A PSC Cymru Statement on the use of the diagnosis of ‘Personality Disorder’ with Children and Young People: A response to ‘Should Child and Adolescent Mental Health Professionals be Diagnosing Personality Disorder in Adolescence? Elvin & Kaess (2022)’
Summary
- The diagnosis of 'personality disorder' lacks scientific validity.
- In the current context it makes more sense to allow the introduction of the diagnosis of 'developmental trauma' or extending the use of the ICD diagnosis of 'complex PTSD' for children and young people.
- Long term we must fund the development and support the implementation of more sophisticated modeling of trauma and mental health which take a holistic, rights-based and needs led approach.
We were surprised to read the Elvin & Kaess editorial in the Child Adolescent Mental Health Journal (May 2022) about diagnosing ‘personality disorder’ in children and young people which argues for its clinical benefit. The authors go on to claim they found 'no scientific arguments' against this debate. However, this is simply not true. We, therefore, thought it important to make public our concerns and provide the counter evidence for giving people generally but especially children the diagnosis of 'personality disorder'.
It is important to note that the diagnosis of 'personality disorder' has been found clinically and anecdotally by the people it has been given to, to be highly problematic and have harmful effects. The article states that some research shows that the concept of 'personality disorder' is as ‘reliable and valid’ for adolescents as adults. But the diagnostic system for mental disorders (DSM-5) is known to be an unreliable and a scientifically invalid system broadly. This means the construct of ‘personality disorder’ also lacks scientific validity, irrelevant of whom it is being applied to.
We are already concerned that it is being inappropriately given to adults and have written earlier this year to the Deputy Minister for Mental Health expressing these concerns (see below). The use of the diagnosis of 'personality disorder' causes diagnostic overshadowing of, for example, developmental, attachment, complex trauma and other related difficulties. Its continued use masks a hidden epidemic of child abuse and neglect. Allowing the application of this diagnostic category to children only adds to this problem.
We know poverty is correlated to child abuse and neglect. We also know that childhood abuse and neglect is correlated to ‘mental disorders’ including the diagnosis of 'personality disorder' and the diagnosis of 'schizophrenia'. The experiences associated with the diagnosis of 'personality disorder' can instead be viewed as normal responses to disruptions to childhood development, our relational and attachment systems, alongside other challenges such as nervous system and emotional regulation. In other words, as the result of our families histroical and the present circumstances we are born into and live in.
The diagnosis of ‘personality disorder’ is also disproportionately given to women. Women are 75% more like to receive it compared to men. Elvin & Kaess believe that there is no longer stigma from health professionals in offering treatments to individuals with a diagnosis of 'personality disorder'. We strongly disagree. We see this routinely in our practice, but don’t take our word for it, ask those that have been given this diagnosis for their views.
The consequences of receiving this diagnosis have been shown to prevent women from accessing appropriate mental health support and impacts how other public services engage with them. As long ago as 1988, an article in the British Journal of Psychiatry reported research showing that psychiatrists treated patients with a diagnosis of ‘personality disorder’ as more difficult and less deserving of care compared with other patients. Little has changed since.
Today, it is still used against women. Still many providers of public services will exclude those with a diagnosis of ‘personality disorder’, and the police will often accompany public services to 999 calls when such calls are flagged as coming from somebody with this diagnosis. We are aware of reports where people feel the diagnosis is used as a threat to manipulate their choice of intervention or as an attempt to control their ‘behaviour’ or belittle their distress. The diagnosis is experienced by some as manipulation and we would be concerned that children and young people would feel forced to internalise social issues and experiences, and comply with interventions they don’t want or feel fit with their experience or reality.
We would be particularly concerned about the impact of this on girls and young women who, rather than opening up a pathway for support, it would close down access to appropriate support - earlier in their lives. Changing how those in their schools, further education, employment, housing providers, or communities treat them as well.
Elvin & Kaess argue that diagnosing 'personality disorder' can facilitate self-advocacy and promote acceptance of evidence-based treatments. We recognise that diagnosis can be helpful for some people but as highlighted it is harmful to others. At the same time a diagnosis of 'personality disorder' tells the person the problem is within you. It says, "there is something wrong with you” rather than acknowledging context and holding in mind “what has happened or happening to you” or what did you not get that you needed.
Here, we must also consider the process of childhood development. Specifically, the implications for teenagers and in early adulthood, when brains are still adapting, developing and maturing. We know teenage brains are more vulnerable to stress. Therefore, it would be clinically essential to take this into consideration. The criteria for the diagnosis of 'personality disorder' already recognises this in acknowledging that 'personality' is not considered ‘stable’ until adulthood (approx. 25 years of age). It would be clinically inappropriate to diagnose a 'personality disorder' before this developmental stage.
Elvin & Kaess also argue that the diagnosis of 'personality disorder' should be given in adolescence because this has better outcomes than for individuals diagnosed later. We would argue that it is not the early diagnosis itself that is the cause of better outcomes but the earlier access to appropriate trauma and relationally informed understanding and holistic support that will most likely be of benefit. It would be more appropriate to allow the use of the diagnosis of developmental trauma, attachment difficulties or focusing on developing the ICD diagnosis of complex PTSD and supporting them to access the associated evidence based whole family or individual interventions.
We, therefore, believe that better recognition and understanding of the impact of the social, commercial, and political determinants for mental health, including, trauma, adverse experiences, diet, toxic stress, systemic and structural inequality, poverty and their impact on individuals’, families and communities’ mental health, must be at the centre of our thinking moving forward.
This approach and perspective would sit comfortably alongside the ambitions set out in the Wellbeing of Future Generations (Wales) Act (2015) and is core to the delivery of the ACEs Hub and Traumatic Stress Wales all-society trauma-informed framework. It should be an important part of the Welsh Government’s new Adverse Childhood Experiences (ACEs) plan. It will also help us achieve the actions in the current and further iterations of the ‘Together for Mental Health Strategy’.
To achieve these aims long-term we must explore and fund the development of more sophisticated modelling of trauma and mental health, to provide better solutions to these complex problems. There are a number of established and emerging fields to draw on including, for example, attachment theory, psychosocial ecology and relational neuroimmunology, alongside models such as Building Underdeveloped Sensorimotor Systems (BUSS), Dynamic Maturational, Neurosequential, Dyadic Developmental Practice and Research Domain Criteria.
This will be paramount to the Welsh Government object of becoming a truly trauma and relationally informed society.
Psychologists for Social Change Cymru
August 2022
It is important to note that the diagnosis of 'personality disorder' has been found clinically and anecdotally by the people it has been given to, to be highly problematic and have harmful effects. The article states that some research shows that the concept of 'personality disorder' is as ‘reliable and valid’ for adolescents as adults. But the diagnostic system for mental disorders (DSM-5) is known to be an unreliable and a scientifically invalid system broadly. This means the construct of ‘personality disorder’ also lacks scientific validity, irrelevant of whom it is being applied to.
We are already concerned that it is being inappropriately given to adults and have written earlier this year to the Deputy Minister for Mental Health expressing these concerns (see below). The use of the diagnosis of 'personality disorder' causes diagnostic overshadowing of, for example, developmental, attachment, complex trauma and other related difficulties. Its continued use masks a hidden epidemic of child abuse and neglect. Allowing the application of this diagnostic category to children only adds to this problem.
We know poverty is correlated to child abuse and neglect. We also know that childhood abuse and neglect is correlated to ‘mental disorders’ including the diagnosis of 'personality disorder' and the diagnosis of 'schizophrenia'. The experiences associated with the diagnosis of 'personality disorder' can instead be viewed as normal responses to disruptions to childhood development, our relational and attachment systems, alongside other challenges such as nervous system and emotional regulation. In other words, as the result of our families histroical and the present circumstances we are born into and live in.
The diagnosis of ‘personality disorder’ is also disproportionately given to women. Women are 75% more like to receive it compared to men. Elvin & Kaess believe that there is no longer stigma from health professionals in offering treatments to individuals with a diagnosis of 'personality disorder'. We strongly disagree. We see this routinely in our practice, but don’t take our word for it, ask those that have been given this diagnosis for their views.
The consequences of receiving this diagnosis have been shown to prevent women from accessing appropriate mental health support and impacts how other public services engage with them. As long ago as 1988, an article in the British Journal of Psychiatry reported research showing that psychiatrists treated patients with a diagnosis of ‘personality disorder’ as more difficult and less deserving of care compared with other patients. Little has changed since.
Today, it is still used against women. Still many providers of public services will exclude those with a diagnosis of ‘personality disorder’, and the police will often accompany public services to 999 calls when such calls are flagged as coming from somebody with this diagnosis. We are aware of reports where people feel the diagnosis is used as a threat to manipulate their choice of intervention or as an attempt to control their ‘behaviour’ or belittle their distress. The diagnosis is experienced by some as manipulation and we would be concerned that children and young people would feel forced to internalise social issues and experiences, and comply with interventions they don’t want or feel fit with their experience or reality.
We would be particularly concerned about the impact of this on girls and young women who, rather than opening up a pathway for support, it would close down access to appropriate support - earlier in their lives. Changing how those in their schools, further education, employment, housing providers, or communities treat them as well.
Elvin & Kaess argue that diagnosing 'personality disorder' can facilitate self-advocacy and promote acceptance of evidence-based treatments. We recognise that diagnosis can be helpful for some people but as highlighted it is harmful to others. At the same time a diagnosis of 'personality disorder' tells the person the problem is within you. It says, "there is something wrong with you” rather than acknowledging context and holding in mind “what has happened or happening to you” or what did you not get that you needed.
Here, we must also consider the process of childhood development. Specifically, the implications for teenagers and in early adulthood, when brains are still adapting, developing and maturing. We know teenage brains are more vulnerable to stress. Therefore, it would be clinically essential to take this into consideration. The criteria for the diagnosis of 'personality disorder' already recognises this in acknowledging that 'personality' is not considered ‘stable’ until adulthood (approx. 25 years of age). It would be clinically inappropriate to diagnose a 'personality disorder' before this developmental stage.
Elvin & Kaess also argue that the diagnosis of 'personality disorder' should be given in adolescence because this has better outcomes than for individuals diagnosed later. We would argue that it is not the early diagnosis itself that is the cause of better outcomes but the earlier access to appropriate trauma and relationally informed understanding and holistic support that will most likely be of benefit. It would be more appropriate to allow the use of the diagnosis of developmental trauma, attachment difficulties or focusing on developing the ICD diagnosis of complex PTSD and supporting them to access the associated evidence based whole family or individual interventions.
We, therefore, believe that better recognition and understanding of the impact of the social, commercial, and political determinants for mental health, including, trauma, adverse experiences, diet, toxic stress, systemic and structural inequality, poverty and their impact on individuals’, families and communities’ mental health, must be at the centre of our thinking moving forward.
This approach and perspective would sit comfortably alongside the ambitions set out in the Wellbeing of Future Generations (Wales) Act (2015) and is core to the delivery of the ACEs Hub and Traumatic Stress Wales all-society trauma-informed framework. It should be an important part of the Welsh Government’s new Adverse Childhood Experiences (ACEs) plan. It will also help us achieve the actions in the current and further iterations of the ‘Together for Mental Health Strategy’.
To achieve these aims long-term we must explore and fund the development of more sophisticated modelling of trauma and mental health, to provide better solutions to these complex problems. There are a number of established and emerging fields to draw on including, for example, attachment theory, psychosocial ecology and relational neuroimmunology, alongside models such as Building Underdeveloped Sensorimotor Systems (BUSS), Dynamic Maturational, Neurosequential, Dyadic Developmental Practice and Research Domain Criteria.
This will be paramount to the Welsh Government object of becoming a truly trauma and relationally informed society.
Psychologists for Social Change Cymru
August 2022