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Debate No.3 (June 2002) - Personality Disorders

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This month's debate - the issue of personality disorders. Read the debate title below and argue for or against it. Rant and rave as appropriate.

Debate: PSYCHIATRISTS SHOULD NOT TREAT 'PERSONALITY DISORDERS'

'Personality disorders' are not disorders at all but simply a shorthand way of describing people who aren't like us. As psychiatrists we should treat people who are ill - this excludes 'personality disorders'.

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AGAINST

Modern society would have us sanitise all spirit and force of being out of our selves.

Recently it has identified certain exremes of personality as disordered.

These people were the movers and shakers of our history, for better or worse.

(-those who could not back down.

-those who obsessed over seemingly irrelevant details.

-those who could not tolerate be ignored.)

Personality is significantly heritable.

Social sanctions against these persons will lead to their reduction in human populations and negatively effect the survival, advancement and adaptability of the human race.

These people clog up the system, they make the system stop and think. They keep the door open for YOU to make express your opinion, and be heard

Should you ever have one you think worth standing behind.

Secondly

Are you and should you be so weak as to not stand up for yourself and what you believe?

Against

Psychopaths?

Nascists?

Anakastics?

If anything this age of beliving in nothing and persecuting the 'abnormal' (those who will not be cowed) needs these stuborn few.

Therfore they are not 'diseased' they are just exteme.

Be wary of the difference.

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The difficulty is that these people cause both suffering to others and to themselves. As psychiatrists we often only see one side to our patients. The labels of borderline personality disorder, histrionic personality disorder etc fit neatly into ICD-10 criterion or else we have a little debate about whether they might slot more neatly into other categories. But at the end of the day some of these people are really nasty characters and the labels have been put there for a very good reason.

Supposing you are somebody involved in a relationship with a borderline personality disorder only you don't know what a BPD is - what would it be like? Well if you take their characteristics you can kind of extrapolate. Just imagine that you and the BPD have a social network. The BPD makes unreasonable demands on you and you don't cooperate. Suddenly you are denigrated in the BPD's little dichotomous mind and that is a really bad thing for you. Before long the same kind of splitting that goes on in the wards is now going on in your personal life. The BPD will make up lies and let all of the BPD's friends know how bad you are. Not only that but if their is infiltration of your social network the same will happen there. When you meet those friends from then on they will react to you in a different way because they are naieve about these matters. The crossover between the ASPD and BPD is I think mainly a theoretical one.

Just imagine that this person is an ASPD we might expect them not only to do a bit of splitting but also to steal from you, to engage in violence, to spend money on drink or drugs and to do this for a considerable amount of time. Their charms would maintain the relationship for sometime whilst trying to conceal all of the above. There are various degrees of overlap with the dramatic personality disorders

What we are after ideally in society is equality and freedom for the individual.

This however is denied by the dramatic personality disorders who have no respect for others and believe that

everybody owes them a living. When they steal off you its not because they can't help themselves or they need to support a drug habit. They are able to steal primarily because they think their victim is worth nothing, that they do not deserve this property in the first place. The ASPD could steal from anyone implying they have projected all of thei negative feelings onto everybody on the planet. There is also little difference between stealing from somebody you don't value and doing other things to those people. This often endears a sense of sympathy in others who will go on a crusade to help these 'shattered individuals' and who will inevitably get sucked into the continuing pattern of abuse.

Nothing's really worked up until now in terms of treatment. But we can go down two lines

(a) An intensive treatment plan - lock them away and treat them as in the governments proposed DSPD plan

(B) Don't do that because they are a little bit different and we are effectively acting as social police.

'A clockwork orange' is a good example of (a)

At the end of the day just as with drugs and alcohol, these people have responsibility for their actions and should be treated accordingly. The best thing to do is to catch them early before the damage is done and that will involve a lot more people going into child psychiatry.

Maybe intensive psychotherapy will help them out - but a different form from the ones we have now. What kind of medication would help with this? It would have to be a medication that stopped people from thinking about themselves all the time and devaluing others - and in short I think very unlikely. The best bet is that there are some subtle neurodevelopmental abnormalities and that sophisticated functional neurosurgery will be able to correct neuroanatomical anomalies perhaps with the help of gene therapy. But at the moment we just don't have the technology. And in the meantime we have a duty to protect others - the services for this are already up and running.

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'as psychiatrists we should treat people who are ill - this excludes personality disorders'

I fundamentally disagree with this statement. As psychiatrists we should attempt to alleviate distress and minimise disability in those with mental health problems. People with personality disorders may not be ill but they do have mental health problems. They are frequently distressed and held back in their lives by their maladaptive emotional responses and coping mechanisms.

I personally feel that the issue here is that people with personality disorders are difficult to treat and raise intense negative countertransferences in us...neither of which we like. They make us feel inadequate for not being able to solve their problems and angry towards them for making us feel out of control. Hence we say...'well they are not really mentally ill and they are causing a lot of problems so its not in our remit to help them'. BIG COP OUT!!!!

I think psychiatrists should aim to help people with personality disorders if they are distressed (which they invariably are). I think we should all take a long hard look at ourselves and think about the real reason this patient group is so unpopular...its more about the way they make us feel than their inappropriateness in psychiatric services.

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Chimaera

Couldn't have said it better myself.

Elvis :lol:

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Personality disorder is not psychiatric illness as poverty and prostitution is not. It exists in the society as many other social evils and it should be dealt with sociopolitical measures. If we continue to encourage pds to be labelled mentally ill, I am sure in a few years time we will have another 20 categories of disorders without treatment and not curable, which are useful only to those who are looking for labels and to escape from responsibilities.All of us are disordered some way or another to a major degree or minor degree but it does not mean we all are ill and need help.Abusing the thin line which delineates the truely ill from fakes should stop.

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Agreed

However in favour of medicalizing this parameter of people; the study of the abnormal teaches us a great deal about the normal. The pathologising of personality is the natural next step of a society on the road to a more advanced level of humanity.

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great debate

;;from an exam point of view check out Kendall

in the bjpsych editorials

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just to add in that there exists a difference between treatability and curability. how many psychiatric illnesses are actually curable, and how many physical ones are? as physicians, don't we try and treat the symptoms?

don't we have people with PD turn up with symptoms that are perhaps treatable?

also of interest is that they perhaps don't exist with the same frequency and severity of illness in developing countries. in india, patients pay for their care most of the times, and also have to earn their meal, so they cannot afford to self harm and turn up to pay for getting sutured, or stay in hospital.

so many aspects to this, ???

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I agree with Chimaera,

Perhaps we are not prepared to accept/face few things-

Sucide as a complication at times

being devalued

inconsistancies

effort not  being sucsessful

hil :D

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Unfortunately, this debate is a product of the contemporary trend to simplify things into black and white.

If as defined (and generally agreed), personality disorder is an exaggeration of normal traits, which may have benefits, as well as disadvantages (I believe this anyway), then surely the 'decision', or 'diagnosis' is a quantative one, because Pd is not qualitatively different from personality.

Assuming this, how can we say that people with personality disorder either

1.Need treatment

or 2.Do not need treatment

I would say common sense dictates that this also is a quantative decision.

Surely by the same measure, just as personality varies along a quantative spectrum, the decision as to whether something is a PD is a somewhat arbitrary one, being made on say the 5th percentile of a particular rating scale for a particular cluster of traits.

Above all, this spectrum is one that measures personalties and not PDs (again highlighting the quantative aspect of this).

In essence, the decision of whether to treat or not treat a personality, is a clinical one.

If we debate about whether PDs, as a broad rubber-stamped label can or cannot be treated in such a black and white fashion, then we miss this point completely.

this is why the governments proposals on D&SPD are so dangerous in the current climate. Because if they are accepted, anyone given this label will be churned up in the process, which has been accepted as a government-driven protocol. The government itself is protocol-driven, and I am sure you can see the vicious circle developing.

Today, things are simply protocol-driven, and buck as we might against these harnesses, our freedom to make pure clinical decisions is ever more caged.

In summary, maybe we ought not to be thinking so much of whether PD is a mental illness, and whether it can be treated, but whether personalities (after all PDs are personalities) have difficulties, and whether these difficulties can be helped.

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I think psychiatry as a whole tends to have a field of study where one places an arbitrary (but coherent from a holistic point of view, in that the criterion for diagnosis is usually contingent on suffering in some way) marked at the verge of 'caseness.' &nbsp:lol:iagnostic schemata like ICD and DSM simplify this, but even in this context the seperate criteria within the categories tend to be subjective; impaired sleep, say may be variable from one to another, as might diminished pleasure in one's activities etc. Even in the context of psychotic illnesses there is plenty of opportunity to argue that most people are subject to occasional overvalued ideas (in the context of relationships, prejudices, tabloid credulity etc) and that in extremis these could give way to transiently 'delusional' symptoms. The binary model of illness that compensates for this, albeit unsophisticated, is in line with the hypothesis that, 'illness is what doctors treat.' This is now an outmoded notion, partly because we can't assume the hegemony of being the only authorities (alternative Rx is here to stay, like it or not,) however, it does provide a philosophical model with which PDs can be regarded as having an illness, and this was happily covered in the old MHA. There is a worry that DSPDs, as 'untreatable,' are therefore not a medical problem. This obviously has the drawback that as treaments change, so the definition of illness must change, clearly a philosophical nonsense, not to metion a little arrogant.

Why so much controversy over PDs then, after all, cancer is frequently untreatable except by palliation, and we have little concerns about making this into a medical issue. Perhaps because PDs are viewed as having arisen in the fundaments of a person, rather than as a discrete entity seperate to them. However, it seems that most illness, physical, mental, and combinations of the above, is explained by a stress-diathesis model, and PDs are no exception.

If it is possible to create an environment where PDs do not have to suffer (I think stamp collecting used to be a popular diversion!) however far removed from the biological nuts and bolts of brain science, then it is possible to apply the rigours of medical science, and interpersonal skills, to creating, and researching it. It would be a shame if the whole drive to improve the environment for, and decrease the pressure on, those with PDs was undertaken wholly by architechts and police forces. Acknowledging that the greatest improvements in physical health were brought about by greater sanitation does not mean that TB should be treated by sewage engineers alone.

So then, I don't feel that it is a matter of whether we should have to be 'responsible' for people's reaction to strees, exceptional or unexceptional, but whether our contribution might improve the lives of such people. Looking at the alternatives ??? one can only feel compelled to offer one's part.

hmm

dx

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My approach to personality problems is to simplify them in to a form which the person/patient, myself and other professionals (GP, nurses, police, SW etc) can work constructively with.

I have a different approach to:

1. Those with psychiatric disorder and personality dysfunction PD (a better term than disorder in my view). Patients with functional personality structures (who tend to have good social support, family relationships etc) and mental illness MI are relatively easy to treat and can frequently be dealt with in Primary Care. Those with PD and MI are far more complex and need expert treatment - i.e. psychiatric services.

2. Those with PD and no MI - explaining their severe and disabling symptoms using such terms as 'emotional instability' can be helpful. People can be helped to put their feelings in to words and discuss their interactions with other people. &nbsp:lol:iscussing 'splitting' and extreme/dichotomous thinking patterns can help people understand their extreme emotional volatility and key issues such as subjective lack of control of feelings/thoughts/behaviours. I often discuss issues of dependence vs independence (including risk of dependence upon psychiatric services and subsequent abandonment when ready for discharge). This allows discussion of lack of usefulness of medication and usefulness of behavioural and cognitive techniques to develop 'functional' coping mechanisms - e.g. diversion and relaxation techniques rather than dysfunctional e.g. self harm, alcohol/drugs. An honest explanation of the patient's role in their own treatment - e.g. keeping regular appointments, how to deal with crisis situations and an explantion of what psychiatric services can and cannot offer (depends on local setup). These people are at a higher risk of developing MI - putting in place preventative strategies and monitoring procedures is entirely justified. The role of forensic services should be openly discussed. Basically, as for alcohol dependence, the 'three option' model - Sad, Mad or Bad - which translates to - 'go away and get on with your life', 'engage with the services and let us help you, abiding reasonably to our terms and conditions of engagement' and 'continue behaving in a reckless and disruptive way and be prosecuted by the criminal justice system'. Patients should always be allowed to return to the 'engagement' model, but this may need to be in a safe and planned way.

As mentioned before, the main problem is trying to engender a level of understanding of personality function within the general population. This is destroyed by dogmatic attitudes of 'experts' such as us, or the government, who promote extreme views either way, rather than developing basic, simple explanations and models of treatment and realistic acceptance of causation and likely progression of syptoms.

I personally find patients with PD much more challenging and satisfying to deal with than 'cook book' psychiatry - treating illnesses is easy, treating people involves us taking a long, hard look at ourselves, which is one of the most rewarding and enlightening aspects of psychiatry for me.

The Admiral

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I remember reading an article by Adshead in APT re: treatability concept. she argues that while we do not give up on treatment resistant depression and schizophrenia, then why wash our hands off personality disordered pts. very little can be done indeed to treat them, but saying we cant treat you is making things difficult for everyone. engagement is important than treatment at times. i know of cases where pts have actually refrained from, say attempting suicide simply because their 'concerned' psychiatrists had asked them not to. what i like is the way adshead has concluded her article.

cheers

zeeto :):)

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Perhaps it is important to think about why psychiatrists in general have negative feelings about the PD patients. Maybe it is the psychiatrists' frustration at not being able to do anything about it. So if and when an effective treament for PD becomes available, we may feel differently.

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I think poopoo's point is important.

But can anyone honestly say that they have no deficiencies in their own personality? Perhaps we are just recognising in others, parts we don't like about our own selves!

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For anyone interested in this topic, Please read Maudsley's Discussion Paper No:7 titled 'Should Psychiatrists Treat Personality Disorders?' by Paul Moran, a 22 page booklet costing £4/-. It has references of the late 90's, so is not a new publication, but is not old either.

Personally we should treat Personality Disorders.I have no doubt over that.

Before people try to lynch me here for saying that listen to my arguement fully.

1) We should treat & Manage them but not in the current service format. It will reorganisation of services with many Therepeutic Communities & Supported Accomodation etc....... We should also have a specialist PD service working in the community having close liason with Probation,Prison service,RSU's & Specialist Forensic services.

2) The recent Draft Mental Health Bill with its broadened definition of mental disorder & provision for the DSPD services, increase of Long Term Medium Secure(LTMS) forensic bed provision under the NHS Modernisation plan 1999 etc. all done by the Blair Government is in my view the Centre right Agenda proposals for Mental Health & this will not substantially whether David Cameron or Gordon Brown come to Power.

3)If we say 'NO' to treating Personality Disorders then Budgets for Mental Health Services will be cut drastically & that will sound the death knell to Psychiatrics services as we know them.

4) Personality Disorders have more Heretability than any other disorder in Medicine let alone Psychiatry.

If one looks at the clusters of PD in DSM-4 Cluster -A(Paranoid & Schizoid ) are Psychotic Personality Disorders.Cluster B are the Affective(mood component) Personality Disorders & Cluster C are Anxiety PD. Ofcourse I am grossly over generalising the whole debate.

All of them can be managed with medication with significant overall improvement in quality of life for this population.

The linear development of Adverse Childhood experiences leading to Conduct Disorder/Oppositional Defiant Disorder/ADHD then leading onto Adult Personality Disorders tell uus that the predisposing factors for PD & Severe & Enduring Mental illness are more or less the same.

If they are managed well, then burden of investing in Criminal Justice System, acute medical services(consequences of smoking,drugs and alcohol & their complications) & building prisons can be reduced substantially.

All of us can save on Home & Car Insurance !LOL! just kidding.

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