Personality disorders and PTSD
It seems I’m coming back to a theme which came up again in the context of my recent “Real Abuse”? post: personality disorders.
Earlier today, I ran across a relevant post elsewhere, and edited one note on that post, on referring to a close family member as a narcissist:
I still feel more than a little uncomfortable describing things this way, seeing some of the unsavory uses personality disorder diagnoses can be put to. I may not agree with the classification system–much less the way these categories are used to dismiss, discredit, and dehumanize people–but sometimes these descriptions really do fit better than anything else I’ve run across. I may not have much use for a lot of the assumptions underpinning the personality disorder characterization, but I have learned through hard experience that this person really does fit the description of a narcissist. I wish there were better terms available, with less baggage attached. Edit: I ran across a post at Narcissistic Parents which really seemed to fit here: The Question of Judgment. Some excellent comments, including this observation:
I was confusing “judging” with “witnessing”. I have witnessed a lot of bad behavior by the personality disordered people in my life. Observing the bad behavior, seeing it for what it is, remembering it, and using that knowledge to keep myself safe in the future is not judging. It’s seeing reality.
I still get uncomfortable pointing out that a lot of this person’s behavior is just plain wrong and hurtful. When it is, in a way that fits the description of Narcissistic Personality Disorder. (She has been diagnosed with at least one personality disorder.) I still half-expect to get jumped on and called a liar, just for pointing out that this person’s behavior is unusual and sometimes abusive–which is a pretty good indication that there is, indeed, a problem! But, besides the personal reluctance, I do have some pretty major objections to the framing of personality disorders as diagnostic entities. On top of my existing objections to the way DSM frames things, which I’ve written about before.
Some of these objections are summed up pretty well in a post I ran across today at The F-Word, Borderline Personality Disorder – a feminist critique. There are some excellent comments, as well.
BPD is a serious mental illness and is difficult to diagnose. Unfortunately it is also well-known as being used by psychiatrists and mental health professionals as a way of labelling ‘difficult’ or ‘problem’ patients – I know at least one woman who was threatened with a diagnosis of BPD by a mental health professional because she wouldn’t do as she was told.
Three-quarters of patients diagnosed with BPD are female.
As Briana wrote in comments:
I have actually heard some psychiatrists laughing about the joke “You know your patient is BPD when you want to punch them in the face.” leaving out the “hilarity” of assaulting patients, how the HELL is that diagnostic criteria? Fortunately, when my sister saw someone OTHER than an emergency room social worker, the label got taken off. I really do see it as a way to control patients with meaningless diagnoses. as said earlier, if there’s no way to treat it, no way to “recover” from it, what’s the point of giving the diagnosis? Especially because 90% of the criteria overlaps with tons of other disorders.
I am still more than a little surprised that I never got diagnosed with BPD myself, when I was still entangled in the psych system–and still identified with a label of bipolar disorder, since the two are frequently diagnosed together, particularly in women.* I knew an awful lot of women (online and IRL) in similar boats who were diagnosed with a side order of BPD. Basically as punishment for acting “noncompliant”, “manipulative“, and/or just plain uppity. If treatments for the presumed bipolar disorder were not working properly, sometimes a BPD label got added on to explain this away–and neatly dismiss whatever the patient had to say, ever again. I sure did have the “inappropriate anger”, for fairly obvious reasons if anyone had cared to look into this rather than just labelling it “inappropriate” and “inexplicable”. (The same with the “inexplicable” depression and mood swings, which were clearly happening in response to triggers.)
Reading the comments on the F-Word post only reinforces my impression that almost everyone who gets diagnosed with BPD is (a) female, and (b) has experienced serious trauma. Not absolutely everyone, certainly, but a suspiciously large proportion. And a lot of the criteria sound like the kinds of things you’d expect with PTSD.
In a number of the cases mentioned above, I now suspect that not just the things interpreted as BPD but a lot of the “bipolar” mood swings, etc. were coming from reactions to trauma. (All of the women in question were abuse survivors.) They certainly were in my case. I haven’t yet read Judith Herman’s Trauma and Recovery, but she apparently very specifically classifies BPD “symptoms” as Complex PTSD. As Frankie comments (emphasis mine):
She argues very convincingly that BPD is a special form of Post Traumatic Stress Disorder that people display after being exposed to trauma in childhood ie it’s not a valid psychiatric diagnosis but rather a set of normal behaviours in response to horrific events/ situations.
She suggests the reasons why women suffer from it more is not only because they are more likely to have been abused. But also, and I think this is the main point of her book, because they live in an environment which is frankly hostile to people who have been victimized. So their trauma remains unacknowledged or worse is derided and they never get the social support they need to recover their trust in other people /life /the world. And if this happens at certain stages of development like in childhood the result is bpd.
PTSD, especially from childhood trauma, is frequently mistaken for other things:
Diagnostic errors are common in the older child of trauma…Many of these older children are labeled ADHD, bipolar-polar [sic] depression, or any one of the anxiety disorders. Both young children and adolescents can experience poor sleep and nightmares, and may engage in what might look like destructive or abnormal behavior, which may actually be attempt to avoid people or situations associated with the trauma.#
It’s not just while they’re kids, either.
People with symptoms such as social avoidance, hyperarousal or anxiety may have also self-medicated their condition with alcohol to mute the symptoms and, as with active alcoholics, they may deny their drinking. Still other patients may experience mixed obsessive recollections with flashbacks and, at times, auditory and visual hallucinations. These patients may be mis-diagnosed as dissociative or psychotic.
Patients with severe insomnia, symptoms of hyperarousal, severe irritability and racing thoughts may be misdiagnosed as manics or hypermanic borderline patients (patients whose mania centers around a desperate fear of abandonment).
A careful interview is necessary to make an accurate diagnosis and discover new behavioral traits wich separate PTSD from other disorders. (Alicia, once worked with a psychiatrist at a major NY hospital who claimed to be able to accurately diagnose schizophrenia and other disorders within the space of a 3 minute interview!) Usually the patients are put on drugs, and very often the wrong drugs, as a result of these misdiagnoses.#
From NIMH (the page is about as full of medicalized awfulness as one would expect):
While less well known than schizophrenia or bipolar disorder (manic-depressive illness), BPD is more common, affecting 2 percent of adults, mostly young women…
Studies show that many, but not all individuals with BPD report a history of abuse, neglect, or separation as young children.8 Forty to 71 percent of BPD patients report having been sexually abused, usually by a non-caregiver.9 Researchers believe that BPD results from a combination of individual vulnerability to environmental stress, neglect or abuse as young children, and a series of events that trigger the onset of the disorder as young adults. Adults with BPD are also considerably more likely to be the victim of violence, including rape and other crimes. This may result from both harmful environments as well as impulsivity and poor judgement in choosing partners and lifestyles.
Yep, let’s blame some victims. This kind of goes along with one of Astrid’s recent posts, Study Blames Childhood Behavior Problems for Victimization to Abuse. Also, let’s ignore Occam’s Razor.
I was reminded again recently of this BPD/PTSD connection, reading Karen Rose’s absolute train wreck, Nothing To Fear. (I picked it up to fill out a Waterstones 3-for-2 deal, hoping for a decent thriller. Similar to remainder tables, this is sometimes a good way to try new authors. Sometimes you get doozies.) There was also what struck me as cochlear implant and autism fails**–among other things–but Rose came up with a baddie described as showing signs of BPD. Which will apparently make you go on revenge killing sprees; kidnap, torture, and drug children; and all sorts of other interesting things. Unfortunately, this book has a 4.5 star overall rating on Amazon, and this is not an unusual bit of a review:
The kidnapping of Alec is just the beginning of a chain of events that was so horrifying and creepy, I had to put the book down at times. Karen Rose writes evil so well, you feel like you’re in Sue’s head w/ her.
Another major (apparently recurring) character starts into a ridiculous “I should have recognized the warning signs that this woman is a monster!” routine. And yes, the words “monster” and “borderline” are used in close proximity. The signs mentioned? Things like flinching back from unexpected touch, getting a look in her eyes that other people did not like when touched without permission and condescended at, and the worst: having visible scars from self-injury, a sure sign of BPD and potential dangerousness. (“It’s all right. I recognized the potential for this kind of behavior when I saw the scars on Sue’s arms. It’s a common behavior in borderline personality types. They make some of the best manipulators you’ll ever meet.”) In short, some of the same kinds of things that convinced mental health professionals that I’d been abused. And, indeed, the sociopathic monster with BPD is described as having been severely abused over a long period of time, both as a child and as an adult in prison.
The real kicker? Said diagnosing character runs a shelter for battered women and their children. And is surprised when someone flinches back from being touched without warning or permission. And interprets this in very negative ways. The author apparently also thinks it’s OK to do things like lift people’s chins and force eye contact, besides generally touching people without any permission whatsoever. Faily fail fail all around.
The generally good reviews say a lot about attitudes toward (and knowledge about) “personality disorders”. Dehumanization based on/backed up by a label sells.
One thing I have kept coming back to in my own experience with someone(s) fitting Narcissistic Personality Disorder criteria? This cluster of behaviors is associated with childhood trauma:
The onset of pathological narcissism is in infancy, childhood and early adolescence. It is commonly attributed to childhood abuse and trauma inflicted by parents, authority figures, or even peers. Pathological narcissism is a defense mechanism intended to deflect hurt and trauma from the victim’s “True Self” into a “False Self” which is omnipotent, invulnerable, and omniscient. The narcissist uses the False Self to regulate his or her labile sense of self-worth by extracting from his environment narcissistic supply (any form of attention, both positive and negative)…
The prognosis for an adult suffering from the Narcissistic Personality Disorder (NPD) is poor, though his adaptation to life and to others can improve with treatment.
BPD is also associated with the idea of a “False Self”.
The hell of it is, as disrespectful as a lot of these descriptions are, I can see how they fit my grandmother. Who, as she has gotten older and her dementia has lowered a lot of inhibitions, has started talking about some of the emotional and physical abuse she suffered growing up, rather than pretending that her family was perfect. Just what she is willing to talk about–and what her younger sister has let slip over the years–sounds horrendous, and I can see why a person might turn out acting strange in response to that kind of trauma. I have more compassion than I might have otherwise; her world is a really freaking scary place to live. The same with my stepdad, who also shows a lot of narcissistic behavior; his father was a real piece of work who abused everyone in the house.
But, that doesn’t make their behavior OK, as it impacts other people. Neither one of them would ever admit that there is a problem, thus the “poor prognosis”. When strong defensiveness is kinda built into your trauma reactions, you’re likely to find the prospect of change–or even the idea that maybe things are not OK–very frightening. Even trying to keep compassion in mind–and avoid engaging when baited/provoked–I have had to go low- or no contact with both of them, for my own mental health. It is not a good situation for anyone involved. Including them.
IMO, the badness of this kind of situation is only compounded by calling people’s responses to trauma “personality disorders”, and chucking them into the incurable bin. Not that “cure” is a useful model in most cases, anyway. But a lot more could be done to help people deal with their everyday lives and their trauma reactions (as in my recent “Artistic temperaments”, mental health, and balance DW post), were they not getting dehumanized and dismissed. And sometimes overmedicated for misdiagnoses based on various sorts of bias. I know I would probably get some extra resentment going to the idea that I needed some help, were it framed in terms of an almost irreparably damaged personality, rather than understandable reactions to bad things that have happened in my life. The same goes with PTSD as presented; that places the problem squarely on the victim, who is considered disordered, rather than on the traumatic situation(s) and very real injuries.
That is one of my major problems with a lot of the ways in which labels get used: the label is taken more seriously than the human being wearing it is. And words mean things.
As polly put it:
I’ve been told by my doctor that what I was quite sure were menopausal symptoms were ‘reactive depression’ because I was ‘too young’ to be menopausal. The point being I could insist on a blood test that immediately proved him wrong, and me right. (He actually apologised, which is the first time I’ve ever heard a GP do that).
Would I have been listened to though, if I was in the psychiatric system by then? I doubt it. Suppose I hadn’t been able to work out what was wrong with me myself, and been referred to a psychiatrist for my ‘depression’. Would my insistence that I wasn’t depressed be taken as a sign of a personality disorder? (Argumentative, think I know better than the doctors etc).
Exactly. I have been on the wrong end of that one multiple times, and really do not want to treat other people with that kind of disrespect and dehumanization. I wish there were more neutral terms readily available and understood.
I also ran across a good post at Modus Dopens, Don’t have answers., involving just some of the dodgy uses to which the DSM/ICD continue to be put:
Notably, there is no disorder of Being An Unmitigated Heterosexist Shit Disorder, so we can safely conclude that heteronormativity is a factor here…
But what exactly is wrong with all the other people who are pathologised by the DSM? Is there something wrong with asexual people? With people who have non-heteronormative sex? Or people with non-sex/gender DSM diagnoses like…autism? As long as the protest chant is “trans people aren’t crazy”, there’s an unspoken rider: “not like those other people, who are“.
Edit: And another from the WordPress “Related Posts” feature, which is actually related: BPD/DSH 9: Unstable relationships:
In the following few posts I hope to show how the very issue of trauma contributes to the criteria above and how, far from being a list of symptoms in their own right, they are all simply different different reactions to the original trauma. In essence the criteria for Borderline Personality disorder are little more than a description of a traumatised individual.
Another interesting one in that series: BPD & DSH 2: What is Personality Disorder?:
An even more primitive forerunner of modern ‘personality disorder’ diagnoses was the now defunct categorisation of ‘moral defective’…
Even back in Edwardian England it was apparent that the diagnosis had little to do with actual ‘disorder’ and a great deal to do with social ideas about acceptability, deservingness and expediency…
What we have instead are judgements about behaviours. Some behaviours are thought to be ‘normal’ and some ‘abnormal’. However they remain no more than behaviours and coping strategies.
Alongside these we have judgements about what sort of emotions are ‘normal’ and the degree of emotional control that people are expected to exercise. People who fail to live up to the expectations of the psychiatric manuals, either because of their thoughts, their feelings or their behaviours are labelled as having a personality disorder of one type or another…
So there is value in classifying different personality traits and types because it helps us to work with people. However when personality classification strays into value judgements and decisions about ‘deservingness’ it becomes a very dangerous ‘double-edged sword’.
* “In a retrospective study of 35 bipolar patients, 40% met criteria for borderline personality disorder….Similarly, results of a double-blind placebo-controlled pilot study suggest that divalproate may be safe and effective in women with borderline personality disorder and comorbid bipolar II disorder, decreasing irritability, anger, volatility in relationships, and impulsive aggression” # Interesting what they’re considering the most serious problems there.
** Apparently, in Karen Rose Land, it’s almost understandable to embezzle $50,000+ in order to get your kid cochlear implants and full-time speech therapists to teach him to use them. And feel guilty for not being able to afford this earlier. You’d easily get the idea that they’re not controversial in any way. And it’s a relief to find out that the kid who won’t make eye contact as expected is deaf, rather than autistic/otherwise severely disturbed. Yeah, I don’t think I’d get along well with this author. Especially if she tried to grab my chin, like my fourth-grade teacher.