“YOU SHOULD never call a psychopath a psychopath. It upsets them.” That’s a favorite quote from the charming, murderous Villanelle in the TV series “Killing Eve.”
Both Villanelle and real-life Theranos founder Elizabeth Holmes, profiled in John Carreyrou’s book Bad Blood and in a Jennifer Lawrence-starring film in the works, have been called psychopaths. Psychopathy is not an official diagnosis but instead encompasses extreme forms of several personality disorders, notably antisocial personality disorder (APD) and often narcissistic personality disorder (NPD).
The 10 personality disorders, which are grouped into three clusters in the DSM 5 (the diagnostic manual for psychological illnesses), “denote rigid, inflexible and maladaptive patterns of thinking and behaving leading to impairment in functioning and/or significant internal distress.” About 30% of people requiring mental health treatment have at least one personality disorder.
Cluster B disorders are “characterized by dramatic, overly emotional or unpredictable thinking or behavior.” Along with APD and NPD, Cluster B includes histrionic personality disorder (HPD) and borderline personality disorder (BPD). Grandiosity, the need for admiration and a callous lack of empathy are characteristics of all four.
(Cluster A is characterized by odd, eccentric thinking or behavior, including paranoid and schizoid disorders; Cluster C is characterized by anxious, fearful thinking and behavior, including obsessive compulsive disorder [OCD].)
While each personality disorder is viewed as a distinct mental illness serious enough to create problems relating to other people, many overlap. Among people with BPD, for example, 85% meet the diagnostic criteria for at least one other personality or mood disorder.
“People with antisocial personality disorder are willing to use deception or manipulation to get what they want… show no regret or guilt…lack a sense of empathy and cannot consider the feelings of others without help,” writes Kathleen Smith on Psycom.
But high-functioning people, who are charismatic and successfully hold positions of power, are “not the norm” with APD. Also labeled sociopaths, they struggle with irritability and aggression and tend to behave impulsively and irresponsibly.
Elizabeth Holmes convinced investors like Henry Kissinger and Betsy DeVos to hand over some $600 million for her seemingly miraculous finger-prick home blood test before being exposed as a fraud. She created an intimidating persona,based on her hero Steve Jobs. She wore all black and lowered her voice to a “mesmerizing deep baritone,” according to Carreyrou—although that tended to slip after a few drinks.
Despite Holmes’s “unflinching” blue-eyed stare, the myth about psychopaths never blinking isn’t true. Some blink very little at photos that are disturbing or unpleasant, but most blink often when lying.
Holmes acted with grandiosity and self-importance, and she fired employees ruthlessly—all typical of those with NPD. Her wealth once estimated at $4.5 billion, Holmes now faces up to 20 years in prison.
Which personality disorder is most prevalent has changed over the years, according to several studies. OCD held the top slot in 2008, APD in 2002 and HPD (characterized by “constant attention seeking, emotional overreaction and seductive behavior…tend to overdramatize situations, easily susceptible to the influence of others”) in 1997.
Louise Turpin, the California woman who has been accused along with her husband of starving, torturing and imprisoning their 13 children, received this diagnosis, though not the hoped-for release from jail to a mental health treatment center while awaiting trial.
Most personality disorders are first diagnosed in adolescence or in early childhood where they are often labeled “conduct disorders,” including the milder variant seen in younger children called “oppositional defiant disorder.” Conduct disorders are “the most common reason for referral to child and adolescent mental health services in Western countries” and are becoming more frequent.
“Untreatable” has always been a defining characteristic of personality disorders, because symptoms reflect ingrained patterns of thinking and behavior. Also, because of difficulty thinking clearly, many sufferers lack insight or awareness about their condition, called “anosognosia” from the Greek meaning to not know a disease.
Most sufferers have such trouble getting along with other people that they rarely seek treatment and, when they do, often drop out. Patients with BPD, the most commonly treated personality disorder, quit treatment programs about 70% of the time, according to “Treatment for the ‘Untreatable’” in the American Psychological Association’s Monitor.
Newer methods have had better success based on a combination of group and individual treatment, such as Dialectical Behavioral Therapy (a skills-based approach teaching management of emotions and improving relationships) and Schema-focused therapy (identifying unmet needs that have led to negative life patterns).
As “Killing Eve” continues, the psychopath label seems less apt for Villanelle, because she is a hired hit woman. She kills those she is asked to kill, whereas “when female psychopaths kill, the motive is usually money, or attention, and the victims are people they know.” (When male psychopaths kill, usually the motive is psychosexual and the victims are strangers.) Also, Villanelle is at times “genuinely thoughtful…and charming.”
Every Tuesday in this space, well-being editor Mary Carpenter reports on health news you can use.