Psychiatrists are giving drugs to most people with emotionally unstable personality disorders outside of the best-practice clinical guidelines, according to a study in the Journal of Clinical Psychiatry. And an accompanying editorial stated that the reason is because “therapy takes time.”
The researchers performed a cross-sectional survey of self-selected psychiatric services, and found that of 2,600 patients with a diagnosis of personality disorder, more than two-thirds (68%) had a diagnosis of emotionally unstable personality disorder (EUPD). Nearly all of these (92%) were being treated with antidepressants or antipsychotics. “The use of psychotropic medication in EUPD in the United Kingdom is largely outside the licensed indications,” concluded the researchers. This was a particular concern, they added, because the practices aren’t often systematically reviewed and monitored, “so opportunities for learning may be lost. Treatment may be continued long term by default.”
“(I)t is now known that specialized treatments such as dialectical behavior therapy and mentalization-based treatment can be helpful for most cases,” stated the accompanying editorial. “Although these more specific psychological treatments are known to be efficacious, they are not readily available. The reason is that therapy takes time and is expensive in human resources. This leaves harried clinicians with an inadequate set of options. The easiest choice is to focus on pharmacologic therapy for target symptoms rather than the personality disorder as a whole.”
The editorial argued that the problem may be even more widespread than found in the study, and stated, “Clearly, psychiatrists need to receive better education about evidence-based treatments for severe personality disorders. However, much of what they think they know is filtered through a climate of opinion shaped by neurobiological models and psychopharmacologic options.”
Paton, Carol, Michael J. Crawford, Sumera F. Bhatti, Maxine X. Patel, and Thomas R. E. Barnes. “The Use of Psychotropic Medication in Patients With Emotionally Unstable Personality Disorder Under the Care of UK Mental Health Services.” The Journal of Clinical Psychiatry, April 22, 2015, e512–18. doi:10.4088/JCP.14m09228. (Abstract)
Paris, Joel. “Why Patients With Severe Personality Disorders Are Overmedicated: (Commentary).” The Journal of Clinical Psychiatry, April 22, 2015, e521–e521. doi:10.4088/JCP.14com09441. (Full text)
“EUPD”, lol never even heard of it.
I wouldn’t have thought they’d go with something so nebulous. Though if there’s a way to fix all the political correctness craziness going on in the Western world i’d be all for something that works and I agree clearly drugs aren’t working on these people.
Borderline. Old insult in new clothing.
No one pathologizes emotions like psychiatry.
Part of the problem (and there are many here) is in the notion of “co-morbidity”. How psychiatry as a profession can pretend that one can take such faulty constructs as psychiatric diagnostic categories and them combine more than one to get something that has meaning and drives clinical decision making has always been beyond my own limited comprehension. But when you ask the prescribing psychiatrist why she is giving 5 drugs to this person who she has labeled with the term “borderline personality disorder’, she will most likely say that it is because she also has the diagnosis of “major depressive disorder” and/or “bipolar disorder, type II,” and/or, in a recent worrisome expansionist trend, “attention deficit disorder” etc., etc. The growth of each of these diagnoses typically directly follows the introduction of a newly patented drug or drugs that is reported to be effective for that particular “co-morbid” condition. This way of thinking has been widely promoted by the field -and exported to our primary care colleagues – for the past 30 years.
“Part of the problem (and there are many here) is in the notion of “co-morbidity”. How psychiatry as a profession can pretend that one can take such faulty constructs as psychiatric diagnostic categories and then combine more than one to get something that has meaning and drives clinical decision making has always been beyond my own limited comprehension.”
You don’t have “limited comprehension,” the psychiatric industry’s current approach is completely unscientific and nonsensical – it’s the absolute opposite of what actual “care” is.
The functional goal of today’s psychiatric system is to defame and tranquilize patients for profit, after promising to first and foremost do no harm. In other words, behave as complete hypocrites while torturing and stealing from other human beings. You actually want to help people, Sandra, which is why what’s going on in your industry doesn’t make sense to you.
As my husband’s old boss used to say, “Get the f-ckin’ money,” at any expense to human life, is the only logical purpose behind today’s DSM based psycho / pharmaceutical industries. “The growth of each of these diagnoses typically directly follows the introduction of a newly patented drug or drugs that is reported to be effective for that particular “co-morbid” condition.”
“This way of thinking has been widely promoted by the field – and exported to our primary care colleagues – for the past 30 years.” And the psycho / pharmaceutical industries have completely corrupted the entire mainstream medical community now. It’s really a shame.
Medicine for profit doesn’t work, at least in a non-competitive corporatocracy. But at least we can psychoanalyze the corporations, who have been making a mockery of the medical literature for the past several decades, and garner insight into whether they are credible “people.”
“It’s the absolute opposite of what actual “care” is.” Precisely.
If you get 3 categories of lists with overlapping elements and you only need a small subset of them to fall into the category then you’ll end up with multiple diagnosis based on the same symptoms. It’s another point why DSM is ridiculous.
In real medicine if you poison your patient with something that is not indented for a given illness there is some small chance you can sue and win. In psychiatry there is no chance since one can’t prove he/she is not “mentally ill” It’s practically impossible.
Just waiting when the social justice really gets into psychiatry. We can have “toxic masculinity disorder” or “privilege checking deficiency disorder” to name a few.
EUPD, not to be confused with the original EUPD, European Union Political Disorder.
This little blurb may very well represent the height of diagnostic insanity.
What next? RTPD, Rational Thinking Personality Disorder? What kind of drug would a psychiatrist give to someone who suffers with that?
What next? RTPD, Rational Thinking Personality Disorder? What kind of drug would a psychiatrist give to someone who suffers with that?
A neuroleptic drug of course.
Smarter Than Your Psychiatrist Disorder is a real thing. I got diagnosed by a guy who was personally offended by my intelligence (I guess because he felt stupid). These people are allowed to judge others’ personalities – what a joke.
I received my wonderful “diagnosis” at the hands of a psychiatrists who thought that it was “interesting” that I’d just been told the day before about my sister’s murder. Then, when I told him that it felt like the world was coming down all around and upon me he jumped at me and screamed, “That’s stupid!”. I guess I was supposed to be as emotionless and cold and unfeeling about life as he was. He never knew how close he came to getting my fist between his eyes! These people can be emotionally and psychologically abusive to people and it’s supposed to be fine. I’ve had my fill of them up to my eyeballs.
Psychiatrists are giving drugs to most people with emotionally unstable personality disorders outside of the best-practice clinical guidelines
Pharmaceutical companies are giving away money to psychiatrists. Perhaps their is a method to their madness.
“Emotionally unstable personality disorder?” I hadn’t previously heard of this UK version of borderline PD. It reminds me of the old school DSM personality disorder diagnoses. I checked my old lecture notes and found this list I compiled of personality disorders in each edition of the DSM that were subsequently eliminated from the next one.
-DSM-I (1952): Emotionally Unstable PD, Passive-Aggressive PD, Inadequate PD, Cyclothymic PD
-DSM-II (1968): Explosive PD, Asthenic PD
-DSM-III (1980): Affective PD
-DSM-III-R (1987): The following 3 examples of Personality Disorder Not Otherwise Specified: Immature PD, Sadistic PD, and Self-Defeating PD
-DSM-IV (1994): Personality disorders “under study”: Depressive PD, Negativistic PD
-DSM-5 (2013): After rejecting a radical new trait-specific method and a compromise hybrid model, the criteria remained unchanged from DSM-IV. Section III lists the hybrid proposal’s six personality disorder types; four of the DSM-IV’s 10 personality disorders are not listed among them. Two of the DSM-5 PD task force members resigned in protest and accused the task force of “display[ing] a truly stunning disregard for evidence.” (http://www.straight.com/life/ubc-prof-emeritus-john-livesley-and-dutch-expert-quit-dsm-v-committee-defining-personality-disorders)
It’s hard to avoid the impression that the DSM personality disorder task force members are just making this stuff up.
“It’s hard to avoid the impression that the DSM personality disorder task force members are just making this stuff up.”
No kidding 😉
“emotionally unstable personality disorder (EUPD)”
Also known as borderline. Or as sophisticated insult against victims of abuse.
Stop drugging abuse victims and sop blaming them for it. The drugs are an absolute crime but the therapy is in some ways more insidious – it tells people they are wrong for who they are and their emotions are wrong and not adequate and so on. Personality is not an illness.
Seriously, can we please abolish psychiatry already? I’m so fed up with this nonsense.
Think about those that “diagnose” others with a ‘personality disorder.’ What does that say about them?
Just answered my own question: I believe this would be a textbook example of ‘intolerance.’
I believe psychiatry is intolerant of personal differences and uniqueness in processes. That’s nothing but trouble. Intolerance leads to oppression and violence, which is what occurs within the culture of psychiatry.
We want a tolerant society, not such rampant and dehumanizing personal judgments, thinly veiled as something ‘medical’ related. That’s a terrible example in society. Now everyone goes running around saying “you have a ‘personality disorder'” when they want to insult or demean someone. No thanks.
While reading this I am wondering why MIA is reporting on a pseudo-label that has zero reliability and validity, the supposed symptoms of which are no more related to each other in nature than are the stars comprising the constellations which astronomers invent.
The title of this article should be, “Human beings with varying degrees of serious but unique and unrelated emotional problems largely being treated inappropriately by psychiatrists.”
That has a nice ring to it.
You rightly identify a question and challenge I face every day, with the vast majority of articles. In response to this challenge, I attempt to do the best job I can in fairly representing some aspect(s) of what the original study or article actually said, while trying not to imply or suggest that I or Mad in America necessarily “support” or “endorse” questionable language or underlying assumptions and beliefs that might be at work in the source material. If, conversely, I were to always function as a personal “filter” on such material, every In the News and Around the Web post would become long investigative journalism articles or personal opinion pieces or creative satirical renditions (and I like your suggested headline by the way), rather than what they currently are, which is mainly simply short news bites flagging stories that I think might be of interest to MIA readers for any of various reasons.
Rob – On that note, I myself would offer a rejoinder to another person commenting in respect to the feed of information you have selected if it weren’t put so as to immediately catch your eye–most likely anyway, to see what their comment was about. Mainly people are not through with the bygone, much less the inaccurate, invalid, and obscure passed off for pure wisdom, until they decide on the positive emphasis they like for themselves and are understanding where to put it more determinedly or more in depth. My idea of what to feature if covering your responsibilities would certainly not come from more of a grand plan, and nothing else than what tends to appear has seemed needed, except what plainly wouldn’t work for updates from/on pertinent news. The related posts selections are also adequately available, I believe, to satisfy “the embarrassment of riches” kind of motivation had by the more acquisitive subscribers here, who are presently reinforcing their views or clarifying and weighing their personal position statements a lot on myriad things.
I actually have to say I also find this a very problematic aspect of some of the content posted on MIA.
For people who’ve nearly been entirely destroyed by these particularly pernicious labels, the editorial staff need to think carefully about how, and indeed why, you report on such studies/articles.
I queried this before abd revieved a spectacularly patronising and condescending response that actually quoted Clinton. I kid you not, it was worthy of a shrink.
Also, coming from a male content contributor to a female, about a notoriously misogynistic label, it was very off.
I can’t speak to what someone else may have said to you. But as I said above, I do understand the “problematic” issue at play in this and it concerns me, too. However, it’s important to be clear about something: I have been managing “In the News” and “Around the Web” for the past year or so, and the whole main point and thrust of these two features of MIA is precisely to simply summarize or highlight aspects of what other people, researchers, or media are saying, more or less in their own words. MIA’s Blogs are where authors are free to opine about what other people are saying.
Incidentally, I chose to post a summary of the above study, notwithstanding my own personal lack of confidence in the scientific validity of the diagnosis, because I thought it was important how the study highlighted that most psychiatrists do not follow even their own best-practice guidelines.
While in theory it may sound perfectly fine that you are posting such content in the news section to ‘simply summarize or highlight aspects of what other people, researchers, or media are saying’, in practice that’s not what occurs. Many of us are seeking a safe space online that is free from pathologising language and stigmatised identities.
It’s evident to me as a survivor reading some of the reposted psychiatric ‘news’ content that there is a lack of insight on the part of certain editorial staff as to the painful impact it has.
The PD labels in particular are extremely pernicious and have done some of the most severe damage of any of the labels in the DSM/ICD that I’ve seen. People very often simply can’t recover from such iatrogenic damage.
Much of the writing on labels like ‘borderline’ fits the profile for hate speech. Were you to substitute the term ‘Black’ or ‘Jew’ where you read ‘borderline’ in 90% of the online content for ‘BPD’, it becomes starkly obvious just how pejorative and malignant the label is.
I therefore don’t feel articles like the above warrant inclusion in a radical/critical mental health setting.
It’s damaging and largely unfair and the responses I’ve received so far upon raising this issue have been unhelpful and defensive.
It would be considered entirely inappropriate to suggest that opposition to the inclusion of racist or antisemitic content in an online resource for people that had been harmed by these smears. was simply ‘reactive’ attempts to ‘shut the conversation down’ by ‘demanding expressions of fealty to one ideology or another’ as a previous MIA news editor suggested when I raised this issue.
I feel it’s the same for those of us who are recovering from the trauma of psychiatric labelling, most particularly the PD labels. It begs the question of whether resources for user/refuser/survivors can ever successfully be curated and managed by by those with no lived experience of the issues involved.
Rob, thanks for your response. I actually think you are doing a great job given that you have difficult choices to make. I understand that the intent of this posting was education and useful information can be gleaned even if one doesn’t totally agree with the point of view of the source. In this case I should have directed my comment more toward the authors/viewpoint of the article, not against the one who chose to post it (you/MIA). Sorry!
Don’t apologise. It’s a very legitimate point and one many others make, regularly.
Hi again, Isis — due to the limit on numbers of ‘nested replies’, I am replying here to your comment June 12, 2015 at 4:51 pm.
You write: “Many of us are seeking a safe space online that is free from pathologising language and stigmatised identities.” and “It begs the question of whether resources for user/refuser/survivors can ever successfully be curated and managed by by those with no lived experience of the issues involved.”
Those are and would be great things, and I encourage you or others to try to build them. But those are not what MIA is. MIA includes board members and bloggers who have had such experiences, but on the whole it is a platform for news, opinions and discussions for and among many diverse people who share an interest in “rethinking psychiatric care.”
And while I know that psychiatric labels can be very harmful, it is simply not possible to briefly summarize news and research about “mental illness” without frequently reiterating the dominant terms such as “mental illness” that are being used in that news and research. At least, I have yet to come up with many reliably effective ways to do it. I am always open to new suggestions. In the meantime, I just hope that, on the whole, for people who visit our site regularly, the items I post contribute towards helping keep people somewhat critically informed about what is going on in the field of “mental health” and also create a space wherein everyone feels that the dominant terms and ideas of “mental health” can be challenged.
Thank you for the spectacularly patronising reply. It’s impressive that editors of a site like M.I.A. could so eerily model the kinds of responses that folks normally only receive from consultant psychiatrists!
The fact that you feel it necessary to clarify the aim of the site, as if this is something critics of specific content don’t understand, is unfortunate.
Including links is just unnecessary and rude.
If you’re only comfortable in asking readers (many of whom are survivors) to “add their voices to this discussion” as long as it doesn’t challenge your editorial ‘authority’, then it’s a hollow invitation.
It’s obvious that certain editors at M.I.A. don’t sufficiently understand the politics of the survivor movement or of critical practice.
It’s disappointing but not surprising as few of the contributors have lived experience themselves and this has shown up in flashing neon in the tone of the responses given.
So, you keep posting psychiatric ‘news’ items about ‘PD’ and other non existent ‘illnesses’ and don’t worry about the damaging message this sends those harmed by them.
Way to have a conversation about ‘rethinking psychiatric care’!
I’m not sure what your main point for me is. Are you suggesting that “In the News” and “Around the Web”, as features on MIA, are causing more harm than good and should be stopped? If so, you may be right. I do worry and wonder about it every day.
I just reread this comment section. Although my last comment was nice – because I didn’t want to be mean to you personally – I do still agree with Isis and consider that reporting news under the dominant labels “mental illness”, “personality disorder” etc. is damaging and discouraging.
Perhaps some MIA readers – IMO more often “professionals” who have not been destroyed by the mental health system and who may even think in these terms themselves – are not so affected by your reporting in terms of the negative labels. (Although as shown in the other comments above, many professionals do not agree with the medical model language at all). But for people who have been so-labeled, I think this language can be very damaging and discouraging, although I can see that it is not intended to be such by you.
So whether or not you agree with the terms personally, the words we use still matter and affect others, and using the pathologizing language of the people that many of us consider oppressors can be harmful. Just because everyone else is doing it does not mean that you/Whitaker/MIA cannot have the will or open-mindedness to initiate a change.
For now I would like to share again my revised dictionary of translations from medical model language to real human being language 🙂
“mental illness” – emotional distress, problems in living
“symptoms” – distress, expressions of distress
“schizophrenia” – psychotic susceptibility syndrome (PSS), see Jim Van Os, as explained here – http://www.arafmi.org/2015/03/dutch-experts-say-schizophrenia-does-not-exist-but-psychosis-does-and-is-very-treatable/ – If Japan and Korea have formally abolished and replaced the term schizophrenia due to its stigma and inaccuracy, why is a group like MIA, in which the large majority of people clearly do not believe in the validity or usefulness of the term, unable to do so in its reporting? If you research it, you’ll find that stopping the usage of the term schizophrenia actually improved severely distressed people’s experience in “treatment”, and lessened their experience of stigma and fear, in Japan and Korea.
“borderline personality disorder” – severely distressed person, symbiotic character structure, someone who uses a predominance of splitting as a psychological defense, person who might in medical model be called borderline.
“major depression” – people who are seriously distressed at one point in their lives. I am not sure why MIA is regularly reporting on a term that received a reliability rating close t0 0.20 (pure chance of agreement between psychiatrists on who “has it”) in the DSM V field trials.
“personality disorders” – Would you want to be called personality disordered? I think we should stop using this term, or in some way make clear that it is not a scientifically valid term. Using this word for me is equivalent to using the word “n—-r” for black people or “s–c” for Mexican or “f—-t” for a gay person. Use “seriously distressed people”. Or “people who would under the medical model be labeled personality disordered”. It’s cumbersome, but better. It lets the reader know these are actually human beings, rather than walking personality disorders (when did you last see a personality disorder walking down the street?). Or use my admittedly cumbersome term, “emotional-disregulation susceptibility syndrome”, after Van Os. It is more accurate, because it shows that severely distressed people are not distressed all the time, but may for various reasons be more vulnerable to stress than most people.
bipolar – person who at one point in their life had a manic experience… These labels make it sound as if having distressed experience at one point in your life makes you have an “illness” for life. That’s just bullshit, and it’s a pessimistic unrealistic outlook that is harming people.
ADHD – person labeled with attention-deficit problems under the medical model. Or, person with attention problems, or distractible child.
“treatment” – provision of help (for therapy), or provision of neuroleptics/antidepressants/antianxiety pills (for drugs)
remission – clearly reduced distress, reduced distress for a defined period
relapse – becoming distressed again!
No one that I have met, including many severely distressed people who were labeled borderline personality disordered by misguided psychiatrists, thinks in these medical model terms in their day to day life. They don’t fit human emotional experience. Do people seek “treatment” for their unhappiness? If they get better, will they think, “I have remitted?” If they become distressed again, will they think, “I have relapsed?” And worst of all, will it help them to be told, “Your personality disorder is the explanation for your problems?”
Don’t think that I don’t see how difficult of an issue this is or understand that you’re trying to help people by this reporting. I do see those things!
From Steven Goldsmith, MD:
My profession’s wholesale medication of people diagnosed with personality disorders reflects fundamental errors in its models of illness, health, treatment, and what it means to be human. These errors have fostered the clinical and philosophical bankruptcy of contemporary Western mainstream psychiatry. The list of these errors is lengthy, so I will cite but a few:
1) DSM labels and equivalent diagnostic epithets are abstract nouns and not reality. Instead, the reality that confronts psychiatrists consists of whole, unique individuals with their particular symptoms, strengths, histories, and quirks. No treatment can help people get well by targeting their diagnostic labels or the symptoms these reflect. Rather, treatment can help people get well only by strengthening the individual self-healing resources of the whole person. In other words, you cannot help someone get well by suppressing perceived sickness, only by utilizing strengths.
2) This is a corollary to 1). Psychiatry views symptoms as the bad guys that must be eradicated or at least lessened. However, in most instances, psychiatric symptoms reflect actual or potential strengths, which must be respected and utilized to enable healing. As a result, those whose symptoms psychotropic meds suppress are often weaker, not stronger. And I haven’t even mentioned side effects yet.
3) Psychiatry is wedded nowadays to a biologic reductionist model in which most symptoms supposedly reflect biological derangements that must be suppressed. Though obviously all human experience is associated with inner physiological/biochemical changes of some sort, there has never been any evidence–none!, zero, nada–that any of the major mental illnesses have a specific biochemical cause. Big Pharma has perpetrated this myth of “chemical imbalance” and psychiatry has swallowed it. (By the way, this is not a controversial assertion.) But we are more than our neurotransmitter molecules.
4) For the above reasons and others, pharma-psychiatry is unable to cure almost anyone of anything (cure meaning the complete and lasting resolution of problems without the need for further treatment). If you doubt me, check the statistics. For instance, no more than 15% and perhaps as few as 3% of depressed people treated with antidepressants get well and remain well. (From the NIMH-sponsored Star*D study.)
5) There are many non-pharmaceutical forms of treatment that can help people with psychological problems get well–CBT, EFT (Emotional Freedom Techniques), orthomolecular psychiatric treatment, chronotherapy (light and sleep therapies), Open Dialogue, EMDR, strategic and systemic psychotherapies, homeopathy, etc. (Over the years, for example, I have seen a number of people diagnosed with bipolar disorder, schizophrenia, OCD, etc. get well with homeopathy so they were able to get off their meds and remain well.) And DBT, while not curative, can be enormously helpful in teaching coping skills to some diagnosed with personality disorders as well as others.
6) Unfortunately, most psychiatrists are not well-trained in any of these non-pharmaceutical methods and don’t utilize them. According to statistics, most psychiatrists no longer even provide competent psychotherapy worthy of the term.
These grim tidings notwithstanding, the good news (as indicated in point 5) is that if you are suffering from a psychological disorder, it is quite possible for you to get well.
What’s strange is the idea that there is this distinct differentiation between Axis I (mood disorders) and axis II (personality disorders). The belief has been that axis I disorders such as depression, bipolar and schizophrenia can be “treated” while disorders such as narcissism, borderline tendencies and sociopathy are inherent, ego-syntonic and cannot be treated. So it used to be that folks with axis II disorders were not given drugs- because they can’t treat underlying personality traits.
But now pretty much everyone is given axis I diagnoses- because you can bill insurance for them. So everyone labelled with a personality disorder also has a co-occurring mood disorder (as Sandra said). That way everyone gets paid. And that means people who are “borderline” and have experienced abuse, and trauma- are not only accused of having this awful borderline personality disorder but they are also pushed to take psych drugs to manage the severe emotional distress associated with trauma.
No, what’s actually strange is that the threads of a critical site are filled with clinicians referring to DSM categories and labels as having any greater validity that star signs.
Hi bpdtransformation, I’m responding here to your comment dated June 13, 2015 at 1:38 pm.
I find it easy to come up with different, better ways of describing the varieties of human experience. But the challenge with respect to In the News and Around the Web is different. Suppose I see a study where researchers state in their conclusions something like “the evidence shows that the mentally ill are more dangerous than the average person.” I could ignore this study entirely. Or, I could decide that I think MIA readers might want to know that this study was done, how it was done, and what it actually found. If I report it, I can remove the offensive term “the mentally ill” and paraphrase the wording to “the researchers concluded that people with mental illnesses tend to be more dangerous than the average person”, or “the researchers concluded that people diagnosed with mental disorders are ‘more dangerous’ than the average person.” I do this a lot in my MIA posts. I can also seek out and highlight details about the study that I think may help people better understand it or see it in a critical light — and I try to do that as much as I’m reasonably able to, especially if I think it’s a particularly questionable or inflammatory study. To some people, though, understandably, my use of those terms is still hurtful. However, I cannot write, “the researchers concluded that people undergoing emotional distress or experiences that some might term as psychotic more often do things that seem harmful to others, depending on the standard you use for evaluating violent acts in a fundamentally oppressive social context.” At that point, it is no longer responsible or accurate reporting. That is not how the researchers themselves used the terms in their study, that’s not what they found or said, and that’s not what they concluded; not even close. So, unfortunately, to accurately report on many studies or articles, I sometimes have to reproduce language and concepts that I know may be especially hurtful to some people.
The standard way to present the terms critically is to write ‘with a diagnosis of…’ and to use scare quotes – ‘schizophrenia’, ‘personality disorder’, ‘bi-polar disorder’ when the label is used in a news item heading.
It’s not overly complicated and simply implies the validity of the term is being called into question.