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What’s In A Name?

Simone Hoermann, Ph.D., is a Psychologist in private practice in New York City. She specializes in providing psychotherapy for Personality Disorders, Anxiety, and Depression ...Read More

Many of the people I work with, unfortunately, still encounter a lot stigmatization around their mental illness. Many of them are also struggling with their own feelings about having a mental illness, and with having to find ways to cope and get better. Psychoeducation, that means, telling people what the problem is and what can be done, is an element of treatment that can be very helpful.  Many people find it important to understand the course and prognosis of their illness, the available treatments, and potential side-effects. Knowing what one might be able do to help oneself, or what to avoid in order to not make things worse, can feel incredibly empowering.

Specifically with personality disorders, the question as to whether or not it is helpful for the patient to know their diagnosis remains somewhat controversial amongst clinicians, and also amongst patients and families. Very understandably, a lot of people have a strong emotional reaction when they first are told they have a “personality disorder”. Many people feel embarrassed and ashamed, and have a feeling as though there is some fatal flaw within them. The name of the disorder, unfortunately, sends the message that there is something terribly wrong with who they are. For this and many other reasons, a lot of clinicians are reluctant to share the diagnosis with their patients. The clinician may not want to hurt the patients’ feelings, they may afraid the patient might become angry or might leave treatment.  Sometimes, the clinician may not be sure about the exact diagnosis, or may not work within a model that places a lot of importance on psychiatric diagnosis. On the other hand, many people also find it helpful to know that there is a name for the problems they are struggling with. I’ve seen people’s relief when they realized that the difficulties they were experiencing were defined, describable, recognizable problems, that there were other people like them out there, that there are defined treatments for these conditions, and there was a whole line of scientific research on these issues.

So, what about that unfortunate term “personality disorder”? Different types of personality have been described since the ancient Greeks, and diagnostic systems that originated in Europe in the early 1900 have described different temperaments and personality types. Around the mid-1900, some clinicians thought that some of the difficulties that were not frank psychosis were merely willful behavior or weakness of character. Freud and other psychoanalysts viewed personality disorders, also referred to as character disorders, as fixations in early developmental stages and as quite resistant to change. During about that same time, there was a lot of confusion around psychiatric diagnosis and diagnostic systems, so the American Psychiatric Association devised the first incarnation of the Diagnostic and Statistical Manual of Mental Disorders (DSM), which reflects a view of personality disorders as patterns of behavior that were quite resistant to change, but not connected to a lot of anxiety or personal distress on part of the patient.

Let me spare you a detailed history of all of the iterations of the DSM, and subsequent changes in view. Suffice to say that in the DSM III, personality disorders were assigned a separate diagnostic axis, which was supposed to include difficulties that were separate from the more episodic clinical syndromes on axis I and indicated a more lifelong style of functioning.  The placement of personality disorders on axis II had the advantage that it sparked a lot of research on personality disorders, and subsequently helped improve diagnostic criteria and treatment. Much controversy nowadays exists around the question whether personality disorders are distinct categories or reflect dimensions of personality traits.

Based on emerging research, many researchers and clinicians these days propose to abandon the concept of a personality disorder, and suggest that certain, if not all, personality disorders be moved to axis I.  For instance, the prominent researcher and psychiatrist Dr. Antonia New suggests that Borderline Personality Disorder constitutes a pattern of emotional and behavioral dysregulation that stems from an interaction of genetic vulnerability and environment with important neurobiological components, and proposes to rename it Interpersonal Emotion Regulation Disorder. For Dr. New’s 2007 talk about renaming BPD, view the website of the National Education Alliance for Borderline Personality Disorder. Similarly, some researchers suggest that Schizotypal Personality Disorder is a in fact a Schizophrenia Spectrum Disorder, and that Avoidant Personality Disorder should and could be diagnosed and treated as Social Phobia. Exactly what will happen with the new incarnation of DSM V remains to be seen. Let’s hope, though, that there will be a move for the stigma associated with mental illness to be reduced.

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