Many people feel very strongly about the term ‘personality disorder’. It is not the adjective that troubles; it is the noun. ‘Disorder’ is used as from 1980 onwards every mental health diagnosis has been listed as a disorder even if the final word is not mentioned. You cannot make a mental diagnosis without using it, and, unfortunately all people in the field have to acknowledge this even when it seems to be unproductive.
People with personality disorders have two core features – interpersonal social dysfunction and distorted self-perception. Put more simply, they do not get on well with other people and yet often do not realise why. The term causes offence to those people who presume that personality disorder is a permanent condition and so by using it you are condemning the person to an underclass from which the person can never emerge. This is scientific nonsense; personality disorder is a very unstable diagnosis and when studied over many years shows as many gyrations as a yo-yo (Yang et al, 2022). But when one looks closely at the subject, it is clear objection to the term refers to one condition only, borderline personality disorder.
I have argued for many years (Tyrer. 2009) that borderline is not a personality disorder, it is a pre-diagnosis to many other diagnoses, and to label it as a personality disorder only casts a stigma on all other personality disorders, most of which would not have any stigma attached but for this association. There was never any stigma attached to the former terms, schizoid, obsessive compulsive or avoidant personality disorders; it is only borderline and its bridesmaid, narcissistic personality disorder, that cast a shadow over the others.
The borderline label is defective in other ways. Because emotional instability is so easy to identify it is used willy-nilly, without thought or reflection, and also tends to invalidate other mental symptoms. ‘
They wouldn’t let me into hospital and even if they did they couldn’t section me because I am not classed as mentally ill. So it’s not really helpful because at times when I am really stressed out and really ill, I really could do with being in hospital but that avenue has been totally shut down to me.”
(Lester et al, p.270)
It is also seen as pejorative as it is often used at a time of conflict.
‘The psychiatrist invested no time in me whatsoever, and it was just like I was a naughty, dirty person … it was like I should be ashamed of myself … it was like being marked out differently”
(Lester et al, p.270).
Other personality labels do not create the same level of distress. Part of this relates to the inability of many professionals in mental health services to feel any degree of confidence in understanding the borderline label. This is hardly surprising as the diagnostic requirements for borderline or emotionally unstable personality disorder are a mess of confusion and cannot be reduced to a set of tick-box labels.
‘The label itself causes the blame. It is located in me, my personality is disordered. For me, the blaming from staff come from their feelings of powerlessness, of not knowing how to help”
(Sibbald, 2020, p,26).
The reasons why the borderline condition is not a personality disorder are many. It is a collection of symptoms and behaviour, not of personality traits. Unlike the main group of personality disorders, ones characterised by social detachment, obsessionality, anxiousness, and aggression, borderline has not been of the slightest evolutionary benefit at any time in the history of man. It also has a better outcome than most other personality disorders. It has also not been recommended for use by the World Hexpert committees that revised personality disorder in ICD 10 in 1992, nor in ICD 11 in 2022, as it did not satisfy the basic requirements for personality disorder to be linked to a constant set of long-standing traits, but nonetheless was forced into some form of bastard inclusion because of political pressures (Tyrer et al, 2019) by what can only be described as ‘the borderline lobby’. There is no evidence that the term is necessary for good practice even though it is loved by many researchers.
This is not to say that the symptoms of borderline personality disorder do not exist. Of course they do, but they should be linked to the mood disorders, or in some cases to post-traumatic disorders, not the personality ones (Tyrer, 2009). The condition also needs to be redefined so that it does not border on every other group of mental health conditions known to science, which includes ADHD, the autism spectrum, transient psychotic disorders, complex post-traumatic stress disorder, mixed anxiety and depressive disorders and bipolar disorder. This makes a nonsense of diagnosis and brings the whole field into disrepute. A minority of people find the diagnosis helpful as it gives substance to the symptoms and distress they are feeling (Lester et al, 2020) but many others find it a term of such stigma that they will not rest until it is removed from the lexicon of mental illness.
Why is it such a stigmatic term?
Mainly because the general public, including most of the staff in general health services, roll their eyes and take a deep sigh when someone is said to be borderIine (you will note in this context the noun ‘person’ has changed into ‘borderline’, the person no longer exists). A set of predetermined responses follows, the ‘borderline’ is given short shrift and is disregarded. This is not how mental health staff are supposed to address the problems of this group (Lamont & Dickens, 2021), but it does so often happen in practice, particularly in A&E departments where staff are under great pressure and are not especially noted for being psychologically minded.
Mental health staff are supposed to be more understanding, but in a careful review, McGrath and Dowling (2012) found similar attitudes to the general public, that those seen as “borderline” were seen to be “challenging and difficult,” “manipulative, destructive and showing threatening behaviour,” “preying on the vulnerable, resulting in splitting staff and other service users,” and interfering with “boundaries and structures”.
The answer is very simple. Borderline is not needed by the vast numbers of people who have some form of emotional stability and should be abandoned (Mulder & Tyrer, 2023). Once it is, the ‘real’ “personality disorders” can be allowed to be assessed and treated in a neutral way, devoid of high emotion and conflict, and the stigma of a completely useless diagnosis will disappear. So, activists, reserve your anger for borderline, not the innocent bystanders caught in the crossfire.
Lamont E, & Dickens GL (2021). Mental health services, care provision, and professional support for people diagnosed with borderline personality disorder: systematic review of service-user, family, and carer perspectives. Journal of Mental Health, 30, 619-33.
Lester R, Prescott L, McCormack M, Sampson M; (2020). Service users experience of receiving a diagnosis of borderline personality disorder: review. Personality & Mental Health, 14, 263-83.
McGrath B, Dowling M (2012). Exploring registered psychiatric nurses’ responses towards service users with a diagnosis of borderline personality disorder. Nursing Research & Practice, 601918.
Mulder R & Tyrer P. (2023). Borderline personality disorder: a spurious condition unsupported by science that should be abandoned. Journal of the Royal Society of Medicine (in press).
Sibbald S (2020). Life and labels: some personal thoughts about personality disorder. In: Working effectively with personality disorder: contemporary and critical approaches to clinical and organisational practice (ed. Ramsden J., Prince S and Blazdell J). Pavilion, Shoreham-by-Sea.
Tyrer P. (2009). Why borderline personality disorder is neither borderline nor a personality disorder. Personality and Mental Health, 3, 86-95.
Tyrer P, Mulder R, Kim Y-R & Crawford MJ. (2019). The development of the ICD-11 classification of personality disorders: an amalgam of science, pragmatism and politics. Annual Review of Clinical Psychology, 15, 481-502.
Yang M, Tyrer H, Johnson T & Tyrer P (2022). Personality change in the Nottingham Study of Neurotic Disorder: 30 year cohort study. Australian and New Zealand Journal of Psychiatry, 56, 260-269.