Self-harm, autism and “personality disorder”

  • June 17, 2024

It isn’t uncommon to find personal accounts of the experience of being diagnosed with autism in adult life. Typically, such accounts comment on what a shame it is that the author wasn’t diagnosed earlier in life – perhaps because they are female and autism was thought to be near non-existent in girls. Quite often the benefit (or the one assumed to have been missed) comes from the simple fact of being able to put a name to difficulties in day-to-day experience of which the individual is already aware but for thinking about which they had no vocabulary.

One subset of these accounts comes from people whose experience, perhaps not so day-to-day, has come from contact with mental health services. The new diagnosis sheds light on what has been problematic about previous encounters and (with luck) what might be done differently in the future.

To a considerable extent in psychiatry (and to some extent in the whole of medicine) diagnosis depends upon pattern-matching. It can work well to produce quick results in situations where speed is important, but it can go wrong. For example, a topic of much recent discussion has been the problems caused because diagnostic “patterns” are derived from clinical practice and research that privileges male examples. In relation to autism the problem is that the presentation of distress does not match the expected pattern – social awkwardness, apparent lack of engagement, seeming detachment, coupled with difficulty in articulating the emotional problem, these do not create the picture we are taught to anticipate in somebody during an emotional crisis.

One area where this can play out is in the assessment of self-harm. It isn’t clear how common it is, but it is likely that at least for some people the mismatch between expected and actual presentation of distress leads to a diagnosis of (guess what) personality disorder. Recently I was alerted to a blog discussing this possibility. I liked it for two reasons. It concludes with noting that “autism” in this context is a way of naming “difference rather than defect or disorder”. I prefer this approach to the alternative “BPD is really … (cPTSD, autism or whatever)” because of its emphasis on the need to consider diversity rather than diagnosis; the former applies to everybody while the latter does not. And, unusually in my reading experience, it offers some practical (and realistic) advice about what to do if you are in this predicament.

An important question raised by this thoughtful blog is the possibility of challenging and overturning a previous diagnosis of personality disorder. Not, I gather, a suggestion that has played well with the clinicians with whom it has been raised so far, but I have the impression that the blog’s author, fortunately, won’t be giving up the attempt any time soon…

Personality disorder as a diagnosis: stereotyping and discrimination aren’t avoidable complications, they are inherent to the diagnostic process.

  • February 14, 2022

In clinical practice, a full diagnosis typically consists in the description of a particular presentation coupled with an account of the associated (causal) pathology that explains the presentation.  Thus: you are breathless and I can’t hear breath sounds on the right side when I listen with my stethoscope (the presentation) because you have fluid surrounding your lung due to tuberculosis (the explanatory pathology). Diagnosis in psychiatry is rarely full in this way, typically consisting only of a description of the presentation.

If we consider the diagnosis of personality disorder in this light, does it make sense? The diagnostic statement is that the person is the presentation, and although there is assumed to be some sort of underlying deficit in psychological function that constitutes the associated (causal) pathology, it has to be said that after 100 years of inquiry what it is remains to be revealed. We are left with the diagnostic statement – your emotions, actions, thoughts aren’t symptoms of some condition you have; they are simply the expression (presentation) of your personality and therefore who you are is a mental disorder.

If that’s right, can debate about the status of the diagnosis be bracketed with debates about the clinical or social status of autism or physical disability? That is, the diagnosis can be criticised for pathologizing diversity or for essentialising the individual who becomes the problems they present?  I don’t think this quite works as an analogy. For example, there is no ineluctable presentation in personality disorder which is why categorising sub-types has proved such a failure. Autism is autism is autism, while psychopathy can look like any number of things.

Apart from the mutability difference, there is something different from the neuro-diversity analogy in the way the “disorder” of personality disorder is defined – not just in social or interpersonal terms but in judgemental terms. The judgements are, at root, about acceptability of behaviour, emotional expression and so on.

So, making a diagnosis of personality disorder isn’t stereotyping or stigmatising as an unfortunate side-effect of the way some ill-informed people choose to treat those so diagnosed, it is inherent to the diagnostic process. If we say that who somebody is constitutes a mental disorder the features of which are socially and personally undesirable, and this “who somebody is” fits them in a category of similar people with the same mental disorder, then how could it be other than stereotyping and stigmatising, with the resulting responses being those we might expect towards anybody who is by definition undesirable?

How long does your personality last?

  • March 29, 2021

The Oxford English Dictionary defines personality as “The quality, character, or fact of being a person as distinct from a thing”, a usage dating from at least the 14th century.  Personhood implies some sort of persistence or continuity of character: we expect who we are to be relatively enduring, perhaps changing only in response to overwhelming “life-changing” experiences. So, if your personality is disordered, then we should expect to see the same picture – if you are a personality-disordered person then you stay one under normal circumstances.

Indeed, through much of the history of psychiatry this has been the predominant way of thinking: personality disorder, with its synonyms such as the psychopathic state, has been taken to be a long-term problem, evident in early life and persistent throughout most of adult life. Thus DSM 5 says: “The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations.” While ICD 11 has it that “Personality disorder is characterised by problems in functioning of aspects of the self … and/or interpersonal dysfunction … that have persisted over an extended period of time…”.

Unfortunately (for those who like the diagnosis, that is) the assumption of stability doesn’t stand up to scrutiny.

The persistence of “personality disorder” can be studied by following up and repeatedly re-assessing a group of people given the diagnosis, a so-called cohort study. Much the same sort of study involves following up people in treatment trials who have been allocated to the comparison arm rather than the active treatment arm – which typically means they don’t get an intervention likely to influence the natural course of what happens to them.

Obsessive-Compulsive Personality Disorder | CBT Psychology

A number of studies* have now shown that people with the diagnosis of personality disorder “get better” – sometimes very quickly after diagnosis, about a half within 1-2 years, and the great majority within 10 years. This is a well-known phenomenon – in fact the ICD-11 definition of an extended period of time is only “2 years or more”.

How to explain this finding? In medical practice it is not uncommon to encounter conditions that improve, sometimes only to come back later – for example multiple sclerosis, tuberculosis, bipolar disorder. There are two views of what is going on here. The condition may not really have gone away but simply be in a dormant or non-aggressive phase (quiescence) or it may have gone away, but the disposition to get it again (perhaps genetic) has not.

The first of these explanations doesn’t work for our purposes: the diagnosis of personality disorder is a description of how somebody is living in the world, not of a bodily state that fluctuates to become be more-or-less easily observable. If the individual doesn’t meet the diagnostic criteria then they haven’t got the condition. It can’t be thought of as lying dormant somewhere any more than somebody who diets their BMI down from 35 to 28 can be thought of as having quiescent obesity.

There are several reasons why somebody might change from meeting to no longer meeting the criteria for diagnosis of personality disorder – adversities resolve, relationships improve, and that means that distress settles and it is these symptoms that now decline enough to take the individual out of the diagnostic range. By the same token a change for the worse may be provoked by a worsening of these same experiences.  Seen like this, personality traits are simply names for the individual vulnerabilities or resiliencies that modify how we respond to circumstances.

So the answer to the question “How long does your personality last?” is “If your personality has been diagnosed as disordered, on average about 2 years”. If that doesn’t match your idea of what the word “personality” means, then you’re on the way to understanding why there are so many critics of a term that is widely seen as conceptually flawed as well as pejorative in its routine usage.

*One or two references…

Shea MT, Stout R, Gunderson J, Morey LC, Grilo CM, McGlashan T, Skodol AE, Dolan-Sewell R, Dyck I, Zanarini MC, Keller MB. Short-term diagnostic stability of schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders. American Journal of Psychiatry. 2002 Dec 1;159(12):2036-41.

McGlashan TH, Grilo CM, Sanislow CA, Ralevski E, Morey LC, Gunderson JG, Skodol AE, Shea MT, Zanarini MC, Bender D, Stout RL. Two-year prevalence and stability of individual DSM-IV criteria for schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders: toward a hybrid model of axis II disorders. American Journal of Psychiatry. 2005 May 1;162(5):883-9.

Zanarini MC, Frankenburg FR, Hennen J, Silk KR. The longitudinal course of borderline psychopathology: 6-year prospective follow-up of the phenomenology of borderline personality disorder. American Journal of Psychiatry. 2003 Feb 1;160(2):274-83.

Gunderson JG, Bender D, Sanislow C, Yen S, Rettew JB, Dolan-Sewell R, Dyck I, Morey LC, McGlashan TH, Shea MT, Skodol AE. Plausibility and possible determinants of sudden “remissions” in borderline patients. Psychiatry: Interpersonal and Biological Processes. 2003 Jun 1;66(2):111-9.

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