Is A PD A Mental Illness.

[LadyMacbeth]

This information was taken from the British Journal of Psychiatry.

REVIEW ARTICLE

The distinction between personality disorder and mental illness

R. E. KENDELL, FRSE

University of Edinburgh, 3 West Castle Road, Edinburgh EH10 5AT, UK

Background Proposals by the UK Government for preventive detention of people with ‘dangerous severe personality disorders’ highlight the unresolved issue of whether personality disorders should be regarded as mental illnesses.

Aims To clarify the issue by examining the concepts of psychopathy and personality disorder, the attitudes of contemporary British psychiatrists to personality disorders, and the meaning of the terms ‘mental illness’ and ‘mental disorder’.

Method The literature on personality disorder is assessed in the context of four contrasting concepts of illness or disease.

Results Whichever of the four concepts or definitions is chosen, it is impossible to conclude with confidence that personality disorders are, or are not, mental illnesses; there are ambiguities in the definitions and basic information about personality disorders is lacking.

Conclusions The historical reasons for regarding personality disorders as fundamentally different from mental illnesses are being undermined by both clinical and genetic evidence. Effective treatments for personality disorders would probably have a decisive influence on psychiatrists' attitudes.

The legislative background

Psychiatrists, and perhaps British psychiatrists more than most, are ambivalent about whether to regard personality disorders as mental illnesses. Until recently, there was no compelling reason for attempting to resolve the issue, but the situation was transformed in 1999 when the UK Government made it clear that it intended to introduce legislation in England and Wales for the compulsory and potentially indefinite detention of people with what it called ‘dangerous severe personality disorder’, whether or not they had been convicted of a serious criminal offence (Home Office & Department of Health, 1999). It is likely that some of these people, almost all of them men, will be detained in prisons and others in high-security hospitals. However, the European Convention on Human Rights, which was incorporated into UK legislation by the Human Rights Act 1998, prohibits the detention of anyone who has not been convicted by a competent court unless they are ‘of unsound mind, alcoholics or drug addicts or vagrants’ or their detention is ‘for the prevention of the spreading of infectious diseases’. This means that, to prevent a successful judicial challenge, the Government will have to argue that the potentially dangerous men it wishes to incarcerate are ‘of unsound mind’, and this means maintaining that they have personality disorders, and that personality disorders are mental disorders.

At present English mental health legislation, which dates from 1983 but had its origins in the recommendations of a Royal Commission in the 1950s, distinguishes between mental illness and psychopathic disorder, but the Government intends to abandon the concept of psychopathic disorder and introduce a new ‘broad definition of mental disorder covering any disability or disorder of mind or brain’ which will cover personality disorders as well as mental illnesses (Department of Health & Home Office, 2000).

Implications of the term ‘personality disorder’

The term ‘psychopathic’ was coined by the German psychiatrist Koch in 1891, and he said firmly that ‘even in the bad cases the irregularities do not amount to mental disorder’ (Lewis, 1974). What Koch meant by mental disorder, however, was largely restricted to insanity and idiocy, and his concept of ‘psychopathic inferiorities’ embraced most non-psychotic mental illness as well as what we now call personality disorder or psychopathy. Even so, Kurt Schneider subsequently argued that personality disorders are simply ‘abnormal varieties of sane psychic life’ (Schneider, 1950), and therefore of little concern to psychiatrists, a view that is still influential in Germany today.

Many  perhaps most  contemporary British psychiatrists seem not to regard personality disorders as illnesses. Certainly, it is commonplace for a diagnosis of personality disorder to be used to justify a decision not to admit someone to a psychiatric ward, or even to accept them for treatment  a practice that understandably puzzles and irritates the staff of accident and emergency departments, general practitioners and probation officers, who find themselves left to cope as best they can with extremely difficult, frustrating people without any psychiatric assistance. The reasons for this attitude were explored by Lewis & Appleby (1988). Using ratings of case vignettes by 240 experienced psychiatrists, they showed that suicide attempts and other behaviours by patients previously diagnosed as having personality disorders were commonly regarded as manipulative and under voluntary control rather than the result of illness, and that the patients themselves were generally regarded as irritating, attention-seeking, difficult to manage and unlikely to comply with advice or treatment.

Personality disorders are described in the International Classification of Mental and Behavioural Disorders (ICD-10) as ‘deeply ingrained and enduring behaviour patterns, manifesting themselves as inflexible responses to a broad range of personal and social situations’; they represent ‘either extreme or significant deviations from the way the average individual in a given culture perceives, thinks, feels, and particularly relates to others’ and are ‘developmental conditions, which appear in childhood or adolescence and continue into adulthood’ (World Health Organization, 1992a). They are distinguished from mental illness by their enduring, potentially lifelong nature and by the assumption that they represent extremes of normal variation rather than a morbid process of some kind. Whether or not these assumptions are justified, there is broad agreement that personality disorders are important to psychiatrists because they impinge on clinical practice in so many different ways. People with personality disorders are at increased risk of several different mental disorders, including depressions and anxiety disorders, suicide and parasuicide, and misuse of and dependence on alcohol and other drugs. In addition, people with schizotypal personalities are at increased risk of schizophrenia and those with anancastic personalities are at increased risk of obsessiveâ€â€compulsive disorders. The presence of a personality disorder also complicates the treatment of most other mental disorders, most obviously because the individuals concerned do not easily form stable relationships with their therapists or take prescribed medication regularly. Indeed, in group settings they often disrupt the treatment of other patients as well. Finally, with or without treatment, the prognosis of most mental disorders is worsened by coexistent personality disorder. Because of these important, complex relationships, it is taken for granted that psychiatrists need to be alert to the presence of personality disorder, even if, as is often the case, the disorder does not correspond to any of the distinct types described in textbooks and listed in glossaries. The contentious issues are whether personality disorders are amenable to treatment, and whether people displaying these habitual abnormalities of behaviour deserve to be accorded the privileges of the ‘invalid role’.

If personality disorders are not to be regarded as mental illnesses despite their undisputed relevance to psychiatric practice, the obvious alternative is to regard them as risk factors and complicating factors for a wide range of mental disorders, in much the same way that obesity is a risk factor for diabetes, myocardial infarction, breast cancer, gallstones and osteoarthritis, and complicates the management of an even wider range of conditions. Like personality disorder, obesity is listed as a disease in the ICD-10: it is coded E66 as an endocrine, nutritional or metabolic disease (World Health Organization, 1992b). Even so, most doctors, whether they be general practitioners, physicians or surgeons, are reluctant to attempt to treat obesity, either because they regard the condition as the result of self-indulgence rather than metabolic abnormality, or simply because they have no effective treatment to offer (Baxter, 2000).

Against the background of the UK Government's legislative proposals it is clearly important for British psychiatrists, legislators and jurists to decide whether personality disorder, or any subset of it, is a mental illness or mental disorder. Unfortunately, there is no agreed medical definition of either term. The World Health Organization has always avoided defining ‘disease’, ‘illness’ or ‘disorder’, and in its current (ICD-10) classification of mental and behavioural disorders (which includes personality disorders) it simply states that ‘the term disorder is used throughout the classification, so as to avoid even greater problems inherent in the use of terms such as disease and illness. Disorder is not an exact term, but it is used here to imply the existence of a clinically recognisable set of symptoms or behaviour associated in most cases with distress and with interference with personal functions’ (World Health Organization, 1992a). The current edition of the Diagnostic and Statistical Manual (DSM-IV) of the American Psychiatric Association, which likewise includes personality disorders, does contain a detailed definition of the term ‘mental disorder’, but although this runs to 146 words it is not cast in a way that allows it to be used as a criterion for deciding what is and is not mental disorder (American Psychiatric Association, 1994). It is important to note, though, that DSM-IV does stipulate that ‘neither deviant behavior nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual’, and that there is a similar unambiguous statement in ICD-10.

There is no fundamental difference between so-called mental illnesses or disorders and physical illnesses or disorders; both are simply subsets of illness or disorder in general (Kendell, 1993; American Psychiatric Association, 1994). This implies that the basic issue is the meaning of the terms ‘illness’ or ‘disorder’ in general. Even in this wider context, however, there is no agreement, and until recently surprisingly little discussion.

DEFINITIONS OF ILLNESS OR DISORDER

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BACKGROUND

DEFINITIONS OF ILLNESS OR...

STATUS OF PERSONALITY DISORDERS

DISCUSSION

Clinical Implications and...

REFERENCES

The most contentious issue is whether disease, illness or disorder (like the World Health Organization, I regard these terms as roughly synonymous) are scientific or biomedical terms, or whether they are socio-political terms which necessarily involve a value judgement. Physicians have generally maintained, or simply assumed, that they are biomedical terms, while philosophers and social scientists have generally argued that they are inherently socio-political, but this is not invariable. The American physician Lester King asserted long ago that ‘biological science does not try to distinguish between health and disease... health or disease are value judgements’ (King, 1954). Conversely, the philosopher Bourse has argued that ‘disease, the theoretical concept... applies indifferently to organisms of all species. That is because... it is to be analysed in biological rather than ethical terms’ (Bourse, 1975). I myself once argued that disease ought to be a biomedical concept (Kendell, 1975), but subsequently became convinced that value judgements were probably inescapable (Kendell, 1986). The issue has attracted much attention in the USA in the past decade, mainly in response to the publication of a closely argued analysis of the concept of mental disorder by Wakefield (1992).

STATUS OF PERSONALITY DISORDERS

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ABSTRACT

BACKGROUND

DEFINITIONS OF ILLNESS OR...

STATUS OF PERSONALITY DISORDERS

DISCUSSION

Clinical Implications and...

REFERENCES

The question of whether personality disorders are mental disorders cannot usefully be discussed until agreement has been reached on the implications of the term ‘mental disorder’, and at present there are at least four quite different, rival concepts of disease or disorder, which are summarised below.

Socio-political

Although it has been suggested in the past that disease is simply what doctors treat (e.g. Kräupl Taylor, 1971), there are no contemporary advocates for such a simplistic view. The simplest plausible socio-political definition is that a condition is regarded as a disease if it is agreed to be undesirable (an explicit value judgement) and if it seems on balance that physicians (or health professionals in general) and their technologies are more likely to be able to deal with it effectively than any of the potential alternatives, such as the criminal justice system (treating it as crime), the church (treating it as sin) or social work (treating it as a social problem).

There is general agreement that the personality traits and behaviours characteristic of personality disorders are undesirable, certainly from society's viewpoint and probably from that of most of the individuals concerned as well. It is unclear, though, whether psychiatry or clinical psychology yet possesses effective treatments for most types of personality disorder. There is evidence that borderline personalities can be helped either by dialectical behaviour therapy (Linehan et al, 1991) or by an analytically oriented day hospital regimen (Bateman & Fonagy, 1999), but little evidence that this is so for any of the other types. Attempts to change the enduring attitudes and behaviours of personality disorders are not often made; when they are, the treatment is often given up prematurely; and few random allocation trials with adequate long-term follow-up of any form of treatment for any type of personality disorder, other than the borderline type, have been conducted. Moreover, in the case of antisocial personality disorders, the most contentious group, it is undoubtedly the case that, worldwide, the majority are ‘managed’ most of the time by the criminal justice system rather than by health services.

Biomedical

The most plausible purely biomedical criterion of disease is the biological disadvantage proposed by Scadding (1967). Scadding, a chest physician, defined a disease as ‘the sum of the abnormal phenomena displayed by a group of living organisms in association with a specified common characteristic or set of characteristics by which they differ from the norm for the species in such a way as to place them at a biological disadvantage’. He never explained what he meant by biological disadvantage, but Kendell (1975) and Bourse (1975) both argued that it must at least encompass reduced fertility and life expectancy.

Little is known about the fertility of people with personality disorders, but there is good evidence that their life expectancy is reduced. Martin et al (1985) studied the mortality over 6-12 years of 500 former psychiatric out-patients in St Louis and found that antisocial personality disorder was associated with a greatly increased mortality (standardised mortality ratio 8.57, P=0.01), mainly from suicide, homicide and accidents. Others have investigated the mortality associated with personality disorder as a whole and found it to be raised in both men and women (Harris & Barraclough, 1998).

Biomedical and socio-political

Wakefield, who is a philosopher with a background in social work, argues that mental disorders are biological dysfunctions that are also harmful. This implies that the concept of mental disorder inevitably involves both a scientific or biomedical criterion (dysfunction) and an explicit value judgement or socio-political criterion  what Wakefield (1992, 1999) calls harm and the World Health Organization (1980) defines as handicap  and is attractive because it reconciles the socio-political and biomedical camps. It also seems to reflect the often intuitive ways in which physicians make disease attributions and does not obviously have unacceptable implications.

Wakefield originally proposed that dysfunction should imply the failure of a biological mechanism to perform a natural function for which it had been designed by evolution, but Lilienfeld & Marino (1995) subsequently pointed out that this evolutionary perspective raises many problems. Too little is known about the evolution of most of the higher cerebral functions whose malfunctioning presumably underlies most mental disorders; mood states such as anxiety and depression may have evolved as biologically adaptive responses to danger or loss rather than being failures of evolutionarily designed functions; and several important cognitive abilities, such as reading and calculating, have been acquired too recently to be plausibly regarded as natural functions designed by evolution. It is, of course, perfectly possible in principle to define dysfunction without reference to either evolution or biological disadvantage, and the DSM-IV definition of mental disorder states that ‘it must currently be considered a manifestation of a behavioral, psychological or biological dysfunction’. The problem is that current understanding of the cerebral mechanisms underlying basic psychological functions such as perception, abstract reasoning and memory is too limited for it to be possible in most cases to do more than infer the probable presence of a biological dysfunction; and rejecting both the evolutionary (Wakefield) and biological disadvantage (Scadding) criteria could open the way to regarding a wide range of purely social disabilities (such as aggressive, uncooperative behaviour or an inability to resist lighting fires or stealing) as mental disorders.

The evidence that personality disorders are harmful is quite strong and not restricted to clinic populations. Drake & Vaillant (1985), for example, compared 86 middle-aged men who met DSMâ€â€III criteria for personality disorder with 283 men who did not. Both groups had originally been members of a cohort of mainly working-class, non-delinquent adolescent boys previously studied as a control population in Boston by the Gluecks, so extensive background information was available for all 369. Compared with the 283 men without personality disorders, the 86 personality-disordered men (only six of whom had disorders of antisocial type) had poor mental health (79% v. 14%), poor occupational performance and job satisfaction, and poor social competence (58% v. 10%), and although alcohol dependence or misuse was partly responsible for their poor occupational performance, it made little contribution to their poor mental health and social competence.

It is much harder to establish that personality disorder involves dysfunction, in the sense of ‘failure of a mental mechanism to perform a natural function for which it was designed by evolution’ (Wakefield, 1992). Indeed, it has been argued that several of the characteristic features of antisocial personality disorder, such as manipulation, aggression and deception, were originally successful predatory strategies that evolved in a prehistoric social environment (Lilienfeld & Marino, 1995). Fundamentally, there are two sources of difficulty. The behaviours and attitudes that define personality disorders are probably graded traits present to a lesser degree in many other people, and also quite different in different types of personality disorder; and as yet little is known of the underlying mechanisms of which they are a manifestation. It could be argued, for example, that the impulsiveness and liability to become dependent on drugs or alcohol  which are such prominent, and frequently lethal, features of antisocial disorders  are prima facie evidence of an underlying dysfunction, but in the absence of any understanding of the cerebral mechanisms involved the argument remains inconclusive.

Ostensive

Lilienfeld & Marino (1995) maintain that mental disorder is an ostensive or Roschian concept, implying that the term can only be understood by considering the prototypes of mental disorder. If this argument is accepted  and it is not easily dismissed  it is impossible even in principle to determine whether personality disorders are mental disorders, because mental disorder is inherently indefinable. The only criterion is whether personality disorders are sufficiently similar to the prototypes of mental disorder (schizophrenia and major depression, perhaps), and similarity is obviously open to a range of interpretations. It is important to note, though, that both the World Health Organization and the American Psychiatric Association include personality disorders in their classifications of mental disorders, without explanation or apology, and have always done so, which implies that both bodies do regard them as sufficiently similar to warrant inclusion. The fact that some forensic psychiatrists see close similarities between personality disorders and schizophrenia, both in the extent of the disturbance of personality involved and in their need for treatment (Blackburn et al, 1993), is also relevant.

DISCUSSION

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BACKGROUND

DEFINITIONS OF ILLNESS OR...

STATUS OF PERSONALITY DISORDERS

DISCUSSION

Clinical Implications and...

REFERENCES

It seems clear from this analysis that it is impossible at present to decide whether personality disorders are mental disorders or not, and that this will remain so until there is an agreed definition of mental disorder. It is also apparent that personality disorders are conceptually heterogeneous, that information about them is limited, and that existing knowledge is largely derived from unrepresentative clinical populations. The clinical literature on personality disorders  indeed, the basic concept of personality disorder  has few points of contact with the psychological literature on personality structure and development, and little is known of the cerebral mechanisms underlying personality traits. There is also a glaring need for a better classification of personality disorders and for more long-term follow-up studies of representative samples, derived from community rather than clinical populations, to answer basic questions about the extent, nature and time course of the handicaps associated with different types of personality disorder.

Epistemologic arguments

It could be argued that personality disorders are mental disorders on the grounds that their high mortality clearly constitutes a biological disadvantage, the key criterion of Scadding's concept of disease. However, there is little support for this definition, and (apart from antisocial personalities) the reduction in life expectancy is fairly modest. If Wakefield's definition, giving a central role to dysfunction, comes to be adopted as a general definition of mental disorder the issue may remain unresolved for some time, because it may not be possible to decide whether there is a dysfunction of some natural mechanism until much more is known of the cerebral mechanisms underlying key personality characteristics such as empathy, impulse control and emotional stability. (There is, though, already evidence that low central serotonergic activity may underlie impulsive, aggressive behaviour in a wide range of settings: see Coccaro & Kavoussi, 1997.)

Although it is difficult to provide irrefutable arguments that personality disorders are mental disorders, it is equally difficult to argue with conviction that they are not. The fact that they have been included in the two most influential and widely used classifications of mental disorders (the ICD and the DSM) for the past half-century is difficult to disregard, whether or not one accepts the view that mental disorder is an ostensive concept. It could be argued, though, that the crucial issue is not whether personality disorder is embraced by any particular definition or concept of mental illness, but what kinds of considerations lead doctors to change their minds about assignations of illness, and in this context two issues loom large.

Assumptions about aetiology and time course

The first is the validity of the assumptions about aetiology and time course which originally underpinned the distinction between personality disorder and mental illness. The former was assumed to be part of the normal spectrum of personality variation and to be stable throughout adult life; the latter to be the result of a morbid process of some kind and to have a recognisable onset and time course. These assumptions both appear increasingly questionable, and as a result the distinction between illness and personality disorder is starting to break down. Some schizophrenic illnesses have the same time course as a personality disorder: they develop during adolescence and persist relatively unchanged throughout adult life. More significantly, it is becoming increasingly clear that the genetic bases of affective personality disorders and mood disorders, and of schizotypal personality disorder and schizophrenia, have much in common. As a result, the affective personality disorder of ICD-9 has been replaced in ICD-10 by two new mood disorders, cyclothymia and dysthymia, ‘because of evidence from family studies that they are genetically related to the mood disorders, and because they are sometimes amenable to the same treatments’. For similar reasons, schizotypal disorder  which is listed as a personality disorder in DSMâ€â€IV  is classified with schizophrenia and delusional disorders (F20-29) in ICD-10 despite the fact that ‘its evolution and course are usually those of a personality disorder’ (World Health Organization, 1992a). Most disconcertingly of all, avoidant personality disorder has so much in common with the mental illness known as generalised social phobia that it is suspected that ‘they may be alternative conceptualisations of the same or similar conditions’ (American Psychiatric Association, 1994). Unsurprisingly, such problems are leading many American psychiatrists to question the value of the distinction between Axis I and Axis II disorders in DSMâ€â€IV, despite the statement in its manual that ‘the coding of personality disorders on axis II should not be taken to imply that their pathogenesis or range of appropriate treatment is fundamentally different from that for the disorders coded on axis I’ (American Psychiatric Association, 1994).

The influence of effective therapies

The second issue is the influence on medical attitudes of the acquisition of an apparently effective therapy. For nearly 150 years, claims that alcoholism was a disease, from Thomas Trotter in 1804 to Alcoholics Anonymous in the 1930s and 1940s, cut little ice with the medical profession. It was only in the late 1940s and 1950s, when disulfiram became available, that doctors changed their minds. Now, of course, it is evident that disulfiram is not generally an effective therapy, but in its early years enthusiastic reports of cures were published in many different countries, and it was against this background that the World Health Organization decided to include alcoholism itself, as distinct from alcoholic psychoses and acute alcohol poisoning, in the ICD, and medical organisations throughout the world issued formal statements to the effect that alcoholism was a disease after all. The reasoning involved suggests an acceptance of the socio-political definition described above, although this has rarely commended itself to the medical profession. It does seem, none the less, that possession of an apparently effective treatment can produce a decisive change in medical opinion, and Campbell et al (1979) showed that an established medical role in diagnosis or treatment has more influence on doctors' concepts of disease than on those of the public. At present, neither personality disorder nor obesity is accepted as a genuine illness by most British doctors; but as effective drugs for treating obesity come into widespread use over the next decade it is likely that obesity will come to be accepted as a genuine metabolic disorder, and the same may happen to personality disorders. Indeed, it is already happening to the ‘borderline’ disorders as evidence accumulates that the disruptive and self-destructive behaviours that characterise the disorder are amenable to forms of psychotherapy (Linehan et al, 1991; Bateman & Fonagy, 1999). There is also some evidence that fluoxetine reduces irritability and aggression in people with a variety of personality disorders (Coccaro & Kavoussi, 1997). If, therefore, the psychiatrists and politicians who maintain that ‘antisocial personality disorder’ has as good a claim to being accepted as a mental disorder as schizophrenia can demonstrate that it responds to some form of treatment that is not simply a disciplined environment, it is likely that the opposition will melt away, and the same will be true for other types of personality disorder.

Economic and cultural influences

Finally, it is necessary to acknowledge the influence of the setting in which psychiatric care is delivered. For the past 50 years the constraints of the National Health Service have ensured that the time and energy of most British psychiatrists have been fully occupied treating patients with severe mental illnesses. As a result, National Health Service psychiatrists have generally been reluctant to add to their workload by also accepting responsibility for people with deeply ingrained maladaptive behaviours for which there were no proven therapies. In North America the situation has been different. The prevailing systems of health care have facilitated the development of both private office practice and various forms of psychotherapy, and the psychoanalytic concept of ‘borderline personality disorder’ has provided a rationale for treating, as personality disorders, large numbers of patients who in Britain would mostly be regarded as suffering from recurrent depression. These economic and cultural differences have probably contributed to the comparative reluctance of British psychiatrists to accept personality disorders as mental disorders.

Clinical Implications and Limitations

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ABSTRACT

BACKGROUND

DEFINITIONS OF ILLNESS OR...

STATUS OF PERSONALITY DISORDERS

DISCUSSION

Clinical Implications and...

REFERENCES

CLINICAL IMPLICATIONS

Because the term mental illness has no agreed meaning it is impossible to decide with confidence whether or not personality disorders are mental illnesses.

The historical reasons for regarding personality disorders as fundamentally different from illnesses are being undermined by both clinical and genetic evidence.

The introduction of effective treatments would probably have a decisive influence on psychiatrists' attitudes.

[lostsoul]

well that was cheery

yeah they dont half get bogged down in this don't they? names and definitions and crietria and all sorts of waffle.

interesting read.

in the beginning of that article i started to think, gosh, i would rather have a straight forward mental illness than a personality disorder, because they weren't saying very nice things about us at all they were being mean saying we are difficult.

Well we're gonna be ******* difficult we feel as if our heads are melting!!!!!!!!!!!!

ahem. anyway. cheers for the post and i will mull it over.

lost

xx

[LadyMacbeth]

We are in the category as murderers..woo hoo! The article is actually pretty biased in my opinion. You cannot classify everyone with a PD in the same category.

[LadyMacbeth]

The lower case "d" in my title is driving me insane! I can't look at it bc its annoying me so much. Its supposed to be "D". Ahh!

[lostsoul]

hahahaha. DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD

DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD

DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD... better????!!!!!!

[LadyMacbeth]

No its still haunting me!!!!!!!!!!!I tried to edit it but can't edit titles.

[Tory]

The title has been edited!!

[LadyMacbeth]

Your the best! You just made my day brighter just for doing that. :D

[lille_eskimit]

I started a thread on this when I first joined up, in this same section...I think it was called 'Erm...a Slight Discrepancy?'. It was quite awhile ago, so it may have shifted to the second page now...Anyhow, I was really confused, 'cos of conflicting information...Some of the literature I've read refers to BPD as an illness, but others do not...and even the medical professionals are having some sort of dispute amongst themselves as to how PDs should be classified.

Anyhow, just to save you the trouble of looking for what I said about it, I'll just copy and paste it here:

Dec 4 2004, 04:30 PM

Just a little confused about something, and wondered if someone here could clear things up. 

It says in the main part of this site that BPD is considered a legitimate form of mental illness "in accordance with any International Classificatory System"...However, another site - BUK, states that this is still in dispute and is in fact only considered a 'disorder' and not an 'illness' as such...Furthermore, because the UK mental health profession does not class it an a psychiatric illness, it is very difficult for BPs to obtain any Disability Living Allowance...

Can anyone shed some light on this?

Dec 5 2004, 05:12 PM

Yes...it is so confusing as we're getting an assortment of information from supposedly reliable sources, most of which are contradictory...

I had this particular conversation the other day with a fellow BPD who's done a bit of research on this subject, and she mentioned that the WHO (World Health Organisation) ICD-10 guideline does not class BPD or any other PDs as psychiatric illnesses. The document is rather long, so I didn't have a chance to read through it all, and only paid attention to the section pertaining to Personality Disorders, and found that although it did not SPECIFICALLY state in that segment that BPD (and other PDs) is NOT a psychiatric illness, it was interesting to note that the ICD-10 placed particular emphasis on distinguishing 'disorders' from 'illnesses' right from the very beginning, so as to avoid any confusion. This obviously suggests that, however marginal, there is a difference between the two. I copied and pasted the relevant passage below:

"DISORDER

The term 'disorder' is used throughout the classification, so as to avoid even greater problems inherent in the use of terms such as 'disease' and 'illness'. 'Disorder' is not an exact term, but it is used here to imply the existence of a clinically recognizable set of symptoms or behaviour associated in most cases with distress and with interference with personal functions. Social deviance or conflict alone, without personal dysfunction, should not be included in mental disorder as defined here."

Throughout its description of PDs, NOWHERE did it refer to them as 'illnesses'. There are other examples of literature that uphold the same perspective, such as in http://news.bbc.co.uk/2/hi/health/medical_notes/279860.stm which highlights the discrepancy...The start of the article does refer to PDs and other forms of mental instability as 'illnesses', but that just appears to be a general journalistic comment...It does elaborate further along in the feature that "unlike personality change, personality disorder is not linked to a mental illness, substance abuse or brain disease." Although this piece was published late 1999, the Mental Health pages of the site does not mention any other significant changes to date, and I find it highly doubtful that BBC would be lax in their updates. But then again, I have been known to be wrong, so I wouldn't quote me on that! 

I suppose one could be pedantic and fall back on the immutable tradition of using the esteemed Oxford Dictionary as a source of reference, in which 'illness' is defined as "the state of being unwell in body or mind" (there is evidence that trauma can damage brain cells, thus making the condition partially 'physical/biological' as well), but I very much doubt that those in the medical profession adhere to this particular system, and would quite possibly go as far as to issue a direct challenge to language itself!  I often wonder what criteria it is that they go by...

I have mixed feelings about this...There is a part of me that hopes BPD isn't a mental illness, because of the stigma attached, especially in Asian communities...I do not want to be viewed as 'mad'. But at times, it seems that no one takes your predicament seriously unless you are pigeon-holed as 'ill'.

Someone suffering from PDs might feel that being diagnosed with a mental illness would remove all responsibility residing in his/her quarter, but I personally feel that this should not be the case...Even if it WERE an illness, some form of self-help would still be necessary (as in the case of most other diseases/conditions not related to mental health), such as turning up for therapy, learning/developing alternative coping mechanisms, remembering to take your medz etc...Even something as simple as acknowledging you have a problem would be the first step to getting better...And since we're not exactly incapacitated 24-7, this is not impossible. The very fact that we are all here and participating in this forum indicates that (despite the struggle it has been), we are more or less lucid, recognise that some sort of treatment is in order, and are reaching out for help...That there are BPDs out there who have recovered is evident that it is possible for us (to a large extent) to take control of our lives...So there is still hope for us yet! 

Dec 5 2004, 06:27 PM

I think you might find this link of interest:

http://tinyurl.com/5fudf

Most BPDs tend to display the marks of Depression anyway, so they'd most likely obtain DLA on the basis of those symptoms affecting their day-to-day functions...That's just by my reckoning though, since I'm no expert on the subject...I haven't found myself in a position to claim DLA as yet, and I hope I'll never have to!

Dec 5 2004, 06:28 PM

(lostsoul @ Dec 5 2004, 07:17 PM)

I think the most important thing is that any problem a person has that they consider serious, is darn well recognised as SERIOUS. I don't care if this is recognition of it as an illness or a disorder, as long as it is RECOGNISED AS SERIOUS.

Yes...After all, what's in a name?

Oh, and rant all you like...We've all been there before!!!

So...erm...where does that leave us? :blink:

[LadyMacbeth]

Good post Charme. It was pretty interesting. Its such a conflicting topic. The reason why I see it as PD rather then a MI is as I have stated in a previous post BPD is not a result of a chemical imbalance in the brain its the traits that can appear along side of BPD. For example, BPD is a label. Most mental health professionals are reluctant to label us with BPD. If we were never diagnosed with BPD we would be treated as having depression, anxiety, psychosis, mood swings, etc... The traits that define BPD such as SI, ED, paranoia, instability can also be connected to other disorders. I hope thhis makes sense. Its an interesting topic which takes a lot of thought and understanding.

[lille_eskimit]

We've gone and opened a can of worms now!! Eeek!!!

Well, this is another subject that's controversial, 'cos there are those experts who say that BPD could be in part due to a form of brain damage caused by trauma in childhood...I read this at the BUK site...Here's the relevant passage:

"Traumatic experiences, especially if severe, sustained and repetitive, lead to cell damage and premature death in key centers [of the brain] and wiring patterns that evoke unmodulated and maladaptive responses to the ordinary events of life." Kernberg et al, Borderline Patients: Extending the Limits of Treatability

I'm glad I'm not a psychiatrist...think of how much info you'll have to cram into your mind!! It's bad enough with the BPD alone!!!

[LadyMacbeth]

Actually when I do go to graduate school and obtain my Master's iin Social Work, counseling, psychology whichever one this would make a great thesis topic.

You are right in the aritcle I posted BPD and the Environment it does state that traumatic experiences as a child can alter the chemistry in your brain. I would have to look at the paragraph again. Claire explained it well....However, BPD is related to PTSD. You can suffer from PTSD without having a dx of BPD but can you have BPD without PTSD? Is PTSD a mental illness or disorder or neither. As you would think the traumatic scars for someone who has PTSD would also cause brain damage as a result but are people who have PTSD mentally ill?

[lille_eskimit]

It's kind of like the chicken or the egg thing, isn't it?

[LadyMacbeth]

I think I am trying to go somewhere now that I am not qualified to talk about. I will have to thnk about this... :wacko:

[lostsoul]

a theory...

perhaps BPD is the form of PTSD that you get if the trauma happened when you were young, when the brain was still forming. also this type of trauma happens a lot of times, and usually in the family environment.

compare this to PTSD, and you find that normally, classical PTSD comes from adult trauma. and the traumatic event may only have happened once. and probably didn't happen in the family home.

the effect of trauma on a child's brain compared to that of a fully developed adult's brain i should think is significant, and prolly explains why although similar, the symptoms of PTSD are different from BPD.

does that make any sense?

[LadyMacbeth]

You are such a smart cookie Claire. It makes sense I wll respond after I have fully woken up from my nap. I think with the lack of caffeine and my body returning back to normal I think I have exhausted myself the past few weeks. I am freezing don't you hate when you wake up are you are so cold.

[lostsoul]

yeah quitting caffeine cold turkey can wreak havoc on your body. i would expect to feel very tired and lethargic and sleepy...

take care. get warm! (have a coffee)...

(ok kidding with the last one) :P

[LadyMacbeth]

Damnit Claire I was just going to make one to. I actually made some decaf tea.

Btw, last night I made a hot bath got into it, then made some hot milk and took a Valerian pill. Out like a light. It was greeeeaaat!!!!!!!!!

[Katherine]

Good o. Hot water bottles are good too.

I actually said to my therapist on Monday that I would rather have PTSD than BPD. She just kind of looked at me, like "What?" But PTSD for me validates my trauma. Hey, how about revising the DSM and having different forms like well, Emotional Traumatic Response, Relational Pain.... etc....

(other compassionate names for emotional pain on a postcard please!)

All this stuff about Disorders does my head in. Sod it I AM a complete human being, I don wanna be seen like someone who's battery's broken and cannot be mended...

I'm just hurting cos my life was wrong, its not MY fault.

*angry* (and I don't even have an f'ing diagnosis of BPD as such)

(crikey, it must be a strong issue for me to start swearing!)

Yikes!

l.

[kraaken]

LadyMacbeth,

Thanks for posting that article from the Br J Psych.....it was quite a tough read

Well the definition of BPD as a mental illness or a disorder, as mentioned by lille_eskimit, has me concerned in connection with getting Disability Living Allowance. The welfare officer I spoke to last month said she thinks I should get it, but I'm worried about the technicalities.

Likewise I've been worried whether I'll suddenly be declared fit for work again by my psychiatrist if I don't have an "illness". However my counsellor said I shouldn't worry about that.

I guess I just have to wait and see how things turn out.

Bye for now,

K

[LadyMacbeth]

Maybe in would be safe not to mention borderline traits maybe severe depression or are you suffering from anything else such as panic attacks. These are physiological as opposed to borderline. I actually thought to myself that the next therapist I would see I would not mention anything about BPD because I would not want them to judge me before they spoke to me. I actually ofund a CB therapist and I left a mesage on her voicemail about my issues with anxiety and BPD traits. I let them accidently slip out but she called me back and told me that she did not want to label me just yet with BPD. Thats good so she will not pre judge me.

[pinklady66]

I have read that bpd is a mental illness. It is now being recognised as an illness. At least here in Canada it is.

There are ways to recover from it and get it under control. I was told by my doctors that therapy and taking the proper meds will help.

[LadyMacbeth]

One of my therapists said I showed traits and the other said I can recover from it when I start feeling better. I trust them both I don't think they would lie to me so I believe them. I think you need to find a good therapist that you can form a good relationship with and you have to work hard at changing to its not all up to the therapist to save tiy as they are not miracle workers. I am not on medication as of now but probably my anxiety is my downfall.