Commentary: Bringing together lived experience, clinical and research expertise – a commentary on the May 2022 debate (should CAMH professionals be diagnosing personality disorder in adolescence?)

Abstract

Background: There is a wealth of evidence to suggest that the Borderline Personality Disorder (BPD, or similar Emotionally Unstable Personality Disorder, EUPD) construct is harmful. We provide a commentary on the ideas expressed in the May Debate issue, highlighting both concerns and alternatives. Method: We bring together lived experience, clinical and research expertise. This commentary was written collaboratively drawing on all these sources of evidence. Results: We outline evidence that the BPD construct is invalid, harmful, not necessary for effective treatment and a potential block to the development and evaluation of alternatives. Conclusions: We ask readers to consider these concerns, perspectives and ideas. Key Practitioner Message• There is a wealth of evidence from a range of sources to suggest that BPD can be a harmful, invalid construct that is unnecessary for and might be detrimental to treatment. • We propose that these risks are even greater in adolescence.• We highlight alternative forms of practice that warrant further consideration, development and evaluation.

Mother and clinician experiences of a trial of a video feedback parent–infant intervention for mothers experiencing difficulties consistent with ‘personality disorder’: A qualitative interview study

“…Parents who meet diagnostic criteria for a ‘personality disorder’ experience enduring difficulties in managing emotions and relationships. Given the growing consensus that this diagnostic label can often be unhelpful, whilst an alternative conceptualisation has not been agreed (Consensus Statement Group, 2018; Hartley et al, 2022), we will place this terminology in quotes. This group of parents – particularly those experiencing difficulties consistent with ‘borderline personality disorder’ – are more likely than others to lack confidence in parenting, to experience parenting stress (Bartsch et al, 2016; Dunn et al, 2020; Zalewski et al, 2015) and to experience difficulties in understanding and responding appropriately to their child's communication (‘parental sensitivity’, Ainsworth et al, 1974; Petfield et al, 2015, Steele et al, 2019).…”

Bringing personality disorder in from the cold: Why personality disorder is a fundamental concern for youth mental health

“…7,21 This is evident in singling out PD for classificatory or diagnostic problems that are actually common to all mental disorders, in rigid adherence to scientifically unsupported and/or outdated beliefs about aetiology, treatability, and what constitutes effective treatment for PD, and in 'straw man' arguments that early intervention for PD is wedded to the categorical diagnosis of BPD, long-term psychotherapy, and only narrow outcomes based upon categorical BPD or PD criterion counts. [22][23][24] Lamentably, it gives rise to the disturbing argument that intervention for PD in young people is unjustifiable because there is insufficient evidence that it alters long-term outcome. 23 Such arguments would seem perverse if they were made for major depression or anorexia nervosa.…”

The social domains organization of mentalizing processes in adolescents: a contribution to the conceptualization of personality function and dysfunction in young people

“…A firm understanding of what we mean by personality functioning would provide an invaluable starting point for examining impairing variations as candidates for personality dysfunction (Sharp, 2022; Sharp & Wall, 2021). Establishing this approach in adolescence will be particularly relevant because of the importance of differentiating normal and problematic functioning at a time of challenge and change (Hartley et al., 2022; Tyrer, 2022). In this paper we bring together a developmental hypothesis for personality functioning, the social domains hypothesis and current findings on social dysfunction and mentalization processes in borderline personality disorder (BPD; Sharp & Hernandez, 2021), to generate hypotheses for normal and variant patterns of personality functioning.…”