Borderline Personality and Self-Understanding of Psychopathology
Reflections on BPD and hermeneutical justice
Like many clinicians, I am conflicted and ambivalent about the diagnosis of borderline personality disorder (BPD). There is a never-ending, exhausting debate around it.
There are several strands of controversy around BPD, pertaining to:
scientific and statistical evidence with regards to BPD as a distinct personality disorder
clinical utility of the diagnosis
negative consequences of diagnosis, including stigmatizing attitudes, diagnosis being perceived as insulting and offensive, and harmful implications for clinical care.
For a strongly-worded summary of these issues, see Mulder and Tyrer (2023). For a psychodynamic, clinical introduction to borderline personality, see Shedler (2021).
Relevant to #3, a recent paper by Jay Watts in BJPsych International makes the case that the diagnosis of BPD is, on top of everything else, epistemically unjust. Regular readers of Psychiatry at the Margins would be familiar with the notion of epistemic justice by now. Epistemic injustice occurs when someone is wronged “specifically in their capacity as a knower.” This comes in two forms: testimonial and hermeneutical injustice. Testimonial injustice happens when a person is assigned lower credibility due to bias and prejudice, and what they have to say is dismissed or not taken as seriously. Hermeneutical injustice occurs when a society collectively lacks concepts that are needed for people of certain (marginalized) groups to make sense of their experiences, properly understand them, and render them intelligible.
Patients with BPD are frequently perceived as less credible due to the negative connotations of this diagnosis. This stigma is rooted in stereotypes that portray individuals with BPD as manipulative, attention-seeking, and overly emotional. These negative perceptions can lead clinicians to dismiss the experiences and reports of BPD patients. Watts argues that the BPD conceptualization fails to adequately capture the lived experiences of patients, leaving them without the necessary language and concepts to articulate their difficulties, further marginalizing them.
In this context, I want to make a case for something that is rather unfashionable in the current state of critical discourse: BPD is in fact a concept that helps people make sense of their experiences, properly understand them, and render them intelligible. That is, the existence of BPD as a diagnostic category facilitates hermeneutical justice. And this is true despite the fact that BPD also perpetuates testimonial injustice and also traps some people in stigmatized identities in current systems of care.
The abstract of Watts’s paper:
“Borderline personality disorder (BPD) has been a controversial diagnosis for over 40 years. It was to be removed from the latest version of the ICD, only to be reintroduced as a trait qualifier as a result of last-minute lobbying. Retaining BPD as a de facto diagnosis keeps us stuck at a deadlock that undermines the voices of patients who have persistently told us this label adds ‘insult to injury’. Miranda Fricker's concept of epistemic injustice helps illuminate how this affects subjectivity and speech, hermeneutically sealing patients in ways of thinking that are not evidence-based, resulting in testimonial smothering (altering or withholding one's narratives) and testimonial quieting (dismissing a speaker's capacity to provide worthy testimony) that prevent more affirmative explanations.”
Watts describes the case of Laura to illustrate:
“The diagnosis of BPD hit Laura like a sharp blow, as she had always attributed her emotional struggles to the traumatic experiences she endured during her formative years. Being told she had a personality disorder felt like an insult rather than a helpful diagnosis… As Laura went through her dialectical behaviour therapy (DBT) sessions, she was overwhelmed by intense feelings of shame, anger and deep humiliation. Every attempt to open up about her traumatic experiences was met with redirection to skills training, leaving Laura feeling that she had done something wrong and her pain was being dismissed. The hurtful stereotypes about patients with BPD being labelled as attention-seeking, manipulative and difficult had already haunted her and when she bravely challenged her diagnosis, her voice seemed to hit a wall of indifference. In the psychoeducational component of DBT, she felt silenced and unseen.”
A lot of people who receive diagnoses of BPD experience something similar. This has a lot to do with the minimization of the role of trauma (especially developmental trauma) in the lives of patients, the disparaging manner in which the diagnosis of BPD is conveyed, a lack of collaboration and personalization during diagnostic assessment, and the shunting of patients into treatment pathways that they don’t want or don’t find helpful.
Mulder and Tyrer have also highlighted these problems very well:
“The indiscriminate use of borderline in multiple contexts is a major source of stigma. Those with emotional instability, a syndrome that undeniably exists but is best thought of as a mood disorder, are combative and often eloquent in seeking care, and employ what were once called ‘immature defences’ such as splitting and projection. Put in simpler form, they distract and annoy the clinician. There are many other reasons patients challenge their doctors, but in the current climate, this behaviour – whether expressed in accident and emergency departments, general practitioners’ surgeries or psychiatric settings – leads to eye-rolling, nods and winks to colleagues and the whispered comment ‘another borderline’ that foreshadows inappropriate and unsympathetic intervention. Health professionals are the worst offenders in promoting stigma and the consequent angry reactions it provokes. As a consequence, the patients so identified are seen as more difficult to manage even when their behaviour is no worse than other patients who are not labelled with borderline pathology. It also makes it more difficult for these patients to have other psychiatric disorders recognised such as depression, anxiety and ADHD. Patients frequently complain that when they mention these other problems, they get responses such as ‘this is all part of your emotional instability diagnosis’ or ‘once we sort out the borderline problem these will disappear’. It is almost as though the mere hint of borderline pathology devalues all other symptoms, not just psychiatric but also medical, on the grounds that they are exaggerated and distorted and can be conveniently disregarded and attention given to more needy patients.
Increasingly, mention of ‘emotional instability’ in correspondence about a patient will be used to exclude the patient from a range of mental health services on spurious grounds of inappropriate behaviour or diagnostic mismatch. This only serves to increase the sense of alienation that many already feel and the sad fact is that now any mention of emotional instability is a major source of refusal to treat by many parts of the psychiatric service. This reinforces the view that the diagnosis of borderline is being used increasingly as one of exclusion; this only serves to increase the sense of alienation and anger by sufferers. As only a tiny proportion of potential referrals can be treated by specialist services, accentuating these feelings as rejection from those services will become the norm.”
I am generally reluctant to diagnose someone with BPD if they do not have a pre-existing diagnosis (and even if they do, I don’t accept it uncritically). When it comes to BPD, I find it vital to distinguish between cases where the diagnosis is an expression of the clinician’s annoyance or frustration with the patient and cases where it is a clinical characterization of a person’s problems for which they are seeking help, and the goal is to provide them with the best treatment possible.
I am mindful that there are important differences in the organization and delivery of psychiatric care in the US and the UK. Watts is writing primarily in the British context. The British mental healthcare system seems diagnosis-driven in a manner that the US is not. In addition, it appears that the scarcity and inaccessibility of resources within the NHS incentivize services to constantly find excuses to exclude or reject patients from psychiatric treatment programs. BPD is a perfect excuse, and the diagnosis has been weaponized to deny patients mental healthcare. Imagine being in extreme distress, experiencing chronic or recurrent suicidal thoughts, actively seeking help, only to be told that you are “just a borderline,” undeserving of even a psychiatric admission, and that if you really wanted to kill yourself, you would already have done so. The scenario appears to be common enough that I’ve come across many British service users talking about it on social media over the years. This is astounding to me as a psychiatrist in the US. In the US, there is little to be gained in most clinical settings by excluding people with BPD. Hospitals don’t make money by excluding patients from services. Clinicians generally bill for services using diagnoses such as mood disorders, anxiety disorders, trauma and stressor-related disorders, even when they are working with a patient with BPD, because insurance companies are not eager to pay for BPD as a sole diagnosis. Comorbidity reigns supreme in US psychiatric practice; no one on paper is “just a borderline.” Even in situations where clinicians may think so or say so, most of them will still document multiple psychiatric diagnoses. In fact, given a lack of incentive to diagnose BPD in the first place, many US clinicians would rather diagnose a patient with a laundry list of “major depression, generalized anxiety, OCD, PTSD, ADHD, and intermittent explosive disorder” than give a sole diagnosis of BPD.
People who have only seen BPD used in a clinician-imposed manner on resentful patients may be surprised to discover that there are, in fact, many patients who readily accept the diagnosis and say it is helpful. Such cases exist even when individuals have the autonomy to dissociate from or reject the label, or when access to care does not depend on BPD diagnosis. I have been surprised by the number of patients I have encountered who have told me themselves that they suffer from borderline personality disorder. When I ask such patients about their understanding of BPD, they verbalize the core diagnostic features of BPD with remarkable accuracy: intense and unstable relationships, unstable self-image, impulsive and self-destructive behaviors, intense emotions and mood swings, fear of rejection, chronic emptiness, etc. They often tell me about how several other diagnoses, such as bipolar disorder or PTSD, given to them never seemed to be the right fit. One woman told me, “For years I was told I had bipolar, but it never made sense to me. Once I got diagnosed with borderline, suddenly everything clicked into place.” Almost all such patients have had abusive childhoods and traumatic lives, and they recognize the link between BPD and trauma. They don’t see the traumatic roots of BPD as invalidating the BPD diagnosis. They see themselves as experiencing a host of mental health problems, with BPD being only one of them.
What is different about these patients I encounter? Why do they embrace a diagnosis that is widely detested, and why do they volunteer it so freely? For such patients, BPD is a tool of tremendous epistemic value. It helps them understand what they are experiencing, over and above other diagnoses. The diagnosis resonates with them, and they accept it. The diagnosis is not imposed on them. Their access to medications and psychotherapy isn’t dependent on their BPD diagnosis.
Many mood disorders programs in the US incorporate DBT principles in their psychotherapy groups. No one gets discharged from services simply because they have a BPD diagnosis. If patients are discharged, they are generally discharged because of violent, disruptive, or inappropriate behaviors, regardless of what diagnosis they have. Nurses and clinicians often colloquially refer to manipulative and attention-seeking behavior as “borderline” amongst themselves, but that may or may not correspond to an actual BPD diagnosis in the chart. There will always be patients that lead healthcare professionals to (internally) roll their eyes or otherwise respond with dread or a lack of sympathy. There have always been and there will always be “difficult” patients, “hateful” patients, patients who are dependent, entitled, or manipulative, and patients who are simultaneously help-seeking and help-rejecting. Anyone who thinks such patients do not exist has a very naive understanding of human nature. Due to a variety of factors, casual use of the term “borderline” to refer to such patients has become common. This has created an inaccurate stereotype of BPD as a diagnostic construct and has actively contributed to the stigma around BPD. Such colloquial use of “borderline” should be rightly disapproved of (in the same vein as “hysterical”), but I do hope people will recognize that deleting the word “borderline” from the colloquial vocabulary of professionals neither eliminates the “difficult” patients nor professional eye-rolling.
From a clinical standpoint, the important thing is not to categorically diagnose BPD but to recognize:
the difficulties relevant to self-image and interpersonal relationships, along with the particular profile of maladaptive traits related to dimensions of negative affectivity, antagonism, and disinhibition.
the link with (developmental) trauma
The diagnostic recognition of the above ought to be followed by the creation of a personalized treatment plan aimed at stabilizing affect (including pharmacological treatment), addressing comorbidities such as anxiety and attention-concentration impairments, the development of skills related to emotional awareness and regulation, addressing symptoms more specific to trauma (e.g., flashbacks, intrusive thoughts, dissociation), and psychotherapy aimed at understanding and changing entrenched patterns of self-identification and interpersonal relationships.
BPD is a powerful clinical prototype that facilitates both the recognition and treatment of these aspects. But all this could technically be done without bringing up the words “borderline personality.” In situations where I think a formal diagnosis would do more harm than good, I proceed without it. A combination of mood disorder and (complex) PTSD does the job for most practical purposes. It is, however, obvious to me that there are many patients whose relationship with their BPD diagnosis is very different from the stereotypical one.
When BPD is used to minimize medical and psychiatric symptoms experienced by patients, when it is used to devalue their traumatic experiences, when it is used to exclude people from services they need, when it is used to shame and blame, and when it is forced on people to dictate their care against their will, a BPD diagnosis is indeed an instrument of injustice, including epistemic justice. I fully accept that this happens, and perhaps this is even the case for the majority of people across the world who get diagnosed with BPD. But I also know that a BPD diagnosis allows for other epistemic possibilities. For many patients, the existence of BPD as a diagnostic construct allows for a richer self-understanding of psychopathology. It allows them to see their lives through a new lens. It permits them to connect their lives to the lives of role models, such as Marsha Linehan. It is for this reason that I am an advocate of abolishing the institutional reliance on BPD (rather than the diagnosis itself) and allowing clinicians and patients greater flexibility and autonomy in making use of various concepts available to them.
There is a tendency to forget that medicine is fundamentally on the side of hermeneutic justice. Medical and scientific classifications collectively expand the conceptual resources available to us. Fricker herself used “postpartum depression” as an example of hermeneutic justice. And I see many patients for whom BPD plays a similar role.
What I am trying to say here is something circumscribed and humble: I am not saying that BPD diagnosis should be officially retained despite the syndrome being psychometrically unsound, nor am I saying that a BPD diagnosis is overwhelmingly a positive force in the lives of patients and we should disregard testimony of harm to the contrary. I am saying that there are both good and bad reasons for the endurance of BPD as a clinical prototype, and continued utilization of BPD in the clinical context is not simply a manifestation of prejudice and ignorance. BPD will live and die as many psychiatric diagnoses do, as scientific understanding evolves and constructs fall in and out of favor. But for the particular moment in history in which we exist, there are at least some patients who find BPD to be a meaningful and helpful conceptualization, amidst many others who resent and detest it. Perhaps these patients are in the minority. Perhaps they are the lucky ones to have escaped the institutional weaponization of BPD and the scorn that surrounds it. But such patients do exist, and they complicate otherwise satisfying stories we like to tell about stigmatizing diagnoses.
See also:
"Almost all such patients have had abusive childhoods and traumatic lives, and they recognize the link between BPD and trauma." This is the single most important sentence in the article. Why don't we call these people "People with multiple ACE's who thereby have serious difficulty regulating their emotions and managing relationships, because they were never regulated by emotionally healthy parents"? If we put their experience of neglect and trauma front and center, then they will be treated with epistemic justice. Far too often, their ACE's are ignored, and their present day behavior is the focus of attention. Never forget the line from The Body Keeps the Score, where Bessel talked to "Chris Perry, the director of research at Cambridge Hospital, who was funded by the National Institute of Mental Health to study BPD and other near neighbor diagnoses, so-called personality disorders, in patients recruited from the Cambridge Hospital. He had collected volumes of valuable data on these subjects but had never inquired about childhood abuse and neglect." (p.212)
Thank you for writing this article up Dr Aftab. As a person advocating for patients with severe PTSD, I myself have previously been diagnosed and treated for BPD and faced exactly these struggles just to get medications, and faced a ramp up of persecution in my family as well as a result. Very freeing to read. It was truly the “rudest” I have been treated in a medical setting and set me back in asking for help with physical illnesses fearing my doctors reactions. I was diagnosed in 15 minutes for intimating to a Muslim psychiatrist my preoccupation with suicide and depression at a time when I was very vulnerable, to have him respond aggressively with religious and culturally biased rhetoric and diagnose me right away. It took many years to find a psychiatrist who even asked me a past trauma history, something I didn’t remember/was aware of myself when I went in for treatment. Do you believe BPD belongs anywhere as an over arching diagnoses secondary to other disorders, as opposed to a category of its own?