Let’s Not Dis Personhood

“A personality disorder is anyone I don’t like”

This was a comment made by one of my first teachers when I started psychiatric training. He was in his mid-70s at the time and knew the writings of Kohut and Kernberg. He meant the statement facetiously, cautioning me, a first year resident, to use such a diagnosis with awareness.

After 30 years being a psychiatrist I still bristle at having the words ‘person’ and ‘disorder’ so close together.  Words have power and are an important tool for psychiatrists.  Over my career I’ve met individuals who’ve been told “You have ________ (insert DSM personality label – usually Borderline or Narcissistic) Personality Disorder”.  For a few this was helpful and made them feel they weren’t alone with the problem. For others being given such a label triggered a sense of hurt and even shame that lasted for years.

I do not object to the construct of personality disorders (PD).  I accept that there are individuals who are emotionally more or less sensitive than optimal, that have difficulty putting themselves in others’ shoes, who find themselves caught in longstanding patterns of behaviour that don’t serve them or those around them well.

It’s not the diagnosis, it’s the language.  We’re taught to first, do no harm.  Language matters and words can hurt.  It’s time to find better language.

Psychiatry has a long history of using terms that later become so stigma-laden that we leave them behind – think of the terms used for persons with intellectual challenges in the 18th century which included idiot, imbecile and moron.  These were diagnoses, not insults, at the time.

Diagnoses are a means of shorthand.  They distill complex ideas into a few words and allows for more efficient communication.  But it has a downside; it allows us to condense many concepts, feelings and biases into just a few words.

When I hear clinicians using the term ‘personality disorder’ it’s usually laden with judgement and judgement of something very deep, of the essence of the human being.  Patients aren’t just being overly sensitive in feeling hurt and shame when told the label; they know they’re being judged as people. Often clinicians are talking about them critically, even mockingly, behind their backs.

Some might point out that denying patients ‘honest’ information around diagnosis deprives them of information they need to effect change.  Do we want to be like physicians of the past who would avoid using the word cancer due to stigma?  Yet cancer and personality disorder are different in how closely they reflect on one’s personhood.

All too often clinicians talk of personality disordered patients with derision and disdain. My sense is that such talk is frequently a reflection of the clinician’s frustration with trying to work with the individual and expressing a sense of powerlessness that the patient/client will ever change.  Yet I cannot imagine oncologists sitting at rounds and talking derisively of patients with cancer for whom they do not yet have effective treatments.

It’s hard to cultivate compassion for persons who seem responsible for their own pain.  Clinicians’ feelings of frustration are inevitable for any but the most sainted among us.  At the same time I’ve never met someone with severe personality pathology who enjoys the intense emotions, the roller-coaster feelings and troubled relationships.  Their suffering is real!

Hopefully my frustration will not come out in the form of hurtful words.  It should however drive me to strive to overcome my still many limitations as a clinician.

Shalom Coodin

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