Sunday, April 29, 2012

Is Personality Destiny? The Evolution of Personality Disorder in Mental Health


The term ‘personality disorder’ has an ominous ring. It calls up images of white-coated psychiatrists scribbling on clipboards as they probe young men in straitjackets, or a crazed commuter jumping out of his vehicle to smash an offending driver’s windscreen with a steering lock.

Perhaps that’s why despite all the public debate about anxiety disorders, depression and the need for better mental health services, the term rarely gets an airing in the media – except when describing a nasty crime, or the rise of the corporate psychopath.

But it seems to me that if you’ve got any sort of mental illness, an accompanying personality disorder, even a minor one, can play a huge role in how successfully you manage it – and your life in general. Personality disorders strike at the very heart of who we are, and can profoundly affect our career and romantic destinies.

Yet personality disorders remain underdiagnosed and untreated.

More than 1 in 10 of us may have one, according to Professor Eddie Kane from the UK’s Institute of Mental Health. He estimates the rate of personality disorder in the community to be somewhere between 4 and 13 per cent.

And mental disorders don’t conveniently travel alone. According to the 2007 Australian National Survey of Mental Health and Wellbeing, about 25 per cent of people with mental disorders were found to have two or more classes of disorder.

To make matters more complicated, the difference between an anxiety disorder and a personality disorder is not as clear cut as you might think. Proneness to anxiety is actually a character trait in some personality disorders.

What about the poor sods who suffer both anxiety disorders and some degree of personality disorder? (I’m one of them.) Do they cancel each other out? Hardly. I’m too socially phobic to open my mouth in some situations but when I do, I have to watch those nasty personality quirks that are lurking, waiting to come out.

Thankfully, the categorisation of personality disorders is currently undergoing revision to reflect the complexity of human behaviour.

What is personality disorder?

The UK National Health Service defines a personality disorder in the following way:

Personality disorders are mental health conditions that affect how people manage their feelings and how they relate to other people.
 Disturbances of feeling and distorted beliefs about other people can lead to odd behaviour, which can be distressing and which other people may find upsetting.

People with a personality disorder are said to respond in a habitual way to life’s problems, regardless of how dysfunctional the response is. They do this to a degree that damages their relationships with family members, friends, and coworkers. Both genetics and upbringing are involved.

Personality disorders are said to differ from anxiety disorders, or more traditionally neuroses, because the sufferer is supposed to identify with the behaviour and have no interest in changing it – that is, the behaviour becomes ‘ego syntonic’.

The assumption is that the sufferer doesn’t think there is anything wrong with their behaviour, but believes the world is to blame; they won’t seek help without outside pressure, or perhaps will seek it only when their life is inexplicably not working out for them. This is the truism offered by the MerkOnline Medical Manual:

People with a personality disorder are unaware that their thought or behavior patterns are inappropriate; thus, they tend not to seek help on their own.

This suggests that those with personality disorders project the disordered parts of themselves onto the world, rather than internalising them. This may often be the case, particularly for, say, a narcissistic personality disorder. But it also implies that as soon as someone with a personality disorder gains insight into their problem it is, by definition, no longer a personality disorder!

Perhaps it would be more accurate to say that the behaviour is so familiar and comfortable that it seems like second nature. Someone who has avoidant personality disorder will feel more comfortable avoiding people but may feel unhappy enough with the consequences to seek help.

I’d always thought that those with personality disorders but not anxiety disorders were more able to operate in the world compared with anxiety and phobia sufferers because they made life more difficult for everyone else rather than turning against themselves, but this doesn’t seem to be true at all. The Merck Manual states that:

Regardless of their usual style … mentally healthy people are likely to try an alternative approach if their first response is ineffective. In contrast, people with a personality disorder are rigid and tend to respond inappropriately to problems.
Perhaps the degree of functionality depends on the severity of the disorder. One of my relatives is unbearably narcissistic, with an overbearing manner and a strong sense of her own superiority. She’s been causing angst for her family for decades now, and had a detrimental effect on my own childhood. Yet she functions capably at work, maintains friendships, and would not dream of seeking professional help in a million years. A major part of the problem is the collusion of her friends and siblings – no one has dared to challenge her over the years, preferring to bitch behind her back instead.

Yet her disorder has caused her some unhappiness. She’s never had a partner, and is constantly feeling let down by people whose behaviour doesn’t conform to her expectations.

Similarly, certain kinds of social organisations and social positions actually encourage and prop up certain disorders, rewarding social dysfunction but enabling the retention of power and position. Thus, patriarchy may encourage narcissism in some men; certainly any degree of celebrity does, in both sexes.

Latest personality disorder definitions

The standard text for identification of mental disorders is the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. The current edition is DSM-IV; DSM-V is due for publication in May 2013.

DSM-IV identifies 10 main categories of personality disorder and places them in three clusters.

Cluster A (odd or eccentric)

Paranoid personality disorder
Schizoid personality disorder
Schizotypal personality disorder

Cluster B (dramatic, emotional, or erratic)

Antisocial personality disorder
Borderline personality disorder
Histrionic personality disorder
Narcissistic personality disorder

Cluster C (anxious or fearful)

Avoidant personality disorder
Dependent personality disorder
Obsessive-compulsive personality disorder

It also identifies an additional four disorders, placing them in a ‘personality disorder not otherwise specified’ category. These are:

Sadistic personality disorder
Self-defeating personality disorder
Depressive personality disorder
Passive aggressive personality disorder.

In DSM-IV, all these disorders have ‘subtypes’. This suggests that the overarching labels may be too simplistic. It would probably be more useful to talk about a finite number of tendencies, behaviours and traits that cause problems if taken to an extreme, and to acknowledge that any combination of these traits, in different strengths, is possible.

DSM-V seems more aware of these nuances and has a more sophisticated approach to personality disorders.

Now there are only seven categorised disorders. Allied to these are five personality trait ‘domains’, with each one broken down into its own set of ‘trait facets’, 25 in all. The wording acknowledges the grey areas: ‘domains’ and ‘facets’ suggests far less rigidity than ‘type’. The seven disorders are:

Borderline
Obsessive-Compulsive
Avoidant
Schizotypal
Antisocial
Narcissistic
Personality Disorder Trait Specified

Five broad personality trait domains are defined, and within these, various trait facets. The trait domains are:

negative affectivity
detachment
 antagonism
disinhibition vs compulsivity
psychoticism

This presents much more flexibility when treating someone who may not be sufficiently pathological to be diagnosed as having a full-blown personality disorder – it’s now possible to have a bit of this and a bit of that. The new schema also allows clinicians to ‘describe the personality characteristics of all patients’. In other words, it’s not exclusively about pathology any more.

This blog entry describes some of the implications of the changes.

This kind of mapping could be very useful. Potentially it could enable treatment protocols and options for tendencies rather than illnesses.

Wouldn’t it be great if every patient was given a personality map showing particular traits that were too pronounced for good mental health, and was then given individualised treatment for dealing with those various traits. If I have a touch of narcissism, there should be behavioural and mental exercises I can do to reduce its effects.

Psychiatric labels – good or bad?

These days there’s a tendency to label an increasing number of human emotions and characteristics as disorders, and it’s just as popular to attack this practice. Grief is an obvious example; a proposal to make it a disorder in DSM-V is causing much controversy.

Abhorrence of such labelling isn’t surprising. Whenever a new malady is created, whether physical or psychiatric, there’s a strong chance of finding the grubby paw prints of the pharmaceutical industry somewhere in its conception, eager to flog a drug to treat it. The industry is often accused of inventing diseases to sell drugs.

As well, once you whack a label on someone, the label then affects how they see themselves and how others see them. I’ve written on this blog about an unfortunate experience I had with a psychiatrist who was determined to diagnose me as an ADD sufferer, and wanted to drug me with dexamphetamine.

Can psychiatric labels be empowering?

 Despite these risks, I still believe that identifying and coming to terms with conditions and tendencies is a necessary first step to effectively managing them. If a doctor is scared to pin labels onto her patients she may be reluctant to look out for all the pathologies that dog them. Once you have a label that you’re ‘happy’ with, it’s up to you to find the treatment that most suits you. And whether that includes pharmaceutical drugs is up to you.

Sandy Jeffs is an advocate for sufferers of schizophrenia who has written a memoir about her condition. She refuses to call herself a schizophrenic, instead describing herself as someone who suffers from schizophrenia. She’s not defined by the label; she uses it simply to identify the nature of her suffering.

Effective criminology also relies on labels. The importance of psychological profiling for crime solving is highlighted in Erased: Missing Women, Murdered Wives by Marilee Strong. This confronting book investigates a particular type of murderer, the eraser killer. The author, not a criminologist but an experienced crime and social issues reporter, suggests a new kind of profile for a certain form of intimate partner killing, very different from the traditional domestic violence perpetrator, who kills in anger and feel remorse afterwards. According to Strong, these men are not the wildly impulsive serial killers of popular imagination; instead, it’s their unique combination of disorders – excessive narcissism and Machiavellianism with a degree of sociopathy – that enables them to kill wives and girlfriends when they become inconvenient.

The reason this knowledge is so important is the same reason it’s so unpalatable. The thought that murderers are not monsters but human beings with extreme version of normal human traits, existing in particularly destructive combinations, makes it difficult to ‘other’ them – there but for the grace of God go we. These killers are not inhuman – on the contrary, they’re all too human.

Yet this degree of knowledge also raises the possibility of prevention through early intervention, social supports, and parenting training. It begs the questions: what style of parenting might produce such a combination of traits, and what styles of parenting would prevent them?

The perfect therapy

Imagine if every consulting psychiatrist and clinical psychologist provided a comprehensive diagnosis for their patients, possibly assisted by brain imaging. This could include a list of all anxiety disorders, including low-level conditions, and personality traits, with traits at a pathological level listed separately.

The therapist would then provide an outline of an individualised treatment plan. This could include acceptance and commitment therapy, exposure therapy and traditional CBT, as well as development of life skills and social skills. The various treatment options would require the patient to undertake various exercises. In some cases drugs might be involved, but not necessarily.

The perfect therapy would include a long-term relationship with a trusted therapist. In a recent Radio National program on self-harm, one sufferer spoke of the slowness of her recovery, hampered by the fact that her therapists were always moving on. Now she's seeing someone she trusts and her need to self-harm is reducing.

A lot of work and public money perhaps. But in the long run it would save money 
by producing happier and more functional people. And needless to say it would improve the quality of life of not just the sufferers of mental illness but their families.

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