The Challenges Of Treating Personality Disorders
NEAL CONAN, HOST:
This is TALK OF THE NATION. I'm Neal Conan, in Washington. Personality disorders come in many forms - avoidant, antisocial, narcissistic to name just a few. They make up a list of conditions difficult to characterize, difficult to treat. A team of psychiatric experts just wrapped up five years of work aimed at simplifying the diagnostic guidelines. Over the weekend the American Psychiatric Association rejected the proposed changes.
Mental health professionals, we want to hear from you this hour. How does the difficulty in defining personality disorder affect you and your patients? Give us a call, 800-989-8255. Email us, firstname.lastname@example.org. You can also join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION.
Later in the program, "Escape from North Korea: The Untold Story of Asia's Underground Railroad." But first, understanding personality disorders. Benedict Carey is a science reporter for the The New York Times. He wrote a piece called "Thinking Clearly about Personality Disorders" that ran on November 26th and joins us now from our bureau in New York. Good to have you back on the program.
BENEDICT CAREY: Thank you.
CONAN: And there's a lot we still don't know about personality disorders, but it is not because they are new.
CAREY: That's right. I mean they've been around forever. I mean personality is the most central and most memorable thing about any person, and of course we've seen all sorts of historical figures with clearly strange, grandiose personalities. You know, the Bible is full of interesting, charismatic characters that seem to represent sort of the extremes of personality.
And the personality disorders that we talk about now, or psychiatrists do, go back to the beginning of the 20th century, most of them do, and come out - mostly out of Freudian analysis, you know, therapists describing very interesting characters that come in to see them that don't fit into any category, any easy category.
CONAN: And how - we're defining terminology here, but how do these differ from things like psychosis or panic attacks, things like that?
CAREY: Right, those are symptoms. Those are things that come and go. Psychosis comes and goes, and so do panic attacks, and for that matter depression and other anxiety pangs. And they were for years in the manual of diagnosis separate, in an entirely separate category from personality, personality being, you know, something more longstanding that's rooted in who the person is, you know, who they - sort of how they grew up and how they deal with others and their emotional responses and much more sort of considered to be intrinsic to the individual than a passing symptom.
CONAN: And that makes it difficult for these people to understand there's something wrong.
CAREY: Right, I mean we all think we're kind of normal, right, more or less.
CONAN: Most days, anyway.
CAREY: That's right. And I don't think, you know, psychiatrists or clinical psychiatrists would say that always, that people are always blind to these things. I mean over time, you know, some of us, our blind spots become visible. But often that's the case. They are not so aware of the patterns, especially the disabling patterns and how they sort of fit together into kind of one archetype.
And so psychiatrists try to, you know, describe that and make it more understandable and so they can be treated.
CONAN: Yet all of this seems to have struck some rocky shoals. You wrote in your piece, and this is a damning thing to say, but many critics, you say, charge that psychiatry is failing patients no other field of medicine can help.
CAREY: That's right, and I think a lot of psychiatrists agree with that, that these things, these personality disorders are difficult to identify. I think you need some training beyond, you know, beyond sort of the usual training. And also the treatments are very difficult too. They tend to be talk therapies, not always, but - and again, they're persistent, longstanding, longstanding problems.
It's really an extra load to be able to go and carefully identify something like this and treat it well. And so I think a lot of psychiatrists would agree that it's getting short shrift and that a lot of people, you know, could be helped by getting this directly addressed and aren't.
CONAN: And another problem that you point up in your story is that there are other symptoms that can accompany this - depression, anxiety. Those tend to get treated rather than the underlying condition.
CAREY: Yeah, that's right. It doesn't - it's not surprising. You know, if you have somebody who's, you know, sort of extremely narcissistic or paranoid or dependent, one of these personality disorder names, and all those things are evocative, and we know they can lead to, you know, severe emotional problems, not to mention, you know, it just - it doesn't help your relationships with other people.
So, you know, the - right now you can get drugs certainly for some of these things that may relieve the symptoms, but without addressing more core problems, you really - it's all temporary.
CONAN: We're talking with Benedict Carey, a science reporter for the The New York Times about personality disorders, and we want to hear from those of you in the mental health profession. How does the difficulty in defining, categorizing, diagnosing, treating these conditions, how does that affect you and your patients? 800-989-8255. Email us, email@example.com. Let's start with Christina(ph), Christina with us from Indianapolis.
CHRISTINA: Hi there.
CHRISTINA: Thank you for taking my call. My experience, I worked as a psychiatric technician in an inpatient hospital after I got my bachelor's degree, and during that time - of course I had taken an abnormal psych class when I was in college and learned a little bit about these disorders - I got most of my training about how to identify various disorders alongside other clinicians.
And that - in that informal setting, there's a kind of a you-know-it-if-you-see-it mentality. And there's a lot of problems with that because what I would see when people would be admitted to the hospital, maybe this is that person's first encounter with this particular clinician, that patient and clinician are just getting to know each other.
And if that patient had a past diagnosis (technical difficulties) personality disorder, but particularly borderline personality disorder, it would seem to bias the view on the clinical staff's part towards that person, whereas if the diagnosis was major depressive disorder or an anxiety disorder or even a psychotic disorder, that didn't seem to happen, the stigma didn't seem to be as strong.
I went on to get my doctoral degree, and now I teach at a campus where I get to teach the abnormal psych class. And so I try to have my students just think critically about this whole category of diagnosis and the many difficulties that are carried in the stigma and in the inconsistency across clinicians in applying the diagnostic category.
I don't want to say that the APA has it completely wrong to retain it in the DSM, but going from DSM-IV to DSM-5, there's a lot of significant changes, and so I just think there are many, many worries about this whole category that leave us with more questions than answers.
CONAN: And just to clarify, the DSM sort of the bible of psychiatry. They're just coming out with a new edition, from four to five, and that's where this difficulty of categorization sort of came to a point, Benedict Carey.
CAREY: Right, they spent years trying to update the manual. They do it every, whatever, 12 to 15 years. It's - it can be an arcane process. It is, mostly. But it's an influential book, and some of the - you know, some of the disorders are very interesting and very common. And so small changes or debates that are, you know, feel scholarly or mundane often have, you know, have consequences, particularly in this book, the DSM-5, or the Diagnostic and Statistical Manual, as it's called.
CONAN: And as you - you know, as you listen to our caller talking about this, you know, bias, it seemed to me that there was a bias, throwing your hands up in the air, personality disorders, but we don't know which one it is.
CAREY: Right, that certainly happens. I think the bias is understandable, because, you know, depression seems like something that happens to you, you know, the same thing with schizophrenia and bipolar and so on, whereas personality disorder, that feels like that's you. You know, that's on you. That's sort of how you've sort of expressed yourself and managed your way through the world, and so you can see where there would be more stigma, I think.
Yeah, part of the problem, and one of the reasons they debated this, was that there are 10 personality disorders and that - and we've mentioned some of them already. Narcissistic is one, antisocial, avoidant, borderline. So people are familiar with some of these labels. But a lot of patients who came in were getting more than one. So that doesn't make a lot of sense.
Or they're being put into a category, which is a kind of a catch-all category, general personality disorder, which meant only that, you know, they had some very strange or extreme kind of behaviors and traits, but the, you know, the therapist couldn't figure out what diagnosis to give them.
CONAN: Let's see if we can get another caller in. This is Pat, and Pat's on the line with us from Durham.
PAT: Yes, hello, I'm Dr. Pat Webster. I'm a clinical psychologist. And I co-authored a book called "Winning at Love: The Alpha Male's Guide to Relationship Success." And in my practice, I think one of the difficulties with narcissistic personality disorders is that it's endemic. I think that it's - we're a culture of narcissists, and I think that often the bigger-than-life beliefs and symptoms that go on with narcissism are rewarded in our culture.
I think the mortgage debacle was engineered in - by people that we would diagnose as narcissistic personality disorders. And in their personal life, usually this doesn't really hit them until, say, the 40s or something like that, when they're lonely, they've had - they've gone through many, many relationships, and then the depression begins.
But it's hard because often we reward the outcome of narcissistic personality disorders in our culture.
CONAN: Do we reward narcissism, Benedict Carey?
CAREY: I mean I don't know the answer to that. I think it's - it's certainly an American type. You know, we grow them here. And I think that, you know, you can be a very successful and also extremely narcissistic person, and yes, be rewarded. I mean, I'm not saying that, you know, this is the predominant personality disorder in the U.S. I doubt it. I think that this is just one of the most annoying ones.
CAREY: And so they tend to be more of a headache than some of the other ones.
CONAN: Pat, thanks very much for the call.
PAT: You're very welcome.
CONAN: We're talking about personality disorders. If you work in mental health, how does the difficulty in defining these disorders affect you and your patients? 800-989-8255. Email us, firstname.lastname@example.org. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION from NPR News.
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CONAN: This is TALK OF THE NATION, from NPR News. I'm Neal Conan. There are 10 commonly accepted syndromes - including paranoid, borderline and dependent - that qualify as personality disorders. They're often divided into three clusters: those characterized by odd, eccentric behavior or emotional and dramatic behavior or anxious, fearful behavior.
Beyond those broad outlines, though, they're incredibly hard to define. We've been talking with the New York Times' Benedict Carey about the difficulty with personality disorders, which he's called some of the most serious and striking syndromes in medicine. We'd like to hear from mental health professionals, too. How does the difficulty in defining personality disorders affect you and your patients?
Give us a call: 800-989-8255. Email is email@example.com. You can also join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION.
Joining us now to shed some light on how the psychiatric community is dealing with these disorders is Mike - Mark, excuse me, Lenzenweger. He is the psychology professor at Binghamton University and professor of psychiatry at the Personality Disorders Institute at the Weill Cornell Medical College, and he's with us by phone from his home in New York.
Good to have you with us today.
MARK LENZENWEGER: Pleasure to be here.
CONAN: Just so we get some sense of scope, how many people suffer from personality disorders, do you think?
LENZENWEGER: Well, the current estimate of prevalence for personality disorders in the United States is roughly 10 percent. So one in 10 Americans probably suffers from a diagnosable personality disorder.
CONAN: And there's a spectrum, though. It's not full-blown immediately.
LENZENWEGER: Well, that's an interesting question, Neal.
CONAN: Oh, good.
LENZENWEGER: There is discussion about how much of a spectrum there can be. But the 10 percent figure is based on people who actually meet the criteria for a diagnosis. So, for example, if it requires five out of nine criteria to meet a diagnosis, what do you say about a person who meets four out of nine? Are they - they're nearing the threshold, but they're not quite there.
But using strict thresholds - where you really expect people to meet the diagnostic criteria in the manual - it's one in 10.
CONAN: And, for example, a lot of us think we know something about some of these, but borderline personality disorder, for one, is not halfway there. It's a separate thing.
LENZENWEGER: Yes. Borderline personality disorder suffers from a bit of a misnomer as a name. It was initially coined as a name to describe a fairly serious, debilitating condition that early clinicians - say, working in the 1930s, 1940s - thought somehow was on the border of psychosis, particularly schizophrenia.
So the term was coined to sort of describe that near-neighbor status, but we know now that's not true. But the name has been used for so long that psychiatry and clinical psychology prefer to stick with it.
CONAN: And we've talked about some of the difficulties that various people have in diagnosis. How does that manifest itself in the patients you see?
LENZENWEGER: The most tricky thing in terms of diagnosis is not so much in the definition of the disorders. That becomes something of a scholarly debate, and can go on for quite a while. The real trick in diagnosis is the actual diagnostic process, meaning sifting through the complicated life story that a person has and looking at the features they bring to life in terms of work, school functioning, social functioning, family functioning, and making sure that the dysfunction that you're calling personality disorder has been longstanding, that it's been there for the better part of the last five years, and then teasing it apart from issues such as depression, anxiety, more transitory things that come and go, to be really sure that what you're looking at is what you intend to be calling personality disorder.
CONAN: And that, I suspect, takes a great deal of time.
LENZENWEGER: It can. It can. And that's one of the drawbacks of diagnosing the disorders, is that many people, frontline clinicians, simply often don't have that kind of time. You know, the researchers who spend hours and hours working on these problems in the laboratories, you might spend two to six hours conducting a diagnostic interview with the person that you're considering, you know, being in a personality disorders research study. Most clinicians simply don't have that time.
CONAN: And most of those interviews are about 45, 50 minutes, and then a lot of patients expect to walk out with a prescription.
LENZENWEGER: If you find a psychiatric interview that lasts that long these days, that's a little bit unusual in contemporary psychiatry, because people are hard-pressed and don't have the time, and many initial diagnostic impressions are gleaned very quickly.
With personality disorders, it's difficult to imagine even being close to having a full picture after 45 minutes, and the interesting thing is that there isn't going to be a prescription that will help the disorder at its core.
CONAN: Because it's - we don't know, or because it's not biological?
LENZENWEGER: Oh, it's probably biological in part, Neal. The research evidence really suggests that genetic factors do play a role in both normal personality and personality disorders, and neuroimaging research - some of which we've done at Cornell Medical - shows that there are, for example, in borderline personality disorder, very identifiable neural circuit abnormalities.
It's biological, but the medications we have don't necessarily make all of that right or fix it in the way that you'll see in, say, depression or anxiety, where you can treat the symptoms, at least, and bring a person to a lower level of distress.
CONAN: Let's get some more callers in on the conversation. 800-989-8255. Email: firstname.lastname@example.org. Richie's on the line with us from Atlanta.
RICHIE: Hi. I have two comments. Number one, the DSM was written as a standardized diagnostic manual. In my experience, it doesn't work out that way in everyday practice because, you know, your client can go to the first clinician and be diagnosed with one thing, and they'll go to another clinician, and it becomes subjective from clinician to clinician.
My second comment is that I currently work in substance abuse, and the clients that I see that have an Axis II diagnosis - when they know about it, my experience has been that it makes it much more difficult to work with them. And I was wondering what your guests would have to say about that.
CONAN: I wonder. Why don't we start with you, Dr. Lenzenweger?
LENZENWEGER: Well, in terms of reliability, the caller is wondering about how reliable are these systems. And in the hands of people that are trained and they're using an instrument - and this is important, that they're using what's called a structured clinical interview - reliability is actually quite good, meaning the same person could be interviewed by four or five different clinicians, and you would come up with broadly the same diagnosis. So the reliability issue is not as challenging as some might think.
The presence of a personality disorder diagnosis and how it affects a person is an interesting question. Some people find it very helpful and liberating, almost, in the sense that they finally have heard what is going on with them and how it can be treated.
Other people - and this partly depends on how it's delivered - see it as yet another strike against them.
CONAN: Yet - let me bring Benedict Carey back into the conversation - you say in your piece that more and more, people don't get that specific, though, a diagnosis. They're told they have personality disorder, not otherwise specified.
CAREY: Right, that's the category I mentioned, which is a more generalized one, which is I think where you see some of the features, but you're not sure that they - they don't seem to line up in any one - under one particular label or name. And so that can be - I think, you know, talk to Dr. Lenzenweger about this, but I think that - I don't know how helpful that is.
I mean, it's - I don't know that there's any specific therapy for that. I don't know if it's helpful for the patient. And basically, you've just been told you're messed up, and they can't tell you anything more about it. I mean, so I think that was one of the motivations; I think that's one of the most common - maybe the most common - of the diagnoses here, and one of the motivations for trying to change or streamline it so it becomes more specific.
CONAN: Dr. Lenzenweger?
LENZENWEGER: Well, yes. I think Ben's right in the sense that the most common diagnosis out there for personality disorders is this so-called personality disorder not otherwise specified. And what that means is you have any number of personality disorder criteria met in your clinical picture, but you don't have enough to satisfy the threshold for any one particular disorder.
So it is something of a general catchall. What it tells the clinician, though, is that there is something that's clinically important that should be treated and should be the focus of treatment. And what you have to understand about personality disorder treatment is that it isn't always specifically directed at the features that make up the descriptions of the disorders.
You might spend a lot of time in therapy working on improving a person's interpersonal relations - you know, how they get along with their family members, their spouse, their partner, their boss, how they regulate their emotions, especially rage and anger and fear. So even though you don't fall into a particular basket with a very specific DSM-IV or DSM-5 name, what you're struggling with still gets treated.
CONAN: Richie, thanks for the call.
RICHIE: Thank you.
CONAN: Here's an email from Christie(ph) in Green Bay: As a psych nurse, I recognize that I do have a bias against some patients with personality disorders, especially those with borderline personality disorders. I work hard to keep my bias from affecting my patient care, but the very nature of BPD can make those patients demanding, manipulative and unpleasant. We all prefer to be around pleasant people, and clinicians are no exception. I have a suspicion that patients with personality disorder get less intensive medical care for just the same reason: lack of likeability with primary care providers.
I wonder, Dr. Lenzenweger, these personalities - likeability, manipulation and - does that factor into their treatment?
LENZENWEGER: Well, it shouldn't in terms of a professional, you know, posture with respect to your patients. If you're treating a personality disordered individual and you're working as a psychologist or a psychiatrist or a social worker, you know what to expect, and you know that someone is presenting a clinical picture. You know, their way of being may be disagreeable. It may be challenging, it may be trying, but your job is to get in there and try to help them.
And the person that commented on having a negative reaction, that's not unusual, especially for people who are interacting with someone with borderline, whether it's on the job, in school or in a nursing situation. But their job there is not necessarily to supply the treatment. When you're doing the treatment, that reaction to the person shouldn't drive the process.
CONAN: Benedict Carey, another question for you. You wrote your piece before news came out about the DSM-5 and the inability to reach some sort of decisions about categorization. Is this, as far as you know, going to continue? Are there going to be more efforts, or is this just hands up in the air and let's wait till next time?
CAREY: I don't know the answer to that. I think that they - you know, it's such a big project that it needs some time to put together. Also, by the way, you know, in research areas, people like Mark know that, you know, that different people have different theories about this. You know, what should it look like? What should we call them? How do we diagnose them?
There's 20 different theories about that, and part of the problem they had this time around was reconciling those or choosing one. There was argument all the way through. So in order to do it entirely again, they're going to need some time. The plan is, I think, for this manual to be updated more frequently - let's say every year or something like that - and to give it a little different numbers, 5.1 and .2.
But something as tricky as personality disorders, I think, is going to take some time, and I think that they will try again. My prediction would be it's going to, you know, be another 15 years.
CONAN: Our guests are Benedict Carey, a science reporter for The New York Times, and Mark Lenzenweger, a professor of psychology at Binghamton University, professor of psychiatry at the Personality Disorders Institute at the Weill Cornell Medical College. We're talking about personality disorders, and you're listening to TALK OF THE NATION, from NPR News.
And let's get Deborah on the line, Deborah with us from Palo Alto.
DEBORAH: Hi. This is Dr. Deborah Rose. I'm a psychiatrist in Palo Alto, and I've been treating post-traumatic stress disorder for 40 years. And I'm concerned that one major factor that leads to personality disorders, as they're called, is being omitted from this discussion and basically from a great deal of American psychiatry, and that is the role of complex post-traumatic stress disorder or early childhood post-traumatic stress disorder.
Post-traumatic stress disorder - whether it occurs acutely in adults or early on and, in many ways, in children - leads to a kind of hypertrophy and distortion of the normal, otherwise developing personality. It hypertrophies the...
CONAN: Excuse me. I don't understand the word hypertrophy. Forgive me.
DEBORAH: I'm sorry. It - I'm sorry to be using it. It leads to an exaggerated growth of certain parts of a person's personality, which are the ways that a person would habitually try to protect themselves emotionally from inner - inside and outside emotional dangers and threats and also get kind of distorted. It's like a burl on a tree that is infected with something. And so you get distortions of personality, which lead then to often being diagnosed as personality disorders.
When I treat somebody for their early childhood post-traumatic stress disorder or their adult-onset acute PTSD, what you find is that as you free them from the PTSD, the personality remains, who they were really meant to be, biologically and then with environmental factors of family and the added environment. So the personality disorder goes away, and you get a normal personality, and this is tremendously overlooked and failed to be diagnosed by the vast majority of mental health professionals in this country.
CONAN: Dr. Lenzenweger?
LENZENWEGER: Well, I appreciate the view about personality disorder and trauma, and, in fact, that is actually a very large focus of contemporary clinical psychiatry and clinical psychology. We know, for example, that a large proportion of individuals diagnosed with borderline personality disorder have been exposed, horrific as it sounds, to early childhood sexual abuse and physical abuse and/or maltreatment. And that's well-recognized and viewed as an important environmental component adding to, you know, that mix of things that could give rise to a personality disorder.
Not everyone who is traumatized goes on to have a personality disorder, and not everyone who has a personality disorder has had trauma in their life. But I think it's important to point out that there are many people doing a lot of research and treatment on the role and sort of effects of trauma in and of themselves as well as in connection to personality disorder. So it's a big focus.
CONAN: Deborah, thank you very much for the call. And I'm sure you could go on from there, but I'm afraid we're out of time.
DEBORAH: Thank you ever so much. Best wishes to you.
CONAN: We appreciate it. And, Dr. Lenzenweger, thank you very much for your time today.
LENZENWEGER: Well, thank you. It's been a pleasure.
CONAN: Mark Lenzenweger, professor of psychology at Binghamton University, professor of psychiatry at the Personality Disorders Institute at the Weill Cornell Medical College, with us by phone from his home in New York. And, Benedict Carey, nice to have you back on the program, and we'll have you back in 15 years once they've sorted this out.
CAREY: That sounds good. It's a date.
CONAN: OK. Benedict Carey, science reporter for The New York Times, joined us from our bureau in New York. Up next, a truly incredible story. It's illegal to leave North Korea, but some small number of North Koreans get out with help from an underground railroad through Asia. Melanie Kirkpatrick, author of "Escape from North Korea," joins us in just a moment. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION from NPR News.