Over the past 10 years as a psychiatrist and a psychiatric patient, I have been privileged to witness the gradual reduction of the stigma around mental illness. While there is still a long way to go, it is a subject that pervades the mainstream media, our Royal Colleges, attracts the support of celebrities, government ministers and, more recently, senior members of the Royal family and forms the plot of award-winning Hollywood movies. Every time a positive story about mental illness appears, another small step is made in the giant leap forward to accepting people with serious mental illness as equal and valuable members of society.
However, when it comes to personality disorders, this forward movement seems slower.
In my own NHS and private practice, I frequently have patients ask me if they have bipolar disorder (my special interest), but on closer examination, they turn out to have an emotionally unstable personality disorder (EUPD) of borderline type. While some accept this diagnosis a significant proportion do not, and either fight ‘tooth and nail’ to have this changed, disengage from services or ask for multiple second opinions in the hope that another psychiatrist might eventually give them a diagnosis they can accept.
Interestingly, over the years, a number of these patients have been doctors and other medical professionals. In many cases, they have not been diagnosed with EUPD, but other related conditions such as recurrent depression that have never been optimally treated for years. Given the option of having a new diagnosis of EUPD and the availability of a number of evidenced-based psychological treatments known to help the condition, they would prefer to continue to suffer with the wrong diagnosis. At the same time, they would opt to take increasing numbers and doses of medications to treat only the depressive dimension of their condition, and live with the subsequent drowsiness and weight gain.
However, aside from those who cannot accept an EUPD diagnosis, I have noticed an increasing number of patients referring themselves to me having Googled their symptoms and come to the conclusion that they have EUPD. This has shown me that, while we criticise the Googling of symptoms to try to self-diagnose, it can be useful and the first step to getting the right help. My own experience is that people who accept the diagnosis do massively better in treatment than those that do not.
There are two important issues to bear in mind here. First, that health professionals hold stigmatising attitudes towards people with personality disorders. Second, mental health professionals are beginning to train in and practice the evidence-based treatments available for EUPD.
That mental health professionals still hold stigmatising views towards mental illness is no surprise, especially to those of us with psychiatric disorders. My own opinion on this is that the reasons are complex, and not the same for all professionals. If there were one central theme, it would be a psychological defence mechanism to maintain an ‘us and them’ boundary between us and our patients. To witness the extreme suffering and bizarre symptoms we see in psychiatry, and on an intellectual level know this could happen to any one of us, causes us to erect a barrier of denial that this could not happen to us. Some research shows healthcare professionals hold more stigmatising attitudes toward mental illness than the general population. Those professionals who experience serious mental illness come to understand the true nature of the experience and learn more positive attitudes.
However, mental health professionals are now learning to utilise evidenced-based treatments, in particular dialectical behavioural therapy (DBT), and often find the approach practical and fascinating. When I began studying psychiatry some years ago the pervading wisdom was that personality disorders could not be treated. The situation is very different in 2016. My own team in Lichfield now provide DBT group therapy sessions for people with EUPD with good results in people engaging positively with the sessions and utilising local health services more appropriately and effectively. This is a fantastic step forward for secondary care community mental health teams.
It is interesting that patients are much more willing to accept a diagnosis of bipolar disorder rather than EUPD. Both conditions share symptoms that can be seen as social taboos: self-harm, addictions, sexually risky activity and odd behaviour in social situations. In the same way as doctors we are more willing to accept diagnoses of physical illnesses than mental ones as they are less stigmatising. Would a medical professional with chest pain reject a diagnosis of anxiety when their presenting symptom had been investigated, and instead hope for a treatment for angina because a physical illness is less stigmatising than a mental one? Would a doctor with shortness of breath reject the diagnosis of panic attacks and instead pursue one of asthma and try to get prescriptions of inhalers instead? The answer is yes: I have seen these cases in practice.
I am reminded of my bipolar disorder, when many years ago during an episode of severe depression I had suicidal thoughts. I told my GP (at the time) and their reflex response was “Oh, I’d better not write that down.” The reason being that this might have a negative impact on my ability to be a doctor, or my career. In reality, this was the most important thing I had told them, and the most important thing to write down at that point. Suicidal thoughts can lead to suicide. Saving a life is the main thing we do as doctors. The stigma of facing this in another doctor seemed too much for that GP, who thought it better to brush it under the carpet and not manage the increased risk of suicide.
There are good services for doctors who experience mental illness provided by the British Medical Association and the Royal College of Psychiatrists, to name two institutions. But the tackling of mental health stigma in our practice, and self-stigma in doctors with mental illness, remains an ongoing challenge.
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