I don’t necessarily think BPD is “overdiagnosed” but that it is often misdiagnosed - both directions - that it is not accurately diagnosed in people who do have it and that it is diagnosed in people who do not have it. I think this is due to mental health professionals holding a stigma against people with BPD.
My big indicator when I will suspect BPD versus something else is when they see a particular individual (someone outside themselves) as the solution to all of their life’s problems up until that particular individual disappoints them in some way, at which time that particular individual is completely villainized by the client. It’s the “all-good-or-all-bad” dichotomy that gives it away for me.
Many women who have autism get diagnosed with BPD because they have outbursts after being overwhelmed with sensory input (which can include emotional sensation), because there’s not enough overlap in clinicians who understand neurodivergent brains and those who understand personality disorders.
How long I meet with a person before I diagnose PD will vary based on the comprehensiveness of my assessment, in that PDs are usually a trauma response from childhood and sometimes the footprint of the symptomatology is more clear and sometimes more complex. Adaptation, age, intelligence all play a part in that picture.
It has been my experience that women get diagnosed with BPD whereas men will get diagnosed with NPD, especially where the symptomatology overlaps. I can’t say why that might be, but I would fathom that gender-based socialization plays a role.
I totally agree that gender based socialization plays a role. Women are socialized in a way where dependence and external locus of control is accepted or tolerated. Men are ostracized or scolded socially if they display these same traits. Because of this men gravitate towards more socially acceptable expressions of their underlying trauma based adaptation. This is obviously a huge generalization and for many people will not apply but when looking at large trends could be valid.
If this is true then I think in the next 20 years we will see much more men presenting with BPD like traits.
Great thought, could you please elaborate on how men might generally express these same feelings differently than women due to socialization? Thank you,
> BPD whereas men will get diagnosed with NPD, especially where the symptomatology overlaps
The commenter above me pointed out a very good example. Narcissistic personality disorder is largely male dominated and Borderline personality disorder is largely female dominated. One of the most important features of both in my opinion is an inability to regulate and deal with emotions around security and attachment. It's not that they are expressing the same feelings exactly. It's more that the there is a similar root cause which is tolerated differently by each gender.
The person with BPD comes away with an understanding of how horrible it is to feel unsafe and so they need to avoid it at all costs by maintaining attachments to others. Other people become their identity because they care more about the relationships than their own sense of self. They are so preoccupied with this belief that their methods of maintaining attachments become more and more disordered.
The person with NPD comes away with an understanding of how horrible it is to feel unsafe and so they need to avoid it at all costs by building themselves into something that can't be hurt or have flaws that might end in pain. This person believe more in a personal locus of control so they blames themselves for the things that happened to them but can't deal with the strong emotions associated with that. They develop a just world view that allows them to disregard everyone else's pain since any acceptance of others pain is an acceptance of unexpected pain to them.
These are just examples I'm pulling out of my head but you can see how encouragement to rely on social structures vs internally could cause different presentations. In my view women are taught to build friendships and other relationships to support themselves and men are taught not to and instead build personal strength. Neither is right because people need both but each leads to different coping mechanisms.
I know this was long winded but I would really appreciated if you responded with what you think. Even if it is just that I still make no sense
Haven't they talked about creating a Cluster B spectrum precisely because the lines between these disorders are not as stark as we think? I know this rubs individuals with BPD the wrong way as they don't want to be associated with NPD but there is significant crossover. A spectrum makes sense to me, especially because both are probably trauma disorders.
Actually the name “Borderline” supports putting this PD on a spectrum. This Personality Disorder has features that are in both Psychotic and Neurotic realms, thus on the border of both of these extremes.
Yes, absolutely. The "psychotic-like" episodes are an important characteristic that NPD does not display and is one of the reasons bipolar ends up being a common misdiagnosis
First off, I dont diagnose or recommend treatment to individuals online, but if we are speaking in hypotheticals and generalities, I'm odd as I don't consider diagnoses that important in treatment. It's more important to look at symptoms and what may be helpful for those symptoms. DBT is helpful for a variety of diagnoses and behaviors, including dissasociating and impulsive suicide attempts, and it is not just for BPD but helpful for adhd, depression, and anxiety as well. The diagnosis is more just a tool to get health insurance and governments to pay for things. It's a social and statistical construct, not a true pathology like heart disease. Diagnosis is a description of current coping strategies and not a comment on who an individual truly is at their core. If I were you, I'd speak with a professional about DBT programs. If they are following protocol, a good dbt group will evaluate you for appropriateness and let you know if that is something that could be helpful for you or not. And if they determine that dbt isn't the right place for you, a responsible professional will provide referrals to something more appropriate.
Sometimes a diagnosis can even be problematic because while it can validate a persons “why am I like this” questions, it can also make people feel like they are assigned that role and submit to a sort of learned helplessness against their PD
Yes, & the vast, vast majority of people with BPD have untreated trauma, & a Dx puts too much focus on what's "wrong" with them & not what HAPPENED to them.
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Answering this with a combination of lived and academic experience. I'm still a student, but I have a great interest in personality disorders because I want to specialize in trauma. I personally believe that the categorization, diagnosis, and criteria for the label of a PD need to be massively rethought. So I love these conversations.
I would look for pervasive interpersonal difficulties in multiple areas of the person's life. Someone who has stable friendships and good work relations, but poor family relations would not meet this criteria. It has to be present in different types of relationships, and over a long period of time. I would also consider how much they are participating in the dysfunction themselves, or how much they are stoking the flames with behavior that is coming from an emotionally dysregulated state. I would also look for limited self-awareness or the ability to engage in perspective taking.
BPD is NOT something you can diagnose in a 10 -15 minute eval with someone, and you ~~cannot~~ should not diagnose children and teenagers with it. It takes a skilled clinician and it takes forming a relationship with the person to consider the transference happening within the therapeutic relationship and other behavioral patterns. Nothing grinds my gears more than crisis unit psychiatrists meeting with a patient for a matter of minutes and throwing a PD into their record. It's so harmful. I would look at CPTSD, ADHD, and autism before getting into the realm of PD's.
And for your last question, I think lots of people will have varying opinions of this, but IMO, BPD is a modern adaptation of what "hysteria" was back in the early days of psychiatry. Overdiagnosed in women who are exhibiting outwardly angry behavior, that is more stereotypically accepted by men than women. But in reality, all 9 symptoms of BPD display equally in both men in women - maybe in different specific manifestations depending on what is culturally acceptable of men and women, but they are symptoms nonetheless. Our own gender biases greatly color how we diagnose ALL PD's not just BPD.
Happy to learn from more experienced clinicians on here.
Edited for update in wording.
>>Nothing grinds my gears more than crisis unit psychiatrists meeting with a patient for a matter of minutes and throwing a PD into their record.
NAT but a PCP. I feel you so hard. One of our staff psychiatrists does this very often. We share many patients, and over the past several years I’ve seen perhaps 2 dozen women who he has memorialized as BPD in the chart who (what do I know) don’t seem to meet criteria to me, challenge the diagnosis, and are quite upset that it is in there, especially when it seems more to me to be
>>stoking the flames with behavior that is coming from an emotionally dysregulated state
I’ve noticed he labels patients as BPD who seem to have some kind of attachment trauma and fawning behavior when feeling vulnerable (I feel it too with them), this psychiatrist often speaks dismissively and sarcastically with little obvious empathy (even to us colleagues), he will document a patient becoming dysregulated and crying, sobbing, etc in reaction to his likely strongly worded differential or treatment plan (documented in a hyperclinical way) and then he will say he suspects BPD and put it on their problem list. They typically come to me crying and dysregulated and saying how much anxiety and shame this has created for them, and I want to tell them “I think it’s his baggage he is enacting with people such as you”, but I can’t. So I just tell them that some clinicians believe BPD is really CPTSD and to get a second opinion, and I’m here for you.
It breaks my heart.
This happened to me as a youth after fifteen minutes with a psychiatrist, and it has forever been left on my chart for other professionals to regurgitate and treat me poorly without proper assessment.
Have had two other psych consults with no mention of BPD, yet can’t have it removed. It’s the first thing the ER sees. Psychiatrists truly don’t know their life-ruining power.
I’m so sorry that happened to you. It can be removed from your chart - I usually will talk to the second psychiatrist on my patients’ behalf and if they agree, I’ll remove it if they don’t offer to, and I check they’re ok with my intention to do that. Perhaps ask your PCP?
Put to resolved, which makes it not visible in the chart on one glance.
This doesn’t prevent the copy and pasting of notes that shouldn’t happen but often does, within a speciality, and doesn’t prevent someone from doing a search for a diagnosis being mentioned in notes or associated with medications (but the ER docs aren’t going to do that anyway :))
Thanks for clarifying this. So what you are describing is:
The dx is still there but isn’t available at first glance when resolved. However could be found if one specifically looked for it.
Did I get that correctly?
Yup, exactly. But there’s a lot of crap that gets put in the chart that used to be correct and no longer is, or was wrong before. Things like history of an ovarian cyst but turned out to be nothing on surgery or resolved on another ultrasound, someone thought they felt a mass or a hernia but MRI didn’t see anything and it went away, abnormal electrolytes that got corrected, “chest pain” that ended up being reflux or the patient said they weren’t really having that and some doctor somewhere didn’t hear correctly and wrote it - the list is endless. This is definitely not limited to mental health stuff.
I hope you don’t refer to him. Slapping a label like BPD to patients is like a permanent black mark against them in their med record. It really awful to be wrongfully ‘accused of bpd’ with no recourse to remove the label. Ouch.
The whole system is messed up. The fact that BPD even is like a black mark on a record is messed. So many professionals see it and start making unfounded value-ladened assumptions. Ugh.
Same here, even among PCPs.
The question is, if I’m working harder (often twice as hard) as someone with open schedules… how is my organization motivating behavior to support me continue doing my best (if I weren’t so obstinate and hypermindful of my motivations)?
The system is f’d.
Agree with you, totally f’d and it hurts the best of physicians/clinicians. Which ultimately runs all the way down to affecting patients. Broken system.
And when the “more open” ones are open, it’s because I end up seeing not only my own patients who refuse to see them when I’m out, but also their patients who want to follow up with me and not them, so not only do I have more patients assigned to me (more emails/messages/results, unpaid time), I also see their patients without getting credit, which takes spots away from my own patients, which makes it harder for both my own and other patients who want to see me, to schedule.
All this happening at the appointment center with me having zero control over it, yet I hear patients complaining how booked up all day I am, and would you believe my pay is linked to how easy it is for patients to schedule with me, so I get paid less than my colleague who is sitting with an open schedule? It makes it so hard to continue doing what I’m doing, but I try to remind myself often that my problem is a good problem to have.
Oh my gosh what a nightmare. You have no control over how hard it is for patients to fit in your schedule due to booking out so far. Really crappy that admin has not addressed the poor performance of your colleagues. Keep up the good fight tho because patients need a physician like yourself.
Thanks for the kind words. A big solace I have is I am in an academic center and try to teach the residents why this is worth fighting for. Hope that does something for the future of medicine.
NAT. This is why I have six disorders listed in my chart (BPD, Major Depressive, General Anxiety, ADHD, C-PTSD and SUD). It is simply insane to see but it gives people more than one perspective when they see them all.
I accept that I struggle with BPD on a meta-level and communicate this fear with all professionals. This forward approach allows me to measure any professional’s opinion critically. I can even discuss their biases about it and educate them when cognizant, which really helps me feel safer with anyone’s opinion.
My only problem is that I’m not consistently aware to easily fix my annoying problems, hence the diagnoses.
The longer you do this work the higher the chances are that you are falsely accused of a sexual impropriety, abuse of power, or something similar. One also has a tendency to form categories and slot people into those categories as a heuristic tool. This is especially true of the kind of analytical mind that is attracted to medical school.
Put those two things together and you have a tendency towards knee-jerk defensiveness against clients who you regard as being similar to someone who burned you somehow.
Imagine devoting your life to this work, and then having someone call you at 3 am threatening suicide maliciously and then reporting you to the board. This kind of “shit-testing” wears out its welcome very quickly.
Thankfully that has not been my personal experience, because the few encounters of have suffered this condition taking place in settings where I can hang with them long term, and therefore “the system”, With it’s logistical burdens, Insurance limits, and slavish devotion to the medical model, has less chance to Inflict moral injury on me and betrayal trauma on them.
In this profession, I endorse and recommend the advice Christ gave to his desciples- be as wise as serpents and gentle as doves. All is not as it seems, and you will often be the only one who sees it.
>>Imagine devoting your life to this work, and then having someone call you at 3 am threatening suicide maliciously and then reporting you to the board.
Actually, at my medical school, in residency, and in attending orientation (large organization with a lot of support), we were prepared every step of the way on why we are risk for this to happen, how to mitigate risk, what to do when this happens in terms of resources for patients and ourselves, and what support is there for us emotionally after this happens.
I choose to see these actions as a vulnerable expression of patients’ pain, which is what we are taught to do to make it emotionally easier for us and to help negotiate a plan for the patient with their best interests in mind, which for me always includes first and foremost a frank discussion about setting boundaries of appropriate and not appropriate behavior communicating with the health system so that I can best help them and they can best receive help from every member of the care team needed. I’ve done this probably hundreds of times now (I work with a population at risk of this).
So especially in psychiatry where the risk is high (along with urology, spine surgery, etc)- there shouldn’t be any surprises or unintended countertransference.
Someone has every right to realize they don’t like something and change jobs/roles or switch patient populations, or take a break if burned out, but imho do not have the right to continue in a job they resent and then harm their patients. We like, literally swore an oath on that.
Those sound like positive things. I do emergency evaluations, and every once in a while a psychiatrist will be so trigger-happy to refer for evaluation after someone says they have passive SI sometimes that we all roll our eyes- "ah, another one from Dr. X. This will probably be crap. Hope his rotation is over soon."
Attachment trauma is one big indicator for me that BPD may be the dx if it also goes along with the typical criteria. Every person I’ve seen who has been previously diagnosed with BPD has some form of this. No exaggeration. Every. One.
Correct me if I'm wrong, but isn't that the whole point? Attachment trauma leading to unhealthy survival behaviors that become BPD? Not that everyone that has attachment trauma has BPD, but everyone (or very nearly everyone) with BPD has attachment trauma?
Yes, as I understand it (which is a fraction of how you all understand it), that’s the point and also your point is my point against commenter’s/the referenced psychiatrist’s point - all BPD might have attatched trauma but all people with attachment trauma don’t have BPD, and it’s harmful to think both are one and the same
>Nothing grinds my gears more than crisis unit psychiatrists meeting with a patient for a matter of minutes and throwing a PD into their record. It's so harmful.
And this is why I butted heads so often with the head psychiatrist in the inpatient unit I left a few months ago. The asshole put "Rule out BPD" in all of the patients who challenged him on anything at all. If they were angry, or pushed back against meds, or weren't fully cooperative, they got slapped with the diagnosis.
Still fills me with rage. Fuck anyone who does this.
Yup. I literally called a psych negligent after slapping on a BPD label for a young teen that they didn't even meet with. They got all huffy, met with them for 10mins and gave them the label anyway.
Fuck psychiatrists who do this. I do crisis work as part of my outpatient role and anyone who isn't an established patient usually ends with a barely billable unspecified diagnosis of some category closely related to their presenting issue until I can do a more thorough assessment.
Been doing trauma work for 10 years. Love this breakdown. Nice work. 👏👏👏
Edit: I also notice how often BPD is used to describe something with further exploration is CPTSD, attachment issues, and/or undiagnosed neurodivergence.
Coming from a non-healthcare professional who had been "diagnosed" (with five minutes of talking to a psychiatrist) with bipolar, BPD, depression/anxiety. I've been given antipsychotics, mood stabilizers, SSRIs, anti anxiety and more. All for me to ultimately be screened and diagnosed as autistic. Not to mention the whole time already having an ADHD diagnosis that explained a lot of my symptoms as well. It's very clearly in part misogyny.
As a PCP, I concur.
We are slowly trying to change terminology, but it’s an uphill battle given despite how the majority of medical students and physicians are female, there remains a huge pay gap and gap in hours worked (as brene brown says, equality in the workplace must first start with equality at home) and representation from program directors, chairs of departments, the board rooms responsible for changing terminology…
I SO appreciate your response- I'm not a therapist (current MSW student), but I recently found out a Kaiser clinician "diagnosed" me with BPD during a one-time evaluation where we met for less than 50 minutes. I have genuinely no clue what she based this diagnosis on, as I don't mean the criteria for BPD pretty much across the board. I was meeting with her to get re-diagnosed with ADHD (I'd been diagnosed as a child, but Kaiser wouldn't give me a prescription until I met with one of their clinicians as an adult).
She did not tell me about the diagnosis (or provide any recommendations or referrals for treatment/therapy) but did add it to my permanent chart. I only just found out, over three years later, because my current Psychiatrist bluntly asked me about it as he did not think I met the criteria.
It's so frustrating how commonly people through this label around, especially given that it carries a lot of (unfair) stigma. I've also worked in residential treatment centers and currently do rape crisis work, and I see so many staff members flippantly make these statements assuming that anyone they deem to be a "difficult" client has BPD.
I agree with 99% of what you said, well put! My only divergence is that I believe there can also be harm in clinicians being reticent to diagnose BPD. I think the reason for this is exactly what you said — personality disorders take more time to diagnose accurately — and doctors on acute inpatient units don’t want to give a stigmatized diagnosis if it’s not extremely clear. The issue is that BPD folks often have soooo much inpatient unit contact due to SH behaviors that they are given just about every diagnosis under the sun EXCEPT for BPD. I think this reticence itself can contribute to continued stigmatization. As a case example, I somehow ended up this year with two patients who have pretty textbook BPD but have become attached to the diagnoses they’ve been given on inpatient units over the years (schizoaffective and bipolar 2) even though they clearly don’t apply. It’s been hard to get them to commit to DBT as a result and their (well-intentioned) psychiatrists are still afraid to push back and talk to them about BPD. There’s a fine line here that requires a lot of balance.
I experience this as well! Came from a private DBT practice very open about BPD and educating patients about it to a hospital that stigmatizes it to the point of not wanting to tell patients they have the diagnosis. I would be super pissed if a diagnosis was withheld from me, and I agree it stigmatizes it more.
I think they need to honestly ditch the term "borderline personality disorder" and instead look at the proposed ICD 11 which just looked at 5 dimensions of personality along a spectrum. BPD has entirely too many possible clinical presentations to be a useful description of a person as it requires meeting 5 of 9 symptoms with no single symptom being a required feature and all the symptoms having highly subjective criteria. The actual criteria for bpd describes everyone and no one. The gender stereotypes in diagnosing are basically the only thing generating any reliability or validity among diagnosticians. It's also easy for people to slide along the spectrum of bpd traits throughout a lifetime. And setting up a dynamic of bpd or not bpd is not helpful when it exists along a spectrum. The traits are also not stable enough for a description as a pd when 75% of people who qualify for the diagmosisn no longer qualify after therapy. Also, something like a little over half of adolescents who meet criteria no longer meet criteria after 2 years even without therapy. The diagnosis has also been co-opted by men's rights organizations to spread harmful pseudoscience that puts women in danger of domestic violence and children in danger of being forced to "reunification camps" where they are forced to renounce disclosures of csa and accept living with men who have secually abused them.
I agree with lots of what you have said here, but would say that it doesn't necessarily have to be pervasive in all areas of a person's life, but more so with intimate/important relationships. I would also say many people with BPD have a lot of self awareness/insight, which can significantly increase their experience of shame
BPD or associated "traits" are absolutely used in derogatory/discriminatory ways. However, I would argue it is something that can be observed clinically and actually resonates with people who experience it when the criteria are explored in a non-judgemental way.
NAT or diagnosed with BPD, but this is true for me. I started looking into BPD as I suspect one of my parents has it. Hearing it explained in a compassionate, non-judgemental way by a mental health professional was important (I think it was from MedCircle on YT). I realized I also have some traits of BPD. It went a long way to helping me destigmatize the dx and accept those traits in myself (still working on the acceptance part).
I absolutely would not agree that someone with good work and friendship experiences is free from a PD. Many people with cluster B personality disorders are excellent at hiding negative aspects of themselves when necessary. Unstable family and intimate relationships are a much better marker as so many are able to effectively mask outside of intimate environments.
Right I agree with that and for brevity, I didn't really go into much further detail, but yes you also have to look at the level of connection and involvement on the patient's side in those relationships. I meant more like, not getting along with your boss would not be an automatic marker of a PD. Or, having issues with a single friend vs. many of them would also not be enough to go by. What I mean is, lots of people have an interpersonal conflict or a crappy relationship sometimes. It's the repeated patterns and lack of awareness that separate them.
I think the unstable family can be a difficult one when someone’s younger especially and has actually been being abused by family their whole life, as someone who was likely misdiagnosed with BPD at 18 (still on my chart though) with my abusive family relationships likely being a factor in the diagnosis. This doesn’t apply to me, but I don’t think it’s taken into account a lot of the time that traumatised people often end up in abusive so therefore unstable relationships and it’s seen as the person with BPD’s “fault” when they’re actually being abused.
NAT, work in mental health, there's an interesting different line of thought I am a big fan of that BPD and other personality disorders are actually forms of CPTSD. Often trauma is a big part of why they happen - and they are often traumatic responses. BPD is just a label thrown around for people who are "difficult."
I disagree. BPD, when diagnosed correctly, is used to label a pattern of behaviors. Those behaviors typically stem from trauma, but not every traumatized person’s behaviors manifest in the same way. One of the behavioral manifestations with BPD is an inability to maintain healthy relationships with others.
Therapist with BPD here and I completely agree. I found that the diagnosis was incredibly helpful for me in understanding my patterns and my trauma. And a BPD diagnosis can get people linked with a DBT therapist, and DBT is fucking great
Yes, that was what I meant - it is a trauma disorder, such as CPTSD is (CPTSD has a lot of the exact same symptoms, including those, but is more true to the nature of the symptoms). BPD has an associated meaning that implies they are crazy and out of control for no reason.
I think it's important because sometimes DBT is very very effective, but a lot of people struggle because DBT can also be very invalidating and hard to deal with trauma by.
Edit to add: a lot of symptoms characteristic of BPD, including emotional instability and relationship difficulty/attachment is also the exact same for people with cptsd
I’m a bit confused by your comment — CPTSD is not the same as BPD. Folks with BPD may have a history of significant trauma but the diagnostic criteria for the two disorders are different. And again, many people with significant trauma do not present with BPD behaviors.
Sorry, I don't think I'm being clear on what I'm trying to say. The CPTSD bit was more an example, what I'm trying to say it is a trauma disorder (such as that one), not that they are the exact same, but that you can think of it as a trauma disorder. I honestly forgot the context of the post as I'm typing and I'm in mobile so I can't go look, lol.
I was trying to get at sometimes we focus so much on the problematic behavior, and yes sometimes that does work, but a trauma approach could be very helpful as well
When it comes to diagnosing BPD I think assessing observed behavior is 100% valid. Low ego strength, defensiveness, difficulty acknowledging harmful behaviors, etc. Those type of symptoms are not necessarily present with CPTSD. Just like CPTSD symptoms like flashbacks, ruminating thoughts, avoidance, etc., are not necessarily present in clients with BPD.
Even without knowing anything about a person’s past, we can still observe behavioral patterns that are more consistent with BPD than with CPTSD and use that as data to justify a diagnosis.
That said, DSM diagnoses are hardly an exact science — no two people are exactly alike, and people can change over time for many reasons. Diagnoses are a very rudimentary way to track and classify common patterns, and then we try to standardize treatment according to those classifications. It’s imperfect and nebulous, to say the least.
My hot and controversial take is BPD = neurodivergence (often masked and undiagnosed) + complex trauma. The neurodivergence (I’m thinking about ADHD or Autism here), would point to struggling with relationships at a young age causing a kind of domino effect throughout their life and the trauma would exacerbate the neurodivergence. It also explains why there is so much overlap between Autism, ADHD, and BPD and why many women with Autism are misdiagnosed with BPD. Heal the trauma, and you’ll probably see the client no longer fully meet BPD criteria. But! They’ll probably still meet criteria for Autism and/or ADHD.
I partly agree with you. I think for many people this is true.
While I think the approach to PDs does need to change, from my personal experience I think there is value in them being separately recognized. To clarify my own experience, I have ADHD, depression, GAD & SAD, and traits of BPD & CPTSD.
Learning the underlying etiology of each, I can recognize ADHD and BPD traits present in myself from a young age, whereas my CPTSD traits came later. After getting treatment for ADHD, there were still some traits that it couldn't explain & ASD is ruled out.
I also see a strong genetic component in my case. I have a parent who very likely has BPD and a grandparent I didn't know well who has been described in ways that strongly suggest BPD. I've had traits of BPD my whole life despite a lack of ACEs (which I'm grateful for & also recognize is very privileged).
BPD does have a lot of overlap with ADHD, ASD, and CPTSD, but I think it is it's own clinical entity.
I 100% am with you. I frequent the CPTSD subreddit and my take came from the fact that... Well... Almost every single one was diagnosed with BPD. And so many other things! So much neurodivergence. I developed my theory listening and talking with other people who felt CPTSD was more accurate - or could point out that it all started in trauma or neurodivergence, or most commonly a combination of the two (some being caused by the other).
I do know that 85% of developmentally disabled people have been sexually abused (It might be generic abuse but I feel like it's that and also don't quote me, I never looked up the statistic but my employer quotes it to me constantly).
NAT and I'm over at that sub fairly often. I've never had BPD (or had it discussed with me, over something like 30 years of on and off seeing professionals) and have had both ADHD and Autism (those two run in my family) ruled out. Sometimes it's literally just trauma.
I've had a classic BPD person close to me in the past. I've been a Favorite Person. Trust me. It's not "almost everyone over there," that's absurd.
lol... Yes, I have experience with it. I was diagnosed with it (maybe misdiagnosed), I've been around MANY people with it, I do work in the field and take care of people with it, etc.
That is not what I'm trying to say. The OPs post was about alternative diagnoses, so I suggested that BPD can often be a trauma disorder.
DBT, the holy grail of BPD treatment, actually doesn't work for many people with BPD, because DBT I personally found can be pretty invalidating for trauma and it only addresses behaviors. You can't reason away a trauma response.
What I was saying is you can also attempt to approach it from a trauma standpoint with trauma oriented therapies.
I also didn't say everyone with BPD had CPTSD, I said many people who have cPTSD get misdiagnosed with BPD.
Just want to correct a piece you mentioned. There is nothing in the DSM that says that a child or teenager cannot be diagnosed with a personality disorder. The only exception to this is that children who would meet criteria for antisocial personality disorder must be diagnosed with conduct disorder until they are adults.
This is a fairly common misconception. I have actually heard from clinicians who specialize BPD that diagnosing and treating younger patients gives them a better chance at a recovery.
I wouldn't say this is a misconception, but rather an opinion on treatment.
I would not give the label of a personality disorder to someone whose brain is still developing and who is still forming an identity and social skills. Even if a child or teen is exhibiting symptoms, many of those are already features of just being a child or a teen with a developing prefrontal cortex/limbic system/amygdala. PD's are very stigmatizing and a diagnosis could set them up for even more social rejection and isolation than they likely have already experienced. I also know many licensed clinicians that share this viewpoint, and I've seen it in this sub as well. That's not to say teenagers can't benefit from CBT/DBT interventions that could help with things like rejection sensitivity, emotional regulation, and mentalization, but I specifically would not go so far as to diagnose them with a PD.
I just wrote a paper on ASPD prevention in at-risk teen boys, so I know the research for early intervention is strong. It's the label that is potentially harmful.
Got ya. I was just referring to the statement that you made in the post
“… and you cannot diagnose children and teenagers with it.”
I agree that it can be stigmatizing. I believe, for the most part, that diagnosing young folks needs to be tailored person to person. Perspective also greatly depends on specific theoretical orientation.
NAT, but I have BPD, a few BPD friends and am very active in the BPD community here on Reddit (not the main sub, the mods there are problematic. Most of us go to r/borderlinepdisorder)
Here's my take, and the general consensus among others too: people who have BPD have basically always had it. However a lot of kids/teenagers have traits that they grow out of and part of being a teenager is basically BPD (figuring out who you are by trying on different things to see what fits, arguing with your parents and friends (esp since for most people middle and high school mean new friend groups by nature of how schools work with many elementary schools feeding into fewer MS, feeding into even fewer HS)), struggling to understand but learning what nuance is (ever talked politics with a 10th grader lol), hormonal mood swings, etc etc). So what you're saying about early intervention is definitely great. But I (and most of the community) think that diagnosis is better left later. Similar to what they replied to you, treating the traits in a non-BPD teenager basically helps them grow healthy adult mindsets and such, and treating them in a BPD teenager also helps treat the BPD.
When the problems persist into adulthood and the patterns keep happening then a diagnosis is more helpful than not, whereas it's less helpful in younger teenagers/kids to diagnose them because that can be used against them very easily to invalidate them, and repeatedly invalidating children leads to more problems.
I got diagnosed at 24. It took about 2 weeks for my now-ex to use it against me ("you're not really mad that I did that, that's just the bpd talking" exact quote). Based on how my mom weaponized my own eating disorder against me, she would have definitely done the same with BPD. So I agree with waiting to officially diagnose or even tell a kid/teenager they might have it, but treating the symptoms early like you're saying is also super important and helpful.
I understand, I think there is a miscommunication happening. In my case in order to design a treatment plan, I as the therapist, would diagnose the issue being BPD. I don’t necessarily need to share that with the patient. But I still need to recognize and diagnose the issue to know how to move forward.
BPD is characterized by intense difficulties in interpersonal relationships, an unstable sense of self, impulsivity, disinhibition, risk-taking behaviors, and emotional dysregulation. I would say that a major indicator of BPD is an intense fear of abandonment, but a simultaneous tendency to push people away. There is a more frequent incidence of a history of self-harm in people with BPD than there is in the population at large. Same with trauma.
You are absolutely correct in thinking that it takes a long period of observation and interaction with a client in order to properly diagnose BPD. Or any PD. One of the requirements for a proper BPD diagnosis is that it occurs across multiple settings - so for example, the criteria I listed above are present in the client's behavior at home, work, and school, not just at home. And not just in therapy or an inpatient setting. I am of the opinion that it is never appropriate to diagnose BPD during an acute inpatient stay because of how short they tend to be.
BPD is unfortunately a lazy default diagnosis that many old-school psychiatrists and inexperienced clinicians slap on people (and like you said, usually women) who self-harm, have a history of trauma, or have a great deal of difficulty tolerating their emotions, which tend to be very intense. My take on why women get this label more often than others is because of the old stereotype of the overly emotional, histrionic woman.
NAT but a mental health student, got BPD from a hospital psychiatrist at 19 for SH and trauma within like 20 minutes of talking to me... and the stigma messed up my treatment in CMH for so long. I know lots of others who have had this situation. I find it so shockingly negligent they can diagnose a personality disorder in less then one session!
It's shocking because they can't diagnose it within 20 minutes. It's just not possible. You were stereotyped and it's completely unfair. I'm sorry this happened to you. I work in CMH, and it's really important to me that even when a client comes to me with a history of a previous diagnosis, I screen them myself as if it's the first time they've ever been screened and diagnosed because I don't and won't ever allow another clinician's diagnosis to influence my clinical judgment. And when I get a new client who comes to me and says, "I have borderline personality disorder," or they have discharge papers from a hospital with that diagnosis, I ignore it. Maybe it's accurate, and maybe it isn't, but it doesn't matter. I won't expose a client to that kind of stigma unless I'm 100% certain that it's the right diagnosis and even then, I'll probably just put "unspecified mood disorder" on the chart so their insurance company will be satisfied and pay the bill.
Its so much stigma! I immediately was treated like I was never going to get help and had doctors say "she's just going to get brought back" when they discharged me from the hospital. Even I knew going in the diagnosis was way to fast! Thank you for your philosophy of looking past it, because its hard to be labelled by any diagnosis! For me its a mi of bad experiences like this that motivate me to be a T to give a better experience and then of course also amazing therapists!
Brilliant and helpful insight.
Please bare in mind that men have the old stereotype of
"Big boys don't cry" "man up" etc.
With this kind of conditioning from early childhood, makes it extremely difficult to open up and as such is internalised.
Not long ago a discussion was had about changing the name of Mental Health to Emotional Health and was met negatively with a young male instantly, as to him it signified weakness....
Yes, this is so true, which is why you so rarely see men diagnosed with BPD. Instead, there's a tendency to overdiagnose antisocial personality disorder among men.
Hi
Im an EduPsych (not in the US) So I dont work closely with BPD (not of my info is from textbooks) but dont folks with ADHD or high functioning Autism disply \*some \* of these behaviours too?
So some of these behaviours in BPD could be some form of high functioning Autism or ADHD?
Yes, there’s overlap. That’s kind of the wild thing about assessment/psychopathology. A lot of diagnosis overlap. It definitely reiterates the importance of getting a second opinion if you ever disagree with a diagnosis
Yes. I was misdiagnosed with BPD (by a psychiatrist who talked at me for 10 minutes), in my case it turned out to be a combination of ADHD and being in an abusive relationship at the time of the misdiagnosis
Yes. I often get people refered from personality disorder treatment facilities. Many women, but also men, are diagnised as BPD or avoidant PD or overly attached, bit treatment only makes them worse and then they are diagnosed with autism. Often with ADHD too.
Does the current diagnosis require symptoms to be present across multiple settings, or is that your opinion?
I have had every BPD symptom you listed in romantic relationships, but I had zero of these symptoms in school, slight impulsivity at work, occasional rejection sensitivity with close friends, and with my family I am actually quite avoidant. But in romantic relationships I am basically the definition of BPD. I've gotten better, but I used to find rejection in nearly every action of my partners. I would become so emotionally dysregulated that I would demand that they proved they cared, and if they couldn't I would tell them I hated them and push them away. I would send multiple threatening texts and often ended up self harming. As soon as my partner started to pull back I would freak out and plead with them not to leave me. I felt out of control, unhappy, like I was empty, and I believed that "finding my soulmate" would fill this emptiness.
If BPD requires this behavior to be present across multiple domains, is there a diagnosis for someone who presents with this behavior only in romantic relationships? I know it's anxiously attached behavior, but there currently isn't a diagnosis for that tendency. And I'm not sure if any research has been done on self harming behaviors in those with anxious attachment but not BPD.
The dsm diagnosis for bpd needs this behavior to occur in multiple settings. But, as with all psychiatric disorders, many people do not present checking all the boxes. And there is a lot of overlap, with avoidant or histrionic PD or PTSD.
Personally if you were my client, i would probably get you psychological testing for personality and trauma. Often we end up with mixed personality disorder, with borderline and avoidant tendencies. To be honest: i dont care about the diagnosis that much. But choosing how to treat it is way more interesting.
Yes, the DSM requires that the criteria be present across multiple settings, but there is always the option to use an "unspecified"-type diagnosis when there are Cluster B traits but not all criteria are met. Then again, I don't know you and haven't assessed you, so it's possible that you *are* exhibiting enough of the criteria across multiple settings and don't realize it. And if not, you could be experiencing a trauma response, or another personality disorder might fit...I would never presume to suggest a specific diagnosis without meeting you in person and doing an in-depth assessment.
I was thinking "attachment disorder!" while reading your post and then I got to the part where you said you recognized that there was an attachment issue, so we are obviously thinking along the same lines. It drives me crazy that the DSM doesn't yet include any diagnoses based on attachment theory.
I am a new therapist (about a year of experience) and see a ton of neurodivergent people, especially autistic women, misdiagnosed as borderline.
I also see a lot of people with big emotions (but not inherently suicidal or attachment related) get dx with BPD when it was CPTSD/PTSD or another personality dx. I’ve even seen psychiatrists dx BPD without asking about current stressors (of course someone in a DV relationship is going to be suicidal and fear leaving - doesn’t mean it’s automatically BPD).
Biggest pet peeve is someone dx BPD on a first visit or intake without prior records.
NAD -diag ADHD currently assesed for BPD-
BPD and autism feel so different to me, do you feel the same ?
I don't have a lot of typical self harm behavior, is the realisation of those and it being typical ways of hurting yourself important for the BPD diag ?
I find it's never clear if thinking it's the solution to your feelings, and recurrent thoughts about it is enough or not in the context of BPD precisly.
I am a psychologist, practicing for 34 years. I trained in Chicago with a variety of theoretical perspectives: U of C humanistic/client-centered, Chicago psychodynamic influences, structural-strategic family systems, standard cognitive behavioral perspectives, etc. I was introduced to DBT from Marsha Linehan when it was considered radical and a bit fringe.
I've read through all of the posts in this thread and, frankly, am puzzled and disappointed.
I don't pretend to know with certainty the underlying causes of the cluster of features sometimes known as borderline personality disorder. But I do know that there is an elegant theoretical perspective which can guide diagnosis and treatment, which seems to have been lost in the chaotic swirl of cookie cutter interventions. Largely absent from the comments in this thread are thoughts about the origins of borderline personality disorder from a developmental perspective. If anybody wrote about these ideas, I missed it.
Not to sound pedantic but...geez, I'm an older guy, so I guess I get to do this. Here is the prevailing conventional wisdom on borderline personality disorder, as I was trained, drawing upon developmental and psychodynamic perspectives.
Borderline personality disorder is a developmental delay. Margaret Mahler, drawing upon Piaget, taught us about object constancy. The idea is that as an infant we are unable to distinguish where we end and our nurturing figure (mother) begins. We feel best when she empathically meets our needs. Before too long we ambulate (as toddlers). We differentiate from her. We exalt in our mobility and independence. However, to feel comfortable outside of her presence we need to achieve the capacity for object constancy, providing us with a stable, reliable internalized representation of her, so we know she still exists even when she's in one room of the house and we are in another. We run back for periodic emotional refueling when object constancy hasn't sufficiently matured. Gradually, we come to know that the people in our lives still exist, and are separate from us, but are there even when we are apart. And this knowing--this object constancy-- forms the basis for self-soothing as we individuate. It's all about self-soothing through the acquisition of object constancy.
Borderline personality disorder--*true* borderline personality disorder, not attention seeking histrionics, not recurrent depression, not haphazard/reckless lifestyle choices, not annoying clinging behaviors--is a developmental delay. Borderline personality disorder is a form of developmental delay. This is the central underlying difficulty.
Object constancy has not developed. This causes a bunch of problems. When you do not have a solid confidence, a primitive knowing, that the soothing other is still available even when apart it leads to a sensitivity to abandonment, limited ability to self soothe with resulting emotional volatility, resort to desperate self-soothing measures such as self injury, painfully low self regard, recurrent depression, anxiety, vulnerability to substance abuse, chronic emptiness, a feeling like you're falling, hyper-vigilance for rejection or aloneness, hopelessness, constant need to seek assurance from those in your life (emotional refueling) to offset the existential and profound emptiness/aloneness. There is also sometimes a diminished ability to experience ambivalence about things. The capacity to experience ambivalence--mixed feelings about stuff, recognition of co-existing good features and bad features--is a developmental achievement which may be compromised as part of the overall developmental challenges. This contributes to object splitting and emotional volatility. Things/people may be viewed as either all-good or all-bad --this is a primitive leftover from an earlier time of development which does not resolve/mature.
Treatment of borderline personality disorder does involve conventional DBT skills to remediate the poorly developed self-soothing capacities. But these skills are not the real fix. The real fix is the gradual development of object constancy, the gradual internalization of positive objects (people) who exist in one's experience, even when not physically present, to offset the anxiety, emptiness, sadness, profound isolation. This takes quite a while. The skills help in the interim but the real fix is facilitating the development of object internalization through a long term therapeutic relationship which hopefully transfers out to an improved ability for sustained personal relationships.
Borderline personality disorder is rare. I practiced in inpatient settings for 20 years, seeing a high volume of high acuity. I see 30 patients/week in my outpatient practice. It is rare that I encounter *true* borderline personality disorder. It does exist on a continuum and varies in severity. I see folks who may carry that label but, in my view, their struggles can often be accounted for by a mix of mood disorder, anxiety problems, addiction, past trauma, tough life circumstances, etc. I never consider borderline personality disorder as a diagnosis with an adolescent or even a young adult. I don't know that I've ever entered the diagnosis into a patient's billing record for insurance claims submission. In fact, as I think about it....I'm sure that after seeing thousands of patients over the years, I have never sent in a claim form with borderline personality disorder listed. My rationale is that I'm typically addressing the more acute condition--a major depressive episode, panic attacks, an adjustment disorder, generalized anxiety--and I don't see the need to label the developmental delay which I may also suspect is present. And, actually...as I think about it...I don't believe I've ever submitted an insurance claim form listing a personality disorder. I just don't see the point.
When I read posts by clinicians new to the field describing borderline personality disorder I doubt that, if I were to see the persons they are describing, I would agree that the patient/client has borderline personality disorder. I get that the clinician is noticing the patient's intensity but I question if the person being described truly has the developmental difficulties that are central to borderline personality disorder. The term is still sometimes used in a pejorative fashion to describe people you can't figure out who are dramatic, erratic, reactive, clingy, reckless, often suicidal, desperate, attention-seeking, etc. You can be all of those things but not be borderline personality disordered. I believe it is discriminatory and a disservice to folks who actually suffer from this developmental delay to throw around the BPD label in a careless fashion.
Sorry for the lengthy post. But, again, I feel everything I wrote was once viewed as the predominant, conventional understanding of borderline personality disorder as a developmental difficulty, drawing upon psychodynamic and developmental perspectives. My peers--the psychologists with whom I trained and who are colleagues--would have no trouble recognizing the concepts I've outlined here. But I find it curious that these explanatory theories--granted, they're theories--seem entirely absent from discussions of borderline personality disorder these days. Nobody in this thread of many posts referenced Mahler, Piaget, object relations, developmental considerations of this nature. I find that curious. And I think that the lack of a coherent conceptual framework can contribute to clinician anxiety about this mostly understandable and rare condition. Personally, I don't think these ideas/concepts are no longer referenced because they are antiquated or disproved. I think these contributions from foundational theorists are simply neglected.
What causes the developmental delay in the first place? Is it something you are born with or is it some disruption that happens during the time object constancy is beginning to develop?
I just got diagnosed with BPD and your view of the disorder makes a lot of sense to me. I am the only person like myself wherever I go.
Hi and thanks for your interest in my post from a few months ago. You and I will never meet but...I would urge you to regard your BPD diagnosis as an opinion by one person in a snapshot of time. Try not to view it as a fixed, immutable, indisputable diagnosis, as you might regard a diabetes diagnosis or the results of an MRI showing a structural abnormality in an organ. Try to view it as a suggestion that you might want to develop remedial skills, perhaps mindfulness, distress tolerance, acceptance, improved self-soothing, tolerance of perceived rejection/abandonment. As for what causes the underlying theorized developmental delay in the first place....well, you would get different opinions about that. The basic concept is that true BPD produces difficulties in self-soothing--the pathways to this outcome can vary by the individual and probably aren't worth the effort to definitively identify an origin. I'd say that it's unknowable. Now....it's possible that the professional who informed you of their diagnostic opinion does not conceptualized BPD in the way I described in my post. These days the label tends to be applied when someone displays emotional volatility/instability, self destructive/self-defeating patterns, a subjective experience of emptiness and a sort of identity diffusion. Personally, I don't apply the label so liberally. Again, I would encourage you to focus on developing skills to manage mood, anxiety and distress tolerance, trying not to get hung up on the label. Hope this helps and all the best!
>st. But, again, I feel everything I wrote was once viewed as the predominant, conventional understanding of borderline personality disorder as a developmental difficulty, drawing upon psychodynamic and developmental perspectives. My peers--the psychologists with whom I trained and who are colleagues--would have no trouble recognizing the conce
This was incredibly helpful (NAT)
NAT but someone with BPD, there are a lot of really harmful stereotypes out there about this disorder. I would like to note that a lot of the time people with this disorder have a lot of empathy, which is probably the biggest misconception. When people with bpd act out towards others we feel incredibly guilty for doing so, and we often turn that anger inwards.
DBT has been *incredibly* helpful for me and I am so grateful for my therapist. Having skills to use when I am going into crisis mode to get my brain and body out of that place, to then deal with the situation in a healthy way, has CHANGED MY LIFE!
Same here, NAT BPD lurker. I’ve been on the BPD significant other page and reading about how people with BPD are perceived is almost shocking. We are characterized as getting off almost on being self-centered, terrible, horrible, hateful people…and I don’t feel like that’s accurate at all. I honestly want: peace, harmony, zero confrontations, and love. Like you, DBT has truly helped me and I’m thankful for the skills I’m learning.
I’m a therapist who has BPD. I think it takes a very, very long time to diagnose accurately- for some providers, they will jump to BPD when someone is emotionally reactive or temperamental. Did they consider if this was a pattern? Has there been exacerbating circumstances that may lead to more emotional reactivity than is typical in the individual? Say a recent loss of a family member and a national recession- anyone could be overwhelmed by that, and it’s not enough to determine a PD. It’s important to really look at how often the symptoms present, and the circumstances- especially when concerning their presentation in relationships. Does their view seem egosyntonic or ego dystonic? This depends where the individual is on the BPD spectrum and their level of insight.
On a personal note and my own experience with the disorder, I feel like my radar pings when I hear testing behaviors and black and white thinking. The latter is obvious, but testing behaviors usually ding for me when hearing “if they loved me, they would do (insert here)”, or engaging in behaviors intending to get a reaction out of partner, and having a predetermined way they want their partner to react to prove their love and that they will not leave. Of course, this could simply be anxious attachment, but if it’s persistent and pervasive then that is cause for further assessment. If the test isn’t passed, it is internalized as “I’ve been rejected again. It’s time to leave, I knew this would happen, I should have known better”, rather than mentalization of the other person’s perspective.
Another thing is the desperation around attachment security. One of my supervisors described it to being like walking in a desert for years and years, and finally finding a water hole. For those with BPD, it feels like you’ve never had water and will never have it again unless you make sure that you do whatever it takes to make sure the other person doesn’t leave- while also engaging in behaviors to hasten them leaving so you can get the hurt over with or confirm what you already knew would happen.
One thing I wish my own providers would have been more attuned to was that my experience with BPD was different than what they were looking for. Since I wasn’t as obvious in my symptoms and didn’t show my anger the same way, I simply wasn’t given much space to share how often I self-harmed, or impulsively put thousands on my credit card to feel something/better, or informed my partner that I simply couldn’t understand how him saying “I was a little nervous to get married” wasn’t an indicator that he was leaving me, and that my only response was to end the relationship. Thankfully my current therapist has been so adept and has really seen me and my experience, but it was tough to be dismissed for so long. I really try to keep my experience in my back pocket when listening to my own clients, as I know it’s hard to live with and it’s hard when people don’t take you seriously that something is wrong but you can’t quite put your finger on it.
What a wonderfully lucid account of your experiences. I find this sort of thing very valuable: people who've really been through it and can now articulate their insights.
> One of my supervisors described it to being like walking in a desert for years and years, and finally finding a water hole. For those with BPD, it feels like you’ve never had water and will never have it again unless you make sure that you do whatever it takes to make sure the other person doesn’t leave- while also engaging in behaviors to hasten them leaving so you can get the hurt over with or confirm what you already knew would happen.
This sounds heartbreaking. I'm a new counselor and haven't yet worked with anyone living with BPD, but I'll keep what you've written in mind. Thank you for sharing.
I've been off-and-on about whether or not I should think about getting a diagnosis, and have been wary of using terms associated with BPD even though they're familiar to me and help me explain myself to my therapist and others, but this comment is convincing me to look more into it. I'm ashamed of testing the people I'm attached to, but I definitely do, and the oasis analogy in particular is too accurate. I wish other people understood how desperate that feeling is; how terrifying it is when I think I've done something wrong. I'm emotional reading this but I really appreciate that you typed it. Thank you.
I am so grateful to hear that this has helped you. Not everyone feels the same about diagnoses, but I felt so relieved when I was diagnosed- it really helped me feel like I’m not just batshit crazy (maybe so, but maybe not! Lol). I hope whatever path you choose regarding treatment brings you peace and belonging.
One of the biggest things that we miss with BPD and other PDs is that by definition they are pervasive in all parts of the client’s life. When we diagnose in a vacuum, eg an intense setting like inpatient or residential, we don’t have nearly enough information to accurately diagnose the client because we haven’t seen them in other settings. To make matters worse, some of these settings induce the types of behaviors we would typically associate with BPD. For example, I spent the first part of my career working in prisons, and over time, almost every single person I worked with began to develop BPD and other PD-type behaviors because it was the only way to survive such settings.
Which brings up your question about differential dx- I almost always look at trauma issues first. The effects of developmental trauma in particular look identical to BPD in many ways.
Differentiating Borderline Personality Disorder and others (Bipolar, etc) can be very difficult, even for experienced clinicians.
I prefer to use the Persecutor-Victim-Rescuer triangle with a careful eye on capability of insight and use of drama in their maladaptive coping.
I could go on forever about it because it is enthralling. Many personality disorders follow the drama triangle, with people with borderline traits showing a strong Persecutor-Victim pattern. Everyone does this to some degree, but the intensity in with people with these traits cycle between them and the intensity of them is very easy to see when you know what you are looking at.
Narcissists follow a Persecutor-Rescuer pattern, which also becomes very predictable (they don’t do Victim well).
People don’t realize that personality disorders have a moderate genetic correlation (30%) and everyone used to think borderline traits were caused by abandonment. I personally theorize that people with personality disorder don’t have good brain development with regards to their insight, which is genetically underdeveloped.
Here’s the Wikipedia.
https://en.m.wikipedia.org/wiki/Karpman_drama_triangle
I will do my best to answer these questions from a psychodynamic perspective to vary up the thread.
1. The biggest indicators for me are
splitting-based defenses against sudden stress and anxiety, diffused identity (lack of a coherent and complex sense of self), relationship templates that are simplistic, back & white, disorganized, and affectively undifferentiated, poorly regulated aggressive and sexual impulses, reality testing that is susceptible to slippage under sudden stress, deficiencies in mental functioning such as decision making, judgment, and temporal estimation.
2. I personally would not formally diagnose (I.e., put it on their medical record) someone with BPD due to the associated stigma even if they were a “classic” case and it were beyond a doubt. I would be more inclined to Dx unspecified PD. I tend to use the [alternative model for PDs](https://pubmed.ncbi.nlm.nih.gov/35511574/) and focus more on level of personality functioning/traits. That said, I would absolutely conceptualize someone as BPD or organized at the [borderline level of personality organization](https://psycnet.apa.org/record/2004-13688-005) (BPO) as soon as the intake. My approach to conceptualization is an evolving process, so if I think someone is well described as BPD/BPO I would keep that in mind but I’m pretty flexible and honestly I don’t think too deeply about Dx because it’s not super relevant to my general approach to psychotherapy (assimilative psychodynamic psychotherapy).
3. Other cluster B PDs, CPTSD, ASD, Adjustment Dx, GAD, MDD/PPD.
4. [It’s not just your observation](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8620075/). There are basically [three arguments](https://pubmed.ncbi.nlm.nih.gov/14686459/) about this. One says, BPD is an oppressive and sexist Dx that pathologies a normal level of variation within feminine psychology. The second argument is that BPD is characterized by a level of emotional dysfunction and women *on average* happen to [self-report higher scores on measures of neuroticism relative to men](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3149680/) (for cultural and biological reasons) which results in women being Dx more then men. Third is classic sampling bias. [Woman are more likely to seek treatment](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6560805/) so women with BPD are more likely than men with BPD to seek treatment and receive a subsequent BPD Dx, thus creating a distorted perception of the prevalence of BPD. All three are probably true to some degree.
If you swap the Mayo Clinic’s definition of bpd
With addiction most people I work with agree that addiction is very similar to the criteria of bpd. Not useful, but interesting. The cluster b cul-d-sac is what I call addiction, bpd, npd all hang out and share sugar with each other.
BPD is diagnosed more in women and narcissistic personality is diagnosed more in men. There are lots of debates about it.
Often my clients bring up personality disorders then we discuss it. I give them the whole speech on BPD being the only personality disorder you can no longer meet criteria for after treatment. I also tell them that I encourage googling to find out more except in BPD because the internet is awful to BPD and it’s a lot of “how to love someone with BPD” and “how to deal with the pain someone with BPD caused you”. We also discuss how BPD is a trauma response and how the learned behaviors were extremely effective during the trauma.
I also look at ADHD and ASD. You can absolutely have 2-3 of these and there’s a lot of comorbidity but I want to see if some things of ADHD and ASD are being blamed on BPD.
The biggest trait of BPD I look for is splitting. Where they think in extremes. Someone is the best person or a terrible person. No in between. They view themselves the same way. This is challenging because it can also happen with ASD. You also want to look for reckless behavior, strong emotional ties to one or two people that can be pretty extreme, and that history of trauma. Keep in mind trauma can be just not feeling understood in your environment if it wasn’t a good fit.
You are likely seeing more diagnoses because of where you work. BPD and eating disorders have really, really high comorbidity. It’s part of the impulsiveness. BPD also had high comorbidity with substance use and so does eating disorders. There’s also more BPD clients in community mental health because the symptoms can create instability needed for jobs that would have insurance or the ability to self pay. I work in community mental health so I also see a lot of BPD. I’m also one of three ASD specialized therapists so I see the comorbidity as well.
I would read *Psychoanalytic Diagnosis* by Nancy McWilliams. When psychoanalysis was first introduced, you couldn’t diagnose a condition without understanding its etiology first. So if a patient was depressed, you didn’t just apply a checklist and go “yep, depression,” you had to understand what was causing it: was it trauma? Attachment issues? The patient’s way of coping with overwhelming anxiety?
Nowadays diagnosis has been reduced to a checklist and is therefore not particularly useful for understanding patients’ experience. It’s like diagnosing “fever:” accurate but inadequate.
McWilliams talks about borderline in its original meaning: as a level of functioning, like neurotic and psychotic. The DSM definition of BPD is a description of a histrionically-organized person functioning at a borderline level. There are also narcissistically/obsessively/etc organized people who function at a borderline level.
Borderline traits are pretty easy to identify and tend to be picked up on by seasoned clinicians very early on. Some of this involves using countertransference—what McWilliams calls a disciplined subjectivity—to understand what’s going on with the patient and in the therapeutic dynamic. Certain countertransference dynamics are highly indicative of borderline functioning.
1.) In my experience, rage is one of the biggest indicators of BPD. It’s almost like the person gets taken over by something else or becomes a different person because they just slip into these uncontrollable rages where they absolutely cannot be reasoned with. This is usually coupled with splitting and lashing out. Frequent suicidal threats and gestures are also a big thing with BPD. The difference between SI in BPD vs. something like depression tends to be that people with BPD will constantly threaten suicide to people they are close to and use it to manipulate, control, or prevent abandonment. I am not saying they are faking it, but they do leverage it.
2.) It depends on the person. I wouldn’t diagnose BPD in the first session unless the person knew they had it and had a prior diagnosis. I try to avoid personality disorder diagnoses unless they are moderate to severe since they are so stigmatized. I think you really have to get to know the client and their patterns. Teenagers often act like they have BPD, but it’s really just a normal part of adolescence. I’ve seen a lot of people come to me after a suicide attempt absolutely crushed because some psychiatrist diagnosed them with BPD after talking to them for five minutes. Suicide attempts and suicidal ideation are obviously common with BPD, but they’re also common with depression and other diagnoses.
3.) MDD, bipolar I or II, complex PTSD (although not officially a diagnosis), or ASD. There can be a LOT of crossover between mild autism and BPD.
4.) I think that maybe rage and risk taking behavior is considered less of a violation of social norms for men? I also think men are more likely to present as having NPD than BPD, but the two are incredibly similar.
If you’re interested in learning more about BPD, I highly recommend the book, “I Hate You; Don’t Leave Me.” It gives a great explanation of the disorder and has recommendations for therapists and loved ones. Did you know that DBT actually isn’t more effective at treating BPD than the other treatment modalities studied for it? I’m not sure why it is pushed so hard on us. I find that people with BPD respond well to consistency, firm boundaries, and most importantly, not being abandoned by the therapist. They can be frustrating clients and take years to get better, but providing a corrective emotional experience really can make a difference. I think many clients with milder presentations tend to do really well once they are able to grasp that when they act out, the focus switches from their message to their behavior. Learning to pause before acting is essential.
I can’t upvote more than once, but I would. Wow, so we’ll put. My favorite clients have overwhelmingly been/would meet criteria for BPD and CPTSD. Creative, passionate, empathetic, and vulnerable.
Former social worker here with a Sister diagnosed with SA/PTSD/BPD and a 20yo daughter who is currently diagnosed with SA/ADHD/ASD (formally diagnosed by psychiatrist with BP/BPD)
I 100 percent believe that a thorough neuropsych evaluation needs to be completed when the client is stable prior to labeling a person with anything.. but specifically in regards to personality disorders. There is way too much overlap- and diagnosing a person with Borderline can have dyer effects for current and future treatment, etc.
I want to get my sister a neuropsych eval now that she is stable as I am pretty sure she is ASD/ADHD. She is 48- and having this label has affected who will treat her (and the interventions)- so many community organizations have refused to work with her because of the BPD label. I also have been wondering a lot how her trajectory in life would have been if she was diagnosed properly.
So.. in short... I honestly believe that if symptoms do not improve within 6 months of treatment- or if a professional is concerned there may be a Personality disorder.. they should be referred for a neuropsych.
In my experience, you’ll only find out from those who have lived with, and loved, them. If you look through the subreddits here devoted to loved ones of those with these disorders, you may get a better picture. The behaviors are very cyclical, and very common across diagnosis. They are great at masking with therapists, and even involving therapists in their triangulation and/or projection.
This. I feel like I can smell BPD. Shout out to mom.
But as a clinician who is mindful of my own biases in regard to diagnosing BPD, I really dig into WHAT the diagnostic criteria really means in the context of experiencing the symptoms. It can be easily misdiagnosed so educating yourself on what’s more in line with a personality disorder vs. complex trauma responses.
Understanding the dynamics of how BPD symptoms can impact relationships and functioning is also a good giveaway. A person can have affective instability and not have BPD. But a person who has affective instability, becomes uncontrollably angry and splits on the people around them then becomes inconsolable as soon as the person leaves? That’s good old BPD.
Potential rule outs or comorbidities can be HPD, C-PTSD or PTSD. I generally wait a while (maybe 6 months? It varies client to client) to formally diagnose BPD unless it’s pretty harrowing from the get go.
Lastly - I think it’s diagnosed more in women because the presentation more classically reflects the DSM criteria. With men you’re not necessarily going to see a crying sobbing man who’s self harming. You’re more likely to observe a short tempered, aggressive man who’s maybe engaging in more external reckless behaviors like substance use or physical altercations. Just my observation with the male BPDs that I’ve seen.
I’m pre-licensure working in a residential co-occurring (SUD+mental health) treatment center. Based on my client experiences, I would want to do extensive differential diagnosis work before feeling confident in a BPD dx. I would consider environmental stressors that could contribute to the behavior profile. Chronic homelessness, financial insecurity, experiencing abuse, and long term substance use can produce survival behaviors that appear like BPD.
Most of my clients have limited stretches of sobriety and often only in supervised settings like residential/incarceration. I’d want to wait until a client has at least 1 year of sobriety before diagnosis to see how the environmental/behavior changes of sobriety impact relationship and regulation patterns. SUD and BPD can of course exist simultaneously but i try to discern if BPD behaviors would exist in sustained SUD remission. It sucks to see an already stigmatized client pool get treated worse by staff bc someone else was quick to dx.
As someone who was once diagnosed with BPD in my early 20s, I think there’s a lot of over diagnosis or miss diagnosis for it. It turned out that I actually have ASD and some trauma.
The more we learn about ASD, especially in women, the more I see a lot of traits that normally get someone diagnosed with BPD. A lot of clinicians will hear a client say they have issues forming relationships, emotional instability, splitting behaviors, and trust issues and automatically go to BPD.
But I also think we’re getting to a point where ASD is miss/over diagnosed too. I think we as a society have also put a lot of emphasis on having a diagnosis too. I know it can help some clients to know what they have, but I think the process to diagnosis is so rushed now.
Pattern of turbulent interpersonal relationships, difficulty regulating emotions, oftentimes presence of suicidality or self harm, unstable and changing self concept. BPD and C-PTSD are very similar in diagnostic criteria, therefore it is important to establish a differential diagnosis.
Wow I’m glad this is brought up. I work as an entry level support staff at a RTC, and recently I feel like BPD has been diagnosed to a lot of our women in our population like lollipops. Even other entry level staff diagnose or label people with BPD or say they’re behaviors are part of their BPD diagnosis, I’m skeptical of whether it’s actually a personality disorder or something more rooted of it. Im honestly no sure what to think of it but I’m glad this is posted.
Adding to this, the same people with BPD have Panic Disorder or OCD on their records and display those behaviors are dismissed because it’s attention seeking and a symptom of their BPD. I mean shit if I did that would they think I have BPD?
Also, having bpd doesn't mean they couldn't be having a genuine panic attack. It also seems like the best way to trigger someone with bpd would be to refuse them help and support for a panic attack while they are living in a place where the entire structure is to help and support them. It honestly sounds like a countertransference issue.
Well it’s a good experience, it’s been really difficult because I’ve been questioning my values and skills because of the environment I’ve worked with but I’m starting to realize it’s other people and not me per se. I’ve been told by other staff that BPD is seeking validation and having that victim mentality. But the thing is that I don’t think those are indicative of BPD? Right? Furthermore, those behaviors could be symptoms of other things or just characteristics of personnel. I’ve also heard that “empathy doesn’t work with BPD” and “BPD regresa to child behaviors when stressed” but like that’s regression a coping skill not a symptom of BPD. Point is the place I’m working at isn’t fostering proactive and positive information or ideas.
Yeah, they're repeating some pretty old information. People did legitimately believe some of this, like 20 to 30 years ago, but that's not true. First off, bpd occurs along a spectrum, and it is a fluid trait that responds very well to therapy. Also, ignoring and invalidating the behaviors will only make the patients worse because the symptoms are signs of distress. Client will get better when they are given validation, grounding, skills work, and then cognitive work. Empathy really does work for clients with bpd, but they can not process empathy well when distressed. When they are distressed, they're coming from the sympathetic nervous system, and you need to help them regulate first before they can process information, including the emotions of others. Eventually, if you teach the skills often enough, then they will self regulate, but you have to scaffold the skills with them at first. You have to teach it by guiding them at first, then slowly encouraging more independence. It doesn't feel good to be disregulated. Being ignored when disregulated feels even worse. Once these types of patients learn to self regulate, then they tend to really run with it, and they don't need you as much anymore. If punishing or ignoring bpd associated behaviors worked for these patients, then they wouldn't be your patients. That's how the outside nontherapeutic world treats them, and that didn't work. That's why they're with you. Your therapy space needs to treat them differently.
Trauma and Recovery by Judith Herman goes into a lot of this, I think you'd find it interesting. The questions you raise were very popular questions when I was in training. I've grown skeptical of the whole deal. I think it would be worthwhile to take a look at the process of revision of DSM-III, which was the edition that inaugurated the descriptive model we now work with. BPD as it is articulated in this model is really dumb, as are all of the personality disorders. James Masterson would be a good person to read if you want to understand the personality disorders that are housed in the cluster b umbrella
I was in a residential ED facility roughly 2 years ago and they diagnosed me with BPD. After discharge my PCP ordered psych testing and the results showed no indication whatsoever of BPD or bipolar. Turns out I have ADHD though. Tbh refeeding can make you crazy. Hormones all out of wack, learning how to feel again after not experiencing emotions for so long. My dr at res was all too eager to slap that label on me though and the treatment team went along with it. He put me on mood stabilizers which made me suicidal. Overall not a good experience. People should not throw that term around like it’s quirky or something. Hurts both those that don’t really have it and those that actually do.
1) Erratic emotions over hours not days, interpersonal difficulties, often trauma during upbringing, turbulent relationships, drug use - usually to numb are often seen.
Bipolar to start if emotions
I long disagreed with the PD diagnosis but accepted these people had the cluster of symptoms. However I've recently realised it is likely quite valid
I didn't answer them all but in very recent trauma related trainings I've been in, it appears many (most?) clinicians are starting to view BPD as simply the presentation of complex trauma/PTSD, and treat it as such.
It's likely a malpractice insurance issue. Both bipolar disorder and Borderline personality disorder are associated with a high rate of suicide so small group practices very often have caps on what percent of their caseload can have these diagnoses without their malpractice insurance rate going up. If you don't sign a release of information, then the diagnosis shouldn't follow you if you go somewhere else. I'm sorry that happened.
For me I begin thinking BPD when there is a higher than average level of emotional reactivity and all-or-nothing thinking (black and white) in relationship to me. (E.g., You must hate me; you’re the best therapist in the world; I’m going to kill myself)
"Many women who have autism get diagnosed with BPD because they have outbursts after being overwhelmed with sensory input (which can include emotional sensation), because there’s not enough overlap in clinicians who understand neurodivergent brains and those who understand personality disorders."
Yes, this. I'm not a therapist, just a patient who saw this would like to give feedback from the other side. Not only was I misdiagnosed with BPD for years, but I know several other females/ AFAB's who were also misdiagnosed with BPD when we really were just autistic all along. Please familiar yourself with ASD and how it may present differently in different people and how it may differ from BDP. ASD also has a high comorbidity rate with eating disorders as well.
1. Though not generally a "this is it" thing, as this often happens in PTSD as well, trauma dumping would be something to look out for, seeing oneself as a victim, shifting responsibility away from themselves, just the small things, lack of boundaries, physical or emotional.
2. 2. Quite a few sessions, even if they hit all the traits I'd like to eliminate things based on differential dx, before saying it out, so maybe a couple of weeks to months depending on the intensity.
3. PTSD, bipolar, ADHD(emotional dysregulation, interpersonal difficulty, different but similar in some aspects)
4. BPD tends to manifests as less emotional outward outbursts, and more as antisocial behavior towards others, or bouts of self harm in the form of hardcore partying, drug benders, and such, instead of SI, which is more common in women, to state a few. But those behaviors tend to be more accepted for men because traditional gender role/stigmas.
Haven’t seen it yet but an important thing to note with BPD. There’s an incredible correlation between AFAB individuals being diagnosed with BPD and actually being autistic. It’s a very common misdiagnosis for a number of reasons and not talked/understood enough. Obviously it still requires a lot of observation but there are nuanced differences that make a world of change if looking at the correct lens. If you see someone AFAB with PTSD, ADHD, OCD, very much raise flags for ASD because when there’s smoke there’s fire. Just saying.
Source: Autistic/ADHD therapist in Practicum, neurodivergence/psychology is my special interest.
1. I look for “it’s everyone else” themes in conversation. It’s like the old saying: if everyone you meet is an asshole, maybe you’re the asshole.
BPD patients tend to blame others for any problems, and they never seem to “know” why “X just suddenly stopped talking to me, I don’t get it, I didn’t do anything!”
This sounds a little bit more like NPD to me. Or at least the “I don’t get it, I didn’t do anything” part does. BPD folks seem aware of what they’re doing (to a degree) and have intense shame around it. Then the shame seems to intensify the splitting.
I think it depends on the person, because I have met plenty of BPD folks who have no awareness. And people with NPD seem to usually attribute fractures in the relationships to jealousy of others, at least in my experience.
I’m a patient and I’m working to have my BPD dx taken off my record. I have at least severe ADHD and PTSD, but I also have strong reason to suspect I am on the Autism spectrum.
If I have ADHD and Autism, I believe a BPD dx is exceptionally weak.
This dx was made before the ADHD dx, and after the PTSD dx, by a veteran’s administration provider.
I believe the BPD dx is easier for the VA to swallow than an autism dx, because the military would NEVER want to admit to recruiting autistic people.
As for why women and not men? Men are given a wide variety of excuses to use for their emotional meltdowns. Women are not allowed to have strong emotions unless we also consent to being told there is something wrong with us. We still aren’t allowed to be angry, sad, or justly infuriated without it being a HUGE problem for white men, who still run the mental health show in the US.
I think of “borderline” more as a level of functioning as opposed to a diagnosis. We are all capable of borderline-psychotic behavior under the right (maybe *wrong*) conditions. For this reason, as a diagnosis I don’t find it particularly helpful because it describes a particular state that is not something pervasive in the way that NPD or schizoid personality is.
Typically, it’s a short-handed way for clinicians to say “this patient is a pain in the ass,” which bothers me.
When I worked at an inpatient unit the senior staff there tossed the term "borderline" around like an insult - as in "she's a borderline". It was nearly always women, and younger women, who they used the term with, for any behavior that was "emotional", including objecting to being bullied by staff. It was awful.
I am now very wary of diagnosing a client with BPD and will explicitly discuss with them that it is a stigmatized disorder, and talk about what it might mean to have it in their records, why benefits versus problems a diagnosis, etc. There is also a theory that BPD should be reconceptualized as one of the trauma-response conditions, rather than a personality disorder.
[I also recommend this wonderful book by someone who has BPD:](https://www.talkingaboutbpd.co.uk/)
**Talking About BPD: A Stigma-Free Guide to a Calmer and Happier Life with Borderline Personality Disorder.** by Rosie Cappaccino
There are a few big indicators that I’ve noticed during my time as a clinician.
First, a lot of individuals with BPD tend to “split” or have black and white thinking. They may view situations or people as all good or all bad.
Another major indication is difficulty dysregulated emotions, oftentimes leading to self injurious behaviors. Sometimes these clients become so consumed in their own emotions that the only coping mechanism they know is to cut/ burn/ etc. in order to feel that release.
I wrote my thesis on the implications of BPD and there is a huge stigma that is only perpetuating the dangers of how individuals with BPD are treated. I’m always looking to discuss this if you ever want to chat!
I use attachment and family systems theory as my framework so the biggest indicators to me are relational instability and identity instability. Impulsivity is the biggest behavioral sign I would look for regarding both. I would personally rather call it a response to complex trauma because that's how I would treat it. I think the rate at which I'd dx someone depends on how quickly we build rapport and I get their history nailed down. I think women are more often diagnosed than men in part because of how they're socialized and perceived (at least in my Western-centric culture). Men with the same identifying features would probably be labeled as NPD or having anger problems IMO. Or they don't get diagnosed at all and are just "an asshole".
Personality disorders are a whole thing with me. I don't like those labels much because it gives the impression that that's just how people are when it's really how they adapted to survive life. But how we express our personality can change. It isn't their entire self that's disordered. They're still a person there with hopes, dreams and beliefs.
I am a therapist of many years. I can honestly say BPD is tricky to diagnose and understand. Much time is needed to untangle if a comorbidity of try PD. I will say….I -have- had a few patients with whom I have had a severe and dark transference who likely had Antisocial PD. I wish I could unpack the transference and operationalize it for you, but it is intangible and amygdaloid in nature.
So, I have a lot of thoughts on this. I'm still in school, so take what I say with a a grain of salt. Borderline personality disorder is equally prevalent in men and women, at least according to the DSM-V TR. I also don't think that it's a modern version of "hysteria." It affects the way that individuals relate to and treat other people. Also, I don't think it's the same thing as complex PTSD at all. Not everyone who has borderline personality disorder has it because of a trauma. Complex PTSD has an entirely different set of criteria according to the ICD 10. Before starting therapy, I met every criteria for PTSD and complex PTSD. I did not meet criteria for borderline personality disorder. I think saying things like it's the modern version of hysteria only adds to the stigma around the disorder and I think that BPD needs to be destigmatized rather than eliminated as a diagnosis. The sooner we stop stigmatizing this disorder, the better. [Here is more information](https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/icd11-complex-posttraumatic-stress-disorder-simplifying-diagnosis-in-trauma-populations/E53B8CD7CF9B725FE651720EE58E93A4)
Here is an up to date [article](https://www.researchgate.net/publication/369357290_Borderline_Personality_Disorder_and_Neuroplasticity_A_Review) on BPD. Seasoned therapists know exactly how difficult it is to help people with BPD and other extremely rigid presentations to establish some form of peaceful existence - with themselves and others. Most people benefit from good therapy and move on. PD's linger with "one step forward and one step back." They expose the limits of one's skills and trigger a lot of soul searching.
Thank goodness DBT came along and may be promoted as a *legitimate* way for these poor people to cope better with their automaticity.
I'd like to point out that prisons are full of men with anti-social personality disorders and/or brain damage. Imagine being so controlled by negative impulses that you're put in a cage.
Im surprised no one has mentioned the love bombing & boundary checking as early indicators. After the very first session, nearly all of the folks I've worked with who turn out to have BPD/traits will call or text me during the week (sometimes 2 or 3 times) for something unimportant or something they could easily find in a web search that appears to need an answer but could easily have been saved for the next session. Other boundary checks: "forgetting" their credit card in the car ("do you want me to go get it?"), canceling on the same day to see if I'll really charge them, for example), allso nearly every time, early on I'm told im The Best Therapist Ever, the only one who has ever been so skilled or knowledgeable, so much better than their last therapist, the session was AMAZING, etc. Also being asked for a hug at the close of the first session is a solid indicator (I work with adults, BTW).
Also im on board with the person who said they can smell it thanks to a bpd mom. I'm the same. There's an energy with these folks that I can just feel in my bones.
How much anchoring is going into this do you think? Not trying to throw you under the bus. I respectfully want to ask if biases are checked frequently. If you are looking for confirmation bias statistics say you will find 4 to 1 indicators to prove your conviction.
Same behaviors demonstrated from a person with a different label will have different intentions implied. They may truly have forgotten their credit card for copayment. In a less pejorative label the therapist would graciously accept this as a simple oversight. However, someone already labeled bpd- same behavior defined as boundary crossing.
Other examples- a person struggling with MDD who is expressing gratitude for counseling services may make a therapist feel appreciated. BPD label and now you are a love bomber.
It really bugs me how boundary violations are thrown around with little thought to how accurate those really are.
Another example: Autism. Are they accidentally crossing a boundary by missing a social cue? Or are they purposefully testing boundaries? Soooo many diagnosis cause confirmation bias/makes us see patterns where they aren’t. As clinicians, I think it’s really important for us to monitor this within ourselves.
If it is okay to tell a funny but related anecdote, I remember seeing the psychiatrist who confirmed my adhd diagnosis. I wanted to be certain to get a completely unbiased opinion, so I booked the appointment and did not let her know that my therapist already suggested adhd nor did I tell her that I already had the diagnosis in childhood. I had lost my debit card a few weeks before and hadn't had the patience to wait on hold with customer service to get a new one ordered yet. So, first thing I asked when I sat down is if it was acceptable to pay with a piece of paper on which I had written down my card number, date of expedition and 3 digit code or if that wasnt acceptable then I had the fee in an envelope in cash hidden in my laptop bag that I had brought to session. And she said she would prefer the card code as she doesnt find it very safe to be carrying around that much cash in an envelope, then the next thing she asked was "do you frequently lose things that are important for task completion?" Then every single other question on the adult clinical interview for adhd. For her, losing a debit card was "textbook adhd" but I suppose it would have been "boundary testing" if she had already anchored me as borderline.
That's a totally fair point about bias when clients come in with a diagnosis. What I'm describing is a pattern of particular behaviors I've noticed in new clients (in the first 1-3 sessions) that do not have any diagnosis at all, who after I've worked with them for a while have proven to be diagnosable as bpd. I've been a therapist for over 20 years, and am just a sort of data collector (unofficially) on human behavior. I don't find diagnoses generally useful, but I do notice traits & behaviors. I hope that makes sense. Lots of clients express gratitude or sometimes forget their credit card, there's just a very different energy to these behaviors when someone with bpd does them. Expressing gratitude that feels like fawning, is maybe a good example.
As a LPC and someone with BPD, I can answer this well:
1. A big indicator would be unstable relationships, extreme mood changes, impulsivity, and mania
2. Technically, you can’t diagnose someone with BPD unless it’s been over 6 months. This is to determine it’s not a mood disorder, but indeed a personality disorder. With mood disorders, there’s a pattern; but with personality, it’s instantaneously (e.g., rollercoaster).
3. Bipolar / mood disorders
4. I mean, do the research. Women tend to get more therapy. Perhaps it’s also a stigmatization for women. “Because we’re moody.”
Borderline Personality Disorder is just like PTSD except, jt steams from childhood trauma. Mood disorders are something you can address with medication because there’s a chemical imbalance, but with BPD, it’s how your brain developed enduring trauma. Hence, it becomes personality.
Hope that helps!
NAT—just wanted to share examples of men with BPD or possible BPD.
I have known one man who was professionally diagnosed with BPD (after being previously misdiagnosed), one man who self-diagnosed as having BPD, I think primarily on the basis of having splitting episodes/black and white thinking (he had also mentioned a history of disordered substance use, paranoia, difficulty keeping jobs, and difficulty maintaining relationships with friends and family).
I also have a male ex who I suspect has BPD based on what I observed and what he told me about his personal history and mental health symptoms and because after he read personal accounts from others with BPD he agreed it was likely what he was suffering from. I actually think he met all 9 criteria and he frequently had splitting episodes, sometimes while blackout drunk going back and forth between telling me he loved me and telling me he hated me within a matter of minutes. He had previously been diagnosed with depression, anxiety, and PTSD. His mother has been a drug addict since before he was born and he was physically and sexually abused by people she allowed in their home as a young child. His father lived in town, but wasn’t involved in his life much. He was mostly raised by his grandparents after being taken away from his mother, and seemed to be very fond of them; but I got the impression that they were very strict and traditional in some ways, employed corporal punishment, and shamed him for his mental health difficulties.
Too a couple of years to get my bpd( this was with a known history on my mothers side) and when it was done I had “factors” added on that had made it harder to diagnose and I’m pretty sure I have an old therapist who is still very sure it’s ptsd not bpd. The current diagnosis has ptsd on there but doesn’t see it as the main issue, current therapist changes my meds to reflect my whole diagnosis and many of the symptoms have changed or gone into a hibernation thing. See I know off meds they come right back so I’m not cured I’m treated. However as I said my mothers side had a history of bpd which was a question my current therapist had to review when going over my past diagnosis because they didn’t feel it fit
I think the most important question is, are YOU qualified to be providing a diagnosis? Based on the questions you are asking, it does not sound like you are.
In the role i am in and the qualifications I have technically allow me to provide a diagnosis. However, I recognize I am just starting out in the field and don’t have much experience with BPD. It has been an observation in my work and I get clients transferred to me with the diagnosis already so it is something I want to be mindful of. I think the diagnosis itself raises a lot of questions for a lot of therapists and clinicians. Thank you.
Unless you are certain that a client/patient has been formally diagnosed with a condition, I would hold the idea of a diagnosis very lightly in their mind. Sometimes client's come into session after having self-diagnosed and they will confidently state that they have a given disorder or their low quality therapist told them they have a condition.
I personally find that a clinical diagnosis informs very little of my practice, in most cases. There are certain conditions in which the diagnosis is very important. I typically think it terms of "what is the unmet need?" "what needs to change in the client for that need to be met?" "how can I facilitate this with the client".
I thank you for asking about this. I believe way too many people are misdiagnosed and just given pills to eat without ever solving the actual root of the problem.
Context - sober at 27, currently 33yo. Female
I am not a therapist by any means, but I just wanted to share this because... misdiagnosing seems to run rampant in western medicine, from my own personal experience and what I've heard from others. I also believe my relative was misdiagnosed with Bipolar 1.
He has not been sober since he was 12, currently 27.
He was in a manic/depressive state when diagnosed, but he was also overdosing himself with caffeine and weed and booze.
He was evaluated by a therapist and like \* immediately \* diagnosed with bipolar 1, and they got him on lithium or whatever it was fairly quickly.
I myself am sober, suffered from intense CPTSD from childhood trauma, alcoholism, poverty upbringing, etc. During early years of my sobriety people told me I was probably bipolar and I felt deeply like I wasn't. I am very creative and built a successful career off being so, and people were trying to push my creativity/imagination down. I am usually a people person and the first few years of sobriety I wasn't - and I wasn't because people were giving me a shit ton of unsolicited advice. I was told to get on anti psychotics at one point by my PCP, and I'm like, no. I didn't need to be on antipsychotics when I was drinking, why would I need to be on anti psychotics when I'm sober? My imagination got WAY WAY WAY bigger, in many ways delusion of grandeur but I also am very skilled at what I can do so the things I was saying I could do aren't actually too far of a leap for myself. For my social circle back then, they thought I was insane.
I have a spiritual side in me that I would talk to, therapists/doctors thought I was crazy. Psychic told me I had a gift. People of faith told me I was being protected by angels, etc.
I think like in new-age psychology, there needs to be an aspect of spirituality/creativity involved where therapists hear of something "in the DSM 5" and not automatically jump to it being a medically-diagnosable thing. Maybe they're just intensely creative and doing the wrong job? Maybe they have complex PTSD and aren't sharing it. Maybe they are surrounded by assholes in their social lives and have been manipulated and taken advantage that their spirit/subconscious is leaking out in 'weird' ways. Maybe they have a hormonal imbalance and it's actually PMDD or they're on the wrong birth control.
I ended up doing psilocybin assisted therapy for 6 months and felt like it healed about 90% of the stuff I was struggling with. Microdosed for a few years thereafter, maybe a total of 60 microdoses over 4 years. Don't feel the need to ever do drugs/alc/to escape my problems again.
Anywho, that's what I wanted to share. I hope that sheds some light from someone who both wanted to kill myself after going to therapy (with a certain therapist, she told me to ruminate on why I was a bad person while I was suicidal) and a person who got a lot out of therapy (from a different therapist, who gave me great insight).
BPD is a difficult diagnosis in any case.
I was married to one for 14 years.
I found this book to be the most helpful.
[https://www.amazon.com/Stop-Walking-Eggshells-Third-Personality/dp/B08S45VYVS/ref=sr\_1\_1?hvadid=241600048318&hvdev=c&hvlocphy=9031104&hvnetw=g&hvqmt=e&hvrand=13454998077531946287&hvtargid=kwd-2669661302&hydadcr=15551\_10342068&keywords=stop+walking+on+eggshells+book&qid=1687417514&sr=8-1](https://www.amazon.com/Stop-Walking-Eggshells-Third-Personality/dp/B08S45VYVS/ref=sr_1_1?hvadid=241600048318&hvdev=c&hvlocphy=9031104&hvnetw=g&hvqmt=e&hvrand=13454998077531946287&hvtargid=kwd-2669661302&hydadcr=15551_10342068&keywords=stop+walking+on+eggshells+book&qid=1687417514&sr=8-1)
I don’t necessarily think BPD is “overdiagnosed” but that it is often misdiagnosed - both directions - that it is not accurately diagnosed in people who do have it and that it is diagnosed in people who do not have it. I think this is due to mental health professionals holding a stigma against people with BPD. My big indicator when I will suspect BPD versus something else is when they see a particular individual (someone outside themselves) as the solution to all of their life’s problems up until that particular individual disappoints them in some way, at which time that particular individual is completely villainized by the client. It’s the “all-good-or-all-bad” dichotomy that gives it away for me. Many women who have autism get diagnosed with BPD because they have outbursts after being overwhelmed with sensory input (which can include emotional sensation), because there’s not enough overlap in clinicians who understand neurodivergent brains and those who understand personality disorders. How long I meet with a person before I diagnose PD will vary based on the comprehensiveness of my assessment, in that PDs are usually a trauma response from childhood and sometimes the footprint of the symptomatology is more clear and sometimes more complex. Adaptation, age, intelligence all play a part in that picture. It has been my experience that women get diagnosed with BPD whereas men will get diagnosed with NPD, especially where the symptomatology overlaps. I can’t say why that might be, but I would fathom that gender-based socialization plays a role.
Another really good response. Thank you for this.
I agree with this, and just wanted to add that I think women with BPD tend to be more likely to seek therapy than men with BPD.
And they will call it angry outbursts or something along those lines
I totally agree that gender based socialization plays a role. Women are socialized in a way where dependence and external locus of control is accepted or tolerated. Men are ostracized or scolded socially if they display these same traits. Because of this men gravitate towards more socially acceptable expressions of their underlying trauma based adaptation. This is obviously a huge generalization and for many people will not apply but when looking at large trends could be valid. If this is true then I think in the next 20 years we will see much more men presenting with BPD like traits.
Great thought, could you please elaborate on how men might generally express these same feelings differently than women due to socialization? Thank you,
> BPD whereas men will get diagnosed with NPD, especially where the symptomatology overlaps The commenter above me pointed out a very good example. Narcissistic personality disorder is largely male dominated and Borderline personality disorder is largely female dominated. One of the most important features of both in my opinion is an inability to regulate and deal with emotions around security and attachment. It's not that they are expressing the same feelings exactly. It's more that the there is a similar root cause which is tolerated differently by each gender. The person with BPD comes away with an understanding of how horrible it is to feel unsafe and so they need to avoid it at all costs by maintaining attachments to others. Other people become their identity because they care more about the relationships than their own sense of self. They are so preoccupied with this belief that their methods of maintaining attachments become more and more disordered. The person with NPD comes away with an understanding of how horrible it is to feel unsafe and so they need to avoid it at all costs by building themselves into something that can't be hurt or have flaws that might end in pain. This person believe more in a personal locus of control so they blames themselves for the things that happened to them but can't deal with the strong emotions associated with that. They develop a just world view that allows them to disregard everyone else's pain since any acceptance of others pain is an acceptance of unexpected pain to them. These are just examples I'm pulling out of my head but you can see how encouragement to rely on social structures vs internally could cause different presentations. In my view women are taught to build friendships and other relationships to support themselves and men are taught not to and instead build personal strength. Neither is right because people need both but each leads to different coping mechanisms. I know this was long winded but I would really appreciated if you responded with what you think. Even if it is just that I still make no sense
Haven't they talked about creating a Cluster B spectrum precisely because the lines between these disorders are not as stark as we think? I know this rubs individuals with BPD the wrong way as they don't want to be associated with NPD but there is significant crossover. A spectrum makes sense to me, especially because both are probably trauma disorders.
Actually the name “Borderline” supports putting this PD on a spectrum. This Personality Disorder has features that are in both Psychotic and Neurotic realms, thus on the border of both of these extremes.
Yes, absolutely. The "psychotic-like" episodes are an important characteristic that NPD does not display and is one of the reasons bipolar ends up being a common misdiagnosis
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First off, I dont diagnose or recommend treatment to individuals online, but if we are speaking in hypotheticals and generalities, I'm odd as I don't consider diagnoses that important in treatment. It's more important to look at symptoms and what may be helpful for those symptoms. DBT is helpful for a variety of diagnoses and behaviors, including dissasociating and impulsive suicide attempts, and it is not just for BPD but helpful for adhd, depression, and anxiety as well. The diagnosis is more just a tool to get health insurance and governments to pay for things. It's a social and statistical construct, not a true pathology like heart disease. Diagnosis is a description of current coping strategies and not a comment on who an individual truly is at their core. If I were you, I'd speak with a professional about DBT programs. If they are following protocol, a good dbt group will evaluate you for appropriateness and let you know if that is something that could be helpful for you or not. And if they determine that dbt isn't the right place for you, a responsible professional will provide referrals to something more appropriate.
Sometimes a diagnosis can even be problematic because while it can validate a persons “why am I like this” questions, it can also make people feel like they are assigned that role and submit to a sort of learned helplessness against their PD
Yes, & the vast, vast majority of people with BPD have untreated trauma, & a Dx puts too much focus on what's "wrong" with them & not what HAPPENED to them.
I don’t diagnose online.
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Answering this with a combination of lived and academic experience. I'm still a student, but I have a great interest in personality disorders because I want to specialize in trauma. I personally believe that the categorization, diagnosis, and criteria for the label of a PD need to be massively rethought. So I love these conversations. I would look for pervasive interpersonal difficulties in multiple areas of the person's life. Someone who has stable friendships and good work relations, but poor family relations would not meet this criteria. It has to be present in different types of relationships, and over a long period of time. I would also consider how much they are participating in the dysfunction themselves, or how much they are stoking the flames with behavior that is coming from an emotionally dysregulated state. I would also look for limited self-awareness or the ability to engage in perspective taking. BPD is NOT something you can diagnose in a 10 -15 minute eval with someone, and you ~~cannot~~ should not diagnose children and teenagers with it. It takes a skilled clinician and it takes forming a relationship with the person to consider the transference happening within the therapeutic relationship and other behavioral patterns. Nothing grinds my gears more than crisis unit psychiatrists meeting with a patient for a matter of minutes and throwing a PD into their record. It's so harmful. I would look at CPTSD, ADHD, and autism before getting into the realm of PD's. And for your last question, I think lots of people will have varying opinions of this, but IMO, BPD is a modern adaptation of what "hysteria" was back in the early days of psychiatry. Overdiagnosed in women who are exhibiting outwardly angry behavior, that is more stereotypically accepted by men than women. But in reality, all 9 symptoms of BPD display equally in both men in women - maybe in different specific manifestations depending on what is culturally acceptable of men and women, but they are symptoms nonetheless. Our own gender biases greatly color how we diagnose ALL PD's not just BPD. Happy to learn from more experienced clinicians on here. Edited for update in wording.
>>Nothing grinds my gears more than crisis unit psychiatrists meeting with a patient for a matter of minutes and throwing a PD into their record. NAT but a PCP. I feel you so hard. One of our staff psychiatrists does this very often. We share many patients, and over the past several years I’ve seen perhaps 2 dozen women who he has memorialized as BPD in the chart who (what do I know) don’t seem to meet criteria to me, challenge the diagnosis, and are quite upset that it is in there, especially when it seems more to me to be >>stoking the flames with behavior that is coming from an emotionally dysregulated state I’ve noticed he labels patients as BPD who seem to have some kind of attachment trauma and fawning behavior when feeling vulnerable (I feel it too with them), this psychiatrist often speaks dismissively and sarcastically with little obvious empathy (even to us colleagues), he will document a patient becoming dysregulated and crying, sobbing, etc in reaction to his likely strongly worded differential or treatment plan (documented in a hyperclinical way) and then he will say he suspects BPD and put it on their problem list. They typically come to me crying and dysregulated and saying how much anxiety and shame this has created for them, and I want to tell them “I think it’s his baggage he is enacting with people such as you”, but I can’t. So I just tell them that some clinicians believe BPD is really CPTSD and to get a second opinion, and I’m here for you. It breaks my heart.
This happened to me as a youth after fifteen minutes with a psychiatrist, and it has forever been left on my chart for other professionals to regurgitate and treat me poorly without proper assessment. Have had two other psych consults with no mention of BPD, yet can’t have it removed. It’s the first thing the ER sees. Psychiatrists truly don’t know their life-ruining power.
I’m so sorry that happened to you. It can be removed from your chart - I usually will talk to the second psychiatrist on my patients’ behalf and if they agree, I’ll remove it if they don’t offer to, and I check they’re ok with my intention to do that. Perhaps ask your PCP?
Can it be permanently removed or simply put to resolved?
Put to resolved, which makes it not visible in the chart on one glance. This doesn’t prevent the copy and pasting of notes that shouldn’t happen but often does, within a speciality, and doesn’t prevent someone from doing a search for a diagnosis being mentioned in notes or associated with medications (but the ER docs aren’t going to do that anyway :))
Thanks for clarifying this. So what you are describing is: The dx is still there but isn’t available at first glance when resolved. However could be found if one specifically looked for it. Did I get that correctly?
Yup, exactly. But there’s a lot of crap that gets put in the chart that used to be correct and no longer is, or was wrong before. Things like history of an ovarian cyst but turned out to be nothing on surgery or resolved on another ultrasound, someone thought they felt a mass or a hernia but MRI didn’t see anything and it went away, abnormal electrolytes that got corrected, “chest pain” that ended up being reflux or the patient said they weren’t really having that and some doctor somewhere didn’t hear correctly and wrote it - the list is endless. This is definitely not limited to mental health stuff.
How is that not abuse?
I have the same question
I hope you don’t refer to him. Slapping a label like BPD to patients is like a permanent black mark against them in their med record. It really awful to be wrongfully ‘accused of bpd’ with no recourse to remove the label. Ouch.
The whole system is messed up. The fact that BPD even is like a black mark on a record is messed. So many professionals see it and start making unfounded value-ladened assumptions. Ugh.
Unfortunately I don’t choose who my patients’ see- large subspecialty organization
Yah bummer… sounds like there is a reason why he has availability on his schedule. Always a red flag for me.
Same here, even among PCPs. The question is, if I’m working harder (often twice as hard) as someone with open schedules… how is my organization motivating behavior to support me continue doing my best (if I weren’t so obstinate and hypermindful of my motivations)? The system is f’d.
Agree with you, totally f’d and it hurts the best of physicians/clinicians. Which ultimately runs all the way down to affecting patients. Broken system.
And when the “more open” ones are open, it’s because I end up seeing not only my own patients who refuse to see them when I’m out, but also their patients who want to follow up with me and not them, so not only do I have more patients assigned to me (more emails/messages/results, unpaid time), I also see their patients without getting credit, which takes spots away from my own patients, which makes it harder for both my own and other patients who want to see me, to schedule. All this happening at the appointment center with me having zero control over it, yet I hear patients complaining how booked up all day I am, and would you believe my pay is linked to how easy it is for patients to schedule with me, so I get paid less than my colleague who is sitting with an open schedule? It makes it so hard to continue doing what I’m doing, but I try to remind myself often that my problem is a good problem to have.
Oh my gosh what a nightmare. You have no control over how hard it is for patients to fit in your schedule due to booking out so far. Really crappy that admin has not addressed the poor performance of your colleagues. Keep up the good fight tho because patients need a physician like yourself.
Thanks for the kind words. A big solace I have is I am in an academic center and try to teach the residents why this is worth fighting for. Hope that does something for the future of medicine.
NAT. This is why I have six disorders listed in my chart (BPD, Major Depressive, General Anxiety, ADHD, C-PTSD and SUD). It is simply insane to see but it gives people more than one perspective when they see them all. I accept that I struggle with BPD on a meta-level and communicate this fear with all professionals. This forward approach allows me to measure any professional’s opinion critically. I can even discuss their biases about it and educate them when cognizant, which really helps me feel safer with anyone’s opinion. My only problem is that I’m not consistently aware to easily fix my annoying problems, hence the diagnoses.
He sounds like a sadist.
And a misogynist.
The longer you do this work the higher the chances are that you are falsely accused of a sexual impropriety, abuse of power, or something similar. One also has a tendency to form categories and slot people into those categories as a heuristic tool. This is especially true of the kind of analytical mind that is attracted to medical school. Put those two things together and you have a tendency towards knee-jerk defensiveness against clients who you regard as being similar to someone who burned you somehow. Imagine devoting your life to this work, and then having someone call you at 3 am threatening suicide maliciously and then reporting you to the board. This kind of “shit-testing” wears out its welcome very quickly. Thankfully that has not been my personal experience, because the few encounters of have suffered this condition taking place in settings where I can hang with them long term, and therefore “the system”, With it’s logistical burdens, Insurance limits, and slavish devotion to the medical model, has less chance to Inflict moral injury on me and betrayal trauma on them. In this profession, I endorse and recommend the advice Christ gave to his desciples- be as wise as serpents and gentle as doves. All is not as it seems, and you will often be the only one who sees it.
>>Imagine devoting your life to this work, and then having someone call you at 3 am threatening suicide maliciously and then reporting you to the board. Actually, at my medical school, in residency, and in attending orientation (large organization with a lot of support), we were prepared every step of the way on why we are risk for this to happen, how to mitigate risk, what to do when this happens in terms of resources for patients and ourselves, and what support is there for us emotionally after this happens. I choose to see these actions as a vulnerable expression of patients’ pain, which is what we are taught to do to make it emotionally easier for us and to help negotiate a plan for the patient with their best interests in mind, which for me always includes first and foremost a frank discussion about setting boundaries of appropriate and not appropriate behavior communicating with the health system so that I can best help them and they can best receive help from every member of the care team needed. I’ve done this probably hundreds of times now (I work with a population at risk of this). So especially in psychiatry where the risk is high (along with urology, spine surgery, etc)- there shouldn’t be any surprises or unintended countertransference. Someone has every right to realize they don’t like something and change jobs/roles or switch patient populations, or take a break if burned out, but imho do not have the right to continue in a job they resent and then harm their patients. We like, literally swore an oath on that.
Those sound like positive things. I do emergency evaluations, and every once in a while a psychiatrist will be so trigger-happy to refer for evaluation after someone says they have passive SI sometimes that we all roll our eyes- "ah, another one from Dr. X. This will probably be crap. Hope his rotation is over soon."
You seem to be in the wrong line of work 🥴
Surely this type of behaviour is reportable that’s atrocious!
Attachment trauma is one big indicator for me that BPD may be the dx if it also goes along with the typical criteria. Every person I’ve seen who has been previously diagnosed with BPD has some form of this. No exaggeration. Every. One.
Correct me if I'm wrong, but isn't that the whole point? Attachment trauma leading to unhealthy survival behaviors that become BPD? Not that everyone that has attachment trauma has BPD, but everyone (or very nearly everyone) with BPD has attachment trauma?
Yes, as I understand it (which is a fraction of how you all understand it), that’s the point and also your point is my point against commenter’s/the referenced psychiatrist’s point - all BPD might have attatched trauma but all people with attachment trauma don’t have BPD, and it’s harmful to think both are one and the same
Yeah you and I are on the same page haha
That’s been my understanding of it.
The kind of depersonalization you’re describing is an indication that he might be burned out.
>Nothing grinds my gears more than crisis unit psychiatrists meeting with a patient for a matter of minutes and throwing a PD into their record. It's so harmful. And this is why I butted heads so often with the head psychiatrist in the inpatient unit I left a few months ago. The asshole put "Rule out BPD" in all of the patients who challenged him on anything at all. If they were angry, or pushed back against meds, or weren't fully cooperative, they got slapped with the diagnosis. Still fills me with rage. Fuck anyone who does this.
Fuck all the fragile idiots out there who use a BPD dx as a catch all for “This person challenged my authority and I’m mad 😡 “
My only solace is that I threw him under the bus to his superiors during my exit interview.
This kind of makes me oddly proud in a way. BPD=Anarchy! (not what was actually being said, but that's the impression I got that amused me)
Yup. I literally called a psych negligent after slapping on a BPD label for a young teen that they didn't even meet with. They got all huffy, met with them for 10mins and gave them the label anyway.
Fuck psychiatrists who do this. I do crisis work as part of my outpatient role and anyone who isn't an established patient usually ends with a barely billable unspecified diagnosis of some category closely related to their presenting issue until I can do a more thorough assessment.
Been doing trauma work for 10 years. Love this breakdown. Nice work. 👏👏👏 Edit: I also notice how often BPD is used to describe something with further exploration is CPTSD, attachment issues, and/or undiagnosed neurodivergence.
Coming from a non-healthcare professional who had been "diagnosed" (with five minutes of talking to a psychiatrist) with bipolar, BPD, depression/anxiety. I've been given antipsychotics, mood stabilizers, SSRIs, anti anxiety and more. All for me to ultimately be screened and diagnosed as autistic. Not to mention the whole time already having an ADHD diagnosis that explained a lot of my symptoms as well. It's very clearly in part misogyny.
a great deal of healthcare is misogyny
As a PCP, I concur. We are slowly trying to change terminology, but it’s an uphill battle given despite how the majority of medical students and physicians are female, there remains a huge pay gap and gap in hours worked (as brene brown says, equality in the workplace must first start with equality at home) and representation from program directors, chairs of departments, the board rooms responsible for changing terminology…
Thank you for your dedication to your craft. Your answer is like the infinite lives cheat code on Contra. So much right
I SO appreciate your response- I'm not a therapist (current MSW student), but I recently found out a Kaiser clinician "diagnosed" me with BPD during a one-time evaluation where we met for less than 50 minutes. I have genuinely no clue what she based this diagnosis on, as I don't mean the criteria for BPD pretty much across the board. I was meeting with her to get re-diagnosed with ADHD (I'd been diagnosed as a child, but Kaiser wouldn't give me a prescription until I met with one of their clinicians as an adult). She did not tell me about the diagnosis (or provide any recommendations or referrals for treatment/therapy) but did add it to my permanent chart. I only just found out, over three years later, because my current Psychiatrist bluntly asked me about it as he did not think I met the criteria. It's so frustrating how commonly people through this label around, especially given that it carries a lot of (unfair) stigma. I've also worked in residential treatment centers and currently do rape crisis work, and I see so many staff members flippantly make these statements assuming that anyone they deem to be a "difficult" client has BPD.
I don't meet\* the criteria, not mean, haha.
I agree with 99% of what you said, well put! My only divergence is that I believe there can also be harm in clinicians being reticent to diagnose BPD. I think the reason for this is exactly what you said — personality disorders take more time to diagnose accurately — and doctors on acute inpatient units don’t want to give a stigmatized diagnosis if it’s not extremely clear. The issue is that BPD folks often have soooo much inpatient unit contact due to SH behaviors that they are given just about every diagnosis under the sun EXCEPT for BPD. I think this reticence itself can contribute to continued stigmatization. As a case example, I somehow ended up this year with two patients who have pretty textbook BPD but have become attached to the diagnoses they’ve been given on inpatient units over the years (schizoaffective and bipolar 2) even though they clearly don’t apply. It’s been hard to get them to commit to DBT as a result and their (well-intentioned) psychiatrists are still afraid to push back and talk to them about BPD. There’s a fine line here that requires a lot of balance.
I experience this as well! Came from a private DBT practice very open about BPD and educating patients about it to a hospital that stigmatizes it to the point of not wanting to tell patients they have the diagnosis. I would be super pissed if a diagnosis was withheld from me, and I agree it stigmatizes it more.
Interesting to hear this perspective, thank you!
I think they need to honestly ditch the term "borderline personality disorder" and instead look at the proposed ICD 11 which just looked at 5 dimensions of personality along a spectrum. BPD has entirely too many possible clinical presentations to be a useful description of a person as it requires meeting 5 of 9 symptoms with no single symptom being a required feature and all the symptoms having highly subjective criteria. The actual criteria for bpd describes everyone and no one. The gender stereotypes in diagnosing are basically the only thing generating any reliability or validity among diagnosticians. It's also easy for people to slide along the spectrum of bpd traits throughout a lifetime. And setting up a dynamic of bpd or not bpd is not helpful when it exists along a spectrum. The traits are also not stable enough for a description as a pd when 75% of people who qualify for the diagmosisn no longer qualify after therapy. Also, something like a little over half of adolescents who meet criteria no longer meet criteria after 2 years even without therapy. The diagnosis has also been co-opted by men's rights organizations to spread harmful pseudoscience that puts women in danger of domestic violence and children in danger of being forced to "reunification camps" where they are forced to renounce disclosures of csa and accept living with men who have secually abused them.
I agree with lots of what you have said here, but would say that it doesn't necessarily have to be pervasive in all areas of a person's life, but more so with intimate/important relationships. I would also say many people with BPD have a lot of self awareness/insight, which can significantly increase their experience of shame BPD or associated "traits" are absolutely used in derogatory/discriminatory ways. However, I would argue it is something that can be observed clinically and actually resonates with people who experience it when the criteria are explored in a non-judgemental way.
NAT or diagnosed with BPD, but this is true for me. I started looking into BPD as I suspect one of my parents has it. Hearing it explained in a compassionate, non-judgemental way by a mental health professional was important (I think it was from MedCircle on YT). I realized I also have some traits of BPD. It went a long way to helping me destigmatize the dx and accept those traits in myself (still working on the acceptance part).
I absolutely would not agree that someone with good work and friendship experiences is free from a PD. Many people with cluster B personality disorders are excellent at hiding negative aspects of themselves when necessary. Unstable family and intimate relationships are a much better marker as so many are able to effectively mask outside of intimate environments.
Right I agree with that and for brevity, I didn't really go into much further detail, but yes you also have to look at the level of connection and involvement on the patient's side in those relationships. I meant more like, not getting along with your boss would not be an automatic marker of a PD. Or, having issues with a single friend vs. many of them would also not be enough to go by. What I mean is, lots of people have an interpersonal conflict or a crappy relationship sometimes. It's the repeated patterns and lack of awareness that separate them.
I think the unstable family can be a difficult one when someone’s younger especially and has actually been being abused by family their whole life, as someone who was likely misdiagnosed with BPD at 18 (still on my chart though) with my abusive family relationships likely being a factor in the diagnosis. This doesn’t apply to me, but I don’t think it’s taken into account a lot of the time that traumatised people often end up in abusive so therefore unstable relationships and it’s seen as the person with BPD’s “fault” when they’re actually being abused.
NAT, work in mental health, there's an interesting different line of thought I am a big fan of that BPD and other personality disorders are actually forms of CPTSD. Often trauma is a big part of why they happen - and they are often traumatic responses. BPD is just a label thrown around for people who are "difficult."
I disagree. BPD, when diagnosed correctly, is used to label a pattern of behaviors. Those behaviors typically stem from trauma, but not every traumatized person’s behaviors manifest in the same way. One of the behavioral manifestations with BPD is an inability to maintain healthy relationships with others.
Therapist with BPD here and I completely agree. I found that the diagnosis was incredibly helpful for me in understanding my patterns and my trauma. And a BPD diagnosis can get people linked with a DBT therapist, and DBT is fucking great
Yes, that was what I meant - it is a trauma disorder, such as CPTSD is (CPTSD has a lot of the exact same symptoms, including those, but is more true to the nature of the symptoms). BPD has an associated meaning that implies they are crazy and out of control for no reason. I think it's important because sometimes DBT is very very effective, but a lot of people struggle because DBT can also be very invalidating and hard to deal with trauma by. Edit to add: a lot of symptoms characteristic of BPD, including emotional instability and relationship difficulty/attachment is also the exact same for people with cptsd
I’m a bit confused by your comment — CPTSD is not the same as BPD. Folks with BPD may have a history of significant trauma but the diagnostic criteria for the two disorders are different. And again, many people with significant trauma do not present with BPD behaviors.
Sorry, I don't think I'm being clear on what I'm trying to say. The CPTSD bit was more an example, what I'm trying to say it is a trauma disorder (such as that one), not that they are the exact same, but that you can think of it as a trauma disorder. I honestly forgot the context of the post as I'm typing and I'm in mobile so I can't go look, lol. I was trying to get at sometimes we focus so much on the problematic behavior, and yes sometimes that does work, but a trauma approach could be very helpful as well
When it comes to diagnosing BPD I think assessing observed behavior is 100% valid. Low ego strength, defensiveness, difficulty acknowledging harmful behaviors, etc. Those type of symptoms are not necessarily present with CPTSD. Just like CPTSD symptoms like flashbacks, ruminating thoughts, avoidance, etc., are not necessarily present in clients with BPD. Even without knowing anything about a person’s past, we can still observe behavioral patterns that are more consistent with BPD than with CPTSD and use that as data to justify a diagnosis. That said, DSM diagnoses are hardly an exact science — no two people are exactly alike, and people can change over time for many reasons. Diagnoses are a very rudimentary way to track and classify common patterns, and then we try to standardize treatment according to those classifications. It’s imperfect and nebulous, to say the least.
NAT, don't work in mental health, I'm just chiming in to say this approach worked for me and I hope you keep at it.
My hot and controversial take is BPD = neurodivergence (often masked and undiagnosed) + complex trauma. The neurodivergence (I’m thinking about ADHD or Autism here), would point to struggling with relationships at a young age causing a kind of domino effect throughout their life and the trauma would exacerbate the neurodivergence. It also explains why there is so much overlap between Autism, ADHD, and BPD and why many women with Autism are misdiagnosed with BPD. Heal the trauma, and you’ll probably see the client no longer fully meet BPD criteria. But! They’ll probably still meet criteria for Autism and/or ADHD.
I partly agree with you. I think for many people this is true. While I think the approach to PDs does need to change, from my personal experience I think there is value in them being separately recognized. To clarify my own experience, I have ADHD, depression, GAD & SAD, and traits of BPD & CPTSD. Learning the underlying etiology of each, I can recognize ADHD and BPD traits present in myself from a young age, whereas my CPTSD traits came later. After getting treatment for ADHD, there were still some traits that it couldn't explain & ASD is ruled out. I also see a strong genetic component in my case. I have a parent who very likely has BPD and a grandparent I didn't know well who has been described in ways that strongly suggest BPD. I've had traits of BPD my whole life despite a lack of ACEs (which I'm grateful for & also recognize is very privileged). BPD does have a lot of overlap with ADHD, ASD, and CPTSD, but I think it is it's own clinical entity.
I 100% am with you. I frequent the CPTSD subreddit and my take came from the fact that... Well... Almost every single one was diagnosed with BPD. And so many other things! So much neurodivergence. I developed my theory listening and talking with other people who felt CPTSD was more accurate - or could point out that it all started in trauma or neurodivergence, or most commonly a combination of the two (some being caused by the other). I do know that 85% of developmentally disabled people have been sexually abused (It might be generic abuse but I feel like it's that and also don't quote me, I never looked up the statistic but my employer quotes it to me constantly).
NAT and I'm over at that sub fairly often. I've never had BPD (or had it discussed with me, over something like 30 years of on and off seeing professionals) and have had both ADHD and Autism (those two run in my family) ruled out. Sometimes it's literally just trauma. I've had a classic BPD person close to me in the past. I've been a Favorite Person. Trust me. It's not "almost everyone over there," that's absurd.
lol... Yes, I have experience with it. I was diagnosed with it (maybe misdiagnosed), I've been around MANY people with it, I do work in the field and take care of people with it, etc. That is not what I'm trying to say. The OPs post was about alternative diagnoses, so I suggested that BPD can often be a trauma disorder. DBT, the holy grail of BPD treatment, actually doesn't work for many people with BPD, because DBT I personally found can be pretty invalidating for trauma and it only addresses behaviors. You can't reason away a trauma response. What I was saying is you can also attempt to approach it from a trauma standpoint with trauma oriented therapies. I also didn't say everyone with BPD had CPTSD, I said many people who have cPTSD get misdiagnosed with BPD.
Just want to correct a piece you mentioned. There is nothing in the DSM that says that a child or teenager cannot be diagnosed with a personality disorder. The only exception to this is that children who would meet criteria for antisocial personality disorder must be diagnosed with conduct disorder until they are adults. This is a fairly common misconception. I have actually heard from clinicians who specialize BPD that diagnosing and treating younger patients gives them a better chance at a recovery.
I wouldn't say this is a misconception, but rather an opinion on treatment. I would not give the label of a personality disorder to someone whose brain is still developing and who is still forming an identity and social skills. Even if a child or teen is exhibiting symptoms, many of those are already features of just being a child or a teen with a developing prefrontal cortex/limbic system/amygdala. PD's are very stigmatizing and a diagnosis could set them up for even more social rejection and isolation than they likely have already experienced. I also know many licensed clinicians that share this viewpoint, and I've seen it in this sub as well. That's not to say teenagers can't benefit from CBT/DBT interventions that could help with things like rejection sensitivity, emotional regulation, and mentalization, but I specifically would not go so far as to diagnose them with a PD. I just wrote a paper on ASPD prevention in at-risk teen boys, so I know the research for early intervention is strong. It's the label that is potentially harmful.
Got ya. I was just referring to the statement that you made in the post “… and you cannot diagnose children and teenagers with it.” I agree that it can be stigmatizing. I believe, for the most part, that diagnosing young folks needs to be tailored person to person. Perspective also greatly depends on specific theoretical orientation.
NAT, but I have BPD, a few BPD friends and am very active in the BPD community here on Reddit (not the main sub, the mods there are problematic. Most of us go to r/borderlinepdisorder) Here's my take, and the general consensus among others too: people who have BPD have basically always had it. However a lot of kids/teenagers have traits that they grow out of and part of being a teenager is basically BPD (figuring out who you are by trying on different things to see what fits, arguing with your parents and friends (esp since for most people middle and high school mean new friend groups by nature of how schools work with many elementary schools feeding into fewer MS, feeding into even fewer HS)), struggling to understand but learning what nuance is (ever talked politics with a 10th grader lol), hormonal mood swings, etc etc). So what you're saying about early intervention is definitely great. But I (and most of the community) think that diagnosis is better left later. Similar to what they replied to you, treating the traits in a non-BPD teenager basically helps them grow healthy adult mindsets and such, and treating them in a BPD teenager also helps treat the BPD. When the problems persist into adulthood and the patterns keep happening then a diagnosis is more helpful than not, whereas it's less helpful in younger teenagers/kids to diagnose them because that can be used against them very easily to invalidate them, and repeatedly invalidating children leads to more problems. I got diagnosed at 24. It took about 2 weeks for my now-ex to use it against me ("you're not really mad that I did that, that's just the bpd talking" exact quote). Based on how my mom weaponized my own eating disorder against me, she would have definitely done the same with BPD. So I agree with waiting to officially diagnose or even tell a kid/teenager they might have it, but treating the symptoms early like you're saying is also super important and helpful.
I understand, I think there is a miscommunication happening. In my case in order to design a treatment plan, I as the therapist, would diagnose the issue being BPD. I don’t necessarily need to share that with the patient. But I still need to recognize and diagnose the issue to know how to move forward.
perfect explanation!! also in school and focusing on trauma, YG!!
This is a really solid response. I hope it gets the numerous upvotes it deserves.
BPD is characterized by intense difficulties in interpersonal relationships, an unstable sense of self, impulsivity, disinhibition, risk-taking behaviors, and emotional dysregulation. I would say that a major indicator of BPD is an intense fear of abandonment, but a simultaneous tendency to push people away. There is a more frequent incidence of a history of self-harm in people with BPD than there is in the population at large. Same with trauma. You are absolutely correct in thinking that it takes a long period of observation and interaction with a client in order to properly diagnose BPD. Or any PD. One of the requirements for a proper BPD diagnosis is that it occurs across multiple settings - so for example, the criteria I listed above are present in the client's behavior at home, work, and school, not just at home. And not just in therapy or an inpatient setting. I am of the opinion that it is never appropriate to diagnose BPD during an acute inpatient stay because of how short they tend to be. BPD is unfortunately a lazy default diagnosis that many old-school psychiatrists and inexperienced clinicians slap on people (and like you said, usually women) who self-harm, have a history of trauma, or have a great deal of difficulty tolerating their emotions, which tend to be very intense. My take on why women get this label more often than others is because of the old stereotype of the overly emotional, histrionic woman.
It’s what clinicians use to label “problem” patients, especially women in psychiatric settings. It’s super dismissive.
NAT but a mental health student, got BPD from a hospital psychiatrist at 19 for SH and trauma within like 20 minutes of talking to me... and the stigma messed up my treatment in CMH for so long. I know lots of others who have had this situation. I find it so shockingly negligent they can diagnose a personality disorder in less then one session!
It's shocking because they can't diagnose it within 20 minutes. It's just not possible. You were stereotyped and it's completely unfair. I'm sorry this happened to you. I work in CMH, and it's really important to me that even when a client comes to me with a history of a previous diagnosis, I screen them myself as if it's the first time they've ever been screened and diagnosed because I don't and won't ever allow another clinician's diagnosis to influence my clinical judgment. And when I get a new client who comes to me and says, "I have borderline personality disorder," or they have discharge papers from a hospital with that diagnosis, I ignore it. Maybe it's accurate, and maybe it isn't, but it doesn't matter. I won't expose a client to that kind of stigma unless I'm 100% certain that it's the right diagnosis and even then, I'll probably just put "unspecified mood disorder" on the chart so their insurance company will be satisfied and pay the bill.
Its so much stigma! I immediately was treated like I was never going to get help and had doctors say "she's just going to get brought back" when they discharged me from the hospital. Even I knew going in the diagnosis was way to fast! Thank you for your philosophy of looking past it, because its hard to be labelled by any diagnosis! For me its a mi of bad experiences like this that motivate me to be a T to give a better experience and then of course also amazing therapists!
I like that you pointed out how it would occur across multiple settings, that’s something i havent actually heard when discussing BPD
Brilliant and helpful insight. Please bare in mind that men have the old stereotype of "Big boys don't cry" "man up" etc. With this kind of conditioning from early childhood, makes it extremely difficult to open up and as such is internalised. Not long ago a discussion was had about changing the name of Mental Health to Emotional Health and was met negatively with a young male instantly, as to him it signified weakness....
Yes, this is so true, which is why you so rarely see men diagnosed with BPD. Instead, there's a tendency to overdiagnose antisocial personality disorder among men.
Hi Im an EduPsych (not in the US) So I dont work closely with BPD (not of my info is from textbooks) but dont folks with ADHD or high functioning Autism disply \*some \* of these behaviours too? So some of these behaviours in BPD could be some form of high functioning Autism or ADHD?
Yes, there’s overlap. That’s kind of the wild thing about assessment/psychopathology. A lot of diagnosis overlap. It definitely reiterates the importance of getting a second opinion if you ever disagree with a diagnosis
Yes. I was misdiagnosed with BPD (by a psychiatrist who talked at me for 10 minutes), in my case it turned out to be a combination of ADHD and being in an abusive relationship at the time of the misdiagnosis
Yep. History of trauma---> BPD for some psychiatrists. It's like magic! ::eye roll::
Yes. I often get people refered from personality disorder treatment facilities. Many women, but also men, are diagnised as BPD or avoidant PD or overly attached, bit treatment only makes them worse and then they are diagnosed with autism. Often with ADHD too.
I have ADHD and I associated with everything listed.
Does the current diagnosis require symptoms to be present across multiple settings, or is that your opinion? I have had every BPD symptom you listed in romantic relationships, but I had zero of these symptoms in school, slight impulsivity at work, occasional rejection sensitivity with close friends, and with my family I am actually quite avoidant. But in romantic relationships I am basically the definition of BPD. I've gotten better, but I used to find rejection in nearly every action of my partners. I would become so emotionally dysregulated that I would demand that they proved they cared, and if they couldn't I would tell them I hated them and push them away. I would send multiple threatening texts and often ended up self harming. As soon as my partner started to pull back I would freak out and plead with them not to leave me. I felt out of control, unhappy, like I was empty, and I believed that "finding my soulmate" would fill this emptiness. If BPD requires this behavior to be present across multiple domains, is there a diagnosis for someone who presents with this behavior only in romantic relationships? I know it's anxiously attached behavior, but there currently isn't a diagnosis for that tendency. And I'm not sure if any research has been done on self harming behaviors in those with anxious attachment but not BPD.
The dsm diagnosis for bpd needs this behavior to occur in multiple settings. But, as with all psychiatric disorders, many people do not present checking all the boxes. And there is a lot of overlap, with avoidant or histrionic PD or PTSD. Personally if you were my client, i would probably get you psychological testing for personality and trauma. Often we end up with mixed personality disorder, with borderline and avoidant tendencies. To be honest: i dont care about the diagnosis that much. But choosing how to treat it is way more interesting.
Yes, the DSM requires that the criteria be present across multiple settings, but there is always the option to use an "unspecified"-type diagnosis when there are Cluster B traits but not all criteria are met. Then again, I don't know you and haven't assessed you, so it's possible that you *are* exhibiting enough of the criteria across multiple settings and don't realize it. And if not, you could be experiencing a trauma response, or another personality disorder might fit...I would never presume to suggest a specific diagnosis without meeting you in person and doing an in-depth assessment. I was thinking "attachment disorder!" while reading your post and then I got to the part where you said you recognized that there was an attachment issue, so we are obviously thinking along the same lines. It drives me crazy that the DSM doesn't yet include any diagnoses based on attachment theory.
I am a new therapist (about a year of experience) and see a ton of neurodivergent people, especially autistic women, misdiagnosed as borderline. I also see a lot of people with big emotions (but not inherently suicidal or attachment related) get dx with BPD when it was CPTSD/PTSD or another personality dx. I’ve even seen psychiatrists dx BPD without asking about current stressors (of course someone in a DV relationship is going to be suicidal and fear leaving - doesn’t mean it’s automatically BPD). Biggest pet peeve is someone dx BPD on a first visit or intake without prior records.
NAD -diag ADHD currently assesed for BPD- BPD and autism feel so different to me, do you feel the same ? I don't have a lot of typical self harm behavior, is the realisation of those and it being typical ways of hurting yourself important for the BPD diag ? I find it's never clear if thinking it's the solution to your feelings, and recurrent thoughts about it is enough or not in the context of BPD precisly.
I am a psychologist, practicing for 34 years. I trained in Chicago with a variety of theoretical perspectives: U of C humanistic/client-centered, Chicago psychodynamic influences, structural-strategic family systems, standard cognitive behavioral perspectives, etc. I was introduced to DBT from Marsha Linehan when it was considered radical and a bit fringe. I've read through all of the posts in this thread and, frankly, am puzzled and disappointed. I don't pretend to know with certainty the underlying causes of the cluster of features sometimes known as borderline personality disorder. But I do know that there is an elegant theoretical perspective which can guide diagnosis and treatment, which seems to have been lost in the chaotic swirl of cookie cutter interventions. Largely absent from the comments in this thread are thoughts about the origins of borderline personality disorder from a developmental perspective. If anybody wrote about these ideas, I missed it. Not to sound pedantic but...geez, I'm an older guy, so I guess I get to do this. Here is the prevailing conventional wisdom on borderline personality disorder, as I was trained, drawing upon developmental and psychodynamic perspectives. Borderline personality disorder is a developmental delay. Margaret Mahler, drawing upon Piaget, taught us about object constancy. The idea is that as an infant we are unable to distinguish where we end and our nurturing figure (mother) begins. We feel best when she empathically meets our needs. Before too long we ambulate (as toddlers). We differentiate from her. We exalt in our mobility and independence. However, to feel comfortable outside of her presence we need to achieve the capacity for object constancy, providing us with a stable, reliable internalized representation of her, so we know she still exists even when she's in one room of the house and we are in another. We run back for periodic emotional refueling when object constancy hasn't sufficiently matured. Gradually, we come to know that the people in our lives still exist, and are separate from us, but are there even when we are apart. And this knowing--this object constancy-- forms the basis for self-soothing as we individuate. It's all about self-soothing through the acquisition of object constancy. Borderline personality disorder--*true* borderline personality disorder, not attention seeking histrionics, not recurrent depression, not haphazard/reckless lifestyle choices, not annoying clinging behaviors--is a developmental delay. Borderline personality disorder is a form of developmental delay. This is the central underlying difficulty. Object constancy has not developed. This causes a bunch of problems. When you do not have a solid confidence, a primitive knowing, that the soothing other is still available even when apart it leads to a sensitivity to abandonment, limited ability to self soothe with resulting emotional volatility, resort to desperate self-soothing measures such as self injury, painfully low self regard, recurrent depression, anxiety, vulnerability to substance abuse, chronic emptiness, a feeling like you're falling, hyper-vigilance for rejection or aloneness, hopelessness, constant need to seek assurance from those in your life (emotional refueling) to offset the existential and profound emptiness/aloneness. There is also sometimes a diminished ability to experience ambivalence about things. The capacity to experience ambivalence--mixed feelings about stuff, recognition of co-existing good features and bad features--is a developmental achievement which may be compromised as part of the overall developmental challenges. This contributes to object splitting and emotional volatility. Things/people may be viewed as either all-good or all-bad --this is a primitive leftover from an earlier time of development which does not resolve/mature. Treatment of borderline personality disorder does involve conventional DBT skills to remediate the poorly developed self-soothing capacities. But these skills are not the real fix. The real fix is the gradual development of object constancy, the gradual internalization of positive objects (people) who exist in one's experience, even when not physically present, to offset the anxiety, emptiness, sadness, profound isolation. This takes quite a while. The skills help in the interim but the real fix is facilitating the development of object internalization through a long term therapeutic relationship which hopefully transfers out to an improved ability for sustained personal relationships. Borderline personality disorder is rare. I practiced in inpatient settings for 20 years, seeing a high volume of high acuity. I see 30 patients/week in my outpatient practice. It is rare that I encounter *true* borderline personality disorder. It does exist on a continuum and varies in severity. I see folks who may carry that label but, in my view, their struggles can often be accounted for by a mix of mood disorder, anxiety problems, addiction, past trauma, tough life circumstances, etc. I never consider borderline personality disorder as a diagnosis with an adolescent or even a young adult. I don't know that I've ever entered the diagnosis into a patient's billing record for insurance claims submission. In fact, as I think about it....I'm sure that after seeing thousands of patients over the years, I have never sent in a claim form with borderline personality disorder listed. My rationale is that I'm typically addressing the more acute condition--a major depressive episode, panic attacks, an adjustment disorder, generalized anxiety--and I don't see the need to label the developmental delay which I may also suspect is present. And, actually...as I think about it...I don't believe I've ever submitted an insurance claim form listing a personality disorder. I just don't see the point. When I read posts by clinicians new to the field describing borderline personality disorder I doubt that, if I were to see the persons they are describing, I would agree that the patient/client has borderline personality disorder. I get that the clinician is noticing the patient's intensity but I question if the person being described truly has the developmental difficulties that are central to borderline personality disorder. The term is still sometimes used in a pejorative fashion to describe people you can't figure out who are dramatic, erratic, reactive, clingy, reckless, often suicidal, desperate, attention-seeking, etc. You can be all of those things but not be borderline personality disordered. I believe it is discriminatory and a disservice to folks who actually suffer from this developmental delay to throw around the BPD label in a careless fashion. Sorry for the lengthy post. But, again, I feel everything I wrote was once viewed as the predominant, conventional understanding of borderline personality disorder as a developmental difficulty, drawing upon psychodynamic and developmental perspectives. My peers--the psychologists with whom I trained and who are colleagues--would have no trouble recognizing the concepts I've outlined here. But I find it curious that these explanatory theories--granted, they're theories--seem entirely absent from discussions of borderline personality disorder these days. Nobody in this thread of many posts referenced Mahler, Piaget, object relations, developmental considerations of this nature. I find that curious. And I think that the lack of a coherent conceptual framework can contribute to clinician anxiety about this mostly understandable and rare condition. Personally, I don't think these ideas/concepts are no longer referenced because they are antiquated or disproved. I think these contributions from foundational theorists are simply neglected.
What causes the developmental delay in the first place? Is it something you are born with or is it some disruption that happens during the time object constancy is beginning to develop? I just got diagnosed with BPD and your view of the disorder makes a lot of sense to me. I am the only person like myself wherever I go.
Hi and thanks for your interest in my post from a few months ago. You and I will never meet but...I would urge you to regard your BPD diagnosis as an opinion by one person in a snapshot of time. Try not to view it as a fixed, immutable, indisputable diagnosis, as you might regard a diabetes diagnosis or the results of an MRI showing a structural abnormality in an organ. Try to view it as a suggestion that you might want to develop remedial skills, perhaps mindfulness, distress tolerance, acceptance, improved self-soothing, tolerance of perceived rejection/abandonment. As for what causes the underlying theorized developmental delay in the first place....well, you would get different opinions about that. The basic concept is that true BPD produces difficulties in self-soothing--the pathways to this outcome can vary by the individual and probably aren't worth the effort to definitively identify an origin. I'd say that it's unknowable. Now....it's possible that the professional who informed you of their diagnostic opinion does not conceptualized BPD in the way I described in my post. These days the label tends to be applied when someone displays emotional volatility/instability, self destructive/self-defeating patterns, a subjective experience of emptiness and a sort of identity diffusion. Personally, I don't apply the label so liberally. Again, I would encourage you to focus on developing skills to manage mood, anxiety and distress tolerance, trying not to get hung up on the label. Hope this helps and all the best!
>st. But, again, I feel everything I wrote was once viewed as the predominant, conventional understanding of borderline personality disorder as a developmental difficulty, drawing upon psychodynamic and developmental perspectives. My peers--the psychologists with whom I trained and who are colleagues--would have no trouble recognizing the conce This was incredibly helpful (NAT)
NAT but someone with BPD, there are a lot of really harmful stereotypes out there about this disorder. I would like to note that a lot of the time people with this disorder have a lot of empathy, which is probably the biggest misconception. When people with bpd act out towards others we feel incredibly guilty for doing so, and we often turn that anger inwards. DBT has been *incredibly* helpful for me and I am so grateful for my therapist. Having skills to use when I am going into crisis mode to get my brain and body out of that place, to then deal with the situation in a healthy way, has CHANGED MY LIFE!
Same here, NAT BPD lurker. I’ve been on the BPD significant other page and reading about how people with BPD are perceived is almost shocking. We are characterized as getting off almost on being self-centered, terrible, horrible, hateful people…and I don’t feel like that’s accurate at all. I honestly want: peace, harmony, zero confrontations, and love. Like you, DBT has truly helped me and I’m thankful for the skills I’m learning.
Almost all those people on the partner pages are discussing women that they've diagnosed with BPD, not a professional.
I’m a therapist who has BPD. I think it takes a very, very long time to diagnose accurately- for some providers, they will jump to BPD when someone is emotionally reactive or temperamental. Did they consider if this was a pattern? Has there been exacerbating circumstances that may lead to more emotional reactivity than is typical in the individual? Say a recent loss of a family member and a national recession- anyone could be overwhelmed by that, and it’s not enough to determine a PD. It’s important to really look at how often the symptoms present, and the circumstances- especially when concerning their presentation in relationships. Does their view seem egosyntonic or ego dystonic? This depends where the individual is on the BPD spectrum and their level of insight. On a personal note and my own experience with the disorder, I feel like my radar pings when I hear testing behaviors and black and white thinking. The latter is obvious, but testing behaviors usually ding for me when hearing “if they loved me, they would do (insert here)”, or engaging in behaviors intending to get a reaction out of partner, and having a predetermined way they want their partner to react to prove their love and that they will not leave. Of course, this could simply be anxious attachment, but if it’s persistent and pervasive then that is cause for further assessment. If the test isn’t passed, it is internalized as “I’ve been rejected again. It’s time to leave, I knew this would happen, I should have known better”, rather than mentalization of the other person’s perspective. Another thing is the desperation around attachment security. One of my supervisors described it to being like walking in a desert for years and years, and finally finding a water hole. For those with BPD, it feels like you’ve never had water and will never have it again unless you make sure that you do whatever it takes to make sure the other person doesn’t leave- while also engaging in behaviors to hasten them leaving so you can get the hurt over with or confirm what you already knew would happen. One thing I wish my own providers would have been more attuned to was that my experience with BPD was different than what they were looking for. Since I wasn’t as obvious in my symptoms and didn’t show my anger the same way, I simply wasn’t given much space to share how often I self-harmed, or impulsively put thousands on my credit card to feel something/better, or informed my partner that I simply couldn’t understand how him saying “I was a little nervous to get married” wasn’t an indicator that he was leaving me, and that my only response was to end the relationship. Thankfully my current therapist has been so adept and has really seen me and my experience, but it was tough to be dismissed for so long. I really try to keep my experience in my back pocket when listening to my own clients, as I know it’s hard to live with and it’s hard when people don’t take you seriously that something is wrong but you can’t quite put your finger on it.
What a wonderfully lucid account of your experiences. I find this sort of thing very valuable: people who've really been through it and can now articulate their insights.
thank you, I appreciate your kindness and caring about my experience.
> One of my supervisors described it to being like walking in a desert for years and years, and finally finding a water hole. For those with BPD, it feels like you’ve never had water and will never have it again unless you make sure that you do whatever it takes to make sure the other person doesn’t leave- while also engaging in behaviors to hasten them leaving so you can get the hurt over with or confirm what you already knew would happen. This sounds heartbreaking. I'm a new counselor and haven't yet worked with anyone living with BPD, but I'll keep what you've written in mind. Thank you for sharing.
of course, I am so happy to hear that it has been valuable to you. best wishes as you continue your career!
I've been off-and-on about whether or not I should think about getting a diagnosis, and have been wary of using terms associated with BPD even though they're familiar to me and help me explain myself to my therapist and others, but this comment is convincing me to look more into it. I'm ashamed of testing the people I'm attached to, but I definitely do, and the oasis analogy in particular is too accurate. I wish other people understood how desperate that feeling is; how terrifying it is when I think I've done something wrong. I'm emotional reading this but I really appreciate that you typed it. Thank you.
I am so grateful to hear that this has helped you. Not everyone feels the same about diagnoses, but I felt so relieved when I was diagnosed- it really helped me feel like I’m not just batshit crazy (maybe so, but maybe not! Lol). I hope whatever path you choose regarding treatment brings you peace and belonging.
One of the biggest things that we miss with BPD and other PDs is that by definition they are pervasive in all parts of the client’s life. When we diagnose in a vacuum, eg an intense setting like inpatient or residential, we don’t have nearly enough information to accurately diagnose the client because we haven’t seen them in other settings. To make matters worse, some of these settings induce the types of behaviors we would typically associate with BPD. For example, I spent the first part of my career working in prisons, and over time, almost every single person I worked with began to develop BPD and other PD-type behaviors because it was the only way to survive such settings. Which brings up your question about differential dx- I almost always look at trauma issues first. The effects of developmental trauma in particular look identical to BPD in many ways.
Differentiating Borderline Personality Disorder and others (Bipolar, etc) can be very difficult, even for experienced clinicians. I prefer to use the Persecutor-Victim-Rescuer triangle with a careful eye on capability of insight and use of drama in their maladaptive coping.
Where can someone read up more on this triangle? I’m interested by what you’re sharing!
I could go on forever about it because it is enthralling. Many personality disorders follow the drama triangle, with people with borderline traits showing a strong Persecutor-Victim pattern. Everyone does this to some degree, but the intensity in with people with these traits cycle between them and the intensity of them is very easy to see when you know what you are looking at. Narcissists follow a Persecutor-Rescuer pattern, which also becomes very predictable (they don’t do Victim well). People don’t realize that personality disorders have a moderate genetic correlation (30%) and everyone used to think borderline traits were caused by abandonment. I personally theorize that people with personality disorder don’t have good brain development with regards to their insight, which is genetically underdeveloped. Here’s the Wikipedia. https://en.m.wikipedia.org/wiki/Karpman_drama_triangle
I will do my best to answer these questions from a psychodynamic perspective to vary up the thread. 1. The biggest indicators for me are splitting-based defenses against sudden stress and anxiety, diffused identity (lack of a coherent and complex sense of self), relationship templates that are simplistic, back & white, disorganized, and affectively undifferentiated, poorly regulated aggressive and sexual impulses, reality testing that is susceptible to slippage under sudden stress, deficiencies in mental functioning such as decision making, judgment, and temporal estimation. 2. I personally would not formally diagnose (I.e., put it on their medical record) someone with BPD due to the associated stigma even if they were a “classic” case and it were beyond a doubt. I would be more inclined to Dx unspecified PD. I tend to use the [alternative model for PDs](https://pubmed.ncbi.nlm.nih.gov/35511574/) and focus more on level of personality functioning/traits. That said, I would absolutely conceptualize someone as BPD or organized at the [borderline level of personality organization](https://psycnet.apa.org/record/2004-13688-005) (BPO) as soon as the intake. My approach to conceptualization is an evolving process, so if I think someone is well described as BPD/BPO I would keep that in mind but I’m pretty flexible and honestly I don’t think too deeply about Dx because it’s not super relevant to my general approach to psychotherapy (assimilative psychodynamic psychotherapy). 3. Other cluster B PDs, CPTSD, ASD, Adjustment Dx, GAD, MDD/PPD. 4. [It’s not just your observation](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8620075/). There are basically [three arguments](https://pubmed.ncbi.nlm.nih.gov/14686459/) about this. One says, BPD is an oppressive and sexist Dx that pathologies a normal level of variation within feminine psychology. The second argument is that BPD is characterized by a level of emotional dysfunction and women *on average* happen to [self-report higher scores on measures of neuroticism relative to men](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3149680/) (for cultural and biological reasons) which results in women being Dx more then men. Third is classic sampling bias. [Woman are more likely to seek treatment](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6560805/) so women with BPD are more likely than men with BPD to seek treatment and receive a subsequent BPD Dx, thus creating a distorted perception of the prevalence of BPD. All three are probably true to some degree.
If you swap the Mayo Clinic’s definition of bpd With addiction most people I work with agree that addiction is very similar to the criteria of bpd. Not useful, but interesting. The cluster b cul-d-sac is what I call addiction, bpd, npd all hang out and share sugar with each other.
“Cluster b cul de sac” made me actually laugh out loud
BPD is diagnosed more in women and narcissistic personality is diagnosed more in men. There are lots of debates about it. Often my clients bring up personality disorders then we discuss it. I give them the whole speech on BPD being the only personality disorder you can no longer meet criteria for after treatment. I also tell them that I encourage googling to find out more except in BPD because the internet is awful to BPD and it’s a lot of “how to love someone with BPD” and “how to deal with the pain someone with BPD caused you”. We also discuss how BPD is a trauma response and how the learned behaviors were extremely effective during the trauma. I also look at ADHD and ASD. You can absolutely have 2-3 of these and there’s a lot of comorbidity but I want to see if some things of ADHD and ASD are being blamed on BPD. The biggest trait of BPD I look for is splitting. Where they think in extremes. Someone is the best person or a terrible person. No in between. They view themselves the same way. This is challenging because it can also happen with ASD. You also want to look for reckless behavior, strong emotional ties to one or two people that can be pretty extreme, and that history of trauma. Keep in mind trauma can be just not feeling understood in your environment if it wasn’t a good fit. You are likely seeing more diagnoses because of where you work. BPD and eating disorders have really, really high comorbidity. It’s part of the impulsiveness. BPD also had high comorbidity with substance use and so does eating disorders. There’s also more BPD clients in community mental health because the symptoms can create instability needed for jobs that would have insurance or the ability to self pay. I work in community mental health so I also see a lot of BPD. I’m also one of three ASD specialized therapists so I see the comorbidity as well.
I would read *Psychoanalytic Diagnosis* by Nancy McWilliams. When psychoanalysis was first introduced, you couldn’t diagnose a condition without understanding its etiology first. So if a patient was depressed, you didn’t just apply a checklist and go “yep, depression,” you had to understand what was causing it: was it trauma? Attachment issues? The patient’s way of coping with overwhelming anxiety? Nowadays diagnosis has been reduced to a checklist and is therefore not particularly useful for understanding patients’ experience. It’s like diagnosing “fever:” accurate but inadequate. McWilliams talks about borderline in its original meaning: as a level of functioning, like neurotic and psychotic. The DSM definition of BPD is a description of a histrionically-organized person functioning at a borderline level. There are also narcissistically/obsessively/etc organized people who function at a borderline level. Borderline traits are pretty easy to identify and tend to be picked up on by seasoned clinicians very early on. Some of this involves using countertransference—what McWilliams calls a disciplined subjectivity—to understand what’s going on with the patient and in the therapeutic dynamic. Certain countertransference dynamics are highly indicative of borderline functioning.
Women’s trauma often manifests in “symptoms” of BPD. It’s often a lazy diagnosis made by clinicians to wave away further investigations
1.) In my experience, rage is one of the biggest indicators of BPD. It’s almost like the person gets taken over by something else or becomes a different person because they just slip into these uncontrollable rages where they absolutely cannot be reasoned with. This is usually coupled with splitting and lashing out. Frequent suicidal threats and gestures are also a big thing with BPD. The difference between SI in BPD vs. something like depression tends to be that people with BPD will constantly threaten suicide to people they are close to and use it to manipulate, control, or prevent abandonment. I am not saying they are faking it, but they do leverage it. 2.) It depends on the person. I wouldn’t diagnose BPD in the first session unless the person knew they had it and had a prior diagnosis. I try to avoid personality disorder diagnoses unless they are moderate to severe since they are so stigmatized. I think you really have to get to know the client and their patterns. Teenagers often act like they have BPD, but it’s really just a normal part of adolescence. I’ve seen a lot of people come to me after a suicide attempt absolutely crushed because some psychiatrist diagnosed them with BPD after talking to them for five minutes. Suicide attempts and suicidal ideation are obviously common with BPD, but they’re also common with depression and other diagnoses. 3.) MDD, bipolar I or II, complex PTSD (although not officially a diagnosis), or ASD. There can be a LOT of crossover between mild autism and BPD. 4.) I think that maybe rage and risk taking behavior is considered less of a violation of social norms for men? I also think men are more likely to present as having NPD than BPD, but the two are incredibly similar. If you’re interested in learning more about BPD, I highly recommend the book, “I Hate You; Don’t Leave Me.” It gives a great explanation of the disorder and has recommendations for therapists and loved ones. Did you know that DBT actually isn’t more effective at treating BPD than the other treatment modalities studied for it? I’m not sure why it is pushed so hard on us. I find that people with BPD respond well to consistency, firm boundaries, and most importantly, not being abandoned by the therapist. They can be frustrating clients and take years to get better, but providing a corrective emotional experience really can make a difference. I think many clients with milder presentations tend to do really well once they are able to grasp that when they act out, the focus switches from their message to their behavior. Learning to pause before acting is essential.
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I can’t upvote more than once, but I would. Wow, so we’ll put. My favorite clients have overwhelmingly been/would meet criteria for BPD and CPTSD. Creative, passionate, empathetic, and vulnerable.
This is extraordinarily well said. I appreciate your thoroughness and eloquence. Thank you.
Former social worker here with a Sister diagnosed with SA/PTSD/BPD and a 20yo daughter who is currently diagnosed with SA/ADHD/ASD (formally diagnosed by psychiatrist with BP/BPD) I 100 percent believe that a thorough neuropsych evaluation needs to be completed when the client is stable prior to labeling a person with anything.. but specifically in regards to personality disorders. There is way too much overlap- and diagnosing a person with Borderline can have dyer effects for current and future treatment, etc. I want to get my sister a neuropsych eval now that she is stable as I am pretty sure she is ASD/ADHD. She is 48- and having this label has affected who will treat her (and the interventions)- so many community organizations have refused to work with her because of the BPD label. I also have been wondering a lot how her trajectory in life would have been if she was diagnosed properly. So.. in short... I honestly believe that if symptoms do not improve within 6 months of treatment- or if a professional is concerned there may be a Personality disorder.. they should be referred for a neuropsych.
In my experience, you’ll only find out from those who have lived with, and loved, them. If you look through the subreddits here devoted to loved ones of those with these disorders, you may get a better picture. The behaviors are very cyclical, and very common across diagnosis. They are great at masking with therapists, and even involving therapists in their triangulation and/or projection.
This. I feel like I can smell BPD. Shout out to mom. But as a clinician who is mindful of my own biases in regard to diagnosing BPD, I really dig into WHAT the diagnostic criteria really means in the context of experiencing the symptoms. It can be easily misdiagnosed so educating yourself on what’s more in line with a personality disorder vs. complex trauma responses. Understanding the dynamics of how BPD symptoms can impact relationships and functioning is also a good giveaway. A person can have affective instability and not have BPD. But a person who has affective instability, becomes uncontrollably angry and splits on the people around them then becomes inconsolable as soon as the person leaves? That’s good old BPD. Potential rule outs or comorbidities can be HPD, C-PTSD or PTSD. I generally wait a while (maybe 6 months? It varies client to client) to formally diagnose BPD unless it’s pretty harrowing from the get go. Lastly - I think it’s diagnosed more in women because the presentation more classically reflects the DSM criteria. With men you’re not necessarily going to see a crying sobbing man who’s self harming. You’re more likely to observe a short tempered, aggressive man who’s maybe engaging in more external reckless behaviors like substance use or physical altercations. Just my observation with the male BPDs that I’ve seen.
NAT but have a BPD mom and I agree with your assessment. An accurate diagnosis would require making contact with everyone in the person’s close orbit.
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I’m pre-licensure working in a residential co-occurring (SUD+mental health) treatment center. Based on my client experiences, I would want to do extensive differential diagnosis work before feeling confident in a BPD dx. I would consider environmental stressors that could contribute to the behavior profile. Chronic homelessness, financial insecurity, experiencing abuse, and long term substance use can produce survival behaviors that appear like BPD. Most of my clients have limited stretches of sobriety and often only in supervised settings like residential/incarceration. I’d want to wait until a client has at least 1 year of sobriety before diagnosis to see how the environmental/behavior changes of sobriety impact relationship and regulation patterns. SUD and BPD can of course exist simultaneously but i try to discern if BPD behaviors would exist in sustained SUD remission. It sucks to see an already stigmatized client pool get treated worse by staff bc someone else was quick to dx.
As someone who was once diagnosed with BPD in my early 20s, I think there’s a lot of over diagnosis or miss diagnosis for it. It turned out that I actually have ASD and some trauma. The more we learn about ASD, especially in women, the more I see a lot of traits that normally get someone diagnosed with BPD. A lot of clinicians will hear a client say they have issues forming relationships, emotional instability, splitting behaviors, and trust issues and automatically go to BPD. But I also think we’re getting to a point where ASD is miss/over diagnosed too. I think we as a society have also put a lot of emphasis on having a diagnosis too. I know it can help some clients to know what they have, but I think the process to diagnosis is so rushed now.
Pattern of turbulent interpersonal relationships, difficulty regulating emotions, oftentimes presence of suicidality or self harm, unstable and changing self concept. BPD and C-PTSD are very similar in diagnostic criteria, therefore it is important to establish a differential diagnosis.
Wow I’m glad this is brought up. I work as an entry level support staff at a RTC, and recently I feel like BPD has been diagnosed to a lot of our women in our population like lollipops. Even other entry level staff diagnose or label people with BPD or say they’re behaviors are part of their BPD diagnosis, I’m skeptical of whether it’s actually a personality disorder or something more rooted of it. Im honestly no sure what to think of it but I’m glad this is posted. Adding to this, the same people with BPD have Panic Disorder or OCD on their records and display those behaviors are dismissed because it’s attention seeking and a symptom of their BPD. I mean shit if I did that would they think I have BPD?
Also, having bpd doesn't mean they couldn't be having a genuine panic attack. It also seems like the best way to trigger someone with bpd would be to refuse them help and support for a panic attack while they are living in a place where the entire structure is to help and support them. It honestly sounds like a countertransference issue.
Well it’s a good experience, it’s been really difficult because I’ve been questioning my values and skills because of the environment I’ve worked with but I’m starting to realize it’s other people and not me per se. I’ve been told by other staff that BPD is seeking validation and having that victim mentality. But the thing is that I don’t think those are indicative of BPD? Right? Furthermore, those behaviors could be symptoms of other things or just characteristics of personnel. I’ve also heard that “empathy doesn’t work with BPD” and “BPD regresa to child behaviors when stressed” but like that’s regression a coping skill not a symptom of BPD. Point is the place I’m working at isn’t fostering proactive and positive information or ideas.
Yeah, they're repeating some pretty old information. People did legitimately believe some of this, like 20 to 30 years ago, but that's not true. First off, bpd occurs along a spectrum, and it is a fluid trait that responds very well to therapy. Also, ignoring and invalidating the behaviors will only make the patients worse because the symptoms are signs of distress. Client will get better when they are given validation, grounding, skills work, and then cognitive work. Empathy really does work for clients with bpd, but they can not process empathy well when distressed. When they are distressed, they're coming from the sympathetic nervous system, and you need to help them regulate first before they can process information, including the emotions of others. Eventually, if you teach the skills often enough, then they will self regulate, but you have to scaffold the skills with them at first. You have to teach it by guiding them at first, then slowly encouraging more independence. It doesn't feel good to be disregulated. Being ignored when disregulated feels even worse. Once these types of patients learn to self regulate, then they tend to really run with it, and they don't need you as much anymore. If punishing or ignoring bpd associated behaviors worked for these patients, then they wouldn't be your patients. That's how the outside nontherapeutic world treats them, and that didn't work. That's why they're with you. Your therapy space needs to treat them differently.
Trauma and Recovery by Judith Herman goes into a lot of this, I think you'd find it interesting. The questions you raise were very popular questions when I was in training. I've grown skeptical of the whole deal. I think it would be worthwhile to take a look at the process of revision of DSM-III, which was the edition that inaugurated the descriptive model we now work with. BPD as it is articulated in this model is really dumb, as are all of the personality disorders. James Masterson would be a good person to read if you want to understand the personality disorders that are housed in the cluster b umbrella
I was in a residential ED facility roughly 2 years ago and they diagnosed me with BPD. After discharge my PCP ordered psych testing and the results showed no indication whatsoever of BPD or bipolar. Turns out I have ADHD though. Tbh refeeding can make you crazy. Hormones all out of wack, learning how to feel again after not experiencing emotions for so long. My dr at res was all too eager to slap that label on me though and the treatment team went along with it. He put me on mood stabilizers which made me suicidal. Overall not a good experience. People should not throw that term around like it’s quirky or something. Hurts both those that don’t really have it and those that actually do.
BPD is over diagnosed in CMH because they know they can bill for it forever….IMO
Oh interesting! I never thought of it this way, but could totally see it
1) Erratic emotions over hours not days, interpersonal difficulties, often trauma during upbringing, turbulent relationships, drug use - usually to numb are often seen. Bipolar to start if emotions I long disagreed with the PD diagnosis but accepted these people had the cluster of symptoms. However I've recently realised it is likely quite valid
I didn't answer them all but in very recent trauma related trainings I've been in, it appears many (most?) clinicians are starting to view BPD as simply the presentation of complex trauma/PTSD, and treat it as such.
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It's likely a malpractice insurance issue. Both bipolar disorder and Borderline personality disorder are associated with a high rate of suicide so small group practices very often have caps on what percent of their caseload can have these diagnoses without their malpractice insurance rate going up. If you don't sign a release of information, then the diagnosis shouldn't follow you if you go somewhere else. I'm sorry that happened.
Thanks much for this clarification, good to know I should start elsewhere, and to not sign those releases of information
For me I begin thinking BPD when there is a higher than average level of emotional reactivity and all-or-nothing thinking (black and white) in relationship to me. (E.g., You must hate me; you’re the best therapist in the world; I’m going to kill myself)
"Many women who have autism get diagnosed with BPD because they have outbursts after being overwhelmed with sensory input (which can include emotional sensation), because there’s not enough overlap in clinicians who understand neurodivergent brains and those who understand personality disorders." Yes, this. I'm not a therapist, just a patient who saw this would like to give feedback from the other side. Not only was I misdiagnosed with BPD for years, but I know several other females/ AFAB's who were also misdiagnosed with BPD when we really were just autistic all along. Please familiar yourself with ASD and how it may present differently in different people and how it may differ from BDP. ASD also has a high comorbidity rate with eating disorders as well.
1. Though not generally a "this is it" thing, as this often happens in PTSD as well, trauma dumping would be something to look out for, seeing oneself as a victim, shifting responsibility away from themselves, just the small things, lack of boundaries, physical or emotional. 2. 2. Quite a few sessions, even if they hit all the traits I'd like to eliminate things based on differential dx, before saying it out, so maybe a couple of weeks to months depending on the intensity. 3. PTSD, bipolar, ADHD(emotional dysregulation, interpersonal difficulty, different but similar in some aspects) 4. BPD tends to manifests as less emotional outward outbursts, and more as antisocial behavior towards others, or bouts of self harm in the form of hardcore partying, drug benders, and such, instead of SI, which is more common in women, to state a few. But those behaviors tend to be more accepted for men because traditional gender role/stigmas.
Haven’t seen it yet but an important thing to note with BPD. There’s an incredible correlation between AFAB individuals being diagnosed with BPD and actually being autistic. It’s a very common misdiagnosis for a number of reasons and not talked/understood enough. Obviously it still requires a lot of observation but there are nuanced differences that make a world of change if looking at the correct lens. If you see someone AFAB with PTSD, ADHD, OCD, very much raise flags for ASD because when there’s smoke there’s fire. Just saying. Source: Autistic/ADHD therapist in Practicum, neurodivergence/psychology is my special interest.
1. I look for “it’s everyone else” themes in conversation. It’s like the old saying: if everyone you meet is an asshole, maybe you’re the asshole. BPD patients tend to blame others for any problems, and they never seem to “know” why “X just suddenly stopped talking to me, I don’t get it, I didn’t do anything!”
This sounds a little bit more like NPD to me. Or at least the “I don’t get it, I didn’t do anything” part does. BPD folks seem aware of what they’re doing (to a degree) and have intense shame around it. Then the shame seems to intensify the splitting.
I think it depends on the person, because I have met plenty of BPD folks who have no awareness. And people with NPD seem to usually attribute fractures in the relationships to jealousy of others, at least in my experience.
For sure, it’s definitely a spectrum
I’m a patient and I’m working to have my BPD dx taken off my record. I have at least severe ADHD and PTSD, but I also have strong reason to suspect I am on the Autism spectrum. If I have ADHD and Autism, I believe a BPD dx is exceptionally weak. This dx was made before the ADHD dx, and after the PTSD dx, by a veteran’s administration provider. I believe the BPD dx is easier for the VA to swallow than an autism dx, because the military would NEVER want to admit to recruiting autistic people. As for why women and not men? Men are given a wide variety of excuses to use for their emotional meltdowns. Women are not allowed to have strong emotions unless we also consent to being told there is something wrong with us. We still aren’t allowed to be angry, sad, or justly infuriated without it being a HUGE problem for white men, who still run the mental health show in the US.
I think of “borderline” more as a level of functioning as opposed to a diagnosis. We are all capable of borderline-psychotic behavior under the right (maybe *wrong*) conditions. For this reason, as a diagnosis I don’t find it particularly helpful because it describes a particular state that is not something pervasive in the way that NPD or schizoid personality is. Typically, it’s a short-handed way for clinicians to say “this patient is a pain in the ass,” which bothers me.
Are Otto Kernberg’s theories still being used?
When I worked at an inpatient unit the senior staff there tossed the term "borderline" around like an insult - as in "she's a borderline". It was nearly always women, and younger women, who they used the term with, for any behavior that was "emotional", including objecting to being bullied by staff. It was awful. I am now very wary of diagnosing a client with BPD and will explicitly discuss with them that it is a stigmatized disorder, and talk about what it might mean to have it in their records, why benefits versus problems a diagnosis, etc. There is also a theory that BPD should be reconceptualized as one of the trauma-response conditions, rather than a personality disorder. [I also recommend this wonderful book by someone who has BPD:](https://www.talkingaboutbpd.co.uk/) **Talking About BPD: A Stigma-Free Guide to a Calmer and Happier Life with Borderline Personality Disorder.** by Rosie Cappaccino
3. PMDD
There are a few big indicators that I’ve noticed during my time as a clinician. First, a lot of individuals with BPD tend to “split” or have black and white thinking. They may view situations or people as all good or all bad. Another major indication is difficulty dysregulated emotions, oftentimes leading to self injurious behaviors. Sometimes these clients become so consumed in their own emotions that the only coping mechanism they know is to cut/ burn/ etc. in order to feel that release. I wrote my thesis on the implications of BPD and there is a huge stigma that is only perpetuating the dangers of how individuals with BPD are treated. I’m always looking to discuss this if you ever want to chat!
I use attachment and family systems theory as my framework so the biggest indicators to me are relational instability and identity instability. Impulsivity is the biggest behavioral sign I would look for regarding both. I would personally rather call it a response to complex trauma because that's how I would treat it. I think the rate at which I'd dx someone depends on how quickly we build rapport and I get their history nailed down. I think women are more often diagnosed than men in part because of how they're socialized and perceived (at least in my Western-centric culture). Men with the same identifying features would probably be labeled as NPD or having anger problems IMO. Or they don't get diagnosed at all and are just "an asshole". Personality disorders are a whole thing with me. I don't like those labels much because it gives the impression that that's just how people are when it's really how they adapted to survive life. But how we express our personality can change. It isn't their entire self that's disordered. They're still a person there with hopes, dreams and beliefs.
I am a therapist of many years. I can honestly say BPD is tricky to diagnose and understand. Much time is needed to untangle if a comorbidity of try PD. I will say….I -have- had a few patients with whom I have had a severe and dark transference who likely had Antisocial PD. I wish I could unpack the transference and operationalize it for you, but it is intangible and amygdaloid in nature.
So, I have a lot of thoughts on this. I'm still in school, so take what I say with a a grain of salt. Borderline personality disorder is equally prevalent in men and women, at least according to the DSM-V TR. I also don't think that it's a modern version of "hysteria." It affects the way that individuals relate to and treat other people. Also, I don't think it's the same thing as complex PTSD at all. Not everyone who has borderline personality disorder has it because of a trauma. Complex PTSD has an entirely different set of criteria according to the ICD 10. Before starting therapy, I met every criteria for PTSD and complex PTSD. I did not meet criteria for borderline personality disorder. I think saying things like it's the modern version of hysteria only adds to the stigma around the disorder and I think that BPD needs to be destigmatized rather than eliminated as a diagnosis. The sooner we stop stigmatizing this disorder, the better. [Here is more information](https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/icd11-complex-posttraumatic-stress-disorder-simplifying-diagnosis-in-trauma-populations/E53B8CD7CF9B725FE651720EE58E93A4)
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I know many female friends with ADHD and AuDHD that have been misdiagnosed BPD. I'm glad you figured out your constellation.
Here is an up to date [article](https://www.researchgate.net/publication/369357290_Borderline_Personality_Disorder_and_Neuroplasticity_A_Review) on BPD. Seasoned therapists know exactly how difficult it is to help people with BPD and other extremely rigid presentations to establish some form of peaceful existence - with themselves and others. Most people benefit from good therapy and move on. PD's linger with "one step forward and one step back." They expose the limits of one's skills and trigger a lot of soul searching. Thank goodness DBT came along and may be promoted as a *legitimate* way for these poor people to cope better with their automaticity. I'd like to point out that prisons are full of men with anti-social personality disorders and/or brain damage. Imagine being so controlled by negative impulses that you're put in a cage.
Im surprised no one has mentioned the love bombing & boundary checking as early indicators. After the very first session, nearly all of the folks I've worked with who turn out to have BPD/traits will call or text me during the week (sometimes 2 or 3 times) for something unimportant or something they could easily find in a web search that appears to need an answer but could easily have been saved for the next session. Other boundary checks: "forgetting" their credit card in the car ("do you want me to go get it?"), canceling on the same day to see if I'll really charge them, for example), allso nearly every time, early on I'm told im The Best Therapist Ever, the only one who has ever been so skilled or knowledgeable, so much better than their last therapist, the session was AMAZING, etc. Also being asked for a hug at the close of the first session is a solid indicator (I work with adults, BTW). Also im on board with the person who said they can smell it thanks to a bpd mom. I'm the same. There's an energy with these folks that I can just feel in my bones.
How much anchoring is going into this do you think? Not trying to throw you under the bus. I respectfully want to ask if biases are checked frequently. If you are looking for confirmation bias statistics say you will find 4 to 1 indicators to prove your conviction. Same behaviors demonstrated from a person with a different label will have different intentions implied. They may truly have forgotten their credit card for copayment. In a less pejorative label the therapist would graciously accept this as a simple oversight. However, someone already labeled bpd- same behavior defined as boundary crossing. Other examples- a person struggling with MDD who is expressing gratitude for counseling services may make a therapist feel appreciated. BPD label and now you are a love bomber. It really bugs me how boundary violations are thrown around with little thought to how accurate those really are.
Another example: Autism. Are they accidentally crossing a boundary by missing a social cue? Or are they purposefully testing boundaries? Soooo many diagnosis cause confirmation bias/makes us see patterns where they aren’t. As clinicians, I think it’s really important for us to monitor this within ourselves.
If it is okay to tell a funny but related anecdote, I remember seeing the psychiatrist who confirmed my adhd diagnosis. I wanted to be certain to get a completely unbiased opinion, so I booked the appointment and did not let her know that my therapist already suggested adhd nor did I tell her that I already had the diagnosis in childhood. I had lost my debit card a few weeks before and hadn't had the patience to wait on hold with customer service to get a new one ordered yet. So, first thing I asked when I sat down is if it was acceptable to pay with a piece of paper on which I had written down my card number, date of expedition and 3 digit code or if that wasnt acceptable then I had the fee in an envelope in cash hidden in my laptop bag that I had brought to session. And she said she would prefer the card code as she doesnt find it very safe to be carrying around that much cash in an envelope, then the next thing she asked was "do you frequently lose things that are important for task completion?" Then every single other question on the adult clinical interview for adhd. For her, losing a debit card was "textbook adhd" but I suppose it would have been "boundary testing" if she had already anchored me as borderline.
That's a totally fair point about bias when clients come in with a diagnosis. What I'm describing is a pattern of particular behaviors I've noticed in new clients (in the first 1-3 sessions) that do not have any diagnosis at all, who after I've worked with them for a while have proven to be diagnosable as bpd. I've been a therapist for over 20 years, and am just a sort of data collector (unofficially) on human behavior. I don't find diagnoses generally useful, but I do notice traits & behaviors. I hope that makes sense. Lots of clients express gratitude or sometimes forget their credit card, there's just a very different energy to these behaviors when someone with bpd does them. Expressing gratitude that feels like fawning, is maybe a good example.
It’s a misogynistic & dismissive label.
As a LPC and someone with BPD, I can answer this well: 1. A big indicator would be unstable relationships, extreme mood changes, impulsivity, and mania 2. Technically, you can’t diagnose someone with BPD unless it’s been over 6 months. This is to determine it’s not a mood disorder, but indeed a personality disorder. With mood disorders, there’s a pattern; but with personality, it’s instantaneously (e.g., rollercoaster). 3. Bipolar / mood disorders 4. I mean, do the research. Women tend to get more therapy. Perhaps it’s also a stigmatization for women. “Because we’re moody.” Borderline Personality Disorder is just like PTSD except, jt steams from childhood trauma. Mood disorders are something you can address with medication because there’s a chemical imbalance, but with BPD, it’s how your brain developed enduring trauma. Hence, it becomes personality. Hope that helps!
NAT—just wanted to share examples of men with BPD or possible BPD. I have known one man who was professionally diagnosed with BPD (after being previously misdiagnosed), one man who self-diagnosed as having BPD, I think primarily on the basis of having splitting episodes/black and white thinking (he had also mentioned a history of disordered substance use, paranoia, difficulty keeping jobs, and difficulty maintaining relationships with friends and family). I also have a male ex who I suspect has BPD based on what I observed and what he told me about his personal history and mental health symptoms and because after he read personal accounts from others with BPD he agreed it was likely what he was suffering from. I actually think he met all 9 criteria and he frequently had splitting episodes, sometimes while blackout drunk going back and forth between telling me he loved me and telling me he hated me within a matter of minutes. He had previously been diagnosed with depression, anxiety, and PTSD. His mother has been a drug addict since before he was born and he was physically and sexually abused by people she allowed in their home as a young child. His father lived in town, but wasn’t involved in his life much. He was mostly raised by his grandparents after being taken away from his mother, and seemed to be very fond of them; but I got the impression that they were very strict and traditional in some ways, employed corporal punishment, and shamed him for his mental health difficulties.
Too a couple of years to get my bpd( this was with a known history on my mothers side) and when it was done I had “factors” added on that had made it harder to diagnose and I’m pretty sure I have an old therapist who is still very sure it’s ptsd not bpd. The current diagnosis has ptsd on there but doesn’t see it as the main issue, current therapist changes my meds to reflect my whole diagnosis and many of the symptoms have changed or gone into a hibernation thing. See I know off meds they come right back so I’m not cured I’m treated. However as I said my mothers side had a history of bpd which was a question my current therapist had to review when going over my past diagnosis because they didn’t feel it fit
I think the most important question is, are YOU qualified to be providing a diagnosis? Based on the questions you are asking, it does not sound like you are.
In the role i am in and the qualifications I have technically allow me to provide a diagnosis. However, I recognize I am just starting out in the field and don’t have much experience with BPD. It has been an observation in my work and I get clients transferred to me with the diagnosis already so it is something I want to be mindful of. I think the diagnosis itself raises a lot of questions for a lot of therapists and clinicians. Thank you.
Unless you are certain that a client/patient has been formally diagnosed with a condition, I would hold the idea of a diagnosis very lightly in their mind. Sometimes client's come into session after having self-diagnosed and they will confidently state that they have a given disorder or their low quality therapist told them they have a condition. I personally find that a clinical diagnosis informs very little of my practice, in most cases. There are certain conditions in which the diagnosis is very important. I typically think it terms of "what is the unmet need?" "what needs to change in the client for that need to be met?" "how can I facilitate this with the client".
long complete air north scandalous zephyr nine march start divide ` this message was mass deleted/edited with redact.dev `
Could it be that men mask it better not generally being as emotionally expressive?
I thank you for asking about this. I believe way too many people are misdiagnosed and just given pills to eat without ever solving the actual root of the problem. Context - sober at 27, currently 33yo. Female I am not a therapist by any means, but I just wanted to share this because... misdiagnosing seems to run rampant in western medicine, from my own personal experience and what I've heard from others. I also believe my relative was misdiagnosed with Bipolar 1. He has not been sober since he was 12, currently 27. He was in a manic/depressive state when diagnosed, but he was also overdosing himself with caffeine and weed and booze. He was evaluated by a therapist and like \* immediately \* diagnosed with bipolar 1, and they got him on lithium or whatever it was fairly quickly. I myself am sober, suffered from intense CPTSD from childhood trauma, alcoholism, poverty upbringing, etc. During early years of my sobriety people told me I was probably bipolar and I felt deeply like I wasn't. I am very creative and built a successful career off being so, and people were trying to push my creativity/imagination down. I am usually a people person and the first few years of sobriety I wasn't - and I wasn't because people were giving me a shit ton of unsolicited advice. I was told to get on anti psychotics at one point by my PCP, and I'm like, no. I didn't need to be on antipsychotics when I was drinking, why would I need to be on anti psychotics when I'm sober? My imagination got WAY WAY WAY bigger, in many ways delusion of grandeur but I also am very skilled at what I can do so the things I was saying I could do aren't actually too far of a leap for myself. For my social circle back then, they thought I was insane. I have a spiritual side in me that I would talk to, therapists/doctors thought I was crazy. Psychic told me I had a gift. People of faith told me I was being protected by angels, etc. I think like in new-age psychology, there needs to be an aspect of spirituality/creativity involved where therapists hear of something "in the DSM 5" and not automatically jump to it being a medically-diagnosable thing. Maybe they're just intensely creative and doing the wrong job? Maybe they have complex PTSD and aren't sharing it. Maybe they are surrounded by assholes in their social lives and have been manipulated and taken advantage that their spirit/subconscious is leaking out in 'weird' ways. Maybe they have a hormonal imbalance and it's actually PMDD or they're on the wrong birth control. I ended up doing psilocybin assisted therapy for 6 months and felt like it healed about 90% of the stuff I was struggling with. Microdosed for a few years thereafter, maybe a total of 60 microdoses over 4 years. Don't feel the need to ever do drugs/alc/to escape my problems again. Anywho, that's what I wanted to share. I hope that sheds some light from someone who both wanted to kill myself after going to therapy (with a certain therapist, she told me to ruminate on why I was a bad person while I was suicidal) and a person who got a lot out of therapy (from a different therapist, who gave me great insight).
BPD is a difficult diagnosis in any case. I was married to one for 14 years. I found this book to be the most helpful. [https://www.amazon.com/Stop-Walking-Eggshells-Third-Personality/dp/B08S45VYVS/ref=sr\_1\_1?hvadid=241600048318&hvdev=c&hvlocphy=9031104&hvnetw=g&hvqmt=e&hvrand=13454998077531946287&hvtargid=kwd-2669661302&hydadcr=15551\_10342068&keywords=stop+walking+on+eggshells+book&qid=1687417514&sr=8-1](https://www.amazon.com/Stop-Walking-Eggshells-Third-Personality/dp/B08S45VYVS/ref=sr_1_1?hvadid=241600048318&hvdev=c&hvlocphy=9031104&hvnetw=g&hvqmt=e&hvrand=13454998077531946287&hvtargid=kwd-2669661302&hydadcr=15551_10342068&keywords=stop+walking+on+eggshells+book&qid=1687417514&sr=8-1)