06.20.12

Sandusky To Try Nearly Obsolete Histrionic Personality Disorder Defense

The former Penn State coach is invoking a soon-to-be-obsolete personality disorder to defend against sex-abuse charges. Jesse Singal on why Sandusky’s defense team may not have done their homework.

It’s not the Twinkie Defense, but it’s not far off.

The claim made by Jerry Sandusky’s defense team that the former Penn State football coach, who is on trial for dozens of counts of sexual abuse of children, suffers from histrionic personality disorder—and that this both explains his predatory behavior and partially absolves his responsibility for it—has been met with derision by many experts.

“It seems implausible to assume that a character disorder with histrionic features could impel or motivate somebody to commit acts that were illegal and immoral,” said Jeffrey Lieberman, chair of psychiatry at Columbia University Medical Center. “It wasn’t like this person was psychotic and was unable to distinguish right from wrong and reality from unreality.”

The evidence Sandusky’s lawyers are relying on is a series of “creepy” letters Sandusky allegedly sent to boys he is accused of abusing, which featured, flowery, emotive prose. These, his lawyers say, should be read not as Sandusky’s attempts to prey on the boys, but rather as a manifestation of his disorder.

There’s just one problem: histrionic personality disorder, or HPD, may not even be a clinical disorder by this time next year.

That’s because the American Psychiatric Association is in the midst of revising its clinical bible, the Diagnostic and Statistical Manual of Mental Disorders, known as the DSM-IV. The hefty manual lays out the specific symptoms that should be present for a psychiatrist or psychologist to diagnose a given disorder. HPD’s symptoms include: “is uncomfortable in situations in which he or she is not the center of attention” and “interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.”

The fifth edition of the manual, or DSM-5, is set to be released in next May, and the APA just finished conducting a six-week open-comment period on many of the proposed changes to the new version. Among these is a revision of how personality disorders are categorized and diagnosed, and HPD is on the chopping block.

To revise the DSM, the APA convened 22 expert groups to focus on different areas of the field. The personality-disorder working group, led by Andrew Skodol of the University of Arizona, consulted the available clinical and research literature and found that there isn’t a strong enough case to be made for maintaining HPD as an independent disorder, or “type” in the parlance of the field. Skodol declined to comment for this article, except to confirm that HPD is not being considered as its own personality type.

The committee has proposed cutting the current list of 10 personality disorders in half, said committee member Renato D. Alarcon, a psychiatrist at the Mayo Clinic, and HPD isn’t on the list of survivors.

“There are a number of reasons why the term histrionic personality disorder has not been considered [for inclusion in the DSM-5],” Alarcon said. What it comes down to, he said, is that there simply isn’t enough robust evidence that HPD can be usefully seen as its own disorder.

“I guess they went to DSM-IV, but perhaps did not know about DSM-5,” Alarcon said with a laugh. “The entity is in DSM-IV, and they thought, ‘Okay, we’re going to use it,’ and perhaps didn’t realize it has such a number of weaknesses.”

Blaise Aguirre, a researcher at MacLean Hospital outside Boston who specializes in borderline personality disorder, said that some of the momentum for these changes came last year at the International Society for the Study of Personality Disorders Congress in Melbourne.

“There was a big discussion there last year,” he said. “And the idea was,  ‘Look, we’ve created all these personality disorders, but there’s actually no real evidence that they exist.’” So in the future, assuming the proposed changes find their way into the DSM 5, patients who present with HPD-like symptoms may instead be diagnosed with another disorder, such as borderline personality disorder.

The removal of HPD “doesn’t mean [histrionic characteristics] should not be studied as a trait, as a little component of a larger entity,” Alarcon said, “but it does not meet the requirements of a personality disorder type.” The characteristics in the current definition of HPD—overwrought, emotional, attention-seizing behavior—may still be important to clinicians in certain cases, Alarcon said.

But to return to Jerry Sandusky: Why resort to histrionic personality disorder to explain his actions? The element of novelty may have been a factor, Columbia’s Lieberman said.

“It’s a less well-known personality disorder,” he said, “so it may have less familiarity to people, and therefore they’re more likely to consider it because they don’t really know what it is.”

Whatever their tactical reasoning, the defense’s use of HPD also suggests they may not have fully done their homework.

“I guess they went to DSM-IV, but perhaps did not know about DSM-5,” Alarcon said with a laugh. “The entity is in DSM-IV, and they thought, ‘Okay, we’re going to use it,’ and perhaps didn’t realize it has such a number of weaknesses.”