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…

Putin’s mental state? It’s time we dropped the childish and uninformative mad man view of history

  • March 4, 2022

Former UK foreign secretary David Owen has recently been reported as saying that Putin’s aggressive behaviour on the international stage may be a consequence of taking steroids. The evidence for this assertion is that Vlad’s got fatter in the face in recent times and is being unreasonably aggressive.

Owen has form in the cod diagnosis of politicians – giving us in 2019 the ridiculous condition of Hubris Syndrome – or hubris as we used to call it. My reading of the formulation there (excuse the technical jargon) is that after a few years in power people tend to get up themselves a bit, arrogant and not keen on being contradicted. However, I may be wrong and there’s more to it: a senior neuropsychologist tells us that Hubris Syndrome affects the frontal lobes drenching them in dopamine, and this could be the cause of Putin’s behaviour.

In the same article that reported the Hubris Syndrome idea, a different expert suggests that it’s something to do with the cognitive effects Long Covid. No less absurd as a hypothesis but I suppose it has the advantage of being bang up to date.

If any of this sounds familiar that’s because it is. Not that long ago experts were telling us that President Trump wasn’t just horrible but mentally disordered – most infamously in the multi-contributor volume The Dangerous Case of Donald Trump. And of course the most famous mad man of recent history is Hitler – name-checked 59 times in the Trump book in case we didn’t spot the provenance of the line of thinking. I could keep going but the trail is long – back to Suetonius at least (I’d have to stop there, my ancient history’s a bit thin).

It’s tempting to dismiss all this as ridiculous, which of course it is. It’s raised a momentary laugh when I’ve chatted about it with friends and that’s about what it’s worth. But there are reasons to think we could do with less of it, for the effect it has on the quality of public discourse.

First, pathologizing of political motives as symptoms of mental disorder is really just a variant of psychiatric name-calling, which is a form of insult we could do without. And it infantilizes public discussion about serious matters. Do we really think that the Ukraine invasion is the result of an aggressive impulse by somebody who has temporarily taken leave of his senses? Or that one man can run not just a complex military adventure but a whole country – without the collusion of others in it for the power, money, sex or whatever it is that motivates them?

Malignant despots have something in common, I think, with buffoon politicians like our own prime minister. They are symptoms of the system that allows them to stay where they are, their endurance reflecting not just something about their callous self-interest but also the values of those on whose collusive support they depend.  All of which is kept out of the spotlight by daft pseudo-diagnostic medicalisation, a sort of dark-side version of the Great Man of History story which downplays the systemic and societal and privileges the role of the individual actor.

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?

New NICE guidelines on management of self-harm won’t lead to the changes needed – lack of investment and the culture in mental health services will see to that.

  • January 28, 2022

It is more than a decade since NICE last published guidelines on the assessment and management of self-harm, so the recently released new guidelines (out in draft for consultation) will be read with some interest.

What we find is a mixed bag. For the most part the proposals are unexceptionable, the generation of novel ideas and advice no doubt hampered by the desperate lack of funded research in the area. Some suggestions are not impressive – for example a blanket endorsement of CBT for all adult self-harm is limited to put it mildly, and the section on harm minimisation is ill-informed and muddled.

There are, however, some welcome recommendations, most notably “1.6.4 Do not use aversive treatment, punitive approaches or criminal justice 5 approaches such as community protection notices, criminal behaviour 6 orders or prosecution for high service use as an intervention for frequent 7 self-harm episodes.” – a clear response to the HIN/SIM scandal and one that will make a difference, not least because it is supported by NHS England.

My guess would be that this is the only recommendation likely to make a substantial difference to service provision in the next few years because there are two barriers to change that NICE can’t really influence – the first is lack of resources and the second is culture in mental health services.

When David Owens and I wrote a lament for the state of self-harm services in the UK my friend Nav Kapur wrote a Pollyanna-ish reply, but in truth the situation is dire. Existing services like CMHT’s and IAPT will see hardly anybody and those they see will get an appointment neither on a timescale nor in the numbers needed for the nature of the problem. Liaison psychiatry services do most of the assessment but none has the clinic capacity to arrange therapeutic follow up. The few specialist services there are will see a small number of referrals for intensive longer-term therapy but only if strict eligibility criteria are met. There are several reasons for this state of affairs, but one of them is undoubtedly lack of investment in trained staff to do the work. Against a background of government “austerity” cuts, money has been found for psychotherapy provision in the NHS (through IAPT) and for an expansion of liaison psychiatry services, but none of it has found its way into the budget for self-harm aftercare. You can come up with as many recommendations as you like about support for people who self-harm, but if there are no services to deliver that support then nothing’s going to happen.

Culture eats strategy for breakfast, and the other piece of the puzzle resides exactly in culture. There are plenty of people who think, and behave as if, self-harm isn’t that important and the people who do it are just a bit of a nuisance. Patient feedback about services repeatedly makes this point – ED isn’t a great place, waiting to be seen is stressful, assessment doesn’t achieve much if there are no useful services to which somebody can be pointed after the assessment, but a lot of this can be tolerated if it doesn’t come with a message of hostility or indifference from the clinician seeing you. Of course it isn’t every clinician but it’s enough…especially for those unfortunate enough to have copped a diagnosis of personality disorder.

These two things play off each other – negative attitudes lead to, or at least lead to tolerance of, poor service provision, and lack of services leads to stressful uncomfortable encounters in which it is all too easy to slip into a hostile or blaming frame of mind.

I don’t think this is all there is to it but these two factors, which I have named here rather than unpacked very carefully, seem to me a good part of why the draft NICE guidelines bring such a sense of anti-climax. Most clinical conditions are now managed in established services delivering care that might be improved by careful attention from a positive and trained workforce to standardised evidence-based practice; that’s what NICE guidelines are for. In self-harm those conditions just don’t apply. Let’s not blame the NICE guideline development team, let’s look elsewhere for solutions.

Should the police be included in mental health crisis teams?

  • April 27, 2021

A spin-off from the practice of police officers wearing body cams is that the footage (in the UK) provides material for fly-on-the-wall documentaries about what day-to-day police work is like. One of the insights you learn from that TV coverage is how often the police are called to incidents where a significant part of what’s going on is explained by the mental health problems of one or more of the protagonists. And one part of that work is generated by people who repeatedly access the crisis services, either by calling 999 or by presenting their distress outside the home to others who then call the emergency services.

It is widely accepted that responses to this phenomenon of frequent crisis contact are not always effective. One recent development has been the emergence of the High Intensity Network of teams delivering what is known by the (frankly silly) name of Serenity Integrated Mentoring. These teams include both mental healthcare staff and police officers, share information and decided on a plan aimed at reducing this so-called high intensity service use.  That plan can include the possibility of formal action by the police, including the use of community behaviour orders or prosecution. I have recently become aware of this scheme and of some of the concerns being raised by patients who have experience of it and by service user activists. I had been alerted to it by a friend who is a service user and activist, and from my reading of social media posts by those people seeking an investigation and curtailing of this activity.  I have come to the conclusion that there are indeed some important concerns being raised: this is not just a Twitter storm in a teacup. I will outline what I take to be the main issues.

First there is the practice of sharing confidential clinical information with police officers. This has been justified by an appeal to the idea that people are only included in the scheme in an emergency, and that sharing is therefore in their best interests.

Here for example is a Tweet from the Network’s director. It is clear however that this idea of data sharing as high-threshold urgent action is being stretched to justify routine sharing of clinical information on all patients managed by the team. To quote the Network’s own description of the people under consideration “They are constantly an emergency case, just fluctuating at different levels of intensity, causing varying levels of impact. Our strong argument therefore is that all agencies involved in the network can share personal data and clinical data about these service users at any time, both in a preventative capacity when they are not using emergency services and in a reactive capacity when they are.”

Second, there is a question about informed consent from patients in the scheme, who must by definition have mental capacity.  There is much made in HIN/SIM documents of the need for consent, and it is said that lack of consent (telling described as “refusal to engage with mentors”) must be respected.

Here is a slide from a talk given about SIM by a team member. The nature of consent in this situation is highly problematic, since it is clear that in these integrated teams the prospect of coercion remains an active option for those who engage in what the team consider undesirable behaviour and yet who “fail to engage”.

The SIM operational delivery guide confirms this overlap of processes, with clinical staff able to contribute to the discussions about police responses to antisocial or illegal behaviour and police able to contribute to discussions about clinical risk management.

Some of the vocabulary used in HIN/SIM documents is not reassuring when seen from a service user perspective. For example stating that “The project team will be dealing with service users with often high risk, malicious and litigious behaviours.” and suggesting (as in this Tweet from the director) that patients do not have the right to share and discuss their care plan with people of their choosing. The FAQ section of the HIN/SIM website notes “Our teams operate multi-agency panels each month to assess which patients should have their consent removed…”

This approach, implying a seamless move from therapeutic responses to coercive responses, is one of the commonest complaints evident in online discussion of the scheme. Because police involvement is evident in all aspects of the process then consent to participate can hardly be given without a sense of duress.

Third, there is a question about evaluation of the scheme and especially assessment of harms. A startling number of benefits are claimed for the mentoring scheme – based it has to be said on minimal evidence: in truth there has not been a substantial independent research evaluation at all, which is surprising considering how enthusiastically the scheme has been promoted. By contrast to the claimed benefits, there is no discussion of potential patient harms such as those that might be caused for example by people avoiding seeking help in a crisis or actively being prevented from doing so. Any deaths that might occur are described as accidental, including those attributed to (a new term to me) accidental suicide.  

It is hard to collect citable evidence on such outcomes from informal reading because so few people are willing to come forward in an identifiable way, but I have seen them reported by reliable sources and there is no reason to doubt that they happen, even if nobody is trying to quantify them.

Complaints are likely to be interpreted in particular ways “Making complaints against staff can often be a way in which service users (at times of stress) attempt to avoid consequences or responsibility. They can also be used in an attempt to distance themselves from the staff who are supervising them so that they do not have to continue with the programme.” And staff who have to respond to what are called allegations are invited first to watch a video prepared by HIN. “The video informs the investigators about the nature of high intensity cases and the behavioural disorders commonly found in these cases. It also explains the motivations for making false allegations and common behaviours that may be witnessed after the allegation has been made.”

In summary: the approach represented by the High Intensity Network has apparently been adopted by more than half the Mental Health Trusts in the country, despite lack of robust evidence for its effectiveness or harms. Reasonable concerns have been raised about the approach to information governance and the sharing of confidential information and about the blurring of boundaries between therapeutic (health services) responses and coercive (police service) responses.

Much of the promotion of this particular scheme has been individualised around the person of Paul Jennings, a policeman who started the SIM programme in the Isle of Wight and now directs the High Intensity Network. Jennings has a rather idiosyncratic take on the issues which no doubt influences the tone of debate: he talks about mental health problems in prisons as if they are relevant to this different context, and his rationale for SIM as a response to what he calls behavioural illness is a mixture of naïve behaviourism and a sort of paternalistic encouragement to people to give up bad habits. Nonetheless, there is more to be questioned here than can be put down to one person’s influence. The problems outlined about confidentiality, consent and coercion are inherent to any scheme in which health care staff and police staff are fully integrated into a single team. There is a serious question about whether the Royal College of Psychiatrists should be supporting such developments at all. It is a worry that so many psychiatrists are likely to be involved either directly or tangentially in this way of working, without these issues being resolved. There are other ways to develop productive working relations with the police and the other agencies involved with crisis care.

Acknowledgments:  There is an impressive social media presence on this topic.  As a start try searching Twitter using #HighIntensityNetwork or #Stop Sim. It is activist and service user-led work that has brought the problems to the fore – critical discussion led by mental health professionals has been bordering on non-existent. The quotes in this piece come from:  HIN/SIN Operational Delivery Guide (SIM London version, March 2018); SIM Business Case  and SIM FAQs (from HIN website www.highintensitynetwork.org unfortunately unavailable since June 2021)

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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