Words matter: the Royal College of Psychiatrists' position statement on personality disorder

January, 2020, saw the publication of the Royal College of Psychiatrists’ position statement on personality disorder.1

In comparison with the current NICE guidelines,2 the statement sets out an arguably more radical vision for the future of services for people diagnosed with personality disorder,2 with recommendations on the need for accurate diagnosis, staff support, and people with lived experience being a part of the workforce. Although the statement recognises the existence of stigma for those diagnosed, we seem to have done a poor job of reducing this stigma in the more than 15 years since the landmark paper Personality disorder: no longer a diagnosis of exclusion, was published by the National Institute for Mental Health in England.

The position statement describes itself as being inspired by The Consensus Statement for People with Complex Mental Health Difficulties who are Diagnosed with a Personality Disorder, a document authored and signed by a range of people with lived and professional experience, including the Royal College of General Practitioners. This document states, “Most of us would rather not use the term at all… We would like to abandon the term ‘personality disorder’ entirely.”3

However, the Royal College of Psychiatrists’ position statement seems to ignore this preference, and references disordered personalities throughout, arguing that “there is a risk that changing terminology will simply cause confusion”.1

I fear this position underestimates the intellect of those calling for change and the mental vigour of psychiatrists. Meanwhile, the medical world seems able to survive the changing terminology of the ICD-114 in which all of the prefixes to “personality disorder” are redundant.

There are two aspects to the diagnosis: the construct itself and the terminology to describe it. Creating a new diagnostic framework is a huge undertaking, but the name that is applied to this construct could be changed tomorrow without hurting anyone. If we are to respect the consensus statement, we need to listen to those given this diagnostic label. The voice of those who want the term personality disorder eradicated is loud; the voice of those insisting that their own personalities are disordered is inaudible.

The Knowledge and Understanding Framework for Personality Disorder5 has been the most sustained organisational intervention to reduce stigma in the UK. This framework involved a shift in perspective, from one of disordered personalities to one of understandable adaptions to life experiences. Our current insistence on labelling people as disordered is a poor start to any therapeutic relationship.

Such are the concerns regarding the damage done to people by placing a personality disorder label upon them that some services avoid the label altogether—a natural response to the weaponisation of the diagnostic term that we seem unable to ameliorate. Clinical experience shows that people are given this diagnosis not because they meet the criteria, but because they are perceived as challenging or unpopular with medical professionals, because they are not responding to treatment or are making complaints about the care they receive, or because they have refused to die from their suicide attempts. It is a label that leads to closed minds rather than open arms. Until it feels safe for someone to receive such a diagnostic label, it makes sense that concerned clinicians and patients will attempt to avoid it.

We need to listen to our patients when they tell us that this terminology is harming them. They are unlikely to trust us to listen to them when we are insistent that the core of their being is disordered. Categorising people, rather than their difficulties, has become archaic; we now frown upon doctors who used terms such as “moron” or “cretin” to describe those entrusted to their care. The term personality disorder will fare equally badly over time, and psychiatry must decide whether its insistence on calling people disordered is worth the harm and alienation that results.

KH serves on the executive committee of the British and Irish Group for the Study of Personality Disorder with the two editors of the position statement.

 

References

  1. Royal College of Psychiatrists. PS01/20: Services for people diagnosed with personality disorder.
  2. NICE. Borderline personality disorder: recognition and management. Clinical guideline [CG78]. https://www.nice.org.uk/guidance/CG78 Date: January, 2009. Date accessed: March 13, 2020
  3. Lamb N, Sibbald S, Stirzacker A. “Shining lights in dark corners of people’s lives”: the consensus statement for people with complex mental health difficulties who are diagnosed with a personality disorder.
    https://www.mind.org.uk/media/21163353/consensus-statement-final.pdf Date: 2018. Date accessed: February 11, 2020
  4. Bach B, First MB. Application of the ICD-11 classification of personality disorders. BMC Psychiatry. 2018; 18351
  5. Davies J, Sampson M, Beesley F, Smith D, Baldwin V. An evaluation of Knowledge and Understanding Framework personality disorder awareness training: can a co-production model be effective in a local NHS mental health trust?. Personal Ment Health. 2014; 8161-168

 

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