Map of life expectancy at birth from Global Education Project.

Tuesday, January 06, 2009

The wind blows cold on the borderline

As you know, I'm highly skeptical of the ontological status of the DSM diagnoses, which is a fancy way of saying I think for the most part that they don't refer to real entities. My philosophy is realism: if it's real, I believe in it, but I don't believe in the DSM-IV. Well, the book is real, the rhetorical categories in it exist, but what I mean is that their referents are not really real.

This is most true of the so-called personality disorders. If you read the diagnostic criteria, you'll probably start thinking, "Oh yeah, that sounds kind of like Uncle Fred or Cousin Mae." But do Uncle Fred and Cousin Mae have a disease, or are they just a pain in the ass? And then you'll think, "Well, Fred isn't exactly like that. A couple of those items don't describe him after all, and one or two others aren't exactly right." Research has shown that the diagnostic reliability of the personality disorders is poor -- people get different diagnoses from different clinicians. Furthermore, lots of people get a diagnosis of a little it of this, and a little bit of that. The person is avoidant with dependent features, that sort of thing. Exactly where to draw the line between your friend the drama queen and a person with the disease of histrionic personality disorder is impossible for anyone to say. Finally, there are no evidence-based etiological theories for most of these disorders.

So all of the above knocks the pins out from under any claim that these are labels for real entities. They are more like character sketches from novels, that resemble actual people to varying degrees, and the main reason for calling them diseases is to provide the required diagnostic label for billing purposes. That is not to say that people who have difficulties with social relationships might not benefit from counseling, and these frameworks might even prove useful as a way in to discussing the problem. I'm not saying nobody should ever talk in these terms, that's a more complicated argument.

However, I'm now going to surprise you (maybe) by saying that I find two of the personality disorders reasonably convincing. One is antisocial personality. It has a clear, well-bounded definition: lack of empathy, pervasive indifference to the rights and well-being of others. Something quite specific is missing which we expect a properly put-together human being to have. It is nevertheless rather odd to call it a disease since the person to whom the label applies probably doesn't think anything is wrong with (usually) him, and doesn't want to be fixed. I have discussed this at greater length in the past and will return to it.

The other personality disorder that pretty much works for me has the grotesquely wrong label of borderline personality. The term comes from a historical misperception that it was close to being a psychosis, since the person consistently fails to see certain aspects of reality which are evident to the people around (usually) her. My friend Gary Greenberg has argued that borderline personality should be thought of, not as a disease, but as a kind of moral judgment, much as homosexuality used to be considered a psychiatric disease essentially because of social disapproval. (I can't link to Gary's original article, which as far as I know is not on-line, so the link is to a discussion of his argument by Linda Nicolosi.) That is different from denying the ontological status of both conditions: homosexuality is obviously real, and Gary's argument presumes that borderline personality is just as real.

I agree with Gary about the latter assertion, but the former -- that it's only social convention that makes borderline personality a problem -- is one of those rare instances where we disagree. I'll take that up in the next post.


kathy a. said...

i tend to agree about personality disorders, since they generally describe personality orientations rather than potentially serious and disabling conditions. someone who is self-centered is not in the same boat as, for example, a mentally retarded person, a traumatized vet, a person who is hallucinating or suicidal, etc.

i have huge problems with antisocial personality disorder, though, because the diagnostic criteria are extremely broad -- some shrinks call it the garbage can of diagnoses -- AND because of how that diagnosis is used.

prosecutors routinely and methodically use ASPD as code for "born evil," using that as a springboard for arguing that an individual is particularly dangerous.

ASPD is an extremely easy amateur diagnosis to make in a serious criminal case. the majority of defendants arguably meet the criteria, even if it has never been diagnosed by a professional. but ASPD does not look at possible etiologies for behaviors [e.g., brain damage; severe trauma; major mental illness; substance abuse; circumstances surrounding a particular event], it simply brands a person evil.

where does that get us, using a diagnosis as a rhetorical club? it does not contribute to a fair assessment of guilt or punishment. it does not help us understand why crimes happen, so we can start looking seriously at prevention and rehabilitation. it *has* served the decades-long push for harsher punishments, resulting in the US being the only industrialized nation still using capital punishment, and the phenomenally high rates of incarceration in this country.

the borderline diagnosis suffers from a lot of the same problems. some shrinks think of it as the feminine version of ASPD; it is more often diagnosed in women, who are less likely to act out in ways attracting prosecutorial attention.

outside the context of prosecution, there is a certain usefulness in knowing [based on the pattern of past behavior] that particular individuals are going to mess with others repeatedly, not be able to see the consequences of their behavior, refuse to listen to reason, always blame others, always view themselves as right, etc. these may be generally high-functioning individuals; they may appear to casual acquaintances as "the life of the party," then savage one person after another behind closed doors, then complain of not being treated well.

in the context of a family, this is a person for whom nothing will ever be enough; a person to be held at arm's length; a person who will squander all available resources. a DSM label is not necessary, but it can help the afflicted decide: "no, the rest of us aren't crazy. no, i bear no responsibility for the problem du jour." etc.

Cervantes said...

The diagnostic label of ASPD, like any diagnosis, can certainly be overused, and I certainly do not believe that everybody who does bad things merits that label. In fact it's quite rare. Yes, it's often associated with head trauma in childhood, but not necessarily. I don't find it useful as a criterion for either moral condemnation or exculpation, and I am opposed to the death penalty under all circumstances so for me, it's irrelevant to that question. The complete lack of empathy is just a fact about some people, and it's a stark enough fact in my view to merit a specific label. As I say, however, I don't know whether it's helpful to call it a "disease."

I'll talk about BPD anon.

kathy a. said...

apologies for being windy on this subject. but there is something related i'd like to bring up.

the vast majority of crimes are committed by people under 25. a lot of solid, caring, productive adult citizens i know displayed antisocial behaviors in their teens and early 20's -- often when things were stressing them -- but that is in no way a measure of their whole personalities and lives. every parent who has been through the teen years knows that even the best and brightest kids can have undeniably awful moments, say and do jaw-dropping things.

there is a developmental explanation for these phenomena. the later teens and early 20's are, in most folks' experiences, times of transition and learning personal and social responsibility -- but it is not simply a time of social development. the prefrontal cortex, responsible for "executive" functions such as good decisionmaking, mediating emotional responses, etc., is still developing into the early 20's.

that is one of the reasons i think it is hideous to slap an ASPD label on a young adult criminal -- and a great many of them ARE very young. [another reason, as mentioned before, is that the label does not explain the overwhelming life problems that many such kids have faced.]

even a bleeding heart like me has limits, though, in my personal life. 'course, the particular relatives in crisis with which we are currently afflicted are near/at 50, have led privileged lives, and continue to be giant pains in the butt.

Anonymous said...

I never gave much thought to the personality disorders. I had a very difficult friend who I thought the world of and put up with indefinitely. I once had her over for dinner to meet a psychiatrist friend and his therapist wife. After that dinner, they discreetly inquired after her a few times over the next year. I was having a LOT of trouble with her and told my friend that, and he eventually confessed that both he and his spouse had actually felt from that one evening that my friend (herself an MD by the way) had borderline personality disorder. This totally opened my eyes. I got out my DSM-IV and read up and decided on my amateurish own that she really had narcissistic personality disorder. This explained almost everything to me about her behavior, which was classic NPD, and about why I was having so much trouble. It also caused me to realize that she not only wasn't going to change but that she was never going to even understand that there were any problems. So I don't know if this is "real" or not, but it really impressed me that I could read up on NPD and find paragraph after paragraph that seemed to perfectly describe my (former) friend, as though she really did have something specific. It helped me at least.