Borderline personality disorder (BPD) is amongst the most-stigmatized psychiatric condition (Knaack et al., 2015; Ring and Lawn, 2018). A vexing condition for everyone, many professionals don’t even understand BPD. The very word "borderline" instills pejorative tones to cope with the welling anxiety around dealing with perceived attention-seeking manipulators. Popular culture doesn’t help, either. A diagnosis conjuring a movie character of a raging, jealous woman leaving mutilated animals for someone doesn’t capture most borderlines, but that’s what the uninitiated are otherwise left to understand it as.
Early in my career, a supervisor literally addressed some patients as, “S/he is just a borderline.” I was taught to understand them as incorrigible and hopeless because their life mission was allegedly to gain attention by any means. The best thing I could do for them is to stay away and have thick boundaries. If I provided the time of day, they’d want me all the time and when I wasn’t available, they’d supposedly unravel. It was essentially forbidden to engage those suspected of BPD.
I never entirely swallowed the aforementioned because I knew there were people who specialized in working with BPD. I wanted a peek at this forbidden condition, so tried my hand. It didn’t take long to realize BPD sufferers were indeed human.
Engaging those with traits and characteristics of BPD, I discovered that treating them firmly but fairly and not discounting their experiences, no matter how over-the-top they might have seemed, yielded decent outcomes. Indeed, BPD individuals pushed boundaries, but thoughtfully addressing, say, inquiries into personal matters, or favor requests, defused the situation. If someone reacted poorly, more often than not they were willing to examine it the next session so long as I wasn’t coming across pedantically or judgmentally.
You see, BPD centers on a fear of abandonment due to deep-seated feelings of unworthiness. Ignoring them or minimizing/discounting their experience just serves to perpetuate the matter. Through experimentation, I found that simply showing them I wished to understand, while modeling appropriate behaviors, and trying to teach being responsive instead of reactive, went a long way. Years later, I learned psychiatrist Francis Mondimore, in Borderline Personality Disorder, New Reasons for Hope, touted a similar, client-centered approach for BPD.
Realizing the damage that popular ideas of BPD caused, as I began teaching abnormal psychology, I wanted to prevent students entering the field from falling into the same traps I was led into. In order to reduce stigma and improve treatment outcomes, we must correct BPD misunderstandings. What follows are four common myths about BPD that need to be busted.
1. BPD is synonymous with “difficult woman.”
Borderline personality disorder is generally believed to be a 3:1 female-to-male ratio (DSM-5), although this is thought to be a matter of gender bias by some (Bjorklund, 2006; Sansone and Sansone, 2011). Given that BPD can be a challenging condition to interact with, it seems this gender/behavior equation leads many to jump to the conclusion of “borderline.” Unfortunately, the first diagnosis that comes to mind is often one that sticks, even if based on a mere one or two core symptoms. (This poor diagnostic practice will be covered in an upcoming Up & Running blog post.)
2. BPD is untreatable.
Perhaps spun from the stigma-inducing crowd and based on how vexing the condition can be, nothing is further from the truth. Is treatment difficult and painstaking? Oftentimes, yes. Will the person with BPD have some element of the condition to deal with eternally? Likely. Personality is very ingrained. However, of those that complete a one-year course of orthodox Dialectical Behavioral Therapy (DBT), the gold standard of BPD treatment, approximately 80 percent no longer meet the full criteria for the condition (Shannon, 2016). Internal Family Systems (IFS) is also met with success, as are other, more psychodynamic approaches in the hands of a skilled psychoanalyst. Readers are referred to psychiatrist Stuart Yudofsky’s Fatal Flaws for an example of the latter.
3. Those with BPD are simply manipulative and could control their behaviors if they wanted to.
People with BPD are much more complex than this reductionist and dismissive idea. The condition is a very complex interplay of genetics and faulty core schema that were ingrained at an early age. Just from a physiological standpoint, it is foolish to request someone with BPD simply discontinue their troubling behaviors.
The analogy of a car can help clarify the complications in brain structure alone that contributed to the complications: BPS sufferers have amygdalar hypersensitivity, or proneness to a “lead foot” on the gas pedal. Their brakes, the prefrontal cortex, the seat of rational thought that helps control impulsivity, are not hooked up correctly. Even if they were, BPD patients are deficient in serotonin, or brake fluid, which would still render it difficult to function properly. Treating BPD is the equivalent of doing a brake job of sorts. Thanks to neuroplasticity, psychotherapy can connect the brakes in a way that will help slow them down if they are stepping on the gas too hard, and psychiatry adds brake fluid for a smoother braking experience.
4. BPD can’t be diagnosed, and therefore can’t be treated, before age 18.
It's somehow a widespread belief that personality disorders can’t be diagnosed before age 18. Not so, says page 647 of the DSM-5, bottom paragraph, first sentence. It's of course imperative that clinicians are sure of the diagnosis given the seriousness of BPD. However, if a long-standing, pervasive, baseline pattern of tumultuous interpersonal relationships, self-destructive behavior, and significant emotional reactivity driven by fears of abandonment is established, the diagnosis applies.
Oftentimes clinicians may recognize BPD in a youth but try to “save them” from the stigma by diagnosing unspecified mood disorder or similar. It’s not helpful. It’s been my experience that a tip-off to a BPD teen is a string of “unspecified” diagnoses trailing a kid like the one described in the previous paragraph.
The sooner they are treated for BPD, the better. Addressing just the mood aspect does not get at the heart of the matter and creates a revolving door. If readers need proof of the damage of such practices, read The Buddha and the Borderline by Kiera van Gelder. If blunt evidence that teens can be diagnosed with BPD and successfully treated for it, look no further than the fact that McLean Hospital in Boston, a Harvard Medical School Affiliate, has a program for teens with BPD.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.)
Bjorklund, P. (2006). No man's land: Gender bias and social constructivism in the diagnosis of borderline personality disorder. Issues in Mental Health Nursing, 27 (1), 3-23.
Knaack, S., Szeto, A.C., Fitch, K., Modgill, G., & Patten, S. (2015). Stigma towards borderline personality disorder. Effectiveness and generalizability of an ant-stigma program for healthcare providers sing a pre-post randomized design. Borderline Personality Disorder & Emotional Dysregulation, 2 (article 9). https://doi.org/10.1186/s40479-015-0030-0
Mondimore, F. and Kelly, P. (2011). Borderline personality disorder: New reasons for hope. Johns Hopkins University Press.
Ring, D & Lawn, S. (2019). Stigma perpetuation at the interface of mental health care: A review to compare patient and clinician perspectives of stigma and borderline personality disorder. Journal of Mental Health, DOI: 10.1080/09638237.2019.1581337
Sansone, R. A., & Sansone, L. A. (2011). Gender patterns in borderline personality disorder. Innovations in Clinical Neuroscience, 8 (5), 16–20.
Shannon, Joseph W. (2016, September 29). Reasoning with unreasonable people: Focus on disorders of emotional regulation. Brattleboro Retreat, Brattleboro, Vermont.
Van Gelder, K. (2011). The Buddha and Borderline: my recovery from borderline personality disorder through dialectical behavioral therapy, buddhism & online dating. New Harbinger.
Yudofsky, S. (2005). Fatal flaws: Navigating destructive relationships with people with disorders of personality and character. American Psychiatric Publishing.