The Danger of Misdiagnosing 'Quiet' Borderline Personality Disorder

Borderline personality disorder (BPD) is often categorized — in short — as a mental illness where a person exhibits explosive anger, impulsive behaviors and unstable relationships with romantic partners, as well as friends and family. Due to the destructive nature of these symptoms, BPD has almost become a “bad word” in the mental health community. As a Master of Social Work (M.S.W.), I have come across professionals who won’t work with individuals who have been diagnosed with BPD due to the stereotypical “abusive” nature of the disease. However, the symptoms listed above provide an overgeneralized assumption of the disorder based on only three out of nine possible symptoms — and all symptoms are frequently linked to trauma.

• What is PTSD?

This overgeneralization of BPD marginalizes people who live with the illness by belittling or oversimplifying their experience — particularly those who don’t fall under the assumed criteria. Furthermore, it makes finding help extremely difficult, let alone receiving an appropriate diagnosis. There are four types of BPD that all present differently. And to be diagnosed with BPD, one must show five out of nine possible criteria. The variation of symptoms then puts the person on a sliding scale of 256 possible representations of the disorder. Because of this, no one person fits 100% into any one of the four categories of BPD due to the number of possible variations. People with BPD often exhibit symptoms that put them in more than one category – and sometimes all four – but the categories help the individual, loved ones and professionals better understand BPD, possible causes and treatment options.

The nine criteria of BPD:

1. Frantic efforts to avoid real or imagined abandonment.

2. A pattern of unstable and intense interpersonal relationships characterized by extremes between idealization and devaluation (also known as “splitting”).

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

4. Impulsive behavior in at least two areas that are potentially self-damaging (spending, sex, substance abuse, reckless driving, binge eating, etc.).

5. Recurrent suicidal behavior, gestures or threats or self-harming behavior.

6. Emotional instability in reaction to day-to-day events (intense episodic sadness, 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 (frequent displays of temper, constant anger, recurrent physical fights).

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

The four types of BPD:

1. Discouraged (or Quiet) BPD

The trademark of discouraged BPD is “acting in” rather than “acting out.” Individuals within this category don’t often exhibit explosive anger or manipulative behavior; instead, they often come off as calm and high-functioning and implode by bottling their emotions or dissociating.

2. Impulsive BPD

Impulsive BPD is linked to a charismatic personality and attitude. Those with impulsive BPD are often flirtatious, outgoing, dramatic and manipulative.

3. Petulant BPD

Petulant BPD is characterized by a need to control others, using self-harm/suicidal tendencies to manipulate others, intense mood swings and being dissatisfied in relationships.

4. Self-Destructive BPD

Self-destructive BPD is linked to self-hatred. People under this type are subject to self-harming behaviors, and they will often sabotage their well-being and/or happiness due to feeling they are undeserving.

I was recently diagnosed with discouraged (or quiet) and petulant BPD following a suicidal episode and inpatient stay. As a social worker in the mental health community, and knowing the stigma associated with BPD, my world came crashing down with my diagnosis.

I began to think, “What if no one wants to work with me because I have this illness? What if my friends and family will no longer see me the same? What if no one will understand?”

I have always been an introverted, quiet person, and I didn’t see myself as exhibiting the stereotypical BPD criteria of manipulation or explosive anger. The anger I have experienced has always been toward myself. I have a history of self-harming behavior and suicidal ideation, but I had never connected BPD to my symptoms — possibly out of the negativity I have witnessed surrounding the disease. When learning about mental illnesses in school, I wasn’t taught the different types of BPD, which added to my confusion and feelings of self-hatred and failure.

Along with BPD, I was also diagnosed with complex post-traumatic stress disorder (C-PTSD) and major depressive disorder (MDD). Having three new diagnoses was overwhelming and hard for me to grasp. However, I felt extensive shame with my BPD diagnosis that I did not feel with the C-PTSD or MDD, and that called me to look further into the illness.

Being the natural scholar I am, I followed my treatment with extensive research into BPD, and I discovered it is one of the most misdiagnosed mental health conditions due to the symptoms correlating with depression. Many professionals aren’t taught extensively about the subtypes of BPD, which can lead to a general lack of knowledge in the mental health field and a line of misdiagnoses in a person’s timeline, which is most likely why it took me going to inpatient treatment to be properly diagnosed.

Discouraged type BPD is a dangerous form of BPD because those who struggle with it don’t often reach out for help due to a feeling of inadequacy and lack of self-care, and self-harming or suicidal behaviors can often go unnoticed. I learned that intense relationships are also a factor with discouraged BPD, but those with the illness often sabotage their own relationships due to a belief they don’t deserve to be loved. All of these factors hit a cord with me and they made me look at myself like I never had. I had to confront my history of intense and dysfunctional relationships, as well as my isolating behavior and inconsistencies with my mood.

Broadening my knowledge made me more aware of all forms of BPD, especially understanding the diagnosis is often connected to past trauma the survivor couldn’t control. While BPD can come off as aggressive, its link to trauma and feeling defenseless is often overlooked. Empathy is necessary for anyone to understand what a person with BPD has gone through, especially in the mental health field. Following my experience and my research, I was relieved to know there is a reason behind why I am the way I am, and there is help for through dialectical behavior therapy (DBT).

I have since been certified in DBT, and I am extremely passionate about helping others who have been affected by BPD and/or PTSD, or those who would like to learn more about either illness. Understanding my diagnosis not only helped me to better understand myself, it helped me to understand all affected by the disorder and to realize there is help. People who live with BPD shouldn’t struggle due to misunderstanding and lack of knowledge, and it is my mission to ensure BPD education and treatment is highly accessible for all. I will be exploring each form of BPD more in-depth in future posts, as well as C-PTSD and PTSD.