Skip to main content

Reading Tyrer and Mulder, "Personality Disorder" (2022), part 1

 Tyrer, P. J., & Mulder, R. (2022). Personality disorder: From evidence to understanding. Cambridge University Press.

At just over 100 pages, Personality Disorder: From Evidence to Understanding is a slim volume with a strong punch. The authors, psychiatry professors in the UK and New Zealand respectively, are leading experts in personality disorder research, and, from what I can tell (although I need to look into this more), they were deeply involved in the major changes in personality disorder classification and diagnosis introduced by ICD-11, which was released in 2022. In many ways, this book is a compact exposition and defense of those changes. Although the authors cite heavily and wade into some of the more technical debates in the field, the book succeeds in its stated aim of being accessible to a non-specialist audience. Indeed, one of the greatest strengths of this book, from my perspective, is that the authors always have in mind the overworked non-specialist mental health professional or primary care doctor working in a community or general practice setting. 

This book is much more, however, than a textbook on ICD-11 personality disorder diagnosis. It is also a polemic against the old ways of personality disorder research and treatment and a plea for taking personality disorder seriously. In what follows, I offer a high-altitude summary of the core theses of the book. In a future post, I hope to explore some of them at more granular level.

Summary:

Personality disorders are serious and highly prevalent—much more so than commonly realized—conditions. The current state of research and treatment for them is dismal. Paying more attention to personality disorder would improve both medical and mental health outcomes, as unaddressed personality disorder frequently explains the failure of both psychiatric and standard medical care. Unfortunately, the categorical approach to personality disorder classification introduced in 1980 by DSM-III has seriously impeded progress in this direction. The categorical approach is manifestly lacking in validity. Moreover, some of the constructs introduced in 1980, such as borderline personality disorder (BPD) and schizotypal disorder, were more or less made up on the spot to placate special interests. Subsequently, for complex reasons, BPD became the most studied personality disorder (with antisocial personality disorder [ASPD] in second place), and an ever-proliferating set of highly-specialized psychotherapies have been developed for BPD since Marsha Linehan’s work from the late 1980s. These therapies, of which DBT and MBT are the best known but hardly the only games in town, all seem to have more or less comparable efficacy. Although DBT, MBT, and a few of the other specialist therapies (e.g., transference-focused psychotherapy) have been supported by randomized controlled trials (RCTs), these studies are generally biased or of low quality, and overall it is not clear that the specialist therapies outperform structured and well-designed but less specialized controls, such as Good Psychiatric Management (GPM) (pp. 69-72, 96-97). Moreover, the focus on developing new therapies for BPD has gotten in the way of developing treatments for the other personality disorders, which have been sadly neglected, despite their greater prevalence than BPD.

At a more fundamental level, the entire BPD construct is suspect both conceptually and empirically, and it ought to be jettisoned. The problem with BPD is not that it is simply a stigmatizing label for complex posttraumatic stress disorder (CPTSD) or that it is really a mood disorder; the problem is that, as defined in the DSM, it is a highly heterogeneous condition: any collection of five or more of the nine diagnostic criteria can suffice for a diagnosis. Empirical research suggests that there is little validity (in the technical sense of construct validity) to the BPD construct. Moreover—and this is the conceptual issue—the diagnostic criteria for BPD, unlike those for the other personality disorders, are not personality traits at all, but behaviors, descriptions of interpersonal patterns, and so on. Adding BPD to the personality disorder section of a diagnostic manual turns it into Borges’ “Chinese encyclopedia.” Indeed, many of the features associated with BPD may be better thought of as general features of a severe personality disorder of any type or as severity markers of personality disorder (p. 20).

In this book, the BPD construct comes across as a detour to nowhere, an “epistemological obstacle” as the French historical epistemologists would put it. It is a detour that has also sucked up all the oxygen (i.e., research funding). In a powerful image at the start of Chapter 8, the authors liken getting treated for personality disorder to going to a restaurant where all that is served are subtly different types of pizza (pp. 69-72).

There is also a more fundamental problem: the entire categorical approach to personality disorder classification needs to be replaced with a dimensional approach. 

(to be continued...)

Comments

Post a Comment

Popular posts from this blog

Wakefield’s Harmful Dysfunction Theory of Mental Disorder

This is now my fourth post in a series on health and disease. I spent the last two posts discussing Boorse’s naturalism, which attempts a purely value-free definition of health and disease.  In this post, I will discuss Jerome Wakefield’s “harmful dysfunction” theory of mental disorder, which is sometimes considered a “hybrid” of naturalism and normativism. My focus here will be on a single article, “The concept of mental disorder. On the boundary between biological facts and social values” ( 1992 ), although Wakefield follows this up with several later elaborations. Wakefield  has doctoral degrees in social work and philosophy and has extensive clinical experience, in addition to holding a professorship in the NYU school of social work . Aside from his classic articles about mental disorder, he is also known for a book co-authored with Allan Horwitz, The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder (2007). Wakefield has a public reach un...
Post a Comment
Read more

Introducing Boorse’s Attempt at a Value Free Account of Health (Disorder, Disease, and Health, part 2)

  “Health is not unconditionally worth promoting, nor is what is worth promoting necessarily health.” (Boorse, “On the Distinction between Disease and Illness,” p. 60)   “The trouble with calling physical or mental or moral excellence health is that it tends to unite under one term a value-neutral notion, freedom from disease, with the most controversial of all prescriptions—the recipe for an ideal human being.” (Boorse, “Health as a Theoretical Concept,” p. 572)   In this series of posts, I am exploring philosophical accounts of disease, health, and disorder. My previous post introduced the topic. In this post and the next one, I will examine Christopher Boorse’s highly-influential attempt at a naturalistic, value-free theory of health and disease. According to Boorse’s 1 997 restatement  of his views , he developed his theory in a single manuscript that covered physical health, mental health, and the concept of biological functions (Boorse 1997, pp. 101-102...
Post a Comment
Read more

Toward Emotional Granularity: Barrett’s Constructionism about Emotions (part 2)

  In the previous post, I discussed Lisa Feldman Barrett’s critique of the “classical theory of emotions.” I covered reasons to reject the idea that there is a simple set of crisply delimited, universal, basic emotions or the idea that such emotions have universal modes of facial expression or invariant physiological or neural “fingerprints.” In this post, I would like to sketch Barrett’s positive account—of how the brain, in interaction with human culture and the environment, constructs emotions.   A word is needed first, though, about the metaphor of “construction.” It is a complex metaphor. It’s a metaphor that can pull us in many different directions. It tugs at other none-too-crisp distinctions we are familiar with, such as the distinction between finding something and making something, or the distinction between simple parts versus complexes of many different parts. It reminds of how we tend to think of some things as natural and others as manufactured—or artificial,...
Post a Comment
Read more