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The Underdiagnosis of Borderline Personality Disorder

March 10, 2015 Mary Hofert Flaherty

Borderline personality disorder (BPD) is widely underdiagnosed. However, the problem is not just a matter of healthcare access, as even BPD individuals who seek treatment are misdiagnosed. The problem runs deeper in the packaging and distribution of knowledge among professionals. The majority of mental healthcare providers hold misconceptions about BPD, and even those who don’t seem to perpetuate myths around borderline personality disorder.

Borderline Personality Disorder Underdiagnosis and Misdiagnosis

When I was a student nurse, I worked at an inpatient psychiatric facility. The nature of the facility meant that patients were acutely ill, but many of them were also chronically sick. Staff would call some of these patients who were readmitted “frequent flyers.” While this term was meant to insult individuals perceived to be abusing the system, I understood that something was wrong with the system. I also saw a pattern in the type of patients that would return. They were a lot like me: they were borderline.

Oddly enough, I never saw the BPD diagnosis anywhere in their charts. In fact, I barely heard any discussion of the disorder at all, except perhaps when it was being used as a pejorative for a difficult patient. Finally, I approached a doctor about a patient I was certain was misdiagnosed as bipolar when he clearly had BPD. The doctor responded that she was aware of the BPD traits, but “couldn’t do anything about it.” Puzzled, I inquired further. I found out the misdiagnosis was intentional.

First, she told me that she couldn’t diagnose hospitalized patients with personality disorders because these particular individuals require an outpatient physician’s observation over the course of six months prior to diagnosis. This rule seemed absurd to me for a couple reasons: (1) she already admitted how obvious the borderline traits were in certain patients, so there was something recognizable that needed to be addressed; and (2) no patient would stick around for six months before receiving a diagnosis and treatment, so what good was the rule?

I looked it up. I couldn’t find such a rule anywhere, so I asked my psychologist who specializes in BPD about it and he said it was baloney. I brought this information to the hospital, causing the doctor to hunt through her documentation. Coming up empty, she conceded that it must have been an old rule. She consulted another doctor, and he said that the real reason they don’t diagnose BPD is because “they can’t do anything about it.” Puzzled, again, I inquired further. He said that even if they were to deliver the diagnosis, the long-term treatment necessary couldn't be provided in the hospital.

Upon further investigation, I learned that the outpatient doctors that the inpatient doctors rely on to diagnose don't diagnose either because the resources are so lacking; the infrastructure doesn’t exist at the community level to support the number of people with BPD. I also learned that some doctors knowingly fail to diagnose BPD because they are under the misapprehension that effective therapies don’t exist and bad outcomes are inevitable. Others don’t give the diagnosis because they fear it will stigmatize the patient and lead to rejection by the mental health system. In the simplest of cases, providers fail to diagnose due to limited knowledge of such a complex disorder.

The Case for Borderline Personality Disorder Diagnosis

I was outraged by these revelations. The issue on the forefront of my mind was that patients deserve to know about their condition. The withholding of knowledge about a patient’s body and health status seemed downright unethical—medical malpractice, even. If adequate resources aren't available, an accurate diagnosis would at least give patients the potential to understand what was going on with them. Eventually, they might even benefit from appropriate treatment, instead of one geared toward another diagnosis—like that of bipolar, a common misdiagnosis. A bipolar diagnosis sends the patient and subsequent providers on a wild goose chase, when really dialectical behavior therapy (DBT) would prove effective. It’s no wonder borderlines are known for polypharmacy when doctors are throwing medication useful for other disorders at every single symptom of BPD.

As a student, I started providing information about BPD to patients after consulting the doctor about the possibility, even when the diagnosis wasn’t in the chart and no one else was making the effort. I made sure patients knew I wasn’t a doctor and that they needed to seek further information once they left the hospital from the right sources. I needed them to know that their destiny wasn’t the hospital or prison (where many of them had spent years of their lives)—that the system had failed them, but that there was hope. Patients who had previously battled every staff member in the unit were crying on my lap, their eyes wide and grateful. “Everything finally makes sense. Now I can do something about it.”

Borderline personality disorder is often underdiagnosed and misdiagnosed. The reasons are numerous but the underdiagnosis of BPD ultimately hurts patients.

This painting was gifted to me by one such patient.

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APA Reference
Hofert, M. (2015, March 10). The Underdiagnosis of Borderline Personality Disorder, HealthyPlace. Retrieved on 2020, September 22 from https://www.healthyplace.com/blogs/borderline/2015/03/the-underdiagnosis-of-borderline-personality-disorder



Author: Mary Hofert Flaherty

Dante
October, 9 2015 at 11:45 am

As someone diagnosed over 50 years ago. I suggest younger BPD individuals
Look to modern science for why they are BPD. Recent studies on BPD children
show the amygdala part of the cerebellum responsible for reason and memory
was 1/5 smaller or 20 percent less in size. They noticed other brain differences.
These are physiological differences not present in "normal" children. These need
To be explained before blaming someones behavior for genetic differences.
I've noticed through the decades BPD was 0 percent genetic in the 60s. The idea
Itself was not even considered. Then in the 90s studies showed a 40 percent
Genetic relationship to BPD. Currently the numbers at 60 percent genetic which
doesnt seemed to be discussed much. I believe the number will only go higher.

anonymous
April, 17 2015 at 3:03 am

I have just stopped all psychiatric so called treatment. It will take me time to regain the functioning I had Prior to ever walking into a mental health practitioner's office.
The stigma and label was far worse than any symptom, the side effects from medication still lingers.
I am focusing on eastern traditions and meditative practices and prayer. I wish I had consulted with a minister and strongly recommend anyone choosing to seek mental health treatment really weigh the risks vs. any potential benefit for their quality of life.

Zula
March, 25 2015 at 9:22 pm

I’m not sure where you're getting your info, but great topic. I needs to spend some time learning much more or understanding more. Thanks for excellent info I was looking for this info for my mission.

Dr Musli Ferati
March, 21 2015 at 8:50 pm

Borderline personality disorder as intermediate mental entity is intrigued issue for professionals of mental health care system. Against the fact that this mental disorder is frequently in daily psychiatric practice, it is rarely present on psychiatric certificates bother: as admitted or released diagnosis. Indeed there are a lot of obnoxious psychiatric patient, which ones frequently seek psychiatric help on outpatient or inpatient basis. Furthermore, they are diagnosed with different psychiatric entities and consequently treated with diversities of therapeutic approaching. This type of psychiatric treatment and management render more difficult the course and definitive prognosis of theirs underdiagnosed or misdiagnosed psychiatric entity. By me, each patient with many differential diagnosis criteria, should be considered as BPD, especially when its psychiatric treatment is going badly. Otherwise we have got many recidivation on psychiatric wards. Anyhow, it would rise the number of unsatisfying psychiatric patients, with many complaint from respective patient and lovers one. These and many others implications of BPD tries to find more attention to this psychiatric entity in current psychiatric service.

anonymous
March, 20 2015 at 7:06 am

When I saw my first therapist. She talked to me for 45 min. She told me she doesn't treat bpd's. I left not knowing what it was and I felt really bad.

anon
March, 13 2015 at 4:47 am

After a period of depression last year I was told that I might have bpd. Unfortunatly I didn't meet the diagnostic criteria, so the psychiatrist implied that I had been withholding information and misrepresenting my symptoms. Being diagnosed with bpd means my gp will not speak to me about mental health, because i have been referred. I can no longer get anti depressants (I do not need them but remember I self referred with depression), I cannot get help from services incase i become "dependant" (I don't need it but I am being excluded on the basis of a psychiatric diagnosis...?), and there is a strong possibility that I will need to declare my "diagnosis" on job aplication forms and if I have children they could be taken from me because of this diagnosis.
During the assessment where I was diagnosed (a 20 minute chat with a hso) I was told that my educational history was "impossible, couldn't have possibly happened" she asked me repeatedly about sex, 5 times if I did drugs, 3 times if I'd been abused, and used bullying from high school as evidence of "long term emotional disturbance". She also took an incorrect history and read me a "statement" of my symptoms 3 times, until i could repeat it back to her, telling me "you have said this, is it true?"
Kicker is that I am no longer depressed, but stuck with this label, and believe me it is stigmatizing. I have recieved 3 hours of counselling for my diagnosis, then someone called my employer and told them I was mentally ill.
So my case is the opposite to what you describe, I believe that I should not have been labelled as the label has brought no help and only problems. I see what you are saying with your "revolving door patients" that something needs to change, but this diagnosis can exempt a person from treatment and something needs to be done about that first. Otherwise we are diagnosing people for the purpose of not treating them.

Helena
March, 12 2015 at 11:30 am

I was diagnosed not long ago with BPD and PTSD and I feel
That there is still no help at all and I'm very upset with the way people
Treat me because of my mental health even professionals !

In reply to by Anonymous (not verified)

Mary Hofert
March, 12 2015 at 1:41 pm

I'm so sorry! It's a common problem; you're not alone! Things will get better with time! Hang in there and keep searching for a good therapist. They're out there, but it's a process of trial and error.

Mmom
March, 12 2015 at 9:06 am

Interesting.

Robinn
March, 12 2015 at 8:55 am

My niece had (finally, after 3 suicide attempts & hospitalizations) with BP -something that I had diagnosed myself. Her Axis I is bipolar, which I agree with. I feel that if her Axis II had been accurately diagnosed at her first hospitalization, her next suicide gestures would not have happened! ( I can usually diagnose properly from working with all kinds of psychiatric patients for several years and read the DSM IV manual and case book.)
I remember from working at a psychiatric day hospitalization facility, that several therapists griped about the obviously Axis II BPD. I did understand their point, but they sure could have been nicer to her and been better educated and compassionate towards her. She didn't choose to be that way...and neither did my niece.

stephanie O'Donnell
March, 11 2015 at 2:35 pm

As far as I can see lots of people are being diagnosed with borderline personality disorder now if they are resistant to certain meds or don't fit neatly in a box.If anything it's increasing as a diagnostic label.I've heard mental health professionals discussing people with this diagnosis and it's not very pleasant.

In reply to by Anonymous (not verified)

Mary Hofert
March, 11 2015 at 3:54 pm

I think more people are being diagnosed as time goes on, especially now that it's not separated from Axis I disorders in the DSM 5. One of the reasons that doctors may not have given the diagnosis so freely in the past (which I didn't specifically talk about) was because, as an Axis II disorder, insurance wasn't as likely to cover it. As I mentioned, BPD is used as a pejorative for "difficult" patients and the talk is not very pleasant--you're right. It's horrible, and it's wrong. But I think that's a separate issue. Personally, I think it's a good thing that more people are getting diagnosed who have problematic behaviors because it means more people will get the therapeutic treatment they need (though of course, it also opens people up to get less-than-therapeutic treatment in the form of slurs and stigma that you mention), but ultimately stigma will decrease in society and more and more people will have access to treatment. People seek help when their behaviors are getting in the way of their lives. To receive a personality disorder diagnosis to me is a positive thing; it is an avenue of hope and for change. But I think you're right in that a lot of people don't present in a way that fits nicely in a box, and I think that's because mental illness exists on a spectrum, and human beings are the ones to categorize illnesses that aren't actually distinct from one another. This is why it's important to treat the origin and not just the symptoms of an illness. And this is another reason why I think it's a good thing that people are being diagnosed more with personality disorders: the appropriate treatments consider the issue of origin unlike pharmaceutical treatments of "Axis I" disorders. So ultimately, the accuracy of the label matters less.

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