November, 2018. Too often in the field of medicine, we refer to patients by their illnesses. She’s a diabetic. He’s an asthmatic. She’s bipolar. He’s a schizophrenic. She’s an addict. He’s a narcissist—the list is a long one. For years as I’ve edited these pages, I’ve tried to suggest person-centered language. For example, not to refer to “the difficult patient” or the “treatment-resistant patient” but, instead, to “the patient with a complex, treatment-refractory illness.” Overall, I think we’ve made progress, and I see the patient=illness false equation less and less, which is good.
I still use the word “patient” when considering an individual with a medical illness who is seeking care or obtaining treatment for the illness. But even so, it’s important not to forget that there’s a whole person to think about, not just a patient who is ill. What are her coping skills? Who’s at home to help? What are his regular habits? How many are healthy and how many are not? What are the life stresses that may interfere with recovery?
One fundamental anchor and driver of any person’s behavior is one’s personality, and it’s remarkable how often this defining feature of being human is not thought about very much. As most of you know, I’ve been interested in personality styles, types, and disorders throughout most of my career. Recently, 2 excellent colleagues and I developed a website (http://www.npsp25.com) to try to inform the public about this fascinating world and, in particular, to interest people in the composite of multiple personality traits that guide our actions, preferences, goals, careers, choice of a life partner, and so on, as well as to profile one’s prominent personality traits as well as those that aren’t very prominent. Then, it’s interesting to consider whether or not a particular trait is too extreme, possibly pointing in the direction of trouble or even a personality disorder.
In this issue of the Journal, Cohen and colleagues take us into a world that is unsettling and that most of us don’t know much about—that of pedophilic desire, with a specific focus on the role of personality traits in determining whether individuals with that predilection just think about it, or if, instead, they put those thoughts and fantasies into criminal action with underage youth. Cohen and colleagues found that antisocial personality traits were the primary personality features that characterized those who engaged in criminal pedophilic behavior, compared with those who did not act on their thoughts and fantasies. Even here, I would argue that we should consider these individuals as troubled people with illnesses that can lead to risky and/or abusive behavior. Unfortunately, our knowledge of effective ways to treat antisocial personality disorder is woefully inadequate. And I readily acknowledge that the boundary between criminal behavior and illness-driven behavior is not so clear-cut and can be a very fuzzy one to figure out.
Also in this issue of the Journal, Gratz and colleagues examine the role of borderline personality pathology in adolescents as a meaningful factor with respect to treatment outcome in a residential treatment center. This type of study is particularly important, since before the publication of DSM-5, many clinicians assumed (not entirely correctly) that personality pathology should not be classified in adolescents under the age of 18, a stipulation no longer present for most of the personality disorders, including borderline. Interestingly, Gratz and colleagues found that adolescents with borderline pathology, a central feature of which is emotion dysregulation, showed greater improvement in emotion regulation than did adolescents without a prominent pattern of emotion dysregulation, after controlling for severity of pathology—a finding that they discuss at length.
Perhaps surprisingly, as a final point, I’d like to mention one other paper in this issue of the Journal, by Hybels, Blazer, and Proeschold-Bell, focusing on persistent depressive symptoms in a population with high levels of occupational stress—in this case, the population in question being the clergy. They found that a substantial percentage of those clergy who experience depressive symptoms showed a sustained symptom pattern over a considerable trajectory of time. Those clergy with higher symptom profiles were more likely to be female, and to report more health problems, more financial and occupational stress, and lower levels of emotional support. It would be interesting in a future study of the clergy to include standardized assessments of personality profiles, to consider the ways in which different personality traits might contribute to either resilience or vulnerability to stress.
JOHN M. OLDHAM, MD