Table of contents
Introduction
This post was originally published here in May 2018 under the title, ‘Rediscovering personality disorders (part 2)‘. In reorganising my blog, I have retitled it to better reflect its content.
This is my second post on Professor Peter Tyrer’s new book, Taming the Beast Within [1], as I begin reading it. In prefacing his new book, Professor Tyrer tells us that experts on personality disorder have “failed the subject”. He wants to challenge misconceptions about personality difficulties and personality disorders shared by the public and medical profession alike. Having chaired the working group for eight years, he is championing radical change in the WHO’s reclassification of personality disorders. This will appear in the next version of the the International Classification of Diseases, ICD-11 [2].
He hopes these changes will help everybody embrace the idea that most of us have some degree of personality problem. And that we will become more understanding of those with worse difficulties than ourselves. The profession will, he says, resist change. Change will take a generation.
Personality disorders: 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. Besides 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. I remember him as a cheerful and friendly pet.)
Hostility towards patients
But what’s 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 term “personality disorder” now has intensely negative connotations.
The author cites the late eighties paper, “Personality disorder: the patients psychiatrists dislike”. If this reflects how health professionals view people diagnosed with a personality disorder, is this not an expression of hostility towards them? If so, those in charge have tolerated it and maybe still do. How has this come about?
Professor Tyrer explains also that 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. It then follows that psychiatrists can use a diagnosis of personality disorder to avoid treating people they simply don’t like. Or whom they deem to be ‘difficult’. The very construction of this diagnosis conveniently becomes an excuse for exclusion and stigma.
Is the language of ‘systems’ good enough?
It is fair, I think, to ask: is the psychiatry profession on the right track in its reclassification of personality disorders?
Firstly, I am 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 its own professional and technical context. But what about having failed the people? This language positions people rather as the author describes Pluto the planet: “only occasionally coming into view”.
Personality disorders are to be defined as medical conditions that affect the quality of people’s relationships. Helping people improve the quality of their relationships requires that the helpers use language that models this. It must reinforce the goal, not undermine it. But the language used has lost sight of the people it sets out to help. Probably, this is part of the problem.
The language used has lost sight of the people it sets out to help.
It would be good to think that medical professionals will stop characterising people as ‘disordered’, but clearly that isn’t going to happen. At the very least, then, any new classification of people’s distress must place the professional’s need to make a diagnosis secondary to the alleviation of suffering. Their language must make those they work with feel valued and deserving of attention and help. Without this, how can the professionals purport to be helping them towards more fruitful ways of relating to others?
Choosing your building blocks
Secondly, in wondering whether the psychiatry profession is on the right track, I wonder if we are starting with the right building blocks for the reclassification of personality disorders.
In discussing the experts, the author talks of the experts in this field combining cartoon images and jargon. And that this takes the subject to a point where no one knows where personality disorder begins or ends.
No one knows where personality disorder begins or ends.
The workability and usefulness of a system of classification depends on choosing a useful intellectual lens from the outset. If a system is so convoluted that no one knows where it starts or ends, we have chosen an unhelpful one. This leads to unhelpful concepts glued together in a way that proves clumsy and doesn’t achieve its goals.
That roughly sums up how some psychiatrists see the classification of personality disorders. It doesn’t work in helping the people they are there to help. And then, powerless in their ability to help those who need it, professionals sometimes blame their patients for that failure. All of this accounts for the desire to redesign the classification.
Reclassifying personality disorders: where do we start?
Given the difficulty of defining personality, defining personality disorder is inevitably hard too. So where do we start? We are choosing the right observable phenomena: people’s difficulties relating to others and themselves. How do we know? Simply because the distress associated with these is what we are trying to alleviate. So why not just meet a person – ‘the patient’ in medical terms – and help them find ways of relating better? We can do this by helping them understand and change the very individual patterns they display now.
This begs a new question: how does classification based on personality help here? If we must classify, maybe a completely difference frame of reference would be helpful. Maybe the new classification should focus on ways of relating and not dimensions of personality? It is clear that is not going to happen.
Are we changing fast enough?
The problems inherent in the current classification demand a rapid resolution. The relevant working group on the reclassification of personality disorders has already met for at least eight years. The author’s view that it will take a generation to change ideas rings true if you take on board his assertion that the new classification represents radical change. The fact that the profession sees this as radical possibly betrays how they view change itself. This predicted, generation-long change must surely ring alarm bells.
Does the author’s suggested timescale stem solely from psychiatrists being so wedded to their current way of thinking? Or is it 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 intellectually radical but also radically helpful, why is he anticipating such a struggle?
Reclassifying personality disorders: just the beginning?
So, will the new ICD classification system prove to be merely an intellectual shift? Or radically helpful in supporting people diagnosed as having personality disorders? Will it usher in a new, stigma-busting era of compassion?
We must ask, is restructuring the framework by which personality disorders are diagnosed and classified that radical? Surely the truly radical option is to stop talking of people as ‘disordered’.
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”. I will run with that message of hope, all the while believing we should demolish that tunnel right now. The ‘system’ must not allow itself the luxury of a whole generation to reach a better place.