In order to work effectively with people with personality disorders it is important that Mental Health Social Workers (MHSWs) have a clear understanding of trauma and its impact on the person. It is also important that they have good relational skills and the support of the team and organisation. Drawing on an analysis of the similarities (and differences) in service user and MHSWs’ perspectives, the book outlines the further skills, knowledge and conditions that will help them to make a more effective contribution to the support of those with personality disorder.
The book will appeal to qualified Mental Health Social Workers and those on Post-Qualifying Programmes because, uniquely, it explores personality disorder from a social work perspective.
About the Author
Julia Warrener, PhD is currently a Principal Lecturer at the University of Hertfordshire teaching social policy on the BSc & MSc in Social Work programs. She qualified as a social worker in 1993 and has worked extensively with adults with mental health problems since 1995. In this time she developed a particular interest in personality disorder. She is also a researcher and committed to service user involvement in research and practice. This book has evolved from qualitative research undertaken in the last 7 years which explored the experiences and perspectives of service users and mental health social workers on personality disorder.
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Critiquing Personality Disorder
A Social Perspective
By Julia Warrener
Critical Publishing LtdCopyright © 2017 Julia Warrener
All rights reserved.
Personality disorder: classifications, myths and risks
How is personality disorder understood?
What questions surround it? What are their implications?
Could psychiatric, psychological, service user and social perspectives be employed to better understand personality disorder?
Does a relationship with traumatic experience underline the need for a multidimensional conceptualisation of personality disorder?
Personality disorder is a contested diagnosis. With a controversial history and more than one classification, as well as questions about responses to treatment, debate about its nature and antecedents predominates. Deliberation about the diagnosis has been evident since Schneider's (1958) revision of Pinel's (1801) original diagnosis of 'moral insanity'. Pinel distinguished abnormal features of personality from traditional symptoms of mental illness whereas Schneider's 'psychopathic personality' stressed continuity with mental illness. Dispute about whether personality disorder is distinct from both normal personality and mental illness (American Psychiatric Association [APA], 1994) has continued to this day, despite the lack of evidence to identify distinct categories of personality whether normal or disordered (Livesley, 2011). Furthermore, evidence suggests that personality disorder is often experienced with the more traditional forms of mental illness (Newton-Howes et al., 2010).
The diagnostic classifications reflect this debate and deliberation. Since its inclusion in the Diagnostic and Statistical Manual, personality disorder has been characterised as distinct from other forms of mental illness (APA, 1980). However, the World Health Organization characterises personality disorder within the same domain as the other forms of mental illness (WHO, 1992). These principal ways of classifying personality disorder are founded on completely different ideas about its nature and its relationship to normal personality and other forms of mental disorder. It is perhaps not surprising therefore that personality disorder is often poorly understood by mental health professionals (National Institute for Mental Health [NIMHE], 2003). Moreover, a number of perspectives offer alternative explanations of the diagnosis.
The psychiatric attention to classification, diagnosis and form (Jaspers, 1963) can be countered by explanations which prioritise broader dimensions of peoples' reality: the subjective, the social (Livesley, 1998; Tew, 2005) and, perhaps most importantly, the experience of distress (Castillo, 2003). A psychological perspective sees a relationship between maladaptive and adaptive personality and the extent of the former's impact on the self, relationships with others and society in general (Livesley, 1998; Ro et al., 2012). The social context and relationships within this, as both a consequence and a contributor to mental distress, are central to a social perspective. Here health and illness are seen as multifactorial, related to a person's social context, position and experience of power and powerlessness (Duggan, 2002; Plumb, 2005). A service user perspective offers a depth of detail about the experience of distress and most importantly offers us insight into the reasons as to why people might think, feel and behave as they do (Castillo, 2003). These different perspectives and explanations contribute a richness of information about personality disorder. However, by competing they can contribute to contested conceptualisations of mental disorder – to which questions about the efficacy of certain treatments, particularly in relation to personality disorder, only appear to add.
While clinical and research interest in treating the disorder has grown (Duggan et al., 2007), evidence for the efficacy of psychotropic medication remains ambiguous and unconvincing (Feuirno and Silk, 2011). No one drug is authorised for the treatment of personality disorder (NICE, 2009). Although some argue that the polymorphic nature of personality disorder means that different classes of drugs are often required (Stoffers et al., 2009), the National Institute for Clinical Excellence (NICE) (2009) states that drugs should not be used specifically for Borderline Personality Disorder (BPD) or for individual symptoms or behaviours. Moreover, drugs that are seen as 'good first line treatments' (Stoffers et al., 2009, s 339) such as second-generation anti-psychotics should not be used in the medium to long term, and sedatives should only be used cautiously in a crisis (NICE, 2009). Questions about the use and efficacy of medication only serve to compound our difficulties in forming a coherent conceptualisation of the disorder, despite evidence that certain structured treatments can improve outcomes for certain diagnoses of personality disorder (Bateman and Fonagy, 2009).
However, a more coherent conceptualisation of the disorder, reflecting its multifactorial nature and drawing on these perspectives in equal measure, would help to minimise the questions which surround it and thereby facilitate greater understanding of person and diagnosis. This book sets out to consider this proposition. Within this it suggests that the recognition of traumatic experience is central to any reconceptualisation of personality disorder. It posits that this not only reflects the disorder's multifactorial nature but also the multidisciplinary context of modern mental health services. As a first step, this chapter sets out and critiques the different classifications in detail. The current and future classifications of the diagnosis (APA, 2013; WHO, 2012) are considered in the context of those which have gone before (APA, 1980, 1994; WHO, 1992). The aforementioned perspectives are then reviewed. The chapter suggests that no one explanation represents a 'gold standard' (Trull, 2005, p 279) and that there are alternatives, which raise debate and can fashion personality disorder as a complex and contested diagnosis. The consequences of this for the stigma, stereotypes and myths surrounding both diagnosis and person are then considered. The chapter concludes by suggesting there is a need to, first, recognise the complementary character of these perspectives and, second, to hold each in equal measure to inform a more rounded conceptualisation of the disorder. It then goes on to underline the significance of associating personality disorders with traumatic experience, which calls for interventions that recognise individual courage, strengths, resilience and empathy. The chapter first offers a summary of the seminal literature on personality disorder to set the context for its later sections.
The seminal literature
The history of personality disorder appears riven with controversy and ambiguity. The works of Pinel(1801) and Prichard (1837) were crucial to the early identification of the diagnosis and the attempt to separate abnormal features of personality from traditional symptoms of mental illness (Prichard, 1837). However, the rise of the medical model, with its need to identify causal mechanisms rather than merely describe classifications or symptoms, led to a number of revisions of Prichard's concept of 'moral insanity' (Prichard, 1837, cited in Tyrer, 2000, p 4). Schneider's (1958) influential revision of the psychopathic personality read: 'abnormal personalities who suffer through their personalities or through whose abnormalities society suffers' (Schneider, 1958, cited in Tyrer, 2000, p 6). Schneider challenged earlier attempts to distinguish abnormal features of personality disorder from traditional symptoms of mental illness, stressing continuity with mental state disorders (Livesley,2003). Whereas Cleckley (1982) argued that psychopathy was a distinct illness of the most profound deficit, Jaspers' work (1963) placed personality disorder on a continuum with mental state disorders rather than as a distinct nosological entity (Livesley, 2003). It is apparent therefore that current debates about personality disorder's categorical or dimensional nature are rooted in long-standing deliberations about whether the diagnosis is distinct from or continuous with the more traditional forms of mental illness.
Specific forms of personality disorder, ie BPD, have similarly been subject to debate and revision. Knight(1953), building on Stern's (1938) earlier work, defined a form which, he argued, was on the borderline with schizophrenia. Kernberg (1967) revised this early construct, defining BPD as a broad form of psychopathology characterised by primitive defences, identity diffusion and lapses in reality testing. Significantly, Grinker (1968) argued that BPD could be reliably assessed using discriminating criteria. While Grinker's work was influential in the inclusion of personality disorder and BPD in DSM III (APA, 1980), questions remained about its precise nature (Gunderson, 2009). Although revision can lead to positive change, it is apparent that the revisions of the general and specific classifications of personality disorder have raised many questions which continue to run like 'fault lines' (Tyrer, 2000, p 6) through this area, which the most recent of classifications, it seems, has done little to assuage.
The recent and current classifications
For about two decades, personality disorder has been classified by the Diagnostic and Statistical Manual IV (APA, 1994) (DSM IV) and the International Classification of Diseases 10 (ICD 10) (WHO, 1992). DSM is the standard classification system in the United States and the most widely used one in clinically orientated research elsewhere (Hebebrand and Buitelaar, 2011). It characterised personality disorder as distinctly different from other mental disorders. Personality disorders were accorded a secondary status to the more traditional forms of mental disorder; indeed, they were regarded as modifers which influence the more traditional forms of mental illness, such as anxiety and depression (APA, 1980). Classified separately on Axis II, personality disorder was defined in DSM IV as An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time and leads to distress or impairment.
(APA, 1994, p 685)
DSM IV then defined three distinct clusters or types of personality disorder.
1. Cluster A, the odd and eccentric (including paranoid personality disorder, schizoid personality disorder and schizotypal personality disorder).
2. Cluster B, the dramatic, emotional or erratic (including anti-social personality disorder, BPD, histrionic personality disorder and narcissistic personality disorder).
3. Cluster C, the anxious or fearful (including avoidant personality disorder, dependent personality disorder and obsessive compulsive personality disorder).
In total, DSM IV identified ten different types or categories of persistent personality disorders (APA, 1994).
Although ICD 10 does not define personality disorder as distinct from other mental illnesses, it does define it as an ingrained and 'severe disturbance in the character logical condition and behavioural tendencies of the individual, usually involving several areas of the personality and nearly always associated with considerable and personal disruption' (WHO, 1992, p 202). It does not separate the diagnosis into different clusters, but does identify nine different categories of personality disorder: (1) paranoid personality disorder; (2) schizoid; (3) dissociation; (4) emotionally unstable; (5) histrionic; (6) anankastic; (7) anxious; (8) avoidant; and (9) dependent. For 20 years personality disorder has therefore been classified on the one hand as a discrete type, distinct from other forms of mental illnesses, and on the other as within the same domain as mental illness (APA, 1994; WHO, 1992). One system identifies nine different types, the other ten. Both systems characterise the diagnosis as extensive and persistent, suggesting it is fixed and unchanging. However, viewing a social category as fixed and unchanging is the first step in seeing it as a natural kind, which can then be used to justify the existing social arrangements (Rothbart and Taylor, 1992; Yzerbyt et al., 1997). Perceiving a social category as a natural kind, comprising members who share a common essence, can encourage stereotypical assumptions and ultimately the construction of members as less than human, as the Other (Leyens et al., 2001).
It is argued that DSM V, published in May 2013 (APA, 2013), is 'of substantial importance for the revisions to be introduced in ICD-11' (Hebebrand and Buitelaar, 2011, p 57; WHO, 2012). Standardising a common vision perhaps? However, it is argued that DSM V will encourage misdiagnosis, divert resources away from those most in need through the creation of millions of new patients and be extremely costly to the US economy (Frances, 2012). Such criticism from the Chair of the DSM IV Task Force indicates the extent of the controversy surrounding DSM V (Yasgur, 2012). DSM V's proposed revision of personality disorder was similarly controversial (Pilkonos et al., 2011). The ten different types of personality disorder were to be reduced to six (ibid.). However, feedback from a multilevel review indicated that DSM IV's ten categories were retained (ibid.; APA, 2013).
The general criteria for personality disorder as defined in DSM V is 'significant impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning' (APA, 2013). For a diagnosis of personality disorder the person must experience significant and enduring difficulties in at least two of the following areas: cognition (distorted thinking patterns); affect (problematic emotional responses); interpersonal functioning (difficulties) and impulse control (either over-regulated or under-regulated). Impairment must be stable and consistent across time and situations and is not best understood as normative for the individual's development stage or socio-cultural environment. Nor must the impairment be related to the physiological effects of a substance or general medical condition (APA, 2012). In addition, each specific personality disorder will also have a separate list of asset criteria.
For a diagnosis of BPD, there must be significant impairments in personality functioning, either an 'impoverished'/'poorly developed' identity or a lack of self-direction. There must also be impairments in interpersonal functioning, ie an inability to show empathy or engage in intimate relationships. BPD will be indicated by the presence of pathological personality traits, ie emotional liability, anxiousness, separation insecurity, hopelessness, impulsivity, risk taking and hostility. Impairment must again be enduring and consistent across time and situations, counter normative and cultural expectations and be unrelated to physiology or substance use.
DSM V was initially proposed as a bridge between categorical and dimensional approaches to personality disorder, with each specific diagnosis conceptualised as a disorder that can be assessed as both a discrete entity and comprising traits which can be measured on a severity scale (Pilkonos et al., 2011). However, is it possible to say that a category has a distinct boundary and also that it can be measured across a dimension? Possibly as a result of similar questions, the proposal to adopt a hybrid approach to personality disorder was not accepted and ultimately the Board of Trustees retained a categorical approach and the ten categories of personality disorder within DSM V (APA, 2013). However, the hybrid model has not been removed from the manual completely. It is retained in Chapter 3, to encourage research, as a methodology and mechanism for advancing future diagnostic and clinical practice. It is interesting to note that although DSM V abandoned the five axes of disorders, it has retained the specific categories of personality disorder, all of which raises the question of whether evidence exists to support such a retention of the categorical approach to personality disorder?
Research has failed to identify the distinct categories of personality disorder and has found that it is continuous with normal personality(Livesley, 2011). This would appear to explain why, in a survey of experts on personality disorder, 80 per cent were found to be in support of a dimensional approach to the diagnosis (Berstein et al., 2007). It is possible that a dimensional approach offers greater scope for assessing what personality does, how it 'serves to adapt individuals to their situations' (Ro et al., 2012, p 48) or not as the case may be. A dimensional approach allows for the role social and environmental factors can play in both managing maladaptive traits or indeed triggering distress and impairment (Widiger and Lowe, 2008). Given the lack of evidence for categorical approaches and, contrastingly, support for dimensional approaches, we are left with further questions about the efficacy of retaining a categorical approach in DSM V. It is quite possible that the confusion and complexity which has surrounded personality disorder since its inception will grow as DSM V is only likely to compound difficulties (Pilknonis et al., 2011). It may well add to the misunderstanding and stigma surrounding the diagnosis rather than challenge it (Livesley, 2010; NIMHE, 2003).
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