Should We Abolish the Diagnosis of Borderline Personality?

Rear view of person with long hair, head turned away, standing by canal at sunsetThe diagnosis of “borderline personality disorder” carries profound stigma for many people. Even some mental health professionals use the term pejoratively, which is not difficult considering that the diagnosis itself implies that someone’s personality is flawed. In reality, the flaw lies within the diagnosis—not to mention all the painful and agitating symptoms that come with it.

I will go into more depth about these challenges, but first a definition is in order.

What Is ‘Borderline Personality Disorder’?

People who are diagnosed with borderline personality tend to have problems with unstable self-image, moods, and relationships. They may experience suicidal thoughts, self-harming behaviors, displays of anger or irritability, and periods of intense sadness or despair called “dysphoria” (the opposite of euphoria).

To receive a diagnosis of borderline personality, a person must meet at least five of the nine characteristics below. Keep in mind while reading the list that, in order to qualify for the diagnosis, the person’s symptoms must be longstanding and inflexible, not just occasional ways of relating to life:

  1. “Frantic” attempts to avoid abandonment
  2. Intense and turbulent relationships, with a tendency to alternate between seeing the other person as all good or all bad
  3. Unstable sense of self, which could lead to radical changes in major aspects of identity such as career, religion, or sexual orientation
  4. Frequent suicidal thoughts or self-harming behaviors, such as cutting
  5. Impulsive behaviors in at least two other areas, such as substance abuse or binge eating
  6. Wild mood swings with extremes of anxiety, irritability, or dysphoria
  7. Persistent feelings of emptiness
  8. Intense anger or rage that is often close to the surface
  9. Brief periods of paranoia or dissociation when under stress

I have seen more than one writer refer to borderline personality as the equivalent of emotional hemophilia: when a person with borderline personality experiences a hurt, even a small one, the emotional bleeding is profuse. The suicide rate for people with borderline personality is about 10%. Most people—up to 90%, by some estimates—with borderline experienced neglect or abuse, particularly sexual abuse, during childhood. Individuals with borderline personality commonly view themselves as inherently defective, bad, or broken.

For many years, borderline personality disorder was considered untreatable. Now, decades of research and treatments have illuminated the errors in such thinking. For one thing, we know that many people “grow out” of the disorder as they age. For another, a great many people with the diagnosis respond positively to treatments such as dialectical behavior therapy.

Stigma and Borderline Personality

All personality disorder diagnoses are controversial. The mere phrase “personality disorder” situates the problem in the person’s personality, rather than neurology or life stressors (including trauma). GoodTherapy.org’s founder, Noah Rubinstein, LMFT, has even explained why he views personality disorder diagnoses to be flawed:

“I believe that by labeling a person as personality disordered or, in its more gentle form, stating that a person has a personality disorder, we are essentially claiming one’s personality, their person-hood, their essence, is fundamentally flawed. What else are we, other than our personality? Such a diagnosis is very, if not absolutely, likely to produce more shame, worthlessness, and rejection in a person who probably has enough of it already.”

I agree with his analysis. In some ways, the situation is even worse for people diagnosed with borderline personality. Any mental health diagnosis can engender feelings of shame, or of being “fundamentally flawed.” On top of that, feelings of shame and badness are both symptoms and consequences of borderline personality. This can create a vicious cycle, as if the diagnostic label alone confirms the feelings of defectiveness that came well before the diagnosis.

Too often, some mental health professionals add to the stigma. It is well known that some clinicians have applied the label “borderline” merely because they do not see an individual improving, or the individual poses challenges such as expressing overt anger toward the therapist. For some therapists, it is easier to blame the client for treatment’s lack of success than it is to look at the clinician’s own inability to help.

Another source of stigma concerns others’ tendencies to judge the person, rather than the person’s behaviors. Some, though certainly not all, people with borderline personality may cope or express their pain in ways that hurt those around them. They may yell or even be physically violent, make unrealistic demands, display intense sadness or anger at what seems a disproportionately small provocation, or even attempt suicide or hurt themselves in ways that make another person feel manipulated.

It helps to keep in mind the fundamental, excruciating pain that often underlies borderline personality disorder. Marsha Linehan, the psychologist who created dialectical behavior therapy, compares the behaviors of people with borderline personality disorder to those of people with painful cancer who will do anything to reduce their pain. The cancer patients may cry, scream, or attempt to “manipulate” others in order to get their pain medication. But we seldom view their efforts negatively, because we understand their abject suffering. Their behaviors make sense.

So, Should the Diagnosis Be Abolished?

I agree with other critics that the label “borderline personality disorder” can compound an already painful situation for people, especially the newly diagnosed. But I also find value in the diagnosis—not the name, but the concept.

Before diagnosis, people with borderline personality often feel bewildered. They may deeply experience their internal chaos yet find that few people understand. I have worked clinically with many people who felt soothed when they learned their problems fell into a distinct category that millions of other people shared. These people felt they were no longer alone.

Once people have a name for a condition, they can more easily find information about challenges and ways to heal. They can find other likeminded people in online support groups. Also, diagnoses enable clinicians to better treat people. Clinicians can draw from a large body of research on borderline personality to identify the best treatment options for individual clients.

The diagnostic label deserves to be changed, but the construct itself should remain, as long as it is supported by continued research. Some researchers, like the psychologist Judith Herman, think that borderline personality actually is a type of posttraumatic stress, and should be reclassified as such. But the idea has not gained much momentum in the field of psychiatric diagnosis.

Changing the name, too, is a pipe dream for now. The American Psychiatric Association only months ago released its first overhaul in almost 20 years of the Diagnostic and Statistical Manual of Mental Disorders, and the group never seriously considered altering the name. That is a shame. The name of a diagnosis should describe the problem—in this case, problems regulating emotions—not the personality. Others have proposed alternate names. My preferred label is one proposed by Dr. Linehan, “Emotion Dysregulation Disorder.”

What Can We Do to Diminish the Stigma?

Use the word “borderline” appropriately. Do not use the word “borderline” as an insult. This especially applies to mental health professionals. I have worked in the mental health field for almost 20 years, and it is disheartening how many times I have heard a professional say “She is so borderline,” or “What a borderline.” Borderline is an adjective to describe a series of symptoms, not a person. And it certainly is not a noun.

Be clear that stigma is undeserved. When we discuss how stigmatizing the diagnosis of borderline personality can be, it is necessary to make clear that the stigma is unfounded. Despite appearances or assumptions, the label does not truly mean that somebody’s personality is flawed. We need not buy into the pejorative meaning.

Exercise compassion. Whether you know somebody with borderline personality or have the symptoms yourself, always keep in mind the underlying pain and anger that can drive behaviors. This is not to say that people with borderline personality are not responsible for their behaviors and cannot make changes. Rather, a compassionate stance helps diminish shame. It also emphasizes the possibility that people can learn more constructive ways to manage their emotions.

Avoid stereotypes. The diagnosis of borderline personality captures a very heterogeneous group. Only five of the nine diagnostic criteria are required for a diagnosis. Two people with the diagnosis could have only one symptom in common. In fact, there are 256 different possible symptom combinations for borderline issues, and every person who has been diagnosed with borderline personality has his or her own unique stories.

Maintain hope. As I noted above, borderline personality need not be a lifelong struggle. The symptoms of borderline personality often mellow with age. Borderline personality disorder, as a diagnosis, also has the advantage of garnering significant attention among researchers, clinicians, and grant funders. New discoveries continue to be made.

More and more, we learn about effective ways to treat people who are diagnosed with borderline personality. These gains in knowledge lead to more hope: hope for people to heal, and hope for the condition, by whatever name, to elicit less stigma and more understanding.

References:

  1. American Psychiatric Association. (2013). The diagnostic and statistical manual of mental disorders – 5. Washington, DC: Author.
  2. Gunderson, J. G., Stout, R. L., McGlasham, T. H., Shea, T., Morey, L., Grilo, C. M., Zanarini, M. C. et al. (2011). Ten-year course of borderline personality disorder: Psychopathology and function from the Collaborative Longitudinal Personality Disorders Study. Archives of General Psychiatry, 68, 827 – 837.
  3. Leichsenring, F., Leibling, E., Kruse, J., New, A. S., & Leweke, F. (2011). Borderline personality disorder. The Lancet, 9759, 1 – 7.
  4. Lilienfeld, S. O., & Arkowitz, H. (2012). Diagnosis of borderline personality disorder is often flawed. Scientific American. http://www.scientificamerican.com/article.cfm?id=the-truth-about-borderline
  5. Linehan, M. M. (1993). Cognitive behavioral treatment for borderline personality disorder. New York: Guilford.

© Copyright 2013 GoodTherapy.org. All rights reserved. Permission to publish granted by Stacey Freedenthal, PhD, LCSW, therapist in Denver, Colorado

The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the preceding article can be directed to the author or posted as a comment below.

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  • Bessie

    Bessie

    October 15th, 2013 at 10:21 AM

    I have no problem with changing the name per se, but why abolish the actual diagnosis if it is indeed valid? Isn’t it the diagnosis that actually gets the person the treatment that they need in most instances?
    I understand that there will be those who use the term in a negative way, but this will most likely be those who don’t understand the diagnosis and honestly almost every illness out there is going to have some idiot who doesn’t understand it and who is critical for no reason.
    If the term hurts then by all means let’s do away with that, but not at the expense of getting rid of the answers that these patients are still seeking.

  • TeD

    TeD

    October 16th, 2013 at 1:07 AM

    I’m all for good treatment and medication. But stopping diagnosis of something because it MIGHT hurt the person is doing no good either, is it? Just because something MAY lead to a bad result does not mean we forego the various good that it can bring with it. I say we continue with the diagnosis. Ignorant people will always disregard the truth, we cannot control that.

  • Van

    Van

    October 16th, 2013 at 11:26 AM

    Well now with the new healthcare initiatives in place no one is SUPPOSED to be discriminated against because pf preexisting conditions so why connfuse matters? if this is what therapists and counselors know the disorder as then why change things now? Don’t you think that changing things so far into the game will cause even more confusion for providers as well as for patients?

  • agirl

    agirl

    October 18th, 2013 at 2:30 AM

    Bessie and Ted have issues with reading comprehension. The author states “The diagnostic label deserves to be changed, but the construct itself should remain the same, as long as it is supported by continued research.” The author basically already said what you are saying.

  • Jan Beauregard, Ph.D.

    Jan Beauregard, Ph.D.

    February 2nd, 2014 at 6:13 AM

    Bessel Van der Kolk views the disorder through the lens of attachment injury which I think is more appropriate. A better name might be “disorganized attachment disorder” as when you look at partterns of attachment you will often see trauma and disorganized attachment. This is the term I prefer and never use the term borderline because it is shaming and pejorative and perceived as having no cure. Treatments that combine DBT, EMDR, ego state therapy and Sensorimotor body based techniques can be very effective with these patients and help them learn to develop inner resources to better manage intolerable feelings.

  • chris60

    chris60

    October 13th, 2014 at 7:22 PM

    Normal people react to distressing experiences with anger and pain. Our bodies react to abuse and trauma in a manner to enable us to receive care, keep safe or learn to avoid the stimuli that causes pain. BPD symptoms can be normalised once we know what caused the intense reaction, and enable clients to express their feelings and have their needs met in a healthy way. Complex PTSD often occurs due to invalidating and highly stressful and painful environments and experiences. A returned soldier is expected to be a bit off and distant after having engaged in war, so too will a person appear changed after enduring violence or trauma. Some people, however, tend to over-react to stimuli, and a tap to them feels like a bashing. Whether due to abuse by our primary carers, or due to trauma suffered in significant relationships, all people tend to respond with anger and pain when they have been intentionally hurt by someone else. The real danger lies in failing to see why the person is suffering and trying to protect them from what may be an extremely dangerous relationship or interaction. The problem lies with trying to express strong reactions once the abuse has ceased, as the body has a habit of trapping painful feelings and reactions until a person is safe enough to express them. What appears really sad is that the person who caused the distressing symptoms rarely shows for therapy; instead the victims of sexual abuse or violence present in the offices to resolve the damage caused by someone else, and they are then re-traumatised again when the treater fails to address the fact that their reactions are normal and what they suffered was the problem. Too few people place blame on the perpetrators of violence, instead becoming impatient and annoyed by the symptoms displayed by those they have violated or attacked. Once the perpetrator is apprehended and given due consequences, many of the victim’s symptoms will abate as they now feel safe, validated and protected from further harm. The real problem is often the failure to address the actual cause of the symptoms; an individual or a group that causes grave harm and damage to other people. We are all animals at heart, and tend to respond aggressively to unjustified pain. Healthy self-soothing and calming techniques lie at the heart of good treatment as the overwhelmed body struggles to find a way to resume balance. Talking about what caused the symptoms actually exacerbates symptoms as people are distressed discussing what hurt them, and actually are searching for a way to forget the past and regain a sense of equilibrium in the present. Mindfulness, meditation, goals setting, breathing and relaxation techniques, positive thinking and thought stopping or distraction work far better to provide relief and break the loop of painful rumination rather than rehash the past. Once triggers are unearthed, clients can learn more effective ways to react than lashing out or withdrawal. Wait, breath, distract, consider, then act seems to be a useful mantra. The odd thing is that the chief cause of distress rarely presents in the office for treatment as they are using violence, deceit and denial to maintain a sense of power and control, and do not care about leaving behind a string of highly distressed victims as long as their needs have been met without facing any consequences. Crazy-making is something that they have perfected without a clue about why people around them are reacting “strangely” or falling apart after they have raped, bashed, exploited, abused, lied or bellowed at them.

  • Brie

    Brie

    December 30th, 2018 at 1:05 PM

    Finally someone says it like it is!. Thank You

  • thomas

    thomas

    November 9th, 2014 at 8:31 PM

    Bessie, actually, the diagnosis keeps lots of people from treatment. Many mental health professionals won’t treat people diagnosed with bpd, and give the diagnosis to prohibit service use by diagnosed people. The self stigma can also make treatment seem hopeless and pointless.

  • elliot

    elliot

    July 2nd, 2015 at 3:08 PM

    as someone diagnosed with borderline personality disorder, finding out there was a name for what I struggled with was probably the best thing that ever happened to me. I never experienced any feelings of hopelessness over it anyway, as the feeling of knowing that other people experienced the same things overtook it completely. I am borderline, and that’s part of me. I don’t think changing the name is necessary.

  • Nikki

    Nikki

    February 26th, 2017 at 7:28 AM

    I have had bpd and bipolar since i was 14 years old. I was diagnosed with borderline in 2003. It is 2017, and I have just now excepted it as a diagnosis and began intense treatment because of the stigma. The belief that there is no treatment for bpd still exists. Change the label, and more people will seek treatment earlier. Nobody wants to believe or tell others that their personality is defective. A better descriptive label for this disorder would be helpful.

  • Lucy

    Lucy

    January 23rd, 2018 at 3:39 AM

    Yes, it is so old fashioned, I am so glad my ad has a forward thinking therapist who dislikes labels but realised we needed one to get the right support. Pervasive developmental trauma ticks all these boxes but directs some responsibility on to society rather than all on the individual

  • Robyn

    Robyn

    January 23rd, 2018 at 10:34 AM

    I long ago changed the label, both in my own usage and that of my clients, to Emotional Intensity Disorder. I have always struggled with labels, given that so many of my clients come to me with a history of a variety of mental health labels that changed depending on the day, and to whom, they were citing their symptoms.
    In the case of emotional intensity I find it much more workable to keep my focus on what’s not working and what we can do to change that. My clients haven’t struggled with the symptom descriptions, they struggle with the label. So we go with a label that describes what they’re experiencing.

  • Mechelle

    Mechelle

    December 29th, 2018 at 9:47 PM

    Many times I have said the exact same thing. I’m offended by the term borderline personality disorder. It insinuates that I was born with a defect, when in fact my defect is from childhood trauma. Years of abuse and torture another person inflicted upon me and every day I pay for it. Even though it was years ago and he’s dead, the name “borderline personality disorder” infers that it is something that is within my control, something that I I had some say over. When actually it is the most uncontrollable thing in my life. And it always has been. I’m okay with complex PTSD or some other name but I am never going to be okay with borderline personality disorder… it’s an insult and it should be changed. And it does not help lift the stigma of mental illness to use a diagnostic title that blames our core being. I mean come on it’s Common Sense how long is it going to take to get this changed what do we have to do?

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