Personality disorders by numbers

Peter Tyrer (2017) knows as much as anyone about the research into personality disorders. He has always been consistent and reasonable in trying to advance our thinking in this area. He is a tireless warrior in the cause of abandoning the categorical system for classifying personality disorders in favour of a dimensional approach. He now hopes to bring order, better research and greater clinical utility, not by making personality disorder traits dimensional, but by making personality disorder itself dimensional and adding domains as modifiers. The dimensional approach to personality traits used to be the province of clinical psychologists before they became enthralled by ‘The Dummies Guide To Instant Psychiatric Expertise’, also known as the DSM. The United Kingdom may be a DSM-free zone where clinicians avoid diagnosing personality disorders, but Australasia is surely not, nor in my experience are forensic mental health professionals, be they from the United Kingdom or anywhere else. They lard almost every court report with a personality disorder diagnosis, always to the detriment of their patient, sorry client, no that is now consumer, no, of course, the offender. But does using the label personality disordered, even in the new International Classification of Diseases (11th Revision; ICD-11) formulation, add much beyond the obvious and the stigmatizing?

When I was a registrar, John Gunn, who was to become the single greatest influence on the development of forensic psychiatry in the United Kingdom, admonished me to avoid using personality disorder labels. Describe the person’s attitudes, how they respond to the world as well as to other people, their strengths, their weaknesses, describe them as human beings in their social context and do not turn them into objects shoved into psychiatry’s latest fabricated box. My years of clinical practice have reinforced John’s words. A person’s temperament and acquired characteristics are often critical to assessment and management. An abused and neglected child may develop into an adult who is overly anxious and withdrawn, or one constantly searching for love and affection only to distrust and reject it when found, or to hide their pain and rage behind a mask of callousness. How does it help to label them personality disordered with domains of negative affective, antisocial, let alone simply borderline? Some of our colleagues have rushed to label President Trump a narcissistic personality disorder, which is an ad hominem argument adding nothing to what is bleeding obvious about him. Even Trump deserves better than to be labelled in this dehumanizing and trivializing manner, our patients certainly deserve better.

Peter Tyrer makes the claim that the new ICD-11 approach to personality disorders is empirically based. The nosology of most psychiatric disorders, including the personality disorders, is currently based on operational definitions which underpin the quantification, not, as with Linnaeus, on using deduction to organize into groups phenomena that permit confirmation or refutation by fellow scientists (Mullen, 2007). Peter’s ‘abundance of psychological research’ and ‘robust’ findings are, for the most part, exercises in the circularity of the operational, detached as it must be from any search for meaning or validity outside its predetermined parameters (Chang, 2009; Parnas and Gallagher, 2015). They start with agreed definition which determines the domain of study, then quantify and confirm what they started out by laying down as the premises. That such constructions occasionally have correlations with behaviour in the real world is hardly surprising as they are defined on the basis of such behaviour. This is not causality but casuistry. Anankastics are rigid and obsessive, dissocials behave badly, the schizoid are not the life and soul of the party, for the simple reason that is how they were all defined.

So how should we; talk about, talk to, manage and help those whose personality traits are causing problems for themselves and others? Not by claiming knowledge and understanding we lack. Not by renaming categories as domains (even a Jesuit would blush). Not by assuming that personality disorders are abiding or immutable. After all you rarely see a 40-year-old borderline, or a dissocial with white hair, or an elderly anankastic, hang on I need to check that last one a few more times. Just describe people’s characteristics as they are and forget about reifying and medicalizing. I often hear colleagues complain personality disorders are untreatable. And so they are, unless you deconstruct them into their component elements most of which are manageable, or at least modifiable. The cognitive distortions, the emotional instabilities and reactivities, the self-defeating behaviours, the dysfunctional self-deceptions and all the other problematic traits need to be recognized and treated. So why construct these personality disorders in the first place other than as security blankets for us professionals. Progress would have been a classification based on trait dimensions, which I suspect Peter Tyrer would have preferred.

See Editorial by Tyrer 51: 1077–1078