Personality
Today’s blog is a mix of my personal thoughts on personality, the use and applicability of personality tests, the construct of personality ‘disorders’ (which I prefer reframing as pervasive personality patterns), and the constraints of the DSM. My thoughts are informed by both personal and professional experience and are likely to continue to change as I learn and as research advances are made. My thoughts are meant just to inform and entertain, and do not substitute therapeutic advice.
Regarding personality itself, current research tells us that our personalities continue to develop until we hit 30, and that after this age, personality patterns are more entrenched and more difficult to change. There are many different types of tests out there that claim to measure personality, yet only the Big Five has a robust evidence-base, with factor analysis having shown that personality can be measured across five traits: openness to experience, conscientiousness, extraversion, agreeableness, and neuroticism. Versions of the NEO are usually used to measure the Big Five traits. An older scale called the 16PF (sixteen personality factors) also does well and can be mapped onto the Big Five.
Yet when you look on the internet, you’ll notice that there’s loads more personality measures out there than those two, such as Myers-Briggs (MBTI) and Enneagram. While those are a lot of fun, neither have scientific evidence to back up their validity or reliability; meaning that what these tests are measuring is not specific enough for us to be sure that our results are not going to be drastically different each time (unless we get attached to a result and start teaching ourselves how to answer the test). Even though these measures are often used, they are essentially no more scientific than astrology.
Don’t let knowing this stop you if you’re having a good time taking these tests and if identifying with a personality type feels helpful and matches what others in your social circles are doing, though. I have taken those and all kinds of other questionnaires ever since I was old enough to access the internet myself (including silly ones such as what vegetable I am and what my spirit animal is), and do not believe it has done me any harm. Plus for some reason in the queer social circles I occupy, astrology signs seem to matter. Sagittarius and INTP here, if anyone’s interested (no sarcasm intended).
Pathologising Personality
This is the icky stuff where I have many complicated thoughts that are hard to articulate. I will try regardless, but please forgive me if my thinking is hard to follow in places. My main point of view here is that pathologising personality by diagnosing personality ‘disorders’ feels icky, which is why I prefer the term ‘pervasive personality patterns’ (or ‘pervasive maladaptive personality patterns’ when these patterns are clearly causing a person distress). When you look at the actual description of personality disorders in the DSM, you’ll notice that the DSM itself also describes the diagnosis as a pattern:
“A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the norms and expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.”
The term ‘disorder’ is used for every neurological or psychological deviation under the sun in the DSM, so it is likely that the authors never even considered that it could be stigmatising to label someone’s personality as ‘disordered’. Individuals carrying these labels have taken note, however – you may even have come across a meme where one person says “I really like your personality” and the other responds “Why thank you – it’s a disorder”. This same concern of course applies to other differences that are not amenable to change, such as autism (referred to as ‘autism spectrum disorder’).
Personality disorders have been included in the DSM since its first edition in 1952 (unlike autism, which did not quite make the cut until 1980). There are various personality disorders that no longer exist in the current DSM but that are still often referred to in daily language, such as passive-aggressive and compulsive personality. The current version of the DSM (DSM-5-TR) includes ten specific personality disorders and options to diagnose a personality change associated with a medical condition, as well as to provide an ‘other specified’ or ‘unspecified’ diagnosis (if someone does not neatly meet criteria or there is no time to specify what personality patterns someone experiences). The DSM acknowledges that the categorical classification of personality disorders that is currently still used may not be ideal, and there is a proposed hybrid dimensional-categorical model that retains six specific personality disorders and is measured based on functioning and traits as opposed to mainly on behaviour.
Of the personality disorders, ‘borderline’ is the most common to be identified, while it is also possibly the most disputed personality disorder. As the term ‘borderline’ has begun to carry such stigma and immediately leads to someone picturing a manipulative or even emotionally abusive individual, there have been multiple calls for a name change (e.g., to ‘emotion regulation disorder’ or to ‘emotionally unstable personality’ [the latter was interestingly a legitimate diagnosis in the first DSM]). There are also those who seek to abolish the diagnostic category altogether, with legitimate concerns about the heterogeneity in traits and experiences among those diagnosed with the condition, and with updated knowledge about how internalised autism and ADHD can present leading to ‘borderline’ being scrapped from many diagnostic records (as there is now a better explanation available for some clients). A borderline personality pattern (e.g., a push-and-pull in relationships to avoid perceived abandonment while inadvertently making rejection by others more likely) is also associated with complex posttraumatic stress and can be seen as an understandable response to attachment trauma.
Regardless of the validity and reliability of ‘borderline’ as a category, it is undeniable that the pattern’s prevalence has led to incredible research investment over the years, meaning that recognising a borderline pattern is often useful as it can inform treatment an individual is likely to respond to (with Dialectical Behaviour Therapy or DBT developed by Marsha Linehan considered first-line treatment). At the same time, it is important to consider the stigma ‘borderline’ as a full diagnosis carries, and to carefully evaluate a person’s story and experiences that have led them to seeking support, and make sure to first verify that there are no other explanations for their traits and challenges. The stigma around ‘borderline’ is carefully reducing: it is now acknowledged that borderline is treatable and that many people attain recovery; there are those disseminating information based on lived experience such as The BPD Bunch; and there are those reclaiming the label and calling themselves ‘Bordies’.
Other personality disorders that carry notable stigma include narcissism and antisocial personality disorder (the latter of which is equated to sociopathy and psychopathy in the DSM, although there is plentiful research and discourse out there that suggests that sociopathy and psychopathy are separate constructs, and that neither matches well with the DSM descriptors for antisocial personality). In daily discourse, abusers and criminals are often called narcissistic or psychopathic, which creates an easy barrier between ‘us’ and ‘them’. The problem is that this tendency makes us forget that people who meet these criteria are human beings who have their own stories, with them being the way they are often a complex interplay between biological and environmental influences. Narcissists are usually deeply insecure, have experienced attachment trauma, and continuously overcompensate to prove their worth. The ‘antisocial’ category, like borderline, is heterogeneous: it includes people who have intellectual or neurodevelopmental differences, who have experienced childhood adversity, who are low on the empathy spectrum, who often feel apathic and act out to stave off boredom, and more.
A recent book that explains the importance of reconsidering our vilification of these personality differences well is ‘Sociopath: A Memoir’ by Patric Gagne, who outlines her own journey to discovering how her brain works and how she can work with rather than against it. Her story closely matches that of many autistic individuals; she would observe people interact and mimic their behaviours so that she would not stand out and be ‘caught’ as someone who does not feel fear, guilt, or remorse. She wanted to do the right thing but did not have an intuitive compass to tell her what the right thing was, and was overcome by apathy and subsequent anxiety that could only be quelled by engaging in destructive acts. She is a succesful psychologist and therapist and eager to support those like her, and helps remind us that no neurological, psychological, or personality difference on their own is ‘evil’. People’s behaviour can be reprehensible, but lacking or having limited access to empathy on its own is not.
Continuous Learning
Science continuously evolves, and however slowly, the DSM changes bit by bit each iteration. It could be that the dimensional view of maladaptive personality patterns becomes the main one and that the category we call ‘borderline’ is eventually abolished, renamed, or taken out of the ‘personality’ section altogether. It could be that personality patterns become something secondary we can add to a person’s primary diagnoses, like we used to be able to do with the DSM-IV-TR multiaxial system, where mental health diagnoses went on Axis I and diagnoses relating to personality or intellectual functioning went on Axis II (with other axes for medical conditions, environmental factors, and global functioning).
Either way, as psychologists, it is important that we are committed to continuous learning and open to changes in our understanding of concepts and their definitions, as well as mindful of the impact these constructs have on our clients’ daily lives. The neurodiversity affirming movement as well as other movements, like the antipsychiatry movement, have made valid points about the cultural bias inherent in classification systems like the DSM. Homosexuality was originally in the DSM and removed in 1973, and there have been various labels for transgender individuals as well, with the current iteration of the DSM listing gender dysphoria but making it explicit that this refers to the distress experienced by a person’s gender and physiology not aligning, with gender non-conformity not seen as a disorder.
Many other labels have also been harmful and been used for practices that we have come to morally reject, such as eugenics. Pharmaceutical companies are also often too closely involved with diagnostic labels and research into their treatment, and health insurance companies will simultaneously fund specific interventions for those with specific diagnoses and subsequently not allow those same individuals access to life insurance. These decisions are based on risk profiles associated with diagnoses that are often merely descriptions of behaviour and that do not acknowledge that most psychological difficulties are transdiagnostic to begin with (i.e., they do not fit neatly into a box).
As a psychologist and diagnostician, I am mindful that I practice from within the constraints of the DSM while also acknowledging genuine criticisms and concerns around our classification system. My own understanding of the various neurological, psychological, and biological differences, traits, illnesses, and challenges that humans experience will (and should) evolve at a faster pace than a classification system like the DSM can, which needs consensus from a large group of peers that serve on committees for years before a new iteration is published. At the same time, the DSM remains our go-to diagnosis book and the book that is used by insurance, funding, and pharmaceutical companies, and discarding it completely is generally not the answer for clients needing to access support.
While this is not always the easiest balance, I am committed to upholding my ethical and professional responsibilities on all counts. In practice, this means that I sometimes have a conversation with clients about the quirks of the DSM when I know some of the language in diagnostic criteria might not fully affirm their neurology or life experience. I consider the diagnostic criteria holistically while aiming not to lose sight of my client as first and foremost, a human being. I may not always find the right explanation for each client’s challenges (in which case I would hope they seek a second opinion), but I will always give my all to help clients feel listened to, validated, and empowered to be their true self.
