Are personality disorders really mental health difficulties, and what can we do about them?
What we mean by personality
Personality is a controversial and divisive concept. It has many definitions, but insufficient agreed understanding. The concept of personality is not just hard to define; it is also problematic, since it is open to distortion, misuse and stigma. Until recently, it was thought that little could be done about mental health difficulties arising in the context of personality.
There is common agreement that personality probably refers to a recognisable and characteristic set of human behaviours, thoughts and feelings. These define our individual identity. How this works in everyday life is important, but personality is too often taken for granted. If we say we know someone, we may not mean that we actually know what someone is truly like. By contrast, there is something genuine and authentic about knowing someone's personality. It is probably only known by those closest to us and it is a knowledge of a unique individual that is particular, longstanding and special. It means we can identify them and, because we know their personality, we think we can depend on them to behave or think or feel in a certain way. To put it more dramatically, if we know or love someone because of who they are, then we know or love them because we know their personality.
Personality in difficult times
We assume that personality is relatively fixed and persistent throughout life. Whether we are right or wrong about this is debatable, but, in everyday life, we expect personality features to persist. When we rely on each other in times of stress or difficulty, we depend on these strengths and characteristics. In this way, we may see personality features as enduring attributes helping each of us to adapt to challenge. Our personality should help us negotiate life through all its ups and downs.
Suppose instead that our particular set of personal characteristics is not helpful. What if our personality actually makes it more difficult to adapt in this way?
Imagine how we might struggle if we had an enduring set of characteristics leading us into repeated difficulties, making us and those around us feel very unhappy. This set of characteristics might have nothing to do with our wisdom or intelligence or status, and yet several enduring unhelpful traits may be recognisable and even characteristic. This is the definition of personality disorder; a characteristic, maladaptive and enduring set of thoughts, feelings, and behaviours, present since before adolescence and persistent throughout adult life.
No single cause exists for personality disorder. As with so many concepts in mental health, it is impossible and unhelpful to ascribe responsibility to either nature or nurture. Undoubtedly, both are at play. The influence of genetic factors is evidenced by research, but this evidence is balanced by evidence of the frequency and force of a childhood history of environmental disadvantage, trauma, neglect and loss.
Challenges of a personality disorder diagnosis
Three broad groups or clusters of personality disorder are described by mental health definitions. These diagnostic groups are Cluster A (Odd or Eccentric), Cluster B (Dramatic or Histrionic) and Cluster C (Anxious or Dependent).
To best illustrate the challenges of a personality disorder diagnosis, let’s just consider issues arising from one of the most controversial of these disorders, a Cluster B disorder known as Borderline Personality Disorder or more recently known as Emotionally Unstable Personality Disorder (EUPD).
Common features described in EUPD are a tendency to:
- difficulty controlling emotions
- feeling bad about yourself
- repeated self-harm
- feeling ‘empty’
- rapidly forming relationships and just as rapidly losing them
- feelings of persecution
- hear noises or even voices when stressed.
The number of people with EUPD and even the number of people who receive this diagnosis is not clear. When you put all the personality disorders together, studies estimate prevalence between one in 20 of the population and one in 5 of the population, depending on the criteria in the the literature. For EUPD, it is estimated (in the United States) that somewhere in the region of 1.5% of the population have this condition. None of these figures is truly reliable in my view. The real issue is the prevalence of misdiagnosis, misuse of the diagnosis and/or under-diagnosis of these problems.
There are many reasons for scepticism regarding EUPD as a concept. EUPD is a diagnosis most frequently made by men, and most frequently about women in distress. Since EUPD was regarded as a problem beyond conventional treatment, women given this label were routinely dismissed. More recently, the diagnosis has been criticised by feminist sociologists and psychologists as an unhelpful paternalistic projection of male frustration, leading inevitably to disregard of women with genuine psychological problems. A more emancipated view was articulated many years ago in a classic paper by Professor George Vaillant of Harvard University entitled The beginning of wisdom is never calling a patient a borderline. His problem-solving approach is therefore very appealing.
Better treatments for personality disorders
A problem-based approach to the EUPD as described by Vaillant allows a broader, more inclusive and helpful response to people with emotional and mental health difficulties. Recognition of the person's problems in a neutral and unbiased way should not be beyond most health professionals. Only that way will the true prevalence of other conditions which commonly coexist with personality be accounted for. These include anxiety disorder, mood disorder, addiction and post-traumatic stress disorder.
Better treatment of these subliminal and/or coexisting problems is not the only benefit of a more holistic approach to people with emotional instability. More recent developments have shown the benefit of modern psychotherapy for EUPD within what is known as the third wave of behaviour psychotherapies. These modern therapies build upon the insights derived from behaviour therapy (BT) and cognitive behavioural therapy (CBT) to offer newer, more patient- and solution-focused therapies. The evidence is that these can lead to better emotional regulation and more self-control. The most immediately relevant of these is a therapy called Dialectical Behaviour Therapy (DBT)
DBT was developed by patients with ongoing difficulty in regulating intense emotion. DBT is effective because it teaches people skills for effectively managing their intense emotions. The therapy was developed by Professor Marsha Linehan, herself a service user.
The real need for more trained therapists and greater access to this and other effective talking treatments is growing, and, yet, providing sufficient psychotherapy for patients with this diagnosis is proving a great challenge. This is true for providers of mental health services whether in the Health Service Executive (HSE) or in the independent sector. Nevertheless, there is a real need to move beyond the historical denial and dismissal of people with personality problems. We need to work together instead to provide meaningful service and real hope of recovery to many more people previously regarded as beyond help.
If you are concerned about any issues in this blog you can contact St Patrick's Mental Health Services at our dedicated Support and Information Line by calling 01 24 93333 to get more information, free of charge, from a qualified mental health professional.
For more background regarding Marsha Linehan and the development of DBT check out this interesting article from the New York Times.
Prof Jim Lucey
Prof. Jim Lucey was Medical Director of St Patrick’s Mental Health Services, Dublin, from 2008 to 2019. He is Clinical Professor of Psychiatry at Trinity College Dublin. He has been working for more than 30 years with patients suffering from mental health problems. In addition to medical management, he maintains his clinical practice at St Patrick`s, where he specialises in the assessment, diagnosis and management of Obsessive Compulsive Disorder (OCD) and other anxiety disorders. He gives public lectures and is a regular broadcaster on mental health matters on RTÉ radio, featuring on ‘Today with Sean O’Rourke’.
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