In my work conducting the structured clinical interview for the Diagnostic and Statistical Manual of Mental Disorders (SCID) at The Menninger Clinic, I have the distinct privilege of discussing with patients, among others things, personality traits. This aspect of my job is particularly enthralling not only because I enjoy listening to and learning about our patients, but also because patients, for the most part, equally enjoy discussing their life experiences.
Patients help guide the interview by completing a brief personality questionnaire, which is concluded prior to the interview. They are then invited to expand on their answers, provide examples and generally talk about the kind of person they believe themselves to be. The SCID has been instrumental in uncovering problematic personality traits that can significantly impact a patient’s clinical treatment.
Problematic personality traits may seem readily recognizable; yet interestingly, personality disorders are some of the most under-diagnosed disorders in mental health treatment. Patients typically seek treatment for more acute problems, such as mood disturbance, anxiety and substance abuse, and often they experience relatively rapid relief of acute symptoms with the aid of medication and therapy.
By contrast, personality disorders require long-term treatment, typically including extensive psychotherapy, which, while effective, is by no means quick. Treatment for personality disorders, however, is especially critical as problematic personality traits can lead to conflict and stress in interpersonal relationships, which in turn play a role in mood disturbance, anxiety and substance abuse.
Failure to diagnosis
So why the failure to diagnose personality disorders? First, psychiatric treatment, as mentioned above, is often focused on the most acute concerns (typically mood, anxiety and substance-related). Second, labeling someone with a personality disorder diagnosis can be stigmatizing. Indeed, patients are likely to be opposed to a personality disorder diagnosis, feeling it might brand them as “a bad person” or, worse yet, beyond help. While avoiding stigma, we also must be judicious in diagnosing these disorders and acknowledge that it is hard to draw a firm line between adaptive and maladaptive traits.
Proud to be a narcissist
One of the most recognizable, if not inadvertently glorified, personality disorders is narcissistic personality disorder. Patients who endorse narcissistic traits are, perhaps not surprisingly, quite proud of them. They report:
“I would not be the person I am today if had not taken a hardnosed approach to business. You do whatever it takes, even if that’s at the cost of friendship.”
“If there is a problem I am going straight to the top; they need to know who they are dealing with.”
“The ends justify the means. I couldn’t let anything stand in the way of my success, and it paid off.”
Narcissistic individuals might acknowledge their inflated views of themselves, or they might skirt around how they truly feel, not wanting to reveal any type of perceived weakness. Those who acknowledge these aspects of their personality outright tend to have a well-defended reason for such traits: It helped them be successful. What might not be obvious to them, however, is the personal cost associated with such achievements.
Paying the price
Extreme personality traits also can contribute to vulnerability to clinical syndromes, including depression, anxiety or substance abuse, in part by creating stress in significant relationships, such as with a spouse or partner, co-workers or bosses. Persons who exhibit extreme personality traits may find themselves at odds with others who do not “buy into” their views, expectations or standards. Extreme personality traits contribute to rigidity and insensitivity to others’ viewpoints. In addition, they can lead to social isolation, reduced opportunities for relationships, limited support networks and less satisfaction in life.
Yet, as obvious as these problematic behaviors may to be others, the person exhibiting such traits may be oblivious to them or their social cost. The individual may be the last to see that the root of their troubles is potentially within their control.
Adaptive vs. maladaptive
So where is the line between adaptive and maladaptive? Sometimes exploration and reflection can help make patients aware of their maladaptive behavior patterns. Questions I ask in the SCID interview include: “How has this (trait) affected your relationships with coworkers, family members and friends?” “How do you think others would describe you as a person?” “Has this (trait) caused any problems at work or home?” A chance to be introspective and “mentalize” about another’s viewpoint can help an individual learn how their behaviors may be contributing to strained relationships and additional stress in their lives.
Personality traits define us; they make us who we are. They are the instigating factors behind relationships, career choices and life experiences. In moderation, such traits are valuable; in the extreme, they become detrimental to our relationships and wellbeing. So, the next time you happen across an individual justifying their narcissism through their copious achievements—remember the high price they might be paying in their relationships.