Facing Machiavelli: Nicole Kidman’s Botox-Flavoured Success

I’m currently at the tail end of a mild obsession with Nicole Kidman. It started when I watched a DVD of The Hours and realised that there were moments in that film when she transcended Nicole Kidman-ness and became a serious actress.

And even times when it was possible to admit that not only did she successfully portray a fictional neurotic, English writing genius resembling Virginia Woolf but that it was fair to say she successfully portrayed Virginia Woolf herself, despite the double insult of her wildly unsuitable physical appearance and ridiculous fake nose.

If someone in the public sphere attracts your attention it may be because they portray a characteristic you've not developed fully. When it comes to Nicole Kidman, I have no trouble working out what it is – her untroubled, lighter-than-air Machiavellianism. This basic human trait (well, primate trait actually) is something I’ve always struggled with.

It also interests me because the sister just below me, I’ll call her Frances, has always had a very healthy Machiavellianism – perhaps even a bit too developed. And I hated her for it. I thought she was outrageous and I fought her bid for status and attention every step of the way. I have no doubt that my hostility, from the time she was only about two, strengthened that Machiavellianism, hardened it in her and made her see life as a fight to survive in the world.

I wonder whether my own Machiavellianism is somehow stuck at this early stage. Even now competition for me always has a pathological aspect. There is a bitchy, childish side to my dealings with the world that sees success as a zero sum game – I’m still working on the template of: if I win, Frances loses; if Frances wins, I lose. What about cooperation in an environment in which it’s safe to reveal you own skills? Other people seem to be able to do this effortlessly, yet it’s a mystery to me.

It’s not that I was devoid of Machiavellianism in the wider world; at school my social phobia meant that I was ultra-conscious of social hierarchy. I was just incapable of using this knowledge to advance my cause, my life, myself; indeed I used this knowledge against myself: I was low on the social hierarchy at school, therefore counted myself as lower in value. There is such a thing as good, healthy Machiavellianism. This is what I find so intriguing about Kidman: is her Machiavellianism pathological or not?

My sister actually looks a bit like Nicole Kidman. I watch Kidman in scenes with the great actors of ‘our day’ – Jude Law, Shirley MacLaine, Miranda Richardson – and wonder: how does she dare? (How come my sister is so different from me? How come she is, partly due to my early influence, Machiavellian to a fault?)

When I started researching this topic, what I discovered surprised me. Machiavellianism is almost always portrayed as a negative thing, a pathology. Wikipedia reports that it’s now lumped in with narcissism and psychopathy as part of a Dark Triad, with researchers claiming that there is significant overlap between these traits; some psychologists believe it to be a subclinical version of psychopathy. Yet interestingly it's never been included in the Diagnostic and Statistical Manual of Mental Disorders. Does this suggest some ambivalence about it on the the part of researchers?

This illustrates what bugs me about the way psychiatrists look at personality. With a focus on pathology, they don't seem interested in character for its own sake. Yes, they talk about 'subclinical' and bicker over what that means. But surely a characteristic such as Machiavellianism is fine within a constellation and only a problem when it gets out of hand? And perhaps insufficient amounts of it could also be a clinical problem? A lack of Machiavellianism – taking everything at face value – could be the very definition of unworldliness. Perhaps mental health researchers need to start concentrating on the factors enabling societies to grow balanced human beings with the right proportion of each characteristic.

Defining Machiavellianism

But what is Machiavellianism anyway? Wikipedia defines it as 'a duplicitous interpersonal style associated with cynical beliefs and pragmatic morality'. I’ve always had a more benign view, assuming it was simply the human desire to advance your chosen interests, combined with the social skills needed to assess the environment you’re in and to use it to advance those interests. That usually means being part of a group, and using the group to get ahead. Even at a non-pathological level, Machiavellian motives have the potential be in conflict with the interests of the larger group.

That all sounds calculating and negative, makes Machiavellianism seem an unpleasant fact of life; perhaps it also demonstrates the gap between the way the world operates and the way we would like it to. Many workplaces are seething hotbeds of the overambitious; the more unequal society gets and the more tears in the welfare net, the rifer Machiavellianism will probably become.

But Machiavellianism is clearly necessary for the complex social groups primates form, and the advances we have made as humans. And we label people who don’t have this ability as having Aspergers, and all too often we let them know in no uncertain terms that they don’t belong.

Machiavellianism is not the same as personal ambition. Someone could have a great deal of ambition, a great desire for success, and be hopeless at using social groups and people to advance those ambitions, or just be average at it.

But nor is it necessarily always about self-interest. If it involves a knowledge of how power works, much depends on what you do with that knowledge, and whose interests you try to advance in using it. Bob Brown, former much-revered leader of the Australian Greens, was and is Machiavellian down to his last pore, but not in a venal way. He wasn’t interested in accumulating money or power. Instead, he cleverly used the structures of power – parliament in this case – to advance the interests of a larger group: his fellow Australians and indeed all the future citizens of planet Earth. Not only that, but he tried to use his position not to consolidate his own power, but to share power around more freely – to make Australia more democratic. So simply a knowledge of how groups work and using that knowledge to advance your cause doesn’t make Machiavellianism pathological.

Perhaps we have to distinguish between the Machiavellianism of a Bob Brown and that of the average, self-interested person who wants their share of power and wealth – let’s call this self-interested Machiavellianism. Even here, it isn’t easily divisible from a healthy interest in one's own welfare and that of one's family. At what stage does Machiavellianism, whether self-interested or not, descend into evil rubbing of palms together and a sinister cackle? At what stage does the calculating type become the stereotypical villain? 

Perhaps this depends on what exactly you’re willing to do with your knowledge of power structures to advance your cause. Are you willing to manipulate others? Pit people against each other? Sabotage their careers? Lie about them? This is clearly Machiavellian behaviour at the unhealthy level, regardless of whether your motives are selfish or selfless. Perhaps a healthy institution is one in which an individual's ability to succeed depends on their ambition, hard work and talent more than it does on their degree of Machiavellianism, whether healthy or unhealthy.

Bob Brown’s version means that his own personal ambitions are not easily separable from those of the larger human group; he positions himself and his struggle as part of the struggle of humanity for a better world. But self-interested Machiavellianism, however seemingly benign and non-pathological, always has the potential to be in conflict with the needs of the larger group.

Botox and self-interest

This leads me back to Nicole Kidman. She is obviously ambitious – nothing wrong with that. She has worked very hard and taken carefully calculated steps to build her career. She has done so to the extent that if you think of her mainly as mediocre, as I do (not in lighter roles – she is perfect for light comedy), her success has prevented much better actresses from playing the fascinating gamut of characters she has portrayed. Who knows what Hilary Swank, Chloe Sevigny, Tilda Swinton or even Cate Blanchett might have done with some of her juicier roles?

This is not something peculiar to her of course. Gwyneth Paltrow did the same thing for many years. Remember her in Sylvia?

Despite her very public breakup with Tom Cruise, Kidman has always struck me as someone who, when compared with a lot of other celebrities of similar prominence, had a high degree of psychological health. Her father is a psychologist, her mother a teacher; the family are close, and Kidman talks about her parents and sister with great warmth. She has never appeared to have a serious drug problem, made inappropriate remarks, or fallen into the traps of celebrity, except in one area – her use of Botox and other ‘fillers’.

And this is part of the question that exercises me – given her apparent psychological health, why has Kidman been willing to distort her face to the extent that she is now the butt of unpleasant YouTube videos? Her balanced personality sits at odds with this extreme.

My answer: Kidman's obsession with Botox isn't the result of some deep-seated childhood emotional deprivation. She's simply Machiavellian enough to know that in a toxic industry that rewards youth and cookie-cutter Barbie Doll beauty, her career will benefit from the regular application of Clostridiuim botulinum. And this canniness has paid off: at 44, she landed the role of Grace Kelly in the forthcoming film Grace of Monaco, directed by Olivier Dahan, a role every female actress in Hollywood was surely drooling over.

I say this not to denigrate her but to acknowledge that Machiavellianism is the ability to judge the particular environment in which one finds oneself and to work out how to succeed within it. That Kidman has judged her level of Botoxification necessary demonstrates that her healthy Machiavellianism is at the upper end of the scale; but also perhaps that the environment she is working in is toxic for women.

Now, bear with, as Miranda would say; this is where things get interesting. As I’ve said earlier, self-interested Machiavellianism is usually in tension with the broader interests of the group. While our toxic societies tend to reward unhealthy Machiavellianism, in our public discussions we applaud those who put the interests of the group ahead of their individual advancement. Not everyone has to make this choice of course, but sometimes a clear choice has to be made. And Kidman, while seeking her own career advancement, is a tiny bit responsible, along with the other legions of the facially adjusted, for making it difficult for women as a whole, and female actresses in particular, to succeed without taking a syringe to their faces.

So, while her Machiavellianism is not pathological in itself, the decisions she has made to appease it are the result of her immersion in a toxic environment. If we still insist on seeing Kidman as part of a community, part of a society, she has failed us. Not only by making an ironed face the norm, but by providing a poor example to the millions of young women who consume Hollywood gossip. Stars are role models, whether they choose to be or not; Kidman has put her career above this consideration.

This is not to say she makes decisions any different from a number of stars. Kate Moss posed topless in a blonde wig for the December 2012 issue of Vanity Fair, in photos accompanying a long  article exploring her career longevity; now that we're saturated in porn culture, it's simply what you do to stay ahead if you're a supermodel. In 1994, Kylie Minogue went raunchy in the video clip for her single 'Confide in me', and stripped naked for the follow-up single, 'Put yourself in my place' (below, looking uncannily Kidmanesque). Unfortunate choices, but plenty of men would have done the same if facing the same constraints; women are no more Machiavellian than men, we just make choices within more difficult circumstances.

Yet these are choices, albeit made in misogynist environments. I don't want to give the impression that you need to do bizarre and antisocial things to succeed in life. Some people are strong and talented enough to carve out their own niches simply by being very, very good at what they do. Australian comedian Magda Szubanski has had a self-admitted weight problem since the year dot, yet through sheer talent, and probably a healthy dose of Machiavellianism in other areas of her life, this aspect is part of the charm she brings to her most memorable characters.

So why was Kidman so damn good in parts of The Hours, I hear you ask? Ha! That's another story and another blog entry.

And, no, my sister Frances doesn’t use Botox – as far as I know.

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Coming your way - the empowered patient

I was reading a forum recently on the topic of 'staring OCD', a very distressing condition. The discussion was headed by a doctor who was either a psychiatrist or psychologist. Some of the sufferers suggested that their condition seemed to be caused by a combination of social anxiety and OCD. The doctor responded that this wasn't the case; instead the staring OCD was causing the social anxiety.

How could he know that this was true for each individual sufferer? To my mind it's arrogant to make a sweeping dismissal of patients' lived experience of comorbidity in this way. Staring OCD has been all but ignored; many therapists seem not to have heard of it. For some patients it could well start off as an obsession with staring and progress to social phobia, but it's not exactly farfetched to suggest that the two are often connected from the beginning; the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) acknowledges that social phobia and OCD in general often occur together.

This is an example of doctors being in love with particular categories that patients then have to squeeze themselves into, even if it's an uncomfortable fit.

It also suggests how important it is for patients to empower themselves and learn to trust their instincts (as opposed to 'listening' to their illness).

An empowered patient might refuse to take this doctor's opinion as gospel truth if it doesn't chime with her lived experience. At the same time she might recognise the doctor's overall expertise and use his knowledge in other areas as a resource.

What does empowerment mean if you have a mental illness?

About two months ago, for the first time in a decade, I started taking Luvox, an SSRI that is often used to treat OCD. Around this time I became fully aware of one of my 'conditions' for the first time, and the many ways it has affected me over the years and continues to do so – pure obsessional OCD, or 'pure O' as it's sometimes called (sounding more like a soap powder than a mental illness).

Being on the drug has made me think a lot about what it means to be mentally ill, to have a condition that affects the way you relate to others, and to be 'medicated'. It's renewed some of my regrets about my earlier failures to make the most of drugs to improve my mental health, and to take responsibility for my life rather than handing over too much power to therapists. Here, then, are some of my thoughts about these issues. Please be aware that the recommendations I make are reflections of my own experiences.

Psychiatric drugs that have an acceptable degree of clinically proven efficacy and safety are neither good nor bad – assuming, of course, that the patient needs the drug and can benefit from it. Along with therapy they are tools, with two people wielding them and responsible for their safe use – the therapist and the patient.

Both need to understand that a drug is not a cure but a starting point. Assuming the drug is compatible with the patient's biochemistry, along with therapy it may enable her to reach a level of functioning that makes further change possible. Positive changes in the brain made by the combination of drugs and therapy may lead the way to further brain changes as the patient gets used to ever riskier and more challenging activities.

Whether positive change takes place depends on the commitment and hard work of the patient, and the effectiveness of the therapy, but there are also a host of other factors: the severity of the illness, the patient's support structure, whether she has security in housing and finance, and whether she has other addictions or health issues.

All this suggests an approach that considers the dynamic between patient, drug, doctor and the patient's larger social context. Within this dynamic there is one factor beyond all others that to my mind determines success.

The patient's degree of maturity is a key element in the treatment. She must be ready for the effects of the therapy, including the initial side effects of drugs, and the ups and downs to expect. She must be able to 'hold herself' and to withstand the whirlwind of change without dropping the therapy in a panic if her beliefs are challenged or as soon as something goes wrong.

Maturity enables the patient to be as fully aware as possible of the nature of her illness, and the way it operates in her life, and to separate the illness from her own self-image.

Maturity implies empowerment and self-advocacy. In some instances it may mean a patient who talks back, who appears to be non-compliant, who doesn't always take the therapist's word as gospel.

In some respects the patient may be more knowledgeable than the doctor about the day-to-day, lived aspects of her illness. This should not be surprising; given that less than half a century ago some doctors were still sticking ice picks into people's eye sockets and detaching the prefrontal cortex from the thalamus, it's fair to say we're at an early stage when it comes to understanding the nature and causes of mental illnesses. For example, we now know that the diagnosis of schizophrenia actually refers to a cluster of illnesses rather than just one.

However, the doctor will be more objective and have insights that the patient needs; the patient must find a balance between trusting her own instincts and taking full advantage of the doctor's expertise and objectivity. And doctors need to retain a degree of open-mindedness about the lived experience of patients and to look at qualitative as well as quantitative evidence, while not indulging or kowtowing to their patients.

Benefits of empowerment

It took me years to become empowered because I had to struggle with lack of information from therapists and my own dysfunctional thought processes to get a clearer view of the world. You need to know yourself and the operations of your illness very well before you can be an empowered, assertive patient and not simply non-compliant.

Ironically, the very psychiatrists who disempowered me by refusing to give me a clear diagnosis – something I didn't think to ask for myself – helped me in other ways by encouraging me to shed many of the deluded ideas I had about life, to grow up and to take some responsibility for myself.

It's my belief that if therapists want ultimate success they should try to foster empowerment in their patients. I'd go so far as to say that encouraging the necessary maturity for patients to actually grapple fully with their illness should be one of the major goals of therapy. While a certain degree of empowerment and self-knowledge can only come from experience, therapists can do a great deal to hasten the process.

No therapist should feel threatened by the idea of an empowered patient. Without life skills, self-knowledge and maturity, the patient can't get the full benefit of the therapy. An empowered patient is one who is motivated to change and recover to the extent possible. An empowered patient and their therapist can become a team with a common goal while still having separate roles and responsibilities.

Below are my ideas for the way therapists might do this. Of course some therapists already do some of the things I call for, such as encouraging their patients to join a self-help group.

A better way

These are the steps I believe therapists should take when they're establishing a relationship with a new patient.

• After gaining an overview of the problem, explain herself, her qualifications and methods of treatment, and let the patient 'interview' her.
  
  The patient needs to find out whether she wants to work with the therapist, while the therapist needs to ascertain whether she feels she can help the patient or whether the patient should be referred to someone else. Many therapists simply assume that they are the person for the job.

• Once enough information has been gained, tell the patient exactly what she believes is wrong with her and the implications of this. The therapist should be open-ended about these implications.
• Point the patient towards resources rather than suggesting that she is the only resource.
• Encourage the patient to arm herself with knowledge and join self-help groups.
• Encourage questioning and feedback, while being willing to call the patient out when she exhibits thoughts and fears that may be related to the disorder.
• Set up a treatment plan with goals (to be agreed by the patient) and ways to achieve those goals.

• Encourage the patient to pursue a healthy lifestyle and to get the basics of life right – housing, work or financial support, strong relationships. If there are barriers to any of these, they should be treated as goals and included in the treatment plan.

• Work out if the illness has created distorted thinking and ideas about life, society, and important life goals, and personality factors such as dependency and narcissism. If these kinds of things aren't identified they could stymie the treatment. Personality problems don't need to be fully blown personality disorders to sabotage progress.
• Share these findings with the patient and incorporate them into the treatment plan. 

• If the patient has concerns about medication (common for OCD sufferers, for example) rather than taking offence or trying to fob the patient off she should talk about risks versus benefits, ways to minimise side effects, and assume the patient has a 'What's in it for me?' approach.

Empowering young people

I was pleased to hear that some aspects of this approach are being used in the treatment of schizophrenia in young people. In a recent discussion on Radio National about the latest treatments, the practitioner spoke about the importance of early intervention, and the need to tell young patients that it was important to focus on two things that are basic to happiness: work and love.

I couldn't agree more. Young people with mental illness need to be encouraged to grow up faster than their peers. Work and love are, after all, the goals of most people's lives (which is not to say that a recovery plan should always aim for, say, a full-time nine-to-five job and a long-term relationship – recovery for some people could mean volunteering and establishing new friendships).

Following a thorough diagnosis (including personality factors) and treatment plan, this is what I wish I'd been told when I first presented to a psychiatrist at the age of 21 with an unspecified nervous problem. I would like to see all young people receive a similar introduction when they first enter therapy.

•  How you manage this condition will affect the quality of your life.  The most important thing you can do now is grow up and learn to look after yourself, and work on your treatment plan. While a certain degree of rebellion and acting out is normal for your age group, it may just hold you back and threaten your recovery.
• Get the basics right.  A secure roof over your head, good diet and exercise, strong and healthy relationships are essential to your recovery.
•  Alcohol and caffeine are not your friends.  If you have any serious addictions, go into treatment for them.
•  Use your time wisely to develop as a person.  Focus on strong friendships, and work towards being partner-ready without being obsessed about finding a partner. A strong relationship can greatly assist your success, so work on yourself.
• Don't try to do all this perfectly.  There will be plenty of times when life gets temporarily busy, and there will be setbacks as well as strides forward.
• Be sensible about sex. Sexual experimentation can be good and healthy but only if it is fully consensual and you feel happy and comfortable about it. But sex as an escape, or sex that is exploitative and not enjoyable for you, is simply a waste of your time.
• Learn to separate your thoughts and intuitions from your feelings.  Trust yourself, but don't necessarily trust all your feelings all the time – they will chop and change. Learn about your intuition and separate it from your emotions. Learn to follow your gut but remember your emotions aren't always telling you the truth.
• Don't give away responsibility for yourself.  Respect professionals and their advice but view them as resources.You are not there for their benefit; if they're not helping you, you are under no obligation to keep seeing them. On the other hand, try to tolerate a state of openness and unknowing; it may take time to form an opinion on whether a treatment is working. Leaving simply because a therapist challenges your boundaries, prejudices or distortions would be self-defeating.
• Understand that there is nothing wrong with the essential you.  Your disorder is stopping your true self and personality from expressing itself. Your goal should be to come home to, and learn to love, the body and mind you have, and to live your own life, not someone else's.
• Work towards a sustainable career.  Where work's concerned, it's a fine balance between taking your illness into account and stretching the boundaries. Accepting and managing the illness is vital to your success. Choose your vocation carefully – whether you have to give up on a particular dream or pursue it will depend on individual circumstances but management of your illness must come first if you want long-term success and health. At the same time, sometimes only experience can tell you if a career path is right or not; cultivate flexibility and be willing to change to a related career or different way of working if a job or vocation is too stressful.

I was a very rigid thinker, and had strange ideas about the world, when I was 21 and first spoke to a psychiatrist about my nervous condition. Would I have been able to take advice like this on board at the time? Probably not if it was verbal, but if something similar had been given to me as a leaflet, and presented as advice from other sufferers, it might have helped.

Most of all, if I'd been told that I had a serious condition, a chronic illness if you like, that I would have it all my life, that no magic Freudian catharsis was going to get rid of it and that it was up to me to accept this and learn to manage it, I might have cultivated more sticking power, patience and resilience. I hope people going into therapy for the first time can get the full benefit of the many resources now available to them, and understand that they are their own greatest resource!

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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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