Is Borderline Personality Disorder a helpful diagnosis?

Sarah Clark asks whether a diagnosis is always useful

A diagnosis has a powerful role in society. It can determine how we, and others, understand our emotions and behaviours. A diagnosis can govern what treatment options are available. A diagnosis can be useful in explaining someone’s extreme behaviour patterns, and some feel it is life changing to get treatment. But can a diagnosis is based on an individual’s judgement, shaped by social, cultural and moral understandings of what is acceptable and rational in society, also be stigmatising?

Borderline Personality Disorder (BPD) is characterised in the Diagnostic and Statistical Manual of Mental Disorders IV (the manual published by the American Psychiatric Association currently undergoing revision), by:

1. frantic efforts to avoid real or imagined abandonment;
2. a pattern of unstable and intense interpersonal relationships;
3. identity disturbance;
4. impulsivity in at least two areas that are potentially self-damaging;
5. recurrent suicidal behaviour and self-mutilation;
6. emotional instability due to significant reactivity of mood;
7. chronic feelings of emptiness;
8. inappropriate, intense anger and;
9. transient stress-related paranoid thoughts or severe dissociative symptoms.

You need to meet at least five of these criteria to be diagnosed. BPD is thought to affect less than one per cent of the general population. It’s been estimated that three-quarters of those given this diagnosis are women.

Help or hindrance?

For some people a question hangs over whether such a diagnosis is helpful in getting the right treatment or a hindrance to someone’s life. BPD is essentially a “label” for a group of experiences and extreme personality traits. A diagnosis of a personality disorder implies that your personality, which is essentially who you are as a person, is flawed and at fault.

Some feel psychiatric diagnoses are subjective – it’s one person making a judgement on another person’s “extreme” behaviour and experiences based on a partial picture. Any decision is bound to be affected to some extent by cultural and moral judgements and what is considered “normal” in society.

When someone has a personality disorder it is easy to view every belief, thought, feeling or action as “proof” of their diagnosis. This can feel like the diagnosis is used to invalidate an emotion most people would feel in the same situation, which is problematic as people with BPD have usually experienced such invalidation repeatedly, throughout their lives. Critics of BPD diagnosis ask: Is it helpful to use a medical label to explain human distress and experiences of coping? Using a diagnosis to define experiences can add to the distress and powerlessness already felt, meaning a person can feel responsible for their faults.

There is also stigma attached to people with BPD. Some people see people with BPD as purposefully causing their own grief and they often evoke intense emotion in others, including therapists. The media often represents people with a personality disorder as dangerous, evoking fear in the public.

NICE Clinical Guidelines (the guidelines used by the NHS to decide on most effective treatments) advise against long term use of medication unless BPD exists alongside another condition such as depression. Treatment offered for BPD is usually Dialectical Behaviour Therapy (DBT). DBT is a type of cognitive behavioural therapy which incorporates mindfulness. In DBT “dialectical” refers to looking for opposite viewpoints, and finding solutions which lie between extremes. DBT teaches 4 modules of skills: core mindfulness, distress tolerance, interpersonal effectiveness and emotional regulation.

However, it is easy for services to equate self harm with a BPD diagnosis, then in turn offer DBT alone- services can sometimes respond to the needs of the diagnosis rather than the individual.

It’s worth remembering that, for some, being diagnosed with BPD is life changing. It means they can put a name to and understand their distress, experiences and behaviour. It can lead to specialist help and the right treatment and finding out what’s helped others. A diagnosis can turn someone’s life around and help them find a better, healthier way to cope with their distress.

This article appears in the Spring 2012 issue of One in Four

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