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Diagnosis of Personality Disorder

Written by Steven Coles on . Posted in Clinical Psychology Bite-Size

Diagnosis of Personality Disorder

Issue 27 – April 2011

Author: Steven Coles (steven.coles@nottshc.nhs.uk)

Key points

  • Research has shown that the diagnosis of borderline personality disorder is stigmatising
  • The diagnosis can be seen as a moral judgement rather than a scientific or medical concept
  • People given this label have often experienced abuse, trauma and disordered environments

Implications for practice

  • Services need to move beyond the diagnosis of borderline personality disorder
  • People can be seen as survivors; and their distress, emotions and interactions understood in the context of their life experiences
  • It is important to highlight people’s strengths as well as their understandable difficulties
  • Staff need space to reflect on their own feelings and how best to support individuals 
Since its inception into the medical nomenclature in 1980 the diagnosis of borderline personality disorder (BPD) has been controversial. However, this controversy is not usually discussed in everyday practice between professionals or with service users. The label often appears to be an accepted part of the language of mental health services. In contrast the following will argue against the diagnosis of BPD.

Stigmatising

Research highlights that the diagnosis of personality disorder carries one of the greatest stigma of all psychiatric diagnoses1. People often experience the label of BPD as derogatory and adding to a sense of being marginalised and mistreated 2. There is a body of evidence that the label of personality disorder negatively influences staff feelings and reactions to the same behaviour 3. The seminal study by psychiatrists Lewis and Appleby (1988)4 used similar case scenarios of someone low in mood, crying, suicidal and in debt, with the only difference being the label of personality disorder. Those with the label, despite the same presentation, were seen as more difficult and less deserving of care, as annoying, as not deserving NHS time, and were given less sympathy. They proposed the concept be abandoned.

Conceptual and Scientific Flaws

The process of diagnosis claims to be grounded in science. However, psychiatric categories often fall short of basic scientific criteria, including the diagnosis of personality disorder. The two main criteria are reliability (can the label be applied consistently by different psychiatrists?) and validity (is it meaningful?). There has questionably been some improvement in reliability over time, but any progress is fairly limited and decreases in day to day practice5. This is not entirely surprising as psychiatric diagnosis, unlike medical diagnosis, is based entirely on interpretation of what people say and do. The authors of diagnostic criteria form categories such as BPD through committee decisions. Statistical analysis does not support the patterns they come up with6, 7. Therefore, the concept of BPD is not scientifically meaningful. Furthermore, the diagnosis is an empty concept as it is based on circular reasoning8, for example
  • How do we know someone has a personality disorder? Because they self harm.
  • Why do they self harm? Because they have a personality disorder.
Overall, the diagnosis of BPD claims to be a neutral and objective scientific concept; instead it is a subjective and moral judgement. A moral judgement mainly passed on women 9.

An Inadequate way to Understand People

People who get labelled as having BPD have often had a number of confusing and difficult life experiences. There are high rates of sexual abuse10, and when you look at a broader range of life events, 94% of people labelled have experienced a traumatic event 11. People can also experience more subtle difficulties, such as inconsistent and confusing communication from others. By placing the weight of the problem on the shoulders of the person, we are concealing the disordered environments and perpetrators of abuse. Rather than people being seen as disordered, their emotions and behaviour can be viewed as understandable reactions to an unacceptable reality. To say a person’s core is disordered and their emotions inappropriate, reinforces the abusive and disordered environments they have already experienced. This can lead people to feel even more distress.

Alternatives

Behaviour such as self-harm can be seen as survival strategies – ways of coping with difficult experiences and feelings. People can be supported to make sense of their distress, emotions and behaviour within the context of their lived experience and current world. Difficulties can be discussed with service users in language that make sense to them, rather than using diagnostic categories. It is also important to highlight people’s strengths as well as discussing understandable difficulties and needs. For staff faced with people who have experienced high levels of abuse and are struggling in life, it is important for workers to have space, supervision and time to reflect on their own feelings and consider the most useful way to help. Overall, it seems unnecessary for services to attempt to convince people to accept a stigmatising label and a concept lacking scientific credibility before they can access support.

Final Thoughts

In the 1970’s mental health services used to brand people who were gay as suffering an illness. Some people who were labelled, even internalised this, accepting the label; however due to activism this idea was eventually abandoned. Currently services label people as disordered, who have often suffered appalling levels of trauma and abuse, are experiencing extreme levels of distress and difficulties in their lives. The diagnosis of BPD is not adequate for helping people make sense of their lives or build meaningful futures.

REFERENCES

  1. NIMHE (2003). Personality disorder: No longer a diagnosis of exclusion. London: NIMH
  2. Nehls, N. (1999). Borderline personality disorder: The voice of patients. Research in Nursing and Health, 22, 285 – 293.
  3. Markham, D. & Trower, P. (2003). The effects of the psychiatric label ‘borderline personality disorder’ on nursing staff’s perceptions and causal attributions for challenging behaviour. British Journal of Clinical Psychology, 42, 243 – 256.
  4. Lewis, G. & Appleby, L. (1988). Personality disorder: The patients’ psychiatrists dislike. British Journal of Psychiatry, 153, 44 – 49.
  5. Kirk, S. & Kutchins, H. (1994).The myth of the reliability of the DSM. Journal of Mind and Behaviour, 15, 71–86.
  6. Koerner, K., Kohlenberg, R.J., &Parker, C. R. (1996). Diagnosis of personality disorder: A radical behavioral alternative. Journal of Consulting and Clinical Psychology, 64, 1169 -1176.
  7. Widiger, T. A. & Samuel, D. B. (2005). Diagnostic Categories or Dimensions? A Question for the Diagnostic and Statistical Manual of Mental Disorders—Fifth Edition. Journal of Abnormal Psychology, 114, 494 – 504
  8. Pilgrim, D. (2001). Disordered personalities and disordered concepts. Journal of Mental Health, 10, 253 -265.
  9. Shaw, C. & Proctor, G. (2005) Women at the margins: A critique of borderline personality disorder. Feminism and Psychology, 15, 483 – 490.
  10. Yen et al. (2002). Traumatic exposure and posttraumatic stress disorder in borderline, schizotypal, avoidant, and obsessive-compulsive personality disorders: Findings from the collaborative longitudinal personality disorders study. Journal of Nervous and Mental Disease, 190, 510 – 518.
  11. 11.Bandelow, B., Krause, J., Wedekind, D., Broock, A., Hajak, G., & Ruther, E. (2005). Early traumatic life events, parental attitudes, family history, and birth risk factors in patients with borderline personality disorder and healthy controls. Psychiatry Research, 134, 169 – 179.
   

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