Category: RITB

By Dr. Jay Watts, Social Psychiatry, Queen Mary, University of London,

The forthcoming International Classiffication of Disease, 11th revision (ICD-11), includes a reconceptualisation of the categorisation of personality disorders with an explicitly expansionist objective. The ICD working group assumes this is a positive step, yet the grounds for this assumption are unclear.

Personality disorders will no longer be classified categorically, but rather using dimensions of severity— mild, moderate, or severe.1 An additional category of personality difficulty will be demarcated not as a disorder, but as the equivalent of a z-code in ICD-10—ie, a non- disease factor that affects health status and encounters with health services. Following assessment of severity, clinicians will then have the option of specifying one or more of five domain trait qualifiers: negative affectivity, anankastia, detachment, dissociality, and disinhibition. ICD-11 will include new guidance for personality disorders to be diagnosed during childhood, albeit with caution, as they had previously been “inappropriately set at late adolescence or early life adult life”[1]. Additionally, the revision will include a borderline pattern qualifier that is not dissimilar to the symptom profiles outlined in ICD-10 and the Diagnostic and Statistical Manual of Mental Disorder, 5th edition.

In their proposals, WHO are neglecting to incorporate progress in alternative approaches. The Hierarchical Taxonomy of Psychopathology transdiagnostic system follows quantitative nosology to its logical conclusion, side-stepping construct validity problems by focusing on internalising, externalising, detachment, thought disorder, and somatisation, as they apply across the spectrum of psychiatric diseases [2]. The #TraumaNotPD movement reframes borderline as a form of complex trauma, evidenced not only by a robust literature connecting childhood trauma and the psychosocial environment with identity disturbance and interpersonal difficulties [3], but also patient testimonials supporting the benign face validity of such an approach.

With the publication of ICD-11, it is likely that more patients than before will be told they have a personality disorder. An explicit aim of the WHO remit for the ICD working group was to increase the diagnosis of personality disorder, on the basis that only around 8% of patients in the UK received this diagnosis, despite suggestions that prevalence of personality disorder is about 40–90% for inpatients and outpatients with psychiatric disorders [1]. The only eld study of ICD-11 diagnosis in practice looked at prevalence in 722 patients presenting with either health anxiety or anxiety and depressive disorders, or inpatients with psychiatric disorders. It showed not only that ICD-11 led to more patients being diagnosed with personality disorder (292 [40·4%] of 722) than did ICD-10 (244 [33·8%] of 722), but also that an additional 248 (34·3%) of the 722 patients were classified as having personality difficulties.2 Thus, 540 (74·8%) of 722 patients were diagnosed as having personality difficulty or disorder [4]. The assumption from WHO is that diagnosis using ICD-11 will prevent patients receiving treatments that they might not benefit from, introduce new treatments, and decrease the stigma that can be associated with personality disorders. However, no evidence as yet supports these assumptions.

In a systematic review investigating personality disorder diagnosis and different clinical populations, a diagnosis often procured negative effects on identity and hope(similar to a diagnosis of psychosis) and did not provide functional utility (such as access to treatments) [5]. This is because the idea of a personality disorder often prejudices clinicians to situate symptoms of distress as manipulative, attention-seeking, and wilful6 and enables disdainful, neglectful, and sometimes even abusive responses that would be recognised as gross misconduct elsewhere in the mental health system, such as ignoring or disbelieving suicidal ideation [7].

The shaping effects of labelling someone as having personality disturbance or disorder appear to be entirely absent from consideration in the revision of the classification of personality disorder, with little or no consultation with service-user led organisations best placed to comment on real-world implications. Clinicians see treatment outcome less optimistically if they are told that someone has borderline personality disorder [8]. Patients have regularly reported that being diagnosed with a personality disorder is the ultimate character slur [9], leading to realisation of every worst fear one has had about themselves, and often reinforcing messages from abusers that they are inherently problematic [10]. To impose this discourse on even more patients, including adolescents, risks setting up a self-fulfilling prophecy by which expectations of a negative trajectory are established, and subsequently met.

Expansionism becomes more dangerous still when we consider that an explicit aim of the WHO working group was to develop a proposal that could be used in low-resource settings by people who are health workers with minimal professional training [1]. Encouraging such a cursory approach to personality diagnosis not only promotes negative thinking regarding differences in mental health and problematic norms, but also gives clinicians in severely overstretched services worldwide a ready signifier to block access to care to anyone who makes them uncomfortable, challenges them, or complains [11]. This will exacerbate discrimination against those from low-income settings, or with a poor education, who are more likely to meet diagnostic criteria for a personality disorder [12].

Borderline pattern has also been included in ICD-11. There is no scientific basis for inclusion, with “noticeable absence of evidence it’s a uni ed syndrome”, and overlap with mood, stress, and dissociation, rather than personality disorders [1]. Indeed “when an assessment was made of borderline features” in the modelling of personality traits “the domain structure seemed to disintegrate, and examining the full implications of this involved a great deal of the group’s time and early studies” [1]. Retention of borderline as a so-called hand- me-down diagnosis not only undermines the scientific claims of the new dimensional model, but also ensures that even patients who find diagnosis legitimising are disadvantaged, being coupled with a diagnosis that is openly contested.

Borderline has only been included in ICD-11 because of relentless campaigning from lobbyists, starting with a letter from the European Society for the Study of Personality Disorders in 2016, followed by campaigning from both the International and the North American Societies for the Study of Personality Disorders [1][13]. This led to a separate working group, though the Chair of the ICD-11 committee chose to exclude himself [1], having written “nothing about it is driven by personality. The very name borderline personality disorder betrays an abrogation of diagnosis” [14]. The discourse from WHO is that the pragmatic compromise of including a borderline pattern to assuage these lobbyists is now unanimous [1]. Unanimous for whom? Certainly not patients, the majority of whom are traumatised women who remain largely unheard and ideologically restricted (coshed) by this most misogynistic of classifications [7] and who cannot take refuge in a narrowly de ned new diagnosis of complex post-traumatic stress disorder, as so many had hoped.

1 Tyrer P, Mulder R, Kim YR, Crawford MJ. The development of the ICD-11 classiffication of personality disorders. Annu Rev Clin Psychol 2019; published online Jan 2. DOI:10.1146/annurev-clinpsy-050718-095736.

2 Kotov R, Krueger RF, Watson D,et al. The hierarchical taxonomy of psychopathology (HiTOP): a dimensional alternative to traditional nosologies. J Abnorm Psychol 2017; 126: 454–77.

3 Giourou E, Skokou M, Andrew SP, Alexopoulou K, Gourzis P, Jelastopulu E. Complex posttraumatic stress disorder: the need to consolidate a distinct clinical syndrome or to reevaluate features of psychiatric disorders following interpersonal trauma? World J Psychiatry 2018; 8: 12–19.

4 Tyrer P, Crawford M, Sanatinia R, et al. Preliminary studies of the ICD-11 classiffcation of personality disorder in practice. Personal Ment Health 2014; 8: 254–63.

5 Perkins A, Ridler J, Browes D, Peryer G, Notley C, Hackmann C. Experiencing mental health diagnosis: a systematic review of service user, clinician, and carer perspectives across clinical settings. Lancet Psychiatry 2018; 5: 747–64.

6 Black DW, Blum N, Pfohl B, et al. Attitudes toward borderline personality disorder: a survey of 706 mental health clinicians. CNS Spectr 2011; 16: 67–74.

7 Phillips S, Stafford P, Turner K. Personality disorder in the bin. 2017. http://aspd-incontext.org/wp-content/uploads/2016/11/PDintheBin- London-PS-KJT-3.5.17-1.pdf (accessed March 28, 2019).

8 Lam DC, Poplavskaya EV, Salkovskis PM, Hogg LI, Panting H. An experimental investigation of the impact of personality disorder diagnosis on clinicians: can we see past the borderline? Behav Cogn Psychother 2016; 44: 361–73.

9 Shaw C. The most savage insult. Equilibrium Magazine 2012; 46: 23–26.

10 Gary H. A diagnosis of ‘borderline personality disorder’. Who am I? Who could I have been? Who can I become? Psychosis: Psychological, Social and Integrative Approaches 2018; 10: 70–75.

11 Recovery in the bin. A simple guide to avoid receiving a diagnosis of ‘Personality Disorder’. Clinical Psychology Forum 2016; 279: 13–16.

12 Coid J, Yang M, Tyrer P, Roberts A, Ullrich S. Prevalence and correlates of personality disorder in Great Britain. Br J Psychiatry 2006; 188: 423–31.

13 Reed GM. Progress in developing a classiffication of personality disorders for ICD-11. World Psychiatry 2018; 17: 227–29.

14 Tyrer P. Borderline personality disorder and mood. Br J Psychiatry 2014; 205: 161–62.

First Published in The Lancet

Recovery In The Bin (RITB) is covered by a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) License

By Maggie Zolobajluk @22magoo, anti-austerity activist. This article first appeared on her blog Telling it as it is

Until two years ago I was a very high functioning Heroin addict and had been self-medicating with heroin since the age of twenty-seven. I had been battling anxiety, depression, anorexia, and addiction from the age of seventeen, all related to physical, psychological and sexual abuse in childhood.

Those of us that function at this level are invisible because from the outside we look like you. Look around you; we could anyone that you see, a friend that you have known for years or a work colleague that you admire and work alongside or the person you chat to at the school gates.

Addiction was not a life style choice; it was a psychological and physical need, like taking a deep breath and exhaling a very long slow deep long sigh of relief, where there is time and space while the drug lasted. The need for these spaces sometimes have lasted for years, other times days, weeks or months and outwardly no-one knew anything was wrong.

After three years of counseling and fast approaching my sixty-seventh birthday, I have been clear of Heroin use for two years.

When I have told people about my past, so far I have come across three different reactions:

One is “Oh wow, that’s amazing. I would never have known, Look at you. Look at what you’ve achieved with your life.

Others unconsciously glance down at my arms to see if I have tract marks, which I don’t. My arms look exactly the same as yours as I have never injected heroin.

And others unconsciously clutch their bags closer to them for a split second, just in case I’m going to snatch it away from them and run off with it.

Words can define how people look and treat us. They create pictures, which are able to shape our beliefs, prejudices and actions.

What picture do you see in your mind’s eye when you hear the words “Dirty Junkie.”

I can guarantee you it won’t be an image of a high functioning addict like me, as I am invisible to you but a stereotype that dehumanises and devalues us, that is very pale looking, often having dark circles around their eyes; they are skinny and always a little bit sweaty. Their clothes look worn-out and unkempt, as if they have not been changed in days.

By judging and reacting to us like this on top of the mountain of pain, fear, isolation and shame we feel already, maybe for things we have done to survive, you give us more shame.  Shame founded on a Puritan belief, where belonging and connectivity comes from hard work and perseverance,

You see us as not deserving, a drain on society, not worthy to be part of your community which reduces your responsibility towards us, as you feel we bought this on ourselves. Your judgement excludes us, when what we need most of all is to feel that we belong and feel connected

This attitude is again reinforced by the media in films like “A street cat called Bob” and “Trainspotting” and perpetrated further by the newspaper in negative reporting.

The media makes a fortune out of it. Its big news, it sells papers, so woe betides a celebrity who falls to pieces due to addiction, as in the recent case of Amy Winehouse.  Images of a public meltdown sell papers. This public scrutiny brings additional pressure at a time where the world was crashing in on her, where she had no space.  Yet we followed and waited for her every move.

The deserving and undeserving is again perpetuated by Government policies of trying to force us into “treatment programs” that we are not ready for, with the threat of sanctions if we don’t or can’t comply.

“DRUG addicts and alcoholics who refuse to have treatment could be stripped of their sickness benefits in a new “tough love” approach to be unveiled by the Government” proclaimed The Express in 2012 It went on to say “From next year in pilot areas, drug addicts will be required to attend discussions about treatment and agree a rehabilitation plan to address their drug problem and other barriers to work that they face, or they risk losing their benefits”

Coercing people into therapy is dangerous as our consent is negated if it is given under duress. Punitive measures have no place in therapy. A safe environment is needed.  Trust needs to be established.  Asking questions about traumatic experiences can be extremely stressful or damaging for us as already traumatized individuals. Subsequent “re-traumatisation” could occur.

Then, when we enter counseling, where words and physical movements, just like music or smells can take us back to a particular event in our past flooding us with the memories and emotions of the trauma we have experienced and suppressed, we are faced with the expression,  “Do you feel dirty?”    A phrase so commonly and thoughtlessly used to describe people that take Heroin. This also perpetuates the stereotype image that’s been around for a long, long time.

These words are also said without thinking by many from the Psychology profession who use them without question. When you stop to think about them they imply that a person who has self medicated with an addictive drug, especially heroin, is dirty.  If you want to use a “d” word think about despair, desperation and dehumanisation.

Yet, after recovery, when we have finished counseling, ready to face the world on our own, we stigmatise ourselves by use the word “clean” to describe our remission. Every time we use the word “clean” to describe our state of health, we reinforce the stigma that once we were “dirty”

Once we stop associating with the word “dirty” we can see ourselves as in the “clear” We have recovered from the trauma of our childhood and are in remission.  We have forged new pathways in our brains that we now follow but just like any remission the old pathways are still there, so relapse is possible.

So finally, I would like you to picture a blank piece of paper. Take a pencil and write the word clean. Then take a rubber and rub away the downward stroke of the letter “n”, the downward stroke that is the stigma that society places upon us.

Many, many thanks to Dr Jay Watts @Shrink_at_Large, jaywatts.co.uk for her support, kind words and comments.

The Worry Tree™ is a complex Psychological Intervention™ which has led to a paradigm shift® in mental health care.

It works like this:

1. Write down your worry.
2. Work out if there is something you can do about your worry.
3. If there is, then do it and LET WORRY GO, change your focus of attention.
4. If there isn’t then… just LET WORRY GO, change your  focus of attention.

You can download a free Worry Tree™ over here.

(This is ACTUALLY USED in IAPT services.)

Case Example 1: Chronic pain and illness

The mindful worry tree cure for all chronic pain and illness, disability and anything non-surgical known to humankind. Basically – DON’T WORRY.

About to die or be killed – LET WORRY GO.

Case Example 2: Imminent austerity death

I am worried I will freeze to death on the street because I have nowhere to live after I was evicted due to Universal Credit… let it go you silly worry head, the nice lady from the government was on TV and said it’s all going really well, Merry Christmas!

Case Example 3: Worrying about worry

I am now worried about whether I worry too much.

Should I let this worry go and refocus my attention?

I am now going to stop worrying about worrying too much, I am going to let that worry go, and refocus my attention on the things I am legitimately worried about.

Case Example 4: Domestic violence

Nearly killed by your husband? All the refuges closing? LET WORRY GO, change your  focus of attention.

Case Example 5: The Worry Tree™ Worry

I am worried about this Worry Tree™. Is it a hypothetical situation or a current problem? I like that the solution in all cases is change focus of attention. This therefore requires “not thinking about The Worry Tree™”. Problem solved. QED.

Recovery In The Bin (RITB) is covered by a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) License