Case Vignettes

The use of case studies runs throughout this guide. None of the vignettes represent actual cases although they are drawn from a mix of highly representative case material. The following case studies should serve to illustrate two very different manifestations of personality disorder:

Billy

Billy was taken into Local Authority care when he was ten years old, due to his mother’s inability to care for him. While in care he was sexually abused by a male worker and suffered bullying at the hands of other children. His behaviour subsequently deteriorated and he became difficult to manage. He frequently tried to run away from the home and was prone to intense aggressive outbursts. During these outbursts he would damage property and, occasionally, also be violent towards other children and staff alike. At this time he also started to self harm, by cutting his forearms and torso and punching and head butting walls. At age twelve he made a suicide attempt by trying to hang himself from the light fitting in his room. He was consistently truanting from school and eventually left care with no formal qualifications. He was then homeless for a time and supported himself by working as a rent boy and selling drugs. He was also a heavy user of alcohol, heroin and crack cocaine. While in the community, he had never managed to hold down regular employment and had a number of intense but short lived relationships with women. These relationships were volatile and characterised by frequent arguments. His offending history started when he was 14 when he received a Police Caution for Criminal Damage. Since then he has received a number of convictions, mostly for drug related offences, but also including a number of more serious offences. He was convicted of arson after he set fire to his flat whilst in a state of emotional turmoil and after an argument with his partner. He has two convictions for domestic burglaries. In custody he was initially volatile and aggressive and was placed on suicide watch, but he then appeared to settle down and worked as a wing cleaner.

It will be apparent that Billy suffers from personality disorder by identifying the presence of the 3 P’s:

  • Problematic
    Billy’s problematic personality symptoms include his impulsivity, self damaging behaviour (substance abuse, prostitution, self harm and suicide attempts) poor impulse control, unstable emotions, intense and volatile relationships, aggressiveness and offending behaviour.
  • Persistent
    These symptoms have been present at least since he was placed into Local Authority care and have persisted into adulthood.
  • Pervasive
    It should also be apparent that the symptoms affect a number of domains of Billy’s psychological functioning; namely his thinking, his moods, his behaviour and his impulse control. These symptoms also cause problems for him in a range of contexts, including relationships, employment, prison, education and offending behaviour.

With regards to diagnosis, Billy’s symptoms are most representative of a Borderline personality disorder (instability in a sense of self, relationships and emotions) although he also meets the criteria for an antisocial personality disorder (disregard for and violation of the rights of others). The overlap between these disorders is particularly common among samples of offenders. He also suffers from episodes of depression and has gone through periods of misusing substances.

A rather different manifestation of personality pathology is presented below:

Robert

Robert was an only child and was initially raised by both his mother and father. However his mother suffered from schizophrenia and committed suicide, when he was five. His father owned a religious bookshop, was reserved, somewhat puritanical and was a heavy drinker. He was not prone to expressing warmth or affection and never once discussed his mother’s death with him. Robert was mostly left to fend for himself, and preferred to spend his time alone. He collected comics and spent time riding his bicycle, but had no close friends. At school he was regarded as a loner and a ‘weirdo’ by the other children and he experienced quite frequent bullying. Although he did not outwardly express any distress, he would often spend time alone ruminating on his poor treatment by others and fantasising to themes of revenge. He did reasonably well academically, but not as well as might have been expected (given that a later IQ assessment found he had above average intellectual ability).

Robert left school at age 16 and took up work in the Civil Service. He also started to drink heavily at this time and developed a dependency to alcohol. Robert was generally a reliable employee but he was unpopular with his colleagues. He was regarded as aloof, quick to take offence and occasionally abrasive. He became further distanced from his colleagues after he took out a number of grievances against them, after misinterpreting benign emails as being malicious. In his early twenties he also ceased all contact with his father (who was his only social contact) after he failed to send him a birthday card. At around the same time he started to drink in the workplace and was subject to disciplinary proceedings. He had no intimate relationships until his early thirties when he met a woman in his local pub and subsequently co-habited with her.

The relationship lasted for several months, but deteriorated rapidly, as his partner found him to be emotionally distant, suspicious and accusatory towards her. He also lacked interest in sexual or intimate contact. Robert found the intensity of close personal contact unsettling, became preoccupied with doubts about his partner’s trustworthiness and eventually became convinced she was having an affair. He had difficulty sleeping and started to drink heavily. During a heated row in which she threatened to leave him, Robert suddenly lost all self-control, became utterly enraged and beat her to death with a hammer. He subsequently disposed of her body by burying her in a shallow grave near his house.

In prison, Robert has received one adjudication for aggressiveness (when asked to share a cell) and another for disobeying orders, but mostly he has caused few management problems and is observed to ‘keep himself to himself’. However, he has steadfastly refused to do any offending behaviour programmes and he is prone to developing grievances against professionals by writing long, acerbic and litigious complaints.

Although the symptoms of Robert’s personality disorder are perhaps less obvious (prior to the murder), the 3 P’s may still be identified:

  • Problematic
    Robert has demonstrated a number of pathological traits. These include a preference for solitary activities, a limited interest in close personal or intimate relationships, suspiciousness, a tendency to perceive malicious intent in other’s motives, ruminate on grievances, bear grudges and an apparent emotional detachment. He also has problems with alcohol misuse and the build up to and loss of control in the index offence was suggestive of some interpersonal problems.
  • Persistent
    Some of his symptoms have been evident since late childhood (such as the rumination, emotional detachment and preference for solitary activities). All symptoms have been persistently present throughout his adult life.
  • Pervasive
    The symptoms of Robert’s personality disorder effect his emotional experience, his thinking style and his behaviour and are evident in a number of different contexts (including his intimate, family and social relationships, as well as at school, work and in prison).

The symptoms present in Robert’s case are most characteristic of schizoid personality disorder (absence of attachments to others, flattened emotions) but he also possesses some paranoid traits (distrust, suspiciousness). He also suffers with an alcohol dependency.