"I can be smooth, charming, and slick. I can make a very confident impression and it's hard to put me at a loss for words. Sometimes, I find myself fantasizing about unlimited success, power, and beauty. I have repeatedly used deceit to cheat, con, or defraud others for my personal gain. To be honest, I don't have much concern for the feelings of other people or their suffering." Doesn't sound like the Hank you know, does it? These are all statements from a self-assessment measure for personality disorders that lets patients describe themselves, ranking each statement in terms of how accurate they think it is. To be honest, you can't really rely too much on this kind of self-reporting to assess what we're talking about today. While some people who are overconfident or obsessed with power or downright deceitful might tell you that they are, there's a certain subset that won't. Many of the disorders we've talked about so far are considered ego-dystonic, meaning that people who have them are aware that they have a problem and tend to be distressed by their symptoms. A person with bipolar disorder, or OCD, generally knows that they have a psychological condition, and they don't like what it does to them. But some disorders are trickier than that. They're ego-syntonic. The person experiencing them doesn't necessarily think that they have a problem, and sometimes they think the problem is with everyone else. Personality disorders fall into this category. These are psychological disorders marked by inflexible, disruptive, and enduring behavior patterns that impair social and other functioning, whether the sufferer recognizes that or not. Unlike many other conditions that we've talked about, personality disorders are often considered to be chronic and enduring syndromes that create noticeable problems in life. And as you can tell from these self-assessment statements, they can range from relatively harmless displays of narcissism to a true and troubling lack of empathy for other people. Not only can personality disorders be difficult to diagnose and understand, they can also be downright scary. Most of the extreme and severe disorders go by names that you probably recognize, like psychopathy and sociopathy. I'm talking about serial killers here, mob bosses, Vlad the Impaler. Cultures have been studying human personality characteristics for thousands of years, but the concept of personality disorders is a much newer idea. Much of our modern classifications of these disorders are based on the work of German psychiatrist Kurt Schneider, who was one of the earliest researchers into what was then known as psychopathy, and published a treatise on the subject in 1923. Today, the DSM-5 contains ten distinct personality disorder diagnoses, grouped into three clusters. The first cluster, Cluster A, includes what are often labeled simply as odd or eccentric personality characteristics. For example, someone with paranoid personality disorder may feel a pervasive distrust of others and be constantly guarded and suspicious, while a person with schizoid personality disorder would seem overly aloof and indifferent, showing no interest in relationships and few emotional responses. Cluster B encompasses dramatic, emotional, or impulsive personality characteristics. For example, a narcissistic personality can display a selfish, grandiose sense of self-importance and entitlement. Meanwhile, a histrionic personality might seem like they're acting apart to get attention, even putting themselves at risk with dramatic, dangerous, and even suicidal gestures. The behavior of Cluster B can be truly self-destructive and frightening, and these disorders are often associated with frequent hospitalization. Finally, Cluster C encompasses anxious, fearful, or avoidant personality traits. For example, those with avoidant and dependent personality disorders often avoid meeting new people or taking risks, and show a lack of confidence, an excessive need to be taken care of, and a tremendous fear of being abandoned. Now, in the past, and to a great extent today, some of these categories have been controversial. Many researchers argue that some of these conditions overlap with each other so much that it can be impossible to tease them apart. A narcissistic personality disorder, for example, has many traits that resemble histrionic personality disorder. And because of this gray area, the most commonly diagnosed personality disorder is actually Personality Disorder Not Otherwise Specified, or PDNOS. The prevalence of this diagnosis suggests that while clinicians can identify a personality disorder in a patient, figuring out the details of the condition can be messy and difficult. One proposed alternative for diagnosing these disorders is the dimensional model, which in essence gets rid of discrete disorders, and replaces them with a range of personality traits or symptoms, rating each person on each dimension. So the dimensional model would assess a patient not with the aim of diagnosing one disorder or another, but instead, simply finding out that they rank high on, say, narcissism and avoidance. It's a work in progress, so with another generation, the clinical definition of personality disorder may evolve pretty radically. One of the best-studied personality disorders right now is Borderline Personality Disorder, or BPD. Borderline makes it sound like patients are, like, pretty close to being healthy, but not quite. But that is not at all the case. BPD sufferers have often learned to use dysfunctional, unhealthy ways to get their basic psychological needs met, like love and validation, by using things like outbursts of rage, or on the other end of the spectrum, self-injury behaviors like cutting or worse. People with BPD were once commonly maligned by clinicians as difficult or attention-seeking, but we now understand BPD as a complicated set of learned behaviors and emotional responses to traumatic or neglectful environments, particularly in childhood. In a sense, people with this disorder learned that rage or self-harm helped them cope with traumatic situations, but as a result, they also end up using them in non-traumatic situations. Although challenging for patients and clinicians alike, the good news is that some psychotherapies have helped even the most severely suffering, repeatedly hospitalized BPD patients. But probably the most famous, well-established, and frankly troubling personality disorder is antisocial personality disorder. I've heard of this before, but maybe by one of its now somewhat out-of-vogue synonyms, psychopathy or sociopathy. People with antisocial personality disorder, usually men, exhibit a lack of conscience for wrongdoing, even towards friends and family members. Their destructive behavior surfaces in childhood or adolescence, beginning with excessive lying, fighting, stealing, violence, or manipulation. As adults, people with this disorder are thought to generally end up in one of two situations. Either they're unable to keep a job and engage in violent, criminal, or similarly dysfunctional behavior, or they become clever, charming con artists or ruthless executives who make their way to positions of power. Tony Soprano would have qualified for a diagnosis, even if he wasn't nearly as bad as, say, serial killer Ted Bundy or Vlad the Impaler, the infamous 15th century Romanian prince who personally watched about 100,000 people get impaled or have the skin of their feet licked off by goats. Yeah, that happened. Despite this classic remorselessness, lack of empathy, and sometimes criminal behavior, criminality is not always a component of antisocial behavior. Certainly, many people with criminal records don't fit that psychopathic profile. Most show remorse, love, and concern for friends and family. But still, although antisocial personalities make up just about 1% of the general population, they were estimated in one study to constitute about 16% of the incarcerated population. So how might someone end up with such a disturbing disorder? Well, as you might expect, the causes are probably a tangled combination of biological and psychological threads, both genetic and environmental. Although no one has found a single genetic predictor of antisocial personality disorder, twin and adoption studies do show that relatives of those with psychopathic features do have a higher likelihood of engaging in psychopathic behavior themselves. And early signs are sometimes detected as young as age 3 or 4, often as an impairment in fear conditioning. In other words, lower-than-normal response to things that typically startle or frighten children, like loud and unpleasant noises. Most kids only need to get burned by a hot dish once to know to stay away, but kids who end up displaying antisocial personalities as adults don't necessarily connect or care about the learned consequences when they're little. From there, like we've seen in other disorders, genetic and biological influences can intersect with an abusive or neglectful environment to help wire the personality in a peculiar and damaged way. While the vast majority of traumatized people don't grow up to be killers or con artists, genes do seem to predispose some people to be more sensitive to abuse or trauma. Meanwhile, studies exploring the neural bases of antisocial disorder have revealed that when shown evocative photographs, like a child being hit or a woman with a knife at her throat, those with psychopathic personality features showed little change in heart rate and perspiration as compared to control groups. And the classic antisocial lack of impulse control and other symptoms have also been linked to deficits in certain brain structures. One study compared PET scans from 41 people convicted of murder to those of non-criminals and found that the convicted killers had greatly reduced activity in the frontal lobe, an area associated with impulse control and keeping aggressive behavior in check. In fact, violent repeat offenders had as much as 11% less frontal lobe tissue than the average brain. Their brains also responded less to facial displays of stress or anguish, something that's also observed in childhood. So it's possible that some antisocial personalities lack empathy because they simply don't or can't register others' feelings. Research has also suggested an overly reactive dopamine reward system, suggesting that the drive to act on impulse to gain stimulation or short-term rewards, regardless of the consequences, may be more intense than the average person's. As we mentioned before, because personality disorders are pretty much egocentronic by definition, people don't often acknowledge that they have a problem or a need for treatment. And in the case of antisocial personality disorder, even if they did, there aren't many specific treatments available, at least not for adults. But there are some promising interventions for kids and adolescents, whose minds and brains are more plastic and adaptable. In this way, the best way to treat antisocial personality disorder may be in trying to prevent it. According to American psychiatrist Donald W. Black, among others, many kids diagnosed with conduct disorder, the diagnostic precursor to antisocial disorder, are at high risk for developing antisocial personalities as adults. But by identifying warning signs early on, and by working with these kids and families to correct their behavior and remove negative influences, some of that impulse fearlessness could be channeled into healthier directions, like toward promoting athleticism or a spirit of adventure. It's important to remember that antisocial personality disorder is only one type of personality disorder. This is a diverse family of psychological conditions determined by many different factors, and we're still in the early stages of diagnosing and understanding the mechanisms behind them. Today, you learned about personality disorders, and the difference between egodystonic and egocentronic disorders. We looked at the three clusters of personality disorder, according to the DSM-5, and how personality disorder symptoms often overlap. We also took a look at borderline and antisocial personality disorders, including their potential biopsychosocial roots. Thank you for watching, especially to all of our Subbable subscribers, without whom we could not make Crash Course. To find out how you can become a supporter, just go to subbable.com/crashcourse. This episode was written by Kathleen Yale, edited by Blake de Pastino, and our consultant is Dr. Ranjit Bhagwat. Our director and editor is Nicholas Jenkins, the script supervisor and sound designer is Michael Aranda, and the graphics team is Thought Café.