Shot.

But one group of conditions does not align itself with these domains – one very important to clinicians in the field – borderline personality disorder. Despite the evidence that these domains are robust, the research findings of people with borderline personality disorder do not pay any respect to this organised system but flagrantly misbehave, crossing over to all the domain traits, but particularly those of negative affectivity, disinhibition and antisociality. This occurs at all levels of borderline personality disturbance and is not confined to the most severe. So, whereas the classification of someone with a mild degree of what used to be called Asperger’s syndrome could now be mild personality disorder in the detached domain, for most people with borderline personality disorder between two and four domain traits may be prominent at all levels of disorder.

How to deal with this in the ICD-11 classification or in a revised DSM-5 is currently a matter of debate. Some feel borderline personality disorder is best regarded as emotional dysregulation disorder (this is Marsha Linehan’s preference), and if the old DSM classification existed, it could be a simple task to move it from Axis II to the Axis I disorders. It is sad that no serious discussion took place with experts in personality disorder when Axis II was abolished, because it least had the value of drawing attention to a different area of psychopathology.

But the reality is that borderline personality disorder is a very heterogeneous condition that overlaps other disorders on every side; the many attempts at its subclassification show how unsatisfactory it is to have a single label. Where DSM-5, in its new form, and ICD-11 agree, is that most other personality disorders can be readily accommodated with both systems without the need to retain categorical labels, which have no evidence base and were committee-determined, not empirically derived. But many feel, with some justification, that the loss of borderline will be too much of a wrench for existing treatment and research programmes. We do not love this diagnosis but we feel we cannot let it go without a struggle.

Tyrer, P. Personality disorder: Good reasons to reclassify Australian & New Zealand Journal of Psychiatry doi: 10.1177/0004867417728808

Chaser

Peter Tyrer knows as much as anyone about the research into personality disorders. He has always been consistent and reasonable in trying to advance our thinking in this area. He is a tireless warrior in the cause of abandoning the categorical system for classifying personality disorders in favour of a dimensional approach. He now hopes to bring order, better research and greater clinical utility, not by making personality disorder traits dimensional, but by making personality disorder itself dimensional and adding domains as modifiers. The dimensional approach to personality traits used to be the province of clinical psychologists before they became enthralled by ‘The Dummies Guide To Instant Psychiatric Expertise’, also known as the DSM. The United Kingdom may be a DSM-free zone where clinicians avoid diagnosing personality disorders, but Australasia is surely not, nor in my experience are forensic mental health professionals, be they from the United Kingdom or anywhere else. They lard almost every court report with a personality disorder diagnosis, always to the detriment of their patient, sorry client, no that is now consumer, no, of course, the offender. But does using the label personality disordered, even in the new International Classification of Diseases (11th Revision; ICD-11) formulation, add much beyond the obvious and the stigmatizing?

When I was a registrar, John Gunn, who was to become the single greatest influence on the development of forensic psychiatry in the United Kingdom, admonished me to avoid using personality disorder labels. Describe the person’s attitudes, how they respond to the world as well as to other people, their strengths, their weaknesses, describe them as human beings in their social context and do not turn them into objects shoved into psychiatry’s latest fabricated box. My years of clinical practice have reinforced John’s words. A person’s temperament and acquired characteristics are often critical to assessment and management. An abused and neglected child may develop into an adult who is overly anxious and withdrawn, or one constantly searching for love and affection only to distrust and reject it when found, or to hide their pain and rage behind a mask of callousness. How does it help to label them personality disordered with domains of negative affective, antisocial, let alone simply borderline? Some of our colleagues have rushed to label President Trump a narcissistic personality disorder, which is an ad hominem argument adding nothing to what is bleeding obvious about him. Even Trump deserves better than to be labelled in this dehumanizing and trivializing manner, our patients certainly deserve better.
cite-key
Mullen, P. Personality disorders by numbers Australian & New Zealand Journal of Psychiatry doi: 10.1177/0004867417731527

The trouble with the classification system is that too many people think classification is understanding. It is not. The correct jargon is formulation: a hypothesis as to why this person is presenting with these symptoms at this time. Formulation should drive understanding and any diagnosis, not any set of checklists.