DBT & Personality Disorders – Week 10 · Clinical Psychology Page 1 of 9
PERSONALITY DISORDER — OVERVIEW & CONTROVERSY
One of the most controversial, stigmatised and ethically difficult areas
Harmful labels used by services:
of mental health diagnosis
Attention seeking
The term is used clinically, but it can feel offensive as it may sound like
Drama queen
the person's 'personality' is the problem
Manipulative
Clinically, the symptoms and needs exist, but the language used to
describe the disorder and service responses can be harmful Playing people off against each other
'Psycho'
History: These labels are often used when MH staff feel overwhelmed or
Described as a "diagnosis of exclusion" — a medical determination unsupported and unable to help people or label them as 'too complex',
made only after all other reasonably known causes for a patient's and they project all this complexity and badness onto the person
symptoms have been ruled out
Often leading to them being deemed "not the business" of mental In 2025, the Minister of Health had to write to all NHS trusts and
health services explain that these words were prohibited from being used in mental
A misunderstood diagnosis, a misused diagnosis, by services; a health services
misunderstood and maligned population, a discriminated population…
by services, by families, by courts, by society and by 'self' Key critique of services:
Often used as an exclusion criterion by mental health services Our services are not set up for people with PDs & we say they are not
treatable when the case is that we just don't have the treatment
Trauma context typically ignored, especially for men
models that are known to be effective
Misused as a term of 'derision' by services — "Oh, she is soooo PD"
RISK IN PERSONALITY DISORDER — MULTI-LAYERED
Risk in PD is often reduced to self or violence, but in fact it is multi-layered:
Risk to Self Risk to Others Risk from Others
Active behaviours: self-harm, suicidal Violence Violence
behaviour, health-risk behaviour such as Sexual aggression Sexual aggression
smoking Exploitation Exploitation
Passive risk: self-neglect, not eating Neglect
properly, not exercising, avoiding screening, Abandonment
not taking medication
Discrimination
People with intense fear of abandonment may be vulnerable to exploitation because they may cling to unsafe relationships or people who take
advantage of them
PERSONALITY DISORDERS AND INTERSECTIONS
Personality disorders are subject to significant amounts of controversy,
Specific population guidance:
not least when considered in the context of:
Personality disorder diagnoses and their associated (validating)
Gender
research does not reflect the diverse nature of people who require
Ethnicity support from MH services
Age Current nosology has been challenged in its validity to different
Neurotypical status — intellectual ability and autism = biggest area of groups
misdiagnosis The Royal College of Psychiatry have produced guidance for
diagnosis in people with 'learning disabilities' — they advocate that
Significant evidence of bias in clinical decision-making within
you shouldn't diagnose PDs in someone with learning
personality disorders, especially in relation to key intersections
disabilities under the age of 25, whereas you can diagnose PDs
People from Black and ethnic minority backgrounds may be less
ordinarily in 18-year-olds
likely to receive a PD diagnosis and may instead be diagnosed with
Autistic people shouldn't be diagnosed with Cluster A PDs =
psychosis
affectionately known as the odd and eccentric group
If they are diagnosed with PD, it is more likely to be something with
dissocial/antisocial rather than emotionally unstable
, DBT & Personality Disorders – Week 10 · Clinical Psychology Page 2 of 9
THE CLINICAL PICTURE — AXIS I DISORDERS VS PERSONALITY DISORDERS
PDs are a class of diagnoses, not just one diagnosis. Axis I disorders = anxiety, depression etc.
Axis I Disorders Personality Disorders
More likely to be time-limited Pervasive. Persistent. Problematic in terms of behaviour, relationships and
functioning.
Often reactive Diagnosis is based on functioning over years, not just current symptoms.
Diagnosis often based on current symptoms/presentation Historically surrounded by a myth of untreatability.
More commonly viewed as treatable Highly stigmatised and pathologising
Stigma exists, but usually less extreme Overrepresented in inpatient, prison and forensic settings & often
underdiagnosed in the community
Can be marginalised in society Portrayed in the media dramatically, negatively and scarily; can be
marginalised and demonised in society
Language used is descriptive Massive ethical issues in working with this population — particularly around
the idea of assisted suicide
Ethical issues
Present in community, and to a lesser extent inpatient settings
DIAGNOSTIC CONSIDERATIONS — DSM-5 AND ICD-11 APPROACHES
Two diagnostic systems: Good diagnostic practice:
DSM-5 = US-based, more culturally well-known, uses a categorical Duration: In adults, symptoms must be stable and traceable back to
approach and groups PDs into clusters adolescence or early adulthood. In under-18s, diagnosis generally
ICD-11 = used diagnostically outside of the US, currently takes a avoided unless traits present for at least 1 year. Antisocial PD cannot
dimensional/severity approach, moving away from its categorical be diagnosed before age 18.
approach of the ICD-10 Multiple assessments: Clinicians should not diagnose after one
The names and types of personality disorder change over time, which crisis appointment — depression, trauma, intoxication or acute
can affect how people make sense of themselves — e.g. older distress can mimic personality traits
diagnostic labels such as "inadequate personality disorder" could State vs trait: Assessment considers whether behaviours are
become part of someone's self-concept in a negative/damaging way temporary reactions or long-standing patterns
Life history: Clinicians review functioning across relationships,
school, work and social life over several years
Collateral information: Family, partners or close others may be
consulted to check whether patterns are stable and longstanding
Structured tools: Interviews such as the SCID-5-PD and IPDE help
assess whether symptoms reflect the person's usual functioning over
time
Fluctuation vs stability: Acute symptoms (e.g. self-harm urges,
anger outbursts) may fluctuate intensely day to day, but core traits
and interpersonal difficulties remain stable when measured over
years (Clark, 2009)
PROBLEMS WITH DIAGNOSIS
Considerable overlap between different personality disorder categories Clinicians should look at the person's actual pattern of difficulties:
Concerns about reliability Feature Meaning
People can have the same diagnosis but very different symptom
Emotional How does the person manage emotions? Reactive,
profiles
regulation blunted, disconnected, quick to escalate, or slow to calm
Formal assessment tools may identify multiple personality disorders — down?
so clinicians should not rely only on the label
Interpersonal Are relationships avoidant, intense, conflictual, exploitative
relationships or dependent?
Intrapersonal How does the person see themselves? Is their sense of
conflict self stable, unstable or inflated?
Shame and The "elephant in the room" — often central across PD
guilt presentations
Behaviours Behaviours may seem unusual, risky or socially
outside the unacceptable, but should be understood in context
norm
PERSONALITY DISORDER — OVERVIEW & CONTROVERSY
One of the most controversial, stigmatised and ethically difficult areas
Harmful labels used by services:
of mental health diagnosis
Attention seeking
The term is used clinically, but it can feel offensive as it may sound like
Drama queen
the person's 'personality' is the problem
Manipulative
Clinically, the symptoms and needs exist, but the language used to
describe the disorder and service responses can be harmful Playing people off against each other
'Psycho'
History: These labels are often used when MH staff feel overwhelmed or
Described as a "diagnosis of exclusion" — a medical determination unsupported and unable to help people or label them as 'too complex',
made only after all other reasonably known causes for a patient's and they project all this complexity and badness onto the person
symptoms have been ruled out
Often leading to them being deemed "not the business" of mental In 2025, the Minister of Health had to write to all NHS trusts and
health services explain that these words were prohibited from being used in mental
A misunderstood diagnosis, a misused diagnosis, by services; a health services
misunderstood and maligned population, a discriminated population…
by services, by families, by courts, by society and by 'self' Key critique of services:
Often used as an exclusion criterion by mental health services Our services are not set up for people with PDs & we say they are not
treatable when the case is that we just don't have the treatment
Trauma context typically ignored, especially for men
models that are known to be effective
Misused as a term of 'derision' by services — "Oh, she is soooo PD"
RISK IN PERSONALITY DISORDER — MULTI-LAYERED
Risk in PD is often reduced to self or violence, but in fact it is multi-layered:
Risk to Self Risk to Others Risk from Others
Active behaviours: self-harm, suicidal Violence Violence
behaviour, health-risk behaviour such as Sexual aggression Sexual aggression
smoking Exploitation Exploitation
Passive risk: self-neglect, not eating Neglect
properly, not exercising, avoiding screening, Abandonment
not taking medication
Discrimination
People with intense fear of abandonment may be vulnerable to exploitation because they may cling to unsafe relationships or people who take
advantage of them
PERSONALITY DISORDERS AND INTERSECTIONS
Personality disorders are subject to significant amounts of controversy,
Specific population guidance:
not least when considered in the context of:
Personality disorder diagnoses and their associated (validating)
Gender
research does not reflect the diverse nature of people who require
Ethnicity support from MH services
Age Current nosology has been challenged in its validity to different
Neurotypical status — intellectual ability and autism = biggest area of groups
misdiagnosis The Royal College of Psychiatry have produced guidance for
diagnosis in people with 'learning disabilities' — they advocate that
Significant evidence of bias in clinical decision-making within
you shouldn't diagnose PDs in someone with learning
personality disorders, especially in relation to key intersections
disabilities under the age of 25, whereas you can diagnose PDs
People from Black and ethnic minority backgrounds may be less
ordinarily in 18-year-olds
likely to receive a PD diagnosis and may instead be diagnosed with
Autistic people shouldn't be diagnosed with Cluster A PDs =
psychosis
affectionately known as the odd and eccentric group
If they are diagnosed with PD, it is more likely to be something with
dissocial/antisocial rather than emotionally unstable
, DBT & Personality Disorders – Week 10 · Clinical Psychology Page 2 of 9
THE CLINICAL PICTURE — AXIS I DISORDERS VS PERSONALITY DISORDERS
PDs are a class of diagnoses, not just one diagnosis. Axis I disorders = anxiety, depression etc.
Axis I Disorders Personality Disorders
More likely to be time-limited Pervasive. Persistent. Problematic in terms of behaviour, relationships and
functioning.
Often reactive Diagnosis is based on functioning over years, not just current symptoms.
Diagnosis often based on current symptoms/presentation Historically surrounded by a myth of untreatability.
More commonly viewed as treatable Highly stigmatised and pathologising
Stigma exists, but usually less extreme Overrepresented in inpatient, prison and forensic settings & often
underdiagnosed in the community
Can be marginalised in society Portrayed in the media dramatically, negatively and scarily; can be
marginalised and demonised in society
Language used is descriptive Massive ethical issues in working with this population — particularly around
the idea of assisted suicide
Ethical issues
Present in community, and to a lesser extent inpatient settings
DIAGNOSTIC CONSIDERATIONS — DSM-5 AND ICD-11 APPROACHES
Two diagnostic systems: Good diagnostic practice:
DSM-5 = US-based, more culturally well-known, uses a categorical Duration: In adults, symptoms must be stable and traceable back to
approach and groups PDs into clusters adolescence or early adulthood. In under-18s, diagnosis generally
ICD-11 = used diagnostically outside of the US, currently takes a avoided unless traits present for at least 1 year. Antisocial PD cannot
dimensional/severity approach, moving away from its categorical be diagnosed before age 18.
approach of the ICD-10 Multiple assessments: Clinicians should not diagnose after one
The names and types of personality disorder change over time, which crisis appointment — depression, trauma, intoxication or acute
can affect how people make sense of themselves — e.g. older distress can mimic personality traits
diagnostic labels such as "inadequate personality disorder" could State vs trait: Assessment considers whether behaviours are
become part of someone's self-concept in a negative/damaging way temporary reactions or long-standing patterns
Life history: Clinicians review functioning across relationships,
school, work and social life over several years
Collateral information: Family, partners or close others may be
consulted to check whether patterns are stable and longstanding
Structured tools: Interviews such as the SCID-5-PD and IPDE help
assess whether symptoms reflect the person's usual functioning over
time
Fluctuation vs stability: Acute symptoms (e.g. self-harm urges,
anger outbursts) may fluctuate intensely day to day, but core traits
and interpersonal difficulties remain stable when measured over
years (Clark, 2009)
PROBLEMS WITH DIAGNOSIS
Considerable overlap between different personality disorder categories Clinicians should look at the person's actual pattern of difficulties:
Concerns about reliability Feature Meaning
People can have the same diagnosis but very different symptom
Emotional How does the person manage emotions? Reactive,
profiles
regulation blunted, disconnected, quick to escalate, or slow to calm
Formal assessment tools may identify multiple personality disorders — down?
so clinicians should not rely only on the label
Interpersonal Are relationships avoidant, intense, conflictual, exploitative
relationships or dependent?
Intrapersonal How does the person see themselves? Is their sense of
conflict self stable, unstable or inflated?
Shame and The "elephant in the room" — often central across PD
guilt presentations
Behaviours Behaviours may seem unusual, risky or socially
outside the unacceptable, but should be understood in context
norm
