You recall perhaps a post I wrote on Oliver James and the article he wrote following the news of the end of John Cleese’s marriage. In it he said:

‘Most – but not all [comedians] – are either depressive or suffer from personality disorders … having done in-depth TV interviews with seven leading comics and having met many others, I feel that it must be acknowledged that misery is a necessary condition for great humour in the vast majority of cases.

I’ve just been reading The Naked Jape by comedian Jimmy Carr and Lucy Greeves. I’m not going to review it for this site, but it is an interesting and thoughtful discussion of jokes, jokers and their societal context. In the book Carr and Greeves discuss the ’sad clown stereotype’ and basically disagree with it. They quote a 1992 study by psychologist James Rotton which found that comedians were actually no more prone to suicidal depression than any other group.

Assuming that we buy the line that childhood trauma or hardship can, in some cases, spur individuals on to high-profile achievements, it’s not surprising that many successful and famous jokers have less than Walton-esque family backgrounds. But would you find any fewer damaged individuals if you were to look at rock musicians, or actors, or any other deeply competitive profession where the stakes are high, your personality is exposed to harsh public criticism and you have a bit too much time on your hands?

Apparently the Rotton study also compared the longevity of comedians with that of other entertainers and non-entertainers. The entertainers died younger, but there was no difference between the life expectancy of a comedian and any other sorts of entertainers.

I’ve been searching for this paper (the book gives no reference) and can’t find it on either pubmed.org or Google scholar so I don’t know how robust it is (I’ve emailed the publishers). We can poke holes in both viewpoints. James has anecdote on his side and also personal experience, and in interviewing leading comics he essentially presents case studies. But it is a big leap that the comedians he has met, who are themselves self selecting, represent leading comedians in general. Carr and Greeves present evidence to the contrary, but commit the heinous sin of not referencing their work, which makes it difficult to research the basis of their assertions. You could argue that Carr, as a professional comedian, is not an impartial researcher. Indeed, there is at least one skeleton in his cupboard.

People in the press have been playing one of my nasty habits - guess the diagnosis of someone you’ve never met.  In this case the beleaguered UK Prime Minister Gordon Brown.

For anyone who lives in a cave, Mr Brown came to be PM about a year ago having been the Chancellor of the Exchequer for ten years.  During this time he presided over unbroken economic growth and was well know for his prudent policies and dour demeanour.  Whilst his lack of easy charm and attention to detail made him apparently trustworthy as the head of the economy, they haven’t played out well as PM, especially as he is following the TV friendly and charismatic - but warmongering  - Tony Blair.  Incidentally, I met Brown’s private secretary, a rather attractive girl, at a party once and was thinking of trying to get off with her but regrettably she left before I could work any magic. 

Writing in The Times, GP Dr Thomas Stuttaford has speculated that Mr Brown has personality traits which might lead him to be diagnosed with a DSM-IV cluster A personality disorder.  He also says that Tony Blair would meet all the criteria for histrionic personality disorder

(If you need to brush up on personality disorders here’s a link to my previous post on the subject) 

BPS research digest disapproves

There are two issues here.  Is Dr Stuttaford proper to speculate in such a way?  Yes, in that we are in a free country, and it would be cheeky for me to say no when I have done similar myself*.  But he is very careless.  You can’t make these kind of diagnoses without meeting the patient, and it is sloppy to take a cursory glance at the DSM criteria and then imply that if someone possibly meets particular criteria and the diagnosis is likely.  He should at least have stated that what he is presenting is purely idle speculation.

Is he actually right?  Unlikely. With regards to Tony Blair, Dr Stuttaford can’t have looked very carefully at the DSM-IV histrionic personality disorder criteria.  Is he saying, for instance, that Tony Blair’s interactions with others are ‘often characterized by inappropriate sexually seductive or provocative behaviour’ or that he ‘consistently uses physical appearance to draw attention to (him)self’? (DSM IV criteria)

He says of Mr Brown:

‘He is likely to be demanding, self- absorbed, have difficulties in relationships with others, suffer discomfort in social situations with unfamiliar people, have vaguely unsettling inappropriate gestures or facial expressions and may be so focused that he finds it difficult to concentrate on subjects other than that which has caught his immediate attention’

I find it difficult to believe that anyone with these sort of characteristics could not only elevate himself to the job of PM(think of the political deals and alliances necessary), but also run the country for more than five minutes with this sort of personality.  ICD-10 states that a personality disorder is ‘usually accompanied with considerable personal and social disruption’ which sounds incompatible with any of Mr Brown’s achievements.   Dr Stuttaford is talking bollocks I fear. 

David Owen, former Labour minister and SDP leader, has written a book about illness suffered by heads of state, and has also coined a term ‘hubris syndrome’ which I think he is un-secretly hoping will pass into common parlance, if not into diagnostic manuals.  Rather less prestigiously, I wrote a post on a leaders and their drug problems, prompted by speculation that Moses was under the influence of psychedelic drugs. 

Other articles on this subject:

NHSBlogdoctor

*It would be hard to imagine that  Josef Fritzl is not  even a little bit anti-social though…

There’s news that Josef Fritzl, the man who imprisoned his daughter for 24 years in a dungeon of his own making, will plead insanity when his case goes to trial.  I also saw Glenn Wilson, who works at the IoP on TV speculating that Mr Fritzl is a psychopath.  

I’ve talked about personality disorders elsewhere; but in brief: your personality can be defined as ‘the characteristic, and to some extent predictable, behaviour-response patterns that each person evolves, but consciously and unconsciously as his or her style of life’ (Campbell’s Psychiatric Dictionary).  Personality disorders on the other hand relate to when the way in which an individual interacts is so rigid and fixed as to severely limit the likelihood of effective functioning and/or satisfying interpersonal relationships.  The point when a personality is sufficiently beyond the normal to warrant a personality disorder diagnosis is difficult and define and personality disorder is less a diagnosis and more a label of social non-conformity.  

Psychopathic personality disorder is synomymous with anti-social personality disorder (DSM-IV) and dissocial personality disorder (ICD-10) 

Back to Mr Fritzl.  Here’s the ICD-10 classification for dissocial personality disorder (DSPD)

F60.2 Dissocial personality disorder

Personality disorder, usually coming to attention because of a gross disparity between behaviour and the prevailing social norms and characterised by:

(a) callous unconcern for the feelings of other

(b) gross and persistent attitude of irresponsibility and disregard for social norms, rules and obligations

(c) incapacity to maintain enduring relationships; though having no difficulty in establishing them

(d) very low tolerance to frustration and a low threshold for discharge of aggression, including violence

(e) incapacity to experience guilt or to profit from experience, especially punishment

(f) marked proneness to blame others or to offer plausible rationalizations for the behaviour that has brought the patient into conflict with society

Mr Fritzl clearly has most of these in spades, so much so that it would not be entirely unreasonable if a whole new subtype of this personality disorder should be invented just for him.  People with DSPD are known to have a reduced ability to empathize with another person’s emotional state, or to recognise it from their face.  I remember a forensic psychiatrist explaining to me the response one of his patient gave when asked to name the emotion of the face of a person shown to him on a card (the emotion was fear)

‘I’m not sure what it’s called but that’s the way people look when I stick a knife in them’ 

Which still gives me the creeps. 

It’s also possible that Mr Fritzl is psychotic in some way, but this seems unlikely given how well he has been seen to function in society and how calculating and precise the planning for his deeds appear to have been. 

It will be brave psychiatrist who attempts to defend his insanity plea as an expert witness. 

***

I’ve also been very interested to learn of how Austrian society could let this sort of thing happen.  I’ve read in the press that people in general and institutions in particular are extremely reluctant to believe that anyone of social standing could do anything untoward.  Data protection laws are also weighed towards the criminal - any conviction is wiped after fifteen years, which means that the information relating to Mr Fritzl’s rape conviction was not available when he applied to adopt the children he had conceived with his daughter.  Austrian police also said almost immediately that Mrs Fritzl knew nothing of her husbands activities - more wishful thinking perhaps?

It would be easy to get snotty.  Here in the UK we’ve had our share of psychopaths whose crimes evaded the authorities for years.  Peter Sutcliff, who killed thirteen, was eventually caught because his car had false number plates.  Dennis Neilsen killed at least fifteen and was caught because his drain was blocked with flesh. 

***

And another thing, which no one else seems to be saying.  Mr Fritzl really looks like a pervert to me.  The supercilious smirk, the arched eyebrows with the right slightly higher as if in challenge.  Dogs and their owners eventually look the same people say.  Is it possible that psychopaths eventually look like their acts?

I was interested to read an article in The Independent recently where psychologist Oliver James wrote that of comic peformers ‘most but not all - are either depressive or personality disordered’. 

James is a psychologist of some experience or, failing that, exposure.  Clearly it takes a particular sort of person to wish to earn their living by entertaining other people – and to subject themselves to the scrutiny this entails – but to make a blanket diagnosis of this nature cannot be right or fair.  Psychiatrists are often almost as guilty, it is a term often used in my by my colleagues to refer to patients or professionals we find difficult or do not like. 

Here’s an introduction to this difficult area.

Definitions

ICD-10 defines personality disorder as follows:

‘A severe disturbance in the character logical condition and behavioural tendencies of the individual, usually involving several areas of the personality, and nearly always associated with considerable personal and social disruption’

And DSM-IV:

‘an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment’

There are nine categories of ICD-10 personality disorder and ten of DSM-IV.  DSM-IV divides its personality disorder classifications into three ‘clusters’.

ICD-10 
(F60.) Specific personality disorders
(F60.0) Paranoid personality disorder
(F60.1) Schizoid personality disorder
(F60.2) Dissocial personality disorder
 (F60.3) Emotionally unstable personality disorder
 (F60.4) Histrionic personality disorder
(F60.5) Anankastic personality disorder
Obsessive-compulsive personality disorder
(F60.6) Anxious (avoidant) personality disorder
(F60.7) Dependent personality disorder
(F60.8) Other specific personality disorders 

DSM-IV
Cluster A (odd or eccentric disorders)
Paranoid personality disorder
Schizoid personality disorder
Schizotypal personality disorder

Cluster B (dramatic, emotional, or erratic disorders)
Antisocial personality disorder
Borderline personality disorder
Histrionic personality disorder
Narcissistic personality disorder

Cluster C (anxious or fearful disorders)
Avoidant personality disorder
Dependent personality disorder
Obsessive-compulsive personality disorder

Problems with the diagnosis

The diagnosis and treatment of people with personality disorder is one of the trickiest areas of psychiatric practice.  Although established as a diagnosis and enshrined in both the ICD-10 and DSM IV, there is not a consensus concerning to what extent behaviours of a negative social and moral value should be considered psychiatric disorders and as a diagnosis personality disorder has a number of problems. 

• There is no definitive definition of ‘personality’ to be disordered, and it is at best a semi-technical term.  Most definitions are based on personality being an enduring combination of traits that serve to characterize an individual’s thoughts feelings and actions which are relatively consistent over a range of situations.  Some people would argue that personality is not a stable entity, but varies with time and situation. 
• Few personality types would fit into a single category listed above.  With its three clusters, DSM-IV goes some way to address this.
• There is an instability between raters when trying to diagnose personality disorder - this occurs even when rating scales are used.
• There is a large overlap of the behaviour of people with personality disorders with those of ‘normal’ people.  ICD-10 and DSM-IV offer categorical diagnoses, whereas in fact personalities exist on a spectrum i.e. they are dimensional.
• It is a hard area to conduct research into, partly due to the changing definitions of personality disorder over time and changing emphasis on personality traits not asked about on entry to the study.
• There is a great deal of stigma attached to the diagnosis
• This diagnosis allows significant deviance from societal norms, such as conscientious objection to a social regime, to be classified as a mental disorder. There is concern that this will be used to justify treatment of political dissidents as though they were psychologically disturbed.

Prevalence

Problems aside, people fitting the criteria for personality disorders are very prevalent in society, between 7 and 13 per cent in the general population and of 20 to 30 per cent in general medical practice.  It is also believed that 40% psychiatric outpatients and 50% inpatients would qualify for a personality disorder diagnosis.   Personality disorders rarely present to services in isolation and are associated with a high co-morbidity frequently being associated with alterations of eating behaviour, alcohol and substance abuse, other mental disorders, antisocial behaviour, and sexual promiscuity.  When someone meeting the criteria for personality disorder presents to health services an in-patient length of stay is likely to be longer and costs higher.

What causes Personality disorder?

As with a lot of mental illnesses, the answer to this question is not clear and genetic and social factors have been implicated.  There is evidence for the involvement of difficult upbringing with people having suffered physical or sexual abuse being over represented in personality disordered people.  Behaviour problems in childhood are also implicated, including severe aggression, disobedience, and repeated temper tantrums.

Treatment

It was felt for a long time that people with personality disorders were not treatable. There has been a perception that people with difficult personality traits can change themselves if they really wish and that it is therefore their fault if they do not. We therefore tend to blame people who have a personality disorder.  The tide has turned somewhat these days, and people are engaging those with a diagnosis of personality disorder in a number of ways.  These include trials of drug treatment, for example for comorbid depression, psychotherapy including dialectical behavioural therapy and therapeutic communities.

What research has been conducted suggests that over 10-30 years the outcome for people with personality disorders is generally favourable, with two-thirds improved at follow up with milder residual symptoms.  The severity of symptoms decreases with age and only one quarter would retain a diagnosis of boarderline personality disorder age 50.  Whilst employment is fairly common, marriage rates are half the average and odds of having children one quarter.