The difficult diagnosis of personality disorder

I have referred to the diagnosis of personality disorder in a few of my previous posts. It’s something I have thought about a lot, both in my own dealings with psychiatry as a patient, and also as a psychiatrist, and I can never feel comfortable with it. I’ve tried to justify it as a response to trauma, and a diagnosis for which there should be sympathy, but it doesn’t really wash.

I suppose one problem is that without it some people would not get psychiatric diagnoses, given that it includes those who might not be diagnosed with another disorder. This might be good or bad – good in that they are not given what is often a stigmatising label, but bad in that they might not get any help for their difficulties. They may also feel that professionals are saying that there is nothing wrong with them. The solution to this might be to completely revise psychiatric diagnoses, which is unlikely to happen, and would also be extremely difficult, given that many of the criteria are fairly subjective.

So what is this diagnosis, and why is it given? Essentially it is a range of diagnoses describing different behaviours. It may include feelings, notably emotional instability, but this is often assumed from behaviour. We all behave in different ways at different times – many of us will have behaved in a way that might have lent itself to a diagnosis of personality disorder, usually in response to specific circumstances, be they physical, emotional or interpersonal. We all react to what happens to us. But does that make our personality disordered? It may only happen at times of stress, and this has to include one obvious example of hospital admission.

There are many definitions of personality, but they all encompass the concept that it describes, or makes up, what we really are. It is the way we think, feel, behave, and is uniquely ours. If I, as a psychiatrist, say that you have a personality disorder (or worse, ‘PD’), what am I saying? That you are behaving in a way that I don’t like, or feel is inappropriate? Despite the subtypes, it is also rather non-specific – I am saying that your personality, a concept which is hard for me to grasp, is disordered in some way. And there can be an unpleasant subtext in psychiatry – that you are therefore untreatable (compared with other diagnoses), and must take responsibility for your actions. At the same time I am relieved of my responsibilities.

There is no doubt in my mind, however, that some people who behave in ways that distress themselves and others, do not easily fit into the other currently available psychiatric disorders. I can’t argue with this, but it is my opinion that there need to be other ways to describe them – whether they be illness-related, societal or even moral. Personality disorder describes a wide range of behaviours, which makes it even less convincing as a concept. But perhaps the most punitive is emotionally unstable personality disorder, as this is the one that is usually meant when people refer to someone having a ‘PD’. This is a nasty label. When I am unwell – and sometimes at other times – I worry that people think I have a personality disorder. When I say this to my psychiatrist, he never asks me why, or what kind, and that can only be because he knows my fears. Actually, I think quite a few health professionals who are also patients do get this label, and they may be particularly anxious about it.

However, it is the behaviours that are being criticised, not the personality. I have said before that psychiatric illness will make one behave differently, and at times this will be perceived as badly. I have often heard people say – ‘Is this behavioural or illness?’ What on earth does this mean? We all behave, and illness is one thing that may make us behave differently. But I would rather someone queried my behaviour than my personality – at least this might open up some sort of discussion about it.

There is, of course, another big issue, and that is one of resources. I don’t know whether we medicalise things more now, but it certainly feels at times as though we are trying to treat misery and deprivation rather than illness, and it is hardly surprising that we don’t often succeed. But we are now expected to diagnose and treat a huge range of distress, so we end up applying labels that we don’t even believe in ourselves. We lack the psychological resources that we might need, and end up over-treating with medication, which then itself gets a bad name.

I said in a previous blog that some people like or accept the diagnosis that they are given of personality disorder, and this is quite true. But it has usually been explained in a way that fits their life experiences and suffering, and thus makes sense. It doesn’t make it a real disorder. The danger with rejecting it is that the people with these diagnoses may end up being even more rejected. There has to be a better way of describing distress or illness than an unproveable denigration of personality. I have long accepted it in my work, while trying to use it positively. But I don’t want to continue using a classification that I find inaccurate and unhelpful. I am happy to describe behaviour and record what people tell me, even my impression, but I think I shall stick with the other diagnoses that we have, or not give one at all. Those other diagnoses may not be perfect, but at least terms like depression or schizophrenia have some utility as regards treatment.

Finally, I know that there are treatments used for people with diagnoses of personality disorder, both psychological and pharmacological, and I do not say that these will not provide benefit, simply that the term personality disorder is not acceptable.