This post is something of a departure from my normal, experience-based posts. Here, I want to review the new diagnostic criteria for personality disorder, as proposed by Tyrer, Reed and Crawford (2015) . The categories trouble me, for several reasons, so here is to (attempt to) explain why.
For those who haven’t heard, the current plan for the International Classification of Diseases – 11 [ICD-11] (see current revision here) is to collapse descriptive labels, (e.g., Emotionally Unstable Personality Disorder, Avoidant Personality Disorder, Narcissistic Personality Disorder) into one diagnosis, personality disorder, where, after general personality disorder criteria are met (surrounding the usual suspects; e.g., empathy, intimacy, dissociation issues) categorisation happens on a continuum, from ‘no disorder’ to ‘severe disorder’.
The first reason I am uneasy about this is its utility. Accepting that I am not the best judge, I cannot definitively put myself into any one of those categories. To have ‘mild disorder’, one has “some problems” in functioning occupationally, with relationship difficulties, but no mention in the criteria of harm to self or others. At the other extreme, to have severe personality disorder, one’s ability or willingness to hold down a job is severely compromised, one has profound social dysfunction, and self-harms to endanger life. And then there is me. Full-time work over two jobs. Plus voluntary work. Plus relationships, that I have to put huge emotional effort into maintaining. Plus self-harm that has put my life in danger (and arguably continues to do so). I feel pretty constantly, inches away from tearing myself to ribbons. A TC contract hangs me a thread’s-width from doing just that. My living arrangements are precarious. But that is my housemate’s responsibility, not mine. No really; he’s in seriously big trouble with the law. My jobs are also due to end. But that is not unusual for someone at my stage in academia. In sum, I do not fit into any one of those categories, neatly or otherwise.
The other reasons I have for disliking the categorisation are more psychological and societal. I take issue with a diagnosis of mental distress that is defined in terms of occupational or relational functioning. I do so, not only because I go to great lengths, and utter exhaustion, to maintain functioning (and these categories invalidate that effort entirely — maybe I’m not ill after all…) but because of the problem of self-fulfilling prophecy and low-expectation — Oh, s/he has a personality disorder, s/he’ll not be able to hold down a job– that those who are younger than me, and who have not yet entered the job market, may face. Not to mention that this criterion for categorisation is blasted out of the water by research showing that there are more folks with significant traits of antisocial PD in a corporate executive boardroom, than there are in prisons, proportionally-speaking (see Babiak, Neumann & Hare, 2006).
When it comes to relationships, I already believe I am all bad, and all to blame for what goes wrong in them. This criterion affirms this perspective. And let’s not forget that lecture I had in second year Psychology, taken from text in Davison et al.’s (2008) Abnormal Psychology textbook, stating that those with BPD are impossible to live with. Many folk have lived with me and survived to tell the tale. I found the conflicts tough. But I kept myself to myself: it was others’ conflicts, into which I did not want to be embroiled, that frightened me.
There should, as noted by Pearce and Haigh (2017) be a number of benefits to receiving a diagnosis of PD. For example, it allows for a meaningful treatment plan, and gives an often relieving explanation of symptoms – as well, I would add – a sense of not being “the only one”. But, all of these benefits are overridden by stigma. Practitioners state reluctance to give this diagnosis, precisely because it is stigmatising. And because it could be that patients will “misuse” the diagnosis to negate responsibility for their actions. So, from the ground, the diagnosis remains hidden. As a case in point, note that my recent reflection mentioned my depression – but not my PD diagnosis.
I am not alone in worrying about this. The most excellent Dr. Jay Watts reviews the psychological research on the prejudice shown by mental health staff to those with PD versus other diagnoses, in particular the finding that PD patients are seen as acting up out of choice, and as more to blame for their problems than other patients. There is, it seems to me, a bitter paradox in receiving this diagnosis. On the one hand, you know what you’re dealing with. On the other hand, the world knows what you’re dealing with. In the media, in films, characters with personality disorder are oftentimes portrayed as dangerous, even criminal. People who are disliked intensely (Donald Trump) are viewed from afar by psychiatrists as having possible personality disorder. PD is stigmatised. And this new severity continuum could well add to that stigma, pulling in multiple innocent parties along the way; those who have never acted aggressively, or selfishly in their lives.
Meanwhile, in academia, the debate rages concerning whether PD may even be considered as a mental illness; in today’s terms, as something for which a person is not to blame (any more than they would be for a broken leg or diabetes) thanks to the work of organizations like Mind and Time to Change. But the rubbish of deciding what counts as mental illness has fallen squarely on the shoulders of PD.( see Kendell, 2002). Rather than being a mental illness, personality disorder is more often cited as a mental health problem. A disorder. And not a disorder of biological functioning (in spite of a plethora of brain imaging evidence pointing to deficits in that regard) but of personality. With varying degrees of success in their essays, my undergraduates define personality for what it is – the essence of who you are – the pattern of thoughts, actions, and feelings, that make you – you. The value judgement placed on our personality, on receiving a PD diagnosis is harrowing. It is confirmation of low (or absent) self-esteem – of a personality not worth having. What will the severity continuum do to the self-worth of those receiving the diagnosis? Nothing good, I suspect.
The ICD-11 severity continuum, now in beta-version, looks set to happen. Mindful of the fear and stigma surrounding personality disorder and its diagnosis even now, among the public, and those who really should know better, I am scared of what that stigma may become. By the time I end TC, I hope to have fewer symptoms of PD with less intensity than I do now. Since, to lose these labels, I have to be symptom-free for five years, I am struggling with the knowledge that the symptom goalposts will change, that I will carry the stigma-by-association of personality traits I never had in the first place. Whatever happens, I think it is time for Psychiatry and Psychology to address with the same honesty and vigour that was seen towards mental illnesses, the stigma of personality disorder.