What are your opinions about personality disorders? *pulls up a chair*
First, I need to give context for how I view the DSM and the process of diagnosis overall. Next, I'm going to largely center this discussion around antisocial and related diagnoses as an example; that is what I'm most familiar with but by no means is the issue of PDs, diagnosis, and systematic abuse limited to the disorders I talk about here.
I think that the DSM can be useful as a compilation of what we know so far about grouping symptoms.
When I call a disorder (like oppositional defiant, a precursor for conduct and antisocial PD) fake, I don't mean that a person isn't experiencing a group of symptoms that are disruptive to their life. As someone with ASPD I know that I'm disordered. My main problem here, specifically with ASPD, is that the symptoms they've chosen to outline focus only on ways an antisocial could be destructive to others, and not at all on their internal experience. We're prone to substance abuse to self-medicate anxiety and boredom. At least half of us qualify for a comorbid anxiety disorder. We're prone to self-harm, recklessness, and premature death by suicide. The DSM instead focuses on stereotypes of sociopathy and looking for a criminal record starting as a minor.
(The same pattern is true for NPD when it comes to focusing dx criteria on others rather than the individual, though it's especially bad with ASPD).
My other main problem with PDs and other diagnoses is that the usefulness of labeling them as a disorder is limited. Acknowledging symptoms that affect your life so that you can get treatment, accommodations, etc is good. This doesn't mean we have a broad understanding (even among clinicians) of how most of these disorders actually work, and when it comes to PDs the diagnostic label is often used to do even more harm to the individual.
It's "fake" when it's being used as a tool to compound a person's trauma and blame them for it. Diagnosis is subjective, people are biased, meaning overdiagnosis and misdiagnosis for the sake of that convenience and bias isn't particularly uncommon.
Oppositional Defiant Disorder is an easy way to label the child as being the problem rather than their experiences and/or environment. It's frequently co-diagnosed in kids with autism or ADHD. These kids frequently go on to develop Conduct Disorder (because you can't dx ASPD in a minor), because the trauma or other factors causing behavioral problems were never appropriately addressed to help the kid. CD is a lazy way of saying "this kid has had such a fucked up home life or gone through so much trauma and chaos in their life that they're acting out by being aggro and committing crimes." Mostly that label is used to blame the kid while cycling them through juvie detention centers, or god forbid, things like wilderness "therapy" camps.
Which is exactly how you continue traumatizing them and perpetuate the disordered behavior until they reach adulthood, at which point they have an even further diminished capacity for empathy etc. They learn that the world has treated them like dirt, so why would they engage in prosocial behavior.
A high percentage of prison populations have an ASPD diagnosis, too. It's not because antisocials are inherently violent, or criminal, or because prosocials don't commit crimes. Plenty of people without PDs do commit crimes, since crime is largely a result of populations whose needs go unmet. Only 7% of people in prison in America are even there because of a violent offense. The most common reason is drugs. The high prevalence of ASPD compared to the general population is partly because antisocials who do commit crimes are more likely to receive a dx. It's also because it's very convenient to label criminals with a disorder that can be used to justify intensifying or lengthening their sentences.
(Also, bear in mind that prisons are disproportionately filled with POC).
So, at the core of my problem with PDs is:
1. Their causes and symptoms are largely misunderstood, misattibuted as inherent to the individual rather than rooted in their experiences (trauma - I believe nearly/all of these disorders are traumagenic).
2. They are often used to ostracize and harm individuals with these traits rather than to aid in treatment or support.
But, there's another component -
3. Once a dx label is used, it often perpetuates a stigmatized view of the disorder and individual. Clinicians don't look at what symptoms the person actually experiences or what they need help with, they look at the DSM and preemptively decide what to think of a client based on assumptions about what the disorder is/looks like. At this point the individual becomes more disorder than person in their eyes, and clinicians meet them with bias that creates a self-fulfilling prophecy. If you meet someone already holdings expectations for them (ASPD makes you criminal, NPD makes you abusive, BPD makes you unstable and resistant to treatment) then that's all the person becomes to you.
Lastly I'd just like to say that I don't believe they're personality disorders. I think they're poorly named, and that this term further solidifies point #1. I think the way we talk about them needs to be completely revised, and the criteria need to be rewritten.
