Thursday, November 5, 2009

Judging Amy - Follow-up

In my previous two blog pieces, I recounted the adventures and misadventures of the fictional Amy, who clearly evidenced personality issues that operated both to her advantage and disadvantage. My point was that before we congratulate ourselves in not being like Amy, it would be far more useful, instead, to acknowledge that we have a lot more in common with people like her than we would care to admit.

In short, we need to be thinking in terms of WE, rather than THEM vs US.

A lot of attention is paid to managing our illness - such as bipolar or depression or anxiety - but what tends to hold us back in life are our unresolved personality issues. I got to observe this close-up in my years of attending and facilitating DBSA support groups. I strongly suspected in some individuals an undiagnosed personality disorder in play, but more often than not I saw myself looking in the mirror at my own personal shortcomings.

We get fearful, we feel threatened, we get overwhelmed. We may flip out, we may become avoidant. We overreact, we under-react. In desperation, it seems, as a way of dealing with a world that seems to be increasingly aligned against us, we restructure our own reality. Call it Me World, where we are no longer hold ourselves accountable, or as accountable.

This may allow us to hold onto our sanity for a little while, but the catch is the real world doesn't buy into our reality.

What psychiatry categorizes as personality disorders sheds invaluable light on what is going on with us, but with this major caveat:

Personality disorders are by no means definitive. The DSM method of separating out and categorizing various personality disorders creates the misleading impression of identifying (and thereby labeling and stigmatizing) an individual by the so-called disease at the expense of understanding the person. The reality is different degrees of symptom severity and overlap, which the next DSM is likely to address, probably in the form of a "dimensional" schema to coexist with its categories.

Okay, now a quick traverse of the four best-known - and closely-related - personality disorders, which the DSM groups together as Axis II, Cluster B:

Borderline Personality Disorder

Freud's successors came up with this term to describe what they saw as problem patients bordering on psychotic. Emotionally unstable is a far more accurate description. Nevertheless, the label borderline stuck, together with the legacy of borderline individuals being regarded as problem patients. Sympathetic hospital staff have been known to turn on individuals in distress once they have been handed this diagnosis.

Borderline made its official debut in the DSM-III of 1980, but on the surface is very difficult to distinguish from bipolar. Unofficially, psychiatry is guided by the common stereotype of the moody and often hysterical teenage girl (or people who act like one) who may have abandonment issues, act impulsively, and engage in destructive behavior such as cutting. Twice as many females are diagnosed with the illness, possibly because problem males better fit the stereotype of antisocial personality disorder.

People living with someone who exhibits borderline tendencies typically describe the relationship as akin to walking on eggs: one minute all love and light, the next a hateful explosion or the sullen silent treatment. A borderline meltdown tends to have its roots in the individual’s lack of ability to handle the stress of any given social situation. Thus it can occur without warning. This tends to contrast with bipolars behaving badly, which typically flows in slower cycles.

Antisocial Personality Disorder

Serial killers generally fall into this class, but the diagnostic criteria is wide enough to include your abusive boss or scheming co-worker, or for that matter your brother who borrows your car and returns it without refilling the tank. According to the old joke, poor people with antisocial disorder are in prison, middle class individuals with this disorder are in therapy, and rich people with the label are CEOs. These are your classic sociopaths, out for number one, with no regard for others. “I’d walk over my own grandmother to re-elect Richard Nixon,” Watergate conspirator Chuck Colson once bragged. He wasn’t joking. He authored an “enemies list” of real and imagined political opponents to be singled out for special treatment, such as FBI harassment and tax audits.

Typically, men are three times more likely than women to receive the diagnosis, leading to a strong suspicion of gender stereotyping between borderline and antisocial. A female who is emotionally overwhelmed and angry may throw a hissy fit. A male in a similar state may throw a punch.

Narcissistic Personality Disorder

We are not simply talking about over-inflated egos. Rather, the narcissist sees him or herself at the center of his or her own personal universe, with everyone else relegated to bit players assigned to specific minor roles. Dare to intrude reality into this individual's fantasy world and brace yourself for a narcissistic rage.

Histrionic Personality Disorder

Most of us enjoy being the center of attention, but people like Tom Cruise tend to go about it by jumping on Oprah’s couch. Those inclined toward displays of excessive emotionality also hate it when the spotlight turns to someone else, even a loved one. “Poor me” may also feature in their routine.

Mind vs Brain

The DSM-I of 1952 interpreted behavior as "determined by inherent personality patterns, the social setting, and the stresses of interpersonal relations" and tended to give far less weight to "the precipitating organic impairment.” This separation of the mind from the brain had far-reaching effects. With the advent of biological psychiatry, personality disorders became the poor relation of psychiatry. The ground-breaking DSM-III of 1980 had the effect of highlighting "Axis I" illnesses such as bipolar, depression, schizophrenia, and anxiety (all with obvious biological underpinnings) at the expense of ghettoizing the personality disorders into "Axis II."

Of all things, biological psychiatry is rescuing personality disorders from past and current neglect. The "stresses of interpersonal relations," for instance, are turning up on brain scans in ways that are screaming, "major paradigm shift."

More later ...

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