For many years, you struggled with impulsive and self-harming behaviors and intense emotional reactions, including when you sensed any signs that someone might be rejecting or abandoning you. You visited psychologists, psychiatrists and other clinicians, but you found no relief. Each clinician gave you a different diagnosis, and each diagnosis led to a different treatment. You tried what seemed like an endless series of medications.
Then, finally, a therapist diagnosed you with borderline personality disorder (BPD), and suddenly the pieces fell into place. The diagnosis makes sense, and treatment approaches designed for BPD are starting to help. You wonder why they didn’t tell you sooner. And while the diagnosis connects you to helpful treatment and helps you understand your problems, you soon discover that some healthcare providers seem to have negative reactions when you mention it to them. For example, they may seem less trusting of you, more distant, or less willing to help.
Unfortunately, the scenario we’ve placed you in is not hypothetical for many people with BPD, and some readers will surely relate to it. As it turns out, it is one of the most stigmatized mental illnesses, even among mental health clinicians. Although stigma significantly affects people with other psychiatric diagnoses, such as depression, schizophrenia, and eating disorders, the stigma around BPD is particularly pernicious and concerning. No disorder is received with more pejorative attitudes by both clinicians and the public.
When people see mental health clinicians, they expect them to be non-stigmatizing sources of knowledge and help. However, the experiences of many people with BPD may not align with those expectations. In , clinicians have felt less optimism, less empathy, and more hostility toward patients with BPD, compared to patients with other disorders. These negative attitudes and ideas may result in one and lead some clinicians to work with patients who have BPD. These patients already struggle with significant shame, negative self-concept, and sensitivity to rejection, and stigmatization by clinicians is likely to exacerbate these problems.
BPD often goes undiagnosed or misdiagnosed for many years due to this stigmatization and misunderstanding by clinicians. Some clinicians do not believe that BPD is a real disorder; Others may be reluctant to give the diagnosis due to concerns that it could expose patients to stigmatization from others. The disorder can be diagnosed in youth and adults, and is associated with significant distress, as well as a substantial risk of premature death; According to one estimate, Early intervention is ideal. However, in another study, . This suggests that if a person’s symptoms begin to appear at age 15, they may not receive a proper diagnosis until age 30. In that period of time, they will have spent most of their adolescence and youth without a diagnosis that would have helped them conceptualize their problems and find treatment.
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Making matters worse, media portrayals of BPD are often riddled with stigma. For example, the character played by Glenn Close in the film Fatal Attraction (1987), or the way in which the diagnosis of BPD was used as a weapon in relation to the recent court case between actors Amber Heard and Johnny Depp: the speculation about Heard’s diagnosis to suggest that she must be a liar and abuser. Additionally, materials ostensibly intended to help people who have a diagnosis of BPD, including self-help books, often do more harm than good. Clinicians experienced in helping people with BPD often warn them that an Internet search can reveal a number of misleading ideas, including the notion that BPD is untreatable, which directly contradicts decades of research on BPD treatments, as the .
Stigma is also embedded in the legal system. For example, California’s pretrial diversion program, which offers treatment as an alternative to prison for people with mental illness, with some exceptions. An effort is being made to change the program’s exclusion rules, which currently prevent people with BPD from accessing it.
Why is borderline personality disorder (BPD) so stigmatized? The answer to this question is complex and not fully understood. However, BPD symptoms and diagnosis history provide clues.
BPD includes a generalized pattern of instability, also called “stable instability.” This instability affects mood and includes intense periods of anger or sadness that last from a few minutes to a few hours. Behavior is also unstable, characterized by impulsivity and self-destructive acts. Likewise, people with BPD have difficulty with relationship stability and finding a stable sense of self. They often oscillate between idealizing other people and devaluing them: one moment they may see a loved one as perfect and caring, and the next they may see that same person as terrible or malevolent. This shift between idealizing and devaluing others is called “splitting” and often occurs when the person with BPD, who is generally very sensitive to abandonment, perceives criticism or rejection.
The term “borderline” is difficult to understand and does not provide useful information about how we think about BPD today. It was first coined in the 1930s and was later used pejoratively to label patients, mostly women, whom doctors believed were difficult, problematic, or untreatable. It has not been updated to reflect modern understandings of BPD. BPD was officially recognized as a disorder in 1980, catalyzing research and development of treatments. However, research on BPD is significantly underfunded compared to research on other disorders, even though the disorder is common, disabling, and life-threatening. The relative lack of focus on BPD is also common in training programs, where many mental health clinicians do not learn about this condition specifically.
The symptoms of BPD can be difficult to understand for both the general public and lay clinicians. The way these symptoms manifest is variable and unstable, which can make them seem controllable by the person, when in reality they are not without treatment. While common behaviors in BPD, such as self-harm, suicidality, and desperate avoidance of abandonment, are often perceived by others as intentional manipulation or attention seeking, they are better understood as the result of overwhelming distress and dysregulation. emotional. People with BPD struggle painfully with these emotions and behaviors, but malicious intent is often quickly attributed to them because their behaviors can be difficult to understand.
For those with BPD, fighting public stigma also provides the opportunity to combat their own internalized stigma.
Fortunately, the future is bright for people with BPD. Researchers and clinicians are working to better understand the disorder and the stigma associated with it. In the coming years, the way BPD and other personality disorders are conceptualized could change significantly. Some have argued that it should no longer be called a “personality disorder.” Moving away from the idea that someone’s personality is disordered can help others see this condition as something a person struggles with, rather than what it is. In the public eye, prominent celebrities such as American comedian and American football player have spoken openly about living with BPD. Stigma science suggests that these personal stories may be especially useful in improving attitudes.
In this context, there are things you too can do about stigma, whether you know someone who has a diagnosis of BPD or simply want to support a change in how it is perceived.
Education can be transformative. Learning about one’s condition, often called psychoeducation, is associated with improved well-being and a reduction in BPD symptoms. Psychoeducation is essential to reduce the stigma that many people with BPD internalize. If you or someone you love has BPD, seek education. There are several organizations that offer free resources to learn about the condition. For example, it provides informational guides and online peer support. Similarly, the National Education Alliance for BPD has a wealth of online resources.
Organizations such as these also provide ample opportunities for patient and family participation in educational seminars, conferences, and advocacy initiatives. These can be empowering experiences. For those with BPD, combating public stigma also provides an opportunity to combat their own internalized stigma.
Education about BPD is useful for both clinicians and patients: learning about the condition leads clinicians to express less dislike for people with BPD, more hope about recovery, a greater willingness to treat people with BPD, a greater empathy and compassion for them, and more confidence that they will be able to make a proper diagnosis and provide help. This suggests that stigma about BPD arises in part from a lack of understanding and uncertainty about how to approach treatment for the disorder. Although it is not the patient’s or family’s responsibility to educate care providers, they can ask questions about the clinician’s training and attitudes about BPD when seeking care and can seek a second opinion on diagnoses and treatment if necessary.
Finally, we can all hope to reserve judgment and seek understanding. People with BPD often act in ways that seem extreme and difficult for those without BPD to understand. We encourage readers to consider that seemingly extreme behavior is not always malicious or intended to harm others. People with BPD deserve to be understood, which may require reserving judgment and recognizing that these behaviors often arise from painful struggles with…