Myths About Borderline Personality Disorder

There are a number of myths that have developed about borderline disorder. The following are among the most common and harmful:

1. Borderline Personality Disorder is Not a Valid Psychiatric Diagnosis: “The Name BPD Is the Problem”

During much of its history, many mental health professionals did not believe that borderline disorder should be considered a valid diagnosis because of lack of agreement and great confusion about the distinguishing symptoms of the disorder. This issue was clarified by research3, and borderline personality disorder was included for the first time in the third edition of the Diagnostic and Statistical Manual (DSM-III), published by the American Psychiatric Association in 1980.

Since 1980, the support for a specific diagnostic name for “Borderline Personality Disorder” has increased  because further research findings have demonstrated that it is associated with significant and specific biological disturbances in the brains of those who suffer from the disorder, that genetic factors contribute significantly to the risk of it’s development, and that medications effective for the reduction of core symptoms of the disorder modulate activity at specific receptor sites in some of the neural pathways that demonstrate the disturbances noted above.10

In spite of these facts, there is still this agreement about what the specific name should be for borderline disorder.  Some researchers have emphasized the emotional disturbances of the disorder and suggest the name should reflect these problems. Others believe the name should focus more on impulsivity, thought disturbances or impairments of relationships.Many others believe that the disorder is not one of personality.  Finally, there remain a hard-core of individuals, although they are decreasing, who still  considered  it to be a “wastebasket” diagnosis, possibly because there are other mental disorders that frequently co-occur with borderline disorder. This increases the complexity of symptoms and the difficulty in making an accurate diagnosis of borderline disorder, especially by those clinicians who are not experienced with the disorder.

Ultimately, this myth, and all of its forms, is harmful because it leads to a significant number of people with the disorder being misdiagnosed. In medicine, the greatest stigma is an inaccurate diagnosis. The most common misdiagnoses made instead of borderline disorder include bipolar disorder, depression, anxiety and panic disorders, post traumatic stress disorder (PTSD), and attention deficit hyperactivity disorder (ADHD). Misdiagnosis of borderline disorder is frequently followed by many years of ineffective treatment and growing frustration on the part of the patients, and their families, and to decreased hope for the future. However, there are a number of events occurring in the field that indicate that this general situation is now in the process of changing for the better.7

2. Almost Everyone Who Has Borderline Disorder is a Woman

This myth, if true, is harmful in two ways. First, it increases the stigma associated with the disorder in women, and understandably results in women being less receptive to the diagnosis. Second, it decreases the awareness of the diagnosis in men. This results in missed diagnosis of the disorder, leading to inadequate treatment and continued suffering. As in women, this myth also decreases the acceptance of the diagnosis by men.

Early research studies did suggest that borderline disorder seemed to occur about two to three times more frequently in women than in men, but also indicated that it does occur fairly commonly in men. A more recent study suggests an equal prevalence in men and women.20,21 Additional studies are needed to further clarify this issue for the reasons stated above.

3. Borderline Disorder Cannot be Diagnosed Accurately Before Age Eighteen

It remains difficult to diagnose borderline disorder in children with a significant degree of certainty. However, it is relatively common for the symptoms of the disorder to appear clearly around the age of puberty. The diagnosis of borderline disorder may be made with a reasonable degree of assurance at that time.17,18,22 It is possible that this myth is based, in part, on the understandable reluctance of psychiatrists and other mental health professionals to make this diagnosis in a young person, and thereby stigmatize her or him. I repeat, there is nothing more stigmatizing in medicine than a misdiagnosis, unintentional or intentional.

This myth obviously holds the potential for considerable harm. Many misdiagnosed adolescents with borderline disorder receive years of psychiatric care for other disorders, with minimal or no success. This results in continued suffering and harmful behaviors, a serious delay of development during these critical years, and an increasing sense of hopelessness by the teenager and parents. When these young patients are properly diagnosed and receive appropriate treatment, not surprisingly, they experience significant improvement, and hope for their future is restored.

4. Borderline Disorder Does Not Respond Well to Treatment

This is another harmful myth about borderline disorder, as it greatly discourages patients and families from seeking effective help. It results in unnecessary, continued suffering; disruption of social, educational and work activities; and in discouragement about the future. The origin of this myth probably dates back to the period up to the 1980s, when borderline disorder was first identified as a potentially distinct clinical diagnosis and found to be partially treatable with certain medications. It was the case until that time that most patients with borderline disorder did not respond well to the most typical forms of psychotherapy then in use, traditional psychoanalysis, or most other forms of psychotherapy then used. Unless specific modifications were made in the psychotherapeutic treatment approach,5 patients with borderline disorder rarely did improve, and some actually became worse.

Another factor probably contributed to this myth. It was often observed that even with the use of appropriate psychotherapeutic approaches, an appreciable number of patients with borderline disorder still did not show significant or sustained improvement.5 This seemed especially true for those with moderate to severe forms of the disorder.

There is now reliable research evidence that even patients with severe borderline disorder do improve significantly with appropriate treatment. It appears that the therapeutic approach which is effective for most patients, except possibly those with mild forms of the disorder, is a combination of medications and psychotherapy. Those with relatively mild forms of the disorder may respond well to psychotherapy alone.

5. Medications Have Limited Use in the Treatment of Borderline Disorder

This myth also interferes with many patients with borderline disorder from receiving a form of treatment that would result in prompt, substantial and sustained improvement. The myth appears to be based, in part, on the long standing conviction by some psychotherapists that the main causes of borderline disorder are environmental. Logically, then, the primary treatment of the disorder would be psychotherapy in order to reverse the psychological consequences of early traumas. In addition, it has been proposed that medications interfere with the process of psychotherapy as they may provide an unrealistic hope of a quick “cure” of symptoms, rather than improvement achieved by the sustained and difficult work of psychotherapy.

Based on clinical experience and careful research, it appears that medications by themselves significantly decrease a number of the core symptoms of borderline disorder. This is true especially in moderate to severe cases. It also appears that this reduction in symptoms enables patients with the disorder to engage more effectively in psychotherapy, and to achieve even greater and more rapid improvements from this therapy than with either medications or therapy alone. These clinical findings are bolstered by research data which demonstrate a strong genetic origin of borderline disorder,10 that result in significant biological brain disturbances in people with the disorder when compared to those without it.<23 This suggests that in many instances the disorder results, in large measure, from biological disturbances in the brain, some of the most severe of which benefit from treatment with medications.

6. Dialectical Behavior Therapy (DBT) is the Psychotherapy of Choice in Borderline Disorder

DBT is the most frequently studied form of psychotherapy for patients with the disorder. It has been shown to be beneficial for certain patients.23 These beneficial effects included a decrease in inappropriate anger, a reduction in self-harm and an improvement in general functioning.

The beneficial results of DBT are obvious and important. However, a misunderstanding has developed about the implications of the research data related to DBT. It appears that some patients, families and mental health care providers are so eager to determine an effective and prompt treatment for borderline disorder, that they have made the unfounded assumption that DBT is more effective in general than other forms of psychotherapy in the treatment of borderline disorder. DBT has not been shown to be more effective3 or less costly24 than other forms of psychotherapy for symptoms of borderline disorder, other than those described in the previous paragraph.

This issue is of additional importance as many patients and families search in vain for therapists who are specifically trained in DBT when the treatment may not be indicated, and do not seek help from therapists highly skilled in other forms of therapy who would be of help.

It is important to remember that in medicine, simple cure-alls for complex disorders are extremely rare. This is equally true in borderline disorder, whether one is referring to medications, psychotherapy, or any form of treatment.

7. It is Disruptive to Include Families in the Treatment Process of Patients With Borderline Disorder

Doctor-patient confidentiality is essential in all branches of medicine, especially in the treatment of mental disorders. However, some mental disorders, by their nature, require close family involvement in the treatment process if it is to be optimally effective. This has been shown to be the case in the treatment of schizophrenia. There are now preliminary research data that suggest that family involvement is also very important in the effective treatment of borderline disorder25. Training programs for families are in great demand. Nonetheless, many psychiatrists and other mental health clinicians continue to deny meaningful input from family members, especially parents and spouses, to aid in the treatment process.

The situation is frustrating for family members, who often provide the sole financial support for everyday living and treatment expenses, and much of the moral support, but who receive little or no response from the treating professionals. Families are especially distressed when the treatment plan is not effective, and their loved one isolates them from their therapists, often with dire consequences. Given the importance of the family in establishing functional relationships in the lives of people with borderline disorder, I believe that this is a particularly harmful myth.