Borderline Personality Disorder; A Dumping Ground of a Diagnosis!

The term Borderline Personality Disorder (BPD) was first coined by Adolf Stern in 1938, to describe what he percieved to be patients who were suffering from a mild form of Schizophrenia and thus were seen to be on the borderline between neurosis and psychosis. In the 1960s and 70s these ideas changed, now rather than being seen as Borderline Schizophrenia, it was instead viewed as a mood disorder, having similarities to Bipolar Affective Disorder and Cyclthymia with its variability, volatility and intensity of moods. Finally with the introduction of the Diagnostic and Statistical Manual (DSM) in 1980, it was labelled as a personality disorder and given its current name. It is now one of ten personality disorders that exist, though BPD by far being the most heavily diagnosed in today’s modern society.

The criteria for BPD is as follows;

(1) Frantic efforts to avoid real or imagined abandonment. Note:

(2) A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealisation and devaluation. This is called “splitting.”

(3) Identity disturbance: markedly and persistently unstable self-image or sense of self.

(4) Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in (5).

(5) Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.

(6) Affective instability due to a marked reactivity of mood (e.g intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

(7) Chronic feelings of emptiness.

(8) Inappropriate, intense anger or difficulty controlling anger (e.g frequent displays of temper, constant anger, recurrent physical fights).

(9) Transient, stress-related paranoid ideation or severe dissociative symptoms.

BPD is a diagnosis most often given to women. 75 to 90 percent of those acquiring a diagnosis are female and even more troubling a fact is that self-injurious behaviour alone can often be the primary diagnostic feature. Thus in effect, if you’re female and also have a propensity for self harm, regardless of the reasons for this coping mechanism, you are more likely to be diagnosed with what can only be described as having ‘an abnormal personality’.

It is suggested that the over-diagnosis of BPD in women could be due to societal and cultural understandings of female behaviour. As women are seen to be the more mild, passive, caring, gentler sex, then showing aggression through the incidence of self-harm for example, even if self-directed, is seen as a deviation from the norm. Being more aggressive generally or more assertive than other women, being successful, overly promiscuous, more focused on self rather than putting the needs of others before one’s own can all be perceived as going against the grain and not conforming to the norms expected of women, in effect rejecting traditional gender stereotypes.

Added to this, a diagnosis of BPD is often handed to females who appear difficult to treat, are more vocal or who are more bothersome or troublesome than other patients. Which obviously begs the question as to why the very idea of a women not fitting the given ideology of a society or culture is so threatening  rather than trying to understand, we are more prone to decide that their behaviour is pathological. Have we really not come much further than the Salem witch trials?

On top of this, a personality disorder per se is one of the most stigmatising diagnoses in psychiatry, so not only are we stigmatising the patient but also, in turn making sure that they are treated differently and sometimes unjustly by healthcare professionals who sadly all too often buy into the lunacy of personality disorder. As they are seen as having something inherently wrong with their personalities, they are viewed as difficult to treat. In the case of BPD, patients can be seen to be difficult, aggressive, manipulative and forever pushing boundaries. Rather than members of staff, being clear with their limits and admitting when they have taken on too much, instead the person needing support and help is seen as the problem. I suspect a lack of resources; time constraints and poor time management may really be the problem as well as in-built professional prejudices around personality disorder, even if its existence is controversial..

Just as much of psychiatry is based on the defunct medical model, so personality disorder is other people (often male) deciding what behaviour is acceptable to them in their given culture and then punishing people who don’t conform. The fact some antipsychotics are licences for BPD now shows just how far psychiatry is prepared to go to wipe out those traits they deem unacceptable in the population.

Sadly, a high percentage of people diagnosed with BPD have had abusive, chaotic childhoods, which often include being victims of sexual abuse. Research has found that the changes in their brains are similar to those suffering from Post Traumatic Stress Disorder (PTSD) and that a diagnosis of such may well serve them better. However, others disagree, claiming that PTSD does not cover all of the symptoms involved with BPD.

If BPD develops during a person’s childhood though various types of trauma, in turn having massive implications on the child’s developing brain, then surely what needs to be addressed is the trauma that person has endured? Would it not be more useful to look at how the presenting person can be helped to come to terms with their experiences and deal with past trauma. Why do we need to first give a person a label, a label whose only use is to make the health professionals life easier, rather than concentrating our efforts on the person and their experiences without the absurdity and nonsense of what is considered to be normality.

It appears that BPD has little or no legitimacy as a psychiatric summary of anyone’s behaviour. Instead what appears to happen is that women are predominately handed a rag- tag of a diagnosis by psychiatrists and professionals who see themselves as fit to decide what constitutes a ‘normal personality’, according to a list of criteria that assumes that one who exhibits these symptoms or behaviours is somehow defective. BPD is then nothing more than a societal and cultural construct, not a psychiatric illness, but a ludicrous label and a sad stigmatisation of people’s personalities especially those that have endured traumas such as abuse. Is not the rage, self-harm and volatile emotions to name a few, nothing more than a normal reaction to what is abnormal behaviour?

Effectively with systematically diagnosing BPD, we are making the individual responsible for their reactions to abuse and trauma, which achieves nothing more than to blame the patient for the way they have reacted to members of society who have harmed and abused them, further adding to their feelings of guilt, shame and low self esteem.

Maybe the emphasis needs to be placed on understanding why women and men, though men usually receive an equally stigmatising diagnosis of Antisocial Personality Disorder are displaying these types of behaviours. Instead of thoughtlessly reaching for the DSM, a book based on criteria and symptoms, decidedly removed from the every day human experience, we need to look at the root cause of the problem, which ironically enough, is society.

© Copyright Henrietta M Ross

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9 thoughts on “Borderline Personality Disorder; A Dumping Ground of a Diagnosis!

  1. As a retired clinician, I have to agree that a diagnosis of BPD does very often get applied to patients seen as “difficult”, “demanding”, and “medication seeking” (Sometimes related to a treatment history of having been prescribed large and long term doses of Benzodiazepines and/or having had poor results with antidepressants.), and nearly all were women. I also notice that the non-medication therapies that seem to have some success, such as Cognitive – Behavioral (CBT) and its variants also are indicated for PTSD.

    The prevailing understanding of “personality” as somehow a hard programmed and invariable feature of a person also leads to the thinking that “personality disorders” are in an essential way untreatable beyond symptom management. That is stigmatizing.

    Liked by 1 person

      • I had another thought about the BPD diagnosis in particular. Most third party payment systems, whether insurance or public funding (Medicare & Medicaid) operate on a fee-for-service basis, even if only for accounting purposes. The auditors want to see a clear (sometimes as documented “best practice’) linkage between the diagnosis and the service provided. Because BPD is seen as especially difficult to treat and contact intensive, the clinician may have more latitude in what services will be approved with that diagnosis than with some others. This is what is known as perverse incentive. I very much doubt that many clinicians give that aspect much conscious thought, but there it is, part of the system.

        Liked by 1 person

      • I suspect that sexism probably plays a larger role than money, along with short staffing leading to clinicians who don’t have time to delve further than the surface of the presenting symptoms. Still, I think it would help, particularly over here in The States with our bizarre and fractured systems, to disentangle the funding from the diagnosis categories. Certainly, with BPD, I’ve known clients who really hated that label.

        Liked by 1 person

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