How to Diagnose Borderline Personality Disorder

This blog post is written with two potential types of readers in mind – mental health consumers (i.e. patients) and mental health providers. The process I suggest here is surely not the only way to make a diagnosis. A guiding philosophy of “free-range” psychology is that there may be several different ways to intervene effectively in therapy. However, I hope to illustrate that even with a diagnosis that some providers may shy away from discussing with their patients, there is at least one way to make a respectful approach.

First, a disclaimer. I am not an expert in Borderline Personality Disorder (BPD). I have never been formally trained in the treatment of BPD – my training background is a generalist one. Nonetheless, across multiple treatment settings, I have often received new patient referrals whose history and clinical presentation fits very well with the diagnosis of BPD. And what I find is that in the vast majority of cases, patients have no idea that borderline personality disorder is their charted diagnosis. (Or the chart has narrative after narrative that fits with borderline personality disorder behavioral patterns but previous clinicians have not charted the diagnosis at all despite this).

My theory is that even among highly educated mental health providers, borderline personality disorder is a diagnosis that inspires a fear/avoidance reaction. I can think of no other obvious reason why these patients so often have no idea what ails them despite years of therapy (often with multiple providers, as this is sometimes part of the clinical picture).

Depressed patients know what their diagnosis is. Anxious patients know what their diagnosis is. Patients with psychotic disorders are generally informed about their condition. Substance dependence concerns are discussed openly and relapses are generally charted. But borderline patients are often left in the dark.

As a theme, people with borderline personality disorder have characteristic difficulties with attachments to others, most often due to vulnerabilities in their early lives. Individuals with BPD have extreme difficulty regulating their own emotions, maintaining healthy close relationships, and holding onto a solid sense of their own identities. This is not the fault of these patients. Most borderline individuals I see are suffering with very limited insight into their condition. Most do not present like Angelina Jolie in the movie “Girl, Interrupted” – provocative, manipulative people to be avoided at all costs.

Sometimes, they are combat-trained men with huge muscles, who are suffering.

I figure that if we as providers are to have a chance to form a better attachment to these patients, it is critical to start by speaking truth, in a respectful way. I have been refining my approach to this conversation for some years and I’m sure it’s not perfect, but it has never resulted in any patient lashing out at me or immediately dropping out of treatment. Quite the contrary - the response has been relief and the beginnings of trust. Here is how I have been making this approach.

First, I have on hand a nonjudgmental explanation of the symptoms of BPD. Then I ask the patient if he or she has ever heard of BPD. It is important to find out what the patient knows and whether he or she comes in with potential unwarranted negative impressions of what BPD is. Then, I explain that based on their early attachment history, it might be likely that they are struggling with something that is treatable when we have the right diagnosis.

Next, I talk about how Marsha Linehan, a high-functioning, very successful psychologist, developed an effective, well-researched treatment (Dialectical Behavioral Therapy – DBT) for borderline personality as someone who has struggled with concerns that may be similar to theirs. Here I will describe available treatments for BPD. For example, at the VA, three of my colleagues launched an excellent DBT group for Veterans with BPD. I then explain that the DBT group program focuses on skills related to emotion regulation, distress tolerance, mindfulness, and interpersonal effectiveness.

Then I ask the patient if he or she can see why I might think this treatment could be on point based on themes in the story of their life and what the DBT group targets. (Here, it is helpful to pick out a line or two from their story, such as “when you told me that you get so overwhelmed when you feel abandoned that you burn your arms with cigarettes.”) In every case I’ve seen, the patient will say "yes" because they will see that you are listening well and they will see how a treatment program with these focus areas may be helpful.

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Next I tell them that I am not sure if they would actually have the diagnosis or not and would like to evaluate the criteria together with them to see if they think this fits. Then we go through a checklist of symptoms and talk together about each one. It is important to make this assessment free of fear and to use a respectful tone. So, you don’t say, “Do you have a pattern of putting therapists on a pedestal and then firing them the first time they disappoint you?” Instead, you might say, “do you tend to see people in your life extreme ways – either seeing people as “the sh-t” or “pieces of sh-t, maybe even with other therapists you have seen in the past?”

And in listening to patients, here’s where therapists need to have clinical discernment. Some symptoms of BPD resemble what anyone at times would express during extremely heightened times of stress. So, clinicians need to assess whether there is a clinically significant pattern for each possible symptom. (As an analogy, when diagnosing manic symptoms for bipolar disorder, for a patient to say, “I went on a shopping spree and spent $500 on a cell phone” is not the same thing as saying, “I have purchased cars I could not afford several times in the past.”)

During this process, I provide supportive psycho-education with the patient. If you do this respectfully, then at the end of this discussion there will likely be no resistance at all to the diagnosis and referral. A patient will see what you are seeing and will essentially be confirming for you what ails him or her. For some patients, when I sense that they need more time to process or need to be even more empowered, I will say:

“So we have a sense now that this may describe well what you are struggling with. Why don’t you take this printed information on BPD (provide them with a fact sheet that has a clear and respectful tone). Give it a few days of thought and then take out two highlighter pens of two different colors. Highlight everything that you think fits in one color and in the other color, highlight everyone that is not a good fit for your experience. Then bring it back to me and we will discuss this at our next meeting.”

Using an approach like this initiates a clinical relationship that is based on truth-telling, which is a form of respect. To summarize, then, although I am by no means an expert in DBT, as a generalist with a free-range approach to practice, I have found that the best way to diagnose borderline personality is to be brave, be kind, and be respectful.