Within the orbits of Mental Illness there can be no doubt that certain diagnoses not only provoke stigma and misunderstanding within the general population, but within the field of Mental Health itself. To be diagnosed with a Personality Disorder is one such illness, if indeed it can be called an illness.
Under the broad church term of Personality Disorders are circles within circles, dependent upon which cluster of Personality Disorder you happen to reside in. I score highly enough to be formally diagnosed with two Personality Disorders, and almost high enough for three. All of them belong in the C Cluster or “Anxious” subtype. The other subtypes are Cluster A – Odd (this includes Paranoid Personality Disorder, Schizoid Personality Disorder and Schizotypal Personality Disorder), and Cluster B – Dramatic (this group includes amongst others, Borderline Personality Disorder (BPD), Narcissistic Personality Disorder and Antisocial Personality Disorder, a diagnosis based upon, but not synonymous with Psychopathy, although it shares many of it’s characteristics). There are also orphaned Personality Disorders which do not belong in any one of the three main clusters, such as Depressive Personality Disorder, and this list has changed and grown over the years.
As more people are being officially diagnosed with Personality Disorders, and perhaps of equal concern, an increasing rate of people are being diagnosed with more than one concurrent Personality Disorder, especially the diagnosis of Borderline Personality Disorder, with or without another Personality Disorder, this begs the question as to whether more people really are becoming more pathologically disordered, or whether psychiatry is choosing to view them as such.
It was first brought to my attention many years ago in my twenties that I probably had an Anxiety related Personality Disorder, as the suite of anxiety disorders I had were so treatment resistant. Both my psychiatrist and my GP were of this opinion, although they would not elaborate on which Personality Disorder I might have. It was only recently, after extensive tests that it was discovered I scored to a diagnostic level for Dependent Personality Disorder and Avoidant Personality Disorder, and to a level which indicated high degrees of symptomatology in Obsessive Compulsive Personality Disorder. All of these disorders are common in adults who have experienced, as I did prior to adoption, neglect and maltreatment. The only good news in knowing about these disorders, is that unlike Cluster A and B disorders, they are usually reactive to at least some degree to therapy and medication. In other words, one’s quality of life can be improved, but the disorders will remain. I have deep reservations over these diagnoses. I think I’m more than a tick box of symptoms.
Personality Disorders “remain” because from the psychiatrist’s perspective, they are fixed and immutable – they are “part of your personality“. Speaking generally, those with Personality Disorders tend to have a more limited skill set to see them through life, and tend to see the world rather more monochromatically than those without Personality Disorders. As a rule, they often react in instinctive ways that don’t always match the usual conventions dictated by society. For example, in my case, I have to fight off feelings of abandonment when my partner goes to work (even though I rarely tell him this), or similar feelings when my parents go abroad on holiday, even though I haven’t lived with my mum and dad for twenty three years! I have always been this way, but even so, I vividly recall a conversation with a CPN, who said they were relieved when they discovered I had Cluster C Personality Disorder, as she said, “they were no trouble”. She wouldn’t elaborate when I pushed her on this, and it was only through experience that I eventually understood her prejudice. This goes back to my early point regarding stigma even within the field of Mental Health.
Anyone who has been diagnosed with Borderline Personality Disorder will recognise who the CPN was alluding to in her inappropriate remark. Apart from Anti-Social Personality Disorder, there is more stigma and misunderstanding surrounding BPD than any other PD. I know a doctor who works as a GP, and even her views on those with BPD leaves much to be desired, which I found shocking. To be given a diagnosis of BPD is not something to be taken lightly. It immediately marks you out as “difficult” or “obstructive” – both words used by my GP friend. This is where the issue of diagnosing an illness with such inflammatory connotations becomes very problematic. And this is where psychiatrists can really carry power over their patients. The reason I say this is because I can wager that as soon as a CPN picks up a clients notes for the first time, and they see that BPD diagnosis, they are going to make Pre-conceived assumptions because of the heat and light that BPD generates.
In a study of psychiatrists it was found that male psychiatrists were far more likely to diagnose a woman with BPD than were female psychiatrists – female psychiatrists diagnosed BPD almost equally between men and women. Male psychiatrists diagnosed females 70% and men 30% of the BPD diagnoses they made. This suggests something very particular at play, which may be the way men how women behave and react and as in someway “over-reactive” or, on a more sinister level, there is a power game at work. Those diagnosed with BPD simply match a set of symptoms. Here are some of them: argumentative behaviour, liability to enter into unstable situations leading to crises, chronic feelings of emptiness, a need for immediate reward, impulsive behaviour and in some cases self harm, few could argue that women in the first instance are more likely to articulate their feelings than men, therefore indicating much of what the problems are. It’s even more interesting that if the female psychiatrists are diagnosing correctly, perhaps this says a lot about their intuitive and listening capabilities and those capabilities being in some way more balanced than men’s?
The most concerning aspect to all of this is the massive power the psychiatrist wields. An individual may not even have BPD, they may simply be assertive individuals that merely disagree with the views of a consultant. This can be seen as capricious and argumentative. This is why I feel extremely strongly that with a diagnosis as serious as a Personality Disorder it should not made on the basis of a single psychiatrist’s assessment, but that of two separate consultations with two disparate psychiatrists who do not know the opinion of the other. I do not want or seek any sympathy for my mental health issues, but I know my “Cluster” does not evoke the same kind of clinical distaste as I have witnessed with regard to BPD, let alone Anti-Social Personality Disorder.
It is only until extremely recently that symptoms such as “manipulative behaviour” were written out of the script for those with BPD. Whilst I do believe that extremely traumatic events, child neglect and abuse and other terrible things can permanently alter a person’s character, I don’t buy into people simply being slotted into one of three convenient clusters. It may be convenient for the psychiatrist, but it can permanently stigmatise the individual being diagnosed. It surely can’t be so that those with Personality Disorders are so emotionally expurgated and reduced down to a set of symptoms, with not even a tint of colour or variation. As a person with mental health issues it’s important to fight against becoming a human notice board upon which those in Mental Health can appear determined to pin post it notes all over you.
Personality Disorders will one day be seen as a bludgeon in mental health. When only a fraction of them are stated as treatable, it poses the question as to why they are there in the first place. If something isn’t killing you and it’s not treatable, then surely it isn’t an illness, it’s simply who you are, however difficult or unlikeable you may be?
