The Most Intimate Disease: a Primer on Personality Disorders
There are many ways to partition up, compare, and reorganize again the various mental disorders that clinical psychologists are familiar with. Obviously.
One of the qualities we might look at to distinguish some type of mental disorder from another is something that I can only think to call ‘intimacy.’ It’s an abstract type of quality, such that it might be best to jump straight into a concrete example to get at what I mean.
Consider mood disorders, one broadly recognized broad category of mental disorder which includes things like Major Depressive Disorder and Bipolar Disorder. When someone has something like Major Depressive Disorder, I think it’s almost always true that their disorder can be described as an ‘intimate’ part of their self and their life. In the sense that Major Depressive Disorder affects things like emotional affect, thought pattern, sexual drive, job and academic performance, physical activity, weight, — and on and on. A person’s depression follows them through, and therefore touches upon, almost every area of their life. Of course, a disorder of a more physical sort — say, gangrene of the foot — could have all of these effects as well, while still seeming less ‘intimate,’ less a part of a person than something like depression might. I think this has to do with a pretty familiar cultural assumption — that our self, whatever it is, has a lot more to do with our minds than our feet; that our bodies are like the carrying-cases of our selves more than anything else.
So maybe that’s another explication of what I’m saying when I say ‘intimacy’: intimacy is something like closeness-to-self; intimacy increases as the sense that what we’re talking about can’t be pinned on anything else but our selves increases. In the case of the gangrened foot versus MDD, we might view the effects of the former problem as being the completely normal reaction of a person — a self — to something being painfully wrong with their body. We can easily attribute the difficulties this person is experiencing to an unambiguously physical problem — a problem that is publicly viewable and, because it only has to do with their body, seems like it’s outside themselves (in the strictest sense of ‘themselves’). Christopher Boorse, a philosopher of medicine whose ideas have already been and will continue to be shamelessly borrowed throughout this essay, has written that this sense of separation is illustrated by the way we blame (or rather, don’t blame) people with illnesses. We may fault someone for things they did or didn’t do to prevent the illness, but we don’t usually fault someone for the actual effects or course of the illness once it takes hold. The doctor in the ER may tut at the patience’s waiting so long to seek medical help for their wounded foot, which lead to the gangrene —and they tut because seeking help was something the patients themselves could control — but the doctor will never blame the patient for (forgive me) the fluid discharge that comes from the wound — because this was something the patients themselves cannot control. It is a mechanical problem with the body the patients themselves are in.
So now, hopefully, using a term like ‘intimacy’ to compare a mechanical problem like gangrene of the foot to a less straightforward problem like MDD will make more sense. MDD is more intimate in the sense that it’s not as easy to attribute its difficulties to something clearly outside the self; it is after all officially called a ‘mood disorder’ to designate that it’s a problem with someone’s emotions, which again I’d wager sounds closer to themselves than their foot tissue does.
We might say that this is only superficial: we might say MDD is actually quite like gangrene of the foot in that it too is a problem that’s mechanical in nature. Whereas gangrene of the foot is the result of the loss of blood circulation and tissue death, MDD is the result of serotonin being recycled at synapses in an unusual way. This is precisely how the most common type of drug used to treat depression, SSRIs, work, after all.
But of course almost no psychologists believe that MDD is only a function of the way serotonin is treated at synapses, and SSRIs alone rarely work to completely treat MDD— which we’d expect them to be able to do invariably, if the disorder was only caused by irregularities in a person’s brain chemistry. Other things — like the experience of childhood trauma and other stressors, learned behaviors and habitual ways of thinking — are part of the etiology, the causes of MDD. How do we fit these into the same format that characterizes gangrene of the foot? Something that’s associated with depression for instance is called ‘loci of control’ — it refers to the extent to which a person believes they have control over the outcomes of their life. Generally speaking people with an ‘external’ loci of control — in other words: people who believe that the outcomes of their life are largely determined by forces they have limited control over — tend to be more depressed. So here is something that is a part of a person’s worldview; here is a fundamental attitude they have. Surely we can’t frame this in a way that makes it seem like a loci of control is something that a person ‘reacts to’ or ‘suffers from’ — rather, a loci of control is something that the person themselves produces.
So MDD is more intimate than gangrene of the foot. MDD is more closely enmeshed with the person who suffers from it than gangrene of the foot is. It is more closely enmeshed — more intimate — because it’s harder to separate MDD from the substance of the person themselves.
And we still haven’t spoken about personality disorders.
For starters, there’s the ‘personality’ in personality disorders. You don’t have to be a stoned sophomore to wonder, genuinely, what the word really refers to. Is there such a thing? Doesn’t psychology teach us that the situations people are placed in have a direct effect on their behavior? Maybe even a predominant effect? What does personality mean if we could act completely differently from one scenario to the next?
Psychology, like all social sciences, is awash with theories, many of which seek to explain the same phenomena, and so end up publicly disagreeing — for example, the person-situation debate, which is over the questions asked above, more or less.
Without wandering off the trail of the topic we’ve been following, it would be helpful to briefly sketch how it is that something that calls itself a science can have disagreements as striking as this. These disagreements, in my own experience, are some of the things people point to most often when tossing aside the social sciences and psychology in general — let alone the narrow corridor of it we’re exploring now — as a bunch of bullshit, more or less. So:
The coexistence of theories which seem to offer contradicting, and even mutually excluding explanations for the same fact is, itself, explained by the nature of the things a science like psychology studies. Behavior, attitudes, perception, sensation, and on down the line — these are the effects of a confluence of causes; they are aggregations of many factors coming together. It may be helpful to draw an analogy from a field with a much easier conscience when it comes to being ‘scientific,’ and which is of increasing importance to psychology: genetics.
Uncounted students over the years have been acquainted with Father Mendel and his very illuminating pea pods. There’s an attractive logic to Mendel’s results: we can see in simple tables the circumstances in which the gene for some shape or some color will be passed down, and under what circumstances it will actually be expressed in an offspring. Dominant and dominant, dominant and recessive, recessive and recessive. Of course, while this makes for a good introduction to the general idea of genetics, many of the features we all exhibit — features which are so much more minute and finely grained than ‘color’ — are actually polygenic, i.e. the product of two or more genes interacting with each other in some way. There isn’t a ‘nose gene,’ for instance, or a gene for how tall you’ll be; there are, instead, sets of genes, all meant to influence a variety of different factors — the production of proteins for carrying nutrients throughout the body, proteins involved in metabolic actions of some particular type of cell — which, in sum, cause you to have the nose you do, or be as tall as you are.
So we come to things like some given person’s behavior at some particular time, and we can see, hopefully, how it can be the additive effect of many different factors coming together, many of which are of a very different character from one another. Psychological theories emphasize some factors over others in their explanations of phenomena — as they can’t help to; theories are almost never as reductionist as they’re made out to be in textbooks — and very often the factors emphasized by one theory carry very different implications for the phenomena being explained than the factors emphasized by another theory. Public debates both acrimonious and civil bloom from the differences between these implications.
I’ll write another long meandering essay about this some other time, but for now we have a pretty good foundation for understanding what’s being talked about when we talk about ‘personality,’ and more specifically, ‘personality disorder.’ Personality psychology as a field is, like psychology more generally, awash with theories and paradigms, but the theory which right now seems to be the best accepted (and therefore, hopefully, the likeliest to be true) is trait psychology.
Trait psychology posits that a person’s personality can be described — not that it is, and only is — but that it can be helpfully described, in the broad strokes, with references to the various traits (dispositions to act in certain ways) that a person exhibits. The most well-accepted and used trait model today, for instance, the Five Factor Model, describes personality at the broadest level in terms of five factors or ‘domains’ of personality: Openness, Conscientiousness, Extroversion, Agreeableness, and Neuroticism (OCEAN). These five factors, and the six more specific ‘facets’ each one of them has, can give a general description of someone’s personality, insofar a personality is a set of dispositions to act (or think or feel) in certain ways.
Personality disorder, then, is a problem with these dispositions, these tendencies. It’s not defined so much by specific, immediately present symptoms like the negative affect, the anhedonia (look it up), and the lack of motivation of depression. Rather, it’s defined by more permanent and chronic tendencies which cause harm to the person and to others, like the tendencies to deal in absolutes and to act impulsively which characterize borderline personality disorder.
Taking our idea of intimacy — which here, again, is a function of the difficulty of attributing some problem to something outside the-self —we can see, at the end of this, why personality disorders are the most intimate, and therefore some of the most difficult diseases, difficult to think about, to live with, to treat. If loci of control was hard to disentangle from a person themselves how hard must something like traits be? The consistent dispositions we have to act in certain ways — how much closer to self can you get? Beliefs, maybe? Something like a ‘worldview’? But wouldn’t these things themselves be downstream from a person’s traits, the basic dispositions which can’t help but play a powerful role in how that person evaluates and selects different beliefs, ideas about the world?
But more importantly, what is all of this for, anyway? The only conclusion on the horizon of all of this seems like a potentially problematic one. It would seem to be the conclusion that, if this is what intimacy is, and personality disorder is indeed the most intimate disease there is, then the amount of understanding or leeway we should give to someone is inversely proportionate to how intimate their problem is, and people suffering from personality disorder, accordingly, should be lent the least leeway of all. Isn’t that only intuitive, if we end up saying that personality disorder is basically a problem with (some part) of someone’s self?
That would be assuming a very hardheaded view of many weighty topics like free will, suffering, and mercy, and while I won’t even touch on these subjects here I’ll say it’s not the view I take. Without being quite as on the nose about it as I am above, many figureheads of anti-psychiatry from the middle of the last century to the present day maintain a similar position, and deny that things like personality disorders should be viewed in the same way things like gangrene of the foot are. They argue that the term ‘personality disorder’ is an attempt to medicalize what is in reality much more mundane: problems some people just have in living life. Some people just deal in absolutes and act impulsively — we shouldn’t try to turn that into some kind of disease (they say.)
None of them, however, to my knowledge argued that people who behave this way should go unhelped. People like Thomas Szasz wrote about these topics always with the ultimate intention of making help better, clearer-sighted: in some broad way, I hope that this writing can do the same. Personality disorders were, until only recently, some of the least validated constructs in the DSM. Diagnoses of personality disorder, for instance, have been shown to be remarkably unreliable, e.g. one clinician may diagnose someone as having borderline personality disorder, and another clinician, one year later, may not diagnose that same person as having BPD. Reliability is one of the most basic hurtles that psychological constructs and models need to clear to establish validity, and while PD research has made great strides since the article I just linked to was published, the field remains characterized by a general sense that there are still many fundamental questions in play about what PDs are, strictly speaking, and how they might be treated, classified, and organized. They remain a puzzle, which — without waxing too, too poetic — I think I can say makes sense, since we’re saying that they’re the disorder most directly related to the cavernous, unplumbed, non-Euclidean menagerie that is the self. I’d hope that idea would engender compassion more than it would callousness.