Personality Disorder.

It's not just the poor.

The author F. Scott Fitzgerald reputedly said to Ernest Hemingway, “You know, Ernest, the rich are different from us.” “Yes,” Hemingway replied, “they’ve got money.” They were both right: the rich certainly are different, psychologically as well as financially. Generally speaking, the rich and powerful have very different attitudes and beliefs from those toward the bottom of the social ladder. As a rule, the higher people climb up the social scale, the stronger their sense of privilege and entitlement. They believe their success in life has nothing to do with their surroundings or circumstances and everything to do with them. That is, they believe they got rich and powerful by virtue of hard work, discipline, self-denial and their generally superior moral equipment, so they sleep well. Tied to that, they believe the poor are poor by virtue of being lazy, undisciplined, self-indulgent, moral dropkicks. Those who are born into wealth and power are convinced that’s how God arranged it, and they sleep even better than those who fought to get rich.

For psychologists, the immediate question is: Do people get rich and/or powerful because they have a certain cluster of attitudes, or do they acquire those attitudes as the pelf rolls in? Answer: Yes. Mr Musk apparently has a vast following among young men (and quite a few women) who soak up his story: “To be as rich as I am, all you have to do is work 80 hours a week” (and, he overlooks, have wealthy and generous relatives with lots of connections, and have truly breath-taking luck, but that spoils his story). Now that he rubs shoulders with power in DC, his true, vicious attitudes are being exposed.

While standard psychiatry says that people’s attitudes and beliefs part of the genetically-determined personality, there is practically no reliable evidence to support this opinion, which just keeps getting recycled year after year. However, the idea is built into the entire system of psychiatry and couldn’t be removed without pulling the whole structure down. The American Psychiatric Association (APA) realised this some years ago when they were revising their diagnostic manual (then DSM-IV) and wanted to replace the section on personality disorders with an entirely different approach. All previous versions of DSM had used the same categorical approach to personality disorder as they used for what they like to call “mental illness,” namely, that there are distinct categories of disorder that have no overlap. This is the same as general medicine: we would say that the category of broken legs is entirely distinct from the category of pneumonia, with no overlap. They wanted to replace it with a dimensional model, where everybody has a score on all possible personality traits, so that we differ from each other only in degree. However, they couldn’t make it work without causing trouble in other sections, so they dropped it, which annoyed a lot of serious researchers [1].

The idea of categories in psychiatry is how they came up with their idea that there is a personality disorder called schizoid and another called obsessional, with no overlap. According to the received view, the symptoms of one personality disorder are unique and entirely distinct from the others, with no overlap. On the face of it, that doesn’t make much sense. Everybody knows that there are borderline cases but psychiatry needs this because of its commitment to biology. Even though the DSMs don’t admit it, the only reason to have a categorical system in psychiatry is so that, eventually, each distinct disorder will map down to a unique and distinct disorder on the genome. This is the same approach that led to the discovery of the genetic disorder that causes Huntington’s chorea. If and when it happened, there could be a drug for each personality disorder, psychiatry would be even easier and the drug companies could make squillions. What could go wrong? Actually, quite a lot.

The trouble starts right at the beginning. Apart from nobody having a clue how personality relates to the brain, and a total lack of any plausible evidence that genetic influences are of more than marginal significance [2], psychiatry can’t actually define personality disorder. Granted, the DSM5 and ICD-11 describe personality disorder as an enduring pattern of dysfunction affecting both mental life and relations to the world, but they don’t define personality and have no idea what it actually means or how it comes about. If you don’t have a theory of personality, then you can’t have a model of personality disorder. This is elementary: it’s like trying to talk about “transport disorders” without knowing anything about roads, ships, trucks, planes, etc.

We see this in an important publication by the National Institute of Mental Health in England from more than 20 years ago [3]. They wanted to get NHS mental health staff to start taking personality disorder seriously and stop using the diagnosis as a form of abuse of patients the staff didn’t like. However, they couldn’t define personality, which means no definition of personality disorder. All they could do was give some examples of what they meant by the expression and hope that readers could divine the meaning. Of course, it doesn’t work, and the reason is simply that there are no categories of personality disorder. Nearly twenty years ago, I showed how the whole idea of categories is no more than artful rephrasing of the same few, basic characteristics so that they look different even though they’re just saying the same thing [4]. Thus, we see that one personality type “engages in solitary pursuits” while another “avoids human relationships.” Same behaviour but they get a different name. This means that two psychiatrists can look at the same patient and assign her to different categories of mental disorder. That’s not science, it’s actually a projective test of the psychiatrists.

However, it gets worse. For years, psychiatry has been engaged in a huge project to “rediagnose” personality disorders, for which it has no treatment and therefore can’t make any money, to “rediagnose” it as mental illness, for which it has lots of expensive and toxic drugs which don’t work on personality. Thus, the patients never “get better” (because they weren’t sick in the first place) but the psychiatrists can look busy while making heaps of money [5]. We see this in particular in the condition called “bipolar disorder.” People who have ups and downs, with good days followed by bad (i.e. all people with personality problems, and most of us), are now put on piles of very powerful drugs which don’t seem to help, so they go in and out of hospital in ever-diminishing cycles, called “rapid cycling bipolar disorder.” This didn’t exist before the drugs were widely-prescribed, starting in about 1980, just when DSM-III was published.

It's also seen in the fad diagnoses, ADHD and ASD. Is that right? Are these social fads, as distinct from scientifically-validated disorders with a proven biological basis? You’re joking. Again, ADHD didn’t exist before 1980. There were a few kids who were given the label ADD, or hyperkinesis, or minimal brain damage or dysfunction, etc. but the idea that 11.4% and rising of American children are “mentally-diseased” would have been seen as ridiculous. Now, however, ADHD is colonising adult psychiatry, which has a sort of sense: if you’ve got a genetic mental illness as a child, it’s not going to disappear just because you turn 18. However, the criteria are so sloppy that we could diagnose a ham sandwich with ADHD and put it on stimulants. This is also true of ASD, an entirely novel “condition” which doesn’t lead to so many drugs but still needs lots of attention.

I’ve described a lot of this before but the outcome is that people now diagnose themselves via the internet, rush off to see a psychiatrist who, for a suitable fee, will confirm that yes, you sure are ADHD and you need stimulant drugs for life, here’s your certificate, drop in next time you’re in the area. In Australia, it is increasingly difficult for people to get appointments with private psychiatrists as most seem to have six month waiting lists. The reason is they are all sooo busy seeing all the immensely distressed people who need to have their diagnosis of ADHD confirmed so they can start their life-changing treatment. At up to $3000 a pop, just pay the girl with the big eyes as you go out. Naturally enough, more and more private psychiatrists are finding they need to restrict their practices to satisfying this urgent and ever-growing demand. They can easily see ten of them a week, with no intellectual effort, so why not?

The nett effect is that increasing numbers of people with genuine mental problems can’t see a private psychiatrist, so they sit at home until things get out of control and they either go or are dragged off to the nearest public hospital emergency department. There, if they can be bothered sitting in the queue for 6-8hrs, they will see a rushed junior medical officer who doesn’t like psychiatry, or maybe a nurse armed with a questionnaire that takes about 10 minutes to fill. Your life in 10 minutes. If the person decides this is bullshit and stands up to walk out, he will quickly find himself knocked out in a locked room with no clothes and a guard at the door. So hospital units become chaotic, with too many patients getting too many drugs after too little time to talk about their crappy lives; staff get the shits with their jobs (called “burnout” in polite circles); patients are given an additional label of “borderline personality disorder” even though none of the staff know what it’s borderline to; staff have more and more administrative work so less time to talk to patients even if they were so inclined; hospitals get more complaints so staff live in fear of more complaints, on and on. And so it reaches breaking point, which we see in New South Wales this week where two thirds of psychiatrists in the public mental health service were refused the 25% pay increase they demanded, so have now submitted their resignations, effective in one month.

I haven’t spoken to any psychiatrists in NSW but I’ll bet the problem is too many patients flooding in, too much administrative work, lack of support from the administration and, underneath it all, not actually knowing what they’re doing. Couple this with the spellbinding allure of pulling in a million a year for next to no intellectual or emotional effort and the system is set up collapse. The problem is quite clear: 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.

I had intended this to lead to the crucial but totally unrecognised question of personality disorder among politicians because, with the world on fire from one end to the other, it seems ever-more important. By that, I don’t mean politicians who are obviously head jobs, like some who lie and cheat and grab women by the privates, imprison their political opponents and threaten to invade countries to get better trade deals. We all know what they are. Instead, I mean the apparently normal, seriously nice politicians who pat children on the heads and give old ladies in wheel chairs outside their churches little air kisses, and everybody thinks they’re just what the country needs. No, they’re not. They’re the ones who smile for the cameras while cancelling school lunches for poor children or signing orders to bomb a city or authorising companies to mine protected areas or cheat poor countries out of their resources (Yes, Mr Downer, we’re looking at you). They’re the dangerous ones because nobody sees them coming. However, the more we look at it, the worse the problem seems to be, so it will have to wait.

As far as possible, have a peaceful Christmas.

*****

PS: can readers put any comments on this post by clicking the comments button below. If you email them to me directly, I get too many to answer but the real problem is that nobody else sees them. Thank you.

References:

1. Hopwood CJ et al (2017). Commentary: The time has come for dimensional personality disorder diagnosis. Personality and Mental Health. https://pubmed.ncbi.nlm.nih.gov/29226598/

2. Gupta P et al (2024). A genome-wide investigation into the underlying genetic architecture of personality traits and overlap with psychopathology. Nature Human Behaviour. https://doi.org/10.1038/s41562-024-01951-3

3. National Institute for Mental Health in England (2003). Personality disorder: No longer a diagnosis of exclusion. Policy implementation guidance for the development of services for people with personality disorder.

4. 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.

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