Diagnoses like Borderline Personality Disorder carry so much stigma that doctors often incorrectly label patients "untreatable" - despite research that says otherwise.
CW: medical abuse, trauma, suicidality, eating disorders
Sexual harassment, gaslighting, invalidating, discriminating, and straight up denying necessary (and sometimes emergency) care are all commonplace for people who have Borderline Personality Disorder and Bipolar Disorder labels on their medical files.
Recently on Instagram, I started a discussion about mental health stigma, particularly around these two diagnoses, and people shared some truly heinous stories with me.
A major theme I saw in responses was something called “diagnostic overshadowing”, which is when someone presents symptoms of illness, and a doctor attributes them to a previous diagnosis that is already on their chart.
One person who responded said that they were denied treatment for several pulmonary embolisms (which are life-threatening emergencies) by more than one doctor because they had a Borderline diagnosis and the doctors assumed they were being dramatic and exaggerating their pain.
Considering that we know neurodivergent traits are often misinterpreted as mood or personality disorders, especially for people assigned female at birth, trans people, and people of color, this gets even more disturbing.
From Hysterical To Borderline
I have joked in the past that Borderline is the new hysteria, but I recently learned that, in fact, the diagnostic criteria is extremely similar!
Here’s the description of Hysterical Personality Disorder from the DSM 2:
“These behavior patterns are characterized by excitability, emotional instability, over-reactivity, and self-dramatization. This self-dramatization is always attention-seeking and often seductive, whether or not the patient is aware of its purpose. These personalities are also immature, self-centered, often vain, and usually dependent on others.”
They’re not even really hiding the misogyny there.
This specific diagnosis morphed into “Histrionic Personality Disorder” in the DSM 3, the description of which just expands on these basic concepts and honestly, sounds like a shittier way to describe Borderline. (There’s also a note at the end of the description that says Borderline and Histrionic PD are commonly co-morbid.)
Borderline first entered the DSM in its third version, and the description focused on emotional instability, fear of abandonment, impulsivity, unstable self-image, and self-harm.
I don’t see a whole lot of difference in concept between this version and the current one in the DSM 5, so let’s look at that:
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behaviour covered in Criterion 5.
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behaviour covered in Criterion 5.
5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger (e.g. frequent displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.
Let’s just stop for a minute and consider who else might have feelings of emptiness, intense uncontrollable emotional reactions, dissociative symptoms, stress verging on paranoia (hypervigilance!), unstable relationships, and self-destructive behaviors?
Sounds like a severely traumatized person to me.
Hurt People Hurt People
People who are diagnosed Borderline are seen as aggressive and manipulative, with zero compassion for why they might act that way.
I feel like we could apply this to other personality disorders, too. People diagnosed with Narcissistic Personality Disorder aren’t just born manipulative or "evil" - something happened to them in childhood that made them develop this negative coping mechanism to get through life. (Often, they have abusive parents.)
But the medical system likes to treat “personality disorder” as synonymous with “moral defect”.
This lets doctors off the hook, because doctors treat illness, not morality, so they label a person "untreatable" and wash their hands of it.
Yes, maladaptive coping strategies like manipulation are abusive, and they do hurt people. I’m not writing a pass for abusive people. I am aware that just putting an abusive person in therapy does not solve everything, and many abusive people use therapy language to further their manipulation.
Someone has to be willing to self-examine, admit their wrongs, process intense shame and trauma, and change their behavior to heal. Some people are not willing to do this, and that is a choice. But writing someone off as disordered and untreatable does not sit well with me.
I don’t personally believe anyone is incapable of change, and we know personality is not permanent. Every single cell in our bodies gets recycled every 7-10 years!
As much as I love astrology, I know I am not biologically “a Gemini” - it’s a story I tell myself and others, a tool I use to describe certain parts of me, but I know that it’s not an intrinsic and unchanging aspect of who I am.
What The Research Says
We are always changing, but the stories we tell ourselves can imprint things in a way that make them feel unchangeable. But research has shown that personality disorders are not necessarily permanent.
“Carefully controlled trials show that patients with BPD are just as treatable as patients with Major Depressive Disorder, the most common diagnosis in the United States”
Studies on Borderline patients found that “at a two-year follow-up, 35% of patients had achieved remission (defined as not meeting criteria for a two-year period), and at a ten-year follow up, 93% no longer met criteria for the disorder.”
Evidence-based treatments for Borderline include Dialectical Behavior Therapy (DBT, which was created by a woman who had Borderline), Mentalization Based Therapy, Narrative Therapy, and Transference-Focused Psychotherapy.
So, we know it’s treatable. We know people can heal (many within TWO YEARS). Yet doctors still act like Borderline is a life-long, "treatment-resistant" disorder, a lost cause that they can’t be bothered with.
This gets even more sinister when we consider that over 70% of people with Borderline diagnoses attempt suicide, and 3-10% succeed.
Interestingly, this study found that the Bipolar diagnosis carries more stigma at work and in someone’s personal life, but the Borderline diagnosis carries far more stigma in healthcare settings.
Healthcare providers’ negative biases against Borderline patients “included being attention-seeking, manipulative, trouble-making, dishonest, childlike, irresponsible, malingerers, untreatable, and pathologically violent/ angry/confrontational.”
I highlighted the words that align with those in the DSM 2 description of Hysterical Personality Disorder. The labels may have changed, but the assumptions certainly have not.
These ideas have extremely dangerous effects on care, as they result in Borderline patients being routinely excluded from services.
A study in 2003 found that many were denied treatment for eating disorders, despite meeting all criteria and having identical symptoms to patients with anorexia who did not have a Borderline diagnosis.
Doctors also “conceptualize cutting and suicidal behaviors among [Borderline] patients as manipulative, whereas patients classify them as a temporary coping method for intense emotional pain.”
How can a group where 70% of people attempt suicide also be faking their suicidality for attention? It’s as if doctors would rather lighten their caseload than actually treat the human beings they vowed to care for.
As one psychiatrist summarized: “In professional circles, borderline is often synonymous with ‘pain in the ass.’ ”
Doctors are essentially blaming victims of trauma for their distress, telling them there’s nothing they can do, and leaving them to suffer or die.
This is gross negligence, and we wouldn’t accept it for car crash victims or someone who had been physically assaulted, so why do we accept it for survivors of emotional injury and abuse?
Trauma Isn't Rare, It's Systemic
I have come across the argument that “not all people with Borderline have trauma”, which makes me wonder what definition of trauma we are working with.
Well into my 20’s, I thought I had a "good" childhood. My parents were together, we had a stable home and we were financially secure. It wasn’t until someone told me that emotional neglect and consistent invalidation of your feelings from a young age is also traumatic that I realized why I have so many trauma responses.
I would bet money that the majority of millennials have emotional trauma, because the Boomer generation, for the most part, is emotionally inept. Their version of managing feelings is “suck it up” and “be a man” and “stop being so sensitive”.
This isn’t their fault, because this is what their parents taught them, but it is indicative of the fact that Western culture as a whole is feelings-averse, and has been for a very long time.
People with intense feelings are mocked at best, and demonized, pathologized, and institutionalized at worst.
Patriarchy has been built on the rejection of emotion, which has resulted in a society where trauma is systemic.
Parents neglect their children’s emotions, so their children develop maladaptive coping strategies like manipulation and self-destruction, get labelled with a personality disorder, and pass that trauma onto their children, too.
This presents a social explanation to the statistics that suggest Borderline is genetic and runs in families, because of course it does. Hurt people hurt people.
It’s really scary to realize how deep the psychiatric rabbit hole goes, but I have so much hope in the fact that most of the young people I know are either in therapy or learning healthy coping strategies and that open discussions about mental health, and especially trauma, are becoming more normalized and encouraged all the time.
We can all heal from this, but we have to acknowledge how common trauma really is, and we need to view “disorder” through the lens of trauma before we turn to pathology.
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