a complex etiology, involving genetic and environmental interactions. Thus, a dysfunctional family, parental maltreatment, and a dangerous neighborhood might increase the risk for antisocial behavior but are not fully predictive of the disorder. Children with antisocial traits might react with aggressive behavior to any or all of these stressors, but children with a different trait profile (for example, one marked by introversion) might not.

An antisocial child who retains the same traits in adulthood is a bit like a pit bull—dangerous when stressed or deprived, yet capable of companionship when the environment is stable, predictable, and sympathetic. That said, children with a genetic predisposition who experience serious environmental adversities are primed to develop ASPD. Although neither ingredient is determinative, it is the combination that “cooks” the disorder.

Treatment Guidance

The psychiatric treatment needs of people with ASPD should be addressed in outpatient settings. There is usually little reason to psychiatrically hospitalize antisocial people, and they can be disruptive to the ward milieu. Exceptions include crisis stabilization for recent (or imminent) suicidal behavior, recent (or threatened) violent or assaultive acts, and/or monitoring of alcohol or drug withdrawal. Patients should be discharged when the crisis has passed.

Table: Symptoms of Antisocial Personality Disorder in 1,422 Person Participating in National Epidemiologic Survey on Alcohol and Related Conditions

The view of many mental health professionals is that ASPD is untreatable. This conclusion is clearly premature because of the lack of relevant research for either medication or psychotherapy to guide treatment decisions. Clinicians are largely on their own to sift through the literature searching for treatment studies. No medications are FDA approved or routinely used to treat patients with ASPD. While medications are sometimes used to treat patients for aggression and irritability, their use is off-label. These medications include lithium carbonate and other mood stabilizers, antidepressants, and atypical antipsychotics. Response to medication is variable, and while some patients improve, others fail to improve at all. When improvement occurs, it tends to be partial, so that improvement may mean only that the individual has fewer outbursts or has a “longer fuse” that gives the person more time to reflect before lashing out.

Importantly, medication can be targeted at the patient’s co-occurring disorders. Mood and anxiety disorders are common, and antidepressants might be relevant to their treatment. Similarly, co-occurring bipolar disorder can be treated with mood stabilizers or atypical antipsychotics. Because benzodiazepines can be disinhibiting, as well as habit forming, their use is not recommended. Likewise, stimulant medications for co-occurring ADHD should be avoided. Instead, nonaddicting alternatives such as bupropion, clonidine, or atomoxetine should be used. Evidence suggests that successful treatment of co-occurring disorders has the potential to reduce the person’s antisocial behavior.

Pharmacological Treatment Points

The evidence for pharmacological treatment of antisocial personality disorder (ASPD) is poor. Very few studies have specifically recruited patients with ASPD, but manifestations of ASPD, primarily aggression and impulsivity, have been studied.

Routine pharmacological treatment of ASPD is not recommended on the basis of the current evidence. If pharmacological treatment is considered, mood stabilizers, selective serotonin reuptake inhibitors, and antipsychotics have been shown to reduce impulsive aggression, although the quality of evidence overall is weak.

Advances in the understanding of the neurobiology of other deficits in ASPD such as lack of empathy or lack of remorse may allow for novel treatments to be designed, but such treatments would be accompanied by significant ethical and practical concerns.

Source: Mario Moscovici, M.D., et al., Chapter 18, Textbook of Antisocial Personality Disorder , APA Publishing, 2022.

Several psychosocial interventions have been tested in patient samples that include antisocial persons. These include cognitive-behavioral therapy, mentalization-based treatment, contingency management, psychoeducation, skills training, and motivational interviewing.

Taken together, these studies suggest that significant positive changes occurred in ASPD and warrant further research. Moreover, there is no evidence that treatment makes people with ASPD worse, as has been alleged.

ASPD is common, problematic, and costly to society. Infrequently diagnosed, people with ASPD are rarely referred for treatment of the condition, though they are often seen by mental health professionals for their co-occurring disorders, anger and irritability, domestic problems, and/or suicidality. ASPD begins early in life and is typically chronic and lifelong, with a trend toward improving as the individual ages. But even if the individual improves, the damage has been done, as antisocial persons fall behind their non-antisocial peers in their educational achievement, income, and career success. ASPD most likely results from the interplay of genes and environment.

Mental health professionals will continue to struggle to help those with ASPD until researchers develop empirically based treatments. Most likely, future treatment recommendations will involve a combination of medication to target anger, irritability, and other antisocial symptoms, while psychotherapy can be used to address the cognitive and moral aspects of the disorder. ■

Author Disclosure Statement

Donald W. Black, M.D., has received royalties from APA Publishing, Oxford University Press, Merck, and Kluwer Wolters; consulting fees from Boehringer Ingelheim; and honoraria from Medscape.

Photo: Donald W. Black, M.D.

Donald W. Black, M.D., is a professor emeritus of psychiatry at the University of Iowa Roy J. and Lucille A. Carver College of Medicine. He is chief of mental health at the Iowa City Veterans Administration Medical Center. He is co-editor of the Textbook of Antisocial Personality Disorder from APA Publishing. APA members may purchase the book at a discount.

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Psychiatry Online

  • March 01, 2024 | VOL. 75, NO. 3 CURRENT ISSUE pp.203-304
  • February 01, 2024 | VOL. 75, NO. 2 pp.107-201
  • January 01, 2024 | VOL. 75, NO. 1 pp.1-71

The American Psychiatric Association (APA) has updated its Privacy Policy and Terms of Use , including with new information specifically addressed to individuals in the European Economic Area. As described in the Privacy Policy and Terms of Use, this website utilizes cookies, including for the purpose of offering an optimal online experience and services tailored to your preferences.

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Personal Accounts: A "Classic" Case of Borderline Personality Disorder

  • Lynn Williams

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  • Structural stigma and its impact on healthcare for borderline personality disorder: a scoping review 29 September 2022 | International Journal of Mental Health Systems, Vol. 16, No. 1
  • The experiences of people with borderline personality disorder admitted to acute psychiatric inpatient wards: a meta-synthesis 7 July 2017 | Journal of Mental Health, Vol. 28, No. 4
  • Inpatient Treatment for Patients With Borderline Personality Disorder Journal of Psychiatric Practice, Vol. 25, No. 3
  • Clinical Problems
  • Epidemiologia e Psichiatria Sociale, Vol. 19, No. 1
  • ‘Stealing Me from Myself’: Identity and Recovery in Personal Accounts of Mental Illness 1 January 2008 | Australian & New Zealand Journal of Psychiatry, Vol. 42, No. 6
  • An Evidence-Based Approach to Managing Suicidal Behavior in Patients with BPD Social Work in Mental Health, Vol. 6, No. 1-2
  • Australasian Emergency Nursing Journal, Vol. 11, No. 4
  • Psychiatric nurses' knowledge, experience and attitudes towards clients with borderline personality disorder 18 September 2007 | Journal of Psychiatric and Mental Health Nursing, Vol. 14, No. 7
  • Managing suicidal crises in patients with severe personality disorders
  • Borderline Personality Disorder: Attitudinal Change Following Training 26 June 2016 | Australian & New Zealand Journal of Psychiatry, Vol. 38, No. 7
  • Professionally Indicated Short-Term Risk-Taking in the Treatment of Borderline Personality Disorder 16 November 2016 | Australasian Psychiatry, Vol. 12, No. 1
  • Half in Love with Easeful Death: The Meaning of Chronic Suicidality in Borderline Personality Disorder Harvard Review of Psychiatry, Vol. 12, No. 1
  • Journal of Psychiatric Practice, Vol. 10, No. 3
  • Journal of Personality Disorders, Vol. 18, No. 3
  • A Description of a Psychosocial/Psychoeducational Intervention for Persons with Recurrent Suicide Attempts Crisis, Vol. 23, No. 4
  • Joel Paris , M.D.
  • Issues in Mental Health Nursing, Vol. 22, No. 5
  • Jeffrey L. Geller , M.D., M.P.H.
  • Organizational Ethics’ Greatest Challenge: Factoring in Less-Reachable Patients The Journal of Clinical Ethics, Vol. 10, No. 4

case study personality disorder

A case study on a severe paranoid personality disorder client treated with metacognitive interpersonal therapy

Affiliations.

  • 1 Center for Psychology and Health, Tages Charity, Florence, Italy.
  • 2 School of Human Health Sciences, University of Florence, Florence, Italy.
  • 3 Center for Metacognitive Interpersonal Therapy, Rome, Italy.
  • PMID: 34263957
  • DOI: 10.1002/jclp.23201

Paranoid personality disorder (PPD) is a severe condition, lacking specialized and empirically supported treatment. To provide the clinician with insights into how to treat this condition, we present a case study of a 61-year-old man with severe PPD who presented with ideas of persecution, emotionally charged hostility, and comorbid antisocial personality disorder. The client was treated with 6 months of Metacognitive Interpersonal Therapy, which included: creating a shared formulation of his paranoid attitudes; trying to change his inner self-image of self-as-inadequate and his interpersonal schemas where he saw the others as threatening. Guided imagery and rescripting techniques, coupled with behavioral experiments, were used to promote a change. At the end of the therapy the client reported a reliable change in general symptomatology and, specifically, in interpersonal sensitivity, hostility, and paranoid ideation; he could no longer be diagnosed as PPD and only some paranoid and antisocial characteristics remained.

Keywords: hostility; metacognition; paranoid ideation; paranoid personality disorder; suspiciousness.

© 2021 Wiley Periodicals LLC.

Publication types

  • Case Reports
  • Antisocial Personality Disorder / therapy*
  • Interpersonal Relations*
  • Metacognition*
  • Middle Aged
  • Paranoid Personality Disorder / therapy*
  • Self Concept

REVIEW article

Twenty years of research on borderline personality disorder: a scientometric analysis of hotspots, bursts, and research trends.

Yuanli Liu

  • 1 Department of Psychology, School of Humanities and Social Sciences, Anhui Agricultural University, Hefei, China
  • 2 College of Computing & Informatics, Drexel University, Philadelphia, PA, United States
  • 3 Department of Psychology, School of Education, China University of Geosciences, Wuhan, China
  • 4 Department of Information Management, Anhui Vocational College of Police Officers, Hefei, China

Borderline personality disorder (BPD), a complex and severe psychiatric disorder, has become a topic of considerable interest to current researchers due to its high incidence and severity of consequences. There is a lack of a bibliometric analysis to visualize the history and developmental trends of researches in BPD. We retrieved 7919 relevant publications on the Web of Science platform and analyzed them using software CiteSpace (6.2.R4). The results showed that there has been an overall upward trend in research interest in BPD over the past two decades. Current research trends in BPD include neuroimaging, biological mechanisms, and cognitive, behavioral, and pathological studies. Recent trends have been identified as “prevention and early intervention”, “non-pharmacological treatment” and “pathogenesis”. The results are like a reference program that will help determine future research directions and priorities.

1 Introduction

Borderline personality disorder (BPD) is a complex and severe psychiatric disorder characterized by mood dysregulation, interpersonal instability, self-image disturbance, and markedly impulsive behavior (e.g., aggression, self-injury, suicide) ( 1 ). In addition, people with BPD may have chronic, frequent, random feelings of emptiness, fear, and so on. These symptoms often lead them to use unhealthy coping mechanisms in response to negative emotions, such as alcohol abuse ( 2 ). BPD has a long course, which makes treatment difficult and may have a negative impact on patients’ quality of life ( 3 ). Due to its clinical challenge, BPD is by far the most studied category of personality disorder ( 4 ). This disorder is present in 1−3% of the general population as well as in 10% of outpatients, 15−20% of inpatients, and 30−60% of patients with a diagnosed personality disorder, and has a suicide rate of up to 10% ( 5 , 6 ). Families of individuals with serious mental illness often experience distress, and those with relatives diagnosed with BPD tend to carry a heavier burden compared to other mental illnesses ( 7 , 8 ). As early as the 20th century, scholars began describing BPD and summarizing its symptoms. However, there was some debate regarding the precise definition of BPD.

In the past few decades, the research community has made remarkable progress in the study of BPD, equipping us with a wider range of perspectives and tools for understanding this intricate condition. However, numerous challenges still remain to be tackled by researchers. Diagnosing BPD is inherently challenging and often more difficult than anticipated. The symptoms of BPD are complex, diverse, and often overlap with those of other mental health conditions. For example, individuals with BPD may experience extreme mood swings similar to those observed in individuals with bipolar disorder ( 9 ); At the same time, they may also be entrenched in long-term depression, making it easy for doctors to initially misdiagnose them with depression ( 10 ). Because these symptoms overlap and interfere with each other, doctors often face the risk of misdiagnosing or overlooking the condition during initial diagnosis. Therefore, researchers are working to develop more accurate and comprehensive diagnostic tools and methods.

According to the “Neuro-behavioral Model” proposed by Lieb ( 1 ), the process of BPD formation is very complex and is determined by the interaction of several factors. The interaction between different factors can be complex and dynamic. Genetic factors and adverse childhood experiences may contribute to emotional disorders and impulsivity, leading to dysfunctional behaviors and inner conflicts. These, in turn, can reinforce emotional dysregulation and impulsivity, exacerbating the preexisting conditions. Genetic factors are an important factor in the development of BPD ( 11 ). Psychosocial factors, including adverse childhood experiences, have also been strongly associated with the development of BPD ( 12 ). Emotional instability and impulsive behavior are even more common in patients with BPD ( 13 ). The current study is based on the “Neuro-behavioral Model” and conducts a literature review of previous scientific research on BPD through bibliometric analysis to reorganize the influencing factors. Through large-sample data analysis, the association between BPD and other diseases is explored, which contributes to further refining this theory’s explanation of the common neurobiological mechanisms among various mental illnesses.

It is worth noting that with the development of BPD, some scholars have conducted bibliometrics studies on BPD to provide insights into this academic field. To date, the current study has identified two published bibliometric studies on the field: One is Ilaria M. A. Benzi and her colleagues’ 2020 metrological analysis of the literature in the field of BPD pathology for the period 1985−2020 ( 14 ). The other is a bibliometric analysis by Taylor Reis and his colleagues of the growth and development of research on personality disorders between 1980 and 2019 ( 15 ). Ilaria M. A. Benzi and her colleagues integrated and sorted out the research results of borderline personality pathology, and revealed the research results and development stages in this field through the method of network and cluster analysis. The results of the study clearly demonstrate that the United States and European countries are the main contributors, that institutional citations are more consistent, and that BPD research is well developed in psychiatry and psychology. At the same time, the development of research in borderline personality pathology is demonstrated from the initial development of the construct, through studies of treatment effects, to the results of longitudinal studies. Taylor Reis and his colleagues used a time series autoregressive moving average model to analyze publishing trends for different personality disorders to reveal their historical development patterns, and projected the number of publications for the period 2024 to 2029. The study finds a trend towards diversity in the research and development of personality disorders, with differences in publication rates for different types of personality disorders, and summarizes the reasons that influence these differences. This may ultimately determine which personality disorders will remain in future psychiatric classifications. These studies have provided valuable insights into the evolution of BPD, focusing primarily on its pathology or a broader personality disorder perspective. While basic bibliometric analyses of these studies have been conducted, there is a need for more in-depth investigations of specific trends in the evolution of BPD and a clearer delineation of emerging research foci. Therefore, in order to enhance the current study, this study extends the analysis to 2022 and utilizes a comprehensive structural variation analysis of the literature using scientometric methods. Building on previous bibliometric studies, we expect to provide new insights and additions to research in this area. At the same time, the research trends and hot topics in the field of BPD are further explored. In addition, several cocitation-based analyses are also carried out in order to better understand citation performance.

2.1 Objectives

One of our goals was to understand the current status and progress of researches on BPD, and to summarize the latest developments and research findings in BPD, such as new treatment methods and disease mechanisms. Through the intuitive presentation of knowledge graphs and other images or data, we aimed to provide clinical practice and research guidance for clinicians, researchers, and policymakers.

Our second goal was to help identify future research directions and priorities, and provide more scientific and systematic research guidance for researchers. For example, by identifying hotspots and associations in certain research areas, we can determine the fields and issues that require further investigations, thus providing clearer directions and focus for researches. Additionally, through bibliometric analysis, we can provide researchers with more targeted and practical research strategies and methods, improving research efficiency and the quality of research outcomes.

2.2 Search strategy and data collection

The selection of appropriate methods and tools in the process of analyzing research information is crucial. Web of Science (WOS) is a popular database for bibliometric analysis that includes numerous respectable and high-impact academic journals. In addition, data information, such as references and citations, is more extensive than other academic databases ( 16 ). Data collection took place on the date of May 10, 2023. The search strategy included the following: topic=“Neuro-behavioral Model” or “borderline characteristics” or “borderline etiology” or “borderline personality disorder”, database selected=WOS Core Collection, time span=2003−2022, index=Science Citation Index Expanded (SCI-EXPENDED) and Social Sciences Citation Index (SSCI). The “Neuro-behavioral Model” serves as a theoretical framework that is useful for explaining the development and pathophysiology of BPD; “borderline characteristics” can describe the related symptoms and features of BPD; “borderline etiology” helps to understand the factors that contribute to the development of BPD; “borderline personality disorder” is the most commonly used terms in relevant research. Using these as keywords in title searches can help researchers find researches related to BPD more accurately, facilitating deeper understanding of the characteristics, pathophysiology, etiology, and other aspects of BPD. In the current study, we focused only on two types of literature: articles and review articles, and limited the language to English. After removing all literature unrelated to BPD, a total of 7919 records met the criteria. They were exported in record and reference formats, and saved in plain text file format.

2.3 Data analysis and tools

Bibliometrics was first proposed by Alan Pritchard in 1969, as a method that combines data visualization to analyze publications statistically and quantitatively in specific fields and journals ( 17 ). Bibliometric analysis is a good way to analyze the trend of knowledge structure and research activities in scientific fields over time, and has been widely used in various fields since it was first used ( 18 ). Scientometrics is the application of bibliometrics in scientific fields, and it focuses on the quantitative characteristics and features of science and scientific researches ( 19 ). Compared to traditional literature review studies, visualized knowledge graphs can accurately identify key articles from many publications, comprehensively and systematically combing existing research in a field ( 20 ).

Currently, two important academic indicators are included in research. The impact factor (IF) is used as an indicator of a publication’s impact to assess the quality and importance of the publication ( 21 ). However, some researchers believe that IF has defects such as inaccuracy and misuse ( 22 ). Although many researchers have proposed to replace the impact factor with other indicators, IF is still one of the most effective ways to measure the impact of a journal ( 23 ). The IF published in the 2021 Journal Citation Reports were used. Another indicator is the H-index, which is an important measure of a scholar’s academic achievements. Some researchers consider it as a correction or supplement to the traditional IF ( 24 ).

All data were imported into CiteSpace (6.2.R4) and Scimago Graphica (1.0.30) for analysis. CiteSpace was used to obtain collaboration networks and impact networks. Scimago Graphica was used to construct a network graph of country collaboration. CiteSpace is a Java-based software developed in the context of scientometrics and data visualization ( 25 ). It combines scientific knowledge mapping with bibliometric analysis to determine the progress and current research frontiers in a particular field, as well as predict the development trends in that field ( 26 ). Scimago Graphica is a no-code tool. It can not only perform visualization analysis on communication data but also explore exploratory data ( 27 ). Currently, it is used for visual analysis of national cooperation relationships, displaying the geographic distribution of countries and publication trends.

3.1 Analysis of publication outputs, and growth trend prediction

Annual publications can provide an overview of the evolution of a research area and its progress ( 28 ). We retrieved 7919 articles from the WOS database on BPD between 2003 and 2022, including 6834 research articles and 1085 reviews ( Figure 1 ). As of the search date, these articles had received a total of 289,958 citations, equating to an average of 14,498 citations per year. Over the past two decades, the number of research articles published on BPD has shown a fluctuating upward trend. In addition, citations to these publications have increased significantly. A polynomial curve fit of the literature on BPD clearly indicates a strong correlation between the year of publication and the number of publications ( R 2 = 0.973). The number of research articles on BPD has indeed fluctuated and increased over the past two decades. This observation does, to some extent, indicate an upward trend, probably due to increasing interest in BPD. However, there are other factors to consider as well. For example, the accumulation of data or technological advances, government policies and corporate investment may also affect the direction of BPD research development.

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Figure 1 Annual publications, citation counts, and the fitting equation for annual publications in BPD.

3.2 Analysis of co-citation references: clusters and timeline of research

Co-cited references, which are cited by multiple papers concurrently, are considered a crucial knowledge base in any given field ( 28 ). In the current study, CiteSpace clustering was utilized to identify common themes within BPD-related literature. Figure 2 presented a co-citation network of highly cited references between 2003 and 2022, comprising 1163 references. A time slice of 1 was used, with the g -index was set at k =25, which resulted in the identification of 14 clusters representing distinct research themes in BPD. The significant cluster structure is denoted by a modularity value ( Q value) of 0.7974, and the high confidence level in the clusters by an average profile value ( S value) of 0.9176.

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Figure 2 Reference co-citation network with cluster visualization in BPD. Trend 1 clinical researches, sub-trend clinical characteristics includes clusters #1, #2, #4, #10, #12; biological mechanisms include clusters #3, #7; nursing treatments includes clusters #0, #8, #13. Trend 2 associations and complications includes clusters #5, #6, #9, #11, #14.

Cluster analysis is performed through CiteSpace. Related clusters are classified into the same trend based on the knowledge of related fields and whether the clusters show similar trends. At the same time, based on the analysis of time series, to identify the movement of one cluster to another. Based on the cluster map of co-cited references on BPD, several different research trends were identified. The first major research trend is clinical research on BPD, which in turn consists of three sub-trends: clinical characterization of BPD, biological mechanisms, and nursing treatment. Of the data obtained, the earliest research on the clinical characterization of BPD began in 1992 with cluster #12, “borderline personality disorder and suicidal behavior” ( S =0.979; 1992). Paul H. Soloff and his colleagues conducted a comparative study of suicide attempts between major depressives and patients with BPD. The aim of this study was to develop more effective intervention strategies for suicide prevention ( 29 ). This cluster was further developed in cluster #4, “nonsuicidal self-injury and suicide” ( S =0.96; 2004). Thomas A. Widiger and Timothy J. Trull proposed a more flexible dimension-based categorization model to overcome the previous drawbacks of personality disorder categorization ( 30 ). Next in cluster #10 “borderline personality disorder and impulsivity” ( S =0.93; 2000), Jim H. Patton and his colleagues revised the Barratt Impulsivity Scale to measure impulsivity to facilitate practical clinical research ( 31 ). Related research continues to evolve into cluster #1 “borderline personality disorder and emotions” ( S =0.87; 2007) and cluster #2 “borderline personality disorder and social cognition” ( S =0.911; 2009), researchers have focused on understanding the causal relationship between BPD traits and factors such as social environment, emotion regulation, and interpersonal evaluative bias, as well as their potential impact ( 32 , 33 ). In the sub-trend of biological mechanisms, two main clusters are involved: cluster #7 “borderline personality disorder and gene-environment interactions” ( S =0.871; 2002) and cluster #3 “borderline personality disorder and neuroimaging” ( S =0.938; 2007). In the related cluster, researchers have found a relationship between BPD and genetic and environmental factors ( 34 ). Researchers have also utilized various external techniques to explore the degree of correlation between the risk of developing BPD and its biological mechanisms, aiming to reveal the complex mechanisms that influence the emergence and development of BPD ( 35 ). In nursing treatment, cluster #8 “treatment of borderline personality disorder “ ( S =0.968; 2001), Silvio Bellino and his colleagues systematically analyzed the current publications on BPD pharmacotherapy research and summarized relevant clinical trials and findings ( 36 ). However, due to the complexity of BPD, there is still a lack of information on the exact efficacy of pharmacotherapy in BPD, and therefore pharmacotherapy remains an area of ongoing development and research. This trend continues to be developed in cluster #0 “borderline personality disorder treatment” ( S =0.887; 2006), which emphasizes the development of novel pharmacotherapies for BPD. Cluster #13 “borderline personality disorder care” ( S =0.997; 2013) mainly focuses on the comprehensive care of people with borderline personality disorder and the education of patients and families. The goal is to improve patients’ quality of life, reduce self-injury and suicidal behavior, and promote full recovery.

The second major research trend is association and comorbidity. This trend first began in cluster #9 “comorbidity and differentiation of disorders” ( S =0.946; 1999). Mary C Zanarini and his colleagues explored the comorbidity of BPD with other psychiatric disorders on Axis I ( 37 ). Cluster #14 “borderline personality disorder and psychosis” ( S =0.966; 2003) also explored symptoms associated with BPD ( 38 ). This trend continues, with researchers studying BPD research in cluster #11 “borderline personality disorder” ( S =0.935; 2004) and cluster #5 “borderline personality disorder research” ( S =0.881; 2007) ( 39 , 40 ). In addition, cluster #6 “borderline personality disorder in adolescents” ( S =0.894; 2011) points out that the focus of BPD research is increasingly shifting towards adolescents ( 41 ).

Figure 3 showed the time span and research process of the developmental evolution of these different research themes. The temporal view reveals the newest and most active clusters, namely #0 “dialectical behavior therapy”, #1 “daily life”, and #2 “social cognition”, which have been consistently researched for almost a decade. Cluster #0 “dialectical behavior therapy” has the largest number and the longest duration, lasting almost 10 years. Similarly, this article by Rebekah Bradley and Drew Westen on understanding the psychodynamic mechanisms of BPD from the perspective of developmental psychopathology has the largest node ( 34 ).

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Figure 3 Reference co-citation network with timeline visualization in BPD.

3.3 Most cited papers

The top 10 highly cited papers on BPD research were presented in Table 1 . The most cited paper, by Marsha M. Linehan and colleagues, focus on the treatment of suicidal behavior in BPD ( 42 ). The transition between suicidal and non-suicidal self-injurious behavior in individuals with BPD has attracted researchers’s attention, mainly in cluster #4 “nonsuicidal self-injury and suicide” ( 52 ). The second is the experimental study by Josephine Giesen-Bloo and his colleagues on the psychotherapy of BPD ( 43 ). In cluster #0 “borderline personality disorder treatment” and Cluster #8 “treatment of borderline personality disorder”, researchers strive to find non-pharmacological approaches with comparable or enhanced therapeutic effects. This was followed by Sheila E. Crowell and her colleagues’ study of the biological developmental patterns of BPD ( 44 ). Research on the biological mechanisms and other contributing factors of BPD, including #7 “borderline personality disorder and gene-environment interactions” have been closely associated with the development of BPD ( 53 ).

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Table 1 Top 10 cited references that published BPD researches.

3.4 Burst analysis and transformative papers

The “citation explosion” reflects the changing research focus of a field over time and indicates that certain literature has been frequently cited over time. Figure 4 showed the top 9 references with the highest citation intensity. The three papers with the greatest intensity of outbursts during the period 2003−2022 are: The first is the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders ( 54 ). In the second article, Vijay A. Mittal and Elaine F. Walker discuss key issues surrounding dyspraxia, tics, and psychosis that are likely to appear in an upcoming edition of the Diagnostic and Statistical Manual of Mental Disorders ( 39 ). In addition, Ioana A. Cristea and colleagues conducted a systematic review and meta-analysis to evaluate the effectiveness of psychotherapy for borderline personality disorder ( 55 ).

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Figure 4 References with the strongest occurrence burst on BPD researches. Article titles correspond from top to bottom: Mittal VA et al. Diagnostic and Statistical Manuel of Mental Disorders; Linehan MM et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder; Giesen-Bloo J et al. Outpatient psychotherapy for borderline personality disorder: Randomized trial of schema-focused therapy vs transference-focused psychotherapy; Clarkin Jf et al. Evaluating three treatments for borderline personality disorder: A multiwave study; Grant BF et al. Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: Results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions; Leichsenring F et al. Borderline personality disorder; American Psychiatric Association, DSM-5 Task Force. Diagnostic and statistical manual of mental disorders: DSM-5™ (5th ed.); Cristea IA et al. Efficacy of psychotherapies for borderline personality disorder: A systematic review and meta-analysis; Gunderson JG et al. Borderline personality disorder.

Structural variation analysis can be understood as a method of measuring and studying structural changes in the field, mainly reflecting the betweenness centrality and sigma of the references. The high centrality of the reference plays an important role in the connection between the preceding and following references and may help to identify critical points of transformation, or intellectual turning points. Sigma values, on the other hand, are used to measure the novelty of a study, combining a combination of citation burst and structural centrality ( 56 ). Table 2 listed the top 10 structural change references that can be considered as landmark studies connecting different clusters. The top three articles with high centrality are the studies conducted by Milton Z. Brown and his colleagues on the reasons for suicide attempts and non-suicidal self-injury in BPD women ( 57 ); the research by Nelson H. Donegan and his colleagues on the impact of amygdala on emotional dysregulation in BPD patients ( 59 ); and the fMRI study by Sabine C. Herpertz and her colleagues on abnormal amygdala function in BPD patients ( 61 ). In addition, publications with high sigma values are listed. They are Larry J. Siever and Kenneth L. Davis on psychobiological perspectives on personality disorders ( 58 ); Ludger Tebartz van Elst and his colleagues on abnormalities in frontolimbic brain functioning ( 60 ); and Marsha M. Linehan on therapeutic approaches in BPD research ( 62 ). These works are recognized as having transformative potential and may generate some new ideas.

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Table 2 Top 7 betweenness centrality and stigma references.

3.5 Analysis of authors and co-authors

Figure 5 showed a map of the co-authorship network over the last two decades. In total, 10 different clusters are shown, each of which gathers co-authors around the same research topic. For example, the main co-authors of cluster #0 “remission” are Christian Schmahl, Martin Bohus, Sabine C. Herpertz, Timothy J. Trull and Stefan Roepke. More recently, the three authors with the greatest bursts of research have been Mary C. Zanarini, Erik Simonsen, and Carla Sharp. As shown in Table 3 , the three most published authors are Martin Bohus (145 publications; 1.83%; H-index=61), Mary C. Zanarini (144 publications; 1.82%; H-index=80) and Christian Schmahl (142 publications; 1.79%; H-index=54).

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Figure 5 Top 10 clusters of coauthors in BPD (2003–2023). Selection Criteria: Top 10 per slice. Clusters labeled by keywords. The five authors with the highest number of publications in each cluster were labeled.

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Table 3 Top 10 authors that published BPD researches.

3.6 Analysis of cooperation networks across countries

The top 10 countries in terms of number of publications in the BPD are added in Table 4 . With 3,440 published papers, or nearly 43% of all BPD research papers, the United States is the leading contributor to BPD research. This is followed by Germany (1196 publications; 15.10%) and the United Kingdom (1020 publications; 9.32%). Centrality refers to the degree of importance or centrality of a node in a network and is a measure of the importance of a node in a network ( 69 ). In Table 4 the United States is also has the highest centrality (0.43). Figure 6 shows the geographic collaboration network of countries in this field, with 83 countries contributing to BPD research, primarily from the United States and Europe.

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Table 4 Top 10 countries that published BPD researches.

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Figure 6 Map of the distribution of countries/regions engaged in BPD researches.

3.7 Analysis of the co-author’s institutions network

Table 5 listed the top 10 institutions ranked by the number of publications. The current study shows that Research Libraries Uk is the institution with the highest number of publications, with 766 publications (9.67%). The subsequent institutions are Harvard University and Ruprecht Karls University Heidelberg with 425 (5.37%) and 389 (4.91%) publications respectively. As can be seen from Table 4 , six of the top 10 institutions in terms of number of publications are from the United States. In part, this reflects the fact that the United States institutions are at the forefront of the BPD field and play a key role in it.

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Table 5 Top 10 institutions that published BPD researches.

3.8 Analysis of journals and cited journals

If the more papers are published in a particular journal and at the same time it has a high number of citations, then it can be considered that the journal is influential ( 70 ). The top 10 journals in the field of BPD in terms of number of publications are listed in Table 6 . Journal of Personality Disorders from the Netherlands published the most literature on BPD with 438 (5.53%; IF=3.367) publications. This was followed by two journals from the United States: Psychiatry Research and Personality Disorders Theory Research and Treatment , with 269 (3.40%, IF=11.225) and 232 (2.93%; IF=4.627) publications, respectively. Among the top 10 journals in terms of number of publications published, Psychiatry Research has the highest impact factor.

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Table 6 Top 10 journals that published BPD researches.

3.9 Analysis of keywords and keywords co-occurrence

Keyword co-occurrence analysis can help researchers to understand the research hotspots in a certain field and the connection between different research topics. As shown in Figure 7 , all keywords can be categorized into 9 clusters: cluster #0 “diagnostic interview”, cluster #1 “diagnostic behavior therapy”, cluster #3 “social cognition”, cluster #4 “emotional regulation”, cluster #5 “substance use disorders “, cluster #6 “posttraumatic stress disorder”, cluster #7 “suicide” and cluster #8 “double blind”. These keywords have all been important themes in BPD research during the last 20 years.

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Figure 7 The largest 9 clusters of co-occurring keywords. The top 5 most frequent keywords in each cluster are highlighted.

Keyword burst is used to identify keywords with a significant increase in the frequency of occurrence in a topic or domain, helping to identify emerging concepts, research hotspots or keyword evolutions in a specific domain ( 71 ). Figure 8 presented the top 32 keywords with the strongest citation bursts in BPD from 2003−2023. Significantly, the keywords “positron emission tomography” (29.63), “major depression” (27.93), and “partial hospitalization” (27.1) had the highest intensity of outbreaks.

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Figure 8 Keywords with the strongest occurrence burst on BPD researches.

4 Discussion

4.1 application of the “neuro-behavioral model” to bpd research.

In this study, we chose specific search terms, particularly “Neuro-behavioral Model”, to efficiently collect and analyze BPD research literature related to this emerging framework. This choice of keyword helped narrow the research scope and ensure its relevance to our objectives. However, it may have excluded some studies using different terminology, thus limiting comprehensiveness. In addition, the ‘Neuro-behavioral Model’, as an interdisciplinary field, encompasses a wide range of connotations and extensions, which also poses challenges to our research. This undoubtedly adds to the complexity of the study, yet it enhances our understanding of the field’s diversity.

4.2 Summary of the main findings

This current study utilized CiteSpace and Scimago Graphic software to conduct a comprehensive bibliometric analysis of the research literature on BPD. The study presented the current status of research, research hotspots, and research frontiers in BPD over the past 20 years (2003–2022) through knowledge mapping. The scientific predictions of future trends in BPD provided by this study can guide researchers interested in this field. This study also uses bibliometrics analysis method to show the knowledge structure and research results in the field of BPD, as well as the scientific prediction of the future trend of BPD research.

4.3 Identification of research hotspots

Previous studies have indicated an increasing trend in the number of papers focused on BPD, with the field gradually expanding into various areas. The first major research trend involves clinical studies on BPD. This includes focusing on emotional recognition difficulties in BPD patients, as well as studying features related to suicide attempts and non-suicidal self-injury. Clinical recognition and confirmation of BPD remains low, mainly related to the lack of clarity of its biological mechanisms ( 72 ). The nursing environment for BPD patients plays an important role in the development of the condition, which has become a focus of research. Researchers are also exploring the expansion of treatment options from conventional medication to non-pharmacological approaches, particularly cognitive-behavioral therapy. Another major research trend involves the associations and complications of BPD, including a greater focus on the adolescent population to reduce the occurrence of BPD starting from adolescence. Additionally, many researchers are interested in the comorbidity of BPD with various clinical mental disorders.

4.4 Potential trends of future research on BPD

Based on the results of the above studies and the results of the research trends in the table of details of the co-citation network clusters in 2022 ( Table 7 ), several predictions are made for the future trends in the field of BPD. In Table 7 , there were some trends related to previous studies, including #1”dialectical behavior therapy”, #7 “dialectical behavior therapy” ( 73 ), #5 “mentalization” ( 74 ), and #9 “non-suicidal self-injury” ( 75 ). The persistence of these research trends is evidence that they have been a complex issue in this field and a focus of researchers. The recently emerged turning point paper provides a comprehensive assessment about BPD, offering practical information and treatment recommendations ( 76 ). New research is needed to improve standards and suggest more targeted and cost-effective treatments.

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Table 7 The references co-citation network cluster detail (2022).

BPD symptoms in adolescents have been shown to respond to interventions with good results, so prevention and intervention for BPD is warranted ( 77 ). This trend can be observed in #3 “youth” ( 78 ). Mark F. Lenzenweger and Dante Cicchetti summarized the developmental psychopathology approach to BPD, one of the aims of which is to provide information for the prevention of BPD ( 79 ). Prevention and early intervention of BPD has been shown to provide many benefits, including reduced occurrence of secondary disorders, improved psychosocial functioning, and reduced risk of interpersonal conflict ( 80 ). However, there are differences between individuals, and different prevention goals are recommended for adolescents at risk for BPD. Therefore, prevention and early intervention for BPD has good prospects for the future.

The etiology of BPD is closely related to many factors, and its pathogenesis is often ignored by clinicians. The exploration of risk factors has been an important research direction in the study. Some studies have found that BPD is largely the product of traumatic childhood experiences, which may lead to negative psychological effects on children growing up ( 81 ). It has also been found that the severity of borderline symptoms in parents is positively associated with poor parenting practices ( 82 ). Future researches need to know more about the biological-behavioral processes of parents in order to provide targeted parenting support and create a good childhood environment.

Because pharmacotherapy is only indicated for comorbid conditions that require medication, psychotherapy has become one of the main approaches to treating BPD. The increasingly advanced performance and availability of contemporary mobile devices can help to take advantage of them more effectively in the context of optimizing the treatment of psychiatric disorders. The explosion of COVID-19 is forcing people to adapt to online rather than face-to-face offline treatment ( 83 ). The development of this new technology will effectively advance the treatment of patients with BPD. Although telemedicine has gained some level of acceptance by the general public, there are some challenges that have been reported, so further research on the broader utility of telemedicine is needed in the future.

4.5 The current study compares with a previous bibliometric review of BPD

As mentioned earlier, there have been previous bibliometric studies conducted by scholars in the field of BPD. This paper focuses more on BPD in personality disorders than the extensive study of personality disorders as a category by Taylor Reis et al. ( 15 ). The results of both studies show an increasing trend in the number of publications in the field of BPD, suggesting positive developments in the field. Taylor Reis et al. focused primarily on quantifying publications on personality disorders and did not delve into other specific aspects of BPD. Ilaria M.A. Benzi et al. focused on a bibliometric analysis of the pathology of BPD ( 14 ). They give three trends for the future development of BPD pathology: first, the growing importance of self-injurious behavior research; second, the association of attention deficit hyperactivity disorder with BPD and the influence of genetics and heritability on BPD; and third, the new focus on the overlap between fragile narcissism and BPD. The study in this paper also concludes that there are three future development directions for BPD: first, the prevention and early intervention of BPD; second, the non-pharmacological treatment of BPD; and third, research into the pathogenesis of BPD. Owing to variations in research backgrounds and data sources, the outcomes presented in the two studies diverge significantly. Nevertheless, both contributions hold merit in advancing the understanding of BPD. In addition to this, this paper also identifies trends in BPD over the past 20 years: the first trend is the clinical research of BPD, which is specifically subdivided into three sub-trends; the second trend is association and comorbidity. The identification of these trends is important for understanding the disorder, improving diagnosis and treatment, etc. Structural variant analysis also features prominently in the study. The impact of literature in terms of innovativeness is detected through in-depth mining and analysis of large amounts of literature data. This analysis is based on research in the area of scientific creativity, especially the role and impact of novel reorganizations in creative thinking. Structural variation analysis is precisely designed to find and reveal embodiments of such innovative thinking in scientific literature, enabling researchers to more intuitively grasp the dynamics and cutting-edge advances in the field of science.

5 Limitations

However, it must be admitted that our study has some limitations. The first is the limited nature of data resources. The data source for our study came from only one database, WOS. Second, the limitation of article type. Search criteria are limited to papers and reviews in SCI and SSCI databases. Third, the effect of language type. In the current study, only English-language literature could be included in the analysis, which may lead us to miss some important studies published in other languages. Fourth, limitations of research software. Although this study used well-established and specialized software, the results obtained by choosing different calculation methods may vary. Finally, the diversity of results interpretation. The results analyzed by the software are objective, but there is also some subjectivity in the interpretation and analysis of the research results. While we endeavor to be comprehensive and accurate in our research, the choice of search terms inevitably introduces certain limitations. Using “Neuro-behavioral Model” as the search term enhances the study’s relevance, but it may also cause us to miss significant studies in related areas. This limits the generalizability and replicability of our results. Furthermore, the inherent complexity and diversity of neurobehavioral models might introduce subjectivity and bias in our interpretation and application of the literature. Although we endeavored to reduce bias via multi-channel validation and cross-referencing, we cannot entirely eliminate its potential impact on our findings.

6 Conclusion

Overall, a comprehensive scientometrics analysis of BPD provides a comprehensive picture of the development of this field over the past 20 years. This in-depth examination not only reveals research trends, but also allows us to understand which areas are currently hot and points the way for future research efforts. In addition, this method provides us with a framework to evaluate the value of our own research results, which helps us to more precisely adjust the direction and strategy of research. More importantly, this in-depth analysis reveals the depth and breadth of BPD research, which undoubtedly provides valuable references for researchers to have a deeper understanding of BPD, and also provides a reference for us to set future research goals. In short, this scientometrics approach gives us a window into the full scope of BPD research and provides valuable guidance for future research.

Author contributions

YL: Data curation, Formal analysis, Investigation, Methodology, Software, Visualization, Writing – original draft, Writing – review & editing. CC: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. YZ: Validation, Visualization, Writing – review & editing. NZ: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. SL: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing.

The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. SL is supported by the Outstanding Youth Program of Philosophy and Social Sciences in Anhui Province (2022AH030089) and the Starting Fund for Scientific Research of High-Level Talents at Anhui Agricultural University (rc432206).

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: neuro-behavioral model, borderline personality disorder, BPD, bibliometric, Scimago Graphica

Citation: Liu Y, Chen C, Zhou Y, Zhang N and Liu S (2024) Twenty years of research on borderline personality disorder: a scientometric analysis of hotspots, bursts, and research trends. Front. Psychiatry 15:1361535. doi: 10.3389/fpsyt.2024.1361535

Received: 12 January 2024; Accepted: 19 February 2024; Published: 01 March 2024.

Reviewed by:

Copyright © 2024 Liu, Chen, Zhou, Zhang and Liu. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Shen Liu, [email protected] ; Chaomei Chen, [email protected] ; Na Zhang, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Shaili Jain M.D.

  • Personality

The Case of Francis Underwood

A textbook example of antisocial personality disorder.

Posted March 11, 2015

I always like to take the opportunity to explain misunderstood psychiatric concepts or diagnoses, and to clarify when a psychiatric term is used incorrectly or prone to misinterpretation. In today’s blog, I aim to do both of these things.

First, I’ll use the character of Frank Underwood as a “case study” to illustrate the misunderstood psychiatric diagnosis of Antisocial Personality Disorder (ASPD). Those with ASPD can inflict significant psychological, emotional, and/or physical trauma on others.

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While enjoying the second season of House of Cards, I could not help but notice how Kevin Spacey’s character, Frank Underwood, meets a textbook definition of Antisocial Personality Disorder (ASPD). Inspired by Spacey’s tremendous performance, I thought I would venture forth and use this example of a central character in a drama to illustrate this misunderstood and, often, underestimated psychiatric disorder.

Individuals with antisocial personality disorder (or sociopaths) are difficult and dangerous; they deny, lie, and contribute to all manner of mayhem in our communities and societies. They know full well what is going on around them and know the difference between right and wrong (and hence are fully responsible for their own behaviors) yet are simply unconcerned about such moral dilemmas.

Below is the “textbook” definition of ASPD interspersed with examples from the life of Frank Underwood, which perfectly illustrate the elements of this disorder.

SPOILER ALERT: For those of you who have not watched all of Season 2 yet, consider yourself warned.

Antisocial Personality Disorder 301.7 (From the DSM V):

A) A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by three (or more) of the following

1) Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.

Murder. Not once, but at least two times (that we know of). He swiftly pushed Zoe Barnes into the path of an oncoming metro train. Let’s not forget this was a woman with whom he had had a physical relationship with and a (sort of) emotional intimacy . No doubt, this personal history contributed to Barnes’ poor judgment and her letting down her guard; she suspected he was a murderer but still underestimated what he was truly capable of. Frank leveraged her miscalculation to his favor.

In addition to murder, let’s not forget the unlawful behaviors carried out, on his orders, by those who work for him—e.g. vanquishing the remaining reporters who tried to expose him for what he truly is.

2) Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure

 Netflix

Honestly, I found it hard to keep track of the web of lies Frank wove during Season 2. What was notable was the sincerity with which he told many of these lies, almost as though in the moment he believed them himself. He repeatedly lied so he could drive a wedge in the previously tight relationship between the Billionaire, Raymond Tusk, and the President—a wedge he created, on purpose (and at much cost and hassle to the American tax payer!) to further his own goal of becoming President.

Then there was the web of lies told to cover the fact that his wife Claire’s (played by Robin Wright) abortion had nothing to do with her alleged rape by General McGinnis, but more to do with the inconvenience of Underwood’s political campaign timings.

A final example is the strategic drama he created (along with Claire) to cover her affair with Galloway. Again, there was no inkling of any remorse or feelings that they should be held accountable for their actions. Instead there was only a rigid entitlement: How dare anyone get in the way of me becoming president?

3) Impulsivity or failure to plan ahead

Underwood has a degree of impulse control. In fact, his ability to plot, scheme, and plan has served him well with regards to his political posturing and career . This is not the case for many with ASPD. Those without means, education , or status can be dangerously impulsive, and this behavior often leaves them in jail, prison, or dead.

case study personality disorder

4) Irritability and aggressiveness, as indicated by repeated physical fights or assaults

See point #3. He is aggressive and violent but has probably learned, over time, to become more measured in his actions. Repeated irritable outbursts and acts of physical aggression are not compatible with life in political office.

5) Reckless disregard for safety of self or others

See point #1.

6) Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations

Did Frank Underwood honor any of his obligations or duties associated with being the Vice President of the United States of America? Did he use his powers to be of service to the American people or to his country? No. His days and nights appeared to be utterly consumed with one goal…to become president of the United States. At any cost.

7) Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated or stolen from another.

This was best illustrated in his reaction to the murder of Zoe Barnes. It was business as usual. Not a hair out of place, no loss of appetite or sleep. No remorse, no guilt or angst. She was getting in his way as he tried to forge a path to the presidency, so he got rid of her and never thought about it again. Her murder was no more of an incident than flicking lint from his jacket lapel. In fact, he was so cool after the event that it makes me wonder about his psychopathic tendencies, but that would be a whole other blog for another day.

B) Individual is at least 18 years old

C) There is evidence of conduct disorder with onset before age 15 years

Who knows what skeletons lie in the Frank Underwood closet?

D) The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder .

One final point that is not done justice in the brief description above (more details can be found here)—those with ASPD are able to be utterly charismatic , charming, and almost bewitching. This characteristic is one Spacey has down to a tee in his performance.

 Melinda Sue Gordon

When Frank wants something or needs to manipulate someone, he is able to “switch on” the charm in an instant. He conveys to others that he cares deeply about them by flashing an infectious smile and being gracious and attentive.

And, as season 2 showed, there were many who fell prey to his deceit…not least of all the President of the free world. Perhaps nowhere is his charisma more evident that in the perverse loyalty of those in his inner circle; all turn a blind eye to what he is capable of and appear to be utterly captivated by his personality and presence.

My second point: The term “antisocial” is used incorrectly or prone to misinterpretation.

The seriousness of ASPD leads me to my next point—the confusing usage of the term “antisocial.” Antisocial is often used in lay language to indicate someone who is shy and unwilling or unable to associate in a normal or friendly way with other people. While this is a legitimate definition of the word, I have never been a fan of how this one word can be used in such opposing ways. I would advocate that we reserve this word for individuals with personality disorders associated with the features described above. People who are described as “antisocial” because they are shy are (typically) not dangerous. This is in sharp contrast to the definition of antisocial widely used in mental health terminology. In this context antisocial goes hand in hand with being “antisociety” and is a disorder associated with much more sinister and outright dangerous and reckless behavior.

At this point, many of you might be saying, well who cares about these individuals? They are just evil, so why bother to make a psychiatric case about them? Just lock them up and throw away the key!

But the situation is vastly more complicated than that.

ASPD is common. For the reasons outlined above (their lies, deception , and charm) sociopaths are not always easy to detect, yet ASPD is associated with huge costs to our society that extend well beyond the individual who has the disorder. We have to stay curious about ASPD—about how the disorder develops, how to detect it, how to manage it—as our societies pay for its consequences on many levels, economically, socially, and emotionally.

And when someone with ASPD ends up in a position of unparalleled power? Well, who knows what trauma (psychological and physical) they will inflict on those around them?

Shaili Jain M.D.

Shaili Jain, M.D., is a professor of psychiatry at Stanford. She is the Medical Director of the Primary Care-Behavioral Health Team, VA Palo Alto.

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The Avoidant Patient - A Case Study

Read therapy session notes from patient diagnosed with Avoidant Personality Disorder. See what it's like living with Avoidant Personality Disorder.

Notes of first therapy session with Gladys, female, 26, diagnosed with Avoidant Personality Disorder

"I would like to be normal" - says Gladys and blushes purple. In which sense is she abnormal? She prefers reading books and watching movies with her elderly mother to going out with her colleagues to the occasional office party. Maybe she doesn't feel close to them? How long has she been working with these people? Eight years in the same firm and "not one raise in salary" - she blurts out, evidently hurt. Her boss bullies her publicly and the searing shame of it all prevents her from socializing with peers, suppliers, and clients.

Does she have a boyfriend? I must be mocking her. Who would date an ugly duckling, plain secretary like her? I disagree wholeheartedly and in details with her self-assessment. I think that she is very intelligent. She half rises from her seat then thinks better of it: "Please, doctor, there no need to lie to me just in order to make me feel better. I know my good sides and they don't amount to much. If we disagree on this crucial point, perhaps I should start looking for another therapist."

A glass of water and mounds of tissue paper later, we are back on track. She dreads the idea of group therapy. "I am a social cripple. I can't work with other people. I declined a promotion to avoid working in a team." Her boss thought highly of her until she turned his offer down, so in effect it's all her fault and she has earned the abuse she is being subjected to on a daily basis. And, anyhow, he overestimated her capabilities and skills.

Why can't she interact with her co-workers? "Well, that's precisely what we are supposed to find out, isn't it?" - she retorts. Everyone is too critical and opinionated and she can't stand it. She accepts people as they are, unconditionally - why can't they treat her the same way? She fantasizes about getting married one day to a soulmate, someone who would love and cherish her regardless of her blemishes.

I ask her to describe how she thinks she is being perceived by others. "Shy, timid, lonely, isolated, invisible, quiet, reticent, unfriendly, tense, risk-averse, resistant to change, reluctant, restricted, hysterical, and inhibited." That's quite a list, I comment, now how does she view herself? The same, she largely agrees with people's perceptions of her "but it doesn't give them the right to ridicule or torment her just because she is different."

This article appears in my book, "Malignant Self Love - Narcissism Revisited"

next: The Histrionic Patient ~ back t o: Case Studies: Table of Contents

APA Reference Vaknin, S. (2009, October 1). The Avoidant Patient - A Case Study, HealthyPlace. Retrieved on 2024, March 9 from https://www.healthyplace.com/personality-disorders/malignant-self-love/avoidant-patient-a-case-study

Medically reviewed by Harry Croft, MD

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Module 12: Personality Disorders

Dependent personality disorder, learning objectives.

  • Describe the characteristics and diagnosis of dependent personality disorder

Dependent personality disorder (DPD) is a cluster C personality disorder characterized by a pervasive psychological dependence on other people.

Dependent personality disorder   (DPD) is a long-term condition  in which people depend on others to meet their emotional and physical needs, with only a minority achieving normal levels of independence. Dependent personality disorder (DPD) is characterized by excessive fear and anxiety. Dependent personality disorder (DPD) begins by early adulthood, is present in a variety of contexts, and is associated with inadequate functioning. Symptoms can include anything from extreme passivity, devastation, or helplessness when relationships end; avoidance of responsibilities; and severe submission.

People who have dependent personality disorder are overdependent on other people when it comes to making decisions. They cannot make a decision on their own as they need constant approval from other people. Consequently, individuals diagnosed with DPD tend to place the needs and opinions of others above their own as they do not have the confidence to trust their decisions. This kind of behavior can explain why people with DPD tend to show passive and clingy behavior. These individuals display a fear of separation and cannot stand being alone. When alone, they experience feelings of isolation and loneliness due to their overwhelming dependence on other people.

DSM-5 Criteria

DSM-5 refers to dependent personality disorder as a pervasive and excessive need to be taken care of, which leads to submissive and clinging behavior and fears of separation. This behavior begins by early adulthood and can be present in a variety of contexts.

According to the DSM-5, the disorder is indicated by at least five of the following factors:

  • has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.
  • needs others to assume responsibility for most major areas of their life.
  • has difficulty expressing disagreement with others because of fear of loss of support or approval.

The backs of two people side-hugging at a viewpoint.

Figure 1. People with DPD can be clingy and may constantly need the approval of others.

  • goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant.
  • feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for themselves.
  • urgently seeks another relationship as a source of care and support when a close relationship ends.
  • is unrealistically preoccupied with fears of being left to take care of themselves.

Differential Diagnosis

There are similarities between individuals with dependent personality disorder and individuals with borderline personality disorder in that they both have a fear of abandonment. Those with dependent personality disorder do not exhibit impulsive behavior, unstable affect, and poor self-image experienced by those with borderline personality disorder.

The following conditions are commonly comorbid with dependent personality disorder:

  • mood disorders
  • anxiety disorders
  • adjustment disorder
  • borderline personality disorder
  • avoidant personality disorder
  • histrionic personality disorder

Epidemiology

Based on a survey of 43,093 Americans, 0.49% of adults meet diagnostic criteria for DPD (National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; Grant et al., 2004).  Traits related to DPD, like most personality disorders, emerge in childhood or early adulthood. DPD is more common among women compared to men as 0.6% of women have DPD compared to 0.4% of men.  A 2004 twin study suggests a heritability of 0.81 for developing dependent personality disorder. Because of this, there is significant evidence that this disorder runs in families.  Children and adolescents with a history of anxiety disorders and physical illnesses are more susceptible to acquiring this disorder.

A mother with her son sitting on her lap.

Figure 2. Overprotective parenting behavior is a risk factor for DPD.

The exact cause of dependent personality disorder is unknown.  A study in 2012 estimated that between 55% and 72% of the risk of the condition is inherited from one’s parents.  The difference between a dependent personality and a dependent personality disorder is somewhat subjective, which makes diagnosis sensitive to cultural influences such as gender role expectations. There is a higher frequency of the disorder seen in women than men.

Dependent traits in children tended to increase with parenting behaviors and attitudes characterized by overprotectiveness and authoritarianism.  Traumatic or adverse experiences early in an individual’s life, such as neglect and abuse or serious illness, can increase the likelihood of developing personality disorders, including dependent personality disorder, later on in life. This likelihood is especially prevalent for those individuals who also experience high interpersonal stress and poor social support.

People who have DPD are generally treated with psychotherapy. The main goal of this therapy is to make the individual more independent and help them form healthy relationships with the people around them. This is done by improving their self-esteem and confidence.

Medication can be used to treat patients who suffer from depression or anxiety because of their DPD, but this does not treat the core problems caused by DPD.

Key Takeaways: Dependent personality disorder

Case study: dependent personality disorder.

This case study looks at the patient of a 27-year-old, white female named Sally. She works as an administrative assistant whose work required extensive data entry. Sally’s mother used her network to get this stable job for her daughter. Sally is consumed with pleasing her mother and even asks for her mother’s advice on what to wear to the office each day. Sally consistently worries about pleasing others and her colleagues at work, even at the expense to herself, which leads to the diagnosis of dependent personality disorder. The degree to which her self-destructive passivity and compliance at work stemmed from her early experiences within the family are unclear, but her parents’ overprotectiveness likely played some role in the etiology of her personality pathology.

This video describes the diagnostic criteria and treatment options for dependent personality disorder.

You can view the transcript for “What is Dependent Personality Disorder?” here (opens in new window) .

dependent personality disorder (DPD):  a personality disorder characterized by a pervasive and excessive need to be taken care of, leading to a lack of independent action

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Living with pathological narcissism: a qualitative study

Nicholas j. s. day.

Illawarra Health and Medical Research Institute and School of Psychology, University of Wollongong Australia, Wollongong, NSW Australia

Michelle L. Townsend

Brin f. s. grenyer, associated data.

The datasets generated during and/or analysed during the current study are not publicly available due to the sensitive and personal nature of participant responses but are available from the corresponding author on reasonable request.

Research into the personality trait of narcissism have advanced further understanding of the pathological concomitants of grandiosity, vulnerability and interpersonal antagonism. Recent research has established some of the interpersonal impacts on others from being in a close relationship with someone having such traits of pathological narcissism, but no qualitative studies exist. Individuals with pathological narcissism express many of their difficulties of identity and emotion regulation within the context of significant interpersonal relationships thus studying these impacts on others is warranted.

We asked the relatives of people high in narcissistic traits (indexed by scoring above a cut-off on a narcissism screening measure) to describe their relationships ( N  = 436; current romantic partners [56.2%]; former romantic partners [19.7%]; family members [21.3%]). Participants were asked to describe their relative and their interactions with them. Verbatim responses were thematically analysed.

Participants described ‘grandiosity’ in their relative: requiring admiration, showing arrogance, entitlement, envy, exploitativeness, grandiose fantasy, lack empathy, self-importance and interpersonal charm. Participants also described ‘vulnerability’ of the relative: contingent self-esteem, hypersensitivity and insecurity, affective instability, emptiness, rage, devaluation, hiding the self and victimhood. These grandiose and vulnerable characteristics were commonly reported together (69% of respondents). Participants also described perfectionistic (anankastic), vengeful (antisocial) and suspicious (paranoid) features. Instances of relatives childhood trauma, excessive religiosity and substance abuse were also described.

Conclusions

These findings lend support to the importance of assessing the whole dimension of the narcissistic personality, as well as associated personality patterns. On the findings reported here, the vulnerable aspect of pathological narcissism impacts others in an insidious way given the core deficits of feelings of emptiness and affective instability. These findings have clinical implications for diagnosis and treatment in that the initial spectrum of complaints may be misdiagnosed unless the complete picture is understood. Living with a person with pathological narcissism can be marked by experiencing a person who shows large fluctuations in affect, oscillating attitudes and contradictory needs.

Introduction

The current diagnostic description of narcissistic personality disorder (NPD) as it appears in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, 5th edition, [ 1 ]) includes a lot of information about how the person affects others, such as requiring excessive admiration, having a sense of entitlement, interpersonal exploitativeness, showing both a lack of empathy for others and feeling others are envious of their perceived special powers or personality features. Despite these features being important aspects of narcissism that have been validated through empirical research [ 2 , 3 ], they have been criticised for their emphasis on grandiosity and the exclusion of vulnerability in narcissism [ 4 , 5 ], a trend that is mirrored in the field more generally and runs counter to over 35 years of clinical theory [ 3 ]. The more encompassing term ‘pathological narcissism’ has been used to better reflect personality dysfunction that is fundamentally narcissistic but allows for both grandiose and vulnerable aspects in its presentation [ 6 ].

Recognising the vulnerable dimension of narcissism has significant implications for treatment [ 7 ], including providing an accurate diagnosis and implementing appropriate technical interventions within treatment settings. Vulnerable narcissism, in marked contrast to the overt grandiose features listed in DSM-5 criteria, includes instances of depressed mood, insecurity, hypersensitivity, shame and identification with victimhood [ 8 – 12 ]. Pincus, Ansell [ 13 ] developed the Pathological Narcissism Inventory (PNI) to capture this narcissistic vulnerability in three factors. The factor ‘contingent self-esteem’ (item example: ‘It’s hard for me to feel good about myself unless I know other people like me’) reflects a need to use others in order to maintain self-esteem. The factor ‘devaluing’ includes both devaluation of others who do not provide admiration needs (‘sometimes I avoid people because I’m concerned that they’ll disappoint me’) and of the self, due to feelings of shameful dependency on others (‘when others disappoint me, I often get angry at myself’). The factor ‘hiding the self’ (‘when others get a glimpse of my needs, I feel anxious and ashamed’) reflects an unwillingness to show personal faults and needs. This factor may involve a literal physical withdrawal and isolation [ 14 ] but may also include a subtler emotional or psychic withdrawal due to feelings of inadequacy and shame which may result in the development of an imposter or inauthentic ‘false self’ [ 11 , 15 ], and which may also include a disavowal of emotions, becoming emotionally ‘empty’ or ‘cold’ [ 14 ]. Another aspect described in the literature are instances of ‘narcissistic rage’ [ 16 ] marked by hatred and envy in response to a narcissistic threat (i.e. threats to grandiose self-concept). Although commonly reported in case studies and clinical reports, it is unclear if it is a feature of only grandiose presentations or if it may more frequently present in vulnerable presentations [ 17 ].

While the differences in presentation between grandiose and vulnerable narcissism appear manifest, it has been argued that they reflect both sides of a narcissistic ‘coin’ [ 9 ] that may be regularly oscillating, inter-related and state dependent [ 6 , 18 – 22 ]. As such, it may not be as important to locate the specific presentation of an individual as to what ‘type’ they are (i.e. grandiose or vulnerable), as it is to recognise the presence of both of these aspects within the person [ 23 ]. The difficulty for these patients is the pain and distress that accompanies having such disparate ‘split off’ or unintegrated parts of the self, which result in the defensive use of maladaptive intra and interpersonal methods of maintaining a stable self-experience [ 24 ]. This defensive operation is somewhat successful, and may give the impression of a coherent and stable identity, however as noted by Caligor and Stern [ 25 ] “manifestly vulnerable narcissists retain a connection to their grandiosity … [and] even the most grandiose narcissist may have internal feelings of inadequacy or fraudulence” (p. 113).

The vulnerable dimension of narcissism, with its internal feelings of emptiness and emotion dysregulation, may reflect a more general personality pathology similar to that of borderline personality disorder (BPD) [ 26 ]. For instance, Euler, Stobi [ 27 ] found grandiose narcissism to be related to NPD, but vulnerable narcissism to be related to BPD. In a similar vein, Hörz-Sagstetter, Diamond [ 28 ] proposes grandiosity as a narcissistic ‘specific’ factor that distinguishes it from other disorders (e.g. BPD). This grandiosity, however, “ predisposes [these individuals] to respond with antagonism/hostility and reduced reality testing when the grandiose self is threatened ” (p.571). This antagonism, hostility and the resultant interpersonal dysfunction are well-documented aspects of pathological narcissism [ 29 – 32 ], that exacts a large toll on individuals in the relationship [ 33 , 34 ]. As the specific features of the disorder are perhaps therefore best evidenced within the context of these relationships, gaining the perspective of the ‘other’ in the relationship would present a unique perspective that may not be observable in other contexts (e.g. clinical or self-report research). For example, a recent study by Green and Charles [ 35 ] provided such a perspective within the context of domestic violence. They found that those in a relationship with individuals with reportedly narcissistic features described overt (e.g. verbal and physical) and covert (e.g. passive-aggressive and manipulative) expressions of abuse and that these behaviours were in response to perceived challenges to authority and to counteract fears of abandonment. As such, informant ratings may be a novel and valid methodology to assess for personality pathology [ 36 ], as documented discrepancies between self-other ratings suggest that individuals with pathological narcissism may not provide accurate self-descriptions [ 37 ]. Further, Lukowitsky and Pincus [ 38 ] report high levels of convergence for informant ratings of narcissism, indicating that multiple peers are likely to score the same individual similarly and, notably, individuals with pathological narcissism agreed with observer ratings of interpersonal dysfunction, again highlighting this aspect as central to the disorder [ 6 ]. The aim of this study is to investigate the reported characteristics of individuals with pathologically narcissistic traits from the perspective of those in a significant personal relationship with these individuals. For this research, partners and family members will be referred to as ‘participants’. Individuals with pathological narcissism will be referred to as the ‘relative’.

Recruitment

Participants were relatives of people reportedly high in narcissistic traits, and all provided written informed consent to allow their responses to be used in research, following institutional review board approval. The participants were recruited through invitations posted on various mental health websites that provide information and support that is narcissism specific (e.g. ‘Narcissistic Family Support Group’). Recruitment was advertised as being specifically in relation to a relative with narcissistic traits. A number of criteria were applied to ensure that included participants were appropriate to the research. First, participants had to identify as having a ‘significant personal relationship’ with their relative. Second, participants had to complete mandatory questions as part of the survey. Mandatory questions included basic demographic information (age, gender, relationship type) and answers to qualitative questions under investigation. Non-mandatory questions included questions such as certain demographic questions (e.g. occupation) and questions pertaining to their own support seeking. Third, the relative had to have a cumulative score of 36 (consistent with previous methodology, see [33]) or above on a narcissism screening measure (described in Measures section), as informed by participants.

Participants

A total of 2219 participants consented to participate in the survey. A conservative data screening procedure was implemented to ensure that participants were appropriate to the research. First, participants were removed who indicated that they did not have a ‘significant’ (i.e. intimate) personal relationship with someone who was narcissistic ( n  = 129). Second, participants who clicked on the link to begin the survey but dropped out within the first 1–5 questions were deemed ‘non-serious’ and were removed ( n  = 1006). Third, participants whose text sample was too brief (i.e. less than 70 words) to analyse were excluded ( n  = 399) as specified by Gottschalk, Winget [ 39 ]. Finally, participants identified as rating relatives narcissism below cut off score of 36 on a narcissism screening measure were removed ( n  = 249). Inspection of pattern of responses indicated that none of the remaining participants had filled out the survey questions inconsistently or inappropriately (e.g. scoring the same for all questions). The remaining 436 participants formed the sample reported here. Table  1 outlines the demographic information of participants and the relative included in the study.

Demographics for participants (partners and family) and their relatives (people high in pathological narcissism) ( N  = 436)

Participants were also asked to report on the diagnosis that their relative had received. These diagnoses were specified as being delivered by a mental health professional and not the participants own speculation. The majority of participants either stated that their relative has not received a formal diagnosis, or that they did not know ( n  = 284, 65%). A total of 152 (35%) participants stated that their relative had received an official diagnosis from a mental health professional (See Table  2 ).

Relatives diagnoses as reported by participants ( n  = 152)

Note . The percentages and numbers of diagnoses endorsed are greater than the total number of participants as many relatives had been diagnosed with ‘co-morbid’ disorders. ‘Other’ personality disorder group includes avoidant ( n  = 3), histrionic ( n  = 2), antisocial ( n  = 4), schizoid ( n  = 1) and paranoid ( n  = 1)

Pathological narcissism inventory (Carer version) (SB-PNI-CV)

Schoenleber, Roche [ 40 ] developed a short version of the Pathological Narcissism Inventory (SB-PNI; ‘super brief’) as a 12 item measure consisting of the 12 best performing items for the Grandiosity and Vulnerability composites (6 of each) of the Pathological Narcissism Inventory [ 13 ]. This measure was then adapted into a carer version (SB-PNI-CV) in the current research, consistent with previous methodology [ 33 ] by changing all self-referential terms (i.e. ‘I’) to refer to the relative (i.e. ‘my relative’). The scale operates on a Likert scale from 0 (‘not at all like my relative’) to 5 (‘very much like my relative’). By summing participant responses, a total score of 36 indicates that participants scored on average ‘a little like my relative’ to all questions, indicating the presence of pathologically narcissistic traits. The SB-PNI-CV demonstrated strong internal consistency (α = .80), using all available data ( N  = 1021). Subscales of the measure also demonstrated internal consistency for both grandiose (α = .73) and vulnerable (α = .75) items. Informant-based methods of investigating narcissism and its effects has previously been found to be effective and reliable [ 30 ] with consensus demonstrated across multiple observers [ 38 ].

Qualitative analyses

Participants who met inclusion criteria were asked to describe their relative using the Wynne-Gift speech sample procedure as outlined by Gift, Cole [ 41 ]. This methodology was developed for interpersonal analysis of the emotional atmosphere between individuals with severe mental illness and their relatives, it has also been used in the context of assessing relational functioning within marital couples [ 41 ]. For the purpose of this study, the speech sample prompt was used to elicit descriptive accounts of relational functioning, which included participants responding to the question:

‘What is your relative like, how do you get on together?’

Participants were given a textbox to respond to this question in as much detail as they would like. However, participants whose text responses were too brief (< 70 words), were removed from analysis as specified by Gottschalk, Winget [ 39 ]. It is important to note however that these participants who were removed ( n  = 399) did not differ from the included participants in any meaningful way regarding demographic information. The mean response length was 233 words (SD = 190) and text responses ranged from 70 to 1279 words.

Analysis of the data occurred in multiple stages. First, a phenomenological approach was adopted which places primacy on understanding the ‘lived experience’ of participant responses [ 42 ] whilst ‘bracketing’ researcher preconceptions. This involved reading and re-reading all participant responses in order to be immersed in the participants subjective world, highlighting text passages regarding the phenomenon under examination (i.e. personality features, descriptions of behaviour, etc) and noting comments and personal reactions to the text in the margins. This is done in an attempt to make the researchers preconceptions explicit, in order to attend as close as possible as to the content of what is being said by the participant. Second, codebook thematic analysis was used for data analysis as outlined by Braun, Clarke [ 43 ], which combines ‘top down’ and ‘bottom up’ approaches. Using this approach, a theory driven or ‘top down’ perspective was taken [ 44 ] in which researchers attempted to understand the reality of participants through their expressed content and within the context of the broader known features informed by the extensive prior work on the topic. In this way, the overarching themes of ‘grandiosity’ and ‘vulnerability’ were influenced by empirically determined features within the research literature (e.g. DSM-5 diagnostic criteria, factors within the PNI), however themes and nodes were free to be ‘split’ or merged organically during the coding process reflecting the ongoing conceptualisation of the data by the researchers. Significant statements were extracted and coded into nodes reflecting their content (e.g. ‘narcissistic rage’, ‘entitlement’) using Nvivo 11. This methodology of data analysis via phenomenologically analysing and grouping themes is a well-documented and regularly utilized qualitative approach (e.g. [ 45 , 46 ]). Once data analysis had been completed the second author completed coding for inter-rater reliability analysis on 10% of data. The second rater was included early in the coding process and the two reviewers meet on several occasions to discuss the nodes that were included and those that were emerging from the data. 10% of the data was randomly selected by participant ID numbers. At the end of this process, it was then confirmed that the representation of the data also reflected the participant relationships (i.e. marital partner, child etc). Cohen’s Kappa coefficient was used to index inter-rater reliability by calculating the similarity of nodes identified by the two researchers. This method takes into consideration the agreement between the researchers (observed agreement) and compares it to how much agreement would be expected by chance alone (chance agreement). Inter-rater reliability for the whole dataset was calculated as κ = 0.81 which reflects a very high level of agreement between researchers that is not due to chance alone [ 47 ].

Cluster analysis

A cluster analysis dendrogram was generated using Nvivo 11 for purposes of visualisation and to explore the underlying dimensions of the data [ 48 ]. This dendrogram displays the measure of similarity between nodes as coded, in which each source (i.e. participant response) is coded by each node. If the source is coded by the node it is listed as ‘1’ and ‘0’ if it is not. Jaccard’s coefficient was used to calculate a similarity index between each pair of items and these items were grouped into clusters using the complete linkage hierarchical clustering algorithm [ 49 ].

Two broad overarching dimensions were identified. The first dimension, titled ‘grandiosity’, included descriptions that were related to an actual or desired view of the self that was unrealistically affirmative, strong or superior. The second dimensions, titled ‘vulnerability’, included an actual or feared view of the self that was weak, empty or insecure. Beyond these two overarching dimensions, salient personality features not accounted for by the ‘grandiose’ or ‘vulnerable’ dimensions were included within a category reflecting ‘other personality features’. Themes not relating specifically to personality style, but that may provide insights regarding character formation or expression were included within the category of ‘descriptive themes’.

A total of 1098 node expressions were coded from participant responses ( n  = 436), with a total of 2182 references. This means participant responses were coded with an average of two to three individual node expressions (e.g. ‘hiding the self’, ‘entitlement’) and there were on average 5 expressions of each node(s) in the text.

Overarching dimension #1: grandiosity

Participants described the characterological grandiosity of their relative. This theme was made up of ten nodes: ‘Requiring Admiration’, ‘Arrogance’, ‘Entitlement’, ‘Envy’, ‘Exploitation’, ‘Grandiose Fantasy’, ‘Grandiose Self Importance’, ‘Lack of Empathy’, ‘Belief in own Specialness’ and ‘Charming’.

Node #1: requiring admiration or attention seeking

Participants described their relative as requiring excessive admiration. For instance, “He puts on a show for people who can feed his self-image. Constantly seeking praise and accolades for any good thing he does” (#1256); “He needs constant and complete attention and needs to be in charge of everything even though he expects everyone else to do all the work” (#1303).

Node #2: arrogance

Relatives were described as often displaying arrogant or haughty behaviours or attitudes. For instance, “ He appears to not be concerned what other people think, as though he is just ‘right’ and ‘superior’ about everything” (#1476) and “My mother is very critical towards everyone around her... family, friends, neighbours, total strangers passing by... everybody is ‘stupid’” (#2126).

Node #3: entitlement

Relatives were also described as having a sense of entitlement. For example, “I paid all of the bills. He spent his on partying, then tried to tell me what to do with my money. He took my bank card, without permission, constantly. Said he was entitled to it” (#1787) and “He won’t pay taxes because he thinks they are a sham and he shouldn’t have to just because other people pay” (#380).

Node #4: envy and jealousy

Participants described instances of their relative being envious or jealous of others. Jealousy, being in relation to the threatened loss of important relationships, was described by participants. For instance, after describing the abusive behaviours of their relative one participant stated “It got worse after our first son was born, because he was no longer the centre of my attention. I actually think he was jealous of the bond that my son and I had” (#1419). Other participants, despite using the term ‘jealous’, described more envious feelings in their relative relating to anger in response to recognising desirable qualities or possessions of others. For instance, another participant stated “[they have] resentment for people who are happy, seeing anyone happy or doing great things with their life makes them jealous and angry” (#1744). Some participants described their relative believing that others are envious of them, for example “ [ he] thought everyone was jealous he had money and good looks.” (#979) and “[he] tried to convince everyone that people were just jealous of him because he had a nice truck” (#1149).

Node #5 exploitation

Relatives were described as being interpersonally exploitative (i.e. taking advantage of others). For instance, one participant stated “He brags how much he knows and will take someone else’s knowledge and say he knew that or claim it’s his idea” (#1293). Another participant stated “ With two other siblings that are disabled, she uses funding for their disabilities to her advantage … I do not think she cares much for their quality of life, or she would use those funds for its intended use.” (#998).

Node #6 grandiose fantasy

Participants also described their relatives as engaging in unrealistic fantasies of success, power and brilliance. For instance, the response “He believes that he will become a famous film screen writer and producer although he has no education in film” (#1002); “He was extremely protective of me, jealous and woefully insecure. [He] went on ‘missions’ where he was sure [world war three] was about to start and he was going to save us, he really believes this” (#1230).

Node #7 grandiose self importance

Relatives were described as having a grandiose sense of self-importance (e.g. exaggerating achievements, expecting to be recognised as superior without commensurate achievements). Examples of this include “He thinks he knows everything … conversations turn into an opportunity for him to ‘educate’ me” (#1046); “ He tells endless lies and elaborate stories about his past and the things he has achieved, anyone who points out inconsistencies in his stories is cut out of his lif e” (#178).

Node #8 compromised empathic ability

Participants described their relatives as being unwilling to empathise with the feelings or perspectives of others. Some examples include “she has never once apologized for her abuse, and she acts as if it never happened. I have no idea how she can compartmentalize like that. There is no remorse” (#1099) and “[he] is incapable of caring for all the needs of his children because he cannot think beyond his own needs and wants, to the point of his neglect [resulting in] harm to the children” (#1488).

Node #9 belief in own specialness

Relatives were described as believing they were somehow ‘special’ and unique. For example, one participant described their relative as fixated with their status as an “important [member] of the community” (#860), another participant stated “he considers himself a cut above everyone and everything... Anyone who doesn’t see him as exceptional will suffer” (#449). Other responses indicated their relatives were preoccupied with being associated with other high status or ‘special’ people. For instance, one participant stated that their relative “likes to brag about how she knows wealthy people as if that makes her a better person” (#318) and another stating that their relative “loves to name drop” (#49).

Node #10 charming

Participants also described their relative in various positive ways which reflected their relatives’ likeability or charm. For instance, “He is fun-loving and generous in public. He is charming and highly intelligent” (#1401); “His public persona, and even with extended family, is very outgoing, funny and helpful. Was beloved by [others]” (#1046) and “He is very intelligent and driven, a highly successful individual. Very social and personable and charming in public, funny, the life of the party” (#1800).

Overarching dimension #2: vulnerability

Participants described the characterological vulnerability of their relative. This theme was made up of nine nodes: ‘Contingent Self Esteem’, ‘Devaluing’, ‘Emotionally Empty or Cold’, ‘Hiding the Self’, ‘Hypersensitive’, ‘Insecurity’, ‘Rage’, ‘Affective Instability’ and ‘Victim Mentality’.

Node #1 contingent self esteem

Participants described their relatives as being reliant on others approval in order to determine their self-worth. For instance, “She only ever seems to be ‘up’ when things are going well or if the attention is on her” (#1196) and “He appears to be very confident, but must have compliments and reassuring statements and what not, several times a day” (#1910).

Node #2 devaluing

Relatives were described as ‘putting down’ or devaluing others in various ways and generally displaying dismissive or aggressive behaviours. For instance, “On more than one occasion, he’s told me that I’m a worthless person and I should kill myself because nobody would care” (#1078) and “He feels intellectually superior to everyone and is constantly calling people idiotic, moron, whatever the insult of the day is” (#1681).

Relatives were also described as reacting to interpersonal disappointment with shame and self-recrimination, devaluing the self. For instance, “They are extremely [grandiose] … [but] when someone has the confidence to stand up against them they crumble into a sobbing mess wondering why it’s always their fault” (#1744) and “I have recently started to stand up for myself a little more at which point he will then start saying all the bad things are his fault and begging forgiveness” (#274).

Node #3 emotionally empty or cold

Participants described regularly having difficulty ‘connecting’ emotionally with their relative. For instance, one participant described that their relative was “largely sexually disengaged, unable to connect, difficulty with eye contact … he used to speak of feeling dead” (#1365); another stated “he was void of just any emotion. There was nothing. In a situation of distress he just never had any feeling. He was totally void of any warmth or feeling” (#323), another stated “I gave him everything. It was like pouring myself into an emotional black hole” (#627).

Node #4 hiding the self

Participants reported instances in which their relative would not allow themselves to be ‘seen’, either psychologically or physically. One way in which they described this was through the construction of a ‘false self’. For instance “He comes across very confident yet is very childish and insecure but covers his insecurities with bullish and intimidating behaviour” (#2109). Another way participants described this hiding of self was through a literal physical withdrawal and isolation. For example, “He will also have episodes of deep depression where he shuts himself off from human contact. He will hide in his room or disappear in his sleeper semi-truck for days with no regard for his family or employer” (#1458).

Node #5 hypersensitive

Participants reported feeling as though they were ‘walking on eggshells’ as their relative would respond volatilely to perceived attacks. For instance, “She cannot take advice or criticism from others and becomes very defensive and abusive if challenged” (#1485); “It was an endless mine field of eggshells. A word, an expression would be taken against me” (#532) and “Very irrational and volatile. Anything can set her off on a rage especially if she doesn’t get her way” (#822).

Node #6 insecurity

Relatives were described as having an underlying sense of insecurity or vulnerability. For instance “He really is just a scared little kid inside of a big strong man’s body. He got stuck when he was a child” (#1481); “At the core he feels unworthy, like a fake and so pretty much all introspection and self-growth is avoided at all costs” (#532) and “At night when the business clothes come off his fears eat him up and he would feel highly vulnerable and needs lots of reassurance” (#699).

Node #7 rage

Participants reported that their relatives were particularly prone to displaying explosive bouts of uncontrolled rage. For example, “He has a very fragile ego … he will fly off the handle and subject his target to hours of screaming, insults and tantrum-throwing” (#1078); “he has a temper tantrum-like rage that is frightening and dangerous” (#1476); “He has hit me once. Left bruises on upper arms and back. He goes into rage and has hit walls, hits himself” (#1637).

Node #8 affective instability (symptom patterns)

Relatives were also described as displaying affective instability which may be related to anxiety and depressive disorders. Relatives were commonly described as being ‘anxious’ (#1091) including instances of hypochondria (#1525), agoraphobia (#756), panic (#699) and obsessive compulsive disorder (#2125). Relatives were also commonly described as having episodes of ‘depression’ (#1106) and depressive symptoms such as low mood (#1931), problems sleeping (#1372). Some participants also described their relative as highly suicidal, with suicidality being linked to relationship breakdowns or threats to self-image. For example, “When I state I can’t take any more or say we can’t be together … he threatens to kill himself” (#1798); “If he feels he is being criticised or blamed for something (real or imagined) … his attacks become self-destructive” (#1800).

Node #9 victim mentality

Participants reported that their relatives often described feeling as though they were the victim of attacks from others or taken advantage of in some way. For instance, “He seems to think that he has been ‘hard done by’ because after all he does for everyone, they don’t appreciate him as much as they should” (#1476); “He will fabricate or twist things that are said so that he is either the hero or the victim in a situation” (#447).

Other personality features

Participants also reported some descriptions of their relative that were not described within prior conceptualisations of narcissism. This theme was made up of 3 nodes: ‘Perfectionism’, ‘Vengeful’ and ‘Suspicious’.

Node #1 perfectionism

Participants repeatedly described their relative displaying perfectionistic or unrelenting high standards for others. For instance, “I cannot just do anything at home everything I do is not to her standard and perfection ” (#1586) and “Everything has to be done her way or it’s wrong and she will put you down. She has complete control over everything” (#1101).

Node #2 vengeful

Participants described their relative as being highly motivated by revenge and displaying vindictive punishing behaviours against others. Examples include, “[He] has expressed thoughts of wanting to hurt those who cause him problems” (#230); “He is degrading to and about anyone who doesn’t agree with him and he is very vengeful to those who refuse to conform to his desires” (#600) and “Once someone crosses him or he doesn’t get his way, he becomes vindictive and will destroy their life and property and may become physically abusive” (#707).

Node #3 suspicious

Participants described their relative as holding paranoid or suspicious beliefs about others intentions or behaviours. For instance, “He would start fights in public places with people because he would claim they were ‘looking at him and mimicking him’” (#1149) and “She is angry most days, obsessively talking about who wronged her in the past, currently or who probably will in the future” (#2116).

Descriptive themes

Several salient descriptive themes were also coded from the data that, while not relating directly to the relatives character, may provide peripheral or contextual information.

Descriptive theme #1: trauma

A number of participants described their relative as having experienced a traumatic or troubled childhood. One participant stated that their relatives’ father “was extraordinarily abusive both emotionally and physically to both him and the mother … [the father] pushed [the relative] as a young boy on prostitutes as a 12th birthday gift … He was beaten on and off from age 6 to 15 when he got tall enough to threaten back” (#1249). Another participant described the emotional upbringing of their relative “[his mother was] prone to being easily offended, fighting with him and cutting off all contact except to tell him what a rotten son he was, for months, then suddenly talking again to him as if nothing had ever happened. His father, he said, was strict and expected a lot of him. Both rarely praised him; whenever he accomplished something they would just demand better instead of congratulating him on his accomplishment” (#1909). Another participant reflected on how their relative’s upbringing may be related to their current emotional functioning, “personally I think he is so wounded (emotional, physical abuse and neglect) that he had to detach from himself and others so much just to survive” (#1640).

Descriptive theme #2: excessive religiosity

While participant’s comments on their relative’s religiosity were common, the content was varied. Some participants described their relative using religion as a mechanism to control, for instance “he uses religion in an extremely malignant way. Manipulating verses and religious sayings and interpret them according to his own will” (#132) and “very religious. She uses scripture to manipulate people into doing what she wants on a regular basis” (#1700). One participant described how their relative’s religiosity became infused with their grandiose fantasy “He has also gone completely sideways into fundamental religious doctrine, as if he knows more than the average ‘Christian’ about End Times, and all kinds of illuminati type conspiracy around that topic. He says God talks to him directly and tells him things and that he has had dead people talk to him” (#1476). Other participants described how their relative’s religiosity was merely an aspect of their ‘false self’, for example “she has a wonderful, loving, spiritual facade that she shows to the world” (#1073).

Descriptive theme #3: substance use

Participants regularly described their relative as engaging in substance use. Substances most frequently named were alcohol, marijuana, cocaine and ‘pills’. Participants reported that when their relative was using substances their behaviour often became dangerous, usually through drink driving, one participant stated “too much alcohol … he would drive back to [his work] … I was always afraid of [a driving accident]” (#76).

Subtype expression

Of 436 participants, a total of 348 unique grandiose node expressions were present and a total of 374 unique vulnerable node expressions were present. Of these, 301 participants included both grandiose and vulnerable descriptions of their relative (69% of sample). Only 47 (11% of sample) focused on grandiose features in their description of their relative, and only 88 participants (20% of sample) focused on vulnerable features.

A cluster analysis dendrogram was generated using Nvivo 11 for purposes of visualising and exploring the underlying dimensions of the data [ 48 ] and is displayed in Fig.  1 . Four clusters of nodes and one standalone node can be distinguished. The first cluster, labelled ‘Fantasy Proneness’, includes nodes reflecting the predominance of ‘fantasy’ colouring an individuals interactions, either intrapersonally (‘grandiose self-importance, belief in specialness’) or interpersonally (‘suspicious, envy’). The second cluster, labelled ‘Negative Other’, reflects nodes concerned with a detached connection with others (‘emotionally empty’) and fostering ‘vengeful’ and ‘exploitative’ drives towards others, as well as feelings of victimhood. Interestingly, despite being related to these other aspects of narcissism, ‘perfectionism’ was factored as reflecting its own cluster, labelled ‘Controlling’. The fourth cluster, labelled ‘Fragile Self’, includes nodes indicating feelings of vulnerability (‘affective instability’, ‘insecurity’) and shameful avoidance (‘hiding the self’, ‘false self’, ‘withdrawal’) due to these painful states. The fifth cluster, labelled ‘Grandiose’ reflects a need (‘contingent self-esteem’, ‘requiring admiration’) or expectation (‘entitlement’, ‘arrogance’) of receiving a certain level of treatment from others. It also includes nodes regarding how individuals foster this treatment (‘charming’, ‘rage’, and ‘devaluing’) and a hypervigilance for if their expectations are being met (‘hypersensitive’).

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Cluster analysis of nodes based on coding similarity. Note. Clusters are labelled as follows: 1. Fantasy Proneness, 2. Negative Other, 3. Controlling, 4. Fragile Self, 5. Grandiose

This study aimed to qualitatively describe the interpersonal features of individuals with traits of pathological narcissism from the perspective of those in a close relationship with them.

Grandiose narcissism

We found many grandiose features that have been validated through empirical research [ 2 , 3 , 19 ]. Grandiosity, as reflected in the DSM-5, has been argued to be a key feature of pathological narcissism that distinguishes it from other disorders [ 26 , 28 ]. One feature regularly endorsed by participants that is not encompassed in DSM-5 criteria is relatives’ level of interpersonal charm and likability. This charm as described by participants appears more adaptive than a ‘superficial charm’ that might be more exclusively ‘interpersonally exploitative’ in nature. However, it should be noted that this charm did not appear to persist, and was most often described as occurring mainly in the initial stages of a relationship or under specific circumstances (e.g. in public with an audience).

Vulnerable narcissism

We also found participants described their relative in ways consistent with the vulnerable dimensions of the pathological narcissism inventory (i.e. hiding the self, contingent self esteem and devaluing [ 50 ];). Dimensions that are also included in other popular measures for vulnerable narcissism were also endorsed by participants in our sample. For instance, the nodes of ‘hypersensitivity’, ‘insecurity’ and ‘affective instability’ reflect dimensions covered in the Hypersensitive Narcissism Scale [ 51 ] and neuroticism within the Five Factor Narcissism Inventory [ 52 ]. These aspects of narcissism have also been documented within published literature [ 12 , 27 , 53 , 54 ].

Subtype expression: cluster analysis

Most participants (69% of sample) described both grandiose and vulnerable characteristics in their relative, which given the relatively small amount of text and node expressions provided per participant is particularly salient. Given the nature of the relationship types typically endorsed by participants (i.e. romantic partner, family member), it suggests that the degree of observational data on their relative is quite high. As such, these results support the notion that an individual’s narcissism presentation may fluctuate over time [ 20 , 21 ] and that vulnerable and grandiose presentations are inter-related and oscillating [ 9 , 19 ].

The cluster analysis indicates the degree to which salient co-occurring features were coded. These features can be grouped to resemble narcissistic subtypes as described in research literature, such as the subtypes outlined by Russ, Shedler [ 55 ] in their Q-Factor Analysis of SWAP-II Descriptions of Patients with Narcissistic Personality Disorder. Our clusters #1–3 (‘Fantasy Proneness’, ‘Negative Other’ and ‘Controlling’) appear to resemble the ‘Grandiose/malignant narcissist’ subtype as described by the authors. This subtype includes instances of self-importance, entitlement, lack of empathy, feelings of victimisation, exploitativeness, a tendency to be controlling and grudge holding. Our cluster #4–5 (‘Fragile Self’ and ‘Grandiose’) appear to resemble the ‘Fragile narcissist’ subtype described including instances of depressed mood, internal emptiness, lack of relationships, entitlement, anger or hostility towards others and hypersensitivity towards criticism. Finally, our ‘Grandiose’ cluster (#5) showed overlap with the ‘high functioning/exhibitionistic narcissist’ subtype, which displays entitled self-importance but also a significant degree of interpersonal effectiveness. We found descriptions of the relative showing ‘entitlement’, being ‘charming’ and ‘requiring admiration’.

While co-occurring grandiose and vulnerable features are described at all levels of clusters in our sample, distinctions between the observed clusters may be best understood as variations in level of functioning, insight and adaptiveness of defences. As such, pathological narcissism has been understood as a characterological way of understanding the self and others in which feelings of vulnerability are defended against through grandiosity [ 56 ], and threats to grandiosity trigger dysregulating and disintegrating feelings of vulnerability [ 53 ]. Recent research supports this defensive function of grandiosity, with Kaufman, Weiss [ 11 ] stating “ grandiose narcissism was less consistently and strongly related to psychopathology … and even showed positive correlations with adaptive coping, life satisfaction and image-distorting defense mechanisms ” (p. 18). Similarly, Hörz-Sagstetter, Diamond [ 28 ] state ‘high levels of grandiosity may have a stabilizing function’ on psychopathology (p. 569). This defence, however, comes at a high cost, whether it be to the self when the defensive grandiosity fails (triggering disintegrating bouts of vulnerability) or to others, as this style of relating exacts a high toll on those in interpersonal relationships [ 33 ].

Participants described their relative as highly perfectionistic, however the perfectionism described was less anxiously self-critical and more ‘other oriented’. This style of other oriented ‘narcissistic perfectionism’ has been documented by others [ 57 ] and appears not to have the hallmarks of overt shameful self-criticism at a surface level, however may still exist in covert form [ 58 ]. Regarding the ‘vengeful’ node, Kernberg [ 16 ], Kernberg [ 59 ] describes that as a result of a pain-rage-hatred cycle, justification of revenge against the frustrating object is an almost unavoidable consequence. Extreme expressions of acting out these “ego-syntonic” revenge fantasies may also highlight the presence of an extreme form of pathological narcissism in this sample – malignant narcissism, which involves the presence of a narcissistic personality with prominent paranoia and antisocial features [ 60 ]. Lastly, Joiner, Petty [ 61 ] report that depressive symptoms in narcissistic personalities may evoke paranoid attitudes, which may in turn be demonstrated in the behaviours and attitudes expressed in the ‘suspicious’ node we found.

While this study focused on a narcissistic presentation, the presence in this sample of these other personality features (which could alternatively be described as ‘anankastic’, ‘antisocial’ and ‘paranoid’) is informed by the current conversation regarding dimensional versus categorical approaches [ 62 , 63 ]. Personality dysfunction from a dimensional perspective, such as in the ‘borderline personality organisation’ [ 23 ] or borderline ‘pattern’ [ 64 ] could understand these co-occurring personality features as not necessarily aspects of narcissism or ‘co-morbidities’, but as an individual’s varied pattern of responding that exists alongside their more narcissistic functioning, reflecting a more general level of disorganisation that resists categorisation. This is particularly reflected in Table ​ Table2 2 as participants reported a wide variety of diagnosed conditions, as well as the ‘Affective Instability’ node which may reflect various diagnostic symptom patterns.

Descriptive features

The relationship between trauma and narcissism has been documented [ 58 , 65 – 67 ] and the term ‘trauma-associated narcissistic symptoms’ has been proposed to identify such features [ 68 ]. Interestingly, while participants in our sample did describe instances of overt abuse which were traumatic to their relative (e.g. physical, verbal, sexual), participants also described hostile environments in which maltreatment was emotionally abusive or manipulative in nature, as well as situations where there was no overt traumatic abuse present but which most closely resemble ‘traumatic empathic failures’. This type of attachment trauma, stemming from emotionally invalidating environments, is central to Kohut’s theory of narcissistic development [ 69 , 70 ], and has found support in recent research [ 71 ]. Relatives religiosity was noteworthy, not necessarily due to its presence, but due to the narcissistic function that the religiosity served. Research on narcissism and religious spirituality has steadily accumulated over the years (for a review see: [ 72 ]) and the term ‘spiritual bypassing’ [ 73 ] is used for individuals who use religion in the service of a narcissistic defence. In our sample this occurred via alignment with an ‘ultimate authority’ in order to bolter esteem and control needs. It may be that the construction of a ‘false self’ rooted in spirituality is conferred by the praise and audience of a community of believers. Finally, participants reported their relative as engaging in various forms of substance use, consistent with prevalence data indicating high co-occurrence of narcissism and substance use [ 65 ]. While the motivation behind relatives substance use was not mentioned by participants, it is consistent with relatives more general use of reality distorting defences, albeit a more physicalised as opposed to an intrapsychic method.

Implications of findings

First, this study extends and supports the widespread acknowledged limitation of DSM-5 criteria for narcissistic personality disorder regarding the exclusion of vulnerable features (for a review of changes to dignostic criteria over time, see [ 74 , 75 ]) and we acknowledge the current discussion regarding therapist decision to provide a diagnosis of NPD [ 76 ]. However, the proliferation of alternate diagnostic labels may inform conceptualisations which do not account for the full panorama of an individual’s identity [ 7 ], adding to the already contradictory and unintegrated self-experience for individuals with a narcissistic personality. This may also impede the treatment process by informing technical interventions which may be contra-indicated. For instance, treatment of individuals with depressive disorders require different approaches than individuals with a vulnerably narcissistic presentation [ 24 , 77 ]. As such, a focus of treatment would include the integration of these disparate self-experiences, through the exploration of an individual’s affect, identity and relationships, consistent with the treatment of personality disorders more generally. Specifically, when working with an individual with a narcissistic personality, this may involve identifying and clarifying instances of intense affect, such as aggression and envy, themes of grandiosity and vulnerability in the self-concept, and patterns of idealization and devaluation in the wider relationships. The clinician will need to clarify, confront or interpret to these themes and patterns, their contradictory nature as extreme polarities, and attend to the oscillation or role reversals as they appear [ 78 ]. Second, as the characterological themes identified in this paper emerged within the context of interpersonal relationships, this highlights the interconnection between impaired self and other functioning. As such, in the context of treating an individual with pathological narcissism, discussing their interpersonal relationships may be a meaningful avenue for exploring their related difficulties with identity and emotion regulation that may otherwise be difficult to access. This is particularly salient as treatment dropout is particularly high for individuals with pathological narcissism [ 4 ], and as typical reason for attending treatment is for interpersonal difficulties [ 79 ]. Third, treatment for individuals with narcissistic personalities can inspire intense countertransference responses in clinicians [ 80 ] and often result in stigmatisation [ 81 ]. As such, these findings also provide a meaningful way for the clinician to extend empathy to these clients as they reflect on the defensive nature of the grandiose presentation, the distressing internal emptiness and insecurity for these individuals, and the potential childhood environment of emotional, sexual or physical trauma and neglect which may have informed this defensive self-organisation. Finally, these findings would also directly apply to clinicians and couples counsellors working with individuals who identify their relative as having significant narcissistic traits, providing them with a way to understand the common ways these difficulties express themselves in their relationships and the impact they may have on the individuals in the relationship. Practically, these findings may inform a heightened need for treating clinicians to assess for interpersonal violence and the safety of clients in a context of potential affective dysregulation and intense aggression. Regarding technical interventions, if working with only one of the individuals in the relationship, these findings may provide avenues for psychoeducation regarding their relatives difficulties with identity and affect regulation, helping them understand the observed oscillating and contradictory self-states of their relative. If working with both individuals or the couple, the treating clinician will need to be able to identify and interpret changes in affect and identity, and the way this manifest in the relationship functioning of the couple and their characteristic ways of responding to each other (e.g. patterns of idealization and devaluation). This may also involve attending to the ways in which the therapist may be drawn into the relationship with the couple, noticing and interpreting efforts at triangulation or any pressure to ‘pick sides’ from either individual.

Limitations

The sample selection procedure may have led to results only being true for some, but not all people living with a relative with narcissistic features. Participants were recruited online limiting the opportunity to understand participant motivation. Second, relying on informant ratings of narcissism for both screening and qualitative analysis is a limitation as we are less unable to control for severity, specificity or accuracy of participant reporting. Further, it is possible that the use of a narcissism screening tool primed participants to artificially report on particular aspects of their relative. However, the risk of biasing or priming participants is a limitation of all studies of this kind, as studies implementing informant methodology for assessing narcissism typically rely on providing participants with a set of diagnostic criteria or narcissism specific measures as their sole indicator of narcissism (e.g. [ 30 , 38 ]). As such, notwithstanding the limitations outlined, this informs the novelty and potential utility of the present approach which relies on identifying narcissism specific features amongst a backdrop of descriptions of more general functioning within intimate relationships. Third, gender disparity in participants and relatives was substantial. However, as NPD is diagnosed more commonly in males (50–75%, American Psychiatric Association, 2013) and as most participants in our sample were in a romantic, heterosexual relationship, this disparity may reflect a representative NPD sample and should not significantly affect the validity of results. Rather, this disparity may strengthen the argument that individuals with a diagnosis of NPD (as specified by DSM-5 criteria) may have co-occurring vulnerable features, which may not be currently reflected in diagnostic categories. Finally, as a result of relying on informant ratings and not assessing narcissistic individuals via structured clinical interview, questions regarding the specificity and severity of the narcissistic sample are unable to be separated in the analysis. We thus probably studied those ranging from ‘adaptive’ or high functioning narcissism [ 82 ] to more severe and disabling character disorders. Whilst we screened for narcissistic features, it was clear the sample studied also reported a broad range of other co-occurring problems.

We investigated the characteristics of individuals with pathologically narcissistic traits from the perspective of those in a significant personal relationship with them. The overarching theme of ‘Grandiosity’ involved participants describing their relative as requiring admiration, displaying arrogant, entitled, envious and exploitative behaviours, engaging in grandiose fantasy, lacking in empathy, having a grandiose sense of self-importance, believing in own sense of ‘specialness’ and being interpersonally charming. The overarching theme of ‘Vulnerability’ involved participants describing their relative’s self-esteem being contingent on others, as being hypersensitive, insecure, displaying affective instability, feelings of emptiness and rage, devaluing self and others, hiding the self through various means and viewing the self as a victim. Relatives were also described as displaying perfectionistic, vengeful and suspicious personality features. Finally, participants also described several descriptive themes, these included the relative having a trauma history, religiosity in the relative and the relative engaging in substance use. The vulnerability themes point to the problems in the relatives sense of self, whilst the grandiose themes show how these express themselves interpersonally. The complexity of interpersonal dysfunction displayed here also points to the importance of assessing all personality traits more broadly.

Acknowledgements

Not applicable.

Authors’ contributions

ND contributed in conceptualisation, design, coordination, data collection, analysis, interpretation and writing of the manuscript. MT contributed in data collection, analysis, interpretation and writing of manuscript. BG contributed in conceptualisation, design, coordination, interpretation and writing of manuscript. All authors read and approved the final manuscript.

ND has received a scholarship relating to this project. Project Air Strategy acknowledges the support of the NSW Ministry of Health.

Availability of data and materials

Ethics approval and consent to participate.

University of Wollongong Institutional Review Board approval was received from the University of Wollongong Human Research Ethics Committee (16/079). All participants provided informed consent to participation.

Consent for publication

Competing interests.

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Nicholas J. S. Day, Email: ua.ude.wou@yadn .

Michelle L. Townsend, Email: ua.ude.wou@nesnwotm .

Brin F. S. Grenyer, Email: ua.ude.wou@reynerg .

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6.124: Histrionic Personality Disorder

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Name : Michael Scott Source : The Office (American television show, 2005-2011)

Background Information

Michael Scott is a forty-six year old Caucasian male from Scranton, Pennsylvania. Scott is the regional manager at Dunder Mifflin Inc., a local paper and printer distribution company, where he has worked for the last fifteen years. There are no known medical conditions held by Scott, though his family history is unknown. He claims to be of English, Irish, German, Scottish, and Native American descent, though this is unconfirmed, and perhaps an exaggeration. The patient’s outward appearance is well put together, as he presents as a business professional, and there are no obvious health concerns. Despite his seemingly composed demeanor, Scott displays exaggerated emotions and reactions. In addition to this, romantic relationships have proven turbulent for Scott throughout his life, as he goes from one relationship to the next with the other person usually being the one to end it. He has few close friends or relatives, and tends to perceive new friendships as closer than they actually are. Scott believes his subordinates to be his family, and often times gets involved in their personal lives without their consent. His parents divorced when he was young (age unknown), and he displays clear resentment towards his stepfather and sister, whom he once didn’t talk to for fifteen years. Scott has a very close relationship with his mother now, though this was not case when he was a child. Though Scott seems to be lacking in managerial style, responsibility, and delegation, he demonstrates above average sales abilities due to his personable qualities. Scott does not have a history of drug or alcohol abuse, though he will drink in social situations and when pressured to do so by coworkers.

Description of the Problem

The patient demonstrates many personality traits that could be indicative of a variety of disorders. Scott seeks attention every opportunity he gets, and this often interferes with his ability to function in his job as manager. In addition to attention-seeking, Scott often interrupts his subordinates from working to discuss his personal life. This behavior not only affects his ability to work, but it interferes with the overall productivity of the office. It is Scott’s belief that he should not be seen as just a boss, but more of a close friend and even family member, to the dismay of his subordinates. This expectation of a close bond leads Scott to display rapidly shifting emotions, from exuberant and hopeful, to depressed and hopeless. There seems to be a lack of consistency in his behavior, rather a dramatic shift from extremely happy to irreversibly sad. In Scott’s depressed state, he feels as if the entire office should be focused on his problem and that others’ problems pale in comparison, such as his birthday being of more importance than a coworkers cancer scare. When he is happy, however, work at the office ceases to a halt, as his well-being is put before the needs of the company. In addition to his attention-seeking and rapidly shifting emotions, the patient is easily suggestible and is often the victim of pyramid schemes and persuasive coworkers. Scott also shows a pattern of theatric behavior, including different characters, voices, and personalities, in which he uses as distractions on a constant basis.

The diagnosis that seems to fit most appropriately for Scott is Histrionic Personality Disorder (301.50) .

To qualify for a diagnosis of Histrionic Personality Disorder, a person must display the following general criteria of a Personality Disorder:

A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:

1. Cognition (I.e., ways of perceiving and interpreting self, other people, and events) 2. Affectivity (I.e., the range, intensity, and appropriateness of emotional response) 3. Interpersonal functioning 4. Impulse Control Mr. Scott displays dysfunctions in many, if not all, of the above categories. His thoughts are consumed by his thinking that he is a comedian, consistently referring to his improv classes and impersonations. The affectivity displayed by the patient is continuously out of proportion to the situation, such as halting the workday for an office meeting over a minor problem, oftentimes a non-work related problem. His interpersonal and relationship functioning is severely limited, demonstrated by his lack insight into the true feelings (I.e. distain) of the people in his life. His impulse control is lacking, if not nonexistent. B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. The displayed symptoms cause, and have caused, significant distress in the areas of work relationships, friendships, and romantic relationships. The observed behavior also has negative consequences in many aspects of his life, including resentment and distain from coworkers, as well as from his superiors and romantic partners. C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. The inflexible nature of his symptoms clearly affects his ability to function in his day-to-day tasks. His ability to function is severely impacted by his need for attention, as he demonstrates a lack of motivation and productiveness in his occupation and social life. This enduring pattern has also led to resentment from his subordinates, who believe he is incompetent due to his emotional outbursts. D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood. Scott’s symptoms have been present for at least six years, though they seem to have been present during his entire employment at Dunder Mifflin, and are pervasive in both his work and personal life. The symptoms can be traced back to his early adulthood, as demonstrated by his lack of friendships and romantic relationships in the past. The symptoms may also be a result of early childhood experiences, as he lacked a father-figure and his mother seemingly neglected him.

E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder. Although the patient demonstrates some characteristics consistent with Narcissistic Personality Disorder, he is too suggestible to fit this criteria. As those with Narcissistic PD are interpersonally exploitative, Scott demonstrates a need for immediate attention as opposed to a need for future success. Neither mood, psychotic, nor anxiety disorders better account for his symptoms.

F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma). The presenting symptoms are not the result of drugs, alcohol or head trauma.

To fit the Diagnostic Criteria for 301.50 Histrionic Type, at least five (or more) of the following criteria must be met:

1. Uncomfortable in situations in which they are not the center of attention In many instances, such as making a coworkers wedding all about him, caring more about his superficial wound than an employee with a concussion, holding impromptu meetings to discuss his personal life, or dozens of other examples, Scott demands the attention be on him and only him. Typically in a situation in which he is not the center of attention, Scott is visibly uncomfortable and can barely sit still. 2. Interaction with others are often characterized by inappropriate sexually seductive or provocative behavior Although Scott does not demonstrate sexually seductive behavior, he exhibits provocative behavior on a regular basis by use of inappropriate jokes or sexual advances on coworkers. 3. Displays rapid shifting and shallow expressions of emotions Scott goes from angry, to upset, to jealous, to happy, to ecstatic very rapidly, and displays a pattern of shallow emotions. For instance, after hitting a coworker with his car, the patient displayed little remorse or genuine emotion. 4. Consistently uses physical appearance to draw attention to self 5. Has a style of speech that is excessively impressionistic and lacking in detail 6. Shows self-dramatization, theatricality, and exaggerated expression of emotion After a superficial wound, the patient exaggerated the symptoms for the entire day, demanding the focus of that workday be on his recovery. Scott also demonstrates theatricality through use of characters, voices, and impromptu presentations. 7. Is suggestible, I.e., easily influenced by others or circumstances Scott is highly suggestible, and has been observed to lose substantial amounts of money in pyramid schemes due to his trusting nature and easily influenced personality. The patient is so suggestible that he has participated in highly risky behaviors, such as placing his face in drying cement, from pressure from those around him. 8. Considers relationships more intimate than they actually are In many aspects of his life, the patient demonstrates a destructive attachment style, oftentimes believing those around him are closer to him than they actually are. Scott believes the office staff to be his family, and considers a temporary employee to be his best friend after only one day of knowing him. As with his friendships, Scott’s personal relationships suffer from the same overzealous attitude. While once dating a woman, Scott placed his own photo over the photo of her ex-husband, while also proposing to her after three dates.

Accuracy of portrayal

To those watching The Office, the portrayal of Michael Scott as a person with Histrionic Personality Disorder is quite good, though those with the disorder are more often females than males. Those with Histrionic Personality Disorder are known to use their body as a seductive tool, and Scott’s portrayal lacks this important quality of the disorder. However, due to the differing presentation of Histrionic Personality Disorder between men and women, this trait may be unnecessary for the diagnosis. The sudden change of emotion is quite accurately portrayed, as well as the attention-seeking behavior patterns. As symptom expression is accurately portrayed, so too is the onset of symptoms. Histrionic PD is expressed most often in a person’s early adult years, and those with the disorder typically come from a family history of neglect or lack of attention from the primary caregiver during pivotal developmental years. For this reason, the attention-seeking and self-centered behavior tends to manifest later in life as a result of the early experience. This symptom is accurately portrayed in the show as well. Overall, the portrayal of Michael Scott as a person with Histrionic Personality Disorder is accurate in many ways.

The best course of treatment for Scott would be therapy. Cognitive-behavioral therapy would be beneficial in a similar way by helping him to cope with his emotional outbursts. CBT would provide Scott tools for controlling his behavior in a more systematic and structured way to be able to function more productively in the workplace. In addition to systematic planning, it is recommended that Scott be given assertiveness training to help with his propensity for taking advice from others. Behavioral rehearsals may aid in his workplace manner and help him to establish appropriate workplace behaviors. Although family counseling is not an option, it is recommended that Scott participate in relationship counseling to help establish a long-lasting, stable relationship.

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Name : Regina George

Source : Mean Girls (movie, 2004)

Regina George is a sixteen year old Caucasian female. She is a junior in high school at North Shore High School. Regina comes from a very wealthy family and does not have a job besides attending school. She is presumed to be in good health since the film did not mention any health conditions. Regina George is considered the ring leader of the meanest girl clique at North Shore High. She is the queen bee of the popular girls group that pride themselves on making each other look as hot as possible while they put others down in the process.

As previously mentioned Regina comes from a very affluent family. They live in a beautiful mansion considered to be the biggest and most lavish house out of any of the ‘mean girl clique’. Regina’s relationship with her parents is very twisted and abnormal. One example of this backward relationship is displayed when Regina brings her friends over and her mom insists on inserting herself into Regina and her friend’s conversations. Not only does her mom think of her as her best friend but her parents allowed her take the master bedroom simply because she desired it. Regina does not have a strong relationship with either parent but drifts more toward her mother.

Regina George has a preoccupation with her looks. She is constantly talking about how she is either too fat or that she is not pretty enough and also seeks confirmation about her body and looks through others. She does not have a regular drinking problem or drug abuse issue since she is so preoccupied with her appearance and that would definitely tarnish her ideal reputation. Her obsession with her appearance would have to be one of her biggest weaknesses. With regard to her weight, she is constantly seeking new and unsearched ways of losing weight.

This patient displays many of the traits associated with a number of personality disorders, but most strongly shows symptoms of Histrionic Personality Disorder. Regina George is an attention junkie. She seeks out attention from people in every aspect of her daily life. This hunger for attention has created tension between Regina and her group of friends. Her need for attention impairs her abilities to function inside the classroom, hindering her performance in school. Regina often wears seductive clothing that most girls and women would not walk out the front door in, let alone wear to school. Another way Regina actively seeks attention is by talking about people behind their backs. In a three way phone call, she deliberately tries to sabotage one of her close friend’s relationships with another close friend of hers. This attack displays her need to be needed. She felt threatened by their relationship so the only means of coping with the problem to her was by pinning two of her friends against each other. When Regina has a problem, the only way she knows to resolve it is by making someone else feel inferior. Along with these distorted coping skills, Regina displays extreme variances in her emotions. When she is happy she is through the moon happy and when she is mad she is definitely going to let someone know about it. When Regina has a problem going on in her life, she thinks that every single one of her friends must stop what they are doing and solve the problem with or for her. One example of this is shown when Regina is eating lunch, wants something else to eat, and then she says that she is really trying to lose five pounds. She is flabbergasted when the rest of the clique does not immediately pipe in to say that she is already flawless.

The diagnosis that seems to fit most appropriately for Regina George is Histrionic Personality Disorder (301.50). To qualify for a diagnosis of Histrionic Personality Disorder, a person must display the following general criteria of a Personality Disorder:

  • Cognition (I.e., ways of perceiving and interpreting self, other people, and events)
  • Affectivity (I.e., the range, intensity, and appropriateness of emotional response)
  • Interpersonal functioning
  • Impulse Control

Regina George has shown impairments through all of these conditions. She has shown that all that consumes her thoughts is the obsession she has with her appearance and the appearance of others. Her displayed affectivity is most often over exaggerated to the situation. Most notable was her reaction to her “friend” not inviting her to her house party: she single handedly brought the entire student body to a crippling halt by sharing a “burn book” with them. This book contained pictures and captions (written by Regina herself) about different people in their school. The pictures were not the most flattering and the captions were mean spirited and hurtful to say the least.

B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.

Her symptoms have caused her significant turmoil in her relationships at home, school, and in her daily life. Her behavior has caused many issues in all aspects of her life, such as with friends turning against her, her family not being very supportive and the entire student body rallying against her.

C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Regina’s apparent inflexible nature has caused tremendous impairment among her social life as well as her occupational or school life. Regina’s preoccupation with her outward appearance has left her little if any time to focus on things that really matter to people such as her character and demeanor towards others.

D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.

The behaviors that Regina displays in the movie Mean Girls has been going on her entire life, per her mother’s report. She has been the same appearance obsessed girl since she was born. This pattern of attention seeking, mean behavior escalated in middle school when she made up a rumor about a girl being a lesbian in the eighth grade.

E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.

This patient does display some of the characteristics of a person with narcissistic personality disorder and perhaps even some dependent PD characteristics, but the disorder that Regina displays through the entire movie is HPD.

F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma).

The symptoms are not as a result of drugs, alcohol, or any general medical condition.

  • Uncomfortable in situations in which they are not the center of attention

Regina George is not only uncomfortable in situations in which she is not the center of attention but she most notably does not allow herself to be in a situation where she is not the center of attention. When a new girl starts going to North Shore, and the girl is as pretty as or prettier than her, Regina makes a consorted effort to make that girl her new best friend forever.

  • Interaction with others are often characterized by inappropriate sexually seductive or provocative behavior

Regina definitely displays this behavior in every aspect of her life. She cannot even sing in the Christmas talent show without being in a midriff tube top shirt with a matching much too short skirt.

  • Displays rapid shifting and shallow expressions of emotions

Regina has an extremely wide range of shallow emotions. For example when she is confronted with an old friend (the one she spread the lesbian rumor about) she shrugs it off as if it never happened. Her ability to show no remorse and be so nonchalant about something that destroyed a young impressionable human being show her shallow expression of emotion.

  • Consistently uses physical appearance to draw attention to self

She uses her body, her beauty, and her weight to keep people focused on herself. When someone tries to shift the conversation she always finds a way to get the attention back on herself.

  • Has a style of speech that is excessively impressionistic and lacking in detail

Regina has an immature speaking style. When talking in the cafeteria she uses many words that are not even words such as ‘skeeze’ to describe other students.

  • Shows self-dramatization, theatricality, and exaggerated expression of emotion

In regard to her constant obsession with her weight, Regina has all of her friends focus on the things that she should be doing on her own to lose the weight. When Regina goes to a dress shop to be fitted for her prom dress and finds that she cannot fit the one she wants she has a tyrannical outburst.

  • Is suggestible, I.e., easily influenced by others or circumstances

Regina is highly suggestible especially since she does not focus on the facts. She is a person who will take a person for their word. When one of her friends tries to help her with a “weight-loss” bar she takes it without question. She is shocked to later find out that the bars she has been eating for the past few months has been the sole contributor to her slow but steady weight gain.

  • Considers relationships more intimate than they actually are

Accuracy of Portrayal

To the average person watching the movie Mean Girls , Regina George would seem like the typical high school bitch. She is popular, pretty, and, most of all, rich. To most laypeople they would not think to make the connection that she has histrionic personality disorder even though she does a phenomenal job portraying an individual with this disorder. Regina displays the symptom most commonly associated with having histrionic personality disorder, those being sexually seductive behaviors. Regina is sexually seductive in appropriate times such as high school girls and Halloween but most notably she is seductive at times when it is completely inappropriate. Her extreme variances and range of shallow emotions are another key symptom of histrionic personality disorder. The fact that Regina is unhappy and uncomfortable with not being the center of attention is another symptom of histrionic personality disorder. The portrayal of Regina George in the movie Mean Girls is an accurate portrayal a person living with histrionic personality disorder.

The best treatment for histrionic personality disorder is through therapy. The most effective therapy treatment would be Cognitive Behavioral Therapy. Cognitive Behavioral Therapy would help Regina to be able to control her emotionality better as well as give her some tools to cope with life in a more adaptive way. Regina would benefit from CBT in that it would help her in her interpersonal relationships to be better able to make and maintain friendships.

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