Grappling with Personality

These posts examine modern psychiatry from a critical point of view. Unfortunately, mainstream psychiatrists usually react badly to any sort of critical analysis of their activities, labelling critics as “anti-psychiatry,” whatever that is. Regardless, criticism is an integral part of any scientific field and psychiatry is no different. As it emerges, there is a lot to be critical about.

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Now that the newly-demoted Mr Andrew Mountbatten-Windsor has lost his pull with the media, we’re starting to hear stories of what a horrible person he actually is. It seems he is demanding, bad-tempered, scheming, abusive of women and, quite likely, financially dishonest – a spoiled rich brat, in other words. The only thing we haven’t heard is that he’s a drunk or uses heaps of drugs but that may yet come as enquiries proceed. Also, nobody has yet said “We should stop picking on him because he’s not a bad chap, he’s got ….” (fill in your favourite mental disorder). However, if matters come to court, which is apparently not out of the question, I’m sure that chorus will start. That would be interesting because we’d have the spectacle of teams of psychiatrists slugging it out, spilling all the family dirty linen in the process. But he’s rich and connected, he’ll get off. He may have to hand back any of the loot his ex hasn’t already spent but, unlike the poor, he probably won’t be locked up in a mental hospital.

That’s a pity because it would be a good opportunity for psychiatry to get its house in order by sorting out the difference between mental disorder and personality disorder. But what does that mean? Surely everything we mean by the word ‘personality’ just is a mental phenomenon, so personality disorder is ipso facto a mental disorder? No, that’s not how it’s used. Mental disorder (previously mental illness or disease) is limited to people who’ve undergone some sort of change, something has come over them and they’re recognisably different. If all goes well, they’ll come back to normal but serious cases may never recover. Personality disorder means this is how they’ve always been and, unless the police or somebody else gets in the way, this is how they’ll continue to be. Drugs don’t work so, apart from a rather dubious label, psychiatry has precious little to offer and usually won’t try. That doesn’t say these people are happy because very often they’re not.

It ends up where a sizeable part of the population are experiencing significant mental problems but the different mental health services have no idea what to do. How sizeable, how significant, and what sort of problems? We know that the incidence of suicide bids is much higher among this group, that they consume a great deal of ambulance and emergency time, and that their bids often succeed, but that’s about it. Their travails are of so little interest that surveys of mental disability often exclude them. For example, personality disorder isn’t included in the long-term study known as the Global Burden of Disease, run by the Institute for Health Metrics and Evaluation (IHME) at Washington University, in Seattle. Fair enough, because nobody is claiming it’s a ‘disease’ but on most psychological and social measures, they struggle. A paper published last week [1] by an international group attempts to put some figures on just how much they struggle but what they didn’t find was probably more important than what they did.

This is a meta-analysis of published studies, not an original survey, so it was very limited by the quality of the input data (as in “garbage in, garbage out”). They wanted to know how common personality disorder is, whether the diagnosis is stable, and whether it affects life span. They did several computer searches of the literature from 1980 to 2024 and found an astounding 35,573 published papers on the epidemiology of personality disorder. However, only 60 addressed those three points; most of the rest were restricted to selected populations, e.g. prisons, or specific disorders, or didn’t follow them for long, etc. Ominously, we’re talking of anything up to 10% of the population but nobody knows what happens to them. We can get an idea of what psychiatrists think of personality disorder by checking their diagnostic manuals: in DSM5, it’s chapter 21, just 40 pages out of 950, starting on p645. That does not scream high priority. Also, psychiatrist want to be told when these unhappy people have committed suicide because they like talking about suicide, but aren’t much interested until then.

A large part of the matter is the simple fact that when it comes to personality, psychiatrists don’t know what they’re talking about. They think they’ve got mental disorder nailed, as a “genetic chemical imbalance of the brain,” even though there is no published scientific model of how mental problems could translate into brain problems. It’s just accepted as a matter of faith, a bit of dogma that’s repeated until everybody thinks it’s true but it ain’t. However, when it comes to personality disorder there is … nothing. There’s no over-arching theory of personality and no model of personality disorder, just a crude descriptive classification which everybody knows is no good. It’s a bit like biology before Linnaeus, where whales were classified as fish because they live in water and tomatoes were thought to be poisonous because they’re related to deadly nightshade. Anyway, when it comes to matters of personality, psychiatry is definitely still prescientific.

The standard approach, still used in the DSM system, is that we can reliably sort all the different personality types into separate and distinct categories, each with its list of criteria and a unique name. Trouble is, it doesn’t work. There are now only ten types but in practice, people end up with two, three or more different diagnoses. A paper from 1995 described several people who had scored no less than eleven personality diagnoses; surely that alone says the system isn’t fit for purpose. Also, as the survey above describes, men tend to be given the diagnosis of antisocial personality while women, showing the same symptoms, are labelled as “borderline personality disorder.” The problem is that the diagnostic criteria are artificial, they can be stretched this way and that depending on what the psychiatrist decides on the day [2].

Anyway, the large meta-analysis found that personality disorder is fairly common in all countries, but more so in high income countries where, of course, people are more likely to see psychiatrists. The incidence ranges from about 6.5% for women in poorer countries to nearly 10% for men in wealthy countries. That doesn’t mean much as in poorer countries, only the most disturbed people will reach mental health services. Given the generally poor quality data it had to use, the authors found that a diagnosis of personality disorder ia stable over time; once you get the label, it sticks. Finally, at any age, these people are more likely to die than their peers who haven’t been given a diagnosis, up to a frightening ten times more likely.

When these figures are combined with other social data, we get a pretty grim picture: these people are much more likely to be out of work, to have criminal records, to be homeless, separated or socially-isolated, using drugs or alcohol, taking overdoses or just plain miserable. Surely that says something has to be done but let’s not forget it, they’re also more likely to be high achievers, billionaires, presidents, generals, film stars, top athletes and even great scientists. However, when they crash, it’s spectacular. There’s no half measures with personality disorder.

So what are we dealing with? How do we decide that Billy is a horrible little brat who needs a spell in the slammer while Milly needs TLC in a nice private hospital? Well, money’s a good place to start. If Billy’s father is a wealthy and influential businessman or politician, he’ll be able to afford a couple of senior psychiatrists who will find a mental disorder to fit his behaviour and he’ll walk free. That’s the crucial point: the criteria for personality disorder are so elastic, so open to interpretation that, with a bit of manipulation, they can be stretched over practically anybody or, more to the point, moulded until they fit a diagnosis of mental disorder. I’ve previously set out the case to say that that is what is happening [2]. People who technically meet criteria for a personality disorder are being rediagnosed as “suffering” an approved mental disorder, started on drugs and then kept on the merry-go-round until they fall off dead. This is particularly the case for the fad diagnoses, ADHD, Bipolar, ASD and a few others. We don’t yet know how that’s going to end but it won’t be pretty.

Meantime, the problem is starting to sink in with the big names. DSM5, published in 2013, finally acknowledged that the idea of distinct categories of personality disorder with no overlap was absurd. Instead, they floated the idea of an “Alternative DSM-5 Model for Personality Disorder” (p761 in my edition). Instead of unique categories, this is based on the idea that we all have the same sets of behaviours, it only becomes personality disorder when it’s extreme. For example, we’re all suspicious to some extent, we have to be otherwise we’d be robbed blind. It only becomes personality disorder at the extremes, when a person can’t stop seeing conspiracies everywhere and is unable to mix through not trusting anybody, and so on. We all have to be reasonably tidy otherwise we’d lose everything and spend all our time looking for things but when tidiness and abiding by rules dominates life to the exclusion of enjoyment (or drive everybody else mad), that’s personality disorder. We all like a bit of attention but if one person consistently tries to dominate the surroundings and demands to be centre of attention, that’s personality disorder. That is, there are dimensions of personality and we all get a score on each one of them.

Now this is only new to psychiatrists, not to psychologists, who have relied on dimensional models of personality since Francis Galton (1822-1911, Darwin’s cousin and inventer of human eugenics) first handed out questionnaires 150 years ago. It’s nice to see psychiatry catching up but instead of taking one of the many proven psychological models off the shelf, they decided to build their own (whatever question you ask at this point, the answer is “Because psychiatry”). And, surprise surprise, their model is a shambles. There’s no attempt at a definition of personality, mainly because they haven’t got one, and it’s built almost entirely on undefined psychological factors such as identity, empathy, intimacy and so on. People will argue that since they’re common knowledge, they don’t have to be defined but that reopens that very large door called “personal interpretation” which the scheme was intended to close. Finally, it ends up with, wait for it, eight categories of personality disorder, down from 10 in DSM-5 and 13 in DSM-IV. They just can’t help themselves, prisoners of their biological training.

The biocognitive model for psychiatry says personality just is a set of deeply-ingrained rules that govern how we act and react in the world and, crucially, how we regard ourselves [4]. Self-esteem is central to any working concept of personality. It is primarily a product of early life experiences but is modified as we go along. A person with poor self-esteem from an unhappy early life may just give up and hide from the world, or find a strong person to depend on, or retreat into fantasy (now called computer games), or rely on rules to get by, or drink or fight or become promiscuous or gamble, or write poetry, or care for people or animals, or by eating or starving, or by running marathons, anything to avoid open contact with people because people hurt. On the other hand, it’s possible to conceal poor self-esteem by acting the life of the party, or by becoming aggressive and domineering, or by putting on a uniform and ordering people around, or by getting rich and ordering people around, there’s no limit.

All of this has to be assessed and then fitted into a proper model, and there are plenty to choose from. I prefer Cattell’s 16PF (personality factor) but MMPI is widely used and there are plenty more. What they have in common is the notion that there is no cut off between normal and abnormal, and that we all have a score on all of the factors. Normality is a broad range somewhere in the middle, fading off along however many dimensions you choose until it’s frankly abnormal. It’s like height; there’s no such thing as normal height because normal is a range. And you’re allowed a couple of quirks just to make sure you’re not boring. The value of the biocognitive model is that it sorts between rules and reactions, between true personality factors and the emotional reactions they generate [4]. Billy may, for example, be sent to prison where he sees the mental health staff. They ask him the right questions, including “How’s your self-esteem, how do you rate yourself as a person?” After a long pause, he replies:

A piece of shit. I’m hopeless and useless, I can never do anything right and nobody would want to waste time on me. I’m a total waste of space.

How does that make you feel?

How do you reckon? Terrible. I wake up each day thinking, Oh no, I’ve got to go out there and mix with people and pretend I’m having a good time when inside, I’m thinking why not just end it all now? So I drink and fight and steal just to make people think I’m tough even though I’m not, then I end up in this place with all these losers because I’m a loser myself.

At this point, the orthodox psychiatrist will start the heavy duty antidepressants and mood stabilisers and side effect drugs, which won’t work so he’ll prescribe more, and then move on to ECT, and that doesn’t work and Billy gets angry and starts lashing out so he’s put in a locked ward and so it goes. On the other hand, his despair can be seen as a perfectly rational response to trying to fit in with the world while handicapped with poor self-esteem, which leads to a totally different treatment program, a psychological program. Sure, he may need drugs for a while but they’re ancillary, never more than temporary supplements to the real work of sorting through the tangle of personality factors.

The value of this approach is that moods are seen as reactions to life events, not as primary disorders in their own right. For example, a person with an abusive background may see the world as a dangerous and threatening place, and reacts accordingly to trivial events, i.e. with a threat response, aka anxiety. The definition of an anxious personality is a person who reacts to neutral events in the environment as though they were a threat. This is the result of being raised in a threatening world. If you’re surrounded by trouble as a child, you start to expect trouble, and if you expect trouble, you must react with anxiety. In time, the idea of another anxiety attack becomes the biggest threat of all, and so the vicious circle is closed. Mainstream psychiatry can’t see that, of course, because everything is biological; their minds are closed to the idea of psychological factors controlling our mental lives. Anyway, if they adopt the dimensional model for personality disorder, they need to be careful as it could pull the whole biological edifice down on their heads. Good, bring it on.

References:

1. Shadid J et al (2025). The global epidemiology of personality disorder: a systematic review and meta-regression. Lancet Psychiatry Nov 3:S2215-0366(25)00299-8. https://pubmed.ncbi.nlm.nih.gov/41197646/

2. McLaren N (2007). The categorical system of diagnosis: Personality Disorder. Chapter 8 in Humanizing Madness: Psychiatry and the Cognitive Neurosciences.; Ann Arbor, Mi.: Future Psychiatry Press.

3. McLaren N (2012). Chapters 14-16 in The Mind-Body Problem Explained: The Biocognitive Model for Psychiatry. Ann Arbor, MI: Future Psychiatry Press.

4. McLaren N (2021): Natural Dualism and Mental Disorder: The biocognitive model for psychiatry. London: Routledge. Amazon

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My critical works are best approached in this order:

The case against mainstream psychiatry:

McLaren N (2024). Theories in Psychiatry: building a post-positivist psychiatry. Ann Arbor, MI: Future Psychiatry Press. Amazon (this also covers a range of modern philosophers, showing that their work cannot be extended to account for mental disorder).

Development and justification of the biocognitive model:

McLaren N (2021): Natural Dualism and Mental Disorder: The biocognitive model for psychiatry. London, Routledge. At Amazon.

Clinical application of the biocognitive model:

McLaren N (2018). Anxiety: The Inside Story. Ann Arbor, MI: Future Psychiatry Press. At Amazon.

Testing the biocognitive model in an unrelated field:

McLaren N (2023): Narcisso-Fascism: The psychopathology of right wing extremism. Ann Arbor, MI: Future Psychiatry Press. At Amazon.

The whole of this work is copyright but may be copied or retransmitted provided the author is acknowledged.