I can be smooth and charming and slick. I
can make a very confident impression and it's hard to leave me at a loss for words. Sometimes I find myself fantasizing about
unlimited success and power, and beauty. I have repeatedly used deceit to cheat, con,
or defraud others for my personal gain. To be honest, I don't have much concern for the
feelings of other people, or their suffering. Doesn't sound like the Hank you know, does
it? These are all statements from the Self-Assessment
measure for Personality Disorders, that lets patients describe themselves, ranking each statement
in terms of how accurate they think it is. To be honest, you can't rely too much on this
kind of self-reporting to assess what we are talking about today because while some people
who are over-confident or obsessed with power or downright deceitful might tell you that
they are, there is a certain subset that won't. Many of the disorders that we have talked
about so far are considered, "ego-dystonic" meaning that people who have them are aware
that they have a problem and tend to be distressed by their symptoms. Like a person with Bipolar Disorder or OCD
generally knows that they have a psychological condition and they don't like what it does
to them. But some disorders are trickier then that.
They are "ego-syntonic," the person experiencing them doesn't necessarily think that they have
a problem and sometimes, they think the problem is with everyone else. Personality disorders fall into this category.
These are psychological disorders marked by inflexible, disruptive, and enduring behavior
patterns that impair social and other functioning -- whether the sufferer recognizes that or not. Unlike many other conditions that we've talked
about, personality disorders are often considered to be chronic and enduring syndromes that
create noticeable problems in life. And as you can tell from these self assessment
statements, they can range from relatively harmless displays of narcissism, to a true
and troubling lack of empathy for other people. Not only can personality disorders be difficult
to diagnose and understand, they can also be downright scary. Most of the extreme and
severe disorders go by names that you probably recognize: psychopathy and sociopathy. I'm talking,
like, serial killers here, mob bosses, Vlad the Impaler. Cultures have been studying human personality
characteristics for thousands of years, but the concept of personality disorders is a
much newer idea. Much of our modern classifications of these
disorders are based on the work of German psychiatrist, Kurt Schneider, who was one
of the earliest researchers into what was then known as psychopathy and published a
treatise on the study in 1923. Today, the DSM 5 contains ten distinct personality
disorder diagnoses, grouped into three clusters. The first cluster, cluster A, includes what
are often labeled simply as "odd" or "eccentric" personality characteristics. For example,
someone with paranoid personality disorder may feel a pervasive distrust of others and
be constantly guarded and suspicious while a person with a schizoid personality disorder
would seem overly aloof and indifferent, showing no interest in relationships and few emotional
responses. Cluster B encompasses dramatic emotional or
impulsive personality characteristics. For example, a narcissistic personality can display
a selfish grandiose sense of self-importance and entitlement. Meanwhile, a histrionic personality
might seem like they're acting a part to get attention, even putting themselves at risk
with dramatic, dangerous, and even suicidal gestures. The behavior of Cluster B can be
truly self-destructive and frightening, and these disorders are often associated with
frequent hospitalization. Finally, Cluster C encompasses anxious, fearful,
or avoidant personality traits. For example, those with avoidant and dependent personality
disorders often avoid meeting new people or taking risks and show a lack of confidence,
an excessive need to be taken care of, and a tremendous fear of being abandoned. Now,
in the past, and, to a great extent, today, some of these categories have been controversial.
Many researchers argue that some of these conditions overlap with each other so much
that it can be impossible to tease them apart. Narcissistic personality disorder, for example,
has many traits that resemble histrionic personality disorder. And because of this gray area, the
most commonly diagnosed personality disorder is actually personality disorder not otherwise
specified or PDNOS. The prevalence of this diagnosis suggests that while clinicians can
identify a personality disorder in a patient, figuring out the details of the condition
can be messy and difficult. One proposed alternative for diagnosing these
disorders is the Dimensional Model, which, in essence, gets rid of discrete disorders
and replaces them with a range of personality traits or symptoms, rating each person on
each dimension. So the Dimensional Model would assess a patient not with the aim of diagnosing
one disorder or another, but instead, simply finding out that they rank high on say, narcissism
and avoidance. It's a work in progress, so with another generation, the clinical definition of
"personality disorder" may evolve pretty radically. One of the best-studied personality disorders
right now is Borderline Personality Disorder, or BPD. Borderline makes it sounds like patients
are like, pretty close to being healthy, but not quite, but that is not at all the case.
BPD sufferers have often learned to use dysfunctional, unhealthy ways to get their basic psychological
needs met, like love and validation, by using things like outbursts of rage, or on the other
end of the spectrum, self-injury behaviors like cutting or worse. People with BPD were
once commonly maligned by clinicians as 'difficult' or 'attention-seeking', but we now understand
BPD as a complicated set of learned behaviors and emotional responses to traumatic or neglectful
environments, particularly in childhood. In a sense, people with this disorder learn that
rage or self-harm helped them cope with traumatic situations, but as a result, they also end
up using them in non-traumatic situations. Although challenging for patients and clinicians
alike, the good news is that some psychotherapies have helped even the most severely suffering,
repeatedly hospitalized BPD patients. But probably the most famous well-established,
and frankly, troubling personality disorder is Antisocial Personality Disorder. Now, you've heard
of this before, but maybe by one of its now somewhat out of vogue synonyms, "psychopathy"
or "sociopathy." People with Antisocial Personality Disorder, usually men, exhibit a lack of conscience
for wrongdoing, even towards friends and family members. Their destructive behavior surfaces
in childhood or adolescence, beginning with excessive lying, fighting, stealing, violence,
or manipulation. As adults, people with this disorder are thought to generally end up in
one of two situations: either they are unable to keep a job and engage in violent criminal
or similarly dysfunctional behavior; or they become clever, charming con-artists, or ruthless
executives who make their way to positions of power. Tony Soprano would have qualified
for a diagnosis, even if he wasn't nearly as bad as, say, serial killer Ted Bundy or
Vlad the Impaler, the infamous 15th century Romanian prince who personally watched about
100,000 people get impaled or have the skin of their feet licked off by goats. Yeah. That happened. Despite this classic remorselessness, lack
of empathy, and sometimes criminal behavior, criminality is not always a component of antisocial
behavior. Certainly many people with criminal records don't fit that psychopathic profile.
Most show remorse, love, and concern for friends and family. But still, although anti-social
personalities make up just about 1% of the general population, they were estimated in one study
to constitute about 16% of the incarcerated population. So, how might someone end up with such a disturbing
disorder? Well, as you might expect, the causes are probably a tangled combination of biological and
psychological threads, both genetic and environmental. Although no one has found a single genetic
predictor of Antisocial Personality Disorder, twin and adoption studies do show that relatives
of those with psychopathic features do have a higher likelihood of engaging in psychopathic
behavior themselves. And early signs are sometimes detected as young as age three or four, often
as an impairment in fear conditioning, in other words, lower than normal response to
things that typically startle or frighten children like loud and unpleasant noises.
Most kids only need to get burned by a hot dish once to know to stay away, but kids who
end up displaying Antisocial Personalities as adults don't necessarily connect or care about
the learned consequences when they're little. From there, like we've seen in other disorders,
genetic and biological influences can intersect with an abusive or neglectful environment
to help wire the personality in a peculiar and damaged way. While the vast majority of
traumatized people don't grow up to be killers or con-artists, genes do seem to predispose some
people to be more sensitive to abuse or trauma. Meanwhile, studies exploring the neural basis
of Antisocial Disorder have revealed that when shown evocative photographs, like a child
being hit or a woman with a knife at her throat, those with psychopathic personality features
showed little change in heart rate and perspiration, as compared to control groups. And the classic antisocial lack of impulse
control and other symptoms have also been linked to deficits in certain brain structures.
One study compared PET scans from 41 people convicted of murder to those of non-criminals
and found that the convicted killers had greatly reduced activity in the frontal lobe, an area
associated with impulse control and keeping aggressive behavior in check. In fact, violent
repeat offenders had as much as 11% less frontal lobe tissue than the average brain. Their
brains also responded less to facial displays of stress or anguish, something that's also
observed in childhood, so it's possible that some antisocial personalities lack empathy
because they simply don't or can't register others' feelings. Research has also suggested
an overly reactive dopamine reward system, suggesting that the drive to act on an impulse
to gain stimulation or short-term rewards regardless of the consequences may be more
intense than the average person's. As we mentioned before, because personality
disorders are pretty much egosyntonic by definition, people don't often acknowledge that they have
a problem or a need for treatment - and in the case of Antisocial Personality Disorder,
even if they did, there aren't many specific treatments available, at least not for adults. But there are some promising interventions
for kids and adolescents whose minds and brains are more plastic and adaptable. In this way,
the best way to treat Antisocial Personality Disorder may be in trying to prevent it. According
to American psychiatrist Donald W. Black, among others, many kids diagnosed with Conduct
Disorder, the diagnostic precursor to Antisocial Disorder, are at high-risk for developing
Antisocial Personalities as adults. But by identifying warning signs early on and by
working with these kids and families to correct their behavior and remove negative influences,
some of that impulse fearlessness could be channeled into healthier directions, like
to reward promoting athleticism, or a spirit of adventure. It's important to remember that
Antisocial Personality Disorder is only one type of personality disorder. This is a diverse
family of psychological conditions determined by many different factors and we're still
in the early stages of diagnosing and understanding the mechanisms behind them. Today, you learned about personality disorders
and the difference between ego-dystonic and ego-syntonic disorders. We looked at the three
clusters of personality disorder, according to the DSM V, and how personality disorder
symptoms often overlap. We also took a look at Borderline and Antisocial Personality Disorders,
including their potential bio-psycho-social roots. Thank you for watching, especially to all
of our Subbable subscribers, without whom we could not make Crash Course. To find out
how you can become a supporter, just go to Subbable.com/CrashCourse. This episode was written by Kathleen Yale,
edited by Blake de Pastino, and our consultant is Dr. Ranjit Bhagwat. Our director and editor
is Nicholas Jenkins, the script supervisor and sound designer is Michael Aranda, and
the graphics team is Thought Cafe.
