1125 "Masters of Denial"-personality disorder article in TIME

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http://www.time.com/time/covers/1101030120/scmpersonality.html

Masters of Denial

As far as these patients are concerned, the problem is yours, not
theirs

By Jeffrey Kluger

Posted Sunday, January 12, 2002; 8:31 a.m. EST

It has got so psychologist Lawrence Josephs can tell right away which
patients are likely to fire him. The narcissists may be the worst.
These are the ones who are there in the first place only because
their spouse would not quit hectoring them to show more interest in
the marriage, and the people at work just didn't seem to give them
the credit or attention they deserve. Often, they stay only long
enough to decide that what they really need is to leave the marriage
and quit the job. After that, they sack the shrink.

"They come in under duress," says Josephs, a psychology professor at
Adelphi University in Garden City, N.Y. "But they don't commit. What
they really want is to have everything on their own terms."

If it's any comfort to Josephs, he's not alone in having such trouble
managing narcissists—and it's not just the narcissists giving
therapists such problems. Narcissism is one of 10 conditions under
the diagnostic heading of personality disorders (PD), and by most
accounts, narcissists are among psychology's toughest nuts to crack.
Talk therapy often doesn't touch them; drug therapy may do just as
little. Researchers know why.

Common mental conditions, such as anxiety disorders, eating disorders
and depression, can be thought of as a pathological rind wrapped
around an intact core. Peel the skin away through talk therapy or
melt it away with drugs, and the problem may abate. Personality
disorders, by contrast, are marbleized through the entire
temperament. Narcissists may be self-absorbed, but they believe they
jolly well have a right to be. Histrionic personalities may make too
much of things, but how else can they be heard? It's hard enough to
persuade most people to see a therapist—harder still when the patient
denies there's a problem at all. "People rarely come in with a self-
diagnosed personality disorder," says Josephs. "Friends and family
push them into it."

These days they have more reason than ever to push. As families
increasingly fragment and as societal pressures grow, experts say
they are seeing more cases of personality disorder than ever. As much
as 9% of the population is thought to suffer from some kind of
personality disorder, and as many as 20% of all mental-health
hospitalizations may be the result of such conditions.
Epidemiologists have not done a very good job of comparing these
figures with those of earlier years, but many doctors report—
anecdotally—that their PD caseload is indeed on the rise. "The more
severe ones are increasing," says Josephs, "especially among people
who grew up in homes with divorce or drug and alcohol problems."
As this happens, more and more researchers are looking for new ways
to treat the conditions—exploring both genetic and environmental
roots, seeking both therapeutic and chemical cures. And well they
might. "The social costs of personality disorders are huge," says Dr.
John Gunderson, director of the Personality Disorders Service at
McLean Hospital in Belmont, Mass. "These people are involved in so
many of society's ills—divorce, child abuse, violence. The problem is
tremendous."

While solutions are elusive, the pathological arc of PDs is
predictable. They tend to show up after age 18, striking men and
women equally—though gender may influence which of the 10 disorders a
person develops. The disorders are grouped into three subcategories,
and of these, the so-called dramatic cluster—borderline, antisocial,
narcissistic and histrionic disorders— is the best known. But it's
the borderlines who cause doctors—to say nothing of families—the most
headaches.

People with borderline-personality disorder form exceedingly volatile
relationships, whipsawing between idealizing family and friends and
dismissing them as worthless or hateful. They are intensely afraid of
being abandoned but react so savagely when a loved one disappoints
them that abandonment is often just what they get. Prod these people
into therapy, and the same dynamic unfolds there. "At one point,
you're their closest friend, and two weeks later, you're the enemy,"
says Norman Clemens, a psychology professor at Case Western Reserve
University in Cleveland.

Histrionic and narcissistic personalities use drama or self-
absorption in much the same way—pushing away family and exasperating
therapists. People with antisocial personalities raise the stakes
higher, exhibiting aggressiveness, lack of conscience and
indifference to the law, often folding criminal behavior into their
pathology.

Less dramatic but just as stubborn is the so-called anxious cluster,
including the straightforwardly named dependent personality, the
socially withdrawn avoidant personality and the rigid and rule-bound
obsessive-compulsive personality (a different diagnosis entirely from
obsessive-compulsive disorder, an anxiety condition). The third group—
actually called the odd cluster—includes the paranoid, schizotypal
and schizoid personalities. Paranoid sounds like just what it is.
Schizotypals and schizoids both have problems forming relationships
and interpreting social cues; schizotypals may also suffer
delusions. "Schizoids are lone wolves," says Clemens. "Schizotypals
skate along the edge of real schizophrenia."

Before scientists can figure out how to treat these conditions, they
must first figure out what's behind them. Few researchers doubt that
when disorders are so woven into temperament, some of what causes
them is written into genes. A Norwegian study published in 2000
examined identical and fraternal twins and found that matched pairs—
with their matched genetic blueprints—were more likely to share
personality disorders than unmatched pairs. The borderline
personality had an estimated 69% level of heritability. This confirms
the observations of doctors in the field who notice higher rates of
personality disorders among descendants of PD sufferers. "There are
almost certainly multiple genes involved in predisposing people to
PDs," says Gunderson.

But genes aren't everything. Therapists who work with narcissists
often uncover childhood abuse or some other trauma leading to low
self-esteem or even self-loathing—just the kind of emotional hole
that pathological grandiosity would be designed to fill. Borderline-
personality disorder affects more women than men, and some research
has shown that up to 70% of borderline women were sexually or
physically abused at some point in their lives. It's hard to hang
that kind of mistreatment on the genes. Poorly handled bipolar
disorder or learning disabilities may also evolve into personality
disorders. Dr. Larry Siever, professor of psychiatry at Mt. Sinai
School of Medicine in New York City, believes that some of the rise
in PDs may be linked to the loss of natural support groups, as
individuals in an increasingly mobile culture migrate farther and
farther from home. "In the past," he says, "we lived close to our
extended families in highly structured communities. People could take
care of their own and rein them in."

Whatever the specific roots of the conditions, once those
environmental and genetic die are cast, is that it for the disordered
personality? The short, bleak answer is often yes—at least as long as
PD patients resist acknowledging the problem. Anxiety disorders such
as phobias are generally referred to as ego-dystonic illnesses: the
sufferer acknowledges the problem and wants to do something about it.
Personality disorders are ego syntonic: individuals believe that the
drama, self-absorption and other traits that characterize their
condition are reasonable responses to the way the world is treating
them. That's a hard patient to heal, but there is hope, and some of
it starts in the pharmaceutical lab.

Researchers are finding that antipsychotics can help alleviate
paranoid, schizoid and schizotypal symptoms. A variety of drugs—
including mood stabilizers, such as lithium and Depakote;
anticonvulsants like Tegretol; and SSRIs—may help control the
impulsive element of the dramatic disorders. And while antidepressant
and antianxiety medications do little to rejigger something as
fundamental as personality, doctors find that if they prescribe the
drugs to relieve the stress that comes with living so disordered a
life, some motivated patients may then take on the harder work of
talk therapy.

For those who do, the options are growing. Analytic therapy, which
explores past traumas, can uncover the deeply rooted conflicts behind
the conditions.

More immediate results can be gained through cognitive and behavioral
therapy, which teach coping skills. A new treatment known as
dialectical behavior therapy, developed by clinical psychologist
Marsha Linehan of the University of Washington, can teach borderlines
to recognize the situations that trigger explosive feelings, helping
them squelch a reaction before it erupts. "The first thing we teach
is to get control of the behavior," says Linehan. "After that, we
work on feeling better."

When patients commit to some form of therapy, even the doctors can be
surprised. A study conducted by Gunderson and colleagues at Harvard,
Yale, Columbia and Brown looked at borderline, avoidant, obsessive-
compulsive and schizotypal patients and found that, after two years
of treatments, including medication, psychotherapy, DBT or group and
family therapy, they showed a 40% improvement. "That's big news,"
says Gunderson. "Nobody would have thought we'd get better than 15%."
Forty percent, however, still leaves 60% suffering, and researchers
hope to tip that balance the other way. At Mt. Sinai, Siever is
looking deeper into what makes people neurologically susceptible to
PDs, studying the structure and function of the brain itself in order
to determine which areas misfire in the course of the disorders as
well as the role played by such neurotransmitters as serotonin and
dopamine. Others are studying such possible causes as high levels of
stress hormones in the womb or even poor nutrition during brain
development. Understanding the biochemistry should make it easier to
develop medications.

Until then, it will mostly be up to patients to deny the lie that the
disorder tells—that there's really nothing wrong with them—and make
the therapeutic commitment necessary to fix things. "Nobody totally
changes," says Josephs. "But anyone can become more flexible and
resilient. Anyone can make progress." That alone is already a better
prognosis than most patients have had.

—With reporting by Sora Song/New York