Sep
20
2011
A blog in The Independent: PD ‘One of the most controversial & misunderstood areas of mental health’
A recent blog by Anthony Bateman in The Independent – in case you missed it.
http://blogs.independent.co.uk/2011/09/14/personality-disorders-one-of-the-most-controversial-misunderstood-areas-of-mental-health/
I suffer from a personality disorder, so I have been informed by a psychiatrist, and it certainly is not a ‘load of rubbish’! Perhaps the lady who thinks personality disorder’s are a load of rubbish, would have a different opinion if she actually has a personality disorder herself? Maybe she should try looking at things from a ‘different view point’?
I am a complete layperson to the field of psychiatry/ healthcare but I have a nagging question regarding ASPD. How do psychiatrists differentiate between ASPD and substance abuse disorder? It is well recognised that individuals with personality disorder often have co-existing substance abuse problems but it seems to me like a “chicken and egg” situation. Surely substance abuse, being an antisocial act in itself, brings about changes in personality whereby the user manipulates the world to fit in around the habit. Alcoholics/ drug abusers also display significantly higher amounts of reactive aggression and/or violence, one of the classifications of ASPD. I am sure that there probably are two distinct disorders here but how does a psychiatrist, with limited knowledge of the patient distinguish between the two? ie. How many substance abusers are wrongly diagnosed as primarily having PD? More importantly, why do we still see a divergence in treatment strategies for mental health and substance use? I worry that, unless a clear distinction is made, diagnosis of ASPD may result, not only in iatrogenic harm but also offer the patient a good excuse to behave badly!
Also with some researchers stating that 50% of our prison population suffer from ASPD, it could be construed as a blanket term for people with loose morals! On the flip side, unfortunately results such as these might actually persuade health care providers to disregard this disorder altogether.
I understand that to be diagnosed as having PD, a patient has to have displayed behavioural problems in childhood. However, NICE guidelines suggest that early intervention during adolescence might prevent development of PD in adulthood. Therefore, could it be that some children adopt maladaptive coping strategies as a result of poor adult guidance/ support and this is carried through into adulthood? This chain of thought suggests that ASPD in itself (ignoring co-occurring mental illness such as depression) is a behavioural disorder rather than a mental health problem. How can anybody be expected to show understanding towards this group of individuals when a clear definition seems yet to be defined? (I apologise to sufferers of ASPD who might misinterpret my questions as lacking empathy. I simply have very little understanding of the subject and can see how difficult it must be to make a precise definition of this disorder and hence why it is so controversial).
As a psychiatrist and specialist in the field, I quite agree with nearly everything you say here.
Why though, as sentient and sensitive beings, can we not live with the uncertainties and imprecisions you rightly identify, without having to ‘sort them out’? (It’s like what we hear constantly on the news at the moment about the financial markets being ‘unable to manage uncertainty’. Isn’t that what they are paid for?)
What that means to me as a clinician is that we can very easily get lost in arguing the technicalities of diagnostic precision and forget the patient (controversial term itself, there). And diagnostic precision helps hardly a jot with actually undertaking the necessary task of therapy, except perhaps by giving us a spurious sense of certainty and authority.
And the same could be said for research in the field…
Dear Rex Haigh,
Many thanks for your reply and yes, you are right. Successful therapy is the most important goal. I started reading up on PD after making friends with someone who has been diagnosed with this disorder. He immediately told me he had been a psychiatric in-patient as if to warn me off. He obviously didn’t need to do this and so I endeavoured to try to understand his problems and what he is going through. The main factor I have noticed is that my friend has an incredibly low self-esteem, and his destructive behaviour (namely alcohol abuse) and reactive aggression appear to be the consequence of his attempts to preserve his esteem. Putting myself in his shoes, I would be horrified to be told I have a “personality disorder”. The name in itself would make me feel inadequate as a social being. On the plus side, he has benefitted greatly from the expert help he has received from clinicians such as yourself. However, the label seems to keep him fixed in the belief that he couldn’t possibly fully recover. What if his problems are transient? Afterall, our esteem is only built on what we believe about ourselves.
I suppose my reasons for posting questions/ comments is to stir a debate to enable experts to defend this diagnosis because its pathophysiology is so complex. To me, the therapy seems fairly beneficial, but the diagnosis makes me feel uneasy. I argue that a clear definition would enable more effective therapy. Unfortunately the label “personality disorder” does seem to reek of the “spurious sense of authority” you are attempting to avoid!
Apologies, I meant psychopathology not pathophysiology!
Indeed – when telling somebody about ‘their diagnosis’ I always explain that it is an out-of-date term (but one which will probably take years to fade away, despite any professional efforts to do so). About half find it reassuring that ‘they have something real and they are not alone’, and half are, as you suggest, horrified with it. But we just don’t have an accepted alternative which everybody who needs to, will understand it – though I expect most of us working in the field have our pet favourites (I have been through ‘attachment disorder’, ‘complex PTSD’, ‘complex trauma’, and others. I’m currently rather liking ‘complex emotional needs’ – but it’s far from good enough)
Another point is that I when I write something about PD, whether to clinical colleagues or in articles to be published, always say ‘so-and-so is diagnosable with PD’ and not ‘so-an-so has PD’. I think there is a big difference, though I find it hard to explain without resorting to sociological ideas about power imbalance and almost the ‘politics of diagnosis’.
But the whole of the mental health field is riven with such conundrums, and I think it’s fundamentally about how we use language to relate to each other – when talking about things for which words are inadequate.
Dear Rex Haigh,
Thank you so much for taking the time to reply to my post. I’m glad that you too share my views on this term, although it does benefit in drawing attention to the matter as we all value our own personality as what makes us who we are. I too like “complex emotional needs” although I agree it doesn’t quite encompass the whole issue. If I were to describe my friend in this way (although I realise everybody is different and it nowhere near covers the whole PD spectrum), I would use the term “complex social apprehension”. And when he jokes that he’s “mad”, I must admit I quite agree because anyone who completely lacks self belief when they are clearly so capable must be bonkers!
I am so appreciative of all the hard work you and others are putting in to making us all aware that this is an issue for the whole society. We need to stop judging people at first glance, although we all do it. I must admit, that being friends with this man has at times, challenged my patience and I’ve doubted his motives but he is a good friend and support to me and has shown me how to laugh when things get tough. I won’t deny that humans are extremely complex but when we strip it down and empathize, we are also very similar and it’s only by working together that we can rationalise and prevent things from leaning to extremes. Keep up your very valuable work!