Almost everyone is pretty screwed up. That's not my opinion, that's official - according to a new paper in the latest British Journal of Psychiatry.
Make sure you're sitting down for this. No less than 48% of the population have "personality difficulties", and on top of that 21% have a full blown "personality disorder", and another 7% have it even worse with "complex" or "severe" personality disorders.That's quite a lot of people. Indeed it only leaves an elite 22.5% with no personality disturbances whatsoever. You're as likely to have a "simple PD" as you are to have a normal personality, and fully half the population fall into the "difficulties" category.
I have difficulties with this.
Where do these results come from? The Adult Psychiatric Morbidity Survey, which is a government study of the British population. They phoned up a random sample of several thousand people, and gave them the SCID interview, in other words they asked them questions. 116 questions in fact.
48% of people answered "yes" to enough questions such that, according to their criteria, they had "personality difficulties". They defined "personality difficulties", which is not a term in common use, as being "one criterion less than the threshold for personality disorder (PD)" according to DSM-IV criteria.
So what? Well, as far as I'm concerned, that means simply that "personality difficulties" is a crap category, which labels normality as pathological. I can tell that most of people with "difficulties" are in fact normal because they are the literally the norm. It's not rocket science.
So we can conclude that "personality difficulties" should either be scrapped or renamed "normal". In which case the weird minority of people without any such features should be relabelled. Maybe they are best known as "saints", or "Übermenschen", or perhaps "people who lie on questionnaires".
This, however, is not what the authors say. They defend their category of Personality Difficulties on the grounds that this group are slightly more likely to have a history of "issues" than the elite 22.5 percent, e.g. homelessness (3.0% vs. 1.6%), 'financial crisis' (10.1% vs. 6.8%), or having had treatment for mental illness (11% vs 6%).
They say:
The finding that 72% of the population has at least some degree of personality disturbance is counterintuitive, but the evidence that those with ‘personality difficulty’ covering two out of five of the population [it's actually closer to half], differs significantly from those with no personality disturbance in the prevalence of a history of running away from home, police contacts, homelessness... shows that this separation is useful from both clinical and societal viewpoints.
Here's what I think is going on:
The "difficulties" group and the "none" group are essentially the same in terms of the levels of crap stuff happening to them - because they are the same, normal, everyday people - except that a small % of the "difficulties" group do have some moderate degree of problems, because they are close to being "PD".This does not mean that the "difficulties" category is good. Quite the reverse, it means it's rubbish, because it spans so many diverse people and lumps them all together. What you should do, if you insist on drawing lines in the sand, would be this:
Now I don't know that that's how things work, but it seems plausible. Bearing in mind that the categories they used are entirely arbitrary, it would be very odd if they did correspond to reality.To be fair to the authors, this is not the only argument in their paper. Their basic point is that personality disturbance is a spectrum: rather than it being a black-and-white question of "normal" vs."PD", there are degrees, ranging from "simple PD" which is associated with a moderate degree of life crap, up to "complex PD" which has much more and "severe PD" which is worst of all.
They suggest that in the upcoming DSM-V revision of psychiatric diagnosis, it would be useful to formally incorporate the severity spectrum in some way - unlike the current DSM-IV, there everything is either/or. They also argue that with more severe cases of PD, it is not very useful to assign individual PD diagnoses (DSM-IV has no less than 10 different PDs) - severe PD is just severe PD.
That's all fine, as long as it doesn't lead to pathologizing 78% of the population - but this is exactly what it might do. The authors do admit that "the SCID screen for personality disorder, like almost all screening instruments, overdiagnoses personality pathology", but provide little assurance that a "spectrum" approach won't do the same thing.
Yang M, Coid J, & Tyrer P (2010). Personality pathology recorded by severity: national survey. The British Journal of Psychiatry 197, 193-9 PMID: 20807963
24 comments:
Ok... so I have this radical idea. What if, just what if, instead of requiring people to have a disorder in order to access services, we found a way to offer help and assistance to people without giving them a lifelong label of anything?
What if instead of calling Bobby who struggles with sports a "sports difficulty disorder" case, we said, the kid needs some extra pratice and coaching. And possibly some guidance picking a hobby where he might have some more skill.
I think psychologists and the ilk, really want to expand diognostic criteria so that they can get services to as many people as possible. Sometimes because of $$, but also because this is the life philosphy of the practice. They believe the more people they can get services to, the more they can help the world. That right there might need to be examined, but it also might not. What if EVERYONE benefited from some targeted counseling/therapy/training in areas of struggle etc?
If so we shouldn't consider these services as applicable to "mentally ill" but as applicable to human beings in general. We would then not be required to bombard the population with labels and disorders in order to offer them some assistance that might improve their lives.
Would be fun to repeat the study with mental health professionals...
The 78% figure is just a bit silly and undermines the whole validity of these diagnostic constructs.
More importantly, is it really true that 1 in 5 of the population meets criteria for full-blown PD?
Really? Reeeeeally?
The central belief in such studies is that we can obtain independently valid clinical data from structured interviews like the SCID. This is a bad case of the tail wagging the dog. The central belief is a central conceit.
Structured interviews were introduced into clinical research as a way to check clinicians’ diagnoses, which often were impressionistic or even idiosyncratic, with a standardized review of the patient’s symptom domains. So, careless clinical diagnoses that did not actually meet diagnostic criteria could be caught. Another benefit is in detecting comorbidity – the structured interview asks about symptom domains that the clinician might ignore because of premature diagnostic closure, which is a well known cognitive trap.
It is a far cry from there, however, to sending non-clinician interviewers into the field armed with something like the SCID, hoping to obtain valid epidemiological data. It is even worse when, as in this case, the interviews are performed over the telephone. You captured the absurdities very well in your post, NS. Thanks.
Presumably SCID-II.
I actually isn't completely counterintuitive to talk about the majority of people having a pathological problem, e.g. if we all become obese that doesn't make obesity non-pathological.
In terms of 'personality difficulties' I'm not massively opposed to that concept - but then we have to make it clear that personality disorders are just personality traits that are dysfunctional - I can quite easily see that half the population have personality charactristics that are to some extent dysfunctional.
If they're emphasising the spectrum nature of PD that's a good thing isn't it?
All this shows is that 'normal' is an abstract concept with no inherent meaning. There is no normal, you can't average out personalities and say that's the mean.
The whole preposition is absurd. To me this is more like creating job security.
It's like the obesity paradox, if you start to narrow the band of what's normal weight many more people become obese and you can sell your product (healthcare in general).
Here one makes this meaningless 'standard', gives it meaning as being the 'norm' and hey presto: as many anormal people as you need/want.
@pj
"I can quite easily see that half the population have personality charactristics that are to some extent dysfunctional."
Yes, but who defines 'dysfunctional'? Psychiatrists?
Are they experts in the 'good life'? Must we adopt the SCID as a guide to how not to live our lives? Are Widiger, Livesely and the rest of the DSM-V committee on PD modern day Aristotles?
Perhaps psychiatry should publish, as an appendix to DSM-V, a guide on how they think we should live our lives? A clear statement on the sort of people they would like us, the public, to aspire to.
(Actually, if you look at the personality disorder proposals in DSM-V you'll see that they've done just that.)
Maybe it's my personality disorder, but it makes me want to tell them to f**k off.
The severity model makes sense on an intuitive level (I understand the 'usefulness' of intuition in science). I know a large number of people who have been diagnosed with depression. However, the severity of the disease varies among individuals and within an individual depending upon time and circumstance.
And what it is true ? What if the world is divided into just two groups ? Nuts, and nuts who lie on questionaries ?
You say that by definition the majotity can not be nuts ?
Imagine that every person on the planet would get flu at the same time. Would flu cease to be a disease ? I think it would be still a contagious disease no matter what percentage of population is infected and what is not.
I'm with you PJ. How many people have suboptimal health? I'd say close to 100% of people could improve their diet, get more exercise, get some medical treatment for a few low-level ailments, and/or lower their stress level.
Of course, you can say that this is all part of life's rich taspestry, we all love the jolly fat bloke who lives down the street, even if he's prediabetic at 25, and we love Aunty June who watches too much TV and never exercises but she's got that great cynical sense of humour, and our the sweet kids who eat too much high-carb food, and blah, blah, blah.
Ditto for mental health. It doesn't mean that we all need to be put on some kind of extreme remedial program; it's just a obvious fact that we could all be doing a bit better with our mental and physical health.
The big difficulties with mental health is that it's very difficult or impossible to assess reliably, except perhaps in extreme cases, and while there are treatments, they aren't either clear or reliable. Mental health is in the state that physical health was a few hundred years ago, no reliable diagnoses, no reliable treatments, and all kinds of crazy ideas floating around, not just from the mental health industry, either.
But there's a deeper and more subtle reason this kind of post produces so much recreational outrage. It's not that we are perfect, or near perfect, or even doing pretty well considering, or any factual statement to do with our mental and physical health. It's that our mental health is bound up in complex ways with our self-narrative. We are biologically programmed to believe that we are better, smarter, stronger, healthier, more important, more above average than we are. This is basic evolutionary biology. If you want to lead the tribe, get the best or any sexual partners, and go to the front of the food queue you have to believe this. The effect of not believing it is immediately felt - for extremely powerful biological reasons it's a physiological "downer" and so we react angrily if anyone tells us so. We're not given to nuanced positions on our own mental functioning.
It's not obvious what's to be done about this. Believing that we are sane and capable is a necessary condition for being sane and capable. Funny how people identify with the conscious activity of their higher brain a lot more than their liver function, isn't it? Cancer used to be considered shameful and there's a movement that aims to do the same for depression; demythologise it down to a practical problem with practical management. But to do so, we have to recognise it that it's an ordinary, natural part of being human and that's an affront to the immaculate self.
Well, take Buddha as the standard "norm" of experiencing esoteric ineffable "Happiness" 24/7 for not being weird. I am sure 99.999% of people can be called as "pretty screwed up" including the authors for this type of survey!!
And by the way, if you extend the runway into the PD column before taking off into air in Fig 1 (just you did the take off a little ahead of PD), the percentages will change.
"...in other words they asked them questions. 116 questions in fact."
Statistics Canada called me two weeks ago for the "Labour Force Survey". They asked roughly thirty questions. After eight I was bored and just started to make shit up. How accurate could a 116 question phone survey possibly be? By question 43 they'd be talking to my cat... which might explain the "48% of people have a PD" number.
I think it's important to keep in mind that these sorts of tests are next to useless as a screening tool for a normal population.
The pre-test probability needs to be taken into account. For example, a positive result in someone you already suspect has a personality disorder is more likely to be a true positive.
A positive test result on random people is much more likely to be a false positive.
PJ & jim: Sure, it's quite possible for everyone to be ill at the same time.
However in the cases of flu and obesity, what this means is that everyone is abnormal relative to a previous, healthy baseline.
Even if everyone in the world became really fat, we would still be unusually fat, because we would be fatter than people from previous generations.
However this survey isn't comparing people to any real healthy baseline. It's comparing people to the ideal baseline of "not answering yes to any of these questions". What the data show is that it is normal not to meet that ideal.
That either means we're all screwed up, or it means the ideal is unrealistic. Given that the ideal is something dreamed up by a bunch of psychiatrists who wrote DSM-IV (and even they didn't intend personality disorder criteria to be used in this way) I suspect it's the latter.
Re: definitions of 'dysfunctional' - I think screwing your life up sufficiently to need referral to a psychiatrist is a good operational definition!
In terms of the question of whether 'we're sll screwed up' it depends what you do with the category - if you pathologise large parts of the public bthat's bad, if you use it to emphasise thhat pd is part of a spectrum of 'normal' behaviour I'm ok with that
...pathologizing 78% of the population...
Which is just plain freaking nuts. This is psycho-ideology gone berserk. Like the 'finding' a while back that about half (?) of patients seen in general practice/primary care will be suffering from a somatisation disorder.
Yeah right. Couldn't possibly be that the medical profession simply does not yet have a proper explanation for these patient's problems, and does not want to admit it. No, couldn't possibly be that at all. Must be those delusional patients, furiously psycho-somatising away. Yep, that's it. Problem explained, if not solved.
Everyone is normal, for differing definitions of "normal". How can anyone sit through a 116 question phone survey and not get bored, lose their train of thought (and start doing something other than paying attention to the questions being asked), make up answers for fun, etc.? Who knows, maybe a bunch of people got caught on a crap day? How can anyone begin to pretend the results of a poorly designed survey are projectable across a population? Sheesh.
As for me, without my meds, I am definitely not "normal".
It's stupid studies like this that give mental health practitioners a bad name and trivialize people who come from real dysfunctional families and have severe problems.
The SCID-II Questionaire is a symptom checklist (Checklists are always inadequate to make a psychiatric diagnosis) which was DESIGNED to have a lot of false positives (that is, people who seem to meet criteria on the questionnaire but do not really have the disorder in question).
The reason for this is that it is supposed to be followed by a SCID interview that examines the criteria in more detail, and asks important follow up questions.
The preliminary questionnaire is given to save the examiner time because you don't have to inquire about the questionnaire items with a "no" answer, since they are very unlikely to be positive.
If the questionnaire was all that was given, then the estimates of personality disorder prevalence will of course be way higher than it really is.
As for the definition of a dysfunctional family, it's like pornography - hard to define in words but you know it when you see it. Good therapists aren't dealing with trivial stuff, but with severe child abuse, neglect, domestic violence, absent or totally inconsistent disciplining of children, extreme invalidation, frequent double message giving, and the like. Ain't subtle!!!
"Ok... so I have this radical idea. What if, just what if, instead of requiring people to have a disorder in order to access services, we found a way to offer help and assistance to people without giving them a lifelong label of anything?"
How about if people who have problems, but are not mentally disabled paid for their own services rather than "have services paid for them?"
"Re: definitions of 'dysfunctional' - I think screwing your life up sufficiently to need referral to a psychiatrist is a good operational definition!"
But when the mental health professionals are the ones defining what screwing up you life means, then, well, they hold the ball so to speak.
"But when the mental health professionals are the ones defining what screwing up you life means, then, well, they hold the ball so to speak."
If you have a personality disorder then, execept for the rare cases of DSPD, the mental health professionals don't have much control over you - most people aren't forcefully labelled by the mental health professionals, they come to see them because of their dysfunction and distress.
Reasons for moving--- I did not mention money at all.
In order to get a person to come in for treatment (that they are paying for our of pocket if you prefer) we still need to have a reason for them to come in for services right? If people believe the only way they should seek services is if they have a severe mental health crisis, then they won't be as likely to go in for services.
If service providers think they are only supposed to treat something that comes up in diagnostic criteria, than if the diagnostic criteria are not given loosely, a provider would be responsible for rejecting some people for services due to them not having an real issue.
But that's not how it works right? If you walk into a therapists office, they are going to treat you. The question is not "if", it's "how". Therefore with this treatment philosophy, making the diagnositic criteria vague allows professionals to treat anyone who walks in their office and still feel they are behaving ethically.
Also they get more money... whether it's out of pocket, or paid for by peoples insurance.
Further more I've seen a lot of interest in pulling more people in for treatment. Therefore, again, opening up the diagnostic criteria is again useful because we can tell everyone that two thirds of the population has personality disorders and need lots and lots of continual therapy.
This study just seems so silly that I'm not sure there is anything sinister going on other just a bad study.
Thomas Armstrong takes this on from in his book Neurodiversity. It is an interesting book. http://www.odemagazine.com/doc/70/Your-brain-is-a-rain-forest/all
I think psychologists and the ilk, really want to expand diognostic criteria so that they can get services to as many people as possible. Sometimes because of $$, but also because this is the life philosphy of the practice. They believe the more people they can get services to, the more they can help the world.
I truely think you hit the nail on the head there. It is in the nature and philosophy of mental health professionals to push their wares into ever new expanding markets even if their subjective motivation is purely altruistic. Sure, maybe everybody should get counseling even if you don't have a "disorder" per se. I think most therapists would be happy with that. But, the question is, who is going to pay for it? If you pay for your own counseling, I don't think anyone cares what label you end up with, but when insurance pays and Medicaid pays, then people care. I think there is a serious ethical problem when professionals construe everyday problems as a serious disorder just so they can be reimbursed by insurance. Not only is it borderline fraud, the costs get passed on to all the insurance clients and, in the case of Medicaid, all of us (those of us who pay taxes anyway)
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