Capping the Capo
More on personality disorder
In the Substack post for December 23rd, I said:
… psychiatry can’t tell the difference between mental disorder and personality disorder, because it doesn’t have models of either to show the difference, and the reason it doesn’t have models of disorder is because it has no theory of mind and no theory of personality in the first place. Which means modern psychiatry is a pseudo-science, but that’s a matter for another day.
Well, that day arrived on January 7th when impending US president DJ Trump gave a press conference at his palace in Florida. Without putting too fine a point on it, his performance was thought-disordered (see interview at 15.00-18.00). The question the world wants answered is: Was this bizarre performance just his usual narcissistic, self-justifying, greedy and rather dim-witted rambling, i.e. evidence of major personality disorder, or was it the cognitive decline of early dementia? We’ve just had four years of a person who showed early signs of dementia on the day he was elected, does the world really need another? If Trump would just stay his side of the ocean, it wouldn’t matter but, as he made crystal clear in his ramblings, he has no intention of doing that. As he said (times shown in brackets):
(31.15): Q: …with your references to Greenland and the Panama Canal and so forth. Can you assure the world that, as you try to get control of these areas, you are not going to use military or economic coercion?
(31.33): No.
(31.34): Q: And can you tell us a little bit about what your plan is? Are you going to negotiate a new treaty? Are you going to ask the Canadians to hold a vote? What is the strategy? And I –
(31.52): I can't assure you -- you're talking about Panama and Greenland. No, I can't assure you on either of those two. But I can say this, we need them for economic security. The Panama Canal was built for our military.
Canada should be the 51st state of the US, Musk says we need Greenland, Panama better hand back the canal and if the Mexicans don’t stop all those immigrants and drugs coming across the border, they can expect to be invaded. Sure, we know that’s how politicians think and how they talk among themselves when they think nobody’s listening, but to say it out loud like that? He returned to the topic later:
(50.20): Well, we need Greenland for national security purposes. I've been told that for a long time, long before I even ran. I mean people have been talking about it for a long time. You have approximately 45,000 people there. People really don't even know if Denmark has any legal right to it, but if they do, they should give it up because we need it for national security.
In fact, there were Viking settlements in Greenland from about 980AD (they named the place) and it has been Danish since 1721 so they do have some sort of claim. However, Trump never worries about legal niceties as he’s “been told” there are vast reserves of oil and critical minerals hiding under the Greenland Ice Shelf, which sets him drooling. That’s pure personality disorder but the issue now is: Can he actually tell when there are complex legal and moral issues, or is he now unable to perceive them, let alone decide them? The future of the world could depend on this. The next question would be: Can psychiatrists help in any way? Short answer: No.
For the long answer, it’s still No because, as I said two weeks ago, modern psychiatry is a pseudo-science. Just how much of a pseudo-science comes clear when we look at the endless squabbling over the classification of personality disorder. Two completely different systems are in use, the categorical American system (DSM) and the rest of the world. The WHO International Classification of Diseases (ICD-11) section on personality disorder has abandoned the clear and simple idea that you’re either a good little obsessional or a naughty psychopath, with no cross-over (Henry Mencken: “For every complex problem there is an answer that is clear, simple, and wrong”). Instead, it lumps all personality disorder together, and grades people as mild, moderate or severe on five different traits (also called domains, to confuse everybody). This way, we all get a score on each trait, consistent with the dimensional model of personality. Unfortunately, they didn’t use the traits psychologists have worked out but made up their own. This means that the systems in use for normal personality classification and for abnormal personality don’t match. Only in psychiatry, as they say.
The first ICD was published in 1900, the plan being to revise it every ten years to take account of scientific developments. After breaks for the various wars along the way, and the change to WHO in 1948, ICD-11 was finally released in 2022. Revising it is an enormous job, involving hundreds of experts from dozens of countries, and extends over the best part of a decade. This time, the mental health committee decided to drop the old categorical system of personality diagnosis and go dimensional. Of course, this provoked a huge outcry from the army of academic psychiatrists who have spent the past fifty years trying to make sense of the categorical system. They can’t do it, it’s a fool’s errand, but there are now so many academic egos invested in it that not even the WHO could quieten them. The problem, as the subcommittee on personality disorder said, is that mainstream psychiatry has next to nothing to say about personality disorder, and has no concept of a possible relationship between personality and what they call “mental disorder/illness/etc.” When orthodox psychiatrists (i.e. 98% of them) are asked about such a relationship, they irritably reply that there is no relationship between mental states. As mental states are non-scientific, the only relationship involved goes straight down to the genome. It’s all biological, got it?
The subcommittee correctly pointed out that psychiatrists normally make only one of two diagnoses of personality disorder, either “borderline” (BPD) or “antisocial” (ASPD) personality disorder. These are seriously over-diagnosed while the rest are ignored: there may be a categorical system but nobody actually uses it. BPD is by far the most common personality diagnosis awarded to women, while men are winners for ASPD. This means that other personality disorders are under-diagnosed, and therefore unrecognised and untreated. That’s not the problem it seems as psychiatry doesn’t have treatments for personality disorder so, for example, people are probably better off than having some amateur think he can cure obsessionality with drugs. However, in practice, staff give out these personality labels to patients they don’t like. Ever after, the patients are treated as trouble-makers to be shoved out the door as soon as possible. This also applies to the “real doctors”: patients with these labels will get second-rate treatment for their physical problems, especially if it can’t be seen, such as dysmenorrhoea or back pain.
The whole idea of categories of personality disorder is a mish-mash but when the alpha version of the new ICD-11 was released in 2011, which had dropped that system, the psychiatrists who had built BPD into the biggest thing since sliced bread were outraged. They weren’t worried about the other nine diagnoses in DSM-5, only their favourite. Eventually, and just to keep the peace, the committee gave in. They released their dimensional system, which was much more objective and soundly-based, but they tagged BPD to it as a “qualifier” diagnosis. This didn’t satisfy the chair of ICD-11’s PD committee, Prof. Peter Tyrer, of Imperial College, London, (also editor of the British Journal of Psychiatry at the time), who made a last-ditch attempt to get rid of it [1]. “What about this?” he asked. “Borderlines have lots of ups and downs, why don’t we move them to bipolar disorder instead of having them stuck on our neat system like a tick on a pig’s ear?” (OK, perhaps he doesn’t talk like that but that’s what it meant). That’s all very well, and clearly the way to do it would be to set out what personality is, what personality disorder is, and why so-called borderline PD doesn’t meet criteria. That’s the way to solve that old pub argument over whether rabbits are birds: define a rabbit, define a bird, and see if they match at any points. But psychiatrists can’t as they don’t have any concept of personality itself. Oh dear.
Undeterred, Dr Tyrer contacted his good friend, Prof. Gordon Parker, of the University of New South Wales and proprietor of something called the Black Dog Institute (nothing to do with dogs), for his view. Rather grumpily, and by way of the cuneus and lingual gyri and mitochondrial dysfunction, Parker replied: No way [2]. “Call me old fashioned or call me a splitter,” he said (both true) but (by implication) the last thing we want is all those personality disorders messing up our tidy clinics. That provoked a couple of letters, one of which asked “Maybe they’re neither bipolar or unipolar but a different sort of bipolar?” [3]. Somewhat put out by Parker’s rejection of his pet idea, Tyler also wrote a rather petulant letter in which he inadvertently revealed a home truth:
The very name ‘borderline personality disorder’ betrays an abrogation of diagnosis. It overlaps with post-traumatic stress disorder, other personality disorders, anxiety, depression, and dissociative and adjustment disorders, yet does not belong to any of them. By having layer upon layer of diagnostic requirements that allow it to become grossly heterogeneous, it has confused everybody and satisfied none [4].
Absolutely true, although that hasn’t touched on the epistemic injustice dumped on vulnerable people who are given this very sticky label. In true form, Parker had the last word [5] which amounted to: “Fiddling with the categorical system of diagnosis is likely to bring down psychiatry’s house of cards, so let’s not start.”
What’s it all add up to? If the equal-most popular personality diagnosis in psychiatry is an “abrogation of diagnosis that confuses everybody and satisfies none” (especially the patients), isn’t that a damning admission? Isn’t it time to deal with the basics rather than trying to keep everything pretty on the surface? For psychiatry, the most basic issue is “What is the nature of mind?” However, that’s too scary for all the people who have devoted their lives to the idea that minds are irredeemably non-scientific, so we’ll skip that one for a while. Next question for psychiatry: “What is the nature of personality?” Answer: “We don’t have a clue, why don’t we ask the psychologists?” Get real, there’s no way the megafauna of the psychiatric jungle could swallow their pride and go cap in hand to psychologists. At a pinch, they could have asked psychologists to help align the five traits in the ICD-11 system with the OCEAN traits mentioned on Dec 23rd. However, that wouldn’t work as the latter describe normal personality and don’t lend themselves to personality disorder. Look at the pairs of each trait:
Openness - closed
Conscientious - disinhibited
Extraversion - introversion
Agreeable - antagonistic
Neuroticism (emotional instability) - emotional stability.
These are the result of decades of research; where should we fit the important (and dangerous) personality called “pathologically jealous”? Obviously it doesn’t work but then the ICD-11 traits also don’t make room, not least because they are “stand alone” traits unrelated to the major personality traits. They are:
Negative affectivity (emotional instability, mistrust, low self-esteem, anxiety etc.)
Detachment (social detachment, emotional coldness)
Dissociality (an ugly neologism that means aggressive, grandiose, self-centred, dishonest, etc)
Disinhibition (impulsivity, risk-taking, irresponsibility, distractibility etc)
Anankastia (old fashioned word for obsessional attention to detail, rule-abiding, rigid perfectionism, etc).
While there are rough parallels, they don’t align. It’s like trying to describe problems in a car without knowing anything about normal cars. Now Peter Tyrer has also published a paper in which he proposed that personality “dysfunction” is the cause of a large part of adult mental disorder. He’s half-right, as it’s the cause of practically all adult mental disorder, and the roots lie in childhood and adolescence. Unfortunately, he has no suggestion how any of this comes about, no models, no mechanism. While it sounds impressive, it’s an idea floating in space with no theoretical framework to hang it on. A hundred years ago, some philosophers and logicians decided that science couldn’t talk about minds. Fifty years ago, psychiatrists jumped on the biological bus without checking to see whether it was going their way. Now, as the ride gets bumpier, it’s becoming clear that it wasn’t. There will never be a biological psychiatry. The sooner the megafauna accept this, the better for all.
Meanwhile, Mr T is getting ready to wreak havoc in the halls of government in Washington. Having failed miserably to “drain the swamp” first time round, will he be any more successful this time? Some people are taking his wandering talk as the sign of a genius who thinks outside the square. Other people think he’s crazy. I don’t believe that. I see his interview as clear evidence of cognitive decline and doubt he will complete his term. But having stuffed DC full of severely disordered personalities, and without the Capo to scare them into some sort of order, what will happen to the rest of us? Hold tight, the ride gets bumpier.
If anybody would like to get acquainted with personality tests, this site is as good as any:
https://www.truity.com/test/big-five-personality-test
References:
1. Tyrer P (2009). Why borderline personality disorder is neither borderline nor a personality disorder. Personal Ment Health 3: 86–95.
2. Parker G (2014). Is borderline personality disorder a mood disorder? Brit J Psychiatry 204, 252–253. doi: 10.1192/bjp.bp.113.136580
3. Marwaha S (2014) Borderline personality disorder and mood. Brit J Psychiatry doi: 10.1192/bjp.205.2.161
4. Tyrer P (2014) Borderline personality disorder and mood. Brit J Psychiatry doi: 10.1192/bjp.205.2.161a
5. Parker G (2014) Borderline personality disorder and mood. Brit J Psychiatry doi: 10.1192/bjp.205.2.161b
6. Tyrer P (2015) Special Issue Article: Personality dysfunction is the cause of recurrent non-cognitive mental disorder: A testable hypothesis. Personal Ment Health 9: 1-7. DOI 10.1002/pmh.1255