walkitout (walkitout) wrote,

Personality Disorders and DSM politics

h/t N. for thinking of me and passing it along


In this entry, Edward Shorter describes the creation of "personality disorders", their evolution over time, and the current debate going on over the proposed modification of PD for DSM-V. Without getting into the politics of DSM-V (much), I'll briefly point a couple things out:

"Personality disorders exist not as natural phenomena but as cultural phenomena"

If you took this idea to its extreme, it's not clear what aspects of psychiatry would remain.

Frances receives a brief, ambiguous reference in terms of DSM-IV and the flowering of PD into its current, impenetrable thicket, but his position with respect to protest against DSM-V is _not_ ambiguous -- but it's hard to blame Shorter for sailing right over that, because I'm going to also.

Shorter seems to have trouble with PD because people with PD primarily present as cartoonishly awful to be around, and that somehow doesn't strike him as a "disease". He thinks it's "cultural" or whatever. I think that you can have real problems with how you relate to people. If that problem is limited to relating to specific people (say one of the many people you have worked for, with or who has worked for you, or two of the several people you have had sex with, or one of your children, or a couple of your more distant relations, or three roommates with a lifetime history of a dozen, etc.), then sure, saying you have a PD may well be "cultural". But if everyone who meets you figures out that you are Just Awful within minutes of talking to you, it's not really cultural any more, now, is it? We've all met people who weren't part of our culture, whether that person was from another continent or a dramatically different subculture within our own region. Not all of those people struck us as Just Awful. I'd argue that a lot of us were quite surprised, in some cases, how Very, Very Nice many people from other cultures were (who we expected to be universally Just Awful). But we've also all met people who are universally considered Assholes, even by people who love them.

And those people really do have personality disorders. Their lives are more painful for them and everyone around them than they need to be and it would be great if we could Make It All Somewhat Better. People who wind up seeing psychiatrists for this type of reason aren't there because they think their life is all perfect thankyouverymuch. They are there because they've lost jobs, spouses, custody, etc. due to their assholishness, and either they think they need to be there, or a judge does.

DSM-V recognizes that trying to delineate a small number of distinct forms of Assholishness has not been successful. While clinical research has shown that psychiatrists and others who work in mental health enjoy wide agreement on who has a PD, they _do not_ have anything like the same level of agreement about _which_ PD. So DSM-V proposes to replace that small number of distinct forms with PD and then a list of descriptors so the particular individual can be described without having to further categorize them. They even showed how you can use the new system to recreate the old system, if you wanted to.

I think the new system is great. But I also recognize that Change Is Bad. And if you've dumped a decade or more of your life into nailing down the difference in presentation between narcissism and borderline, having someone come along and tell you to code them the same and then add a long list of further codes, well, that's not going to go over well.

I do agree with Shorter on part of his conclusion:

"It will be interesting to see how the APA sorts this out."

But I think that limiting psychiatry to things-which-can-be-treated-pharmaceutically is every bit as limited as treating psychiatry as things-which-can-be-treated-by-talking-a-really-long-time-in-a-really-odd-setting.

We can do better. We are doing better. It will be messy as it goes along.

ETA: The article mentions a recent NYT article on the same topic. The NYT article was better. But of course I'm bound to believe that, because it mentions dialectical behavior therapy for borderline, and I have completely believed in that ever since I heard of it. YMMV, time and well-constructed research will give us better evidence for future decision making.

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