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Welcome to Science Pub, a monthly series exploring the exciting scientific world around us.

I'm Nancy Coddington, your host and director of science content for WSKG Public Media.

This season, we have a great lineup of speakers, including topics ranging from mental health, to the big boom that killed off the dinosaurs.

Tonight's talk is on The Nature of Personality Disorder: Understanding Narcissistic, Borderline, and Psychopathic Personality Disorders.

Personality disorder is a term used to represent a well-defined collection of signs and symptoms that characterize a particular group of psychologically impaired conditions.

These conditions affect as many as one in 10 Americans, and caused a great deal of disturbance in social and family life; functioning on the job and psychological wellbeing for the effected person and those around them.

Many people have heard terms such as a narcissistic personality disorder, borderline personality disorder, or a psychopathic.

These terms, though tossed around in the media and common discourse, have technical definitions and are the objects of intensive scientific study and active clinical treatment interventions.

Our guest Professor Lenzenweger will discuss what is known about these conditions, what remains to be learned, and what distortions accompany the use of these terms in society today.

Dr. Mark Lenzenweger is a distinguished professor of psychology at SUNY Binghamton, and professor of psychology in psychiatry at Weil Cornell Medical College.

And a licensed clinical psychologist in New York and Massachusetts.

His previous professional posts were at Harvard and Cornell, where he was a tenured professor.

Dr. Lenzenweger is the author of nearly 200 research publications, and has written an unclaimed monograph on schizophrenia, and is the editor of six scholarly volumes; one of which is the field standard for theories of personality disorder.

Welcome Dr. Lenzenweger.

- Thank you, Nancy.

And thank you to all who are signing in from all over the world and all over the country.

It's a pleasure to be here this evening.

- We are very excited about your talk.

So one last thing I wanna mention before we dive in, is as we get started, owing to the professional ethics and legal constraints, Dr. Lenzenweger will not comment on mental health related issues connected to past or current public figures, including political figures.

Nor can he comment on mental health matters related to the diagnosis or treatment of individuals, or the family members of such individuals that might contact or view this program.

So please keep that in mind tonight when you are asking your questions.

So Dr. Lenzenweger, the floor is yours.

- Thanks again, Nancy.

It's a pleasure to be here.

Hello, everyone.

Tonight, what I'd like to do is share with you some definitions and some concepts that relate to personality disorders, to try to give you a scientific appreciation for how they're defined, how we think of them in the world of both clinical treatment and research, and walk you through narcissistic borderline and psychopathic disorders.

So we're going to focus on these three broad disorders.

They're relatively broad.

As you'll see they're defined variably depending on which theoretician or which research group you're tuning into.

But they're also just three of several personality disorders that are not going to be discussed tonight.

So there are more personality disorders out there, so to speak, we're just gonna focus on these three tonight.

So thanks again to WSKG and Science Pub.

Let's get started.

So defining a personality disorder, let's begin by making sure we're on the same page.

So a personality disorder is a long-standing pervasive impairment in mental functioning related to a dysfunction fundamentally in personality.

About one in 10 people in this country, probably the same rough number around the world, one in 10, suffer from a diagnosable personality disorder.

What's important to know about these personality disorders is they're not due to transitory factors such as stress, temporary anxiety or periodic depression.

They're rather enduring more trait like; meaning they're more sort of evidence of how one consistently is, how one typically conducts oneself, how one typically behaves.

They're not due to psychotic illnesses.

Many of you have heard of illnesses like schizophrenia or bipolar disorder, that's not what personality disorders are.

Understanding these disorders requires an appreciation of both genetic and environmental factors, or stated differently; one has to have a perspective that embraces both nature and nurture.

Gone are the days in the science of psychopathology or the science of mental illness, where we think that the causes of an illness are all in the environment or all in the genes.

It's really an interactive picture for the personality disorders, just as it is for all the other psychiatric disorders, as well as most physical medical disorders.

So the American Psychiatric Association describes personality disorder as follows.

They say it's an enduring pattern of inner experience and behavior that deviates markedly from expectations from the individual's culture, is pervasive and inflexible, has an onset in late adolescence or early adulthood, and is stable over time, and leads to distress or impairment.

That's quite a bit packed into that sentence.

There are parts of that definition that come from the American Psychiatric Association, which was largely assembled in 1980, that particular definition.

There are aspects of it that we now know are not true, and we're still researching others.

So for example, the assumption that personality disorders are stable and enduring over time.

For the last 100 years, we thought that that was completely true, and that's what I was taught, that's what many psychiatrists were taught, many clinical psychologists were taught.

But empirical research done over the past 15 to 20 years now tells us that personality disorders do change over time, which is good news for treatment, of course, but it's also important for us to know that is part of what they are like in terms of their natural history.

So they're not engraved in granite never to change.

Or as William James once said, "They're not set like plaster, never to soften again."

There are differing approaches to organizing or systematizing personality disorders.

One can take a traditional American Psychiatric Association approach, that's embodied in a volume known as the diagnostic and statistical manual, that's called the DSM.

And that's a categorical approach.

The clinical psychological science perspective emphasizes dimensions of personality dysfunction.

So imagine a dimension is something like a dimmer switch, where you walk into a room, you turn on the light.

And instead of it just being a digital on, off kind of a set up, it's graded, it's quantitative, it's continuous.

It ranges from low, to medium, to high.

In terms of the light, it's on to barely noticeable, on clearly noticeable, on very bright.

There's also the psychoanalytic perspective, which emphasizes both dimensions and categories.

And the psychoanalytic perspective is a complicated perspective, and it has grown and evolved and changed over the years.

So for many of you, you'd probably just heard the word psychoanalytic, and you probably thought, Freud, and you probably then thought, oh my goodness, does anyone pay attention to Freud?

The answer to that is yes, they do.

But they also pay attention to the last 125 years of development of psychoanalytic models and insights and research data.

And finally, there's a new alternative model that is a new perspective on personality disorders.

It's sort of parked in the diagnostic and statistical manual.

It represents a blending of traditions of both the traditional psychiatric perspective and some of the insights cleaned from the clinical psychological science perspective.

We won't have time to talk about all of these tonight.

What I wanna do is get everyone comfortable with these three major domains of personality disorder, and leave you with some sense of how they're defined, what they're like, how often they appear in the population, and things that we do know about them; and give you a sense of where the science is going, where the clinical intervention treatment work is going.

So let's first start with narcissism and narcissistic personality disorder.

We have to go back to the myth of Narcissus as reported by Ovid.

And this is frequently a myth that is misunderstood.

The myth suggests for many people, or the way they learned it, was that somehow Narcissus was in love with himself.

And it's not so much that he was in love with himself, he couldn't pull himself away and escape from his preoccupation with this reflection to actually love others.

He had really what we think of as a tragic inability to love.

It was not self-love, it was an inability to connect with others.

And another way to think about it is that he never gives, he only gets; and that's typical of the narcissist.

He never gives, he only gets, he only wants.

So narcissism is something we've all heard a lot about over the last 10 to 20 years in psychology and psychiatry.

We've heard a lot about it in general societal discussions, it's in the newspaper, it's on YouTube, it's in books, it's trotted out in a great deal to characterize young people somewhat inaccurately, the current generation.

But where did this notion come from?

Where did it emerge from?

It didn't just emerge in the 1990s or in the early 2000s.

There are many contributors to our understanding of what we call narcissism and ultimately narcissistic personality disorder.

Freud himself, yes, the fellow up there on the left with the cigar, he wrote a paper in 1914.

And in many ways, this did get the ball rolling.

Freud thought narcissism represented withdrawal of one's connection with the outside world.

And linked it rather incorrectly, and I'll emphasize that, linked it incorrectly to psychosis, meaning schizophrenia.

It wasn't horrible that he made a mistake in terms of linking narcissism to psychosis, because the greater good was that he brought the attention of others to this important area.

Melanie Klein, who is the second from the left, she described early relationships and their impact on the development of the foundations of personality.

Karen Horney discussed pathological self inflation.

Annie Wright talked about pathological self-esteem regulation.

Auto Kernberg, who's third from the right discussed narcissistic personality structure.

And he described very carefully personality style, a personality structure that was characterized by grandiosity, aggression, coldness, unempathic, entitled attitude toward others.

Heinz Kohat described narcissistic personality disorder.

And Miller proposed very similar ideas to Kohat at about the same time, but in Germany.

And this work spans a good 120 years or so.

And I emphasize this because sometimes one has the impression that we've just become interested in narcissism, and nothing could be further from the truth.

What have psychiatrists and psychologists seen in their consulting rooms that made them pay attention to this kind of psychopathology, this kind of mental disorder?

Well, in individuals who were in touch with reality, there was no evidence that they had lost touch with reality, they don't have a psychotic illness, and they weren't merely a little depressed or anxious or upset by some poor turn of events in life.

Rather they would show up, seek treatment, and in the course of getting to know their psychiatrist or their psychologist, they would begin to reveal about themselves, their extreme levels of grandiosity, their very strong sensitivity to perceive slights, how they would rage at people who don't behave in a certain way.

And they would show considerable aggression.

They oftentimes had an exaggerated sense of brilliance or importance or skills, and they did not have a commensurate record of achievement in the world to back up their brilliance or their importance or their skills.

Someone might think of themselves as a genius, but if there's no evidence in the world to back that up, that's a problem.

Many were arrogant and haughty and disparaging of others.

Many of them were described as very entitled.

Thought that the clinician should buy a new carpet for the office because they thought the one that was there didn't quite have the right aesthetic, that in fact maybe the narcissistic individual could consult on purchasing the new carpet.

They were often insensitive to the feelings of others, preoccupied with their appearance.

Traditional psychotherapy, this should come as no surprise, did not work with such people.

And that's true for many of the personality disorders.

Traditional talk therapy, as we knew it in the forties, fifties, and sixties, even into the seventies, did not work with such people.

In 1980, the American Psychiatric Association revised its diagnostic nomenclature very heavily.

And one of the great advances of the big revision that took place in 1980 was the inclusion finally of some explicit criteria for the various personality disorders.

And narcissistic personality disorder made its formal appearance in the form of an explicitly defined entity or condition.

Now, consistent with the American Psychiatric Association approach to defining the personality disorders, what appeared in 1980 was atheoretical; meaning there was no guiding theory that they espoused or said accounted for this disorder.

The criteria were described as polytheistic.

And that means a collection of different features that don't always share in common with one another, but they sort of hang together.

And it was purely descriptive.

There were no insights offered in the diagnostic manual about how it came to be.

The diagnostic criteria for narcissistic personality disorder sound a lot like the list of descriptors that I just gave you for what the clinician saw in their office.

So a grandiose sense of self-importance, preoccupied with fantasies of unlimited success, power or brilliance, thinking that he or she is extremely special, requires excessive admiration, a sense of entitlement and so on.

And the rule was established, and this was somewhat arbitrary that one needed to get five or more of these nine criteria to be considered to have the condition.

You can mix and match however you wanted out of the nine.

There was none that were more important than others.

The idea was to get five out of the nine, or six out of the nine and so on, and you would be designated as having this disorder.

Another approach, the narcissistic personality disorder categorical approach has really dominated psychiatry for most of the last 30, 40 years in terms of research.

The dimensional approaches that I mentioned earlier espoused largely by clinical psychologists have made major inroads as well into the study of narcissism.

It actually helped us learn that there is another form of narcissism that's not just the grandiose form.

This work has been done in large part by Professor Aaron Pincus at Penn State University.

And he's done amazing work on parsing pathological narcissism into two components that are now very clearly and reliably defined, and appears to be a valid distinction.

There is narcissistic grandiosity along the lines of what I described, but there's also something referred to as narcissistic vulnerability.

And you can express your grandiosity either overtly or covertly, meaning in a way others can see or not see, same with vulnerable narcissism; you can express it overtly or covertly, meaning you can express it so people can see it or keep it to yourself.

The vulnerable narcissist is very good at keeping his or her fragile fragmented sense of self to themselves and try not to let it be seen by others.

In fact, individuals who with high vulnerable narcissism are frequently described as being defensive, avoidant or insecure.

They are hypersensitive too and very vigilant for criticism.

At the same time, they do need people's recognition to bolster their self-worth.

They have an unusual propensity for enjoying the shortcomings or failures of others.

This is often captured by the German term Schadenfreude.

This is when someone actually enjoys seeing someone else fail.

There is finally a form of narcissism that you don't hear as much about, but it is very important because it is very destructive.

This I refer to as the worst of the worst form.

It is known as malignant narcissism.

Alluded to by form, but really developed as a concept by Otto Kernberg at Weill Cornell Medical Center.

Described by others, and we've actually done empirical research on the concept of malignant narcissism.

Just what is it?

Well, these photographs should give you some sense of who we're talking about.

Malignant narcissism is a form of narcissism that not only has the grandiose component that we've been talking about, but it is infused with other terribly powerful and destructive components.

Malignant narcissism includes the entitlement, the grandiosity, the self-importance, the perceived brilliance and greatness, with sadistic tendencies, a great deal of aggression, a paranoid posture, which means you think people are trying to undermine you, they're out to get you, they're working against you, they're trying to ruin your good standing in your field or your chosen profession, as well as psychopathic features.

Those are the features that go along with being willing to break rules, break laws, violate ethics, violate morals.

This is a form of narcissism that has taken on greater interest to those who studied the functioning of organizations, and how an individual who possesses malignant narcissism not only can be very destructive in their own life and in their own social circle, their own family life, but also at the level of the organizations, or even in the case of those individuals, as I showed you, at the level of entire countries.

Moving to borderline personality disorder.

Borderline personality disorder has long been known to exist.

Again, this is not a new disorder, this is not a disorder of recent discovery or making.

It's long been known to be heterogeneous.

What that means is, think of borderline personality disorder as an umbrella term.

And there are many people that would fit under that umbrella in terms of their behavioral features.

They're not all the same, they're not all identical, but they help by and large fit under this umbrella.

Early observers going back upwards of a 100 years have often given highly variable descriptions of the phenomenology of this particular illness.

But one thing is for sure; they all were more or less describing a similar phenomenon.

Just like in narcissism, people were describing the individuals that came to see them for clinical treatment, and then eventually those insights found their way into the diagnostic system to formalize those insights.

And then that helped to stimulate research into the causes, the emergence, the etiology of these conditions.

The current diagnostic nomenclature, the DSM system that we use embraces this variability, this heterogeneity in the polytheistic criteria set just like as was the case with narcissism.

We do know, for example, however, that even if you define borderline personality disorder, for example, in a consistent and reliable way, the context in which you discover individuals suffering from this condition and recruit them for research matters.

So for example, if you recruit individuals from a clinical setting like a hospital setting as opposed to a community setting, you will generate two groups of people who both have borderline personality disorder, but who have remarkably different features in some ways.

These are the diagnostic criteria for BPD.

Frantic efforts to avoid real or imagined abandonment, a pattern of unstable intense interpersonal relationships, characterized by alternating between extremes of idealization and devaluation.

This is the person who loves you in the morning and hates you at night, and then loves you the next morning, and there's no discernible reason as to why.

Identity disturbance; markedly and persistently unstable self-image or sense of self.

Most people, including young people begin to consolidate a sense of who they are, what their values are, what their aspirations are, what their goals are.

They can tell you where they've been in life, where they are now in life and where they hope to go in life.

That is all related to a sense of identity.

People with BPD have a very difficult time with identity.

They also show impulsivity that can be self damaging, particularly in substance abuse, sexual behavior, spending behavior, reckless driving.

There's also high level of recurrent suicidal behavior and gestures, there's a great deal of unstable emotion, ranging from anxiety, depression, anger, running the whole gamut, and sometimes changing very quickly.

Chronic feelings of emptiness, and inappropriate intense anger, difficulty controlling anger.

And sometimes under extreme stress, under extreme stress, a person who suffers from BPD can actually begin to become very suspicious of others, suspecting that others are out to harm them or do them wrong or hurt them in some manner.

We know about 1.3 to 1.9% of the population has this disorder.

This is not a myth.

This is not just a label that we assign to people that are difficult to understand.

These individuals are struggling with very unstable relationships and very unstable emotions.

And this is a personality disorder that is built upon a complex matrix of genetic factors, temperamental factors, probably neuro-biological factors, as well as environmental factors such as trauma.

It occurs equally often in men and women in the general population.

This is not just a disorder that affects women.

That's a myth.

It is a disorder that affects men and women equally in the population.

It's not on the border of anything.

That's a term that came in from the 1930s.

And we've just never gotten rid of it.

It used to be thought that somehow borderline personality disorder was on the border of psychosis.

We're on the border of major depression.

We're on the border of something else.

It's really not on the border of anything, it's its own thing.

It's associated with considerable comorbidity.

That's epidemiologic jargon for meaning, people who suffer from BPD also have a lot of other conditions affecting their life.

Typically anxiety, substance abuse, trauma histories, as well as depression.

It's a challenging disorder to treat, but here's the good news.

There are now very good, modern specialized treatment techniques for BPD.

You don't use treatment as usual to approach someone with borderline personality disorder to try to help them improve their mental health, improve their life, improve their functioning.

You choose one of the newly developed, meaning the past 20 years or so, 30 years, newly developed empirically supported treatments such as transference focused psychotherapy, dialectical behavior therapy, mentalization approaches.

Sometimes just good psychiatric management done in a careful manner can yield positive results.

But the important thing is whoever's doing the treatment for borderline personality disorder has to be schooled in one of the modern approaches.

Research in the BPD is now working across psychological and neural domains.

This is no longer just a discussion about parenting and child rearing experiences in the early life.

We are probing the brain.

And much of this work is focused on bringing together what we know about emotion, affective neuroscience, the science, the neurobiology of emotion, and cognition, how we think, and what the brain is doing.

This is a classic study that I'm showing you here done by David Silbersweig and our team at Weill Cornell, where individuals with this disorder were asked to do a task where they had to be actively engaging some inhibitory processes.

They were trying to not do something in the context of some strong emotion.

And what we see is that people who had very low levels of the psychological experience or trait or process of constraint, also showed a relatively low activation of the part of the brain that helped with control.

So a psychological factor lined up perfectly with what was going on in the brain.

Similarly, off to the right, when you look at negative emotion, you see that in cases of high levels of negative emotion in the people that had high levels, they showed a great deal of activation in the part of the brain that is known to be very connected to emotion, the amygdala.

So I share this with you to show you what's happening.

We are beginning to cut across what are called levels of analysis, looking at the brain, the personality, behavior, social functioning.

There's a great deal of interest in working across those levels of analysis to try to learn more about what causes this disorder.

And let's move on to psychopathy and antisocial personality disorder.

Here are three individuals who by most accounts would be thought to have psychopathy.

Bernie Madoff, who ran the Madoff Ponzi scheme, Ted Bundy, who was a serial killer, and John Walker, who had been in the Navy and was busy selling intelligence and information about the United States to foreign adversaries.

And he thought there was no problem with that, just like Bundy thought there was no problem with killing young women, and Bernie Madoff thought that there was no problem bilking people out of their retirement funds so that he could accumulate more personal wealth.

Very little remorse, very little guilt, very diminished appreciation for the impact of their behavior on others.

So remember that definition from the American Psychiatric Association, we're talking about an enduring pattern of inner experience and behavior that deviates markedly from expectations.

I emphasize this because people who are psychopathic tend not to show a lot of distress about their behavior.

The people that show distress about their behavior are the people around them; their family members, their associates at work, the people that have to work with them in organizations, that people that have to work with them in the legal system.

Psychopathy antisocial personality disorder, sort of start with observations.

In fact, the first real observation was done by a fellow named George Partridge.

He's the fellow on the far left.

He was working at Sheppard Pratt Hospital in Baltimore, Maryland.

And he talked about something known as sociopathy.

Harvey collectively in the middle there, the fellow with the big smile, he talked about psychopathy, and he pretty much gave us that term.

And then Lee Robins off to the right, she worked at Washington University in St. Louis.

And she told us something that was very important, which was deviant childhood behaviors that are malicious representative of rule-breaking, lawbreaking, aggressive behavior in children predicts in many instances, not all, but in many instances, adult antisocial personality disorder.

So we have psychopathy, sociopathy, and antisocial personality disorder.

Keep those terms in mind.

But realize sociopathy is a concept that is no longer used in science.

You'll hear it in the paper, you'll read it in the New York Times or the Wall Street Journal, you'll hear it from news reporters, you'll hear it in common discussion.

Sociopathy as the young people say these days, is no longer a thing.

It's not a thing.

We really have abandoned the term, because it implied a model of causation that was never validated.

It implied the etiology or the cause of these conditions has to be coming from the environment, solely from the environment.

So what we're left with is psychopathy and anti-social PD, Hervey Cleckley's notion of psychopathy has a great personality basis.

It is anchored in the personality.

Lee Robin's notion of what predicted adult antisocial behavior was anchored in clear-cut antisocial act, especially performed in childhood like destroying property, repeated fighting and theft.

In the 1980 overhaul that I've mentioned to you a few times, the American Psychiatric Association, when it decided what to do with respect to this kind of personality pathology, opted to go with antisocial personality disorder because it was easily rated and it was reliably rated.

Psychopathy is a more complicated construct.

More complicated idea, required a more sophisticated clinician, and a times involved a little more nuanced subjective assessments.

And the DSM system wanted to go with straightforward, clear cut, reliable criteria if possible.

That said, most of the very fruitful research done in psychopathy has really focused on Cleckley's notion of the disorder and not on the DSM notion of antisocial personality disorder.

So think of Cleckley as being more linked to understanding the complex personality of the psychopath, or antisocial personality disorder was a cataloging of bad behaviors that some people do, who in fact, then go on to be called antisocial as adults.

Here's the important thing.

Many psychopathic individuals do have histories of antisocial behavior, but not all of them do.

And there are some people that are truly antisocial who don't have the personality configuration of psychopathy.

These terms can not be used interchangeably.

So one has to be very careful in using the terms.

They're not what we call fungible.

They cannot be thought of synonymously.

So what is psychopathy?

It's a longstanding discussion that is in front of us and behind us when we think about this.

There are two dominant perspectives.

One is that psychopathy is a massive psychological disturbance.

And this is the idea that Cleckley gave us.

That on the surface, the person looks relatively intact, is functioning properly, is conducting themselves in some manner that seems reasonable, but deeper down, they've got a very profound disturbance.

Another view of psychopathy is that the psychopath is a callous predatory individual with a great deal of criminal deviance in their history.

This was reflected in part in the work in Robin's.

Cleckley, as I described is the person who described psychopathy to us as a psychological concept.

And he referred to it as a paradoxical condition in which severe behavioral pathology and positive adjustments seem to go hand in hand.

And he worked with many people who had this condition.

And he ended up thinking that what many of them presented to you was what he called a mask of sanity.

On the surface they appeared reasonably well adjusted, reasonably intact in terms of their performance and their behavioral organization, but deeper down, they were quite impaired.

He goes on to talk about a mask suggesting robust mental health, but deep below the mask is a pattern of dysfunction that he believes rivaled what saw in psychotic individuals.

So he focused on overt adjustment that you can see in some psychopaths, meaning some degree of social charm, some degree of intelligence, absence of psychosis, chronic behavioral disturbance, like impulsive antisocial behaviors, failure to learn from experience, being very irresponsible, being very promiscuous.

And then emotional interpersonal deficits; lack of remorse, not feeling bad for something awful that you did, poverty of emotion; not having the right reactions, meaning the typical or the natural reactions to emotion that you experience or see.

Not being upset when you see a child crying or a person hurt, or a person being fearful.

Cleckley's contributions have been described in a recent paper by the late Scott Lilienfeld, as well as a bunch of other researchers in psychopathy.

If you're interested, you can find this in the journal of personality disorders theory, research and treatment.

In the 1950s and 1960s, seminole laboratory studies were done by David Lickin, who up in the upper left, and Robert Hare in the lower right, basically showing us that there was early evidence, early laboratory evidence that psychopathic individuals don't learn to avoid punishment.

And even when they know some punishment is coming, they have very little fear about it.

They don't show the same physiological reaction that other people do when an electrical shock is coming, or when something painful is coming.

This led to a dual process model of psychopathy, such that on the one hand we thought, I think people who are psychopathic have almost no fear, a trait fearlessness, if you will.

But they're also given to what we call externalizing behaviors.

They have a propensity toward impulse control problems, such as fighting, aggression, substance use, reckless sexual behavior, and so on and so forth.

How do we evaluate people for psychopathy?

The primary tools remain interviews and psychological tests.

There are no biological tests for personality disorders for psychopathy, for narcissism, for borderline, for anything.

There are no biological tests.

So we still rely on interviews and tests.

The most important interview that's out there, and you've probably heard about this if you've read anything about psychopathy, is Robert Hare's psychopathy checklist.

One factor in the checklist taps into emotional-interpersonal problems, the other taps into behavioral deviance.

People are not always comfortable with the heavy loading of the antisocial behaviors in the psychopathy checklist, but the checklist make good sense, given that Hare developed it in forensic and correctional settings.

What are contemporary issue in understanding psychopathy?

There is a consensus that the personality basis for psychopathy is appreciable and should be understood.

Meaning we need to follow up on a lot of collect leads insights, and people are doing that.

There may have been too much emphasis on the antisocial aspects of this concept over the years.

Such that some people think, well, if you're a psychopathic, you must be antisocial.

And if you're antisocial, you must be psychopathic.

Some people see it as that tightly linked.

Other people, other theoreticians, other scholars say, no, it's not that tightly linked.

So this is still being discussed.

And are there ways to begin to detect signs of psychopathy earlier in life than in young adulthood?

So are there things that we could tap into?

Maybe use some of those insights that Lee Robins gave us, to begin to see what's going on in children or young individuals that might be headed down the direction, down the direction of the psychopathic road?

The modern era of psychopathy research has been dominated by two individuals.

Scott Lilienfeld, upper left.

Scott passed away about a year ago.

And Chris Patrick in the lower right.

I'll just quickly go through their models.

The Lilienfeld model emphasizes fearless dominance, impulsive antisocial behaviors, and a cold-heartedness.

He developed an inventory, and no one score on any one dimension seals the deal and says, you're a psychopath, but rather one has to look at the level and the combination of factors.

Some of these factors in certain manifestations might actually have some adaptive value.

And that has to be studied too.

So for example, Lilienfeld did a very clever and interesting study to see, is there a positive side to some of these underlying components of psychopathy?

Let's consider the case of fearless dominance.

Well, if we look at the United States presidents, down through George W. Bush, and rate them by expert historians who know these presidents extremely well, as if they know them as real people that they have a relationship with.

These are not individuals who have a passing familiarity with these presidents, but rather these are people that know them inside and out.

Well, we see that on average, US presidents have higher levels of fearless dominance than the average bear, than the average person.

And the people you see across the top had the highest levels.

Theodore Roosevelt, John F. Kennedy, and Franklin D. Roosevelt.

The Patrick model's a little different.

It emphasizes boldness, disinhibition and meanness.

Again, personality constructs, personality dimensions.

It's measured with the Triarchic Psychopathy Measure.

And again, the level and combination matters.

So boldness, for example, here's an item, I can get over things that would traumatize others, I can convince people to do what I want.

Meanness; how other people feel is important to me, false.

I enjoy pushing people around sometimes, true.

Disinhibition; I often act on immediate needs, true.

I have good control over myself, false.

The Triarchic model concedes of psychopathy as encompassing these three distinct phenotypic dispositions.

And the syndrome of psychopathy, meaning when we get concerned about it clinically, is defined as disinhibition, plus either boldness or meanness.

It is a conceptualization that is closer in spirit to Cleckley's.

It tends to be consistent with his view of the bold nature of the psychopath.

Many criminologic conceptions and instruments emphasize what for lack of a better term would be meanness; which are tapped into by the Patrick model.

And David Lykkens's low fear conception of the successful or the higher achieving or the heroic psychopath, places a predominant emphasis on Patrick's boldness.

So it's a nice unifying model.

Finally, just like in borderline personality disorder, research into psychopathy is now working across psychological and neural dimensions.

This is a report in 2008, I believe.

It focuses on children who are callous and unemotional.

There are 12 of them.

They're compared with healthy children and adolescents with attention deficit hyperactivity disorder.

And what you see is activation in the brain, it corresponds to what their brain is doing when they see fearful stimuli, when they see scary stuff.

Normally when you see scary things, there's a fair amount of activation of that part of your brain that taps into strong emotion; the fight or flight part of the brain, the amygdala in part.

And I'm simplifying things considerably here just to get the concept across.

Bottom line, adolescents with callous unemotional traits, which are a lot like Patrick's meanness and Lilienfeld cold heartedness features, those individuals show very little activation of the amygdala when those children are seeing stimuli, and they are significantly different from healthy comparison children and adolescents with ADHD.

So once again, we are seeing in modern research, a linkage across clinical dimensions, symptom dimensions, in this case, Cleckley's on emotional traits, and what's going on in the brain in response to emotion.

So this has been, I know a high-speed overview treatment of these three broad domains, a very serious psychopathology.

Remember one in 10 people in the population has some form of personality disorder.

So this is a clinical research and public health challenge.

This is not just something that happens very rarely to some people somewhere not near you.

One in 10, remember that number, one in 10, when you think about this type of mental disorder, this general class of mental disorder.

Thank you very much for your attention.

I've enjoyed being here this evening.

I look forward to your questions.

- Thank you, Dr. Lenzenweger.

That was really fascinating, and you covered a lot of material.

So a really great job doing that.

We do have some questions coming in from our audience.

And I would like to remind you to please ask your questions in the chat, and we will work through to get to those.

I wanted to start off with a question.

Is there research or theories indicating that narcissistic personality disorder is increasing?

Thinking more of due to nature versus not nurture.

- There has been a lot of discussion about increases in scores on a certain narcissistic personality or narcissistic personality disorder inventory.

And those discussions of those increases have gotten rather overheated and exaggerated.

The actual increase in those scores is quite small.

So in science we talk about what's called an effect size.

The effect size of the change is really quite small, but it is something to talk about, in terms of its statistical significance.

It doesn't necessarily mean it has scientific significance.

Is narcissistic personality disorder increasing over time?

There are no studies to point to that at this time.

- Thank you.

We stay on that same thought process.

So when you're talking about one in 10 Americans experiencing personality disorder here in the US, is that something that is seen across the world in a similar statistic?

- Yes, it is.

In fact, there was a review of the literature done in 2018.

It appeared in the British Journal of Psychiatry.

And it showed remarkably similar figures from data sets around the world.

The very first prevalence estimate we generated years ago at Cornell University in Ithaca was about 9%.

About 10 years later when I was at Harvard working with the national comorbidity study, headed by Professor Kessler, we did the nationwide study, we came up with a number of pretty similar, about 11%.

When these investigators have aggravated data from around the world, it's about the same, it's about 11%, 10%.

So it's the one in 10 number holds up worldwide.

- Are there any cultures where personality disorders are virtually unheard of?

- If there are, I'm not aware of what those would be.

There was a study done by the World Health Organization many years ago, headed up by Professor Armand Loranger, it was at Weill Cornell at the time.

And they studied personality disorders in numerous different countries, numerous different cultures around the world.

And they found evidence of personality disorders in all of those countries.

That doesn't mean that maybe somewhere in some sort of small sort of niche culture, you might find a different prevalence rate, but I suspect you will find personality disorders just about any place you look.

- Well, it definitely makes sense.

What are some of the typical effects that narcissistic parents have on children?

- Well, this is an area of great speculation.

Some people feel, and there are a lot of theoretical papers on this, a lot of interest in parenting around this theme.

The feeling is that some narcissistic parents might actually use their children to meet their own narcissistic needs.

So the parent might need to have their child be an ultra high achiever or to be highly accomplished, not for the child's sake, but for the parent's say, so that they can feel that their child's accomplishments, their child's glowing status in the world somehow reflects on them, and boils up their sense of self-esteem and their sense of importance.

Now, that's a complicated dynamic.

There is a lot of interest in the role of early childhood experience.

We've just finished a study where we've looked at the joint contribution of psychological engagement with children and temperament.

And we find that in fact, both matter, that you are going to see environmental inputs and probably ultimately genetics/ temperamental inputs into narcissism and narcissistic disorders.

- Thank you.

How do personality disorders affect marriages?

Is there a notice in the divorce rates?

- I don't know that there's a study that actually links the presence of personality disorders to differential divorce rates.

Though I can tell you that my colleagues that treat couples and work with couples, and I do some of that work myself, it is not uncommon to see one member of the couple or sometimes both suffer from a personality disorder, and it can lead to a great deal of dysfunction in the relationship, and can lead in many cases to separations, divorces, so on and so forth.

But I don't know, I can't cite a statistic that would link the presence of a personality disorder with an elevated divorce rate.

It's a great hypothesis.

So whatever listeners sent that in, that's a great study.

It may have been done, may need to be done.

- Can you comment on the significance of Linehan's theory on the involvement of the invalidating environment in the development of borderline personality disorder?

- Linehan's theory?

- Yes.

- I think it's an approach that has a lot of promise.

And in many ways, mirrors what others have said that the child trying to develop a coherent, intact and functional sense of self needs to have their achievements validated, needs to have their emotions validated.

It's a sensible approach.

And I can't tell you that anyone has as nailed down confirmatory evidence for it, mainly because most of the research that gets done on parents is retrospective in nature.

Meaning there's an individual effected with say borderline, and you seek to study what they remember about their upbringing, their early experience.

And it can be challenging from a scientific perspective to know that what you're hearing from them is reliable and valid, and oftentimes cannot be corroborated.

So it's a very sensible hypothesis, and it dovetails nicely with what others have said, such as individuals like Hernberg or Cohort.

- Thank you.

So with these conditions of personality disorder, do you see them often early in life in young children?

- The diagnosis of personality disorders in children is an area of great interest and some disagreement.

Children's personalities are still forming.

Their temperaments are still playing an important role in shaping the emergence of their personality.

And they haven't gotten into the complex world of relationships that emerge later in life.

That said, there is great interest in the diagnosis of personality disorders in children, and there are people that are expert in that area.

- So thinking on that same line, if a child is treated early on, do you think that there is ability for them to get better?

- That is in fact the mantra of almost all mental health interventions.

We often refer to interventions as being either primary, secondary, or tertiary.

We would love to find out what indicates a child is at risk for any kind of mental disorder early in life, and try to help them avoid the emergence of that mental disorder later in life.

That would be what's referred to as secondary prevention, where you apply some kind of intervention to a person who's deemed to be at risk.

Right now, when you go to see your doctor and you go to their office or go to your Zoom psychotherapy session, you are engaged in what's called tertiary prevention.

Meaning you've already got some distressing condition or distressing situation that's affecting your life.

You're an adult and you need some clinical remedy to help you improve or to move forward.

We don't necessarily have the predictors yet for identifying children at risk specifically for personality disorders.

But it is a goal.

That kind of work is being done for other disorders as well.

So for example, schizophrenia.

- Thank you.

Are people with personality disorders generally reluctant or unwilling to get help?

Do they feel that they don't need treatment?

- That's an excellent question, because in some cases, people will come to see you because their life is in tatters.

They have difficulty at work, they're having difficulty in a relationship, or they just know they're not terribly happy.

And those are very reasonable things to bring you into therapy.

And many people show up with those kinds of chief complaints.

And on the other hand, you have people who probably should get into therapy, who probably never will, in part, because either they don't think anything is wrong, or they have never taken seriously the feedback they're getting from other people.

Many people will end up in your office for a consultation because they've been told for example, by the employee assistance program at their organization, that they should seek help.

Or maybe their clergy person has said, "You should seek some help."

Or a loved one will say, "I just wanna say, I think it's time for you to talk to a professional."

It really depends on a person's state of mind as to whether or not they're gonna be reluctant.

If a person is open to therapy and is open to trying to take a look at their life, they're oftentimes much more engaged and not reluctant.

If you're a psychopathic individual and you think your life is just a bowl of cherries, and you're quite happy doing all the things you're doing, even though you're leaving a trail of destruction and sadness and distress and you're weak, you're probably never gonna seek treatment, until you bump into a situation that demands that you seek treatment.

- So we have a question about malignant psychopath.

So somebody who verbalizes in a constant victim mode to gain sympathy or handouts, and then either physically or verbally attacks or blackmails, are those characteristics of malignant psychopath?

- Do you mean malignant narcissism?

- Would it be either one of those?

- Yeah, I think the listener might be thinking about the term malignant narcissism.

It is conceivable that those behaviors would go along with malignant narcissism.

The speculation about e-mails and blackmail and things like that, that's a more complicated picture.

And normally that kind of behavior goes along with what we call disgruntlement.

People will begin to try to threaten or manipulate or extort even information or money from a company or whatever.

And that oftentimes is tied to disgruntlement, but it's also tied to narcissistic disorders and psychopathy.

So it's hard to know exactly.

When a person begins to get to the point of actually enacting some of those things, that's fairly serious.

Is it malignant narcissism?

We would have to assess the person to see if all the features are there.

- Thank you.

- You are welcome.

- This is something that I think we have seen, especially, I think in the last couple of years, but callousness in adolescents seems to be very high these days.

So can you comment on that?

Do you think it's digital communication that might be partly to blame with that?

- Well, again, just like the question, these are excellent questions about the increase in narcissism.

I don't know that there's an increasing callousness.

We see examples of it a lot more these days because we have the world of the internet linking us to social media and all manner of videos, and social media platforms that show us all manner of behavior.

So we get to see much more of these days of behavior that probably has existed for some time, but we never got to see it the way we do now.

So we don't get to see the behaviors that kids in the 1950s did.

It was never recorded.

You don't get to see much from the 1960s.

But now we get to see all manner of behaviors that young people exhibit, and it's all recorded.

So it's kind of recorded for posterity.

So will there be evidence that it is increasing over time?

That'll have to be studied to see if indeed it's a real increase.

Now, this is a case where oftentimes if there's speculation that callousness, for example, might be increasing, it can be reported as if there is an increase or a known increase.

It may not be based in empirical data or scientific data.

So one thing I wanna emphasize is, to all these wonderful questions is, empirical data, scientific data are required to answer most of them.

And especially for the things that, you know, concern recurrence over time or change over time, then you need not only data, but data collected over meaningful chunks of time, meaning years or decades.

People are doing that work, but it does take time.

- Yeah, I agree that we definitely have the platforms now where we're able to watch that in real time, where we didn't have that previously back, as you mentioned in the 1940s and fifties.

So it certainly seems like it's a little more prevalent.

- Yeah, you might have heard that a teenager down in Texas did some horrendous thing in the 1950s, because it got reported in the newspaper.

But the only reason you heard about it was someone took the time to report it and you read it in a newspaper.

Now, you just go on a social media platform and you can see awful things that young people might be doing.

And not just young people, awful things that even adults are doing the world over every day.

- That's very true, yeah, it's really at our fingertips.

What can be done to integrate mental health into public health models, especially in school curriculum?

- I think public health information, especially around mental health needs to be part of any health curriculum.

I think if a health curriculum say in middle school and high school does not include mental health, then it's really falling down on the job.

We know that anxiety and depression affect many, many people, and affect productivity, affect quality of life, affect length of life, mortality.

We now know that mental health matters in so many areas, that it's incumbent on us to make sure that children are learning, and young people are learning about the signs and features of mental health issues that will be real in their life, that will impact their life.

Maybe they already have.

But it should get equal airtime as other illnesses or conditions or other risk factors.

Absolutely.

- So what do you do to maintain your own safety while treating people with personality disorders?

- Well, that's a good question.

And the vast majority of people who have any form of mental disturbance or a psychopathology or mental illness are not dangerous, they don't pose a risk.

So for example, in the case of schizophrenia, for example, a profound psychotic illness, there have been distortions and stereotypes floating around in our society, that somehow that everyone who suffers from those biologically-based, brain-based conditions are inherently violent.

And that all clinicians are somehow putting their life on the line.

And that's simply not true.

There are people in the world who are violent and aggressive, and the vast majority of people with some form of mental disturbance are no more inclined toward that than anyone else.

So, everyone is trained in the treatment of mental disorders, in clinical work, in psychiatry, in clinical psychology, to use good judgment, when to see the signs of potential danger, and how to handle those.

That's part of good psychiatric, good clinical psychological science training.

- Dr. Lenzenweger, are there any surprising experimental treatments that are on the horizon?

- Well, we don't know yet, right?

We don't know if we should be surprised.

We do know that people are doing a lot of interesting work with newer forms of pharmacology.

There's always some interest in advancing psychopharmacology.

There are interests in various forms of brain stimulation.

There are sort of packages of empirically supported psychotherapy, psychiatry, psychopharmacology approaches that work well.

For example, I mentioned a while back, what's called good psychiatric management.

And that is an approach to working with borderline personality disorder that actually works quite well for some people.

And the fact that it worked as well as it did was somewhat surprising to the clinical community, because what we had been learning was that we needed to use very complicated and specialized approaches, such as transference focused psychotherapy or dialectical behavior therapy or mentalization approaches.

And when we learned that when good psychiatric management, and there's more to it than just those words, but when that was done, it got good results.

And that was a surprise.

And we all embraced it as, hey, this is another tool in everyone's toolbox.

And this is fundamentally a net gain for the field.

Is there something super revolutionary out there that is sort of "Star Wars" quality in revolutionary, a surprise, potential.

I don't know and I tend to think not.

- Dr. Lenzenweger, can you recommend any good books or documentaries on these topics for our general audience?

- Yes.

So for example, I would, for example, psychopathy, believe it or not, I think if you're really interested, start with reading Hervey Cleckley's book, "The Mask of Sanity."

It is written the 1940s, and he updated it a little bit as time went by.

So some of the language feels a little dated at times, but it is an amazing account of psychopathy.

It is wonderful.

It has a very, very rich clinical descriptions and case histories.

You will walk away from that book knowing what we mean when we say psychopathy.

As far as other books, in terms of narcissism, there are many.

The book written by Miller called "The Drama of the Gifted Child," written in a less technical way, is interesting and thought-provoking for narcissistic personality disorder.

There are many, many books about borderline personality disorder, too many to comment on and talk about.

There are excellent websites that people could visit to get that information.

The website at the New York Presbyterian Personality Disorders Institute has a lot of resources for families and interested individuals about borderline personality disorder.

That would be a great place to start looking for literature.

- Thank you, that's great.

And we were able to pop the link in the chat for that one book that you mentioned.

And we are going to wrap up with our final question for this evening.

Can there be similarities with a schizoaffective disorder bipolar-type and borderline personality disorder, as schizoaffective disorder bipolar-type may have similar complications?

- Boy, that's a mouthful of different conditions.

Schizoaffective disorder is a psychotic illness.

And by bipolar-type there, the listeners probably meaning mainly bipolar or mainly affected.

It is a very different condition than borderline personality disorder.

Now, there may be similarities in the sense that many individuals with schizoaffective disorder do suffer from depression, and the effect of disturbance.

Effect is the word we use in psychiatry and psychology to mean emotion and the experience of emotion, and what you show the world.

Many people with borderline personality disorder also have trouble with depression.

So there may be similarities at the level of the sort of symptoms, but they are not thought of as being in any way closely related in a genetic or biological manner, or at the etiology, meaning the cause or the source of the two disorders is the same.

Schizoaffective disorder tends to reside mainly within the psychotic realm of disorders, and borderline personality disorder is not a psychotic disorder.

- Thank you, thank you so much.

Yes, that was a mouthful.

Thank you everybody for all your wonderful questions this evening.

I would like to thank our guest, Dr. Mark Lenzenweger, a professor of psychology at SUNY Binghamton, and professor of psychology in psychiatry at Weil Cornell Medical College.

And a licensed clinical psychologist in New York and Massachusetts.

He is currently continuing his landmark research project known as the longitudinal study of personality and personality disorders, and he is also developing new methods for the detection and quantification of insider risk indicators.

To find out more information about Dr. Lenzenweger's work, there is a link in the chat.

Thank you so much.

- Thank you as well.

I've enjoyed being part of the program, and I enjoyed the questions that the listeners sent in.

Many great ideas, and some really excellent ideas for research studies.

And I appreciate the opportunity to talk about mental health issues on WSKG and NPR.

- Thank you so much.

Our next Science Pub is on Tuesday, November 9th, with guest speakers, Dr. Corey Myers and Dr. Carly Pesh.

Who will share how paleontologists are unraveling the extinction that killed the dinosaurs.

You can watch past Science Pubs through the WSKG app on demand on your smart device, and on WSKG's website.

Be sure to like our Facebook page for future events and science updates.

I want to thank Dr. Lenzenweger for your time and expertise tonight.

This was a really fascinating talk.

I would like to thank our team, co-founder of Science Pub, Kristine Kieswer.

She was fielding your questions tonight.

Patrick Holmes, our chat moderator, Andy Pia, our director and producer for this evening, and Julia Diana, who was tweeting for us.

I'm your host, Nancy Coddington, thank you for joining us.

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