It is my position that Borderline Personality Disorder is not a scientifically valid or reliable diagnosis. Here I’ll explain why this is the case, but also discuss how the diagnosis can paradoxically prove useful to sufferers and therapists.
First, I ask the reader to consider Rainer Maria Rilke’s short poem, The Unicorn. Like the mythical unicorn, Borderline Personality Disorder, when considered scientifically, exists in only in popular imagination.
“This is the creature that has never been.
They never knew it, and yet, nonetheless,
they loved the way it moved, its suppleness,
its neck, its very gaze, mild and serene.
Not there, because they loved it, it behaved
as though it were. They always left some space.
And in the clear unpeopled space they saved
it lightly reared its head, with scarce a trace
of not being there. They fed it, not with corn,
but only with the possibility
of being. And that was able to confer
such strength, its brow put forth a horn. One horn.
Whitely, it stole up to a maid, to be
within the silver mirror and in her.”
Like the unicorn, BPD is a mythic construct, the existence of which has never been proven. It exists only because people believe in it. Nevertheless, it can be useful, as will now be described.
How BPD Is Useful – Helping Survivors Find Each Other
Despite its many flaws, the diagnosis of Borderline Personality Disorder serves valuable functions.
First, it allows those struggling with the difficult symptoms of BPD to find each other. Because the BPD label covers a range of serious difficulties in regulating feelings and managing relationships, it includes millions of people with different backgrounds and problems. Nevertheless, those diagnosed with BPD often have enough experience in common that they can understand and support each other in a way not possible for those who have never “been borderline.”
On this type of blog and on other online support forums; people diagnosed with BPD are often very empathic and supportive of one another. Rarely do I see “bad” borderlines who are only selfish and manipulative, as in one popular but misleading caricature of BPD. Rather, most diagnosed borderlines are looking for any help they can find, and are willing to provide encouragement to other with similar challenges.
If no such label as BPD existed, there might be no way for those struggling with emotional dysregulation, lack of identity, fear of abandonment, and so on to find one another. Therefore, labels such as BPD do have utility in that they allow for a form of consistent self-definition, and promote communication with others who so define themselves.
How BPD Is Useful – For Finding A Therapist
Borderline Personality Disorder is also useful because if one knows about the disorder, one can search for a therapist who is good at treating it.
Worldwide, there are many psychodynamically-trained and DBT-trained therapists who are excellent at treating borderlines. They have helped many former borderlines improve to the point where they can live a rewarding, meaningful life and are no longer diagnosable with BPD. I have met several of these therapists in my real life (yes, I do exist outside of this blog!). These included Gerald Adler in Boston, Lawrence Hedges in Los Angeles, James Masterson in New York (before he died), and three of my past therapists in the Eastern United States.
Searching for therapists who treat BPD can be a double-edged sword, because many therapists are still uninformed about the disorder. Some even refuse to treat borderlines because they do not understand how to effectively work with them. So it is critical to find well-trained therapists who are optimistic about working with this condition.
As an aside, far too many borderlines are not receiving treatment from a therapist competent at treating BPD. Hopefully this can change in the coming years. As noted in an earlier post, it is quite possible to find therapists who specialize in BPD and/or DBT via sites like Psychology Today’s Therapist Finder. Please refer to that earlier post below if you want more information.
How BPD is Useful – For Therapists To Communicate about BPD
The BPD label allows therapists to communicate among each other in order to understand BPD and develop more effective treatment for it. In my opinion, the best psychodynamic-psychoanalytic and DBT-focused therapists are both oustanding at treating BPD already. If someone has sufficient resources to attend good treatment consistently over the long term, it can make a huge difference on one’s recovery journey.
Most of the public today does not know that psychoanalytic therapists had already created clear treatment plans for Borderline Personality Disorder by the 1970s and 1980s. In their books, these therapists give many detailed case studies of borderlines they treated who recovered fully.
As a teenager, I remember how encouraging it was to read James Masterson’s accounts of the dozens of borderline young adults whose outcome he tracked in the Borderline Adolescent Trilogy of books (culminating in From Borderline Adolescent to Functioning Adult: The Test of Time). These borderlines were tracked over decades, with many of them improving to the point that they had few or no traces of the disorder left as older adults. Using both the DSM and his own experience, Masterson had a clear way of diagnosing BPD that helped him to create this study.
Some examples of books on successful treatment of adult BPD would be Borderline Psychopathology and Its Treatment (Gerald Alder), Psychotherapy of the Borderline Adult (James Masterson), Six Steps in the Treatment of Borderline Personality Organization (Vamik Volkan), and The Bad Object (Jeffrey Seinfeld). Reading these books was extremely useful for me in understanding BPD and drawing encouragement from those who had already recovered. If the BPD diagnosis had never existed, I would never have found them.
To conclude, without a clear term encompassing the symptoms of people who are severely neglected and/or abused in childhood, therapists would find it difficult to communicate about what sort of people they are treating and how to treat them. There has to be some common terminology and a framework in which to discuss approaches to different “types” of patients.
How BPD Is Useful – Validating One’s Problems
A final note is that I see some diagnosed borderlines who feel that the BPD label is useful because it provides some explanation for what is happening to them. It validates that there is something really wrong and that they are not crazy or just experiencing random symptoms.
Initially, it can be useful to know that your problems come from a “disorder” with a name. I see the value in this, although at a deeper level I disagree with it. More importantly, knowing that one fits the BPD label can help a person find effective help via therapy, support groups, and fellow sufferers.
Why I Do Not Believe In BPD
Despite everything noted above, Borderline Personality Disorder is a fabrication. “Fabrication” refers to something conjured out of nothing, something misleading, untruthful, that does not actually exist.
To understand why many people doubt the validity of BPD, it is instructive to look at the history of its development. Psychoanalysts working in the first half of the 20th century began using the term “borderline” to describe patients they saw who were neither neurotic, meaning mildly troubled, or psychotic, meaning experiencing a break with consensus reality.
Such psychiatrists never diagnosed BPD via any physical measurement. There are to this date no blood tests, gene tests, brain scans, or other physical measures that can identify BPD. This obvious fact bears repeating because it tends to be forgotten when people discuss the disorder. Instead, BPD was always classified, in various ways, according to observed behaviors, thoughts, and feelings seen in individual patients.
Borderline Personality Disorder in the DSM
Eventually, “Borderline Personality Disorder” crystalized into its current Diagnostic and Stastical Manual of Mental Disorders form, in which 5 out of 9 subjective criteria must be assessed by a mental health professional for a diagnosis to be made. It is useful here to list those criteria in brief form:
1. frantic efforts to avoid real or imagined abandonment.
2. a pattern of unstable and intense interpersonal relationships
3. identity disturbance
4. impulsivity in at least two areas that are potentially self-damaging
5. recurrent suicidal behavior or ideation
6. affective instability
7. chronic feelings of emptiness
8. inappropriate, intense anger
9. transient, stress-related paranoid ideation or severe dissociative symptoms
Here are some questions to consider about BPD as it is defined via these nine traits:
– Mathematically, there are at least 126 possible ways that one can be diagnosed with BPD, if any 5 out of 9 of these criteria is the threshold for a diagnosis. Is each of those 126+ “forms” of BPD an equally valid and meaningful form of the same disorder?
– Is it possible for psychiatrists to consistently determine the degree of each of the 5 (out of 9) traits that is needed for a BPD diagnosis? That is, how can a psychiatrist consistently say, for example, at what point a person’s interpersonal relationships are “intense enough” or “unstable enough” to warrant inclusion as a factor in a BPD diagnosis?
– Given personal bias and the differences in understanding of the English language between psychiatrists, are such treaters likely to consistently agree with each other about whether or not the same patient if borderline?
– Can psychiatrists determine when the approximately 100 billion neuron cells in a human brain have become arranged in a way that warrants a diagnosis of Borderline Personality Disorder?
These questions obviously cast doubt on the validity and reliability of BPD. Perhaps “Borderline Personality Disorder” is a fantastic construct that exists only in the minds of psychiatrists, from where it is projected onto individual people.
We still understand relatively little about how the human brain’s 100+ billion cells interact with the environment in trillions of different ways. In this light, to think we can accurately create and then diagnose a “disorder” like BPD seems doubtful.
Why BPD Can Appear Valid
This is not to say that people (supposedly) diagnosed with BPD cannot appear very similar. Because of the imperatives for relating to peers and functioning independently that are part of every human being’s development, problems in these areas will manifest with related, but not identical symptoms based on each person’s unique history.
But the degree and kind of problems in areas such as relating to others, relating to oneself, and functioning independently will always differ subtly (and sometimes greatly) in each case. Given the endlessly complex, individualized problems that people experience, it is naive to think that precise “mental disorders” can be clearly separated and accurately diagnosed.
Why BPD Should Be Rejected As A Medical Condition
Therefore, instead of developing an objective, scientific way of diagnosing the disorder – something which is admittedly difficult with a “disorder” based on observed behaviors and human emotions – psychiatrists left everything up to the treatment provider’s subjective judgment. The psychiatrist himself had to determine whether or not each problematic behavior, thought, and feeling was of a degree and kind to justify inclusion in the diagnostic picture.
In my view, this fact alone – that the subjective judgment of mental health workers supposedly determines BPD’s “presence” or lack therefore – invalidates BPD as a diagnosis which can be taken seriously, at least in a strict scientific sense.
Psychiatrists face several quandaries in diagnosing BPD: 1) From patient to patient they cannot consistently agree who has BPD and who does not, 2) They cannot agree on what criteria should be used to diagnose BPD (the DSM’s is not the only model, and the words used for each traits, plus the number of trait, changes from year to year), and 3) They use complex, subjectively assessed human behaviors as the diagnostic criteria rather than physical, quantifiable phenomena. In this way BPD differs fundamentally from actual medical disorders like diabetes, for which insulin levels are measured, or cancer, for which the presence of tumors and observable cancerous cells are involved.
Given these challenges, psychiatrists and researchers are doomed to fail in their attempts to prove BPD’s statistical validity or its genetic basis. I am often amused to hear therapists talking about BPD as a disorder which can be “studied” using twins or other genetic testing. To me they are out of contact with reality, to put it charitably. But since I am kind, I will not diagnose them with anything 🙂
Valid medical conditions absolutely have to be based on criteria which can be reliably and repeatedly diagnosed by different doctors. The scientific tradition requires that a theory not be accepted until it has been repeatedly proven by observable experiments. Since psychiatrists have not demonstrated beyond a reasonable doubt that BPD exists or that it can be reliably diagnosed, BPD itself should be rejected outright as a false diagnosis.
What Then, Is BPD?
For me, BPD represents people’s attempts to simplify and name complex problems in emotional and relational functioning. These problems really defy classification and naming, but it is comforting and sometimes useful to believe that, like a fly in amber, they can be “caught” and crystallized in a mythical diagnosis like Borderline Personality Disorder.
Much research shows that human beings are uncomfortable with ambiguity and uncertainty (not just those diagnosed with BPD, who are supposedly very uncomfortable with it). So it is not surprising that many psychiatrists believe that they can, in fact, accurately diagnose “mental disorders” based on the complex, related, but ultimately unique problems that their patients present. The books of Amos Tversky and Daniel Kahnemann (for example, Heuristics and Biases) gives numerous examples of how human beings distort reality based on a need for predictability and reliability which is not there in the real world.
In my view, BPD refers roughly and imperfectly to problems in human emotional development arising on a “spectrum” or range of early functioning that could be called “symbiotic.” Symbiotic is the term that psychoanalysts used to describe the way the young, 1-3 year old child relates to its parent. In symbiotic development, the child demands supportive responses and tries to play both child and parent to its parent.
When the parent is neglectful, unavailable, or abusive to varying degrees, the child becomes “stuck” or arrested in its emotional development. Many psychoanalytic writers describe this process, for example, Robert Stolorow in his book Psychoanalysis of Developmental Arrests. All of the borderline symptoms flow from different kind and degrees of problems in childhood symbiotic development. Rather than learn to regulate his feelings, relate positively to others, and become independent, the child becomes stymied by bad relationships and lack of love and support, and goes on to develop some or all of the symptoms of BPD.
Humans as a species have many common requirements for growing from childhood to mature adulthood – for example, learning to regulate feelings, learning to relate positively to others in friendships and love relationships, learning self-control, developing a sense of personal identity, and so on. Because we have much in common with our fellow human beings, problems in human emotional development have a lot of crossover.
One abused person may superficially look a lot like another abused one, and it is easy to pull five observed “symptoms” out of each of them and say they both have Borderline Personality Disorder. However, as noted above, the complexity and innumerable variations in each person’s development render this process impossible and meaningless.
Like the unicorn, BPD was a myth when it was created, and it is still a myth today. It only appears to have life when people believe in it.
With luck, the public will gradually realize what many therapists already know – that BPD is a fraudulent diagnosis, and that no one individual “has” BPD. Instead, it will be seen that, like the unicorn, BPD has more value as a metaphor referring to the spectrum of severe problems that emerge from abuse and neglect.
I welcome any correspondance at firstname.lastname@example.org
If you are struggling with BPD yourself or are trying to help a borderline individual, I would be happy to listen to your story and provide feedback if possible. Feel free to provide constructive criticism of this site also.
This article is the opinion of a non-professional layperson, and should not be taken as medical advice or as the view of a therapist who is professionally qualified to treat Borderline Personality Disorder or any other mental health condition. Readers should consult with a qualified mental health professional before undertaking any treatment.
– Edward Dantes