The so-called ‘personality disorders’ are among the most controversial and complicated of psychiatric diagnoses. Critics say that stigma is baked into the concept itself – the label implies that there is something pathological about a person's personality.
The term ‘personality disorder’ is meant to reflect how a person's psychological problems are long-lasting and permeate many aspects of their lives, from their daily emotional experiences to their relationships.
For some, receiving a formal diagnosis of a personality disorder can help them understand why they find life so difficult, and, in positive cases, it can help them obtain the professional support they need.
Of the 10 specific personality disorders recognised by psychiatry, among the most widely misunderstood is borderline personality disorder (BPD) – a condition that is estimated to affect one to two per cent of the population.
The term ‘borderline’ is a throwback to the 1930s. During this time psychoanalytically trained psychiatrists saw the diagnosis as being on the margins of the now largely defunct categories of the psychoses (conditions that were considered more serious and untreatable) and the neuroses (conditions that were considered treatable with psychoanalysis).
People with BPD typically experience a lot of anxiety; they worry about being abandoned by people close to them; they often struggle to form a stable sense of who they are; and they can find stress particularly difficult to cope with.
It can prompt them to act impulsively, to experience paranoid feelings or a sense of being detached from reality. To try to cope, people with BPD will often self-harm and they might think about taking or try to take their own life.
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As well as fearing abandonment, another common experience for people with BPD is to swing from one extreme to the other in terms of how they feel about people close to them. One day they see family and friends as perfect, the next they believing those same people have let them down and are really bad. Inevitably this can contribute to difficulties in close relationships for everyone involved.
There are competing theories for what is going on in BPD. For instance, one influential account states that BPD is an emotional regulation problem – people with the condition experience particularly intense and prolonged difficult emotions.
Another theory holds that BPD is primarily rooted in difficulties interpreting other people's feelings and intentions, manifesting as a kind of hypersensitivity to perceived slights.
Sadly, there is evidence that BPD tends to be stigmatised in everyday conversations and media portrayals, which tend to pander to ‘crazy person’ stereotypes and emphasise the person's troublesome behaviour, rather than what it's like for them to live with their psychological difficulties. Perhaps worse, many clinicians also tend to hold negative and pejorative views towards people with diagnosed BPD.
For example, surveys show mental health professionals saying they'd rather avoid this patient group and feel less optimistic about helping them. Harmful misguided beliefs that swirl around and feed these prejudices include the notion that people with this condition are untreatable or are deliberately manipulative.
Trusted and compassionate experts today recognise that what people with BPD need, above all, is love and support. We should see behaviour associated with BPD, including self harm and excessive worry about being abandoned, not as forms of attention seeking or manipulation, but rather as consequences of the intense emotional discomfort that people with BPD experience.
Many people with BPD have difficult pasts – suffering childhood maltreatment is the most significant risk factor for being diagnosed with the condition. Contrary to the widespread misconception that BPD is untreatable, in fact there are now well-developed methods for helping people with the diagnosis.
Probably the most well-supported is known as Dialectical Behaviour Therapy, which is a specialised form of Cognitive Behavioural Therapy. Its emphasis is on helping people with BPD better manage their emotions, to better understand other people's behaviour and emotions, to increase their confidence and self-esteem and to develop skills around socialising and self-awareness.
Whatever treatment approach is used, experts emphasise that it's important for the therapist not to be judgmental and to adopt a warm, supportive, collaborative style of working.
There are drug treatments available too, but these are generally seen as an adjunct to psychotherapy – to help the person with BPD cope with some of their more troubling symptoms while working on their emotional and other skills in therapy.
Promisingly, there's some evidence that simply learning trustworthy background information about BPD can help people with the diagnosis feel more hopeful and better understand their experiences, and that educating clinicians about BPD can improve their attitudes too.
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