The nature of personality disorder and the importance of personal recovery concepts

In this post I want to provide a brief overview of the background to my research project: Experiences of personal recovery in personality disorder in community and forensic settings. I want to try and do this a little differently to how I would lay out the question in terms of a research proposal though and look at some of the more existential questions that I think arise from the research title.

Questions to answer?

I think that four main questions are raised relating to two definitions that need clarifying and, as this is a research project, explanations as to why these questions need addressing.

  1. What is personality disorder?
  2. What is personal recovery?
  3. Why study personal recovery?
  4. Why study personality disorder?

I’m not intending to provide any answers to these questions today – I have opinions, but I’m going to try my best not to share them. My beliefs are informed by my reading of the literature, but, I hope that during the course of my PhD I will be able to provide more direct evidence to, not answer, but explore these topics.

Neo-Szaszian?

Thomas Szasz (1920-2012) argued that the concept of mental illness could not be logically sustained; that only the body and not the mind could be “ill”. Existing, somewhat uncomfortably, at the frontier between mental disorder and society personality disorder represents a perpetual battlefield regarding the concept, and nature, of mental disorder. A recent article proposed that the diagnosis of, so called, Cluster B personality disorders (Emotionally unstable, dissocial, histrionic, narcissistic) represented a moral judgement on the part of the diagnosing clinician (Charland, L. C. (2006). Moral nature of the DSM-IV Cluster B personality disorders).

This criticism obviously needs addressing. Zachar (2011) does so by reviewing the possible nature of personality disorder as a diagnostic category.

What is personality disorder?

Zachar proposes four different possible interpretations as to the nature of personality disorder, listed here in ascending order relating to the strength of the claim:

Personality disorder represents an at risk state

In this proposal if personality represents a collection of individual traits, determined by previous experience and heritable temperament. Those with a personality disorder diagnosis are, by virtue of their personality construct, “at risk” of developing a more severe mental disorder; Schizophrenia, Bipolar affective or major depression for example. An analogy would be raised blood pressure of cholesterol.

Represents a pathoplastic state

Personality alters the experience, the phenotypic expression, of mental disorder – those with a personality disorder will experience more severe, protracted, episodes of mental disorder.

Exists on a spectrum with other mental disorders

This view suggests that personality disorder share a common origin with other mental disorders, that the phenomenology of mental disorder exists on a spectrum of severity with personality disorder at the milder end of experience.

Represents a deficit condition

Most physical illness leads to a deficit in functioning – a broken leg reduces mobility for example. In this, the strongest claim, personality disorder is proposed as leading to a functional deficit like any other disorder. One way to conceptualise this is to consider the psychodynamic theories of personality functioning, where we seek to balance unconscious drives against social pressures, societal norms. Personality disorder (and all other mental disorder in classical psychodynamic thinking) represents a failure to achieve this balance, resulting in distress and deficit of experience.

What is personal recovery?

The role of personal recovery in current mental health practice is still in development. Many mental health NHS trusts now specifically advocate recovery oriented practice as being the norm in mental health care. The precise nature of what is meant by personal recovery in this context is not always clear however. For the purpose of this discussion I want to provide three possible definitions of personal recovery as outlined by David Pilgrim (2008).

Recovery from illness

As for any physical disorder, recovery represents cure of deficit through treatment.

Recovery from impairment

Given existing deficits and restriction, recovery represents a rehabilitative approach in which the impact of any existing deficits are minimised.

Recovery from invalidation

The individual’s experience of life has been invalidated as a result of events. The individual will experience recovery as survival in the face of trauma.

In both the definition of personal recovery and personality disorder in this article I am not seeking to express a preference, or belief, I have my opinions but think at this point it is more interesting to open discussion.

Why study personal recovery?

I want to propose three reasons why it is important to study personal recovery. The first two relate directly to care for those with mental disorder and research into the evidence base for mental health treatment. The final point is a stronger, and perhaps, more interesting claim.

  1. Understanding concepts of personal recovery allows better specific tailoring of individual care
  2. It also allows outcome measure development (a topic I have now talked about on more than one occasion).
  3. Research into personal recovery may inform our understanding of the nature of personality disorder

Why study personality disorder?

There are various reasons to study personality disorder, primarily as it represents a common cause of significant distress. The precise nature of personality disorder is unclear however and, as I hope I have indicated here needs further detailed exploration. I have one additional, stronger, claim – that personality disorder represents a significant border area between psychiatric practice and society. I believe that by exploring the limits of mental experience, as in personality disorder, we can gain insight into the nature of mental disorder in general.

I’ve attached the slides from a talk I’m going to give on this topic in a couple of weeks – PD and recovery

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