Personality Disorder

Al Pacino - Scarface

I’ve seen a lot of drug dealers lately. I’ve never met one in my personal life, but I have met plenty as a doctor. I must be on some list somewhere, because in the last week, I’ve seen three of them. In the process of doing my assessments I have seen an interesting trend.

3 out of three were diagnosed with anti-social personality disorder with narcissistic traits.

I’ve always been a bit of a skeptic when it comes to personality disorders. It always seems to me like a bit of a diagnostic cop-out.

It just so happens that in psychiatric circles, it’s pretty much a known fact that there is no treatment for personality disorders. That’s very handy.  If we don’t like you, and there is no treatment, then we have no duty to care for you. It’s the perfect ‘out’. So, if we don’t know what is wrong with you and we don’t like you, and we’d just as soon wash our hands of you, guess what… You have a personality disorder.

That’s why it struck me as odd that three of the last three patients I saw last week who had been diagnosed with personality disorders had recently had a psychiatric assessment on their way out of jail.

I know, you’re probably thinking… ‘They are the scum of the earth, let’s be done with them’! OK, I get that. It’s hard to have empathy for someone who has no empathy.

But what struck me was that each of these fellows was actually relatively likeable. I don’t mean ‘take them home for dinner’, likeable, but not as bad as you would think. They have a number of things in common that might explain why they are often tagged with the diagnosis, “personality disorder”

1. They all grew up with mother’s who were either not around, or were pre-occupied, or just didn’t ‘get’ them. They did not have strong attachment to their primary caregiver. In fact, many were bullied, neglected or abused as children, so they often have little attachment to anyone.
2. They are reward deficient. Meaning they have a tendency to be easily bored, are risk takers, defiant, irritable and sensitive to criticism.

    The first trait, ‘attachment disorder’ means they do not feel the misfortune of others. This allows them to lie, cheat, steal, manipulate, defraud, assault or even kill people, without losing sleep. If no one ever cared about you, why should you care about anyone else.

The second trait, ‘reward deficiency’ means that earning a living the legal way is too boring. It means you don’t sweat it too much when you are on a ‘most wanted’ list, because risk is part of the allure. It means you are oppositional; you don’t bow down to authority (because that’s no fun). It also means that you are quick to anger and you’d just as soon kill someone who disrespects you, than look at them. Remember Pacino in Scarface or Brando in The Godfather?

    Reward deficiency also ties into narcissism. Narcissism is a moral not a biological construct. In the animal kingdom you don’t call the alpha male a narcissist. He’s just looking out for number one, that’s how he got to be the alpha male. In our society we consider that being selfish. When I get to know these guys, I don’t see selfish. I see self preservation. I see a person who feels so bad, that he can’t tolerate things getting any worse. That manifests as not liking: being told what to do; being criticized; or not having things your way.

    In other words, he’s reward deficient. That pretty much explains it. If your like that, and you have attachment disorder, people consider you a narcissistic asshole. But is it really their fault? It’s not their fault that they inherited genes that disrupted their dopaminergic reward circuit. And, it’s not their fault that their mother and other’s did not teach them the language of empathy. That’s why when you talk to them, even though they just got out of jail for some pretty nasty business, they seem a lot less horrible than you would think, relatively likeable actually.

    However, I’m not saying it’s OK to be a drug dealer. But if you hear the whole story, like I do, you are less likely to ascribe blame. As one of my psyche teachers said. It’s maybe not their fault, but it is there responsibility and as such, even though I get where they are coming from, I still think they should pay for their crimes. However, while they are in jail, paying for their crimes, maybe they can get some therapy to help them understand themselves, or maybe they might get some medication to increased the voltage in their dopamine circuits. Maybe that might help them turn around more than just being in jail and then being diagnosed with an untreatable personality disorder.

Anthony Ocana MD