The War Against Personality Disorder

For years, I’ve been saying that mainstream psychiatry is engaged in a long-term project of re-diagnosing personality disorders, which psychiatry can’t treat, as mental disorder and putting everybody on drugs [1]. That way, patients who would normally be sent to the psychologists or social workers can be brought back indefinitely (and profitably) for “review.” Psychiatric drugs being what they are, if the newly-anointed patients weren’t mentally disturbed to start with, they soon will be [2] so the project becomes self-fulfilling.

But, you might ask, how could anybody confuse personality disorder and mental disorder? That’s easy. If you don’t have a theory of personality and thence a model of personality disorder, nor a theory of mind or model of mental disorder, then anything goes. More to the point, if everybody is doing it, who’s to say you’re wrong?

It doesn’t mean psychiatrists never diagnose personality disorder as they do, but only when it’s unavoidably obvious (or they want to punish a patient). A diagnosis of personality disorder is not used as the starting point on a tailored treatment program because, with few exceptions, they don’t have such a thing. The reason lies with psychiatry’s blinkered approach to mental problems. Because all mental disorder is deemed biological, and because biological causes of anything are necessarily separate and distinct, then it follows that all mental disorders must be separate and distinct. Notice how this is actually working backwards. The correct move is to start with the facts and try to find an explanation, but psychiatry starts with the explanation and trims the facts to fit. That’s how we end up with the concept of categories of mental disorder, where each distinct category is unrelated to all the others because, the theory dictates, they all have separate and unrelated genetic origins. If, as commonly happens, two or more mental disorders occur in the same individual, that’s bad luck, two set of bad genes (known as ‘comorbidity’).

That’s the (unwritten) theory but when this idea is applied to personality, it breaks down for the simple reason there are no unique categories of personality. In technical terms, personality disorders are not natural kinds. We all show a huge range of behaviour, which can be roughly lumped into clusters but, like height or weight or intelligence, each characteristic that can be measured varies as a dimension, it ranges smoothly across the whole population. Just as there is no cut-off between “short person” and “normal height,” we are all somewhere on the dimension of “height,” so too there are no natural divisions separating “ordinarily tidy person” from “total slob” at one extreme and “neatness freak” at the other. This means that every attempt to devise a scheme of “categories of personality disorder” is artificial and must eventually break down.

The mainstream understand this because, for their latest attempt at classification of mental disorder, they toyed with the idea of discarding their categorical system for personality and adopting a dimensional system. Instead of saying “You belong in this category but your weirdo mate goes over in that one,” every person gets a score on each cluster or dimension of behaviour. For example, they may have made one cluster related to tidiness, rule-abiding and perfection, another which groups all forms of suspicion and mistrust, and another cluster related to sociability. Hans Eysenck, of the Institute of Psychiatry in London, wanted to get by with just three; Raymond Cattell thought we needed sixteen (I prefer this) but by hammering the factors, today’s psychologists have decided we can only have five: Openness, Conscientiousness, Extraversion, Agreeableness and Neuroticism, known as OCEAN.

With the fifth version of their “bible of psychiatry,” the DSM committee wondered about a dimensional system but they wanted one that would give their favourite diagnoses; they wanted to tell the model what to do instead of letting the model tell them. Needless to say, it didn’t work so they stuck with their old system (the one that doesn’t work). However, it has the very real advantage for psychiatrists in that they can take any person with personality problems, reword the symptoms [3] and shuffle them around to give an entirely new diagnosis. That allows them to prescribe lots of drugs and hey presto, a life-long mental patient. A recent article in Psychiatric Times, a drug company propaganda sheet for the mainstream, illustrates this very well. With the snappy title “Adding Insult to Narcissistic Injury: the Comorbidity of Narcissistic Personality Disorder and Major Depressive Disorder,” they showed how mainstream psychiatry really doesn’t have a clue what it’s doing.  

The article is based around the case history of Jeffrey, a 52yo single man in New York with a long psychiatric history of “… treatment-refractory MDD and generalized anxiety disorder, with numerous failed medication trials and several psychiatric hospitalizations.” Over the years, he had been prescribed “…5 selective serotonin reuptake inhibitors [SSRIs], 1 serotonin-norepinephrine reuptake inhibitor, 2 atypical antidepressants, 2 tricyclics, 2 monoamine oxidase inhibitors, 3 mood stabilizers, 5 neuroleptics, ketamine, and electroconvulsive therapy, all with minimal effect,” i.e. 22 different forms of treatment. In view of this litany of failure, they decided to … add more drugs. Jeffrey was given another three drugs (including pramipexole, an anti-Parkinsonian drug that causes compulsive and/or impulsive behaviour, such as suicide bids), with the predictable outcome. While they made some effort to see some of his symptoms as the result of personality factors, they were hamstrung as they were unable to integrate them into a whole. He was discharged to some talk program but soon returned in the same state.

You have to remember that we humans see what we believe, not the other way around. This is true enough when looking at the natural world, but especially the case when we are looking at humans. If we believe that Jones is evil, then it doesn’t matter what good he does, we will turn it around so that it becomes further evidence of his evil nature. Psychiatrists like to put it about that they’re terribly scientific but they’re not. They too see what they want to see. So when Jeffrey presented with depression and anxiety, his psychiatrists had to see them as separate conditions, unrelated to his obviously unstable personality and poor self-esteem. They could not admit that his “mental illnesses” of anxiety and depression were entirely the result of his personality which, in turn, came from his early life experiences and had nothing to do with genes. They were thus condemned to fall into the definition of insanity, of doing the same thing twice but expecting a different result (and no, it wasn’t Einstein, it was feminist author, Rita Mae Brown), just because they didn’t know what they were doing.

That’s a rather sweeping condemnation. My experience is that psychiatrists get a little peeved when told that, so what does it mean? Imagine you’re driving your car along and the engine suddenly stops. You guide it to the roadside, check the fuel and temperature gauges are normal, test the battery, check the wheels, poke around under the bonnet but you can’t see anything wrong, so you call a tow truck. At the garage, a mechanic comes out, listens to your story and, with a cheerful grin, says “No worries, mate, we’ll fix this in two shakes.” He dashes inside and comes out wearing what looks like a voodoo mask. He hands you a rabbit’s foot charm and says “Now we join hands and dance around the car while I repeat the magic phrases and vroom, it will start.” Astounded, you grab the tow truck driver who is about to leave and tell him to take you to another garage: “And if it’s not too much trouble, sunshine,” you say sternly, “I’d like a mechanic who actually knows what he’s doing.”

“Knowing what you’re doing” means you have a working understanding of the unseen mechanism(s) generating the observable behaviour. In the case of a car, we expect a mechanic to understand the ins and outs of an internal combustion engine, of how chemical energy in the fuel is converted into kinetic energy of movement by entirely rational processes that don’t respond to emanations from rabbits’ feet. When the car malfunctions, they can quickly work out the specific point in the conversion process where it is breaking down. In the case of the malfunctioning Jeffrey, the psychiatrists said:

As with all patients, it is critical to examine aspects of the patient’s inner experience, as well as patterns of interpersonal functioning, to assess for the presence of a personality disorder and inform a robust biopsychosocial formulation.*

They then ignored the “psychosocial” part and gave him more drugs, just because their impoverished model of mental disorder couldn’t take them into account, which the patient kept telling them:

Jeffrey recounted that his treatment teams “did nothing” for him and “had no idea what to do” with him.

He wasn’t stupid, was he, but it did him no good. They didn’t know what to do because, for all their talk of a “robust biopsychosocial formulation,” they don’t have an integrative model of mind and body, so they couldn’t see that his personality came first and generated his anxiety, which then wrecked his life and led to depression. So simple, cause and effect, but if you believe that depression and anxiety are stand-alone mental illnesses, you will be unable to see how that comes about.

The definition of anxiety is “the psychosomatic response to a threat,” also known as the fight or flight reaction. If a person in ordinary life sees too many threats, i.e. reacts to  neutral events in the environment as though they were a threat, then that person will be constantly anxious. For an anxious person, the world is endlessly dangerous but that is an acquired cognitive matter, not biological. And since constant anxiety is intolerable, anxious people have to do something about it such as avoid the threat (e.g. school refusal, taking time off work, never going out, avoiding any competition etc), or drink or use drugs, but eventually it comes too much and they sink into despair: “This is terrible, nothing seems to help. I can’t face this for the rest of my life, I’d be better off out of it.”

That’s it. So simple, but if your doctrinal “understanding” of mental disorder doesn’t go beyond genes and neurotransmitters, then you can’t take being mistreated as a child into account, and therefore can’t understand why the person is anxious and has poor self-esteem. That is, you don’t know what you’re doing, and the patient just goes round and round in the revolving door of drugs, hospital, more drugs and ECT until one day, he gives up.

* “inform a robust biopsychosocial formulation.” A truly inspired example of gobbledegook, as per William Lutz’s Doublespeak, see August 6^th Substack.  

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This week, the  Royal Commission investigating Defence and Veteran Suicides handed its report to the Government. After three years, thousands of witnesses and who knows how much money, the 3000+ pages of their report are now available, in seven volumes. I’ve got Volume I and will slowly work through it but won’t be reading the rest. My submission of some 28 pages still hasn’t been listed, a year after everybody else’s were made public. Every time I ask why, I’m told “We’re terribly busy, we’ll get back to you,” which they never do. Since it detailed some highly questionable practices among psychiatrists who make a shitload of money from “treating” veterans, I’m keen to find out what’s going on.  

References:

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

2.      Gotzsche P (2024). Is Psychiatry a Crime Against Humanity? Copenhagen: Institute for Scientific Freedom. (free download).

3.      McLaren N (2007). Chapter 8 in Humanizing Madness: Psychiatry and the Cognitive Neurosciences.; Ann Arbor, Mi.: Future Psychiatry Press.