We all have a personality, but, when you move into the realms of psychiatry and mental health, this term can take on a rather different meaning. It is often also very difficult to discuss, something which is hardly surprising, given the fact that personality disorder can be seen as a punitive diagnosis, one of exclusion and personal responsibility, and one that is very hard to treat.
My own experiences of mental illness inform my views, but I don’t deny that these have been influenced by my other role as a psychiatrist. However I’m not writing this with textbooks by my side, I want to think about the overall meaning rather than the minutiae which can make up a diagnosis. Not that that’s not important – it is poor practice and insulting to patients not to attempt to make accurate diagnoses with the tools we have to hand – and to share them and even change them, should the need arise.
A small number of patients find the label of personality disorder helpful. I think that this is usually when the effort is made to describe the criteria to the patient, and to relate them to the problems that have been experienced, in a thoughtful and compassionate way. Even more important, this may also be when support and therapy are provided, although these are often, or usually, under-resourced. Patients have sometimes said that they are grateful for the diagnosis, that it explains their feelings and suffering.
There is often a belief that biology underpins “true” mental illness, such as schizophrenia or bipolar disorder. Personality disorders are more and more often put down to past trauma. But it is a sad fact that many psychiatric patients have experienced trauma; as to biology, we don’t really know enough to say. Sometimes personality disorders are said not to be true illnesses because they don’t respond to treatment – well, that is the kind of statement that makes me embarrassed to be a professional. We wouldn’t say that about cancer.
But it is more the concept of what personality is that makes it so very difficult. Your personality is who you are, it shows you as a type of person, it is your being. I would go as far as to say that we feel responsible for it, and that when it is disordered, some kind of moral lack or weakness is implied. Whereas depression is far less owned by the individual, it is seen as a disease of the brain, rather than the personality – or the soul, or mind. Yet personality is displayed by actions and behaviour and speech, all things which are also affected by other mental disorders. I think that this is why I personally find it so difficult to tell which is wrong with me, and why, when depressed, I become so convinced that I have a personality disorder. There is more – the views of staff and people generally can be less than kind to those with personality disorders, and they can see the behaviours as something over which the person should exercise complete control. This makes you feel guilty when depressed, and also makes you ask yourself – Why can’t I do this? What power is preventing me? Those who are depressed are seen far less as being responsible for their actions – yet this must vary widely. I struggle with this.
The increasing acknowledgement of trauma combined with this ongoing culture of responsibility, and even blame, also sits uncomfortably. If we are saying such traits develop because of often horrible abuse, should we not be kinder? Are these disorders, sometimes considered untreatable, as a result perhaps worse than many others?
I have said before that I think severe mental illness affects personality. Mental illness is hugely traumatic in itself, both the experience and the treatment, and often the aftermath and stigma. I am not saying that everyone with, for example, schizophrenia, develops a personality disorder, but I think, for many, that their personality will be affected. It is often said that personality is fixed from early adulthood; there is truth in this, but personality evolves over the years, it is affected by further traumas, joys and life generally. For me, the shock and trauma of my illness, combined with hospital admissions, had a huge impact. I didn’t respond in a helpful way, I fought and denied my illness, and kept stopping my medication. Maybe those traits were there before, but hadn’t been activated. I think it’s fair to say that they are still there, but perhaps I manage them better. Or perhaps my illness and its treatments exacerbated, or triggered, certain traits that weren’t helpful. They probably didn’t amount to a personality disorder, but could certainly have been perceived as part of one; and although connected, they were not an intrinsic part of my depressive illness.
I must add that illnesses such as schizophrenia and mood disorders may co-exist with personality disorders, and when this happens they need treatment and support for both.
It is interesting that mental illness as portrayed in much popular literature and many films would often be described by psychiatry as personality disorder. Histrionic behaviour, self-harm, odd behaviour with no obvious biological cause – whether this is what many perceive as mental illness, or whether it is just more dramatic, is unclear. But if that is what people understand as mental illness, even if it is what psychiatrists would call personality disorder, what right have we to deny its importance? Culturally, our stiff upper lips can get in the way of expressing distress, and different people do it differently, which might also give them contrasting diagnoses for what may transpire to be similar illnesses.
I want sympathy and empathy and, most of all, resources for people with personality disorders. I want it for all people with mental illness, but I think that those diagnosed with personality disorder get the short straw on the whole. And I also want people to react with kindness (I include myself). I don’t want people to feel threatened or undervalued by this diagnosis, or to see it as discriminatory. We need to look to ourselves for our reactions to others, and acknowledge that our understanding is still very incomplete.