Wednesday 29 January 2020

Patricia Casey: the alienation of personality disorder

Irish people are increasingly aware of mental health and illness
Irish people are increasingly aware of mental health and illness

Patricia Casey

Public awareness of personality disorder is limited and a diagnosis of the condition often leads to stigmatisation.

Irish people, in my opinion, are increasingly knowledgeable and informed about mental illness. The media discusses suicide ceaselessly. Terms like bipolar disorder, anorexia, bulimia nervosa and post-traumatic disorder are very familiar to the general public and need little explanation. Discussing mental illness with family members has become much easier, due to the change in health literacy.

The one area in mental health about which there is poor knowledge among the public relates to personality disorder. It is seldom discussed in the media apart from the occasional bellowing headline about 'psychos'. Even within psychiatry itself, personality disorder has only been the subject of quality research in the past decade or so. 

Comments are often to the effect that surely everybody has some form of personality disorder - after all, nobody is perfect. Some of us are shy, some demanding, others may be fiery or driven perfectionists and so on. The number and combination of personality traits that exist, according to scientific data in this area, amount to over 80. The combinations of various traits are myriad. But the imperfections that we all possess in the form of these unlikeable features are counterbalanced by positive attributes.

So, for example, a person may be overly conscientious but may also be very kind and helpful to others. So the irritation that people may feel towards their excessively conscientious workmate is vitiated by his helpfulness and willingness to assist others. Relationships are, therefore, preserved. And it is this that distinguishes the normal trait variations from those which constitute personality disorder.

In those with personality disorder, the traits are usually much more extreme than simply being irritating. The attitudes and behaviours of the individual with personality disorder alienate others, relationships are compromised.

The impact on others extends beyond those who know them well to acquaintances in social and work settings, and at times into society itself. So not only are the traits abnormal in the problems they generate for others, but they must be apparent from adolescence and throughout adulthood, although they sometimes attenuate as time passes. Indeed, the emergence of abnormal traits and behaviours in adulthood is usually indicative of some acute psychiatric illness.

In psychiatry, we attach various labels to the personality of individuals meeting these criteria. We speak of the 'sociopath' (instead of the more charged term 'psychopath'). We describe those with avoidant personality disorder, obsessional personality disorder (as distinct from obsessive compulsive disorder) and borderline personality disorder to name but a few. However, the traits that constitute these 'disorders' are present in many of these categories. This has led to calls for these labels to be abandoned and replaced by a single term, 'personality disorder', with varying degrees of severity, depending on the impact on the individual and on others.

The idea that personality problems exert a negative influence on self and others has been around since Hippocrates (460BC-375BC) first related personality disorder to an imbalance in the four humours, which he said were secreted by the body. His pupil, Theophrastus, systematically described 30 types of personality disorder, some of which closely resemblance the categories described now; for example the reckless man is similar to the antisocial person described now.

There is debate within the specialty as to whether these should be regarded as mental illness at all since they appear to stem largely from environmental factors that arise in the early years of life, although some studies have identified a small genetic component.

The presence of a personality disorder is not a criterion for compulsory admission to hospital under the Mental Health Act. Despite doubts about the recognition of personality disorder as a mental illness, the overwhelming view in the profession worldwide is that it should continue to be recognised as such. One reason for this is because the co-occurrence of a personality disorder along with some other illness, such as depressive disorder, not only influences treatment but also prognosis.

Studies carried out in the general population suggest that about 15pc have some type of personality disorder. Not surprisingly, most do not come to psychiatrists since they fail to recognise their problems or the effect their way of behaving has on others. And even if they did seek help, the success is limited.

Interventions are based on various types of talking therapies and the positive effects are confined to controlling certain behaviour rather than changing the underlying structure of the individual's makeup.

This diagnosis is difficult to convey to patients and their families since public information is so limited and because it is a stigmatising diagnosis. For this reason it is a diagnosis which should be made sparingly and cautiously.

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