Part 17 of The Mental Health Workers' Guide introduces the topic of Personality Disorder. Don't forget that you can download the movie links that accompany the entire series by clicking here.

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According to ICD-10 (the World Health Organisation’s diagnostic manual) Personality Disorders comprise:

“…..deeply ingrained and enduring behaviour patterns, manifesting themselves as inflexible responses to a broad range of personal and social situations. They represent either extreme or significant deviations from the way the average individual in a given culture perceives, thinks, feels and particularly relates to others. Such behaviour patterns tend to be stable and to encompass multiple domains of behaviour and psychological functioning. They are frequently, but not always, associated with various degrees of subjective distress and problems in social functioning and performance.”

“Personality disorders differ from personality change in their timing and the mode of their emergence: they are developmental conditions, which appear in childhood or adolescence and continue into adulthood.”

WHO (1992)

This seems to be quite straightforward in many ways. It’s a description of lifelong problems that show up in all situations that individuals finds themselves in. To put it another way…

Wherever you go – you always take yourself with you.

Unfortunately there are very real problems with the way that psychiatry has developed and ultimately settled upon its notions of personality disorder. But that does not mean that we should ‘throw the baby out with the bathwater’. If nothing else the current medical diagnostic framework allows us a starting place to build upon so long as we do not allow ourselves to become complacent and simply settle for the current diagnostic ‘status quo’:

According to the British Psychological Society (2006)

“It is widely accepted that the psychiatric classification of personality disorders is unsatisfactory, but it provides a common terminology that is essential as a starting point for clinical communication and further research.”

Of all the diagnoses used in mental health services the ‘personality disorder’ group is arguably the most controversial. In order to understand why this might be it’s helpful to consider where the diagnosis might have come from.

According to the 1999 Report of the Committee of Inquiry into the Personality Disorder Unit at Ashworth Special Hospital

“Moral insanity gradually fell into disuse, but moral imbecility was defined further and incorporated in the Mental Deficiency Act of 1913, subsequently changed to "moral defective" in the Act of 1917. Its contemporary meaning, which is closer to anti-social personality, has evolved from the influence of French, German and American psychiatrists during the hundred years and more following Prichard when defects of "the moral sense" continued to persist, virtually until the Mental Health Act of 1959; indeed its current usage still has moral and pejorative resonance.”

Modern mental health services have inherited a legacy from the past and the diagnoses we use have been left a legacy too. It’s always worth remembering that the services we deliver in 2012 are not the end of the road. Just as we are left to build upon the legacy of the past so we will leave our own mark on the services of the future. It’s all part of a much longer timeline of service development and provision.

In fact, far from being particularly advanced in our current culture and understanding we’re probably very primitive today compared to what will happen in the future.

As I often say to my students:

“It’s only 2012”

Moral Defective was a relatively common ‘diagnosis’ during the early part of the twentieth century and tended to result in long-term or even lifelong incarceration in a lunatic asylum.

Criteria for the ‘diagnosis’ of moral defective included:

„X       Childbirth out of wedlock (only if the woman lacked financial means);

„X       Petty criminals;

„X       Homosexuality.

It’s a good thing that these criteria are no longer used to determine personality disorder or things in the modern world might be very interesting indeed. Even back in Edwardian England it was apparent that the diagnosis had little to do with actual ‘disorder’ and a great deal to do with social ideas about acceptability, deservingness and expediency.

If the criteria for moral deficiency was really about morality then there would have been no prostitution outside the walls of the asylums. However the emphasis was not so much on moral conformity as the public purse. An unmarried mother who could not support herself and her offspring became a burden on local society – unless she was insane. The emphasis upon expediency is the reason the diagnosis only applied to unmarried mothers if they lacked the means to support themselves. Wealthy women could have as many illegitimate children as they wished. Tongues might wag but they were unlikely to be incarcerated in an asylum for it.

Now I am not suggesting that modern personality disorder diagnoses depend upon financial means. That’s not the legacy that was handed down to us. I am suggesting (and I intend to demonstrate) that in 2012 the diagnoses that make up the personality disorder group depend upon ideas of acceptable behaviour and social value judgements just as surely as did their Edwardian predecessors.

There are no blood tests for personality disorders. Neither are there any physical examinations. In point of fact there is no particularly reliable evidence that personality disorders are ‘medical’ conditions at all. Hence the controversy.

What we have instead are judgements about behaviours. Some behaviours are thought to be ‘normal’ and some ‘abnormal’. However they remain no more than behaviours and coping strategies.

Alongside these we have judgements about what sort of emotions are ‘normal’ and the degree of emotional control that people are expected to exercise. People who fail to live up to the expectations of the psychiatric manuals, either because of their thoughts, their feelings or their behaviours are labelled as having a personality disorder of one type or another.

Of course there is nothing wrong with trying to understand the people we work with. Such understanding is vital if we truly are to help them. People do have different personalities and those differences really do present particular issues relevant for mental health. The more we know about these issues the more help we can be.

So there is value in classifying different personality traits and types because it helps us to work with people. However when personality classification strays into value judgements and decisions about ‘deservingness’ it becomes a very dangerous ‘double-edged sword’.

My own view is that this understanding is crucial and positive but we must keep it in perspective. We must not make judgements about a person’s worth or write them off as ‘incurable’. After all – we are not meant to ‘cure’ personality.

Think about it. If you became depressed and needed mental health care you wouldn’t expect the care team to try to change your personality, would you? You’d want help with your mood. It’s the same for people with personality disorders. Their personalities may make them more prone to certain problems than other people but that doesn’t mean we need to change who they are. We treat the problem – not the personality, disordered or not.

Really the work of mental health services can be boiled down (very broadly) into treating and/or alleviating four types of problem only. They are – anxiety, depression, psychosis and dementia. We can, however, treat these problems far more effectively when we understand the personality of the individual at hand.

It is my earnest hope that the legacy we leave for future generations of mental health service providers will be a focus upon understanding the personality without the value judgements of our Edwardian predecessors.