Borderline Personality Disorder

"Every time I say something they find hard to hear, they chalk it up to my anger, and never to their own fear."
--Ani DiFranco

Unfortunately, the most popular diagnosis assigned to anyone who self-injures is borderline personality disorder. Patients with this diagnosis are frequently treated as outcasts by psychiatrists; Herman (1992) tells of a psychiatric resident who asked his supervising therapist how to treat borderlines was told, "You refer them." Miller (1994) notes that those diagnosed as borderline are often seen as being responsible for their own pain, more so than patients in any other diagnostic category. BPD diagnoses are sometimes used as a way to "flag" certain patients, to indicate to future care givers that someone is difficult or a troublemaker. I sometimes used to think of BPD as standing for "Bitch Pissed Doc."

This is not to say that BPD is a fictional illness; I have encountered people who meet the DSM criteria for BPD. They tend to be people in great pain who are struggling to survive however they can, and they often unintentionally cause great pain for those who love them. But I have met many more people who don't meet the criteria but have been given the label because of their self-injury.

Consider, however, the DSM-IV Handbook of Differential Diagnosis (First et al. 1995). In its decision tree for the symptom "self-mutilation," the first decision point is "Motivation is to decrease dysphoria, vent angry feelings, or to reduce feelings of numbness... in association with a pattern of impulsivity and identity disturbance." If this is true, then a practitioner following this manual would have to diagnose someone as BPD purely because they cope with overwhelming feelings by self-injuring.

This is particularly disturbing in light of recent findings (Herpertz, et al., 1997) that only 48% of their sample of self-injurers met the DSM criteria for BPD. When self-injury was excluded as a factor, only 28% of the sample met the criteria.

Similar results were seen in a 1992 study by Rusch, Guastello, and Mason. They examined 89 psychiatric inpatients who had been diagnosed as BPD, and summarized their results statistically.

Different raters examined the patients and the hospital records and indicated the degree to which each of the eight defining BPD symptoms were present. One fascinating note: only 36 of the 89 patients actually met the DSM-IIIR criteria (five of eight symptoms present) for being diagnosed with the disorder. Rusch and colleagues ran a statistical procedure called factor analysis in an effort to discover which symptoms tend to co-occur.

The results are interesting. They found three symptom complexes: the "volatility" factor, which consisted of inappropriate anger, unstable relationships, and impulsive behavior; the "self-destructive/unpredictable" factor, which consisted of self-harm and emotional instability; and the "identity disturbance" factor.

The SDU (self-destructive) factor was present in 82 of the patients, while the volatility was seen in only 25 and the identity disturbance in 21. The authors suggest that either self-mutilation is at the core of BPD or clinicians tend to use self-harm as a sufficient criterion to label a patient BPD. The latter seems more likely, given that fewer than half of the patients studied met the DSM criteria for BPD.

One of the foremost researchers into Borderline Personality Disorder, Marsha Linehan, does believe that it is a valid diagnosis, but in a 1995 article notes: "No diagnosis should be made unless the DSM-IV criteria are strictly applied. . . . the diagnosis of a personality disorder requires the understanding of a person's long-term pattern of functioning." (Linehan, et al. 1995, emphasis added.) That this does not happen is evident in the increasing numbers of teenagers being diagnosed as borderline. Given that the DSM-IV refers to personality disorders as longstanding patterns of behavior usually beginning in early adulthood, one wonders what justification is used for giving a 14-year-old a negative psychiatric label that will stay with her all of her life? Reading Linehan's work has caused some therapists to wonder if perhaps the label "BPD" is too stigmatized and too over-used, and if it might be better to call it what it really is: a disorder of emotional regulation.

If a care giver diagnoses you as BPD and you're fairly certain the label is inaccurate and counterproductive, find another doctor. Wakefield and Underwager (1994) point out that mental health professionals are no less likely to err and no less prone to the cognitive shortcuts we all take than anyone else is:

When many psychotherapists reach a conclusion about a person, not only do they ignore anything that questions or contradicts their conclusions, they actively fabricate and conjure up false statements or erroneous observations to support their conclusion [note that this process can be unconscious] (Arkes and Harkness 1980). When given information by a patient, therapists attend only to that which supports the conclusion they have already reached (Strohmer et al. 1990). . . . The frightening fact about conclusions reached by therapists with respect to patients is that they are made within 30 seconds to two or three minutes of the first contact (Ganton and Dickinson 1969; Meehl 1959; Weber et al. 1993). Once the conclusion is reached, mental health professionals are often impervious to any new information and persist in the label assigned very early in the process on the basis of minimal information, usually an idiosyncratic single cue (Rosenhan 1973) (emphasis added).

[NOTE: My inclusion of a quote from these authors does not constitute a full endorsement of their entire body of work.]