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26 October 2018

Subscriber Says: We’re treating personality disorders the way we once treated mental health

There are many treatments for personality disorder now available.

By peter tyrer

“Remember ‘dissemination’,” said the adviser from the National Institute of Clinical Excellence (more commonly known as NICE), “It’s not enough to get your guidelines published. It is up to you to make sure everyone knows why and what you have recommended.”

This is the message now being given to university academics. No longer can you bury your pearls in the learned journal sand, hoping that a nosy reporter will find them and tell the world. You have to help them by doing it yourself. But what do you do with a subject like “personality disorder”? This is the stuff of ribald derision, of mocking laughter, of whispered gossip, not of science. People we don’t like, such as Donald Trump, Boris Johnson, Recep Tayyip Erdogan, Hannibal Lecter and Margaret Thatcher have personality disorders, not our friends or ourselves. David Owen, the former foreign secretary, has also joined in, by claiming Tony Blair and George Bush have an “acquired personality disorder” called the hubris syndrome.

As a former professor of psychiatry, I felt I needed to follow my NICE guidelines, correct this pop psychology and get the truth out about personality disorder. What makes this subject particularly important now is that the World Health Organisation this year introduced a new classification of personality disorder, which has taken into account all the available scientific evidence. As a result it has abolished all the pejorative and indiscriminately used epithets like “narcissistic” , “psychopathic” and “histrionic”. Instead it places us all on a single spectrum of personality disturbance, in which only a minority qualify for “normal personality”. We are all in this together.

There is very little popular literature on personality disorder that properly covers the topic. There are many books, mainly written by women who describe suffering from “borderline” and “emotionally unstable” personality disorder. In my reading, their evocative accounts of past abuse show they should be really re-diagnosed as complex post-traumatic stress disorder. But these conditions account for only one in ten of all personality disorders, all of which are slightly more common in men. The only other genre of books is about psychopathic personalities, which dominate the crime and thriller literature (where would be without them?), but which is very poorly covered in non-fiction. So we have to be satisfied with Snakes in Suits or Jon Ronson’s The Psychopath Test, the latter which treats the subject as though it was just a huge joke. This joke is a macabre one; the next nuclear confrontation is much more likely to be started by someone with a personality disorder than by any considered or planned policy.

So why is it important for everybody to know a little more about personality disorder? Imagine if doctors had just found a physical disorder that led to people consulting GPs six times more often, costing three times more in service costs, and dying many years earlier than those who did not have the disorder. There would be a national outcry, extra resources would be pumped into its identification and treatment, and it would hog the headlines for months. Personality disorder is such a disorder, but is almost totally ignored by the medical establishment.

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Some disagree with personality problems being recorded on a single spectrum. It all seems to come down to the sanctity of personhood. It is quite all right to classify anxiety, depression and other disorders but in attempting to classify personality problems you invade the central parts of us, our inviolable intrinsic core. So we set up barriers, particularly if we have doubts about our personality status, and take refuge in confining personality disorder to cardboard cutouts of people we do not like. We view personality abnormality in the same way in which mental illness was viewed 500 years ago. At that time a very small number of people were regarded as mentally ill, but as they were possessed by demons or were really witches in disguise, everyone else could feel secure. 

We also need to get away from the notion of untreatability. Personality is a fairly persistent characteristic; personality disorder is not. Long-term follow-up studies show that most people with personality disorder improve greatly and only a tiny minority satisfy the criteria for diagnosis five or 10 years later. There are also many treatments for personality disorder now available, most of them psychological or environmental in nature, and these too are adding to the benefit. There are even some mental disorders that have a better outcome with treatment in those with personality problems that in those without.

There are some who feel so annoyed with the diagnosis that they have formed a group to abolish the term. They call themselves “Personality Disorder in the Bin”. I would argue this only perpetuates stigma, and we now need a new group “Personality Disorder in the Spotlight”. That is where it needs to be.

Peter Tyrer is a retired professor of psychiatry who chaired the revision group for the reclassification of personality disorder for the World Health Organisation between 2010 and 2017. He is the author of ‘Taming the Beast Within: Shredding the Stereotypes of Personality Disorder’ (Sheldon Press, 2018) and chair of a charity (NIDUS-UK) supporting environmental treatments for personality disorder, that receives all the proceeds from the book.