Personality disorders and other diagnoses

[Zetetic]

Split out from another thread, for that thread's sake.

but there is some at least in theory, such a label suggests there should be some treatment, of some kind.

No, that's simply not how "personality disorder" diagnoses have been used by services themselves, let alone in the wider population. Mental health services continue to explicitly shut out people who have attracted the diagnosis. These labels have openly and explicitly been used to mean "this person is beyond help".

That's changing in services, haphazardly and slowly. (There is an abundance of studies running up the present day on how the label affects professionals' views of a person, even if they're not actually locking them out.) The folk-meaning that the term has acquired remains pretty clear.

(Crazy Ex-Girlfriend deals with this, weakly, right? The milieu ultimately allows it a happy ending, but it still recognises that BPD has history unlike 'diseases of the mind'-type diagnoses.)

The lack of support seems to be more of an issue than the labels. I guess you wouldn't dispute this.

Yeah.

I think I'm often less worked up by the idea of cranking the euphemism treadmill in actual mental health services (since they can turn any new jargon towards a slur exceptionally quickly) than when these labels get used in more causal conversation in a way that - to me - tries to make them carry more diagnostic weight than they can handle.

Isn't it better that diagnoses are given rather than insults?

I think the advantage of insults is that they at least often advertise that this is the attitude and perspective of the utterer, while diagnostic labels pretend to be a judgement-free explanation of the facts.

What's the difference between 'anger management issues' and 'conduct disorder'?

A few years? Antisocial personality disorder a few years after that, maybe.

[pancreas]

How often is someone genuinely beyond help, do you think? Do you think cimh's wife fits the bill? (I don't expect an answer.) I certainly thought this about another poster's delightful wife; and I do tend to think I was right.

[Just to be clear, some of my best friends are women. Even this far into homosex, I could prove it by taking a wife and paying for her hair to be permed or whatever one does with them.]

[pancreas]

(Crazy Ex-Girlfriend deals with this, weakly, right? The milieu ultimately allows it a happy ending, but it still recognises that BPD has history unlike 'diseases of the mind'-type diagnoses.)

I suppose the difference is the self-awareness. This is what saves her from ruining absolutely everything and making herself miserable. I don't know if that is an option for most people who are diagnosed [word used with some apprehensiveness] with BPD.

[Zetetic]

How often is someone genuinely beyond help, do you think?

I think in the context of either:
- Providing a mental health service, or
- Dealing with someone that you love or loved,
it's not a useful question.

Even if the latter, you might have to recognise that you aren't helping and it's hurting you too much to keep trying right now.

(I don't expect an answer.)

Good, I suppose.

[Zetetic]

I suppose the difference is the self-awareness. This is what saves her from ruining absolutely everything and making herself miserable.

I think this is a fantasy written by people making the usual error of over-emphasising personal attributes over situational ones.

Enough cash and social support saves people, mostly.

[pancreas]

We should have a whip-round for cimh's wife, then.

[BlodwynPig]

How often is someone genuinely beyond help, do you think? Do you think cimh's wife fits the bill? (I don't expect an answer.) I certainly thought this about another poster's delightful wife; and I do tend to think I was right.

Never said you were wrong.

[Zetetic]

We should have a whip-round for cimh's wife, then.

Why?

[pancreas]

Enough cash _{[and social support]} saves people, mostly.

[Zetetic]

That doesn't really seem to be the most relevant part for her, yet.

[pancreas]

Maybe you were being glib? Or maybe you would say that insecurity is the root of it all, at least one source of which is money. What is the distribution of personality disorders with wealth, I wonder? I imagine data would be hard to gather, somehow.

[Zetetic]

No, I would say that poverty kills people and that having great difficulties with your sense of self, engaging in deliberately self-destructive behaviour and struggling to maintain functional relationships are good routes into poverty. Not least if those things stem in part from periods of trauma and neglect that have opened you up to all sorts of other coping strategies with unhelpful long-term consequences (particularly when you run out of money).

Having enough cash and goodwill to burn through, and enough cash to obtain paid-for help rather than being turned away from services that don't like how you make them feel and that are always focused on the easily-helped, gives you a chance of finding another way to live before you're dead.

What is the distribution of personality disorders with wealth, I wonder. I imagine data would be hard to gather, somehow.

This would be a trivial, if pointless, linkage project in one of many databanks. Rich people tend to do a decent job of staying away from (public) mental health services, not least because the extent to which your behaviour is a problem to you is always tied up with how much cash you have.

[BlodwynPig]

[Zetetic]

(It's not like the essential relationship between lunacy and poverty is subtle either. The predecessor of the asylum was the workhouse. In some cases they were literally the same buildings.)

[pancreas]

(It's not like the essential relationship between lunacy and poverty is subtle either. The predecessor of the asylum was the workhouse. In some cases they were literally the same buildings.)

There might be more moving parts here than just poverty; not that your point isn't well-made, rather generally, as a statement about public health. But individual cases would no doubt still exist, even in a socialist utopia.

In Victorian Britain, masturbation was a reason for locking people up, evidently.

https://www.ssoar.info/ssoar/bitstream/handle/document/3302/ssoar-hsr-1992-no_3__no_63-johnson-the_insane_in_19th-century_britain.pdf?sequence=1&isAllowed=y&lnkname=ssoar-hsr-1992-no_3__no_63-johnson-the_insane_in_19th-century_britain.pdf

I don't do it myself, of course, but I wouldn't censure others for it. There are people on this very forum who wank, they lead one to believe.

Disobeying your husband was a big cause, apparently. Again—I wouldn't consider it, but technically one could.

I suppose my point is that many of the poor may have been locked up when perfectly sane by today's standards. BPD doesn't feel like the same thing as masturbation.

[Zetetic]

But individual cases would no doubt still exist, even in a socialist utopia.

I think this misses the point, but you seem closer to it later on.

I suppose my point is that many of the poor may have been locked up when perfectly sane by today's standards. BPD doesn't feel like the same thing as masturbation.

It's not, in so far as people who end up with the label are usually made unhappy by their responses to the world, and that's what has initially brought them willingly to services in the first place.

I get the feeling that you're still so intent on seeing personality disorders as things that can be found in people's minds[nb]Which I'm not virulently opposed to, in theory. It's just that, in practice, any sense that we might trace back to a classification manual ends up being ... poorly served by its actual application.[/nb], to the exclusion of seeing "personality disorder" as a label applied by a human in a context and for a purpose.

An infatuation with semantics is making it hard to really engage with the pragmatics? Something like that?

I guess I'd emphasise that people end up with the label, not just because of how they respond to situations, but in virtue of the situations that they find themselves in, including the interactions with services that they're asking for help[nb]And it's worth considering how narrow a view of someone that mental health services generally have. They don't observe their life, they see certain catastrophic outcomes, try to grope around by asking the person themselves, but mostly observe in the snatches of time that those services spend with that person.[/nb]. Those interactions are not just driven by the person seeking help, and services often come with much of the same class and gender and race prejudices as the outside world.

[Zetetic]

^ EDIT FUCK

[pancreas]

I get the feeling that you're still so intent on seeing personality disorders as things that can be found in people's minds[nb]Which I'm not virulently opposed to.[/nb],

This is true, probably. My experience of my own mental health has been rather placid. So I have a rather detached relationship with mental health problems. At some level, I can't really understand why people don't just try pulling themselves together.

to the exclusion of seeing "personality disorder" as a label applied by a human in a context and for a purpose.

Shouldn't this be medicine? With a view to curing diseases? Doesn't effective medicine intrinsically require classification? Which then requires labels. I'm sure the current system, and people, may be abusing labels, but it's difficult to approach anything scientifically without trying to put names to things.

[Zetetic]

It should be to determine appropriate treatment, yes.

However, it turns out that psychology is the only genuinely difficult science and that trying to cobble diagnostic categories that are strongly predictive at an individual level of what is likely to be an effective treatment is quite hard.[nb]This is me being a bit glib.[/nb]

(It's made harder still because there's a whole bunch of other things that aren't really the "illness" per se that are probably also relevant to determining what is helpful for that person at that time. This is also true of physical problems, of course.)

"Formulation" is one way that people have tried to come up with to approach this, focusing less on being able to place the person into a highly generalisable framework and instead trying to bring together someone's situation, beliefs, behaviours (etc.) and what problems they're trying to solve in these things a way that - while still informed by theory - tries to relate these together in a way that make sense for that individual. (This is not very helpful for research, of course. And "informed by theory" is doing a lot of work there.)

Or there's "transdiagnostic" approaches which are less focused on globbing a bunch of disparate symptoms into "disorders" and instead focused trying to identify multiple common factors and process that seem to contributing to or forming part of someone's problems. (These factors and processes are open to research, but of course the point is that they're generally not independent, but reinforce and mediate each other.)

(In my work, I've mostly just pushed for "please for fuck's sake can we just capture what problems people say they're turning up with and we'll try to make sense of these after the fact". But while I think that's useful for making sense of demand for services, say, it's not good enough to helping an actual individual.)



Going back to the idea that the purpose should be to determine appropriate treatment:

As has been discussed, personality disorder labels have overwhelmingly been used to exclude people from treatment and to mark them out as too unpleasant for professionals to engage with (and this continues to be the case), rather than to inform future support.

The context, purpose and effect of applying the term is simply too much to shrug off.

[chveik]

being officially diagnosed does make it easier to deal with social services and claim benefits though

in terms of self-awareness, you can recognize the patterns you're trapped in but I won't necessarily help you overcome them.

[Zetetic]

being officially diagnosed does make it easier to deal with social services and claim benefits though

This is another major consideration[nb]Particularly if you're trying to advocate an alternative to existing classification systems...[/nb], and another point that shows that the supposed semantics of mental health diagnoses aren't nearly sufficient to begin understand how and why they're actually applied.

[pancreas]

So, if I have this right, you don't think mental health problems are the result of underlying (mental) diseases which could be identified, like for example 'brain Aids' or 'mind Cholera' or 'psycho-leprosy'. You think one merely sees the tip of a wild swirling iceberg of random bits of sociological issues and, to a more limited degree, fundamental cognitive problems.

This would make it rather difficult to cure people, no? When you're trying to reverse engineer how the graphical equaliser of lunacy has been configured. Perhaps we should go back to electrotherapy.

To return to my point at the beginning, I think you basically don't see that BPD is sufficiently well-defined based on any agreed list of symptoms so as to be useful.

This is a hypothesis. I wonder how one could test it.

[bgmnts]

What if you're just a bit of a spacker mentalist?

[pancreas]

Well, I would politely suggest you grab a hold of yourself, with a view to pulling yourself quite firmly together.

[Zetetic]

So, if I have this right, you don't think mental health problems are the result of underlying (mental) diseases which could be identified, like for example 'brain Aids' or 'mind Cholera' or 'psycho-leprosy'.

I wouldn't go that far. I think that - for example - "depression", "anxiety", "psychosis" all mean something and they're good enough as a starting point for doing some science and maybe for supporting a proper discussion with someone.

I think the examples I've picked are some of the best ones for actually informing a choice of effective treatment - and they're pretty rubbish at that. (Trenter might well disagree with me that these are the best ones, incidentally.)

You think one merely sees the tip of a wild swirling iceberg of random bits of sociological issues and, to a more limited degree, fundamental cognitive problems.

Not sure about "fundamental". But, yeah, a lot of people's mental illness seems to be made up of a combination of being constantly confronted with shitty situations and having developed ways of living (often in response to shitty situations, and sometimes adaptive - after a fashion, in the short term - to those situations) that help make those situations worse or bring them back them again and again (although the world does a decent job of that as well).

This would make it rather difficult to cure people, no?

It does seem to, particularly while we remain committed to 1) making the sociological issues constantly worse and 2) withdrawing anything that might have resembled asylum from those issues or ongoing support to help people with anything other than the mildest bad habits.

To return to my point at the beginning, I think you basically don't see that BPD is sufficiently well-defined based on any agreed list of symptoms so as to be useful.

I think, as I believe we discussed 3 years ago, it is getting at something in people in some cases - but that its definition (and the applicability to individual on that basis) is still often beside the point, because its the effects of applying it that are important.

This is a hypothesis. I wonder how one could test it.

I think we have sufficient evidence from both the dead and living to conclude "hey, BPD still mostly seems to be used to consign people to the dustbin".

As part of a piece of work on frequent attenders/callers/etc., I did once end up digging through the fragments of someone's life in our datasets that suggested an interesting piece of research - you could look at how hazardous the act of labelling someone with BPD was. (If we think that the label was true, then we must assume that they had already carried the hazard of the thing itself for some time.)

The person that prompted this thought had been repeatedly admitted over several years with recorded diagnoses of variations on depression and various intentional self-injuries and their sequelae, up until the admission where an ICD-10 code of F60.3 appeared. I think it was something like four months before they killed themselves.

(Edit: There is of course a lot of existing case literature on these sorts of routes to death, not least via people like NCISH, but also a fair bit of research into how being told that someone has this or that diagnoses causes professionals to appraise behaviours and patients so very differently.)

[Zetetic]

^ STILL EDIT FUCK

[Mr_Simnock]

..... did once end up digging through the fragments of someone's life in our datasets that suggested an interesting piece of research - you could look at how hazardous the act of labelling someone with BPD was. (If we think that the label was true, then we must assume that they had already carried the hazard of the thing itself for some time.)

The person that prompted this thought had been repeatedly admitted over several years with recorded diagnoses of variations on depression and various intentional self-injuries and their sequelae, up until the admission where an ICD-10 code of F60.3 appea.....