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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Looking for Alternative Sources of Sustainable Energy? Try a Menopausal Woman

Picture: Retro Adverto

I’m going through it. It’s got me. It seemed as if I’d only just completed my second adolescence when it struck.

It was perimenopause for a while, a long while. Sleeping badly. Thinning skin and other signs of ageing. The onset of tinnitus, rosacea and a worsening of allergy symptoms. Losing more hair than usual with each wash, and constantly finding stray hairs on every household surface. Terrible PMT but longer and longer gaps between periods. Then my cycle seemed to have packed up and called it a day, and instead all the blood went to my head.

I didn’t mind the first set of hot flushes. I just found them weird and disorientating. The flush seemed like some strange form of energy, some odd kind of bodily weather, that started in my chest and literally moved up my body, expelling itself in a facial heat wave. As if I was suffering a kind of automatically induced induced embarrassment. Set and forget.

But then my periods started again, and the PMT was truly awful, starting about nine days before the onset, manifesting in heightened anxiety and reduced sleep, with extreme fatigue just beforehand.

Then the periods stopped and the flushes started again, as if my body couldn’t decide whether or not it wanted to end my child-bearing capacities. This is where I’m at right now. And this time, I don’t like the species of hot flush at all. It engulfs me quickly, fills the upper part of my body with heat, then drops me like a hot potato, going away somewhere to plot its imminent return. I’m left not only wildly throwing my outer garments off in an attempt to cool down (I can deal with that) but uncomfortably sweaty. I wish I could store some of this heat and use it to warm my house in the mornings.

Through all these changes, and starting from perimenopause, an increased level of body- and self-consciousness has manifested. No one warned me that my anxiety, already unmanageable, was going to get worse. That every bodily perception would be heightened and every fear increased. Menopause is like adolescence without the good looks and sexual opportunities.

Sorry to bore you with these details, but I can see why menopause has a bad name. The symptoms become tedious not only to those suffering them but to their partners and families. The awful thing is, you have no idea how long it’s all going to go on for. At least the progress of adolescence is entirely predictable – pimply and pained followed by lissome and love-hungry followed by substance-abusing and driving homicidally followed by reluctantly growing up. But how long will this transition take? And what will the new me look and feel like at the end of it?

Pharmaceutical help?

I have considered HRT, but I foresee many problems with it. 

I’m not worried about the increased risk of breast cancer, heart disease and stroke that was reported in a large and controversial 2002 study on the effects of HRT use. The study has since been discredited because the women who took part in in were older when first put on HRT than the optimum age of commencing, and because of dosage issues. Anyway, I’m on a strict allergy diet, don’t drink or smoke, have low blood pressure and no family history of breast cancer so am probably in a low-risk group.

It’s more the cosmetic side effects of HRT that concern me. As someone with body image issues, I’m not sure I want to risk the facial breakouts that are one possibility (confusingly, HRT can sometimes clear the acne that perimenopause produces). I shouldn't let this put me off, however, as I can always try an alternative medication if the first one isn't right for me. The possible weight gain wouldn’t bother me – I could do with some extra weight.

On the other hand, the protection from osteoporosis that synethetic oestrogen offers could end up being crucial to my future health. A few years ago my mother developed  osteoporosis  in a way that was both sudden and disabling, as well as incredibly unfair – she'd been eating yoghurt regularly for years, and her GP worked in an expensive practice that prided itself on its preventative care. As someone who rarely eats dairy, I need all the protection from brittle bones that I can get.

An upside of menopause?

I know there are women who want to reclaim menopause as a time of personal power, creativity and freedom. Certainly as a feminist I want those going through it to be supported rather than denigrated, and given a range of effective treatment options. And I don’t want to exaggerate its ill effects. I’m no vaguer than usual and while I’m sleeping less, I rarely lie awake trying to get to sleep – it’s waking too early that’s the problem. Also, oddly enough for such a low-energy person, I’m surprised at how much energy I have, during the day at least. I get up as early as 5.30 in the morning and work away at the PC for hours (although I do tend to collapse into a stupor of exhaustion early in the evening). And apparently women who experience hot flashes early on in menopause are actually at lower risk of heart disease and stroke.

But the bodily changes lead to difficult emotional reckonings. Women, it's said, are more grounded than men because our reproductive cycle never lets us forget that we are embodied beings whose lives are at least partly determined by biology. While we can make lifestyle decisions that influence our health, we are to some extent the playthings of an impersonal force that has far larger ends in mind than our individual health and wellbeing. Menopause is a bodily reminder of a specific kind: that reproductive life is at an end, and old age looms. I’m fine with not having had  kids, but in the years to come sex and relationships will be complicated by further bodily changes. And that part of my life is difficult enough for me already. In a way, menopausal women are reaching the pointy end of the life cycle.

But this forced change is part of an even larger story than the end of the possibility of motherhood and challenges to sexual fulfillment. In menopause, whether we like it or not, the force that is ageing our bodies has as its ultimate aim for us that great taboo of Western culture: death. It's an eventuality that  our consumer culture, obsessed with youth and endless novelty, fails to prepare us for.

To make things even more difficult, the timing of menopause means that it frequently coincides with a number of other life crises and losses. I’m currently coming to terms with the facts of parental illness, which I’ll write about in a future post.

Someone once said old age wasn’t for the faint hearted. I think the reckoning comes much earlier. As we face our fifties, we’re forced to jettison the illusions we had about life in our earlier years. We’re also challenged to take control of our health and make decisions about how we can minimise problems in years to come (something I’m signally failing to do at the moment).

It’s not an easy time by any stretch, but it can produce a great deal of strength and resilience. Without illusions, it’s possible to appreciate the present and enjoy life for what it is, rather than what we’d like it to be. It's possible, too, to make lifestyle choices that at least swing the odds into our favour where future mental and physical health is concerned. Accommodation to reality, while not succumbing to negativity – that’s my major challenge now, and it will remain so in the years to come.

If you enjoyed this entry, you might also like Vein Hopes.

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Haunted by the Ghosts of Memory: Is Memoir Writing Good Therapy?

Photo by Harmony and Home

Can writing a memoir actually help heal a painful past? Is it therapeutic, or does it simply provoke bitter memories and angry ghosts that are better left alone? Like an explorer returning exhausted but triumphant from a gruelling journey, full of information about the terrain she’s traversed, I can assure you that the psychic knowledge that results from memoir writing is well worth the effort.

But there is a catch. If you want your writing to come alive, you'll need to revisit the raw trauma of the original pain, and risk being seared and burned by it once more.

To write a memoir that I considered worthwhile, I had to relive painful experiences and periods. I was aiming for a sensual, immediate tone that strongly evoked each episode (I’m not saying I achieved that – just that I tried). So I plunged myself back into each stinging memory, and consciously tried to recall exactly how it felt to be in that situation at the time.

Not an exercise for the fainthearted.

That goes for particular episodes. But what happens when you’re writing about a significant period of your life for a matter of weeks and even months? When I was 20 I moved into a share house in the inner-city suburb of Fitzroy that was opposite an estate of high-rise public housing flats. This was way before Fitzroy’s gentrification and the culture shock was immense, not only in regard to the geography but to the lifestyles of my lefty housemates. I soon developed a crush on one of them, and the intensity of those feelings is inseparable from the bohemian romanticism of the shabby iron-laced terrace we inhabited.

While I was writing the scenes set in my Fitzroy abode, I felt haunted. I was living in two eras at once, the present and the early 1980s, and two places at once, the terrace house and my current flat. The contrast between my past and present lifestyle, combined with strong feelings of connectedness with people I hadn’t seen for more than 25 years, was profoundly disorientating. I was surrounded by ghosts who would not let me go. Perhaps – and here’s the kicker – I was releasing feelings for them that I hadn’t felt secure enough to fully experience (let alone express)  at the time.

When you’re going through something like that it can feel as if it will never end. You wonder if you’ll be permanently trapped in an emotional time warp. But it does pass. Not that the feelings don’t come up again every now and again – I believe now that if a traumatic experience is sufficiently intense it creates its own momentum in the psyche, and complete freedom from it may never be possible. But for me at least the intensity is now far less, and I’m a freer human being through having released those pent-up emotions.

Not only that, but in a strange way you may gain a stronger relationship with yourself. I know myself better now. I’m Adrienne McGill who experienced certain very human emotions at a particular time, not simply Adrienne McGill who went into meltdown when she moved out of home for the first time. I’ve become better acquainted with the non-pathological aspects of my younger self; it’s like meeting a scary stranger who is much less frightening once you get to know them.

Memoir writing and forgiveness

Sometimes writing the memoir involved not just reliving old emotions, but experiencing difficult new ones. A memoir forces you to examine your personal journey with a keen and bloodless eye. While you're working out what really happened, no one can be allowed to get off the hook.

So, not the most forgiving daughter at the best of times, I was faced with powerful anger as I put together the jigsaw puzzle picture of my life. The mistakes my parents made were routine rather than extreme, but they sometimes had profound effects. For much of the time of writing I was furious with both of them in a way I hadn’t been before, but particularly so with my mother.

But understanding something cognitively ultimately allows you to move beyond it. Discovering something new about the reasons for a pathology makes you realise that your brain is much more adaptable and creative than you'd given it credit for. You begin to perceive the perverse rationality of your dysfunction, to view it as a logical reaction to circumstances. Aha you say, this is why I closed up, or this is why I acted out. You gain more compassion for yourself.

You may also end up with compassion for the authority figures that once oppressed you. It took me a long time to escape from the deep well of anger for my mother that I was thrown into. I was angry with her even before I started writing the memoir and, in the way described above, my anger intensified while writing it. I’ll never completely lose the anger, but it has now substantially subsided.

This is partly because however egregious my mum’s perceived failures, writing about her has forced me to see her as a separate human being with a life independent of me, and her own story of parental failure. (Making me less narcissistic in the process.)

But it’s also because I now own my own story. I’ve set it out, and my mother’s an important part of it, and I’ve told what I believe to be the truth about our relationship. I’m somehow freed by the fact that the story of me and her is now on the public record. And this is not dependent on some kind of public naming and shaming – it’s all been done very discreetly.

This greater ability to distinguish my identity from hers makes it possible for me to go forward with the understanding and knowledge that I don’t have to live my life as an endless response to our story and relationship. Instead, I can live my life with courage, stretching myself and fulfilling the potential of the creativity that was buried so long under neurosis.

Publishing a book can give you a stronger sense of self regardless of whether it's about your own life. Completing my first book, which was about shopping, and having it out in the public realm helped me start to separate from my family. The memoir has boosted this process simply by being another book, but its subject matter has also helped to free me from the psychoanalytic aspects of my background. I’m now an author with my name on the cover of three books (even if it’s a pseudonym for two of them). I can begin to stop hoping that my family will one day be what I want them to be, and instead get on with being the person that I am.

If you enjoyed this blog entry, you might also like You Must Remember This.

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Body Dysmorphic Disorder and the Sins of the Camera

I have a mild verson of body dysmorphic disorder. I impose impossibly high standards on my attractiveness and then feel dismayed and inadequate when I can’t meet those standards. It’s a mean way to live, to judge myself so harshly.

I’ve never been diagnosed with BDD, and its arrival in my life was subtle – it never really felt like a new disorder, more like another outlet for my existing obsessiveness.

Most of the time I’m okay with my appearance these days, but every now and then something happens that throws me completely off kilter.

Given that BDD is related to OCD, I imagine one treatment would be exposure therapy based on getting used to the sufferer's own appearance. In the case of ageing, this exposure would need to be constant: our faces regularly show small alterations as we age, alterations that would be imperceptible to the average person but can spell doom to the BDD afflicted.

This is disconcerting, but I’ve learned to cope. I can now adjust my expectations each time there’s some slight change in my actual appearance. I’ve learned to accept and live with many changes  in recent years and I’m confident I can keep doing this.

Photos of me present an additional problem: I have the sort of bone structure that doesn’t flatten well into the two-dimensional image. This means that the face that I’m familiar with simply doesn’t translate to a photo. I look different in the mirror from how I look in a pic.

Just as I’ve gotten used to my changing appearance in real life, I’ve resigned myself to the fact that photos of me will not look like the image I see when I look in the mirror. I don’t like this state of affairs, but I can live with it.

This shouldn’t matter. Photos are an important means of recording our lives for ourselves, friends and family as well as posterity. Even if we personally let down by them (as I do), avoiding the camera isn’t the answer.

But flash photography represents another degree of foreignness altogether.

The other night I was planning to spend the evening at a friend’s place, and I asked him if he’d mind taking some photos of me for my business website. The photo that’s currently on the site is two and a half years old. I’ve kept it on the site that long not just because it shows a younger version of me but because it’s a good photo – and I’m not the most photogenic person in the world.

Because it was evening, my friend took the photos using flash. The result? Pictures that were so at odds with my actual appearance that they gave me a distinct downer. I looked like a ghost, incredibly gaunt and with dark shadows under my eyes.

I don’t think I’m being overly critical here. I think the camera is! Now I've reached my late forties the camera's two-dimensional images are harsher than they've ever been, and flash photography increases the disparity between the real me and the photographic one.

So the question is: now that I know flash photos show a ghostly avatar that bears little resemblance to the real me, what should my response be? Should I gradually expose myself to these images for longer and longer periods of time so that they eventually lose their ability to discombobulate? Or should I avoid flash photography like a vampire avoids the light?

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