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