Tuesday, February 04, 2020

Labelling of personality disorder

Keir Harding has an excellent The Mental Elf blog post summarising the new position statement on personality disorder by the Royal College of Psychiatrists. He expresses disappointment about the way in which the position statement has approached the issue of the diagnosis of personality disorder.

Considering the way I have been critical of those that want to completely abandon the term 'mental illness' in recent posts (see example), it may seem surprising that I agree with Keir. I think a distinction needs to be made between personality disorder and mental illness. In a way, the diagnosis of 'personality disorder' can be taken to imply that the person does not have a mental illness as such. This is why it can become a diagnosis of exclusion, if services are seen as only dealing with people with mental illness. In my practice, I was often reluctant to use the term personality disorder, instead using a description such as 'personal problems or difficulties'. In fact, if the term 'personality disorder' has any meaning, what it does mean is personal problems or difficulties. This isn't to underestimate the potential severity of such problems which can be very incapacitating (and for which such severe conditions a diagnosis of ‘illness’ may actually make sense).

As The Consensus Statement for People with Complex Mental Health Difficulties who are diagnosed with a Personality Disorder makes clear (albeit with slightly clumsy wording), there is a lack of "consensus on what words we should use to talk about the problems and difficulties people with this diagnostic label experience". The implication that there is something wrong with the person's personality can be very misleading and it may well be better if the term is abandoned or replaced. Personality disorder also shouldn't imply that there is no room for improvement.

It is reasonable to expect that the College would properly deal with this issue in its position statement, although the title of its statement 'Services for people diagnosable with personality disorder' implies that the diagnosis, as such, may not necessarily be needed or used. As Adrian James, newly elected President of the College, acknowledges in the foreword, "there is the potential for a diagnosis [of personality disorder] to cause harm, particularly if this is done in a way that lacks appropriate dialogue". However, he goes on, "on balance, we believe that the diagnosis has brought benefits of better describing the impact of such difficulties on people’s health and social outcomes".

It worries me that the position statement countenances the use of the term personality disorder in adolescents, rather than conduct, or even emotional disorders (although these may predispose to a diagnosis of personality disorder as an adult). I'm not sure if the diagnosis of personality disorder as such always "interferes with the sufferer’s sense of wellbeing and ability to function in full in ordinary social settings". Some people diagnosed as being personality disordered (eg. antisocial personality disorder) may well not have any subjective sense of being unwell. Although the College accepts that the issue is controversial, I don't agree that "a range of evidence exists to support a neurobiological role". It is of concern that the College believes that "changing terminology will simply cause confusion and divert attention (and funding support) from the need to develop accessible, effective and safe services". However, a scientific statement about personality disorder shouldn't be determined by such expectations. I'm not sure if the College is making a pitch for psychiatrists to be the only ones that are sufficiently qualified to make a diagnosis of personality disorder.

Like Keir, I am disappointed by this position statement. To me there seems to be more work that the College needs to do. Maybe the wish to come to some agreement amongst The British and Irish Group for the Study of Personality Disorder executive avoided the hard work needed to deal with these issues, although as Keir points out, "The document doesn't actually describe how it came together". In fact, I don't think it does 'come together'.

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