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The Stigma of Personality Disorder and Philosophical Problems about Personality. On Tyrer and Mulder, Part 3

This is my third and for now final entry on Tyrer and Mulder’s recent book on personality disorder. In previous entries, I looked at the problems with the old categorical way of classifying personality disorders and the arguments for a dimensional approach, such as is found in ICD-11 or the DSM-5 Alternative Model.

I want to step back now and examine some of the larger implications of this book. First, I will consider what the authors have to say about stigma. This will lead naturally to my underlying working thesis: that there are underlying philosophical problems with concept of personality disorder, philosophical problems connected to how we think about selfhood and moral character. These problems do not disappear simply by operationalizing the term “personality” in more sophisticated ways.

There is no doubt that, at present, personality disorders are heavily stigmatized diagnoses. The authors cite extensive empirical evidence of this in Chapter 9 (pp. 98-111). They also reprise these points succinctly in a more recent editorial. Among other things, there is ample evidence that mental health providers share in this stigma. Personality disorder is often a diagnosis of exclusion or of last resort, signifying little more than “this person is difficult.” I imagine anyone who has worked long enough in the community or public mental health sphere has probably heard someone say of a patient, “It’s personality stuff.”

 At the same time, the success of dialectical behavior therapy (DBT) and then of the other players in the BPD treatment world (MBT, TFP, schema-focused therapy, cognitive analytic therapy, etc.) has potentially changed attitudes somewhat, especially among younger practitioners. I do not want to exaggerate this point, of course, and I am not aware of any empirical research that backs up what I am saying, just anecdotes and impressions. Similarly, there has been a modest effort to de-stigmatize BPD through the well-trod strategy of public disclosure. See, for example, this website, sponsored by McLean Hospital in the Boston area. The strategy of celebrity self-disclosure has not gotten nearly as far with BPD as it has with some other mental disorders, but there has been a bit of this from the former NFL receiver Brandon Marshall, who has spoken publicly about his BPD diagnosis. Some Ph.D. students have spoken up about their own experiences. And there is much more to be found on the internet. Nevertheless, the impact of these efforts should not be exaggerated.

The fact of stigma leads some people to reject the concept of personality disorder entirely. Tyrer and Mulder do a largely-admirable job of considering and responding to arguments for this sort of abolitionist position—within the confines of a book that is, again, just about 100 pages in length. The authors consider 10 objections, which I think can be distilled into just two main trains of thought: 


Objection set 1. A diagnosis of personality disorder is merely an expression of dislike for a patient; at very least, it amounts to a value judgment. It is a diagnosis of a person, rather than a condition, and so expresses the view that there is something fundamentally wrong with the patient. Quite frequently, such diagnoses are misogynistic. At minimum, they have been heavily gendered. Diagnosing someone with a personality disorder is consigning them to a “life sentence of despair.”

·       Objection set 2. There is no need for the diagnostic construct of personality disorder. Everything this construct refers to can be captured, and captured better, by other constructs. There are different ways of carving up the territory: some bits will be sent off the mood disorders, some will be considered formes frustes of the psychotic disorders or the mood or anxiety disorders, and some will be sent off to the land of complex trauma. (Surprisingly, though, the authors do not consider the territorial disputes between personality disorder and autism spectrum disorder.) At any rate, the whole notion of a personality disorder is hopelessly fuzzy and vague.

 

These are powerful and complex objections, and the authors, for the most part, respond carefully. It is not possible to do these questions justice in a blog post. For the second object set, Tyrer and Mulder’s answer is basically this: even though there is overlap, even though the borders are fuzzy, there is something clinically important and valid captured by the personality disorder construct that is not ultimately captured by the neighboring constructs.

As for the first set of objections, in a nutshell, the authors’ response is this: a personality disorder diagnosis ought not to signify despair, pejorative labeling, or the indication of an immutable flaw. The argument strategy depends partly on empirical evidence from studies of the course of personality disorders. There are several longitudinal studies of personality disorder course. They are, admittedly, not of the greatest quality, but they tend to suggest that, over time, people do tend to stop having personality disorders. Personality disorders are not life sentences.* People can and do get better, and there are therapies that are at least somewhat effective for BPD. On a more conceptual level, the shift to a dimensional and trait-based classification system—and the abandonment of the requirement that the pattern must have been present more or less unchanged since late adolescence or early adulthood—obviates most of the other objections.

Now for my own view: I agree with a lot of what Tyrer and Mulder have to say. But they neglect to consider the many forces shaping how those who are diagnosed will understand, take up, and respond to the social fact of receiving a personality disorder diagnosis. They also neglect to consider the broader social forces—such as the criminal legal system, among many others—shaping how other people will perceive and treat those who are diagnosed with personality disorders.

Behind this sociological problem is a philosophical issue: an operational definition of personality as a cluster of traits derived from factor analysis does not do justice to the more fundamental question of what personality is. And human beings, insofar as they are self-understanding and self-interpreting animals, will naturally raise this question for themselves and others. In so doing, they will naturally run into questions about selfhood, identity, and moral character. Who am I? What is it to be me? What makes me me? What makes me the same person I was yesterday, ten years ago? What is the relationship between my personality and my moral character, that is, my virtues and vices? To what extent am I separable from my personality? To what extent am I responsible for my personality? To what extent does what I do or say or feel or think “follow” from (get caused by, explained by) my personality?

Now, these are not the sorts of questions that can be answered by reading DSM-5-TR or ICD-11. Nor do mental health professionals, at least in virtue of their professional education, receive much that would help answer them. But they are certainly the sorts of questions that others have answered. Aristotle and Simone de Beauvoir try to answer them, among many other philosophers. Religious and cultural traditions of all sorts try to answer them. Popular culture and everyday life, with its endless proliferation of social types (e.g., to use an already well-dated example, the manic pixie dream girl), also give a kind of answer.

The type of personality disorder classification system discussed by the authors captures something clinically significant and not currently reducible to other diagnostic constructs. Yet fundamental and inevitable philosophical questions arise when someone is diagnosed with a personality disorder, and these cannot merely be operationalized (i.e., wished) away. In the inevitable epistemic vacuum opened up by diagnosis—what Jake Jackson, writing about depression, calls the experience of being “epistemically adrift”—an abundance of conflicting options for answering the philosophical questions intrudes. This field of conflicting options then guides how the diagnosed, the practitioners,** and the rest of society make sense of personality disorder, and this field cannot be merely wished away in the name of scientific purity. And so, similarly, highly stigmatizing answers to the aforementioned questions are not simply going to go away because a classification system changed or longitudinal studies suggest something new.

 

 

 

 

*I had previously read a more technical discussion of this research on course, which discusses a 16-year prospective study by Zanarini and colleagues; at the 16 year mark, the remission rate was 80-90% in the two study groups, BPD and Other Personality Disorder. Other measures of change, such as interpersonal or vocational functioning, are less rosy.

 

**Of course, the therapies for personality disorder also provide a sort of answer to these philosophical issues, albeit not always very adequate ones. I may write about this in the future.

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