To Mental Health Professionals: Stop Calling Your 'Difficult' Patients 'Borderline'

When I was diagnosed with borderline personality disorder (BPD), years of my pain, abandonment reactions and emotion dysregulation finally made sense. Understanding my condition served as a significant tool for my treatment and progress. I was better equipped to identify my triggers, plan and cope ahead and understand underlying mechanisms and precipitants. For once, I did not feel alone. I felt validated, heard and understood.

Unfortunately, numerous studies show many people who have BPD are initially misdiagnosed. For example, one showed 40% of people with BPD in the sample were misdiagnosed with bipolar disorder type II. An inaccurate or partial diagnosis can be harmful because treatment may not focus on the symptoms as a whole and their pattern.

With a diagnosis of clinical depression alone, my extreme abandonment preoccupations, frequent self-injury, changeable and reactive moods, and paranoid ideation were often overlooked. Pharmacological treatment seemed to be prioritized, when psychotherapy is the main treatment for BPD. Certain distresses of mine were left unchecked. Even more, an inaccurate diagnosis can lead to feeling misunderstood, confused, invalidated and hopeless.

Yet, there is another problem that needs to be directed to mental health professionals when misdiagnoses are addressed. As paradoxical as it seems, BPD is not only sometimes under-diagnosed, but it may at times also be over-diagnosed. Instead of thoughtfully considering symptom presentation, differential diagnosis and criteria, BPD may be incorrectly tagged onto certain stigmatized patients who may not even have the condition at all.

Research on stigma and the language associated with BPD can elucidate how it relates to under-diagnosis and over-diagnosis. There is surplus stigma and negative language associated to BPD symptom presentations — as well as the diagnosis itself.

Historically, the term “borderline” has been incorrectly used synonymously by professionals who adopted the term to stigmatize patients as “difficult” or “treatment-resistant.” Thankfully, these myths and biases have improved and shifted over time, but they can still impact care and clinician decisions today.

Like my case, clinicians may be reluctant to accurately diagnose and treat BPD. On the other hand, it can also be drawn that patients who have symptom presentations considered intense, chronic or stereotyped as “resistant/difficult,” especially female patients, may be incorrectly diagnosed with BPD.

While there are several factors that influence an inaccurate BPD diagnosis, it is important to look out for possible gender bias. Women have been more likely stereotyped as “emotional,” “hysterical” and “promiscuous.” Self-injury and intense emotions, which can be signs of BPD, are often sometimes seen as a “women-only” issue. This bias contributes to under-diagnosis in men and relates to harmful stereotypes about masculinity.

As a psychology student studying clinical science, I notice stigma can permeate practices, teachings and textbooks today. People with BPD are periodically portrayed as female patients who are “exaggerating,” “dramatic,” or “difficult and resistant” without any explanation of the actual symptoms. The depictions may be described with judgmental or invalidating terms. Not only does this harm people who have BPD, but it stigmatizes certain symptom presentations and gives the impression that they are synonymous.

Further, BPD may be incorrectly used interchangeably with transdiagnostic mechanisms and behaviors, such as self-injury. This means it is a behavior present across multiple conditions. While up to 80% of people with BPD struggle with bodily self-injury and it is part of the symptom criteria, self-injury is seen in people who have clinical depression, post-traumatic stress disorder or bipolar disorder. In fact, the majority of people who have self-injured in the general population do not have BPD.

It is also important to keep in mind that the term or diagnosis alone cannot fully explain the stigma towards certain symptom presentations. It is often assumed stigma towards a patient comes from the BPD diagnosis alone, without any consideration for how the patient and their symptoms or behaviors were perceived in the first place, or why they may have been misdiagnosed with BPD. The association is often discussed as a simplified unidirectional relationship, which leaves out the multiple other factors and contexts.

While I am not doubting there is stigma associated to a BPD diagnosis in itself, I argue that is not the full picture. In the real world, it appears as a complex and interlocking association to different contexts that may include BPD, symptom presentation, ableism, gender and other characteristics and clinical settings, rather than a single and overly simplified sequence. Indeed, I have experienced stigma in relation to my BPD-specific symptoms before I even disclose diagnosis.

Although stigma extends outside of clinical circles (e.g., media and interpersonally), more research also suggests BPD stigma is often professional specific, rather than present across the general population. It also shows a lack of diagnosis may actually make it harder for people in the community to understand someone’s symptoms and increase stigma.

Some other factors of misdiagnosis professionals need to keep in mind include the myth that BPD is not treatable (despite evidence showing otherwise), that it cannot be diagnosed before adulthood, poor BPD literacy and insufficient education and training on BPD and diagnosis. To adequately address the stigma and misuse of a BPD diagnosis, it is vital to look at numerous factors, how they relate and the specific context.

For one example, a white female inpatient who self-injures and is stereotyped as “challenging to treat” and “manipulative” may be misdiagnosed with BPD.

Clearly, misuse of a diagnosis can be harmful whether it is under-diagnosed or over-diagnosed, as it can perpetuate stigma, interfere with treatment and other internal consequences. However, BPD over-diagnosis is clearly harmful to other people who actually have BPD too. It is infuriating to hear my condition and pain used synonymously as an insult and to stigmatize other people who struggle and deserve respect and appropriate care.

In reality, BPD is a treatable mental health condition characterized by emotion dysregulation and extreme emotional hypersensitivity. People with BPD tend to experience intense emotional reactivity for long periods of time, with a slow return to a stable emotional baseline. The specific symptoms impact major areas of functioning, including emotion, behavior, interpersonal, cognitive and sense of self/identity.

Just a few of the main symptoms include chronic emptiness, an unstable self-image and sense of self, mood reactivity and instability (for example, intense anger to idealization to anxiety, all within a few hours), recurring self-injury, suicidal ideation and impulsivity (e.g., drug use or reckless driving). Other main symptoms include stress-induced dissociation, paranoid ideation and hallucinations.

One of the most notable symptoms of BPD are the extreme reactions to and preoccupations with abandonment or rejection. Mundane events, such as brief separations at work or school, perceived slights, or misunderstandings may trigger extreme emotions, frantic efforts to avoid abandonment or paranoia. Someone with BPD may have abandonment themed nightmares, repeatedly beg someone not to leave or try to prevent someone from leaving somehow. When alone or triggered, people with BPD may feel like they are being watched or like people are plotting to abandon or hurt them.

Briefly, there are a combination of risk factors that lead to the development of BPD, including the level of heritability (estimated to be about 50% but up to 70%), biogenetic dispositions (e.g., temperaments, heightened emotional arousal and hypersensitivities) and environmental factors such as abuse, invalidating environments or early loss.

To discriminate against a particular group of patients in this pain is despicable. I suggest mental health professionals who negatively regard certain patients and conditions rethink where it came from and how they violate the ethics and conducts to which they claim to be committed. The need for humility and respect warrants considerable attention in the field.

Professionals need to address and correct the misuse of the terms “borderline” and “BPD” if encountered and regularly check their own beliefs, conclusions and the potential biases. Broader change (e.g., education and textbooks, standard practices and procedures) need to shift away from the ideas that BPD and its symptoms are “hopeless,” untreatable and synonymous with pejorative terms. Also, patients do not “resist” treatment. They resist treatments or approaches that are unhelpful to them or not designed to help them. For symptoms such as self-injury that may be falsely deemed a deliberate attempt to “defeat treatment,” they are actually a symptom and emotion regulation attempt that needs to be understood with care