I didn’t want to lose the person behind the diagnosis.
Yes, John had likened me to a prostitute, acted as though he were the only person in the room, and felt that he was better than everyone else. But underneath all that, how different, really, was he from the rest of us?
The term personality disorder evokes all kinds of associations, not just for therapists, who consider these patients to be a handful, but in the popular culture as well. There’s even a Wikipedia entry that catalogs movie characters and the personality disorders they exemplify.
The most recent version of the Diagnostic and Statistical Manual of Mental Disorders, the clinical bible of psychological conditions, lists ten types of personality disorders, broken into three groups, called clusters:
Cluster A (odd, bizarre, eccentric):
Paranoid PD, Schizoid PD, Schizotypal PD
Cluster B (dramatic, erratic):
Antisocial PD, Borderline PD, Histrionic PD, Narcissistic PD
Cluster C (anxious, fearful):
Avoidant PD, Dependent PD, Obsessive-Compulsive PD
In outpatient practice, we mostly see patients in cluster B. People who are untrusting (paranoid), loners (schizoid), or oddballs (schizotypal) don’t tend to seek out therapy, so there goes cluster A. People who shun connection (avoidant), struggle to function like adults (dependent), or are rigid workaholics (obsessive-compulsive) also don’t look for help very often, so there goes cluster C. The antisocial folks in cluster B generally won’t be calling us either. But the people who experience difficulty in relationships and are either extremely emotional (histrionics and borderlines) or married to people like this (narcissists) do make their way to us. (Borderline types tend to couple up with narcissists, and we see that pairing often in couples therapy.)
Until very recently, most mental-health practitioners believed that personality disorders were incurable because unlike mood disorders, such as depression and anxiety, personality disorders consist of long-standing, pervasive patterns of behavior that are very much a part of one’s personality. In other words, personality disorders are ego-syntonic, which means the behaviors seem in sync with the person’s self-concept; as a result, people with these disorders believe that others are creating the problems in their lives. Mood disorders, on the other hand, are ego-dystonic, which means the people suffering from them find them distressing. They don’t like being depressed or anxious or needing to flick the lights on and off ten times before leaving the house. They know something’s off with them.
But personality disorders lie on a spectrum. People with borderline personality disorder are terrified of abandonment, but for some, that might mean feeling anxious when their partners don’t respond to texts right away; for others, that might mean choosing to stay in volatile, dysfunctional relationships rather than being alone. Or consider the narcissist. Who doesn’t know somebody who fits the bill to varying degrees—accomplished, charismatic, smart, and witty but alarmingly egocentric?
Most important, having traits of a personality disorder doesn’t necessarily mean that a person meets the criteria for an official diagnosis. From time to time—on a doozy of a bad day or when pushed until a fragile nerve is struck—everyone exhibits a tad of this or that personality disorder, because each is rooted in the very human wish for self-preservation, acceptance, and safety. (If you don’t think this applies to you, just ask your spouse or best friend.) In other words, just as I always try to see the whole person and not just the snapshot, I also try to see the underlying struggle and not just the five-digit diagnosis code I can put on an insurance form. If I rely on that code too much, I start to see every aspect of the treatment through this lens, which interferes with forming a real relationship with the unique individual sitting in front of me. John may be narcissistic, but he’s also just . . . John. Who can be arrogant and, to use a nonclinical description, incredibly fucking annoying.
And yet.
Diagnosis has its usefulness. I know, for example, that people who are demanding, critical, and angry tend to suffer from intense loneliness. I know that a person who acts this way both wants to be seen and is terrified of being seen. I believe that for John, the experience of being vulnerable feels pathetic and shameful—and I’m guessing that he somehow got the message not to show “weakness” at six years old when his mother died. If he spends any time at all with his emotions, they likely overwhelm him, so he projects them onto others as anger, derision, or criticism. That’s why patients like John are especially challenging: they’re masters at getting your goat—all in the service of deflection.
My job is to help both of us understand what feelings he’s hiding from. He’s got fortresses and moats to keep me out, but I know that part of him is in the turret calling for help, hoping to be saved—from what, I don’t know yet. And I’ll apply my knowledge of diagnosis without getting lost in it to help John see that the way he acts in the world might be causing more problems for him than the so-called idiots around him are.
“Your light is on.”
John and I are discussing his irritation with my questions about his childhood when he announces that the green light on the wall near my door that’s connected to a button in the waiting room is illuminated. I glance at the light, then at the clock. It’s just five minutes past the hour, so I figure that my next patient must be uncharacteristically early.
“It is,” I say, wondering if John is trying to change the subject or if he might even have some feelings about the fact that he’s not my only patient. Many patients secretly wish to be their therapist’s only patient. Or, at least, the favorite—the funniest, most entertaining and, above all, most beloved.
“Can you get it?” John says, nodding toward the light. “It’s my lunch.”
I’m confused. “Your lunch?”
“The food delivery guy is out there. You said no cell phones, so I told him to press the button. I haven’t had time for lunch yet, and now I have a free hour—I mean, fifty minutes. I need to eat.”
I’m floored. People don’t generally eat in therapy, but if they do, they’ll say something along the lines of “Is it okay if I eat in here today?” And they bring their own food. Even my patient with hypoglycemia brought food into this room only once, and that was to avoid going into shock.
“Don’t worry,” John says, registering the look on my face. “You can have some if you want.” Then he gets up, walks down the hall, and retrieves his lunch from the delivery person in the waiting room.
When John comes back, he unpacks the bag, puts a napkin on his lap, unwraps his sandwich, takes a bite, then loses it.
“Jesus Christ, I said no mayo! Look at this!” He opens up the sandwich to show me the mayonnaise, and with his free hand he reaches for his cell phone—presumably to call about his order—but I give him a look reminding him of the no-cell-phone policy.
His face turns bright red, and I wonder if he might yell at me too, but instead he just explodes with “Idiot!”
“Me?” I ask.
“You what?”
“I remember you once described your last therapist as nice, but an idiot. Am I also nice, but an idiot?”