I have just been cured of a major mental illness. The cure was cheap, effective and instant. And the original diagnosis did not involve any ‘road to Damascus’ experience after hours on the couch, years of painful soul searching in therapy, or complex cognitive behavioural therapy. No drugs or surgery either — NHS executives take note. I have a real cure, which is not a word clinicians like. They prefer ‘treatment’, or better still, the ‘management’ of a mental illness (as with something like diabetes, where there is effective management, not total cure). The secret? Simple — abolish the illness. I am cured because my disorder has been declassified. It is no longer a sickness, illness, or disorder. It is okay to have it.
Psychiatric diagnoses have always been difficult and unreliable. This is one of the major reasons why illnesses seem to come and go. It was said that the best way to cure schizophrenics in America in the 1960s was to move them to England, where they would be considered merely ‘eccentric’. And it remains true that schizophrenia is still diagnosed less frequently in the UK than in the US. America has always dominated the psychiatric world.
Americans might not be too eager to accept that mental illness could be culturally determined, but in the UK we have tended to import their illness in much the same as we have embraced their taste in personal injury lawyers, sitcoms and diet. In the US, someone might be regarded as socially unskilled, unassertive and emotionally repressed; in Japan, the exact same behaviour might be considered simply demure or polite.
Psychiatrists have a tendency to colonise and pathologise behaviour patterns. New syndromes appear, the diagnostic manuals grow larger with each new edition. Naughty children now have attention deficit-hyperactivity disorder or adolescent defiant disorder. All sorts of behaviour previously thought of as selfish, immoral, even shameful, now gets nicely medicalised with a label that can be seen to excuse it. And soon there will be pharmaceutical companies with appropriate drugs to cure these new illnesses.
The DSM-II declared that homosexuality was a mental illness, and set out criteria by which people of that persuasion could be definitely diagnosed
Psychiatrists rely on an expanding and ever more complicated book for their diagnoses. The fifth edition is due out in May, and it’s called the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association. The group of experts who have been working on this edition have been labouring for a decade. They include all the great names in various areas of specialism. And yet the whole endeavour remains highly controversial. The new edition’s criteria are far more evidence-based than ever before. That is, assertions cannot be made without providing good empirical evidence to support them. It seeks to make diagnosis — an issue that still vexes the whole field — more accurate and reliable.
Psychiatrists are now made acutely aware of the biases and errors in previous editions of the tome. For example, DSM-II, published in 1968, declared that homosexuality was a mental illness, and set out criteria by which people of that persuasion could be definitely diagnosed, though not ‘cured’. In some areas the manual has, over the years, been trimmed rather than expanded. One key area is that of the personality disorder. While psychologists and lay people alike tend to discuss personality traits or types, psychiatrists prefer to discuss disorders. So while we might say ‘he is extraverted’, ‘she somewhat moody’ and that lot just ‘outright disagreeable’, psychiatrists have personality disorders — deficits in developing a sense of identity and establishing relationships.
The various lists of these disorders have changed over the years, just as cultural norms and deviations themselves have. The powers that be at the DSM claim that passive-aggressive behaviour is now so common in the wider population that it is no longer deemed ‘abnormal’. The previous edition of the manual, technically referred to as DSM-IV-TR (fourth edition, text revision), published in 2000, had a dozen of these disorders that fell into three groups, variously labelled. The most memorable criterion was that of being seen to ‘move’ (both emotionally and indeed often physically) away from, against, or towards people. The psychopath moves against others, the dependent personality moves away from people, and the borderline personality moves towards (and often into) others.
In the DSM-IV (1994) there were 10 agreed personality disorders. They were put in three clusters: odd and eccentric; dramatic, emotional and erratic; and anxious or fearful. The most recent manual, however, has only five disorders. Moreover it stresses that there are two very neat and pervasive features that underlie all disorders. The first is the ability to form and maintain relationships: or, in psychobabble, to ‘develop effective interpersonal functioning’. In short, can you make and keep friends at work and play over a significant period of time? The second is the notion of being self-aware. That is, are you insightful and realistic about your personality, appearance, skills and gifts? If not, the jargon says, you have an ‘impaired sense of self-identity’.
While one doctor was clear that a patient was schizoid, another deemed him merely ‘a cold fish’, and a third said he was ‘just a typical actuary’
And yet, at times we all struggle to maintain relationships, at work or in our private lives. Similarly, knowing ourselves and being realistic about our abilities is something we often wrestle with at various stages in life. Indeed, psychiatrists have often found it hard to come to agreement on specific diagnosis. While one doctor was clear that a patient was schizoid, another deemed him merely ‘a cold fish’, and a third said he was ‘just a typical actuary’. But perhaps one of the problems in this diagnostic model is the issue of co-morbidity — that is, having more than one disorder at the same time. For instance, it is (or was) not uncommon to read about people who have clinical narcissism while also being psychopathic. Co-morbidity, in many respects, makes the very notion of defining clusters or specific types of personality problematic. Human beings are more complex and dynamic than an inflexible diagnostic definition.
Yet over the years clinicians have become experts on a few of these disorders. Some attracted a great deal of research (such as antisocial or borderline disorder); others seemed pretty much ignored. No surprise there really — some disorders are simply ‘sexier’ than others. Who wants to ‘play with’ an anhedonic — a socially withdrawn, intimacy-avoiding schizoid person, or a submissive, dependent patient, obsessed with fear of loss?
Mental health is about degrees on a spectrum rather than rigid categories, and so tests to measure disorders developed. There are multiple tests for the more popular personality disorders. More importantly, some discerning psychometricians developed what are called ‘dark-side’ measures that are based around 11 or 12 categories of behaviour. The idea is simple: many people (who might otherwise experience ‘good mental health’) under stress or at times of crisis behave in ways that look very much like the typical behaviours of those with specific personality disorders. Some become obsessive when faced with an unknown future. Others could become a tad paranoid after being victims of crime. Others avoid company when grieving a death.
These ‘dark side’ measures have spawned numerous popular psychology books on issues such as leadership derailment and failure. It’s all about trying to understand pathological behaviour through the lens of the personality disorders. You take the test to become aware of your own potential dark side. I’ve used these dark-side tests extensively and have rarely encountered a successful senior manager or leader without — how to put this politely? — rather a lot of mud at the bottom of the pool. Many have a profile that suggests multiple ‘dark side’ habits, from sudden total withdrawal from all social intercourse in a crisis, to Machiavellian manipulation to achieve one’s end.
But let’s get back to me. Of course, I too had to take the ‘dark side’ test. I had only one strong dark side. You see, doctor, I have — just a touch of — histrionic personality disorder (HPD). Odd, really, as it’s most often seen in theatrical ‘luvvies’, and in women more than men. My feedback report told me that I seem colourful, quick-witted and socially skilled; that I often over-commit myself; that I might not listen well to others and don’t like details. And that my ‘tendency to get swept up in the moment might cause [me] to forget to share credit and celebrate successes, big and small’. Furthermore, I am ‘an engaging person with a talent for self-promotion, but might not value self-development as a priority for either [myself] or [my] staff’. These observation are, I have to admit, too true.
There are various diagnostic criteria associated with HPD. The essence of the disorder is attention-seeking and self-dramatisation. I do recognise some symptoms — but only some — in myself. Of course, many clinicians would say the mere fact that I am writing this article is itself sound evidence in support of the diagnosis. But perhaps this explains why I feel so bereft, now that HPD has been dropped from DSM-V. I can no longer be a patient, a victim or even an interesting case study. I am cured. I am well. And the reason for this change?
So farewell hysteria. These days it’s okay to let it all hang out
Essentially threefold, but I prefer the first. That is, those with the disorder showed no reduction in quality of life or social functioning. Indeed the reverse: histrionic personality disorder is associated often positively with status and wealth. Think not just psychology professor such as me but actors, politicians, TV personalities, journalists, motivational speakers and barristers. Cultural shifts now encourage us to think of such behaviour as a gift, or an asset to be exploited. We should celebrate an ability to ‘colour’ everything with emotion.
Secondly, the various ‘parts’, ‘facets’ or ‘behaviours’ thought to characterise HPD did not hold together very well as a cluster. They did not form a coherent, observable, syndrome. Thirdly, biological and genetic studies have uncovered no factors of any note. This disorder is rather unstable, it seems, and the ‘symptoms’ are associated with other disorders as much as with each other. So bye-bye hysteria. These days it’s okay to let it all hang out.
And so I am cured. I no longer have HPD. No dark side. No worrying derailment potential. I can enjoy the ‘am-dram’ of lecturing, and the confessional aspect of being a columnist and the ‘star’ at dinner parties. Many years ago, my career guidance teacher said the test results indicated that either journalism or law would suit me best. He was, I now concede, half right. If you can make friends and are realistic enough about who you are, it is quite okay to be a little HPD.
But perhaps it’s too easy to pour scorn on the DSM and its attempt to provide the ‘periodic table’ of mental illnesses. If you look back to earlier editions, there is no doubt that we are making progress. If you have ever attempted an in-depth assessment of another adult, say a job applicant, you immediately become aware both of the complexities of human beings and their contradictions. Things just don’t seem to fit together easily. It is tempting to ignore some information and exaggerate other bits to come up with a ‘coherent’ story — a whole person. You can see this temptation at work when psychiatrists and psychologist are asked to comment on (read ‘explain’) the evil behaviour of individuals. Think of the Norwegian mass murderer Anders Breivik and the debate as to whether he was ‘insane’ or not.
Moreover, there is another group who really benefit from these diagnostic systems. It is those who live with, are married to, or who work for, those exhibiting a disorder. We know that what is now called ‘mental health literacy’ is poor — that is, knowledge and beliefs about mental disorders that aid their recognition, management or prevention. Most people can recognise depression in others as well as obsessive-compulsive disorder, but they are surprising ignorant about the more dangerous personality disorders: the anti-social personality disorder (the psychopath) and narcissistic personality disorder. There are now numerous popular books on both these disorders that try to explain to people why those they know behave so egocentrically and without guilt. To be given a diagnosis with a set of suggestions about how to deal with these ‘difficult characters’ really helps. This is all the more apparent when you see the books on offer to help bewildered and frustrated managers try to understand some difficult colleagues.
A quick survey of Amazon throws up some wonderful titles: Jerks at Work: How to Deal with People Problems and Problem People by Ken Lloyd (1999); I Hate People!: Kick Loose from the Overbearing and Underhand Jerks at Work and Get What You Want Out of Your Job by Jonathan Littman and Marc Hershon (2009); Since Strangling Isn’t an Option…: Dealing with Difficult People — Common Problems and Uncommon Solutions by Sandra Crowe (2004). After reading any of these titles, one can’t help but be impressed by the DSM systems and their persistent attempt to help people understand one another better.