For those of you fortunate enough to have no clue what that title means, either
a). Enjoy your final moments of bliss, or
b). Stop reading and continue such bliss (perhaps at your peril).
For those of you who do know what the title at least could mean,
a). Just wanted to let somebody on this planet know that if I read that phrase one more time, I’m going to start smashing windows, and
b). Given that I will most likely read that phrase at least one more time before noon today, I am going to start a multi-day rant instead. Be warned.
Or how about this: I’ll rant for a while, then I’ll get serious. Again, be warned. About both.
Back to those of you without a clue . . .
Let me reveal some dirty little secrets of my profession. First, about our Sacred Scripture in psychiatry, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (known far more lovingly as DSM-IV-TR):
First sub one: Have no fear. The Fifth Edition cometh, brought to you by the most august group of scholars assembled since the translators of the King James. Thy redemption draweth nigh.
First sub two: Until that glorious day, you–and, yes, I–are stuck with Edition Four.
Sub three: We must consult it day and night, without ceasing, for within it are powerful truths.
Sub four: Many of us (if not most) in mental health basically ignore DSM-IV our every breathing moment except when we have to submit a bill; determine a disability payment; talk to a lawyer; try to impress our teachers/colleagues who are so-much-smarter-than-we-are (probably the most common reason); or want to send out a secret code to other clinicians, kind of like those fires set from hill to hill by the beseiged Men in Lord of the Rings.
Second: it is to this code that I wish turn our attention.
One of the deep truths (and fun facts to know and tell) of the DSM is that our emotional lives can usefully (and in the view of some, definitively) be categorized into two groups: Axis I disorders and Axis II disorders. These two groups may easily be differentiated from each other as follows:
Axis I: Poor Souls
Axis II: Losers
Fleshed out a bit more: in the view of many, the Axis I Disorders are the real psychiatric disorders, ones such as schizophrenia, depression, substance dependence, eating disorders, Alzheimer’s, you get the drift; stuff you don’t want to have, but for which you do not necessarily have to tred the walk of shame every time you darken the door of a mental health clinic.
In contrast, the Axis II Disorders are (for our present purposes, essentially exclusively) the Personality Disorders. And indeed, that’s as bad as it sounds. In the view of many, your whole personality is screwed up–understandably, of course, and with neurobiologic underpinnings, have no fear, and with our deepest respect for the complexities of the human spirit, naturellement. But I repeat: you’re screwed up–again, at least according to many.
Funny thing is: many of these many clinicians are loathe to actually make an Axis II diagnosis. It’s as if the very act of naming itself is somehow the height of impoliteness, akin to taking the last roll in the bread dish without asking permission.
Fear not, though, for there are traits!! In other words, the patient doesn’t actually have to have a personality disorder, but rather can merely have personality traits. It’s an ingenious device, truth be told. Now one can warn all comers (remember the fires?) that “this person ain’t no picnic to deal with” without having really to put one’s money where one’s mouth is.
Even more fun: you have different kinds of traits to choose from. You can choose Cluster A traits, the traits of those whom some might call a bit “different.” You can choose Cluster C traits, the traits of those whom some might call a bit “uptight.” Or, best yet, you can choose Cluster B traits, the traits of those whom some might call a bit “over-the-top pains-in-the-neck.”
The fun continues: Cluster B traits come in four varieties, all of which can be mixed and matched at will:
1.) Borderline Traits, or “Good Lord, man/woman, can’t you pull your life together?” or
2). Histrionic Traits, or “Cut the drama, will ya?” or
3). Narcissistic Traits, or “You’re a jerk and I want to slap you,” or
4). Antisocial Traits, or “You’re a jerk and you make me want to check my wallet.”
And finally, most fun of all: today, somewhere in the great land of ours, who knows how many times, some combat veteran is going to get the diagnosis of Cluster B Traits.
Time to get serious.
Personality disorders are real, and they can be quite devastating, often to the patients themselves, almost always to the persons around the individuals with the personality disorder. Borderline personality disorder, for example, is an extremely emotionally-painful condition in which individuals, usually who have suffered severe trauma as youngsters, struggle with tremendous emotional upheavals in the context of their closest relationships. Personality disorders are not something to take lightly.
But, then, that’s the point. Because individuals with personality disorders are often challenging to deal with, clinicians can often be quite cavalier when discussing them, leaving one with the sense that in the hands of some, all the diagnosis of “personality disorder” or “personality traits” tells you is that the diagnostician didn’t feel treated well enough by the patient, darn it.
Even more importantly, emotional upheaval per se does not equal “personality disorder” or “Cluster B traits.” Combat veterans have plenty of good reasons to be in emotional turmoil–and not necessarily be pleasant 24/7 about it, even with their I’m-here-for-you therapists or prescribers. The fires in the lands of Men are often false alarms. It is not the goblins who are coming. It’s the men and women who are depending on somebody in this world to understand that sometimes it hurts too much to be nice.
Therefore, let’s next consider what “personality disorders” actually are. Before then, though, I’ve got to sweep up some shards of glass.