Category Archives: Personality Disorder

BORDERLINE PERSONALITY DISORDER: INTRODUCING A TRILOGY

connor-kinsella-jck-training Sian5 

I’ve known Siân Lacey Taylder for many years. A shared masochistic love of a) writing and b) a non-league football team sort of brought us together a long time ago, but it was much later on I discovered her history of Borderline Personality Disorder (BPD). It never was and still isn’t a big deal to me, and I can’t actually remember how I came to know, probably because it doesn’t matter. I love her writing, she’s thoroughly individual and supports Weymouth Football Club, so that’s quite enough for me.

But there is one area where perhaps we’re not quite on the same team. I spent many years as a mental health nurse, particularly in forensic secure units. Siân has spent many years living with BPD. I’ve helped physically restrain people like Siân, usually in an attempt to stop patients gouging their eyes out or rip their arm to shreds with pieces of glass. If some parts of the blogosphere and Twitter are to be believed, I’ve more than played my part in a rather nasty, controlling, self-serving, stigmatising and hugely anti-therapeutic mental health ‘system’. And Siân has been one of our victims. We shouldn’t get on. But we do.

We first posted these articles in the summer of 2012 following a conversation where I moaned about my fellow mental health professionals being at least under-appreciated and at worst, branded as some sort of fascist movement dedicated to making the lives of the mentally ill as impossible as possible. So taking her own experiences of BPD and often less than positive contact with ‘the system’ as a starting point, we thought we’d put this series together.

A recent Twitter discussion on the @mhchat community featured BPD and while I didn’t catch it ‘live’ it certainly caught my attention later, not least because of a number of comments from service users highlighting some of the issues which had precipitated the original series, and the fact that as a trainer I’m currently rewriting and updating a shortish book on personality disorder aimed at mental health professionals and community mental health workers. I could have just posted a link but soon discovered that WordPress had somehow mangled the formatting of the original work so here I am rewriting and reformatting my contributions while leaving my collaborator’s  contributions in their original and, in my opinion, highly readable state.

Part 1 is a very personal account of BPD from Siân herself. She describes the ‘good Siân’, the ‘gregarious, outgoing, quirky, generous’ person who is very good company and makes people like me like her very much. And she describes the ‘bad Sian’. The one whom ‘mental health professionals would like to eradicate from the face of the earth.’

In Part 2 she looks at some of the pitfalls of the mental health system and how labels such as ‘Borderline’ have proved so spectacularly unsuccessful at describing or helping someone as atypical as she is. But (and it’s a big ‘but’) do professionals and service users really have to be so many poles apart, and might we work together more effectively?

Finally in Part 3, I put a mental health professionals viewpoint on Siân’s observations. And while certainly not agreeing 100% with all she has to say, I ask if it’s possible for both the online and real-world camps of professionals and survivors to ‘put down the weapons’ and work more collaboratively, more imaginatively with a disorder which is so often castigated and misunderstood by so many.

BORDERLINE PERSONALITY DISORDER: PART 1 OF A GUEST SERIES FROM SIAN LACEY TAYLDER

 Sian5

When Connor very kindly asked me to contribute to his excellent blog from the perspective of someone living with BPD (Borderline Personality Disorder) I think he was preparing himself for a metaphorical kicking. ‘I’m getting a bit hot under the collar over the survivor movement’s constant haranguing of the mental health professions’ he told me, as if he could almost feel me winding myself to vent my spleen.

I want to say ‘it ain’t so’ but that would be telling an untruth. The two sides of the equation – let’s call them ‘the professional’ and ‘the patient’ – ought to be travelling in the same direction, should, really, be striving for the same goal but I would suggest that isn’t always the case.

Why? Surely ‘the professional’ works with ‘the patient’ and in her/his interest? To answer that question I would like to describe, in sometimes quite graphic detail, the ‘realities’ of living with BPD and its various relatives (amongst others Narcissistic Personality Disorder, Paranoid Personality Disorder). Forget, for a few minutes, any textbook or clinical definitions, put any preconceptions to on side and try to see how from my perspective.

Let me begin by stating the bleeding obvious. There is no typical BPD ‘sufferer’ and maybe the condition lends itself to a greater variety of manifestations than other, similar, maladies. There is no one-size-fits-all and therein, I think, lies the first of the problems I would argue that the mental health profession – not necessarily the practitioners but the managers and commissioners, still believe in a universal panacea.

That stipulation – not necessarily the practitioners but the managers and commissioners – will become a recurring theme.

Some of the clichés are true enough. The underlying theme is one of instability and insecurity, in every aspect of life: emotional, professional, financial. But ‘instability’ is a pejorative term; in the mindset of the mental health professional it’s symptom of BPD that really must be cured and I think that’s something we need to address.

More of that anon. I haven’t yet mentioned the almost fanatical devotion to extremes. Everything is black or white; there can be nothing inbetween. Grey represents tedium and orthodoxy, the mediocre and the banal; characteristics that should not just be avoided but sought out and destroyed at all costs. I once had a psychotherapist who tried to persuade me that the grey was, in fact, in silver. I was lost in a haze of antidepressants at the time and she very nearly fooled me.

Very nearly, but not quite because deep down inside, you see, I don’t want to be ‘cured’. I’ve become so viscerally hostile to anything that might be construed as conformity or compromise that it might appear, to the neutral and/or relatively rational observer, that I seek out adversity even in places where it doesn’t really exist. For example, writing this essay – some would call it a rant – I soon realised that I wanted the reader to either love me or hate me; the last thing I desire is pity because pity is the preserve of the weak and the wretched. I don’t so self-pity, I don’t do misery; I only do self-destruct.

And that’s the Narcissistic aspect of BPD. I’m so often overcome with loathing for my fellow human beings that I could easily be mistaken for a misanthrope. Yet when I love someone I love them with a passion that soon veers into self-destruct. I rarely vent my anger on others; hatred – and violence – always turns in on itself.

BPD has led in more directions than there are points on the compass. On the negative side it fuelled a latent gender dysphoria which ended up in gender reassignment surgery (in tabloid talk that’s a sex-change). It’s brought me to the verge of alcoholism and anorexia and encourage – yes, encouraged – me not only to self-harm but to revel in it; for several years gin and a sharp blade were my constant and sometimes exclusive bedfellows and I would literally spend hours gazing lovingly at the rows of knives on display in my local supermarkets. I tread a thin line between wealth and destitution; I’m perennially in debt because I don’t understand money in the same way as many of you do. If it’s there, I spend it; if it’s not, I borrow or blag and something always comes up in the end.

You can see how it can lead to a precarious existence. One more than one occasion BPD compelled me to quit my job, my home and my family to seek refuge on the other side of the world but guess what? Those bastard little demons saw it coming; they packed their bags and followed me; they turned up in El Salvador 48 hours later on my hotel doorstep.

You don’t believe me? Ask the duty manager; he’s the one who talked me down. And he didn’t laugh when I told him that although I hated those bastard little demons I couldn’t live without them. If there’s one phrase that defines the nature of my BPD it’s my relationship with those bastard little demons; I’m drawn to that which ought to repel me. Like a moth to a flame.

Finally it drove me to two overdoses, the latter of which was, I concede, pretty damned stupid and could well have proved fatal. But I survived. And you know what I’m going to say next, don’t you?
I don’t regret any of it.

Because, ridiculous as it might seem, there are positives and even if they appear to you to be vastly outweighed by the negatives, and if you were to offer me a pill or a course of therapy that put everything on an even keel I’d tell you where to stick it. What you call normality I call subservience; what you call instability I call a voyage of self-exploration. You’ll note how everything revolves around the self; the ego is the sun around which the rest of humanity must revolve. There are those who know me who would speak of my gregarious, outgoing personality – and that’s the key word, isn’t it? Personality. They would describe me as generous of spirit, intelligent, quirky and good company but they would be describing the ‘good’ Siân; some of them have known me long enough to come across the ‘bad’ Siân but she keeps herself to herself; locked away in her own little world.

The ‘bad’ Siân, of course, is the Siân the mental health professionals want to treat. They’d like to eradicate her from the face of the earth. Trouble is, more often than not I prefer the ‘bad’ to the ‘good’ and I don’t want to be rid of either.

Still with me? Well done! Now, with Connor’s permission I shall, in the second and concluding part of this polemic I shall endeavour to find some common ground on which mental health professional and service users might meet and smoke the pipe of peace.
It’s not going to be easy!

Siân is author of The Society of Sin, a Victorian Goth-erotic fiction inspired by her Dorset connections, and is currently in the process of publishing her autobiographical novel Death by Eyeliner. You can find out more about her here.

BORDERLINE PERSONALITY DISORDER: PART 3 OF A TRILOGY FROM SIAN LACEY TAYLDER AND CONNOR KINSELLA

connor-kinsella-jck-training 

As an author and trainer I’ve written enough about mental health to wallpaper a small room. I’ve travelled the length and breadth of the country running courses on personality disorder, and can list the DSM-IV diagnostic criteria while hopping on one leg and loading the dishwasher. I’ve also spent many years working with personality disordered people in secure units, in acute admission wards, in the community. I’ve spent literally hours at a time trying to prevent patients gouging out their eyes, setting fire to themselves or trying to hang themselves with a bath towel, all the while trying to avoid the saliva aimed at my face and blotting out the screaming and shouting with ‘nice thoughts’ about home, family and the post-shift kebab. 

So I know a lot about BPD, then? Er, actually no.
Before reading Siân’s posts I assumed, with the eyes of one who has for many years seen BPD from the ‘professional’ side of the ward or treatment room, that BPD rendered a more or less constant diet of chaos, misery, institutionalisation and sometimes death. Through training and writing I try hard to dispel the idea that all individuals with BPD are manipulative, wildly emotional and self-destructive, but if you’re paid to treat or support people with this diagnosis, it’s always seen as bloody hard work and universally unpopular.
I was keen to hear Siân’s account of her encounters with ‘the system’. I’m certainly no apologist for the many, many faults of a mental health structure which has not so much failed over the years but never really got it’s act together in the first place.
As Siân puts it, we have: “A system that insists that mental illness is no longer taboo but hasn’t yet worked out how to deal with it. Whether through ignorance, lack of funding or wilful desire, it just doesn’t take us seriously.”
And it’s just this sort of voice I wanted readers to hear as opposed to some of the increasingly ‘shouty’ anti-psychiatry stuff spouted on just about any online forum having the words ‘mental’ and ‘health’ in the title. I asked Siân for a service user perspective that might inform and stimulate without stereotyping all mental health workers as a battalion of burnt-out, syringe brandishing stormtroopers whipping out section papers at the mere suggestion of deviation from the cultural norm.
To quote Siân again: “The two sides of the equation – let’s call them ‘the professional’ and ‘the patient’ – ought to be travelling in the same direction, should, really, be striving for the same goal but I would suggest that isn’t always the case.”
No it most certainly isn’t, for reasons that are far more widespread and complex than can be tested on the attention span of our readership. But I’d like to think that my guest blogger has eschewed anti-psychiatry polemic for a considered argument as to where at least some of the problems emerge. Siân highlights a rigid mental health care bureaucracy focussed on crisis management and firefighting, often where an inferno might have been averted with the pre-emptive application of a damp tea towel. And please let’s not have any ‘lack of resources’ argument here. Early intervention can save lives AND money.
At the more individual end of the scale, Siân offers us a glimpse of the ‘piss poor professional’. This is a phenomenon I know only too well as being far too common in the caring professions and about which I’ve guest posted in the Not So Big Society blog.

I probably don’t agree wholeheartedly with everything Siân argues. As a self-confessed science nerd I’m actually quite excited by much of the recent research evidence pouring out of the world’s ever growing collection of CAT and MRI scanners. I would argue argue that neither BPD nor any other mental disorder cannot be explained purely by environmental circumstances or social construction. But like Siân I do believe very strongly that ‘patient’ and ‘professional’ should be travelling in the same direction. So how can we do this?

Only by both sides dropping their weapons and beginning to realise that there is nature AND nurture, that there is medication AND talking treatments, that not anyone wearing an NHS badge is the spawn of Satan and that not everyone labelled as BPD is a spitting, screaming attention-seeking nightmare. A little understanding could go a long way on both sides of the void.
I could go on but let’s save that for another time. To paraphrase Star Trek’s Mr Spock, sometimes the needs of the reader outweigh those of the blogger, so let’s just leave it there and say a very big Thank You to Sian Lacey Taylder.

If you missed Part 1 of our BPD trilogy, it’s here, and Part 2 is here.

Siân is author of The Society of Sin, a Victorian Goth-erotic fiction inspired by her Dorset connections, and is currently in the process of publishing her autobiographical novel Death by Eyeliner. You can find out more about her here.

BORDERLINE PERSONALITY DISORDER: PART 2 OF A GUEST SERIES FROM SIÂN LACEY TAYLDER

Sian5 

You should know that some of my best friends are mental health professionals. Indeed, my best friend is a clinical psychologist and I’ve nothing against the profession per se. True, there have been occasions when the system has let me down – sometimes quite badly. Like the time when, in the immediate aftermath of a serious trauma, a trainee RMN pitched up with the suggestion that I be referred to an alcohol dependency unit without being aware of my specific circumstances (I had, as it happens, just been raped).

Or the time my GP sent me to the local A&E because I’d carved ‘Siân is a bitch’ into my forearms (yes, I even did the circumflex); the duty psychiatric nurse asked me a few cursory questions then told me to ask my doctor for a course of Prozac.

Or the time when, sensing an imminent descent into the emotional abyss, I contacted my local community mental health team to ask for help. The reply I received was courteous but patronising, more or less implying that unless I staggered into the surgery with my wrists already slashed there was nothing they could do.

The upshot of all this? The worst in short-term planning. Instead of trying to avert the crisis why not wait until it comes crashing through your front door in all its bloody glory? Those few pennies you might save by limiting preventative care will be peanuts when you’re presented with the bill for my incapacity to engage with society – and pay my taxes.

Please don’t misunderstand me. I’m not suggesting the entire NHS should rearrange its priorities to account for my every change in mood swing, and I’m sure some of you – from the Julie Burchill School of Empathy, perhaps – will be shouting at your computer telling me to get a grip. I don’t want your pity, I really, really don’t; all I’m asking for is a little more consistency and some ‘joined up thinking’.

For example: I have been, more than once, referred to a therapist of some kind but the referral always comes with some sort of proviso. Normally it’s a limited number of sessions; last time it was six which was just about time for us to get to know each other. I had the option to continue on a private basis but a recent outbreak of BPD had left me with a paltry, part-time income.

Then there was the time I struck up a productive relationship with a Freudian psychotherapist. What should have been – and did, indeed, start out as – a fractious, adversarial relationship ended up like a marriage made in heaven.

Does it sound like a physical relationship? In some ways it was – only without the intimate contact, of course – because it has to be intense. Sadly, after a summer of psychotherapy, she suddenly disappeared. I never did find out what happened to her; I managed, eventually, to get an appointment with someone else but when I told him I was feeling better he declared me fully restored to health and no longer in need of therapeutic support.

Three months later I was up to my old tricks again and never really let up for the best part of eight years. I should add that in all that time various GPs, medical professionals and even the police were nothing less than understanding; what constrained them, what we were all fighting against, was – still is – an inflexible, unimaginative system. A system that insists that mental illness is no longer taboo but hasn’t yet worked out how to deal with it. Whether through ignorance, lack of funding or wilful desire, it just doesn’t take us seriously.

But I’ll say it again. I don’t want your pity and I certainly don’t want to stretch the resources of an increasingly-underfunded public service which, in any case, can’t offer much more than a metaphorical plaster and a patronising pat-on-the-head. On the basis that prevention is usually better than cure what I would really like to see is a radical rethink on the nature of BPD; of what it means to be sane or insane. It’s an argument that is more sociological than medical because BPD is as much a political condition as a psychological malady.

In Madness Explained, an excellent exposé of the myths surrounding mental health, Richard P Bentall argues that mental illness is not a product of brain dysfunction than can be cured – usually with medication – but a series of symptoms only a minority of which cause significant problems for the ‘sufferer’. In the words of one Amazon reviewer ‘I go to the doctors and they want to drug me to get rid of everything ‘wrong’ with me and flatten my personality … when only 10% of these symptoms are actually causing me any distress!’

Perhaps we should dissect the nomenclature. According to Bentall, the term Borderline Personality Disorder was coined to ‘describe a type of personality characterised by extreme emotional instability, severe problems of self-esteem, self-destructive behaviours and intense and unstable relationships with others’. All well and good; that’s an accurate-enough description of my own condition but phrased in a manner which would seem to render me pretty much incapable of living anything resembling a ‘normal’ life.

Not that I’ve any desire to live a ‘normal’ life; sounds like complete and utter madness to me. The fortunate truth is that I’m perfectly capable of being a fully-functioning, productive member of society – for most of the time. There are certain environments in which I couldn’t survive: the office, the nine-to-five; the corporate world or the micro-managing boss. But within the relative freedom of self-employment I thrive.

But society loves labels; whether it’s class, race, gender or sexuality it insists on packaging the relevant behaviour and prescribing it as the norm. Then capitalism comes in and sells it back to us; we no longer live lifestyles, we consume them.

Society will tolerate a certain amount of variation from the norm – the English love an eccentric, after all – but it also has its boundaries and when we transgress them we are considered deviant.

Deviant, disordered and, sometimes, dangerous.

Because that’s what it all boils down to, isn’t it? My personality is on the borderline; the borderline of what? Of what society perceives as functional and dysfunctional? Normal and abnormal? If, during a period of intense emotional distress, I feel compelled to cut myself I am doing so for a reason. I don’t expect to be condemned for my behaviour and even on the warmest summer day I’ll cover up the scars to spare your distress.

The problem is that the cutting comes with the territory; it’s a coping strategy to deal with a society I consider to be alien and hostile (there’s the paranoia talking) and any attempt to treat it, to remove it from my emotional repertoire, would be tantamount to a full-frontal lobotomy. It would kill my creativity, imagination and character stone dead.

Your sanity is my insanity; your chaos my order. Madness is as much environmental as it is neurological, if not more so. I’m a bit like a snake in the grass: leave me to my own desires and I’ll cause you no harm; trap me and try to change me and I’ll do my best to bite back.

If you missed Part 1 of our BPD trilogy, it’s here.

Siân is author of The Society of Sin, a Victorian Goth-erotic fiction inspired by her Dorset connections, and is currently in the process of publishing her autobiographical novel Death by Eyeliner. You can find out more about her here.

The Occasional Tragedy of Mental Health


A Problem of Understanding
I used to work with people who had committed the most serious and often disturbing of crimes. All in all I spent twelve years in very close proximity to patients in secure psychiatric units. I played cards with killers, badminton with rapists and darts with men you had last seen played by an actor on Crimewatch.

I’ve been shopping with people who hadn’t seen a town centre for twenty years. I’ve handed out tissues to those still haunted by what they had done, and locked up patients in small secure rooms as the voices commanded them to kill anyone within range of a pool cue.

I’ve had the sort of conversations you could and should never forget with fellow human beings who have done unimaginable things. But one thing I have never done is to understand.

Not for want of trying or because I wasn’t clever enough. I ‘got’ the psychopathology of the psychopath. I ‘got’ the biochemistry of psychosis. I ‘got’ the medical model and the social model. But faced with someone who had tortured a child, blown off a neighbours head with a shotgun, or knocked nails into someone’s skull, I simply failed to truly understand.

Thirteen-year old Casey Kearney was walking through a park on her way to a friend’s. She was stabbed by a woman walking in the opposite direction. It wasn’t a frenzied attack, just one brief blow with a one of two kitchen knives purchased earlier that day by a woman called Hannah Bonser, who simply continued on her way before turning up at a local mental health resource to confess to what she called “a silly thing” and hand over her knives.

This was an appallingly random act of extreme violence. Bonser would have expended more time and energy stopping to ask her victim for the time. For any parent to imagine the deliberate killing of a child is not only incomprehensible, but entirely unimaginable for any more than the most fleeting of dark moments. But Casey Kearney’s family have had to deal with this reality since February 14 this year, and have no doubt tried and failed to make sense of the senseless.

Making Sense of the Senseless
Hannah Bonser was yesterday convicted of murder and sentenced to life imprisonment. She will serve an absolute minimum of twenty-two years before being able to seek parole. Those not involved with the case might have been surprised that Bonser did not receive a Mental Health Act hospital order and a conviction for Manslaughter rather than Murder.

After all, this was a bizarre and random killing committed by someone well-known to mental health services for some time before the event. Her legal defence argued she was suffering from Paranoid Schizophrenia at the time of the offence, and that her responsibility for the crime was therefore ‘diminished.’ The jury did not accept this argument.

But as with all homicides involving mental health service users, an independent inquiry will now take place in the aftermath of the trial. Like the dozens that have preceded it since the mid-1990s (when such inquiries became mandatory) the report will provide a public and detailed account of Bonser’s relationship with mental health services in the months and years prior to February 14th 2012.

As both a practitioner and trainer who has read with depressing regularity how tragedy has resulted from the failure of various services involved in mental health care over the years, I very much hope we will not be hearing from the usual suspects. Failures of communication, lack of information sharing, poorly motivated professionals, bureaucracy. All these and more have become depressingly familiar to readers of such reports, but seldom appear to change the way we work with potentially dangerous people.

What’s in a Diagnosis?
For some months prior to the killing, a close friend of Hannah Bonser had noted how her behaviour had become increasingly unusual. She claimed that her flat was possessed by demons. Her self-care deteriorated and she travelled down to London, where she slept rough and searched for a character called ‘Simon of Lambeth’. She was detained under the Mental Health Act before being transferred back to a Doncaster hospital, but was discharged shortly afterwards. Life appears to have become increasingly disjointed and chaotic. Shortly before Casey’s death, her killer had presented to mental health staff stating she was hearing voices commanding her to harm others.

Her legal defence was that her actions were driven by severe mental illness. It’s well beyond the scope of a short blog post to attempt to describe what we mean by this, but on current evidence we could state the following. That at the time of the offence her brain was showing signs of abnormal structural and biochemical functioning and was interacting with an environment which to Hannah Bonser would be a very, very different place to how most of you reading this would experience that environment. It may have been quite a terrifying place. Perhaps terrifying enough to randomly stab a complete stranger.

The prosecution argued that Bonser was not psychotic but suffered from a Personality Disorder. We know even less about the inner workings of PD than Schizophrenia, and argue about it a great deal more. This diagnosis would imply that the person is fully aware of one’s actions and knows exactly what they are doing, even when what they are doing is indescribably unpleasant.

The Sadness of Madness v Badness
The difference between severe mental illness and personality disorder is characterised by some as the ‘mad versus bad’ dichotomy. This is a very false dichotomy. In fact, it’s not a dichotomy at all.  The opposite of ‘mad’ is ‘sane’ and the opposite of bad is of course ‘good’. It’s an old and rather stale argument often used by lazy mental health professionals to characterise the difference between behaviours which are driven by ‘genuine’ and ‘proper’ mental illness on the one hand, and behaviours which are apparently ‘manipulative’ or ‘attention seeking’ on the other.

Being ‘Mad’ is beyond both the conscious control of the sufferer, and the moral judgement of others. It warrants our intervention, diagnosis and treatment, particularly with pharmacological means which offer a quick and relatively simple solution to ‘Mad.’

But ‘Bad’ is just, well, bad. If it isn’t ‘Mad’, isn’t a psychiatric problem, we needn’t offer an intervention. Personality Disorder is ‘Bad’ and this is what Hannah Bonser is now judged to be. She’ll go to prison not hospital.

The jury at Doncaster Crown Court accepted medical evidence suggesting Bonser suffered from a Personality Disorder. Essentially, she knew what she was doing.

The conception from both the public and aggrieved families is often that a ‘proper’ sentence is infinitely more acceptable than the apparently soft option of a psychiatric bed. Part of the argument around this case was that the stabbing of Casey Kearney was a calculated and manipulative act designed to achieve Bonser’s demands for hospital admission. To have received a Mental Health Act section might have been seen as a triumph for Bonser’s manipulation, and one could understand how that might be seen as unacceptable by many.

To Inquire or Not Inquire?
Nonetheless, an inquiry will now take place and the report will tell us something of how a family have lost a 13-year old girl who just happened to be in the wrong place at the wrong time. The court has already delivered it’s verdict on Hannah Bonser, but the inquiry will hopefully reveal a highly complex interaction between a twenty-six year old woman, her troubled background, her environment, her mental state, the services she turned to for help and the killing of Casey Kearney.

There are some who now call for the end of mandatory inquiries into each and every mental health related homicide. I wouldn’t disagree. It’s a hugely expensive procedure which, as we’ve already seen, throws up very similar conclusions time after time without seemingly making much difference.

But perhaps we should continue to study events such as these which, incredibly rare as they are, remain sufficiently horrific to merit the deepest scrutiny and may help us to at least try to prevent the preventable in future.

What is Narcissism?

Most of us know that describing ourselves as ‘narcissistic’ isn’t a good thing to put on a job application, and definitely isn’t a selling point on MeetYourEverlastingLove.com. But what does the term actually mean, and how does it manifest (in it’s most extreme flavours) as a psychiatric disorder?


Narcissus is a character from Greek mythology. He was the son of a God and Goddess and were he around today would no doubt be described by Beliebers and the like as as ‘totes buff’. But Narcissus was only too well aware of his own buffness and rejected numerous come-ons from lots of water nymphs and other mythological characters. Why? Because none of the boys, girls or hermaphrodites (this is Ancient Greece after all) who fancied him were deemed by Narcissus to be anywhere near good enough for him.

To cut a long story short, Narcissus caught sight of himself in a pool and fell in love with his own reflection. Which wouldn’t have been too bad if he hadn’t become so obsessed with his gorgeousness that he couldn’t prise himself away from his own image long enough to get a bite of whatever they ate in Ancient Greece, and eventually died of starvation.

You’re probably thinking of more modern analogues of this mythical tale, but we don’t need celebrities to recognise the clinical reality of being smitten by one’s own self-esteem. A person diagnosed with Narcissistic Personality Disorder (NPD) might be thought of as pathologically self-obsessed, vain and arrogant to the point that they really are very difficult people to warm to. They are, like their namesake, so ‘in love’ with themselves they reject the attentions of others as being little more than an irrelevance. But they may just tolerate people who can a) achieve objectives for themselves such as the confirmation of their wonderfulness, or b) are of such high status that they are actually seen as almost being good enough to be in the same room, and c) may provide the narcissist with material resources and family associations to confirm their exalted sense of self-worth.

This is often a person who, to anyone else but themselves, is actually a rather strange, unlikeable person who tells very tall tales to confirm their own inflated opinion of themselves – in fact, some of us sometimes refer to NPD as ‘Walter Mitty Syndrome’.

I once worked with a colleague who would tell anyone that would listen (a rapidly diminishing number, surprise surprise) about his previous exploits of derring-do as a member of the SAS. Now anyone who knew this chap would immediately know that this and his many other stories were patently ludicrous, but he not only told these obvious lies with great and even entertaining conviction but even seemed to actually believe them himself. This is very typically narcissistic. The last time I saw him he (a mental health nurse) was being arrested at work for a serious assault on his wife, and much to the relief of his former colleagues was never seen again.

In extreme circumstances, NPD erupts in crime or extreme violence, usually as a means of perpetuating a lie or a self-belief.  The Brian Blackwell case is an example of where narcissism becomes more than just irritating and unlikeable, but a potentially sinister and dangerous psychiatric disorder. The Theresa Riggi murders are another example about which I have previously blogged and edited for the #mhchat Narcissism Twitter debate. Fortunately most of will never meet a Brian Blackwell or Theresa Riggi, but may certainly know someone who spends an awfully long time staring at their reflection and being very (ahem) wonderful.

Empathy, Psychopaths, Nature and Nurture: All in 1200 Words

Re: ‘Zero Degrees of Empathy: A New Theory of Human Cruelty’ by Simon Baron-Cohen

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I haven’t actually read this book yet, which isn’t a promising start. So if this isn’t a book review, what the hell is it? Well, it’s a brief attempt to combine the main plank of the book (the clue’s in the title) with a discussion on the nature/nurture debate topped off with a completion of my rather long previous post on Personality Disorder. The latter was in fact so long I fear some readers actually died and decomposed long before they got to the end. Apologies to you if you’re reading this in the after-life.

Professor Baron-Cohen is a well-known specialist in the study of autism, and yes, if you’re trying to place the surname it’s his cousin Sacha’s various alter egos doing the jumping around in G-Strings and spoofing ‘da voice of da yoof. Innit’.  As a mental health trainer I’ve often referred delegates to the professor’s work whenever autism is discussed, but his latest theory takes a slight step away from the study of disorders such as Aspergers Syndrome and zooms down to one key aspect of the human condition: empathy. Or rather, lack of it.

Most people have a basic understanding of empathy. The ability to see the world through the eyes of another person or to understand how it might feel to be ‘the other’ is the key construct of an individual empathy rating which Baron-Cohen calibrates from zero to six. If you’re the sort of person who instinctively knows when your friends really can’t cope with your 407th holiday snap or you descend into floods of tears before Holby City has even got past the opening credits, you probably score in the upper regions of Professor Baron-Cohens empathy scale.

Looking at the reviews and in particular the commentary from Guardian readers, it would appear the unfortunate professor has been left with a bit of a scorched arse, at least from the more liberal end of the mental health/psychology spectrum. Firstly, he dares to suggest that something as subjective and nebulous as ‘empathy’ can be scored and rated with a questionnaire. Secondly, and perhaps even more heinously to some, he suggests the existence of an ‘empathy circuit’ consisting of various interconnected brain bits which are either turbo-charged, mid-range saloon or phutting away like an old Skoda. In the latter case (the ‘zero empathy’ range), we have the ‘psychopath’. This is the man or woman who simply doesn’t understand why the elderly lady whose fingers they’re breaking could possibly get upset: “Look, I’m only after the housekeeping money. What’s yer problem, luv?”

This ‘hard science’ approach to the explanation of complex mental disorders is often described as  ‘biological reductionism’ and is to many mental health professionals, sociologists and service users the psychiatric equivalent of a devastating fart in a crowded lift. Hence the less than favourable reviews from those for whom the ‘social model’ of mental health is sacrosanct.

We live in an age where huge brain scanners are soon to be miniaturised to the size of hat. These will no doubt be available at PC World with a Wi-Fi link to YouTube, leading to multiple postings from Baz in Thurrock: “This is my brain while I’m doing a poo”. Yeah, can’t wait for those clips. But more seriously, the previously complex and highly secretive brain is opening up to neuroscience like a ripe melon. 


Advances in genetic research are another major tool in the investigation of mental illness. In the not too distant future our personal genome will be available to anyone who wants to know how much Viking they have rattling around them, or more seriously, how susceptible they might be to Alzheimers Disease or Schizophrenia. Look out for the ‘Test your Genome Here’ booths at Tesco.

So far, so biological, but as a very experienced mental health professional I’m also only too aware of the devastating effects that trauma, abuse and childhood neglect have on the adult mind. Our surroundings, our circumstances and the events to which we’re exposed are crucial in determining whether we crash and burn with a handful of Seroxat or skip gaily through life like one of those ridiculously smiley people at folk festivals.

I like to think that, when asked to explain the causes of this or that psychiatric disorder, I can give a reasonably balanced overview from both sides of the ‘medical v social model’ debate. But even my balanced approach hasn’t always prevented me getting the ‘stare of death’ treatment at the merest mention of a gene, MRI scanner or (say it very quietly) Serotonin.

But here’s the thing. The ‘versus’ part of the ‘nature v nurture’ debate is gradually becoming as redundant as the public phone box. Remarkable evidence has been hitting the journals of the malleability of the brain long into adulthood. We’ve known for some time now how, for example, the memory circuits of London cabbies literally rewire themselves during ‘The Knowledge’. These changes can be observed with MRI scanners, although as far as I’m aware a predilection for TalkSport radio and an opinion on immigration has yet to evidenced by neuroscience. Even our genetic make-up is far from being the indelible clump of Cs, Gs, As and Ts formed at conception. Like our brains, our genes are susceptible to ongoing renovation long into adulthood and courtesy of the outside world.

Those of us who have worked with Baron-Cohen’s ‘zero empathy psychopaths’ will be all too familiar with the histories of childhood neglect, trauma and abuse described by patients/clients/service users. But can we infer a cause of personality disorder from these stories?

Of course not. Lots of people have experienced awful childhoods which haven’t turned them into serial killers, ethnic cleansers, concentration camp guards or sadistic sexual predators. There has to be some other factor gnawing away at the nascent mind to generate what some may refer to as ‘evil’. And if you’re a sociologist thinking ‘infamous Stanley Millgram experiments’ around about now, I did promise to keep this post brief.

Recent evidence is not pointing at previously simplistic nature or nurture explanations for psychiatric disorder, but toward a ‘perfect storm’ of environmental conditions, genetic predisposition and physical brain changes. There is certainly a worthwhile body of evidence that, in the case of Personality Disorder, a congenital potential for anti-social, callous and non-empathic behaviour exists in many of us at birth. Whether or not this genetic On-Off button is left on standby or blows up the microwave is highly dependent on the sort of environment we experience both as we grow up and long into adulthood.

I would like to think that someone as undoubtedly insightful as Professor Baron-Cohen doesn’t  seriously consider a wonky neural empathy circuit as the sole cause of human barbarity and that he’s been unfairly ‘dissed’ (to quote Ali G) by opinions which are perhaps not empathic enough to see both sides of an argument. But to find that out for sure I’d better get out the debit card and head over to Amazon books.



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