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Personality disorders, the DSM, and the future of diagnosis

By Edward Shorter

Ben Carey’s thought-provoking article in the New York Times about the treatment of personality disorders in the forthcoming fifth edition of the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association raises two questions:

1. Do disorders of “personality” really exist as natural phenomena, comparable to mania or dementia?

2. If they do exist, do they belong to the clinical specialty of psychiatry, or are they better considered characteristics of the human condition that have little to do with illness? Psychosis and melancholia are real illnesses, comparable to tuberculosis and mumps. Do personality disorders have that status?

Psychiatry’s involvement with personality disorders goes back to the early nineteenth century and the diagnosis of “hysteria”: the female character was considered weak and vulnerable. Women by virtue of their very personalities were deemed more vulnerable than men to feelings and emotional changability. Viennese psychiatry professor Ernst von Feuchtersleben wrote in 1845, “[The causes of] hysteria include everything that increases sensitivity, weakens spontaneity, gives predominance to the sexual sphere, and validates the feelings and drives associated with sexuality.”

In terms of the scientific assessment of personality and its breakdowns, this was not a promising beginning.

Things got worse. In 1888 German psychiatrist Julius Koch said there was such a thing as a personality that was “psychopathically inferior,” a product of genetic degeneration. Such degenerates were not exactly mentally ill, he said, merely unable to get their act together, and also showed “a pathological lack of reproductive drive.”

So psychiatry has always thought there were people who had something really wrong with their characters without being necessarily depressed or psychotic. But how to classify them?

Classification is obsessing the current debate. The struggle over what disorders to identify began with the great German classifier of disease (nosologist) Emil Kraepelin who, in the eighth edition of his Psychiatry textbook in 1915 expanded to seven types the list of “psychopathic personalities” with which he and his colleagues had been working. The list is interesting because it is very different from our own: the “excitable”; the irresolute; those driven by pleasure to seek out alochol, gambling, and who generally become wastrels; the eccentric; the liars and swindlers; and the quarrelsome, sometimes called the querulants.

Doesn’t sound very familiar, does it? That’s because each culture compiles a list of the personality traits it dislikes, or that are harmful to the further flourishing of things; and in Imperial Germany being querulous by challenging authority or being irresolute by not seeing France as the enemy were viewed as disorders.

There was lots yet to come, that I’m going to skip over. But what has most greatly influenced the current debate is the concept of personality disorders laid down by the psychoanalysts, the followers of Freud. Their list is quite different from Kraepelin’s because they were not interested in making war on France but on inner conflicts within the psyche. In 1908 Freud suggested the existence of an “anal” character, poeple who were orderly, tidy and meticulous and who in childhood had somehow come to dwell upon the anal region.

Freud’s followers came up with a whole list of character pathologies: Fritz Wittels’ “hysterical character,” Wilhelm Reich’s notion of “character armor” and its various guises, such as the “compulsive character,” the “phallic-narcissitic character,” and so forth.

We’re getting hot now. The modern concept of personality disorder comes directly to us from the psychoanalysts and from their current desperate desire to stay relevant. In 1938 Adolph Stern laid out a kind of personality disorder that was unresponsive to psychoanalysis, calling it “borderline personality disorder.”

Fourteen years later, in 1952, the American Psychiatric Association took a first cut at personality disorders, in its new DSM series, assigning them to three groups: (1) Those that were constitutional (inborn) in nature and unresponsive to change though psychotherapy, including “inadequate personality” and “paranoid personality”; (2) Those individuals with emotionally “unstable” and “passive aggressive” personalities; and (3) the sociopaths, such as the homosexuals, fetishists and other deviants.

American society in the early 1950s did not like those who deviated from the missionary position, who were inadequate to the challenges of empire-building, and who accepted authority but badmouthed it at the water-cooler.

Wilhelm Reich had laid out the concept of “narcicism” in 1933 and New York psychiatrist Heinz Kohut gave it pride of place in 1971. We are totally mired in the swamp of psychoanalysis here, a swamp that DSM-II in 1968 and DSM-III in 1980 failed to pull us out of, though DSM-III constructed an “axis II,” along which personality disorders could be arrayed, in addition to axis I for the real psychiatric disorders.

So this brings us to the current scene. The most recent edition of the DSM series, DSM-IV in 1994, had a whole slew of personality disorders, including histrionic, narcissistic, borderline, and so forth. The editor of DSM-IV, Allen Frances, was a psychoanalyst, and the list is a kind of last gasp. The problem is that patients who qualified for one, tended to qualify for almost all of them. The individual “disorders” were quite incapable of identifying individuals who had something psychiatrically wrong with them; the “disorders” had become labels for personality characteristics that are found in abundance in the population.

Moreover, who needed labels? Psychiatrists had a seat-of-the pants definition of a PD: “If your first impression of your patient is that he is an asshole, then he probably has a personality disorder.”

And what kind of disorder was this anyway, an illness in which the identified patient thinks he personally is fine but is making everyone around him unhappy? This is not like psychosis.

You can see why the drafters of DSM-V, due this May, have despaired. They wanted something clinically relevant and that also would sound vaguely like science (which psychoanalysis certainly didn’t). It will be interesting to see how the APA sorts this out. Personality disorders exist not as natural phenomena but as cultural phenomena: We as a society need some way of identifying people who can’t quite get it all together. But is this an illness that psychiatrists can treat? In the way that they treat schizophrenia with Zyprexa and depression with Prozac? What do we, as a society in 2012, do with people who can’t quite get it all together? I’m asking you.

Edward Shorter is an internationally-recognized historian of psychiatry and the author of numerous books, including A History of Psychiatry from the Era of the Asylum to the Age of Prozac (1997), Before Prozac (2009), and the forthcoming How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown. Shorter is the Jason A. Hannah Professor in the History of Medicine and a Professor of Psychiatry in the Faculty of Medicine, University of Toronto. Read his previous OUPblog posts.

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Recent Comments

  1. […] How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown, talks about how doctors diagnose personality disorders. The most recent edition of the DSM series, […]

  2. Debbie Corso

    My name is Debbie, and I have Borderline Personality Disorder. Although medication is not typically used to treat this disorder, there is an effective therapy called Dialectical Behavior Therapy (DBT) that focuses on behavior modification and changing the way one thinks and responds to intense distress and difficulty with regulating emotions.

    I get the sense from your article that, because personality disorders aren’t treated with medication as some other mental (and most physical) illnesses are, that they are not “real.”

    I can tell you that the manifestation of one “not having their lives together” is a culmination of a fractured sense of self and other symptoms commonly present with the disorder that I suffer from.

    There is help available. People with this particular type of personality disorder can and do get better with DBT.

  3. Clare

    I felt compelled to respond to your article, as someone with a diagnosed personality disorder I feel that the uninformed prejudice of your piece adds to the stigma that I and others like me have to endure on a daily basis.

    I was born with an inability to regulate my emotions, research is being conducted in order to ascertain the cause of this problem but just because neurology hasn’t quite got there yet, does not mean that it isn’t real. Just because medicine hasn’t found a pill that eases my symptoms it does not mean they don’t actually exist.

    I understand the argument that psychiatric conditions are quite often a social construct, but your article only looks at personality disorders from one point of view: that the disordered are quite happy being “assholes”, it’s the rest of the world that has to suffer, because we “can’t quite get it all together”. My personality disorder materialised from a desperate need to make people like me so that they would stop hurting me, the emotional disregulation meant that I could not cope with the mistreatment I suffered as a child. I am therefore the most considerate, caring person you could meet, the suffering is internal. And considerable. I have made many sincere attempts to end my life because of it.

    How do you suggest I receive treatment for my condition? I am not entirely convinced that my personality disorder is an illness but I do need help and support to overcome the difficulties it has presented to me. In our culture that process is medicalised, whether that is right or wrong it is a fact. Where else would you like us to go or would you prefer if we suffered in silence?

  4. […] Apart Personalities Posted at 10:45 on December 8, 2012 by Andrew Sullivan Edward Shorter spotlights the difficulty in diagnosing personality disorders: Psychiatrists had a seat-of-the pants […]

  5. Rob

    The last paragraph seems to imply that drugs are the only way for psychiatrists to treat mental illnesses. Was this implication intended?

  6. Mark

    Working in community mental healh and having had a relationshiip with a guy wih Borderline PD I’ve seen this, and other conditions, up close, too close at some times.
    BPD has a pretty loose definition but the range of behaviours are surprisingly consistent.
    Charismatic, superficial, a complete inability to regulate their emotions, a terror of being abandoned, and not because they will be alone but because they will cease to exist.
    This terror motivates highly manipulative and extreme behaviour usually exacerbated by drug use. The aim? A relationship that is alternatively, clung to with the same intensity as a drowning man, and destroyed through controlling behaviour, threats of suicide, violence and degrading acts, with no acceptance of personal responsibility.
    A nightmare in a relationship, chaotic and time consuming in a work environment.
    I have seen this set of behaviours change, most consistently through an acceptance of personal responsibility and learning techniques, such as mindfullness meditation to lessen the overwhelming emotional ride.
    It would be a bitch of a condition to have so I sympathise but they cannot be “saved”, supported, yes…..at a distance

  7. Mike

    “[Kraepelin’s] list is interesting because it is very different from our own: the “excitable”; the irresolute; those driven by pleasure to seek out alochol, gambling, and who generally become wastrels; the eccentric; the liars and swindlers; and the quarrelsome, sometimes called the querulants”

    Is this list really so different from our own? “excitable” = mood disorders; ‘those driven by pleasure to seek out alcohol, gambling etc.’ = addictive personality; ‘liars and swindlers’ = sociopathic tendencies, etc.etc.

    “And what kind of disorder was this anyway, an illness in which the identified patient thinks he personally is fine but is making everyone around him unhappy? This is not like psychosis.”

    In my experience this is quite common with psychosis.

  8. Liz

    I see it as a spectrum disorder. I have no professional background in treatment or diagnosis, but I was married in to a family where personality disorders are sprinkled thru in a distribution like eye color. I hadn’t heard the asshole line before, but that’s what my ex and his seven siblings called their dad. And there are manifestations of his personality down to one of my own children.

    What I gradually picked up on in my father in law and his sister was an innate narcissim, an inabilty to empathize. As very intelligent people they knew that acting empathetic was what society calls for, and they were successful to a point. I have found that when things are going well it’s easy for personality disorders to blend in. When shit hits the fan, coping becomes more difficult.

    What I see in my daughter is what I saw in my husband, an inability to form strong bonds. My ex doesn’t see that his daughter is like him he just sees that she has a difficult personality like his sister’s. My other children both adore and are perplexed and angered by their sister (they are teens and young adults). I don’t speak of my armchair diagnosis as I don’t know what good it would do. My daughter has been in therapy before and now as an adult can make her own choices. She is not as strongly effected as the her two aunts that I’ve seen the same thing in, so I hope she will learn to deal with what’s she’s been dealt. She’s not yet at an age when she’ll listen tto her mother and a gentle warning (I thought) to watch for tendancies to ‘fly off the handle’ like her aunts was not well received.

    But it is fascinating at some level. About fifteen years ago when I first started noticing this trait there was a big family wedding on my ex’s side, rare since there is such a fractious element. but they are an attractive and fairly well-off bunch and have reproduced widely so here we all were. And I spent the day quietly them out. And by nightfall, after a few drinks and the tensions that accompany any large gathering the PD people were not doing well. They were either leaving early or getting that last word in what would become the new relationship fault line down the road. I wish there was an easy answer for this; a pill to take. I think it’s part of brain chemistry, almost (and maybe related to) a genetic disposition to having a bad temper.

  9. Patrick

    Professor Shorter, Thanks for your work on the history of psychopathology. As a practicing psychotherapist of 16 years and a student of theory, I have reached the conclusion that much of the diagnosis that takes place these days is essentially a way of characterizing various aspects of the human condition as biologically determined medical conditions. Perhaps personality problems shouldn’t be in a medical book (the DSM) but historically at least they have conveyed a different meaning to people about the nature of their suffering and, therefore, about what might be done about it. Our understanding of psychopathology seems to be in an early stage of development and it is epistemologically very messy. Why not simply acknowledge this and use our diagnostic system clinically as a work in progress?

  10. Sam Jandwich

    Found this article while googling for information on the recently-released DSM-V – and I just thought I’d say here that I wholeheartedly reject this casting of personality disorders as entirely a “cultural phenomenon”.

    To me this position represents the easy way out, the cynic’s view, and an irresponsible exercise in bad faith and absolutism. Personality disorders are by their nature challenging to identify and comprehend, and this difficulty is reflected in the history the article alludes to of psychiatry’s proposing continuously varying models for the description of these complex phenomena. To my mind, the DSM-V has done quite a good job at refining the knowledge that already existed, and at tightening up the definitions so that the disorders can be better differentiated from each other, and from clusters of “symptoms” in an individual that nonetheless don’t quite merit the description of a “disorder”. Looking at it historically, I would say it’s eminently arguable that a common thread of thinking can be seen from von Feuchtersleben right up to the present day.

    As someone who works in research into the effects of childhood abuse (and for what it’s worth, having a very instructive relationship experience with a BPD sufferer), I am often struck by the similarity in the experiences and descriptions of feeling states given both by people diagnosed with BPD, and also those close to them… and the (often but not exclusively) close association of these with childhood trauma. One need only come across this phenomenon enough times to realise that there is something real going on.

    I find it helpful to think of BPD in particular as a disability, as opposed to a mental illness or a factor of “personality” (and perhaps here we see the genealogical origin of thinking about personality disorders as “cultured” – as it could be said that the foundational concept of “personality” is to some extent cultured, and so by extension is everything that hinges on it). As I understand it, this is a disability of the emotions, and secondarily, of the way that under-developed emotions lend themselves to the person’s having difficulty in developing a conception of themselves as being a discreet, independent entity – as all healthy adults manage to do. Essentially, from my perspective it looks like the emotional development of these individuals becomes interrupted early in life (whether by trauma, genetics, or a combination of the two), and whereas they maintain an intelligence and analytical ability commensurate with (and often superior to) their age, their lack of emotional development inhibits their ability to turn this intelligence to productive purposes, such that their behaviour becomes overtly anti-social (hence, I would think, the earlier characterisations of this phenomenon as “psychopathic”), when in reality they are actually just struggling to survive, the only way they know how.

    One point that is important to emphasise is that such a description when given sincerely is not “stigmatising”, except insofar as it is taken the wrong way by people whose intentions are less than admirable. And this brings me full-circle back to the original point: to claim that the conceptualisation of a personality disorder is unscientific, or that it is “cultural”, is in itself a dysfunctional position, as it presupposes an ability in oneself to imagine that one is entirely correct on an issue that exceeds any person’s ability to understand fully.

    Rather I would suggest that a lot of useful work and thinking on the part of a large number of people has gone into the declaration of personality disorder as a legitimate, verifiable phenomenon – and that instead of giving up in the face of complexity, we should acknowledge that we are still only part of the way there, and to keep working.

  11. Simon

    Although many in this thread have supported the Borderline Personality Disorder diagnosis, I still find the whole PD diagnosis to be about quick dismissive thinking that rounds everything up easily.

    Contrary to the idea that history/child abuse/neglect should be sympathised or understood, it isn’t. Generally the practitioner has no idea about the realtime experience. For me the sense of depression I get from bereavement is different to that of the depression I go to my doctor for. No questions are asked about this as I don’t think the profession even knows it’s actually like that.

    The same goes for anxiety. The anxiety I experience is overwhelming, like I’m about to be killed. It has no specific route, certainly not anymore, but it’s horrific. This is very different to social shyness. Yet again the profession cannot seem to tell the difference.

    I therefore feel that the profession is often led by people who, quite simply, feel they are naturally above the crowd and have the right to look, guess and just judge with confidence. When a service user feels the same in reverse, BANG, dismissive diagnosis…

    And never, ever, ever complain about the services, even if they leave you feeling like hell and have driven you to a suicide attempt. They will only ever pathologise it and backtrack further.

    We have environmental (housing), political and financial problems driving people crazy. Yet alone childhood abuse. Having dismissive diagnosis simply allows the profession and society at large to ignore what is actually going on. Everything reduced to “unnecessary reaction”.

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