When a diagnosis hurts

A friend of mine has unfortunately been struggling with her mental health of late. Recently she confided that her psychologist had suggested that perhaps it was not related to the diagnosis they had previously conceptualised, but possibly a personality disorder (PD).

PD’s are quite a controversial and highly complex aspect of psychiatric diagnosis. The current diagnostic tool asserts that normal personality traits become a personality disorder when the pattern of behaviour these traits cause can become extreme, inflexible and not responsive to different situations. Personality disorders can cause major disruption to the lives of the people who have them. There are a few criteria that need to be satisfied to diagnose a personality disorder:

  • It needs to be a long-standing, enduring pattern of behaviour and include particular ways of thinking, feeling, interacting with other people, and a lack of emotional control.
  • The pattern of behaviour must be pervasive and inflexible in a wide range of social, work and other life situations.
  • It leads to distress and problems with daily living and relationships
  • The behavioural pattern has to deviate in a major harmful way from the normal cultural expectations of the rest of the society in which the person lives.

My friend – like many others before her – seemed really upset by this news. And this is totally justified. There’s nothing more distinctive about someone than their personality – it’s one of the things that makes us all unique. They are the things we recognise in ourselves and others. So I think it’s quite natural to feel hurt or angry if someone – the psychiatry Gods – informs you that your personality is the cause of your distress.

I really feel for my friend. Receiving a diagnosis like this, or even discussing the possibility, can be devastating. But it really shouldn’t be.

As with most conversations, I wish there were things I had have said to my friend at the time. Or things I had said more eloquently. So, here is my attempt to have the conversation over.

Firstly my friend, I – and I’m not the only one - find the term ‘personality disorder’ problematic.

It tends to assume that certain types of personality traits need to be treated and that one’s personality is at fault. Since our personality is considered such an essential part of who we are, many people feel that being given a diagnosis of personality disorder is insulting and invalidating. A label of PD can be seen as critical of the individual rather than being a useful description of their experience and behaviour. Sometimes labelling someone with a ‘personality disorder’ can slot this person into a category that takes into account only one aspect of their overall personality.

My lovely friend, I know for a fact that your personality is bigger than this ‘disorder’, and I like the whole lot of it.

Secondly, there is a misconception around that personality disorders are permanent and not able to be treated. However, the fact of the matter is that with the right treatment and time the symptoms of these disorders will dissipate. One study out of the DBT Centre of Vancouver found that Dialectical Behavioural Therapy (DBT) effectively treated 70 percent of patients with borderline personality disorder. Of those patients, 94 percent have not experienced an episode again. The myths that all PDs are difficult-to-impossible to treat and guaranteed to reoccur are just that: bad information.

If this is a personality disorder my friend, please be aware and have hope that treatment can be successful.

Thirdly, the idea that personality disorders exist is controversial because it is based on a particular way of understanding human distress, known as the medical model.  This model assumes that we can explain human emotion by drawing on a medical and scientific framework and virtually all mainstream mental health services are based on this model. It has been argued – over and over again - that PDs don’t really exist but have been created as a way to understand and categorise certain feelings, ways of thinking and behaving to fit with the medical psychiatric system.

Personality disorders, like other psychiatric diagnoses, are based on judgements made by one person about another. It is often assumed that these are objective, scientific measures. Much of the status of psychiatry and the acceptance of diagnoses are based on this assumption. Many of the diagnostic criteria for most personality disorders refer to ‘extreme’, ‘unrealistic’, ‘excessive’, ‘inappropriate’ or ‘unusual’ thoughts, feelings and behaviours. To give someone a diagnosis, one person must determine whether the behaviour of another is reasonable or ‘unusual’, ‘excessive’, ‘unrealistic’, etc.

The term personality disorder covers such a broad range of feelings, experiences and ways of behaving that some question whether these are meaningful diagnoses or unhelpful constructions. The way that people are diagnosed from a list of possible criteria means that within any one specific personality disorder category, there will be a huge range of different experiences. For example, there are 246 different ways to meet the criteria for a diagnosis of borderline personality disorder. In addition, people are likely to be given a diagnosis of two or more personality disorders, again increasing the diversity of experience captured under these labels. Bringing together such a large range of experiences into these few diagnostic categories contributes to the controversies surrounding PD.

Remember this when considering this possible diagnosis my friend, the diagnostic criteria is still not totally worked out and categories are flawed. But you are a whole person. Not just something trying to be fitted into a hole.

Finally, it’s not that uncommon at particular times in our lives to meet, or very nearly meet the criteria for a PD. When I undertook my psyc training our class completed a lengthy, reliable and well-validated personality disorder assessment tool. And it provided some fascinating insights into ourselves – and psychologists in general. There was a much higher than normal prevalence of Cluster C personality disorder traits in the room – the anxious/fearful cluster. And I was one of them.

When I have been particularly unwell, I’ve probably been very close to meeting the full criteria for a PD as well – the Obsessive Personality Disorder. A disorder preoccupied with rules, regulations and orderliness. Such perfectionism coming at the expense of being flexible and having meaningful interactions with others.

I’ll always have these traits. They’re a part of my personality. And when it boils down to it, I don’t really want to give them away. But I do want to ensure that they don’t become my entire personality. That they don’t dominate my life to the point that I become significantly distressed and life becomes joyless. But the best thing in my armory is insight. I know when these traits can get a little out of control and I can intervene (now, anyway) to make sure they don’t become overly compulsive.

My lovely friend, with your level of smarts, you’re probably aware of all these such issues surrounding these possible diagnoses, but I hope you can stand up against it. I hope you can use this diagnosis as a helpful way of explaining and understanding your distress. I hope you can somehow use it to put a name to some of these crappy experiences and feel less alone. I hope the diagnosis can help you to find out more information and learn more and get the right treatment and the best forms of support so that you can feel in control again. And you can back to getting the most out of your life.

Like all the psychiatric diagnoses, this does not define you my friend. It’s just a thing. A thing to deal with for now. I believe that you’re way bigger than this thing. And if you need any extra help or love to deal with this thing, I’m always here.

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