Mad, Bad or Sad?

The sorry saga of personality disorder.

Imagine a factory that produces a machine that sells very well among the in-crowd. As soon as it is delivered, buyers eagerly unwrap it and find a black box about so big. It is a uniform cube apart from the front where there are a single white button and five little coloured lights: Orange, Cobalt, Emerald, Amethyst and a lurid Neon pink, usually abbreviated by the cognoscenti to OCEAN. Each time the button is pressed, which the excited new owners can do two or three times a day, one or other of the lights glows. However, the lights are fairly unpredictable so it takes time to build a picture of what your box will do. There are no screws on the box and no way of opening it so nobody can alter the settings, as they say.

Eventually, owners get a score for each colour, which indicates what their box is likely to do in future. Boxes with the most desirable combination are treated almost as members of the family, and can command quite high prices at auction. Normally, if they're looked after nicely and even pampered, they continue in much the same pattern but it's not foolproof. Sometimes a box seems to get sullen, especially after being sold, and its score changes so there is quite a cottage industry in "diagnosing black boxes" and trying to improve them.

Assume you have bought one and, after a month or so, your box's score is O-8, C-13, E-11, A-19, and N-12. What does that tell you? In particular, what does it tell you about the inner workings of the box? Of course, it tells you absolutely nothing. The box's mechanicals are a total mystery - it is truly a black box. All you can say is: "This is our box's score for the past month. We expect it will continue with this pattern, but only time will tell." That is, you have a description of the output of your box, but you do not have an explanation. Description and explanation are epistemically different, i.e. different orders of knowledge.

In mental health, OCEAN stands for the "five factor model" of personality. There are many different tests available but they all ask people to rate themselves on each of a long list of questions. Everybody gets a score ranging from low to high on each factor, so a picture emerges of the person. The factors are:

• Openness to experience (consistent/cautious vs inventive/curious)

• Conscientiousness (extravagant/careless vs efficient/organized)

• Extraversion (solitary/reserved vs outgoing/energetic)

• Agreeableness (critical/judgmental vs friendly/compassionate)

• Neuroticism (resilient/confident vs sensitive/nervous).

These "factors" aren't fixed in concrete or even divinely ordained. It’s just that if you ask enough questions, they will tend to cluster into these main groups. Crucially, this is not intended as an explanatory model of personality, it is purely descriptive. All it says is that on this day, a particular person scored thus on the test. That's it. It tells us nothing whatsoever about his or her inner workings, nothing about the mental mechanisms that generate the observable behaviour. However, it's not enough to say "This is what the person does," the question that counts is Why? Why is she like that? Why does he keep doing those dumb things? The five factor model can't answer those types of questions as it is not based in an explanatory model of human behaviour.

As it is, I don't think these factors are much help as they blur important differences in mental traits , e.g. they don't give anywhere near enough emphasis to paranoid thinking, but there will never be complete agreement. Ms AB, for example, scores in mid-levels except she gives herself a high score on neuroticism, but the scores tell us nothing about why this happens. In fact, it's all related to how she is performing at tasks. She doesn't like disapproval as her mother was very critical and they used to argue a lot. Mr CD, however, scores low on O, E, A and N, but high on C. He is rigid, dislikes change, is distant and dismissive of people and keeps to himself. What it doesn't say is that, after a truly atrocious childhood, he has terrible self-esteem and feels the world is out to get him so he follows rules rigidly in order to forestall trouble. The essential message is this: A description of a person's behavioural output is not the same as an explanation of that output.

As a description of observable behaviour only, the 5-Factor score tells us nothing about the person's inner mental workings because it's not meant to. This is true of all DSM-5 "personality disorder diagnoses." Giving people labels tells us (and them) nothing about what goes on to produce the disturbance. However, and critically, mainstream psychiatry isn't interested in the inner mental workings of its patients because it doesn't believe they're significant. For orthodox psychiatry, ca. 2024, it's all brain chemistry. And genes, don't forget the genes.

With that in mind, we can move to the second of the two articles in the recent Psychiatric Times, on "borderline personality disorder." As I said last week, this diagnosis tells us nothing about the patient's background or mental life. It indicates only two things: (1) the severity of the disturbed behaviour, and (2) the hostility of the mental health staff. Hostile staff can be a problem in mental health, but they're often no better in the general medical setting, which is the topic of the article. It says that people who get this diagnosis generally have fairly poor health so they often turn up in medical wards where staff don’t know what to do. As a result, they tend to die younger than the rest of the population.

The article asks: "Why do patients with BPD have worse physical health and medical outcomes?" They offer three explanatory "models" (which aren't explanations, just descriptions), "the reciprocal model, the biological predisposition model, and the countertransference model." The first or reciprocal model says "The medical illness makes the effects of personality disorder worse, and the personality disorder means they can't look after themselves properly," which is no real improvement on common sense. A "biological predisposition" means they have some common genetic risk of poor health and mental disturbance, which is no help because we have no idea what it might be (and also is exceedingly unlikely). The last one, countertransference, is a psychoanalytic concept which says "The patients are difficult, so the staff get angry." In case anybody doesn't understand angry, it comes with a scary photo, although it doesn't have a caption so it may just be the staff "venting" (don’t laugh: it happens).

Physically sick people with the diagnosis "borderline personality disorder" can be demanding and manipulative and aggressive but, by being aware of all the awful things these patients do, staff can " ... avoid the common pitfall of over-prescribing psychotropic medication for patients with BPD who are transiently acting out" ("acting out" is psychobabble for being naughty, also filched from psychoanalysis where it was unrelated to being naughty). That's actually fairly daring of the authors, suggesting that staff may hit back via their power over the patients. To drive this home, they point out:

Very weak evidence exists to support the use of psychotropic medications in BPD; behavioral interventions and psychotherapeutic approaches should be first line.

This must be a shock for the mainstream, who believe there's a drug for all occasions. Discreetly hedged, it says: "We don't know what goes on in patients to produce difficult and/or destructive behaviour, it may be biological, psychological or social, or even the hospital, but drugs aren't any help. Talk to the patient, try to find out what the trouble is and deal with it without resorting to drugs. Learn to talk to your patients." Wow.

What they implied but haven't said is that by not putting people on drugs, they may actually prevent iatrogenic (medically-caused) mental disorder. As they say, Primum non nocere, First, do no harm. However, if you don't have a model of personality or of personality disorder, you don't actually know what you're doing, so it's hard to know whether you're making things worse. But if your "treatment" does make things worse, you can always blame the patient who, after all, had a personality disorder.

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Continuing with the new volume, tentatively named Theories in Psychiatry: Building a Post-Positivist Psychiatry, and probably for release in July, Chapter 2 is titled: Biological Psychiatry: Reductio ad Absurdum. For any critical work, I try to follow a standard formula: "This is what the supporters of this idea say, and this is why it's all wrong." Fortunately, biological psychiatrists like to trumpet their opinions so it's a simple matter of collecting a few of the more outrageous claims, knowing that mainstream psychiatry soaks them up like blotting paper, i.e. without any attempt to examine them critically. Biological psychiatry says "All mental disorder reduces to a case of brain disorder, with no questions unanswered." This is textbook positivism from 1929. The chapter sets out the theoretical options available to anybody who believes this, and shows that each of them fails. They don't just fail, they can't be developed to the point where biology could say anything interesting about mental distress. Eventually, biological psychiatry will collapse in a heap, but don't expect any apologies for all the damage it's done. Robert Whitaker's essay in Mad in America this week looks at different reasons why this is likely to happen, and is a good source of critical references.

Chapter 3: The Disorder of Mentalism, is anti-positivist, i.e. it says there is a mind and we can study it meaningfully to work out what goes wrong in mental disorder. Unfortunately, the most highly-developed groups of theories have all had serious flaws. These included Freud's theory of psychoanalysis and what is now called cognitive psychology. Despite its shortcomings, psychoanalysis refuses to die. The ideas that Freud and his followers discovered keep popping up, mainly because, at base, they're descriptions of human behaviour rather than formal explanations. It's true that we distort our perceptions of today's world based on our early life experiences; the only question is how to incorporate this in an explanatory model. Cognitive psychology is now a big business and spreads across into philosophy, of which more in Part II of the book.

The goal of these chapters is to take each set of theories in psychiatry and cut through the propaganda to see if they can tell us anything meaningful about the troubled mind. Having spent decades on this, I'm satisfied they can't but convincing the mainstream their theories are wrong is proving problematic. Have I used this quote before? "It's difficult to get a man to understand something when his salary depends on his not understanding it" (Upton Sinclair, American author and critic, in about 1934).

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