Personality disorders (PD) are extremely controversial diagnoses, provoking heated debate among people with personal experience of these diagnoses, mental health staff, researchers and policy makers. Controversy centres on the three following points:
- Do personality disorders actually exist as objective ‘disorders’?
- Are these diagnoses a useful way of understanding distress and coping strategies?
- What are the implications of these diagnoses for broader political questions about inequality, abuse and other social problems?
Diagnosis – helpful or harmful?
A diagnosis of ‘personality disorder’ suggests that one’s personality is at fault. Since our personality is considered such an essential part of who we are, many people feel that being given a diagnosis of personality disorder is insulting and invalidating. A label of PD can be seen as critical of the individual rather than being a useful description of their experience and behaviour. Concerns have been raised that a diagnosis of ‘PD’ does not even begin to address what might have lead someone to feel and behave as they do.
All mental health issues are stigmatised by society and can lead to discrimination, but personality disorder is perhaps one of the most misunderstood and feared diagnoses. There are strong links in the media and the public imagination between all types of personality disorder and dangerous, criminal behaviour. Many people do not know about the different types of personality disorder and make the totally incorrect assumption that anyone given a diagnosis of personality disorder must be a dangerous threat.
People given a diagnosis of personality disorder have also had very difficult experiences in health services where stigma and discrimination have been equally common, with devastating effect. For many years, it was thought that people given this diagnosis were untreatable. Difficult assumptions were made by service providers about the behaviour of people with a PD diagnosis, e.g. that they are manipulative, difficult or attention seeking. As a result, people given this diagnosis have often been unpopular within mental health services. They may have been turned away from services or not received the support and understanding that anyone in distress deserves.
More recently, there have been a number of training initiatives, policy developments, and campaigns to tackle these attitudes but this work needs to continue. Such attitudes, once very common, will take time to be eradicated completely.
Some individuals argue that being given a diagnosis of personality disorder is damaging and creates further problems for individuals by undermining their sense of self, denying their experience and locating the problems in themselves. This is in addition to exposing people to stigma and discrimination, both within the mental health system and more broadly in our society.
However, other people have a different point of view and find that being given a diagnosis is a very positive experience. These people find the diagnosis a helpful way of explaining and understanding their distress. They can put a name to their experiences and so feel less alone. Through diagnosis, people may feel better able to find more information about what might have led to their problems and what has helped others. Some argue that being given a diagnosis enables them to get specialist help and support to turn their lives around.
Human distress Or disorder?
The idea that personality disorders exist is controversial because it is based on a particular way of understanding human distress, known as the medical model. This model assumes that we can explain human emotion by drawing on a medical and scientific framework; virtually all mainstream mental health services are based on this model. It has been argued that PD does not really exist but has been created as a way to understand and categorise certain feelings, ways of thinking and behaving to fit with the medical psychiatric system.
There is no dispute over the fact that people have difficult experiences which are often described as symptoms. The controversial question is whether it is helpful to understand them as symptoms of a disease or as expressions of human distress and ways of coping.
This is not just an academic debate but is an important question for all of us. How we understand feelings and ways of behaving forms the basis for how people are treated, how we think about and investigate what has caused these difficulties, and what we do about it.
It is argued that although the notion of PD is based on a medical and scientific framework, PD diagnoses are actually based on expectations, roles, and judgements about what is normal within a culture.
There are no physical tests that can be carried out to diagnose someone with a personality disorder - there is no blood test, brain scan or genetic test. This can be argued to undermine the existence of PD; if there is no objective test to make a diagnosis, then the basis of that diagnosis is questionable.
Personality disorders, like other psychiatric diagnoses, are based on judgements made by one person about another. It is often assumed that these are objective, scientific measures. Much of the status of psychiatry and the acceptance of diagnoses are based on this assumption. Many of the diagnostic criteria for most personality disorders refer to ‘extreme’, ‘unrealistic’, ‘excessive’, ‘inappropriate’ or ‘unusual’ thoughts, feelings and behaviours. To give someone a diagnosis, one person must determine whether the behaviour of another is reasonable or ‘unusual’, ‘excessive’, ‘unrealistic’, etc.
Many people argue these judgements are not scientific or objective, which throws the whole concept of PD into doubt. There are three main reasons for these doubts:
- How can one person judge what an appropriate response is to often traumatic past experiences? They will only ever have a partial understanding of an individual’s history. To decide if a response is appropriate or excessive is a value judgement passed by one person upon another.
- These individual judgements are likely to be shaped by cultural and moral expectations. For example, what is considered ‘inappropriately provocative behaviour’ for a woman may be understood very differently for a man. The threshold for what is acceptable behaviour and what is disordered also differs across cultures and according to an individual’s status.
- The role of politics in shaping mental health diagnoses is clear in the creation of the term Dangerous and Severe Personality Disorder (DSPD). This is not a medical diagnosis but a legal definition that was created by the Government in the white paper for reform of the Mental Health Act (1983). It refers to a very small proportion of individuals but has been the focus of a great deal of media attention and government policy. It is a clear illustration of PD as a socially and politically situated concept rather than an objective scientific category of illness.
When the application of diagnostic criteria is affected by so many factors, the question is raised about how helpful the diagnoses are and whether we might be better focusing on the experience of distress and how the individual understands this.
The impact of diagnosis – positive help or loss of self?
The term personality disorder covers such a broad range of feelings, experiences and ways of behaving that some question whether these are meaningful diagnoses or unhelpful constructions. The way that people are diagnosed from a list of possible criteria means that within any one specific personality disorder category, there will be a huge range of different experiences. For example, there are 246 different ways to meet the criteria for a diagnosis of borderline personality disorder. In addition, people are likely to be given a diagnosis of two or more personality disorders, again increasing the diversity of experience captured under these labels. Bringing together such a large range of experiences into these few diagnostic categories contributes to the controversies surrounding PD.
Campaigners argue that one of the dangers of mental health diagnosis is the very real possibility of losing sight of individual needs and experiences. Mental health professionals and services often respond to people on the basis of diagnosis rather than individual needs and preferences. In relation to personality disorder, people often talk of assumptions being made about their personal history on the basis of their diagnosis (i.e. if a woman has a diagnosis of BPD, it is assumed that she must have a history of abuse). Similarly, people report that prescriptive decisions are made about what treatment is offered (e.g. someone with a diagnosis of BPD is automatically given DBT).
When a diagnosis determines how someone is understood and treated, rather than their individual needs and choices, then we can once again see the potential damage that diagnoses can do. It has been argued that the use of diagnosis to define experience and determine treatment reinforces a sense of powerlessness that many people experiencing distress already feel. Whilst some people have felt the positive benefits of being able to access services they want because they have been given a diagnosis, others will be frustrated and angered to find they are pushed towards certain treatments considered ‘good for PD’ and steered away from or refused the services they would prefer. This highlights the powerful role of diagnosis within the psychiatric system and the reasons that controversy exists around this subject.
Individual or society?
A further argument surrounding PD relates to the evidence that a very high proportion of people given a PD diagnosis have had traumatic childhood experiences and life events. It is suggested that the concept of personality disorder obscures the wider social issues of childhood abuse, neglect, poverty and inequality by focusing on the individual. Rather than being concerned with the impact and prevalence of these issues, public outrage is focussed on containing people perceived to be dangerous. We have government policy, initiatives and new laws which focus on individuals given this diagnosis, but very little that directly addresses these underlying social problems.
The emphasis on the individual being given a diagnosis, to the exclusion of social causes and the broader context, also returns us to the stigmatising effects of diagnosis. People given a diagnosis often report how damaging it feels to be told that the problem lies within them, that they are at fault somehow. For many people this mirrors earlier traumatic experiences where people have been told they are to blame or are made to feel responsible for the abuse or neglect they suffered.
Work has been done looking at the ways in which such diagnoses have arisen out of social and cultural contexts. For example, there is a long history of feminist work which is critical of psychiatry. Writers highlight a pattern of women being driven to behave in ways society considers unacceptable or ‘mad’ because of social pressures such as oppression and sexual abuse. Women are then punished for behaving in ‘unacceptable’ ways. The social causes of their behaviour are obscured and hidden as the focus becomes the individual’s ‘mad’ and unacceptable behaviour. Hysteria is the most widely known example: some women responded to the oppression of Victorian society by expressing emotions in ways that were not considered appropriate for a woman. These women were discredited, their experience dismissed, and the broader issue of women’s oppression obscured by describing them as mad. It is argued that Borderline Personality Disorder is a modern day version of this same pattern.
Diagnosis has a very powerful role in society at large and within the psychiatric system. The diagnosis given determines how our feelings and behaviours are understood, how we are treated, and what options are available to us. And yet, the basis for diagnosis is an individual judgement shaped by social, cultural and gendered understandings of what is acceptable, normal and rational.
References
Emmelkamp P.M.G. & Kamphuis, J.H. (2007) Personality Disorders Psychology Press
Geraghty, R. (2002) The Dialogue Guide to Personality Disorder Personality Disorder Network
Haigh, Rex (2006) ‘People’s Experience of Having a Diagnosis of Personality Disorder’ in Sampson, McCubbin and Tyrer, P. (Eds.) (2006) Personality Disorder and Community Mental Health Teams
Paris, J (1996) Social Factors in the Personality Disorders Cambridge University Press
Proctor.G. 'Disordered Boundaries? A Critique of Borderline Personality Disorder' published by psychminded.co.uk and available on 23.8.09 at http://www.psychminded.co.uk/news/news2007/June07/borderline001.htm
Shaw, Clare ‘Women at the Margins: me, Borderline Personality Disorder and Women at the Margins’ Annual Review of Critical Psychiatry
Discussion between Louise Pembroke and Fenella Lemonsky on comments board of psychminded available at: http://www.psychminded.co.uk/news/news2007/June07/borderline001.htm
Presentation given by Gail Hornstein at Critical Psychiatry Network Conference 22.07.09
