This is my second post as I read, chapter by chapter, through Professor Peter Tyrer’s new book on personality disorder.
The story begins
In his preface to the book, that author tells us clearly that experts on personality disorder have “failed the subject”. He wants to challenge misconceptions about personality, personality difficulties and personality disorder which are shared by the public and medical profession alike. Having chaired the relevant working group for the last eight years, he now wants to promote the radical change in how the World Health Organisation will, from later this year, present personality disorder in its International Classification of Diseases. He hopes this will help everybody embrace the idea that most of us have some degree of personality problem. Ideally, we will then become more understanding – both intellectually and compassionately, I would say – of those with worse difficulties than ourselves. Radical change will, he says, be resisted and take a generation.
What has gone wrong?
For many years, Professor Tyrer explains, personality disorder has been on the fringe of psychology and psychiatry; and mental health has been on the margins of medicine. As well as being far from the centre of the system, personality disorder has the irregular, wacky orbit of the planet Pluto. (The link to Pluto the Disney dog is lost on me, as I remember him as a cheerful and friendly pet.)
But there is nothing inherently wrong with being peripheral or quirky. The real problem, I think, is that the term “personality disorder” now has intensely negative connotations. It has, we learn, been rejected by psychiatrists, equated with moral degradation, and used as an expression of disgust. The author cites the late eighties paper, “Personality disorder: the patients psychiatrists dislike” as accurately reflecting (now) the view of personality disorder across the health professions.
If that isn’t enough, he explains, experts in personality disorder have become an exclusive group, understood only by themselves. In doing so, personality disorder has been both trivialised in the way it is presented and complicated with unnecessary jargon. This facilitates the framing of personality disorder as something untreatable, following which a diagnosis of personality disorder can be used to avoid treating people psychiatrists simply don’t like. We have conveniently set up its diagnosis as an excuse for exclusion and stigma.
Choosing your building blocks
In discussing the experts, the author talks of them combining cartoon images and jargon to take the subject to a point where “no one really knows where personality disorder begins or where it ends”.
Given the difficulty of defining personality, defining personality disorder is inevitably going to be hard too. And the author’s view that we will take a generation to change ideas rings true if you take on board his assertion that the new classification system, the development of which he has presided over for the last eight years, is a radical change. But this predicted, generation-long change also rings alarm bells in my head.
When the description of a system has become so convoluted that no one knows where it starts or ends, it is sometimes because we have chosen the right observable phenomena, but glued them together in a very clumsy way. Under the mildest of challenges, it fails to give the answers we need. Probably we have built this description out of a bunch of labels and constructs so clunky (and probably overlapping and leaving gaps) that they are pretty useless in helping us with the more important and complicated job of understanding how the system works. Or, in the case of personality disorder, why a person is suffering and how to help.
Conversely, when we change our frame of reference, we can sometimes choose a better set of constructs and suddenly get a much clearer picture. Arguably, this is the number one thing by to evaluate any new classification system. Does the author’s warning of needing a generation to make the necessary shift stem solely from psychiatrists being so wedded to their current way of thinking? Or is it given because the new system doesn’t radically up-end the old one at all, meaning there will be little incentive to change? If the new one is not only radical but also radically helpful, why is he anticipating such a struggle?
I’m also struck by the very language of the preface. It makes repeated references to a “body of knowledge”, “a new system”, “a new order” and states that experts have “failed the subject”. The terminology makes sense in context. I often think in this way myself. But what about having failed the people?
The language positions people rather as the author describes Pluto the planet: “only occasionally coming into view”. Which points to the other thing many of us – including the author, I believe – are looking for in a new understanding of personality disorder: a framework which places the need to make a diagnosis secondary to the alleviation of suffering. One which treats people as human and deserving of help.
The beginning of the end?
So, will the new ICD classification system prove to be radically helpful in supporting people thought of as having personality disorder and usher in a new, stigma-busting era of compassion? Here, at the start of my journey with this book, I learn from the Professor that “we are coming to the end of the tunnel of prejudice and gloom”. Well, not yet even on the first chapter, I am going to run with that message of hope, believing we should all be doing what we can to demolish that tunnel now. We must not allow ourselves a whole generation to reach a better place.
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