Like most, I found my way to psychiatry through hardship and turmoil. I came looking for explanations, but more importantly for the solutions I desperately needed. My issues were quickly deemed to be clinically significant, and I was diagnosed with Borderline Personality Disorder, amongst other things. To be subjected to such scrutiny and judgment was strange, and at times confusing. I went through consultation after consultation, never hearing anything remotely straightforward. Medications were easy to attain and had positive effects which I was grateful for, but the overall problem remained completely elusive. As it went on, I grew increasingly frustrated with the practice as a whole.

Psychiatry has come a long way from asylums and lobotomies to reach the place it holds today in the global healthcare system. It is among the 24 primary specialties officially recognized by the American Board of Medical Specialties, granting practitioners the esteemed title of “Dr.” The impermeability and gravitas of the field of medicine gives it an authoritative quality, heightened by its consequential nature. Collective deference to medical judgment is warranted by the quality of medical research and the intense training that doctors go through. The diagnoses which they operate on are known to be the product of extensive biomedical research, precise and reliable. More importantly, they are known to be real. A virus, a bacteria, a tumor, all designate a real, tangible thing causing harm, which can (hopefully) be eliminated through direct intervention. Even misunderstood physical ailments can at least be traced back to specific mechanisms in the body. Psychiatry, however, despite holding the same place as other branches of medicine, lags far behind in terms of solid empirical evidence. 

Recent advances in neurobiology and genetics have helped close this gap, but psychiatry still heavily relies on syndromic diagnoses and patient self-reporting, neither of which are objective facts. The inherent subjectivity of both psychiatric assessments and treatments becomes especially problematic given that patients are largely unaware of it. 

I initially took the validity of the diagnosis for granted, and didn’t question my doctors. When I’d made attempts to find explanations of my behavior beforehand,  I’d generally been discouraged by the overwhelming complexity of mental health and ultimately reverted to professional authority. But pretty quickly I came to realize that the professionals didn't really understand what was going on either. So I went back to the literature, starting with the DSM-5, source of psychiatric diagnosis. 

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) sets the standard for doctors, and the wider healthcare system as Medicare only covers the treatment of patients with a DSM-5 diagnosis. Despite its authoritative nature, a quick read through revealed a concerning level of uncertainty. Diving deeper into the topic, I was consistently disappointed by the lack of solid explanations for psychiatric ailments and treatments.

This deficiency was especially remarkable for the ten personality disorders outlined in the manual. Here, the complete lack of any objective element called into question the clinical validity of personality disorders as a whole. The term “personality disorder” itself is loaded. Personality is a holistic group of traits, both innate and constructed, that drive action, thought, and emotion; it perhaps represents the closest tangible manifestation of a metaphysical self. A disorder is something scary, wrong, and abnormal. Like its synonym, illness, a disorder is something that one is subjected to and must fight against. Joining the two concepts raises complex ontological questions for both patients and the general public.

Personality disorders are generally conceptualized as an enduring pattern of inner experience and behavior that significantly deviates from cultural expectations, inflexible and pervasive across various personal and social contexts, leading to clinically significant distress or impairment in important areas of functioning. They cannot be better explained by another mental disorder or the physiological effects of substances or medical conditions.

 The 10 outlined disorders are grouped into three clusters: a) odd/eccentric, b) dramatic/emotional/erratic, and c) anxious/fearful. The diagnosis of a personality disorder is a fairly straightforward process. Each disorder has a list of 7-9 traits, of which the patient must exhibit 3-5 or more over a durable period of time, excluding certain age groups and other psychoactive influences. Not a single genetic, physiological, or even environmental cause has been found for any of these disorders, meaning there can be no tangible evidence of the illness. The disorders themselves aren’t even consistent in their manifestation, as traits reoccur across diagnoses and can be combined in a variety of ways. Both the criteria listed and the patient’s accounts of their manifestation are completely subjective. Personality disorder assessments are basically glorified Buzzfeed quizzes with lasting outcomes.

Not only do personality disorders lack any kind of identifiable cause(s), they don’t have any officially recognized course of treatment, be it pharmaceutical or other. In certain cases medicine can be given to alleviate associated symptoms, such as depression or mood instability, and therapy can help individuals manage their thoughts and behavior. But there is no treatment for the disorders themselves. 

Because of this I struggled to find the distinction between symptoms of the “disorder” and things I’d previously just viewed as personal flaws. I compared it to other more common mental disorders I knew of, and came to a mildly insulting conclusion. For example the distinction between “lazy” and “depressed” is important, as one implies personal fault and the other highlights the presence of a problem outside the individual’s control, which warrants compassion and help. The key to this distinction are the various chemical and structural imbalances that are to blame in the latter case. 

On the other hand, I found virtually no difference between being diagnosed with Borderline Personality Disorder and being called a clingy, hysterical, drama queen. Similarly, having narcissistic personality disorder looks a lot like just being a self-centered egomaniac.  The traits themselves are medically correct descriptions of poor behavior, but ultimately, the individual, for lack of another answer, is to blame.

 Without cause or cure, and so little consistency, personality disorder’s place as an illness in the DSM-5 is laughable.

Beyond just clinically questionable, I found the pathologization of personality to be an existential nightmare. The concept itself raises a variety of ontological problems, for both patients and the general public. The establishment of these disorders is preceded by the supposition of a “normal” way of being, which has yet to be defined, and for good reason. Humans seem to be, beyond their innate traits, impossible to standardize. Personality is the manifestation of a unique gene set in a unique set of circumstances. Despite similarities across populations, it is ultimately irreplicable. These similarities are also generally contained to one society or culture. All in all, the idea of a “normal” personality is flawed, and therefore so is the idea of a “clinically significant” deviation from it. A threshold could be drawn where behavior and thoughts cause genuine harm, but even then I found characterizing such ways of being as illnesses to be harmful and incorrect.

Illness or disorder implies some unintentional and intrusive harm that one must get rid of. Accordingly, personality disorders imply a complete alienation from the self. Patients subsequently attempt to distinguish the “bad” from the “normal” within their conscious processing, completely fracturing their sense of identity. Having taken personality as the manifestation of the self for granted, one now has to grapple with the idea that their way of being isn’t their own but the product of some internal disease. It becomes near impossible to find security when authenticity is constantly called into question. 

Through this diagnosis my already shaky sense of self was broken down even more.  The lack of any kind of tangible cause for my “illness” brought on feelings of guilt and anxiety. Without another explanation it seemed that there was something inherently monstrous about me. The complete psychological dissociation that comes with a personality disorder diagnosis also weakens holistic sovereignty over oneself. The idea that I was subjected to an illness stripped me of my agency, and stunted my self-control by eroding my sense of self-efficacy. Whereas before my personality was the conscious manifestation of myself, it was now a source of harm which I was subjected to. It became this negative thing I “had.”

For people who fully lean into the dissociation, the diagnosis can bring comfort, as well as for people who are trying to diagnose their friend, ex-boyfriend, or family member, because it becomes a certification of their poor behavior and an explanation for it as well.  I found there was no relief, as regardless of personal responsibility I suffered the same crippling consequences. Accepting the disorder comes at the cost of one’s power of self-determination. This labeling grossly undercuts individual complexity, which is all the more unfair to people who receive these diagnoses who often come from a background of hardship. To say that their experiences have resulted in them presenting with an illness implies their complete subjugation to their struggles—a depressing take.

Conceptualizing my struggles through the prism of borderline personality disorder did nothing to alleviate them. Eventually, I broke from the label entirely and reworked my approach to the various problems I dealt with. And things got better from there. Renouncing the notion of an inherent illness allowed for a holistic view, with the belief that my feelings and behavior could be understood, managed, and changed. 

This shift opened the door to self-exploration and self-improvement, recognizing my personal responsibility and control rather than helplessness. Instead of lumping all my problems under one broad, stigmatizing label, I approached each challenge individually, not as a symptom of an overarching disorder but as a specific, addressable issue. Working on individual traits gave room for alternative and varied means to help. I was also then able to return to natural sciences, and apply tangible solutions. This also reframed these issues within a personal context, where I could work the ones that were actually affecting me the most. 

Regardless of improvement, it was a relief to stop thinking that my personality was a “disease”. Letting go of labels gave me the freedom to navigate intense emotions typical of late teens and early adulthood, to make mistakes, and to pursue growth for my own well being-- rather than because of a diagnosis that didn’t feel like an all-encompassing take on my life and my character. Since my diagnosis and hearing similar stories from friends, I’ve wondered how someone who doesn’t spend a significant amount of time with you and has so little understanding of the mechanisms of your brain, deals you such a heavy hand.