Is BPD a real disorder or should it be eliminated as a diagnosis?

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The myriad ways experts “see” borderline personality disorder. (click to enlarge)

There’s a great deal of confusion and disagreement in the professional literature about the nature of Borderline Personality Disorder. The blogger BPDTransformation (whose blog is excellent if sometimes a little on the scholarly side), who was cured of BPD, thinks the label should simply be done away with and that BPD doesn’t really exist at all–the label being merely a placeholder for a group of symptoms that are widely variable, and that experts can’t even agree on. He believes BPD is categorized as a Cluster B (dramatic/emotional) disorder only because mental health experts can’t decide where else to put it.

The stigma of BPD as a Cluster B disorder.

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The problem with labeling BPD in the Cluster B category of personality disorders is the stigma that classification carries–that people with BPD (like those with NPD or ASPD) are evil, untrustworthy, selfishly manipulative, grandiose, dishonest, lack empathy, and really no better than people with malignant narcissism or even ASPD. (It sure doesn’t help any that an obviously sociopathic criminal like Jodi Arias has a diagnosis of BPD, when she more likely fits the criteria for high spectrum [malignant] narcissism, at the very least.) Insurance companies assume anyone with a Cluster B disorder is incurable, and therefore will not pay claims where a person is diagnosed with a Cluster B disorder. This is very damaging to those of us with BPD who have either successfully learned to modify and control our symptoms–or have even been cured, as BPDTransformation has been. People continue to believe we are lying about the success of the treatments or therapy we have received. Borderlines who have never been treated may find it difficult to find a therapist willing to work with them.

BPD is far more amenable to deep insight therapy than NPD (which is extremely difficult to cure but not impossible for non-malignants) and light years away from a disorder like ASPD (antisocial personality disorder), which can probably not be cured. Because the symptoms of BPD are so disagreeable to the sufferer (and not just to others), it is common for borderlines to present themselves for therapy, unlike people with NPD or ASPD. The vast majority or borderlines are unhappy with themselves and the way their lives have turned out. But many therapists won’t work with borderlines (other than with behavior modification treatments like DBT) because they know insurance companies will not pay such a claim.

What are borderlines on the border of, anyway?

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The name “borderline” itself is confusing. What are borderlines on the border of anyway? Neurosis and psychosis? A normal sense of self and Narcissism? Mexico and the United States?

The experts are all over the map on this, with some recent theories stating that BPD is actually a less adaptive, more ego-dystonic form of narcissism. But the original term “borderline” actually referred to the belief that the disorder was on the “border” between psychosis and neurosis:

[…]It is called borderline because it was originally thought that people were on the ‘border’ of psychosis and neurosis. BPD is also sometimes called Emotionally Unstable Personality Disorder (Borderline type). Approximately 75% of people given this diagnosis are women and 50% have experienced physical and/or sexual abuse.

Because BPD is more commonly diagnosed in women than in men, it’s also been referred to as the female form of narcissistic personality disorder (which is more commonly diagnosed in men than in women).

Psychotic, neurotic, both, or none of the above?

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Credit: Judgybitch/Dzhokhar Tsarnaev

The reason why BPD is sometimes regarded as the midpoint between neuroses (mild and easily treated anxiety or depressive disorders) and psychoses (disorders where the victim is out of touch with reality, such as schizophrenia and the manic-depressive form of bipolar disorder) is because people with BPD can, when emotionally upset, display psychotic or delusional symptoms such as splitting (black and white thinking), dissociation (feelings of unreality either about the self or the environment), magical thinking, severe paranoia, delusions of grandeur or persecution, and sometimes even hallucinations and disorganized speech or thought. However, for a borderline, these psychotic symptoms don’t last and as soon as the emotional crisis has passed, the borderline’s “sanity” normally returns. Antipsychotic medication can be helpful, but isn’t always necessary, as it usually is for a truly psychotic individual.

Others have speculated that BPD is really a severe form of PTSD or C-PTSD caused by trauma, and should be treated the same way as PTSD. Personally, I think it’s more long-standing than a reactive disorder like PTSD and is a true personality disorder, but it does make sense that BPD may have originally begun as a form of PTSD at an early age, often due to sexual abuse.

There is so much confusion and contradiction in the literature about BPD that I’m slowly coming around to BPDTransformation’s way of thinking that it should possibly be removed from the Diagnostic and Statistical Manual of Mental Disorders (DSM) until mental health professionals can get a better handle on what BPD actually is, and whether it’s even a valid diagnosis (or simply a group of symptoms that could indicate several other disorders). There should at least be more agreement among the professionals at any rate.

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8 thoughts on “Is BPD a real disorder or should it be eliminated as a diagnosis?

  1. Thanks for linking to me… sometimes it’s helpful to think about this issue in the most simple, common sense way… does it really make sense that something as complicated and individual as the emotional maturational process of a human being can be effectively encapsulated by an illness label like BPD? I don’t think so.
    All of the disciplines you put in the elephant picture have a grain of truth so they can all be useful. I suggest that the psychopharmacologists are saying that serotonin and dopamine level differences are associated/correlated with people they think are borderline… they have never proven that changes in these chemicals cause borderline functioning; to me, that would be a reversal of cause (environmental stress) and effect (brain chemical composition). In a sense, borderline states represent the natural neurobiological reaction to trauma and stress.
    In the psychodynamic way of thinking I like, a person’s personality can have psychotic and neurotic parts/levels at the same time. Someone with a mix of psychotic and neurotic parts, where the all-bad split-off self/other images exerted significant power over the person’s daily life (these all-bad elements, which by definition involve splitting, would be considered psychotic = out of touch with the real good-and-bad world)… this type of person would be considered developmentally somewhere in the borderline spectrum; i.e. they would have psychotic parts but the neurotic sections are strong enough for them to function ok in some ways, despite all the conflicts, unlike someone who is totally psychotic. But that is different from saying someone “has BPD”. Because BPD is not one thing; it doesn’t work to reduce human emotional experience to something so concrete and simplistic. That is why I think the medical model approach to BPD is doomed to roam a circular labyrinth; human experience does not work in the reductionistic way that the DSM conceptualizes BPD.
    Unfortunately, my cynical side says that many people are not interested in understanding BPD in depth; many people naively believe that BPD is valid without ever examining the concept. That might explain why your in depth articles tend to get less comments; some people want simple explanations, even if those explanations mislead and harm them. So many people think about BPD as the cause of their problems without realizing that the BPD illness concept is fundamentally incorrect and misleading. You can see this all over Reddit, Psychforums, and Psychcentral, where (mostly young) people are agonizing over how BPD is affecting their lives.
    To answer the question that started this article, I’d suggest the borderline spectrum of functioning is real, but BPD is best not conceptualized as one disorder that is consistent from person to person.

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    • These are all good points. I agree most people want a simplistic explanation and don’t care to try to understand BPD as a whole array of coping mechanisms that differ vastly from one individual to the next. I don’t think the label is going anywhere any time soon–I would even bet that NPD will be removed from the DSM before BPD is, which is stupid IMHO. So lacking a conscience isn’t a mental illness deserving of inclusion in the DSM ? It’s my understanding it almost was removed already. But it’s more “adaptive” in our sick society, so there you go.

      I’ve been reading Psychforums (the NPD forum) — I will have to check their BPD forum and also maybe sign up for Reddit. I don’t have an account with them.

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    • Thank you, both, bpdtransformation and luckyotter for this particular blog. As someone who has been referred to casually as ‘probably BPD’ by medics but never able to access any kind of definition/diagnosis other than ‘depression’ (going on 40 years now), the last thing needed is a simplistic answer that has consistently failed to make sense or any real improvement in things. I think you’re right, bpdtransformation, that while finding a level at which to function is possible it comes at one heck of a price without any kind of effective medical/professional support. Or even when some support is offered, we, as patients, often end up suspecting that those treating us are either ideologically chained to their beloved treatment/theory, regardless of results, or they too suspect that something is not quite right with the methodology and implementation of their treatments/theories but are unclear how to address those doubts. Either way, people are left floundering at best and drowning at worst. Knowledge is a great thing. At least we know we’re not totally a lost cause because of places and people like you where someone is at least willing to discuss and debate things that elsewhere would be branded near-heretical.

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  2. I agree with the C-PTSD line. Unless you were born borderline, there’s really no point in not treating the trauma. Treat the trauma, and you go some way to helping the problems. I firmly believe that the only people who should be diagnosed as BPD are those that present with it at an early age with no trauma history- it’s too confusing otherwise, and the label is damaging. I also think it’s a great way for psychiatrists to throw people- mostly women – in the crazy bin cause they don’t understand trauma. I really think it should be removed as a diagnosis. It’s pretty archaic, to keep telling many women and men they will never heal and they’ll always be a damaged fuckup. I would say that great care should be given whenever someone says that someone who has suffered trauma can never heal- trauma is a brain injury. With help, yes it can heal, and with kindness and understanding, of course it will. Thank you for writing this article. X

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    • Thank you for acknowledging how damaging this label of BPD is for those of us who suffered abuse. The symptoms of BPD closely resemble C-PTSD but become more long-standing. I get so annoyed at how many people on the web automatically dismiss all cluster B’s as incurable, hopeless and evil. Not only that, but then they attack those (like me) who even dare to suggest a narcissist might be able to be healed in some cases–and BPD’s probably in most cases.

      I think the fact I have moved on to a place where I don’t automatically “hate all narcs” (when we are disconnecting it’s healthy to be angry and bitter because it gives us the courage to go NC– but a lifetime of hatred and anger only hurts the bearer) and even feel a little empathy for them (it depends on the narc’s self awareness and willingness to change) kinda proves I have empathy and therefore proves I’m not a narc. But some of my critics beg to differ, and one person even called me a “sociopath” and evil just for believing there MAY be hope for SOME narcissists. That’s crazy! I think it’s ridiculous and a very toxic (and narcissistic) attitude to have.

      I have been on some NPD and BPD forums and some self-aware sufferers of both disorders (who want to change) are very upset at the way the mental health community, the ACON blogging community, and society in general just automatically demonize all Cluster B’s and tell them they have no hope and even that they are evil and destined for hell. That is such a damaging and yes, evil attitude imho.

      Yes, there are some high spectrum narcs and sociopaths who will not change because they don’t want to, or because they have no insight into their disorder. But there are quite a few non-malignant narcissists out there who want to change and HATE their disorder (I’m including BPD’s in this too, because they are almost as badly demonized as NPDs).

      I have received personal emails from several narcissists who are DESPERATE to change and one who is so severely depressed over his broken relationships and broken life (he has a npd dx) that I’m afraid he may attempt to kill himself. I don’t know how to respond to these people but I do try to write back to them and at least point them in the right direction to get the help they need and offer them a little hope. That’s all I can do. My first priority is of course helping victims (and myself), NOT the narcs–but when one writes to me privately begging for help and tells me he cries himself to sleep every night because he feels so wasted and empty inside, what can I do? To tell them to F off (as a few ACONs would have me do) would make an unempathic narc out of me. I have a heart– no matter what you may think of them, these are still human beings who were most likely abuse victims themselves. I feel like I must stress here that this DOES NOT mean I condone abusive or narcissistic behavior or encourage anyone to stay with a narcissist or an abuser.

      Of course anger and rage is a natural reaction to abuse and gives victims the motivation to leave their narcissist (or abusive BPD, whatever), but holding onto that rage long past when it’s useful anymore keeps us from moving forward into a place of true healing. It was no longer doing anything for me, so I had to let it go. I am not a “narc hugger.” I just don’t want to dismiss anyone–no matter what their dx–who shows a genuine desire to change as “having no hope.”

      Off my soapbox. Some may take issue with this, and I’m sorry if you do, but it’s my opinion and I’m sticking to it.

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      • You stick to your guns- it’s your opinion and it actually makes a lot of sense to me. I just think anyone with BPD has had their reactions to life damaged, not their personality. X

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        • Thanks, SI, I appreciate it. You’re right too. I’m so tired of being lumped in with N’s as “hopeless” because it’s in the cluster B category, which I don’t even think it should be. I think BPD is a long standing form of PTSD or I’m slowly coming to that conclusion

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