Summary:

• The diagnosis of Personality Disorder (PD) is a label that is used disproportionality on women, with 75% of those receiving the diagnosis women. Yet 81% of those diagnosed with PD have disclosed past trauma.
• This misdiagnosis affects sexual abuse survivors more than anyone else because they commonly display the ‘symptoms’ common to both ‘disorders’, such as suicidal thoughts, anger, dissociative symptoms, hearing voices, impulsive behaviours, mood swings, depression, emptiness and displaced anger. As a result, diagnostic overshadowing occurs when someone who is dealing with complex trauma is told that they are “having a problem regulating their emotions”.
• The use of the term blames the victim for their reaction to adverse experiences. An understandable reaction to a horrifying life experience gets converted into an illness, which a person is held responsible for and then rejected by the system for having.
• This use of the term obscures justice because it means the accounts of victims of abuse and violence are often discredited in the courts. The label ‘personality disorder’ is used pejoratively by defence teams to discredit victims. A similar process occurs in the family courts.
• People given this diagnosis are stigmatised, discriminated against and excluded from many public services, creating a re-traumatising system.
• This is why Platfform is calling on the Welsh Government to review the use of BPD in Wales, and consider whether a more appropriate diagnosis of Complex Post Traumatic Stress Disorder (complex PTSD) should be used instead.

A diagnosis of ‘PD’ vs Complex PTSD

The ‘symptoms’ or ‘diagnostic criteria’ of PD are answering yes to 5 or more of the following ‘symptoms’: Fear of being left alone causing behaviour that may not be ordinary, having a pattern of unstable or short relationships, not having a strong sense of self, doing impulsive or self-destructive behaviours, self-harm, mood swings lasting minutes or hours, feelings of emptiness, sudden and Intense feelings of anger, and feeling suspicious, paranoid or disassociating.

The ‘symptoms’ of complex PTSD are: feelings of shame or guilt, difficulty controlling emotions, periods of losing attention and concentration (dissociation), physical symptoms (headaches, dizziness, chest pains and stomach aches), cutting friends and family off, relationship difficulties, self – destructive or risky behaviour, and suicidal thoughts.

These ‘symptoms’ clearly have a broad overlap. The major difference is that ‘complex PTSD’ is only diagnosed when there is awareness that the person has experienced repeated trauma such as violence, abuse or neglect in childhood and/or adulthood.

To diagnose a personality disorder a psychiatrist makes the decision as to whether an expression of emotion or behaviour is ‘appropriate’ given a particular situation. This is highly subjective and allows medical staff’s values, experiences and prejudices to affect the use of the diagnosis of ‘PD’ and other personality disorders. We know that institutional racism and sexism exist within the mental health system, and allowing such stigmatising labels to be given on such a subjective basis is problematic.

The consequences of receiving a diagnosis of ‘PD’

The consequences of abuse survivors receiving a diagnosis of ‘PD’ will be with them for life. They may be refused access to services, refused access to education, housing, occupations, college courses, insurance and volunteering opportunities. They may be told they are ‘too unstable’ to be involved in projects or to start therapy. Their diagnosis may even be flagged to their local police force, ambulance crews, fire service, GP surgeries and to social services.

A psychiatric diagnosis can be passed to emergency services who then use that information out of context to label people as ‘high risk’ and then respond inappropriately to situations. It may even mean that they call for the police to support them. Further, it may mean that a GP is less likely to believe them when they seek other medical help because they have been flagged as having a diagnosis of ‘PD’.

Concerns about the impact of this diagnosis go as far back as 1988, where a study published in the British Journal of Psychiatry found that:

Patients given a previous diagnosis of personality disorder (PD) were seen as more difficult and less deserving of care compared with control subjects who were not. The PD cases were regarded as manipulative, attention-seeking, annoying, and in control of their suicidal urges and debts. PD therefore appears to be an enduring pejorative judgement rather than a clinical diagnosis. It is proposed that the concept be abandoned.

Many external organisations will use the diagnosis to write women off. The criminal justice system and family courts may regard women who have received such a diagnosis as unreliable or not to believed. A 2019 study showed that Incidents involving victims-survivors with MHI (‘mental health issues’) were significantly less likely than those without MHI to be deemed a crime, to result in charge, to proceed to trial, and to result in conviction. Rape and Domestic Violence are already difficult crimes to prosecute, and the use of the BPD label exacerbates  and contributes to this.

There are also concerns about the impact the label will have in the family courts system, where custody battles themselves can be traumatising and victims of abuse are often cross examined on mental health.

A diagnosis puts the problem on the person and means they internalise it. There are many damaging consequences associated with this. It makes the person think it is their fault, and that their ‘faulty personality’ is to blame for the abuse. That there is nothing they can do to recovery from their ‘symptoms and outcomes associated with the diagnosis is poor. This can perpetuate the distress and can mean people are unable to seek justice for the abuses they experienced. It also prevents the right interventions and support from being accessed or delivered. A diagnosis of ‘BPD’ means people get told ‘there is nothing more we can do’. contributing to the hopelessness and powerlessness many people will already be feeling.

It also means that as a society we are continuing to pretend that symptoms of mental distress and responses to trauma are the result of random faulty genetics. This obscures the role social determinants and our circumstances play in our mental health outcomes.

In conclusion, this is a diagnosis that makes little scientific sense, is sexist, and contributes to the re-traumatisation of victims of abuse. It cannot be part of a trauma informed mental health system.

So, what are we calling for?

Platfform believes that the time has come for a review into the use of the diagnostic categories of ‘personality disorder, in particular the use of ‘Personality Disorder’ when people have experienced trauma. We would like a review to specifically consider:

1. Whether the diagnosis is being applied properly, and only after alternatives such as complex PTSD are ruled out
2. The extent to which institutional misogyny within the mental health system is resulting in the disproportionate use of this diagnosis on women.
3. How victims of abuse and violence can be more appropriately supported and helped to recover by the mental health system, instead of having the abuse perpetuated by an inappropriate label.
4. The evidence base that supports the construct validity of ‘personality disorder’ and whether it is time for that label to retire.