PERSONALITY does not yield to ready analysis, and heaven help if it ever did. For years, the DSM’s Axis II section, where personality disorders used to reside, was by far its most problematic. It’s not that the old-timers in the field didn’t know what they were doing. To the contrary, their powers of clinical observation rivaled Kraepelin’s.
It’s just that organizing our destructive behaviors into neat symptom lists is simply asking too much. For instance, is someone who abruptly breaks off a friendship an “antisocial” individual with no remorse or a person with “borderline” who can’t cope? Perhaps your classic “narcissist” who cares only about him or herself?
The DSM-5 work group charged with updating personality disorders expressly recognized the limits of symptom lists when they proposed a parallel “dimensional” system to sit alongside a reformed “categorical” one. On one level, this would have allowed clinicians and their patients to effectively build their own diagnosis, much like IKEA furniture, based on interchangeable parts. On another, even using the old labels, the casual reader would have picked up an appreciation for how common personality traits (such as hostility and impulsivity) cut across numerous categorical lines and blur them.
In the end, institutional opposition proved too strong. The old symptom lists stayed, along with their impermeable categorical walls. A chopped-down version of the working group’s proposals was consigned to the back of the DSM-5 under the heading, “Alternative Model for Personality Disorders.”
Now that we’ve set the scene, we need to bring Dr Akiskal from Part I back into the picture. As you recall, Dr Akiskal has gone on record for his contempt of the borderline diagnosis, a position that put him in the forefront back in 1985 but has left him pretty much on his own in the second decade of this millennium. But this version of history is entirely misleading, and only makes sense if you think categorically, in terms of dueling symptom lists, bipolar vs borderline.
Dr Akiskal has been a dimensional thinker all his life, and this changes everything. If there is one thing bipolar and personality disorders experts can agree on, it is their contempt for the DSM and its rigid symptom lists. Thinking dimensionally literally begs for a new world view, a unification, a grand theory of practically everything. Here, perhaps unintentionally, Dr Akiskal has laid the framework for a reconciliation.
In two articles in the Journal of Affective Disorders in 2006, with the Brazilian Diogo Lara as his main collaborator, Dr Akiskal published what I refer to as his “fear and anger equation.” In a nutshell, Akiskal and Lara work from these two basic emotions to embrace nearly the entire universe of mood and temperament.
It almost doesn’t matter what appears in the equatioon or where we place things so long as we acknowledge the interplay of all the forces inside and around us and how each exerts an effect on the other. If we must include symptom lists, they exist as rough guides only.
Nothing is static, everything is changing. At the same time, though, hidden but pervasive is that strange entity—that mysterious dark energy of the universe—we refer to as “normal.” It may not appear on anyone’s map, as such, but the mere existence of such a map demands we direct our attention toward it.
So when we find ourselves touching down upon it—this strange place called “normal”—what can we expect? If fear and anger govern our lives, our “normal” is going to look an awful lot like a personality disorder. At the very least, it’s going to be consistent with any number of unenviable behavioral traits that leave us stuck in our misery and turn people against us.
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"Fear is the path of the Dark Side. Fear leads to anger, anger leads to hate, hate leads to suffering." Is all of psychiatry and psychology nothing more than a remedial attempt to catch up to Master Yoda?
The suffering cuts two ways. The individuals I encountered trying to set up a state DBSA certainly possessed in abundance this unbearable darkness of being. These were not happy people. But what really impressed me was their sheer unbounded enthusiasm in unloading their miserable surplus on others. I finally got smart and cut them out of my life, but not before a thudding sensation in my head told me I was about to sink into a monster depression.
Nevertheless, I owe these people a certain debt of reluctant gratitude. You see, in my campaign to figure out their behavior, I was forced to redirect my analytical focus on myself. Call it the Eye of Socrates—know thyself—brutal, uncompromising, unforgiving.
Freud had it wrong. He thought all our scary stuff lurked out of sight in the id, the sub-basement of our unconscious mind. But the actual reality show is going on upstairs, where numerous unwanted houseguests have turned up in our living room. Welcome to normal.
In some of us, "normal" may be equivalent to sharing a fine wine with our cultural folk heroes. My version would involve having Einstein and Louis Armstrong and Eleanor Roosevelt drop by for a beer and buffalo wings. Nikola Tesla and Emily Dickinson, too. On my good days, I almost feel my neurons resonating in harmony, all those traits that reflect the best in our nature.
But then Attila the Hun turns up demanding protection money and the reality show spins into its next phase. So it goes …
Facing Up to Borderline
I do not want wish to leave the impression that I am describing a THEM vs US situation. We all have personality issues we must deal with, and in my observations these often pose a greater problem in our recovery than our actual illness.
Accordingly, I urge individuals to study the personality disorders as if each one applied to them.
Psychiatry and its allied disciplines will never figure out personality to everyone's satisfaction, and it would be a sad indictment on our uniqueness as individuals if they ever did. But you can employ these various diagnostic rough guides to connect your own dots, fill in your own blanks, and get to know yourself better.
In the meantime, whether you meet the threshold for a borderline diagnosis or not, dialectical-behavioral therapy - a form of cognitive therapy directed at reconciling apparent opposites - is extremely useful, with a very high success rate. Meds may help in the sense of slowing down an over-reactive brain, but they cannot turn destructive behavioral traits into constructive ones. The best biological weapon in this case is using the brain to change the brain.
DBT lays heavy stress on the practice of mindfulness - the mind watching the mind - which can be a tall order when your brain won't cooperate, but even a minor improvement is a major achievement.
We think of personal change as drawn-out and incremental, but quantum breakthroughs are fairly common, of entire neural networks realigning in response to new habits and eye-opening realizations. Never give up on yourself ...
Revised June 27, 2016
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