At some point I’m going to write a great treatise on what I think of diagnosis and personality disorder, but today I’m just going to focus a bit on how the diagnostic criteria for personality disorder is interpreted and applied. Because that’s something of a dull topic, we’re going to explore this with a few extra dragons, knights and sorceresses than your average medical textbook.
Now as an Occupational Therapist, I’m generally not that interested in diagnosis. I’m far more concerned with the difficulties people have and the impact those difficulties have on their lives. As a pedant however, I’m very interested in what rules are and what it means when they’re not followed. I was particularly irked this week to read a blog hosted on the British Medical Association website saying of personality disorder “There is usually no history, just a sudden change”.
Now this is just wrong. If we have a glance at the DSM 5 (the big book with all the illnesses and disorders in) we can read about someone’s difficulties having ‘onset in adolescence or early adulthood and being stable over time’. If someone’s personality suddenly changes, ‘disordered’ or otherwise, you’re better off checking for a brain injury or whether there are any recreational substances floating around their bloodstream. That the BMA hasn’t bothered to correct anything in the blog they hosted reflects very badly on them in my opinion, however, they are not the only people I think are misapplying diagnostic criteria this week. (There’s a better critique of the BMA blog here)
Andrea Schneider has written a series of blogs where she goes through characters in the TV series Game of Thrones and identifies problematic personality traits. I’d recommend you check them out as they’re quite entertaining, however, Andrea goes on to diagnose characters and it’s here I don’t think the diagnostic manual is being followed. Just before we start, the entire series of GOT should have TRIGGER WARNING plastered all over it and what I write below is going to reflect that. Here we go…
In blog 1 of Andrea’s series she diagnosis Cersi Lannister with Antisocial Personality Disorder. Cersi is one of twins who lost their mother at an early age. Her younger brother was identified as killing her mother during childbirth and she was taught that he was less than human, someone to taunt, hurt and insult. Her father was renowned for his ruthlessness and cruelty and she would have seen regular examples that people who are against you should be humiliated and annihilated. Cersi had little experience of love, her biggest attachment being to her twin brother. When their play became sexual, they were separated with guards at the door to prevent them keeping each other company at night, the message being that their feelings of love were dirty, wrong and something to be punished. Once their mother had died, Cersi and her twin brother became closer and their sexual relationship an open secret that if not approved of, was openly tolerated. Cersi was given the message by her father that her feelings were not important and that her value was in who she could be married to. She was told on a number of occasions who she would marry without her having any say.
Now regardless of what we think of the term ‘personality disorder’, we would probably agree that anyone living through those experiences would grow up with some ideas about themselves, other people and the world that, while totally appropriate for the environment they have come from, would cause difficulties if they were suddenly plonked down onto the streets of London. Cersi grows into an adult with her fathers cruelty, perhaps a paranoia that others are plotting against her, a disregard for the feelings of others and certainly some high levels of impulsiveness. Now if someone walked into your clinic tomorrow with these features which had been present for a long time (remember the DSM!) it might be accurate to say that they fit with what the textbook describes as Antisocial Personality Disorder. If your clinic was in Westeros (the setting for Game of Thrones) I’m certain that this wouldn’t be the case.
To visit the DSM again, it tells us about “inner experience and and behaviour that deviates markedly from the expectations of the individuals culture”. In other words to get a diagnosis, you need to be very different from everyone else around you. We have covered the cruelty of Cersi’s father who for example, had his son watch as his wife was raped by all the guards of the palace. Cersi’s husband regularly raped her and made no secret of his frequent infidelity. Her brother in law burned his daughter alive and killed his other brother. The ‘mad king’ was busy burning many people alive, the Freys in the North were happy to massacre hundreds of people who had sat down for dinner with them, the princesses down south assumed power by killing their brother and the Lady of high garden thought it best to have the king vomiting to death on his wedding day to make sure her daughter could marry someone else. Across the sea Daenerys is seen a a good person, but even she is content to burn people alive and crucify thousands. When we compare Cersi to her peers can we honestly say that her behaviour ‘deviates markedly’ from what others are doing? We can’t. She hasn’t even killed the most people. When looking at diagnosis people often lose sight of whether a person’s behaviour is entirely adaptive given the background they have come from, or even the environment they are currently living in. Put bluntly, if everyone has got ‘a personality disorder’, then no one has got a personality disorder.
As a slight aside, there is someone in Game of Thrones it might be possible to pin a label on and make it stick. With his behaviour that was markedly different, with his attitudes and values that couln’t be adapted and that led to huge amounts of stress and the impairment of having his head cut off, Ned Stark is the person whose way of seeing himself, others and the world caused him the most problems.
While we’re looking at the misapplication of diagnosis, lets have a quick peek at a tyrannical leader a bit closer to home. This time were going to hang onto the “leads to distress or impairment” part of the DSM. Donald Trump frequently has people throwing the label of Narcissistic Personality Disorder at him. And narcissistic he is. Impulsive too. But are his behaviours enough to say that he has a disorder? Party politics and emotions aside, we need to look at the fact that he was elected President. We need to acknowledge that whatever vacuous statement he throws out to contradict the last clanger he dropped, a sizeable braying mob will applaud, cheers and believe his lies. He may well be a very dangerous man, but he is adored by his followers because of who and how he is. Whatever you think of him, his way of being has, rather than caused him problems, got him into the position of being the most powerful man in the world. God help us all.
Whenever you’re thinking that someone’s presentation fits with what the textbook would define as personality disorder, you need to consider the 3 Ps.
Are the difficulties persistent? This was the mistake the BMA blog made. You’re looking for issues that have been around all their lives. Not something that comes out of the blue.
Are the difficulties pervasive? Do they affect every aspect of the person’s life or are they limited to specific situations? If they’re very contained then whatever PD criteria you’re trying to apply isn’t going to fit.
Are the difficulties problematic? This is the mistake the Trump diagnosers make. Just because you loath someone, if your loathing doesn’t impact them then its not a problem for them. Its a problem for you.
Now this blog is very silly, but I hope it makes some serious points about how diagnostic criteria is applied. It is by no means an argument in favour of diagnosis but just a suggestion that if you are going to use diagnoses, then at least do it properly. If you have a look at this there’s a link to a publication from the National Offender Management Service which has all the diagnostic criterial you could dream of. People often feel that if they can absorb this then they’ll be more effective in their work but honestly, you’re far better off talking to people and creating a narrative out of what they tell you rather than plonking a label on them. Diagnosis can obscure people’s stories and it’s those stories that matter. Go weave some stories together.
All the above are ideas rather than truth and many other ideas are available online. Do let me know what you think.
Keir provides training, therapy and consultancy via beamconsultancy.co.uk